Abordaje del uso y las complicaciones de las siliconas líquidas inyectables en población travesti y trans: experiencias de profesionales de la salud de Argentina

The use of injectable liquid silicone (ILS) in the travesti and trans population poses a public health challenge in Argentina and worldwide. Although ILS and other unauthorized polymers represent a significant risk for this population, there is no consensual and effective approach, nor has the issue been addressed through health policy. This study aimed to explore the experiences of healthcare professionals from various specialties and levels of care regarding the use, management, and treatment of ILS-related complications in trans and travesti individuals. Between August and December 2023, a qualitative, exploratory and descriptive study was carried out with 14 semi-structured interviews with health professionals from four Argentine provinces. According to their accounts, ILS users constitute a population facing multiple vulnerabilities, resorting to these practices due to the immediacy of results and the barriers to accessing safe gender-affirming procedures. Professionals agree on the lack of information and guidelines for addressing ILS-related complications, particularly in managing chronic pain. Furthermore, ILS use is identified as a public health issue requiring an intersectoral and interdisciplinary approach.El uso de siliconas líquidas inyectables (SLI) en la población travesti y trans constituye un desafío para la salud pública de Argentina y el mundo. Aunque las SLI y otros polímeros no autorizados representan un importante riesgo para esta población, no existe un abordaje consensuado y efectivo, ni una atención de la problemática desde la política sanitaria. El objetivo del estudio fue explorar la experiencia de profesionales de la salud, de distintas especialidades y niveles de atención, en el uso, abordaje y tratamiento de las complicaciones de SLI en personas trans y travestis. Entre agosto y diciembre de 2023, se realizó un estudio cualitativo, exploratorio y descriptivo, con 14 entrevistas semiestructuradas a profesionales de la salud de cuatro provincias argentinas. Según sus relatos, las personas usuarias de SLI son una población atravesada por muchas vulneraciones, que recurre a estas prácticas debido a la inmediatez de sus resultados y a las barreras para acceder a procedimientos seguros de afirmación de género. Las y los profesionales coinciden en la no disponibilidad de información y de directrices para abordar las complicaciones del uso de SLI, especialmente en el tratamiento del dolor crónico. A su vez, se identifica el uso de SLI como un problema de salud pública, que requiere de un abordaje intersectorial e interdisciplinario

Approach to the use and complications of injectable liquid silicone in the trans and travesti population: experiences of healthcare professionals in Argentina

The use of injectable liquid silicone (ILS) in the travesti and trans population poses a public health challenge in Argentina and worldwide. Although ILS and other unauthorized polymers represent a significant risk for this population, there is no consensual and effective approach, nor has the issue been addressed through health policy. This study aimed to explore the experiences of healthcare professionals from various specialties and levels of care regarding the use, management, and treatment of ILS-related complications in trans and travesti individuals. Between August and December 2023, a qualitative, exploratory and descriptive study was carried out with 14 semi-structured interviews with health professionals from four Argentine provinces. According to their accounts, ILS users constitute a population facing multiple vulnerabilities, resorting to these practices due to the immediacy of results and the barriers to accessing safe gender-affirming procedures. Professionals agree on the lack of information and guidelines for addressing ILS-related complications, particularly in managing chronic pain. Furthermore, ILS use is identified as a public health issue requiring an intersectoral and interdisciplinary approach

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

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background: Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods: The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results: A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion: Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Management of Hemorrhoidal Disease in Special Conditions: A Word of Caution

Background: Hemorrhoids are a common disease that is often considered an easy problem to solve. Unfortunately, some particular clinical conditions, including Inflammatory Bowel Diseases (IBD), pregnancy, immunosuppression, coagulopathy, cirrhosis with portal hypertension, and proctitis after radiotherapy, challenge hemorrhoids management and the outcomes. Methods:: Research and online contents related to hemorrhoids’ treatment in special conditions are reviewed in order to help colorectal surgeons in daily practice. Results: There are very limited data about the outcomes of hemorrhoids treatment in these subgroups of patients. Patients in pregnancy can be effectively treated with medical therapy, reserving surgical intervention in highly selected and urgent cases. In case of thrombosed haemorrhoids, the excision allows a fast symptoms’ resolution, with a low incidence of recurrence and a long remission interval. In case of immunosuppressed patients, there is no consensus for the best treatment, even in most HIV positive patients, a surgical procedure can be safely proposed when indicated. There is no sufficient data in the literature related to transplanted patients. The surgical treatment of hemorrhoids in patients with IBD, especially Crohn’s Disease, can be unsafe, although there is a paucity of literature on this topic. In case of previous pelvic radiotherapy, it must always be considered that severe complications, like abscesses and fistulas with subsequent pelvic and retroperitoneal sepsis, can occur after surgical treatment of hemorrhoids, so a conservative treatment is advocated. Moreover, caution is recommended in treating patients with coagulopathy, considering possible complications (mostly bleeding) also after outpatient treatments. In case of portal hypertension and cirrhosis, a ‘conservative treatment’ is recommended. Bleeding hemorrhoids can be treated with hemorrhoidectomy when they do not respond to other treatments. Conclusion: International literature is very scant about the treatment of patients affected by hemorrhoids in particular situations. A word of caution and concern even about the indication for minor outpatient procedures must be expressed in these patients, in order to avoid possible life-threatening complications. The first-line treatment is the conservative medical approach associated with the treatment of the primary disease. </jats:sec

Oral neomycin and bacitracin are effective in preventing surgical site infections in elective colorectal surgery: a multicentre, randomized, parallel, single-blinded trial (COLORAL-1)

AbstractSeveral regimens of oral and intravenous antibiotics (OIVA) have been proposed with contradicting results, and the role of mechanical bowel preparation (MBP) is still controversial. This study aims to assess the effectiveness of oral antibiotic prophylaxis in preventing Surgical Site Infections (SSI) in elective colorectal surgery. In a multicentre trial, we randomized patients undergoing elective colorectal resection surgery, comparing the effectiveness of OIVA versus intravenous antibiotics (IVA) regimens to prevent SSI as the primary outcome (NCT04438655). In addition to intravenous Amoxicillin/Clavulanic, patients in the OIVA group received Oral Neomycin and Bacitracin 24 h before surgery. MBP was administered according to local habits which were not changed for the study. The trial was terminated during the COVID-19 pandemic, as many centers failed to participate as well as the pandemic changed the rules for engaging patients. Two-hundred and four patients were enrolled (100 in the OIVA and 104 in the IVA group); 3 SSIs (3.4%) were registered in the OIVA and 14 (14.4%) in the IVA group (p = 0.010). No difference was observed in terms of anastomotic leak. Multivariable analysis indicated that OIVA reduced the rate of SSI (OR 0.21 / 95% CI 0.06–0.78 / p = 0.019), while BMI is a risk factor of SSI (OR 1.15 / 95% CI 1.01–1.30 p = 0.039). Subgroup analysis indicated that 0/22 patients who underwent OIVA/MBP + vs 13/77 IVA/MBP- experienced an SSI (p = 0.037). The early termination of the study prevents any conclusion regarding the interpretation of the data. Nonetheless, Oral Neomycin/Bacitracin and intravenous beta-lactam/beta-lactamases inhibitors seem to reduce SSI after colorectal resections, although not affecting the anastomotic leak in this trial. The role of MBP requires more investigation.</jats:p