Morbidity Scoring System Research Articles

Intensity-modulated radiotherapy and cisplatin-based chemotherapy for anal cancer: long-term outcomes at a single institution.

To evaluate oncological outcomes and late toxicities in a retrospective series of patients with locally-extended anal squamous cell carcinoma (ASCC), treated with curative Intensity Modulated Radiotherapy (IMRT) and chemotherapy. ASCC patients who underwent chemo-radiotherapy with IMRT from 2010 to 2020 were included. Oncological outcomes were assessed in terms of overall survival (OS), disease-free survival (DFS), colostomy-free survival (CFS) and event-free survival (EFS). Late toxicity was detected according to CTCAE v.5.0 and RTOG late radiation morbidity scoring system. Ninety-five patients were included. Most patients (83%) received chemotherapy with oral Fluoropyrimidine plus Cisplatin. The median follow-up was 5.5years. The OS was 85.2%, 82.1% and 79.3% at 3, 5 and 8years, respectively. The DFS was 73.1%, 70%, and 65.3% at 3, 5 and 8years, respectively; 3, 5 and 8years CFS was 86.2%, 84.3% and 84.3%, respectively. The EFS was 71%, 67.9% and 63.1%, at 3, 5 and 8years, respectively. On univariable analysis, a statistically significant lower OS was found for patients with T3-T4 stage (HR = 4.58, p = 0.005) and overall treatment time (OTT) ≥ 47days (HR = 3.37, p = 0.038). A statistically significant lower DFS was reported for patients with T3-T4 stage (HR = 2.72, p = 0.008) and Serum Squamous Cell Carcinoma Antigen (SCC) value post-RT > 1.5 (HR = 2.90, p = 0.038.). Ten severe late toxicity (≥ G3) events were reported in 8 patients (8.6%). Our data confirm IMRT concomitant with a Cisplatin-based chemotherapy as an effective treatment of ASCC, ensuring acceptable long-term toxicities and good oncological outcomes.

PREDICTORS OF POST OPERATIVE MORTALITY AND MORBIDITY USING THE PPOSSUM SCORING SYSTEM IN GENERAL SURGICAL PATIENTS

Introduction: The risk scoring system in all elds of medicine is gaining popularity in order to assess the outcome and improve the patient care. Various scoring systems are available to predict the surgical outcome, but most of them fail to incorporate surgical factors. Portsmouth Physiological and Operative Severity Scores for the enumeration of Mortality and Morbidity (P-POSSUM) scoring system help in predicting the outcome in the surgical patients. This study was conducted to evaluate the validity of P- POSSUM in patients undergoing major surgery and to enumerate the risk factors for low outcome in our setup. Methods: A longitudinal observational study on 250 consenting patients who underwent medium, major and major + surgeries as dened by POSSUM scoring system. Data was collected as per 12 physiological and 6 operative factors to obtain P-POSSUM scores and statistical analysis was done to compare the actual and predicted mortality. Result: The predicted mortality score was statistically signicant in predicting the death (p- 0.0004). Among all the risk factors studied, 12 physiological and the 5 operative parameters had a signicant contribution towards predicting the post operative mortality. A threshold score beyond which the mortality can be predicted was also obtained by plotting the ROC curve. Conclusion: This study validates P-POSSUM scoring system accurately in predicting mortality in patients who underwent major surgical procedures in our setup and helped in identifying the factors responsible for the poor outcome.

Intensity-modulated radiotherapy (IMRT) in the treatment of squamous cell anal canal cancer: acute and early-late toxicity, outcome, and efficacy.

