Malnutrition represents a key priority for global health policy, yet the impact of nutritional state on cancer surgery worldwide remains poorly described. We aimed to analyse the effect of malnutrition on early postoperative outcomes following elective surgery for colorectal or gastric cancer. We did an international, multicentre, prospective cohort study of patients undergoing elective surgery for colorectal or gastric cancer between April 1, 2018, and Jan 31, 2019. Patients were excluded if the primary pathology was benign, they presented with cancer recurrence, or if they underwent emergency surgery (within 72 h of hospital admission). Malnutrition was defined with the Global Leadership Initiative on Malnutrition criteria. The primary outcome was death or a major complication within 30 days of surgery. Multilevel logistic regression and a three-way mediation analysis were done to establish the relationship between country income group, nutritional status, and 30-day postoperative outcomes. This study included 5709 patients (4593 with colorectal cancer and 1116 with gastric cancer) from 381 hospitals in 75 countries. The mean age was 64·8 years (SD 13·5) and 2432 (42·6%) patients were female . Severe malnutrition was present in 1899 (33·3%) of 5709 patients, with a disproportionate burden in upper-middle-income countries (504 [44·4%] of 1135) and low-income and lower-middle-income countries (601 [62·5%] of 962). After adjustment for patient and hospital risk factors, severe malnutrition was associated with an increased risk of 30-day mortality across all country income groups (high income: adjusted odds ratio [aOR] 1·96 [95% CI 1·14-3·37], p=0·015; upper-middle income: 3·05 [1·45-6·42], p=0·003; low income and lower-middle income: 11·57 [5·87-22·80], p<0·0001). Severe malnutrition mediated an estimated 32% of early deaths in low-income and lower-middle-income countries (aOR 1·41 [95% CI 1·22-1·64]) and an estimated 40% of early deaths in upper-middle-income countries (1·18 [1·08-1·30]). Severe malnutrition is common in patients undergoing surgery for gastrointestinal cancers and is a risk factor for 30-day mortality following elective surgery for colorectal or gastric cancer. There is an urgent need to examine whether perioperative nutritional interventions can improve early outcomes following gastrointestinal cancer surgery worldwide. National Institute for Health Research Global Health Research Unit.

Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. National Institute for Health and Care Research.

Surgery is a physiologically demanding event [1,2], and modifying aspects of the endocrine stress response and postoperative catabolic processes to optimise care in the perioperative period is increasingly being recognised as a means of improving outcomes [3]. This began with the concept of fast track surgery [4], followed by enhanced recovery after surgery (ERAS) [5] […]

Background: A discharge summary should be a clinical report that documents a patient’s hospital stay, including test results, diagnoses, management, and follow-up. Currently, discharge summaries are written by clinicians who manually locate pertinent information across the electronic health record, of which approximately 80% is free text. This process is time-consuming and may be suitable for automation using large language models. Objective: This study developed a template-based prompting system that can produce clinically acceptable discharge summaries, specifically the “clinical summary” and “plan and requested actions” sections, from routinely collected electronic patient records. Methods: This study used electronic health record data from Imperial College Healthcare National Health Service Trust, a network of 5 hospitals in northwest London. It was conducted within the Imperial Secure Data Environment under Data Access and Ethics Committee approval. In total, 52 inpatient encounters were selected by the clinical team to ensure diversity in clinical specialty, reason for admission, complexity, length of stay, and sociodemographic characteristics; 83% (n=43) of the cases were allocated to the development dataset, and 17% (n=9) comprised the test dataset. The system synthesized clinical notes related to an inpatient hospital encounter and used structured template prompts with OpenAI’s generative pretrained transformer-4 to generate a discharge summary. The prompt was co-designed across 3 iterations. Resident physicians completed an evaluation form to assess the clinical acceptability of the generated summaries, including the primary outcome (global confidence rating) and secondary outcomes (accuracy, completeness, readability, formatting, sociodemographic bias, and potential clinical harm). Sensitivity analyses assessed the effect of length of stay and admission type (emergency department vs other and surgical vs other) on the primary outcome. Results: A total of 52 patients (n=32, 62% female) were included, with a mean age of 44.8 (SD 27.1) years and an average length of stay of 15.2 (SD 21.1) days. In the test dataset, 89% (8/9) of generative pretrained transformer-4–generated summaries received a positive global confidence rating (“yes” or “yes, with minor changes”). Secondary outcomes were positive for the “clinical summary” section (8/9, 89% complete and 7/9, 78% accurate) and the “plan and requested actions” section (7/9, 78% complete and 7/9, 78% accurate). Readability, formatting, sociodemographic bias, and potential clinical harm also showed positive results in the test dataset. Sensitivity analyses showed no statistically significant variation in the primary outcome across length of stay or admission type (length of stay: P=.29; surgical admission: P=.99; emergency department admission: P=.15). Conclusions: Our results demonstrate the feasibility of the pipeline, but rigorous statistical evaluation in a larger, adequately powered sample is needed.

