Surgeon and community factors affecting breast cancer sentinel lymph node biopsy

BACKGROUND: We sought to determine whether the results of sentinel lymph node (SLN) biopsy are related to practice and community factors. METHODS: This prospective study included more than 300 surgeons from a variety of practice environments. Most surgeons had minimal experience with SLN biopsy prior to this study. Patients underwent attempted SLN biopsy, followed by completion axillary dissection. Univariate and multivariate analyses were performed to assess factors related to the SLN identification rate and the false negative rate. RESULTS: A total of 4131 patients were enrolled. SLN identification rate was 93%; the false negative (FN) rate was 7.9%. The only factor that was significantly associated with improved SLN identification rate (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.12 to 2.36, P = .0126) and FN rate (OR 2.39, 95% CI 1.32 to 4.79, P = .0073) was surgeon experience (>20 SLN cases). CONCLUSIONS: Surgeon experience is the major factor that contributes to improved SLN biopsy results. SLN biopsy can be performed equally well by community and academic surgeons.     

Risk factors affecting nutritional status of dialysis patients: a quality improvement project

People with chronic kidney disease on dialysis are at very high risk for protein energy malnutrition (PEM). It is well documented that malnourished patients have increased frequency of hospital admissions, longer hospital stays, lower quality of life, and increased risk of death. Serum albumin level is a valid measure for nutritional status of PEM. Clinical practice guidelines for nutrition, established by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI), recommend that patients on dialysis achieve an albumin of 3.7 g/dL (BCP) to ensure optimal nutrition and decrease risks of PEM. At Mercy Dialysis Center, it was determined that only 6% (n=97) of patients at Mercy Dialysis Center met this recommended albumin level. This led to an extensive continuous quality improvement project to improve these results. The nephrologist, nurse practitioner, dietitian, social worker, nurses, and dialysis technicians all contributed to this team project. PROJECT SUMMARY: Eleven risk factors for low serum albumin levels were identified. All patients at Mercy Dialysis Center were assessed for each risk factor. Interventions were implemented to reduce these risks. Serum albumin levels were tracked at the beginning of our study, at six months, and at one year on all patients. RESULTS: At the end of the study, 36% of the patients met the KDOQI recommendations for serum albumin levels (compared to only 6% prior to the project), and albumin levels overall improved. The risk factors that affected our patients the most included: dentition, infections or sepsis, multiple medications, and pain. It was determined that these, and all other risk factors had an impact on the nutritional status of our patients and need to be addressed on a regular basis.     

Enhanced care for primary hip arthroplasty: factors affecting length of hospital stay

Background

Enhanced care in joint replacement requires identification and correction of the causes of delay in discharge while ensuring practice remains safe. We conducted prospective studies of factors delaying discharge following hip replacement in 2006 and 2010.

Methods

Daily data were twice collected prospectively in 100 consecutive unselected primary cemented THR, by an independent observer. Reasons for delays in discharge and variation from the patient pathway were identified and addressed.

Results

The mean length of stay (LOS) in 2006 was 4.3 days and in 2010, 3.56 days (target for discharge 4 days). In 2006, 31 patients had a stay of more than 4 days, 17 due to inadequate physiotherapy provision, 10 for medical and 4 for other reasons. In 2010, 15 patients had a stay of more than 4 days, 1 patient had inadequate physiotherapy provision, in 7 cases discharge was delayed because of need for blood transfusion and 7 because of need for catheterisation. Women aged more than 70 with preoperative haemoglobin of <12 g/dL were at particularly high risk of requiring transfusion. Catheterisation was also identified as a factor causing significant increase in LOS. Patients going home in less than 4 days were more likely to have had their operation in the morning.

Conclusion

Patient LOS is multifactorial and can be reduced by regular review of the care pathway to effect incremental changes that have a significant impact on reducing stay.     

肾移植患者性生活质量的影响因素

目的 探讨肾移植患性生活质量的影响因素。方法 对86例男性和50例女性肾移植术后患的性心理、对性生活的认识、经济状况和年龄等与性生活质量的关系进行调查。结果 认为性生活影响康复、经济状况较差、高年龄组的患，性生活满意率：男性分别为42．1％、42．4％和40．9％；女性分别为37％、33．3％和25％。认为性生活不影响康复、经济状况较好、低年龄组的患，性生活满意率：男性分别为75％、80．8％和80．0％．女性分别为65．2％、72．7％和76．9％。结论 性心理状态、对性生活的认识以及经济状况和年龄等均可影响肾移植患术后的性生活质量。     

Operating room efficiency and hospital capacity: factors affecting operating room use during maximum hospital census

BACKGROUND: Academic medical centers are faced with increasing volumes, higher acuity, and, as a consequence, capacity issues. These affect operating room (OR) use and patient throughput, with negative impact on finances and patient and physician satisfaction. We evaluated our experiences in dealing with OR efficiency at a time of maximum hospital capacity and occupancy. STUDY DESIGN: Using a multidisciplinary approach, we put in place seven agreed-upon strategies: daily communication, improved bed planning, discharge by noon program, internal staffing pool, special assignments for a patient transition unit, incentives, and stepped up environmental services. RESULTS: After institution of these strategies, we were able to realize a gain in OR patient volume of 8% and a decrease in OR holds of 37%. This resulted in a decrease in canceled OR cases from 4.3% to 3.1%. CONCLUSIONS: Academic medical centers face occupancy issues that are not likely to go away and will have an impact on OR volume and productivity. To improve the situation in a short-term fashion, a multidisciplinary approach involving several strategies will be needed.     

儿科重症监护病房护理质量影响因素分析及对策

分别从结构、过程、结果三个类别对影响儿科重症监护病房(PICU)护理质量的因素进行分析,其主要因素包括护理管理、人力资源、病房环境、药物使用、感染控制、护患沟通、身份识别等方面.提出需建立PICU专科护士培训基地和评价标准,增强护士的安全意识及沟通能力,营造护理安全氛围,加强用药管理及手卫生管理等,以提高PICU护理质量,确保PICU护理安全.     

维持性血液透析患者生活质量影响因素的研究

目的 分析维持性血液透析(HD)患者生活质量的各种影响因素.方法 选择血液透析治疗患者共88例,登记基本情况,使用肾脏病生活质量简表(KDQOL-SFTM)问卷调查,对其生活质量(QOL)进行统计.结果 原发病情况及费用来源与生活质量不具有相关性(P＞0.05);年龄、性别、婚姻、透龄、教育程度、工作及收入情况与生活质量均有相关性(P＜0.05).结论 透龄、教育程度、年龄、婚姻情况、性别、收入及工作情况严重影响透析患者的生活质量.     

专科护理质量指标信息系统的构建与应用

目的构建适用于护理质量管理的专科护理质量指标信息系统。方法护理部与计算机中心合作,开发专科护理质量管理信息系统,以专科护理质量指标的使用对象为出发点、数据流转过程为依据设置各个节点,由护理部统一为各病区配置个性化的专科护理质量指标。构建的信息系统包括指标配置、病区指标数据录入、系统统计生成各类图表3部分,经临床调试后投入临床使用。结果系统对人员登陆实行分级权限,能自动识别与提取部分数据,对护理质量指标的异常波动提出警示提醒。结论专科护理质量指标信息系统优化了专科护理质量管理流程,将结果质量控制前移至过程质量控制,明确了专科护理质量管理目标,规范了专科护理质量的信息化管理。     

冻融胚胎移植结局相关影响因素的研究进展

冻融胚胎移植(FET)是体外受精与胚胎移植(IVF-ET)的补充和延续,已逐渐成为辅助生殖的重要治疗手段之一。为了满足人民日益增长的生育需求,如何有效的改善FET受治者的临床结局已变得越来越重要。本文对近年来国内外学者的研究成果进行梳理和整合,将影响FET结局的相关因素,例如年龄及不孕年限、胚胎因素、子宫内膜容受性等因素进行归纳整理与总结,为今后FET相关研究提供可参考的文献依据。     

持续性非卧床腹膜透析患者生存质量影响因素的研究

目的评估持续性非卧床腹膜透析(CAPD)患者的生存质量状况,探讨营养状态、透析充分性、微炎症、腹膜转运和残余肾功能对腹透患者生存质量的影响。方法选择稳定的CAPD3个月以上的患者88例,使用KDQOL-SFTM生存质量研究量表计分。同时检测患者营养状态、透析充分性、微炎症、腹膜转运功能和残存肾功能,用SPSS10软件包分析数据。结果(1)CAPD患者肾病、透析相关生存质量(KDTA)评分为:58.6±14.2,SF-36总分为50.4±12.8。(2)营养指标(MQSGA、白蛋白和血红蛋白等)与KDTA和SF-36总分及其部分领域呈显著相关,其中以MOSGA相关性最好。(3)微炎症(IL-6、CRP和TNFα)与KDTA和SF-36总分及其分支领域呈显著相关,其中以IL-6相关性最为显著。(4)腹膜转运功能与KDTA和SF-36总分呈显著等级相关。(5)残存尿量与KDTA和SF-36总分及部分领域呈显著相关。(6)Kt/V与KDTA和SF-36无显著相关。(7)对KDTA的影响分别为腹膜转运功能、残存尿量、MQSGA、IL-6、Kt/V、TNFα、CRP,其中腹膜转运功能、残存尿量、MQSGA、IL-6是独立影响因素。(8)对SF-36的影响分别为腹膜转运功能、MQSGA、残存尿量、IL-6、Kt/V、TNFα、CRP,其中,腹膜转运功能、MQSGA、残存尿量、IL-6是独立影响因素。结论(1)腹膜转运功能、残存尿量影响腹透患者生存质量,但是,     

Incidence of fractures requiring inpatient care

Background

The overall incidence of fractures has been addressed in several studies, but there are few data on different types of fractures that require inpatient care, even though they account for considerable healthcare costs. We determined the incidence of limb and spine fractures that required hospitalization in people aged ≥ 16 years.

