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BackgroundA workforce crisis exists in global surgery. One solution is task-shifting, the delegation of surgical tasks to non-physician clinicians or associate clinicians (ACs). Although several studies have shown that ACs have similar postoperative outcomes compared with physicians, little is known about their surgical training. This study aimed to characterize the surgical training and experience of ACs compared with medical officers (MOs) in Tanzania.MethodsAll surgical care providers in Pwani Region, Tanzania, were surveyed. Participants reported demographic data, years of training, and procedures assisted and performed during training. They answered open-ended questions about training and post-training surgical experience. The median number of training cases for commonly performed procedures was compared by cadre using Wilcoxon rank sum and Student's t tests. The researchers performed modified content analysis of participants' answers to open-ended questions on training needs and experiences.ResultsA total of 21 ACs and 12 MOs participated. ACs reported higher exposure than MOs to similar procedures before their first independent operation (median 40 versus 17 cases respectively; P = 0·031). There was no difference between ACs and MOs in total training surgical volume across common procedures (median 150 versus 171 cases; P = 0·995). Both groups reflected similarly upon their training. Each cadre relied on the other for support and teaching, but noted insufficient specialist supervision during training and independent practice.ConclusionsACs report similar training and operative experience compared with their physician colleagues in Tanzania.

A system for optical tracking of frozen hydrogen microsphere targets (pellets) has been designed. It is intended for the upcoming hadron physics experiment PANDA at FAIR, Darmstadt, Germany. With such a tracking system one can reconstruct the positions of the individual pellets at the time of a hadronic interaction in the offline event analysis. This gives information on the position of the primary interaction vertex with an accuracy of a few 100 µm, which is very useful e.g. for reconstruction of charged particle tracks and secondary vertices and for background suppression. A study has been done at the WASA detector setup (Forschungszentrum Jülich, Germany) to check the possibility of classification of hadronic events as originating in pellets or in background. The study has been done based on the instantaneous rate a Long Range TDC which was used to determine if a pellet was present in the accelerator beam region. It was clearly shown that it is possible to distinguish the two event classes. Also, an experience was gained with operation of two synchronized systems operating in different time scales, as it will also be the case with the optical pellet tracking.

Objective: To investigate reproducibility of fluorine-18 fludeoxyglucose (18F-FDG) uptake on 18F-FDG positron emission tomography (PET)/CT and 1SF-FDG PET/MR scans in patients with head and neck squamous cell carcinoma (FINSCC). Methods: 30 patients with HNSCC were included in this prospective study. The patients were scanned twice before radiotherapy treatment with both PET/CT and PET/MR. Patients were scanned on the same scanners, 3 days apart and according to the same protocol. Metabolic tumour activity was measured by the maximum and peak standardized uptake value (SUVmax and SUVmax, respectively), and total lesion glycolysis from the metabolic tumour volume defined from ≥50% SUVmax. Bland-Altman analysis with limits of agreement, coefficient of variation (CV) from the two modalities were performed in order to test the reproducibility. Furthermore, CVs from SUVmax and SUVmax were compared. The area under the curve from cumulative SUV-volume histograms were measured and tested for reproducibility of the distribution of 18F-FDG uptake. Results: 24 patients had two pre-treatment PET/CT scans and 21 patients had two pre-treatment PET/MR scans available for further analyses. Mean difference for SUVmax, peak and mean was approximately 4% for PET/CT and 3% for PET/MR, with 95% limits of agreement less than ±20%. CV was small (5-7%) for both modalities. There was no significant difference in CVs between PET/CT and PET/MR (p = 0.31). SUVmax was not more reproducible than SUVmax(p = 0.09). Conclusion: 18F-FDG uptake in PET/CT and PET/MR is highly reproducible and we found no difference in reproducibility between PET/CT and PET/MR. [ABSTRACT FROM AUTHOR]

