Search

Background: Non-communicable diseases account for nearly three-fourths of global deaths impacting public health and development. Coexisting diseases can complicate the management of surgical diseases, increasing the risk of perioperative mortality. Despite this, few studies have examined the burden of comorbidities among surgical patients and their effect on perioperative outcomes in low-income countries. In this study, we assessed the impact of comorbidity burden on 28-day perioperative mortality using a prospective data set., Methods: This was a facility-based prospective cohort study. Adult patients aged ≥ 18 who underwent non-cardiac surgery were included. Patients were followed for 28 days following surgery. Perioperative data were collected using an electronic data collection system from June 01, 2019, to June 30, 2021, at Tibebe Ghion Specialized Hospital, Northwest, Ethiopia. A propensity score-matched analysis was employed to assess the effect of comorbidity on the 28-day perioperative mortality rate., Results: Of the 3030 patients included in this study, 715 (23.59%) had at least one comorbidity. Based on the prevalence rate, the top four comorbid conditions observed were hypertension (0.050), cancer (0.036), diabetes mellitus (0.021), and human immunodeficiency virus (0.021). The 28-day perioperative mortality rate was shown to be significantly higher among patients with comorbidity, where 45 (6.29%) of the 715 patients with comorbidity died compared to 49 (2.12%) of the 2315 patients with no comorbidity (p-value < 0.0001). After propensity score matching potential confounders, patients who have comorbidity had a 2.52% (average treatment effect on treated (ATT) = 0.0252) higher risk of perioperative death at 28 days after surgery compared with patients who did not have comorbidity., Conclusion: This study found a moderate prevalence of comorbid illnesses among non-cardiac surgical patients, with comorbidity increasing the risk of 28-day perioperative mortality. Preoperative screening and optimization are highly recommended for patients with comorbid illness to decrease perioperative mortality rate., Competing Interests: Declarations Ethical approval and consent to participate The institutional review board (IRB) of the College of Medicine and Health Science, Bahir Dar University (reference number: 0163/2018) approved the protocol to conduct this study. The need for written informed consent was waived for all study subjects by the institutional review board (IRB) of the College of Medicine and Health Science, Bahir Dar University and Tibebe Ghion Specialized Hospital since the study included emergency and critical patients. During follow-up phone calls oral consent to participate in the study was obtained from patients or family members. The confidentiality and security of all patient information were maintained to prevent unauthorized access. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: There has been a concerning rise in the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) following noncardiac surgeries (NCS), significantly impacting surgical outcomes and patient prognosis. Glucose metabolism abnormalities induced by stress response under acute medical conditions may be a risk factor for postoperative MACCE. This study aims to explore the association between stress hyperglycemia ratio (SHR) and postoperative MACCE in patients undergoing general anesthesia for NCS., Methods: There were 12,899 patients in this perioperative cohort study. The primary outcome was MACCE within 30 days postoperatively, defined as angina, acute myocardial infarction, cardiac arrest, arrhythmia, heart failure, stroke, or in-hospital all-cause mortality. Kaplan-Meier curves visualized the cumulative incidence of MACCE. Cox proportional hazard models were utilized to assess the association between the risk of MACCE and different SHR groups. Restricted cubic spline analyses were conducted to explore potential nonlinear relationships. Additionally, exploratory subgroup analyses and sensitivity analyses were performed., Results: A total of 592 (4.59%) participants experienced MACCE within 30 days after surgery, and 1,045 (8.10%) within 90 days. After adjusting for confounding factors, compared to the SHR T2 group, the risk of MACCE within 30 days after surgery increased by 1.34 times (95% CI 1.08-1.66) in the T3 group and by 1.35 times (95% CI 1.08-1.68) in the T1 group respectively. In the non-diabetes group, the risk of MACCE within 30 days after surgery increased by 1.60 times (95% CI 1.21-2.12) in the T3 group and by 1.61 times (95% CI 1.21-2.14) in the T1 group respectively, while no statistically significant increase in risk was observed in the diabetes group. Similar results were observed within 90 days after surgery in the non-diabetes group. Additionally, a statistically significant U-shaped nonlinear relationship was observed in the non-diabetes group (30 days: P for nonlinear = 0.010; 90 days: P for nonlinear = 0.008)., Conclusion: In this large perioperative cohort study, we observed that both higher and lower SHR were associated with an increased risk of MACCE within 30 and 90 days after NCS, especially in patients without diabetes. These findings suggest that SHR potentially plays a key role in stratifying cardiovascular and cerebrovascular risk after NCS., (© 2024. The Author(s).)

Background: Postoperative mortality might be influenced by postoperative care, vigilance, and competence to rescue. This study aims to describe the course of events preceding death in a high-risk surgical cohort., Methods: We analyzed hospital records of patients who died within 30 days after surgery in 4 high volume hospitals using (1) reflective narrative thematic approach to identify recurring themes reflecting issues with conduct of care and (2) Global Trigger Tool to describe incidence, timing, and types of adverse events (AEs) leading to harm., Results: Preoperative predicted median risk of death in the studied group was 9%/13% according to SORT/P-POSSUM, respectively. Nine recurring themes were identified. Prominent themes were "consensus concerning aim and/or risk with planned surgery," "level of (intraoperative) competence and monitoring," and in the postoperative period "level of care and vigilance" on signs of deterioration. We found a total of 303 AEs, with only three patients (5%) having no adverse events. Most common severity category was "I," that is "contributed to patient's death" (n = 110, 36% of all AEs). Of these, 60% were classified as preventable or probably preventable. The peak incidence of AEs was seen on the day of index surgery. Most common types of AEs were "failure of vital functions" (n = 79, 26%), followed by infections (n = 45, 15%)., Conclusions: A high predicted risk of death and a peak of adverse events on the day of index surgery were detected. Identified themes reflect lack of documented multi-professional consensus on how to handle prevalent perioperative risk, vigilance, and postoperative level of care., (© 2024 Acta Anaesthesiologica Scandinavica Foundation.)

Background: Up to half of all surgical adverse events are due to non-technical errors, making non-technical skill assessment and improvement a priority. No specific tools are available to retrospectively identify non-technical errors that have occurred in surgical patient care. This original study aimed to develop and provide evidence of validity and inter-rater reliability for the System for Identification and Categorization of Non-technical Error in Surgical Settings (SICNESS)., Methods: A literature review, modified Delphi process, and two pilot phases were used to develop and test the SICNESS tool. For each pilot, 12 months of surgical mortality data from the Australian and New Zealand Audit of Surgical Mortality were assessed by two independent reviewers using the SICNESS tool. Main outcomes included tool validation through modified Delphi consensus, and inter-rater reliability for: non-technical error identification and non-technical error categorization using Cohen's κ coefficient, and overall agreement using Fleiss' κ coefficient., Results: Version 1 of the SICNESS was used for pilot 1, including 412 mortality cases, and identified and categorized non-technical errors with strong-moderate inter-rater reliability. Non-technical error exemplars were created and validated through Delphi consensus, and a novel mental model was developed. Pilot 2 included an additional 432 mortality cases. Inter-rater reliability was near perfect for leadership (κ 0.92, 95% c.i. 0.82 to 1.00); strong for non-technical error identification (κ 0.89, 0.84 to 0.93), communication and teamwork (κ 0.89, 0.79 to 0.99), and decision-making (κ 0.85, 0.79 to 0.92); and moderate for situational awareness (κ 0.79, 0.71 to 0.87) and overall agreement (κ 0.69, 0.66 to 0.73)., Conclusion: The SICNESS is a reliable and valid tool, enabling retrospective identification and categorization of non-technical errors associated with death, occurring in real surgical patient interactions., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.)

