The incidence of malignancy in the residual rectum of IBD patients after colectomy: a systematic review and meta-analysis.

BACKGROUND: Patients with inflammatory bowel disease (IBD) who have had a total colectomy remain with their rectum in situ, and are therefore at risk of rectal carcinoma. It is not clear how high the incidence of rectal cancer is in this cohort. The primary objective of this meta-analysis was to estimate the incidence of rectal cancer in patients with ulcerative colitis or Crohn's disease who have undergone colectomy but have a residual rectum, and to identify the risk factors for its development. In doing so, we explore the current recommendations for screening processes for these patients. METHODS: A systematic review of the literature was performed. Five databases (Medline, Embase, Pubmed, Cochrane Library and Scopus) were searched from inception to 29 October 2021, to identify studies adhering to the population, intervention, control and outcomes (PICO) criteria. The included studies were critically appraised, and the relevant data was extracted. Cancer incidence was estimated from the reported information. Risk stratification was analysed using RevMan. A narrative approach was undertaken for the exploration of the existing screening guidelines. RESULTS: Data from 23 of the 24 identified studies was suitable for analysis. The pooled incidence of rectal carcinoma was calculated to be 1.3%. Subgroup analysis showed an incidence of 0.7% and 3.2% for patients with a de-functioned rectal stump and ileorectal anastomosis, respectively. Patients with a history of a colorectal carcinoma were more likely to have a subsequent diagnosis of rectal carcinoma (RR 7.2, 95% CI 2.4-21.1). Patients with previous colorectal dysplasia were also at higher risk (RR 5.1, 95% CI 3.1-8.2). No universal standardised guidance regarding screening for this cohort could be identified in the available literature. CONCLUSIONS: The overall risk of malignancy was estimated to be 1.3%, which is lower than previously reported. There is a need for clear and standardised screening guidance for this group of patients.

Assessing the impact of rurality on oesophagogastric cancer survival in the North-East of Scotland- a prospective population cohort study.

INTRODUCTION: Despite advances in oncology therapies and surgical techniques, survival from oesophagogastric cancer remains low. Poorer cancer outcomes and survival for rural dwellers is documented worldwide and has been an area of focus in Scotland since 2007 when changes to suspected cancer national referral guidelines and governmental mandates on delivering remote and rural healthcare occurred. Whether these changes in clinical practice has impacted upon upper gastrointestinal cancer remains unclear. METHODS: A prospective, single-centre observation study was performed. Data from the regional oesophagogastric cancer MDT between 2013 and 2019 were included. The Scottish Index of Multiple Deprivation 2020 tool provided a rurality code (1 or 2) based on patient postcode at time of referral. Survival outcomes for urban and rural patients were compared across demographic factors, disease factors and stage at presentation. RESULTS: A total of 1038 patients were included in this study. There was no significant difference between rural and urban groups in terms of sex of patient, age at diagnosis, cancer location, or tumour stage. Furthermore, no difference was identified between those commenced on a radical therapy with other treatment plans. Despite this, rurality predicted for an improved outcome on survival analysis (p = 0.012) and this was independent of other factors on multivariable analysis (HR = 0.78, 95%CI 0.66-0.98; p = 0.032). DISCUSSION: The difference in survival demonstrated here between urban and rural groups is not easily explained but may represent improvements to rural access to healthcare delivered as a result of Scottish Government reports.

A review of pig and poultry diseases in the Eastern Cape Province of South Africa, 2000-2020.

ABSTRACT: The informal poultry and pig sector in the Eastern Cape Province (ECP) of South Africa is of significant socio-economic importance as it sustains livelihoods and ensures food security; yet little is known about the distribution and prevalence of infectious and zoonotic diseases in this region. This paper reviews data published for pig and poultry diseases in the province during the last 20 years (2000-2020). The review included relevant published papers identified by a computerised literature search from Web of Science; provincial animal health reports; the national database from the Department of Agriculture, Land Reform and Rural Development (DALRRD); animal health reports submitted by DALRRD to the World Organisation for Animal Health (OIE) via the World Animal Health Information Database (WAHID) interface and laboratory records. A publication was considered eligible if it included qualitative or quantitative information on any disease affecting pigs and poultry including zoonosis. The search retrieved 174 publications, of which 26 were relevant. The review found that Newcastle disease (ND), coccidiosis and fowl pox (FP) were the most reported avian diseases in the national database, whereas avian infectious bronchitis (AIB), ND and highly pathogenic avian influenza (HPAI) were the most reported diseases in the OIE database. Classical swine fever (CSF) was the most reported pig disease in both databases. The retrieved literature on pig and poultry diseases was scarce and no longer up to date, providing decision makers with little information. The review identified important zoonotic diseases that require further studies yet failed to find information on important neglected diseases like leptospirosis.

