Strategies to improve clinical research in surgery through international collaboration

Best Practices for Developing International Academic Partnerships in Orthopaedics

ABSTRACT

Traumatic and nontraumatic orthopaedic conditions are major contributors to global morbidity and account for the majority of life-years lived with disability worldwide. Additionally, the burden of musculoskeletal injuries has increased substantially over the past 3 decades. Unfortunately, in low and middle-income countries (LMICs), access to orthopaedic care is limited, leading to a disproportionate burden of disease. The Lancet Commission on Global Surgery has emphasized the urgent need for unified international commitment and research collaboration to achieve universal access to safe and affordable surgical care. However, conducting high-quality orthopaedic research in LMICs remains challenging as a result of disparities in training, access to resources, infrastructure, and equipment availability. Partnerships between high-income countries (HICs) and LMICs have emerged in recent decades as an effective approach to combatting some of these challenges. These partnerships aim to bridge the gaps by facilitating collaborative research and knowledge exchange. The establishment of successful partnerships requires a collaborative and reciprocal approach that starts with a clear understanding of mutual research aims and the availability of resources. Despite the potential benefits, various factors can make establishing such partnerships difficult. However, these partnerships can have a substantial impact in delivering quality orthopaedic education and research training, thus improving access to care in resource-limited environments. This paper represents the collaborative effort of multiple international academic orthopaedic surgeons with extensive experience in HIC-LMIC partnerships. Our aims were to outline the best practices for conducting orthopaedic research within these relationships and to provide guidance for future successful collaborations.

Health Research Collaborations by Academic Entities: A Systematic Review

PURPOSE

To review the literature on health research collaborations by academic entities and to identify the main phases, components, and concepts of these research collaborations.

METHOD

The authors conducted a systematic review of the literature, searching 4 databases in March 2022 for studies on health research collaboration between an academic entity (individual, group, or institution) and any other entity included. They excluded non-health-related studies and studies in which collaboration was not for the purpose of research. From included studies, reviewers abstracted data about the 4 main phases of research collaborations (initiation, conduct, monitoring, and evaluation) and synthesized their corresponding components and concepts using thematic analysis method.

RESULTS

A total of 59 studies met inclusion criteria. These studies described building research collaborations between an academic entity and other academic entities (n = 29; 49%), communities (n = 28; 47%), industry (n = 7; 12%), and/or governmental entities (n = 4; 7%). Of the 59 studies, 22 addressed 2 phases of collaboration, 20 addressed 3 phases, and 17 addressed all 4 phases. All included studies described at least 1 of the components relevant to the initiation phase and at least 1 relevant to the conduct phase. Team structure was the most common component discussed in relation to the initiation phase (n = 48; 81%), and team dynamics was the most common component discussed in relation to the conduct phase (n = 55; 93%). At least 1 of the components relevant to the monitoring phase was reported in 36 studies, and at least 1 component relevant to the evaluation phase was reported in 28 studies.

CONCLUSIONS

This review provides important information for groups aiming to engage in collaborative research. The synthesized list of collaboration phases and their components can serve as a road map for collaborators at different steps of their research.

Middle East Authors' Contribution to the Journal of Arthroplasty’s Publications in the Past 20 years (2000–2020)

Background

Methods

Results

Conclusion

Diversity in Plastic Surgery Authorship: A 14-Year Analysis of 2688 Articles Published in Plastic and Reconstructive Surgery

BACKGROUND

Publication in peer-reviewed journals is a duty and privilege. It is essential to the advancement of evidence-based medicine and often used as a proxy for academic achievement, contributing to decisions around promotion in academia. Within plastic surgery, authors have historically been male surgeons affiliated with academic institutions, lacking representation of women, private practice, medical students, and international collaboration. This study analyzes differences in authors' gender, practice affiliation, degree of education, and international collaboration in articles published in Plastic and Reconstructive Surgery, which was chosen as the representative journal given its high impact factor (3.946) and consistent ranking as the number one journal in plastic surgery worldwide.

METHODS

A list of Breast, Cosmetic, and Hand/Peripheral Nerve articles published between 2006 and 2019 was compiled from the online archive of Plastic and Reconstructive Surgery. Demographic author characteristics were recorded, and statistical analyses were performed to identify trends over time.

RESULTS

A total of 2688 articles were analyzed. The proportion of articles written by female authors in the Breast category, authors in private practice with academic affiliation in the Cosmetic section, and U.S. collaboration with other countries increased over time (p = 0.038, p = 0.029, p < 0.001, respectively). First authors with bachelor's, master's, and doctorate degrees have also been contributing increasingly.

CONCLUSIONS

This analysis revealed increasing demographic heterogeneity of authors in Plastic and Reconstructive Surgery over time, with increasing contributions from women, surgeons in private practice with academic affiliation, medical students, and international collaborations. The Journal is capturing contributions from an increasingly diverse authorship, consistent with the changing demographics of plastic surgeons.

Current status and future perspectives of collaboration in surgical research: A scoping review of the evidence

BACKGROUND

Surgery is rapidly changing in terms of techniques, education, and methods of conducting research. To keep up with this pace, surgeons have recently focused on collaborative research projects. The aim of this review was to investigate practices for collaborations in surgical research.

METHODS

A scoping review was conducted according to the guidelines proposed by Peters et al. Publications on patterns of collaboration in surgical research between January 2000 and December 2020, irrespective of the study design or language of publication, which were indexed in PubMed, the Cochrane Library, and Google Scholar, were included. A research librarian assisted in choosing the search terms and conducting the search. The very broad nature of the subject necessitated a pragmatic search strategy, with primary focus on reviews about collaboration. A new form of crowd science was used that explored collaborations using social media and online shared documents.

RESULTS

The search identified 38 studies that covered different aspects of collaboration in surgical research. Global, specialist, trainee-/student-led, and patient-led collaboratives are growing in number and size. Implementation of information technologies in surgical collaboration is still limited. The review identified attempts to include researchers from low- and middle-income countries in these collaborations, but these were at the early stages.

CONCLUSION

There are many patterns of collaboration in surgical research. Involvement of low- and middle-income countries will lead to capacity building in these countries, fast recruitment for surgical trials, and more generalizability of trial results. Due to the complex nature of surgical research, implementation of information technologies might improve the quality of research.

Citation classics: the 50 most cited articles in surgery in Asia

Objective: The term ‘citation classics’ is used for highly cited papers in the scientific literature. It was aimed to understand the current landscape of academic surgery and the quality of the scientific contribution of authors belonging to Asia using citation classics.

Material and Methods: We searched the WoS core collection database under the category ‘surgery’ to include the 50 most cited articles whose lead author was affiliated to an Asian country during the research period. We noted the following characteristics for each article: total citations, average cita- tions per year, year of publication, publishing journal, institution and country, journal quartile and impact factor, authorship, field of surgical research. Results were analyzed using IBM SPSS Statistics v26.

Results: The number of citations ranged from 447 to 1170 (mean +/- SD is 616.9 +/- 150.16) and citations per year ranged from 10.04 to 98.17 (mean +/- SD is 30.87 +/- 17.27). Most productive decade was 1991-2000 (n= 19 articles). Majority of the articles were published in ‘Annals of Surgery’ (28%). Four authors contributed two or more articles as lead author with ‘Poon RTP’ taking the lead. Japan’s contribution was highest (60%) followed by China and its dependents’ (26%). University of Hong Kong was the leading institution (n= 7). Observational study was the most commonly used design (n= 24). Most papers belonged to gastrointestinal surgery (n= 28) and surgical oncology (n= 26). 66% articles originated from a single institution, 22% had inter-institutional collaboration and 12% had national collaboration from countries outside Asia.

Conclusion: The study identified the most influential papers in surgery from Asia. This should provoke interest in academic surgery and research col- laboration with other nations in Asia and the rest of the world.

Exploring new uses for existing drugs: innovative mechanisms to fund independent clinical research

BACKGROUND

Finding new therapeutic uses for existing medicines could lead to safe, affordable and timely new treatment options for patients with high medical needs. However, due to a lack of economic incentives, pharmaceutical developers are rarely interested to invest in research with approved medicines, especially when they are out of basic patent or regulatory protection. Consequently, potential new uses for these medicines are mainly studied in independent clinical trials initiated and led by researchers from academia, research institutes, or collaborative groups. Yet, additional financial support is needed to conduct expensive phase III clinical trials to confirm the results from exploratory research.

METHODS

In this study, scientific and grey literature was searched to identify and evaluate new mechanisms for funding clinical trials with repurposed medicines. Semi-structured interviews were conducted with 16 European stakeholders with expertise in clinical research, funding mechanisms and/or drug repurposing between November 2018 and February 2019 to consider the future perspectives of applying new funding mechanisms.

RESULTS

Traditional grant funding awarded by government and philanthropic organisations or companies is well known and widely implemented in all research fields. In contrast, only little research has focused on the application potential of newer mechanisms to fund independent clinical research, such as social impact bonds, crowdfunding or public-private partnerships. Interviewees stated that there is a substantial need for additional financial support in health research, especially in areas where there is limited commercial interest. However, the implementation of new funding mechanisms is facing several practical and financial challenges, such as a lack of expertise and guidelines, high transaction costs and difficulties to measure health outcomes. Furthermore, interviewees highlighted the need for increased collaboration and centralisation at a European and international level to make clinical research more efficient and reduce the need for additional funding.

CONCLUSIONS

New funding mechanisms to support clinical research may become more important in the future but the unresolved issues identified in the current study warrant further exploration.

Disparities Among Leading Publishers of Arthroplasty Research

BACKGROUND

Despite the importance of diversity in advancing scientific progress, diversity among leading authors in arthroplasty has not been examined. This study aimed to identify, characterize, and assess disparities among leading authors in arthroplasty literature from 2002 to 2019.

METHODS

Articles published between 2002 and 2019 from 12 academic journals that publish orthopedic and arthroplasty research were extracted from PubMed. Original articles containing keywords related to arthroplasty were analyzed. Author gender was assigned using the Genderize algorithm. Gender and characterization of the top 100 male and female authors utilized available information on academic profiles.

RESULTS

From the 14,692 articles that met inclusion criteria, the genders of 23,626 unique authors were identified. Women were less likely than men to publish 5 years after beginning their publishing careers (adjusted odds ratio 0.51, 95% confidence interval 0.45-0.57, P < .001). Of the top 100 authors, 96 were men, while only 4 were women. Orthopedic surgeons made up 93 of 100 top authors, of which 92 were men and 1 was a woman. Among the top 10 publishing female and male authors, 10 of 10 men were orthopedic surgeons, only 2 of 10 women were physicians, and only one was an attending orthopedic surgeon.

CONCLUSION

While the majority of authors with high arthroplasty publication volume were orthopedic surgeons, there were significant gender disparities among the leading researchers. We should continue working to increase gender representation and supporting the research careers of women in arthroplasty.

Global Research on Maxillofacial Fracture Over the Last 40 Years: A Bibliometric Study

ABSTRACT

Maxillofacial injuries are widely investigated worldwide as it consists a significant portion of trauma patients. Many researchers from various regions have reported the clinical and statistical analyses of maxillofacial fractures (MFFs) as the statistical data of MMFs are of great importance for both effective control and prevention of these cases. The number of studies concerning the diagnosis and treatment modalities of MFFs has significantly increased over the years. The bibliometric method was used to analyze publication outputs, countries, journals, most citations, and trends. In this study, the bibliometric analysis method was used in the publications related to MFFs published between 1980 and 2019, which were Science Citation Index Expanded indexed in the Web of Science database. Bibliometric analysis is applied to evaluate existing data in an evidence-based manner. The highest number of scientific articles on MFFs came from the USA, which was also the most cited country among others. When the distribution of the words in abstracts and titles by years was examined, it was seen that there was a significant change in the words "navigation," "computer," and "technology" between 2009 and 2012. The authors predict that our study would provide a novel perspective to the studies about MFFs and contribute to the researchers about the limits of the topic, and being aware of the active journals that publish the papers on this issue would facilitate the work of the researchers.

Recruitment patterns in a large international randomized controlled trial of perioperative care in cancer patients

INTRODUCTION

The Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) randomized controlled trial (RCT) was the first study to prospectively enroll and randomize orthopedic oncology patients in multiple centers internationally. The objective of this study was to describe recruitment patterns, to examine the differences in enrollment across different PARITY sites, and to identify variables associated with differing levels of recruitment.

METHODS

Data from this study was obtained from the PARITY trial Methods Center and records of correspondence between the Methods Center and recruiting sites. We performed descriptive statistics to report the recruitment patterns over time. We compared recruitment, time to set up, and time to enroll the first patient between North American and international sites, private and public healthcare models, and the presence or absence of research personnel. Two-tailed non-paired t tests were performed to test average monthly recruitment rates between groups.

RESULTS

A total of 602 patients from 36 North American and 12 international sites were recruited from 2013 to 2019. North American sites were able to become fully enrollment-ready at an average of 19.5 months and international sites at an average of 27 months. Once enrolling, international sites were able to enroll 0.59 patients per/month whereas North American sites averaged a monthly recruitment rate of 0.2 patients/month once enrolling. Sites with research personnel reached enrollment-ready status at an average of 19.3 months and sites without research support at an average of 30.3 months. Once enrolling, the recruitment rate was 0.28 patients/month and 0.2 patients per month for sites with and without research support, respectively. Publicly funded sites had a monthly enrollment of 0.4 patients/month whereas privately funded sites had a monthly enrollment rate of 0.17 patients/month.

CONCLUSIONS

As a collaborative group, the PARITY investigators increased the pace of recruitment throughout the trial, likely by increasing the number of active sites. The longer time to start-up at international sites may be due to the complex governing regulations of pharmaceutical trials. Nevertheless, international sites should be considered essential as they recruited significantly more patients per month once active. The absence of research support personnel may lead to delays in the time to start-up. The results of the current study will provide guidance for choosing which sites to recruit for participation in future collaborative clinical trials in orthopedic oncology and other surgical specialties.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01479283 . Prospectively registered on November 24, 2011.

Latin American Research on Bariatric Surgery: a Bibliometric Study

We performed a bibliometric analysis of Latin American documents published between 1984 to 2019 in Scopus-indexed journals. A total of 1856 documents were analyzed. The annual scientific production was 64 documents per year, with an annual increase rate of 15.9%. The countries with the highest scientific production on BS were Brazil (64.7%) and Chile (14.5%). Most of the publications were original (76.6%) and review articles (11.9%). The journal with the highest publication record was "Obesity Surgery" (25.8%). The extra-regional collaboration was mainly with the USA. In conclusion, Latin American scientific production on BS has shown a significant increase in recent years. However, more participation is needed, fostering intra-regional collaboration and involving universities and health institutions in BS research.

Surgical Innovation in the Era of Global Surgery: A Network Analysis

OBJECTIVE

To present a novel network-based framework for the study of collaboration in surgery and demonstrate how this can be used in practice to help build and nurture collaborations that foster innovation.

BACKGROUND

Surgical innovation is a social process that originates from complex interactions among diverse participants. This has led to the emergence of numerous surgical collaboration networks. What is still needed is a rigorous investigation of these networks and of the relative benefits of various collaboration structures for research and innovation.

METHODS

Network analysis of the real-world innovation network in robotic surgery. Hierarchical mixed-effect models were estimated to assess associations between network measures, research impact and innovation, controlling for the geographical diversity of collaborators, institutional categories, and whether collaborators belonged to industry or academia.

RESULTS

The network comprised of 1700 organizations and 6000 links. The ability to reach many others along few steps in the network (closeness centrality), forging a geographically diverse international profile (network entropy), and collaboration with industry were all shown to be positively associated with research impact and innovation. Closed structures (clustering coefficient), in which collaborators also collaborate with each other, were found to have a negative association with innovation (P < 0.05 for all associations).

CONCLUSIONS

In the era of global surgery and increasing complexity of surgical innovation, this study highlights the importance of establishing open networks spanning geographical boundaries. Network analysis offers a valuable framework for assisting surgeons in their efforts to forge and sustain collaborations with the highest potential of maximizing innovation and patient care.

Investing in Pediatric Surgical Research to Advance Universal Health Coverage for Children in Nigeria

About 1.7 billion children and adolescents most of whom are in low- and middle-income countries lack access to safe and affordable surgical and anesthesia care when needed. 43% of Nigeria's population of 199 million are below the age of 15 years. In 2015, Nigeria had a pediatric surgeon workforce deficit of 693 for children <15 years. While threats and constraints to achieving universal health coverage in Nigeria have been highlighted, the role of research is often not included. Over the years, there has been a slow but progressive increase in pediatric surgical workforce and research output, both locally and with international collaborations, and in trainee involvement in research as lead authors. There has unfortunately been a challenge with translation of research findings, outcomes, and recommendations into actions. Despite the various challenges mitigating against pediatric surgery research, efforts must be committed to developing and implementing innovative approaches to address the problems and challenges, as well as implementing quality improvement programs and deploying technology to advance children's care. It is hoped that inclusion of children's surgery in the National Surgical, Obstetrics, Anaesthesia, and Nursing Plan would strengthen pediatric surgical research in Nigeria.

Challenges of international oncology trial collaboration-a call to action

International collaboration in oncology trials has the potential to enhance clinical trial activity by expediting the recruitment of large patient populations, testing treatments in diverse populations and facilitating the study of rare tumours or specific molecular subtypes. However, a number of challenges continue to hinder the efficient and productive conduct of both commercial and non-commercial international clinical trials. These challenges include complex and burdensome regulatory requirements, the high cost of conducting trials, and logistical challenges associated with ethics review, drug supply and biospecimen collection and management. We propose solutions to promote oncology trial collaboration, such as regulatory reform, harmonisation of trial initiation and management processes and greater recognition and funding of academic (non-commercial) clinical trials. It is only through coordinated effort and leadership from researchers, regulators and those responsible for health systems that the full potential of international trial collaboration can be realised.

Differences and Similarities in Diabetes Research between China and the USA

Diabetes mellitus is one of the major non-communicable diseases (NCD) with increasing prevalence in China. There is a lack of high-quality research focusing on prevention and management of diabetes in low and middle income countries (LMICs) compared to developed countries. This comparative study aims to describe the characteristics of diabetes research conducted in China and the USA. The study included 800 studies on diabetes mellitus from both countries. Compared with studies in the USA, studies in China were more likely to be laboratory-based primary research (50.5% versus 30.8%), more likely to use animal subjects (47% versus 27.5%), more likely to focused on risk factors (22.7% versus. 14.7%), more likely to be case-controlled studies (17.7% versus 10.0%), and more likely to evaluate pharmacological treatments (36.5% versus 20.7%). Further, compared with studies in the USA, studies in China were less likely to involve patients (42.7% versus 60.7%), less likely to be clinical trials (6.2% versus 14.5%), less likely to be cohort studies (8.8% versus. 26.0%), and less likely to evaluate disease management interventions (3.3% versus 13.3%). Clinical studies in China should be more patient-based to facilitate more effective control and management of diabetes.

Systematic review of management of incidental gallbladder cancer after cholecystectomy

BACKGROUND

Gallbladder cancer is rare, but cancers detected incidentally after cholecystectomy are increasing. The aim of this study was to review the available data for current best practice for optimal management of incidental gallbladder cancer.

METHODS

A systematic PubMed search of the English literature to May 2018 was conducted.

RESULTS

The search identified 12 systematic reviews and meta-analyses, in addition to several consensus reports, multi-institutional series and national audits. Some 0·25-0·89 per cent of all cholecystectomy specimens had incidental gallbladder cancer on pathological examination. Most patients were staged with pT2 (about half) or pT1 (about one-third) cancers. Patients with cancers confined to the mucosa (T1a or less) had 5-year survival rates of up to 100 per cent after cholecystectomy alone. For cancers invading the muscle layer of the gallbladder wall (T1b or above), reresection is recommended. The type, extent and timing of reresection remain controversial. Observation time may be used for new cross-sectional imaging with CT and MRI. Perforation at initial surgery had a higher risk of disease dissemination. Gallbladder cancers are PET-avid, and PET may detect residual disease and thus prevent unnecessary surgery. Routine laparoscopic staging before reresection is not warranted for all stages. Risk of peritoneal carcinomatosis increases with each T category. The incidence of port-site metastases is about 10 per cent. Routine resection of port sites has no effect on survival. Adjuvant chemotherapy is poorly documented and probably underused.

CONCLUSION

Management of incidental gallbladder cancer continues to evolve, with more refined suggestions for subgroups at risk and a selective approach to reresection.

Evaluating the collection, comparability and findings of six global surgery indicators

Background

In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the indicators, and to present available data and updated estimates.

Methods

Nationally representative data were compiled for all World Health Organization (WHO) member states from 2010 to 2016 through contacts with official bodies and review of the published and grey literature, and available databases. Availability, comparability and utility were assessed for each indicator: access to timely essential surgery, specialist surgical workforce density, surgical volume, perioperative mortality, and protection against impoverishing and catastrophic expenditure. Where feasible, imputation models were developed to generate global estimates.

Results

Of all WHO member states, 19 had data on the proportion of the population within 2h of a surgical facility, 154 had data on workforce density, 72 reported number of procedures, and nine had perioperative mortality data, but none could report data on catastrophic or impoverishing expenditure. Comparability and utility were variable, and largely dependent on different definitions used. There were sufficient data to estimate that worldwide, in 2015, there were 2 038 947 (i.q.r. 1 884 916–2 281 776) surgeons, obstetricians and anaesthetists, and 266·1 (95 per cent c.i. 220·1 to 344·4) million operations performed.

Conclusion

Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution.

Global Inequities in Precision Medicine and Molecular Cancer Research

Precision medicine based upon molecular testing is heralded as a revolution in how cancer is prevented, diagnosed, and treated. Large efforts across the world aim to conduct comprehensive molecular profiling of disease to inform preclinical models, translational research studies and clinical trials. However, most studies have only been performed in patients from high-income countries. As the burden on non-communicable diseases increases, cancer will become a pressing burden across the world, disproportionately affecting low-middle income settings. There is emerging evidence that the molecular landscape of disease differs geographically and by genetic ancestry, which cannot be explained by environmental factors alone. There is a lack of good quality evidence that characterises the molecular landscape of cancers found in low-middle income countries. As cancer medicine becomes increasingly driven by molecular alterations in high-income settings, low-income settings may become left behind. Further efforts on an international scale must be made by researchers, funders, and policymakers to ensure cancer research addresses disease across the world, so models are not limited to subtypes of disease found in high-income countries. In this review, we discuss differences found in the molecular profiles of tumours worldwide and the implication this has for the future of global cancer care. Finally, we identify several barriers currently limiting progress in this field and innovative solutions, which may address these shortcomings.

