Anatomy Teaching at the School of Health Sciences of University of Minho

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Obras clásicas para la historia de las Islas del Atlántico [Recurso electrónico]

PC 486; 8 Mb de memoria RAM; MS-DOS 6.0 y Microsoft Windows 3.1 o superior; Espacio libre superior a 10 Mb; Monitor VGA, resolución 800x600; Lector de CD-ROM local o en red.Tít. tomado de la etiquetaAlamada, Andrés Alvares De: Tratado breve dos rios de Guiné. Lisboa: [s. n.], 1946. -- Almada, Vicente Pinheiro Lobo Machado De Mello E: As ilhas de S. Thomé e Principe: (notas de uma Administração Colonial). Lisboa: Typographia da Academia Real das Sciencias, 1884. -- Almeida, João María De Sousa E: As plantações de Cacau nas Ilhas de S. Thomé e Principe em 1851 a 1858. Lisboa: Typographia da Companhia Nacional Editora, 1898. -- Andrade, Jerónimo Emiliano De: Topographia ou Descripção phisica, politica, civil, ecclesiastica, e historica da ilha Terceira dos Açores: Parte primeira. [Angra do Heroismo]: Livraria Religiosa, 1891. -- Avellar, José Candido Da Silveira: Ilha de S. Jorge (Açores): apontamentos para a sua historia. Horta: Typ. Minerva Insulana, 1902. -- Azevedo, Alvaro Rodrigues De: As saudades da terra: Historia das ilhas do Porto-Sancto, Madeira, Desertas e Selvagens. Funchal: Typ. Funchalense, 1873. -- Barcellos, Christiano José De Senna: Subsidios para a historia de Cabo Verde e Guiné: Memoria apresentada a Academia Real das Sciencias de Lisboa [3 vol.]. [Lisboa?]: [s. n.], [s. d.]. -- Barcellos, Christiano José De Senna: Roteiro do Archipelago de Cabo Verde. Lisboa: Typographia do Jornal, 1892. -- Barcellos, Christiano José De Senna: Alguns apontamentos sobre as fomes em Cabo-Verde desde 1719 a 1904. Lisboa: Typ. da Cooperativa Militar, 1904. -- Bettencourt, E. A.: Memoria sobre a descoberta das Ilhas de Porto Santo e Madeira 1418-1419: (Fragmento de um livro inedito). Porto: Typographia do Commercio do Porto, 1875. -- Calle, Henrique F. F.: A revolta na Madeira e a commissão de inquerito: Breves considerações e apontamentos. Madeira: Typographia Funchalense, 1888. -- Camara, Paulo Perestrello Da: Breve noticia sobre a Ilha da Madeira ou Memorias sobre a sua Geographia, Historia, Geologia, Topographia, Agricultura, Commercio, etc. offerecida a Sua Magestade Fidelissima a Sr.ª D.ª Maria Segunda. Lisboa: Typographia da A. das Bellas Artes, 1841. -- V Centenario do Descobrimento da Madeira: Publicação Comemorativa: Dezembro de 1922. [S. l.]: Comissão de Propaganda e Publicidade do Centenario, 1922. -- Chelmicki, José Conrado Carlos De: Corografia cabo-verdiana ou descripção geographico-historica da Provincia das Ilhas de Cabo-Verde e Guiné [2 vol.]. Lisboa: Typ. de L. C. da Cunha, 1841. -- Cordeyro, Antonio: Historia Insulana das Ilhas a Portugal sugeytas no Oceano Occidental. Lisboa: Na Officina de Antonio Pedrozo Galram, 1717. -- Corrêa, Marquez De Jacome: A ilha da Madeira: impressões e notas archeologicas ruraes, artisticas e sociaes: escriptas de janeiro a maio de 1923. Coimbra: Imprensa da Universidade, 1927. -- Costa, Henrique C. S. Barahona E: Carteira de um africanista (excerpto): Apontamentos sobre as fortalezas de S. Thomé e Principe. Lisboa: Typographia do Commercio, 1910. -- Costa, Josquim Vieira Botelho Da: A ilha de S. Vicente de Cabo Verde: 1886 a 1891. Lisboa: Imprensa Nacional, 1896. -- Cunha, Henrique De Lima E: Plano de melhoramentos para a Ilha da Madeira. Lisboa: Imprensa Democratica, 1879. -- Dias, Urbano De Mendoça: Historia dos Açores. Vila-franca do Campo: Agencia de Obras Literarias de Antonio Silveiro deMedeiros, [s. d.]. -- Drummond, Francisco Ferreira: Annaes da ilha Terceira [4 vol.]