151
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Purcell LN, Robinson B, Msosa V, Gallaher J, Charles A. District General Hospital Surgical Capacity and Mortality Trends in Patients with Acute Abdomen in Malawi. World J Surg 2020; 44:2108-2115. [PMID: 32166470 PMCID: PMC7292121 DOI: 10.1007/s00268-020-05468-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The burden of emergency general surgery conditions is high in sub-Saharan Africa, and poor access to surgical care leads to poor patient outcomes. We examined the trends in mortality in patients presenting with an acute abdomen to a referral hospital. METHODS A retrospective analysis of the prospectively collected Kamuzu Central Hospital Acute Care Surgery database was performed (January 2014 to July 2019). Bivariate analysis was conducted by year of admission. A multivariate Poisson regression was performed to identify predictors of mortality. RESULTS During the study, 2509 patients with acute abdomen presented. The majority of patients presenting were transferred from outside hospitals (n = 2097, 83.9%). Mortality was highest in patients with preoperative diagnosis of peritonitis (n = 119, 22.2%), bowel obstruction (n = 214, 18.7%), and volvuli (n = 51, 18.6%). There was no difference in mortality by year, p = 0.1. On multivariate Poisson regression, there was an increased relative risk of mortality with being transferred (RR 1.31, 95% CI 1.12-1.55, p = 0.002), as well as undergoing an operation within 1-2 days (RR 1.48, 95% CI 1.16-1.87, p < 0.001) and >2 days (RR 1.46, 95% CI 1.17-1.82, p = 0.001) after presentation. CONCLUSION The majority of patients in our study who presented with an acute abdomen were transferred from district hospitals, which resulted in high mortality due to delays in surgical care. Therefore, the WHO's recommendation that the majority of district hospitals perform the Bellwether procedures does not occur in district hospitals in central Malawi. District hospitals require significant resource investment to reduce transfers needs and patient mortality.
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Affiliation(s)
- Laura N Purcell
- Department of Surgery, UNC School of Medicine, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA
| | - Brittany Robinson
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | | | - Jared Gallaher
- Department of Surgery, UNC School of Medicine, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA
| | - Anthony Charles
- Department of Surgery, UNC School of Medicine, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA.
- Kamuzu Central Hospital, Lilongwe, Malawi.
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152
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Li Z, Zhang H, Huang H. Cerebral Venous Sinus Thrombosis in a Patient with Appendicular Abscess. World Neurosurg 2020; 142:108-111. [PMID: 32599191 DOI: 10.1016/j.wneu.2020.06.183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/21/2020] [Accepted: 06/22/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute appendicitis is a common abdominal emergency, while cerebral venous sinus thrombosis (CVST) is a rare cerebral vascular disease. Cases of CVST in patients with appendicitis have not been reported in the literature. We present a case of CVST in a patient with appendicular abscess. CASE DESCRIPTION A 56-year old man presented to our department with a headache for 6 days; he had a history of abdominal pain 15 days before admission. Abdominal contrast-enhanced computed tomography revealed appendicular abscess. Head magnetic resonance venography and contrast-enhanced magnetic resonance imaging showed thrombosis in the left transverse and sigmoid sinus. Antithrombotic treatments were administered, and antibiotic treatments and puncture and drainage were used to treat the appendicular abscess. The patient's headache disappeared after 10 days of treatment, and he had recovered well clinically at 3-month follow-up. CONCLUSIONS CVST after acute appendicitis is rare, and clinicians should be aware of this complication when suspicious symptoms occur. The underlying mechanisms require further investigation.
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Affiliation(s)
- Zhao Li
- Department of Neurosurgery, Shengzhou People's Hospital, the First Affiliated Hospital of Zhejiang University Shengzhou Branch, Shengzhou, Zhejiang, China.
| | - Han Zhang
- Department of Neurosurgery, Shengzhou People's Hospital, the First Affiliated Hospital of Zhejiang University Shengzhou Branch, Shengzhou, Zhejiang, China
| | - Hangbin Huang
- Department of Neurosurgery, Shengzhou People's Hospital, the First Affiliated Hospital of Zhejiang University Shengzhou Branch, Shengzhou, Zhejiang, China
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153
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Peripheral Cytotoxic T Cell Lymphoma of the Appendix Presenting as Acute Appendicitis. Case Rep Oncol Med 2020; 2020:8569426. [PMID: 32612863 PMCID: PMC7317332 DOI: 10.1155/2020/8569426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/17/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction Lymphoma of the appendix is a rare cause of acute appendicitis; however, acute appendicitis is a common first manifestation of appendiceal lymphomas. Cytotoxic peripheral T cell lymphoma (PTCL) is a type of aggressive non-Hodgkin lymphoma that portends a generally poor outcome. Cytotoxic PTCL of the appendix is extremely rare with few cases reported in the literature. Case Presentation. This is the report of a 23-year-old man who had experienced lower abdominal pain for three months before presenting to the emergency department with severe right lower abdominal pain, nausea, vomiting, and anorexia since the day prior to admission. The patient was diagnosed with acute appendicitis, and the pathology report confirmed cytotoxic PTCL of the appendix. Conclusion Patients with appendiceal PTCL commonly present with signs and symptoms of acute appendicitis due to luminal obstruction by the tumor. Therefore, appendiceal tumors such as PTCL should be considered in the differential diagnosis of patients presenting as acute appendicitis. In addition, since there is no standard chemotherapy regimen for cytotoxic PTCL, this and other case reports hopefully help in providing the clinical evidence needed for establishing appropriate treatment guidelines.
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154
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Lelli Chiesa P, Osman OTM, Aloi A, Andriani M, Benigni A, Catucci C, Giambelli P, Lisi G, Nugud FM, Presutti P, Prussiani V, Racalbuto V, Rossi F, Santoponte G, Turchetta B, Salman DEYM, Chiarelli F, Calisti A. Improving standard of pediatric surgical care in a low resource setting: the key role of academic partnership. Ital J Pediatr 2020; 46:80. [PMID: 32517726 PMCID: PMC7285579 DOI: 10.1186/s13052-020-00827-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 05/05/2020] [Indexed: 11/23/2022] Open
Abstract
Background An epidemiological transition is interesting Sub-Saharan Africa increasing the burden of non-communicable diseases most of which are of surgical interest. Local resources are far from meeting needs and, considering that 50% of the population is less than 14 years of age, Pediatric surgical coverage is specially affected. Efforts are made to improve standards of care and to increase the number of Pediatric surgeons through short-term specialist surgical Missions, facilities supported by humanitarian organization, academic Partnership, training abroad of local surgeons. This study is a half term report about three-years Partnership between the University of Chieti- Pescara, Italy and the University of Gezira, Sudan to upgrade standard of care at the Gezira National Centre for Pediatric Surgery (GNCPS) of Wad Medani. Four surgical Teams per year visited GNCPS. The Program was financed by the Italian Agency for Development Cooperation. Methods The state of local infrastructure, current standard of care, analysis of caseload, surgical activity and results are reported. Methods utilized to assess local needs and to develop Partnership activities are described. Results Main surgical task of the visiting Team were advancements in Colorectal procedures, Epispadias/Exstrophy Complex management and Hypospadias surgery (20% of major surgical procedures at the GNCPS). Intensive care facilities and staff to assist more complex cases (i.e. neonates) are still defective. Proctoring, training on the job of junior surgeons, anaesthetists and nurses, collaboration in educational programs, advisorship in hospital management, clinical governance, maintenance of infrastructure together with training opportunities in Italy were included by the Program. Despite on-going efforts, actions have not yet been followed by the expected results. More investments are needed on Healthcare infrastructures to increase health workers motivation and prevent brain drain. Conclusions The key role that an Academic Partnership can play, acting through expatriated Teams working in the same constrained contest with the local workforce, must be emphasized. Besides clinical objectives, these types of Global Health Initiatives address improvement in management and clinical governance. The main obstacles to upgrade standard of care and level of surgery met by the Visiting Team are scarce investments on health infrastructure and a weak staff retention policy, reflecting in poor motivation and low performance.
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Affiliation(s)
- Pierluigi Lelli Chiesa
- Cattedra e UOC di Chirurgia Pediatrica - Università "Gabriele d'Annunzio" Chieti-Pescara, Via Fonte Romana, 8, 65124, Pescara, Italy.
| | | | - Antonio Aloi
- Dipartimento di Medicina e Scienze dell'Invecchiamento, Università "Gabriele d'Annunzio", Chieti-Pescara, Italy
| | | | - Alberto Benigni
- Dipartimento di Emergenza, Urgenza e Area Critica - A.S.S.T. "Papa Giovanni XXIII", Bergamo, Italy
| | | | - Paolo Giambelli
- Agenzia Italiana Cooperazione Allo Sviluppo, Sede di Khartoum, Wad Medani, Sudan
| | - Gabriele Lisi
- Cattedra e UOC di Chirurgia Pediatrica - Università "Gabriele d'Annunzio" Chieti-Pescara, Via Fonte Romana, 8, 65124, Pescara, Italy
| | - Faisal M Nugud
- Gezira National Center Of Pediatric Surgery, Wad Medani, Sudan
| | - Paola Presutti
- Anestesia e Rianimazione, A.O. "San Camillo Forlanini", Roma, Italy
| | - Viviana Prussiani
- Dipartimento di Emergenza, Urgenza e Area Critica - A.S.S.T. "Papa Giovanni XXIII", Bergamo, Italy
| | - Vincenzo Racalbuto
- Agenzia Italiana Cooperazione Allo Sviluppo, Sede di Khartoum, Wad Medani, Sudan
| | - Fabio Rossi
- UOC di Chirurgia Pediatrica, A.O.U. "Maggiore della Carità", Novara, Italy
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155
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Mjema KM, Sawe HR, Kulola I, Mohamed AS, Sylvanus E, Mfinanga JA, Weber EJ. Aetiologies and outcomes of patients with abdominal pain presenting to an emergency department of a tertiary hospital in Tanzania: a prospective cohort study. BMC Gastroenterol 2020; 20:173. [PMID: 32503438 PMCID: PMC7275297 DOI: 10.1186/s12876-020-01313-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/20/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Abdominal pain in adults represents a wide range of illnesses, often warranting immediate intervention. This study is to fill the gap in the knowledge about incidence, presentation, causes and mortality from abdominal pain in an established emergency department of a tertiary hospital in Tanzania. METHODS This was a prospective cohort study of adult (age ≥ 18 years) patients presenting to the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH) in Dar Es Salaam, Tanzania with non-traumatic abdominal pain from September 2017 to October 2017. A case report form was used to record data on demographics, clinical presentation, management, diagnosis, outcomes and patient follow-up. The primary outcome of mortality was summarized using descriptive statistics; secondary outcome was, risks for mortality. RESULTS Among 3381 adult patients present during the study period, 288 (8.5%) presented with abdominal pain, and of these 199 (69%) patients were enrolled in our study. Median age was 47 years (IQR 35-60 years), 126 (63%) were female, and 118 (59%) were referred from another hospital. Most common final diagnoses were malignancies 71 (36%), intestinal obstruction 11 (6%) and peptic ulcer disease 9 (5%). Most common EMD interventions given were intravenous fluids 57 (21%), analgesia 49 (25%) and antibiotics 40 (20%). 160 (80%) were admitted of which 15 (8%) underwent surgery directly from EMD. 24-h and 7-day mortality were 4 (2%) and 7 (4%) respectively, while overall in hospital-mortality was 16 (8%). Among the risk factors for mortality were male sex Relative Risk (RR) 2.88 (p = 0.03), hypoglycemia (RR) 5.7 (p = 0.004), ICU admission (RR) 14 (p < 0.0001), receipt of IV fluids (RR) 3.2 (p = 0.0151) and need for surgery (RR) 6.6 (p = 0.0001). CONCLUSION Abdominal pain was associated with significant morbidity and mortality as evidenced by a very high admission rate, need for surgical intervention and a high in-hospital mortality rate. Future studies and quality improvement efforts should focus on identifying why such differences exist and how to reduce the mortality.
