Publications

Injuries are a public health crisis. Neurotrauma, a specific type of injury, is a leading cause of death and disability globally, with the largest burden in low- and middle-income countries (LMICs). However, there is a lack of quality neurotrauma-specific data in LMICs, especially at the national level. Without standard criteria for what constitutes a national registry, and significant challenges frequently preventing this level of data collection, we argue that single-institution or regional databases can provide significant value for context-appropriate solutions. Although granular data for larger populations and a universal minimum dataset to enable comparison remain the gold standard, we must put progress over perfection. It is critical to engage local experts to explore available data and build effective information systems to inform solutions and serve as the foundation for quality and process improvement initiatives. Other items to consider include adequate resource allocation and leveraging of technology as we work to address the persistent but largely preventable injury pandemic.

Background

There is a large unmet children’s surgical need in low- and middle-income countries (LMICs). This study examines the impact of installing dedicated pediatric operating rooms (ORs) on surgical volume at National Hospital Abuja, a hospital in Abuja, Nigeria.

Methods

A Non-Governmental Organization installed two pediatric ORs in August 2019. We assessed changes in volume from July 2018 to September 2021 using interrupted time series analysis.

Results

Total surgical volume increased by 13 cases (p = 0.01) in 1-month post-installation, with elective operations making up 85% (p = 0.02) of cases. There was an increase in elective volume by about 1 case per month (p = 0.01) post-installation and the difference between pre-and post-trends was 1.23 cases per month (p = 0.009). The baseline volume of neonatal surgeries increased by 9 cases per month (p < 0.001) post-installation and this difference between pre- and post-trends was statistically significant (p = 0.001). Similarly, one-month post-installation, the cases classified as ASA class >2 increased by 14 (p < 0.001). There was no significant difference between pre-and post-installation mortality rate at about 2% per month.

Conclusions

There were significant changes in surgical volume after OR installation, primarily composed of elective operations, reflecting an increased capacity to address surgical backlogs and/or perform more specialized surgeries. Despite a significant increase in volume and higher ASA class, there was no significant difference in mortality. This study supports the installation of surgical infrastructure in LMICs to strengthen capacity without increasing postoperative mortality.

Introduction

Area-based social determinants of health (SDoH) associated with disparities in children’s surgical outcomes are not well understood, though some may be risk factors modifiable by public health interventions.

Methods

This retrospective cohort study investigated the effect of high social vulnerability index (SVI), defined as ≥90th percentile, on postoperative outcomes in children classified as ASA 1-2 who underwent surgery at a large institution participating in the National Surgical Quality Improvement Program (2015-2021). Primary outcome was serious postoperative complications, defined as postoperative death, unplanned re-operation, or readmission at 30 days after surgery.

Results

Among 3278 pediatric surgical procedures, 12.1% had SVI in the ≥90th percentile. Controlling for age, sex, racialization, insurance status, and language preference, serious postoperative complications were associated with high overall SVI (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.02-2.44) and high socioeconomic vulnerability (SVI theme 1, OR 1.75, 95% CI 1.03-2.98).

Conclusion

Neighborhood-level socioeconomic vulnerability is associated with worse surgical outcomes in apparently healthy children, which could serve as a target for community-based intervention.

A virtual point-of-care ultrasound (POCUS) education program was initiated to introduce handheld ultrasound technology to Georgetown Public Hospital Corporation in Guyana, a low-resource setting. We studied ultrasound competency and participant satisfaction in a cohort of 20 physicians-in-training through the urology clinic. The program consisted of a training phase, where they learned how to use the Butterfly iQ ultrasound, and a mentored implementation phase, where they applied their skills in the clinic. The assessment was through written exams and an objective structured clinical exam (OSCE). Fourteen students completed the program. The written exam scores were 3.36/5 in the training phase and 3.57/5 in the mentored implementation phase, and all students earned 100% on the OSCE. Students expressed satisfaction with the program. Our POCUS education program demonstrates the potential to teach clinical skills in low-resource settings and the value of virtual global health partnerships in advancing POCUS and minimally invasive diagnostics.

Background

While the prevalence of free, open access medical education resources for health professionals has expanded over the past 10 years, many educational resources for health care professionals are not publicly available or require fees for access. This lack of open access creates global inequities in the availability and sharing of information and may have the most significant impact on health care providers with the greatest need. The extent of open access online educational websites aimed for clinicians and trainees in anesthesiology worldwide is unknown. In this study, we aimed to identify and evaluate the quality of websites designed to provide open access educational resources for anesthesia trainees and clinicians.

Methods

A PubMed search of articles published between 2009 and 2020, and a Startpage search engine web search was conducted in May 2021 to identify websites using the following inclusion criteria: (1) contain educational content relevant for anesthesia providers or trainees, (2) offer content free of charge, and (3) are written in the English language. Websites were each scored by 2 independent reviewers using a website quality evaluation tool with previous validity evidence that was modified for anesthesia (the Anesthesia Medical Education Website Quality Evaluation Tool).

Results

Seventy-five articles and 175 websites were identified; 37 websites met inclusion criteria. The most common types of educational content contained in the websites included videos (66%, 25/37), text-based resources (51%, 19/37), podcasts (35%, 13/37), and interactive learning resources (32%, 12/37). Few websites described an editorial review process (24%, 9/37) or included opportunities for active engagement or interaction by learners (30%,11/37). Scores by tertile differed significantly across multiple domains, including disclosure of author/webmaster/website institution; description of an editorial review process; relevancy to residents, fellows, and faculty; comprehensiveness; accuracy; disclosure of content creation or revision; ease of access to information; interactivity; clear and professional presentation of information; and links to external information.

Conclusions

We found 37 open access websites for anesthesia education available on the Internet. Many of these websites may serve as a valuable resource for anesthesia clinicians looking for self-directed learning resources and for educators seeking to curate resources into thoughtfully integrated learning experiences. Ongoing efforts are needed to expand the number and improve the existing open access websites, especially with interactivity, to support the education and training of anesthesia providers in even the most resource-limited areas of the world. Our findings may provide recommendations for those educators and organizations seeking to fill this needed gap to create new high-quality educational websites.

Introduction

Global surgery efforts have significantly expanded in the last decade. While an increasing number of general surgery residents are incorporating global surgery experiences and research into their training, few resources are available for residency applicants to evaluate opportunities at programs to which they are applying.

Materials and methods

A 17-question survey of all general surgery residency program directors (PDs) was conducted by the Global Surgery Student Alliance through emails to the Association of Program Directors in Surgery listserv. PDs indicated if they wished to remain anonymous or include program information in an upcoming online database.

Results

Two hundred fifty eight general surgery PDs were emailed the survey and 45 (17%) responses were recorded. Twenty eight (62%) programs offered formal global surgery experiences for residents, including clinical rotations, research, and advocacy opportunities. Thirty one (69%) programs were developing a global health center. Forty two (93%) respondents indicated that global surgery education was an important aspect of surgical training. Barriers to global surgery participation included a lack of funding, time constraints, low faculty participation, and minimal institutional interest.

Conclusions

While most respondents felt that global surgery was important, less than two-thirds offered formal experiences. Despite the significant increase in public awareness and participation in global surgery, these numbers remain low. While this study is limited by a 17% response rate, it demonstrates that more efforts are needed to bolster training, research, and advocacy opportunities for surgical trainees and promote a global perspective on healthcare.

Importance

Cataract surgery in the US is routinely performed with anesthesia care, whereas anesthesia care for other elective, low-risk, outpatient procedures is applied more selectively.

Objective

To identify predictors of anesthesia care in Medicare beneficiaries undergoing cataract surgery and evaluate anesthesia care for cataract surgery compared with other elective, low-risk, outpatient procedures.

Design, setting, and participants

This population-based, retrospective observational cohort study included Medicare beneficiaries 66 years or older who underwent cataract surgery in 2017. The data were analyzed from August 2020 through May 2021.

Interventions (for clinical trials) or exposures (for observational studies)

Anesthesia care during elective, low-risk, outpatient procedures.

