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 &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

The use of intra-operative ultrasound in gynecological surgery: a review

Ultrasound is a readily available, safe and portable imaging modality that is widely applied in gynecology. However, there is limited guidance for its use intra-operatively especially with complex gynecological procedures. This narrative review examines the existing literature published on the use of intraoperative ultrasound (IOUS) in benign gynecology and in gynecological oncology. We searched for the following terms: ‘intraoperative,’ ‘ultrasonography,’ ‘gynecology’ and ‘oncology’ using Pubmed/Medline. IOUS can minimize complications and facilitate difficult benign gynecological procedures. There is also a role for its use in gynecological oncology surgery and fertility-sparing surgery. The use of IOUS in gynecological surgery is an emerging field which improves visualization in the surgical field and aids completion of minimally invasive techniques

Menstrual cycles and the impact upon performance in elite British track and field athletes: a longitudinal study

Objective: To assess the prevalence of menstrual disorders and the perceived effect of menstrual cycles upon performance in elite athletes. Methodology: A longitudinal survey in the form of a questionnaire was sent to female track and field athletes at British Athletics every 6 months, over a five-year period between 1st October 2014 and 1st October 2019 in the United Kingdom (UK). Results: 128 athletes completed an average of 4.2 ± 2.9 questionnaires across the study period. The mean age of menarche was 14.2 ± 1.4 years, 13.4 ± 1.3 years and 12.8 ± 1.4 years in endurance, power, and thrower athletes respectively (p < 0.05). Two-thirds (66%; n = 82) reported consistently regular cycles, 30% (n = 37) irregular at some point during the period of observation and 4% (n = 5) were amenorrhoeic. 87 athletes (68%) reported dysmenorrhoea and 40 (31%) menorrhagia. More than three quarters (76.8%; n = 96) described their cycle negatively affected performance. Amongst those who reported when the negative impact occurred (n = 91), 40% (n = 36) reported this in the late luteal phase and 35% (n = 32) during the early follicular phase. 79% (n = 100) of athletes reported at least one cyclical symptom, of which bloating, lower back and pelvic pain were most frequently experienced. Conclusion: This data highlights the complex interrelationship between women’s health and elite athletic performance. Athletes perceive a negative impact from their menstrual cycles upon performance with a desire to manage these more effectively, particularly during competition. Female reproductive health expertise in the multi-disciplinary management of elite athletes is required

Future projections of the surface heat and water budgets of the Mediterranean Sea in an ensemble of coupled atmosphere-ocean regional climate models

Within the CIRCE project "Climate change and Impact Research: the Mediterranean Environment", an ensemble of high resolution coupled atmosphere-ocean regional climate models (AORCMs) are used to simulate the Mediterranean climate for the period 1950-2050. For the first time, realistic net surface air-sea fluxes are obtained. The sea surface temperature (SST) variability is consistent with the atmospheric forcing above it and oceanic constraints. The surface fluxes respond to external forcing under a warming climate and show an equivalent trend in all models. This study focuses on the present day and on the evolution of the heat and water budget over the Mediterranean Sea under the SRES-A1B scenario. On the contrary to previous studies, the net total heat budget is negative over the present period in all AORCMs and satisfies the heat closure budget controlled by a net positive heat gain at the strait of Gibraltar in the present climate. Under climate change scenario, some models predict a warming of the Mediterranean Sea from the ocean surface (positive net heat flux) in addition to the positive flux at the strait of Gibraltar for the 2021-2050 period. The shortwave and latent flux are increasing and the longwave and sensible fluxes are decreasing compared to the 1961-1990 period due to a reduction of the cloud cover and an increase in greenhouse gases (GHGs) and SSTs over the 2021-2050 period. The AORCMs provide a good estimates of the water budget with a drying of the region during the twenty-first century. For the ensemble mean, he decrease in precipitation and runoff is about 10 and 15% respectively and the increase in evaporation is much weaker, about 2% compared to the 1961-1990 period which confirm results obtained in recent studies. Despite a clear consistency in the trends and results between the models, this study also underlines important differences in the model set-ups, methodology and choices of some physical parameters inducing some difference in the various air-sea fluxes. An evaluation of the uncertainty sources and possible improvement for future generation of AORCMs highlights the importance of the parameterisation of the ocean albedo, rivers and cloud cover. © 2011 Springer-Verlag

Erratum to: Future projections of the surface heat and water budgets of the Mediterranean Sea in an ensemble of coupled atmosphere-ocean regional climate models (Clim Dyn, 10.1007/s00382-011-1261-4)

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THE CIRCE SIMULATIONS Regional Climate Change Projections with Realistic Representation of the Mediterranean Sea

In this article, the authors describe an innovative multimodel system developed within the Climate Change and Impact Research: The Mediterranean Environment (CIRCE) European Union (EU) Sixth Framework Programme (FP6) project and used to produce simulations of the Mediterranean Sea regional climate. The models include high-resolution Mediterranean Sea components, which allow assessment of the role of the basin and in particular of the air\u2013sea feedbacks in the climate of the region. The models have been integrated from 1951 to 2050, using observed radiative forcings during the first half of the simulation period and the Intergovernmental Panel on Climate Change (IPCC) Special Report on Emissions Scenarios (SRES) A1B scenario during the second half. The projections show a substantial warming (about 1.5\ub0\u20132\ub0C) and a significant decrease of precipitation (about 5%) in the region for the scenario period. However, locally the changes might be even larger. In the same period, the projected surface net heat loss decreases, leading to a weaker cooling of the Mediterranean Sea by the atmosphere, whereas the water budget appears to increase, leading the basin to lose more water through its surface than in the past. Overall, these results are consistent with the findings of previous scenario simulations, such as the Prediction of Regional Scenarios and Uncertainties for Defining European Climate Change Risks and Effects (PRUDENCE), Ensemble-Based Predictions of Climate Changes and Their Impacts (ENSEMBLES), and phase 3 of the Coupled Model Intercomparison Project (CMIP3). The agreement suggests that these findings are robust to substantial changes in the configuration of the models used to make the simulations. Finally, the models produce a 2021\u201350 mean steric sea level rise that ranges between +7 and +12 cm, with respect to the period of reference

The CIRCE simulations : Regional Climate Change Projections with Realistic Representation of the Mediterranean Sea

International audienceIn this article, the authors describe an innovative multimodel system developed within the Climate Change and Impact Research: The Mediterranean Environment (CIRCE) European Union (EU) Sixth Framework Programme (FP6) project and used to produce simulations of the Mediterranean Sea regional climate. The models include high-resolution Mediterranean Sea components, which allow assessment of the role of the basin and in particular of the air–sea feedbacks in the climate of the region.The models have been integrated from 1951 to 2050, using observed radiative forcings during the first half of the simulation period and the Intergovernmental Panel on Climate Change (IPCC) Special Report on Emissions Scenarios (SRES) A1B scenario during the second half.The projections show a substantial warming (about 1.5°–2°C) and a significant decrease of precipitation (about 5%) in the region for the scenario period. However, locally the changes might be even larger. In the same period, the projected surface net heat loss decreases, leading to a weaker cooling of the Mediterranean Sea by the atmosphere, whereas the water budget appears to increase, leading the basin to lose more water through its surface than in the past. Overall, these results are consistent with the findings of previous scenario simulations, such as the Prediction of Regional Scenarios and Uncertainties for Defining European Climate Change Risks and Effects (PRUDENCE), Ensemble-Based Predictions of Climate Changes and Their Impacts (ENSEMBLES), and phase 3 of the Coupled Model Intercomparison Project (CMIP3). The agreement suggests that these findings are robust to substantial changes in the configuration of the models used to make the simulations