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

Investigation of the osteochondral response to injury in racing Thoroughbreds

© 2013 Dr. Ebrahim Bani HassanFor prevention and appropriate treatment of subchondral bone (SCB) injuries a thorough understanding of the prevalence, pathogenesis and repair mechanisms of the condition are mandatory. Palmar/plantar osteochondral disease (POD) is a SCB fatigue injury in racehorses that occurs with a high prevalence. There is limited quantitative data on the role of microfractures, osteocyte death, modelling, remodelling, loading intensity and unloading on SCB injury (SCBI) and repair. The association between articular cartilage and SCB injuries in this condition is not well understood. Qualitative associations have been established between SCBI, modelling and remodelling and it has been speculated that modelling and remodelling may contribute to injury by creating brittle and/or porotic bone or stiffness gradients within bone. To better understand the pathogenesis of SCBI and its association with loading intensity, the injury and bone response to injury (resorption and formation) were quantified and their associations with recent and life-time exercise intensity were investigated in a cross-sectional study. It was also intended to study if resting from training had an effect on removal of microdamage from SCB. It was hypothesized that SCBI occurs prior to cartilage damage, is consistent with bone fatigue and therefore is associated with the history of exercise duration and intensity. According to second hypothesis the response of bone to injury could contribute to the pathogenesis of SCBI. Fore- and hind limbs from two separate groups of Thoroughbred racehorse cadavers were collected at post-mortem and severity of POD was graded 0-3. Forelimbs from 38 horses were examined using high-resolution peripheral quantitative CT, back scattered electron microscopy and histomorphometry. Also, hind limbs from 46 horses were collected for histomorphometry using cryosections, 1 µm thick resin embedded sections and transmission electron microscopy. Of the forelimb cohort 65.8% of horses had some degree of POD and 30.7% of horses had at least one Grade 2-3 lesion. In hind limbs 57.8% had at least one POD lesion of any severity and 24.4% had grade 2-3 lesions. The majority of horses had some degree of SCB microfracture or osteocyte loss. SCB microfractures were present in all grades of the disease whereas significant cartilage changes were limited to grade 3 lesions. SCB lesions were characterised by accumulations of microfractures, osteocyte loss in the affected area, sclerosis of the surrounding trabecular bone, focal resorption of superficial SCB, and in grade 3 lesions, articular surface attrition (collapse). Short term rest was associated with greater focal bone resorption which in some cases was concentrated in the immediate SCB leading to loss of support of the overlying cartilage and subchondral plate. The severity of macroscopic and microscopic lesions correlated with age and indicators of the accumulation of training distance. In conclusion, SCB appears to respond to fatigue injury in a similar manner to cortical bone i.e. sclerosis in the surrounding bone accompanies localised resorption at the site of damage. It is unclear whether focal resorption at the site of fatigue injury contributes to further bone fatigue however, bone resorption accelerates when horses are rested from training and this appears to contribute to collapse of the articular cartilage into the SCB. SCB was the primary site of the injury and articular cartilage changes were only associated with severe injuries where SCB attrition had occurred. A better understanding of the effects of training and rest on bone turnover rate is required to reduce the accumulation of SCB fatigue damage that occurs throughout the careers of equine athletes

Clinical Utility of Thigh and Mid‐Thigh Dual‐Energy x‐Ray Absorptiometry to Identify Bone and Muscle Loss

Abstract Sarcopenia and osteoporosis are highly prevalent syndromes in older people, characterized by loss of muscle and bone tissue, and related to adverse outcomes. Previous reports indicate mid‐thigh dual‐energy X‐ray absorptiometry (DXA) is well suited for the simultaneous assessment of bone, muscle, and fat mass in a single scan. Using cross‐sectional clinical data and whole‐body DXA images of 1322 community‐dwelling adults from the Geelong Osteoporosis Study (57% women, median age 59 years), bone and lean mass were quantified in three unconventional regions of interest (ROIs): (i) a 2.6‐cm‐thick slice of mid‐thigh, (ii) a 13‐cm‐thick slice of mid‐thigh, and (iii) the whole thigh. Conventional indices of tissue mass were also calculated (appendicular lean mass [ALM] and bone mineral density [BMD] of lumbar spine, hip, and femoral neck). The performance of thigh ROIs in identifying osteoporosis, osteopenia, low lean mass and strength, past falls, and fractures was evaluated. All thigh regions (especially whole thigh) performed well in identifying osteoporosis (area under the receiver‐operating characteristic [ROC] curve [AUC] > 0.8) and low lean mass (AUC >0.95), but they performed worse in the diagnosis of osteopenia (AUC 0.7–0.8). All thigh regions were equivalent to ALM in discrimination of poor handgrip strength, gait speed, past falls, and fractures. BMD in conventional regions was more strongly associated with past fractures than thigh ROIs. In addition to being faster and easier to quantify, mid‐thigh tissue masses can be used for identifying osteoporosis and low lean mass. They are also equivalent to conventional ROIs in their associations with muscle performance, past falls, and fractures; however, further validation is required for the prediction of fractures. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research

Addition of intrathecal Dexamethasone to Bupivacaine for spinal anesthesia in orthopedic surgery

