The postoperative bacteriuria score: a new way to predict nosocomial infection after prostate surgery.

OBJECTIVE: Urinary tract infections are the leading nosocomial urologic infections and may be a cause of added morbidity and costs, and sometimes sepsis. The aim of this study was to design a predictive score for these complications after prostate surgery. DESIGN: Multicenter prospective survey. SETTING: Eleven French urology centers. PATIENTS: All patients undergoing transurethral resection of prostate (TURP) during a 3-month period. RESULTS: The overall incidence of postoperative bacteriuria was 25.0% (95% confidence interval, 17.7%-29.5%). Almost all patients (95.7%) received antibiotic prophylaxis. A predictive postoperative bacteriuria score (POBS), with a 6-point scale of 0 to 5, was constructed on the basis of independent risk factors identified in multivariate analysis of a test sample of patients (n=135) and tested in a validation sample (n=73). Significantly more infections occurred in patients with a POBS of 2 or higher (87 [8%] vs 48 [50%]; P<.0001). With the test sample, this yielded a sensitivity of 77%, a specificity of 77%, a positive predictive value of 50%, a negative predictive value of 92%, and a global accuracy of 77%. CONCLUSIONS: POBS could be used to distinguish patients at risk of developing infection after TURP. This information might be useful for implementing selective prevention measures or for adjustment for differences in nosocomial infection rates when comparing data between urology centers.     

EM for regularized zero‐inflated regression models with applications to postoperative morbidity after cardiac surgery in children

This paper proposes a new statistical approach for predicting postoperative morbidity such as intensive care unit length of stay and number of complications after cardiac surgery in children. In a recent multi‐center study sponsored by the National Institutes of Health, 311 children undergoing cardiac surgery were enrolled. Morbidity data are count data in which the observations take only nonnegative integer values. Often, the number of zeros in the sample cannot be accommodated properly by a simple model, thus requiring a more complex model such as the zero‐inflated Poisson regression model. We are interested in identifying important risk factors for postoperative morbidity among many candidate predictors. There is only limited methodological work on variable selection for the zero‐inflated regression models. In this paper, we consider regularized zero‐inflated Poisson models through penalized likelihood function and develop a new expectation–maximization algorithm for numerical optimization. Simulation studies show that the proposed method has better performance than some competing methods. Using the proposed methods, we analyzed the postoperative morbidity, which improved the model fitting and identified important clinical and biomarker risk factors. Copyright © 2014 John Wiley & Sons, Ltd.     

Management of postoperative inflammatory response and pain with nimesulide after cardiac surgery

INTRODUCTION: Nimesulid (Mesulid) is a non-steroid anti-inflammatory drug (NSAID), acting by the selective inhibition of the Cyclooxygenase-2 (COX-2) isoenzyme. In this study the efficacy of nimesulid following cardiac surgery has been investigated in comparison with that of a COX-1 isoenzyme inhibitor drug. PATIENTS AND METHODS: 200 cardiac surgical patients operated on cardiopulmonary bypass have been involved in this prospective study. 100 patients received 100 mg. nimesulid bd. routinely in the postoperative period (group M). Another 100 patients were given 275 mg naproxen bd. (group A). In both groups the White Blood Cell (WBC), the blood sedimentation (We), the C-Reactive Protein (CRP) levels were determined from venous blood samples before the operation and on the first five postoperative days. Venous blood samples of 20 patients of each group in the same period were used to determine the Interleukin-6 (IL-6), and the Soluble Tumour Necrosis Factor Receptor-I (sTNF-RI) levels. Postoperative complications related to the use of the investigated drugs as well as the side effects have been compared in the two groups. A visual analogue pain scale was used before and after drug administration. Kruskal Wallis and student t tests were used for the statistical analysis. RESULTS: No serious complication related to the use of the investigated drugs has developed in either group. In group A gastrointestinal side effect were recorded in 7 cases (7%) whilst in group M no such complaints were found. Drug doses defined in the study protocol had to be raised or another drug had to be added in 11 and 3 cases in group A and M respectively. Neither the laboratory findings, nor the visual pain scale results have not shown any significant difference between the groups. CONCLUSION: The efficacy of nimesulid in postoperative inflammatory inhibition and pain relief has proved equal to that of the investigated COX-1 inhibitor drug, however less gastrointestinal side effects have been related to its administration.     

