Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

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

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

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

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

Photodynamic Therapy for Vulvar Lichen Sclerosus - A Systematic Review

Objective Lichen sclerosus (LS) is a disease affecting mostly genital and perianal areas. Photodynamic therapy (PDT) has gained interest during the past years. The present study accumulates current evidence on the efficacy of PDT in the management of vulvar LS. Methods We used Medline (1966-2017), Scopus (2004-2017), ClinicalTrials.gov (2008-2017) and Cochrane Central Register of Controlled Trials CENTRAL (1999-2017) databases in our primary search along with the reference lists of electronically retrieved full-text papers. Results Eleven studies were finally included in our systematic review, which recruited 337 women. The existing evidence supports that PDT results in significant relief of symptoms related to LS, hence remains confusing in evaluating the progress in the clinical appearance of the lesion. No major adverse effects were reported during therapy and during the posttreatment period. Pathologic findings seem to be conflicting, as current data do not unanimously support a beneficial histological effect. Conclusions According to the findings of our study, PDT seems to be promising in the treatment of patients with vulvar LS. Nonetheless, current knowledge is extremely limited, and further observational studies with large patient series are needed in the field to elucidate the efficacy of PDT. © Lippincott Williams & Wilkins

Role of critical care units in the management of obstetric patients (Review)

Pregnancy is considered a natural process for the majority of women. However, a limited proportion of pregnancies and deliveries can present with a broad variety of complications that may require admission to a Critical Care Unit (CCU). In the present review, the indications of admission of obstetrical and postpartum patients to CCUs were critically evaluated with a particular focus on the management of their complications. The management of critically ill obstetric patients remains challenging due to the physiological changes that occur during pregnancy, pregnancy-related diseases and the need to carefully consider the well-being of the fetus before any intervention can be recom-mended/performed. Indications for admission to CCUs include both obstetric and non-obstetric conditions that may require continuous monitoring and further interventions. Hypertensive disorders of pregnancy and mass hemorrhage are amongst the most common causes of admission to CCUs in pregnant and postpartum women. The establishment of a diagnostic and care algorithm based on the contribution of a multidisciplinary team is of critical importance to aid in the determination of which patients will require intensive care, and to assist in deciding what type of critical care each critically ill patients receives. © 2021, Spandidos Publications. All rights reserved

The impact of subcutaneous tissue suturing at caesarean section on wound complications: a meta-analysis

Background Caesarean wound complications are frequently observed in everyday practice. Objectives To study whether subcutaneous tissue closure following caesarean section results in decreased wound complications. Search strategy We systematically searched Medline (1966-2016), Scopus (2004-2016), ClinicalTrials. gov (2008-2016) and Cochrane Central Register of Controlled Trials CENTRAL (1999-2016) databases together with reference lists from included studies. Selection criteria Randomised and quasi-randomised trials that investigated the impact of subcutaneous tissue suturing on wound complications following caesarean section were held eligible for inclusion. Retrospective studies and prospective nonrandomised studies were excluded from the present meta-analysis. Data collection and analysis The methodological quality of studies was assessed with the Jadad scale. Statistical meta-analysis was performed with the REVMAN 5.3 software. Main results Ten studies were finally included in our metaanalysis, which involved 3696 women delivered by caesarean section. Re-approximation of the subcutaneous tissue significantly reduced the odds of developing any type of wound complication [3811 women, random effects model (REM), odds ratio (OR) 0.66, 95% CI 0.47-0.93]. The incidence of seroma was also decreased (1979 women, REM, OR 0.53, 95% CI 0.330.84). On the other hand, the incidence of haematoma remained unaffected by subcutaneous closure (1663 women, REM, OR 0.74, 95% CI 0.22-2.42) as well as the likelihood of developing a wound infection (1971 women, REM, OR 0.99, 95% CI 0.70-1.41). Conclusions The results of our meta-analysis suggest that subcutaneous tissue closure may benefit women undergoing caesarean section. Current data in women with high body mass index remain very limited; hence, definitive conclusions are precluded for this specific group

Familiarization of undergraduate medical students with the two-dimensional vision of laparoscopic surgery: Preliminary results of a prospective follow-up study

Background: To date, the feasibility of pre-graduate training in 2D vision has not been studied thoroughly. The purpose of this pilot study is to present the preliminary results of a pre-graduate laparoscopic training program. Materials and methods: We invited pre-graduate medical students to participate in an experimental training program which strengthened their essential skills in 2D-vision. An easy-to-use, cost-effective, hand-made laparoscopic training box was constructed and used. Results: Twenty-four pre-graduate students participated in our study. The ability of medical students to co-ordinate their movements on the 2D-space was strengthened from the first to the fourth time of performing the easiest tasks (bead transfer and rope cutting) (P <.001). This was not observed in the case of the two harder tasks (necklace formation and intracorporeal knot), despite the fact that time to fulfillment differed (P =.058 & P =.082) respectively. The overall assessment of the simulator in terms of portability, imaging, light, camera convenience to use and significance ranked from high to very high. Conclusion: Familiarization with the 2D environment of laparoscopic surgery is extremely important for medical students. The results of our study seem to be promising, as they show that basic tasks are easy to learn with the use of relatively inexpensive equipment. © 2018 Elsevier Masson SA