Short-term Outcome Measures Research Articles

Achieving Minimum Clinically Important Difference in Oxford Knee Score and Short Form-36 Physical Component Summary Is Less Likely with Single-Radius Compared with Multiradius Total Knee Arthroplasty in Asians.

Single-radius (SR) and multiradius (MR) total knee arthroplasties (TKAs) have produced similar outcomes, albeit most studies originate from Western nations. There are known knee kinematic differences between Western and Asian patients after TKA. The aim of this study is to compare the short-term patient-reported outcome measures (PROMs) of SR-TKA versus MR-TKA in Asians. Registry data of 133 SR-TKA versus 363 MR-TKA by a single surgeon were analyzed. Preoperative and 2-year postoperative range of motion (ROM) and PROMs were compared with Student's t-test and Mann-Whitney U-test. Logistic regression model was used to evaluate the odds of SR-TKA or MR-TKA achieving the minimum clinically important difference (MCID) of studied outcomes. Patients in both groups had similar age (65.7 ± 7.6 vs. 65.8 ± 8.2 years; p = 0.317), gender proportion (71% females vs. 79% females; p = 0.119), and ethnic distribution (80% Chinese vs. 84% Chinese; p = 0.258). Preoperatively, there were no statistically significant differences between both groups for ROM, Knee Society Score (KSS), Oxford Knee Score (OKS), and Short Form (SF)-36 scores. At 2 years, all outcomes were statistically similar or failed to achieve a difference of MCID. Controlling for all preoperative variables, SR-TKA has significantly lower odds of achieving MCID for OKS (odds ratio [OR]: 0.275, 95% confidence interval [CI]: 0.114-0.663; p = 0.004) and SF-36 Physical Component Summary (PCS) (OR: 0.547; 95% CI: 0.316-0.946; p = 0.031) compared with MR-TKA. In conclusion, there are no significant differences in the absolute PROMs between SR-TKA and MR-TKA at 2 years following TKA in Asians. However, SR-TKA has significantly lower odds of achieving the MCID for OKS and SF-36 PCS.

Relationship between hospital volume and short-term outcomes: a nationwide population-based study including 75,280 rectal cancer surgical procedures.

There is growing interest on the potential relationship between hospital volume (HV) and outcomes as it might justify the centralization of care for rectal cancer surgery.From the National Italian Hospital Discharge Dataset, data on 75,280 rectal cancer patients who underwent elective major surgery between 2002 and 2014 were retrieved and analyzed. HV was grouped into tertiles: low-volume performed 1-12, while high-volume hospitals performed 33+ procedures/year. The impact of HV on in-hospital mortality, abdominoperineal resection (APR), 30-day readmission, and length of stay (LOS) was assessed. Risk factors were calculated using multivariate logistic regression.The proportion of procedures performed in low-volume hospitals decreased by 6.7 percent (p<0.001). The rate of in-hospital mortality, APR and 30-day readmission was 1.3%, 16.3%, and 7.2%, respectively, and the median LOS was 13 days. The adjusted risk of in-hospital mortality (OR = 1.49, 95% CI = 1.25-1.78), APR (OR 1.10, 95%CI 1.02-1.19), 30-day readmission (OR 1.49, 95%CI 1.38-1.61), and prolonged LOS (OR 2.29, 95%CI 2.05-2.55) were greater for low-volume hospitals than for high-volume hospitals.This study shows an independent impact of HV procedures on all short-term outcome measures, justifying a policy of centralization for rectal cancer surgery, a process which is underway.

Quality of Recovery, Postdischarge Hospital Utilization, and 2-Year Functional Outcomes After an Outpatient Total Knee Arthroplasty Program

