Resource variation in colorectal surgery; a national centre-level analysis.

BACKGROUND: Delivery of quality colorectal surgery requires adequate resources. We set out to assess the relationship between resources and outcomes in English colorectal units. METHODS: Data was extracted from the ACPGBI resource questionnaire to profile resources. This was correlated with Hospital Episode Statistics (HES) outcome data including 90-day mortality and readmissions. Patient satisfaction measures were extracted from the Cancer Experience Patient Survey (CEPS) and compared at unit level. Centres were divided by workload into low, middle, and top tertile. RESULTS: Completed questionnaires were received from 75 centres in England. Service resources were similar between low and top tertiles in access to CEPOD theatre, level 2 or 3 beds per 250,000 population or likelihood of having a dedicated colorectal ward. There was no difference in staffing levels per 250,000 unit of population. Each 10% increase in the proportion of cases attempted laparoscopically, was associated with reduced 90-day unplanned readmission (RR 0.94, 95% CI 0.91 to 0.97, p<0.001). The presence of a dedicated colorectal ward (RR 0.85, 95% CI 0.73 to 0.99, p =0.040) was also associated with a significant reduction in unplanned readmissions. There was no association between staffing or service factors and patient satisfaction. DISCUSSION AND CONCLUSIONS: Resource levels do not vary based on unit of population. There is benefit associated with increased use of laparoscopy and a dedicated surgical ward. Alternative measures to assess the relationship between resources and outcome, such as failure to rescue, should be explored in UK practice. This article is protected by copyright. All rights reserved

Risk factors for ischaemic colitis after surgery for abdominal aortic aneurysm: a systematic review and observational meta-analysis

BACKGROUND: Ischaemic colitis is an infrequent but serious complication following repair of abdominal aortic aneurysm (AAA), with high mortality rates. This systematic review set out to identify risk factors for the development of ischaemic colitis after AAA surgery. METHODS: A systematic search of the MEDLINE, EMBASE and CINAHL databases was performed. This search was limited to studies published in the English language after 1990. Abstracts were screened by two authors. Eligible studies were obtained as full text for further examination. Data was extracted by two authors, and any disputes were resolved via consensus. Extracted data was pooled using Mantel-Haenszel random effects models. Bias was assessed using two Cochrane-approved tools. Effect sizes are expressed as relative risk ratios alongside the 95 % confidence interval. Statistical significance was defined at the level of p < 0.05. RESULTS: From 388 studies identified in the initial search, 33 articles were included in the final synthesis and analysis. Risk factors were grouped into patient (female gender, disease severity) and operative factors (peri-procedural hypotension, operative modality). The risk of ischaemic colitis was significantly higher when undergoing emergency repair versus elective (risk ratio (RR) 7.36, 3.08 to 17.58, p < 0.001). Endovascular repair reduced the likelihood of ischaemic colitis (RR 0.22, 0.12 to 0.39, p < 0.001). DISCUSSION: The quality of published evidence on this subject is poor with many retrospective datasets and inconsistent reporting across studies. Despite this, emergency presentation and open repair should prompt close monitoring for the development of IC

UK-based, multisite, prospective cohort study of small bowel obstruction in acute surgical services: National Audit of Small Bowel Obstruction (NASBO) protocol

Introduction Small bowel obstruction (SBO) is a common indication for emergency laparotomy in the UK, which is associated with a 90-day mortality rate of 13%. There are currently no UK clinical guidelines for the management of this condition. The aim of this multicentre prospective cohort study is to describe the burden, variation in management and associated outcomes of SBO in the UK adult population. Methods and analysis UK hospitals providing emergency general surgery are eligible to participate. This study has three components: (1) a clinical preference questionnaire to be completed by consultants providing emergency general surgical care to assesses preferences in diagnostics and therapeutic approaches, including laparoscopy and nutritional interventions; (2) site resource profile questionnaire to indicate ease of access to diagnostic services, operating theatres, nutritional support teams and postoperative support including intensive care; (3) prospective cohort study of all cases of SBO admitted during an 8-week period at participating trusts. Data on diagnostics, operative and nutritional interventions, and in-hospital mortality and morbidity will be captured, followed by data validation. Ethics and dissemination This will be conducted as a national audit of practice in conjunction with trainee research collaboratives, with support from patient representatives, surgeons, anaesthetists, gastroenterologists and a clinical trials unit. Site-specific reports will be provided to each participant site as well as an overall report to be disseminated through specialist societies. Results will be published in a formal project report endorsed by stakeholders, and in peer-reviewed scientific reports. Key findings will be debated at a focused national meeting with a view to quality improvement initiatives

