Sustainability in surgical practice: a collaborative call toward environmental sustainability in operating rooms.

BACKGROUND: The healthcare system plays a pivotal role in environmental sustainability, and the operating room (OR) significantly contributes to its overall carbon footprint. In response to this critical challenge, leading medical societies, government bodies, regulatory agencies, and industry stakeholders are taking measures to address healthcare sustainability and its impact on climate change. Healthcare now represents almost 20% of the US national economy and 8.5% of US carbon emissions. Internationally, healthcare represents 5% of global carbon emissions. US Healthcare is an outlier in both per capita cost, and per capita greenhouse gas emission, with almost twice per capita emissions compared to every other country in the world. METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic Surgery (EAES) established the Sustainability in Surgical Practice joint task force in 2023. This collaborative effort aims to actively promote education, mitigation, and innovation, steering surgical practices toward a more sustainable future. RESULTS: Several key initiatives have included a survey of members' knowledge and awareness, a scoping review of terminology, metrics, and initiatives, and deep engagement of key stakeholders. DISCUSSION: This position paper serves as a Call to Action, proposing a series of actions to catalyze and accelerate the surgical sustainability leadership needed to respond effectively to climate change, and to lead the societal transformation towards health that our times demand.

Improving equitable access for effective antibacterial: an ecosystem approach.

BACKGROUND: Antibiotics are indispensable to modern healthcare, yet their equitable access remains a pressing global challenge. Factors contributing to inequities include insufficient evidence for optimal clinical use, limited registration, pricing for Reserve antibiotics, and supply chain challenges. These issues disproportionately affect low- and middle-income countries, exacerbating antimicrobial resistance burdens. OBJECTIVES: This paper explores the multifaceted dimensions of inequitable antibiotic access and proposes a comprehensive framework to address the crisis. SOURCES: Published articles, grey literature analysis, and the authors' own expertise contributed to this article. CONTENT: While much attention has been paid to push-and-pull incentives for antibiotic development, these interventions are inadequate to reach sustainable and equitable access to antibiotics. Improving equitable antibiotic access requires an ecosystem approach, involving multiple stakeholders and including public-private partnerships. The paper advocates for initiatives spanning research and development, regulatory pathways, procurement strategies, and financing mechanisms and suggests concrete interventions in each of these areas. The specific interventions and mix of public and private actors may vary according to antibiotic, market, and health system context, but must be designed to meet public health needs while also supporting a market that will sustain quality-assured production and delivery of antibiotics. IMPLICATIONS: Addressing the challenge of equitable antibiotic access requires coordinated efforts across sectors and regions. By embracing an ecosystem approach centred on public health priorities, stakeholders can pave the way for a sustainable supply of antibiotics, and equitable access, safeguarding the future of global healthcare amidst the growing threat of antimicrobial resistance.

Ensuring progress on sustainable access to effective antibiotics at the 2024 UN General Assembly: a target-based approach.

Rising antimicrobial resistance (AMR) is a global health crisis for countries of all economic levels, alongside the broader challenge of access to antibiotics. As a result, development goals for child survival, healthy ageing, poverty reduction, and food security are at risk. Preserving antimicrobial effectiveness, a global public good, requires political will, targets, accountability frameworks, and funding. The upcoming second high-level meeting on AMR at the UN General Assembly (UNGA) in September, 2024, is evidence of political interest in addressing the problem of AMR, but action on targets, accountability, and funding, absent from the 2016 UNGA resolution, is needed. We propose ambitious yet achievable global targets for 2030 (relative to a prepandemic 2019 baseline): a 10% reduction in mortality from AMR; a 20% reduction in inappropriate human antibiotic use; and a 30% reduction in inappropriate animal antibiotic use. Given national variation in current levels of antibiotic use, these goals (termed the 10-20-30 by 2030) should be met within a framework of universal access to effective antibiotics. The WHO Access, Watch, Reserve (AWARE) system can be used to define, monitor, and evaluate appropriate levels of antibiotic use and access. Some countries should increase access to narrow-spectrum, safe, and affordable (Access) antibiotics, whereas others should discourage the inappropriate use of broader-spectrum (Watch) and last-resort (Reserve) antibiotics; AWARE targets should use a risk-based, burden-adjusted approach. Improved infection prevention and control, access to clean water and sanitation, and vaccination coverage can offset the selection effects of increased antibiotic use in low-income settings. To ensure accountability and global scientific guidance and consensus, we call for the establishment of the Independent Panel on Antimicrobial Access and Resistance and the support of leaders from low-income and middle-income countries.

