Focused Risk Analysis: Regression Model Based on 5,314 Total Hip and Knee Arthroplasty Patients from a Single Institution

We aimed to identify significant demographic, preoperative comorbidity and surgical predictors for major complications for use in the development of a risk prediction tool for a well-defined population as Total Joint Arthroplasty (TJA) patients. Data on 5314 consecutive patients who underwent primary total hip or knee arthroplasty from October 1, 2008 through September 30, 2011 at a single institution were used in a multivariate regression analysis. The overall incidence of a primary endpoint (reoperation during same admission, extended length of stay, and 30-day readmission) was 3.8%. Significant predictors include certain preexisting genitourinary, circulatory and respiratory conditions; ASA >2; advanced age and prolonged operating time. Mental health conditions demonstrate a strong predictive effect for subsequent serious complication(s) in TJA patients and should be included in a risk-adjustment tool.     

Management of low (favourable)-risk prostate cancer

What's known on the subject? and What does the study add? Most men who are diagnosed with favourable‐risk prostate cancer undergo some form of active intervention, despite evidence that treatment will not improve health outcomes for many. The decision to undergo treatment after diagnosis is, in part, related to the inability to precisely determine the long‐term risk of harm without treatment. Nevertheless, physicians should consider patient age, overall health, and preferences for living with cancer and the potential side effects of curative treatments, before recommending a management option. This is especially important for older men, given the high level of evidence that those with low‐risk disease are unlikely to accrue any benefit from curative intervention. What is known on the subject: Over treatment of favourable‐risk prostate cancer is common, especially among older men. What does the study add: A review of the natural history of favourable‐risk prostate cancer in the context of choices for management of the disease. ? The management of favourable‐risk prostate cancer is controversial, and in the absence of controlled trials to inform best practice, choices are driven by personal beliefs with resultant wide variation in practice patterns. ? Men with favourable‐risk prostate cancer diagnosed today often undergo treatments that will not improve overall health outcomes. ? A shared‐decision approach for selecting optimal management of favourable‐risk disease should account for patient age, overall health, and preferences for living with cancer and the potential side effects of curative treatments.     

Transplantation Risks and the Real World: What Does ‘High Risk’ Really Mean?

Candidates for, and recipients of, transplants face numerous risks that receive varying degrees of attention from the media and transplant professionals. Characterizations such as 'high risk donor' are not necessarily accurate or informative unless they are discussed in context with the other risks patients face before and after transplantation. Moreover, such labels do not provide accurate information for informed consent discussions or decision making. Recent cases of donor-transmitted diseases from donors labeled as being at 'high risk' have engendered concern, new policy proposals and attempts to employ additional testing of donors. The publicity and policy reactions to these cases do not necessarily better inform transplant candidates and recipients about these risks. Using comparative risk analysis, we compare the various risks associated with waiting on the list, accepting donors with various risk characteristics, posttransplant survival and everyday risks we all face in modern life to provide some quantitative perspective on what 'high risk' really means for transplant patients. In our analysis, donor-transmitted disease risks are orders of magnitude less than other transplantation risks and similar to many everyday occupational and recreational risks people readily and willingly accept. These comparisons can be helpful for informing patients and guiding future policy development.     

Genetic determinants of breast cancer risk: a review of current literature and issues pertaining to clinical application

Despite major advances in breast cancer therapy, annual mortality remains significant with a sizeable proportion of patients eventually succumbing to metastatic disease. Clearly, optimizing approaches for identification and management of women at heightened risk for breast cancer will reduce overall morbidity and mortality from the disease. Over the past few decades, advances in molecular genetics and linkage analyses have allowed for the identification of specific germline mutations underlying a significant fraction of hereditary breast cancer. Genome-wide association studies have been developed as a powerful tool in identifying lower penetrance mutations, and it is believed that such genome-level variations may act in concert to give rise to the majority of inherited breast cancer risk. Controversies and uncertainties remain in clinical application of newly identified genomic loci that confer genetic susceptibility. This article reviews the well-characterized breast cancer susceptibility genes, highlights recent publications pertaining to the less well known and lower penetrance genetic polymorphisms, summarizes challenges in translating research findings to the clinical scenario, and offers some recommendations for clinical practice.     

