Micaela Esquivel, MD

All Publications

• Using AI and computer vision to analyze technical proficiency in robotic surgery. Surgical endoscopy Yang, J. H., Goodman, E. D., Dawes, A. J., Gahagan, J. V., Esquivel, M. M., Liebert, C. A., Kin, C., Yeung, S., Gurland, B. H. 2022

  Abstract

  BACKGROUND: Intraoperative skills assessment is time-consuming and subjective; an efficient and objective computer vision-based approach for feedback is desired. In this work, we aim to design and validate an interpretable automated method to evaluate technical proficiency using colorectal robotic surgery videos with artificial intelligence.METHODS: 92 curated clips of peritoneal closure were characterized by both board-certified surgeons and a computer vision AI algorithm to compare the measures of surgical skill. For human ratings, six surgeons graded clips according to the GEARS assessment tool; for AI assessment, deep learning computer vision algorithms for surgical tool detection and tracking were developed and implemented.RESULTS: For the GEARS category of efficiency, we observe a positive correlation between human expert ratings of technical efficiency and AI-determined total tool movement (r=-0.72). Additionally, we show that more proficient surgeons perform closure with significantly less tool movement compared to less proficient surgeons (p<0.001). For the GEARS category of bimanual dexterity, a positive correlation between expert ratings of bimanual dexterity and the AI model's calculated measure of bimanual movement based on simultaneous tool movement (r=0.48) was also observed. On average, we also find that higher skill clips have significantly more simultaneous movement in both hands compared to lower skill clips (p<0.001).CONCLUSIONS: In this study, measurements of technical proficiency extracted from AI algorithms are shown to correlate with those given by expert surgeons. Although we target measurements of efficiency and bimanual dexterity, this work suggests that artificial intelligence through computer vision holds promise for efficiently standardizing grading of surgical technique, which may help in surgical skills training.

  View details for DOI 10.1007/s00464-022-09781-y

  View details for PubMedID 36536082

• Faculty Lead Coaching as a Method to Enhance Feedback Culture and Communication Skills Development in Surgical Education-Needs Assessment (Study in Progress) Nassar, A., Sasnal, M., Tung, J., Ko, A., Esquivel, M., Knowlton, L. LIPPINCOTT WILLIAMS & WILKINS. 2022: S74

  View details for Web of Science ID 000867877000185

• Laparoscopic Heller Myotomy and Toupet Fundoplication. World journal of surgery Alimi, Y. R., Esquivel, M. M., Hawn, M. T. 2022

  Abstract

  Esophageal achalasia is a primary motility disorder of unknown origin. The goal of treatment is to eliminate the resistance caused by a non-relaxing lower esophageal sphincter, therefore allowing passage of foodand liquid from the esophagus into the stomach. A myotomy with a partial fundoplication (anterior Doror posteriorToupet) is considered the standard of care for patients with achalasia. In the following review, we describe the indications and technique for a posterior partial fundoplication (Toupet).

  View details for DOI 10.1007/s00268-022-06471-7

  View details for PubMedID 35220453

• Enhanced Recovery after Bariatric Surgery: Further Reduction in Opioid Use with the Introduction of Dexmedetomidine and Transverse Abdominis Plane Block Alimi, Y. R., Crawford, E., Hoorzuk, S., Cheng, N., Lu, A., Kennedy, L., Ahmed, T., Esquivel, M., Azagury, D. E., Zak, Y. ELSEVIER SCIENCE INC. 2021: S21

  View details for Web of Science ID 000718303100015

• Gastric Peroral Endoscopic Myotomy (GPOEM) Improves Symptoms and Need for Hospital Admission for Gastroparesis and Lung Transplant Patients Li, A., Ofosu, A., Kim, W., Podboy, A., Esquivel, M., Hwang, J. LIPPINCOTT WILLIAMS & WILKINS. 2021: S466-S467

  View details for Web of Science ID 000717526101452

• Peroral Endoscopic Myotomy for Achalasia Subtypes and Esophagogastric Outflow Obstruction: Clinical Success and GERD Li, A., Podboy, A., Kim, W., Esquivel, M., Hwang, J. LIPPINCOTT WILLIAMS & WILKINS. 2021: S467

  View details for Web of Science ID 000717526101453

• Impact of COVID-19 on presentation, management, and outcomes of acute care surgery for gallbladder disease and acute appendicitis. World journal of gastrointestinal surgery Farber, O. N., Gomez, G. I., Titan, A. L., Fisher, A. T., Puntasecca, C. J., Arana, V. T., Kempinsky, A., Wise, C. E., Bessoff, K. E., Hawn, M. T., Korndorffer, J. R., Forrester, J. D., Esquivel, M. M. 2021; 13 (8): 859-870

  Abstract

  The ongoing coronavirus disease 2019 (COVID-19) pandemic has significantly disrupted both elective and acute medical care. Data from the early months suggest that acute care patient populations deferred presenting to the emergency department (ED), portending more severe disease at the time of presentation. Additionally, care for this patient population trended towards initial non-operative management.To examine the presentation, management, and outcomes of patients who developed gallbladder disease or appendicitis during the pandemic.A retrospective chart review of patients diagnosed with acute cholecystitis, symptomatic cholelithiasis, or appendicitis in two EDs affiliated with a single tertiary academic medical center in Northern California between March and June, 2020 and in the same months of 2019. Patients were selected through a research repository using international classification of diseases (ICD)-9 and ICD-10 codes. Across both years, 313 patients were identified with either type of gallbladder disease, while 361 patients were identified with acute appendicitis. The primary outcome was overall incidence of disease. Secondary outcomes included presentation, management, complications, and 30-d re-presentation rates. Relationships between different variables were explored using Pearson's r correlation coefficient. Variables were compared using the Welch's t-Test, Chi-squared tests, and Fisher's exact test as appropriate.Patients with gallbladder disease and appendicitis both had more severe presentations in 2020. With respect to gallbladder disease, more patients in the COVID-19 cohort presented with acute cholecystitis compared to the control cohort [50% (80) vs 35% (53); P = 0.01]. Patients also presented with more severe cholecystitis in 2020 as indicated by higher mean Tokyo Criteria Scores [mean (SD) 1.39 (0.56) vs 1.16 (0.44); P = 0.02]. With respect to appendicitis, more patients were diagnosed with a perforated appendix at presentation in 2020 [20% (36) vs 16% (29); P = 0.02] and a greater percentage were classified as emergent cases using the emergency severity index [63% (112) vs 13% (23); P < 0.001]. While a greater percentage of patients were admitted to the hospital for gallbladder disease in 2020 [65% (104) vs 50% (76); P = 0.02], no significant differences were observed in hospital admissions for patients with appendicitis. No significant differences were observed in length of hospital stay or operative rate for either group. However, for patients with appendicitis, 30-d re-presentation rates were significantly higher in 2020 [13% (23) vs 4% (8); P = 0.01].During the COVID-19 pandemic, patients presented with more severe gallbladder disease and appendicitis. These findings suggest that the pandemic has affected patients with acute surgical conditions.

