Use of case fatality and readmission measures to compare hospital performance in gynaecology.

OBJECTIVE: To identify suitable outcome measures for comparing gynaecology performance between hospitals. DESIGN: Analysis of routinely collected statistics. SETTING: England. POPULATION A total of 1.45 million gynaecology admissions in 1999/2001. METHODS: The database used was a linked file of English NHS hospital admission statistics and death certificate data. Case fatality rates (CFRs)and emergency readmission (ERA) rates were calculated for different components of gynaecology workload. Funnel plots, using age-sex standardised measures, were displayed to compare the outcomes. MAIN OUTCOME MEASURES: CFRs and ERA rates. RESULTS: The CFR within 30 days after admission for patients with cancer was 5.1%. These patients accounted for only 3% of all the admissions but for 73% of all 30-day deaths. All other 30-day CFRs were extremely low-below 0.5%. The 30-day ERA rates ranged from 1.8% after day case care to 17.4% after emergency admissions for people who did not have an operation. Funnel plots showed considerable variation between hospitals for ERA after day case care but not after elective abdominal hysterectomy. CONCLUSIONS: There are no measures of mortality that could be used routinely and meaningfully to compare the performance of gynaecology units. We suggest that two suitable comparative measures of outcome, derivable from routine hospital statistics, are 30-day ERA rates after day case admissions and after elective abdominal hysterectomy, excluding those records with a cancer diagnosis. These measures are relatively homogeneous with respect to their likely rates of adverse events and have sufficient numbers to produce potentially useful comparative results.

Clinicopathologic features of surgically excised choroidal neovascular membranes.

PURPOSE: The purpose of this study is a descriptive correlation of the clinical, fluorescein angiographic, and pathologic features in a large series of patients who underwent surgical removal of choroidal neovascular membranes. METHODS: The patients' clinical data were recorded for each surgically removed choroidal neovascular membrane received in the authors' laboratory. Fluorescein angiographic characteristics of the membranes, including well-demarcated versus poorly demarcated preoperative appearance, postoperative choroidal atrophy, and membrane recurrence, were recorded whenever possible. The pathologic features of the membranes, including cellular and extracellular constituents, were determined on light and electron microscopic examination. RESULTS: A total of 123 membranes were studied. Underlying diseases in decreasing order of frequency were age-related macular degeneration, ocular histoplasmosis syndrome, myopia, idiopathic and pattern dystrophy. The cellular and extracellular constituents of the membranes were similar, regardless of underlying disease, with the exception of basal laminar deposit, seen almost exclusively in age-related macular degeneration. Well-demarcated membrane components were localized with a central subretinal pigment epithelium fibrovascular core. Poorly demarcated membranes were represented by a subneurosensory retinal (breakthrough) component, although most of these membranes had associated retinal pigment epithelium. Fragments of Bruch's membrane were common in specimens from patients with postoperative choroidal atrophy, and there was generally a lack of vascular channels in membranes that led to recurrence. CONCLUSIONS: This study suggests that choroidal neovascular membranes represent a stereotypic, nonspecific response, regardless of underlying disease. Most membranes are subretinal pigment epithelium, and what is recognized angiographically as a subneurosensory retinal component contains associated retinal pigment epithelium in most instances. Fragments of Bruch's membrane in the specimen correlate with postoperative choroidal atrophy. Lack of vascular channels in the surgical specimen may correlate with a risk for postoperative membrane recurrence.

Magnetic resonance imaging and computed tomographic scanning of fresh (green) wood foreign bodies in dog orbits.

Wooden foreign bodies in the orbit can extend into the intracranial cavity without diagnostic clues from the small eyelid entrance wound, from neurologic examination, and from imaging studies such as ultrasound, plain x-rays, or computed tomography (CT) scans. In cadaver magnetic resonance imaging (MRI) studies, dry wood in the orbit can be seen as a negative or hypointense image in contrast to orbital fat. We studied fresh, green wood in dogs to determine the reliability of CT and MRI scans to image hydrated wood. Wood was placed into each orbit of two dogs. After 24 h the wood was removed from one orbit, but not the other. The dogs were then scanned with CT and MRI. Radiologists were asked to determine if any wood had been left in either or both orbits. The fresh wooden foreign bodies could not be detected despite an intensive effort. MRI does not appear to reliably demonstrate fresh wood in the orbit. MRI can show dry wooden foreign bodies that have not become hydrated, but has not yet been reliable in the clinical situation to rule out the presence of wood in the orbit.

Intrathoracic lipoma in a dog.

A 0.9 kg lipoma was removed surgically from the cranial mediastinum of an 11-year-old dog. Clinical signs related to the mass consisted of coughing and dyspnea. Postoperative recovery was uncomplicated and the clinical signs diminished immediately. The thoracic cavity is an unusual location for the development of a lipoma.

Maternal serum alpha-fetoprotein screening in a provincial Health District.

Maternal serum alpha-fetoprotein (AFP) estimation as a routine screening test for neural tube defect (NTD) was introduced into the West Berkshire Health District, where 17 per cent of all deliveries and most of the antenatal care is undertaken by the general practitioners. In the first year, 4458 patients were screened and 43 of those (0.96 per cent) had raised serum AFP levels. Amniocentesis was performed on 31 patients (0.69 per cent). Ten fetuses with severe NTDs and one with exomphalos were detected and the pregnancies terminated. In six patients, raised serum AFP levels were due to fetal death. No normal pregnancy was terminated. Acceptability by patients was high. Provided that a good diagnostic ultrasound facility is available locally, maternal serum AFP estimation seemed to be a valuable screening test.

The measurement of uterine activity in induced labour.

A simple electronic system for quantifying uterine activity in labour has been developed. The basic construction of the system is described. It has been used to confirm the hypothesis of Steer et al (1975) that oxytocin-induced labour has a stable phase during which uterine activity is largely independent of oxytocin infusion rate.