Search

Background The location of tissue expanders in implant-based breast reconstruction remains controversial, due to variation in surgical techniques and devices. Objectives This study aims to provide a comprehensive assessment of early and late complication rates between prepectoral and subpectoral placement of tissue expanders. Methods A retrospective cohort study was conducted of all adult female patients who had two-staged implant-based breast reconstruction from 2013 to 2019 in our institution. Early complication was defined as complications that occurred within 30 days after surgery. Time-to-event analyses were performed and Cox proportional hazard models were used to adjust for confounders. Results 854 patients were included with 76% of patients underwent a subpectoral tissue expander placement. After the first stage procedure, the early complication rate was 34%, and the late complication rate was 36.4%. After the second stage procedure, the early complication rate was 16.3%, and the late complication rate was 16.1%. Location of the tissue expander did not predict either overall early or late complication rates, regardless of the stages of reconstruction, after adjusting for confounders. Tissue expanders placed in prepectoral plane were associated with a higher hazard ratio (HR) for developing early and late infection after the first stage of reconstruction (HR 2.1, HR 2.4, respectively) as well as late infection after the second stage of reconstruction (HR 5.3, all p Conclusions Location of tissue expanders did not predict risk of complication. However, the prepectoral group was associated with an increased risk of developing infection.

Treating pain in burn patients with a history of opioid or drug abuse is challenging. There is no consensus on pain management for burn patients with a history of drug usage. Our aim was to study the association of previous drug addiction and the treatment of acute burn patients, focusing on daily morphine milligram equivalent (MME) requirements and outcomes. We compared patients with (group 1) and without (group 2) a drug addiction history who were admitted to an American Burn Association verified burn center using the Premier database from 2013 to 2018 (n = 3046). Primary outcome was daily MME usage. Secondary outcomes included mortality, expected mortality rate, length of stay (LOS), and number of surgeries. Linear regression was performed to predict MME usage. In total, 16.6% of patients had history of drug abuse. In unadjusted analysis, group 1 had more males (68.1% vs. 57.3%, p < 0.001) and was younger (median 47 vs. median 53, p < 0.001) compared to group 2. In the adjusted analysis, group 1 required 84.1 additional daily MME usage than group 2 (p < 0.01). Drug addiction was associated with an increased number of surgeries, LOS, and higher daily MME usage. Patients with a history of drug usage required almost 60 mg of additional oxycodone per day.

AIM Emerging evidence has suggested that metformin may be protective against the development of human-papillomavirus-related cancers. Anal intraepithelial neoplasia (AIN) is highly associated with human papillomavirus infection and a precancerous status of anal cancer. The aim of this study was to investigate the relationship between metformin usage and the development of AIN in a large national sample. METHODOLOGY The IBM MarketScan dataset was used to design a nested case-control study from 2010 to 2017. Patients aged 18-65 years with type 2 diabetes mellitus (DM) were evaluated, and cases of AIN were identified. Four controls were randomly selected in the risk set of each case by using incidence density sampling. The association between metformin usage and AIN was assessed using multivariate logistic regression modelling. RESULTS A total of 258 patients with type 2 DM were diagnosed with AIN during the study interval, and these were matched to 1032 control patients without a diagnosis of AIN. Patients who developed AIN had 38% lower odds of prior metformin use compared to those without a history of AIN (P

Background There are conflicting data regarding the relationship between pathologic complete response (pCR) and post-operative complications following rectal cancer resection. The objective of this study was to compare the rates of morbidity among pCR patients and non-pCR patients and to identify factors that predict pCR morbidity in a large national database. Methods This is a retrospective study using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted proctectomy data (2016–18). Patients with neoadjuvant chemoradiation therapy followed by proctectomy were included, and divided into pCR and non-pCR groups according to final stage. The groups were compared with Student’s t-test, Chi-squared or Fisher’s exact test. Multivariate logistic regression models were constructed to estimate the association between pCR status and post-operative morbidity while adjusting for key covariates. Results 244 pCR and 1656 non-pCR patients were included. pCR patients had higher body mass index (28.1 ± 6.2 vs. 29.1 ± 5.9 kg/m2; p = 0.01) and lower pre-operative stage (T stage, p = 0.03; N stage, p 0.05). Post-operative complications in pCR patients were less frequent than in non-pCR patients (23.0% vs. 29.3%; p = 0.04). This association was robust to adjustment for confounders in logistic regression, as patients with pCR had decreased odds of post-operative morbidity (OR 0.66, CI [0.43, 0.96], p = 0.04). Conclusion pCR is associated with fewer post-operative complications compared to non-pCR, suggesting that pCR is not a marker of severe pelvic fibrosis. This difference may be due to underlying tumor biology, and associated increased technical challenges resecting larger, non-responsive tumors.

