Advancements in tetronic acid chemistry. Part 1: Synthesis and reactions

AbstractThe preparation and the properties of the elusive tetronic acid are reviewed, including its synthesis, chemical reactivity and reactions

Ligation of Intersphincteric Fistulous Tract versus Fistulotomy in Low Trans-Sphincteric Perianal Fistula

Background: Anal fistula, which causes periodic swelling and pain in the perianal area followed by spontaneous leakage, is an abnormal connection between the anal canal and the perianal skin. The majority are connected to the development of abscesses, with a perianal fistula existing at the time of presentation in one-third of patients with an anorectal abscess. Objectives: to determine the safety and efficacy of the Ligation of Intersphicteric Fistulous Tract operation (LIFT) in comparison with fistulotomy. Patients and methods: On 60 patients with low trans-sphincteric perianal fistulas, this prospective, randomized comparative research was done at the General Surgery Department of Qena Faculty of Medicine. Patients were split into two groups: Group (A): 30 patients underwent LIFT techniques. Group (B): 30 patients underwent fistulotomy. The duration of the study ranged between 6-12 months, Results: Body Mass Index (BMI) was statistically substantial greater in patients treated by LIFT than those treated by fistulotomy. While pain score and healing time were statistically substantial lower in patients treated by LIFT than those treated by fistulotomy. There is no statistically substantial variation between patients treated by fistulotomy and LIFT as regard the development of complications as recurrence or incontinence. Conclusion: In comparison to open fistulotomy, the LIFT operation is a successful and preferred sphincter-saving method for fistula-in-ano, with a quicker healing period and a decreased frequency of postoperative anal leakage

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

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

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

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

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

GSTM1, GSTT1 and EPHX1 gene polymorphisms and susceptibility to COPD in a sample of Egyptian population

Background: Gene polymorphisms and COPD susceptibility have been paid special attention and were explored in a large number of studies. The results varied between studies and populations. We aimed to analyze the relation between susceptibility to COPD and polymorphisms of Glutathione S-transferases (GST); GSTM1, GSTT1 and Microsomal epoxide hydrolase-1 (EPHX1) genes in a sample of Egyptian population. Methods: Genetic polymorphisms of GSTM1, GSTT1 and EPHX1 genes in 146 COPD patients and 130 controls were investigated using multiplex PCR for GSTM1 and GSTT1 genes and PCR-RFLP for EPHX1 genes. Results: The frequency of GSTM1-null genotype was higher in patients than in controls (72.6% versus 43.8%, P < 0.001). Carriers with both null GSTT1 and GSTM1 genes were at a higher risk of COPD (OR 3.45, 95% CI = 1.07–11.14). The frequency of EPHX1 exon 3 His allele was higher in patients than controls (19.2% versus 12.7%, P = 0.04). Carriers with exon 3 His allele were at a higher risk of COPD (OR 1.63, 95% CI = 1.02–2.6, P = 0.04). Carriers with both GSTM1-null and EPHX1 113Tyr/Tyr or EPHX1 113Tyr/His genotypes were at a higher risk of COPD (OR 3.33, 95% CI = 1.32–8.35 and OR 14.24, 95% CI = 3.02–67.17 respectively). Carriers with both GSTM1-null and EPHX1 139His/His genotypes were at a higher risk of COPD (OR 5.58, 95% CI = 2.14–14.52). Conclusions: EPHX1 exon 3 His allele in addition to the coexistence of other genetic variants, were significant risk factors in susceptibility to COPD in the Egyptian population

Bioremediation of a pesticide and selected heavy metals in wastewater from various sources using a consortium of microalgae and cyanobacteria

The presence of organophosphate pesticides and heavy metals in water are known to be toxic to aquatic organisms. Bioremediation makes use of naturally-occurring organisms to remove pollutants from the environment. This study explored the potential of using a consortium of microalgae and cyanobacteria (Chlorella vulgaris, Scenedesmus quadricuda and Spirulina platensis) to remove the organophosphate pesticide malathion and the heavy metals cadmium, nickel and lead from water samples taken from varying combinations of urban wastewater and agricultural drainage water in Egypt. The fastest algal growth observed in this study was in a treatment containing the microorganismal consortium, malathion and heavy metals cultured in water samples taken from agriculture drainage and urban wastewater. Microalgae in this study were able to remove malathion from samples of wastewater with up to 99% efficacy and were able to bioaccumulate nickel at up to 95% efficacy. Moreover, microalgae demonstrated the ability to uptake lead and cadmium at up to 89% and 88% efficacy respectively. The results from this study suggest that a consortium of Chlorella vulgaris, Scenedesmus quadricuda and Spirulina platensis can be effective in remediating the pesticide malathion and the heavy metals cadmium, lead and nickel from wastewater