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

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study

Background Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours.Methods In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186.Findings Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78 center dot 6%] female patients and 4922 [21 center dot 4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1 center dot 4 [IQR 0 center dot 6-3 center dot 4]) compared with the prepandemic phase (2 center dot 0 [0 center dot 9-3 center dot 7]; p<0 center dot 0001) and pandemic decrease phase (2 center dot 3 [1 center dot 0-5 center dot 0]; p<0 center dot 0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69 center dot 0%] of 3704 vs 1515 [71 center dot 5%] of 2119; OR 1 center dot 1 [95% CI 1 center dot 0-1 center dot 3]; p=0 center dot 042), lymph node metastases (343 [9 center dot 3%] vs 264 [12 center dot 5%]; OR 1 center dot 4 [1 center dot 2-1 center dot 7]; p=0 center dot 0001), and tumours at high risk of structural disease recurrence (203 [5 center dot 7%] of 3584 vs 155 [7 center dot 7%] of 2006; OR 1 center dot 4 [1 center dot 1-1 center dot 7]; p=0 center dot 0039).Interpretation Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation.Funding None.Copyright (c) 2023 Published by Elsevier Ltd. All rights reserved

Trichloroethylene solubilization using a series of commercial biodegradable ethoxylated fatty alcohol surfactants

BACKGROUND Although certain pollutants are prohibited or heavily regulated, particularly in Europe and the USA, contaminated sites still represent a serious threat to the environment and health. The physical and chemical properties of 'dense non-aqueous phase liquid' (DNAPL) pollutants such as trichloroethylene (TCE), including their low solubility, high specific density and tendency to remain adsorbed to organic materials, make their removal from polluted sites extremely difficult. RESULTS This study tested the ability of a series of commercial fatty alcohol ethoxylated surfactants of CiEj type (i = number of carbons in the alkyl chain; j = number of ethylene oxide (EO) units), known to be biodegradable and low-cost, to improve the solubility of TCE in water; this would make its removal from contaminated sites more effective. The solubility of TCE in Synperonic (TM) 91/5 (C10E5), 91/6 (C10E6), 91/8 (C10E8), 91/10 (C10E10) and 13/8 (C13E8) aqueous solutions was evaluated and the solubilization performances were reported as molar and weight solubilization ratios (MSR and WSR). Solubility was measured above the critical micelle concentration (CMC) up to 0.7 mol L-1 at 5, 20 and 30 degrees C to assess the feasibility of the approach for TCE removal from sites located in different climatic areas. Increasing EO units contributed to improved TCE solubility (at constant alkyl chain length). CONCLUSION The best surfactant was Synperonic (TM) 91/10 with an MSR of 3.54 at 19 degrees C. The results show that an optimal combination of EO units and alkyl chain length, and not only the hydrophilic-lipophilic balance (HLB) value, is key for the design of effective TCE remediation systems from groundwater. (c) 2019 Society of Chemical Industr

Physico-chemical characterization of Synperonic™ 91/5 self-assembly behaviour in water

We studied the self-assembled aggregates of Synperonic™ 91/5 (SYN) in water solution. This surfactant presents the peculiarity of having an odd number of aliphatic carbons, with a tail composed of C9H19 and C11H23, and the headgroup having an average of 5 ethoxy units. While the general family of CiEOj nonionic surfactants has been widely studied, there is little knowledge for the case of surfactants with odd-number carbons. For this reason, we carried out an in depth physico-chemical characterization of water solutions containing SYN in the wide range of concentration from 2 % to 50 % (i.e. 0.05–1.4 M), considering that high concentrated systems are relevant for industrial applications. This class of surfactants is also interesting as remediation agent since they can incorporate different polluting molecules, both polar and nonpolar, such as volatile Organic Compounds (VOCs) and Dense Non Aqueous Phase liquids (DNAPLs). The rheological and transport properties of SYN solutions were investigated through diffusion coefficients and viscosity, while shape and size of self-assemblies were determined by Dynamic Light Scattering and by Small Angle Scattering of Neutrons (SANS) and X-rays (SAXS). Results show that SYN generally behaves as other nonionic surfactants in dilute solutions, but shows some peculiarity of aggregate packing at high concentration. We recently demonstrated the efficiency of the Synperonic™ family of surfactants in solubilising trichloroethylene (TCE), in particular above a critical concentration of 0.1 M, thus being a good candidate for remediation purposes. Here, the solubility of TCE was correlated with the number and the size of micelles at different surfactant concentrations. Our work helps filling a gap in the literature about technical grade surfactants with odd-number carbons, and the results can help in assessing the performances of Synperonic™ products for technical tasks

Physico-chemical characterization of Synperonic™ 91/5 self-assembly behaviour in water

We studied the self-assembled aggregates of Synperonic™ 91/5 (SYN) in water solution. This surfactant presents the peculiarity of having an odd number of aliphatic carbons, with a tail composed of C9H19 and C11H23, and the headgroup having an average of 5 ethoxy units. While the general family of CiEOj nonionic surfactants has been widely studied, there is little knowledge for the case of surfactants with odd-number carbons. For this reason, we carried out an in depth physico-chemical characterization of water solutions containing SYN in the wide range of concentration from 2 % to 50 % (i.e. 0.05–1.4 M), considering that high concentrated systems are relevant for industrial applications. This class of surfactants is also interesting as remediation agent since they can incorporate different polluting molecules, both polar and nonpolar, such as volatile Organic Compounds (VOCs) and Dense Non Aqueous Phase liquids (DNAPLs). The rheological and transport properties of SYN solutions were investigated through diffusion coefficients and viscosity, while shape and size of self-assemblies were determined by Dynamic Light Scattering and by Small Angle Scattering of Neutrons (SANS) and X-rays (SAXS). Results show that SYN generally behaves as other nonionic surfactants in dilute solutions, but shows some peculiarity of aggregate packing at high concentration. We recently demonstrated the efficiency of the Synperonic™ family of surfactants in solubilising trichloroethylene (TCE), in particular above a critical concentration of 0.1 M, thus being a good candidate for remediation purposes. Here, the solubility of TCE was correlated with the number and the size of micelles at different surfactant concentrations. Our work helps filling a gap in the literature about technical grade surfactants with odd-number carbons, and the results can help in assessing the performances of Synperonic™ products for technical tasks. © 2023 Elsevier B.V

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

Current ophthalmology practice patterns for syphilitic uveitis

Abstract BACKGROUND: Syphilitic uveitis is re-emerging alongside the systemic infection. In July 2017, an international group of uveitis-specialised ophthalmologists formed the International Ocular Syphilis Study Group to define current practice patterns. METHODS: 103 Study Group members based in 35 countries completed a 25-item questionnaire focused on case load, clinical presentations, use and interpretation of investigations, treatment and clinical indicators of poor prognosis. RESULTS: Members managed a mean of 6.1 patients with syphilitic uveitis in clinics that averaged 707 annual cases of uveitis (0.9%); 53.2% reported increasing numbers over the past decade. Patients presented to more members (40.2%) during secondary syphilis. Uveitis was usually posterior (60.8%) or pan (22.5%); complications included optic neuropathy, macular oedema and posterior synechiae. All members diagnosed syphilitic uveitis using serological tests (simultaneous or sequential testing algorithms), and 97.0% routinely checked for HIV co-infection. Cerebrospinal fluid (CSF) analysis was ordered by 90.2% of members, and 92.7% took uveitis plus Venereal Disease Research Laboratory test (VDRL) or fluorescent treponemal antibody absorption test (FTA-ABS) to indicate neurosyphilis. Patients were commonly co-managed with infectious disease physicians, and treated with penicillin for at least 10-14 days, plus corticosteroid. Features predicting poor outcome included optic neuropathy (86.3%) and initial misdiagnosis (63.7%). Reasons for delayed diagnosis were often practitioner-related. 82.5% of members tested every patient they managed with uveitis for syphilis. CONCLUSION: This comprehensive report by an international group of uveitis-specialised ophthalmologists provides a current approach for the management of syphilitic uveitis

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery