Large Thrombus on a Prosthetic Mitral Valve During Early Pregnancy

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Maternal satisfaction with delivery services at tertiary university hospital in upper Egypt, is it actually satisfying?

Background: Maternal health has therefore become an important aspect of policy and planning for healthcare, as reflected by its inclusion as the fifth Millennium Development Goal (MDG). The objective of the present investigation was to determine the maternal satisfaction towards delivery services at Women's Health Hospital, Assiut University, Upper EgyptMethods: A cross sectional study was performed. The study was conducted during February- April 2016 on a sample of 400 delivering mothers; the data were collected using a semi-structured questionnaire and analyzed by SPSS version21. Statistical tests were used, and significance level was taken at p-value <0.05.Results: A total of 400 delivering mothers were interviewed, of which 67.0 % of the respondents were between the age group of 20-30, 76.75 % were from rural areas, 48.0%were illiterate, 86.75% were house wives and 46.0% belonged to the income group of less than 500 EGP. The findings of the study showed that the overall maternal satisfaction level with the delivery services rendered at the hospital was 78.5%, while 21.5% were dissatisfied. Furthermore, satisfaction with the delivery service was found to have a significant association with the age of the respondents and educational level of the respondents. Moreover, results suggest that women are satisfied with the communication factors, interpersonal behavior, good management, and general satisfaction. Women were least satisfied with privacy sensation during hospital stay and obligatory blood donation.Conclusions: Although most participants were satisfied by the delivery service provided to them during delivery, Dissatisfaction by a minority group resulted in a limited ability of communication with mothers, lack of privacy sensation during hospital stay and obligatory blood donation. Thus, mechanisms should be developed to increase maternal satisfaction in our hospital

Three-Dimensional Power Doppler Evaluation of Adnexal Masses. Which Parameter Performs Best?

Objective:To evaluate the role of 3D power Doppler in assessment of adnexal masses vascularity, its ability to discriminate benign from malignant adnexal masses. Then, to determine which one of the 3D power Doppler parameters has the highest reliability for detection of adnexal malignancy.Materials and Methods:A cross sectional prospective study was conducted on patients scheduled for surgery due to presence of adnexal masses at Woman’s Health Center, Assiut University, Egypt between October 2012 and October 2013. All patients were evaluated by 3-DPD ultrasound for assessement of tumor vascularization with calculation of vascular indices using Virtual organ computer-aided analysis program. A definitive histopathological diagnosis was obtained in every case to be used as a gold standard.Results:One hundred sixty-one patients were recruited, 115 with benign masses, 46 with malignant masses. The mean vascularization index (16.36 versus 10.98; p<0.05), and the mean vascularization-flow index (3.91 versus 2.13; p<0.01) were significantly higher in malignant tumors. No significant difference was found in the mean flow index. Chaotic architecture of vessels was significantly associated with malignancy (80.4% versus 6.1%; p<0.001) than benign possibility of masses. Also, complex branching pattern of vessels was more significantly present in malignant masses than benign ones (47.8% versus 4.3%; p<0.001). 3D power Doppler had a sensitivity of 80%, specificity of 94%, PPV of 84% and NPV of 92% in detection of malignant adnexal masses.Conclusion:Careful evaluation of the architectiure of vessels was the best parameter in evaluation of the masses with 3D power Doppler. Evaluation of branching pattern had a low sensitivity and specificity in detection of malignancy. In spite of no clear cut-off values for vascular indices to be accurate in differentiation of adnexal masses, higher values of vascularization index and vascularization-flow index were strongly associated with adnexal malignancy

Evaluation of adnexal masses by Three-Dimensional ultrasound multi-slice view: Do we really need it?

Objective:The purpose of this study is to evaluate the benefit of use of three-dimensional ultrasound multi-slice view in detailed assessment of adnexal masses morphology. Methods:Two-hundred thirty one patients with adnexal masses elected for surgery at Woman’s Health Center, Assiut, Egypt between October 2012 and October 2013 were recruited for the study. Each patient had 2D ultrasound and detailed morphological evaluation was reported. Then, 3D ultrasound volumes were obtained. The stored 3D volumes were then digitally analyzed using 3D ultrasound multi-slice view. The results of 2D, 3D ultrasound multi-slice were compared to the postoperative histopathological findings.Results:The mean age of included patients was 30.2 ± 12.7 years. Overall, 189 patients (81.8%) confirmed to have benign masses, and 42 patients (18.2%) with malignant masses according to their final histopathological analysis. Subjective assessment by 2D ultrasound correctly classified 95.6% of benign masses and 87% of malignant masses. On detailed assessment of the masses by 3D ultrasound multi-slice view, there was agreement in morphological assessment of all masses except in 3 cases in which 3D ultrasound multi-slice view permitted better description of their morphological criteria and hence changing the presumed diagnosis and management.Conclusions: The ability of detailed analysis of the volumes taken during 3D ultrasound using multi-slice view can aid in better morphological assessment of adnexal masses especially in detection of papillary projections in adnexal cysts. This information is valuable in deciding the optimal management of adnexal masses in some cases

Placental pouch closure: a novel, safe and effective surgical procedure for conservative management of placenta accreta

Background: Placenta accreta spectrum (PAS) has become a global problem secondary to the high rate of cesarean delivery (CD). The current study presents an effective surgical procedure (placental pouch closure) for uterine preservation in patients with PAS. Methods: We applied this procedure in sixty cases at a tertiary university hospital between September 2017 and January 2019. We included women who were diagnosed as PAS based on preoperative ultrasound and Doppler evaluation, and who had the desire for uterine preservation. Results: The procedure was successful in almost all cases; the uterus was conserved 98.33 % of participants, with no associated severe maternal morbidities or mortality. In all cases, no additional surgical procedures were needed. The mean blood loss was 1263 ml, and the mean number of units of blood required for transfusion was 2.31 units. Conclusion: Identifying and meticulously closing the placental pouch is a novel surgical procedure for conservative management of PAS. In well-selected cases with the availability of facilities and expertise, the technique could have a place as a safe and effective surgical technique in women presenting with placenta accreta who desire uterine preservation. Trial registration number: NCT03241849. Registered on August 8, 201

A critique of the WHO TobReg's "Advisory Note" report entitled: "Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators"

BACKGROUND AND AIM: The World Health Organisation Study Group on Tobacco Product Regulation (TobReg) has issued in 2005 an "Advisory Note" entitled: "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators". "Waterpipe" smoking is now considered a global public health threat and the corresponding artefact is actually known in the world under three main terms: hookah, narghile and shisha. This important report, the first ever prepared by WHO on the subject, poses two major problems. On one hand, its bibliographical references dismiss world chief relevant studies. On the other, it contains a certain number of errors of many orders: biomedical, sociological, anthropological and historical. The purpose of the present study is to highlight, one by one, where these weaknesses and errors lie and show how this official report can be considerably improved. RESULTS: We realise that widely advertised early anthropological studies were not taken into consideration whereas they shed a substantial light on this peculiar form of smoking and help understanding its high complexity. As for concrete errors to be found in this report, they deal with the chemistry of smoke, health-related effects, smoking patterns, description and history of the artefact and its use, gender and underage use aspects, prevention and research needs in this field. CONCLUSION: The scientific credibility of an international expert report may be at stake if its recommendations do not rely on sound objective research findings and a comprehensive review of the existing literature. The critical comments in this study will certainly help improve the present WHO report

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

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

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&lt;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&lt;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