Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

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

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

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

Diagnosis and keys of the main dipterous families and species collected from rabbit and guinea pig carcasses in Cairo, Egypt

Abstract Background In the current study, 23 species within 18 genera and 13 families of order Diptera were taxonomically studied. These members were collected from, on, in, around and beneath the carcasses of rabbits and guinea pigs. Results The families which collected from the carcasses are as follows: Agromyzidae (one subfamily, one genus and only one species), Calliphoridae (three subfamilies, three genera and sex species), Dolichopodidae (one subfamily, one genus and only one species), Drosophilidae (one subfamily, one genus and only one species), Ephydridae (one subfamily, one genus and only one species), Fanniidae (one genus and only one species), Muscidae (two subfamilies, three genus and four species), Phoridae (one subfamily, one genus and only one species), Piophilidae (one subfamily, one genus and only one species), Psychodidae (one subfamily, one genus and only one species), Sarcophagidae (two subfamilies, two genera and three species), Sphaeroceridae (one subfamily, one genus and only one species), and finally Ulidiidae (one subfamily, one genus and only one species). Only seven of which (Calliphoridae, Fanniidae, Muscidae, Phoridae, Piophilidae, Sarcophagidae and Ulidiidae) are of forensic importance or necrophagous. Other families are the following: Drosophilidae, Psychodidae, Agromyzidae, Dolichopodidae, Ephydridae, and Sphaeroceridae are of minor importance as forensic indicators. Conclusions Taxonomic keys for the adults which collected from the carcasses were constructed. Also diagnosis, synonyms, photographs and the forensic importance for the taxa were provided

Graft copolymerization of nylon-6 with glycidylmethacrylate using potassium persulphate-cupric ion system

130-135<span style="font-size:11.0pt;line-height:115%; font-family:" calibri","sans-serif";mso-ascii-theme-font:minor-latin;mso-fareast-font-family:="" "times="" new="" roman";mso-fareast-theme-font:minor-fareast;mso-hansi-theme-font:="" minor-latin;mso-bidi-font-family:calibri;mso-bidi-theme-font:minor-latin;="" mso-ansi-language:en-us;mso-fareast-language:en-us;mso-bidi-language:ar-sa"="">The kinetics of grafting of glycidylmethacrylate onto nylon-6 fibre induced by potassium persulphatecupric ion system was investigated. The rate of grafting was determined by varying the concentrations of the monomer, potassium persulphate and cupric ion. The reaction order was calculated. Raising the reaction temperature from 60°C to 80°C enhanced the rate of grafting significantly, and the apparent activation energy was 68.94 kJ/mol.</span

Synthesis of new 4-aryl-isoxazolo[5,4-<i style="">d</i>]pyrimidin-6-one(thione) and 4-aryl-pyrazolo[3,4-<i style="">d</i>]-pyrimidin-6-one derivatives of potential antihypertensive activity

2091-2098Some aromatic aldehydes are subjected to react with urea (or thiourea) and acetyl acetone in a one-pot Biginelli-type cyclocondensation reaction to give 5-acetyl-4-aryl-6-methyl-1,2,3,4-tetrahydro-pyrimidines 2a-j. Aldehydes with ortho-hydroxy substituent namely salicylaldehyde and 2-hydroxy-3-methoxybenzaldehyde undergo Michael-type addition of the hydroxyl-proton to the C5-C6 double bond of the pyrimidine ring to form the tricyclic derivatives 3a-d while 2-hydroxy-3-nitrobenzaldehyde reacted normally to give 2j. Compounds from the type 2 react with basic hydroxylamine to give the respective isoxazolopyrimidine derivatives 4a-g through an intramolecular addition of the oxim-hydroxyl proton to the C5-C6 double bond of the pyrimidine ring. The oxime derivatives from the tricyclic compounds 3a,c undergo rupture of the oxacyclic ring followed by addition of the oxim-proton to the C5-C6 double bond of the pyrimidine ring giving rise to the corresponding isoxazolophenols 5a,b. Furthermore, when hydrazine hydrate reacts with the acetyl derivatives 2a, 2f and 2h afford the corresponding 4-aryl-5-(1-hydrazono-ethyl)-6-methyl-3,4-dihydro-1H-pyrimidin-2-one 6a-c, while the compounds 2d and 3c react under the same reaction conditions to give the pyrazolopyrimidine derivatives 7 and 8, respectively

Water-in-diesel fuel nanoemulsions: Preparation, stability and physical properties

In this work, water-in-diesel fuel nanoemulsions were prepared with mixed nonionic surfactants. Several mixtures of sorbitan monooleate and polyoxyethylene (20) sorbitan monooleate, with different Hydrophilic–Lipophilic Balance (HLB) values (9.6, 9.8, 10, 10.2 and 10.4) were prepared to achieve the optimal HLB value. Three mixed surfactant concentrations were prepared at 6%, 8% and 10% to identify the optimum concentration. Five emulsions with different water contents: 5%, 6%, 7%, 8% and 9% (wt./wt.) were prepared using high energy method at the optimum conditions (HLB = 10 and mixed surfactant concentration = 10%). The effect of HLB value, mixed surfactant concentration and water content on the droplet size has been studied. The interfacial tension and thermodynamic properties of the individual and the blended emulsifiers were investigated. Droplet size of the prepared nanoemulsions was determined by dynamic light scattering and the nanoemulsion stability was assessed by measuring the variation of the droplet size as a function of time. From the obtained results, it was found that the mean droplet sizes were formed between 49.55 and 104.4 nm depending on HLB value, surfactant concentration and water content of the blended emulsifiers. The physical properties, kinematic viscosity and density, of the prepared nanoemulsions and the effect of different temperatures on these properties were measured