Patients and methods

We collected data on the diagnosis (ICD10 code), procedure code (NOMESCO), and 9 additional characteristics of patients admitted to the trauma ward of Central Finland Hospital between 2002 and 2008. Incidence rates were calculated for all fractures using data on the population at risk.

Results and interpretation

During the study period, 3,277 women and 2,708 men sustained 3,750 and 3,030 fractures, respectively. The incidence of all fractures was 4.9 per 10³ person years (95% CI: 4.8–5.0). The corresponding numbers for women and men were 5.3 (5.1–5.4) and 4.5 (4.3–4.6). Fractures of the hip, ankle, wrist, spine, and proximal humerus comprised two-thirds of all fractures requiring hospitalization. The proportion of ankle fractures (17%) and wrist fractures (9%) was equal to that of hip fractures (27%). Four-fifths of the hospitalized fracture patients were operated. In individuals aged < 60 years, fractures requiring hospitalization were twice as common in men as in women. In individuals ≥ 60 years of age, the opposite was true.Inpatient hospital treatment of fractures is significantly more expensive than outpatient fracture treatment (Cummings and Melton 2002). In most cases, the costs are increased if surgery is needed (Bouee et al. 2006). Thus, preventing fractures that commonly require surgical treatment is cost effective. However, except for hip fractures, there has been little research on the incidence of fractures requiring inpatient care, and the current profile of fractures sustained by adults admitted to trauma units is unknown. This profile is likely to differ from the overall fracture profile in a population. We determined the incidence of limb and spine fractures that require hospitalization in individuals aged ≥ 16 years.     

Surgeon information giving practices prior to laryngectomy: a national survey.

Prior to the proposed development of a pretreatment counselling package for patients with cancer of the larynx or pharynx, a study was undertaken to determine current information giving practice prior to laryngectomy. A postal questionnaire was sent to all UK ENT consultants registered in the Medical Directory. The response rate was 88%, with 48% meeting the study's entry criteria. Counselling practice varies widely. Surgeons report an average of 15 min available for discussion with the patient: 84% gave the diagnosis and discussed the treatment options at the same consultation. The size of the department, as measured by cases seen per year, did not correlate with the consultation time although it did with the numerous different issues discussed. Whilst the survey supports the need and desire for an appropriate counselling package, many surgeons feel that they alone know what the patient's information needs are.     

Hip disarticulation: factors affecting outcome

Hip disarticulation, especially in patients with peripheral vascular disease, has been associated with high morbidity and mortality rates. This report describes patient characteristics that influence the clinical outcome of hip disarticulation. The medical records of all patients undergoing hip disarticulation from 1966 to 1989 were reviewed for surgical indication, perioperative wound complications, and postoperative deaths. Fifty-three patients underwent hip disarticulation for limb ischemia (10), infection (12), infection and ischemia (14), or tumor (17). The overall incidence of wound complications was 60%, and no significant differences were found among the groups. Prior above-knee amputation and urgent/emergent operations were significantly associated with increased wound complications (p less than 0.05). The overall mortality rate was 21%, ranging from 0% (tumor) to 50% (ischemia) and differed significantly among the groups (p less than 0.02). Mortality was significantly associated with urgent/emergent operations (p less than 0.01). Age, diabetes mellitus, and previous inflow procedures did not influence mortality rates. The presence of limb ischemia influenced mortality rates to a greater extent than did infection, and a history of cardiac disease was statistically predictive of death. Wound complications frequently accompanied hip disarticulation, regardless of operative indication, and were significantly increased by urgent/emergent operations and prior above-knee amputation. Hip disarticulation can be performed with low mortality rates in selected patients. Both limb ischemia and infection substantially increase operative mortality rates.     

Surgeon workload and motion efficiency with robot and human laparoscopic camera control

Background: Surgeons are now being assisted by robotic systems in a wide range of laparoscopic procedures. Some reports have suggested that robot-assisted camera control (RACC) may be superior to a human driver in terms of quality of view and directional precision, as well as long-term cost savings. Therefore, we setout to investigate the impact of RACC of surgeon motion efficiency. Methods: Twenty pigs were randomized to undergo a standardized laparoscopic Nissen fundoplication with either a human or RACC system, the AESOP 2000. All procedures were performed by the same surgical fellow. Time was recorded for dissection and suture phases. Inertial motion sensors were used to monitor both the surgeon's hands and the camera. Digitized data were analyzed to produce summary measures related to overall motion. Results: The operative times were slightly longer with RACC (mean 80.2 ± 20.6 vs 73.1 ± 15.4 min, not significant). With regard to operative times and surgeon motion measures, the only statistically significant differences were for setup and breakdown times, which contributed <15% to the total time for the procedure. Conclusion: In terms of impact on surgeon motion efficiency and operative time under normal surgical conditions, RACC is essentially the same as an expert human driver. However, careful planning and structuring of the surgical suite may yield some small gains in operative time.