The center effect in liver transplantation in the Eurotransplant region: a retrospective database analysis

Apart from donor and recipient risk factors, the effect of center‐related factors has significant impact on graft survival after liver transplantation (LT). To investigate this effect in Eurotransplant, a retrospective database analysis was performed, including all LT's in adult recipients (≥18 years) in the Eurotransplant region from 1.1.2007 until 31.12.2013. Additionally, a survey was sent out to all transplant centers requesting information on surgeons’ experience and exposure. In total, 10 265 LT's were included (median follow‐up 3.3 years), performed in 39 transplant centers. Funnel plots showed significant differences in graft survival between the transplant centers. After correction for donor and recipient risk, with the Eurotransplant donor risk index (ET‐DRI) and the simplified recipient risk index (sRRI) and random effects, these differences diminished. Mean historical volume (in the preceding 5 years) was a significant (P < 0.001), nonlinear marker for graft survival in the multivariate analysis. This study demonstrates that funnel plots can be used for benchmarking purposes in LT. Case‐mix correction can be performed with the use of the ET‐DRI and sRRI. The center effect encompasses the entire complex process of preoperative workup, operation to follow‐up.     

老年病人手术风险评估

已步入老龄化社会,接受外科手术的老年病人通常合并多种长期慢性疾病、营养不良、多器官功能受损或功能障碍,这些老年病人往往要接受一次或多次的择期、限期或急诊外科手术.为保证手术治疗成功,外科医师面临着更高的要求和挑战.因此,通过手术前评估作好手术病人的生理和心理准备至关重要.     

Environmental risk factors in the history of male patients of an infertility clinic

Summary: 93 consecutive patients attending our andrologic department for marital infertility were asked for possible environmental risk factors including traumata, heat, nois, smoking, radiation, micro waves, pesticides, and plastics. The data were correlated to the mean seminal parameters. No signifcant differences were found between patients being positive for a certain risk factor and those being negative.
Zusammenfassung: Umweltbedingte Risikofaktoren in der Geschichte männlicher Patienten in einer Klinik für Infertilität
93 unausgewählte Patienten, die unsere andrologische Sprechstunde wegen Infertilität aufsuchten, wurden nach möglichen Umweltbelastungen (Traumata, Wärme, Lärm, Rauchen, Bestrahlungen, Mikrowellen, Pestizide, Kunststoffe) in der Ana-mnese befragt. Die Angaben wurden mit den mittleren Ejakulatparametern verglichen. Signifikante Unterschiede zwischen Patientengruppen mit Angaben bestimmter Belastun-gen und ohne diese wurden nicht gefunden.     

Failure modes and effects analysis for testicular sperm extraction management process

Failure modes and effects analysis (FMEA) is a proactive risk evaluation to identify and reduce potential failures that may occur during a procedure within a quality management programme. One of the procedures performed in assisted reproduction technology centres is testicular sperm extraction (TESE) as treatment of azoospermic patients. To examine the risks associated with the ‘TESE management’ process, we applied the FMEA method, before and after implementation of corrective measures defined in a standard operative procedure (SOP). A multidisciplinary team was formed. Possible causes of failures and their potential effects were identified, and risk priority number (RPN) for each failure was calculated. The FMEA team identified 4 process activities, 19 process steps and 19 potential failure modes. The re-evaluation after the corrective measures disclosed a reduction in the number of phases with high/moderate risk (pre-SOP: n = 13; post-SOP: n = 3). Improvements in the traceability system removed 11 out of 13 (85%) steps with a low risk of occurrence. In our experience, FMEA is efficient in helping multidisciplinary groups to strengthen knowledge and awareness on routine processes, identifying critical steps and planning practical improvements for a better compliance with criteria of traceability and conformity of biological samples and patients.     

Male Gender Impact on the Outcome of Laparoscopic Cholecystectomy

Background and Objectives:

Our aim was to assess the impact of male gender on the outcomes of laparoscopic cholecystectomy by eliminating associated risk factors for conversion.

Methods:

A quantitative comparative study was set up on the background of our null hypothesis that male gender has no impact on the outcomes of laparoscopic cholecystectomy. We performed a retrospective study of 241 patients and recorded the duration of surgery, length of postoperative hospital stay, conversion rate, and procedure-specific complications. Risk factors for conversion were excluded. Inferential statistics were applied, and a 2-sided P value of < .05 was considered the cutoff point to indicate the amount of evidence against the null hypothesis. We used SPSS for Windows, version 12 (IBM, Armonk, New York). Parametric data were analyzed with the independent-samples t test, and nonparametric data were analyzed with the χ² test.

