Specific Types Of Procedures Research Articles

Judgment Errors in Surgical Care.

Human error is impossible to eliminate, particularly in systems as complex as healthcare. The extent to which judgment errors in particular impact surgical patient care or lead to harm is unclear. The American College of Surgeons NSQIP (2018) procedures from a single institution with 30-day morbidity or mortality were examined. Medical records were reviewed and evaluated for judgment errors. Preoperative variables associated with judgment errors were examined using logistic regression. Of the surgical patients who experienced a morbidity or mortality, 18% (31 of 170) experienced an error in judgment during their hospitalization. Patients with hepatobiliary procedure (odds ratio [OR] 5.4 [95% CI 1.23 to 32.75], p = 0.002), insulin-dependent diabetes (OR 4.8 [95% CI 1.2 to 18.8], p = 0.025), severe COPD (OR 6.0 [95% CI 1.6 to 22.1], p = 0.007), or with infected wounds (OR 8.2 [95% CI 2.6 to 25.8], p < 0.001) were at increased risk for judgment errors. Specific procedure types and patients with certain preoperative variables had higher risk for judgment errors during their hospitalization. Errors in judgment adversely impacted the outcomes of surgical patients who experienced morbidity or mortality in this cohort. Preventing or mitigating errors and closely monitoring patients after an error in judgment is prudent and may improve surgical safety.

Impact of COVID-19 on ophthalmic surgical procedures in sub-Saharan Africa: a multicentre study

BackgroundThe COVID-19 pandemic had a profound impact on healthcare and ophthalmology services globally. Numerous studies amongst various medical and surgical specialties showed a reduction in patient attendance and surgical procedures performed. Prior published ophthalmic literature focused on specific types of procedures and were usually single centre. The current study attempts to quantify the impact on a larger scale, namely that of sub-Saharan Africa, and to include all ophthalmic subspecialties.MethodsThis is a retrospective analysis of the surgical records from 17 ophthalmology centres in seven countries located in East, Central, West and Southern Africa. The date of declaration of the first lockdown was used as the beginning of the pandemic and the pivot point to compare theatre records one year prior to the pandemic and the first year of the pandemic. We examined the total number of surgical procedures over the two year period and categorized them according to ophthalmic subspecialty and type of procedure performed. We then compared the pre-pandemic and pandemic surgical numbers over the two year period.ResultsThere were 26,357 ophthalmic surgical procedures performed with a significant decrease in the first year of the pandemic (n = 8942) compared to the year prior to the pandemic (n = 17,415). The number of surgical procedures performed was lower in the first year of the pandemic compared to the year prior to the pandemic by 49% [Incidence rate ratio (IRR) 0.51, 95% CI 0.41–0.64), 27% (0.73, 0.55–0.99), 46% (0.54, 0.30–0.99), 40% (0.60, 0.39–0.92) and 59% (0.41, 0.29–0.57) in sub-Saharan Africa (4 regions combined), West, Central, East and Southern Africa, respectively]. The number of surgical procedures in the different sub-specialty categories in sub-Saharan Africa (4 regions combined) was significantly lower in the first year of the pandemic compared to the year prior to the pandemic, except for glaucoma (IRR 0.72, 95% CI 0.52–1.01), oncology (0.71, 0.48–1.05), trauma (0.90, 0.63–1.28) and vitreoretinal (0.67, 0.42–1.08) categories.ConclusionThis study provides insight into the impact of the COVID-19 pandemic in multiple regions and countries on the African continent. The identification of which surgical subspecialty was most affected by the COVID-19 pandemic in each region allows for better planning and resource allocation to address these backlogs.

Impact of the endovascular revolution on vascular training through analysis of national data case reports

BackgroundIn the last couple of decades, there has been a shift in use of endovascular procedures in vascular surgery. We aim to examine the impact of this endovascular shift on vascular trainees, determine whether the surgical experiences of trainees in the integrated residency and fellowship program changed over time, and identify differences between the two training paradigms. MethodsData were extracted from the Accreditation Council for Graduate Medical Education National Data Case Logs for the vascular surgery fellowship (1999-2021) and integrated residency (2012-2021) programs. Every procedure was categorized as open or endovascular, then designated into the following subcategories: thoracic aneurysm repairs, cerebrovascular, abdominal aneurysm repairs, venous, vascular access, peripheral arterial disease, visceral, or miscellaneous. We compared the prevalence of open and endovascular cases in the fellowship and integrated residency using data from overlapping years (2012-2021). In addition, we compared the mean number of cases per trainee per year within designated time intervals. The vascular surgery fellowship was grouped into three intervals: 1999 to 2006, 2006 to 2013, and 2013 to 2021; the integrated vascular surgery residency was grouped into two intervals: 2012 to 2017 and 2017 to 2021. Data were standardized to represent the average number of cases per trainee per year. ResultsWithin the fellowship, we found a 362.37% increase in endovascular procedures (mean, 56.80 ± 32.57 vs 262.63 ± 9.91; P < .001), although there was only a 32.47% increase in open procedures (220.19 ± 4.55 vs 291.68 ± 8.20) between the first and last time intervals. There was a decrease in abdominal aneurysm repair (24.46 ± 7.30 vs 13.85 ± 0.58; P < .001) and visceral (6.41 ± 0.44 vs 5.80 ± 0.42; P = .039) open procedures. For the integrated residency, there was an increase in open procedures by 8.52% (352.18 ± 8.23 vs 382.20 ± 5.84; P < .001). Residents had greater total, open, and endovascular procedures per year than fellows (all P < .001). Chief residents had approximately one-half as many cases as vascular fellows per year. Fellows performed more open abdominal aneurysm repair (14.04 ± 0.80 vs 12.40 ± 1.32; P = .007) and visceral (5.83 ± 0.41 vs 4.88 ± 0.46; P > .001) procedures than residents. Overall, 52% to 53% of cases performed by trainees per year were open procedures in both the fellowship and integrated residency (288.56 ± 12.10 vs 261.27 ± 10.13, 365.52 ± 17.23 vs 319.58 ± 6.62; both P < .001). Within the subcategories, only cerebrovascular, vascular access, and miscellaneous had more open procedures performed per trainee. ConclusionsVascular surgery training has incorporated new endovascular techniques and technologies while maintaining operative training in open procedures. Despite changes in vascular surgery training, trainees are still performing more open procedures than endovascular procedures per year. However, there are evolving deficits in specific types of procedures.

New and Off-Label Uses of Tranexamic Acid.

New and Off-Label Uses of Tranexamic Acid.

Patient Satisfaction After Lower Extremity Total Joint Arthroplasty: An Analysis of Medical Comorbidities and Patient Demographics

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey has received increased attention to determine which demographics may influence patient satisfaction after Total Hip and Knee Arthroplasty. The purpose of this study was to evaluate the various effects that patient-specific factors, medical comorbidities, and demographics had on patient satisfaction. Two thousand and ninety-two patients underwent lower extremity total joint arthroplasty at our institution between 2014 and 2018. Nine hundred twenty-three of these patients responded to their HCAHPS survey (44%). Most patients (609, 66%) underwent primary total knee arthroplasty followed by 244 (26.4%) total hip arthroplasties, 35 (3.8%) revision total knee arthroplasties, 28 (3.0%) bilateral total knee arthroplasties, and 7 (0.8%) revision total hip arthroplasties. Increasing age and length of stay were associated with a decrease in patient satisfaction whereas patients who were married reported higher satisfaction. Patients discharged to a rehabilitation facility had a 12% decrease in top-box response rate compared to those discharged home. Contrary to our hypothesis, specific procedure type and the presence of comorbidities failed to predict patient satisfaction. The results of this study shed light on the intricate relationship between patient satisfaction and patient-specific factors. Furthermore, health care workers can counsel patients on expected satisfaction when considering total hip and knee arthroplasty.

Systematic review with meta-analysis: abnormalities in the international normalised ratio do not correlate with periprocedural bleeding events among patients with cirrhosis.