An experimental study was carried out in eight dogs to investigate whether the Cushing response (CR) during intracranial hypertension is due to pressure per se, tissue distortion, or ischemia in the brain stem. To minimize the effects of rostrocaudal displacement, intracranial pressure was raised by an expanding mass lesion located in the posterior fossa. Regional cerebral blood flow (rCBF) was measured with radioactive microspheres and compartmental cerebrospinal fluid (CSF) pressures were recorded during the CR which was induced by the continuous inflation at a constant rate of an infratentorial epidural rubber balloon in two groups of four dogs. In one group (A) rCBF was measured at the onset of the CR and in the other group (B) at the peak of the systemic blood pressure rise. In the animals of group A blood flow in the mesencephalon, pons and upper medulla oblongata was reduced from control values by 32%, 57% and 85% respectively. In group B blood flow in the same areas did not differ significantly from pre-inflation values. In contrast, the recorded balloon volume, which was assumed to be an index of mechanical distortion of the brain stem, varied considerably at the beginning of the blood pressure rise (from 2.5 to 4.7% of the calculated intracranial space). Similarly, CSF pressure in the posterior fossa at the onset of the CR also varied considerably (from 52 to 117 mmHg). Thus, the large quantitative variations meant that both absolute pressure and tissue distortion were poor predictors of the onset of the CR. The findings suggest that ischemia, rather than brain stem distortion per se or pressure by itself, is responsible for the initiation of the CR. The rise in blood pressure elicited during the CR seems capable of restoring blood flow in the brain stem back to control values. [ABSTRACT FROM AUTHOR]

Objective: To assess long-term outcomes following inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana., Background: Task sharing of surgical care with nonsurgeons can increase access to essential surgery. Long-term safety and outcomes of task sharing are not well-described for hernia repair., Methods: This prospective cohort study was conducted in Ho, Ghana. After completing a training course, 3 medical doctors and 2 surgeons performed inguinal hernia repairs with mesh on men with primary, reducible hernias. The primary outcome of this study was hernia recurrence at 5 years. The noninferiority limit was 5 percentage points. Secondary endpoints included pain and self-assessed health status at 5 years., Results: A total of 242 operations in 241 participants were included, including 119 hernia repairs performed by the medical doctors and 123 performed by the surgeons. One hundred and sixty-nine participants (70.1%) were seen in follow-up at 5 years, 29 participants (12.0%) had died and 43 (17.8%) were lost to follow-up. The overall 5-year recurrence rate was 4.7% (n = 8). The absolute difference in recurrence rate between the medical doctor group (2 [2.3%]) and the surgeon group (6 [7.3%]) was -5.0 (1-tailed 95% confidence interval, -10.5; P = 0.06), demonstrating noninferiority of the medical doctors. Participants experienced improvements in groin pain and self-assessed health status that persisted at 5 years., Conclusions: Long-term outcomes of elective mesh inguinal hernia repair in men performed by medical doctors and surgeons in Ghana were excellent. Task sharing is a critical tool to address the substantial morbidity of unmet hernia surgery needs in Ghana., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The situation for patients with ostomy can be challenging, probably more in a resource-constrained environment. Our objective was to evaluate quality of life (QoL) (using EQ5D-5L) and stoma-specific QoL (using Stoma QoL) in a high- and low-income setting., Methods: In this cross-sectional study from the Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, and South General Hospital (SGH), Stockholm, patients with a permanent or temporary ostomy at TASH (EthioPerm), (EthioTemp), and patients with ostomy at SGH (SweSto) were included in October 2022-January 2023., Results: Patients N = 66 were included in groups: EthioPerm N = 28, EthioTemp N = 17, and SweSto N = 21. In EthioTemp, 88% used homemade stoma bags. Although morbidity related to the nipple itself was similar in the groups, the overall score from Stoma QoL was significantly lower in EthioPerm, 48/100 than in SweSto, 74/100. Scores were significantly lower for pouch-related problems and social interactions in Ethiopian patients. In EthioPerm, 71% of the patients worried that they were a burden to the people close to them compared to 14% in SweSto (p < 0.001). Leakage was over four times more common in EthioPerm than in SweSto. Mean overall EQ5D-5L score was 18 percentage points lower than the national mean score in EthioPerm and 2 percentage points lower in SweSto., Conclusion: QoL was more affected in the Ethiopian study participants than in the Swedish, even when commercial stoma bags were available. The largest problems were leakage, embarrassment with social interactions, and pouch-related problems., Trial Registration: NCT05970458 Clinicaltrials.gov, https://clinicaltrials.gov/study/NCT05970458?locStr=Ethiopia&country=Ethiopia&distance=50&cond=Stoma%20Ileostomy&rank=1., (© 2024 The Authors. World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Background: Immediate vascularized reconstruction after sarcoma resection may reduce wound complications common in primary closure, but previous research is conflicting. The present study analysed wound complication rates and compared wound-related outcomes among immediate vascularized reconstruction with primary closure., Materials and Methods: Patient- and tumour characteristics were collected from patients who received primary surgery with curative intent between 2010 and 2020 at the Stockholm Sarcoma Centre. Clinical outcomes were sought in free text in medical records. The primary outcome measures were early (<30 days) wound complications. Secondary outcome measures included late (30-day to 2-year) wound complications, time to wound healing, 30-day postoperative complications according to Clavien Dindo, and health care consumption., Results: A total of 482 patients were included, of whom 69 had immediate vascularized reconstruction. Comparison of early complications for reconstructive surgery with primary closure revealed a significantly higher complication rate for the first group (59.4 % vs 29.8 %, p < 0.01). The groups had comparable health care consumption the first and second postoperative years. In-depth analyses identified BMI >25, smoking and high-grade lesions as factors with adverse effects on wound healing., Conclusions: Sarcoma patients experience high rates of wound complications and consume considerable health care resources. Reconstructed individuals were more susceptible to such complications than were subjects with primary closure., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Published by Elsevier Ltd.)

