Predicting loss of independence after high-risk gastrointestinal abdominal surgery: Frailty vs. NSQIP risk calculator

BackgroundLoss of independence (LOI) is a significant concern for patients undergoing high-risk abdominal surgery. Although the risk for morbidity and mortality has been well studied, there is a dearth of data on risk for LOI.MethodsThis study utilized NSQIP data from 2015 to 2018 in a retrospective cohort study of patients undergoing high-risk gastrointestinal surgery (e.g. gastric, colorectal, liver, and pancreatic).ResultsThe study included 229,573 patients who were preoperatively functionally independent. Of those, 5.3% experienced LOI. The median age for LOI patients was 74 (CI: 67–81), and 56% were female. The most common race was white (n = 9585), followed by African-American (n = 1223) and other (n = 369). The most common GI procedure was colorectal (65%), followed by the pancreas (23%), liver (8.2%), and gastric (3%). On univariate analysis, age, sex, BMI, race, frailty, and pancreatectomy were associated with LOI. On multivariate analysis age (≥85, OR 18.3 CI:16.9–19.9 p < 0.001), female sex (OR 1.24CI: 1.19–1.29 p < 0.001), BMI <18.5 (OR 1.66 CI:1.48–1.86 p < 0.001), BMI >40 (OR 1.43 CI:1.31–1.56 p < 0.001), African American race (OR 1.20 CI:1.12–1.28 p < 0.001), smoking (OR 1.21 CI:1.14–1.28 p < 0.001), frailty (MFI-5 > 2, OR 4.47 CI:2.63–7.31 p < 0.001), and pancreatectomy (OR 1.86 CI:1.74–1.98 p < 0.001) continued to be associated with LOI. To better define a predictive model, the NSQIP risk calculator was compared to the modified frailty index-5. AUC was 0.80 (CI: 0.797–0.805) and 0.76 (0.760–0.769), respectively.ConclusionLOI occurs in over five percent of patients undergoing high-risk abdominal surgery. LOI occurs more commonly after pancreatectomy or for those who are frail, underweight, or morbidly obese. Both frailty and the NSQIP risk calculator models similarly predicted LOI.     

Disorders of swallowing

Disorders of swallowing are very common and, when looked for, occur regularly in most branches of surgery. Dysphagia is often not the patient’s presenting complaint and can be easily missed. The consequences of missed or delayed diagnosis of dysphagia can be insidious but profound and, in some cases, fatal. The investigation and treatment of these patients is normally highly multidisciplinary, potentially involving gastroenterology, general surgery, otolaryngology, acute medicine, stroke medicine, paediatrics, speech and language therapy (SLT) and dietitians. While this article is aimed at surgeons and will thus concentrate mostly on those conditions seen by surgeons, it must be remembered that the most common cause of dysphagia is a neurological disturbance and is managed by physicians and SLT. That said, the incidence of these conditions rises with age, as does the incidence of many surgically treatable conditions. It is therefore common to assess a patient with a known neurological condition for the presence of a second pathology affecting their swallow. A basic knowledge of non-surgical conditions is therefore useful.     

Kidney Transplantation Outcome Predictions (KTOP): A Risk Prediction Tool for Kidney Transplants from Brain-dead Deceased Donors Based on a Large European Cohort

