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,...
This study suggests that acculturation has different effects on drinking for men and women. This finding needs some attention as literature also indicates that women drink more and may develop more alcohol-related problems as they acculturate. This increase in women's drinking is probably because of U.S. society's more liberal norms governing female drinking. The "bimodal" distribution of risk, in which only men in "very Anglo" group are at a lower risk than the others, may be unique to the Border. The association between acculturation and alcohol use disorders does not appear to be linear and the effect of acculturation is not uniform on individuals' drinking behavior.
Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov , NCT03471494 . Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.
This study describes the prevalence of alcohol and drug use, abuse, and dependence among adults on the Texas-Mexico border in 2002-2003. The findings are based on survey responses from a random sample of 1,200 adults living in households in three communities: El Paso, a densely populated city in west Texas; the less dense urbanized areas of the lower Rio Grande Valley in south Texas; and rural or semirural colonias—unregulated settlements characterized by lack of basic public services—in south Texas. The findings revealed similarity in drug use across the three sites but higher rates of binge drinking and alcohol dependence in the colonias. Border alcohol and drug use appeared similar or lower than use among residents of Texas as a whole or Hispanics nationwide; however, problems of abuse and dependence appeared somewhat higher on the border.
Background Public health emergencies like epidemics put enormous pressure on health care systems while revealing deep structural and functional problems in the organization of care. The current coronavirus disease (COVID-19) pandemic illustrates this at a global level. The sudden increased demand on delivery systems puts unique pressures on pre-established care pathways. These extraordinary times require efficient tools for smart governance and resource allocation. Objective The aim of this study is to develop an innovative web-based solution addressing the seemingly insurmountable challenges of triaging, monitoring, and delivering nonhospital services unleashed by the COVID-19 pandemic. Methods An adaptable crisis management digital platform was envisioned and designed with the goal of improving the system’s response on the basis of the literature; an existing shared health record platform; and discussions between health care providers, decision makers, academia, and the private sector in response to the COVID 19 epidemic. Results The Crisis Management Platform was developed and offered to health authorities in Ontario on a nonprofit basis. It has the capability to dramatically streamline patient intake, triage, monitoring, referral, and delivery of nonhospital services. It decentralizes the provision of services (by moving them online) and centralizes data gathering and analysis, maximizing the use of existing human resources, facilitating evidence-based decision making, and minimizing the risk to both users and providers. It has unlimited scale-up possibilities (only constrained by human health risk resource availability) with minimal marginal cost. Similar web-based solutions have the potential to fill an urgent gap in resource allocation, becoming a unique asset for health systems governance and management during critical times. They highlight the potential effectiveness of web-based solutions if built on an outcome-driven architecture. Conclusions Data and web-based approaches in response to a public health crisis are key to evidence-driven oversight and management of public health emergencies.
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