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The article presents abstracts on medical topics which include the Great Britain higher surgical training, the Laparoscopic adrenal contouring using fluorescence imaging and validation of Microrna Signatures for detecting pancreatic malignant transformation.

The article presents abstracts on medical topics which include an audit to identify factors involved in making recommendations to decrease unplanned readmissions, study to determine safety profile following gastrointestinal surgery and thromboprophylaxis after major abdominal cancer surgery.

Background: Global surgery research is often generated through collaborative partnerships between researchers from both low‐ and middle‐income countries (LMICs) and high‐income countries (HICs). Inequitable engagement of LMIC collaborators can limit the impact of the research. Methods: This article describes evidence of inequities in the conduct of global surgery research and outlines reasons why the inequities in this research field may be more acute than in other global health research disciplines. The paper goes on to describe activities for building a collaborative research portfolio in rural Rwanda. Results: Inequities in global surgery research collaborations can be attributed to: a limited number and experience of researchers working in this field; time constraints on both HIC and LMIC global surgery researchers; and surgical journal policies. Approaches to build a robust, collaborative research portfolio in Rwanda include leading research trainings focused on global surgery projects, embedding surgical fellows in Rwanda to provide bidirectional research training and outlining all research products, ensuring that all who are engaged have opportunities to grow in capacities, including leading research, and that collaborators share opportunities equitably. Of the 22 published or planned papers, half are led by Rwandan researchers, and the research now has independent research funding. Conclusion: It is unacceptable to gather data from an LMIC without meaningful engagement in all aspects of the research and sharing opportunities with local collaborators. The strategies outlined here can help research teams build global surgery research portfolios that optimize the potential for equitable engagement. Power dynamics in the field of global surgery research lead to inequitable opportunities for researchers in low‐ and middle‐income countries. This paper describes the authors' own experiences in Rwanda, and outlines strategies to develop a strong global surgery research portfolio and fair partnerships. Probity is key [ABSTRACT FROM AUTHOR]

Background: With the well established shift to neoadjuvant treatment for locally advanced rectal cancer, there is increasing focus on the use of radiosensitizers to improve the efficacy and tolerability of radiotherapy. There currently exist few randomized data exploring novel radiosensitizers to improve response and it is unclear what the clinical endpoints of such trials should be. Methods: A qualitative systematic review was performed according to the PRISMA guidelines using preset search criteria across the PubMed, Cochrane and Scopus databases from 1990 to 2017. Additional results were generated from the reference lists of included papers. Results: A total of 123 papers were identified, of which 37 were included; a further 60 articles were obtained from additional referencing to give a total of 97 articles. Neoadjuvant radiosensitization for locally advanced rectal cancer using fluoropyrimidine‐based chemotherapy remains the standard of treatment. The oral derivative capecitabine has practical advantages over 5‐fluorouracil, with equal efficacy, but the addition of a second chemotherapeutic agent has yet to show a consistent significant efficacy benefit in randomized clinical assessment. Preclinical and early‐phase trials are progressing with promising novel agents, such as small molecular inhibitors and nanoparticles. Conclusion: Despite extensive research and promising preclinical studies, a definite further agent in addition to fluoropyrimidines that consistently improves response rate has yet to be found. Promising agents coming [ABSTRACT FROM AUTHOR]

Background: In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the indicators, and to present available data and updated estimates. Methods: Nationally representative data were compiled for all World Health Organization (WHO) member states from 2010 to 2016 through contacts with official bodies and review of the published and grey literature, and available databases. Availability, comparability and utility were assessed for each indicator: access to timely essential surgery, specialist surgical workforce density, surgical volume, perioperative mortality, and protection against impoverishing and catastrophic expenditure. Where feasible, imputation models were developed to generate global estimates. Results: Of all WHO member states, 19 had data on the proportion of the population within 2h of a surgical facility, 154 had data on workforce density, 72 reported number of procedures, and nine had perioperative mortality data, but none could report data on catastrophic or impoverishing expenditure. Comparability and utility were variable, and largely dependent on different definitions used. There were sufficient data to estimate that worldwide, in 2015, there were 2 038 947 (i.q.r. 1 884 916–2 281 776) surgeons, obstetricians and anaesthetists, and 266·1 (95 per cent c.i. 220·1 to 344·4) million operations performed. Conclusion: Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution. This paper examines the availability, comparability and utility of six global surgery indicators. Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution. An update, and a plea for improvement [ABSTRACT FROM AUTHOR]

WS4.224 The current practice of preoperative risk assessment in patients undergoing elective surgery... Ashrafun Nessa, Irfan Ahmed Aberdeen Royal Infirmary Aim: In the preoperative assessment of a surgical patient, it is prudent to counsel the patient on the risks of postoperative mortality and need for critical care monitoring after surgery, identifying patients for prehabilitation, perioperative shared decision-making process, guiding allocation of resources and improving patient outcomes. WS4.269 Preventing Post-operative Nausea and Vomiting (PONV) - are we doing enough for day case patie... Will Sargent, Emma Gorst Ealing Hospital, London North West University Healthcare Aim: • Enhanced recovery protocols recommend risk-stratification of patients and tailoring of antiemetic prophylaxis accordingly to prevent post-operative nausea and vomiting (PONV) • The widely-used Apfel score for PONV risk was created before the routine propofol induction and antiemetic prophylaxis • As more procedures are performed as day case, patients may be sent home before PONV manifests • We wanted to see how effective our current strategies are at preventing post-operative PONV Method: • 65 patients undergoing general surgical or gynaecological procedures were prospectively risk-stratified for PONV according to their Apfel score (high risk >2) • Their anaesthesia and intra-operative prophylactic antiemesis was recorded from the anaesthetic chart • They were asked about PONV at 2 and 24 hours after their operation end, the latter by telephone Results • 24.2% (15/62) patients were nauseated after leaving hospital • 35.5% (11/31) high-risk patients experienced PONV vs 12.9% (4/31) in the low-risk group (p <0.05, Fisher's exact test) • There was no difference in the number of antiemetic agents used between high- and low-risk groups (median 2). [Extracted from the article]

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Background: Shortages of specialist surgeons in African countries mean that the needs of rural populations go unmet. Task‐shifting from surgical specialists to other cadres of clinicians occurs in some countries, but without widespread acceptance. Clinical Officer Surgical Training in Africa (COST‐Africa) developed and implemented BSc surgical training for clinical officers in Malawi. Methods: Trainees participated in the COST‐Africa BSc training programme between 2013 and 2016. This prospective study done in 16 hospitals compared crude numbers of selected numbers of major surgical procedures between intervention and control sites before and after the intervention. Volume and outcomes of surgery were compared within intervention hospitals between the COST‐Africa trainees and other surgically active cadres. Results: Seventeen trainees participated in the COST‐Africa BSc training. The volume of surgical procedures undertaken at intervention hospitals almost doubled between 2013 and 2015 (+74 per cent), and there was a slight reduction in the number of procedures done in the control hospitals (–4 per cent) (P = 0·059). In the intervention hospitals, general surgery procedures were more often undertaken by COST‐Africa trainees (61·2 per cent) than other clinical officers (31·3 per cent) and medical doctors (7·4 per cent). There was no significant difference in postoperative wound infection rates for hernia procedures at intervention hospitals between trainees and medical doctors (P = 0·065). Conclusion: The COST‐Africa study demonstrated that in‐service training of practising clinical officers can improve the surgical productivity of district‐level hospitals. This implementation research project developed, implemented and evaluated Malawi's first postgraduate surgical training programme for non‐physician clinicians. The training model has proved to be effective and has been embedded within the mainstream educational programmes offered in the country. Implementing training standards [ABSTRACT FROM AUTHOR]

Background: The field of global surgery has gained significant recent momentum, catalysed by the 2015 publication of the Lancet Commission on Global Surgery, Disease Control Priorities 3 and World Health Assembly resolution 68.15. These reports characterized the global burden of disease amenable to surgical care, called for global investment in surgical systems, and recognized surgery and anaesthesia as essential components of universal health coverage. Methods: A strategy proposed to strengthen surgical care is the development of national surgical, obstetric and anaesthesia plans (NSOAPs). This review examined how NSOAPs could contribute to the achievement of sustainable development goals (SDGs) 1, 3, 5, 8, 9, 10, 16 and 17 by 2030, focusing on their potential impact on the healthcare systems in Ethiopia, Tanzania and Zambia. Results: Due to the cross‐cutting nature of surgery, obstetrics and anaesthesia, investing in these services will escalate progress to achieve gender equality, economic growth and infrastructure development. Universal health coverage will not be achieved without addressing the financial ramifications to the poor of seeking and receiving surgical care. NSOAPs provide a strategic framework and a data collection platform for evidence‐based policy‐making, accountability and implementation guidance. Conclusion: The development and implementation of data‐driven NSOAPs should be recognized as a powerful road map to accelerate achievement of the SDGs by 2030. Must work to agreed national plans [ABSTRACT FROM AUTHOR]

Background: Surgery is among the most neglected parts of healthcare systems in low‐ and middle‐income countries. Ethiopia has launched a national strategic plan to address challenges in the surgical system. This study aimed to assess surgical capacity in two Ethiopian regions to inform priority areas for improvement. Methods: A mixed‐methods study was conducted using two tools adapted from the Lancet Commission's Surgical Assessment Tools: a quantitative Hospital Assessment Tool and a qualitative semistructured interview tool. Fifteen hospitals selected by the Federal Ministry of Health were surveyed in the Tigray and Amhara regions to assess the surgical system across five domains: service delivery, infrastructure, workforce, information management and financing. Results: Service delivery was low across hospitals with a mean(s.d.) of 5(6) surgical cases per week and a narrow range of procedures performed. Hospitals reported varying availability of basic infrastructure, including constant availability of electricity (9 of 15) and running water (5 of 15). Unavailable or broken diagnostic equipment was also common. The majority of surgical and anaesthesia services were provided by non‐physician clinicians, with little continuing education available. All hospitals tracked patient‐level data regularly and eight of 15 hospitals reported surgical volume data during the assessment, but research activities were limited. Hospital financing specified for surgery was rare and the majority of patients must pay out of pocket for care. Conclusion: Results from this study will inform programmes to simultaneously improve each of the health system domains in Ethiopia; this is required if better access to and quality of surgery, anaesthesia and obstetric services are to be achieved. Much to be done still [ABSTRACT FROM AUTHOR]

Background: The WHO Surgical Safety Checklist improves surgical outcomes, but evidence and theoretical frameworks for successful implementation in low‐income countries remain lacking. Based on previous research in Madagascar, a nationwide checklist implementation in Benin was designed and evaluated longitudinally. Methods: This study had a longitudinal embedded mixed‐methods design. The well validated Consolidated Framework for Implementation Research (CFIR) was used to structure the approach and evaluate the implementation. Thirty‐six hospitals received 3‐day multidisciplinary training and 4‐month follow‐up. Seventeen hospitals were sampled purposively for evaluation at 12–18 months. The primary outcome was sustainability of checklist use at 12–18 months measured by questionnaire. Secondary outcomes were CFIR‐derived implementation outcomes, measured using the WHO Behaviourally Anchored Rating Scale (WHOBARS), safety questionnaires and focus groups. Results: At 12–18 months, 86·0 per cent of participants (86 of 100) reported checklist use compared with 31·1 per cent (169 of 543) before training and 88·8 per cent (158 of 178) at 4 months. There was high‐fidelity use (median WHOBARS score 5·0 of 7; use of basic safety processes ranged from 85·0 to 99·0 per cent), and high penetration shown by a significant improvement in hospital safety culture (adapted Human Factors Attitude Questionnaire scores of 76·7, 81·1 and 82·2 per cent before, and at 4 and 12–18 months after training respectively; P < 0·001). Acceptability, adoption, appropriateness and feasibility scored 9·6–9·8 of 10. This approach incorporated 31 of 36 CFIR implementation constructs successfully. Conclusion: This study shows successfully sustained nationwide checklist implementation using a validated implementation framework. Implementation works [ABSTRACT FROM AUTHOR]

