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

New insights on Alzheimer's disease

AbstractAlzheimer's disease (AD), the most common age-associated dementing disorder, is clincopathologically manifested by progressive cognitive dysfunction concomitant with the accumulation of senile plaques (SP). SP is consisting of amyloid-β (Aβ) peptides and neurofibrillary tangles (NFTs) of hyper-phosphorylated tau (p-tau) protein aggregates in the brain of affected individuals. Lipid rafts promote interaction of the amyloid precursor protein (APP) with the β-secretase enzyme responsible for generation of the Aβ peptides. Fibrillar Aβ oligomers, which have been shown to correlate with the onset and severity of AD, bind preferentially to cells and neurons expressing cellular prion protein (PrPC). The binding of Aβ oligomers to cell surface PrPC, as well as their downstream activation of Fyn kinase, was dependent on the integrity of cholesterol-rich lipid rafts. Rafts also regulate cholinergic signaling as well as acetylcholinesterase and Aβ interaction. Such major lipid raft components as cholesterol and ganglioside (GM1) have been directly implicated in pathogenesis of the disease. Perturbation of lipid raft integrity can also affect various signaling pathways leading to cellular death and AD.In this review, I will discuss the more recent findings on the biopathological mechanisms, candidate bio-markers, and therapeutic interventions of the elusive AD

Hepatobiliary scintigraphy in the distinction between biliary hypoplasia and biliary atresia

The aim of this work is to see whether distinction between biliary atresia and biliary hypoplasia is possible or not and to present the value and usefulness of hepatobiliary scintigraphy in the investigation of infants with persistent hyperbilirubinemia. Seventy-seven patients of the age between five days and six months (average 62 days), 43 females and 34 males of which 65 Saudi, and 12 non-Saudis were investigated. Laboratory tests, abdominal ultrasound, hepatobiliary scintigraphy, liver biopsy, explorative laparatomy and intraoperative cholangiography were performed whenever indicated. The findings on hepatobiliary scintigraphy of nonvisualization of the gallbladder and no activity in the bowel upto 24 hours post injection were considered consistent with the diagnosis of biliary atresia. Minimal bowel activity, or visualization of the gallbladder where consistent with biliary hypoplasia. In addition, the liver in the two entities appeared in a different shape and can be used as an additional distinctive feature. Thirty-four infants were diagnosed by hepatobiliary scintigraphy as having biliary atresia. Only 3 of the 34 were false positives as compared to cholangiogram and liver biopsy results. Five cases were biliary hypoplasia. Hepatobiliary scintigraphy in infants with persistent hyperbilirubinemia can be distinguished between BA and BH in a simple and noninvasive approach

TC-99m-labeled red blood cell scintigraphy in the investigation of patients with hepatic cavernous hemangioma

Objective: To evaluate the diagnostic accuracy of 99m Tc-red blood cell scintigraphy in the diagnosis of hepatic cavernous hemangiomas. Patients and Methods: Sixty three patients, 56 females (89%) and 7 males (1 I%), with ages between 22 and 54 years (median 33 years) were investigated for liver masses found on ultrasonography of the abdomen. All the patients had undergone 99m Tc-liver-spleen scan followed by 99m Tc-red blood cells scintigraphy. The size of the lesions ranged between 3 and 9 cm. The final diagnosis was reached through cytology, and/or histopathology or follow up for more than 3 years. Results: A total of 70 lesions were found as a single lesion in 60 patients and multiple (i.e. total of 10 lesions) in the other 3 patients. The results of 99m Tc-red blood cells scintigraphy, compared to the results of the final diagnosis, showed sensitivity and specificity rates of 100% and 89% respectively, positive and negative predictive values of 98% and 100% repectively, and accuracy rate of 98.6%. A single false positive case was a hepatocellular carcinoma. Conclusion: 99m Tc- red blood cell scintigraphy is highly accurate in the diagnosis of liver cavernous hemangioma and should characterize liver mass found on ultrasonography and suspected for hemangioma

Radionuclide esophageal transit time for the assessment of pneumatic dilation in patients with achalasia

