Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background 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.Methods 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.Findings 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.Interpretation 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

19. Radial artery ultrasound predicts the success of transradial coronary angiography

Smaller radial artery diameter, CSA, and perimeter is associated with higher vascular access complications during coronary angiography. The transradial approach has become the preferred vascular access during conventional coronary angiography (CCA). A small mean radial artery diameter (RAD), however, may lead to higher rates of vascular access complications (VAC). To date, there are no data regarding the effect of the radial artery cross-sectional area (CSA) and perimeter. We evaluated the impact of preprocedure radial artery diameters, the CSA, and the perimeter on vascular complications. We conducted a single-center prospective analysis of 513 patients who underwent CCA. Radial artery ultrasonography was performed before and after CCA to measure the RAD, CSA, and perimeter.The average RAD, CSA, and perimeter were 2.60 ± 0.48 mm, 6.2 ± 3.0 mm2, and 8.9 ± 1.7 mm, respectively. The same measurements were significantly larger in men than in women: 2.8 ± 0.5 vs. 2.4 ± 0.4 mm (P < 0.0001), 6.6 ± 3.4 vs. 5.3 ± 1.5 mm (P < 0.0001), and 9.3 ± 1.7 vs. 8.2 ± 1.5 mm (P< 0.0001), respectively. In all, 56 patients (11%) had VACs. The RAD, CSA, and perimeter were significantly smaller in patients whose procedures had VACs than in those with no complications: 2.3 ± 0.5 vs. 2.70 ± 0.54 mm (P = 0.0001), 4.9 ± 2.1 vs. 6.4 ± 3 mm2 (P = 0.001), and 7.6 ± 2.1 vs. 9.2 ± 1.6 mm (P = 0.0001), respectively. Univariate logistic regression showed that radial ultrasonographic parameters can independently predict VACs as follows: odds ratio (OR) 1.2, 95% CI 1.12–1.28 (P < 0.0001) for RAD; OR 1.55. 95% CI 1.29–1.84, (P < 0.0001) for CSA; OR 1.83, 95% CI 1.5–2.46 (P < 0.0001) for the perimeter.Ultrasonographic study of the radial artery before CCA can provide important information regarding vascular access. We found that a small radial diameter, CSA, and perimeter are associated with higher VAC rates

Estimating the Reduction in the Radiation Burden From Nuclear Cardiology Through Use of Stress-Only Imaging in the United States and Worldwide

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Comparison of Radiation Doses and Best-Practice Use for Myocardial Perfusion Imaging in US and Non-US Laboratories: Findings From the IAEA (International Atomic Energy Agency) Nuclear Cardiology Protocols Study

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Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

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