. Angra do Heroismo: Publicadas pela Camara Municipal d’Angra do Heroismo, 1856- 1864. -- Faro, Conde De Sousa E: A Ilha de S. Thomé e a Roça Agua-Izé. Lisboa: Typ. do Annuario Commercial, 1908. -- Feijó, João Da Silva: Memoria sobre a Fábrica Real do Anil da Ilha de Santo Antão. Lisboa: Academia Real das Sciencias de Lisboa, 1789. -- Feijó, João Da Silva: Ensaio economico sobre as Ilhas de Cabo Verde em 1797. Lisboa: Academia Real das Sciencias, 1815. -- Feijó, João Da Silva: Memoria sobre a Urzella de Cabo Verde. Lisboa: Academia Real das Sciencias de Lisboa, 1815. -- Freitas, Jordão De: Quando foi descoberta a Madeira?: resenha historica. Lisboa: Imprensa Libanio da Silva, 1911. -- Friedlaender, Immanuel: Subsidios para o conhecimento das ilhas de Cabo Verde: resultados de uma viagem de estudo no verão da 1912. Lisboa: Tipografia da Cooperativa Militar, 1914. -- Henriques, Julio A.: A ihla de S. Tomé sob o ponto de vista historico-natural e agrícola. Coimbra: Imprensa da Universidade, 1917. -- Inso, Egydio: As Ilhas de S. Tomé e Principe: Terras de Pedro Escobar e João de Santarem. [S. Tomé?]: Imprensa Nacional de S. Tomé, 1922. -- Lereno, Álvaro: Dicionário corográfico do Arquipélago de Cabo Verde. [S. l.]: Divisão de publicações e biblioteca: Agencia Geral do Ultramar, 1952. -- Lima, Gervasio: A Patria Açoreana. Angra do Heroismo: Tip. Editora Açoreana de Manuel de Freitas Mariano, 1928. -- Lima, Marcelino: Familias Faialenses: (Subsidios para a história da ilha do Faial). Horta: Tipografia “Minerva Insulana”, 1922. -- Loureiro, Adolpho: Breves noticias sobre os Archipelagos da Madeira, Açores, Cabo Verde e Canarias; conferencias feitas na Associação dos Engenheiros Civis Portuguezes. Lisboa: Imprensa Nacional, 1898. -- Machado, Francisco Soares De Lacerda: História do Concelho das Lages: Tomo I. [S. l.]: [s. n.], [1723?]. (**) -- Matos, Raimundo José Da Cunha: Corografia historica das Ilhas de S. Tomé e Principe, Ano Bom e Fernando Pó. S. Tomé: Imprensa Nacional, 1916. -- Moniz, Silveira: Terras Açoreanas: (Notas chorographicas e historicas, ilustradas). Lisboa: Typ. do «Pimpão», 1906. -- Nascimiento, JoãO Cabral Do: Apontamentos de História Insular. [Funchal]: [s. n.] (Madeirense Editora, Lda.), 1927. -- Nascimiento, JoãO Cabral Do: Documentos para a história das capitanias da Madeira. Lisboa: [s. n.] (Ottosgrafica), 1930. -- Negreiros, Antonio Lobo De Almada: Historia etnographica da Ilha de S. Thomé. Lisboa: Antiga Casa Bertrand-José Bastos, 1895. -- Nogueira, A. F.: A Ilha de S. Thomé a questão bancaria no ultramar e o nosso problema colonial. Lisboa: Typ. do Jornal as Colonias Portuguezas, 1893. -- Peres, Damiaõ: O desembargador João Leitão: Primeiro Governador Geral da Madeira. Porto: [s. n.], [19??]. -- Peres, Damiaõ: A Madeira sob os Donatarios: Sec. XV e XVI. Funchal: [s. n.], 1914. -- Peres, Damiaõ: O problema dos governadores gerais da ilha da Madeira. Porto: [Faculdade de letras da Universidade do Porto?], 1925. -- Rebello, Ernesto: Notas Açorianas. Ponta Delgada: Typ. do Archivo dos Açores, 1885-87. -- Rebelo, Pequeno: As Ilhas do Cacáu: crónicas e impressões do que é a vida e aperfeiçoamento da agricultura de S. Tomé e Principe. Lisboa: Pequeño Rebelo, 1930. -- Ribeiro, Manuel Ferreira: A provincia de S. Thomé e Principe e suas dependencias ou a salubridade e insalubridade relativadas provincias do Brazil, das colonias de Portugal e de outras Nações da Europa. Lisboa: Imprensa Nacional, 1877. -- Sampaio, Alfredo Da Silva: Memoria sobre a Ilha Terceira. Angra do Heroismo: Imprensa Municipal, 1904. -- Serpa, Antonio Ferreira De: Os flamengos na ilha do Faial: A familia Utra (Hurtere). Lisboa: [s. n.] (Centro tipografico colonial), 1929. -- Silva, Fernando Augusto Da: A Sé catedral do Funchal: Breve Noticia Histórica e Descritiva. Funchal: Fernando Augusto da Silva, 1936. -- Silva, Francisco Ferreira Da: Apontamentos para a historia da administração da Diocese e da organisação do Seminario Lyceu: Acompanhados de photographias e mappas estatisticos. Lisboa: Typographia Minerva Central, 1899. -- SOUSA, JOÃO SOARES DE ALBERGARIA DE: Corographia açorica, ou descripção phizica, politica, e histórica dos Açores. Lisboa: Na Imprensa de Jolo Nunes Esteves, 1822. -- Telles, Alberto: Chorographia Geral dos Açores. Lisboa: Imprensa Nacional, 1889. -- Vasconcellos, Ernesto J. De C. E: Colonias Portuguezas, I: Archipelago de Cabo Verde: Estudo elementar de Geographia phisica, economica e politica. Lisboa: [s. n.] (Centro tipographico colonial), 1916. -- Vasconcellos, Ernesto J. De C. E: S. Tomé e Principe: Estudo elementar de Geografia fisica, economica e politica: Colonias portuguesas tomo III. Lisboa: Tip. da cooperativa militar, 1918

Obras clásicas para la historia de las Islas del Atlántico [Recurso electrónico]

PC 486; 8 Mb de memoria RAM; MS-DOS 6.0 y Microsoft Windows 3.1 o superior; Espacio libre superior a 10 Mb; Monitor VGA, resolución 800x600; Lector de CD-ROM local o en red.Tít. tomado de la etiquetaAlamada, Andrés Alvares De: Tratado breve dos rios de Guiné. Lisboa: [s. n.], 1946. -- Almada, Vicente Pinheiro Lobo Machado De Mello E: As ilhas de S. Thomé e Principe: (notas de uma Administração Colonial). Lisboa: Typographia da Academia Real das Sciencias, 1884. -- Almeida, João María De Sousa E: As plantações de Cacau nas Ilhas de S. Thomé e Principe em 1851 a 1858. Lisboa: Typographia da Companhia Nacional Editora, 1898. -- Andrade, Jerónimo Emiliano De: Topographia ou Descripção phisica, politica, civil, ecclesiastica, e historica da ilha Terceira dos Açores: Parte primeira. [Angra do Heroismo]: Livraria Religiosa, 1891. -- Avellar, José Candido Da Silveira: Ilha de S. Jorge (Açores): apontamentos para a sua historia. Horta: Typ. Minerva Insulana, 1902. -- Azevedo, Alvaro Rodrigues De: As saudades da terra: Historia das ilhas do Porto-Sancto, Madeira, Desertas e Selvagens. Funchal: Typ. Funchalense, 1873. -- Barcellos, Christiano José De Senna: Subsidios para a historia de Cabo Verde e Guiné: Memoria apresentada a Academia Real das Sciencias de Lisboa [3 vol.]. [Lisboa?]: [s. n.], [s. d.]. -- Barcellos, Christiano José De Senna: Roteiro do Archipelago de Cabo Verde. Lisboa: Typographia do Jornal, 1892. -- Barcellos, Christiano José De Senna: Alguns apontamentos sobre as fomes em Cabo-Verde desde 1719 a 1904. Lisboa: Typ. da Cooperativa Militar, 1904. -- Bettencourt, E. A.: Memoria sobre a descoberta das Ilhas de Porto Santo e Madeira 1418-1419: (Fragmento de um livro inedito). Porto: Typographia do Commercio do Porto, 1875. -- Calle, Henrique F. F.: A revolta na Madeira e a commissão de inquerito: Breves considerações e apontamentos. Madeira: Typographia Funchalense, 1888. -- Camara, Paulo Perestrello Da: Breve noticia sobre a Ilha da Madeira ou Memorias sobre a sua Geographia, Historia, Geologia, Topographia, Agricultura, Commercio, etc. offerecida a Sua Magestade Fidelissima a Sr.ª D.ª Maria Segunda. Lisboa: Typographia da A. das Bellas Artes, 1841. -- V Centenario do Descobrimento da Madeira: Publicação Comemorativa: Dezembro de 1922. [S. l.]: Comissão de Propaganda e Publicidade do Centenario, 1922. -- Chelmicki, José Conrado Carlos De: Corografia cabo-verdiana ou descripção geographico-historica da Provincia das Ilhas de Cabo-Verde e Guiné [2 vol.]. Lisboa: Typ. de L. C. da Cunha, 1841. -- Cordeyro, Antonio: Historia Insulana das Ilhas a Portugal sugeytas no Oceano Occidental. Lisboa: Na Officina de Antonio Pedrozo Galram, 1717. -- Corrêa, Marquez De Jacome: A ilha da Madeira: impressões e notas archeologicas ruraes, artisticas e sociaes: escriptas de janeiro a maio de 1923. Coimbra: Imprensa da Universidade, 1927. -- Costa, Henrique C. S. Barahona E: Carteira de um africanista (excerpto): Apontamentos sobre as fortalezas de S. Thomé e Principe. Lisboa: Typographia do Commercio, 1910. -- Costa, Josquim Vieira Botelho Da: A ilha de S. Vicente de Cabo Verde: 1886 a 1891. Lisboa: Imprensa Nacional, 1896. -- Cunha, Henrique De Lima E: Plano de melhoramentos para a Ilha da Madeira. Lisboa: Imprensa Democratica, 1879. -- Dias, Urbano De Mendoça: Historia dos Açores. Vila-franca do Campo: Agencia de Obras Literarias de Antonio Silveiro deMedeiros, [s. d.]