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

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

Prevalence and Knowledge of Respiratory Symptoms Among the General Public in the Southern Area of Najran, Saudi Arabia: A Cross-Sectional Health Survey Study

Mohammad H Alyami,1 Abdallah Y Naser,2 Hamad S Alyami,1 Thamer S Algahtani,1 Abdullah H Alyami,3 Saleh A Alsalem,3 Abdullah H Almansour,3 Hadi S Alswar,3 Ali M Al Alhareth3 1Department of Pharmaceutics, College of Pharmacy, Najran University, Najran, Saudi Arabia; 2Department of Applied Pharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan; 3Directorate of Health Affairs Najran, Ministry of Health, Najran, Saudi ArabiaCorrespondence: Mohammad H Alyami, Department of Pharmaceutics, College of Pharmacy, Najran University, Najran, 11001, Saudi Arabia, Tel +966 565022774, Email [email protected] Abdallah Y Naser, Department of Applied Pharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan, Tel +962 795285555, Email [email protected]: To investigate the knowledge, prevalence of chronic respiratory disorders, and utilization of their medications among the adults at Najran region, Saudi Arabia.Methods: An online cross-sectional survey was carried out in Najran region, Saudi Arabia. A self-administered questionnaire was distributed among a random sample of the general population, aged 18 or above between March and December 2022. The survey instrument included questions regarding history and exposure, physician diagnosed-disorders, respiratory symptoms, allergy, use of medications and possible risk-related factors.Results: This research had a total of 712 individuals. Nearly one-third of the participants in the survey (n = 218; 30.6%) said that they or a member of their family suffer from respiratory ailments. The majority of research participants (n = 167; 76.8%) identified asthma as their primary respiratory condition. A total of 32.0% of participants (n = 70) reported dealing with dust or chemicals such as paints, fertilizers, and cleaning products on a daily basis at work or at home. Around 62.0% of the participants (n = 134) said that exposure to gases, fragrances, and other such substances negatively impacts their health. Almost 78.0% (n = 169) of them indicated that summer weather affects their health, whereas 63.0% (n = 138) reported that winter cold affects their health. Participants aged 41– 50 years were 38.0% less likely to have CRDs compared to others (p < 0.05).Conclusion: This study is among the first few studies that explored the knowledge, prevalence of chronic respiratory disorders, and utilization of their medications among the adults at Najran region, Saudi Arabia. In the southern area of Najran, respiratory symptoms are frequent among the inhabitants of Saudi Arabia. More research is required to discover avoidable risk factors and create countermeasures for them. It is recommended that healthcare personnel increase their efforts to educate their patients about respiratory illness prevention methods.Keywords: diseases, respiratory, Saudi Arabia, symptom

Seasonal variations in cardiovascular disease

Cardiovascular disease (CVD) follows a seasonal pattern in many populations. Broadly defined winter peaks and clusters of all subtypes of CVD after 'cold snaps' are consistently described, with corollary peaks linked to heat waves. Individuals living in milder climates might be more vulnerable to seasonality. Although seasonal variation in CVD is largely driven by predictable changes in weather conditions, a complex interaction between ambient environmental conditions and the individual is evident. Behavioural and physiological responses to seasonal change modulate susceptibility to cardiovascular seasonality. The heterogeneity in environmental conditions and population dynamics across the globe means that a definitive study of this complex phenomenon is unlikely. However, given the size of the problem and a range of possible targets to reduce seasonal provocation of CVD in vulnerable individuals, scope exists for both greater recognition of the problem and application of multifaceted interventions to attenuate its effects. In this Review, we identify the physiological and environmental factors that contribute to seasonality in nearly all forms of CVD, highlight findings from large-scale population studies of this phenomenon across the globe, and describe the potential strategies that might attenuate peaks in cardiovascular events during cold and hot periods of the year.Simon Stewart, Ashley K. Keates, Adele Redfern and John J. V. McMurra

Seasonal variations in cardiovascular disease

Cardiovascular disease (CVD) follows a seasonal pattern in many populations. Broadly defined winter peaks and clusters of all subtypes of CVD after 'cold snaps' are consistently described, with corollary peaks linked to heat waves. Individuals living in milder climates might be more vulnerable to seasonality. Although seasonal variation in CVD is largely driven by predictable changes in weather conditions, a complex interaction between ambient environmental conditions and the individual is evident. Behavioural and physiological responses to seasonal change modulate susceptibility to cardiovascular seasonality. The heterogeneity in environmental conditions and population dynamics across the globe means that a definitive study of this complex phenomenon is unlikely. However, given the size of the problem and a range of possible targets to reduce seasonal provocation of CVD in vulnerable individuals, scope exists for both greater recognition of the problem and application of multifaceted interventions to attenuate its effects. In this Review, we identify the physiological and environmental factors that contribute to seasonality in nearly all forms of CVD, highlight findings from large-scale population studies of this phenomenon across the globe, and describe the potential strategies that might attenuate peaks in cardiovascular events during cold and hot periods of the year

Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle-income countries

Background: Child health is a key priority on the global health agenda, yet the provision of essential and emergency surgery in children is patchy in resource-poor regions. This study was aimed to determine the mortality risk for emergency abdominal paediatric surgery in low-income countries globally. Methods: Multicentre, international, prospective, cohort study. Self-selected surgical units performing emergency abdominal surgery submitted prespecified data for consecutive children aged &lt;16 years during a 2-week period between July and December 2014. The United Nation's Human Development Index (HDI) was used to stratify countries. The main outcome measure was 30-day postoperative mortality, analysed by multilevel logistic regression. Results: This study included 1409 patients from 253 centres in 43 countries; 282 children were under 2 years of age. Among them, 265 (18.8%) were from low-HDI, 450 (31.9%) from middle-HDI and 694 (49.3%) from high-HDI countries. The most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p&lt;0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed. Conclusions: Adjusted mortality in children following emergency abdominal surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries. Effective provision of emergency essential surgery should be a key priority for global child health agendas