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

Charge carrier recombination channels in the low-temperature phase of organic-inorganic lead halide perovskite thin films

The optoelectronic properties of the mixed hybrid lead halide perovskite CH3NH3PbI3-xClx have been subject to numerous recent studies related to its extraordinary capabilities as an absorber material in thin film solar cells. While the greatest part of the current research concentrates on the behavior of the perovskite at room temperature, the observed influence of phonon-coupling and excitonic effects on charge carrier dynamics suggests that low-temperature phenomena can give valuable additional insights into the underlying physics. Here, we present a temperature-dependent study of optical absorption and photoluminescence (PL) emission of vapor-deposited CH3NH3PbI3-xCl x exploring the nature of recombination channels in the room- and the low-temperature phase of the material. On cooling, we identify an up-shift of the absorption onset by about 0.1 eV at about 100 K, which is likely to correspond to the known tetragonal-to-orthorhombic transition of the pure halide CH3NH3PbI3. With further decreasing temperature, a second PL emission peak emerges in addition to the peak from the room-temperature phase. The transition on heating is found to occur at about 140 K, i.e., revealing significant hysteresis in the system. While PL decay lifetimes are found to be independent of temperature above the transition, significantly accelerated recombination is observed in the low-temperature phase. Our data suggest that small inclusions of domains adopting the room-temperature phase are responsible for this behavior rather than a spontaneous increase in the intrinsic rate constants. These observations show that even sparse lower-energy sites can have a strong impact on material performance, acting as charge recombination centres that may detrimentally affect photovoltaic performance but that may also prove useful for optoelectronic applications such as lasing by enhancing population inversion. © 2014 Author(s)

Influence of interface morphology on hysteresis in vapor-deposited perovskite solar cells

Hysteresis in the current–voltage characteristics of vapor-deposited perovskite solar cells is shown to originate from an amorphous region of CH3NH3PbI3 at the interface with the device's electron transport layer. Interface engineering is used to produce highly crystalline perovskite material at this interface which results in hysteresis-free evaporated planar heterojunction solar cells

Charge selective contacts, mobile ions and anomalous hysteresis in organic-inorganic perovskite solar cells

High-efficiency perovskite solar cells typically employ an organic-inorganic metal halide perovskite material as light absorber and charge transporter, sandwiched between a p-type electron-blocking organic hole-transporting layer and an n-type hole-blocking electron collection titania compact layer. Some device configurations also include a thin mesoporous layer of TiO2 or Al2O3 which is infiltrated and capped with the perovskite absorber. Herein, we demonstrate that it is possible to fabricate planar and mesoporous perovskite solar cells devoid of an electron selective hole-blocking titania compact layer, which momentarily exhibit power conversion efficiencies (PCEs) of over 13%. This performance is however not sustained and is related to the previously observed anomalous hysteresis in perovskite solar cells. The "compact layer-free" meso-superstructured perovskite devices yield a stabilised PCE of only 2.7% while the compact layer-free planar heterojunction devices display no measurable steady state power output when devoid of an electron selective contact. In contrast, devices including the titania compact layer exhibit stabilised efficiency close to that derived from the current voltage measurements. We propose that under forward bias the perovskite diode becomes polarised, providing a beneficial field, allowing accumulation of positive and negative space charge near the contacts, which enables more efficient charge extraction. This provides the required built-in potential and selective charge extraction at each contact to temporarily enable efficient operation of the perovskite solar cells even in the absence of charge selective n- and p-type contact layers. The polarisation of the material is consistent with long range migration and accumulation of ionic species within the perovskite to the regions near the contacts. When the external field is reduced under working conditions, the ions can slowly diffuse away from the contacts redistributing throughout the film, reducing the field asymmetry and the effectiveness of the operation of the solar cells. We note that in light of recent publications showing high efficiency in devices devoid of charge selective contacts, this work reaffirms the absolute necessity to measure and report the stabilised power output under load when characterizing perovskite solar cells

Optical description of mesostructured organic–inorganic halide perovskite solar cells

Herein we describe both theoretically and experimentally the optical response of solution-processed organic–inorganic halide perovskite solar cells based on mesostructured scaffolds. We develop a rigorous theoretical model using a method based on the propagation of waves in layered media, which allows visualizing the way in which light is spatially distributed across the device and serves to quantify the fraction of light absorbed by each medium comprising the cell. The discrimination between productive and parasitic absorption yields an accurate determination of the internal quantum efficiency. State-of-the-art devices integrating mesoporous scaffolds infiltrated with perovskite are manufactured and characterized to support the calculations. This combined experimental and theoretical analysis provides a rational understanding of the optical behavior of perovskite cells and can be beneficial for the judicious design of devices with improved performance. Notably, our model justifies the presence of a solid perovskite capping layer in all of the highest efficiency perovskite solar cells based on thinner mesoporous scaffolds