Practical and Ethical Guidelines for the Involvement of Trainees in Global Surgery: Consensus Statement and Recommendations from the Resident and Associate Society of the American College of Surgeons Global Surgery Work Group.

BACKGROUND: The guidelines provided by US professional surgical organizations for involvement of trainees in global surgery are limited. The aim of this consensus statement is to provide surgical trainees with official recommendations from the Resident and Associate Society of the American College of Surgeons Global Surgery Work Group (GSWG) regarding professional, practical, and ethical guidelines for participation in global surgery endeavors. STUDY DESIGN: A task force was created within the GSWG to review and define the scope of involvement of trainees in global surgery, and a consensus process was undertaken for the group at large to approve a set of proposed guidelines. RESULTS: The list of practical and ethical guidelines for the engagement of trainees in global surgery covering the themes of preparedness, reciprocity and collaboration, ethical considerations, and sustainability was approved with consensus from the GSWG. CONCLUSIONS: This consensus statement from the Resident and Associate Society of the American College of Surgeons GSWG outlines the official recommendations for guidelines for involvement of trainees in global surgery, with an aim to support equitable, sustainable collaborations that center on improving access to safe, timely, and affordable surgical care for the global community at large. Future processes seek to involve representation and perspectives from a larger body of low- to middle-income country surgical trainees.

Patient understanding regarding opioid use in an orthopaedic trauma surgery population: a survey study.

BACKGROUND: Prior studies have assessed provider knowledge and factors associated with opioid misuse; similar studies evaluating patient knowledge are lacking. The purpose of this study was to assess the degree of understanding regarding opioid use in orthopaedic trauma patients. We also sought to determine the demographic factors and clinical and personal experiences associated with level of understanding. METHODS: One hundred and sixty-six adult orthopaedic trauma surgery patients across two clinical sites of an academic institution participated in an internet-based survey (2352 invited, 7.1% response rate). Demographic, clinical, and personal experience variables, as well as perceptions surrounding opioid use were collected. Relationships between patient characteristics and opioid perceptions were identified using univariate and multivariable logistic regressions. Alpha = 0.05. RESULTS: Excellent recognition (> 85% correct) of common opioids, side effects, withdrawal symptoms, and disposal methods was demonstrated by 29%, 10%, 30%, and 2.4% of patients; poor recognition (< 55%) by 11%, 56%, 33%, and 52% of patients, respectively. Compared with white patients, non-white patients had 7.8 times greater odds (95% confidence interval [CI] 1.9-31) of perceiving addiction discrepancy (p = 0.004). Employed patients with higher education levels were less likely to have excellent understanding of side effects (adjusted odds ratio [aOR] 0.06, 95% CI 0.006-0.56; p = 0.01) and to understand that dependence can occur within 2 weeks (aOR 0.28, 95% CI 0.09-0.86; p = 0.03) than unemployed patients. Patients in the second least disadvantaged ADI quartile were more knowledgeable about side effects (aOR 8.8, 95% CI 1.7-46) and withdrawal symptoms (aOR 2.7, 95% CI 1.0-7.2; p = 0.046) than those in the least disadvantaged quartile. Patients who knew someone who was dependent or overdosed on opioids were less likely to perceive addiction discrepancy (aOR 0.24, 95% CI 0.07-0.76; p = 0.02) as well as more likely to have excellent knowledge of withdrawal symptoms (aOR 2.6, 95% CI 1.1-6.5, p = 0.03) and to understand that dependence can develop within 2 weeks (aOR 3.8, 95% CI 1.5-9.8, p = 0.005). CONCLUSIONS: Level of understanding regarding opioid use is low among orthopaedic trauma surgery patients. Clinical and personal experiences with opioids, in addition to demographics, should be emphasized in the clinical history.

United in earnest: First pilot sites for increased surgical capacity for rheumatic heart disease announced by Cardiac Surgery Intersociety Alliance.

BACKGROUND: Rheumatic heart disease affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration on Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for rheumatic heart disease patients. METHODS: As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance was formed, the purpose of this article is to describe the history of the Cardiac Surgery Intersociety Alliance, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites. RESULTS: The Cardiac Surgery Intersociety Alliance is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for Cardiac Surgery Intersociety Alliance support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda). CONCLUSIONS: Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the Cardiac Surgery Intersociety Alliance, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for rheumatic heart disease patients.

Theory-Based Development of an Implementation Intervention Using Community Health Workers to Increase Palliative Care Use.

CONTEXT: Opportunities for the use of palliative care services are missed in African American (AA) communities, despite Level I evidence demonstrating their benefits. OBJECTIVES: Single-institution and stakeholder-engaged study to design an intervention to increase palliative care use in AA communities. METHODS: Two-phased qualitative research design guided by the Behavior Change Wheel and Theoretical Domains Framework models. In Phase 1, focus group sessions were conducted to identify barriers and facilitators of palliative care use and the viability of community health workers (CHWs) as a solution. After applying the Behavior Change Wheel and Theoretical Domains Framework to data gathered from Phase 1, Phase 2 consisted of a stakeholder meeting to select intervention content and prioritize modes of delivery. RESULTS: A total of 15 stakeholders participated in our study. Target behaviors identified were for patients to gain knowledge about benefits of palliative care, physicians to begin palliative care discussions earlier in treatment, and to improve patient-physician interpersonal communication. The intervention was designed to improve patient capability, physician capability, patient motivation, physician motivation, and increase patient opportunities to use palliative care services. Strategies to change patient and physician behaviors were all facilitated by CHWs and included creation and dissemination of brochures about palliative care to patients, empowerment and activation of patients to initiate goals-of-care discussions, outreach to community churches, and expanding patient social support. CONCLUSION: Use of a theory-based approach to facilitate the implementation of a multi-component strategy provided a comprehensive means of identifying relevant barriers and enablers of CHWs as an agent to increase palliative care use in AA communities.

Missed psychosocial risk factors during routine preoperative evaluations are associated with increased complications after elective cancer surgery.

BACKGROUND: Certain behavioral traits and inadequate social support are known risk factors for complications after cancer surgery. Despite their importance, it is unclear whether conventional patient preoperative evaluation captures them. This study was conducted to assess concordance between documentation and patient survey of selected risk factors and to determine whether failure to document affected postoperative outcomes. METHODS: Adult patients at a tertiary academic medical center were surveyed before abdominal cancer surgery to assess 6 psychosocial risk factors. Risk factors were also assessed by retrospective chart review and compared with survey results through concordance measures. Thirty-day postoperative complications were abstracted by chart review. Rates of major complications for those with and without clinically missed risk factors were compared. RESULTS: Comparisons between chart review and screening survey revealed poor-to-moderate positive agreement (0%-47%) for 5 risk factors and strong negative agreement (82%-99%) among all risk factors. Kappa analysis demonstrated poor-to-fair agreement among 5 risk factors (κ = 0.112-0.423). The overall complication rate was 36%. The complication rate for patients with at least 1 clinically missed risk factor was 49% vs 24% in those without (P = .021), with a similar effect replicated for each individual risk factor. CONCLUSION: This study shows a high level of discordance between formal screening and routine clinician documentation in a preoperative setting for psychosocial risk factors. There is a significant association between missing these risk factors and worse postoperative outcomes. Future work should examine whether structured screening of psychosocial risk factors may improve preoperative risk stratification through proactive interventions.

Psychosocial Risks are Independently Associated with Cancer Surgery Outcomes in Medically Comorbid Patients.

BACKGROUND: The specific effect of psychosocial risk factors on surgical outcomes in cancer patients remains unexplored. The purpose of this prospective observational study was to assess the association of preoperative psychosocial risk factors and 30-day complications following cancer surgery. METHODS: Psychosocial risks among elective gastrointestinal cancer surgery patients were ascertained through structured interviews using well-established screening forms. We then collected postoperative course by chart review. Multivariable analysis of short-term surgical outcomes was performed in those with a low versus high number of psychosocial risks. RESULTS: Overall, 142 patients had a median age of 65 years (interquartile range 55-71), 55.9% were male, and 23.1% were non-White. More than half (58.2%) of the study population underwent a resection for a hepato-pancreato-biliary primary tumor, and 31.9% had a colorectal primary tumor. High-risk biomedical comorbidities were present in 43.5% of patients, and three-quarters of patients (73.4%) had at least one psychosocial risk. Complication rates in patients with at least one psychosocial risk were 28.0 absolute percentage points higher than those with no psychosocial risks (54.4% vs. 26.2%, p = 0.039). Multiple psychosocial risk factors in medically comorbid patients independently conferred an increase in the odds of a complication by 3.37-fold (95% CI 1.08-10.48, p = 0.036) compared with those who had one or no psychosocial risks. CONCLUSIONS: We demonstrated a more than threefold odds of a complication in medically comorbid patients with multiple psychosocial risks. These findings support the use of psychosocial risks in preoperative assessment and consideration for inclusion in preoperative optimization efforts.

