Management of hepatitis C virus genotype 4: recommendations of an international expert panel.

HCV has been classified into no fewer than six major genotypes and a series of subtypes. Each HCV genotype is unique with respect to its nucleotide sequence, geographic distribution, and response to therapy. Genotypes 1, 2, and 3 are common throughout North America and Europe. HCV genotype 4 (HCV-4) is common in the Middle East and in Africa, where it is responsible for more than 80% of HCV infections. It has recently spread to several European countries. HCV-4 is considered a major cause of chronic hepatitis, cirrhosis, hepatocellular carcinoma, and liver transplantation in these regions. Although HCV-4 is the cause of approximately 20% of the 170 million cases of chronic hepatitis C in the world, it has not been the subject of widespread research. Therefore, this document, drafted by a panel of international experts, aimed to review current knowledge on the epidemiology, natural history, clinical, histological features, and treatment of HCV-4 infections

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

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10&nbsp;years; 78.2% included were male with a median age of 37&nbsp;years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p&lt;0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p&lt;0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

A Monte Carlo study of arms effect in myocardial perfusion of normal and abnormal cases utilizing STL heart shape

Arms influence in myocardial perfusion single photon emission computed tomography (SPECT) imaging has been studied for the last two decades. These studies suggested that arms positioning next to the patient would not show cardiac abnormalities or perfusion defects in SPECT imaging while it would not affect the scan during positron emission tomography (PET) scans. As a recent improvement in Geant4 Application for Tomographic Emission (GATE), -a Monte Carlo simulation toolkit- a new feature was added to enable the use of STereoLithography (STL). STL files are implanted as an input geometry for most human organs, which would give superior advantages in details compared to analytical geometry shapes. This study is adopting this recent improvement in GATE to study arms effect in SPECT imaging with the consideration of four scenarios; normal heart perfusion imaging with and without arms positioned next to the patient and two of the same scenarios with a perfusion myocardial defected. The results showed that perfusion defect could be observed with arms next to the patient. For image reconstruction, both filtered backprojection (FBP) and iterative technique – maximum likelihood expectation maximization (MLEM) were used. The MLEM was performed to analyse the four different patient scenarios. The difference in counts between arms-up and arms-down position for the abnormal case was shown to be less than 6%. The conclusion from this paper is that arm influence during abnormal heart SPECT imaging can be measured and has a minimal contribution to the reconstructed images. Keywords: GATE, Reconstruction, SPECT, Arms, Heart, Myocardial, Perfusion, ST

Utilization of an energy-resolving detection system for mammography applications : a preliminary study

Breast cancer remains one of the major causes of mortality among female cancer patients. This fact caused a spark in the medical field, which in turn helped to improve the diagnostic and treatment of breast cancer patients over the years making this field always active with new ideas and innovative methods. In our study, a new method was explored using an energy-resolving detection system made from a NaI (Tl) scintillation detector to detect the gamma photons from an Am-241 radiation source to try and construct an image by scanning the American College of Radiology (ACR) mammography phantom. In addition to the experimental work, a Geant4 Application for Tomographic Emission (GATE) toolkit was used to investigate more complex options to improve the image quality of mammographic systems, which is limited by the experimental setup. From the experimental setup, the researchers were able to construct an image using the 26.3 keV and the 59.5 keV energy photons, to show the largest size tumour (12 mm) in the ACR phantom. With an improved setup in the simulation environment, the majority of the ACR phantom tumours was visible using both energy windows from the 26.3 keV and the 59.5 keV, where the 26.3 keV yielded better quality images showing four tumours compared to three when using 59.5 keV. The simulation results were promising; however, several improvements need to be incorporated into the experimental work so that the system can generate high-resolution mammographic images similar to the ones obtained by the GATE simulation setup

Utilization of an energy-resolving detection system for mammography applications: A preliminary study

Abstract Breast cancer remains one of the major causes of mortality among female cancer patients. This fact caused a spark in the medical field, which in turn helped to improve the diagnostic and treatment of breast cancer patients over the years making this field always active with new ideas and innovative methods. In our study, a new method was explored using an energy-resolving detection system made from a NaI (Tl) scintillation detector to detect the gamma photons from an Am-241 radiation source to try and construct an image by scanning the American College of Radiology (ACR) mammography phantom. In addition to the experimental work, a Geant4 Application for Tomographic Emission (GATE) toolkit was used to investigate more complex options to improve the image quality of mammographic systems, which is limited by the experimental setup. From the experimental setup, the researchers were able to construct an image using the 26.3 keV and the 59.5 keV energy photons, to show the largest size tumour (12 mm) in the ACR phantom. With an improved setup in the simulation environment, the majority of the ACR phantom tumours was visible using both energy windows from the 26.3 keV and the 59.5 keV, where the 26.3 keV yielded better quality images showing four tumours compared to three when using 59.5 keV. The simulation results were promising; however, several improvements need to be incorporated into the experimental work so that the system can generate high-resolution mammographic images similar to the ones obtained by the GATE simulation setup.</jats:p