Comparison of measures to assess outcomes in total hip replacement surgery.

OBJECTIVES--To compare the performance of a disease specific and a general health questionnaire in assessing changes resulting from total hip replacement. DESIGN--Two stage prospective study of patients undergoing total hip replacement surgery involving an assessment at a clinic before and six months after surgery. 60(32%) patients were followed up by post. SETTING--Outpatient departments at a specialist orthopaedic hospital and peripheral clinics within Oxfordshire. PATIENTS--188 patients admitted for unilateral total hip replacement between February and mid-August 1994. MAIN MEASURES--Patients' self assessed scores with the 12 item Oxford hip score and SF-36 general health questionnaire together with surgeons' assessment with Charnley hip score obtained before and again at six months after surgery. RESULTS--186 patients were followed up six months after total hip replacement; a subsample (n=60) by post. Of the 60 postal patients, 59(98.3%) fully completed the Oxford hip score compared with 44(73.3%) who fully completed the SF-36. For the followup sample as a whole, post operative changes in scores produced a large effect size of 2.75 on the Oxford hip score, compared with -1.89 physical function (SF-36), -2.13 pain (SF-36). With the exception of physical function and role (physical), postoperative SF-36 scores were shown to be similar to or better than those found by two population surveys on patients of comparable age. The responsiveness of a disease specific questionnaire, the Oxford hip score, and relevant sections of a general questionnaire, SF-36, were found to be similar as assessed by three different criteria. CONCLUSIONS--A disease specific questionnaire, the Oxford hip score, and a general state of health questionnaire, SF-36, performed similarly in assessing outcomes of total hip replacement except that the disease specific questionnaire resulted in a higher completion rate and greater responsiveness in some sections. On the other hand the general health questionnaire drew attention to broader problems of physical function not considered by the Oxford hip score. The health questionnaires examined here offer a valid and practical means of monitoring outcomes of hip replacement surgery.     

The total body burden of Dieldrin

Bulletin of Environmental Contamination and Toxicology -     

The Postoperative Morbidity Survey was validated and used to describe morbidity after major surgery

OBJECTIVES: To describe the reliability and validity of the Postoperative Morbidity Survey (POMS). To describe the level and pattern of short-term postoperative morbidity after major elective surgery using the POMS. STUDY DESIGN AND SETTING: This was a prospective cohort study of 439 adults undergoing major elective surgery in a UK teaching hospital. The POMS, an 18-item survey that address nine domains of postoperative morbidity, was recorded on postoperative days 3, 5, 8, and 15. RESULTS: Inter-rater reliability was perfect for 11/18 items (Kappa=1.0), with Kappa=0.94 for 6/18 items. A priori hypotheses that the POMS would discriminate between patients with known measures of morbidity risk, and predict length of stay were generally supported through observation of data trends, and there was statistically significant evidence of construct validity for all but the wound and neurological domains. POMS-defined morbidity was present in 325 of 433 patients (75.1%) remaining in hospital on postoperative day 3 after surgery, 231 of 407 patients (56.8%) on day 5, 138 of 299 patients (46.2%) on day 8, and 70 of 111 patients (63.1%) on day 15. Gastrointestinal (47.4%), infectious (46.5%), pain-related (40.3%), pulmonary (39.4%), and renal problems (33.3%) were the most common forms of morbidity. CONCLUSION: The POMS is a reliable and valid survey of short-term postoperative morbidity in major elective surgery. Many patients remain in hospital without any morbidity as recorded by the POMS.     

The value of short and simple measures to assess outcomes for patients of total hip replacement surgery.

OBJECTIVES: To evaluate the performance of a patient assessed outcome measure, the Oxford Hip Score, in a national study of primary hip replacement surgery. DESIGN: A survey of patients' health status before undergoing primary hip replacement surgery and three months and one year after surgery. SETTING: 143 hospitals in three NHS English regions. PATIENTS: 7151 patients admitted for primary total hip replacement surgery over a period of 13 months from September 1996. MAIN MEASURES: For patients, Oxford Hip Score and satisfaction with hip replacement and, for surgeons, American Anesthesiologists' Society (ASA) classification of physical status. RESULTS: The response rates to the postal questionnaire at three and 12 months follow up were 85.2% and 80.7%, respectively. Including all three administrations of the questionnaire, all except two items of the Oxford Hip Score were completed by 97% or more respondents and only one item at one administration appeared marginally to reduce the reliability of the score. The effect sizes for changes in the score from baseline to three months was 2.50 and to 12 months was 3.05. Patients rated by surgeons as being healthy preoperatively by the ASA classification were somewhat more likely to return a completed questionnaire at three months (79.4% versus 75.3%) and 12 months (72.4% versus 70.3%) than those rated as having poorer health. CONCLUSIONS: Overall there was little evidence of difficulties for patients in completing the Oxford Hip Score or of unreliable data, except in relation to one questionnaire item. The instrument was very responsive to change over time and score changes for the Oxford Hip Score related well to patients' satisfaction with their surgery. The instrument is an appropriate measure in terms of validity, responsiveness, and feasibility for evaluating total hip replacement from the     

Using patient reports to assess health-related quality of life after total hip replacement

Data on disease severity, co-morbidity, and process of care were obtained from the medical records of 356 patients without rheumatoid arthritis undergoing a first unilateral total hip replacement at four teaching hospitals in California and Massachusetts. Sociodemographic characteristics, functional status prior and subsequent to hospitalization, and improvement in health status were measured with a patient questionnaire 12 months after discharge. Completed questionnaires were received from 284 patients, a reponse rate of 79.8%. The questionnaire was acceptable to patients, reliable, and had good construct validity. The data indicate substantial benefits from hip arthroplasty. As expected, pre-surgical functioning was a strong predictor of outcomes 1 year after surgery. Controlling for pre-surgical functioning, age was not related to outcomes.     

The development of a participant questionnaire to assess continuing medical education presentations

OBJECTIVE: Feedback on presentation skills is important for developing skilled educators, but often this feedback is based on evaluation tools that have been developed with little concern for psychometric issues or for how the information will be used for feedback. The purpose of this study was to develop a reliable participant questionnaire to assess the quality of continuing medical education (CME) presentations and to provide presenters with feedback. DESIGN: The questionnaire was developed using an iterative approach, with doctors as raters, and tested during a variety of CME presentations. The resulting questionnaire consists of 9 items rated on a 7-point Likert scale. The psychometric analysis reported in this paper was completed using data from grand rounds presentations. RESULTS: Psychometric analysis, based on 319 evaluations from 17 presentations (average of 19 evaluations/presentation), revealed a high level of reliability (0.91), indicating that the items met a reasonable standard and that the raters were discriminating between the quality of the presentations adequately. CONCLUSION: This 9-item, participant questionnaire provides a reliable measure of the quality of CME presentations, while also providing presenters with useful feedback. Further studies will investigate if this instrument can be used to assess other CME formats and how best to provide feedback to presenters.     

A probabilistic method to estimate the burden of maternal morbidity in resource-poor settings: preliminary development and evaluation

Background

Maternal morbidity is more common than maternal death, and population-based estimates of the burden of maternal morbidity could provide important indicators for monitoring trends, priority setting and evaluating the health impact of interventions. Methods based on lay reporting of obstetric events have been shown to lack specificity and there is a need for new approaches to measure the population burden of maternal morbidity. A computer-based probabilistic tool was developed to estimate the likelihood of maternal morbidity and its causes based on self-reported symptoms and pregnancy/delivery experiences. Development involved the use of training datasets of signs, symptoms and causes of morbidity from 1734 facility-based deliveries in Benin and Burkina Faso, as well as expert review. Preliminary evaluation of the method compared the burden of maternal morbidity and specific causes from the probabilistic tool with clinical classifications of 489 recently-delivered women from Benin, Bangladesh and India.

Results

Using training datasets, it was possible to create a probabilistic tool that handled uncertainty of women’s self reports of pregnancy and delivery experiences in a unique way to estimate population-level burdens of maternal morbidity and specific causes that compared well with clinical classifications of the same data. When applied to test datasets, the method overestimated the burden of morbidity compared with clinical review, although possible conceptual and methodological reasons for this were identified.

Conclusion

The probabilistic method shows promise and may offer opportunities for standardised measurement of maternal morbidity that allows for the uncertainty of women’s self-reported symptoms in retrospective interviews. However, important discrepancies with clinical classifications were observed and the method requires further development, refinement and evaluation in a range of settings.

     

Disability after encephalitis: development and validation of a new outcome score

Objective

To develop a simple tool for assessing the severity of disability resulting from Japanese encephalitis and whether, as a result, a child is likely to be dependent.

Methods

A new outcome score based on a 15-item questionnaire was developed after a literature review, examination of current assessment tools, discussion with experts and a pilot study. The score was used to evaluate 100 children in Malaysia (56 Japanese encephalitis patients, 2 patients with encephalitis of unknown etiology and 42 controls) and 95 in India (36 Japanese encephalitis patients, 41 patients with encephalitis of unknown etiology and 18 controls). Inter- and intra-observer variability in the outcome score was determined and the score was compared with full clinical assessment.

Findings

There was good inter-observer agreement on using the new score to identify likely dependency (Κ = 0.942 for Malaysian children; Κ = 0.786 for Indian children) and good intra-observer agreement (Κ = 1.000 and 0.902, respectively). In addition, agreement between the new score and clinical assessment was also good (Κ = 0.906 and 0.762, respectively). The sensitivity and specificity of the new score for identifying children likely to be dependent were 100% and 98.4% in Malaysia and 100% and 93.8% in India. Positive and negative predictive values were 84.2% and 100% in Malaysia and 65.6% and 100% in India.

Conclusion

The new tool for assessing disability in children after Japanese encephalitis was simple to use and scores correlated well with clinical assessment.     

Mothers' view on late postoperative pain management by the nursing team in children after cardiac surgery

Postoperative pain management in children is a complex, multidimensional and subjective phenomenon. It represents a challenge for children, parents and health professionals. This study aimed to understand how mothers assess their children's pain management by the nursing team in the late postoperative phase of cardiac surgery. Empirical data collection was carried out through semistructured interviews with 17 mothers who accompanied their children. Data were subject to qualitative analysis, revealing that, for the mothers, taking good care results from the confidence they vest in the nursing team and from the observation of the medication interventions this team performs. Not taking good care of their children is a consequence of lack of information or inadequate communication between the team and the mothers. The results of this study permit identifying aspects that strengthen and weaken nursing care for these clients, contributing to the improvement of the delivered care.     

The effect of nutritional status on morbidity after elective surgery for benign gastrointestinal disease

The effect of nutritional status on the morbidity and mortality of major gastrointestinal surgery for benign disease was studied in 32 patients. Malnutrition was defined as a serum albumin less than 3.5 g/dl and a recent weight loss greater than 10%, in addition to any two of the following: weight for height, midarm circumference or triceps skin-fold thickness less than 10th percentile. The morbidity and mortality in the 17 malnourished patients was 59% and 29%, respectively, compared with 20% and 7% in 15 well-nourished patients matched for age and operative procedure (p less than 0.05). After operation, the mean duration of inadequate oral nutritional intake period (IONIP, defined as a caloric intake greater than 60% requirement) was 11.9 days +/- 2.9 (SEM) in well-nourished patients compared with 30.5 days +/- 3.7 in the malnourished group. The longer IONIP in malnourished patients was a consequence of the higher morbidity in this group, thus warranting the consideration of supportive (postoperative) parenteral nutrition in malnourished patients who undergo major gastrointestinal surgery for benign disease.     

Surgical site infections in cardiac surgery after a hospital catastrophe

On 2 November 1999, one of the main hospital fa?ades adjoining cardiovascular surgery collapsed in a 900-bed teaching hospital in Santander, Spain. The purpose of this study was to determine whether the accident affected the safety of patients by increasing the risk for nosocomial and surgical site infections (SSI). Measures for the prevention of nosocomial infections were immediately reinforced. A total of 217 consecutive patients were operated on before 2 November 1999, with another 296 after this date. Patients in both study periods showed similar severity of illness, complexity of surgical procedure and length of hospital stay. The overall rate of nosocomial infection before and after the accident was 28.1% and 24.7%, respectively (P=0.381). The rates of respiratory infection, urinary infection and bacteraemia were also similar. A statistically significant reduction in the SSI rate in the second period was observed (14.8% vs 4.4%, P=0.008). The collapse of the fa?ade was not associated with any increase in nosocomial infection rates, but there was a significant reduction of SSI rates in relation to intensive infection control measures implemented after the collapse.