Using value chain and trade networks in the Eastern Cape Province of South Africa, as a basis for targeted rural chicken surveillance.

Despite the benefits of rural chickens in the Eastern Cape Province (ECP) of South Africa, this sector is still underdeveloped and poorly surveyed for poultry diseases. The lack of a sustainable poultry disease surveillance system coupled with communities and practices where the interactions between birds are high, emphasize the need for targeted surveillance of chicken diseases in the province. However, to set up such a system requires knowledge of the value chain and trade networks. Consequently, a survey, which involved a rural chicken value chain analysis that also included an assessment of trading practices to identify biosecurity hotspots and an identification of barriers to market entry for rural farmers was conducted. Secondly, a social network analysis of chicken movements in the province was carried out to identify trade hubs that could be targeted for disease surveillance based on their centrality within the network and their size and influence within their ego networks. Traders and their transport vehicles were identified as biosecurity hotspots that could be targeted for disease surveillance within the chain. Social network analysis identified three municipalities viz. Umzimvubu, King Sabata Dalindyebo (KSD) and Enoch Mgijima as trade hubs where interaction between rural chickens occurs and resources can be focused. The movement of spent hens from commercial operations that are transported over long distances and distributed in the rural areas and townships were a major risk for spread of poultry diseases. This is the first study to formally describe chicken trade networks within the province and the surrounding region. Its findings provide a model for cost effective targeted surveillance in the ECP and similar resource poor regions of the world. The study also provides insight into the profitability of rural chickens and a possible contribution to job creation and poverty alleviation once the barriers to market entry are lifted.

Improved outcomes for patients undergoing colectomy for acute severe inflammatory colitis by adopting a multi-disciplinary care bundle.

PURPOSE: Severe inflammatory colitis as a consequence of inflammatory bowel disease (IBD) may not be amenable to medical management, and surgery is often required. The optimal timing of surgery and perioperative therapeutic care requires a formal link between surgical department and gastroenterology which is often lacking. In this study, we assess the impact of adopting a multidisciplinary care bundle on complication rates of subtotal colectomy in IBD patients. METHODS: This is a single-centre retrospective observational study. Patients were identified through clinical discharge ICD10 codes. Clinical notes of patients who underwent subtotal colectomies from 1 January 2006 to 31 December 2019 were analysed. Socio-demographics, diagnosis, and medical and surgical management data were collected. A multimodule bundle, including weekly MDT discussions, was started in our unit on 1 April 2014. Multivariable logistic regression analysis was performed on these data. RESULTS: A total of 296 patients were identified with 113 patients of these (38.2%) experiencing a complication post operation. The overall complication rate improved over time (p = 0.023). Those patients treated after the initiation of the MDT bundle had reduced complication rates (44.6% versus 33.7%, p = 0.045). On multivariate analysis, increasing age (1.023 OR; 95% CI 1.004, 1.041) and procedure performed before MDT bundle (3.1 OR; 95% CI 1.689, 5.723) were independent predictors for post-operative complications. CONCLUSIONS: Closer links between gastroenterology and colorectal specialties have improved patient outcomes in our unit. Whilst IBD MDTs have previously been shown to improve outcomes for patients managed medically, we demonstrate that this interaction, implemented as a multidisciplinary care bundle, also improves surgical outcomes.

Mesh fixation techniques for inguinal hernia repair: an overview of systematic reviews of randomised controlled trials.

