Background
We sought to evaluate trends in selection of high volume (HV) hospitals for pancreatic surgery, as well as examine trends in preoperative complications, mortality, and failure to rescue ...(FTR).
Method
Patients who underwent pancreatic resection between 2000 and 2011 were identified from the Nationwide Inpatient Sample (NIS). Preoperative morbidity, mortality, and FTR were examined over time. Hospital volume was stratified into tertiles based on the number of pancreatic resections per year for each time period. Logistic regression models were used to assess the effect of hospital volume on risk of complication, postoperative mortality, and FTR over time.
Result
A total of 35,986 patients were identified. Median hospital volume increased from 13 in 2000–2003 to 55 procedures/year in 2008–2011 (
P
< 0.001). Morbidity remained relatively the same over time at low volume (LV), intermediate volume (IV), and HV hospitals (all
P
> 0.05). Overall postoperative mortality was 5 %, and it decreased over time across all hospital volumes (
P
< 0.05). FTR was more common at LV (12.0 %) and IV (8.5 %) volume hospitals compared with HV hospitals (6.4 %). The improvement in FTR over time was most pronounced at LV and IV hospitals versus HV hospitals (
P
= 0.001).
Conclusion
Median hospital volume for pancreatic surgery has increased over the past decade. While the morbidity remained relatively stable over time, mortality improved especially in LV and IV hospitals. This improvement in mortality seems to be related to a decreased FTR.
Abstract
Background and Aims
The current study proposes a novel volume–outcome (V–O) meta-analytical approach to determine the optimal annual hospital case volume threshold for cardiovascular ...interventions in need of centralization. This novel method is applied to surgery for acute type A aortic dissection (ATAAD) as an illustrative example.
Methods
A systematic search was applied to three electronic databases (1 January 2012 to 29 March 2023). The primary outcome was early mortality in relation to annual hospital case volume. Data were presented by volume quartiles (Qs). Restricted cubic splines were used to demonstrate the V–O relation, and the elbow method was applied to determine the optimal case volume. For clinical interpretation, numbers needed to treat (NNTs) were calculated.
Results
One hundred and forty studies were included, comprising 38 276 patients. A significant non-linear V–O effect was observed (P < .001), with a notable between-quartile difference in early mortality rate 10.3% (Q4) vs. 16.2% (Q1). The optimal annual case volume was determined at 38 cases/year 95% confidence interval (CI) 37–40 cases/year, NNT to save a life in a centre with the optimal volume vs. 10 cases/year = 21. More pronounced between-quartile survival differences were observed for long-term survival 10-year survival (Q4) 69% vs. (Q1) 51%, P < .01, adjusted hazard ratio 0.83, 95% CI 0.75–0.91 per quartile, NNT to save a life in a high-volume (Q4) vs. low-volume centre (Q1) = 6.
Conclusions
Using this novel approach, the optimal hospital case volume threshold was statistically determined. Centralization of ATAAD care to high-volume centres may lead to improved outcomes. This method can be applied to various other cardiovascular procedures requiring centralization.
Structured Graphical Abstract
Structured Graphical Abstract
Overview of the process to determine the volume-outcome relation and the optimal annual case volume in surgery for acute type A aortic dissection. Grey line: first quartile, yellow line: second quartile, blue line: third quartile, and red line: fourth quartile. ATAAD, acute type A aortic dissection.
Audio Abstract
10.1093/eurheartj/ehad551media1
Audio Abstract
ehad551media1
6335404329112
Background: Inhaled bronchodilators can increase exercise capacity in chronic obstructive pulmonary disease (COPD) by reducing dynamic hyperinflation, but treatment is not always effective. This may ...reflect the degree to which the abdomen allows dynamic hyperinflation to occur. Method: A double blind, randomised, crossover trial of the effect of 5 mg nebulised salbutamol or saline on endurance exercise time was conducted in 18 patients with COPD of mean (SD) age 67.1 (6.3) years and mean (SD) forced expiratory volume in 1 second (FEV1) of 40.6 (15.0)% predicted. Breathing pattern, metabolic variables, dyspnoea intensity, and total and regional chest wall volumes were measured non-invasively by optoelectronic plethysmography (OEP) at rest and during exercise. Results: Salbutamol increased FEV1, forced vital capacity (FVC) and inspiratory capacity and reduced functional residual capacity (FRC) and residual volume significantly. OEP showed the change in resting FRC to be mainly in the abdominal compartment. Although the mean (SE) end expiratory chest wall volume was 541 (118) ml lower (p<0.001) at the end of exercise, the endurance time was unchanged by the bronchodilator. Changes in resting lung volumes were smaller when exercise duration did not improve, but FEV1 still rose significantly after active drug. After the bronchodilator these patients tried to reduce the end expiratory lung volume when exercising, while those exercising longer continued to allow end expiratory abdominal wall volume to rise. The change to a more euvolumic breathing pattern was associated with a lower oxygen pulse and a significant fall in endurance time with higher isotime levels of dyspnoea. Conclusions: Nebulised salbutamol improved forced expiratory flow in most patients with COPD, but less hyperinflated patients tried to reduce the abdominal compartmental volume after active treatment and this reduced their exercise capacity. Identifying these patients has important therapeutic implications, as does an understanding of the mechanisms that control chest wall muscle recruitment.
Previous studies have shown that high-volume centers and laparoscopic techniques improve outcomes of colectomy. These evidence-based measures have been slow to be accepted, and current trends are ...unknown. In addition, the current rates and outcomes of robotic surgery are unknown.
The purpose of this study was to examine current national trends in the use of minimally invasive surgery and to evaluate hospital volume trends over time.
This was a retrospective study.
This study was conducted in a tertiary referral hospital.
Using the National Inpatient Sample, we evaluated trends in patients undergoing elective open, laparoscopic, and robotic colectomies from 2009 to 2012. Patient and institutional characteristics were evaluated and outcomes compared between groups using multivariate hierarchical-logistic regression and nonparametric tests. The National Inpatient Sample includes patient and hospital demographics, admission and treating diagnoses, inpatient procedures, in-hospital mortality, length of hospital stay, hospital charges, and discharge status.
In-hospital mortality and postoperative complications of surgery were measured.
A total of 509,029 patients underwent elective colectomy from 2009 to 2012. Of those 266,263 (52.3%) were open, 235,080 (46.2%) laparoscopic, and 7686 (1.5%) robotic colectomies. The majority of minimal access surgery is still being performed at high-volume compared with low-volume centers (37.5% vs 28.0% and 44.0% vs 23.0%; p < 0.001). A total of 36% of colectomies were for cancer. The number of robotic colectomies has quadrupled from 702 in 2009 to 3390 (1.1%) in 2012. After adjustment, the rate of iatrogenic complications was higher for robotic surgery (OR = 1.73 (95% CI, 1.20-2.47)), and the median cost of robotic surgery was higher, at $15,649 (interquartile range, $11,840-$20,183) vs $12,071 (interquartile range, $9338-$16,203; p < 0.001 for laparoscopic).
This study may be limited by selection bias by surgeons regarding the choice of patient management. In addition, there are limitations in the measures of disease severity and, because the database relies on billing codes, there may be inaccuracies such as underreporting.
Our results show that the majority of colectomies in the United States are still performed open, although rates of laparoscopy continue to increase. There is a trend toward increased volume of laparoscopic procedures at specialty centers. The role of robotics is still being defined, in light of higher cost, lack of clinical benefit, and increased iatrogenic complications, albeit comparable overall complications, as compared with laparoscopic colectomy.
•What is currently known about this topic?Previously, there was no systematic analysis of the evidence on the relationship between hospital as well as surgeon volume and outcomes for neonates with ...gastroschisis.•What new information is contained in this article?Findings from this systematic review suggest that higher hospital volume may reduce in-hospital mortality for gastroschisis. There is no evidence on the surgeon volume-outcome relationship.
Newborns with gastroschisis need surgery to reduce intestines into the abdominal cavity and to close the abdominal wall. Due to an existing volume-outcome relationship for other high-risk, low-volume procedures, we aimed at examining the relationship between hospital or surgeon volume and outcomes for gastroschisis.
We conducted a systematic literature search in Medline, Embase, CENTRAL, CINAHL and Biosis Previews in June 2021 and searched for additional literature. We included (cluster-) randomized controlled trials (RCTs) and prospective or retrospective cohort studies analyzing the relationship between hospital or surgeon volume and mortality, morbidity or quality of life. We assessed risk of bias of included studies using ROBINS-I and performed a systematic synthesis without meta-analysis and used GRADE for assessing the certainty of the evidence.
We included 12 cohort studies on hospital volume. Higher hospital volume may reduce in-hospital mortality of neonates with gastroschisis, while the evidence is very uncertain for other outcomes. Findings are based on a low certainty of the evidence for in-hospital mortality and a very low certainty of the evidence for all other analyzed outcomes, mainly due to risk of bias and imprecision. We did not identify any study on surgeon volume.
