Breast Surgery Outcomes as Quality Measures According to the NSQIP Database

Background

The National Surgical Quality Improvement Program (NSQIP) is a risk-adjusted database designed to benchmark quality initiatives. NSQIP captures uniform morbidity variables for all operations and calculates expected morbidity probabilities. Given the frequent need for reoperation following breast-conserving surgery (BCS) and mastectomy, we hypothesized that NSQIP may inaccurately reflect surgical morbidity after breast cancer operations.

Methods

Using the 2008 NSQIP database, we identified 24,447 breast surgery patients. We calculated the observed versus expected (O/E) morbidity ratios, compared them to other general surgery procedures, and analyzed the O/E morbidity ratios among benign and malignant breast diagnoses.

Results

The NSQIP database shows that breast surgery has an O/E morbidity ratio of 3.11, which is higher than other general surgery procedures. Additionally, breast operations for malignancy have higher O/E morbidity ratios (3.22) than those performed for benign disease (2.59). Analysis of malignant patients by CPT code revealed that BCS patients had an O/E morbidity ratio of 7.75 and attributed 89?% of morbidity to reoperation, whereas mastectomy patients had an O/E morbidity ratio of only 1.7. Elimination of the reoperation variable from morbidity calculations in breast surgery reduces the O/E morbidity ratio to less than expected in all breast procedures.

Discussion

Breast surgery has a higher O/E morbidity ratio than other general surgery procedures. Reoperations are expected in BCS for positive margins and in mastectomy for completion ALND. Breast surgeons should advocate for benchmarking by surgical site-specific metrics, because current NSQIP criteria may negatively affect the quality assessment of high-volume breast centers.     

早产儿瘦素质量浓度与早期静脉营养及生长发育相关性探讨

目的探讨瘦素质量浓度与早期静脉营养及生长发育的关系。方法新疆医科大学第一 附属医院新生儿科于2005 01—2006 02，将收治的86例早产适于胎龄儿用随机数字表法分为观察组(早期微量喂养同时辅助胃肠外营养组)45 例和对照组(单纯早期微量喂养组)47例，分别测定脐血及第7天血清瘦素质量浓度，同时监测营养状况和生长发育指标，并作对比分析。结果 (1)观察组与对照组脐血瘦素质量浓度分别为(4.6±3.7)ng/mL、(4.8±2.2)ng/mL，生后第7天两组瘦素质量浓度分别为(4.3±2.2)ng/mL、(3.1 ±1.7)ng/mL。对照组第7天血清瘦素质量浓度明显低于脐血(P<0.05)，而观察组其差异无统计学意义(P>0.05)。(2)脐血瘦素质量浓度与出生体 重、胎龄成正相关(r=0.56、r=0.67)。(3)观察组第7天热卡及蛋白质摄入量、血清瘦素质量浓度、皮褶厚度变化值与对照组相比，差异有统计 学意义(P<0.05)。结论对早产儿应尽早喂养，同时需要胃肠外营养作为肠内营养的补充。瘦素可作为新生儿营养效果判定的实验室指标之一。     

Iotrol versus metrizamide in lumbar myelography: a double-blind study

In a prospective, randomized, double-blind study, 49 patients underwent lumbar myelography using iotrol (24 patients) or metrizamide (25 patients). The diagnostic imaging adequacy of iotrol was comparable with that of metrizamide. After iotrol myelography, adverse reactions were fewer, less severe, and of shorter duration than were those following metrizamide myelography. Thirteen of 24 patients (54%) receiving iotrol reported some adverse reactions compared with 24 of 25 patients (96%) receiving metrizamide. Five moderate and one severe adverse reaction occurred in the group receiving iotrol. Fourteen moderate and eight severe adverse reactions occurred in the group receiving metrizamide. Thirty-eight patients underwent electroencephalography both before and after myelography (19 iotrol and 19 metrizamide). None of the EEGs obtained after iotrol myelography changed from baseline, while seven of the EEGs obtained after metrizamide myelography showed changes from baseline. Iotrol was judged superior to metrizamide as a contrast medium in this patient population.     