Results:

A total of 175 women (72.6%) and 66 men (27.4%) underwent laparoscopic cholecystectomy. The mean age was 51.4 ± 14.8 years for women and 55 ± 12.7 years for men (P = .08). Women had a higher body mass index (28.4 ± 4.5) than men (26.8 ± 3.5) (P < .005). There were no statistically significant differences in the conversion rate and perioperative morbidity rate. The conversion rate was 2.9% for women and 7.5% for men (P = .142); the morbidity rate was 10.2% and 12.1%, respectively (P = .66). The mean duration of surgery was longer in men, at 67.9 ± 27.8 minutes, than in women, at 56.5 ± 23.98 minutes (P < .002). Both genders had an equal length of postoperative hospital stay, with 1.9 ± 1.8 days for men and 1.9 ± 2.1 days for women (P = .8).

Conclusions:

Male gender has no impact on the outcomes of laparoscopic cholecystectomy. Gender affects the duration of surgery. Larger-scale studies may disclose the factors responsible for variations in the operative time.     

Community-dwelling seniors who present to the emergency department with a fall do not receive Guideline care and their fall risk profile worsens significantly: a 6-month prospective study

Introduction Fall risk is a major contributor to fracture risk; implementing fall reduction programmes remains a challenge for health professionals and policy-makers. Materials and methods We aimed to (1) ascertain whether the care received by 54 older adults after an emergency department (ED) fall presentation met internationally recommended ‘Guideline Care’, and (2) prospectively evaluate this cohort’s 6-month change in fall risk profile. Participants were men and women aged 70 years or older who were discharged back into the community after presenting to an urban university tertiary-care hospital emergency department with a fall-related complaint. American Geriatric Society (AGS) guideline care was documented by post-presentation emergency department chart examination, daily patient diary of falls submitted monthly, patient interview and physician reconciliation where needed. Both at study entry and at a 6-month followup, we measured participants physiological characteristics by Lord’s Physiological Profile Assessment (PPA), functional status, balance confidence, depression, physical activity and other factors. Results We found that only 2 of 54 (3.7%) of the fallers who presented to the ED received care consistent with AGS Guidelines. Baseline physiological fall risk scores classified the study population at a 1.7 SD higher risk than a 65-year-old comparison group, and during the 6-month followup period the mean fall-risk score increased significantly (i.e. greater risk of falls) (1.7±1.6 versus 2.2±1.6, p=0.000; 29.5% greater risk of falls). Also, functional ability [100 (15) versus 95 (25), p=0.002], balance confidence [82.5 (44.4) versus 71.3 (58.7), p=0.000] and depression [0 (2) versus 0 (3), p=0.000] all worsened over 6 months. Within 6 months of the index ED visit, five participants had suffered six fall-related fractures. Discussion We conclude that this group of community-dwelling fallers, who presented for ED care with a clinical profile suggesting a high risk of further falls and fracture, did not receive Guideline care and worsened in their fall risk profile by 29.5%. This gap in care, at least in one centre, suggests further investigation into alternative approaches to delivering Guideline standard health service.     

Quantitative risk assessment of African swine fever virus introduction to Japan via pork products brought in air passengers’ luggage

The spread of African swine fever (ASF) has reached pandemic levels over the last decade, and outbreaks of this disease in China, Mongolia, Vietnam and Cambodia in 2018 and 2019 could accelerate its transmission to neighbouring Asian territories. Thus, the risk that the ASF virus (ASFV) will be introduced to disease‐free territories increases each year. Since Japan is an island nation, the most likely way in which ASFV would be introduced is via pork products brought in air passengers’ luggage (PPAP). Therefore, in the present study, we assessed the risk of ASFV introduction to Japan via PPAP. For the purposes of this analysis, we considered 214 international commercial flights travelling from 47 origin territories to 31 destination airports as potential routes of ASFV introduction via PPAP. The risk was estimated quantitatively through a stochastic model that considered the volume of air passengers’ luggage, the amount of confiscated pork products that were carried in air passengers’ luggage and the disease status of the origin territory. The overall mean annual probability of ASFV introduction to Japan via PPAP was found to be 0.941 [95% confidence interval (CI), 0.661–1.000], which approximately corresponds to one introduction every 1.06 years. At the origin territory level, Mongolia was led as the highest risk territory, with a risk of 0.864 (95% CI, 0.434–1.000), followed by China (0.697; 0.223–0.999), Vietnam (0.662; 0.196–0.998) and the Russian Federation (0.136; 0.018–0.401). At the destination airport level, Narita International Airport had the highest risk (0.905; 0.537–1.000), followed by Kansai International Airport (0.496; 0.109–0.961), Tokyo International Airport (0.389; 0.072–0.879) and Chubu Centrair International Airport (0.338; 0.058–0.816). This information will help improve risk management activities and monitoring systems to prevent the introduction of ASFV to Japan.