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)

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

3DCRT for posterior fossa: Sparing of surrounding organs at risk

Introduction: Radiotherapy of the posterior fossa is routinely delivered using 3DCRT parallel-opposed lateral fields. However high incidence of sensorineural hearing loss, hypothalamic–pituitary dysfunction, thyroid and gonadal dysfunction during radiotherapy makes the need for treatment plan which provides adequate coverage of the target volume while sparing of the cochlea and other surrounding organs at risk (OARs) at same time inevitable. Aim of the work: To compare the coverage of posterior fossa and the dose to surrounding OARs including non-posterior fossa brain, pituitary, cochlea, eyes, optic nerves, optic chiasm, cervical spinal cord, thyroid gland, pharynx, parotid glands and mandible using three different 3DCRT plans. Methods: Ten patients underwent CT simulation for treatment planning of posterior fossa boost. The CT data were transferred to Precise Elekta treatment planning system where posterior fossa, non-posterior fossa brain, pituitary, cochlea, parotid glands, cervical spinal cord, thyroid gland, pharynx, mandible, eyes, lenses, optic nerves and optic chiasm were all contoured. For each patient, three plans were carried out; two parallel opposed open lateral photon fields, a pair of wedged posterior oblique fields, and a pair of wedged posterior oblique fields and an open vertex field. For all plans, the dose distributions and dose volume histogram parameters (DVPs) for the PTV and OARs were compared and analyzed statistically using excel sheet 2003 and SPSS spreadsheet (SPSS base 18). Results: Posterior fossa dose coverage and its homogeneity were adequate and comparable for the three plans. A part from high mean dose received by cochlea, plan 1 shows the best sparing for other OARs. Conclusion: 3DCRT using parallel opposed fields is recommended for posterior fossa irradiation boost as it minimizes the exit dose to all structures other than the cochlea, however its mean dose was within the tolerance

Isolates of Staphylococcus aureus and saprophyticus resistant to antimicrobials isolated from the Lebanese aquatic environment

The indiscriminate use of antimicrobials especially in developing countries has evoked serious bacterial resistance and led to the emergence of new and highly resistant strains of bacteria to commonly used antimicrobials. In Lebanon, pollution levels and bacterial infections are increasing at a high rate as a result of inadequate control measures to limit untreated effluent discharges into the sea or freshwater resources. The aim of this study was to isolate and molecularly characterize various Staphylococcus strains isolated from sea water, fresh water, sediments, and crab samples collected from representative communities along the coast of Lebanon. The results on the antimicrobial resistance indicated that the level of resistance of Staphylococcus aureus varied with various antimicrobials tested. The resistance patterns ranged between 45% in freshwater isolates and 54.8% in seawater ones. Fifty one percent of the tested isolates have shown resistance to at least one of the five tested antimicrobials; with seawater isolates exhibiting the highest rates of antimicrobial resistanc

Noise impact assessment of multi-highways in urban areas: Parametric sensitivity analysis

Traffic noise along highways varies with the projected growth in future traffic use, particularly near developing urban areas, and the conditions of the tire–road surfacing interface. When traffic demand increases and those interface conditions deteriorate, highway noise impacts become significant and mitigation strategies required. This paper presents a leading application of the US Federal Highway Administration (FHWA)—a newly released Traffic Noise Model (TNM)— which is now being phased in by the FHWA to replace the old STAMINA/OPTIMA package. An uncommon application of TNM to evaluate the noise impact of multihighways running parallel and above each other is examined in the context of a developing city with limited building regulations and inadequate setback distances between the edge of roadways and building lines. For this purpose, traffic flow characteristics, including volume, vehicular classification, and travel speeds, were defined along existing and proposed highways. Sensitive noise receptors were identified and noise measurements were taken during peak traffic periods. Field measurements were used to calibrate the FHWA-TNM. Model simulations were then conducted to predict future noise exposure levels, evaluate the effect of noise barriers, and assess the model sensitivity to parameter variation

Modeling noise at elevated highways in urban areas: a practical application

Traffic noise along highways is continuously increasing; with the projected growth in future traffic use, particularly near developing urban areas, it will not cease to increase. As a result, highway noise impacts are expected to be significant and mitigation strategies will undoubtedly be required. This paper presents a noise impact analysis along a coastal stretch of highway that forms the major entrance into the greater Beirut metropolitan area. Geometric layout includes a proposed 13 km elevated highway-viaduct with underlying service roads running parallel to an existing 4 × 4-lane highway currently accommodating an average daily traffic (ADT) volume of about 160,000 vehicles per day. The proposed viaduct is planned to be a BOT (build-operate-transfer) project and thus includes two toll plazas and three interchanges. Traffic flow characteristics including volumes, vehicular classification, and travel speeds were defined along the proposed coastal highway. Sensitive noise receptors were identified and noise measurements were taken during the noisiest periods. The FHWA traffic noise model was used to simulate base year and future noise exposure of adjacent land uses. The model was calibrated using the combination of field measurements and model predictions. Noise mitigation strategies were defined as well as the locations where they were deemed appropriate. The model was used to evaluate the efficacy of the proposed mitigation measures in satisfying absolute and relative noise-abatement criteria. Finally, the feasibility of implementation of relevant mitigation measures is discussed within the site-specific constraints

