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

Thermal effects on the enhanced ductility in non-monotonic uniaxial tension of DP780 steel sheet

To understand the material behavior during non-monotonic loading, uniaxial tension tests were conducted in three modes, namely, the monotonic loading, loading with periodic relaxation and periodic loading-unloadingreloading, at different strain rates (0.001/s to 0.01/s). In this study, the temperature gradient developing during each test and its contribution to increasing the apparent ductility of DP780 steel sheets were considered. In order to assess the influence of temperature, isothermal uniaxial tension tests were also performed at three temperatures (298 K, 313 K and 328 K (25 A degrees C, 40 A degrees C and 55 A degrees C)). A digital image correlation system coupled with an infrared thermography was used in the experiments. The results show that the non-monotonic loading modes increased the apparent ductility of the specimens. It was observed that compared with the monotonic loading, the temperature gradient became more uniform when a non-monotonic loading was applied.1132Nsciescopuskc

Thermomechanical response of a TWIP steel during monotonic and non-monotonic uniaxial loading

The tensile properties of a Fe-18%Mn-0.6%C-1.5%Al Twinning-Induced Plasticity (TWIP) steel were investigated at different strain rates in three loading modes, i.e. uniaxial monotonic loading, stress relaxation and loading-unloading-reloading. Infrared thermography was used to investigate the effect of the dynamic strain aging, the strain rate and the temperature on the flow stress. In addition to the standard, i.e., non-isothermal tensile tests, isothermal uniaxial tensile tests were performed at 25 degrees C, 45 degrees C and 65 degrees C. While the non-monotonic loading modes resulted in an increase of the total elongation at a low strain rate of 10(-3) s(-1), no increase was observed for strain rates higher than 6 x 10(-3) s(-1). The temperature gradients observed during non-isothermal tests were reduced when non-monotonic loading conditions were used. Temperature changes were found to influence the hardening behavior, and consequently the ductility, of the TWIP steel. Deformation twinning also had a significant influence on the results as its kinetics in TWIP steel are determined by the temperature dependence of the stacking fault energy. (C) 2016 Elsevier B.V. All rights reserved.1132sciescopu