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

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio as Predictive Factors for Mortality and Length of Hospital Stay after Cardiac Surgery

Background: Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are widely accepted indices positively correlated with disease severity, progression, and mortality. In this study, we tested whether NLR and PLR could predict mortality and length of hospital stay (LOS) after cardiac surgery. Methods: NLR and PLR were calculated on days 0, 3, 5, and 7 postoperatively. A ROC curve was generated to assess their prognostic value; multivariate logistic analysis identified independent risk factors for 90-day mortality. Results: Analysis was performed on 179 patients&rsquo; data, 11 of whom (6.15%) died within 90 days. The discriminatory performance for predicting 90-day mortality was better for NLR7 (AUC = 0.925, 95% CI:0.865&ndash;0.984) with the optimal cut-off point being 7.10. NLR5 and PLR3 also exhibited a significant strong discriminative performance. Similarly, a significant discriminative performance was prominent for PLR3, NLR5, and NLR7 with respect to LOS. Moreover, NLR7 (OR: 2.143, 95% CI: 1.076&ndash;4.267, p = 0.030) and ICU LOS (OR:1.361, 95% CI: 1.045&ndash;1.774, p = 0.022) were significant independent risk factors for 90-day mortality. Conclusions: NLR and PLR are efficient predictive factors for 90-day mortality and LOS in cardiac surgery patients. Owing to the simplicity of determining NLR and PLR, their postoperative monitoring may offer a reliable predictor of patients&rsquo; outcomes in terms of LOS and mortality

The effect of parathyroidectomy on the quality of life of patients suffering from primary hyperparathyroidism due to a solitary parathyroid adenoma

Introduction: Patients with asymptomatic primary hyperparathyroidism (PHPT) have been found to experience various symptoms, leading to a negatively affected quality of life (QoL). This study primarily aims at examining the effect of parathyroidectomy on the QoL of PHPT patients due to solitary parathyroid adenoma. Furthermore, secondary outcomes are to assess the physical activity and the frailty of patients with PHPT after surgical intervention, to evaluate cardiac function, and to translate and adapt the questionnaire of Pasieka (PAS-Q) for the Greek population. Materials and methods: Any patient with biochemically proven PHPT due to solitary parathyroid adenoma was eligible for inclusion to the study. For the primary outcome two groups were formed. The PTx-group whose patients underwent parathyroidectomy and the NonPTx-group whose patients were under conservative treatment. Both groups were evaluated at three time points: T1: preoperatively, T2: 3 months later, T3: 3 years later. Moreover, an additional sub-study was conducted including patients who were divided into two age groups, with a cut-off age of 65 years. The PAS-Q was first translated and adapted for the Greek population and then applied to assess the QoL of patients with PHPT. In addition, the Godin-Shephard Leisure-Time Physical Activity Questionnaire was used to assess the physical activity of the sample. The Frailty Index (FI) was also calculated to determine the frailty status of the patients. Cardiac function was assessed and the left ventricular mass index (LVMI) was calculated. Finally, statistical analysis was performed using IBM Statistical Package for Social Science (SPSS), Inc. software (v 25.0; Chicago, IL). Results: The PAS-Q was translated into Greek with no significant discrepancies. In the PTx-group, the mean total PAS-Q score was 518 at T1, at T2 it decreased to 309 (p=0.003, compared to T1) and at T3 it appeared even lower at 212 (p=0.001, compared to T1 and p=0.008, compared to T2). In contrast, in the NonPTx-group the mean total PAS-Q score was 326 at T1. At T2, the mean total score was 336 (p=0.073, compared to T1 and p=0.673, compared to T2 of the PTH group). At T3, it was 350 (p=0.019 compared to T1, p=0.023 compared to T3 of the PTx group). The mean Godin & Shephard questionnaire total score was 45.0 for both groups (PTx and non-PTx) at T1, while a statistically significant gradual increase was shown only for PTx-group. The LVMI was found to be within normal range both preoperatively and postoperatively. However, showing a statistically significant decrease. The FI in group 2 (>65 years old) decreased significantly from 0.31 to 0.22 (p65ετών) μειώθηκε από το 0.31 στο 0.22 (p<0.001). Συμπεράσματα: Η ποιότητα ζωής των ασθενών με ΠΥΠ οφειλόμενο σε μονήρες αδένωμα παραθυρεοειδή αδένα βελτιώνεται ήδη από τους τρεις μήνες μετά την παραθυρεοειδεκτομή και η βελτίωση αυτή συνεχίζεται ως και τρία χρόνια μετά. Επιπλέον, η φυσική δραστηριότητα των ασθενών που αντιμετωπίζονται χειρουργικά αυξάνεται, ενώ η σωματική αδυναμία/ευθραυστότητα μειώνεται αντανακλώντας αμφότερα στη βελτίωση της ποιότητας ζωής τους

