Reingeniería del sistema de señalización horizontal y vertical para las parroquias urbanas del cantón Riobamba, provincia de Chimborazo

El trabajo de titulación realizado, tiene como objetivo efectuar una reingeniería al sistema de señalización horizontal y vertical de las parroquias urbanas del cantón Riobamba con la finalidad de mejorar la seguridad vial del cantón, para el desarrollo de la investigación fue necesario identificar las especificaciones técnicas para la señalética en base a la norma técnica INEN 004, para posteriormente realizar un diagnóstico al estado actual de la infraestructura vial; por lo que, se realizó una investigación directa recorriendo las diferentes vías y a su vez observando e identificando las condiciones de funcionalidad y operatividad de la señalización vial. Para la presente investigación se partió de la circulación vial de la ciudad de Riobamba, y los problemas generados por espacios en los que la señalética no corresponde a la normal circulación o la entorpece, se recopilaron los casos y se plantea una solución global atacando cada situación de forma particular. Concluida la investigación se determina que un 76% de las vías analizadas no cuentan con la señalización respectiva y que el 9% de las señales que actualmente están ubicadas requieren ser reemplazadas. Se recomienda al Gobierno Autónomo Descentralizado del cantón Riobamba realizar la implementación de la señalética establecida en el presente trabajo de titulación con el fin de mejorar la movilidad y seguridad vial en el cantón.The purpose of the research work is to reengineer the horizontal and vertical signaling system of the urban “parroquias”, located in the Riobamba County with the aim of improving its road safety. For the development of the research, it was necessary to identify the technical specifications for the signage based on the technical standard INEN 004 to subsequently make a diagnosis of the current state of the road infrastructure, and then it carried out a direct investigation through different routes in order to observe and identify the conditions of functionality and operability of road signs. For the current investigation, it started from the circulation road of the Riobamba city, and the problems generated by spaces in which the signage does not correspond to the normal circulation or interrupts it. At the same time, the cases were collected, and a global solution is proposed to face each situation in a particular way. After finishing the investigation, it was determined that 76% of the analyzed routes do not have the respective signaling, and the 9% of the signals that are currently located need to be replaced. Finally, it recommend to “Gobierno Autónomo Descentralizado del canton Riobamba” to carry out the implementation of the signage established in the current work in order to improve the mobility and road safety of the county

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

© 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

© 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