Liver transplantation (LT) provides better outcome than surgical resection (SR) although both are acceptable surgical options for hepatocellular carcinoma (HCC). It is unclear whether non-clinical factors drive treatment decisions. Our goal is to identify factors that may affect treatment decisions.Patients aged 18-74 with T2 HCC undergoing either LT or SR in Surveillance, Epidemiology, and End Results Database from 2004 to 2014 were included. Healthcare resources data were analyzed to assess factors that predict utilization of LT versus SR, adjusted for demographic, clinical outcomes, and socioeconomic factors.51% of patients (Total N = 2616) received LT, with a substantial state-level variation in LT rates (0.0%-66.9%). Higher LT center density [OR = 1.04 per 1% increment, P 0.01], male gender (OR = 1.38, P = 0.02), and numbers of potential donors (OR = 1.19, P = 0.03) were positively associated with LT utilization. Conversely, higher incidence of chronic liver disease/cirrhosis (OR = 0.41 per one additional case per 100,000 populations, P = 0.001) and minority populations were negatively correlated with LT utilization. Notably, short-term surgical outcomes (in-hospital LTSR mortality) were not associated with LT utilization.Liver transplant center density and organ availability, but not surgical outcomes, affect utilization of LT. Future studies should focus on increasing availability of resources.

INTRODUCTION Discharging older individuals to rehabilitation facilities is associated with adverse outcomes, including readmission or increased mortality rate. As preoperative functional status is an important factor impacting patient outcome, we hypothesized that this would be associated with patient disposition to nonhome locations. MATERIALS AND METHODS A retrospective analysis was performed using data from the 2013-2018 American College of Surgeons National Surgical Quality Improvement Program, including targeted variables from the Geriatric Pilot Project. Patients aged 65 and older in 33 institutions across the nation were included (n = 44,219). Preoperative functional status was categorized as independent, partially dependent, and dependent. The primary outcome was home versus nonhome disposition. Nonhome was defined as rehabilitation facility and nursing home. Descriptive analyses were performed. Variables associated with postoperative discharge to nonhome were identified using logistic regression. RESULTS The largest percentage of operations was orthopedics (40.8%), followed by general surgery (29.2%) and vascular operations (10.0%). The majority of the patients were independent before operations (93.1% independent, 6% partially dependent, and 0.9% totally dependent). In regression analyses, patients who were partially dependent preoperatively had five times higher odds of discharging to nonhome, compared to patients who were independent (odds ratio [OR] 5.04, p

To quantify the changes in joint movement control and motor planning of the more-affected upper extremity (UE) during a reach-grasp-eat task in children with Unilateral Spastic Cerebral Palsy (USCP) after either constraint-induced movement therapy (CIMT) or hand-arm bimanual intensive therapy (HABIT).Twenty children with USCP (average age 7.7; MACS levels I-II) were randomized into either a CIMT or HABIT group. Both groups received intensive training 6 h a day for 15 days. Children performed a reach-grasp-eat task before and after training with their more-affected hand using 3D kinematic analysis.Both groups illustrated shorter movement time during reaching, grasping, and eating phases after training (The current findings showed that both CIMT and HABIT improved UE joint control, but there were greater effects of CIMT on the more-affected UE motor planning and head control for children with USCP.

