Sistemas circulares de radionavegación

Estudio de los principios de funcionamiento del sistema radiogoniométric

Problem Based Learning: a tool to improve maritime safety learning in the Merchant Maritime University degrees

Since 2010, the University of Cádiz offers three new degree programs related to merchant marine officers studies. These three degrees cover the training and certification of deck officers, marine engineers and radio- electronic officers, clustered under the EINAMAR (Escuela de Ingeniería Marina,Naútica y Radioelectrónica) umbrella. These degrees are designed to provide the students not only with the proper academic certificate but also with a fully worldwide recognized professional certificate. This is the reason why the studies not only have to fully fulfill the academic quality requirements laid down by ANECA (Agencia Nacional de Evaluación de la Calidad y Acreditación) or DEVA (Dirección de Evaluación y Acreditación – Agencia Andaluza del Conocimiento-) but also with the standard qualifications set up by the International Convention on Standard of Training, Certification and Watchkeeping (STCW 95) for seafarers as amended in 2010 (Manila Amendments). According to this, as far as the students finish successfully their studies, and after an onboard training period, they will be able to obtain both, the academic and the professional certificates. “Maritime Safety” is a one of the core subjects for these three programs and it has been designed as a transversal subject in such a way that all the students have the same contents and schedule. This subject aims to provide the students with the theoretical and practical training to cope with any situation involving fire prevention and firefighting as well as incident and accident prevention and resolution on board. It also introduces student into the world of contingency planning and evacuation procedures on board, the knowledge of how to use survival crafts and equipment to increase probabilities of survival when abandoning the ship, and the most appropriate techniques and procedures when abandoning the ship and boarding the survival crafts. The main aim of the practical part of the subject is to improve the on board safety and risk awareness and to let the students get used to the most appropriate techniques and procedures as well as the use and maintenance of the protective equipment available on board. To achieve this goal, problem based learning techniques related to real situations on board have been applied. One of the specific practical workshop that have been implemented during the course, deals with the student training level in the use of SCBA (Self-contained reathing apparatus) and other protective equipment as well as orientation and search and rescue techniques within hostile environments with sensorial losses. As these situations can arise on board students must be familiar with them in order to properly face them. The aim of this specific workshop is not only to improve the students’ safety and risk awareness but also to encourage, strengthen and increase other professional and social skills

Clonal chromosomal mosaicism and loss of chromosome Y in elderly men increase vulnerability for SARS-CoV-2

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) had an estimated overall case fatality ratio of 1.38% (pre-vaccination), being 53% higher in males and increasing exponentially with age. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, we found 133 cases (1.42%) with detectable clonal mosaicism for chromosome alterations (mCA) and 226 males (5.08%) with acquired loss of chromosome Y (LOY). Individuals with clonal mosaic events (mCA and/or LOY) showed a 54% increase in the risk of COVID-19 lethality. LOY is associated with transcriptomic biomarkers of immune dysfunction, pro-coagulation activity and cardiovascular risk. Interferon-induced genes involved in the initial immune response to SARS-CoV-2 are also down-regulated in LOY. Thus, mCA and LOY underlie at least part of the sex-biased severity and mortality of COVID-19 in aging patients. Given its potential therapeutic and prognostic relevance, evaluation of clonal mosaicism should be implemented as biomarker of COVID-19 severity in elderly people. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, individuals with clonal mosaic events (clonal mosaicism for chromosome alterations and/or loss of chromosome Y) showed an increased risk of COVID-19 lethality

Viajes y descubrimientos españoles en el Pacífico: Magallanes, Elcano, Loaysa y Saavedra

