Restrictiveness Index Research Articles

The Regulatory Impact on Services Trade in Korea

Purpose – This study aims to analyze the effect of Korea's Services Trade Restrictiveness Index (STRI) and STRI Heterogeneity Index (HG) on Korea’s services trade.
 Design/Methodology/Approach – Using the Poisson Pseudo Maximum Likelihood (PPML) model, this study analyzes the impact of STRI and STRI HG provided by the OECD for 26 countries on Korea’s services trade (imports). The reason for using PPML is that first, a consistent estimator can be obtained regardless of the error term’s distribution. Second, if there is net-zero services trade in the data, sample selection bias can occur as the zero-trade data is excluded from the analysis when using ordinary least squares (OLS).
 Findings – After converting the STRI and the STRI HG into a single index through principal component analysis (PCA), results show that the STRI is not statistically significant, but the STRI HG shows a statistically significant negative (-) sign in all analysis models. This means that the greater the STRI HG with Korea's trading partners, the more negative the impact on services trade, which implies that even if the level of services restrictiveness is low, services trade volume will reduce as regulatory coherence with trading partners decreases.
 Research Implications – Whereas previous studies primarily focused on major advanced countries such as OECD nations or specific service industries, this study analyzes the impact of the services trade restrictiveness on services trade for Korea and each services sector. In addition, existing studies perform cross-sectional analyses due to data availability, whereas this study reflects changes in services restrictiveness levels over time by constructing panel data for 2014–2019.

Moderators of Resistance Training Effects in Overweight and Obese Adults: A Systematic Review and Meta-analysis.

This study aimed to analyze whether the effects of resistance exercise on whole-body fat and lean mass are moderated by exercise dosage (i.e., duration, volume, and intensity), age, body mass index, baseline values, assessment methods, and prescription of aerobic exercise and caloric restriction in overweight/obese adults. A systematic search was undertaken in 11 databases from inception to December 2020, with an updated search undertaken in April 2022. Eligible randomized controlled trials examined the effects of resistance-based exercise programs on whole-body fat mass and lean mass in adults who were overweight or obese. Meta-analysis was undertaken with a random-effects model. Associations between mean differences and potential moderators were tested by meta-regression models. Sixty-seven articles describing 65 trials ( n = 2537) were included. Resistance-based exercise programs resulted in a significant change of -1.6 kg (95% confidence interval [CI] = -1.9 to -1.3 kg, P < 0.001) in whole-body fat mass and +0.8 kg (95% CI = 0.6 to 0.9 kg, P < 0.001) in lean mass. Male participants experienced greater effects than females ( P < 0.001), whereas those presenting with higher levels of fat mass at baseline experienced greater reductions in this outcome ( P = 0.084). For lean mass, younger adults experienced greater improvements compared with older participants ( P = 0.009), whereas programs comprising resistance exercise and caloric restriction resulted in significant reductions in lean mass ( P = 0.035). Resistance exercise dosage or prescription of aerobic exercise was not associated with change in these outcomes. Resistance-based programs improve body composition regardless of the resistance exercise dosage or aerobic component prescribed in adults who are overweight or obese. In addition, subgroups based on demographic characteristics, baseline levels, and presence of caloric restriction may present with more favorable responses in body composition.

Properties of objective functions and search algorithms in multi-objective optimization problems

Objectives. A frequently used method for obtaining Pareto-optimal solutions is to minimize a selected quality index under restrictions of the other quality indices, whose values are thus preset. For a scalar objective function, the global minimum is sought that contains the restricted indices as penalty terms. However, the landscape of such a function has steep-ascent areas, which significantly complicate the search for the global minimum. This work compared the results of various heuristic algorithms in solving problems of this type. In addition, the possibility of solving such problems using the sequential quadratic programming (SQP) method, in which the restrictions are not imposed as the penalty terms, but included into the Lagrange function, was investigated.Methods. The experiments were conducted using two analytically defined objective functions and two objective functions that are encountered in problems of multi-objective optimization of characteristics of analog filters. The corresponding algorithms were realized in the MATLAB environment.Results. The only heuristic algorithm shown to obtain the optimal solutions for all the functions is the particle swarm optimization algorithm. The sequential quadratic programming (SQP) algorithm was applicable to one of the analytically defined objective functions and one of the filter optimization objective functions, as well as appearing to be significantly superior to heuristic algorithms in speed and accuracy of solutions search. However, for the other two functions, this method was found to be incapable of finding correct solutions.Conclusions. A topical problem is the estimation of the applicability of the considered methods to obtaining Pareto-optimal solutions based on preliminary analysis of properties of functions that determine the quality indices.

Use of Pharmacogenetics to Optimize Immunosuppressant Therapy in Kidney-Transplanted Patients.

Immunosuppressant drugs (ISDs) are routinely used in clinical practice to maintain organ transplant survival. However, these drugs are characterized by a restricted therapeutic index, a high inter- and intra-individual pharmacokinetic variability, and a series of severe adverse effects. In particular, genetic factors have been estimated to play a role in this variability because of polymorphisms regarding genes encoding for enzymes and transporters involved in the ISDs pharmacokinetic. Several studies showed important correlations between genetic polymorphisms and ISDs blood levels in transplanted patients; therefore, this review aims to summarize the pharmacogenetics of approved ISDs. We used PubMed database to search papers on pharmacogenetics of ISDs in adults or pediatric patients of any gender and ethnicity receiving immunosuppressive therapy after kidney transplantation. We utilized as search term: “cyclosporine or tacrolimus or mycophenolic acid or sirolimus or everolimus and polymorphism and transplant”. Our data showed that polymorphisms in CYP3A5, CYP3A4, ABCB1, and UGT1A9 genes could modify the pharmacokinetics of immunosuppressants, suggesting that patient genotyping could be a helpful strategy to select the ideal ISDs dose for each patient.

Identification of Spring Wheat with Superior Agronomic Performance under Contrasting Nitrogen Managements Using Linear Phenotypic Selection Indices.

Both the Linear Phenotypic Selection Index (LPSI) and the Restrictive Linear Phenotypic Selection Index (RLPSI) have been widely used to select parents and progenies, but the effect of economic weights on the selection parameters (the expected genetic gain, response to selection, and the correlation between the indices and genetic merits) have not been investigated in detail. Here, we (i) assessed combinations of 2304 economic weights using four traits (maturity, plant height, grain yield and grain protein content) recorded under four organically (low nitrogen) and five conventionally (high nitrogen) managed environments, (ii) compared single-trait and multi-trait selection indices (LPSI vs. RLPSI by imposing restrictions to the expected genetic gain of either yield or grain protein content), and (iii) selected a subset of about 10% spring wheat cultivars that performed very well under organic and/or conventional management systems. The multi-trait selection indices, with and without imposing restrictions, were superior to single trait selection. However, the selection parameters differed quite a lot depending on the economic weights, which suggests the need for optimizing the weights. Twenty-two of the 196 cultivars that showed superior performance under organic and/or conventional management systems were consistently selected using all five of the selected economic weights, and at least two of the selection scenarios. The selected cultivars belonged to the Canada Western Red Spring (16 cultivars), the Canada Northern Hard Red (3), and the Canada Prairie Spring Red (3), and required 83–93 days to maturity, were 72–100 cm tall, and produced from 4.0 to 6.2 t ha−1 grain yield with 14.6–17.7% GPC. The selected cultivars would be highly useful, not only as potential trait donors for breeding under an organic management system, but also for other studies, including nitrogen use efficiency.

The evaluation of the immune status of COVID-19 recovered subjects with persistent abnormal lung CT after one year: A longitudinal cohort study

