Patient Pathway Research Articles

The Measurement of Delay in Diagnosis and Treatment among Moroccan Women with Cervical Cancer

In Morocco, most of the cervical cancer patients have been reported diagnosed at advanced stage indicating delay in seeking diagnosis and treatment. The main purpose of this investigation was to measure the delay from the first symptom to treatment among Moroccan women with cervical cancer. Methods: We conducted a cross-sectional study at the National Institute of Oncology Sidi Mohammed Ben Abdellah in Rabat, Morocco. A consecutive series of patients with locally advanced cervical cancer or metastasic [stage II-IV] were recruited. We calculated delay by using two events dates of two periods in patient's pathway. Multivariate binary logistic regression analysis was performed to measure the association between all categories of delay and magnitude of total delay. Results: Four hundred and one patients were reached in this study. The median total delay was 183 days, the median patient delay was 120 days, the median diagnosis delay was 110 days, and the median Treatment delay was 57 days. Bivariate analysis showed that patients who did not have respectively patient and diagnosis delay were less likely to have total delay (p<0.001, p<0.001). Conclusions: Future studies are needed to better inform the scientific and healthcare system to effectively address a clear picture of delays.

Factors associated with late stage at diagnosis among Puerto Rico's government health plan colorectal cancer patients: a cross-sectional study.

BackgroundLate stage at diagnosis of cancer is considered a key predictor factor for a lower survival rate. Knowing and understanding the barriers to an early diagnosis of colorectal cancer is critical in the fight to reduce the social and economic burden caused by cancer in Puerto Rico. This study evaluates factors associated to colorectal cancer stage at diagnosis among Puerto Rico’s Government Health Plan (GHP) patients.MethodsWe conducted a cross-sectional study based on a secondary data analysis using information from the Puerto Rico Central Cancer Registry (PRCCR) and the Puerto Rico Health Insurance Administration (PRHIA). Logistic regression models were used to estimate the unadjusted odds ratio (ORs) and adjusted odds ratio (AORs), and their 95 % confidence intervals (CIs). Colorectal cancer cases diagnosed between January 1, 2012 and December 31, 2012, among persons 50 to 64 years of age, participants of the GHP and with a cancer diagnosis reported to the PRCCR were included in the study.ResultsThere were 68 (35.79 %) colorectal cancer patients diagnosed at early stage while 122 (64.21 %) where diagnosed at late stage. In the multivariate analysis having a diagnostic delay of more than 59 days (AOR 2.94, 95 % CI: 1.32 to 6.52) and having the first visit through the emergency room (AOR 3.48, 95 % CI: 1.60 to 7.60) were strong predictors of being diagnosed with colorectal cancer at a late stage.ConclusionsThese results are relevant to understand the factors that influence the outcomes of colorectal cancer patients in the GHP. Therefore, it is important to continue developing studies to understand the Government Health Plan patient’s pathways to a cancer diagnosis, in order to promote assertive decisions to improve patient outcomes.

The clinical nurse specialist's role in head and neck cancer care: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It discusses the role of the clinical nurse specialist in the head and neck cancer patient journey and provides recommendations on the clinical nurse specialist led assessments and interventions for this group of patients receiving cancer care. Recommendations • All cancer patients should meet a clinical nurse specialist at the point of diagnosis. (R) • Clinical nurse specialists must act as gate keeper to the patients' cancer pathway to provide a seamless journey. (R) • Holistic needs assessment should be completed at different stages of the patient's pathway to reflect the changes of the patients' needs. (R) • Clinical nurse specialists to be part of local and national initiatives for health promotion and raising awareness in the public domain. (G) • Clinical nurse specialists should lead in redesigning of services and policies to ensure they are responsive to patient's needs for the future. (G) • Treatment summaries should become part of practice to provide good communication between primary and secondary care to enable continuity of care for the patient. (G).

Neurocognitive Deficits and Neurocognitive Rehabilitation in Adult Brain Tumors.

Neurocognitive deficits are common with brain tumors. If assessed at presentation using detailed neurocognitive tests, problems are detected in 80% of cases. Neurocognition may be affected by the tumor, its treatment, associated medication, mood, fatigue, and insomnia. Interpretation of neurocognitive problems should be considered in the context of these factors. Early post-operative neurocognitive rehabilitation for brain tumor patients will produce rehabilitation outcomes (e.g., quality of life, improved physical function, subjective neurocognition) equivalent to stroke, multiple sclerosis, and head injury, but the effect size and duration of benefit needs further research. In stable patients treated with radiotherapy +/- chemotherapy, the most frequent causes of distress include neurocognitive problems, psychological factors of anxiety, depression, fatigue, and sleep. Exercise, neurocognitive training, neurocognitive behavioral therapy, and medications to treat fatigue, behavior, memory, mood, and removal of drugs that may be associated with neurocognitive side effects (e.g., anti-epileptic drugs) all show promise in helping patients to manage the effects of their neurocognitive impairments better. As these are complex symptoms, multidisciplinary expertise is necessary to evaluate the influence of each variable to plan appropriate support and intervention. Neurocognitive rehabilitation should therefore occur in parallel with disease-centered, medical management from the outset. It should not occur in series, as a restricted phase in a patient's pathway. It should be considered in the pre- and post-operative period where there are good prospects of recovery, as one would for any brain-injured patient, so that the person may reach their optimal physical, sensory, intellectual, psychological, and social functional level. Yet the identification and selection of patients for early neurological rehabilitation and routine evaluation of cognition is uncommon in neurosurgical wards.

Panamerican Trauma Society Basic Trauma Education Course Administration in Resource-limited Areas

ABSTRACT Introduction and objectives Injuries and noncommunicable diseases account for greater than 73% deaths and 76% disability adjusted life years (DALYs) in Latin America, where trauma care is challenging especially when resources are scarce. Education and training is a basic step in trauma systems development, which was shown to improve survival. Except for urban areas, trauma courses are unavailable and unaffordable in the Latin region. The aim of this study is to evaluate the feasibility of implementation of a basic trauma education course (BTC) for resource-limited areas adopted and promulgated by the Panamerican Trauma Society (PTS) since 2011. Materials and methods Basic trauma education course was administered in Paraguay, Medellin, Chile, and Panama during the PTS congresses (2011-2013). The two-day course was based on the patient's pathway system, addressing the management of the patient through various echelon of care from rural health centers to local provincial hospital and tertiary treatment facilities. It contained 20 hours of didactic lectures and hands on skill labs on basic trauma resuscitation, stabilization, and transport, as well as trauma system-oriented teaching (triage, EMS, kinematics, trauma registries). Panamerican Trauma Society international and national instructors administered the courses. Course logistics and coordination were carried out by international and local coordinators and by trauma league medical students. Pre and post (30 multiple-choice questions) tests were used to assess participants. Paired t-test was used to compare scores. Results Fifty-four students (rural physicians, EMS providers, students, nurses, and administrators) participated. Pre and posttest score comparison showed significant improvement 74% vs 85% respectively, p-value &lt; 0.0001. Conclusion A tailored trauma course and evaluation can be feasible in educating local providers. The PTS can promulgate the application of BTCs that may serve as a model for continuing trauma care education in developing countries. Course follow-up evaluation is pending. How to cite this article Mata LV, Mora FE, Quiodettis M, Fischer J, Machain GM, Salamea JC, Rodas EB, Aboutanos MB. Panamerican Trauma Society Basic Trauma Education Course Administration in Resource-limited Areas. Panam J Trauma Crit Care Emerg Surg 2016;5(2):83-87.

An audit cycle of consent form completion: A useful tool to improve junior doctor training.

