Women’s Awareness and Attitude toward Epidural Analgesia

Introduction: Women’s awareness and attitudes toward Epidural Analgesia (EA) are not clearly identified.  The benefits of EA in relieving labor pain are well recognized.  However, women’s preferences in using EA to relieve labor pain differ between cultures. The objective of this study was to assess women’s awareness and attitudes toward EA. Methods: A descriptive correlational cross-sectional design was used to collect data from a convenience sample of 550 women in childbearing age.   Women were interviewed face-to-face after they agreed to participate in the study.  Data were collected from shopping malls, women’s cafeterias, beauty salons and outpatient clinics in Riyadh, KSA. Demographic profiles, knowledge and attitudes of EA questionnaires were used to collect data for the study. Results:  The majority of women were young, married, multigravids, lived in Riyadh, were well educated, unemployed, and had a significant monthly income.  Women reported a good level of knowledge regarding most of the items on the EA questionnaire.  42% reported that they know about EA from family members/relatives and friends, 18% from the media or readings, 13% from previous delivery experience and 8% from brochures at antenatal clinics.  Women’s attitudes toward using EA in future labor were varied since similar percentages agreed, did not agree and weren’t sure about using EA in their future labor.  The reasons for the unclear attitudes were advice from relatives not to use EA, and a desire to experience natural labor pain.  There was a significance moderate correlation between knowledge and parity (r = .40**, p = .000), income (r = .39**, p = .001), education (r = .31**, p = .000), and attitude (r = .31**, .000). Conclusion and recommendations: Although women’s awareness regarding EA was relatively high, their attitude toward using EA in future labor was not clear.  Culturally sensitive educational programs are needed to improve women’s perception and attitude toward using EA in their future labor and to have a satisfactory labor. Keywords: Awareness, attitude, epidural, labor pain, wome

Evaluación de la prescripción y uso de medicamentos supresores de ácido en hospitales centrales en la región de Abha, Arabia Saudita

Objective: The aim of this study was to study and assess the indications of acid suppressive drugs and to find out percentage of irrational prescriptions with acid suppressive drugs. Material/Methods: It is a prospective observational study conducted in the Armed Forces Hospitals Southern Region and Abha Maternity Hospital, both in Abha in Assir region (Saudi Arabia). The sample size of study was 185 patients. The case sheets of the patients’ prescription order were reviewed for acid suppressive drugs prescription and relevant data was taken. Patients’ age above 18 were identified. The duration of study was 8 weeks, between May and June 2017. Results: Our results showed that the majority of the prescriptions of proton pump inhibitors (68.1%) were unjustifiable and that proton pump inhibitor was the most commonly prescribed acid suppressive drugs for the patients (97.8%). The frequency of prescribing for the autism spectrum disorders in our study was found to be higher in patients with an existing risk factor and was mostly recommended by physicians as concomitant medications (67.6%). The most common concomitant medications used with the proton pump inhibitors were non-steroidal anti-inflammatory drugs (29.2%) in which aspirin composed 13.5% of the non-steroidal anti-inflammatory drugs prescribed followed by antimicrobials (9.2%). Conclusion: Acid suppressive drugs are the most commonly prescribed drugs with no proper indications hence irrational. Based on the results of this study, creating awareness about reasonable use of acid suppressive drugs is a necessity.Objetivo: El objetivo de este estudio fue estudiar y evaluar las indicaciones de los medicamentos supresores de ácidos y averiguar el porcentaje de recetas irracionales con medicamentos supresores de ácidos. Material / Métodos: es un estudio observacional prospectivo realizado en los Hospitales de las Fuerzas Armadas del Sur y en el Hospital de Maternidad Abha, ambos en Abha en la región de Assir (Arabia Saudita). El tamaño muestral del estudio fue de 185 pacientes. Se revisaron las hojas de casos de orden de prescripción de los pacientes para la prescripción de medicamentos supresores de ácido y se tomaron los datos pertinentes. Se identificó la edad de los pacientes mayores de 18 años. La duración del estudio fue de 8 semanas, entre mayo y junio de 2017. Resultados: nuestros resultados mostraron que la mayoría de las prescripciones de inhibidores de la bomba de protones (68,1%) eran injustificables y que este era el fármaco supresor de ácido más comúnmente prescrito para los pacientes (97,8%). La frecuencia de prescripción para los trastornos del espectro autistas en nuestro estudio, fue mayor en pacientes con un factor de riesgo existente y fue recomendada principalmente por los médicos como medicamentos concomitantes (67,6%). Los medicamentos concomitantes más comunes que se usaron con los inhibidores de la bomba de protones fueron los antiinflamatorios no esteroideos (29.2%) en los cuales la aspirina supuso el 13,5% de los antiinflamatorios no esteroideos prescritos, seguidos por los antimicrobianos (9.2%) Conclusión: los medicamentos supresores de ácido son los medicamentos más comúnmente recetados sin indicaciones adecuadas, por lo que son irracionales. Basado en los resultados de este estudio, crear conciencia sobre el uso razonable de los medicamentos supresores del ácido es una necesidad

