I. Grigoras | University of Medicine and Pharmacy "Gr. T. Popa", Iasi (original) (raw)

Papers by I. Grigoras

Research paper thumbnail of A rare complication of colostomy

Chirurgia (Bucharest, Romania), Jul 1, 2006

A case of a 64 years old female patient who had had a Miles operation 6 years ago for rectal canc... more A case of a 64 years old female patient who had had a Miles operation 6 years ago for rectal cancer and at the present hospital admission she came in with a severe infection around her left colostomy. Initially, she presented a quite localized peristomal infection but, subsequently, the infection has evolved to an extensive necrotizing fasciitis of the abdomen, a large dehiscence of colostomy and severe sepsis. Repeated surgery and transverse colostomy, to put at rest infected left colostomy, plus aggressive medical treatment resulted in a good recovery, with the wounds healing and redo of the left colostomy. Now she is on the waiting list to get rid of the transverse colostomy.

Research paper thumbnail of Mean number of lymph nodes in colonic cancer specimen: possible quality control index for surgical performance

Chirurgia (Bucharest, Romania : 1990)

Lymphatic involvement in colonic cancer explains the need for extensive lymphadenectomy for inten... more Lymphatic involvement in colonic cancer explains the need for extensive lymphadenectomy for intended curative operations. Surgical skills may determine the actual extent of the procedure and indirectly the number of lymphnodes (LN) removed from each specimen. We looked on a series of 329 consecutive patients with colonic cancer who underwent a standardized procedure including extensive lymphadenectomy. The main endpoints were survival as well as the number of LN and the mean number of Differences in Kaplan-Meyer survival curves between average and high performance colectomies have been identifled for right colectomies both in stage II (85.7% vs 64.7%) as well in stage III (71.4% vs 56.5% 5-year survival), and also in stage II for segmental colectomies (85.7% vs 78.9%), showing a definitive advantage in survival for patients operated by surgeons with a mean LN retrieval above cutoff values. our study suggests that the mean number of LN retrieved from the surgical specimen can be used...

Research paper thumbnail of Efficacy and safety of anidulafungin in elderly, critically ill patients with invasive Candida infections: a post hoc analysis

International Journal of Antimicrobial Agents, 2012

Post hoc analysis of a non-comparative, prospective, multicentre, phase IIIb study was performed ... more Post hoc analysis of a non-comparative, prospective, multicentre, phase IIIb study was performed to compare efficacy and safety of anidulafungin in elderly (≥65 years) versus non-elderly (<65 years) Intensive Care Unit (ICU) patients with candidaemia/invasive candidiasis (C/IC). Adult ICU patients with confirmed C/IC meeting ≥1 of the following criteria were enrolled: post-abdominal surgery; solid tumour; renal/hepatic insufficiency; solid organ transplantation; neutropenia; age ≥65 years. Patients received anidulafungin (200 mg on Day 1, 100 mg/day thereafter) for ≥10 days followed by optional azole stepdown therapy for a total treatment duration of 14-56 days. The primary efficacy endpoint was global (clinical and microbiological) response at the end of all therapy (EOT). Primary efficacy analysis was performed in the modified intent-to-treat (mITT) population (n = 170), excluding unknown and missing responses. In total, 80 patients (47.1%) were aged ≥65 years and 90 (52.9%) were aged <65 years; the mean age difference between the two groups was 21.9 years. Global success at EOT in mITT patients was similar in elderly (68.1%) and non-elderly (70.7%) patients (P = 0.719). However, global success rates were significantly lower in elderly versus non-elderly patients at 2 and 6 weeks after EOT (P = 0.045 and P = 0.016, respectively). Ninety-day survival was significantly lower (P = 0.006) for elderly (42.8%) versus non-elderly patients (63.3%). The incidence and profile of adverse events were similar in elderly and non-elderly patients. Anidulafungin was effective and safe for treatment of C/IC in elderly ICU patients, despite higher baseline severity of illness scores.