BackgroundOutpatient total knee arthroplasty (TKA) has been made possible with advances in perioperative care and standardized clinical inpatient pathways. While many studies report on benefits of outpatient programs, none explore patient-reported outcome measures. As such, our goals were to compare the short-term quality of recovery; highlight postdischarge hospital resources utilization; and report on 2-year functional outcomes scores. MethodsThis was a prospective comparative cohort study of 43 inpatients (43 TKAs) and 43 outpatients (43 TKAs) operated on by a single surgeon between September 28, 2010 and May 5, 2015. All patients were given a diary to complete at 1, 3, 7, 14, and 28 days postoperatively; we collected 90-day complications, readmissions, and emergency department visits; Knee Injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index scores were completed preoperatively and 2 years postoperatively. SPSS (IBM, version 22.0) was used for all statistical analyses. ResultsQuality of recovery (QoR-9) was similar in the outpatient TKA group compared with the inpatient group. No statistically significant differences were observed for Knee Injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index subscores (P > .05). There was 1 readmission in both outpatient and inpatient groups. Six inpatients and 8 outpatients returned to the emergency department for any reason within 90 days, with no statistical significance observed between the 2 groups (P = .771). ConclusionOutpatient TKA in selected patients produced similar short-term and 2-year patient-reported outcome measures and a comparable 90-day postdischarge hospital resource utilization when compared to an inpatient cohort, supporting further investigation into outpatient TKA.

Outcomes for Elderly Patients With Atypical Femoral Fractures Compared to Typical Femoral Fractures for Length of Stay, Discharge Destination, and 30-Day Mortality Rate.

Introduction:Despite increasing recognition of atypical femoral fractures (AFFs), there’s conflicting evidence about incidence, aetiology, and short-term outcomes of these injuries. This study reports the incidence of AFFs at our center and compares the early postoperative outcomes against typical femoral fractures (TFFs).Methods:A retrospective observational cohort study of patients presenting to our trauma unit between November 2015 and July 2016 was undertaken. Inclusion criteria required radiologically confirmed proximal femoral fracture, which was then categorized as AFF or TFF. Primary outcome measures included length of stay, discharge destination, and 30-day mortality.Results:Two hundred thirty-nine patients presented to our trauma unit over 9 months with either a fractured neck of femur or proximal femoral fracture. A total of 122 were identified as pertrochanteric, subtrochanteric, or proximal femoral shaft fractures of which 25 (20.5%) displayed atypical radiographic features consistent with AFF. The 2 groups were similar for average age (TFF 85.3 years vs AFF 85.0 years), gender (19% vs 16% male gender), American Society of Anaesthesiology grade (3.0 vs 3.0), cognitive score (abbreviated mental test score = 7.03 vs 7.08), and preinjury place of residence (88.9% vs 92.0% lived in own home). Typical fractures were fixed with either dynamic hip screw or intramedullary nailing, all atypical fractures were fixed with intramedullary nailing. There was no statistical difference between the 2 groups for length of stay (12.8 days vs 14.3 days; P > .05), discharge to preinjury residence (45.1% vs 36%; P > .05), or 30-day mortality (8.1% vs 12%; P > .05).Discussion:In our predominantly geriatric population atypical radiographic features were observed in around 10% of patients presenting with proximal femoral fractures or fractured neck of femur. Previous studies have reported poor outcomes for pain, mobility, and length of stay after AFF. However, we observed no difference in short-term outcome measures when compared to patients with typical proximal femoral fracture patterns at our trauma unit.Conclusion:With modern principles of trauma care outcomes achieved following AFFs may be equivalent to typical femoral fractures in the geriatric population.

Short- and long-term outcomes following pelvic exenteration for gynae-oncological and colorectal cancers: A 9 year consecutive single-centre cohort study

