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)

Use of early pulse oximetry in the detection of cardiac lesions among asymptomatic term newborns

Background and objectives: Cardiovascular malformations are the commonest form of congenital defects and could result in significant morbidity. Antenatal and early postnatal detection is still unreliable, especially in developing countries and low-income communities. The aim of the study was to assess the value of early pulse oximetry in the detection of cardiac lesions among asymptomatic term newborns with subnormal oxygen saturation. Patients and methods: A cross-sectional study was conducted at the well-baby nursery of a community hospital, between March and August 2013. A total of 120 asymptomatic, apparently healthy term newborns who had persistent postductal SpO2 < 95% in the initial and repeat tests within the first 24 h after birth were consecutively enrolled. Pulse oximetry testing was performed after the age of 2 h and confirmed 2 h later. Cases with persistent saturation below 95% underwent echocardiography. Results: Significant cardiac lesions were detected in 38 newborns (31.6%); they had significantly lower oxygen saturation compared to those with insignificant lesions (n = 41, 34.2%) and normal hearts (n = 41, 34.2%). Repeat testing after 2 h was more reliable. Using cut-offs lower than 95% missed a significant number of lesions. Conclusion: Pulse oximetry can be used as a tool in apparently healthy term newborns for the early detection of cardiac lesions that might necessitate specialized follow-up and care. An initial test after the age of 2 h followed by a confirmatory test 2 h later, with a cut-off value of <95% is proposed. A comprehensive study is necessary to validate the results of this study. This might be of significant importance in low-income communities

Effect of early procedural pain experience on subsequent pain responses among premature infants

Background and objectives: Preterm newborns are exposed to repeated procedural pain during their NICU stay. Acute pain has negative short-term effects and may have adverse neurodevelopmental sequelae. Disagreement among researchers exists in the direction of pain responses. We aimed at evaluating the short-term effects of early procedural pain exposure on subsequent behavioral and physiological responses among preterm infants; and to define possible contributing factors. Patients and methods: A prospective study included 203 preterm newborns recruited from 2 community centers, excluding cases having conditions that may affect pain responses. They were categorized into: group I including cases who were exposed to painful procedures; and group II were not exposed. Pain response to heel-stick procedure was assessed by Neonatal Infant Pain Scale to measure behavioral response, and changes in heart rate and oxygen saturation to evaluate physiological responses. Results: History of pain exposure and number of procedures were the only independent variables that predicted subsequent pain responses while other contextual factors had no significant impact. The behavioral pain responses were blunted in group I with lower pain scores during and after the heel-stick test, while physiological responses were exaggerated with a higher heart rate and oxygen saturation variability. Conclusion: On studying the physiological and behavioral responses to pain in the premature infants, it was found that prior pain exposure and the number of procedures predict dampened behavioral and exaggerated physiologic subsequent pain responses. Protocols for minimization of pain exposure and pain control need to be implemented to avoid infant distress and long-term neurodevelopmental sequelae

Immunosuppressive therapy in children with steroid-resistant, frequently-relapsing, and steroid-dependent idiopathic nephrotic syndrome: a single center experience

Introduction: Immunosuppressive agents are recommended for the management of children with steroidresistant (SRNS), frequently-relapsing (FRNS), and steroid-dependent idiopathic nephrotic syndrome (SDNS). This study evaluated the efficacy of immunosuppressive agents in these cases. Methods: This is a retrospective analysis of the records of 130 pediatric cases recruited from a tertiary-care center over a period of two years. They were divided into two groups: 51 patients with SRNS (Group I) and 79 cases with SDNS and FRNS (Group II). They were treated with immunosuppressive agents in addition to steroids, either as double- or triple-combination therapy. Complete or partial remission was considered a good response. Results: In group I, the proportions of good response to cyclophosphamide, cyclosporine A, and mycophenolate mofetil were 48.6, 60, and 80%, respectively (p = 0.162). In group II, the resistance rate was significantly higher with levamisole than with cyclophosphamide and azathioprine (p = 0.046). Leukopenia was reported infrequently after the administration of cyclophosphamide or azathioprine. The most serious adverse reaction was to cyclosporine A, which induced nephrotoxicity (6.4%), while no adverse effects related to levamisole were reported. Histopathological diagnoses were available in only 39 patients. Conclusion: The high potency of cyclosporine with steroids recommends its use in patients with idiopathic SRNS with a normal glomerular filtration rate. Its efficacy is augmented when combined with mycophenolate mofetil. Cyclophosphamide, orally or as intravenous boluses, together with alternate-day steroids, could be a good option outside the peripubertal age. The outcomes of FRNS and SDNS could be improved by encouraging compliance with the use of levamisole

Iron chelation monotherapy in transfusion-dependent beta-thalassemia major patients: a comparative study of deferasirox and deferoxamine

Introduction: Iron overload is the primary cause of mortality and morbidity in thalassemia major (TM) despite advances in chelation therapy. The aim of this study was to compare the effectiveness and safety of deferasirox (DFX) and deferoxamine (DFO) as iron-chelating agents in patients with transfusion-dependent β-thalassemia major. Methods: This prospective randomized study included 60 patients with transfusion-dependent β-TM during the period from September 2014 to September 2015. Their ages were ≥ 6 years, and they had serum ferritin above 1500 µg/L and were on irregular DFO therapy. Patients had regular packed red cell transfusion in a dose of 10 mL/kg/session. They were randomized to receive DFX (single oral daily dose of 20-40 mg/kg/day) or DFO (20- 50 mg/kg/day via subcutaneous infusion over 8-10 hours, 5 days a week). Iron overload was determined by serum ferritin level. The primary endpoint was decrease of serum ferritin level below 1500 μg/L. The secondary endpoint was drug safety. Results: Both drugs significantly reduced serum ferritin (p < 0.001). At the end of follow-up, there were no significant differences between the two groups in serum ferritin levels (p = 0.673) and in percent reduction of ferritin (p = 0.315). There were no significant differences between the two groups in the total amount of blood transfusion (p = 0.166) and average iron intake (p = 0.227). There were no mortalities or any serious adverse effects, neutropenia, arthropathy, or pulmonary toxicity. Gastrointestinal upset and skin rash occurred more frequently with DFX than with DFO (p = 0.254 and 0.095, respectively). Conclusion: With appropriate dosing and compliance with drugs, both DFX and DFO are generally well tolerated, safe, and effective in reducing serum ferritin levels in iron-overloaded, regularly-transfused thalassemia major patients. Therefore, oral DFX is recommended for more convenience and adherence to the treatment regimen

Efficacy and safety of cefpodoxime in the treatment of acute otitis media in children

Background: Acute otitis media (AOM) is a community-acquired respiratory tract infection in childhood frequently encountered by primary-care physicians and can cause a significant morbidity. Increasing bacterial resistance has led to concern about the current options for empirical antibiotic treatment and has prompted a search for effective treatments. Objectives: To evaluate the clinical efficacy and safety of cefpodoxime proxetil in the treatment of children with acute otitis media. Patients and methods: A prospective, multicenter study was conducted on 1380 children aged from 1 to 13 years with AOM who were prescribed a 5–10 day course of cefpodoxime proxetil (8 mg/kg/day). Patients were followed-up after 7–14 days from baseline visit. Efficacy was assessed by the percentage of patients with clinical cure, improvement or failure at the follow-up visit. Safety was evaluated by recording the occurrence and severity of any adverse events and by the physicians’ and patients’ assessment of overall tolerability. Results: Clinically, 82.5% of patients were cured, 16.4% improved and there was failure of therapy in 1.1% of the patients. The overall combined cure and improvement rate of all related signs and symptoms was 98.9%. Adverse events, diarrhea and skin rash, were reported by only 16 patients (1.2%). The overall tolerability according to the physicians’ and patients’ assessment was excellent in 93.9% and 88.9%, respectively. Compliance was attained in 99.5% of patients. Conclusion: Cefpodoxime proxetil is an effective, safe, well-tolerated antimicrobial agent for treatment of acute otitis media in children. It can be considered as an excellent choice for the empirical treatment of bacterial AOM

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

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