[Post-trauma mandibular osteoma]

INTRODUCTION

Osteomas are benign bone tumors with a slow progressive growth. These lesions are predominantly located in craniofacial sinuses, but other locations including mandible have been described. Their etiopathogenesis remains controversial. We report a case of post-trauma mandibular osteoma. Gardner syndrome was ruled out.

OBSERVATION

A 31-year-old female patient consulted for a peri-mandibular swelling present for the previous two years. On radiological examination, a bone sclerotic lesion was observed, located on the right lower mandibular edge. Patient history documented an initial trauma at the lesion site. Surgery was performed and anatomopathological examination confirmed the diagnosis of compact osteoma. There was no recurrence one year after surgery.

DISCUSSION

The etiopathogenesis of osteomas is controversial and several hypotheses are suggested. It is regarded as a true benign tumoral process, or abnormality of development, or as a reaction to trauma or infection. The development of osteoma after trauma has been described in several cases, notably in mandibular locations exposed to shocks (angle and lower edge). Multiple osteomas must mandatorily lead to screening for a Gardner's syndrome, because of the associated risk of colon cancer.

Multidisciplinary team working across different tumour types: analysis of a national survey

BACKGROUND

Using data from a national survey, this study aimed to address whether the current model for multidisciplinary team (MDT) working is appropriate for all tumour types.

PATIENTS AND METHODS

Responses to the 2009 National Cancer Action Team national survey were analysed by tumour type. Differences indicate lack of consensus between MDT members in different tumour types.

RESULTS

One thousand one hundred and forty-one respondents from breast, gynaecological, colorectal, upper gastrointestinal, urological, head and neck, haematological and lung MDTs were included. One hundred and sixteen of 136 statements demonstrated consensus between respondents in different tumour types. There were no differences regarding the infrastructure for meetings and team governance. Significant consensus was seen for team characteristics, and respondents disagreed regarding certain aspects of meeting organisations and logistics, and patient-centred decision making. Haematology MDT members were outliers in relation to the clinical decision-making process, and lung MDT members disagreed with other tumour types regarding treating patients with advanced disease.

CONCLUSIONS

This analysis reveals strong consensus between MDT members from different tumour types, while also identifying areas that require a more tailored approach, such as the clinical decision-making process, and preparation for and the organisation of MDT meetings. Policymakers should remain sensitive to the needs of health care teams working in individual tumour types.

Patient involvement in blood transfusion safety: patients' and healthcare professionals' perspective

BACKGROUND

Blood transfusion is one of the major areas where serious clinical consequences, even death, related to patient misidentification can occur. In the UK, healthcare professional compliance with pre-transfusion checking procedures which help to prevent misidentification errors is poor. Involving patients at a number of stages in the transfusion pathway could help prevent the occurrence of these incidents.

OBJECTIVES

To investigate patients' willingness to be involved and healthcare professionals' willingness to support patient involvement in pre-transfusion checking behaviours.

MEASURES

A cross-sectional design was employed assessing willingness to participate in pre-transfusion checking behaviours (patient survey) and willingness to support patient involvement (healthcare professional survey) on a scale of 1-7.

PARTICIPANTS

One hundred and ten patients who had received a transfusion aged between 18 and 93 (60 male) and 123 healthcare professionals (doctors, nurses and midwives) involved in giving blood transfusions to patients.

RESULTS

Mean scores for patients' willingness to participate in safety-relevant transfusion behaviours and healthcare professionals' willingness to support patient involvement ranged from 4.96-6.27 to 4.53-6.66, respectively. Both groups perceived it most acceptable for patients to help prevent errors or omissions relating to their hospital identification wristband. Neither prior experience of receiving a blood transfusion nor professional role of healthcare staff had an effect on attitudes towards patient participation.

CONCLUSION

Overall, both patients and healthcare professionals view patient involvement in transfusion-related behaviours quite favourably and appear in agreement regarding the behaviours patients should adopt an active role in. Further work is needed to determine the effectiveness of this approach to improve transfusion safety.

Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital

OBJECTIVE

To assess the frequency and nature of adverse events to patients in selected hospitals in developing or transitional economies.

DESIGN

Retrospective medical record review of hospital admissions during 2005 in eight countries.

SETTING

Ministries of Health of Egypt, Jordan, Kenya, Morocco, Tunisia, Sudan, South Africa and Yemen; the World Health Organisation (WHO) Eastern Mediterranean and African Regions (EMRO and AFRO), and WHO Patient Safety.

PARTICIPANTS

Convenience sample of 26 hospitals from which 15,548 patient records were randomly sampled.

