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

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

Immobilization of glucoamylase on the plain and on the spacer arm-attached poly(HEMA-EGDMA) microspheres

WOS: 000169585100018Immobilization glucoamylase onto plain and a six-carbon spacer arm (i.e., hexamethylene diamine, HMDA) attached poly(2-hydroxyethylmethacrylate-ethylen col dimethacrylate) [poly(HEMA-EGDMA] microspheres was studied. The microspheres were prepared by suspension polymerization and the spacer arm was attached covalently by the reaction of carbonyl groups of poly(HEMA-EGDMA). Glucoamylase was then covalently immobilized either on the plain of microspheres via CNBr activation or on the spacer arm-attached microspheres via CNBr activation and/or using carbodiimide (CDI) as a coupling agent. Incorporation of the spacer arm resulted an increase in the apparent activity of the immobilized enzyme with respect to enzyme immobilized on the plain of the microspheres. The activity yield of the immobilized glucoamylase on the spacer arm-attached poly(HEMA-EGDMA) microspheres was 63% for CDI coupling and 82% for CNBr coupling. This was 44% for the enzyme, which was immobilized on the plain of the unmodified poly(HEMA-EGDMA microspheres via CNBr coupling. The Km values for the immobilized glucoamylase preparations ton the spacer arm-attached microspheres) via CDI coupling 0.9% dextrin (w/v) and CNBr coupling 0.6% dextrin (w/v) were higher than that of the free enzyme 0.2% dextrin (w/v). The temperature profiles were broader for both immobilized preparations than that of the free enzyme. The operational inactivation rate constants (k(iop)) of immobilized enzymes were found to be 1.42 x 10(-5) min(-1) for CNBr coupled and 3.23 x 10(-5) min(-1) for CDI coupled glucoamylase. (C) 2001 John Wiley & Sons, Inc

Material properties of the Menderes Massif marbles from SW Turkey

Marbles are extensively quarried at four different stratigraphical levels from Permo-Carbonifereous to Paleogene in the southern flank of the Menderes Massif in SW Turkey. These marbles differ in color, texture and pattern depending on their stratigraphical levels and are well known in the international trade as the Mugla Black (Permo-Carbonifereous), Mugla White (Cretaceous), Milas Lemon, Lilac, Aubergine, Pearl, Veined and White (Triassic) and Aegean Bordeaux (Paleogene) marbles. The mineralogical, chemical, physical and mechanical properties of the representative marbles samples obtained from the quarries working in four major metamorphic carbonate horizons in the cover successions of the Menderes Massif's southern flank in SW Turkey are determined and the results of over 1700 tests carried out on the selected marble samples are presented. The mean test values of the physical and mechanical tests are in general, found to be above the threshold acceptance values suggested by the American and Turkish Standards for the use of marbles as a building stone and in the same order as the properties of Italian (Carrara) and Greek marbles reported in the literature. Additionally, the mean test values of the marbles have given high correlations with one another and the relations obtained between the index test results determined by simple techniques requiring minimal sample preparation effort and the mean values of the more elaborate engineering tests results are presented as tables and graphs for wider use. (c) 2005 Elsevier B.V. All rights reserved

Age assessment by rib phase analysis in Turks

The Iscan's phase method for the estimation of adult age at death from the sternal extremity of the fourth rib was introduced in 1983. Over the years, numerous tests have confirmed the reliability of this technique on varied samples. However, no large scale study has been conducted to test the application of this method on a modem white sample geographically, genetically, and culturally diverse from the American white database. Therefore, the purpose of this paper is to apply rib phase standards to a Turkish sample to test if the progression of morphological changes follow the same age sequence. Using a sample of 150 males and 144 females of known age at death, each rib was phased using the standards developed by Iscan and associates in 1984 and 1985. The phase estimations were then subject to an analysis of variance. The results of the study indicated that Turkish ribs show the same morphological characteristics that define the phases at nearly identical ages. Variation as measured by the standard deviation increased from phase 5 on in both sexes. In conclusion, this study demonstrated that the rib phase standards can be accurately applied to Turks. Investigations of this nature are vital because one cannot assume that a method developed from one group is applicable to a distant population, especially in medicolegal proceedings. (C) 1998 Elsevier Science Ireland Ltd. All rights reserved

Geological parameters affecting the marble production in the quarries along the southern flank of the Menderes Massif, in SW Turkey

The Mugla province is one of the major marble producing regions located in the southern flank of the Menderes Massif in SW Turkey. The Menderes Massif is a regionally metamorphosed massif with an old Pan-African core and cover successions from the Permo-Carboniferous to Paleocene. There are four major metamorphic carbonate horizons in the cover successions exploited for the marble production. These horizons are located within the Permo-Carboniferous, Triassic, Upper Cretaceous and Paleocene successions along the southern flank of the Menderes Massif Here the world wide known marbles with names such as the Mugla Black, the Milas White, Veined, Pearl, Aubergine, Lilac and Lemony, the Mugla White and the Aegean Bordeaux are found

Nonporous monosize polymeric sorbents: Dye and metal chelate affinity separation of lysozyme

Garipcan, Bora/0000-0002-1773-5607WOS: 000085582800001Lysozyme adsorption onto dye-attached nonporous monosize poly(2-hydroxyethyl-methacrylate-methylmethacrylate) [poly(HEMA-MMA)] microspheres was investigated. Poly(HEMA-MNA) microspheres were prepared by dispersion polymerization. The monochloro-triazine dye, Cibacron Blue F3GA, was immobilized covalently as dye-ligand. These dye-affinity microspheres were used in the lysozyme adsorption-desorption studies. The effect of initial concentration of lysozyme and medium pH on the adsorption efficiency of dye-attached and metal-chelated microspheres were studied in a batch reactor. Effect of Cu(II) chelation on lysozyme adsorption was also studied. The nonspecific adsorption of lysozyme on the poly(HEMA-MMA) microspheres was 3.6 mg/g. Cibacron Blue F3GA attachment significantly increased the lysozyme adsorption up to 247.8 mg/g. Lysozyme adsorption capacity of the Cu(II) incorporated microspheres (318.9 mg/g) was greater than that of the Cibacron Blue F3GA-attached microspheres. Significant amount of the adsorbed lysozyme (up to 97%) was desorbed in 1 h in the desorption medium containing 1.0M NaSCN at pH 8.0 and 25 mM EDTA at pH 4.9. In order to examine the effects of separation conditions on possible conformational changes of lysozyme structure, fluorescence spectrophotometry was employed. We conclude that dye-attached and metal-chelate affinity chromatography with poly(HEMA-MMA) microspheres can be applied for lysozyme separation without causing any significant changes and denaturation. Repeated adsorption/desorption processes showed that these novel dye-attached monosize microspheres are suitable for lysozyme adsorption. (C) 2000 John Wiley & Sons, Inc

Immobilization of glucoamylase onto spacer-arm attached magnetic poly(methylmethacrylate) microspheres: characterization and application to a continuous flow reactor

WOS: 000165463000007Magnetic poly(methylmethacrylate) microspheres (MPMMA) were prepared by the solvent evaporation method and a 6-carbon spacer-arm (i.e. hexamethylene diamine, HMDA) was covalently attached by the reaction of carbonyl groups of poly(methylmethacrylate). Glucoamylase was then covalently immobilized through the spacer-arm of the MPMMA microspheres by using either carbodiimide (CDI) or cyanogen bromide (CNBr) as a coupling agent. The activity yield of the immobilized glucoamylase was 57% for CDI coupling and 73% for CNBr coupling. Kinetic parameters were determined for both immobilized glucoamylase preparations as well as for the free enzyme. The K-m values for immobilized glucoamylases CDI coupling (12.5 g l(-1) dextrin) and CNBr coupling (9.3 g l(-1) dextrin) were higher than that of the free enzyme (2.1 g l(-1) dextrin) whereas V-max values were smaller for the immobilized glucoamylase preparations. The optimum operational temperature was 5 degreesC higher for both immobilized preparations than that of the free enzyme. Operational, thermal and storage stabilities were found to be increased with immobilization. (C) 2000 Elsevier Science B.V. All rights reserved