Differentiation between benign and atypical cranial Meningiomas. Can ADC measurement help? MRI findings with hystopathologial correlation

Objective: To determine the diagnostic value of mean apparent diffusion coefficient (ADC) measures to distinguish between benign (grade I) and atypical (grade II) cranial meningiomas. Patients and methods: Forty-seven patients (10 men and 37 women) with cranial meningiomas were included in the study and underwent MRI examination including diffusion-weighted imaging (DWI). Signal characteristics on conventional MR and diffusion-weighted images were evaluated. The intratumoral mean ADC values were obtained and correlated with the final histopathological findings of the excised tumors. The optimum cutoff value of mean ADC measurements to differentiate between grade I and II was determined using the generated receiver operating characteristic (ROC) Results: Thirty-six meningiomas were benign (WHO grade I), while 11 were atypical (grade II). No grade III meningiomas were encountered during the study period. At standard MRI sequences, only the enhancement pattern had produced a significant statistical correlation with the tumoural grade (p = 0.001). Tumoural margins, peritumoural edema, and the DWI signal showed none statistical relationship (p = 0.105, 0.11 and 0.219 respectively). Intratumoral mean ADC values were significantly lower in grade II meningiomas (p < 0.001). The mean ADC value was 1.02 ± 0.16 × 10−3 mm2/s for grade I meningiomas and 0.72 ± 0.09 × 10−3 mm2/s−1 for grade II. According to the generated receiver operating curve (ROC), we determined a threshold of 0.79 × 10−3 mm2/s−1 to produce the best diagnostic performance to distinguish between grade I and II meningiomas (sensitivity 81.2%, specificity 91.7% and accuracy 89.3%). The positive and negative predictive values were 75% and 94.3%. Conclusion: The intratumoral mean ADC measurement provides a discriminative feature to discriminate between benign (grade I) and atypical (Grade II) cranial meningiomas. Keywords: Apparent diffusion coefficient, Diffusion-weighted MRI, Meningioma

General support of physical exercise programs in pediatric oncology but differences in perception by childhood cancer care professionals at European and North-African/Arab centers

Purpose: To explore the perception of physical exercise programs for pediatric oncology patients among childhood cancer care professionals. We also aimed at comparing such perceptions between cultures. Healthcare professionals’ endorsement may be essential for initiating and promoting such programs. Methods: An anonymous survey was designed and administered voluntarily to childhood cancer care professionals (including pediatric oncologists, nurses, and physiotherapists) in European, North-African and Arab pediatric oncology centers. Results: Five-hundred-and twenty-eight professionals from 14 sites answered the survey. Most respondents considered physical exercise programs as a suitable therapeutic approach for pediatric cancer patients with a potential positive contribution to survival (81%), wellbeing (82%), quality of life (80%), and self-esteem (75%). 91% of respondents would also support the future introduction of physical exercise programs into standard pediatric oncological care. There was a comparatively higher appreciation of physical exercise programs among European centers compared to North-African / Arab centers. Conclusion: We registered a broad acceptance of physical exercise programs among all European and North-African / Arab childhood cancer care professionals. The positive perception was independent of any pre-existing experience with such programs and seems therefore representative. This finding may encourage the further promotion of physical exercise programs in pediatric oncology

Impact of the COVID-19 pandemic on patients with paediatric cancer in low-income, middle-income and high-income countries: a multicentre, international, observational cohort study

OBJECTIVES: Paediatric cancer is a leading cause of death for children. Children in low-income and middle-income countries (LMICs) were four times more likely to die than children in high-income countries (HICs). This study aimed to test the hypothesis that the COVID-19 pandemic had affected the delivery of healthcare services worldwide, and exacerbated the disparity in paediatric cancer outcomes between LMICs and HICs. DESIGN: A multicentre, international, collaborative cohort study. SETTING: 91 hospitals and cancer centres in 39 countries providing cancer treatment to paediatric patients between March and December 2020. PARTICIPANTS: Patients were included if they were under the age of 18 years, and newly diagnosed with or undergoing active cancer treatment for Acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin lymphoma, Wilms' tumour, sarcoma, retinoblastoma, gliomas, medulloblastomas or neuroblastomas, in keeping with the WHO Global Initiative for Childhood Cancer. MAIN OUTCOME MEASURE: All-cause mortality at 30 days and 90 days. RESULTS: 1660 patients were recruited. 219 children had changes to their treatment due to the pandemic. Patients in LMICs were primarily affected (n=182/219, 83.1%). Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 12.1 (95% CI 2.93 to 50.3) and 7.9 (95% CI 3.2 to 19.7) times the odds of death at 30 days and 90 days, respectively, after presentation during the COVID-19 pandemic (p<0.001). After adjusting for confounders, patients with paediatric cancer in LMICs had 15.6 (95% CI 3.7 to 65.8) times the odds of death at 30 days (p<0.001). CONCLUSIONS: The COVID-19 pandemic has affected paediatric oncology service provision. It has disproportionately affected patients in LMICs, highlighting and compounding existing disparities in healthcare systems globally that need addressing urgently. However, many patients with paediatric cancer continued to receive their normal standard of care. This speaks to the adaptability and resilience of healthcare systems and healthcare workers globally