MAIN OUTCOME MEASURES

Two stage screening. Initial screening based on 18 explicit criteria. Records that screened positive were then reviewed by a senior physician for determination of adverse event, its preventability, and the resulting disability.

RESULTS

Of the 15,548 records reviewed, 8.2% showed at least one adverse event, with a range of 2.5% to 18.4% per country. Of these events, 83% were judged to be preventable, while about 30% were associated with death of the patient. About 34% adverse events were from therapeutic errors in relatively non-complex clinical situations. Inadequate training and supervision of clinical staff or the failure to follow policies or protocols contributed to most events.

CONCLUSIONS

Unsafe patient care represents a serious and considerable danger to patients in the hospitals that were studied, and hence should be a high priority public health problem. Many other developing and transitional economies will probably share similar rates of harm and similar contributory factors. The convenience sampling of hospitals might limit the interpretation of results, but the identified adverse event rates show an estimate that should stimulate and facilitate the urgent institution of appropriate remedial action and also to trigger more research. Prevention of these adverse events will be complex and involves improving basic clinical processes and does not simply depend on the provision of more resources.

[Idiopathic sudden deafness: a report of 96 patients]

OBJECTIVES

Evaluation of the management of idiopathic sudden deafness indicating the usefulness of biological assessments and the pronostic factors of hearing recovery.

PATIENTS AND METHODS

This is a retrospective study of 96 patients with idiopathic sudden deafness referred to a tertiary centre between 2005 and 2009 treated with corticosteroids intravenously at a daily dose of 1 mg/kg. Mean tonal thresholds were assessed (PTA = [500 Hz + 1000 Hz + 2000 Hz + 4000 Hz]/4). Each audiogram was classified as five classes according to its frequency profile.

RESULTS

The hearing recovery is significant between D0-D5 and D5-M1 for the frequencies 0.5, 1 and 2 kHz. For 4 kHz, the recovery is significant between 0 and J5. There is no statistically significant correlation between the presence of associated signs (tinnitus, vertigo) and hearing recovery. Hearing recovery according to the five types of audiograms has the same evolution in the follow-up time but with audiograms type E (cophosis or subcophosis) often associated with an hyporeactivity at the videonystagmography. The presence of cardiovascular disease is a predictor of poor hearing recovery. The usefullness of systematic extensive blood tests is low.

CONCLUSION

In sudden deafness, the maximum hearing recovery takes place in the month following the onset of symptoms. The predictors of poor hearing recovery are an initial mean threshold > 70 dB, the existence of an associated cardiovascular disease.

Development and evaluation of a checklist to support decision making in cancer multidisciplinary team meetings: MDT-QuIC

BACKGROUND

The quality of decision-making in cancer multidisciplinary team (MDT) meetings is variable, which can result in suboptimal clinical decision making. We developed MDT-QuIC, an evidence-based tool to support clinical decision making by MDTs, which was evaluated by key users.

METHODS

Following a literature review, factors important for high-quality clinical decision making were listed and then converted into a preliminary checklist by clinical and safety experts. Attitudes of MDT members toward the tool were evaluated via an online survey, before adjustments were made giving rise to a final version: MDT-QuIC.

RESULTS

The checklist was evaluated by 175 MDT members (surgeons = 38, oncologists = 40, specialist nurses = 62, and MDT coordinators = 35). Attitudes toward the checklist were generally positive (P < 0.001, 1-sample t test), although nurses were more positive than other groups regarding whether the checklist would improve their contribution in MDT meetings (P < 0.001, Mann-Whitney U test). Participants thought that the checklist could be used to prepare cases for MDT meetings, to structure and guide case discussions, or as a record of MDT discussion. Regarding who could use the checklist, 70% thought it should be used by the MDT chair, 54% by the MDT coordinator, and 38% thought all MDT members should use it.

CONCLUSION

We have developed and validated an evidence-based tool to support the quality of MDT decision making. MDT members were positive about the checklist and felt it may help to structure discussion, improve inclusivity, and patient centeredness. Further research is needed to assess its effect on patient care and outcomes.

Predictability of drug release from cochlear implants

A simplified mathematical theory is presented allowing for in silico simulation of the effects of key parameters of miniaturized implants (size and composition) on the resulting drug release kinetics. Such devices offer a great potential, especially for local drug treatments, e.g. of the inner ear. However, the preparation and characterization of these systems is highly challenging, due to the small system dimensions. The presented mathematical theory is based on Fick's second law of diffusion. Importantly, theoretical predictions do not require the knowledge of many system-specific parameters: Only the "apparent" diffusion coefficient of the drug within the implant matrix is needed. This parameter can be easily determined via drug release measurements from thin, macroscopic films. The validity of the theoretical model predictions was evaluated by comparison with experimental results obtained with a cochlear implant. The latter consisted of miniaturized electrodes, which were embedded in a silicone matrix loaded with various amounts of dexamethasone. Importantly, independent experimental results confirmed the theoretical predictions. Thus, the presented simplified theory can help to significantly speed up the optimization of this type of controlled drug delivery systems, especially if long release periods are targeted (e.g., several months or years). Straightforward experiments with thin, macroscopic films and computer simulations can allow for rapid identification of optimal system design.

