Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages.

BACKGROUND: There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work-life balance globally. METHODS: A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career. RESULTS: Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P = 0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P < 0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work-life balance. CONCLUSION: Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects.

European guidelines from the EHTG and ESCP for Lynch syndrome: an updated third edition of the Mallorca guidelines based on gene and gender.

BACKGROUND: Lynch syndrome is the most common genetic predisposition for hereditary cancer but remains underdiagnosed. Large prospective observational studies have recently increased understanding of the effectiveness of colonoscopic surveillance and the heterogeneity of cancer risk between genotypes. The need for gene- and gender-specific guidelines has been acknowledged. METHODS: The European Hereditary Tumour Group (EHTG) and European Society of Coloproctology (ESCP) developed a multidisciplinary working group consisting of surgeons, clinical and molecular geneticists, pathologists, epidemiologists, gastroenterologists, and patient representation to conduct a graded evidence review. The previous Mallorca guideline format was used to revise the clinical guidance. Consensus for the guidance statements was acquired by three Delphi voting rounds. RESULTS: Recommendations for clinical and molecular identification of Lynch syndrome, surgical and endoscopic management of Lynch syndrome-associated colorectal cancer, and preventive measures for cancer were produced. The emphasis was on surgical and gastroenterological aspects of the cancer spectrum. Manchester consensus guidelines for gynaecological management were endorsed. Executive and layperson summaries were provided. CONCLUSION: The recommendations from the EHTG and ESCP for identification of patients with Lynch syndrome, colorectal surveillance, surgical management of colorectal cancer, lifestyle and chemoprevention in Lynch syndrome that reached a consensus (at least 80 per cent) are presented.

Autologous Platelet-Rich Plasma in the Treatment of Perianal Fistula in Crohn's Disease.

AIM: To assess clinical healing in patients with perianal Crohn's disease with local intrafistular injection of autologous platelet-rich plasma. METHOD: The pilot study was conducted at a single centre between January 2013 and December 2015. Autologous platelet-rich plasma was prepared in platelet-rich and platelet-poor fractions for local intrafistular injection in patients with proven, established perianal Crohn's disease. Patients were permitted biological therapies, and the Perianal Crohn's Disease Activity Index was recorded. Patients were followed for 48 weeks for clinical signs of healing (complete, partial or non-healing), monitoring fistula drainage, closure and epithelialization. RESULTS: The study included 29 patients (19 males; mean age 38 ± 12.8 years) with four exclusions in the operating room because surgery was not indicated and four lost to follow-up. Five adverse events were recorded, with two requiring the drainage of abscess collections. Of the 21 patients assessable at 24 weeks, there was complete healing, partial healing and non-healing in 7 (33.3%), 8 (38.1%) and 6 (28.6%) patients, respectively. By 48 weeks, there was complete healing, partial healing and non-healing in 6 (40%), 6 (40%) and 3 (20%) patients, respectively, with a reduction in the number of visible external fistula openings at both time points (P = 0.021). By the end of the study, there was a higher trend of healing if biological therapies were continued (85.7% with biologics vs. 75% without, P = 0.527), but there were no statistically significant differences and no differences in the Perianal Crohn's Disease Activity Index. CONCLUSION: Autologous platelet-rich plasma is safe in patients with perianal Crohn's disease, with an acceptable healing rate over a medium-term follow-up, particularly if biological therapies are used concomitantly.

Treatment of transsphincteric fistula-in-ano with growth factors from autologous platelets: results of a phase II clinical trial.