Individual surgeon mortality rates: can outliers be detected? A national utility analysis

Objectives: There is controversy on the proposed benefits of publishing mortality rates for individual surgeons. In some procedures, analysis at the level of an individual surgeon may lack statistical power. The aim was to determine the likelihood that variation in surgeon performance will be detected using published outcome data. Design: A national analysis surgeon-level mortality rates to calculate the level of power for the reported mortality rate across multiple surgical procedures. Setting: The UK from 2010 to 2014. Participants: Surgeons who performed colon cancer resection, oesophagectomy or gastrectomy, elective aortic aneurysm repair, hip replacement, bariatric surgery or thyroidectomy. Outcomes: The likelihood of detecting an individual with a 30-day, 90-day or in-patient mortality rate of up to 5 times the national mean or median (as available). This was represented using a novel heat-map approach. Results: Overall mortality rates for the procedures ranged from 0.07% to 4.5% and mean/median surgeon volume was between 23 and 75 cases. The national median case volume for colorectal (n=55) and upper gastrointestinal (n=23) cancer resections provides around 20% power to detect a mortality rate of 3 times the national median, while, for hip replacement, this is a rate 5 times the national average. At the mortality rates reported for thyroid (0.08%) and bariatric (0.07%) procedures, it is unlikely a surgeon would perform a sufficient number of procedures in his/her entire career to stand a good chance of detecting a mortality rate 5 times the national average. Conclusions: At present, surgeons with increased mortality rates are unlikely to be detected. Performance within an expected mortality rate range cannot be considered reliable evidence of acceptable performance. Alternative approaches should focus on commonly occurring meaningful outcome measures, with infrequent events analysed predominately at the hospital level

Restricting quark matter models by gravitational wave observation

We consider the possibilities for obtaining information about the equation of state for quark matter by using future direct observational data on gravitational waves. We study the nonradial oscillations of both fluid and spacetime modes of pure quark stars. If we observe the $f$ and the lowest $w_{\rm II}$ modes from quark stars, by using the simultaneously obtained radiation radius we can constrain the bag constant $B$ with reasonable accuracy, independently of the $s$ quark mass.Comment: To appear in Phys. Rev.

Two lectures on color superconductivity

The first lecture provides an introduction to the physics of color superconductivity in cold dense quark matter. The main color superconducting phases are briefly described and their properties are listed. The second lecture covers recent developments in studies of color superconducting phases in neutral and beta-equilibrated matter. The properties of gapless color superconducting phases are discussed.Comment: 56 pages, 9 figures. Minor corrections and references added. Lectures delivered at the IARD 2004 conference, Saas Fee, Switzerland, June 12 - 19, 2004, and at the Helmholtz International Summer School and Workshop on Hot points in Astrophysics and Cosmology, JINR, Dubna, Russia, August 2 - 13, 200

Atrial fibrillation after gastrointestinal surgery: incidence and associated risk factors

BACKGROUND: Atrial fibrillation (AF) is a common dysrhythmia that can occur after major physiological stress including surgery (postoperative AF). There are few data on postoperative AF after abdominal surgery. We set out to define the incidence of de novo postoperative AF after abdominal surgery and associated risk factors. METHODS: The Patient History Integrated Data store administrative database was interrogated for patients aged ≥65 y undergoing abdominal surgery from April 2012 to April 2014. Patients with pre-existing AF were excluded. The primary outcome was diagnosis of AF. RESULTS: Two thousand nine hundred and sixty-seven cases were included of whom 187 developed postoperative AF within 90 d (6.3%). The rate of postoperative AF varied by operation and was highest in small bowel resection (17.2%) and lowest in biliary surgery (4.8%). Median time to detection of postoperative AF was 32 d. Patients who developed postoperative AF were significantly older than those who did not develop AF (median age 75.3 y versus 72.4 y, P < 0.01). Logistic regression modeling found increasing age (odds ratio [OR] 1.03 [confidence interval {CI} 1.01-1.06], hypertension OR 1.73 [CI 1.19-2.51]), congestive cardiac failure (OR 3.04 [CI 1.88-4.92], and vascular disease OR 2.29 [CI 1.39-3.37]) were predictive of the development of postoperative AF within 30 d. The area under the curve for this model was 0.733. CONCLUSIONS: Postoperative AF affects a significant number of patients after abdominal surgery. Demographics such as history of cardiovascular disease might aid prediction of postoperative AF. Postoperative AF is mostly identified after discharge, suggesting the need for postoperative screening

