Summary 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.
Age-adjusted charlson comorbidity index (a-cci) score has been used to weight comorbid conditions in predicting adverse outcomes. A retrospective cohort study on adult patients diagnosed with complicated intra-abdominal infections (ciAi) requiring emergency surgery was conducted in order to elucidate the role of age and comorbidity in this scenario. two main outcomes were evaluated: 90-day severe postoperative complications (grade ≥ 3 of Dindo-Clavien Classification), and 90-day all-cause mortality. 358 patients were analyzed. a-CCI score for each patient was calculated and then divided in two comorbid categories whether they were ≤ or > to percentile 75 (= 4): Grade-A (0-4) and Grade-B (≥ 5). Univariate and multivariate regression analyses were performed, and the predictive validity of the models was evaluated by the area under the receiver operating characteristics (AUROC) curve. Independent predictors of 90-day severe postoperative complications were Charlson Grade-B (Odds Ratio [OR] = 3.49, 95% confidence interval [95%CI]: 1.86-6.52; p < 0.0001), healthcarerelated infections (oR = 7.84, 95%CI: 3.99-15.39; p < 0.0001), diffuse peritonitis (OR = 2.64, 95%CI: 1.45-4.80; p < 0.01), and delay of surgery > 24 hours (OR = 2.28, 95%CI: 1.18-4.68; p < 0.02). The AUROC was 0.815 (95%CI: 0.758-0.872). Independent predictors of 90-day mortality were Charlson Grade-B (OR = 8.30, 95%CI: 3.58-19.21; p < 0.0001), healthcare-related infections (OR = 6.38, 95%CI: 2.72-14.95; p < 0.0001), sepsis status (OR = 3.98, 95%CI: 1.04-15.21; p < 0.04) and diffuse peritonitis (oR = 3.06, 95%CI: 1.29-7.27; p < 0.01). The AUROC for mortality was 0.887 (95%CI: 0.83-0.93). Posthoc sensitivity analyses confirmed that the degree of comorbidity, estimated by using an age-adjusted score, has a critical impact on the postoperative course following emergency surgery for ciAi. early assessment and management of patient's comorbidity is mandatory at emergency setting. Complicated intra-abdominal infections (cIAI) are the second most common site of invasive infections in critically ill patients 1. They are associated with poor outcomes in high risk patients, with an estimated overall mortality ranging from 10% to 35% 2-4. cIAI implies the extension of the process beyond the organ to the peritoneal cavity and is then associated with localized or diffuse peritonitis. A landmark multi-centric international prospective cohort study, evaluated adult patients presenting with cIAI undergoing surgery or interventional drainage and identified the independent risk factors of mortality 3. They were namely patient's age, immunosuppression, small bowel perforations, a delay of initial intervention over 24 hours, and intensive care unit (ICU) admission. Previous studies on IAI also showed other factors that potentially influence patient's prognosis, such as an extended peritonitis, sepsis development, or healthcare-related infections 4. An emergency surgical procedure is often needed in the management of cIAI, leading to a non-despicable cost burden to healthcare ...
Sedation is routinely required for successful Magnetic Resonance imaging in infants and children. Five hundred and ninety-six paediatric patients (270 female and 326 male, age (mean +/- SD) 41 +/- 30 months and weight 14.8 +/- 6.5 kg) entered an open, non-comparative, prospective study to assess oral chloral hydrate sedation in a large and homogeneous paediatric population undergoing Magnetic Resonance imaging. Chloral hydrate syrup 70 mg/ml was administered 20-40 min prior to the procedure. Effective sedation was reached in 94.1% with a total dose (mean +/- SEM) of 68 +/- 1 mg/kg (range 20-170 mg/kg). Statistical analysis of sedation failures vs. successful examinations after the total dose showed significant differences for dose (62 +/- 4 vs. 69 +/- 1 mg/kg; P < 0.05), age (64 +/- 7 vs. 40 +/- 1 months; P < 0.001) and weight (19.8 +/- 1.5 vs. 14.5 +/- 0.0 kg; P < 0.001). Effectiveness fell to around 80% in children with encephalic white matter alterations, medullary tumours or syringohydromyela (P = 0.07). The mean time of onset of sedation was 26 +/- 1 min, and the mean time to spontaneous awakening after the completion of the Magnetic Resonance examination was 38 +/- 2 min. Fifty-nine children (9.9%) experienced adverse reactions, with nausea and vomiting being the most common (n = 41), followed by nervousness and unusual excitement (n = 6). Discriminant function analysis identified age and total dose as the quantitative variables helping to differentiate between sedation failures and satisfactory examinations (sensitivity = 0.73, and specificity = 0.61; r = 0.20, P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
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