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

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p&lt;0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p&lt;0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Potential Use of Biomphalaria Alexandrina Snail Antigens for Serodiagnosis of Schistosomiasis Mansoni by Immunoblot Analysis

Background: The aim of this study was to evaluate the possible use of Biomphalaria alexandrina snail antigens in diagnosis of schistosomiasis mansoni using enzyme linked immunolectrotransfere blot (EITB).Methods: S. mansoni adult worm crude antigens (AWA), feet and visceral humps of B. alexandrina and Bulinus truncatus were used. Hyperimmune mice sera (HIS) versus each antigen were prepared for diagno­sis of S. mansoni using western blot (WB).Results: Snail foot antigens were more specific in antibodies detection than visceral hump antigens. Three of five polypeptides of B. alexandrina foot antigen identified by S. mansoni HIS showed specific positive reactivity. These polypeptides were at MW of 31/32 and 43 kDa. While, only one of the six polypeptides of B. alexandrina hepatopancrease antigen identified by S. mansoni HIS, at a MW of 43 kDa was specific. Similarly, 2 polypeptides at MW of 44 and 55 kDa were specific in detection of anti- S. haematobium antibodies. However, the antigenically active polypeptide of B. truncatus hepatopan­crease antigen had no specific reactivity towards anti-S. haematobium antibodies.Conclusion: B. alexandrina foot antigens were the most specific of the tested snail antigens in diagno­sis of schistosomiasis mansoni

Novel tanning agent based on silica-nanocomposite emulsion polymers

Purpose The purpose of this paper is devoted to application of the emulsion polymer of poly(methyl methacrylate-co-butyl acrylate) prepared with in situ nano-silica as a novel tanning agent of hide to partly or totally replace chrome salt and to improve physical, thermal and mechanical properties of the tanned leather and to reduce the environmental impact of chrome tanning effluent. Design/methodology/approach Polymer/nano-silica hybrid emulsions were prepared via in situ seed emulsion polymerisation. The prepared polymers were characterised for solid content, molecular weight, viscosity, drying time, minimum film-forming temperature (MFFT) and microstructures (via transmission electron microscopy). The mechanical, thermal and surface morphological (by scanning electron microscope) properties of the treated samples were also investigated. The influences of the increase in the content of organic nano-silica on the properties of the tanned leather are discussed. Findings It was found that the viscosity, the particle size and the solid content of the prepared polymers increased as the content of the nano-silica increased while gloss and drying time of the resulting polymer film decreased. Tanning buffalo hide by Polymer F (containing a high content of nano-silica) gave desirable properties in terms of tensile strength, thermal stability and shrinkage temperature. Research limitations/implications This paper discusses the preparation and the characterisation of emulsion polymers with in situ nano-silica and their application in tanning process to enhance and improve the leather quality, as well as reduce the use of chrome tanning materials and consequently chrome tanning waste. Practical implications The tanned leather showed an improvement of physico-mechanical properties and enhancement of thermal stability. Furthermore, the tanned leather has uniform colour, softness and firmness of grain. All these promising results provide evidence to support the applicability of the prepared co-polymer/nano-silica emulsions as an efficient tanning agent that also provides lubricating properties for leather. Originality/value Since May 2015, REACH Annex XVII restricts Cr(VI) in leather articles or leather parts of articles that come into contact with skin to a concentration of less than 3 mg/kg. Cases of discovery of Cr(VI) in leather papers have been reported by the European rapid alert system on dangerous consumer products (RAPEX). The emulsion poly (methyl methacrylate-co-butyl acrylate) with in situ nano-silica that has been developed via the study reported in this paper is one of the better technologies for the reduction of chromium ratio used in tanning industry

The Diagnostic Utility of Natural Killer Cell Subsets in Deep Vein Thrombosis

Alshaymaa M Alhabibi,1 Maisa A Wahab,2 Ahmed Khairy Sakr,2 Samar M Abd El-Hamid,1 Mohamed Yahia Zakaria,3 Azza Ali Althoqapy,4 Hanaa Mohammed Eid El Sayed,5 Sammar Ahmed Kasim,5 Hanan F Ibrahim,4 Ola I Saleh,6 Howida A Ahmed,6 Alaa H Sayed,7 Mahmoud Lotfy8 1Department of Clinical Pathology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt; 2Department of Vascular Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt; 3Department of Vascular and EndoVascular Surgery, Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt; 4Medical Microbiology and Immunology Department, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt; 5Internal Medicine Department, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt; 6Department of Radio-Diagnosis, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt; 7Hormones Department, Medical Research and Clinical Studies Institute, National Research Centre, Giza, Egypt; 8Molecular Biology Department, Genetic Engineering & Biotechnology Research Institute, University of Sadat City, Sadat City, Minufiya, EgyptCorrespondence: Alshaymaa M Alhabibi, Tel +201002894075, Email [email protected]: Natural killer (NK) cells are important components of adaptive and innate immune responses. NK cell subsets have different functions and may play a role in vascular disorders. This study aimed to evaluate the proportions of NK cells and their subsets to determine whether they can be used as markers of venous thrombosis and to identify whether there was a link between NK cell proportion and citrullinated histone (H3) levels.Patients and Methods: This study included 100 participants divided into Group I (n=50, patients with deep venous thrombosis (DVT)) and Group II (n=50, age- and sex-matched healthy controls). Group I was further categorized into Group Ia (n=25, patients with acute DVT) and Group Ib (n=25, patients with chronic DVT). The proportions of NK cells and their subsets were evaluated by flow cytometry using CD3/CD16/CD56. The levels of citrullinated histones (H3) were estimated using enzyme-linked immunosorbent assay (ELISA).Results: Compared to the control group, DVT patients had a significantly lower proportion of (CD56 dim/CD16+) NK cells, a significantly higher proportion of (CD56-/CD16+) NK cells and a high level of citrullinated histone (H3).Conclusion: NK cell subsets and citrullinated histone (H3) could be used as markers for DVT and as targets for therapeutic drugs to inhibit the formation or progression of thrombosis.Keywords: natural killer cell, natural killer cell subsets, citrullinated histone, deep venous thrombosi