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

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)

Effect of amniotic membrane versus collagen membrane on sticky bone graft in lateral sinus lifting with simultaneous implant placement: Clinical and radiographic study

Objectives: to compare of effect amniotic membrane versus collagen membrane on sticky bone with simultaneous implant placement after lateral sinus lifting procedure. Patients and methods: Seven patients with bilateral sever bone resorption undergone immediate implant after lateral sinus lifting and placement of sticky bone. In G (I): Collagen membrane covered sticky bone and implant while in G (II): Amniotic membrane covered sticky bone and implant. Surgical sites were evaluated clinically for any signs of infection, wound dehiscence, or exposure of implant threads. Also, Implant stability and bone density were obtained at 0, 3, 6 and 9 months. Results: Amniotic group revealed statistically significant value in percentage increase of bone density. Conclusion: The application of sticky bone with amniotic membrane was more likely proved to have the ability to assist and accelerate bone healing and osseointegration. &nbsp

Potential fungicidal and antiaflatoxigenic effects of cinnamon essential oils on Aspergillus flavus inhabiting the stored wheat grains

Abstract Wheat is one of the essential crops for the human and animal nutrition, however, contamination with aflatoxigenic fungi, due to the improper storage conditions and high humidity, was the main global threats. So, preventing the growth of aflatoxigenic fungi in stored wheat grains, by using different essential oils was the main objective of this work. Aspergillus flavus EFBL-MU12 PP087400, EFBL-MU23 PP087401 and EFBL-MU36 PP087403 isolates were the most potent aflatoxins producers inhabiting wheat grains. The effect of storage conditions of wheat grains “humidity, temperature, incubation period, and pH” on growth of A. flavus, was assessed by the response surface methodology using Plackett-Burman design and FCCD. The highest yield of aflatoxins EFBL-MU12 B1 and B2 by A. flavus grown on wheat grains were 145.3 and 7.6 μg/kg, respectively, at incubation temperature 35°C, 16% moisture contents, initial pH 5.0, and incubated for 14 days. The tested oils had a powerful antifungal activity for the growth and aflatoxins production by A. flavus in a concentration-dependent manner. Among these oils, cinnamon oil had the highest fungicidal activity for A. flavus at 0.125%, with about 85-90 % reduction to the aflatoxins B1 and B2, conidial pigmentation and chitin contents on wheat grains. From the SEM analysis, cinnamon oils had the most deleterious effect on A. flavus with morphological aberrations to the conidial heads, vegetative mycelia, alteration in conidiophores identity, hyphae shrank, and winding. To emphasize the effect of the essential oils on the aflatoxins producing potency of A. flavus, the molecular expression of the aflatoxins biosynthetic genes was estimated by RT-qPCR. The molecular expression of nor-1, afLR, pKsA and afLJ genes was suppressed by 94-96%, due to cinnamon oil at 0.062% compared to the control. Conclusively, from the results, cinnamon oils followed by the peppermint oils displayed the most fungicidal activity for the growth and aflatoxins production by A. flavus grown on wheat grains

Yang’s keyhole plate versus conventional plate for treatment of mandibular sub-condylar fractures: Clinical and radiographic evaluation

Objectives: The use of a keyhole plate vs two miniplates in the treatment of mandibular subcondylar fractures. Materials and methods:Twenty patients were randomized into two equal groups. Ten patients with subcondylar fractures were treated with two Yang's keyhole plates in Group I. Ten patients with subcondylar fractures were treated with two conventional miniplates in Group II. Maximum mouth opening (MMO), Protrusive excursive movement, Lateral excursive movement, and Time for reduction and fixation were all used to evaluate patients clinically vertical height of ramus, and antero-posterior condylar angulation are all measured radiographically. Results: There was a statistically non-significant difference between the study and control groups at all intervals regarding MMO, Protrusive excursive movement, Lateral excursive movement, vertical height of the ramus, antero-posterior condylar angulation, but was significant at time for reduction and fixation. Conclusion: reducing a mandibular condylar fracture using a YK-plate, the results were similar and the operating time was quicker than when utilizing a traditional mini plate fixation

In Vitro Evaluation of Biological Activities and Phytochemical Analysis of Different Solvent Extracts of <i>Punica granatum</i> L. (Pomegranate) Peels

Antimicrobial resistance is a public health concern resulting in high rates of morbidity and mortality worldwide. Furthermore, a high incidence of food poisoning diseases besides harmful implications of applying synthetic food additives in food preservation necessitates fabrication of safe food preservatives. Additionally, damaging effects of free radicals on human health has been reported to be involved in the incidence of serious diseases, including cancer, diabetes and cardiovascular diseases; hence, finding safe sources of antioxidants is vital. Therefore, the present study was carried out to assess the antibacterial, antiradical and carcinopreventive efficacy of different solvent extracts of pomegranate peels. Agar disk diffusion assay revealed that Staphylococcus aureus, MRSA, E. coli and S. typhimurium were highly susceptible to methanolic fraction of Punica granatum L. peels recording inhibition zones of 23.7, 21.8, 15.6 and 14.7 mm respectively. Minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of the methanolic fraction of Punica granatum L. peels against S. aureus were 0.125 and 0.250 mg/mL, respectively. In addition, the pomegranate acetonic and methanolic fractions revealed an impressive antiradical efficiency against DPPH (2,2-diphenyl-1-picrylhydrazyl) radical recording radical scavenging activity percentages of 86.9 and 79.4%, respectively. In this regard, the acetonic fraction of pomegranate peels revealed the highest anti-proliferative efficiency after 48 h incubation against MCF7 cancer cells recording IC50 of 8.15 µg/mL, while the methanolic extract was highly selective against transformed cancer cells compared to normal cell line recording selectivity index of 5.93. GC–MS results demonstrated that 5-Hydroxymethylfurfural was the main active component of methanolic and acetonic extracts of pomegranate peels recording relative percentages of 37.55 and 28.84% respectively. The study recommends application of pomegranate peel extracts in the biofabrication of safe food preservatives, antioxidants and carcinopreventive agents

Assessment of narrow alveolar ridge expansion by ossiodensification vs. ridge splitting technique for dental implant placement: Clinical and radiographic study

Objectives: Comparing osseodensification vs. ridge splitting techniques in dental implant placement regarding implant stability, insertion torque, bone width and density. Patients and Method: Twenty individuals with a narrow ridge width of 3-6 mm at crestal bone level were included in this study. They were divided into two groups: Group I Osseodensification technique, Group II Ridge splitting technique with bone expanders and sticky bone augmentation. Implant stability, insertion torque, surgical procedure duration, bone width, and density were all evaluated by CBCT. Results: Group (I) had showed higher statistically significant Insertion torque than group (II). While group (II) had showed statistically significant increase in mean ISQ reading after 6 months (p&lt;0.001). Group (II) showed statistically significant higher surgical time than group (I). Group (II) showed a higher increase in bone gain than group (I). Group (I) had showed statistically significant increase in mean bone density postoperatively, after 3 and 6 months (p&lt;0.001*). While group (II) had showed statistically significant increase in mean bone density postoperatively, after 3 and 6 months (p&lt;0.001). Conclusion: Osseodensification technique had been shown to increase ridge width while maintaining primary implant stability and bone density around dental implants without sacrificing bone