Hospital Division Research Articles

Implementation of an adapted Safe Childbirth Checklist in rural Chiapas, Mexico: an evaluation study

Abstract Background The Mexican Ministry of Health has advocated for increased skilled birth attendance in hospital facilities to decrease maternal and newborn morbidity and mortality. Partners In Health (PIH) works in a rural region of Mexico where the home birth rate is 60%. The primary purpose of this project is to improve the quality of care, including adherence to evidence-based practices and promotion of respectful practices during childbirth, in a rural hospital in Chiapas, Mexico. Additionally, we hope to strengthen the role of professional midwives and obstetric nurses as competent clinicians in managing women with low-risk pregnancies during childbirth. Methods PIH collaborated with Ariadne Labs to adapt and implement the WHO Safe Childbirth Checklist in a rural hospital in Angel Albino Corzo, Chiapas. Four pause points (at admission, just before delivery, within 1h of birth, and before discharge) were adapted according to the local context. Additional items were added to capture respectful practices during childbirth. We provided coaching training to the professional midwife and perinatal and obstetric nurses to make optimal use of the checklist for ongoing quality improvement in a team-based environment. The checklist and coaching tools have been developed into a mobile application using CommCare for instant data capture and continuous monitoring and evaluation. We used a mixed-methods study to capture adherence to evidence-based practices and integrated these findings with patient and provider experiences during labour and delivery. We conducted post-discharge surveys and post-partum interviews to explore how patients perceive the care they received during childbirth. Findings By August, 2016, five obstetric nurses, one perinatal nurse, and one professional midwife were using the adapted Safe Childbirth Checklist in the study hospital. Data collection using CommCare began in September, 2016, and will continue until June, 2017. By March, 2017, we had captured data from about 350 birthing women using the WHO Safe Childbirth Checklist and 160 women who had completed the discharge survey. We have conducted interviews with 25 postpartum women and some of their birth companions. Data collection is ongoing but preliminary data from September to December, 2016, show that 64% (171/266) of women were asked at least two questions about their preferences in labour, 13% (28/216) of women received episiotomies without indication, 68% (147/216) initiated skin-to-skin within 1h of delivery, and 56% (122/216) of women initiated breastfeeding after delivery. Preliminary analysis of the discharge surveys reveal high satisfaction with the care women received at the hospital. Qualitative interviews indicate some variation in birth experiences. Interpretation There is some variation in adherence with evidence-based practices and perceptions of good quality of care at the rural hospital since implementing the adapted Safe Childbirth Checklist along with other PIH-driven community initiatives. While we do not have a baseline for these indicators, our intervention represents the first attempt at any quality improvement initiative for childbirth care in this region, and adoption will require continued buy-in from hospital staff. Funding The MacArthur Foundation, and Brigham and Women's Hospital Division of Women's Health.

Does leadership style of modern matrons contribute to safer and more effective clinical services?

At the time of writing, the author was a modern matron in a surgical division of an NHS teaching hospital in London. This article considers the differences between leadership and management, and discusses the skills required by modern matrons to lead safe and successful clinical services. It also examines three leadership styles - transactional, transformational and situational - and their relevance to the role of modern matron.