PURPOSE: The aim of this paper is to evaluate to the safety, feasibility and efficacy of a novel treatment for transsphincteric cryptoglandular fistula: injection of autologous plasma rich in growth factors (PRGF) into the fistula tract accompanied by sealing using a fibrin plug created from the activated platelet-poor fraction of the same plasma. METHOD: This article is a prospective, phase II clinical trial. The procedure was externally audited. Thirty-six patients diagnosed with transsphincteric fistula-in-ano were included. All patients underwent follow-up examinations at 1 week and again at 3, 6 and 12 months after discharge. Main outcome measures safety (number of adverse events), feasibility and effectiveness of the treatment. RESULTS: A total of 36 patients received the study treatment, with the procedure found to be feasible in all patients. A total of seven adverse events (AE) related to the injected product or surgical procedure were identified in 4 of 36 patients. At the end of the follow-up period (12 months), 33.3% of patients (12/36) had achieved complete fistula healing and 11.1% of patients (4/36) had achieved partial healing. In total, this amounted to 44.4% of patients (16/36) being asymptomatic at final follow-up. In successfully healed patients, a gradual reduction in pain was observed, as measured using a Visual Analog Scale (VAS) (p = 0.0278). Compared to baseline, a significant improvement in Wexner score was seen in patients achieving total or partial healing of the fistula (p = 0.0195). CONCLUSIONS: The study treatment was safe and feasible, with apparently modest efficacy rates. Continence and pain improvement following treatment may be considered predictive factors for healing.

Ultrasonographic evidence of Gatekeeper™ prosthesis migration in patients treated for faecal incontinence: a case series.

BACKGROUND: Faecal incontinence (FI) is both a medical and social problem, with an underestimated incidence. For patients with internal anal sphincter damage, implantation of biomaterial in the anal canal is a recognised treatment option. One such material, Gatekeeper™, has previously shown promising short- and medium-term results without any major complications, including displacement. The main aim of the present study is to assess the degree to which displacement of Gatekeeper prostheses may occur and to determine whether this is associated with patient outcomes. METHODS: Seven patients (six females) with a mean age of 55.6 years [50.5-57.2] and a mean FI duration of 6 ± 2 years were prospectively enrolled in the study. Each subject was anaesthetised and underwent implantation of six prostheses in the intersphincteric region, guided by endoanal 3D ultrasound (3D-EAU). Follow-up was performed at post-interventional months 1, 3, and 12 (median 12 ± 4 months), during which data were obtained from a defaecation diary, Wexner scale assessment, anorectal manometry (ARM), 3D-EAU, and a health status and quality of life questionnaire (FIQL). RESULTS: At 3-month follow-up, 3D-EAU revealed displacement of 24/42 prostheses in 5/7 patients. Of these, 15 had migrated to the lower portion and 9 to the upper portion of the anal canal and rectum. Despite this migration, treatment was considered successful in 3/7 patients. In one patient, it was necessary to remove a prosthesis due to spontaneous extrusion. CONCLUSIONS: We have shown that displacement of the Gatekeeper™ prosthesis occurs, but is not associated with poorer clinical outcomes.

Is the interval from surgery to ileostomy closure a risk factor for low anterior resection syndrome?

AIM: Low anterior resection syndrome (LARS) comprises a collection of symptoms affecting patients after restorative surgery for rectal cancer. The aim of the present study was to analyse the incidence of LARS in patients undergoing rectal cancer surgery with and without subsequent ileostomy and to determine whether the interval to ileostomy closure is a factor associated with its occurrence. METHOD: All patients undergoing curative anterior resection for rectal cancer from 2008 to 2012 in our institution were included in the study. They were divided into two groups according to whether or not a defunctioning ileostomy had been performed. Patients were assessed for LARS at a median interval of 23.60 ± 16.73 (12-48) months from anterior resection in those who did not have an ileostomy and at an interval of 11.31 ± 14.24 (12-60) months from closure of the ileostomy in those who did. They underwent a structured telephone interview based on a validated LARS score questionnaire. Univariate and multivariate analysis was carried out to assess possible associations between LARS and the variables studied. RESULTS: There were 150 patients (93 men) of whom 54.7% had no evidence of LARS, 17.3% had minor symptoms and 28% major symptoms of LARS. Univariate analysis showed that male gender, the presence of a temporary ileostomy and neoadjuvant therapy were predisposing factors for LARS. The interval from construction of the ileostomy to its closure did not appear to be a factor associated with LARS. In multivariate analysis, male gender and preoperative neoadjuvant therapy were significant predisposing factors for LARS. CONCLUSION: Male gender and preoperative neoadjuvant therapy are risk factors for LARS. The presence of ileostomy or time to ileostomy closure is not associated with the development of this syndrome.