Cirrhotic coagulopathy is a delicate interplay comprising deficiencies of both procoagulant and anticoagulant factors. To identify the relationship between international normalised ratio [INR] with periprocedural bleeding risk among patients with cirrhosis. Following a thorough database search of the primary literature, 29 studies were targeted for analysis, including 13 276 patients with cirrhosis undergoing indicated procedures. There was no significant association between periprocedural bleeding events and pre-procedural INR [pooled odds ratio 1.52; 95% CI 0.99, 2.33; P = 0.06]. Furthermore, there was no significant difference in mean INR [pooled mean difference 0.05; 95% CI -0.03, 0.13; P = 0.23] upon comparison of patients who either did or did not experience a periprocedural bleeding event. Significant heterogeneity among some studies was primarily fuelled by significant subgroup effects of both specific procedure types performed. Additionally, there were markedly inconsistent transfusion practices across studies. INR fails to serve as a significant correlate for periprocedural bleeding events among patients with cirrhosis. Ideally, these new findings will help serve as a springboard for future studies, as well as to minimize transfusion of blood products, which command a myriad of adverse effects among patients with cirrhosis.

Medical Malpractice in Interventional Cardiology: Identifying Patterns and Areas for Improvement

Introduction: The feared possibility of involvement in a medical malpractice lawsuit ultimately becomes reality for many physicians in high-risk specialties including cardiology. In a survey of cardiologists and fellows, 15.9% of those from the United States and 13.5% from China stated they were influenced by the fear of malpractice litigation in at least half of all cases they managed daily. A study of 40,916 physicians covered by a large nationwide professional liability insurer from 1991 to 2005 found that the percentage of cardiologists facing a malpractice claim each year is between 7.5%-10%, above the average across all physicians. This study analyzes interventional cardiology malpractice claims by specific procedure and allegation types. Methods: Seventy-nine cardiology malpractice claims involving procedures were identified in a major nationwide legal database (over 200,000 cases) called VerdictSearch. An exemption was obtained from the Yale University Institutional Review Board. Baseline patient characteristics, reasons for lawsuit, and case outcomes were recorded. Statistical analysis included percentage distributions and Fisher’s exact test. Results: A defendant verdict was reached in 64.6% of cases; plaintiƒ verdict, 21.5% (with average payout $5,212,719.79); and settlement, 13.9%. Death was the injury in 48.1% of cases and did not influence the likelihood of a plaintiƒ verdict. Of the 53.2% of cases involving cardiac catheterization, angioplasty, or stenting, periprocedural injury was alleged in 83.3%, lack of informed consent in 7.1%, failure to perform the correct procedure in a timely manner or at all in 14.3%, and performance of an unnecessary procedure in 7.1% (Figure 1). The most common injury type was arterial (non-coronary), including injury to the catheterization site, followed by coronary artery dissection or tamponade (Figure 2). Electrophysiology procedures were the next most common category, and receiving a defendant verdict was significantly less likely for these cases than any other type. A cardiothoracic or vascular surgeon was named as a co-defendant in 25.3% of cases. In 12.6% of cases, cardiologist failure to obtain timely surgical consultation or ensure backup surgeon availability during procedure performance was alleged. Discussion: Comprehensively reviewing interventional cardiology malpractice claims can elucidate common contributory factors to adverse outcomes and practice improvement opportunities. This study ’ s results suggest, for instance, that securing appropriate cardiothoracic surgical backup prior to a catheterization, angioplasty, or stent procedure would significantly decrease the number of lawsuits. Diligence in the informed consent process should also be prioritized, as this area generated allegations in 7.1% of cases. Though VerdictSearch is a large, nationwide legal database, its content is limited to those attorneys, courts, and states who choose to report cases. However, any selection biases may be bidirectional and ultimately cancel each other out, since the attorney on the prevailing side of every case theoretically has equal incentive to report it to a public database so the verdict can be used as a marketing tool for that attorney. By uniquely stratifying cardiology malpractice claims within a large nationwide database by specific procedure types and allegations, this study points to factors that commonly contribute to adverse patient outcomes and enables cardiologists to reflect upon opportunities for clinical practice improvement.

Commentary on: Comparison of three transfusion protocols prior to central venous catheterization in patients with cirrhosis: A randomized controlled trial

Commentary on: Comparison of three transfusion protocols prior to central venous catheterization in patients with cirrhosis: A randomized controlled trial

Site of service influence on stent use for hemodialysis access interventions

ObjectiveWith rising health care spending in the United States, the Centers for Medicare and Medicaid Services (CMS) in recent years attempted to use reimbursement rates to influence use of less expensive care sites for covered patients, such as ambulatory surgery centers (ASCs) and office-based laboratories (OBLs), in lieu of hospital service sites. It has been suggested that cost savings have not been realized because of more procedures being performed by physicians with ownership interests in nonhospital facilities. CMS adopted massive reimbursement changes for 2019 OBL and ASC-based procedures, which reduced dialysis access angioplasty reimbursement in the ASC setting by 50%, whereas facility reimbursement for stenting increased by 33% above prior levels. The clinical utility of adjunctive stenting in treating dialysis access stenosis remains controversial and highly discretionary. As a vascular group performing such procedures in both a hospital and nonhospital facility in which we have equity interest, we reviewed our use of stents in dialysis access procedures both in the hospital and in the ASC/OBL to determine whether site of service affected stent use. MethodsA retrospective review of a prospectively maintained database was performed from 2014 to 2018. All patients undergoing dialysis access angiography with angioplasty and adjunctive stent placement at our OBL (later ASC) and our primary hospital were included in the study. ResultsThere were 961 angioplasty or stent procedures performed for dialysis accesses between the two sites, 564 (58.7%) in the hospital setting and 397 (41.3%) at the OBL/ASC. There was a significant difference in race and age between the two sites, with younger, minority patients more frequently being treated in the hospital and older, white patients more likely to be treated in the ambulatory setting; 153 (27.1%) underwent adjunctive stent placement in the hospital and 127 (32.0%) in the ambulatory setting (P = .09). ConclusionsWhereas financial incentives have not yet had an appreciable influence on stent use for dialysis access within previous reimbursement paradigms, the dramatic changes recently adopted by CMS may well alter this dynamic and could lead to substantially higher overall costs without proven clinical advantage. Interventionalists may be incentivized to add stents when performing balloon angioplasty in ASCs. With high failure and reintervention rates and increasingly expensive adjuncts (drug-coated balloons and stents, covered stents), the cost implications of attempts to incentivize interventionalists toward a specific type of procedure or site of care are substantial, and unintended negative consequences are likely to occur.

The role of extended venous thromboembolism prophylaxis for major urological cancer operations

ObjectivesVenous thromboembolism (VTE), consisting of both pulmonary embolism (PE) and deep vein thromboses (DVT), remains a well‐recognised complication of major urological cancer surgery. Several international guidelines recommend extended thromboprophylaxis (ETP) with LMWH, whereby the period of delivery is extended to the post‐discharge period, where the majority of VTE occurs. In this literature review we investigate whether ETP should be indicated for all patients undergoing major urological cancer surgery, as well procedure specific data that may influence a clinician's decision.MethodsWe performed a search of six databases (PubMed, Cochrane, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and British Nursing Index (BNI)) from inception to June 2019, for studies looking at adult patients who received VTE prophylaxis after surgery for a major urological malignancy.ResultsEighteen studies were analysed. VTE risk is highest in open and robotic Radical Cystectomy (RC) (2.6–11.6%) and ETP demonstrates a significant reduction in risk of VTE, but not a significant difference in Pulmonary Embolism (PE) or mortality. Risk of VTE in open Radical Prostatectomy (RP) (0.8–15.7%) is comparable to RC, but robotic RP (0.2–0.9%), open partial/radical nephrectomy (1.0–4.4%) and robotic partial/radical nephrectomy (0.7–3.9%) were lower risk. It has not been shown that ETP reduces VTE risk specifically for RP or nephrectomy.ConclusionThe decision to use ETP is a fine balance between variables such as VTE incidence, bleeding risk and perioperative morbidity/mortality. This balance should be assessed for each specific procedure type. While ETP still remains of net benefit for open RP as well as open and robotic RC, the balance is closer for minimally invasive RP as well as radical and partial nephrectomy. Due to a lack of procedure specific evidence for the use of ETP, adherence with national guidelines remains poor. Therefore, we advocate further studies directly comparing ETP vs standard prophylaxis, for specific procedure types, in order to allow clinicians to make a more informed decision in future.