PURPOSE: Inguinal hernia repair using surgical mesh is a very common surgical operation. Currently, there is no consensus on the best technique for mesh fixation. We conducted an overview of existing systematic reviews (SRs) of randomised controlled trials to compare the risk of chronic pain and recurrence following open and laparoscopic inguinal hernia repairs using various mesh fixation techniques. METHODS: We searched major electronic databases in April 2020 and assessed the methodological quality of identified reviews using the AMSTAR-2 tool. RESULTS: We identified 20 SRs of variable quality assessing suture, self-gripping, glue, and mechanical fixation. Across reviews, the risk of chronic pain after open mesh repair was lower with glue fixation than with suture and comparable between self-gripping and suture. Incidence of chronic pain was lower with glue fixation than with mechanical fixation in laparoscopic repairs. There were no significant differences in recurrence rates between fixation techniques in open and laparoscopic mesh repairs, although fewer recurrences were reported with suture. Many reviews reported wide confidence intervals around summary estimates. Despite no clear evidence of differences among techniques, two network meta-analyses (one assessing open repairs and one laparoscopic repairs) ranked glue fixation as the best treatment for reducing pain and suture for reducing the risk of recurrence. CONCLUSION: Glue fixation may be effective in reducing the incidence of chronic pain without increasing the risk of recurrence. Future research should consider both the effectiveness and cost-effectiveness of fixation techniques alongside the type of mesh and the size and location of the hernia defect.

A study of rural chicken farmers, diseases and remedies in the Eastern Cape province of South Africa.

The source of emerging diseases and antimicrobial resistance is of increasing interest to epidemiologists. This paper looks at village chickens as such a source. In addition, infectious diseases constitute a major challenge to the growth and profitability of the rural poultry sector in Sub-Saharan Africa. A serological survey was conducted to estimate the apparent seroprevalence of selected chicken diseases in the Eastern Cape Province of South Africa alongside a sociological survey of poultry farmers and the remedies most commonly used to prevent diseases in their flocks. Sera collected from village chickens (n = 1007) in the province were screened for specific antibodies against Newcastle disease (ND), avian influenza (AI), avian infectious bronchitis (IB) and Mycoplasma gallisepticum (MG). The overall seroprevalence of ND, AI, IB and MG in the province was found to be 69.2 % (95 % CI 51.9-86.5%); 1.8 % (95 % CI 0.2-3.4%); 78.5 % (95 % CI 74.9-82%) and 55.8 % (95 % CI 41.3-70.3%) respectively with clustering found at the District level. Cross hemagglutination inhibition (HI) tests indicated that the chickens were exposed to the ND vaccine. AI ELISA-positive samples were tested using HIs against the H5, H6 and H7-subtypes, but only H6-specific antibodies were detected. Avian influenza strains shared the common ancestor responsible for the 2002 chicken outbreak in KwaZulu-Natal Province. The majority of chicken farmers were females and pensioners (69 % and 66.1 % respectively) and had a primary school education (47.1 %). Traditional remedies were commonly used by farmers (47.15 %) and among the remedies, Aloe plant (Aloe ferox Mill.) or ikhala (Xhosa) was the most commonly used product (28.23 %) for preventing and reducing mortalities among village chickens. The findings stress the importance of village chickens as a substitute for social welfare and highlight the exposure of village chickens to important chicken pathogens. The economic impact of these pathogens on the development of this sub-sector needs further investigation. Village chickens are a potential source of virulent Newcastle disease virus (NDV) because of the lack of vaccination and biosecurity. They may serve as amplification hosts which increases the probability that virulent NDV could spill over into commercial poultry flocks due to large amounts of circulating virus. The zoonotic threat of circulating H6N2 viruses raise concern due to their mutation and reassortment among chickens and a potential movement of infected birds within the province. Finally, the use of antibiotics by untrained chicken farmers constitute another major concern as it could serve as a source of antimicrobial resistance (AMR).

Causes of death after emergency general surgical admission: population cohort study of mortality.

BACKGROUND: A substantial number of patients treated in emergency general surgery (EGS) services die within a year of discharge. The aim of this study was to analyse causes of death and their relationship to discharge diagnoses, in patients who died within 1 year of discharge from an EGS service in Scotland. METHODS: This was a population cohort study of all patients with an EGS admission in Scotland, UK, in the year before death. Patients admitted to EGS services between January 2008 and December 2017 were included. Data regarding patient admissions were obtained from the Information Services Division in Scotland, and cross-referenced to death certificate data, obtained from the National Records of Scotland. RESULTS: Of 507 308 patients admitted to EGS services, 7917 died while in hospital, and 52 094 within 1 year of discharge. For the latter, the median survival time was 67 (i.q.r. 21-168) days after EGS discharge. Malignancy accounted for 48 per cent of deaths and was the predominant cause of death in patients aged over 35 years. The cause of death was directly related to the discharge diagnosis in 56.5 per cent of patients. Symptom-based discharge diagnoses were often associated with a malignancy not diagnosed on admission. CONCLUSION: When analysed by subsequent cause of death, EGS is a cancer-based specialty. Adequate follow-up and close links with oncology and palliative care services merit development.

