A very warm welcome to the first edition of the NIHR Global Health Research Unit on Global Surgery newsletter. We will be using this newsletter to share the latest news and developments from across the Unit. It is important that we recognise and keep each other informed about the many exciting developments that are happening in each of our partner countries. Please send us any items of news that you would like us to include in future editions of the newsletter. We look forward to hearing from you.

NEWS FROM THE UNIT

Highlight: launch of study of COVID-19 infected patients undergoing surgery
CovidSurg has been designed to capture real-world data and share international experience which will inform the management of this complex group of patients undergoing surgery throughout the COVID-19 pandemic, improving their clinical care.

Read more about this timely and much needed study at https://globalsurg.org/covidsurg/

Growing Surgical Network across India

Growing Surgical Network across India
Nearly 50 delegates representing 19 Indian states and Union territories participated in a 2-day workshop held in New Delhi held in February.

Within the workshop:

  • Indian surgeons presented and discussed new surgical research areas that are important to Indian and global patients. This is the first-ever surgical research prioritisation done in India and is a leap towards creating sustainability. Selected topics will be taken forward to seek funding.
  • The existing GSU global research portfolio pertinent to India was showcased, leading to the expansion of the GSU hub-spoke network in India.
  • In-depth training was provided around CHEETAH and EAGLE

The workshop was attended by the Chancellor (Lord Bilimoria) and Vice-Chancellor (Professor Sir David Eastwood) of the University of Birmingham (UoB) and was supported by the UoB India Institute. It was very well received by all who participated. Congratulations to the India Hub team and those who were involved in making it such a huge success

First set of NIHR Global Surgery Guidelines set for publication!

Our first set of guidelines resulting from the Prioritisation Workshop in Kigali in 2018 has been accepted for publication. NIHR Global Surgery Unit Surgical Site infection guidelines will published shortly in BJS.

We are working to translate the SSI guidelines into different languages which will be available on www.nihrglobalsurgery.org following publication.

UPDATES ON THE UNIT PROJECTS

We would like to take this opportunity to congratulate every member of our global team for their contribution to the tremendous success of the FALCON trial. This is an astounding achievement and we must take a moment to reflect on the hard work and dedication that has led to this position – we are grateful to each and every individual who has contributed to date and to those who will in future – kudos to you all.

FALCON is currently active and recruiting in 6 countries (Mexico, India, Rwanda, Nigeria, South Africa and Ghana), reaching a network of 48 hospitals over three continents. We envisage that Benin and the Philippines will obtain the green light to start recruitment this month. At the time of production (11/03/2020), 4164 patients had been recruited to the trial; which is around 76% of the total sample size.

As recruitment to the clean-contaminated stratum is now closed, roughly 1600 more contaminated/dirty cases are needed to meet our overall sample size. At the current rate of recruitment, we anticipate completing the trial by late August 2020; this means the trial is currently running more than a year ahead of our anticipated schedule, which is generally a very rare occurrence in clinical trials! As it is likely that the trial will be completed later this year, if you are aware of any potential FALCON spokes that have not yet started their ethics and regulatory approvals submissions, we suggest they should concentrate their efforts on setting up CHEETAH.

Our next challenges for FALCON will be to focus on data completeness and validation in the REDCap database. We hope to publish the trial by the end of the year, and to do so we must ensure that data is complete, accurate and clean. We would like to highlight some specific issues for your attention:

  • 30 day follow up data must be collected from every patient possible. In the event that patients do not return for their 30 day follow up appointment, please encourage staff across your network to contact patients until 30 day follow up data is retrieved (either in person or via telephone) or until the patient is confirmed as lost to follow up (at which point a trial exit form must be completed).
  • Our Data Monitoring Committee (DMC) and Trial Steering Committee (TSC) are due to meet in March and May respectively to review the trial as it stands. To ensure the data is high quality ahead of their review, please ensure your network prioritises data entry on REDCap and responding to queries raised on data in the coming months.
  • Part of our overall monitoring activities will focus on data verification – these activities have begun in Mexico and India, and we hope to visit Nigeria, Ghana, Rwanda and SA imminently to support you in this task.

