The Incidence of Obstetrics and Gynecology Cases Returning to Operation Theater due to Postoperative Complications in a Tertiary Care Hospital

Introduction: Unexpected return to operation theater carries high rate of morbidity and mortality for patients, in addition to increased hospital stay. A close look at such cases would help in identifying high-risk patients thus improving outcome. The aim of the study was to evaluate the incidence of Obs/Gyn cases returning to OT due to postoperative complications in a tertiary care hospital. Methods: It was a retrospective observational study done at tertiary care hospital settings affiliated with academic center in the UAE. The records of patients were scrutinized, and all booked and non-booked pregnant patients of any age undergoing emergency or elective obstetrics or gynecological procedure from January 1, 2016 to December 31, 2020 were enrolled in the study. Relaparotomy was defined as cases opened within same admission and causally associated with previous primary obstetrics or gynecological operation. Result: A total of 21,276 operations were performed from 2016 to 2020. In these 4 years, 33 patients had unexpected return to operation theater making the incidence of re-exploration to 0.15% (33/21,276). There were 16 (48.48%) emergency operations and 17 (51.52%) elective operations previously done on these patients. The most common primary procedure for which re-exploration was done was lower segment caesarean section done in 11 (33.3%) of cases followed by laparoscopic adhesiolysis and myomectomy. Hematoma in the pelvic region and ooze from raw area were the most common per-operative finding in 48.48% of cases. There was no mortality in the abovementioned cases; however, 2 (6.06%) had early acute kidney injury and both recovered from it. Discussion: The incidence of relaparotomy in our hospital is comparable to international literature. Most patients returned to OT within 48 h. Bleeding was the most common indication for laparotomy, and lower segment cesarean section was most common primary operation. This study underscores the need for meticulous hemostasis before closing to avoid return to OT. Conclusion: Return to OT for the right indication saves life. Mortality in such cases may be reduced by earlier detection and treatment of postoperative problems, consideration of relaparotomy, active ICU monitoring, and postoperative care

Global strategies and local implementation of health and health-related SDGs: Lessons from consultation in countries across five regions

Evidence on early achievements, challenges and opportunities would help low-income and middle-income countries (LMICs) accelerate implementation of health and health-related sustainable development goals (HHSDGs). A series of country-specific and multicountry consultative meetings were conducted during 2018-2019 that involved 15 countries across five regions to determine the status of implementation of HHSDGs. Almost 120 representatives from health and non-health sectors participated. The assessment relied on a multidomain analytical framework drawing on existing public health policy frameworks. During the first 5 years of the sustainable development goals (SDGs) era, participating LMICs from South and Central Asia, East Africa and Latin America demonstrated growing political commitment to HHSDGs, with augmentation of multisectoral institutional arrangements, strengthening of monitoring systems and engagement of development partners. On the other hand, there has been limited involvement of civic society representatives and academia, relatively few capacity development initiatives were in place, a well-crafted communication strategy was missing, and there is limited evidence of additional domestic financing for implementing HHSDGs. While the momentum towards universal health coverage is notable, explicit linkages with non-health SDGs and integrated multisectoral implementation strategies are lacking. The study offers messages to LMICs that would allow for a full decade of accelerated implementation of HHSDGs, and points to the need for more implementation research in each domain and for testing interventions that are likely to work before scale-up

Evaluation of the Impact of Iron Deficiency Anemia during Pregnancy on Hospital Admission and Utilization of Hospital Resources in Latifa Women and Children Hospital, Dubai, UAE

Introduction: Iron deficiency anemia (IDA) is endemic among pregnant females worldwide. Liposomal iron preparation is a novel therapy for treating IDA in pregnant females. There is a lack of research on cost-effect and comparison between various new iron preparations as liposomal and intravenous (IV) iron supplements in the international literature. Objective: The objective of this study was to evaluate the cost-effect and maternal-fetal outcome of IDA during pregnancy in Latifa Women and Children Hospital, Dubai, UAE. Design: The study was a quasi-experimental study. Settings: Settings include tertiary-care hospital settings affiliated with academic center in UAE. Patients and Methods: A total of 226 pregnant women were inducted in the study who were controlled in terms of age, BMI, baseline hemoglobin (Hb), severity of anemia, and ferritin levels. There were 116 patients who received oral liposomal iron pyrophosphate and 110 patients received IV iron saccharate complex for 4 weeks. The overall cost-effect and maternal-fetal outcomes were compared in 2 groups. Main Outcomes Measured: The main outcomes measured the cost-effect of liposomal and IV iron therapy, and the 2 treatments were compared in terms of maternal and fetal outcomes. Result: The subjects were matched for age and body mass index and showed that the patients in the IV group were more symptomatic than those in the oral group (18.1 vs. 31.9% p value <0.01). There was no statistically significant difference among women from different nationalities living in UAE (p value 0.079). There were 98 (84.4%) patients in the oral group and 99 (90%) patients in the IV group who achieved the desired Hb levels after 1 month of treatment (p value = 0.878). Moreover, the side effects were also comparable in both groups (1.72 vs. 1.82% p value = 0.56). The incremental cost-effect ratio for IV iron was USD 108,633/rise to desired Hb. Conclusion: Liposomal iron preparations may be cost-effective and have fewer side effects than IV iron. In terms of outcome, the maternal and fetal variables are comparable in liposomal and IV groups

