Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

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

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

Guía oficial de la Sociedad Española de Neurología de práctica clínica en epilepsia

Resumen: Las anteriores Guías oficiales de práctica clínica en epilepsia elaboradas por el Grupo de Estudio de Epilepsia de la Sociedad Española de Neurología (GE-SEN) estaban basadas en la opinión de expertos.La actual Guía de práctica clínica (GPC) en epilepsia se basa en el método científico que extrae recomendaciones a partir de evidencias científicas constatadas. Su principal función es disminuir la variabilidad de la práctica clínica a través de la homogeneización de la práctica médica. Alcance y objetivos: Esta GPC se centra en la atención integral de personas afectadas por una epilepsia, como síntoma principal y predominante, independiente de la edad de inicio y ámbito asistencial. Metodología: 1) Constitución del grupo de trabajo integrado por neurólogos del GE-SEN, con la colaboración de neuropediatras, neurofisiólogos y neurorradiólogos; 2) determinación de los aspectos clínicos a cubrir: diagnóstico, pronóstico y tratamiento; 3) búsqueda y selección de la evidencia científica relevante; 4) formulación de recomendaciones basadas en la clasificación de las evidencias científicas disponibles. Resultados: Contienen 192 recomendaciones. El 57% son de consenso entre autores y editores, como consecuencia del desconocimiento en muchos campos de esta patología. Conclusiones: Esta GPC, en epilepsia, con una metodología formal y rigurosa en la búsqueda de evidencias explícitas donde ha sido posible, formula recomendaciones extraídas de las mismas.En este artículo incluimos el capítulo de la GPC dedicado a situaciones de urgencia en crisis epilépticas y epilepsia, que pueden presentarse como una primera crisis epiléptica, una evolución desfavorable en un paciente con una epilepsia conocida o en su forma más grave como un estado epiléptico. Abstract: Previous Official Clinical Practice Guidelines (CPGs) in Epilepsy were based on expert opinions and developed by the Epilepsy Study Group of the Spanish Neurological Society (GE-SEN).The current CPG in epilepsy is based on the scientific method, which extracts recommendations from published scientific evidence. A reduction in the variability in clinical practice through standardization of medical practice has become its main function. Scope and objectives: This CPG is focused on comprehensive care for individuals affected by epilepsy as a primary and predominant symptom, regardless of the age of onset and medical policy. Methodology: 1. Creation of GE-SEN neurologists working group, in collaboration with Neuropediatricians, Neurophysiologists and Neuroradiologists. 2. Identification of clinical areas to be covered: diagnosis, prognosis and treatment. 3. Search and selection of the relevant scientific evidence. 4. Formulation of recommendations based on the classification of the available scientific evidence. Results: It contains 161 recommendations of which 57% are consensus between authors and publishers, due to an important lack of awareness in many fields of this pathology. Conclusions: This Epilepsy CPG formulates recommendations based on explicit scientific evidence as a result of a formal and rigorous methodology, according to the current knowledge in the pre-selected areas.This paper includes the CPG chapter dedicated to emergency situations in seizures and epilepsy, which may present as a first seizure, an unfavorable outcome in a patient with known epilepsy, or status epilepticus as the most severe manifestation. Palabras clave: Guía de práctica clínica en epilepsia, Urgencias en crisis epilépticas, Primera crisis epiléptica, Evolución desfavorable de una epilepsia, Estados epilépticos, Keywords: Clinical practice guidelines in epilepsy, Emergencies in seizures, First seizure, Unfavorable outcome in epilepsy, Status epilepticu

The Spanish Society of Neurology's official clinical practice guidelines for epilepsy

