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

Prehospital Ultrasound in Trauma: A Review of Current and Potential Future Clinical Applications

Ultrasound (US) is an essential tool for evaluating trauma patients in the hospital setting. Many previous in-hospital studies have been extrapolated to out of hospital setting to improve diagnostic accuracy in prehospital and austere environments. This review article presents the role of prehospital US in blunt and penetrating trauma management with emphasis on its current clinical applications, challenges, and future implications of such use

Brown Recluse Spider in the Mediterranean Region: A Review of the Literature

Spiders are eight-legged arthropods that belong tothe arachnids class and are found on every continentexcept Antarctica.1 As of 2020, there are over 48000recognized species of spiders with more than 5000in the Mediterranean area. Out of these, only twospiders, the Latrodectus tredecimguttatus and theLoxosceles rufescens are of medical significance in theMediterranean area.1 Although most spider bites arebenign; however, severe reactions and life-threateningenvenomation do occur

Acute Stroke Care and Thrombolytic Therapy Use in a Tertiary Care Center in Lebanon

Background. Thrombolytic therapy (rt-PA) is approved for ischemic stroke presenting within 4.5 hours of symptoms onset. The rate of utilization of rt-PA is not well described in developing countries. Objectives. Our study examined patient characteristics and outcomes in addition to barriers to rt-PA utilization in a tertiary care center in Beirut, Lebanon. Methods. A retrospective chart review of all adult patients admitted to the emergency department during a one-year period (June 1st, 2009, to June 1st, 2010) with a final discharge diagnosis of ischemic stroke was completed. Descriptive analysis was done followed by a comparison of two groups (IV rt-PA and no IV rt-PA). Results. During the study period, 87 patients met the inclusion criteria and thus were included in the study. The mean age was found to be 71.9 years (SD = 11.8). Most patients arrived by private transport (85.1%). Weakness and loss of speech were the most common presenting signs (56.3%). Thirty-three patients (37.9%) presented within 4.5 hours of symptom onset. Nine patients (10.3%, 95% CI (5.5–18.5)) received rt-PA. The two groups (rt-PA versus non rt-PA) had similar outcomes (mortality, symptomatic intracerebral hemorrhage, modified Rankin scale scores, and residual deficit at hospital discharge). Conclusion. In our setting, rt-PA utilization was higher than expected. Delayed presentation was the main barrier to rt-PA administration. Public education regarding stroke is needed to decrease time from symptoms onset to ED presentation and potentially improve outcomes further

Predictors of intensive care unit admission in adult cancer patients presenting to the emergency department with COVID-19 infection: A retrospective study.

BackgroundAdult cancer patients with COVID-19 were shown to be at higher risk of Intensive Care Unit (ICU) admission. Previously published prediction models showed controversy and enforced the importance of heterogeneity among different populations studied. Therefore, this study aimed to identify predictors of ICU admission (demographic, clinical, and COVID-19 targeted medications) in cancer patients with active COVID-19 infection presenting to the Emergency Department (ED).MethodsThis is a retrospective cohort study. It was conducted on adult cancer patients older than 18 years who presented to the American University of Beirut Medical Center ED from February 21, 2020, till February 21, 2021, and were found to have COVID-19 infection. Relevant data were extracted from electronic medical records. The association between different variables and ICU admission was tested. Logistic regression was done to adjust for confounding variables. A p-value less than 0.05 was considered significant.ResultsEighty-nine distinct patients were included. About 37% were admitted to the ICU (n = 33). Higher ICU admission was seen in patients who had received chemotherapy within one month, had a respiratory rate at triage above 22 breaths per minute, oxygen saturation less than 95%, and a higher c-reactive protein upon presentation to the ED. After adjusting for confounding variables, only recent chemotherapy and higher respiratory rate at triage were significantly associated with ICU admission.ConclusionPhysicians need to be vigilant when taking care of COVID-19 infected cancer patients. Patients who are tachypneic at presentation and those who have had chemotherapy within one month are at high risk for ICU admission

Telephonic Medical Toxicology Service in a Low- Resource Setting: Setup, Challenges, and Opportunities

Poisoning and envenomation are a global health problem for which the mortality burden is shouldered heavily by middle- and low-income countries that often lack poison prevention programs and medical toxicology expertise. Although telehealth or teleconsult services have been used to bridge the expertise gap between countries for multiple specialties, the use of medical toxicology teleconsult services across borders has been limited. We aim to describe the use of a United States-based medical toxicology teleconsult service to support patient care at a hospital in a middle-income country that lacks this expertise. This report outlines the logistics involved in setting up such a service, including the challenges and opportunities that emerged from establishing medical toxicology teleconsult service in a low-resource setting

Telephonic Medical Toxicology Service in a Low- Resource Setting: Setup, Challenges, and Opportunities

Poisoning and envenomation are a global health problem for which the mortality burden is shouldered heavily by middle- and low-income countries that often lack poison prevention programs and medical toxicology expertise. Although telehealth or teleconsult services have been used to bridge the expertise gap between countries for multiple specialties, the use of medical toxicology teleconsult services across borders has been limited. We aim to describe the use of a United States-based medical toxicology teleconsult service to support patient care at a hospital in a middle-income country that lacks this expertise. This report outlines the logistics involved in setting up such a service, including the challenges and opportunities that emerged from establishing medical toxicology teleconsult service in a low-resource setting

Snakebites in lebanon: a descriptive study of snakebite victims treated at a tertiary care center in Beirut, Lebanon

Background: Snakebites lead to at least 421,000 envenomations and result in more than 20,000 deaths per year worldwide. Few reports exist in the Mediterranean region. This study describes demographic and clinical characteristics, treatment modalities, and outcomes of snakebites in Lebanon. Materials and Methods: This was a retrospective chart review of patients who presented with snakebite complaint to the emergency department between January 2000 and September 2014. Results: A total of 24 patients were included in this study. The mean age was 34.6 (±16.4) years and 58.3% were males. Local manifestations were documented in 15 (62.5%) patients, systemic effects in 10 (41.7%), hematologic abnormalities in 10 (41.7%), and neurologic effects in 4 (16.7%) patients. Nine patients (37.5%) received antivenom. The median amount of antivenom administered was 40 ml or 4 vials (range: 1–8 vials). About 50% of patients were admitted to the hospital with 75% to an Intensive Care Unit and 25% to a regular bed. All were discharged home with a median hospital length of stay of 4 (interquartile range 11) days. Among those admitted, seven patients (58.3%) had at least one documented complication (compartment syndrome, fasciotomy, intubation, deep vein thrombosis, coagulopathy, acute respiratory distress syndrome, sepsis, congestive heart failure, cellulitis, upper gastrointestinal bleeding, and vaginal bleeding). Conclusion: Victims of snakebites in Lebanon developed local, systemic, hematologic, or neurologic manifestations. Complications from snakebites were frequent despite antivenom administration. Larger studies are needed to assess the efficacy of available antivenom and to possibly create a local antivenom for the treatment of snakebites in Lebanon

A Case Report of a Lebanon Viper (Montivipera bornmuelleri) Envenomation in a Child

Introduction: Snake envenomation is a serious public health concern. In the Middle East little is known about snakebite envenomation, which raises several challenges for emergency physicians caring for these patients.Case report: We report the case of a five-year-old boy bitten by a rare snake, Montivipera bornmuelleri, who presented to an emergency department in Lebanon. We also discuss the proper management of snake envenomation.Conclusion: This case is unique as snakebites in Lebanon are poorly studied, and little is known about the epidemiology and clinical manifestations of local snakebites

Human Zinc Phosphide Exposure in Lebanon: A Case Report and Review of the Literature

Introduction: Toxicity from rodenticides such as metal phosphides is common worldwide, particularly in developing countries where consumers have access to unlabeled and uncontrolled insecticides and pesticides.Case Report: We present the first documentation of a metal phosphide exposure in Lebanon. A middle-aged woman presented to the emergency department following the ingestion of an unknown rodenticide. Spectroscopy analysis of the sample brought by the patient was used and helped identify zinc phosphide. The patient developed mild gastrointestinal symptoms and was admitted to the intensive care unit for observation without further complications.Review: We subsequently conducted a literature review to understand the diagnosis, pathophysiology, clinical presentation, and management of metal phosphide toxicity. Multiple searches were conducted on MEDLINE and PubMed, and articles related to the topics under discussion were included in the review. Metal phosphide is associated with significant morbidity and mortality involving all body systems. Patients presenting with metal phosphide intoxication need extensive workup including blood testing, electrocardiogram, and chest radiography. To date there is no antidote for metal phosphide toxicity, and management is mostly supportive. Many treatment modalities have been investigated to improve outcomes in patients presenting with metal phosphide toxicities.Conclusion: Emergency physicians and toxicologists in developing countries need to consider zinc and aluminum phosphides on their differential when dealing with unlabeled rodenticide ingestion. Treatment is mostly supportive with close monitoring for sick patients. Further research is needed to better understand metal phosphide toxicity and to develop better treatment options