The Department of Veterans Affairs'' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program.

OBJECTIVE: To provide reliable risk-adjusted morbidity and mortality rates after major surgery to the 123 Veterans Affairs Medical Centers (VAMCs) performing major surgery, and to use risk-adjusted outcomes in the monitoring and improvement of the quality of surgical care to all veterans. SUMMARY BACKGROUND DATA: Outcome-based comparative measures of the quality of surgical care among surgical services and surgical subspecialties have been elusive. METHODS: This study included prospective assessment of presurgical risk factors, process of care during surgery, and outcomes 30 days after surgery on veterans undergoing major surgery in 123 medical centers; development of multivariable risk-adjustment models; identification of high and low outlier facilities by observed-to-expected outcome ratios; and generation of annual reports of comparative outcomes to all surgical services in the Veterans Health Administration (VHA). RESULTS: The National VA Surgical Quality Improvement Program (NSQIP) data base includes 417,944 major surgical procedures performed between October 1, 1991, and September 30, 1997. In FY97, 11 VAMCs were low outliers for risk-adjusted observed-to-expected mortality ratios; 13 VAMCs were high outliers for risk-adjusted observed-to-expected mortality ratios. Identification of high and low outliers by unadjusted mortality rates would have ascribed an outlier status incorrectly to 25 of 39 hospitals, an error rate of 64%. Since 1994, the 30-day mortality and morbidity rates for major surgery have fallen 9% and 30%, respectively. CONCLUSIONS: Reliable, valid information on patient presurgical risk factors, process of care during surgery, and 30-day morbidity and mortality rates is available for all major surgical procedures in the 123 VAMCs performing surgery in the VHA. With this information, the VHA has established the first prospective outcome-based program for comparative assessment and enhancement of the quality of surgical care among multiple institutions for several surgical subspecialties. Key features to the success of the NSQIP are the support of the surgeons who practice in the VHA, consistent clinical definitions and data collection by dedicated nurses, a uniform nationwide informatics system, and the support of VHA administration and managerial staff.     

The use of somatostatin and its analogs in the treatment of surgical disorders

Somatostatin is a naturally occurring peptide with a wide spectrum of biologic actions, most of which are inhibitory in nature. It has wide distribution, and within the gastrointestinal tract is is found in the pancreas, the stomach, intestinal mucosa, and myenteric neurons. It appears to function as a classic circulating hormone, as well as both a paracrine or locally acting agent and a neurocrine agent. Because of its inhibitory actions on gut endocrine, secretory, and motor functions, it has potential applicability in the treatment of a variety of disorders of interest to the surgeon. Indeed, it has been used successfully in the management of upper gastrointestinal hemorrhage, secretory diarrhea, short bowel syndrome, pancreatitis, gastrointestinal fistulas, and peptide-secreting tumors of the gut (apudomas). This review discusses physiology, pathophysiology, and therapeutic applications of somatostatin that may be important in surgical practice.     

Local recurrence after curative resection of rectal cancer: a comparison of low anterior resection and abdominoperineal resection

Local recurrence rates after either low anterior resection or abdominoperineal resection were compared in 109 patients undergoing curative surgery for adenocarcinoma of the rectum between 1979 and 1984. Follow-up information was available for 99 patients (91%). The overall recurrence rate was 19%; ten recurrences (26.3%) for low anterior resections and nine (14.7%) for abdominoperineal resections. (P less than .08). Recurrences were confirmed by biopsy or at reoperation. No significant difference in size of the lesion was evident at initial resection (average largest dimension 4.8 cm for low anterior and 5.5 cm for abdominoperineal resection). The average time to recurrence after resection was 18 months (16.5 months in the low anterior group vs. 19 months in the abdominoperineal group). Mean survival after recurrence was shorter for the abdominoperineal (3.4 months) as compared to the low anterior group (9.5 months) (P = .10). The overall median survival was 21 months (range 0-75 months) in both groups, and 38 patients were alive. Risk factors for recurrence were Dukes C lesions in patients who had a low anterior resection (8/18 or 44% recurrence) and poor histologic differentiation in patients who had either operation (3/6 or 50% recurrence).     

Appropriate use of medications for seizures. Guiding principles on the path of efficacy.

Selection of medication for treatment of seizures requires careful consideration and a multifactorial, individualized evaluation. First and foremost, the choice of a particular AED should be based on its efficacy against the seizure type or types or epilepsy syndrome being treated. Other factors, such as concomitant medical conditions, may also play a role in the type or dosage of medication prescribed. (For example, dosages of topiramate and levetiracetam should be adjusted in patients with renal impairment, and dosages of tiagabine should be adjusted in patients with liver dysfunction.) Other guidelines, discussed in detail in this article, can be applied irrespective of the particular drug chosen. Because the presence of epilepsy can have a significant bearing on quality of life, the decision to discontinue treatment should be made in congruence with the patient's needs, wishes, and commitments.     

Elevated serum prolactin level in the Zollinger-Ellison syndrome

To estimate the prevalence of prolactinoma in the Zollinger-Ellison syndrome (ZES), serum prolactin (PRL) levels were measured by radioimmunoassay in 36 patients with ZES. Eight patients had elevated PRL levels; however, in one patient the finding was attributed to primary hypothyroidism rather than a prolactinoma. The seven other patients were believed to have previously undiagnosed prolactinomas on the basis of elevated serum PRL levels; the presence of pituitary tumors were confirmed in four by demonstration of sella turcica erosions or enlargement. Serial determinations over three to six years showed a tendency for serum PRL levels to increase modestly in four of six patients. Thus far, two patients have undergone transsphenoidal tumor resections with good results. This study suggests that the prevalence of prolactinoma in patients with ZES is substantial (10% for those with isolated ZES and 54% for those with ZES with multiple endocrine neoplasia, type 1, syndrome), and that early diagnosis is possible with measurement of serum PRL levels. Since levels of PRL tend to increase and clinically significant pituitary tumors can develop, determinations of serial serum PRL levels are recommended for all patients with ZES.     

Colonic diverticulitis in patients under age 40: Need for earlier diagnosis

Despite a clinical presentation and physical findings consistent with diverticulitis, this diagnosis was considered only in one third of 37 patients under age 40. Barium enema was particularly valuable and presented no risk to the patients with an incorrect diagnosis of acute appendicitis. In the medically treated group, 7 of 17 patients required subsequent operation. Those who had emergency surgery had a high wound infection rate. The need to consider the diagnosis in patients under age 40 years is stressed.     

Influence of cisternal pressure on passage of neuropeptides from the cerebrospinal fluid into the peripheral circulation

Passage of neuropeptides from the cerebrospinal fluid to circulation depends upon cisternal pressure. When cisternal collecting pressure was kept at -20 cm, plasma levels of gastrin-17 and somatostatin-14 remained at basal values despite perfusion of high doses of the peptides into the cerebro-ventricular system. Progressive reduction of this pressure above -15 cm results in a progressive rise of the peripheral concentration of the peptides. Discrimination between central and peripheral action of centrally administered neuropeptides is, therefore, possible.