Main outcomes and measures

Prevalence of anesthesia care during cataract surgery compared with other low-risk procedures; association of anesthesia care with patient, clinician, and health system characteristics; and proportion of patients experiencing a systemic complication within 7 days of cataract surgery compared with patients undergoing other low-risk procedures.

Results

Among 36 652 cataract surgery patients, the mean (SD) age was 74.7 (6.1) years; 21 690 (59.2%) were female; 2200 (6.6%) were Black and 32 049 (87.4%) were White. Anesthesia care was more common among patients undergoing cataract surgery compared with patients undergoing other low-risk procedures (89.8% vs range of <1% to 70.2%). Neither the patient's age (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; P = .01) nor Charlson Comorbidity Index (CCI) score (CCI of ≥3: adjusted odds ratio, 1.06; 95% CI, 0.95-1.18; P = .28; reference, CCI score of 0-1) was strongly associated with anesthesia care for cataract surgery, but a model comprising a single variable identifying the ophthalmologist predicted anesthesia care with a C statistic of 0.96. Approximately 6.0% of ophthalmologists never used anesthesia care, 76.6% always used anesthesia care, and 17.4% used it for only a subset of patients. Fewer cataract surgery patients experienced systemic complications within 7 days (2833 [7.7%]), even when limited to patients of ophthalmologists who never used anesthesia care (108 [7.4%]), than patients undergoing other low-risk procedures (range, 13.2%-52.2%).

Conclusions and relevance

The results of this cohort study suggest that systemic complications occurred less frequently after cataract surgery compared with other elective, low-risk, outpatient procedures during which anesthesia care was less commonly used. Anesthesia care was not associated with patient characteristics, such as older age or worse health status, but with the ophthalmologists’ usual approach to cataract surgery sedation. The study findings suggest an opportunity to use anesthesia care more selectively in patients undergoing cataract surgery.

Background

1.7 billion of the world’s 2.2 billion children do not have access to surgical care. COVID-19 acutely exacerbated this problem; delaying or preventing presentation and access to surgical care globally. We sought to quantify the effect of COVID-19 on children requiring surgery in Uganda.

Methods

Average monthly incident, elective pediatric surgical patient volume was calculated by sampling clinic logs before and during the pandemic, and case volume was quantified by reviewing operative logbooks for all surgeries in 2020 at Mulago Hospital, Kampala. Disability-Adjusted Life Years (DALYs) resulting from untreated disease were calculated and used to estimate economic impact using three different models.

Results

Expected elective pediatric surgery cases were 956. In 2020, pediatric surgery at Mulago was limited to 46 elective cases, approximately 5% of the expected incident cases, leading to a backlog of 910 patients and a loss of 10,620.12 DALYs. The economic impact of more than 10,000 disability years in Uganda is conservatively estimated at $23 million USD with other measures estimating ~ $120 million USD.

Conclusion

The COVID-19 pandemic limited access to pediatric surgery in Uganda, making a chronic problem acutely worse, with costly consequences for the children and health system.

Background

Surgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life.

Methods

Epidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries.

Results

An estimated 314,609 (95% UI, 239,619-402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year.

Conclusions

Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.

Background

Building capacity for surgical care in low-and-middle-income countries is essential for the improvement of global health and economic growth. This study assesses in-hospital delays of surgical services at Soroti Regional Referral Hospital (SRRH), a tertiary healthcare facility in Soroti, Uganda.

Methods

A prospective general surgical database at SRRH was analyzed. Data on patient demographics, surgical characteristics, delays of care, and adverse clinical outcomes of patients seen between January 2017 and February 2020 were extracted and analyzed. Patient characteristics and surgical outcomes, for those who experienced delays in care, were compared to those who did not.

Results

Of the 1160 general surgery patients, 263 (22.3%) experienced at least one delay of care. Deficits in infrastructure, particularly lacking operating theater space, were the greatest contributor to delays (n = 192, 73.0%), followed by shortage of equipment (n = 52, 19.8%) and personnel (n = 37, 14.1%). Male sex was associated with less delays of care (OR 0.63) while undergoing emergency surgeries (OR 1.65) and abdominal surgeries (OR 1.44) were associated with more frequent delays. Delays were associated with more adverse events (10.3% vs. 5.0%), including death (4.2% vs. 1.6%). Emergency surgery, unclean wounds, and comorbidities were independent risk factors of adverse events.

