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 juvenile- versus adult-onset distinction appears to be important to heterogeneity in adult depression, implicating different individual and environmental factors during childhood, and different mechanisms in adult life.

Recent years have seen the development of policy guidance documents in both Wales and Englandrelating to the protection of vulnerable adults from abuse. This policy guidance does, however, require translation into policies at the local level and that these policies are then implemented in day-to-day practice. This article reports some of the findings of a two-year study that examined the development and implementation of such policies in services for people with learning disabilities within Wales. Data were gathered by means of a survey of service providers from across Wales and also via focus groups held with direct care staff and those with a responsibility for investigating alleged abuse. Positive developments include a commitment to multi-disciplinary working, increased clarity and consistency, and greater awareness. Less positive aspects include the potential for policy 'overload' and a feeling that, while there is awareness of the existence of vulnerable adults policies, knowledge of their content may be more limited. Recommendations are made for the development of policy, practice and research.

Piling is a behavior in laying hens whereby individuals aggregate in larger densities than would be normally expected. When piling behavior leads to mortalities it is known as smothering and its frequent but unpredictable occurrence is a major concern for many egg producers. There are generally considered to be three types of piling: panic, nest box and recurring piling. Whilst nest box and panic piling have apparent triggers, recurring piling does not, making it an enigmatic and ethologically intriguing behavior. The repetitive nature of recurring piling may result in a higher incidence of smothering and could have unconsidered, sub-lethal consequences. Here, we consider the possible causes of recurring piling from an ethological perspective and outline the potential welfare and production consequences. Drawing on a wide range of literature, we consider different timescales of causes from immediate triggers to ontogeny and domestication processes, and finally consider the evolution of collective behavior. By considering different timescales of influence, we built four hypotheses relevant to the causes of piling, which state that the behavior: (i) is caused by hens moving toward or away from an attractant/repellent; (ii) is socially influenced; (iii) is influenced by early life experiences and; (iv) can be described as a maladaptive collective behavior. We further propose that the following could be welfare consequences of piling behavior: Heat stress, physical injury (such as keel bone damage), and behavioral and physiological stress effects. Production consequences include direct and indirect mortality (smothering and knock-on effects of piling, respectively), potential negative impacts on egg quality and on worker welfare. In future studies the causes of piling and smothering should be considered according to the different timescales on which causes might occur. Here, both epidemiological and modeling approaches could support further study of piling behavior, where empirical studies can be challenging.