Percutaneous neuromodulation of the posterior tibial nerve for the treatment of faecal incontinence - mid-term results: is retreatment required?

AIM: Posterior tibial nerve stimulation (PTNS) has emerged in recent years as a therapy for faecal incontinence. Its long-term effectiveness is yet to be established, along with what the form of retreatment should be in the event of loss of effectiveness. The present study aimed to establish the mid-term results to identify the proportion of patients who may need further treatment, and if so when. METHOD: A prospective study including 30 patients was conducted at an academic hospital. The patients underwent 12 weekly outpatient treatment sessions, each lasting 30 min (first PTNS phase). Neuromodulation was discontinued in those patients who did not have a 40% decrease in their pretreatment Wexner score. Patients having a better than 40% response were offered another 12-week course of complete treatment (second PTNS phase), following which they received no further PTNS treatment (phase without PTNS) but were assessed at 6 months and 2 years. RESULTS: All patients finished the first phase and 22/30 patients continued to the second phase. During this phase 11 patients showed an improved Wexner score (baseline/first phase/second phase: 14.3 ± 4.2 vs 9.9 ± 5.4 vs 6.8 ± 5.4). After a 6-month period without any treatment, the score was still improved in 11/30 patients (9.1 ± 6.2). At 2 years there was improvement in 16/30 patients (8.8 ± 7.1). There was a significant improvement in three variables of the quality of life questionnaire: lifestyle, coping behaviour and embarrassment. CONCLUSION: The response to first and second phase PTNS was maintained for up to 2 years. Retreatment was not required in about half of patients, even when they had finished the treatment 6 months or 2 years previously.

Nuevas tecnologías; posibilidades de apoyo a la investigación en red / New technologies: support opportunities for network research

La consolidación de una zona de apoyo a la investigación en red, que fomente la investigación colaborativa, la formación y la difusión de conocimientos mediante las Tecnologías de la Información y la Comunicación (TIC) suponen ante todo la organización de una metodología de trabajo para compartir e intercambiar recursos en una red concreta que ya está en funcionamiento. Serán necesarios el establecimiento de mecanismos de comunicación entre los investigadores de distintos grupos; introducción de las TIC en la formación y entornos avanzados de formación en investigación; diversos inventarios de recursos de investigación susceptibles de intercambio y de utilización conjunta entre grupos y laboratorios; un sistema de documentación científica compartida y un adecuado mantenimiento de todas estas herramientas. No se trata de crear grandes estructuras administrativas y planes detallados para cumplir todas estas funciones, sino de disponer de herramientas efectivas para combinar esfuerzos y buscar recursos en todas estas áreas, con la agilidad y flexibilidad que nos permiten hoy el uso de las nuevas tecnologías de comunicación e información. Los resultados de esta zona de apoyo a la investigación, deben traducirse en un aumento de la eficacia y calidad de la red, al aumentar el flujo de información y la colaboración intergrupos en la docencia, investigación y desarrollo profesional así como la transferencia y difusión de los resultados de investigación (AU)

The consolidation of a support area for network research, which promotes collaborative research, training and the dissemination of knowledge through the use of ICTs, requires the organization of a work methodology to share and exchange resources in a specific network that is already running. The establishment of communication mechanisms between researchers from different groups will be necessary along with the introduction of the ICTs in the teaching and advanced environments of research training, different inventories of the research resources that are available for exchanges and shared use between groups and laboratories, and finally, a shared scientific documentation system with the appropriate maintenance of the previously listed tools. Large administrative structures and detailed plans are not needed to comply with all of the above functions. The availability of effective tools, however, to combine efforts and search for resources in all of these areas is needed, with the agility and flexibility that allow us to currently use new communication and information technologies. The results of this research support area should lead to an increase in the efficacy and quality of the network by increasing the flow of information and the inter-group collaboration in teaching, research and professional development, along with the transfer and dissemination of research results (AU)

[New technologies: support opportunities for network research]. / Nuevas tecnologías: posibilidades de apoyo a la investigación en red.

The consolidation of a support area for network research, which promotes collaborative research, training and the dissemination of knowledge through the use of ICTs, requires the organization of a work methodology to share and exchange resources in a specific network that is already running. The establishment of communication mechanisms between researchers from different groups will be necessary along with the introduction of the ICTs in the teaching and advanced environments of research training, different inventories of the research resources that are available for exchanges and shared use between groups and laboratories, and finally, a shared scientific documentation system with the appropriate maintenance of the previously listed tools. Large administrative structures and detailed plans are not needed to comply with all of the above functions. The availability of effective tools, however, to combine efforts and search for resources in all of these areas is needed, with the agility and flexibility that allow us to currently use new communication and information technologies. The results of this research support area should lead to an increase in the efficacy and quality of the network by increasing the flow of information and the inter-group collaboration in teaching, research and professional development, along with the transfer and dissemination of research results.

Análisis de determinantes sociales de la desnutrición en Latinoamérica / Social determinants analysis of malnutrition in Latin America

Nuestro comportamiento alimentario se encuentra condicionado por variados determinantes socioculturales y adquiere muchos significados sociales. Reconociendo la enorme influencia de los condicionantes económicos, biológicos, ambientales, tecnológicos, políticos, etc., aquí nos interesamos por los de carácter más sociocultural. La alimentación de cualquier población puede determinarse por el nivel educativo, el empleo, el género y la edad, la diferenciación étnica, la cobertura social, las redes sociales de apoyo, el empoderamiento y la participación ciudadana, la cohesión social, etc., y se encuentra mediatizada por la conservación de tradiciones familiares o comunitarias (celebraciones, fiestas populares, actitudes hospitalarias, costumbres religiosas, tabúes…) por la publicidad y el marketing, y por otros factores socioculturales. La pobreza en Latinoamérica afecta a la tercera parte de población y la desnutrición a una sexta parte de la región. Aunque la educación ha mejorado en todos los países en las dos últimas décadas, todavía necesita progresar. La tasa de desempleo es mayor para los más pobres, las mujeres y los jóvenes, y es superior también en el ámbito rural y para la población indígena. Las mujeres sufren el doble que los varones las consecuencias de las crisis alimentarias. Y en relación al estado de salud y de la nutrición en las poblaciones indígenas se observa una menor esperanza de vida respecto al resto de la población, mayores tasas de mortalidad infantil, más pobreza, y más desnutrición y hambre entre los niños menores de cinco años y entre las mujeres pertenecientes a minorías étnicas y hogares pobres en zonas agrícolas (AU)

Our food conduct is influenced by several sociocultural determinants and acquires many social meanings. Recognizing the enormous influence of the economic, biological, environmental, technological, political conditions, etc., here we are interested for those of more socioculturalcharacter. The food of any population can be determined by the educational level, the employment, the gender and age, ethnic differentiation, social coverage, the social support networks, the empowerment and civil participation, the social cohesion, etc., and it is mediated by the preservation of familiar or community traditions (celebrations, festivals, hospitable attitudes, religious customs, taboos...) for advertising and marketing, and other sociocultural factors. Poverty in Latin America affects the third part of population and one sixth part of the region is undernourished. Although education has improved in all countries in last two decades, it still needs to progress. The unemployment rate is higher for the poorest, the women and youth, and is also higher in rural and indigenous populations. Women suffer the food crises consequences twice more than the men. And in relation to health and nutrition state, in indigenous populations we are observed a minor life expectancy compared of the rest of the population, higher infant mortality rates, more poverty, more hunger and malnutrition among children under five, and women from ethnic minorities and poor households in agricultural areas (AU)