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Introduction: This cohort study aimed to elucidate the caregiver burden of helmet therapy (HT), following endoscopic strip craniectomy (ESC) to treat craniosynostosis, in an effort to inform clinicians and future caregivers navigating this therapeutic option., Methods: Fourteen caregivers of children with positional plagiocephaly (6) and craniosynostosis treated by ESC (8) undergoing HT at a single center were recruited via convenience sampling. Using a phenomenological qualitative approach, semi-structured interviews were conducted to understand the experience of HT for caregivers. Data collection and analysis were iterative and conducted until thematic saturation was reached., Results: Emerging themes revealed five domains of caregiver burden: emotional, cognitive, physical, psychosocial, and financial. No caregiver felt the therapy was too burdensome to complete. Caregivers of both groups also expressed positive aspects of HT related to support from the team, the noninvasive nature of treatment, and the outcomes of therapy. Furthermore, caregivers report overall satisfaction with the process, stating willingness to repeat the treatment with subsequent children if required., Conclusion: HT is associated with five major domains of caregiver burden; however, none of the caregivers regret choosing this treatment option, nor was the burden high enough to encourage treatment cessation. This study will inform future prospective analyses that will quantify real-time caregiver burden throughout HT., (© 2024 S. Karger AG, Basel.)

Objective: Craniopharyngiomas with a predominant cystic component are often seen in children and can be treated with an Ommaya reservoir for aspiration and/or intracystic therapy. In some cases, cannulation of the cyst can be challenging via a stereotactic or transventricular endoscopic approach due to its size and proximity to critical structures. In such cases, a novel placement technique for Ommaya reservoirs via a lateral supraorbital incision and supraorbital minicraniotomy has been used., Methods: The authors conducted a retrospective chart review of all children undergoing supraorbital Ommaya reservoir insertion from January 1, 2000, to December 31, 2022, at the Hospital for Sick Children, Toronto. The technique involves a lateral supraorbital incision and a 3 × 4-cm supraorbital craniotomy, with identification and fenestration of the cyst under the microscope and insertion of the catheter. The authors assessed baseline characteristics and clinical parameters of surgical treatment and outcome. Descriptive statistics were conducted. A review of the literature was performed to identify other studies describing a similar placement technique., Results: A total of 5 patients with cystic craniopharyngioma were included (3 male, 60%) with a mean age of 10.20 ± 5.72 years. The mean preoperative cyst size was 11.6 ± 3.7 cm3, and none of the patients suffered from hydrocephalus. All patients suffered from temporary postoperative diabetes insipidus, but no new permanent endocrine deficits were caused by the surgery. Cosmetic results were satisfactory., Conclusions: This is the first report of lateral supraorbital minicraniotomy for Ommaya reservoir placement. This is an effective and safe approach in patients with cystic craniopharyngiomas, which cause local mass effect but are not amenable to traditional Ommaya reservoir placement stereotactically or endoscopically.

Background: Dual venous drainage for anterolateral thigh flaps has been proposed to protect against flap-related complications in head and neck applications. Here we report our experience with single vs dual venous anastomosis during lower extremity free-tissue transfer., Methods: All free anterolateral thigh flaps for lower extremity reconstruction from 2011 to 2017 were retrospectively reviewed. An algorithm was used to determine the type and number of venous anastomoses, emphasizing patient anatomy, venous quality, and size match. Patients were divided into single- and dual-venous-anastomosis groups. Univariate analysis determined differences between the groups. A multivariable analysis identified independent risk factors., Results: Fifty patients met the inclusion criteria. Patient demographics, recipient sites, wound type, and flap characteristics were similar in 1 and 2 vein groups. Average follow-up was 9.6 months. Forty-two percent underwent single venous drainage anastomoses. Mean age was 52.7 years, 78.0% were male, and 60% had defects of the foot and ankle. Increased flap area and early dangling did not increase flap demise. Thirty-three percent of single-drainage patients and 31.0% of dual-drainage patients had a complication. A body mass index of greater than 30 kg/m 2 was a predictor for both flap complication ( P = 0.025) and partial flap loss ( P = 0.031) in univariate analysis. No independent predictors were found in multivariate analysis., Conclusions: The number of venous anastomoses, area, and dangling protocol did not influence outcomes while using our lower extremity vein method. Thoughtful evaluation of venous egress should outweigh the routine use of multiple veins in perforator flap reconstructions of the lower extremity., Competing Interests: Conflicts of interest and sources of funding: The authors did not receive any funding for this study. None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this article. There are also no commercial associations., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Hypertrophic burn scars contribute to morbidity through secondary symptoms of pain, pruritus, and scar contracture. Traditional treatment methods are now augmented by the use of monochromatic light therapies, which are generally accepted as safe and effective. However, little literature is available regarding the complications of laser treatments of hypertrophic burn scars and even less regarding inflammatory and infectious complications., Methods: A literature search using PubMed was performed to identify literature pertaining to infectious and inflammatory complications of cutaneous laser treatments. Additionally, we reviewed cases of inflammatory and infectious complications occurring at our institution after laser treatment of hypertrophic burn scars., Results: We identified 1 publication related to complications of laser therapy in the treatment of burn scars. In this series of 163 laser sessions, the reported incidence of adverse events was 25.1%, of which 6 cases 3.7% were related to inflammatory and infectious processes. In the 391 laser sessions performed at our institution (December, 2015 and July, 2016) 9 cases of inflammatory and infectious complications were noted yielding an incidence of 2.3%. Cases included 3 each of cellulitis, Systemic Inflammatory Response Syndrome (SIRS), and complicated SIRS., Conclusion: We found the most common inflammatory complication was SIRS with MSSA positive wound cultures. Three cases underwent hospitalization along with fluids and vasopressors, despite negative blood cultures. In light of the high prevalence of MSSA in the natural skin flora and negative blood cultures, the inability to establish a true source of infection lead to declaring these cases "complicated SIRS" and not sepsis. Correlative factors that may have led to complications reported in our cases were: preoperative evidence of infection, no preoperative antibiotics administered, no postoperative antibiotic dressings, combined procedures, and large treatment areas. The true mechanism of inflammatory and infectious complication is yet to be determined, but we postulate that these factors place a greater challenge on an already burdened immune system. Determining whether this is a true causal mechanism, leading to an aggravated inflammatory response, benefits from further investigation., Applicability of Research to Practice: We urge institutions preforming such procedures to advise patients on preoperative wound preparation. We recommend that each individual with a preexisting history of infection and/or preoperative culture evidence of infection receive antibiotics, particularly when undergoing combined procedures or procedures involving higher surface areas. Although complications are rare, the benefits of these precautionary measures outweigh the risks when it comes to prevention and management., (Copyright © 2021 Elsevier Ltd and ISBI. All rights reserved.)

Abstract: Meningothelial hamartoma of the scalp is a rare entity characterized by a mix of meningothelial tissue and various connective tissue elements. To the best of the authors' knowledge, there has only been one reported case of meningothelial hamartoma of the scalp in the setting of Gorlin syndrome in the literature. In this report, we describe the case of a 3-year-old boy with Gorlin syndrome who presented with a congenital scalp lesion. Histologic examination revealed scattered islands of meningothelial cells in a background of dense fibrous and vascular tissue, in keeping with meningothelial hamartoma of the scalp. The differential diagnoses of congenital scalp lesions and the association between Gorlin syndrome and meningothelial hamartoma of the scalp are discussed., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Bilateral coronal craniosynostosis in Apert syndrome is traditionally managed with open cranial vault remodeling procedures like fronto-orbital advancement (FOA). However, as minimally invasive procedures gain popularity, limited data exist to determine their efficacy in this syndromic population. This study examines whether endoscopic strip craniectomy (ESC) is inferior to FOA in correcting head growth in patients with Apert syndrome., Methods: The authors conducted a retrospective review of children with Apert syndrome over a 23-year period. Postoperative head circumferences until 24 months of age were compared for patients treated with ESC versus FOA by using normative growth curves. Intraoperative and postoperative morbidity was compared between groups., Results: The median postoperative follow-up for the FOA (n = 14) and ESC (n = 16) groups was 40 and 28.5 months, the median age at operation was 12.8 and 2.7 months, and the median operative time was 285 and 65 minutes, respectively (p < 0.001). The FOA group had significantly higher rates of blood transfusion, ICU admission, and longer hospital length of stay (p < 0.01). There were no statistically significant differences in premature reossification rates, complications, need for further procedures, or complaints of asymmetry. Compared to normative growth curves, all patients in both groups had head circumferences comparable to or above the 85th percentile at last follow-up., Conclusions: Children with Apert syndrome and bilateral coronal craniosynostosis treated with ESC experience early normalization of head growth and cephalic index that is not inferior to those treated with FOA. Longer-term assessments are needed to determine long-term aesthetic results and the correlation between head growth and neurocognitive development in this population.

Background: Plastic surgeons have been early adopters of social media, and the efficacy and ethics of this practice have been studied. In addition, plastic and reconstructive surgery (PRS) training programs have begun using social media to connect with the public, including prospective PRS applicants. The ability of social media to attract prospective residency applicants is unknown. This study aims to examine the influence of social media on prospective residency applicants and their perception of a plastic surgery program., Methods: In the academic years 2018 and 2019, we conducted an anonymous, voluntary survey among applicants applying to both the integrated and independent Harvard PRS residency programs. The survey collected data regarding demographics, social media usage, online information gathering, and PRS programs' social media influence on applicants' perception/rank position of programs., Results: One hundred nine surveys were completed (23%). Ninety-seven percent of respondents reported searching online for information about residency programs. Twenty percent of respondents noted that a residency program's social media platform "influenced their perception of a program or intended rank position of a program" and 72% of those respondents indicated a positive effect on their perception of a program and its rank list position. At least 15% of respondents were concerned that engaging with a program's social media account would attract attention to their own social media accounts., Conclusions: Applicants routinely rely on online resources to gather information regarding prospective residency programs. Fear of attracting attention to their own personal social media pages may limit applicants' engagement with PRS programs on social media. However, residency programs can still utilize social media to deliver important messages, especially as social media usage continues to grow., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Control of tip projection and rotation is critical to a successful rhinoplasty. Suture techniques that change the relationship of the medial crura to the caudal septum can effectively manage tip position, but may be technically challenging or require specialized sutures. The authors present a technique ("tip delamination") that allows symmetrical exposure of the medial crura and caudal septum for accurate placement of projection control sutures using commonly available suture materials., Methods: We describe a novel technique to completely expose (or delaminate) the medial crura of the lower lateral cartilages to allow for 360-degree access to and manipulation of these critical structures. We present a case series of 3 patients., Results: Exemplary cases with 1 intraoperative video will be reviewed to demonstrate how tip delamination allows for more precise control of the medial crura and nasal tip., Conclusions: Nasal tip delamination is a simple technique for manipulating the medial crura and nasal tip in rhinoplasty procedures. Nasal tip delamination adds minimal time and morbidity to the procedure and offers significant control for the surgeon, with beneficial outcomes for the patient., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: The Lancet Commission on Global Surgery showed that countries with surgeon, anesthetist, and obstetrician (SAO) densities of 20-40 SAO/100,000 population were associated with improved health outcomes and recommended a global surgical workforce scale-up by 2030. Whether countries would be able to achieve such scale-up efforts in that time-frame is unknown., Methods: A differential equation model was used to estimate the growth rate and number of SAO necessary for each country to reach the aforementioned SAO densities. Workforce data from Mexico and India were used to estimate achievable rates of SAO scale-up for middle- and low-income countries, respectively. Secular surgical growth rates were estimated to demonstrate what might occur without dedicated scale-up efforts., Results: To reach at least 20 SAO/100,000 population in all countries by 2030, over 808 thousand SAO need to be trained by 2030. To reach at least 40 SAO/100,000 population, over 2.1 million SAO need to be trained. If countries adopt a scale-up rate similar to Mexico's previously achieved rate of scale-up, 66% of countries would have 20 SAO/100,000 population by 2030. If countries adopt a scale-up rate similar to India's previously achieved rate of scale-up, 56% would have 20 SAO/100,000 population by 2030., Conclusion: With dedicated efforts in surgical workforce scale-up, significant gains in SAO density can be made worldwide. However, without intervention, many countries are unlikely to improve their current workforce densities. Investments in workforce scale-up are likely to yield workforce gains that mirror current resource states.

Background: Five billion people lack access to safe, affordable, and timely surgical care; this is in part driven by severe shortages in the global surgical workforce. Task shifting is commonly implemented to expand the surgical workforce. A more complete understanding of the global distribution and use of surgical, obstetric, and anesthetic task shifting is lacking in the literature. We aimed to document the use of task shifting worldwide with a systematic review of the literature., Methods: We performed a systematic review of 10 health literature databases. We included journal articles published between January 1, 1995, and February 17, 2017, documenting the provision of surgical or anesthetic care by associate clinicians (any non-physician clinician). We extracted data for health cadres performing task shifting, types of tasks performed, training programs, and levels of supervision, and compared these across regions and income groups., Results: We identified 55 relevant studies, with data for 52 countries for surgery and 147 countries for anesthesia. Surgical task shifting was documented in 19 of 52 countries and anesthetic task shifting in 119 of 147. Task shifting was documented across all World Bank income groups. No associate clinicians were found to perform surgical procedures unsupervised in high-income countries (0 of 3 countries with data). Independent anesthesia care by associate clinicians was noted in 3 of 19 countries with data. In low-income countries, associate clinicians performed surgical procedures independently in 2 of 3 countries and independent anesthesia care in 17 of 17 countries with data., Conclusion: Task shifting is used to augment the global surgical, obstetric, and anesthetic workforce across all geographic regions and income groups. Associate clinicians are ubiquitous among the global surgical workforce and should be considered in plans to scale up the surgical workforce. Further research is required to assess outcomes, especially in low-income and middle-income countries where documented supervision is less robust., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: There are little primary data available on the delivery or quality of surgical treatment in rural sub-Saharan African hospitals. To initiate a quality improvement system, we characterized the existing data capture at a Ugandan Regional Referral Hospital., Methods: We examined the surgical ward admission (January 2008-December/2011) and operating theater logbooks (January 2010-July 2011) at Mbarara Regional Referral Hospital., Results: There were 6346 admissions recorded over three years. The mean patient age was 31.4 ± 22.3 years; 29.8 % (n = 1888) of admissions were children. Leading causes of admission were general surgical problems (n = 3050, 48.1 %), trauma (n = 2041, 32.2 %), oncology (n = 718, 11.3 %) and congenital condition (n = 193, 3.0 %). Laparotomy (n = 468, 35.3 %), incision and drainage (n = 188, 14.2 %) and hernia repair (n = 90, 6.8 %) were the most common surgical procedures. Of 1325 operative patients, 994 (75 %) had an ASA I-II score. Of patients undergoing 810 procedures booked as non-elective, 583 (72 %) had an ASA "E" rating. Records of 41.3 % (n-403/975) of patients age 5 years or older undergoing non-obstetric operations were missing from the ward logbook. Missing patients were younger (25 [13,40] versus 30 [18,46] years, p = 0.002) and had higher ASA scores (ASA III-V 29.0 % versus 18.9 %, p < 0.001) than patients recorded in the logbbook; there was no diffence in gender (male 62.8 % versus 67.0 %, p = 0.20)., Conclusions: The hospital records system measures surgical care, but improved data capture is needed to determine outcomes with sufficient accuracy to guide and record expansion of surgical capacity.

Background: Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care., Methods: We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures., Findings: The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p < 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures., Interpretation: Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.

Background: Charitable organizations may play a significant role in the delivery of surgical care in low- and middle-income countries (LMICs). However, in order to quantify their collective contribution, to account for the care they provide in national surgical plans, and to maximize coordination between organizations, a comprehensive database of these groups is required. We aimed to create such a database using web-available data., Methods: We searched for organizations that meet the United Nations Rule of Law definition of non-governmental organizations and provide surgery in LMICs. We termed these surgical non-governmental organizations (s-NGOs). We screened multiple sources including a listing of disaster relief organizations, medical volunteerism databases, charity commissions, and the results of a literature search. We performed a secondary review of each eligible organization's website to verify inclusion criteria and extracted data., Results: We found 403 s-NGOs providing surgery in all 139 LMICs, with most (61 %) incorporating surgery into a broader spectrum of health services. Over 80 % of s-NGOs had an office in the USA, the UK, Canada, India, or Australia, and they most commonly provided surgery in India (87 s-NGOs), Haiti (71), Kenya (60), and Ethiopia (55). The most common specialties provided were general surgery (184), obstetrics and gynecology (140), and plastic surgery (116)., Conclusions: This new catalog includes the largest number of s-NGOs to date, but this is likely to be incomplete. This list will be made publicly available to promote collaboration between s-NGOs, national health systems, and global health policymakers.

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future., Competing Interests: Competing interests: AV is director of Developing Health Globally at the GE foundation, the philanthropic organisation of GE. SMR is Chief Executive Officer of Gradian Health Systems, a non-profit medical device company that manufactures and distributes technology for anaesthesia and surgical applications in low income environments.

Objective: The Massachusetts General Hospital (MGH) Department of Surgery established the Global Surgery Initiative (GSI) in 2013 to transform volunteer and mission-based global surgery efforts into an educational experience in surgical systems strengthening. The objective of this newly conceived mission is not only to perform advanced surgery but also to train surgeons beyond MGH through international partnerships across disciplines. At its inception, a clear pathway to achieve this was not established, and we sought to identify steps that were critical to realizing our mission statement., Setting: Massachusetts General Hospital, Boston, MA, USA and Mbarara Regional Referral Hospital, Mbarara, Uganda, Participants: Members of the MGH and MRRH Departments of Surgery including faculty, fellows, and residents, Results: The MGH GSI steering committee identified 4 steps for sustaining a robust global surgery program: (1) administer a survey to the MGH departmental faculty, fellows, and residents to gauge levels of experience and interest, (2) catalog all ongoing global surgical efforts and projects involving MGH surgical faculty, fellows, and residents to identify areas of overlap and opportunities for collaboration, (3) establish a longitudinal partnership with an academic surgical department in a limited-resource setting (Mbarara University of Science and Technology (MUST) at Mbarara Regional Referral Hospital (MRRH)), and (4) design a formal curriculum in global surgery to provide interested surgical residents with structured opportunities for research, education, and clinical work., Conclusions: By organizing the collective experiences of colleagues, synchronizing efforts of new and former efforts, and leveraging the funding resources available at the local institution, the MGH GSI hopes to provide academic benefit to our foreign partners as well as our trainees through longitudinal collaboration. Providing additional financial and organizational support might encourage more surgeons to become involved in global surgery efforts. Creating a partnership with a hospital in a limited-resource setting and establishing a formal global surgery curriculum for our residents allows for education and longitudinal collaboration. We believe this is a replicable model for building other academic global surgery endeavors that aim to strengthen health and surgical systems beyond their own institutions., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, affordable surgical and anaesthesia care when needed. We aimed to estimate the number of individuals worldwide without access to surgical services as defined by the Commission's vision., Methods: We modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and affordability. We built a chance tree for each country to model the probability of surgical access with respect to each dimension, and from this we constructed a statistical model to estimate the proportion of the population in each country that does not have access to surgical services. We accounted for uncertainty with one-way sensitivity analyses, multiple imputation for missing data, and probabilistic sensitivity analysis., Findings: At least 4·8 billion people (95% posterior credible interval 4·6-5·0 [67%, 64-70]) of the world's population do not have access to surgery. The proportion of the population without access varied widely when stratified by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western sub-Saharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access., Interpretation: Most of the world's population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all., Funding: None., (Copyright © 2015 Alkire et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.)

Background: In the face of staggering global unmet need for surgical care, non-governmental organisations (NGOs) play a substantial part in the surgical workforce, providing surgical care for those who are without it. The number of NGOs providing surgical care in low-income and middle-income countries (LMICs) is unknown. This information is needed to determine the scope of such care, its contributions to global surgical case volume, to improve collaboration in an effort to maximise efficiency, and to inform national surgical workforce planning. We aimed to create a comprehensive, publicly available catalogue of NGOs providing surgery in LMICs., Methods: We used the United Nations Rule Of Law definition to define NGOs. We included low-income, lower-middle- income, and upper-middle-income countries as defined by World Bank lending groups. Delivery of surgical care by an NGO was defined as the therapeutic manipulation of tissues taking place within an operating room, and was distinguished from the financial or logistical support of such care. We screened an online humanitarian clearing house (ReliefWeb), a large public NGO database (Idealist.org), two surgical volunteerism databases (Operation Giving Back and the Society for Pediatric Anesthesia), and the US State Department Private Volunteer Organizations database, did a review of the literature, and used a social media outlet (Twitter) to identify organisations meeting criteria for inclusion. A complementary analysis additionally provided a list of organisations delivering exclusively surgical care from a search of the OmniMed database, the Foundation Center Online Directory, UK Charity Commission, Australia Charity Commission, New Zealand Charity Commission, and the Canada Revenue Agency Charity Search., Findings: We identified 313 unique organisations, working in all 139 LMICs. Organisations often used more than one model of care and engaged in several surgical specialties. Both short-term surgical missions (206 organisations, 66%) and long-term partnerships (213, 68%) were common models, with 40 organisations (13%) engaging in humanitarian interventions in crisis settings. The most commonly represented specialty was general surgery (120, 38%), but subspecialty surgery such as ophthalmology (88, 28%) and cleft lip and palate surgery (70, 22%) were also frequently performed., Interpretation: To our knowledge, this is the most complete directory of NGOs undertaking surgery in resource-limited settings in existence. However, it is difficult to determine whether this review is exhaustive. Further work is needed to determine the total and relative contributions of these organisations to global surgical volume. This database will be made available for public use and should be maintained and updated to further coordinate global efforts and maximise impact., Funding: None., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Billions of people worldwide lack access to surgical care; this is in part driven by severe shortages in the global surgical workforce. Task shifting, the movement of tasks to associate clinicians or non-specialist physicians, is a commonly implemented yet often contentious strategy to expand the surgical workforce. A more complete understanding of the global distribution and use of surgical and anaesthetic task shifting is needed to strengthen strategic planning efforts to bridge the gap between surgical and anaesthetic providers. We aimed to document the use of task shifting worldwide with an in-depth review of the literature and subsequent confirmation of practices through a provider survey., Methods: We did a literature search according to PRISMA guidelines. We searched PubMed, Embase, The Cochrane Library, CINAHL, WHOLIS, and five regional databases for journal articles published between Jan 1, 1995, and Aug 29, 2014, for titles or abstracts mentioning surgical or anaesthetic care provision by associate clinicians or non-specialist physicians. We also searched article references and online resources. We extracted data for health cadres performing task shifting, the types of tasks performed, training programmes, and supervision of those performing tasks and compared these across regions and income groups. Additionally, we then undertook an unvalidated survey to investigate the use of task shifting at the country level, which was sent to surgeons and anaesthetists in 19 countries across all major regions of the world., Findings: We identified 62 studies. The review and survey provided data for 163 and 51 countries respectively, totalling 174 countries. Surgical task shifting occured in 30 (33%) of 92 countries. Anaesthetic task shifting occured in 108 (65%) of 165 countries. Task shifting was documented across all World Bank income groups. Where relevant data were available, in high-income countries, associate clinicians were commonly supervised (100% [four countries] for surgery and 90% [20 countries] for anaesthesia). In low-income countries, associate clinicians undertook surgical and anaesthetic procedures without supervision (100% for surgery [five countries] and 100% for anaesthesia [22 countries])., Interpretation: Task shifting is used to augment the global surgical workforce across all geographical regions and income groups. Associate clinicians are ubiquitous among the global surgical workforce and should be considered in plans to scale up the surgical workforce in countries with workforce shortages. Reporting bias is likely to have favoured the more novel and successful task shifting initiatives, which could have caused our results to underestimate the absolute number of countries that use task shifting. Although surgical and anaesthetic task shifting has been described in many countries, further research is required to assess outcomes, especially in low-income and middle-income countries where supervision is less robust., Funding: None., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: The Lancet Commission on Global Surgery calls for universal access to safe, affordable, and timely surgical care. Two requisite components of timely access are (1) the ability to reach a surgical provider in a given timeframe, and (2) the ability to receive appropriately prompt care from that provider. We chose a threshold of 2 h in view of its relevance in time-to-death in post-partum haemorrhage. Here, we use geospatial mapping to enumerate the percentage of a nation's population living within 2 h of a surgeon and the surgeon-to-population ratio for each provider., Methods: Geospatial mapping was used to identify the population living within a 2-h driving distance (access zone) of a health-care facility staffed by a surgeon. Surgeon locations were extracted from Ministries of Health, professional society databases, and published literature for countries which had available data. Data were reviewed by individuals knowledgeable of in-country distribution. Spatial distribution of providers was mapped with Google Maps engine. Access zones were constructed around every provider through estimation of driving times in Google Maps. The number of people living within zones was estimated with the Socioeconomic Data and Applications Center Population Estimation Service. Surgeon-to-population ratios were constructed for every individual access zone and averaged to report a single ratio., Findings: Results (% country's population living within an access zone; average surgeon:population ratio within all access zones) are reported for nine countries with available data: Somaliland (16·9%; 1:118 306), Botswana (31·0%; 1:64 635), Ethiopia (39·6%; 1:229 696), Rwanda (41·3%; 1:158 484), Namibia (43·4%; 1:69 385), Zimbabwe (54%; 1:148 292), Mongolia (55·5%; 1:10 500), Sierra Leone (70·3%; 1:106 742), and Pakistan (84·4%, 1:139 299). Surgeon-to-population ratios vary substantially even within countries; in Sierra Leone, urban access zones have a ratio of 1:45 058 and rural access zones have a ratio of 1:467 929., Interpretation: Surgical access is poor in many low-income and middle-income countries, even when using a narrow definition of surgical access consisting only of timeliness. Living outside of an access zone makes timely access to surgical care highly unlikely, and in view of low surgeon-to-population ratios and poor prehospital transport, even living within a 2-h access zone might not confer 2-h access. Investments in infrastructure and training must be prioritised to address widespread disparity in access to timely surgery., Funding: None., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Billions of people are without access to surgical care, in part because of the inequitable distribution of the surgical workforce. Drawing on recently collected data for the number of surgeons, anaesthesiologists, and obstetricians worldwide, we sought to show their global maldistribution by identifying thresholds of surgical workforce densities, and by calculating the number of additional providers needed to reach those thresholds., Methods: From the WHO Global Surgical Workforce Database, national data for the number of specialist surgeons, anaesthesiologists, and obstetricians per 100 000 population (density) were compared with the number of maternal deaths per 100 000 live births (maternal mortality ratio; MMR) in WHO member countries. A regression line was fit between density of specialist surgeons, anaesthesiologists, and obstetricians and the logarithm of MMR, and we explored the correlation for an upper and a lower density threshold. Based on previous estimates of the global volume of surgical procedures, a global average productivity per specialist was derived. We then multiplied the average productivity with the derived upper and lower threshold densities, and compared these numbers to previously estimated global need of surgical procedures (4664 procedures per 100 000 population). Finally, the numbers of additional providers needed to reach the thresholds in countries with a density below the respective threshold were calculated., Findings: Each 10-unit increase in density of surgeons, anaesthesiologists, and obstetricians, corresponded to a 13·1% decrease in MMR (95% CI 11·3-14·8). We saw particularly steep improvements in MMR from 0 to roughly 20 per 100 000 population. Above roughly 40 per 100 000 population, higher density was associated with relatively smaller improvements in MMR. These arbitrary thresholds of 20 and 40 specialists per 100 000 corresponded with a volume of surgery of 2917 and 5834 procedures per 100 000 population, respectively, and were symmetrically distributed around the estimated global need of 4664 surgical procedures per 100 000 population. Our density thresholds are slightly higher than the current average in lower-middle income countries (16 per 100 000) and upper-middle-income countries (38 per 100 000), respectively. To reach the threshold of at least 20 per 100 000 in each country today, another 440 231 (IQR 438 900-443 245) providers would be needed. To reach 40 per 100 000, 1 110 610 (IQR 1 095 376-1 183 525) providers would be needed., Interpretation: Assuming uniform productivity, a global surgical workforce between 20 and 40 per 100 000 would suffice to provide the world's missing surgical procedures. We concede that causality cannot be implied, but our results suggest that countries with a workforce density above certain thresholds have better health outcomes. Although the thresholds cannot be interpreted as a minimum standard, they are useful to characterise the global surgical workforce and its deficits. Such thresholds could also be used as markers for health system capacity., Funding: None., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Countries with fewer than 20 specialist surgeons, anaesthetists, and obstetricians (SAO) per 100 000 population have worse health outcomes. To achieve surgical workforce densities of 20 per 100 000 by 2030, a scale up of the surgical workforce is required. No previous study has shown what this will cost, how many providers will be required, or how long it will take to increase the global surgical workforce. We aim to identify these answers for health-care systems that employ SAO alone and for those that use a hybrid model of SAO and task shifting to inform strategic planning., Methods: Data for the density of SAO per country were obtained from the WHO Global Surgical Workforce Database. To find the total number of SAO that need to enter the workforce by 2030 to achieve surgical workforce thresholds of 20 per 100 000, the population growth formula (P=0e(rt)) was used and we assumed exponential surgical workforce growth and two potential retirement rates of either 1% or 10%. We did not account for migration. The same calculations were used for associate clinicians needed to enter the workforce in either a 2:1 or 4:1 associate clinicians-to-SAO ratio. The costs to train SAO and associate clinicians were estimated with data for training costs imputed into a regression analysis with health-care expenditure per capita for each country. We assumed training costs will remain constant, and we did not account for inflation. The time needed to train new surgical and anaesthetic providers was estimated with average length of training for SAO and associate clinicians and was measured in person years. Two models (one for a system of SAO only and one for a hybrid of SAO and associate clinicians) were created to show how many providers will need to enter the workforce per year once training is complete to reach targets by 2030. The model did not involve the scale-up of the surgical workforce needed to address unmet needs of essential surgical services., Findings: By 2030, the world will need 1 272 586 new surgical workforce providers to meet a surgical workforce density of 20 per 100 000 assuming a 1% retirement rate. This will cost US$71-146 billion depending on the model used. Low-income and lower-middle-income countries show the largest required scale-up. An additional 806 352 (median 3412 [IQR 691-6851]) providers are needed in those countries. In the SAO only model, this will cost a median of US$19·66 per 2013 capita (IQR 15·79-25·07) and will take a median of 34 121 person years (IQR 6911-68 509). In the 4:1 associate clinician-to-SAO ratio, it will cost a median of US$7·57 per capita and take 20 472 person years. When accounting for the delay of entry to the workforce due to training in these countries, the median rate of entry to meet the goal density will have to increase 10·9 times after a 10 year delay in an SAO only model as opposed to 4·98 times with a 5 year delay in the hybrid 4:1 associate clinician-to-SAO model., Interpretation: Although low-income countries, lower-middle-income countries, and upper-middle-income countries will require a surgical workforce scale-up, lower-middle-income countries will require the largest scale-up. In these countries, implementing a system of task shifting can decrease costs and training times by 40%. Meeting densities of 20 per 100 000 will not guarantee quality care or improved access in rural areas, and equal attention must be paid to the provision of safe, affordable, accessible surgical care to all who need it., Funding: None., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objectives: To describe the prevalence of preinjury warfarin use in a large national sample of trauma patients and to define the relationship between preinjury warfarin use and mortality., Design: Retrospective cohort study., Setting: The National Trauma Databank (7.1)., Patients: All patients admitted to eligible trauma centers during the study period; 1,230,422 patients (36,270 warfarin users) from 402 centers were eligible for analysis., Main Outcome Measures: Prevalence of warfarin use and all-cause in-hospital mortality. Multivariate logistic regression was used to estimate the odds ratio (OR) for mortality associated with preinjury warfarin use., Results: Warfarin use increased among all patients from 2.3% in 2002 to 4.0% in 2006 (P < .001), and in patients older than 65 years, use increased from 7.3% in 2002 to 12.8% in 2006 (P < .001). Among all patients, 9.3% of warfarin users died compared with only 4.8% of nonusers (OR, 2.02; 95% confidence interval [CI], 1.95-2.10; P < .001). After adjusting for important covariates, warfarin use was associated with increased mortality among all patients (OR, 1.72; 95% CI, 1.63-1.81; P < .001) and patients 65 years and older (OR, 1.38; 95% CI, 1.30-1.47; P < .001)., Conclusions: Warfarin use is common among injured patients and its prevalence has increased each year since 2002. Its use is a powerful marker of mortality risk, and even after adjusting for confounding comorbidities, it is associated with a significant increase in death.

Soil-transmitted helminth (STH) infections affect an estimated 2 billion people world wide. Children experience the greatest morbidity, limiting their potential in academic and physical endeavors. Our study assessed the prevalence of STH infections in primary school-aged children in a rural village in the Nyanza Province of Kenya. Over two-thirds (68%) of the sampled population tested positive using a direct smear microscopic analysis of single stool samples. Only heavy worm infections would be detected with this technique; thus 68% is a minimum estimate of prevalence. Prior to our study, there were no deworming programs in this village, despite WHO and Kenyan government guidelines supporting regular deworming programs. Our study demonstrates the significant burden of STH infections in a rural Kenyan village and highlights the need for deworming programs in similar venues. We also demonstrate that with basic infrastructure and community involvement, regular deworming can be implemented effectively in remote, rural communities.