Previous official clinical practice guidelines (CPGs) for epilepsy were based on expert opinions and developed by the Epilepsy Study Group of the Spanish Society of Neurology (GE-SEN).The current CPG in epilepsy is based on the scientific method, which extracts recommendations from published scientific evidence. Reducing variability in clinical practice through standardisation of medical practice is its main function. Scope and objectives: This CPG focuses on comprehensive care for individuals affected by epilepsy as a primary and predominant symptom, regardless of the age of onset and medical policy. Methodology: (1) Creation of a working group of GE-SEN neurologists, in collaboration with neuropediatricians, neurophysiologists and neuroradiologists. (2) Identification of clinical areas to be covered: diagnosis, prognosis and treatment. (3) Search and selection of the relevant scientific evidence. (4) Formulation of recommendations based on the classification of the available scientific evidence. Results: The CPG contains 161 recommendations of which 57% were established by consensus between authors and publishers, due to significant lack of awareness of this disorder in many fields. Conclusions: This epilepsy CPG formulates recommendations based on explicit scientific evidence as a result of a formal and rigorous methodology, according to the current knowledge in the pre-selected areas.This paper includes the CPG chapter dedicated to emergency situations in seizures and epilepsy. These may present as a first seizure, an unfavourable outcome in a patient with known epilepsy, or status epilepticus (SE) as the most severe manifestation. Resumen: Las anteriores Guías oficiales de práctica clínica en epilepsia elaboradas por el Grupo de Estudio de Epilepsia de la Sociedad Española de Neurología (GE-SEN) estaban basadas en la opinión de expertos.La actual Guía de práctica clínica (GPC) en epilepsia se basa en el método científico que extrae recomendaciones a partir de evidencias científicas constatadas. Su principal función es disminuir la variabilidad de la práctica clínica a través de la homogeneización de la práctica médica. Alcance y objetivos: Esta GPC se centra en la atención integral de personas afectadas por una epilepsia, como síntoma principal y predominante, independiente de la edad de inicio y ámbito asistencial. Metodología: 1) Constitución del grupo de trabajo integrado por neurólogos del GE-SEN, con la colaboración de neuropediatras, neurofisiólogos y neurorradiólogos; 2) determinación de los aspectos clínicos a cubrir: diagnóstico, pronóstico y tratamiento; 3) búsqueda y selección de la evidencia científica relevante; 4) formulación de recomendaciones basadas en la clasificación de las evidencias científicas disponibles. Resultados: Contienen 192 recomendaciones. El 57% son de consenso entre autores y editores, como consecuencia del desconocimiento en muchos campos de esta patología. Conclusiones: Esta GPC, en epilepsia, con una metodología formal y rigurosa en la búsqueda de evidencias explícitas donde ha sido posible, formula recomendaciones extraídas de las mismas.En este artículo incluimos el capítulo de la GPC dedicado a situaciones de urgencia en crisis epilépticas y epilepsia, que pueden presentarse como una primera crisis epiléptica, una evolución desfavorable en un paciente con una epilepsia conocida o en su forma más grave como un estado epiléptico. Keywords: Clinical practice guidelines in epilepsy, Seizure emergencies, First seizure, Unfavourable outcome in epilepsy, Status epilepticus, Palabras clave: Guía de práctica clínica en epilepsia, Urgencias en crisis epilépticas, Primera crisis epiléptica, Evolución desfavorable de una epilepsia, Estados epiléptico

Prognosis in epilepsy: initiating long-term drug therapy

Introduction: Prognosis in epilepsy refers to the probability of either achieving seizure remission (SR), whether spontaneously or using antiepileptic drugs (AED), or failing to achieve control of epileptic seizures (ES) despite appropriate treatment.Use of AED is recommended after a second unprovoked ES. For a first episode, the decision of whether or not to start drug treatment depends on the risk of recurrence and the advantages or disadvantages of the antiepileptic drug. The main goal of treatment is achieving absence of ES without adverse effects (AE). AED is selected according to epilepsy type and the demographic and clinical characteristics of the patient. Development: A PubMed search located articles and recommendations by the most relevant scientific societies and clinical practice guidelines concerning epilepsy prognosis and treatment. Evidence and recommendations are classified according to the prognostic criteria of the Oxford Centre for Evidence-Based Medicine (2001) and the European Federation of Neurological Societies (2004) for therapeutic actions. Conclusions: Most newly diagnosed epileptic patients achieve good control over their ES. The majority of the AEDs available at present provide effective control over all types of ES, and choice therefore depends on the patient's individual characteristics. Treatment should be initiated as monotherapy at the lowest effective dose, which in half of all patients provides ES control and is well tolerated. In cases in which the first AED is not effective, alternative therapy should be started, and monotherapy should be employed before combination therapy where possible. The probability of achieving good control over ES decreases with each successive treatment failure. Resumen: Introducción: El pronóstico en la epilepsia implica la probabilidad de alcanzar la remisión de las crisis epilépticas (CE) de forma espontánea o bajo tratamiento con fármacos antiepilépticos (FAE), o no conseguirla a pesar de un tratamiento oportuno.El tratamiento con FAE es recomendable después de una segunda CE no provocada. Tras una primera CE la decisión de iniciar o no el tratamiento con FAE depende de los riesgos de recurrencia y las ventajas o inconvenientes del tratamiento con FAE. El objetivo del tratamiento es alcanzar la ausencia de CE sin efectos adversos (EA). La selección de los FAE se realiza según tipo de epilepsia y las características demográficas y clínicas del paciente. Desarrollo: Búsqueda de artículos en Pubmed y recomendaciones de las Guías de Práctica Clínica (GPC) y Sociedades Científicas más relevantes referentes a pronóstico de la epilepsia y su tratamiento. Se clasifican las evidencias y recomendaciones según los criterios pronósticos del Oxford Centre for Evidence-Based Medicine (2001) y de la European Federation of Neurological Societies (2004) para las actuaciones terapéuticas. Conclusiones: La mayoría de pacientes que inician una epilepsia consigue el control de sus CE. La mayoría de los FAE disponibles son útiles para el control de cualquier tipo de CE, su elección depende de las características del paciente. Se debe iniciar el tratamiento en monoterapia y a la menor dosis eficaz del FAE elegido, que suele controlar las CE en la mitad de los pacientes y con buena tolerancia. Ante la falta de eficacia del primer FAE, debe intentarse otra terapia alternativa, a ser posible en monoterapia, antes de instaurar una politerapia. Las posibilidades de control de las CE disminuyen con sucesivos fracasos terapéuticos. Keywords: Epilepsy, Evidence-based medicine, Clinical practice guidelines, Prognosis, Onset of long-term treatment, Failure of first antiepileptic drug, Palabras clave: Epilepsia, Medicina basada en la evidencia, Guía de Práctica Clínica, Pronóstico, Inicio del tratamiento crónico, Fracaso del primer fármaco antiepiléptic

