Psychosocial outcomes following emergency laparotomy (POLO) study: a study protocol for a multicentre mixed-methods prospective cohort study assessing the psycho-social outcomes following emergency laparotomy in adults.

INTRODUCTION: Morbidity from an emergency laparotomy (EmLap) is difficult to define and poorly understood. Morbidity is a holistic concept, reliant upon an interplay of bio-psychosocial outcomes that evolve long after discharge. To date, no previous study has explored the psychosocial outcomes following EmLap as a collective, nor their change over time. This study aims to describe the holistic morbidity following EmLap within the first year following surgery. METHODS AND ANALYSIS: This is a multicentre, mixed-methods prospective 12-month cohort study with two participant populations: patient participants and family caregivers (FCGs). A target of 160 adult patients who undergo EmLap and can give informed consent will be included in the patient participant group. Patient participants will be asked to complete three patient surveys, incorporating validated patient-reported outcome measures (PROMs) to assess bio-psychosocial outcomes (EuroQol five-dimension five-level (EQ5D-5L), Gastrointestinal Quality Life Index-36, Patient Health Questionnaire-9, Generalised Anxiety Disorder 7, International Trauma Questionnaire, Caregiver Interaction Scale and Fatigue Severity Scale) in the 12 months following surgery. A subgroup of 15 patient participants will be asked to take part in two semistructured interviews at 6 and 12 months. A target of 15 associated family caregivers will be included in the FCG group. FCGs will be asked to take part in a semi-structured interview at 6 months to assess the EmLap impact on the wider support network. The primary outcome will be a change in quality of life (EQ5D-5L) at 12 months. Secondary outcomes will be changes in bio-psychosocial status at 3 and 12 months. Qualitative analysis will allow contextualisation of PROMS and further explore themes of EmLap morbidity. It is anticipated that the results of this study will help inform and develop standards of aftercare for future EmLap patients. ETHICS AND DISSEMINATION: This study has received ethical approval (Wales REC7;12/WA/0297) and will be undertaken in accordance with the principles of Good Clinical Practice. We intend to disseminate study results in peer-reviewed journals and medical conferences, as well as a lay report to study participants. TRIAL REGISTRATION NUMBER: Clinical Trials.gov NCT05281627.

Developing respiratory pathogen pandemic preparedness plans

Planning for public health emergencies should ensure that capabilities developed during previous emergencies are maintained, incorporated, and put into practice when a new event of public health concern arises. Investments in pandemic preparedness lead to more rapid detection and a stronger response to public health threats, thereby shielding communities from the debilitating social and economic effects of epidemics and pandemics. The Pan American Health Organization (PAHO) recognizes the efforts of countries in the Region of the Americas to develop and/or strengthen their respiratory pathogen pandemic plans. PAHO supports planning activities with tools and expertise, aligning these efforts with the Preparedness and Resilience for Emerging Threats (PRET) initiative. The PRET initiative is an innovative approach to improving disease pandemic preparedness. It recognizes that the same systems, capacities, knowledge, and tools can be leveraged and applied for groups of pathogens based on their mode of transmission (respiratory, vector-borne, foodborne etc.). The PRET initiative incorporates the latest tools and approaches for shared learning and collective action established during the COVID-19 pandemic and other recent public health emergencies. It places the principles of equity, inclusivity, and coherence at the forefront. This document outlines four steps for respiratory pathogen pandemic planning (PRET Module1). Step 1: Prepare, analyze the situation and engage stakeholders, Step 2: Draft the plan, Step 3: Evaluate, finalize and disseminate the plan and Step 4: Implement, monitor and continuously evaluate the plan. The scope of this document is guide the process of updating and developing preparedness and response plans for pandemics caused by respiratory pathogens, in order to strengthen their basic capacities and encourage the countries of the Region of the Americas to have operational, proven plans, and with a regular monitoring and updating plan to address epidemics and pandemics in the face of this type of threat.

