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

Lessons from patient-specific 3D models of the cardiac chambers after the Mustard operation.

The recent ability to create detailed 3D models of the atrial and ventricular chambers using CT, MRI and rapid prototyping offers unique opportunities to study the size and shape of the different cardiac chambers both before and following operation for complex cardiac anomalies. We here describe the techniques for creating detailed 3D models of the heart and demonstrate the utility of these techniques in a patient studied after the Mustard operation. This can give important insights into the changes in size and shape of the different chambers and the patterns of blood flow from the pulmonary and systemic veins to the appropriate ventricle. This information in turn could be extremely helpful in understanding and optimizing the overall hemodynamic function after the Mustard operation

Comparison of different intraocular pressure measurement techniques in normal eyes, post surface and post lamellar refractive surgery

Shireen MA Shousha, Mahmoud AH Abo Steit, Mohamed HM Hosny, Wael A Ewais, Ahmad MM ShalabyDepartment of Ophthalmology, Faculty of Medicine, Cairo University, Cairo, EgyptBackground: The purpose of this study was to determine the accuracy of intraocular pressure (IOP) measurement after laser in situ keratomileusis (LASIK) or epithelial laser in situ keratomileusis (Epi)-LASIK using Goldmann applanation tonometry, air puff tonometry, ocular response analyzer corneal compensated IOP (ORA IOPcc) and Pentacam corrected IOP.Methods: A prospective comparative clinical study was conducted between February and September 2011 on 30 eyes divided into four groups, i.e. 20 corneas of 10 patients before LASIK (group A), 20 corneas of the same patients 2 months postoperatively (group B), 10 corneas of five patients before Epi-LASIK (group C), and 10 corneas of the same patients 2 months postoperatively (group D). Patient age ranged from 20 to 50 years. IOP was measured using Goldmann applanation and air puff tonometry, ORA corneal compensation, and Pentacam correction (which also measured central corneal thickness).Results: Significant positive linear correlations were found between IOP values measured by Goldmann applanation tonometry and other techniques, and with preoperative pachymetry in group A. The correlation between preoperative Pentacam-corrected and preoperative ORA corneal-compensated IOP was strongest for Goldmann applanation tonometry (r = 0.97 and r = 0.858 respectively, P &amp;lt; 0.001). Compared with preoperative values, postoperative IOP measured by the four methods were significantly lower. The difference was statistically significant when IOP was measured using Goldmann applanation and air puff tonometry compared with the ORA and Pentacam methods (P &amp;lt; 0.001 for LASIK patients and P = 0.017 for Epi-LASIK patients). Nonsignificant correlations were found between the degree of lowering of postoperative IOP and postoperative pachymetry in groups B and D.Conclusion: Refractive surgery causes significant lowering of IOP as measured using Goldmann applanation tonometry, air puff tonometry, ORA compensation, and Pentacam correction. LASIK has a greater effect than Epi-LASIK on IOP measurement error following refractive surgery.Keywords: intraocular pressure measurement, refractive surgery, corneal biomechanics, corneal thicknes

The effect of flap thickness on corneal biomechanics after myopic laser in situ keratomileusis using the M-2 microkeratome

Iyad A Goussous,1 Mohamed-Sameh El-Agha,1 Ahmed Awadein,1 Mohamed H Hosny,1 Alaa A Ghaith,2 Ahmed L Khattab2 1Department of Ophthalmology, Faculty of Medicine, Cairo University, Cairo, 2Faculty of Medicine, Alexandria University, Alexandria, Egypt Purpose: The purpose of this study was to determine the effect of flap thickness on corneal biomechanics after myopic laser in situ keratomileusis (LASIK).Methods: This is a prospective controlled non-randomized, institutional study. Patients underwent either epi-LASIK with mitomycin (advanced surface ablation [ASA]), thin-flap LASIK (90 &micro;m head), or thick-flap LASIK (130 &micro;m head). In ASA, the Moria Epi-K hydroseparator was used. LASIK flaps were created using the Moria M-2 mechanical microkeratome. The corneal hysteresis (CH) and corneal resistance factor (CRF) were measured preoperatively and 3 months after surgery, using the Ocular Response Analyzer&reg;.Results: Ten patients (19 eyes) underwent ASA, 11 patients (16 eyes) underwent thin-flap LASIK, and 11 patients (16 eyes) underwent thick-flap LASIK. The mean preoperative CH was 10.47&plusmn;0.88, 10.52&plusmn;1.4, and 11.28&plusmn;1.4&nbsp;mmHg (p=0.043), respectively, decreasing after surgery by 1.75&plusmn;1.02, 1.66&plusmn;1.00, and 2.62&plusmn;1.03&nbsp;mmHg (p=0.017). The mean reduction of CH per micron of central corneal ablation was 0.031, 0.023, and 0.049 mmHg/&micro;m (p=0.005). Mean preoperative CRF was 10.11&plusmn;1.28, 10.34&plusmn;1.87, and 10.62&plusmn;1.76 mmHg (p=0.66), decreasing after surgery by 2.33&plusmn;1.35, 2.77&plusmn;1.03, and 2.92&plusmn;1.10 mmHg (p=0.308). The mean reduction of CRF per micron of central corneal ablation was 0.039, 0.040, and 0.051 mmHg/&micro;m (p=0.112).Conclusion: Thick-flap LASIK caused a greater reduction of CH and CRF than thin-flap LASIK and ASA, although this was statistically significant only for CH. ASA and thin-flap LASIK were found to be biomechanically similar. Keywords: flap thickness ectasia, hysteresis, LASIK, surface ablatio