Development of a Unifying Target and Consensus Indicators for Global Surgical Systems Strengthening: Proposed by the Global Alliance for Surgery, Obstetric, Trauma, and Anaesthesia Care (The G4 Alliance)

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world

Bacterial Microbiome Dynamics in Post Pull-Through Hirschsprung-Associated Enterocolitis (HAEC): An Experimental Study Employing the Endothelin Receptor B-Null Mouse Model

PurposeHirschsprung-associated enterocolitis (HAEC) is the most frequent potentially life-threatening complication in children with Hirschsprung disease (HSCR) even after definitive corrective surgery. Mounting evidence suggests that intestinal microbiota likely contribute to the etiology of enterocolitis, so the aim of this study was to use a mouse model of post pull-through HAEC to compare the fecal bacterial communities of animals which developed HAEC to those free of enterocolitis.MethodsTen Ednrb−/− and 8wild type mice underwent the microsurgical pull-through surgery, and stool was collected at the time of surgery, and then either at 2 and 4 weeks after the operation, or when the mice developed enterocolitis. The mid-colon of all animals was collected, prepared and histologically graded for enterocolitis. Fecal DNA was isolated and bacterial 16S rRNA genes analyzed using Illumina sequencing.ResultsSix Ednrb−/− mice developed HAEC with a mean enterocolitis score of 5.7, while the remaining 4 mutant and 8 WT mice remained free of enterocolitis by 4 weeks. The HAEC group had lower alpha diversity by Chao1 analysis compared with WT group, while the Ednrb−/− mice demonstrated distinct bacterial communities from WT mice on beta diversity analysis. The most striking finding was increased proportion of Akkermansia and reduced Bacteroidetes compared with the NO HAEC and WT groups, suggesting Akkermansia may contribute to development of enterocolitis while Bacteroidetes may be protective. Less abundant genera that were reduced in HAEC were Dysgonomas and Clostridium XIVa which may play a protective role.ConclusionsThis is the first study to identify Akkermansia as potentially playing a role in HAEC, either as a pathobiont taxa contributing to pathogenesis of enterocolitis, or possibly a protective commensal taxa expanded in response to inflammation. These findings characterized the dynamic shifts in the gut microbial communities through the onset of post pull-through HAEC, and suggests that there may be identifiable bacterial community differences in HSCR patients that are high risk for developing HAEC

A Study of VITOM in Pediatric Surgery and Urology: Evaluation of Technology Acceptance and Usability by Operating Team and Surgeon Musculoskeletal Discomfort

© Copyright 2017, Mary Ann Liebert, Inc. 2017. Introduction: We studied operating team acceptability of Video Telescopic Monitor (VITOM®) exoscope by exploring the ease of use of the device in two centers. We also assessed factors affecting surgeon musculoskeletal discomfort. Methods: We focused on how the operating team interacted with the VITOM system with surrogate measures of usefulness, image quality, ease of use, workload, and setup time. Multivariable linear regression was used to model the relationships between team role, experience, and setup time. Relationships between localized musculoskeletal discomfort and use of VITOM alone, and with loupes, were also analyzed. Results: Four surgeons, 7 surgical techs, 7 circulating nurses, and 13 surgical residents performed 70 pediatric surgical and urological operations. We found that subjective views of each team member were consistently positive with 69%-74% agreed or strongly agreed that VITOM enhanced their ability to perform their job and improved the surgical process. Unexpectedly, the scrub techs and nurses perceived more value and utility of VITOM, presumably because it provides them a view of the operative field that would otherwise be unavailable to them. Team members rated perceptions of image quality highly and workload generally satisfactory. Not surprisingly, setup time decreased with team experience and multivariable modeling showed significant correlations with surgeon and surgical tech experience, but not circulating nurse. An important finding was that surgeon neck discomfort was reduced with use of VITOM alone for magnification, compared with use of loupes and VITOM. The most likely explanation for these findings is improved posture with the neck at a neutral position when viewing the VITOM images, compared with neck flexion with loupes, and thus, a less favorable ergonomic position. Conclusion: This study suggests that there may be small drawbacks associated with VITOM use initially, but these reduce with increased experience and benefit both the surgeon and the rest of the team

Late onset of necrotizing enterocolitis in the full-term infant is associated with increased mortality: Results from a two-center analysis

The effect of timing of onset of necrotizing enterocolitis (NEC) on outcomes has not been determined for the full-term infant. In this study we aimed to characterize the full-term NEC population and to evaluate onset of NEC. We performed a two-center retrospective review of all full-term infants (≥ 37weeks) with a diagnosis of NEC between 1990 and 2012. Patients were identified by ICD-9 and age. Early onset for NEC was ≤7days and late onset after 7days of life. Demographics, comorbidities, maternal factors, clinical factors, surgical intervention, complications, and mortality were evaluated. Wilcoxon’s test was performed on continuous variables and Fisher’s exact test on categorical data. A p-value<0.05 was considered significant. Univariate outcomes with a p-value<0.1 were selected for multivariable analysis. Thirty-nine patients (24 boys, 15 girls) with median EGA of 39weeks were identified. Overall mortality was 18%. Univariate predictors of mortality included congenital heart disease and placement of an umbilical artery (UA) catheter. Multivariate analysis revealed late onset of NEC to be an independent predictor of mortality (OR 90.8, 95% CI 2.6–3121). Full-term infants who develop NEC after 7days of life, have congenital heart disease, and/or need UA catheterization have increased mortality

A Study of VITOM in Pediatric Surgery and Urology: Evaluation of Technology Acceptance and Usability by Operating Team and Surgeon Musculoskeletal Discomfort.

