Correction: Academic global surgical competencies: A modified Delphi consensus study

[This corrects the article DOI: 10.1371/journal.pgph.0002102.].

Academic global surgical competencies: A modified Delphi consensus study

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Global Surgery at the National Landscape: Perspectives after the XXXIV Brazilian Congress of Surgery

The XXXIV Brazilian Congress of Surgery included Global Surgery for the first time in its scientific program. Global Surgery is any action in research, clinical practice, and policy-making that aims to improve access and quality of care in surgical specialties. In 2015, The Lancet Commission on Global Surgery highlighted that five billion people lack safe, timely, and affordable surgical care. Even more critical, nine of ten people cannot access essential surgical care in low and middle-income countries, where a third of the worldwide population resides, and only 6% of global surgical procedures are performed. Although Brazilian researchers and institutions have been contributing to lay the movement's foundations since 2014, Global Surgery remains a barely debated subject in the country. It is urgent to expand the field and break paradigms regarding the surgeons' role in public health in Brazil. Accomplishing these standards requires a joint effort to strategically allocate resources and identify collaboration opportunities, including those from medical societies and regulatory bodies. As members of the International Student Surgical Network of Brazil - a nonprofit organization by and for students, residents, and young physicians focused on Global Surgery - we review why investing in surgery is cost-effective to strengthen health systems, reduce morbimortality, and lead to economic development. Additionally, we highlight and propose key recommendations to foster the field at the national level.

Women Representation in Surgical Specialties: Reflections about Gender Equity after the 34th Brazilian Surgical Conference

In September 2021, the 34th Brazilian Surgical Conference hosted the "Panel: Women in Surgery" - the only session in the event solely composed of female speakers. Although gender inequities in surgery are well recognized in the international literature, the panel portrayed how distant we are from the desired equity in our country. In addition, the session emphasized the need to broaden the debate and identify the mechanisms for greater inclusion and maintenance of women in the surgical career. In this editorial, we provide a historical overview of gender disparities in the Brazilian surgical ecosystem, highlight the contributing factors to a reduced number of female surgeons, and how the structure of medical societies may influence the rise of women to leadership positions. Accordingly, we discuss the benefits of gender diversity for surgeons, patients, and institutions. Furthermore, we analyze the representation of women in the Brazilian College of Surgeons since its foundation and in the scientific sessions at the conference, demonstrating that more initiatives are required to encourage female representation in the college. Finally, we propose a series of recommendations to foster engagement and contribute to the prosperity of women surgeons in Brazil.

Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study

Background

The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care.

Methods

Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil's Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state.

Findings

Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog.

Interpretation

Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

Assessment of diagnostics capacity in hospitals providing surgical care in two Latin American states

BACKGROUND

Diagnostic services are an essential component of high-quality surgical, anesthesia and obstetric (SAO) care. Efforts to scale up SAO care in Latin America have often overlooked diagnostics capacity. This study aims to analyze the capacity of diagnostic services, including radiology, pathology, and laboratory medicine, in hospitals providing SAO care in the states of Chiapas, Mexico and Amazonas, Brazil.

METHODS

A stratified cross-sectional evaluation of diagnostic capacity in hospitals performing surgery in Chiapas and Amazonas was performed using the Surgical Assessment Tool (SAT). National data sources were queried for indicators of diagnostics capacity in terms of workforce, infrastructure and diagnosis utilization. Fisher's exact tests and chi-square tests were used to compare categorical variables between the private and public sector in Chiapas while descriptive statistics are used to compare Amazonas and Chiapas.

FINDINGS

In Chiapas, 53% (n = 17) of public and 34% (n = 20) of private hospitals providing SAO care were assessed. More private hospitals than public hospitals could always provide x-rays (35% vs 23.5%) and ultrasound (85% vs 47.1%). However neither sector could consistently perform basic laboratory testing such as complete blood counts (70.6% public, 65% private). In Amazonas, 30% (n = 18) of rural hospitals were surveyed. Most had functioning x-ray machine (77.8%) and ultrasound (55.6%). The majority of hospitals could provide complete blood count (66.7%) but only one hospital (5.6%) could always perform an infectious panel. Both Chiapas and Amazonas had dramatically fewer diagnostic practitioners per capita in each state compared to the national average capacity.