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Affiliation(s)
- Kilalo M Mjema
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania. .,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
| | - Irene Kulola
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Amour S Mohamed
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Erasto Sylvanus
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania
| | - Juma A Mfinanga
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Ellen J Weber
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.,Department of Emergency Medicine, University of California, San Francisco, CA, USA
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156
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Becher RD, Sukumar N, DeWane MP, Stolar MJ, Gill TM, Schuster KM, Maung AA, Zogg CK, Davis KA. Hospital Variation in Geriatric Surgical Safety for Emergency Operation. J Am Coll Surg 2020; 230:966-973.e10. [PMID: 32032720 PMCID: PMC7409563 DOI: 10.1016/j.jamcollsurg.2019.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The American College of Surgeons maintains that surgical care in the US has not reached optimal safety and quality. This can be driven partially by higher-risk, emergency operations in geriatric patients. We therefore sought to answer 2 questions: First, to what degree does standardized postoperative mortality vary in hospitals performing nonelective operations in geriatric patients? Second, can the differences in hospital-based mortality be explained by patient-, operative-, and hospital-level characteristics among outlier institutions? STUDY DESIGN Patients 65 years and older who underwent 1 of 8 common emergency general surgery operations were identified using the California State Inpatient Database (2010 to 2011). Expected mortality was obtained from hierarchical, Bayesian mixed-effects logistic regression models. A risk-adjusted hospital-level standardized mortality ratio (SMR) was calculated from observed-to-expected in-hospital deaths. "Outlier" hospitals had an SMR 80% CI that did not cross the mean SMR of 1.0. High-mortality (SMR >1.0) and low-mortality (SMR <1.0) outliers were compared. RESULTS We included 24,207 patients from 107 hospitals. SMRs varied widely, from 2.3 (highest) to 0.3 (lowest). Eleven hospitals (10.3%) were poor-performing high-SMR outliers, and 10 hospitals (9.3%) were exceptional-performing low-SMR outliers. SMR was 3 times worse in the high-SMR compared with the low-SMR group (1.7 vs 0.6; p < 0.001). Patient-, operation-, and hospital-level characteristics were equivalent among outlier-hospitals. CONCLUSIONS Significant hospital variation exists in standardized mortality after common general surgery operations done emergently in older patients. More than 10% of institutions have substantial excess mortality. These findings confirm that the safety of emergency operation in geriatric patients can be significantly improved by decreasing the wide variability in mortality outcomes.
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Affiliation(s)
- Robert D Becher
- Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT.
| | - Nitin Sukumar
- Yale Center for Analytical Sciences Yale School of Public Health, New Haven, CT
| | - Michael P DeWane
- Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT
| | - Marilyn J Stolar
- Yale Center for Analytical Sciences Yale School of Public Health, New Haven, CT
| | - Thomas M Gill
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kevin M Schuster
- Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT
| | - Adrian A Maung
- Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT
| | - Cheryl K Zogg
- Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT
| | - Kimberly A Davis
- Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, New Haven, CT
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157
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Byun J, Min JY, Yang HB, Ko D, Kim HY, Min KB, Jung SE. Impact of hospital size on the outcomes of appendectomy in children: an analysis of a comprehensive nationwide pediatric dataset. Surg Today 2020; 50:1515-1523. [PMID: 32474641 DOI: 10.1007/s00595-020-02035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/17/2020] [Indexed: 11/26/2022]
Abstract
PURPOSES The purpose of this study was to investigate the outcomes after appendectomy in children according to hospital size. METHODS The records of 11,565 patients with the diagnosis-related group code for appendectomy were extracted from HIRA-Pediatric Patient Sample from 2012 to 2016. The number of hospital visits and the length of stay in hospital within 30 days after appendectomy were analyzed. RESULTS Patients who were treated at large-sized hospitals were more likely to be younger, more likely to reside in metropolitan areas, and tended to receive laparoscopic surgery. The number of hospital visits within 30 days in patients managed by medium- and large-sized hospitals decreased in comparison to small-sized hospitals. The length of hospital stay in large-sized hospitals was decreased in comparison to small- and medium-sized hospitals. A subgroup analysis revealed that complicated appendectomy did not have a significant impact on the difference in the length of hospital stay between hospital sizes. CONCLUSION The number of hospital visits and the length of hospital stay was higher in small-sized hospitals in comparison to large-sized hospitals. Appendectomy performed in the larger hospital showed better outcomes in pediatric patients. We recommend that pediatric surgical procedures be performed in large hospitals, and that proper incentives be given for procedures to be performed by pediatric specialists.
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Affiliation(s)
- Jeik Byun
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Jin-Young Min
- Institute of Health and Environment, Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Hee-Beom Yang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dayoung Ko
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery, College of Medicine, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
| | - Kyoung-Bok Min
- Department of Preventive Medicine, College of Medicine, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
| | - Sung Eun Jung
- Department of Pediatric Surgery, College of Medicine, Seoul National University, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea
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158
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Affording unavoidable emergency surgical care - The lived experiences and payment coping strategies of households in Ibadan metropolis, Southwestern Nigeria. PLoS One 2020; 15:e0232882. [PMID: 32433652 PMCID: PMC7239385 DOI: 10.1371/journal.pone.0232882] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 04/23/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pre-payment and risk pooling schemes, central to the idea of universal health coverage, should protect households from catastrophic health expenditure and impoverishment; particularly when emergency care is required. Inadequate financial protection consequent on surgical emergencies occurs despite the existence of risk-pooling schemes. This study documented the experiences and coping strategies of slum and non-slum dwellers in a southwestern metropolis of Nigeria who had undergone emergency surgery. METHODS In-depth interviews were conducted with 31 participants (13 slums dwellers, 18 non-slum dwellers) who had recently paid for emergency surgical care in Ibadan. Patients who had experienced catastrophic health expenditure from the use of emergency surgical care were identified and people who paid for the care were purposively selected for the interviews. Using an in-depth interview guide, information on the experiences and overall coping strategies during and after the hospitalization was collected. Data were analyzed inductively using the thematic approach. RESULTS The mean age of the 31 participants (consisting of 7 men and 24 women) was 31 ± 5.6years. Apathy to savings limited the preparation for unplanned healthcare needs. Choice of hospital was determined by word of mouth, perceptions of good quality or prompt care and availability of staff. Social networks were relied on widely as a coping mechanism before and during the admission. Patients that were unable to pay experienced poor and humiliating treatment (in severe cases, incarceration). Inability to afford care was exacerbated by double billing and extraneous charges. It was opined that health care should be more affordable for all and that the current National Health Insurance Scheme, that was operating sub-optimally, should be strengthened appropriately for all to benefit. CONCLUSION The study highlights households' poor attitude to health-related savings and pre-payment into a social solidarity fund to cover the costs of emergency surgical care. It also highlights the factors influencing costs of emergency surgical care and the role of social networks in mitigating the high costs of care. Improving financial protection from emergency surgical care would entail promoting a positive attitude to health-related savings, social solidarity and extending the benefits of social health insurance.
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159
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Soft Tissue Sepsis Places a Massive Burden on Regional and Tertiary Surgical Services in KZN Province South Africa. World J Surg 2020; 44:2526-2532. [DOI: 10.1007/s00268-020-05510-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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160
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The Changing Face of Emergency General Surgery: A 20-year Analysis of Secular Trends in Demographics, Diagnoses, Operations, and Outcomes. Ann Surg 2020; 271:581-589. [PMID: 30260804 DOI: 10.1097/sla.0000000000003066] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate secular trends in the epidemiology of emergency general surgery (EGS), by analyzing changes in demographics, diagnoses, operations, and outcomes between 1997 and 2016. SUMMARY BACKGROUND DATA The provision and delivery of EGS services is a globally and regionally important issue. The impact of changing demographics and surgical disease incidence on EGS services is not well understood. METHODS Data from all EGS hospital episodes of adults (aged >15) in Scotland between 1997 and 2016 were prospectively collected, including ICD-10 diagnostic codes and OPCS-4 procedure codes. The number and age- and sex-standardized rates per 100,000 population, per year, of the most common diagnoses and operations were calculated. We analyzed demographic changes over time using linear regression, and changes in characteristics, diagnoses, operations, and outcomes using Poisson analysis. RESULTS Data included 1,484,116 EGS hospital episodes. The number and age- and sex-standardized rate, per 100,000 population, of EGS admissions have increased over time, whereas that of EGS operations have decreased over time. Male admissions were unchanged, but with fewer operations over time, whereas female admissions increased significantly over time with no change in the operation rate. Poisson analysis demonstrated secular trends in demographics, admissions, operations, and outcomes in depth. CONCLUSIONS This 20-year epidemiological study of all EGS hospital episodes in Scotland has enhanced our understanding of secular trends of EGS, including demographics, diagnoses, operations, and outcomes. These data will help inform stakeholders in EGS service planning and delivery, as well as in surgical training, what has occurred in recent history.
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161
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Discovery of Urinary Proteomic Signature for Differential Diagnosis of Acute Appendicitis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3896263. [PMID: 32337245 PMCID: PMC7165319 DOI: 10.1155/2020/3896263] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/18/2019] [Indexed: 12/29/2022]
Abstract
Acute appendicitis is one of the most common acute abdomens, but the confident preoperative diagnosis is still a challenge. In order to profile noninvasive urinary biomarkers that could discriminate acute appendicitis from other acute abdomens, we carried out mass spectrometric experiments on urine samples from patients with different acute abdomens and evaluated diagnostic potential of urinary proteins with various machine-learning models. Firstly, outlier protein pools of acute appendicitis and controls were constructed using the discovery dataset (32 acute appendicitis and 41 control acute abdomens) against a reference set of 495 normal urine samples. Ten outlier proteins were then selected by feature selection algorithm and were applied in construction of machine-learning models using naïve Bayes, support vector machine, and random forest algorithms. The models were assessed in the discovery dataset by leave-one-out cross validation and were verified in the validation dataset (16 acute appendicitis and 45 control acute abdomens). Among the three models, random forest model achieved the best performance: the accuracy was 84.9% in the leave-one-out cross validation of discovery dataset and 83.6% (sensitivity: 81.2%, specificity: 84.4%) in the validation dataset. In conclusion, we developed a 10-protein diagnostic panel by the random forest model that was able to distinguish acute appendicitis from confusable acute abdomens with high specificity, which indicated the clinical application potential of noninvasive urinary markers in disease diagnosis.
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162
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Chapman SJ, Lee MJ, Blackwell S, Arnott R, Ten Broek RPG, Delaney CP, Dudi-Venkata NN, Hind D, Jayne DG, Mellor K, Mishra A, O'Grady G, Sammour T, Thorpe G, Wells CI, Wolthuis AM, Fearnhead NS. Establishing core outcome sets for gastrointestinal recovery in studies of postoperative ileus and small bowel obstruction: protocol for a nested methodological study. Colorectal Dis 2020; 22:459-464. [PMID: 31701620 DOI: 10.1111/codi.14899] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/08/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Gastrointestinal recovery describes the restoration of normal bowel function in patients with bowel disease. This may be prolonged in two common clinical settings: postoperative ileus and small bowel obstruction. Improving gastrointestinal recovery is a research priority but researchers are limited by variation in outcome reporting across clinical studies. This protocol describes the development of core outcome sets for gastrointestinal recovery in the contexts of postoperative ileus and small bowel obstruction. METHOD An international Steering Group consisting of patient and clinician representatives has been established. As overlap between clinical contexts is anticipated, both outcome sets will be co-developed and may be combined to form a common output with disease-specific domains. The development process will comprise three phases, including definition of outcomes relevant to postoperative ileus and small bowel obstruction from systematic literature reviews and nominal-group stakeholder discussions; online-facilitated Delphi surveys via international networks; and a consensus meeting to ratify the final output. A nested study will explore if the development of overlapping outcome sets can be rationalized. DISSEMINATION AND IMPLEMENTATION The final output will be registered with the Core Outcome Measures in Effectiveness Trials initiative. A multi-faceted, quality improvement campaign for the reporting of gastrointestinal recovery in clinical studies will be launched, targeting international professional and patient groups, charitable organizations and editorial committees. Success will be explored via an updated systematic review of outcomes 5 years after registration of the core outcome set.