Research paper thumbnail of Lung Ultrasound as a Bedside Tool for Postoperative Fluid Management in Surgical Icu Patients: A Randomized Study

Research paper thumbnail of Role of nutrition in the management of inflammatory bowel disease – current status –

A lot of medical literature is lately dedicated to nutrition in inflammatory bowel disease (IBD).... more A lot of medical literature is lately dedicated to nutrition in inflammatory bowel disease (IBD). The growing recognition of the importance of nutrition in the management of IBD is reflected by the increasing number of papers dedicated to the topic and by the evidence based guidelines. When analyzing nutrition and IBD, three major aspects must be concerned: the influence of nutritional components in the pathogenesis of IBD, the impact of IBD on nutritional status and the potential role of nutritional therapy. Many nutrients are under scrutiny for their involvement in the pathogenesis of IBD: carbohydrates, fibers, fruits, vegetables, fats, proteins. Their role is still under debate. Modern food may induce in predisposed individuals mucosal damage and increased translocation, continuous exposure to bacterial antigens and sustained immunologic stimulation. Malnutrition is frequently associated with IBD and its severity is influenced by the phase of disease activity and the length and ...

Research paper thumbnail of Mortality after surgery in Europe: a 7 day cohort study

The Lancet, 2012

Background Clinical outcomes after major surgery are poorly described at the national level. Evid... more Background Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfi rmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe. Methods We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ² and Fisher's exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Signifi cance was set at p<0•05. We constructed multilevel logistic regression models to adjust for the diff erences in mortality rates between countries. Findings We included 46 539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients were admitted to critical care after surgery with a median length of stay of 1•2 days (IQR 0•9-3•6). 1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude mortality rates varied widely between countries (from 1•2% [95% CI 0•0-3•0] for Iceland to 21•5% [16•9-26•2] for Latvia). After adjustment for confounding variables, important diff erences remained between countries when compared with the UK, the country with the largest dataset (OR range from 0•44 [95% CI 0•19-1•05; p=0•06] for Finland to 6•92 [2•37-20•27; p=0•0004] for Poland). Interpretation The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients.

Research paper thumbnail of Candida bloodstream infections in intensive care units: Analysis of the extended prevalence of infection in intensive care unit study*

Critical Care Medicine, 2011

Research paper thumbnail of Point prevalence of surgical checklist use in Europe: relationship with hospital mortality

British journal of anaesthesia, Jan 13, 2015

The prevalence of use of the World Health Organization surgical checklist is unknown. The clinica... more The prevalence of use of the World Health Organization surgical checklist is unknown. The clinical effectiveness of this intervention in improving postoperative outcomes is debated. We undertook a retrospective analysis of data describing surgical checklist use from a 7 day cohort study of surgical outcomes in 28 European nations (European Surgical Outcomes Study, EuSOS). The analysis included hospitals recruiting >10 patients and excluding outlier hospitals above the 95th centile for mortality. Multivariate logistic regression and three-level hierarchical generalized mixed models were constructed to explore the relationship between surgical checklist use and hospital mortality. Findings are presented as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). A total of 45 591 patients from 426 hospitals were included in the analysis. A surgical checklist was used in 67.5% patients, with marked variation across countries (0-99.6% of patients). Surgical checklist...

Research paper thumbnail of Is intragastric administration of enteral nutrition safe in acute severe pancreatitis?

Critical Care, 2009

There is considerable uncertainty about the reproducibility of the various instruments used to me... more There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Research paper thumbnail of Is intragastric administration of enteral nutrition safe in acute severe pancreatitis?

Critical Care, 2009

There is considerable uncertainty about the reproducibility of the various instruments used to me... more There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Research paper thumbnail of Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery

BJA: British Journal of Anaesthesia

Research paper thumbnail of Anaesthesia and Intensive Care Residents’ Perception of Simulation Training in Four Romanian Centres

The Journal of Critical Care Medicine, 2017

Simulation training offers an opportunity to educate anaesthesia and intensive care (AIC) residen... more Simulation training offers an opportunity to educate anaesthesia and intensive care (AIC) residents safely. At present, it is not yet a mandatory part of residency curriculum.

