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

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

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 &lt; 0⋅001) or low (363 of 860, 42⋅2 percent; OR 0⋅08, 0⋅07 to 0⋅10, P &lt; 0⋅001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference −9⋅4 (95 per cent c.i. −11⋅9 to −6⋅9) per cent; P &lt; 0⋅001), but the relationship was reversed in low-HDI countries (+12⋅1 (+7⋅0 to +17⋅3) per cent; P &lt; 0⋅001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0⋅60, 0⋅50 to 0⋅73; P &lt; 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

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. Funding DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant

Mapping the optimal forest road network based on the multicriteria evaluation technique: the case study of Mediterranean Island of Thassos in Greece

The sustainable management of forest resources can only be achieved through a well-organized road network designed with the optimal spatial planning and the minimum environmental impacts. This paper describes the spatial layout mapping for the optimal forest road network and the environmental impacts evaluation that are caused to the natural environment based on the multicriteria evaluation (MCE) technique at the Mediterranean island of Thassos in Greece. Data analysis and its presentation are achieved through a spatial decision support system using the MCE method with the contribution of geographic information systems (GIS). With the use of the MCE technique, we evaluated the human impact intensity to the forest ecosystem as well as the ecosystem’s absorption from the impacts that are caused from the forest roads’ construction. For the human impact intensity evaluation, the criteria that were used are as follows: the forest’s protection percentage, the forest road density, the applied skidding means (with either the use of tractors or the cable logging systems in timber skidding), the timber skidding direction, the visitors’ number and truck load, the distance between forest roads and streams, the distance between forest roads and the forest boundaries, and the probability that the forest roads are located on sights with unstable soils. In addition, for the ecosystem’s absorption evaluation, we used forestry, topographical, and social criteria. The recommended MCE technique which is described in this study provides a powerful, useful, and easy-to-use implement in order to combine the sustainable utilization of natural resources and the environmental protection in Mediterranean ecosystems

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

Bird community characteristics as indicators of sustainable management in olive grove ecosystems of Central Greece

The role of breeding birds as indicators of sustainable management in olive groves was investigated. The data revealed significantly higher alpha diversity in organic and abandoned olive groves and maquis than in conventional ones. The highest beta diversity was found between the following pairs: organic olive groves-maquis, and abandoned olive groves-maquis. Breeding bird diversity, Heteroptera, Hymenoptera, Hemiptera and Coleoptera densities positively influenced bird species richness in organic olive groves and maquis, and additionally, manure application positively influenced bird species richness in organic ones. Bird species richness was negatively influenced by pesticide and inorganic fertilizer application in conventional ones. Moreover, isopod density was unimportant in explaining breeding bird richness in organic olive groves. Finally, our study suggests a difference in bird communities of various olive groves as a result of different management and practices, and concludes that birds might serve as indicators of overall olive grove health. Furthermore, these findings could be used as a tool for prediction of breeding bird species richness probability in different olive grove management systems and maquis. Finally, the results of the present study may contribute to highlighting some aspects of the effect of different farming practices on the dynamics of Mediterranean bird communities

Contribution of Agro-Environmental Factors to Yield and Plant Diversity of Olive Grove Ecosystems (<i>Olea europaea</i> L.) in the Mediterranean Landscape

Olive cultivation (Olea europaea L.) is one of the most significant sources of income for agricultural areas in the Mediterranean basin, and the olive oil industry as well as the environmental protection are an important part of the Greek agricultural sector. Generalized Linear Models were applied in order to investigate the predictive strength of several biodiversity components and agro-environmental factors for yield and herbaceous plant diversity (species richness) in organic and conventional olive groves of Greece. Our study highlights an increase in yields of organic olive groves by increasing manure application and the earthworms’ density. In the conventional olive groves, yields increase by increasing soil organic matter and the application of inorganic fertilizer N. Also, the herbaceous plant species richness increases with increasing the Shannon diversity index of herbaceous plants, the field area, the application of organic fertilizer K and the manure in organic olive groves. As for the conventional ones, herbaceous plant species richness increases with the increase of the application of inorganic fertilizer N. Moreover, some plant species could be regarded as indicators of the differently managed olive groves. Conclusively, this study contributes to the integration of biodiversity conservation with ecologically sustainable agriculture and conservation of agroecosystem. Finally, it could be utilized as a decision and management tool to the scientific and agricultural community reinforcing the knowledge about the agro-environmental impact in olive grove management systems

Predicting Woody Plant Diversity as Key Component of Ecosystems

The Mediterranean basin is a global hotspot of biodiversity. Woody plants are key components of ecosystems. This article explores the environmental impacts on woody plant species richness and diversity in maquis and abandoned olive groves in an important ecological area of central Greece. The results showed that woody plant species richness and diversity had increasing values in maquis compared to abandoned olive groves. According to Principal Component Analysis, woody plant species richness and diversity (Shannon diversity index) were positively correlated with soil organic matter, plant litter, N, P, K, slope and precipitation in maquis. Also, positive correlations among woody plant species richness and diversity, and soil organic matter, and slope were detected in abandoned olive groves. Conclusively, the present study is the first in the area and the results it will be utilized as a decision support tool for sustainability assessment of ecosystems with the help of the information systems.</jats:p

Contribution of Agro-Environmental Factors to Yield and Plant Diversity of Olive Grove Ecosystems (Olea europaea L.) in the Mediterranean Landscape

Olive cultivation (Olea europaea L.) is one of the most significant sources of income for agricultural areas in the Mediterranean basin, and the olive oil industry as well as the environmental protection are an important part of the Greek agricultural sector. Generalized Linear Models were applied in order to investigate the predictive strength of several biodiversity components and agro-environmental factors for yield and herbaceous plant diversity (species richness) in organic and conventional olive groves of Greece. Our study highlights an increase in yields of organic olive groves by increasing manure application and the earthworms&rsquo; density. In the conventional olive groves, yields increase by increasing soil organic matter and the application of inorganic fertilizer N. Also, the herbaceous plant species richness increases with increasing the Shannon diversity index of herbaceous plants, the field area, the application of organic fertilizer K and the manure in organic olive groves. As for the conventional ones, herbaceous plant species richness increases with the increase of the application of inorganic fertilizer N. Moreover, some plant species could be regarded as indicators of the differently managed olive groves. Conclusively, this study contributes to the integration of biodiversity conservation with ecologically sustainable agriculture and conservation of agroecosystem. Finally, it could be utilized as a decision and management tool to the scientific and agricultural community reinforcing the knowledge about the agro-environmental impact in olive grove management systems