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

Apreciaciones sobre la Muerte en Estudiantes del Último Año de Medicina.

Objective: To characterized attitudes of last year students of medicine in Universidad de Carabobo, Venezuela, towards death and the process of dying and how they rate their their university training in these subjects. Methodology: Observational study of 61 voluntaries who responded a survey. Results: The majority of respondents (82.7%) think that they will deal with death as part of their professional duties. 78.7% define death as a natural event, but 57,9% feel that they are not prepared to deal properly with it and think necessary to have undergraduate training in this subject. 62,2% support the practice of euthanasia.El estudio de la muerte es un área compleja por sus múltiples dimensiones, significados e impactos que produce. Objetivo: caracterizar como asumen los estudiantes de medicina del último año de la carrera en la Universidad de Carabobo-Valencia. Venezuela, la situación del morir y la muerte y su preparación universitaria al respecto, Metodología: Estudio observacional, en 61 estudiantes voluntarios, mediante aplicación de encuesta. Resultados: 82,7% de los encuestados piensan con frecuencia que enfrentarán la muerte en su profesión. Aunque 78,7% define la muerte como algo natural, 40.4% tiende a su negación, habiéndola vivenciado en algún familiar en 73,8%. Un 51,78% y 57,9%, manifiesta no estar preparado ante la muerte de un familiar o de un paciente, respectivamente; 90% creen necesario instruirles en pregrado, mientras que 67,2% apoya la práctica de la Eutanasia. Conclusiones: aunque hay una posición variable frente a la muerte, existe una tendencia en los estudiantes a pensar con frecuencia que la van a enfrentar en su ejercicio profesional, y reconocen que necesitan ser preparados en su formación universitaria para su manejo. Igualmente, siendo esta área de investigación compleja y multidimensional, requiere de la incorporación de equipos y proyectos de investigación multidisciplinaria que consideren nuevas metodologías para su abordaje

Apreciaciones sobre la Muerte en Estudiantes del Último Año de Medicina

El estudio de la muerte es un área compleja por sus múltiples dimensiones, significados e impactos que produce. Objetivo: caracterizar como asumen los estudiantes de medicina del último año de la carrera en la Universidad de Carabobo-Valencia. Venezuela, la situación del morir y la muerte y su preparación universitaria al respecto, Metodología: Estudioobservacional, en 61 estudiantes voluntarios, mediante aplicación de encuesta. Resultados: 82,7% de los encuestados piensan con frecuencia que enfrentarán la muerte en su profesión. Aunque 78,7% define la muerte como algo natural, 40.4% tiende a su negación, habiéndola vivenciado en algún familiar en 73,8%. Un 51,78% y 57,9%, manifiesta no estar preparado ante la muerte de un familiar o de un paciente, respectivamente; 90% creen necesario instruirles en pregrado, mientras que 67,2% apoya la práctica de la Eutanasia. Conclusiones: aunque hay una posición variable frente a la muerte, existe una tendencia en los estudiantes a pensar con frecuencia que la van a enfrentar en su ejercicio profesional, y reconocen que necesitan ser preparados en su formación universitaria para su manejo. Igualmente, siendo esta área de investigación compleja y multidimensional, requiere de la incorporación de equipos y proyectos de investigación multidisciplinaria que consideren nuevas metodologías para su abordaje.Insights on death in students of the last year of medical studiesAbstractObjective: To characterized attitudes of last year students of medicine in Universidad de Carabobo, Venezuela, towards death and the process of dying and how they rate their their university training in these subjects. Methodology: Observational study of 61 voluntaries who responded a survey. Results: The majority of respondents (82.7%) think that they will deal with death as part of their professional duties. 78.7% define death as a natural event, but 57,9% feel that they are not prepared to deal properly with it and think necessary to have undergraduate training in this subject. 62,2% support the practice of euthanasia

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

The European Multiple System Atrophy-Study Group (EMSA-SG)

Introduction. The European Multiple System Atrophy-Study Group (EMSA-SG) is an academic network comprising 23 centers across Europe and Israel that has constituted itself already in January 1999. This international forum of established experts under the guidance of the University Hospital of Innsbruck as coordinating center is supported by the 5th framework program of the European Union since March 2001 (QLK6-CT-2000-00661). Objectives. Primary goals of the network include (1) a central Registry for European multiple system atrophy (MSA) patients, (2) a decentralized DNA Bank, (3) the development and validation of the novel Unified MSA Rating Scale (UMSARS), (4) the conduction of a Natural History Study (NHS), and (5) the planning or implementation of interventional therapeutic trials. Methods. The EMSA-SG Registry is a computerized data bank localized at the coordinating centre in Innsbruck collecting diagnostic and therapeutic data of MSA patients. Blood samples of patients and controls are recruited into the DNA Bank. The UMSARS is a novel specific rating instrument that has been developed and validated by the EMSA-SG. The NHS comprises assessments of basic anthropometric data as well as a range of scales including the UMSARS, Unified Parkinson's Disease Rating Scale (UPDRS), measures of global disability, Red Flag list, MMSE (Mini Mental State Examination), quality of live measures, i.e. EuroQoL 5D (EQ-5D) and Medical Outcome Study Short Form (SF-36) as well as the Beck Depression Inventory (BDI). In a subgroup of patients dysautonomic features are recorded in detail using the Queen Square Cardiovascular Autonomic Function Test Battery, the Composite Autonomic Symptom Scale (COMPASS) and measurements of residual urinary volume. Most of these measures are repeated at 6-monthly follow up visits for a total study period of 24 months. Surrogate markers of the disease progression are identified by the EMSA-SG using magnetic resonance and diffusion weighted imaging (MRI and DWI, respectively). Results. 412 patients have been recruited into the Registry so far. Probable MSA-P was the most common diagnosis (49% of cases). 507 patients donated DNA for research. 131 patients have been recruited into the NHS. There was a rapid deterioration of the motor disorder (in particular akinesia) by 26.1% of the UMSARS II, and - to a lesser degree - of activities of daily living by 16.8% of the UMSARS I in relation to the respective baseline scores. Motor progression was associated with low motor or global disability as well as low akinesia or cerebellar subscores at baseline. Mental function did not deteriorate during this short follow up period. Conclusion. For the first time, prospective data concerning disease progression are available. Such data about the natural history and prognosis of MSA as well as surrogate markers of disease process allow planning and implementation of multi-centre phase II/III neuroprotective intervention trials within the next years more effectively. Indeed, a trial on growth hormone in MSA has just been completed, and another on minocycline will be completed by the end of this year