Multicentric survey of patient doses in fluoroscopy guided diagnostic and interventional cardiac procedures: comparison with Diagnostic Reference Levels and follow-up levels for patients at risk for radiation induced skin effects

Въведение. Интервенционалните кардиологични процедури, често са свързани с голямо облъчване на пациентите, поради което изискват специално внимание по отношение на защитата от появата на радиационно индуцирани ефекти при пациента.Материали и методи. Проучването на типичните стойности на дозата е проведено ретроспективно, в девет лечебни заведения, с общо четиринадесет ангиографски уредби. За две от най-често извършваните процедури - перкутанна коронарна интервенция (PCI) и коронарна артериография (CA) са изчислени типичните стойности на величините произведение керма-площ (КАП), кумулативна доза (КД) и време на скопия (ВС) и са сравнени с актуалните Национални диагностични референтни нива (НДРН) за България. Извършен е анализ на данните по отношение на риска от възникване на кожно индуцирани ефекти, вследствие на интервенционалните кардиологични процедури.Цел. 1) да се представят и анализират типичните стойности на величината КАП за най-често провежданите кардиологични процедури - перкутанна коронарна интервенция и коронарна артериография в кардиологични отделения с голяма работна натовареност и да се сравнят с НДРН; 2) да се сравнят дозите на пациентите с публикуваните в Наредба 2 нива за проследяване, за установяване на пациенти с риск за възникване на радиационно индуцирани ефекти.Резултати. Резултатите показват, че типични стойности на изследваните величини за PCI и CA при някои от уредбите, са по-високи от НДРН. Във всяко от разглежданите лечебни заведения има пациенти с поне едно превишено ниво за проследяване за процедура PCI.Изводи. Резултатите показват потенциал за оптимизиране, както на работата в отделенията с високи типични стойности на дозата, така и при уредбите с много ниски типични стойности на изследваните величини. При проследените пациенти не се наблюдават оплаквания и поява на радиационно индуциран ефект. Изготвянето и въвеждането в рутинната клинична практика на процедури за рутинно прилагане на „Инструкцията за пациента след проведена интервенционална/и процедура/и с по-голяма степен на сложност и дълго време на скопия“ ще позволи навременна диагностика и навременно лечение на кожните ефекти в следствие на проведените кардиологични процедури под рентгенов контрол. Introduction. Interventional cardiac procedures are often associated with high patient exposure and therefore require special care in protecting patients from radiation-induced effects.Materials and methods. A retrospective study of typical patients’doses was performed in nine hospitals, with a total number of fourteen angiography systems. The typical values for kerma-area product (KAP), cumulative dose (CD) and fluoroscopy time (FT) for two of the most commonly performed procedures - percutaneous coronary intervention (PCI) and coronary arteriography (CA), were calculated and compared with the Bulgarian National Diagnostic Reference Levels (NDRL). Data analysis, regarding the risk of radiation-induced skin effects due to interventional cardiac procedures, was performed.Aim. 1) to present and analyze the typical KAP values for PCI and CA procedures in cardiology departments with high workload and to compare them with the NDRL; 2) to compare the patient doses with the follow-up levels published in Ordinance 2, to identify patients at risk for radiation-induced effects.Results. The results show that typical values for PCI and CA procedures for some of the angiography systems are higher than the NDRL. In all investigated departments there are patients with at least one exceeded follow-up level for PCI.Conclusions. The results show a potential for optimization in the departments with both high or very low typical dose or FT values. No radiation-induced effect was observed in the followed-up group of patients. The introduction of procedure with "Instruction to the patient after an interventional cardiac procedure(s) with greater complexity and a long fluoroscopy time" for patient follow-up and its regular implementation into the routine clinical practice will help for timely diagnosis and treatment of radiation-induced skin effects after cardiac procedures under fluoroscopy control

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