INTERPRETATION

Facilities providing SAO care in low-resource states in Mexico and Brazil often lack functioning diagnostics services and workforce. Scale-up of diagnostic services is essential to improve SAO care and should occur with emphasis on equitable and adequate resource allocation.

Cross-sectional study of surgical quality with a novel evidence-based tool for low-resource settings

BACKGROUND

Adverse events from surgical care are a major cause of death and disability, particularly in low-and-middle-income countries. Metrics for quality of surgical care developed in high-income settings are resource-intensive and inappropriate in most lower resource settings. The purpose of this study was to apply and assess the feasibility of a new tool to measure surgical quality in resource-constrained settings.

METHODS

This is a cross-sectional study of surgical quality using a novel evidence-based tool for quality measurement in low-resource settings. The tool was adapted for use at a tertiary hospital in Amazonas, Brazil resulting in 14 metrics of quality of care. Nine metrics were collected prospectively during a 4-week period, while five were collected retrospectively from the hospital administrative data and operating room logbooks.

RESULTS

183 surgeries were observed, 125 patient questionnaires were administered and patient charts for 1 year were reviewed. All metrics were successfully collected. The study site met the proposed targets for timely process (7 hours from admission to surgery) and effective outcome (3% readmission rate). Other indicators results were equitable structure (1.1 median patient income to catchment population) and equitable outcome (2.5% at risk of catastrophic expenditure), safe outcome (2.6% perioperative mortality rate) and effective structure (fully qualified surgeon present 98% of cases).

CONCLUSION

It is feasible to apply a novel surgical quality measurement tool in resource-limited settings. Prospective collection of all metrics integrated within existing hospital structures is recommended. Further applications of the tool will allow the metrics and targets to be refined and weighted to better guide surgical quality improvement measures.

Mid-term post-fire losses of nitrogen and phosphorus by overland flow in two contrasting eucalypt stands in north-central Portugal

Wildfires affect vast areas of Mediterranean forests, thereby triggering changes in hydrological and geomorphological processes that can negatively affect both terrestrial and aquatic ecosystems. Although several studies have evaluated the post-fire hydrological and erosive response in burnt forest areas, an important knowledge gap remains with respect to nutrient mobilization by overland flow. To address this gap, a recently burnt area was selected near the Ermida village (north-central Portugal). The study area was instrumented shortly after a wildfire that occurred in July 2010, to evaluate the export of dissolved (nitrate - NO₃-N and orthophosphate - PO₄-P) and total nitrogen (TN) and phosphorus (TP) forms by overland flow. This was done in two burnt eucalyptus plantations due to their contrasting slope aspects (south-east vs. north-west). Bounded micro-plots were installed in August 2010 and monitored over two years. During this period, overland flow samples were collected on a 1- to 2-weekly basis, depending on the occurrence of rain. Results showed that the north west-facing slope (BE-N) presented higher nutrient losses than the south east-facing slope (BE-S), contradicting the findings of previous studies in the Mediterranean region. A logging operation that had taken place at the BE-N site shortly before the fire might account for these findings, by causing soil compaction and/or reducing the protective vegetation and litter cover. TN and TP exports were particularly pronounced during the first four months following the wildfire. After this initial period, further peaks in TN and TP exports occurred sporadically, mainly associated to intense rainfall events. The observed mid-term post-fire nutrient losses not only suggested a threat to the soil nutrient balance of Mediterranean eucalypt forests but also a potential risk of eutrophication of downstream water bodies.

Surgical quality indicators in low-resource settings: A new evidence-based tool

BACKGROUND

Worldwide efforts to improve access to surgical care must be accompanied by improvements in the quality of surgical care; however, these efforts are contingent on the ability to measure quality. This report describes a novel, evidence-based tool to measure quality of surgical care in low-resource settings.

METHODS

We defined a widely applicable, multidimensional conceptual framework for quality. The suitability of currently available quality metrics to low-resource settings was evaluated. Then we developed new indicators with sufficient supportive evidence to complete the framework. The complete set of metrics was condensed into four collection sources and tools.

RESULTS

The following 15 final evidence-based indicators were defined: (1) Safe structure: morbidity and mortality conference; (2) safe process: use of the safe surgery checklist; (3) (4) safe outcomes: perioperative mortality rate and proportion of cases with complications graded >2 on the Clavien-Dindo scale; (5) effective structure: provider density; (6) effective process: procedure rate; (7) effective outcome: rate of caesarean sections; (8) patient-centered process: use of informed consent; (9) patient-centered outcome: patient hospital satisfaction questionnaire; (10) timely structure: travel time to hospital; (11) timely process: time from emergency department presentation to non-elective abdominal surgery; (12) timely outcome: patient follow-up plan; (13) efficient process: daily operating room usage; (14) equitable outcome: comparative income of patients compared with population; and (15) proportion of patients facing catastrophic expenditure because of surgical care.

CONCLUSION

This tool provides an evidence-based conceptual tool to assess the quality of surgical care in diverse low-resource settings.

Short-term nitrogen losses by overland flow in a recently burnt forest area in north-central Portugal: A study at micro-plot scale

Over the past decades, wildfires have affected extensive areas of the Mediterranean region with negative impacts on the environment. Most of the studies on fire-affected areas have focused on sediment losses by overland flow, whereas few have addressed post-fire nutrient export. The present study aimed to address this research gap by assessing nitrogen (nitrate and total nitrogen) losses by overland flow in a recently burnt area in north-central Portugal. To this end, three burnt slopes were selected for their contrasting forest types (eucalypt vs. pine) and parent materials (granite vs. schist). The selected study sites were a eucalypt site on granite (BEG), a eucalypt site on schist (BES) and a maritime pine site on schist (BPS). Overland flow samples were collected during the first six months after the wildfire on a 1- to 2-weekly basis, after which this study had to be cancelled due to bench terracing of some of the sites. A peak in total nitrogen concentrations was observed in burnt areas immediately after the first post-fire rainfall event as a response to the erosion of the N-enriched ash layer. After this initial peak, smaller peaks were observed throughout the study period, mainly as a response to overland flow and/or erosion events. Nitrogen export differed strikingly between the two types of forests on schist, being higher at the eucalypt than at the pine site, due to the lack of a protective soil layer. Parent material did not play an important role on nitrogen export by overland flow since no significant differences were found between the eucalypt sites on granite and schist. The present study provides some insight into the differences in post-fire soil fertility losses between forest types and parent materials in the Mediterranean region, which is crucial information for defining post-fire land management measures to reduce soil degradation.

Short-time phosphorus losses by overland flow in burnt pine and eucalypt plantations in north-central Portugal: A study at micro-plot scale

Over the past decades, wildfires have affected vast areas of Mediterranean ecosystems leading to a variety of negative on- and off-site environmental impacts. Research on fire-affected areas has given more attention to sediment losses by fire-enhanced overland flow than to nutrient exports, especially in the Mediterranean region. To address this knowledge gap for post-fire losses of phosphorus (P) by overland flow, a recently burnt forest area in north-central Portugal was selected and instrumented immediately after a wildfire. Three slopes were selected for their contrasting forest types (eucalypt vs. pine) and parent materials (granite vs. schist). The selected study sites were a eucalypt site on granite (BEG), a eucalypt site on schist (BES) and a maritime pine site on schist (BPS). Micro-plots were monitored over a period of six months, i.e. till the construction of terraces for reforestation obliged to the removal of the plots. During this 6-month period, overland flow samples were collected at 1- to 2-weekly intervals, depending on rainfall. Total P and PO4-P losses differed markedly between the two types of forests on schist, being lower at the pine site than at the eucalypt site, probably due to the presence of a protective layer of pine needle cast. Parent material did not play an important role in PO4-P losses by overland flow but it did in TP losses, with significantly lower values at the eucalypt site on granite than that on schist. These differences in TP losses can be attributed to the coarser texture of granite soils, typically promoting infiltration and decreasing runoff. The present findings provided further insights into the spatial and temporal patterns of post-fire soil nutrient losses in fire-prone forest types during the initial stages of the window-of-disturbance, which can be useful for defining post-fire emergency measures to reduce the risk of soil fertility losses.