Discussion

Patients at SRRH face significant delays in surgical care from deficits in infrastructure and lack of capacity for emergency surgery. Delays are associated with increased mortality and other adverse events. Investing in solutions to prevent delays is essential to improving surgical care at SRRH.

Background

Post-injection paralysis (PIP) of the sciatic nerve is an iatrogenic paralysis that occurs after an intramuscular injection, with resultant foot deformity and disability. This study investigates the epidemiology and treatment of PIP in Uganda.

Methods

Health records of pediatric patients surgically treated for PIP at the CoRSU Rehabilitation Hospital from 2013 to 2018 were retrospectively reviewed. Pre-operative demographics, perioperative management, and outcomes were coded and analyzed with descriptive statistics, chi-square for categorical variables, and linear models for continuous variables.

Results

Four-hundred and two pediatric patients underwent 491 total procedures. Eighty-three percent of reported injection indications were for febrile illness. Twenty-five percent of reported injections explicitly identified quinine as the agent. Although ten different procedures were performed, achilles tendon lengthening, triple arthrodesis, tibialis posterior and anterior tendon transfers composed 83% of all conducted surgeries. Amongst five different foot deformities, equinus and varus were most likely to undergo soft tissue and bony procedures, respectively (p=0.0223). Ninteen percent of patients received two or more surgeries. Sixty-seven percent of patients achieved a plantigrade outcome; 13.61% had not by the end of the study period; 19.3% had unreported outcomes. Those who lived further from the facility had longer times between the inciting injection and initial hospital presentation (p=0.0216) and were more likely to be lost to follow-up (p=0.0042).

Conclusion

PIP is a serious iatrogenic disability. Prevention strategies are imperative, as over 400 children required 491 total surgical procedures within just six years at one hospital in Uganda.

Objectives

Children of minority background have reduced access to surgery. This study assessed for racial/ethnic differences in surgical utilization by location.

Materials and methods

We conducted a cross-sectional analysis of U.S. children (0-17 years of age) participating in the nationally representative Medical Expenditure Panel Survey (MEPS, 2015-2018). Race/ethnicity was the variable of interest. The primary outcome variables were prevalence rates of surgery defined by location of surgical procedure (inpatient, emergency department, hospital outpatient, and office). Covariates included contextual factors that may influence access to and need for healthcare services, including age, sex, insurance status, residential geographic status, usual source of care, and parental reports of child’s physical and mental health. We employed multivariate logistic regression models to assess the relationship between outcomes and race/ethnicity.

Results

The study population included 31,024 children with an overall surgical rate of 4.8%. Adjusted odds of surgery in an ambulatory location were lower for all racial/ethnic minority groups compared to non-Hispanic White counterparts (non-Hispanic Black aOR = 0.3, 95% CI: 0.2-0.5; Hispanic aOR = 0.4, 95% CI: 0.3-0.6; non-Hispanic Asian aOR = 0.2, 95% CI 0.0-0.5 for hospital outpatient surgery; for office-based setting, non-Hispanic Black aOR = 0.4, 95% CI 0.3-0.6; Hispanic aOR = 0.5, 95% CI: 0.4-0.7; non-Hispanic Asian aOR = 0.4; 95% CI 0.3-0.7). No racial/ethnic differences were observed for surgical procedures in inpatient or emergency department locations.

Conclusions

Staggering differences exist in pediatric surgery utilization patterns by racial/ethnic background, even after adjusting for important contextual factors (income, insurance, health status). Our findings in a nationally representative dataset may suggest systemic barriers related to racial/ethnic background for the pediatric surgical population.

Introduction

Racial and ethnic minority patients continue to experience disparities in health care. It is important to understand provider-level factors that may contribute to these inequities. This study aims to evaluate the presence of implicit racial bias among pediatric orthopaedic surgeons and determine the relationship between bias and clinical decision making.

Methods

A web-based survey was distributed to 415 pediatric orthopaedic surgeons. One section measured for potential implicit racial bias using a child-race implicit association test (IAT). IAT scores were compared with US physicians and the US general population using publicly available data. Another section consisted of clinical vignettes with associated questions. For each vignette, surgeons were randomly assigned a single race-version, White or Black. Vignette questions were grouped into an opioid recommendation, management decision, or patient perception category for analysis based on subject tested. Vignette answers from surgeons with IAT scores that were concordant with their randomized vignette race-version (ie, surgeon with pro-White score assigned White vignette version) were compared with those that were discordant.

Results

IAT results were obtained from 119 surveyed surgeons (29% response rate). Overall, respondents showed a minor pro-White implicit bias ( P <0.001). Implicit bias of any strength toward either race was present among 103/119 (87%) surgeons. The proportion of pediatric orthopaedic surgeons with a strong pro-White implicit bias (29%) was greater than that of US physicians overall (21%, P =0.032) and the US general population (19%, P =0.004). No differences were found in overall opioid recommendations, management decisions, or patient perceptions between concordant and discordant groups.

Conclusion

Most of the pediatric orthopaedic surgeons surveyed demonstrated implicit racial bias on IAT testing, with a large proportion demonstrating strong pro-White bias. Despite an association between implicit bias and clinical decision making in the literature, this study observed no evidence that implicit racial bias affected the management of pediatric fractures.

Level of evidence

Level IV.

Background

Half the world’s population is at risk of catastrophic health expenditure (CHE, out-of-pocket spending of more than 10% of annual expenditure) should they require surgery. Protection against CHE is a key indicator of successful health care delivery and has been identified as a priority area by the Global Initiative for Children’s Surgery (GICS). Data specific to pediatric surgical patients is limited. This study examines the financial risks for pediatric surgical patients and their families from a provider’s perspective.

Methods

We surveyed GICS members about the existing financial protection mechanisms and estimated expenditures for their patients. Questions were structured based on the National Surgical, Obstetric and Anesthesia Planning Surgical Indicators and finalized based on multi-institutional consensus between high-income country and low-and middle-income country (LMIC) providers. Chi-squared test, Fisher’s exact test and student’s t-test were used as appropriate.

Results

Among 107 respondents, 72.4% were from low income or lower-middle income (LIC/LMIC) countries, and 55.1% were attending or consultant physicians. Families were most likely to decline surgery in LIC/LMIC due to inability to afford treatment (mean Likert = 3.77 ± 1.06). The odds of incurring CHE after children’s surgery are up to 17 times greater in LIC/LMIC (P = 0.001, unadjusted OR 17.28, 95%CI 2.13-140.02). Over 50% of families of children undergoing major surgery in these settings face CHE. An estimated 5.1% of providers in LIC/LMIC and 56.2% (P < 0.001) of providers in UMIC/HIC reported that families are able to pay for their direct medical costs with the assistance available to them and were more likely to sell assets (74.4% vs. 33.3%, P = 0.005).

Conclusion

Patients in LMICs are at greater risk for CHE and have less financial risk protection than their HIC counterparts. Given this disparity, intervention is needed to make safe surgery affordable for children worldwide.

Background

The impact of the COVID-19 pandemic on surgical care delivery in low- and middle-income countries (LMIC) has been challenging to assess due to a lack of data. This study examines the impact of COVID-19 on pediatric surgical volumes at four LMIC hospitals.

Methods

Retrospective and prospective pediatric surgical data collected at hospitals in Burkina Faso, Ecuador, Nigeria, and Zambia were reviewed from January 2019 to April 2021. Changes in surgical volume were assessed using interrupted time series analysis.

Results

6078 total operations were assessed. Before the pandemic, overall surgical volume increased by 21 cases/month (95% CI 14 to 28, p < 0.001). From March to April 2020, the total surgical volume dropped by 32%, or 110 cases (95% CI - 196 to - 24, p = 0.014). Patients during the pandemic were younger (2.7 vs. 3.3 years, p < 0.001) and healthier (ASA I 69% vs. 66%, p = 0.003). Additionally, they experienced lower rates of post-operative sepsis (0.3% vs 1.5%, p < 0.001), surgical site infections (1.3% vs 5.8%, p < 0.001), and mortality (1.6% vs 3.1%, p < 0.001).

Conclusions

During the COVID-19 pandemic, children’s surgery in LMIC saw a sharp decline in total surgical volume by a third in the month following March 2020, followed by a slow recovery afterward. Patients were healthier with better post-operative outcomes during the pandemic, implying a widening disparity gap in surgical access and exacerbating challenges in addressing the large unmet burden of pediatric surgical disease in LMICs with a need for immediate mitigation strategies.

The medical and surgical management of kidney stones is one of the most common functions of the urologist. Management choices are often nuanced, involving the decision to embark on one surgical plan among several options. As the wider medical community critically evaluates the care we provide to an increasingly diverse population, it will be important to examine patient outcomes with a particular focus on ensuring equitable care. This review examines the influence of social parameters on the care of kidney stone patients. The dearth of literature in this area warrants rigorous studies on the relationship between race as well as socioeconomic status and the management of kidney stone disease.

Background

One aim of publicly-funded health care systems is to provide equitable access to care irrespective of ability to pay. At the same time, differences in socioeconomic status (SES) are associated with health outcomes and access to care, including waiting times for surgery. In public systems where both high- and low-SES patients use the same resources, low-SES patients may be adversely impacted in surgical waiting times. The purpose of this study was to determine whether a publicly-funded health system can provide equitable access to surgical care across socioeconomic status.

Methods

Patient-level records were obtained from a comprehensive provincially-administered surgical wait time database, encompassing years 2006-2015 and 98% of Ontario hospitals. Patient SES was determined by linking postal code with the Material and Social Deprivation Index. Surgical waiting times (time in days between decision to treat and surgery) accounted for patient-initiated delays in treatment, and regression analysis considered age, SES, rurality, sex, priority level for surgical urgency (assigned by surgeons), surgical subspecialty, number of visits, and procedure year.

Results

For the 4,253,305 surgical episodes, the mean wait time was 62.3 (SD 75.4) days. Repeated measures least squares regression analysis showed the least deprived SES quintile waited 3 days longer than the most deprived quintile. Wait times dropped in the initial study period but then increased. The proportion of procedures exceeding wait time access targets remained low at 11-13%.

Conclusions

The least deprived SES quintile waited the longest, although the absolute difference was small. This study demonstrates that publicly-funded healthcare systems can provide equitable access to surgical care across SES.

Purpose of review

Although recent census demonstrates that women comprise 50.8% and ethnic minority groups collectively consist of 42.1% of the US population, the field of anesthesiology still demonstrates disparity in representation and health outcomes across race, ethnicity, and gender. In addition, the growing percentage of people that identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ) compounded with limited representation among providers of their care can augment existing disparate outcomes within this community.

Recent findings

Compared to male colleagues, women physicians across all specialties have a decreased likelihood of professorship as well as equitable pay and leadership roles. Additionally, a 2019 study of anesthesia residents across race and ethnicity within the Accreditation Council for Graduate Medical Education established that whites were 58.9%, Asians were 24.7%, Hispanics were 7.8%, Blacks were 5.9%, multiracial groups were 3.8%, and Native Americans were 0.3% of the total 6272 residents. In a survey of members of the American Society of Anesthesiologists, self-identification as part of the sexual and gender minoritycommunity was independently associated with an increased risk of burnout. Furthermore, teams with higher diversity in cognitive styles solve problems more efficiently.

Summary

To achieve an optimized quality of healthcare, anesthesiologists and other providers should be a reflection of the communities they serve, including women, people of color, and LGBTQ. In this way, there is an increased likelihood of empathy, effective communication, and insightful perspectives on how to bridge the gap in health equity. A diverse lens is essential to ensure grassroots efforts lead to lasting transformational change.

Background

As surgical access expands in low- and middle-income countries, risk-adjusted outcomes data are needed to measure and improve surgical quality. Existing data collection tools in high-income countries are complex and may be burdensome to implement in low and middle income countries. This study determined the minimum dataset needed for adequate risk adjustment to predict perioperative mortality using data collected in a low- and middle-income countries.

