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

CXCL16 Regulates Cell-Mediated Immunity to Salmonella enterica Serovar Enteritidis via Promotion of Gamma Interferon Production

CXCL16 is a recently discovered multifaceted chemokine that has been shown not only to recruit activated T lymphocytes but also to play a direct role in the binding and phagocytosis of bacteria by professional antigen-presenting cells. In this study, we investigated the role of CXCL16 in vivo in the regulation of the immune response using a murine model of Salmonella enterica serovar Enteritidis infection. The expression of CXCL16 was strongly upregulated in the spleens and livers of animals developing an immune response to a primary acute infection but not in the Peyer's patches. Animals developing a secondary response after reexposure to the bacteria displayed a similar pattern of expression. During the primary response, prior treatment with neutralizing antibodies to CXCL16 induced a significant increase in bacterial burden in the spleen and liver. The production of gamma interferon (IFN-γ) by the lymphocytes in the spleen was decreased by anti-CXCL16 treatment. In comparison, during the secondary response, anti-CXCL16 treatment also significantly increased bacterial burden in both the spleen and liver but had no effect on IFN-γ production. No role was found for CXCL16 in the production of antibody against SefA, a major surface antigen of S. enteritidis. Together, these results demonstrate a role for CXCL16 in the control of bacterial colonization of target organs and, more specifically, in the regulation of the cell-mediated arm of the primary response to S. enteritidis

Small scale fisheries in Europe: A comparative analysis based on a selection of case studies

Full text: http://archimer.ifremer.fr/doc/00118/22934/20757.pdf (Version "auteur", 0.44 Mo)International audienceSmall-scale fisheries have traditionally received less research effort than large-scale fisheries and are generally under-studied in Europe. In spite of their comparatively low volume of catches and economic importance, small-scale fisheries are socially important and an integral part of the European coastal zone. Considering the high heterogeneity of situations and the paucity of quantitative data, we used an analytical methodology based on the comparative method. We carried out an analysis of small-scale fisheries (SSFs) in Europe based on a selection of nine case studies. Our objective was to obtain a comprehensive description of small-scale fleets covering different areas/fisheries/species, encompassing the diversity and specific conditions under which SSFs operate, in order to demonstrate the ecological and social sustainability of this often overlooked fisheries segment. A common approach formulated so that the case studies could be compared with the case histories of other competing users, required that for each set of criteria - technical, biological, socio-economic, and institutional - a set of relevant items and indicators was established. An analysis of characteristics common to the selected case studies is conducted and an attempt made to extend our comparisons to the whole of the European Union. Our results show that (as compared with large-scale fleets, their main competitor) small-scale fleets: (i) are composed of smaller vessels and, consequently, travel lower distances to fishing grounds, and are more reliant on coastal areas; (ii) have smaller crews (although the global employment figure is similar to that of large-scale fleets in Europe); (iii) use mostly, but not exclusively, passive gears; (iv) use multi-purpose fishing approaches, and can change the fish species they target during the year; (v) have lower extraction rates; (vi) have lower total capital investments (including fishing rights), turnover and costs; and (vii) have lower fuel consumption, making them less sensitive to changing oil prices. Dependence on subsidies is lower (viii). Involvement in fisheries management is variable, conservation and access regulation measures are largely local in origin. For the selected case studies, the most significant competitors are large-scale fleets, and recreational fisheries, but other sources of interaction (water quality, invasive species, etc.) cannot be ignored

Contents of carotenoids, tocopherols and sterols in acacia cyanophylla seed oils

WOS:000320433100013 ; http://link.springer.com/journal/11746International audienceSeeds from 12 Acacia cyanophylla ecotypes, harvested in Tunisia, were examined for their seed oil contents of carotenoids, tocopherols and phytosterols. The average carotenoid content (lutein and zeaxanthin) was ca. 102 mg kg(-1) of total extracted lipids. Lutein (ca. 97 mg kg(-1) of total extracted lipids) was usually more abundant than zeaxanthin (ca. 5 mg kg(-1) of total extracted lipids). The mean total tocopherol content was ca. 704 mg kg(-1) of total extracted lipids. The main isomer was alpha-tocopherol, with more than 75 % of total tocopherols (ca. 528 mg kg(-1) of total extracted lipids), followed by gamma-tocopherol (ca. 168 mg kg(-1) of total extracted lipids) and delta-tocopherol (ca. 86 mg kg(-1) of total lipids). High levels of phytosterols (ca. 7.8 g kg(-1) of total extracted lipids) were detected, among which beta-sitosterol was the most abundant (47 %). All these results highlight the richness of carotenoids, tocopherols and sterols in A. cyanophylla seed oil, and imply that this species might constitute a potential resource for the development of functional foods

Control of Salmonella dissemination in vivo by macrophage inflammatory protein (MIP)-3a/CCL20

Copyright © 2007 United States and Canadian Academy of PathologyWhile chemokines are clearly important in the generation of protective immunity, the role of individual chemokines in the control of bacterial infection is still poorly understood. In this study, we investigated the role of macrophage inflammatory protein (MIP)-3alpha/CCL20, a chemokine that attracts activated T and B lymphocytes and immature dendritic cells, in host responses to bacterial infection. CCL20 production was induced in subcutaneous tissue in the BALB/c mouse in response to Salmonella enteritidis, Staphylococcus aureus and zymosan, with S. enteritidis being the most potent. S. enteritidis induced CCL20 production in the spleen following either oral administration or injection into the peritoneal cavity. In contrast, no increase was observed in the Peyer's patches. In this model, following intraperitoneal injection, dose-dependent colonization of the spleen and Peyer's patches by S. enteritidis, expression of IFNgamma and IL-4, and production of antibodies against the S. enteritidis surface antigen SefA were observed. Prior treatment with neutralizing antibodies against CCL20 enhanced bacterial dissemination to the spleen and Peyer's patches and strongly biased the IFNgamma/IL-4 ratio towards a type 2 profile in the spleen, while the humoral response was unaffected. In contrast, treatment with neutralizing anti-MIP-1alpha/CCL3 antibodies enhanced the bacterial burden in the Peyer's patches but not in the spleen, had no significant effect on the cytokine ratio, but significantly inhibited anti-SefA production. Together, these results demonstrate an important role for CCL20 in the control of bacterial infection and more specifically in the regulation of cell-mediated immunity against intracellular bacteria such as S. enteritidis.Olivier L Fahy, Scott L Townley, Nicholas J Coates, Ian Clark-Lewis and Shaun R McCol