Low-volume Group Research Articles

Trends in the use of partial nephrectomy for cT1 renal tumors: Analysis of a 10-yr European multicenter dataset

AimAlthough extensively addressed in US registries, the utilization rate of Partial Nephrectomy has been poorly addressed in European settings. Our aim is to evaluate the impact of hospital volume on the use of PN for cT1 renal tumors. Methods2526 patients with cT1N0M0 renal tumors treated with either PN or radical nephrectomy at 10 European centres in the last decade were included in the analysis. Joinpoint regression analysis was used to identify significant changes over time in linear slope of the trend for each center. The correlation between yearly caseload and the slopes was assessed with the non-parametric Spearman test. Coincident pairwise tests and regression analyses were used to generate and compare the trends of high-volume (HV), mid-volume (MV) and low-volume (LV) groups. ResultsYearly caseload was significantly associated with increased use of PN (R = 0.69, p = 0.028). The utilization rate of PN was stable at LV centres (p = 0.67, p = 0.7, p = 0.76, for cT1, cT1a, and cT1b tumors, respectively), while increased significantly at MV (p = 0.002, 0.0005 and 0.007, respectively) and HV centers (all p < 0.0001). Regression analysis confirmed the trends for HV and MV as significantly different from those observed in LV centres (all p ≤ 0.002) and highlighted significant differences also between MV and HV centres (all p ≤ 0.03). ConclusionsWe confirmed the association between caseload and the use of PN for cT1 tumors. Our findings suggest that a minimum caseload might turn the tide also in LV centres while a selective referral to HV centers for cT1b tumors should be considered.

(412) - Risk Factors at Presentation Predict Outcomes of Pediatric Myocarditis: A Contemporary Multi-Center Cohort

s S157 Methods: We infused MSC using a dose escalation model: 3 patients received a low volume infusion (1 million MSC/Kg), 3 received an intermediate volume ( 2 million MSC/kg) and 3 received high volume infusion (4 million MSC/Kg). Blood samples were collected as baseline (day -1), on day +1 and day +7 following infusion to measure biomarker assays (B cells, natural killer -NKcells), and T cell enumerations (T-regulatory cells). We used a multiplex cytokine assay to assess pro-inflammatory cytokine (TH1) and tolerogenic cytokine (TH2) levels and pro-angiogenic factors (vascular endothelial growth factor-VEGF). Changes in cytokine levels greater or less than 1 standard deviation from the mean baseline levels was considered significant. Results: We observed no increment in circulating MSC on days +1 and +7 regardless of the volume of MSC infused, suggesting that MSC were trapped in the lung as has been reported. Blood levels of tolerance-inducing T regulatory cells doubled in patients receiving low infusion MSC. NK and B cell numbers decreased in the low volume group. Contrarily, an increase or no change was observed in the other groups. Epidermal Growth Factor (EGF), a potent promoter of cell proliferation, anti-apoptotic and pro-angiogenic factor was significantly increased in the low volume group while no significant change was observed in other groups. Tolerance-inducing TH2 cytokines such as IL-4 significantly increased on patients receiving low and intermediate volume MSC infusion. Pro-inflammatory TH1 cytokines(IL-1, IL-6, and IL-8), and pro-inflammatory chemokines (MCP-1, MIP-1α , and MIP-1β ) significantly decreased in patients receiving low volume infusion. Overall, the biological effects of the MSC therapy appeared to decrease with increasing cell volumes infused. Conclusion: Low volume MSC infusion induces anti-inflammatory effects and promotes cell proliferation and angiogenesis in patients with obstructive CLAD. Higher MSC volumes appear to have less positive biological effects. These results need clinical correlation.

The interaction between physical activity and amount of baseline knee cartilage.

Conflicting reports of the effect of physical activity on knee cartilage may be due to the heterogeneity of populations examined and, in particular, the underlying health of the knee joint. This study examined the influence of recreational and occupational physical activity on cartilage volume loss. A total of 250 participants with no significant musculoskeletal disease were recruited. A gender-specific median cartilage volume split was used to define people in the lowest and highest 50% of baseline cartilage volume. Baseline recreational and occupational activity was examined by questionnaire, while cartilage volume was assessed by MRI at baseline and 2.4 years later. Significant interactions were demonstrable between physical activity and cartilage volume loss based on stratification of baseline cartilage volume (all P ⩽ 0.03). There was a dose-response relationship between frequently performed baseline occupational activities and medial cartilage volume loss in both the low (B = 0.2% per annum, 95% CI: 0.0, 0.04% per annum) and high (B = -0.2% per annum, 95% CI: -0.4, 0.0% per annum) baseline cartilage volume groups (P = 0.001 for interaction). Individuals with low baseline cartilage volume who were active in their occupation and/or recreational activity had greater medial cartilage volume loss than their more inactive counterparts (2.4% per annum vs 1.5% per annum, P = 0.02). Whereas people with less baseline cartilage volume are more at risk of structural knee damage with either heavy occupational or recreational workloads or both, individuals with high baseline cartilage volume may advantageously modify their risk for knee OA by participating in more frequent occupational physical activities.