Tipo de archivo: TextoPC 486 ; 8 Mb de memoria RAM; MS-DOS 6.0 y Microsoft Windows 3.1 o superior; Espacio libre en disco superior a 10 Mb; Monitor VGA; Lector de CD-ROMTít. tomado de la etiquetaÁlvarez Guerra, Juan: Memoria sobre el estado material, moral y político en que se encuentran las islas Marianas. Manila: [s. n.], 1872. -- Álvarez Guerra, Juan: De Manila a Marianas. Madrid: [s. n.] (Imprenta de Fontanet), 1887. -- Ambrosio De Valencina: Primer ensayo de gramática de la lengua de Yap (Carolinas occidentales): con un pequeño diccionario y varias frases en forma de diálogo. Manila: [s. n.] (Imprenta del Colegio de Santo Tomás), 1888. -- Ambrosio De Valencina: Mi viaje a Oceanía: Hisstoria de la fundación de las misiones capuchinas en las islas Garolinas y Palaos. Sevilla: [s. n.] (Imp. de la Divina Pastora), 1917. -- Ansón, Jorge: Viaje alrededor del mundo, hecho en los años desde 1740 al 1744: tomo segundo. Madrid: [s. n.] (Imp. de Don Tomás Jordán), 1833 (**). -- Ansón, Jorge: Viaje alrededor del mundo, hecho en los años desde 1740 al 1744: tomo tercero. Madrid: [s. n.] (Imp. de Don Tomás Jordán), 1833 (**). -- Arago, Jacques: Souvenirs d´un Aveugle: Voyage autour du monde: Tome deuxième. Paris: Hortet et Ozanne, 1839 (**). -- Arago, Jacques: Souvenirs d´un Aveugle: Voyage autour du monde: Tome troisième. Paris: Hortet et Ozanne, 1839 (**). -- Aranda, Gabriel De: Vida y gloriosa mverte delV. Padre Sebastian de Monroy religioso de la compañia de Jesvs que murió dilatando la Fé alanceado de los barbaros en las Islas Marianas. En Sevilla: Por Thomas Lopez de Haro, 1690. -- Aríñez, Agustín: Diccionario hispano-kanaka: o sea modesta colección de las voces más usuales y conocidas de esta lengua de la Ascensión oó Ponapé é islas inmediatas (Carolinas orientales)... Tambobong: [s. n.] (Pequeña imprenta del Asilo de Huérfanos de Nuestra Señora de Consolación), 1892. -- Armengol y Cornet, Pedro: ¿A las islas Marianas ó al golfo de Guinea?. Madrid: [s. n.] (Imprenta y librería de Eduardo Martínez), 1878. -- Balaciart, Daniel: Las Carolinas: precedido de Glorias de la Marina Española. Madrid: [s. n.] (Imprenta de Ramón Moreno y Ricardo Rojas), 1885. -- Barreiro, Agustín Jesús: El origen de la raza indígena de las islas Carolinas. Madrid: [s. n.] (Imprenta del Asilo de Huérfanos del S. C. de Jesús), 1920. -- Beltrán y Rózpide, Ricardo: Descubrimiento de la Oceanía por los españoles: Conferencia. Madrid: [s. n.] (Establecimiento tipográfico “Sucesores de Rivadeneyra”), 1892. -- Butróny De La Serna, Emilio José: Memoria sobre las islas Carolinas y Palaos. Madrid: [s. n.] (Imprenta de Fortanet), 1885. -- Cabeza Pereiro, A.: La Isla de Ponape. Conferencia dada en reunión de la Sociedad Geográfica de Madrid. [s. l.]: Establecimiento tipográfico de Fortanet, 1893. -- Cabeza Pereiro, A.: Estudios sobre Carolinas: La isla de Ponapé: Geografía, etnografía, historia. Manila: [s. n.] (Tipo-litografía de Chofré y Compañía), 1895. -- Campo Echevarría, Antonio Del: España en Oceanía. Descripción histórico, geográfica y estadística de nuestras posesiones... Santander: [s. n.] Imprenta y encuadernación de Blanchard y Arce., 1897. -- Cantova, José Antonio: Carolines: Déscouverte et description des Isles Garbanzos. Paris: Sociète Académique Indo-Chincise, 1881. -- Cartas edificantes y curiosas escritas de las misiones extranjeras por algunos missioneros... Madrid: Imprenta de laViuda de Manuel Fernández y del Supremo Consejo de Inquisición, 1754. -- Chacón Lara, Francisco: Memoria, proyecto y estatutos de colonización de las islas españolas Marianas, Carolinas y Palaos. Sevilla: [s. n.] (Imprenta de Salvador Acuña), 1885. -- Código de comercio para las islas Filipinas y demás archipiélagos españoles de Oceanía. Madrid: [s. n.] (Imprenta de Ramón Moreno y Ricardo Rojas), 1888 -- Coello, Francisco: La conferencia de Berlín y la cuestión de las Carolinas. Madrid: [s. n.] Imprenta de Fontanet, 1885. -- Corte y Ruano Calderón, Felipe De La: Memoria descriptiva é histórica de las islas Marianas: otras que las rodean en relación