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

BACKGROUND

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.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

How is Evaluated Mental Health Recovery?

Introduction

There is an increasingly recognition of the concept of recovery in the treatment of mental illness. Recovery defined as living a fulfilling, rewarding life, even in the ongoing presence of a mental illness. Consequently, a number of instruments have been designed to assess recovery-oriented outcomes.

Objective

The objective of the study was to conduct a systematic revision of the instruments used to assess recovery with appropriate psychometric properties.

Method

A systematic review of the literature has been realized. The adequacy of the instruments utilization, the content validity and psychometrics properties were gathered and analyzed.

Results/discussion

After a systematic review, it has been obtained 25 different instruments for measuring personal recovery and 17 for assessing the orientation of recovery in mental health services. As a consequence of the lack of consensus that exists in the conceptualization of recovery; several instruments have been developed and used to assess the different recovery domains. But it is essential to select scales that match with the recovery model and assess adequately the individual's recovery, and also, the recovery orientation of services. Moreover, those instruments should have appropriate psychometric properties and should be suitable to be introduced in routinely clinical settings.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The e-handover: applications for surgical training

BACKGROUND

Workplace-based assessments introduced in part to compensate for the reduced 'hands on' experience of surgical trainees are now a compulsory facet of surgical training. Taking the form of 'tick box' exercises they largely focus on procedural competence. This work aimed to ascertain whether a standardised electronic handover could also be used as a surrogate marker of trainees' diagnostic skills.

METHODS

All data inputted by surgical trainees 'on call' were collected prospectively and saved in an encrypted database within the Department of Surgery. Presumptive diagnoses made by the admitting trainee over a 2-year time period were then compared with the discharge diagnosis as recorded on the hospital's computer system.

RESULTS

Seventeen surgical trainees were analysed over the study time period, with 936 patients requiring in-patient admission suitable for inclusion. An improvement in trainees' diagnostic accuracy was noted over a 6-month period (p = 0.047). Further subgroup analysis demonstrated increased accuracy amongst trainees with general surgical posts as opposed to urology trainees (p = 0.046), and increased accuracy with increased workload (p = 0.042).

CONCLUSION

The e-handover has real potential as an adjunct to established assessment tools currently in use and may provide the stimulus for valuable feedback to trainees. [Can a] standardised e-handover also be used as a surrogate marker of trainees' diagnostic skills?

An international survey of medical licensing requirements for immigrating physicians, focusing on communication evaluation

OBJECTIVE

To identify current entry requirements set by international medical licensing bodies for immigrating physicians, focusing on postgraduate level communication skills, clinical and technical skill assessments.

METHODS

A standardised, author developed survey was administered to a selection of national, state and provincial licensing institutions across 6 continents. Representative institutions were selected from the most populated regions of each continent. Surveys were administered by email and telephone. The information was also searched by website review. Website information alone was used if no response was received by the targeted institution after 2 phone/2 email attempts. Statistical analysis of the non-parametric data was conducted using SPSS (v.21).

RESULTS

Thirty-seven licensing bodies were contacted from 30 countries; verifiable information was available for 29; twenty-six responded to the communication inquiry. Sixty five 65.4% (n=17) surveyed communication skills, 100% involved language proficiency testing; 11.5% tested other forms of communication skills. For clinical and technical skills, 86.2% (n=25) assessed candidates by credential review, 72.4% (n=21) required both credential review and exam and 62.1% (n=18) used country-specific examination. A mentorship period were required by 37.9% (n=11), ranging from 3 months to 1 year. Only 2 countries identified examinations for recertification. No technical/clinical skills nor communication skill evaluation (beyond language proficiency) are routinely assessed at the postgraduate level.

CONCLUSIONS

International assessments of migrating physicians are heterogeneous. Communication skills, beyond language proficiency, are not routinely assessed in foreign trained physicians seeking entry. The majority of clinical and technical skills are assessed by credential review only. This study highlights the lack of standardisation of assessment internationally and the need for steps toward a global agreement on training schemes and summative assessment.

Pilot evaluation of a novel observational tool for collaboration and communication within multidisciplinary team meetings (MDTs)

BACKGROUND

Despite widespread use of multidisciplinary team meetings (MDTs) to facilitate patient care, little evidence exists that MDTs improve patient survival or impact care. Research into MDT function and outcome is limited. This pilot study looks to validate a novel tool developed to assess MDT functioning.

METHODS

A tool was developed with predefined Likert behaviour stems in the areas of structure, communication and collaboration. The tool was evaluated in nine MDTs by three independent observers and included participant evaluation. Inter-rater reliability was calculated with intraclass-correlation coefficients (ICC); Student's t-test was used to calculate significance in participant evaluation and matched observations.

RESULTS

The tool was used to evaluate 9 MDTs, discussing 133 cases. The overall ICC for the three coders was 0.935; for each MDT: 0.776-0.917. The inter-rater reliability for each MDT observation ranged from 0.245-0.923; the majority with an ICC >0.8. No significant difference was noted between participant evaluation and observer response.

DISCUSSION

MDTs provide a means of coordinating complex care for patients. This tool provides a means of evaluating group interaction within MDTs and is designed for use by different medical personnel. The pilot study has shown promising ICC; further evaluation is needed using a broader group of MDTs and including case complexity and outcome.

Nutrition treatment of deficiency and malnutrition in chronic pancreatitis: a review

Chronic pancreatitis results in exocrine and endocrine dysfunction, affecting normal digestion and absorption of nutrients. In individuals with chronic pancreatitis, nutrition status may be further affected by poor dietary intake, often related to alcoholism. However, some deficiencies may be overlooked, potentially leading to nutrition-related problems with bone health and fatigue. The aim of this article is to describe the deficiencies that occur and to propose an evidence-based algorithm for the nutrition assessment and treatment of patients with chronic pancreatitis.

Occupational exposure to organic solvents and long-term nervous system damage detectable by brain imaging, neurophysiology or histopathology

The purpose of the present review is to assess the evidence published in scientific literature that industrial organic solvents as a generic group have the ability to induce long-term nervous system damage in workers that can be detected by techniques other than neuropsychological testing. The main body of evidence considered in this review was 40 studies involving the use of brain imaging, neurophysiological testing, gross autopsy or histopathology in groups of workers with long-term solvent exposure. Case reports involving both solvent abuse and occupational exposure, and experimental animal data have also been reviewed as supporting data. A number of the studies in groups of workers provide evidence of the presence of marginal atrophic abnormalities in the brain or deficits in nerve conduction velocity in solvent-exposed workers. However, there are limitations in the design of many of these studies, the strength of association between exposure and effect is not consistently strong, no dose-response relationship can be detected, the reported changes lack specificity and there is no coherence between the human and experimental animal data. Overall, it is not possible to draw reliable conclusions with respect to the presence or absence of nervous system damage related to the common properties of organic solvents.

Statistical evaluation of the revised fixed-dose procedure

The fixed-dose procedure (FDP) was introduced as OECD Test Guideline 420 in 1992, as an alternative to the conventional median lethal dose (LD50) test for the assessment of acute oral toxicity (OECD Test Guideline 401). The FDP uses fewer animals and causes less suffering than the conventional test, while providing information on the acute toxicity to allow substances to be ranked according to the EU hazard classification system. Recently the FDP has been revised, with the aim of providing further reductions and refinements, and classification according to the criteria of the Globally Harmonized Hazard Classification and Labelling scheme (GHS). This paper describes the revised FDP and analyses its properties, as determined by a statistical modelling approach. The analysis shows that the revised FDP classifies substances for acute oral toxicity generally in the same, or a more stringent, hazard class as that based on the LD50 value, according to either the GHS or the EU classification scheme. The likelihood of achieving the same classification is greatest for substances with a steep dose-response curve and median toxic dose (TD50) close to the LD50. The revised FDP usually requires five or six animals with two or fewer dying as a result of treatment in most cases.

Restorying psychiatric disability: learning from first person recovery narratives

This qualitative study examines first person accounts of recovery from psychiatric disability. Common themes and patterns are identified and findings are linked to narrative and resiliency theories. Implications for policy, practice, and research are provided.

CAF-1 and the inheritance of chromatin states: at the crossroads of DNA replication and repair

Chromatin is no longer considered to be a static structural framework for packaging DNA within the nucleus but is instead believed to be an interactive component of DNA metabolism. The ordered assembly of chromatin produces a nucleoprotein template capable of epigenetically regulating the expression and maintenance of the genome. Factors have been isolated from cell extracts that stimulate early steps in chromatin assembly in vitro. The function of one such factor, chromatin-assembly factor 1 (CAF-1), might extend beyond simply facilitating the progression through an individual assembly reaction to its active participation in a marking system. This marking system could be exploited at the crossroads of DNA replication and repair to monitor genome integrity and to define particular epigenetic states.

Tetracycline-regulated gene expression switch in Xenopus laevis

Xenopus is a well-characterized model system for the investigation of biological processes at the molecular, cellular, and developmental level. The successful application of a rapid and reliable method for transgenic approaches in Xenopus has led to renewed interest in this system. We have explored the applicability of tetracycline-regulated gene expression, first described by Gossen and Bujard in 1992, to the Xenopus system. By optimizing conditions, tetracycline repressor induced expression of a luciferase reporter gene was readily and reproducibly achieved in both the Xenopus oocyte and developing embryo. This high level of expression was effectively abrogated by addition of low levels of tetracycline. The significance of this newly defined system for studies of chromatin dynamics and developmental processes is discussed.