To retrospectively review our experience on 84 patients with squamous cell anal canal cancer (SCAC) within 12months after combined treatment with intensity-modulated RT (IMRT), in terms of acute and early-late toxicity, overall treatment time and interruptions, colostomy-free survival (CFS), and tumor response. Acute gastrointestinal (GI), genitourinary (GU), and cutaneous (CU) toxicities were assessed according to Common Toxicity Criteria for Adverse Events (CTCAE) version 4.03. Early-late toxicity was scored using the Radiation Therapy Oncology Group (RTOG) late radiation morbidity scoring system. Tumor response was evaluated with response evaluation criteria in solid tumors (RECIST) v1.1. Acute toxicity for 84 subjects (100%): severe (≥ G3) GI and skin toxicity was observed in 4 (5%) and 19 patients (23%), respectively. Early-late toxicity for 73 subjects (87%): severe (≥ G3) GI and vulvo-vaginal toxicity was observed in 2 (3%) and 2 (3%) patients, respectively. No acute or early-late severe GU toxicity was reported. A treatment interruption occurred in 65 patients (77%). CFS was 96% (95% CI 89-99) at 6months and 92% (95% CI 83-96) at 12months. At 6months complete response (CR), partial response (PR) and progressive disease (PD) was observed in 70 (83%), 3 (4%), and 7 patients (8%), respectively. At 12months, CR was observed in 60 patients (81%); eleven patients (15%) experienced PD. Our study showed an excellent clinical result and very low acute toxicity rates, confirming the IMRT as standard of care for curative treatment of anal cancer patients. The current trial was registered with the number IEO N87/11.

Can zinc supplementation widen the gap between control and complications in head and neck cancer patients treated with concurrent chemo-radiotherapy

Introduction: Zinc as an antioxidant can attenuate the effects of ionizing radiation. Contrary to theoretical radiobiological concepts, studies have pointed to the differential effects of zinc on normal and tumor cells, respectively. Therefore the present study was conducted to highlight the effects of zinc supplementation on adverse events and response rates of head and neck cancer patients who had undergone definitive concurrent chemo-radiotherapy (CCRT). Materials and Methods: Case records of patients with head and neck cancer who underwent definitive chemo-RT were analyzed from July 2015 to July 2018. Those who received zinc supplements were categorized as Arm A and those who did not as Arm B. All patients received a total of 6600–7000 cGray RT with weekly cisplatinum. Radiation Morbidity Scoring System was used to summarize data on adverse events. Computed tomogram scans were compared for documenting response rates. Results: Data were collected from 95 patients under Arm A and 107 in Arm B. 15.8% in Arm A and 21.5% in Arm B had RT interrupted for >1 week. Although the results were not statistically different for > Grade 2 toxicities, patients in Arm A fared better than those in Arm B. Interestingly, when the two groups were analyzed for salivary gland adverse events, 74 patients in Arm B complained of ≥ Grade 2 toxicities as compared to 37 in Arm A, the results being statistically significant (P = 0.000017). Overall, response rates were 88.4% in Arm A and 92% in Arm B. Conclusions: Zinc supplementation lends some of its radioprotective effects in normal tissues with salivary glands deriving the major benefits.

Intensity-modulated radiotherapy and hypofractionated volumetric modulated arc therapy for elderly patients with breast cancer: comparison of acute and late toxicities.

To evaluate the differences between conventional fractionated intensity-modulated radiotherapy (IMRT) and hypofractionated (HypoRT) volumetric modulated arc therapy (VMAT) in elderly women affected by early-stage breast cancer (BC) in terms of RT-related acute/late side effect. Between October 2011 and July 2015, 80 consecutive elderly BC patients were treated with IMRT for 5weeks (40 patients) or HypoRT-VMAT for 3weeks (40 patients). Inclusion criteria were: age ≥ 70years, early BC (pT1-2 pN0-1), no prior neoadjuvant chemotherapy and non-metastatic disease. For patients receiving IMRT or HypoRT-VMAT, a total dose of 50Gy (25 fractions) or 40.5Gy (15 fractions) was prescribed to the whole ipsilateral breast, respectively. All patients received a simultaneously integrated boost up to a total dose of 60Gy for IMRT and 48Gy for HypoRT-VMAT. Acute and late side effects were evaluated using the RTOG/EORTC radiation morbidity scoring system. With a median follow-up of 45months, acute skin toxicity was overall very low, with grade 1 in 25 cases (62.5%) of the IMRT group and 21 cases (52.5%) of the HypoRT-VMAT group, while grade 2 toxicity was reported in 10 IMRT patients (25%) and 1 HypoRT-VMAT patient (2.5%) (p = 0.001). Regarding late adverse events, only grade 1 skin toxicity was recorded. The present study showed that whole breast IMRT and HypoRT-VMAT are feasible and well tolerated in early-stage BC elderly patients and that HypoRT-VMAT is affected by lower risk of acute and late RT-related side effects.

