Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

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

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

GlideScope versus McCoy laryngoscope: Intubation profile for cervically unstable patients in critical care setting

Background: Endotracheal intubation for cervically unstable patients remains a challenging procedure. We compared the utility of a relatively new promising airway tool “GlideScope” (GL) with the routinely used McCoy laryngoscope in our critical care unit. Methods: Forty intubated patients with suspected or proved cervical spine injury who were scheduled for replacing a conventional endotracheal tube (ETT) by ETT with subglottic suction facility were enrolled in this randomized controlled trial. Patients were randomly intubated using either GL “G group” or McCoy laryngoscope “M group”. The first attempt was performed by anesthetic residents inexperienced in using both scopes. In case of failure, a second attempt was done by a consultant anesthetist using these tools masterly. If these two attempts failed to intubate the trachea, a third one was attempted using a fiberoscope by the same consultant anesthetist. We compared the intubation profiles of both scopes. Results: There was a higher success rate of primary intubation attempts among the G group population (85% versus 55% in the M group “P value 0.03”). Moreover, all secondary intubation attempts succeeded in intubating the trachea. The mean time for primary intubation attempts was statistically longer in the M group (27.6 ± 2.7 S versus 19.8 ± 5.2 S in the G group “P value < 0.001”). However, there was no statistical difference as regards the mean time of intubation among the study population during the secondary intubation attempts. The Cormack and Lehane score and the percentage of required optimization maneuvers were significantly higher in the M group for both attempts. Conclusion: In critical care setting, GL is an excellent primary intubating tool for patients with potential cervical spine instability even if being performed by inexperienced users

Effect of Aging Treatment on the Damping Capacity and Mechanical Properties of Mg-6Al-1Zn Alloy

The damping capacity and mechanical properties of Mg-6Al-1Zn alloy after heat treatment were investigated. The damping characteristics of un-heat-treated, solution treated, and aged Mg-6Al-1Zn specimens were determined by measuring the damping ratio and the logarithmic decrement of free vibrations of a bending beam clamped at one side. The microstructural evaluations confirmed that the β-Mg17Al12 phase was reprecipitated after aging and increased with an increase in aging time. The peak level of damping ratio and logarithmic decrement was obtained after 34 hr of aging time, over which the damping capacity declined according to increasing amount of strong pining points

Influence of Microstructure and Alloy Composition on the Machinability of α/β Titanium Alloys

A comparative study was conducted for the machining of two α/β titanium alloys, namely Ti-6Al-4V (Ti64) and Ti-6Al-7Nb (Ti67), using wire electric discharge machining (WEDM). The influence of cutting speed and cutting mode on the machined surfaces in terms of surface roughness (Ra), recast layer (RL), and micro-hardness have been evaluated. Rough cut (RC) mode at a cutting speed of 50 µm/s resulted in thermal damage; Ra was equal to 5.68 ± 0.44 and 4.52 ± 0.35 µm for Ti64 and Ti67, respectively. Trim-cut mode using seven cuts (TRC-VII) at the same speed decreased the Ra to 1.02 ± 0.20 µm for Ti64 and 0.92 ± 0.10 µm for Ti67. At 100 µm/s, Ra reduced from 2.34 ± 0.28 µm to 0.88 ± 0.12 µm (Ti64), and from 1.42 ± 0.15 µm to 0.90 ± 0.08µm (Ti67) upon changing from TRC-III to TRC-VII. Furthermore, a thick recast layer of 30 ± 0.93 µm for Ti64 and 14 ± 0.68 µm for Ti67 was produced using the rough mode, while TRC-III and TRC-VII modes produced layers of 12 ± 1.31 µm and 5 ± 0.72 µm for Ti64 and Ti67, respectively. Moreover, rough cut and trim cut modes of WEDM played a significant role in promoting the surface hardness of Ti64 and Ti67. By employing the Response Surface Methodology, it was found that the machining mode followed by cutting speed and the interaction between them are the most influential parameters on surface roughness. Finally, mathematical models correlating machining parameters to surface roughness were successfully developed. The results strongly promote the trim-cut mode of WEDM as a promising machining route for two-phase titanium alloys

Gamma irradiation induced surface modification of (PVC/HDPE)/ZnO nanocomposite for enhancing the oil removal and conductivity using COMSOL multiphysics

Abstract Blend nanocomposite film was prepared by loadings of irradiated ZnO in ratios of (5 wt%) inside the PVC/HDPE matrix using a hot-melt extruder technique. The physical and chemical properties of the irradiated and unirradiated ZnO samples are compared. The Vis–UV spectrum of ZnO shows an absorption peak at a wavelength of 373 nm that was slightly red-shifted to 375 nm for an irradiated sample of ZnO at a dose of 25 kGy due to the defect of crystal structure by the oxygen vacancy during gamma irradiations. This growth of the defect site leads to a decrease in energy gaps from 3.8 to 2.08 eV. AC conductivity of ZnO sample increased after the gamma irradiation process (25 kGy). The (PVC/HDPE)/ZnO nanocomposites were re-irradiated with γ rays at 25 kGy in the presence of four different media (silicon oil, sodium silicate, paraffin wax and water). FTIR and XRD were performed to monitor the changes in chemical composition. The new peak at 1723 cm−1 attributed to C=O groups was observed in irradiated (PVC/HDPE)ZnO samples at only sodium silicate and water media. This process induced new function groups on the surface of the (PVC/HDPE)/ZnO blend sample. This work aims to develop (PVC/HDPE)ZnO for oil/water separation. The highest oil adsorption capability was observed in samples functionalized by C=O groups based on the different tested oils. The results suggest that the surface characterization of the (PVC/HDPE)/ZnO can be modified to enhance the oil adsorption potential. Further, the gamma irradiation dose significantly enhanced the AC conductivity compared to the unirradiated sample. According to COMSOL Multiphysics, the irradiated sample (PVC/HDPE)ZnO in water shows perfect uniform electric field distribution in medium voltage cables (22.000 V)