1
|
McClintock S, Stupart D, Hoh SM, Redden AM, Schultz B, Robertson A, Moore E, Pollard J, Guest G, Watters D. Oral versus intravenous antibiotics in the treatment of uncomplicated colonic diverticulitis: results of a randomized non-inferiority control trial. ANZ J Surg 2024; 94:397-403. [PMID: 37962086 DOI: 10.1111/ans.18768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/24/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Colonic diverticular disease is common and its incidence increases with age, with uncomplicated diverticulitis being the most common acute presentation (1). This typically results in inpatient admission, placing a significant burden on healthcare services (2). We aimed to determine the safety and effectiveness of using intravenous or oral antibiotics in the treatment of uncomplicated diverticulitis on 30-day unplanned admissions, c-reactive protein (CRP), White Cell Count (WCC), pain resolution, cessation of pain medication, return to normal nutrition, and return to normal bowel function. METHODS This single centre, 2-arm, parallel, 1:1, unblinded non-inferiority randomized controlled trial compared the safety and efficacy of oral antibiotics versus intravenous antibiotics in the outpatient treatment of uncomplicated colonic diverticulitis. Inclusion criteria were patients older than 18 years of age with CT proven acute uncomplicated colonic diverticulitis (Modified Hinchey Classification Stage 0-1a). Patients were randomly allocated receive either intravenous or oral antibiotics, both groups being treated in the outpatient setting with a Hospital in the Home (HITH) service. The primary outcome was the 30-day unplanned admission rate, secondary outcomes were biochemical markers, time to pain resolution, time to cessation of pain medication, time to return to normal function and time to return to normal bowel function. RESULTS In total 118 patients who presented with uncomplicated colonic diverticulitis were recruited into the trial. Fifty-eight participants were treated with IV antibiotics, and 60 were given oral antibiotics. We found there was no significant difference between groups with regards to 30-day unplanned admissions or inflammatory markers. There was also no significant difference with regards to time to pain resolution, cessation of pain medication use, return to normal nutrition, or return to normal bowel function. CONCLUSION Outpatient management of uncomplicated diverticulitis with oral antibiotics proved equally as safe and efficacious as intravenous antibiotic treatment in this randomized non-inferiority control trial.
Collapse
Affiliation(s)
- Sam McClintock
- Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Douglas Stupart
- Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Su Mei Hoh
- Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Ann-Maree Redden
- Hospital in the Home (HITH), University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Belinda Schultz
- Hospital in the Home (HITH), University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Amy Robertson
- Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Eileen Moore
- Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - James Pollard
- Hospital in the Home (HITH), University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Glenn Guest
- Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - David Watters
- Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| |
Collapse
|
2
|
Muir M, Baric A, Kumta S, Watters D, Hodgson R. Measuring and reporting theatre utilization and efficiency. Br J Surg 2024; 111:znad384. [PMID: 37995260 DOI: 10.1093/bjs/znad384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/07/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023]
Affiliation(s)
- Mathew Muir
- Division of Surgery, Northern Health, Epping, Victoria, Australia
| | - Amanda Baric
- Department of Anaesthetics, Northern Health, Epping, Victoria, Australia
- Department of Medical Education, University of Melbourne, Epping, Victoria, Australia
| | - Shekhar Kumta
- Division of Surgery, Northern Health, Epping, Victoria, Australia
- Department of Surgery, University of Melbourne, Epping, Victoria, Australia
| | - David Watters
- Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- Department of Surgery, Deakin University, Geelong, Victoria, Australia
| | - Russell Hodgson
- Division of Surgery, Northern Health, Epping, Victoria, Australia
- Department of Surgery, University of Melbourne, Epping, Victoria, Australia
| |
Collapse
|
3
|
Divakaran P, Hong JS, Abbas S, Gwini SM, Nagra S, Stupart D, Guest G, Watters D. Failure to Rescue in Major Abdominal Surgery: A Regional Australian Experience. World J Surg 2023; 47:2145-2153. [PMID: 37225931 PMCID: PMC10208200 DOI: 10.1007/s00268-023-07061-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Failure to rescue (FTR) is increasingly recognised as a measure of the quality care provided by a health service in recognising and responding to patient deterioration. We report the association between a patient's pre-operative status and FTR following major abdominal surgery. METHODS A retrospective chart review was conducted on patients who underwent major abdominal surgery and who suffered Clavien-Dindo (CDC) III-V complications at the University Hospital Geelong between 2012 and 2019. For each patient suffering a major complication, pre-operative risk factors including demographics, comorbidities (Charlson Comorbidity Index (CCI)), American Society of Anaesthesiology (ASA) Score and biochemistry were compared for patients who survived and patients who died. Statistical analysis utilised logistic regression with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS There were 2579 patients who underwent major abdominal surgery, of whom 374 (14.5%) suffered CDC III-V complications. Eighty-eight patients subsequently died from their complication representing a 23.5% FTR and an overall operative mortality of 3.4%. Pre-operative risk factors for FTR included ASA score ≥ 3, CCI ≥ 3 and pre-operative serum albumin of < 35 g/L. Operative risk factors included emergency surgery, cancer surgery, greater than 500 ml intraoperative blood loss and need for ICU admission. Patients who suffered end-organ failure were more likely to die from their complication. CONCLUSION Identification of patients at high risk of FTR should they develop a complication would inform shared decision-making, highlight the need for optimisation prior to surgery, or in some cases, result in surgery not being undertaken.
Collapse
Affiliation(s)
- Pranav Divakaran
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia.
| | - Joshua Sungho Hong
- Warrnambool Base Hospital, Southwest Healthcare, 25 Ryot Street, Warrnambool, VIC, 3280, Australia
| | - Saleh Abbas
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
- Geelong Clinical School, Deakin University School of Medicine, Little Malop Street, Geelong, VIC, 3220, Australia
| | - Stella-May Gwini
- Biostatistics Support Service, Level 2 Kitchner House, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
| | - Sonalmeet Nagra
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
- Geelong Clinical School, Deakin University School of Medicine, Little Malop Street, Geelong, VIC, 3220, Australia
| | - Douglas Stupart
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
- Geelong Clinical School, Deakin University School of Medicine, Little Malop Street, Geelong, VIC, 3220, Australia
| | - Glenn Guest
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
- Geelong Clinical School, Deakin University School of Medicine, Little Malop Street, Geelong, VIC, 3220, Australia
| | - David Watters
- Department of Surgery, University Hospital Geelong, Barwon Health 272-322 Bellarine Street and Ryrie Street, Geelong, VIC, 3220, Australia
- Geelong Clinical School, Deakin University School of Medicine, Little Malop Street, Geelong, VIC, 3220, Australia
| |
Collapse
|
4
|
Tippett E, Hitch D, Irving L, Watters D. Post-acute COVID-19 condition (PACC): a perspective on collaborative Australian research imperatives and primary health models of care. Aust J Prim Health 2023; 29:293-295. [PMID: 36502582 DOI: 10.1071/py22009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/31/2022] [Indexed: 08/15/2023]
Abstract
Post-acute COVID-19 condition (PACC) - also known as long COVID - is a serious and growing problem in primary health. This letter describes the work of the Victorian Post-Acute COVID-19 Study (VPACS) group, which comprises clinician researchers, basic scientists and consumers. Two key priorities for PACC research in Australia are identified and discussed: (1) the establishment of COVID-19 patient registries and data linkage; and (2) the consolidation of clinical guidelines. Collaboration between consumers, researchers, clinicians and institutions must be the foundation of PACC management in Australia. Ongoing research should focus on large, multicentre controlled studies, the protective effect of vaccination, differential impacts from variants, pathobiological underpinnings, disease mechanisms to avoid severe and enduring impacts on the Australian economy. The lived experience of people with PACC is also essential to enable the design and implementation of effective models of care. VPACS brings a diverse group of people together to work on a shared vision of holistic and high-quality care, and collectively maximise their impact on outcomes for patients and the broader community.
Collapse
Affiliation(s)
- Emma Tippett
- Infectious Diseases Unit, Peninsula Health, Frankston, Vic. 3199, Australia
| | - Danielle Hitch
- Department of Allied Health, Sunshine Hospital, Western Health, St Albans, Vic. 3021, Australia; and Occupational Therapy and Science, School of Health and Social Development, Deakin University, Geelong, Vic. 3220, Australia
| | - Louis Irving
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Melbourne Health, Parkville, Vic. 3050, Australia
| | - David Watters
- Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, Vic. 3220, Australia; and School of Medicine, Deakin University, Geelong, Vic. 3220, Australia
| |
Collapse
|
5
|
Qin RX, Stankey M, Jayaram A, Fowler ZG, Yoon S, Watters D, Gelb AW, Park KB. Strategic partnerships to improve surgical care in the Asia-Pacific region: proceedings. BMC Proc 2023; 17:11. [PMID: 37488604 PMCID: PMC10367227 DOI: 10.1186/s12919-023-00257-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
Emergency and essential surgery is a critical component of universal health coverage. Session three of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region focused on strategic partnerships. During this session, a range of partner organisations, including intergovernmental organisations, professional associations, academic and research institutions, non-governmental organisations, and the private sector provided an update on their work in surgical system strengthening in the Asia-Pacific region. Partner organisations could provide technical and implementation support for National Surgical, Obstetric, and Anaesthesia Planning (NSOAP) in a number of areas, including workforce strengthening, capacity building, guideline development, monitoring and evaluation, and service delivery. Participants emphasised the importance of several forms of strategic collaboration: 1) collaboration across the spectrum of care between emergency, critical, and surgical care, which share many common underlying health system requirements; 2) interprofessional collaboration between surgery, obstetrics, anaesthesia, diagnostics, nursing, midwifery among other professions; 3) regional collaboration, particularly between Pacific Island Countries, and 4) South-South collaboration between low- and middle-income countries (LMICs) in mutual knowledge sharing. Partnerships between high-income countries (HIC) and LMIC organisations must include LMIC participants at a governance level for shared decision-making. Areas for joint action that emerged in the discussion included coordinated advocacy efforts to generate political view, developing common monitoring and evaluation frameworks, and utilising remote technology for workforce development and service delivery.
Collapse
Affiliation(s)
- Rennie X Qin
- The Program in Global Surgery and Social Change, the Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA.
| | - Makela Stankey
- The Program in Global Surgery and Social Change, the Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA
- Keck School of Medicine at the University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Anusha Jayaram
- The Program in Global Surgery and Social Change, the Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA
| | - Zachary G Fowler
- The Program in Global Surgery and Social Change, the Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA
| | - Sangchul Yoon
- The Program in Global Surgery and Social Change, the Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA
- Department of Medical Humanities and Social Sciences, College of Medicine, Yonsei University, Seoul, South Korea
| | - David Watters
- Faculty of Health, School of Medicine, Deakin University, Bellerine St, Geelong, VIC, 3220, Australia
| | - Adrian W Gelb
- Department of Anesthesia and Perioperative Care, University of California San Francisco, 521 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Kee B Park
- The Program in Global Surgery and Social Change, the Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA
| |
Collapse
|
6
|
Watters D. Inspirational Women in Surgery: Rev Prof Anne Christine Bayley OBE (1934-), Surrey, England. World J Surg 2023; 47:1607-1608. [PMID: 37154905 DOI: 10.1007/s00268-023-07022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2023] [Indexed: 05/10/2023]
Affiliation(s)
- David Watters
- Department of Surgery, Deakin University and Barwon Health, Victoria, Australia.
| |
Collapse
|
7
|
Watters D. Supporting Safe Surgery with Simple, Low-Cost Solutions. World J Surg 2023; 47:1648-1649. [PMID: 37002483 PMCID: PMC10064947 DOI: 10.1007/s00268-023-06989-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 04/03/2023]
Affiliation(s)
- David Watters
- School of Medicine and Health Sciences, Deakin University, Geelong, Australia.
- University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.
| |
Collapse
|
8
|
Eqbal H, Owen A, Guest G, Watters D, Nagra S. Small bowel resection for ischemia following transcatheter arterial embolization for bleeding jejunal diverticulum: an easily forgotten complication. ANZ J Surg 2022; 93:1027-1028. [PMID: 36107114 DOI: 10.1111/ans.18042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/28/2022] [Accepted: 08/29/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Henna Eqbal
- Department of Surgery University Hospital Geelong Geelong Australia
| | - Andrew Owen
- Department of Radiology University Hospital Geelong Geelong Australia
| | - Glenn Guest
- Department of Surgery University Hospital Geelong Geelong Australia
| | - David Watters
- Department of Surgery University Hospital Geelong Geelong Australia
| | - Sonal Nagra
- Department of Surgery University Hospital Geelong Geelong Australia
| |
Collapse
|
9
|
Crebbin W, Guest G, Beasley S, Tobin S, Duvivier R, Watters D. Learning and teaching stage 4 clinical decision making: progression from novice to expert. ANZ J Surg 2022; 92:2088-2093. [PMID: 35938734 DOI: 10.1111/ans.17955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/15/2022] [Accepted: 07/15/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND This paper describes the development of learning from novice to expert in Stage 4: Clinical Decision Making (CDM) in surgery: Postoperative reflection and review. It also outlines some or the assessment and teaching approaches suitable to facilitate that transition in skill level. METHODS This paper is drawn from a much broader study of learning and teaching CDM, that used qualitative methodology based on Constructivist and Grounded Theory. Data was collected in individual interviews and focus groups. Using thematic analysis the data were analysed to identify key ideas. All participants worked in the Department of Surgery at one large regional hospital in Victoria. RESULTS For each stage there is a sequence of learning beginning from relying on external resources, gradually developing internal resources to guide and direct the learner's CDM. Those internal resources built through experience include multisensory and kinaesthetic memories that expand to facilitate the ability to cope with complexity. DISCUSSION Armed with the mind-map and rubric table included in this paper it should be possible for any senior clinician or teacher to diagnose their trainees' progression in Stage 4 CDM. This will enable them to tailor their teaching to best match the capabilities of the trainee and to enable to be more effectively targeted. CONCLUSION CDM can be taught and both trainees and senior clinicians can benefit from understanding the processes involved.
Collapse
Affiliation(s)
- Wendy Crebbin
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - Glenn Guest
- Faculty of Health, Deakin University, Melbourne, Victoria, Australia.,Department of Surgery, Epworth Hospital, Melbourne, Victoria, Australia
| | - Spencer Beasley
- Department of Paediatrics, Melbourne University, Melbourne, Victoria, Australia.,Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Stephen Tobin
- School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Robbert Duvivier
- School of Medicine & Public Health, Center for Educational Development and Research in Health Sciences (CEDAR), University Medical Center Groningen, University of Newcastle, Australia, Groningen, The Netherlands
| | - David Watters
- Faculty of Medicine, Edinburgh University, Edinburgh, UK.,Department of Surgery, University Hospital, Geelong, Victoria, Australia
| |
Collapse
|
10
|
Underwood K, Drysdale H, Nagra S, Guest G, Watters D. Recurrent gastro-jejunal intussusception: a call for caution with non-revisional management. ANZ J Surg 2022; 92:3093-3095. [PMID: 35188702 DOI: 10.1111/ans.17561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 11/02/2022]
Affiliation(s)
- Kirk Underwood
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Henry Drysdale
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Sonal Nagra
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Glenn Guest
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria.,Department of Surgery, Epworth Hospital, Geelong, Victoria
| | - David Watters
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria.,Department of Surgery, Epworth Hospital, Geelong, Victoria
| |
Collapse
|
11
|
Underwood KH, Doole E, Breen D, Guest G, Watters D, Moore EM, Nagra S. Tertiary Survey in the Days of Modern Imaging: Assessing the Detection Rate of Clinically Significant Injuries on Tertiary Survey in a Level 2 Trauma Centre. Cureus 2022; 14:e21962. [PMID: 35282524 PMCID: PMC8904185 DOI: 10.7759/cureus.21962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/20/2022] Open
Abstract
Aim: To determine the utility of tertiary survey (TS) in patients subjected to whole-body CT (WBCT) or selective CT (SCT) following trauma. Methods: A retrospective analysis was performed on trauma patients admitted to a level 2 trauma centre following the introduction of a standardised TS form in 2017. The initial imaging protocol (WBCT versus selective CT versus x-ray), subsequently requested imaging, standardised injury data, and length of stay (LOS) were recorded. Clinically significant injuries were defined as those with an Injury Severity Score (ISS) of 1 on the Abbreviated Injury Scale (AIS). Results: Five hundred and seven patients were included. The rate of additional significant injuries at the time of TS was 1.18% (n=6), each requiring conservative management only. There was no significant difference in injury detection based on the initial imaging protocol; however, there were three near-misses identified. Of these patients, two underwent selective CT and one was subjected to a plain film series, with clinically significant injuries identified early upon completion of trauma imaging. Overall, 2.9% (n=15) of patients had completed trauma imaging during the same admission. WBCT was associated with higher ISS and length of stay (p<0.05). After controlling for ISS, there was no difference in length of stay between imaging modalities except in those patients with an ISS of 0 (no clinically significant injuries), who appeared to have longer admissions if subject to WBCT (p<0.001). Conclusion: The rate of missed injuries identified at TS is low. The imaging modality did not alter this. This may allow for the omission of the tertiary survey and earlier discharge in many trauma patients.
Collapse
|
12
|
McGuinness AJ, Davis JA, Dawson SL, Loughman A, Collier F, O’Hely M, Simpson CA, Green J, Marx W, Hair C, Guest G, Mohebbi M, Berk M, Stupart D, Watters D, Jacka FN. A systematic review of gut microbiota composition in observational studies of major depressive disorder, bipolar disorder and schizophrenia. Mol Psychiatry 2022; 27:1920-1935. [PMID: 35194166 PMCID: PMC9126816 DOI: 10.1038/s41380-022-01456-3] [Citation(s) in RCA: 146] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/22/2021] [Accepted: 01/18/2022] [Indexed: 02/07/2023]
Abstract
The emerging understanding of gut microbiota as 'metabolic machinery' influencing many aspects of physiology has gained substantial attention in the field of psychiatry. This is largely due to the many overlapping pathophysiological mechanisms associated with both the potential functionality of the gut microbiota and the biological mechanisms thought to be underpinning mental disorders. In this systematic review, we synthesised the current literature investigating differences in gut microbiota composition in people with the major psychiatric disorders, major depressive disorder (MDD), bipolar disorder (BD) and schizophrenia (SZ), compared to 'healthy' controls. We also explored gut microbiota composition across disorders in an attempt to elucidate potential commonalities in the microbial signatures associated with these mental disorders. Following the PRISMA guidelines, databases were searched from inception through to December 2021. We identified 44 studies (including a total of 2510 psychiatric cases and 2407 controls) that met inclusion criteria, of which 24 investigated gut microbiota composition in MDD, seven investigated gut microbiota composition in BD, and 15 investigated gut microbiota composition in SZ. Our syntheses provide no strong evidence for a difference in the number or distribution (α-diversity) of bacteria in those with a mental disorder compared to controls. However, studies were relatively consistent in reporting differences in overall community composition (β-diversity) in people with and without mental disorders. Our syntheses also identified specific bacterial taxa commonly associated with mental disorders, including lower levels of bacterial genera that produce short-chain fatty acids (e.g. butyrate), higher levels of lactic acid-producing bacteria, and higher levels of bacteria associated with glutamate and GABA metabolism. We also observed substantial heterogeneity across studies with regards to methodologies and reporting. Further prospective and experimental research using new tools and robust guidelines hold promise for improving our understanding of the role of the gut microbiota in mental and brain health and the development of interventions based on modification of gut microbiota.
Collapse
Affiliation(s)
- A. J. McGuinness
- grid.1021.20000 0001 0526 7079The Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine and Barwon Health, Deakin University, Geelong, VIC Australia
| | - J. A. Davis
- grid.1021.20000 0001 0526 7079The Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine and Barwon Health, Deakin University, Geelong, VIC Australia
| | - S. L. Dawson
- grid.1021.20000 0001 0526 7079The Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine and Barwon Health, Deakin University, Geelong, VIC Australia ,grid.1058.c0000 0000 9442 535XMurdoch Children’s Research Institute, Parkville, VIC Australia
| | - A. Loughman
- grid.1021.20000 0001 0526 7079The Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine and Barwon Health, Deakin University, Geelong, VIC Australia
| | - F. Collier
- grid.1021.20000 0001 0526 7079The Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine and Barwon Health, Deakin University, Geelong, VIC Australia
| | - M. O’Hely
- grid.1021.20000 0001 0526 7079The Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine and Barwon Health, Deakin University, Geelong, VIC Australia ,grid.1058.c0000 0000 9442 535XMurdoch Children’s Research Institute, Parkville, VIC Australia
| | - C. A. Simpson
- grid.1008.90000 0001 2179 088XMelbourne School of Psychological Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC Australia ,grid.1008.90000 0001 2179 088XMelbourne Neuropsychiatry Centre, Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne and Melbourne Health, Melbourne, VIC Australia
| | - J. Green
- grid.1021.20000 0001 0526 7079The Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine and Barwon Health, Deakin University, Geelong, VIC Australia ,grid.1002.30000 0004 1936 7857Monash Alfred Psychiatry Research Centre (MAPcr), Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Parkville, VIC Australia ,grid.466993.70000 0004 0436 2893Department of Psychiatry, Peninsula Health, Frankston, VIC Australia
| | - W. Marx
- grid.1021.20000 0001 0526 7079The Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine and Barwon Health, Deakin University, Geelong, VIC Australia
| | - C. Hair
- grid.1021.20000 0001 0526 7079Deakin University, School of Medicine, Geelong, VIC Australia ,grid.414257.10000 0004 0540 0062Department of Gastroenterology, Barwon Health, Geelong, VIC Australia
| | - G. Guest
- grid.1021.20000 0001 0526 7079Deakin University, School of Medicine, Geelong, VIC Australia ,grid.415335.50000 0000 8560 4604Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, VIC Australia
| | - M. Mohebbi
- grid.1021.20000 0001 0526 7079Biostatistics Unit, Faculty of Health, Deakin University, Melbourne, VIC Australia
| | - M. Berk
- grid.1021.20000 0001 0526 7079The Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine and Barwon Health, Deakin University, Geelong, VIC Australia ,grid.1021.20000 0001 0526 7079Deakin University, School of Medicine, Geelong, VIC Australia ,grid.1008.90000 0001 2179 088XOrygen, The National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, Florey Institute for Neuroscience and Mental Health and the Department of Psychiatry, The University of Melbourne, Melbourne, Australia
| | - D. Stupart
- grid.1021.20000 0001 0526 7079Deakin University, School of Medicine, Geelong, VIC Australia ,grid.415335.50000 0000 8560 4604Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, VIC Australia
| | - D. Watters
- grid.1021.20000 0001 0526 7079Deakin University, School of Medicine, Geelong, VIC Australia ,grid.415335.50000 0000 8560 4604Department of Surgery, University Hospital Geelong, Barwon Health, Geelong, VIC Australia
| | - F. N. Jacka
- grid.1021.20000 0001 0526 7079The Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine and Barwon Health, Deakin University, Geelong, VIC Australia ,grid.1058.c0000 0000 9442 535XCentre for Adolescent Health, Murdoch Children’s Research Institute, Melbourne, VIC Australia ,grid.418393.40000 0001 0640 7766Black Dog Institute, Sydney, NSW Australia ,grid.1011.10000 0004 0474 1797College of Public Health, Medical & Veterinary Sciences, James Cook University, Townsville, QLD Australia
| |
Collapse
|
13
|
Truche P, Campos LN, Marrazzo EB, Rangel AG, Bernardino R, Bowder AN, Buda AM, Faria I, Pompermaier L, Rice HE, Watters D, Dantas FLL, Mooney DP, Botelho F, Ferreira RV, Alonso N. Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study. ACTA ACUST UNITED AC 2021; 3:100056. [PMID: 34725652 PMCID: PMC8552244 DOI: 10.1016/j.lana.2021.100056] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 12/01/2022]
Abstract
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.
Collapse
Affiliation(s)
- Paul Truche
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States
| | | | - Enzzo Barrozo Marrazzo
- Institute of Biological Sciences, Faculty of Medicine Pontifícia Universidade Católica de Minas Gerais Poços de Caldas, MG, Brazil
| | - Ayla Gerk Rangel
- Faculty of Medical Sciences, Universidad Católica Argentina, Buenos Aires, Argentina
| | - Ramon Bernardino
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Alexis N Bowder
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States
| | - Alexandra M Buda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States
| | - Isabella Faria
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Laura Pompermaier
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States
| | - Henry E Rice
- Duke University Medical Center and Duke Global Health Institute, Durham, NC, United States
| | - David Watters
- Deakin University and Barwon Health, Melbourne, Australia
| | | | | | | | | | - Nivaldo Alonso
- Department of Plastic Surgery, University of São Paulo, São Paulo, Brazil
| |
Collapse
|
14
|
Davies JI, Gelb AW, Gore-Booth J, Martin J, Mellin-Olsen J, Åkerman C, Ameh EA, Biccard BM, Braut GS, Chu KM, Derbew M, Ersdal HL, Guzman JM, Hagander L, Haylock-Loor C, Holmer H, Johnson W, Juran S, Kassebaum NJ, Laerdal T, Leather AJM, Lipnick MS, Ljungman D, Makasa EM, Meara JG, Newton MW, Østergaard D, Reynolds T, Romanzi LJ, Santhirapala V, Shrime MG, Søreide K, Steinholt M, Suzuki E, Varallo JE, Visser GHA, Watters D, Weiser TG. Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report. PLoS Med 2021; 18:e1003749. [PMID: 34415914 PMCID: PMC8415575 DOI: 10.1371/journal.pmed.1003749] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 09/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. METHODS AND FINDINGS The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees. CONCLUSIONS To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.
Collapse
Affiliation(s)
- Justine I. Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
- Department of Public Health, Wits University, Johannesburg, South Africa
- * E-mail:
| | - Adrian W. Gelb
- World Federation of Societies of Anaesthesiologists, London, United Kingdom
- Department of Anesthesia & Perioperative Care, University of California San Francisco, California, United States of America
| | - Julian Gore-Booth
- World Federation of Societies of Anaesthesiologists, London, United Kingdom
| | - Janet Martin
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
| | - Jannicke Mellin-Olsen
- World Federation of Societies of Anaesthesiologists, London, United Kingdom
- Department of Anaesthesia and Intensive Care Medicine, Baerum Hospital, Sandvika, Norway
| | - Christina Åkerman
- Dell Medical School, University of Texas at Austin, Austin, Texas, United States of America
- Institute for Strategy and Competitiveness, Harvard Business School, Boston, Massachusetts, United States of America
| | - Emmanuel A. Ameh
- Division of Paediatric Surgery, The National Hospital, Abuja, Nigeria
- National Surgical, Obstetric and Anaesthesia Planning Committee, Federal Ministry of Health, Abuja, Nigeria
| | - Bruce M. Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Cape Town, South Africa
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Western Cape, South Africa
| | - Geir Sverre Braut
- Research Department of Community Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Kathryn M. Chu
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Miliard Derbew
- School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia
| | - Hege Langli Ersdal
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Norway
| | | | - Lars Hagander
- Paediatric Surgery, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Carolina Haylock-Loor
- World Federation of Societies of Anaesthesiologists, London, United Kingdom
- Department of Anesthesia, Intensive Care Medicine, Interventional Pain Unit, Hospital Del Valle, San Pedro Sula, Honduras
| | - Hampus Holmer
- Paediatric Surgery, Department of Clinical Sciences in Lund, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Walter Johnson
- Department of Neurosurgery, Loma Linda University, Loma Linda, California, United States of America
| | - Sabrina Juran
- Population and Development, United Nations Population Fund, New York, New York, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Nicolas J. Kassebaum
- Anesthesiology and Pain Medicine, Health Metrics Sciences, Global Health, and Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | | | - Andrew J. M. Leather
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
| | - Michael S. Lipnick
- Center for Health Equity in Surgery and Anesthesia, University of California San Francisco, San Francisco, United States of America
| | - David Ljungman
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Emmanuel M. Makasa
- SADC-Wits Regional Collaboration Centre for Surgical Healthcare (WitSSurg), Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - John G. Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Mark W. Newton
- Department of Anesthesiology and Pediatrics, Vanderbilt University Medical Center, Tennessee, United States of America
- AIC Kijabe Hospital, Kenya
| | - Doris Østergaard
- Copenhagen Academy for Medical Education and Simulation, The University of Copenhagen, Copenhagen, Denmark
| | - Teri Reynolds
- Clinical Services and Systems, Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Lauri J. Romanzi
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Vatshalan Santhirapala
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Anaesthesia and Perioperative Care, Guy’s and St. Thomas’ Hospital, London, United Kingdom
| | - Mark G. Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, United States of America
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Norway
| | - Margit Steinholt
- Helgeland Hospital Trust, Sandnessjøen, Norway
- Norwegian University of Science and Technology, Trondheim, Norway
| | - Emi Suzuki
- The World Bank, Washington, DC, United States of America
| | - John E. Varallo
- Department of Safe Surgery, Jhpiego, Baltimore, Maryland, United States of America
| | - Gerard H. A. Visser
- Department of Obstetrics, University Medical Center, Utrecht, the Netherlands
| | - David Watters
- University Hospital Geelong, Victoria, Australia
- Faculty of Health, School of Medicine, Deakin University, Victoria, Australia
- Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Thomas G. Weiser
- Stanford University School of Medicine, Department of Surgery Division of General Surgery, Section of Trauma & Critical Care Stanford University, Stanford, United States of America
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, Scotland
| |
Collapse
|
15
|
Crebbin W, Guest G, Beasley S, Tobin S, Duvivier R, Watters D. The influence of experience and expertise on how surgeons prepare to perform a procedure. ANZ J Surg 2021; 91:2032-2036. [PMID: 34184378 DOI: 10.1111/ans.17019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is a paucity of literature describing how surgeons (either novice or expert) mentally prepare to carry out a surgical procedure. This paper focuses on these processes, and is part of a larger piece of research based on the Royal Australasian College of Surgeons (RACS) Clinical Decision Making model. METHODS Interviews were conducted over a 3-year period with registrars, trainees, fellows and consultants in the Department of Surgery at one large regional hospital in Victoria. Analysis began from the first interview with no pre-conceived codes. Emerging themes were drawn from participants' interpretation of their experiences. Further information was obtained during discussions in theatre while patients were being prepared for surgery. RESULTS The findings show that the process of rehearsal changes as a surgeon gains more experience in a procedure. A 'novice' relies on external sources of information, for example textbooks and videos. After participating in a number of similar procedures their reliance gradually moves to their own sensory memories. Surgeons at all levels of experience discuss their preparations with peers, colleagues, senior clinicians, and where appropriate, with members of other disciplines. CONCLUSION These findings offer insight into how surgeons, at different levels of experience, prepare for a procedure. These understandings have the potential to improve the teaching and learning of this essential component of surgical practice.
Collapse
Affiliation(s)
- Wendy Crebbin
- School of Medicine and Health Sciences, Deakin University Faculty of Health, Geelong, Victoria, Australia.,Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Glenn Guest
- School of Medicine and Health Sciences, Deakin University Faculty of Health, Geelong, Victoria, Australia.,Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia.,Department of Surgery, Epworth Hospital Geelong, Geelong, Victoria, Australia
| | - Spencer Beasley
- Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia.,Paediatric Surgery, University of Otago, Christchurch, New Zealand
| | - Stephen Tobin
- Deanery, Faculty of Medicine, University of Western Sydney, Sydney, New South Wales, Australia
| | - Robbert Duvivier
- School of Medicine and Population Health, University of Newcastle, Newcastle, New South Wales, Australia.,Center for Educational Development and Research in Health Sciences (CEDAR), University Medical Centre, Groningen, Hanzeplein, 9713 GZ, Netherlands
| | - David Watters
- School of Medicine and Health Sciences, Deakin University Faculty of Health, Geelong, Victoria, Australia.,Royal Australasian College of Surgeons, Melbourne, Victoria, Australia.,Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia
| |
Collapse
|
16
|
Aitken RJ, Griffiths B, Van Acker J, O'Loughlin E, Fletcher D, Treacy JP, Watters D, Babidge WJ. Two-year outcomes from the Australian and New Zealand Emergency Laparotomy Audit-Quality Improvement pilot study. ANZ J Surg 2021; 91:2575-2582. [PMID: 34184372 DOI: 10.1111/ans.17037] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/28/2021] [Accepted: 06/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of the Australian and New Zealand Emergency Laparotomy Audit-Quality Improvement (ANZELA-QI) pilot study was to determine (i) the outcomes of emergency laparotomy (EL) and (ii) the feasibility of a national, multi-disciplinary quality improvement (QI) project based on a bundle of evidence-based care standards. METHODS An online database was created using the Research Electronic Data Capture (REDCap) programme. National ethics approval with waiver of consent was obtained. Data were entered directly onto REDCap and extracted monthly for eight care standards (preoperative consultant radiologist reporting of computed tomography scans, preoperative mortality risk score, consultant presence in theatre, timely access to theatre and critical care commensurate with risk and involvement of aged care). Monthly QI run charts using 'traffic' light graphics (green ≥80%, amber ≥50% to <80% and red <50%) reported compliance with the standards. RESULTS Sixty hospitals indicated interest, but difficulties with site-specific ethics approval resulted in only 24 hospitals participating (2886 EL in 2755 patients). The overall in-hospital mortality was 7.1% (2.3%-13.3%) and average length of stay 15.5 (8.6-22.7) days. Both significantly declined. Preoperative risk assessment (overall 45%) improved almost three-fold during the study. Only 60% had timely access to theatre and only 70% with a predicted mortality risk of >10% were admitted to critical care. CONCLUSION Overall mortality compared favourably with similar international studies and declined in association with participation in the audit. Compliance with some care standards shows considerable scope to improve EL care using QI methodology.
Collapse
Affiliation(s)
| | - R James Aitken
- Department of General Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Ben Griffiths
- Department of Anaesthetics, Auckland Hospital, Auckland, New Zealand
| | - Jill Van Acker
- Department of Anaesthetics, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Edmond O'Loughlin
- Department of General Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - David Fletcher
- Department of General Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - John P Treacy
- Department of General Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - David Watters
- Department of General Surgery, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Wendy J Babidge
- Research, Audit and Academic Surgery, Royal Australian College of Surgeons, Adelaide, South Australia, Australia.,Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
17
|
Dangen J, Hsueh YHS, Lau SYC, Nagra S, Watters D, Guest GD. Live-streaming surgery during COVID-19 using a 3D printed camera. ANZ J Surg 2021; 91:1056-1058. [PMID: 34121283 PMCID: PMC8420233 DOI: 10.1111/ans.16797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/04/2021] [Accepted: 03/06/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Jordyn Dangen
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia.,Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | | | - Steve Yee Chiang Lau
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia.,Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - Sonal Nagra
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia.,Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - David Watters
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia.,Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Glenn Douglas Guest
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia.,Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| |
Collapse
|
18
|
Morgan FH, Drysdale HRE, Watters D, Brockman S. Caecal volvulus within the lesser sac: a rare cause of large bowel obstruction. ANZ J Surg 2021; 91:E787-E788. [PMID: 33949068 DOI: 10.1111/ans.16906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 11/26/2022]
Affiliation(s)
- F Hamish Morgan
- Barwon Health, Department of General Surgery, Geelong, Victoria, Australia.,Deakin University, Department of Medicine and Surgery, Geelong, Victoria, Australia
| | - Henry R E Drysdale
- Barwon Health, Department of General Surgery, Geelong, Victoria, Australia.,Deakin University, Department of Medicine and Surgery, Geelong, Victoria, Australia
| | - David Watters
- Barwon Health, Department of General Surgery, Geelong, Victoria, Australia.,Deakin University, Department of Medicine and Surgery, Geelong, Victoria, Australia
| | - Stephen Brockman
- Barwon Health, Department of General Surgery, Geelong, Victoria, Australia.,St John of God Geelong Hospital, Geelong, Victoria, Australia
| |
Collapse
|
19
|
McLeod E, Watters D. Global Health in the ANZ Journal of Surgery. ANZ J Surg 2021; 90:1833-1834. [PMID: 33710740 DOI: 10.1111/ans.16305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Elizabeth McLeod
- Department of Neonatal and Paediatric Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia.,RACS Global Health, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - David Watters
- Department of Surgery, Deakin University and Barwon Health, Geelong, Victoria, Australia.,RACS Global Health, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| |
Collapse
|
20
|
Salendo J, Soares A, de Sousa Saldanha Soares SB, Martins J, Korin S, Nagra S, Watters D, McCaig E, Guest G. Conducting clinical surgical examinations in Timor-Leste during the COVID-19 global pandemic. ANZ J Surg 2020; 90:2399-2401. [PMID: 33336482 DOI: 10.1111/ans.16411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Junius Salendo
- Global Health, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Alito Soares
- Department of Surgery, Guido Valadares National Hospital, Dili, Timor-Leste
| | | | - Joao Martins
- Faculty of Medicine and Health Sciences, National University Timor-Leste, Dili, Timor-Leste
| | - Stephanie Korin
- Global Health, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Sonal Nagra
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia
| | - David Watters
- Department of Surgery, Geelong Hospital and Deakin University, Geelong, Victoria, Australia
| | - Eddie McCaig
- Department of Surgery, Colonial War Memorial Hospital, Suva, Fiji
| | - Glenn Guest
- Department of Clinical and Biomedical Sciences, Deakin University, Geelong, Victoria, Australia
| |
Collapse
|
21
|
Stupart D, Watters D. Perioperative thromboprophylaxis: inconsistent guidelines and evidence gaps lead to variable practice. ANZ J Surg 2020; 90:2391-2392. [DOI: 10.1111/ans.16403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/13/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Douglas Stupart
- University Hospital Geelong Barwon Health Bellerine St Newtown Australia
| | - David Watters
- School of Medicine Deakin University Geelong Victoria Australia
| |
Collapse
|
22
|
Stupart D, Beattie J, Lawson M, Watters D, Fuller L. Medical Students Can Learn Surgery Effectively in a Rural Longitudinal Integrated Clerkship. J Surg Educ 2020; 77:1407-1413. [PMID: 32451311 DOI: 10.1016/j.jsurg.2020.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/11/2020] [Accepted: 04/12/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND At Deakin University School of Medicine, compulsory formal teaching in Surgery occurs in year 3. This may occur as part of a rural longitudinal integrated clerkship (LIC), or in a traditional teaching hospital block rotation (BR). The purpose of this study was to compare these groups' exposure to surgical common conditions and their academic outcomes. METHODS Part I: This was a survey of students' encounters with patients with common surgical conditions between 2016 and 2018. Self-reported data were collected describing the nature of the encounters and their clinical settings. Part II: All third year Surgery MCQ and OSCE results from 2011 to 2017 were analyzed. Students were deidentified and grouped according to whether they were in the LIC or BR programme. RESULTS Part I: Thirty-eight third year students (20 LIC, 18 BR) submitted data for a total of 188 clinical encounters. Both groups encountered all nominated common surgical conditions, but the settings in which this occurred were different. BR students saw most patients as hospital inpatients whereas LIC student encounters were distributed across multiple clinical sites. Part II: A total of 942 (121 [26%] LIC and 821 [74%] BR) students' assessment results were analyzed. The groups performed similarly in the MCQ (p = 0.21) and OSCE (p = 0.16) examinations. CONCLUSIONS Students who were taught surgery in a LIC program performed similarly to on their final exams to their peers in traditional clerkships, with self-reported student data indicating both groups encountered a similar range of conditions.
Collapse
Affiliation(s)
- Douglas Stupart
- Department of Surgery, Deakin University, Geelong, Australia.
| | - Jessica Beattie
- Rural Community Clinical School, Deakin University, Geelong, Australia
| | - Mary Lawson
- School of Medicine, Deakin University, Geelong, Australia
| | - David Watters
- Department of Surgery, Deakin University, Geelong, Australia
| | - Lara Fuller
- Rural Community Clinical School, Deakin University, Geelong, Australia
| |
Collapse
|
23
|
Pellegrino SA, Watters D. Not just a simple case of terminal ileitis. ANZ J Surg 2020; 91:E355-E356. [PMID: 33099861 DOI: 10.1111/ans.16389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/16/2020] [Accepted: 09/22/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - David Watters
- Department of General Surgery, Barwon Health, Geelong, Victoria, Australia.,Department of Surgery, Deakin University, Geelong, Victoria, Australia
| |
Collapse
|
24
|
Nataraja RM, Yin Mar Oo, Andolfatto L, Moore EM, Watters D, Aye Aye, Htun Oo, Moe Moe Tin, Shrime M, McLeod E. Analysis of Financial Risk Protection Indicators in Myanmar for Paediatric Surgery. World J Surg 2020; 44:3986-3992. [PMID: 32920705 DOI: 10.1007/s00268-020-05775-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To estimate proportion of Myanmar paediatric population at risk of impoverishment and catastrophic expenditure due to emergency surgical intervention. METHODS Prospective data were collected at two tertiary surgical centres including income, household expenses, expenses related to surgery. Data analysis was performed to estimate out-of-pocket (OOP) direct medical costs and OOP total costs. Catastrophic expenditure: expense exceeded 10% of household income. Risk of impoverishment: net income drops were below an impoverishment threshold (PPP-purchasing power parity): I$ 2.00 PPP/day, I$ 1.25/day PPP, national poverty line. Distribution of income was estimated using a gamma distribution. Comparison to an adult cohort was performed using Chi-square test with a p value of <0.05 being significant. RESULTS A total of 145 surveys were collected, and 119 (82.1%) contained sufficient data: Paediatric Centre (n = 99) and Adult Centre (n = 20). Overall average per patient direct medical and non-medical OOP costs was I$493: Centre 1: I$540 PPP (range I$41-6,588 PPP) and Centre 2: I$437 PPP (range I$ 36-1,405 PPP). 64% experienced catastrophic expense. There is no significant difference between the centres in the risks of impoverishment or catastrophic expenditure (p = 0.05). Up to 44% are at risk of catastrophic expenditure should surgery be required. Most of the risk (90%) is derived from direct non-medical costs. A high proportion were at the national poverty line threshold (36.1%). Seeking surgical treatment would imperil up to 37% at the national poverty line threshold, and up to 5.7% at the I$2 PPP per day limit. CONCLUSIONS A large proportion of the Myanmar population are at risk of impoverishment or catastrophic expenditure should they require surgery. Financial risk protection mechanisms are needed.
Collapse
Affiliation(s)
- Ramesh Mark Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, 246 Clayton Road, Clayton, Melbourne, 3168, Australia. .,Departments of Paediatrics & Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.
| | - Yin Mar Oo
- Department of Paediatric Surgery, Yangon Children's Hospital, Yangon, Myanmar
| | - Lilly Andolfatto
- The Faculty of Medicine, Dentistry and Health Sciences, Melbourne University, Melbourne, Australia
| | - Eileen M Moore
- Department of General Surgery, Barwon Health, Geelong, Australia.,Department of General Surgery, Deakin University, Geelong, Australia
| | - David Watters
- Department of General Surgery, Barwon Health, Geelong, Australia.,Department of General Surgery, Deakin University, Geelong, Australia
| | - Aye Aye
- Department of Paediatric Surgery, Yangon Children's Hospital, Yangon, Myanmar
| | - Htun Oo
- Department of ENT Surgery, NOGH, Yangon, Myanmar
| | - Moe Moe Tin
- Department of General Surgery, North Okkalapa General Hospital, Yangon, Myanmar
| | - Mark Shrime
- Center for Global Surgery Evaluation, Massachusetts Eye and Ear Infirmary, Boston, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Center for Health and Well-Being, Princeton University, Princeton, USA
| | - Elizabeth McLeod
- Department of Paediatric Surgery, Monash Children's Hospital, 246 Clayton Road, Clayton, Melbourne, 3168, Australia
| |
Collapse
|
25
|
Naresh D, Kefalianos J, Watters D, Stupart D. Who tolerates early enteral feeding after colorectal surgery? ANZ J Surg 2020; 90:1335-1339. [PMID: 32418349 DOI: 10.1111/ans.15979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early enteral feeding and avoidance of routine nasogastric tube (NGT) placement have become standard care following colorectal surgery. However, some patients require NGT decompression post-operatively for vomiting or distension. METHODS This was a retrospective cohort study of all patients undergoing elective intra-abdominal colorectal surgery at University Hospital, Geelong, from 2014 to 2018. Failure of early feeding was defined by the placement of an NGT post-operatively, beyond the day of surgery. RESULTS A total of 754 patients were identified. Of these, 28 were excluded due to protocol violations (NGT was left in situ at the end of the operation), leaving 726 patients that were included in the analysis. Overall, 156/726 (21%) patients failed early feeding. The strongest independent predictor of failure was undergoing a total or subtotal colectomy compared with all other operations (15/28 (54%) failed versus 141/698 (20%); P < 0.001). Laparoscopic surgery was independently associated with a lower risk of failure compared with open surgery (43/278 (15%) versus 113/448 (25%); P = 0.002). Risk of failure was not associated with gender, age, American Society of Anesthesiologists score, indication for procedure, presence of anastomosis or duration of surgery. CONCLUSION Laparoscopic surgery is associated with a lower risk of failure of early feeding compared with open surgery. Patients undergoing subtotal or total colectomy have a high rate (54%) of failure. This may assist in selecting appropriate patients for early feeding after colorectal surgery.
Collapse
Affiliation(s)
- Divya Naresh
- Department of Surgery, Deakin University, University Hospital Geelong, Geelong, Victoria, Australia
| | - John Kefalianos
- Department of Surgery, Deakin University, University Hospital Geelong, Geelong, Victoria, Australia
| | - David Watters
- Department of Surgery, Deakin University, University Hospital Geelong, Geelong, Victoria, Australia
| | - Douglas Stupart
- Department of Surgery, Deakin University, University Hospital Geelong, Geelong, Victoria, Australia
| |
Collapse
|
26
|
Fordyce A, Vorias B, Taranto L, Soares A, Watters D, Saunders C. Breast disease in Timor-Leste. ANZ J Surg 2020; 90:1920-1924. [PMID: 32062871 DOI: 10.1111/ans.15720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/09/2020] [Accepted: 01/12/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgically treatable conditions are well documented in high-income countries. There is a gap in epidemiological understanding of breast pathology in many developing countries, Timor-Leste among them. This study was conducted to determine the burden of breast disease and to inform public health measures to address early detection, diagnosis and management. METHODS A retrospective quantitative case-control study was conducted at Guido Valadares National Hospital in Dili. Patients were included if they attended surgical outpatients or had a pathology specimen recorded between 1 September 2016 and 1 September 2017. RESULTS There were 444 female patients with a clinical diagnosis of breast disease over the 12-month period. The average age was 33.7 years. There were 188 (42.3% of total sample) cases of fibroadenoma and 122 (27.4% of total sample) diagnoses consistent with non-specific lumps. Of the 116 female patients presenting to Guido Valadares National Hospital who had a biopsy, 62.6% were malignant or hyperplastic in nature, and 86% of those with a malignant biopsy had clinically locally advanced disease. CONCLUSION Breast conditions including cancer in Timor-Leste are relatively common and occur in young women in the prime of their lives (37 years of age). Developing a national cancer registry and funding directed towards improving early presentation and good clinical care of breast cancer patients will be critical for reducing early morbidity and mortality and improving other patient outcomes including income loss, gender health inequality and the intergenerational effects of early parental death.
Collapse
Affiliation(s)
- Andrew Fordyce
- Department of General Surgery, Alfred Health, Melbourne, Victoria, Australia.,Global Health Division, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Blake Vorias
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Lucas Taranto
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Alito Soares
- Department of Surgery, Guido Valadares National Hospital, Dili, Timor-Leste
| | - David Watters
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Department of Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Christobel Saunders
- School of Surgery and Pathology, The University of Western Australia, Perth, Western Australia, Australia.,Department of Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Surgery, St John of God Hospital, Perth, Western Australia, Australia
| |
Collapse
|
27
|
Beasley SW, Smith K, Watters D. What leadership means as a core surgical competence in everyday practice. ANZ J Surg 2020; 90:154-158. [DOI: 10.1111/ans.15640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/29/2019] [Accepted: 12/03/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Spencer W. Beasley
- Department of Paediatric SurgeryChristchurch Hospital and Christchurch School of Medicine, University of Otago Christchurch New Zealand
| | - Kyleigh Smith
- Education DevelopmentPeter MacCallum Cancer Centre Melbourne Victoria Australia
| | - David Watters
- Department of SurgeryDeakin University and Barwon Health Geelong Victoria Australia
| |
Collapse
|
28
|
Sarfati D, Dyer R, Sam FAL, Barton M, Bray F, Buadromo E, Ekeroma A, Foliaki S, Fong J, Herman J, Huggins L, Maoate K, Meredith I, Mola G, Palafox N, Puloka V, Shin HR, Skeen J, Snowdon W, Tafuna'i M, Teng A, Watters D, Vivili P. Cancer control in the Pacific: big challenges facing small island states. Lancet Oncol 2019; 20:e475-e492. [PMID: 31395476 PMCID: PMC7746436 DOI: 10.1016/s1470-2045(19)30400-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 01/03/2023]
Abstract
This Series paper describes the current state of cancer control in Pacific island countries and territories (PICTs). PICTs are diverse but face common challenges of having small, geographically dispersed, isolated populations, with restricted resources, fragile ecological and economic systems, and overburdened health services. PICTs face a triple burden of infection-related cancers, rapid transition to lifestyle-related diseases, and ageing populations; additionally, PICTs are increasingly having to respond to natural disasters associated with climate change. In the Pacific region, cancer surveillance systems are generally weaker than those in high-income countries, and patients often present at advanced cancer stage. Many PICTs are unable to provide comprehensive cancer services, with some patients receiving cancer care in other countries where resources allow. Many PICTs do not have, or have poorly developed, cancer screening, pathology, oncology, surgical, and palliative care services, although some examples of innovative cancer planning, prevention, and treatment approaches have been developed in the region. To improve cancer outcomes, we recommend prioritising regional collaborative approaches, enhancing cervical cancer prevention, improving cancer surveillance and palliative care services, and developing targeted treatment capacity in the region.
Collapse
Affiliation(s)
- Diana Sarfati
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand.
| | - Rachel Dyer
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Filipina Amosa-Lei Sam
- Pathology Department, Tupua Tamasese Meaole Hospital, Private Bag National Health Services, Apia, Samoa
| | - Michael Barton
- Collaboration for Cancer Outcomes Research and Evaluation, Ingham Institute for Applied Medical Research, University of New South Wales, Liverpool, NSW, Australia
| | - Freddie Bray
- Cancer Surveillance Section, International Agency for Research on Cancer, Lyon, France
| | - Eka Buadromo
- Pathology Department, Vaiola Hospital, Nuku'alofa, Tonga
| | - Alec Ekeroma
- Department of Obstetrics and Gynaecology, National University of Samoa, Apia, Samoa; Department of Obstetrics and Gynaecology, University of Otago, Wellington, New Zealand
| | - Sunia Foliaki
- Centre for Public Health Research, Massey University-Wellington Campus, Wellington, New Zealand
| | - James Fong
- Obstetrics and Gynaecology Unit, Colonial War Memorial Hospital, Ministry of Health, Suva, Fiji; Department of Obstetrics and Gynaecology, Fiji National University, Suva, Fiji
| | | | - Linda Huggins
- Palliative Care Services, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand
| | - Kiki Maoate
- Department of Paediatric Surgery, Christchurch Public Hospital, Christchurch, New Zealand
| | - Ineke Meredith
- Department of Surgery, Capital; Coast District Health Board, Wellington Regional Hospital, Wellington, New Zealand
| | - Glen Mola
- Department of Obstetrics, Gynaecology and Reproductive Health, Port Moresby General Hospital, Port Moresby, Papua New Guinea; School of Medicine and Health Sciences, University of Papua New Guinea, Boroko, Papua New Guinea
| | - Neal Palafox
- Pacific Regional Cancer Programs, Department of Family Medicine and Community Health, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA; Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Viliami Puloka
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand; Health Promotion Forum of New Zealand, Auckland, New Zealand
| | - Hai-Rim Shin
- Non-communicable Disease and Health Promotion, Western Pacific Regional Office, World Health Organization, Manila, Philippines
| | - Jane Skeen
- Starship Blood and Cancer Centre, Starship Children's Health, Auckland, New Zealand
| | - Wendy Snowdon
- Division of Pacific Technical Support, World Health Organization, Suva, Fiji
| | - Malama Tafuna'i
- Department of Obstetrics and Gynaecology, National University of Samoa, Apia, Samoa
| | - Andrea Teng
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - David Watters
- Deakin University and Barwon Health, University Hospital Geelong, Geelong, VIC, Australia
| | - Paula Vivili
- Public Health Division, Pacific Community, Noumea, New Caledonia
| |
Collapse
|
29
|
Bagguley D, Fordyce A, Guterres J, Soares A, Valadares E, Guest GD, Watters D. Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste's national referral hospital. BMJ Open 2019; 9:e029812. [PMID: 31446414 PMCID: PMC6720142 DOI: 10.1136/bmjopen-2019-029812] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Our objectives were to characterise the nature and extent of delay times to essential surgical care in a developing nation by measuring the actual stages of delay for patients receiving Bellwether procedures. SETTING The study was conducted at Timor Leste's national referral hospital in Dili, the country's capital. PARTICIPANTS All patients requiring a Bellwether procedure over a 2-month period were included in the study. Participants whose procedure was undertaken more than 24 hours from initial hospital presentation were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES Data pertaining to the patient journey from onset of symptoms to emergency procedure was collected by interview of patients, their treating surgeons or anaesthetists and the medical records. Timelines were then calculated against the Three Delays Framework. RESULTS Fifty-six patients were entered into the study. Their mean delay from symptom onset to entering the anaesthesia bay for a procedure was 32.3 hours (+/-11.6). The second delay (4.1+/-2.5 hours) was significantly less than the first (20.9+/-11.5 hours; p<0.005) and third delays (7.2+/-1.2 hours; p<0.05). Additionally, patients with acute abdominal pain (of which 18/20 ultimately had open appendicectomy and two emergency laparotomies) had a delay time of 53.3 hours (+/-21.3), significantly more than that for emergency caesarean (22.9+/-18.6 hours; p<0.05) or management of an open long-bone fracture (15.5+/-5.56 hours; p<0.05). CONCLUSIONS Substantial delays were observed for all three stages and each Bellwether procedure. This study methodology could be used to measure access and the three delays to emergency surgical care in low/middle-income countries, although the actual reasons for delay may vary between regions and countries and would require a qualitative study.
Collapse
Affiliation(s)
- Dominic Bagguley
- Department of Surgery, Northern Health, Epping, Victoria, Australia
| | - Andrew Fordyce
- Department of Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Jose Guterres
- Department of Surgery, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Alito Soares
- Department of Surgery, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Edgar Valadares
- Department of Surgery, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Glenn Douglas Guest
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - David Watters
- Royal Australasian College of Surgeons, Geelong, Victoria, Australia
- Surgery, Deakin University Faculty of Health, Geelong, Victoria, Australia
| |
Collapse
|
30
|
Ekeroma A, Dyer R, Palafox N, Maoate K, Skeen J, Foliaki S, Vallely AJ, Fong J, Hibma M, Mola G, Reichhardt M, Taulung L, Aho G, Fakakovikaetau T, Watters D, Toliman PJ, Buenconsejo-Lum L, Sarfati D. Cancer management in the Pacific region: a report on innovation and good practice. Lancet Oncol 2019; 20:e493-e502. [PMID: 31395474 DOI: 10.1016/s1470-2045(19)30414-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/03/2019] [Accepted: 06/03/2019] [Indexed: 12/12/2022]
Abstract
Pacific island countries and territories (PICTs) face the challenge of a growing cancer burden. In response to these challenges, examples of innovative practice in cancer planning, prevention, and treatment in the region are emerging, including regionalisation and coalition building in the US-affiliated Pacific nations, a point-of-care test and treat programme for cervical cancer control in Papua New Guinea, improving the management of children with cancer in the Pacific, and surgical workforce development in the region. For each innovation, key factors leading to its success have been identified that could allow the implementation of these new developments in other PICTs or regions outside of the Pacific islands. These factors include the strengthening of partnerships within and between countries, regional collaboration within the Pacific islands (eg, the US-affiliated Pacific nations) and with other regional groupings of small island nations (eg, the Caribbean islands), a local commitment to the idea of change, and the development of PICT-specific programmes.
Collapse
Affiliation(s)
- Alec Ekeroma
- National University of Samoa, Le Papaigalagala Campus, To'omatagi, Samoa; Department of Obstetrics and Gynaecology, University of Otago, Wellington, Wellington, New Zealand.
| | - Rachel Dyer
- Department of Public Health, University of Otago, Wellington, Wellington, New Zealand
| | - Neal Palafox
- Pacific Regional Cancer Programs, Department of Family Medicine and Community Health, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HA, USA; Population Sciences in the Pacific Program (Cancer Prevention in the Pacific), University of Hawaii Cancer Center, Honolulu, HA, USA
| | - Kiki Maoate
- Pacific Islands Programme, Royal Australasian College of Surgeons, Melbourne, VIC, Australia; Department of Paediatric Surgery, Christchurch Public Hospital, Christchurch, New Zealand
| | - Jane Skeen
- Starship Blood and Cancer Centre, Starship Children's Health, Auckland, New Zealand
| | - Sunia Foliaki
- Centre for Public Health Research, Massey University-Wellington Campus, Wellington, New Zealand
| | - Andrew J Vallely
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea; Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - James Fong
- Obstetrics and Gynaecology Unit, Colonial War Memorial Hospital, Ministry of Health, Suva, Fiji; Fiji National University, Suva, Fiji
| | - Merilyn Hibma
- Cervical Cancer Prevention in the Pacific Alliance, Dunedin, New Zealand; Department of Pathology, University of Otago, Dunedin, New Zealand
| | - Glen Mola
- Department of Obstetrics, Gynaecology and Reproductive Health, Port Moresby General Hospital, Port Moresby, Papua New Guinea; School of Medicine and Health Sciences, University of Papua New Guinea, Boroko, Papua New Guinea
| | - Martina Reichhardt
- Cancer Council of the Pacific Islands, Yap State Department of Health Services, Yap State, Federated States of Micronesia
| | - Livinston Taulung
- Cancer Council of the Pacific Islands, Kosrae State Department of Health Services, Kosrae State, Federated States of Micronesia
| | - George Aho
- Department of Paediatrics, Vaiola Hospital, Nuku'alofa Tonga
| | | | - David Watters
- Deakin University and Barwon Health, University Hospital Geelong, Geelong, VIC, Australia
| | - Pamela J Toliman
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea; Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Lee Buenconsejo-Lum
- Pacific Regional Cancer Programs, Department of Family Medicine and Community Health, John A Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HA, USA
| | - Diana Sarfati
- Department of Public Health, University of Otago, Wellington, Wellington, New Zealand
| |
Collapse
|
31
|
Fehlberg T, Rose J, Guest GD, Watters D. The surgical burden of disease and perioperative mortality in patients admitted to hospitals in Victoria, Australia: a population-level observational study. BMJ Open 2019; 9:e028671. [PMID: 31118179 PMCID: PMC6549668 DOI: 10.1136/bmjopen-2018-028671] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Comprehensive reporting of surgical disease burden and outcomes are vital components of resilient health systems but remain under-reported. The primary objective was to identify the Victorian surgical burden of disease necessitating treatment in a hospital or day centre, including a thorough epidemiology of surgical procedures and their respective perioperative mortality rates (POMR). DESIGN Retrospective population-level observational study. SETTING The study was conducted in Victoria, Australia. Access to data from the Victorian Admitted Episodes Dataset was obtained using the Dr Foster Quality Investigator tool. The study included public and private facilities, including day-case facilities. PARTICIPANTS From January 2014 to December 2016, all admissions with an International Statistical Classification of Diseases-10 code matched to the Global Health Estimates (GHE) disease categories were included. PRIMARY AND SECONDARY OUTCOME MEASURES Admissions were assigned a primary disease category according to the 23 GHE disease categories. Surgical procedures during hospitalisations were identified using the Australian Refined Diagnosis Related Groups (AR-DRG). POMR were calculated for GHE disease categories and AR-DRG procedures. RESULTS A total of 4 865 226 admitted episodes were identified over the 3-year period. 1 715 862 (35.3%) of these required a surgical procedure. The mortality rate for those undergoing a procedure was 0.42%, and 1.47% for those without. The top five procedures performed per GHE category were lens procedures (162 835 cases, POMR 0.001%), caesarean delivery (76 032 cases, POMR 0.01%), abortion with operating room procedure (65 451 cases, POMR 0%), hernia procedures (52 499 cases, POMR 0.05%) and other knee procedures (47 181 cases, POMR 0.004%). CONCLUSIONS Conditions requiring surgery were responsible for 35.3% of the hospital admitted disease burden in Victoria, a rate higher than previously published from Sweden, New Zealand and the USA. POMR is comparable to other studies reporting individual procedures and conditions, but has been reported comprehensively across all GHE disease categories for the first time.
Collapse
Affiliation(s)
- Trafford Fehlberg
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - John Rose
- Department of Plastics and Reconstructive Surgery, Johns Hopkins, Baltimore, Maryland, USA
| | - Glenn Douglas Guest
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - David Watters
- Royal Australasian College of Surgeons, Geelong, Victoria, Australia
- Surgery, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| |
Collapse
|
32
|
Crebbin W, Beasley S, Tobin S, Guest G, Duvivier R, Watters D. Judgement: clinical decision‐making as a core surgical competency. ANZ J Surg 2019; 89:760-763. [DOI: 10.1111/ans.15098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 01/07/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Wendy Crebbin
- Royal Australasian College of Surgeons Melbourne Victoria Australia
| | - Spencer Beasley
- Paediatric SurgeryRoyal Australasian College of Surgeons, Department of Paediatric Surgery, Christchurch Hospital Christchurch New Zealand
| | - Stephen Tobin
- Central Highlands Surgeons, Ballarat Health Services Ballarat Victoria Australia
| | - Glenn Guest
- Department of Clinical and Biomedical SciencesDeakin University Geelong Victoria Australia
| | - Robbert Duvivier
- Department of Surgery, University Hospital and Deakin University Geelong Victoria Australia
| | - David Watters
- School of Health Professions EducationMaastricht University Maastricht The Netherlands
| |
Collapse
|
33
|
Richardson TE, Yanada BA, Watters D, Stupart D, Lamichhane P, Bell C. What young Australians think about a tax on sugar‐sweetened beverages. Aust N Z J Public Health 2018; 43:63-67. [DOI: 10.1111/1753-6405.12858] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/01/2018] [Accepted: 10/01/2018] [Indexed: 10/27/2022] Open
Affiliation(s)
| | | | | | | | | | - Colin Bell
- School of MedicineDeakin University Victoria
| |
Collapse
|
34
|
Ng SC, Stupart D, Bartolo D, Watters D. Anastomotic leaks in stage IV colorectal cancer. ANZ J Surg 2018; 88:E649-E653. [DOI: 10.1111/ans.14494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/06/2018] [Accepted: 02/25/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Suat Chin Ng
- Department of Surgery; University Hospital Geelong; Geelong Victoria Australia
| | - Douglas Stupart
- Department of Surgery; University Hospital Geelong and Deakin University; Geelong Victoria Australia
| | - David Bartolo
- Department of General Surgery; The University of Western Australia; Perth Western Australia Australia
| | - David Watters
- Department of Surgery; University Hospital Geelong and Deakin University; Geelong Victoria Australia
| |
Collapse
|
35
|
Ooi S, Stupart D, Gillies H, Watters D. Does the Alexis wound retractor increase the risk of blood splashes to the eyes? Early closure of a double blinded randomised controlled trial. Contemp Clin Trials Commun 2018; 10:199-200. [PMID: 30023452 PMCID: PMC6046451 DOI: 10.1016/j.conctc.2018.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 01/04/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Sally Ooi
- University Hospital Geelong, Australia
| | - Douglas Stupart
- University Hospital Geelong, Australia
- Deakin University, Australia
- Corresponding author. Dept. Surgery, University Hospital Geelong, Bellerine Street, Geelong, VIC 3220, Australia.
| | | | - David Watters
- University Hospital Geelong, Australia
- Deakin University, Australia
| |
Collapse
|
36
|
Scarfe A, Duncan J, Ma N, Cameron A, Rankin D, Karatassas A, Fletcher D, Watters D, Maddern G. Day case hernia repair: weak evidence or practice gap? ANZ J Surg 2018; 88:547-553. [PMID: 29573102 DOI: 10.1111/ans.14302] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/10/2017] [Accepted: 10/01/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Analysis of a private insurer's administrative data set revealed significant variation in the length of hospital stay following hernia surgery. OBJECTIVES This review examined factors influencing the performance of day surgery for inguinal, femoral and umbilical hernia repair in adults. DATA SOURCES A systematic literature search was conducted in the PubMed, Embase and Cochrane Library databases to identify studies and clinical practice guidelines (CPGs) comparing same day hernia surgery to surgery followed by an overnight stay. REVIEW METHODS Screening of studies by abstract and full text was completed by a single researcher and checked by a second. Studies were selected for inclusion based on a step-wise approach across three phases. RESULTS Limited evidence from one systematic review, and three case series studies including 3213 patients found that same day hernia surgery was as safe and effective as an overnight stay. All identified CPGs recommended a same day procedure for most patients. Two case series studies reported that 3-8% of patients were ineligible for day procedures due to medical reasons; however, the characteristics of patients, in general, which are not suitable, have not been adequately investigated. CONCLUSIONS Day surgery for groin hernia repair is safe and effective for most patients. However, evidence-based support is only one of many factors that may contribute to the uptake of day surgery in Australia. There is an opportunity for key stakeholders across the private healthcare system to deliver an equally effective but more sustainable and affordable hernia care by increasing the day surgery rates.
Collapse
Affiliation(s)
- Anje Scarfe
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, North Adelaide, South Australia, Australia
| | - Joanna Duncan
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, North Adelaide, South Australia, Australia
| | - Ning Ma
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, North Adelaide, South Australia, Australia
| | - Alun Cameron
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, North Adelaide, South Australia, Australia
| | - David Rankin
- Provider Networks and Integrated Care, Medibank Private, Melbourne, Victoria, Australia
| | - Alex Karatassas
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - David Fletcher
- Department of General Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - David Watters
- Department of Surgery, Geelong Hospital and Deakin University, Geelong, Victoria, Australia
| | - Guy Maddern
- Department of Surgery, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| |
Collapse
|
37
|
Khajehnoori M, Stupart D, Watters D. Publication rate of General Surgery abstracts presented at the Royal Australasian College of Surgeons Annual Scientific Congress. ANZ J Surg 2017; 88:16-19. [DOI: 10.1111/ans.14103] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/03/2017] [Accepted: 05/09/2017] [Indexed: 11/28/2022]
Affiliation(s)
| | - Douglas Stupart
- Department of Surgery; University Hospital; Geelong Victoria Australia
| | - David Watters
- Department of Surgery; University Hospital; Geelong Victoria Australia
| |
Collapse
|
38
|
McQueen KA, Coonan T, Derbew M, Tangi V, Bickler S, Banguti P, Gruen R, Watters D. The 2015 Bangkok Global Surgery Declaration: A Call to the Global Health Community to Promote Implementation of the World Health Assembly Resolution for Surgery and Anaesthesia Care. World J Surg 2016; 41:7-9. [DOI: 10.1007/s00268-016-3697-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
39
|
Sullivan R, Alatise OI, Anderson BO, Audisio R, Autier P, Aggarwal A, Balch C, Brennan MF, Dare A, D'Cruz A, Eggermont AMM, Fleming K, Gueye SM, Hagander L, Herrera CA, Holmer H, Ilbawi AM, Jarnheimer A, Ji JF, Kingham TP, Liberman J, Leather AJM, Meara JG, Mukhopadhyay S, Murthy SS, Omar S, Parham GP, Pramesh CS, Riviello R, Rodin D, Santini L, Shrikhande SV, Shrime M, Thomas R, Tsunoda AT, van de Velde C, Veronesi U, Vijaykumar DK, Watters D, Wang S, Wu YL, Zeiton M, Purushotham A. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2016; 16:1193-224. [PMID: 26427363 DOI: 10.1016/s1470-2045(15)00223-5] [Citation(s) in RCA: 396] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 08/07/2015] [Accepted: 08/07/2015] [Indexed: 12/20/2022]
Abstract
Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.
Collapse
Affiliation(s)
- Richard Sullivan
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; King's Centre for Global Health, King's Health Partners and King's College London, London, UK.
| | | | - Benjamin O Anderson
- University of Washington School of Medicine, Seattle, WA, USA; Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Ajay Aggarwal
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK; London School of Hygiene & Tropical Medicine, London, UK
| | - Charles Balch
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Anna Dare
- Centre for Global Health Research, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anil D'Cruz
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | | | - Kenneth Fleming
- Green Templeton College, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Trust, Oxford, UK
| | - Serigne Magueye Gueye
- University Cheikh Anta Diop, Dakar, Senegal; Grand Yoff General Hospital, Dakar, Senegal
| | - Lars Hagander
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden
| | - Cristian A Herrera
- Cabinet of the Minister, Ministry of Health, Santiago, Chile; Department of Public Health, School of Medicine, Pontificia Universidad Católica, Santiago, Chile
| | - Hampus Holmer
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden
| | - André M Ilbawi
- University of Texas MD Anderson Cancer Centre, Houston, TX, USA; Union for International Cancer Control, Geneva, Switzerland
| | - Anton Jarnheimer
- Paediatric Surgery and Global Paediatrics, Department of Paediatrics, Lund University, Lund, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jia-Fu Ji
- Peking University Cancer Hospital and Institute, Beijing, China; Chinese Anti-Cancer Association, Tianjin, China
| | | | | | - Andrew J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - John G Meara
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shilpa S Murthy
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Public Health, Boston, MA, USA; Department of General Surgery, Indiana University, Bloomington, IN, USA
| | | | - Groesbeck P Parham
- Department of Obstetrics and Gynecology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA; University of Zambia, Lusaka, Zambia
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Robert Riviello
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Public Health, Boston, MA, USA
| | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Luiz Santini
- INCA (Brazilian National Cancer Institute), Rio de Janeiro, Brazil
| | | | - Mark Shrime
- Program in Global Surgery and Social Change, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Thomas
- Department of Health & Human Services, Melbourne, VIC, Australia
| | - Audrey T Tsunoda
- Gyne-Oncology Department, Barretos Cancer Hospital, Barretos, Brazil
| | - Cornelis van de Velde
- Department of Surgical Oncology, Endocrine and Gastrointestinal Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | | | - David Watters
- Deakin University, Geelong, VIC, Australia; Barwon Health, Geelong, VIC, Australia
| | - Shan Wang
- Peking University People's Hospital, Beijing, China; Chinese College of Surgeons, Beijing, China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong General Hospital, Guangzhou, China; Guangdong Academy of Medical Sciences, Guangzhou, China; Chinese Society of Clinical Oncology, Beijing, China
| | - Moez Zeiton
- Sadeq Institute, Tripoli, Libya; Trauma and Orthopaedic Rotation, North-West Deanery, Manchester, UK
| | - Arnie Purushotham
- Institute of Cancer Policy, King's Health Partners Comprehensive Cancer Centre, London, UK; King's Centre for Global Health, King's Health Partners and King's College London, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
40
|
Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SLM, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg G, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth 2015; 25:75-8. [PMID: 26597405 DOI: 10.1016/j.ijoa.2015.09.006] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- John G Meara
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA; Boston Children's Hospital, Boston, MA, USA.
| | - Andrew J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Lars Hagander
- Pediatric Surgery and Global Pediatrics, Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Blake C Alkire
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Nivaldo Alonso
- Plastic Surgery Department, University of São Paulo, São Paulo, Brazil
| | - Emmanuel A Ameh
- Department of Surgery, Division of Peadiatric Surgery, National Hospital, Abuja, Nigeria
| | - Stephen W Bickler
- Rady Children's Hospital, University of California, San Diego, San Diego, CA, USA
| | - Lesong Conteh
- School of Public Health, Imperial College London, London, UK
| | - Anna J Dare
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | | | | | | | - Paul E Farmer
- Department of Global Health and Social Medicine, Division of Global Health Equity, Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA; Partners in Health, Boston, MA, USA
| | - Atul Gawande
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Ariadne Labs Boston, MA, USA
| | - Rowan Gillies
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Sarah L M Greenberg
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA; Boston Children's Hospital, Boston, MA, USA; Medical College of Wisconsin, Milwaukee, WI, USA
| | - Caris E Grimes
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Russell L Gruen
- The Alfred Hospital and Monash University, Melbourne, VIC, Australia; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | - Thaim Buya Kamara
- Connaught Hospital, Freetown, Sierra Leone; Department of Surgery, University of Sierra Leone, Freetown, Sierra Leone
| | - Chris Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ganbold Lundeg
- Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Nyengo C Mkandawire
- Department of Surgery, College of Medicine, University of Malawi, Blantyre, Malawi; School of Medicine, Flinders University, Adelaide, SA, Australia
| | - Nakul P Raykar
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA; Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Johanna N Riesel
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA; Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Edgar Rodas
- The Cinterandes Foundation, Universidad del Cuenca, and Universidad del Azuay, Cuenca, Ecuador; Universidad del Azuay, Cuenca, Ecuador
| | - John Rose
- Department of Surgery, University of California, San Diego, CA, USA
| | | | - Mark G Shrime
- Department of Otology and Laryngology, Harvard Medical School, Boston, USA; Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA; Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA; Harvard Interfaculty Initiative in Health Policy, Cambridge, MA, USA
| | - Richard Sullivan
- Institute of Cancer Policy, Kings Health Partners Integrated Cancer Centre, King's Centre for Global Health, King's College London, London, UK
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - David Watters
- Royal Australasian College of Surgeons, East Melbourne and Deakin University, Melbourne, VIC, Australia
| | - Thomas G Weiser
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Iain H Wilson
- Department of Anaesthesia, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Gavin Yamey
- Evidence to Policy Initiative, Global Health Group, University of California, San Francisco, CA, USA
| | - Winnie Yip
- Blavatnik School of Government, University of Oxford, Oxford, UK
| |
Collapse
|
41
|
Sullivan R, Olusegun I, Anderson B, Audisio R, Autier P, Aggarwal A, Balch C, Brennan M, Dare A, D'Cruz A, Eggermont A, Fleming K, Hagander L, Herrera C, Ilbawi A, Ji J, Kingham T, Liberman J, Leather A, Meara J, Murthy S, Omar S, Parham G, Pramesh C, Riviello R, Rodin D, Santini L, Shrikhande S, Shrime M, Thomas R, Tsunoda A, Watters D, Wang S, Wu Y, Van de Velde F, Veronesi U, Zeiton M, Purushotham A. 9LBA Delivering safe and affordable cancer surgery to all - a Lancet Oncology Commission. Eur J Cancer 2015. [DOI: 10.1016/s0959-8049(16)31933-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
42
|
Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SLM, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg G, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015; 386:569-624. [PMID: 25924834 DOI: 10.1016/s0140-6736(15)60160-x] [Citation(s) in RCA: 2072] [Impact Index Per Article: 230.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- John G Meara
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA; Boston Children's Hospital, Boston, MA, USA.
| | - Andrew J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Lars Hagander
- Pediatric Surgery and Global Pediatrics, Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Blake C Alkire
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Nivaldo Alonso
- Plastic Surgery Department, University of São Paulo, São Paulo, Brazil
| | - Emmanuel A Ameh
- Department of Surgery, Division of Peadiatric Surgery, National Hospital, Abuja, Nigeria
| | - Stephen W Bickler
- Rady Children's Hospital, University of California, San Diego, San Diego, CA, USA
| | - Lesong Conteh
- School of Public Health, Imperial College London, London, UK
| | - Anna J Dare
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | | | | | | | - Paul E Farmer
- Department of Global Health and Social Medicine, Division of Global Health Equity, Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA; Partners in Health, Boston, MA, USA
| | - Atul Gawande
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Ariadne Labs Boston, MA, USA
| | - Rowan Gillies
- Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Sarah L M Greenberg
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA; Boston Children's Hospital, Boston, MA, USA; Medical College of Wisconsin, Milwaukee, WI, USA
| | - Caris E Grimes
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Russell L Gruen
- The Alfred Hospital and Monash University, Melbourne, VIC, Australia; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | - Thaim Buya Kamara
- Connaught Hospital, Freetown, Sierra Leone; Department of Surgery, University of Sierra Leone, Freetown, Sierra Leone
| | - Chris Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ganbold Lundeg
- Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Nyengo C Mkandawire
- Department of Surgery, College of Medicine, University of Malawi, Blantyre, Malawi; School of Medicine, Flinders University, Adelaide, SA, Australia
| | - Nakul P Raykar
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA; Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Johanna N Riesel
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Edgar Rodas
- The Cinterandes Foundation, Universidad del Cuenca, and Universidad del Azuay, Cuenca, Ecuador; Universidad del Azuay, Cuenca, Ecuador
| | - John Rose
- Department of Surgery, University of California, San Diego, CA, USA
| | | | - Mark G Shrime
- Department of Otology and Laryngology, Harvard Medical School, Boston, USA; Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA; Harvard Interfaculty Initiative in Health Policy, Cambridge, MA, USA
| | - Richard Sullivan
- Institute of Cancer Policy, Kings Health Partners Integrated Cancer Centre, King's Centre for Global Health, King's College London, London, UK
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - David Watters
- Royal Australasian College of Surgeons, East Melbourne, and Deakin University, Melbourne, VIC, Australia
| | - Thomas G Weiser
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Iain H Wilson
- Department of Anaesthesia, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Gavin Yamey
- Evidence to Policy Initiative, Global Health Group, University of California, San Francisco, CA, USA
| | - Winnie Yip
- Blavatnik School of Government, University of Oxford, Oxford, UK
| |
Collapse
|
43
|
Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SL, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Ganbold L, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Surgery 2015; 158:3-6. [DOI: 10.1016/j.surg.2015.04.011] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 04/14/2015] [Indexed: 11/24/2022]
|
44
|
Moore E, Pasco J, Mander A, Sanders K, Carne R, Jenkins N, Black M, Schneider H, Ames D, Watters D. The prevalence of vitamin B12 deficiency in a random sample from the Australian population. ACTA ACUST UNITED AC 2014. [DOI: 10.5455/jib.20140716041521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
45
|
Mahar PD, Wasiak J, Cleland H, Watters D, Paul E, Marsh P, Gin D. Mortality and use of the auxiliary score in extensive toxic epidermal necrolysis patients admitted to an adult burns referral centre. Dermatology 2013; 227:180-5. [PMID: 24080507 DOI: 10.1159/000354264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 07/08/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Toxic epidermal necrolysis (TEN) is a rare but fatal condition characterised by cutaneous exfoliation of the dermoepidermal layer and mucosal surfaces. Extensive TEN with epidermal detachment >30% of the total body surface area has been associated with a high mortality. OBJECTIVE This study aims to evaluate factors associated with mortality in extensive TEN. In the absence of data to qualify scoring systems such as SCORTEN, this study also aims to evaluate the use of the auxiliary score as a tool for calculating expected mortality. METHODS A retrospective chart review of all patients presenting to our burns service with extensive TEN was undertaken. Application and evaluation of the auxiliary score was also undertaken for this patient population. RESULTS In extensive TEN, age and delay in admission to a burns centre were factors associated with mortality. Applying the auxiliary score to our patient population, there were no significant differences between expected mortality and observed mortality. CONCLUSION Mortality was associated with age and delay in definitive treatment in extensive TEN. Whilst SCORTEN is the gold standard prognostic tool for patients with TEN, in the absence of SCORTEN values, the auxiliary score provides an alternative scoring system to evaluate expected mortality.
Collapse
Affiliation(s)
- Patrick D Mahar
- Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Vic., Australia
| | | | | | | | | | | | | |
Collapse
|
46
|
Affiliation(s)
- M.F. Lavin
- Queensland Cancer Fund Research Unit, Queensland Institute of Medical Research, Bancroft Centre, 300 Herston Road, Brisbane, 4029, Australia
| | - K.K. Khanna
- Department of Surgery, University of Queensland, Herston, Brisbane, 4029, Australia
| | - H. Beamish
- Queensland Cancer Fund Research Unit, Queensland Institute of Medical Research, Bancroft Centre, 300 Herston Road, Brisbane, 4029, Australia
| | - B. Teale
- Department of Surgery, University of Queensland, Herston, Brisbane, 4029, Australia
| | - K. Hobson
- Queensland Cancer Fund Research Unit, Queensland Institute of Medical Research, Bancroft Centre, 300 Herston Road, Brisbane, 4029, Australia
| | - D. Watters
- Department of Surgery, University of Queensland, Herston, Brisbane, 4029, Australia
| |
Collapse
|
47
|
Kalogeropoulos G, Watters D, Brereton S. GS20�*ADVERSE EVENTS IN GENERAL SURGERY. ANZ J Surg 2009. [DOI: 10.1111/j.1445-2197.2009.04917_20.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
48
|
Bernardi MP, Watters D. SH18�BARBER-SURGEONS: A DOOMED GUILD OF MASTERS AND MISTERS IN THE MIDDLE AGES. ANZ J Surg 2009. [DOI: 10.1111/j.1445-2197.2009.04931_18.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
49
|
Watters D. "Where do we go from here boys, where do we go from here?". Scand J Haematol Suppl 2009; 40:567-8. [PMID: 6591411 DOI: 10.1111/j.1600-0609.1984.tb02620.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
50
|
Dickinson I, Watters D, Graham I, Montgomery P, Collins J. Guide to the Assessment of Competence and Performance in Practising Surgeons. ANZ J Surg 2009; 79:198-204. [DOI: 10.1111/j.1445-2197.2008.04839.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|