Occupational Stress and Burnout among Surgeons in Fiji

This study examined the levels of occupational stress and burnout among surgeons in Fiji. A document set comprising a cover letter; a consent form; a sociodemographic and supplementary information questionnaire; the Maslach Burnout Inventory (MBI); the 12-item General Health Questionnaire (GHQ-12); the Alcohol Use Disorders Identification Test (AUDIT); and the Professional Quality of Life (ProQOL) questionnaires were provided to surgeons from three public divisional hospitals in Fiji. Thirty-six of 43 (83.7%) invited surgeons participated in the study. According to their MBI scores, surgeons suffered from low (10, 27.8%), moderate (23, 63.9%), and high (3, 8.3%) levels of burnout. Comparatively, 23 (63.9%) demonstrated moderate burnout according to their ProQOL scores. Substantial psychiatric morbidity was observed in 16 (44.0%) surgeons per their GHQ-12 scores. Consumption of alcohol was noted in 29 (80.6%) surgeons, and 12 (33.4%) had AUDIT scores characterizing their alcohol use in excess of low-risk guidelines or as harmful or hazardous drinking. Surgeons of Fijian nationality showed higher MBI emotional exhaustion and depersonalization scores compared with surgeons of other nationalities. Surgeons with an awareness of the availability of counseling services at their hospitals showed low AUDIT and ProQOL burnout scores. Smokers, alcohol drinkers, and kava drinkers showed higher AUDIT scores. This study highlights a level of occupational stress and burnout among surgeons in Fiji and a lack of awareness of their mental and physical well-being. The authors recommend that occupational stress and burnout intervention strategies be put in place in hospitals in Fiji.

Establishing a System for Effectively Explaining Indications for Driving Prohibition Contained in Drug Package Inserts.

To prevent onset and proliferation of public health/hygiene hazards arising from adverse reactions to drugs, physicians and pharmacists in Japan are now required to provide sufficient explanation of precautions when prescribing or dispensing drugs with package inserts indicating that the patient should not drive, or should take precautions when driving, while taking the drug. Additionally, to ensure proper use of drugs dispensed in accordance with the prescriptions issued by physicians or dentists, the Law for Partial Amendment of the Pharmaceutical Affairs Law (Law No. 103 of 2013) mandates that pharmacists must provide necessary pharmacological research-supported information and guidance to the person receiving the prescribed drug. Under such circumstances, at the Ehime University Hospital Division of Pharmacy we have recently standardized our system for in-person explanation of precautions and necessary guidance to be practiced by pharmacists at our hospital's pharmacy with outpatients being prescribed any drug that requires driving caution. We present concrete examples to support that such standardization of the explanation and guidance system at our hospital has reduced the burden placed on pharmacists in their provision of routine clinical services.

Adherence to standard precautions in a teaching hospital.

analyze related factors and the level of adherence to standard precautions of nursing professionals from the clinical medical division of a teaching hospital. a quantitative, cross-sectional, analytical study was conducted with 54 nursing professionals using the Psychometric Scale of Adherence to Standard Precautions, translated and validated to Brazilian Portuguese. the global score of adherence was intermediate (4.41); no statistically significant correlation was observed between adherence and professional category (p=0.404) and length of professional practice (p= 0.612). A correlation was observed between 'Washes hands after removing disposable gloves' (p=0.026) and professionals with nursing practice above 10 years. adherence to standard precautions by the nursing team was intermediate, with no statistically significant difference in relation to the professional category and length of professional practice.

The determinants and costs of bypassing small hospitals in a ‘free’ health system: A cross sectional study in Sri Lanka

Background: Rising out-of-pocket health expenditure due to policy issues is a major factor contributing to deterioration of efficiency and equity of healthcare systems. Objective: The objective of this study was to estimate the determinants of bypassing divisional hospitals in Sri Lanka, and to estimate the effect of bypassing behaviour on the direct out of pocket costs of the patients. Methods: The study employed a hospital based cross sectional analytical design. Out patients department of District General Hospital – Gampaha was selected as the referral facility. Out patients departments of the two selected divisional hospitals were selected as the bypassed facilities. The patients who bypassed the two divisional hospitals and attended the out patients department of the general hospital were identified using a screening tool and a map. The reasons for bypassing were evaluated among those who bypassed. Out of pocket costs of the bypassed were assessed using an interviewer administered questionnaire and compared with the patients who did not bypass the divisional hospitals. Bivariate analysis of the out of pocket expenditure was performed using the Mann-Whitney test, placing the level of significance at 0.05. Results: Patients who bypassed the divisional hospitals were more likely to be married, permanently employed, and have monthly incomes above Rs. 20000. The mean out of pocket expenditure for travelling of bypassed patients and their family members was more than four folds higher than those who did not bypass. The out of pocket expenditure on meals and snacks was also higher among the bypassed. However, more patients among the bypassed group had to spend on outside purchase of medicine and investigations. The average out of pocket expenditure among the bypassed group was about 75% greater than (Rs 63/= more) their counterparts who did not bypass. Conclusions: Bypassing increases the out of pocket expenditure of patients. A primary care based model with designated draining areas and proper referral policies would help to address the issue.