ObjectivesRadical pelvic exenteration can be undertaken for locally invasive or recurrent disease in both colorectal and gynaecological malignancies. In the UK this procedure is usually undertaken by the respective surgical specialties who have undergone divergent surgical training. This study describes and compares outcomes between colorectal and gynae-oncological teams following pelvic exenteration for primary and recurrent gynaecological and colorectal cancers in a single-centre multi-disciplinary team. MethodA retrospective review of consecutive pelvic exenteration patients undertaken over a nine-year period in a tertiary referral centre. Analyses comparing short- and long-term morbidity and mortality outcomes were undertaken by chi-square test for categorical variables and Mann-Whitney U for continuous variables. Cumulative survival rates were calculated according to the Kaplan-Meier method and factors associated with recurrence and survival determined using a Cox regression model. ResultsThirty-four exenterations were undertaken; fourteen colorectal and twenty gynae-oncological. Morbidity was seen in 50% of colorectal and 75% of gynae-oncological patients. Recurrence was seen earlier and with greater frequency in the gynaeoncology group (44.4% and median time 11 months) than the colorectal group (21.4%, median time 41 months; p > 0.05). Survival in the gynae-oncology group was also lower than the colorectal group at 1-year (69.6% vs. 92.9%) and 5-years (58.0% vs. 92.9%; p = 0.115). The majority of gynae-oncological mortality occurred within 3-years of surgery, whilst the majority of mortality in the colorectal group was after 5-years. ConclusionLong-term patient outcome measures, including disease recurrence and 5-year survival, for colorectal exenteration appear better than for gynaeoncology patients, however, no statistical significant difference exists between short-term outcome measures between specialties. This is likely to be caused by different baseline pathologies and disease pattern influencing longer term prognosis but may also be a function of differing surgical thresholds and patient selection bias between specialties. Peri-operative and short-term morbidity appear equivalent despite divergent surgical backgrounds and training.

Information Engineering for Value in Pediatric Emergency Medicine

Emergency medicine continues to suffer from information gaps that limit progress on measurement and action on quality of care. Important progress has been made in defining structure, process, and short-term outcome measures that occur within the time boundary of the emergency department (ED) visit itself for ill and injured children. However, true progress toward value-based care requires insight into outcomes beyond the walls of the ED. Existing measures such as return visits are not uniformly endorsed as a reliable and actionable measure of quality. The advent of concepts such as learning networks and patient-reported outcomes, and changes in technology use and connectivity at the population level offer potential strategies for ED systems to consider in the creation of scalable and sustainable information strategies to drive our progress toward value-based care.

Inflammatory Activity on Natalizumab Predicts Short-Term but Not Long-Term Disability in Multiple Sclerosis.

BackgroundIn people with multiple sclerosis treated with interferon-beta or glatiramer acetate, new MRI lesions and relapses during the first year of treatment predict a poor prognosis.ObjectiveTo study this association in those receiving natalizumab.MethodsData were collected on relapses, new MRI activity, and Modified Rio Score after initiation of natalizumab in an observational cohort of 161 patients with high baseline disability. These were correlated with Expanded Disability Status Scale (EDSS) progression at years 1, 2, 3, and 3–7 after treatment initiation, versus pre-treatment baseline.Results46/161 patients had a relapse in the first year and 44/161 had EDSS progression by year 2. Relapses and Modified Rio Score in the first year of treatment predicted EDSS progression at year 1 and 2 after treatment initiation. However, this effect disappeared with longer follow-up. Paradoxically, there was a trend towards inflammatory activity on treatment (first year Modified Rio Score, relapses, and MRI activity) predicting a lower risk of EDSS progression by years 3–7, although this did not reach statistical significance. Those with and without EDSS progression did not differ in baseline age, EDSS, or pre-treatment relapse rate. Relapses in year 0–1 predicted further relapses in years 1–3.ConclusionsBreakthrough inflammatory activity after natalizumab treatment is predictive of short-term outcome measures of relapses or EDSS progression, but does not predict longer term EDSS progression, in this cohort with high baseline disability.

Morbidity analysis in minimally invasive esophagectomy for oesophageal cancer versus conventional over the last 10 years, a single institution experience.

BACKGROUND:There has been an increasing inclination towards minimally invasive esophagectomies (MIEs) at our institute recently for resectable oesophageal cancer.OBJECTIVES:The purpose of the present study is to report peri-operative and long-term procedure specific outcomes of the two groups and analyse their changing pattern at our institute.METHODS:All adult patients with a diagnosis of oesophageal cancer managed at our institute from 2005 to 2015 were included in this retrospective study. Patients’ demographic and clinical characteristics were recorded through our hospital information system. The cohort of esophagectomies was allocated into two groups, conventional open esophagectomy (OE) or total laparoscopic MIE; hybrid esophagectomies were taken as a separate group. The short-term outcome measures are an operative time in minutes, length of hospital and Intensive Care Unit (ICU) stay in days, post-operative complications and 30 days in-hospital mortality. Complications are graded according to the Clavien-Dindo classification system. Long-term outcomes are long-term procedure related complications over a minimum follow-up of 1 year. Trends were analysed by visually inspecting the graphic plots for mean number of events in each group each year.RESULTS:Our results showed no difference in mortality, length of hospital and ICU stays and incidence of major complications between three groups on uni- and multi-variate analysis (P > 0.05). The operative time was significantly longer in MIE group (odds ratio [OR]: 1.66, confidence interval [CI]: 2.4–11.5). The incidence of long-term complication was low for MIE (OR: 1.0, CI: 133–1.017). However, all post-operative surgical outcomes trended to improve in both groups over the course of this study and stayed better for MIE group except for the operative time.CONCLUSION:MIE has overall comparable surgical outcomes to its conventional counterpart. Furthermore, the peri-operative outcomes tend to improve in our centre with the maturation of program and experience.

