Correspondence
www.thelancet.com Vol 387 February 6, 2016
is widespread, and perhaps needed, for all publicly supported agencies in democratic societies; but reason must prevail. Although not perfect, we believe the VHA is probably the best health-care model for people who have borne the burden of battle. Health-care professionals help those who are called to arms in the tradition of excellence they deserve; the quality of these services needs recognition and respect. We are employees of the Department of Veterans Affairs. The opinions expressed are those of the authors and not those of the US Government or the Department of Veterans Affairs.
*Earl Gaar, Jon White, Ralph G DePalma [email protected] Department of Veterans Affairs, Robley Rex Veteran Affairs Medical Center, University of Louisville School of Medicine, Louisville, KY, USA (EG); Department of Veterans Affairs, Washington DC Veterans Affairs Medical Center, Washington, DC, USA (JW); Department of Surgery, George Washington University, Washington, DC, USA (JW); Veteran Affairs Office of Research and Development, Department of Veterans Affairs, Washington, DC, USA (RGD); and Department of Surgery, Uniformed University of the Health Sciences, Bethesda, MD, USA (RGD) 1 2
3
The Lancet. Veterans’ health care: a call of duty. Lancet 2015; 386: 1014. United States Department of Veterans Affairs. National Center for Veteran Analysis and Statistics. 2015. http://www.va.gov/vetdata (accessed Nov 1, 2015). Longman P. Best care anywhere: why VA health care is better than yours. San Francisco, CA: Berrett-Koehler Publishers, 2012.
Bacterial neonatal sepsis and antibiotic resistance in low-income countries Tackling neonatal sepsis and antibiotic resistance is extremely challenging in low-income countries where neonatal mortality is high and antibiotic resistance is growing.1,2 Essential data on the burden of severe bacterial infections in neonates and bacterial causes are scarce in low-income countries, and the role of antibiotic resistance remains unclear. Relevant surveillance systems are needed to improve understanding of these issues and to guide local, regional,
and international public health policies. Importantly, surveillance of infections should include rigorous population-level measures within the community because a large proportion of people in low-income countries might not consult in-health facilities. Additionally, effective surveillance must account for the timely diagnosis of severe bacterial infections, which can be challenging in low-income country settings and particularly for neonates as infections can quickly become fatal. Along with scarce access to health facilities, early detection of severe bacterial infections is further delayed by inadequate family knowledge of clinical signs suggestive of neonatal infections and training of health-care workers. Lastly, accurate bacterial diagnosis and resistance profiles need health-care workers to be trained to take samples from infants and need skilled staff with access to appropriate laboratory equipment, which are generally only available in hospitals in low-income countries.3 Additionally, optimisation of treatment against severe bacterial infections should be a priority in lowincome countries to reduce mortality and manage antibiotic resistance. Unfortunately, it is not currently possible to update local antibiotic guidelines and change patient antibiotic regimens in many countries because there is no diagnostic capacity (eg, resistance profiles). Development of innovative point-of-care instruments for use in low-income countries might provide a solution. New antibiotics would help to restrict the emergence of resistance and to treat severe bacterial infections, but their use needs to be monitored to avoid the development of new resistance mechanisms.4 Lastly, a better understanding of the driving forces of bacterial sepsis and transmission, particularly the role of mother-to-child transmission, is needed to help fight neonatal sepsis and antibiotic resistance. 5 Insights are needed into the factors that affect pathogenicity and
Mauro Fermariello/Science Photo Library
many published, peer-reviewed studies. Both the VHA and the NHS face unique public relations problems. In the USA, however, 151 VHA hospitals operate in the same geographical area served by 5000 non-VHA hospitals. Both the VHA and the NHS are directed by and answer to political administrative organisations responsible for overseeing the service, which might not be as responsive as private sector organisations. The VHA should respond with honesty and integrity to congressional oversight. The increase in veteran enrollees and demand for more primary and emergent care led to access problems in the VHA system. The well publicised mistakes at the Phoenix Veteran Affairs Medical Center in 2014 have been published. Prompt responses allowed veterans who lived 40 miles away from a VHA facility, needed specialty services that were not available, or had to wait more than 30 days for any appointment to access the Veterans Choice programme of private care. VHA health services research is now carefully assessing efficiency