ObjectivesCOVID-19 is an immune-related disease caused by novel Coronavirus SARS-COV-2. Lung lesions persist in some recovered patients, making long-term follow-up monitoring of their health necessary. The mechanism of these abnormalities is still unclear. In this study, the immune status was observed to explore the immune mechanism of persistent lung CT abnormalities in one-year COVID-19 recovered subjects. MethodsOne-year follow-up of 73 recovered patients from COVID-19 confirmed in Taizhou City, Zhejiang Province, was conducted to collect laboratory indicators such as blood immune cells, cytokines, complement series, immunoglobulin, and lung imaging; According to the results of lung CT, 60 patients were divided into normal CT group (n = 40) and abnormal CT group (n = 20). We compared the dynamic changes of immune indexes at three timepoints namely onset (T1), discharge (T2), and 1-year follow-up (T3), and studied the relationship between immune indexes and pulmonary sequelae. ResultsCompared with the healthy control, there was no significant difference in immune-related indexes, and immune levels had recovered. Patients with elder age, high BMI, severe patients, and those with underlying diseases (hypertension or diabetes) had a higher CT abnormal rate after recovery. Longitudinal observation showed that immunoglobulin increased first and then decreased, immune cell TBNK decreased in the onset period and increased in the recovery period, cytokine level increased significantly in the onset period and decreased to the normal level in the recovery period, and complement series C1q, C3 and C4 increased at the onset and decreased during the one-year follow-up. Complement C3 remained at a high level in the CT abnormal group (CT normal group vs CT abnormal group; P = 0.036). Correlation analysis showed that C3 negatively correlated restrictive ventilation index (TLC-He (ratio) (r = −0.302, P = 0.017). The above results suggest that complement C3 is a negative factor correlating abnormal pulmonary function 1 year after the recovery. ConclusionAfter one year recovering from COVID-19, the subjects were with stable immune indicators. High levels of complement C3 were associated with persistent lung abnormalities in COVID-19 recovered subjects.

Impact of data trade restrictions on IT services export: A cross-country analysis

Trade in digital goods and services have witnessed increasing growth in recent years, accompanied by a corresponding increase in data flows across national boundaries. At the same time, governments around the world have enacted data policies that restrict such cross border data flows in their effort to claim sovereignty over data generated from within their countries. However, scholars have long proclaimed that any restrictions to the Internet and associated digital trade will have serious economic consequences. Given this context, we analyze the impact of data policies that impose restrictions on digital trade, specifically on cross border data flows. We construct Market Data Restrictions Index (MDRI), that measures the data restrictions faced by an exporting country from their trade partners. We use a variation of random effect model on a panel data set consisting of 60 countries that contribute to more than 50 percent of IT services export during the period 2006–2017. The results indicate that apart from variables such as Foreign Direct Investment, and Service Value Added, the MDRI of partner countries has a moderate negative effect on IT services export. If countries move from liberal policies to stringent data restrictions, the economies of the country that exports its ICT services to these partner countries is affected substantially. Hence government regulators shall be cautious in imposing stringent data restrictions as it affects global digital trade.

The determinants of banking regulation in the MENA region

Theoretical foundations in banks' response to capital settlement suggest that the systems proposed by Basel are not sound. It is conceivable that regulators will consider alternative approaches to enhance the safety and soundness of the banking system. The regulation includes several decrees and ratios; the areas of interest encompassing the areas are subject to principal component analysis (PCA).The paper aims to present a regulatory framework based on balance sheet ratios, such as Capital requirements (equity ratio; Tier 1 ratio; Total Equity/Net Loans; Total Equity/Deposits); for liquidity needs (liquidity/deposits; liquidity/total assets; liquidity/deposits and loans, and net loans/total assets); for leverage requirements (total liabilities/total assets; total assets/equity; and total liabilities/equity); also banking restriction index; Official supervision index; Private surveillance index, finally global index of regulations and supervision. Besides, it performs a PCA analysis on a set of 13 financial ratios to exploit and compare the financial characteristics of 239 banks (175 Conventional and 64 Islamic commercial banks) in the MENA region over a 2004-2015 period. This gives the main indices EXIGCP, EXIGLIQ, LEVCP, and LEVP.

Selection criteria for yield in hot pepper (Capsicum chinense Jacq.)

ABSTRACT Capsicum chinense Jacq., believed to have been domesticated 1000–2000 BC, is indigenous to tropical South America and the Caribbean and the most important pepper species grown in the Caribbean. Despite its economic importance, the low productivity of landraces grown in the Caribbean affects its profitability. The objective of the study was to understand the interrelationships between yield and its components in C. chinense towards developing selection criteria for improving yield. Two field experiments, first involving a diversity set of 86 accessions and the second with a subset of 22 promising accessions were carried out in a randomised complete block design with three replications each, and were evaluated for yield as well as 6 yield components (fruit number, clusters per plant, fruits per cluster, average fruit weight, flowers per node and reproductive efficiency) and three partitioning components (total dry weight, shoot dry weight and harvest index). Path coefficient analyses indicated that the important yield attributing characters to be fruit number (or clusters per plant) and average fruit weight whilst principal component analysis revealed the importance of average fruit weight, clusters per plant and harvest index. A restricted selection index involving three yield components is recommended for improving yield in hot pepper.

