Pakistan Registry of Intensive CarE (PRICE): Expanding a lower middle-income, clinician-designed critical care registry in South Asia.

INTRODUCTION: In resource-limited settings - with inequalities in access to and outcomes for trauma, surgical and critical care - intensive care registries are uncommon. AIM: The Pakistan Society of Critical Care Medicine, Intensive Care Society (UK) and the Network for Improving Critical Care Systems and Training (NICST) aim to implement a clinician-led real-time national intensive care registry in Pakistan: the Pakistan Registry of Intensive CarE (PRICE). METHOD: This was adapted from a successful clinician co-designed national registry in Sri Lanka; ICU information has been linked to real-time dashboards, providing clinicians and administrators individual patient and service delivery activity respectively. OUTPUT: Commenced in August 2017, five ICU's (three administrative regions - 104 beds) were recruited and have reported over 1100 critical care admissions to PRICE. IMPACT AND FUTURE: PRICE is being rolled out nationally in Pakistan and will provide continuous granular healthcare information necessary to empower clinicians to drive setting-specific priorities for service improvement and research.

Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair.

BACKGROUND: The aim was to conduct a meta-analysis of the randomized evidence to determine the relative merits of laparoscopic (LIHR) and open (OIHR) inguinal hernia repair. METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified all randomized clinical trials that compared OIHR and LIHR and were published in the English language between January 1990 and the end of October 2000. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement. The six outcome variables analysed were operating time, time to discharge from hospital, return to normal activity and return to work, postoperative complications and recurrence rate. Random effects meta-analyses were performed using odds ratios and weighted mean differences. RESULTS: Twenty-nine trials were considered suitable for meta-analysis. Some 3017 hernias were repaired laparoscopically and 2972 hernias were repaired using an open method in 5588 patients. For four of the six outcomes the summary point estimates favoured LIHR over OIHR; there was a significant reduction of 38 per cent in the relative odds of postoperative complications (odds ratio 0.62 (95 per cent confidence interval (c.i.) 0.46 to 0.84); P = 0.002), 4.73 (95 per cent c.i. 3.51 to 5.96) days in time to return to normal activity (P < 0.001), 6.96 (95 per cent c.i. 5.34 to 8.58) days in time to return to work (P < 0.001) and 3.43 (95 per cent c.i. 0.35 to 6.50) h in time to discharge from hospital (P = 0.029). There was a significant increase of 15.20 (95 per cent c.i. 7.78 to 22.63) min in the mean operating time for LIHR (P < 0.001). The relative odds of short-term recurrence were increased by 50 per cent for LIHR compared with OIHR, although this result was not statistically significant (odds ratio 1.51 (95 per cent c.i. 0.81 to 2.79); P = 0.194). CONCLUSION: LIHR was associated with earlier discharge from hospital, quicker return to normal activity and work, and significantly fewer postoperative complications than OIHR. However, the operating time was significantly longer and there was a trend towards an increase in the relative odds of recurrence after laparoscopic repair.

Hepatitis C: an epidemiological review.

The aim of the study was to analyse the current literature regarding the mode of transmission of HCV and its global prevalence in different groups of people. A systematic review of the literature on the epidemiology of hepatitis C from 1991 to 2000 using computerized bibliographic databases which include Medline, Current Content and Embase. The prevalence of hepatitis C virus (HCV) varies tremendously in different parts of the world, with the highest incidence in the Eastern parts of the globe compared with the Western parts. Furthermore, certain groups of individuals such as intravenous drug users are at increased risk of acquiring this disease irrespective of the geographical location. Although the main route of transmission is via contaminated blood, curiously enough in up to 50% of the cases no recognizable transmission factor/route could be identified. Therefore, a number of other routes of transmission such as sexual or household exposure to infected contacts have been investigated with conflicting results. Hepatitis C infection is an important public health issue globally. Better understanding of routes of transmission will help to combat the spread of disease. In order to prevent a world wide epidemic of this disease, urgent measures are required to (i) develop a strategy to inform and educate the public regarding this disease and (ii) expedite the efforts to develop a vaccine.

Hepatobiliary manifestations of inflammatory bowel disease.

Hepatobiliary manifestations occur quite frequently in patients suffering from chronic ulcerative colitis and Crohn's disease and carry with them considerable morbidity and mortality. Although the true incidence is difficult to determine, clinically significant hepatobiliary disease occurs in 5%-10% of patients. At the present moment, the aetiology and pathogenesis of inflammatory bowel disease and its systemic manifestations remains speculative. For those hepatobiliary manifestations that respond to therapy of the underlying bowel disease, medical and/or surgical therapy must be aggressively pursued. More urgent research is required towards understanding the underlying cause(s) of the primary bowel disease and its systemic manifestations in order to improve the overall management of this condition.

Laparoscopic common bile duct exploration: the past, the present, and the future.

BACKGROUND: The advent of laparoscopic cholecystectomy (LC) has created a dilemma for treating patients with known or suspected choledocholithiasis. With rapid technologic growth and experience in laparoscopic skills, many surgeons are now routinely performing laparoscopic common bile duct exploration (LCBDE) and questioning the wisdom of preoperative endoscopic retrograde cholangiography (ERC) with or without endoscopic sphincterotomy. The purpose of this article is to review the current literature on the subject of LCBDE and critically evaluate the clinical results of this emerging technology. METHODS: Medline and Science Citation Index databases were used to search English language articles published on LCBDE since 1989. RESULTS: Transcystic common bile duct exploration has a better clearance rate, and carries less morbidity and mortality compared with laparoscopic choledochotomy. Compared with two-stage ERCP and LC, one-stage LC and LCBDE seems to be associated with a shorter hospital stay, a quicker recovery, less expense, and less morbidity and mortality. CONCLUSIONS: LCBDE is a feasible, safe and effective procedure that carries a low morbidity and mortality and will decrease the need for unnecessary ERC in the future for suspected or proved choledocholithiasis.