con ellas y de su organización actual con estudio analítico de todos sus elementos físicos, morales y políticos... Madrid: [s. n.] (Imprenta Nacional), 1875. -- Descalante Alvarado, García: Relación del viaje que hizo desde la Nueva-España a las Islas del Poniente Ruy Gómez de Villalobos, por orden del virey D. Antonio Mendoza. [S.l.]: [s.n.], 1548. -- Escudé Bartolí, Manuel: Nuestras colonias: Las Carolinas: descripción geográfica y estadística del archipiélago carolino con datos recopilados y ampliados: Primera parte. Barcelona: [s. n.] (Administración. Imprenta de Luís Tasso Serra), 1885. -- Florencia, Franciso De: Exemplar vida, y gloriosa muerte por Christo del fervoroso P. Luis de Medina... Sevilla: Iuan Francisco de Blas, 1673. -- García, Francisco: Vida y martyrio de el venerable padre Diego Lvis de Sanvitores de la Compañía de Iesvs... desde el año de mil setecientos y sesenta y ocho, asta el de mil seiscientos y ochenta y vno. En Madrid: Por Ivan Garcia Infanzon, 1683. -- Gómez, Juan Gualberto: Las islas Carolinas y las Marianas. Madrid: [s. n.] (Nueva imprenta y librería de San José), 1885. -- Gracia y Parejo, Rafael De: Consideraciones acerca del derecho de España sobre las Islas Carolinas. Madrid: [s. n.] (Establecimiento tipográfico de Gregorio Juste), 1885. -- Guimerá, Vicente: Marino y misionero o el P. Julián de Madariaga de la Compañía de Jesús misionero en las islas Marianas, Carolinas y Marshall. Sevilla: [s. n.] (Imprenta y Librería de Eulogio de las Heras), 1929. -- Herrera Oria, Julio y Luis: En China y Carolinas. Episidios de misiones. Burgos: “El Siglo de las Misiones”, [1931]. -- Ibáñez Del Carmen, Aniceto: El verdadero cristiano instruido. Manila: [s. n.] (Imp. de Ramírez y Giraudier), 1863. -- Ibáñez Del Carmen, Aniceto: Diccionario español-chamorro. Manila: [s. n.] (Imp. de Ramírez y Giraudier), 1865 -- Ibáñez Del Carmen, Aniceto: Gramática chamorra. Manila: [s. n.] (Imp. de Ramírez y Giraudier), 1865. -- Ibáñez Del Carmen, Aniceto: Devocion a San Francisco de Borja, patron de Rota: Esplicacion de los Santos Sacramentos y modo de recibirlos dignamente: Devocion a San Dimas el Buen Ladron, patron de Merizo, y doctrina esplicada. Manila: [s. n.] Imprenta “Amigos del País”, 1887. -- Ibáñez y García, Luis De: Historia de las Islas Marianas con su derrotero y de las Carolinas y Palaos: desde el descubrimiento por Magallanes en el año 1521 hasta nuestro días. Granada: [s. n.] (Imp. y lib. de Paulino V. Sabatel), 1886. -- Instrucciones para la navegación del Archipiélago de las Carolinas incluyendo el grupo de las Palaos. Madrid: [s. n.] (Dirección de Hidrografía), 1886. -- Keate, George: Relación de las islas de Pelew situadas en la parte occidental del Oceano Pacífico: deducida de los diarios y noticias verbales del capitán Enrique Wilson y algunos de los oficiales que en agosto de 1783 naufragaron en el Antelope paquebote inglés... Madrid: por Gomez Fuentenebro y compañía, 1805. -- Lastres y Juiz, Francisco: La colonización penitenciaria de las Marianas y Fernando Póo. Madrid: [s. n.] (Imprenta y librería de Eduardo Martínez), 1878. -- Le Gobien, Charles: Histoire des isles Marianes: nouvellement converties à la Religion Chrestienne & de la mort glorieuse des premiers Missionnaires qui y ont prêché la Foy. A Paris: Chez Nicolas Papie, 1700. -- Ledesma, Andrés: Noticia de los progressos de nuestra Santa Fe, en las Islas Marianas llamadas antes de los Ladrones y del fruto que han hecho en ellas el padre Diego Luis de Sanvitores, y sus compañeros de la Compañía de Jesús. [s. l.]: [s. n.], [s. d.]. -- Marenco, Servando: La ficción y la verdad de lo ocurrido en Yap: Reseña histórica con las instrucciones y documentos oficiales. Madrid: [s. n.] (Establecimiento tipográfico de El Globo), 1886. -- Maturana, Margarita: Viaje misionero alrededor del mundo: Impresiones, planes, esperanzas. Burgos: «El Siglo de las Misiones», 1929. -- Michelena y Rojas, Francisco: Viajes científicos en todo el mundo, desde 1822 hasta 1842: durante los cuales fueron visitadas la Oceanía en sus tres nuevas divisiones geográficas... el Asia y sus grandes regiones... el África en lo más interesante de ella... cuatro veces la Europa en sus imperios, reinos y ciudades... otras tantas veces la América en los principales estados que la componen. Madrid: I. Boix, Editor, 1843 (**). -- Miguel, Gregorio: Estudio sobre las Islas Carolinas. Madrid: [s. n.] Imprenta de José Perales y Martínez, 1887. -- Montero y Vidal, José: El archipiélago filipino y las islas Marianas, Carolinas y Palaos: su historia, geografía y estadística. Madrid: [s. n.] (Imprenta y fundición de Manuel Tello), 1886. -- Moya, Francisco De: Nuestro ejército en las Carolinas. Madrid: [s. n.] (Imprenta del Cuerpo de Artillería), 1891. -- Muñoz Barreda, V.: La Micronesia española ó los Archipiélagos de Marinas, Palaos y Carolinas. Manila: [s. n.] (Tipografía “Amigos del País), 1894 -- Napolés, Vicencio De: Relación hecha por Vicencio de Nápoles, del viaje que hizo la Armada que Hernán Cortés envió en busca de las Islas de la Especiería. [S.l.]: [s.n.], [s. d.]. -- Noticias de los misioneros de las islas Carolinas y Marianas. Madrid: [s. n.] (Establecimiento tipográfico Nieto y compañía), 1923. -- Nuevo viajero universal: enciclopedia de viajes modernos: recopilación de las obras más notables sobre descubrimientos, esploraciones y aventuras publicadas por los más célebres viajeros del siglo XIX HUmboldt, Bruckhardt, Livingstone...: Tomo IV: Oceanía. Madrid: Imprenta y librería de Gaspar y Roig, 1862 (**). -- Olive y García, Francisco: Islas Marianas: Lijeros apuntes acerca de las mismas porvenir á que pueden y deben aspirar y ayuda que ha de prestar la administración para conseguirlo. Manila: [s. n.] (Imprenta y Litografía de M. Pérez, hijo), 1887. -- Pozo y Bresó, Julián Del: Contra la colonización por España de las islas Carolinas: Artículos publicados en el periódico “La Opinión” de Manila. Manila: [s. n.] (Tipo-litografía de Chofré y Cª), 1890. -- Romero y Girón, Vicente: La cuestión de las Carolinas ante el derecho internacional: colección de artículos publicados en la “Revista de los tribunales”. Madrid: Góngora, Editores, 1885. -- Santisteban, Jerónimo De: Carta escrita por Fr. Gerónimo de Santisteban á Don Antonio Mendoza, virey de Nueva España, relacionando la pérdida de la Armada que salió en 1542 para la Islas del Poniente. [S.l.]: [s.n.], 1547. -- Sociedad Española De Africanistas y Colonistas: El conflicto hispano-alemán sobre la Micronesia. Madrid: [s. n.] (Imprenta de Fontanet), 1886. -- Soderini, Edoardo: La mediazione di Leone XIII nel conflitto ispano-tedesco sulle Isole Caroline. Roma: [s. n.] (Tipografía A. Befani), 1886. -- Taviel De Andrade, Enrique: Historia del conflicto de las Carolinas: prueba del derecho de soberanía que sobre ellas posee España y demostración de la trascendencia que tiene la mediación del Papa. Madrid: [s. n.] (Imprenta y Fundación de Manuel Tello), 1886. -- Urdaneta, Andrés De: Relaciones del viaje hecho á las Islas Molucas ó de la Especiería por la Armada á las órdenes del comendador García Jofre Loaysa. [S.l.]: [s.n.], 1537. -- Viajes y descubrimientos españoles en el Pacífico: Magallanes, Elcano, Loaysa y Saavedra. Madrid: Renovación, 1919. -- Viaje pintoresco alrededor del Mundo: resumen jeneral de los viajes y descubrimientos de Magallanes, Tasman, Dampier, Anson, Byron, Wallis, Carteret, Bougainville, Cook, Lapérouse, G. Bligh, Vancouver, D’Entrecasteaux, Wilson, Baudin, Flinders, Krusenstern, Porter, Kotzebue, Freyeinet, Bellinghausen, Bsil Hall, Duperrey, Paulding, Becchey, Dumont, D’Urville, Lutke, Dillon, Laplace, B. Morrell, etc.: Tomo III. Barcelona: [s. n.] (Imprenta y librería de Juan Oliveres), 1841 (**). -- Vidal, José: Carta escrita en la Ciudad de México. [S. l.]: [s. n.]: [s. d.]. -- Vidart, Luis: Vasco da Gama y el descubrimiento de Oceanía: apuntes histórico-geográficos. Madrid: [s. n.] (Imprenta de los hijos de M. G. Hernández), 1895. -- Vidart, Luis: El descubrimiento de Oceanía por los portugueses: apuntes históricos. Madrid: [s. n.] (Imprenta del Cuerpo de Artillería), 1896