Importance In the US, approximately 40 000 people die due to firearm-related injuries annually. However, nonfatal firearm-related injuries are less precisely tracked. Objectives To assess the annual incidence of hospitalization for nonfatal firearm-related injuries in New York and to compare the annual incidence by sex, race/ethnicity, county of residence, and calendar years. Design, Setting, and Participants This retrospective cross-sectional study used data from the New York Statewide Planning and Research Cooperative System for patients aged 15 years or older who presented to an emergency department in New York with nonfatal firearm-related injuries from January 1, 2005, to December 31, 2016. Data were analyzed from January 15, 2019, to April 21, 2021. Exposure A nonfatal firearm-related injury, defined byInternational Classification of Diseases, Ninth Revision, Clinical ModificationandInternational Statistical Classification of Diseases, Tenth Revision, Clinical Modificationcodes. Main Outcomes and Measures The annual incidence of nonfatal firearm-related injuries was calculated by determining the number of patients with a nonfatal firearm-related injury each year divided by the total population of New York. Results The study included 31 060 unique patients with 35 059 hospital encounters for nonfatal firearm-related injuries. The mean (SD) age at admission was 28.5 (11.9) years; most patients were male (90.6%) and non-Hispanic Black individuals (62.0%). The overall annual incidence was 18.4 per 100 000 population. Although decreasing trends of annual incidence were observed across the state during the study period, this trend was not present in all 62 counties, with 32 counties (51.6%) having an increase in the incidence of injuries between 2005 and 2010 and 29 (46.8%) having an increase in the incidence of injuries between 2010 and 2015. In 19 of the 30 counties (63.3%) that had a decrease in incidence in earlier years, the incidence increased in later years. Conclusions and Relevance The annual incidence of hospitalization for nonfatal firearm-related injuries in New York during the study period was 18.4 per 100 000 population. Reliable tracking of nonfatal firearm-related injury data may be useful for policy makers, hospital systems, community organizers, and public health officials as they consider resource allocation for trauma systems and injury prevention programs.

Background Many articles in the surgical literature were faulted for committing type 2 error, or concluding no difference when the study was “underpowered”. However, it is unknown if the current power standard of 0.8 is reasonable in surgical science. Methods PubMed was searched for abstracts published in Surgery, JAMA Surgery, and Annals of Surgery and from January 1, 2012 to December 31, 2016, with Medical Subject Heading terms of randomized controlled trial (RCT) or observational study (OBS) and limited to humans were included (n = 403). Articles were excluded if all reported findings were statistically significant (n = 193), or if presented data were insufficient to calculate power (n = 141). Results A total of 69 manuscripts (59 RCTs and 10 OBSs) were assessed. Overall, the median power was 0.16 (interquartile range [IQR] 0.08-0.32). The median power was 0.16 for RCTs (IQR 0.08-0.32) and 0.14 for OBSs (IQR 0.09-0.22). Only 4 studies (5.8%) reached or exceeded the current 0.8 standard. Two-thirds of our study sample had an a priori power calculation (n = 41). Conclusions High-impact surgical science was routinely unable to reach the arbitrary power standard of 0.8. The academic surgical community should reconsider the power threshold as it applies to surgical investigations. We contend that the blueprint for the redesign should include benchmarking the power of articles on a gradient scale, instead of aiming for an unreasonable threshold.

Background Circumcision is widely accepted for newborns in the United States. However, circumcision carries a risk of complications, the rates of which are not well described in the contemporary era. Methods We performed a longitudinal population analysis of the California Office of Statewide Health Planning and Development database between 2005 and 2010. Using International Classification of Procedures, Ninth Revision, Clinical Modification and Current Procedural Terminology codes, we calculated early and late complication rates by Kaplan–Meier survival estimates. Late complications were defined as those that occurred between 30 d and 5 y after circumcision. Descriptive analysis of complications was obtained by analysis of variance, chi-square test, or log-rank test. On adjusted analysis, a Cox proportional hazard model was performed to determine the risk of early and late complications, adjusting for patient demographics. Results A total of 24,432 circumcised children under age 5 y were analyzed. Overall, cumulative complication rates over 5 y were 1.5% in neonates, 0.5% of which were early, and 2.9% in non-neonates, 2.2% of which were early. On adjusted analysis, non-neonates had a higher risk of early complications (OR 18.5). In both neonates and non-neonates, the majority of patients with late complications underwent circumcision revision. Conclusions Circumcision has a complication rate higher than previously recognized. Most patients with late complications after circumcision received an operative circumcision revision. Clinicians should weigh the surgical risks against the reported medical benefits of circumcision when counseling parents about circumcision.