Development and implementation of a comprehensive spine surgery enhanced recovery after surgery protocol: the Cleveland Clinic experience.

Enhanced recovery after surgery (ERAS) protocols have been shown to be effective at reducing perioperative morbidity and costs while improving outcomes. To date, spine surgery protocols have been limited in scope, focusing only on specific types of procedures or specific parts of the surgical episode. The authors describe the creation and implementation of one of the first comprehensive ERAS protocols for spine surgery. The protocol is unique in that it has a comprehensive perioperative paradigm encompassing the entire surgical period that is tailored based on the complexity of each individual spine patient.

Neurosurgical procedures performed during residency in Europe-preliminary numbers and time trends.

Differences in the postgraduate training programs of neurosurgical residents are suspected throughout Europe. The influence of working hour restrictions by the European Working Time Directive (WTD) 2003/88/EC on the number of surgical procedures remains unclear. We designed a survey to collect information on the number of surgical procedures, performed by European neurosurgical trainees during residency. This article reports preliminary data. An electronic survey was distributed among the European Association of Neurosurgical Societies (EANS) member countries by national delegates of the training committee, as well as by members of the Young Neurosurgeons' committee. The EANS mailing list of individual members was also used for distribution. All responses received between 04/2018 and 12/2018 were considered. From n = 180 responses received, 42 were omitted as responders were still in residency and for 58 relevant information was missing. The final sample was n = 80, with a mean responder's age of 43.0years (SD 8.6) and 88.8% being male. Responses came from 16 European countries; board certification was received between the years of 1976-2018. The numbers of surgical procedures performed independently were 511 (mean, 95% confidence interval (CI) 413-610), supervised were 514 (95%CI 360-668) and assisted were 752 (95%CI 485-1019) throughout residency. More detailed numbers for specific procedure types are reported in the article. Independently performed cranial procedures outnumbered spinal procedures (p < 0.006), and adult procedures outnumbered pediatric procedures (p < 0.001). There was a strong decrease in caseload between 1976 and 2018, with trainees performing on average 65 cases less throughout residency for each calendar year increase in board certification (95% CI - 116 to - 15, p = 0.012). Trainees graduating residency before introduction of the European WTD 2003/88/EC participated in more procedures than those graduating afterwards (mean 2797 vs. 1418, p = 0.005). The preliminary analysis of the first 80 responses now provides a first reference frame for caseload that can be used by current and future European residents to critically compare their own operative numbers to. There was a strong decline in surgical cases over time, and trainees graduating after introduction of the European WTD 2003/88/EC had less surgical exposure. The survey remains open, and we invite further European neurosurgeons to provide their data in order to get even more robust estimates.

Radiation Risk Categories in Cardiac Catheterization for Congenital Heart Disease: A Tool to Aid in the Evaluation of Radiation Outcomes.

To stratify diverse procedure types into categories with similar radiation exposure in cardiac catheterization for congenital heart disease. Radiation exposures for a comprehensive list of specific procedure types and stratification of outcomes based on radiation risk are not currently available. Data between January 2014 and December 2015 were collected on all cases performed at sites participating in C3PO-QI (Congenital Cardiac Catheterization Outcomes Project-Quality Improvement Initiative) and 9 centers were included. Using expert consensus, 40 unique procedure types were defined by diagnostic characteristics or the intervention(s) performed, and dose area product (DAP) per kilogram of body weight (µGy × m2/kg) was summarized. Using empiric and consensus methods, three radiation risk categories were created. A total of 11,735 cases were included for analysis. Thirteen (n = 7918) procedure types with median DAP/kg < 100 were categorized in the low radiation exposure category (median DAP/kg 39). The medium exposure category (n = 1807) consisted of 16 procedure types with median DAP/kg values ranging 100 to < 200 (overall median DAP/kg 131). Finally, the high radiation exposure category (n = 1073) consisted of 11 procedure types with median DAP/kg ≥ 200 (overall median DAP/kg of 231). The radiation exposure risk categories created in this multi-center dataset are a critical step towards the development of a robust risk adjustment methodology for radiation exposure in catheterization for congenital heart disease.

CORR Insights®: What Factors are Predictive of Patient-reported Outcomes? A Prospective Study of 337 Shoulder Arthroplasties.

Where Are We Now? In an age where an impending burden will be placed on physicians to show benefits of treatment, studies that elucidate factors impacting the results of treatment of disease will undoubtedly grow in importance. Orthopaedic surgeons understand that patient-reported outcomes and patient satisfaction can differ substantially from surgeon-perceived outcomes. But while a surgeon may consider successful restoration of functional mobility as a good result, a patient may not place the same level of importance on an objective parameter like that, instead perceiving subjective factors such as absence or presence of night pain as more important. The development of, and extensive experience with, the Simple Shoulder Test has validated the usefulness of patient-reported outcomes scores. The Simple Shoulder Test allows the collection of outcomes data even when the patient is unable to physically return to the evaluator for followup. Of course, there are limitations to data interpretation due to the absence of radiographic and physical examination followup. For example, whether a patient's responses to the questions included in the Simple Shoulder Test correlate to a radiographic finding or clinical examination finding go unanswered. Still, the current study by Matsen and colleagues represents a great start to answering many questions regarding factors associated with outcome following shoulder arthroplasty. Where Do We Need To Go? But questions do remain. Although, a relatively large number of patients are included in this study, the patient population and specific procedure type are quite heterogeneous. More narrowly focused outcome studies are needed to better understand factors influencing the outcomes in specific diagnoses. More narrowly focused outcome studies are also needed to better understand factors influencing the outcomes in specific arthroplasty procedures (anatomic total shoulder arthroplasty, hemiarthroplasty, reverse shoulder arthroplasty, for example). Additionally, studies exploring the relationship between radiographic and clinical examination findings and subjective outcome measurement tools such as the Simple Shoulder Test are needed because this investigation is representative of patients at a relatively short followup period. Middle- and long-term followup periods are necessary, as they could certainly impact the relationship between radiographic and clinical examination findings. How Do We Get There? Clearly, future studies using the same basic study design employed by Matsen and colleagues in this study should try to strengthen the conclusions of this study and yield new information more specific to certain diagnoses and certain procedures. Additionally, longer followup could strengthen or possibly change the conclusions in a study such as this. Finally, although it is certainly difficult, if not impossible, to get all patients to return for radiographic and clinical examination followup, a study including a correlation of these findings with the Simple Shoulder Test in perhaps a more limited number of patients is warranted.

Assessing the comparability of hip arthroplasty registries in order to improve the recording and monitoring of outcome.

We aimed to assess the comparability of data in joint replacement registries and identify ways of improving the comparisons between registries and the overall monitoring of joint replacement surgery. We conducted a review of registries that are full members of the International Society of Arthroplasty Registries with publicly available annual reports in English. Of the six registries which were included, we compared the reporting of: mean age, definitions for revision and re-operation, reasons for revision, the approach to analysing revisions, and patient-reported outcome measures (PROMs) for primary and revision total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA). Outcomes were infrequently reported for HRA compared with THA and all hip arthroplasties. Revisions were consistently defined, though re-operation was defined by one registry. Implant survival was most commonly reported as the cumulative incidence of revision using Kaplan-Meier survival analysis. Three registries reported patient reported outcome measures. More consistency in the reporting of outcomes for specific types of procedures is needed to improve the interpretation of joint registry data and accurately monitor safety trends. As collecting additional details of surgical and patient-reported outcomes becomes increasingly important, the experience of established registries will be valuable in establishing consistency among registries while maintaining the quality of data. As the volume of joint replacements performed each year continues to increase, greater consistency in the reporting of surgical and patient-reported outcomes among joint replacement registries would improve the interpretation and comparability of these data to monitor outcomes accurately.