Predictors of morbidity and mortality post emergency abdominal surgery: A national study

BACKGROUND/AIM

Emergency surgeries have increased in Saudi Arabia. This study examines these surgeries and associated complications.

PATIENTS AND METHODS

This was a prospective multicenter cohort study of patients undergoing emergency intraperitoneal surgery from the eight health sectors of Saudi Arabia. Patients' data were collected over 14 days.

RESULTS

In total, 283 patients were included (163 men [54.06%]). The majority of cases were open surgery (204 vs. 79). The 24 h and 30-day mortality rates for the cohort were 0.7 and 2.47%, respectively. Twenty-nine patients (10.24%) required re-intervention, while 19 (8.12%) needed critical care admission. The median length of hospital stay was 3 days. Multivariate analysis showed American Society of Anesthesiologist (ASA) classification score (P = 0.0003), diagnosis (P < 0.0001), stoma formation (P = 0.0123), and anastomotic leak (P = 0.0015) to correlate significantly with 30-day mortality.

CONCLUSION

American Society of Anesthesiologist score, diagnosis, stoma formation and anastomotic leak are associated with 30-day mortality after emergency surgery in Saudi Arabia.

Frequency of equivocation in surgical meta-evidence: a review of systematic reviews within IBD literature

OBJECTIVE

To assess the level of equivocation among level 1 evidence in ulcerative colitis and Crohn's disease and determine whether any predisposing factors are present.

METHOD

MEDLINE, Embase, CINHAL and Cochrane were searched from 2006 to 2017. Papers were scored using AMSTAR and categorised into surgical (S), medical (M) or medical and surgical (MS) groups. The ability of each paper to make a recommendation and conclusiveness in doing so was recorded.

RESULTS

278 papers were assessed. 82% (n=227) could make a recommendation, 18% (n=51) could not. There was a significant difference in ability to provide a recommendation between S and M (P=0.003) but not MS and M (P=0.022) nor S and MS (P=0.79). Where a recommendation was made, S papers were more likely to be tempered than M papers (P=0.014) but not MS papers (P=0.987).

CONCLUSIONS

Surgical meta-evidence within the inflammatory bowel disease domain is more than twice as likely as medical meta-evidence to be unable to provide a recommendation for clinical practice. Where a recommendation was made, surgical reviews were twice as likely to temper their conclusion.

Visiting scholarships in cardio-thoracic surgery: a valuable experience for fostering collaboration

Visiting scholarships to other institutions have a rich history in medicine and are an exciting opportunity to exchange ideas, learn new clinical techniques and form collaborative relationships for research advancements. Such experiences are also important in fostering a well-rounded surgical education. In this article we reflect on the valuable nature of international collaboration and provide a few guidelines to optimize the experience.

The Outcomes and Patterns of Treatment Failure After Surgery for Locally Recurrent Rectal Cancer. Ann Surg. 2016;264:323-329. [PMID: 26692078 DOI: 10.1097/sla.0000000000001524]

OBJECTIVE

To assess the outcomes and patterns of treatment failure of patients who underwent pelvic exenteration surgery for recurrent rectal cancer.

BACKGROUND

Despite advances in the management of rectal cancer, local recurrence still occurs. For appropriately selected patients, pelvic exenteration surgery can achieve long-term disease control.

METHODS

Prospectively maintained databases of 5 high volume institutions for pelvic exenteration surgery were reviewed and data combined. We assessed the combined endpoints of overall 5-year survival, cancer-specific 5-year mortality, local recurrence, and the development of metastatic disease.

RESULTS

Five hundred thirty-three patients who had undergone surgery for locally recurrent rectal cancer were identified. Five-year cancer-specific survival for patients with a complete (R0) resection is 44%, which was achieved in 59% of patients. For those with R1 and R2 resections, the 5-year survival was 26% and 10%, respectively. Radical resection required sacrectomy in 170 patients (32%), and total cystectomy in 105 patients (20%). Treatment failure included local recurrence alone in 75 patients (14%) and systemic metastases with or without local recurrence in 226 patients (42%). Chemoradiotherapy before exenteration was associated with a significant (P < 0.05) improvement in overall 5-year cancer-specific survival for those patients with an R0 resection. Postoperative chemotherapy did not alter outcomes.

CONCLUSIONS

R0 resection of the pelvic recurrence is the most significant factor affecting overall and disease-free survival. The surgery is complex and often highly morbid, and where possible patients should be given perioperative chemoradiotherapy. Further investigations are required to determine the role of adjuvant chemotherapy.

Barriers and facilitators experienced in collaborative prospective research in orthopaedic oncology: A qualitative study

Objectives

As tumours of bone and soft tissue are rare, multicentre prospective collaboration is essential for meaningful research and evidence-based advances in patient care. The aim of this study was to identify barriers and facilitators encountered in large-scale collaborative research by orthopaedic oncological surgeons involved or interested in prospective multicentre collaboration.

Methods

All surgeons who were involved, or had expressed an interest, in the ongoing Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) trial were invited to participate in a focus group to discuss their experiences with collaborative research in this area. The discussion was digitally recorded, transcribed and anonymised. The transcript was analysed qualitatively, using an analytic approach which aims to organise the data in the language of the participants with little theoretical interpretation.

Results

The 13 surgeons who participated in the discussion represented orthopaedic oncology practices from seven countries (Argentina, Brazil, Italy, Spain, Denmark, United States and Canada). Four categories and associated themes emerged from the discussion: the need for collaboration in the field of orthopaedic oncology due to the rarity of the tumours and the need for high level evidence to guide treatment; motivational factors for participating in collaborative research including establishing proof of principle, learning opportunity, answering a relevant research question and being part of a collaborative research community; barriers to participation including funding, personal barriers, institutional barriers, trial barriers, and administrative barriers and facilitators for participation including institutional facilitators, leadership, authorship, trial set-up, and the support of centralised study coordination.

Conclusions

Orthopaedic surgeons involved in an ongoing international randomised controlled trial (RCT) were motivated by many factors to participate. There were a number of barriers to and facilitators for their participation. There was a collective sense of fatigue experienced in overcoming these barriers, which was mirrored by a strong collective sense of the importance of, and need for, collaborative research in this field. The experiences were described as essential educational first steps to advance collaborative studies in this area. Knowledge gained from this study will inform the development of future large-scale collaborative research projects in orthopaedic oncology.

Cite this article: J. S. Rendon, M. Swinton, N. Bernthal, M. Boffano, T. Damron, N. Evaniew, P. Ferguson, M. Galli Serra, W. Hettwer, P. McKay, B. Miller, L. Nystrom, W. Parizzia, P. Schneider, A. Spiguel, R. Vélez, K. Weiss, J. P. Zumárraga, M. Ghert. Barriers and facilitators experienced in collaborative prospective research in orthopaedic oncology: A qualitative study. Bone Joint Res 2017;6:–314. DOI: 10.1302/2046-3758.65.BJR-2016-0192.R1.

Establishing a Cancer Research Consortium in Low- and Middle-Income Countries: Challenges Faced and Lessons Learned

PURPOSE

There is an increasing effort in the global public health community to strengthen research capacity in low- and middle-income countries, but there is no consensus on how best to approach such endeavors. Successful consortia that perform research on HIV/AIDS and other infectious diseases exist, but few papers have been published detailing the challenges faced and lessons learned in setting up and running a successful research consortium.

METHODS

Members of the African Research Group for Oncology (ARGO) participated in generating lessons learned regarding the foundation and maintenance of a cancer research consortium in Nigeria.

RESULTS

Drawing on our experience of founding ARGO, we describe steps and key factors needed to establish a successful collaborative consortium between researchers from both high- and low-income countries. In addition, we present challenges we encountered in building our consortium, and how we managed those challenges. Although our research group is focused primarily on cancer, many of our lessons learned can be applied more widely in biomedical or public health research in low-income countries.

CONCLUSIONS

As the need for cancer care in LMICs continues to grow, the ability to create sustainable, innovative, collaborative research groups will become vital. Assessing the successes and failures that occur in creating and sustaining research consortia in LMICs is important for expansion of research and training capacity in LMICs.

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

BACKGROUND

Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI).

METHODS

This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression.

RESULTS

Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1·6 per cent at 24 h (high 1·1 per cent, middle 1·9 per cent, low 3·4 per cent; P < 0·001), increasing to 5·4 per cent by 30 days (high 4·5 per cent, middle 6·0 per cent, low 8·6 per cent; P < 0·001). Of the 578 patients who died, 404 (69·9 per cent) did so between 24 h and 30 days following surgery (high 74·2 per cent, middle 68·8 per cent, low 60·5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2·78, 95 per cent c.i. 1·84 to 4·20) and low-income (OR 2·97, 1·84 to 4·81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days.

CONCLUSION

Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role.

REGISTRATION NUMBER

NCT02179112 (http://www.clinicaltrials.gov).

Assessment of clinically related outcomes and biomarker analysis for translational integration in colorectal cancer (ACROBATICC): study protocol for a population-based, consecutive cohort of surgically treated colorectal cancers and resected colorectal liver metastasis

Background

More accurate predictive and prognostic biomarkers for patients with colorectal cancer (CRC) primaries or colorectal liver metastasis (CLM) are needed. Outside clinical trials, the translational integration of emerging pathways and novel techniques should facilitate exploration of biomarkers for improved staging and prognosis.

Methods

An observational study exploring predictive and prognostic biomarkers in a population-based, consecutive cohort of surgically treated colorectal cancers and resected colorectal liver metastases. Long-term outcomes will be cancer-specific survival, recurrence-free survival and overall survival at 5 years from diagnosis. Beyond routine clinicopathological and anthropometric characteristics and laboratory and biochemistry results, the project allows for additional blood samples and fresh-frozen tumour and normal tissue for investigation of circulating tumour cells (CTCs) and novel biomarkers (e.g. immune cells, microRNAs etc.). Tumour specimens will be investigated by immunohistochemistry in full slides. Extracted DNA/RNA will be analysed for genomic markers using specific PCR techniques and next-generation sequencing (NGS) panels. Flow cytometry will be used to characterise biomarkers in blood. Collaboration is open and welcomed, with particular interest in mutual opportunities for validation studies.

Status and perspectives

The project is ongoing and recruiting at an expected rate of 120–150 patients per year, since January 2013. A project on circulating tumour cells (CTCs) has commenced, with analysis being prepared. Investigating molecular classes beyond the TNM staging is under way, including characteristics of microsatellite instability (MSI) and elevated microsatellite alterations in selected tetranucleotides (EMAST). Hot spot panels for known mutations in CRC are being investigated using NGS. Immune-cell characteristics are being performed by IHC and flow cytometry in tumour and peripheral blood samples. The project has ethical approval (REK Helse Vest, #2012/742), is financially supported with a Ph.D.-Grant (EMAST project; Folke Hermansen Cancer Fund) and a CTC-project (Norwegian Research Council; O. Nordgård). The ACROBATICC clinical and molecular biobank repository will serve as a long-term source for novel exploratory analysis and invite collaborators for mutual validation of promising biomarker results. The project aims to generate results that can help better discern prognostic groups in stage II/III cancers; explore prognostic and predictive biomarkers, and help detail the biology of colorectal liver metastasis for better patient selection and tailored treatment. The project is registered at http://www.ClinicalTrials.gov NCT01762813.

Systematic Review of Surgical Literature from Resource-Limited Countries: Developing Strategies for Success

BACKGROUND

Injuries and surgical diseases are leading causes of global mortality. We sought to identify successful strategies to augment surgical capacity and research endeavors in low-income countries (LIC's) based on existing peer-reviewed literature.

METHODS

A systematic review of literature from or pertaining to LIC's from January 2002 to December 2011 was performed. Variables analyzed included type of intervention performed, research methodology, and publication demographics such as surgical specialty, partnerships involved, authorship contribution, place and journal of publication.

FINDINGS

A total of 2049 articles met the inclusion criteria between 2002 and 2011. The two most common study methodologies performed were case series (44%) and case reports (18%). A total of 43% of publications were without outcome measures. Only 21% of all publications were authored by a collaboration of authors from low-income countries and developed country nationals. The five most common countries represented were Nepal (429), United States (408), England (170), Bangladesh (158), and Kenya (134). Furthermore, of countries evaluated, Nepal and Bangladesh were the only two with a specific national journal.

INTERPRETATION

Based on the results of this research, the following recommendations were made: (1) Describe, develop, and stimulate surgical research through national peer-reviewed journals, (2) Foster centers of excellence to promote robust research competencies, (3) Endorse partnerships across regions and institutions in the promotion of global surgery, and (4) Build on outcome-directed research.

Advances and Concepts in Cervical Cancer Trials: A Road Map for the Future

OBJECTIVE

Cervical cancer is responsible for more than a quarter of a million deaths globally each year, mostly in developing countries, making therapeutic advances in all health care settings a top priority. The Gynecologic Cancer InterGroup (GCIG) is a worldwide collaboration of leading national research groups that develops and promotes multinational trials in gynecologic cancer. In recognition of the pressing need for action, the GCIG convened an international meeting with expert representation from the GCIG groups and selected large sites in low- and middle-income countries.

METHODS

The focus was to develop a consensus on several concepts for future clinical trials, which would be developed and promoted by the GCIG and launched with major international participation. The first half of the meeting was devoted to a resume of the current state of the knowledge and identifying the gaps in need of new evidence, validating control arms for present and future clinical trials and identifying national and international barriers for studies of cervix cancers. The second half of the meeting was concerned with achieving consensus on a path forward.

RESULTS AND CONCLUSIONS

There were 5 principal outcomes as follows: first, a proposal to expand fertility-preserving options with neoadjuvant chemotherapy; second, validation of the assessment of sentinel lymph nodes using minimally invasive surgery with an emphasis on identification and management of low-volume metastasis, such as isolated tumor cells and micrometastasis; third, evaluation of hypofractionation for palliative and curative radiation under the umbrella of the GCIG Cervix Cancer Research Network; fourth, adding to the advances in antiangiogenesis therapy in the setting of metastatic disease; and fifth, developing a maintenance study among women at high risk of relapse. The latter 2 systemic interventions could study PI3K (phosphatidylinositol-3-kinase) inhibitors, immunotherapy, anti-human papillomavirus approaches, or novel antiangiogenic agents/combinations.

Differential Globalization of Industry- and Non-Industry-Sponsored Clinical Trials

BACKGROUND

Mapping the international landscape of clinical trials may inform global health research governance, but no large-scale data are available. Industry or non-industry sponsorship may have a major influence in this mapping. We aimed to map the global landscape of industry- and non-industry-sponsored clinical trials and its evolution over time.

METHODS

We analyzed clinical trials initiated between 2006 and 2013 and registered in the WHO International Clinical Trials Registry Platform (ICTRP). We mapped single-country and international trials by World Bank's income groups and by sponsorship (industry- vs. non- industry), including its evolution over time from 2006 to 2012. We identified clusters of countries that collaborated significantly more than expected in industry- and non-industry-sponsored international trials.

RESULTS

119,679 clinical trials conducted in 177 countries were analysed. The median number of trials per million inhabitants in high-income countries was 100 times that in low-income countries (116.0 vs. 1.1). Industry sponsors were involved in three times more trials per million inhabitants than non-industry sponsors in high-income countries (75.0 vs. 24.5) and in ten times fewer trials in low- income countries (0.08 vs. 1.08). Among industry- and non-industry-sponsored trials, 30.3% and 3.2% were international, respectively. In the industry-sponsored network of collaboration, Eastern European and South American countries collaborated more than expected; in the non-industry-sponsored network, collaboration among Scandinavian countries was overrepresented. Industry-sponsored international trials became more inter-continental with time between 2006 and 2012 (from 54.8% to 67.3%) as compared with non-industry-sponsored trials (from 42.4% to 37.2%).

CONCLUSIONS

Based on trials registered in the WHO ICTRP we documented a substantial gap between the globalization of industry- and non-industry-sponsored clinical research. Only 3% of academic trials but 30% of industry trials are international. The latter appeared to be conducted in preferentially selected countries.