Palliative Care Utilization among Patients Admitted for Gastrointestinal and Thoracic Cancers.

BACKGROUND: Although a growing body of literature recommends the early initiation of palliative care (PC), the use of PC remains variable. OBJECTIVE: The current study sought to describe the use of PC and to identify factors associated with the use of inpatient PC. DESIGN: Retrospective, cross-sectional analysis of data from the National Inpatient Sample. SETTING AND SUBJECTS: Patients admitted with a primary diagnosis of gastrointestinal and/or thoracic cancer from 2012 to 2013. MEASUREMENTS: In-hospital length of stay (LOS), morbidity, mortality, and total charges. RESULTS: A total of 282,899 patients were identified who met inclusion criteria of whom, 24,100 (8.5%) patients received a PC consultation during their inpatient admission. Patients who received PC were more likely to have a longer LOS (LOS >14 days: 5.4% vs. 9.4%) and were more likely to develop a postoperative complication (28.3% vs. 45.9%, both p < 0.001). Inpatient mortality was significantly higher among patients who had received PC than those who did not (5.4% vs. 44.1%, p < 0.001). On multivariable analysis, patient age (age ≥75 years: Odds Ratio [OR] = 2.54, 95% CI: 2.33-2.78), comorbidity (CCI >6: OR = 2.60, 95% CI: 2.48-2.74), and admission to larger hospitals (reference small: OR = 1.20, 95% CI: 1.14-1.25) were associated with greater odds of receiving PC (all p < 0.05). Patients who underwent a major operation during their inpatient admission demonstrated 79% lower odds of receiving PC (OR = 0.21, 95% CI: 0.20-0.22, p < 0.001). CONCLUSIONS: Among patients admitted for cancer, PC services were used in 8.5% of patients during their inpatient admission with surgical patients being 79% less likely to receive a PC consultation. Further research is required to delineate the barriers to the use of PC so as to promote the use of PC among high-risk patients.

Sunlight-driven photochemical halogenation of dissolved organic matter in seawater: a natural abiotic source of organobromine and organoiodine.

Reactions of dissolved organic matter (DOM) with photochemically generated reactive halogen species (RHS) may represent an important natural source of organohalogens within surface seawaters. However, investigation of such processes has been limited by difficulties in quantifying low dissolved organohalogen concentrations in the presence of background inorganic halides. In this work, sequential solid phase extraction (SPE) and silver-form cation exchange filtration were utilized to desalt and preconcentrate seawater DOM prior to nonspecific organohalogen analysis by ICP-MS. Using this approach, native organobromine and organoiodine contents were found to range from 3.2-6.4 × 10(-4) mol Br/mol C and 1.1-3.8 × 10(-4) mol I/mol C (or 19-160 nmol Br L(-1) and 6-36 nmol I L(-1)) within a wide variety of natural seawater samples, compared with 0.6-1.2 × 10(-4) mol Br/mol C and 0.6-1.1 × 10(-5) mol I/mol C in terrestrial natural organic matter (NOM) isolates. Together with a chemical probe method specific for RHS, the SPE+ICP-MS approach was also employed to demonstrate formation of nanomolar levels of organobromine and organoiodine during simulated and natural solar irradiation of DOM in artificial and natural seawaters. In a typical experiment, the organobromine content of 2.1 × 10(-4) mol C L(-1) (2.5 mg C L(-1)) of Suwannee River NOM in artificial seawater increased by 69% (from 5.9 × 10(-5) to 1.0 × 10(-4) mol Br/mol C) during exposure to 24 h of simulated sunlight. Increasing I(-) concentrations (up to 2.0 × 10(-7) mol L(-1)) promoted increases of up to 460% in organoiodine content (from 8.5 × 10(-6) to 4.8 × 10(-5) mol I/mol C) at the expense of organobromine formation under the same conditions. The results reported herein suggest that sunlight-driven reactions of RHS with DOM may play a significant role in marine bromine and iodine cycling.