© Copyright 2017, Mary Ann Liebert, Inc. 2017. Introduction: We studied operating team acceptability of Video Telescopic Monitor (VITOM®) exoscope by exploring the ease of use of the device in two centers. We also assessed factors affecting surgeon musculoskeletal discomfort. Methods: We focused on how the operating team interacted with the VITOM system with surrogate measures of usefulness, image quality, ease of use, workload, and setup time. Multivariable linear regression was used to model the relationships between team role, experience, and setup time. Relationships between localized musculoskeletal discomfort and use of VITOM alone, and with loupes, were also analyzed. Results: Four surgeons, 7 surgical techs, 7 circulating nurses, and 13 surgical residents performed 70 pediatric surgical and urological operations. We found that subjective views of each team member were consistently positive with 69%-74% agreed or strongly agreed that VITOM enhanced their ability to perform their job and improved the surgical process. Unexpectedly, the scrub techs and nurses perceived more value and utility of VITOM, presumably because it provides them a view of the operative field that would otherwise be unavailable to them. Team members rated perceptions of image quality highly and workload generally satisfactory. Not surprisingly, setup time decreased with team experience and multivariable modeling showed significant correlations with surgeon and surgical tech experience, but not circulating nurse. An important finding was that surgeon neck discomfort was reduced with use of VITOM alone for magnification, compared with use of loupes and VITOM. The most likely explanation for these findings is improved posture with the neck at a neutral position when viewing the VITOM images, compared with neck flexion with loupes, and thus, a less favorable ergonomic position. Conclusion: This study suggests that there may be small drawbacks associated with VITOM use initially, but these reduce with increased experience and benefit both the surgeon and the rest of the team

Late onset of necrotizing enterocolitis in the full-term infant is associated with increased mortality: Results from a two-center analysis

Purpose: The effect of timing of onset of necrotizing enterocolitis (NEC) on outcomes has not been determined for the full-term infant. In this study we aimed to characterize the full-term NEC population and to evaluate onset of NEC. Methods: We performed a two-center retrospective review of all full-term infants (≥ 37 weeks) with a diagnosis of NEC between 1990 and 2012. Patients were identified by ICD-9 and age. Early onset for NEC was ≤ 7 days and late onset after 7 days of life. Demographics, comorbidities, maternal factors, clinical factors, surgical intervention, complications, and mortality were evaluated. Wilcoxon&apos;s test was performed on continuous variables and Fisher&apos;s exact test on categorical data. A p-value b 0.05 was considered significant. Univariate outcomes with a p-value b 0.1 were selected for multivariable analysis. Results: Thirty-nine patients (24 boys, 15 girls) with median EGA of 39 weeks were identified. Overall mortality was 18%. Univariate predictors of mortality included congenital heart disease and placement of an umbilical artery (UA) catheter. Multivariate analysis revealed late onset of NEC to be an independent predictor of mortality (OR 90.8, 95% CI 2.6-3121). Conclusion: Full-term infants who develop NEC after 7 days of life, have congenital heart disease, and/or need UA catheterization have increased mortality. © 2014 Elsevier Inc. All rights reserved. The pathogenesis of necrotizing enterocolitis (NEC) in infants remains incompletely understood. Most commonly, NEC occurs in the premature infant, with less than 10% occurring in full-term neonates It is not known whether the underlying pathophysiology of NEC in the term infant is distinctly different from that in the premature infant. In addition to the frequent presence of significant co-morbidities, term infants are frequently reported to present with NEC earlier in postnatal life Methods Patient Population We performed a two-center retrospective review of all full-term infants (≥ 37 weeks) with a diagnosis of NEC between 1990 and 2012. Charts were identified by including ICD-9 codes (777.5-777.6) and were reviewed to verify diagnosis of NEC and gestational age. Term infants determined to have Bell&apos;s stage 2 or 3 NEC were included. Term infants with possible Bell&apos;s stage I NEC were excluded from analysis. Infants who had an estimated gestational age less than 37 weeks were also excluded from the study. The subject met inclusion criteria for NEC if he/she had evidence of Bell&apos;s stage II or greater and had diagnosis of NEC documented in the chart with signs and symptoms that included temperature instability, apnea, bradycardia, lethargy, pneumatosis, metabolic acidosis, peritonitis, and/or pneumoperitoneum Similar to a previous publication, early-onset NEC was defined as development of NEC during the 1st week of life (≤ 7 days) and lateonset NEC as any time after day 7 of lif