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

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

Prediction of wind drift and evaporation losses of a sprinkler irrigation system using principal component analysis and artificial neural network technique

Principal component analysis was merged with the artificial neural network (ANN) technique to predict wind drift and&nbsp;evaporation losses (WDEL) from a sprinkler irrigation system. For this purpose, field experiments were conducted to determine&nbsp;WDEL under different conditions. Data from field experiments and previous studies were used as sample data to train the ANN&nbsp;model. Three models were developed to predict WDEL. In the first model (ANN1), 9 neurons (riser height, main nozzle diameter,&nbsp;auxiliary nozzle diameter, discharge rate of the main nozzle, discharge rate of the auxiliary nozzle, operating pressure, wind&nbsp;speed, air temperature and relative humidity) were used as the input layer. In the second model (ANN2), 7 neurons (riser height,&nbsp;operating pressure, wind speed, air temperature and relative humidity, diameter ratio and discharge ratio) were used as the input&nbsp;layer. The third model (ANN3) used a multivariate technique (PC1, PC2, and PC3). Results revealed that the ANN3 model had&nbsp;the highest coefficient of determination (R2 = 0.8349). The R2 values for the ANN1 and ANN2 models were 0.7792 and 0.4807,&nbsp;respectively. It can be concluded that the ANN3 model has the highest predictive capacity

Satellite-Based Determination of the Water Footprint of Carrots and Onions Grown in the Arid Climate of Saudi Arabia

Increasing demand for food, climate change, and other human interventions are leading to significant increases in water consumption by the agricultural sector. This requires rationalizing the water used for the production of agricultural crops through improved irrigation management practices. Therefore, this study aimed to estimate the water footprint (WF) of onion (Allium cepa L.) and carrot (Daucus carota) crops using the CROPWAT model and the SSEB (Simplified Surface Energy Balance) algorithm. Experiments were carried out at two center-pivot irrigated fields belonging to Tawdeehiya Commercial Farms in the southeastern region of the Riyadh governorate, Saudi Arabia. Individual bands and vegetation indices (VIs) were retrieved from Sentinel-2 satellite data, including the normalized difference vegetation index (NDVI), soil adjusted vegetation index (SAVI), optimized soil adjusted vegetation index (OSAVI), renormalized difference vegetation index (RDVI), and enhanced vegetation index (EVI), and the land surface temperatures (LST) extracted from Landsat-8 data were used to estimate crop productivity (CP), crop water use (CWU) (i.e., evapotranspiration—ETa), and crop WF. Crop growth/phenology stages and georeferenced biophysical parameters were recorded during the growth period, and crop yield samples were collected randomly from predetermined sampling locations. It was found that the NIR band was appropriate for predicting onion yield (R2 = 0.68; p > F = 0.02) and carrot yield (R2 = 0.77; p > F = 0.02). The results also showed the feasibility of using the RDVI and EVI to estimate the yields of onion and carrot crops, with bias values of 15% and –17%, respectively. The CWU has also been successfully estimated using the SSEB algorithm, with an overall accuracy of 89%. The SSEB-estimated CWU was relatively high compared to the applied amounts by 10.6% (onions) and 12.6% (carrots). Finally, the crop WF was successfully estimated at 312 m3 t−1 and 230 m3 t−1 for carrots and onions, respectively, with an overall accuracy of 71.11%. The outcomes of this study can serve as a reference for crop irrigation management practices in the study region and areas with similar environmental conditions

Integrating Tillage and Mulching Practices as an Avenue to Promote Soil Water Storage, Growth, Production, and Water Productivity of Wheat under Deficit Irrigation in Arid Countries

Ensuring food security with limited water resources in arid countries requires urgent development of innovative water-saving strategies. This study aimed to investigate the effects of various tillage and mulching practices on soil water storage (SWS), growth, production, irrigation water use efficiency (IWUE), and water productivity (WP) of wheat under full (FL) and limited (LM) irrigation regimes in a typical arid country. The tillage practices comprised the conventional tillage (CT) and reduced tillage (RT), each with five mulching treatments (MT), including non-mulched (NM), plastic film mulch (PFM), wheat straw mulch (WSM), palm residues mulch (PRM), and a mixture of wheat straw and palm residues at 50/50 ratio (MM). Results showed higher SWS at different measured time points in CT than RT at 20–40 cm, 40–60 cm, and 0–60 cm soil depth under FL regime, and at 40–60 cm under LM regime, while the opposite was observed at 0–20 cm and 20–40 cm soil depth under LM regime. SWS at different soil depths under MT, in most cases, followed the order of PFM > PRM ≈ MM > WSM > NM under FL, and PFM ≈ PRM > MM > WSM > NM under LM regimes. No significant differences were observed for traits related to growth between CT and RT, but RT increased the traits related to yield, IWUE, and WP by 5.9–11.6% than did CT. PFM and PRM or PRM and MM showed the highest values for traits related to growth or yield, IWUE, and WP, respectively. No significant differences in all traits between CT and RT under the FL regime were observed, however, RT increased all traits by 8.0–18.8% than did CT under the LM regime. The yield response factor (Ky) based on plant dry weight (KyPDW) and grain yield (KyGY) under RT was acceptable for four MT, while KyGY under CT was acceptable only for PRM, as the Ky values in these treatments were 2 range 0.57 to 0.92), while they exhibited a second order polynomial and moderate correlation with IWUE and WP (R2 range 0.29 to 0.54). Overall, combining RT with plant residue mulching, particularly using the readily available palm residues in sufficient amount is a feasible and sustainable water-saving strategy for enhancing wheat yield and WP in irrigated arid countries, such as Saudi Arabia

CART and IDC – based classification of irrigated agricultural fields using multi-source satellite data

To understand water productivity of crops cultivated in the Eastern Province of Saudi Arabia, this study was conducted to generate a reliable crop type map using a multi-temporal satellite data (ASTER, Landsat-8 and MODIS) and crop phenology. Classification And Regression Tree (CART) and ISO-DATA Cluster (IDC) classification techniques were utilized for the identification of crops. The Ideal Crop Spectral Curves were generated and utilized for the formulation of CART decision rules. For IDC, the stacked images of the phenology-integrated Normalized Difference Vegetation Index were utilized for the classification. The overall accuracy of the classified maps of CART was 76, 77 and 81% for ASTER, MODIS and Landsat-8, respectively. For IDC, the accuracy was determined at 67, 63 and 60% for ASTER, MODIS and Landsat-8, respectively. The developed decision rules can be efficiently used for mapping of crop types for the same agro-climatic region of the study area