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

Kinematic and thermal evolution of the Moroccan rifted continental margin: Doukkala-High Atlas Transect

The Atlantic passive margin of Morocco developed during Mesozoic times in association with the opening of the Central Atlantic and the Alpine Tethys. Extensional basins formed along the future continental margin and in the Atlas rift system. In Alpine times, this system was inverted to form the High and Middle Atlas fold-and-thrust belts. To provide a quantitative kinematic analysis of the evolution of the rifted margin, we present a crustal section crossing the Atlantic margin in the region of the Doukkala Basin, the Meseta and the Atlas system. We construct a post-rift upper crustal section compensating for Tertiary to present vertical movements and horizontal deformations, and we conduct numerical modeling to test quantitative relations between amounts and distribution of thinning and related vertical movements. Rifting along the transect began in the Late Triassic and ended with the appearance of oceanic crust at 175 Ma. Subsidence, possibly related to crustal thinning, continued in the Atlas rift in the Middle Jurassic. The numerical models confirm that the margin experienced a polyphase rifting history. The lithosphere along the transect preserved some strength throughout rifting with the Effective Elastic Thickness corresponding to an isotherm of 450°C. A mid-crustal level of necking of 15 km characterized the pre-rift lithosphere. © 2010 by the American Geophysical Union

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

La dislocation de la plateforme carbonatée dévonienne de la Meseta marocaine dans le Maroc central occidental

Dislocation of the Devonian carbonate platform of the moroccan Meseta in western central Morocco. Lithostratigraphic and sedimentological studies of Devonian strata in the western central Morocco show that a carbonate platform was progressively built-up in this area during the Lower Devonian (individualisation stage). By Middle Devonian time, this platform was completly established to be subsequently dismantled by Upper Devonian tectonic movements following the opening of basins in central Morocco.L'étude lithostratigraphique et sédimentologique des terrains dévoniens du Maroc central occidental permet de mettre en évidence l'installation progressive dès le Dévonien inférieur d'une plate-forme carbonatée (stade d'individualisation) dont la maturation s'affirme au Dévonien moyen. A partir du Dévonien supérieur, cette plate-forme est le siège d'une importante dislocation interprétée comme induite par des mouvements tectoniques liés à l'ouverture de bassins dans le Maroc central pendant cette époque.Chakiri S., Benammi Mouloud, Tayebi Mohamed, Tahiri Abdelfattah. La dislocation de la plateforme carbonatée dévonienne de la Meseta marocaine dans le Maroc central occidental. In: Géologie Méditerranéenne. Tome 28, numéro 3-4, 2001. pp. 181-191

Magnetostratigraphy and Chronology of the Lower Pleistocene Primate Bearing Dafnero Fossil Site, N. Greece

This paper aims to contribute to the stratigraphic and geochronological evaluation of the primate bearing Dafnero fossil site of Northern Greece by means of lithostratigraphic, paleomagnetic and paleontological analyses. The 60 m thick fossiliferous deposits of fluviatile origin are recognized as representing a typical braided-river sequence unconformably overlying molassic sediments. Rock magnetic investigations indicate the presence of both medium and low coercivity minerals. Paleomagnetic sampling of the Dafnero sediments yielded a stable magnetic remanence, and the characteristic remanent magnetization directions pass reversal test with dual polarity. Based on calibration from mammal fossils, the normal polarity magnetozone N1 located in the upper third of the studied section could correlate with chron C2n (the Olduvai subchron), suggesting that the fossil horizon is within C2r with an extrapolated age of 2.4&ndash;2.3 Ma and rather closer to the upper age limit. The results allow the re-calibration of several middle Villafranchian assemblages of S. Balkans and the correlation of the corresponding mammal fauna with the environmental shifts of Praetiglian, as it is recorded in climatostratigraphic data from the Black Sea

P446 Long-term Clinical Effectiveness And Stoma Outcome Of Fecal Diversion In Refractory Crohn's Proctitis

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