and quality outcomes of this alternative care option. Anecdotal reports suggest that some patients who used the Veterans Choice programme returned to the VHA because waiting times in the private sector are often longer than those in the VHA. Despite the deluge of criticisms, a large, loyal group of patients prefer to receive health care from the VHA. Most healthcare systems outside of the VHA are not equipped to handle the unique health-care needs of veterans, who have two to three times the number of comorbidities as non-veteran patients in the private sector. Comparisons of VHA and private sector health care have been highly complimentary of VHA care.3 The VHA Surgical Quality Improvement Program has been adopted by the American College of Surgeons as a national model. Continued vilification of the VHA is as demoralising to its committed professionals as it would be to those working in the NHS. Public critique
533
Correspondence
transmissibility of multidrug-resistant bacteria and mobile genetic elements, especially about extended-spectrum β-lactamases or carbapenemase producing Enterobacteriaceae that cause a substantial proportion of neonatal sepsis. Currently, bacterial infections and antibiotic resistance in children— especially neonates—in low-income countries is a neglected, international, public health problem. To tackle and decrease neonatal mortality from these two major threats requires addressing the challenges described in addition to increasing awareness of national policy makers, establishing programmes to combat bacterial neonatal sepsis and resistance in health-care systems, and stimulating necessary research programmes. All authors report grants from TOTAL Corporate Foundation, MSDAVENIR, Monaco Department of International Cooperation, and Institut Pasteur. We declare no competing interests.
For the members of the BIRDY study group see appendix
*Bich-Tram Huynh, Michael Padget, Benoit Garin, Elisabeth Delarocque-Astagneau, Didier Guillemot, on behalf of the BIRDY study group [email protected] INSERM UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases, (B2PHI), F-75015 Paris, France (B-TH, MP, ED-A, DG); Molecular Prevention and Therapy of Human Diseases (BG), Institut Pasteur, B2PHI, Paris, France (B-TH, MP, ED-A, DG); Université de Versailles Saint-Quentin, UMR 1181, B2PHI, Montigny-le-Bretonneux, France (DG); and AP-HP, Raymond Poincare Hospital, Garches, France (DG) 1
2
3
4
5
534
Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet 2015; 385: 430–40. WHO. Antimicrobial resistance: global report on surveillance 2014. Geneva: World Health Organization, 2014. Huynh BT, Padget M, Garin B, et al. Burden of bacterial resistance among neonatal infections in low income countries: how convincing is the epidemiological evidence? BMC Infect Dis 2015; 15: 127. Köser CU, Ellington MJ, Peacock SJ. Whole-genome sequencing to control antimicrobial resistance. Trends Genet 2014; 30: 401–07. Chan GJ, Lee AC, Baqui AH, Tan J, Black RE. Risk of early-onset neonatal infection with maternal infection or colonization: a global systematic review and meta-analysis. PLoS Med 2013; 10: e1001502.
Closure of abdominal midline incisions: STITCH trial In the STITCH randomised controlled trial (Sept 26, p 1254),1 the rate of incisional hernia after midline abdominal closure was significantly lower in patients who had received sutures with small tissue bites than in those with sutures with large tissue bites. Eva Deerenberg and colleagues state that small bite running sutures should become the standard closure technique for midline incisions, but this statement might not be supported by solid evidence. Continuous sutures are not always better than interrupted sutures in terms of incisional hernia rates after midline abdominal closure. Results from a meta-analysis of randomised controlled trials using various suture materials showed an advantage in using running sutures,2 whereas a large multicentre randomised controlled trial 3 did not show a difference between the two techniques. Although the European Hernia Society guidelines2 recommend a continuous suture technique for midline abdominal closure on the basis of one metaanalysis, the Society acknowledges that most of the studies included in the meta-analysis were at high risk of bias.4 Eva Deerenberg and colleagues argue that their results can be applied to the general surgical population. The STITCH trial seems to be designed on the basis of a randomised controlled trial, in which wounds were closed with an inadequate ratio of suture length to wound length in 9·8% of patients in the short-stitch group and 2·9% of patients in the long-stitch group.5 As the stitch length becomes shorter, an appropriate suture length to wound length ratio might become more difficult to achieve. In one multicentre randomised controlled trial,3 incisional hernia rates among participating institutions were considerably different, ranging from 0% to 25%. If the outcomes of operation vary considerably among the
institutions and surgeons in the STITCH trial, running sutures with small tissue bites might not be highly generalisable. I declare no competing interests.
Tetsuji Fujita [email protected] Department of Surgery, Jikei University School of Medicine, Tokyo 105–8461, Japan 1
2
3
4
5
Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet 2015; 386: 1254–60. Diener MK, Voss S, Jensen K, et al. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann Surg 2010; 251: 843–56. Seiler CM, Bruckner T, Diener MK, et al. Interrupted or continuous slowly absorbable sutures for primary closure of elective midline abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). Ann Surg 2009; 249: 576–82. Muysoms FE, Antoniou SA, Bury K, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia 2015; 19: 1–24. Fujita T. Choosing a better technique for midline abdominal closure. J Am Coll Surg 2014; 218: 150–52.
We read with interest the results of the STITCH trial, 1 which included laparotomies for different subspecialist surgeries (vascular, gynaecological, and upper and lower gastrointestinal). The rate of incisional hernia varied depending on disease state, and patient characteristics were different between subspecialties. We believe that the trial is flawed in design and, therefore, the conclusions are invalid. Comparison of the two different suture materials and needles is inappropriate—this should have been standardised to eliminate bias. Because of this drawback, general statements cannot be made because the effect might be due to the suture material rather than the technique itself. The authors have mixed clean laparotomy cases with contaminated cases involving bowel surgery. The mortality rates and re-laparotomy rates were very high, which certainly does not match with gynaecological cancer surgery cases. We also believe that the 1 year followup is inadequate to establish true www.thelancet.com Vol 387 February 6, 2016
www.thelancet.com Vol 387 February 6, 2016
is widespread, and perhaps needed, for all publicly supported agencies in democratic societies; but reason must prevail. Although not perfect, we believe the VHA is probably the best health-care model for people who have borne the burden of battle. Health-care professionals help those who are called to arms in the tradition of excellence they deserve; the quality of these services needs recognition and respect. We are employees of the Department of Veterans Affairs. The opinions expressed are those of the authors and not those of the US Government or the Department of Veterans Affairs.
*Earl Gaar, Jon White, Ralph G DePalma [email protected] Department of Veterans Affairs, Robley Rex Veteran Affairs Medical Center, University of Louisville School of Medicine, Louisville, KY, USA (EG); Department of Veterans Affairs, Washington DC Veterans Affairs Medical Center, Washington, DC, USA (JW); Department of Surgery, George Washington University, Washington, DC, USA (JW); Veteran Affairs Office of Research and Development, Department of Veterans Affairs, Washington, DC, USA (RGD); and Department of Surgery, Uniformed University of the Health Sciences, Bethesda, MD, USA (RGD) 1 2
3
The Lancet. Veterans’ health care: a call of duty. Lancet 2015; 386: 1014. United States Department of Veterans Affairs. National Center for Veteran Analysis and Statistics. 2015. http://www.va.gov/vetdata (accessed Nov 1, 2015). Longman P. Best care anywhere: why VA health care is better than yours. San Francisco, CA: Berrett-Koehler Publishers, 2012.
