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

Favoring D2-Lymphadenectomy in Gastric Cancer

The role of extended lymphadenectomy in the surgical treatment of gastric cancer has been debated for many years. So far six prospective randomized trials and a number of meta-analyses comparing D1- to D2-lymphadenectomy in open surgery have been published with contradicting results. The possible oncologic benefit of radical lymphadenectomy has been blurred by a number of reasons. In most of the trials the strategies under comparison were made similar after protocol violations. Imperfect design of the trials could not exclude the influence of cofounding factors. Inappropriate endpoints could not detect evidently the difference between the two surgical strategies. On the other hand radical lymphadenectomy was characterized by increased morbidity and mortality. This was mostly caused by the addition of pancreatico-splenectomy in all D2-dissections, even when not indicated. A careful analysis of the available evidence indicates that D2-lymphadenectomy performed by adequately trained surgeons without resection of the pancreas and/or spleen, unless otherwise indicated, decreases Gastric Cancer Related Deaths and increases Disease Specific Survival. This evidence is not compelling but cannot be ignored. D2-lymphadendctomy is nowadays considered to be the standard of care for resectable gastric cancer. © Copyright © 2018 Karavokyros and Michalinos

RESPONSE OF SACCHAROMYCES-CEREVISIAE STRAINS TO ANTINEOPLASTIC AGENTS

The effect of several antineoplastic agents on Saccharomyces cerevisiae strains has been investigated. Minimum inhibitory concentration (MIC), minimum cytotoxic concentration (MCC) and median effective concentration (EC(50)) were determined to identify strains with inherent sensitivity to the agents tested. Several strains proved to be sensitive to the antimetabolites 5-fluorouracil and methotrexate as well as to doxorubicin and cis-platine. On the contrary m-amsacrine, procarbazine, vinca alcaloids, melphalan and hydroxyurea were inactive at concentrations up to 400 mu g ml(-1). The strain ATCC 2366, the most relatively sensitive to the agents tested, was used for studying the effect of treatment duration and of drug concentration on cell survival. Methotrexate and cis-platine, which according to MIC and MCC tests seemed ineffective for this strain, reduced survival significantly after 6 h of treatment. A correlation of the shape of the survival curves with MIC and MCC values was attempted

Effect of calcium channel blockers on the action of various antitumour agents in the yeast Saccharomyces cerevisiae

The cytotoxic effects of a 22 h treatment with four antineoplastic agents in the yeast Saccharomyces cerevisiae ATCC 2366 were investigated. Two agents, doxorubicin and 5-fluorouracil (5-FU), were effective in decreasing the colony-forming ability of yeast cells. Following examination under the light microscope, the effect of doxorubicin appeared to be, at least partially, due to killing of yeast cells whereas the effect of 5-FU was rather due to changes in cell structure leading to abnormal bud formation. For amsacrine (AMSA) and melphalan, cytotoxicity was totally absent. In the presence of diltiazem the above described effects were not significantly changed. When verapamil was added in the culture medium the cytotoxic activity of doxorubicin and 5-FU did not change. However, following treatment with AMSA in combination with verapamil, cell survival was significantly decreased whereas the presence of verapamil increased the yeast survival which was observed after melphalan treatment

Neutrophils to lymphocytes ratio as a useful prognosticator for stage II colorectal cancer patients

Background: The incidence of colorectal cancer (CRC) is expected to increase by 80% in year 2035. Even though advantages in treatment of CRC have being made over the last decades, the outcome remains poor. Recently, several inflammatory markers including pretreatment neutrophil to lymphocyte ratio (NLR), have being used as prognostic factors, since host inflammatory response to cancer is believed to determine disease progression. The aim of this study is to evaluate the prognostic significance of pretreatment NLR, in terms of overall survival (OS), 5-year survival, disease-free survival (DFS) and recurrence, in CRC patients who underwent curative resection. Methods: We retrospectively reviewed 296 patients, who were submitted to elective surgery as first therapeutic option in curative intent, between January 2010 and December 2015. Pretreatment NLR, as well as demographics, clinical, histopathologic, and laboratory data were analyzed. Univariate and multivariate analyses were conducted to identify prognostic factors associated with OS, 5-year survival, DFS and recurrence. Results: The cutoff point of NLR was calculated with Kaplan-Meier curves and log-rank test to 4.7. Univariate and multivariate analyses disclosed elevated NLR as a significant dismal prognostic factor for DFS (HR 1.88; 95% CI 1.01-3.52; p = 0.048), 5-year survival (HR 2.14; 95% CI 1.12-4.10; p = 0.021) and OS (HR 2.11; 95% CI 1.11-4.03; p = 0.023). In a subgroup analysis, in patients with stage II CRC, NLR > 4.7 was a stronger poor predictor for DFS (HR 2.76; 95% CI 1.07-7.13; p = 0.036), 5-year survival (HR 3.84; 95% CI 1.39-10.63; p = 0.01) and OS (HR 3.62; 95% CI 1.33-4.82; p = 0.012). After adjusting stage for gender, age, location of the primary tumor, differentiation, as well as the presence of perineural, vascular, and lymphovascular invasion, the significance of NLR > 4.7 became more prominent for DFS (HR 2.85; 95% CI 1.21-6.73; p = 0.0176), 5-year survival (HR 4.06; 95% CI 1.66-9.93; p = 0.002) and OS (HR 4.07; 95% CI 1.69-9.91; p = 0.002) in stage II patients. Conclusion: Pretreatment NLR > 4.7 is a poor prognostic factor for DFS, 5-year survival and OS in CRC patients undergoing curative resection. The dismal prognostic effect of NRL is magnified in Stage II CRC patients. © 2018 The Author(s)

A retained foreign body in the peritoneal cavity causing intestinal obstruction by intraluminal migration

Background: Forgetting a foreign body in the abdominal cavity is an unpleasant and avoidable situation. It usually occurs when the preventive protocols are not followed precisely. In such a case clinical consequences are unpredictable and relaparotomy may become necessary. Case presentation: We present the case of a temporary intestinal obstruction six months after a transabdominal hysterectomy. Diagnostic workup revealed a laparotomy-gauze left in the abdominal cavity at the previous operation. Exploration showed that the gauze was actually located in the intestinal lumen. The inflammatory reaction elicited by the foreign body eroded the intestinal wall and allowed its intraluminal migration. The gauze moved distally due to peristalsis until it became trapped in the ileocecal valve causing obstruction. When it finally passed through the valve the obstruction was relieved. Intraoperative maneuvers advanced the foreign body further forward until it was removed transanally. Conclusion: The formal processes-counting the gauzes continually and double crossing the counting-must be kept in every laparotomy to avoid the unpleasant experience of gauze remaining in the peritoneal cavity. In such an unfortunate case traditional open surgery provides a safe solution to the patient’s problem

Medical students' perceptions on factors influencing a surgical career: The fate of general surgery in Greece

Background: A decline of medical students' interest in a general surgery career is occurring in the Western medical world. We sought data on the mentality of Greek students toward specialty selection, and we determined whether trends indicated a decline in interest for general surgery in Greece. Methods: A structured questionnaire was distributed to 3 groups of medical students: to pre-4th-year (group 1) surgical clerkship, post-4th-year (group 2) surgical clerkship, and post-6th-year internship students in surgery (group 3). The questions covered a wide spectrum of data including career choices, influential factors, and satisfaction rates on educational and training issues. Results: From a total of 500 distributed questionnaires 363 were returned. Most students (63.1%) indicated preference toward nonsurgical (medical) specialties. Surgical specialties within the 3 groups gathered 19.5% (group 1), 26.5% (group 2) and 31.2% (group 3) preference rates. Among surgical specialties, general surgery was chosen by 29.4% in group 1, 10.0% in group 2, and 17.9% in group 3. The most common criterion for specialty selection was "quality of life" (68.6%) among group 1 students and "patient contact" for group 2 and group 3 students (77.3% and 65.3%, respectively). Among the 96 students who chose surgical specialties, the most common criterion for specialty selection was "scientific challenge" (100%) in group 1 and "patient contact" in groups 2 and 3 (62.5% and 69.2%, respectively). The 3 more frequently chosen factors that influenced the "picture" of surgery positively were attending live surgery cases in the operating room (37.6%), clinical experience (29.6%), and patient care (14.4%), followed by assisting in the operating room (8.8%). Conclusion: Our survey suggests a limited interest of Greek medical students for surgical specialties and general surgery in particular. As the medical curriculum is restructured, our data underscore the need for actions by surgical educators and medical school authorities so as to enhance the interest of medical students in general surgery in Greece. © 2010 Mosby, Inc. All rights reserved

Clinical Significance of Hu-Antigen Receptor (HuR) and Cyclooxygenase-2 (COX-2) Expression in Human Malignant and Benign Thyroid Lesions

Hu-antigen R (HuR) is considered to play a crucial role in tumor formation and growth by binding to mRNAs encoding proteins such as Cyclooxygenase-2 (COX-2) and inducing their expression via mRNA stabilization and/or altered translation. The present study aimed to evaluate the clinical significance of HuR and COX-2 proteins’ expression in human benign and malignant thyroid lesions. HuR and COX-2 proteins’ expression was assessed immunohistochemically on paraffin-embedded thyroid tissues obtained from 98 patients with benign (n = 48) and malignant (n = 50) lesions and was statistically analyzed with clinicopathological parameters, follicular cells’ proliferative capacity and recurrence risk rate. Enhanced HuR and COX-2 expression was significantly more frequently observed in malignant compared to benign thyroid lesions (p = 0.0073 and p = 0.0016, respectively), as well as in papillary carcinomas compared to hyperplastic nodules (p = 0.0039 and p = 0.0009, respectively). Positive associations of both HuR and COX-2 expression with follicular cells’ proliferation rate were also noted (p = 0.0087 and p = 0.0127, respectively). In malignant thyroid lesions, elevated COX-2 expression was significantly associated with female patients’ gender (p = 0.0381) and the presence of lymph node metastases (p = 0.0296). The present data support evidence that both HuR and COX-2 may be involved in the malignant state of thyroid neoplasia and may be utilized in the diagnosis of malignant thyroid tumors. © 2015, Arányi Lajos Foundation