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

Electrical Brain Stimulation During a Retrieval-Based Learning Task Can Impair Long-Term Memory

Anodal transcranial direct current stimulation (tDCS) to the left dorsolateral prefrontal cortex (DLPFC) has been shown to improve performance on a multitude of cognitive tasks. These are, however, often simple tasks, testing only one cognitive domain at a time. Therefore, the efficacy of brain stimulation for complex tasks has yet to be understood. Using a task designed to increase learning efficiency, this study investigates whether anodal tDCS over the left DLPFC can modulate both learning ability and subsequent long-term memory retention. Using a within-subject design, participants (N = 25) took part in 6 training sessions over consecutive days in which active or sham stimulation was administered randomly (3 of each). A computer-based task was used, containing flags from countries unknown to the participants. Each training session consisted of the repetition of 8 pairs of flag/country names. Subsequently, in three testing sessions, free, cued, and timed cued recall, participants were assessed on all 48 flags they had learnt. No difference in learning speed between active and sham tDCS was found. Furthermore, in the timed cued recall phase, flags learnt in the sham tDCS sessions were recalled significantly better than flags learnt in the active tDCS sessions. This effect was stronger in the second testing session. It was also found that for the flags answered incorrectly; thus, meaning they were presented more frequently, subsequent long-term retention was improved. These results suggest that for a complex task, anodal tDCS is ineffective at improving learning speed and potentially detrimental to long-term retention when employed during encoding. This serves to highlight the complex nature of brain stimulation, providing a greater understanding of its limitations and drawbacks

Floral diversity during Plio-Pleistocene Siwalik sedimentation (Kimin Formation) in Arunachal Pradesh, India, and its palaeoclimatic significance

A morpho-taxonomic study of leaf remains from the upper part of the Siwalik succession of sediments (Kimin Formation; upper Pliocene to lower Pleistocene) of Papumpare district, Arunachal Pradesh, India, revealed 23 species representing 20 genera belonging to 15 angiosperm families. The recovered fossil leaves are comparable to modern Bambusa tulda Roxb. (Poaceae), Mangifera indica Linn., Dracontomelum mangiferum Blume (Anacardiaceae); Chonemorpha macrophylla G. Don (Apocynaceae); Pongamia pinnata (L) Pierre., Millettia pachycarpa Benth., Dalbergia rimosa Roxb., Millettia extensa (Fabaceae); Macaranga denticulate Muell. Arg., Croton caudatus Geisel. (Euphorbiaceae); Combretum decandrum Roxb. (Combretaceae); Dysoxylum procerum Hiern. (Meliaceae); Dipterocarpus sp. Gaertn.f. (Dipterocarpaceae); Actinodaphne angustifolia Nees., Actinodaphne obovata Blume., Lindera pulcherrima Benth., Litsea salicifolia Roxb. (Lauraceae); Calophyllum polyanthum Wall. (Clusiaceae); Knema glaucescens Hook.f. (Myristaceae); Canarium bengalense Roxb. (Burseraceae); Quercus lamellose Smith; Quercus semicarpifolia Smith (Fagaceae); and Berchemia floribunda Wall. (Rhamnaceae). Among these taxa, 11 species are recorded as new to the Neogene flora of India. Analysis of the floral assemblage with respect to the distribution pattern of modern equivalent taxa and the physiognomic characters of the fossil leaves, suggests that a tropical evergreen forest was growing in a warm humid climate in the region at the time of deposition. This is in contrast to modern tropical semi-evergreen forests that occupy the area. Values of mean annual temperature (MAT) of 29.3°C and mean annual precipitation (MAP) of 290 mm have been calculated using leaf-margin characters and fossil leaf size

Arteriolar biomechanics in a rat polycystic ovary syndrome model - Effects of parallel vitamin D3 treatment

To clarify the effects of dihydrotestosterone (DHT)-induced polycystic ovary syndrome (PCOS) on arteriolar biomechanics in a rat model and the possible modulatory role of vitamin D3. METHODS AND RESULTS: The PCOS model was induced in female Wistar rats by ten-weeks DHT treatment. Arteriolar biomechanics was tested in arterioles by pressure arteriography in control as well as DHT- and DHT with vitamin D3-treated animals in contracted and passive conditions. Increased wall stress and distensibility as well as increased vascular lumen were detected after DHT treatment. Concomitant vitamin D3 treatment lowered the mechanical load of the arterioles and restored the vascular diameter. CONCLUSION: The hyperandrogenic state resulted in more rigid, less flexible arteriolar walls with increased vascular lumen compared with controls. DHT treatment caused eutrophic remodelling of gracilis arteriole. These prehypertensive alterations caused by chronic DHT treatment were mostly reversed by concomitant vitamin D3 administration

Surgical Management of Melanoma in Situ on Chronically Sun-Damaged Skin

Lentigo maligna (LM) commonly presents as a slow-growing pigmented macular lesion in chronically sun-damaged skin and may progress to invasive melanoma. Many regard it as a subtype of melanoma in situ (MIS), and surgical excision remains the preferred treatment, but standard 5-mm surgical margins recommended for typical MIS are often insufficient for LM due to its indistinct borders both clinically and histologically. A search of the literature was conducted to review specialized surgical techniques for the treatment of LM, focusing on methods that employ total peripheral margin assessment prior to definitive closure, using either frozen or permanent histologic sections. Many investigators have reported surgical modalities utilizing permanent sections for margin control, including variations of the "square" procedure and "perimeter" technique. Recurrence rates are low with these methods, but only short-term data have been reported. Similarly, several studies have demonstrated the efficacy of Mohs micrographic surgery (MMS) for treatment of MIS, with recurrence rates generally less than 1% over 3 to 5 years of follow-up. Many investigators have had success with immunohistochemical stains to identify melanocytes on frozen sections, aiding margin assessment in MMS. Compared to standard excision, methods that employ surgical margin control offer superior cure rates for LM and should be utilized when available. Total peripheral margin assessment using staged excisions and permanent sections is a simple and effective alternative to MMS for institutions that lack the resources for intraoperative frozen section analysis