. -- Drummond, Francisco Ferreira: Annaes da ilha Terceira [4 vol.]. Angra do Heroismo: Publicadas pela Camara Municipal d’Angra do Heroismo, 1856- 1864. -- Faro, Conde De Sousa E: A Ilha de S. Thomé e a Roça Agua-Izé. Lisboa: Typ. do Annuario Commercial, 1908. -- Feijó, João Da Silva: Memoria sobre a Fábrica Real do Anil da Ilha de Santo Antão. Lisboa: Academia Real das Sciencias de Lisboa, 1789. -- Feijó, João Da Silva: Ensaio economico sobre as Ilhas de Cabo Verde em 1797. Lisboa: Academia Real das Sciencias, 1815. -- Feijó, João Da Silva: Memoria sobre a Urzella de Cabo Verde. Lisboa: Academia Real das Sciencias de Lisboa, 1815. -- Freitas, Jordão De: Quando foi descoberta a Madeira?: resenha historica. Lisboa: Imprensa Libanio da Silva, 1911. -- Friedlaender, Immanuel: Subsidios para o conhecimento das ilhas de Cabo Verde: resultados de uma viagem de estudo no verão da 1912. Lisboa: Tipografia da Cooperativa Militar, 1914. -- Henriques, Julio A.: A ihla de S. Tomé sob o ponto de vista historico-natural e agrícola. Coimbra: Imprensa da Universidade, 1917. -- Inso, Egydio: As Ilhas de S. Tomé e Principe: Terras de Pedro Escobar e João de Santarem. [S. Tomé?]: Imprensa Nacional de S. Tomé, 1922. -- Lereno, Álvaro: Dicionário corográfico do Arquipélago de Cabo Verde. [S. l.]: Divisão de publicações e biblioteca: Agencia Geral do Ultramar, 1952. -- Lima, Gervasio: A Patria Açoreana. Angra do Heroismo: Tip. Editora Açoreana de Manuel de Freitas Mariano, 1928. -- Lima, Marcelino: Familias Faialenses: (Subsidios para a história da ilha do Faial). Horta: Tipografia “Minerva Insulana”, 1922. -- Loureiro, Adolpho: Breves noticias sobre os Archipelagos da Madeira, Açores, Cabo Verde e Canarias; conferencias feitas na Associação dos Engenheiros Civis Portuguezes. Lisboa: Imprensa Nacional, 1898. -- Machado, Francisco Soares De Lacerda: História do Concelho das Lages: Tomo I. [S. l.]: [s. n.], [1723?]. (**) -- Matos, Raimundo José Da Cunha: Corografia historica das Ilhas de S. Tomé e Principe, Ano Bom e Fernando Pó. S. Tomé: Imprensa Nacional, 1916. -- Moniz, Silveira: Terras Açoreanas: (Notas chorographicas e historicas, ilustradas). Lisboa: Typ. do «Pimpão», 1906. -- Nascimiento, JoãO Cabral Do: Apontamentos de História Insular. [Funchal]: [s. n.] (Madeirense Editora, Lda.), 1927. -- Nascimiento, JoãO Cabral Do: Documentos para a história das capitanias da Madeira. Lisboa: [s. n.] (Ottosgrafica), 1930. -- Negreiros, Antonio Lobo De Almada: Historia etnographica da Ilha de S. Thomé. Lisboa: Antiga Casa Bertrand-José Bastos, 1895. -- Nogueira, A. F.: A Ilha de S. Thomé a questão bancaria no ultramar e o nosso problema colonial. Lisboa: Typ. do Jornal as Colonias Portuguezas, 1893. -- Peres, Damiaõ: O desembargador João Leitão: Primeiro Governador Geral da Madeira. Porto: [s. n.], [19??]