Motivators and barriers to general surgery as a career among junior doctors and medical students in New Zealand.

AIM: Increasing diversity among surgeons is a priority of the Royal Australasian College of Surgeons (RACS).1 This study aimed to identify motivators and barriers to general surgery among junior doctors (JD) and medical students (MS) to help guide the recruitment of under-represented minorities into surgical training. METHODS: An online survey was sent to 2,170 participants-1,327 JD in New Zealand and 843 MS at The University of Auckland (UA). Participants were asked about motivators or barriers to a career in general surgery. RESULTS: Twenty-one percent (452/2170) completed the survey. Most were female (65.1%), NZ European (53.6%) and MS (62.4%). Factors guiding career decision include interest in clinical and practical aspects (weighted average 4.43 and 4.34, respectively) and work-life balance (weighted average 4.11). Barriers to training were long hours and feeling overwhelmed (weighted average 4.05 and 3.64, respectively). There were perceived biases with 79.7% reporting a gender bias and 99.7% reporting male over-representation. Similarly, 68.4% reported an ethnicity bias; 97% reporting NZ European over-representation. 92.2% considered mentorship important but only 15.3% have a mentor. CONCLUSION: This study identified motivators and barriers to general surgery and perceived gender and ethnicity biases. With demand for a diverse surgical workforce, there should be focus on recruitment of underrepresented minorities and mentorship.

Prevalence of pretreatment HIV drug resistance in key populations: a systematic review and meta-analysis.

INTRODUCTION: WHO's 2019 report on HIV drug resistance (HIVDR) documents a high prevalence of pretreatment drug resistance (PDR) among populations initiating first-line antiretroviral therapy (ART) in low- and middle-income countries (LMIC). However, systematic evidence on the prevalence of PDR among key populations remains limited. We performed a systematic review to characterize levels of PDR in key population groups and compared them to levels of PDR in the "general population" across different geographical regions. METHODS: Ten electronic databases were searched for papers published until February 2019 that included predefined search terms. We included studies that reported the number of successfully tested genotypes and the number of genotypes with drug resistance mutations among antiretroviral therapy treatment naïve people, recently infected people, or people initiating first-line ART from key populations. To assess the prevalence of PDR for each key population, we pooled estimates using random-effects meta-analysis of proportions. Where possible, we computed the differences in the odds of PDR (any, and by drug class) present in each key population compared to the "general population". The I2 statistic (a measure of heterogeneity between studies) is reported. RESULTS AND DISCUSSION: A total of 332 datasets (from 218 studies) and 63,111 people with successful HIVDR genotyping were included in the analysis. The pooled prevalence estimate of any PDR was high among men who have sex with men (13.0%, 95% CI 11.0 to 14.0%, I2  = 93.19), sex workers (17.0%, 95% CI 6.0 - 32.0, I2  = 87.31%) and people in prisons (18.0%, 95% CI 11.0 to 25.0, I2  = 70.18%), but less so among people who inject drugs (7.0%, 95% CI 5.0 to 10.0, I2  = 90.23). Overall, men who have sex with men were more likely to carry any PDR compared to the "general population," a finding which was statistically significant (odds ratio (OR) 1.28, 95% CI 1.13 - 1.46, I2 48.9%). CONCLUSIONS: High prevalence of PDR found in key populations highlights the need to increase access to effective first-line HIV treatment. The low prevalence of nucleotide reverse transcriptase inhibitor (NRTI) PDR suggests that current WHO recommendations for pre-exposure prophylaxis (PrEP) regimens will remain effective and can be scaled up to prevent new HIV infections in high-risk groups.

COVID-19 lockdown impact on common general surgical acute presentations to a regional centre in New Zealand.

AIM: New Zealand's stated goal of eradicating COVID-19 included the enforcement of a national lockdown. During this time, a perceived decrease in hospital presentations nationwide was noted. This was also the experience of the Department of General Surgery, Bay of Plenty District Health Board (BOPDHB). We sought to quantify this reduction by analysing the frequency and severity of three common acute general surgical presentations; appendicitis, cholecystitis and diverticulitis. METHODS: Data on presentations of patients with appendicitis, cholecystitis and diverticulitis were retrospectively collected for the national lockdown period (25 March 2020-27 April 2020) and the immediate pre-lockdown period (21 February 2020-25 March 2020). Data collected included patient demographics, duration of symptoms, method of diagnosis, treatment, severity of disease, length of stay and complications. RESULTS: A reduction of 62.2% was noted in the frequency of appendicitis during the lockdown period compared to the pre-lockdown period. Patients presented later during lockdown and had a higher complication rate (5.4% versus 42.8%). Similarly, a 39.2% reduction in presentations of cholecystitis during lockdown was found. The lockdown group of patients had a longer length of stay (6.9 versus 4 days) and only one patient (9.1%, 1/11) was managed with laparoscopic cholecystectomy during the lockdown period, compared to 52.9% of patients (9/17) over the pre-lockdown period. No difference in frequency or severity of acute diverticulitis presentations between the two periods was found. CONCLUSIONS: The COVID-19 lockdown led to fewer presentations, but these were often delayed, with more complications and a longer length of stay. This could be partly explained by patient fear around exposure to the virus and reluctance to attend hospital. More research is needed to study the flow-on effects of the COVID-19 lockdown on surgical presentations.

Ingested bread clip as an unexpected diagnostic tool.

We describe a case where a bread clip has in fact became lodged adjacent to a portion of small bowel affected by a deposit of previously undiagnosed metastatic serous carcinoma of likely ovarian origin.