PD47-01 ASSESSING THE VOLUME-OUTCOME RELATIONSHIP FOR PCNL IN 2014- ANALYSIS USING UK NATIONAL REGISTRY DATA OF OVER 2000 CASES

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation II1 Apr 2016PD47-01 ASSESSING THE VOLUME-OUTCOME RELATIONSHIP FOR PCNL IN 2014- ANALYSIS USING UK NATIONAL REGISTRY DATA OF OVER 2000 CASES John Withington, William Finch, Sarah Fowler, James Armitage, Jonathan Glass, Stuart Irving, Neil Burgess, Kay Thomas, and Oliver Wiseman John WithingtonJohn Withington More articles by this author , William FinchWilliam Finch More articles by this author , Sarah FowlerSarah Fowler More articles by this author , James ArmitageJames Armitage More articles by this author , Jonathan GlassJonathan Glass More articles by this author , Stuart IrvingStuart Irving More articles by this author , Neil BurgessNeil Burgess More articles by this author , Kay ThomasKay Thomas More articles by this author , and Oliver WisemanOliver Wiseman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2689AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Volume-outcome studies in PCNL have reported mixed findings. In the UK, PCNL was previously shown to be equally safe in high and low volume hospitals; this study investigates the relationship between volume and stone clearance, adjusted for stone complexity. METHODS Data from the prospective British Association of Urological Surgeons PCNL registry in 2014 were analysed. Two groups were defined; hospitals performing fewer than 20 and those performing 20 or more cases per year. Comparisons performed between these groups included stone complexity and outcomes, including stone clearance at day one, blood transfusion, sepsis and median post-operative length of stay (LOS). Subgroups of complex (Guy’s Stone Score III-IV) and non-complex (GSS I-II) stones were also compared. RESULTS 2042 procedures were recorded in the registry in 2014. There was no significant difference between stone complexity (p=0.056), or stone dimensions (p=0.18) of cases undertaken at high and low volume centres. Overall stone clearance, by imaging at day 1, was higher in the high volume group than the low volume group (73% vs 63%, p<0.05). This was true for both complex and non-complex stones (55%vs 45%, p<0.05; 85% vs 77%, p<0.05). Blood transfusion rates did not differ significantly between high and low volume groups overall (2.5% vs 2.6%, p=0.92), or when subdivided by stone complexity (GSS III-IV: 3.0% vs 4.9%, p=0.22; GSS I-II, 0.9%vs 2.2%, p=0.09). Post-operative sepsis occurred in 3.1% patients overall. Hospital volume made no significant difference overall (p=0.1), in complex stones (p=0.09) or in non-complex stones (p=0.97). Overall, median total length of stay (LOS) was shorter at high volume centres than low volume centres (2d v 3d). For GSS I-II stones, LOS was shorter for high volume (2d v 3d); this difference was less for GSS III-IV (3.5d v 4d). CONCLUSIONS Hospital volume does not appear to significantly affect transfusion or sepsis rates post-PCNL; stone complexity seems to be more relevant to these outcomes. Stone clearance, however is clearly associated with hospital volume, higher volume centres achieving significantly higher stone free rates. These findings may inform the debate around centralisation of complex PCNL. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1170 Advertisement Copyright & Permissions© 2016MetricsAuthor Information John Withington More articles by this author William Finch More articles by this author Sarah Fowler More articles by this author James Armitage More articles by this author Jonathan Glass More articles by this author Stuart Irving More articles by this author Neil Burgess More articles by this author Kay Thomas More articles by this author Oliver Wiseman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The interaction between physical activity and amount of baseline knee cartilage

OBJECTIVES: Conflicting reports of the effect of physical activity on knee cartilage may be due to the heterogeneity of populations examined and, in particular, the underlying health of the knee joint. This study examined the influence of recreational and occupational physical activity on cartilage volume loss. METHODS: A total of 250 participants with no significant musculoskeletal disease were recruited. A gender-specific median cartilage volume split was used to define people in the lowest and highest 50% of baseline cartilage volume. Baseline recreational and occupational activity was examined by questionnaire, while cartilage volume was assessed by MRI at baseline and 2.4 : years later. RESULTS: Significant interactions were demonstrable between physical activity and cartilage volume loss based on stratification of baseline cartilage volume (all P ⩽ 0.03). There was a dose-response relationship between frequently performed baseline occupational activities and medial cartilage volume loss in both the low (B = 0.2% per annum, 95% CI: 0.0, 0.04% per annum) and high (B = -0.2% per annum, 95% CI: -0.4, 0.0% per annum) baseline cartilage volume groups (P = 0.001 for interaction). Individuals with low baseline cartilage volume who were active in their occupation and/or recreational activity had greater medial cartilage volume loss than their more inactive counterparts (2.4% per annumvs1.5% per annum, P = 0.02). CONCLUSION: Whereas people with less baseline cartilage volume are more at risk of structural knee damage with either heavy occupational or recreational workloads or both, individuals with high baseline cartilage volume may advantageously modify their risk for knee OA by participating in more frequent occupational physical activities.