Introducing the concept of digitally smart health facilities: a vision for the future

The adoption of the digitally smart health facilities (DSHFs) concept introduces a new paradigm in today’s public health environment, potentially opening possibilities for addressing many challenges. This editorial explores the concept, emphasizing its potential to revolutionize the health care landscape by integrating digital infrastructure, tools, services and digital literacy within the planning and construction or renovation of health facilities at all levels of care. This innovative concept could pave the way for transformative changes in health care delivery, and improve patients’ outcomes and operational efficiencies, bringing health care closer to patients not only during day-to-day operations but also during health emergencies and disasters. This editorial highlights the significant contributions made by digital health solutions to the safe hospitals initiative led by the Pan American Health Organization (PAHO), emphasizing the role of information and communication technologies in enhancing access to care.

Minimally invasive approach in a rare emergency surgery, gallbladder perforation.

BACKGROUND: Gallbladder perforations are challenging to manage for surgeons due to their high morbidity and mortality, rarity, and surgical approach. Laparoscopic cholecystectomy (LC) is now included with open cholecystectomy in surgical managing gallbladder perforations. This study aimed to evaluate the factors affecting conversion from laparoscopic to open cholecystectomy in cases of type I gallbladder perforation according to the Modified Niemeier classification. METHODS: Patients who met the inclusion criteria were divided into two groups: LC and conversion to open cholecystectomy (COC). Demographic, clinical, radiologic, intraoperative, and postoperative factors were compared between groups. RESULTS: This study included 42 patients who met the inclusion criteria, of which 28 were in the LC group and 14 were in the COC group. Their median age was 68 (55-85) years. Age did not differ significantly between groups (p = 0.218). However, the sex distribution did differ significantly between groups (p = 0.025). The location of the perforation differed significantly between groups (p < 0.001). In the LC group, 22 patients were perforated from the fundus, four from the trunk, and two from the neck. In the COC group, two patients were perforated from the fundus, four from the trunk, and eight from the neck. Surgical procedure times differed significantly between the LC (105.0 min [60-225]) and COC (125.0 min [110-180]) groups (p = 0.035). The age of the primary surgeons also differed significantly between the LC (42 years [34-63]) and COC (55 years [36-59]) groups (p = 0.001). CONCLUSIONS: LC can be safely performed for modified Niemeier type I gallbladder perforations. The proximity of the perforation site to Calot's triangle, Charlson comorbidity index (CCI), and Tokyo classification are factors affecting conversion from laparoscopic to open surgery of gallbladder perforations.

Health policy and regulatory authorities: challenges of technology regulation in Public Health Emergencies. / Política de saúde e Autoridades Reguladoras: desafios da regulação de tecnologias nas Emergências em Saúde Pública.

Public Health Emergencies (PHE) have had repercussions on health systems on a global scale, and timely access to new health technologies is a challenge for health policy. The national regulatory authorities (NRA) play a key role in the evaluation and regulation of these technologies. The present study aims to analyze the main strategies and regulatory instruments used to deal with the challenges of regulating new technologies necessary for the health system's effective response during a PHE. This research, based on WHO and Brazilian NRA norms and documents, considered dimensions related to strategies for strengthening regulatory activities and regulatory instruments used to accelerate access to technologies, especially during PHEs. International cooperation between the NRA and the WHO were important strategies for strengthening the NRA, with emphasis on the use of reliance, regionalization, accelerated assessments, and work/information sharing, as well as the processes of regulatory harmonization and convergence. In addition to the use of existing regulatory instruments, efforts were also identified in order to implement new ones.

As Emergências em Saúde Pública (ESP) têm repercutido nos sistemas de saúde em escala global. O acesso às novas tecnologias em saúde em tempo oportuno é um desafio para a política de saúde. As autoridades reguladoras nacionais (ARN) têm papel fundamental na avaliação e regulação dessas tecnologias. O estudo objetiva analisar as principais estratégias e instrumentos regulatórios utilizados para lidar com os desafios da regulação de novas tecnologias necessárias à resposta do sistema de saúde durante as ESP. Trata-se de uma pesquisa normativa e documental, tendo como fonte a OMS e a ARN brasileira. Foram consideradas as dimensões relacionadas às estratégias para o fortalecimento das atividades regulatórias e os instrumentos regulatórios utilizados para acelerar o acesso às tecnologias, especialmente durante as ESP. A cooperação e a colaboração internacional entre as ARN e com a OMS foram importantes estratégias para o fortalecimento das ARN, com destaque para o uso de confiança, regionalização, avaliações aceleradas e compartilhamento de trabalho/informações, bem como os processos de harmonização e convergência regulatória. Identificou-se, além da utilização de instrumentos regulatórios já existentes, esforços na implementação de novos, com destaque para Autorização de Uso Emergencial.

Robotic versus laparoscopic general surgery in the emergency setting: a systematic review.

Robot-assisted general surgery, an advanced technology in minimally invasive procedures, is increasingly employed in elective general surgery, showing benefits over laparoscopy in specific cases. Although laparoscopy remains a standard approach for common acute abdominal conditions, the role of robotic surgery in emergency general surgery remains uncertain. This systematic review aims to compare outcomes in acute general surgery settings for robotic versus laparoscopic surgeries. A PRISMA-compliant systematic search across MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane Library was conducted. The literature review focused on articles comparing perioperative outcomes of emergency general surgery managed laparoscopically versus robot-assisted. A descriptive analysis was performed, and outcome measures were recorded. Six articles, involving 1,063 patients, compared outcomes of robotic and laparoscopic procedures. Two articles covered cholecystectomies, while the others addressed ileocaecal resection, subtotal colectomy, hiatal hernia and repair of perforated gastrojejunal ulcers. The level of evidence was low. Laparoscopic bowel resection in patients with inflammatory bowel disease (IBD) had higher complications; no significant differences were found in complications for other operations. Operative time showed no differences for cholecystectomies, but robotic approaches took longer for other procedures. Robotic cases had shorter hospital length of stay, although the associated costs were significantly higher. Perioperative outcomes for emergency robotic surgery in selected general surgery conditions are comparable to laparoscopic surgery. However, recommending robotic surgery in the acute setting necessitates a well-powered large population study for stronger evidence.

Assessing the impact of frailty in elderly patients undergoing emergency laparotomies in Singapore.

Introduction: The global rise in ageing populations poses challenges for healthcare systems. By 2030, Singapore anticipates a quarter of its population to be aged 65 or older. This study addresses the dearth of research on frailty's impact on emergency laparotomy (EL) outcomes in this demographic, emphasising the growing significance of this surgical intervention. Method: Conducted at 2 tertiary centres in Singapore from January to December 2019, a retrospective cohort study examined EL outcomes in patients aged 65 or older. Frailty assessment, using the Clinical Frailty Scale (CFS), was integrated into demographic, diagnostic and procedural analyses. Patient data from Tan Tock Seng Hospital and Khoo Teck Puat Hospital provided a comprehensive view of frailty's role in EL. Results: Among 233 participants, 26% were frail, revealing a higher vulnerability in the geriatric population. Frail individuals exhibited elevated preoperative risk, prolonged ICU stays, and significantly higher 90-day mortality (21.3% versus 6.4%). The study illuminated a nuanced connection between frailty and adverse outcomes, underlining the critical need for robust predictive tools in this context. Conclusion: Frailty emerged as a pivotal factor influencing the postoperative trajectory of older adults undergoing EL in Singapore. The integration of frailty assessment, particularly when combined with established metrics like P-POSSUM, showcased enhanced predictive accuracy. This finding offers valuable insights for shared decision-making and acute surgical unit practices, emphasising the imperative of considering frailty in the management of older patients undergoing emergency laparotomy.

Novel Textbook Outcomes following emergency laparotomy: Delphi exercise.

BACKGROUND: Textbook outcomes are composite outcome measures that reflect the ideal overall experience for patients. There are many of these in the elective surgery literature but no textbook outcomes have been proposed for patients following emergency laparotomy. The aim was to achieve international consensus amongst experts and patients for the best Textbook Outcomes for non-trauma and trauma emergency laparotomy. METHODS: A modified Delphi exercise was undertaken with three planned rounds to achieve consensus regarding the best Textbook Outcomes based on the category, number and importance (Likert scale of 1-5) of individual outcome measures. There were separate questions for non-trauma and trauma. A patient engagement exercise was undertaken after round 2 to inform the final round. RESULTS: A total of 337 participants from 53 countries participated in all three rounds of the exercise. The final Textbook Outcomes were divided into 'early' and 'longer-term'. For non-trauma patients the proposed early Textbook Outcome was 'Discharged from hospital without serious postoperative complications (Clavien-Dindo ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation or death). For trauma patients it was 'Discharged from hospital without unexpected transfusion after haemostasis, and no serious postoperative complications (adapted Clavien-Dindo for trauma ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation on or death)'. The longer-term Textbook Outcome for both non-trauma and trauma was 'Achieved the early Textbook Outcome, and restoration of baseline quality of life at 1 year'. CONCLUSION: Early and longer-term Textbook Outcomes have been agreed by an international consensus of experts for non-trauma and trauma emergency laparotomy. These now require clinical validation with patient data.

Quantification of referrals received at two emergency-capable hyperbaric medicine centers.

Emergency hyperbaric oxygen treatment capability is limited in the United States, and there is little documentation of calls received by centers available 24 hours a day, seven days a week, 365 days a year. Our study aimed to calculate the number of calls received for urgent hyperbaric oxygen (HBO2). We logged calls from two HBO2 chambers on the East Coast of the United States that serve a densely populated region in 2021. The total number of emergency calls was 187 at the University of Maryland (UMD) and 127 at the University of Pennsylvania (UPenn). There were calls on 180/365 (46%) days during the study period at UMD and 239/365 (63%) days at UPenn. The most common indication was carbon monoxide toxicity. The peak month of calls was March. Emergency HBO2 calls are common, and more centers must accept emergency cases. Data from geographically diverse centers would add generalizability to these results and capture more diving-related emergencies.

Herramienta para la autoevaluación del índice de seguridad hospitalaria. Gases medicinales

Durante la pandemia de COVID-19 se detectaron problemas críticos en cuanto al suministro de oxígeno a nivel mundial. El colapso de los sistemas de oxígeno medicinal puso en evidencia no solo la falta de personal capacitado, sino también una gestión deficiente y, en muchos casos, la falta de preparación de los hospitales para hacer frente a una emergencia de salud con necesidades altas de oxígeno. Con el índice de seguridad hospitalaria se aspira a mejorar el funcionamiento de los hospitales durante las emergencias. Es importante que se lleven a cabo autoevaluaciones de la infraestructura de los hospitales, con el objetivo de detectar áreas de oportunidad o de mejoría en su infraestructura, instalaciones y respuesta operativa a los desastres. Esta herramienta de Excelâ y el manual de instrucciones que la acompaña se crearon con el fin de mejorar las redes y equipos de gases medicinales de los hospitales de la Región de las Américas.

Features of databases that supported searching for rapid evidence synthesis during COVID-19: implications for future public health emergencies.

BACKGROUND: As evidence related to the COVID-19 pandemic surged, databases, platforms, and repositories evolved with features and functions to assist users in promptly finding the most relevant evidence. In response, research synthesis teams adopted novel searching strategies to sift through the vast amount of evidence to synthesize and disseminate the most up-to-date evidence. This paper explores the key database features that facilitated systematic searching for rapid evidence synthesis during the COVID-19 pandemic to inform knowledge management infrastructure during future global health emergencies. METHODS: This paper outlines the features and functions of previously existing and newly created evidence sources routinely searched as part of the NCCMT's Rapid Evidence Service methods, including databases, platforms, and repositories. Specific functions of each evidence source were assessed as they pertain to searching in the context of a public health emergency, including the topics of indexed citations, the level of evidence of indexed citations, and specific usability features of each evidence source. RESULTS: Thirteen evidence sources were assessed, of which four were newly created and nine were either pre-existing or adapted from previously existing resources. Evidence sources varied in topics indexed, level of evidence indexed, and specific searching functions. CONCLUSION: This paper offers insights into which features enabled systematic searching for the completion of rapid reviews to inform decision makers within 5-10 days. These findings provide guidance for knowledge management strategies and evidence infrastructures during future public health emergencies.

Analgesia for emergency laparotomy: a systematic review.