  View details for DOI 10.4240/wjgs.v13.i8.859

  View details for PubMedID 34512909

  View details for PubMedCentralID PMC8394376

• Preoperative Weight Loss Before Bariatric Surgery-The Debate Continues. JAMA network open Esquivel, M. M., Azagury, D. n. 2020; 3 (5): e204994

  View details for DOI 10.1001/jamanetworkopen.2020.4994

  View details for PubMedID 32407500

• A protected time policy to improve dental health among resident physicians JOURNAL OF THE AMERICAN DENTAL ASSOCIATION Jun, T., Liebert, C., Esquivel, M., Cox, J., Trockel, M., Katznelson, L. 2019; 150 (5): 362-+

  Abstract

  Resident physicians underuse preventive dental health services. The authors assessed the barriers to and need for oral health care among residents and piloted a program to enhance dental health care among house staff.Participants from 5 residency programs received 2 hours of protected time during business hours for visits to a nearby dental office. The authors surveyed participating residents before and after the visits about barriers to seeking oral health care and their experiences with the program. The authors recorded dental findings for each participant.A total of 35 of 243 eligible residents (14.4%) participated in the study; 71.4% reported delaying or skipping preventive dental examinations during residency. Lack of time and norms and peer perceptions were important barriers; 28.6% of residents had dental findings requiring further management.Residents neglect preventive oral health care because of work obligations. More than one-quarter of residents had clinically significant dental findings. Providing protected time addressed common barriers and was well received.Resident physicians have unmet oral health care needs. Collaborations between residency programs and dental practices to provide protected time for residents to seek oral health care could address common barriers to care.

  View details for DOI 10.1016/j.adaj.2018.12.016

  View details for Web of Science ID 000465431400024

  View details for PubMedID 31029211

• Authors' response. Journal of the American Dental Association (1939) Jun, T. W., Liebert, C. A., Esquivel, M. n., Cox, J. A., Trockel, M. n., Katznelson, L. n. 2019; 150 (7): 568–69

  View details for DOI 10.1016/j.adaj.2019.05.010

  View details for PubMedID 31248480

• Surgical deserts in California: an analysis of access to surgical care JOURNAL OF SURGICAL RESEARCH Uribe-Leitz, T., Esquivel, M. M., Garland, N. Y., Staudenmayer, K. L., Spain, D. A., Weiser, T. G. 2018; 223: 102–8

  Abstract

  Areas of minimal access to surgical care, often called "surgical deserts", are of particular concern when considering the need for urgent surgical and anesthesia care. We hypothesized that California would have an appropriate workforce density but that physicians would be concentrated in urban areas, and surgical deserts would exist in rural counties.We used a benchmark of six general surgeons, six orthopedists, and eight anesthesiologists per 100,000 people per county to define a "desert". The number and location of these providers were obtained from the Medical Board of California for 2015. ArcGIS, version 10.3, was used to geocode the data and were analyzed in Redivis.There were a total of 3268 general surgeons, 3188 orthopedists, and 5995 anesthesiologists in California in 2015, yielding a state surgeon-to-population ratio of 7.2, 6.7, and 10.2 per 100,000 people, respectively; however, there was wide geographic variability. Of the 58 counties in California, 18 (31%) have a general surgery desert, 27 (47%) have an orthopedic desert, and 22 (38%) have an anesthesiology desert. These counties account for 15%, 25%, and 13% of the state population, respectively. Five, seven, and nine counties, respectively, have none in the corresponding specialty.Overall, California has an adequate ratio of surgical and anesthesia providers to population. However, because of their uneven distribution, significant surgical care deserts exist. Limited access to surgical and anesthesia providers may negatively impact patient outcome in these counties.

  View details for PubMedID 29433860

• Why do patients receive care from a short-term medicalmission? Survey study from rural Guatemala JOURNAL OF SURGICAL RESEARCH Esquivel, M. M., Chen, J. C., Woo, R. K., Siegler, N., Maldonado-Sifuentes, F. A., Carlos-Ochoa, J. S., Cardona-Diaz, A. R., Uribe-Leitz, T., Siegler, D., Weiser, T. G., Yang, G. P. 2017; 215: 160–66

  Abstract

  Hospital de la Familia was established to serve the indigent population in the western highlands of Guatemala and has a full-time staff of Guatemalan primary care providers supplemented by short-term missions of surgical specialists. The reasons for patients seeking surgical care in this setting, as opposed to more consistent care from local institutions, are unclear. We sought to better understand motivations of patients seeking mission-based surgical care.Patients presenting to the obstetric and gynecologic, plastic, ophthalmologic, general, and pediatric surgical clinics at the Hospital de la Familia from July 27 to August 6, 2015 were surveyed. The surveys assessed patient demographics, surgical diagnosis, location of home, mode of travel, and reasons for seeking care at this facility.Of 252 patients surveyed, 144 (59.3%) were female. Most patients reported no other medical condition (67.9%, n = 169) and no consistent income (83.9%, n = 209). Almost half (44.9%, n = 109) traveled >50 km to receive care. The most common reasons for choosing care at this facility were reputation of high quality (51.8%, n = 130) and affordability (42.6%, n = 102); the least common reason was a lack of other options (6.4%, n = 16).Despite long travel distances and the availability of other options, reputation and affordability were primarily cited as the most common reasons for choosing to receive care at this short-term surgical mission site. Our results highlight that although other surgical options may be closer and more readily available, reputation and cost play a large role in choice of patients seeking care.

  View details for PubMedID 28688642

• The prevalence of psychiatric diagnoses and associated mortality in hospitalized US trauma patients JOURNAL OF SURGICAL RESEARCH Townsend, L. L., Esquivel, M. M., Uribe-Leitz, T., Weiser, T. G., Maggio, P. M., Spain, D. A., Tennakoon, L., Staudenmayer, K. 2017; 213: 171–76

  Abstract

  We hypothesized that psychiatric diagnoses would be common in hospitalized trauma patients in the United States and when present, would be associated with worse outcomes.The Nationwide Inpatient Sample (NIS, 2012) was used to determine national estimates for the number of patients admitted with an injury. Psychiatric diagnoses were identified using diagnosis codes according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.A total of 36.5 million patients were admitted to hospitals in the United States in 2012. Of these, 1.3 million (4%) were due to trauma. Psychiatric conditions were more common in patients admitted for trauma versus those admitted for other reasons (44% versus 34%, P < 0.001). Trauma patients who had a psychiatric diagnosis compared to trauma patients without a psychiatric diagnosis were older (mean age: 61 versus 56 y, P < 0.001), more often female (52% versus 50%, P < 0.001), and more often white (73% versus 68%, P < 0.001). For ages 18-64, drug and alcohol abuse predominated (41%), whereas dementia and related disorders (48%) were the most common in adults ≥65 y. Mortality was lower for trauma patients with a psychiatric diagnosis compared to those who did not in both unadjusted and adjusted analysis (1.9% versus 2.8%; odds ratio: 0.56, P < 0.001).Psychiatric conditions are present in almost half of all hospitalized trauma patients in the United States; however, the types of conditions varied with age. The frequency of psychiatric conditions in the trauma population suggests efforts should be made to address this component of patient health.