Predictors of hospitalized patients' intentions to prevent healthcare harm: a cross sectional survey

BACKGROUND

Patients can play an important role in reducing healthcare harm but little is known about the factors that may affect patients' willingness to participate. In order to encourage the 'active' patient it is critical that we gain a deeper understanding of the antecedents of safety-relevant behaviours. Doing this will enable the implementation of effective interventions aimed at supporting patients to work with healthcare professionals in ensuring safe care.

OBJECTIVE

To examine predictors of patients' intentions to engage in two safety behaviours: (1) reminding healthcare staff to wash their hands and; (2) notifying healthcare staff if they are not wearing a hospital identification bracelet.

DESIGN

Cross-sectional survey study.

PARTICIPANTS

A purposive sampling method was employed to recruit 80 medical and surgical hospital inpatients aged 18-80 (mean 48) from one inner city London teaching hospital.

METHODS

A 42 item survey that measured the extent that patients' control beliefs, behavioural beliefs, normative beliefs and perceived susceptibility and severity towards a hospital-acquired infection or a misidentification error could predict their intentions to ask doctors/nurses about their hand washing compliance or notify doctors/nurses if they are not wearing a hospital identification bracelet. Data was analysed using multiple regression analysis.

RESULTS

Control beliefs, normative beliefs and perceived severity were the strongest predictors of patients' intentions to participate in both behaviours. The regression models accounted for a smaller percentage of the variance in patients' intentions to ask doctors/nurses if they have washed their hands (42%/37%) than notifying staff if they were not wearing an identification bracelet (54%/56%).

CONCLUSIONS

If patients understand why a behaviour is beneficial, they perceive it as acceptable to participate in and that they have control over the decision to engage in the behaviour, we hypothesise that more patients will intend to participate in that behaviour. When designing interventions aimed at encouraging the participation of patients in promoting their own safety, consideration should be given to the potential influence of patients' control beliefs, normative beliefs and perceived severity of errors on their intentions to participate.

[Stability of Le Fort I impaction osteotomies]

INTRODUCTION

Long-term results of Le Fort I osteotomy with vertical impaction for maxillary vertical excess may be not stable. We had for aim to analyze postoperative maxillary and dental displacement after a Le Fort I vertical impaction osteotomy, to identify causes of relapse.

PATIENTS AND METHODS

A clinical and radiological evaluation was made on postoperative occlusion (early and late). The position of three bone (O: lower orbit; P: greatest palatine convexity; T: lowest part of the mandibular foramen) and of three dental landmarks (I: occlusal edge of the upper incisor; i: occlusal edge of the lower incisor; m: first molar distal vestibular cuspid) was measured in a standardized method on pre-surgical, early and late (1 to 2.5 years) postoperative cephalometric X rays. Eighteen patients were operated by the same surgeon for maxillary anterior vertical excess and underwent Le Fort I impaction osteotomy, alone or associated with a mandibular osteotomy. Stability was defined by a postoperatory displacement smaller than 1mm.

RESULTS

All patients had stable bone landmarks. Three patients had unstable dental landmarks due to relapse.

DISCUSSION

Impaction maxillary osteotomy provides stable bone results for maxillary facial height excess. Unsatisfactory outcome is always due to postoperative dental and alveolar displacement. These results correlate to published data.

Establishing quality in colorectal surgery

AIM

The review aimed to offer a contemporary perspective of the quality of current colorectal surgery.

METHOD

A literature search was undertaken to identify relevant indicators. Citations were included if they related to quality in colorectal surgery. The search terms used included the Medical Subject Heading terms and Boolean characters: 'colon' OR 'colorectal', OR 'rectal' OR 'rectum' AND 'Quality Indicators', OR 'Quality Assurance', OR 'Quality of healthcare', OR 'Reference Standards', OR 'Quality' plus a variable floating term. A two-person independent review was undertaken from resulting citations and their consequent reference lists. The search was limited to citations from 2000 to 2010 in humans and to the English language.

RESULTS

Metrics identified as potential quality indicators in colorectal surgery are discussed according to the structure, process and outcome framework.

CONCLUSION

A clear appreciation of the scope of individual metrics for quality appraisal purposes is necessary if they are to be used meaningfully for performance benchmarking.

Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection

Background

Complication management appears to be of vital importance to differences in survival following surgery between surgical units. Failure-to-rescue (FTR) rates have not yet distinguished surgical from general medical complications. The aim of this study was to assess whether variability exists in FTR rates after reoperation for serious surgical complications following colorectal cancer resections in England.

Methods

The Hospital Episode Statistics (HES) database was used to identify patients undergoing primary resection for colorectal cancer between 2000 and 2008 in English National Health Service (NHS) trusts. Units were ranked into quintiles according to overall risk-adjusted mortality. Highest and lowest mortality quintiles were compared with respect to reoperation rates and FTR—surgical (FTR-S) rates. FTR-S was defined as the proportion of patients with an unplanned reoperation who died within the same admission.

Results

Some 144 542 patients undergoing resection for colorectal cancer in 150 English NHS trusts were included. On ranking according to risk-adjusted mortality, rates varied significantly between lowest and highest mortality quintiles (5·4 and 9·3 per cent respectively; P = 0·029). Lowest and highest mortality quintiles had equivalent adjusted reoperation rates (both 4·8 per cent; P = 0·211). FTR-S rates were significantly higher at units within the worst mortality quintile (16·8 versus 11·1 per cent; P = 0·002).

Conclusion

FTR-S rates differed significantly between English colorectal units, highlighting variability in ability to prevent death in this high-risk group. This variability may represent differences in serious surgical complication management. FTR-S represents a readily collectable marker of surgical complication management that is likely to be applicable to other surgical specialties.

Quality improvement in multidisciplinary cancer teams: an investigation of teamwork and clinical decision-making and cross-validation of assessments

PURPOSE

Teamworking and clinical decision-making are important in multidisciplinary cancer teams (MDTs). Our objective is to assess the quality of information presentation and MDT members' contribution to decision-making via expert observation and self-report, aiming to cross-validate the two methods and assess the insight of MDT members into their own team performance.

MATERIALS AND METHODS

Behaviors were scored using (i) a validated observational tool employing Likert scales with objective anchors, and (ii) a 29-question online self-report tool. Data were collected from observation of 164 cases in five MDTs, and 47 surveys from MDT members (response rate 70%). Presentation of information (case history, radiological, pathological, comorbidities, psychosocial, and patients' views) and quality of contribution to decision-making of MDT members (surgeons, oncologists, radiologists, pathologists, nurses, and MDT coordinators) were analyzed via descriptive statistics and the Jonckheere-Terpstra test. Correlation between observational and self-report assessments was assessed with Spearman's correlations.

RESULTS

Quality of information presentation: Case histories and radiology information rated highest; patients' views and comorbidities/psychosocial issues rated lowest (observed: Z = 14.80, P ≤ 0.001; self-report: Z = 3.70, P < 0.001). Contribution to decision-making: Surgeons and oncologists rated highest, nurses and MDT coordinators rated lowest, and others in between (observed: Z = 20.00, P ≤ 0.001; self-report: Z = 8.10, P < 0.001). Correlations between observational and self-report assessments: Median Spearman's rho = 0.74 (range = 0.66-0.91; P < 0.05).

CONCLUSIONS

The quality of teamworking and clinical decision-making in MDTs can reliably be assessed using observational and self-report metrics. MDT members have good insight into their own team performance. Such robust assessment methods could provide the basis of a toolkit for MDT team evaluation and improvement.

Complete exon sequencing of all known Usher syndrome genes greatly improves molecular diagnosis

BACKGROUND

Usher syndrome (USH) combines sensorineural deafness with blindness. It is inherited in an autosomal recessive mode. Early diagnosis is critical for adapted educational and patient management choices, and for genetic counseling. To date, nine causative genes have been identified for the three clinical subtypes (USH1, USH2 and USH3). Current diagnostic strategies make use of a genotyping microarray that is based on the previously reported mutations. The purpose of this study was to design a more accurate molecular diagnosis tool.

METHODS

We sequenced the 366 coding exons and flanking regions of the nine known USH genes, in 54 USH patients (27 USH1, 21 USH2 and 6 USH3).

RESULTS

Biallelic mutations were detected in 39 patients (72%) and monoallelic mutations in an additional 10 patients (18.5%). In addition to biallelic mutations in one of the USH genes, presumably pathogenic mutations in another USH gene were detected in seven patients (13%), and another patient carried monoallelic mutations in three different USH genes. Notably, none of the USH3 patients carried detectable mutations in the only known USH3 gene, whereas they all carried mutations in USH2 genes. Most importantly, the currently used microarray would have detected only 30 of the 81 different mutations that we found, of which 39 (48%) were novel.

CONCLUSIONS

Based on these results, complete exon sequencing of the currently known USH genes stands as a definite improvement for molecular diagnosis of this disease, which is of utmost importance in the perspective of gene therapy.

Observational Skill-based Clinical Assessment tool for Resuscitation (OSCAR): development and validation

Aim

The aim of the study reported here was to address the need to assess and train teamwork and non-technical skills in the context of Resuscitation. Specifically, we sought to develop a tool that is feasible to use and psychometrically sound to assess team behaviours during cardiac arrest resuscitation attempts.

Methods

To ensure validity, reliability, and feasibility, the Observational Skill based Clinical Assessment tool for Resuscitation (OSCAR) was developed in 3 phases. A review of the literature leading to initial tool development was followed by an assessment of face and content validity, and finally a thorough reliability assessment, using Cronbach's α to assess internal consistency and intraclass correlation to assess inter-rater reliability.

Results

OSCAR was developed methodically, and tested for face and content validity. Cronbach's α results ranged from 0.736 to 0.965 demonstrating high internal consistency, and intraclass correlation results ranged from 0.652 to 0.911, all of which are strongly significant and indicate good inter-rater reliability.

Conclusion

On the basis of our results, we conclude that OSCAR is psychometrically robust, scientifically sound, and clinically relevant. We have developed the Observational Skill-based Clinical Assessment tool for Resuscitation (OSCAR) for the assessment of non-technical skills in Resuscitation teams. We propose the use of this tool in simulation and real Cardiac Arrest Resuscitation attempts to assess, guide and train non-technical skills to team members, to improve patient safety and maximise the chances of successful resuscitation.

Evaluation of tag entanglement as a factor in harmonic radar studies of insect dispersal

The observation of insects and other small organisms entangled in the habitat after the addition of vertical or trailing electronic tags to their body has generated concerns on the suitability of harmonic radars to track the dispersal of insects. This study compared the walking behavior of adult Colorado potato beetle (Leptinotarsa decemlineata (Say) Chrysomelidae), plum curculio (Conotrachelus nenuphar (Herbst) Curculionidae), and western corn rootworm (Diabrotica virgifera virgifera (LeConte) Chrysomelidae) with and without vertical and or trailing tags in field plots or arenas. The frequency of the larger Colorado potato beetles crossing bare ground or grassy plots was unaffected by the presence of an 8 cm trailing harmonic radar tag. However, plum curculios and western corn rootworms, were either unable to walk with a 4 cm trailing tag (plum curculio) or displayed a reduced ability to successfully cross a bare ground arena. Our results revealed the significant impact of vegetation on successful insect dispersal, whether tagged or not. The vertical movement of these insects on stems, stalks, and tubes was also unaffected by the presence of vertical tags. Trailing tags had a significant negative effect on the vertical movement of the western corn rootworm. Results show that harmonic radar technology is a suitable method for studying the walking paths of the three insects with appropriate tag type and size. The nuisance factor generated by appropriately sized tags was small relative to that of vegetation.

PG545, a dual heparanase and angiogenesis inhibitor, induces potent anti-tumour and anti-metastatic efficacy in preclinical models

Background:

PG545 is a heparan sulfate (HS) mimetic that inhibits tumour angiogenesis by sequestering angiogenic growth factors in the extracellular matrix (ECM), thus limiting subsequent binding to receptors. Importantly, PG545 also inhibits heparanase, the only endoglycosidase which cleaves HS chains in the ECM. The aim of the study was to assess PG545 in various solid tumour and metastasis models.

Methods:

The anti-angiogenic, anti-tumour and anti-metastatic properties of PG545 were assessed using in vivo angiogenesis, solid tumour and metastasis models. Pharmacokinetic (PK) data were also generated in tumour-bearing mice to gain an understanding of optimal dosing schedules and regimens.

Results:

PG545 was shown to inhibit angiogenesis in vivo and induce anti-tumour or anti-metastatic effects in murine models of breast, prostate, liver, lung, colon, head and neck cancers and melanoma. Enhanced anti-tumour activity was also noted when used in combination with sorafenib in a liver cancer model. PK data revealed that the half-life of PG545 was relatively long, with pharmacologically relevant concentrations of radiolabeled PG545 observed in liver tumours.

Conclusion:

PG545 is a new anti-angiogenic clinical candidate for cancer therapy. The anti-metastatic property of PG545, likely due to the inhibition of heparanase, may prove to be a critical attribute as the compound enters phase I clinical trials.