Introduction: The American College of Surgeons Children's Surgery Verification (CSV) status recognizes hospitals that deliver high-quality pediatric surgical care. Texas has 5 CSV centers in three cities, which may limit equitable access to care. We explored the characteristics and outcomes of infants admitted in Texas as a function of facility CSV status., Materials and Methods: We retrospectively reviewed a state-wide hospital discharge database (2013-2021). All patients <1 y of age were included. Patients transferred to an outside hospital were excluded to avoid double counting. Descriptive statistics and chi-square analysis were performed., Results: We analyzed 3,617,173 admissions, with 211,278 (6%) treated at CSV centers. CSV admissions were less likely to be inborn (46% versus 93%) and more likely to be transfers (16% versus 1%). CSV centers also had sicker patients (32% versus 13% extreme illness severity) with higher mortality rates (1% versus 0%), longer length of stay (9 ± 22 versus 4 ± 9), and higher operative rates (33% versus 20%). However, mortality was lower at CSV centers when matched for illness severity. Proportionately more patients from rural counties (9% versus 4%) and counties along the United States-Mexico border (13% versus 1%), as well as patients of Hispanic ethnicity (39% versus 33%), were treated at non-CSV centers. Meanwhile, proportionately more African Americans (21% versus 11%) were treated at CSV centers., Conclusions: CSV centers are associated with improved outcomes among patients with high illness severity. Population differences among patients treated at CSV centers compared to non-CSV centers may represent disparities in access to care and warrant further evaluation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Noncardiac surgery is associated with an inflammatory response. Whether increased inflammation in the perioperative period is associated with subsequent morbidity and mortality is unknown., Methods: MEDLINE, EMBASE, and CENTRAL were systematically searched from date of inception until May 2023. Longitudinal studies were included if they reported multivariable adjusted associations of biomarkers measured preoperatively and/or within 10 days after surgery with at least one prespecified adverse outcome in noncardiac surgery patients. Data were extracted independently and in duplicate. Risk estimates were pooled using DerSimonian-Laird random-effects models and reported as summary odds ratios (ORs) with 95% CIs. The outcomes were all-cause mortality and major adverse cardiovascular events., Results: Fifty-two studies with a total of 121,849 patients were included. The median follow-up was 56 [IQR, 28-63] months and the average age was 57 (±3) years. Elevated preoperative C-reactive protein (CRP) levels were associated with a higher risk of mortality (OR 1.57, 95% CI 1.29-1.90, I 2  = 93%, 28 studies). This association was stronger in non-cancer surgery populations (OR 2.10, 95% CI 1.92-2.31, I 2  = 0%, 4 studies) when compared to cancer surgery populations (OR 1.51, 95% CI 1.26-1.81, I 2  = 83%, 24 studies) (p for subgroup difference = 0.001). Similarly, higher postoperative CRP levels were associated with all-cause mortality (OR 1.61, 95% CI 1.17-2.20, I 2  = 90%, 7 studies). Higher preoperative CRP levels were associated with major cardiovascular events (OR 2.11, 95% CI 1.51-2.94, I 2  = 0%, 2 studies). Other preoperatively measured biomarkers associated with all-cause mortality were fibrinogen (OR 1.48, 95% CI 1.05-2.09, I 2  = 52%, 5 studies), interleukin-6 (OR 1.17, 95% CI 1.07-1.28, I 2  = 27%, 3 studies), and tumour necrosis factor-alpha (OR 1.37, 95% CI 1.16-1.61, I 2  = 0%, 2 studies)., Conclusion and Relevance: Inflammatory biomarker levels in the perioperative period were associated with all-cause mortality and adverse cardiovascular events in patients undergoing noncardiac surgery., Competing Interests: Declaration of competing interest MKW is supported by the PSI Foundation – Research Trainee Award and the CANTRAIN Clinical Trials Training Platforms – Doctoral Studentship Award. DC received consultation fees from Roche Diagnostics and Trimedics, and speaker fees from Servier, all outside of the current work. SB received grants from the Swiss National Science Foundation, the Mach-Gaensslen Foundation and the Gottfried and Julia Bangerter-Rhyner Foundation outside the submitted work., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Emergent surgical conditions are common in geriatric patients, often necessitating major operative procedures on frail patients. Understanding risk profiles is crucial for decision-making and establishing goals of care., Methods: We queried NSQIP 2015-2019 for patients ≥65 years undergoing open abdominal surgery for emergency general surgery conditions. Logistic regression was used to identify 30-day mortality predictors., Results: Of 41,029 patients, 5589 (13.6 ​%) died within 30 days of admission. The highest predictors of mortality were ASA status 5 (aOR 9.7, 95 ​% CI,3.5-26.8, p ​< ​0.001), septic shock (aOR 4.9, 95 ​% CI,4.5-5.4, p ​< ​0.001), and dialysis (aOR 2.1, 95 ​% CI,1.8-2.4, p ​< ​0.001). Without risk factors, mortality rates were 11.9 ​% after colectomy and 10.2 ​% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4 ​% and 100 ​% following colectomy and small bowel resection, respectively., Conclusions: In older adults undergoing emergent open abdominal surgery, septic shock, ASA status, and dialysis were strongly associated with futility of surgical intervention. These findings can inform goals of care and informed decision-making., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Many current trauma mortality prediction tools are either too intricate or rely on data not readily available during a trauma patient's initial evaluation. Moreover, none are tailored to those necessitating urgent or emergent surgery. Our objective was to design a practical, user-friendly scoring tool using immediately available variables, and then compare its efficacy to the widely-known Revised Trauma Score (RTS). Methods: The adult 2017-2021 Trauma Quality Improvement Program (TQIP) database was queried to identify patients ≥18 years old undergoing any urgent/emergent operation (direct from Emergency Department to operating room). Patients were divided into derivation and validation groups. A three-step methodology was used. First, multiple logistic regression models were created to determine risk of death using only variables available upon arrival. Second, the weighted average and relative impact of each independent predictor was used to derive an easily calculated Immediate Operative Trauma Assessment Score (IOTAS). We then validated IOTAS using AUROC and compared it to RTS. Results: From 249 208 patients in the derivation-set, 14 635 (5.9%) died. Age ≥65, Glasgow Coma Scale score <9, hypotension (SBP <90 mmHg), and tachycardia (>120/min) on arrival were identified as independent predictors for mortality. Using these, the IOTAS was structured, offering scores between 0-8. The AUROC for this was .88. A clear escalation in mortality was observed across scores: from 4.4% at score 1 to 60.5% at score 8. For the validation set (250 182 patients; mortality rate 5.8%), the AUROC remained consistent at .87, surpassing RTS's AUROC of .83. Conclusion: IOTAS is a novel, accurate, and now validated tool that is intuitive and efficient in predicting mortality for trauma patients requiring urgent or emergent surgeries. It outperforms RTS, and thereby may help guide clinicians when determining the best course of action in patient management as well as counseling patients and their families., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Whether the anaesthetic agent used influences postoperative mortality in older patients remains unclear. We evaluated the effect of total intravenous anaesthesia (TIVA) vs inhalation anaesthesia on long-term mortality in older patients after noncardiac surgery., Methods: We retrospectively analysed 45,879 patients aged ≥60 yr who underwent noncardiac surgery under general anaesthesia (for ≥2 h) between January 2011 and June 2019. They were divided into two groups according to the type of maintenance anaesthetic. The primary outcome was all-cause mortality within 1 yr after surgery. Secondary outcomes included postoperative complications (postoperative pulmonary complications, perioperative adverse cardiovascular events, and acute kidney injury), and 3-yr and 5-yr mortality after surgery. The stabilised inverse probability of treatment weighting method was used to adjust for potential confounders., Results: Among 45,879 patients, 7273 (15.9%) patients received TIVA and 38,606 (84.1%) patients received inhalation anaesthesia. After adjustment with inverse probability of treatment weighting, there was no association between the type of anaesthetic agent and 1-yr mortality (hazard ratio=0.95; 95% confidence interval [CI] 0.84-1.08). Results for 3-yr and 5-yr mortality were similar. However, inhalation anaesthesia was associated with increased risk of postoperative complications (odds ratio [OR]=1.30; 95% CI 1.22-1.37 for postoperative pulmonary complications, OR=1.34; 95% CI 1.22-1.48 for perioperative adverse cardiovascular events, and OR=2.19; 95% CI 1.88-2.57 for acute kidney injury). In the subgroup analysis, the choice of anaesthetic agent showed differential effects on 1-yr mortality for female patients and emergency surgery., Conclusion: The choice of anaesthetic agent during the intraoperative period was not associated with 1-yr mortality in older patients undergoing noncardiac surgery., Clinical Trial Registration: Clinical Research Information Service of the Republic of Korea (KCT 0006363)., (Copyright © 2024 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Study Objective: To assess the association of intraoperative hypotension with long-term survivals in older patients after major noncardiac surgery mainly for cancer., Design: A secondary analysis of databases from three randomized trials with long-term follow-up., Setting: The underlying trials were conducted in 17 tertiary hospitals in China., Patients: Patients aged 60 to 90 years who underwent major noncardiac thoracic or abdominal surgeries (≥ 2 h) in a single center were included in this analysis., Exposures: Restricted cubic spline models were employed to determine the lowest mean arterial pressure (MAP) threshold that was potentially harmful for long-term survivals. Patients were arbitrarily divided into three groups according to the cumulative duration or area under the MAP threshold. The association between intraoperative hypotension exposure and long-term survivals were analyzed with the Cox proportional hazard regression models., Measurements: Our primary endpoint was overall survival. Secondary endpoints included recurrence-free and event-free survivals., Main Results: A total of 2664 patients (mean age 69.0 years, 34.9% female sex, 92.5% cancer surgery) were included in the final analysis. MAP < 60 mmHg was adopted as the threshold of intraoperative hypotension. Patients were divided into three groups according to duration under MAP < 60 mmHg (<1 min, 1-10 min, and > 10 min) or area under MAP <60 mmHg (< 1 mmHg⋅min, 1-30 mmHg⋅min, and > 30 mmHg⋅min). After adjusting confounders, duration under MAP < 60 mmHg for > 10 min was associated with a shortened overall survival when compared with the < 1 min patients (adjusted hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.09 to 1.57, P = 0.004); area under MAP < 60 mmHg for > 30 mmHg⋅min was associated with a shortened overall survival when compared with the < 1 mmHg⋅min patients (adjusted HR 1.40, 95% CI 1.16 to 1.68, P < 0.001). Similar associations exist between duration under MAP < 60 mmHg for > 10 min or area under MAP < 60 mmHg for > 30 mmHg⋅min and recurrence-free or event-free survivals., Conclusions: In older patients who underwent major noncardiac surgery mainly for cancer, intraoperative hypotension was associated with worse overall, recurrence-free, and event-free survivals., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The Victorian Audit of Surgical Mortality (VASM) investigates all surgically related deaths in Victoria. The Victorian Admitted Episodes Database (VAED) is an administrative dataset maintained by the Health Department's Victorian Agency of Health Information (VAHI). We have reviewed clinical records to assess the correlation between deaths reported to the databases., Methods: Data July 2019 to June 2020 were compared. All hospitals that had surgical deaths not reported to VASM were asked to provide clinical summaries which were analysed to assess the deaths should have been reported. Case note review of 280 deaths only reported to VAHI through VAED was undertaken to establish whether these should have been reported to VASM., Results: VASM received 1763 reported surgical deaths with VAHI recording 1907. Using individual patient identifiers, 517 (29.3%) of the VASM deaths were not reported to VAHI but subsequent data analysis revealed they were correctly identified as reportable deaths in 385 (74.5%). There were 914 (47.9%) VAED recorded deaths that were not reported to VASM. 280/914 (30.6%) were reviewed from 21 hospitals. Only 24 (8.6%) of these had a surgical procedure in the patient's final admission and should have been reported. This suggests that the current method of VASM capture of surgical mortality only missed 4% cases for the 2019/20 year., Conclusion: There were major differences between surgical deaths reported to VASM and those reported by health services and recorded in VAED. Less than 5% of cases are not reported to VASM and thus not subjected to peer review., (© 2024 The Author(s). ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: The American Heart Association (AHA) recently defined the cardiovascular-kidney-metabolic syndrome (CKM) as a new entity to address the complex interactions between heart, kidneys, and metabolism. The aim of this study was to assess the outcome impact of CKM syndrome in patients undergoing noncardiac surgery., Methods: This is a secondary analysis of a prospective international cohort study including patients aged ≥45 years with increased cardiovascular risk undergoing noncardiac surgery. Main exposure was CKM syndrome according to the AHA definition. The primary end point was a composite of major adverse cardiovascular events (MACE) 30 days after surgery. Secondary end points included all-cause mortality and non-MACE complications (Clavien-Dindo class ≥3)., Results: This analysis included 14,634 patients (60.8% male, mean age = 72±8 years). MACE occurred in 308 patients (2.1%), and 335 patients (2.3%) died. MACE incidence by CKM stage was as follows: CKM 0: 5/367 = 1.4% (95% confidence interval [CI], 0.4%-3.2%); CKM 1: 3/367 = 0.8% (95% CI, 0.2%-2.4%); CKM 2: 102/7440 = 1.4% (95% CI, 1.1%-1.7%); CKM 3: 27/953 = 2.8% (95% CI, 1.9%-4.1%); CKM 4a: 164/5357 = 3.1% (95% CI, 2.6%-3.6%); CKM 4b: 7/150 = 4.7% (95% CI, 1.9%-9.4%). In multivariate logistic regression, CKM stage ≥3 was independently associated with MACE, mortality, and non-MACE complications, respectively (MACE: OR 2.26 [95% CI, 1.78-2.87]; mortality: OR 1.42 [95% CI: 1.13 -1.78]; non-MACE complications: OR 1.11 [95% CI: 1.03-1.20])., Conclusion: The newly defined CKM syndrome is associated with increased morbidity and mortality after non-cardiac surgery. Thus, cardiovascular, renal, and metabolic disorders should be regarded in mutual context in this setting., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Background: Failure to rescue, or the death of a patient after a surgical complication, largely occurs in patients who develop a cascade of postoperative complications. However, it is unclear whether there are specific types of index complications that are more strongly associated with failure to rescue, additional secondary complications, or other types of postoperative outcomes. This is a national cohort study of veterans who underwent noncardiac surgery at Veterans Affairs hospitals using data from the Veterans Affairs Surgical Quality Improvement Program (January 1, 2016 to September 30, 2021). Index complications were grouped into categories (cardiovascular, venous thromboembolism, pulmonary, bleeding/transfusion, renal, central nervous system, wound, sepsis, Clostridium difficile colitis, graft, or minor [defined as complications having an associated mortality rate <1%]). The association between type of index complication and failure to rescue, secondary complications, reoperation, and postoperative length of stay was evaluated with multivariable, hierarchical regression, and risk of death assessed with shared frailty modeling., Results: Among 574,195 patients, 5.3% had at least 1 complication (of which 26.1% had secondary complications, and 8.2% had failure to rescue), and 4.5% had a reoperation. Secondary complication (5.0%-61.4%) and failure to rescue (0.8%-34.2%) rates varied by the type of index complication. Relative to index minor complications, index bleeding was most associated with secondary complication (subdistribution hazard ratio 1.4, 95% confidence interval [1.1-1.8]), index cardiac complications were most associated with failure to rescue (odds ratio 45.4 [34.5-59.7]), index graft complications were most associated with reoperation (odds ratio 96.0 [79.5-115.8]), and index pulmonary complications were associated with 2.6 times longer length of stay (incident rate ratio 2.6 [2.6-2.7]). Index cardiac and central nervous system complications were most strongly associated with risk of death (cardiac-hazard ratio 2.45, 95% confidence interval [2.14-2.81]; central nervous system-hazard ratio 1.84 [1.49-2.27])., Conclusion: Different types of index complications are associated with different outcome profiles. This suggests surgical quality improvement efforts should be tailored not only to the type of index complication to be addressed but also to the desired outcome to improve., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Racial and ethnic disparities in emergency general surgery (EGS) patients have been well described in the literature. Nonetheless, the burden of these disparities, specifically within the more vulnerable older adult population, is relatively unknown. This study aims to investigate racial and ethnic disparities in clinical outcomes among older adult patients undergoing EGS., Methods: This retrospective analysis used data from 2013 to 2019 American College of Surgeons National Surgery Quality Improvement Program database. EGS patients aged 65 y or older were included. Patients were categorized based on their self-reported race and ethnicity. The primary outcomes evaluated were in-hospital mortality, 30-d mortality, and overall morbidity. Multivariable logistic regression was performed to examine the relationship between race/ethnicity and postoperative outcomes while adjusting for relevant factors including age, comorbidities, functional status, preoperative conditions, and surgical procedure., Results: A total of 54,132 patients were included, of whom 79.8% identified as non-Hispanic White, 9.5% as non-Hispanic Black (NHB), 5.8% as Hispanic, and 4.2% as non-Hispanic Asian. After risk adjustment, compared to non-Hispanic White patients, NHB, non-Hispanic Asian, and Hispanic patients had decreased odds of 30-d mortality. For 30-d readmission and reoperation, differences among groups were comparable. However, NHB patients had significantly increased odds of overall morbidity (adjusted odds ratio, 1.18; 95% confidence interval: 1.10-1.26; P < 0.001) and postoperative complications including sepsis, venous thromboembolism, and unplanned intubation. Hispanic ethnicity was associated with lower odds of postoperative myocardial infarction and stroke., Conclusions: Among older adult patients undergoing emergency general surgery, minority patients experienced higher morbidity rates, but paradoxical disparities in mortality were detected. Further research is necessary to identify the cause of these disparities and develop targeted interventions to eliminate them., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Preoperative anaemia and red blood cell (RBC) transfusions are associated with poorer clinical outcomes. It is unknown whether perioperative RBC transfusions mediate the relationship between preoperative haemoglobin levels and postoperative outcomes., Methods: This was a prospective observational study among patients aged ≥50 yr undergoing elective major noncardiac surgery from four Swedish hospitals. The co-primary outcomes were 1-yr major adverse cardiovascular and cerebrovascular events (MACCEs) and all-cause mortality. The secondary outcome was a composite of 30-day mortality, MACCEs, acute kidney injury (AKI), pulmonary embolism, anastomotic leak, and postoperative infection. Mediation analyses were conducted with preoperative haemoglobin as the exposure and RBC transfusion as a mediator., Results: Among 1060 patients (mean age 70 [SD 9] yr; 472 [45%] women), 171 patients (16.1%) developed 1-yr MACCEs, and 105 patients (9.9%) died within 1 yr. Preoperative haemoglobin levels were significantly associated with both 1-yr MACCEs (b=-0.015, P=0.041) and all-cause mortality (b=-0.028, P<0.001). Volume of RBC transfusion was not directly associated with the outcomes and did not mediate the relationship between preoperative haemoglobin levels and 1-yr MACCEs (b=-0.001, P=0.451) or all-cause mortality (b=-0.002, P=0.293). For the secondary outcome, RBC transfusions had a significant mediating effect between preoperative haemoglobin and the composite 30-day outcome; however, no direct association was observed (b=0.006, P=0.554)., Conclusions: Preoperative haemoglobin levels were significantly associated with 1-yr MACCEs and all-cause mortality. This effect was not mediated by perioperative RBC transfusions. Further research is needed to confirm these findings., (Copyright © 2024 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: The purpose of this study was to develop and validate a mortality risk algorithm for pediatric surgery patients treated at KidsOR sites in 14 low- and middle-income countries., Methods: A SuperLearner machine learning algorithm was trained to predict post-operative mortality by hospital discharge using the retrospectively and prospectively collected KidsOR database including patients treated at 20 KidsOR sites from June 2018 to June 2023. Algorithm performance was evaluated by internal-external cross-validated AUC and calibration., Findings: Of 23,905 eligible patients, 21,703 with discharge status recorded were included in the analysis, representing a post-operative mortality rate of 3.1% (671 mortality events). The candidate algorithm with the best cross-validated performance was an extreme gradient boosting model. The cross-validated AUC was 0.945 (95% CI 0.936 to 0.954) and cross-validated calibration slope and intercept were 1.01 (95% CI 0.96 to 1.06) and 0.05 (95% CI -0.10 to 0.21). For Super Learner models trained on all but one site and evaluated in the holdout site for sites with at least 25 mortality events, overall external validation AUC was 0.864 (95% CI 0.846 to 0.882) with calibration slope and intercept of 1.03 (95% CI 0.97 to 1.09) and 1.18 (95% CI 0.98 to 1.39)., Interpretation: The KidsOR post-operative mortality risk algorithm had outstanding cross-validated discrimination and strong cross-validated calibration. Across all external validation sites, discrimination of Super Learner models trained on the remaining sites was excellent, though re-calibration may be necessary prior to use at new sites. This model has the potential to inform clinical practice and guide resource allocation at KidsOR sites world-wide., Type of Study and Level of Evidence: Observational Study, Level III., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The Gompertz-Makeham law describes a characteristic pattern of mortality in human populations where the death rate is near constant between ages 18 and 30 yr (Makeham law) and rises exponentially thereafter (Gompertz law). This pattern has not been described in surgical populations, but if true, it would have important implications for understanding surgical risk and design and interpretation of surgical risk models. The aim of this study was to determine whether the Gompertz-Makeham law applies to perioperative mortality risk and the conditions under which it may apply., Methods: This study examined the relationship between age and 1-month postoperative all-cause mortality risk in a 10-yr New Zealand administrative dataset comprising 5,615,100 surgical procedures from 2007 to 2016. The dataset includes patient and surgical factors including procedures, American Society of Anesthesiologists (ASA; Schaumburg, Illinois) Physical Status score, diagnoses, and other relevant details. Semilogarithmic graphs of mortality risk and age were plotted. Linear regression models were fitted, with regression line slope and Pearson correlation coefficient calculated., Results: The primary outcome occurred in 114,782 (2.0%) of 5,615,100 included participants. The Gompertz-Makeham law seems to apply to the national surgical population as a whole (slope = 0.0241; R2 = 0.971). The law applies in all subgroups studied including sex, ASA Physical Status, surgical acuity, surgical severity category, cancer status, and ethnicity (slopes, 0.0066 to 0.0307; R2, 0.771 to 0.990). Important interactions were found between age, mortality risk, and three high-risk groups (cancer diagnosis, ASA Physical Status IV to V, and high surgical severity)., Conclusions: The Gompertz-Makeham law seems to apply in a national cohort of surgical patients. The inflection point for increased 1-month risk is apparent at age 30 yr. A strict exponential rise in mortality risk occurs thereafter. This finding improves the understanding of surgical risk and suggests a concept-driven approach to improve modeling of age and important interactions in future surgical risk models., (Copyright © 2024 American Society of Anesthesiologists. All Rights Reserved.)

Background: Emergency general surgery performed among patients over 65 years of age represents a particularly high-risk population. Although interhospital transfer has been linked to higher mortality in emergency general surgery patients, its impact on outcomes in the geriatric population remains uncertain. We aimed to establish the effect of interhospital transfer on postoperative outcomes in geriatric emergency general surgery patients., Methods: Emergency general surgery patients 65 years and older were identified with American College of Surgeons National Surgical Quality Improvement Program 2013 to 2019. Patients were categorized based on admission source as either directly admitted or transferred from an outside hospital inpatient unit or emergency department. The primary outcomes evaluated were in-hospital mortality, 30-day mortality, and overall morbidity. Propensity score matching was used to control for confounders, including age, race, comorbidities, and preoperative conditions. Kaplan-Meier survival analysis and the log-rank test were used to compare 30-day survival in the matched cohort., Results: Among the 88,424 patients identified, 13,872 (15.7%) were transfer patients. The median age was 74, and 53% were of female sex. Transfer patients had higher rates of comorbidities and preoperative conditions, including a higher prevalence of preoperative sepsis (21.8% vs 19.3%, P < .001) and ventilator dependence (6.4% vs 2.6%, P < .001). After propensity score-matched analysis, transferred patients exhibited higher rates of in-hospital mortality, 30-day mortality, and overall morbidity. Transfer patients were also less likely to be discharged home and more likely to be discharged to an acute care facility. Kaplan-Meier survival analysis confirmed a poorer 30-day survival in transferred patients., Conclusion: Interhospital transfer independently contributed to overall mortality and morbidity amongst geriatric emergency general surgery patients. Further investigation into improved coordination between hospitals, tailored care plans, and comprehensive risk assessments are needed to help mitigate the observed differences in outcomes., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: This study describes the experience with common neonatal surgical conditions and their outcomes at a single center in the Eastern Democratic Republic of the Congo (DRC) over a period of 7 years (2016-2022)., Methods: A retrospective review of neonatal surgical admissions and their outcomes was performed for patient admitted between January 2016 and December 2022 at HEAL Africa teaching hospital. Data were collected from the neonatal admission and discharge registry for all patients with a potential surgical condition., Results: 107 neonates potentially requiring surgery were identified. 81.3% were referred from facilities within 10 km of HEAL Africa. The most common diagnosis was myelomeningocele/meningocele (27.1%). 68.2% of patients had an operation. The overall mortality was 29% for all patients and mean length of stay 9.9 days. Operated patients had a lower mortality at 16.4% (p-value < 0.001, OR 0.155, CI 0.062-0.389) while patients with a birth weight of less than 2500 g were more likely to die (p-value < 0.001, OR 5.333, CI 2.062-13.79)., Conclusion: The neonatal mortality rate for patients presenting with a potential surgical condition is extremely high. This is multifactorial and largely related to patient selection inherent to resource limitations., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Health inequities persist among First Nations people living in developed countries. Surgical care is pivotal in addressing a significant portion of the global disease burden. Evidence regarding surgical outcomes among First Nations people in Australia is limited. The perioperative mortality rate (POMR) indicates timely access to safe surgery and predicts long-term survival after major surgery. This systematic review will examine POMR among First Nations and non-First Nations peoples in Australia., Methods: A systematic search strategy using MEDLINE, Embase, Emcare, Global Health, and Scopus will identify studies that include First Nations people and non-First Nations people who underwent a surgical intervention under anaesthesia in Australia. The primary focus will be on documenting perioperative mortality outcomes. Title and abstract screening and full-text review will be conducted by independent reviewers, followed by data extraction and bias assessment using the ROBINS-E tool. Meta-analysis will be considered if there is sufficient homogeneity between studies. The quality of cumulative evidence will be evaluated following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria., Discussion: This protocol describes the comprehensive methodology for the proposed systematic review. Evaluating disparities in perioperative mortality rates between First Nations and non-First Nations people remains essential in shaping the discourse surrounding health equity, particularly in addressing the surgical burden of disease., Systematic Review Registration: PROSPERO CRD42021258970., (© 2024. Crown.)

