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

Obeticholic acid for the treatment of non-alcoholic steatohepatitis: interim analysis from a multicentre, randomised, placebo-controlled phase 3 trial

Background Non-alcoholic steatohepatitis (NASH) is a common type of chronic liver disease that can lead to cirrhosis. Obeticholic acid, a farnesoid X receptor agonist, has been shown to improve the histological features of NASH. Here we report results from a planned interim analysis of an ongoing, phase 3 study of obeticholic acid for NASH. Methods In this multicentre, randomised, double-blind, placebo-controlled study, adult patients with definite NASH,non-alcoholic fatty liver disease (NAFLD) activity score of at least 4, and fibrosis stages F2–F3, or F1 with at least oneaccompanying comorbidity, were randomly assigned using an interactive web response system in a 1:1:1 ratio to receive oral placebo, obeticholic acid 10 mg, or obeticholic acid 25 mg daily. Patients were excluded if cirrhosis, other chronic liver disease, elevated alcohol consumption, or confounding conditions were present. The primary endpointsfor the month-18 interim analysis were fibrosis improvement (≥1 stage) with no worsening of NASH, or NASH resolution with no worsening of fibrosis, with the study considered successful if either primary endpoint was met. Primary analyses were done by intention to treat, in patients with fibrosis stage F2–F3 who received at least one dose of treatment and reached, or would have reached, the month 18 visit by the prespecified interim analysis cutoff date. The study also evaluated other histological and biochemical markers of NASH and fibrosis, and safety. This study is ongoing, and registered with ClinicalTrials.gov, NCT02548351, and EudraCT, 20150-025601-6. Findings Between Dec 9, 2015, and Oct 26, 2018, 1968 patients with stage F1–F3 fibrosis were enrolled and received at least one dose of study treatment; 931 patients with stage F2–F3 fibrosis were included in the primary analysis (311 in the placebo group, 312 in the obeticholic acid 10 mg group, and 308 in the obeticholic acid 25 mg group). The fibrosis improvement endpoint was achieved by 37 (12%) patients in the placebo group, 55 (18%) in the obeticholic acid 10 mg group (p=0·045), and 71 (23%) in the obeticholic acid 25 mg group (p=0·0002). The NASH resolution endpoint was not met (25 [8%] patients in the placebo group, 35 [11%] in the obeticholic acid 10 mg group [p=0·18], and 36 [12%] in the obeticholic acid 25 mg group [p=0·13]). In the safety population (1968 patients with fibrosis stages F1–F3), the most common adverse event was pruritus (123 [19%] in the placebo group, 183 [28%] in the obeticholic acid 10 mg group, and 336 [51%] in the obeticholic acid 25 mg group); incidence was generally mild to moderate in severity. The overall safety profile was similar to that in previous studies, and incidence of serious adverse events was similar across treatment groups (75 [11%] patients in the placebo group, 72 [11%] in the obeticholic acid 10 mg group, and 93 [14%] in the obeticholic acid 25 mg group). Interpretation Obeticholic acid 25 mg significantly improved fibrosis and key components of NASH disease activity among patients with NASH. The results from this planned interim analysis show clinically significant histological improvement that is reasonably likely to predict clinical benefit. This study is ongoing to assess clinical outcomes

Outcome of coronary angiography and percutaneous coronary intervention in Egyptian women with chronic stable angina

AbstractBackgroundA suboptimal degree of attention has focused on the detection and management of coronary artery disease (CAD) in women until recently. We sought out to study the anatomy of coronary arteries in women by the means of coronary angiography in comparison to men. The results of percutaneous coronary intervention (PCI) and in hospital outcomes were studied and compared to men.MethodsThe study included 488 female and 492 male patients with chronic stable angina undergoing coronary angiography±PCI taken consecutively. The angiographic results, interventional details and procedural success, and related complications were collected and statistically analyzed.ResultsFemale patients had similar coronary risk factors with higher incidence of diabetes mellitus and lower history of smoking. The likelihood of non-atherosclerotic affliction of the coronaries was 47% in women vs. 25.5% in men (P<0.001). The prevalence of multivessel affliction and more complex lesions were significantly lower in the female patients compared to their male counterparts (P<0.001). Female patients had lower rate of PCI procedures and lower number of stents implanted (P<0.001) including drug eluting stents. The success rates were similar in both the sexes, with relatively higher complication rate in the female group.ConclusionEgyptian women have generally similar risk profile to male patients with CAD and tend to receive less aggressive therapy. They showed less severe coronary atherosclerosis than men and potentially have lower PCI procedures with similar acute success rates and relatively higher procedure-related complications

Water treatment technologies in removing heavy metal ions from wastewater: A review

The scarcity of clean water resources leads to many scientific and technological advancements in wastewater treatment processes. The recalcitrance of heavy metals in wastewater has been proven to be a challenging concern. Therefore, there is a need for more water treatment technologies to completely remove heavy metals down to a non-hazardous level. In this article, current development in recent waste-water treatment technologies to remove heavy metals has been reviewed and summarized. This review evaluates the state-of-the-art removal processes, including chemical precipitation, photocatalysis, flotation, ion exchange, remediation, electrochemical treatment, adsorption, membrane technologies, and coagulation/flocculation. These processes are leading technologies with industrial efficiency and practical feasibility. In general, the key factors in selecting the most appropriate process for wastewater treatment are the cost required and characteristics of wastewater plus the applicability of the process

Angiographic patterns of coronary sinus anatomy and its relation to successful ablation sites in accessory pathway patients

AbstractBackgroundThe epicardial coronary venous system assumes importance in accessory pathway (AP) ablation especially in case of lengthy or failed attempts of ablation. Epicardial accessory pathways may be related to CS myocardial coat along one of its tributaries or to a CS diverticulum. The purpose of the present study was to use CS angiography to evaluate the relation of different patterns of CS anatomy to successful ablation sites of APs.Methods and resultsThe CS-angiographic features and incidence of structural anomalies were prospectively studied in 56 patients undergoing AP radiofrequency ablation. Retrograde CS angiography was successfully performed in 46/56pt (82%), (33 males/13 females). The CS angiographic findings of the 46 patients were compared to the AP localization established by electrophysiological mapping and to the successful ablation sites. CS anomalies were identified in 17 (37%) patients and included the following: CS diverticulum (seven patients), funnel shaped ostium (three patients), CS aneurysm (two patients), subthebasian pouch (one patient), sharp angulation (one patient), and bulbous malformation (one patient). CS diverticuli represented (41%) of the encountered CS anomalies. Seventy-one percent of the CS diverticuli were seen in posteroseptal and left posterior locations of APs. Successful ablation site was related to CS-anomalies in seven (15.2%) patients (five patients with CS diverticulum, one patient with CS aneurysm, and one patient with CS angulation). Successful ablation was achieved from within the CS (coronary sinus – accessory pathway) (CS AP) in 10 patients (21.7%) (in relation to CS tributary in six (13%) and in relation to the neck of a CS diverticulum in four patients). CS AP represented 50% of the encountered posteroseptal and left posterior APs.ConclusionCS angiography can guide us in reaching successful ablation sites of AP inside or outside the CS. CS diverticulum is the most common CS anomaly in posteroseptal and left posterior APs