Effects of Different Aerobic Exercise Programs with Nutritional Intervention in Primary Hypertensive and Overweight/Obese Adults: EXERDIET-HTA Controlled Trial

Background: Both exercise training and diet are recommended to prevent and control primary hypertension (HTN) and overweight/obesity. Aerobic exercise is firmly established as an effective measure for lowering blood pressure (BP) and reducing cardiovascular risk. However, there is no agreement about the optimal dose of frequency, intensity, time and type of exercise. This study is a randomized control trial to investigate the effectiveness of different aerobic exercise programs and diet for reducing BP, for improving body composition, cardiorespiratory fitness, biochemical profile, physical activity and sedentary behavior and health-related quality of life in adults with primary HTN and overweight or obesity. Methods/Design: One hundred sixty-four overweight or obese participants (18-70 yr old) diagnosed with primary HTN will perform different assessments to evaluate BP, physical, biochemical and nutritional condition, sedentary behavior and quality of life before and after 16-week of follow-up. All participants will receive an energy-hypocaloric diet based on 25% of measured resting metabolic rate and will be randomly assigned to control group (only diet) or exercise groups (diet plus aerobic exercise). Participants assigned to an exercise group will train 2 days/week under supervision (treadmill and bike protocol). There will be three aerobic exercise groups: (1) moderate continuous exercise and high volume (MCT) group, (2) high-intensity interval training and high-volume (HV-HIIT) group, and (3) high-intensity interval training and low-volume (LV-HIIT) group. The measurements used in the protocol will be taken before and after the intervention period (16-weeks), and after a six-month period in all participants (i.e., 6 months with only recommendations and no supervision). Discussion: The results of this intervention will help to better understand the potential of non-pharmacological treatment for improving the well-being of people with primary HTN and overweight or obesity.

Pancreaticoduodenectomy: A study from India on the impact of evolution from a low to a high volume unit.

To analyse the impact of turning of our department from a low to a high volume provider of pancreaticoduodenectomy (PD) on surgical outcome. A retrospective collection of data was done for patients who underwent PD. According to the number of PDs undertaken per year, we categorized the volume into low volume (< 10 PDs/year), medium volume (10-24 PDs/year) and high volume (> 25 PDs/year) groups. From 2002 to 2013, 200 patients underwent PD. The annual number of PD increased from 4 in 2002 to 34 in 2013. The mean operative time, operative blood loss and need for intraoperative blood transfusion decreased considerably over the volume categories (P < 0.001, P < 0.001 and P < 0.001, respectively). Increased procedural volume was associated with a lower morbidity (P = 0.021) and shorter length of hospital stay (P < 0.001). Similarly the rate of mortality dropped from 10% for the low volume group to 2.2% for the medium volume group and 0.0% for the high volume group (P = 0.007). The transformation from a low volume to a high volume provider of PD resulted in most favourable outcomes favouring the continued centralization of this high risk procedure.

