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

Use of Telemedicine for Postdischarge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review With Meta-analysis

Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardized assessment tools are needed. // Background: Surgical site infection (SSI) is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. // Methods: The primary outcome of this study was SSI reported up to 30 days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analyzed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30 days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). // Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs 11.1%, P<0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval: 0.63–0.84, P<0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In 9 eligible nonrandomized studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47–0.94) than in-person (reference) follow-up (I2=0.45, P=0.12), although there a high risk of bias in included studies. // Conclusions: Use of telemedicine to assess the surgical wound postdischarge is feasible, but risks underreporting of SSI. Standardized tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally

Epidemiology of surgery associated acute kidney injury (EPIS-AKI): a prospective international observational multi-center clinical study

Purpose: The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. Methods: We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (&gt; 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72&nbsp;h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. Results: We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1-3) days vs. 3 (Q1-Q3, 1-6) days) and hospital length of stay (median 14 (Q1-Q3, 9-24) days vs. 10 (Q1-Q3, 7-17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. Conclusion: In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide

Global, regional, and national burden of colorectal cancer and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Funding: F Carvalho and E Fernandes acknowledge support from Fundação para a Ciência e a Tecnologia, I.P. (FCT), in the scope of the project UIDP/04378/2020 and UIDB/04378/2020 of the Research Unit on Applied Molecular Biosciences UCIBIO and the project LA/P/0140/2020 of the Associate Laboratory Institute for Health and Bioeconomy i4HB; FCT/MCTES through the project UIDB/50006/2020. J Conde acknowledges the European Research Council Starting Grant (ERC-StG-2019-848325). V M Costa acknowledges the grant SFRH/BHD/110001/2015, received by Portuguese national funds through Fundação para a Ciência e Tecnologia (FCT), IP, under the Norma Transitória DL57/2016/CP1334/CT0006.proofepub_ahead_of_prin

Global, regional, and national burden of household air pollution, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Despite a substantial reduction in the use of solid fuels for cooking worldwide, exposure to household air pollution (HAP) remains a leading global risk factor, contributing considerably to the burden of disease. We present a comprehensive analysis of spatial patterns and temporal trends in exposure and attributable disease from 1990 to 2021, featuring substantial methodological updates compared with previous iterations of the Global Burden of Diseases, Injuries, and Risk Factors Study, including improved exposure estimations accounting for specific fuel types. Methods: We estimated HAP exposure and trends and attributable burden for cataract, chronic obstructive pulmonary disease, ischaemic heart disease, lower respiratory infections, tracheal cancer, bronchus cancer, lung cancer, stroke, type 2 diabetes, and causes mediated via adverse reproductive outcomes for 204 countries and territories from 1990 to 2021. We first estimated the mean fuel type-specific concentrations (in μg/m3) of fine particulate matter (PM2·5) pollution to which individuals using solid fuels for cooking were exposed, categorised by fuel type, location, year, age, and sex. Using a systematic review of the epidemiological literature and a newly developed meta-regression tool (meta-regression: Bayesian, regularised, trimmed), we derived disease-specific, non-parametric exposure–response curves to estimate relative risk as a function of PM2·5 concentration. We combined our exposure estimates and relative risks to estimate population attributable fractions and attributable burden for each cause by sex, age, location, and year. Findings: In 2021, 2·67 billion (95% uncertainty interval [UI] 2·63–2·71) people, 33·8% (95% UI 33·2–34·3) of the global population, were exposed to HAP from all sources at a mean concentration of 84·2 μg/m3. Although these figures show a notable reduction in the percentage of the global population exposed in 1990 (56·7%, 56·4–57·1), in absolute terms, there has been only a decline of 0·35 billion (10%) from the 3·02 billion people exposed to HAP in 1990. In 2021, 111 million (95% UI 75·1–164) global disability-adjusted life-years (DALYs) were attributable to HAP, accounting for 3·9% (95% UI 2·6–5·7) of all DALYs. The rate of global, HAP-attributable DALYs in 2021 was 1500·3 (95% UI 1028·4–2195·6) age-standardised DALYs per 100 000 population, a decline of 63·8% since 1990, when HAP-attributable DALYs comprised 4147·7 (3101·4–5104·6) age-standardised DALYs per 100 000 population. HAP-attributable burden remained highest in sub-Saharan Africa and south Asia, with 4044·1 (3103·4–5219·7) and 3213·5 (2165·4–4409·4) age-standardised DALYs per 100 000 population, respectively. The rate of HAP-attributable DALYs was higher for males (1530·5, 1023·4–2263·6) than for females (1318·5, 866·1–1977·2). Approximately one-third of the HAP-attributable burden (518·1, 410·1–641·7) was mediated via short gestation and low birthweight. Decomposition of trends and drivers behind changes in the HAP-attributable burden highlighted that declines in exposures were counteracted by population growth in most regions of the world, especially sub-Saharan Africa. Interpretation: Although the burden attributable to HAP has decreased considerably, HAP remains a substantial risk factor, especially in sub-Saharan Africa and south Asia. Our comprehensive estimates of HAP exposure and attributable burden offer a robust and reliable resource for health policy makers and practitioners to precisely target and tailor health interventions. Given the persistent and substantial impact of HAP in many regions and countries, it is imperative to accelerate efforts to transition under-resourced communities to cleaner household energy sources. Such initiatives are crucial for mitigating health risks and promoting sustainable development, ultimately improving the quality of life and health outcomes for millions of people. Funding: Bill & Melinda Gates Foundation

Effect of preheating on polymerization shrinkage strain of BIS-GMA free and containing resin composite restorative materials (in vitro study)

Abstract Background This study investigated the effect of preheating of bulk-fill BIS-GMA free and containing resin composite on post-gel shrinkage strain. In a split Teflon mold, sixty resin composite specimens were prepared with dimensions 7 mm length × 4 mm width × 4 mm height. Thirty specimens of each tested restorative materials were prepared, ten specimens for each selected temperature used in the study (room temperature 23 °C, 50 °C and 65 °C). The resin composite was monitored for post-gel shrinkage strain for 3 min after light irradiation using strain gauges. For pairwise comparisons, Duncan’s multiple range test was used to analyze the data after two-way ANOVA. The p ≤ 0.05 significance level was chosen. Results Viscalor thermoviscous bulk-fill composite Bis-GMA containing had the lowest polymerization shrinkage strain values in the three different temperatures. There was a statistically significant difference between groups according to material used at different temperatures. Both tested materials showed the highest shrinkage strain when preheated at 65 °C. Conclusions While the technology of thermoviscous is introduced to deliver the viscosity of a flowable resin composite so reducing the polymerization strain, it actually had adverse effect on it. Preheating of bulk-fill BIS-GMA free resin composite either to 50 °C or 65 °C had no effect on decreasing the polymerization shrinkage strain. Polymerization shrinkage strain of bulk-fill BIS-GMA contains resin composite either without or with preheating far superior to that of BIS-GMA free resin composite. </jats:sec

Nanostructured Lipid Carriers to Mediate Brain Delivery of Temazepam: Design and In Vivo Study

The opposing effect of the blood–brain barrier against the delivery of most drugs warrants the need for an efficient brain targeted drug delivery system for the successful management of neurological disorders. Temazepam-loaded nanostructured lipid carriers (NLCs) have shown possibilities for enhancing bioavailability and brain targeting affinity after oral administration. This study aimed to investigate these properties for insomnia treatment. Temazepam-NLCs were prepared by the solvent injection method and optimized using a 42 full factorial design. The optimum formulation (NLC-1) consisted of; Compritol® 888 ATO (75 mg), oleic acid (25 mg), and Poloxamer® 407 (0.3 g), with an entrapment efficiency of 75.2 ± 0.1%. The average size, zeta potential, and polydispersity index were determined to be 306.6 ± 49.6 nm, −10.2 ± 0.3 mV, and 0.09 ± 0.10, respectively. Moreover, an in vitro release study showed that the optimized temazepam NLC-1 formulation had a sustained release profile. Scintigraphy images showed evident improvement in brain uptake for the oral 99mTc-temazepam NLC-1 formulation versus the 99mTc-temazepam suspension. Pharmacokinetic data revealed a significant increase in the relative bioavailability of 99mTc-temazepam NLC-1 formulation (292.7%), compared to that of oral 99mTc-temazepam suspension. Besides, the NLC formulation exhibited a distinct targeting affinity to rat brain. In conclusion, our results indicate that the developed temazepam NLC formulation can be considered as a potential nanocarrier for brain-mediated drug delivery in the out-patient management of insomnia.</jats:p

Temperature change of the pulpal floor and restoration with preheated bis-GMA free and containing resin composite (a randomized clinical trial)

Abstract Background Preheating is one of several innovative approaches and improvements developed to increase the durability and clinical behavior of resin composites. Development of preheated composites is to reduce its viscosity in order to improve resin composite adaptation and placement ease. The purpose of this clinical trial was to study the effect of preheating Bis-GMA free and Bis-GMA-containing resin composites at different temperatures on the pulpal floor and restoration temperature. A total of twenty individuals (N = 40) have two carious posterior teeth that need to be restored were randomly assigned to one of two groups based on the type of restorative materials used: (group 1) Bis-GMA-containing resin composite VisCalor bulk (VCB), and (group 2) Bis-GMA-free resin composite Admira Fusion x-tra (AFX). Preheating temperatures of 50 °C and 70 °C were utilized to separate each group into two subgroups. Class I or II cavities were prepared. Thermometer device with two separate K-type temperature probes was used to measure the base line temperature values at the pulpal floor before beginning the restorative procedure (C0), pulpal floor during packing of preheated composite (C1), the top composite surface after packing and before curing (C2), pulpal floor after curing of the preheated composite (C3), and top composite surface after curing (C4). One-way ANOVA and the Kruskal–Wallis test were used to analyze the data. Results The measured temperature of pulpal floor for both preheated VCB or AFX at 50 °C or 70 °C revealed significant increasing from base line measured temperature to during packing as well as after curing with (P-value &lt; 0.001). There was no significant difference for mean composite surface temperature for both preheated materials at 50 °C or 70 °C whether before or after curing. Conclusions Preheating of bulk fill Bis-GMA free and containing resin composite rises both the pulpal floor and the restoration temperature; meanwhile, the rise in temperature was limited. The application of the curing unit caused the greatest temperature rise. </jats:sec

Total Breast Reconstruction Using Thoracodorsal Artery Perforator (TDAP) Flap with or Without Implants: Two Centers Experience

Introduction: The thoracodorsal artery perforator (TDAP) flap has been increasingly used for breast reconstruction mainly due to reduced donor site morbidity compared to latissimus dorse (LD) flap. TDAP flap was mainly described for partial reconstruction of breast defects following breast conserving surgery. This study describes the use of the TDAP flap in total breast reconstruction with or without synthetic implants in two breast units. Methods: Between June 2017 and June of 2022, seven patients were included. Six patients from the Oncology Center, Egypt and one patient from Cambridge Breast Unit. Preoperative perforator mapping method was recorded. Patients' demographic data, type of mastectomy and reconstruction and surgical outcome were recorded. Results: Five patients had total breast reconstruction without implants, whilst two patients had implant-enhanced TDAP reconstruction. The mean age of was 39 years (31-43), and the mean mean body mass index (BMI) was 28 kg/m2 (23-36). Median hospital stay was 3 days. All patients had immediate breast reconstruction following mastectomy without the need for contralateral symmetrization or corrective surgery. No seroma was reported. Only one patient had complete flap loss, while one patient who had minor wound infection.&nbsp