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

Association entre l'utilisation de la chamma et les lésions de type leucoplasie buccale chez les hommes adultes de la vallée de Dawan, au Yémen

International audienceHintergrund: Shammah ist eine traditionelle Form des Schnupftabak-Eintauchtabaks (eine rauchfreie Tabakform), die im Jemen häufig verwendet wird. Orale Schleimhautveränderungen aufgrund der Verwendung von Shammah können normalerweise in den Schleimhautoberflächen beobachtet werden, die das Produkt berührt. Das Ziel dieser Studie war es, den Zusammenhang zwischen Shammah-Konsum und oralen Leukoplakie-ähnlichen Läsionen zu bestimmen. Andere damit verbundene Faktoren wurden ebenfalls bestimmt. Material und Methoden: Eine Querschnittsstudie wurde an 346 zufällig ausgewählten erwachsenen Männern durchgeführt. Zur Auswahl des Untersuchungsortes wurde eine mehrstufige Zufallsstichprobe verwendet. Nach Ausfüllen der strukturierten Fragebogeninterviews wurden alle Teilnehmer einer klinischen Untersuchung zum Screening oraler Leukoplakie-ähnlicher Läsionen unterzogen. Die klinischen Merkmale einer oralen Leukoplakie-ähnlichen Läsion wurden anhand der Noten von Axéll et al. (1976) charakterisiert. Univariable logistische Regression und multivariable logistische Regression wurden verwendet, um die potenziellen damit verbundenen Faktoren zu bewerten. Ergebnisse: Von 346 männlichen Teilnehmern ab 18 Jahren gaben 68 (19,7%) an, derzeit Shammah-Benutzer zu sein. Die multivariable Analyse ergab, dass Alter, nicht formales oder primäres Bildungsniveau, ehemaliger Shammah-Benutzer, aktueller Shammah-Benutzer und Häufigkeit des Shammah-Konsums pro Tag statistisch mit dem Vorhandensein oraler Leukoplakie-ähnlicher Läsionen assoziiert waren [Adjusted Odds Ratio (AOR) = 1,03; 95% -Konfidenzintervall (CI): 1.Background: Shammah is a traditional form of snuff dipping tobacco (a smokeless tobacco form) that is commonly used in Yemen. Oral mucosal changes due to the use of shammah can usually be observed in the mucosal surfaces that the product touches. The aim of this study was to determine the association between shammah use and oral leukoplakia-like lesions. Other associated factors were also determined. Materials and Methods: A cross sectional study was conducted on 346 randomly selected adult males. Multi-stage random sampling was used to select the study location. After completing the structured questionnaire interviews, all the participants underwent clinical exanimation for screening of oral leukoplakia-like lesions Clinical features of oral leukoplakia-like lesion were characterized based on the grades of Axéll et al (1976). Univariable logistic regression and multivariable logistic regression were used to assess the potential associated factors. Results: Out of 346 male participants aged 18 years and older, 68 (19.7%) reported being current shammah users. The multivariable analysis revealed that age, non-formal or primary level of education, former shammah user, current shammah user, and frequency of shammah use per day were statistically associated with the presence of oral leukoplakia-like lesions [Adjusted odds ratio (AOR) = 1.03; 95% confidence interval (CI) : 1.Contexte: La shammah est une forme traditionnelle de tabac à priser (une forme de tabac sans fumée) qui est couramment utilisée au Yémen. Des modifications de la muqueuse buccale dues à l'utilisation de la shammah peuvent généralement être observées dans les surfaces muqueuses que le produit touche. Le but de cette étude était de déterminer l'association entre l'utilisation de la shammah et les lésions de type leucoplasie buccale. D'autres facteurs associés ont également été déterminés. Matériel et méthodes: Une étude transversale a été menée sur 346 mâles adultes sélectionnés au hasard. Un échantillonnage aléatoire à plusieurs degrés a été utilisé pour sélectionner l'emplacement de l'étude. Après avoir terminé les entretiens par questionnaire structuré, tous les participants ont subi une exanimation clinique pour le dépistage des lésions de type leucoplasie buccale Les caractéristiques cliniques des lésions de type leucoplasie buccale ont été caractérisées sur la base des grades d'Axéll et al (1976). Une régression logistique univariée et une régression logistique multivariée ont été utilisées pour évaluer les facteurs potentiels associés. Résultats: Sur 346 participants masculins âgés de 18 ans et plus, 68 (19,7%) ont déclaré être des utilisateurs actuels de la shammah. L'analyse multivariée a révélé que l'âge, le niveau d'éducation non formel ou primaire, l'ancien utilisateur de la shammah, l'utilisateur actuel de la shammah et la fréquence d'utilisation de la shammah par jour étaient statistiquement associés à la présence de lésions de type leucoplasie buccale [rapport de cotes ajusté (AOR) = 1,03; Intervalle de confiance (IC) à 95%: 1

Prevalence and association of smokeless tobacco use with the development of periodontal pocket among adult males in Dawan Valley, Yemen: a cross-sectional study

Background The traditional type of smokeless tobacco used in the Arabian Peninsula, particularly common in Yemen, is called shammah. This study aims to determine the prevalence of shammah use and its association with the development of periodontal pockets. Other associated factors with the development of periodontal pocket were also determined. Methods This cross-sectional study included 346 adult males aged 18 years old to 68 years old. Socio-demographic characteristics, oral hygiene practices, and shammah use history were surveyed by using a structured interview questionnaire. The clinical assessment for the presence or absence of periodontal pockets was assessed on the basis of community periodontal index. The chi-square test was used to assess significant differences in study groups in terms of the presence of periodontal pockets. Multivariable logistic regression was selected to assess potential associated factors with the development of periodontal pockets. Results Among the 346 adult males, 248 (71.7 %), 30 (8.6 %), and 68 (19.7 %) males never used shammah, were former shammah users, and were current shammah users, respectively. The significant associated factors with the development of periodontal pocket were age group (30 years old and above) (Adjusted Odds Ratio (AOR) = 2.03, 95 % CI: 1.13, 3.65; P = 0.018), low family income category (AOR = 2.35, 95 % CI: 1.39, 3.99; P = 0.001), former shammah user (AOR = 2.66, 95 %: CI: 1.15, 6.15; P = 0.022), and current shammah user (AOR = 6.62, 95 %: CI: 3.59, 12.21; P = 0.001). Conclusions The results revealed that periodontal pockets were significantly associated with age group (30 years old and above), low family income category, former shammah use, and current shammah use. The findings of the current study highlighted the need to develop comprehensive shammah prevention programs and reduce periodontal disease and other shammah-associated diseases

Prévalence et association de l'usage du tabac sans fumée avec le développement de la poche parodontale chez les hommes adultes dans la vallée de Dawan, Yémen: une étude transversale

International audienceBackground: The traditional type of smokeless tobacco used in the Arabian Peninsula, particularly common in Yemen, is called shammah. This study aims to determine the prevalence of shammah use and its association with the development of periodontal pockets. Other associated factors with the development of periodontal pocket were also determined. Methods: This cross-sectional study included 346 adult males aged 18 years old to 68 years old. Sociodemographic characteristics, oral hygiene practices, and shammah use history were surveyed by using a structured interview questionnaire. The clinical assessment for the presence or absence of periodontal pockets was assessed on the basis of community periodontal index. The chi-square test was used to assess significant differences in study groups in terms of the presence of periodontal pockets. Multivariable logistic regression was selected to assess potential associated factors with the development of periodontal pockets. Results: Among the 346 adult males, 248 (71.7 %), 30 (8.6 %), and 68 (19.7 %) males never used shammah, were former shammah users, and were current shammah users, respectively. The significant associated factors with the development of periodontal pocket were age group (30 years old and above) (Adjusted Odds Ratio (AOR) = 2.03,Contexte: Le type traditionnel de tabac sans fumée utilisé dans la péninsule arabique, particulièrement courant au Yémen, est appelé shammah. Cette étude vise à déterminer la prévalence de l'utilisation de la shammah et son association avec le développement de poches parodontales. D'autres facteurs associés au développement de la poche parodontale ont également été déterminés. Méthodes: Cette étude transversale a inclus 346 hommes adultes âgés de 18 à 68 ans. Les caractéristiques sociodémographiques, les pratiques d'hygiène bucco-dentaire et les antécédents d'utilisation de la shammah ont été étudiés à l'aide d'un questionnaire d'entretien structuré. L'évaluation clinique de la présence ou de l'absence de poches parodontales a été évaluée sur la base de l'indice parodontal communautaire. Le test du chi carré a été utilisé pour évaluer les différences significatives dans les groupes d'étude en termes de présence de poches parodontales. Une régression logistique multivariée a été choisie pour évaluer les facteurs potentiels associés au développement de poches parodontales. Résultats: Parmi les 346 hommes adultes, 248 (71,7%), 30 (8,6%) et 68 (19,7%) hommes n'ont jamais utilisé la shammah, étaient d'anciens utilisateurs de la shammah et étaient des utilisateurs actuels de la shammah, respectivement. Les facteurs associés significatifs au développement de la poche parodontale étaient le groupe d'âge (30 ans et plus) (Odds Ratio ajusté (AOR) = 2,03

Oral melanosis and severe periodontitis in toombak case report

International audienceBackground: Toombak is a traditional type of smokeless tobacco used by people in Yemen, especially in Dawan Valley, Hadramout Province, Yemen. The use of smokeless tobacco may be considered as a predisposing risk factor for several oral diseases. Case Presentation: This paper presents two cases. The first is that of a 27-year-old male toombak user with severe periodontitis and oral melanosis. The second case is that of a 44year-old male toombak user with oral hypermelanosis. The patients were subjected to dental cleaning. Quit toombak counseling was conducted, and the patients were educated about the adverse effects of toombak usage. Conclusion: Oral tissues are severely affected by toombak usage. Thus, comprehensive toombak prevention programs should be implemented to reduce toombak-associated diseases

Three-dimensional phenotype characteristics of skeletal class III malocclusion in adult Chinese: a principal component analysis–based cluster analysis

Background: Skeletal class III malocclusion has a diverse and complicated aetiology involving environmental and genetic factors. It is critical to correctly classify and define this malocclusion to be diagnosed and treated on a clinically sound basis. Thus, this study aimed to provide reliable and detailed measurements in a large ethnically homogeneous sample of Chinese adults to generate an adequate phenotypic clustering model to identify and describe the skeletal variation present in skeletal class III malocclusion. Materials and methods: This is a retrospective cross-sectional study in which 500 pre-treatments cone-beam computed tomography (CBCT) scans of patients with skeletal class III malocclusion (250 males and 250 females) were selected following specific selection criteria. Seventy-six linear, angular, and ratios measurements were three-dimensionally analysed using InVivo 6.0.3 software. These measurements were categorised into 47 skeletal, 18 dentoalveolar, and 11 soft tissue variables. Multivariate reduction methods: principal component analyses and cluster analyses were used to present the most common phenotypic groupings of skeletal class III malocclusion in Han ethnic group of Chinese adults. Results: The principal component analysis revealed eight principal components accounted for 72.9% of the overall variation of the data produced from the seventy-six variables. The first four principal components accounted for 53.37% of the total variations. They explained the most variation in data and consisted mainly of anteroposterior and vertical skeletal relationships. The cluster analysis identified four phenotypes of skeletal class III malocclusion: C1, 34%; C2, 11.4%; C3, 26.4%; and C4, 28.2%. Conclusion: Based on three-dimensional analyses, four skeletal class III malocclusion distinct phenotypic variations were defined in a large sample of the adult Chinese population, showing the occurrence of phenotypic variation between identified clusters in the same ethnic group. These findings might serve as a foundation for accurate diagnosis and treatment planning of each cluster and future genetic studies to determine the causative gene(s) of each cluster.This work was supported by the project of the National Natural Science Foundation of Gansu Province, China (No. 20JR5RA264)

Introducing the Comprehensive Unit-based Safety Program for mechanically ventilated patients in Saudi Arabian Intensive Care Units

Over the past decade, there have been major improvements to the care of mechanically ventilated patients (MVPs). Earlier initiatives used the concept of ventilator care bundles (sets of interventions), with a primary focus on reducing ventilator-associated pneumonia. However, recent evidence has led to a more comprehensive approach: The ABCDE bundle (Awakening and Breathing trial Coordination, Delirium management and Early mobilization). The approach of the Comprehensive Unit-based Safety Program (CUSP) was developed by patient safety researchers at the Johns Hopkins Hospital and is supported by the Agency for Healthcare Research and Quality to improve local safety cultures and to learn from defects by utilizing a validated structured framework. In August 2015, 17 Intensive Care Units (ICUs) (a total of 271 beds) in eight hospitals in the Kingdom of Saudi Arabia joined the CUSP for MVPs (CUSP 4 MVP) that was conducted in 235 ICUs in 169 US hospitals and led by the Johns Hopkins Armstrong Institute for Patient Safety and Quality. The CUSP 4 MVP project will set the stage for cooperation between multiple hospitals and thus strives to create a countrywide plan for the management of all MVPs in Saudi Arabia

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

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