A guide to the anti-innovation “pharmaphobia” narrative for the aspiring innovator

Thomas P. Stossel is an American Cancer Society Professor of Medicine Emeritus at Harvard Medical School, Honorary Physician in the Hematology Division of Brigham & Women's Hospital, founding scientist of BioAegis Therapeutics, Visiting Scholar of The American Enterprise Institute and cofounder of Options for Children in Zambia.

Essential drug stock alert tracker in provincial department of Health Services Western Province

Introduction The health indices in Sri Lanka are well above the regional health indices, which can be partly attributed to the free health care system. However, lack of pharmacy supplies in government health institutions, especially in divisional hospitals, is a major complaint from the general public. Health care institutions under the purview of Provincial Director of Health Services (PDHS) receive pharmacy items from the Regional Medical Supplies Division (RMSD). Some of the reasons for shortage of pharmacy items are poor communication between RMSD and health institutions, mal-distribution of items at RMSD and actual drug shortage. Currently there is no manual or electronic mechanism to monitor the institution’s essential drugs at any level, resulting in difficulty to replenish stocks in a timely manner. Objective The objective of this system is to alert the health care institutional heads and regional/provincial administrators about essential drug status and to effectively mobilize the available drugs. Methods A Web based system was designed with a simple data entry format and color code system. A dashboard facilitates the visualization of the available stock with green (satisfactory), yellow (reorder), red (zero stock). User levels in the system include institution, RMSD, Regional and Provincial levels. Currently 26 essential drug items are monitored by the system. Results Before implementing the system, there were 38 occasions (11.73%) of zero stock level for any of the 26 essential drugs in Divisional hospitals. In 66(20.37%) occasions the drugs were at low stock level. This has improved to 1.54% and 8.02% respectively as at April 2016. Conclusion Both Knowledge and Practices for a preparedness of a chemical hazard were not adequate. Some key factors were significantly associated with service duration and teaching subject at school of study subjects. Policy guidelines to assess the disaster drills, training programmes ensuring attendance of all school population are recommended. Coordinated assistance from Disaster Management Centre and health sector should be arranged.

Evaluation of flood preparedness in government healthcare facilities in Eastern Province, Sri Lanka

ABSTRACT Background: Sri Lanka is vulnerable to floods and other hydro-meteorological disasters. Climate change is projected to increase the intensity of these events. Objective: This study aimed to assess the flood preparedness in healthcare facilities in Eastern Province. Design: This was a cross-sectional, descriptive, mixed methods study conducted in Trincomalee District. Surveys were conducted in 31 government healthcare facilities, using a pre-tested, structured questionnaire covering the last 5 years. Seven in-depth interviews were conducted with randomly selected Medical Officers in Charge or their equivalent, and 3 interviews were conducted with Medical Offices of Health. Results: Two general hospitals, 3 base hospitals, 11 divisional hospitals, and 15 primary care units were included. Six respondents (19.4%) reported flooding in their facility, and 19 (61.3%) reported flooding in their catchment area. For the health workforce, 77.4% of respondents reported not enough staff to perform normal service delivery during disasters, and 25.5% reported staff absenteeism due to flooding. Several respondents expressed a desire for more disaster-specific and general clinical training opportunities for themselves and their staff. Most respondents (80.7%) reported no delays in supply procurement during weather emergencies, but 61.3% reported insufficient supplies to maintain normal service delivery during disasters. Four facilities (12.9%) had disaster preparedness plans, and 4 (12.9%) had any staff trained on disaster preparedness or management within the last year. One quarter (25.8%) of respondents had received any written guidance on disaster preparedness from the regional, provincial, or national level in the last year. Conclusions: While there is a strong health system operating in Sri Lanka, improvements are needed in localized and appropriate disaster-related training, resources for continuing clinical education, and investments in workforce to strengthen flood and other disaster resilience within the government healthcare system in the study district.

