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

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

A Review of Targeted Pulmonary Arterial Hypertension-Specific Pharmacotherapy

Significant advances in the understanding of the pathophysiology of pulmonary arterial hypertension over the past two decades have led to the development of targeted therapies and improved patient outcomes. Currently, a broad armamentarium of pulmonary arterial hypertension-specific drugs exists to assist in the treatment of this complex disease state. In this manuscript, we provide a comprehensive review of the current Food and Drug Administration (FDA)-approved pulmonary arterial hypertension-specific therapies, and their supporting evidence for adults, targeting the nitric oxide, soluble guanylate cyclase, endothelin, and prostacyclin pathways

Application des techniques de simulation aux systemes de production : le logiciel SIMAF

SIGLECNRS T Bordereau / INIST-CNRS - Institut de l'Information Scientifique et TechniqueFRFranc

The legality of forms of evidence in the criminal process in French and Lebanese law

Que se passe-t-il si une preuve pénale a été recueillie en violation de la loi ou sans respecter les règles de procédure et les principes généraux? Est-il possible ou interdit d'utiliser cette preuve en justice ? Voici une question délicate et compliquée qui a déjà fait couler beaucoup d'encre. La preuve illégale, qui a fait l’objet d’innombrables débats, demeure à ce jour discutable et n’est pas encore tranchée. L’action pénale ou publique vise à élucider la vérité. Pour ce faire, il est nécessaire d’avoir une preuve confirmant la commission de l’infraction et son attribution à son auteur. La recherche de la preuve pénale est assujettie au principe de la liberté de la preuve. Toutefois,la liberté de la preuve et la recherche de la preuve pénale n’est pas une liberté absolue et illimitée, car il est indispensable de concilier l’intérêt de la société pour l’élucidation de l’infraction et son auteur afin d’aboutir à la vérité,d’une part, pour mettre en oeuvre le droit de l’État de recourir à la peine.D’autre part, il est interdit la mise à profit des moyens de preuve qui constituent une atteinte à la liberté des individus et à leur sécurité corporelle sous couvert de la liberté de preuve. A cet effet, la théorie de la légalité de la preuve pénale a vu le jour car l’élucidation de la vérité ne peut avoir lieu par l’utilisation d’un moyen illégal dans un État de droit. Le principe de la légalité de la preuve pénale est, en fait, un principe négligé dans la loi (le droit). De plus, des doutes sont émis à propos de son existence réelle dans le système juridique. La présente étude ambitionne d’affirmer et de confirmer l’existence du principe de légalité de la preuve pénale en droit libanais et français à travers la définition d’un concept précis et stable du principe de légalité de la preuve pénale et l’étude de sa relation avec le principe de loyauté de la preuve pénale et la mise en exergue des différents aspects caractérisant le principe de légalité de la preuve, le principe de loyauté de la preuve et le degré de leur corrélation ; d’où la nécessité de distinguer la preuve illégale moyennant la définition d’un concept précis de la preuve illégale dans la preuve pénale, en recouvrant toutes les violations des règles substantielles,des règles procédurales et tous les moyens de preuve illégaux. Après la définition du principe de légalité de la preuve pénale et la notion de la preuve illégale, nous passons dans la présente étude à la recherche de l’exécution ou l’application pratique du principe de légalité de la preuve pénale au Liban et en France. Partant de ce principe, nous avons tenté d’apporter une contribution rigoureuse à la confirmation de l’existence du principe de légalité de la preuve pénale, ainsi que la démonstration de sa valeur légale en droit libanais et français. Par la suite, nous avons étudié le sort de cette preuve illégale et l’évaluation des systèmes de nullité adoptés au Liban et en France, le degré de leur efficacité et la mise en oeuvre effective du principe de légalité de la preuve pour répondre à la problématique principale de cette étude, c’est-à-dire que le principe de légalité de la preuve pénale correspond à un vif besoin qui impose un appui législatif au Liban et en France afin de consacrer la mise en oeuvre effective de ce principe. La consécration législative du principe de légalité de la preuve pénale avec une sanction procédurale innovante constitue le seul moyen de vaincre la position de la jurisprudence, laquelle s’efforce