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

Classificação do tomate por atacadistas e produtores Curitiba Classification of tomatoes by wholesalers and producers in Curitiba, Brazil

Identificou-se o sistema efetivamente utilizado para classificação do tomate para mesa por atacadistas e produtores em Curitiba. Verificou-se também por que não são adotadas as normas legais de classificação. Foram entrevistados 11 atacadistas e 31 produtores de tomate que comercializam sua produção na CEASA Curitiba. Outros dois produtores foram entrevistados em suas propriedades e acompanhados desde a produção até a comercialização. Após tabulação dos dados calculou-se a porcentagem de entrevistados enquadrados em cada questão, em relação ao número total de entrevistados. Constatou-se que há mais de uma linguagem de classificação no mercado e embora não haja padrões de classificação, essas linguagens são compreendidas no momento da comercialização. Para os atacadistas da CEASA Curitiba, a classificação do tomate baseia-se nas cores e nos tamanhos dos frutos. Os frutos podem ser verdes, coloridos (ou pintados) ou vermelhos (ou maduros) e apresentar tamanho Extra 3A ou boca 5 (diâmetro maior que 7,5 cm), Extra 2A ou bocas 6 ou 7 (diâmetro entre 6,2 e 7,5 cm), Extra 1A ou bocas 8 ou 9 (diâmetro entre 4,8 e 6,2 cm). Os frutos Extra 2A (médios) são os mais freqüentes no comércio. Já a maioria dos produtores classifica os frutos em graúdos, médios e miúdos, em uma clara correspondência com a classificação adotada pelos atacadistas. Ambos os sistemas de classificação diferem do oficial que, segundo a maioria de atacadistas e produtores, é difícil de aplicar, encareceria o produto final e levaria a um aumento considerável do volume de frutos a serem descartados. Por esses motivos, antes que as normas oficiais de classificação de tomate possam ser adotadas, é necessário que se disponibilizem para o setor produtivo tecnologias de produção e assistência técnica qualificada. É necessário ainda que as normas de classificação sejam internalizadas pelos agentes do mercado por meio de cursos e treinamentos que estimulem a sua adoção.<br>The effectively used system for classification of table tomatoes by wholesalers and producers was studied in Curitiba, Brazil. We also identified why the laws of classification are not adopted. Eleven wholesalers and 31 tomato planters, which sell their production in CEASA Curitiba, were interviewed. Other two producers were also interviewed in their properties and tracked from production to marketing. After tabulation of the data, we calculated the percentage of respondents in each issue framed in relation to the total number of interviewees. More than one language of classification was identified on the market, and although there are no patterns of grading standards, these languages are included on saling. For wholesalers of CEASA Curitiba, the classification of tomatoes is based on the color and fruit size. The fruits can be green, colorful (or painted) or red (or mature) and present size Extra 3A or mouth 5 (diameter greater than 7.5 cm), Extra 2A or mouths 6 or 7 (diameter between 6.2 and 7,5 cm), Extra 1A or mouths 8 or 9 (diameter between 4.8 and 6.2 cm). The fruits Extra 2A (average) are the most frequent in trade. Most producers rank the fruits in great, intermediate and little, in a clear correlation with the classification adopted by the wholesalers. Both rating systems differ from the official; according to the majority of wholesalers and producers, it is difficult to enforce, and the final product can become expensive and lead to a considerable increase in the discarded fruits. For these reasons, rather than official standards for the classification of tomatoes could be adopted, it is necessary to provide for the productive sector technologies and qualified technical assistance. It is also necessary that the rules of classification are internalized by the agents of the market through courses and training to encourage their adoption