Information on whole-body coordination involving bimanual coordination for children with unilateral spastic cerebral palsy (USCP) is limited.The purpose of the current study is to test the hypothesis that during a whole-body pick up task, children with USCP will organize their whole- body movements and bimanual coordination differently than typically-developing children (TDC).Twelve children with USCP (average age: 8.3; MACS levels: I-II) and twelve age-matched TDC participated in the study. Children were asked to reach down, grasp, and pick up an empty box to waist height while Kinematic and Kinetic data were recorded and analyzed using a VICON system and two AMTI force plates.Children with USCP had longer overall movement time, reaching down time, and grasping movement time (all P 0.05) than TDC. Less bimanual coordination was indicated by greater finger vertical position differences and movement onset and offset timing differences (all P 0.05). Additionally, greater bilateral joint position on differences were found for shoulder, elbow, hip, and knee when reaching down and for shoulder and elbow at the end of the task (all P 0.05). Greater asymmetric bilateral ground reaction force and greater lateral and anterior center of pressure excursion were also found in children with USCP (all P 0.05).Impairments in both bimanual and whole-body coordination were found during a simple whole-body task in children with USCP. Future treatments or assessments should consider whole-body tasks involving dual task constraints.

Information on the effects of obesity on the biomechanics of whole body movement control in children is limited. The purpose of the current study is to test the hypothesis that during a simple pick up task, overweight and obese children will organize their whole body movements differently than those in normal weight children. Twelve children who were overweight or obese (5-13 years old) and twelve age matched normal weight children participated in the study. Children picked up an empty box to waist height at a self-selected pace while kinematic and kinetic data were recorded and analyzed using a VICON system and two AMTI force plates. The overweight and obese group showed less knee flexion in both legs, more spine flexion, and less excursion in the height of their center of mass (all Ps

Background Children with unilateral spastic cerebral palsy (USCP) exhibit impaired bimanual coordination, gait control, and whole body movement control. Intensive upper extremity training has been found to be effective for improving upper extremity function. However, the effectiveness of the intensive upper extremity training on whole body movement control is not known. Research question The present study aimed to evaluate the effects of Constraint Induced Movement Therapy (CIMT) and Hand Arm Bimanual Intensive Therapy (HABIT) on bimanual coordination and gait control during a complex whole body task. Methods Sixteen children with congenital hemiplegia (age 6–12 years; GMFCS: I-II, MACS: I-II) were randomly assigned to either CIMT or HABIT for 6 h per day training for 15 days. Children were asked to perform two whole body tasks (walking with and without a tray carrying) while 3-D kinematic analysis was performed before and after training. Results After training, the HABIT group increased the symmetry in height of their hands during tray carrying (more leveled tray). Both CIMT and HABIT groups decreased the lateral motion of the tray. The CIMT group increased speed and stride length after training in both the walking and tray carrying tasks. Both groups also increased their minimum toe clearance (all p Significance Two types of intensive upper extremity training have provided significant improvements to whole body movement control for children with USCP. Adhering to the specificity of practice concept, HABIT improved bimanual coordination after training during the whole body tray carrying tasks. Given extensive interactions between the upper and lower extremities in real-world activities, future studies should focus on the effects of such combined training.

Practice pattern and work environment differences may impact career advancement opportunities and contribute to the gender gap within highly competitive surgical specialties.Using a 2000-2015 New York statewide dataset, we compared board-certified pediatric surgeons by specialist case volume and Herfindahl-Hirschman Index (HHI), which quantifies surgeon focus within specialist case mix.51 pediatric surgeons were analyzed for 461 surgeon-years. Female surgeons had lower case volume (159 cases/year versus 214, p 0.01), lower shares of specialist cases (14.1% versus 16.7%, p = 0.04), and less focused practices (HHI 0.16 versus 0.20, p = 0.03). Female surgeons' networks had fewer colleagues (7.2 versus 12.1, p 0.01), and lower annual total (388 versus 726, p 0.01) and specialist case volume (83 versus 159, p 0.01), even after accounting for career length. However, female surgeons performed more cases within their networks (49% versus 36%, p = 0.04) and worked at major teaching hospitals as often as men (76% versus 76%, p = 0.97).The challenges that female surgeons face may be reflective of organizational inequities that necessitate intentional scrutiny and change.

