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

Evaluation of maternal serum and umbilical cord brain-derived neurotrophic factor (BDNF) levels in COVID-19-infected pregnancies

OBJECTIVE: COVID-19 is a disease that affects and damages the neurological system. The aim of this study was to evaluate the fetal neurodevelopmental status through maternal serum and umbilical cord BDNF levels. PATIENTS AND METHODS: In this prospective study, 88 pregnant women were evaluated. Demographic and peripartum characteristics of the patients were recorded. Samples were collected from pregnant women for maternal serum and the umbilical cord BDNF levels during delivery. RESULTS: In this study, 40 pregnant women hospitalized with COVID-19 formed the infected group and 48 pregnant women without COVID-19 formed the healthy control group. Demographic and postpartum characteristics were similar in both groups. Maternal serum BDNF values were significantly lower in the COVID-19 infected group (1597.0 ± 337.3 pg/ml) than in the healthy group (1783.2 ± 394.1 pg/ml) (p=0.019). Fetal BDNF levels were 1794.9 ± 440.3 pg/ml in the healthy group and 1691.0 ± 368.6 pg/ml in COVID-19 infected pregnant women group and statistically similar between groups (p=0.232). CONCLUSIONS: Results showed that while maternal serum BDNF levels decreased in the presence of COVID-19, there was no difference in umbilical cord BDNF levels. This may be an indication that the fetus is not affected and is protected

The effect of hyperemesis gravidarum on the 75g oral glucose tolerance test screening and gestational diabetes mellitus

Objective: To clarify the effect of hyperemesis gravidarum (HG) on the 75g oral glucose tolerance test (OGTT) and gestational diabetes mellitus.Methods: This retrospective cohort study was conducted via an evaluation of the hospital database medical records of 700 pregnant women. Of these, 60 were included in the study group as a result of hospitalization due to HG, 41 were excluded, and the remaining 599 formed a control group. The body mass index (BMI), urine ketone levels, and ages of all participants were separately recorded, both in the initial examination and during the 75g OGTT.Results: At initial examination, no significant differences in maternal age and BMI were observed between the two groups. There was a significant decrease in BMI after 75g OGTT in the study group. No significant difference in fasting serum glucose levels was found between the two groups, but significant differences in first and second hour serum glucose levels were observed.Conclusions: HG may improve in many women in the late second trimester, and loss of fatty tissue may affect the 75g OGTT screening results. The appropriate cutoff value of 75g OGTT for HG should be reevaluated following future, larger, studies

Maternal type 1collagen N-terminal telopeptide levels in severe hyperemesis gravidarum

Abstract Background Nausea and vomiting occur 50–90% during the first trimester of pregnancy. However, patients with hyperemesis gravidarum (HG) may be hospitalized at an incidence rate of 0.8–2% before the 20th week of gestational age. The symptoms generally start during the 5–6th gestational weeks, reaching the highest degree during the 9th week, and decline after the 16–20th weeks of gestation. Clinical findings are proportional to the severity of the disease and severe HG is characterized with dehydration, electrolyte imbalance, and nutritional deficiency as a result of vomiting. Methods The study population consisted of two groups of pregnant volunteers at 5–12 weeks of gestation: a severe HG group and a control group. The HG severity was scored using the Pregnancy-Unique Quantification of Emesis (and nausea) (PUQE).The serum levels of the maternal Ca, parathyroid hormone (PTH), Na, K, blood urea nitrogen(BUN), creatinine, vitamin D(25OHD3), and the maternal urine NTx levels were compared between the groups. Results In total, 40 volunteers were enrolled in this study: 20 healthy pregnant volunteers and 20 with severe HG. There were no statistically significant differences between the maternal characteristics. The first trimester weight loss of ≥5 kg was significantly higher in the severe HG group (p < 0.001), while the control group had a significantly higher sunlight exposure ratio than the severe HG group (p = 0.021). The urine NTx levels were significantly higher in the severe HG group (39.22 ± 11.68NTx/Cre) than in the control group(32.89 ± 8.33NTx/Cre) (p = 0.028).The serum Ca, PTH, Na, K, BUN, and creatinine levels were similar between the groups (p = 0.738, p = 0.886, p = 0.841, p = 0.957, p = 0.892, and p = 0.824, respectively). In the severe HG group, the serum 25OHD3 levels were significantly lower than in the control group (p < 0.001). Conclusions The data from this study indicated that severe HG is associated with increased urine NTx levels. However, large-scale studies are required to understand the clinical significance of this finding, as well as the long-term consequences of elevated urine NTx levels and the underlying mechanisms. Trial registration NCT02862496 Date of registration: 21/07/2016

Fetal Diaphragmatic Excursion Is Decreased in Hospitalized Pregnant Women Infected with COVID-19 during the Second and Third Trimesters

Objective In the present study, we aimed to evaluate coronavirus disease 2019 (COVID-19) infection effects on fetal diaphragm thickness and diaphragmatic excursion, which together show the quality of diaphragmatic contractions. Study Design One hundred and ninety-two pregnant women were included in this prospective case-control study. Patients were divided into four groups according to their COVID-19 infection history in their second or third trimester: hospitalized COVID-19-infected pregnant women group (n = 48), outpatient COVID-19-infected pregnant women group (n = 48), common cold (COVID-19 polymerase chain reaction negative) pregnant women group (n = 48), and noninfected healthy controls (n = 48). The number of patients was determined by power analysis following the pilot study. All participants underwent an ultrasound examination to determine fetal diaphragm parameters at 32 to 37 weeks of gestation. Results Demographic characteristics were similar among the four groups. The gestational age at ultrasound examination and gestational age at delivery were similar among the groups. Neonatal intensive care unit (NICU) admission rate was significantly higher in the hospitalized COVID-19-infected pregnant women group than the other groups. The fetal diaphragm thickness during inspiration and expiration, and fetal costophrenic angles at inspiration and expiration were similar among the groups. Fetal diaphragmatic excursion was significantly decreased in the hospitalized COVID-19-infected pregnant women group compared with the other groups. Conclusion Our results indicated that moderate maternal COVID-19 infection decreased fetal diaphragmatic excursion, and ultrasonographic evaluation of fetal diaphragmatic excursion before delivery can provide critical information to predict whether infants will require NICU admission. Key Points Diaphragm ultrasound as a new technique for characterizing the diaphragm's structure and function. Fetal diaphragmatic excursion is decreased in the presence of moderate COVID-19 infection. Ultrasonographic evaluation of fetal diaphragmatic excursion provides critical information to predict NICU admission