Perioperative Mortality Prediction Using Possum in Patients with Gastrointestinal Tumors: Do Immunological Variables Affect Individual Predictive Mortality Risk?

Abstract The aim of this study was to evaluate whether the addition of immunological variables to the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system improves the predictability of postoperative mortality. One hundred and thirty-two consecutive patients who underwent moderate, major or major-plus elective surgical interventions for gastrointestinal tumors were scored using the POSSUM mortality risk analysis. Patients were placed in one of the two groups based on their POSSUM mortality rates which were either lower or higher than 5%. An additional 26 pre-operative and post-operative metabolic and immunological variables were measured and mortality-dependent variables were selected. Regression analysis with backward elimination of twelve pre-operative and post-operative variables correlating with POSSUM score revealed that post-operative neopterin, IL-6 and albumin were significantly dependent on the predicted mortality rates. According to these selected variables, the number of patients with a POSSUM predicted mortality rate higher than 5% increased from 64 to 88, but the percentage of the mean mortality decreased. Statistical differences between the original POSSUM and modified scoring system was highly significant (p<0.0001). The sensitivity and specificity of the modified scoring system was calculated to be 52.9% and 87.5%, respectively.

Efficacy of the P-POSSUM scoring system in prediction of post-operative mortality and morbidity in patients undergoing emergency laparotomy in a tertiary institute

Background: The Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system and its modification P-POSSUM (Portsmouth-POSSUM) has been studied in various clinical settings, with varied results. Due to its simplicity and wide application, the efficacy must be verified in individual settings. We wish to assess the system’s efficacy among emergency laparotomies in a south Indian clinical scenario.Methods: A prospective study was undertaken with a sample size of 50. All cases taken for emergency laparotomy were included. 12 physiological and 6 intra-operative characteristics were taken and according to the equation the predicted rates of mortality and morbidity were predicted. This was compared with the observed rates. With these results, the efficacy of the scoring system was assessed.Results: Of the 50 cases included 5 expired (10%) and 29 (58%) experienced some form of morbidity. The P-POSSUM score was found to be an accurate predictor of mortality (x2 =1.174, d.f=8) with a p-value of 0.997. The POSSUM score was not found to be an accurate predictor of morbidity (x2 =16.949, d.f=8) with a p-value of 0.0403, as the p-value was <0.05.Conclusions: The P-POSSUM scoring system produced accurate results even in the setting of emergency laparotomies in a south Indian setting. It has proved to be a useful tool for predicting mortality, though not completely accurate to assess post-operative morbidity (POSSUM) due to post-operative factors playing a major role in its determination.

Late Rectal Bleeding Following Radiation Therapy for Prostate Cancer: The Importance of Concomitant Medications and Cardiovascular Risk Factors

Rectal bleeding is a common late side effect following prostate radiotherapy that can significantly impair quality of life. Additional investigations and treatments are also burdensome on healthcare resources. We examined potential risk factors and treatment characteristics of a group of patients who experienced late rectal bleeding following prostate radiotherapy. We hypothesize that a predictive model could be generated to predict a patient’s subsequent risk of bleeding incorporating these potential risk factors. We identified 80 patients with rectal bleeding who underwent prostate radiotherapy between 2011 and 2016. We included those treated definitively or adjuvantly with external beam radiotherapy (EBRT), brachytherapy or both. Severity was graded according to the RTOG /EORTC Late Radiation Morbidity Scoring System. We retrospectively evaluated patient records from their baseline and follow-up visits and recorded use of antiplatelet(AP) or anticoagulant(AC) medications. We also recorded the presence of the following vascular risk factors: hypertension, hypercholesterolaemia, diabetes mellitus or ischaemic heart disease (IHD), peripheral vascular disease (PVD) or a history of stroke. The EBRT plans were evaluated with reference to D2cc, V65Gy and PTV volume(cc). For statistical purposes patients were divided into 2 groups; Group A containing patients with grades 1-2 rectal bleeding and Group B containing grades 3-4. Groups were compared for statistical significance using Chi-squared tests and Mann-Whitney U tests. 42 patients (52.5%) were on AP/AC medication. There were 57 patients with Grades 1-2 rectal bleeding and 23 with Grades 3-4. Proportionally more patients in Group B were on AP/AC medication compared with Group A (65.2% versus 47.4%), however this was not statistically significant (p=0.15). There was a high prevalence of cardiovascular risk factors in both groups. 22 patients had ≥3 cardiovascular risk factors representing 24.6% of Group A and 34.8% of Group B, but this was not statistically significant (p=0.35). There were no statistically significant differences in rectal doses D2cc, V65Gyor PTV volume between the groups. The majority of patients experiencing late rectal bleeding were on AP/AC agents. The highest prevalence of AP/AC use was in those with ≥grade 3 bleeding. Patients with more vascular risk factors had numerically higher rates of high grade rectal bleeding. We did not identify any significant difference between the groups in terms of radiation dose to the rectum. We hypothesize that use of AP/AC agents and cardiovascular comorbidity are risk factors for late rectal bleeding following prostate radiotherapy. This requires prospective validation.

2056A - Treatment compliance and outcome in geriatric patients with locally advanced non-small cell lung cancer: Experience from India

Objectives: To evaluate treatment compliance, toxicity and survival in geriatric patients (≥65 years) with locally advanced non-small cell lung cancer (LA-NSCLC). Methods: Departmental archive was collected for the details of demographics, treatment and outcome in elderly patients with LA-NSCLC (2008 - 2013) (n = 96). Both progression-free survival (PFS) and overall survival (OS) were evaluated using Kaplan-Meier method. Acute and late morbidity were scored using common terminology criteria for adverse events version 4, radiation therapy and oncology group late morbidity scoring system. Results: Overall treatment completion rate was 65%. The rates of acute grade ≥ 3 hematologic and non-hematologic toxicities were 20% and 17% respectively. Overall rate of late toxicity was 12.5%. The median PFS and OS values were 7.4 months and 10.54 months, respectively. Patients with multiple comorbidities, poor socio-economic background and serum albumin level (< 3.5g/dL) were observed to have poor survival. Survival was lower for non-compliant patients. Conclusions: Curative multi-modality therapy in elderly patients with LA-NSCLC is a challenging task. They are susceptible to poor compliance, treatment-associated toxicities and poor survival.

Portsmouth physiological and operative severity score for the Enumeration of Mortality and morbidity scoring system in general surgical practice and identifying risk factors for poor outcome.

Background:Estimation of the outcome is paramount in disease stratification and subsequent management in severely ill surgical patients. Risk scoring helps us quantify the prospects of adverse outcome in a patient. Portsmouth-Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM) the world over has proved itself as a worthy scoring system and the present study was done to evaluate the feasibility of P-POSSUM as a risk scoring system as a tool in efficacious prediction of mortality and morbidity in our demographic profile.Materials and Methods:Validity of P-POSSUM was assessed prospectively in fifty major general surgeries performed at our hospital from May 2011 to October 2012. Data were collected to obtain P-POSSUM score, and statistical analysis was performed.Results:Majority (72%) of patients was male and mean age was 40.24 ± 18.6 years. Seventy-eight percentage procedures were emergency laparotomies commonly performed for perforation peritonitis. Mean physiological score was 17.56 ± 7.6, and operative score was 17.76 ± 4.5 (total score = 35.3 ± 10.4). The ratio of observed to expected mortality rate was 0.86 and morbidity rate was 0.78.Discussion:P-POSSUM accurately predicted both mortality and morbidity in patients who underwent major surgical procedures in our setup. Thus, it helped us in identifying patients who required preferential attention and aggressive management. Widespread application of this tool can result in better distribution of care among high-risk surgical patients.

Treatment Compliance and Outcome in Geriatric Patients with Locally Advanced Non-Small Cell Lung Cancer: Experience from India

Objectives: To evaluate treatment compliance, toxicity and survival in geriatric patients (≥65 years) with locally advanced non-small cell lung cancer (LA-NSCLC). Methods: Departmental archive was collected for the details of demographics, treatment and outcome in elderly patients with LA-NSCLC (2008 - 2013) (n = 96). Both progression-free survival (PFS) and overall survival (OS) were evaluated using Kaplan-Meier method. Acute and late morbidity were scored using common terminology criteria for adverse events version 4, radiation therapy and oncology group late morbidity scoring system. Results: Overall treatment completion rate was 65%. The rates of acute grade ≥ 3 hematologic and non-hematologic toxicities were 20% and 17% respectively. Overall rate of late toxicity was 12.5%. The median PFS and OS values were 7.4 months and 10.54 months, respectively. Patients with multiple comorbidities, poor socio-economic background and serum albumin level (< 3.5g/dL) were observed to have poor survival. Survival was lower for non-compliant patients. Conclusions: Curative multi-modality therapy in elderly patients with LA-NSCLC is a challenging task. They are susceptible to poor compliance, treatment-associated toxicities and poor survival.

Proton Beam Radiation for Head and Neck Cancers: A Single-Institution Report on Feasibility and Early Outcomes

Definitive radiation of the head and neck has become a mainstay for locally advanced head and neck malignancies. This combined with initial surgery and/or adjuvant chemotherapy yields significant morbidity to the patients both short term and long term. This is a review of our prospective registry database of head and neck patients treated with proton beam radiation at our hybrid community practice/academic proton center to highlight our initial experience with relative long term follow up. All patients in our study were treated with the uniform scanning proton beam technology via the IBA system. Standard fractionation schemes with or without chemotherapy were delivered with curative intent. Acute and late toxicities were assessed by the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0 and the by the Radiation Therapy Oncology Group late radiation morbidity scoring system, respectively. The cumulative incidence of locoregional failure (LRF) was calculated with death as a competing risk. The actuarial freedom from distant metastases (FFDM) and overall survival (OS) rates were calculated with the Kaplan-Meier method. A total of 66 patients were analyzed from our prospective registry. We focused on the 36 de-novo patients as our 30 re-irradiation patients are in process in upcoming literature. The scope of our patient population included patients with malignancies of the paranasal sinuses, nasopharynx, oropharynx, hypopharynx, and major salivary gland. Squamous Cell Carcinoma was the predominant histology, but others were Mucoepidermoid Carcinoma, Adenoid Cystic Carcinoma, Undifferentiated Carcinomas and Esthesioneuroblastomas. The median follow up was 33 months (9 – 53). The 2 and 5 year OS rates were 83% and 75%, respectively. The 2 and 5 year FFDM rates were 92% and 80%, respectively. There was 17% and 25% 2 and 5 year LRF rate. The mean time to failure was 17 months post initial proton beam treatment. Acute grade 3+ toxicity rate was 30.5% (mainly skin, mucositis, odynophagia, dysphagia, and anorexia), while the long term grade 3+ toxicity rate was 6% (anorexia and dysphagia). Ten patients had feeding tubes at some point during the radiation therapy, but none remained on tube feedings beyond 6 months post proton radiation therapy. Proton beam radiation of the head and neck can provide excellent disease control along with great sparing of the OARs. Longer follow up is needed with a less heterogeneous population to validate this modality. In addition, with the advent of intensity modulated proton beam radiation, even better conformality of proton beam will hopefully improve the toxicity profiles of even the acute toxicities.

