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

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

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century

On-Farm Experimentation with Improved Maize Seed and Soil Amendments in Southern Ghana: Productivity Effects in Small Holder Farms

Maize production in Ghana is limited by several factors including inadequate use of improved varieties and poor soil fertility management. To contribute to addressing these challenges in maize production, two on-farm experiments were conducted each in the semi deciduous forest and coastal savannah agroecological zones (AEZs) of Ghana during the major and minor cropping seasons of 2017. The study adopted a 3 × 4 factorial arranged in an RCBD with four replications in the major season. The factors were three maize varieties (Omankwa, Obatanpa, and Ahomatea) and four soil amendments (goat manure at 5 t·ha−1; inorganic fertilizer (N-P2O5-K2O at 95-37.5–37.5 kg·ha−1); 50% goat manure (2.5 t·ha−1) + 50% inorganic fertilizer (N-P2O5-K2O at 47.5–18.75–18.75 kg·ha−1); and the control (no soil amendment)).To evaluate the residual implications of these soil amendments in the minor season, each plot used in the major season was further divided into two except for the control plot, resulting in a split plot design with factorial of 3 maize varieties × 7 soil amendments. The results revealed a significant interaction between maize variety and soil amendment in both seasons with the use of sole inorganic fertilizer resulting in significantly higher (p<0.05) grain yields for all varieties in both AEZs in the major cropping season. In the minor season, the combined treatment of 50% goat manure + 50% inorganic fertilizer resulted in higher grain yields for all the varieties in both AEZs with improved maize (Omankwa and Obatanpa) having significantly higher (p<0.05) grain yields (33–40%) than the landrace (Ahomatea). The significantly lower (p<0.05) performance of maize varieties on the residual plots in both AEZs suggests that there were minimal residual effects from the major season. Thus, in continuously cropped fields, the use of inorganic fertilizer + goat manure is required in addition to improved seeds for sustainable maize production

Variation in the susceptibility of okra (Abelmoschus esculentus L. Moench) genotypes to okra mosaic virus and Podagrica species under field conditions

A total of 21 okra (Abelmoschus escuentus L. Moench) genotypes were screened for their reactions against okra mosaic disease (OMD) and flea beetles (Podagrica species) infestations in field trials which were conducted from May to October, 2015 (wet season) and November 2015 to March 2016 (dryseason), in order to identify sources of resistance and or tolerance. The trials were laid out in a randomised complete block design (RCBD) with four replications. Field resistance in the genotypes was assessed at 2, 6 and 10 weeks after planting using a 0 to 5 visual scale based on disease symptoms(where 1 denotes no symptom and 5, very severe symptom). Enzyme linked immunosorbent assay (ELISA) was performed to detect the presence of Okra mosaic virus (OkMV) in the okra genotypes.Populations of the flea beetle (Podagrica spp.), the vector of OkMV, and the associated leaf and fruit damage were also assessed. All the okra genotypes exhibited a varying range of disease symptoms and the flea beetle infestations, and lacked immunity. Genotypes GH2052, GH2063, GH2026, GH3760,GH5302, GH5332, GH5793, GH6105 and UCCC6 exhibited mild symptoms of OMD, and were less susceptible to flea beetle infestation and associated leaf damage during both seasons. Using ELISA, OkMV was detected in all the 21 genotypes. The mean number of fruits per plant and the mean fruit yield (t ha-1) differed significantly (P&lt;0.05) among the okra genotypes. Genotype GH5332 had the highest fruit yield of 11.88 t ha-1 followed by genotype GH6105 (9.34 t ha-1). Percentage fruit damage due to the flea beetle infestation differed significantly among the okra genotypes, ranging between 43.7 and 91.2% and from 47 to 84% in both trials respectively

The search for yield predictors for mature field-grown plants from juvenile pot-grown cassava (Manihot esculenta Crantz).

Cassava is the 6th most important source of dietary energy in the world but its root system architecture (RSA) had seldom been quantified. Ability to select superior genotypes at juvenile stages can significantly reduce the cost and time for breeding to bridge the large yield gap. This study adopted a simple approach to phenotyping RSA traits of juvenile and mature cassava plants to identify genotypic differences and the relationships between juvenile traits and harvest index of mature plants. Root classes were categorised and root and shoot traits of eight (8) juvenile pot-grown cassava genotypes, were measured at 30 and 45 days after planting (DAP). The same or related traits were measured at 7 months after planting of the same genotypes grown in the field while yield and yield components were measured in 12-months old field-grown plants. The field experiment was done in 2017 and repeated in 2018. Differences between genotypes for the measured traits were explored using analysis of variance (ANOVA) while traits in juvenile plants were correlated or regressed onto traits measured in 7- and 12-months old plants. The results show significant genotypic variations for most of the traits measured in both juvenile and 7-months old plants. In the 12-months old plants, differences between genotypes were consistent for both 2017 and 2018. Broad-sense heritability was highest for the number of commercial roots (0.87) and shoot fresh weight (0.78) and intermediate for the total number of roots (0.60), harvest index (0.58), fresh weight of roots (0.45). For all the sampling time points or growth stages, there were greater correlations between traits measured at a particular growth stage than between the same traits at different growth stages. However, some juvenile-mature plant trait relationships were significant, positive and consistent for both 2017 and 2018. For example, total root length and the total number of roots in 30 DAP, and branching density of upper nodal roots in 45 DAP, positively correlated with harvest index of 12-months old plants in both 2017 and 2018. Similarly, the diameter of nodal roots, for example, had a negative, significant correlation with fresh shoot biomass of mature plants in both 2017 and 2018. Regression of traits measured in 30 DAP explained up to 22% and 36% of the variation in HI of mature plants in 2017 and 2018, respectively. It is concluded that the simple, rapid, inexpensive phenotyping approach adopted in this study is robust for identifying genotypic variations in juvenile cassava using root system traits. Also, the results provide seminal evidence for the existence of useful relationships between traits of juvenile and mature cassava plants that can be explored to predict yield and yield components