Summary
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.
Abstract-Underwater Wireless Sensor Network (UWSN) is newly developed branch of Wireless Sensor network (WSN).UWSN is used for exploration of underwater resources, oceanographic data collection, flood or disaster prevention, tactical surveillance system and unmanned underwater vehicles. UWSN uses sensors of small size with a limited energy, memory and allows limited range for communication. Due to multiple differences from terrestrial sensor network, radio waves cannot be used over here. Acoustic channel are used for communication in deep water, which has many limitations like low bandwidth, high end to end delay and path loss. With the above limitations while using acoustic waves, it is very important to develop energy efficient and reliable protocols. Energy efficient communication in underwater networks has become uttermost need of UWSN technology. The main aim nowadays is to operate sensor with smaller battery for a longer time. This paper will analyse various routing protocols in the area of UWSN through simulation. This paper will analyse Depth Based Routing (DBR), Energy Efficient Depth Based Routing (EEDBR) and Hop by Hop Dynamic Addressing Based (H2-DAB) protocol through simulation. This comparison is carried out on the basis of total consumed energy, end to end delay, path loss and data delivery ratio.
Background: The COVID-19 pandemic has changed the delivery of primary care in the NHS. Consultations have largely moved from face-to-face to remote, forcing practitioners to modify the ways in which they deliver care to patients. Aim: In this study, we aim to investigate the appropriateness of antibiotic prescribing in tonsillitis during the COVID-19 pandemic. Design and Setting: An observational quantitative analysis in the North Wales primary care setting. Method: Retrospective review of computer records across 5 GP centers from March 2020 until the end of October 2020. Data was extracted and analyzed using chi-square or fisher exact rank and Mann–Whitney test. Results: Our results have shown no significant difference in antibiotic prescribing behavior comparing face-to-face and remote consultations. Conclusion: Remote consultation is as effective as face-to-face consultation with regards to the assessment of tonsillitis and the appropriateness of antibiotic prescription in primary care.
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