Proton Beam Reirradiation for Recurrent Head and Neck Cancer: Multi-institutional Report on Feasibility and Early Outcomes

Reirradiation therapy (re-RT) is the only potentially curative treatment option for patients with locally recurrent head and neck cancer (HNC). Given the significant morbidity with head and neck re-RT, interest in proton beam radiation therapy (PBRT) has increased. We report the first multi-institutional clinical experience using curative-intent PBRT for re-RT in recurrent HNC. A retrospective analysis of ongoing prospective data registries from 2 hybrid community practice and academic proton centers was conducted. Patients with recurrent HNC who underwent at least 1 prior course of definitive-intent external beam radiation therapy (RT) were included. Acute and late toxicities were assessed with the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0 and the Radiation Therapy Oncology Group late radiation morbidity scoring system, respectively. The cumulative incidence of locoregional failure was calculated with death as a competing risk. The actuarial 12-month freedom-from-distant metastasis and overall survival rates were calculated with the Kaplan-Meier method. Ninety-two consecutive patients were treated with curative-intent re-RT with PBRT between 2011 and 2014. Median follow-up among surviving patients was 13.3 months and among all patients was 10.4 months. The median time between last RT and PBRT was 34.4 months. There were 76 patients with 1 prior RT course and 16 with 2 or more courses. The median PBRT dose was 60.6 Gy (relative biological effectiveness, [RBE]). Eighty-five percent of patients underwent prior HNC RT for an oropharynx primary, and 39% underwent salvage surgery before re-RT. The cumulative incidence of locoregional failure at 12 months, with death as a competing risk, was 25.1%. The actuarial 12-month freedom-from-distant metastasis and overall survival rates were 84.0% and 65.2%, respectively. Acute toxicities of grade 3 or greater included mucositis (9.9%), dysphagia (9.1%), esophagitis (9.1%), and dermatitis (3.3%). There was 1 death during PBRT due to disease progression. Grade 3 or greater late skin and dysphagia toxicities were noted in 6 patients (8.7%) and 4 patients (7.1%), respectively. Two patients had grade 5 toxicity due to treatment-related bleeding. Proton beam re-RT of the head and neck can provide effective tumor control with acceptable acute and late toxicity profiles likely because of the decreased dose to the surrounding normal, albeit previously irradiated, tissue, although longer follow-up is needed to confirm these findings.

Value of predicting preoperative risk in orthopedic surgery by using POSSUM

To assess the use of Physical and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) scoring system in predicting outcomes of patients undergoing orthopedic surgery and provide guidance for operation treatment decisions. From April 2009 to September 2010, a total of 779 cases went operation in Beijing Hospital were collected.They were divided into two groups according to the presence or absence of complications.The patients' postoperative complications were predicted by POSSUM and compared to the actual morbidity to verify the effectiveness of the equation.Logistic regression was taken to make appropriate improvements for the POSSUM equation.ROC curve was drawn to describe the compliance of the original and new equations. In the 779 cases, the morbidity predicted by POSSUM is 212 cases while the actual morbidity is 65 cases.Of all risk factors, echocardiography ejection fraction showed a close relationship with postoperative complications (P<0.01). In the original equation, actual complication group compared with non-complication group, the difference was statistically significant (P<0.01). In the modified equation, complication group compared with non-complication group, the difference was statistically significant (P<0.01). Compared with the original one , the modified POSSUM had better predictive value on postoperative morbidity, and the comparison of AUC between the two groups was statistically significant ((0.67 ± 0.12) vs (0.75 ± 0.08), P<0.01). POSSUM over predicted morbidity of patients undergoing orthopedic surgery, it can be more accurate when modified appropriately.

