Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

(Re)pensando a gerência em enfermagem a partir de conceitos utilizados no campo da Saúde Coletiva (Re)thinking nursing management based on Collective Health concepts

Estudos mostram que para gerenciar a assistência de enfermagem, o enfermeiro utiliza métodos e estratégias de gestão oriundos da teoria clássica da administração. Este estilo de gerência não tem permitido aos trabalhadores de enfermagem criarem espaços coletivos de gestão, onde possam atuar como sujeitos sociais. Partindo do princípio de que a gerência em enfermagem necessita, na atualidade, ser vista e exercitada sob um novo olhar, procurou-se neste ensaio teórico elaborar uma reflexão acerca desta prática, utilizando os conceitos de sujeito social e de coletivo, que são fundamentais no campo da Saúde Coletiva. Assim, aproximar deste campo, além de contribuir para ampliar os conhecimentos e os questionamentos acerca da temática, contribuiu também para compreender a equipe de enfermagem como um coletivo de sujeitos sociais em ação, visto que os trabalhadores são seres humanos dotados de interesses próprios, de necessidades e de desejos, que produzem relações sociais, na medida em que interagem constantemente com outros sujeitos e podem adquirir capacidade para intervir na sua realidade. Este coletivo organizado possui como objetivo principal a prestação de uma assistência integral à população, realizando ações de forma ética, digna, segura e humanizada.<br>Studies show that in order to manage nursing care, nurses use management methods and strategies based on the classic administration theory. This management does not enable nursing workers to create collective spaces, where they can act as social subjects. Based on the principle that nursing management needs, at the moment, to be seen and exercised under a new view, the author aims at elaborating a reflection on this practice, using the concepts of collective and social subject that are fundamental to Collective Health. Thus, the possibility of approaching this field contributed to expand the author's knowledge and concerns regarding the theme as well as to better understand the nursing theme as a collective of social subjects in action. Therefore, it is important to emphasize that the workers are human beings with their own interests, needs and wishes, producing social relations as they constantly interact with other subjects and are able to build capacities to intervene in this reality. This organized group has the main objective to provide an integral care to the population, performing actions in an ethic, secure and humanized direction

The influence of natural vs anthropogenic factors on trace metal(loid) levels in the Mussel Watch programme: Two decades of monitoring in the Spanish Mediterranean sea

The spatial distribution and temporal trends of trace metals (i.e. Cd, Cu, Hg, Pb and Zn) and a metalloid (i.e. As) along the Spanish Mediterranean coast from 1993 to 2013 are presented with a new estimation of their background levels monitored using wild mussels. Over a 20 years period, yearly mussel monitoring was undertaken with a rigorous field sampling protocol using 3 pooled samples strategy (3 x n = 80, with 8 mussels in the 3.0 to 3.9 size categories at each site), obtained in the pre-spawning period (May–June) to minimize biological factors and seasonal variability, which is a fundamental element of the international programme. Spatial distribution was characterized every 5 years and temporal trends were determined in 11 locations. The main aims of the present long term study are to evaluate the environmental status of different coastal locations regarding trace metal levels and follow the evolution of these levels over time after the implementation of regulatory measures. Regarding spatial distribution, the highest values for Cd, Cu, Hg and Pb were found close to known highly anthopogenic cities or shipyard areas. However, As and Zn did not strictly follow this pattern, showing natural increased concentrations in the Levantine Balearic and Strait of Gibraltar-Alboran Sea demarcations respectively. These distributions are associated with the conjunction of two geological formation inputs (Massif Central in France and Iberian Pyritic Belt in Spain) and the oceanographic conditions in the adjacent coastal area. In the case of temporal trends, metal concentrations decreased significantly over time in most stations, confirming the effectiveness of the regulatory measures and prohibitions established under European legislation. Concentrations of Pb were above the established thresholds for human consumption in only 12–14% of the sampling areas. With the information obtained for this study, we estimate background concentrations and propose new Background Assesment Criteria (BAC) for the Spanish Mediterranean coast as a threshold criterion: 1.62 mg/kg d.w. for Cd, 8.75 mg/kg d.w. for Cu, 0.202 mg/kg d.w. for Hg and 2.83 mg/kg d.w. for Pb. Exceptions should exist for As and Zn, for which there should be different levels in each demarcation, due to the geological, hydrological and oceanographic peculiarities of the Spanish coast. For the Levantine-Balearic demarcation, the proposed background concentrations are 117 mg/kg d.w. for As and 200 mg/kg d.w. for Zn., whereas in the Strait of Gibraltar-Alboran Sea demarcation, they are 27.5 mg/kg d.w. for As, and 471 mg/kg d.w. for Zn. This work demonstrates the vital importance of defining the background levels of metal(loid)s at a regional or subregional level because, for areas not affected by anthropogenic causes which have high values as the result of natural processes, this would avoid the risk of constantly surpassing the levels proposed in directives.Postprint1,95