P3.06-004 A Systematic Review of Outcome Reporting in Studies of Radical Radiotherapy and Chemoradiotherapy in Lung Cancer: Topic: Clinical Studies

Clinical decision making in lung oncology is informed by evidence about the risks and benefits of proposed treatments, alongside other important factors including clinician experience and patient preference. There is no consensus about which outcome measures are most meaningful to patients or informative for clinicians. Measures relating to disease response and survival are common, but it is not known which specific measures are most favored, how consistently they are defined, and how frequently domains such as quality of life are represented. A systematic review of EMBASE, COCHRANE and MEDLINE was conducted. Prospective studies of radical radiotherapy or chemoradiotherapy for lung cancer published during 2013-2016 were included, where clinically-relevant outcomes (including patient-reported outcomes) were reported. Individual outcomes were recorded and categorized. Frequency of outcomes, reported definitions and consistency of reporting both within and between studies were examined. Study quality was assessed against UK national standards. 29 papers met the full inclusion criteria. 124 separate outcome measures were reported, within which, 68 distinct outcomes were identified. 47/124 outcome measures were defined or referenced. None were defined consistently between studies. 3 papers described an outcome measure in their Methods but did not report it in their Results. 24/29 papers reported outcomes not introduced in their Methods. One paper included patient-reported outcome measures. No short-term outcome measures (such as 30 or 90 day mortality) were reported. This systematic review has highlighted significant variation in practice in outcome measure reporting in studies of radical lung cancer treatments. A large number of different outcome measures were reported, the majority of which weren’t defined. Where apparently identical outcome measures were reported in more than one study, definitions were inconsistent. Outcome measures relating to short-term survival were not reported at all, despite the fact that long-term survival in this patient population was uncommon. Only one study included patient-reported outcome measures. If lung cancer research is to optimally inform clinical decision making, study endpoints should reflect outcomes that are most meaningful to patients and their clinicians. Variation in outcome-reporting practice, particularly where definitions are lacking and inconsistent, is a significant concern. It threatens the ability of clinicians to assimilate the findings from multiple studies and limits the extent to which the true benefits and burdens of proposed treatments can be understood. Consideration should be given as to whether a core outcome set, incorporating clinically meaningful and patient-reported outcomes, might be warranted in lung cancer. Further research is needed.

The Roles of the Charlson Comorbidity Index and Time to First Antibiotic Dose as Predictors of Outcome in Pneumococcal Community-Acquired Pneumonia.

In this retrospective study, we aimed to investigate the role of comorbidities using the Charlson comorbidity index (CCI) and time to first antibiotic dose (TFAD) in patients with pneumococcal community-acquired pneumonia (PCAP). All consecutive ER admissions with PCAP who were hospitalized in the University Hospital, Zurich between 2006 and 2012 were included. The primary outcome was to determine possible determinants of all-cause in-hospital mortality (ACIHM). The second endpoint was to detect risk factors for adverse events (AEs) and determinants of length of stay (LOS). 108 subjects (mean age 57.6years) were included. The median (IQR) CCI was 4 (1, 8). The median (IQR) TFAD was 210 (150, 280) min. ACIHM was 6.5% (7/108), and median (IQR) LOS was 9 (6, 14) days. PCAP-related AEs were observed in 57 cases (52.8%). In the multivariable analysis, neither CCI nor TFAD was associated with the outcome measures. Pneumonia severity index (PSI) was the only statistically significant predictor of ACIHM (HR 1.31/10 point increase, 95% CI 1.12-1.53, p=0.001) and AE rate (OR 1.31, 95% CI 1.15-1.50, p<0.001). In this study including comparatively young patients with rather mild disease severity, we found no strong evidence supporting that CCI or TFAD influenced short-term outcome measures of PCAP. Yet, pneumonia severity appears to be the most important factor for the outcome.

