Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

An unusual case of complete pathological response to Paget's disease of the breast.

Mammary Paget's disease is a rare form of breast cancer present in ~0.5-2.8% of breast cancers. The patients have a poorer prognosis, and usually, the appropriate therapy is based on the pathologic findings of the mass and axillary staging. This report adds the outcomes of Paget's disease following neoadjuvant chemotherapy to the literature by description of a case of a 48-year-old patient with Paget's disease who had a complete pathological response to Paget's disease of the breast following neoadjuvant chemotherapy

Management based on grading of animation deformity following implant-based subpectoral breast reconstruction

Subpectoral breast reconstruction using implants and meshes have been used widely in Europe, the United States and the United Kingdom. Although this technique has several advantages, animation deformity is a well-documented problem. We propose a new grading system to classify breast animation in patients undergoing subpectoral implant based breast reconstruction. We also discuss different techniques to avoid and correct animation deformity