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Affiliation(s)
- S J Chapman
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - M J Lee
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK
| | | | - R Arnott
- Patient Representative, Green Templeton College, Oxford, UK
| | - R P G Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - C P Delaney
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - N N Dudi-Venkata
- Discipline of Surgery, Faculty of Health and Medical Science, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - D Hind
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - D G Jayne
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - K Mellor
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - A Mishra
- Department of Surgery, Maulana Azad Medical College, New Delhi, India
| | - G O'Grady
- Department of Surgery, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - T Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - G Thorpe
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - C I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A M Wolthuis
- Department of Abdominal Surgery, University Hospital Leuven, Leuven, Belgium
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Salmasi MY, Al-Saadi N, Hartley P, Jarral OA, Raja S, Hussein M, Redhead J, Rosendahl U, Nienaber CA, Pepper JR, Oo AY, Athanasiou T. The risk of misdiagnosis in acute thoracic aortic dissection: a review of current guidelines. Heart 2020; 106:885-891. [PMID: 32170039 DOI: 10.1136/heartjnl-2019-316322] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 12/24/2022] Open
Abstract
Acute aortic syndrome and in particular aortic dissection (AAD) persists as a cause of significant morbidity and mortality despite improvements in surgical management. This clinical review aims to explore the risks of misdiagnosis, outcomes associated with misdiagnosis and evaluate current diagnostic methods for reducing its incidence.Due to the nature of the pathology, misdiagnosing the condition and delaying management can dramatically worsen patient outcomes. Several diagnostic challenges exist, including low prevalence, rapidly propagating pathology, non-discrete symptomatology, non-specific signs, analogy with other acute conditions and lack of management infrastructure. A similarity to acute coronary syndromes is a specific concern and risks patient maltreatment. AAD with malperfusion syndromes are both a cause of misdiagnosis and marker of disease complication, requiring specifically tailored management plans from the emergency setting.Despite improvements in diagnostic measures, including imaging modalities and biomarkers, misdiagnosis of AAD remains commonplace and current guidelines are relatively limited in preventing its occurrence. This paper recommends the early use of AAD risk scoring, focused echocardiography and most importantly, fast-tracking patients to cross-sectional imaging where the suspicion of AAD is high. This has the potential to improve the diagnostic process for AAD and limit the risk of misdiagnosis. However, our understanding remains limited by the lack of large patient datasets and an adequately audited processes of emergency department practice.
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Affiliation(s)
- M Yousuf Salmasi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nina Al-Saadi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Philip Hartley
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Omar A Jarral
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Shahzad Raja
- Cardiac Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
| | - Muthana Hussein
- Emergency Medicine, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, London, UK
| | - Julian Redhead
- Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Ulrich Rosendahl
- Cardiac Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
| | - Christoph A Nienaber
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - John R Pepper
- Cardiac Surgery, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
| | - Aung Y Oo
- Cardiac Surgery, Barts Health NHS Trust, London, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
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164
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Peiffer S, Pelton M, Keeney L, Kwon EG, Ofosu-Okromah R, Acharya Y, Chinchilli VM, Soybel DI, Oh JS, Ssentongo P. Risk factors of perioperative mortality from complicated peptic ulcer disease in Africa: systematic review and meta-analysis. BMJ Open Gastroenterol 2020; 7:e000350. [PMID: 32128227 PMCID: PMC7039611 DOI: 10.1136/bmjgast-2019-000350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 01/26/2023] Open
Abstract
Introduction In 2013, peptic ulcer disease (PUD) caused over 300 000 deaths globally. Low-income and middle-income countries are disproportionately affected. However, there is limited information regarding risk factors of perioperative mortality rates in these countries. Objective To assess perioperative mortality rates from complicated PUD in Africa and associated risk factors. Design We performed a systematic review and a random-effect meta-analysis of literature describing surgical management of complicated PUD in Africa. We used subgroup analysis and meta-regression analyses to investigate sources of variations in the mortality rates and to assess the risk factors contributing to mortality. Results From 95 published reports, 10 037 patients underwent surgery for complicated PUD. The majority of the ulcers (78%) were duodenal, followed by gastric (14%). Forty-one per cent of operations were for perforation, 22% for obstruction and 9% for bleeding. The operations consisted of vagotomy (38%), primary repair (34%), resection and reconstruction (12%), and drainage procedures (6%). The overall PUD mortality rate was 6.6% (95% CI 5.4% to 8.1%). It increased to 9.7% (95% CI 7.1 to 13.0) when we limited the analysis to studies published after the year 2000. The correlation was higher between perforated PUD and mortality rates (r=0.41, p<0.0001) than for bleeding PUD and mortality rates (r=0.32, p=0.001). Non-significant differences in mortality rates existed between sub-Saharan Africa (SSA) and North Africa and within SSA. Conclusion Perioperative mortality rates from complicated PUD in Africa are substantially high and could be increasing over time, and there are possible regional differences.
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Affiliation(s)
- Sarah Peiffer
- Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Matthew Pelton
- Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Laura Keeney
- Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Eustina G Kwon
- Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Yubraj Acharya
- Department of Health Policy and Administration, College of Health and Human Development, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Vernon M Chinchilli
- Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - David I Soybel
- Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - John S Oh
- Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Paddy Ssentongo
- Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.,Department of Public Health Science, Penn State College of Medicine, Hershey, Pennsylvania, USA.,Center for Neural Engineering, Department of Engineering, Science and Mechanics, Pennsylvania State University, University Park, Pennsylvania, USA
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165
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Hyponatremia as a marker of complicated appendicitis: A systematic review. Surgeon 2020; 18:295-304. [PMID: 32035730 DOI: 10.1016/j.surge.2020.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 12/30/2019] [Accepted: 01/06/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Acute appendicitis, the most common cause of acute surgical abdomen, is associated with intra-abdominal complications, such as perforation, that increase morbidity and mortality. Early and accurate preoperative diagnosis of complicated appendicitis mandates the identification of new diagnostic markers. This systematic review summarizes current literature on the adoption of hyponatremia as an early diagnostic and predictive marker of complicated appendicitis. METHODS Pubmed, Cochrane Library, Scopus, Google Scholar, WHO Global Health Library, System for Information on Grey Literature, ISI Web of Science, EBSCOHost and Virtual Health Library were searched in accordance with the PRISMA guidelines in order to identify original human studies investigating the association between hyponatremia and the presence or development of complicated appendicitis. RESULTS A total of 7 studies conducted in 6 different countries were identified. A prospective diagnostic accuracy study reported a strong association between hyponatremia and complicated appendicitis in children. The largest sample size study performed in adults reported a significant association between hyponatremia and perforated or gangrenous appendicitis. CONCLUSIONS The admission serum sodium level measurement, a routinely performed, low-cost test, should be taken into account in patients with clinical presentation compatible with acute appendicitis and suspicion of underlying complications. Future well-designed prospective diagnostic accuracy studies are required to further establish the association between hyponatremia and perforated appendicitis.
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166
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Kim KB, Park HJ, Song DH. Semi-dynamic Control of FCM Initialization for Automatic Extraction of Inflamed Appendix from Ultrasonography. Curr Med Imaging 2020; 15:810-816. [PMID: 32008549 PMCID: PMC7040513 DOI: 10.2174/1573405614666180719142536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 06/24/2018] [Accepted: 07/05/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Current naked-eye examination of the ultrasound images for inflamed appendix has limitations due to its intrinsic operator subjectivity problem. OBJECTIVE In this paper, we propose a fully automatic intelligent method for extracting inflamed appendix from ultrasound images. Accurate and automatic extraction of inflamed appendix from ultrasonography is a major decision making resource of the diagnosis and management of suspected appendicitis. METHODS The proposed method uses Fuzzy C-means learning algorithm in pixel clustering with semi-dynamic control of initializing the number of clusters based on the intensity contrast dispersion of the input image. Thirty percent of the prepared ultrasonography samples are classified into four different groups based on their intensity contrast distribution and then different number of clusters are assigned to the images in accordance with such groups in Fuzzy C-means learning process. RESULTS In the experiment, the proposed system successfully extracts the target without human intervention in 82 of 85 cases (96.47% accuracy). The proposed method also shows that it can cover the false negative cases occurred previously that used self-organizing map as the learning engine. CONCLUSION Such high level reliable correct extraction of inflamed appendix encourages to use the automatic extraction software in the diagnosis procedure of suspected acute appendicitis.
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Affiliation(s)
- Kwang Baek Kim
- Division of Computer Software Engineering, Silla University, Busan 46958, South Korea
| | - Hyun Jun Park
- Division of Software Convergence, Cheongju University, Cheongju 28503, South Korea
| | - Doo Heon Song
- Department of Computer Games, Yong-In SongDam College, Yongin 17145, South Korea
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167
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Destek S, Gül VO, Menteş MÖ, Çiçek AF. Diagnostic efficacy of serum procalcitonin, IL-6, IL-2, and D-dimer levels in an experimental acute appendicitis model. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:641-647. [PMID: 31290753 DOI: 10.5152/tjg.2019.18534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND/AIMS Acute appendicitis is the most frequent cause of acute abdomen emergency surgery. It continues to be a problem today due to delayed diagnosis and its high perforation rate. For this reason, diagnostic tests continue to be developed. In this experimental study, the diagnostic significance of blood procalcitonin (PCT), interleukin (IL)-6, IL-2, and D-dimer levels in an acute appendicitis model in rabbits was investigated. MATERIALS AND METHODS A total of five groups were included: control group, sham group, and three different acute appendicitis groups. In the appendicitis groups, the appendix was ligated by laparotomy, and the blood PCT, IL-6, IL-2, and D-dimer levels were measured at 12 (group 3), 24 (group 4), and 48 h (group 5). Then, an appendectomy was performed. RESULTS In the present study, PCT and IL-6 levels increased in parallel with the inflammation of the appendix in all groups and were found to be statistically significant. IL-2 and D-dimer values were higher in the groups diagnosed with appendicitis but were not statistically significant. CONCLUSION In our experimental study, PCT and IL-6 levels were determined to be important in the early diagnosis of acute appendicitis, especially IL-6, and that these two parameters are more important markers than IL-2 and D-dimer.
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Affiliation(s)
- Sabahattin Destek
- Department of General Surgery, Bezmialem Vakif University School of Medicine, İstanbul, Turkey
| | - Vahit Onur Gül
- Department of General Surgery, Gülhane Military Medical Academy, Ankara, Turkey
| | - Mustafa Öner Menteş
- Department of General Surgery, Gülhane Military Medical Academy, Ankara, Turkey
| | - Ali Fuat Çiçek
- Department of Pathology, Gülhane Military Medical Academy, Ankara, Turkey
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169
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Brunner M, Lapins P, Langheinrich M, Baecker J, Krautz C, Kersting S, Weber GF, Grützmann R, Maak M. Risk factors for appendiceal neoplasm and malignancy among patients with acute appendicitis. Int J Colorectal Dis 2020; 35:157-163. [PMID: 31811385 DOI: 10.1007/s00384-019-03453-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Non-operative management of acute uncomplicated appendicitis has shown promising results but might carry the risk of delayed diagnosis of premalignant or malignant appendiceal tumors found by chance in 0.7-2.5% of appendiceal specimen after appendectomy. Purpose of this study was to analyze whether appendiceal tumors are associated with a complicated appendicitis and to determine risk factors for appendiceal neoplasm and malignancy in patients with acute appendicitis. METHODS We performed a retrospective analysis of 1033 adult patients, who underwent appendectomy for acute appendicitis from 2010 to 2016 at the University hospital Erlangen. Data included patients' demographics; comorbidities; pre-, intra- and postoperative findings; and histopathological results. Complicated appendicitis was defined in the presence of perforation or abscess. RESULTS Appendiceal neoplasm respectively malignancy rate was 2.8% respectively 1.5%. Using univariate analysis, we identified seven risk factors at least for appendiceal neoplasm or malignancy: age, ASA, C-reactive protein, appendiceal diameter, perforation, intraoperative perithyphilitic abscess, and complicated appendicitis. Risk for appendiceal neoplasm or malignancy was 4.4% respectively 2.7% in complicated acute appendicitis compared to 2.0% respectively 1.0% in uncomplicated appendicitis (p = 0.043 respectively p = 0.060). In multivariate analysis, age ≥ 50 years and a diameter of the appendix in the sonography ≥ 13 mm were independent risk factors predicting the presence of appendiceal neoplasm and malignancy. CONCLUSION Among patients with appendicitis, there are relevant risk factors predicting appendiceal tumors, especially age and appendiceal diameter in sonography. But the identified risk factors have a low sensitivity and specificity, so obtaining a confident preoperative diagnosis is challenging.
