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,...

BackgroundEarly temporal artery biopsy is recommended in all patients with suspected cranial GCA (Giant Cell Arteritis) by the BSR (British Society of Rheumatology) and BHPR (British Health Professionals in Rheumatology) guidelines. This should be performed within one week ideally.AimTo assess ACR (American College of Rheumatology) score at presentation and whether temporal artery biopsy result affects clinical management of the clinically suspected GCA patient.MethodCase records of all temporal artery biopsies performed within January 2012 until December 2014 were analysed for size and result of biopsy and this was correlated to clinical management following result.Results129 temporal arteries were biopsied with a total of 17 positive biopsy results. 10 biopsy samples were insufficient to confirm or refute GCA. 8 patients within the biopsies negative for GCA had their prednisolone therapy stopped. 5 patients had unknown follow up, with the remainder (89, 87.3%) of the patients continued prednisolone management for treatment of GCA for at least 6 weeks.ConclusionOverall 13.2% of our biopsies were positive for GCA and 87.3% of biopsy negative patients continued prednisolone therapy on clinical grounds. In the face of new diagnostic tests (high resolution MRI (Magnetic Resonance Imaging), colour duplex USS (Ultra Sound Scan) and PET (Positive Emission Topography) can we justify invasive surgery to all patients on histological grounds when the results may not alter management? Further investigation is needed directly comparing newer imaging modalities to histology.

No abstract

Aim The purpose of this study was to evaluate whether patients with a high BMI can undergo safe day case LC for cholecystitis compared to groups of patients with a lower BMI. Setting NHS District General Hospital, UK. Methods A retrospective review of 2391 patients who underwent an attempted day case LC between 1 January 2009 and 15 August 2015 was performed. Patients were divided into five groups depending on their BMI. Inclusion criteria were patients undergoing elective day case laparoscopic cholecystectomy with cholecystitis on histology. The endpoints were complication requiring readmission and postoperative length of stay (LOS). Results There were 2391 LCs performed in the time period of which 1646 were eligible for inclusion. These LCs were classified as 273 (16.9%), 608 (37.8%), 428 (26.6%), 208 (12.9%), and 91 (5.66%) patients in the groups with BMI values of 18.5–24.9, 25–29.9, 30–34.9, 35–39.9, and >40, respectively. Average BMI was 30.0 (±5.53, 19–51) with an average postoperative LOS of 0.86, and there was no difference between the BMI groups. Overall complication rate was 4.3%; there was no significance between BMI groups. Conclusions Increased BMI was not associated with worse outcomes after day case LC.

Most TED stockings do not produce a standardised Siegel profile pressure gradient decrease from ankle to calf. This may be due in part to fluid changes after surgery in combination with the large variation in size of lower limbs. Our District general hospital utilises three of the six sizes of TED stocking, and remeasurement was not taking place every 24 h as per guidance. This as the result show not only negates the benefit of TED stockings but may also exert harm in terms of venous thromboembolism risk. This finding adds further weight to the argument of whether TED stockings may not be having the desired prophylactic effect and may even be resulting in harm in select cases.