d’affaiblir le principe de légalité de la preuve pénale et de marginaliser ce principe. D’où la nécessité urgente et indispensable d’innover une nouvelle technique et des outils juridiques qui permettent d’exclure la preuve illégale.What happens if a criminal evidence has been obtained in violation of law orwith disregard for the procedural rules and the general principles? Is itpossible or forbidden to use such an evidence in court? This constitutes,indeed, a complicated and a tricky question that has already been widelydiscussed. The illegal evidence, which was subject to many debates, remainsstill questionable and not yet solved. The criminal or public action aims atclarifying the truth. Therefore, it is necessary to have an evidence to confirmthe commission of offence and its imputation to its perpetrator. The searchfor criminal evidence is subject to the principle of freedom of evidence. Yet,the freedom of evidence and the search for the criminal evidence is not anabsolute and unrestricted freedom, for it is vital to reconcile the society’sinterest in order to clear the offence and its perpetrator to reach the truth, inthe one hand, and to implement the right of the State to resort to punishment.Besides, it is prohibited to put to use the forms of evidence which representan infringement of freedom of individuals and their personal safety under thefreedom of proof. To that end, the theory of legality of criminal evidence sawthe light of the day since the clarification of the truth cannot happen throughthe use of an illegal means in a State of law.The principle of legality of criminal evidence is, basically, a principleneglected in the law. Moreover, there are some doubts as far as its realexistence in the legal system is concerned. This very study is aimed forasserting and confirming that the principle of legality of criminal evidenceexists, indeed, both in the Lebanese and French laws through the definitionof a specific and stable concept of the principle of legality of criminalevidence, the study of its relationship with the principle of loyalty of criminalevidence in addition to the emphasis on the various aspects characterizingthe principle of legality of evidence, the principle of loyalty of evidence andthe level of their interrelationship ; hence the need for distinguishing illegalevidence via the definition of a specific concept of illegal evidence in thecriminal evidence, by covering the whole violations of substantive rules,procedural rules as well as all forms of illegal evidence. After the definition ofthe principle of legality of criminal evidence and the concept of illegalevidence, we move on, in this study, to the search for the implementation orthe practical application of the principle of legality of criminal evidence inLebanon and France. Based on this principle, we have tried to bring a strictcontribution to the confirmation that the principle of legality of criminalevidence exists indeed, besides, we have proved its legal value in theLebanese and French laws. Afterwards, we have examined the destiny ofthis illegal evidence and the assessment of systems of invalidity adopted inLebanon and France, the level of their efficiency and the effectiveimplementation of the principle of legality of evidence so as to answer themain issue of this study, otherwise said the principle of legality of criminalevidence meets a vital need that requires a legislative support in Lebanonand France in a bid to devote the effective implementation of this principle.The legislative recognition of the principle of legality of criminal evidence withan innovative procedural sanction is the only means for convincing thestance of jurisprudence, which strives for weakening the principle of criminalevidence and for marginalizing it. Thus, there is an urgent and vital need forinnovating a new technique and legal tools likely to exclude illegal evidence

A Review of Targeted Pulmonary Arterial Hypertension-Specific Pharmacotherapy

Significant advances in the understanding of the pathophysiology of pulmonary arterial hypertension over the past two decades have led to the development of targeted therapies and improved patient outcomes. Currently, a broad armamentarium of pulmonary arterial hypertension-specific drugs exists to assist in the treatment of this complex disease state. In this manuscript, we provide a comprehensive review of the current Food and Drug Administration (FDA)-approved pulmonary arterial hypertension-specific therapies, and their supporting evidence for adults, targeting the nitric oxide, soluble guanylate cyclase, endothelin, and prostacyclin pathways