Research paper thumbnail of Incomplete deployment of an expandable metallic stent in a patient with esophageal malignant stenosis

Journal of gastrointestinal and liver diseases : JGLD, 2010

The use of self expandable metallic stents (SEMS) in the palliation of dysphagia due to malignant... more The use of self expandable metallic stents (SEMS) in the palliation of dysphagia due to malignant esophageal stenosis is a gold standard. Covered stents are used in all cases with overt air-digestive fistula or high potential for fistula development. The procedure is associated with a low incidence of procedure-related complications. We present a case with a major accident which developed during stent deployment. The delivery system became blocked and we found it impossible to fully deploy the stent, which remained attached to the introductory system. The stent was forcefully removed and replaced later on with a new stent. This is the first report of a SEMS related accident due to malfunction of the stent deployment system. Stent malfunction is unusual and unlikely to happen, but one should be aware and prepared for such unusual situations.

Research paper thumbnail of Is intragastric administration of enteral nutrition safe in acute severe pancreatitis?

Critical Care, 2009

There is considerable uncertainty about the reproducibility of the various instruments used to me... more There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Research paper thumbnail of P280 Nutritionday in Romania - Where Do We Stand?

Clinical Nutrition Supplements, 2008

Rationale: Nutritional status influences the survival of patients on long-term hemodialysis (HD).... more Rationale: Nutritional status influences the survival of patients on long-term hemodialysis (HD). This study was performed to assess the nutritional status in patients on HD at a university hospital in Isfahan, Iran. Methods: In this cross-sectional study, 79 patients with ESRD on HD included 40 females and 39 males with mean age 46.6±16.3 (18 80) years were recruited. The mean time on HD was 30.94±28.87 (30 132) months. Anthropometric measurements including triceps skin-fold thickness (TSF), mid-arm circumference (MAC) and midarm muscle circumference (MAMC) were taken on all patients. Body mass index (BMI) was also calculated. Relevant laboratory parameters were also checked. Data analysis was carried out using the SPSS, Pearson correlation, t-test, and regression. Results: Based on the MS, 83.54 of patients had malnutrition (mean score: 18.11±4.64). MS showed a statistically significant correlation with TSF (r = 0.26), MAC (r = 0.32), MAMC (r = 0.27), serum albumin (r = 0.44), and BMI (r = 0.26). There wasn't any correlation between MS and transferrin concentration and lymphocyte count. Conclusion: Most of our studied patients were suffering from malnutrition. Our study suggests that MS is a reliable, easy performing and precise method of assessing nutritional status in HD patients

Research paper thumbnail of Is intragastric administration of enteral nutrition safe in acute severe pancreatitis?

Critical Care, 2009

There is considerable uncertainty about the reproducibility of the various instruments used to me... more There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Research paper thumbnail of Presumed Consent for Organ Donation: Is Romania Prepared for It?

Transplantation Proceedings, 2010

In November 2007, a legislative initiative regarding the presumed consent for organ donation was ... more In November 2007, a legislative initiative regarding the presumed consent for organ donation was proposed for parliamentary debate in Romania and was followed by public debate. The study aimed to asses public opinions expressed in the Romanian media. An Internet search was made. The pro and con reasons, the affiliation of parts involved in the debate and suggested future direction of action were identified. The Internet search had 8572 results. The parts involved in the pro and con debate consisted of governmental structures, physicians, ethicists, politicians, media, religious authorities, nongovernmental associations, and lay persons. The main pros were the low rate of organ donation and the long waiting lists, enhancement of organ procurement, avoidance of wasting valuable organs, avoiding responsibility, and the stress imposed to the family in giving the donation consent, humanitarian purposes (saving lives), going along with the scientific progress, and less bureaucracy. The main cons were an unethical issue, violation of human rights, denial of brain death, unethical advantage of public ignorance, unethical use of underprivileged people, little results in terms of organ procurement, but huge negative effects on public opinion, public mistrust in transplant programs and impossibility of refusal identification due to particularities of the Romanian medical system. The con opinions prevailed. For the moment, Romania seems to be unprepared to accept presumed consent. A future change in public perception regarding organ transplantation may modify the terms of a public debate.

