Survival after liver transplantation in the United Kingdom and Ireland compared with the United States

<b>Background and Aim</b>: Surgical mortality in the US is widely perceived to be superior to that in the UK. However, previous comparisons of surgical outcome in the two countries have often failed to take sufficient account of case-mix or examine long-term outcome. The standardised nature of liver transplantation practice makes it uniquely placed for undertaking reliable international comparisons of surgical outcome. The objective of this study is to undertake a risk-adjusted disease-specific comparison of both short- and long-term survival of liver transplant recipients in the UK and Ireland with that in the US. <b>Design, setting and participants</b>: Multi-centre cohort study using two high quality national databases including all adults who underwent a first single organ liver transplant in the UK and Ireland (n=5,925) and the US (n=41,866) between March 1994 and March 2005. <b>Main outcome measures</b>: Post-transplant mortality during the first 90 days, 90 days-1 year and beyond the first year, adjusted for donor and recipient characteristics. <b>Results</b>: Risk-adjusted mortality in the UK and Ireland was generally higher than in the US during the first 90 days (hazard ratio 1.17 95%CI 1.07-1.29), both for patients transplanted for acute liver failure (hazard ratio 1.27 95%CI 1.01-1.60) as well as those transplanted for chronic liver disease (hazard ratio 1.18 95% CI 1.07- 1.31). Between 90 days and 1 year post-transplantation, no statistically significant differences in overall risk- adjusted mortality were noted between the two cohorts. Survivors of the first post-transplant year in the UK and Ireland had lower overall risk-adjusted mortality than those transplanted in the US (hazard ratio 0.88 95% CI 0.81- 0.96). This difference was observed among patients transplanted for chronic liver disease (hazard ratio 0.88 95%CI 0.81-0.96) but not those transplanted for acute liver failure (hazard ratio 1.02 95%CI 0.70- 1.50). <b>Conclusions</b>: Whilst risk adjusted mortality is higher in the UK and Ireland during the first 90 days following liver transplantation, it is higher in the US among those liver transplant recipients who survived the first post- transplant year. Our results are consistent with the notion that the US has superior acute peri-operative care whereas the UK appears to provide better quality chronic care following liver transplantation surgery

Is there overutilisation of cataract surgery in England?

<b>Objectives:</b> Following a 3.7-fold increase in the rate of cataract surgery in the UK between 1989 and 2004, concern has been raised as to whether this has been accompanied by an excessive decline in the threshold such that some operations are inappropriate. The objective was to measure the impact of surgery on a representative sample of patients so as to determine whether or not overutilisation of surgery is occurring. <b>Design:</b> Prospective cohort assessed before and 3 months after surgery. <b>Setting:</b> Ten providers (four NHS hospitals, three NHS treatment centres, three independent sector treatment centres) from across England. <b>Participants:</b> 861 patients undergoing first eye (569) or second eye (292) cataract surgery provided preoperative data of whom 745 (87%) completed postoperative questionnaires. <b>Main outcome measures:</b> Patient-reported visual function (VF-14); general health status and quality of life (EQ5D); postoperative complications; overall view of the operation and its impact. <b>Results:</b> Overall, visual function improved (mean VF-14 score increased from 83.2 (SD 17.3) to 93.7 (SD 13.2)). Self-reported general health status deteriorated (20.3% fair or poor before surgery compared with 25% afterwards) which was reflected in the mean EQ5D score (0.82 vs 0.79; p = 0.003). At least one complication was reported by 66 (8.9%) patients, though this probably overestimated the true incidence. If the appropriateness of surgery is based on an increase in VF-14 score of 5.5 (that corresponds to patients’ reporting being "a little better"), 30% of operations would be deemed inappropriate. If an increase of 12.2 (patients’ reports of being "much better") is adopted, the proportion inappropriate is 49%. Using a different approach to determining a minimally important difference, the proportion inappropriate would be closer to 20%. Although visual function (VF-14) scores were unchanged or deteriorated in 25% of patients, 93.1% rated the results of the operation as "good," "very good" or "excellent," and 93.5% felt their eye problem was "better." This partly reflects inadequacies in the validity of the VF-14. <b>Conclusions:</b> Improvement in the provision of cataract surgery has been accompanied by a reduction in the visual function threshold. However, methodological difficulties in measuring the impact of cataract surgery on visual function and quality of life mean it is impossible to determine whether or not overutilisation of cataract surgery is occurring. N Black1, J Browne1, J van der Meulen1, L Jamieson2, L Copley2 and J Lewsey

Context, Complexity and Contestation: Birmingham's Agreed Syllabuses for Religious Education since the 1970s

publication-status: AcceptedThis is an Author's Original Manuscript of an article whose final and definitive form, the Version of Record, has been published in the Journal of Beliefs and Values, September 2011. Available online at: http://www.tandfonline.com/ or DOI: 10.1080/13617672.2011.600823The present article offers an historical perspective on the 1975, 1995 and 2007 Birmingham Agreed Syllabuses for Religious Education. It draws upon historical evidence uncovered as part of ‘The hidden history of curriculum change in religious education in English schools, 1969–1979’ project, and curriculum history theories, especially David Labaree’s observations about the distance between the ‘rhetorical’ and ‘received’ curricula. We argue that, contrary to the existing historiography, curriculum change in religious education (RE) has been evolutionary not revolutionary. Multiple reasons are posited to explain this, not least among which is the capacity and agency of teachers. Furthermore, we argue that ongoing debates about the nature and purpose of RE, as exemplified in the Birmingham context, reflect the multiple expectations that religious educators and other stakeholders had, and continue to have, of the curriculum subject. These debates contribute to the inertia evident in the implementation of RE curriculum reforms. A consciousness of the history of RE enables curriculum contestations to be contextualised and understood, and, thereby, provides important insights which can be applied to ongoing and future debates and developments

Validation of the OAKS prognostic model for acute kidney injury after gastrointestinal surgery

Background Postoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies.Methods The Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study ('IMAGINE') of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study ('Tayside') in major abdominal surgery (2011-2015). Multivariable logistic regression was used to predict risk of AKI, with multiple imputation used to account for data missing at random. Prognostic accuracy was assessed for patients at high risk (greater than 20 per cent) of postoperative AKI.Results In the validation cohorts, 12.9 per cent of patients (661 of 5106) in IMAGINE and 14.7 per cent (106 of 719 patients) in Tayside developed 7-day postoperative AKI. Using the OAKS model, 558 patients (9.6 per cent) were classified as high risk. Less than 10 per cent of patients classified as low-risk developed AKI in either cohort (negative predictive value greater than 0.9). Upon external validation, the OAKS model retained an area under the receiver operating characteristic (AUC) curve of range 0.655-0.681 (Tayside 95 per cent c.i. 0.596 to 0.714; IMAGINE 95 per cent c.i. 0.659 to 0.703), sensitivity values range 0.323-0.352 (IMAGINE 95 per cent c.i. 0.281 to 0.368; Tayside 95 per cent c.i. 0.253 to 0.461), and specificity range 0.881-0.890 (Tayside 95 per cent c.i. 0.853 to 0.905; IMAGINE 95 per cent c.i. 0.881 to 0.899).Conclusion The OAKS prognostic model can identify patients who are not at high risk of postoperative AKI after gastrointestinal surgery with high specificity.Presented to Association of Surgeons in Training (ASiT) International Conference 2018 (Edinburgh, UK), European Society of Coloproctology (ESCP) International Conference 2018 (Nice, France), SARS (Society of Academic and Research Surgery) 2020 (Virtual, UK).Nephrolog