Risk-Appropriate Care to Improve Practice and Birth Outcomes

Identification and referral of women with high-risk pregnancies to hospitals better equipped and staffed to provide care for them have been important steps to improve birth outcomes. Based on recent recommendations from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine to provide regionalized maternal care for pregnant women at high risk and reduce rates of maternal morbidity and mortality, health care organizations and providers have refocused their attention to women’s well-being rather than solely on the well-being of the fetus or newborn. Opportunities to improve practice and birth outcomes exist through the implementation of a more standardized and integrated system of risk-appropriate care.     

Temporal trends in liver transplant centre volume in the USA

Background:

Although prior studies have suggested an inverse association between liver transplant centre volume and postoperative patient mortality, more recent analyses have failed to confirm this association. To date, all studies of the relationship between centre volume and outcomes in liver transplantation have been cross-sectional in design.

Objective:

The objective of our study was to examine temporal trends in the volume–outcomes relationship for liver transplantation.

Methods:

We used information obtained from the Scientific Registry of Transplant Recipients (SRTR) programme-specific data reports to examine the outcomes of adult liver transplant recipients stratified by annual centre volume. This relationship between centre volume and patient outcomes was assessed over three consecutive time periods from 2000 through 2007.

Results:

The overall 25% increase in adult liver transplant volume in the USA from 2000 to 2007 appeared to be distributed fairly equally among existing transplant centres. In the earliest time period of our analysis, high-volume centres achieved superior risk-adjusted 1-year patient outcomes compared with low-volume centres. By the third and most recent time period of the analysis, this discrepancy between the outcomes of high- and low-volume centres was no longer statistically apparent.

Conclusions:

The relationship between centre volume and patient outcomes for liver transplantation in the USA has become less pronounced over time, suggesting that the use of procedure volume as a marker of liver transplant centre quality cannot be justified. The performance-based review process currently utilized in the USA may have contributed to this diminishing influence of centre volume on liver transplant recipient outcomes. This type of review process should be considered as a potential alternative to the volume-based referral initiatives that have been developed for other non-transplant, complex surgical procedures.     

Regional mechanisms within anterior pituitary of lactating rats may regulate prolactin secretion

Prolactin (PRL) release was compared after incubating the central and peripheral regions of the anterior pituitary of lactating rats, either nonsuckled or suckled in conditioned medium obtained by incubating medium with the same anterior pituitary regions from nonsuckled or suckled rats. To collect conditioned media, anterior pituitary regions were incubated in Earle’s medium for 4 h, and conditioned medium was filtered and employed double concentrated. Each anterior pituitary was incubated in conditioned medium for 30 min. PRL released in vitro was determined by polyacrylamide gel electrophoresis. As a control, anterior pituitary regions from lactators were incubated in medium conditioned by male rat anterior pituitary regions, and they showed no changes of PRL release compared with those cultured in Earle’s medium. In general, conditioned media from both anterior pituitary regions of nonsuckled and suckled rats inhibited PRL release in peripheral anterior pituitary regions, whereas PRL release was stimulated in central regions of both nonsuckled and suckled rats. A higher number of stimulatory effects was provoked by conditioned media from suckled than from nonsuckled rats, and most of these effects were from conditioned media of the peripheral region of suckled rats. Together, these results suggest the existence within anterior pituitary regions of factors that regulate PRL secretion and that their action depends on the physiologic condition of the animal.     

Incorporating Ethics in Priority Setting: A Case Study of a Regional Health Board in Canada

The authors were involved in developing an ethical framework to assist the Queens Region Board (Prince Edward Island, Canada) set priorities in health and health care. Two and one half years after the adoption of this framework, the authors undertook an evaluation of the framework. This paper will discuss: a) the historical background of regionalization in Canada, and in particular the circumstances leading up to the institution of regional boards in Prince Edward Island; b) the sorts of ethical issues facing the Queens Regional Board; c) issues arising in connection with the use and development of ethics frameworks for managing ethical issues in priority setting; d) the framework adopted by the Queens Board and the process that led to its development; e) issues arising as concerns implementation of the framework; f) questions and issues pertinent to other boards and bodies considering similar initiatives. This revised version was published online in August 2006 with corrections to the Cover Date.     

OUTCOME OF PATIENTS WITH NEUROTRAUMA: THE EFFECT OF A REGIONALIZED TRAUMA SYSTEM

A system of regionalized trauma care was introduced to Sydney in early 1992. This study was carried out to assess the effect of regionalization on the outcome of patients suffering major head injury within the central Sydney area. A prospective before and after study extending over 3 years and centred on the time of designation of Royal Prince Alfred Hospital (RPAH) as a trauma centre, was the methodology used. The study group consisted of all patients admitted with head injury (Glasgow Coma Score < 9; admission systolic blood pressure >90mmHg; Injury Severity Score > 15) to RPAH from the central Sydney area. Outcome criteria include survival rates, transfer numbers, and time to definitive neurosurgical care. Fifty patients were entered during the first 18 months of the study, and 38 during the second 18 months. Fifteen in the first group required evacuation of intracranial mass lesions, as did nine in the second group. The overall mortality fell from 42 to 26% (P= 0.13). During the study period there were 77 primary retrievals and 20 required evacuation of mass lesions. The median time from injury to commencement of operation in these patients was 2 h 13 min (range 1 h 3 min-5 h 35 min). There were 11 transfers, four requiring craniotomy. The median time from injury to surgery was 7 h 24 min (range 3 h 2 min-10 h 25 min; P < 0.01). A trend towards a decreased mortality following regionalization, as well as a statistical difference (P <; 0.01) in the time taken for primary retrieval patients to undergo craniotomy when compared to transferred patients, has been shown. This evidence, in conjunction with the decrease in transferred patients post-regionalization, helps validate regionalization in the setting of major neurotrauma.