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

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10&nbsp;years; 78.2% included were male with a median age of 37&nbsp;years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

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

Efficient Placement of Service Function Chains in Cloud Computing Environments

The widespread adoption of network function virtualization (NFV) leads to providing network services through a chain of virtual network functions (VNFs). This architecture is called service function chain (SFC), which can be hosted on top of commodity servers and switches located at the cloud. Meanwhile, software-defined networking (SDN) can be utilized to manage VNFs to handle traffic flows through SFC. One of the most critical issues that needs to be addressed in NFV is VNF placement that optimizes physical link bandwidth consumption. Moreover, deploying SFCs enables service providers to consider different goals, such as minimizing the overall cost and service response time. In this paper, a novel approach for the VNF placement problem for SFCs, called virtual network functions and their replica placement (VNFRP), is introduced. It tries to achieve load balancing over the core links while considering multiple resource constraints. Hence, the VNF placement problem is first formulated as an integer linear programming (ILP) optimization problem, aiming to minimize link bandwidth consumption, energy consumption, and SFC placement cost. Then, a heuristic algorithm is proposed to find a near-optimal solution for this optimization problem. Simulation studies are conducted to evaluate the performance of the proposed approach. The simulation results show that VNFRP can significantly improve load balancing by 80% when the number of replicas is increased. Additionally, VNFRP provides more than a 54% reduction in network energy consumption. Furthermore, it can efficiently reduce the SFC placement cost by more than 67%. Moreover, with the advantages of a fast response time and rapid convergence, VNFRP can be considered as a scalable solution for large networking environments

Efficient Placement of Service Function Chains in Cloud Computing Environments

The widespread adoption of network function virtualization (NFV) leads to providing network services through a chain of virtual network functions (VNFs). This architecture is called service function chain (SFC), which can be hosted on top of commodity servers and switches located at the cloud. Meanwhile, software-defined networking (SDN) can be utilized to manage VNFs to handle traffic flows through SFC. One of the most critical issues that needs to be addressed in NFV is VNF placement that optimizes physical link bandwidth consumption. Moreover, deploying SFCs enables service providers to consider different goals, such as minimizing the overall cost and service response time. In this paper, a novel approach for the VNF placement problem for SFCs, called virtual network functions and their replica placement (VNFRP), is introduced. It tries to achieve load balancing over the core links while considering multiple resource constraints. Hence, the VNF placement problem is first formulated as an integer linear programming (ILP) optimization problem, aiming to minimize link bandwidth consumption, energy consumption, and SFC placement cost. Then, a heuristic algorithm is proposed to find a near-optimal solution for this optimization problem. Simulation studies are conducted to evaluate the performance of the proposed approach. The simulation results show that VNFRP can significantly improve load balancing by 80% when the number of replicas is increased. Additionally, VNFRP provides more than a 54% reduction in network energy consumption. Furthermore, it can efficiently reduce the SFC placement cost by more than 67%. Moreover, with the advantages of a fast response time and rapid convergence, VNFRP can be considered as a scalable solution for large networking environments

Maximizing the output power for electric vehicles charging station powered by a wind energy conversion system using tip speed ratio

Abstract This study investigates the influence of tip speed ratio (TSR) as maximum power point tracking (MPPT) technique on energy conversion for wind-powered electric vehicles (EVs) charging stations. The data for 14 different models of (EVs) as well as the energy demand profile for El Sherouk city in new Cairo, Egypt, is used in the study. Those vehicles represent the models that are most likely to be used according to the nature of the Egyptian market from economic and technological concerns. This includes range, battery capacity, battery technology and charging methods. charging can be in the form of fast DC, three phases which are suitable for commercial charging stations or a single phase charging suitable for residential use. A simulation is done using MATLAB/Simulink for a wind turbine Permanent Magnet Synchronous Generator (PMSG) system including TSR MPPT algorithm. The energy output is compared with and without implementing the MPPT algorithms to measure the difference in energy. The system simulation optimized by the TSR MPPT algorithm shows an increase in the energy yield by 41.68%. The economic analysis showed a 30% reduction in the levelized cost of energy while utilizing the TSR concerning a bare system without an MPPT algorithm

Investigating the trade-off between response time and complexity in the Levenberg–Marquardt ANN-MPPT algorithm used in wind energy conversion systems

Abstract The integration of artificial intelligence (AI) models in renewable energy resources management, particularly in the utilization of maximum power point tracking (MPPT) optimizers, has gained significant attention. This study focuses on investigating the tradeoff between accuracy, response time, and system complexity by varying the number of neurons in artificial neural network (ANN) models for MPPT in wind energy conversion systems (WECSs). Traditionally, MPPT algorithms in WECSs are implemented using direct or indirect methods. However, these methods lack an accumulative learning curve and rely on instantaneous inputs. In contrast, ANN models trained on pre-existing datasets offer the potential for improved maximum point capturing processes. Nevertheless, the incorporation of ANN models may introduce additional complexity to the system. Two ANN models, direct and indirect, are examined in comparison to a reference model using the perturb and observe conventional MPPT algorithm. The results show that the ANN direct model exhibits better time response in the face of high variations in wind speed profiles. On the other hand, the ANN indirect model demonstrates a 4% increase in accuracy with minimal ripples