  View details for PubMedID 28601311

• A geospatial evaluation of timely access to surgical care in seven countries BULLETIN OF THE WORLD HEALTH ORGANIZATION Knowlton, L. M., Banguti, P., Chackungal, S., Chanthasiri, T., Chao, T. E., Dahn, B., Derbew, M., Dhar, D., Esquivel, M. M., Evans, F., Hendel, S., LeBrun, D. G., Notrica, M., Saavedra-Pozo, I., Shockley, R., Uribe-Leitz, T., Vannavong, B., McQueen, K. A., Spain, D. A., Weiser, T. G. 2017; 95 (6): 437–44

  Abstract

  To assess the consistent availability of basic surgical resources at selected facilities in seven countries.In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (n = 14), the Plurinational State of Bolivia (n = 18), Ethiopia (n = 19), Guatemala (n = 20), the Lao People's Democratic Republic (n = 12), Liberia (n = 12) and Rwanda (n = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital's catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available.Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh.Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.

  View details for PubMedID 28603310

  View details for PubMedCentralID PMC5463808

• Perceived Value of a Program to Promote Surgical Resident Well-being. Journal of surgical education Salles, A., Liebert, C. A., Esquivel, M., Greco, R. S., Henry, R., Mueller, C. 2017

  Abstract

  The demands of surgical residency are intense and threaten not only trainees' physical wellness, but also risk depression, burnout, and suicide. Our residency program implemented a multifaceted Balance in Life program that is designed to improve residents' well-being. The purpose of this study was to evaluate the program utilization and perceived value by residents.Residents (n = 56, 76% response rate) were invited to participate in a voluntary survey from December 2013 to February 2014 regarding utilization, barriers to use, and perceived value of 6 program components (refrigerator, After Hours Guide, psychological counseling sessions, Resident Mentorship Program, Class Representative System, and social events). They were also asked questions about psychological well-being, burnout, grit, and sleep and exercise habits before and after implementation of the program.The most valued components of the program were the refrigerator (mean = 4.61) and the psychological counseling sessions (mean = 3.58), followed by social events (mean = 3.48), the Resident Mentorship Program (mean = 2.79), the Class Representative System (mean = 2.62), and the After Hours Guide (mean = 2.10). When residents were asked how they would allocate $100 among the different programs, the majority was allocated to the refrigerator ($54.31), social events ($26.43), and counseling sessions ($24.06). There was no change in psychological well-being or burnout after the program. Residents had higher levels of grit (β = 0.26, p < 0.01) and exercised (β = 1.02, p < 0.001) and slept (β = 1.17, p < 0.0001) more after the program was implemented.This study demonstrated that a multifaceted program to improve the well-being of trainees is feasible, highly valued, and positively perceived by the residents. Further research is needed to quantify the effectiveness and longitudinal impact such a program has on resident depression, burnout, and other psychological factors.

  View details for DOI 10.1016/j.jsurg.2017.04.006

  View details for PubMedID 28457875

• Regional block via continuous caudal infusion as sole anesthetic for inguinal hernia repair in conscious neonates. Pediatric surgery international Mueller, C. M., Sinclair, T. J., Stevens, M., Esquivel, M., Gordon, N. 2017; 33 (3): 341-345

  Abstract

  The use of general anesthesia in young children has come under increasing scrutiny due to its potential long-term neurotoxic effects. Meanwhile, regional anesthesia for surgical procedures in neonates has many advantages, including preservation of respiratory status and faster return to feeding. We describe the successful use of 3% 2-chloroprocaine administered via continuous caudal infusion as the sole anesthetic agent during elective surgical procedures in infants.A retrospective chart review of all patients who underwent elective surgical procedures under continuous caudal regional anesthetic at a single institution was performed. Thirty patients (27 males, three females) were identified: 28 patients underwent inguinal hernia repairs. Caudal anesthesia was established via continuous infusion of 3% 2-chloroprocaine through an indwelling catheter.Successful analgesia by regional block alone was achieved in all patients for the duration of each surgical procedure without need for rescue anesthesia. Mean operative time was 49 min. Patients were able to return to feeding immediately after surgery and were ready for discharge home within that day.Continuous caudal infusion of chloroprocaine is a safe and effective way to maintain adequate analgesia for elective surgeries in infants. This successful regional approach obviates the use of general anesthetic which reduces post-operative recovery time and avoids concerns for neurotoxicity.

  View details for DOI 10.1007/s00383-016-4027-6

  View details for PubMedID 27873010

• The American College of Surgeons (ACS) Needs-Based Assessment of Trauma Systems (NBATS): Estimates for the State of California. journal of trauma and acute care surgery Uribe-Leitz, T., Esquivel, M. M., Knowlton, L. M., Ciesla, D., Lin, F., Hsia, R. Y., Spain, D. A., Winchell, R. J., Staudenmayer, K. L. 2017

  Abstract

  In 2015, the American College of Surgeons Committee on Trauma convened a consensus conference to develop the Needs-Based Assessment of Trauma Systems (NBATS) tool to assist in determining the number of trauma centers required for a region. We tested the performance of NBATS with respect to the optimal number of trauma centers needed by region in California.Trauma center data were obtained from the California Emergency Services Authority Information Systems (CEMSIS). Numbers of admitted trauma patients (ISS > 15) were obtained using statewide nonpublic admissions data from the California Office of Statewide Health Planning and Development (OSHPD), CEMSIS, and data from local emergency medical service agency (LEMSA) directors who agreed to participate in a telephone survey. Population estimates per county for 2014 were obtained from the U.S. Census. NBATS criteria used included population, transport time, community support, and number of discharges for severely injured patients (ISS > 15) at nontrauma centers and trauma centers. Estimates for the number of trauma centers per region were created for each of the three data sources and compared to the number of existing centers.A total of 62 state-designated trauma centers were identified for California: 13 (21%) Level I, 36 (58%) Level II, and 13 (11%) Level III. NBATS estimates for the total number of trauma centers in California were 27% to 47% lower compared to the number of trauma centers in existence, but this varied based on urban/rural status. NBATS estimates were lower than the current state in 70% of urban areas but were higher in almost 90% of rural areas. All data sources (OSHPD, CEMSIS, local data) produced similar results.Estimates from the NBATS tool are different from what is currently in existence in California, and differences exist based on whether the region is rural or urban. Findings from the current study can help inform future iterations of the NBATS tool.Economic, level V.

