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

Cabbage and fermented vegetables : From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

Large differences in COVID-19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS-CoV-2 binds to its receptor, the angiotensin-converting enzyme 2 (ACE2). As a result of SARS-CoV-2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT(1)R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID-19. The nuclear factor (erythroid-derived 2)-like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT(1)R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof-of-concept of dietary manipulations that may enhance Nrf2-associated antioxidant effects, helpful in mitigating COVID-19 severity.Peer reviewe

Nrf2-interacting nutrients and COVID-19 : time for research to develop adaptation strategies

There are large between- and within-country variations in COVID-19 death rates. Some very low death rate settings such as Eastern Asia, Central Europe, the Balkans and Africa have a common feature of eating large quantities of fermented foods whose intake is associated with the activation of the Nrf2 (Nuclear factor (erythroid-derived 2)-like 2) anti-oxidant transcription factor. There are many Nrf2-interacting nutrients (berberine, curcumin, epigallocatechin gallate, genistein, quercetin, resveratrol, sulforaphane) that all act similarly to reduce insulin resistance, endothelial damage, lung injury and cytokine storm. They also act on the same mechanisms (mTOR: Mammalian target of rapamycin, PPAR gamma:Peroxisome proliferator-activated receptor, NF kappa B: Nuclear factor kappa B, ERK: Extracellular signal-regulated kinases and eIF2 alpha:Elongation initiation factor 2 alpha). They may as a result be important in mitigating the severity of COVID-19, acting through the endoplasmic reticulum stress or ACE-Angiotensin-II-AT(1)R axis (AT(1)R) pathway. Many Nrf2-interacting nutrients are also interacting with TRPA1 and/or TRPV1. Interestingly, geographical areas with very low COVID-19 mortality are those with the lowest prevalence of obesity (Sub-Saharan Africa and Asia). It is tempting to propose that Nrf2-interacting foods and nutrients can re-balance insulin resistance and have a significant effect on COVID-19 severity. It is therefore possible that the intake of these foods may restore an optimal natural balance for the Nrf2 pathway and may be of interest in the mitigation of COVID-19 severity

Structural performance evaluation of cold formed steel cantilever beams with varying perforation Patterns

Cold-formed steel, prized for its affordability and durability, gains enhanced structural performance through perforated patterns on beams. This study explores the impact of perforation on load-carrying capacity and capability-to-weight ratio in cold-formed steel cantilever beams, specifically focusing on ''C'' sections. Assessing beams of varying lengths under uniform loading, the investigation, employing ABAQUS software, reveals significant load-carrying capability reductions of 35% to 95% for beams subjected to minor-axis bends, depending on hole quantity and placement. The findings stress the imperative precision needed when incorporating perforated sections into load-bearing structural systems. Flange perforations result in substantial drops, up to 90%, in load-carrying capacity, while web holes in beams bent about the major axis cause only minor reductions. This study informs the establishment of innovative design standards for perforated cold-formed steel beams, enhancing efficiency in construction and minimizing environmental impact. The proposed cold-formed steel cantilever beam exhibits a substantial load-bearing capacity of 185.4 kg/KN, surpassing capacities of simply-supported RC beams (119 kg/KN) and fixed beams (165 kg/KN), suggesting its potential advantages in structural applications. Bridging structural engineering and material science, this research pioneers sustainable and cost-effective construction approaches for the future

Novel strategy in endovascular treatment of coronary steal using histoacryl®

Background: Coronary steal is an often encountered clinical condition attributable to multiple etiologies. Diverse treatment modalities have been previously elucidated. Aim: To elucidate the potential role of interventional approach using N-butyl Cyanoacrylate (Histoacryl®) to treat coronary steal. Material and methods: We present four patients with coronary steal due to different causes. Three patients had coronary arterial fistulas, and the fourth patient underwent prior Coronary Artery Bypass Graft (CABG) surgery with a patent unligated Left Internal Mammary Artery (LIMA) side-branch. We report the attempted trans-catheter closure of the fistulas and LIMA side-branch using n-butyl cyanoacrylate as an embolic agent. Results: In our series, Coronary angiography was the imaging modality used for diagnosing and guiding the treatment of all cases. Multi-detector CT was used to track the pathway and termination of the fistula in one case only. From the three fistula cases, two originated from the left anterior descending (LAD) coronary artery and one from the left circumflex (LCX) coronary artery. We accomplished successful occlusion in two of the three fistula cases and in the LIMA side-branch case as well. Conclusion: N-butyl Cyanoacrylate (Histoacryl®) is a useful interventional embolic agent that could be used to treat coronary steal of diverse etiology

Adaptation of a Bacterial Bioluminescent Assay to Monitor Bioeffects of Gold Nanoparticles

Our current study aimed to adapt a bioluminescent bacteria-based bioassay to monitor the bioeffects of gold nanoparticles (AuNPs). Luminous marine bacteria Photobacterium phosphoreum and AuNPs modified with polyvinylpyrrolidone were employed; low-concentration (≤10−3 g/L) bioeffects of AuNPs were studied. Bioluminescence intensity was used as an indicator of physiological activity in bacteria. Two additional methods were used: reactive oxygen species (ROS) content was estimated with a chemiluminescent luminol method, and bacterial size was monitored using electron microscopy. The bacterial bioluminescent response to AuNPs corresponded to the “hormesis” model and involved time-dependent bioluminescence activation, as well as a pronounced increase in the number of enlarged bacteria. We found negative correlations between the time courses of bioluminescence and the ROS content in bacterial suspensions, demonstrating the relationship between bioluminescence activation and bacterial ROS consumption. The combined effects of AuNPs and a beta-emitting radionuclide, tritium, revealed suppression of bacterial bioluminescent activity (as compared to their individual effects) and a reduced percentage of enlarged bacteria. Therefore, we demonstrated that our bacteria-based bioluminescence assay is an appropriate tool to study the bioeffects of AuNPs; the bioeffects can be further classified within a unified framework for rapid bioassessment

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