Background:Consent for surgical procedures is an essential part of the patient's pathway. Junior doctors are often expected to do this, especially in the emergency setting. As a result, the aim of our audit was to assess our practice in consenting and institute changes within our department to maintain best medical practice.Methods:An audit of consent form completion was conducted in March 2013. Standards were taken from Good Surgical Practice (2008) and General Medical Council guidelines. Inclusion of consent teaching at a formal consultant delivered orientation programme was then instituted. A re-audit was completed to reassess compliance.Results:Thirty-seven consent forms were analysed. The re-audit demonstrated an improvement in documentation of benefits (91–100%) and additional procedures (0–7.5%). Additional areas for improvement such as offering a copy of the consent form to the patient and confirmation of consent if a delay occurred between consenting and the procedure were identified.Conclusion:The re-audit demonstrated an improvement in the consent process. It also identified new areas of emphasis that were addressed in formal teaching sessions. The audit cycle can be a useful tool in monitoring, assessing and improving clinical practice to ensure the provision of best patient care.

Improving weekend handover in trauma and orthopaedics: A four cycle audit

s / International Journal of Surgery 23 (2015) S15eS134 S86 Aim: The surgical wound is routinely infiltrated with local anaesthetic in minor and major orthopaedic procedures. Increasingly, all-comers are treated with volar locking plates. Local anaesthetic (LA) can be infiltrated as a single dose or via a wound catheter at the end of the procedure with low or negligible side effects. We audited the use of LA in patients who underwent open reduction and internal fixation for distal forearm fractures over a six month period in our designated orthopaedic theatre and performed a cost analysis. Methods: Data was collected on patients who underwent insertion of a volar locking plate for a distal forearm fracture in the preceding 6 months. Prior to closure, incisions were subcutaneously infiltrated with 10mls of 0.5% bupivacaine using a 10 ml syringe. Results: n 1⁄4 89 patients (61 women& 28 men) who met the audit criteria. Age ranged from 14 -71, with average age at the time of injury 57. Total cost was calculated for the use of needle, syringe & 0.5% bupivacaine. Conclusion: Total cost of local anaesthesia was V138.84. There were no needle stick injuries. Future studies based from this audit will evaluate LA lavage of surgical incision and compare cost, opiate consumption and pain scores. 0609: IMPROVING WEEKEND HANDOVER IN TRAUMA AND ORTHOPAEDICS: A FOUR CYCLE AUDIT A. Lunt, S. Yan, J. Stones. Worcester Royal Hospital, UK Aim: Handover between teams has been highlighted as a point of vulnerability in a patient's pathway. The Royal College of Surgeons (RCS) has published guidance on recommended handover practices. We aimed to assess the quality of weekend handover practices in our department, implement changes and re-assess for improvement. Methods: Data for 14 domains, based on RCS guidelines, were retrospectively collected from weekend handovers. The four cycles took place in June, July, August and November 2014 respectively (n 1⁄4 50, 58, 61, 55). Following the first cycle an electronic proforma for weekend handover was developed. Results: Overall compliance in each cycle was 73, 94, 72 and 95% respectively. Median handover scores were 9, 13, 10 and 13 in each cycle with a maximum possible score of 14. Improvement was demonstrated after implementation of electronic proforma, however this reversed in the third audit following the change over of doctors. Following education of the team, further improvement was demonstrated in the fourth audit cycle. Conclusion: Development and implementation of a simple proforma can improve the quality and effectiveness of patient handovers, however education of incoming doctors is essential in maintaining these standards. 0622: AN INTERNAL AUDIT ON EXOGEN USE IN THE EAST MIDLANDS N. Ibrahim , J. Mangwani , R. Natarajan , D. Mahadevan , I. Chauhan , W. Groom, J. Rudd . 1 Leicester Royal Infirmary, UK; Northampton General Hospital, UK Aim: EXOGEN is a portable medical device which utilises ultrasound to stimulate bone remodelling in cases of fracture non-union. Published healing rates are as high as 86%. We evaluated the outcomes of all EXOGEN use at two East Midlands centres e Northampton (NGH) and Leicester (LRI). Methods: Indications for EXOGEN initiation were analysed and compared against published gold standards using clinical notes and imaging. Results: 27 Patients were analysed at the LRI and 20 patients at NGH. 33% of LRI patients initiated on EXOGEN showed bone consolidation at 6 months and 25% at NGH. 26% of LRI patients underwent subsequent definitive surgery after trial and failure of EXOGEN, similarly 25% at NGH. Overall 26% of LRI patients did not meet the criteria for use. Conclusion: The published success of EXOGEN was not reproducible at either centre. The relative success of EXOGEN is heavily dependent on patient selection/adherence. The cost per unit is £2562.50 with an estimated spend of £74,123.50 at the LRI between Jul 2011 and Jan 2014. This Audit demonstrates the importance of establishing a protocol for EXOGEN use and monitoring adherence using a database. This is vital as the cost of the device can reimbursed in certain cases of clinical failure. 0630: RADIOGRAPHIC AND FUNCTIONAL OUTCOMES FOLLOWING KNEE ARTHRODESIS USING THE WICHITA FUSION NAIL IN IRELAND P. McQuail, J. Baker, P. Keogh, P. Kenny. James Connolly Memorial Hospital,

Évaluation de l’acceptabilité du point de vue du médecin traitant et de la faisabilité de la prise en charge ambulatoire de l’embolie pulmonaire

In France, initial management of pulmonary embolism (PE) is performed in the hospital setting. The latest international guidelines suggest that PE at low risk of mortality can be treated in the ambulatory care setting. This means that ambulatory care pathways and general practitioner (GP) opinions concerning such a change in practice need to be determined. To determine: (1) rate of patients eligible for an ambulatory management of their PE and reasons for hospitalization of PE at low risk of mortality; (2) acceptability for GPs of PE home care and patient's desired care pathway. Two-part prospective observational study conducted in Montpellier University Hospital from May 2012 to August 2013: (1) in-hospital study including all consecutive patients with non-hospital acquired PE; (2) telephonic survey on PE patient's ambulatory care pathway conducted among GPs. In-hospital study: 99.1% (n=211) of included patients were hospitalized and only 14.1% (n=30) had all criteria for home care. Patient's pathway survey: 68.3% (n=112) of GPs, particularly those aged 40-54 years and those who had already managed patients alone after hospital discharge, were in favour of home care for PE. One hundred and thirty-nine (84.8%) GPs wanted a collaborative management with an expert thrombosis physician and an outpatient follow-up visit at one week. Few patients managed at Montpellier University Hospital are eligible for ambulatory management of their PE. GPs have a favorable opinion of home care for PE if it is conducted in collaboration with an expert thrombosis physician.

89: Recognising the valuable role a lung cancer CNS can play at the start of the patient's pathway

89: Recognising the valuable role a lung cancer CNS can play at the start of the patient's pathway

“I couldn’t have done it on my own.” Perspectives of patients preparing for discharge from a UK high secure hospital

Purpose – Discharge preparation from high to medium levels of security has received little attention from researchers to date, but is a critical stage in a patient's pathway. This paper aims to capture the perspectives of patients who are preparing to move on from high to medium security. Design/methodology/approach – Nine patients who were in the “discharge preparation” stage of their pathway were interviewed to capture their perspectives on the process. Interview transcripts were analysed using thematic analysis. Findings – Nine themes were identified as representing the patient interviews: trust and support, feeling empowered, journey of self-acceptance, skilling-up, getting to know the Medium Secure Unit (MSU), feeling disempowered and unvalued, issues with the system, anxiety about endings, and stigma and society. Originality/value – This paper gives voice to patients across clinical directorates at a UK high secure hospital regarding their perspectives on what has helped and hindered their discharge preparation. It presents some new findings, and recommended good practice, which should be of use to clinicians and managers who wish to enhance discharge preparation interventions for patients within high secure services.

Navigating and Circumventing a Fragmented Health System: The Patient's Pathway in the Sierra Madre Region of Chiapas, Mexico

Mexico has implemented several important reforms in how health care for its poorest is financed and delivered. Seguro Popular, in particular, a recently implemented social insurance program, aims to provide new funds for a previously underfunded state-based safety net system. Through in-depth ethnographic structured interviews with impoverished farmers in the state of Chiapas, this article presents an analysis of Seguro Popular from the perspective of a highly underserved beneficiary group. Specific points of tension among the various stakeholders--the government system (including public clinics, hospitals, and vertical programs), community members, private doctors, and pharmacies--are highlighted and discussed. Ethnographic data presented in this article expose distinct gaps between national health policy rhetoric and the reality of access to health services at the community level in a highly marginalized municipality in one of Mexico's poorest states. These insights have important implications for the structure and implementation of on-going reforms.