  View details for DOI 10.1097/TA.0000000000001408

  View details for PubMedID 28248801

  View details for PubMedCentralID PMC5400714

• Prevalence and predictors of depression among general surgery residents. American journal of surgery Lin, D. T., Liebert, C. A., Esquivel, M. M., Tran, J., Lau, J. N., Greco, R. S., Mueller, C. M., Salles, A. 2017; 213 (2): 313-317

  Abstract

  Recent resident suicides have highlighted the need to address depression among medical trainees. This study sought to identify the prevalence and predictors of depression among surgical residents.Surgical residents at a single institution were surveyed. Depression and personal traits were assessed using validated measures; participant demographics were also obtained.73 residents completed the survey (response rate 63%). 36% met criteria for at least mild depression, of which 20% met criteria for moderate to severe depression. In multivariate linear regression analyses controlling for demographic factors, trait emotional intelligence alone was a significant inverse predictor of depression (β = -0.60, p < 0.001).Depression is prevalent among general surgery residents. Identifying protective factors and at-risk populations may allow for effective initiatives to be developed to address depression, and optimize the mental health of trainees.The aim of this study is to identify the prevalence and predictors of depression among surgical trainees. Over one third of respondents met criteria for at least mild depression, of which 20% met criteria for moderate to severe depression. Among demographic and personal trait variables, emotional intelligence emerged as a significant inverse predictor of depression.

  View details for DOI 10.1016/j.amjsurg.2016.10.017

  View details for PubMedID 28017297

• Grit as a predictor of risk of attrition in surgical residency. American journal of surgery Salles, A., Lin, D., Liebert, C., Esquivel, M., Lau, J. N., Greco, R. S., Mueller, C. 2017; 213 (2): 288-291

  Abstract

  Grit, a measure of perseverance, has been shown to predict resident well-being. In this study we assess the relationship between grit and attrition.We collected survey data from residents in a single institution over two consecutive years. All residents in general surgery were invited to participate (N = 115). Grit and psychological well-being were assessed using validated measures. Risk of attrition was measured using survey items.73 residents participated (63% response rate). Grit was positively correlated with general psychological well-being (r = 0.30, p < 0.05) and inversely correlated with depression (r = -0.25, p < 0.05) and risk of attrition (r = -0.37, p < 0.01). In regression analyses, grit was positively predictive of well-being (B = 0.77, t = 2.96, p < 0.01) and negatively predictive of depression (B = -0.28 t = -2.74, p < 0.01) and attrition (B = -0.99, t = -2.53, p < 0.05).Attrition is a costly and disruptive problem in residency. Grit is a quick, reliable measure which appears to be predictive of attrition risk in this single-institution study.

  View details for DOI 10.1016/j.amjsurg.2016.10.012

  View details for PubMedID 27932088

• Effects of mechanism of injury and patient age on outcomes in geriatric rib fracture patients. Trauma surgery & acute care open Shi, H. H., Esquivel, M., Staudenmayer, K. L., Spain, D. A. 2017; 2 (1): e000074

  Abstract

  Background: Patients older than 65 years have 2-5 times higher mortality if they sustain ≥2 rib fractures compared to younger adults. As a result, our level I trauma center guidelines suggest that older adults with rib fractures be admitted to the intensive care unit for the first 24 hours. In this study, we evaluated the outcomes associated with these guidelines.Methods: We retrospectively reviewed all patients aged ≥65 years in our Trauma Registry who sustained rib fractures from January 2008 to March 2015. Data included demographics, comorbidities, injuries, length of intensive care and hospital stay (LOS), ventilator days, analgesic used, morbidity, mortality, and disposition.Results: 97 patients aged ≥65 years with at least one rib fracture and an Abbreviated Injury Score of ≤2 for other regions were admitted. Falls caused 58% of the injuries, while motor vehicle collisions (MVC) accounted for 33%. Overall mortality was 4%. Patients who fell had a median hospital LOS that was 0.5 to 1 day longer than in those who suffered other mechanisms of injury or were involved in an MVC respectively. Patients aged ≥70 years had a median LOS of 4 days, twice that of those aged 65 to 69 years. Of the 87 patients with more than one rib fracture, 59 (68%) were not admitted directly to the intensive care unit (ICU) from the emergency department as recommended by our guidelines. 6 of these 59 patients (9%) were later transferred to the ICU and 2 of these patients expired.Conclusions: Although overall compliance with the geriatric rib fracture guideline was low, both mortality and hospital LOS were low in this group. This suggests that the guideline could be modified to reduce ICU resource usage without compromising patient outcomes.Level of evidence: Level III, retrospective cohort study.

  View details for PubMedID 29766084

• Mapping Disparities in Access to Safe, Timely, and Essential Surgical Care in Zambia JAMA SURGERY Esquivel, M. M., Uribe-Leitz, T., Makasa, E., Lishimpi, K., Mwaba, P., Bowman, K., Weiser, T. G. 2016; 151 (11): 1064-1069

  Abstract

  Surgical care is widely unavailable in developing countries; advocates recommend that countries evaluate and report on access to surgical care to improve availability and aid health planners in decision making.To analyze the infrastructure, capacity, and availability of surgical care in Zambia to inform health policy priorities.In this observational study, all hospitals providing surgical care were identified in cooperation with the Zambian Ministry of Health. On-site data collection was conducted from February 1 through August 30, 2011, with an adapted World Health Organization Global Initiative for Emergency and Essential Surgical Care survey. Data collection at each facility included interviews with hospital personnel and assessment of material resources. Data were geocoded and analyzed in a data visualization platform from March 1 to December 1, 2015. We analyzed time and distance to surgical services, as well as the proportion of the population living within 2 hours from a facility providing surgical care.Surgical capacity, supplies, human resources, and infrastructure at each surgical facility, as well as the population living within 2 hours from a hospital providing surgical care.Data were collected from all 103 surgical facilities identified as providing surgical care. When including all surgical facilities (regardless of human resources and supplies), 14.9% of the population (2 166 460 of 14 500 000 people) lived more than 2 hours from surgical care. However, only 17 hospitals (16.5%) met the World Health Organization minimum standards of surgical safety; when limiting the analysis to these hospitals, 65.9% of the population (9 552 780 people) lived in an area that was more than 2 hours from a surgical facility. Geographic analysis of emergency and essential surgical care, defined as access to trauma care, obstetric care, and care of common abdominal emergencies, found that 80.7% of the population (11 704 700 people) lived in an area that was more than 2 hours from these surgical facilities.A large proportion of the population in Zambia does not have access to safe and timely surgical care; this percentage would change substantially if all surgical hospitals were adequately resourced. Geospatial visualization tools assist in the evaluation of surgical infrastructure in Zambia and can identify key areas for improvement.

