Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

BACKGROUND

Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.

METHODS

This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.

RESULTS

The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.

CONCLUSION

Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

The African Research Group for Oncology: A decade fostering colorectal cancer research in Nigeria

The African Research Group for Oncology (ARGO) was formed in 2013 to undertake methodologically rigorous cancer research in Nigeria, and to strengthen cancer research capacity in the country through training and mentorship of physicians, scientists, and other healthcare workers. Here, we describe how ARGO's work in colorectal cancer (CRC) has evolved over the past decade. This includes the consortium's scientific contributions to the understanding of CRC in Nigeria and globally and its research capacity-building program.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

The unrestricted global effort to complete the COOL trial

BACKGROUND

Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.

METHODS

The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.

DISCUSSION

OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.

TRIAL REGISTRATION

National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).

Abdominal Trauma Imaging in a Nigerian Tertiary Hospital-Our Experience with 87 Adult Patients

Introduction

Abdominal trauma is a major cause of morbidity and mortality in low- and medium-income countries (LMICs). Abdominal trauma imaging is important in determining the location and severity of organ injury, the need for surgery, and the identification of complications. The choice of imaging in abdominal trauma in LMICs is influenced by peculiar problems, which include the availability of imaging modality, expertise, and cost. There are few reports on options of trauma imaging in LMICs, and this study aimed to identify and characterise the type of imaging done for patients presenting with abdominal trauma at the University of Ilorin Teaching Hospital.

Materials and Methods

This was a retrospective observational study of patients with abdominal trauma who presented at the University of Ilorin Teaching Hospital from 2013 to 2019. Records were identified, and data were extracted and analysed.

Results

A total of 87 patients were included in the study. There were 73 males and 14 females. The abdominal ultrasound was the commonest modality done in 36 (41%) patients, whereas abdominal computed tomography was done in five (6%) patients. Eleven patients (13%) had no imaging done, and 10 of these patients proceeded to having surgery. In patients with intraoperative finding of perforated viscus, the sensitivity of radiography was 85% and specificity was 100%, whereas that of the ultrasound was 86.7% and 50% for sensitivity and specificity, respectively. The ultrasound scan was the commonest imaging done for patients who presented with features of haemorrhage (P = 0.04), odds ratio (OR) = 1.29 (95% confidence interval [CI] = 1.08-1.6), and patients with severe injury, P = 0.03, OR = 2.07 (95% CI = 1.06-4.06). Gender (P = 0.64), shock at presentation (P = 0.19), and mechanism of injury (P = 0.11) did not influence the choice of imaging.

Conclusions

Abdominal trauma imaging in this setting was majorly via ultrasound and abdominal radiographs. Factors suggested to influence the pattern of abdominal trauma imaging in LMICs include the availability of specific imaging modality, cost, lack of standardisation and definite abdominal trauma protocols.

Injury severity score as a predictor of mortality in patients with abdominal trauma at a tertiary Nigerian hospital

Background

Abdominal trauma is a major cause of morbidity and mortality in low-and middle-income countries. Typical patients present late and very sick with early recognition key to improving outcome. There is a paucity of trauma data in this environment and trauma scoring systems which have been validated in the developed world are yet to find widespread use here.

Aim

This study aimed at evaluating role of injury severity score (ISS) in predicting mortality.

Patients and Methods

This is a retrospective observational study of patients with abdominal trauma who presented at the University of Ilorin Teaching Hospital from 2013 to 2019. Records were identified and data were extracted and analyzed using Statistical package for social sciences 23.

Results

A total of 87 patients were included in the study. There were 73 males and 14 females. The mean overall ISS in this study was 16.06 ± 7.9. Concerning morbidity, the area under the receiver operating characteristic curve in predicting morbidity was 0.843 (95% confidence interval 0.737-0.928). ISS had a strong sensitivity of 90% and specificity 55% at a cut-off of 14.50. Also, the area under the receiver operating characteristic curve in predicting mortality was 0.746 (95% confidence interval 0.588-0.908) and at a cut-off of 16.50; ISS had a specificity of 80% and sensitivity of 60%. The mean ISS of patients with mortality was 22.60 ± 10.5 while the survivors had a mean ISS of 14.7 ± 6.5 (P <.001). The mean ISS for patients who had morbidity was 22.8 ± 8.1 while those without morbidity had a mean ISS of 13.1 ± 5.7 (P <.05).