Research paper thumbnail of Transfusion policy and outcome in critically ill patients with a long ICU stay

Critical Care, 2008

all 10 cities including the rural areas of the province of Kerman. All data were finally analyzed... more all 10 cities including the rural areas of the province of Kerman. All data were finally analyzed by SPSS software (version 11.5). Results On the basis of recorded statistical analysis, the mortality cases of human rabies in the province of Kerman during one decade was 10 persons (eight males and two females). One-half of them (50%) were bitten by dogs and the others (50%) by foxes. Among the reported deaths, 40% were from Kahnooj county (Jiroft region). The reported data indicated that 21,546 persons were bitten by animals during 10 years in the province of Kerman. The mean of age of the people who were bitten by dogs was 24.80 years (SD = ±14.6), while the mean age of the people who were bitten by foxes was 57.25 years (SD = ±1.50). There was a significant difference between the mean age of these two groups of the people (P < 0.05). The most frequent rate of injured people was reported in the age group 10-19 years old and the frequency rate of males (76.00%) was more than females (24.00%). Therefore, there was a statistically significant difference between males and females in this study (P < 0.01). About 60% of all persons that were bitten by animals were from rural areas and 40% of them were from urban areas (P < 0.05). Among the people who were bitten and injured by animals during one decade in the province of Kerman, 85.70% of them were not treated by the rabies prophylaxis treatment regimen. Among all of them who were bitten by animals, 50% were injured through hands and feet, 40%

Research paper thumbnail of Anidulafungin for the treatment of candidaemia/invasive candidiasis in selected critically ill patients

Clinical Microbiology and Infection, 2012

A prospective, multicentre, phase IIIb study with an exploratory, open-label design was conducted... more A prospective, multicentre, phase IIIb study with an exploratory, open-label design was conducted to evaluate efficacy and safety of anidulafungin for the treatment of candidaemia/invasive candidiasis (C/IC) in specific ICU patient populations. Adult ICU patients with confirmed C/IC meeting ≥ 1 of the following criteria were enrolled: post-abdominal surgery, solid tumour, renal/hepatic insufficiency, solid organ transplant, neutropaenia, and age ≥ 65 years. Patients received anidulafungin (200 mg on day 1, 100 mg/day thereafter) for 10-42 days, optionally followed by oral voriconazole/fluconazole. The primary efficacy endpoint was global (clinical and microbiological) response at the end of all therapy (EOT). Secondary endpoints included global response at the end of intravenous therapy (EOIVT) and at 2 and 6 weeks post-EOT, survival at day 90, and incidence of adverse events (AEs). The primary efficacy analysis was performed in the modified intent-to-treat (MITT) population, excluding unknown/missing responses. The safety and MITT populations consisted of 216 and 170 patients, respectively. The most common pathogens were Candida albicans (55.9%), C. glabrata (14.7%) and C. parapsilosis (10.0%). Global success was 69.5% (107/154; 95% CI, 61.6-76.6) at EOT, 70.7% (111/157) at EOIVT, 60.2% (77/128) at 2 weeks post-EOT, and 50.5% (55/109) at 6 weeks post-EOT. When unknown/missing responses were included as failures, the respective success rates were 62.9%, 65.3%, 45.3% and 32.4%. Survival at day 90 was 53.8%. Treatment-related AEs occurred in 33/216 (15.3%) patients, four (1.9%) of whom had serious AEs. Anidulafungin was effective, safe and well tolerated for the treatment of C/IC in selected groups of ICU patients.

Research paper thumbnail of Point prevalence of surgical checklist use in Europe: relationship with hospital mortality

British journal of anaesthesia, Jan 13, 2015

The prevalence of use of the World Health Organization surgical checklist is unknown. The clinica... more The prevalence of use of the World Health Organization surgical checklist is unknown. The clinical effectiveness of this intervention in improving postoperative outcomes is debated. We undertook a retrospective analysis of data describing surgical checklist use from a 7 day cohort study of surgical outcomes in 28 European nations (European Surgical Outcomes Study, EuSOS). The analysis included hospitals recruiting >10 patients and excluding outlier hospitals above the 95th centile for mortality. Multivariate logistic regression and three-level hierarchical generalized mixed models were constructed to explore the relationship between surgical checklist use and hospital mortality. Findings are presented as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). A total of 45 591 patients from 426 hospitals were included in the analysis. A surgical checklist was used in 67.5% patients, with marked variation across countries (0-99.6% of patients). Surgical checklist...