BackgroundEuropean kidney donation shortages mandate efficient organ allocation by optimizing the prediction of success for individual recipients.ObjectiveTo develop the first European online risk tool for kidney transplant outcomes on the basis of recipient-only and recipient plus donor characteristics.Design, setting, and participantsWe used individual recipient and donor risk factors and three outcomes (death, death with functioning graft [DWFG], and graft loss) for 32 958 transplants within the Eurotransplant kidney allocation system and the Eurotransplant senior program between January 2006 and May 2018 in eight European countries to develop and validate a risk tool.Outcome measurements and statistical analysisCox proportional-hazards models were used to analyze the association of risk factors with overall patient mortality, and proportional subdistribution hazard regression models for their association with graft loss and DWFG. Prediction models were developed with recipient-only and recipient-donor risk factors. Sensitivity analyses based on time-specific area under the receiver operating characteristic curve (AUC) with leave-one-country-out validation were performed and calibration plots were generated.Results and limitationsThe 10-yr cumulative incidence rate was 37% for mortality, 12% for DWFG, and 41% for graft loss. In recipient-donor models the leading risk factors for mortality were recipient diabetes (hazard ratio [HR] 10.73), retransplantation (HR 3.08 per transplant), and recipient age (HR 1.08). Effects were similar for DWFG. For graft loss, diabetes (subdistributional HR [SHR] 1.32), increased donor age (SHR 1.02), and prolonged cold ischemia time (SHR 1.02) had increased SHRs. All p values were <0.001.ConclusionsPreviously identified risk factors for outcomes following kidney transplants allow for outcome prediction with 10-yr AUC values of up to 0.81.Patient summaryUsing European data, we estimated individual risks to predict the success of kidney transplants and support physicians in decision-making. An online tool is now available (https://riskcalc.org/ktop/) for predicting kidney transplant outcomes both before and after a donor has been identified.     

Comparisons of risk prediction methods using nested case‐control data

Using both simulated and real datasets, we compared two approaches for estimating absolute risk from nested case‐control (NCC) data and demonstrated the feasibility of using the NCC design for estimating absolute risk. In contrast to previously published results, we successfully demonstrated not only that data from a matched NCC study can be used to unbiasedly estimate absolute risk but also that matched studies give better statistical efficiency and classify subjects into more appropriate risk categories. Our result has implications for studies that aim to develop or validate risk prediction models. In addition to the traditional full cohort study and case‐cohort study, researchers designing these studies now have the option of performing a NCC study with huge potential savings in cost and resources. Detailed explanations on how to obtain the absolute risk estimates under the proposed approach are given. Copyright © 2016 John Wiley & Sons, Ltd.     

3D打印技术在放疗中的应用进展

3D打印技术是一种新兴的制造技术,可以制作出各种精细、结构复杂的产品,降低了产品的制造难度,在医学领域被广泛应用。本文总结了3D打印技术及其实现方式,在制作放疗组织补偿膜、射程补偿器方面的应用,还介绍了3D技术在后装放疗及放疗剂量验证方面的应用,总结前人研究发现3D打印产品可以实现提高放疗靶区的剂量精度,降低周围正常组织的剂量,而3D打印技术与放疗技术相结合,可以提高放疗的精确度和安全性,为肿瘤精确放疗提供强有力支撑。本文总结分析的3D打印技术在放疗中的应用现状和进展有助于他人研究快速获取参考资料。     

安列克在HIFU治疗子宫肌瘤中的作用探讨

目的 探讨宫颈注射安列克能否提高HIFU治疗子宫肌瘤的效率.方法 选择该院2014年12月至2015年9月期间140例单发子宫肌瘤患者随机分为安列克组和对照组.安列克组HIFU术前宫颈注射安列克250μg,对照组注射等量生理盐水;在达到治疗标准后,比较两组患者HIFU治疗的辐照时间、治疗时间、团状强回声的出现率及术后并发症情况.结果 安列克组的肌瘤平均体积(71.46±72.43)cm3,在显著大于对照组(35.84±39.27)cm3的情况下,两组的平均辐照时间分别为(715.4±478.1)s和(745.0±544.8)s,差异无统计学意义(P＞0.05),但安列克组的患者在HIFU治疗中的团状强回声的出现率(70.37％)显著高于对照组(54.10％),得出安列克组消融单位体积肌瘤所用的平均时间(19.15±23.31)s/cm3,显著低于对照组(40.22±38.27)s/cm3,提高了治疗效率;而除了仅有暂时性的安列克药物不良反应外,两组均无严重的并发症出现.结论 安列克增加了子宫肌瘤HIFU术中团状强回声的出现率,能安全有效地提高HIFU治疗的效率.