  View details for DOI 10.1001/jamasurg.2016.2303

  View details for Web of Science ID 000388404500020

  View details for PubMedID 27580500

  View details for PubMedCentralID PMC5179136

• A Multinational Evaluation of Timely Access to Basic Surgical Services Using Geospatial Analyses Knowlton, L., Esquivel, M., Uribe-Leitz, T., Mcqueen, K., Chackungal, S., LeBrun, D. G., Chao, T. E., Weiser, T. G., Spain, D. A. ELSEVIER SCIENCE INC. 2016: E118

  View details for DOI 10.1016/j.jamcollsurg.2016.08.296

  View details for Web of Science ID 000395825100255

• Belonging, Well-being, and Attrition in General Surgery Salles, A., Lin, D. T., Liebert, C. A., Esquivel, M., Mueller, C. ELSEVIER SCIENCE INC. 2016: E40–E41

  View details for DOI 10.1016/j.jamcollsurg.2016.08.106

  View details for Web of Science ID 000395825100087

• Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data LANCET GLOBAL HEALTH Uribe-Leitz, T., Jaramillo, J., Maurer, L., Fu, R., Esquivel, M. M., Gawande, A. A., Haynes, A. B., Weiser, T. G. 2016; 4 (3): E165-E174

  Abstract

  Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures-caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair-to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety.We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates.From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs.All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care.None.

  View details for Web of Science ID 000370675000019

  View details for PubMedID 26916818

• Size and distribution of the global volume of surgery in 2012. Bulletin of the World Health Organization Weiser, T. G., Haynes, A. B., Molina, G., Lipsitz, S. R., Esquivel, M. M., Uribe-Leitz, T., Fu, R., Azad, T., Chao, T. E., Berry, W. R., Gawande, A. A. 2016; 94 (3): 201-209F

  Abstract

  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.

  View details for DOI 10.2471/BLT.15.159293

  View details for PubMedID 26966331

  View details for PubMedCentralID PMC4773932

• Size and distribution of the global volume of surgery in 2012 BULLETIN OF THE WORLD HEALTH ORGANIZATION Weiser, T. G., Haynes, A. B., Molina, G., Lipsitz, S. R., Esquiye, M. M., Uribe-Leitz, T., Fu, R., Azad, T., Chao, T. E., Berry, W. R., Gawande, A. A. 2016; 94 (3): 201-209

  Abstract

  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.

  View details for DOI 10.2471/BLT.15.159293

  View details for Web of Science ID 000372774200017

  View details for PubMedCentralID PMC4773932

• Endoscopic Submucosal Dissection of a Large Hamartoma in a Young Child. Journal of pediatric gastroenterology and nutrition Wall, J., Esquivel, M., Bruzoni, M., Wright, R., Berquist, W., Albanese, C. 2016; 62 (1): e5-7

  View details for DOI 10.1097/MPG.0000000000000376

  View details for PubMedID 26709909

• Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality. JAMA Molina, G., Weiser, T. G., Lipsitz, S. R., Esquivel, M. M., Uribe-Leitz, T., Azad, T., Shah, N., Semrau, K., Berry, W. R., Gawande, A. A., Haynes, A. B. 2015; 314 (21): 2263-2270

  Abstract

  Based on older analyses, the World Health Organization (WHO) recommends that cesarean delivery rates should not exceed 10 to 15 per 100 live births to optimize maternal and neonatal outcomes.To estimate the contemporary relationship between national levels of cesarean delivery and maternal and neonatal mortality.Cross-sectional, ecological study estimating annual cesarean delivery rates from data collected during 2005 to 2012 for all 194 WHO member states. The year of analysis was 2012. Cesarean delivery rates were available for 54 countries for 2012. For the 118 countries for which 2012 data were not available, the 2012 cesarean delivery rate was imputed from other years. For the 22 countries for which no cesarean rate data were available, the rate was imputed from total health expenditure per capita, fertility rate, life expectancy, percent of urban population, and geographic region.Cesarean delivery rate.The relationship between population-level cesarean delivery rate and maternal mortality ratios (maternal death from pregnancy related causes during pregnancy or up to 42 days postpartum per 100,000 live births) or neonatal mortality rates (neonatal mortality before age 28 days per 1000 live births).The estimated number of cesarean deliveries in 2012 was 22.9 million (95% CI, 22.5 million to 23.2 million). At a country-level, cesarean delivery rate estimates up to 19.1 per 100 live births (95% CI, 16.3 to 21.9) and 19.4 per 100 live births (95% CI, 18.6 to 20.3) were inversely correlated with maternal mortality ratio (adjusted slope coefficient, -10.1; 95% CI, -16.8 to -3.4; P = .003) and neonatal mortality rate (adjusted slope coefficient, -0.8; 95% CI, -1.1 to -0.5; P < .001), respectively (adjusted for total health expenditure per capita, population, percent of urban population, fertility rate, and region). Higher cesarean delivery rates were not correlated with maternal or neonatal mortality at a country level. A sensitivity analysis including only 76 countries with the highest-quality cesarean delivery rate information had a similar result: cesarean delivery rates greater than 6.9 to 20.1 per 100 live births were inversely correlated with the maternal mortality ratio (slope coefficient, -21.3; 95% CI, -32.2 to -10.5, P < .001). Cesarean delivery rates of 12.6 to 24.0 per 100 live births were inversely correlated with neonatal mortality (slope coefficient, -1.4; 95% CI, -2.3 to -0.4; P = .004).National cesarean delivery rates of up to approximately 19 per 100 live births were associated with lower maternal or neonatal mortality among WHO member states. Previously recommended national target rates for cesarean deliveries may be too low.