Background: Understanding how patients' frailty and the physiological stress of surgical procedures affect postoperative outcomes may inform risk stratification of older patients undergoing surgery. The objective of the study was to examine the association of peri-operative frailty with mortality, 30-day readmission and days at home after non-cardiac surgical procedures of different physiological stress., Methods: This retrospective study used Medicare claims data from a 7.125% random sample of Medicare fee-for-service beneficiaries from 2015 to 2019 who were aged ≥ 65 years and underwent non-cardiac surgical procedure listed in the Operative Stress Score categories. The exposure of the study was claims-based frailty index (robust, < 0.15; pre-frail, 0.15 to < 0.25; mildly frail, 0.25 to < 0.35; and moderate-to-severely frail, ≥ 0.35) with Operative Stress Score categories being 1, very low stress to 5, very high stress. The primary outcome was all-cause mortality at 30 days and 365 days after the surgical procedure., Results: In total, 1,019,938 patients (mean (SD) age of 76.1 (7.3) years; 52.3% female; 16.8% frail) were included. The cumulative incidence of mortality generally increased with Operative Stress Score category, ranging from 5.0% (Operative Stress Score 2) to 24.9% (Operative Stress Score 4) at 365 days. Within each category, increasing frailty was associated with mortality at 30 days (hazard ratio comparing moderate-to-severe frailty vs. robust ranged from 1.59-3.91) and at 365 days (hazard ratio 1.30-4.04). The variation in postoperative outcomes by patients' frailty level was much greater than the variation by the operative stress category., Conclusions: These results emphasise routine frailty screening before major and minor non-cardiac procedures and the need for greater clinician awareness of postoperative outcomes beyond 30 days in shared decision-making with older adults with frailty., (© 2024 Association of Anaesthetists.)

Background: Postdischarge primary care follow-up is associated with lower readmission rates after medical hospitalizations. However, the effect of primary care utilization on readmission has not been studied in surgical patients., Methods: Retrospective cohort study of Medicare beneficiaries aged 65 and older undergoing major inpatient diagnostic or therapeutic procedures (n = 3,552,906) from 2017 through 2018, examining the association between postdischarge primary care visits within 14 days of discharge (primary exposure), and Annual Wellness Visits in the year prior (secondary exposure), with 30-day unplanned readmission (primary outcome), emergency department visits, and mortality (secondary outcomes)., Results: Overall, 9.5% (n = 336,837) had postdischarge visits within 14 days, 2.9% (n = 104,571) had Annual Wellness Visits in the year preceding the procedure, 9.5% (n = 336,401) were readmitted, 9% (n = 319,054) had emergency department visits, and 0.6% (n = 22,103) of the cohort died within 30 days. Our fully adjusted propensity-matched proportional hazards Cox regression analysis showed that postdischarge visits were associated with a 5% lower risk of readmission (hazard ratio [HR], 0.95, 95% confidence interval [CI], 0.93-0.97), 43% higher risk of emergency department use (HR, 1.43, 95% CI, 1.40-1.46) and no difference in mortality risk (HR, 0.98, 95% CI, 0.90-1.06), compared with not having a visit within 14 days of discharge. In a separate set of regression models, Annual Wellness Visits were associated with a 9% lower risk of readmission (HR, 0.91, 95% CI, 0.88-0.95), 45% higher risk of emergency department utilization (HR, 1.45, 95% CI, 1.40-1.49) and an 18% lower mortality risk (HR, 0.82, 95% CI, 0.75-0.89) compared with no Annual Wellness Visit in the year before the procedure., Conclusions: Both postdischarge visits and the Medicare Annual Wellness Visit appear to be extremely underutilized among the older surgical population. In those patients who do utilize primary care, compared with propensity-matched patients who do not, our study suggests primary care use is associated with modestly lower readmission rates. Prospective studies are needed to determine whether targeted primary care involvement can reduce readmission., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Background: Early operation is assumed to improve outcomes after emergency general surgery (EGS) procedures; however, few data exist to inform this opinion. We aimed to (1) characterize time-to-operation patterns among EGS procedures and (2) test the association between timing and patient outcomes. We hypothesize that patients receiving later operations are at greater risk for mortality and morbidity., Methods: We performed a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program data for adults aged 18 to 89 years who underwent nonelective intra-abdominal operations (appendectomy, cholecystectomy, small bowel resection, lysis of adhesions, and colectomy) from 2015 to 2020. The primary outcome was 30-day postoperative mortality. Secondary outcomes were serious morbidity and all morbidity. Admission-to-operation timing was calculated and classified as early (≤48 hours) or late (>48 hours). A multivariable logistic regression model adjusted risk estimates for age, comorbidities, frailty (Modified Frailty Index, 5-item score), and other confounders., Results: Of 269,959 patients (mean age, 47.0 years; 48.0% male, 61.6% White), 88.7% underwent early operation, ranging from 70.36% (lysis of adhesions) to 98.67% (appendectomy). Unadjusted 30-day mortality was higher for late versus early operation (6.73% vs. 1.96%; p < 0.0001). After risk adjustment, late operation significantly increased risk for 30-day mortality (odds ratio [OR], 1.545; 95% confidence interval [CI], 1.451-1.644), serious morbidity (OR, 1.464; 95% CI, 1.416-1.514), and all morbidity (OR, 1.468; 95% CI, 1.417-1.520). This mortality risk persisted for all EGS procedures; risk of serious and any morbidity persisted for all procedures except cholecystectomy., Conclusion: Late operation significantly increased risk for 30-day mortality, serious morbidity, and all morbidity across a variety of EGS procedures. We believe that these findings will inform decisions regarding timing of EGS operations and allocation of surgical resources., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: No study has contextualized the aggregate human costs attributable to disparities in pediatric postsurgical mortalities in the United States, a critical step needed to convey the scale of racial inequalities to clinicians, policymakers, and the public., Methods: We conducted a population-based study of 673 677 children from US hospitals undergoing intermediate to high-risk surgery between 2000 and 2019. We estimated the excess deaths that could be avoided if Black and Hispanic children had comparable mortality rates to white children. We estimated the mortality reduction required to eliminate disparities within the next decade. We finally evaluated the impact of policy changes targeting a modest annual 2.5% reduction in disparity-attributable mortality., Results: During 2000 to 2019, risk-adjusted postoperative mortality trended consistently higher for both Black (adjusted RR [aRR]: 1.42, 95% confidence interval [CI]: 1.36-1.49) and Hispanic children (aRR: 1.22, 95% CI: 1.17-1.27) than for white children. These disparity gaps were driven by higher mortality in Black and Hispanic children receiving surgery in nonteaching hospitals (Black versus white aRR: 1.63, 95% CI: 1.38-1.93; Hispanic versus white aRR: 1.50, 95% CI: 1.33-1.70). There were 4700 excess deaths among Black children and 5500 among Hispanic children, representing. 10 200 (average: 536 per year) excess deaths among minoritized children. Policy changes achieving an annual 2.5% reduction in postoperative mortality would prevent approximately 1100 deaths among Black children in the next decade., Conclusions: By exploring the solution, and not just the problem, our study provides a framework to reduce disparities in pediatric postoperative mortality over the next decade., (Copyright © 2024 by the American Academy of Pediatrics.)

