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

System selection, benefits, and financial feasibility of implementing an advanced public transportation system

A procedure for selecting a suitable backbone radio communications system necessary for the implementation of advanced public transportation system technologies is presented. This procedure was used by the Regional Transportation Commission of Clark County, Nevada, in preparation of a radio communications master plan for the Las Vegas Citizens Area Transit system. The procedure recognizes the importance of taking into account not only the relative costs of the alternative candidate systems, but also other important factors such as the degree of system control by the transit agency, confidence in system development and technical practicality, potential for future expansion, and technical simplicity. Several alternative technologies for radio communications are reviewed and evaluated. Selection of the recommended system is based on the procedure that assigns relative weights to the important factors and gives each candidate system a score for each factor. The system with the highest total score is recommended for implementation. Potential system benefits are discussed and financial feasibility of the recommended system is evaluated by computing the annual rate of return on invested capital. Analysis shows that the system can pay for itself and also produce significant net savings in operation and capital costs. Although the analysis considered only potential savings in fleet size, an annual rate of return of over 21% on the invested capital has been shown to be achievable. Such savings can enable transit agencies to provide the same level of service at significantly reduced cost or expand the service without increasing operating costs

Current trends in admissions and outcomes of cardiac diseases in Ghana

Cardiovascular diseases (CVDs) pose a major burden in Africa, but data on temporal trends in disease burden are lacking. We assessed trends in CVD admissions and outcomes in central Ghana using a retrospective analysis of data from January 2004 to December 2015 among patients admitted to the medical wards of a tertiary medical center in Kumasi, Ghana. Rates of admissions and mortality were expressed as CVD admissions and deaths divided by the total number of medical admissions and deaths, respectively. Case fatality rates per specific cardiac disease diagnosis were also computed. Over the period, there were 4226 CVD admissions, with a male-to-female ratio of 1.1 to 1. There was a progressive increase in percentage of CVD admissions from 4.6% to 8.2%, representing an 78% increase, between 2004 and 2014. Of the 2170 CVD cases whose data were available, the top 3 causes of CVD admissions were heart failure (HF; 88.3%), ischemic heart disease (IHD; 7.2%), and dysrhythmias (1.9%). Of all HF admissions, 52% were associated with hypertension. IHD prevalence rose by 250% between 2005 and 2015. There were 976 deaths (23%), with an increase in percentage of hospital deaths that were cardiovascular in nature from 3.6% to 7.3% between 2004 and 2014, representing a 102% increase. Cardiac disease admissions and mortality have increased progressively over the past decade, with HF as the most common cause of admission. Once rare, IHD is emerging as a significant contributor to the CVD burden in sub-Saharan Afric

Next-Generation Sequencing Reveals Frequent Opportunities for Exposure to Hepatitis C Virus in Ghana.

Globally, hepatitis C Virus (HCV) infection is responsible for a large proportion of persons with liver disease, including cancer. The infection is highly prevalent in sub-Saharan Africa. West Africa was identified as a geographic origin of two HCV genotypes. However, little is known about the genetic composition of HCV populations in many countries of the region. Using conventional and next-generation sequencing (NGS), we identified and genetically characterized 65 HCV strains circulating among HCV-positive blood donors in Kumasi, Ghana. Phylogenetic analysis using consensus sequences derived from 3 genomic regions of the HCV genome, 5'-untranslated region, hypervariable region 1 (HVR1) and NS5B gene, consistently classified the HCV variants (n = 65) into genotypes 1 (HCV-1, 15%) and genotype 2 (HCV-2, 85%). The Ghanaian and West African HCV-2 NS5B sequences were found completely intermixed in the phylogenetic tree, indicating a substantial genetic heterogeneity of HCV-2 in Ghana. Analysis of HVR1 sequences from intra-host HCV variants obtained by NGS showed that three donors were infected with >1 HCV strain, including infections with 2 genotypes. Two other donors share an HCV strain, indicating HCV transmission between them. The HCV-2 strain sampled from one donor was replaced with another HCV-2 strain after only 2 months of observation, indicating rapid strain switching. Bayesian analysis estimated that the HCV-2 strains in Ghana were expanding since the 16th century. The blood donors in Kumasi, Ghana, are infected with a very heterogeneous HCV population of HCV-1 and HCV-2, with HCV-2 being prevalent. The detection of three cases of co- or super-infections and transmission linkage between 2 cases suggests frequent opportunities for HCV exposure among the blood donors and is consistent with the reported high HCV prevalence. The conditions for effective HCV-2 transmission existed for ~ 3-4 centuries, indicating a long epidemic history of HCV-2 in Ghana

Maximum likelihood tree reconstructed with NS5b gene sequences from West and Central Africa.

<p>Sequences from Ghana generated in this study are shown as red filled circles, those reported from West Africa as black filled triangles and those from Central Africa as black unfilled squares. Ghanaian sequences obtained from the GenBank are shown in blue filled circles.</p

Maximum likelihood tree reconstructed with consensus NS5b, 5'UTR and consensus HVR1 gene sequences generated in this study.

<p>HCV-1 isolates are shown in black unfilled circles while HCV-2 are shown in black filled circles.</p

Bayesian skyline plot, showing the epidemic history of HCV genotype 2.

<p>The thick black line in the middle represents the estimated mean effective number of infections through time in years. The two grey lines represent the 95% highest posterior density of this estimate.</p

Maximum likelihood tree reconstructed with intra-host variants of HVR1 gene sequences of HCV genotype 1.

<p>Only unique haplotypes are shown. Individual samples are labeled with distinct identifiers beginning with letter ‘k’ and displayed with different colors.</p

PFnet of all sequences present in two patients at different time points.

<p>Each time point is shown with a different color. Sequences found on the first time point are shown in red and the second time point in blue. Each node represents a single sequence variant. The size of the node reflects frequency of the corresponding variant in the population. This network includes all of the links in any minimum spanning tree. The time interval between each time point is ~2 months.</p