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

Rendimento e teores de macronutrientes em alface americana em função de doses de nitrogênio e molibdênio Nitrogen and molybdenum rates on the yield and macronutrients content in crisphead lettuce

O trabalho foi conduzido no município de Três Pontas, sul de Minas Gerais, de abril a julho de 2003, com o objetivo de avaliar a influência de doses de nitrogênio e molibdênio no rendimento e teor de macronutrientes da alface americana. Utilizou-se o delineamento de blocos ao acaso em arranjo fatorial 4 x 5, compreendendo quatro doses de nitrogênio em cobertura (0, 60, 120 e 180 kg ha-1) e cinco doses de molibdênio via foliar (0,0; 35,1; 70,2; 105,3 e 140,4 g ha-1) e três repetições. A massa fresca evidenciou efeitos significativos para doses de nitrogênio e de molibdênio, assim como para sua interação, enquanto os teores de nitrogênio e magnésio agiram de forma independente. Os teores de potássio reduziram-se com o aumento das doses de nitrogênio e molibdênio, sendo que para a maior dose de molibdênio (140,4 kg ha-1), estabeleceu-se um efeito quadrático no qual a dose de 76,1 kg ha-1 de nitrogênio em cobertura propiciou o maior teor de potássio. Para os teores de fósforo, cálcio e enxofre verificaram-se efeito significativo da interação N x Mo, cujas concentrações na parte aérea aumentaram com as doses de nitrogênio e molibdênio.<br>The trial was carried out at Três Pontas, Minas Gerais state, Brazil, from April to July 2003, to evaluate the influence of nitrogen and molybdenum rates on yield and macronutrients uptake of crisphead lettuce. A randomized complete blocks design with three replications was used. The treatments consisted of a factorial combination of four top dressing nitrogen levels (0.0; 60.0; 120.0 and 180.0 kg ha-1) and five foliar molybdenum levels (0.0, 35.1; 70.2; 105.3 and 140.4 g ha-1). The marketable fresh mass showed significant effect for levels of nitrogen and of molybdenum, as well as for their interaction, while the content of nitrogen and magnesium acted independently. The levels of potassium were reduced with the increase of the doses of nitrogen and molybdenum, and for the highest level of molybdenum (140.4 g ha-1) occurred a quadratic effect in which the dose of 76.1 kg ha-1 of N in top dressing showed the highest level of potassium. For the content of P, Ca and S a significant effect from the interaction N x K was verified, which had their content increased in the plant tops with the levels of nitrogen and molybdenum

Soil and leaf fertilization of lettuce crop with cow urine Fertilização com urina de vaca em alface via solo e foliar

The use of cow urine can be considered an agricultural practice of low cost for farmers. Nevertheless, its efficiency on crop needs research information. The present research aimed to evaluate the effect of cow urine on the growth and yield of 'Regina 2000' lettuce, in an experiment carried out from January 13, 2006 to March 22, 2006. The experiment was set up with 12 treatments, in a split-plot design and four completely randomized blocks. The soil and leaf applications were installed in the plot. In the split-plot, cow urine was applied at different concentrations (0.00; 0.25; 0.50; 0.75; 1.00 and 1.25 %). The plot presented four rows with 1.75 m each, in 0.25 x 0.25 m spacing. The six central plants of the two central rows formed the sampled split-plot. At harvest, the following variables were evaluated: fresh (FLM) and dry (DLM) leaf mass, fresh (FSM) and dry (DSM) stem mass, stem length (SL), fresh (FRM) and dry (DRM) root mass, fresh (FHM) and dry (DHM) head mass and commercial yield (CY). The increase in cow urine concentrations increased the performance of all lettuce characteristics, except DRM, which presented reduction, and DSM and FRM, which were not affected. The highest yield was obtained with the concentration of 1.25% (17.00 t ha-1) applied to leaves and with 1.01% (14.92 t ha-1), applied to soil, corresponding, respectively to increases of 28.1% and 47.3%, in comparison to the control. Application to leaves, in comparison to application to soil, resulted in greater FLM (0.50 and 1.25%), SL (0.50; 0.75 and 1.25%), FSM and FRM (0.5%), FHM and CY (0.50 and 1.25%), but lower DSM and FRM (1.25%) and DRM (1.0 and 1.25%). The application of cow urine solution at 1.25% to leaves or 1.0% to soil is recommended for lettuce crops.<br>A utilização da urina de vaca pode ser considerada uma prática de custo baixo para os produtores rurais. Todavia, a sua eficiência sobre as culturas carece de informações da pesquisa. Assim, objetivou-se avaliar o efeito da urina de vaca sobre o crescimento e produção da alface em experimento conduzido de 13 de janeiro de 2006 a 22 de março de 2006, com a cv. Regina 2000. O experimento foi constituído de 12 tratamentos, em esquema de parcelas subdivididas, delineamento de blocos ao acaso, com quatro repetições. Nas parcelas foram alocadas as aplicações das soluções de urina (solo e foliar) e, nas subparcelas, as concentrações (0,00; 0,25; 0,50; 0,75; 1,00 e 1,25%). A subparcela foi constituída por quatro fileiras de 1,75 m, espaçamento de 0,25 x 0,25 m e consideraram-se, como úteis, as seis plantas centrais das duas fileiras centrais. Na colheita foram avaliados a massa da matéria fresca (MFF) e seca de folhas (MSF); massa da matéria fresca (MFC) e seca de caule (MSC); comprimento de caule (CC); massa da matéria fresca (MFR) e seca de raízes (MSR); massa da matéria fresca (MFCA) e seca da cabeça (MSCA) e produtividade comercial (PROD). Exceto a MSR, que diminuiu e MSC e MFR que não foram alteradas na aplicação via foliar, as demais características avaliadas apresentaram incremento às concentrações aplicadas. Maior produtividade de cabeça foi obtida com concentrações de 1,25% (17,0 t ha-1) aplicada via foliar e de 1,01% (14,9 t ha-1) aplicada via solo correspondendo, respectivamente, a aumentos em produtividade de 28,1% e de 47,3%, comparados à testemunha. A aplicação foliar, comparada via solo, proporcionou maior MFF (0,50 e 1,25%), CC (0,50; 0,75 e 1,25%), MFC e MFR (0,5%), MFCA e PROD (0,50 e 1,25%) e menores MSC e MFR (1,25%) e MSR (1,0 e 1,25%). Sugere-se, no cultivo da alface, a aplicação das doses de solução de urina às concentrações de 1,25% via foliar ou de 1,0%, via solos