ADT-G as a promising biomarker for peripheral hyperandrogenism in adult female acne.

ABSTRACTAcne vulgaris is a chronic inflammatory disease that affects the pilosebaceous unit. Recent studies have shown an increasing number of cases of acne in adult women. These cases are predominantly normoandrogenic and present some clinical differences compared to adolescent acne. Local glandular metabolism turns some weak hormonal precursors into more active substances that increase the production of sebum, leaving these areas more prone to an increasing the colonization by Propionibacterium acnes (P. acnes). Our objective was to evaluate the usefulness of an androgenic metabolite as an adult female acne biomarker. The study population consisted of 38 adult women with acne without any features of hyperandrogenism and a control group. They were recruited from the clinic of Dermatology Hospital Division of São Paulo, Federal University of São Paulo from January 2012 to September 2014. After the first hormonal dosages, patients with acne were randomized into two different groups: one receiving a combined oral contraceptive (COC) containing 0,02 mg of ethinylestradiol and 3 mg drospirenone in a regimen of 24 days of medication, and the other group was treated with a topical gel containing 15% azelaic acid (AA), twice daily, both for six months. With the end of treatment new dosages were performed. Regarding the hormones, total and free testosterone and dehydroepiandrosterone sultate were quantified. In addition, the detection and quantification of androsterone glucuronate (ADT-G), an androgenic metabolite, has been developed. Only ADT-G was sensitive in detecting differences between the control and acne groups, and presented reduction of their values with systemic treatment. Therefore, only ADT-G was able to analyze the peripheral hyperandrogenism in cases of adult female acne.

The effect on acne quality of life of topical azelaic acid 15% gel versus a combined oral contraceptive in adult female acne: A randomized trial.

ABSTRACTAcne vulgaris is a chronic inflammatory disease that affects the pilosebaceous unit. Recent studies have shown an increasing number of cases of acne in adult women. These cases are predominantly normoandrogenic and have show some clinical differences compared to adolescent acne. In addition to the physical aspects, acne has a strong psychosocial impact and can lead to the onset of signs and symptoms of depression, such as anger. Our objective was to evaluate the effect on acne-specific quality of life in adult women treated with topical azelaic acid versus a combined oral contraceptive. The study population consisted of 38 adult women with acne and without any features of hyperandrogenism recruited from the clinic of Dermatology Hospital Division of São Paulo, Federal University of São Paulo from January 2012 to September 2014. Patients were randomized into two different groups: one receiving containing 20 ug of ethinylestradiol and 3 mg drospirenone in a regimen of 24 days of medication, a combined oral contraceptive (COC), and the other group topical 15% azelaic acid (AA) gel, twice daily, both for six months. The quality of life was evaluated at baseline and end of treatment with an acne specific measure (Acne-QoL). Before treatment, our data revealed a significant impact of the presence of acne on quality of life. Both treatments resulted in improvement with significant statistical values in quality of life scores. Comparing the four domains of Acne-QoL, patients treated with an oral contraceptive showed greater improvement in two domains (self-perception and acne symptoms) than those treated with azelaic acid.

Stroke risk in treatment of type 2 diabetes in China: a 7 year retrospective cohort study