Effect of Garden Cress Seeds Powder and Its Alcoholic Extract on the Metabolic Activity of CYP2D6 and CYP3A4

The powder and alcoholic extract of dried seeds of garden cress were investigated for their effect on metabolic activity of CYP2D6 and CYP3A4 enzymes. In vitro and clinical studies were conducted on human liver microsomes and healthy human subjects, respectively. Dextromethorphan was used as a common marker for measuring metabolic activity of CYP2D6 and CYP3A4 enzymes. In in vitro studies, microsomes were incubated with NADPH in presence and absence of different concentrations of seeds extract. Clinical investigations were performed in two phases. In phase I, six healthy female volunteers were administered a single dose of dextromethorphan and in phase II volunteers were treated with seeds powder for seven days and dextromethorphan was administered with last dose. The O-demethylated and N-demethylated metabolites of dextromethorphan were measured as dextrorphan (DOR) and 3-methoxymorphinan (3-MM), respectively. Observations suggested that garden cress inhibits the formation of DOR and 3-MM metabolites. This inhibition of metabolite level was attributed to the inhibition of CYP2D6 and CYP3A4 activity. Garden cress decreases the level of DOR and 3-MM in urine and significantly increases the urinary metabolic ratio of DEX/DOR and DEX/3-MM. The findings suggested that garden cress seeds powder and ethanolic extract have the potential to interact with CYP2D6 and CYP3A4 substrates

Multiomics Characterization of Preterm Birth in Low- and Middle-Income Countries.

Importance: Worldwide, preterm birth (PTB) is the single largest cause of deaths in the perinatal and neonatal period and is associated with increased morbidity in young children. The cause of PTB is multifactorial, and the development of generalizable biological models may enable early detection and guide therapeutic studies. Objective: To investigate the ability of transcriptomics and proteomics profiling of plasma and metabolomics analysis of urine to identify early biological measurements associated with PTB. Design, Setting, and Participants: This diagnostic/prognostic study analyzed plasma and urine samples collected from May 2014 to June 2017 from pregnant women in 5 biorepository cohorts in low- and middle-income countries (LMICs; ie, Matlab, Bangladesh; Lusaka, Zambia; Sylhet, Bangladesh; Karachi, Pakistan; and Pemba, Tanzania). These cohorts were established to study maternal and fetal outcomes and were supported by the Alliance for Maternal and Newborn Health Improvement and the Global Alliance to Prevent Prematurity and Stillbirth biorepositories. Data were analyzed from December 2018 to July 2019. Exposures: Blood and urine specimens that were collected early during pregnancy (median sampling time of 13.6 weeks of gestation, according to ultrasonography) were processed, stored, and shipped to the laboratories under uniform protocols. Plasma samples were assayed for targeted measurement of proteins and untargeted cell-free ribonucleic acid profiling; urine samples were assayed for metabolites. Main Outcomes and Measures: The PTB phenotype was defined as the delivery of a live infant before completing 37 weeks of gestation. Results: Of the 81 pregnant women included in this study, 39 had PTBs (48.1%) and 42 had term pregnancies (51.9%) (mean [SD] age of 24.8 [5.3] years). Univariate analysis demonstrated functional biological differences across the 5 cohorts. A cohort-adjusted machine learning algorithm was applied to each biological data set, and then a higher-level machine learning modeling combined the results into a final integrative model. The integrated model was more accurate, with an area under the receiver operating characteristic curve (AUROC) of 0.83 (95% CI, 0.72-0.91) compared with the models derived for each independent biological modality (transcriptomics AUROC, 0.73 [95% CI, 0.61-0.83]; metabolomics AUROC, 0.59 [95% CI, 0.47-0.72]; and proteomics AUROC, 0.75 [95% CI, 0.64-0.85]). Primary features associated with PTB included an inflammatory module as well as a metabolomic module measured in urine associated with the glutamine and glutamate metabolism and valine, leucine, and isoleucine biosynthesis pathways. Conclusions and Relevance: This study found that, in LMICs and high PTB settings, major biological adaptations during term pregnancy follow a generalizable model and the predictive accuracy for PTB was augmented by combining various omics data sets, suggesting that PTB is a condition that manifests within multiple biological systems. These data sets, with machine learning partnerships, may be a key step in developing valuable predictive tests and intervention candidates for preventing PTB

Prediction of gestational age using urinary metabolites in term and preterm pregnancies.

Assessment of gestational age (GA) is key to provide optimal care during pregnancy. However, its accurate determination remains challenging in low- and middle-income countries, where access to obstetric ultrasound is limited. Hence, there is an urgent need to develop clinical approaches that allow accurate and inexpensive estimations of GA. We investigated the ability of urinary metabolites to predict GA at time of collection in a diverse multi-site cohort of healthy and pathological pregnancies (n = 99) using a broad-spectrum liquid chromatography coupled with mass spectrometry (LC-MS) platform. Our approach detected a myriad of steroid hormones and their derivatives including estrogens, progesterones, corticosteroids, and androgens which were associated with pregnancy progression. We developed a restricted model that predicted GA with high accuracy using three metabolites (rho = 0.87, RMSE = 1.58 weeks) that was validated in an independent cohort (n = 20). The predictions were more robust in pregnancies that went to term in comparison to pregnancies that ended prematurely. Overall, we demonstrated the feasibility of implementing urine metabolomics analysis in large-scale multi-site studies and report a predictive model of GA with a potential clinical value

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research