The risk of adverse outcomes for pediatric renal transplant patients is highest during the transition from pediatric to adult care. While there have been many studies focus on graft failure and death, loss to follow-up likely plays a large role in patient outcomes. We hypothesize patients are lost to follow-up during this transition period and that patients transplanted at pediatric centers with a closely affiliated adult center (AFFs) are less likely to suffer from fragmentation of care and become lost to follow-up. AFFs were defined as those pediatric centers whose transplant surgeons were also on staff at an adult center and were identified using center websites. We included patients undergoing renal transplantation at

To evaluate the influence of accuracy constraints on functional symmetric bimanual coordination for children with Unilateral Spastic Cerebral Palsy (USCP).Ten children with USCP (average age: 9.6; MACS levels: I-II), ten typically developing children, and ten adults lifted a tray with a water bottle on top. Two accuracy constraints of handle size and cap condition were manipulated.Children with USCP exhibited greater bilateral asymmetry in hand vertical position, timing, upper arm, and elbow control than other groups. Smaller handle decreased bilateral timing differences at lift onset and offset, and decreased bilateral elbow asymmetry at reach and lift offset. Without a cap (accuracy constraint), they showed greater trunk involvement, and less bilateral vertical position and lift offset timing differences (allChildren with USCP showed impaired symmetric bimanual coordination. Higher accuracy constraints improved some bimanual spatial and temporal control. Therefore, task accuracy constraints should be manipulated carefully for training.

PURPOSE: Breast masses in pediatric patients are often managed in a similarly to adult breast masses despite significant differences in pathology and natural history. Emerging evidence suggests that clinical observation is safe. The purpose of this study was to quantify the clinical appropriateness of the management of benign breast disease in pediatric patients. METHODS: A multi-institutional retrospective cohort study was completed between 1995–2017. Patients were included if they had benign breast disease and were 19 years old or younger. A timeline of all interventions (ultrasound, biopsy, or excision) was generated to quantify the number of patients who were observed for at least 90 days, deemed appropriate care. To quantify inappropriate care, the number of interventions performed within 90 days, and the pathologic concordance to clinical decisions was determined by reviewing the radiology reports of all ultrasounds and pathology reports of all biopsies and excisions. RESULTS: A total of 1,909 patients were analyzed. Mean age was 16.4 years old (± 2.1). The majority of masses were fibroadenomas (60.4%). Only half of patients (54.3%) were observed for 90 or more days. 81.1% of interventions were unnecessary, with pathology revealing masses that would be safe to observe. The positive predictive value (PPV) of clinical decisions made based on suspicious ultrasound findings was 16.2%, not different than a PPV of 21.9% (p

OBJECTIVETraumatic brain injury (TBI)—the “silent epidemic”—contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups.METHODSOpen-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group.RESULTSRelevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64–74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650–1947) and Europe (1012 cases, 95% CI 911–1113) and least in Africa (801 cases, 95% CI 732–871) and the Eastern Mediterranean (897 cases, 95% CI 771–1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs.CONCLUSIONSSixty-nine million (95% CI 64–74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.

Study Objective Current literature lacks data-driven guidelines for surgical treatment of adolescent and young adult (AYA) patients with chronic pelvic pain. We hypothesized that there is a significant variation in treatment of these patients, which might be an indicator of over- or undertreatment by some providers. Design and Setting We completed a retrospective population-based analysis of the Nationwide Inpatient Sample from 1998 to 2016. Participants We included AYA patients aged 9-25 years whose primary diagnosis was adenomyosis, endometriosis, or chronic pelvic pain. Patients who might have undergone pelvic or abdominal procedures for other primary diagnoses were excluded. Interventions and Main Outcome Measures Trends of inpatient surgical intervention were calculated. Logistic regression was performed to determine the likelihood of undergoing an intervention, adjusted for patient demographic characteristics. Results A total of 13,111 AYA patients were analyzed. Median age at diagnosis was 22 (interquartile range, 20-24) years. The overall inpatient intervention rate was 5879/13111 (45.0%) (2445/5897 (18.6%) for excision/ablation, 2057/5897 (15.7%) for hysterectomy, 1239/5897 (9.5%) for diagnostic laparoscopy, and 156/5897 (1.2%) for biopsy). Rate of hysterectomy increased in the late 2000s while rates of all other interventions decreased. Patients in the northeast were less likely to undergo an intervention than patients in the rest of the country. Rates of intervention also differed according to race, insurance status, and type of hospital. Conclusion There is wide variation in the use of surgical treatment for chronic pelvic pain in AYA patients across the country and between types of institutions. Of concern, the rate of hysterectomy has increased over time. There is a need for data-directed treatment guidelines for the management of AYA patients with chronic pelvic pain to ensure appropriate application of surgical treatments and expand high-value surgical care.

There is limited and conflicting data on the optimal intervention for the treatment of achalasia in adolescents and young adults (AYA), Heller myotomy (HM), esophageal dilation (ED) or botulinum toxin injection (botox). The goal of this study is to determine the most appropriate index intervention for achalasia in the AYA population.We completed a longitudinal, population-based analysis of the California (2005-2010) and New York (1999-2014) statewide databases. We included patients 9-25 years old with achalasia who underwent HM, ED or botox. Comparisons were made based on the patients' index procedure. Rates of 30-day complications, long-term complications, and re-intervention up to 14 years were calculated. Cox regression was performed to determine the risk of re-intervention, adjusting for patient demographics.A total of 442 AYAs were analyzed, representing the largest cohort of young patients with this disease studied to date. Median follow-up was 5.2 years (IQR 1.8-8.0). The overall rate of re-intervention was 29.3%. Rates of re-intervention for ED and botox were equivalent and higher than HM (65.0% for ED, 47.4% for botox and 16.4% for HM, p 0.001). Ultimately, 46.9% of ED and botox patients underwent HM. The overall short-term complication rate was 4.3% and long-term, 1.9%. There was no difference in the short-term and long-term complication rates between intervention groups (p 0.05). On adjusted analysis, ED and botox were associated with increased risks of re-intervention when compared to HM (HR 5.9, HR 4.8, respectively, p 0.01). Black patients were found to have a risk of re-intervention twice that of white patients (HR 2.0, p = 0.05).HM has a similar risk of complications but a significantly lower risk of re-intervention when compared to ED and botox. Based on our findings, we recommend HM as the optimal index procedure for AYAs with achalasia.

Current global surgery initiatives focus on increasing surgical workforce; however, it is unclear whether this approach would be helpful globally, as patients in low-resource countries may not be able to reach hospitals in a timely fashion without formal Emergency Medical Services (EMS). We hypothesize that increased surgical workforce correlates with decreased road traffic deaths (RTDs) only in countries with EMS.Estimated RTDs were obtained from the Global Status Report on Road Safety 2013, which estimated the RTD rate in 2010 (RTD 2010). The classification of EMS was defined by the Global Status Report on Road Safety 2009. The density of surgeons, anesthesiologists, and obstetricians (SAO density) and 2010 income classification were accessed from the World Bank. Multivariable regression analysis was performed adjusting for different countries, income levels, and trauma system characteristics. Sensitivity analysis was performed.One-fourth of the countries reported not having formal EMS (n = 41, 23.4%). On adjusted analysis, SAO density was not associated with changes in RTD 2010 in countries without EMS (n = 25, P = 0.50). However, in countries with EMS, each increase in SAO density per 100,000 population decreased RTDs by 0.079 per 100,000 population (n = 97, P 0.001). Income was the only other factor resulting in reduced mortality rates (P = 0.004). Sensitivity analysis confirmed these findings.Increases in surgical workforce reduce RTDs only when EMS exist. Surgical workforce and EMS must be seen as part of the same system and developed together to maximize their effect in reducing RTDs. Global health initiatives should be tailored to individual country need.Level II (Ecological study).

