The R Package tipsae: Tools for Mapping Proportions and Indicators on the Unit Interval

The tipsae package implements a set of small area estimation tools for mapping proportions and indicators defined on the unit interval. It provides for small area models defined at area level, including the classical beta regression, zero- and/or one-inflated beta and flexible beta ones, possibly accounting for spatial and/or temporal dependency structures. The models, developed within a Bayesian framework, are estimated through Stan language, allowing fast estimation and customized parallel computing. The additional features of the tipsae package, such as diagnostics, visualization and exporting functions as well as variance smoothing and benchmarking functions, improve the user experience through the entire process of estimation, validation and outcome presentation. A shiny application with a user-friendly interface further eases the implementation of Bayesian models for small area analysis

Global disparities in surgeons’ workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study

: The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity > 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Small Area Estimation of Relative Inequality Indices using Mixtures of Beta

The paper aims at proposing a small area estimation strategy for the Theil Index, an entropy-based inequality measure. Specifically, we have developed an area-level model of its relative index, i.e. Theil index over its maximum, which has more manageable support between 0 and 1. Classical proposals in area-level context for measures defined on the unit interval are mostly based on proportions modelling and show limitations when dealing with asymmetric heavy-tailed data, such as in our case. We propose a Hierarchical Bayes model with alternative likelihood assumptions based on a particular Beta mixture, providing a more flexible framework

ESAME EMOCROMOCITOMETRICO COME TEST DI VALUTAZIONE CLINICA DEL DONATORE

Le attuali normative in merito alle attività di medicina trasfusionale ribadiscono il ruolo della tutela della salute dei donatori, garantito anche attraverso l’effettuazione regolare di esami di laboratorio, al fine di assicurare un elevato livello di protezione della salute umana. Anche se non previsto tra gli esami per la validazione biologica degli emocomponenti, l’esame emocromocitometrico rientra tra gli esami obbligatori ad ogni donazione; d’altra parte le linee guida nazionali e comunitarie richiedono che gli emocomponenti soddisfino requisiti di qualità, strettamente connessi con le caratteristiche del donatore e condizionanti l’efficacia della terapia trasfusionale nel ricevente. L’esame emocromocitometrico rappresenta senza dubbio l’indagine da richiedere in prima istanza per verificare lo stato di salute di un individuo e rappresenta sicuramente un criterio di protezione del donatore di sangue, consentendo da un lato di evidenziare precocemente le manifestazioni di effetti collaterali connessi alla periodicità del dono, dall’altro potendo rappresentare la spia di un eventuale danno ematologico primitivo o secondario a patologie di organi o apparati extra-emopoietici. Uno dei principali effetti collaterali della donazione di sangue è rappresentato dall’insorgenza di alterazioni del metabolismo del ferro, dal momento che la perdita di 200 mL di eritrociti con una donazione di sangue intero comporta la perdita di circa 225 mg di ferro. In condizioni di compenso delle perdite marziali e di una normale funzionalità dei meccanismi fisiologici di risposta all’ipossia, il sistema ematopoietico riesce a rigenerare un normale contenuto di emoglobina. Tuttavia, in condizioni di bilancio marziale in equilibrio instabile, come nel caso di donne in età fertile o anche in donatori di sesso maschile in relazione alla frequenza delle donazioni, la concentrazione di emoglobina nel sangue può progressivamente ridursi. La determinazione dell’emoglobina, obbligatoria in fase di selezione del donatore, è stata giustamente considerata dal legislatore determinante per il giudizio di idoneità del donatore. Tuttavia succede che individui con valori di emoglobina anche superiori rispetto ai limiti stabiliti presentino una carenza marziale latente ed è dovere del medico di medicina trasfusionale intervenire, dal momento che “possono sussistere motivi per i quali è necessario, ai fini della protezione della salute del candidato donatore, rinviare la donazione” (Allegato, 3 DM 3 Marzo 2005). In questo contesto la sola determinazione dell’emoglobina è inadeguata nell’evidenziare precocemente condizioni carenziali mentre maggiori informazioni possono essere fornite da altri parametri emocromocitometrici (MCV, MCH, MCHC, RDW). Inoltre problemi di natura etica sorgono sia in caso di carenza di ferro legata alle frequenti donazioni, sia nel caso, meno frequente ma più grave, in cui la carenza marziale sia legata a patologie ancora asintomatiche. Altri parametri forniti dall’emocromo possono segnalare condizioni che impongono l’esclusione, anche solo temporanea, del donatore: alterazione dei leucociti e delle popolazioni leucocitarie o della conta piastrinica potrebbero essere associate a patologie infettive, ematologiche o immunologiche, meritevoli di maggiori approfondimenti diagnostici. Pertanto è auspicabile che il processo di arruolamento del donatore di sangue ed emocomponenti preveda l’esecuzione di un esame emocromocitometrico preliminarmente alla donazione, al fine della tutela dello stesso donatore dall’effettuazione di una donazione in condizioni di salute non sempre ottimali che impongono, in fase di validazione, l’eliminazione dell’unità donata a causa di alterazioni anche importanti di parametri emometrici

Flexible Small Area Estimation of Theil Index using Mixtures of Beta

The aim of the paper is to propose a small area estimation model for Theil Index, an entropy-based measure used to quantify economic inequality, industrial concentration and, in general, the disparity related to economic phenomena. We developed an area-level model of its relative index, i.e. Theil index over its maximum, which has a more manageable support between 0 and 1. Classical proposals in area-level context for measures on (0,1) are mostly based on proportions modelling and show limitations when dealing with asymmetric heavy-tailed data, such as in our case. We propose a model with alternative distributional assumptions based on a particular Beta mixture with unconstrained mean modeling, estimated under a Hierarchical Bayes approach. An application to ITSILC income data is provided, showing that our proposal yields a more flexible framework in comparison with Beta regression with unmatched sampling and linking models

Mapping non-monetary poverty at multiple geographical scales

Poverty mapping is a powerful tool to study the geography of poverty. The choice of the spatial resolution is central as poverty measures defined at a coarser level may mask their heterogeneity at finer levels. We introduce a small area multi-scale approach integrating survey and remote sensing data that leverages information at different spatial resolutions and accounts for hierarchical dependencies, preserving estimates coherence. We map poverty rates by proposing a Bayesian Beta-based model equipped with a new benchmarking algorithm accounting for the double-bounded support. A simulation study shows the effectiveness of our proposal and an application on Bangladesh is discussed