Photo essay: a great anointment in the 21st century

Every 12 years, thousands of people gather in the Southern Indian state of Karnataka to witness the Mahamastakabhisheka or the 'Great Head Anointment' of the 57-foot high statue of Bahubali. This photo essay captures the nearly thousand year old ceremony, which has been embellished with some 21st century additions in the form of material and technological changes. Text by Sweta Daga and Dhruva Ghosh. Photos by Rajiv Rathod, Sweta Daga, and Dhruva Ghosh

More is Better in Modern Machine Learning: when Infinite Overparameterization is Optimal and Overfitting is Obligatory

In our era of enormous neural networks, empirical progress has been driven by the philosophy that more is better. Recent deep learning practice has found repeatedly that larger model size, more data, and more computation (resulting in lower training loss) improves performance. In this paper, we give theoretical backing to these empirical observations by showing that these three properties hold in random feature (RF) regression, a class of models equivalent to shallow networks with only the last layer trained. Concretely, we first show that the test risk of RF regression decreases monotonically with both the number of features and the number of samples, provided the ridge penalty is tuned optimally. In particular, this implies that infinite width RF architectures are preferable to those of any finite width. We then proceed to demonstrate that, for a large class of tasks characterized by powerlaw eigenstructure, training to near-zero training loss is obligatory: near-optimal performance can only be achieved when the training error is much smaller than the test error. Grounding our theory in real-world data, we find empirically that standard computer vision tasks with convolutional neural tangent kernels clearly fall into this class. Taken together, our results tell a simple, testable story of the benefits of overparameterization, overfitting, and more data in random feature models

Prognostic models for surgical-site infection in gastrointestinal surgery: systematic review

BACKGROUND: Identification of patients at high risk of surgical-site infection may allow clinicians to target interventions and monitoring to minimize associated morbidity. The aim of this systematic review was to identify and evaluate prognostic tools for the prediction of surgical-site infection in gastrointestinal surgery.METHODS: This systematic review sought to identify original studies describing the development and validation of prognostic models for 30-day SSI after gastrointestinal surgery (PROSPERO: CRD42022311019). MEDLINE, Embase, Global Health, and IEEE Xplore were searched from 1 January 2000 to 24 February 2022. Studies were excluded if prognostic models included postoperative parameters or were procedure specific. A narrative synthesis was performed, with sample-size sufficiency, discriminative ability (area under the receiver operating characteristic curve), and prognostic accuracy compared.RESULTS: Of 2249 records reviewed, 23 eligible prognostic models were identified. A total of 13 (57 per cent) reported no internal validation and only 4 (17 per cent) had undergone external validation. Most identified operative contamination (57 per cent, 13 of 23) and duration (52 per cent, 12 of 23) as important predictors; however, there remained substantial heterogeneity in other predictors identified (range 2-28). All models demonstrated a high risk of bias due to the analytic approach, with overall low applicability to an undifferentiated gastrointestinal surgical population. Model discrimination was reported in most studies (83 per cent, 19 of 23); however, calibration (22 per cent, 5 of 23) and prognostic accuracy (17 per cent, 4 of 23) were infrequently assessed. Of externally validated models (of which there were four), none displayed 'good' discrimination (area under the receiver operating characteristic curve greater than or equal to 0.7).CONCLUSION: The risk of surgical-site infection after gastrointestinal surgery is insufficiently described by existing risk-prediction tools, which are not suitable for routine use. Novel risk-stratification tools are required to target perioperative interventions and mitigate modifiable risk factors.</p

Erratum to 'Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries' [BJA Open 7 (2023) 100207]

[This corrects the article DOI: 10.1016/j.bjao.2023.100207.].</p

Global Variation in Out-of-Pocket Payments for Cancer Surgery

INTRODUCTION: Cancer is one of the most expensive global health challenges and surgery is needed in most cases. This study aimed to describe out-of-pocket payments for cancer surgery across country income groups.METHODS: This was a preplanned secondary analysis from an international prospective cohort study of consecutive patients undergoing cancer surgery in October 2020. Out-of-pocket payments (OOPP) to cover most of the cost of cancer surgery were compared across country income groups. Other funding sources were also described as follows: public funds, insurance, or others. A logistic regression model was used to identify variables independently associated with OOPP in low- and middle-income countries.RESULTS: There were 24,498 patients included from 1332 hospitals from 108 countries. Overall, 6.4% (1571/24,498) had OOPP to cover most of the cost of their cancer surgery. OOPP rates varied across country income groups: 0.5% (89/16,680) in HICs, 5.7% (272/4784) in UMICs, 38.6% (1008/2614) in LMICs, and 48.1% (202/429) in LICs. Besides the country income, male sex (OR 1.16, 95% CI 1.02-1.32, and p = 0.024) and elective surgery (OR 1.31, 1.04-1.67, and p = 0.022) were associated with OOPP for cancer surgery.DISCUSSION: Patients accessing cancer surgery in LMICs are at an increased risk of catastrophic expenditure. Governments should prevent this by developing health insurance plans that cover elective cancer surgery, possibly involving diverse stakeholders. The interpretation of gender-related risks demands deeper understanding of the ability to pay out-of-pocket and access care.</p