Conclusion

ISS was a good predictor of morbidity and mortality in abdominal trauma in patients in this study. A prospective study with standardized abdominal imaging would be needed to further validate this scoring tool.

Pattern of Presentation and Outcome of Adult Patients with Abdominal Trauma - A 7-Year Retrospective Study in a Nigerian Tertiary Hospital

Introduction

Abdominal trauma is a major cause of morbidity and mortality in low- and middle-income countries. There is a paucity of trauma data in this region and this study aimed to show the pattern of presentation and outcome of patients with abdominal trauma at a North-Central Nigerian Teaching Hospital.

Methods

This was a retrospective, observational study of patients with abdominal trauma who presented at the University of Ilorin Teaching Hospital from January 2013 to December 2019. Patients with clinical and/or radiological evidence of abdominal trauma were identified, and data extracted and analyzed.

Results

A total of 87 patients were included in the study. There were 73 males and 14 females (5.2:1) with a mean age of 34.2 years. Blunt abdominal injury occurred in 53 (61%) patients with 10 patients (11%) having concomitant extra-abdominal injuries. A total of 105 abdominal organ injuries occurred in 87 patients with the small bowel being the most frequently injured organ in penetrating trauma, while in blunt abdominal injury, the spleen was most commonly injured. A total of 70 patients (80.5%) had emergency abdominal surgery with a morbidity rate of 38.6% and negative laparotomy rate of 2.9%. There were 15 deaths in the period accounting for 17% of patients with sepsis as the most common cause of death (66%). Shock at presentation, late presentation >12 h, need for perioperative intensive care unit admission, and repeat surgery were associated with a higher risk of mortality (P < 0.05).

Conclusion

Abdominal trauma in this setting is associated with a significant amount of morbidity and mortality. Typical patients present late and with poor physiologic parameters often resulting in an undesirable outcome. There should be steps targeted at preventive policies focused on reducing the incidence of road traffic crashes, terrorism, and violent crimes as well as improving health care infrastructure to cater to this specific group of patients.

Molecular and phenotypic profiling of colorectal cancer patients in West Africa reveals biological insights

Understanding the molecular and phenotypic profile of colorectal cancer (CRC) in West Africa is vital to addressing the regions rising burden of disease. Tissue from unselected Nigerian patients was analyzed with a multigene, next-generation sequencing assay. The rate of microsatellite instability is significantly higher among Nigerian CRC patients (28.1%) than patients from The Cancer Genome Atlas (TCGA, 14.2%) and Memorial Sloan Kettering Cancer Center (MSKCC, 8.5%, P < 0.001). In microsatellite-stable cases, tumors from Nigerian patients are less likely to have APC mutations (39.1% vs. 76.0% MSKCC P < 0.001) and WNT pathway alterations (47.8% vs. 81.9% MSKCC, P < 0.001); whereas RAS pathway alteration is more prevalent (76.1% vs. 59.6%, P = 0.03). Nigerian CRC patients are also younger and more likely to present with rectal disease (50.8% vs. 33.7% MSKCC, P < 0.001). The findings suggest a unique biology of CRC in Nigeria, which emphasizes the need for regional data to guide diagnostic and treatment approaches for patients in West Africa.

Understanding the molecular and phenotypic profile of colorectal cancer (CRC) in West Africa is important for early detection and treatment. Here, the authors use a multigene next-generation sequencing panel to identify genomic differences in Nigerian CRCs compared to those from TCGA and MSKCC cohorts.

Determinants of late detection and advanced-stage diagnosis of breast cancer in Nigeria

Late detection of Breast cancer(BC) and progressing with advanced-stage diagnosis after early detection contribute differently to the challenges of managing BC in Africa. Understanding the difference may improve cancer education programs and their effectiveness.

The Indications and Findings at Colonoscopy in a Tertiary Hospital in North-Central Nigeria: A Seven-Year Review

BACKGROUND

Colonoscopy is an invaluable tool used in the diagnosis of colorectal diseases. It is also useful in the prevention and treatment of some of these diseases. The knowledge of the prevailing colorectal diseases is key to planning for prevention.

OBJECTIVES

This study aimed at determining the spectra of indications and findings at colonoscopy in a tertiary health facility.

METHODS

This was a hospital-based cross-sectional study of all patients who underwent colonoscopy between March 2013 and February 2020. The patients' biodata, indications and findings at colonoscopy were retrieved from the Endoscopy Register.

