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

Assessing the potential use of microtraces of gastropod predation as a diagnostic for predator-prey interactions in the fossil record

Predatory gastropods have left signs of boring predation in the fossil record as early as the Cambrian (McMenamin and Schulte McMenamin, 1990; putative Proterozoic examples [e.g., Bengtson and Zhao, 1992] remain controversial). Through studying drill holes in prey, we can better understand predator-prey interactions in marine communities. It has been proposed that further study of the interior of drill holes yields microtraces left by the radular teeth during the drilling process (Schiffbauer et al., 2008; Tyler and Schiffbauer, 2012). The pattern and orientation of the traces can be used to associate predator with prey and act as a diagnostic feature to identify the predator. Trace fossils can provide great insight into past environments, but only when they are well preserved. Through assessing one hundred and eighty drill holes using scanning electron microscopy, I provide here evidence suggesting the limited presence of predatory microtraces. Interpreting shell deterioration and extrapolating the observed degradation of modern specimens to hypothetical paleoenvironments suggests that preservation of such minute traces would be poor and would thus negate the purpose of creating such a diagnostic. Additionally, the current understanding of the drilling process suggests that the preservation of microtraces within the drill hole margins is an infrequent occurrence. This may be due to the fact that before utilizing their radular teeth, predatory gastropods deploy secretions from the accessory boring organ (ABO) to break down the shell surface, lessening the preservation potential of predatory microtraces (Carriker, 1969). This study has discovered porcellaneous rims surrounding the drill holes in the Miocene Saxolucina. Further study into these rims may provide additional insight into the drilling strategy of naticid gastropods.Geolog