Transparency in a Pediatric Quality Improvement Collaborative: A Passionate Journey by NPC‐QIC Clinicians and Parents

Transparency—sharing data or information about outcomes, processes, protocols, and practices—may be the most powerful driver of health care improvement. In this special article, the development and growth of transparency within the National Pediatric Cardiology Quality Improvement Collaborative is described. The National Pediatric Cardiology Quality Improvement Collaborative transparency journey is guided by equal numbers of clinicians and parents of children with congenital heart disease working together in a Transparency Work Group. Activities are organized around four interrelated levels of transparency (individual, organizational, collaborative, and system), each with a specified purpose and aim. A number of Transparency Work Group recommendations have been operationalized. Aggregate collaborative performance is now reported on the public‐facing web site. Specific information that the Transparency Work Group recommends centers provide to parents has been developed and published. Almost half of National Pediatric Cardiology Quality Improvement Collaborative centers participated in a pilot of transparently sharing their outcomes achieved with one another. Individual centers have also begun successfully implementing recommended transparency activities. Despite progress, barriers to full transparency persist, including health care organization concerns about potential negative effects of disclosure on reputation and finances, and lack of reliable definitions, data, and reporting standards for fair comparisons of centers. The National Pediatric Cardiology Quality Improvement Collaborative's transparency efforts have been a journey that continues, not a single goal or destination. Balanced participation of clinicians and parents has been a critical element of the collaborative's success on this issue. Plans are in place to guide implementation of additional transparency recommendations across all four levels, including extension of the activities beyond the collaborative to support transparency efforts in national cardiology and cardiac surgery societies.     

Maxillary dentinogenic ghost cell tumour

Dentinogenic ghost cell tumours are extremely rare, and pose significant diagnostic and therapeutic challenges as this case clearly demonstrates. An awareness of different clinical presentations and distinct histopathological features is important in establishing an early definitive diagnosis and instituting appropriate management. Furthermore, there is little precedent in the literature to guide management in such a case, and we therefore consider this report to be noteworthy and instructive in this respect.     

Transanal surgery for obstructed defecation syndrome: Literature review and a single-center experience

Obstructed defecation syndrome (ODS) is a functional disorder commonly encountered by colorectal surgeons and gastroenterologists, and greatly affects the quality of life of patients from both societal and psychological aspects. The underlying anatomical and pathophysiological changes of ODS are complex. However, intra-rectal intussusception and rectocele are frequently found in patients with ODS and both are thought to play an important role in the pathogenesis of ODS. With the development of evaluation methods in anorectal physiology laboratories and radiology studies, a great variety of new operative procedures, especially transanal procedures, have been invented to treat ODS. However, no procedure has been proved to be superior to others at present. Each operation has its own merits and defects. Thus, choosing appropriate transanal surgical procedures for the treatment of ODS remains a challenge for all surgeons. This review provides an introduction of the current problems and options for treatment of ODS and a detailed summary of the essential assessments needed for patient evaluation before carrying out transanal surgery. Besides, an overview of the benefits and problems of current transanal surgical procedures for treatment of ODS is summarized in this review. A report of clinical experience of some transanal surgical techniques used in the authors’ center is also presented.     

Dermal type I collagen assessment by digital image analysis

Type I collagen is the main dermal component, and its evaluation is relevant to quantitative studies in dermatopathology. However, visual gradation (0 to 4+) has low precision and high subjectivity levels. This study aimed to develop and validate a digital morphometric analysis technique to estimate type I collagen levels in the papillary dermis. Four evaluators visually quantified (0 to 4+) the density of type I collagen in 63 images of forearm skin biopsies marked by immunohistochemistry and two evaluators analyzed the same images using digital morphometric techniques (RGB split colors (I) and color deconvolution (II)). Automated type I collagen density estimation in the papillary dermis (two techniques) were correlated with visual evaluations (Spearman''s rho coefficients of 0.48 and 0.62 (p<0.01)). With regard to the inter-observer repeatability, the four evaluators who used visual classification had an intraclass correlation coefficient (for absolute agreement) of 0.53, while the other two evaluators who used digital analysis (algorithm II) had an intraclass correlation coefficient of 0.97.     

Audit-induced change reduces complications of the Ganz trochanteric flip approach

INTRODUCTION

The Ganz trochanteric flip approach aims to avoid the potential risk of avascular necrosis in hip conserving surgery and may reduce the risk of femoral neck fractures, neck thinning and femoral head implant migration in hip resurfacing. Our initial audit revealed the complications of non-union and trochanteric screw irritation to be associated with this approach. We, therefore, modified our selection criteria and re-audited our results.

SUBJECTS AND METHODS

The initial audit (IA) ran between January 2003 and November 2007 after which an age limit of 50 years was recommended. The re-audit (RA) ran between November 2007 and December 2008 where one of the senior authors stopped using the approach in the over 50 year age group whilst the other senior author continued on selected patients over 50 years.

RESULTS

There were 545 hips in the IA and 152 hips in the RA group. The incidence of non-union decreased in the RA after the change of selection criteria (6.2% [IA] vs 1.3% [RA]). In both audit groups, the incidence of non-union increased with age, and in the RA no non-unions were observed under the age of 50 years. The incidence of screw irritation and the necessity for removal remained relatively unchanged (20.7% [IA] vs 28.3% [RA]) with a combined incidence of 22.4%.

CONCLUSIONS

The trochanteric flip approach to the hip can be used safely with an acceptable complication rate in young adult impingement and resurfacing surgery. Caution must, however, be exercised in patients over 50 years of age as they have a higher incidence of trochanteric non-union. In addition, all patients should be consented for the possibility of screw removal as a second procedure.