The evidence suggests that higher hospital volume reduces in-hospital mortality of newborns with gastroschisis. However, the magnitude of this effect seems to be heterogeneous and results should be interpreted with caution. There is no evidence on the relationship between surgeon volume and outcomes.
In contrast to Andean natives, high-altitude Tibetans present with a lower hemoglobin concentration that correlates with reproductive success and exercise capacity. Decades of physiological and ...genomic research have assumed that the lower hemoglobin concentration in Himalayan natives results from a blunted erythropoietic response to hypoxia (i.e., no increase in total hemoglobin mass). In contrast, herein we test the hypothesis that the lower hemoglobin concentration is the result of greater plasma volume, rather than an absence of increased hemoglobin production. We assessed hemoglobin mass, plasma volume and blood volume in lowlanders at sea level, lowlanders acclimatized to high altitude, Himalayan Sherpa, and Andean Quechua, and explored the functional relevance of volumetric hematological measures to exercise capacity. Hemoglobin mass was highest in Andeans, but also was elevated in Sherpa compared with lowlanders. Sherpa demonstrated a larger plasma volume than Andeans, resulting in a comparable total blood volume at a lower hemoglobin concentration. Hemoglobin mass was positively related to exercise capacity in lowlanders at sea level and in Sherpa at high altitude, but not in Andean natives. Collectively, our findings demonstrate a unique adaptation in Sherpa that reorientates attention away from hemoglobin concentration and toward a paradigm where hemoglobin mass and plasma volume may represent phenotypes with adaptive significance at high altitude.
Relatively little is known about the trading volume in derivatives relative to the volume in underlying stocks. We study the time-series properties and the determinants of the options/stock trading ...volume ratio (O/S) using a comprehensive cross-section and time-series of data on equities and their listed options. O/S is related to many intuitive determinants such as delta and trading costs, and it also varies with institutional holdings, analyst following, and analyst forecast dispersion. O/S is higher around earnings announcements, suggesting increased trading in the options market. Further, post-announcement absolute returns are positively related to pre-announcement O/S, which suggests that at least part of the pre-announcement options trading is informed.
Abstract
Ventricular pressure–volume (PV) analysis is the reference method for the study of cardiac mechanics. Advances in calibration algorithms and measuring techniques brought new perspectives for ...its application in different research and clinical settings. Simultaneous PV measurement in the heart chambers offers unique insights into mechanical cardiac efficiency. Beat to beat invasive PV monitoring can be instrumental in the understanding and management of heart failure, valvular heart disease, and mechanical cardiac support. This review focuses on intra cardiac left ventricular PV analysis principles, interpretation of signals, and potential clinical applications.
Nasopharyngeal cancer is a challenging malignancy with unique characteristics, and its management often involves a combination of radiotherapy, chemotherapy, and targeted therapies.
This abstract ...discusses the significant influence of tumor volume assessment on radiotherapy strategies for treating nasopharyngeal cancer.
Tumor volume measurement has become a critical aspect of nasopharyngeal cancer treatment planning. We conducted a retrospective study of 257 patients treated with the VMAT technique in the external radiotherapy department at the National Institute of Oncology RABAT between January 2018 and December 2021, using various imaging modalities, such as MRI and CT scans, to assess tumor volumes accurately.
We identified 257 patients. Sex repartition: 82% men and 18% women. Comorbidities were observed in 15% cases.
Tumors were classified as T1 in 7 %, T2 in 21 %, T3 in 29 %, and T4 in 43 % 21% based on AJCC stage 8th edition.
The GTV mensuration was mentioned in 32% cases (n=83), median GTV was 77 mm (14mm-140mm)
The predominant histological type was undifferentiated nasopharyngeal carcinoma (UCNT) in 87% of cases.
86% patient received NAC-CCRT, and 14 % patient received CCRT (p < 0.001).
Toxicities were reported at 42% of the patients with a higher incidence of radiomucositis Grade 3 and 4 in important GTV size 25%.
At a Median follow-up of 48 months, locoregional control was found in 75% of patients treated, with 11% of recurrence and 4% metastatic progression. 6% of patients died of their cancer and 4% were lost to follow-up
Our analysis reveals a strong correlation between tumor volume and treatment response in nasopharyngeal cancer patients undergoing radiotherapy. Larger tumor volumes often lead to increased treatment resistance, local recurrence, and distant metastasis. Moreover, high tumor volumes are associated with higher rates of treatment-related toxicity.
The prognostic implications of intravascular volume status assessed by blood volume analysis (BVA) in ambulatory heart failure (HF) remain uncertain. The incremental benefits of assessing volume ...status, beyond the well-established filling pressures, in predicting HF outcomes are unknown.
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