Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

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

Statistical power of latent growth curve models to detect quadratic growth

Latent curve models (LCMs) have been used extensively to analyze longitudinal data. However, little is known about the power of LCMs to detect nonlinear trends when they are present in the data. For this study, we utilized simulated data to investigate the power of LCMs to detect the mean of the quadratic slope, Type I error rates, and rates of nonconvergence during the estimation of quadratic LCMs. Five factors were examined: the number of time points, growth magnitude, interindividual variability, sample size, and the R 2s of the measured variables. The results showed that the empirical Type I error rates were close to the nominal value of 5 %. The empirical power to detect the mean of the quadratic slope was affected by the simulation factors. Finally, a substantial proportion of samples failed to converge under conditions of no to small variation in the quadratic factor, small sample sizes, and small R 2 of the repeated measures. In general, we recommended that quadratic LCMs be based on samples of (a) at least 250 but ideally 400, when four measurement points are available; (b) at least 100 but ideally 150, when six measurement points are available; (c) at least 50 but ideally 100, when ten measurement points are available

Search for pair-produced vector-like top and bottom partners in events with large missing transverse momentum in pp collisions with the ATLAS detector

A search for pair-produced vector-like quarks using events with exactly one lepton (e or μ), at least four jets including at least one b-tagged jet, and large missing transverse momentum is presented. Data from proton–proton collisions at a centre-of-mass energy of s= 13 TeV , recorded by the ATLAS detector at the LHC from 2015 to 2018 and corresponding to an integrated luminosity of 139&nbsp;fb - 1 , are analysed. Vector-like partners T and B of the top and bottom quarks are considered, as is a vector-like X with charge + 5 / 3 , assuming their decay into a W, Z, or Higgs boson and a third-generation quark. No significant deviations from the Standard Model expectation are observed. Upper limits on the production cross-section of T and B quark pairs as a function of their mass are derived for various decay branching ratio scenarios. The strongest lower limits on the masses are 1.59 TeV assuming mass-degenerate vector-like quarks and branching ratios corresponding to the weak-isospin doublet model, and 1.47 TeV (1.46 TeV) for exclusive T→ Zt (B/ X→ Wt) decays. In addition, lower limits on the T and B quark masses are derived for all possible branching ratios

Search for Higgs boson pair production in association with a vector boson in pp collisions at s=13 TeV\sqrt{s}=13\,\text {TeV} with the ATLAS detector

AbstractThis paper reports a search for Higgs boson pair (hh) production in association with a vector boson ($$W\; {\text {o}r}\; Z$$ W o r Z ) using 139 fb$$^{-1}$$ - 1 of proton–proton collision data at $$\sqrt{s}=13\,\text {TeV}$$ s = 13 TeV recorded with the ATLAS detector at the Large Hadron Collider. The search is performed in final states in which the vector boson decays leptonically ($$W\rightarrow \ell \nu ,\, Z\rightarrow \ell \ell ,\nu \nu$$ W → ℓ ν , Z → ℓ ℓ , ν ν with $$\ell =e, \mu$$ ℓ = e , μ ) and the Higgs bosons each decay into a pair of b-quarks. It targets Vhh signals from both non-resonant hh production, present in the Standard Model (SM), and resonant hh production, as predicted in some SM extensions. A 95% confidence-level upper limit of 183 (87) times the SM cross-section is observed (expected) for non-resonant Vhh production when assuming the kinematics are as expected in the SM. Constraints are also placed on Higgs boson coupling modifiers. For the resonant search, upper limits on the production cross-sections are derived for two specific models: one is the production of a vector boson along with a neutral heavy scalar resonance H, in the mass range 260–1000 GeV, that decays into hh, and the other is the production of a heavier neutral pseudoscalar resonance A that decays into a Z boson and H boson, where the A boson mass is 360–800 GeV and the H boson mass is 260–400 GeV. Constraints are also derived in the parameter space of two-Higgs-doublet models.</jats:p