Renal Restrictive Index (RRI) Versus Urinary Neutrophil Gelatinase-Associated Lipocalin (uNGAL) for early prediction of acute kidney injury (AKI) in adults undergoing elective cardiac surgeries with cardiopulmonary bypass: A prospective randomized observational study

ABSTRACT Background Acute kidney injury (AKI) complicates most cardiac surgery patients. This study assessed the accuracy of urine neutrophil gelatinase-associated lipocalin (uNGAL) and Renal Resistive Index (RRI) to early predict (AKI) after cardiopulmonary bypass (CPB). Methods This work enrolled 57 cases of elective cardiac surgery with CPB. Urinary NGAL and RRI were measured preoperatively and at 1, 6 and 24 h postoperatively. The primary outcome was AKI, defined by Acute Kidney Injury Network Classification (AKIN) System. The secondary aim was to assess the diagnostic accuracy, cut-off point of uNGAL and RRI, and their relation with AKI severity. Results AKI developed in 22 patients (38.5%), with 2 cases required dialysis. Mean uNGAL significantly increased by 10 folds at 1h and 15 folds at 6h postoperatively. As regard uNGAL,the 1 h diagnostic accuracy was 94.8%, The area under the curve (AUC) was 0.888, using a cut-off value of 194.3 ng/ml. The 6 h diagnostic accuracy was 96.5%, AUC was 0.995 at a cut-off value 67.1 ng/ml. The 1 and 6 h uNGAL were unrelated to AKI severity. As regard RRI, AKI patients had significantly higher 1 h and 6 h RRI. The diagnostic accuracy at 1 h was 93.0%, AUC was 0.991, using a cut-off value of 0.72. The diagnostic accuracy at 6 h was 94.8%, AUC 0.995 at a cut-off value of 0.71. Values of RRI were significantly related only to severe cases requiring dialysis. Conclusion Urinary NGAL and RRI are early accurate indicators of AKI. High RRI can predict dialysis-requirement.

Variation in Restrictive Abortion Policies and Adverse Birth Outcomes in the United States from 2005 to 2015.

Since 2011, U.S. states have enacted more than 400 policies restricting abortion access. As structural determinants, abortion policies have the potential to influence maternal and child health access, outcomes, and equity through multiple mechanisms. Limited research has examined their implications for birth outcomes. We created a state-level abortion restrictiveness index composed of 18 restrictive abortion policies and evaluated the association between this index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW) within the United States and by Census Region, using data from the 2005-2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files. We used logistic multivariable regression modeling, adjusting for individual- and state-level factors and state and year fixed effects. Among 2,500,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average from 2005 to 2015, states had approximately seven restrictive abortion policies enacted, with more policies enacted in the Midwest and South. Nationally, relationships between state restrictiveness indices and adverse birth outcomes were insignificant. Regional analyses revealed that a 1 standard deviation increase in a state's restrictiveness index was associated with a 2% increase in PTB in the Midwest (marginal effect [ME], 0.25; 95% confidence interval [CI], 0.04-0.45; p<.01), a 15% increase in LBW in the Northeast (ME, 1.24; 95% CI, 0.12-2.35; p<.05), and a 2% increase in LBW in the West (ME, 0.12; 95% CI, 0.01-0.25; p<.05). Variation in restrictive abortion policy environments may have downstream implications for birth outcomes, and increases in abortion restrictions were associated with adverse birth outcomes in three out of four Census Regions.

The impact of the COVID-19 pandemic and behavioral restrictions on electricity consumption and the daily demand curve in Turkey

The rapid spread of COVID-19 has severely impacted many sectors, including the electricity sector. The reliability of the electricity sector is critical to the economy, health, and welfare of society; therefore, supply and demand need to be balanced in real-time, and the impact of unexpected factors should be analyzed. During the pandemic, behavioral restrictions such as lockdowns, closure of factories, schools, and shopping malls, and changing habits, such as shifted work and leisure hours at home, significantly affected the demand structure. In this research, the restrictions and their corresponding timing are classified and mapped with the Turkish electricity demand data to analyze the estimated impact of the restrictions on total demand and daily demand profile. A modulated Fourier Series Expansion evaluates deviations from normal conditions in the aggregate demand and the daily consumption profile. The aggregate demand shows a significant decrease in the early phase of the pandemic, during the period March–June 2020. The shape of the daily demand curve is analyzed to estimate how much demand shifted from daytime to night-time. A population-based restriction index is proposed to analyze the relationship between the strength and coverage of the restrictions and the total demand. The persistency of the changes in the daily demand curve in the post-contingency period is analyzed. These findings imply that new scheduling approaches for daily and weekly loads are required to avoid supply-demand mismatches in the future. The long-term policy implications for the energy transition and lessons learned from the COVID-19 pandemic experience are also presented.

