Antibiotic lock solutions as adjunct therapy for catheter-related blood stream infections in pediatric hemodialysis patients

The predominant use of intravenous catheters as primary access type in the pediatric hemodialysis population is associated with an increased risk of catheter related blood stream infections. While strict adherence to catheter placement and long-term care guidelines have helped to decrease the incidence of these infections, blood stream infections remain an infection burden in pediatric patients with long term hemodialysis catheters. The formation of biofilms on the surfaces of these catheters has been shown to be a source of microbes causing blood stream infections. One of the strategies for preventing bacterial colonization, inhibiting microbial multiplication, and suppressing the seeding of these microbes from biofilms upon maturation, has been the use of antibiotic-based lock solutions in-between dialysis treatments. Although clinical guidelines for the use of antibiotic lock solutions are yet to be developed, available evidence suggests a beneficial role of antibiotic lock solutions in the management of catheter related blood stream infections. Additionally, a clear understanding of how biofilms are formed and their role in the pathogenesis of catheter related bloodstream infection will facilitate the development of solutions that can prevent biofilm formation and inhibit their multiplication, maturation and seeding into the bloodstream.

Splenic artery embolisation for blunt splenic trauma: 10 years of practice at a trauma centre

INTRODUCTION

Splenic artery embolisation (SAE) has transformed the management of splenic trauma. The aim of this study was to review the outcomes and postprocedural management of blunt splenic trauma patients treated with SAE at a trauma centre over a 10-year period.

METHODS

Details of patients undergoing SAE for blunt trauma between January 2012 and January 2022 were acquired from a prospectively maintained database. Patient records were reviewed for demographic information, splenic injury grades, embolisation efficacy, complications, and associated injuries and mortality. Data relating to Injury Severity Scores (ISS) and postprocedural practice (vaccinations, antibiotic prescribing, follow-up imaging) were also obtained.

RESULTS

Thirty-six patients (24 male, 12 female) with a median age of 42.5 years (range 13-97 years) were identified. American Association for the Surgery of Trauma splenic injury grades were III (n = 7), IV (n = 20) and V (n = 9). Seventeen patients had isolated splenic injury and 19 had additional injuries to other organ systems. Median ISS was 18.5 (range 5-50). SAE succeeded first time in 35/36 cases, and upon the second attempt in 1/36 cases. No patients died because of splenic injury or SAE although four patients with polytrauma died owing to other injuries. SAE complications occurred in 4/36 cases. For survivors, vaccinations were administered in 17/32 cases, and long-term antibiotics were initiated in 14/32 cases. Formal follow-up imaging was arranged in 9/32 cases.

CONCLUSIONS

These data show that SAE is an effective means of controlling splenic haemorrhage secondary to blunt trauma with no patient requiring subsequent laparotomy. Major complications occurred in 11% of cases. Follow-up practice varied regarding further imaging, antibiotic and vaccination administration.

