SummaryBackgroundSurgical 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.MethodsThis 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.FindingsBetween 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).InterpretationCountries 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.FundingDFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant,...

ObjectivesThis study examined the attitudes of nurses and doctors to key patient safety concepts, evaluated differences and similarities between professional groups and assessed positive and negative attitudes to identify target areas for future training.SettingFour major governmental hospitals in the Gaza-Strip.ParticipantsA convenience sample of 424 nurses and 150 physicians working for at least 6 months in the study hospitals.Primary and secondary outcome measuresThe primary outcome measures were mean scores with SD as measured for individual items and nine main patient safety domains assessed by the Attitudes to Patient Safety Questionnaire. Secondary outcome measures were the proportions of doctors and nurses, that gave a positive response to each item, represented as percentage of each group.ResultsNurses and doctors held moderately positive attitudes towards patient safety with five out of nine domain scores >3.5 of 5. Doctors showed slightly more positive attitudes than nurses, despite a smaller proportion of doctors having received patient safety training with 37.5% compared with 41.9% of nurses. Both professions displayed their most positive patient safety attitudes in the same domains (‘team functioning’ and ‘working hours as a cause for error’), as well as their two most negative attitudes (‘importance of patient safety in the curriculum’ and ‘professional incompetence as a cause of error’), demonstrating significant deficits in understanding medical errors. A specific challenge will be the negative attitudes of both professions towards patient safety training for wider dissemination of this content in the postgraduate curriculum.ConclusionPatient safety attitudes were moderately positive in both professional groups. Target of future patient safety training should be enhancing the understanding of error in medicine. Any training has to be motivating and relevant for clinicians, demonstrating its importance in ongoing professional learning.

Objectives Cancer is the second leading cause of death in the Gaza Strip, Palestine, but there is an absence of evidence systematically assessing symptom burden and quality of life (QoL) using validated tools. Our objective was to assess associations between socio-demographic and disease-related characteristics, symptom burden and QoL in a sample of cancer patients accessing outpatient services in the Gaza Strip. Design A cross-sectional, descriptive survey using interviews and medical record review involving patients with cancer accessing oncology outpatient services at Al Rantisi Hospital and European Gaza Hospital (EGH) in the Gaza Strip was employed. Socio-demographic and disease-related data, the Lebanese version of the Memorial Symptom Assessment Scale (MSAS-Leb), and the Arabic version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) were collected. Multiple linear regression was used to judge the relative influence of determinants of QoL. Results Of 414 cancer patients approached, 385 patients consented to participation. The majority were women (64.7%) with a mean age of 52 years (SD = 16.7). Common cancer diagnoses were breast (32.2%), haematological (17.9%) and colorectal (9.1%). The median number of symptoms was 10 (IQR 1.5–18.5). Mean overall QoL was 70.5 (SD 19.9) with common physical and psychological symptoms identified. A higher burden of symptoms was associated with marital status, education and income. Limited access to both opioids and psychological support were reported. Conclusions A high symptom burden was identified in outpatients with cancer. Increasing provision and access to supportive care for physical and psychological symptoms should be prioritised alongside exploring routine assessment of symptom burden and QoL.

Background Patient safety is important, as in increasingly complex medical systems, the potential for unintended harm to patients also increases. This study assessed the attitudes of doctors in the Gaza Strip towards patient safety and medical error. It also explored variables that impacted their attitudes. Methods Doctors, working for at least 6 months in one of the four major government hospitals of the Gaza Strip, were invited to complete a 28-item, self-administered Arabic version of the Attitudes to Patient Safety Questionnaire III (APSQ-III); which assessed patient safety attitudes over nine domains, independent of the workplace. Results A total of 150 doctors from four government hospitals participated in this study, representing 43.5% of all 345 doctors working in the four study hospitals at the time of the study. The mean age was 36.6 (±9.7) years. The majority (72.7%) were males, 28.7% worked in surgical, 26.7% in pediatric, 23.3% in medical, 16.7% in obstetrics and gynecology, and 4.7% in other departments. Most participants (62.0%) had never received patient safety training. The overall APSQ score was 3.58 ± 0.3 (of a maximum of 5). The highest score was received by the domain “Working hours as a cause of errors” (4.16) and the lowest score by “Importance of Patient Safety in the Curriculum” (3.25). Older doctors with more professional experience had significantly higher scores than younger doctors (p = 0.003), demonstrating more positive attitudes toward patient safety. Furthermore, patient safety attitudes became more positive with increasing years of experience in some domains. However, no significant impact on overall APSQ scores was found by workplace, specialty or whether the participants had received previous training about patient safety. Conclusion Doctors in Gaza demonstrated relatively positive patient safety attitudes in areas of “team functioning” and “working hours as a cause for error”, but neutral attitudes in understanding medical error or patient safety training within the curriculum. Patient safety concepts appear to be acquired by doctors via informal learning over time in the job. Inclusion of such concepts into formal postgraduate curricula might improve patient safety attitudes among younger and less experienced doctors, support behaviour change and improve patient outcomes.

Background For patients with breast cancer, the quality of care following mastectomy should be designed with long-term goals to ensure the physical and psychosocial wellbeing of survivors. This study explores the impact of mastectomy on the quality of life of breast cancer survivors in the Gaza Strip. Methods This cross-sectional study involved the only two oncology centres of the Gaza Strip. In total, 173 patients who had undergone mastectomy were chosen using convenience sampling. Upon their arrival at the oncology centres (a minimum of 3 months after mastectomy), the patients completed face-to-face questionnaires made up of five sections: sociodemographic data, physical, psychological, and social wellbeing, and family dynamics. Data were collected from August, 2015, to September, 2016. SPSS software (version 21) was used for data analysis. Ethics approval was obtained from the Palestinian Ministry of Health.