Late sensorial alterations in different radiotherapy techniques for nasopharyngeal cancer.

Intensity-modulated radiation therapy (IMRT) for nasopharyngeal cancer (NPC) allowed a better distribution of the dose to the tumor volume, sparing surrounding structures. Aim of the study is the objective evaluation of olfactory and gustatory impairments in patients who underwent chemo-radiotherapy for NPC. Correlation between smell and taste alterations, xerostomy, and radiation technique was investigated. Thirty healthy subjects and 30 patients treated with chemo-radiation therapy for NPC, with at least a 2-years follow-up period, were evaluated. All subjects underwent symptoms evaluation, endoscopic fiber optic nasal examination, taste strips, Sniffin' sticks tests, Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer late radiation morbidity scoring system. Patients were divided in 2 groups: 2-dimensional radiotherapy/conformal 3-dimensional radiotherapy and IMRT. A higher percentage of rhinorrhea, nasal obstruction, xerostomy, hyposmia, hypogeusia, mucosal hyperemia, and presence of nasopharyngeal secretions was found in irradiated subjects (P < 0.05). Concerning olfactory and gustatory scores, we demonstrated a statistically significant difference between healthy subjects and irradiated patients (P < 0.05), with lower gustatory total score in IMRT group (P < 0.01). In conclusion, chemo-radiotherapy for NPC induces long-term smell and taste impairments, which can compromise quality of life. Although based on small samples, it is also important to consider that IMRT can induce higher taste dysfunction compared with traditional techniques.

The use of the Thoracic Morbidity and Mortality system for the internal analysis of performance: a case-matched temporal audit

The aim of the present study was to evaluate the usefulness of the Thoracic Morbidity and Mortality (TMM) scoring system in auditing the quality of care of our unit. We analysed the performance of our unit comparing the incidence of complications and mortality occurring after anatomic lung resections during two different periods: early period (January 2000 to December 2009: 830 lobectomy, 134 pneumonectomy and 78 segmentectomy) and recent period (January 2010 to August 2012: 191 lobectomy, 8 pneumonectomy and 19 segmentectomy). The cardiopulmonary complications as traditionally defined in the European Society of Thoracic Surgeons (ESTS) database were also classified according to the TMM system: this method grades the postoperative adverse events from 1 to 5 reflecting an increasing severity of management regardless the type of complication. Complications graded higher than 2 are regarded as major complications. To account for confounders, several baseline and surgical factors were used to build a propensity score that was applied to match the patients of the most recent group with their early-group counterparts. These two matched groups were compared in terms of cardiopulmonary morbidity (codified by ESTS definitions) and mortality rates and incidence of major complications according to the TMM system. The propensity score analysis yielded 209 well-matched pairs of patients operated on in the two periods. The two groups had similar rates of ESTS-defined cardiopulmonary complications (recent: 38 patients vs early: 37 patients, P = 0.9). The use of the TMM system revealed a higher incidence of major (grade > 2) complications rate in the recent period (recent: 29 patients vs early: 14 patients, P = 0.02). The TMM scoring system for classifying the postoperative complications revealed a decline of quality of care of our unit otherwise undetected by applying traditional outcome measures. This tool can be used as an additional graded outcome endpoint to refine internal audit of performance.

The applied value of modified POSSUM score in evaluating lung cancer surgery’s risk

Objective The aim of this study was to explore the modified physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scoring system and the relationship between predicted data and actual data of complication and surgical mortality of lung cancer radical surgery made by such score system.

Evaluation of a Modified POSSUM Scoring System for Predicting the Morbidity in Patients Undergoing Lumbar Surgery.