SAGES White Paper on the importance of diversity in surgical leadership: creating the fundamentals of leadership development (FLD) curriculum.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has long recognized and championed increasing diversity within the surgical workplace. SAGES initiated the Fundamentals of Leadership Development (FLD) Curriculum to address these needs and to provide surgeon leaders with the necessary tools and skills to promote diversity, equity, and inclusion (DEI) in surgical practice. In 2019, the American College of Surgeons issued a request for anti-racism initiatives which lead to the partnering of the two societies. The primary goal of FLD was to create the first surgeon-focused leadership curriculum dedicated to DEI. The rationale/development of this curriculum and its evaluation/feedback methods are detailed in this White Paper. METHODS: The FLD curriculum was developed by a multidisciplinary task force that included surgeons, education experts, and diversity consultants. The curriculum development followed the Analysis, Design, Development, Implementation and Evaluation (ADDIE) instructional design model and utilized a problem-based learning approach. Competencies were identified, and specific learning objectives and assessments were developed. The implementation of the curriculum was designed to be completed in short intervals (virtual and in-person). Post-course surveys used the Kirkpatrick's model to evaluate the curriculum and provide valuable feedback. RESULTS: The curriculum consisted of interactive online modules, an online discussion forum, and small group interactive sessions focused in three key areas: (1) increasing pipeline of underrepresented individuals in surgical leadership, (2) healthcare equity, and (3) conflict negotiation. By focusing on positive action items and utilizing a problem-solving approach, the curriculum aimed to provide a framework for surgical leaders to make meaningful changes in their institutions and organizations. CONCLUSION: The FLD curriculum is a novel leadership curriculum that provided surgeon leaders with the knowledge and tools to improve diversity in three areas: pipeline improvement, healthcare equity, and conflict negotiation. Future directions include using pilot course feedback to enhance curricular effectiveness and delivery.

Age is just a number: The role of advanced age in predicting complications following ventral hernia repair with component separation.

BACKGROUND: While advanced age is often considered a risk factor for complications following abdominal surgery, its impact on outcomes after complex open ventral hernia repair (VHR) with component separation technique (CST) remains unclear. METHODS: A single-center retrospective review of patients who VHR with CST from November 2008 to January 2022 was performed and cohorts were stratified by presence of advanced age (≥60 years). RESULTS: Of 219 patients who underwent VHR with CST, 114 patients (52.1 â€‹%) were aged ≥60 years. Multivariate analysis demonstrated BMI to be an independent predictor for any complication (OR 1.1, p â€‹= â€‹0.002) and COPD was positively associated with seroma development (OR 20.1, p â€‹= â€‹0.012). Advanced age did not independently predict postoperative outcomes, including hernia recurrence (OR 0.8, p â€‹= â€‹0.766). CONCLUSIONS: VHR with CST is generally safe to perform in patients of advanced age. Every patient's comorbidity profile should be thoroughly assessed preoperatively for risk stratification regardless of age.

The Elephant in the Room: Racial Microaggressions and Implicit Bias in Surgical Training.

OBJECTIVE: The aim of this study was to examine the association between race, experience of microaggressions, and implicit bias in surgical training. BACKGROUND: There is persistent underrepresentation of specific racial and ethnic groups in the field of surgery. Prior research has demonstrated significant sex differences among those who experience microaggressions during training. However, little research has been conducted on the association between race and experiences of microaggressions and implicit bias among surgical trainees. METHODS: A 46-item survey was distributed to general surgery residents and residents of surgical subspecialties through the Association of Program Directors in Surgery listserv and social media platforms. The questions included general information/demographic data and information about experiencing, witnessing, and responding to microaggressions during surgical training. The primary outcome was the prevalence of microaggressions during surgical training by self-disclosed race. Secondary outcomes were predictors of and adverse effects of microaggressions. RESULTS: A total of 1624 resident responses were obtained. General surgery residents comprised 825 (50.8%) responses. The female-to-male ratio was nearly equal (815:809). The majority of respondents identified as non-Hispanic White (63.4%), of which 5.3% of residents identified as non-Hispanic Black, and 9.5% identified as Hispanic. Notably, 91.9% of non-Hispanic Black residents (n=79) experienced microaggressions. After adjustment for other demographics, non-Hispanic Black residents were more likely than non-Hispanic White residents to experience microaggressions [odds ratio (OR): 8.81, P <0.001]. Similar findings were observed among Asian/Pacific Islanders (OR: 5.77, P <0.001) and Hispanic residents (OR: 3.35, P <0.001). CONCLUSIONS: Race plays an important role in experiencing microaggressions and implicit bias. As the future of our specialty relies on the well-being of the pipeline, it is crucial that training programs and institutions are proactive in developing formal methods to address the bias experienced by residents.

Prospects for dog rabies elimination in Nigeria by 2030.

The attainment of the global target of zero dog-mediated human rabies by 2030 depends on functional rabies programmes. Nigeria, a rabies-endemic country, and the most populous country in Africa has a very poor rabies control strategy with a score of 1.5 out of 5 based on the Stepwise Approach towards Rabies Elimination (SARE). In this article, we report a scoping review that we conducted to highlight the strengths, weaknesses, opportunities and threats as well as situational analysis of rabies control in Nigeria and suggest a timeline for key activities that are needed to ensure zero by 30. Our findings reveal that rabies is grossly under-reported as only 998 human and 273 dog-suspected rabies cases were reported across Nigeria between 2017 and 2022. Our literature review also demonstrates a paucity of information on rabies in both human and animal health sectors. A total of 49 studies on dog rabies in Nigeria, with a predominance of reports from the North Central geopolitical region (48%, n = 23) were therefore included in this study. Currently, only 16.2% (n = 6/37) of Nigerian states have available data related to the estimated dog populations, the dog ownership rates, the vaccination status of dogs or the incidence of dog bites. Based on a dog-to-human ratio of 1:16.3, we estimated that the dog population in Nigeria was 12,969,368 (95% CI: 12,320,900-13,617,836). Thus, to attain herd immunity and dog rabies control in Nigeria, at least 9.1 million dogs must be vaccinated annually. Our review reveals that, despite the strengths and available opportunities to achieve rabies control in Nigeria by 2030, the weaknesses and challenges will make the attainment of zero by 30 very difficult or impossible. Nigeria's best-case scenario by the year 2030 is SARE stage 3-4 (control-elimination) out of 5. Otherwise, the rabies control programme might not surpass SARE stages 2-3. To attain zero by 30, Nigeria must re-strategize its current rabies control programme by funding and implementing the national strategic plan for rabies control, creating a rabies desk office in the 37 states (FCT inclusive), rigorously conducting mass vaccination campaigns, providing post-exposure prophylaxis, prioritizing mass enlightenment with a focus on responsible pet ownership and conduct baseline national rabies surveillance in the animal and human health sectors.

Outcomes of Immediate Multistaged Abdominal Wall Reconstruction of Infected Mesh: Predictors of Surgical Site Complications and Hernia Recurrence.

BACKGROUND: Mesh infection is one of the most devastating complications after ventral hernia repair. To date, no clear consensus exists on the optimal timing of definitive abdominal wall reconstruction (AWR) after excision of infected mesh. We evaluated outcomes of immediate multistaged AWR in patients with mesh infection. METHODS: We performed a retrospective review of patients with mesh infection who underwent immediate, multistaged AWR, which consisted of exploratory laparotomy with debridement and mesh explantation, followed by definitive AWR during the same admission. Primary outcomes included hernia recurrence and surgical site occurrences, defined as wound dehiscence, surgical site infection, hematoma, and seroma. RESULTS: Forty-seven patients with infected mesh were identified. At mean follow-up of 9.5 months, 5 patients (10.6%) experienced hernia recurrence. Higher body mass index (P = 0.006), bridge repair (P = 0.035), and postoperative surgical site infection (P = 0.005) were associated with hernia recurrence. CONCLUSION: Immediate multistaged AWR is an effective surgical approach in patients with infected mesh.

Strengthening coordination and collaboration of one health approach for zoonotic diseases in Africa.

Despite the One Health progress made in some African countries in addressing zoonotic disease outbreaks, many still lack formal and funded One Health programs. Countries lack diagnostic capacity for zoonotic diseases, coordinated surveillance mechanisms, multisectoral response strategies and skilled workforce. With the devasting impacts of zoonotic disease outbreaks, recent epidemics have caused a loss of lives and negatively impacted the economy. Strengthening One Health approach across African Union (AU) Member States will improve the continent's ability and capacity to efficiently prevent, detect, and respond to emerging and re-emerging zoonotic diseases. The policy and practice changes needed to address zoonotic diseases require strong political commitment, financial investments, and institutionalised national One Health programs. The African Union endorses a One Health approach in which multiple sectors work jointly to raise awareness, gather credible data, implement programs, and promote evidence-based policy and practice in improve human, animal, and environmental health. The African Union working through its technical agencies set up an interagency multidisciplinary group "the One Health Coordinating Group on Zoonotic Diseases" to strengthen coordinated surveillance, prevention and control of zoonotic diseases on the continent. There is an urgent need to strengthen the coordination of One Health activities across the African continent. The African Union will leverage its unique political position on the continent to raise awareness, secure commitments, and influence policy at the head of state level. This manuscript highlights the opportunity to improve and strengthen One Health coordination and harmonisation of efforts through a continental strategy for zoonotic disease control.

