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

Research and Design of a Routing Protocol in Large-Scale Wireless Sensor Networks

无线传感器网络，作为全球未来十大技术之一，集成了传感器技术、嵌入式计算技术、分布式信息处理和自组织网技术，可实时感知、采集、处理、传输网络分布区域内的各种信息数据，在军事国防、生物医疗、环境监测、抢险救灾、防恐反恐、危险区域远程控制等领域具有十分广阔的应用前景。 本文研究分析了无线传感器网络的已有路由协议，并针对大规模的无线传感器网络设计了一种树状路由协议，它根据节点地址信息来形成路由，从而简化了复杂繁冗的路由表查找和维护，节省了不必要的开销，提高了路由效率，实现了快速有效的数据传输。 为支持此路由协议本文提出了一种自适应动态地址分配算——ADAR（AdaptiveDynamicAddre...As one of the ten high technologies in the future, wireless sensor network, which is the integration of micro-sensors, embedded computing, modern network and Ad Hoc technologies, can apperceive, collect, process and transmit various information data within the region. It can be used in military defense, biomedical, environmental monitoring, disaster relief, counter-terrorism, remote control of haz...学位：工学硕士院系专业：信息科学与技术学院通信工程系_通信与信息系统学号：2332007115216

Changement climatique et enjeux cliniques

Climate change and global warming present major clinical challenges. We focus on cardiovascular and renal clinical consequences. The physiological adaptations and physiopathological effects are described, especially in vulnerable populations. The clinical consequences during heat waves, are mainly cardiovascular with stroke, acute ischemic heart disease and sudden death increased by up to 40%. Likewise, episodes of acute renal failure, electrolyte disturbances and kidney stones disease increase. The chronic consequences should not be overlooked, as the risk of heart failure also increases in high ambient temperature regions and there is also some evidence of an increase in chronic kidney disease in tropical zones. Physicians must be aware of these consequences as they will be involved in their management in the future.Les changements climatiques liés au réchauffement planétaire comportent des enjeux cliniques majeurs. Nous nous concentrerons sur les enjeux cardiovasculaires et rénaux. Les adaptations physiologiques et effets physiopathologiques sont décrits, particulièrement chez des populations vulnérables. Les conséquences cliniques des vagues de chaleur sont en grande majorité cardiovasculaires. Les accidents vasculaires cérébraux, cardiopathies ischémiques aiguës et morts subites sont augmentés jusqu’à 40 %. De même, les épisodes d’insuffisance rénale aiguë, les troubles électrolytiques et les lithiases rénales augmentent. Le risque d’insuffisance cardiaque et le nombre d’insuffisances rénales chroniques augmentent également dans les régions tropicales. Les médecins doivent être conscients de ces conséquences pour lesquelles ils seront impliqués à l’avenir

Approche pragmatique des syndromes de microangiopathie thrombotique

Whilst the pathophysiology underlying the diverse thrombotic microangiopathy syndromes is better understood, management of these entities and of the various therapeutic options currently available remains challenging. Early identification of these syndromes is essential to improving prognosis. In the absence of treatment, mortality is high, including in the first days following diagnosis. We present a summary of the diagnostic strategy and therapeutic management of thrombotic microangiopathy in adults.Alors que la physiopathologie de la microangiopathie thrombotique est de mieux en mieux comprise, la gestion de cette entité en aigu et les différentes options thérapeutiques à disposition restent moins claires. Son identification précoce est indispensable pour permettre une amélioration du pronostic. En l’absence de traitement, le taux de mortalité est très élevé, et ce dans les premiers jours qui suivent le diagnostic. Cet article a pour objectif de permettre une synthèse des stratégies diagnostique et thérapeutique à adopter devant une suspicion de microangiopathie thrombotique chez l’adulte

Prognosis of patients eligible for dapagliflozin in acute heart failure

Background: Dapagliflozin, a sodium-glucose cotransporter 2 inhibitor, was shown in the DAPA-HF study to reduce the risk of worsening heart failure or death in symptomatic patients with left ejection fraction Materials and methods: Analysis of 815 patients recruited in a prospective cohort of acute heart failure at the University Hospitals of Geneva, consisting of consecutive patients admitted with ADHF. Eligibility for dapagliflozin was determined using criteria described DAPA-HF.Results: Of 815 patients, 220 (27%) were eligible for dapagliflozin treatment. In survival analysis, patients who were eligible for dapagliflozin had better clinical outcomes with respect to all-cause mortality and rehospitalization as compared to those who were not eligible. In multivariate analysis, the hazard ratio for all-cause mortality or readmission in patients eligible for dapagliflozin was 0.82 (95% CI 0.68-0.999, P = .049) as compared to the non-eligible.Conclusions: Using DAPA-HF criteria, only 27% of non-selected patients admitted for ADHF are theoretically eligible for dapagliflozin. This eligibility for dapagliflozin is associated with better outcomes. Further evaluation of the benefits of dapagliflozin in selected HF patients may be of interest. This may have implications for selection criteria in future randomized effectiveness studies.</p

Eligibility for sacubitril-valsartan in patients with acute decompensated heart failure

