OBJECTIVE:To determine the difference in in-hospital mortality and length of hospital stay (LOS) after esophagectomy between the United States and England.
BACKGROUND:Since 2001, complex procedures ...such as esophagectomy have been centralized in England, but in the United States no formal plan for centralization exists.
METHODS:Patients who underwent esophagectomy for cancer between 2005 and 2010 were identified from the Nationwide Inpatient Sample (United States) and the Hospital Episodes Statistics (England). In-hospital mortality and LOS were compared.
RESULTS:There were 7433 esophagectomies performed in 66 English hospitals and 5858 resections in 775 US hospitals; median number of resections per center per year was 17.5 in England and 2 in the United States. In-hospital mortality was greater in US hospitals (5.50% vs 4.20%, P = 0.001). In multiple regression analysis, predictors of mortality included patient age, comorbidities, hospital volume, and surgery performed in the United States odds ratio (OR) = 1.20 (1.02–1.41), P = 0.03. Median LOS was greater in the English hospitals (15 vs 12 days, P < 0.001). However, when subset analysis was done on high-volume centers in both health systems, mortality was significantly better in US hospitals (2.10% vs 3.50%, P = 0.02). LOS was also seen to decrease in the US high-volume centers but not in England.
CONCLUSIONS:The findings from this international comparison suggest that centralization of high-risk cancer surgery to centers of excellence with a high procedural volume translates into an improved clinical outcome. These findings should be factored into discussions regarding future service configuration of major cancer surgery in the United States.
Re-operation due to disease being inadvertently close to the resection margin is a major challenge in breast conserving surgery (BCS). Indocyanine green (ICG) fluorescence imaging could be used to ...visualize the tumor boundaries and help surgeons resect disease more efficiently. In this work, ICG fluorescence and color images were acquired with a custom-built camera system from 40 patients treated with BCS. Images were acquired from the tumor in-situ, surgical cavity post-excision, freshly excised tumor and histopathology tumour grossing. Fluorescence image intensity and texture were used as individual or combined predictors in both logistic regression (LR) and support vector machine models to predict the tumor extent. ICG fluorescence spectra in formalin-fixed histopathology grossing tumor were acquired and analyzed. Our results showed that ICG remains in the tissue after formalin fixation. Therefore, tissue imaging could be validated in freshly excised and in formalin-fixed grossing tumor. The trained LR model with combined fluorescence intensity (pixel values) and texture (slope of power spectral density curve) identified the tumor's extent in the grossing images with pixel-level resolution and sensitivity, specificity of 0.75 ± 0.3, 0.89 ± 0.2.This model was applied on tumor in-situ and surgical cavity (post-excision) images to predict tumor presence.
At present, there is no accepted, ideal imaging modality or technique for diagnosis of lymph-node metastases. We aimed to assess the diagnostic precision of MRI with ferumoxtran-10—an ultrasmall ...superparamagnetic iron-oxide nanoparticle used as a contrast agent for diagnosis of lymph-node metastases, compared with that of unenhanced MRI and final histological diagnosis.
We did a meta-analysis of prospective studies that compared MRI, with and without ferumoxtran-10, with histological diagnosis after surgery or biopsy. Sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated for every study; summary receiver operating characteristic (ROC) and subgroup analyses were done; and study quality and heterogeneity were assessed. Metaregression analysis was used to analyse the effect of ferumoxtran-10 in diagnostic precision of MRI.
Summary ROC curve analysis for per-lymph-node data showed an overall sensitivity of 0·88 (95% CI 0·85–0·91) and overall specificity of 0·96 (0·95–0·97) for ferumoxtran-10-enhanced MRI. Overall weighted area under the curve for ferumoxtran-10-enhanced MRI was 0·96 (SE 0·01), DOR 123·05 (95% CI 5·93–256·93). Unenhanced MRI had less overall sensitivity (0·63 0·57–0·69) and specificity (0·93 0·91–0·94), with an overall weighted area under the ROC curve of 0·84 (SE 0·11) and DOR of 26·75 (95% CI 8·48–84·42). Significant heterogeneity was noted for studies reporting enhanced MRI and unenhanced MRI. Metaregression analysis confirmed the significant effect of ferumoxtran-10 in the diagnostic precision of MRI (p=0·001).
Ferumoxtran-10-enhanced MRI is sensitive and specific in detection of lymph-node metastases for various tumours. It offers higher diagnostic precision than does unenhanced MRI for detection of lymph-node metastases, and allows functional and anatomical definition when used as an imaging modality.
In a 2015 global study of low-cost or frugal innovations, we identified five leading innovations that scaled successfully in their original contexts and that may provide insights for scaling such ...innovations in the United States. We describe common themes among these diverse innovations, critical factors for their translation to the United States to improve the efficiency and quality of health care, and lessons for the implementation and scaling of other innovations. We highlight promising trends in the United States that support adapting these innovations, including growing interest in moving care out of health care facilities and into community and home settings; the growth of alternative payment models and incentives to experiment with new approaches to population health and care delivery; and the increasing use of diverse health professionals, such as community health workers and advanced practice providers. Our findings should inspire policy makers and health care professionals and inform them about the potential for globally sourced frugal innovations to benefit US health care.
Surgical metabonomics has great potential to improve the quality of surgical care delivered in the operating theatre, postoperative monitoring of patients in critical care situations, and beyond. ... ...we are engaging in large-scale prospective studies into the surgical journey (figure) of patients randomly assigned to groups defined by metabonomic analysis or by current gold standards of surgical diagnostics.