Effect of BML-111 on ventilator-induced lung injury in rats

Objective To evaluate the effect of BML-111 on ventilator-induced lung injury in rats. Methods Forty-eight healthy male Sprague-Dawley rats, weighing 200-250 g, aged 6-8 weeks, were randomized into 6 groups (n=8 each) using a random number table: control group (C group), low tidal volume (VT) group (LVTgroup), high VT group (HVTgroup), low dose BML-111 group (BL group), high dose BML-111 group (BH group), and BML-111 plus BOC-2 (lipoxin A4 receptor antagonist) group (BOC-2 group). Group C kept spontaneous breathing after tracheotomy, and received no mechanical ventilation.The rats in the other 5 groups were mechanically ventilated (respiratory rate 80 breaths/min, fraction of inspired oxygen 21%, positive end-expiratory pressure 0). The VT was 6 ml/kg in group LVT, or 20 ml/kg in HVT, BL, BH and BOC-2 groups.BML-111 0.1 and 1.0 mg/kg were injected intraperitoneally during ventilation in BL and BH groups, respectively.In group BOC-2, BOC-2 50 μg/kg was injected intraperitoneally before ventilation, and BML-111 1.0 mg/kg was injected intraperitoneally during ventilation.Arterial blood samples were collected at 4 h of ventilation, arterial oxygen partial pressure (PaO2) was determined.Then animals were sacrificed by exsanguination.Bronchoalveolar lavage fluid (BALF) of the left lung was collected for determination of neutrophil count, and the level of neutrophil was calculated.The right lung tissue specimens were obtained for microscopic examination, and for determination of wet/dry lung weight ratio (W/D ratio), myeloperoxidase (MPO) activity, and contents of malondialdehyde (MDA), monocyte chemoattractant protein-1 (MCP-1), tumor necrosis factor-alpha (TNF-α), interleukin-1beta (IL-1β) and IL-6. Results Compared with group C, PaO2 was significantly decreased, and the level of neutrophil in BALF, W/D ratio, MPO activity, and contents of MDA, MCP-1, TNF-α, IL-1β and IL-6 were increased in group HVT (P 0.05). Compared with group HVT, PaO2 was significantly increased, and the level of neutrophil in BALF, W/D ratio, MPO activity, and contents of MDA, MCP-1, TNF-α, IL-1β and IL-6 were decreased in group BH, and the contents of TNF-α, IL-1β and IL-6 were significantly decreased (P 0.05). Compared with group BH, PaO2 was significantly decreased, and the level of neutrophil in BALF, W/D ratio, MPO activity, and contents of MDA, MCP-1, TNF-α, IL-1β and IL-6 were increased in group BOC-2 (P<0.05). The pathological changes were significantly attenuated in group BL as compared with HVT and BOC-2 groups. Conclusion BML-111 can attenuate ventilator-induced lung injury in rats, and activated lipoxin A4 receptors are involved in the mechanism. Key words: Receptors, lipoxin; Respiration, artificial; Respiratory distress syndrome, adult

Intraoperative use of low volume ventilation to decrease postoperative mortality, mechanical ventilation, lengths of stay and lung injury in patients without acute lung injury.

During the last decade, there has been a trend towards decreasing tidal volumes for positive pressure ventilation during surgery. It is not known whether this new trend is beneficial or harmful for patients. To assess the benefit of intraoperative use of low tidal volume ventilation (< 10 mL/kg of predicted body weight) to decrease postoperative complications. We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 9), MEDLINE (OvidSP) (from 1946 to 5 September 2014) and EMBASE (OvidSP) (from 1974 to 5 September 2014). We included all parallel randomized controlled trials (RCTs) that evaluated the effect of low tidal volumes (defined as < 10 mL/kg) on any of our selected outcomes in adult participants undergoing any type of surgery. We did not retain studies with participants requiring one-lung ventilation. Two authors independently assessed the quality of the retained studies with the Cochrane 'Risk of bias' tool. We analysed data with both fixed-effect (I(2) statistic < 25%) or random-effects (I(2) statistic > 25%) models based on the degree of heterogeneity. When there was an effect, we calculated a number needed to treat for an additional beneficial outcome (NNTB) using the odds ratio. When there was no effect, we calculated the optimal size information. We included 12 studies in the review. In total these studies detailed 1012 participants (499 participants in the low tidal volume group and 513 in the high volume group). All studies included were at risk of bias as defined by the Cochrane tool. Based on nine studies including 899 participants, we found no difference in 0- to 30-day mortality between low and high tidal volume groups (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.40 to 1.54; I(2) statistic 0%; low quality evidence). Based on four studies including 601 participants undergoing abdominal or spinal surgery, we found a lower incidence of postoperative pneumonia in the lower tidal volume group (RR 0.44, 95% CI 0.20 to 0.99; I(2) statistic 19%; moderate quality evidence; NNTB 19, 95% CI 14 to 169). Based on two studies including 428 participants, low tidal volumes decreased the need for non-invasive postoperative ventilatory support (RR 0.31, 95% CI 0.15 to 0.64; moderate quality evidence; NNTB 11, 95% CI 9 to 19). Based on eight studies including 814 participants, low tidal volumes during surgery decreased the need for postoperative invasive ventilatory support (RR 0.33, 95% CI 0.14 to 0.80; I(2) statistic 0%; NNTB 36, 95% CI 27 to 202; moderate quality evidence). Based on three studies including 650 participants, we found no difference in the intensive care unit length of stay (standardized mean difference (SMD) -0.01, 95% CI -0.22 to 0.20; I(2) statistic = 42%; moderate quality evidence). Based on eight studies including 846 participants, we did not find a difference in hospital length of stay (SMD -0.16, 95% CI -0.40 to 0.07; I(2) statistic 52%; moderate quality evidence). A meta-regression showed that the effect size increased proportionally to the peak pressure measured at the end of surgery in the high volume group. We did not find a difference in the risk of pneumothorax (RR 2.01, 95% CI 0.51 to 7.95; I(2) statistic 0%; low quality evidence). Low tidal volumes (defined as < 10 mL/kg) should be used preferentially during surgery. They decrease the need for postoperative ventilatory support (invasive and non-invasive). Further research is required to determine the maximum peak pressure of ventilation that should be allowed during surgery.