  View details for DOI 10.1001/jama.2015.15553

  View details for PubMedID 26624825

• Surgical deserts in California: an analysis of access to surgical care Uribe-Leitz, T., Esquivel, M. M., Staudenmayer, K. L., Spain, D. A., Weiser, T. G. ELSEVIER SCIENCE INC. 2015: E29

  View details for DOI 10.1016/j.jamcollsurg.2015.08.375

  View details for Web of Science ID 000386899000067

• Analysis of a Hospital-Based Trauma Registry in Rural Cameroon: Description of Initial Results and Recommendations Esquivel, M. M., Long, C., Kaggya, K. M., Uribe-Leitz, T., Weiser, T. G., Wren, S. M. ELSEVIER SCIENCE INC. 2015: S86–S87

  View details for DOI 10.1016/j.jamcollsurg.2015.07.196

  View details for Web of Science ID 000361119700168

• Proposed Minimum Rates of Surgery to Support Desirable Health Outcomes: An Observational Study Based on Three Strategies WORLD JOURNAL OF SURGERY Esquivel, M. M., Molina, G., Uribe-Leitz, T., Lipsitz, S. R., Rose, J., Bickler, S., Gawande, A. A., Haynes, A. B., Weiser, T. G. 2015; 39 (9): 2126-2131

  Abstract

  The global volume of surgery is estimated at 312.9 million operations annually, but rates of surgery vary dramatically. Identifying surgical rates associated with improved health outcomes would be useful for benchmarking and targeted health system strengthening.We identified rates of surgery associated with a life expectancy (LE) of 74-75 years, a maternal mortality ratio (MMR) of less than or equal to 100 per 100,000 live births, and the estimated need for surgery in the seven global burden of disease (GBD) super-regions based on the prevalence of surgical conditions. We compared our findings to surgical rates from Chile, China, Costa Rica, and Cuba ("4C"), countries with moderate resources but high health outcomes.The median surgical rates associated with LE of 74-75 years (N = 17) and MMR below 100 (N = 109) are 4392 (IQR 2897-4873) and 5028 (IQR 4139-6778) operations per 100,000 people annually, respectively. The mean surgical rate estimated for the seven super-regions was 4723 (95 % CI 3967-5478) operations per 100,000 people annually. The "4C" countries had a mean surgical rate of 4344 (95 % CI 2620-6068) operations per 100,000 people annually. Thirteen of the twenty-one GBD regions, accounting for 78 % of the world's population, do not achieve rates of surgery at the lowest end of this range.We identified a narrow range of surgical rates associated with important health indicators. This target range can be used for benchmarking of surgical services, and as part of a policy aimed at strengthening health care systems and surgical capacity.

  View details for DOI 10.1007/s00268-015-3092-7

  View details for Web of Science ID 000359447800004

  View details for PubMedID 25968342

• Projections for Achieving the Lancet Commission Recommended Surgical Rate of 5000 Operations per 100,000 Population by Region-Specific Surgical Rate Estimates WORLD JOURNAL OF SURGERY Uribe-Leitz, T., Esquivel, M. M., Molina, G., Lipsitz, S. R., Verguet, S., Rose, J., Bickler, S. W., Gawande, A. A., Haynes, A. B., Weiser, T. G. 2015; 39 (9): 2168-2172

  Abstract

  We previously identified a range of 4344-5028 annual operations per 100,000 people to be related to desirable health outcomes. From this and other evidence, the Lancet Commission on Global Surgery recommends a minimum rate of 5000 operations per 100,000 people. We evaluate rates of growth and estimate the time it will take to reach this minimum surgical rate threshold.We aggregated country-level surgical rate estimates from 2004 to 2012 into the twenty-one Global Burden of Disease (GBD) regions. We calculated mean rates of surgery proportional to population size for each year and assessed the rate of growth over time. We then extrapolated the time it will take each region to reach a surgical rate of 5000 operations per 100,000 population based on linear rates of change.All but two regions experienced growth in their surgical rates during the past 8 years. Fourteen regions did not meet the recommended threshold in 2012. If surgical capacity continues to grow at current rates, seven regions will not meet the threshold by 2035. Eastern Sub-Saharan Africa will not reach the recommended threshold until 2124.The rates of growth in surgical service delivery are exceedingly variable. At current rates of surgical and population growth, 6.2 billion people (73 % of the world's population) will be living in countries below the minimum recommended rate of surgical care in 2035. A strategy for strengthening surgical capacity is essential if these targets are to be met in a timely fashion as part of the integrated health system development.

  View details for DOI 10.1007/s00268-015-3113-6

  View details for Web of Science ID 000359447800010

  View details for PubMedID 26067635

• Global access to surgical care: a modelling study. The Lancet. Global health Alkire, B. C., Raykar, N. P., Shrime, M. G., Weiser, T. G., Bickler, S. W., Rose, J. A., Nutt, C. T., Greenberg, S. L., Kotagal, M., Riesel, J. N., Esquivel, M., Uribe-Leitz, T., Molina, G., Roy, N., Meara, J. G., Farmer, P. E. 2015; 3 (6): e316-23

  Abstract

  More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, affordable surgical and anaesthesia care when needed. We aimed to estimate the number of individuals worldwide without access to surgical services as defined by the Commission's vision.We modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and affordability. We built a chance tree for each country to model the probability of surgical access with respect to each dimension, and from this we constructed a statistical model to estimate the proportion of the population in each country that does not have access to surgical services. We accounted for uncertainty with one-way sensitivity analyses, multiple imputation for missing data, and probabilistic sensitivity analysis.At least 4·8 billion people (95% posterior credible interval 4·6-5·0 [67%, 64-70]) of the world's population do not have access to surgery. The proportion of the population without access varied widely when stratified by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western sub-Saharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access.Most of the world's population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all.None.

  View details for DOI 10.1016/S2214-109X(15)70115-4

  View details for PubMedID 25926087

• Global access to surgical care: a modelling study LANCET GLOBAL HEALTH Alkire, B. C., Raykar, N. P., Shrime, M. G., Weiser, T. G., Bickler, S. W., Rose, J. A., Nutt, C. T., Greenberg, S. L., Kotagal, M., Riesel, J. N., Esquivel, M., Uribe-Leitz, T., Molina, G., Roy, N., Meara, J. G., Farmer, P. E. 2015; 3 (6): E316-E323

  Abstract

  More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, affordable surgical and anaesthesia care when needed. We aimed to estimate the number of individuals worldwide without access to surgical services as defined by the Commission's vision.We modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and affordability. We built a chance tree for each country to model the probability of surgical access with respect to each dimension, and from this we constructed a statistical model to estimate the proportion of the population in each country that does not have access to surgical services. We accounted for uncertainty with one-way sensitivity analyses, multiple imputation for missing data, and probabilistic sensitivity analysis.At least 4·8 billion people (95% posterior credible interval 4·6-5·0 [67%, 64-70]) of the world's population do not have access to surgery. The proportion of the population without access varied widely when stratified by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western sub-Saharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access.Most of the world's population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all.None.

  View details for DOI 10.1016/S2214-109X(15)70115-4

  View details for Web of Science ID 000354827300012

  View details for PubMedID 25926087

• Proposed minimum rates of surgery to support desirable health outcomes: an observational study based on four strategies. Lancet Esquivel, M. M., Molina, G., Uribe-Leitz, T., Lipsitz, S. R., Rose, J., Bickler, S. W., Gawande, A. A., Haynes, A. B., Weiser, T. G. 2015; 385: S12-?