Objectives: Spinal anesthesia has the advantage that profound nerve block can be produced in a large part of the body by the relatively simple injection of a small amount of local anesthetic. Intrathecal local anesthetics have limited duration. Different additives have been used to prolong spinal anesthesia. The effect of corticosteroids in prolonging the analgesic effects of local anesthetics in peripheral nerves is well documented. The purpose of this investigation was to determine whether the addition of dexamethasone to intrathecal bupivacaine would prolong the duration of sensory analgesia or not. Methods: We conducted a randomized, prospective, double-blind, case-control, clinical trial. A total of 50 patients were scheduled for orthopedic surgery under spinal anesthesia. The patients were randomly allocated to receive 15 mg hyperbaric bupivacaine 0.5% with 2 cc normal saline (control group) or 15 mg hyperbaric bupivacaine 0.5% plus 8 mg dexamethasone (case group) intrathecally. The patients were evaluated for quality, quantity, and duration of block; blood pressure, heart rate, nausea, and vomiting or other complications. Results: There were no signification differences in demographic data, sensory level, and onset time of the sensory block between two groups. Sensory block duration in the case group was 119±10.69 minutes and in the control group was 89.44±8.37 minutes which was significantly higher in the case group (P<0.001). The duration of analgesia was 401.92±72.44 minutes in the case group; whereas it was 202±43.67 minutes in the control group (P<0.001). The frequency of complications was not different between two groups. Conclusion: This study has shown that the addition of intrathecal dexamethasone to bupivacaine significantly improved the duration of sensory block in spinal anesthesia without any changes in onset time and complications

Association between structural changes in brain with muscle function in sarcopenic older women : The Women’s Healthy Ageing Project (WHAP)

Objectives: The involvement of changes in brain structure in the pathophysiology of muscle loss (sarcopenia) with aging remains unclear. In this study, we investigated the associations between brain structure and muscle strength in a group of older women. We hypothesized that structural changes in brain could correlate with functional changes observed in sarcopenic older women. Methods: In 150 women (median age of 70 years) of the Women’s Healthy Ageing Project (WHAP) Study, brain grey (total and cortex) volumes were calculated using magnetic resonance imaging (MRI) analyses. Grip strength and timed up and go (TUG) were measured. The brain volumes were compared between sarcopenic vs. non-sarcopenic subjects and women with previous falls vs. those without. Results: Based on handgrip strength and TUG results respectively, 27% and 15% of women were classified as sarcopenic; and only 5% were sarcopenic based on both criteria. At least one fall was experienced by 15% of participants. There was no difference in brain volumetric data between those with vs. without sarcopenia (p>0.24) or between women with falls (as a symptom of weakness or imbalance) vs. those without history of falls (p>0.25). Conclusions: Brain structure was not associated with functional changes or falls in this population of older women

Validation of a Semiautomatic Image Analysis Software for the Quantification of Musculoskeletal Tissues.

Accurate quantification of bone, muscle, and their components is still an unmet need in the musculoskeletal field. Current methods to quantify tissue volumes in 3D images are expensive, labor-intensive, and time-consuming; thus, a reliable, valid, and quick application is highly needed. Tissue Compass is a standalone software for semiautomatic segmentation and automatic quantification of musculoskeletal organs. To validate the software, cross-sectional micro-CT scans images of rat femur (n = 19), and CT images of hip and abdomen (n = 100) from the Osteoporotic Fractures in Men (MrOS) Study were used to quantify bone, hematopoietic marrow (HBM), and marrow adipose tissue (MAT) using commercial manual software as a comparator. Also, abdominal CT scans (n = 100) were used to quantify psoas muscle volumes and intermuscular adipose tissue (IMAT) using the same software. We calculated Pearson's correlation coefficients, individual intra-class correlation coefficients (ICC), and Bland-Altman limits of agreement together with Bland-Altman plots to show the inter- and intra-observer agreement between Tissue Compass and commercially available software. In the animal study, the agreement between Tissue Compass and commercial software was r &gt; 0.93 and ICC &gt; 0.93 for rat femur measurements. Bland-Altman limits of agreement was -&nbsp;720.89 (-&nbsp;1.5e+04, 13,074.00) for MAT, 4421.11 (-&nbsp;1.8e+04, 27,149.73) for HBM and -&nbsp;6073.32 (-&nbsp;2.9e+04, 16,388.37) for bone. The inter-observer agreement for QCT human study between two observers was r &gt; 0.99 and ICC &gt; 0.99. Bland-Altman limits of agreement was 0.01 (-&nbsp;0.07, 0.10) for MAT in hip, 0.02 (-&nbsp;0.08, 0.12) for HBM in hip, 0.05 (-&nbsp;0.15, 0.25) for bone in hip, 0.02 (-&nbsp;0.18, 0.22) for MAT in L1, 0.00 (-&nbsp;0.16, 0.16) for HBM in L1, and&nbsp;0.02 (-&nbsp;0.23, 0.27) for bone in L1. The intra-observer agreement for QCT human study between the&nbsp;two applications was r &gt; 0.997 and ICC &gt; 0.99. Bland-Altman limits of agreement was 0.03 (-&nbsp;0.13, 0.20) for MAT in hip, 0.05 (-&nbsp;0.08, 0.18) for HBM in hip, 0.05 (-&nbsp;0.24, 0.34) for bone in hip, -&nbsp;0.02 (-&nbsp;0.34, 0.31) for MAT in L1, -&nbsp;0.14 (-&nbsp;0.44, 0.17) for HBM in L1, -&nbsp;0.29 (-&nbsp;0.62, 0.05) for bone in L1, 0.03 (-&nbsp;0.08, 0.15) for IMAT in psoas, and 0.02 (-&nbsp;0.35, 0.38) for muscle in psoas. Compared to a conventional application, Tissue Compass demonstrated high accuracy and non-inferiority while also facilitating easier analyses. Tissue Compass could become the tool of choice to diagnose tissue loss/gain syndromes in the future by requiring a small number of CT sections to detect tissue volumes and fat infiltration