Evidence of muscular adaptations within four weeks of barbell training in women

We investigated the time course of neuromuscular and hypertrophic adaptations associated with only four weeks of barbell squat and deadlift training. Forty-seven previously untrained women (mean±SD, age=21±3years) were randomly assigned to low volume training (n=15), moderate volume training (n=16), and control (n=16) groups. The low and moderate volume training groups performed two and four sets, respectively, of five repetitions per exercise, twice a week. Testing was performed weekly, and included dual X-ray absorptiometry and vastus lateralis and rectus femoris B-mode ultrasonography. Bipolar surface electromyographic (EMG) signals were detected from the vastus lateralis and biceps femoris during isometric maximal voluntary contractions of the leg extensors. Significant increases in lean mass for the combined gynoid and leg regions for the low (+0.68kg) and moderate volume (+0.47kg) groups were demonstrated within three weeks. Small-to-moderate effect sizes were shown for leg lean mass, vastus lateralis thickness and pennation angle, and peak torque, but EMG amplitude was unaffected. These findings demonstrated rapid muscular adaptations in response to only eight sessions of back squat and deadlift training in women despite the absence of changes in agonist–antagonist EMG amplitude.

Effect of Low Tidal Volume During General Anesthesia for Urological Procedures on Lung Functions

Background: Postoperative lung function impairment is common after surgery specially in the lateral decubitus position. Evidence suggests that if we use low tidal volume during mechani- cal ventilation this may limit post-operative lung injury. We compared post-operative lung func- tions in patients put in the lateral position when ventilated with low vs. high tidal volumes. Methods: This prospective open label clinical trial was performed on 104 patients ASA I&II sched- uled for elective urological operations done in the right or left lateral position expected to last more than 2 hours. Patients were divided into two groups: group L ventilated with 5-7 ml/kg tidal vol- ume, with positive end expiratory pressure (PEEP) 10 cm H2O and recruitment maneuver (RM) and group H ventilated with 10-12 ml/kg tidal volume with zero-end expiratory pressure and no recruitment maneuver. Pulmonary functions were measured pre-operatively and 6, 12, 24 hours after extubation. Results: Better pulmonary functions were found in the first post-operative six hours in the low tidal volume group and significant difference was found in all parameters. FVC and FEV1/FVC were significantly higher in the low tidal volume group (P = 0.000) after 12 hours of extubation. After 24 hours we found significant difference in the predicted FEV1 and FVC and FEV1/FVC ratio (P = 0.000) being higher in the low tidal volume group. Conclusion: In comparison with conventional mechanical ventilation using high tidal volume with zero PEEP and no RM: a lung protective strategy using low tidal volume with 5-10 cm H2O PEEP and RM did improved lung functions in the first post-operative 24 hours. The overall postoperative follow up did not show significant difference between the two groups. a 2015 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Anesthesiologists.

Lung-Protective Ventilation With Low Tidal Volumes and the Occurrence of Pulmonary Complications in Patients Without Acute Respiratory Distress Syndrome: A Systematic Review and Individual Patient Data Analysis.

Protective mechanical ventilation with low tidal volumes is standard of care for patients with acute respiratory distress syndrome. The aim of this individual patient data analysis was to determine the association between tidal volume and the occurrence of pulmonary complications in ICU patients without acute respiratory distress syndrome and the association between occurrence of pulmonary complications and outcome in these patients. Individual patient data analysis. ICU patients not fulfilling the consensus criteria for acute respiratory distress syndrome at the onset of ventilation. Mechanical ventilation with low tidal volume. The primary endpoint was development of a composite of acute respiratory distress syndrome and pneumonia during hospital stay. Based on the tertiles of tidal volume size in the first 2 days of ventilation, patients were assigned to a "low tidal volume group" (tidal volumes ≤ 7 mL/kg predicted body weight), an "intermediate tidal volume group" (> 7 and < 10 mL/kg predicted body weight), and a "high tidal volume group" (≥ 10 mL/kg predicted body weight). Seven investigations (2,184 patients) were included. Acute respiratory distress syndrome or pneumonia occurred in 23% of patients in the low tidal volume group, in 28% of patients in the intermediate tidal volume group, and in 31% of the patients in the high tidal volume group (adjusted odds ratio [low vs high tidal volume group], 0.72; 95% CI, 0.52-0.98; p = 0.042). Occurrence of pulmonary complications was associated with a lower number of ICU-free and hospital-free days and alive at day 28 (10.0 ± 10.9 vs 13.8 ± 11.6 d; p < 0.01 and 6.1 ± 8.1 vs 8.9 ± 9.4 d; p < 0.01) and an increased hospital mortality (49.5% vs 35.6%; p < 0.01). Ventilation with low tidal volumes is associated with a lower risk of development of pulmonary complications in patients without acute respiratory distress syndrome.

Dual Energy CT Angiography of Peripheral Arterial Disease: Feasibility of Using Lower Contrast Medium Volume.

ObjectiveOne of the main drawbacks associated with Dual Energy Computed Tomography Angiography (DECTA) is the risk of developing contrast medium-induced nephropathy (CIN). The aim of the present study was firstly, to design an optimal CT imaging protocol by determining the feasibility of using a reduced contrast medium volume in peripheral arterial DECTA, and secondly, to compare the results with those obtained from using routine contrast medium volume.MethodsThirty four patients underwent DECTA for the diagnosis of peripheral arterial disease. They were randomly divided into two groups: Group 1 (routine contrast volume group) with n = 17, injection rate 4–5 ml/s, and 1.5 ml/kg of contrast medium, and Group 2 ((low contrast volume group), with n = 17, injection rate 4–5ml/s, and contrast medium volume 0.75 ml/kg. A fast kilovoltage—switching 64-slice CT scanner in the dual-energy mode was employed for the study. A total of 6 datasets of monochromatic images at 50, 55, 60, 65, 70 and 75 keV levels were reconstructed with adaptive statistical iterative reconstruction (ASIR) at 50%. A 4-point scale was the tool for qualitative analysis of results. The two groups were compared and assessed quantitatively for image quality on the basis of signal-to-noise ratio (SNR) and contrast-to-noise-ratio (CNR). Radiation and contrast medium doses were also compared.ResultsThe overall mean CT attenuation and mean noise for all lower extremity body parts was significantly lower for the low volume contrast group (p<0.001), and varied significantly between groups (p = 0.001), body parts (p<0.001) and keVs (p<0.001). The interaction between group body parts was significant with CT attenuation and CNR (p = 0.002 and 0.003 respectively), and marginally significant with SNR (p = 0.047), with minimal changes noticed between the two groups. Group 2 (low contrast volume group) displayed the lowest image noise between 65 and 70 keV, recorded the highest SNR and CNR at 65 keV, and produced significantly lower results with respect to contrast medium volume and duration of contrast injection (p<0.001). The effect of radiation dose was not statistically significant between the two groups.ConclusionsDECTA images created at 65 keV and 50% ASIR with low contrast medium volume protocol, yielded results that were comparable to routine contrast medium volume, with acceptable diagnostic images produced during the evaluation of peripheral arteries.

Effect of limited fluid resuscitation on coagulation in patients with severe traumatic brain injury

Objective To study the effect of limited fluid resuscitation (LFR) on coagulation in patients with severe traumatic brain injury (sTBI) and investigate its clinical significance. Methods Seventy-nine patients were assigned to low volume group (≤2 000 ml, 40 cases) and high volume group (>2 000 ml, 39 cases) according to the random number table. LFR was performed for all patients. Prothrombin time (PT), partial thromboplastin time (APTT), thrombin time (TT) and fibrinogen (FIB) level were measured in both groups at different time points. Mean heart rate, blood pressure, blood gas values and blood electrolytes were monitored. Meantime, NICU days, hospital length of stay and incidence of multiple organ dysfunction syndrome (MODS) were recorded. Glasgow Outcome Scale (GOS) was evaluated. Results In constrast to high volume group, PT, APTT and TT were shortened and FIB was elevated in low volume group (P 0.05). The chances of good recovery in low volume group was higher than that in high volume group (22.5% vs 7.3%) (P 0.05). Conclusion For patients with sTBI, low volume LFR can ameliorate coagulation disorders and improve prognosis, indicating a safe and effective therapy. Key words: Craniocerebral trauma; Resuscitation; Coagulation disorders

Relationship between hospital volume and major cardiac complications of rotational atherectomy: A nationwide retrospective cohort study in Japan

BackgroundPrevious studies on life-threatening complications of rotational atherectomy (RA) were based on small sample sizes from a limited number of cardiovascular centers. No study has examined the relationship between hospital volume of RA and complications. MethodsUsing the Diagnosis Procedure Combination database in Japan, we identified inpatients aged ≥20 years who underwent RA. Hospital volume was defined as the annual number of patients undergoing RA at each hospital and eligible patients were categorized into hospital-volume tertile (low-, medium-, and high-volume) groups. The composite outcome consisted of cardiac complications requiring urgent procedures (covered stent implantation, coronary artery bypass grafting, or pericardiocentesis) or death on the day of RA. We examined the association between hospital-volume categories and the composite outcome by using a multivariable logistic regression model fitted with a generalized estimating equation. ResultsA total of 9970 patients (median age, 73 years; male, 69.8%) underwent RA in 309 hospitals. The 309 hospitals were categorized into 215 low-volume (≤15/year), 67 medium-volume (16–30/year), and 27 high-volume hospitals (≥31/year). Overall, the composite outcome occurred in 62 (0.62%) patients (36 covered stent implantation, 11 coronary artery bypass grafting, 9 pericardiocentesis, and 14 death). Patients in the high-volume group had a significantly lower rate of the composite outcome (0.29%) than those in the low-volume (0.72%, p=0.010) or medium-volume group (0.89%, p=0.001). With reference to the low-volume group, risk-adjusted odds ratios (95% confidence intervals) of the medium-volume and high-volume groups for the composite outcome were 1.10 (0.64–1.89) and 0.42 (0.20–0.88), respectively. ConclusionsThis study showed that higher hospital volume was significantly associated with lower complication rates of RA. Our results also suggested that the major complication rates were low even in low-volume hospitals.