Introduction: In low-income settings, there is a high unmet need for hernia surgery, and most procedures are performed with tissue repair techniques. In preparation for a randomized clinical trial, medical doctors and associate clinicians received a short-course competency-based training on inguinal hernia repair with mesh under local anaesthesia. The aim of this study was to evaluate feasibility, safety and effectiveness of the training., Methods: All trainees received a one-day theoretical module on mesh hernia repair under local anaesthesia followed by hands-on training. Performance was assessed using the American College of Surgeon's Groin Hernia Operative Performance Rating System. Patients were followed up two weeks and one year after surgery. Outcomes of the patients operated on during the training trial were compared to the 229 trial patients operated on after the training., Results: During three surgical camps, seven medical doctors and six associate clinicians were trained. In total, 129 patients were operated on as part of the training. Of the 13 trainees, 11 reached proficiency. Patients in the training group had more wound infections after two weeks (8.5% versus 3.1%; p = 0.041). There was no difference in recurrence and mortality after one year, and none of the deaths were attributed to the surgery., Discussion and Conclusion: Mesh repair is the international standard for inguinal hernia repair worldwide. Nevertheless, this is not widely accessible in low-income settings. This study has demonstrated that short-course intensive hands-on training of MDs and ACs in mesh hernia repair is effective and safe., Trial Registration: International Clinical Trial Registry ISRCTN63478884., (© 2023. The Author(s).)