RESULTS

A total of 385 colonoscopy reports were included in the analysis. The age of the patients ranged from 14 to 95 years with a mean age (standard deviation) of 55.9 (15.4) years. There were 219 (57.0%) males and 166 (43.0%) females. The commonest indication for colonoscopy was haematochezia 150 (38.9%) followed by suspected colorectal malignancy 98 (25.5%), abdominal pain 28 (7.3%), altered bowel habit 21 (5.5%), constipation 20 (5.2%), chronic diarrhoea 19 (4.9%), surveillance/ screening 16 (4.2%), occult bleeding and anal pain 7 (1.8%) each, and others 19 (4.9%). The colonoscopy findings were normal findings 116 (30.1%), haemorrhoids 127 (32.9%), colorectal polyps 70 (18.2%), diverticulosis 46 (11.9%), rectal tumour 43 (11.2%), colonic tumour 32 (8.3%), colitis 23 (5.9%), angiodysplasias 6 (1.6), others 12 (3.1%). The findings were not mutually exclusive. Our diagnostic yield was 69.9%.

CONCLUSION

The commonest indication and diagnosis for colonoscopy were haematochezia and haemorrhoids respectively. Our diagnostic yield was 69.9%.

Core outcome set for surgical trials in gastric cancer (GASTROS study): international patient and healthcare professional consensus

BACKGROUND

Surgery is the primary treatment that can offer potential cure for gastric cancer, but is associated with significant risks. Identifying optimal surgical approaches should be based on comparing outcomes from well designed trials. Currently, trials report different outcomes, making synthesis of evidence difficult. To address this, the aim of this study was to develop a core outcome set (COS)-a standardized group of outcomes important to key international stakeholders-that should be reported by future trials in this field.

METHODS

Stage 1 of the study involved identifying potentially important outcomes from previous trials and a series of patient interviews. Stage 2 involved patients and healthcare professionals prioritizing outcomes using a multilanguage international Delphi survey that informed an international consensus meeting at which the COS was finalized.

RESULTS

Some 498 outcomes were identified from previously reported trials and patient interviews, and rationalized into 56 items presented in the Delphi survey. A total of 952 patients, surgeons, and nurses enrolled in round 1 of the survey, and 662 (70 per cent) completed round 2. Following the consensus meeting, eight outcomes were included in the COS: disease-free survival, disease-specific survival, surgery-related death, recurrence, completeness of tumour removal, overall quality of life, nutritional effects, and 'serious' adverse events.

CONCLUSION

A COS for surgical trials in gastric cancer has been developed with international patients and healthcare professionals. This is a minimum set of outcomes that is recommended to be used in all future trials in this field to improve trial design and synthesis of evidence.

Methods for conducting international Delphi surveys to optimise global participation in core outcome set development: a case study in gastric cancer informed by a comprehensive literature review

Background

Core outcome sets (COS) should be relevant to key stakeholders and widely applicable and usable. Ideally, they are developed for international use to allow optimal data synthesis from trials. Electronic Delphi surveys are commonly used to facilitate global participation; however, this has limitations. It is common for these surveys to be conducted in a single language potentially excluding those not fluent in that tongue. The aim of this study is to summarise current approaches for optimising international participation in Delphi studies and make recommendations for future practice.

Methods

A comprehensive literature review of current approaches to translating Delphi surveys for COS development was undertaken. A standardised methodology adapted from international guidance derived from 12 major sets of translation guidelines in the field of outcome reporting was developed. As a case study, this was applied to a COS project for surgical trials in gastric cancer to translate a Delphi survey into 7 target languages from regions active in gastric cancer research.

Results

Three hundred thirty-two abstracts were screened and four studies addressing COS development in rheumatoid and osteoarthritis, vascular malformations and polypharmacy were eligible for inclusion. There was wide variation in methodological approaches to translation, including the number of forward translations, the inclusion of back translation, the employment of cognitive debriefing and how discrepancies and disagreements were handled. Important considerations were identified during the development of the gastric cancer survey including establishing translation groups, timelines, understanding financial implications, strategies to maximise recruitment and regulatory approvals. The methodological approach to translating the Delphi surveys was easily reproducible by local collaborators and resulted in an additional 637 participants to the 315 recruited to complete the source language survey. Ninety-nine per cent of patients and 97% of healthcare professionals from non-English-speaking regions used translated surveys.

