TB case fatality and recurrence in a private sector cohort in Mumbai, India.

BACKGROUND: Half of India´s three million TB patients are treated in the largely unregulated private sector, where quality of care is often poor. Private provider interface agencies (PPIAs) seek to improve private sector quality of care, which can be measured in terms of case fatality and recurrence rates.METHODS: We conducted a retrospective cohort survey of 4,000 private sector patients managed by the PATH PPIA between 2014 and 2017. We estimated treatment and post-treatment case-fatality ratios (CFRs) and recurrence rates. We used Cox proportional hazards models to identify predictors of fatality and recurrence. Patient loss to follow-up was adjusted for using selection weighting.RESULTS: The treatment CFR was 7.1% (95% CI 6.0-8.2). At 24 months post-treatment, the CFR was 2.4% (95% CI 1.7-3.0) and the recurrence rate was 1.9% (95% CI 1.3-2.5). Treatment fatality was associated with age (HR 1.02, 95% CI 1.02-1.03), clinical diagnosis (HR 0.61, 95% CI 0.45-0.84), treatment duration (HR 0.09, 95% CI 0.06-0.10) and adherence. Post-treatment fatality was associated with treatment duration (HR 0.87, 95% CI 0.79-0.91) and adherence.CONCLUSIONS: We found a moderate treatment phase CFR among PPIA-managed private sector patient with low rates of post-treatment fatality and recurrence. Routine monitoring of patient outcomes after treatment would strengthen PPIAs and inform future post TB interventions.

Clinical standards for the assessment, management and rehabilitation of post-TB lung disease.

BACKGROUND: Increasing evidence suggests that post-TB lung disease (PTLD) causes significant morbidity and mortality. The aim of these clinical standards is to provide guidance on the assessment and management of PTLD and the implementation of pulmonary rehabilitation (PR).METHODS: A panel of global experts in the field of TB care and PR was identified; 62 participated in a Delphi process. A 5-point Likert scale was used to score the initial ideas for standards and after several rounds of revision the document was approved (with 100% agreement).RESULTS: Five clinical standards were defined: Standard 1, to assess patients at the end of TB treatment for PTLD (with adaptation for children and specific settings/situations); Standard 2, to identify patients with PTLD for PR; Standard 3, tailoring the PR programme to patient needs and the local setting; Standard 4, to evaluate the effectiveness of PR; and Standard 5, to conduct education and counselling. Standard 6 addresses public health aspects of PTLD and outcomes due to PR.CONCLUSION: This is the first consensus-based set of Clinical Standards for PTLD. Our aim is to improve patient care and quality of life by guiding clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage PTLD.

Cost-effectiveness of a quality improvement bundle for emergency laparotomy.

BACKGROUND: The recent Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) study showed that the use of a specific care bundle reduced mortality in patients undergoing emergency laparotomy. However, the costs of implementation of the ELPQuiC bundle remain unknown. The aim of this study was to assess the in-hospital and societal costs of implementing the ELPQuiC bundle. METHODS: The ELPQuiC study employed a before-after approach using quality improvement methodology. To assess the costs and cost-effectiveness of the bundle, two models were constructed: a short-term model to assess in-hospital costs and a long-term model (societal decision tree) to evaluate the patient's lifetime costs (in euros). RESULTS: Using health economic modelling and data collected from the ELPQuiC study, estimated costs for initial implementation of the ELPQuiC bundle were €30 026·11 (range 1794·64-40 784·06) per hospital. In-hospital costs per patient were estimated at €14 817·24 for standard (non-care bundle) treatment versus €15 971·24 for the ELPQuiC bundle treatment. Taking a societal perspective, lifetime costs of the patient in the standard group were €23 058·87, compared with €19 102·37 for patients receiving the ELPQuiC bundle. The increased life expectancy of 4 months for patients treated with the ELPQuiC bundle was associated with cost savings of €11 410·38 per quality-adjusted life-year saved. CONCLUSION: Implementation of the ELPQuiC bundle is associated with lower mortality and higher in-hospital costs but reduced societal costs.

Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland.

BACKGROUND: Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery. METHODS: The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future. RESULTS: Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems. CONCLUSIONS: The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

Use of a care bundle to reduce mortality following emergency laparotomy.

Emergency laparotomy is a common intra-abdominal procedure with outcomes recognized to be poor. Efforts are being made to improve these outcomes, both nationally and internationally. This article describes the methodology of a successfully implemented collaborative quality improvement project that improved outcomes following emergency laparotomy in four NHS trusts.

Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy.

BACKGROUND: Emergency laparotomies in the U.K., U.S.A. and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care. METHODS: The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model. RESULTS: Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6.47 in the baseline interval (299 patients included) to 12.44 after implementation (427 patients included) (P < 0.001). The overall case mix-adjusted risk of death decreased from 15.6 to 9.6 per cent (risk ratio 0.614, 95 per cent c.i. 0.451 to 0.836; P = 0.002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0.197 and 0.223 before and after implementation respectively; P = 0.395). CONCLUSION: Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.

A systematic review of the role of cardiopulmonary exercise testing in vascular surgery.

OBJECTIVE: To perform a systematic review of cardiopulmonary exercise testing (CPET) in the pre-operative evaluation of patients with abdominal aortic aneurysm or peripheral vascular disease requiring surgery. METHODS: Review methods and reporting were according to the PRISMA guidelines. Studies were eligible if they reported CPET-derived physiological parameters in patients undergoing abdominal aortic aneurysm repair or lower extremity arterial bypass. Data were extracted regarding patient populations and correlation between CPET and surgical outcomes including mortality, morbidity, critical care bed usage and length of hospital stay. RESULTS: The searches identified 1301 articles. Although 53 abstracts referred to the index vascular procedures, only seven articles met inclusion criteria. There were no data from randomised controlled trials. Data from prospective studies did not comprehensively correlate CPET and surgical outcomes in patients with abdominal aortic aneurysms. There were no studies reporting CPET in patients undergoing lower extremity arterial bypass. Major limitations included small sample sizes, lack of blinding, and an absence of reporting standards. CONCLUSION: The paucity of robust data precludes routine adoption of CPET in risk stratifying patients undergoing major vascular surgery. The use of CPET should be restricted to clinical trials and experimental registries, reporting to consensus-defined standards.

Use of a tissue expander and a polyglactic acid (Vicryl) mesh to reduce radiation enteritis: case report and literature review.

Management of stage IV rhabdomyosarcoma comprises systemic chemotherapy with local control by conservative surgery and radiotherapy. Abdominal radiotherapy may lead to radiation enteritis causing such serious morbidity as malabsorption, fistulae or stricture formation. The risk increases with the dose of radiation and length of bowel involved. Various methods have been utilised to displace the bowel from the radiation field. Usually these are applied in patients requiring pelvic irradiation. We report a case of metastatic alveolar rhabdomyosarcoma requiring radiotherapy to the right renal bed. Effective displacement of small bowel from the tumour site was achieved by a combined use of a tissue expander and Vicryl mesh. There were no complications from the surgery. This is the first report discussing combined use of a tissue expander and Vicryl mesh to aid radiotherapy to the renal fossa in a paediatric patient.

Sacrococcygeal teratomas: the UK Children's Cancer Study Group's experience. I. Neonatal.

The aim of this study was to review the United Kingdom Children's Cancer Study Group (UKCCSG) experience of sacrococcygeal teratomas (SCT) including histological presentation, response to surgery and chemotherapy, and long term effects of the tumour and treatment. This paper presents the results for those children diagnosed during the neonatal period. Children aged up to 4 weeks with biopsy proven localised or metastatic sacrococcygeal germ cell tumours were eligible. From 1st January 1989 to 31st December 1997 (9 years), 15 UKCCSG centres registered 51 neonates with SCT into GC 8901. Surgery alone was performed in all and the prognosis was good - except for 1 baby who died from massive haemorrhage at the initial operation and 1 who died from the complications of prematurity. Seven of the 51 children (14%) who had teratomas in the neonatal period (5 mature, two immature) had yolk sac tumour (YST) recurrence at: 4, 12, 15, 20, 20, 28 and 32 months of age. These children received chemotherapy in the form of etoposide/bleomycin/carboplatin (JEB) and are alive and well at review. These results emphasise the need for oncological follow-up of SCT and the good response to JEB chemotherapy of malignant teratomas and YST.