Environmentally sustainable surgical systems

Surgeons, anaesthetists, wider surgical teams and hospital managers are a large global group that has the capacity and power to play a leadership role to contribute to change. Hospitals are a good target for improvement since they are centres of communities, linking together surrounding healthcare facilities and influencing wider determinants of the environment. District and rural hospitals are good sites to start since they serve large populations, have the least sustained energy and clean water supplies and will benefit most from quality improvement. Within hospitals, surgeons and surgical pathways are the ideal places to start decarbonising healthcare. Surgery is a high-resource activity, but it focuses on one patient at a time, allowing measures to be introduced, and their effects closely monitored. Through a mass movement, surgical teams should be able to influence policy-makers for healthcare and industry supply chains, amplifying their effect. This article describes how we can make personal, professional and organisational changes to start creating impact. Change can be hard, especially in healthcare, so this new community needs to blend carbon literacy and behavioural change techniques for success. The article is focused on the front-line team and written by clinician experts in behavioural change and sustainable practice. As such, it will not tackle the technicalities of sustainability and carbon accounting. It intends to challenge individual readers to start making changes now, and to challenge systems leaders to start making larger-scale changes urgently.</p

The impact of preoperative oral nutrition supplementation on outcomes in patients undergoing gastrointestinal surgery for cancer in low- and middle-income countries:a systematic review and meta-analysis

Abstract Malnutrition is an independent predictor for postoperative complications in low- and middle-income countries (LMICs). We systematically reviewed evidence on the impact of preoperative oral nutrition supplementation (ONS) on patients undergoing gastrointestinal cancer surgery in LMICs. We searched EMBASE, Cochrane Library, Web of Science, Scopus, WHO Global Index Medicus, SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) databases from inception to March 21, 2022 for randomised controlled trials evaluating preoperative ONS in gastrointestinal cancer within LMICs. We evaluated the impact of ONS on all postoperative outcomes using random-effects meta-analysis. Seven studies reported on 891 patients (446 ONS group, 445 control group) undergoing surgery for gastrointestinal cancer. Preoperative ONS reduced all cause postoperative surgical complications (risk ratio (RR) 0.53, 95% CI 0.46–0.60, P < 0.001, I 2 = 0%, n = 891), infection (0.52, 0.40–0.67, P = 0.008, I 2 = 0%, n = 570) and all-cause mortality (0.35, 0.26–0.47, P = 0.014, I 2 = 0%, n = 588). Despite heterogeneous populations and baseline rates, absolute risk ratio (ARR) was reduced for all cause (pooled effect −0.14, −0.22 to −0.06, P = 0.006; number needed to treat (NNT) 7) and infectious complications (−0.13, −0.22 to −0.06, P < 0.001; NNT 8). Preoperative nutrition in patients undergoing gastrointestinal cancer surgery in LMICs demonstrated consistently strong and robust treatment effects across measured outcomes. However additional higher quality research, with particular focus within African populations, are urgently required

Achieving Surgical, Obstetric, Trauma, and Anesthesia (SOTA) care for all in South Asia

South Asia is a demographically crucial, economically aspiring, and socio-culturally diverse region in the world. The region contributes to a large burden of surgically-treatable disease conditions. A large number of people in South Asia cannot access safe and affordable surgical, obstetric, trauma, and anesthesia (SOTA) care when in need. Yet, attention to the region in Global Surgery and Global Health is limited. Here, we assess the status of SOTA care in South Asia. We summarize the evidence on SOTA care indicators and planning. Region-wide, as well as country-specific challenges are highlighted. We also discuss potential directions-initiatives and innovations-toward addressing these challenges. Local partnerships, sustained research and advocacy efforts, and politics can be aligned with evidence-based policymaking and health planning to achieve equitable SOTA care access in the South Asian region under the South Asian Association for Regional Cooperation (SAARC)

Health systems strengthening through surgical and perioperative care pathways- a changing paradigm

Global health has traditionally focused on the primary health development with disease-specific focus such as HIV, malaria and non-communicable diseases (NCDs). As such, surgery has traditionally been neglected in global health as investment in them is often expensive, relative to these other priorities. Therefore, efforts to improve surgical care have remained on the periphery of initiatives in health system strengthening. However, today, many would argue that global health should focus on universal health coverage with primary health and surgery and perioperative care integrated as a part of this. In this article, we discuss the past developments and future-looking solutions on how surgery can contribute to the delivery of effective and equitable healthcare across the world. These include bidirectional integration of surgical and chronic disease pathways and better understanding financing initiatives. Specifically, we focus on access to safe elective and emergency surgery for NCDs and an integrated approach towards the rising multimorbidity from chronic disease in the population. Underpinning these, data-driven solutions from high-quality research from clinical trials and cohort studies through established surgical research networks are needed. Although challenges will remain around financing, we propose that development of surgical services will strengthen and improve performance of whole health systems and contribute to improvement in population health across the world