BackgroundDiabetes and stroke are leading causes of death and disability, and major public health concerns in China, which accounts for 25% of patients with diabetes worldwide. Type 2 diabetes is an independent risk factor for cerebral ischaemia and accounts for about 20% of stroke cases. We previously showed that KATP channel activation provides neuroprotection against cerebral ischaemia and that sulfonylureas blocking these channels increase the stroke risk in patients with type 2 diabetes. We aimed to further determine whether different classes of antidiabetic drugs increase the risk of stroke in Chinese patients with type 2 diabetes. MethodsIn this retrospective cohort study, we used data from medical records (Jan 1, 2008, to Dec 30, 2015) of the Endocrinology Division of the Third Affiliated Hospital of Jilin University, Jilin, China. Patients aged 32–80 years with type 2 diabetes whose blood glucose control treatment included sulfonylureas, metformin, insulin, or restricted diet were eligible for inclusion. All patients also received education on diet, exercise, blood glucose monitoring, and other aspects of diabetes management. We used χ2 test was to determine significance (p<0·05) between two sets of categorical data and Student's t-test for continuous data. To determine the overall risk, we used multivariate logistic regression with stroke occurrence as the dependent variable and hypoglycaemic drug as the independent variable. Ethics approval was granted by The Third Affiliated Hospital of Jilin University. Results1829 patients were eligible for inclusion, of whom 528 had sulfonylureas, 611 had metformin, 535 had insulin, and 155 were on a restricted diet. 55 individuals who switched to alternative therapy or were lost to follow-up were excluded, and 1774 patients were included in analysis. 116 cases of stroke were recorded: 42 in the sulfonylurea group, 29 in the metformin group, 36 in the insulin group, and nine in the restricted diet group. The risk of stroke in patients given sulfonylureas was increased by 2·65 times (95% CI 1·56–4·50) compared with those given metformin, 1·21 times (0·79–1·86) compared with those given insulin, 1·13 times (0·56–2.25) compared with those on a restricted diet, and 1·63 times (1·12–2·37) compared with all three non-sulfonylurea groups. InterpretationChinese patients with diabetes receiving sulfonylureas seem to have a higher risk of stroke than those using non-sulfonylurea antidiabetic treatments. Cardiovascular safety of antidiabetic drugs needs to be carefully assessed to improve health care and quality of life in Chinese patients with diabetes. FundingHeart and Stroke Foundation of Canada (G-13-0003069) and National Sciences and Engineering Research Council of Canada (NSERC-249962-09).

Prognostic Effect of Isolated Nocturnal Hypertension in Chinese Patients With Nondialysis Chronic Kidney Disease.

BackgroundIsolated nocturnal hypertension (INH) has been studied among the general population and hypertensive patients. However, little insight is available on the prognostic effect of INH in patients with chronic kidney disease (CKD). This study investigated the prognostic effect of INH in a cohort of Chinese patients with nondialysis CKD.Methods and ResultsA total of 588 Chinese CKD patients who were admitted to the Third Affiliated Hospital of Sun Yat‐Sen University were enrolled in this study. We monitored blood pressure (BP) throughout the day and followed health outcomes in the 588 CKD patients admitted to our hospital division. We recorded time to total mortality, cardiovascular mortality, renal events, and cardiovascular events. A total of 370 (62.92%) individuals had nocturnal hypertension, which included 136 (23.13%) patients with INH. Multivariable Cox regression analyses showed that nocturnal BP was a significant risk factor for renal events and cardiovascular events in CKD patients, even when adjusted for clinic BP, 24‐hour BP, or daytime BP. Patients with nocturnal hypertension showed a worse prognosis compared with patients with nocturnal normotension (P<0.05), and nocturnal hypertension (versus nocturnal normotension) was associated with an increased risk for renal events (hazard ratio [HR], 3.81; 95% CI, 1.74–8.36) and cardiovascular events (HR, 8.34; 95% CI, 1.98–35.07). In addition, patients with INH had a worse prognosis than patients with normotension (P<0.017), whereas INH (versus normotension) was associated with a higher risk of renal events (HR, 2.78; 95% CI, 1.16–6.65) and cardiovascular events (HR, 6.82; 95% CI, 1.52–30.63).Conclusions INH was associated with a poor prognosis in Chinese nondialysis CKD patients.

Prevalence, determinants, and clinical significance of masked hypertension and white-coat hypertension in patients with chronic kidney disease.