Social and Economic Factors that Influence Health Outcomes in Family Medicine

Over the last twenty years, the social determinants of health (SDOH) have gained more and more attention in the public health community. SDOH are non-medical elements that may be significantly impacted by social policies and have an impact on health. The increasing variety that exists within our societies makes it absolutely necessary for us to incorporate into undergraduate medical education social determinants of health such as racial factors, financial instability, partner violence, insufficient accessibility to transportation, and inadequate social supports, as well as the crucial role of health education.  Nonetheless, a growing body of research indicates that a variety of health outcomes are fundamentally caused by socioeconomic variables including wealth, income, and education together. In this review we highlight the influence of socio-economic factors on health outcomes, approaches to incorporate social determinants of health in family medicine practice, and we also talk about challenges and solutions in addressing social determinants in family medicine. The objective of this research was to assess the impact of social determinants of health on family medicine practice in which socioeconomic determinants of health might have an effect on health outcomes and healthcare delivery within the context of a family medicine clinical environment

Impact Of Bariatric Surgery on Gastroesophageal Reflux Disease: A Cross-Sectional Study

Objective: To assess the occurrence of GERD after bariatric surgery and surgery impact on GERD. Methods: This research employs a cross-sectional study design to investigate the impact of bariatric surgery on Gastroesophageal Reflux Disease (GERD) among individuals who have undergone various types of bariatric surgeries. Results: The study included 302 participants. The most frequent weight among them was more than 96 kg (n= 130, 43%) followed by 76-85 kg (n= 51, 16.9%). The most frequent height among study participants was 1.61-1.70 m (n= 100, 33.1%) followed by 1.51-1.60 m (n= 99, 32.8%). The most frequent body mass index (BMI) value among study participants was more than 35 kg/m2 (n= 126, 41.7%) followed by 25-29.9 kg/m2 (n= 67, 22.2%). The most frequent age among study participants was 26-36 years (n= 104, 34.4%) followed by 15-25 years (n= 83, 27.5%). The most frequent gender among study participants was Female (n= 162, 53.6%) followed by Male (n= 140, 46.4%). Participants were asked about the type of obesity surgery. The most frequent was Gastric sleeve (n=222, 73.5%), followed by Gastric bypass (n=33, 10.9%).   Conclusion: Study results showed that most of the study participants are extremely obese according to their BMI. The most common obesity surgery type was a Gastric sleeve followed by a Gastric bypass. The most of participants were a non-smoker. Most of them had weight loss. In addition, most of the study participants had good social connection

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

Comparison of total endoscopic thyroidectomy with conventional open thyroidectomy for treatment of papillary thyroid cancer

BackgroundRecent advance of endoscopic techniques has allowed surgeons to perform thyroidectomy via an incision placement at hidden places which lead to better cosmetic acceptability compared with conventional open thyroidectomy.AimsThis study was conducted to summarize the current evidence that compare open thyroidectomy with endoscopic ‎thyroidectomy in treatment of papillary thyroid cancer‎.‎Methods An electronic literature review, including PubMed, Google Scholar, and EBSCO that examining randomized trials of endoscopic thyroidectomy (ET), conventional open thyroidectomy (COT), and management of papillary thyroid carcinoma was carried out.Results The review included 8 randomized studies that compare total endoscopic thyroidectomy versus conventional open thyroidectomy in treatment of papillary thyroid cancer. The findings showed endoscopic thyroidectomy had statically significant cosmetic appearance, less amount of blood loss and occurrence of transient hypocalcaemia than conventional open thyroidectomy in form of cosmetic outcome, amount lower blood loss.ConclusionThe current review showed that, ET has a better cosmetic outcome and lower blood loss compared with COT. While COT was associated with significantly low operation time, hospital stay, drainage time, amount of drainage fluid and transient recurrent laryngeal nerve (RLN) palsy

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

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

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

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