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

Membrane protein extraction and purification using partially-esterified SMA polymers

Styrene maleic acid (SMA) polymers have proven to be very successful for the extraction of membrane proteins, forming SMA lipid particles (SMALPs), which maintain a lipid bilayer around the membrane protein. SMALP-encapsulated membrane proteins can be used for functional and structural studies. The SMALP approach allows retention of important protein-annular lipid interactions, exerts lateral pressure, and offers greater stability than traditional detergent solubilisation. However, SMA polymer does have some limitations, including a sensitivity to divalent cations and low pH, an absorbance spectrum that overlaps with many proteins, and possible restrictions on protein conformational change. Various modified polymers have been developed to try to overcome these challenges, but no clear solution has been found. A series of partially-esterified variants of SMA (SMA 2625, SMA 1440 and SMA 17352) has previously been shown to be highly effective for solubilisation of plant and cyanobacterial thylakoid membranes. It was hypothesised that the partial esterification of maleic acid groups would increase tolerance to divalent cations. Therefore, these partially-esterified polymers were tested for the solubilisation of lipids and membrane proteins, and their tolerance to magnesium ions. It was found that all partially esterified polymers were capable of solubilising and purifying a range of membrane proteins, but the yield of protein was lower with SMA 1440, and the degree of purity was lower for both SMA1440 and SMA17352. SMA2625 performed comparably to SMA 2000. SMA 1440 also showed an increased sensitivity to divalent cations. Thus, it appears the interactions between SMA and divalent cations are more complex than proposed and require further investigation

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

Background Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications. Methods We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC). Findings In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683–0·717]). Interpretation In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required. Funding British Journal of Surgery Society

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Feasibility and Efficacy of Text-Messaging to Promote Care Among Trauma Patients Screened for HIV at an Urban Tertiary Emergency Department in Tanzania

Abstract BackgroundDue the high prevalence of Human Immune Virus (HIV), provider-initiated HIV testing for patients attending any health care setting is recommended. However, follow-up and linkage to care by those tested remains poor. We determined the feasibility and efficacy of text-messaging to promote follow-up among otherwise healthy trauma patients who underwent provider-initiated HIV testing and counseling at an Emergency Department (ED) in Tanzania. Material and methodsThis randomized controlled trial was conducted at Muhimbili National Hospital (MNH) ED between September 2019 to February 2020. Adult trauma patients consenting to HIV testing and follow-up text messaging were randomized to standard care (pre and post-test counseling) or standard care plus a series of 3 text-message reminders for follow-up in an HIV clinic, if positive, or retesting, if negative. Investigators blinded to study assignment called participants 2-months after the ED visit if HIV positive, or 4 months if HIV negative. We compared the proportion of people in the intervention and control groups completing recommended follow- up. Secondary outcomes were proportion accepting testing, agreeing to receive SMS and follow-up compliance by HIV status. ResultsOf 290 patients approached, 255 (87.9%) opted-in for testing and consented to the study. The median age of the study population was 29 [IQR 24-40] years. 127 (49.8%) were randomized to the intervention group and 128 (50.2%) to the control group. The short message service (SMS) system verified that 381 text messages in total were received. We traced 242 (94.9%) participants: 124 (51.2%) from intervention group and 118 (48.8%) controls. 100 (39.2%) subjects reported attending a follow-up visit, of which 77 (60.6%) were from the intervention group and 23 (17.9%) were controls. (RR = 3.4, 95%CI (2.3-5.0) resulting in number needed to treat (NNT) of 2.3. Of 246 HIV negative participants, 37% went for repeat-screening: 59% of those in the intervention group and 16% in the control group (RR= 3.7, P =&lt;0.0001, NNT 2.3). Among 9 positive patients, all 5 in the intervention group and 3 of 4 controls had follow-up visits. ConclusionAutomated text message is a feasible and effective way to increase follow up in HIV tested individuals in a limited income country.</jats:p

Comparing the surgical management of acute paediatric scrotal pain between adult urologists and general surgeons in the UK: an observational study.

INTRODUCTION Acute scrotal pain is a common paediatric surgical emergency. Assessment and timely exploration are required to rule out testicular torsion (TT) and prevent unnecessary morbidity. METHODS A retrospective observational cohort study was carried out at two district general hospitals in the UK for boys aged ≤16 years presenting with acute scrotal pain between January 2014 and October 2017 managed by adult general surgery (AGS) at one hospital and adult urology (AU) at the other. RESULTS Some 565 patients were eligible for inclusion (=364 AGS, =201 AU). A higher proportion of patients underwent surgical exploration at AGS compared with AU (277/346 (80.1%) vs 96/201 (47.8%); <0.001). Of those who underwent exploration, 101/373 (27.1%) had TT, of whom 25/101 (24.8%) underwent orchidectomy and 125/373 (33.5%) had torted testicular appendage. There was no statistically significant difference in rates of orchidectomy between AGS (19/68, 27.9%) and AU (6/33, 18.2%) with testicular salvage rates of 72.1% and 81.8%, respectively (=0.334). Patients were twice as likely to be readmitted at AGS as at AU (28/346 (8.1%) vs 8/201 (4.0%); =0.073). CONCLUSION Although intraoperative findings were similar between adult general surgeons and urologists, there were significant differences in surgical management, with a higher rate of surgical exploration by general surgeons. Testicular salvage and 30-day postoperative morbidity rates at both institutions were acceptable but the readmission rate was high at 6.6%. It is not known why there is a heterogeneity in management of acute scrotal pain between specialist centres, and further prospective investigations are warranted

Out-of-pocket cost for medical care of injured patients presenting to emergency department of national hospital in Tanzania: a prospective cohort study

ObjectiveWe aimed to determine the out-of-pocket (OOP) costs for medical care of injured patients and the proportion of patients encountering catastrophic costs.DesignProspective cohort studySettingEmergency department (ED) of a tertiary-level hospital in Dar es Salaam, Tanzania.ParticipantsInjured adult patients seen at the ED of Muhimbili National Hospital from August 2019 to March 2020.MethodsDuring alternating 12-hour shifts, consecutive trauma patients were approached in the ED after stabilisation. A case report form was used to collect social-demographics and patient clinical profile. Total charges billed for ED and in-hospital care and OOP payments were obtained from the hospital billing system. Patients were interviewed by phone to determine the measures they took to pay their bills.Primary outcome measureThe primary outcome was the proportion of patients with catastrophic health expenditure (CHE), using the WHO definition of OOP expenditures ≥40% of monthly income.ResultsWe enrolled 355 trauma patients of whom 51 (14.4%) were insured. The median age was 32 years (IQR 25–40), 238 (83.2%) were male, 162 (56.6%) were married and 87.8% had ≥2 household dependents. The majority 224 (78.3%) had informal employment with a median monthly income of US$86. Overall, 286 (80.6$176.98 (IQR 62.33–311.97). Chest injury and spinal injury incurred the highest OOP payments of US$282.63 (84.71–369.33) and 277.71 (191.02–874.47), respectively. Overall, 85.3% had a CHE. 203 patients (70.9%) were interviewed after discharge. In this group, 13.8% borrowed money from family, and 12.3% sold personal items of value to pay for their hospital bills.ConclusionOOP costs place a significant economic burden on individuals and families. Measures to reduce injury and financial risk are needed in Tanzania.</jats:sec