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.

The natural history of coronary heart disease (CAD) commonly begins with atherosclerosis, progressing to chronic coronary syndrome (CCS), acute coronary syndrome (ACS), and eventually, heart failure. Despite advancements in preventive and therapeutic strategies, there is room for further cardiovascular risk reduction. Recently, inflammation has emerged as a potential therapeutic target. The neutrophil-to-lymphocyte ratio (NLR) is a novel inflammatory biomarker which predicts poor prognosis in several conditions such as metabolic syndrome, sepsis, malignancy and CAD. In atherosclerosis, a high NLR predicts plaque vulnerability and severe stenosis. This is consistent with observations in CCS, where an elevated NLR predicts long-term major adverse cardiac events (MACEs). In ACS patients, high NLR levels are associated with larger infarct sizes and poor longterm outcomes. Possible reasons for this include failure of fibrinolysis, ischemia-reperfusion injury and in-stent restenosis, all of which are associated with raised NLR levels. Following myocardial infarction, an elevated NLR correlates with pathological cardiac remodeling which propagates chronic heart failure. Finally, in heart failure patients, an elevated NLR predicts long-term MACEs, mortality, and poor left ventricular assist device and transplant outcomes. Further studies must evaluate whether the addition of NLR to current risk-stratification models can better identify high-risk CAD patients.

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Funding Acknowledgements Type of funding sources: None. Background The neutrophil to lymphocyte ratio (NLR) is an inflammatory biomarker with prognostic value in several cardiovascular conditions. Hyperinflammation contributes to severe coronavirus disease 2019 (COVID-19), which is characterized by a multi-organ dysfunction. Cardiovascular complications of COVID-19 include arrhythmias, myocardial damage, acute heart failure, and acute coronary syndrome. Transthoracic echocardiography (TTE) can be used to assess cardiovascular structure and function non-invasively. Purpose To investigate the association between NLR at admission and TTE abnormalities in hospitalised adults with COVID-19. Methods This single-centre retrospective study was conducted at a COVID-19 referral hospital in Indonesia. All consecutive hospitalised adults with confirmed COVID-19 who underwent TTE assessments between 3 April 2020 to 6 April 2021 were included. Comprehensive data including NLR at admission, demographics, co-morbidities, peak severity of COVID-19, and TTE parameters were extracted from electronic medical records. A receiver operating characteristic (ROC) curve analysis was conducted to determine the optimal NLR cut-off for prediction of severe-critical COVID-19. Patients with high and low NLR were compared using the chi-square test and odds ratios (OR), with a confidence level of 95%. Results A total of 487 patients were included in this study. From ROC curve analysis, the area under curve was 0.80 (95% CI: 0.76 – 0.84). The optimal NLR cut-off was determined as 4.42, which predicted severe-critical COVID-19 with a sensitivity of 74.5% and a specificity of 74.6%. Based on this, the low NLR and high NLR groups had 223 and 264 patients, respectively.  Male sex, diabetes, and chronic kidney disease occurred more frequently in the high NLR group (P < 0.05). On TTE assessment, the high NLR group had higher odds of left ventricular (LV) systolic dysfunction (OR: 2.49; 95% CI: 1.14 – 5.45), LV wall motion abnormalities (OR: 2.62; 95% CI: 1.41 – 4.87), valve abnormalities (OR: 2.04; 95% CI: 1.35 – 3.07), and right ventricular (RV) dysfunction (OR: 10.55; 95% CI: 2.46 – 45.25). Conclusions COVID-19 patients with a high NLR at admission had higher odds of abnormal TTE findings, including LV systolic dysfunction, LV wall motion abnormalities, valve abnormalities, and RV dysfunction. This indicates a possible link between inflammation and cardiovascular dysfunction in COVID-19, which must be confirmed in larger prospective studies. Abstract Figure. ROC Curve Analysis  Abstract Figure. Odds Ratios for TTE Abnormalities

Background: Cardiac involvement in coronavirus disease 2019 (COVID-19) is associated with poor outcomes. Transthoracic echocardiography (TTE) can be used to assess cardiac structure and function non-invasively, and has been shown to influence management in COVID-19. Objectives: We aim to investigate the prognostic value of TTE findings in hospitalized adults with confirmed COVID-19. Methods: All consecutive hospitalized adult patients with confirmed COVID-19 who underwent TTE assessment between 3rd April 2020-6th April 2021 were included. Comprehensive clinical data including TTE findings were collected from electronic medical records. Patients with mild-moderate and severe-critical COVID-19 were compared. Within the severe-critical group, patients who survived hospitalization and died were compared. Further analyses were conducted after matching for age >60 years, obesity, and diabetes. Results: A total of 488 COVID-19 patients were included in this study; 202 with mild-moderate and 286 severe-critical disease. All mild-moderate patients and 152 severe-critical patients survived hospitalization. In the matched cohorts, TTE findings associated with severe-critical COVID-19 included left ventricular (LV) hypertrophy (OR: 1.91; CI: 1.21-3.02), LV diastolic dysfunction (OR: 1.55; CI: 1.00-2.38), right ventricular (RV) dysfunction (OR: 3.86; CI: 1.06-14.08), wall motion abnormalities (WMAs) (OR: 2.76; CI: 1.28-5.96), and any TTE abnormalities (OR: 2.99; CI: 1.73-5.17). TTE findings associated with mortality included RV dysfunction (OR: 3.53; CI: 1.12-11.19) and WMAs (OR: 2.63; CI: 1.26-5.49). Conclusion: TTE is a non-invasive modality that can potentially be used for risk-stratification of hospitalized COVID-19 patients. These findings must be confirmed in larger prospective studies.