Emergency surgery in the elderly: the balance between function, frailty, fatality and futility

Becoming old is considered a privilege and results from the socioeconomic progress and improvements in health care systems worldwide. However, morbidity and mortality increases with age, and even more so in acute onset disease. With the current prospects of longevity, a considerable number of elderly patients will continue to live with good function and excellent quality of life after emergency surgical care. However, mortality in emergency surgery may be reported at 15-30%, doubled if associated with complications, and notably higher in patients over 75 years. A number of risks associated with death are reported, and a number of scores proposed for prediction of risk. Frailty, a decline in the physiological reserves that may make the person vulnerable to even the most minor of stressful event, appears to be a valid indicator and predictor of risk and poor outcome, but how to best address and measure frailty in the emergency setting is not clear. Futility may sometimes be clearly defined, but most often becomes a borderline decision between ethics, clinical predictions and patient communication for which no solid evidence currently exists. The number and severity of other underlying condition(s), as well as the treatment alternatives and their consequences, is a complex picture to interpret. Add in the onset of the acute surgical disease as a further potential detrimental factor on function and quality of life – and you have a perfect storm to handle. In this brief review, some of the challenging aspects related to emergency surgery in the elderly will be discussed. More research, including registries and trials, are needed for improved knowledge to a growing health care challenge.

Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation

Background

The objective of this systematic review and meta-analysis was to assess the relationship between the chloride content of intravenous resuscitation fluids and patient outcomes in the perioperative or intensive care setting.

Methods

Systematic searches were performed of PubMed/MEDLINE, Embase and Cochrane Library (CENTRAL) databases in accordance with PRISMA guidelines. Randomized clinical trials, controlled clinical trials and observational studies were included if they compared outcomes in acutely ill or surgical patients receiving either high-chloride (ion concentration greater than 111 mmol/l up to and including 154 mmol/l) or lower-chloride (concentration 111 mmol/l or less) crystalloids for resuscitation. Endpoints examined were mortality, measures of kidney function, serum chloride, hyperchloraemia/metabolic acidosis, blood transfusion volume, mechanical ventilation time, and length of hospital and intensive care unit stay. Risk ratios (RRs), mean differences (MDs) or standardized mean differences (SMDs) and confidence intervals were calculated using fixed-effect modelling.

Results

The search identified 21 studies involving 6253 patients. High-chloride fluids did not affect mortality but were associated with a significantly higher risk of acute kidney injury (RR 1·64, 95 per cent c.i. 1·27 to 2·13; P < 0·001) and hyperchloraemia/metabolic acidosis (RR 2·87, 1·95 to 4·21; P < 0·001). High-chloride fluids were also associated with greater serum chloride (MD 3·70 (95 per cent c.i. 3·36 to 4·04) mmol/l; P < 0·001), blood transfusion volume (SMD 0·35, 0·07 to 0·63; P = 0·014) and mechanical ventilation time (SMD 0·15, 0·08 to 0·23; P < 0·001). Sensitivity analyses excluding heavily weighted studies resulted in non-statistically significant effects for acute kidney injury and mechanical ventilation time.

Conclusion

A weak but significant association between higher chloride content fluids and unfavourable outcomes was found, but mortality was unaffected by chloride content.

Determining universal processes related to best outcome in emergency abdominal surgery: a multicentre, international, prospective cohort study

INTRODUCTION

Emergency abdominal surgery outcomes represent an internationally important marker of healthcare quality and capacity. In this study, a novel approach to investigating global surgical outcomes is proposed, involving collaborative methodology using 'snapshot' clinical data collection over a 2-week period. The primary aim is to identify internationally relevant, modifiable surgical practices (in terms of modifiable process, equipment and clinical management) associated with best care for emergency abdominal surgery.

METHODS AND ANALYSIS

This is a multicentre, international, prospective cohort study. Any hospital in the world performing acute surgery can participate, and any patient undergoing emergency intraperitoneal surgery is eligible to enter the study. Centres will collect observational data on patients for a 14-day period during a 5-month window and required data points will be limited to ensure practicality for collaborators collecting data. The primary outcome measure is the 24 h perioperative mortality, with 30-day perioperative mortality as a secondary outcome measure. During registration, participants will undertake a survey of available resources and capacity based on the WHO Tool for Situational Analysis.

ETHICS AND DISSEMINATION

The study will not affect clinical care and has therefore been classified as an audit by the South East Scotland Research Ethics Service in Edinburgh, Scotland. Baseline outcome measurement in relation to emergency abdominal surgery has not yet been undertaken at an international level and will provide a useful indicator of surgical capacity and the modifiable factors that influence this. This novel methodological approach will facilitate delivery of a multicentre study at a global level, in addition to building international audit and research capacity.

TRIAL REGISTRATION NUMBER

The study has been registered with ClinicalTrials.gov (Identifier: NCT02179112).

Predicting outcomes in patients with perforated gastroduodenal ulcers: artificial neural network modelling indicates a highly complex disease

Purpose

Mortality prediction models for patients with perforated peptic ulcer (PPU) have not yielded consistent or highly accurate results. Given the complex nature of this disease, which has many non-linear associations with outcomes, we explored artificial neural networks (ANNs) to predict the complex interactions between the risk factors of PPU and death among patients with this condition.

Methods

ANN modelling using a standard feed-forward, back-propagation neural network with three layers (i.e., an input layer, a hidden layer and an output layer) was used to predict the 30-day mortality of consecutive patients from a population-based cohort undergoing surgery for PPU. A receiver-operating characteristic (ROC) analysis was used to assess model accuracy.

Results

Of the 172 patients, 168 had their data included in the model; the data of 117 (70 %) were used for the training set, and the data of 51 (39 %) were used for the test set. The accuracy, as evaluated by area under the ROC curve (AUC), was best for an inclusive, multifactorial ANN model (AUC 0.90, 95 % CIs 0.85–0.95; p < 0.001). This model outperformed standard predictive scores, including Boey and PULP. The importance of each variable decreased as the number of factors included in the ANN model increased.

Conclusions

The prediction of death was most accurate when using an ANN model with several univariate influences on the outcome. This finding demonstrates that PPU is a highly complex disease for which clinical prognoses are likely difficult. The incorporation of computerised learning systems might enhance clinical judgments to improve decision making and outcome prediction.