Sexual and reproductive health for all: a call for action

At the United Nations International Conference on Population and Development in Cairo in 1994, the international community agreed to make reproductive health care universally available no later than 2015. After a 5-year review of progress towards implementation of the Cairo programme of action, that commitment was extended to include sexual, as well as reproductive, health and rights. Although progress has been made towards this commitment, it has fallen a long way short of the original goal. We argue that sexual and reproductive health for all is an achievable goal--if cost-effective interventions are properly scaled up; political commitment is revitalised; and financial resources are mobilised, rationally allocated, and more effectively used. National action will need to be backed up by international action. Sustained effort is needed by governments in developing countries and in the donor community, by inter-governmental organisations, non-governmental organisations, civil society groups, the women's health movement, philanthropic foundations, the private for-profit sector, the health profession, and the research community.     

Quantification of hepatic functional capacity: a call for standardization

Reliable assessments of liver function are becoming increasingly important as more patients with surgically amenable liver disease are considered for treatment. Static markers of liver function are not sufficient to provide accurate assessments of hepatic function in order to risk stratify patients undergoing hepatic resection. Metabolic tests are dynamic indicators of liver function, but can be unreliable under certain conditions and thus difficult to make comparisons. Clearance tests avoid some of the pitfalls encountered during metabolic testing, but depend on hepatic blood flow and say little about hepatocyte function. Testing that combines imaging with measures of hepatocyte uptake may offer the most utility when planning surgical resections.     

Prediction of risk of death using 30-day outcome: a practical end point for quality auditing in intensive care

STUDY OBJECTIVE: To validate the APACHE (acute physiology and chronic health evaluation) III unadjusted and similar hospital mortality estimate models on 30-day mortality, and to propose a simple approach to modeling local 30-day in-hospital mortality of critically ill hospitalized adults for quality management and risk-adjusted monitoring. DESIGN: Noninterventional, observational study. PATIENTS: A total of 5,278 consecutive eligible hospital admissions between January 1, 1995, and December 31, 1999. MEASUREMENTS: Prospective collection of demographic, diagnostic, physiologic, laboratory, and hospital admission and discharge data. RESULTS: The APACHE III mortality predictions exhibited excellent discrimination (receiver operating characteristic [ROC] curve area) for 30-day outcome (ROC area, 0.89) and hospital outcome (ROC area, 0.89). Calibration curves and Hosmer-Lemeshow statistics demonstrated good calibration of all models on 30-day outcome, except for the unadjusted APACHE III model. New, simplified risk adjustment models showed good discrimination and calibration on development and test data. ROC areas were 0.88 (developmental data) and 0.87 (test data), and the new model calibration was equivalent to the APACHE III model. CONCLUSION: For quality audit, 30-day in-hospital mortality can be used as an alternative outcome to survival to hospital discharge. New logistic regression models provide evidence that local models, possessing good calibration and discrimination, may be built from a few explanatory variables.     

Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system

The Brisbane 2000 system of nomenclature of hepatic anatomy and resections was introduced to provide a universal terminology in an area that was plagued by confusing and inappropriate terminology. The article describes historical developments central to the emergence of the new terminology and describes the terminology, its attributes, and rules of application.     

Development of process and outcome measures for improvement: lessons learned in a quality improvement collaborative for pediatric inflammatory bowel disease

The Institute of Medicine's publications, To Err is Human and Crossing the Quality Chasm, publicized the widespread deficits in healthcare quality. The quality of care in inflammatory bowel disease (IBD) has not been comprehensively evaluated, in part due to a lack of well-established IBD measures of quality. Quality can be measured for evaluation, benchmarking, or continuous quality improvement, using structural, process, and outcome measures. Measurement is an essential component of the model for improvement, necessary to determine whether changes made have resulted in improvement. Measures used for quality improvement should be based on evidence and consensus, be clear and collectable in a timely fashion, occur with sufficient frequency, and have the potential to improve outcomes. While no current IBD measures of quality are perfect, an iterative process of measure development can produce a set of measures that are feasible, relevant, and useful for performing quality improvement. This review describes the history, rationale, and methods of quality measurement and discusses the early work and lessons learned from measuring quality of care in a pediatric IBD quality improvement collaborative.     

