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,...

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Purpose: Micro-ultrasound is a novel high resolution ultrasound technology aiming to improve prostate imaging and, consequently, the diagnostic accuracy of ultrasound-guided prostate biopsy. Micro-ultrasoundeguided prostate biopsy may present comparable detection rates to the standard of care multiparametric magnetic resonance imaging-targeted prostate biopsy for the diagnosis of clinically significant prostate cancer. We aimed to compare the detection rate of micro-ultrasound vs multiparametric magnetic resonance imaging-targeted prostate biopsy for prostate cancer diagnosis. Materials and Methods: We performed a systematic review and meta-analysis of diagnostic accuracy studies comparing micro-ultrasoundeguided prostate biopsy to multiparametric magnetic resonance imaging-targeted prostate biopsy as a reference standard test (PROSPERO ID: CRD42020198326). Records were identified by searching in PubMedÒ, ScopusÒ and Cochrane Library databases, as well as in potential sources of gray literature until November 30th, 2020. Results: We included 18 studies in the qualitative and 13 in the quantitative synthesis. In the quantitative synthesis, 1,125 participants received micro-ultrasoundeguided followed by multiparametric magnetic resonance imaging-targeted and systematic prostate biopsy. Micro-ultrasound and multiparametric magnetic resonance imaging-targeted prostate biopsies displayed similar detection rates across all prostate cancer grades. The pooled detection ratio for International Society of Urological Pathology Grade Group !2 prostate cancer was 1.05 (95% CI 0.93e1.19, I 2 [0%), 1.25 (95% CI 0.95e1.64, I 2 [0%) for Grade Group !3 and 0.94 (95% CI 0.73e1.22, I 2 [0%) for clinically insignificant (Grade Group 1) prostate cancer. The overall detection ratio for prostate cancer was 0.99 (95% CI 0.89e1.11, I 2 [0%). Conclusions: Micro-ultrasoundeguided prostate biopsy provides comparable detection rates for prostate cancer diagnosis with the multiparametric magnetic resonance imaging-guided prostate biopsy. Therefore, it could be considered as an attractive alternative to multiparametric magnetic resonance imaging-targeted prostate biopsy. Nevertheless, high quality randomized trials are warranted to corroborate our findings.

Background There is lack of evidence-based optimization of the protocol for low-intensity shockwave therapy for erectile dysfunction. Furthermore, the safety and efficacy of repeating shockwave therapy have not been explored. Aim To compare the efficacy and safety of 6 and 12 treatment sessions within a 6-week treatment period and investigate the effect of repeat treatment after a 6-month period in a 2-phase study. Methods Patients with vasculogenic erectile dysfunction that responded to phosphodiesterase type 5 inhibitors were randomized into 2 groups: low-intensity shockwave therapy sessions once (group A, n = 21) or twice (group B, n = 21) per week for 6 consecutive weeks (phase 1). Patients who completed 6-month follow-up were offered 6 additional sessions (phase 2); group A received 2 sessions per week and group B received 1 session per week. Patients were followed for 6 months. Outcomes International Index for Erectile Function erectile function domain (IIEF-EF) score, minimally clinical important differences (MCIDs), Sexual Encounter Profile question 3 (SEP3) score, and triplex ultrasonographic parameters. Results In phase 1, groups A and B showed improvement in IIEF-EF score, MCID, SEP3 score, and mean peak systolic velocity compared with baseline. MCIDs were achieved in 62% of group A and 71% of group B, and the percentage of yes responses to SEP3 was 47% in group A and 65% in group B (P = .02). Mean peak systolic velocity at baseline and at 3-month follow-up were 29.5 and 33.4 cm/s for group A and 29.6 and 35.4 cm/s for group B (P = .06). In phase 2, group A showed a greater increase in the percentage of yes responses to SEP3 (group A = +14.9; group B = +0.3). When the impact of the total number of sessions received was examined, MCIDs in IIEF-EF score from baseline were achieved in 62%, 74%, and 83% of patients after 6, 12, and 18 sessions, respectively. No treatment-related side effects were reported. Clinical Implications The total number of low-intensity shockwave therapy sessions affects the efficacy of erectile dysfunction treatment. Retreating patients after 6 months could further improve erectile function without side effects. 12 sessions can be delivered within 6 weeks without a 3-week break period. Strengths and Limitations This study lacked a sham-controlled arm. However, all patients were randomized to different groups, and baseline characteristics were similar between groups. Also, all patients were confirmed by triplex ultrasonography to have arterial insufficiency. Conclusion Patients can benefit more in sexual performance from 12 sessions twice per week compared with 6 sessions once a week. Shockwave therapy can be repeated up to a total of 18 sessions.

This systematic review and meta-analysis compares the outcomes of monotherapy and combination treatments according to self-reports of erectile function by men with erectile dysfunction.

Background We evaluated the short‐term outcomes of robotic colorectal cancer surgery in octogenarian patients, focussing on postoperative morbidity and survival. Methods All patients ≥80 years in a prospective colorectal cancer database undergoing robotic curative colorectal cancer resection were included. Patient demographics, intraoperative findings, postoperative and oncological outcomes were recorded. Patients were further subdivided into two groups named: old (OG 80–85 years) and very old (VOG ≥ 86 years). Results Fifty‐eight consecutive patients were included (median age, 83 years; male, 53.4%; median BMI, 26.5). Median total operative time was 230 min, median blood loss 20 ml, median length of stay 7 days. Major complications were seen in 12% of patients; and the 90‐day mortality rate was 1.7%. Complete R0 resection achieved in 93% of cases, average lymph node harvest was 22. Overall and disease‐free survival was 81% and 87.3%, respectively (median follow‐up 24.5 months). We noticed a trend towards more advanced lesion staging in the VOG, but only N2 stage was significant (p = 0.03). There was a statistically significant difference in overall survival in favour of the OG (p = 0.024). Conclusions Robotic surgery is feasible in octogenarian patients undergoing curative colorectal cancer resection and is associated with good post‐operative outcomes and overall survival.

The quest for dietary patterns and supplements efficient in down-regulating prostate-specific antigen (PSA) concentrations among men with prostate cancer (PCa) or increased PCa risk has been long. Several antioxidants, including lycopene, selenium, curcumin, coenzyme Q10, phytoestrogens (including isoflavones and flavonoids), green tea catechins, cernitin, vitamins (C, E, D) and multivitamins, medicinal mushrooms (Ganoderma lucidum), fruit extracts (saw palmetto, cranberries, pomegranate), walnuts and fatty acids, as well as combined supplementations of all, have been examined in randomized controlled trials (RCTs) in humans, on the primary, secondary, and tertiary PCa prevention level. Despite the plethora of trials and the variety of examined interventions, the evidence supporting the efficacy of most dietary factors appears inadequate to recommend their use.

Background Sexual dysfunction is relatively common in young men, presenting in diverse manifestations, including erectile dysfunction (ED), for which dietary modifications, including increased intake of dietary antioxidants, have been suggested as promising and cost-efficient approaches. Aim To assess the consumption of selected dietary antioxidants, in particular flavonoids, in relation to ED symptoms in young men. Methods Men 18 to 40 years old were invited to complete an anonymous web-based questionnaire for this case-control study. ED was diagnosed with the International Index of Erectile Function (IIEF) and flavonoid intake was recorded using food-frequency questionnaires, with an emphasis on flavonoid-rich foods such as coffee, fruits, etc. Participants without ED (IIEF score ≥ 26; n = 264) formed the control group and those with ED (IIEF score &lt; 26; n = 86) formed the case group. Outcomes Dietary flavonoid intake. Results Men with ED reported a lower median monthly intake of total flavonoids (−2.18 g, 95% CI = −3.15 to −1.21, P &lt; .001) and all flavonoid subclasses (P &lt; .001) compared with controls. Adjustment of intake for age and body mass index showed that consumption of flavonoids 50 mg/day lowered the risk for ED by 32% (odds ratio = 0.68, 95% CI = 0.55–0.85, P &lt; .001). Of all recorded flavonoids, flavones appeared to contribute the most to healthy erectile function. Controls reported a greater consumption of vegetables and fruits, a lower intake of dairy and alcoholic beverages, and a less intense smoking habit compared with cases (P &lt; .001). Clinical Implications Increased intake of fruits, vegetables, and flavonoids decreases the risk of ED in young men. Strength and Limitations The strength of this study stems from the innovative hypothesis, the young age of participants, and the suggested therapeutic effects of cheap dietary components against ED. Limitations include the relatively small sample and cross-sectional design. Conclusion Low flavonoid—in particular flavone—intake is associated with ED in young adult men.