A framework to improve retention of Black surgical trainees: A Society of Black Academic Surgeons white paper.

Attrition is high among surgical trainees, and six of ten trainees consider leaving their programs, with two ultimately leaving before completion of training. Given known historically and systemically rooted biases, Black surgical trainees are at high risk of attrition during residency training. With only 4.5% of all surgical trainees identifying as Black, underrepresentation among their peers can lend to misclassification of failure to assimilate as clinical incompetence. Furthermore, the disproportionate impact of ongoing socioeconomic crisis (e.g., COVID-19 pandemic, police brutality etc.) on Black trainees and their families confers additional challenges that may exacerbate attrition rates. Thus, attrition is a significant threat to medical workforce diversity and health equity. There is urgent need for surgical programs to develop proactive approaches to address attrition and the threat to the surgical workforce. In this Society of Black Academic Surgeons (SBAS) white paper, we provide a framework that promotes an open and inclusive environment conducive to the retention of Black surgical trainees, and continued progress towards attainment of health equity for racial and ethnic minorities in the United States.

A continent-wide effort and solidarity at curbing COVID-19 pandemic: the Africa task force for novel coronavirus (AFTCOR) infection prevention and control technical working group's experience.

A continent-wide Africa Task Force for Coronavirus with its six technical working groups was formed to prepare adequately and respond to the novel Coronavirus disease (COVID-19) outbreak in Africa. This research in practice article aimed to describe how the infection prevention and control (IPC) technical working group (TWG) supported Africa Centre for Disease Control and Prevention (Africa CDC) in preparedness and response to COVID-19 on the continent. To effectively address the multifaceted IPC TWG mandate of organizing training and implementing rigorous IPC measures at healthcare service delivery points, the working group was sub-divided into four sub-groups-Guidelines, Training, Research, and Logistics. The action framework was used to describe the experiences of each subgroup. The guidelines subgroup developed 14 guidance documents and two advisories; all of which were published in English. In addition, five of these documents were translated and published in Arabic, while three others were translated and published in French and Portuguese. Challenges faced in the guidelines subgroup included the primary development of the Africa CDC website in English, and the need to revise previously issued guidelines. The training subgroup engaged the Infection Control Africa Network as technical experts to carry out in-person training of IPC focal persons and port health personnel across the African continent. Challenges faced included the difficulty in conducting face-to-face IPC training and onsite technical support due to the lockdown. The research subgroup developed an interactive COVID-19 Research Tracker on the Africa CDC website and conducted a context-based operation and implementation research. The lack of understanding of Africa CDC's capacity to lead her own research was the major challenge faced by the research subgroup. The logistics subgroup assisted African Union (AU) member states to identify their IPC supply needs through capacity building for IPC quantification. A notable challenge faced by the logistics subgroup was the initial lack of experts on IPC logistics and quantifications, which was later addressed by the recruitment of professionals. In conclusion, IPC cannot be built overnight nor can it be promoted abruptly during outbreaks of diseases. Thus, the Africa CDC should build strong national IPC programmes and support such programmes with trained and competent professionals.

Training a Continent: A Process Evaluation of Virtual Training on Infection Prevention and Control in Africa During COVID-19.

BACKGROUND: Strengthening infection prevention and control (IPC) capacity was identified as a key intervention to prepare African Union member states to curb the COVID-19 pandemic. As part of the Africa Taskforce for Coronavirus, which helped implement the Africa Joint Continental Strategy for COVID-19 Outbreak response, the IPC Technical Working Group (IPC TWG) was convened to coordinate the development of IPC core components for preparedness, response, and recovery from COVID-19. As part of the IPC TWG's work, the Africa Centres for Disease Control and Prevention, in collaboration with the Infection Control Africa Network, delivered virtual IPC training sessions targeted to African Union member states. We aimed to undertake a process evaluation of this training to inform and improve both ongoing and future programming. METHODS: The scope of the evaluation was agreed upon through discussion with the training organizers and advisory members and a design workshop. A mixed-methods approach was used; data collection was partly prospective and partly retrospective due to the rapid start of some of the training activities. Existing available data included: usage analytics, the content of questions posed during the webinar and community of practice, and participant feedback survey results. In addition, in-depth qualitative interviews were conducted with a sample of webinar participants. RESULTS: The rapid development of this training was efficient and responsive. The training reached more than 3,000 participants across the 2 rounds, but the numbers varied substantially by location. Participants engaged well during the question period during each webinar, but the asynchronous community of practice was less utilized during the evaluation time frame. Many participants appreciated the African focus of the webinars and gave positive feedback on the practical and context-specific content. CONCLUSIONS: The move toward online training provides an important opportunity to improve IPC across the African continent.