Assessment of liver function for successful hepatectomy in patients with hepatocellular carcinoma with impaired hepatic function

Background/Purpose

This study aimed to construct a formula for assessing liver function in order to prevent post-hepatectomy liver failure.

Methods

A formula was constructed by analyzing data from 28 patients with hepatocellular carcinoma (HCC) with liver cirrhosis operated on between 1981 and 1984. Next, we evaluated the validity of this formula in 207 hepatectomy patients operated on from 1985 to 1999. For 145 hepatectomy patients operated on from 2000 to 2006, this formula was calculated before surgery in order to assess their risk of hepatectomy.

Results

The formula for liver functional evaluation, constructed from preoperative hepatic function parameters, was: liver failure score = 164.8 ? 0.58 × Alb ? 1.07 × HPT + 0.062 × GOT ? 685 × K. ICG ? 3.57 × OGTT. LI + 0.074 × RW, where Alb is albumin (g/dl); HPT, hepaplastin test (%); GOT, glutamate oxaloacetate transaminase (U/l); K. ICG, K value of indocyanine green clearance test; OGTT. LI, 60-min/120-min glucose level in 75-g oral glucose tolerance test. linearity index of OGTT; and RW, weight of resected liver (g). We decided that a score below 25 would be safe for hepatectomy.

Conclusions

The mortality rate decreased from 3.9% in 1985–1999 to 1.3% in 2000–2006. This finding allows us to conclude that the formula is valid for assessing the risk of post-hepatectomy liver failure.

     

Health of children with chronic arthritis: relationship of different measures and the quality of parent proxy reporting

OBJECTIVE: To examine the strength of the association between different measures of health-related quality of life (HRQOL), disability, pain, and well-being in children with chronic arthritis. To evaluate whether HRQOL scores vary as a function of disability status beyond chance. To assess the quality of the parent proxy report for HRQOL as compared with disability, pain, and well-being. METHODS: Measures of HRQOL (visual analog scale [VAS] of health, Pediatric Quality of Life Inventory [PedsQL], Juvenile Arthritis Quality of Life Questionnaire (JAQQ), and modified standard gamble technique [SG]), disability (Childhood Health Assessment Questionnaire), VAS of pain, and VAS of well-being (VAS-well) were completed by the parents (n = 119) and patients > or =8 years (SG: > or =12 years). RESULTS: HRQOL was highest when measured by the SG, whose utilities were no more than weakly correlated with any of the other outcomes. The values of all other HRQOL measures were at least moderately correlated with each other and with the VAS-well. Irrespective of the measure used, disability was associated with significantly decreased HRQOL. There was fair to good agreement and moderate consistency of the HRQOL ratings (SG: fair consistency) between patients and parents with marked differences between health domains. CONCLUSION: HRQOL measured by the PedsQL, JAQQ, and VAS are moderately to highly correlated with each other in children with chronic arthritis. The children's HRQOL significantly decreases with increasing disability. Despite more pronounced differences for some health domains, parents are moderate to good proxy reporters of HRQOL, disability, and well-being of children with chronic arthritis.     

Combined hepatic and portal vein embolization as preparation for major hepatectomy: a systematic review

BackgroundSome patients remain deemed unsuitable for resection after portal vein embolization (PVE) because of insufficient hypertrophy of the future remnant liver (FRL). Hepatic and portal vein embolization (HPVE) has been shown to induce hypertrophy of the FRL. The aim of this study was to provide a systematic review of the available literature on HPVE as preparation for major hepatectomy.MethodsThe literature search was performed on online databases. Studies including patients who underwent preoperative HPVE were retrieved for evaluation.ResultsSix articles including 68 patients were published between 2003 and 2017. HPVE was performed successfully in all patients with no mortality and morbidity-related procedures. The degree of hypertrophy of the FRL after HPVE ranged from 33% to 63.3%. Surgical resection after preoperative HPVE could be performed in 85.3% of patients, but 14.7% remained unsuitable for resection because of insufficient hypertrophy of the FRL or tumor progression. Posthepatectomy morbidity and mortality rates were 10.3% and 5.1%, respectively. The postoperative liver failure rate was nil.ConclusionHPVE as a preparation for major hepatectomy appears to be feasible and safe and could increase the resectability of patients initially deemed unsuitable for resection because of absent or insufficient hypertrophy of the FRL after PVE alone.     

Patient-derived outcome measures for HIV services in the developed world: a systematic review

This review sought to establish the themes and approaches used in the measurement of patient satisfaction regarded by HIV service users as crucial to improving service quality. It also investigated how feedback has been measured previously and whether a gold standard instrument exists that is generalizable across HIV inpatient and clinic settings. Twelve databases and other sources yielded 1474 titles. Using a clinically-focused question and pre-defined inclusion and exclusion criteria, 32 articles were retrieved and reviewed for quality using a quality appraisal checklist. Two reviewers used a data extraction form to identify and verify key patient experiences. Thematic analysis revealed that clinic staffs' current knowledge of HIV was an essential factor in positive feedback. Treating patients with dignity and respecting their autonomy and confidentiality were also important. Developments in treatment, extended life expectancy and quality of life have altered patients' experience and level of satisfaction. Three instruments developed to assess patient satisfaction with HIV care were identified but there was no gold standard method of measuring it. There is a need to develop a specific, valid instrument that is easy to complete and analyse, and the data should be used to inform the redesign of services to promote a dynamic model of care.     

Symptom-based outcome measures for dyspepsia and GERD trials: a systematic review

BACKGROUND: Symptom assessment using questionnaires has been recommended as the primary outcome measure in clinical gastroesophageal reflux and dyspepsia trials. Questionnaires should have proven reliability, validity, and responsiveness, and may assess the frequency and/or severity of dyspepsia symptoms. Although a number of measures have been developed, it remains unclear which of these should be used in new trials. OBJECTIVE: To describe existing questionnaire outcome measures that assess symptoms of gastroesophageal reflux dyspepsia for use in clinical trials. METHODS: Studies were identified from Medline, Embase, the Cochrane library, and reference lists. The inclusion criterion was that the study assessed a questionnaire, which measured the frequency or severity of dyspepsia or gastroesophageal reflux symptoms, in a sample of patients. RESULTS: No direct comparison between questionnaires was possible due to methodological heterogeneity. Thirty-seven studies describing 26 questionnaires met the inclusion criteria. Twelve were unidimensional (assessed symptoms only) and 14 were multidimensional (also assessed quality of life). Eleven questionnaires assessed both frequency and severity of dyspepsia, and 10 had proven reliability, validity, and responsiveness. No studies compared different questionnaires. CONCLUSIONS: Future gastroesophageal reflux and dyspepsia clinical trials should use unidimensional or multidimensional outcome measures that assess both the frequency and severity of symptoms, and have proven reliability, validity, and responsiveness. Further research is necessary to compare existing outcome measures to determine which are the most reliable, valid, and responsive instruments.     

Modification of right hepatectomy results in improvement outcome: a retrospective comparative study

Objective

To evaluate any change in the operative and survival outcomes in patients undergoing a right hepatectomy after adoption of the no-clamp technique using a radiofrequency dissecting sealer (TissueLink™) in liver resection.

Methods

In all, 58 consecutive patients who underwent a right hepatectomy from July 2003 to December 2007 (Group 1) were compared with 66 consecutive patients who underwent a right hepatectomy from January 1999 to June 2003 (Group 2). In group 1, a liver transection was performed with a cavitron ultrasonic surgical aspirator (CUSA) and TissueLink™ without hilar clamping whereas in group 2, a liver transection was performed with CUSA and diathermy with routine continuous hilar clamping.

Results

For the operative outcomes, there was significantly less blood loss (median 450 vs. 900 ml, P < 0.001) in group 1. The complication rate was also significantly lower in group 1 (22.4% vs. 47.0%, P = 0.004). In subgroup analysis for patients with hepatocellular carcinoma (HCC), the overall survival rate was significantly better in group 1; 1-, 3- and 5-year survival rates were 78%, 72% and 57% in group 1 vs. 72%, 44% and 39% in group 2, respectively (P = 0.048).

Conclusions

When compared with the retrospective cohort, a right hepatectomy utilizing TissueLink™ without hilar clamping was feasible with potential benefits in surgical outcomes.