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

Coexistence of Primary GEJ Adenocarcinoma and Pedunculated Gastric Gastrointestinal Stromal Tumor

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the digestive system, although they account for only 0.1–3% of all gastrointestinal (GI) malignancies. They can arise anywhere along the GI tract with gastric predominance. Concurrent occurrence of GIST and gastroesophageal junction (GEJ) neoplasm is rare. We report a 55-year-old gentleman presenting with a polyp at the GEJ and a synchronous, large, and pedunculated gastric mass at the greater curvature. Those were treated with a wedge resection of the gastric pedunculated mass with negative margins along with transgastric submucosal resection of the GEJ polyp. Pathological examination confirmed synchronous invasive GEJ adenocarcinoma and a high-grade gastric GIST

Factors predicting recurrence in thymic epithelial neoplasms

Abstract OBJECTIVES Thymic epithelial neoplasms (TENs) represent a heterogeneous group of rare thoracic malignancies. We analysed the clinicopathological features, survival outcomes, risk factors, and patterns of recurrence in patients undergoing resection. METHODS Records were reviewed for adult patients with TEN who underwent resection from 2006 to 2019. Survival rates were assessed using the Kaplan–Meier method. Univariable and multivariable analyses were performed using the log-rank test and Cox proportional hazards model. RESULTS A total of 100 patients were analysed (51 females, median age 58 years). Thymoma was the most common histology (n = 92), followed by thymic carcinoma (n = 5) and thymic neuroendocrine tumour (n = 3). Stage II (Masaoka) tumours were most common (n = 51), followed by stage I (n = 27). World Health Organization B2/B3 was the most prominent histological subtype (n = 34). Complete resection (R0) was achieved in 91 patients: 86/92 thymoma, 4/5 thymic carcinoma and 1/3 neuroendocrine tumour. The most common treatment modality was surgery alone in 72 patients, followed by surgery and radiation therapy in 24, and adjuvant chemoradiotherapy in 3 patients. Only one patient with thymic carcinoma received neoadjuvant chemotherapy. The 10-year overall and disease-free survival rates were 86.6% and 83.9%, respectively. Recurrence was most common in neuroendocrine tumours (3/3). Risk factors for recurrence identified on multivariable analyses were: R1/2 resection (hazard ratio 9.30; 95% confidence interval 1.82–36.1), TEN subtype (hazard ratio 8.08; 95% confidence interval 1.24–34.6), and presence of lymphovascular invasion (hazard ratio 9.56; 95% confidence interval 2.56–25.8). CONCLUSIONS Complete resection remains critical in patients with TEN. Incomplete resection, high-risk histology, and lymphovascular invasion highlight the need for effective adjuvant modalities. Given the rarity of these diseases, emphasis must be placed on collaborative research conducted on TEN. </jats:sec

The Challenge of Designing Key Performance Indicators for Academic Hospitals:

Background: This study assesses whether patients with ischemic heart disease receive comparable care and achieve similar outcomes compared to the rest of patients in the department of medicine at our tertiary academic center.&#x0D; Methods: This retrospective study examined the level of care received by all patients who were admitted to the Internal Medical Services at King Abdulaziz University Hospital from January 2010 through December 2012. A number of potential performance indicators were evaluated to ascertain level of care, including clinical deterioration with unplanned intensive care unit transfers, in-hospital complications, in-hospital mortality, and the rate of 30-day readmission. The t test or Mann-Whitney U-test was used to compare means and medians, respectively. The chi-square test was used to compare categorical variables.&#x0D; Results: Of 3838 patients, about a fifth of ischemic heart disease patients (19.3%) required intensive care unit transfer (P &lt; 0.001). Patients admitted through the emergency department were the largest group to require subsequent intensive care unit transfer (65.9% of all cases). The length of stay was significantly shorter in patients admitted to the cardiac care unit, compared with those admitted to other services (3.5 [1.5] days versus 5.8 [5.5] days for patients admitted to other units; P &lt; 0.001). Thirty-day readmission rate was significantly lower in ischemic heart disease patients (11.7%) compared with non- ischemic heart disease cases (18.5%) (P &lt; 0.0001).&#x0D;  &#x0D;  </jats:p

Determinants of Intensive Care Unit Transfer in Patients Admitted to the Medical Ward of an Academic Hospital in Jeddah

Objective:  This study aimed to identify the proportion of patients who had clinical deterioration in the medical ward that required intensive care unit transfer and the factors associated with this transfer.&#x0D; Methods:  A retrospective study of all patients admitted to the medical wards of King Abdulaziz University Hospital between 2010 and 2013 was performed.  The demographics, admitting department, diagnosis at the time of admission to the ward, and cause of intensive care unit transfer were collected.  Patients at risk for deterioration and early intensive care unit transfer were identified using physiologic threshold criteria.&#x0D; Results:  A screening of 38,380 patients admitted to the various medical services during the study period was performed.  Of these, 356 (0.9%) required intensive care unit transfer.  Most patients were initially admitted from the emergency department (66.3%), while transfers from another hospital comprised approximately 1%.  Intensive care unit transfer patients were more likely to have ischemic heart disease (P &lt; 0.001), diabetes (P &lt; 0.001), renal failure (P &lt; 0.001), or sepsis associated with pressure ulcers (P &lt; 0.001). They were also more likely to be bedridden (P &lt; 0.001) or initially ventilated in the medical ward (P &lt; 0.001).  The mortality rate of the patients was 3.9% with patients who died being more likely to have unstable blood pressure at the time of admission (P = 0.026).&#x0D; Conclusion: This study identified several factors that were associated with intensive care unit transfer.  Clinicians should consider these factors when determining patient disposition to ensure timely and appropriate management.</jats:p