The constipated child: how likely is Hirschsprung's disease?

The incidence of Hirschsprung's disease (HD) was determined in children who presented with constipation to a specialist paediatric surgical unit. During a 5-year period, 355 rectal biopsies were performed on 182 neonates, infants and children presenting with chronic constipation or intestinal obstruction: 25 (14%) were diagnosed HD. One hundred and four patients had suction and 78 had full-thickness rectal biopsies. Haematoxylin-eosin (HE) staining and acetylcholinesterase (AChE) histochemistry was used. In 13 cases (8%) of suction and 2 cases (2.5%) of full thickness rectal biopsies, specimens were inadequate to diagnose HD. The mean age of all patients was 2.9 years and that of patients diagnosed with HD was 3.64 months. Nineteen patients with HD were diagnosed in the first month, 5 in 1-12 months and 1 at 4 years of age (Fig. 1). The authors found that along with onset of constipation convincing indications for rectal biopsy to exclude HD were as follows: those infants and children who do not pass meconium within 48 hours, have low intestinal obstruction of unknown cause, severe constipation, chronic abdominal distension and failure to thrive. A diagnostic accuracy of 94% was achieved with AChE histochemistry for suction rectal biopsy. After this review, referring paediatricians were advised that screening of other common organic causes of constipation with the least invasive investigations, including laboratory, dietary and paediatric gastroenterology advice, should be undertaken to avoid unnecessary rectal biopsy to exclude HD and related disorders.

A case of fatal tumor embolus following trauma in a patient with undiagnosed Wilms' tumor.

Involvement of the inferior vena cava with tumor thrombus has been reported in 5 to 10% of patients with Wilms' tumor. Preoperative imaging usually alerts the surgeon to the extent of the intravascular extension. We present a case report of trauma to a previously undiagnosed Wilms' tumor that resulted in a fatal intraoperative pulmonary tumor embolus.

Mesh hiatal reinforcement in Nissen fundoplication.

Persistent or recurrent gastro-oesophageal reflux (GOR) following Nissen fundoplication occurs in up to one in five cases, especially if the child is neurologically impaired. We advocate the use of mesh hiatal reinforcement for patients undergoing reoperation for GOR or if the diaphragmatic crura are thought to require reinforcement at the time of the original surgery.

Hirschsprung's disease: present UK practice.

A postal survey was performed to assess the management by consultant members of the British Association of Paediatric Surgeons (BAPS) of a well neonate with Hirschsprung's disease (HD). Replies were received from 63 (84%) of the 75 consultant surgeons who operate on neonates with gastrointestinal problems. Twenty-six surgeons (41%) would aim to perform a primary pull through without colostomy, and 37 (51%) would stage the pull through, with stoma formation in the neonatal period. Timing of definitive surgery varied as did the choice of procedure (Soave 24%, Swenson 8%, Duhamel 62%, other 6%), but there was no evidence that surgical experience influenced the choice of operation. Most surgeons see 4-5 new cases of Hirschsprung's disease per year. This study shows great variation in operative procedures for the same clinical condition, and indicates the need for further audit.

Retrospective study of prognostic value of DNA ploidy and proliferative activity in neuroblastoma.

AIM: To assess the prognostic value of age and stage at diagnosis, site of primary tumour, cell ploidy and N-myc copy number in children with neuroblastoma. METHODS: Flow cytometry was used to determine the cellular DNA content of paraffin wax embedded archival material from 69 cases of neuroblastoma and was successful in 52. RESULTS: The age, stage, and survival distribution of the sampled cases was not significantly different from that in a larger population based series. There were seven diploid ("non-aneuploid") and 45 aneuploid (including two tetraploid and four triploid) tumours. The 10 year survival was significantly better for cases of aneuploid rather than diploid tumours (p < 0.05). An important new finding was that 10 year survival was also significantly better for tumours with a low percentage of cells in S phase (p < 0.03). CONCLUSION: The percentage of cells in S phase, a measure of the proliferative activity of the tumour, correlated with prognosis in neuroblastoma. This should be measured with other biological features of the disease, such as N-myc copy number, when prognostic indicators are being assessed.