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

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

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

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Television viewing and abdominal obesity in women according to smoking status: results from a large cross-sectional population-based study in Brazil.

OBJECTIVE: To investigate the associations between television viewing and abdominal obesity (AO) in Brazilian women, according to smoking status. METHODS: Data of 13,262 adult women (18-49 years) from the 2006's Demographic Health Survey, a cross-sectional household study with complex probabilistic sample and national representativeness, were analyzed. AO, defined as waist circumference ≥ 80.0 cm, was the outcome. Television viewing frequency (≥ 5 times/week, 1-4 times/week, &lt; 1 time/week) was the main exposure variable, and smoking status (yes or no) the main co-variable. Prevalence ratios were estimated using Poisson regression models separately for smokers and non-smokers. RESULTS: A statistically significant interaction term was observed between smoking status and television viewing (p &lt; 0.05). Prevalence of AO among smokers who reported television viewing ≥ 5 times/week amounted to 59.0%, higher than the 35.0% for those with &lt; 1 time/week television viewing (p-value = 0.020). The values for non-smokers were 55.2% and 55.7%, respectively. Smokers with television viewing ≥ 5 times/week were 1.7 times (95% CI: 1.1 - 2.5) more likely to pre-sent AO, compared to those who reported a frequency &lt; 1 time/week. There was no significant association among non-smokers. CONCLUSIONS: Television viewing ≥ 5 times/week may increase the prevalence of AO among women who smoke. More detailed information on media use, as hours per day, may offer better estimates

Total cholesterol and leptin concentrations are associated with prospective changes in systemic blood pressure in healthy pregnant women.

BACKGROUND: Lipids and leptin have been associated with high blood pressure (BP) levels during pregnancy. The aim was to evaluate the associations between serum lipids and leptin concentrations during the first trimester and longitudinal changes of SBP and DBP in healthy pregnancies. METHODS: Prospective cohort of pregnant women followed at a public healthcare center in Rio de Janeiro, Brazil. SBP and DBP were obtained at the ≤13th, 20-26th, and 30-36th weeks of gestation and were the dependent variables. Serum lipids and plasma leptin concentrations were collected at 13 weeks or less of gestation and were the main independent variables. Statistical analyses included longitudinal linear mixed-effects regression models, with (β) coefficients and their 95% confidence intervals (CI). RESULTS: Mean BPs were 109.8/66.9, 107.8/64.3, and 111.2/66.9  mmHg, respectively in the 1st, 2nd, and 3rd trimester. Multiple longitudinal regressions revealed that leisure time physical activity before pregnancy (β(SBP) = -3.003, 95% CI = -5.034 to -0.971; β(DBP) = -2.620, 95% CI = -4.177 to -1.064), baseline BMI (β(SBP) = 4.003, 95% CI = 1.924-6.081; β(DBP) = 1.862, 95% CI = 0.252-3.412), parity (β(SBP) = -2.778, 95% CI = -4.627 to -0.929; β(DBP) = -1.780, 95% CI = -3.168 to -0.392), and Homeostasis model of assessment-Insulin Resistance (HOMA-IR; β(SBP) = 2.554, 95% CI = 0.552-4.557; β(DBP) = 2.962, 95% CI = 1.436-4.489) were the covariates independently associated with SBP and DBP changes. Monthly per-capita family income (β(SBP) = -0.006, 95% CI = -0.010 to -0.001), total cholesterol (β(SBP) = 2.094, 95% CI = 0.223-3.965), and leptin (β(SBP) = 2.211, 95% CI = 0.159-4.263) were associated only with SBP changes. CONCLUSION: Serum total cholesterol and leptin concentrations, HOMA-IR, and BMI were positively associated with changes in BP during healthy pregnancies, whereas physical activity, parity, and family income were negatively associated

Total cholesterol and leptin concentrations are associated with prospective changes in systemic blood pressure in healthy pregnant women.

