Pragmatic multicentre factorial randomized controlled trial testing measures to reduce surgical site infection in low‐ and middle‐income countries: study protocol of the FALCON trial

Aim
Surgical site infection (SSI) is the commonest postoperative complication worldwide, representing a major burden for patients and health systems. Rates of SSI are significantly higher in low‐ and middle‐income countries (LMICs) but there is little high‐quality evidence on interventions to prevent SSI in LMICs.

Method
FALCON is a pragmatic, multicentre, 2 x 2 factorial, stratified randomized controlled trial, with an internal feasibility study, which will address the need for evidence on measures to reduce rates of SSI in patients in LMICs undergoing abdominal surgery. To assess whether either (1) 2% alcoholic chlorhexidine versus 10% povidone‐iodine for skin preparation, or (2) triclosan‐coated suture versus non‐coated suture for fascial closure, can reduce surgical site infection at 30‐days post‐surgery for each of (1) clean‐contaminated and (2) contaminated/dirty surgery. Patients with predicted clean‐contaminated or contaminated/dirty wounds with abdominal skin incision ≥ 5 cm will be randomized 1:1:1:1 between (1) 2% alcoholic chlorhexidine and noncoated suture, (2) 2% alcoholic chlorhexidine and triclosan‐coated suture, (3) 10% aqueous povidone–iodine and noncoated suture and (4) 10% aqueous povidone–iodine and triclosan‐coated suture. The two strata (clean‐contaminated versus contaminated/dirty wounds) are separately powered. Overall, FALCON aims to recruit 5480 patients. The primary outcome is SSI at 30 days, based on the Centers for Disease Control definition of SSI.

Conclusion
FALCON will deliver high‐quality evidence that is generalizable across a range of LMIC settings. It will influence revisions to international clinical guidelines, ensuring the global dissemination of its findings.

The Cervical Cancer (CC) Epidemiology and Human Papillomavirus (HPV) in the Middle East

Viral infections contribute 15–20 percent of all human cancers as a cause. Oncogenic virus infection may spur various stages of carcinogenesis. For several forms for HPV, about 15 associated with cancer. Following successful test techniques, cervical cancer remains a significant public health issue. Prevalence and mortality of per geographic area of cervical cancer were vastly different. The fourth most common cause of death from cancer among women is cervical cancer (CC). Human papillomavirus (HPV) infection in the cervix is the most significant risk factor for forming cervical cancer. Inflammation is a host-driven defensive technique that works rapidly to stimulate the innate immune response against pathogens such as viral infections. Inflammation is advantageous if it is brief and well-controlled; however, it can cause adverse effects if the inflammation is prolonged or is chronic in duration. HPV proteins are involved in the production of chronic inflammation, both directly and indirectly. Also, the age-specific prevalence of HPV differs significantly. Two peaks of HPV positive in younger and older people have seen in various populations. A variety of research has performed worldwide on the epidemiology of HPV infection and oncogenic properties due to specific HPV genotypes. Nevertheless, there are still several countries where population-dependent incidences have not yet identified. Additionally, the methods of screening for cervical cancer differ among countries.

Ventriculoperitoneal shunt complication in pediatric hydrocephalus: Risk factor analysis from a single institution in Nepal

Objective
Ventriculoperitoneal (VP) shunt surgery is one of the commonly performed neurosurgical procedures. Complications due to shunt failure are associated with high morbidity and mortality. We report an analysis of risk factors for shunt failure in pediatric patients from a single institution in Nepal.
Materials and methods
A retrospective analytical study with prospective data was designed. All children younger than 15 years, with first time VP shunting, at a tertiary government hospital in Kathmandu during 2014-2017 were followed up. Association of independent variables with the primary outcome variable (complication of VP shunt) was analyzed using Chi-square test. Bivariate logistic regression was performed to identify unadjusted odds ratio (OR) with 95% confidence interval (CI). Multivariate logistic regression model was designed to calculate adjusted OR with 95% CI.
Results
Of 120 patients, more than half (55.8%) of the patients were male. Mean age was 62.97 months. Maximum duration of follow-up was 30 months. Most common cause of hydrocephalus was congenital aqueductal stenosis (40.8%) followed by tumors (29.2%). Overall shunt complication was found in 26.7% (95% CI 19.0%-35.5%). Shunt infection was seen in 5% while malfunction without infection was found in 21.7%. Bivariate logistic regression showed duration of surgery more than 1 h (OR 2.67, 95% CI 1.11-6.42, P = 0.028) compared to 1 h or less, experienced surgeon (OR 0.37, 95% CI 0.16-0.89, P = 0.026) compared to residents, and emergency surgery (OR 3.97, 95% CI 1.69-9.29, P = 0.001) compared to elective surgery as significant risk factors, while emergency surgery was the only significant variable for shunt failure on multivariate regression analysis (OR 3.3, 95% CI 1.16-9.35, P = 0.025).
Conclusion
Longer duration of surgery, less experience of the surgeon, and the priority of the case (emergency) were independent risk factors for shunt complications.