Perioperative mortality rate (POMR) is a suggested indicator for surgical quality worldwide. Currently, POMR is often sampled by convenience; a data-driven approach for calculating sample size has not previously been attempted. We proposed a novel application of a bootstrapping sampling technique to estimate how much data are needed to be collected to reasonably estimate POMR in low-resource countries where 100% data capture is not possible. Six common procedures in low- and middle-income countries were analysed by using population database in New York and California. Relative margin of error by dividing the absolute margin of error by the true population rate was calculated. Target margin of error was ±50%, because this level of precision would allow us to detect a moderate-to-large effect size. Target margin of error was achieved at 0.3% sampling size for abdominal surgery, 7% for fracture, 10% for craniotomy, 16% for pneumonectomy, 26% for hysterectomy and 60% for C-section. POMR may be estimated with fairly good reliability with small data sampling. This method demonstrates that it is possible to use a data-driven approach to determine the necessary sampling size to accurately collect POMR worldwide.

Background An estimated 5 billion people worldwide lack access to basic surgical care. In particular, the vast majority of low-income and middle-income countries (LMICs) currently struggle to provide adequate neurosurgical services. Significant barriers exist, including limited access to trained medical, nursing, and allied health staff; lack of equipment; and availability of services at reasonable distance and at reasonable cost to patients. An accurate assessment of current neurosurgical capacity in LIMCs is an essential first step in tackling this deficit. Objective To quantify the neurosurgical operational capacity and assess access to neurosurgical services in LMICs, by taking into account the location of workforce and services. Methods A total of 141 LMICs were contacted and asked to report the number of currently practicing neurosurgeons, access to computed tomographic and magnetic resonance imaging, and availability of neurosurgical equipment (microscope, endoscope, bipolar diathermy, high-speed neurosurgical drill). A proposed World Federation of Neurosurgeons classification was used to stratify cities based on the level of neurosurgical care that could be provided. The data were geocoded and analyzed in Redivis (Redivis Inc.) to assess the percentage of the population covered within a 2-hour travel time of a city offering differing levels of neurosurgical care. Results 68 countries provided complete data (response rate, 48.2%). Eleven countries reported having no practicing neurosurgeons. The average percentage of the population with access to neurosurgical services within a 2-hour window is 25.26% in sub-Saharan Africa, 62.3% in Latin America and the Caribbean, 29.64% in East Asia and the Pacific, 52.83% in South Asia, 79.65% in the Middle East and North Africa, and 93.3% in Eastern Europe and Central Asia. Conclusions There are several challenges to the provision of adequate neurosurgical services in low-resource settings. This study used mapping techniques to determine the current global neurosurgical workforce capacity and distribution. We have used our findings to identify areas for improvement. These include increasing and improving neurosurgical training programs worldwide, recruiting students and young physicians into the field, and retaining existing neurosurgeons within their home countries.

To evaluate the effects of home-based intensive bimanual training for children with unilateral spastic cerebral palsy (USCP) on bimanual coordination using 3-D kinematic analyses.Seven children with USCP (aged 29-54 months, MACS level: I-III) received 90 hours (2 hrs/day, 5days/week for 9 weeks) of Home Hand-Arm Bimanual Intensive Training (H-HABIT) provided by trained caregivers. A bimanual drawer-opening task was evaluated with eight infrared cameras using VICON workstation4.6 before and after training to assess improvements in bimanual coordination.H-HABIT training significantly decreased the time between one hand opening the drawer and the other hand manipulating its contents (p0.05) and increased the percentage of time when both hands were moving simultaneously (p = 0.001), which are indicators of improved temporal bimanual coordination. In addition, participants demonstrated a 26% decrease in trunk displacement (p0.05), a 30% increase in upper arm joint excursion (p0.01), and a 25% increase in elbow extension (p0.05) for the affected side. All the improvements were maintained at 6-month posttest.H-HABIT improved not only temporal, but also quality of movement during a bimanual task for seven children with USCP. Thus, H-HABIT could be an alternative or adjunctive treatment for children with USCP.