Background: Malnutrition is a state linked to worse postoperative outcomes, and cancer patients are particularly vulnerable due to cachexia. We aimed to explore the effect of malnutrition on 30-day mortality following gastric and colorectal cancer surgery. Method: GlobalSurg3 was multicentre international cohort study which collected data from consecutive patients undergoing emergency or elective surgery for gastric and colorectal cancer. Malnutrition was defined using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Multilevel variable regression approaches determined the relationship between malnutrition and early postoperative outcomes. Results: 6438 patients were included in the final analysis (1184 gastric cancer; 5254 colorectal cancer). Severe malnutrition was common across all income-strata, affecting 1 in 4 patients overall, with a higher burden in low and lower-middle income countries (64%). In patients undergoing elective surgery (n = 5709), severe malnutrition was independently associated with increased mortality (aOR = 1.62 (1.07-2.48, P = 0.024) after accounting for patient factors, disease stage and country effects. Conclusions: Severe malnutrition represents a high global burden in cancer surgery, particularly within lower income settings. Malnutrition is an independent risk-factor for 30-day mortality following elective surgery for gastric and colorectal cancer, suggesting perioperative nutritional interventions may improve outcomes after cancer surgery.

BACKGROUND A discharge summary should be a clinical report that documents a patient’s hospital stay, including test results, diagnoses, management, and follow-up. Currently, discharge summaries are written by clinicians who manually locate pertinent information across the electronic health record, of which approximately 80% is free text. This process is time-consuming and may be suitable for automation using large language models. OBJECTIVE This study developed a template-based prompting system that can produce clinically acceptable discharge summaries, specifically the “clinical summary” and “plan and requested actions” sections, from routinely collected electronic patient records. METHODS This study used electronic health record data from Imperial College Healthcare National Health Service Trust, a network of 5 hospitals in northwest London. It was conducted within the Imperial Secure Data Environment under Data Access and Ethics Committee approval. In total, 52 inpatient encounters were selected by the clinical team to ensure diversity in clinical specialty, reason for admission, complexity, length of stay, and sociodemographic characteristics; 83% (n=43) of the cases were allocated to the development dataset, and 17% (n=9) comprised the test dataset. The system synthesized clinical notes related to an inpatient hospital encounter and used structured template prompts with OpenAI’s generative pretrained transformer-4 to generate a discharge summary. The prompt was co-designed across 3 iterations. Resident physicians completed an evaluation form to assess the clinical acceptability of the generated summaries, including the primary outcome (global confidence rating) and secondary outcomes (accuracy, completeness, readability, formatting, sociodemographic bias, and potential clinical harm). Sensitivity analyses assessed the effect of length of stay and admission type (emergency department vs other and surgical vs other) on the primary outcome. RESULTS A total of 52 patients (n=32, 62% female) were included, with a mean age of 44.8 (SD 27.1) years and an average length of stay of 15.2 (SD 21.1) days. In the test dataset, 89% (8/9) of generative pretrained transformer-4–generated summaries received a positive global confidence rating (“yes” or “yes, with minor changes”). Secondary outcomes were positive for the “clinical summary” section (8/9, 89% complete and 7/9, 78% accurate) and the “plan and requested actions” section (7/9, 78% complete and 7/9, 78% accurate). Readability, formatting, sociodemographic bias, and potential clinical harm also showed positive results in the test dataset. Sensitivity analyses showed no statistically significant variation in the primary outcome across length of stay or admission type (length of stay: P=.29; surgical admission: P=.99; emergency department admission: P=.15). CONCLUSIONS Our results demonstrate the feasibility of the pipeline, but rigorous statistical evaluation in a larger, adequately powered sample is needed.