Conclusion

Consideration of the issues described will improve planning by other COS developers and can be used to widen international participation from both patients and healthcare professionals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05338-x.

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

Is Colorectal Cancer Screening Appropriate in Nigeria?

PURPOSE

The global burden of colorectal cancer (CRC) will continue to increase for the foreseeable future, largely driven by increasing incidence and mortality in low- and middle-income countries (LMICs) such as Nigeria.

METHODS

We used the Wilson-Jungner framework (1968) to review the literature relevant to CRC screening in Nigeria and propose areas for future research and investment.

RESULTS

Screening is effective when the condition sought is both important and treatable within the system under evaluation. The incidence of CRC is likely increasing, although the exact burden of disease in Nigeria remains poorly understood and access to definitive diagnosis and treatment has not been systematically quantified. In high-income countries (HICs), CRC screening builds on a well-known natural history. In Nigeria, a higher proportion of CRC seems to demonstrate microsatellite instability, which is dissimilar to the molecular profile in HICs. Prospective trials, tissue banking, and next-generation sequencing should be leveraged to better understand these potential differences and the implications for screening. Fecal immunochemical test for hemoglobin (FIT) is recommended for LMICs that are considering CRC screening. However, FIT has not been validated in Nigeria, and questions about the impact of high ambient temperature, endemic parasitic infection, and feasibility remain unanswered. Prospective trials are needed to validate the efficacy of stool-based screening, and these trials should consider concomitant ova and parasite testing.

CONCLUSION

Using the Wilson-Jungner framework, additional work is needed before organized CRC screening will be effective in Nigeria. These deficits can be addressed without missing the window to mitigate the increasing burden of CRC in the medium to long term.

Presentation intervals and the impact of delay on breast cancer progression in a black African population

Background

The help-seeking interval and primary-care interval are points of delays in breast cancer presentation. To inform future intervention targeting early diagnosis of breast cancer, we described the contribution of each interval to the delay and the impact of delay on tumor progression.

Method

We conducted a multicentered survey from June 2017 to May 2018 hypothesizing that most patients visited the first healthcare provider within 60 days of tumor detection. Inferential statistics were by t-test, chi-square test, and Wilcoxon-Signed Rank test at p-value 0.05 or 95% confidence limits. Time-to-event was by survival method. Multivariate analysis was by logistic regression.

Results

Respondents were females between 24 and 95 years (n = 420). Most respondents visited FHP within 60 days of detecting symptoms (230 (60, 95% CI 53–63). Most had long primary-care (237 of 377 (64 95% CI 59–68) and detection-to-specialist (293 (73% (95% CI 68–77)) intervals. The primary care interval (median 106 days, IQR 13–337) was longer than the help-seeking interval (median 42 days, IQR 7–150) Wilcoxon signed-rank test p = 0.001. There was a strong correlation between the length of primary care interval and the detection-to-specialist interval (r = 0.9, 95% CI 0.88–0.92). Patronizing the hospital, receiving the correct advice, and having a big tumor (> 5 cm) were associated with short intervals.

Tumors were detected early, but most became advanced before arriving at the specialist clinic. The difference in tumor size between detection and arriving at a specialist clinic was 5.0 ± 4.9 cm (95% CI 4.0–5.0). The hazard of progressing from early to locally advanced disease was least in the first 30 days (3%). The hazard was 31% in 90 days.

Conclusion

Most respondents presented early to the first healthcare provider, but most arrived late at a specialist clinic. The primary care interval was longer than the help-seeking interval. Most tumors were early at detection but locally advanced before arriving in a specialist clinic. Interventions aiming to shorten the primary care interval will have the most impact on time to breast cancer presentation for specialist oncology care in Nigeria.

Safety and tolerability of injectable Rilpivirine LA in HPTN 076: A phase 2 HIV pre-exposure prophylaxis study in women

BACKGROUND

Daily oral TDF/FTC is protective against HIV infection when used for pre-exposure prophylaxis (PrEP). However, daily adherence to oral PrEP is difficult for many; therefore, finding alternative PrEP strategies remains a priority. HPTN 076 evaluated the long-acting injectable form of rilpivirine (RPV), known as RPV LA for safety, pharmacokinetics and acceptability.