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Affiliation(s)
- Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany.
| | - Philipp Lapins
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Melanie Langheinrich
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Justus Baecker
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Stephan Kersting
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Matthias Maak
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054, Erlangen, Germany
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Rickard J, Beilman G, Forrester J, Sawyer R, Stephen A, Weiser TG, Valenzuela J. Surgical Infections in Low- and Middle-Income Countries: A Global Assessment of the Burden and Management Needs. Surg Infect (Larchmt) 2019; 21:478-494. [PMID: 31816263 DOI: 10.1089/sur.2019.142] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: The burden of surgical infections in low- and middle-income countries (LMICs) remains poorly defined compared with high-income countries. Although there are common infections necessitating surgery prevalent across the world, such as appendicitis and peptic ulcer disease, other conditions are more localized geographically. To date, comprehensive assessment of the burden of surgically treatable infections or sequelae of surgical infections in LMICs is lacking. Methods: We reviewed the literature to define the burden of surgical infections in LMICs and characterize the needs and challenges of addressing this issue. Results: Surgical infections comprise a broad range of diseases including intra-abdominal, skin and soft tissue, and healthcare-associated infections and other infectious processes. Treatment of surgical infections requires a functional surgical ecosystem, microbiology services, and appropriate and effective antimicrobial therapy. Systems must be developed and maintained to evaluate screening, prevention, and treatment strategies. Solutions and interventions are proposed focusing on reducing the burden of disease, improving surveillance, strengthening antibiotic stewardship, and enhancing the management of surgical infections. Conclusions: Surgical infections constitute a large burden of disease globally. Challenges to management in LMICs include a shortage of trained personnel and material resources. The increasing rate of antimicrobial drug resistance, likely related to antibiotic misuse, adds to the challenges. Development of surveillance, infection prevention, and antimicrobial stewardship programs are initial steps forward. Education is critical and should begin early in training, be an active process, and be sustained through regular programs.
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Affiliation(s)
- Jennifer Rickard
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gregory Beilman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joseph Forrester
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Robert Sawyer
- Department of Surgery, Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Andrew Stephen
- Department of Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Julie Valenzuela
- Department of Surgery, Northwell Health, New Hyde Park, New York, USA
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171
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Lin W, Han W, Wen K, Huang S, Tang Y, Lin Z, Han M. The Alterations of Copper and Zinc Homeostasis in Acute Appendicitis and the Clinical Significance. Biol Trace Elem Res 2019; 192:116-122. [PMID: 30771140 DOI: 10.1007/s12011-019-01661-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/04/2019] [Indexed: 02/05/2023]
Abstract
Copper (Cu) and zinc (Zn) are involved in inflammatory process. This study was to investigate the clinical significance of Cu and Zn homeostasis alterations in acute appendicitis (AA). One hundred twenty-two AA patients and 102 healthy controls were enrolled in this study. Of which, 85 patients' appendixes were collected after appendectomy. Another six appendixes from colon cancer patients were collected as tissue controls. The contents of Cu and Zn in serum or appendix were detected, and the Cu to Zn ratio (CZr) was calculated. The concentrations of serum ceruloplasmin (CP), Cu/Zn superoxide dismutase (SOD1), interleukin-6 (IL-6), and interleukin-22 in serum were measured, as well as the activity of CP and SOD1. The serum Zn concentration and SOD1 activity, appendix contents of Cu and Zn significantly decreased in AA patients, compared with those of controls, while serum CZr, concentrations of CP, SOD1, and IL-6, as well as CP activity increased significantly in AA patients. Additionally, serum concentrations of Zn, CP, CZr, or SOD1 activity varied in different pathological types of AA. Indicators such as serum SOD1 activity might serve as predictors for pathological classification before surgery. The serum Zn and CZr may be helpful for diagnosis of pure AA. The Cu and Zn homeostasis was altered in AA patients, which might contribute to inflammatory process of AA.
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Affiliation(s)
- Wenhao Lin
- Emergency Department of Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Wei Han
- Emergency Department of Shenzhen University General Hospital, Shenzhen, China
| | - Ke Wen
- Department of Microsurgery, Taihe Hospital, Shiyan, China
| | - Sunhua Huang
- Emergency Department of Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Yao Tang
- Emergency Department of Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Zhexuan Lin
- Bio-analytical Laboratory, Shantou University Medical College, Shantou, China.
| | - Ming Han
- Emergency Department of Shenzhen University General Hospital, Shenzhen, China.
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172
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Factors influencing surgical management of acute appendicitis in a large university hospital without a dedicated emergency theatre. Ir J Med Sci 2019; 189:649-653. [PMID: 31773540 DOI: 10.1007/s11845-019-02135-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/05/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute appendicitis is the most common surgical emergency. Its management reflects the efficacy of acute care surgery. Limited theatre space is an escalating issue, especially without dedicated emergency theatre access. Pre-operative delays are associated with longer length of stay, higher costs and post-operative complications. AIMS Calculate time to theatre (TTT) from admission to appendicectomy and investigate factors impacting TTT. METHODS A retrospective review of all emergency appendicectomies from June 2017 to October 2018. Demographic, clinico-pathological and radiological data were extracted from electronic patient record. RESULTS One hundred forty-eight patients underwent emergency appendicectomy during the study period. Fifty-six percent (n = 84) were male, and the median (range) age was 30.5 (17-76) years. Sixty-one percent had pre-operative imaging. The median (range) TTT was 18.37 (2-114) h; 7.5% (n = 11) waited > 48 h, 29.7% (n = 44) were operated on after 8 p.m. and 26% (n = 38) were done on elective lists. Male gender, admission CRP > 100 and admission before 12 p.m. significantly shortened TTT (p = 0.030, p = 0.004 and p = 0.001, respectively). However, pre-operative ultrasound, previous acute appendicitis and surgery on an elective list significantly prolonged TTT (p = 0.015 and p = 0.024, respectively). The median (range) LOS was 3 (1-24) nights. Ten percent (n = 15) had post-operative complications; however, longer TTT was not associated with higher complication rates (p = 0.196). CONCLUSIONS This review highlights the impact of limited theatre access for on-call emergency admissions, with a significant portion of appendicectomies being done on elective lists or out-of-hours.
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173
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Benchmarking Global Trauma Care: Defining the Unmet Need for Trauma Surgery in Ghana. J Surg Res 2019; 247:280-286. [PMID: 31690530 DOI: 10.1016/j.jss.2019.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/01/2019] [Accepted: 10/05/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND The Lancet Commission on Global Surgery recommended 5000 operations/100,000 persons annually, but did not define condition-specific guidelines. New Zealand, Lancet Commission on Global Surgery's benchmark country, documented 1158 trauma operations/100,000 persons, providing a benchmark for trauma surgery needs. We sought to determine Ghana's annual trauma operation rate compared with this benchmark. METHODS Data on all operations performed in Ghana from June 2014 to May 2015 were obtained from representative sample of 48/124 district (first level), 8/11 regional, and 3/5 tertiary hospitals and scaled up for nationwide estimates. Trauma operations were grouped by hospital level and categorized into "essential" (most cost-effective, highest population impact) versus "other" (specialized) as per the World Bank's Disease Control Priorities Project. Ghana's annual trauma operation rate was compared with the New Zealand benchmark to quantify current met needs for trauma surgery. RESULTS About 232,776 operations were performed in Ghana; 35,797 were for trauma. Annual trauma operation rate was 134/100,000 (95% UI: 98-169), only 12% of the New Zealand benchmark. District hospitals performed 62% of all operations in the country, but performed only 38% of trauma operations. Eighty seven percentage of trauma operations were deemed "essential". Among specialized trauma operations, only open reduction and internal fixations had even modest numbers (3483 operations). Most other specialized trauma operations were rare. CONCLUSIONS Ghana has a large unmet need for operative trauma care. The low percentage of trauma operations in district hospitals indicates an even greater unmet need in rural areas. Future global surgery benchmarking should consider benchmarks for trauma and other specialties, as well as for different hospital levels.
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174
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Killinger BA, Madaj Z, Sikora JW, Rey N, Haas AJ, Vepa Y, Lindqvist D, Chen H, Thomas PM, Brundin P, Brundin L, Labrie V. The vermiform appendix impacts the risk of developing Parkinson's disease. Sci Transl Med 2019; 10:10/465/eaar5280. [PMID: 30381408 DOI: 10.1126/scitranslmed.aar5280] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/14/2018] [Accepted: 06/08/2018] [Indexed: 12/12/2022]
Abstract
The pathogenesis of Parkinson's disease (PD) involves the accumulation of aggregated α-synuclein, which has been suggested to begin in the gastrointestinal tract. Here, we determined the capacity of the appendix to modify PD risk and influence pathogenesis. In two independent epidemiological datasets, involving more than 1.6 million individuals and over 91 million person-years, we observed that removal of the appendix decades before PD onset was associated with a lower risk for PD, particularly for individuals living in rural areas, and delayed the age of PD onset. We also found that the healthy human appendix contained intraneuronal α-synuclein aggregates and an abundance of PD pathology-associated α-synuclein truncation products that are known to accumulate in Lewy bodies, the pathological hallmark of PD. Lysates of human appendix tissue induced the rapid cleavage and oligomerization of full-length recombinant α-synuclein. Together, we propose that the normal human appendix contains pathogenic forms of α-synuclein that affect the risk of developing PD.
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Affiliation(s)
- Bryan A Killinger
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA
| | - Zachary Madaj
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA
| | - Jacek W Sikora
- Proteomics Center of Excellence, Northwestern University, Evanston, IL, USA
| | - Nolwen Rey
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA.,Paris-Saclay Institute of Neuroscience, Centre National de la Recherche Scientifique, 91190 Gif-sur-Yvette, France
| | - Alec J Haas
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA
| | - Yamini Vepa
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA
| | - Daniel Lindqvist
- Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden.,Psychiatric Clinic, Lund, Division of Psychiatry, Lund, Sweden
| | - Honglei Chen
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Paul M Thomas
- Proteomics Center of Excellence, Northwestern University, Evanston, IL, USA
| | - Patrik Brundin
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA
| | - Lena Brundin
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA
| | - Viviane Labrie
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA. .,Centre for Addiction and Mental Health, Toronto, ON, Canada
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Miyo M, Urabe S, Hyuga S, Nakagawa T, Michiura T, Hayashi N, Yamabe K. Clinical outcomes of single-site laparoscopic interval appendectomy for severe complicated appendicitis: Comparison to conventional emergency appendectomy. Ann Gastroenterol Surg 2019; 3:561-567. [PMID: 31549016 PMCID: PMC6750141 DOI: 10.1002/ags3.12277] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/17/2019] [Accepted: 06/28/2019] [Indexed: 02/06/2023] Open
Abstract
AIM Single-site laparoscopic interval appendectomy (SLIA) for severe complicated appendicitis after conservative treatment (CT) to ameliorate inflammation and eradicate the abscess should be safer and less invasive than emergency appendectomy (EA). However, only a few reports have been published regarding SLIA. METHODS We retrospectively collected data on 264 consecutive patients admitted to Kinan Hospital for treatment of appendicitis between 2012 and 2018. The safety and feasibility of SLIA and its perioperative outcomes for severe complicated appendicitis were investigated. RESULTS A total of 61 patients were included in this study, 25 of whom underwent CT and 36 EA. Among the 25 patients who underwent CT, 23 (92.0%) succeeded; a total of 16 patients (69.5%) underwent SLIA. Compared to the EA group, the SLIA group had less bleeding (median volume 8.5 vs 50 mL, P = .005) and lower rate of expansion surgery (0% vs 27.8%, P = .022). Although the postoperative hospital stay was shorter in the SLIA group than in the EA group (9 vs 12 days, P = .008), the total hospital stay, including the CT period, was longer in the SLIA group than in the EA group (24 vs 12 days, P < .001). CONCLUSION SLIA is safe, feasible, and less invasive than EA and may provide the advantages of minimally invasive surgery even if appendicitis is severe. SLIA may be a promising option for complicated appendicitis in select cases despite its disadvantage of prolonging the hospital stay.
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Affiliation(s)
- Masaaki Miyo
- Department of SurgeryKinan HospitalTanabeJapan
- National Hospital Organization Osaka National HospitalOsakaJapan
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Kim SY, Oh DJ, Park B, Park IS, Choi HG. Increased risk of appendectomy in patients with asthma: A nested case-control study using a national sample cohort. Medicine (Baltimore) 2019; 98:e17203. [PMID: 31567971 PMCID: PMC6756725 DOI: 10.1097/md.0000000000017203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The study aimed to expand previous data regarding an association between asthma and appendectomy in children compared with the population of all ages.The Korean Health Insurance Review and Assessment Service-National Sample Cohort from 2002 through 2013 was used. In all, 22,030 participants who underwent appendectomy were matched for age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia with 88,120 participants who were included as a control group. In both the appendectomy and control groups, previous history of asthma was investigated. Appendectomy for appendicitis was identified based on a surgical code (International Classification of Disease-10 [ICD-10]: K35). Asthma was classified using an ICD-10 code (J45 and J46) and medication history. The crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of asthma for appendectomy were analyzed using conditional logistic regression analysis. Subgroup analyses were conducted according to age and sex.Approximately 15.2% (3358/22,030) of individuals in the appendectomy group and 13.3% (11,749/88,120) of those in the control group had asthma (P < .001). The appendectomy group demonstrated a higher adjusted odds of asthma than the control group (adjusted OR 1.18, 95% CI 1.13-1.23, P < .001). This result was consistent in the subgroups divided according to age and sex.The odds for asthma were higher in the appendectomy group than in the control group.
