Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception

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

National Socialism Before Nazism: Friedrich Naumann and Theodor Fritsch, 1890-1914

This dissertation is a rethinking and critique of the concept of "national socialism." I show that this concept not only emerged in Germany years before Nazism, but also arose within the mainstream of German society, alongside and independently of parallel developments in the radical right. Alarmed by the dramatic rise of an internationalist, Marxist socialism in the years following German unification, a succession of prominent public figures gave voice to an alternative, nationalist reading of the social problems accompanying capitalist industrialization. This endeavor involved a wholesale reconceptualization of social life and social reform, and a marginalization of the concern for social justice and emancipation in favor of a preoccupation with national order, homogeneity, and power. The dissertation focuses on two variants of national socialism developed in Germany prior to the First World War, one by the left-leaning bourgeois reformist Friedrich Naumann and the other by the right-wing völkisch antisemite Theodor Fritsch. Their differences notwithstanding, both strands of national socialism shared two major ideational foundations. First, both were underpinned by a national existentialism: the claim that the nation is facing a "struggle for existence" which necessitates aggressive international expansion, colonization, and ethnic purification. The social reforms demanded by national socialism were, accordingly, geared at systematically harnessing all socio-economic forces in the service of these purportedly "existential" struggles. Second, both variants of national socialism adhered to a national productivism that, by stressing the need for cooperation among all the "productive" strata of the nation, elided the class-based exploitation characteristic of industrial capitalism. On the basis of their national productivism, both Naumann and Fritsch were opposed simultaneously to Marxism with its class-conflict view of society on the one hand, and to liberalism with its individualistic worldview on the other hand. Given that Naumann and Fritsch were pivotal figures in their respective social, cultural, and political milieux--Naumann in the reformist bourgeoisie, Fritsch in the radical right--their articulation of a national-existential claim on the social is indicative of a profound generational shift in the ideational climate of Imperial Germany. This generational shift did not consist in the appearance of national socialism itself, which had already been articulated in the 1870s by prominent figures such as political economist Gustav Schmoller and Christian socialist Adolf Stoecker. Rather, the shift consisted in the shedding of the ethical-conservative sensibility of the first generation of national socialism in favor of a sense of existential urgency grounded in a biologistic imagination. The impact of national socialism on the generation of Naumann and Fritsch reached its apex in the First World War, when an existential national socialism constituted the ideological underpinning of Germany's war economy, i.e. the systematic regimentation and mobilization of the national economy in service of the war effort. Beyond the fresh perspective it offers on the historical dynamics of Imperial Germany, the dissertation also sheds new light on the intellectual-historical context in which national socialism made its way into the name and program of the Nazi movement from 1920 onward. The study suggests that the conceptual field of national socialism into which Nazism entered after the First World War was more variegated, more sophisticated, and had deeper historical and intellectual roots than previously believed

COVID-19 Lockdown Has No Significant Impact on Trauma Epidemiology and Outcomes in a Tertiary Trauma Center&mdash;Retrospective Cohort Study

Background: The aim of this study was to describe the impact of a COVID-19 lockdown on the variation in the volumes and types of injuries at a level one trauma center while focusing on preserving trauma care resources. Methods: A retrospective, descriptive study of prospectively collected data from the Trauma Registry. Data collection included patient demographics, injury mechanism, injury type and treatment required. The time periods studied corresponded with the lockdown period in Israel and a parallel period in 2019. Results: Overall, there was no reduction in all injury-related admissions. There was a significant reduction in pedestrian injuries (p &lt; 0.02) and a non-significant increase in children admissions aged 0&ndash;2 years. Compared to the previous years, the severity of injuries during the March&ndash;April 2020 lockdown was unchanged. Hospital resources (number and percentage of trauma patients who required an operation, ICU stay and LOS) were not different between the lockdown period compared to the previous 5 years. Less trauma patients arrived with a Trauma Team Activation code during the lockdown period (58, 33% decrease compared to the control), but a significantly higher proportion of those patients required hospitalization (77.6%, p &lt; 0.0001). Conclusions: During a lockdown period, road accidents were still the main cause for major trauma admissions, resulting in prolonged and complex surgeries, and hospitals should continue to provide full services until resource limitations are unavoidable. Maintenance of an effective full-staffed trauma service is vital throughout a COVID-19 lockdown