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

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Die turbulente Taylor-Couette-Strömung mit sehr weitem Spalt : experimentelle Untersuchung

Die Taylor-Couette-Strömung (TC), die Strömung zwischen zwei konzentrischen, unabhängig voneinander rotierenden Zylindern, wird als perfektes Modell zur Untersuchung von Scherströmungen über konkaven Oberflächen verwendet und ist eines der paradigmatischen Systeme der Fluidphysik. In dieser Arbeit wird eine experimentelle Untersuchung der turbulenten TC-Strömung in einer sehr breiten Spaltgeometrie mit einem Radiusverhältnis = 0,1 durchgeführt. Das physikalische und dynamische Verhalten der Strömung wird in einer Geometrie untersucht, die vor der vorliegenden Studie kaum untersucht wurde, was diese Studie einzigartig macht. Ziel der Studie ist es, die Auswirkungen der Krümmung auf die TC-Strömung zu verstehen, insbesondere in Fällen, in denen die Umfangslänge des inneren Zylinders kleiner ist als die Spaltbreite. Die Strömung wird in den verschiedenen Rotationsregimen untersucht: gegenläufige, mitläufige und reine Innenzylinder-Rotationsregime bis zu Scher-Reynoldszahlen Re_s≤ 150000. Das Strömungsfeld wurde mit Hilfe von Visualisierungstechniken qualitativ untersucht. Bei der Untersuchung der verschiedenen Strömungsparameter zeigen sich bekannte kohärente TC-Strömungsmuster sowie neu beobachtete Muster, von denen wir annehmen, dass sie nur bei TC-Strömungen mit sehr großem Spalt existieren. Für eine detailliertere quantitative Untersuchung wurde eine zeitaufgelöste Messung des Geschwindigkeitsfeldes mit der Hochgeschwindigkeits-Partikel-Image-Velocimetry-Technik durch die Endplatte des Systems durchgeführt. Die radialen und azimutalen Geschwindigkeitskomponenten in der horizontalen 2D-Ebene werden an verschiedenen axialen Positionen gemessen, um die axiale Varianz der Strömung zu erfassen. Das aufgezeichnete Strömungsfeld wird verwendet, um den Drehimpulstransport in Form der Quasi-Nusselt-Zahl (Nu_ω) zu berechnen. Die Ergebnisse zeigen ein Maximum der Nu_ω für niedrige gegenläufige Raten von -0,011 ≤ μ_max ≤ -0,0077, was mit großräumigen Strukturen verbunden ist, die den gesamten Spalt überspannen. Darüber hinaus nimmt Nu_ω für Gegenrotationsraten, die höher als μ_max sind, ab, bis es einen Minimalwert erreicht, und steigt dann für höhere Gegenrotationsfälle tendenziell wieder an. Das Raum-Zeit-Verhalten des turbulenten Strömungsfeldes für die Fälle mit hoher Gegenrotation zeigt die Existenz neu beobachteter Muster neben der äußeren Zylinderwand, die sich nach innen ausbreiten, den Drehimpulstransport verstärken und zu einem zweiten Maximum im Transport für höhere Gegenrotationsraten führen. Das Raum-Zeit-Verhalten des turbulenten Strömungsfeldes für die Fälle mit hoher Gegenrotation zeigt die Existenz von neu beobachteten Mustern neben der äußeren Zylinderwand, die sich nach innen ausbreiten, den Drehimpulstransport verstärken und zu einem zweiten Maximum des Transports für höhere Gegenrotationsraten führen. Für den rein rotierenden inneren Zylinder skaliert der Impulstransport.The Taylor-Couette (TC) flow, the flow confined between two concentric independently rotating cylinders, is used as a perfect model to investigate shear flow over concave surfaces and one of the paradigmatic systems of the physics of fluids. In this thesis, an experimental investigation of the turbulent TC flow in a very wide gap geometry with a radius ratio = 0.1 is performed. The physical and dynamic behavior of the flow is studied in a geometry that has rarely been investigated before the current study, which makes this study unique. The study aims to understand the effect of curvature on the TC flow, particularly in cases where the circumferential length of the inner cylinder is smaller than the gap width. The flow is studied in the different rotation regimes: counter-rotating, co-rotating, and purely inner cylinder rotating regimes up to shear Reynolds numbers Re_s≤ 150000. The flow field has been qualitatively studied using visualization techniques. By probing the different flow parameters, familiar coherent TC flow patterns appear, in addition to newly observed patterns we assume only exist for very wide gap TC flows. For a more detailed quantitative study, a time-resolved velocity field measurement has been conducted using the High-speed Particle Image Velocimetry technique through the system end plate. The radial and azimuthal velocity components in the 2D horizontal plane are measured at different axial positions, in order to scan the axial variance of the flow. The recorded flow field is used to compute the angular momentum transport in terms of the quasi-Nusselt number (Nu_ω). The results show a maximum of Nu_ω for low counter-rotating rates of −0.011 ≤ μ_max ≤ −0.0077, which is associated with large-scale structures that span the entire gap. Moreover, the Nu_ω decreases for counter-rotation rates higher than μ_max until it reaches a minimum value and then tends to increase again for higher counter-rotation cases. The space-time behavior of the turbulent flow field for the high counter-rotating cases shows the existence of newly observed patterns next to the outer cylinder wall that propagates inward, enhancing the angular momentum transport and resulting in a second maximum in transport for higher counter-rotating rates. For the pure rotating inner cylinder, the momentum transport scaling with the shear rate Nu_ω ∼ Re_s^α has been studied, and it shows a transition in scaling to = −0.76 for all flows with Re_(s )≥ 25000. This new scaling reveals the transition of the flow from the classical turbulent regime to the ultimate one, where this transition is accompanied by a clear change in the flow behavior. Moreover, the flow in the co-rotating regime and particularly in the centrifugal stable regime ( > +0.01) is investigated. The Velocity measurements show the presence of disturbed flow near the inner cylinder, where the measured velocity profiles showed a clear deviation from those predicted by laminar flow for flows up to = +0.04

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global Impact of COVID-19 on Stroke Care and IV Thrombolysis

Objective To measure the global impact of COVID-19 pandemic on volumes of IV thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with 2 control 4-month periods. Methods. We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases. Results. There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95% confidence interval [CI] −11.7 to −11.3, p \u3c 0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95% CI −13.8 to −12.7, p \u3c 0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95% CI −13.7 to −10.3, p = 0.001). Recovery of stroke hospitalization volume (9.5%, 95% CI 9.2–9.8, p \u3c 0.0001) was noted over the 2 later (May, June) vs the 2 earlier (March, April) pandemic months. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was noted in 3.3% (1,722/52,026) of all stroke admissions. Conclusions. The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID-19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months

Second asymptomatic carotid surgery trial (ACST-2) : a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86-1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91-1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable