Association Between Anesthesiology Volumes and Early and Late Outcomes After Cystectomy for Bladder Cancer: A Population-Based Study.

BACKGROUND: Hospital and surgeon volume are related to postoperative complications and long-term survival after radical cystectomy. Here, we describe the relationships between these provider characteristics and anesthesiologist volumes on early and late outcomes after radical cystectomy for bladder cancer. METHODS: Records of treatment and surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients with radical cystectomy in Ontario during 1994 to 2008. Volume was divided into quartiles and determined on the basis of mean annual number of hospital/surgeon/anesthesiologist radical cystectomy cases during a 5-year study period. A composite anesthesiologist volume also was used and defined as major colorectal procedures in addition to radical cystectomy given the similar complexity of these cases. Logistic and Cox proportional hazards regression models were used to explore the associations between volume and outcomes while adjusting for potential patient-, disease-, and system-related confounders. The primary outcomes were postoperative readmission rates, postoperative mortality, and 5-year survival. RESULTS: The study included 3585 patients with radical cystectomy between 1994 and 2008. Median annual anesthesiologist radical cystectomy volume was 1 (maximum 8.8 cases/year); lowest volume quartile (Q1) 1.4 cases/year. The median annual composite anesthesiologist volume was 9 radical cystectomy and colorectal cases (Q1 [range 0.2-6.4 cases/year], Q4 [range 11.8-29.2 cases/year]); subsequent analyses used this composite volume. Anesthesiologist volume was associated with readmission rates at 30 days (P = .02, Q1 mean = 27% versus Q4 mean = 21%) and at 90 days (P = .01, Q1 mean = 39% versus Q4 mean = 31%). In multivariable analysis, including the adjustment for surgeon and hospital volume, the cohort of anesthesiologists who performed the lowest volume of cases annually (Q1) was associated with greater rates of readmission at 30 days (OR 1.36, 95% CI 1.09-1.71, P = .04) and at 90 days (OR 1.36, 95% CI 1.11-1.66, P = .03). Anesthesiologist volumes were not associated with postoperative mortality or long-term survival. CONCLUSIONS: Anesthesiologist case volume for radical cystectomy was low, reflecting the lack of subspecialization in urologic procedures in routine clinical practice. Lower volume anesthesia providers were associated with higher readmission rates after radical cystectomy. Further studies are needed to validate this finding and to identify the processes that may explain an association between provider volume and patient outcome. (C) 2017 International Anesthesia Research Society

http://ift.tt/2kZ6C3v

A Role for Adrenergic Receptors in the Uterotonic Effects of Ergometrine in Isolated Human Term Nonlaboring Myometrium.

BACKGROUND: Ergometrine is a uterotonic agent that is recommended in the prevention and management of postpartum hemorrhage. Despite its long-standing use, the mechanism by which it acts in humans has never been elucidated fully. The objective of this study was to investigate the role of adrenoreceptors in ergometrine's mechanism of action in human myometrium. The study examined the hypothesis that [alpha]-adrenoreceptor antagonism would result in the reversal of the uterotonic effects of ergometrine. METHODS: Myometrial samples were obtained from women undergoing elective cesarean delivery. The samples were then dissected into strips and mounted in organ bath chambers. After the generation of an ergometrine concentration-response curve (10-15 to 10-5 M), strips were treated with increasing concentrations of ergometrine (10-15 to 10-7 M) alone and ergometrine (10-7 to 10-5 M) in the presence of phentolamine (10-7 M), prazosin (10-7 M), propranolol (10-6 M), or yohimbine (10-6 M). The effects of adding ergometrine and the effect of drug combinations were analyzed using linear mixed effects models with measures of amplitude (g), frequency (contractions/10 min), and motility index (gxcontractions/10 min). RESULTS: A total of 157 experiments were completed on samples obtained from 33 women. There was a significant increase in the motility index (adding 0.342 g x counts/10 min/[mu]M; 95% confidence interval [CI] 0.253-0.431, P

http://ift.tt/2m0pbBQ

Is It Quality Improvement or Is It Research?: Ethical and Regulatory Considerations.

No abstract available

http://ift.tt/2kZ1o7K

The CARE approach to reducing diagnostic errors

Abstract

Background

Diagnostic errors appear to be the most common, costly, and dangerous of all medical mistakes. There has been a notable increase on the focus of error prevention as part of a growing patient safety movement. However, diagnostic errors have received less attention than other types of error. Our goal is to present a short mnemonic that can act as a checklist or posted reminder to help practitioners in dermatology or any field of medicine to avoid diagnostic errors.

Methods

To meet this goal, the authors reviewed the literature and discussed errors and potential errors they have experienced over 55 years of combined practice, to create a short mnemonic.

Results

The CARE method has helped the authors prepare and review their differential diagnoses in the relatively fast-paced practice of dermatology, but it has yet to be tested on a large scale.

Conclusion

The CARE (communicate, assess for biased reasoning, reconsider differential diagnoses, enact a plan) method is an efficient, recallable checklist that uses an educational approach to reduce diagnostic error while reminding us to simply "care" from a humanistic perspective. This method may help reduce preventable diagnostic errors and improve patient care.

http://ift.tt/2m0tkWn

Concerns about “The spectrum of skin diseases in a black population in Durban, KwaZulu-Natal, South Africa”

http://ift.tt/2loyxL6

Bronchial allergen challenge – An old, but still useful tool in research and diagnostics

Publication date: Available online 16 February 2017
Source:Alergologia Polska - Polish Journal of Allergology
Author(s): Zenon Siergiejko, Grzegorz Siergiejko, Mark Klukowski, Ewa Maria Swiebocka
A bronchial allergen challenge may serve both as a diagnostic as well as investigative procedure. Its usage in the diagnosis of asthma is infrequent due to its time-consuming nature as well as (in our opinion) an unfounded fear for a patient's safety. It is quite useful in the diagnostics of workplace related illnesses. Due to its ability to produce a controlled, long-lasting allergic-inflammatory reaction in the bronchi, this procedure is commonly used in research settings as well as in the assessment of new substances which may potentially have a place in the treatment of asthma, for ex. through the blocking of late asthmatic reactions. Changes stimulated by a bronchial allergen challenge may be evaluated by many methods using different materials, i.e. samples obtained from direct biopsies, bronchoalveolar lavages, exhaled breath condensates, or measured fractional exhaled nitric oxide. This procedure is a seemingly ideal research and diagnostic tool, however, a common protocol for its execution has not yet been accepted. Recent legal regulations have resulted in difficulties obtaining various allergens for challenge tests. Hopefully this is a temporary and minor setback for this very useful and constantly developing procedure.



http://ift.tt/2lcGtNc

Bronchial allergen challenge – An old, but still useful tool in research and diagnostics

Publication date: Available online 16 February 2017
Source:Alergologia Polska - Polish Journal of Allergology
Author(s): Zenon Siergiejko, Grzegorz Siergiejko, Mark Klukowski, Ewa Maria Swiebocka
A bronchial allergen challenge may serve both as a diagnostic as well as investigative procedure. Its usage in the diagnosis of asthma is infrequent due to its time-consuming nature as well as (in our opinion) an unfounded fear for a patient's safety. It is quite useful in the diagnostics of workplace related illnesses. Due to its ability to produce a controlled, long-lasting allergic-inflammatory reaction in the bronchi, this procedure is commonly used in research settings as well as in the assessment of new substances which may potentially have a place in the treatment of asthma, for ex. through the blocking of late asthmatic reactions. Changes stimulated by a bronchial allergen challenge may be evaluated by many methods using different materials, i.e. samples obtained from direct biopsies, bronchoalveolar lavages, exhaled breath condensates, or measured fractional exhaled nitric oxide. This procedure is a seemingly ideal research and diagnostic tool, however, a common protocol for its execution has not yet been accepted. Recent legal regulations have resulted in difficulties obtaining various allergens for challenge tests. Hopefully this is a temporary and minor setback for this very useful and constantly developing procedure.



http://ift.tt/2lcGtNc