Monitoring the impact of HPV vaccine in males—Considerations and challenges

In this article, we examine the issues involved if national or sub-national programs are considering extending post HPV vaccine introduction monitoring to include males. Vaccination programs are now being extended to include males in some countries, in order to improve population level HPV infection control and to directly prevent HPV-related disease in males such as anogenital warts and anal cancers. Coverage and adverse events surveillance are essential components of post-vaccination monitoring. Monitoring the impact of vaccination on HPV infection and disease in men raises some similar challenges to monitoring in females, such as the long time frame until cancer outcomes, and also different ones given that genital specimens suitable for monitoring HPV prevalence are not routinely collected for other diagnostic or screening purposes in males. Thus, dedicated surveillance strategies must be designed; the framework of these may be country-specific, dependent upon the male population that is offered vaccination, the health care infrastructure and existing models of disease surveillance such as STI networks. The primary objective of any male HPV surveillance program will be to document changes in the prevalence of HPV infection and disease due to vaccine targeted HPV types occurring post vaccination. The full spectrum of outcomes to be considered for inclusion in any surveillance plan includes HPV prevalence monitoring, anogenital warts, potentially pre-cancerous lesions such as anal squamous intraepithelial lesions (SIL), and cancers. Ideally, a combination of short term and long term outcome measures would be included. Surveillance over time in specific targeted populations of men who have sex with men and HIV-infected men (populations at high risk for HPV infection and associated disease) could be an efficient use of resources to demonstrate impact.

Laparoscopic Management of Colonic Diverticular Disease and its Complications: an Analysis.

Dense inflammatory reactions, loss of tissue planes and sepsis make surgical treatment of diverticulitis complex and difficult. Experience with laparoscopic management of this disease is scanty in our country. This study aims to assess the pattern of presentation, the site of involvement and complications of diverticulitis coli. This study also aims to audit the results of laparoscopic approach for complicated colonic diverticulitis. A retrospective analysis of all patients who had laparoscopic management of complicated diverticulitis patients from August 2007 to October 2014 was done from the database. The site of involvement, extent and presence or absence of complications of diverticular disease was noted. The surgical approach, intraoperative parameters and short-term outcome measures were analysed. There were 38 (8.8%) patients with diverticular disease out of 427 patients who had laparoscopic colorectal surgery in the study period with a median age of 59years. Out of 38 patients, 50% had comorbid conditions. Internal fistulae were seen in 9 (23.6%) patients, 6 with colovesical and 3 with colovaginal fistulae. Elective laparoscopic colectomy with primary anastomosis was done in 34 (89%) cases of which, and 10 (26%) patients had abscess on presentation requiring drainage. Four patients required emergency laparoscopic surgery of which primary resection and anastomosis was done in 3 (7.8%), and Hartmann's operation was done in 1 (2.6%) patient. Two patients required stoma. The morbidity was seen in 15% cases, and the mean hospital stay was 9.54days. Laparoscopic approach for diverticular disease and its complication is feasible and safe. Careful selection of patients, judicious use of diverting stoma and appropriate selection of the procedure help to achieve good results even in those with septic complications and fistulising disease.