Aims/Background Poorly controlled pain is common after emergency laparotomy. It causes distress, hinders rehabilitation, and predisposes to complications: prolonged hospitalisation, persistent pain, and reduced quality of life. The aim of this systematic review was to compare the relative efficacies of pre-emptive analgesia for emergency laparotomy to inform practice. Methods We performed a search of MEDLINE, MEDLINE In-Process, Embase, PubMed, Web of Science and SCOPUS for comparator studies of preoperative/intraoperative interventions to control/reduce postoperative pain in adults undergoing emergency laparotomy (EL) for general surgical pathologies. Exclusion criteria: surgery including non-abdominal sites; postoperative sedation and/or intubation; non-formal assessment of pain; non-English manuscripts. All manuscripts were screened by two investigators. Results We identified 2389 papers. Following handsearching and removal of duplicates, 1147 were screened. None were eligible for inclusion, with many looking at elective and/or laparoscopic surgeries. Conclusion Our findings indicate there is no evidence base for pre-emptive analgesic strategies in emergency laparotomy. This contrasts substantially with elective cohorts. Potential reasons include variation in practice, management of physiological derangement taking priority, and perceived contraindications to neuraxial techniques. We urge a review of contemporary practice, with analysis of clinical data, to generate expert consensus.

Transforming the delivery of care from "I" to "We" by developing the crisis resource management skills in pediatric interprofessional teams to handle common emergencies through simulation.

BACKGROUND: The healthcare system is highly complex, and adverse events often result from a combination of human factors and system failures, especially in crisis situations. Crisis resource management skills are crucial to optimize team performance and patient outcomes in such situations. Simulation-based training offers a promising approach to developing such skills in a controlled and realistic environment. METHODS: This study employed a mixed-methods (quantitative-qualitative) design and aimed to assess the effectiveness of a simulation-based training workshop in developing crisis resource management skills in pediatric interprofessional teams at a tertiary care hospital. The effectiveness of the intervention was evaluated using Kirkpatrick's Model, focusing on reaction and learning levels, employing the Collaboration and Satisfaction about Care Decisions scale, Clinical Teamwork Scale, and Ottawa Global Rating Scale for pre- and post-intervention assessments. Focused group discussions were conducted with the participants to explore their experiences and perceptions of the training. RESULTS: Thirty-nine participants, including medical students, nurses, and residents, participated in the study. Compared to the participants' pre-workshop performance, significant improvements were observed across all measured teamwork and performance components after the workshop, including improvement in scores in team communication (3.16 ± 1.20 to 7.61 ± 1.0, p < 0.001), decision-making (3.50 ± 1.54 to 7.16 ± 1.42, p < 0.001), leadership skills (2.50 ± 1.04 to 5.44 ± 0.6, p < 0.001), and situation awareness (2.61 ± 1.13 to 5.22 ± 0.80, p < 0.001). No significant variations were observed post-intervention among the different teams. Additionally, participants reported high levels of satisfaction, perceived the training to be highly valuable in improving their crisis resource management skills, and emphasized the importance of role allocation and debriefing. CONCLUSIONS: The study underscores the effectiveness of simulation-based training in developing crisis resource management skills in pediatric interprofessional teams. The findings suggest that such training can impact learning transfer to the workplace and ultimately improve patient outcomes. The insights from our study offer additional valuable considerations for the ongoing refinement of simulation-based training programs. There is a need to develop more comprehensive clinical skills evaluation methods to better assess the transferability of these skills in real-world settings. The potential challenges unveiled in our study, such as physical exhaustion during training, must be considered when refining and designing such interventions.

Facteurs influençant le délai de prise en charge aux urgences chirurgicales du CHU Sourô Sanou.

INTRODUCTION: Assessing patient turnaround times is essential for improving the quality of care in emergency service departments. PURPOSE OF THE RESEARCH: This study looked at waiting and treatment times, and their associated factors, in the surgical emergency service department at the Souro Sanou National Teaching Hospital (SSNTH) in Bobo-Dioulasso, Burkina Faso. RESULTS: This study was carried out on 380 patients with a median age of thirty-eight. The sex ratio was 0.54. In 63.7 percent of cases, the participants lived in urban areas. Most of the patients surveyed were farmers (34.7 percent). The median waiting time for patients was eleven minutes. The nature of the trauma sustained was associated with the waiting time. The median time taken to administer first aid was sixty-three minutes, with the unavailability of medication at the hospital pharmacy cited as a factor contributing to this delay. The median time taken to obtain paraclinical results was 134 minutes and 102 minutes for laboratory tests and scans, respectively. The factor associated with delays in obtaining scan results was the need for surgical intervention. The median waiting time for surgery was 24.3 hours. CONCLUSIONS: The turnaround times in the SSNTH surgical emergency department are long. For the improvement of patient turnaround times to be possible, an overhaul of the department is in order. In particular, a rapid consultation team needs to be established, and essential drugs for emergency care need to be made readily available.

[Neurologischer Notfall nach dentaler Implantation - was nun?]

Mit der Verbreitung von Zahnimplantaten ist die Zahl neurologischer Komplikationen gestiegen, wobei diese vor allem im Unterkiefer vorkommen. Verletzungen des Nervus alveo- laris inferior sind eine ernste Komplikation mit Inzidenzen für transiente Nervschäden bis zu 24% und persistierenden Schädigungen bis zu 11%.

Quality of emergency oncological surgery: time for advanced oncological life support.

OBJECTIVE: In the emergency care of cancer patients, in addition to cancer-related factors, two aspects influence the outcome: (1) where the patient is treated and (2) who will perform the surgery. In Brazil, a significant proportion of patients with surgical oncological emergencies will be operated on in general hospitals by surgeons without training in oncological surgery. OBJECTIVE: The objective was to discuss quality indicators and propose the creation of an urgent oncological surgery advanced life support course. METHODS: Review of articles on the topic. RESULTS: Generally, nonelective resections are associated with higher rates of morbidity and mortality, as well as lower rates of cancer-specific survival. In comparison to elective procedures, the reduced number of harvested lymph nodes and the higher rate of positive margins suggest a compromised degree of radicality in the emergency scenario. CONCLUSION: Among modifiable factors is the training of the emergency surgeon. Enhancing the practice of oncological surgery in emergency settings constitutes a formidable undertaking that entails collaboration across various medical specialties and warrants endorsement and support from medical societies and educational institutions. It is time to establish a national registry encompassing oncological emergencies, develop quality indicators tailored to the national context, and foster the establishment of specialized training programs aimed at enhancing the proficiency of physicians serving in emergency services catering to cancer patients.

The role of RObotic surgery in EMergency setting (ROEM): protocol for a multicentre, observational, prospective international study on the use of robotic platform in emergency surgery.

BACKGROUND: Robotic surgery has gained widespread acceptance in elective interventions, yet its role in emergency procedures remains underexplored. While the 2021 WSES position paper discussed limited studies on the application of robotics in emergency general surgery, it recommended strict patient selection, adequate training, and improved platform accessibility. This prospective study aims to define the role of robotic surgery in emergency settings, evaluating intraoperative and postoperative outcomes and assessing its feasibility and safety. METHODS: The ROEM study is an observational, prospective, multicentre, international analysis of clinically stable adult patients undergoing robotic surgery for emergency treatment of acute pathologies including diverticulitis, cholecystitis, and obstructed hernias. Data collection includes patient demographics and intervention details. Furthermore, data relating to the operating theatre team and the surgical instruments used will be collected in order to conduct a cost analysis. The study plans to enrol at least 500 patients from 50 participating centres, with each centre having a local lead and collaborators. All data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. Ethical considerations and data governance will be paramount, requiring local ethical committee approvals from participating centres. DISCUSSION: Current literature and expert consensus suggest the feasibility of robotic surgery in emergencies with proper support. However, challenges include staff training, scheduling conflicts with elective surgeries, and increased costs. The ROEM study seeks to contribute valuable data on the safety, feasibility, and cost-effectiveness of robotic surgery in emergency settings, focusing on specific pathologies. Previous studies on cholecystitis, abdominal hernias, and diverticulitis provide insights into the benefits and challenges of robotic approaches. It is necessary to identify patient populations that benefit most from robotic emergency surgery to optimize outcomes and justify costs.