  Abstract

  The global volume of surgery in 2012 is estimated at 312·9 million operations per year, but rates of surgery vary substantially. Maternal health advocates proposed minimum caesarean delivery rates for benchmarking and to improve perinatal outcomes; however, this has not been done for surgery because the association between rates of surgical care provision as a whole and population health outcomes have not been well described. We use available data to estimate minimum rates of surgery that are associated with important health indicators.We defined surgical operations as procedures done in operating theatres that need general or regional anaesthesia or profound sedation to control pain. We used four strategies to identify rates of surgery based on estimated rates of surgery per country for 2012 associated with life expectancy of 74-75 years; estimated rates of surgery associated with a maternal mortality ratio of less than or equal to 100 per 100 000 live births; estimated minimum need for surgery in the 21 Global Burden of Disease (GBD) regions based on the prevalence of disorders; and surgical rates from the so-called 4C countries (Chile, China, Costa Rica, and Cuba) identified in The Lancet Commission on Global Surgery as exemplary for their achievement of high health status, despite resource limitations.Based on 2012 national surgical rates, countries with reported life expectancy of 74-75 years (n=17) had a median surgical rate of 4392 (IQR 2897-4873) operations per 100 000 population annually. The median surgical rate associated with maternal mortality ratio lower than 100 (n=109) is 5028 (IQR 4139-6778) operations per 100 000 population annually. The median surgical rate estimated for all 21 GBD regions was 4669 (IQR 4339-5291) operations per 100 000 population annually. The 4C countries had a mean surgical rate of 4344 (95% CI 2620-6068) operations per 100 000 population annually. 13 of the 21 GBD regions, accounting for 78% of the world's population, do not achieve the lowest end of the surgical rate range.We identified a surprisingly narrow range of surgical rates associated with important health indicators. This target range can be used for benchmarking of surgical services, and as part of a policy aimed at strengthening health-care systems and surgical capacity.None.

  View details for DOI 10.1016/S0140-6736(15)60807-8

  View details for PubMedID 26313058

• Projections to achieve minimum surgical rate threshold: an observational study Uribe-Leitz, T., Esquivel, M. M., Molina, G., Lipsitz, S. R., Verguet, S., Rose, J., Bickler, S. W., Gawande, A. A., Haynes, A. B., Weiser, T. G. ELSEVIER SCIENCE INC. 2015: 14

  View details for Web of Science ID 000360573400015

• Proposed minimum rates of surgery to support desirable health outcomes: an observational study based on four strategies Esquivel, M. M., Molina, G., Uribe-Leitz, T., Lipsitz, S. R., Rose, J., Bickler, S. W., Gawande, A. A., Haynes, A. B., Weiser, T. G. ELSEVIER SCIENCE INC. 2015: 12

  View details for Web of Science ID 000360573400013

• Avoidable maternal and neonatal deaths associated with improving access to caesarean delivery in countries with low caesarean delivery rates: an ecological modelling analysis Molina, G., Esquivel, M. M., Uribe-Leitz, T., Lipsitz, S. R., Azad, T., Shah, N., Semrau, K., Berry, W. R., Gwande, A. A., Weiser, T. G., Haynes, A. B. ELSEVIER SCIENCE INC. 2015: 33

  View details for Web of Science ID 000360573400034

• Variability in mortality after caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: implications for expanding surgical services Weiser, T. G., Uribe-Leitz, T., Fu, R., Jaramillo, J., Maurer, L., Esquivel, M. M., Gawande, A. A., Haynes, A. B. ELSEVIER SCIENCE INC. 2015: 34

  View details for Web of Science ID 000360573400035

• Avoidable maternal and neonatal deaths associated with improving access to caesarean delivery in countries with low caesarean delivery rates: an ecological modelling analysis. Lancet Molina, G., Esquivel, M. M., Uribe-Leitz, T., Lipsitz, S. R., Azad, T., Shah, N., Semrau, K., Berry, W. R., Gwande, A. A., Weiser, T. G., Haynes, A. B. 2015; 385: S33-?

  Abstract

  Reducing maternal and neonatal deaths are important global health priorities. We have previously shown that up to a country-level caesarean delivery rate (CDRs) of roughly 19·0%, cesarean delivery rates and maternal mortality ratio (MMR) and neonatal mortality rate (NMR) were inversely correlated. We investigated the absolute reductions in maternal and neonatal deaths if countries with low CDR increased their rates to a range of greater than 7·2% but less than or equal to 19·1%.We calculated maternal and neonatal deaths in 2013 and 2012, respectively, for countries with CDR 7·2% or less (N=45) with available data from the World Bank Development Indicators. We modelled the expected reduction in deaths in these countries if they had the 25th and 75th MMR and NMR percentiles observed for countries (N=48) with CDRs ranging from greater than 7·2% but less than or equal to 19·1%. This model assumes that if countries with low CDRs increased their rates of caesarean delivery to greater than 7·2% but less than or equal to 19·1%, they would achieve levels of MMR and NMR observed in countries with those CDRs.We estimate 176 078 (95% CI 163 258-188 898) maternal and 1 117 257 (95% CI 1 033 611-1 200 902) neonatal deaths occurred in 45 countries with low CDRs in 2013 and 2012, respectively. If these countries had the 25th and 75th MMR and NMR percentiles (MMR, IQR 36-190; NMR, 9-24) observed in countries (N=48) with a CDR ranging from greater than 7·2% but less than or equal to 19·1%, there would be a potential reduction of 109 762-163 513 and 279 584-803 129 maternal and neonatal deaths, respectively.Increasing caesarean delivery in countries with low CDRs could avert as many as 163 513 maternal deaths and 803 129 neonatal deaths annually. These findings assume that as health systems develop the capacity to deliver surgical care, there is a concurrent improvement in the quality of care and in the ability to rescue women and neonates who would otherwise die. Improving access to safe caesarean delivery should be a central focus in surgical care globally.None.

  View details for DOI 10.1016/S0140-6736(15)60828-5

  View details for PubMedID 26313081

• Projections to achieve minimum surgical rate threshold: an observational study. Lancet Uribe-Leitz, T., Esquivel, M. M., Molina, G., Lipsitz, S. R., Verguet, S., Rose, J., Bickler, S. W., Gawande, A. A., Haynes, A. B., Weiser, T. G. 2015; 385: S14-?

