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

Removable Partial Dentures: Use of Rapid Prototyping

The CAD/CAM technology associated with rapid prototyping (RP) is already widely used in the fabrication of all-ceramic fixed prostheses and in the biomedical area; however, the use of this technology for the manufacture of metal frames for removable dentures is new. This work reports the results of a literature review conducted on the use of CAD/CAM and RP in the manufacture of removable partial dentures

Stress distribution around osseointegrated implants with different internal-cone connections: photoelastic and finite element analysis

The goal of this study was to evaluate the distribution of stresses generated around implants with different internal-cone abutments by photoelastic (PA) and finite element analysis (FEA). For FEA, implant and abutments with different internal-cone connections (H- hexagonal and S- solid) were scanned, 3D meshes were modeled and objects were loaded with computer software. Trabecular and cortical bones and photoelastic resin blocks were simulated. The PA was performed with photoelastic resin blocks where implants were included and different abutments were bolted. Specimens were observed in the circular polariscope with the application device attached, where loads were applied on same conditions as FEA. FEA images showed very similar stress distribution between two models with different abutments. Differences were observed between stress distribution in bone and resin blocks; PA images resembled those obtained on resin block FEA. PA images were also quantitatively analyzed by comparing the values assigned to fringes. It was observed that S abutment distributes loads more evenly to bone adjacent to an implant when compared to H abutment, for both analysis methods used. It was observed that the PA has generated very similar results to those obtained in FEA with the resin block.Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES

Effect of the interfacial area measurement parameters on the push-out strength between fiber post and dentin

Purpose: To verify the influence of different instruments and operators on the bonding interfacial area and on the push-out bond strength values.Material and methods: Fifteen anterior human teeth (n=15) were selected, cleaned and standardized to 15 mm length. Root canals were prepared in 12 mm and the fiber posts were cemented using the RelyX U-100 cement. Three slices were obtained per tooth (N=45) and submitted to the push-out bond strength test. The bonding interfacial area (mm(2)) of each specimen was calculated based on the disc slice dimensions: coronal and apical diameter and height. The bonding area of each specimen was used to calculate the bond strength (Mpa). The dimensions were analyzed by different operators, using two instruments: G1 - Operator A with a digital caliper; G2 - Operator A with a stereomicroscope; G3 - Operator B with a digital caliper; G4 - Operator B with a digital stereomicroscope; G5 - Operator C with a digital caliper; G6 - Operator C with a stereomicroscope. The mean area was submitted to inter-operator and intra-operator analyses, while the mean area and mean of bond strength were submitted to the 2-way ANOVA with repeated measures and the Tukey test (alpha=0.05).Results: The inter-operator kappa was 0.83 to the digital caliper and 0.91 to the stereomicroscope, while the intra-operator kappa was 0.76. The operator and the measurement instrument influenced the interfacial bonding area (p=0.000 and p=0.001) and the push-out bond strength values (p=0.000 and p=0.000, respectively) of the disc slices.Conclusion: The final push-out bond strength values are influenced by the measuring instrument and by the measurer operator. (C) 2014 Published by Elsevier Ltd.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Finite element analysis of the influence of geometry and design of zirconia crowns on stress distribution

Purpose: To evaluate the influence of the geometry and design of prosthetic crown preparations on stress distribution in compression tests, using finite element analysis (FEA). Materials and Methods: Six combinations of 3D drawings of all-ceramic crowns (yttria-stabilized zirconia framework and porcelain veneer) were evaluated: F, flat preparation and simplified crown; FC, flat preparation and crown with contact point; FCM, flat preparation and modified crown; A, anatomical preparation and simplified anatomical crown framework; AC, anatomical preparation and crown with contact point; and ACM, anatomical preparation and modified crown. Bonded contact types at all interfaces with the mesh were assigned, and the material properties used were according to the literature. A 200 N vertical load was applied at the center of each model. The maximum principal stresses were quantitatively and qualitatively analyzed. Results: The highest values of tensile stress were observed at the interface between the ceramics in the region under the load application for the simplified models (F and A). Reductions in stress values were observed for the model with the anatomical preparation and modified infrastructure (ACM). The stress distribution in the flat models was similar to that of their respective anatomical models. Conclusions: The modified design of the zirconia coping reduces the stress concentration at the interface with the veneer ceramic, and the simplified preparation can exert a stress distribution similar to that of the anatomical preparation at and near the load point, when load is applied to the center of the crown

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