Is there overutilisation of cataract surgery in England?

OBJECTIVES: Following a 3.7-fold increase in the rate of cataract surgery in the UK between 1989 and 2004, concern has been raised as to whether this has been accompanied by an excessive decline in the threshold such that some operations are inappropriate. The objective was to measure the impact of surgery on a representative sample of patients so as to determine whether or not overutilisation of surgery is occurring. DESIGN: Prospective cohort assessed before and 3 months after surgery. SETTING: Ten providers (four NHS hospitals, three NHS treatment centres, three independent sector treatment centres) from across England. PARTICIPANTS: 861 patients undergoing first eye (569) or second eye (292) cataract surgery provided preoperative data of whom 745 (87%) completed postoperative questionnaires. MAIN OUTCOME MEASURES: Patient-reported visual function (VF-14); general health status and quality of life (EQ5D); postoperative complications; overall view of the operation and its impact. RESULTS: Overall, visual function improved (mean VF-14 score increased from 83.2 (SD 17.3) to 93.7 (SD 13.2)). Self-reported general health status deteriorated (20.3% fair or poor before surgery compared with 25% afterwards) which was reflected in the mean EQ5D score (0.82 vs 0.79; p = 0.003). At least one complication was reported by 66 (8.9%) patients, though this probably overestimated the true incidence. If the appropriateness of surgery is based on an increase in VF-14 score of 5.5 (that corresponds to patients' reporting being "a little better"), 30% of operations would be deemed inappropriate. If an increase of 12.2 (patients' reports of being "much better") is adopted, the proportion inappropriate is 49%. Using a different approach to determining a minimally important difference, the proportion inappropriate would be closer to 20%. Although visual function (VF-14) scores were unchanged or deteriorated in 25% of patients, 93.1% rated the results of the operation as "good," "very good" or "excellent," and 93.5% felt their eye problem was "better." This partly reflects inadequacies in the validity of the VF-14. CONCLUSIONS: Improvement in the provision of cataract surgery has been accompanied by a reduction in the visual function threshold. However, methodological difficulties in measuring the impact of cataract surgery on visual function and quality of life mean it is impossible to determine whether or not overutilisation of cataract surgery is occurring.

Findings of the International Subarachnoid Aneurysm Trial and the National Study of Subarachnoid Haemorrhage in context.

Concern has been expressed about the applicability of the findings of the International Subarachnoid Aneurysm Trial (ISAT) with respect to the relative effects on outcome of coiling and clipping. It has been suggested that the findings of the National Study of Subarachnoid Haemorrhage may have greater relevance for neurosurgical practice. The objective of this paper was to interpret the findings of these two studies in the context of differences in their study populations, design, execution and analysis. Because of differences in design and analysis, the findings of the two studies are not directly comparable. The ISAT analysed all randomized patients by intention-to-treat, including some who did not undergo a repair, and obtained the primary outcome for 99% of participants. The National Study only analysed participants who underwent clipping or coiling, according to the method of repair, and obtained the primary outcome for 91% of participants. Time to repair was also considered differently in the two studies. The comparison between coiling and clipping was susceptible to confounding in the National Study, but not in the ISAT. The two study populations differed to some extent, but inspection of these differences does not support the view that coiling was applied inappropriately in the National Study. Therefore, there are many reasons why the two studies estimated different sizes of effect. The possibility that there were real, systematic differences in practice between the ISAT and the National Study cannot be ruled out, but such explanations must be seen in the context of other explanations relating to chance, differences in design or analysis, or confounding.

Survival after liver transplantation in the United Kingdom and Ireland compared with the United States.

BACKGROUND AND OBJECTIVE: Surgical mortality in the US is widely perceived to be superior to that in the UK. However, previous comparisons of surgical outcome in the two countries have often failed to take sufficient account of case-mix or examine long-term outcome. The standardised nature of liver transplantation practice makes it uniquely placed for undertaking reliable international comparisons of surgical outcome. The objective of this study is to undertake a risk-adjusted disease-specific comparison of both short- and long-term survival of liver transplant recipients in the UK and Ireland with that in the US. METHODS: A multicentre cohort study using two high quality national databases including all adults who underwent a first single organ liver transplant in the UK and Ireland (n = 5925) and the US (n = 41,866) between March 1994 and March 2005. The main outcome measures were post-transplant mortality during the first 90 days, 90 days to 1 year and beyond the first year, adjusted for recipient and donor characteristics. RESULTS: Risk-adjusted mortality in the UK and Ireland was generally higher than in the US during the first 90 days (HR 1.17; 95% CI 1.07 to 1.29), both for patients transplanted for acute liver failure (HR 1.27; 95% CI 1.01 to 1.60) and those transplanted for chronic liver disease (HR 1.18; 95% CI 1.07 to 1.31). Between 90 days and 1 year post-transplantation, no statistically significant differences in overall risk-adjusted mortality were noted between the two cohorts. Survivors of the first post-transplant year in the UK and Ireland had lower overall risk-adjusted mortality than those transplanted in the US (HR 0.88; 95% CI 0.81 to 0.96). This difference was observed among patients transplanted for chronic liver disease (HR 0.88; 95% CI 0.81 to 0.96), but not those transplanted for acute liver failure (HR 1.02; 95% CI 0.70 to 1.50). CONCLUSIONS: Whilst risk-adjusted mortality is higher in the UK and Ireland during the first 90 days following liver transplantation, it is higher in the US among those liver transplant recipients who survived the first post-transplant year. Our results are consistent with the notion that the US has superior acute perioperative care whereas the UK appears to provide better quality chronic care following liver transplantation surgery.

The national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis.

OBJECTIVES: This study summarises the results of a National Audit of sino-nasal surgery carried out in England and Wales. It describes patient and operative characteristics as well as patient outcomes up to 36 months after surgery. DESIGN: Prospective cohort study. SETTING: NHS hospitals in England and Wales. PARTICIPANTS: Consecutive patients undergoing surgery for nasal polyposis and/or chronic rhinosinusitis. MAIN OUTCOME MEASURE: The total score derived from a 22-item version of the Sino-Nasal Outcome Test (SNOT-22). Lower scores represent better health-related quality of life. RESULTS: A total of 3128 consecutive patients at 87 NHS hospitals were enrolled. There is a large improvement in SNOT-22 scores from the pre-operative period (mean = 42.0) to 3 months after surgery (mean = 25.5). The scores for patients undergoing nasal polypectomy improved from 41.0 before surgery to 23.1 at 3 months after surgery, while the scores for patients undergoing surgery for chronic rhinosinusitis alone improved from 44.2 to 31.2. The SNOT-22 scores reported at 12 and 36 months after surgery were similar to those reported at 3 months. Excessive bleeding occurred in 5% of patients during the operation and in 1% of patients after the operation. Intra-orbital complications were reported in 0.2%. Of those patients undergoing primary surgery for bilateral grade I or II polyposis, 18% had not received a pre-operative course of steroid treatment. At the 36-month follow-up, 11.4% of patients had undergone revision surgery. CONCLUSIONS: The audit confirms that sino-nasal surgery is generally safe and effective. There is some evidence that patient selection for surgery could be improved.

A comparison of various angles of halo pin insertion in an immature skull model.

STUDY DESIGN: A basic science biomechanical study involving an animal model. OBJECTIVES: To evaluate the effect of varying angles of halo pin insertion on the force generated at the pin-bone interface, and thereby the stability of the halo pin-bone interaction during insertion. BACKGROUND DATA: Because of variations in the shape and size of the pediatric skull, halo pins often are inserted at various angles rather than perpendicular to the skull. Concern exists that the high complication rate associated with pediatric halo use may result in part from less than ideal structural properties at the halo pin-bone interface. METHODS: The authors used a fetal calf skull model to simulate the thickness and structural properties of the pediatric skull. Halo pins were inserted at angles of 0 degree (perpendicular), 10 degrees, 15 degrees, and 30 degrees into skull segments via a halo ring. Load generated at the pin-bone interface was measured using a modified mechanical testing device. Twenty trials were conducted per angle, with the endpoint being specimen failure, pin penetration, or maximum load. RESULTS: Mean maximum loads per unit thickness were 82.15 +/- 7.54 N/mm at 0 degree, 68.80 +/- 4.79 N/mm at 10 degrees, 51.49 +/- 5.08 N/mm at 15 degrees, and 42.38 +/- 3.51 N/mm at 30 degrees, There was a significant difference between perpendicular insertion (0 degree) and 15 degrees angles of insertion. There was also a significant difference between the 10 degrees and 30 degrees angles of insertion. CONCLUSIONS: Perpendicular halo pin insertion in an immature skull model was shown to result in increased load at the pin-bone interface. This improved structural behavior may help to reduce the incidence of complications of halo application in children.

Hemodilution as a method to reduce transfusion requirements in adolescent spine fusion surgery.

STUDY DESIGN: A case-control study. OBJECTIVES: 1) To determine if hemodilution adequately meets the transfusion needs in children who undergo posterior spinal fusion for idiopathic scoliosis and 2) to compare the efficacy of the various methods used to reduce the risk of allogeneic blood transfusion at the authors' institution. SUMMARY OF BACKGROUND DATA: Methods to reduce blood loss and avoid allogeneic blood transfusion caused by extensive spinal surgery in adolescents include 1) autologous blood predonation, 2) controlled hypotensive anesthesia, 3) intraoperative salvage of shed blood (cell saver), 4) acute normovolemic hemodilution, and 5) transfusion decisions by clinical judgment rather than by a preset value of hemoglobin. Although all methods have some efficacy, it is not clear which methods, separate or combined, are best in the adolescent scoliosis population. METHODS: Hemodilution, hypotensive anesthesia, and cell saver were used in 43 children between June 1996 and July 1997. A comparison group (43 children) underwent similar surgery with hypotensive anesthesia and cell saver, but no hemodilution (between July 1995 and December 1996). These two groups were similar with respect to means of age, levels of instrumentation, magnitude of curvature, estimated blood volume, mean arterial pressure, duration of surgery, duration of anesthesia, estimated blood loss, volume returned from cell saver, volume in the hemovac drain, and length of hospitalization. The groups differed in preoperative hemoglobin and hematocrit and in volume of crystalloid used. RESULTS: Transfusions were given to 34 of 43 patients (79%) in the nonhemodilution group. These patients received 61 units of packed cells (57 autologous, 2 donor directed, and 2 allogeneic). In comparison, 16 of 43 patients (37%) in the hemodilution group required transfusion. They received 16 units of packed cells (15 autologous and 1 allogeneic). There was no significant difference between the groups with respect to postoperative hemoglobin and hematocrit immediately after surgery (hemodilution, 10.2/29.2; nonhemodilution, 10.0/29.1), postoperative day 1 (hemodilution, 9.2/26.9; nonhemodilution, 9.2/27.3), and postoperative day 2 (hemodilution 9.0/26.4; nonhemodilution, 9.2/27.1). There were non complications related to the technique of hemodilution in the 43 patients of this group. Cell saver was used in all patients, but sufficient volume to return blood to the patient was available in only 23 hemodilution patients (mean volume, 230 mL) and 25 nonhemodilution patients (mean volume, 215 mL). In only two patients of each group (< 5%) did the volume returned prevent the absolute need for additional transfusions. CONCLUSIONS: Hemodilution was safely used as a method to satisfy the perioperative transfusion requirements of adolescents undergoing extensive spinal surgery. By allowing patients to arrive at surgery with a higher preoperative hemoglobin and hematocrit, and by decreasing the quantity of predonated autologous blood-collected and therefore used, the hemodilution method may indirectly decrease the quantity of postoperative autologous transfusions in this population. Cell saver was not shown to be effective, and its selective use is recommended.

Drain entrapment and titanium to ceramic head deposition: two unique complications following closed reduction of a dislocated total hip arthroplasty.

Postoperative dislocation remains one of the most frequent complications following total hip replacement. In this report, a case is presented that illustrates two potential concerns with postoperative dislocation and subsequent closed reduction. The first complication presented in this report is entrapment of a closed drainage system tube in the joint space following closed reduction. The second complication, transfer of metallic debris to a ceramic femoral head from contact with an acetabular shell during closed reduction, was documented by analysis of a femoral head using scanning electron microscopy and energy dispersive x-ray spectrometry. This report emphasizes the need for the surgeon to express caution when relocating a dislocated hip, particularly when a closed drainage system is used postoperatively.

Cervical spine disorders in infants and children.

The evaluation of children with cervical spine disorders requires an understanding of the anatomic and developmental features that are particular to the pediatric spine. In this article, cervical spine developmental anatomy is briefly reviewed, along with common radiographic features of the pediatric cervical spine. The epidemiology, clinical presentation, and management of congenital cervical anomalies are considered. The evaluation and management of pediatric cervical trauma are also reviewed. Other disorders with common cervical spine involvement, such as skeletal dysplasias, connective tissue disorders, inflammatory arthritides, and storage disorders, are discussed.

A comparative evaluation of halo pin designs in an immature skull model.

To design an improved halo pin for use in pediatric patients, three commonly used halo pins were evaluated with a mechanical testing apparatus and segments of prepared fetal calf skull. The pins were driven through the bone segments while the load at the bone-pin interface was measured. New pins were designed with respect to pin tip and flange width and similarly compared. Mean maximum loads to penetration, normalized for bone segment thickness, were 55.6 N/mm for the PMT Corporation pin, 61.5 N/mm for the Bremer pin, and 73.6 N/mm for the Ace pin. Four new, short tipped pins were designed and compared with the Ace pin, and there was no significant difference. Finally, four new pins were designed with varying flange widths. Mean maximum loads, normalized for bone segment thickness, were 68.9 N/mm for the 4.2 mm flange, 72.2 N/mm for the 4.7 mm flange, 92.9 N/mm for the 5.2 mm flange, and 96.4 N/mm for the 5.7 mm flange. The findings of this investigation are clinically important because they may help to explain the variability in the complication rates seen with the use of different halo systems in children. The three halo pins currently on the market have different pin designs, including tip lengths and flange distances, which contribute to the difference in load to penetration for each pin. The new, wide flanged, short tipped halo pin design might decrease the complication rate of halo use in children by providing an improved capacity to resist penetration despite increased loads of application.

The influence of intramedullary fixation on figure-of-eight wiring for surgical neck fractures of the proximal humerus: a biomechanical comparison.

The resistance to torsional load was measured in a human cadaver model of a surgical neck fracture. Ten fresh-frozen human cadaver shoulders were thawed, dissected free of soft tissue attachments, and analyzed with dual energy x-ray absorptiometry to establish bone mineral density. Osteotomies were fixed with figure-of-eight wire alone and figure-of-eight wire supplemented with intramedullary Enders rods. Intramedullary Enders rods improved the mean maximum load by 1.5 times (p < 0.05). No statistically significant correlation was found between mean maximum load and bone mineral density.

Benign pediatric bone tumors. Evaluation and treatment.

Several recent significant advances have been made in the evaluation and treatment for bone lesions in children. Most advances have come as a result of better imaging of these lesions, namely with magnetic resonance imaging. When a child presents with a bone lesion, several aids allow the treating physician to develop a differential diagnosis. Both recent advance and newer techniques in the diagnosis and treatment of children with benign bone lesions are discussed.

Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: toward a goal of prevention.

Between 1988 and 1994, 128 consecutive children with grade III supracondylar humeral fractures presented for treatment at our hospital. Seventeen had absent or diminished (detected with Doppler but not palpable) radial pulses on initial examination. Fourteen of these 17 children recovered pulse (palpable) after reduction and stabilization of their fractures. The remaining three had persistent absence of radial pulse. Each of these three children was explored immediately and found to have a significant vascular injury requiring repair. Two of the 14 children who had initially regained their pulses had a progressive postoperative deterioration in their circulatory status during the first 24-36 h, including loss of the radial pulse. Both of these children had arteriograms that identified vascular injuries. Both underwent exploration and bypass grafting. One of these two children had been transferred 48 h after injury, resulting in delay of management of his vascular impairment. Despite exploration, vascular repair, and fasciotomy, he ultimately developed Volkmann's ischemic contracture. All five children with significant vascular injuries had absent or diminished radial pulses on presentation. Immediate reduction and fixation followed by careful evaluation and treatment of ischemia were associated with excellent outcome in four of the five children.