Objective: To compare hospital surgical performance in older and younger patients., Background: In-hospital mortality after surgical procedures varies widely among hospitals. Prior studies suggest that failure-to-rescue rates drive this variation for older adults, but the generalizability of these findings to younger patients remains unknown., Methods: We performed a retrospective cohort study of patients ≥18 years undergoing one of 10 common and complex general surgery operations in 16 states using the Healthcare Cost and Utilization Projects State Inpatient Databases (2016-2018). Patients were split into 2 populations: patients with Medicare ≥65 (older adult) and non-Medicare <65 (younger adult). Hospitals were sorted into quintiles using risk-adjusted in-hospital mortality rates for each age population. Correlations between hospitals in each mortality quintile across age populations were calculated. Complication and failure-to-rescue rates were compared across the highest and lowest mortality quintiles in each age population., Results: We identified 579,582 patients treated in 732 hospitals. The mortality rate was 3.6% among older adults and 0.7% among younger adults. Among older adults, high- relative to low-mortality hospitals had similar complication rates (32.0% vs 29.8%; P = 0.059) and significantly higher failure-to-rescue rates (16.0% vs 4.0%; P < 0.001). Among younger adults, high-relative to low-mortality hospitals had higher complications (15.4% vs 12.1%; P < 0.001) and failure-to-rescue rates (8.3% vs 0.7%; P < 0.001). The correlation between observed-to-expected mortality ratios in each age group was 0.385 ( P < 0.001)., Conclusions: High surgical mortality rates in younger patients may be driven by both complication and failure-to-rescue rates. There is little overlap between low-mortality hospitals in the older and younger adult populations. Future work must delve into the root causes of this age-based difference in hospital-level surgical outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Australia's ageing population is challenging for surgical units and there is a paucity of evidence for geriatric co-management in acute general surgery. We aimed to assess if initiating a Geriatric Medicine in-reach service improved outcomes for older adults in our Acute Surgical Unit (ASU)., Methods: The Older Adult Surgical Inpatient Service (OASIS) was integrated into ASU in 2021. We retrospectively reviewed all patients over age 65 admitted to ASU over a 12-month period before and after service integration with a length of stay (LOS) greater than 24 h. There was no subsequent truncation or selection. Primary outcomes were 30-day mortality, LOS, and 28-day readmissions. Secondary outcomes were discharge disposition, in-hospital mortality, and hospital-acquired complications (HACs)., Results: 1339 consecutive patients were included in each group, with no differences in baseline characteristics. There was a significant decrease in 28-day readmissions from 20.2% to 16.0% (P < 0.05), greatest in patients undergoing non-EL operative procedures (21.9% pre-OASIS vs. 12.6% post-OASIS; P < 0.05). Trends towards reduced 30-day mortality (7.17% vs. 5.90%; P = 0.211), in-hospital mortality (3.88% vs. 2.91%; P = 0.201), permanent care placement (7.77% vs. 7.09%; P = 0.843) and HACs (8.14% vs. 7.62%; P = 0.667) were seen, although statistical significance was not demonstrated. LOS remained unchanged at 4 days (P = 0.653)., Conclusion: The addition of a geriatric in-reach service to a tertiary ASU led to a significant reduction in 28-day readmissions. Downtrends were seen in mortality, permanent care placement, and HAC rates, while LOS remained unchanged., (© 2024 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Surgical risk stratification is crucial for enhancing perioperative assistance and allocating resources efficiently. However, existing models may not capture the complexity of surgical care in Brazil. Using data from various healthcare settings nationwide, we developed a new risk model for 30-day in-hospital mortality (the Ex-Care BR model)., Methods: A retrospective cohort study was conducted in 10 hospitals from different geographic regions in Brazil. Data were analysed using multilevel logistic regression models. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC), Brier score, and calibration plots. Derivation and validation cohorts were randomly assigned., Results: A total of 107,372 patients were included, and 30-day in-hospital mortality was 2.1% (n=2261). The final risk model comprised four predictors related to the patient and surgery (age, ASA physical status classification, surgical urgency, and surgical size), and the random effect related to hospitals. The model showed excellent discrimination (AUROC=0.93, 95% confidence interval [CI], 0.93-0.94), calibration, and overall performance (Brier score=0.017) in the derivation cohort (n=75,094). Similar results were observed in the validation cohort (n=32,278) (AUROC=0.93, 95% CI, 0.92-0.93)., Conclusions: The Ex-Care BR is the first model to consider regional and organisational peculiarities of the Brazilian surgical scene, in addition to patient and surgical factors. It is particularly useful for identifying high-risk surgical patients in situations demanding efficient allocation of limited resources. However, a thorough exploration of mortality variations among hospitals is essential for a comprehensive understanding of risk., Clinical Trial Registration: NCT05796024., (Copyright © 2024 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: The Saint Louis University Score (SLUScore) was developed to quantify intraoperative blood pressure trajectories and their associated risk for adverse outcomes. This study examines the prevalence and severity of intraoperative hypotension described by the SLUScore and its relationship with 30-day mortality in surgical subtypes., Methods: This retrospective analysis of perioperative data included surgical cases performed between January 1, 2010, and December 31, 2020. The SLUScore is calculated from cumulative time-periods for which the mean arterial pressure is below a range of hypotensive thresholds. After calculating the SLUScore for each surgical procedure, we quantified the prevalence and severity of intraoperative hypotension for each surgical procedure and the association between intraoperative hypotension and 30-day mortality. We used binary logistic regression to quantify the potential contribution of intraoperative hypotension to mortality., Results: We analysed 490 982 cases (57.7% female; mean age 57 yr); 33.2% of cases had a SLUScore>0, a median SLUScore of 13 (inter-quartile range [IQR] 7-21), with 1.19% average mortality. The SLUScore was associated with mortality in 12/14 surgical groups. The increases in the odds ratio for death within 30 days of surgery per SLUScore increment were: all surgery types 3.5% (95% confidence interval [95% CI] 3.2-3.9); abdominal/transplant surgery 6% (95% CI 1.5-10.7); thoracic surgery1.5% (95% CI 1-3.3); vascular surgery 3.01% (95% CI 1.9-4.05); spine/neurosurgery 1.1% (95% CI 0.1-2.1); orthopaedic surgery 1.4% (95% CI 0.7-2.2); gynaecological surgery 6.3% (95% CI 2.5-10.1); genitourinary surgery 4.84% (95% CI 3.5-6.15); gastrointestinal surgery 5.2% (95% CI 3.9-6.4); gastroendoscopy 5.5% (95% CI 4.4-6.7); general surgery 6.3% (95% CI 5.5-7.1); ear, nose, and throat surgery 1.6% (95% CI 0-3.27); and cardiac electrophysiology (including pacemaker procedures) 6.6% (95% CI 1.1-12.4)., Conclusions: The SLUScore was independently, but variably, associated with 30-day mortality after noncardiac surgery., (Copyright © 2024 British Journal of Anaesthesia. All rights reserved.)

