Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Avaliação da atenção básica pela ótica político-institucional e da organização da atenção com ênfase na integralidade Political, institutional, and organizational evaluation of primary health care with an emphasis on comprehensiveness

Este artigo apresenta parte dos dados de uma avaliação da Atenção Básica, implementada como parte de uma pesquisa com financiamento do Ministério da Saúde durante o ano de 2005. Trinta e um municípios, dos estados de Minas Gerais e Espírito Santo, Brasil, formaram a amostra do estudo. Dados coletados com base em métodos qualitativos (entrevistas e análise de documentos) foram sintetizados com a produção de um conjunto de variáveis categoriais. A distribuição dos diversos valores assumidos pelas variáveis nos diferentes municípios são apresentadas. Essas variáveis foram submetidas à análise de correspondência, que mostrou sua validade interna. Adicionalmente, observações sobre aspectos relevantes do campo são apresentados. Em conclusão, a avaliação mostra avanços da estratégia de saúde na família, com importantes contribuições do Projeto de Expansão e Consolidação do Saúde da Família, embora obstáculos consideráveis ainda permaneçam, em particular no que diz respeito à força de trabalho das estratégias de saúde na família e na utilização local das informações produzidas.<br>This article presents part of the data from an evaluation of primary care, implemented as part of research funded by the Brazilian Ministry of Health in 2005. Thirty-one municipalities from the States of Minas Gerais and Espírito Santo comprised the study sample. Data collected with qualitative methods (interviews and documents) were summarized, with the production of a set of categorical variables. The article presents the distribution of values for the variables by municipality. The variables were submitted to correspondence analysis, which showed their internal validity. The article also provides observations on relevant aspects of the field. In conclusion, the evaluation demonstrates advances in the Family Health Strategy in Brazil, with important contributions to the Project for Expansion and Consolidation of the Family Health Strategy, despite persistent obstacles, particularly related to human resources in the family health strategies and local use of the data produced