High Expressed Emotion and Warmth among Families of Patients with Schizophrenia in Greece

Expressed emotion (EE) is an established prognostic factor for relapse in schizophrenia. Through critical comments (CC), hostility (H) and emotional overinvolvement (EOI), a relative can be rated as high or low EE, but the role of warmth should also be evaluated in order to consider the influence of a positive affect within the family context. In this study, EE was assessed in a sample of 48 relatives of patients with schizophrenia using the Camberwell Family Interview (CFI). Questionnaires assessing coping (brief-COPE), their wellbeing (World Health Organization Well-Being Index WHO-5) and the socio-demographic variables were also administered. Relatives who expressed a higher level of warmth were found to make fewer CC (5.2 &plusmn; 4.6 vs. 8.4 &plusmn; 4.6, p = 0.009) and have, on average, higher EOI scores (3.2 &plusmn; 1.0 vs. 1.9 &plusmn; 1.1, p = 0.002) than those who expressed no or very little warmth. High EE was found to be associated with having fewer family members (p = 0.035), while relatives with a higher level of education expressed less warmth (p = 0.007). Relatives with a low level of warmth had higher maladaptive coping scores and tended to score worse for their overall wellbeing in comparison to relatives who showed a higher level of warmth (28.4 &plusmn; 5.0 vs. 24.1 &plusmn; 5.2, p = 0.006 and 39.1 &plusmn; 20.4 vs. 51.3 &plusmn; 22.0, p = 0.073, respectively). Since the role of warmth is important, it should be taken into account when designing family interventions, independently from lowering EE. Customized interventions to promote warmth and the routine screening of relatives are recommended

Endoscopic Salvage of Gastrointestinal Anastomosis Leaks—Past, Present, and Future—A Narrated Review

Background: Anastomotic leakage, which is defined as a defect in the integrity of a surgical join between two hollow viscera leading to communication between the intraluminal and extraluminal compartments, continues to be of high incidence and one of the most feared complications following gastrointestinal surgery, with a significant potential for a fatal outcome. Surgical options for management are limited and carry a high risk of morbidity and mortality; thus, surgeons are urged to look for alternative options which are minimally invasive, repeatable, non-operative, and do not require general anesthesia. Methods: A narrative review of the international literature took place, including PubMed, Scopus, and Google Scholar, utilizing specific search terms such as “Digestive Surgery AND Anastomotic Leakage OR leak OR dehiscence”. Results: In the present review, we try to describe and analyze the pros and cons of the various endoscopic techniques: from the very first (and still available), fibrin gluing, to endoclip and over-the-scope clip positioning, stent insertion, and the latest suturing and endoluminal vacuum devices. Finally, alongside efforts to improve the existing techniques, we consider stem cell application as well as non-endoscopic, and even endoscopic, attempts at intraluminal microbiome modification, which should ultimately intervene pre-emptively, rather than therapeutically, to prevent leaks. Conclusions: In the last three decades, this search for an ideal device for closure, which must be safe, easy to deploy, inexpensive, robust, effect rapid and stable closure of even large defects, and have a low complication rate, has led to the proposal and application of a number of different endoscopic devices and techniques. However, to date, there is no consensus as to the best. The literature contains reports of only small studies and no randomized trials, failing to take into account both the heterogeneity of leaks and their different anatomical sites