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

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Background: Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. // Methods: We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. // Findings: We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. // Interpretation: Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

CFD investigation of indoor hygrothermal performance in academic research storage room : measurement and validation

Poor hygrothermal performance exacerbates deterioration risk from mould growth, corrosion and damage to archival materials. Improved microcomputers’ computational power has significantly advanced computational fluid dynamics (CFD) models and research developments in indoor airflow, heat transfer and contaminant transport. Nevertheless, numerous uncertainties exist in the CFD experiments which require adequate clarifications for improved results’ reliability. This paper presents the measurement and validation of a CFD model for the investigation of the hygrothermal performance in an indoor environment with known cases of microbial proliferations. The room, 5.2 m × 4.8 m × 3.0 m high, is air-conditioned and ventilated by constant air volume (CAV) system controlling the indoor airflow and hygrothermal profiles with ceiling mounted four-way supply diffuser and extract grille for indoor air distribution. The methodology combines in-situ experiment and numerical simulation with a commercial CFD tool using the standard k–ε model. Microclimate and airflow parameters obtained from in-situ experiments were used as boundary conditions in the CFD. The study shows a good agreement between the predicted and measured indoor hygrothermal profile with less than 10% deviation. The results indicate that the model can be employed for further investigation with high confidence

Nitric oxide confers cadmium tolerance in fragrant rice by modulating physio-biochemical processes, yield attributes, and grain quality traits

Cadmium (Cd) stress causes serious disruptions in plant metabolism, physio-biochemical processes, crop yield, and quality characters. Nitric oxide (NO) improves the quality features and nutritional contents of fruit plants. However, how NO confers Cd toxicity in fragrant rice plants, is sparse. Hence, the present study investigated the effects of 50 µM NO donor sodium nitroprusside (SNP) on physio-biochemical processes, plant growth attributes, grain yield, and quality traits of fragrant rice under Cd stress (100 mg kg−1 soil). The results revealed that Cd stress diminished rice plant growth, impaired photosynthetic apparatus and antioxidant defense system, and deteriorated the grain quality traits. However, foliar application of SNP mitigated Cd stress by improving plant growth and gas exchange attributes. Higher electrolyte leakage (EL) was accompanied with elevated levels of malondialdehyde (MDA) and hydrogen peroxide (H2O2) under Cd stress; however, exogenous application of SNP reduced them. The activities and relative expression levels of enzymatic antioxidants; superoxide dismutase (SOD), peroxidase (POD), catalase (CAT) and ascorbate peroxidase (APX) and non-enzymatic antioxidants, glutathione (GSH) contents were reduced by Cd stress, while SNP application regulated their activity and transcript abundances. SNP application improved fragrant rice grain yield and 2-acetyl-1-pyrroline content by 57.68 % and 75.54 % respectively, which is concomitant with higher biomass accumulation, photosynthetic efficiency, photosynthetic pigment contents, and an improved antioxidant defense system. Collectively, our results concluded that SNP application regulated the fragrant rice plant physio-biochemical processes, yield traits and grain quality characters under Cd-affected soil

Developing the Optimal Osteotome Hand-Sharpening Method

Background: Rhinoplasty osteotomes can be sharpened in various ways: professional sharpening or hand sharpening using whetstones or rotary powered devices. Objective: To compare the effectiveness of sharpening osteotomes using various sharpening methods with that of professional sharpening as measured by a custom edge tester. Materials and Methods: We performed repeated serial osteotome impacts on bovine femoral cortical bone. These dull osteotomes were sharpened using preidentified sharpening techniques. Edge morphology was evaluated. Sharpness was tested using a custom mechanical testing platform. Optimized sharpness was achieved with a whetstone sharpening method wherein the osteotome is flipped after every stroke. Results: Seven distinct sharpening methods were tested for sharpness five times each to determine the optimal sharpening method versus professional sharpening (control). The two sharpening methods, 5 (5.51 ± 0.32) and 6 (5.55 ± 0.32), that used this flipping technique were significantly sharper than other methods. Methods 5 (p = 1.0) and 6 (p = 1.0) were the only methods that were not significantly different from control. Conclusion: Single stroke with successively alternating surfaces created the sharpest blades that achieved results similar to professional sharpening