Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov , NCT03471494 . Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

O comportamento da infecção humana pelo Trypanosoma cruzi quando vigente imunodeficiência ainda requer melhores esclarecimentos. Essa necessidade está ficando cada vez mais imperiosa porque a concomitância de doença de Chagas e afecções nas quais o distúrbio imunitário existe é atualmente mais comum e, também, em virtude do maior u s o a t u a l d e f á r m a c o s q u e o r i g i n a m a imunodepressão 2 9 10 . Além disso, a crescente realização de transplantes de órgãos, sendo preciso coibir rejeições, envolve hoje, em várias oportunidades, pacientes acometidos pela enfermidade referida, figurando eles como doadores ou receptores 6 8 11 . O número de relatos de investigações experimentais, sobre a atuação de corticóide, desenvolvidas nos modelos baseados em diferentes tipos de animais, representados sobretudo por camundongos, é razoável. A despeito de não haver unanimidade, as deduções indicam comumente aumentos da parasitemia, do parasitismo tecidual e da mortalidade, revelando também mudança do tropismo em relação aos órgãos que o T. cruzi infecta e atenuação do contingente inflamatório.Tais estudos focalizaram as fases aguda, pós-aguda imediata e crônica, tendo apontado, além do que já citamos, comportamentos diversos de cepas 1 3 5 12 13. Nessas pesquisas, diferentes modalidades de corticóide foram utilizadas, isoladamente ou em associação com compostos tripanossomicidas.No que concerne a pacientes com doença de Chagas, reativações vêm sendo comprovadas quando recebem coração por meio de transplante, corticóide fazendo parte da tática imunossupressora, ou em virtude da administração de certos fár macos para tratamento de leucemias, acrescentando-se a isso, hoje em dia, a participação da síndrome da imunodeficiência adquirida (AIDS)

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Campos Costa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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