The effects of restrictive measures on cross‐border investment: Evidence from OECD and emerging countries

This paper investigates the effects of global and sectoral restrictive measures on cross-border FDI among 49 advanced and emerging countries. We use a gravity model with panel data from 2010 to 2019 and the FDI Restrictiveness Index of the OECD that quantifies the level of restriction in FDI. Our results suggest that global restrictive measures do not significantly affect cross-border FDI in OECD countries, while restrictions in the service sector have negative and significant effects on FDI. Moreover, the overall restrictive measures and those in the primary, secondary and service sectors negatively impact inward FDI among OECD and big emerging countries. The restrictions in the primary sector are a main obstacle to inward FDI in the big emerging countries. In addition, global and sectoral restrictions do not have a significant effect on FDI between advanced and African countries. The analysis of disaggregated sectoral restrictive measures shows that restrictions in business and other financial services are negatively associated with intra-OECD FDI. We also find that restrictions in the manufacturing sector have restrictive impacts on inward FDI in the large emerging countries, and those in the mining, quarrying and oil extraction sector hinder inward FDI in African countries. Reforms to liberalise sectoral restrictions by country have positive effects on FDI, but deregulation of the services sector has beneficial effects on inward FDI from advanced and emerging countries.

Evaluation and prediction of water resources carrying capacity in Jiangsu Province, China

Abstract Water resources carrying capacity (WRCC) is an important component of the carrying capacity of regional natural resources. It is a restrictive index indicating whether a region can support the coordinated development of its population, economy, and environment. In order to solve the problem that WRCC varies with the supporting capacity of, load on, and capacity for regulation of the water resources, this study establishes the relationship between WRCC and the level of socio-economic development (carrying level) and then develops a WRCC evaluation model by analyzing the connotations, characteristics and influencing factors of WRCC. The model is applied to calculate the population and economic scales supportable by water resources in Jiangsu Province under different carrying levels. Predictions are made of the effects of varying water consumption quotas and the industrial structure so as to explore methods of regulating and controlling WRCC in the region. The evaluation, prediction, and control results provide an important reference for the rational allocation of water resources in Jiangsu Province so as to further improve the regional WRCC and achieve sustainable development of regional water resources. The regional WRCC evaluation model has strong applicability and good application effects.

Goal-directed fluid therapy versus restrictive fluid therapy: A cardiomerty study during one-lung ventilation in patients undergoing thoracic surgery

ABSTRACT Background Fluid management during thoracic anaesthesia is a challenge for the anaesthesiologists. The “safe zone” between volume overload (pulmonary oedema risk) and hypovolemia (renal failure risk) remains to be narrow and hard to determine. Purpose The aim of the present study was to assess goal-directed fluid therapy using cardiometry versus restrictive fluid therapy during one-lung ventilation in patients planned for having thoracic surgery. Methods After receiving the Ethics Committee approval and taking an informed written consent, a prospective randomized study was conducted. Fifty adult patients of both genders were scheduled for thoracic surgery with one lung ventilation. Patients were randomly categorized using closed envelope technique into two equal groups (25 patients each). Group I: a number of 25 patients underwent thoracic surgery and were managed with goal directed fluid therapy using intraoperative cardiometry. Group II: a number of 25 patients underwent thoracic surgery and were managed with intraoperative restrictive fluid therapy. Results There was a significantly increased serum lactate level, serum creatinine with decreased urine output in restrictive therapy group (RT) by the end of the surgery, immediately postoperative and 6 h postoperative (p value of <0.001). The restrictive hypoxic index values were much higher than the goal directed group values, yet, both were of normal range and no patient suffered of lung injury. A significant increase in serum neutrophil gelatinase-associated lipocalin (Ngal) in the restrictive therapy group compared to the goal directed therapy group. (p value of <0.001). Conclusion From these results, we concluded that patients undergoing thoracic surgery are preferably to be maintained over goal directed therapy protocol using electrical cardiometry. Fluid restriction is better to be individualized and aided by new technologies based on beat-to-beat variations.

