The Clavien-Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien-Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs).This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien-Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs.A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien-Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59).Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.
Abstract Introduction Endurance athletic training may lead to left ventricular (LV) dilatation and mildly reduced resting LV function which can be difficult to differentiate from dilated cardiomyopathy (DCM). Myocardial fibrosis is increasingly recognised in lifelong athletes and is also prevalent in DCM where it confers adverse prognosis.(1,2) However, it is unknown whether the pattern and prevalence of fibrosis in athletes with cavity dilatation differs from DCM. In this study, we compared the CMR fibrosis distribution and tissue characteristics between athletic LV dilatation and mild DCM patients. Methods We prospectively recruited 113 males; 64 endurance athletes and 49 mild DCM patients. Inclusion criteria Age 50-80 years, LVEF 45-54% and LV end-diastolic volume indexed to body surface area (LVEDVi)≥110ml/m2. Athletes trained≥10 weekly hrs for≥15 yrs. Exclusion criteria; Chest pain, prior coronary revascularisation, severe valvular disease, myocarditis, hypertrophic cardiomyopathy, inducible ischaemia or myocardial infarction on CMR. CMR protocol included volumetric assessment, T1 mapping, quantitative stress perfusion and quantitative late gadolinium enhancement. Statistical analysis between groups was performed using unpaired t-test and receiver-operator curve (ROC) analysis. Results LVEDVi was not significantly different between athletes and mild DCM patients (123.3±12.6 vs 129.8±23.1ml/m2, P=0.057). However, LVEF (52.0±6.1 vs 47.6±5.2%, P<0.001) and right ventricular (RV) EDVi (121.0±14.3 vs 97.6±25.2ml/m2, P<0.001) were both greater in athletes. There was no difference in non-ischaemic fibrosis prevalence between both groups (50.0 vs 49.0%, P=0.915) nor the burden of fibrosis (3.5±2.9 vs 7.4±12.0g, P=0.087). However, the distribution of fibrosis varied with a significantly greater prevalence of basal mid-myocardial inferolateral fibrosis amongst athletes (87.5 vs 50.0%, P=0.002) whereas basal mid-myocardial inferoseptal fibrosis was significantly more common in mild DCM (45.8 vs 9.4%, P=0.002). Native T1 (1249.0±38.1 vs 1308.3±47.1ms, P<0.001) and extracellular volume (ECV) (22.0±2.1 vs 25.9±3.5%, P<0.001) were both lower in athletes than mild DCM patients. Furthermore, athletes had higher myocardial perfusion reserve (MPR) (3.65±1.30 vs 2.76±0.92, P<0.001) and stress myocardial blood flow (MBF) (2.09±0.70 vs 1.62±0.66, P<0.001). On ROC analysis, native T1 (area under curve (AUC) 0.89, P<0.001), ECV (AUC 0.85, P<0.001) and stress MBF (AUC 0.68, P<0.001) were able to differentiate athletes and mild DCM. Native T1 and ECV were significantly better at discriminating than MPR (P<0.001). Conclusion Myocardial fibrosis was highly prevalent in both veteran endurance athlete's heart and mild DCM whilst its distribution was distinctive between the groups. Native T1 and ECV were the best discriminators. Recognition of fibrosis patterns and associated tissue characteristics may be clinically useful to differentiate these two overlapping phenotypes.Figure 1; LGE distribution in athletes cFigure 2; CMR tissue characteristics to
Objective: Patients suffering from rheumatic diseases are characterized by increased cardiovascular risk, demonstrated by elevated rates of cardiovascular morbidity and mortality. Although systemic inflammation and autoimmune-mediated atherosclerosis have been identified as potential contributors, their impact on macrovascular function remains under intense investigation, with available studies often demonstrating conflicting results. Design and method: The aim of the present study was to evaluate macrovascular function in consecutive patients with rheumatoid arthritis attending a rheumatology outpatient clinic, and compare the status of the macrovasculature with individuals matched for age, sex, blood pressure and cholesterol levels. Arterial stiffness was evaluated with measurement of carotid-femoral pulse wave velocity (PWV), which was assessed by use of applanation tonometry (Sfygmocor device). Carotid ultrasound was used for the measurement of mean carotid intima-media thickness (cIMT). Results: A total of 132 individuals, 28 males and 104 females, were included in the study. Of them, 61.4% were suffering from rheumatoid arthritis, 6.8% from systemic sclerosis, 2.3% from systemic lupus erythematosus, while the rest 29.5% comprised the control population. Rheumatic patients were matched to controls in terms of age (60.3 ± 13 versus 57.4 ± 8.1 years, p = 0.147), sex (19.4% versus 25.6% males, p = 0.420), systolic blood pressure (123.7 ± 15 versus 122.3 ± 11.7 mmHg, p = 0.614), diastolic blood pressure (74.7 ± 10 versus 77.0 ± 7.9 mmHg, p = 0.187), body mass index (26.5 ± 5.3 versus 27.1 ± 4.4, p = 0.510), smoking status (28.4% versus 33.3%, p = 0.656) and total cholesterol levels (204.9 ± 38.2 versus 214.5 ± 38.5 mg/dl, p = 0.249). Mean PWV in rheumatic patients significantly differed compared to controls (8.4 ± 2.2 versus 7.3 ± 1.2, p = 0.010). Likewise, mean cIMT was significantly higher in rheumatic patients compared to controls (0.69 ± 0.13 versus 0.62 ± 0.09 mm, p = 0.026). Conclusions: Patients suffering from rheumatic diseases exhibit significantly higher levels of both arterial stiffness and cIMT compared to well-matched controls. This difference appears to be independent of blood pressure and other cardiovascular risk factors. This is one of the few studies simultaneously assessing indices of macrovascular function in patients with rheumatic diseases, compared to well-matched controls. Further studies are needed to clarify to which extent macrovascular damage in these patients contributes to their increased cardiovascular morbidity and mortality, independent of traditional cardiovascular risk factors.
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