OC-005 Mortality following elective colorectal cancer resection: does size really matter?

Introduction Regional volume-outcome analysis of UK colorectal cancer registries has demonstrated survival benefit if major cancer resections are performed in high compared to low volume units. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the National Bowel Cancer Audit (NBCA) have published NHS Trust and individual surgeon outcomes, allowing the hypothesis to be tested against a more representative sample. Grouping individual hospital data under a Trust to reflect multidisciplinary team resources may over-estimate numbers of high volume colorectal units where surgeons operate in separate hospitals with different clinical teams. A hospital based volume-outcome analysis was conducted on the comprehensive dataset for patients treated by elective colorectal cancer resection with curative intent in England April 2010–March 2013. Method Number of procedures, deaths, adjusted 90-day mortality rate (DMR) and Trust for each surgeon was extracted. The DMR had been adjusted for age, sex, ASA grade, TNM stage, admission mode, cancer site, co-morbidities, interaction between age and metastases using multivariate logistic regression. Trusts with multiple hospitals providing colorectal surgical services were contacted to confirm if consultant surgeons were site-specific, unless detailed in Trust literature. Trusts with site-specific services were sub-divided into individual hospitals. Institutions were categorised as low (0–209 procedures; n = 54), medium (210–309; n = 55) or high volume (310–708; n = 54). Results 42,877 operations were performed in 163 centres at 143 NHS trusts. Procedures and surgeons per unit ranged from 30–708 (median 259) and 1–9 (median 4). 1,222 patients died within 90 days of resection, DMR 2.85. DMR for each volume group was: low 3.40, medium 2.93, high 2.61. 53.9% of surgeons experienced ≤1 death; 2.7% >5 deaths. 37% (20/54) of low volume units had lower mortality than the average of the high volume group, 2.61; 24% (13/54) of high volume units had higher mortality than the average of the low volume group. Conclusion Unlike previous smaller studies our analysis fails to demonstrate a significance in correlation between low, medium or high volume units and DMR (r = –0.097). The majority of surgeons had good outcomes delivering major resectional elective cancer care. The argument for centralisation develops the idea that there is an unacceptable risk adjusted mortality rate; here expressed as 3.4%. The argument fails to recognise the relatively large proportion of low volume centres with better outcomes than high volume centres. 22% more perioperative deaths occur in 13 large volume units with ‘unacceptable’ mortality rates than in 24 small units with these same rates. These observations add insight to the reasons many surgeons fail to engage with centralisation agenda. Disclosure of interest None Declared.

Hospital Volume Does Not Influence the Safety of Percutaneous Nephrolithotomy in England: A Population-Based Cohort Study.

This study aims to investigate the relationship between hospital case volume and safety-related outcomes after percutaneous nephrolithotomy (PCNL) within the English National Health Service (NHS). The study used the Hospital Episode Statistics (HES) database, a routine administrative database, recording information on operations, comorbidity, and outcomes for all NHS hospital admissions in England. Records for all patients undergoing an initial PCNL between April 1, 2006 and March 31, 2012 were extracted. NHS trusts were divided into low-, medium-, and high-volume groups, according to the average annual number of PCNLs performed. We used multiple regression analyses to examine the associations between hospital volume and outcomes incorporating risk adjustment for sex, age, comorbidity, and hospital teaching status. Postoperative outcomes included: Emergency readmission, infection, and hemorrhage. Mean length of stay was also measured. There were 7661 index elective PCNL procedures performed in 163 hospital trusts, between April 2006 and March 2012. There were 2459 patients who underwent PCNL in the 116 units performing fewer than 10 PCNL procedures per year; 2643 patients in the 37 units performing 10 to 19 procedures per year; and 2459 patients in the 9 hospitals performing more than 20 procedures per year. For low-, medium-, and high-volume trusts, there was little variation in the rates of emergency readmission (L 9.7%, M 9.3%, H 8.4%), infection (3.0%, 4.2%, 3.8%), or hemorrhage (1.3%, 1.5%, 1.5%), and there was no statistical evidence that volume was associated with adjusted outcomes. Mean length of stay was slightly shorter in the medium- (5.0 days) and high-volume (5.0) groups compared with the low-volume group (5.3). The effect remained statistically significant after adjusted for confounding. Hospital volume was not associated with emergency readmission, infection, or hemorrhage. Length of stay appears to be shorter in higher volume units.

Accumulation of epicardial adipose tissue increases coronary morbidity in non-obese patients with suspected coronary artery disease

BackgroundWe explored the relationship between epicardial adipose tissue (EAT) volume, body mass index (BMI) and the incidence of major coronary events in non-obese patients with suspected coronary artery disease (CAD). MethodsWe measured EAT volume in a cohort of 722 patients who had undergone coronary computed tomography, and recorded subsequent occurrences of major coronary events (cardiac death and acute coronary syndrome), simultaneously evaluating all coronary events and all-cause death. ResultsEighteen patients experienced major coronary events: there were five cardiac deaths and 13 cases of acute coronary syndrome. BMI was inversely predictive of major coronary events (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.63–0.87; p<0.001), but not for all-cause death. EAT volume predicted all coronary events (HR per 10mL, 1.11; 95% CI, 1.03–1.19; p=0.003). Although there was a trend suggestive of an inverse association with major coronary events, this was not statistically significant (HR per 10mL, 1.10; 95% CI; 1.00–1.21; p=0.059), and there was no significant relationship with all-cause death. When stratified by the first quartile (QI) of BMI (≤21.4kg/m2) and median EAT volume (107mL), the event rates in the high EAT volume and BMI QI group were significantly higher than those of other groups (adjusted HR, 5.45; 95% CI, 1.51–25.3 p=0.009, compared with the low EAT volume and BMI QI group). ConclusionOur findings suggest that suspected CAD patients with low BMI but high EAT volume are at an increased risk of major coronary events, but not all-cause death.

Effect of low tidal volume during general anesthesia for urological procedures on lung functions

BackgroundPostoperative lung function impairment is common after surgery specially in the lateral decubitus position. Evidence suggests that if we use low tidal volume during mechanical ventilation this may limit post-operative lung injury. We compared post-operative lung functions in patients put in the lateral position when ventilated with low vs. high tidal volumes.MethodsThis prospective open label clinical trial was performed on 104 patients ASA I&II scheduled for elective urological operations done in the right or left lateral position expected to last more than 2 hours. Patients were divided into two groups: group L ventilated with 5–7 ml/kg tidal volume, with positive end expiratory pressure (PEEP) 10 cm H2O and recruitment maneuver (RM) and group H ventilated with 10–12 ml/kg tidal volume with zero-end expiratory pressure and no recruitment maneuver. Pulmonary functions were measured pre-operatively and 6, 12, 24 hours after extubation.ResultsBetter pulmonary functions were found in the first post-operative six hours in the low tidal volume group and significant difference was found in all parameters. FVC and FEV1/FVC were significantly higher in the low tidal volume group (P = 0.000) after 12 hours of extubation. After 24 hours we found significant difference in the predicted FEV1 and FVC and FEV1/FVC ratio (P = 0.000) being higher in the low tidal volume group.ConclusionIn comparison with conventional mechanical ventilation using high tidal volume with zero PEEP and no RM: a lung protective strategy using low tidal volume with 5–10 cm H2O PEEP and RM did improved lung functions in the first post-operative 24 hours. The overall postoperative follow up did not show significant difference between the two groups.

Effect of high-volume systematic local infiltration analgesia in Caesarean section: a randomised, placebo-controlled trial.

Pain after Caesarean section is often treated with opioids with a risk of side effects. Wound infiltration with local anaesthetics is effective and has few side effects, but volume vs. dose concentration has not been examined. Ninety patients scheduled for elective Caesarean section included in a randomised, double-blinded, placebo-controlled trial receiving infiltration with 50 ml ropivacaine 0.5% or 125 ml ropivacaine 0.2% or 50 ml 0.9% saline (placebo) during surgery. Surgery was performed under lumbar spinal anaesthesia. Primary endpoint was post-operative pain. Secondary endpoints were rescue analgesic, post-operative nausea and vomiting, time spent in the postanesthesia care unit (PACU) and time to first mobilisation. No difference in pain response between groups, but time until maximum pain score was prolonged in the ropivacaine 0.5% group compared with the placebo group (P = 0.0493). The administration of ketobemidone at 24 h post-operatively in the ropivacaine 0.5% group was reduced compared with the placebo group (P = 0.020), and between the ropivacaine 0.2% group and the ropivacaine 0.5% group (P = 0.044). No significant differences between groups were found concerning time spent in the PACU, to first mobilisation or in number of women with nausea/vomiting (P ≥ 0.05). No complications related to ropivacaine were observed. Systematic infiltration with a high concentration, low volume compared with low concentration, high volume showed no significant effect on post-operative pain intensity. However, a statistically significant, but clinically limited opioid sparing effect was demonstrated compared with placebo in the high concentration, low volume group.