Research paper thumbnail of A rare complication of colostomy

Chirurgia (Bucharest, Romania), Jul 1, 2006

A case of a 64 years old female patient who had had a Miles operation 6 years ago for rectal canc... more A case of a 64 years old female patient who had had a Miles operation 6 years ago for rectal cancer and at the present hospital admission she came in with a severe infection around her left colostomy. Initially, she presented a quite localized peristomal infection but, subsequently, the infection has evolved to an extensive necrotizing fasciitis of the abdomen, a large dehiscence of colostomy and severe sepsis. Repeated surgery and transverse colostomy, to put at rest infected left colostomy, plus aggressive medical treatment resulted in a good recovery, with the wounds healing and redo of the left colostomy. Now she is on the waiting list to get rid of the transverse colostomy.

Research paper thumbnail of Mean number of lymph nodes in colonic cancer specimen: possible quality control index for surgical performance

Chirurgia (Bucharest, Romania : 1990)

Lymphatic involvement in colonic cancer explains the need for extensive lymphadenectomy for inten... more Lymphatic involvement in colonic cancer explains the need for extensive lymphadenectomy for intended curative operations. Surgical skills may determine the actual extent of the procedure and indirectly the number of lymphnodes (LN) removed from each specimen. We looked on a series of 329 consecutive patients with colonic cancer who underwent a standardized procedure including extensive lymphadenectomy. The main endpoints were survival as well as the number of LN and the mean number of Differences in Kaplan-Meyer survival curves between average and high performance colectomies have been identifled for right colectomies both in stage II (85.7% vs 64.7%) as well in stage III (71.4% vs 56.5% 5-year survival), and also in stage II for segmental colectomies (85.7% vs 78.9%), showing a definitive advantage in survival for patients operated by surgeons with a mean LN retrieval above cutoff values. our study suggests that the mean number of LN retrieved from the surgical specimen can be used...

Research paper thumbnail of Efficacy and safety of anidulafungin in elderly, critically ill patients with invasive Candida infections: a post hoc analysis

International Journal of Antimicrobial Agents, 2012

Post hoc analysis of a non-comparative, prospective, multicentre, phase IIIb study was performed ... more Post hoc analysis of a non-comparative, prospective, multicentre, phase IIIb study was performed to compare efficacy and safety of anidulafungin in elderly (≥65 years) versus non-elderly (<65 years) Intensive Care Unit (ICU) patients with candidaemia/invasive candidiasis (C/IC). Adult ICU patients with confirmed C/IC meeting ≥1 of the following criteria were enrolled: post-abdominal surgery; solid tumour; renal/hepatic insufficiency; solid organ transplantation; neutropenia; age ≥65 years. Patients received anidulafungin (200 mg on Day 1, 100 mg/day thereafter) for ≥10 days followed by optional azole stepdown therapy for a total treatment duration of 14-56 days. The primary efficacy endpoint was global (clinical and microbiological) response at the end of all therapy (EOT). Primary efficacy analysis was performed in the modified intent-to-treat (mITT) population (n = 170), excluding unknown and missing responses. In total, 80 patients (47.1%) were aged ≥65 years and 90 (52.9%) were aged <65 years; the mean age difference between the two groups was 21.9 years. Global success at EOT in mITT patients was similar in elderly (68.1%) and non-elderly (70.7%) patients (P = 0.719). However, global success rates were significantly lower in elderly versus non-elderly patients at 2 and 6 weeks after EOT (P = 0.045 and P = 0.016, respectively). Ninety-day survival was significantly lower (P = 0.006) for elderly (42.8%) versus non-elderly patients (63.3%). The incidence and profile of adverse events were similar in elderly and non-elderly patients. Anidulafungin was effective and safe for treatment of C/IC in elderly ICU patients, despite higher baseline severity of illness scores.

Research paper thumbnail of Lung Ultrasound as a Bedside Tool for Postoperative Fluid Management in Surgical Icu Patients: A Randomized Study

Research paper thumbnail of Role of nutrition in the management of inflammatory bowel disease – current status –

A lot of medical literature is lately dedicated to nutrition in inflammatory bowel disease (IBD).... more A lot of medical literature is lately dedicated to nutrition in inflammatory bowel disease (IBD). The growing recognition of the importance of nutrition in the management of IBD is reflected by the increasing number of papers dedicated to the topic and by the evidence based guidelines. When analyzing nutrition and IBD, three major aspects must be concerned: the influence of nutritional components in the pathogenesis of IBD, the impact of IBD on nutritional status and the potential role of nutritional therapy. Many nutrients are under scrutiny for their involvement in the pathogenesis of IBD: carbohydrates, fibers, fruits, vegetables, fats, proteins. Their role is still under debate. Modern food may induce in predisposed individuals mucosal damage and increased translocation, continuous exposure to bacterial antigens and sustained immunologic stimulation. Malnutrition is frequently associated with IBD and its severity is influenced by the phase of disease activity and the length and ...

Research paper thumbnail of Mortality after surgery in Europe: a 7 day cohort study

The Lancet, 2012

Background Clinical outcomes after major surgery are poorly described at the national level. Evid... more Background Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfi rmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe. Methods We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ² and Fisher's exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Signifi cance was set at p<0•05. We constructed multilevel logistic regression models to adjust for the diff erences in mortality rates between countries. Findings We included 46 539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients were admitted to critical care after surgery with a median length of stay of 1•2 days (IQR 0•9-3•6). 1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude mortality rates varied widely between countries (from 1•2% [95% CI 0•0-3•0] for Iceland to 21•5% [16•9-26•2] for Latvia). After adjustment for confounding variables, important diff erences remained between countries when compared with the UK, the country with the largest dataset (OR range from 0•44 [95% CI 0•19-1•05; p=0•06] for Finland to 6•92 [2•37-20•27; p=0•0004] for Poland). Interpretation The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients.

Research paper thumbnail of Candida bloodstream infections in intensive care units: Analysis of the extended prevalence of infection in intensive care unit study*

Critical Care Medicine, 2011

Research paper thumbnail of Point prevalence of surgical checklist use in Europe: relationship with hospital mortality

British journal of anaesthesia, Jan 13, 2015

The prevalence of use of the World Health Organization surgical checklist is unknown. The clinica... more The prevalence of use of the World Health Organization surgical checklist is unknown. The clinical effectiveness of this intervention in improving postoperative outcomes is debated. We undertook a retrospective analysis of data describing surgical checklist use from a 7 day cohort study of surgical outcomes in 28 European nations (European Surgical Outcomes Study, EuSOS). The analysis included hospitals recruiting >10 patients and excluding outlier hospitals above the 95th centile for mortality. Multivariate logistic regression and three-level hierarchical generalized mixed models were constructed to explore the relationship between surgical checklist use and hospital mortality. Findings are presented as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). A total of 45 591 patients from 426 hospitals were included in the analysis. A surgical checklist was used in 67.5% patients, with marked variation across countries (0-99.6% of patients). Surgical checklist...

Research paper thumbnail of Is intragastric administration of enteral nutrition safe in acute severe pancreatitis?

Critical Care, 2009

There is considerable uncertainty about the reproducibility of the various instruments used to me... more There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Research paper thumbnail of Is intragastric administration of enteral nutrition safe in acute severe pancreatitis?

Critical Care, 2009

There is considerable uncertainty about the reproducibility of the various instruments used to me... more There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Research paper thumbnail of Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery

BJA: British Journal of Anaesthesia

Research paper thumbnail of Anaesthesia and Intensive Care Residents’ Perception of Simulation Training in Four Romanian Centres

The Journal of Critical Care Medicine, 2017

Simulation training offers an opportunity to educate anaesthesia and intensive care (AIC) residen... more Simulation training offers an opportunity to educate anaesthesia and intensive care (AIC) residents safely. At present, it is not yet a mandatory part of residency curriculum.

Research paper thumbnail of Incomplete deployment of an expandable metallic stent in a patient with esophageal malignant stenosis

Journal of gastrointestinal and liver diseases : JGLD, 2010

The use of self expandable metallic stents (SEMS) in the palliation of dysphagia due to malignant... more The use of self expandable metallic stents (SEMS) in the palliation of dysphagia due to malignant esophageal stenosis is a gold standard. Covered stents are used in all cases with overt air-digestive fistula or high potential for fistula development. The procedure is associated with a low incidence of procedure-related complications. We present a case with a major accident which developed during stent deployment. The delivery system became blocked and we found it impossible to fully deploy the stent, which remained attached to the introductory system. The stent was forcefully removed and replaced later on with a new stent. This is the first report of a SEMS related accident due to malfunction of the stent deployment system. Stent malfunction is unusual and unlikely to happen, but one should be aware and prepared for such unusual situations.

Research paper thumbnail of Is intragastric administration of enteral nutrition safe in acute severe pancreatitis?

Critical Care, 2009

There is considerable uncertainty about the reproducibility of the various instruments used to me... more There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Research paper thumbnail of P280 Nutritionday in Romania - Where Do We Stand?

Clinical Nutrition Supplements, 2008

Rationale: Nutritional status influences the survival of patients on long-term hemodialysis (HD).... more Rationale: Nutritional status influences the survival of patients on long-term hemodialysis (HD). This study was performed to assess the nutritional status in patients on HD at a university hospital in Isfahan, Iran. Methods: In this cross-sectional study, 79 patients with ESRD on HD included 40 females and 39 males with mean age 46.6±16.3 (18 80) years were recruited. The mean time on HD was 30.94±28.87 (30 132) months. Anthropometric measurements including triceps skin-fold thickness (TSF), mid-arm circumference (MAC) and midarm muscle circumference (MAMC) were taken on all patients. Body mass index (BMI) was also calculated. Relevant laboratory parameters were also checked. Data analysis was carried out using the SPSS, Pearson correlation, t-test, and regression. Results: Based on the MS, 83.54 of patients had malnutrition (mean score: 18.11±4.64). MS showed a statistically significant correlation with TSF (r = 0.26), MAC (r = 0.32), MAMC (r = 0.27), serum albumin (r = 0.44), and BMI (r = 0.26). There wasn't any correlation between MS and transferrin concentration and lymphocyte count. Conclusion: Most of our studied patients were suffering from malnutrition. Our study suggests that MS is a reliable, easy performing and precise method of assessing nutritional status in HD patients

Research paper thumbnail of Is intragastric administration of enteral nutrition safe in acute severe pancreatitis?

Critical Care, 2009

There is considerable uncertainty about the reproducibility of the various instruments used to me... more There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Research paper thumbnail of Presumed Consent for Organ Donation: Is Romania Prepared for It?

Transplantation Proceedings, 2010

In November 2007, a legislative initiative regarding the presumed consent for organ donation was ... more In November 2007, a legislative initiative regarding the presumed consent for organ donation was proposed for parliamentary debate in Romania and was followed by public debate. The study aimed to asses public opinions expressed in the Romanian media. An Internet search was made. The pro and con reasons, the affiliation of parts involved in the debate and suggested future direction of action were identified. The Internet search had 8572 results. The parts involved in the pro and con debate consisted of governmental structures, physicians, ethicists, politicians, media, religious authorities, nongovernmental associations, and lay persons. The main pros were the low rate of organ donation and the long waiting lists, enhancement of organ procurement, avoidance of wasting valuable organs, avoiding responsibility, and the stress imposed to the family in giving the donation consent, humanitarian purposes (saving lives), going along with the scientific progress, and less bureaucracy. The main cons were an unethical issue, violation of human rights, denial of brain death, unethical advantage of public ignorance, unethical use of underprivileged people, little results in terms of organ procurement, but huge negative effects on public opinion, public mistrust in transplant programs and impossibility of refusal identification due to particularities of the Romanian medical system. The con opinions prevailed. For the moment, Romania seems to be unprepared to accept presumed consent. A future change in public perception regarding organ transplantation may modify the terms of a public debate.

