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

Existing Infection Facilitates Establishment and Density of Malaria Parasites in Their Mosquito Vector

Very little is known about how vector-borne pathogens interact within their vector and how this impacts transmission. Here we show that mosquitoes can accumulate mixed strain malaria infections after feeding on multiple hosts. We found that parasites have a greater chance of establishing and reach higher densities if another strain is already present in a mosquito. Mixed infections contained more parasites but these larger populations did not have a detectable impact on vector survival. Together these results suggest that mosquitoes taking multiple infective bites may disproportionally contribute to malaria transmission. This will increase rates of mixed infections in vertebrate hosts, with implications for the evolution of parasite virulence and the spread of drug-resistant strains. Moreover, control measures that reduce parasite prevalence in vertebrate hosts will reduce the likelihood of mosquitoes taking multiple infective feeds, and thus disproportionally reduce transmission. More generally, our study shows that the types of strain interactions detected in vertebrate hosts cannot necessarily be extrapolated to vectors

Consensus statement on abusive head trauma in infants and young children

Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature

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

Avaliação da Polpa de Citros Peletizada como Material para Cama de Frangos de Corte Evaluation of Citrus Pulp Pellet as a Broiler Litter

O objetivo deste trabalho foi avaliar a utilização da polpa de citros peletizada (PCP) como cama de frango, bem como analisar a composição bromatológica desse material. O experimento foi constituído de 1.792 pintos de um dia-machos e dividido em duas fases: 1 a 21 e 35 a 49 dias. Foi utilizado o delineamento em blocos ao acaso, com quatro repetições, em esquema fatorial 2x2x2, sendo os fatores tipo de cama: PCP e maravalha x altura de cama: 7 e 10 cm x densidade: 10 e 14aves/m². Foram avaliados os parâmetros: gsnho de peso(GP), consumo de ração (CR), conversão alimentar (CA),viabilidade (V), incidência de lesões no coxim plantar e de calo de peito, matéria seca (MS) e pH da cama aos 21 e 49 dias. Para verificar as possíveis alterações bromatológicas na cama foram feitas análises de Weende e Van Soest, bem como de energia bruta. Independentemente da altura da cama, as aves criadas em PCP numa densidade de 14 aves/m² apresentaram piores resultados de GP e CR no período de 35 a 49 dias. Em geral, os resultados de GP e CR foram mais influenciados pelas densidades do que pelos materiais utilizados. Não houve diferença significativa entre os tratamentos para ambas as lesões. De uma maneira geral, a MS da cama de PCP foi maior enquanto o pH foi menor quando comparados com a maravalha. Nas análises bromatológicas, observou-se um efeito significativo dos tratamentos para todas as variáveis, com exceção da MM, a qual não apresentou diferença entre as médias (p>0,05). Melhores valores de PB, FDN e FDA foram obtidos com a cama de PCP.<br>The object of this experiment was to evaluate the citrus pulp-pelleted (CPP) as a broiler litter and their chemical composition. The experiment used 1792 one day-old males, and it was divided into two phases: 1 to 21 and 35 to 49 days of age. The experimental design was a factorial 2x2x2 with four replicates. The factors were: type of broiler litter (CPP and wood shaving), broiler litter depth (7 and 10 cm) and stocking densities (10 and 14 broilers/m²). The parameters analyzed were: weight gain (WG), feed consumption(FC), feed conversion, incidence of breast blister and foot pad lesion, survivability, dry matter and pH of the broiler litter (21 and 49 days old). To evaluate the possible alteration in the litter chemical composition Weende and van Soest analyses was performed and gross energy was also determined. Independently of depth of litter, the broilers reared on CPP and in the density of 14 broiler/m² showed worse results to WG and FC of 35 to 49 days of age. The results of WG and FC were more affected by the density than the types of broiler litter. There was no significant difference among the treatments for footpad lesion and for lesions of breast blister. The dry matter was higher in CPP than wood shaving. The pH of the broiler litter of CPP was smaller than wood shaving. The chemical analysis showed significant differences due to treatment (p<0.05) for all variables except to mineral matter (MM), with no significant differences between the means. Best values of CP, NDF, ADF were obtained with the CPP used as material for broiler litter