Objective: The aim of this study was to assess the value of radionuclide esophageal transit time (RET) in prediction of the results of pneumatic dilation in patients with achalasia. Patients and methods: Thirty patients (13 males) with a mean age of 37 ± 15.6 years (range 17-73 years) were included in the study. All patients were diagnosed to have idiopathic achalasia of the cardia and selected for pneumatic dilation. Each patient had three RET, two the same day of dilation (pre-and postdilation) and a third follow up one within three months of dilation (4 patients failed to come for follow up and were excluded). Results: Several parameters were derived from RET studies, T/50: time required for 50% of activity in the esophagus to be cleared, T/10 : time required for 90% of activity in the esophagus to be cleared and percentage clearance at 10 min. These parameters were compared to response of dysphagia to dilation. It was evident that the higher the esophageal clearance postdilation, the better the outcome. When immediate post dilation clearance was 85% or more the success rate was 83.3% whereas when it was 20-50% the success rate was only 21.4%. No relation was found between T/50, T/10 and dysphagia response. Conclusion: RET appears to be a useful quantitative procedure in the assessment of pneumatic dilation outcome in achalasia patients

‏ فيتامين (أ) والتجدد الطرفي في أطوار العلجوم المصري ، بوفو رجيولارس ريوس - دراسة نسيجية

The histogenesis of regenerated limbs, of both control and treated /larvae/ with 30 I.U./ml of retinol palmitate for 3 days, was studied in two larval stages (viz. stages 53 & 54) of the anuran amphibian, Bufo regularis Reuss. Some histological changes took place in the amputated limbs of treated larvae in two phases: (a) during treatment and (b) after cessation of treatment and thereafter. In (a): the wound epidermal superficial layer became corrugated, basement membrane was not discernible, local haemorrhage was extensive and blastema call accumulation was inhibited. In (b): the epidermal surface maintained its irregularity for some days and contained numerous large vocuolated cells. Also, cells from the dedifferentiated stump tissues underwent active proliferation leading to the establishment of a large blastema, particularly in the case of the earlier stage. Cellular condensations in these blastemas were mostly unevenly distributed; they appeared more closely packed together posteriorly than anteriorly along the antero-posterior axis. Histological observations concerning blastema cells and theair active proliferation after cessation of treatment, were confirmed quantitatively through the blastema volume in both stages.اختص هذا البحث بدراسة تأثير فيتامين "أ" على تجدد الطرف الخلفي لطورين يرقيين للعلجوم المصري (برمائيات لا ذيلية) وذلك بعمل فحوص نسيجية لكل من يرقات مجموعة ضابطة ويرقات مجموعة معالجة بفيتامين "أ" (تركيز ٣٠ ‏وحدة دولية/ملليلتر) لمدة ثلاثة أيام بعد البتر عند منتصف الساق . ‏وقد لوحظ حدوث بعض التغيرات النسيجية في أطراف المجموعة المعالجة بالفيتامين مقارنة بأطراف المجموعة الضابطة ، وذلك على مرحلتين : (1) أثناء المعالجة بالفيتامين ، (2) بعد توقف المعالجة . وفي المرحلة الأولى لوحظ ما يلي : ظهور تعرج واضح في بشرة الجلد التي تغطي الجزء المبتور من الطرف ، عدم تميز الغشاء ‏القاعدي أسفل البشرة ، حدوث نزيف دموي داخلي عند مستوى البتر ، وعدم تكون خلايا البلاستيما . في المرحلة الثانية استمر وجود التعرجات في بشرة الجرح لعدة أيام بعد توقف المعالجة بالفيتامين . كما ظهرت بعض خلايا البشرة منتفخة نتيجة وجود فجوات واضحة بها ، كذلك تكونت بلاستيما كبيرة الحجم نتيجة حدوث تكاثر خلوي نشط خصوصا في الأطراف المنتمية إلى الطور المبكر . وقد لوحظ أن خلايا البلاستيما المتكونة كانت في أغلب الأحوال أكثر تراكما في المنطقة الخلفية للطرف عنها في المنطقة الأمامية . ‏وتم أيضا قياس ~ البلاستيما لكل من المجموعة الضابطة والمجموعة المعالجة بالفيتامين في كل من الطورين اليرقيين ، وعمل مقارنة بينهما لتأكيد النتائج التي تم الحصول عليها بهذا الخصوص . تدعم نتائج هذا البحث الدراسة المورفولوجية عن التجدد الطرفي والمعالجة بذات التركيز من الفيتامين (ميخائيل وآخرون ، 1994) والتي أوضحت تأخر البدد في التجدد وظهور تضاعف طرفي في بعض الحالات خصوصا في الطور المبكر

Hepatobiliary scintigraphy in the diagnosis of choledochal cysts in children

The objective is to present the usefulness of hepatobiliary scintigraphy in the investigation of children with suspected choledochal cysts through our experience in King Khalid University Hospital at King Saud University, Riyadh. Seven patients aged between I and 10 years (average 4.8 yrs) comprising six females and one male were investigated. Laboratory tests, abdominal Ultrasound and/or CT, and cholangiography were performed whenever indicated. Persistent activity in a dilated common bile duct, with or without dilatation of intrahepatic bile ducts, was considered a positive indicator for choledochal cyst disease. Four children with cystic dilatation (type I) were diagnosed by hepatobiliary scintigraphy, one saccular (type II), and two cases of Caroli′s disease (type V). The diagnosis of choledochal cyst was proven by surgery with histological confirmation. Visualization of the gallbladder occurred in one case only. The common bile duct was seen in four cases. Late activity in the bowel was noted in two cases

Treatment of Graves' hyperthyroidism: prognostic factors for outcome

Objectives: To determine whether clinical and biochemical features of Graves' disease at presentation predict response to medical and radioiodine treatment.\ud \ud Methods: We carried out a retrospective 10-year study of 194 consecutive Saudi subjects with Graves’ disease who were treated with antithyroid drugs, radioiodine therapy, or both, between January 1995 and December 2004 at King Khalid University Hospital, Riyadh, Saudi Arabia.\ud \ud Results: At diagnosis, the mean age was 32 +/- 0.9 years. Only 26% of patients had successful outcome after a course of antithyroid medication. None of the clinical or biochemical factors were associated with a favorable outcome of antithyroid treatment. One dose of radioiodine [13-15 mCi (481-555 MBq)] cured hyperthyroidism in 83% of patients. Presence of ophthalmopathy at presentation was shown to be a significant contributing factor to failure to respond to a single dose of radioiodine (odds ratio, 6.4; 95% CI, 1.51-24.4; p<0.01). Failure of radioiodine treatment was also associated with higher serum free T3 concentration at presentation (p=0.003).\ud \ud Conclusions: In patients with Graves’ hyperthyroidism, radioiodine treatment is associated with higher success rate than antithyroid drugs. A dose of 13-15 mCi (481-555 MBq) seems to be practical and effective, and should be considered as first line therapy. Patients with high free T3 concentration and, those with ophthalmopathy at presentation were more likely to fail radioiodine treatment. A higher dose of radioiodine may be advisable in such patients

Graves' disease in Saudi Arabia: a ten-year hospital study

Objective: To determine clinical manifestation and mode of treatment of Graves' disease at King Khalid University Hospital Riyadh, Saudi Arabia.\ud \ud Methods: A retrospective study of all cases of Graves' disease diagnosed at the hospital in the period between January 1995 and December 2004, who received a minimum of two years treatment were included in the study.\ud \ud Results: A total of 194 patients were seen with female: male ratio of 2.9: 1 and mean age of 32 ± 0.9 years. Sixty nine percent of the patients had positive thyroid antibodies. Palpitations, tremors, weight loss and nervousness were the most common presenting manifestations. Forty nine percent of patients were treated with radioiodine, 38% with antithyroid drugs, and 13% underwent subtotal thyroidectomy.\ud \ud Conclusion: Clinical manifestations of Graves' disease in our patients distinctly differed from those reported in the West and Pacific Islanders with notable rarity of pretibial myxoedema and hyperpigmentation respectively. We also noted higher male to female ratio and an increasing utility of radioactive iodine therapy while use of antithyroid drugs and surgery are declining