Research paper thumbnail of Transfusion policy and outcome in critically ill patients with a long ICU stay

Critical Care, 2008

all 10 cities including the rural areas of the province of Kerman. All data were finally analyzed... more all 10 cities including the rural areas of the province of Kerman. All data were finally analyzed by SPSS software (version 11.5). Results On the basis of recorded statistical analysis, the mortality cases of human rabies in the province of Kerman during one decade was 10 persons (eight males and two females). One-half of them (50%) were bitten by dogs and the others (50%) by foxes. Among the reported deaths, 40% were from Kahnooj county (Jiroft region). The reported data indicated that 21,546 persons were bitten by animals during 10 years in the province of Kerman. The mean of age of the people who were bitten by dogs was 24.80 years (SD = ±14.6), while the mean age of the people who were bitten by foxes was 57.25 years (SD = ±1.50). There was a significant difference between the mean age of these two groups of the people (P < 0.05). The most frequent rate of injured people was reported in the age group 10-19 years old and the frequency rate of males (76.00%) was more than females (24.00%). Therefore, there was a statistically significant difference between males and females in this study (P < 0.01). About 60% of all persons that were bitten by animals were from rural areas and 40% of them were from urban areas (P < 0.05). Among the people who were bitten and injured by animals during one decade in the province of Kerman, 85.70% of them were not treated by the rabies prophylaxis treatment regimen. Among all of them who were bitten by animals, 50% were injured through hands and feet, 40%

Research paper thumbnail of Anidulafungin for the treatment of candidaemia/invasive candidiasis in selected critically ill patients

Clinical Microbiology and Infection, 2012

A prospective, multicentre, phase IIIb study with an exploratory, open-label design was conducted... more A prospective, multicentre, phase IIIb study with an exploratory, open-label design was conducted to evaluate efficacy and safety of anidulafungin for the treatment of candidaemia/invasive candidiasis (C/IC) in specific ICU patient populations. Adult ICU patients with confirmed C/IC meeting ≥ 1 of the following criteria were enrolled: post-abdominal surgery, solid tumour, renal/hepatic insufficiency, solid organ transplant, neutropaenia, and age ≥ 65 years. Patients received anidulafungin (200 mg on day 1, 100 mg/day thereafter) for 10-42 days, optionally followed by oral voriconazole/fluconazole. The primary efficacy endpoint was global (clinical and microbiological) response at the end of all therapy (EOT). Secondary endpoints included global response at the end of intravenous therapy (EOIVT) and at 2 and 6 weeks post-EOT, survival at day 90, and incidence of adverse events (AEs). The primary efficacy analysis was performed in the modified intent-to-treat (MITT) population, excluding unknown/missing responses. The safety and MITT populations consisted of 216 and 170 patients, respectively. The most common pathogens were Candida albicans (55.9%), C. glabrata (14.7%) and C. parapsilosis (10.0%). Global success was 69.5% (107/154; 95% CI, 61.6-76.6) at EOT, 70.7% (111/157) at EOIVT, 60.2% (77/128) at 2 weeks post-EOT, and 50.5% (55/109) at 6 weeks post-EOT. When unknown/missing responses were included as failures, the respective success rates were 62.9%, 65.3%, 45.3% and 32.4%. Survival at day 90 was 53.8%. Treatment-related AEs occurred in 33/216 (15.3%) patients, four (1.9%) of whom had serious AEs. Anidulafungin was effective, safe and well tolerated for the treatment of C/IC in selected groups of ICU patients.

Research paper thumbnail of Point prevalence of surgical checklist use in Europe: relationship with hospital mortality

British journal of anaesthesia, Jan 13, 2015

The prevalence of use of the World Health Organization surgical checklist is unknown. The clinica... more The prevalence of use of the World Health Organization surgical checklist is unknown. The clinical effectiveness of this intervention in improving postoperative outcomes is debated. We undertook a retrospective analysis of data describing surgical checklist use from a 7 day cohort study of surgical outcomes in 28 European nations (European Surgical Outcomes Study, EuSOS). The analysis included hospitals recruiting >10 patients and excluding outlier hospitals above the 95th centile for mortality. Multivariate logistic regression and three-level hierarchical generalized mixed models were constructed to explore the relationship between surgical checklist use and hospital mortality. Findings are presented as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). A total of 45 591 patients from 426 hospitals were included in the analysis. A surgical checklist was used in 67.5% patients, with marked variation across countries (0-99.6% of patients). Surgical checklist...