El hepatocarcinoma en la Comunidad Foral de Navarra: estudio de características y evolución en la práctica clínica habitual

Fundamento. El hepatocarcinoma asienta generalmente sobre una cirrosis hepática. El cribado pretende mejorar la supervivencia. Los objetivos de nuestro trabajo son conocer las características del hepatocarcinoma, su evolución y la influencia del cribado en su supervivencia, en la práctica clínica en Navarra. Material y Métodos. Estudio prospectivo y retrospectivo de 111 pacientes diagnosticados de hepatocarcinoma en hospitales públicos navarros, entre enero de 2009 y enero de 2015. Se analizaron características epidemiológicas, clínicas, analíticas, radiológicas, estadio tumoral, tratamiento y evolución, y el efecto del cribado. Resultados. El 84,7% de los pacientes eran varones. La edad media fue 67 años. El 85,6% tenían cirrosis. La etiología más frecuente fue la enólica (40,7%). El 62,2% se diagnosticó en estadios tempranos, el 15,3% en intermedio y el 22,5% en avanzado o terminal. El 4,5% se trató mediante trasplante, el 21,6% con resección, el 23,4% mediante ablación, el 10,8% con quimioembolización, el 5,4% con radiembolización, el 2,7% con embolización, el 13,5% con sorafenib y el 18% de modo sintomático. Solamente 32 pacientes (28,8%) realizaban cribado. No se han encontrado diferencias significativas en la supervivencia según la realización de cribado (mediana de 32 y 34 meses; p = 0,971). Conclusiones. En Navarra, el hepatocarcinoma se desarrolla generalmente sobre una cirrosis, cuya etiología más frecuente es el consumo de alcohol. El hepatocarcinoma se ha diagnosticado con más frecuencia en estadios iniciales, fuera de cribado. El cribado no ha mejorado la supervivencia.Background. Hepatocellular carcinoma generally arises in a cirrhotic liver. The aim of screening is to improve survival. The aims of our study are to determine the characteristics and evolution of hepatocellular carcinoma and the effect of screening on survival, in clinical practice in Navarre. Methods. Prospective and retrospective study of 111 patients diagnosed with hepatocellular carcinoma in public hospitals in Navarre between January 2009 and January 2015. Epidemiological, clinical, analytical, radiological characteristics, tumour staging, treatment and evolution were analyzed. Survival was compared between patients subjected to screening and those not. Results. Mean age was 67 years. The patients (84.7%) were mainly male and 85.6% had cirrhosis. The most frequent aetiology was alcohol consumption (40.7%). 62.2% were diagnosed in early stages, 15.3% in intermediate and 22.5 % in advanced or terminal stages. 4.5% received transplants, 21.6% received surgical resection, 23.4% were treated with ablation techniques, 10.8 % with chemoembolization, 5.4% with radiembolization, 2.7% with embolization, 13.5 % with sorafenib and 18% symptomatically. Only 32 patients (28.8%) were subjected to screening. No statistical differences were found in survival depending on surveillance (32 month versus 34; p = 0.971). Conclusions. In Navarre, hepatocellular carcinoma generally appears against a background of cirrhosis, and alcohol is the most frequent aetiology. Hepatocellular carcinoma is diagnosed most frequently in early stages and out of screening practices. Screening was not associated to better survival

El hepatocarcinoma en la Comunidad Foral de Navarra: estudio de características y evolución en la práctica clínica habitual