A tale of two unconventional adult diaphragmatic hernias

Diaphragmatic hernias can be congenital or acquired and are a protrusion of intra-abdominal contents through an abnormal opening in the diaphragm. Acquired defects are rare and occur secondary to direct penetrating injury or blunt abdominal trauma. This case review demonstrates two unconventional cases of large diaphragmatic hernias with viscero-abdominal disproportion in adults. Case 1 is a 27-year-old man with no prior medical or surgical history. He presented following a 24-h history of increasing shortness of breath and left-sided pleuritic chest pain, and no history of trauma. Chest X-ray demonstrated loops of bowel within the left hemithorax with displacement of the mediastinum to the right. Computed tomography (CT) scan confirmed a large diaphragmatic defect causing herniation of most of his abdominal contents into the left hemithorax. He underwent emergency surgery, which confirmed the viscero-abdominal disproportion. He required an extended right hemicolectomy to reduce the volume of the abdominal comtents and laparostomy to reduce the risk of abdominal compartment syndrome and recurrence of the hernia. Case 2 is a 76-year-old man with significant medical comorbidities who presented with acute onset of abdominal pain. He had a history of traumatic right-sided chest injury as a child resulting in right-sided diaphragmatic paralysis. Chest X-ray demonstrated a large right-sided diaphragmatic hernia with abdominal viscera in the right thoracic cavity. CT scan of the chest, abdomen and pelvis demonstrated both small and large bowel loops within the right hemithorax, compression of the right lung and displacement of the mediastinum to the left. The CT scan also demonstarted viscero-abdominal disproportion. Operative management was considered initially but following improvement with basic medical management and no further deterioration, a non-operative approach was adopted. Both cases illustrate atypical presentations of adults with diaphragmatic hernias. In an ideal scenario, these are repaired surgically. When the presumed diagnosis shows characteristics of a viscero-abdominal disproportion and surgery is pursued, the surgeon must consider that primary abdominal closure may not be possible and multiple operations may be necessary to correct the defect and achieve closure. Sacrifice of abdominal viscera may also be necessary to reduce the volume of abdominal contents.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Total neoadjuvant chemotherapy: a silver lining during the COVID pandemic for a patient with locally advanced diffuse distal gastric adenocarcinoma

Perioperative oncological therapies resulting in pathological complete response (pCR) in diffuse-type distal gastric adenocarcinoma are extremely rare. We report a case of locally advanced (cT3 N2 M0) diffuse-type distal gastric adenocarcinoma treated with 'total neoadjuvant' FLOT (eight cycles), due to the COVID-19 pandemic, and laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy. The patient demonstrated a progressive radiological response on positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography (¹⁸F-FDG PET-CT) and pCR in the resected specimen (ypT0 N0). As far as we are aware, this is the first case of pCR in locally advanced T3 N2 diffuse distal gastric cancer to be reported in the literature. It introduces a novel approach of total neoadjuvant chemotherapy with ¹⁸F-FDG PET-CT to assess response, combined with radical minimally invasive surgical management to provide optimal care for patients with gastric cancer.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Follow-up after emergency laparotomy suggests high one- and five-year mortality with risk stratified by ASA

INTRODUCTION

We investigated all-cause mortality following emergency laparotomy at 1 and 5 years. We aimed to establish a basis from which to advise patients and relatives on long-term mortality.

METHODS

Local data from a historical audit of emergency laparotomies from 2010 to 2012 were combined with National Emergency Laparotomy Audit (NELA) data from 2017 to 2020. Covariates collected included deprivation status, preoperative blood work, baseline renal function, age, American Society of Anesthesiologists (ASA) grade, operative time, anaesthetic time and gender. Associations between covariates and survival were determined using multivariate logistic regression and Kaplan-Meier analysis. We used patients undergoing laparoscopic cholecystectomy between 2015 and 2020 as controls.

RESULTS

ASA grade was the best discriminator of long-term outcome following laparotomy (n=894) but was not a predictor of survival following cholecystectomy (n=1,834), with mortality being significantly greater in the laparotomy group. Following cholecystectomy, 95% confidence intervals for survival at 5 years were 98-99%. Following laparotomy these intervals were: ASA grade 1, 79-96%; ASA grade 2, 69-82%; ASA grade 3, 44-58%; ASA grade 4, 33-48%; and ASA grade 5, 4-51%. The majority of deaths occurred after 30 days.

CONCLUSIONS

Emergency laparotomy is associated with a significantly increased risk of death in the following 5 years. The risk is strongly correlated to ASA grade. Thirty-day mortality estimation is not a good basis on which to advise patients and carers on long-term outcomes. ASA grade can be used to predict long-term outcomes and to guide patient counsel.

