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.
Smokers who are carriers of the SFTPD AG and AA polymorphic genotypes may be at a higher risk of developing COPD when compared with wild-type GG genotype carriers. IL-1RN rs2234663/IL-1β rs16944 haplotypes influence FEF25-75 % predicted and FEV1/FVC. SFTPD rs2243639 polymorphism did not influence serum SP-D levels in our group of recruited subjects.
Recent concerns about the potential carcinogenicity of estragole necessitate accurate determination of estragole in different products and extracts. GC-MS method has been used for characterization of Fennel extract; Estragole was found to constitute more than 65% of the extract. Accurate and simple method for the determination of estragole in pharmaceutical products, herbal teas and herbal extracts was developed using GC-FID technique and p-anisaldehyde as an internal standard. Target analyte was extracted from different matrices by applying various extraction procedures such as hydro-distillation and ultrasound-assisted extraction. The hydro-distillation technique provided higher amounts of extracted estragole compared to ultrasound-assisted extraction. The calibration curve showed excellent linearity over a concentration range of 0.1-10 mg/ml with a correlation coefficient of 0.9997. Accuracy of back calculated calibration standards were within ±7.3 %. Precision and accuracy of quality control samples were within ± 9.0 %. Estragole levels were accurately measured in Fennel fruits, Chinese and Japanese Star Anise, Sekem ® teabags for cough, Baby Calm® teabags, Balsam®, Guava® syrup for cough and Aqua ream® syrup for diarrhea. Accurate concentrations of estragole should replace the non-specific label information found on most of the tested products.
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