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Affiliation(s)
- So Young Kim
- Department of Otorhinolaryngology-Head & Neck Surgery, CHA Bundang Medical Center, CHA University, Seongnam
| | - Dong Jun Oh
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul Hospital
| | - Bumjung Park
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Anyang
| | - Il-Seok Park
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Dongtan
| | - Hyo Geun Choi
- Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Anyang
- Hallym Data Science Laboratory, Hallym University College of Medicine, Anyang, Republic of Korea
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Bailey K, Choynowski M, Kabir SMU, Lawler J, Badrin A, Sugrue M. Meta-analysis of unplanned readmission to hospital post-appendectomy: an opportunity for a new benchmark. ANZ J Surg 2019; 89:1386-1391. [PMID: 31364257 DOI: 10.1111/ans.15362] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/03/2019] [Accepted: 06/10/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. While many studies report readmission, a meta-analysis of readmission post-appendectomy has not been published. This meta-analysis was undertaken to determine rates and predictors of hospital readmission following appendectomy and to potentially provide a metric benchmark. METHODS An ethically approved PROSPERO-registered (ID CRD42017069040) meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using databases PubMed and Scopus, was undertaken for studies published between January 2012 and June 2017. Articles relating to outcomes and readmissions after appendectomy were identified. Those scoring >15 for comparative studies and >10 for non-comparative studies, using Methodological Index for Non-Randomized Studies criteria were included in the final analysis. The odds ratios (OR) using random-effects, Mantel-Haenszel method with 95% confidence intervals (CI), were computed for each risk factor with RevMan5. RESULTS A total of 1757 articles reviewed were reduced to 45 qualifying studies for a final analysis of 836 921 appendectomies. 4.3% (range 0.0-14.4%) of patients were readmitted within 30 days. Significant preoperative patient factors for increased readmission were diabetes mellitus (OR 1.93, CI 1.63-2.28, P < 0.00001), complicated appendicitis (OR 3.6, CI 2.43-5.34, P < 0.00001) and open surgical technique (OR 1.39, CI 1.08-1.79, P < 0.00001). Increased readmission was not associated with gender, obesity or paediatric versus general surgeons or centres. CONCLUSION This meta-analysis identified that readmission is not uncommon post-appendectomy, occurring in one in 25 cases. The mean readmission rate of 4.3% may act as a quality benchmark for improving emergency surgical care. Targeting high-risk groups with diabetes or complicated appendicitis and increasing use of laparoscopic technique may help reduce readmission rates.
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Affiliation(s)
- Kate Bailey
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Michelle Choynowski
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Syed Mohammad Umar Kabir
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland.,Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland
| | - Jack Lawler
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Adibah Badrin
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | - Michael Sugrue
- Donegal Clinical and Research Academy, Letterkenny University Hospital, Letterkenny, Ireland.,Department of Surgery, Letterkenny University Hospital, Letterkenny, Ireland.,EU INTERREG Centre for Personalised Medicine Project, Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Magee Campus, Londonderry, Northern Ireland
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178
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Aluisio AR, Waheed S, Cameron P, Hess J, Jacob ST, Kissoon N, Levine AC, Mian A, Ramlakhan S, Sawe HR, Razzak J. Clinical emergency care research in low-income and middle-income countries: opportunities and challenges. BMJ Glob Health 2019; 4:e001289. [PMID: 31406600 PMCID: PMC6666826 DOI: 10.1136/bmjgh-2018-001289] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/05/2019] [Accepted: 01/12/2019] [Indexed: 12/29/2022] Open
Abstract
Disease processes that frequently require emergency care constitute approximately 50% of the total disease burden in low-income and middle-income countries (LMICs). Many LMICs continue to deal with emergencies caused by communicable disease states such as pneumonia, diarrhoea, malaria and meningitis, while also experiencing a marked increase in non-communicable diseases, such as cardiovascular diseases, diabetes mellitus and trauma. For many of these states, emergency care interventions have been developed through research in high-income countries (HICs) and advances in care have been achieved. However, in LMICs, clinical research, especially interventional trials, in emergency care are rare. Furthermore, there exists minimal research on the emergency management of diseases, which are rarely encountered in HICs but impact the majority of LMIC populations. This paper explores challenges in conducting clinical research in patients with emergency conditions in LMICs, identifies examples of successful clinical research and highlights the system, individual and study design characteristics that made such research possible in LMICs. Derived from the available literature, a focused list of high impact research considerations are put forth.
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Affiliation(s)
- Adam R Aluisio
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Shahan Waheed
- Department of Emergency Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Jermey Hess
- Department of Emergency Medicine, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Shevin T Jacob
- Division of Allergy and Infectious Diseases, Universityof Washington, Seattlel, WA, United States
| | - Niranjan Kissoon
- Departmentof Pediatrics and Emergency Medicine, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Adam C Levine
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Asad Mian
- Department of Emergency Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Shammi Ramlakhan
- Emergency Department, Sheffield Children's Hospital, Sheffield, UK.,Faculty of Medical Sciences, University of the West Indies, Kingston, Jamaica
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Junaid Razzak
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Haijanen J, Sippola S, Tuominen R, Grönroos J, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Salminen P. Cost analysis of antibiotic therapy versus appendectomy for treatment of uncomplicated acute appendicitis: 5-year results of the APPAC randomized clinical trial. PLoS One 2019; 14:e0220202. [PMID: 31344073 PMCID: PMC6657874 DOI: 10.1371/journal.pone.0220202] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/10/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The efficacy and safety of antibiotic treatment for uncomplicated acute appendicitis has been established at long-term follow-up with the majority of recurrences shown to occur within the first year. Overall costs of antibiotics are significantly lower compared with appendectomy at short-term follow-up, but long-term durability of these cost savings is unclear. The study objective was to compare the long-term overall costs of antibiotic therapy versus appendectomy in the treatment of uncomplicated acute appendicitis in the APPAC (APPendicitis ACuta) trial at 5 years. METHODS AND FINDINGS This multicentre, non-inferiority randomized clinical trial randomly assigned 530 adult patients with CT-confirmed uncomplicated acute appendicitis to appendectomy or antibiotic treatment at six Finnish hospitals. All major costs during the 5-year follow-up were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis. Between November 2009 and June 2012, 273 patients were randomized to appendectomy and 257 to antibiotics. The overall costs of appendectomy were 1.4 times higher (p<0.001) (€5716; 95% CI: €5510 to €5925) compared with antibiotic therapy (€4171; 95% CI: €3879 to €4463) resulting in cost savings of €1545 per patient (95% CI: €1193 to €1899; p<0.001) in the antibiotic group. At 5 years, the majority (61%, n = 156) of antibiotic group patients did not undergo appendectomy. CONCLUSIONS At 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy. As the majority of appendicitis recurrences occur within the first year after the initial antibiotic treatment, these results suggest that treating uncomplicated acute appendicitis with antibiotics instead of appendectomy results in lower overall costs even at longer-term follow-up.
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Affiliation(s)
- Jussi Haijanen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Suvi Sippola
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Risto Tuominen
- Department of Public Health, University of Turku, Turku, Finland
- University of Namibia, Windhoek, Namibia
| | - Juha Grönroos
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - Hannu Paajanen
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Tero Rautio
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Pia Nordström
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - Markku Aarnio
- Department of Surgery, Jyväskylä Central Hospital, Jyväskylä, Finland
| | - Tuomo Rantanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Saija Hurme
- Department of Biostatistics, University of Turku, Turku, Finland
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
- * E-mail:
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180
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Abstract
Background Data on common practice in the management of patients with complex appendicitis are scarce, especially for the adult population. Variation in the definition of complex appendicitis, indications for and the type of prolonged antibiotic prophylaxis have not been well studied yet. The aim of this study was to document current practice of the classification and postoperative management of complex appendicitis on an international level. Methods An online survey was dispersed among practicing surgeons and surgical residents. Survey questions pertained to the definition of a complex appendicitis, indications for antibiotic prophylaxis after appendectomy, the duration, route of administration and antibiotic agents used. Results A total of 137 survey responses were eligible for analysis. Most respondents were from Northern or Western Europe and were specialized in gastrointestinal surgery. Opinion varied substantially regarding the management of appendicitis, in particular for phlegmonous appendicitis with localized pus, gangrenous appendicitis and iatrogenic rupture of appendicitis. The most common duration of postoperative antibiotics was evenly spread over <3, 3, 5 and 7 days. Whereas most respondents indicated a combined intravenous and oral route of administration was common practice, 28% answered a completely intravenous route of administration was standard practice. Conclusion Current practice patterns in the classification and postoperative management of complex appendicitis are highly variable. Electronic supplementary material The online version of this article (10.1007/s00268-018-4806-4) contains supplementary material, which is available to authorized users.
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181
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Tseng J, Cohen T, Melo N, Alban RF. Imaging utilization affects negative appendectomy rates in appendicitis: An ACS-NSQIP study. Am J Surg 2019; 217:1094-1098. [DOI: 10.1016/j.amjsurg.2018.12.072] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 10/17/2018] [Accepted: 12/29/2018] [Indexed: 12/29/2022]
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Seyoum N, G/Giorgis D, Nega B. Pattern of Vascular Diseases at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. Ethiop J Health Sci 2019; 29:377-382. [PMID: 31447506 PMCID: PMC6689717 DOI: 10.4314/ejhs.v29i3.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 02/27/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Vascular diseases are evolving fast in sub-Saharan Africa, but its management is challenged by lack of expertise and infrastructure. In the light of the prevailing challenge, this study was done to see the pattern of vascular disease and its treatment in a tertiary referral hospital. METHODS A prospective cross-sectional study was done over a period of one year (February 9, 2016 to February 8, 2017) at Tikur Anbessa specialized hospital (TASH) at Addis Ababa, Ethiopia. RESULTS A total of 386 patients were seen at the surgical OPD. Of these, 78(20.2%) were admitted and operate on. The male to female ratio was 1.3:1. The mean age affected was 39 +/- 10 (Range 12-91 years). On the other hand, 132 (34.2%) patients came with PAD. Of them, 46(34.8%) presented with either frank Gangrene or pre-gangrene stage. The rest 86(65.1%) had claudication pain. The other diseases seen are Varicose Vein, 100(25.9%), Carotid body tumors, 60(15.4%), Aneurysmal diseases, 36(9.1%), Vascular malformations, 34(8.7%), and Vascular injuries, 22(5.6%). During the study period, 28(35.9%) PAD, 22(28.2%) trauma patients, 8(10.2%) Chemodectomas, 8(10.2%) aneurysms, 6(7.7%) hemangiomas, 4(5.1%) varicose vein and 2(2.6%) AV fistula patients were operated. CONCLUSION The pattern of vascular disease in Ethiopia is becoming a challenge. The gap created due to limited vascular surgeons, poor infrastructure and absent supply chain system has significantly compromised the number and type of operated-on patients. These challenges result in preventable morbidity and mortality.
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Affiliation(s)
- Nebyou Seyoum
- Cardiothoracic and Vascular Unit, Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia
| | - Dawit G/Giorgis
- Cardiothoracic and Vascular Unit, Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia
| | - Berhanu Nega
- Cardiothoracic and Vascular Unit, Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Ethiopia
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183
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Ragheb M, Shah AH, Jernigan S, Koru-Sengul T, Ragheb J. Epidemiology of pediatric hydrocephalus in Haiti: analysis of a surgical case series. J Neurosurg Pediatr 2019; 23:568-576. [PMID: 30797213 DOI: 10.3171/2018.12.peds18568] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 12/12/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hydrocephalus is recognized as a common disabling pediatric disease afflicting infants and children disproportionately in the developing world, where access to neurosurgical care is limited and risk of perinatal infection is high. This surgical case series describes the Project Medishare Hydrocephalus Specialty Surgery (PMHSS) program experience treating hydrocephalus in Haiti between 2008 and 2015. METHODS The authors conducted a retrospective review of all cases involving children treated for hydrocephalus within the PMHSS program in Port-au-Prince, Haiti, from 2008 through 2015. All relevant epidemiological information of children treated were prospectively collected including relevant demographics, birth history, hydrocephalus etiology, head circumference, and operative notes. All appropriate associations and statistical tests were performed using univariate and multivariate logistic regression analyses. RESULTS Among the 401 children treated within PMHSS, postinfectious hydrocephalus (PIH) accounted for 39.4% (n = 158) of cases based on clinical, radiographic, and endoscopic findings. The majority of children with hydrocephalus in Haiti were male (54.8%, n = 197), born in the rainy season (59.7%, n = 233), and born in a coastal/inland location (43.3%, n = 61). The most common surgical intervention was endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) (45.7%, n = 175). Multivariate logistic regression analysis yielded coastal birth location (OR 3.76, 95% CI 1.16-12.18) as a statistically significant predictor of PIH. Increasing head circumference (adjusted OR 1.06, 95% CI 0.99-1.13) demonstrated a slight trend toward significance with the incidence of PIH. CONCLUSIONS This information will provide the foundation for future clinical and public health studies to better understand hydrocephalus in Haiti. The 39.4% prevalence of PIH falls within observed rates in Africa as does the apparently higher prevalence for those born during the rainy season. Although PIH was the most frequent etiology seen in almost all birth locations, the potential relationship with geography noted in this series will be the focus of further research in an effort to understand the link between climate and PIH in Haiti. The ultimate goal will be to develop an appropriate public health strategy to reduce the burden of PIH on the children of Haiti.
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Affiliation(s)
| | - Ashish H Shah
- 2Neurological Surgery, University of Miami Miller School of Medicine
| | - Sarah Jernigan
- 3Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | | | - John Ragheb
- 2Neurological Surgery, University of Miami Miller School of Medicine
- 4Division of Pediatric Neurosurgery, Miami Children's Health System, Nicklaus Children's Hospital, Miami, Florida; and
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Becher RD, DeWane MP, Sukumar N, Stolar MJ, Gill TM, Becher RM, Maung AA, Schuster KM, Davis KA. Hospital Operative Volume as a Quality Indicator for General Surgery Operations Performed Emergently in Geriatric Patients. J Am Coll Surg 2019; 228:910-923. [PMID: 31005629 DOI: 10.1016/j.jamcollsurg.2019.02.053] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/15/2019] [Accepted: 02/15/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Within the growing geriatric population, there is an increasing need for emergency operations. Optimizing outcomes can require a structured system of surgical care based on key quality indicators. To investigate this, the current study sought to answer 2 questions. First, to what degree does hospital emergency operative volume impact mortality for geriatric patients undergoing emergency general surgery (EGS) operations? Second, at what procedure-specific hospital volume will geriatric patients undergoing an emergency operation achieve at or better than average mortality risk? STUDY DESIGN Retrospective cohort study of geriatric patients (aged 65 years and older) who underwent 1 of 10 EGS operations identified from the California State Inpatient Database (2010 to 2011). β-Logistic generalized linear regression was used, with the hospital as the unit of analysis, to investigate the relationship between hospital operative volume and in-hospital riskv-adjusted mortality. Hospital operative volume thresholds to optimize probability of survival were defined. RESULTS There were 41,860 operations evaluated at 299 hospitals. For each operation, mortality decreased as hospital emergency operative volume increased (p < 0.001 for each operation); for every standardized increase in volume (meaning +1 natural logarithm of volume), the reduction in mortality ranged from 14% for colectomy to 61% for appendectomy. Hospital volume thresholds, which optimize to 95% probability of survival, varied by procedure, with a mean of 14 operations over 2 years. More than 50% of hospitals did not meet the threshold benchmarks, representing 22% of patients. CONCLUSIONS Survival rates for geriatric patients were improved substantially when emergency operations were performed at hospitals with higher operative volumes. Consistent with all active Quality Programs of the American College of Surgeons, hospital operative volume appears to be an important metric of surgical quality for older patients undergoing emergency operations.
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Affiliation(s)
- Robert D Becher
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT.
| | - Michael P DeWane
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Nitin Sukumar
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Marilyn J Stolar
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Thomas M Gill
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | | | - Adrian A Maung
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Kevin M Schuster
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Kimberly A Davis
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT
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Abstract
BACKGROUND Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce. OBJECTIVE In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda. METHODS In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda). FINDINGS Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated. CONCLUSIONS Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor.
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186
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de Wijkerslooth EML, van den Boom AL, Wijnhoven BPL. Disease burden of appendectomy for appendicitis: a population-based cohort study. Surg Endosc 2019; 34:116-125. [PMID: 30919056 PMCID: PMC6946751 DOI: 10.1007/s00464-019-06738-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/06/2019] [Indexed: 01/07/2023]
Abstract
Background Few large-scale epidemiologic studies evaluate the clinical and economic burden of appendicitis. These data may impact future research and treatment strategies. In this study, the objective was to determine the burden of appendectomy for appendicitis in terms of incidence rates, length of hospital stay (LOS) and hospital costs on a national level. In addition, outcomes were compared for subgroups based on surgical treatment, age and hospital setting. Methods Observational retrospective population-based cohort study using the national Dutch healthcare reimbursement registry, which covers hospital registration and reimbursement for 17 million inhabitants. Patients with a diagnosis of appendicitis who underwent appendectomy between 2006 and 2016 were included. Primary outcomes were incidence rates, LOS and hospital costs. Results A total of 135,025 patients were included. Some 53% of patients was male, and 64% was treated in a general hospital. The overall incidence rate of appendectomy was 81 per 100,000 inhabitants and showed a significant decreasing trend across time and age. Mean ± SD LOS per patient was 3.66 ± 3.5 days. LOS showed a significant increase with age and was significantly longer for open versus minimally invasive appendectomy. Mean ± SD hospital costs per patient were €3700 ± 1284. Costs were initially lower for open compared to minimally invasive appendectomy, but were similar from 2012 onward. Compared to non-university hospitals, patients treated in university hospitals had a significantly longer LOS and higher costs. Conclusions Appendectomy for appendicitis represents a substantial clinical and economic burden in the Netherlands. A preference for minimally invasive technique seems justified.
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Affiliation(s)
| | - Anne Loes van den Boom
- Department of Surgery, Erasmus MC - University Medical Center, PO Box 2040, 3000CA, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Center, PO Box 2040, 3000CA, Rotterdam, The Netherlands
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Washington State abdominal aortic aneurysm-related mortality shows a steady decline between 1996 and 2016. J Vasc Surg 2019; 70:1115-1122. [PMID: 30850292 DOI: 10.1016/j.jvs.2018.12.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/13/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Management of abdominal aortic aneurysms (AAA) has undergone considerable advances over the last two decades. Our aim was to evaluate AAA-related mortality trends in Washington State over a 21-year period and to assess variation in AAA-related mortality by sex, race, and county over the same time period. We hypothesized that a significant decrease in AAA-related mortality in Washington State would be noted. METHODS Death certificate records were obtained from the Washington State Department of Health from 1996 to 2016. Records in which AAA was listed as an underlying or associated cause of death were selected for analysis. Age-standardized mortality rates for each year were calculated using the 2016 Washington State population as the standard. Mortality trends were compared by sex and race using linear regression. County-specific age-standardized ruptured AAA (rAAA) mortality rates were compared using a Kruskal-Wallis test. RESULTS Of the 1,014,039 deaths occurring in Washington State during the study period, 4438 (0.4%) had AAA listed as an underlying or associated cause of death (66.1% male; 94.8% white; mean age at death, 79.4 ± 9.3 years). In 64.1% of the cases, AAA was listed as the underlying cause of death. AAA-related mortality rates decreased by 62.1% over the 21 years from 5.8 to 2.2 deaths per 100,000. Notably, there was a statistically significant decrease in rAAA-related mortality rates (from 3.2 to 0.95 per 100,000, a decrease of 0.12 deaths/100,000/year; 95% confidence interval, 0.11-0.14; r2 = 0.95). Men had a significantly steeper decrease in age-standardized AAA-related mortality rates with a 55% decrease (from 6.5 to 3.0 per 100,000) vs a 41% decrease (2.4 to 1.4 per 100,000) among women. Men were younger at the time of death than women (78.1 ± 9.4 years vs 81.9 ± 8.6 years, respectively; P < .001). Individuals who were white had a significantly steeper decrease in age-standardized AAA-related mortality rates with a 53% decrease (from 5.3 to 2.5 per 100,000) compared with a 13% decrease among individuals who were nonwhite (from 1.5 to 1.3 per 100,000). Age-standardized rAAA-related mortality rates varied by county (P < .001). CONCLUSIONS Age-standardized AAA-related mortality rate has decreased in Washington State between 1996 and 2016, with a notable decrease in the rAAA-related mortality rate. The decrease in AAA-related mortality rates varied by sex and race. Additionally, rAAA-related mortality rates differed between counties. These observations are a first step toward regional population assessments. Future work to understand the sources of variation can influence public health interventions on a state level.
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Enumeration of Operations Performed for Elderly Patients in Ghana: An Opportunity to Improve Global Surgery Benchmarking. World J Surg 2019; 43:1644-1652. [PMID: 30824962 DOI: 10.1007/s00268-019-04963-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The Lancet Commission on Global Surgery proposed 5000 operations/100,000 people annually as a benchmark for developing countries but did not define benchmarks for different age groups. We evaluated the operation rate for elderly patients (≥65 years) in Ghana and estimated the unmet surgical need for the elderly by comparison to a high-income country benchmark. METHODS Data on operations performed for elderly patients over a 1-year period in 2014-5 were obtained from representative samples of 48/124 small district hospitals and 12/16 larger referral hospitals and scaled-up for nationwide estimates. Operations were categorized as essential (most cost-effective, highest population impact) versus other according to The World Bank's Disease Control Priority project (DCP-3). Data from New Zealand's National Minimum Dataset were used to derive a benchmark operation rate for the elderly. RESULTS 16,007 operations were performed for patients ≥65 years. The annual operation rate was 1744/100,000 (95% UI 1440-2048), only 12% of the New Zealand benchmark of 14,103/100,000. 74% of operations for the elderly were in the essential category. The most common procedures (15%) were for urinary obstruction. 58% of operations were performed at district hospitals; 54% of these did not have fully-trained surgeons. Referral hospitals more commonly performed operations outside the essential category. CONCLUSION The operation rate was well beneath the benchmark, indicating a potentially large unmet need for Ghana's elderly population. Most operations for the elderly were in the essential category and delivered at district hospitals. Future global surgery benchmarking should consider specific benchmarks for different age groups.
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Hamidi M, Ho C, Zeeshan M, O'Keeffe T, Hamza A, Kulvatunyou N, Jehan F, Joseph B. Can Sarcopenia Quantified by Computed Tomography Scan Predict Adverse Outcomes in Emergency General Surgery? J Surg Res 2019; 235:141-147. [DOI: 10.1016/j.jss.2018.09.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 07/30/2018] [Accepted: 09/11/2018] [Indexed: 02/07/2023]
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Tran TM, Fuller AT, Butler EK, Muhumuza C, Ssennono VF, Vissoci JR, Makumbi F, Chipman JG, Galukande M, Haglund MM, Luboga S. Surgical need among the ageing population of Uganda. Afr Health Sci 2019; 19:1778-1788. [PMID: 31149008 PMCID: PMC6531960 DOI: 10.4314/ahs.v19i1.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Uganda's ageing population (age 50 years and older) will nearly double from 2015 to 2050. HIV/AIDS, diabetes, stroke among other disease processes have been studied in the elderly population. However, the burden of disease from surgically-treatable conditions is unknown. OBJECTIVES To determine the proportion of adults above 50 years with unmet surgical need and deaths attributable to probable surgically-treatable conditions. METHODS A cluster randomized sample representing the national population of Uganda was enumerated. The previously validated Surgeons Overseas assessment of surgical need instrument, a head-to-toe verbal interview, was used to determine any surgically-treatable conditions in two randomly-selected living household members. Deaths were detailed by heads of households. Weighted metrics are calculated taking sampling design into consideration and Taylor series linearization was used for sampling error estimation. RESULTS The study enumerated 425 individuals above age 50 years. The prevalence proportion of unmet surgical need was 27.8% (95%CI, 22.1-34.3). This extrapolates to 694,722 (95%CI, 552,279-857,157) individuals living with one or more surgically treatable conditions. The North sub-region was observed to have the highest prevalence proportion. Nearly two out of five household deaths (37.9%) were attributed to probable surgically treatable causes. CONCLUSION There is disproportionately high need for surgical care among the ageing population of Uganda with approximately 700,000 consultations needed.
