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

One Parameter Composite Semigroups of Linear Bounded Operators in Strong Operator Topology of Schatten Class Cp

For semigroups of linear bounded operators on Hilbert spaces, the problem of being in Cp , 0 Keyword

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Comparative Effects of MMT Clay Modified with Two Different Cationic Surfactants on the Thermal and Rheological Properties of Polypropylene Nanocomposites

Polypropylene montmorillonite (MMT) nanocomposites were prepared by melt blending using two different organoclays modified with imidazolium and alkylammonium surfactants. The imidazolium and ammonium modified organoclays were characterized by the FTIR and SEM analysis. The effect of organic clay (MMT) on the physical properties of polypropylene was evaluated, thermal and rheological properties with different filler weight percentage. Differential scanning calorimetric results showed that imidazolium modified clay (IMMT) exhibits low melting temperature compared to the ammonium modified clay (AMMT). The crystallinity analysis showed that crystallization improved in all nanocomposites irrespective of surface modification; the thermogravimetric analysis showed that the imidazolium modified polymer composites are more thermally stable than conventional ammonium modified composites. The Transmission Electron Microscopy (TEM) analyses indicated that the PP-IMMT composites displayed exfoliated morphologies compared with the intercalated structure in PP-AMMT, and the rheological analysis at 180°C showed an enhancement in the viscoelastic properties as the clay concentration increases. The melt viscosity, crossover modulus, and relaxation times were comparable for both the surface modified composites with two different cations. The imidazolium based surfactant was found to be an effective organic modification for MMT to prepare thermally stable PP/MMT nanocomposites

The Influence of Nano CaCO3 on Nucleation and Interface of PP Nano Composite: Matrix Processability and Impact Resistance

Polypropylene (PP) is a commodity material that has been increasingly used in different industries in the past two decades due to its versatile properties when enhanced with additives. Homo polypropylene, in general, has weak mechanical properties and limited chemical resistance; thus, using a different type of fillers to adjust such properties to fit the required applications opened a large market for this commodity. Understanding the interface constituent between the polymer matrix and the added filler and the nucleation behavior is a key to fine control of the enhancement of PP properties. In this study, PP was incorporated with nano calcium carbonate (CaCO3) at 2 and 5 wt% in the presence of maleic anhydride (MAH) to overcome the weak interface due to low polymer polarity. The mix was compounded in a twin screws extruder at a temperature range of 180–200 °C ; then, the prepared samples were left to dry for 24 h at 25 °C. Nuclear Magnetic Resonance (NMR) was used to study the interface adhesion of the nanofiller and the curved revealed that at 2% of nano CaCO3 PP structure remained the same and the nano experienced good adhesion to the polymer matrix. The mechanical impact resistance results showed a real enhancement to the polymer matrix of the nanocomposite by 37%. Moreover, DSC results showed a faster crystallinity rate due to the nanofiller acting as a nucleating agent and rheology tests indicated that low content of nano additive (2%) has better processability behavior, with suitable viscosity complex values at high frequencies

The Influence of Nano CaCO3 on Nucleation and Interface of PP Nano Composite: Matrix Processability and Impact Resistance

Polypropylene (PP) is a commodity material that has been increasingly used in different industries in the past two decades due to its versatile properties when enhanced with additives. Homo polypropylene, in general, has weak mechanical properties and limited chemical resistance; thus, using a different type of fillers to adjust such properties to fit the required applications opened a large market for this commodity. Understanding the interface constituent between the polymer matrix and the added filler and the nucleation behavior is a key to fine control of the enhancement of PP properties. In this study, PP was incorporated with nano calcium carbonate (CaCO3) at 2 and 5 wt% in the presence of maleic anhydride (MAH) to overcome the weak interface due to low polymer polarity. The mix was compounded in a twin screws extruder at a temperature range of 180–200 °C ; then, the prepared samples were left to dry for 24 h at 25 °C. Nuclear Magnetic Resonance (NMR) was used to study the interface adhesion of the nanofiller and the curved revealed that at 2% of nano CaCO3 PP structure remained the same and the nano experienced good adhesion to the polymer matrix. The mechanical impact resistance results showed a real enhancement to the polymer matrix of the nanocomposite by 37%. Moreover, DSC results showed a faster crystallinity rate due to the nanofiller acting as a nucleating agent and rheology tests indicated that low content of nano additive (2%) has better processability behavior, with suitable viscosity complex values at high frequencies.</jats:p

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe