Using National Medical Care Survey data to validate examination content on a performance-based clinical skills assessment for osteopathic physicians

Patient characteristics, chief complaints, and diagnoses can be used to specify the examination content for performance-based assessments of clinical skills. The purpose of this investigation was to explore osteopathic and allopathic medical practice patterns and to provide summary statistics that can be used to delimit potential assessment content areas for a clinical skills assessment targeted at osteopathic physicians. Analyses of the National Ambulatory Medical Care Survey indicated that the types of patients seen by osteopathic and allopathic physicians in office-based settings are somewhat different. Furthermore, the reasons that patients seek care, and accompanying diagnostic outcomes, can vary by physician type. These differences suggest that from a content perspective, a performance-based clinical skills evaluation targeted at osteopathic physicians should be characteristically different from one designed for allopathic physicians.     

Using modified Delphi method to propose and validate the components of a child injury surveillance system for Iran

Purpose: Child injuries are a public health concern globally. Injury surveillance systems (ISSs) have beneficial impact on child injury prevention. There is a need for evidence-based consensus on frameworks to establish child ISSs. This research aims to investigate the key components of a child ISS for Iran and to propose a framework for implementation.Methods: Data were gathered through interview with experts using unstructured questions from January 2017 to December 2018 to identify child ISS functional components. Qualitative data were analyzed using content analysis method. Then, modified Delphi method was used to validate the functional components. Based on the outcomes of the content analysis, a questionnaire with closed questions was developed andpresented to a group of experts. Consensus was achieved in two rounds.Results: In round I, 117 items reached consensus. In round II, 5 items reached consensus and were incorporated into final framework. Consensus was reached for 122 items comprising the final framework and representing 7 key components: goals of the system, data sources, data set, coalition of stakeholders, data collection, data analysis and data distribution. Each component consisted of several subcomponents and respective elements.Conclusion: This agreed framework will assist in standardizing data collection, analysis and distribution,which help to detect child injury problems and provide evidence for preventive measures.     

慢性前列腺炎综合征病人NIH-CPSI问卷分析

目的 :探讨NIH CPSI对慢性前列腺炎综合征的临床价值。　方法 :应用NIH CPSI问卷 ,随机对 2 2 7例慢性前列腺炎综合征 (CPS) /慢性盆腔疼痛综合征 (CPPS ,包括ⅢA和ⅢB)和 32例良性前列腺增生 (BPH)进行观察。结果 :①CPS病人的主要症状表现为疼痛或不适 ,明显多于BPH病人 ;② 79.30 %CPS病人有排尿不尽 ,而排尿后 2h以内又有尿意为 4 4 .93% ;③ 5 1.5 1%CPS病人因慢性前列腺炎症状影响工作 ,90 .31%的病人影响业余生活 ,6 8.72 %的病人影响生活质量 ,与BPH病人比较 ,明显影响CPS病人的生活质量。　结论 :应用NIH CPSI问卷观察CPS ,表明CPS病人的主要症状是疼痛或不适 ,且对工作与生活质量有明显的影响     

Using the 6-minute walk test to predict disability-free survival after major surgery

Background

The 6-min walk test (6MWT) is a common means of functional assessment. Its relationship to disability-free survival (DFS) is uncertain.

Using tumor markers to predict the survival of patients with metastatic renal cell carcinoma

PURPOSE: Approximately 30% of renal cell carcinomas (RCCs) present as metastatic disease. Molecular markers have the potential to characterize accurately the biological behavior of tumors and they may be useful for determining prognosis. MATERIALS AND METHODS: A custom tissue array was constructed using clear cell RCC from 150 patients with metastatic RCC who underwent nephrectomy prior to immunotherapy. The tissue array was stained for 8 molecular markers, namely Ki67, p53, gelsolin, carbonic anhydrase (CA)9, CA12, PTEN (phosphatase and tensin homologue deleted on chromosome 10), epithelial cell adhesion molecule and vimentin. Marker status and established clinical predictors of prognosis were considered when developing a prognostic model for disease specific survival. RESULTS: On univariate Cox regression analysis certain markers were statistically significant predictors of survival, namely CA9 (p <0.00001), p53 (p = 0.0072), gelsolin (p = 0.030), Ki67 (p = 0.036) and CA12 (p = 0.043). On multivariate Cox regression analysis that included all markers and clinical variables CA9 (p = 0.00002), PTEN (p <0.0001), vimentin (p = 0.0032), p53 (p = 0.028), T category (p = 0.0025) and performance status (p = 0.0013) were significant independent predictors of disease specific survival and they were used to construct a combined molecular and clinical prognostic model. The bias corrected concordance index (C-index) of this combined prognostic model was C = 0.68, which was significantly higher (p = 0.0033) than that of a multivariate clinical predictor model (C = 0.62) based on the UCLA Integrated Staging System (T category, histological grade and performance status). CONCLUSIONS: In patients with clear cell RCC a prognostic model for survival that includes molecular and clinical predictors is significantly more accurate than a standard clinical model using the combination of stage, histological grade and performance status.     

Expansion of the Kidney Donor Pool by Using Cardiac Death Donors with Prolonged Time to Cardiorespiratory Arrest

Donation after Cardiac Death (DCD) is an increasingly important source of kidney transplants, but because of concerns of ischemic injury during the agonal phase, many centers abandon donation if cardiorespiratory arrest has not occurred within 1 h of controlled withdrawal of life‐supporting treatment (WLST). We report the impact on donor numbers and transplant function using instead a minimum ‘cut‐off’ time of 4 h. The agonal phase of 173 potential DCD donors was characterized according to the presence or absence of: acidemia; lactic acidosis; prolonged (>30 min) hypotension, hypoxia or oliguria, and the impact of these characteristics on 3‐ and 12‐month transplant outcome evaluated by multivariable regression analysis. Of the 117 referrals who became donors, 27 (23.1%) arrested more than 1 h after WLST. Longer agonal‐phase times were associated with greater donor instability, but surprisingly neither agonal‐phase instability nor its duration influenced transplant outcome. In contrast, 3‐ and 12‐month eGFR in the 190 transplanted kidneys was influenced independently by donor age, and 3‐month eGFR by cold ischemic time. DCD kidney numbers are increased by 30%, without compromising transplant outcome, by lengthening the minimum waiting time after WLST from 1 to 4 h.     

Using the Veterans Administration National Surgical Quality Improvement Program to improve patient outcomes

BACKGROUND: The primary goal of collecting quality assurance data is to ultimately improve patient care. The VA National Surgical Quality Improvement Program (NSQIP) provides each station with risk-adjusted morbidity and mortality data on a regular basis. This report of one medical center's use of the risk-adjusted data shows how it can be used to improve patient care. MATERIALS AND METHODS: Risk-adjusted surgical outcome data for Fiscal Year 1996 (FY96) was received from the NSQIP coordinating center. The Salt Lake City VA medical center was identified as a high outlier for morbidity in general surgery. Patient charts were reviewed and data analyzed to determine practice patterns and to determine if there were any provider issues. Data analysis revealed a large number of wound complications and uncovered a practice pattern of closure of contaminated wounds. Using these data and data from the literature, wound infection and disruption prevention protocols were instituted in the fall of 1997. Wound complications from January to December 1996 (preprotocol) and January to December 1998 (postprotocol) were compared using Student's t test. RESULTS: The total number of operations in 1998 was 719 compared with 634 in 1996. Superficial wound infections dropped from 3.6 to 1.7%, while overall wound complications dropped from 5.5 to 2.9%. None of these changes were statistically significant. CONCLUSIONS: Although introduction of wound infection and disruption prevention protocols did not result in a statistically significant decrease in wound complication, it did result in a clinically significant improvement in patient care.     

Competing risks survival analysis applied to data from the Australian Orthopaedic Association National Joint Replacement Registry

Background and purpose

The Kaplan-Meier (KM) method is often used in the analysis of arthroplasty registry data to estimate the probability of revision after a primary procedure. In the presence of a competing risk such as death, KM is known to overestimate the probability of revision. We investigated the degree to which the risk of revision is overestimated in registry data.

Patients and methods

We compared KM estimates of risk of revision with the cumulative incidence function (CIF), which takes account of death as a competing risk. We considered revision by (1) prosthesis type in subjects aged 75–84 years with fractured neck of femur (FNOF), (2) cement use in monoblock prostheses for FNOF, and (3) age group in patients undergoing total hip arthroplasty (THA) for osteoarthritis (OA).

Results

In 5,802 subjects aged 75–84 years with a monoblock prosthesis for FNOF, the estimated risk of revision at 5 years was 6.3% by KM and 4.3% by CIF, a relative difference (RD) of 46%. In 9,821 subjects of all ages receiving an Austin Moore (non-cemented) prosthesis for FNOF, the RD at 5 years was 52% and for 3,116 subjects with a Thompson (cemented) prosthesis, the RD was 79%. In 44,365 subjects with a THA for OA who were less than 70 years old, the RD was just 1.4%; for 47,430 subjects > 70 years of age, the RD was 4.6% at 5 years.

Interpretation

The Kaplan-Meier method substantially overestimated the risk of revision compared to estimates using competing risk methods when the risk of death was high. The bias increased with time as the incidence of the competing risk of death increased. Registries should adopt methods of analysis appropriate to the nature of their data.Arthroplasty registries typically present results of joint replacement in terms of the Kaplan-Meier (KM) estimates of the survival of the primary prosthesis. The estimates are interpreted as the probability of the prosthesis surviving until a nominated time after implantation. Alternatively, a registry may quote the complement (in probability) of the KM survivorship function. In the Australian Orthopaedic Association National Joint Replacement Registry (AOA NJRR) (AOANJRR 2009), this latter measure of revision is termed the “cumulative per cent revision” (CPR).A registry follows up patients from the date of the primary procedure until the date of statistical analysis. The observation time of a patient who has undergone a primary procedure but who has not had a revision by the date of analysis is said to be right censored at that date. We do not know when, in the future, that patient may undergo a revision. All we know is that it has not happened yet, and the KM method takes that into account using all the information on that patient up until the date of censoring. Crucially, the KM method assumes that patients whose time is censored will have the same chance of revision at any subsequent time as those whose time is not censored. In a sense, censoring is an inconvenience that prevents us from seeing what may happen in the future.The problem with the use of the KM method in the analysis of registry data is that deaths are handled in exactly the same way: the patient''s follow-up time is right censored at the time of death. However, death differs from censoring in that it does not merely conceal the occurrence of a future revision, it changes the probability of revision occurring. Essentially, under the KM method we are assuming that dead patients will have the same chance of eventually having a revision as those still living.When a patient is at risk of experiencing multiple events, with each precluding the other events or altering the probability of occurrence of the other events, these events are called competing risks (Gooley et al. 1999). Death changes the probability of a patient''s prosthesis being revised and is said to be a competing risk for revision, the event of interest. Similarly, revision is a competing risk to death as it precludes the occurrence of death as a first event.The above mentioned problem with the KM method has sometimes been approached by pretending that the competing event, in this case death, can be removed and by assuming that the revision rate is unaffected by this. However, since it is impossible to know from the data at hand how removing one outcome would affect the outcome of the other event(s), this is purely speculative (Prentice et al. 1978, Andersen et al. 2002). Furthermore, since there is a negative correlation between the likelihood of undergoing a revision and death, the 2 events are not independent. The implication of the violation of the KM assumptions is that the KM estimates in the presence of competing risks do not have a meaningful probability interpretation (Andersen et al. 2002); that is, the KM estimate of revision is not a valid estimate of the probability of revision assuming that the patient does not die. Kalbfleisch and Prentice (1980) have developed a method for estimating the probability of revision in the competing risks situation, based on a measure called the cumulative incidence function (CIF). The CIF for revision at any time depends on both the number of patients who have been revised and the number of patients who have not experienced any event (death or revision) by that time. Hence, when the CIF is used to estimate the probability of revision, the probability of death is taken into account. Patients who have neither died nor been revised by the date of analysis are treated as right censored, just as with the KM method.In the presence of a competing risk such as death, the standard KM method will always overestimate the true revision rate (Biau et al. 2007, Putter et al. 2007). If the death rate is low, then the bias in estimating the risk of revision using KM is small. But in elderly and frail patients, or in registry data where long-term observation is the goal, the competing risk of death becomes greater and the magnitude of the KM overestimate of revision will become more substantial.In this study, we applied methods of competing risk to data from large cohorts of patients in the AOA National Joint Replacement Registry and contrasted the results with those obtained from the standard Kaplan-Meier method.     

Analyzing the Impact of Compliance with National Guidelines for Pancreatic Cancer Care Using the National Cancer Database

Importance

Management of pancreatic cancer is complex, requiring coordination of multiple providers. National Comprehensive Cancer Network guidelines, developed for standardization and quality improvement, recommend a multimodal approach.

Objective

This study analyzed national rates of compliance with National Comprehensive Cancer Network recommendations, assessed factors affecting compliance, and evaluated whether compliance with evidence-based guidelines improved overall survival.

Design

This is a retrospective review of adults diagnosed with pancreatic cancer entered into the National Cancer Database. Patients included had stage I and II pancreatic cancer, and complete data in the database. Patients were classified as compliant if they underwent both surgery and a second treatment modality (chemotherapy, radiation, or chemoradiation). Clinico-pathologic variables were analyzed using univariate and multivariate models to predict overall survival.

Setting

Hospital-based national study population.

Participants

Patients with stage I or II pancreatic cancer.

Main Outcomes and Measures

Compliance with National Comprehensive Cancer Network recommendations, factors affecting compliance, and overall survival based on compliance.

Results

A total of 52,450 patients were included; 19,272 patients (37%) were compliant. Patients were found to be most compliant in the 50–59-year-old range (49% complaint), with decreased compliance at the extremes of age. Male patients were more compliant than female patients (39 vs 34%, p?<?0.0001). Caucasians were more compliant (39%) than African Americans (32%) or other races (32%, p?<?0.0001). Patients treated at academic/research centers were more compliant than patients treated at other facilities (39% compliant, p?<?0.0001). Patients with stage II disease were more compliant compared with stage I disease (43 vs 18%, p?<?0.0001). Compliance was shown to improve overall survival (p?<?0.0001).

Conclusion

Adherence to National Comprehensive Cancer Network guidelines for pancreatic cancer patients improves survival. Compliance nationwide is low, especially for older patients and minorities and those treated outside academic centers. More studies will need to be performed to identify factors that hinder compliance.

     

The Italian version of the National Institutes of Health Chronic Prostatitis Symptom Index

OBJECTIVES: To perform the Italian version of the National Institutes of Health Chronic Prostatitis Symptom Index (NHI-CPSI), and to study its linguistic validity and its correlations with the Visual Analogue Scale for pain (VAS) and the Italian version of International Prostatic Symptom Score (I-PSS) in men with chronic pelvic pain syndrome (CPPS) and healthy controls. METHODS: A rigorous double-back translation of the original English NHI-CPSI was performed by a staff composed of 3 professional bilingual experts and 3 urologists. The study population consisted of 160 male CPPS patients and 125 healthy controls, who were asked to self complete the Italian version of the NHI-CPSI together with the VAS and the Italian I-PSS. The discriminatory power, psychometric properties, internal correlations and convergent validity of the questionnaire were tested. RESULTS: Of the 285 enrolled patients, 223 patients (142 with CPPS and 81 healthy patients) were definitively considered for the study. The overall Italian NIH-CPSI scores and each subscale differed significantly (p<0.001) between the two groups, and so that the index proved a good discriminant validity. High correlations were found between the VAS and the pain domain (0.88) and between I-PSS and void domain (0.94), suggesting a good convergent validity of the Italian version of the NIH-CPSI. The questionnaire proved to have a high internal consistency. CONCLUSIONS: The Italian NIH-CPSI is a reliable symptom index that can be self-administrated in about 5 minutes in daily clinical practice for the follow-up of the Italian patients with chronic prostatitis.     

National Surgical Quality Improvement Program (NSQIP) risk factors can be used to validate American Society of Anesthesiologists Physical Status Classification (ASA PS) levels

OBJECTIVE: The purpose of this study was to determine the relationship between the American Society of Anesthesiologists' Physical Status (ASA PS) classifications and the other National Surgical Quality Improvement Program (NSQIP) preoperative risk factors. BACKGROUND: The ASA PS has been shown to predict morbidity and mortality in surgical patients but is inconsistently applied and clinically imprecise. It is desirable to have a method for validating ASA PS classification levels. METHODS: The NSQIP preoperative risk factors, including ASA PS, were recorded from a random sample of 5878 surgical patients on 6 services between October 1, 2001 and September 30, 2003 at the University of Kentucky Medical Center. Mortality, morbidity, costs, and length of stay were obtained and compared across ASA PS levels. The ability of 1) ASA PS alone, 2) the other NSQIP risk factors, and, 3) all factors combined to predict outcomes was analyzed. A model using the other NSQIP risk factors was developed to predict ASA PS. RESULTS: ASA PS alone was a strong predictor of outcomes (P < 0.01). However, the other NSQIP risk factors were better predictors as a group. There was significant interdependence between the ASA PS and the other NSQIP risk factors. Predictions of ASA PS using the other factors showed strong agreement with the anesthesiologists' assignments. CONCLUSIONS: The NSQIP risk factors other than ASA PS can and should be used to validate ASA PS classifications.     

带第二掌背动脉及神经的食指背侧皮瓣修复虎口挛缩

探讨用带第２掌背动脉及神经的示指侧皮瓣修复虎口重度挛缩。方法：切取带第２掌背动脉及神经的示指背侧皮瓣,皮瓣以第２、３掌骨基底部连线的中占与示指近指间关节桡侧中点的斜形连线为皮瓣轴线,以第２、３掌骨基底部连线中点为旋转点,临床应用８例。结果：８例皮瓣完全成活,皮瓣薄,外形美观,感觉良好,拇指外展,对掌功能正常,经２掌指关节活动良好。结论此方法效果呆靠,满意损伤小,手术操作简便易行,切取范围大。