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

Past vegetation changes in the Brazilian Pantanal arboreal-grassy savanna ecotone by using carbon isotopes in the soil organic matter

Measurements of the organic carbon inventory, its stable isotopic composition and radiocarbon content were used to deduce vegetation history from two soil profiles in arboreal and grassy savanna ecotones in the Brazilian Pantanal. The Pantanal is a large floodplain area with grass-dominated lowlands subject to seasonal flooding, and arboreal savanna uplands which are only rarely flooded. Organic carbon inventories were lower in the grassy savanna site than in the upland arboreal savanna site, with carbon decreasing exponentially with depth from the surface in both profiles. Changes in C-13 of soil organic matter (SOM) with depth differed markedly between the two sites. Differences in surface SOM C-13 values reflect the change from C-3 to C-4 plants between the sites, as confirmed by measurements of C-13 Of vegetation and the soil surface along a transect between the upland closed-canopy forest and lowland grassy savanna. Changes of C-13 in SOM with depth at both sites are larger than the 3-4 per mil increases expected from fractionation associated with organic matter decomposition. We interpret these as recording past changes in the relative abundance of C-3 and C-4 plants at these sites. Mass balances with C-14 and C-13 suggest that past vegetational changes from Cg to Cg plants in the grassy savanna, and in the deeper part of the arboreal savanna, occurred between 4600 and 11 400 sp, when major climatic changes were also observed in several places of the South American Continent. The change from C-4 to C-3, observed only in the upper part of the arboreal savanna, was much more recent (1400 sp), and was probably caused by a local change in the flooding regime

Do the seasonal forests in northeastern Brazil represent a single floristic unit?

Floristic analyses (Principal Component Analysis and Analysis of Group Indicators) at the genus level were employed to characterize and compare seasonal forest formations in northeastern Brazil. The presence - absence of 248 genera of woody plants occurring in 24 floristic surveys was correlated with geomorphology and climatic variables. The analyses were consistent and point to the existence of two floristic groups of seasonal forests in the region, one more closely related to the Atlantic Coastal Forest (mata atlântica) and the other to the xerophytic formations (caatinga) of the region. The driest seasonal forest group experiences more than 8 dry months per year and/or a total annual rainfall of <1000 mm, and is found on the ancient eroded peaks in the semi-arid core and on the western slopes of the Borborema Plateau