This study used meta-analytical techniques to compare the incidence of recurrence and the indication for reoperation in patients with Crohn's disease (CD) who underwent their first operation, due to ...perforating disease versus patients who underwent their first operation due to nonperforating disease.
Comparative studies published between 1988 and 2005 of perforating versus nonperforating CD were included. Using a random effects model, end points evaluated were recurrence of CD given as reoperation, and the indication for reoperation, i.e., perforating or nonperforating. Heterogeneity (HG) was assessed and a sensitivity analysis was performed to account for bias in patient selection.
Thirteen studies (12 nonrandomized retrospective, 1 nonrandomized prospective) reported on 3,044 patients, of which 1,337 (43.9%) had perforating indications (P group) and 1,707 (56.1%) had nonperforating indications (NP group) for surgery. The recurrence was found to be significantly higher in the P group compared to the NP group (HR 1.50, P= 0.002), with significant HG among studies (P < 0.001). The recurrence remained significantly higher in the P group compared with the NP group during sensitivity analysis of high-quality studies (HR 1.47, P= 0.005) and more recent studies (HR 1.51, P= 0.05), but still demonstrating significant HG (P= 0.08 and P < 0.001, respectively). At reoperation, concordance was found in the disease type of those patients re-presenting with perforating disease (OR 5.93, P < 0.001, without significant HG among studies P= 0.15) and those with nonperforating disease (OR 5.73, P < 0.001, with significant HG among studies P < 0.001). Concordance in disease type remained when considering only high-quality studies (P: OR 7.48, P < 0.001; NP: OR 7.48, P < 0.001) and more recent studies (P: OR 5.95, P < 0.001; NP: OR 5.95, P < 0.001), both not associated with HG among studies (P= 0.47 and P= 0.60, respectively).
The indication for reoperation in CD tends to be the same as the primary operation, i.e., perforating disease tends to re-present as perforating disease, and nonperforating as nonperforating. Also, perforating CD appears to be associated with a higher recurrence rate compared with nonperforating CD. However, because of significant HG among studies, further studies should be undertaken to confirm this finding.
The Imperial College Healthcare National Health Service Trust, a large health care provider in London, together with an academic research unit, used a learning health systems cycle of interventions. ...The goals were to improve patient safety incident reporting and learning and shape a more just organizational safety culture. Following a phase of feedback gathering from front-line staff, seven evidence-based interventions were implemented and evaluated from October 2016 to August 2018. Indicators of safety culture, incident reporting rates, and reported rates of harm to patients and "never events" (events that should not happen in medical practice) were continuously monitored. In this article we report on this initiative, including its early results. We observed improvement on some measures of safety culture and incident reporting rates. Staff members' perceptions of six of the seven interventions were positive. The intervention exercise demonstrated the importance of health care policies in supporting local ownership of safety culture and encouraging the application of rigorous research standards.
The aim of this study was to assess the diagnostic precision of antiSaccharomyces cerevisiae (ASCA) and perinuclear antineutrophil cytoplasmic antibodies (pANCA) in inflammatory bowel disease (IBD) ...and evaluate their discriminative ability between ulcerative colitis (UC) and Crohn's disease (CD).
Meta-analysis of studies reporting on ASCA and pANCA in IBD was performed. Sensitivity, specificity, and likelihood ratios (LR+, LR-) were calculated for different test combinations for CD, UC, and for IBD compared with controls. Meta-regression was used to analyze the effect of age, DNAse, colonic CD, and assay type.
Sixty studies comprising 3,841 UC and 4,019 CD patients were included. The ASCA+ with pANCA- test offered the best sensitivity for CD (54.6%) with 92.8% specificity and an area under the ROC (receiver operating characteristic) curve (AUC) of 0.85 (LR+ = 6.5, LR- = 0.5). Sensitivity and specificity of pANCA+ tests for UC were 55.3% and 88.5%, respectively (AUC of 0.82; LR+ = 4.5, LR- = 0.5). Sensitivity and specificity were improved to 70.3% and 93.4% in a pediatric subgroup when combined with an ASCA- test. Meta-regression analysis showed decreased diagnostic precision of ASCA for isolated colonic CD (RDOR = 0.3).
ASCA and pANCA testing are specific but not sensitive for CD and UC. It may be particularly useful for differentiating between CD and UC in the pediatric population.
Background Surgical technology has led to significant improvements in patient outcomes. However, failures in equipment and technology are implicated in surgical errors and adverse events. We aim to ...determine the proportion and characteristics of equipment-related error in the operating room (OR) to further improve quality of care. Methods A systematic review of the published literature yielded 19 362 search results relating to errors and adverse events occurring in the OR, from which 124 quantitative error studies were selected for full-text review and 28 were finally selected. Results Median total errors per procedure in independently-observed prospective studies were 15.5, interquartile range (IQR) 2.0–17.8. Failures of equipment/technology accounted for a median 23.5% (IQR 15.0%–34.1%) of total error. The median number of equipment problems per procedure was 0.9 (IQR 0.3–3.6). From eight studies, subdivision of equipment failures was possible into: equipment availability (37.3%), configuration and settings (43.4%) and direct malfunctioning (33.5%). Observed error rates varied widely with study design and with type of operation: those with a greater burden of technology/equipment tended to show higher equipment-related error rates. Checklists (or similar interventions) reduced equipment error by mean 48.6% (and 60.7% in three studies using specific equipment checklists). Conclusions Equipment-related failures form a substantial proportion of all error occurring in the OR. Those procedures that rely more heavily on technology may bear a higher proportion of equipment-related error. There is clear benefit in the use of preoperative checklist-based systems. We propose the adoption of an equipment check, which may be incorporated into the current WHO checklist.
PDF