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

GWAS and meta-analysis identifies 49 genetic variants underlying critical COVID-19

Data availability: Downloadable summary data are available through the GenOMICC data site (https://genomicc.org/data). Summary statistics are available, but without the 23andMe summary statistics, except for the 10,000 most significant hits, for which full summary statistics are available. The full GWAS summary statistics for the 23andMe discovery dataset will be made available through 23andMe to qualified researchers under an agreement with 23andMe that protects the privacy of the 23andMe participants. For further information and to apply for access to the data, see the 23andMe website (https://research.23andMe.com/dataset-access/). All individual-level genotype and whole-genome sequencing data (for both academic and commercial uses) can be accessed through the UKRI/HDR UK Outbreak Data Analysis Platform (https://odap.ac.uk). A restricted dataset for a subset of GenOMICC participants is also available through the Genomics England data service. Monocyte RNA-seq data are available under the title ‘Monocyte gene expression data’ within the Oxford University Research Archives (https://doi.org/10.5287/ora-ko7q2nq66). Sequencing data will be made freely available to organizations and researchers to conduct research in accordance with the UK Policy Framework for Health and Social Care Research through a data access agreement. Sequencing data have been deposited at the European Genome–Phenome Archive (EGA), which is hosted by the EBI and the CRG, under accession number EGAS00001007111.Extended data figures and tables are available online at https://www.nature.com/articles/s41586-023-06034-3#Sec21 .Supplementary information is available online at https://www.nature.com/articles/s41586-023-06034-3#Sec22 .Code availability: Code to calculate the imputation of P values on the basis of SNPs in linkage disequilibrium is available at GitHub (https://github.com/baillielab/GenOMICC_GWAS).Acknowledgements: We thank the members of the Banco Nacional de ADN and the GRA@CE cohort group; and the research participants and employees of 23andMe for making this work possible. A full list of contributors who have provided data that were collated in the HGI project, including previous iterations, is available online (https://www.covid19hg.org/acknowledgements).Change history: 11 July 2023: A Correction to this paper has been published at: https://doi.org/10.1038/s41586-023-06383-z. -- In the version of this article initially published, the name of Ana Margarita Baldión-Elorza, of the SCOURGE Consortium, appeared incorrectly (as Ana María Baldion) and has now been amended in the HTML and PDF versions of the article.Copyright © The Author(s) 2023, Critical illness in COVID-19 is an extreme and clinically homogeneous disease phenotype that we have previously shown1 to be highly efficient for discovery of genetic associations2. Despite the advanced stage of illness at presentation, we have shown that host genetics in patients who are critically ill with COVID-19 can identify immunomodulatory therapies with strong beneficial effects in this group3. Here we analyse 24,202 cases of COVID-19 with critical illness comprising a combination of microarray genotype and whole-genome sequencing data from cases of critical illness in the international GenOMICC (11,440 cases) study, combined with other studies recruiting hospitalized patients with a strong focus on severe and critical disease: ISARIC4C (676 cases) and the SCOURGE consortium (5,934 cases). To put these results in the context of existing work, we conduct a meta-analysis of the new GenOMICC genome-wide association study (GWAS) results with previously published data. We find 49 genome-wide significant associations, of which 16 have not been