Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov , NCT03471494 . Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

Background The Covid-19 pandemic led to significant changes and disruptions to medical education worldwide. We evaluated medical student perceived views on training, their experiences and changes to teaching methods during the pandemic. Methods An online survey of medical students was conducted in the Autumn of 2020. An international network of collaborators facilitated participant recruitment. Students were surveyed on their perceived overall impact of Covid-19 on their training and several exposure variables. Univariate analyses and adjusted multivariable analysis were performed to determine strengths in associations. Results A total of 1604 eligible participants from 45 countries took part in this survey and 56.3% (n = 860) of these were female. The median age was 21 (Inter Quartile Range:21–23). Nearly half (49.6%, n = 796) of medical students were in their clinical years. The majority (n = 1356, 84.5%) were residents of a low or middle income country. A total of 1305 (81.4%) participants reported that the Covid-19 pandemic had an overall negative impact on their training. On adjusted analysis, being 21 or younger, females, those reporting a decline in conventional lectures and ward based teaching were more likely to report an overall negative impact on their training (p ≤ 0.001). However, an increase in clinical responsibilities was associated with lower odds of participants reporting a negative impact on training (p < 0.001). The participant’s resident nation economy and stage of training were associated with some of the participant training experiences surveyed (p < 0.05). Conclusion An international cohort of medical students reported an overall significant negative impact of the Covid-19 pandemic on their undergraduate training. The efficacy of novel virtual methods of teaching to supplement traditional teaching methods warrants further research.

Background Laparoscopic cholecystectomy is increasingly performed in an ever ageing population; however, the risks are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of cholecystectomy in the elderly population compared to younger patients. Method A systematic literature search of PubMed, EMBASE and the Cochrane Library databases were conducted including studies reporting laparoscopic cholecystectomy in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were conversion to open surgery, bile leaks, postoperative mortality and length of stay. Results This review identified 99 studies incorporating 326,517 patients. Increasing age was significantly associated with increased rates of overall complications (OR 2.37, CI95% 2.00–2.78), major complication (OR 1.79, CI95% 1.45–2.20), risk of conversion to open cholecystectomy (OR 2.17, CI95% 1.84–2.55), risk of bile leaks (OR 1.50, CI95% 1.07–2.10), risk of postoperative mortality (OR 7.20, CI95% 4.41–11.73) and was significantly associated with increased length of stay (MD 2.21 days, CI95% 1.24–3.18). Conclusion Postoperative outcomes such as overall and major complications appear to be significantly higher in all age cut-offs in this meta-analysis. This study demonstrated there is a sevenfold increase in perioperative mortality which increases by tenfold in patients > 80 years old. This study appears to confirm preconceived suspicions of higher risks in elderly patients undergoing cholecystectomy and may aid treatment planning and informed consent.

Musculoskeletal loss in actual or simulated microgravity occurs at a high rate. Bed rest studies are a reliable ground-based spaceflight analogue that allow for direct comparison of intervention and control participants. The aim of this review was to investigate the impact of exercise compared to no intervention on bone mineral density (BMD) and muscle cross-sectional area (muscle CSA) in bed rest studies relative to other terrestrial models. Eligible bed rest studies with healthy participants had an intervention arm with an exercise countermeasure and a control arm. A search strategy was implemented for MEDLINE. After screening, eight studies were identified for inclusion. Interventions included resistive exercise (RE), resistive vibration exercise (RVE), flywheel resistive exercise, treadmill exercise with lower body negative pressure (LBNP) and a zero-gravity locomotion simulator (ZLS). Lower limb skeletal sites had the most significant BMD losses, particularly at the hip which reduced in density by 4.59% ( p < 0.05) and the tibial epiphysis by 6% ( p < 0.05). Exercise attenuated bone loss at the hip and distal tibia compared to controls ( p < 0.05). Muscle CSA changes indicated that the calf and quadriceps were most affected by bed rest. Exercise interventions significantly attenuated loss of muscle mass. ZLS, LBNP treadmill and RE significantly attenuated bone and muscle loss at the hip compared to baseline and controls. Despite exercise intervention, high rates of bone loss were still observed. Future studies should consider adding bisphosphonates and pharmacological/nutrition-based interventions for consideration of longer-duration missions. These findings correlate to terrestrial bed rest settings, for example, stroke or spinal-injury patients.

Introduction The COVID‐19 pandemic has resulted in a significant burden on healthcare systems causing disruption to the medical and surgical training of doctors globally. Aims and Objectives This is the first international survey assessing the perceived impact of the COVID‐19 pandemic on the training of doctors of all grades and specialties. Methods An online global survey was disseminated using Survey Monkey ® between 4th August 2020 and 17th November 2020. A global network of collaborators facilitated participant recruitment. Data were collated anonymously with informed consent and analysed using univariate and adjusted multivariable analyses. Results Seven hundred and forty‐three doctors of median age 27 (IQR: 25‐30) were included with the majority (56.8%, n = 422) being male. Two‐thirds of doctors were in a training post (66.5%, n = 494), 52.9% (n = 393) in a surgical specialty and 53.0% (n = 394) in low‐ and middle‐income countries. Sixty‐nine point two percent (n = 514) reported an overall perceived negative impact of the COVID‐19 pandemic on their training. A significant decline was noted amongst non‐virtual teaching methods such as face‐to‐face lectures, tutorials, ward‐based teaching, theatre sessions, conferences, simulation sessions and morbidity and mortality meetings ( P ≤ .05). Low or middle‐income country doctors’ training was associated with perceived inadequate supervision while performing invasive procedures under general, local or regional anaesthetic. ( P ≤ .05). Conclusion In addition to the detrimental impact of the COVID‐19 pandemic on healthcare infrastructure, this international survey reports a widespread perceived overall negative impact on medical and surgical doctors’ training globally. Ongoing adaptation and innovation will be required to enhance the approach to doctors’ training and learning in order to ultimately improve patient care.

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Introduction The COVID-19 pandemic has resulted in a significant burden on healthcare systems causing disruption to medical and surgical training of doctors globally. Aims and objectives This is the first international survey assessing the perceived impact of the COVID-19 pandemic on training of doctors of all grades and specialties. Methods An online global survey was disseminated using Survey Monkey® between 4th August 2020 and 17th November 2020. A global network of collaborators facilitated participant recruitment. Data was collated anonymously with informed consent and analysed using univariate and adjusted multivariable analysis. Results 743 doctors of median age 27 (IQR: 25-30) were included with the majority (56.8%, n=422) being male. Two-thirds of doctors were in a training post (66.5%, n=494), 52.9% (n=393) in a surgical specialty and 53.0% (n= 394) in low- and middle-income countries. 69.2% (n=514) reported an overall perceived negative impact of the COVID-19 pandemic on their training. A significant decline was noted among non-virtual teaching methods such as face-to-face lectures, tutorials, ward-based teaching, theatre sessions, conferences, simulation sessions and morbidity and mortality meetings (p≤0.05). Doctors from low or middle-income countries were associated with perceived inadequate supervision while performing invasive procedures under general, local or regional anaesthetic. (p≤0.05) Conclusion In addition to the detrimental impact of the COVID-19 pandemic on healthcare infrastructure, there has been an indirect consequence of disrupted training within medical and surgical subspecialties. A focus on reconfiguration of training programs through a variety of additional resources will become imperative to reduce the long-term sequalae of COVID-19 on doctors’ training.