Masked hypertension and white-coat hypertension have been studied among the general population and in hypertensive patients. However, little insight is available on masked and white-coat hypertension among patients with chronic kidney disease (CKD). We recruited 1322 CKD patients admitted to our hospital division. Patients were divided into four groups: normotension; white-coat hypertension (WCHT); masked hypertension (MHT); sustained hypertension. Multivariable logistic regression analyses were used to evaluate the correlation between WCHT, MHT and renal/cardiovascular parameters. The prevalence of WCHT and MHT was 10.21% and 16.11%, respectively. Patients with WCHT and MHT had more severe target-organ damage (TOD) than patients with normotension, but had less severe TOD than patients with sustained hypertension. MHT correlated with impaired renal function and left-ventricular hypertrophy, whereas WCHT was associated with abnormal carotid intima media thickness. Age, body mass index, clinic and 24-h systolic blood pressure correlated with MHT, whereas clinic, 24-h diastolic blood pressure and night-time systolic blood pressure was associated with WCHT. Prevalence of WCHT and MHT was 10.21% and 16.11%, respectively. WCHT and MHT show a close relationship with TOD in CKD patients.

Abstract: Does the Organization of Plastic Surgery into Independent Departments Affect Academic Productivity?

INTRODUCTION: Plastic surgery has traditionally been a division of general surgery. However, there are an increasing number of plastic surgery departments. A microeconomic analysis of divisions versus departments in 2011 concluded that different surgical services under a single financial and administrative umbrella is no longer logical or optimal1. The purpose of this study was to determine whether or not departmental status (independent department vs. division) affects academic productivity in plastic surgery, as measured by publications, citations and NIH funding. MATERIALS AND METHODS: The American Council of Academic Plastic Surgeons (ACAPS) website was used to generate a list of all plastic surgery divisions/departments with residency programs. Scholarly metrics were determined for 955 faculty at the 88 ACGME plastic surgery departments and divisions with residency programs. Divisions and departments were ranked based on publications, citations and NIH funding and general characteristics were compared. RESULTS: The majority of programs continue to be divisions of general surgery (64 vs 24). The highest cited plastic surgery program in this dataset was at the Brigham and Women’s Hospital (division). Brigham and Women’s Hospital (division) also had the highest total publications, and Stanford University (division) also had the highest total numbers of NIH awards. There were no clear differences between the top five institutions by each category regarding whether they were divisions or independent departments. Departments had higher numbers of integrated residents (9 vs. 5, p = 0.03), had a more even male to female ratio (2.8 vs 4.1, p = 0.06), and a trend towards higher numbers of PhDs (0.67 vs 0.28 p = 0.1). CONCLUSIONS: No one program is the strongest in every metric of productivity, and the top five most academically productive programs using the metrics in this study represented both independent departments and divisions of general surgery. Based on this study, plastic surgery departments are at least equivalent to divisions and may be better resourced to meet their clinical obligations but also to develop their academic enterprise going forward. 1. Mar PL, Yu RA, Yu JC. Division or department: a microeconomic analysis. Plast. Reconstr. Surg. 127: 2487, 2011.

Abstract: Risk Stratification of Major Complications After Outpatient Abdominoplasty or Panniculectomy