If you have any queries, please contact the BCTU team ([email protected]) and we will be happy to assist.

Congratulations again on your continued success – FALCON is just the beginning!

Off the back of the tremendous FALCON success story – we are excited to be moving into our next round of studies, with CHEETAH now beginning its sprint across the African plains, the swathes of Asia, and across the Mexican border.

CHEETAH will be fast-paced, recruiting consecutive patients (excluding C-sections!) and for some of you this will involve co-enrollment with FALCON. Some of you will complete quickly, some will need a little longer to reach the ~200 patients. Our advice would be prepare, prepare, prepare! If recruitment is anywhere close to the amazing FALCON you are going to be busy. Line up your teams ready for the next wave of GS activity, there is no time to kick back and relax…

CHEETAH Next steps…

CHEETAH trial set-up – All of the Hub Managers have a long list of next steps to opening CHEETAH both at the Hub and in each of the spoke hospitals across the network. Please encourage your teams to work with the central CHEETAH trials team at UoB ([email protected]) to progress these steps asap. We are keen to maintain momentum and demonstrate that FALCON is just the beginning for all of us!

  • Training – get as many of your teams through our online training modules via the REDCap platform; https://is.gd/CheetahOnlineTraining
    • SIV training – sadly COVID-19 has impacted on our planned face to face travel plans, however second to in-person training would be SIV training via teleconference. If not already scheduled please start thinking about suitable dates to gather your teams and get a date in your diary, contact [email protected] to coordinate
    • GCP training – any new team members requiring GCP training should be encouraged to access the online GCP module: https://globalhealthtrainingcentre.tghn.org/ich-good-clinical-practice/

Once completed, the certificate should be sent to your Hub team and subsequently shared with the BCTU trials team as part of the site activation process.

  • Spoke set-up – The UoB CHEETAH trials team are working closely with the Hub Managers and hub teams to help guide you all through the windy road of spoke set-up over the next couple of weeks.
    • We need 64 clusters as you know, early engagement with your spoke teams is essential to reach our 12,800 patient target. The spoke set-up process is in 3 key stages; pre-randomisation/randomisation phase, initiation, activation/`green light`.  All related documents can be found on the BEARSHARE platform; https://beardatashare.bham.ac.uk/login. We encourage you to focus your efforts on CHEETAH now. We are confident we can iron out any issues early on and help facilitate speedy set-up in all corners of your networks.

The CHEETAH trials team are always on hand to assist, please contact us at any time ([email protected]) or via WhatsApp +44 7814253820 and don`t forget to tweet any exciting news

Twitter

PENGUIN is currently in the set-up phase of the internal pilot. Four GSU hubs – India, Nigeria, South Africa, and Mexico – have been identified to participate in this pilot phase to determine the global feasibility and adherence to the trial interventions in LMICs.

The Unit has submitted a full grant proposal (after being successful in the outline stage) to the MRC Joint Global Health Trials call for the full Penguin trial. We hope to have a decision on this in July 2020.

This workstream on identifying barriers & solutions to improving access to acute care in LMICS is successfully progressing in all 5 of its planned Work packages: systematic review completed, stakeholder and patient interviews conducted in in Ghana, Nigeria and India, and economic model developed. Keep an eye out for news of upcoming publications.

GlobalSurg 3

The GlobalSurg 3 data analysis is now completed and the manuscript is in preparation. We will be aiming for a high impact medical journal and will keep everyone informed of the submission and peer review process as soon as we are able.

Crane is a cluster RCT of a nutritional intervention to improve outcomes after cancer surgery in LMIC. The study is being conducted in GSU hubs and centres in Ghana, India, Philippines and Zambia. The study is aiming to:

  • Identify and validate a nutritional screening tool for patients in LMIC undergoing cancer surgery
  • Identify a low cost sustainable nutritional intervention for patients in LMIC undergoing cancer surgery
  • Establish the feasibility of a cluster RCT of a sustainable nutritional intervention for patients in LMIC undergoing surgery for cancer.

The study is making excellent progress – ethics applications are either granted or underway in all partner countries, interviews with over 20 healthcare professionals and patients have been performed, and we plan to use nutritional data collected in GS3 to help inform a larger grant application in the coming months.

