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.
IntroductionIn Palestine (West Bank and Gaza), there have been more than 320 890 known cases of COVID-19, resulting in 3452 deaths. The detrimental effects of the virus can be seen in the nation’s health, economy and government operations, leading to radical uncertainty that is exacerbated by the absence of any definitive treatment or vaccines. The level of knowledge about and trust in treatment and vaccination varies worldwide. This study aims to assess the willingness of Palestinians to receive a COVID-19 vaccine and their knowledge about such vaccines.MethodsAn online survey of adults over 18 years old (n=1080) was conducted in Palestine in October 2020. Using multivariate logistic regression, we identified correlates of participants’ willingness to get a COVID-19 vaccine.ResultsWe found that about 63% of participants were willing to get a COVID-19 vaccine. However, acceptance varied with the specific demographic variables that were investigated. Women, married participants and those aged 18–24 years are more likely to take the vaccine. Further, participants with good knowledge about the vaccine and its side effects are more willing to get the vaccine.ConclusionThe availability of a safe and effective COVID-19 vaccine in Palestine is crucial to decrease the burden of COVID-19 morbidity and mortality. In addition, to ensure a high vaccination rate, health awareness campaigns should target those who are not willing to get the vaccine, especially those who are more vulnerable and the elderly.
Introduction: Orofacial clefts (OFC) are the most common congenital craniofacial anomaly. The relationship between intermarriage (consanguinity) and positive family history for OFC is not well described. Consanguinity rates in developed countries are <1% but are considerably higher in the Middle East (45%). Familial clefting rates in developed countries are under 20% but in the Middle East are reported at 30% or higher. Objective: To determine OFC demographics and to clarify the relationship between consanguinity and familial clefting among Palestinians. Design: The Palestinian Congenial Anomalies Database is based on a 700-question survey administered to mothers of children with congenital anomalies. Orofacial clefts were diagnosed in 540 children. All demographic data were analyzed using χ2 tests with a level of significance at α < .05. Results: Demographics for OFC among Palestinians were similar to other published reports. Overall consanguinity rate was 53% and familial clefting rate was 49%. Parental rates of consanguinity were significantly different for patients with cleft palate. Patients with consanguineous parents had a higher rate of positive family history of clefting (67%). Recurrence of clefts in siblings was significantly higher among those born to consanguineous parents (73%) when compared to nonconsanguineous parents. Conclusion: Consanguinity rates for Palestinians with OFC were higher than those reported in the Middle East. Familial clefting and sibling recurrence rates were also higher than expected. The risk of OFC may be mitigated with improved education about anticipated genetic consequences of consanguinity in high-risk populations such as the southern West Bank.
We conclude that 250 USD underestimates the actual costs to perform a single cleft surgery in Palestine and Sudan. If international cleft organizations are genuinely committed to creating sustainable international cleft programs, they should focus exclusively on training local professionals to perform surgery in hospitals of their own choosing.
Background Orofacial clefts (OFCs) are the most common craniofacial malformation at birth worldwide, with an incidence of 1•05 out of 1000 live births in the occupied Palestinian territory. The majority of OFCs present as singletons (without a family history of clefts), and a minority present as multiplex cases (greater than one OFC in the family). Consanguineous marriages (marriage between blood relatives) among Palestinians is approximately 40%. This study aims to define the incidence and impact of multiplicity in Palestinians with OFC, and to determine how his may be related to rates of consanguinity. Methods We conducted a non-randomised longitudinal study using a 700-question survey administered in colloquial Arabic to mothers of patients with congenital anomalies (including patients with any craniofacial anomaly). Volunteer researchers fluent in English and Arabic were trained to recruit participants and administer surveys during craniofacial surgery screening events in Palestinian Government Hospitals. Selection criteria were a child in the family with an orofacial cleft, and family consent for participation in the survey. In a non-probability sampling method, the frequency of OFC in immediate and distant family members, and the extent of consanguineous marriages, were documented. Comparisons were made using chi squared tests; p<0•05 was considered statistically significant. The study methods and questionnaire were approved by the Institutional Review Board of Cincinnati Children's Hospital Medical Complex (IRB 2015-0607). Informed written consent was obtained from participants and legal guardians. Findings Of 613 completed surveys, 536 reported OFC, among whom 265 families (46%) reported another family member with a cleft, and 271 did not. Among multiplex families, 26% of OFCs (69 of 265) were in first-degree relatives (parents or siblings), 74% (196) in distant relatives, and 15% (39) in both. Nearly half of the patients from multiplex families (118) represented 42 families with multiple clefts. Compared with families in which only one member had a cleft, patients from multiplex families were more likely to be diagnosed with a cleft lip (29% vs 18%; p<0•01), less likely to be diagnosed with a cleft lip and palate (37% vs 48%; p=0•02), and had a similar likelihood of being diagnosed with a cleft palate alone. Patients from multiplex families were more likely to come from Hebron (52%) than from any other city in the West Bank (39%; p<0•01), and were more likely to have family members with non-cleft birth anomalies (61% vs 13%; p<0•001). Parents of children with clefts in a multiplex family were more likely to be consanguineous (related to each other) than parents of singletons (60% vs 40%; p<0•01). Interpretation The percentage of multiplex families (46%) in this study appears to be higher than reported previously from the Middle East (including Iran and Saudi Arabia). There also appears to be a higher rate of consanguinity among multiplex families than reported previously, especially among those families ...
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