Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov , NCT04384926 . Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include...

Background There are few prospective studies of outcomes following surgery in rural district hospitals in sub‐Saharan Africa. This study aimed to estimate the prevalence and predictors of surgical‐site infection (SSI) following caesarean section at Kirehe District Hospital in rural Rwanda. Methods Adult women who underwent caesarean section between March and October 2017 were given a voucher to return to the hospital on postoperative day (POD) 10 (±3 days). At the visit, a physician evaluated the patient for an SSI. A multivariable logistic regression model was used to identify risk factors for SSI, built using backward stepwise selection. Results Of 729 women who had a caesarean section, 620 were eligible for follow‐up, of whom 550 (88·7 per cent) returned for assessment. The prevalence of SSI on POD 10 was 10·9 per cent (60 women). In the multivariable analysis, the following factors were significantly associated with SSI: bodyweight more than 75 kg (odds ratio (OR) 5·98, 1·56 to 22·96; P = 0·009); spending more than €1·1 on travel to the health centre (OR 2·42, 1·31 to 4·49; P = 0·005); being a housewife compared with a farmer (OR 2·93, 1·08 to 7·97; P = 0·035); and skin preparation with a single antiseptic compared with a combination of two antiseptics (OR 4·42, 1·05 to 18·57; P = 0·043). Receiving either preoperative or postoperative antibiotics was not associated with SSI. Conclusion The prevalence of SSI after caesarean section is consistent with rates reported at tertiary facilities in sub‐Saharan Africa. Combining antiseptic solutions for skin preparation could reduce the risk of SSI.

Objective Arterial stiffness and peripheral artery disease (PAD) are both associated with an elevated risk of major adverse cardiac events (MACE); however, the association between arterial stiffness and PAD is less well characterized. The goal of the present study was to examine the association between parameters of radial artery tonometry, a non-invasive measure of arterial stiffness, and PAD. Methods We conducted a cross-sectional study of 134 vascular surgery outpatients (controls=33, PAD=101) using arterial applanation tonometry. Central augmentation index normalized to 75bpm (central AIX) and peripheral augmentation index (peripheral AIX) were measured using radial artery pulse wave analysis (PWA). Pulse wave velocity (PWV) was recorded at the carotid and femoral arteries. PAD was defined as symptomatic claudication with an ankle-brachial index (ABI) of <0.9 or a history of peripheral revascularization. Controls had no history of atherosclerotic vascular disease and an ABI≥0.9. Results Among the 126 participants with high quality tonometry data, compared to controls (n=33), patients with PAD (n=93) were older, with higher rates of hypertension, hyperlipidemia, diabetes, and smoking (P<.05). Patients with PAD also had greater arterial stiffness as measured by central AIX, peripheral AIX, and PWV (P<.05). In a multivariable model, each 10-unit increase in central and peripheral AIX was associated with significantly increased odds of PAD (OR 2.1, 95% CI 1.1–3.9, P=.03 and OR 1.9, 95% CI 1.2–3.2, P=.01, respectively). Additionally, central and peripheral AIX were highly correlated (r(120)=.76, P<.001). Conclusions In a cross-sectional analysis, arterial stiffness as measured by the augmentation index is independently associated with PAD, even when adjusting for several atherosclerotic risk factors. Further prospective data is needed to establish whether radial artery tonometry could be a tool for risk stratification in the PAD population.