Bacterial neonatal sepsis and antibiotic resistance in low-income countries Tackling neonatal sepsis and antibiotic resistance is extremely challenging in low-income countries where neonatal mortality is high and antibiotic resistance is growing.1,2 Essential data on the burden of severe bacterial infections in neonates and bacterial causes are scarce in low-income countries, and the role of antibiotic resistance remains unclear. Relevant surveillance systems are needed to improve understanding of these issues and to guide local, regional,
and international public health policies. Importantly, surveillance of infections should include rigorous population-level measures within the community because a large proportion of people in low-income countries might not consult in-health facilities. Additionally, effective surveillance must account for the timely diagnosis of severe bacterial infections, which can be challenging in low-income country settings and particularly for neonates as infections can quickly become fatal. Along with scarce access to health facilities, early detection of severe bacterial infections is further delayed by inadequate family knowledge of clinical signs suggestive of neonatal infections and training of health-care workers. Lastly, accurate bacterial diagnosis and resistance profiles need health-care workers to be trained to take samples from infants and need skilled staff with access to appropriate laboratory equipment, which are generally only available in hospitals in low-income countries.3 Additionally, optimisation of treatment against severe bacterial infections should be a priority in lowincome countries to reduce mortality and manage antibiotic resistance. Unfortunately, it is not currently possible to update local antibiotic guidelines and change patient antibiotic regimens in many countries because there is no diagnostic capacity (eg, resistance profiles). Development of innovative point-of-care instruments for use in low-income countries might provide a solution. New antibiotics would help to restrict the emergence of resistance and to treat severe bacterial infections, but their use needs to be monitored to avoid the development of new resistance mechanisms.4 Lastly, a better understanding of the driving forces of bacterial sepsis and transmission, particularly the role of mother-to-child transmission, is needed to help fight neonatal sepsis and antibiotic resistance. 5 Insights are needed into the factors that affect pathogenicity and
Mauro Fermariello/Science Photo Library
many published, peer-reviewed studies. Both the VHA and the NHS face unique public relations problems. In the USA, however, 151 VHA hospitals operate in the same geographical area served by 5000 non-VHA hospitals. Both the VHA and the NHS are directed by and answer to political administrative organisations responsible for overseeing the service, which might not be as responsive as private sector organisations. The VHA should respond with honesty and integrity to congressional oversight. The increase in veteran enrollees and demand for more primary and emergent care led to access problems in the VHA system. The well publicised mistakes at the Phoenix Veteran Affairs Medical Center in 2014 have been published. Prompt responses allowed veterans who lived 40 miles away from a VHA facility, needed specialty services that were not available, or had to wait more than 30 days for any appointment to access the Veterans Choice programme of private care. VHA health services research is now carefully assessing efficiency and quality outcomes of this alternative care option. Anecdotal reports suggest that some patients who used the Veterans Choice programme returned to the VHA because waiting times in the private sector are often longer than those in the VHA. Despite the deluge of criticisms, a large, loyal group of patients prefer to receive health care from the VHA. Most healthcare systems outside of the VHA are not equipped to handle the unique health-care needs of veterans, who have two to three times the number of comorbidities as non-veteran patients in the private sector. Comparisons of VHA and private sector health care have been highly complimentary of VHA care.3 The VHA Surgical Quality Improvement Program has been adopted by the American College of Surgeons as a national model. Continued vilification of the VHA is as demoralising to its committed professionals as it would be to those working in the NHS. Public critique
533
Correspondence
transmissibility of multidrug-resistant bacteria and mobile genetic elements, especially about extended-spectrum β-lactamases or carbapenemase producing Enterobacteriaceae that cause a substantial proportion of neonatal sepsis. Currently, bacterial infections and antibiotic resistance in children— especially neonates—in low-income countries is a neglected, international, public health problem. To tackle and decrease neonatal mortality from these two major threats requires addressing the challenges described in addition to increasing awareness of national policy makers, establishing programmes to combat bacterial neonatal sepsis and resistance in health-care systems, and stimulating necessary research programmes. All authors report grants from TOTAL Corporate Foundation, MSDAVENIR, Monaco Department of International Cooperation, and Institut Pasteur. We declare no competing interests.
