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

Identifying HIV most-at-risk groups in Malawi for targeted interventions: a classification tree model

Objectives: To identify HIV-socioeconomic predictors as well as the most-at-risk groups of women in Malawi.Design: A cross-sectional survey.Setting: MalawiParticipants: The study used a sample of 6395 women aged 15–49 years from the 2010 Malawi Health and Demographic Surveys.Interventions: N/APrimary and secondary outcome measures: Individual HIV status: positive or not.Results: Findings from the Pearson Chi-square and Chi-square Automatic Interaction Detector analyses revealed that marital status is the most significant predictor of HIV. Women who are no longer in union and living in the highest wealth quintiles households constitute the most-at-risk group, whereas the less-at-risk group includes young women (15–24) never married or in union and living in rural areas.Conclusions: In the light of these findings, this study recommends: (1) that the design and implementation of targeted interventions should consider the magnitude of HIV prevalence and demographic size of most-at-risk groups. Preventive interventions should prioritise couples and never married people aged 25–49 years and living in rural areas because this group accounts for 49% of the study population and 40% of women living with HIV in Malawi; (2) with reference to treatment and care, higher priority must be given to promoting HIV test, monitoring and evaluation of equity in access to treatment among women in union disruption and never married or women in union aged 30–49 years and living in urban areas; (3) community health workers, households-based campaign, reproductive-health services and reproductive-health courses at school could be used as canons to achieve universal prevention strategy, testing, counselling and treatment

RET/PTC Rearrangements Are Associated with Elevated Postoperative TSH Levels and Multifocal Lesions in Papillary Thyroid Cancer without Concomitant Thyroid Benign Disease

<div><p>RET/PTC rearrangements, resulting in aberrant activity of the RET protein tyrosine kinase receptor, occur exclusively in papillary thyroid cancer (PTC). In this study, we examined the association between RET/PTC rearrangements and thyroid hormone homeostasis, and explored whether concomitant diseases such as nodular goiter and Hashimoto's thyroiditis influenced this association. A total of 114 patients diagnosed with PTC were enrolled in this study. Thyroid hormone levels, clinicopathological parameters and lifestyle were obtained through medical records and surgical pathology reports. RET/PTC rearrangements were detected using TaqMan RT-PCR and validated by direct sequencing. No RET/PTC rearrangements were detected in benign thyroid tissues. RET/PTC rearrangements were detected in 23.68% (27/114) of PTC tissues. No association between thyroid function, clinicopathological parameters and lifestyle was observed either in total thyroid cancer patients or the subgroup of patients with concomitant disease. In the subgroup of PTC patients without concomitant disease, RET/PTC rearrangement was associated with multifocal cancer (P = 0.018). RET/PTC rearrangement was also correlated with higher TSH levels at one month post-surgery (P = 0.037). Based on likelihood-ratio regression analysis, the RET/PTC-positive PTC cases showed an increased risk of multifocal cancers in the thyroid gland (OR = 5.57, 95% CI, 1.39–22.33). Our findings suggest that concomitant diseases such as nodular goiter and Hashimoto's thyroiditis in PTC may be a confounding factor when examining the effects of RET/PTC rearrangements. Excluding the potential effect of this confounding factor showed that RET/PTC may confer an increased risk for the development of multifocal cancers in the thyroid gland. Aberrantly increased post-operative levels of TSH were also associated with RET/PTC rearrangement. Together, our data provides useful information for the treatment of papillary thyroid cancer.</p></div

Association between RET/PTC rearrangements and changes in thyroid function in thyroid cancer patients.

<p>Association between RET/PTC rearrangements and changes in thyroid function in thyroid cancer patients.</p

Association between RET/PTC rearrangement and thyroid function in thyroid cancer patients without nodular goiter or Hashimoto's thyroiditis.

<p>Association between RET/PTC rearrangement and thyroid function in thyroid cancer patients without nodular goiter or Hashimoto's thyroiditis.</p

Association between RET/PTC rearrangement and pathological parameters in thyroid cancer patients.

<p>Association between RET/PTC rearrangement and pathological parameters in thyroid cancer patients.</p

Association between haplotypes of RET tagSNPs and susceptibility to thyroid cancer.

<p>Association between haplotypes of RET tagSNPs and susceptibility to thyroid cancer.</p

Amplification and sequencing of RET/PTC variants.

<p>The qRT-PCR amplification curves show amplification of RET/PTC1, 2 and 3 (red curves) and GAPDH control (green curve). (A) Tumor with the RET/PTC1 fusion gene. (B) Tumor without the RET/PTC2 fusion gene. (C) Tumor without the RET/PTC3 fusion gene (D) DNA sequencing analysis of PCR products containing RET/PTC1. (E) DNA sequencing analysis of PCR products containing RET/PTC2. (F) DNA sequencing analysis of PCR products containing RET/PTC3.</p

Association between RET/PTC rearrangements and thyroid function in all thyroid cancer patients.

<p>Association between RET/PTC rearrangements and thyroid function in all thyroid cancer patients.</p