{Ni4} Cubanes from enantiomerically pure 2-(1-hydroxyethyl)pyridine ligands: supramolecular chirality

Homometallic {NiII4} cubane-like clusters with a rare chiral core have been prepared via the employment of enantiomerically pure 2-(1-hydroxyethyl)pyridine (Hmpm). Comparison with the achiral cubanes derived from the related 2-pyridinemethanol (Hpym) ligand reveals drastic structural changes as a consequence of the transfer of chirality from the ligands to the whole structure. Their magnetic properties have been related to the structural features of their cubane-type cores

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Creation of an enhanced recovery after surgery protocol with Wilms tumours in low- and middle-income countries

Introduction - Enhanced Recovery After Surgery guidelines have been developed and shown to improve outcomes for many surgical procedures. Most existing guidelines have been created for patients in high-resource settings. There is a dearth of guidelines for pediatric populations particularly in low- and middleincome countries (LMIC). All children with Wilms tumours require resection for cure and therefore a perioperative care pathway can streamline care for all curative-intent nephrectomies. Methods – A two-round Delphi consensus of clinicians in LMICs was utilized to determine the scope and content of recommendations for an enhanced recovery protocol for children with Wilms tumours undergoing nephrectomy in LMICs. Consensus was predefined a priori as ≥70% of panelists indicating a topic or recommendation should be included. Results – Twenty-six topics met consensus for inclusion and were consolidated into twenty recommendations for implementation in the preoperative, intraoperative, and postoperative setting. Predominant themes included perioperative nutrition, surgical safety, anesthetic concerns, and interdisciplinary oncology care. Ten participants completed round one and six completed round two. All recommendations met consensus for inclusion after two rounds. Conclusions – A consensus-derived perioperative care pathway for children with Wilms tumours in low-resource settings is presented. Recommendations share many priorities with high-resource pathways, but also contain unique considerations for a low-resource setting.Medicine, Faculty ofUnreviewedGraduat

Free intestinal perforation in children with Crohn's disease

Background: Free intestinal perforation in children with Crohn's disease (CD) is a rare, but serious complication that requires urgent surgical management. The incidence, contributing risk factors, diagnostic workup, and management strategies for these complex pediatric patients are not well established. Methods: We present a recent case of free intestinal perforation in a patient with CD. In addition, a systematic review of the literature was conducted by searching the PubMed, Embase, Ovid, Scopus and Cochrane databases. Two authors independently extracted data, reviewed the abstracts, and assessed them for inclusion in the review. Results: The literature review identified 21 pediatric patients documented in 14 publications; including our case, there are a total of 22 pediatric patients reported. The majority of patients presented with features of peritonitis. Perforation occurred early in the disease course (median 6.5 months), and was most commonly a single perforation in the ileum with active Crohn's disease (82%). Colonic perforation occurred in 18% of patients. All patients underwent urgent surgical management. Surgical approaches included resection of the diseased bowel segment with proximal diversion in eleven patients (50%), resection with primary anastomosis in 9 (41%) or direct suture repair in two (9%). Both patients who underwent simple primary repair developed post-operative complications. Conclusions: Free intestinal perforation may occur at any age and stage of Crohn's disease. Three-dimensional imaging may be required to confirm the diagnosis. The management of free intestinal perforation in CD is surgical. This should involve resection of the involved segment with proximal diversion or resection with primary anastomosis in selected cases. Primary suture closure of the perforation is discouraged. Keywords: Free intraperitoneal perforation, Pediatric Crohn's diseas

Work-Related Factors and Pregnancy Outcomes in Female Surgeons

Objective:. To describe work-related factors, pregnancy, and pregnancy outcomes in female surgeons is the objective of this study. Background:. Some data suggest surgeon workload may deter pregnancy and adversely affect pregnancy outcomes in female surgeons. Methods:. A cross-sectional, web-based survey was distributed via e-mail to members of the Society of Obstetrics and Gynaecologists of Canada and to surgical departments of 6 Canadian universities from October 2019 to January 2020. Results:. A total of 223 surgeons with 451 pregnancies participated. Work hours were reduced in 33.3% of pregnancies, and 28.0% had a policy for pregnancy in their workplace. A total of 57% of surgeons intentionally delayed pregnancy due to heavy workload and 39% to career concerns, and 31% reported work adversely affected their pregnancy. Adverse maternal outcomes included miscarriage (14.9%), preterm labor (6.2%), hypertension (5.5%), pre-eclampsia (2.9%), and placenta praevia (1.3%). Adverse infant outcomes included preterm birth (6.9%), small for gestational age at birth (6.9%), and neonatal intensive care unit admission (4%). Congenital anomalies occurred in 4.2% of pregnancies. Surgeons who reported a policy for working while pregnant were more likely to have reduced their work hours than those without a policy (48.4% vs 28.5% respectively, P < 0.0001). In unadjusted models, those who reduced their work hours while pregnant were less likely to have a miscarriage than those who did not (odds ratio = 0.2, 95% confidence interval, 0.1–0.4). Conclusions:. Female surgeons reported delays in pregnancy due to work, adverse effects of work on pregnancy, and some elevated rates of adverse outcomes. These data support policies for pregnancy in surgeons and surgical trainees