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

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

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

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

PREVALENCE AND RISK FACTORS OF CYTOMEGALOVIRUS INFECTION AMONG HAEMODIALYSIS PATIENTS IN SOUTHERN GAZA STRIP, PALESTINE

Introduction: End-Stage Renal Disease patients (ESRD) on maintenance Haemodialysis (HD) are at high risk of acquiring Cytomegalovirus (CMV). The aim of the study was to determine the prevalence and risk factors of CMV infection among HD patients from Nasser's medical complex and Abu Yousef Al Najjar Hospital Southern Gaza strip. Methods: This study was an analytical cross-sectional from March to September 2019. Serum samples were taken from 96 patients (51.1% of them from Nasser medical complex and 48.9% of them from Abu Yousef Al Najjar Hospital), analyzed for CMV-specific immunoglobulin G (IgG) by using the Chemiluminescence immunoassay (CLIA) techniques, questionnaire, and Virological identification. Results: CMV-IgG was detected in 80 patients (83.3%), were 16 patients (16.7%) were CMV IgG Negative. The prominent risk factors were HD duration time, Receiving Injection, and previous blood transfusion. Conclusion: The prevalence of CMV infection among HD patients in the Southern Gaza strip was very high. We recommend that HD patients should be vaccinated against CMV

الأشجار والشجيرات المتزاجدة في الحرم الرئيس للجامعة الإسلامية بغزة، قطاع غزة، فلسطين

The Gaza Strip, which has a population of about 2.0 million and an area of about 365 km2, has many higher education institutions. The green quadrates, corridors and gardens of these institutions are commonly cultivated with many horticultural plants including trees and shrubs that provide many environmental, health, and aesthetic values. The Palestinian universities of the Gaza Strip have never been studied for the composition and numbers of their trees and shrubs. Therefore, the current study aims at identifying and recording the trees and shrubs prevailing and enhancing the ecology and environmental health aspects of the main campus of the Islamic University of Gaza (MC-IUG). Frequent surveys and observations were carried out during a six-month study extended from February, 2018 to July, 2018 in order to identify and totally count the trees and shrubs existing at MC-IUG. A total number of 2248 trees and shrubs belonging to 53 species, 25 families and 16 orders were identified and recorded at the MC-IUG. The Gymnosperms included 5 species (9.43%) only, while the Angiosperms was represented by 48 species (90.57%), of which the monocots were 9 species (16.98%) and the dicots were 39 species (73.59%). Rosales was the biggest order and comprised 9 (16.98%) of the recorded species. It was followed by Lamiales and Myrtales which comprised 5 (9.43%) for each. The orders Pinales, Arecales, Asparagales and Malpighiales were represented by 4 species (7.55%) for each. Moraceae was the biggest family and comprised 8 (15.09%) of the recorded species. It was followed by the two families Arecaceae and Asparagaceae, which comprised 5 species (9.43% for each). Six tree and shrub species (11.32%) of MC-IUG were found to exceed the threshold of 100 individuals for each. These comprised 1657 individuals (73.71%) of the 2248 counted. The Chinese Hibiscus (Hibiscus rosa-sinensis) was, by far, the most common species. It comprised 31.98% of the individuals counted. This was followed by the Benjamin Fig (Ficus benjamina) (10.45%), Hopbush (Dodonea viscose) and Moringa (Moringa oleifera) (8.63% for each), Dwarf Umbrella Tree (Schefflera arboricola) (8.19%) and Weeping Fig (Ficus nitida) (5.82%). The majority of tree and shrub species 49 (92.45%) recoded in the current study are exotic, while the native ones are restricted to only 4 species (7.55%). Finally, the current study recommends the selection of tree and shrub species corresponding with the local prevailing environmental conditions in order to ensure the ecological and environmental health values needed by the university community.The Gaza Strip, which has a population of about 2.0 million and an area of about 365 km2, has many higher education institutions. The green quadrates, corridors and gardens of these institutions are commonly cultivated with many horticultural plants including trees and shrubs that provide many environmental, health, and aesthetic values. The Palestinian universities of the Gaza Strip have never been studied for the composition and numbers of their trees and shrubs. Therefore, the current study aims at identifying and recording the trees and shrubs prevailing and enhancing the ecology and environmental health aspects of the main campus of the Islamic University of Gaza (MC-IUG). Frequent surveys and observations were carried out during a six-month study extended from February, 2018 to July, 2018 in order to identify and totally count the trees and shrubs existing at MC-IUG. A total number of 2248 trees and shrubs belonging to 53 species, 25 families and 16 orders were identified and recorded at the MC-IUG. The Gymnosperms included 5 species (9.43%) only, while the Angiosperms was represented by 48 species (90.57%), of which the monocots were 9 species (16.98%) and the dicots were 39 species (73.59%). Rosales was the biggest order and comprised 9 (16.98%) of the recorded species. It was followed by Lamiales and Myrtales which comprised 5 (9.43%) for each. The orders Pinales, Arecales, Asparagales and Malpighiales were represented by 4 species (7.55%) for each. Moraceae was the biggest family and comprised 8 (15.09%) of the recorded species. It was followed by the two families Arecaceae and Asparagaceae, which comprised 5 species (9.43% for each). Six tree and shrub species (11.32%) of MC-IUG were found to exceed the threshold of 100 individuals for each. These comprised 1657 individuals (73.71%) of the 2248 counted. The Chinese Hibiscus (Hibiscus rosa-sinensis) was, by far, the most common species. It comprised 31.98% of the individuals counted. This was followed by the Benjamin Fig (Ficus benjamina) (10.45%), Hopbush (Dodonea viscose) and Moringa (Moringa oleifera) (8.63% for each), Dwarf Umbrella Tree (Schefflera arboricola) (8.19%) and Weeping Fig (Ficus nitida) (5.82%). The majority of tree and shrub species 49 (92.45%) recoded in the current study are exotic, while the native ones are restricted to only 4 species (7.55%). Finally, the current study recommends the selection of tree and shrub species corresponding with the local prevailing environmental conditions in order to ensure the ecological and environmental health values needed by the university community

Arab West Report 2009, Weeks 02-52: Investigative Reporting into Muslim-Christian Relations and Monastic Life

This dataset contains the Arab-West Report special reports that were published in 2009. This dataset mainly contains the writings of Cornelis Hulsman, Drs., among other authors on topics related to Muslim- Christian relations and interfaith dialogue Notably, this dataset contains certain reports related to the Christian faith in Egypt, Monastic life and Coptic Traditions. Some of the articles addressed Muslim-Christian incidents and sectarian tensions that took place in 2009 in Upper Egypt. Articles also address the situation of civil society organizations in Egypt. Additionally, reports document field visits by the Arab-West Report interns and interviews conducted with intellectuals and clergymen. Furthermore, it contained commentary on published material from other sources (reviews / critique of articles)