Aspectos econômicos das comunidades que sustetam a agricultura no Brasil e na Alemanha: Proposição de indicadores qualitativos e análise comparativa entre os países/ Economic aspects of the communities that support agriculture in Brazil and Germany: Proposal of qualitative indicators and comparative analysis between the countries

A história agrícola brasileira mostra uma mudança nos padrões de conhecimentos e tecnologias aplicados na agricultura. Buscando minimizar os impactos negativos gerados pela “revolução verde” surgem as práticas orgânicas e agroecológicas de produção que abrangem também conceitos da agricultura familiar, economia solidária e dos circuitos curtos de comercialização no Brasil e Europa. Neste contexto se desenvolvem as Comunidades que Sustentam a Agricultura (CSA). Os estudos sobre as CSA no Brasil são recentes e há uma demanda por orientações em busca do seu estabelecimento enquanto uma opção sustentável de agricultura, assim, as SoLaWi – Solidariche Landwirtschaften - na Alemanha foram escolhidas como um paralelo para o desenvolvimento deste artigo. O objetivo é analisar os aspectos econômicos que constituem as práticas e relações das SoLaWi e das CSA e, assim, construir indicadores qualitativos, e realizar uma comparação entre os países. A pesquisa foi qualitativa embasada na metodologia comunicativa crítica e complementada pela análise de conteúdo. No que tange aos aspectos econômicos avaliou-se as Comunidades em números, Organização financeira e custos de produção, Imprevistos, Construção do planejamento e participação dos membros. A partir dos dados foram criados indicadores excludentes e transformadores e observou-se que as CSA atuam fortalecendo a agroecologia na Alemanha e Brasil. A busca pela sustentabilidade econômica é representada de forma heterogênea devido aos distintos contextos das comunidades, principalmente no que se refere às políticas públicas voltadas aos circuitos curtos de comercialização e a economia solidária

Community Supported Agriculture (CSA) in São Paulo and Solidary Agriculture (SoLaWi) in Germany: building social, economical and ecological indicators

Our history shows a shift in the standards of knowledge and technology applied in agriculture. In order to minimize the negative impacts generated by the "green revolution", organic and agroecological production practices also emerge. These include concepts of family agriculture, solidarity economy and local Food systems in Brazil and Europe, and in this context CSA (Community Supported Agriculture) emerges. Studies abour CSA in Brazil are recent and there is a demand for guidelines in pursuit of their establishment as a sustainable option. In this sense we chose the SoLaWi - Solidarich Landwirtschaften (Solidarity Agriculture) in Germany as a parallel for the development of this work. The objective of this work is to analyze the social, economic and environmental aspects that constitute the practices and relations of SoLaWi and CSA, to construct qualitative indicators for each aspect and make a qualitative comparison between SoLaWi and CSA describing the strategies and difficulties, making contributions about the main challenges. The research was qualitative based on the critical communicative methodology and complemented by content analysis and documentary analysis. From the data were created excludent and transformative indicators and it was observed that CSA act by strengthening agroecology in Germany and Brazil. Farmers 'support and empowerment, membership and work opportunity for members, self-management and farmers' autonomy are indicators of transformative social aspects, and this is challenged by the difficulty of member participation and management of volunteer work. The search for economic sustainability is represented in a heterogeneous way due to the different contexts of the communities, especially in what refers to the public policies directed to the local food systems and the solidarity economy. The indicators of the environmental aspects of the communities are the search for biodiversity, soil conservation and health of people and ecosystems, finding limitations in soil conservation and access to land. Future studies on the process of community formation and construction in the context of Latin America are indicated, seeking the training of farmers and members for management and investment in the critical education of members through public policies.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Nossa história mostra uma mudança nos padrões de conhecimentos e tecnologias aplicados na agricultura. Buscando minimizar os impactos negativos gerados pela “revolução verde” surgem as práticas orgânicas e agroecológicas de produção que abrangem também conceitos da agricultura familiar, economia solidária e dos circuitos curtos de comercialização no Brasil e Europa e neste contexto se desenvolvem as CSA (Comunidades que Sustentam a Agricultura). Os estudos sobre as CSA no Brasil são recentes e há uma demanda por orientações em busca do seu estabelecimento enquanto uma opção sustentável de agricultura. Neste sentido escolhemos as SoLaWi – Solidariche Landwirtschaften (Agricultura Solidária) na Alemanha como um paralelo para o desenvolvimento deste trabalho. O objetivo deste trabalho é analisar os aspectos sociais, econômicos e ambientais que constituem as práticas e relações das SoLaWi e das CSA, construir indicadores qualitativos para cada aspecto e realizar uma comparação qualitativa entre as SoLaWi e CSA descrevendo as estratégias e dificuldades, tecendo contribuições acerca dos principais desafios. A pesquisa foi qualitativa embasada na metodologia comunicativa crítica e complementada pela análise de conteúdo e análise documental. A partir dos dados foram criados indicadores excludentes e transformadores e observou-se que as CSA atuam fortalecendo a agroecologia na Alemanha e Brasil. O apoio e empoderamento dos agricultores, a militância e oportunidade de trabalho para membros, a autogestão e autonomia dos agricultores são indicadores dos aspectos sociais transformadores e este aspecto é desafiado pela dificuldade na participação dos membros e gestão do trabalho voluntário. A busca pela sustentabilidade econômica é representada de forma heterogênea devido aos distintos contextos das comunidades, principalmente no que se refere às políticas públicas voltadas aos circuitos curtos de comercialização e a economia solidária. Os indicadores dos aspectos ambientais das comunidades são a busca pela biodiversidade, preservação do solo e saúde das pessoas e dos ecossistemas, encontrando limitações na conservação do solo e acesso à terra. São indicados estudos futuros sobre o processo de formação e construção de comunidades no contexto da América Latina, buscando a capacitação de agricultores e membros para a gestão e o investimento na educação crítica dos membros através das políticas públicas

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Outcomes from elective colorectal cancer surgery during the SARS‐CoV‐2 pandemic

Aim This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic. Method This was an international cohort study of patients undergoing elective resection of colon or rectal cancer without preoperative suspicion of SARS-CoV-2. Centres entered data from their first recorded case of COVID-19 until 19 April 2020. The primary outcome was 30-day mortality. Secondary outcomes included anastomotic leak, postoperative SARS-CoV-2 and a comparison with prepandemic European Society of Coloproctology cohort data. Results From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. Thirty-day mortality was 1.8% (38/2073), the incidence of postoperative SARS-CoV-2 was 3.8% (78/2073) and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS-CoV-2 (14/1601, 0.9%) and highest in patients with both a leak and SARS-CoV-2 (5/13, 38.5%). Mortality was independently associated with anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58–14.06), postoperative SARS-CoV-2 (16.90, 7.86–36.38), male sex (2.46, 1.01–5.93), age >70 years (2.87, 1.32–6.20) and advanced cancer stage (3.43, 1.16–10.21). Compared with prepandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%) and an overall shorter length of stay (6 versus 7 days) but higher mortality (1.7% versus 1.1%). Conclusion Surgeons need to further mitigate against both SARS-CoV-2 and anastomotic leak when offering surgery during current and future COVID-19 waves based on patient, operative and organizational risks

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 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

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research

Delaying surgery for patients with a previous SARS-CoV-2 infection

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