For the members of the BIRDY study group see appendix
*Bich-Tram Huynh, Michael Padget, Benoit Garin, Elisabeth Delarocque-Astagneau, Didier Guillemot, on behalf of the BIRDY study group [email protected] INSERM UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases, (B2PHI), F-75015 Paris, France (B-TH, MP, ED-A, DG); Molecular Prevention and Therapy of Human Diseases (BG), Institut Pasteur, B2PHI, Paris, France (B-TH, MP, ED-A, DG); Université de Versailles Saint-Quentin, UMR 1181, B2PHI, Montigny-le-Bretonneux, France (DG); and AP-HP, Raymond Poincare Hospital, Garches, France (DG) 1
2
3
4
5
534
Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet 2015; 385: 430–40. WHO. Antimicrobial resistance: global report on surveillance 2014. Geneva: World Health Organization, 2014. Huynh BT, Padget M, Garin B, et al. Burden of bacterial resistance among neonatal infections in low income countries: how convincing is the epidemiological evidence? BMC Infect Dis 2015; 15: 127. Köser CU, Ellington MJ, Peacock SJ. Whole-genome sequencing to control antimicrobial resistance. Trends Genet 2014; 30: 401–07. Chan GJ, Lee AC, Baqui AH, Tan J, Black RE. Risk of early-onset neonatal infection with maternal infection or colonization: a global systematic review and meta-analysis. PLoS Med 2013; 10: e1001502.
Closure of abdominal midline incisions: STITCH trial In the STITCH randomised controlled trial (Sept 26, p 1254),1 the rate of incisional hernia after midline abdominal closure was significantly lower in patients who had received sutures with small tissue bites than in those with sutures with large tissue bites. Eva Deerenberg and colleagues state that small bite running sutures should become the standard closure technique for midline incisions, but this statement might not be supported by solid evidence. Continuous sutures are not always better than interrupted sutures in terms of incisional hernia rates after midline abdominal closure. Results from a meta-analysis of randomised controlled trials using various suture materials showed an advantage in using running sutures,2 whereas a large multicentre randomised controlled trial 3 did not show a difference between the two techniques. Although the European Hernia Society guidelines2 recommend a continuous suture technique for midline abdominal closure on the basis of one metaanalysis, the Society acknowledges that most of the studies included in the meta-analysis were at high risk of bias.4 Eva Deerenberg and colleagues argue that their results can be applied to the general surgical population. The STITCH trial seems to be designed on the basis of a randomised controlled trial, in which wounds were closed with an inadequate ratio of suture length to wound length in 9·8% of patients in the short-stitch group and 2·9% of patients in the long-stitch group.5 As the stitch length becomes shorter, an appropriate suture length to wound length ratio might become more difficult to achieve. In one multicentre randomised controlled trial,3 incisional hernia rates among participating institutions were considerably different, ranging from 0% to 25%. If the outcomes of operation vary considerably among the
institutions and surgeons in the STITCH trial, running sutures with small tissue bites might not be highly generalisable. I declare no competing interests.
Tetsuji Fujita [email protected] Department of Surgery, Jikei University School of Medicine, Tokyo 105–8461, Japan 1
2
3
4
5
Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial. Lancet 2015; 386: 1254–60. Diener MK, Voss S, Jensen K, et al. Elective midline laparotomy closure: the INLINE systematic review and meta-analysis. Ann Surg 2010; 251: 843–56. Seiler CM, Bruckner T, Diener MK, et al. Interrupted or continuous slowly absorbable sutures for primary closure of elective midline abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). Ann Surg 2009; 249: 576–82. Muysoms FE, Antoniou SA, Bury K, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia 2015; 19: 1–24. Fujita T. Choosing a better technique for midline abdominal closure. J Am Coll Surg 2014; 218: 150–52.
We read with interest the results of the STITCH trial, 1 which included laparotomies for different subspecialist surgeries (vascular, gynaecological, and upper and lower gastrointestinal). The rate of incisional hernia varied depending on disease state, and patient characteristics were different between subspecialties. We believe that the trial is flawed in design and, therefore, the conclusions are invalid. Comparison of the two different suture materials and needles is inappropriate—this should have been standardised to eliminate bias. Because of this drawback, general statements cannot be made because the effect might be due to the suture material rather than the technique itself. The authors have mixed clean laparotomy cases with contaminated cases involving bowel surgery. The mortality rates and re-laparotomy rates were very high, which certainly does not match with gynaecological cancer surgery cases. We also believe that the 1 year followup is inadequate to establish true www.thelancet.com Vol 387 February 6, 2016