BACKGROUND: Ambulatory surgery centers offer the advantages of greater efficiency and overall patient experience. As more procedures are performed in the outpatient setting, reliably identifying patients at higher risk for major complications will be critical. Abdominoplasty and panniculectomy represent a large component of ambulatory plastic surgery procedures. While recent studies have identified risk factors for complications in the outpatient setting, there is no clinically actionable tool available for use currently.1, 2 This study utilizes the ACS-NSQIP dataset to develop a risk-stratification model for complications requiring secondary clinical intervention after outpatient abdominal surgery. METHODS: Patients undergoing abdominoplasty or panniculectomy were identified from the NSQIP databases for 2012–2013. The primary outcome was need for secondary clinical intervention, defined as unplanned readmission or reoperation. Patient comorbidities and operative characteristics were correlated with complication risk. A step-wise multivariate logistic regression of all factors with p value< 0.1 was conducted and resulting significant factors were entered into a bootstrap technique. Adjusted multivariate beta-coefficients were used to generate weighted risk scores for each factor. Each patient was then assigned an aggregate complication risk score, yielding the risk-assessment tool. RESULTS: 1,429 patients underwent outpatient abdominal surgery and were included for analysis. Unplanned reoperation or readmissions were observed in 4.1% of surgeries (n=59). Independent patient factors predictive of secondary clinical intervention included malnutrition (OR=8.1), male gender (OR=3.4), diabetes (OR=2.8), smoking (OR=2.5), BMI 35 or higher (OR=2.2), and age over 45 (OR=2.2). Regarding operative characteristics, patients undergoing concurrent breast implant insertion were at increased risk (OR=4.4), while those undergoing trunk liposuction were less likely to require secondary clinical intervention (OR=0.48). Patients were stratified into 4 groups according to complication risk: low risk (complication=1.7%), average risk (complication=2.7%), high risk (complication=8.8%), and extreme risk (complication=21.0%). The model demonstrated high sensitivity and specificity for discriminating need for secondary intervention with a C-statistic=0.76. It was also applicable to secondary outcomes, and accurately predicted surgical complications, overall complications, and prolonged hospital stay during the index procedure. CONCLUSIONS: This study builds upon previous work by providing a quantifiable risk stratification system for clinically relevant complications experienced after abdominal surgery in the ambulatory setting. Malnutrition, male gender, and concurrent breast prosthetic implantation were strong independent predictors of risk. This tool may enhance preoperative counseling and improve patient selection in the ambulatory setting. DISCLOSURE/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Funded by the Division of Plastic Surgery, Brown University and Rhode Island Hospital. REFERENCES: 1. Basta MN, Bauder AR, Kovach SJ, et al. Assessing the predictive accuracy of the American College of Surgeons National Surgical Quality Improvement Project Surgical Risk Calculator in open ventral hernia repair. Am J Surg. 2016; 2. Fischer JP, Basta MN, Wink JD, et al. Optimizing patient selection in ventral hernia repair with concurrent panniculectomy: an analysis of 1974 patients from the ACS-NSQIP datasets. J Plast Reconstr Aesthet Surg. 2014; (67) 11: 1532–1540

Incident reporting systems: a comparative study of two hospital divisions.

BackgroundPrevious studies of incident reporting in health care organizations have largely focused on single cases, and have usually attended to earlier stages of reporting. This is a comparative case study of two hospital divisions’ use of an incident reporting system, and considers the different stages in the process and the factors that help shape the process.MethodThe data was comprised of 85 semi-structured interviews of health care practitioners in general internal medicine, obstetrics and neonatology; thematic analysis of the transcribed interviews was undertaken. Inductive and deductive themes are reported. This work is part of a larger qualitative study found elsewhere in the literature.ResultsThe findings showed that there were major differences between the two divisions in terms of: a) what comprised a typical report (outcome based vs communication and near-miss based); b) how the reports were investigated (individual manager vs interdisciplinary team); c) learning from reporting (interventions having ambiguous linkages to the reporting system vs interventions having clear linkages to reported incidents); and d) feedback (limited feedback vs multiple feedback).ConclusionsThe differences between the two divisions can be explained in terms of: a) the influence of litigation on practice, b) the availability or lack of interprofessional training, and c) the introduction of the reporting system (top-down vs bottom-up approach). A model based on the findings portraying the influences on incident reporting and learning is provided. Implications for practice are addressed.

Prevalence of Homocysteine-Related Hypertension in Patients With Chronic Kidney Disease.

Patients with both hypertension and hyperhomocysteinemia, termed H-type hypertension, have a high risk for cardiocerebrovascular diseases. However, little is known about the prevalence of H-type hypertension or its role in target organ damage in patients with chronic kidney disease (CKD). The authors recruited 1042 patients with CKD who were admitted to their hospital division. Multiple linear regression analyses were used to evaluate the association between H-type hypertension and renal/cardiovascular parameters. A total of 460 (44.14%) CKD patients had H-type hypertension. Multivariate logistic regression analysis showed that H-type hypertension is associated with serum albumin, uric acid, estimated glomerular filtration rate (eGFR), and 24-hour systolic blood pressure. Patients with H-type hypertension had the worst renal function and left ventricular hypertrophy among all patients, while the levels of carotid intima-media thickness (cIMT) in patients with H-type hypertension were only slightly higher than in patients with normotension and normohomocysteinemia (P<.05). H-type hypertension was associated with eGFR, left ventricular mass index, and cIMT according to multiple linear regression analyses. The prevalence of H-type hypertension was high and H-type hypertension was associated with target organ damage in patients with CKD.

Robot-Assisted Abdominoperineal Resection: Clinical, Pathologic, and Oncologic Outcomes.

The extralevator approach to abdominoperineal resection is associated with a decreased incidence of rectal perforation and circumferential resection margin positivity translating to lower recurrence rates. The abdominoperineal resection, as such, is an operation associated with poorer outcomes in comparison with low anterior resections, and any improvements in short-term outcomes are likely to be related to surgical technique. Robot assistance in extralevator abdominoperineal resection has shown improvement in these pathologic outcomes. Because these are surrogate markers for local recurrence and disease-free survival, long-term survival data are needed to assess the efficacy of this robot-assisted technique, exclusively in a dedicated abdominoperineal resection cohort. We assessed the perioperative, pathologic, and oncologic outcomes of the robot-assisted extralevator abdominoperineal resection for rectal cancer. This study was a review of a prospective database of patients over a 5-year period. Procedures were performed in the colorectal division of a tertiary hospital from April 2007 to July 2012. Patients with rectal cancer were operated on robotically. Indications for abdominoperineal resection were low rectal cancers invading the sphincter complex or location in the anal canal precluding anastomosis. All patients received a robot-assisted extralevator abdominoperineal resection. Operative and perioperative measures, pathologic outcomes, and disease-free survival and overall survival were documented and assessed. Twenty-two patients (15 men) with a mean age of 65.5 years and mean BMI of 28.6 kg/m underwent robotic abdominoperineal resection. Circumferential resection margin was positive in 13.6%. There was 1 tumor/rectal perforation. At a mean follow-up of 33.9 months, overall survival was 81.8% with a disease-free survival of 72.7%. Local recurrence was 4.5%. This was a single-institution study with no comparative open or laparoscopic group. Robot-assisted abdominoperineal resection is safe, feasible, and oncologically sound with short-term and long-term outcomes comparable to open and laparoscopic surgery.

Return to Sport After Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Athlete.

Determine the percentage of skeletally immature athletes returning to sports after anterior cruciate ligament (ACL) injury and reconstruction. Retrospective case series. Boston Children's Hospital Division of Sports Medicine. Eligible participants were identified by chart review. Males and females aged ≤14 year old who were greater than 2 years after ACL reconstruction surgery seen between January 2001 and May 2009. A total of 250 patients completed the questionnaires. Age, sex, mechanism, and sport played at time of ACL injury. Response to the survey was 75% (250 of 333) which was analyzed using descriptive statistics to provide a summary of the study cohort. Kaplan-Meier survivorship analysis was applied to determine time to return to sports participation after ACL reconstruction with Greenwood formula used to calculate 95% confidence intervals around the estimated percentage returning at 6, 9, 12, 18, and 24-month follow-up. After undergoing ACL reconstruction, 96% of skeletally immature athletes are able to return to sports at the same skill level. Median time to return to sports was 9 months postoperative, with most athletes returning to sports (85%) by 12 months. After undergoing ACL reconstruction, most child athletes are able to return to sports and 50% of these athletes return within 9 months after surgery. After undergoing ACL reconstruction, 96% of athletes ≤14 year old are able to return to sports at the same skill level. Median time to return to sports was 9 months postoperative, with most athletes returning to sports (85%) by 12 months. In our study, patients cited physical limitation, loss of interest in sport, and fear of reinjury as reasons for not returning to previous level of sport. Return to sport may be improved by additional research into sports-specific training and rehabilitation in this cohort.