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

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

NDER

Medical students require a strong foundation in normal histology. However, current trends in medical school curricula have diminished time devoted to histology. Thus, there is a need for more efficient methods of teaching histology. We have developed a novel software program (Novel Diagnostic Educational Resource; https://pcs-webtest0.pathology.washington.edu/academics/pattern/ ) that uses annotated whole slide images to teach normal histology. Whole slide images of a wide variety of tissues were annotated by a trainee and validated by an experienced pathologist. Still images were extracted and transferred to the Novel Diagnostic Educational Resource web application. In Novel Diagnostic Educational Resource, an image was displayed briefly and the user was forced to identify the tissue type. The display time changed inversely based on cumulative accuracy to challenge the user and maintain engagement. A total of 129 second-year medical students completed the 30-minute Novel Diagnostic Educational Resource module. Surveys showed an increase in confidence from premodule (0% extremely confident, 4% very, 47% somewhat, and 49% not) to postmodule (9% extremely confident, 57% very, 32% somewhat, and 2% not), P < .0001. Accuracy increased from 72.6% pretest to 95.7% posttest, P < .002. The effect size (Cohen d = 2.30) was very large, where 0.2 is a small effect, 0.5 moderate, and 0.8 large. Ninety-six percent of students would recommend Novel Diagnostic Educational Resource to other medical students, and 98% would use Novel Diagnostic Educational Resource to further enhance their histology knowledge. Novel Diagnostic Educational Resource drastically improved medical student accuracy in classifying normal histology and improved confidence. Additional study is needed to determine knowledge retention, but Novel Diagnostic Educational Resource has great potential for efficient teaching of histology given the curriculum time constraints in medical education

Book of Abstracts: 2019 Health Equity Summer Research Summit Organized by the Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, Texas 77030, USA on June 18th, 2019

Copyright © 2020 Harris. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited

Search for top quark decays t → qH with H → γγ using the ATLAS detector

A search is performed for flavour-changing neutral currents in the decay of a top quark to an up-type (c, u) quark and a Higgs boson, where the Higgs boson decays to two photons. The proton-proton collision data set used corresponds to 4.7 fb-1 at √ = 7TeV and 20.3fb-1 at √ = 8TeV collected by the ATLAS experiment at the LHC. Top quark pair events are searched for in which one top quark decays to qH and the other decays to bW. Both the hadronic and the leptonic decay modes of the W boson are used. No significant signal is observed and an upper limit is set on the t → qH branching ratio of 0.79 at the 95% confidence level. The corresponding limit on the tqH coupling combination λtcH 2 + λtuH 2 is 0.17