  Abstract

  Recent work has indicated an increase in surgical services, especially in resource poor settings. However, the rate of growth is poorly understood and likely insufficient to meet public health needs. We previously identified a range of 4344 to 5028 operations per 100 000 population annually to be related to desirable health outcomes. From this and other evidence, the Lancet Commission on Global Surgery recommends a minimum rate of 5000 operations per 100 000 population. We evaluate rates of growth in surgery and estimate the time it will take to reach this minimum surgical rate threshold.We aggregated 2004 and 2012 country-level surgical rate estimates into the 21 Global Burden of Disease (GBD) regions. We calculated mean rates of surgery proportional to population size and estimate rate of growth between these years. We then extrapolated the time it will take to reach a surgical rate of 5000 operations per 100 000 population based on linear rates of change.All but two regions (central Europe and southern Latin America) experienced growth in their surgical rates during the past 8 years; the fastest growth occurred in regions with the lowest surgical rates. 14 regions representing 79% of the world's population (5·5 billion people) did not meet the recommended surgical rate threshold in 2012. If surgical capacity grows at current rates, seven regions (central sub-Saharan Africa, east Asia, eastern sub-Saharan Africa, north Africa and middle east, south Asia, southeast Asia, and western sub-Saharan Africa) will not meet the recommended surgical rate threshold by 2035; Eastern Sub-Saharan Africa will not reach this level until 2124.The rates of growth in surgical service delivery are exceedingly variable, but the largest growth rates were noted in the poorest regions. Although this study does not address the quality of care, and rates of surgery are unlikely to change linearly, this exercise is useful to project how many years it could take regions to reach specific surgical rates. At current rates of growth, 4·9 billion people (70% of the world's population) will still be living in countries below the minimum recommended rate of surgery in 2035. A strategy for strengthening surgical capacity is essential if these targets are to be met as part of integrated health system development.None.

  View details for DOI 10.1016/S0140-6736(15)60809-1

  View details for PubMedID 26313060

• Variability in mortality after caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: implications for expanding surgical services. Lancet Weiser, T. G., Uribe-Leitz, T., Fu, R., Jaramillo, J., Maurer, L., Esquivel, M. M., Gawande, A. A., Haynes, A. B. 2015; 385: S34-?

  Abstract

  While surgical interventions occur at lower rates in resource-poor settings, rates of complication and death after surgery are substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that quality accompanies increased global access to surgical care. We aimed to assess mortality following surgery to assess the risks of such interventions in these environments.We collected the most recent demographic, health, and economic data from WHO for 114 countries classified as low-income or lower-middle-income according to the World Bank in 2005. We searched OVID, MedLine, PubMed, and SCOPUS to identify studies in these countries reporting all-cause mortality after three commonly performed operations: caesarean delivery, appendectomy, and groin hernia repair. Reports from governmental and other agencies were also identified. We modelled surgical mortality rates for countries without reported data with the lasso technique that performs continuous variable subset selection to avoid model overfitting. We validated our model against known case fatality rates for caesarean delivery. We aggregated mortality results by subregion to account for variability in data availability. We then created collective surgical case fatality rates by WHO region.We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality rates were 7·7 per 1000 operations for caesarean delivery (IQR 3-14), 4·0 per 1000 operations for appendectomy (IQR 0-17), and 4·7 per 1000 operations for hernia groin (IQR 0-13); all recorded deaths occurred during the same admission to hospital as the operation. Based on our model, case fatality rate estimates by subregion ranged from 0·7 (central Europe) to 13·9 (central sub-Saharan Africa) per 1000 caesarean deliveries, 5·6 (central Asia) to 6·4 (central sub-Saharan Africa) per 1000 appendectomies, and 3·5 (tropical Latin America) to 33·9 (central sub-Saharan Africa) per 1000 hernia repairs.All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments, and substantially higher than those in middle-income and high-income settings. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care.None.

  View details for DOI 10.1016/S0140-6736(15)60829-7

  View details for PubMedID 26313082

• Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet Weiser, T. G., Haynes, A. B., Molina, G., Lipsitz, S. R., Esquivel, M. M., Uribe-Leitz, T., Fu, R., Azad, T., Chao, T. E., Berry, W. R., Gawande, A. A. 2015; 385: S11-?

  Abstract

  It was previously estimated that 234·2 million operations were performed worldwide in 2004. The association between surgical rates and population health outcomes is not clear. We re-estimated global surgical volume to track changes over time and assess rates associated with healthy populations.We gathered demographic, health, and economic data for 194 WHO member states. Surgical volumes were obtained from published studies and other reports from 2005 onwards. We estimated rates of surgery for all countries without available data based on health expenditure in 2012 and assessed the proportion of surgery comprised by caesarean delivery. The rate of surgery was plotted against life expectancy to describe the association between surgical care and this health indicator.We identified 66 countries reporting surgical data between 2005 and 2013. We estimate that 312·9 million operations (95% CI 266·2-359·5) took place in 2012-a 33·6% increase over 8 years; the largest proportional increase occurred in countries spending US$400 or less per capita on health care. Caesarean delivery comprised 29·8% (5·8 million operations) of the total surgical volume in poor health expenditure countries compared with 10·8% (7·8 million operations) in low health expenditure countries and 2·7% (5·1 million operations) in high health expenditure countries. We noted a correlation between increased life expectancy and increased surgical rates up to 1533 operations per 100 000 people, with significant but less dramatic improvement above this rate.Surgical volume is large and continues to grow in all economic environments. A single procedure-caesarean delivery-comprised almost a third of surgical volume in the most resource-limited settings. Surgical care is an essential part of health care and is associated with increased life expectancy, yet many low-income countries fail to achieve basic levels of service. Improvements in capacity and delivery of surgical services must be a major component of health system strengthening.None.

  View details for DOI 10.1016/S0140-6736(15)60806-6

  View details for PubMedID 26313057

• Congenital peribronchial myofibroblastic tumor: case report of an asymptomatic infant with a rapidly enlarging pulmonary mass and review of the literature. Annals of clinical and laboratory science Brock, K. E., Wall, J., Esquivel, M., Newman, B., Marina, N., Albanese, C., Hazard, F. K. 2015; 45 (1): 83-89

  Abstract

  Congenital peribronchial myofibroblastic tumor (CPMT) is a rare, benign lung tumor of infants, with only 19 reported cases worldwide. It is often diagnosed by prenatal imaging or in the immediate postnatal period due to co-morbidities like polyhydramnios, fetal hydrops, respiratory distress, and heart failure.We report the oldest known infant (8 weeks old) diagnosed with CPMT, and present his clinical course including the relevant radiographic and histopathologic findings.CPMT is a rare tumor that should be considered among other primary lung tumors of infancy (developmental, benign, and malignant) even if not detected prenatally or in the immediate postnatal period.

  View details for PubMedID 25696016

• PREDICT: Instituting an Educational Time Out in the Operating Room. Journal of graduate medical education Yang, R. L., Esquivel, M., Erdrich, J., Lau, J., Melcher, M. L., Wapnir, I. L. 2014; 6 (2): 382-383

  View details for DOI 10.4300/JGME-D-14-00086.1

  View details for PubMedID 24949168