Cation export by overland flow in a recently burnt forest area in north-central Portugal

The current fire regime in the Mediterranean Basin constitutes a serious threat to natural ecosystems because it drastically enhances surface runoff and soil erosion in the affected areas. Besides soil particles themselves, soil cations can be lost by fire-enhanced overland flow, increasing the risk of fertility loss of the typically shallow and nutrient poor Mediterranean soils. Although the importance of cations for land-use sustainability is widely recognized, cation losses by post-fire runoff have received little research attention. The present study aimed to address this research gap by assessing total exports of Na(+), K(+), Ca(2+) and Mg(2+) in a recently burnt forest area in north-central Portugal. These exports were compared for two types of planted forest (eucalypt vs. maritime pine plantations), two types of parent materials (schist vs. granite) and for two spatial scales (micro-plot vs. hill slope). The study sites were a eucalypt plantation on granite (BEG), a eucalypt plantation on schist (BES) and a maritime pine plantation on schist (BPS). Overland flow samples were collected during the first six months after the wildfire. Cation losses differed strikingly between the two forest types on schist, being higher at the eucalypt than pine site. This difference was evident at both spatial scales, and probably due to the extensive cover of a needle cast from the scorched pine crowns. The role of parent material in cation export was less straightforward as it varied with spatial scale. Cation losses were higher for the eucalypt plantation on schist than for that on granite at the micro-plot scale, whereas the reverse was observed at the hill slope scale. Finally, cation yields were higher at the micro-plot than slope scale, in agreement with the general notion of scaling-effect in runoff generation.

Characterization of superparamagnetic iron oxide coated with silicone used as contrast agent for magnetic resonance image for the gastrointestinal tract

The present work is a report of the characterization of superparamagnetic iron oxide nanoparticles coated with silicone used as a contrast agent in magnetic resonance imaging of the gastrointestinal tract. The hydrodynamic size of the contrast agent is 281.2 nm, where it was determined by transmission electron microscopy and a Fe3O4 crystalline structure was identified by X-ray diffraction, also confirmed by Mössbauer Spectroscopy. The blocking temperature of 190 K was determined from magnetic measurements based on the Zero Field Cooled and Field Cooled methods. The hysteresis loops were measured at different temperatures below and above the blocking temperature. Ferromagnetic resonance analysis indicated the superparamagnetic nature of the nanoparticles and a strong temperature dependence of the peak-to-peak linewidth deltaH(pp), giromagnetic factor g, number of spins N(s) and relaxation time T2 were observed. This behavior can be attributed to an increase in the superexchange interaction.

The water quality of the Cértima River basin (Central Portugal)

The aim of this study was to evaluate the water quality of the Cértima River basin (Central Portugal). For that purpose, surface water samples were collected in March, May and July 2003, at 10 selected sampling sites, and were analysed for physicochemical parameters, namely temperature, conductivity, pH, total suspended solids, dissolved oxygen, biochemical oxygen demand (BOD(5)), Kjeldahl nitrogen and total phosphorus. Results revealed an acceptable water quality during the spring season. Maxima of 64 mg dm(-3) for BOD(5), 39 mg dm(-3) for Kjeldahl nitrogen, and 5.2 mg dm(-3) for total phosphorus, were recorded during summer, indicating a significant degradation of the water quality in a river stretch located downstream of the town of Mealhada. These values, which did not comply with the objectives of minimum quality for surface waters prescribed by the Portuguese legislation, were related to domestic wastewater discharges and runoff waters from a cattle farm. Besides their effects on the middle stretch of the river, these pollution sources were the most likely cause of the high nutrient load in downstream waters, and thus may have a major impact on the trophic status of Pateira de Fermentelos, a sensitive wetland area located in the lower Cértima basin.