The diagnostic dilemma of congenital unstable hemoglobinopathies

Unstable hemoglobin variants represent a rare etiology of congenital hemolytic anemia. Without a high index of suspicion, plus proper laboratory testing and interpretation, the correct diagnosis can be elusive. We report on five children who were initially thought to have other congenital disorders such as hereditary spherocytosis or thalassemia, before β‐globin gene sequencing led to the definitive diagnosis. Recognizing the variable clinical presentation and laboratory data reported will aid clinicians in diagnosis of unstable hemoglobins variants in children with atypical forms of hemolytic anemia, particularly those with low pulse oximetry values or whose hemoglobin electrophoresis suggest β‐thalassemia trait. Pediatr Blood Cancer. 2010;55:1393–1395. © 2010 Wiley‐Liss, Inc.     

Effects of dopaminergic medications on psychosis and motor function in dementia with Lewy bodies

Dopaminergic treatment in dementia with Lewy bodies (DLB) requires balancing risk of worsened psychosis and potential motor benefit. We assessed the effects of increased dopaminergic medication on psychosis and motor function in DLB. We studied 19 subjects fulfilling probable DLB Consensus criteria before and after increased dopaminergic medications. Standard clinical measures included: Thought Disorder score from the Unified Parkinson's disease Rating Scale (UPDRS) Part I, total motor score (UPDRS Part III), and Hoehn–Yahr (H&Y) stage. Motor benefit defined as >10% improvement over baseline UPDRS Part III score, occurred in only one‐third of subjects. In this group, worsened hallucinations or psychosis developed in one‐third. Considering motor benefit without exacerbation of psychosis as our aim, only 4 DLB subjects (22%) achieved this goal. Our results suggest that dopaminergic medications have limited benefit in DLB because of the low likelihood of motor improvement and the risk of psychosis exacerbation. © 2008 Movement Disorder Society     

Association of <Emphasis Type="Italic">RGS4</Emphasis> variants with schizotypy and cognitive endophenotypes at the population level

Background  

While association studies on schizophrenia show conflicting results regarding the importance of the regulator of the G-protein signaling 4 (RGS4) gene, recent work suggests that RGS4 may impact on the structural and functional integrity of the prefrontal cortex. We aimed to study associations of common RGS4 variants with prefrontal dependent cognitive performance and schizotypy endophenotypes at the population level.     

Osteosarcoma: use of MR imaging and MR spectroscopy in clinical decision making

Magnetic resonance (MR) imaging was performed on 14 patients with histologically proved osteosarcoma (mean age, 14.4 years). There was excellent correlation of intramedullary tumor extent as determined with MR imaging and pathologic examination (r = 99%). This was facilitated by the presence of a chemical shift artifact at the tumor-marrow interface on the T1-weighted images. The correlation between CT and pathologic findings was not as good (r = 84%). In a single patient, however, a 10-cm length of sclerotic bone was incorrectly interpreted as being tumor. If this case is excluded, the correlation between CT and pathologic findings improves significantly (r = 96%). T2-weighted images were optimal in demonstrating soft-tissue bulk and breach of the epiphysis or cortex. Vascular involvement was also readily defined. The T2 value of the tumor soft-tissue component decreased in patients who were deemed to have responded well to therapy. Two patients with very high T2 values after chemotherapy developed wide-spread metastatic disease and died. Phosphorus-31 MR spectroscopy of five patients with osteosarcoma showed elevated levels of phosphomonoesters (PMEs), inorganic phosphate (Pi), and phosphodiesters (PDEs). PME and PDE peak areas decreased in three patients after chemotherapy, while Pi peak areas increased.     

Evaluation of fine-needle aspiration biopsy in the diagnosis of renal transplant dysfunction

Fine-needle aspiration biopsy (FNAB) was performed in 41 renal transplant patients to assess its value in the diagnosis of the cause of graft dysfunction. The procedure was used on 71 occasions, and in each case a clinical diagnosis was made and compared with the cytological diagnosis made independently by a pathologist. When available, core biopsy histopathology was used to confirm the final diagnosis. Fifty-seven (80%) of the aspirates yielded adequate material. A clinical diagnosis of acute cellular rejection (ACR) was made in 21 patients, 18 (78%) of whom showed confirmatory immune activation on FNAB. The clinical diagnosis of either acute tubular necrosis (ATN) or cyclosporine toxicity was confirmed in 31 (91%) of 34 aspirates. In eight aspirates, the cytological diagnosis was different than that made clinically. Humorally mediated vascular rejection, and lymphocytosis secondary to causes other than rejection, such as viral infection, were considered as possible causes of this discrepancy. Provided that adequate samples are obtained. FNAB is valuable in the clinical management of renal transplant patients. Its accuracy should not be overestimated and the results obtained should be evaluated in the light of the overall clinical picture.