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To estimate global surgical volume in 2012 and compare it with estimates from 2004. For the 194 Member States of the World Health Organization, we searched PubMed for studies and contacted key informants for reports on surgical volumes between 2005 and 2012. We obtained data on population and total health expenditure per capita for 2012 and categorized Member States as very-low, low, middle and high expenditure. Data on caesarean delivery were obtained from validated statistical reports. For Member States without recorded surgical data, we estimated volumes by multiple imputation using data on total health expenditure. We estimated caesarean deliveries as a proportion of all surgery. We identified 66 Member States reporting surgical data. We estimated that 312.9 million operations (95% confidence interval, CI: 266.2-359.5) took place in 2012, an increase from the 2004 estimate of 226.4 million operations. Only 6.3% (95% CI: 1.7-22.9) and 23.1% (95% CI: 14.8-36.7) of operations took place in very-low- and low-expenditure Member States representing 36.8% (2573 million people) and 34.2% (2393 million people) of the global population of 7001 million people, respectively. Caesarean deliveries comprised 29.6% (5.8/19.6 million operations; 95% CI: 9.7-91.7) of the total surgical volume in very-low-expenditure Member States, but only 2.7% (5.1/187.0 million operations; 95% CI: 2.2-3.4) in high-expenditure Member States. Surgical volume is large and growing, with caesarean delivery comprising nearly a third of operations in most resource-poor settings. Nonetheless, there remains disparity in the provision of surgical services globally.

Although the extent of hospital and intensive-care use at the end of life is well known, patterns of surgical care during this period are poorly understood. We examined national patterns of surgical care in the USA among elderly fee-for-service Medicare beneficiaries in their last year of life. We did a retrospective cohort study of elderly beneficiaries of fee-for-service Medicare in the USA, aged 65 years or older, who died in 2008. We identified claims for inpatient surgical procedures in the year before death and examined the relation between receipt of an inpatient procedure and both age and geographical region. We calculated an end-of-life surgical intensity (EOLSI) score for each hospital referral region defined as proportion of decedents who underwent a surgical procedure during the year before their death, adjusted for age, sex, race, and income. We compared patient characteristics with Rao-Scott χ 2 tests, resource use with generalised estimating equations, regional differences with generalised estimating equations Wald tests, and end-of-life surgical intensity scores with Spearman's partial-rank-order correlation coefficients. Of 1 802 029 elderly beneficiaries of fee-for-service Medicare who died in 2008, 31·9% (95% CI 31·9–32·0; 575 596 of 1 802 029) underwent an inpatient surgical procedure during the year before death, 18·3% (18·2–18·4; 329 771 of 1 802 029) underwent a procedure in their last month of life, and 8·0% (8·0–8·1; 144 162 of 1 802 029) underwent a procedure during their last week of life. Between the ages of 80 and 90 years, the percentage of decedents undergoing a surgical procedure in the last year of life decreased by 33% (35·3% [95% CI 34·7–35·9; 8858 of 25 094] to 23·6% [22·9–24·3; 3340 of 14 152]). EOLSI score in the highest intensity region (Munster, IN) was 34·4 (95% CI 33·7–35·1) and in the lowest intensity region (Honolulu, HI) was 11·5 (11·3–11·7). Regions with a high number of hospital beds per head had high end-of-life surgical intensity (r=0·37, 95% CI 0·27–0·46; p<0·0001), as did regions with high total Medicare spending (r=0·50, 0·41–0·58; p<0·0001). Many elderly people in the USA undergo surgery in the year before their death. The rate at which they undergo surgery varies substantially with age and region and might suggest discretion in health-care providers' decisions to intervene surgically at the end of life. None.

In this study, the authors designed checklists to guide care during operating-room crises and evaluated them in a simulated operating room. The availability of checklists improved adherence to best practices by operating-room teams during simulations of surgical crises. Operating-room crises (e.g., massive hemorrhage and cardiac arrest) are high-risk, stressful events that require rapid and coordinated care in a time-critical setting. The reported incidence may be rare for an individual practitioner, 1 but the aggregate incidence for a hospital with 10,000 operations a year is estimated to be approximately 145 such events annually. 2 These are situations in which the way the team cares for a patient will make the difference between life and death. Failure to effectively manage life-threatening complications in surgical patients has been recognized as the largest source of variation in surgical mortality among hospitals. 3 – 7 Small-scale studies . . .

Strong primary health care (PHC) is essential for achieving universal health coverage, but in many low- and middle-income countries (LMICs) PHC services are of poor quality. Facility management is hypothesized to be critical for improving PHC performance, but evidence about management performance and its associations with PHC in LMICs remains limited. We quantified management performance of PHC facilities in Ghana and assessed the experiences of women who sought care at sampled facilities. Using multi-level models, we examined associations of facility management with five process outcomes and eight experiential outcomes. On a scale of 0 to 1, the average overall management score in Ghana was 0·76 (IQR = 0·68-0·85). Facility management was significantly associated with one process outcome and three experiential outcomes. Controlling for facility characteristics, facilities with management scores at the 90th percentile (management score = 0·90) had 22% more essential drugs compared to facilities with management scores at the 10th percentile (0·60) (p = 0·002). Positive statistically non-significant associations were also seen with three additional process outcomes-integration of family planning services (p = 0·054), family planning types provided (p = 0·067), and essential equipment availability (p = 0·104). Compared to women who sought care at facilities with management scores at the 10th percentile, women who sought care at facilities at the 90th percentile reported 8% higher ratings of trust in providers (p = 0·028), 15% higher ratings of ease of following provider's advice (p = 0·030), and 16% higher quality rating (p = 0·020). However, women who sought care in the 90th percentile facilities rated their waiting times as worse (22% lower, p = 0·039). Higher management scores were associated with higher scores for some process and experiential outcomes. Large variations in management performance indicate the need to strengthen management practices to help realize the full potential of PHC in improving health outcomes.

In eight hospitals throughout the world, implementation of a 19-item surgical safety checklist was associated with improved outcomes. Use of the checklist may improve the safety of surgical procedures in hospitals in various economic circumstances. In eight hospitals throughout the world, implementation of a 19-item surgical safety checklist was associated with improved outcomes. Surgical care is an integral part of health care throughout the world, with an estimated 234 million operations performed annually. 1 This yearly volume now exceeds that of childbirth. 2 Surgery is performed in every community: wealthy and poor, rural and urban, and in all regions. The World Bank reported that in 2002, an estimated 164 million disability-adjusted life-years, representing 11% of the entire disease burden, were attributable to surgically treatable conditions. 3 Although surgical care can prevent loss of life or limb, it is also associated with a considerable risk of complications and death. The risk of complications is poorly characterized in . . .

Little is known about the amount and availability of surgical care globally. We estimated the number of major operations undertaken worldwide, described their distribution, and assessed the importance of surgical care in global public-health policy. We gathered demographic, health, and economic data for 192 member states of WHO. Data for the rate of surgery were sought from several sources including governmental agencies, statistical and epidemiological organisations, published studies, and individuals involved in surgical policy initiatives. We also obtained per-head total expenditure on health from analyses done in 2004. Major surgery was defined as any intervention occurring in a hospital operating theatre involving the incision, excision, manipulation, or suturing of tissue, usually requiring regional or general anaesthesia or sedation. We created a model to estimate rates of major surgery for countries for which such data were unavailable, then used demographic information to calculate the total worldwide volume of surgery. We obtained surgical data for 56 (29%) of 192 WHO member states. We estimated that 234·2 (95% CI 187·2–281·2) million major surgical procedures are undertaken every year worldwide. Countries spending US$100 or less per head on health care have an estimated mean rate of major surgery of 295 (SE 53) procedures per 100 000 population per year, whereas those spending more than $1000 have a mean rate of 11 110 (SE 1300; p<0·0001). Middle-expenditure ($401–1000) and high-expenditure (>$1000) countries, accounting for 30·2% of the world's population, provided 73·6% (172·3 million) of operations worldwide in 2004, whereas poor-expenditure (≤$100) countries account for 34·8% of the global population yet undertook only 3·5% (8·1 million) of all surgical procedures in 2004. Worldwide volume of surgery is large. In view of the high death and complication rates of major surgical procedures, surgical safety should now be a substantial global public-health concern. The disproportionate scarcity of surgical access in low-income settings suggests a large unaddressed disease burden worldwide. Public-health efforts and surveillance in surgery should be established. WHO.

Doxorubicin chemotherapy is associated with cardiomyopathy. Dexrazoxane reduces cardiac damage during treatment with doxorubicin in children with acute lymphoblastic leukaemia (ALL). We aimed to establish the long-term effect of dexrazoxane on the subclinical state of cardiac health in survivors of childhood high-risk ALL 5 years after completion of doxorubicin treatment. Between January, 1996, and September, 2000, children with high-risk ALL were enrolled from nine centres in the USA, Canada, and Puerto Rico. Patients were assigned by block randomisation to receive ten doses of 30 mg/m 2 doxorubicin alone or the same dose of doxorubicin preceded by 300 mg/m 2 dexrazoxane. Treatment assignment was obtained through a telephone call to a centralised registrar to conceal allocation. Investigators were masked to treatment assignment but treating physicians and patients were not; however, investigators, physicians, and patients were masked to study serum cardiac troponin-T concentrations and echocardiographic measurements. The primary endpoints were late left ventricular structure and function abnormalities as assessed by echocardiography; analyses were done including all patients with data available after treatment completion. This trial has been completed and is registered with ClinicalTrials.gov, number NCT00165087. 100 children were assigned to doxorubicin (66 analysed) and 105 to doxorubicin plus dexrazoxane (68 analysed). 5 years after the completion of doxorubicin chemotherapy, mean left ventricular fractional shortening and end-systolic dimension Z scores were significantly worse than normal for children who received doxorubicin alone (left ventricular fractional shortening: −0·82, 95% CI −1·31 to −0·33; end-systolic dimension: 0·57, 0·21–0·93) but not for those who also received dexrazoxane (−0·41, −0·88 to 0·06; 0·15, −0·20 to 0·51). The protective effect of dexrazoxane, relative to doxorubicin alone, on left ventricular wall thickness (difference between groups: 0·47, 0·46–0·48) and thickness-to-dimension ratio (0·66, 0·64–0·68) were the only statistically significant characteristics at 5 years. Subgroup analysis showed dexrazoxane protection (p=0·04) for left ventricular fractional shortening at 5 years in girls (1·17, 0·24–2·11), but not in boys (−0·10, −0·87 to 0·68). Similarly, subgroup analysis showed dexrazoxane protection (p=0·046) for the left ventricular thickness-to-dimension ratio at 5 years in girls (1·15, 0·44–1·85), but not in boys (0·19, −0·42 to 0·81). With a median follow-up for recurrence and death of 8·7 years (range 1·3–12·1), event-free survival was 77% (95% CI 67–84) for children in the doxorubicin-alone group, and 76% (67–84) for children in the doxorubicin plus dexrazoxane group (p=0·99). Dexrazoxane provides long-term cardioprotection without compromising oncological efficacy in doxorubicin-treated children with high-risk ALL. Dexrazoxane exerts greater long-term cardioprotective effects in girls than in boys. US National Institutes of Health, Children's Cardiomyopathy Foundation, University of Miami Women's Cancer Association, Lance Armstrong Foundation, Roche Diagnostics, Pfizer, and Novartis.

Surgery is an essential part of health care, but resources to ensure the availability of surgical services are often inadequate. We estimated the global distribution of operating theatres and quantified the availability of pulse oximetry, which is an essential monitoring device during surgery and a potential measure of operating theatre resources. We calculated ratios of the number of operating theatres to hospital beds in seven geographical regions worldwide on the basis of profiles from 769 hospitals in 92 countries that participated in WHO's safe surgery saves lives initiative. We used hospital bed figures from 190 WHO member states to estimate the number of operating theatres per 100 000 people in 21 subregions throughout the world. To estimate availability of pulse oximetry, we sent surveys to anaesthesia providers in 72 countries selected to ensure a geographically and demographically diverse sample. A predictive regression model was used to estimate the pulse oximetry need for countries that did not provide data. The estimated number of operating theatres ranged from 1·0 (95% CI 0·9–1·2) per 100 000 people in west sub-Saharan Africa to 25·1 (20·9–30·1) per 100 000 in eastern Europe. High-income subregions all averaged more than 14 per 100 000 people, whereas all low-income subregions, representing 2·2 billion people, had fewer than two theatres per 100 000. Pulse oximetry data from 54 countries suggested that around 77 700 (63 195–95 533) theatres worldwide (19·2% [15·2–23·9]) were not equipped with pulse oximeters. Improvements in public-health strategies and monitoring are needed to reduce disparities for more than 2 billion people without adequate access to surgical care. WHO.

Background In recent years, there has been considerable interest in addressing racial disparities in prostate cancer (PCa) care including risk-adapted screening. This study examined trends in metastatic PCa incidence by race and placed them in context of changes in PSA screening recommendations. Methods We analyzed metastatic PCa incidence trends by race (using Surveillance Epidemiology and End Results data, 2005–2021) and PSA screening trends (using Behavioral Risk Factors Surveillance Survey data, 2012–2020). We fitted a generalized linear model with an interaction term for race and year of diagnosis and calculated annual incidence rate ratios (metastatic disease) and odds ratios (screening) for Non-Hispanic Black (NHB) vs. Non-Hispanic White (NHW) men. Results From 2005 to 2021, the age-adjusted metastatic PCa incidence (per 100,000) increased from 16.4 to 22.3 in NHB men, and from 6.2 to 10.8 in NHW men. While the incidence increased in both groups, the NHB vs. NHW incidence rate ratio declined from 2.6 (95%CI: 2.4, 2.9) in 2005 to 2.1 (95%CI:2.0,2.2) in 2021 ( p  < .0001), indicating a narrowing racial gap. From 2012 to 2020, PSA screening declined in both groups. NHB men initially had higher rates (OR:1.34, 95%CI: 1.21, 1.49, p  < 0.0001) but experienced a steeper decline, resulting in no significant difference by 2020 (OR: 1.04, 95% CI: 0.91, 1.19, p  = 0.59). Conclusions The racial gap in metastatic PCa narrowed over the study period, while overall incidence increased. Higher screening rates among Black men in the early 2010s may explain the narrowing gap. The subsequent more rapid decline among Black men raises concerns about resurgence of racial disparities in the coming years.

A transtibial prosthetic interface typically comprises a compliant liner and an outer rigid socket. The preponderance of today’s conventional liners are mass produced in standard sizes, and conventional socket design is labor-intensive and artisanal, lacking clear scientific rationale. This work tests the clinical efficacy of a novel, physics-based digital design framework to create custom prosthetic liner-socket interfaces. In this investigation, we hypothesize that the novel digital approach will improve comfort outcomes compared to a conventional method of liner-socket design. The digital design framework generates custom transtibial prosthetic interfaces starting from MRI or CT image scans of the residual limb. The interface design employs FEA to simulate limb deformation under load. Interfaces are fabricated for 9 limbs from 8 amputees (1 bilateral). Testing compares novel and conventional interfaces across four assessments: 5-min walking trial, thermal imaging, 90-s standing pressure trial, and an evaluation questionnaire. Outcome measures include antalgic gait criterion, skin surface pressures, skin temperature changes, and direct questionnaire feedback. Antalgic gait is compared via a repeated measures linear mixed model while the other assessments are compared via a non-parametric Wilcoxon sign-rank test. A statistically significant ( ) decrease in pain is demonstrated when walking on the novel interfaces compared to the conventional. Standing pressure data show a significant decrease in pressure on novel interfaces at the anterior distal tibia ( ), with no significant difference at other measured locations. Thermal results show no statistically significant difference related to skin temperature. Questionnaire feedback shows improved comfort on novel interfaces on posterior and medial sides while standing and the medial side while walking. Study results support the hypothesis that the novel digital approach improves comfort outcomes compared to the evaluated conventional method. The digital interface design methodology also has the potential to provide benefits in design time, repeatability, and cost.