Preparation, spectral study and antimicrobial activity of binary Co(II) complexes derived from 2’-hydroxy chalcones

ABSTRACT. The present work comprises preparation, characterization, thermal behavior and growth inhibitory activity of some novel Co(II) complexes derived from substituted (E)-1-(1-hydroxy-4-iodonaphthalen-2-yl)-3-phenylprop-2-en-1-one (L1) and (E)-1-(4-bromo-1-hydroxynaphthalen-2-yl)-3-phenylprop-2-en-1-one (L2-L6). Newly synthesized metal-ligand complexes were structurally confirmed with suitable spectroscopic technique such as FT-IR, EPR, NMR (both 1H and 13C). XRD analysis for complex C1 confirmed the crystal system; tetragonal and space group; P 42/n: 2 with unit cell dimensions a, b = 13.3516 Å, c = 10.8009 Å; α, β, γ = 90o. The IR and EPR study demonstrated that interaction between metal ions and ligand occurs through carbonyl oxygen and hydroxyl oxygen. From the values of magnetic moment (μ) it was observed that synthesized complexes (C1-C6) are paramagnetic with three unpaired electrons contain one electron in t2g orbital and two electrons in eg orbitals. Further all these complexes have been evaluated in-vitro for their antimicrobial activity against the Gram positive bacteria Staphylococcus aureus, Gram negative bacteria Escherichia coli and the yeast Candida albicans. The complex C1 showed the significant antimicrobial activity, whereas the complexes C2, C4, C5 and C6 are moderately active against the tested pathogens. The antimicrobial data revealed that growth inhibitory activities of complexes were enhanced comparatively than its respective ligands. The enhanced antimicrobial activity is attributed to the presence of halogens (Br, Cl, I) and hydroxyl (OH) active substituents associated with the basic nucleus of complexes. Therefore, the present study helps to develop a new class of antimicrobial analogues.                     KEY WORDS: Metal complexes synthesis, 1,3-Diaryl-2-propene-1-one, Crystal structure, Thermal properties, Antimicrobial activity   Bull. Chem. Soc. Ethiop. 2021, 35(3), 513-524. DOI: https://dx.doi.org/10.4314/bcse.v35i3.4

Challenging the "old boys club" in academia: Gender and geographic representation in editorial boards of journals publishing in environmental sciences and public health

In light of global environmental crises and the need for sustainable development, the fields of public health and environmental sciences have become increasingly interrelated. Both fields require interdisciplinary thinking and global solutions, which is largely directed by scientific progress documented in peer-reviewed journals. Journal editors play a critical role in coordinating and shaping what is accepted as scientific knowledge. Previous research has demonstrated a lack of diversity in the gender and geographic representation of editors across scientific disciplines. This study aimed to explore the diversity of journal editorial boards publishing in environmental science and public health. The Clarivate Journal Citation Reports database was used to identify journals classified as Public, Environmental, and Occupational (PEO) Health, Environmental Studies, or Environmental Sciences. Current EB members were identified from each journal's publicly available website between 1 March and 31 May 2021. Individuals' names, editorial board roles, institutional affiliations, geographic locations (city, country), and inferred gender were collected. Binomial 95% confidence intervals were calculated for the proportions of interest. Pearson correlations with false discovery rate adjustment were used to assess the correlation between journal-based indicators and editorial board characteristics. Linear regression and logistic regression models were fitted to further assess the relationship between gender presence, low- and middle-income country (LMIC) presence and several journal and editor-based indicators. After identifying 628 unique journals and excluding discontinued or unavailable journals, 615 journal editorial boards were included. In-depth analysis was conducted on 591 journals with complete gender and geographic data for their 27,772 editors. Overall, the majority of editors were men (65.9%), followed by women (32.9%) and non-binary/other gender minorities (0.05%). 75.5% journal editorial boards (n = 446) were composed of a majority of men (>55% men), whilst only 13.2% (n = 78) demonstrated gender parity (between 45-55% women/gender minorities). Journals categorized as PEO Health had the most gender diversity. Furthermore, 84% of editors (n = 23,280) were based in high-income countries and only 2.5% of journals (n = 15) demonstrated economic parity in their editorial boards (between 45-55% editors from LMICs). Geographically, the majority of editors' institutions were based in the United Nations (UN) Western Europe and Other region (76.9%), with 35.2% of editors (n = 9,761) coming solely from the United States and 8.6% (n = 2,373) solely from the United Kingdom. None of the editors-in-chief and only 27 editors in total were women based in low-income countries. Through the examination of journal editorial boards, this study exposes the glaring lack of diversity in editorial boards in environmental science and public health, explores the power dynamics affecting the creation and dissemination of knowledge, and proposes concrete actions to remedy these structural inequities in order to inform more equitable, just and impactful knowledge creation.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Systematic analysis of authorship demographics in global surgery

Background

Global surgery has recently gained prominence as an academic discipline within global health. Authorship inequity has been a consistent feature of global health publications, with over-representation of authors from high-income countries (HICs), and disenfranchisement of researchers from low-income and middle-income countries (LMICs). In this study, we investigated authorship demographics within recently published global surgery literature.

Methods

We performed a systematic analysis of author characteristics, including gender, seniority and institutional affiliation, for global surgery studies published between 2016 and 2020 and indexed in the PubMed database. We compared the distribution of author gender and seniority across studies related to different topics; between authors affiliated with HICs and LMICs; and across studies with different authorship networks.

Results

1240 articles were included for analysis. Most authors were male (60%), affiliated only with HICs (51%) and of high seniority (55% were fully qualified specialist or generalist clinicians, Principal Investigators, or in senior leadership or management roles). The proportion of male authors increased with increasing seniority for last and middle authors. Studies related to Obstetrics and Gynaecology had similar numbers of male and female authors, whereas there were more male authors in studies related to surgery (69% male) and Anaesthesia and Critical care (65% male). Compared with HIC authors, LMIC authors had a lower proportion of female authors at every seniority grade. This gender gap among LMIC middle authors was reduced in studies where all authors were affiliated only with LMICs.

Conclusion

Authorship disparities are evident within global surgery academia. Remedial actions to address the lack of authorship opportunities for LMIC authors and female authors are required.

Medicine or martyrdom? A peek into the rising violence against doctors during times of COVID 19

One would think, at a time where healthcare workers are the frontline warriors against the COVID 19 pandemic, the violence against them would subside; however, this is far from the truth. This commentary article addresses the underlying causes and implications of such acts of violence against health professionals, particularly those involved in primary healthcare, in India, and barriers to implementation of laws protecting these professionals from violence. Recommendations for administrative and on ground interventions, with a proposed collaboration with government and private medical establishments, have been discussed, as a probable solution to the problem of violence at hand.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

P68 International Survey Of Medical students Exposure to Relevant global Surgery (ISOMERS): A cross-sectional study

Introduction

Medical students around the world have been showing an increasing interest in Global Surgery as evident by their participation in various organizations on local and international levels. We set out to evaluate exposure of medical students to global surgery, modes of exposure, whether the exposure meets the needs of students, awareness of the key messages of the Lancet Commission on Global Surgery, global surgery career aspirations and barriers to said aspirations.

Methods

We developed the International Survey Of Medical students Exposure to Relevant global Surgery (ISOMERS) study, an online, international, questionnaire-based study. This survey will collect data from final year medical students across the world. The questionnaire utilises a combination of the Likert scale, multiple choice options and free text questions and will be disseminated by email and social media through the International Student Surgical Network, a global surgery student interest group with more than 5,000 members.

Results

Primary outcomes will include exposure to global surgery research, advocacy and education among medical students. We will generate simple descriptive statistics and identify determinants of exposure among medical students and subgroups (country income class and geographic region). Also, we will use multinomial regression analysis to identify confounders and significant dependent variables.

Conclusion

The ISOMERS study will identify the level of exposure to global surgery among students during medical education. An understanding of this exposure will be crucial in developing the foundation for global surgery education at the level of undergraduate medical curriculum and furthered in addressing perceived barriers to joining the global surgery workforce.