Abstract TP291: Outcomes of Intravenous Thrombolysis in Mild and Rapidly Resolving Ischemic Stroke

Introduction: Mild and rapidly resolving ischemic strokes (RRIS) are controversial, relative contraindications for IV thrombolysis. Methods: A retrospective review of GWTG database was performed for a 5-hospital stroke network between 2010 and 2014. Acute ischemic stroke (AIS) patients that arrived within 4.5 hours from symptom onset and had a baseline NIHSS &lt;=5 were included. The short-term outcome measures were ambulation status at discharge, discharge disposition, mortality, and length of stay. 29% of admission and 26% of discharge ambulatory statuses were unknown and included in the independent ambulatory groups. Discharge disposition was dichotomized as good (home or rehab) or bad (SNF, hospice, or death). Results: Of 5133 AIS patients, 480 (44% women, 49% White, 41% Hispanic, and 5.7% Black) met inclusion criteria, of which 122 (27%) were treated with IV TPA. The average age of treated patients was 73 (range of 29-92) and not treated was 67 (range 18-100). Outcome measures were not significantly different between groups (Table 1). Discussion: This study did not find a significant difference in discharge outcomes for mild and RRIS patients who did or did not receive IV TPA. Our sample size may be too small to demonstrate a treatment effect. Both groups, however, had significant disability at discharge with ∼25% unable to ambulate independently and ∼15% bad discharge disposition. These findings provide further evidence that strokes with low NIHSS can be disabling.

The effects of proximal and distal routes of intraosseous epinephrine administration on short-term resuscitative outcome measures in an adult swine model of ventricular fibrillation: a randomized controlled study

IntroductionIt is unknown if the anatomical distance of intraosseous (IO) epinephrine injection from the heart affects resuscitative outcome. The purpose of this study was to explore the relationships between the anatomical distance of IO epinephrine injection and measures of resuscitative outcome in an adult swine model of ventricular fibrillation (VF). MethodsThirty-two Yorkshire-cross swine (60–80 kg) were randomly assigned to four groups: humeral IO (HIO), tibial IO (TIO), IV with defibrillation and epinephrine, and IV control: with defibrillation but no epinephrine. Ventricular fibrillation was induced. Swine remained in VF for 4 minutes prior to mechanical chest compressions. After 6 minutes in VF, swine were defibrillated and epinephrine (0.01 mg/kg) administered by group assignment. Defibrillation was repeated every 2 minutes. Epinephrine was repeated every 4 minutes. Interventions continued until return of spontaneous circulation (ROSC) or 26 post-arrest minutes elapsed. Swine achieving ROSC were observed for 30 minutes post-ROSC. ResultsThere were no significant differences between the HIO, TIO, and IV groups relative to the occurrence of ROSC (P > .05 in all cases), 30-minute post-ROSC survival (P > .05 in all cases), and time to ROSC (P = .43). There were significant differences between the HIO, TIO, and IV groups compared to the control group relative to the occurrence of ROSC (P = .02, .01, and .007 respectively), and 30 minute post-ROSC survival (P = .05, .03, and .007, respectively). ConclusionThe anatomical distance of IO epinephrine injection from the heart did not affect short-term measures of resuscitative outcome in an adult swine model of VF including the occurrence of ROSC, 30 minute post-ROSC survival, and time to ROSC. Rapidly administered epinephrine, irrespective of route of administration, increased the chance ROSC and survival to 30 minutes post-ROSC would occur in this study.

Bedside Injection Medialization Laryngoplasty in Immediate Postoperative Patients.

The morbidity of glottic insufficiency resulting from unilateral vocal fold immobility may significantly compromise postoperative recovery in patients with decreased pulmonary reserve or inability to protect their airway. Injection medialization laryngoplasty is an effective means of treating glottic insufficiency due to unilateral vocal fold immobility. The purpose of this study is to present our experience with bedside transoral injection medialization laryngoplasty in the immediate postoperative period. Case series with chart review. Academic tertiary care hospital. Patient demographics, clinical characteristics, procedural details, and short-term outcome measures of oral intake were recorded in a cohort of 68 patients over 5 years with unilateral vocal cord paralysis who underwent injection medialization as a bedside procedure in the immediate postoperative period. Mean time to injection was 8.2 days postoperatively. At the time of injection, 40 of 68 patients were nil per os. Seventy percent (28 of 40) had their diet advanced to adequate oral intake within 5 days of injection. Greater than half of the injections (36 of 68) were performed in the intensive care unit. No complications were noted, and all patients in this cohort were able to tolerate the bedside injection. Bedside injection medialization laryngoplasty in the immediate postoperative period via the transoral approach can be performed in patients, even in the intensive care unit, while on anticoagulation, and may be of benefit for hospitalized patients with unilateral vocal fold immobility. Further studies quantifying improvement in voice and swallowing data are merited.