METHODS

HPTN 076 (NTC 02165202) was a phase 2, double-blind, 2:1 randomized trial comparing the safety of 1200mg RPV LA (LA) to placebo (P). The study included a 28-day oral run-in phase of daily, self- administered oral RPV (25 mg), with directly observed oral dosing about six times. Of 136 enrolled sexually active, HIV-uninfected, low HIV-risk African (100) and US (36) adult women, injectable product was administered in two gluteal, intramuscular (IM) injections once every eight weeks to 122 participants following the oral run-in phase. A maximum of six injection time points occurred over a 48-week period. Acceptability, safety, tolerability and pharmacokinetic (PK) data were collected throughout the study. This paper includes primary endpoint data collected up to the week 52 post enrollment.

FINDINGS

The median age of the enrolled population was 31 years (IQR: 25,38), median weight 75 kg (IQR: 64, 89), median body mass index (BMI) 30 (IQR: 27, 35), 46% married, 94% Black and 60% unemployed. A total of 122 (80 LA, 42 P) women received at least one injection and 98 (64 LA, 34 P) received all six injections. During the injection phase, three women withdrew from the study (2 LA, 1 P) and 16 women discontinued study product (10 LA, 6 P). Fourteen women (11 LA and 3 P) discontinued oral study product and did not enter the injection phase. Study product discontinuations were not significantly different between the two arms throughout. Of the product discontinuations in the injection phase, 8% in LA and 5% in P arm were due to adverse events (AEs), including one randomized to the P arm with prolonged QTc interval on EKG. The proportion of women who experienced Grade 2 or higher AEs during the injection phase as the primary outcome was not significantly different between the two arms [73.8%, 95% CI: (63.2%, 82.1%) for LA and 73.8%, 95% CI: (58.9%, 84.7%), p>0.99]. Transient Grade ≥2 liver abnormalities occurred in 14% of women in the LA arm compared with 12% in P arm. Three LA women (4%) developed Grade 3 injection site reactions compared with none in P arm. In participants who received at least 1 injection, the geometric mean of overall RPV trough concentrations (Ctrough) was 62.2 ng/mL. In participants who received all six injections, the geometric mean of CTrough through the injection phase and after the last injection were 72.8 ng/mL and 100.9 ng/mL, respectively. At week 52 (eight weeks after last injection), the geometric mean of RPV Ctrough was 75.0 ng/mL. At the last injection visit (Week 44), 80 % of women who answered acceptability questions strongly agreed that they would think about using- and 68% that they would definitely use a PrEP injectable in the future.

INTERPRETATION

RPV LA IM injections every eight weeks in African and US women were safe and acceptable. Overall, despite more injection site reactions and pain in the participants receiving RPV LA the injections were well tolerated. Data from this study support the further development of injectable PrEP agents.

Treatment of colorectal cancer in Sub-Saharan Africa: Results from a prospective Nigerian hospital registry

BACKGROUND

Colorectal cancer (CRC) is the third most common cancer worldwide. Mortality for CRC is improving in high income countries, but in low and middle income countries, rates of disease and death from disease are rising. In Sub-Saharan Africa, the ratio of CRC mortality to incidence is the highest in the world. This study investigated the nature of CRC treatment currently being offered and received in Nigeria.

METHODS

Between April 2013 and October 2017, a prospective study of consecutively diagnosed cases of CRC was conducted. Patient demographics, clinical features, and treatment recommended and received was recorded for each case. Patients were followed during the study period every 3 months or until death.

RESULTS

Three hundred patients were included in our analysis. Seventy-one percent of patients received a recommended surgical operation. Of those that didn't undergo surgery as recommended, 37% cited cost as the main reason, 30% declined due to personal reasons, and less than 5% absconded or were lost to follow up. Approximately half of patients (50.5%) received a chemotherapy regimen when it was recommended, and 4.1% received radiotherapy when this was advised as optimal treatment. With therapy, the median overall survival for patients diagnosed with stage III and stage IV CRC was 24 and 10.5 months respectively. Overall, we found significantly better median survival for patients that received the recommended treatment (25 vs 7 months; P < .01).

CONCLUSIONS

A number of patients were unable to receive the recommended treatment, reflecting some of the burden of untreated CRC in the region. Receiving the recommended treatment was associated with a significant difference in outcome. Improved healthcare financing, literacy, training, access, and a better understanding of tumor biology will be necessary to address this discrepancy.

