Responding to Emerging Diseases Requires Multi-disciplinary and One Health Training, Egypt

Background: In Egypt, several infectious diseases of zoonotic origin have emerged in recent years like H1N1, MERSCoV and H5N1, the latter now endemic. Responding to these diseases requires a workforce trained in multi-disciplinary approaches to zoonotic disease research and control. It is difficult to deliver multidisciplinary and one health training globally because of the limited number of higher education programs that support such training. In low and middle-income countries where the impacts of emerging zoonotic diseases are felt more directly there is enthusiasm for such training and the use of e-technology can foster international, long-term collaborations. Objectives: To provide health training for infectious diseases research and to foster multidisciplinary collaboration. Methods: We designed and simultaneously held two training workshops, one focused on pediatric infectious diseases and another on emerging infectious diseases to meet the objective. Both workshops had pre- and post-workshop activities for multi-disciplinary methods with an emphasis on the use of mobile technologies to enhance emerging infectious diseases surveillance and research for public health professionals in Egypt. Faculty and scientists from all universities in Egypt and from the National Research Center were invited to participate. Results: 85 participants attended, 31 abstracts were submitted, and over a 3 year period 3 international grant applications were submitted, and 4 abstracts were presented at international conferences. An online forum was developed to continue building collaboration. Conclusions: Interactive on-site workshops are suitable for providing multi-disciplinary training for disease surveillance, research and disease control. Participants shared the opinion that grant proposal and scientific manuscript writing were important skills that they felt they did not have. Long term investments in workshops of this nature are needed to build upon the excitement generated by these activities

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

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

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)

Efficacy of fluoride varnish containing xylitol coated calcium phosphate or potassium nitrate gel versus conventional fluoride varnish in management of hypersensitivity of exposed root surfaces in adult patients: A randomized clinical trial

Objective: This clinical trial was conducted to compare the efficacy of fluoride varnish containing xylitol coated calcium and phosphate or potassium nitrate gel versus conventional fluoride varnish in the management of hypersensitivity of non-carious exposed root surfaces in adult patients. Material and Methods: 35 patients having 105 hypersensitive teeth were randomly allocated to be treated either using Embrace varnish (PULPDENT Corporation, Watertown, MA, USA) or UltraEz gel (Ultradent Products Inc. South Jordan, UT, USA) or Fluoride varnish FluoroDose (Centrix Inc., Milford, Connecticut, USA), all agents were used according to the manufacturers’ instructions. Hypersensitivity scores were assessed using the visual analogue scale (VAS), after applying different stimuli. The assessment was done at baseline, after 4 hours of application, after two days, then after 4, 8 and 12 months. Results: UltraEZ gel showed the best immediate relief with a significant difference from other treatment methods, fluoride varnish showed the best relief at both short and long term follow up periods. Embrace varnish showed the least success in reducing hypersensitivity.&nbsp; Conclusions: Fluoride varnish showed the best reduction in hypersensitivity values while UltraEZ showed the best immediate relief and Embrace varnish showed the least efficacy &nbsp

In vitro assessment of the antimicrobial activity of silver and zinc oxide nanoparticles against fish pathogens

Abstract Background Antibiotic resistance is a global issue that threatens public health. The excessive use of antibiotics contributes to this problem as the genes of antibiotic resistance can be transferred between the bacteria in humans, animals and aquatic organisms. Metallic nanoparticles could serve as future substitutes for some conventional antibiotics because of their antimicrobial activity. The aim of this study was to evaluate the antimicrobial effects of silver and zinc oxide nanoparticles against major fish pathogens and assess their safety in vitro. Silver nanoparticles were synthesized by chemical reduction and characterized with UV–Vis spectroscopy, transmission electron microscopy and zeta sizer. The concentrations of silver and zinc oxide nanoparticles were measured using inductively coupled plasma-mass spectrometry. Subsequently, silver and zinc oxide nanoparticles were tested for their antimicrobial activity against Aeromonas hydrophila, Aeromonas salmonicida subsp. salmonicida, Edwardsiella ictaluri, Edwardsiella tarda, Francisella noatunensis subsp. orientalis, Yersinia ruckeri and Aphanomyces invadans and the minimum inhibitory concentrations were determined. MTT assay was performed on eel kidney cell line (EK-1) to determine the cell viability after incubation with nanoparticles. The interaction between silver nanoparticles and A. salmonicida was investigated by transmission electron microscopy. Results The tested nanoparticles exhibited marked antimicrobial activity. Silver nanoparticles inhibited the growth of both A. salmonicida and A. invadans at a concentration of 17 µg/mL. Zinc oxide nanoparticles inhibited the growth of A. salmonicida, Y. ruckeri and A. invadans at concentrations of 15.75, 31.5 and 3.15 µg/mL respectively. Silver nanoparticles showed higher cell viability when compared to zinc oxide nanoparticles in the MTT assay. Transmission electron microscopy showed the attachment of silver nanoparticles to the bacterial membrane and disruption of its integrity. Conclusions This is the first study on inhibitory effects of silver and zinc oxide nanoparticles towards A. salmonicida and A. invadans. Moreover, zinc oxide nanoparticles inhibited the growth of Y. ruckeri. In low concentrations, silver nanoparticles were less cytotoxic than zinc oxide nanoparticles and represent an alternative antimicrobial compound against A. hydrophila, A. salmonicida and A. invadans

Silver and gold nanoparticles as a novel approach to fight Sarcoptic mange in rabbits

Abstract Various kinds of pets have been known to contract the ectoparasite Sarcoptes scabiei. Current acaricides are becoming less effective because of the resistance developed by the mite besides their adverse effects on the general activity and reproductive performance of domestic pets. For this reason, the present study aims to discover a novel and safe approach using silver and gold nanoparticles to fight Sarcoptic mange in rabbits as well as to explain their mechanism of action. 15 pet rabbits with clinical signs of Sarcoptic mange that were confirmed by the microscopic examination were used in our study. All rabbits used in this study were assessed positive for the presence of different developing stages of S. scabiei. Three groups of rabbits (n = 5) were used as follows: group (1) didn’t receive any treatment, and group (2 and 3) was treated with either AgNPs or GNPs, respectively. Both nanoparticles were applied daily on the affected skin areas via a dressing and injected subcutaneously once a week for 2 weeks at a dose of 0.5 mg/kg bwt. Our results revealed that all rabbits were severely infested and took a mean score = 3. The skin lesions in rabbits that didn’t receive any treatments progressed extensively and took a mean score = of 4. On the other hand, all nanoparticle-treated groups displayed marked improvement in the skin lesion and took an average score of 0–1. All NPs treated groups showed remarkable improvement in the microscopic pictures along with mild iNOS, TNF-α, and Cox-2 expression. Both nanoparticles could downregulate the m-RNA levels of IL-6 and IFγ and upregulate IL-10 and TGF-1β genes to promote skin healing. Dressing rabbits with both NPs didn’t affect either liver and kidney biomarkers or serum Ig levels indicating their safety. Our residual analysis detected AgNPs in the liver of rabbits but did not detect any residues of GNPs in such organs. We recommend using GNPs as an alternative acaricide to fight rabbit mange

الممارسات القياسية والمبادئ التوجيهية في علم الحشرات الجنائي

زادت أهمية علم الحشرات الجنائي واستعمال الحشرات وغيرها من المفصليات في تحقيقات الطب الشرعي، ولضمان الاستعمال الأمثل من قبل المحققين الجنائيين، كان من الضروري وجود إطار عام من الممارسات القياسية والمبادئ التوجيهية التي يمكن الدفاع عنها في المحكمة؛ لذلك وضعت المجموعة العلمية العربية لعلم الحشرات الجنائي وثيقة (بروتوكول) لأفضل الممارسات في علم الحشرات الجنائي، والتي تشمل تعريفات المصطلحات الرئيسية ووصفاً تفصيلياً للطرق والأدوات المستخدمة لجمع الأدلة الحشرية. جنباً إلى جنب مع مقدمة قصيرة عن أهم الطرق لتقدير الحد الأدنى للوقت بعد الوفاة، وتحليل البيانات الحشرية، ووصف لنماذج تعاقب الحشرات على الجثث، وبيانات الطقس والأحوال الجوية في موقع الجريمة، وطرق تربية الحشرات فى المختبر، وتعريف بأهم النماذج الحيوانية فى التجارب، وطرق التعريف المورفولوجي والجزيئي لحشرات الجثث، وعلم تحليل السموم في الحشرات، وسجلات وتقارير القضايا باستعمال حشرات الجثث، وصفات عالِم الحشرات الجنائي، وكذلك معايير ضمان الجودة والاعتماد للممارسات القياسية. وتهدف هذه المقالة بشكل عام إلى الوصول إلى مستوى عالٍ من الكفاءة في مجال علم الحشرات الجنائي