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

Bougie assisted endotracheal intubation using the Air-Q™ Intubating Laryngeal Airway: A prospective randomized clinical study

Background: Air-Q™ Intubating Laryngeal Airway is an extraglottic airway device used as a primary airway tool or as an adjunct to tracheal intubation. The bougie is a simple flexible device that might increase the success rate of endotracheal intubation either blindly or through a supraglottic device. We hypothesized that using bougie guided intubation through air-Q™ can improve the success rate with minimal complications. Methods: One hundred and forty patients of either sex, >18 years old, ASA I-II scheduled for elective surgical procedures under general anesthesia with intubation were randomly allocated to one of two groups of 70 patients each. Blind tracheal intubation was performed through air-Q™ with bougie assistance (Group B) or without (Group Q). In both groups, 3 attempts were allowed for successful device insertion. After obtaining normal capnographic wave, 3 more attempts were tried for intubation with or without bougie guidance. Lung ventilation through air-Q™ was permitted between intubation attempts. If tracheal intubation through air-Q™ was unsuccessful, it was performed by direct laryngoscopy. Results: Air-Q™ time, ease, attempts number of insertion and ventilation grade were comparable between both groups. Total intubation time was significantly longer in group-B (P = 0.001) while overall success rate for intubation was comparable (64.3%). Group-B showed significant (P = 0.001) higher incidence of complications (trauma (P = 0.023), sore throat (P = 0.001), dysphonia (P = 0.023) and dysphagia (P = 0.001)) as compared with group-Q. In spite of significant decrease in both heart rate and mean arterial pressure in both groups after air-Q™ insertion, yet there was significant increase in both parameters after intubation compared to baseline values (P < 0.05) which was more prominent in group-B than in group-Q. Significant increase in HR and MAP was elicited after bougie placement in group-B (P < 0.01). Conclusion: Bougie guided tracheal intubation through air-Q™ didn’t improve overall success rate with significant longer time, hemodynamic derangement and traumatic sequelae

Comparative study between continuous epidural anaesthesia and continuous Wiley Spinal® anaesthesia in elderly patients undergoing TURP

Background: This study compared haemodynamics of continuous Wiley Spinal® anaesthesia with continuous epidural anaesthesia in elderly patients undergoing transurethral resection of prostate (TURP). Methods: After Institutional Review Board approval, thirty elderly male patients undergoing TURP classified as ASA physical status II or III were assigned into either the following: Continuous Epidural Anaesthesia group (Group CEA) receiving fentanyl 50 μg with plain bupivacaine 0.5% in 5 ml boluses or Wiley Spinal® Anaesthesia group (Group WSA) receiving fentanyl 5 μg with plain bupivacaine 0.5% given as 0.5 ml boluses until reaching sensory level of T10. Sensory and motor block onset and recovery, haemodynamics, time to first analgesia and adverse events were documented. Results: On reviewing WSA and CEA groups, onset of T10 sensory block [2 (1–8) vs. 5 (3–20) min], and motor block [9 (2–25) vs. 12 (5–40) min], with sensory recovery [161.7 ± 28.3 vs. 253.3 ± 52.7 min] and motor block duration [100.0 ± 27.4 vs. 130.7 ± 19.5 min] respectively (P < 0.05) being shorter in Group WSA. Haemodynamics revealed significant reduction in mean arterial pressure after three and five minutes of injection of local anaesthetic and heart rate after fifteen minutes in Group WSA when compared with Group CEA (P < 0.05). Time to first analgesia and adverse events were non-significant. Conclusion: In elderly patients undergoing TURP, continuous Wiley Spinal® anaesthesia showed nearly comparable haemodynamics as continuous epidural anaesthesia with minimal adverse effects. This technique also provided good anaesthetic profile as well as fast sensory and motor block onset and recovery

Analgesic effects of ultrasound guided paravertebral block versus transversus abdominis plane block in hepatic patients undergoing laparoscopic cholecystectomy: PVB vs TAP in hepatic patients

Background: Several analgesic modalities after laparoscopic cholecystectomy were used in hepatic patients but with various complications. Bilateral ultrasound-guided transverse abdominis plane block (TAP) or thoracic paravertebral block (PVB) may provide safer techniques than others. The aim of this study is to delineate the more efficient and safer technique either TAP or PVB in hepatic patients. Methods: The research was conducted on sixty adult hepatic patients, ASA II or III, Child A or B, undergoing laparoscopic cholecystectomy. Patients were allocated randomly into one of two equal groups, to attain bilateral ultrasound guided either PVB (Group P) or TAP block (Group T). Group P showed significant postoperative lower pain scores using visual analogue score at 2, 4, 6 and 24 h (P &lt; 0.01) and less intraoperative desflurane and fentanyl consumption (P &lt; 0.001) versus group T. In addition, group P exhibited less total postoperative pethidine requirement (23.3±25.4 mg vs. 38.3±21.5 mg, P = 0.017), fewer number of patients asked for postoperative analgesia (46.7% vs. 76.7%, P value = 0.017), longer duration to first analgesic demand (20.5±5.1 h vs. 15.1±8.4 h, P = 0.021), and compared to group T respectively. Regarding liver functions and haemodynamics, both groups were comparable at different intervals

The Association of Smoking with Contact Dermatitis: A Cross-Sectional Study

Contact dermatitis is a chronic inflammatory skin disorder with a highly variable prevalence worldwide. Smoking plays a crucial role in mediating inflammatory skin conditions such as contact dermatitis. The present study aimed to investigate the association between smoking status and contact dermatitis in the Saudi population. The patients in the present study were individuals older than 18 years who were diagnosed with contact dermatitis and received a patch test at the Department of Dermatology of King Saud University Medical City from March 2003 through February 2019. All patients were interviewed by phone to complete a specific pre-designed questionnaire to assess tobacco use or exposure history. The total number of enrolled patients in the study was 308 (91 males and 217 females), all with contact dermatitis. Data from the present study suggest that the prevalence of allergic contact dermatitis in smokers may be less than that in non-smokers. Moreover, the prevalence of irritant contact dermatitis in smokers is more significant than in non-smokers. Finally, left-hand contact dermatitis is significantly associated with smoking. Therefore, there is a strong association between smoking and irritant contact dermatitis, especially in the Saudi population, regarding the left hand. Further epidemiologic studies are needed to further explore the role of smoking in the occurrence of contact dermatitis and to explore the possible mechanisms

The Association of Smoking with Contact Dermatitis: A Cross-Sectional Study

Contact dermatitis is a chronic inflammatory skin disorder with a highly variable prevalence worldwide. Smoking plays a crucial role in mediating inflammatory skin conditions such as contact dermatitis. The present study aimed to investigate the association between smoking status and contact dermatitis in the Saudi population. The patients in the present study were individuals older than 18 years who were diagnosed with contact dermatitis and received a patch test at the Department of Dermatology of King Saud University Medical City from March 2003 through February 2019. All patients were interviewed by phone to complete a specific pre-designed questionnaire to assess tobacco use or exposure history. The total number of enrolled patients in the study was 308 (91 males and 217 females), all with contact dermatitis. Data from the present study suggest that the prevalence of allergic contact dermatitis in smokers may be less than that in non-smokers. Moreover, the prevalence of irritant contact dermatitis in smokers is more significant than in non-smokers. Finally, left-hand contact dermatitis is significantly associated with smoking. Therefore, there is a strong association between smoking and irritant contact dermatitis, especially in the Saudi population, regarding the left hand. Further epidemiologic studies are needed to further explore the role of smoking in the occurrence of contact dermatitis and to explore the possible mechanisms

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