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

EXPERIMENTAL AND FINITE-ELEMENT STUDIES ON MODE-I AND MIXED-MODE (I AND II) STABLE CRACK-GROWTH .2. FINITE-ELEMENT ANALYSIS

Finite element studies are presented on both mode I and mixed mode stable crack growth under static loadings through an aluminium (D16AT) alloy. A COD based criterion has been used to predict the load-displacement diagram from initiation to instability. The theoretical predictions are compared with experimental results presented in Part I. Results on computed crack profiles, stress-strain distribution ahead of the crack tip, J integrals, J resistance curves, plastic zones, etc., are included. The study indicates that the load-displacement diagram associated with a mixed mode stable crack growth in a compact tension type of specimen geometry can be predicted reasonably accurately using the criterion of a fixed crack opening displacement at a finite distance behind the crack tip provided the crack is allowed to grow in the direction of initial growth in the finite element analysis. The crack assumes a more blunted profile in a mixed mode than in the mode I at all the stages of stable extension. The distributions of normal stress and strain in the direction perpendicular to the crack extension line, ahead of the current crack tip, have similarities between the mode I and mixed mode, irrespective of loading angle. Both the stress and strain levels increase as the crack extension proceeds. In a mixed mode, the J integral at the onset of crack extension is the lowest compared with the values at the later stages of the extension. Further, the tearing modulus associated with initial kinking is very small; it becomes close to the mode I values at the later stages. The tearing modulus remained approximately constant during the whole mode I stable growth and it had a similar trend subsequent to kinking in a mixed mode. The specific work of crack extension is zero as DELTA-a-->0 and it increases gradually with DELTA-a irrespective of the mode of loading; the actual variation depends on the loading angle. The plastic zone size grows as the stable extension progresses; the growth is approximately the maximum along the crack extension line

EXPERIMENTAL AND FINITE-ELEMENT STUDIES ON MODE-I AND MIXED-MODE (I AND II) STABLE CRACK-GROWTH .1. EXPERIMENTAL

Experimental results on mode I and mixed mode stable crack growth under static loadings through an aluminium alloy (D16AT) are presented. The compact tension type of geometry was employed for both the sets of tests. Data pertaining to load-deflection diagrams, crack opening displacements, crack front geometry, etc., are included. There is a greater spurt of crack growth at the initiation stage in a mixed mode than in mode I. The crack opening angle (COA) remained nearly constant during the whole stable growth. There is a substantial tunneling, the extent of which increases as the extension progresses in both mode I and mixed mode. The tunneling reduces as the ratio a(0)/W increases. Because of this tunneling, the COD at a point finite distance behind the crack tip and on the specimen surface is much more than expected. At the maximum load the tunneling is 2 to 3.5 mm in the case of mode I. The crack extends intially almost along a straight line at an angle with the initial crack in a mixed mode. The maximum to initiation load ratio varied in the range 1.50 to 1.75 for the whole range of tests

EXPERIMENTAL INVESTIGATIONS ON STABLE CRACK-GROWTH IN 3-POINT BEND SPECIMENS UNDER MODE-I AND MIXED-MODE (I AND II) LOADING

In many ductile materials, there is evidence of stable crack growth prior to instability. The instability occurs at a load level higher than the crack initiation load. A design based on the initiation load may lead to an under utilisation of the material. In order to exploit the full potential of the material, it is necessary to characterise the stable crack growth. Experiments were conducted in an aircraft grade aluminium alloy (D16AT) to investigate crack initiation, stable crack growth and instability under quasi-static loadings. The three-point bend (TPB) specimen was chosen for the investigations. The ratio between initial crack length (a0) to width (w) of the TPB specimen (a0/w) was taken as 0.5. Different loading angles (beta) of 45-degrees, 60-degrees, 75-degrees and 90-degrees were tested, where beta = 90-degrees corresponds to the mode I case. Crack opening displacement at the crack mouth (CMOD) was measured by a clip gauge for crack initiation and stable crack growth investigations. Data pertaining to load-displacement diagrams, crack initiation angle, crack initiation load (P(i)) and crack mouth opening displacement (CMOD) at different stages of crack growth, maximum fracture load (P(max)), crack front geometry etc. for different beta were obtained. The CMOD at the initiation point remained almost constant within a range for the whole span of beta. Initially the crack extends along a straight line for mixed mode cases, and is inclined at an angle with the initial crack. A substantial amount of tunnelling (i.e. crack front curving) is observed in all the experiments at all stages of stable crack growth. At the maximum load P(max), the tunnelling is between 5.5 and 9.0 mm for different beta. The ratio between P(max) and P(i) ranges from 1.195 to 1.40. From these studies, it can be concluded that CMOD can be used as a characterising parameter to study stable crack growth in mode I and mixed mode (I and II) loading

Distinct roles for interleukin-12p40 and tumour necrosis factor in resistance to oral candidiasis defined by gene-targeting

Cell-mediated immunity is important for anti-Candida host defence in mucosal tissues. In this study we used cytokine-specific gene knockout mice to investigate the requirement for T helper type 1 (Th1) and Th2 cytokines in recovery from oral candidiasis. Knockout mice used in this study included interleukin-4 (IL-4), IL-10, IL-12p40, interferon-gamma (IFN-gamma), and tumour necrosis factor (TNF). The mice were challenged either orally or systemically with Candida albicans yeasts, and levels of colonization were determined. IL-12p40 knockout mice developed chronic oropharyngeal candidiasis, but were not more susceptible to systemic challenge. On the other hand, TNF knockout mice displayed increased susceptibility to both oral and systemic challenge, but only in the acute stages of infection. TNF apparently has a protective effect in the acute stages of both oral and systemic candidiasis, whereas IL-12p40 is essential for recovery from oral but not systemic candidiasis. The role of IL-12p40, and its relation to T-cell-mediated responses remain to be determined