Carbon dots: A novel trend in pharmaceutical applications

Carbon quantum dots (CQDs, C-dots, or CDs), are generally small carbon nanoparticles having a size less than 10nm. Carbon dots (CDs) were accidentally discovered during the purification of single-walled carbon nanotubes through preparative electrophoresis in 2004. Carbon is an organic material having poor water solubility that emits less fluorescence. However, CDs have good aqueous solubility and excellent fluorescent property, hence more attention has been given to the synthesis of CDs and their applications in chemistry and allied sciences. CDs being easily accessible for in-house synthesis, simpler fabrication as per compendial requirements are wisely accepted. In addition, since CDs are biocompatible, of low toxicity, and of biodegradable nature, they appear as a promising tool for the health care sector. Furthermore, owing to their capabilities of expressing significant interaction with biological materials, and their excellent photoluminescence (PL), CDs have been emerging as novel pioneered nanoparticles useful for pharmaceutical and theranostic applications. Also, CDs are more eco-friendly in synthesis and therefore can be favorably consumed as alternatives in the further development of biological, environmental, and food areas. A massive study has been performed dealing with different approaches which are adopted for CDs synthesis and their applications as, filters for the separation of pollutants from polluted water, food safety, toxicological studies, and optical properties, etc. While still less emphasis is given on the applications of CDs in pharmaceuticals like for sustained and targeted drug delivery systems, theranostic study, etc. Hence, in the present review, we are exploring CQDs as a boon to pharmaceutical concerns.

Closure of the appendiceal stump in laparoscopic appendectomy: A systematic review of the literature

Background

Closure of the appendiceal stump is a key step performed during laparoscopic appendicectomy. Inadequate management of the appendiceal stump has the potential to cause significant morbidity. Several methods of stump closure have been described, however high-level evidence is limited. We performed a systematic review evaluating clinical outcomes and quality of the evidence for the methods of appendiceal stump closure.

Methods

A systematic literature search was performed using Medline, Embase, Cochrane Database and Google Scholar to identify studies comparing appendiceal stump closure methods in laparoscopic appendectomy for acute appendicitis from inception to October 2019. Data regarding operative duration, peri-operative complications, length of stay and costs were collated from all included studies.

Results

From 160 identified studies, 19 met the inclusion criteria. Endoloops and endoclips provide equivalent clinical outcomes at lower cost, while operative duration was shortest with endoclip closure. Endostapler devices have the lowest rate of peri-operative complications (3.56%), however their cost limits their regular use in many healthcare environments. Post-operative complication rate and length of stay were similar for all stump closure methods. Conclusion: Although there are no significant differences in method of stump closure in laparoscopic appendectomy, closure with endoclips provides the shortest operative duration. There is a need for robust and standardized reporting of cost data when comparing stump closure methods, together with higher level evidence in the form of multi-centre randomized controlled trials before firm conclusions can be drawn regarding the optimal method of stump closure.

•

Currently there is no robust higher order evidence which assesses clinical outcomes, cost and time efficiency of methods of stump closure in laparoscopic appendicectomy.

•

This is the first systematic review to investigate clinical outcomes, cost and quality of current evidence for all methods of laparoscopic appendiceal stump closure in acute appendicitis.

•

No difference was observed in methods of stump closure in complication rate, length of stay, cost, and time efficiency.

•

Endostaplers appear to provide most robust closure, albeit at a higher economic cost.

•

Endoloops appear to provide efficient and successful closure, and are currently the most frequently studied method of closure.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Where Does Indian Medical Education Stand Amidst a Pandemic?

The recent outbreak of COVID-19, declared a pandemic, has affected medical education globally. The scenario is no different for medical students in India as they find themselves at a crossroads in their careers, with clinical and elective postings called off. Missing out on the opportunity to learn from "first-hand" clinical observation stands to threaten the quality of medical education and learning procured by Indian medical students which is extremely essential to deal with the vast patient load that awaits them in their impending future as healthcare professionals. Is the Indian medical education system being able to cope with the challenges imposed by the increasing burden of COVID-19? The authors propose few administrative and on-ground interventions that must seek to work collectively with all government and private medical institutions in order to help students/interns and residents in coping with stress, anxiety or academic losses incurred due to the pandemic.

T cell functionality in HIV-1, HIV-2 and dually infected individuals: correlates of disease progression and immune restoration

The role of suppressive anti-retroviral therapy (ART) in eliciting restoration of dysregulated immune function remains unclear in HIV-1 infection. Also, due to tailoring of therapeutic regimens towards HIV-1, this possible impairment of therapy may be even more pronounced in HIV-2 and dual (HIV-D) infection. Thus, we evaluated the impact of ART on immune restoration by assessing T cell functions, including HIV specific responses in HIV-1-, HIV-2- and HIV-D-infected individuals. Both ART-treated and naive infected subjects showed persistently altered frequency of CD4⁺ T cell subsets [regulatory T cells (T_reg ), naive/central memory, effector memory], increased immune activation, cytoxicity and decreased frequency of natural killer T (NKT)- like cells and T helper type 17 (Th17)/T_reg ratio with elevated microbial translocation. Further, HIV-specific responses were dominated by gag-specific CD4⁺ T cells in virologically suppressed HIV-D individuals, suggesting retention of T cell memory for both viruses. Increased antigen-specific responses, including dual-functional interleukin (IL)-2/interferon (IFN)-γ CD4⁺ T cells, were detected in therapy receiving HIV-2-infected individuals indicative of a greater and more functionally diverse T cell memory repertoire. We delineated immune signatures specific to therapy-naive single HIV infection, as well as a unique signature associated with HIV-2 disease progression and immune restoration. Circulating T_reg frequency, T cell activation and microbial translocation levels correlated with disease progression and immune restoration among all types of HIV infection. Also, memory responses negatively correlated, irrespective of type of infection, in ART receiving infected individuals, with CD4 rebound and decreased pan T cell activation. Our data highlight the need for adjunct immunomodulatory therapeutic strategies to achieve optimal immune restoration in HIV infection.

Watson for Oncology and breast cancer treatment recommendations: agreement with an expert multidisciplinary tumor board

Background

Breast cancer oncologists are challenged to personalize care with rapidly changing scientific evidence, drug approvals, and treatment guidelines. Artificial intelligence (AI) clinical decision-support systems (CDSSs) have the potential to help address this challenge. We report here the results of examining the level of agreement (concordance) between treatment recommendations made by the AI CDSS Watson for Oncology (WFO) and a multidisciplinary tumor board for breast cancer.

Patients and methods

Treatment recommendations were provided for 638 breast cancers between 2014 and 2016 at the Manipal Comprehensive Cancer Center, Bengaluru, India. WFO provided treatment recommendations for the identical cases in 2016. A blinded second review was carried out by the center's tumor board in 2016 for all cases in which there was not agreement, to account for treatments and guidelines not available before 2016. Treatment recommendations were considered concordant if the tumor board recommendations were designated 'recommended' or 'for consideration' by WFO.

Results

Treatment concordance between WFO and the multidisciplinary tumor board occurred in 93% of breast cancer cases. Subgroup analysis found that patients with stage I or IV disease were less likely to be concordant than patients with stage II or III disease. Increasing age was found to have a major impact on concordance. Concordance declined significantly (P ≤ 0.02; P < 0.001) in all age groups compared with patients <45 years of age, except for the age group 55-64 years. Receptor status was not found to affect concordance.

Conclusion

Treatment recommendations made by WFO and the tumor board were highly concordant for breast cancer cases examined. Breast cancer stage and patient age had significant influence on concordance, while receptor status alone did not. This study demonstrates that the AI clinical decision-support system WFO may be a helpful tool for breast cancer treatment decision making, especially at centers where expert breast cancer resources are limited.