Результаты внедрения новой формы управляемой самостоятельной работы студентов в учебный процесс на кафедре патофизиологии

МЕДИЦИНСКИЕ ИНСТИТУТЫОБУЧЕНИ

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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Attrition of TCR Va7.2+CD161++ MAIT Cells in HIV-Tuberculosis Co-Infection Is Associated with Elevated Levels of PD-1 Expression

Mucosal-associated invariant T (MAIT) cells are evolutionarily conserved antimicrobial MR1-restricted CD8+ T cells co-expressing the semi-invariant TCR V alpha 7.2, and are numerous in the blood and mucosal tissues of humans. MAIT cells appear to undergo exhaustion in chronic viral infections. However, their role in human immunodeficiency virus type 1 (HIV1) mono-infection and HIV/tuberculosis (TB) co-infection have seldom been elaborately investigated. We conducted a cross-sectional study to investigate the frequencies and phenotypes of CD161++ CD8+ T cells among anti-retroviral therapy (ART)/anti-TB therapy (ATT) treatment-naive HIV/TB co-infected, ART/TB treated HIV/TB co-infected, ART naive HIV-infected, ART-treated HIV-infected patients, and HIV negative healthy controls (HCs) by flow cytometry. Our data revealed that the frequency of MAIT cells was severely depleted in HIV mono-and HIV/TB co-infections. Further, PD-1 expression on MAIT cells was significantly increased in HIV mono-and HIV-TB co-infected patients. The frequency of MAIT cells did not show any significant increase despite the initiation of ART and/or ATT. Majority of the MAIT cells in HCs showed a significant increase in CCR6 expression as compared to HIV/TB co-infections. No marked difference was seen with expressions of chemokine co-receptor CCR5 and CD103 among the study groups. Decrease of CCR6 expression appears to explain why HIV-infected patients display weakened mucosal immune responses.Funding Agencies|High Impact Research [UM.C/625/1/HIR/MOHE/MED/014]; University of Malaya Research of the Health and Translational Medicine Research Cluster [RP021A-13HTM, RG448-12HTM]; Swedish Research Council [AI52731]; Swedish Physicians against AIDS Research Foundation; Swedish International Development Cooperation Agency; SIDA SARC; VINNMER for Vinnova; Linkoping University Hospital Research Fund; CALF; Swedish Society of Medicine</p

Demographic, clinical and laboratory characteristics of study participants.

<p>Footnotes: Statistical analyses performed using (A) Fisher’s Exact test and (B) Kruskal-Wallis non-parametric ANOVA test:</p><p>*p<0.05</p><p>**p<0.01</p><p>***p<0.001</p><p>CPTN: HIV/TB co-infection treatment naïve; CPTP: HIV/TB co-infection treatment positive; HVTN: HIV mono-infection treatment naïve; HVTP: HIV mono-infection treatment positive; NA: non- applicable. All values are expressed as mean ±SD.</p><p>Demographic, clinical and laboratory characteristics of study participants.</p

Percentage of CD8⁺ T cells expressing CD161⁺⁺ across different study groups.

<p><b>(A)</b> Scatter plots (gated on the CD3⁺ T-cell population) show co-staining with CD8 and CD161 on representative samples from 5 different clinical groups: CPTNs, CPTPs, HVTNs, HVTPs, and HCs. <b>(B)</b> CD161⁺⁺CD8⁺ T (MAIT cell) frequency in HCs showed significantly increased MAIT cell levels compared to other study groups. <b>(C)</b> CD161⁺CD8⁺ T cell frequency showed no difference across the different study groups. <b>(D-E)</b> CD161⁺⁺CD8⁺ MAIT cell frequency in subjects with HIV mono-infection and HIV/TB co-infection shows no significant correlation with either HIV plasma viral load (copies/mL) or CD4⁺ T-cell counts (cells/mm³). All graphs show median (red bars) and range (blue whiskers); <i>P</i> values are reported for two-sided Mann-Whitney tests with threshold for significance <i>P</i> = 0.025 after Bonferroni correction for 2 comparisons. Correlations between MAIT cell frequency and markers of HIV disease progression were assessed using two-tailed non-parametric Spearman’s rank. (Note: TN, treatment naïve; TP, treatment positive; HC, healthy control; CP, HIV/TB co-infection; HV, HIV mono-infection).</p

Profile of expression of CD161 on MAIT cells.

<p><b>(A)</b> The zebra plots depict the gating strategy for the analysis of expression of CD161 on MAIT cells. CD8⁺ T cells were gated for TCR Vα7.2 specific for MAIT cells. After gating on CD8⁺ TCR Vα7.2⁺ MAIT cell population, CD161 expression was subsequently analyzed. <b>(B-C)</b> MAIT cells of HCs showed significant increase of CD161 compared to other infected groups. Conversely, HCs has the lowest amount of CD161^- MAIT cells. All graphs show median (red bars) and range (blue whiskers); <i>P</i> values are reported for two-sided Mann-Whitney tests with threshold for significance <i>P</i> = 0.025 after Bonferroni correction for 2 comparisons. (Note: TN, treatment naïve; TP, treatment positive; HC, healthy control; CP, HIV/TB co-infection; HV, HIV mono-infection).</p

Expression levels of different markers by CD161⁺⁺CD8⁺ T-cell subsets in the study population.

<p><b>(A)</b> Zebra plots of double-gating strategy (gated on the CD161⁺⁺ CD8⁺ T cells) show staining with 4 different markers (CD103, PD-1, CCR6, CCR5) on representative samples from a HC and a CPTN. HCs showed increased amount of CCR6-expressing MAIT cells and decreased amount of PD-1 expressing MAIT cells compared to CPTNs. <b>(B)</b> HC showed significantly lower expression level of inhibitory receptor, PD-1 while HIV/TB co-infected patients show significantly increased PD-1 expressing MAIT cells. <b>(C)</b> Significantly increased CCR6-expressing MAIT cells were found in HCs compared to HIV and TB infected groups. <b>(D)</b> No significant difference was observed in CCR5 expression levels by MAIT cells among the different study subjects. The significant difference in CCR5 expression between HVTPs and HCs may be due to the limited number of samples. All graphs show median (red bars) and range (blue whiskers); <i>P</i> values are reported for two-sided Mann-Whitney tests with threshold for significance <i>P</i> = 0.025 after Bonferroni correction for 2 comparisons. (Note: TN, treatment naïve; TP, treatment positive; HC, healthy control; CP, HIV/TB co-infection; HV, HIV mono-infection).</p