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

POPs in a major conurbation in Turkey: ambient air concentrations, seasonal variation, inhalation and dermal exposure, and associated carcinogenic risks

Semi-volatile organic compounds were monitored over a whole year, by collection of gas and particle phases every sixth day at a suburban site in Izmir, Turkey. Annual mean concentrations of 32 polychlorinated biphenyls (∑32PCBs) and 14 polycyclic aromatic hydrocarbons (∑14PAHs) were 348 pg/m3 and 36 ng/m3, respectively, while it was 273 pg/m3 for endosulfan, the dominant compound among 23 organochlorine pesticides (OCPs). Monte Carlo simulation was applied to the USEPA exposure-risk models for the estimation of the population exposure and carcinogenic risk probability distributions for heating and non-heating periods. The estimated population risks associated with dermal contact and inhalation routes to ∑32PCBs, ∑14PAHs, and some of the targeted OCPs (α-hexachlorocyclohexane (α-HCH), β-hexachlorocyclohexane (β-HCH), heptachlor, heptachlor epoxide, α-chlordane (α-CHL), γ-chlordane (γ-CHL), and p,p′-dichlorodiphenyltrichloroethane (p,p′-DDT)) were in the ranges of 1.86 × 10−16–7.29 × 10−9 and 1.38 × 10−10–4.07 × 10−6, respectively. The inhalation 95th percentile risks for ∑32PCBs, ∑14PAHs, and OCPs were about 6, 3, and 4–7 orders of magnitude higher than those of dermal route, respectively. The 95th percentile inhalation risk for ∑32PCBs and OCPs in the non-heating period were 1.8- and 1.2–4.6 folds higher than in the heating period, respectively. In contrast, the 95th percentile risk levels for ∑14PAHs in the heating period were 4.3 times greater than that of non-heating period for inhalation, respectively. While risk levels associated with exposure to PCBs and OCPs did not exceed the acceptable level of 1 × 10−6, it was exceeded for 47 % of the population associated with inhalation of PAHs with a maximum value of about 4 × 10−6