International validation of a risk prediction algorithm for patients with malignant colorectal polyps.

AIM: The optimal management strategy for patients with endoscopically resected malignant colorectal polyps (MCP) has yet to be defined. The aim of this study was to validate a published decision-making tool, termed the Scottish Polyp Cancer Study (SPOCS) algorithm, on a large international population. METHODS: The SPOCS algorithm allocates patients to risk groups based on just two variables: the polyp resection margin and the presence of lymphovascular invasion (LVI). The risk groups are termed low (clear margin, LVI absent), medium (clear margin, LVI present) or high (involved/non-assessable margin). The International Polyp Cancer Collaborative was formed to validate the algorithm on data from Australia, Denmark, UK and New Zealand. RESULTS: In total, 1423 patients were included in the final dataset. 680/1423 (47.8%) underwent surgical resection and 108/680 (15.9%) had residual disease (luminal disease 8.8%, lymph node metastases 8.8%). The SPOCS algorithm classified 602 patients as low risk (in which 1.5% had residual disease), 198 patients as medium risk (in which 7.1% had residual disease) and 484 as high risk (in which 14.5% had residual disease) (P < 0.001, χ2 test). Receiver operating characteristic curve analysis demonstrated good accuracy of the algorithm in predicting residual disease (area under the curve 0.732, 95% CI 0.687-0.778, P < 0.001). When patients were designated as low risk, the negative predictive value was 98.5%. CONCLUSION: The SPOCS algorithm can be used to predict the risk of residual disease in patients with endoscopically resected MCPs. Surgery can be safely avoided in patients who have a clear margin of excision and no evidence of LVI.

Video consultation for new colorectal patients.

AIM: For patients, an outpatient review can lead to a stressful journey to hospital with the resultant risks associated with breaching social distancing. Despite this, video consultations (VCs) have not been frequently used in colorectal practice. We assessed outcomes, including the economic and environmental impact, of a VC clinic for new colorectal referrals. METHOD: This was a prospective observational study. Fifty consecutive patients attending a VC colorectal appointment were reviewed between March 2019 and February 2020. Face-to-face appointments during the same time period were also assessed. The distance, time, cost and carbon emissions of journeys were estimated using web-based resources. Estimated loss of earnings used data from the Office for National Statistics. The subsequent management plans were also recorded. RESULTS: Of 50 patients using VC, 40 used home devices and 10 used equipment in their local medical facility. Three patients had difficulties with the technology and converted to telephone review. Failure to attend VC appointments was less than for face-to-face appointments (4% vs 6.1%). VC appointments saved 6685 miles of travel (range 2-364 miles), 148 h travelling time and £1767 costs. Additional savings for loss of earnings were approximately £33.56 per patient. The carbon emissions saved was 4659 lb CO2 equivalent, corresponding to over 250 000 charges of a smartphone. CONCLUSION: The use of VC resulted in significant savings related to travel and reduced time and costs for patients who chose to use the service, in addition to the environmental benefits. In this current climate VC clinics have a central role in outpatient care for both new patients and follow-ups.

Colon capsule endoscopy.

There are multiple indications for luminal imaging of the colon. From assessment of known disease, to diagnosing new pathology; intra-luminal visualisation is the mainstay of gastrointestinal diagnosis. Colonoscopy and radiological imaging are currently the most frequently deployed diagnostic methods. However, both have an associated risk profile, have significant resource pressures and are not universally tolerated. Colon capsule endoscopy (CCE) offers an adjunct to these diagnostic options. In this narrative review the utility of CCE is described. Its current uses, potential benefits and future developments are also discussed.

Analysing the impact of living in a rural setting on the presentation and outcome of colorectal cancer. A prospective single centre observational study.