The Services Trade Restrictiveness Index: Applications in Quantitative Assessments of Trade Agreements

The Services Trade Restrictiveness Index: Applications in Quantitative Assessments of Trade Agreements

Legal services global market: current state and development prospects

The article answers the question: what are the distinctive features of the global legal services market in the context of globalization, as well as what place and role it occupies in international trade and trade policy? The study is divided into 3 parts. The first part structures the main theoretical aspects concerning the legal services world market: the concept and classification of legal services, forms and methods of international trade in legal services. The second part analyzes the market indicators of the global legal services market, characterizes the main problems and trends in its development. The place and role of Russia in the global legal services market are revealed. The third part deals with the foreign trade policy issues, mechanisms for protecting the internal market. Special attention is paid to the analysis of the Services Trade Restrictiveness Index for legal services. The mechanism of countries foreign trade policies influence on the British legal services sector is illustrated in the context of Brexit.

Does service trade liberalization relieve manufacturing enterprises’ financial constraints? Evidence from China

A growing body of literature has discussed the effect of service trade liberalization on external financial constraints of enterprises in China. Based on a dataset of Chinese manufacturing firms and service trade restriction indices, we contribute to this discussion by analyzing how service trade liberalization affects financial constraints of Chinese enterprises through altering their ability to access external financing, as well as internal financing and commercial credit financing. We find that service trade liberalization alleviates financial constraints of Chinese enterprises through strengthening their ability to obtain both external and internal financing. There exist heterogeneous outcomes for different types of firms. While service trade liberalization eases exporters’ financial constraints, it deteriorates financial constraints of non-exporters through tightening their commercial credit financing. In addition, non-SOEs or SMEs gain from service trade liberalization through easing internal and external financing constraints while SOEs or large enterprises lose due to tightening commercial credit financing constraints.

Resilience of elective cancer surgery systems during COVID-19 lockdowns: an international, multicentre, prospective cohort study

BackgroundSurgery is the main modality of cure for solid cancers and was prioritised to continue during SARS-CoV-2 outbreaks. This study aimed to identify areas for health system strengthening by comparing the delivery of elective cancer surgery during COVID-19 in periods of lockdown versus light restriction. MethodsIn this international, multicentre, prospective cohort study, we enrolled patients with 15 cancer types who had a decision for surgery during the SARS-CoV-2 pandemic (between Jan 21, 2020 and April 14, 2020) to Aug 31, 2020. Any hospital worldwide providing elective cancer surgery was eligible. The primary outcome was the non-operation rate (proportion of patients who did not undergo planned surgery). Reasons for non-operation were classified as COVID-19 related (societal, operational, or personal) or unrelated. Average national Oxford COVID-19 Stringency Index scores were calculated for each patient during their wait for surgery and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). Cox proportional-hazards regression models were used to explore associations between lockdowns and non-operation. This study was registered at ClinicalTrials.gov, NCT04384926. FindingsWe enrolled 27 700 participants, of whom 20 006 patients (8526 men and 11480 women) from 466 hospitals and 61 countries did not receive surgery after a minimum of 3-months' follow up (median 23 weeks [IQR 16–30]). All patients had a COVID-19-related reason for non-operation. Light restrictions were associated with a 0·6% reference non-operation rate, moderate lockdowns with a 5·5% rate (HR 0·81, 95% CI 0·77–0·84, p<0·0001), and full lockdowns with a 15·0% rate (0·51, 0·50– 0·53, p<0·0001). In sensitivity analyses, including adjustment for SARS-COV-2 case notification rates, moderate (0·84, 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001) remained independently associated with non-operation. Frail patients with advanced cancer, particularly those from low-income and middle-income countries and those requiring postoperative critical care, were more likely to not have an operation. InterpretationCancer surgery systems worldwide were affected by lockdowns, including in the UK, with one in seven patients not undergoing planned surgery. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which could include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies. In the UK, a whole-health system approach is required to mitigate against further harm for NHS patients. FundingNational Institute for Health Research (NIHR) Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, Economic and Social Research Council, European Society of Coloproctology, Medtronic, NIHR Academy, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study

SummaryBackgroundSurgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.MethodsThis international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.FindingsOf eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays.InterpretationCancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services.FundingNational Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.