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

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

Lipid extraction maximization and enzymatic synthesis of biodiesel from microalgae

© 2020 by the authors. Microalgae has received overwhelming attention worldwide as a sustainable source for energy generation. However, the production of biofuel from microalgae biomass consists of several steps, of which lipid extraction is the most important one. Because of the nature of feedstock, extraction needs special attention. Three different methods were studied to extract algal oil from two different algae variant, Chlorella sp. and Spirulina sp. The highest percentage oil yield was obtained by ultrasonication (9.4% for Chlorella sp., 6.6% for Spirulina sp.) followed by the Soxhlet and solvent extraction processes. Ultrasonication and Soxhlet extraction processes were further optimized to maximize oil extraction as solvent extraction was not effective in extracting lipid. For ultrasonication, an amplitude of 90% recorded the highest percentage yield of oil for Spirulina sp. and a 70% amplitude recorded the highest percentage yield of oil for Chlorella sp. On the other hand, for Soxhlet extraction, a combination of chloroform, hexane, and methanol at a 1:1:1 ratio resulted in the highest yield of algal oil. Afterward, the crude algae oil from the ultrasonication process was transesterified for 5 h using an immobilized lipase (Novozyme 435) at 40 °C to convert triglycerides into fatty acid methyl ester and glycerol. Thus, ultrasonic-assisted lipid extraction was successful in producing biodiesel from both the species

Bioenergy recovery potential through the treatment of the meat processing industry waste in Australia

The farm animal and meat processing industry generate waste, including manure, fat, blood, sludge, bones, and wastewater, which create environmental problems worldwide. The effluents generated by this industry are rich in proteins, lipids, fibres, and carbohydrates. All these pollutants have the potential to be used as a resource for energy recovery. The organic matters obtained from the farm animal and meat processing industry are critical sources for biogas production via anaerobic digestion. This process leads to the production of energy-rich biogas, reducing greenhouse gas emissions. This study attempts to determine biogas amount and the energy value produced from the farm animal and meat processing industry in Australia. Australia's livestock population mainly consists of dairy cattle, meat cattle, sheep and lambs, pigs, layers, and meat chickens. Results show a potential biogas amount of 23,874,165 million m3 (Mm3), 215,670 Mm3, 288,228 Mm3, 18,430 Mm3, and 392,284 Mm3 can be obtained from cattle, lamb, sheep, pig, and poultry annually, respectively. The methane generated from slaughterhouse waste and wastewater is estimated to provide 4.52E+ 14 MJ/yr of heat energy with total electricity generation potential from livestock wastes of 4.4E+ 13 kWh/yr. About half of the electricity can be generated in Queensland State. Finally, the present study suggests farm animal and meat processing industry effluent as a potential sustainable energy source in Australia

Enhancement in combustion, performance, and emission characteristics of a diesel engine fueled with Ce-ZnO nanoparticle additive added to soybean biodiesel blends

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/). This study considered the impacts of diesel-soybean biodiesel blends mixed with 3% cerium coated zinc oxide (Ce-ZnO) nanoparticles on the performance, emission, and combustion characteristics of a single cylinder diesel engine. The fuel blends were prepared using 25% soybean biodiesel in diesel (SBME25). Ce-ZnO nanoparticle additives were blended with SBME25 at 25, 50, and 75 ppm using the ultrasonication process with a surfactant (Span 80) at 2 vol.% to enhance the stability of the blend. A variable compression ratio engine operated at a 19.5:1 compression ratio (CR) using these blends resulted in an improvement in overall engine characteristics. With 50 ppm Ce-ZnO nanoparticle additive in SBME25 (SBME25Ce-ZnO50), the brake thermal efficiency (BTE) and heat release rate (HRR) increased by 20.66% and 18.1%, respectively; brake specific fuel consumption (BSFC) by 21.81%; and the CO, smoke, and hydrocarbon (HC) decreased by 30%, 18.7%, and 21.5%, respectively, compared to SBME25 fuel operation. However, the oxides of nitrogen slightly rose for all the nanoparticle added blends. As such, 50 ppm of Ce-ZnO nanoparticle in the blend is a potent choice for the enhancement of engine performance, combustion, and emission characteristics