The Impact of Diet on the Involvement of Non-Coding RNAs, Extracellular Vesicles, and Gut Microbiome-Virome in Colorectal Cancer Initiation and Progression

Cancer is the major cause of morbidity and mortality in the world today. The third most common cancer and which is most diet related is colorectal cancer (CRC). Although there is complexity and limited understanding in the link between diet and CRC, the advancement in research methods have demonstrated the involvement of non-coding RNAs (ncRNAs) as key regulators of gene expression. MicroRNAs (miRNAs) which are a class of ncRNAs are key players in cancer related pathways in the context of dietary modulation. The involvement of ncRNA in cancer progression has recently been clarified throughout the last decade. ncRNAs are involved in biological processes relating to tumor onset and progression. The advances in research have given insights into cell to cell communication, by highlighting the pivotal involvement of extracellular vesicle (EV) associated-ncRNAs in tumorigenesis. The abundance and stability of EV associated ncRNAs act as a new diagnostic and therapeutic target for cancer. The understanding of the deranging of these molecules in cancer can give access to modulating the expression of the ncRNAs, thereby influencing the cancer phenotype. Food derived exosomes/vesicles (FDE) are gaining interest in the implication of exosomes in cell-cell communication with little or no understanding to date on the role FDE plays. There are resident microbiota in the colon; to which the imbalance in the normal intestinal occurrence leads to chronic inflammation and the production of carcinogenic metabolites that lead to neoplasm. Limited studies have shown the implication of various types of microbiome in CRC incidence, without particular emphasis on fungi and protozoa. This review discusses important dietary factors in relation to the expression of EV-associated ncRNAs in CRC, the impact of diet on the colon ecosystem with particular emphasis on molecular mechanisms of interactions in the ecosystem, the influence of homeostasis regulators such as glutathione, and its conjugating enzyme-glutathione S-transferase (GST) polymorphism on intestinal ecosystem, oxidative stress response, and its relationship to DNA adduct fighting enzyme-0-6-methylguanine-DNA methyltransferase. The understanding of the molecular mechanisms and interaction in the intestinal ecosystem will inform on the diagnostic, preventive and prognosis as well as treatment of CRC.

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

BACKGROUND

Surgical 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.

METHODS

This 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.

FINDINGS

Between 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).

INTERPRETATION

Countries 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.

FUNDING

DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.

A symptom-based model to predict colorectal cancer in low-resource countries: Results from a prospective study of patients at high risk for colorectal cancer

BACKGROUND

Colorectal cancer (CRC) rates in low-resource countries, which typically lack CRC screening programs, are rising. This study determined whether a risk model for patients with rectal bleeding could identify patients with curable CRC.

METHODS

This prospective, cross-sectional study evaluated a model constructed from data from 1 hospital and validated at 2 other hospitals. The primary endpoint was the ability of the model to predict CRC, as diagnosed by colonoscopy, from clinical characteristics. The secondary endpoint was to determine the percentage of patients who had CRC.

RESULTS

Consecutive patients who were 45 years old or older and had self-reported rectal bleeding for more than 1 week were evaluated. From January 2014 to July 2016, 362 patients answered a questionnaire and underwent colonoscopy. In the validation cohort, 56% of patients with rectal bleeding, weight loss, and changes in bowel habits had CRC, whereas 2% of patients with bleeding alone did. Overall, 18.2% of the patients had CRC, and 8.6% had adenomas. The proportion of CRC patients with potentially curable stage II or III disease was 74%, whereas the historical rate was 36%. The combination of rectal bleeding with both symptoms significantly predicted CRC in the validation set (odds ratio, 12.8; 95% confidence interval, 4.6-35.4; P < .001).

CONCLUSIONS

In low-resource settings, patients with rectal bleeding, weight loss, and changes in bowel habits should be classified as high risk for CRC. Patients with a high risk score should be prioritized for colonoscopy to increase the number of patients diagnosed with potentially curable CRC. Cancer 2018;124:2766-2773. © 2018 American Cancer Society.