Aspectos epidemiológicos da hanseníase na cidade de Recife, PE em 2002 Epidemiologic aspects of leprosy in the city of Recife, Pernambuco state, 2002

FUNDAMENTOS: Ainda é de grande importância a hanseníase como problema de Saúde Pública no Brasil, devido a sua alta endemicidade. OBJETIVO: Determinar as principais características dessa enfermidade na cidade de Recife no ano de 2002. MÉTODOS: Realizou-se estudo observacional retrospectivo, mediante o preenchimento de um questionário específico, analisando-se 100 prontuários de pacientes assistidos em centro de referência do Recife em 2002. Elaborou-se um banco de dados, e a análise foi feita utilizando-se o software EPI-Info-6. Obtiveram-se as freqüências simples das variáveis, e realizou-se análise bivariada, estudando-se as diferenças entre as proporções por meio do qui-quadrado. O ponto de corte foi p<0,05. RESULTADOS: Observou-se aumento da freqüência dos casos de hanseníase com a idade (7% dos casos ocorreram em crianças e adolescentes, e 11% em maiores de 65 anos) (p<0,001). A distribuição por sexo mostrou diferença significativa (masculino 57%, feminino 43%) (p<0,001). A forma tuberculóide possui a maior prevalência, com 42% dos casos (p<0,001) e maior incidência no sexo feminino, enquanto no sexo masculino prevaleceu a dimorfa (x²=18,83; p<0,001). As formas paucibacilares (tuberculóide e indeterminada) apresentaram lesão única ou variação de duas a cinco lesões em 55,4% e 37,5% dos casos, respectivamente (x²=37,04; p<0,001). CONCLUSÕES: Foi possível constatar que a cidade ainda é uma região endêmica devido à grande incidência da forma tuberculóide no meio, indicador epidemiológico sugestivo de tendência crescente da endemia na região. Só o diagnóstico e o tratamento precoce dos casos poderão quebrar a cadeia de transmissão da doença.<br>BACKGROUND: As a problem of Public Health in Brazil, leprosy is still important due mainly to its high endemicity. OBJECTIVES: Determine the main characteristics of this disease in the city of Recife, Pernambuco state (PE), in 2002. METHODS: Based on data acquired from a questionnaire completed by patients, a retrospective study was carried out to analyze 100 handbooks of patients attended to in a reference center of Recife in 2002. A data base was elaborated and EPI-INFO-6 software was used for the analysis. Simple variable frequencies were obtained and a bi-varied analysis was made by studying ratio differences by means of chi-square. The cut off point was p<0.05. RESULTS: An increase of leprosy was observed to occur with age (7.0% of cases in children and adolescents and 11.0% in adults over 65 years of age), (p<0.001). Distribution per sex showed significant differences (male 57.0%, female 43.0%), (p<0.001). The tuberculoid form had the highest prevalence in all of the age ranges studied, with 42.0% of cases (p<0.001), and its incidence was highest in females, while borderline cases predominated in males (x²=18.83; p<0.001). The paucibacillary forms (tuberculoid and indeterminate) showed only one lesion or two-to-five lesions in 55.4% and 37.5% of the cases, respectively (x²=37.04; p<0.001). CONCLUSIONS: It was possible to demonstrate that Recife is still an endemic region due to a high incidence of the tuberculoid form, i.e. the epidemiological pointer suggestive of increased endemic diseases in the region. Only with the diagnosis and early treatment of the cases can the transmission of the illness chain be broken