Background: To allocate healthcare resources optimally, complication‐related quality initiatives should target complications that have the greatest overall impact on outcomes after surgery. The aim of this study was to identify the most clinically relevant complications after oesophagectomy for cancer in a nationwide cohort study. Methods: Consecutive patients who underwent oesophagectomy for cancer between January 2011 and December 2016 were identified from the Dutch Upper Gastrointestinal Cancer Audit. The adjusted population attributable fraction (PAF) was used to estimate the impact of specific postoperative complications on the clinical outcomes postoperative mortality, reoperation, prolonged hospital stay and readmission to hospital in the study population. The PAF represents the percentage reduction in the frequency of a given outcome (such as death) that would occur in a theoretical scenario where a specific complication (for example anastomotic leakage) was able to be prevented completely in the study population. Results: Some 4096 patients were analysed. Pulmonary complications and anastomotic leakage had the greatest overall impact on postoperative mortality (risk‐adjusted PAF 44·1 and 30·4 per cent respectively), prolonged hospital stay (risk‐adjusted PAF 31·4 and 30·9 per cent) and readmission to hospital (risk‐adjusted PAF 7·3 and 14·7 per cent). Anastomotic leakage had the greatest impact on reoperation (risk‐adjusted PAF 47·1 per cent). In contrast, the impact of other complications on these outcomes was relatively small. Conclusion: Reducing the incidence of pulmonary complications and anastomotic leakage may have the greatest clinical impact on outcomes after oesophagectomy. Pulmonary and anastomotic complications matter most [ABSTRACT FROM AUTHOR]

Background: Patients with non‐resectable colorectal metastases are currently treated with chemotherapy. However, liver transplantation can increase the 5‐year survival rate from 9 to 56 per cent if the cancer is confined to the liver. The aim of this study was to estimate the cost‐effectiveness of liver transplantation for colorectal liver metastases. Methods: A Markov model with a lifetime perspective was developed to estimate the life‐years, quality‐adjusted life‐years (QALYs), direct healthcare costs and cost‐effectiveness for patients with non‐resectable colorectal liver metastases who received liver transplantation or chemotherapy alone. Results: In non‐selected cohorts, liver transplantation increased patients' life expectancy by 3·12 life‐years (2·47 QALYs), at an additional cost of €209 143, giving an incremental cost‐effectiveness ratio (ICER) of €67 140 per life‐year (€84 667 per QALY) gained. In selected cohorts (selection based on tumour diameter, time since primary cancer, carcinoembryonic antigen levels and response to chemotherapy), the effect of liver transplantation increased to 4·23 life‐years (3·41 QALYs), at a higher additional cost (€230 282), and the ICER decreased to €54 467 per life‐year (€67 509 per QALY) gained. Given a willingness to pay of €70 500, the likelihood of transplantation being cost‐effective was 0·66 and 0·94 (0·23 and 0·67 QALYs) for non‐selected and selected cohorts respectively. Conclusion: Liver transplantation was cost‐effective but only for highly selected patients. This might be possible in countries with good access to grafts and low waiting list mortality. Not cost effective for everyone [ABSTRACT FROM AUTHOR]

Background: The majority of lesions resulting in pathological nipple discharge are benign. Conventional surgery is undirected and targeting the causative lesion by duct endoscopy may enable more accurate surgery with fewer complications. Methods: Patients requiring microdochectomy and/or major duct excision were randomized to duct endoscopy or no duct endoscopy before surgery. Primary endpoints were successful visualization of the pathological lesion in patients randomized to duct endoscopy, and a comparison of the causative pathology between the two groups. The secondary endpoint was to compare the specimen size between groups. Results: A total of 68 breasts were studied in 66 patients; there were 31 breasts in the duct endoscopy group and 37 in the no‐endoscopy group. Median age was 49 (range 19–81) years. Follow‐up was 5·4 (i.q.r. 3·3–8·9) years in the duct endoscopy group and 5·7 (3·1–9·0) years in no‐endoscopy group. Duct endoscopy had a sensitivity of 80 (95 per cent c.i. 52 to 96) per cent, specificity of 71 (44 to 90) per cent, positive predictive value of 71 (44 to 90) per cent and negative predictive value of 80 (52 to 96) per cent in identifying any lesion. There was no difference in causative pathology between the groups. Median volume of the surgical resection specimen did not differ between groups. Conclusion: Diagnostic duct endoscopy is useful for identifying causative lesions of nipple discharge. Duct endoscopy did not influence the pathological yield of benign or malignant diagnoses nor surgical resection volumes. Registered as INTEND II in CancerHelp UK clinical trials database (https://www.cancerresearchuk.org/about‐cancer/find‐a‐clinical‐trial/a‐study‐looking‐at‐changes‐inside‐the‐breast‐ducts‐of‐women‐who‐have‐nipple‐discharge). Identifies causative lesion [ABSTRACT FROM AUTHOR]

Background: In the POISE‐2 (PeriOperative ISchemic Evaluation 2) trial, perioperative aspirin did not reduce cardiovascular events, but increased major bleeding. There remains uncertainty regarding the effect of perioperative aspirin in patients undergoing vascular surgery. The aim of this substudy was to determine whether there is a subgroup effect of initiating or continuing aspirin in patients undergoing vascular surgery. Methods: POISE‐2 was a blinded, randomized trial of patients having non‐cardiac surgery. Patients were assigned to perioperative aspirin or placebo. The primary outcome was a composite of death or myocardial infarction at 30 days. Secondary outcomes included: vascular occlusive complications (a composite of amputation and peripheral arterial thrombosis) and major or life‐threatening bleeding. Results: Of 10 010 patients in POISE‐2, 603 underwent vascular surgery, 319 in the continuation and 284 in the initiation stratum. Some 272 patients had vascular surgery for occlusive disease and 265 had aneurysm surgery. The primary outcome occurred in 13·7 per cent of patients having aneurysm repair allocated to aspirin and 9·0 per cent who had placebo (hazard ratio (HR) 1·48, 95 per cent c.i. 0·71 to 3·09). Among patients who had surgery for occlusive vascular disease, 15·8 per cent allocated to aspirin and 13·6 per cent on placebo had the primary outcome (HR 1·16, 0·62 to 2·17). There was no interaction with the primary outcome for type of surgery (P = 0·294) or aspirin stratum (P = 0·623). There was no interaction for vascular occlusive complications (P = 0·413) or bleeding (P = 0·900) for vascular compared with non‐vascular surgery. Conclusion: This study suggests that the overall POISE‐2 results apply to vascular surgery. Perioperative withdrawal of chronic aspirin therapy did not increase cardiovascular or vascular occlusive complications. Registration number: NCT01082874 (http://www.clinicaltrials.gov). No evidence to start or stop aspirin [ABSTRACT FROM AUTHOR]

Background: Optimal management of the endometrium in patients with oestrogen receptor‐positive breast cancer taking extended tamoxifen therapy (for 10 years) remains uncertain. A meta‐analysis was performed to determine the cumulative risk ratio (RR) for endometrial malignancy following extended compared with standard tamoxifen treatment. A systematic review was undertaken to identify whether routine endometrial surveillance in patients receiving tamoxifen is associated with earlier detection and reduced incidence of endometrial malignancy. Methods: Two independent searches were undertaken in the Cochrane Library, PubMed and MEDLINE. A meta‐analysis was performed of RCTs reporting on endometrial malignancy risk in extended tamoxifen therapy. A systematic review included prospective studies investigating the benefit of endometrial surveillance during tamoxifen therapy. Results: Four RCTs reported on endometrial risk in extended tamoxifen therapy. The cumulative risk of endometrial malignancy increased twofold from 1·5 to 3·2 per cent with extended therapy compared with the standard 5 years of tamoxifen (RR 2·29, 95 per cent c.i. 1·60 to 3·28; P < 0·001). Four studies analysed the value of endometrial screening in 5‐year cohorts. Endometrial cancer rates of up to 2 per cent were reported, which is higher than rates in the large extended tamoxifen trials. Conclusion: Extended adjuvant tamoxifen is associated with an increase in endometrial cancer. No clear benefit has been shown for routine endometrial surveillance in asymptomatic patients on tamoxifen therapy. [ABSTRACT FROM AUTHOR]

Background: Ileostomy construction is a common procedure but can be associated with morbidity. The stoma is commonly secured to the skin using transcutaneous sutures. It is hypothesized that intracutaneous sutures result in a tighter adherence of the peristomal skin to the stoma plate to prevent faecal leakage. The study aimed to compare the effect of intracutaneous versus transcutaneous suturing of ileostomies on faecal leakage and quality of life. Methods: This randomized trial was undertaken in 11 hospitals in the Netherlands. Patients scheduled to receive an ileostomy for any reason were randomized to intracutaneous or transcutaneous suturing (IC and TC groups respectively). The primary outcome was faecal leakage. Secondary outcomes were stoma-related quality of life and costs of stoma-related materials and reinterventions. Results: Between April 2011 and February 2016, 339 patients were randomized to the IC (170) or TC (169) group. Leakage rates were higher in the IC than in the TC group (52.4 versus 41.4per cent respectively; risk difference 11.0 (95 per cent c.i. 0.3 to 21.2) per cent). Skin irritation rates were high (78.2 versus 72.2 per cent), but did not differ significantly between the groups (risk difference 6.1 (95 per cent c.i. -3.2 to 15.10) per cent). There were no significant differences in quality of life or costs between the groups. Conclusion: Intracutaneous suturing of an ileostomy is associated with more peristomal leakage than transcutaneous suturing. Overall stoma-related complications did not differ between the two techniques. [ABSTRACT FROM AUTHOR]

Background In countries with universal health coverage, the delivery of care should be driven by need. However, other factors, such as proximity to local facilities or neighbourhood socioeconomic status, may be more important. The objective of this study was to evaluate which geographic and socioeconomic factors affect the delivery of bariatric care in Canada. Methods This was a national retrospective cohort study of all adult patients undergoing bariatric surgery between April 2008 and March 2015 in Canada (excluding Quebec). The main outcome was neighbourhood rate of bariatric surgery per 1000 obese individuals ( BMI over 30 kg/m2). Geographic cluster analysis and multilevel ordinal logistic regression were used to identify high-use clusters, and to evaluate the effect of geographic and socioeconomic factors on care delivery. Results Having a bariatric facility within the same public health unit as the neighbourhood was associated with a 6·6 times higher odds of being in a bariatric high-use cluster (odds ratio ( OR) 6·60, 95 per cent c.i. 1·90 to 22·88; P = 0·003). This finding was consistent across provinces after adjusting for utilization rates. Neighbourhoods with higher obesity rates were also more likely to be within high-use clusters ( OR per 5 per cent increase: 2·95, 1·54 to 5·66; P = 0·001), whereas neighbourhoods closer to bariatric centres were less likely to be ( OR per 50 km: 0·91, 0·82 to 1·00; P = 0·048). Conclusion In this study, across provincial healthcare systems with high and low utilization, the delivery of care was driven by the presence of local facilities and neighbourhood obesity rates. Increasing distance to bariatric centres substantially influenced care delivery. [ABSTRACT FROM AUTHOR]

