7 research outputs found

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

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    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

    Sistemas de uso de água não potável no Distrito Federal : diretrizes voltadas para um modelo específico de captação de recursos por meio de financiamento público

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    Diante da crise de abastecimento de água, entre os anos de 2016 e 2018 e do elevado consumo de água em Brasília, apresentou-se uma oportunidade mercadológica para a introdução dos sistemas de água não potáveis como um instrumento tecnológico de gestão ambiental urbana que estimula a sustentabilidade, a qualidade e a eficiência no uso da água no ambiente urbano construído. Assim, esta pesquisa tem como objetivo geral propor um modelo específico de captação de recursos com menor custo voltado ao fomento por meio de financiamento público para instalação de sistemas prediais de água não potável em edificações residenciais e comerciais do Distrito Federal. Para tanto, foi realizada uma revisão sistemática da literatura considerando: i) a adaptação predial, custos e benefícios envolvidos, o potencial de redução do consumo de água potável e benefícios econômicos, ambientais e sociais gerados; e ii) o levantamento dos atos normativos legais e infralegais relevantes para implementação de sistemas de água não potável, federais e distritais. Foram verificadas as variáveis obtidas por meio da revisão da literatura que estejam diretamente ligadas às tomadas de decisões de investimentos por parte do público alvo no que concerne à implementação de sistema de uso de água não potável, através de uma Matriz de SWOT. Observou-se que os investimentos em Sistemas de Aproveitamento de Águas Pluviais (SAAP) em residências unifamiliares possuem um payback, que variam, entre 2 até 14,9 anos para residências de renda alta, de 2,8 até 9,4 anos para renda média-alta, de 15,4 até 23,4 anos para renda média-baixa e para renda baixa 16 anos até 24,7 anos para o retorno do investimento. O tempo de vida útil do sistema é de 30 anos. No caso dos Sistemas de Reúso de Águas Cinzas (SRAC), a viabilidade econômica financeira para o uso desse sistema alcança uma melhor eficiência para residenciais multifamiliares de renda média-alta, e comerciais a economia de água chega a 65m³/residência/ano, equivalente a 9.858,69 R/reside^nciaaolongodoano,combenefıˊciosecono^micosde5,04R/residência ao longo do ano, com benefícios econômicos de 5,04 R/m³ de água economizada. O conjunto de indicadores econômicos, tais como o VPL positivo, a taxa de retorno inferior ao custo do investimento e a vida útil dos equipamentos superiores à taxa de retorno, tanto no SAAP como no SRAC, aponta para ganhos econômicos e financeiros aos usuários residenciais e comerciais em relação à substituição do uso da água potável. A Matriz Estratégica da SWOT apontou resultados satisfatórios relacionados aos ganhos, ambientais, econômicos e sociais na implantação de políticas públicas voltadas à implementação de sistema de uso de água não potável em residências e comércio. Concluiu-se que se faz necessário o desenvolvimento de políticas públicas direcionadas para o financiamento público de 100% do projeto, com taxa de juros acessíveis, prazos não inferiores ao tempo de vida útil dos sistemas para alavancar implementação dos SAAP E SRAC. Assim, apresentamos 3 modelos específicos de captação de recursos com menor custo voltado ao fomento por meio de financiamento público para instalação de sistemas prediais de água não potável em edificações residenciais e comerciais do Distrito Federal.Faced with the water supply crisis, between 2016 and 2018 and the high water consumption in Brasilia, a market opportunity was presented for the introduction of non-potable water systems as a technological instrument of urban environmental management that stimulates sustainability, quality and efficiency in the use of water in the built urban environment. Thus, this research had as general objective to propose a specific model of fundraising with lower cost aimed at the promotion through public funding for the installation of building systems of non-drinking water in residential and commercial buildings of the Federal District. For this, a systematic review of the literature was carried out considering: i) the building adaptation, costs and benefits involved, the potential to reduce the consumption of drinking water and economic, environmental and social benefits generated; and ii) the survey of legal and infralegal normative acts relevant to the implementation of non-potable, federal and district water systems. The variables obtained through the literature review were verified that are directly linked to investment decision-making by the target audience regarding the implementation of a non-potable water use system, through a SWOT Matrix. It was observed that investments in Rainwater Use Systems (SAAP) in single-family homes have a payback, ranging from 2 to 14.9 years for high-income households, from 2.8 to 9.4 years for high-middle income, from 15.4 to 23.4 years for low-middle income and for low income 16 years to 24.7 years for return on investment. The life of the system is 30 years. In the case of Ash Water Reuse Systems (SRAC), the financial economic viability for the use of this system achieves better efficiency for multi-family residential with medium-high income, and commercial water savings reach 65m³/residence/year, equivalent to R9,858.69/residencethroughouttheyear,witheconomicbenefitsof5.04R9,858.69/residence throughout the year, with economic benefits of 5.04 R/m³ of water saved. The set of economic indicators, such as positive LPV, the rate of return lower than the cost of investment and the useful life of equipment higher than the rate of return, both in SAAP and SRAC, points to economic and financial gains for residential and commercial users in relation to the substitution of the use of drinking water. The Strategic Matrix of SWOT pointed out satisfactory results related to gains, environmental, economic and social in the implementation of public policies aimed at the implementation of a system for the use of non-drinking water in homes and commerce. It was concluded that it is necessary to develop public policies directed to the public financing of 100% of the project, with an affordable interest rate, deadlines not lower than the lifetime of the systems to leverage the implementation of SAAP and SRAC. Thus, we present 3 specifics model of fundraising with lower cost focused on the promotion through public funding for the installation of non-drinking water building systems in residential and commercial buildings of the Federal District.Faculdade de Arquitetura e Urbanismo (FAU)Programa de Pós-Graduação em Arquitetura e Urbanism

