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

POPs in a major conurbation in Turkey: ambient air concentrations, seasonal variation, inhalation and dermal exposure, and associated carcinogenic risks

Semi-volatile organic compounds were monitored over a whole year, by collection of gas and particle phases every sixth day at a suburban site in Izmir, Turkey. Annual mean concentrations of 32 polychlorinated biphenyls (∑32PCBs) and 14 polycyclic aromatic hydrocarbons (∑14PAHs) were 348 pg/m3 and 36 ng/m3, respectively, while it was 273 pg/m3 for endosulfan, the dominant compound among 23 organochlorine pesticides (OCPs). Monte Carlo simulation was applied to the USEPA exposure-risk models for the estimation of the population exposure and carcinogenic risk probability distributions for heating and non-heating periods. The estimated population risks associated with dermal contact and inhalation routes to ∑32PCBs, ∑14PAHs, and some of the targeted OCPs (α-hexachlorocyclohexane (α-HCH), β-hexachlorocyclohexane (β-HCH), heptachlor, heptachlor epoxide, α-chlordane (α-CHL), γ-chlordane (γ-CHL), and p,p′-dichlorodiphenyltrichloroethane (p,p′-DDT)) were in the ranges of 1.86 × 10−16–7.29 × 10−9 and 1.38 × 10−10–4.07 × 10−6, respectively. The inhalation 95th percentile risks for ∑32PCBs, ∑14PAHs, and OCPs were about 6, 3, and 4–7 orders of magnitude higher than those of dermal route, respectively. The 95th percentile inhalation risk for ∑32PCBs and OCPs in the non-heating period were 1.8- and 1.2–4.6 folds higher than in the heating period, respectively. In contrast, the 95th percentile risk levels for ∑14PAHs in the heating period were 4.3 times greater than that of non-heating period for inhalation, respectively. While risk levels associated with exposure to PCBs and OCPs did not exceed the acceptable level of 1 × 10−6, it was exceeded for 47 % of the population associated with inhalation of PAHs with a maximum value of about 4 × 10−6

Chitosan-Immobilized Pumice for the Removal of As(V) from Waters

A novel sorbent, chitosan-immobilized pumice, has been prepared for the sorption of As(V) from waters prior to its determination by hydride generation atomic absorption spectrometry. The success of the immobilization has been checked with such characterization techniques as scanning electron microscopy, thermal gravimetric analysis, and elemental analysis. Points of zero charge of the sorbents were determined with potentiometric mass titration. Batch-type equilibration studies have shown that the novel sorbent can be employed at a wide pH range resulting in quantitative sorption (>90 %) at pH 3.0-7.0 and greater than 70 % sorption at pH >8.0. These results demonstrate the advantage of immobilizing chitosan onto pumice, because, under the same conditions, pumice displays <20 % sorption toward As(V), whereas chitosan gives approximately 90%sorption only at pH 3.0. The validity of the method was verified through the analysis of ultrapure, bottled drinking, and tap water samples spiked with arsenate; the respective sorption percentages of 93.2 (±0.7), 89.0 (±1.0), and 80.9 (±1.3) were obtained by batch-type equilibration. Arsenic sorption was also examined in the presence of common interfering ions resulting in competing effects of PO3- 4 and NO- 3on As(V) adsorption

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

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