Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

Despite current guidelines, intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of intraperitoneal collections, but were associated with prolonged hospital stay and increased risk of surgical-site infections.Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk

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

Background 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

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Rural risk: Geographic disparities in trauma mortality

Background: Barriers to trauma care for rural populations are well documented, but little is known about the magnitude of urban-rural disparities in injury mortality. This study sought to quantify differences in injury mortality comparing rural and nonrural residents with traumatic injuries.Methods: Using data from the 2009-2010 Nationwide Emergency Department Sample, multiple logistic regression analyses were conducted to estimate odds of death after traumatic injury for rural residents compared with nonrural residents, while controlling for age, sex, injury type and severity, comorbidities, trauma designation, and Census region.Results: Rural residents were 14% more likely to die after traumatic injury compared with nonrural residents (P \u3c .001). Increased odds of death for rural residents were observed at level I (odds ratio = 1.20, P \u3c .001), level II (odds ratio = 1.34, P \u3c .001), and level IV/nontrauma centers (odds ratio = 1.23, P \u3c .001). The disparity was greatest for injuries occurring in the South and Midwest (odds ratio = 1.54, P \u3c .001 and odds ratio = 2.06, P \u3c .001, respectively) and for cases with an injury severity score \u3c9 or unknown severity (odds ratio = 2.09, P \u3c .001 and odds ratio = 1.31, P \u3c .001, respectively).Conclusion: Rural residents are significantly more likely than nonrural residents to die after traumatic injury. This disparity varies by trauma center designation, injury severity, and US Census region. Distance and time to treatment likely play a role in rural injury outcomes, along with regional differences in prehospital care and trauma system organization

3-dimensional sundials

R. Hartshorne and A. Hirschowitz proved that a generic collection of lines on P^n, n>2, has bipolynomial Hilbert function. We extend this result to a specialization of the collection of generic lines, by considering a union of lines and 3-dimensional sundials (i.e., a union of schemes obtained by degenerating pairs of skew lines)

Beating the weekend trend: Increased mortality in older adult traumatic brain injury (TBI) patients admitted on weekends

Background: Weekend admission is associated with mortality in cardiovascular emergencies and stroke but the effect of weekend admission for trauma is not well defined. We sought to determine whether differences in mortality outcomes existed for older adults with substantial head trauma admitted on a weekday versus over the weekend. Methods: Data from the 2006, 2007, and 2008 Nationwide Inpatient Sample were combined and head trauma admissions were isolated. Abbreviated injury scale (AIS) scores were calculated using ICDMAP-90 Software. Individuals aged 65 to 89 y with head AIS equal to 3 or 4 and no other region score \u3c3 were included. Individual Charlson comorbidity scores were calculated and individuals with missing mortality, sex, or insurance data were excluded. Wilcoxon rank sum and Student t-tests compared demographics, length of stay, and total charges for weekday versus weekend admissions. The χ2 tests compared sex and head injury severity. Logistic regression modeled mortality adjusting for age, sex, injury severity, comorbidity, and insurance status. Results: Of the 38,675 patients meeting criteria, 9937 (25.6%) were admitted on weekends. Mean age was similar (78.4 versus 78.4, P = 0.796) but more weekend admissions were female (51.6% versus 50.2%, P = 0.022). Weekend patients demonstrated slightly lower comorbidity (mean Charlson = 1.07 versus 1.14, P \u3c 0.001) and head injury severity (58.3% versus 60.8% AIS = 4, P \u3c 0.001). Median weekend length of stay was shorter (4 versus 5 d, P \u3c 0.001). Weekend and weekday median total charges did not differ ($27,128 versus$27,703, respectively, P = 0.667). Proportional mortality was higher among weekend patients (9.3% versus 8.4%, P = 0.008). After adjustment, weekend patients demonstrated 14% increased odds of mortality (OR 1.14, 95% CI 1.05-1.23). Conclusion: Older adults with substantial head trauma admitted on weekends are less severely injured, carry less comorbidity, and generate similar total charges compared with those admitted on weekdays. However, after accounting for known risk confounders, weekend patients demonstrated 14% greater odds of mortality. Mechanisms behind this disparity must be determined and eliminate