reported previously. To investigate the therapeutic implications of these findings, we infer the structural consequences of protein-coding variants, and combine our GWAS results with gene expression data using a monocyte transcriptome-wide association study (TWAS) model, as well as gene and protein expression using Mendelian randomization. We identify potentially druggable targets in multiple systems, including inflammatory signalling (JAK1), monocyte–macrophage activation and endothelial permeability (PDE4A), immunometabolism (SLC2A5 and AK5), and host factors required for viral entry and replication (TMPRSS2 and RAB2A).GenOMICC was funded by Sepsis Research (the Fiona Elizabeth Agnew Trust), the Intensive Care Society, a Wellcome Trust Senior Research Fellowship (to J.K.B., 223164/Z/21/Z), the Department of Health and Social Care (DHSC), Illumina, LifeArc, the Medical Research Council, UKRI, a BBSRC Institute Program Support Grant to the Roslin Institute (BBS/E/D/20002172, BBS/E/D/10002070 and BBS/E/D/30002275) and UKRI grants MC_PC_20004, MC_PC_19025, MC_PC_1905 and MRNO2995X/1. A.D.B. acknowledges funding from the Wellcome PhD training fellowship for clinicians (204979/Z/16/Z), the Edinburgh Clinical Academic Track (ECAT) programme. This research is supported in part by the Data and Connectivity National Core Study, led by Health Data Research UK in partnership with the Office for National Statistics and funded by UK Research and Innovation (grant MC_PC_20029). Laboratory work was funded by a Wellcome Intermediate Clinical Fellowship to B.F. (201488/Z/16/Z). We acknowledge the staff at NHS Digital, Public Health England and the Intensive Care National Audit and Research Centre who provided clinical data on the participants; and the National Institute for Healthcare Research Clinical Research Network (NIHR CRN) and the Chief Scientist’s Office (Scotland), who facilitate recruitment into research studies in NHS hospitals, and to the global ISARIC and InFACT consortia. GenOMICC genotype controls were obtained using UK Biobank Resource under project 788 funded by Roslin Institute Strategic Programme Grants from the BBSRC (BBS/E/D/10002070 and BBS/E/D/30002275) and Health Data Research UK (HDR-9004 and HDR-9003). UK Biobank data were used in the GSMR analyses presented here under project 66982. The UK Biobank was established by the Wellcome Trust medical charity, Medical Research Council, Department of Health, Scottish Government and the Northwest Regional Development Agency. It has also had funding from the Welsh Assembly Government, British Heart Foundation and Diabetes UK. The work of L.K. was supported by an RCUK Innovation Fellowship from the National Productivity Investment Fund (MR/R026408/1). J.Y. is supported by the Westlake Education Foundation. SCOURGE is funded by the Instituto de Salud Carlos III (COV20_00622 to A.C., PI20/00876 to C.F.), European Union (ERDF) ‘A way of making Europe’, Fundación Amancio Ortega, Banco de Santander (to A.C.), Cabildo Insular de Tenerife (CGIEU0000219140 ‘Apuestas científicas del ITER para colaborar en la lucha contra la COVID-19’ to C.F.) and Fundación Canaria Instituto de Investigación Sanitaria de Canarias (PIFIISC20/57 to C.F.). We also acknowledge the contribution of the Centro National de Genotipado (CEGEN) and Centro de Supercomputación de Galicia (CESGA) for funding this project by providing supercomputing infrastructures. A.D.L. is a recipient of fellowships from the National Council for Scientific and Technological Development (CNPq)-Brazil (309173/2019-1 and 201527/2020-0)

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 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

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: 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. Funding: National Institute for Health and Care Research