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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

The Oldest Vocation: Christian Motherhood in the Medieval West

According to an old story, a woman concealed her sex and ruled as pope for a few years in the ninth century. Pope Joan was not betrayed by a lover or discovered by an enemy; her downfall came when she went into labor during a papal procession through the streets of Rome. From the myth of Joan to the experiences of saints, nuns, and ordinary women, The Oldest Vocation brings to life both the richness and the troubling contradictions of Christian motherhood in medieval Europe. After tracing the roots of medieval ideologies of motherhood in early Christianity, Clarissa W. Atkinson reconstructs the physiological assumptions underlying medieval notions about women's bodies and reproduction; inherited from Greek science and popularized through the practice of midwifery, these assumptions helped shape common beliefs about what mothers were. She then describes the development of "spiritual motherhood" both as a concept emerging out of monastic ideologies in the early Middle Ages and as a reality in the lives of certain remarkable women. Atkinson explores the theological dimensions of medieval motherhood by discussing the cult of the Virgin Mary in twelfth-century art, story, and religious expression. She also offers a fascinating new perspective on the women saints of the later Middle Ages, many of whom were mothers; their lives and cults forged new relationships between maternity and holiness. The Oldest Vocation concludes where most histories of motherhood begin—in early modern Europe, when the family was institutionalized as a center of religious and social organization. Anyone interested in the status of motherhood, or in women's history, the cultural history of the Middle Ages, or the history of religion will want to read this book

The Oldest Vocation

According to an old story, a woman concealed her sex and ruled as pope for a few years in the ninth century. Pope Joan was not betrayed by a lover or discovered by an enemy; her downfall came when she went into labor during a papal procession through the streets of Rome. From the myth of Joan to the experiences of saints, nuns, and ordinary women, The Oldest Vocation brings to life both the richness and the troubling contradictions of Christian motherhood in medieval Europe.After tracing the roots of medieval ideologies of motherhood in early Christianity, Clarissa W. Atkinson reconstructs the physiological assumptions underlying medieval notions about women's bodies and reproduction; inherited from Greek science and popularized through the practice of midwifery, these assumptions helped shape common beliefs about what mothers were. She then describes the development of "spiritual motherhood" both as a concept emerging out of monastic ideologies in the early Middle Ages and as a reality in the lives of certain remarkable women. Atkinson explores the theological dimensions of medieval motherhood by discussing the cult of the Virgin Mary in twelfth-century art, story, and religious expression. She also offers a fascinating new perspective on the women saints of the later Middle Ages, many of whom were mothers; their lives and cults forged new relationships between maternity and holiness. The Oldest Vocation concludes where most histories of motherhood begin—in early modern Europe, when the family was institutionalized as a center of religious and social organization.Anyone interested in the status of motherhood, or in women's history, the cultural history of the Middle Ages, or the history of religion will want to read this book.According to an old story, a woman concealed her sex and ruled as pope for a few years in the ninth century. Pope Joan was not betrayed by a lover or discovered by an enemy; her downfall came when she went into labor during a papal procession through the streets of Rome. From the myth of Joan to the experiences of saints, nuns, and ordinary women, The Oldest Vocation brings to life both the richness and the troubling contradictions of Christian motherhood in medieval Europe.After tracing the roots of medieval ideologies of motherhood in early Christianity, Clarissa W. Atkinson reconstructs the physiological assumptions underlying medieval notions about women's bodies and reproduction; inherited from Greek science and popularized through the practice of midwifery, these assumptions helped shape common beliefs about what mothers were. She then describes the development of "spiritual motherhood" both as a concept emerging out of monastic ideologies in the early Middle Ages and as a reality in the lives of certain remarkable women. Atkinson explores the theological dimensions of medieval motherhood by discussing the cult of the Virgin Mary in twelfth-century art, story, and religious expression. She also offers a fascinating new perspective on the women saints of the later Middle Ages, many of whom were mothers; their lives and cults forged new relationships between maternity and holiness. The Oldest Vocation concludes where most histories of motherhood begin—in early modern Europe, when the family was institutionalized as a center of religious and social organization.Anyone interested in the status of motherhood, or in women's history, the cultural history of the Middle Ages, or the history of religion will want to read this book

The oldest vocation : Christian motherhood in the Middle Ages.

Electronic access restricted; authentication may be required

Carta de 1988-10-05 a José Ferrater Mora des de Cambridge (EUA) (Estats Units d'Amèrica)

S'agraeix els comentaris positius enviats per Ferrater en favor del Prof. MacGrego