Background Designing RCTs in surgery requires consideration of existing evidence, stakeholders' views and emerging interventions, to ensure that research questions are relevant to patients, surgeons and the health service. When there is uncertainty about RCT design, feasibility work is recommended. This study aimed to assess how feasibility work could inform the design of a future pilot study and RCT (Bluebelle, HTA - 12/200/04). Methods This was a prospective survey of dressings used to cover abdominal wounds. Surgical trainees from 25 hospitals were invited to participate. Information on patient risk factors, operation type and type of wound dressings used was recorded for elective and unplanned abdominal procedures over a 2-week interval. The types of dressing used were summarized, and associations with operation type and patient risk factors explored. Results Twenty hospitals participated, providing data from 727 patients (1794 wounds). Wounds were predominantly covered with basic dressings (1203 of 1769, 68·0 per cent) and tissue adhesive was used in 27·4 per cent (485 of 1769); dressing type was missing for 25 wounds. Just 3·6 per cent of wounds (63 of 1769) did not have a dressing applied at the end of the procedure. There was no evidence of an association between type of dressing used and patient risk factors, type of operation, or elective and unscheduled surgery. Conclusion Based on the findings from this large study of current practice, the pilot study design has evolved. The inclusion criteria have expanded to encompass patients undergoing unscheduled surgery, and tissue adhesive as a dressing will be evaluated as an additional intervention group. Collaborative methods are recommended to inform the design of RCTs in surgery, helping to ensure they are relevant to current practice. [ABSTRACT FROM AUTHOR]

Where is the funding? [ABSTRACT FROM AUTHOR]

Background To determine a true denominator of worldwide surgical need, it is imperative to include estimations at a population-based level, to capture those individuals unable to access surgical care. This study was designed to validate the Surgeons OverSeas Assessment of Surgical need ( SOSAS) tool with the addition of a visual physical examination, and describe the prevalence of surgical conditions, deaths possibly averted with access to surgical care, and the number of surgical procedures performed annually, in Nepal. Methods The SOSAS tool, developed to measure the prevalence of surgical conditions at a population level and used in two African countries, was employed. Fifteen of the 75 districts of Nepal were chosen proportional to population. Responses were recorded for the head of the household for demographic information and recalled deaths, and two randomly selected household members underwent a verbal head-to-toe interview for surgical conditions and a visual physical examination by a trained physician. Results A total of 1350 households were surveyed (2695 respondents). Observed agreement between the verbal response and physical examination findings was 94·6 per cent. Some 10·0 (95 per cent c.i. 8·9 to 11·2) per cent of respondents had a current condition requiring surgical care and 23 per cent of deaths may have been averted with proper access to surgical care. An estimated 291·8 major operations per 100 000 population are performed annually in Nepal. Conclusion The visual physical examination component validated the SOSAS tool, and justified the estimates of previous studies in Sierra Leone and Rwanda. These data provide insights into the health needs of Nepal and provide evidence to develop surgical programmes, assist with monitoring and evaluation, and help with advocacy for increased resources in Nepal. [ABSTRACT FROM AUTHOR]

Background At the core of surgical development in any economic environment lies innovation. Innovation in high-income countries ( HICs) often derives from research, whereas innovation in low- and middle-income countries ( LMICs) may be spontaneous owing to a desperate drive to meet a local need. The local needs are substantial because of the unequal access to healthcare in LMICs. Methods The experience of the author in working in LMICs through Operation Hernia, a medical charity, provides a backdrop for this review. Other published innovative devices and models are discussed. Results Innovation in income-poor countries has provided cost-effective but efficient solutions to local health needs. Some innovations have been enhanced and adopted worldwide. Conclusion HICs can learn more from innovative strategies adopted in LMICs. [ABSTRACT FROM AUTHOR]

The article presents abstracts on medical topics which include an emergency surgery team training, knee osteoarthritis pain and outcomes of endovascular aneurysm repair in octogenerians.