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Affiliation(s)
- Tu M Tran
- Duke University Division of Global Neurosurgery and Neuroscience
| | - Anthony T Fuller
- Duke University Division of Global Neurosurgery and Neuroscience
- Duke University School of Medicine
| | - Elissa K Butler
- University of Washington Department of Surgery 1959 NE Pacific Street Box 356410 Seattle, WA 98195 USA
| | | | - Vincent F Ssennono
- Uganda Bureau of Statistics, Kampala, Uganda; Statistics House, Plot 9 Colville Street Box 7186 Kampala, Uganda
| | | | | | - Jeffrey G Chipman
- University of Minnesota Department of Surgery, Minneapolis, MN, USA; 420 Delaware Street SE Mayo Mail Code 195 Minneapolis, MN 55455 USA
| | - Moses Galukande
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Michael M Haglund
- Duke University Division of Global Neurosurgery and Neuroscience
- Duke University School of Medicine
- Duke University Department of Neurosurgery, Durham, NC, USA Durham, NC, USA 310 Trent Drive, Room 301 Durham, NC 27710 USA
| | - Samuel Luboga
- Makerere University College of Health Sciences, Department of Anatomy, Kampala, Uganda P. O. Box 7072, New Mulago Hospital Complex Kampala, Uganda
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Abstract
BACKGROUND Surgical emergencies account for a major part of the surgeon's workload. Evaluation of pattern of surgical emergencies will assist in developing concrete proposals for improved care. The aim was to assess the pattern of surgical emergencies in our center. METHODS We undertook one-year prospective study of all the emergency surgical admissions at Federal Medical Centre Makurdi from January to December 2011. RESULTS There were 575 surgical emergencies which constituted 56.8% of surgical admission, and 27.2% of allemergency hospital admissions. The commonest trauma cases were soft tissue injuries (30.3%), while the commonest non-trauma case was acute abdomen (41.6%). The mean age of the patients was 33.7 ± 17.2 years. Multiple injuries and traumatic brain injuries requiring intensive care monitoring, and malignancies were associated with higher mortality rates (p = 0.001). The 1-year mortality rate was 7.8% and the preventable death rate (PDR) for the trauma-related emergencies was 71.4%. CONCLUSION There is a wide spectrum of surgical emergencies in our setting with trauma accounting for a substantial proportion of cases. Improved trauma care, neurosurgical services and intensive care facilities may improve the outcome of surgical emergencies in our environment.
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Affiliation(s)
- Ndubuisi Oc Onyemaechi
- Department of Surgery College of Medicine University of Nigeria, Ituku-Ozalla Enugu, Nigeria. . +234-8035504767
| | - Sunday U Urube
- Department of Surgery Federal Medical Center Makurdi Benue State Nigeria.
| | - Sebastian O Ekenze
- Department of Surgery College of Medicine University of Nigeria Ituku-Ozalla Enugu Nigeria.
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Lee MJ, Sayers AE, Drake TM, Marriott PJ, Anderson ID, Bach SP, Bradburn M, Hind D, Verjee A, Fearnhead NS. National prospective cohort study of the burden of acute small bowel obstruction. BJS Open 2019; 3:354-366. [PMID: 31183452 PMCID: PMC6551410 DOI: 10.1002/bjs5.50136] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 11/27/2018] [Indexed: 12/21/2022] Open
Abstract
Background Small bowel obstruction is a common surgical emergency, and is associated with high levels of morbidity and mortality across the world. The literature provides little information on the conservatively managed group. The aim of this study was to describe the burden of small bowel obstruction in the UK. Methods This prospective cohort study was conducted in 131 acute hospitals in the UK between January and April 2017, delivered by trainee research collaboratives. Adult patients with a diagnosis of mechanical small bowel obstruction were included. The primary outcome was in‐hospital mortality. Secondary outcomes included complications, unplanned intensive care admission and readmission within 30 days of discharge. Practice measures, including use of radiological investigations, water soluble contrast, operative and nutritional interventions, were collected. Results Of 2341 patients identified, 693 (29·6 per cent) underwent immediate surgery (within 24 h of admission), 500 (21·4 per cent) had delayed surgery after initial conservative management, and 1148 (49·0 per cent) were managed non‐operatively. The mortality rate was 6·6 per cent (6·4 per cent for non‐operative management, 6·8 per cent for immediate surgery, 6·8 per cent for delayed surgery; P = 0·911). The major complication rate was 14·4 per cent overall, affecting 19·0 per cent in the immediate surgery, 23·6 per cent in the delayed surgery and 7·7 per cent in the non‐operative management groups (P < 0·001). Cox regression found hernia or malignant aetiology and malnutrition to be associated with higher rates of death. Malignant aetiology, operative intervention, acute kidney injury and malnutrition were associated with increased risk of major complication. Conclusion Small bowel obstruction represents a significant healthcare burden. Patient‐level factors such as timing of surgery, acute kidney injury and nutritional status are factors that might be modified to improve outcomes.
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Affiliation(s)
- M J Lee
- Department of General Surgery Northern General Hospital Sheffield UK.,South Yorkshire Surgical Research Group Sheffield UK
| | - A E Sayers
- South Yorkshire Surgical Research Group Sheffield UK.,Department of General Surgery Doncaster Royal Infirmary Doncaster UK
| | - T M Drake
- South Yorkshire Surgical Research Group Sheffield UK.,Department of Clinical Surgery University of Edinburgh Edinburgh UK
| | - P J Marriott
- Department of General Surgery Warwick Hospital Warwick UK.,Department of General Surgery Salford Royal Infirmary Salford UK
| | - I D Anderson
- West Midlands Research Collaborative, Academic Department of Surgery Queen Elizabeth Hospital Birmingham UK
| | - S P Bach
- Academic Department of Surgery Queen Elizabeth Hospital Birmingham UK
| | - M Bradburn
- Clinical Trials and Research Unit University of Sheffield Sheffield UK
| | - D Hind
- Clinical Trials and Research Unit University of Sheffield Sheffield UK
| | - A Verjee
- Patient Representative, Association of Coloproctology of Great Britain and Ireland Patient Liaison Group London UK
| | - N S Fearnhead
- Department of Surgery Addenbrooke's Hospital Cambridge UK
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Eddama M, Fragkos KC, Renshaw S, Aldridge M, Bough G, Bonthala L, Wang A, Cohen R. Logistic regression model to predict acute uncomplicated and complicated appendicitis. Ann R Coll Surg Engl 2019; 101:107-118. [PMID: 30286649 PMCID: PMC6351858 DOI: 10.1308/rcsann.2018.0152] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION While patients with acute uncomplicated appendicitis may be treated conservatively, those who suffer from complicated appendicitis require surgery. We describe a logistic regression equation to calculate the likelihood of acute uncomplicated appendicitis and complicated appendicitis in patients presenting to the emergency department with suspected acute appendicitis. MATERIALS AND METHODS A cohort of 895 patients who underwent appendicectomy were analysed retrospectively. Depending on the final histology, patients were divided into three groups; normal appendix, acute uncomplicated appendicitis and complicated appendicitis. Normal appendix was considered the reference category, while acute uncomplicated appendicitis and complicated appendicitis were the nominal categories. Multivariate and univariate regression models were undertaken to detect independent variables with significant odds ratio that can predict acute uncomplicated appendicitis and complicated appendicitis. Subsequently, a logistic regression equation was generated to produce the likelihood acute uncomplicated appendicitis and complicated appendicitis. RESULTS Pathological diagnosis of normal appendix, acute uncomplicated appendicitis and complicated appendicitis was identified in 188 (21%), 525 (59%) and 182 patients (20%), respectively. The odds ratio from a univariate analysis to predict complicated appendicitis for age, female gender, log2 white cell count, log2 C-reactive protein and log2 bilirubin were 1.02 (95% confidence interval, CI, 1.01, 1.04), 2.37 (95% CI 1.51, 3.70), 9.74 (95% CI 5.41, 17.5), 1.57 (95% CI 1.40, 1.74), 2.08 (95% CI 1.56, 2.76), respectively. For the same variable, similar odds ratios were demonstrated in a multivariate analysis to predict complicated appendicitis and univariate and multivariate analysis to predict acute uncomplicated appendicitis. CONCLUSIONS The likelihood of acute uncomplicated appendicitis and complicated appendicitis can be calculated by using the reported predictive equations integrated into a web application at www.appendistat.com. This will enable clinicians to determine the probability of appendicitis and the need for urgent surgery in case of complicated appendicitis.
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Affiliation(s)
- Mmr Eddama
- Division of Surgery and Interventional Science, University College London , London , UK
- Department of Colorectal Surgery, University College london Hospital , London , UK
| | - K C Fragkos
- Department of Colorectal Surgery, University College london Hospital , London , UK
| | - S Renshaw
- Department of Colorectal Surgery, University College london Hospital , London , UK
| | - M Aldridge
- Department of Surgery, Lister Hospital Stevenage , Stevenage , UK
| | - G Bough
- Department of Colorectal Surgery, University College london Hospital , London , UK
| | - L Bonthala
- Department of Colorectal Surgery, University College london Hospital , London , UK
| | - A Wang
- Department of Colorectal Surgery, University College london Hospital , London , UK
| | - R Cohen
- Division of Surgery and Interventional Science, University College London , London , UK
- Department of Colorectal Surgery, University College london Hospital , London , UK
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van Dijk ST, van Dijk AH, Dijkgraaf MG, Boermeester MA. Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis. Br J Surg 2019; 105:933-945. [PMID: 29902346 PMCID: PMC6033184 DOI: 10.1002/bjs.10873] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 01/12/2018] [Accepted: 03/08/2018] [Indexed: 12/15/2022]
Abstract
Background The traditional fear that every case of acute appendicitis will eventually perforate has led to the generally accepted emergency appendicectomy with minimized delay. However, emergency and thereby sometimes night‐time surgery is associated with several drawbacks, whereas the consequences of surgery after limited delay are unclear. This systematic review aimed to assess in‐hospital delay before surgery as risk factor for complicated appendicitis and postoperative morbidity in patients with acute appendicitis. Methods PubMed and EMBASE were searched from 1990 to 2016 for studies including patients who underwent appendicectomy for acute appendicitis, reported in two or more predefined time intervals. The primary outcome measure was complicated appendicitis after surgery (perforated or gangrenous appendicitis); other outcomes were postoperative surgical‐site infection and morbidity. Adjusted odds ratios (ORs) were pooled using forest plots if possible. Unadjusted data were pooled using generalized linear mixed models. Results Forty‐five studies with 152 314 patients were included. Pooled adjusted ORs revealed no significantly higher risk for complicated appendicitis when appendicectomy was delayed for 7–12 or 13–24 h (OR 1·07, 95 per cent c.i. 0·98 to 1·17, and OR 1·09, 0·95 to 1·24, respectively). Meta‐analysis of unadjusted data supported these findings by yielding no increased risk for complicated appendicitis or postoperative complications with a delay of 24–48 h. Conclusion This meta‐analysis demonstrates that delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical‐site infection or morbidity. Delaying appendicectomy for up to 24 h may be an acceptable alternative for patients with no preoperative signs of complicated appendicitis. Delay is safe
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Affiliation(s)
- S T van Dijk
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - A H van Dijk
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - M G Dijkgraaf
- Clinical Research Unit, Academic Medical Centre, Amsterdam, Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
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Peeters T, Penders J, Smeekens SP, Galazzo G, Houben B, Netea MG, Savelkoul PHM, Gyssens IC. The fecal and mucosal microbiome in acute appendicitis patients: an observational study. Future Microbiol 2019; 14:111-127. [DOI: 10.2217/fmb-2018-0203] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aim: We aimed to study the mucosal microbiota of the appendix in a prospective appendicitis cohort and to compare the fecal microbiota of patients and controls. We hypothesized that the microbiota may be associated with susceptibility to appendicitis. Patients & methods: The fecal microbiota of 99 patients and 106 controls were characterized using 16S–23S intergenic spacer profiling. Richness, diversity and community structure were compared. The appendiceal microbiota from 90 patients was analyzed according to the severity of appendicitis. Results: Overall fecal microbial richness and diversity were similar in patients and controls, yet richness and diversity within the group of Firmicutes, Actinobacteria, Fusobacteria and Verrucomicrobia phyla were lower in patients. Discriminant analyses could correctly classify patients and controls with fair accuracy. No differences were found according to severity in appendiceal or fecal microbiota. Conclusion: This study demonstrates differences in the composition of intestinal microbiota of appendicitis patients and healthy individuals.
