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

Hepatic Antioxidant, Oxidative Stress And Histopathological Changes Induced By Nicotine In A Gender Based Study In Adult Rats

Nicotine is generally regarded to be a primary risk factor in the development of hepatic, cardiovascular and pulmonary disorders. Therefore, the current study was designed to compare the extent of the oxidative stress induced by nicotine upon the liver of adult male and female rats. Nicotine toxicity was induced by intraperitoneal injection of 0.5 mg base/Kg body weight for 2 months. Cellular damage of liver was assessed by measuring the activity of serum transaminases. Antioxidant status was assessed in liver by measuring the levels of malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPX), glutathione-S-transferase (GST) and reduced glutathione (GSH). Histopathological liver changes were examined. The results showed a significant elevation in serum ALT and AST in nicotine-treated rats versus control groups. In comparison with the control findings of male and female rats, nicotine-treated male and female rats showed significant increase in MDA content by 57.3 and 41.8% respectively and a significant reduction in GSH levels by 60.1 and 30.7% respectively with observed significant inhibition in GPX activity by 56.5 and 28.6% respectively and a concomitant significant inhibition in GST activity by 71.2 and 51.2% respectively. Also, significant inhibition in SOD activity was achieved in nicotine-treated male and female rats by 66 and 51.6% versus control groups respectively. Male rats appeared to be more susceptible to nicotine toxicity than females. Histological examination of liver tissues in nicotine-treated male and female rats significantly revealed marked tissue damage and changes versus control counterparts. These changes included focal and confluent necrosis, portal tract inflammation and steatosis. These changes being more obvious and severe in male rats. In conclusion, the results showed the existence of significant sex dependent difference between male and female rats towards nicotine toxicity. Further studies are required to elucidate the precise gonadal hormones mechanism upon the sex dependent difference. Keywords: Liver, Nicotine, Sex, Oxidative Stress, Antioxidants. Egyptian Journal of Biochemistry and Molecular Biology Vol. 26 (2) 2008: pp. 189-20

Modulation Of Immune Response In Asthmatic Patients By Using Inhaled Tuberculin

Bronchial asthma is a chronic immuno inflammatory reversible lung disease with airway responsiveness to various stimuli which relived by proper therapy using inhaled steroids or the highly expensive recombinant interferon gamma (IFN-). This study undertaken to investigate for the first time a novel treatment method using inhaled tuberculin (PPD) to determine whether PPD inhalation could be safely and effectively delivered into the airways of bronchial asthmatic patients in attempt to bring immune deviation away from atopy via inhaling an economic dose of tuberculin. Sixty patients suffering from mild atopic bronchial asthma along with twenty healthy volunteers were included in our study. Patients were randomly categorized into three equally-sized groups received 2, 5 and 10 PPD units respectively. Treatment doses taken every 72 hours for two weeks. Respiratory function tests were examined before and after treatment regime. Interleukin 2 (IL-2), IL-4 and immunoglobulin E (IgE) were measured by ELISA technique in serum and bronchoalveolar lavage fluid (BALF) samples before and after treatment regime. Eosinophil count in BALF was also examined. The results showed that PPD treatment doses caused a significant increase in lung function standards (FEV1 and FEV1/FVC ratio) as compared with before treatment values. Also, the different doses of PPD resulted in a highly significant increase in the levels of serum and BALF IL-2 with a concomitant significant decrease in BALF IL-4 levels when compared with before treatment values. A highly significant decrease in serum and BALF IgE along with eosinophil count was obtained with PPD inhaled doses as compared with before treatment values. To conclude, PPD treatment could be safely, economically and effectively used as a potential therapeutic drug for patients with atopic bronchial asthma. A marked improvement in our laboratory results was observed with 5 and 10 units of PPD. Keywords: Asthma, T Helper Cells, Tuberculin, Interleukins, IgE Egyptian Journal of Biochemistry and Molecular Biology Vol. 26 (2) 2008: pp. 135-15

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