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

The burden of bacterial antimicrobial resistance in the WHO African region in 2019: a cross-country systematic analysis

Background A critical and persistent challenge to global health and modern health care is the threat of antimicrobial resistance (AMR). Previous studies have reported a disproportionate burden of AMR in low-income and middle-income countries, but there remains an urgent need for more in-depth analyses across Africa. This study presents one of the most comprehensive sets of regional and country-level estimates of bacterial AMR burden in the WHO African region to date. Methods We estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with AMR for 23 bacterial pathogens and 88 pathogen–drug combinations for countries in the WHO African region in 2019. Our methodological approach consisted of five broad components: the number of deaths in which infection had a role, the proportion of infectious deaths attributable to a given infectious syndrome, the proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antimicrobial drug of interest, and the excess risk of mortality (or duration of an infection) associated with this resistance. These components were then used to estimate the disease burden by using two counterfactual scenarios: deaths attributable to AMR (considering an alternative scenario where infections with resistant pathogens are replaced with susceptible ones) and deaths associated with AMR (considering an alternative scenario where drug-resistant infections would not occur at all). We obtained data from research hospitals, surveillance networks, and infection databases maintained by private laboratories and medical technology companies. We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. Findings In the WHO African region in 2019, there were an estimated 1·05 million deaths (95% UI 829 000–1 316 000) associated with bacterial AMR and 250 000 deaths (192 000–325 000) attributable to bacterial AMR. The largest fatal AMR burden was attributed to lower respiratory and thorax infections (119 000 deaths [92 000–151 000], or 48% of all estimated bacterial pathogen AMR deaths), bloodstream infections (56 000 deaths [37 000–82 000], or 22%), intra-abdominal infections (26 000 deaths [17 000–39 000], or 10%), and tuberculosis (18 000 deaths [3850–39 000], or 7%). Seven leading pathogens were collectively responsible for 821 000 deaths (636 000–1 051 000) associated with resistance in this region, with four pathogens exceeding 100 000 deaths each: Streptococcus pneumoniae, Klebsiella pneumoniae, Escherichia coli, and Staphylococcus aureus. Third-generation cephalosporin-resistant K pneumoniae and meticillin-resistant S aureus were shown to be the leading pathogen–drug combinations in 25 and 16 countries, respectively (53% and 34% of the whole region, comprising 47 countries) for deaths attributable to AMR. Interpretation This study reveals a high level of AMR burden for several bacterial pathogens and pathogen–drug combinations in the WHO African region. The high mortality rates associated with these pathogens demonstrate an urgent need to address the burden of AMR in Africa. These estimates also show that quality and access to health care and safe water and sanitation are correlated with AMR mortality, with a higher fatal burden found in lower resource settings. Our cross-country analyses within this region can help local governments to leverage domestic and global funding to create stewardship policies that target the leading pathogen–drug combinations. Funding Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund

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

PENGENDALIAN PENCEMARAN UDARA TERKAIT PEMBANGUNAN JALAN TOL BEKASI-KAMPUNG MELAYU ( Studi di Kantor Dinas Lingkungan Hidup Kota Bekasi )

ABSTRAK Penulisan skripsi ini membahas mengenai Pengendalian Pencemaran Udara Terkait Pembangunan Jalan tol Bekasi-Kampung Melayu ( Studi Di Dinas Lingkungan Hidup Kota Bekasi ). Permasalahan yang dibahas dalam skripsi ini adalah terkait penerapan Pasal 40 Perda Kota Bekasi No. 2 Tahun 2014 Tentang Pengendalian Pencemaran Udara terkait pembangunan Jalan tol Bekasi. Penerapan Pasal 40 Perda Kota Bekasi No. 2 Tahun 2014 Tentang Pengendalian Pencemaran Udara belum maksimal atau belum efektif karena dalam struktur hukum terlihat pola pikir birokrasi yang cenderung lama, sulit dan berbelit-belit. Kemudian substansi hukum yang masih terdapat celah hukum yang dimanfaatkan oleh kontraktor pembangunan jalan tol Bekasi Kampung Melayu. Ditinjau dari budaya hukum bahwa budaya melanggar peraturan dan menggampangkan sesuatu yang mendasar merupakan sikap apatis / kurang bertanggungjawabnya kontraktor dalam hal pembangunan jalan tol ini. Hambatan Dinas Lingkungan Hidup dalam penerapan pasal 40 adalah belum adanya peraturan perundangan yang menampung permasalahan ini, Keterbatasan sarana dan sumber daya manusia Benturan kepentingan penanggung jawab kegiatan. Solusi untuk menghadapi hambatan itu adalah Solusi teknis berupa bentuk pengendalian yang dilakukan oleh DLH Kota Bekasi seperti kajian AMDAL. Solusi non teknis yaitu usaha untuk mengurangi dan menanggulangi pencemaran dengan cara menciptakan peraturan perundangan yang bisa mengatur, mengawasi segala macam bentuk kegiatan dari industry dan perkembangan teknologi.Pemberian sanksi salah satu cara agar bisa menimbulkan efek jera bagi pelaku usaha yang mendirikan minimarket tanpa SIUP. Kata Kunci : Penerapan, Pengendalian, Pencemaran Udara CONTROL OF AIR POLLUTIONS RELATED TO TOL BEKASI-KAMPUNG MELAYU ROAD (Study at Bekasi City Environment Agency) ABSTRACT Writing this thesis discusses about Air Pollution Control Related Development of Bekasi-Kampung Melayu Toll Road (Study In Environment Agency of Bekasi City). The problems discussed in this thesis is related to the application of Article 40 of Perda Kota Bekasi. 2 Year 2014 on Air Pollution Control related to the construction of Bekasi toll road. Implementation of Article 40 of Perda Kota Bekasi. 2 Year 2014 About Air Pollution Control has not been maximal or not effective because in the legal structure looks bureaucratic mindset that tend to be long, difficult and convoluted. Then the legal substance that still there is a legal gap that is utilized by contractor of Bekasi toll road development Kampung Melayu. Judging from the culture of the law that culture violates the rules and explains something basic is the apathy / lack of responsibility of contractors in terms of construction of this toll road. The obstacles of the Environmental Office in the application of article 40 are the absence of legislation that accommodates this problem, the limited of facilities and human resources. The solution to face the obstacles is technical solution in the form of control done by DLH Kota Bekasi such as study of AMDAL. Non-technical solutions are efforts to reduce and cope with pollution by creating legislation that can regulate, oversee all kinds of activities from industry and technological developments. Penalty is one way to create a deterrent effect for business actors who establish minimarket without SIUP.Keyword : Implementation, Control, Air PollutionÂ

Performance analysis of hybrid fiber reinforced high volume fly ash cement composite

Fly ash is a well-known pozzolanic material that can be used in high volume as a partial replacement of cement. This paper attempts to characterize the mechanical properties of hybrid fiber reinforced high volume fly ash (HVFA) cement mortar. An experimental program was designed to show how the addition of steel (ST), polypropylene (PP) and basalt fibers (BF) in various volume fractions affected under an applied compressive and flexural load. High volume flyash cement composites were reinforced with fibers at 1.0, 1.5 and 2.0% by volume and these mixtures were tested for the compressive stress-strain curves. Different sizes of fibers are combined to modify the crack propagation mechanism, thus producing an increase in the peak strain and the post-peak ductility. From this study, the most effective hybrid fiber was found to be the composition of 1.0% ST + 0.5% PP + 0.5% BF (H7). Scanning electron microscope (SEM) analysis of the microstructure was also carried out to determine the durability characteristics of basalt fibers in HVFA cement mortar