Background: Increasing life expectancy affects all aspects of healthcare. During surgery, elderly patients are prone to complications and have a higher risk of death. The authors aimed to investigate if adult patients undergoing surgery at a large Swedish university hospital were getting older and sicker over time and if this potential shift in age and illness severity was associated with higher patient mortality rates., Materials and Methods: This was a 16-year cohort study on all surgical procedures performed in adult patients 2006-2021 at two sites of Karolinska University Hospital. Study data was obtained from the surgical system, electronic medical records, and cause-of-death register. Information on age, sex, American Society of Anesthesiologists (ASA) classification, date, type, acuity and duration of surgery was collected. ICD codes were used to calculate the Charlson comorbidity index (CCI). Short-term, medium-term and long-term mortality rates were assessed. Logistic regression models were used to evaluate changes over time., Results: There were 622 814 surgical procedures 2006-2021. Age, ASA classification, and CCI increased over time ( P <0.0001). The proportions of age older than or equal to 60 years increased from 41.8 to 52.8% and of ASA class greater than or equal to 3 from 22.5 to 47.6%. Comparing 2018-2021 with 2006-2009, odds ratios (95% CIs) of 30-day, 90-day and 365-day mortality, adjusted for age, sex, non-elective surgery and ASA classification, decreased significantly to 0.75 (0.71-0.79), 0.72 (0.69-0.76), and 0.76 (0.74-0.79), respectively., Conclusion: Although the surgical population got older and sicker during the 16-year study period, short-term, medium-term and long-term mortality rates decreased significantly. These demographic shifts must be taken into account when planning for future healthcare needs to preserve patient safety., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The triglyceride-glucose (TyG) index, a tool for assessing insulin resistance, is increasingly recognized for its ability to predict cardiovascular and metabolic risks. However, its relationship with trauma and surgical patient prognosis is understudied. This study investigated the correlation between the TyG index and mortality risk in surgical/trauma ICU patients to identify high-risk individuals and improve prognostic strategies., Methods: This study identified patients requiring trauma/surgical ICU admission from the Medical Information Mart for Intensive Care (MIMIC-IV) database, and divided them into tertiles based on the TyG index. The outcomes included 28-day mortality and 180-day mortality for short-term and long-term prognosis. The associations between the TyG index and clinical outcomes in patients were elucidated using Cox proportional hazards regression analysis and RCS models., Results: A total of 2103 patients were enrolled. The 28-day mortality and 180-day mortality rates reached 18% and 24%, respectively. Multivariate Cox proportional hazards analysis revealed that an elevated TyG index was significantly related to 28-day and 180-day mortality after covariates adjusting. An elevated TyG index was significantly associated with 28-day mortality (adjusted hazard ratio, 1.19; 95% confidence interval 1.04-1.37) and 180-day mortality (adjusted hazard ratio, 1.24; 95% confidence interval 1.11-1.39). RCS models revealed that a progressively increasing risk of mortality was related to an elevated TyG index. According to our subgroup analysis, an elevated TyG index is associated with increased risk of 28-day and 180-day mortality in critically ill patients younger than 60 years old, as well as those with concomitant stroke or cardiovascular diseases. Additionally, in nondiabetic patients, an elevated TyG index is associated with 180-day mortality., Conclusion: An increasing risk of mortality was related to an elevated TyG index. In critically ill patients younger than 60 years old, as well as those with concomitant stroke or cardiovascular diseases, an elevated TyG index is associated with adverse short-term and long-term outcomes. Furthermore, in non-diabetic patients, an elevated TyG index is associated with adverse long-term prognosis., (© 2024. The Author(s).)

Purpose: This systematic review aimed to summarize the literature regarding the prognostic accuracy of the emergency surgery score (ESS)., Method: PubMed, Embase, Web of Science, and Scopus were comprehensively searched by May 30, 2023. Two independent researchers performed the initial screening by reviewing the titles and abstracts of the non-duplicate records and selecting the full text of articles meeting our inclusion criteria. Finally, original studies that reported the prognostic accuracy of ESS in any emergency surgeries were included. Data from the included studies were extracted into a checklist designed based on the PRISMA guidelines. The area under the curve (AUC) was used to compare the prognostic accuracy of ESS in different settings., Results: Twenty-six studies met the inclusion criteria. ESS performed excellently in 30-day post-op mortality (AUC 0.84-0.89) and incidence of cardiac arrest (AUC 0.86-0.88) in emergency general surgeries. The AUC of ESS in overall 30-day morbidities varied from 0.72 to 0.82 in five cohort studies. In predicting the need for ICU admission, the study with the largest sample size reported the best sensitivity of ESS at 80% and the specificity at 85%. Moreover, an outstanding accuracy was observed for the prediction of 30-day sepsis/septic shock in emergency general surgeries (AUC 0.75-0.92)., Conclusion: Despite the acceptable prognostic accuracy of ESS in 30-day mortality, morbidities, and in-hospital ICU admission in different emergency surgeries, the high number of required variables and the high probability of missing data highlight the need for modifications to this scoring system., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Objectives: Medical errors and complications pose a major threat to the safety of healthcare systems worldwide. This article was hence aimed at determining the current burden of complications of medical and surgical care in the US., Methods: We searched the latest version of the US Centers for Disease Control and Prevention (CDC) WONDER online database (years 2018-2022) using ICD-10 codes Y40-Y84 (complications of medical and surgical care)., Results: The age-adjusted death rate for complications of medical and surgical care increased from 1.17 × 100,000 in 2018 to 1.49 × 100,000 in 2021, but then declined to 0.85 × 100,000 in 2022. The gender-specific analysis showed a similar trend, with the age-adjusted death rate values always being higher in men than in women. A clear age-dependent relationship was also found in the crude mortality rate for complications of medical and surgical care, as higher death rates were observed in older patients., Conclusions: This analysis reveals that the burden of complications of medical and surgical care has increased over time, especially during the COVID-19 pandemic, but has then considerably declined in 2022. However, root cause analysis and actions are still needed for preventing the still noticeable consequences of medical complications., (© 2024 Walter de Gruyter GmbH, Berlin/Boston.)

Background: The magnitude of the risk of death and cardiac arrest associated with emergency surgery and anesthesia is not well understood. Our aim was to assess whether the risk of perioperative and anesthesia-related death and cardiac arrest has decreased over the years, and whether the rates of decrease are consistent between developed and developing countries., Methods: A systematic review was performed using electronic databases to identify studies in which patients underwent emergency surgery with rates of perioperative mortality, 30-day postoperative mortality, or perioperative cardiac arrest. Meta-regression and proportional meta-analysis with 95% confidence intervals (CIs) were performed to evaluate global data on the above three indicators over time and according to country Human Development Index (HDI), and to compare these results according to country HDI status (low vs. high HDI) and time period (pre-2000s vs. post-2000s)., Results: 35 studies met the inclusion criteria, representing more than 3.09 million anesthetic administrations to patients undergoing anesthesia for emergency surgery. Meta-regression showed a significant association between the risk of perioperative mortality and time (slope: -0.0421, 95%CI: from - 0.0685 to -0.0157; P = 0.0018). Perioperative mortality decreased over time from 227 per 10,000 (95% CI 134-380) before the 2000s to 46 (16-132) in the 2000-2020 s (p < 0-0001), but not with increasing HDI. 30-day postoperative mortality did not change significantly (346 [95% CI: 303-395] before the 2000s to 292 [95% CI: 201-423] in the 2000s-2020 period, P = 0.36) and did not decrease with increasing HDI status. Perioperative cardiac arrest rates decreased over time, from 113 per 10,000 (95% CI: 31-409) before the 2000s to 31 (14-70) in the 2000-2020 s, and also with increasing HDI (68 [95% CI: 29-160] in the low-HDI group to 21 [95% CI: 6-76] in the high-HDI group, P = 0.012)., Conclusions: Despite increasing baseline patient risk, perioperative mortality has decreased significantly over the past decades, but 30-day postoperative mortality has not. A global priority should be to increase long-term survival in both developed and developing countries and to reduce overall perioperative cardiac arrest through evidence-based best practice in developing countries., (© 2024. The Author(s).)

Background: Risk stratification is an important step in perioperative evaluation. However, the main risk scores do not incorporate biomarkers in their set of variables., Objective: Evaluate the incremental power of troponin to the usual risk stratification., Methods: A total of 2,230 patients admitted to the intensive care unit after non-cardiac surgery were classified according to three types of risk: cardiovascular risk (CVR), Revised Cardiac Risk Index (RCRI); and inherent risk of surgery (IRS). The main outcome was all-cause mortality. Cox regression was used as well as c-statistics before and after addition of high-sensitivity troponin (at least one measurement up to three days after surgery). Finally, net reclassification index and integrated discrimination improvement were used to assess the incremental power of troponin for risk stratification. Significance level was set at 0.05., Results: Mean age of patients was 63.8 years and 55.6% were women. The prevalence of myocardial injury after non-cardiac surgery (MINS) was 9.4%. High CVR-patients had a higher occurrence of MINS (40.1 x 24.8%, p<0.001), as well as high IRS-patients (21.3 x 13.9%, p=0.004) and those with a RCRI≥3 (3.0 x 0.7%, p=0.009). Patients without MINS, regardless of the assessed risk, had similar mortality rate. The addition of troponin to the risk assessment improved the predictive ability of death at 30 days and at 1 year in all risk assessments., Conclusion: The prevalence of MINS is higher in the high-risk population. However, its prevalence in lower-risk population is not negligible and causes a higher risk of death. The addition of high-sensitivity troponin increased the predictive ability of risk assessment in all groups.

Objective: To evaluate the health outcomes (postoperative morbidity and mortality) and the functional status at discharge of elderly patients older than 80 years who underwent emergency surgery., Method: Patients > 80 years of age who underwent emergency surgery during one year at the Marqués de Valdecilla University Hospital, Santander, Spain. Preoperative data (age, sex, type of surgery, comorbidity) and postoperative data (complications) were evaluated, as well as in-hospital mortality, at 30 days and 6 months after surgery., Results: Five-hundred-sixty-eight patients underwent emergency surgery between 2018 and 2019. After the review, 407 patients were included in the study. Average age: 86.9 years. Women 61.7%. Mean hospital stay: 10.4 days. Traumatic interventions 41.3%, vascular surgery 19.7%, general-digestive surgery 25.3%. Medium ASA risk: 2.88. Functional status at discharge: 3.15. Postoperative complications: Clavien-Dindo I 40.8%, II 40.3%, IIIA 3.4%, IIIB 2.5%, IVA 3.9%, IVB 2.0% and V 7.1%. Hospital mortality 7.1%, 30-day mortality 10.3%, mortality at 6 months 24.6%., Conclusions: Patients > 80 years of age undergoing urgent surgery have high preoperative comorbidity, postoperative complications, and high mortality at 30 days and 6 months after surgery. This mortality is more significant in those ASA IV, nonagenarians and those undergoing high-risk surgery., (Copyright: © 2024 Permanyer.)