The current status of clinical trials in emergency gastrointestinal surgery. A systematic analysis of contemporary clinical trials

BACKGROUND: Emergency gastrointestinal surgery (EGS) conditions represent a significant healthcare burden globally requiring emergency operations that are associated with mortality rates as high as 80%. EGS is currently focussed on quality improvement and internal audits, which occurs at a national or local level. An appreciation of what EGS trials are being conducted is important to reduce research wastage and develop coordinated research strategies in surgery. The primary aim of this study was to identify and quantify recent and active trials in emergency gastrointestinal surgery. The secondary aim was to identify conditions of interest, and which aspects of care were being modified. METHODS: A systematic search of WHO, UK, US, Australian and Canadian trials databases was undertaken using broad terms to identify studies addressing emergency abdominal surgery and specific high-risk diagnoses. Studies registered between 2013-2018 were eligible for inclusion. Data on study topic, design, and funding body were collected. Interventions were classified into 'peri-operative', 'procedural', 'post-operative', 'non-surgical' and 'other' categories. RESULTS: Searches identified 5603 registered trials. After removal of duplicates, 4492 studies remained and 42 were eligible for inclusion. Almost 50% of trials were located in Europe and 17% (n=7) in the USA. The most common condition addressed was acute appendicitis (n=11), with the most common intervention being procedure based (n=23). Hospital based funding was the most common funder (n=30). CONCLUSION: There is large disparity in the number of surgical trials in emergency surgery, which are primarily focussed on high-volume conditions. More research is needed into high-mortality conditions. EVIDENCE LEVEL: 1a (oxford)

An Integrated TCGA Pan-Cancer Clinical Data Resource to Drive High-Quality Survival Outcome Analytics

For a decade, The Cancer Genome Atlas (TCGA) program collected clinicopathologic annotation data along with multi-platform molecular profiles of more than 11,000 human tumors across 33 different cancer types. TCGA clinical data contain key features representing the democratized nature of the data collection process. To ensure proper use of this large clinical dataset associated with genomic features, we developed a standardized dataset named the TCGA Pan-Cancer Clinical Data Resource (TCGA-CDR), which includes four major clinical outcome endpoints. In addition to detailing major challenges and statistical limitations encountered during the effort of integrating the acquired clinical data, we present a summary that includes endpoint usage recommendations for each cancer type. These TCGA-CDR findings appear to be consistent with cancer genomics studies independent of the TCGA effort and provide opportunities for investigating cancer biology using clinical correlates at an unprecedented scale. Analysis of clinicopathologic annotations for over 11,000 cancer patients in the TCGA program leads to the generation of TCGA Clinical Data Resource, which provides recommendations of clinical outcome endpoint usage for 33 cancer types

A mathematical framework for critical transitions: normal forms, variance and applications

Critical transitions occur in a wide variety of applications including mathematical biology, climate change, human physiology and economics. Therefore it is highly desirable to find early-warning signs. We show that it is possible to classify critical transitions by using bifurcation theory and normal forms in the singular limit. Based on this elementary classification, we analyze stochastic fluctuations and calculate scaling laws of the variance of stochastic sample paths near critical transitions for fast subsystem bifurcations up to codimension two. The theory is applied to several models: the Stommel-Cessi box model for the thermohaline circulation from geoscience, an epidemic-spreading model on an adaptive network, an activator-inhibitor switch from systems biology, a predator-prey system from ecology and to the Euler buckling problem from classical mechanics. For the Stommel-Cessi model we compare different detrending techniques to calculate early-warning signs. In the epidemics model we show that link densities could be better variables for prediction than population densities. The activator-inhibitor switch demonstrates effects in three time-scale systems and points out that excitable cells and molecular units have information for subthreshold prediction. In the predator-prey model explosive population growth near a codimension two bifurcation is investigated and we show that early-warnings from normal forms can be misleading in this context. In the biomechanical model we demonstrate that early-warning signs for buckling depend crucially on the control strategy near the instability which illustrates the effect of multiplicative noise.Comment: minor corrections to previous versio