Universal dependence of the spin wave band structure on the geometrical characteristics of two-dimensional magnonic crystals

In the emerging field of magnon-spintronics, spin waves are exploited to encode, carry and process information in materials with periodic modulation of their magnetic properties, named magnonic crystals. These enable the redesign of the spin wave dispersion, thanks to its dependence on the geometric and magnetic parameters, resulting in the appearance of allowed and forbidden band gaps for specific propagation directions. In this work, we analyze the spin waves band structure of two-dimensional magnonic crystals consisting of permalloy square antidot lattices with different geometrical parameters. We show that the frequency of the most intense spin-wave modes, measured by Brillouin light scattering, exhibits a universal dependence on the aspect ratio (thickness over width) of the effective nanowire enclosed between adjacent rows of holes. A similar dependence also applies to both the frequency position and the width of the main band gap of the fundamental (dispersive) mode at the edge of the first Brillouin zone. These experimental findings are successfully explained by calculations based on the plane-wave method. Therefore, a unified vision of the spin-waves characteristics in two-dimensional antidot lattices is provided, paving the way to the design of tailored nanoscale devices, such as tunable magnonic filters and phase-shifters, with predicted functionalities.

Residues of organochlorine pesticides in fruits, vegetables and tubers from Nigerian markets

Residue levels of organochlorine pesticides have been determined in raw fruits, vegetables and tubers from markets in Nigeria. In the fruits, total HCH, aldrin and total DDT were detected in 77, 38 and 30% of all samples, respectively. In the vegetables, total HCH, HCB, total DDT and aldrin were detected from 95, 53, 50 and 30%, respectively, of all samples. Aldrin + dieldrin, total HCH, and total DDT were detected from 98, 79 and 49%, respectively, of all tuber samples. Other pesticides were below their detection limits. The average levels were generally low and none were above the FAOs maximum residue limits.

Studies on the antigenic S-type lipopolysaccharides of Brucella abortus strains 7 and Mustapha

Antigenic phenol phase S-type lipopolysaccharides (LPS) isolated from Brucella abortus (B. abortus) strains 7 and Mustapha were observed to have 13C n.m.r. spectra which were almost identical to the one reported for the Brucella abortus 1119-3. The glycosyl content of the lipid A obtained from the LPS of strain 7 was found to be 2-acetamido-2-deoxyglucose only while strain Mustapha was found to contain both 2-acetamido-2-deoxyglucose and 2-acetamido-2-deoxygalactose. The fatty acid present in the lipid A of both strains was mainly n-hexadecanoic acid. Octadecanoic acid, 3-hydroxytetradecanoic acid as well as small quantities of 3-hydroxydodecanoic acid were also identified. This contrasts with the earlier reports of the absence of 3-OH-14:0 in the LPS of Brucella abortus.

Studies on the chemical constitution of cell wall lipo-oligosaccharide from Campylobacter coli Labet 227

The lipo-oligosaccharide (LOS) from Campylobacter coli Labet 227 was extracted by aqueous phenol. After delipidation and gel chromatography, two oligosaccharides were isolated. The higher molecular weight material OS (I) which was estimated to contain six to seven sugar units was found to contain glucose, galactose, 2-acetamido-2-deoxyglucose, 2-acetamido-2-deoxygalactose and heptose. Analysis of the partially methylated alditol acetates by g.c.-m.s. revealed the presence of terminal hexoses, a 1.3-linked hexose, a terminal heptose, a 1,2,3-linked heptose as well as smaller quantities of a 1,3,4-linked heptose. 1H-n.m.r. spectra showed signals corresponding to six anomeric protons. The signals which corresponded to the methyl protons of the acetamido side chain confirmed that the acetamido forms of both amino sugars were present in OS (I). The lower molecular weight material OS (II) which was estimated to contain four sugar units was found to contain glucose, 2-acetamido-2-deoxy-galactose and very small quantities of heptose. It thus appears that OS (I) and OS (II) are the core oligosaccharides elaborated by this micro-organism. The possibility of a heterogeneous core is thus presented. The fatty acids present in the LOS were mainly 3-hydroxytetradecanoic acid, n-hexadecanoic acid and trace amounts of n-tetradecanoic acid and n-octadecanoic acid.

Structural studies of the Escherichia coli O-149 O-antigen polysaccharide

The structure of the O-antigen polysaccharide from Escherichia coli O-149 has been investigated; methylation analysis, partial hydrolysis with acid, and n.m.r. spectroscopy were the principal methods used. It is concluded that the polysaccharide is composed of trisaccharide repeating-units having the following structure. (Formula: see text). The absolute configuration at the acetalic carbon atom of the pyruvic acid residue is S.