Background: Postoperative bleeding and transfusion are correlated with mortality risk. Furthermore, postoperative bleeding may often initiate the cascade of complications that leads to death. Given that minority children have increased risk of surgical complications, this study aimed to investigate the association of race with pediatric surgical mortality following postoperative transfusion., Methods: We used the NSQIP-P PUF to assemble a retrospective cohort of children <18 who underwent inpatient surgery during 2012-2021. We included White, Black, Hispanic, and 'Other' children who received a transfusion within 72 h of surgery. The primary outcome was defined as all-cause mortality within 30 days following the primary surgical procedure. Using logistic regression models, we estimated the risk-adjusted odds ratio (aOR) and 95% confidence intervals (CI) of mortality, comparing each racial/ethnic cohort to White children., Results: A total of 466,230 children <18 years of age underwent inpatient surgical procedures from 2012 to 2021. Of these, 46,200 required transfusion and were included in our analysis. The majority of patients were non-Hispanic White (64.6%, n = 29,850), while 18.9% (n = 8752) were non-Hispanic Black, 11.7% (n = 5387) were Hispanic, and 4.8% (n = 2211) were 'Other' race. The overall rate of mortality following transfusion was 2.5%. White children had the lowest incidence of mortality (2.0%), compared to children of 'Other' race (2.5%), Hispanic children (3.1%), and Black children (3.6%). After adjusting for sex, age, comorbidities, case status, preoperative transfusion within 48 h, and year of operation, we found that Black children experienced 1.24 times the odds of mortality following a postoperative transfusion compared to a White child (aOR: 1.24; 95%CI, 1.03-1.51; P = 0.025). Hispanic children were also significantly more likely to die following a postoperative transfusion than White children (aOR: 1.19; 95%CI, 1.02-1.39; P = 0.027)., Conclusion: We found that minority children who required a postoperative transfusion had a higher odds of death than White children. Future studies should explore adverse events following postoperative transfusion and the differences in their management by race that may contribute to the higher mortality rate for minority children., Level of Evidence: Level II., Clinical Trial Number and Registry: Not applicable., Competing Interests: Conflicts of interest The authors declare no conflict of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: While disparities in Black and Hispanic and Latino patients undergoing general surgeries are well described, most analyses leave out Asian, American Indian or Alaskan Native (AIAN), and native Hawaiian or Pacific Islander patients. This study identified general surgery outcomes for each racial group in the National Surgical Quality Improvement Program., Methods: National Surgical Quality Improvement Program was queried to identify all procedures conducted by a general surgeon from 2017 to 2020 (n = 2,664,197). Multivariable regression models were used to investigate the impact of race and ethnicity on 30-day mortality, readmission, reoperation, major and minor medical complications, and non-home discharge destinations. Adjusted odds ratios (AOR) and 95% confidence intervals were calculated., Results: Compared to non-Hispanic White patients, Black patients had higher odds of readmission and reoperation, and Hispanic and Latino patients had higher odds of major and minor complications. AIAN patients had higher odds of mortality (AOR: 1.003 (1.002-1.005), P < 0.001), major complication (AOR: 1.013 (1.006-1.020), P < 0.001), reoperation (AOR: 1.009, (1.005-1.013), P < 0.001), and non-home discharge destination (AOR: 1.006 (1.001-1.012), P = 0.025), while native Hawaiian or Pacific Islander patients had lower odds of readmission (AOR: 0.991 (0.983-0.999), P = 0.035) and non-home discharge destination (AOR: 0.983 (0.975-0.990), P < 0.001) compared to non-Hispanic White patients. Asian patients had lower odds of each adverse outcome., Conclusions: Black, Hispanic and Latino, and AIAN patients are at higher odds for poor postoperative results than non-Hispanic White patients. AIANs had some of the highest odds of mortality, major complications, reoperation, and non-home discharge. Social health determinants and policy adjustments must be targeted to ensure optimal operative results for all patients., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Acute kidney injury (AKI) is a major complication that occurs following an operation. Therefore, there is an increasing need to discover new predictors of AKI. We hypothesized that the preoperative neutrophil-to-lymphocyte ratio (NLR) was associated with postoperative AKI and in-hospital mortality following noncardiac surgery., Methods: This is a retrospective observational study of patients who underwent noncardiac surgery at Sichuan University West China Hospital from 2018 to 2020. Multivariable logistic regression was performed as the major analytic method. In addition, sensitivity and subgroup analyses were performed to validate the results., Results: A total of 44,065 patients were included in this study. The prevalence of postoperative AKI was 5.62%, and the in-hospital mortality was 1.58%. Multivariable analysis demonstrated that NLR ≥ 5 was independently associated with the development of postoperative AKI (OR 1.42, 1.24-1.73; P < 0.001) and in-hospital mortality (OR 2.03, 1.63-2.52; P < 0.001). Similar results were achieved when propensity-score matching was performed for patients with NLR ≥ 5 and < 5 on the baseline. In stratified analysis, the associations remained persistent in most subgroups. For the sensitivity analysis, we took NLR as a continuous variable and demonstrated the potential linear relationship between NLR and postoperative AKI and mortality., Conclusions: Our results indicated that preoperative NLR is associated with the prevalence of postoperative AKI and in-hospital mortality that occur after major noncardiac surgery. These findings suggest that NLR has the potential to be a significant correlation biomarker associated with perioperative risk assessment of patients undergoing noncardiac surgeries., (© 2023. The Author(s).)

Background: Five million surgeries take place in the NHS each year. Little is known about the prevalence of chronic diseases among these patients, and the association with postoperative outcomes., Methods: Analysis of routine data from all NHS hospitals in England including patients aged ≥18 yr undergoing non-obstetric surgery between January 1, 2010 and December 31, 2015. The primary outcome was death within 90 days after surgery. For each chronic disease, we adjusted for age, sex, presence of other diseases, emergency surgery, and year using logistic regression models. We defined high-risk diseases as those with an adjusted odds ratio (OR) for death ≥2 and report associated 2-yr survival., Results: We included 8 624 611 patients (median age, 53 [36-68] yr), of whom 6 913 451 (80.2%) underwent elective surgery and 1 711 160 (19.8%) emergency surgery. Overall, 2 311 600 (26.8%) patients had a chronic disease, of whom 109 686 (4.7%) died within 90 days compared with 24 136 (0.4%) of 6 313 011 without chronic disease. Respiratory disease (1 002 281 [11.6%]), diabetes mellitus (662 706 [7.7%]), and cancer (310 363; 3.6%) were the most common. Four chronic diseases accounted for 7.7% of patients but 59.0% of deaths: cancer (37 693 deaths [12.1%]; OR=8.3 [8.2-8.5]), liver disease (8638 deaths [10.3%]; OR=4.5 [4.4-4.7]), cardiac failure (26 604 deaths [12.6%]; OR=2.4 [2.4-2.5]), and dementia (19 912 deaths [17.9%]; OR=2.0 [1.9-2.0]). Two-year survival was 67.7% among patients with high-risk chronic disease, compared with 97.1% without., Conclusion: One in four surgical patients has a chronic disease with an associated 10-fold increase in risk of postoperative death. Two-thirds of all deaths after surgery occur among patients with high-risk diseases (cancer, cardiac failure, liver disease, dementia)., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: A diagnosis of cirrhosis increases a patient's risk of postoperative mortality. Surgeons are reticent to operate when cirrhosis is known unless no option is available. This study aimed to identify the modern perioperative risk in cirrhotic patients undergoing intervention under general anesthesia for non-transplant operations., Methods: A retrospective chart review was conducted utilizing the Rush Medical Center electronic medical record. All patients over 18 years of age with a diagnosis of cirrhosis undergoing intervention between 2009 and 2019 were reviewed. 90-day mortality rates in patients grouped by Child's score, Model for End-Stage Liver Disease (MELD), and Model for End-Stage Liver Disease with sodium incorporated (MELDNa) were compared to previously accepted rates., Results: 93 patients (46% women) aged 22-72 years of all Child-Turcot-Pugh (CTP) (40% A, 36% B, and 25% C) classifications and MELD/MELDNa ranging 6-40 were analyzed. 90-day mortality of the entire population was 16%, significantly lower than expected based on CTP score (16% vs. 32%; P = .0005), MELD (16% vs. 41%; P < .0001), and MELDNa (16% vs. 46.8%; P < .0001). This was also true for CTP-B patients (12% vs. 30%; P = .025), CTP-C patients (35% vs. 70%; P = .0002), patients with MELD >14 (27% vs. 70%; P < .001), and patients with MELDNa >14 (23% vs. 70%; P < .0001)., Conclusion: Data indicate that perioperative mortality is lower than widely accepted. This suggests the need for a national database study using a representative population to determine the risk of mortality for patients with cirrhosis having surgery in recent times. Accurate estimation of this risk allows for meaningful discussion between physicians and patients when deciding to proceed with elective, necessary operations.

Background: Risk prediction models for postoperative mortality after intra-abdominal surgery have typically been developed using preoperative variables. It is unclear if intraoperative data add significant value to these risk prediction models., Methods: With IRB approval, an institutional retrospective cohort of intra-abdominal surgery patients in the 2005 to 2015 American College of Surgeons National Surgical Quality Improvement Program was identified. Intraoperative data were obtained from the electronic health record. The primary outcome was 30-day mortality. We evaluated the performance of machine learning algorithms to predict 30-day mortality using: 1) baseline variables and 2) baseline + intraoperative variables. Algorithms evaluated were: 1) logistic regression with elastic net selection, 2) random forest (RF), 3) gradient boosting machine (GBM), 4) support vector machine (SVM), and 5) convolutional neural networks (CNNs). Model performance was evaluated using the area under the receiver operator characteristic curve (AUROC). The sample was randomly divided into a training/testing split with 80%/20% probabilities. Repeated 10-fold cross-validation identified the optimal model hyperparameters in the training dataset for each model, which were then applied to the entire training dataset to train the model. Trained models were applied to the test cohort to evaluate model performance. Statistical significance was evaluated using P < .05., Results: The training and testing cohorts contained 4322 and 1079 patients, respectively, with 62 (1.4%) and 15 (1.4%) experiencing 30-day mortality, respectively. When using only baseline variables to predict mortality, all algorithms except SVM (area under the receiver operator characteristic curve [AUROC], 0.83 [95% confidence interval {CI}, 0.69-0.97]) had AUROC >0.9: GBM (AUROC, 0.96 [0.94-1.0]), RF (AUROC, 0.96 [0.92-1.0]), CNN (AUROC, 0.96 [0.92-0.99]), and logistic regression (AUROC, 0.95 [0.91-0.99]). AUROC significantly increased with intraoperative variables with CNN (AUROC, 0.97 [0.96-0.99]; P = .047 versus baseline), but there was no improvement with GBM (AUROC, 0.97 [0.95-0.99]; P = .3 versus baseline), RF (AUROC, 0.96 [0.93-1.0]; P = .5 versus baseline), and logistic regression (AUROC, 0.94 [0.90-0.99]; P = .6 versus baseline)., Conclusions: Postoperative mortality is predicted with excellent discrimination in intra-abdominal surgery patients using only preoperative variables in various machine learning algorithms. The addition of intraoperative data to preoperative data also resulted in models with excellent discrimination, but model performance did not improve., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: Operations require collaboration between surgeons, anaesthetia professionals, and nurses. The aim of this study was to determine whether intraoperative briefings influence patient outcomes., Methods: In a before-and-after controlled trial (9 months baseline; 9 months intervention), intraoperative briefings were introduced in four general surgery centres between 2015 and 2018. During the operation, the responsible surgeon (most senior surgeon present) briefed the surgical team using the StOP? protocol about: progress of the operation (Status), next steps (Objectives), possible problems (Problems), and encouraged asking questions (?). Differences between baseline and intervention were analysed regarding surgical-site infections (primary outcome), mortality, unplanned reoperations, and duration of hospital stay (secondary outcomes), using inverse probability of treatment (IPT) weighting based on propensity scores., Results: In total, 8256 patients underwent surgery in the study. Endpoint data were available for 7745 patients (93.8 per cent). IPT-weighted and adjusted intention-to-treat analyses showed no differences in surgical-site infections between baseline and intervention (9.8 versus 9.6 per cent respectively; adjusted difference (AD) -0.15 (95 per cent c.i. -1.45 to 1.14) per cent; odds ratio (OR) 0.92, 95 per cent c.i. 0.83 to 1.15; P = 0.797), but there were reductions in mortality (1.6 versus 1.1 per cent; AD -0.54 (-1.04 to -0.03) per cent; OR 0.60, 0.39 to 0.92; P = 0.018), unplanned reoperations (6.4 versus 4.8 per cent; AD -1.66 (-2.69 to -0.62) per cent; OR 0.72, 0.59 to 0.89; P = 0.002), and fewer prolonged hospital stays (21.6 versus 19.8 per cent; AD -1.82 (-3.48 to -0.15) per cent; OR 0.87, 0.77 to 0.98; P = 0.024)., Conclusion: Short intraoperative briefings improve patient outcomes and should be performed routinely., (© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd.)

Background: Few surgical studies have provided adjusted comparative postoperative outcome data among contemporary patients with and without COVID-19 infection and patients treated before the pandemic. The aim of this study was to determine the impact of performing emergency surgery in patients with concomitant COVID-19 infection., Methods: Patients who underwent emergency general and gastrointestinal surgery from March to June 2020, and from March to June 2019 in 25 Spanish hospitals were included in a retrospective study (COVID-CIR). The main outcome was 30-day mortality. Secondary outcomes included postoperative complications and failure to rescue (mortality among patients who developed complications). Propensity score-matched comparisons were performed between patients who were positive and those who were negative for COVID-19; and between COVID-19-negative cohorts before and during the pandemic., Results: Some 5307 patients were included in the study (183 COVID-19-positive and 2132 COVID-19-negative during pandemic; 2992 treated before pandemic). During the pandemic, patients with COVID-19 infection had greater 30-day mortality than those without (12.6 versus 4.6 per cent), but this difference was not statistically significant after propensity score matching (odds ratio (OR) 1.58, 95 per cent c.i. 0.88 to 2.74). Those positive for COVID-19 had more complications (41.5 versus 23.9 per cent; OR 1.61, 1.11 to 2.33) and a higher likelihood of failure to rescue (30.3 versus 19.3 per cent; OR 1.10, 0.57 to 2.12). Patients who were negative for COVID-19 during the pandemic had similar rates of 30-day mortality (4.6 versus 3.2 per cent; OR 1.35, 0.98 to 1.86) and complications (23.9 versus 25.2 per cent; OR 0.89, 0.77 to 1.02), but a greater likelihood of failure to rescue (19.3 versus 12.9 per cent; OR 1.56, 95 per cent 1.10 to 2.19) than prepandemic controls., Conclusion: Patients with COVID-19 infection undergoing emergency general and gastrointestinal surgery had worse postoperative outcomes than contemporary patients without COVID-19. COVID-19-negative patients operated on during the COVID-19 pandemic had a likelihood of greater failure-to-rescue than prepandemic controls., (© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To evaluate the association of historical racist housing policies and modern-day healthcare outcomes., Summary of Background Data: In 1933 the United States Government Home Owners Loan Corporation (HOLC) used racial composition of neighborhoods to determine creditworthiness and labeled them "Best", "Still Desirable", "Definitely Declining", and "Hazardous." Although efforts have been made to reverse these racist policies that structurally disadvantage those living in exposed neighborhoods, the lasting legacy on modern day healthcare outcomes is uncertain., Methods: We performed a cross-sectional retrospective review of 212,179 Medicare beneficiaries' living in 171,930 unique neighborhoods historically labeled by the HOLC who underwent 1 of 5 of common surgical procedures - coronary artery bypass, appendectomy, colectomy, cholecystectomy, and hernia repair - between 2012 and 2018. We compared 30-day mortality, complications, and readmissions across HOLC grade and Area Deprivation Index (ADI) of each neighborhood. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods ADI; a modern day measure of neighborhood disadvantage that includes education, employment, housing-quality, and poverty measures., Results: Overall, 212,179 Medicare beneficiaries (mean age, 71.2 years; 54.2% women) resided in 171,930 unique neighborhoods historically graded by the HOLC. Outcomes worsened in a stepwise fashion across HOLC neighborhoods. Overall, 30-day postoperative mortality was 5.4% in "Best" neighborhoods, 5.8% in "Still Desirable", 6.1% in "Definitely Declining", and 6.4% in "Hazardous" (Best vs Hazardous Odds Ration: 1.23, 95% CI: 1.13-1.24, P < 0.001). The same stepwise pattern was seen from "Best" to "Hazardous" neighborhoods for complications (30.5% vs 32.2%; OR: 1.12 [95% CI: 1.07-1.17]; P < 0.001) and Readmissions (16.3% vs 17.1%; OR: 1.06 [95% CI: 1.01-1.11]; P = 0.023). After controlling for modern day deprivation using ADI, the patterns persisted with "Hazardous" neighborhoods having higher mortality (OR: 1.17 [95% CI: 1.08-1.27]; P < 0.001) and complications (OR: 1.07 [95% CI: 1.02-1.12]; P = 0.003), but not for readmissions (OR: 1.02 [95% CI: 0.97-1.07]; P = 0.546)., Conclusions: Patients residing in neighborhoods previously "redlined" or labeled "Hazardous" were more likely to experience worse outcomes after inpatient hospitalization compared to those living in "Best" neighborhoods, even after taking into account modern day measures of neighborhood disadvantage., Competing Interests: Dr. Dimick is a cofounder of ArborMetrix, Inc, a company that makes software for profiling hospital quality and efficiency. Dr. Ibrahim is a Principal at HOK architects, a global design and architecture firm. The authors have no conflicts of interest pertaining to the work herein., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The health care systems of low-income countries have severely limited capacity to treat surgical diseases and conditions. There is limited information about which hospital mortality outcomes are suitable metrics in these settings., Methods: We did a 1-year observational cohort study of patient admissions to the Surgery and the Obstetrics and Gynecology departments and of newborns delivered at a Ugandan secondary referral hospital. We examined the proportion of deaths captured by standardized metrics of mortality., Results: There were 17,015 admissions and 9612 deliveries. A total of 847 deaths were documented: 385 (45.5%) admission deaths and 462 (54.5%) perinatal deaths. Less than one-third of admission deaths occurred during or after an operation (n = 126/385, 32.7%). Trauma and maternal mortality combined with perioperative mortality produced 79.2% (n = 305/385) of admission deaths. Of 462 perinatal deaths, 412 (90.1%) were stillborn, and 50 (10.9%) were early neonatal deaths. The combined metrics of the trauma mortality rate, maternal mortality ratio, thirty-day perioperative mortality rate, and perinatal mortality rate captured 89.8% (n = 761/847) of all deaths documented at the hospital., Conclusions: The combination of perinatal, maternal, trauma, and perioperative mortality metrics captured most deaths documented at a Ugandan referral hospital., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Background: There is a paucity of data on older adults (age ≥65 years) undergoing surgery who had an inpatient do-not-resuscitate (DNR) order, and the association between timing of DNR order and outcomes., Methods: This was a retrospective analysis of 1976 older adults in the American College of Surgeons National Surgical Quality Improvement Program geriatric-specific database (2014-2018). Patients were stratified by institution of a DNR order during their surgical admission ("new-DNR" vs. "no-DNR"), and matched by age (±3 years), frailty score (range: 0-1), and procedure. The main outcome of interest was occurrence of death or hospice transition (DoH) ≤30 postoperative days; this was analyzed using bivariate and multivariable methods., Results: One in 36 older adults had a new-DNR order. After matching, there were 988 new-DNR and 988 no-DNR patients. Median age and frailty score were 82 years and 0.2, respectively. Most underwent orthopedic (47.6%), general (37.6%), and vascular procedures (8.4%). Overall DoH rate ≤30 days was 44.4% for new-DNR versus 4.0% for no-DNR patients (p < 0.001). DoH rate for patients who had DNR orders placed in the preoperative, day of surgery, and postoperative setting was 16.7%, 23.3%, and 64.6%, respectively (p < 0.001). In multivariable analysis, compared to no-DNR patients, those with a new-DNR order had a 28-fold higher adjusted odds of DoH (odds ratio [OR] 28.1, 95% confidence interval: 13.0-60.1, p < 0.001); however, odds were 10-fold lower if the DNR order was placed preoperatively (OR: 5.8, p = 0.003) versus postoperatively (OR: 52.9, p < 0.001). Traditional markers of poor postoperative outcomes such as American Society of Anesthesiologists class and emergency surgery were not independently associated with DoH., Conclusions: An inpatient DNR order was associated with risk of DoH independent of traditional markers of poor surgical outcomes. Further research is needed to understand factors leading to a DNR order that may aid early recognition of high-risk older adults undergoing surgery., (© 2021 The American Geriatrics Society.)