Pooled analysis of who surgical safety checklist use and mortality after emergency laparotomy

Background: The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods: In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results: Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89⋅6 per cent) compared with that in countries with a middle (753 of 1242, 60⋅6 per cent; odds ratio (OR) 0⋅17, 95 per cent c.i. 0⋅14 to 0⋅21, P < 0⋅001) or low (363 of 860, 42⋅2 percent; OR 0⋅08, 0⋅07 to 0⋅10, P < 0⋅001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference −9⋅4 (95 per cent c.i. −11⋅9 to −6⋅9) per cent; P < 0⋅001), but the relationship was reversed in low-HDI countries (+12⋅1 (+7⋅0 to +17⋅3) per cent; P < 0⋅001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0⋅60, 0⋅50 to 0⋅73; P < 0⋅001). The greatest absolute benefit was seen for emergency surgery in low-and middle-HDI countries. Conclusion: Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries

Effects of alirocumab on types of myocardial infarction: insights from the ODYSSEY OUTCOMES trial

Aims  The third Universal Definition of Myocardial Infarction (MI) Task Force classified MIs into five types: Type 1, spontaneous; Type 2, related to oxygen supply/demand imbalance; Type 3, fatal without ascertainment of cardiac biomarkers; Type 4, related to percutaneous coronary intervention; and Type 5, related to coronary artery bypass surgery. Low-density lipoprotein cholesterol (LDL-C) reduction with statins and proprotein convertase subtilisin–kexin Type 9 (PCSK9) inhibitors reduces risk of MI, but less is known about effects on types of MI. ODYSSEY OUTCOMES compared the PCSK9 inhibitor alirocumab with placebo in 18 924 patients with recent acute coronary syndrome (ACS) and elevated LDL-C (≥1.8 mmol/L) despite intensive statin therapy. In a pre-specified analysis, we assessed the effects of alirocumab on types of MI. Methods and results  Median follow-up was 2.8 years. Myocardial infarction types were prospectively adjudicated and classified. Of 1860 total MIs, 1223 (65.8%) were adjudicated as Type 1, 386 (20.8%) as Type 2, and 244 (13.1%) as Type 4. Few events were Type 3 (n = 2) or Type 5 (n = 5). Alirocumab reduced first MIs [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77–0.95; P = 0.003], with reductions in both Type 1 (HR 0.87, 95% CI 0.77–0.99; P = 0.032) and Type 2 (0.77, 0.61–0.97; P = 0.025), but not Type 4 MI. Conclusion  After ACS, alirocumab added to intensive statin therapy favourably impacted on Type 1 and 2 MIs. The data indicate for the first time that a lipid-lowering therapy can attenuate the risk of Type 2 MI. Low-density lipoprotein cholesterol reduction below levels achievable with statins is an effective preventive strategy for both MI types.For complete list of authors see http://dx.doi.org/10.1093/eurheartj/ehz299</p

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001). Interpretation Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication. Funding DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Effect of alirocumab on mortality after acute coronary syndromes. An analysis of the ODYSSEY OUTCOMES randomized clinical trial

Background: Previous trials of PCSK9 (proprotein convertase subtilisin-kexin type 9) inhibitors demonstrated reductions in major adverse cardiovascular events, but not death. We assessed the effects of alirocumab on death after index acute coronary syndrome. Methods: ODYSSEY OUTCOMES (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) was a double-blind, randomized comparison of alirocumab or placebo in 18 924 patients who had an ACS 1 to 12 months previously and elevated atherogenic lipoproteins despite intensive statin therapy. Alirocumab dose was blindly titrated to target achieved low-density lipoprotein cholesterol (LDL-C) between 25 and 50 mg/dL. We examined the effects of treatment on all-cause death and its components, cardiovascular and noncardiovascular death, with log-rank testing. Joint semiparametric models tested associations between nonfatal cardiovascular events and cardiovascular or noncardiovascular death. Results: Median follow-up was 2.8 years. Death occurred in 334 (3.5%) and 392 (4.1%) patients, respectively, in the alirocumab and placebo groups (hazard ratio [HR], 0.85; 95% CI, 0.73 to 0.98; P=0.03, nominal P value). This resulted from nonsignificantly fewer cardiovascular (240 [2.5%] vs 271 [2.9%]; HR, 0.88; 95% CI, 0.74 to 1.05; P=0.15) and noncardiovascular (94 [1.0%] vs 121 [1.3%]; HR, 0.77; 95% CI, 0.59 to 1.01; P=0.06) deaths with alirocumab. In a prespecified analysis of 8242 patients eligible for ≥3 years follow-up, alirocumab reduced death (HR, 0.78; 95% CI, 0.65 to 0.94; P=0.01). Patients with nonfatal cardiovascular events were at increased risk for cardiovascular and noncardiovascular deaths (P<0.0001 for the associations). Alirocumab reduced total nonfatal cardiovascular events (P<0.001) and thereby may have attenuated the number of cardiovascular and noncardiovascular deaths. A post hoc analysis found that, compared to patients with lower LDL-C, patients with baseline LDL-C ≥100 mg/dL (2.59 mmol/L) had a greater absolute risk of death and a larger mortality benefit from alirocumab (HR, 0.71; 95% CI, 0.56 to 0.90; Pinteraction=0.007). In the alirocumab group, all-cause death declined wit h achieved LDL-C at 4 months of treatment, to a level of approximately 30 mg/dL (adjusted P=0.017 for linear trend). Conclusions: Alirocumab added to intensive statin therapy has the potential to reduce death after acute coronary syndrome, particularly if treatment is maintained for ≥3 years, if baseline LDL-C is ≥100 mg/dL, or if achieved LDL-C is low. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01663402

Uptake and distribution of sinigrin in microspore derived embryos of Brassica napus L.

In Brassica napus, glucosinolates are transported from all parts of the plant into the embryo during seed development. In this study we describe the uptake of the alkenyl glucosinolate sinigrin by microspore derived embryos from high and low glucosinolate genotypes. Microspore derived embryos develop completely isolated from maternal tissues unlike zygotic embryos, which contains glucosinolates transported into the embryo synthesised in the vegetative tissues. The sinigrin in the culture medium was almost completely absorbed by the embryos after three days of culture. The embryos of high and low glucosinolate genotypes were equally capable of absorbing sinigrin from the medium. A significant increase in different alkenyl glucosinolates following feeding of sinigrin suggests induction of biosynthetic; enzymes in the embryos. Following excess feeding of sinigrin, we found a strong uptake against a concentration gradient and stable accumulation by the embryos. The glucosinolate was detected in single dissected cotyledons by a photometric test and by HPLC. This test could potentially be useful for screening mutants defective in glucosinolate uptake into the embryo

The Displaced Northern Muslims of Sri Lanka: Special Problems and the Future

It has been widely established as fact that ethno-political conflict and civil war between the Tamils and the Sinhalese in Sri Lanka have generated immense sufferings among the Tamil and Sinhalese ethnic groups at the level of the masses. However, very little has been discussed about the plights of the Muslims of the North and East, particularly the former who became victims of the Sri Lanka’s long running ethnic conflict. In October 1990, the entire Muslim population of Jaffna, Vavumiya, Mullaitivu, Mannar and Kilinochchi districts in the northern region were evicted from their homes at gun point and turned into Internally Displaced Persons overnight by the Tamil Tigers (Liberation Tigers of Tamil Eelam). Muslims of the North claim that they have some basic and important problems to be solved. This study attempts to identify some of the special problems of the expelled Northern Muslims who are languishing in the state supported refugee camps in Puttalam district. A questionnaire on the special problems of the Northern Muslims was circulated to the North Eastern youth, students, unemployed Muslims, and farmers. The population of the target group was selected randomly. More than 250 questionnaires were issued. Ninety percent of them responded to the questionnaire. Interviews were also conducted over the phone with an educated section of the Northern Muslims. Finally, solutions are suggested to the protracted ethno-political conflict based on power-sharing and easing the special problems of the Northern Muslims. </jats:p

Mechanistic understanding of crystal violet dye sorption by woody biochar: implications for wastewater treatment

Dye-based industries, particularly small and medium scale, discharge their effluents into waterways without treatment due to cost considerations. We investigated the use of biochars produced from the woody tree Gliricidia sepium at 300 °C (GBC300) and 500 °C (GBC500) in the laboratory and at 700 °C from a dendro bioenergy industry (GBC700), to evaluate their potential for sorption of crystal violet (CV) dye. Experiments were conducted to assess the effect of pH reaction time and CV loading on the adsorption process. The equilibrium adsorption capacity was higher with GBC700 (7.9 mg g−1) than GBC500 (4.9 mg g−1) and GBC300 (4.4 mg g−1), at pH 8. The CV sorption process was dependent on the pH, surface area and pore volume of biochar (GBC). Both Freundlich and Hill isotherm models fitted best to the equilibrium isotherm data suggesting cooperative interactions via physisorption and chemisorption mechanisms for CV sorption. The highest Hill sorption capacity of 125.5 mg g−1 was given by GBC700 at pH 8. Kinetic data followed the pseudo-second-order model, suggesting that the sorption process is more inclined toward the chemisorption mechanism. Pore diffusion, π–π electron donor–acceptor interaction and H-bonding were postulated to be involved in physisorption, whereas electrostatic interactions of protonated amine group of CV and negatively charged GBC surface led to a chemisorption type of adsorption. Overall, GBC produced as a by-product of the dendro industry could be a promising remedy for CV removal from an aqueous environment

Bioenergy-derived waste biochar for reducing mobility, bioavailability, and phytotoxicity of chromium in anthropized tannery soil

Purpose: This study was aimed to investigate the potential of biochar (BC), a waste byproduct of a bioenegy industry, Sri Lanka, as a soil amendment to immobilize and reduce the phytotoxicity of Cr in tannery waste-polluted soil (TWS). Materials and methods: The TWS and bioenergy waste BC were characterized for physio-chemical parameters. A pot experiment was conducted by adding three BC application rates, 1, 2.5, and 5 % (w/w) to investigate the immobilizing capacity and bioaccumulation of chromium (Cr) in tomato plants (Lycopersicon esculentum L.). Soils and plants were digested via microwave digestion and analyzed for total Cr. Further, sequential extraction was conducted to assess the fractionation of Cr before and after the application of bioenergy waste BC on TWS. Results and discussion: The total Cr concentration in TWS was 12,285 mg/kg. The biomass of tomato plants grown in the 5 % BC amendment doubled compared to the biomass in BC-unamended soil. Bioaccumulation of Cr in plants grown in 5 % BC-amended TWS showed a decrease by 97 % compared to that of the BC-unamended soil. The CaCl2 extractability of Cr indicated that the bioavailability of Cr in the 5 % BC amendment has decreased by 68 % compared to the control. Sequentially extracted Cr in the exchangeable fraction decreased by 98 % in the 5 % BC amendment. Conclusions: Pore diffusion, and adsorption via π-π electron donor-acceptor interactions were the primary mechanisms to be involved in the Cr retention in BC. Results suggested that the addition of BC to TWS reduces the mobility, bioavailability, and phytotoxicity of Cr in tomato plants

Assessment of plant diversity and foliar chemistry on the Sri Lankan ultramafics reveals inconsistencies in the metal hyperaccumulator trait

Some of the largest expanses of ultramafic soils occur in South Asia, but knowledge of the plant diversity and biogeochemistry of these systems in Sri Lanka is very limited. This study aimed to assess the plant diversity and bedrock and foliar chemistry of all known Sri Lankan ultramafic outcrops. The field survey yielded a total of 132 plant taxa from 44 families. The enigmatic nickel hyperaccumulator Rinorea bengalensis (Violaceae), first reported in Sri Lanka over four decades ago, was rediscovered at a newly surveyed ultramafic site, however, it did not hyperaccumulate nickel. No new metal hyperaccumulator plants were identified, suggesting that R. bengalensis is a facultative nickel hyperaccumulator. This study is the first to highlight the floristic diversity of all known Sri Lankan ultramafic outcrops while revealing the facultative nature of nickel and copper hyperaccumulation among some of Sri Lanka's ultramafic plants