Systematic review and meta-analysis of outcomes after cardiopulmonary arrest in childhood.

BackgroundCardiopulmonary arrest in children is an uncommon event, and often fatal. Resuscitation is often attempted, but at what point, and under what circumstances do continued attempts to re-establish circulation become futile? The uncertainty around these questions can lead to unintended distress to the family and to the resuscitation team.ObjectivesTo define the likely outcomes of cardiopulmonary resuscitation in children, within different patient groups, related to clinical features.Data SourcesMEDLINE, MEDLINE in-Process & Other non-Indexed Citations, EMBASE, Cochrane database of systematic reviews and Cochrane central register of trials, Database of s of Reviews of Effects (DARE), the Health Technology Assessment database, along with reference lists of relevant systematic reviews and included articles.Study Eligibility CriteriaProspective cohort studies which derive or validate a clinical prediction model of outcome following cardiopulmonary arrest.Participants and InterventionsChildren or young people (aged 0 – 18 years) who had cardiopulmonary arrest and received an attempt at resuscitation, excluding resuscitation at birth.Study Appraisal and Synthesis MethodsRisk of bias assessment developed the Hayden system for non-randomised studies and QUADAS2 for decision rules. Synthesis undertaken by narrative, and random effects meta-analysis with the DerSimonian-Laird estimator.ResultsMore than 18,000 episodes in 16 data sets were reported. Meta-analysis was possible for survival and one neurological outcome; others were reported too inconsistently. In-hospital patients (average survival 37.2% (95% CI 23.7 to 53.0%)) have a better chance of survival following cardiopulmonary arrest than out-of-hospital arrests (5.8% (95% CI 3.9% to 8.6%)). Better neurological outcome was also seen, but data were too scarce for meta-analysis (17% to 71% ‘good’ outcomes, compared with 2.8% to 3.2%).LimitationLack of consistent outcome reporting and short-term neurological outcome measures limited the strength of conclusions that can be drawn from this review.Conclusions and Implications of Key FindingsThere is a need to collaboratively, prospectively, collect potentially predictive data on these rare events to understand more clearly the predictors of survival and long-term neurological outcome.Systematic Review Registration NumberPROSPERO 2013:CRD42013005102

Hyperbaric Oxygen in Lower Limb Trauma (HOLLT); protocol for a randomised controlled trial

IntroductionOpen fractures with significant soft tissue injury are associated with high rates of complications, such as non-union, infection, chronic pain and disability. Complications often require further inpatient care, and in...

Outcomes when congenital heart disease is diagnosed antenatally versus postnatally in the UK: a retrospective population-based study

BackgroundFor major congenital heart disease, the benefits of antenatal diagnosis on some post-natal measures have been suggested. However, findings have been inconclusive and focus on short term outcome measures alone with little data from a UK population. Our aim is to describe differences in reported outcomes for patients born with isolated Hypoplastic Left Heart Syndrome or Transposition of the Great Arteries in a UK population, following either antenatal or postnatal diagnosis.MethodsRetrospective population-based study with case note review covering a 15 year period (1st January 1998 to 31st December 2012) in the British county of Leicestershire. Cases were identified from two local registers: the East Midlands and South Yorkshire Congenital Anomaly Register and a list of surgical patient held by the East Midlands Congenital Heart Centre.ResultsIn total 52 cases of Hypoplastic Left Heart Syndrome or Transposition of the Great Arteries were identified with 24 (46.2%) diagnosed antenatally. Maximum and minimum follow up was 181 and 16 months respectively. Median follow up was 83 months (IQR: 44–111).The risk of intubation in the postnatal period (OR: 4.64, 95% CI: 1.40 - 15.32) was greater in cases of Hypoplastic Left Heart Syndrome or Transposition of the Great Arteries diagnosed after birth when compared to those diagnosed antenatally. There was a non-significant increase in the risk of metabolic acidosis in the postnatal period (OR: 12.5, 95% CI: 0.64 - 245.46). No differences in mortality or long-term outcomes were demonstrated between antenatally and postnatally diagnosed cohorts.ConclusionsThese results confirm data from American and European populations that, for a British population, an antenatal diagnosis of a major congenital heart disease can have a favourable impact on some postnatal outcome measures. There appears to be no evidence that time of diagnosis impacts on long-term outcome measures.