For most spine surgeons, operative intervention is common for the treatment of lumbar disc herniation, lumbar stenosis, lumbar fracture or lumbar spondylolisthesis. However, with the increase in lumbar surgery, the complication rate increases accordingly. Whereas the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system has been widely used to predict morbidity in various surgical fields, the application of this system in lumbar surgery has not been reported. From January 2008 to January 2010, we recruited 158 patients (85 males and 73 females) with operation for lumbar disc herniation, lumbar stenosis, lumbar fracture, or lumbar spondylolisthesis. All patients were analyzed to compare the morbidity by a modified POSSUM scoring system. According to the modified POSSUM, the expected morbidity was 51 cases (32.3%), whereas the observed mortality was 42 cases (26.6%). The overall observed-to-expected ratio was 0.82, and the chi-squared test indicated no statistically significant difference between the expected and observed morbidities (χ (2) = 1.23, P = 0.27), suggesting that the modified POSSUM can accurately estimate the outcome. The modified POSSUM scoring system we developed is a useful tool for predicting and evaluating morbidity in lumbar surgery. Further studies are required to investigate whether this scoring system can predict mortality.

Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity scoring system in general surgical practice and identifying risk factors for low outcome

Background and Objectives: Scoring system in all areas of medicine is receiving close attention because of the need to evaluate and monitor healthcare delivery and outcomes. The main application is in comparative surgical audit to monitor quality of care provided to the patient with a risk adjusted scoring system rather than using crude morbidity and mortality rates. In this prospective study, the validity of P-POSSUM is tested in patients undergoing major surgery and risk factors for low outcome were noted. Materials and Methods: A total of 277 major general surgical procedures as defined by the POSSUM scoring system criteria were included in the study during the period from September 2010 to February 2012, and final analysis was done. Results: The observed mortality rate was compared with the P-POSSUM predicted mortality rate. On using P-POSSUM the predicted mortality was 37 deaths. An O: P ratio of 0.91 was obtained. There was found to be no statistically significant difference between the observed and predicted mortality rates (χ2 = 7.859, DF = 5, P -value = 0.164). On analysing risk-factors we found that out of the 17 factors considered 10 are found to have significant rate of increment, whereas remaining 7 don't have significant change statistically. Conclusion: This study therefore, validates P-POSSUM as a valid means of assessing adequacy of care provided to the patient.

Predictive Value of the POSSUM, p-POSSUM, cr-POSSUM, APACHE II and ACPGBI Scoring Systems in Colorectal Cancer Resection

This study investigated the ability of the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) scoring system to predict postoperative morbidity (complication rate) and compared the ability of POSSUM and four other scoring systems (Portsmouth POSSUM [p-POSSUM], colorectal POSSUM [cr-POSSUM], Association of Coloproctology of Great Britain and Ireland [ACPGBI] and Acute Physiology and Chronic Health Evaluation II [APACHE II]) to predict mortality within 30 days in 1695 patients undergoing surgery for colorectal cancer. Receiver operating characteristic (ROC) curve, Student's t-test and the χ(2)-test were used to estimate the predictive ability of these scoring systems. The observed complication rate of 38.7% was not significantly different to the rate of 36.3% predicted by the POSSUM scoring system (observed : expected [O : E] ratio 1.07). The observed mortality rate was 3.0%. For predicting mortality, POSSUM had an O : E ratio of 0.37, compared with p-POSSUM O : E ratio 1.00, cr-POSSUM O : E ratio 0.91, APACHE II O : E ratio 0.31 and ACPGBI O : E ratio 1.41. It was concluded that the POSSUM scoring system had high value for predicting the risk of morbidity following colorectal cancer resection. For predicting postoperative mortality, p-POSSUM, cr-POSSUM and ACPGBI were superior to POSSUM and APACHE II, however ROC curve analysis showed that cr-POSSUM and ACPGI discriminated best between survivors and non-survivors, so were more accurate predictors of postoperative mortality than the other three scoring systems.