Clinician Perspectives on Preparing for and Conducting Family Meetings (S773)

T13 and T18 over a 20-year period; 2) To evaluate the association between interventions and survival. Methods. Using linked Ontario health administrative databases that capture all hospitalizations in the single-payer healthcare system, we created a retrospective cohort of children born between April 1, 1991 and March 31, 2012 with a diagnosis code for T13 or T18 on a discharge record. Demographic data and procedure codes were extracted from hospitalization discharges through March 31, 2013. Survival times were calculated from listed birth and death dates; patients without death dates were censored at the most recent hospital discharge date. Results. The trisomy 13 cohort included 195 individuals; 161 (82.6%) died during follow-up. Of the 268 children with trisomy 18, 232 (86.6%) died. Median ages at death were 7 days and 5.5 days, respectively; the oldest children in the cohorts were 17 years in trisomy 13 and 15 years in trisomy 18. 80 children with trisomy 13 and 100 children with trisomy 18 received a total of 2141 procedures. Interventions per year increased over time from 10 in 1991 to 58 in 2012. Details about specific procedure types and association with survival will be forthcoming. Conclusions. Children with T13 and T18 in Ontario are receiving increasing numbers of interventions over time. Implications. Interventional outcomes will help guide family and clinician decision-making for care of children with T13 and T18.

Invasive procedures in the elderly after stage IV cancer diagnosis

BackgroundInvasive procedures are resource intense and may be associated with substantial morbidity. These harms must be carefully balanced with the benefits gained in life expectancy and quality of life. Prior research has demonstrated an increasing aggressiveness of care in cancer patients at the end-of-life. To better characterize surgical care in this setting, we sought to examine trends in the use of invasive procedures in patients diagnosed with metastatic cancer on presentation. Materials and methodsUsing Surveillance Epidemiology and End Results -Medicare data, we identified invasive procedure claims from 1994–2009 for patients diagnosed with incident stage IV breast, colorectal, lung, and prostate cancer patients in 1995–2006. We grouped procedures into surgically relevant categories, using an adaptation of the Clinical Classifications Software, and measured utilization and relative changes over time. ResultsOf stage IV patients diagnosed in 2002–2006, 96% underwent a procedure during the course of their cancer care including 63% after the diagnostic period, and 25% in the last month of life. Between 1996 and 2006, minimal change was observed in utilization during the diagnostic period (+1.5%). However, there were significant increases during continuing care (+20.7%) and the last month of life (+21.5%). Procedures consistent with primary tumor resection decreased, whereas those with probable palliative intent and those unrelated to cancer increased. ConclusionsNearly all patients who present with metastatic cancer undergo invasive procedures. Although overall utilization is increasing, the specific procedure types indicate that it may be appropriate, enhancing the quality of life in this vulnerable population.

Open bypass and endovascular procedures among diabetic foot ulcer cases in the United States from 2001 to 2010

The objective of this study was to evaluate trends in outcomes of inpatient mortality, surgical complications, charges, and length of stay stratified according to open vs endovascular revascularization and amputation status in patients admitted to the hospital with diabetic foot ulcers (DFUs). Inpatient discharge records from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project were used in this retrospective cohort study spanning 2001 to 2010. Multivariate regression analyses were used to simultaneously control for patient demographic and socioeconomic attributes, hospital characteristics, and comorbid case-mix disease severity. During the study period, 2.5 million inpatient DFU cases were observed, of which 412,051 (16.5%) involved amputation (34.8% major, 61.2% minor). Overall, 211,534 (8.5%) of DFU cases underwent revascularization (43.5% open, 51.1% endovascular treatment [EVT], 5.4% both). From 2001 vs 2010, the volume of open procedures decreased 34.9%, and EVT volume increased 197.1%. The percentage of amputations for DFUs remained relatively unchanged, and a major:minor ratio of 0.534 was observed among all cases. Across specific procedure type and amputation status, multivariate analyses indicated equal or decreased inpatient mortality and lengths of stay since 2001, and inflation-adjusted charges generally increased. The presence of a surgical complication, however, was observed to increase by >50% for open procedures involving minor amputations and >30% for open procedures involving no amputations. Because of many potential factors, surgical complications were noted to exceed approximately 900% among cases of EVT involving major amputations beginning in 2007 relative to2001. This nationally-representative investigation found that DFU admissions are common, long, and costly (often >$100,000 per case), with a marked shift having occurred from open bypass to EVT. Although hospital mortality and length of stay either remained the same or have decreased significantly, an increase in procedure-specific surgical complications was observed across several intervention categories.