Background: Rectal cancer is a common cancer worldwide. Surgery for rectal cancer with low anterior resection often includes the formation of a temporary protective loop ileostomy. The temporary ostomy is later reversed in a separate operation. One complication following stoma closure is the development of a hernia at the former stoma site, and this has been reported in 7-15% of patients. The best method to avoid hernia after stoma closure is unclear. The most common closure is by suturing only, but different forms of mesh have been tried. Biological mesh has in a randomized trial halved hernia incidence after stoma reversal. Biosynthetic mesh and retromuscular mesh are currently being evaluated in ongoing studies., Methods: The present multicenter, double-blinded, randomized, controlled study will compare standard suture closure of the abdominal wall in loop ileostomy reversal with retromuscular synthetic mesh at the stoma site. The study has been approved by the Regional Ethical Review board in Stockholm. Patients aged 18-90 years, operated on with low anterior resection and a protective loop ileostomy for rectal cancer and planned for ileostomy reversal, will be considered for inclusion in the study. Randomization will be 1:1 on the operation day with concealed envelopes. The estimated sample size is intended to evaluate the superiority of the experimental arm and to detect a reduction of hernia occurrence from 12 to 3%. The operation method is blinded to the patients and in the chart and for the observer at the 30-day follow-up. The main outcome is hernia occurrence at the stoma site within 3 years postoperatively, diagnosed through CT with strain. Secondary outcomes are operation time, length of hospital stay, pain, and 30-day complications., Discussion: This double-blinded randomized controlled superiority study will compare retromuscular synthetic mesh during the closure of loop ileostomy to standard care. If this study can show a lower frequency of hernia with the use of prophylactic mesh, it may lead to new surgical guidelines during stoma closure., Trial Registration: ClinicalTrials.gov NCT03720262. Registered on October 25, 2018., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Current recommendations regarding the number of open groin hernia repairs that surgical trainees are required to perform during their residency are arbitrarily defined and vary between different curricula. This register-based study sought to investigate the learning curve of surgeons performing open anterior mesh repair for groin hernia by assessing hernia recurrence rates, surgical complications and operating times in relation to the number of procedures performed., Method: Nationwide data on open anterior mesh repair for groin hernia performed by surgical residents were collected from the Swedish Hernia Register between 2005 and 2020. The data were analysed in a cohort undergoing procedures carried out by surgeons performing their first registered repair as resident general surgeons. Repairs by surgeons with fewer than 30 repairs were excluded., Results: A total of 38 845 repairs carried out by 663 surgeons were included. Operation time decreased with increasing number of performed procedures, mean (s.d.) operation time was 79 (26) min for the first 15 procedures and 60 (23) min after 241 procedures (P <0.001). A turning point where complication rates began to decrease was seen after 60 procedures. Complication rates were 3.6 per cent (396 of 10 978) for procedures 31-60 and 2.7 per cent (157 of 5 798) for procedures 61-120 (P = 0.002). There was no significant relationship between the number of procedures performed and the rate of operation on for recurrence (P = 0.894)., Conclusion: Sixty performed procedures during surgical residency is a reasonable target for achieving competency to perform open anterior mesh repair for groin hernia safely without supervision., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.)

We present a gauge-invariant framework for bubble nucleation in theories with radiative symmetry breaking at high temperature. As a procedure, this perturbative framework establishes a practical, gauge-invariant computation of the leading order nucleation rate, based on a consistent power counting in the high-temperature expansion. In model building and particle phenomenology, this framework has applications such as the computation of the bubble nucleation temperature and the rate for electroweak baryogenesis and gravitational wave signals from cosmic phase transitions.

Background: Knowledge about the prevalence of groin hernias in sub-Saharan Africa is limited. Previous studies have demonstrated a higher incidence of the condition than the annual repair rate. This study aimed to investigate prevalence, incidence, annual repair rate, morbidity, and health-seeking behaviour of persons with groin hernias in Sierra Leone., Methods: This population-based, cross-sectional household survey on groin hernias in Sierra Leone was part of the Prevalence Study on Surgical Conditions 2020 (PRESSCO 2020). Those who indicated possible groin hernia were asked problem-specific questions and underwent physical examination to confirm or exclude the diagnosis., Results: 3626 study participants were interviewed. The prevalence of untreated groin hernia was 1.1 per cent (95 per cent c.i. 0.8 to 1.5 per cent), whereas the prevalence of untreated and treated groin hernia was 2.5 per cent (95 per cent c.i. 2.0 to 3.0 per cent). The proportion of recurrence was 13.1 per cent. An incidence of 389 (95 per cent c.i. 213 to 652) groin hernia cases per 100 000 people per year was identified, while a population-based annual hernia repair rate estimation was 470 (95 per cent c.i. 350 to 620) per 100 000 people. Out of 39 participants with groin hernia, non-ignorable pain was reported by eight and 27 reported financial shortcomings as a reason for not seeking healthcare., Conclusions: Groin hernias are common in Sierra Leone and although the repair rate might match the incidence, the existing backlog of untreated hernias is likely to remain. It may be possible to reduce the number of recurrences through improved management. Measures to reduce financial barriers to treatment seem crucial to improve the health of people with groin hernias in Sierra Leone., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.)