Summary Background Risk of mortality following surgery in patients across Africa is twice as high as the global average. Most of these deaths occur on hospital wards after the surgery itself. We aimed to assess whether enhanced postoperative surveillance of adult surgical patients at high risk of postoperative morbidity or mortality in Africa could reduce 30-day in-hospital mortality. Methods We did a two-arm, open-label, cluster-randomised trial of hospitals (clusters) across Africa. Hospitals were eligible if they provided surgery with an overnight postoperative admission. Hospitals were randomly assigned through minimisation in recruitment blocks (1:1) to provide patients with either a package of enhanced postoperative surveillance interventions (admitting the patient to higher care ward, increasing the frequency of postoperative nursing observations, assigning the patient to a bed in view of the nursing station, allowing family members to stay in the ward, and placing a postoperative surveillance guide at the bedside) for those at high risk (ie, with African Surgical Outcomes Study Surgical Risk Calculator scores ≥10) and usual care for those at low risk (intervention group), or for all patients to receive usual postoperative care (control group). Health-care providers and participants were not masked, but data assessors were. The primary outcome was 30-day in-hospital mortality of patients at low and high risk, measured at the participant level. All analyses were done as allocated (by cluster) in all patients with available data. This trial is registered with ClinicalTrials.gov , NCT03853824 . Findings Between May 3, 2019, and July 27, 2020, 594 eligible hospitals indicated a desire to participate across 33 African countries; 332 (56%) were able to recruit participants and were included in analyses. We allocated 160 hospitals (13 275 patients) to provide enhanced postoperative surveillance and 172 hospitals (15 617 patients) to provide standard care. The mean age of participants was 37·1 years (SD 15·5) and 20 039 (69·4%) of 28 892 patients were women. 30-day in-hospital mortality occurred in 169 (1·3%) of 12 970 patients with mortality data in the intervention group and in 193 (1·3%) of 15 242 patients with mortality data in the control group (relative risk 0·96, 95% CI 0·69–1·33; p=0·79). 45 (0·2%) of 22 031 patients at low risk and 309 (5·6%) of 5500 patients at high risk died. No harms associated with either intervention were reported. Interpretation This intervention package did not decrease 30-day in-hospital mortality among surgical patients in Africa at high risk of postoperative morbidity or mortality. Further research is needed to develop interventions that prevent death from surgical complications in resource-limited hospitals across Africa. Funding Bill & Melinda Gates Foundation and the World Federati...
Background: There are many laparoscopic techniques for pediatric congenital inguinal hernia repair. Needlescopic surgery was introduced recently in pediatric patients aiming at getting excellent cosmetic outcomes. Purpose:The aim of this study was to describe a novel technique for needlescopic inguinal hernia repair in children.Patients and Methods: Needlescopic division of the hernial sac was carried out on 369 children in 6 pediatric tertiary centers during the period from August 2016 to May 2019. All hernias were repaired by a novel needlescopic procedure that replicates all the steps of the open herniotomy.Results: A total of 369 patients with 410 hernias were included in this study. They were 232 (62.9%) males and 137 (37.1%) females, with a mean age of 3.58 ± 1.26 (range = 2 to 8 y) and mean internal inguinal ring diameter was 13.65 ± 3.85 mm (range = 8 to 20 mm). The mean operative time was 23.36 ± 4.67 minutes for bilateral and 14.28 ± 2.98 minutes for unilateral cases. All cases were completed without conversion to conventional laparoscopy. All cases were followed up for a mean of 19.6 ± 3.2 months. None of our patients developed recurrence or testicular atrophy and the scars were nearly invisible 3 months postoperatively.Conclusions: Needlescopic pediatric inguinal hernia repair using disconnection of the hernia sac at internal inguinal ring with pursestring suture closure of peritoneum is feasible and safe with no recurrence and with outstanding cosmetic results.
Background The study aimed to review recent literature not included in previous reviews and ascertain the correlation between early marijuana use among adolescents, between 12 and 18 years of age, and the development of schizophrenia in early adulthood. A further aim was to determine if the frequency of use of marijuana demonstrated any significant effect on the risk of developing schizophrenia in early adulthood. Methods Five hundred and ninety‐one studies were examined; six longitudinal cohort studies were analyzed using a series of nonparametric tests and meta‐analysis. Results Nonparametric tests, Friedman tests, and Wilcoxon signed tests showed a highly statistically significant difference in odds ratios for schizophrenia between both high‐ and low‐cannabis users and no‐cannabis users. Conclusion Both high‐ and low‐frequency marijuana usage were associated with a significantly increased risk of schizophrenia. The frequency of use among high‐ and low‐frequency users is similar in both, demonstrating statistically significant increased risk in developing schizophrenia.
Purpose To evaluate laparoscopic management of hydroceles in pediatrics, with evaluation of the internal inguinal ring (IIR) and the PPV (patent processus vaginalis) in different types of hydroceles, and the incidence of the contralateral PPV. Methods The IIR and the type of hydrocele on the same side of 93 patients with 106 infantile hydroceles were evaluated and managed, in addition to contralateral side. Results The IIR on same side was closed in 8.5% (Type I) and patent in 91.5% (Type II and III) with different shapes. Contralateral IIR was open in 88.7% of cases. The operative time was 30.99 ± 7.23 min, with no intra-operative complication. The vas deferens and testicular vessels were secured and there were no injuries or bleeding. The conversion rate was zero, and all procedures (Type II and II) were completed totally laparoscopic. No post-operative complications except a case of tense hydrocele developed scrotal edema that managed conservatively. Conclusion Laparoscopic hydrocelectomy is safe, applicable and feasible for management of different types of hydroceles in pediatrics. The IIR is patent in nearly all cases with/out communication to the hydrocele. The contralateral IIR can be managed in the same session. Laparoscopic hydrocelectomy with/out hydrocelectomy and IIR closure is essential in preventing recurrence.
Aim of the Study: We aimed to compare the management of pediatric benign ovarian tumors between an English center and three Egyptian institutions. Materials and Methods: This was a retrospective review of all children presenting with benign ovarian tumors between January 2014 and January 2019. A standardized dataset was used to compare between both sides. Results: Eighty-nine patients were included (54 English and 35 Egyptians). Median age at diagnosis in England was 13 years (2-16y), while in Egypt it was 7 years (9m-16y) with P =0.001. Mature teratomas or dermoid cysts were the most common findings in England and Egypt; 75.9% and 82.8% of cases, respectively. The presentation with an acute abdomen represented 27.8% of English and 28.6% of Egyptian patients. Incidentally diagnosed lesions constituted 15% of English patients, whereas none of the Egyptian cases were discovered incidentally. There were variations in diagnostic imaging; England: Ultrasound (USS) (54), magnetic resonance imaging (MRI) (37), and computed tomography (CT) (only one)–Egypt: USS (35), CT (17), and MRI (only one). Minimally invasive surgery (MIS) was performed in 15% of English and 23% of Egyptian patients ( P = 0.334). Ovarian-sparing surgery (OSS) was performed in: England 35%, Egypt 37%; P = 0.851. OSS was performed using MIS in 87.5% (7/8) of English patients and 100% (8/8) of Egyptians. Patients presented as emergencies generally had open oophorectomies: England; 86.7% open and 80% oophorectomy–Egypt; 100% open and 90% oophorectomy. Recurrences or metachronous disease occurred in 5.6% of English and 5.7% of Egyptian patients. Conclusions: There were no significant differences regarding surgical management, tumor pathology, and recurrence or metachronous disease. However, age, incidental diagnosis, and imaging modalities showed notable differences. MIS was correlated with ovarian preservation, whereas emergency surgery generally resulted in open oophorectomy.
Pediatric inguinal hernias are not the same and there is extreme variation in the presentation regarding the size of the defect. We proposed a nouvelle pediatric hernia classification modified from the original Nyhus classification for adult inguinal hernia with tailored surgical approach to each type (PHCTT). Applying this (PHCTT), it has the benefit of a significant reduction of recurrence rate.
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