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

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

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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Maize response to elevated plant density combined with lowered N-fertilizer rate is genotype-dependent

AbstractIncreasing plant density and improving N fertilizer rate along with the use of high density-tolerant genotypes would lead to maximizing maize (Zea mays L.) grain productivity per unit land area. The objective of this investigation was to match the functions of optimum plant density and adequate nitrogen fertilizer application to produce the highest possible yields per unit area with the greatest maize genotype efficiency. Six maize inbred lines differing in tolerance to low N and high density (D) [three tolerant (T); L-17, L-18, L-53, and three sensitive (S); L-29, L-54, L-55] were chosen for diallel crosses. Parents and crosses were evaluated in the 2012 and 2013 seasons under three plant densities: low (47,600), medium (71,400), and high (95,200)plantsha−1 and three N fertilization rates: low (no N addition), medium (285kgNha−1) and high (570kgNha−1). The T×T crosses were superior to the S×S and T×S crosses under the low N–high D environment in most studied traits across seasons. The relationships between the nine environments and grain yield per hectare (GYPH) showed near-linear regression functions for inbreds L54, L29, and L55 and hybrids L18×L53 and L18×L55 with the highest GYPH at a density of 47,600plantsha−1 and N rate of 570kgNha−1 and a curvilinear relationship for inbreds L17, L18, and L53 and the rest of the hybrids with the highest GYPH at a density of 95,200plantsha−1 combined with an N rate of 570kgNha−1. Cross L17×L54 gave the highest grain yield in this study under both high N–high-D (19.9tha−1) and medium N–high-D environments (17.6tha−1)

Combined Application of Compost, Zeolite and a Raised Bed Planting Method Alleviate Salinity Stress and Improve Cereal Crop Productivity in Arid Regions

Soil salinity and climate change have a negative impact on global food production and security, especially in arid regions with limited water resources. Despite the importance of planting methods, irrigation, and soil amendments in improving crop yield, their combined impact on saline soil properties and cereal crop yield is unknown. Therefore, the current study investigated the combined effect of soil amendments (i.e., compost, C and zeolite, Z) and planting methods such as raised bed (M1) and conventional (M2), and different fractions of leaching requirements from irrigation water, such as 5% (L1) and 10% (L2), on the soil physio-chemical properties and wheat and maize productivity in an arid region. The combined application of C + Z, L2, and M1 decreased soil salinity (EC) and sodicity (ESP) after wheat production by 37.4 and 28.0%, respectively, and significantly decreased by these factors by 41.0 and 43.0% after a maize growing season. Accordingly, wheat and maize yield increased by 16.0% and 35.0%, respectively under such a combination of treatments, when compared to crops grown on unamended soil, irrigated with lower leaching fraction and planted using conventional methods. This demonstrates the significance of using a combination of organic and inorganic amendments, appropriate leaching requirements and the raised bed planting method as an environmentally friendly approach to reclaiming saline soils and improving cereal crop production, which is required for global food security.</jats:p

Combined Application of Compost, Zeolite and a Raised Bed Planting Method Alleviate Salinity Stress and Improve Cereal Crop Productivity in Arid Regions

Soil salinity and climate change have a negative impact on global food production and security, especially in arid regions with limited water resources. Despite the importance of planting methods, irrigation, and soil amendments in improving crop yield, their combined impact on saline soil properties and cereal crop yield is unknown. Therefore, the current study investigated the combined effect of soil amendments (i.e., compost, C and zeolite, Z) and planting methods such as raised bed (M1) and conventional (M2), and different fractions of leaching requirements from irrigation water, such as 5% (L1) and 10% (L2), on the soil physio-chemical properties and wheat and maize productivity in an arid region. The combined application of C + Z, L2, and M1 decreased soil salinity (EC) and sodicity (ESP) after wheat production by 37.4 and 28.0%, respectively, and significantly decreased by these factors by 41.0 and 43.0% after a maize growing season. Accordingly, wheat and maize yield increased by 16.0% and 35.0%, respectively under such a combination of treatments, when compared to crops grown on unamended soil, irrigated with lower leaching fraction and planted using conventional methods. This demonstrates the significance of using a combination of organic and inorganic amendments, appropriate leaching requirements and the raised bed planting method as an environmentally friendly approach to reclaiming saline soils and improving cereal crop production, which is required for global food security