Readmission following pancreatectomy: what can be improved?

AbstractBackgroundReadmissions after pancreatectomy, largely for the management of complications, may also occur as a result of failure to thrive or for diagnostic endeavours. Potential mechanisms to reduce readmission rates may be elucidated by assessing the adequacy of the initial disposition and the real necessity for readmission.MethodsUsing previously identified categories of readmission following pancreatectomy, details of reasons for and results of readmissions were scrutinized using a root cause analysis approach.ResultsOf 658 patients subjected to pancreatectomy between 2001 and 2010, 121 (18%) were readmitted within 30 days. The clinical course in 30% of readmitted patients was found to deviate from the pathway assumed on the initial admission. Patients were readmitted at a median of 9 days (range: 1–30 days) after initial discharge and had a median readmission length of stay of 7 days (mode = 4). Postoperative complications accounted for most readmissions (n = 77, 64%); 17 patients (14%) were readmitted for failure to thrive and 16 (13%) for diagnostics. Root cause analysis detailed subtextual reasons for readmission, including, for example, the initiation of new medications that could potentially have been ordered in an outpatient setting.ConclusionsMore than one quarter of readmissions after pancreatectomy occurred in the setting of failure to thrive or for diagnostic evaluation alone. Root cause analysis revealed potentially avoidable readmissions. The development of a system for stratifying patients at risk for readmission or the failure of the initial disposition, along with an alternative means of efficiently evaluating patients in an outpatient setting, could limit unnecessary readmissions and resource utilization

Doping, European Law and the Implications of Meca-Medina

The ruling of the European Court of Justice in the anti-doping case of Meca Medina v. The Commission has important implications for athletes, domestic governing bodies, international federations and supra-national actors such as WADA and the Court of Arbitration for Sport. Meca-Medina has been criticised as an unwelcome interference by the courts in the legitimate activities of sporting organisations, but after Bosman it was fanciful to argue that those organisations should be ‘above the law’ and the courts should have no jurisdiction over their activities. That said, there is a stark difference between the courts having jurisdiction over sports’ decisions and being willing to overturn them - the courts have been, and remain, willing to defer to the expertise of sporting organisations. However, the ECJ’s ruling in MOTOE confirms that the courts will intervene in appropriate circumstances. In order to avoid sanction on competition law grounds sports organisations must thus be able to justify their provisions on (for example) what is an unacceptable level of nandrolone, show that athletes’ fundamental rights such as the right to a fair hearing have been respected, and ensure that any sanctions imposed upon athletes who fall foul of doping regulations are proportionate to the offence committed

A Root-Cause Analysis of Mortality Following Major Pancreatectomy

Abstract Introduction Although mortality rates from pancreatectomy have decreased worldwide, death remains an infrequent but profound event at an individual practice level. Root-cause analysis is a retrospective method commonly employed to understand adverse events. We evaluate whether emerging mortality risk assessment tools sufficiently predict and account for actual clinical events that are often identified by root-cause analysis. Methods We assembled a Pancreatic Surgery Mortality Study Group comprised of 36 pancreatic surgeons from 15 institutions in 4 countries. Mortalities after pancreatectomy (30 and 90 days) were accrued from 2000 to 2010. For root-cause analysis, each surgeon "deconstructed" the clinical events preceding a death to determine cause. We next tested whether mortality risk assessment tools (ASA, POSSUM, Charlson, SOAR, and NSQIP) could predict those patients who would die (n=218) and compared their prognostic accuracy against a cohort of resections in which no patient died (n=1,177). Results Two hundred eighteen deaths (184 Whipple's resection, 18 distal pancreatectomies, and 16 total pancreatectomies) were identified from 11,559 pancreatectomies performed by surgeons whose experience averaged 14.5 years. Overall 30-and 90-day mortalities were 0.96% and 1.89%, respectively. Individual surgeon rates ranged from 0% to 4.7%. Only 5 patients died intraoperatively, while the other 213 succumbed at a median of 29 days. Mean patient age was 70 years old (38% were >75 years old). Malignancy was the indication in 90% of cases, mostly pancreatic cancer (57%). Median operative time was 365 min and estimated blood loss was 700 cc (range, 100-16,000 cc). Vascular repair or multivisceral resections were required for 19.7% and 15.1%, respectively. Seventy-seven percent had a variety of major complications before death. Eighty-seven percent required intensive care unit care, 55% were transfused, and 35% were reoperated upon. Fifty percent died during the index admission, while another 11% died after a readmission. Almost half (n=107) expired between 31 and 90 days. Only 11% had autopsies. Operation-related complications contributed to 40% of deaths, with pancreatic fistula being the most evident (14%). Technical errors (21%) and poor patient selection (15%) were cited by surgeons. Of deaths, 5.5% had associated cancer progression-all occurring between 31 and 90 days. Even after root-cause scrutiny, the ultimate cause of death could not be determined for a quarter of the patients-most often between 31 and 90 days. While assorted risk models predicted mortality with variable discrimination from nonmortalities, they consistently underestimated the actual mortality events we report. Conclusion Root-cause analysis suggests that risk prediction should include, if not emphasize, operative factors related to pancreatectomy. While risk models can distinguish between mortalities and nonmortalities in a collective fashion, they vastly miscalculate the actual chance of death on an individual basis. This study reveals the contributions of both comorbidities and aggressive surgical decisions to mortality