    PD-L1 Expression Associated with Epstein—Barr Virus Status and Patients’ Survival in a Large Cohort of Gastric Cancer Patients in Northern Brazil

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    Gastric cancer (GC) is a worldwide health problem, making it one of the most common types of cancer, in fifth place of all tumor types, and the third highest cause of cancer deaths in the world. There is a subgroup of GC that consists of tumors infected with the Epstein–Barr virus (EBV) and is characterized mainly by the overexpression of programmed cell death protein-ligand-1 (PD-L1). In the present study, we present histopathological and survival data of a thousand GC patients, associated with EBV status and PD-L1 expression. Of the thousand tumors analyzed, 190 were EBV-positive and the vast majority (86.8%) had a high relative expression of mRNA and PD-L1 protein (p < 0.0001) in relation to non-neoplastic control. On the other hand, in EBV-negative samples, the majority had a low PD-L1 expression of RNA and protein (p < 0.0001). In the Kaplan–Meier analysis, the probability of survival and increased overall survival of EBV-positive GC patients was impacted by the PD-L1 overexpression (p < 0.0001 and p = 0.004, respectively). However, the PD-L1 low expression was correlated with low overall survival in those patients. Patients with GC positive for EBV, presenting PD-L1 overexpression can benefit from immunotherapy treatments and performing the quantification of PD-L1 in gastric neoplasms should be adopted as routine

    Código Florestal, função socioambiental da terra e soberania alimentar

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    O presente artigo tem como objetivo discutir alterações do Código Florestal, especialmente aspropostas de mudanças nas noções de Reserva Legal e Área de Preservação Permanente (APP), em processo de rediscussão no Congresso, após sanção presidencial com vetos no texto aprovado na Câmara em 25 de abril de 2012. Para suprir lacunas da nova Lei, o Executivo Federal editou a Medida Provisória (MP) 571/2012, que retoma a discussão da matéria. Tanto dispositivos da nova Lei como alterações propostas ao texto da MP geram insegurança alimentar e visam a eliminar a função socioambiental da terra. A motivação das mudanças não está relacionada à sustentabilidade ambiental ou às mudanças climáticas, temas fundamentais na agenda mundial, mas parte do princípio de que a natureza é um empecilho ao desenvolvimento. Este artigo resgata as principais alterações no Código Florestal relacionadas à Reserva Legal e às APPs, estabelecendo relações (impactos negativos) com a função socioambiental da terra e a soberania alimentar

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

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    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

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

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    © 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

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    © 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
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