Increased Complications in Obese Patients Undergoing Direct Anterior Total Hip Arthroplasty

The direct anterior (DA) approach for total hip arthroplasty (THA) has demonstrated successful short term outcomes in several studies. However, there is no consensus about which patients are appropriate candidates for DA total hip arthroplasty. It is also unclear if short term outcomes in obese patients undergoing THA through a DA approach are elevated in comparison to non-obese patients. The purpose of this study was to evaluate complication rates and short term outcomes of obese, pre-obese, and normal body mass index (BMI) patients undergoing THA with a DA approach in a consecutive group of patients. This study was a retrospective review of 210 consecutive patients who underwent unilateral THA through a DA approach for osteoarthritis or avascular necrosis during the early peri-operative period. The study included 61 patients with normal BMI, 70 pre-obese patients, and 79 obese patients according to World Health Organization (WHO) classification (49 class I obese, 22 class II obese, and 8 class III obese patients). Patient charts were reviewed to determine differences in surgical time, length of stay, disposition, major complications, wound complications, and short term outcome measures. When comparing normal and pre-obese patients (BMI <30) to a combined group of WHO class I, II, and III obese patients (BMI >30), the obese group demonstrated increased surgical times by 12.7minutes (P<0.0001), as well as increased length of stay (P=0.0303), narcotic use (P=0.0037), and assistive device use at two weeks (P<0.0030). In addition, major complications and wound complications were both significantly increased in the obese group (odds ratio [OR], 8.8; P=0.0493 and OR, 3.6; P=0.0431, respectively). There was also a trend toward increased use of rehabilitation facilities in the obese group at disposition, 15.4% vs 7.6% (P=0.0774). This study demonstrates that obese patients undergoing a DA approach have a 8.8 and 3.6 times increase in major and wound complications, respectively, compared to patients with a BMI <30. Obese patients also demonstrated significant increases in operative time, use of narcotics, use of assistive devices, and length of stay. There was a trend toward higher use of rehabilitation placement. While significant, these findings are similar to complication rates in the literature for other THA operative approaches. This study further defines the risks associated with performing THA on obese patients regardless of approach.

Prospective randomized controlled trial of conventional laparoscopic versus laparoendoscopic single-site radical nephrectomy for localized renal cell carcinoma: a preliminary report regarding quality of life.

The safety and efficacy of laparoendoscopic single-site surgery (LESS) for renal cell carcinoma (RCC) have not been clearly demonstrated. We aimed to present preliminary data from a prospective randomized controlled trial of LESS versus conventional laparoscopic radical nephrectomy for localized RCC. Patients with cT1-2 RCC were randomized to LESS (n = 17) or conventional laparoscopy (n = 18) group. The short-term outcome measures assessed were perioperative morbidity, postoperative pain, and quality of recovery as determined using QoR-40. No significant differences were observed between the LESS and conventional laparoscopy groups with respect to operative time (143.5 vs. 126.1 min, p = 0.218), blood loss (143.6 vs. 118.2 ml, p = 0.121), hospital stay (3.8 vs. 3.1 day s, p = 0.170), analgesic requirements (63.2 vs. 60.0 mg, p = 0.956), and complication rates (26.7 vs. 22.2 %, p = 0.767). However, postoperative quality of recovery was better in the LESS group (176.4 vs. 152.6, p = 0.005). Furthermore, quality of recovery, as measured using the QoR-40 dimensions of emotional state (39.9 vs. 34.0, p = 0.003), physical comfort (51.9 vs. 46.7, p = 0.034), psychological support (32.2 vs. 25.8, p = 0.003), and physical independence (20.7 vs. 17.5, p = 0.047), but not pain (31.8 vs. 29.6, p = 0.259), was significantly better in the LESS group. The preliminary results from this prospective trial suggest that LESS could be a safe and effective treatment option for localized RCC with equivalent surgical outcomes and improved postoperative quality of recovery compared with conventional laparoscopic surgery.