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

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)

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

[[alternative]]Comparative Study of School-Based Suicide Prevention Models for Adolescents

[[abstract]]The purpose of this thesis is to establish the most effective, evidence-based model of adolescent suicide prevention, which combined of screening for psychiatric disorders and three-leveled interventions. Procedures were divided into three steps. First, self-administered inventories were used as tools for large scale screening. Second, subjects with moderate to high cutoff scores were interviewed by psychiatrists to decide tentative diagnosis and exclude those who could not be managed in a school setting. Third, a group of 90 high risk subjects were randomly assigned to three different levels of interventions and received 6 successive weeks of suicide interventions among intensive, usual and minimal intervention groups. A total of 1826 subjects were recruited from one of the high school in southern part of Taiwan. Screening tools were Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Beck Hopelessness Scale (BHS) and Beck Suicide Scale (BSS). Results were summarized as the following: 1.Results of large scale screening by self-administered inventories were as follows, moderate to severe depression were 13.14%, moderate to severe anxiety were 15.61%, moderate to severe hopelessness were 19.71% and suicide ideations were 44.43%. 2.Results from high risk subjects interviewed by the psychiatrist, tentative diagnosis made and distributions were as follows, adjustment disorders with depressed mood 36.67% (n=33), depressive disorder, NOS 33.33% (n=30), depressive disorder with co morbidity 7.78%, adjustment disorder with co morbidity 6.67%, major depressive disorder 4.44% (n=4),dysthymic disorder 3.33% (n=3). 3.Comparison among three-level interventions shown, intensive and usual groups were significantly superior to minimal level intervention in BDI, BAI and BSS scales. Intensive group was significantly superior to usual group in BHS (Hopelessness) but not significantly superior to usual group in other three scales (BDI, BAI and BSS). Conclusions and suggestions: Integrated intensive model, which include large scale screening, diagnostic interview, and intensive interpersonal intervention were shown to be a superior and promising model in adolescent suicide prevention, especially the therapeutic effects by reduction of hopelessness level and further risk of suicide. The model extends medical diagnostic interviews and interventions to school-based suicide prevention. This model could be generalized to larger areas upon further research.

Comparative Study of School-Based Suicide Prevention Models for Adolescents

[[abstract]]The purpose of this thesis is to establish the most effective, evidence-based model of adolescent suicide prevention, which combined of screening for psychiatric disorders and three-leveled interventions. Procedures were divided into three steps. First, self-administered inventories were used as tools for large scale screening. Second, subjects with moderate to high cutoff scores were interviewed by psychiatrists to decide tentative diagnosis and exclude those who could not be managed in a school setting. Third, a group of 90 high risk subjects were randomly assigned to three different levels of interventions and received 6 successive weeks of suicide interventions among intensive, usual and minimal intervention groups. A total of 1826 subjects were recruited from one of the high school in southern part of Taiwan. Screening tools were Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Beck Hopelessness Scale (BHS) and Beck Suicide Scale (BSS). Results were summarized as the following: 1.Results of large scale screening by self-administered inventories were as follows, moderate to severe depression were 13.14%, moderate to severe anxiety were 15.61%, moderate to severe hopelessness were 19.71% and suicide ideations were 44.43%. 2.Results from high risk subjects interviewed by the psychiatrist, tentative diagnosis made and distributions were as follows, adjustment disorders with depressed mood 36.67% (n=33), depressive disorder, NOS 33.33% (n=30), depressive disorder with co morbidity 7.78%, adjustment disorder with co morbidity 6.67%, major depressive disorder 4.44% (n=4),dysthymic disorder 3.33% (n=3). 3.Comparison among three-level interventions shown, intensive and usual groups were significantly superior to minimal level intervention in BDI, BAI and BSS scales. Intensive group was significantly superior to usual group in BHS (Hopelessness) but not significantly superior to usual group in other three scales (BDI, BAI and BSS). Conclusions and suggestions: Integrated intensive model, which include large scale screening, diagnostic interview, and intensive interpersonal intervention were shown to be a superior and promising model in adolescent suicide prevention, especially the therapeutic effects by reduction of hopelessness level and further risk of suicide. The model extends medical diagnostic interviews and interventions to school-based suicide prevention. This model could be generalized to larger areas upon further research.

