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

Performance evaluation of Iran University of medical sciences' hospital wastewater treatment plants

Background and aimsDespite increasing concerns about hospital waste management, scantattention has been paid to hospitals and medical research laboratories. These effluents containpathogenic microorganisms, incomplete metabolized Pharmaceutical, radioactive elements andother toxic chemicals. The purpose of present work is evaluation of hospitals wastewater treatmentplants performance of Iran University of medical science, analysis and comparison of thepollutants' removal and sludge quality with the national standards (Iran EPA).Methodsin this study that was conducted over a period of 6 months, 4 hospitals were selected  out of hospitals of Iran University of medical science. Once in each month were sampled and Totally 72 Samples were obtained (including 6 samples from treatment plant input, treatment  plant effluent and 6 samples from return activated sludge), respectively.  Results The results showed that Shahid Hasheminejad hospital using integrated fixed activatedsludge had the highest efficiency in removal of COD, BOD5 and TSS and Sludge quality meet the B class of EPAstandard.ConclusionShahid Hasheminejad hospital wastewater treatment plant had the best performance, because of its treatment system and capability of treating variable organic and hydraulic loading and simple operation and maintenance

Clinical risk score for the diagnosis of acute cor pulmonale in acute respiratory distress syndrome

Context Acute cor pulmonale (ACP) is a common sequela in patients with acute respiratory distress syndrome (ARDS) and represents the most severe presentation of right ventricular dysfunction, secondary to pulmonary vascular dysfunction. Although most previous studies adopted transesophageal echocardiography in the diagnosis of ACP in patients with ARDS, transthoracic echocardiography (TTE) appears as a promising alternative, being noninvasive and more available with continuously improving expertise in its use by ICU physicians. Aims Our study aimed to test the accuracy of ACP risk score by TTE. Settings and design This is a prospective observational cross-sectional study that was carried out over 6 months in our department. Patients and methods Our study was carried out on 45 mechanically ventilated patients with ARDS, who had been subjected to lung-protective approach. TTE was performed within the first 72 h of ARDS diagnosis. ACP was diagnosed when the ratio of right ventricular/left ventricular end-diastolic area more than 0.6 on parasternal short-axis view or apical four chambers view associated with interventricular septum dyskinesia in a parasternal short-axis or long-axis view at end-systole. ACP risk score parameters were checked and scored; (one point for each parameter). It consisted of pneumonia, hypercapnia arterial carbon dioxide tension of at least 48 mmHg, driving pressure of at least 18 cmH2O, and arterial oxygen tension/fractional inspired oxygen less than 150 mmHg. Qualitative data were described using number and percentage. Quantitative data were described using mean and SD, median, minimum and maximum. Comparison between different groups’ variables had been tested using χ2-test. Receiver operating characteristic curve expressed a recommended cutoff. The area under the receiver operating characteristic curve denotes the diagnostic performance of the test. Area of significance of the obtained results was judged at the 5% level (P<0.05). Results ACP risk score showed high sensitivity (100%), average specificity (51.43%), and good overall accuracy (62.2%) when score of at least 2 was used as a cutoff value. Hypercapnia, pneumonia, hypoxia, high plateau pressure, and positive end-expiratory pressure were associated with increased ACP incidence in patients with ARDS. Conclusion ACP risk score is a highly sensitive score in predicting and diagnosing ACP in patients with ARDS

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

Delivering safe and affordable cancer surgery to all - a Lancet Oncology Commission

CPCI-S(ISTP)S713-S7135

Global cancer surgery: delivering safe, aff ordable, and timely cancer surgery

Surgical oncolog