OBJECTIVEIn 2000, the global density of neurosurgeons was estimated at 1 per 230,000 population, which remains the most recent estimate of the global neurosurgeon workforce density. In 2004, the World Health Organization (WHO) estimated that there were 33,193 neurosurgeons worldwide, including trainees. There have been no updates to this estimate in the past decade. Moreover, only WHO region–level granularity regarding neurosurgeon distribution exists; country-level estimates are limited. The neurosurgery workforce is a crucial component to meeting the growing burden of neurosurgical diseases, which not only represent high absolute incidences and prevalences, but also represent correspondingly high disability-adjusted life years affecting hundreds of millions of people worldwide. Combining the lack of knowledge about the availability of the neurosurgical workforce and the increasing demand for neurosurgical services underscores the need for a system of neurosurgical workforce density surveillance.METHODSThis study involved 3 key steps: 1) global survey/literature review to obtain the number of working neurosurgeons per WHO-recognized country, 2) regression to interpolate any missing data, and 3) calculation of workforce densities and comparison to available historical data by WHO region.RESULTSData for 198 countries were collected (158) or interpolated (40). The global total number of neurosurgeons was estimated at 49,940. Overall, neurosurgeon density ranged from 0 to 58.95 (standardized to per 1,000,000 population) with a median of 3.56 (IQR 0.29–8.26). Thirty-three countries were found to have no neurosurgeons (zero). The highest density, 58.95, was in Japan, where 7495 neurosurgeons are taking care of a population of 127,131,800.CONCLUSIONSIn 2015, the Lancet Commission on Global Surgery estimated that 143 million additional surgical procedures are needed in low- and middle-income countries each year, and a subsequent study revealed that approximately 15% of those surgical procedures are neurosurgical. Based on our results, we can conclude that there are approximately 49,940 neurosurgeons currently, worldwide. The availability of neurosurgeons appears to have increased in all geographic regions over the past decade, with Southeast Asia experiencing the greatest growth. Such remarkable expansion should be assessed to determine factors that could play a role in other regions where the acceleration of growth would be beneficial.

The purpose of the current study was to evaluate the effects of dual task constraints on walking and bimanual coordination for children with and without unilateral Cerebral Palsy (CP). Ten children with unilateral CP (age 7-11 years; MACS levels I-II) and ten age-matched typically developed children were asked to first stand still while holding a box level (standing condition), second, to walk along a path (baseline condition), and third to walk again while carrying a box steady and level (dual task condition) at a preferred speed. The results showed that children with unilateral CP decreased their walking speed, stride length, step width, and toe clearance from the floor under dual task constraints when compared to the baseline condition (all p's0.05), however, typically developing children did not change. Children with unilateral CP also had less level box carrying, larger vertical box movement, and larger elbow movements when compared to typically developing children under dual task condition (all p's0.05). Dual task constraints with a secondary motor task like the current walking with a box task seemed challenging for children with unilateral CP. Therefore, future treatments or assessments should consider using dual task constraints to manipulate the difficulty of tasks.

Little is known about how obesity relates to motor planning and skills during functional tasks. We collected 3-D kinematics and kinetics as normal weight (n=10) and overweight/obese (n=12) children walked on flat ground and as they crossed low, medium, and high obstacles. We investigated if motor planning and motor skill impairments were evident during obstacle crossing. Baseline conditions showed no group differences (all ps>.05). Increased toe clearance was found on low obstacles (p=.01) for the overweight/obese group and on high obstacles (p=.01) for the normal weight group. With the crossing leg, the overweight/obese group had larger hip abduction angles (p=.01) and medial ground reaction forces (p=.006) on high obstacles and high anterior ground reaction forces on low obstacles (p=.001). With the trailing leg, overweight/obese children had higher vertical ground reaction forces on high obstacles (p=.005) and higher knee angles (p=.01) and anterior acceleration in the center of mass (p=.01) on low obstacles. These findings suggest that differences in motor planning and skills in overweight/obese children may be more apparent during functional activities.

The original version of this article went online on 28 April 2019 and was erroneously updated on 12 June 2019 with the supplementary files removed. The original version was restored on 28 June 2019. The Publisher apologizes for the removal of the supplementary files, which was done without the permission of the Editor.