Aims: Large-scale clinical trials have demonstrated clinical benefits of sacubitril-valsartan in symptomatic heart failure with reduced ejection fraction patients (PARADIGM-HF), with potential benefits in patients hospitalized for acute decompensated heart failure (ADHF) (PIONEER-HF) and fewer benefits in patients with heart failure with preserved ejection fraction (PARAGON-HF). The aim of this study was to evaluate eligibility for sacubitril-valsartan using criteria described in PIONNER-HF in non-selected patients hospitalized for ADHF. Methods and results: Between November 2014 and May 2019, 799 patients were recruited in a prospective registry of acute heart failure at the University Hospitals of Geneva (ClinicalTrials.gov: NCT02444416). The cohort consists of consecutive patients admitted to the Department of Medicine with ADHF. Eligibility for sacubitril-valsartan was determined using criteria described in PIONEER-HF, including left ventricular ejection fraction, clinical parameters, and co-morbidities. Of 799 patients, 123 (15.39%) were eligible for sacubitril-valsartan treatment. Clinical outcomes including all-cause mortality and readmission were similar in eligible and non-eligible groups, hazard ratio 1.02 (95% confidence interval 0.81-1.29, P = 083). Conclusions: Using current criteria from randomized controlled trials, only 15% of non-selected patients admitted for ADHF are theoretically eligible for sacubitril-valsartan. Eligibility for sacubitril-valsartan using published criteria is not associated with worse outcome, suggesting that further evaluation of benefits of sacubitril-valsartan in heart failure patients based on parameters other than left ventricular ejection fraction may be of interest.</p

Furosémide intraveineux dans l’insuffisance cardiaque aiguë : administration continue ou intermittente ?

Loop diuretics are strongly recommended by current guidelines for the treatment of acute heart failure. Intravenous furosemide can be administered either as a continuous infusion or as an intermittent bolus. The choice between these two routes is not always obvious in clinical practice. The understanding of their different mechanisms of action, as well as the notion of diuretic resistance, can help identify patients who may benefit from either of these two routes. This article aims at discussing these aspects and their pathophysiology, as well as summarizing the current body of evidence from randomized trials comparing continuous vs. intermittent administration of furosemide in acute heart failure.Les diurétiques de l’anse sont fortement recommandés par les directives cliniques actuelles dans l’insuffisance cardiaque aiguë. Le furosémide intraveineux peut être administré sous formes continue et intermittente. En pratique clinique, le choix de la modalité d’administration n’est pas toujours évident. La compréhension de leur action et des mécanismes de résistance aux diurétiques permet d’identifier les situations cliniques qui répondent le mieux à l’une ou l’autre de ces méthodes d’administration. Cet article a pour but de discuter de ces différents aspects, notamment des mécanismes physiopathologiques en jeu, puis de synthétiser et évaluer le corpus d’évidences randomisées comparant ces deux modalités pour le traitement de l’insuffisance cardiaque aiguë

Risks and benefits of urinary catheterisation during inpatient diuretic therapy for acute heart failure: a retrospective, non-inferiority, cohort study

Objectives Patients with acute congestive heart failure (HF) regularly undergo urinary catheterisation (UC) at hospital admission. We hypothesised that UC has no clinical benefits with regard to weight loss during inpatient diuretic therapy for acute congestive HF and increases the risk of urinary tract infection (UTI). Design Retrospective, non-inferiority study. Setting Geneva University Hospitals’ Department of Medicine, a tertiary centre. Participants In a cohort of HF patients, those catheterised within 24 hours of diuretic therapy (n=113) were compared with non-catheterised patients (n=346). Primary and secondary outcome measures The primary endpoint was weight loss 48 hours after starting diuretic therapy. Secondary endpoints were time needed to reach target weight, discontinuation of intravenous diuretics and resolution of respiratory failure. Complications included the time to a first UTI, first hospital readmission and death. Results A total of 48-hour weight loss was not statistically different between groups and the adjusted difference was below the non-inferiority boundary of 1 kg (0.43 kg (95% CI: −0.03 to 0.88) in favour of UC, p&lt;0.01 for non-inferiority). UC was not associated with time to reaching target weight (adjusted HR 1.0; 95% CI: 0.7 to 1.5), discontinuation of intravenous diuretics (aHR 0.9; 95% CI: 0.7 to 1.2) or resolution of respiratory failure (aHR 1.1; 95% CI: 0.5 to 2.4). UC increased the risk of UTI (aHR 2.5; 95% CI: 1.5 to 4.2) but was not associated with hospital readmission (aHR 1.1; 95% CI: 0.8 to 1.4) or 1-year mortality (aHR 1.4; 95% CI: 1.0 to 2.1). Conclusion In this retrospective study, with no obvious hourly diuresis-based diuretic adjustment strategy, weight loss without UC was not inferior to weight loss after UC within 24 hours of initiating diuretic treatment. UC had no impact on clinical improvement and increased the risk of UTI. This evidence, therefore, argues against the systematic use of UC during a diuretic therapy for HF.</p

Prognostic value of the echocardiographic probability of pulmonary hypertension in patients with acute decompensated heart failure

The prognostic value of pulmonary hypertension (PH) estimated by echocardiography in unselected patients with acute decompensated heart failure (ADHF) is poorly studied. Between November 2014 and September 2018, 657 patients were recruited in a prospective registry of ADHF (ClinicalTrials.gov NCT02444416). The probability of pulmonary hypertension was based on European Society of Cardiology (ESC) guidelines for echocardiographic evaluation. The median survival without all-cause mortality or readmission was 7 months. During the median follow-up period of 15 months, there were 450 events including 185 deaths. In multivariate analysis, the hazard ratio (HR) of all-cause mortality or readmission for patients with a high probability of PH was 1.67 (95% CI 1.29-2.17, p &lt; 0.001) as compared to patients with a low or intermediate probability. The left ventricular ejection fraction (LVEF) and right ventricular function (RVF) were not associated with the primary outcome-HR 1.02 (95% CI 0.81-1.29; p = 0.84) and 0.96 (95% CI 0.76-1.23; p = 0.77) respectively. In patients admitted for ADHF, a high probability of PH as evaluated by echocardiography provided the highest independent prognostic value for mortality and readmission, whereas LVEF and RVF were not associated with prognosis. The identification of patients at high risk of PH by non-invasive measurement conveys important prognostic information and may guide management.</p