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,...

The prevalence of hyperphosphatemia and increased calcium-phosphorus product has never been evaluated in a large multicenter study in a developing country. Our aim is to study the prevalence of hyperphosphatemia in 38 HD centers in Egypt (as an example of a developing country) and to correlate it with different co-morbid conditions and the patient's demographic data. This is a cross-sectional study conducted on 1005 chronic kidney disease stage 5 patients (CKD-stage 5) on HD for a period of more than 1 year in 38 dialysis centers in Egypt. All patients were receiving calcium-based salts as a phosphate binder. Hyperphosphatemia and increased calcium-phosphorus product were evaluated and correlated with different parameters including age, sex, knowledge by diet parameters, HD session duration, the frequency of HD per week, the type of dialysis membrane, the surface area of the dialyzer, dialyzer phosphorus clearance (phosphorus KoA), and the type of dialysate. Other co-morbid medical conditions and evidence of IHD were also investigated. Hyperphosphatemia was present in 69.1% of cases and a high calcium-phosphorus product was present in 30.2%. A higher calcium-phosphorus product was found among males. 83.2% of those with a poor knowledge by diet parameters had hyperphosphatemia compared with 67.6% in patients with a satisfactory knowledge by diet parameters. 72.3% of patients using a membrane with low-to-medium clearance had hyperphosphatemia, compared with 67.2% using a membrane with a high clearance. Seventy-two percent of patients with IHD were hyperphosphatemic compared with 67.6% of the non-ischemic patients. Hyperphosphatemia is a major problem in dialysis patients in developing countries, reflecting differences from developed countries regarding dietary habits, ethnic factors, dialysis quality, types of dialysis membranes, as well as economic factors hampering the use of the more expensive phosphate binders. Extended dialysis hours may be a good alternative solution in developing countries.

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Fibroblast growth factor 23 (FGF-23) is a recently discovered regulator of phosphate and mineral metabolism and has been associated with both progression of CKD and mortality in dialysis patients. To evaluate the association between serum FGF-23 levels and echocardiographic measurements in long-term HD (HD) patients without cardiac symptoms, we studied 90 consecutive patients treated in a single HD center (51 males, 39 females; mean age 41.5 ± 14.2 years, mean HD duration 71.2 ± 14.2 months). Comprehensive echocardiography was performed after HD and blood samples were obtained before HD. The serum FGF-23 level in dialysis patients was 95.7 ± 88.4 pg/mL. In univariate analysis, serum calcium levels (r = 0.33, P <0.05), serum creatinine (r = 0.34, P <0.05), serum albumin (r = 0.35, P <0.05) and left ventricular mass index (LVMI) (r = 0.33, P <0.001) were correlated weakly with the FGF-23 levels. Neither s. phosphorus nor calcium x phosphorus product correlated with FGF-23. In univariate regression analysis, only LVMI [β = 0.42, P <0.05, confidence interval (CI) 0.3-4.3], serum calcium (β= 0.87, P <0.001, CI 0.8-7.3), serum albumin (β= 0.87, P < 0.001, CI 0.8-7.3) and serum creatinine (β= 0.67, P <0.05, CI 0.5-6.5) significantly correlated with FGF-23. FGF-23 was identified as a factor that is weakly associated with LVMI. Thus, FGF-23 alone may not be a parameter that can be used for evaluation of the cardiac status in HD patients.

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