Molecular Approaches for the Validation of the Baboon as a Nonhuman Primate Model for the Study of Zika Virus Infection

Nonhuman primates (NHP) are particularly important for modeling infections with viruses that do not naturally replicate in rodent cells. Zika virus (ZIKV) has been responsible for sporadic epidemics, but in 2015 a disseminated outbreak of ZIKV resulted in the World Health Organization declaring it a global health emergency. Since the advent of this last epidemic, several NHP species, including the baboon, have been utilized for modeling and understanding the complications of ZIKV infection in humans; several health issues related to the outcome of infection have not been resolved yet and require further investigation. This study was designed to validate, in baboons, the molecular signatures that have previously been identified in ZIKV-infected humans and macaque models. We performed a comprehensive molecular analysis of baboons during acute ZIKV infection, including flow cytometry, cytokine, immunological, and transcriptomic analyses. We show here that, similar to most human cases, ZIKV infection of male baboons tends to be subclinical, but is associated with a rapid and transient antiviral interferon-based response signature that induces a detectable humoral and cell-mediated immune response. This immunity against the virus protects animals from challenge with a divergent ZIKV strain, as evidenced by undetectable viremia but clear anamnestic responses. These results provide additional support for the use of baboons as an alternative animal model to macaques and validate omic techniques that could help identify the molecular basis of complications associated with ZIKV infections in humans

Barriers and facilitators of effective self-management in asthma: systematic review and thematic synthesis of patient and healthcare professional views

Self-management is an established, effective approach to controlling asthma, recommended in guidelines. However, promotion, uptake and use among patients and health-care professionals remain low. Many barriers and facilitators to effective self-management have 25 been reported, and views and beliefs of patients and health care professionals have been explored in qualitative studies. We conducted a systematic review and thematic synthesis of qualitative research into self-management in patients, carers and health care professionals regarding self-management of asthma, to identify perceived barriers and facilitators associated with reduced effectiveness of asthma self-management interventions. Electronic databases and guidelines were searched systematically for qualitative literature that explored factors relevant to facilitators and barriers to uptake, adherence, or outcomes of self-management in patients with asthma. Thematic synthesis of the 56 included studies identified 11 themes: 1) partnership between patient and health care professional; 2) issues around medication; 3) education about asthma and its management; 4) health beliefs; 5) self-management interventions; 6) co-morbidities 7) mood disorders and anxiety; 8) social support; 9) non-pharmacological methods; 10) access to healthcare; 11) professional factors. From this, perceived barriers and facilitators were identified at the level of individuals with asthma (and carers), and health-care professionals. Future work addressing the concerns and beliefs of adults, adolescents and children (and carers) with asthma, effective communication and partnership, tailored support and education (including for ethnic minorities and at risk groups), and telehealthcare may improve how self-management is recommended by professionals and used by patients. Ultimately, this may achieve better outcomes for people with asthma

Something in the atmosphere? Michael Chekhov, Deirdre Hurst Du Prey, and a web of practices between acting and dance

This article contextualises principles of Chekhov’s technique within convergent developments in dance by bringing into focus the interesting web of connections between Chekhov’s female colleagues — specifically his associate Deirdre Hurst Du Prey — and key pioneers in the field of dance and dance-mime, including Mary Wigman, Isadora Duncan, Martha Graham and Margaret Barr. Their cross-connections broaden our view on the canon of embodied theatre practice, and also open up reflection on how overlaps between acting- and dance principles may be useful for contemporary embodied theatre practice and its efforts to work across these currently (in the Western conservatoire context) quite segregated disciplines