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

CROHN'S DISEASE COMPLICATED BY ILEOSIGMOID FISTULA: ASSESSMENT AND MANAGEMENT UPDATE

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CROHN’S DISEASE COMPLICATED BY ILEOSIGMOID FISTULA: ASSESSMENT AND MANAGEMENT UPDATE

Abstract BACKGROUND The preoperative evaluation of Crohn’s-related ileosigmoid fistula (ISF) is complex with multiple preoperative diagnostic modalities available. Intraoperative management is also complicated when deciding whether to repair the fistula or resect the involved sigmoid. How these choices impact outcomes is not clear. We aim to evaluate the impact of sigmoid resection versus conservative fistula repair on postoperative complications when treating ISF. METHODS Patients with Crohn’s disease (CD) undergoing ileocolic resection in the setting of an ISF between January 1, 2007 and December 31, 2017 were identified. A retrospective chart review was conducted to collect data on preoperative workup, intra-operative technique, and 30-day complications. Intra-abdominal sepsis was defined as the presence of an intra-abdominal abscess or anastomotic leak from the sigmoid colon postoperatively. Univariate comparisons were performed between those undergoing primary repair versus sigmoid resection with primary anastomosis. RESULTS 61 patients (62.3% female) with a median age of 37 years (range, 18-73)were included. Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) each had a sensitivity of 100% versus 42% sensitivity for colonoscopy. When accounting for pre-operative endoscopy results, patients with endoscopic sigmoidal mucosal CD more often underwent sigmoid resection than patients with a normal sigmoidal mucosa or only a solitary fistulous opening in the sigmoid colon (p&amp;lt;0.001). When comparing primary repair vs sigmoid resection there was no difference in the occurrence of intra-abdominal septic complications (p=0.342) or anastomotic leak complication (p=0.239). CONCLUSION In summary, our study shows that conservative repair of the fistula is a safe option. Appropriate patient assessment and preoperative identification of the fistula is critical so that the management strategies for ISF and the potential implications can be discussed with the patient. CTE and MRE are the modalities of choice to diagnose ISF, while colonoscopy has a role in staging the burden of mucosal disease in the sigmoid colon. These tests help guide surgical decision-making with respect to resection versus primary repair of the sigmoid colon and will allow patients in whom the sigmoid colon is an innocent bystander to undergo a less extensive operation. </jats:sec

Acute Medical Unit Healthcare workers’ interaction in a developing country: Social Network Analysis

INTRODUCTIONSocial network analysis is used to increase the awareness of leaders about the power of networks, to further catalyze relationships and connections, and to strengthen the capacity of the network to act collectively. We focus on understanding and measuring the communication patterns in an acute medical unit team. We sought to use Social Network Analysis to describe the patterns of communications in teamwork of an acute medical unit.METHODSNetwork Analysis was conducted to examine network structure in 58 teamwork professional communication in an AMU. Team members reported the frequency (0 to 10+ times) of professional discussion with every other coworker during the last 48-hoursk, density, degree and betweenness centralization, degree and betweenness centrality; and homophily were calculated. P-value was obtained based on 1000 quadratic assignment procedure QAP permutations of the network. The network analysis was used to construct network maps using multidimentional scaling and generates a visual representation of networks through network diagrams.RESULTSthere were 460 connections (density=28%). The whole network has a moderate degree centralization (37%) and lower betweenness centralization (8%). Three senior physicians, the head nurse, the physiotherapist, the medical secretary and the archive manager were most central in network. There was evidence regarding heterophily in a network indicated by high level of E-I index value 0.34 (P&lt;0.01, by QAP).CONCLUSIONSNA provided a description of patterns of communications in teamwork in an acute medical unit. We used SNA statistics to reveal variation in patterns of team communication and teammate interconnectedness by shift.</jats:sec

Health workers’ psychological distress during early phase of the covid-19 pandemic in Morocco

ABSTRACTIntroductionThe mental being of healthcare workers with the COVID 19 pandemic is a determinant of their resilience. We investigated the psychological impact of health workers during early phase of Covid 19 pandemic in Morocco.MethodsThis was a cross-sectional study based on a survey of health workers of the Rabat University Hospital Ibn-Sina in Morocco. Data were collected during the first week of health emergency state –between 23 and 30 march-related to the covid-19 pandemic declaration in Morocco. Sociodemographic, health characteristics and professional characteristics of each health worker were collected. We also evaluated the knowledge of health workers concerning the protective measures against COVID 19. The mental health status of the health workers was investigated using the Arabic validated version of HADS 14 items, evaluating hospital anxiety and depressionResultsTwo hundred eighty-seven health workers were included.The mean age was 34.4±12.18 year; and 64.5% were female, 54% have been trained regarding protection procedures, and 94.8% declared that they are aware of individual protection measures. The incidence of anxiety and depression was respectively 77.4% and 73.9%. High degree of anxiety and depression was associated with female gender. However, Higher degree of anxiety was also related to function, specialty of practice, and knowledge of the protective measures against COVID-19.ConclusionWe reported the result of the first evaluation of psychological burden of health worker during early period of COVID-19 pandemic in a developing country. The study showed high frequency of anxiety and depression among Moroccan health worker in a hospital faced to COVID-19 patient management.</jats:sec