A qualitative analysis describing attrition from bariatric surgery to identify strategies for improving retention in patients who desire treatment.

BACKGROUND: Among patients who express interest in bariatric surgery, dropout rates from bariatric surgery programs are reported as high as 60%. There is a lack of understanding how we can better support patients to obtain treatment of this serious chronic disease. METHODS: Semi-structured interviews with individuals who dropped out of bariatric surgery programs from three clinical sites were conducted. Transcripts were iteratively analyzed to understand patterns clustering around codes. We mapped these codes to domains of the Theoretical Domains Framework (TDF) which will serve as the basis of future theory-based interventions. RESULTS: Twenty patients who self-identified as 60% female and 85% as non-Hispanic White were included. The results clustered around codes of "perceptions of bariatric surgery," "reasons for not undergoing surgery," and "factors for re-considering surgery." Major drivers of attrition were burden of pre-operative workup requirements, stigma against bariatric surgery, fear of surgery, and anticipated regret. The number and time for requirements led patients to lose their initial optimism about improving health. Perceptions regarding being seen as weak for choosing bariatric surgery, fear of surgery itself, and possible regret over surgery grew as time passed. These drivers mapped to four TDF domains: environmental context and resources, social role and identity, emotion, and beliefs about consequences, respectively. CONCLUSIONS: This study uses the TDF to identify areas of greatest concern for patients to be used for intervention design. This is the first step in understanding how we best support patients who express interest in bariatric surgery achieve their goals and live healthier lives.

Microaggressions and Implicit Bias in Surgical Training: An Undocumented but Pervasive Phenomenon.

OBJECTIVE: To examine the prevalence, nature, and source of microaggressions experienced by surgical residents during training. SUMMARY AND BACKGROUND DATA: The role of microaggressions in contributing to workplace culture, individual performance, and professional satisfaction has become an increasingly studied topic across various fields. Little is known about the prevalence and impact of microaggressions during surgical training. METHODS: A 46-item survey distributed to current surgical residents in training programs across the United States via the Association of Program Directors in Surgery listserv and social media platforms between January and May 2020. Survey questions explored the frequency and extent of events of experiencing, witnessing, and responding to microaggressions in the workplace. The primary outcome was the occurrence of microaggressions experienced by surgical residents. Secondary outcomes included the nature, impact, and responses to these events. RESULTS: A total of 1624 responses were collected, with an equal distribution by self-identified gender (female, n = 815; male, n = 809). The majority of trainees considered themselves heterosexual (n = 1490, 91.7%) and White (n = 1131, 69.6%). A majority (72.2%, n = 1173) of respondents reported experiencing microaggressions, most commonly from patients (64.1%), followed by staff (57.5%), faculty (45.3%), and co-residents (38.8%). Only a small proportion (n = 109, 7.0%) of residents reported these events to graduate medical education office/program director. Nearly one third (30.8%) of residents said they experienced retaliation due to reporting of micro-aggressions. CONCLUSIONS: Based on this large, national survey of general surgery and surgical subspecialty trainees, microaggressions appear to be pervasive in surgical training. Microaggressions are rarely reported to program leadership, and when reported, can result in retaliation.

Management of Incidentally Detected Gallbladder Polyps: Society of Radiologists in Ultrasound Consensus Conference Recommendations.

Gallbladder polyps (also known as polypoid lesions of the gallbladder) are a common incidental finding. The vast majority of gallbladder polyps smaller than 10 mm are not true neoplastic polyps but are benign cholesterol polyps with no inherent risk of malignancy. In addition, recent studies have shown that the overall risk of gallbladder cancer is not increased in patients with small gallbladder polyps, calling into question the rationale for frequent and prolonged follow-up of these common lesions. In 2021, a Society of Radiologists in Ultrasound, or SRU, consensus conference was convened to provide recommendations for the management of incidentally detected gallbladder polyps at US. See also the editorial by Sidhu and Rafailidis in this issue.