Assessing Reliability of Medical Record Reviews for the Detection of Hospital Adverse Events

Objectives:

The purpose of this study was to assess the inter-rater reliability and intra-rater reliability of medical record review for the detection of hospital adverse events.

Methods:

We conducted two stages retrospective medical records review of a random sample of 96 patients from one acute-care general hospital. The first stage was an explicit patient record review by two nurses to detect the presence of 41 screening criteria (SC). The second stage was an implicit structured review by two physicians to identify the occurrence of adverse events from the positive cases on the SC. The inter-rater reliability of two nurses and that of two physicians were assessed. The intra-rater reliability was also evaluated by using test-retest method at approximately two weeks later.

Results:

In 84.2% of the patient medical records, the nurses agreed as to the necessity for the second stage review (kappa, 0.68; 95% confidence interval [CI], 0.54 to 0.83). In 93.0% of the patient medical records screened by nurses, the physicians agreed about the absence or presence of adverse events (kappa, 0.71; 95% CI, 0.44 to 0.97). When assessing intra-rater reliability, the kappa indices of two nurses were 0.54 (95% CI, 0.31 to 0.77) and 0.67 (95% CI, 0.47 to 0.87), whereas those of two physicians were 0.87 (95% CI, 0.62 to 1.00) and 0.37 (95% CI, -0.16 to 0.89).

Conclusions:

In this study, the medical record review for detecting adverse events showed intermediate to good level of inter-rater and intra-rater reliability. Well organized training program for reviewers and clearly defining SC are required to get more reliable results in the hospital adverse event study.     

Expression of VEGF,EGFR, and IL-6 in Gastric Adenomas and Adenocarcinomas by Endoscopic Submucosal Dissection

Background  

The degree of intratumoral microvascular density is thought to affect tumor metastasis and prognosis in various human cancers, including gastric cancer. Despite recent medical advancements, gastric adenoma or adenocarcinoma remains a considerable therapeutic challenge. Endoscopic submucosal dissection (ESD) is a more recent approach that is now commonly used for radical resection of gastric adenoma and adenocarcinoma.     

Calf-Contouring Surgery of Gastrocnemius Hypertrophy: Selective Neurectomy of the Sural Nerve

Generally, Asians tend to have obese calves that are shorter and thicker than those of Caucasians. The cause of the enlarged calves is either an excess of subcutaneous fat or calf muscular hypertrophy, but some patients have both conditions. These features are accentuated by the contraction of the calf muscles when patients stand in tiptoe position or wear high heels. In the case of calf muscular hypertrophy without excessive subcutaneous fat, manipulation of the calf muscle is an effective method for reducing calf circumference. From January 2005 to December 2006, the authors performed selective sural neurectomy for 20 patients who complained of obese calves. Using a popliteal incision, the sural nerve branches to the medial and/or lateral gastrocnemius muscles were dissected from the posterior tibial nerve. Using a nerve stimulator, the branches with the most contractile portions were resected in 1 cm lengths at the distal ends. One medial branch was resected in 15 patients, and two branches were resected in 5 patients. In the case of a lateral neurectomy, only one branch was resected. Ultrasound-assisted liposuction was combined for five patients who also showed excessive subcutaneous fat. The patients ranged in age from 19 to 29 years (mean, 23 years). The follow-up period varied from 6 to 18 months. The circumferential change was checked 6 months postoperatively 15 cm below the medial condyle and 15 cm above the medial malleolus. These average circumferences were reduced, respectively, from 36.6 and 32.5 cm to 35.5 and 32.2 cm. In gait analysis performed at 6 months postoperatively, the calf muscle power was slightly reduced to 95% of the preoperative state, but still remained above the normal range. Subjectively, no patient complained of muscle weakness or gait disturbance. One patient showed lower leg edema after mountain climbing that subsided after 1 day of rest. The authors believe a selective neurectomy technique can be an effective method for treating obese calves.     

Chronologically different incidences of post-transplant malignancies in renal transplant recipients: single center experience

The incidence of malignancy in transplant recipients is known to be higher than the same in the general population. However, the types of malignancies vary geographically, and the relative risks (RR) for malignancy in transplant recipients, compared with that of the general population, also differ country-by-country. In this study, we investigated the incidence and characteristics of malignancies after renal transplantation in a single center. A total of 2630 renal recipients who underwent surgery between April 1979 and June 2007 were enrolled in this study. The cumulative and interval incidences of malignancies were calculated for every 3 years post-transplantation. One-hundred ninety cases of postrenal transplant malignancies among 177 recipients (6.73%) were reported until 2007. The post-transplant malignancies were detected from 6 to 290 months after transplantation, with a mean duration of 112.6 ± 66.0 months. Skin cancer [35 (18.4%)] was the most common post-transplant malignancy, followed by thyroid [25 (13.2%)], stomach [22 (11.6%)], colorectal [22 (11.6%)], and urologic cancers [19 (10.0%)]. As the post-transplant period increased, the interval incidence of malignancy correspondingly increased. Virus-related malignancies, such as Kaposi's sarcoma and cervical cancer, developed earlier within the post-transplant period, while urologic cancer, colorectal cancer developed late in the post-transplant period. The recipient's age at the time of transplantation was the sole independent risk factor for post-transplant malignancy based on the multivariate analysis (RR = 2.723, P  < 0.0001 in the >50-year-old age group). We should establish strategies for post-transplant malignancy-screening based on the recipient's age at the time of transplantation, the post-transplant interval, and the national trend of post-transplant malignancy.     

Characterization of a profile of the anthocyanins isolated from Vitis coignetiae Pulliat and their anti-invasive activity on HT-29 human colon cancer cells

We isolated anthocyanins from fruits of Vitis coignetiae Pulliat, characterized the anthocyanin profile, and investigated the anti-invasive effects of the anthocyanins on human colon cancer cells. The anthocyanins inhibited cell invasion in a dose-dependent manner, as measured by Matrigel invasion assays, by suppression of matrix metalloproteinase (MMP)-2 and MMP-9 expression. The anti-invasive activity of the anthocyanins was associated with modulation of constitutive nuclear factor κB (NF-κB) activation. The activation of NF-κB triggered by tumor necrosis factor-α was also inhibited by the anthocyanins through suppression IκBα phosphorylation. AIMs inhibited the expression of NF-κB-regulated proteins. In conclusion, this study suggested that the anthocyanins isolated from fruits of V. coignetiae Pulliat should have anti-invasive activities on human colon cancer cells and the activities should be related to the inhibition of NF-κB-regulated proteins such as MMP-2 and MMP-9 expression through the inhibition of NF-κB activation.     

Anti‐inflammatory effects of synthetic compound KT‐14480 in lipopolysaccharide‐stimulated microglia cells

Objectives Neurodegenerative diseases have a prominent inflammatory component. Several synthetic fluorovinyloxyacetamide derivatives were screened by microglia cell‐based assay in order to identify novel compounds that inhibit the inflammatory activation of microglia. Methods Microglia cell‐based nitric oxide assay was employed to screen the compounds. RT‐PCR and ELISA were conducted to evaluate the expression of inflammatory gene expression. Molecular mechanisms were determined by western blot analysis, immunocytochemistry, EMSA, and microglia/neuroblastoma cocultures. Key findings A fluorovinyloxyacetamide compound KT‐14480 significantly suppressed nitric oxide production in lipopolysaccharide‐stimulated microglia cells. KT‐14480 also suppressed the secretion and expression of several inflammatory mediators such as tumour necrosis factor‐α, interleukin‐1β and inducible nitric oxide synthase. Additional studies showed that these inhibitory effects were accompanied by the suppression of nuclear factor‐κB and neuroprotection in the microglia/neuroblastoma coculture. Conclusions Our results indicate that the anti‐inflammatory compound KT‐14480 may be a novel therapeutic drug candidate against neuroinflammatory diseases.     

Serum C-peptide, IGFBP-1 and IGFBP-2 and risk of colon and rectal cancers in the European Prospective Investigation into Cancer and Nutrition

Western style diets and lifestyles are associated with increasing rates of obesity, diabetes and insulin resistance. Higher circulating insulin levels may modulate cell proliferation and apoptosis either directly or indirectly by increasing the bioactivity of IGF-I and decreasing the bioactivity of some of its binding proteins. The objective of this study was to determine the association of increasing levels of serum C-peptide, a biomarker of pancreatic insulin secretion, and IGF binding proteins (IGFBP) -1 and -2 with colorectal cancer risk in a case-control study nested within the European Prospective Investigation into Cancer and Nutrition (EPIC), a large cohort involving 10 Western European countries. A total of 1,078 colorectal cancer cases were matched (age, date of blood donation, fasting status, gender, study center) to an equal number of control subjects. Relative cancer risks were estimated using conditional logistic regression models. Serum C-peptide concentration was positively associated with an increased colorectal cancer risk for the highest versus the lowest quintile (OR=1.56, 95% CI=1.16-2.09, p(trend)<0.01), which was slightly attenuated after adjustment for BMI and physical activity (OR=1.37, 95% CI=1.00-1.88, p(trend)=0.10). When stratified by anatomical site, the cancer risk was stronger in the colon (OR=1.67, 95% CI=1.14-2.46, p(trend)<0.01) than in the rectum (OR=1.42, 95% CI=0.90-2.25, p(trend)=0.35). The cancer risk estimates were not heterogeneous by gender or fasting status. No clear colorectal cancer risk associations were observed for IGFBP-1 or -2. This large prospective study confirms that hyperinsulinemia, as determined by C-peptide levels, is associated with an increased colorectal cancer risk.     

Incidental Gallbladder Cancer Diagnosed Following Laparoscopic Cholecystectomy

Background

Laparoscopic cholecystectomy (LC) is the treatment of choice for benign gallbladder disease. Gallbladder cancers have been found following LC. The aim of the present study was to evaluate the survival outcome and prognosis of incidental gallbladder cancer diagnosed after LC.

Methods

From January 2002 to December 2007, 3,145 patients underwent LC at the Department of Surgery, Korea University Medical Center. Of these, 33 patients (1.05%) were diagnosed with gallbladder cancer after LC. Clinicopathological characteristics were retrospectively reviewed in this study.

Results

Of the 33 patients studied, 9 were men and 24 were women. Laparoscopic cholecystectomy alone was performed in 26 patients, and additional radical surgery was performed in 7 others. Regarding tumor staging, there were 2 Tis, 6 T1a, 4 T1b, 17 T2, and 4 T3 tumors. Male patients had a significantly higher incidence of moderately and poorly differentiated tumors (P < 0.001), T2 and T3 tumors (P = 0.02), additional second operations (P = 0.046), and recurrence (P = 0.016). The cumulative 1-, 3-, and 5-year survival rates were 87.2, 73.1, and 47.0%, respectively. Univariate analysis revealed that significant prognostic factors for poorer survival were male gender (P = 0.026), age older than 65 years (P = 0.013), the presence of inflammation (P = 0.009), moderately or poorly differentiated tumor (P < 0.001), nonpolypoid gross type (P = 0.003), and pT stage (P < 0.001). Tumor differentiation was a significantly independent predictor of poor prognosis.

Conclusions

Male patients exhibited aggressive tumor characteristics. Laparoscopic cholecystectomy is an adequate treatment for pT1 tumors. For pT2 and pT3 patients, additional radical surgery might be needed to achieve a tumor-free surgical margin, along with lymph node dissection.     

CTLA-4 inhibition facilitates follicular T and B cell interaction and the production of tumor-specific antibodies

Immune checkpoint inhibitors (ICIs) induce activation and expansion of cytotoxic T cells. To depict a comprehensive immune cell landscape reshaped by the CTLA-4 checkpoint inhibitor, we performed single-cell RNA sequencing in a mouse syngeneic tumor transplant model. After CTLA-4 inhibition, tumor regression was accompanied by massive immune cell expansion, especially in T and B cells. We found that B cells in tumor transplant represented follicular, germinal center and plasma B cells, some of which shared identical B cell receptor clonotypes and possessed tumor reactivity. Furthermore, the posttreatment tumor contained a tertiary lymphoid-like structure with intermingled T and B cells. These data suggest germinal center formation within the tumor mass and in situ differentiation of tumor-specific plasma cells. Taken together, our data provide a panoramic view of the immune microenvironment after CTLA-4 inhibition and suggest a role for tumor-specific B cells in antitumor immunity.