BACKGROUND: Lipids and leptin have been associated with high blood pressure (BP) levels during pregnancy. The aim was to evaluate the associations between serum lipids and leptin concentrations during the first trimester and longitudinal changes of SBP and DBP in healthy pregnancies. METHODS: Prospective cohort of pregnant women followed at a public healthcare center in Rio de Janeiro, Brazil. SBP and DBP were obtained at the ≤13th, 20-26th, and 30-36th weeks of gestation and were the dependent variables. Serum lipids and plasma leptin concentrations were collected at 13 weeks or less of gestation and were the main independent variables. Statistical analyses included longitudinal linear mixed-effects regression models, with (β) coefficients and their 95% confidence intervals (CI). RESULTS: Mean BPs were 109.8/66.9, 107.8/64.3, and 111.2/66.9  mmHg, respectively in the 1st, 2nd, and 3rd trimester. Multiple longitudinal regressions revealed that leisure time physical activity before pregnancy (β(SBP) = -3.003, 95% CI = -5.034 to -0.971; β(DBP) = -2.620, 95% CI = -4.177 to -1.064), baseline BMI (β(SBP) = 4.003, 95% CI = 1.924-6.081; β(DBP) = 1.862, 95% CI = 0.252-3.412), parity (β(SBP) = -2.778, 95% CI = -4.627 to -0.929; β(DBP) = -1.780, 95% CI = -3.168 to -0.392), and Homeostasis model of assessment-Insulin Resistance (HOMA-IR; β(SBP) = 2.554, 95% CI = 0.552-4.557; β(DBP) = 2.962, 95% CI = 1.436-4.489) were the covariates independently associated with SBP and DBP changes. Monthly per-capita family income (β(SBP) = -0.006, 95% CI = -0.010 to -0.001), total cholesterol (β(SBP) = 2.094, 95% CI = 0.223-3.965), and leptin (β(SBP) = 2.211, 95% CI = 0.159-4.263) were associated only with SBP changes. CONCLUSION: Serum total cholesterol and leptin concentrations, HOMA-IR, and BMI were positively associated with changes in BP during healthy pregnancies, whereas physical activity, parity, and family income were negatively associated

Blood Pressure in Healthy Pregnancy and Factors Associated With No Mid-Trimester Blood Pressure Drop: A Prospective Cohort Study.

BACKGROUND: The well-known mid-trimester drop in blood pressure (BP) during normal pregnancy was recently questioned. OBJECTIVE: To describe longitudinal changes in BP during healthy pregnancies and to investigate factors associated with no mid-trimester drop in BP. METHODS: A prospective cohort with 158 healthy pregnant women was followed up in a public health care center in Rio de Janeiro, Brazil. We used linear mixed-effects models to estimate longitudinal changes in systolic BP (SBP) and diastolic BP (DBP) during pregnancy. Poisson regression models were performed to identify factors associated with no mid-trimester drop in BP. RESULTS: Significant mid-trimester increase in SBP (5.6mm Hg; 95% confidence interval (CI) = 4.6-6.7) and DBP (4.4mm Hg; 95% CI = 3.4-5.3) was observed in 44.3% and 39.9% of the sample, respectively. Women (37.1%) who had not a mid-trimester SBP drop still had a DBP drop. White skin color (incidence ratio (IR): 1.71; 95% CI = 1.22-2.39), family history of hypertension (IR: 1.93; 95% CI = 1.29-2.89), early pregnancy obesity (IR: 2.29; 95% CI = 1.27-4.11), outside temperature variation (IR: 1.45; 95% CI = 1.00-2.10), and gestational weight gain from the first to second trimester (IR: 1.71; 95% CI = 1.01-2.88 and IR: 2.32; 95% CI = 1.39-3.89 for second and third tertiles) were characteristics associated with no mid-trimester drop in SBP. The same characteristics were associated with no mid-trimester drop in DBP, except family history of hypertension and outside temperature variation. CONCLUSIONS: Some women without a mid-trimester SBP drop still present a DBP drop. The different patterns of mid-trimester change in BP seem to be determined by preexisting and pregnancy-related factors

Blood Pressure in Healthy Pregnancy and Factors Associated With No Mid-Trimester Blood Pressure Drop: A Prospective Cohort Study.

BACKGROUND: The well-known mid-trimester drop in blood pressure (BP) during normal pregnancy was recently questioned. OBJECTIVE: To describe longitudinal changes in BP during healthy pregnancies and to investigate factors associated with no mid-trimester drop in BP. METHODS: A prospective cohort with 158 healthy pregnant women was followed up in a public health care center in Rio de Janeiro, Brazil. We used linear mixed-effects models to estimate longitudinal changes in systolic BP (SBP) and diastolic BP (DBP) during pregnancy. Poisson regression models were performed to identify factors associated with no mid-trimester drop in BP. RESULTS: Significant mid-trimester increase in SBP (5.6mm Hg; 95% confidence interval (CI) = 4.6-6.7) and DBP (4.4mm Hg; 95% CI = 3.4-5.3) was observed in 44.3% and 39.9% of the sample, respectively. Women (37.1%) who had not a mid-trimester SBP drop still had a DBP drop. White skin color (incidence ratio (IR): 1.71; 95% CI = 1.22-2.39), family history of hypertension (IR: 1.93; 95% CI = 1.29-2.89), early pregnancy obesity (IR: 2.29; 95% CI = 1.27-4.11), outside temperature variation (IR: 1.45; 95% CI = 1.00-2.10), and gestational weight gain from the first to second trimester (IR: 1.71; 95% CI = 1.01-2.88 and IR: 2.32; 95% CI = 1.39-3.89 for second and third tertiles) were characteristics associated with no mid-trimester drop in SBP. The same characteristics were associated with no mid-trimester drop in DBP, except family history of hypertension and outside temperature variation. CONCLUSIONS: Some women without a mid-trimester SBP drop still present a DBP drop. The different patterns of mid-trimester change in BP seem to be determined by preexisting and pregnancy-related factors