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Affiliation(s)
- Toon Peeters
- Department of Infectious Diseases & Immunity, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine & Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - John Penders
- School of Nutrition & Translational Research in Metabolism (NUTRIM) & School for Public Health & Primary Care (CAPHRI), Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Sanne P Smeekens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gianluca Galazzo
- School of Nutrition & Translational Research in Metabolism (NUTRIM) & School for Public Health & Primary Care (CAPHRI), Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Bert Houben
- Department of Abdominal & Oncological Surgery, Jessa Hospital, Hasselt, Belgium
| | - Mihai G Netea
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Paul HM Savelkoul
- School of Nutrition & Translational Research in Metabolism (NUTRIM) & School for Public Health & Primary Care (CAPHRI), Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Medical Microbiology & Infection Control, VU University Medical Center, Amsterdam, The Netherlands
| | - Inge C Gyssens
- Department of Infectious Diseases & Immunity, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine & Life Sciences, Hasselt University, Hasselt, Belgium
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
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Beecham J, Hart A, Alexandre L, Hernon J, Kumar B, Lam S. Single Nucleotide Polymorphisms and Post-operative Complications Following Major Gastrointestinal Surgery: a Systematic Review and Meta-analysis. J Gastrointest Surg 2019; 23:2298-2306. [PMID: 31270721 PMCID: PMC6831536 DOI: 10.1007/s11605-019-04300-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 06/04/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The human genome is an under-researched area of pre-operative risk stratification. Studies of genetic polymorphisms and their associations with acute post-operative complications in gastrointestinal surgery have reported statistically significant results, but have varied in methodology, genetic variations studied, and conclusions reached. To provide clarity, we conducted a systematic review and meta-analysis of single nucleotide polymorphisms and their association with post-operative complications after major gastrointestinal surgery. METHODS We performed a literature search using Ovid MEDLINE and Web of Science databases. Studies were included if they investigated genetic polymorphisms and their associations with post-operative complications after major gastrointestinal surgery. We extracted clinical and genetic data from each paper and assessed for quality against the STrengthening the REporting of Genetic Association Studies (STREGA) guidelines. Odds ratios were presented, with 95% confidence intervals, to assess strengths of association. We conducted a meta-analysis on TNF-α-308, which had been assessed in three papers. RESULTS Our search returned 68 papers, of which 5 were included after screening and full-text review. Twenty-two different single nucleotide polymorphisms (SNPs) were investigated in these studies. We found that all papers were genetic association studies, and had selected SNPs related to inflammation. The outcome investigated was most commonly post-operative infection, but also anastomotic leak and other non-infectious complications. Statistically significant associations were found for TNF-α-308, IL-10-819, PTGS2-765 and IFN-γ-874. There was significant variability in study quality and methodology. We conducted a meta-analysis on associations between the TNF-α-308 polymorphism and post-operative infection and report an OR of 1.18 (CI 0.27-5.21). CONCLUSIONS We found biologically plausible associations between SNPs involved in inflammation and post-operative infection, but the available data were too limited and of insufficient quality to reach definitive conclusions. Further work is needed, including genome-wide association studies (GWAS).
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Affiliation(s)
- Joseph Beecham
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
| | - Andrew Hart
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
| | - Leo Alexandre
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
| | - James Hernon
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
| | - Bhaskar Kumar
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
| | - Stephen Lam
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, NR4 7UY UK
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Singh K, Wilson MSJ, Coats M. Does time of surgery influence the rate of false-negative appendectomies? A retrospective observational study of 274 patients. Patient Saf Surg 2018; 12:33. [PMID: 30564285 PMCID: PMC6293631 DOI: 10.1186/s13037-018-0180-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/05/2018] [Indexed: 01/20/2023] Open
Abstract
Background Multiple disciplines have described an “after-hours effect” relating to worsened mortality and morbidity outside regular working hours. This retrospective observational study aimed to evaluate whether diagnostic accuracy of a common surgical condition worsened after regular hours. Methods Electronic operative records for all non-infant patients (age > 4 years) operated on at a single centre for presumed acute appendicitis were retrospectively reviewed over a 56-month period (06/17/2012–02/01/2017). The primary outcome measure of unknown diagnosis was compared between those performed in regular hours (08:00–17:00) or off hours (17:01–07:59). Pre-clinical biochemistry and pre-morbid status were recorded to determine case heterogeneity between the two groups, along with secondary outcomes of length of stay and complication rate. Results Out of 289 procedures, 274 cases were deemed eligible for inclusion. Of the 133 performed in regular hours, 79% were appendicitis, compared to 74% of the 141 procedures performed off hours. The percentage of patients with an unknown diagnosis was 6% in regular hours compared to 15% off hours (RR 2.48; 95% CI 1.14–5.39). This was accompanied by increased numbers of registrars (residents in training) leading procedures off hours (37% compared to 24% in regular hours). Pre-morbid status, biochemistry, length of stay and post-operative complication rate showed no significant difference. Conclusions This retrospective study suggests that the rate of unknown diagnoses for acute appendicitis increases overnight, potentially reflecting increased numbers of unnecessary procedures being performed off hours due to poorer diagnostic accuracy. Reduced levels of staffing, availability of diagnostic modalities and changes to workforce training may explain this, but further prospective work is required. Potential solutions may include protocolizing the management of common acute surgical conditions and making more use of non-resident on call senior colleagues.
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Affiliation(s)
- Kirit Singh
- 1Department of General Surgery, Ninewells Hospital, NHS Tayside, Dundee, UK.,2Cardiff University, Cardiff, UK
| | - Michael S J Wilson
- 1Department of General Surgery, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - Maria Coats
- 1Department of General Surgery, Ninewells Hospital, NHS Tayside, Dundee, UK
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Securing the Appendiceal Stump During Emergency Appendicectomy: Options and Influencing Factors in Current UK Surgical Practice. Surg Laparosc Endosc Percutan Tech 2018; 28:209-213. [PMID: 29994869 DOI: 10.1097/sle.0000000000000558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The aim of our study was to identify the most commonly employed methods and influencing factors for securing the appendiceal stump in current NHS practice. METHODS An electronic survey of the Scottish Surgical Research Group network, invitation extended to the UK National Research Collaborative. RESULTS A total of 111 responses were received from 32 surgical centers; 28 (25.2%) consultants, 66 (59.5%) specialty trainees and 12 (10.8%) core trainees. Endoscopic ligatures were the preferred method in 96 (86.5%) with no difference in those with the greatest operative experience (P=0.79), 12 (10.8%) preferred polymeric clips. Ease of application (70.3%) and severity of stump inflammation (65.8%) had the greatest influence on the method chosen. Cost was a factor in 36.0%. CONCLUSIONS The preferred method for securing the appendiceal stump in UK practice is endoscopic ligatures regardless of operative experience. Factors with the greatest influence on the method employed include the ease of application and severity of stump inflammation. Our findings are likely to be representative of current NHS practice in Scotland.
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Gauger VT, Rooney D, Kovatch KJ, Richey L, Powell A, Berhe H, Zopf DA. A multidisciplinary international collaborative implementing low cost, high fidelity 3D printed airway models to enhance Ethiopian anesthesia resident emergency cricothyroidotomy skills. Int J Pediatr Otorhinolaryngol 2018; 114:124-128. [PMID: 30262349 PMCID: PMC6170009 DOI: 10.1016/j.ijporl.2018.08.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/30/2018] [Accepted: 08/30/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Similar to other sub-Saharan countries, Ethiopia suffers from a severe shortage of adequately trained health professionals. Academic partnerships can support sustainable training programs and build capacity for low-resource settings. 3D modeling and simulation-based training provide necessary tools, especially for rarely-encountered clinical situations, such as needle cricothyroidotomy. METHODS Departments of Anesthesiology, Otolaryngology, and Learning Health Sciences collaborated to develop a low-cost, high-fidelity simulator and Cricothryoidotomy Skills Maintenance Program (CSMP). Twelve anesthesia residents at St. Paul's Hospital Medical Millennium College in Addis Ababa, Ethiopia participated in CSMP. The program consisted of a didactic session with presentation and demonstration and an immersive CICO scenario. Program evaluation was performed using pre/post-training knowledge and 2 procedural performance assessments-the CSMP Global Rating Scale and the Checklist. With consent, performances were videotaped and rated independently by 3 University of Michigan faculty. RESULTS Improvements were identified in all areas, including residents' knowledge, measured by mean summed test scores (Mpre = 3.31,Mpost = 4.46,p = 0.003), time to perform cricothyroidotomy (Mpre = 96.64,Mpost = 72.82,p = 0.12), residents' performance quality, measured by overall mean Global ratings, (Mpre = 0.20; Mpost = 0.70) with improvements identified at the item-level, p = 0.001 with moderate-large effect sizes, and residents' ability to complete tasks, measured by mean Checklist ratings (Mpre = 0.51,Mpost = 0.90, with item-level improvements observed, p ≤ 0.01, with small-large effect sizes. Residents' self-reported confidence also improved (Mpre = 1.69, Mpost = 3.08,p = 0.001). CONCLUSION Our work shows that cricothyroidotomy skills taught to anesthesia residents at SPHMMC with a 3D printed laryngotracheal model improves knowledge, skills, and confidence. The creation of a low-cost, high-fidelity simulator and a CSMP has the potential to impact patient care and safety world-wide.
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Affiliation(s)
- Virginia T Gauger
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI, 48109, USA.
| | - Deborah Rooney
- Department of Learning Health Sciences, Michigan Medicine, Ann Arbor, MI, 48109, USA
| | - Kevin J Kovatch
- Department of Otolaryngology Head & Neck Surgery, Michigan Medicine, Ann Arbor, MI, 48109, USA
| | - Lauren Richey
- Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI, 48109, USA
| | | | | | - David A Zopf
- Department of Otolaryngology Head & Neck Surgery, Michigan Medicine, Ann Arbor, MI, 48109, USA
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Tessler RA, Stadeli KM, Chadbunchachai W, Gyedu A, Lagrone L, Reynolds T, Rubiano A, Mock CN. Utilization of injury care case studies: a systematic review of the World Health Organization's "Strengthening care for the injured: Success stories and lessons learned from around the world". Injury 2018; 49:1969-1978. [PMID: 30195833 PMCID: PMC6432919 DOI: 10.1016/j.injury.2018.08.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Translation of evidence to practice is a public health priority. Worldwide, injury is a leading cause of morbidity and mortality. Case study publications are common and provide potentially reproducible examples of successful interventions in healthcare from the patient to systems level. However, data on how well case study publications are utilized are limited. To our knowledge, the World Health Organization (WHO) published the only collection of international case studies on injury care at the policy level. We aimed to determine the degree to which these injury care case studies have been translated to practice and to identify opportunities for enhancement of the evidence-to-practice pathway for injury care case studies overall. METHODS We conducted a systematic review across 19 databases by searching for the title, "Strengthening care for the injured: Success stories and lessons learned from around the world." Data synthesis included realist narrative methods and two authors independently reviewed articles for injury topics, reference details, and extent of utilization. FINDINGS Forty-seven publications referenced the compilation of case studies, 20 of which included further descriptions of one or more of the specific cases and underwent narrative review. The most common category utilized was hospital-based care (15 publications), with the example of Thailand's quality improvement (QI) programme (10 publications) being the most commonly cited case. Also frequently cited were case studies on prehospital care (10 publications). There was infrequent utilization of case studies on rehabilitation (3 publications) and trauma systems (2 publications). No reference described a case translated to a new scenario. CONCLUSIONS The only available collection of policy-level injury care case studies has been utilized to a moderate extent however we found no evidence of case study translation to a new circumstance. QI programs seem especially amenable for knowledge-sharing through case studies. Prehospital care also showed promise. Greater emphasis on rehabilitation and health policy related to trauma systems is warranted. There is also a need for greater methodologic rigor in evaluation of the use of case study collections in general.
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Affiliation(s)
- Robert A Tessler
- Harborview Injury Prevention and Research Center, Seattle, USA; University of Pittsburgh, Pittsburgh, USA.
| | | | | | - Adam Gyedu
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | | | | | - Charles N Mock
- Harborview Injury Prevention and Research Center, Seattle, USA; University of Washington, Seattle, USA
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