Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Serum ferritin levels, socio-demographic factors and desferrioxamine therapy in multi-transfused thalassemia major patients at a government tertiary care hospital of Karachi, Pakistan

<p>Abstract</p> <p>Background</p> <p>Beta thalassemia is the most frequent genetic disorder of haemoglobin synthesis in Pakistan. Recurrent transfusions lead to iron-overload manifested by increased serum Ferritin levels, for which chelation therapy is required.</p> <p>Findings</p> <p>The study was conducted in the Pediatric Emergency unit of Civil Hospital Karachi after ethical approval by the Institutional Review Board of Dow University of Health Sciences. Seventy nine cases of beta thalassemia major were included after a written consent. The care takers were interviewed for the socio-demographic variables and the use of Desferrioxamine therapy, after which a blood sample was drawn to assess the serum Ferritin level. SPSS 15.0 was employed for data entry and analysis.</p> <p>Of the seventy-nine patients included in the study, 46 (58.2%) were males while 33 (41.8%) were females. The mean age was 10.8 (± 4.5) years with the dominant age group (46.2%) being 10 to 14 years. In 62 (78.8%) cases, the care taker education was below the tenth grade. The mean serum Ferritin level in our study were 4236.5 ng/ml and showed a directly proportional relationship with age. Desferrioxamine was used by patients in 46 (58.2%) cases with monthly house hold income significant factor to the use of therapy.</p> <p>Conclusions</p> <p>The mean serum Ferritin levels are approximately ten times higher than the normal recommended levels for normal individuals, with two-fifths of the patients not receiving iron chelation therapy at all. Use of iron chelation therapy and titrating the dose according to the need can significantly lower the iron load reducing the risk of iron-overload related complications leading to a better quality of life and improving survival in Pakistani beta thalassemia major patients.</p> <p>Conflicts of Interest: None</p

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set

Background Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy

Assessment of Influence of Percolation Pits on Groundwater Quality in Gaza Strip (Khan Younis As Case Study)

The majority of rural areas, which are not connected to an engineered-sewage system, depend primarily on Percolation Pits in order to dispose wastewater. Contemporary, 92% of rural houses dispose wastewater to either Percolation Pits or open channels. In most cases, the untreated water contained in septic tanks is likely to be leaked down into the soil and then into groundwater, collected by tank-vehicles or left flowing in the valleys without any treatment. These practices lead to significant deterioration of the environment and the quality of drinking water. Percolation Pits had been widely adopted in Khan Younis city before the establishment of the first sewerage system in 2008 serving 65 % of the population and covering 35% of the Khan Yunis area. During the development stage, 500 Percolation Pits were destroyed as they were blocking the routes of the new network. According to CMWU, Khan Yunis had approximately 2500 Percolation Pit’s in 2008. This study aims to assess the impacts of Percolation Pits on soil and groundwater in Khan Yunis because it is considered a strategic aquifer of ground water in the Gaza Strip. Two Percolation Pits are covered in this study. The first Percolation Pit is located in the eastern area “Satar Sharqi” where the ground water level is 37m below the ground. The second Percolation Pit is located in Al-Mawasi area where groundwater is only 4 meters below the ground (Al-nazaz water), several factors (e.g. location of Percolation pit, Type of soil ,Distance to surface water ,System Age , Soil / Topography) were taken into considerations while choosing the location of the study area. Soil samples were extracted from a distance of one and a half meters from the edge of the Percolation pit at different depths (1.5, 3, 6, 9, and 13) m beside the pits. Organic Matter, Total Nitrogen, and Fecal Coliform tests were carried out for all samples. Both Wastewater and groundwater were, to conduct various water-related tests (e.g. pH, BOD, COD, Total Suspended Solid, and TC). The study shows that the groundwater in Al-nazaz area contains significantly high contamination, therefore it is not suitable for both drinking and agricultural us. Accordingly, recommendation and future interventions are made to tackle the problem

Global governance for climate justice : A cross-national analysis of CO2 emissions

Sustainable energy transitions are key to achieving climate justice for all. Carbon dioxide emissions’(CO2) unequal distribution globally is one of the many issues preventing climate justice. Efforts to reduceglobal CO2impacts are vital for environmental justice efforts and a future free from climate change is-sues. Researchers have long been interested in how the rise of global governance initiatives, such asmultilateral treaties, impact environmental outcomes across the world. However, little is known abouthow global governance concerning energy usage and technologies impacts CO2emissions across theworld. Using two-wayfixed effects regression analysis from 1996 to 2011, we test how 24 multilateralenvironmental treaties with an energy focus impact CO2emissions per capita, CO2emissions as a per-centage of gross domestic product, and total CO2emissions for 162 nations. The multilateral energytreaties were collected from Ecolex. This analysis assesses how the legitimacy of global contracts mayimpact actual decreases in CO2emissions, resulting in climate justice outcomes. Additionally, thisanalysis considers how factors of institutional state governance, including control of corruption, rule oflaw, political stability, government effectiveness, and regulatory quality moderate the impact of multi-lateral energy environmental treaties and CO2emissions. Wefind that stocks of environmental treatyratification are associated with decreases in all three types of CO2emissions. Renewable energy con-sumption, GDP per capita, and urban and total population are associated with increased CO2 emissions.We alsofind some support for the idea that treaties are associated with larger decreases in emissions innations with higher levels of state governance. Understanding how state accountability, transparency,and legitimacy factor into the effectiveness of multilateral environmental treaties on reducing CO2emissions is essential to combating climate change issues

Investigation of the Functional Performance Properties and Antimicrobial Behavior of Sports Socks Knitted from Eco-Friendly Materials

The material components of the sports sock provide; impact protection, injury avoidance, anti-frictional, absorption and antibacterial properties. The quality of socks can vary depending on many factors. These can be summarized as the type andproperties of the used yarns, knitting conditions and machine properties, finishing method and the used finishing materials andthe form giving operation applied on socks. With the growing demand for more com-fortable, healthier and environmentallyfriendly products, efforts in research and development in the textile industry have focused on the utilization of renewable andbiodegradable resources. This study comprised an experimental investigation to determine the functional performance properties and anti-microbial behavior of socks manufactured using not only traditional cotton or polyester yarns but also yarns made of new kinds of eco-friendly fibers like bamboo. This paper studies the influence of different sports socks compositions on the functional performance properties and anti-microbial behavior of knitted fabrics made of two types of structures ( Rib- Jersey)knitted from elstane yarns with eco- friendly fibers effect. The results demonstrated that all tested properties influenced by bothmaterial and knitted structure parameters. These findings are an important tool in the design of healthy comfortable sports socks