Differences in Perioperative Care at Low- and High-Mortality Hospitals with Cancer Surgery

Objective

To evaluate adherence to perioperative processes of care associated with major cancer resections.

Background

Mortality rates associated with major cancer resections vary across hospitals. Because mechanisms underlying such variations are not well-established, we studied adherence to perioperative care processes.

Methods

There were 1,279 hospitals participating in the National Cancer DataBase (2005–2006) ranked on a composite measure of mortality for bladder, colon, esophagus, stomach, lung, and pancreas cancer operations. We sampled hospitals from among those with the lowest and highest mortality rates, with 19 low-mortality hospitals [(LMHs), risk-adjusted mortality rate of 2.84 %] and 30 high-mortality hospitals [(HMHs), risk-adjusted mortality rate of 7.37 %]. We then conducted onsite chart reviews. Using logistic regression, we examined differences in perioperative care, adjusting for patient and tumor characteristics.

Results

Compared to LMHs, HMHs were less likely to use prophylaxis against venous thromboembolism, either preoperative or postoperatively [adjusted relative risk (aRR) 0.74, 95 % CI 0.50–0.92 and aRR 0.80, 95 % CI 0.56–0.93, respectively]. The two hospital groups were indistinguishable with respect to processes aimed at preventing surgical site infections, such as the use of antibiotics prior to incision (aRR, 0.99, 95 % CI 0.90–1.04), and processes intended to prevent cardiac events, including the use of β-blockers (1.00, 95 % CI 0.81–1.14). HMHs were significantly less likely to use epidurals (aRR, 0.57, 95 % CI 0.32–0.93).

Conclusions

HMHs and LMHs differ in several aspects of perioperative care. These areas may represent opportunities for improving cancer surgery quality at hospitals with high mortality.     

食管恶性狭窄支架置入术后并发症观察

目的 观察内支架对食管恶性狭窄患者进行姑息性治疗并发症，探讨其防治措施。方法 对我院2001年1月至2005年1月应用内支架置入治疗食管恶性狭窄75例患者临床资料进行回顾总结。结果 手术成功率100％，最常见的并发症是胸骨后疼痛，上段食管癌尤为明显，其次是出血、食团阻塞和再狭窄。6个月生存时间72．7％，1年生存时间32．7％，平均生存时间8月。结论 食管内支架置入是恶性狭窄患者姑息治疗的主要方法，积极预防其并发症能大大提高患者生活质量，延长生存时间。     

Changes, challenges and choices for the primary health care workforce: looking to the future

AIMS: The main aim of this paper is to draw attention to problems facing the primary health care workforce in terms of demand for treatment of minor illness over the next two decades. These predictions have implications for the community nursing workforce in particular and the flexibility of primary health care teams in general. BACKGROUND: Care delivered in the primary care sector influences, and is influenced by, the characteristics of the health care workforce. These characteristics fall into two main groups: firstly, the shape of the present medical and nursing workforce and manpower trends; and secondly, the changes in doctors' and nurses' workloads. DESIGN: This paper draws on two studies, both commissioned by the Department of Health; the first study focusing on skill mix and delegation in primary health care teams and the second addressing the implications of skill mix for medical workforce scenarios in the changing policy environment. FINDINGS: From the first study, general practitioners across ten general practices were prepared to delegate at least one topic from over a third of 836 consultations and a further 17% of entire consultations. This potential delegation fell mainly to practice nurses and nurse practitioners. The second study used data extracted from the National Morbidity Surveys of 1981 and 1991 predicting that minor consultations are set to increase by 11 million from the 1990s to 2020--a minimal estimate. The authors argue that many of these extra predicted consultations will find their way onto practice nurses' and nurse practitioners' caseloads. CONCLUSIONS: Workforce issues and questions of professional roles and boundaries, in the context of the "greying" community nursing workforce, demand solutions if patient/client demand is to be met over the next two decades.     

结核感染T细胞斑点试验在脊柱结核诊断中的应用

目的：探讨结核感染T细胞斑点试验在脊柱结核诊断中的临床应用价值。方法选取2012年4月～2013年1月本院骨科病区收治的疑似脊柱结核患者156例,分别采用结核感染T细胞斑点试验和结核菌素试验进行诊断,比较两者对脊柱结核诊断的临床意义（包括灵敏性、特异性、假阳性率和假阴性率指标的差别）。结果结核感染T细胞斑点试验的灵敏性和特异性明显高于结核菌素试验（P＜0．05）;同时,结核感染T细胞斑点试验的假阳性率和假阴性率明显低于结核菌素试验试验（P＜0．05）。结论结核感染T细胞斑点试验在诊断脊柱结核中具有良好的敏感性和特异性,具有重要临床应用价值。     

结肠CT仿真内窥镜充气方法及压力的研究

目的：探讨结肠CT仿真内窥镜较理想的充气方法和充气压力。材料和方法：8名志愿者中，男4名，女4名，最大年龄50岁，最小年龄40岁，平均44.4岁。用电脑遥控灌肠整复仪通过双腔气囊胶乳导尿管向志愿者结肠内注入气体。先行最大耐受气压CT扫描，扫描期间持续注入这个压力直到扫描结束，然后每降低7.5mmHg进行一次CT扫描，最低压力为30mmHg。结果：肛门插管用双腔气囊胶乳导尿管。CT扫描时，用持续性注入同一压力气体的方法。结肠扩张程度，在52.5mmHg，40mmHg，37.5mmHg，30mmHg 4个级别气压之间，无显著性差异。结肠充气CT扫描后，腹部不适消失时间，男女之间有显著性差异。结论：CT扫描时，持续性注入同一压力气体的方法，可以保持肠管扩张的稳定性，保证CTVE检查的顺利进行。肠管充气压力的控制，不应以患者的最大耐受为标准，应以较低的气压为妥，本研究为30mmHg。肛门插管用双腔气囊胶乳导尿管，其膨胀的气囊可以起到固定导尿管和减少导尿管与肛门间的漏气作用。CT充气扫描后，腹部不适消失时间，女性较男性为长。