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Global surgery broadly refers to a rapidly expanding multidisciplinary field concerned with providing better and equitable surgical care across international health systems. Global surgery initiatives primarily focus on capacity building, advocacy, education, research, and policy development in low- and middle-income countries (LMICs). The inadequate surgical, anesthetic, and obstetric care currently contributes to 18 million preventable deaths each year. Hence, there is a growing interest in the rapid growth of artificial intelligence (AI) that provides a distinctive opportunity to enhance surgical services in LMICs. AI modalities have been used for personalizing surgical education, automating administrative tasks, and developing realistic and cost-effective simulation-training programs with provisions for people with special needs. Furthermore, AI may assist with providing insights for governance, infrastructure development, and monitoring/predicting stock take or logistics failure that can help in strengthening global surgery pillars. Numerous AI-assisted telemedicine-based platforms have allowed healthcare professionals to virtually assist in complex surgeries that may help to improve surgical accessibility across LMICs. Challenges in implementing AI technology include the misrepresentation of minority populations in the datasets leading to discriminatory bias. Human hesitancy, employment uncertainty, automation bias, and role of confounding factors need to be further studied for equitable utilization of AI. With a focused and evidence-based approach, AI could help several LMICs overcome bureaucratic inefficiency and develop more efficient surgical systems.

IntroductionEmpirical, observational data relating to the diagnosis, management and outcome of three common worldwide cancers requiring surgery is lacking. However, it has been demonstrated that patients in low/middle-income countries undergoing surgery for cancer are at increased risk of death and major complications postoperatively. This study aims to determine quality and outcomes in breast, gastric and colorectal cancer surgery across worldwide hospital settings.Methods and analysisThis multicentre, international prospective cohort study will be undertaken by any hospital providing emergency or elective surgical services for breast, gastric or colorectal cancer. Centres will collect observational data on consecutive patients undergoing primary emergency or elective surgery for breast, gastric or colorectal cancer during a 6-month period. The primary outcome is the incidence of mortality and major complication rate at 30 days after cancer surgery. Infrastructure and care processes in the treatment of these cancers worldwide will also be characterised.Ethics and disseminationThis project will not affect clinical practice and has been classified as clinical audit following research ethics review. The protocol will be disseminated through the international GlobalSurg network.Trial registration number NCT03471494; Pre-results.

South Africa is an upper-middle-income country with widespread social and geographical inequality of surgical provision. The National Forum on Surgery and Anaesthesia in South Africa brought together various stakeholders, including government, societies, academic clinicians and the biomedical industry, to define the core strategy for a national surgical plan.During the forum, presentations and breakaway workshops explored and reported the challenges and opportunities these stakeholders may have in sustaining and improving surgical provision in South Africa. We present the recommendations of these reports with a literature review and other recent reports from organisations involved in healthcare systems in South Africa.We acknowledge the importance of access to safe and affordable surgery for all as a core component of healthcare provision for South Africa. The proposed core strategies for a South African National Surgical Plan to achieve these goals are the following. First, research will focus on high-quality interdisciplinary collaborative research and audit, which addresses the Global Surgery indices, adopts internationally consistent data points and focuses particularly on maternal mortality and the ‘Bellwether procedures’. Second, workforce and training must be tailored to the country’s specific surgical needs, based on a primary healthcare and district hospital model, which is supported by government and academic organisations. Third, the surgical infrastructure and service delivery needs to be strengthened by the district hospital. Finally, strong leadership with appropriate financial support by healthcare managers who partner with clinicians both locally and nationally is needed to achieve these objectives.

IntroductionSurgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings.MethodsA multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI).ResultsOf 1159 children across 181 hospitals in 51 countries, 523 (45·1%) children were from high HDI, 397 (34·2%) from middle HDI and 239 (20·6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12·8% (51/397) in middle HDI and 24·7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI.ConclusionThe odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.

Mycobacterium tuberculosis ( Mtb ) has complex and dynamic interactions with the human host, and subpopulations of Mtb that emerge during infection can influence disease outcomes. This study implicates zinc ion (Zn 2+ ) availability as a likely driver of bacterial phenotypic heterogeneity in vivo . Zn 2+ sequestration is part of “nutritional immunity”, where the immune system limits micronutrients to control pathogen growth, but this defense mechanism seems to be ineffective in controlling Mtb infection. Nonetheless, Zn 2+ -limitation is an environmental cue sensed by Mtb , as calprotectin triggers the zinc uptake regulator (Zur) regulon response in vitro and co-localizes with Zn 2+ -limited Mtb in vivo . Prolonged Zn 2+ limitation leads to numerous physiological changes in vitro , including differential expression of certain antigens, alterations in lipid metabolism and distinct cell surface morphology. Furthermore, Mtb enduring limited Zn 2+ employ defensive measures to fight oxidative stress, by increasing expression of proteins involved in DNA repair and antioxidant activity, including well described virulence factors KatG and AhpC, along with altered utilization of redox cofactors. Here, we propose a model in which prolonged Zn 2+ limitation defines a population of Mtb with anticipatory adaptations against impending immune attack, based on the evidence that Zn 2+ -limited Mtb are more resistant to oxidative stress and exhibit increased survival and induce more severe pulmonary granulomas in mice. Considering that extracellular Mtb may transit through the Zn 2+ -limited caseum before infecting naïve immune cells or upon host-to-host transmission, the resulting phenotypic heterogeneity driven by varied Zn 2+ availability likely plays a key role during early interactions with host cells.