Methods

All patients admitted to the pediatric surgery ward at Mulago National Referral Hospital in Kampala, Uganda, from January 1, 2014 through December 31, 2018 were included. Studies were performed modelling the effects of reducing data granularity and reducing number of variables on the area under the receiver operating curve.

Results

Of the 3,194 patients included, 1,941(61%) were male, 957(30%) were neonates, 1,714 (54%) had an operation, and the overall mortality rate was 14%. Granularity reduction analyses found that measuring age in ranges was equivalent to recording age in days (area under the receiver operating curve = 0.776; 95% confidence interval, 0.754%-0.798%, vs 0.815, 95% confidence interval, 0.794%-0.837%). Variable reduction analyses found that models with 3 predictor variables (diagnosis, procedure, and district) reached a maximum area under the receiver operating curve of 0.915 (95% confidence interval, 0.903%-0.928%), which was equivalent to the model using all available predictor variables (area under the receiver operating curve = 0.932; 95% confidence interval, 0.922%-0.943%). For all 3-variable models, the primary diagnosis contributed most to predictive ability (P < .001).

Conclusion

Effective risk adjustment for perioperative mortality can be performed in low and middle income countries using minimal, objective variables often already part of the patient’s medical record. This approach can be used by clinicians, hospital administrators, and policymakers low- and middle-income countries looking to begin data collection to track and improve patient outcomes.

The rapid pace of the COVID-19 pandemic precluded traditional approaches to evaluating clinical research and guidelines. We highlight notable successes and pitfalls of clinicians’ new approaches to managing evidence amidst an unprecedented crisis. In “Era 1” (early 2020), clinicians relied on anecdote and social media, which democratized conversations on guidelines, but also led clinicians astray. “Era 2” (approximately late 2020 to early 2021) saw preprints that accelerated new interventions but suffered from a surfeit of poor-quality data. In the current era, clinicians consolidate the evidentiary gains of Era 2 with living, online clinical guidelines, but the public suffers from misinformation. The COVID-19 pandemic is a laboratory on how clinicians adapt to an absence of clinical guidance amidst an informational and healthcare crisis. Challenges remain as we integrate new approaches to innovations made in the traditional guideline process to confront both the long tail of COVID-19 and future pandemics.

It has long been known that many pulse oximeters function less accurately in patients with darker skin. Reasons for this observation are incompletely characterized and potentially enabled by limitations in existing regulatory oversight. Based on decades of experience and unpublished data, we believe it is feasible to fully characterize, in the public domain, the factors that contribute to missing clinically important hypoxemia in patients with darkly pigmented skin. Here we propose 5 priority areas of inquiry for the research community and actionable changes to current regulations that will help improve oximeter accuracy. We propose that leading regulatory agencies should immediately modify standards for measuring accuracy and precision of oximeter performance, analyzing and reporting performance outliers, diversifying study subject pools, thoughtfully defining skin pigmentation, reporting data transparently, and accounting for performance during low-perfusion states. These changes will help reduce bias in pulse oximeter performance and improve access to safe oximeters.

The Earth’s mean surface temperature is already approximately 1.1°C higher than pre-industrial levels. Exceeding a mean 1.5°C rise by 2050 will make global adaptation to the consequences of climate change less possible. To protect public health, anaesthesia providers need to reduce the contribution their practice makes to global warming. We convened a Working Group of 45 anaesthesia providers with a recognised interest in sustainability, and used a three-stage modified Delphi consensus process to agree on principles of environmentally sustainable anaesthesia that are achievable worldwide. The Working Group agreed on the following three important underlying statements: patient safety should not be compromised by sustainable anaesthetic practices; high-, middle- and low-income countries should support each other appropriately in delivering sustainable healthcare (including anaesthesia); and healthcare systems should be mandated to reduce their contribution to global warming. We set out seven fundamental principles to guide anaesthesia providers in the move to environmentally sustainable practice, including: choice of medications and equipment; minimising waste and overuse of resources; and addressing environmental sustainability in anaesthetists’ education, research, quality improvement and local healthcare leadership activities. These changes are achievable with minimal material resource and financial investment, and should undergo re-evaluation and updates as better evidence is published. This paper discusses each principle individually, and directs readers towards further important references.