EAGLE is an international cluster randomised-sequence study of a ‘safe-anastomosis’ Quality Improvement Intervention to reduce anastomotic leak following right colectomy and ileocecal resection. It will assess whether the implementation of the European Society of Coloproctology (ESCP) safe-anastomosis intervention reduces the risk of anastomotic leak up to 30-days following right colectomy.

The study aims to recruit 333 hospitals and 4,400 patients from across the globe. As of now, over 100 hospitals have been randomised to receive the intervention and begin data collection, and over 300 hospitals have registered an interest in the study. Recruitment for further sites is ongoing and further details can be found at https://is.gd/EAGLEsitesetup. The study is open to any hospital or surgical unit performing elective and/or emergency colorectal surgery.

A number of our GSU partner countries are already participating in this study and we look forward to further involvement.

Health Economics cuts across the Unit’s projects
  • FALCON KIWI (Key resource Use in Wound Infection) is planning to collect resource use for SSI and non-SSI patients to quantify the cost burden of SSI across three continents.
  • A model-based cost-effectiveness analysis is planned to estimate the cost-effectiveness of the CHEETAH intervention.
  • Before the main PENGUIN trial commences, early economic modeling is currently underway to assess the preliminary cost-effectiveness of the trial interventions. Findings from the model will provide intuition of the main cost drivers and prioritize data collection efforts of important uncertain variables in the main trial
  • An economic evaluation alongside the PENGUIN trial is planned to assess the cost-effectiveness of the interventions on reducing SSI and post-operative pneumonia
  • An economic evaluation alongside the TIGER trial is planned to assess the cost-effectiveness of task-shifting in inguinal hernia repair between surgeons and nonsurgeon physicians in Ghana
  • A cost of illness study is in the works to quantify the cost burden of SSI in appendectomy patients across income settings. The research is using the GlobalSurg datasets to populate the model.
  • An LMIC collaborator is leading a costing study with Health Economics support on open and laparoscopic appendectomies in Nigeria.

We are pleased to announce the launch of our CEI webpages which can now be found here, highlighting our current activities. Case studies and videos of projects in Ghana and The Philippines are coming soon.

After successfully finishing a CEI project in Ghana in November last year to inform the TIGER RCT, similar projects in India and South Africa are being discussed to grow our reach into communities and inform pump-priming studies and future research. Further information on these exciting developments will follow shortly.

These studies are building and strengthening research capacity in areas specifically relevant to patients in our partner countries. It is anticipated that they will generate early pilot data that can be used to inform applications for future grant funding and so develop these projects into larger studies and trials across the network.

We currently have 9 pump-priming studies at varying stages, and 1 completed study, across 8 countries. All of our studies are progressing well so please watch this space. Further information on the studies will be presented in an upcoming edition of the newsletter.

As part of our annual research prioritisation meeting hosted in Ghana at the end of last year, we have established a Data Centre at the Hub in Tamale.  20 researchers have been trained in advanced data analysis techniques, and a working analysis platform was established on 15 laptop computers to build capacity for data driven research within the Ghana hub. As part of this programme, we’re delighted to be welcoming 2 senior lecturers from the Ghanaian Hub, Mr. Kwame Opare and Mr. Majeed Saed, to Edinburgh University at the end of March. Mr Opare and Mr Saed will spend time with Professor Ewen Harrison, Professor of Surgery & Data Science, and Dr Riinu Ots, GlobalSurg Senior Data Manager, consolidating the training they received in Tamale. Dr Ots will also return to visit the Data Centre in Ghana later in 2020 as part of a ‘Train the Trainers’ programme to maximise impact of the Data Centre.

UPCOMING EVENTS

Due to the unprecedented and unpredictable circumstances brought on by COVID-19 we are unfortunately having to postpone international GSU visits and meetings planned for the next couple of months. We will keep you updated on any developments

We would love to hear from you for the next edition of the newsletter.
Please send any updates to Tammy Dufty that you would like included by Friday 10th April.

Please feel free to forward this newsletter to whoever may be interested in the Newsletter.

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