A national analysis of trends, outcomes and volume-outcomes relationships in thyroid surgery

OBJECTIVES: Thyroid conditions are common and their incidence is increasing. Surgery is the mainstay treatment for many thyroid conditions, and understanding its utilisation trends and morbidity are central to improving patient care. DESIGN: An N=near-all analysis of the English administrative dataset to identify trends in thyroid surgery specialisation, volume-outcome relationships, and the incidence and risk factors for short- and long-term morbidity. MAIN OUTCOME MEASURES: Between 2004 and 2012, 72594 patients underwent elective thyroidectomy in England. Information about age, sex, morbidities, thyroid disease and surgery, adjuvant treatments, and complications including hypocalcaemia and vocal palsy were recorded. RESULTS: Mean age at surgery was 49±30 and a female predominance (82%) was observed. Most patients underwent hemithyroidectomy (51%) or total thyroidectomy (32%). Patients underwent surgery for benign (52.5%), benign inflammatory (21%), and malignant (17%) thyroid diseases. Thyroid surgery grew by 2.9% a year and increased in specialization. Increased surgeon volume significantly reduced lengths of stay: the proportion of length of stay outliers fell from 11.8% for patients of occasional thyroidectomists (50 thyroidectomies a year). Post-discharge vocal palsy and hypocalcaemia occurred in 1.87% and 1.58% of cases respectively. High-volume surgeons had a reduced incidence of vocal palsy and volumes >30 were consistently protective. CONCLUSIONS: Thyroid surgery is increasingly specialised. High-volume surgeons achieve lower complications rates, including lower vocal palsy rates, and length of stay. This article is protected by copyright. All rights reserved

Paradox as invitation to act in problematic change situations

It has been argued that organizational life typically contains paradoxical situations such as efforts to manage change which nonetheless seem to reinforce inertia. Four logical options for coping with paradox have been explicated, three of which seek resolution and one of which ‘keeps the paradox open’. The purpose of this article is to explore the potential for managerial action where the paradox is held open through the use of theory on ‘serious playfulness’. Our argument is that paradoxes, as intrinsic features in organizational life, cannot always be resolved through cognitive processes. What may be possible, however, is that such paradoxes are transformed, or ‘moved on’ through action and as a result the overall change effort need not be stalled by the existence of embedded paradoxes

Contribution of the physical environment to socioeconomic gradients in walking in the Whitehall II study

Socioeconomic gradients in walking are well documented but the underlying reasons remain unclear. We examined the contribution of objective measures of the physical environment at residence to socioeconomic gradients in walking in 3363 participants (50-74years) from the Whitehall II study (2002-2004). Individual-level socioeconomic position was measured as most recent employment grade. The contribution of multiple measures of the physical environment to socioeconomic position gradients in self-reported log transformed minutes walking/week was examined by linear regression. Objective measures of the physical environment contributed only to a small extent to socioeconomic gradients in walking in middle-aged and older adults living in Greater London, UK. Of these, only the number of killed and seriously injured road traffic casualties per km of road was predictive of walking. More walking in areas with high rates of road traffic casualties per km of road may signal an effect not of injury risk but of more central locations with multiple destinations within short distances ('compact neighbourhoods'). This has potential implications for urban planning to promote physical activity

How are falls and fear of falling associated with objectively measured physical activity in a cohort of community-dwelling older men?

BACKGROUND: Falls affect approximately one third of community-dwelling older adults each year and have serious health and social consequences. Fear of falling (FOF) (lack of confidence in maintaining balance during normal activities) affects many older adults, irrespective of whether they have actually experienced falls. Both falls and fear of falls may result in restrictions of physical activity, which in turn have health consequences. To date the relation between (i) falls and (ii) fear of falling with physical activity have not been investigated using objectively measured activity data which permits examination of different intensities of activity and sedentary behaviour. METHODS: Cross-sectional study of 1680 men aged 71-92 years recruited from primary care practices who were part of an on-going population-based cohort. Men reported falls history in previous 12 months, FOF, health status and demographic characteristics. Men wore a GT3x accelerometer over the hip for 7 days. RESULTS: Among the 12% of men who had recurrent falls, daily activity levels were lower than among non-fallers; 942 (95% CI 503, 1381) fewer steps/day, 12(95% CI 2, 22) minutes less in light activity, 10(95% CI 5, 15) minutes less in moderate to vigorous PA [MVPA] and 22(95% CI 9, 35) minutes more in sedentary behaviour. 16% (n = 254) of men reported FOF, of whom 52% (n = 133) had fallen in the past year. Physical activity deficits were even greater in the men who reported that they were fearful of falling than in men who had fallen. Men who were fearful of falling took 1766(95% CI 1391, 2142) fewer steps/day than men who were not fearful, and spent 27(95% CI 18, 36) minutes less in light PA, 18(95% CI 13, 22) minutes less in MVPA, and 45(95% CI 34, 56) minutes more in sedentary behaviour. The significant differences in activity levels between (i) fallers and non-fallers and (ii) men who were fearful of falling or not fearful, were mediated by similar variables; lower exercise self-efficacy, fewer excursions from home and more mobility difficulties. CONCLUSIONS: Falls and in particular fear of falling are important barriers to older people gaining health benefits of walking and MVPA. Future studies should assess the longitudinal associations between falls and physical activity

Chlamydia trachomatis Summary and conclusions of CMO's Expert Advisory Group

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