The binding of a Fos/Jun heterodimer can completely disrupt the structure of a nucleosome

An important first step in the chromatin remodelling process is the initial binding of a transcriptional activator to a nucleosomal template. We have investigated the ability of Fos/Jun (a transcriptional activator involved in the signal transduction pathway) to interact with its cognate binding site located in the promoter region of the mouse fos-related antigen-2 (fra-2) promoter, when this site was reconstituted into a nucleosome. Two different nucleosome assembly systems were employed to assemble principally non-acetylated or acetylated nucleosomes. The ability of Fos/Jun to interact with an acetylated or an unacetylated nucleosome differed markedly. Fos/Jun bound to an unacetylated nucleosome with only a 4- to 5-fold reduction in DNA binding affinity compared with naked DNA. Strikingly, the binding of Fos/Jun to a single high-affinity site incorporated into an acetylated nucleosome resulted in the complete disruption of nucleosomal structure without histone displacement. Moreover, this disruption was sufficient to facilitate the subsequent binding of a second transcription factor.

Transcriptional regulation of the PCNA promoter by p53

We have examined the ability of p53 to affect transcription from the PCNA promoter in a number of cell types. In HeLa cells, p53 activates the PCNA promoter whereas in CV1, CHO, L929, and Saos-2 cells the same promoter is strongly repressed. By using stepwise deletions of the PCNA promoter, we have identified two potential regions of the promoter which are important for the ability of p53 to activate transcription in HeLa cells.

Residential programs for persons with severe mental illness: a nationwide survey of state-affiliated agencies

About 1,500 agencies responded to a nationwide survey of community residential programs affiliated with state departments of mental health that was conducted in 1986-87. The agencies served more than 59,000 individuals who had psychiatric disabilities in more than 16,000 residential settings. The results reveal rapid growth in the number of programs since 1980 and the availability of a broad range of residential programs. Group homes and supervised apartments were the most common types of residential programs identified in the survey. The most commonly offered services were social and recreational activities, medication supervision, and on-site crisis intervention. Programs also offered such services as client advocacy and case management. Most program staff did not have professional training in a mental health field.

Comparison of outcomes for clients seeking and assigned to supported housing services

As part of state-supported interventions to reduce risk of rehospitalization, seriously disabled psychiatric patients who had been involuntarily hospitalized twice in the previous three years were assigned to receive supported housing services in an Oregon community. Compared with 22 voluntary clients in the same supported housing program, the 21 involuntary (assigned) clients rated higher on risk factors such as history of suicide attempts, self-neglect, homelessness, and medication noncompliance, The involuntary clients showed a much higher utilization of supported housing services and case management, psychiatric, and shelter services during the nine months after entry into the program, and they had a higher one-year rehospitalization rate. However, they used substantially fewer inpatient days in the six months after entry in the program than in the six months before.

A possible fragile-site at Yq12: case report and possible relevance to de novo structural rearrangements of the Y-chromosome

In a routine chromosome study it was noted that cells from a patient had different lengths of Y-chromosome: 20% of the cells had a Y-chromosome with about 40% of the normal length of heterochromatin, whereas the majority of cells had an average size Yq12 region. A break within Yq12 was found in 3-4% of the cells with the long Yq12 chromosome, indicating the presence of a possible new fragile site. The frequency of cells with the 2 different sizes of Y-chromosomes was unaffected by culture conditions, as was the frequency of cells with a break or gap. Possible consequences of a fragile-site within Yq12 are discussed.

Tachyphylaxis to beta-adrenoceptor agonists in guinea pig airway smooth muscle in vivo and in vitro

Beta-Adrenoceptor tachyphylaxis was induced by incubating spirally cut guinea pig tracheas with isoproterenol (2.4 x 10(-7) M) for 20 min. This incubation reduced the relaxant effects of catecholamines but not of dibutyryl cyclic AMP, theophylline or sodium nitrite. Tracheas incubated with norepinephrine, phosphodiesterase inhibitors or cyclic nucleotides became tachyphylactic to isoproterenol. Pretreatment with indomethacin prevented induction of tachyphylaxis. Incubation with adenosine, methoxamine or sodium nitrite did not induce beta-adrenoceptor tachyphylaxis. When we gave isoproterenol intramuscularly to guinea pigs, airway sensitivity to aerosolized histamine was unchanged but the toxicity of parenterally administered histamine was increased. A prolonged treatment with isoproterenol reduced airway sensitivity to histamine aerosols; this reduced sensitivity was reversed by indomethacin. Thus, beta-adrenoceptor tachyphylaxis may not explain increased toxicity of parenteral histamine after isoproterenol treatment. Elevated levels of cyclic AMP and an increased synthesis of prostaglandins may result in diminished response to beta-receptor stimulation.