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Background The Bluebelle Wound Healing Questionnaire (WHQ) is a universal-reporter outcome measure developed in the UK for remote detection of surgical-site infection after abdominal surgery. This study aimed to explore cross-cultural equivalence, acceptability, and content validity of the WHQ for use across low- and middle-income countries, and to make recommendations for its adaptation. Methods This was a mixed-methods study within a trial (SWAT) embedded in an international randomized trial, conducted according to best practice guidelines, and co-produced with community and patient partners (TALON-1). Structured interviews and focus groups were used to gather data regarding cross-cultural, cross-contextual equivalence of the individual items and scale, and conduct a translatability assessment. Translation was completed into five languages in accordance with Mapi recommendations. Next, data from a prospective cohort (SWAT) were interpreted using Rasch analysis to explore scaling and measurement properties of the WHQ. Finally, qualitative and quantitative data were triangulated using a modified, exploratory, instrumental design model. Results In the qualitative phase, 10 structured interviews and six focus groups took place with a total of 47 investigators across six countries. Themes related to comprehension, response mapping, retrieval, and judgement were identified with rich cross-cultural insights. In the quantitative phase, an exploratory Rasch model was fitted to data from 537 patients (369 excluding extremes). Owing to the number of extreme (floor) values, the overall level of power was low. The single WHQ scale satisfied tests of unidimensionality, indicating validity of the ordinal total WHQ score. There was significant overall model misfit of five items (5, 9, 14, 15, 16) and local dependency in 11 item pairs. The person separation index was estimated as 0.48 suggesting weak discrimination between classes, whereas Cronbach’s α was high at 0.86. Triangulation of qualitative data with the Rasch analysis supported recommendations for cross-cultural adaptation of the WHQ items 1 (redness), 3 (clear fluid), 7 (deep wound opening), 10 (pain), 11 (fever), 15 (antibiotics), 16 (debridement), 18 (drainage), and 19 (reoperation). Changes to three item response categories (1, not at all; 2, a little; 3, a lot) were adopted for symptom items 1 to 10, and two categories (0, no; 1, yes) for item 11 (fever). Conclusion This study made recommendations for cross-cultural adaptation of the WHQ for use in global surgical research and practice, using co-produced mixed-methods data from three continents. Translations are now available for implementation into remote wound assessment pathways.

Streptococcus pluranimalium has mainly been found to cause infections in animals and was rarely isolated in humans. Very few cases of streptococcus pluranimalium have been reported in the literature. We report a first case of streptococcus pluranimalium meningitis in a pediatric patient. This patient was treated successfully with a combination of 3rd generation cephalosporin and chloramphenicol since her first day of admission. Only 4 of the reported human infections caused by Streptococcus pluranimalium were pediatric cases. We didn’t find neither adult nor pediatric cases of meningitis caused by this new novel species of Streptococcus pluranimalium. Clinical doctors have to remember that a rare pathogen like Streptococcus pluranimalium isolated primarily in animals can be a causative agent of human infection. More diagnostic methods are needed to detect early what could be rare causative germs of human infection. And when streptococcus pluranimalium is isolated, the first line antibiotics will be vancomycin, carbapenems, linezolid, aminoglycosides, and 3rd generation cephalosporins.

Background Cluster randomised controlled trials (cRCT) present challenges regarding risks of bias and chance imbalances by arm. This paper reports strategies to minimise and monitor biases and imbalances in the ChEETAh cRCT. Methods ChEETAh was an international cRCT (hospitals as clusters) evaluating whether changing sterile gloves and instruments prior to abdominal wound closure reduces surgical site infection at 30 days postoperative. ChEETAh planned to recruit 12,800 consecutive patients from 64 hospitals in seven low-middle income countries. Eight strategies to minimise and monitor bias were pre-specified: (1) minimum of 4 hospitals per country; (2) pre-randomisation identification of units of exposure (operating theatres, lists, teams or sessions) within clusters; (3) minimisation of randomisation by country and hospital type; (4) site training delivered after randomisation; (5) dedicated ‘warm-up week’ to train teams; (6) trial specific sticker and patient register to monitor consecutive patient identification; (7) monitoring characteristics of patients and units of exposure; and (8) low-burden outcome-assessment. Results This analysis includes 10,686 patients from 70 clusters. The results aligned to the eight strategies were (1) 6 out of 7 countries included ≥ 4 hospitals; (2) 87.1% (61/70) of hospitals maintained their planned operating theatres (82% [27/33] and 92% [34/37] in the intervention and control arms); (3) minimisation maintained balance of key factors in both arms; (4) post-randomisation training was conducted for all hospitals; (5) the ‘warm-up week’ was conducted at all sites, and feedback used to refine processes; (6) the sticker and trial register were maintained, with an overall inclusion of 98.1% (10,686/10,894) of eligible patients; (7) monitoring allowed swift identification of problems in patient inclusion and key patient characteristics were reported: malignancy (20.3% intervention vs 12.6% control), midline incisions (68.4% vs 58.9%) and elective surgery (52.4% vs 42.6%); and (8) 0.4% (41/9187) of patients refused consent for outcome assessment. Conclusion cRCTs in surgery have several potential sources of bias that include varying units of exposure and the need for consecutive inclusion of all eligible patients across complex settings. We report a system that monitored and minimised the risks of bias and imbalances by arm, with important lessons for future cRCTs within hospitals.

Background: Induction time delays in Operating room (OR) is an issue that affects the productivity of an operating unit especially in a setting with limited resources. It can also results in providing inappropriate services to the patients and their families. The aim of this study was to determine the causes of induction time delays and to propose solutions on how to avoid the reasons of delays. Methods: A prospective observational study was conducted. It focused on elective general surgeries and orthopedic surgeries as they were mainly being performed during the study period. The data on the type of operation, the type of anesthesia, delay or no delay of induction (DOI) of anesthesia, causes of DOI were collected. DOI was considered as the time between the previous patient out of the OR and the next one in of more than 30 minutes. Emergency surgeries and elective obstetric surgeries were excluded from the study. Results: 24.8% of surgeries were done after delays of induction of anesthesia as opposed to 75.2% surgeries for which anesthesia was induced without delay. 48.6% of delays of induction to anesthesia were due to the hospital issues followed by anesthesia provision related issues. (40.0%). The surgery related and patient related issues accounted each one 5.7%. Conclusions: There was a high rate of surgeries that had delays in induction times. The OR managers need to work more with the hospital administration and the OR team to correct causes of delays.