Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

PORT significantly reduces LRF but has no effect on OS and DFS. However, due to poor patient accrual and older radiotherapy techniques in previous studies, there is a need for a new trial to evaluate PORT using conformal and intensity-modulated radiotherapy techniques.

y The SNAP-2: EPICCS collaborators are listed in Supplementary material. AbstractBackground: Decisions to admit high-risk postoperative patients to critical care may be affected by resource availability. We aimed to quantify adult ICU/high-dependency unit (ICU/HDU) capacity in hospitals from the UK, Australia, and New Zealand (NZ), and to identify and describe additional 'high-acuity' beds capable of managing high-risk patients outside the ICU/HDU environment. Methods: We used a modified Delphi consensus method to design a survey that was disseminated via investigator networks in the UK, Australia, and NZ. Hospital-and ward-level data were collected, including bed numbers, tertiary services offered, presence of an emergency department, ward staffing levels, and the availability of critical care facilities. Results: We received responses from 257 UK (response rate: 97.7%), 35 Australian (response rate: 32.7%), and 17 NZ (response rate: 94.4%) hospitals (total 309). Of these hospitals, 91.6% reported on-site ICU or HDU facilities. UK hospitals

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high‐ (HICs) and low‐ and middle‐income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7‐day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.

Background: The rapid changes in practice of radiotherapy have taken place over the past 5 years in Pakistan. With advent of computed tomography simulator, and multileaf collimators–assisted linear accelerators and electronic portal imaging system, few centres in Pakistan have switched from conventional radiotherapy to modern computer-based technology. Our hospital is first centre in Pakistan which is using virtual simulation since March 2006. We present our experience with list of merits and demerits.Design: Retrospective study.Patient collection: Medical records of all patients who received radiotherapy in our centre were reviewed. Parameters included were type of malignancy, type radiotherapy (curative/palliative), simulation and planning process time and the displacement of the beam-axis from the planning isocentre in clinical situations during three-dimensional conformal radiotherapy using electronic portal imaging device (EPID). Data were collected on written proforma. Percentages, frequencies, measures of central tendency and dispersion were calculated using SPSS version 17.0.Results: A total of 289 patients were treated from March 2006 to November 2008. Transitional cell carcinoma of urinary bladder was most common malignancy seen (42.4%) followed by prostate (28.62%) and renal cell carcinoma (14.14%). Of these 34.26% patients were treated on curative basis. The virtual simulation process could be completed in an average time of 5 min (SD 3.5). Under many cases, the treatment portals could be designed and the patient marked in one session. The displacements were recorded for 43 portals for early prostate cancer using an EPID system. The mean displacement was found 2.44 ± 0.8 mm in x (transverse), y (craniocaudal), and z (anteroposterior) directions during treatment. Standard deviation (SD) was 0.87 (90% CI 2.21–2.66). Average number of portals taken was 10 (6–27) per treatment session.Conclusion: Computer-based simulation and treatment over conventional methods is appropriate for curative patients, achieving more accurate tumour localisation, sparing normal organs at risk, reduced field sizes and a film free environment; however efforts are required to achieve maximum immobilisation during treatment.