Have the new commissioning guidelines for bariatric surgery improved patient's pathways?

Have the new commissioning guidelines for bariatric surgery improved patient's pathways?

DEVELOPMENT OF AN INTEGRATED END OF LIFE CARE PATHWAY FOR PATIENTS WITH COPD

IntroductionChronic Obstructive Pulmonary Disease (COPD) is a progressive disease ultimately resulting in death, usually in a secondary care setting. Historically, many of these patients have never had the opportunity to...

Ketoacidosis at diagnosis of type 1 diabetes in French children and adolescents

ObjectivesThis study aimed to evaluate the frequency of diabetic ketoacidosis (DKA) and its associated factors at the diagnosis of type 1 diabetes (T1D) in French children and adolescents prior to launching a public-health campaign of information to prevent DKA. Patients and methodsOver a 1-year period, 1299 youngsters (aged<15 years) were diagnosed with T1D at 146 paediatric centres in all regions of France. Age, gender, duration of symptoms, patient's pathway to diagnosis, clinical and biological signs, and family history of T1D were collected for each newly diagnosed patient. DKA was defined as pH<7.30 or bicarbonate<15mmol/L, and severe DKA as pH<7.10 or bicarbonate<5mmol/L. ResultsAt the time of diagnosis, 26% of the children were aged 0–5 years, 34% were 5–10 years and 40% were 10–15 years. The overall prevalence of DKA was 43.9% (0–5 years: 54.2%; 5–10 years: 43.4%; and 10–15 years: 37.1%) and 14.8% for severe DKA (0–5 years: 16.6%; 5–10 years: 14.4%; and 10–15 years: 13.9%;<2 years: 25.3%). Severe DKA was more frequent when the child was hospitalized at the family's behest (26.6%) than when referred by a general practitioner (7.6%) or paediatrician (5.1%; 30.6%, 53.7% and 9.2%, respectively, by patients’ age group). The frequency of DKA decreased to 20.1% (severe DKA: 4.4%) in families with a history of T1D. Multivariate analysis showed that age, pathway to diagnosis, duration of polyuria/polydipsia (< 1 week) and family history of T1D were associated with the presence of DKA, while pathway to diagnosis and family history of T1D were associated with severe DKA. ConclusionDKA at the time of T1D diagnosis in children and adolescents is frequent and often severe. Patients’ age, pathway to hospitalization and family history of diabetes were the main factors associated with DKA. These data suggest that a public-health campaign to prevent DKA at diagnosis can help reduce the frequency of DKA and also provide baseline data for evaluating the efficacy of such a campaign.

Skeletal-Related Events In Myeloma: A Population-Based Study

IntroductionNew therapies have resulted in improvements in myeloma survival, with increasing numbers of patients receiving treatment over several years. Despite this progress, the remitting and relapsing course of the disease continues to be associated with increases in patient morbidity and mortality due to skeletal related events (SREs), including fractures and spinal cord compression. Contemporary information on SRE frequency in myeloma patients at a population-based level is, however, sparse. The aim of this study was to evaluate the incidence of SREs and associated inpatient (I/P) reimbursement costs for myeloma patients. MethodsMyeloma patients newly diagnosed between 2004-9 were identified from a UK specialist population-based study (the Haematological Malignancy Research Network – www.hmrn.org) and followed-up until April, 2011. Information on diagnosis, treatment (first and subsequent lines) and response was abstracted from medical records and all subjects were linked to Hospital Episodes Statistics (HES), a national database containing details of all hospital admissions in England. In our analyses, SREs within HES were identified by diagnosis and procedure codes using International Classification of Diseases (ICD-10) and Operating Procedure Code Set (OPCS-4), respectively. Associated reimbursements were estimated using Healthcare Resource Group (HRG codes); this was done for both SRE related events and the total inpatient treatment pathway. ResultsOf the 1,112 patients newly diagnosed (median age 72.6 years, 57% males, incidence rate - 6.7 per 100,000), 72% received induction chemotherapy; the remainder received supportive care or radiotherapy only, or were asymptomatic and actively monitored. Overall, 32% of patients had an I/P episode related to an SRE; with 15% having non-vertebral fractures, 6% vertebral fractures, 6% spinal cord compression and 17% undergoing surgery to bone (Table 1).The Figure, which presents data by vital status, clearly shows that SREs occurred throughout the pathway. Median follow-up time was 3.8 years and each individual patient's pathway is illustrated by a single grey line, spanning 90 days pre-diagnosis through to death/end of follow-up. SRE I/P episodes are shown in blue and other I/Ps in green. Overall, the average number of bed days for each patient, for any reason, was 43.6, with a total reimbursement cost (excluding drug costs for myeloma) of pounds sterling (GBP) 13,930, equating to GBP 656/month. For myeloma patients with an SRE, the total number of SRE related bed days was 27.3, and total SRE related reimbursement costs were GBP 4,488. ConclusionsIn our contemporary UK population-based dataset, around a third of myeloma patients experienced at least one SRE associated I/P episode at some point in their pathway, with such events being at least as common after diagnosis and first/subsequent treatment(s) as before. Clearly, in the era of novel myeloma therapies, SREs remain an important cause of morbidity, attracting significant inpatient health care costs. [Display omitted] Disclosures:Ashcroft:Celgene: Research Funding. Jack:Roche /Genentech: Research Funding. Roman:Celgene: Research Funding.

Classification of hospital pathways in the management of cancer: Application to lung cancer in the region of burgundy

Context: The evaluation of national cancer plans is an important aspect of their implementation. For this evaluation, the principal actors in the field (doctors, nurses, etc.) as well as decision-makers must have access to information that is reliable, synthetic and easy to interpret, and which reflects the implementation process in the field. We propose here a methodology to make this type of information available in the context of reducing inequalities with regard to access to healthcare for patients with lung cancer in the region of Burgundy. Methods: We used the national medico-administrative DRG-type database, which gathers together all hospital stays. By using this database, it was possible to identify and reconstruct the care management history of these patients. That is, by linking together all attended hospitals, sorted chronologically. Eligible patients were at least 18 years old, whatever the gender and had undergone surgery for their lung cancer. They had to be residents of Burgundy at the time of the first operation between 2006 and 2008. Patient's pathway was defined as the sequence of all attended hospitals (hospital stays) during the year of follow up linked together using an anonymised patient identifier. We then constructed a pathway typology of pathway using an unsupervised clustering method, and conducted a spatial analysis of this typology. Results: Between 2006 and 2008, we selected 495 patients in the 4 administrative departments of the Burgundy region. They accounted for a total of 3821 stays during the year of follow-up. There were 393 men (79%) and the mean age was 64 (95% confidence interval: 63–65) years. We reconstructed 94 pathways (about five per patient). Here, neighbourhood's cares accounted for 41% of them, while 44% included a surgical intervention outside the region of Burgundy. We constructed a pathway typology with five classes. Spatial analysis showed that the vast majority of initial surgeries took place in the major regional centres. Conclusion: The construction of a pathway typology leads to better understanding of the reasoning that lies behind the movements of patients. It opens the way for analysis of the collaboration between the different healthcares establishments attended, which should bring to light associations that need to be developed.

The orthodontic-restorative interface in patients with hypodontia: the patient's journey

Congenitally absent teeth may pose aesthetic and functional problems for patients. Treatment is often complex and involves a multidisciplinary team. Using retrospective data, the patient's pathway, when a combined orthodontic-restorative dentistry approach was used, will be summarized. It was found that the number of teeth missing ranged from 1 to 8 with a mean of 3.4 per patient. Combined treatment was found to take on average around 38 months, using over 20 appointments. Hypodontia is a relatively common condition. It is important that practitioners and patients are aware of the length of time treatment can take.

A rare case of liver lymphangioma

Finding an unexpected large mass in the liver requires prompt careful investigation and management. Imaging plays a vital part in the patient's pathway but histological analysis remains the gold standard for accurate diagnosis and may prevent unnecessary surgical intervention. We report the incidental detection and subsequent management of a large intra-abdominal mass located directly adjacent to the left lobe of the liver. Imaging appearances were consistent with a necrotic metastasis or a fibrolamellar hepatocellular carcinoma (FLHCC), both of which carry a poor prognosis. However, tissue analysis from a core biopsy correlated with lymphangioma, thus affording conservative management. Both FLHCC and lymphangioma are rare tumours but the prognosis for these conditions is very different. We describe briefly the demographics and imaging features associated with each one.

Management of fluid balance

Managing fluid balance mandates a clear identification of what goals are being sought at a particular point in the patient's pathway, an accurate assessment of both filling status and the degree of tissue hypoperfusion (if present), and a precise evaluation of response. As no definitive data exist to show how the above targets should be optimally achieved, and with what fluid, many opinions of varied veracity currently exist. A perception from recent surveys is that critical care and intraoperative patients in Europe are more likely to receive synthetic colloid as the primary resuscitation fluid and to have cardiac output monitored by noninvasive or minimally invasive monitoring techniques. However, these preferences are based largely on tradition and local technology developments, albeit with an increasing evidence base for high-risk surgery. There is an increasing consensus that excess fluid should be avoided and that, after the initial resuscitation phase, efforts should be made to keep the patient in neutral (or perhaps negative) balance, unless clinically indicated. Likewise, the intravascular compartment should not remain underfilled if tissue hypoperfusion exists, acknowledging the above difficulties in agreeing upon definition and diagnosis. Achieving and maintaining optimal fluid balance remains a significant challenge; better monitoring tools and definitive studies are needed.

Machine learning for improved pathological staging of prostate cancer: A performance comparison on a range of classifiers

Prediction of prostate cancer pathological stage is an essential step in a patient's pathway. It determines the treatment that will be applied further. In current practice, urologists use the pathological stage predictions provided in Partin tables to support their decisions. However, Partin tables are based on logistic regression (LR) and built from US data. Our objective is to investigate a range of both predictive methods and of predictive variables for pathological stage prediction and assess them with respect to their predictive quality based on U.K. data. The latest version of Partin tables was applied to a large scale British dataset in order to measure their performances by mean of concordance index (c-index). The data was collected by the British Association of Urological Surgeons (BAUS) and gathered records from over 1700 patients treated with prostatectomy in 57 centers across UK. The original methodology was replicated using the BAUS dataset and evaluated using concordance index. In addition, a selection of classifiers, including, among others, LR, artificial neural networks and Bayesian networks (BNs) was applied to the same data and compared with each other using the area under the ROC curve (AUC). Subsets of the data were created in order to observe how classifiers perform with the inclusion of extra variables. Finally a local dataset prepared by the Aberdeen Royal Infirmary was used to study the effect on predictive performance of using different variables. Partin tables have low predictive quality (c-index=0.602) when applied on UK data for comparison on patients with organ confined and extra prostatic extension conditions, patients at the two most frequently observed pathological stages. The use of replicate lookup tables built from British data shows an improvement in the classification, but the overall predictive quality remains low (c-index=0.610). Comparing a range of classifiers shows that BNs generally outperform other methods. Using the four variables from Partin tables, naive Bayes is the best classifier for the prediction of each class label (AUC=0.662 for OC). When two additional variables are added, the results of LR (0.675), artificial neural networks (0.656) and BN methods (0.679) are overall improved. BNs show higher AUCs than the other methods when the number of variables raises The predictive quality of Partin tables can be described as low to moderate on U.K. data. This means that following the predictions generated by Partin tables, many patients would received an inappropriate treatment, generally associated with a deterioration of their quality of life. In addition to demographic differences between U.K. and the original U.S. population, the methodology and in particular LR present limitations. BN represents a promising alternative to LR from which prostate cancer staging can benefit. Heuristic search for structure learning and the inclusion of more variables are elements that further improve BN models quality.