Acercamiento a la voz humana, su fisiología y rehabilitación

The present study focuses on an innovative approach to the human voice, its physiology and rehabilitation. We present a single case study of a 29-year-old woman with a diagnosis of dysphonia, who worked as a music teacher in an elementary school. The patient had a cyst on her right vocal cord due to voice abuse and misuse. In this article, a specific type of procedure is proposed for the rehabilitation of vocal disorders. This procedure is based on and developed by means of a holistic view of human beings for their rehabilitation. An observation protocol for the speech therapist was designed, which included a series of items related to the anatomy and physiology of the human body and their influence on phonation. Another protocol for vocal self-perception by the patient and its impact on the effectiveness of the therapy was designed. An A-B-A-B design methodology was applied and the results were fully analyzed. Two treatment phases were established: (1) posture and breathing rehabilitation therapy based on the observation protocol, and considering the patient's responses to the vocal self-perception protocol, and (2) voice acoustic rehabilitation therapy based on the patient's posture and breathing. Patient scores on the vocal self-perception evaluation were used to assess the effectiveness of the intervention.

Analysis of colonoscopic perforations at a local clinic and a tertiary hospital

To define the clinical characteristics, and to assess the management of colonoscopic complications at a local clinic. A retrospective review of the medical records was performed for the patients with iatrogenic colon perforations after endoscopy at a local clinic between April 2006 and December 2010. Data obtained from a tertiary hospital in the same region were also analyzed. The underlying conditions, clinical presentations, perforation locations, treatment types (operative or conservative) and outcome data for patients at the local clinic and the tertiary hospital were compared. A total of 10 826 colonoscopies, and 2625 therapeutic procedures were performed at a local clinic and 32 148 colonoscopies, and 7787 therapeutic procedures were performed at the tertiary hospital. The clinic had no perforations during diagnostic colonoscopy and 8 (0.3%) perforations were determined to be related to therapeutic procedures. The perforation rates in each therapeutic procedure were 0.06% (1/1609) in polypectomy, 0.2% (2/885) in endoscopic mucosal resection (EMR), and 3.8% (5/131) in endoscopic submucosal dissection (ESD). Perforation rates for ESD were significantly higher than those for polypectomy or EMR (P < 0.01). All of these patients were treated conservatively. On the other hand, three (0.01%) perforation cases were observed among the 24 361 diagnostic procedures performed, and these cases were treated with surgery in a tertiary hospital. Six perforations occurred with therapeutic endoscopy (perforation rate, 0.08%; 1 per 1298 procedures). Perforation rates for specific procedure types were 0.02% (1 per 5500) for polypectomy, 0.17% (1 per 561) for EMR, 2.3% (1 per 43) for ESD in the tertiary hospital. There were no differences in the perforation rates for each therapeutic procedure between the clinic and the tertiary hospital. The incidence of iatrogenic perforation requiring surgical treatment was quite low in both the clinic and the tertiary hospital. No procedure-related mortalities occurred. Performing closure with endoscopic clipping reduced the C-reactive protein (CRP) titers. The mean maximum CRP titer was 2.9 ± 1.6 mg/dL with clipping and 9.7 ± 6.2 mg/dL without clipping, respectively (P < 0.05). An operation is indicated in the presence of a large perforation, and in the setting of generalized peritonitis or ongoing sepsis. Although we did not experience such case in the clinic, patients with large perforations should be immediately transferred to a tertiary hospital. Good relationships between local clinics and nearby tertiary hospitals should therefore be maintained. It was therefore found to be possible to perform endoscopic treatment at a local clinic when sufficient back up was available at a nearby tertiary hospital.