Risk factors of orthopedic surgical site infection in Jordan: A prospective cohort study

Background
Orthopedic surgical site infection represents a hospital acquired infection among orthopedic surgery patients, which in turn delays normal recovery process and increases hospital length of stay and health care costs. As a result, risk factors for orthopedic surgical site infection should be identified thereby allowing the application of protective interventions that may inhibit the occurrence of such infection.

Objectives
To determine risk factors of surgical site infection in patients undergoing orthopedic surgery in Jordan.

Materials and methods
The study employed prospective, multi-center approach to collect data about orthopedic surgery patients through assessing their health status and reviewing their medical records and monitoring for occurrence of surgical site infection within 90 days after operation.

Results
286 patients met the eligibility criteria from 18 hospitals. Only surgical wound classification and length of postoperative stay wound were found to be significant risk factors for orthopedic surgical site infection.

Conclusion
Surgical wound classification and length of postoperative stay were identified as risk factors for orthopedic surgical site infection. Risk factors that did not predict occurrence of orthopedic surgical site infection can be identified by other research strategies than the one used in this study, which could be conducted retrospectively or by conducting prospective studies that are both community-based and hospital-based with larger sample sizes

Urbanization in Sub-Saharan Africa: Declining Rates of Chronic and Recurrent Infection and Their Possible Role in the Origins of Non-communicable Diseases.

Non-communicable diseases (NCDs), such as atherosclerosis and cancers, are a leading cause of death worldwide. An important, yet poorly explained epidemiological feature of NCDs is their low incidence in under developed areas of low-income countries and rising rates in urban areas.With the goal of better understanding how urbanization increases the incidence of NCDs, we provide an overview of the urbanization process in sub-Saharan Africa, discuss gene expression differences between rural and urban populations, and review the current NCD determinant model. We conclude by identifying research priorities.Declining rates of chronic and recurrent infection are the hallmark of urbanization in sub-Saharan Africa. Gene profiling studies show urbanization results in complex molecular changes, with almost one-third of the peripheral blood leukocyte transcriptome altered. The current NCD determinant model could be improved by including a possible effect from declining rates of infection and expanding the spectrum of diseases that increase with urbanization.Urbanization in sub-Saharan Africa provides a unique opportunity to investigate the mechanism by which the environment influences disease epidemiology. Research priorities include: (1) studies to define the relationship between infection and risk factors for NCDs, (2) explaining the observed differences in the inflammatory response between rural and urban populations, and (3) identification of animal models that simulate the biological changes that occurs with urbanization. A better understanding of the biological changes that occur with urbanization could lead to new prevention and treatment strategies for some of the most common surgical diseases in high-income countries.

Surgical Site Infections Rates in More Than 13,000 Surgical Procedures in Three Cities in Peru: Findings of the International Nosocomial Infection Control Consortium

BACKGROUND: Surgical site infections (SSIs) are a threat to patient safety. However, there are not available data on SSI rates stratified by surgical procedure (SP) in Peru.

METHODS: From January 2005 to December 2010, a cohort prospective surveillance study on SSIs was conducted by the International Nosocomial Infection Control Consortium (INICC) in four hospitals in three cities of Peru. Data were recorded from hospitalized patients using the U.S. Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) methods and definitions for SSI. Surgical procedures (SPs) were classified into 4 types, according to ICD-9 criteria.

RESULTS: We recorded 352 SSIs, associated to 13,904 SPs (2.5%; CI, 2.3-2.8) SSI rates per type of SP were the following for this study’s Peruvian hospitals, compared with rates of the INICC and CDC-NHSN reports, respectively: 2.9% for appendix surgery (vs. 2.9% vs. 1.4%); 2.8% for gallbladder surgery (vs. 2.5% vs. 0.6%); 2.2% for cesarean section (vs. 0.7% vs. 1.8%); 2.8% for vaginal hysterectomy (vs. 2.0% vs. 0.9%).

CONCLUSIONS: Our SSIs rates were higher in all of the four analyzed types of SPs compared with CDC-NHSN, whereas compared with INICC, most rates were similar. This study represents an important advance in the knowledge of SSI epidemiology in Peru that will allow us to introduce targeted interventions.