Fundamento. El hepatocarcinoma asienta generalmente sobre una cirrosis hepática. El cribado pretende mejorar la supervivencia. Los objetivos de nuestro trabajo son conocer las características del hepatocarcinoma, su evolución y la influencia del cribado en su supervivencia, en la práctica clínica en Navarra. Material y Métodos. Estudio prospectivo y retrospectivo de 111 pacientes diagnosticados de hepatocarcinoma en hospitales públicos navarros, entre enero de 2009 y enero de 2015. Se analizaron características epidemiológicas, clínicas, analíticas, radiológicas, estadio tumoral, tratamiento y evolución, y el efecto del cribado. Resultados. El 84,7% de los pacientes eran varones. La edad media fue 67 años. El 85,6% tenían cirrosis. La etiología más frecuente fue la enólica (40,7%). El 62,2% se diagnosticó en estadios tempranos, el 15,3% en intermedio y el 22,5% en avanzado o terminal. El 4,5% se trató mediante trasplante, el 21,6% con resección, el 23,4% mediante ablación, el 10,8% con quimioembolización, el 5,4% con radiembolización, el 2,7% con embolización, el 13,5% con sorafenib y el 18% de modo sintomático. Solamente 32 pacientes (28,8%) realizaban cribado. No se han encontrado diferencias significativas en la supervivencia según la realización de cribado (mediana de 32 y 34 meses; p = 0,971). Conclusiones. En Navarra, el hepatocarcinoma se desarrolla generalmente sobre una cirrosis, cuya etiología más frecuente es el consumo de alcohol. El hepatocarcinoma se ha diagnosticado con más frecuencia en estadios iniciales, fuera de cribado. El cribado no ha mejorado la supervivencia.Background. Hepatocellular carcinoma generally arises in a cirrhotic liver. The aim of screening is to improve survival. The aims of our study are to determine the characteristics and evolution of hepatocellular carcinoma and the effect of screening on survival, in clinical practice in Navarre. Methods. Prospective and retrospective study of 111 patients diagnosed with hepatocellular carcinoma in public hospitals in Navarre between January 2009 and January 2015. Epidemiological, clinical, analytical, radiological characteristics, tumour staging, treatment and evolution were analyzed. Survival was compared between patients subjected to screening and those not. Results. Mean age was 67 years. The patients (84.7%) were mainly male and 85.6% had cirrhosis. The most frequent aetiology was alcohol consumption (40.7%). 62.2% were diagnosed in early stages, 15.3% in intermediate and 22.5 % in advanced or terminal stages. 4.5% received transplants, 21.6% received surgical resection, 23.4% were treated with ablation techniques, 10.8 % with chemoembolization, 5.4% with radiembolization, 2.7% with embolization, 13.5 % with sorafenib and 18% symptomatically. Only 32 patients (28.8%) were subjected to screening. No statistical differences were found in survival depending on surveillance (32 month versus 34; p = 0.971). Conclusions. In Navarre, hepatocellular carcinoma generally appears against a background of cirrhosis, and alcohol is the most frequent aetiology. Hepatocellular carcinoma is diagnosed most frequently in early stages and out of screening practices. Screening was not associated to better survival

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

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\ub75%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31\ub72%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10\ub72%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12\ub73%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9\ub74%] of 7339 patients), middle (549 [14\ub70%] of 3918 patients), and low (298 [23\ub72%] of 1282) HDI (p<0\ub7001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17\ub78%] of 574 patients in high-HDI countries; 74 [31\ub74%] of 236 patients in middle-HDI countries; 72 [39\ub78%] 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\ub760, 95% credible interval 1\ub705\u20132\ub737; p=0\ub7030). 132 (21\ub76%) 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\ub76%) of 295 patients in high-HDI countries, in 37 (19\ub78%) of 187 patients in middle-HDI countries, and in 46 (35\ub79%) of 128 patients in low-HDI countries (p<0\ub7001). 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. Funding: DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant

Use of Telemedicine for Post-discharge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review with Meta-analysis

Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardised assessment tools are needed. Summary background data: Surgical site infection is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. Methods: The primary outcome of this study was surgical site infection reported up to 30-days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analysed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30-days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs. 11.1%, P<0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval 0.63-0.84, P<0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In nine eligible non-randomised studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47-0.94) than in-person (reference) follow-up (I2=0.45, P=0.12), although there a high risk of bias in included studies. Conclusions: Use of telemedicine to assess the surgical wound post-discharge is feasible, but risks underreporting of SSI. Standardised tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally