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

Detention dams in hydrographic basin with the use of synthetic triangular hydrograms and volume curves [Barragens de detenção em bacia hidrográfica com o uso de curvas cota-volume e hidrogramas triangulares sintéticos]

Made available in DSpace on 2019-09-12T16:26:10Z (GMT). No. of bitstreams: 0 Previous issue date: 2016This study aimed to apply a flood control proposal, through the use of dams to the runoff of detention for the area of influence of the Itaim stream in Taubaté, Brazil. The basin was divided from upstream to downstream into 4 sections that defined this way, sub-basins A, B, C and D. To calculate the maximum inflow of water into the pond we adopted the maximum rainfall with 100 years of time and return time equal to the concentration time using the PAI-I-Wu method to obtain the C2 volume flow coefficient using the curve number method. To verify the level of flooding, a synthetic triangular hydrograph methodology and the quota-volume curve were observed. Flow coefficients (C) obtained by the method of curve number of values of 0.24 showed; 0.18; 0.24; 0.32 and 0.34, respectively, for the Itaim basin and sub basins A, B, C and D. These values are lower than those recommended by DAEE SP. Flood areas and levels were assigned and the result showed that the bridge over the Itaim stream would be flooded from the leaf 0.5 meters of a maximum precipitation of 100 years. On the other hand, in the construction of dams (A, B, C and D) at the edge of the sub-basins, flows would be contained, and the bridge on the highway would have a difference of about 1.80 meters above the D of water. These results reflect the buffer capacity of the flood of buses, because the flows diminish with the adoption of these practices. © 2016, Institute for Environmental Research in Hydrographic Basins (IPABHi). All rights reserved.Filho, P.J.M., Universidade de Taubaté (UNITAU), Taubaté, SP, Brazildos Santos Targa, M., Universidade de Taubaté (UNITAU), Taubaté, SP, BrazilSantos, P.S., Universidade de Taubaté (UNITAU), Taubaté, SP, BrazilNeto, N.M., Universidade de Taubaté (UNITAU), Taubaté, SP, Brazi

The challenge of interdisciplinarity in graduate programs in the environmental sciences [O desafio da interdisciplinaridade nos Programas de Pós-graduação em Ciências Ambientais]

Made available in DSpace on 2019-09-12T16:26:10Z (GMT). No. of bitstreams: 0 Previous issue date: 2016During 18 years of experience in graduate education in the environmental area, the graduate programs in environmental sciences of the University of Taubaté have been consolidating the treatment of environmental issues in different geographic conditions, associated with the development of the metropolitan region of Vale do Paraíba, São Paulo, as well as environmental issues in the Amazon region. This edition of Ambi-Água presents 15 original articles from dissertations presented in the last three years, which reinforce the challenge in the treatment of environmental issues in an interdisciplinary context. The commitment of the PPGCA in the construction of knowledge in the environmental area that must guide the development of this important metropolitan region of the state of São Paulo is well known. © 2016, Institute for Environmental Research in Hydrographic Basins (IPABHi). All rights reserved.dos Santos Targa, M., Universidade de Taubaté (UNITAU), Taubaté, SP, Brazilda Silva Almeida, A.A., Universidade de Taubaté (UNITAU), Taubaté, SP, BrazilCocco, M.D.A., Universidade de Taubaté (UNITAU), Taubaté, SP, Brazi

2016 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Boston, Massachusetts, USA, 16-19 March 2016 : Poster Presentations

Objectives: To determine the impact on postoperative recovery and cost-effectiveness of a standardized enhanced recovery program (ERP) for colorectal surgery. Methods: A prospective series of patients (N = 76) undergoing elective colorectal resection completing a standardized ERP in 2013–2015 (ERP group) was compared to patients (N = 74) operated on at the same academic hospital in 2010–2011 (conventional group), before the introduction of the ERP methodology. The exclusion criteria for both groups were: age[80 years old, ASA score IV, TNM stage IV, and inflammatory bowel disease. Functional recovery time, morbidity and mortality, hospital length of stay (LOS), and readmission rate in-between groups were compared. Direct costs related to the preoperative phase and hospitalization, and implementation of the ERP were collected. Results: Age, gender, and BMI were comparable in-between groups. Outcome variables and institutional costs are shown in the table. After adjusting for potential confounders, following a conventional perioperative protocol was the only factor associated to prolonged hospital LOS (P\0.001). Conclusion: Implementing an ERP in elective colorectal surgery: 1) significantly reduced time to functional recovery and postoperative hospital LOS; 2) did not increase morbidity, mortality, and 30-day readmissions; and 3) significantly decreased institutional costs

Impact of an Enhanced Recovery Program (ERP) on clinical outcomes and institutional costs in elective laparoscopic colorectal resections.

Objectives: To determine the impact on postoperative recovery and cost-effectiveness of a standardized enhanced recovery program (ERP) for colorectal surgery. Methods: A prospective series of patients (N=76) undergoing elective colorectal resection completing a standardized ERP in 2013-2015 (ERP group) was compared to patients (N=74) operated on at the same academic hospital in 2010-2011 (conventional group), before the introduction of the ERP methodology. The exclusion criteria for both groups were: age>80 years old, ASA score IV, TNM stage IV, and inflammatory bowel disease. Functional recovery time, morbidity and mortality, hospital length of stay (LOS), and readmission rate in-between groups were compared. Direct costs related to the preoperative phase and hospitalization, and implementation of the ERP were collected. Data were analyzed using chi-square, t-Student, log-rank tests, and Cox regression analysis. Results: Age, gender, and BMI were comparable in-between groups. Outcome variables and institutional costs are shown in the table. After adjusting for potential confounders, following a conventional perioperative protocol was the only factor associated to prolonged hospital LOS (P<0.001). Conclusion: Implementing an ERP in elective colorectal surgery: 1) significantly reduced time to functional recovery and postoperative hospital LOS; 2) did not increase morbidity, mortality, and 30-day readmissions; and 3) significantly decreased institutional costs

Impact of an ERAS programme on clinical outcomes and institutional costs in elective laparoscopic and open colorectal resections

Objectives: The aim of this study was to assess the cost-effectiveness of standardised ERAS colorectal programme. We have investigated the impact of colorectal ERAS programme on different dimensions of effectiveness, in order to compare relevant cost items across treatment groups. Methods: To determine the costs-effectiveness of the ERAS programme vs. traditional care for patients undergoing elective colorectal surgery we collected costs on: 1) Preoperative phase (i.e. counselling) 2) Direct cost of hospitalisation and re-hospitalisation (i.e. drugs, exams, length of stay (LOS)) in a prospective series of 76 patients undergoing elective colorectal resection following a standardised ERAS protocol in 2013-2014 (ERAS group) compared to 74 patients operated in the same institution before the introduction of ERAS methodology in 2010-11 (Traditional group). In both groups exclusion criteria were: age >80 years, ASA IV, TNM IV and inflammatory bowel disease. Functional recovery time, morbidity and mortality, LOS and readmission rate between groups were compared. Data (median [IQR 25-75] or mean±SD) were analyzed using chi-square, t-Test, and log-rank tests. Linear regression analysis was performed to identify factors associated with an increase in costs. Results: Time to functional recovery and LOS (4 [4-6] vs. 8 [7-9] days, p<0.001) were shorter in the ERAS group vs. controls. Morbidity, mortality, and 30-day readmissions did not significantly differ between groups. Total mean direct costswere significantly higher in the traditional group compared with the ERAS group (V7,664.93±4,018.15 vs.V5,350.19±1,560.78;p<0.001). Linear regression analysis showed that the average differences in cost between the two groups appear to be driven by LOS.Conclusion: Implementing an ERAS programme in elective colorectal surgery: 1) significantly reduced both time to functional recovery and LOS; 2) did not increase morbidity, mortality, and 30-day readmissions; 3) significantly decreased direct costs