Attention Inhibition Training Can Reduce Betel-Nut Chewing Time

Betel nut (or areca) is the fourth most commonly used drug worldwide after tobacco, alcohol, and caffeine. Many chemical ingredients of betel nut are carcinogenic. We examined whether the manipulation of attentional inhibition toward the areca-related stimuli could affect betel-nut chewing time. Three matched groups of habitual chewers were recruited: inhibit-areca, inhibit-non-areca, and control. This study consisted of a Go/No-Go task for inhibition training, followed by a taste test for observing chewing behavior. The Go/No-Go task constituted three phases (pretest, training and posttest). In the taste test, the habitual chewers were asked to rate the flavors of one betel nut and one gum. The purpose (blind to the chewers) of this taste test was to observe whether their picking order and chewing time were affected by experimental manipulation. Results from the Go/No-Go task showed successful training. Further, the training groups (the inhibit-areca and inhibit-non-areca groups) showed a significant reduction in betel nut chewing time, in comparison to the control group. Since both training groups showed reduced chewing time, the inhibition training may affect general control ability, in regardless of the stimulus (areca or not) to be inhibited. Reduced chewing time is important for reducing areca-related diseases

Development and validation of a Quality of Life Scale for elementary school students

Antecedentes/Objetivo: El bienestar emocional afecta el rendimiento escolar de los ni˜nos de Educación Primaria. Las mediciones de la calidad de vida (QoL) son indicativas del bienestar emocional. Sin embargo, el desarrollo de herramientas de evaluación adecuadas para medir la calidad de vida de ni˜nos de Educación Primaria ha recibido escasa atención y, por lo tanto, se requiere la creación de herramientas de evaluación confiables para medir la calidad de vida en esta población. Método: Se empleraron métodos de investigación cualitativa y cuantitativa para desarrollar y validar una escala de QoL para ni˜nos de Primaria en Taiwán. Se utilizó un muestreo aleatorio por grupos para reclutar a 711 estudiantes de Quinto y Sexto Grado, de 10 a 12 a˜nos, de 14 escuelas primarias. Resultados: La escala agrupa seis factores (Función escolar, Función familiar, Vida ambiental, Vitalidad para la vida, Capacidad de aprendizaje y Relaciones entre compa˜neros) que explican el 44% de la varianza. El instrumento de QoL (ESQoL) de 21 ítems tiene alta fiabilidad de consistencia interna y validez satisfactoria. Conclusiones: El instrumento ESQoL puede facilitar la evaluación de factores asociados con el bienestar emocional de los escolares. Se requieren estudios adicionales utilizando el instrumento ESQoL para evaluar su aplicabilidad en el análisis de las relaciones entre QoL y rendimiento escolar, y otras áreas del ámbito escolar

Moving toward Personalized Medicine in the Methadone Maintenance Treatment Program: A Pilot Study on the Evaluation of Treatment Responses in Taiwan

This pilot study simultaneously evaluated the effects of various factors, including genetic variations of CYP2B6, CYP2C19, and ABCB1, demographic characteristics, disease states, methadone-drug interactions (MDIs), and poly-substance use, on the treatment responses among non-HIV patients in the methadone maintenance treatment program (MMTP) in Taiwan. A total of 178 patients were recruited from two major hospitals that provided MMTP services in southern Taiwan, and information regarding concomitant medications and diseases was acquired from the National Health Insurance (NHI) program. The results demonstrated that the methadone maintenance dose, CYP2B6 785G allele, and ABCB1 2677T allele have positive effects on the methadone plasma concentration. In contrast, patients with HCV coinfection, alcohol problems, and psychiatric diseases may have a negative response to treatment. Thus, a comprehensive evaluation of treatment responses in the MMTP should include not only genetic polymorphisms in methadone metabolism and transporter proteins, but also concomitant diseases, MDIs, and poly-substance use. The results also suggest that personalized medicine may be indispensable for a better outcome of the MMTP

Can we do better? A guide to pandemics – some Dos and Don'ts for the next one

Specific features of any rapidly spread pathogen needs early recognition and assessment for possible pandemic potential.These include: inter-person transmissibility and exponential spread, which results in significant morbidity, mortality.These also include its ability to continue spreading locally, nationally and internationally, without attenuation over time.Inter-pandemic funding and maintenance of capability is essential and can feed into ongoing routine healthcare resource use.Delayed interventional responses during the early pandemic can have severe consequences on public health and the economy