Giant solitary neurofibroma in the gluteal area of a patient without neurofibromatosis

Neurofibromas are benign tumours arising from neurons and perineural cells. Although they are common in neurofibromatosis, occasionally solitary neurofibromas may occur. A rare case of solitary neurofibroma presenting as a giant gluteal mass in a male patient without a personal or family history of neurofibromatosis is presented. Pre-operative imaging gave useful information about the extent of the mass which was then totally excised with histology revealing a non-plexiform neurofibroma. Distinguishing between isolated neurofibromas and those associated with neurofibromatosis is important because the treatment and prognosis differ greatly with the former having a good prognosis after total excision

Prevalence of cholelithiasis among persons undergoing abdominal ultrasound at the Komfo Anokye Teaching Hospital, Kumasi, Ghana.

Background: The prevalence of gallstones among Ghanaians is unknown. We aimed to determine the prevalence of gallstones among persons undergoing abdominal ultrasound at the Komfo Anokye Teaching Hospital (KATH).Methods: We performed a cross-sectional study of patients aged ≥14years presenting to KATH for abdominal ultrasound between 2009 and 2012. Patient demographics were recorded. The gallbladder was assessed by ultrasonography. Cholelithiasis was defined as presence of gallstones or absence of gallbladder. Data was expressed as descriptive and inferential statistics.Results: There were 2824 participants. 55% were females. Mean age was 47±18 years. Mean body mass index (BMI) was 24.0±5.5. Mean parity among females was 3±3. Prevalence of cholelithiasis was 5.9 (95%C.I:5.0,6.8). Females had a high prevalence compared to males (6.8 vs 4.7). Prevalence increased steadily by age. Prevalence was 6.6, 5.1 and 8.8 for patients with BMI <18.5, 18.5-24.9 and ≥30 respectively. Prevalence among women with parity of 0,1-5 and >5 was 3.1, 6.7 and 6.4 respectively.On multivariate regression analysis, female sex (AOR=1.55;p<0.05), age≥40 years (AOR=2.05;p<0.01), BMI<18.5 (AOR=1.25;p>0.05) or BMI≥30 (AOR=1.39;p>0.05) and family history of gallstones (AOR=11.9;p<0.01) increased the odds of cholelithiasis.Conclusions: Prevalence of cholelithiasis among patients undergoing ultrasonography at KATH was 5.9. Patient age, sex and family history significantly influenced the prevalence.Key words: Cholelithiasis, Prevalence, Kumasi, Ghan

Intestinal obstruction in older children in Komfo Anokye Teaching Hospital: A tertiary referral centre in Kumasi, Ghana

Background Childhood intestinal obstruction can either be congenital or acquired and both types result in high morbidity and mortality in  developing countries, mainly as a result of late presentation and diagnosis.Patients and methods From January 2007 to December2010, a retrospective analysis of all older children with  intestinal obstruction admitted to Komfo Anokye Teaching Hospital (Kumasi, Ghana) was carried out. This was to establish the causes of intestinal obstruction and to determine its morbidity and mortality among the children studied.Results There were 98 children who were treated with a diagnosis of intestinal obstruction during the period. The mean age of the children, in months, was 34.7 ±5.0 SEM (range 3–180, median age 10 months), with a male : female ratio of 1.5 : 1. About 70.6% of the children were  admitted with acquired causes of intestinal obstruction and 29.4% with congenital causes of intestinal obstruction. In all, 21.2% of the children, treated for intestinal obstruction, underwent bowel resection as a result of nonviability of a segment of the intestine; the majority of the bowel resections were performed in the intussusception group. The mean length of hospital stay, in days, was 8.2± 5.7. There were 15 children (15.3%) with various postoperative complications, mainly surgical site infections; the mortality rate was 11.2%. Here again, most of the deaths occurred in the intussusception group of children.Conclusion Intestinal obstruction is a serious emergencyin children and must be diagnosed early and treated  promptly to avoid high morbidity and unnecessary deaths among children in our subregion

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

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

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

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