INTRODUCTION: Approximately 17% of the Scottish population lives in a remote or rural location. Current research is contradictory as to whether living a rural location leads to poorer outcomes or affects survival from colorectal cancer (CRC). We aimed to assess if living in a rural location influences outcome of CRC patients in 21st century UK medicine. METHODS: A prospective single-centre observational study was conducted. All patients who underwent resection for colorectal cancer 2005-2016 in NHS Grampian were included. Patients were split into two groups for comparison (urban post-code vs rural) using the Scottish government two-tier classification system. Tumour location, one-year survival, lymph node involvement and extra-mural vascular invasion was recorded and compared between the groups. RESULTS: Of 2463 patients, 843 (34.2%) lived in a rural area. Rural patients were more likely to be detected through screening (17.4% versus 14.6%, p = 0.04). There were no differences in pathology between rural and urban groups if detected through screening. However, rural patients detected through symptomatic pathways were more likely to be node positive p = 0.015. On multivariable analysis, rurality did not independently predict for node positive presentation. Furthermore, there were no differences in cumulative survival between the two groups. CONCLUSION: Although there were some differences in pathological characteristics between rural and urban patients, place of residence did not independently predict for outcome in this cohort. Rurality had previously been shown to impact on outcome up to 20 years ago. Improvements in infrastructure and rural healthcare may have influenced this change.

A 19 year population-based cohort study analysing reoperation for recurrence following laparoscopic and open inguinal hernia repairs.

INTRODUCTION: Laparoscopic (LHR) and open (OHR) inguinal hernia repairs are both used to treat primary herniae. This study analyses the rates of operation for recurrence after laparoscopic and open inguinal hernia repair, at a population level, while considering competing risks, such as death and other operative interventions. METHODS: This is a population cohort study in Scotland. All adult patients who had a primary inguinal hernia repair in Scotland between 01/04/1996 and 01/01/2015 were included. The main outcome was recurrent operations. Cumulative incidence functions (CIF) were calculated for competing risks of death. A cox proportional hazards regression model was used to control for confounders of age, gender, bilateral herniae, deprivation and year of procedure. RESULTS: Of 88,590 patients, there were 10,145 LHR and 78,445 OHR. Recurrent operations were required in 1397 (1.8%) OHR and 362 (3.6%). LHR had greater hazard of recurrence than OHR (HR 1.83, 95% CI 1.61-2.08, p < 0.001). Faster time to recurrence was also associated with being older (HR for one year increase: 1.010, 95% CI 1.007-1.013, p < 0.001), being more affluent (HR 1.18, 95% CI 1.01-1.38, p = 0.04) and having a bilateral index operation (HR 2.53, 95% CI 2.22-2.88, p < 0.001). CONCLUSIONS: LHR is becoming more popular in Scotland over the past 2 decades. However, when other key confounding factors are controlled, it is associated with a higher recurrence rate.

Twenty-year study of in-hospital and postdischarge mortality following emergency general surgical admission.

Background: Emergency general surgery (EGS) patients have a higher mortality than those having elective surgery. Few studies have investigated changes in EGS-associated mortality over time or explored mortality rates after discharge. The aim of this study was to conduct a comprehensive, population-based analysis of mortality in EGS patients over a 20-year time frame. Methods: This was a cross-sectional study of all adult EGS admissions in Scotland between 1996 and 2015. Data were obtained from national records. Co-morbidities were defined by Charlson Co-morbidity Index, and operations were coded by OPCS-4 classifications. Linear and multivariable logistic regression models were used to evaluate changes over time. Results: Among 1 450 296 patients, the overall inpatient, 30-day, 90-day and 1-year mortality rates were 1·8, 3·8, 6·4 and 12·5 per cent respectively. Mortality was influenced by age at admission, co-morbidity, operation performed and date of admission (all P < 0·001), and improved with time on subgroup analysis by age, co-morbidity and operation status. Medium-term mortality was high: the 1-year mortality rate in patients aged over 75 years was 35·6 per cent. The 1-year mortality rate in highly co-morbid patients decreased from 75·1 to 57·1 per cent over the time frame of the study (P < 0·001). Conclusion: Mortality after EGS in Scotland has reduced significantly over the past 20 years. This analysis of medium-term mortality after EGS admission demonstrates strikingly high rates, and postdischarge death rates are higher than is currently appreciated.

Antecedentes: Los pacientes sometidos a cirugía general urgente (emergency general surgery, EGS) presentan una mortalidad más elevada que los pacientes sometidos a cirugía electiva. Pocos estudios han investigado los cambios en la mortalidad asociada a la EGS a lo largo del tiempo o han analizado las tasas de mortalidad tras el alta hospitalaria. El objetivo de este estudio fue llevar a cabo un análisis exhaustivo de base poblacional de la mortalidad en pacientes en EGS durante un horizonte temporal de 20 años. Métodos: Se trata de un estudio transversal de todos los ingresos de adultos por EGS en Escocia entre 1996 y 2015. Los datos se obtuvieron de los registros nacionales. Las comorbilidades se definieron según el índice de comorbilidad de Charlson y las operaciones se codificaron con las clasificaciones OPCS4. Se utilizaron modelos de regresión logística lineal y multivariante para evaluar cambios a los largo del tiempo. Resultados: En un total de 1.450.296 pacientes, las tasas globales de mortalidad hospitalaria, a los 30 días, 90 días y un año fueron de 1,8%, 3,8%, 6,4% y 12,5%, respectivamente. La mortalidad estaba influida por la edad en el momento del ingreso, comorbilidad, la intervención quirúrgica realizada y la fecha de ingreso (todas las variables P < 0,001) y mejoró con el tiempo en el análisis por subgrupos de edad, comorbilidad e intervenciones quirúrgicas. La mortalidad a medio plazo fue elevada: la tasa de mortalidad a un año en pacientes mayores de 75 años fue de 35,6%. La mortalidad a un año en pacientes con elevada morbilidad disminuyó de un 75% a un 57% a lo largo del periodo del estudio (P < 0,001). Conclusión: La mortalidad tras EGS en Escocia ha disminuido significativamente a lo largo de los últimos 20 años. No obstante, el análisis de la mortalidad a medio plazo después de un ingreso por EGS demuestra unas tasas sorprendentemente elevadas y, por ello, actualmente hay que tener en cuenta la mortalidad tras el alta de forma especial.

Meta-analysis of laparoscopic transcystic versus transcholedochal common bile duct exploration for choledocholithiasis.

Background: It is not clear whether laparoscopic transcystic exploration (LTCE) laparoscopic choledochotomy (LCD) is superior in the management of choledocholithiasis. In this meta-analysis, the success of LTCE versus LCD was evaluated. Methods: Cochrane Central Register of Controlled Trials, Web of Science, Trip, PubMed, Ovid and Embase databases were searched systematically for relevant literature up to May 2017. Studies that compared the success rate of LTCE and LCD in patients with choledocholithiasis were included. PRISMA guidelines were followed. Multiple independent reviewers contributed on a cloud-based platform. Random-effects model was used to calculate odds ratios (ORs) or standardized mean differences (MDs) with 95 per cent confidence intervals. An a priori hypothesis was generated based on clinical experience that LTCE is as successful as LCD. Results: Of 3533 screened articles, 25 studies comprising 4224 patients were included. LTCE achieved a lower duct clearance rate than LCD (OR 0.38, 95 per cent c.i. 0·24 to 0·59). It was associated with a shorter duration of surgery (MD -0·86, 95 per cent c.i. -0·97 to -0·77), lower bile leak (OR 0·46, 0·23 to 0·93) and shorter hospital stay (MD -0·78, -1·14 to -0·42) than LCD. There was no statistically significant difference in conversion, stricture formation or reintervention rate. Conclusion: LCD has a higher rate of successful duct clearance, but is associated with a longer duration of surgery and hospital stay, and a higher bile leak rate.

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist.

BACKGROUND: The WHO Surgical Safety Checklist has been implemented widely since its launch in 2008. It was introduced in Scotland as part of the Scottish Patient Safety Programme (SPSP) between 2008 and 2010, and is now integral to surgical practice. Its influence on outcomes, when analysed at a population level, remains unclear. METHODS: This was a population cohort study. All admissions to any acute hospital in Scotland between 2000 and 2014 were included. Standardized differences were used to estimate the balance of demographics over time, after which interrupted time-series (segmented regression) analyses were performed. Data were obtained from the Information Services Division, Scotland. RESULTS: There were 12 667 926 hospital admissions, of which 6 839 736 had a surgical procedure. Amongst the surgical cohort, the inpatient mortality rate in 2000 was 0·76 (95 per cent c.i. 0·68 to 0·84) per cent, and in 2014 it was 0·46 (0·42 to 0·50) per cent. The checklist was associated with a 36·6 (95 per cent c.i. -55·2 to -17·9) per cent relative reduction in mortality (P < 0·001). Mortality rates before implementation were decreasing by 0·003 (95 per cent c.i. -0·017 to +0·012) per cent per year; annual decreases of 0·069 (-0·092 to -0·046) per cent were seen during, and 0·019 (-0·038 to +0·001) per cent after, implementation. No such improvement trends were seen in the non-surgical cohort over this time frame. CONCLUSION: Since the implementation of the checklist, as part of an overall national safety strategy, there has been a reduction in perioperative mortality.

Analysing production and financial data from farmers can serve as a tool for identifying opportunities for enhancing extension delivery among the rural poultry sub-sector in Zambia.

There are limited data on production and financial performance of the rural poultry sector in developing countries like Zambia that could be used by extension services as a feedback loop to enhance service delivery in the sector. Thus, a study that used production and financial data obtained from poultry farmers of Eastern Zambia was conducted to describe the rural poultry sub-sector and conduct financial analysis. It compared the financial performance of indigenous chicken production to broiler and layer production. The aim of the study was to identify opportunities and knowledge gaps among poultry farmers that could be used to initiate and enhance a participatory extension approach and build capacity of farmers in the sector. Descriptive, spatial, gross margin and breakeven analysis was used to analyse data obtained from 459 rural poultry farmers and expert opinion from 5 local extension workers. Poultry ranked highest in terms of popularity and numbers when compared with other animals kept by respondents (median = 20). Most poultry were kept under free-range and brood an average of 3.1 clutches. Except for annual set up costs, some variable costs and household poultry consumption, the study could obtain data on most production costs and income generated from poultry farmers. Nevertheless, gross margin analysis conducted using costing data from poultry farmers and expert opinion of extension workers revealed that indigenous chicken enterprises had the highest gross margin percentage of 72% compared to commercial broilers and layers which had gross margin percentages of 53% and 56% respectively. Breakeven analysis revealed that indigenous chickens required the lowest number of products to be sold (27) to realise profit compared to broilers (1011) and layers (873). The study justifies investment into the rural poultry sub-sector and discusses the use of gross margin templates as a means of incentivising rural farmers to participate in extension programmes.

Is syndromic data from rural poultry farmers a viable poultry disease reporting tool and means of identifying likely farmer responses to poultry disease incursion?

Syndromic surveillance is a well described tool used in developed countries for alerting authorities to livestock disease incursions. However, little work has been done to evaluate whether this could be a viable tool in countries where disease reporting infrastructure and resources is poor. Consequently, a syndrome-based questionnaire study in Eastern Zambia was designed to gather data on previous encounters farmers had with poultry diseases, as well as control measures they use to mitigate them. Descriptive statistics and logistic regression were used to analyse the data. Farmers reported an overall annual disease incidence in rural poultry for eastern Zambia of 31% (90% CI 29-32%). Occurrence of poultry disease in the last 12 months was associated with use of middlemen to purchase poultry products (p = 0.05, OR = 7.87), poultry products sold or given away from the farm (p = 0.01, OR = 1.92), farmers experiencing a period with more trade of poultry and its products (p = 0.04, OR = 1.70), presence of wild birds near the farm or village (p = 0.00, OR = 2.47) and poultry diseases being reported from neighbouring farms or villages (p = 0.00, OR = 3.12). The study also tentatively identified three poultry diseases (Newcastle Disease, Gumboro Disease and Fowl Pox) from the thirty-four disease syndromes provided by farmers. Farmers reported an incidence of 27% for Newcastle Disease in 2014. When compared with the state veterinary services data which reported Newcastle Disease incidence at 9% in 2014, it seems syndromic data obtained from farmers may be more sensitive in identifying disease incursion. Thirty-six remedies and strategies farmers use to treat and control these diseases were revealed. The main control strategy for identified diseases was vaccination and the main treatment was unspecified herbs, which warrants further investigation and presents an opportunity for further research in ethno-veterinary medicine. More still, this study identified chilli, Aloe Vera, garlic onion, moringa, and ash as traditional remedies that are commonly being used in Eastern Zambia, and which are also used to treat poultry diseases in Zimbabwe and Botswana. Only fourteen remedies described are conventionally accepted by veterinarians as remedies and disease control measures for poultry diseases. This study shows that syndromic data obtained from farmers is a useful disease reporting tool and could be used as an effective means of alerting authorities to disease incursion. In addition, it shows that these data may give a more accurate estimate of incidence for certain diseases than current surveillance methods and could be useful in assessing significant risk factors associated with disease occurrence.