Pronóstico de la epilepsia. Inicio del tratamiento crónico farmacológico

Resumen: Introducción: El pronóstico en la epilepsia implica la probabilidad de alcanzar la remisión de las crisis epilépticas (CE) de forma espontánea o bajo tratamiento con fármacos antiepilépticos (FAE), o no conseguirla a pesar de un tratamiento oportuno.El tratamiento con FAE es recomendable después de una segunda CE no provocada. Tras una primera CE la decisión de iniciar o no el tratamiento con FAE depende de los riesgos de recurrencia y las ventajas o inconvenientes del tratamiento con FAE. El objetivo del tratamiento es alcanzar la ausencia de CE sin efectos adversos (EA). La selección de los FAE se realiza según tipo de epilepsia y las características demográficas y clínicas del paciente. Desarrollo: Búsqueda de artículos en Pubmed y recomendaciones de las Guías de Práctica Clínica (GPC) y Sociedades Científicas más relevantes referentes a pronóstico de la epilepsia y su tratamiento. Se clasifican las evidencias y recomendaciones según los criterios pronósticos del Oxford Center for Evidence-Based Medicine (2001) y de la European Federation of Neurological Societies (2004) para las actuaciones terapéuticas. Conclusiones: La mayoría de pacientes que inician una epilepsia consigue el control de sus CE. La mayoría de los FAE disponibles son útiles para el control de cualquier tipo de CE, su elección depende de las características del paciente. Se debe iniciar el tratamiento en monoterapia y a la menor dosis eficaz del FAE elegido, que suele controlar las CE en la mitad de los pacientes y con buena tolerancia. Ante la falta de eficacia del primer FAE, debe intentarse otra terapia alternativa, a ser posible en monoterapia, antes de instaurar una politerapia. Las posibilidades de control de las CE disminuyen con sucesivos fracasos terapéuticos. Abstract: Introduction: Prognosis in epilepsy refers to the probability of either achieving seizure remission (SR), whether spontaneously or using antiepileptic drugs (AED), or failing to achieve control of epileptic seizures (ES) despite appropriate treatment.Use of AED is recommended after a second unprovoked ES. For a first episode, the decision of whether or not to start drug treatment depends on the risk of recurrence and the advantages or disadvantages of the antiepileptic drug. The main goal of treatment is achieving absence of ES without adverse effects (AE). AED is selected according to epilepsy type and the demographic and clinical characteristics of the patient. Development: A PubMed search located articles and recommendations by the most relevant scientific societies and clinical practice guidelines concerning epilepsy prognosis and treatment. Evidence and recommendations are classified according to the prognostic criteria of the Oxford Centre for Evidence-Based Medicine (2001) and the European Federation of Neurological Societies (2004) for therapeutic actions. Conclusions: Most newly diagnosed epileptic patients achieve good control over their ES. The majority of the AEDs available at present provide effective control over all types of ES, and choice therefore depends on the patient's individual characteristics. Treatment should be initiated as monotherapy at the lowest effective dose, which in half of all patients provides ES control and is well tolerated. In cases in which the first AED is not effective, alternative therapy should be started, and monotherapy should be employed before combination therapy where possible. The probability of achieving good control over ES decreases with each successive treatment failure. Palabras clave: Epilepsia, Medicina basada en la evidencia, Guía de Práctica Clínica, Pronóstico, Inicio del tratamiento crónico, Fracaso del primer fármaco antiepiléptico, Keywords: Epilepsy, Evidence-based medicine, Clinical Practice Guidelines, Prognosis, Onset of long-term treatment, Failure of first antiepileptic dru

Protective factors in patients aged over 65 with stroke treated by physiotherapy, showing cognitive impairment, in the Valencia Community. Protection Study in Older People (EPACV)

<p>Abstract</p> <p>Background</p> <p>Family function may have an influence on the mental health deterioration of the caregivers of dependent family members and it could have a varying importance on the care of dependents. Little attention has been paid to the preparation of minor stroke survivors for the recovery trajectory or the spouse for the caregiving role. Therefore, this study protocol intends to analyze the influence of family function on the protection of patients with stroke sequels needing physiotherapy in the family environment.</p> <p>Methods/Design</p> <p>This is an analytical observational design, prospective cohort study and using a qualitative methodology by means of data collected in the “interviews of life”. The study will be carried out by the Rehabilitation Service at Hospital of Elda in the Valencia Community.</p> <p>All patients that have been diagnosed with stroke and need physiotherapy treatment, having a dependency grade assigned and consent to participate in the study, will undergo a monitoring of one year in order to assess the predictive factors depending on the dependence of the people affected.</p> <p>Discussion</p> <p>Our research aims to analyze the perception of caregivers, their difficulties to work, and the influence of family function. Moreover, it aims to register the perception of the patients with stroke sequel over the care received and whether they feel protected in their family environment.</p