Magnetic resonance imaging and previous cesarean section in placenta accrete spectrum disorder: Predictor model

Objective: To evaluate objective criteria of Magnetic Resonance Imaging (MRI) of Placenta Accreta Spectrum disorder (PAS) analyzing interobserver agreement and to derive a model including imaging and clinical variables to predict PAS. Methods: A retrospective review including patients submitted to MRI with suspicious findings of PAS on ultrasound. Exclusion criteria were lack of pathology or surgical information and missing or poor-quality MRI. Two radiologists analyzed six MRI features, and significant clinical data were also recorded. PAS confirmed on pathology or during intraoperative findings were considered positive for the primary outcome. Variables were tested through logistic regression models. Results: Final study included 96 patients with a mean age of 33 years and 73.0% of previous C-sections. All MRI features were significantly associated with PAS for both readers. After logistic regression fit, including MRI signs with a moderate or higher interobserver agreement, intraplacental T2 dark band was the most significant radiologic criteria, and ROC analysis resulted in an AUC = 0.782. After including the most relevant clinical data (previous C-section) to the model, the ROC analysis improved to an AUC = 0.893. Conclusion: Simplified objective criteria on MRI, including intraplacental T2 dark band associated with clinical information of previous C-sections, had the highest accuracy and was used for a predictive model of PAS

Asma na gestação: efeitos na vitalidade fetal, complicações maternas e perinatais

OBJETIVO: Avaliar os efeitos da asma materna sobre a gravidez, analisando as repercussões da gravidade da doença no comprometimento do bem-estar fetal, bem como as complicações maternas e perinatais associadas. MÉTODOS: Foi realizado estudo retrospectivo de 117 gestações complicadas pela asma materna e sem outras comorbidades, no período de janeiro de 2005 a dezembro de 2010. Os critérios de inclusão foram: gestação única; diagnóstico de asma prévio à gestação; início do pré-natal antes da 28ª semana de gravidez; parto realizado na instituição; peso do recém-nascido acima de 500g e idade gestacional no parto acima de 22 semanas; ausência de malformações fetais ou anomalias cromossômicas; ausência de comorbidades maternas. A gravidade da asma foi classificada em intermitente, persistente leve, persistente moderada, persistente grave. Foram analisados os resultados do perfil biofísico fetal e da dopplervelocimetria de artéria umbilical realizados até 14 dias antes do parto. RESULTADOS: Do total de 117 gestantes asmáticas analisadas: 41 (35,0%) eram intermitentes, 33 (28,2%) persistentes leves, 21 (17,9%) persistentes moderadas e 22 (18,8%) persistentes graves. Não houve diferença significativa entre os grupos quanto ao tipo de parto: a cesárea foi realizada em 65,8% dos casos, a corticoterapia materna no momento do parto em 20,5%, a idade gestacional no parto apresentou média de 38,6 semanas (DP 1,9 semanas) e o peso ao nascimento apresentou média de 3056 g (DP 581 g). O perfil biofísico fetal realizado no período anteparto (n = 90, 76,9%) apresentou resultado normal (8 ou 10) em 99% dos casos. A dopplervelocimetria de artéria umbilical foi avaliada em 23,9% (n = 28) das gestantes, e apresentou-se normal em 100% dos casos. O uso de corticoterapia sistêmica foi significativamente (p< 0,001) diferente entre os grupos intermitente (4,9%) e persistente leve (9,1%), persistente moderada (28,6%), persistente grave (45,5%). quanto ao início do parto, houve maior proporção de cesárea eletiva no grupo com asma persistente moderada (52,5%) e persistente grave (54,6%) quando comparados aos grupos intermitente (21,9%) e persistente leve (24,2%) (p = 0,039). CONCLUSÃO: A gravidade da asma materna não parece influenciar diretamente os resultados perinatais e não compromete a vitalidade fetal. A conduta ativa proporcionando melhor quadro clínico materno promove evolução favorável para a gestação complicada pela asma

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research