. -- Peres, Damiaõ: A Madeira sob os Donatarios: Sec. XV e XVI. Funchal: [s. n.], 1914. -- Peres, Damiaõ: O problema dos governadores gerais da ilha da Madeira. Porto: [Faculdade de letras da Universidade do Porto?], 1925. -- Rebello, Ernesto: Notas Açorianas. Ponta Delgada: Typ. do Archivo dos Açores, 1885-87. -- Rebelo, Pequeno: As Ilhas do Cacáu: crónicas e impressões do que é a vida e aperfeiçoamento da agricultura de S. Tomé e Principe. Lisboa: Pequeño Rebelo, 1930. -- Ribeiro, Manuel Ferreira: A provincia de S. Thomé e Principe e suas dependencias ou a salubridade e insalubridade relativadas provincias do Brazil, das colonias de Portugal e de outras Nações da Europa. Lisboa: Imprensa Nacional, 1877. -- Sampaio, Alfredo Da Silva: Memoria sobre a Ilha Terceira. Angra do Heroismo: Imprensa Municipal, 1904. -- Serpa, Antonio Ferreira De: Os flamengos na ilha do Faial: A familia Utra (Hurtere). Lisboa: [s. n.] (Centro tipografico colonial), 1929. -- Silva, Fernando Augusto Da: A Sé catedral do Funchal: Breve Noticia Histórica e Descritiva. Funchal: Fernando Augusto da Silva, 1936. -- Silva, Francisco Ferreira Da: Apontamentos para a historia da administração da Diocese e da organisação do Seminario Lyceu: Acompanhados de photographias e mappas estatisticos. Lisboa: Typographia Minerva Central, 1899. -- SOUSA, JOÃO SOARES DE ALBERGARIA DE: Corographia açorica, ou descripção phizica, politica, e histórica dos Açores. Lisboa: Na Imprensa de Jolo Nunes Esteves, 1822. -- Telles, Alberto: Chorographia Geral dos Açores. Lisboa: Imprensa Nacional, 1889. -- Vasconcellos, Ernesto J. De C. E: Colonias Portuguezas, I: Archipelago de Cabo Verde: Estudo elementar de Geographia phisica, economica e politica. Lisboa: [s. n.] (Centro tipographico colonial), 1916. -- Vasconcellos, Ernesto J. De C. E: S. Tomé e Principe: Estudo elementar de Geografia fisica, economica e politica: Colonias portuguesas tomo III. Lisboa: Tip. da cooperativa militar, 1918

Characterisation of microbial attack on archaeological bone

As part of an EU funded project to investigate the factors influencing bone preservation in the archaeological record, more than 250 bones from 41 archaeological sites in five countries spanning four climatic regions were studied for diagenetic alteration. Sites were selected to cover a range of environmental conditions and archaeological contexts. Microscopic and physical (mercury intrusion porosimetry) analyses of these bones revealed that the majority (68%) had suffered microbial attack. Furthermore, significant differences were found between animal and human bone in both the state of preservation and the type of microbial attack present. These differences in preservation might result from differences in early taphonomy of the bones. © 2003 Elsevier Science Ltd. All rights reserved

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status

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

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

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine