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Kovoor JG, Gupta AK, Bacchi S, Stretton B, O'Callaghan PG, Murphy E, Hugh TJ, Padbury RT, Trochsler MI, Maddern GJ. Achieving equity: patient demographics and outcomes after surgical and non-surgical procedures in South Australia, 2022. ANZ J Surg 2024; 94:96-102. [PMID: 38291008 DOI: 10.1111/ans.18871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Although modern Australian healthcare systems provide patient-centred care, the ability to predict and prevent suboptimal post-procedural outcomes based on patient demographics at admission may improve health equity. This study aimed to identify patient demographic characteristics that might predict disparities in mortality, readmission, and discharge outcomes after either an operative or non-operative procedural hospital admission. METHODS This retrospective cohort study included all surgical and non-surgical procedural admissions at three of the four major metropolitan public hospitals in South Australia in 2022. Multivariable logistic regression, with backwards selection, evaluated association between patient demographic characteristics and outcomes up to 90 days post-procedurally. RESULTS 40 882 admissions were included. Increased likelihood of all-cause, post-procedure mortality in-hospital, at 30 days, and 90 days, were significantly associated with increased age (P < 0.001), increased comorbidity burden (P < 0.001), an emergency admission (P < 0.001), and male sex (P = 0.046, P = 0.03, P < 0.001, respectively). Identification as ATSI (P < 0.001) and being born in Australia (P = 0.03, P = 0.001, respectively) were associated with an increased likelihood of 30-day hospital readmission and decreased likelihood of discharge directly home, as was increased comorbidity burden (P < 0.001) and emergency admission (P < 0.001). Being married (P < 0.001) and male sex (P = 0.003) were predictive of an increased likelihood of discharging directly home; in contrast to increased age (P < 0.001) which was predictive of decreased likelihood of this occurring. CONCLUSIONS This study characterized several associations between patient demographic factors present on admission and outcomes after surgical and non-surgical procedures, that can be integrated within patient flow pathways through the Australian healthcare system to improve healthcare equity.
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Affiliation(s)
- Joshua G Kovoor
- The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- Ballarat Base Hospital, Ballarat, Victoria, Australia
| | - Aashray K Gupta
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Prince of Wales Hospital, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Stephen Bacchi
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- Flinders University, Adelaide, South Australia, Australia
- Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Brandon Stretton
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Patrick G O'Callaghan
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Elizabeth Murphy
- University of Adelaide, Adelaide, South Australia, Australia
- Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Thomas J Hugh
- Royal North Shore Hospital, Sydney, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
| | - Robert T Padbury
- Flinders University, Adelaide, South Australia, Australia
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Guy J Maddern
- The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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Kovoor JG, Bacchi S, Gupta AK, Nann SD, Stretton B, Chong EHL, Hewitt JN, Bhanushali A, Nathin K, Aujayeb N, Lu A, Ovenden CD, John A, Reid JL, Gluck S, Liew D, Reddi BA, Hugh TJ, Dobbins C, Padbury RT, Hewett PJ, Trochsler MI, Maddern GJ. Sociocultural and Demographic Factors Predict Readmissions for General Surgery Patients. World J Surg 2023; 47:3124-3130. [PMID: 37775572 PMCID: PMC10694098 DOI: 10.1007/s00268-023-07177-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION Readmission is a poor outcome for both patients and healthcare systems. The association of certain sociocultural and demographic characteristics with likelihood of readmission is uncertain in general surgical patients. METHOD A multi-centre retrospective cohort study of consecutive unique individuals who survived to discharge during general surgical admissions was conducted. Sociocultural and demographic variables were evaluated alongside clinical parameters (considered both as raw values and their proportion of change in the 1-2 days prior to admission) for their association with 7 and 30 days readmission using logistic regression. RESULTS There were 12,701 individuals included, with 304 (2.4%) individuals readmitted within 7 days, and 921 (7.3%) readmitted within 30 days. When incorporating absolute values of clinical parameters in the model, age was the only variable significantly associated with 7-day readmission, and primary language and presence of religion were the only variables significantly associated with 30-day readmission. When incorporating change in clinical parameters between the 1-2 days prior to discharge, primary language and religion were predictive of 30-day readmission. When controlling for changes in clinical parameters, only higher comorbidity burden (represented by higher Charlson comorbidity index score) was associated with increased likelihood of 30-day readmission. CONCLUSIONS Sociocultural and demographic patient factors such as primary language, presence of religion, age, and comorbidity burden predict the likelihood of 7 and 30-day hospital readmission after general surgery. These findings support early implementation a postoperative care model that integrates all biopsychosocial domains across multiple disciplines of healthcare.
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Affiliation(s)
- Joshua G Kovoor
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA, Australia
- Royal Australasian College of Surgeons, Adelaide, SA, Australia
- Port Augusta Hospital, Port Augusta, SA, Australia
| | - Stephen Bacchi
- Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Aashray K Gupta
- University of Adelaide, Adelaide, SA, Australia
- Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Silas D Nann
- Port Augusta Hospital, Port Augusta, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Brandon Stretton
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Esther H L Chong
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA, Australia
- Port Augusta Hospital, Port Augusta, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Joseph N Hewitt
- Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Ameya Bhanushali
- Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | | | | | - Amy Lu
- University of Adelaide, Adelaide, SA, Australia
| | - Christopher D Ovenden
- Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Athul John
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA, Australia
| | - Jessica L Reid
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA, Australia
| | - Samuel Gluck
- Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Danny Liew
- Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Benjamin A Reddi
- Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Thomas J Hugh
- University of Sydney, Sydney, NSW, Australia
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - Christopher Dobbins
- Port Augusta Hospital, Port Augusta, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Robert T Padbury
- Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
- Flinders Medical Centre, Adelaide, SA, Australia
| | - Peter J Hewett
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA, Australia
| | - Markus I Trochsler
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA, Australia
- Port Augusta Hospital, Port Augusta, SA, Australia
| | - Guy J Maddern
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA, Australia.
- Royal Australasian College of Surgeons, Adelaide, SA, Australia.
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Kovoor JG, Bacchi S, Gupta AK, Stretton B, Nann SD, Aujayeb N, Lu A, Nathin K, Lam L, Jiang M, Lee S, To MS, Ovenden CD, Hewitt JN, Goh R, Gluck S, Reid JL, Khurana S, Dobbins C, Hewett PJ, Padbury RT, Malycha J, Trochsler MI, Hugh TJ, Maddern GJ. Surgery's Rosetta Stone: Natural language processing to predict discharge and readmission after general surgery. Surgery 2023; 174:1309-1314. [PMID: 37778968 DOI: 10.1016/j.surg.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/04/2023] [Accepted: 08/16/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND This study aimed to examine the accuracy with which multiple natural language processing artificial intelligence models could predict discharge and readmissions after general surgery. METHODS Natural language processing models were derived and validated to predict discharge within the next 48 hours and 7 days and readmission within 30 days (based on daily ward round notes and discharge summaries, respectively) for general surgery inpatients at 2 South Australian hospitals. Natural language processing models included logistic regression, artificial neural networks, and Bidirectional Encoder Representations from Transformers. RESULTS For discharge prediction analyses, 14,690 admissions were included. For readmission prediction analyses, 12,457 patients were included. For prediction of discharge within 48 hours, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.86 and 0.86 for Bidirectional Encoder Representations from Transformers, 0.82 and 0.81 for logistic regression, and 0.82 and 0.81 for artificial neural networks. For prediction of discharge within 7 days, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.82 and 0.81 for Bidirectional Encoder Representations from Transformers, 0.75 and 0.72 for logistic regression, and 0.68 and 0.67 for artificial neural networks. For readmission prediction within 30 days, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.55 and 0.59 for Bidirectional Encoder Representations from Transformers and 0.77 and 0.62 for logistic regression. CONCLUSION Modern natural language processing models, particularly Bidirectional Encoder Representations from Transformers, can effectively and accurately identify general surgery patients who will be discharged in the next 48 hours. However, these approaches are less capable of identifying general surgery patients who will be discharged within the next 7 days or who will experience readmission within 30 days of discharge.
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Affiliation(s)
- Joshua G Kovoor
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia; Royal Australasian College of Surgeons, Adelaide, South Australia, Australia; Health and Information, Adelaide, South Australia, Australia. https://twitter.com/josh.kovoor
| | - Stephen Bacchi
- Health and Information, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia; Health and Information, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia; Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Brandon Stretton
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia; Health and Information, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Silas D Nann
- Health and Information, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia; Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Nidhi Aujayeb
- Health and Information, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Amy Lu
- Health and Information, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Kayla Nathin
- Health and Information, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Lydia Lam
- Health and Information, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Melinda Jiang
- Health and Information, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Shane Lee
- Health and Information, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Minh-Son To
- Health and Information, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia; Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Christopher D Ovenden
- Health and Information, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Joseph N Hewitt
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia; Health and Information, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rudy Goh
- Health and Information, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Samuel Gluck
- University of Adelaide, Adelaide, South Australia, Australia
| | - Jessica L Reid
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sanjeev Khurana
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Christopher Dobbins
- Royal Adelaide Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Peter J Hewett
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Robert T Padbury
- Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - James Malycha
- Royal Adelaide Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Thomas J Hugh
- University of Sydney, Sydney, New South Wales, Australia; Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Guy J Maddern
- Department of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia; Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.
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Kovoor JG, Bacchi S, Gupta AK, Vo T, Lam C, Lam L, Jiang M, Stretton B, To MS, Nann S, Ovenden CD, Hewitt JN, Goh R, Reid JL, Hugh TJ, Dobbins C, Hewett PJ, Trochsler MI, Kette FE, Maddern GJ. Opioid prescribing, pain, and hospital stay of general surgery patients with oxycodone allergies in South Australia. ANZ J Surg 2023; 93:2631-2637. [PMID: 37837230 DOI: 10.1111/ans.18722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/16/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND The frequency of oxycodone adverse reactions, subsequent opioid prescription, effect on pain and patient care in general surgery patients are not well known. This study aimed to determine prevalence of documented oxycodone allergy and intolerances (independent variables) in a general surgical cohort, and association with prescribing other analgesics (particularly opioids), subjective pain scores, and length of hospital stay (dependent variables). METHODS This retrospective cohort study included general surgery patients from two South Australian hospitals between April 2020 and March 2022. Multivariable logistic regression evaluated associations between previous oxycodone allergies and intolerances, prescription records, subjective pain scores, and length of hospital stay. RESULTS Of 12 846 patients, 216 (1.7%) had oxycodone allergies, and 84 (0.7%) oxycodone intolerances. The 216 oxycodone allergy patients had lower odds of receiving oxycodone (OR 0.17, P < 0.001), higher odds of tramadol (OR 3.01, P < 0.001) and tapentadol (OR 2.87, P = 0.001), but 91 (42.3%) still received oxycodone and 19 (8.8%) morphine. The 84 with oxycodone intolerance patients had lower odds of receiving oxycodone (OR 0.23, P < 0.001), higher odds of fentanyl (OR 3.6, P < 0.001) and tramadol (OR 3.35, P < 0.001), but 42 (50%) still received oxycodone. Patients with oxycodone allergies and intolerances had higher odds of elevated subjective pain (OR 1.60, P = 0.013; OR 2.36, P = 0.002, respectively) and longer length of stay (OR 1.36, P = 0.038; OR 2.24, P = 0.002, respectively) than patients without these. CONCLUSIONS General surgery patients with oxycodone allergies and intolerances are at greater risk of worse postoperative pain and longer length of stay, compared to patients without. Many still receive oxycodone, and other opioids that could cause cross-reactivity.
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Affiliation(s)
- Joshua G Kovoor
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- University of Adelaide, Adelaide, South Australia, Australia
- Flinders Medical Centre, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- University of Adelaide, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Tammy Vo
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Cindy Lam
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Lydia Lam
- University of Adelaide, Adelaide, South Australia, Australia
| | - Melinda Jiang
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Brandon Stretton
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Minh-Son To
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Silas Nann
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher D Ovenden
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joseph N Hewitt
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rudy Goh
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jessica L Reid
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Thomas J Hugh
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Christopher Dobbins
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Peter J Hewett
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Frank E Kette
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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5
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Kovoor JG, Bacchi S, Stretton B, Gupta AK, Lam L, Jiang M, Lee S, To MS, Ovenden CD, Hewitt JN, Goh R, Gluck S, Reid JL, Hugh TJ, Dobbins C, Padbury RT, Hewett PJ, Trochsler MI, Flabouris A, Maddern GJ. Vital signs and medical emergency response (MER) activation predict in-hospital mortality in general surgery patients: a study of 15 969 admissions. ANZ J Surg 2023; 93:2426-2432. [PMID: 37574649 DOI: 10.1111/ans.18648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/28/2023] [Accepted: 07/21/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND The applicability of the vital signs prompting medical emergency response (MER) activation has not previously been examined specifically in a large general surgical cohort. This study aimed to characterize the distribution, and predictive performance, of four vital signs selected based on Australian guidelines (oxygen saturation, respiratory rate, systolic blood pressure and heart rate); with those of the MER activation criteria. METHODS A retrospective cohort study was conducted including patients admitted under general surgical services of two hospitals in South Australia over 2 years. Likelihood ratios for patients meeting MER activation criteria, or a vital sign in the most extreme 1% for general surgery inpatients (<0.5th percentile or > 99.5th percentile), were calculated to predict in-hospital mortality. RESULTS 15 969 inpatient admissions were included comprising 2 254 617 total vital sign observations. The 0.5th and 99.5th centile for heart rate was 48 and 133, systolic blood pressure 85 and 184, respiratory rate 10 and 31, and oxygen saturations 89% and 100%, respectively. MER activation criteria with the highest positive likelihood ratio for in-hospital mortality were heart rate ≤ 39 (37.65, 95% CI 27.71-49.51), respiratory rate ≥ 31 (15.79, 95% CI 12.82-19.07), and respiratory rate ≤ 7 (10.53, 95% CI 6.79-14.84). These MER activation criteria likelihood ratios were similar to those derived when applying a threshold of the most extreme 1% of vital signs. CONCLUSIONS This study demonstrated that vital signs within Australian guidelines, and escalation to MER activation, appropriately predict in-hospital mortality in a large cohort of patients admitted to general surgical services in South Australia.
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Affiliation(s)
- Joshua G Kovoor
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Flinders Medical Centre, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Brandon Stretton
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Lydia Lam
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Melinda Jiang
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Shane Lee
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Minh-Son To
- Health and Information, Adelaide, South Australia, Australia
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Christopher D Ovenden
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joseph N Hewitt
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rudy Goh
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Samuel Gluck
- University of Adelaide, Adelaide, South Australia, Australia
| | - Jessica L Reid
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Thomas J Hugh
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Christopher Dobbins
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Peter J Hewett
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Arthas Flabouris
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Guy J Maddern
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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Kovoor JG, Bacchi S, Gupta AK, Stretton B, Malycha J, Reddi BA, Liew D, O'Callaghan PG, Beltrame JF, Zannettino AC, Jones KL, Horowitz M, Dobbins C, Hewett PJ, Trochsler MI, Maddern GJ. The Adelaide Score: An artificial intelligence measure of readiness for discharge after general surgery. ANZ J Surg 2023; 93:2119-2124. [PMID: 37264548 DOI: 10.1111/ans.18546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/17/2023] [Accepted: 05/21/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND This study aimed to examine the performance of machine learning algorithms for the prediction of discharge within 12 and 24 h to produce a measure of readiness for discharge after general surgery. METHODS Consecutive general surgery patients at two tertiary hospitals, over a 2-year period, were included. Observation and laboratory parameter data were stratified into training, testing and validation datasets. Random forest, XGBoost and logistic regression models were evaluated. Each ward round note time was taken as a different event. Primary outcome was classification accuracy of the algorithmic model able to predict discharge within the next 12 h on the validation data set. RESULTS 42 572 ward round note timings were included from 8826 general surgery patients. Discharge occurred within 12 h for 8800 times (20.7%), and within 24 h for 9885 (23.2%). For predicting discharge within 12 h, model classification accuracies for derivation and validation data sets were: 0.84 and 0.85 random forest, 0.84 and 0.83 XGBoost, 0.80 and 0.81 logistic regression. For predicting discharge within 24 h, model classification accuracies for derivation and validation data sets were: 0.83 and 0.84 random forest, 0.82 and 0.81 XGBoost, 0.78 and 0.79 logistic regression. Algorithms generated a continuous number between 0 and 1 (or 0 and 100), representing readiness for discharge after general surgery. CONCLUSIONS A derived artificial intelligence measure (the Adelaide Score) successfully predicts discharge within the next 12 and 24 h in general surgery patients. This may be useful for both treating teams and allied health staff within surgical systems.
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Affiliation(s)
- Joshua G Kovoor
- Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Flinders University, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Brandon Stretton
- Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- Flinders University, Adelaide, South Australia, Australia
| | - James Malycha
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Benjamin A Reddi
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Danny Liew
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Patrick G O'Callaghan
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - John F Beltrame
- Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Karen L Jones
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michael Horowitz
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher Dobbins
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Peter J Hewett
- Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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7
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Jolly S, Chu MKW, Gupta AK, Mitchell J, Kovoor JG, Stewart SK, Babidge WJ, Chan JCY, Trochsler MI, Maddern GJ. Potentially avoidable mortality after endoscopic retrograde cholangiopancreatography in Australia: an 8-year qualitative analysis. ANZ J Surg 2023; 93:1825-1832. [PMID: 37209092 DOI: 10.1111/ans.18511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 04/14/2023] [Accepted: 04/29/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure worldwide. The aim of this study was to examine cases of mortality after ERCP to identify clinical incidents that are potentially preventable, to improve patient safety. METHODS The Australian and New Zealand Audit of Surgical Mortality provides an independent and externally peer-reviewed audit of surgical mortality pertaining to potentially avoidable issues. A retrospective review of prospectively collected data within this database was performed for the 8-year audit period from 1 January 2009 to 31 December 2016. Clinical incidents were identified by assessors through first- or second-line review, and thematically coded into periprocedural stages. These themes were then qualitatively analysed. RESULTS There were 58 potentially avoidable deaths following ERCP, with 85 clinical incidents. Preprocedural incidents were most common (n = 37), followed by postprocedural (n = 32) and then intraprocedural (n = 8). Communication issues occurred across the periprocedural period (n = 8). Preprocedural incidents included delay to procedure, inadequate resuscitative management, decision to perform procedure and inadequate assessment. Intraprocedural incidents comprised technical factors and inadequate support. Postprocedural incidents involved inappropriate treatment, delay in definitive surgical treatment or in recognizing complications, inappropriate second-line intervention and inadequate assessment. Communication incidents comprised inadequate documentation, failure to escalate care and poor inter-clinician communication. CONCLUSION Causes of mortality following ERCP are wide-ranging, and reviewing clinical incidents associated with potentially avoidable mortality can serve to inform and educate practitioners. In collating a subset of cases in which procedure-related mortality was deemed avoidable, a series of cautionary tales about ERCP is presented that may provide cues to practitioners on improving patient safety and inform future surgical practice.
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Affiliation(s)
- Samantha Jolly
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Matthew K W Chu
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
- The Department of Gastroenterology and Hepatology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Jessica Mitchell
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Joshua G Kovoor
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Sasha K Stewart
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Wendy J Babidge
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Justin C Y Chan
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
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8
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Kovoor JG, Jacobsen JHW, Stretton B, Bacchi S, Gupta AK, Claridge B, Steen MV, Bhanushali A, Bartholomeusz L, Edwards S, Asokan GP, Asokan G, McGee A, Ovenden CD, Hewitt JN, Trochsler MI, Padbury RT, Perry SW, Wong ML, Licinio J, Maddern GJ, Hewett PJ. Depression after stoma surgery: a systematic review and meta-analysis. BMC Psychiatry 2023; 23:352. [PMID: 37217917 DOI: 10.1186/s12888-023-04871-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 05/15/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Depression is the leading cause of global disability and can develop following the change in body image and functional capacity associated with stoma surgery. However, reported prevalence across the literature is unknown. Accordingly, we performed a systematic review and meta-analysis aiming to characterise depressive symptoms after stoma surgery and potential predictive factors. METHODS PubMed/MEDLINE, Embase, CINAHL and Cochrane Library were searched from respective database inception to 6 March 2023 for studies reporting rates of depressive symptoms after stoma surgery. Risk of bias was assessed using the Downs and Black checklist for non-randomised studies of interventions (NRSIs), and Cochrane RoB2 tool for randomised controlled trials (RCTs). Meta-analysis incorporated meta-regressions and a random-effects model. REGISTRATION PROSPERO, CRD42021262345. RESULTS From 5,742 records, 68 studies were included. According to Downs and Black checklist, the 65 NRSIs were of low to moderate methodological quality. According to Cochrane RoB2, the three RCTs ranged from low risk of bias to some concerns of bias. Thirty-eight studies reported rates of depressive symptoms after stoma surgery as a proportion of the respective study populations, and from these, the median rate across all timepoints was 42.9% 42.9% (IQR: 24.2-58.9%). Pooled scores for respective validated depression measures (Hospital Anxiety and Depression Score (HADS), Beck Depression Inventory (BDI), and Patient Health Questionnaire-9 (PHQ-9)) across studies reporting those scores were below clinical thresholds for major depressive disorder according to severity criteria of the respective scores. In the three studies that used the HADS to compare non-stoma versus stoma surgical populations, depressive symptoms were 58% less frequent in non-stoma populations. Region (Asia-Pacific; Europe; Middle East/Africa; North America) was significantly associated with postoperative depressive symptoms (p = 0.002), whereas age (p = 0.592) and sex (p = 0.069) were not. CONCLUSIONS Depressive symptoms occur in almost half of stoma surgery patients, which is higher than the general population, and many inflammatory bowel disease and colorectal cancer populations outlined in the literature. However, validated measures suggest this is mostly at a level of clinical severity below major depressive disorder. Stoma patient outcomes and postoperative psychosocial adjustment may be enhanced by increased psychological evaluation and care in the perioperative period.
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Affiliation(s)
- Joshua G Kovoor
- University of Adelaide, Adelaide, South Australia, Australia.
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.
- Royal Adelaide Hospital, Adelaide, South Australia, Australia.
- Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia.
- Health and Information, Adelaide, South Australia, Australia.
| | | | - Brandon Stretton
- University of Adelaide, Adelaide, South Australia, Australia
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- University of Adelaide, Adelaide, South Australia, Australia
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- University of Adelaide, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Brayden Claridge
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Matthew V Steen
- Glenside Health Services, Adelaide, South Australia, Australia
| | - Ameya Bhanushali
- University of Adelaide, Adelaide, South Australia, Australia
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Lorenz Bartholomeusz
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- University of Adelaide, Adelaide, South Australia, Australia
| | - Gayatri P Asokan
- Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Gopika Asokan
- University of Adelaide, Adelaide, South Australia, Australia
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Amanda McGee
- Stoma Care Services, Adelaide, South Australia, Australia
| | - Christopher D Ovenden
- University of Adelaide, Adelaide, South Australia, Australia
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
| | - Joseph N Hewitt
- University of Adelaide, Adelaide, South Australia, Australia
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- University of Adelaide, Adelaide, South Australia, Australia
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Robert T Padbury
- Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Seth W Perry
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Ma-Li Wong
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Julio Licinio
- Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Guy J Maddern
- University of Adelaide, Adelaide, South Australia, Australia
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Peter J Hewett
- University of Adelaide, Adelaide, South Australia, Australia
- The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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9
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Kovoor JG, Bacchi S, Gupta AK, O'Callaghan PG, Trochsler MI, Maddern GJ. Standardizing optimization in surgery. ANZ J Surg 2023; 93:24-25. [PMID: 36546639 DOI: 10.1111/ans.18201] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/24/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Joshua G Kovoor
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia.,Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,Health and Information, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Health and Information, Adelaide, South Australia, Australia.,Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia.,University of Adelaide, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Health and Information, Adelaide, South Australia, Australia.,University of Adelaide, Adelaide, South Australia, Australia.,Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Patrick G O'Callaghan
- Royal Adelaide Hospital, Adelaide, South Australia, Australia.,University of Adelaide, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia.,Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,Health and Information, Adelaide, South Australia, Australia
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10
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Reid JL, Ting YY, Salih S, Trochsler MI, Mazzarolo D, Bonnici A, Maddern GJ. Is four years enough? An audit of post-hepatectomy surveillance for liver metastases. HPB (Oxford) 2022; 24:1697-1702. [PMID: 35491338 DOI: 10.1016/j.hpb.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/03/2022] [Accepted: 04/07/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Optimal timing and modality of surveillance post hepatectomy for colorectal cancer liver metastases (CLM) has not been established. Recommendations vary between countries and surgical units. Individual clinicians do not always adhere to guidelines. METHODS Using a prospectively collected database of consecutive hepatectomy patients at The Queen Elizabeth Hospital in Adelaide, Australia, CLM patients were reviewed for evidence of recurrent disease (20 February 1996-30 June 2018). Timing and modality of disease detection was analysed. Follow up was until 30 June 2020 or death. RESULTS 244 patients underwent hepatectomy for CLM during the study period. 139 patients (57%) experienced recurrence post initial hepatectomy (mean time 13.2 months; range 0.6-84.7). For all hepatic recurrences (n = 172), majority of disease was detected in the first seven months post hepatectomy (55%) and by four years, 97.7% of recurrent disease was detected. 51 patients underwent curative repeat hepatectomy after recurrence was detected. Nearly all disease was detected via surveillance CT (160/172; 93%); 12 patients presented with clinical symptoms. CONCLUSION Hepatectomy patients are likely to experience recurrent disease and clinicians must ensure a robust surveillance plan is in place. We recommend a triple-phase CT at 6, 12, 18, 24, 36 and 48 months.
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Affiliation(s)
- Jessica L Reid
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road Woodville South, South Australia 5011, Australia
| | - Ying Yang Ting
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road Woodville South, South Australia 5011, Australia
| | - Salma Salih
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road Woodville South, South Australia 5011, Australia
| | - Markus I Trochsler
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road Woodville South, South Australia 5011, Australia
| | - Deanna Mazzarolo
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road Woodville South, South Australia 5011, Australia
| | - Aliyah Bonnici
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road Woodville South, South Australia 5011, Australia
| | - Guy J Maddern
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, 28 Woodville Road Woodville South, South Australia 5011, Australia.
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11
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Hewitt JN, Kovoor JG, Dobbins C, Trochsler MI. Re: Emergency laparotomy: time to improve? ANZ J Surg 2022; 92:1288. [PMID: 35535000 DOI: 10.1111/ans.17588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Joseph N Hewitt
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joshua G Kovoor
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Christopher Dobbins
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
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12
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Young E, Kopunic HS, Trochsler MI, Maddern GJ. Predictors of interhospital transfer delays in acute surgical patient deaths in Australia: a retrospective study. ANZ J Surg 2022; 92:1322-1331. [PMID: 35373494 DOI: 10.1111/ans.17669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Interhospital transfers in Australia facilitate access to acute surgical services, however transfer delays can occur. The aims of this study were to examine Australian mortality audit data on acute surgical patients who were transferred after presenting with a surgical emergency, and to identify modifiable predictors of transfer delay. METHODS Surgical admissions between 1 January 2001 and 18 August 2020 were retrospectively extracted from the Australian and New Zealand Audit of Surgical Mortality database. Relevant factors and themes of interest were collated. Results were presented as odds ratios (OR) and 95% confidence intervals (CI), with statistical significance defined as P <0.05. RESULTS After exclusion, a final 8270 cases were analysed. Non-modifiable predictors identified were female gender (OR 1.34, 95% CI 1.05-1.70, P = 0.0184), comorbidities (OR 1.50, 95% CI 1.40-161, P <0.0001) and major non-trauma non-vascular specialty (OR 1.54 to 7.77, depending on specialty, P < 0.05). Modifiable predictors were inadequate clinical assessment (OR 49.48, 95% CI 32.91-74.38, P <0.0001), poor communication (OR 6.62, 95% CI 3.70-11.85, P <0.0001) and multiple transfers (OR 6.30, OR 95% 4.31-9.21, P <0.0001). Age, lack of bed and after-hours transfer did not predict transfer delays. Metropolitan transfers was protective against transfer delays (OR 0.64, 95% CI 0.47-0.86, P = 0.0035). CONCLUSION In the view of the receiving surgeon or assessor, all transfer delays potentially contributed to patient deaths, and may have been preventable. Strategies directed at modifiable factors could minimize delays. Increased surgical services in non-metropolitan regions could reduce need for transfer. Prospective data is required to examine if the same predictors are observed in surgical patients who survive.
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Affiliation(s)
- Edward Young
- The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Helena S Kopunic
- Australian and New Zealand Audit of Surgical Mortality (ANZASM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- The University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Australian and New Zealand Audit of Surgical Mortality (ANZASM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,The University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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13
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Granchi N, Ting YY, Foley KP, Reid JL, Vreugdenburg TD, Trochsler MI, Bruening MH, Maddern GJ. Coaching to enhance qualified surgeons' non-technical skills: a systematic review. Br J Surg 2021; 108:1154-1161. [PMID: 34476480 DOI: 10.1093/bjs/znab283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 07/08/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION The lack of an effective continuing professional development programme for qualified surgeons, specifically one that enhances non-technical skills (NTS), is an issue receiving increased attention. Peer-based coaching, used in multiple professions, is a proposed method to deliver this. The aim of this study was to undertake a systematic review of the literature to summarize the quantity and quality of studies involving surgical coaching of NTS in qualified surgeons. METHODS A systematic search of the literature was performed through MEDLINE, EMBASE, Cochrane Collaboration and PsychINFO. Studies were selected based on predefined inclusion and exclusion criteria. Data for the included studies was independently extracted by two reviewers and the quality of the studies evaluated using the Medical Education and Research Study Quality Instrument (MERSQI). RESULTS Some 4319 articles were screened from which 19 met the inclusion criteria. Ten studies involved coaching of individual surgeons and nine looked at group coaching of surgeons as part of a team. Group coaching studies used non-surgeons as coaches, included objective assessment of NTS, and were of a higher quality (average MERSQI 13.58). Individual coaching studies focused on learner perception, used experienced surgeons as coaches and were of a lower quality (average MERSQI 11.58). Individual coaching did not show an objective improvement in NTS for qualified surgeons in any study. CONCLUSION Surgical coaching of qualified surgeons' NTS in a group setting was found to be effective. Coaching of individual surgeons revealed an overall positive learner perception but did not show an objective improvement in NTS for qualified surgeons.
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Affiliation(s)
- N Granchi
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Y Y Ting
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - K P Foley
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - J L Reid
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - T D Vreugdenburg
- Research and Evaluation Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - M I Trochsler
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - M H Bruening
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - G J Maddern
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Research and Evaluation Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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14
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Kovoor JG, Stretton B, Jacobsen JHW, Gupta AK, Ovenden CD, Hewitt JN, Glynatsis JM, Edwards S, Campbell K, Asokan GP, Tivey DR, Babidge WJ, Rayner CK, Anthony AA, Trochsler MI, Horowitz M, Hewett PJ, Jones KL, Maddern GJ. Gastrointestinal recovery after surgery: protocol for a systematic review. BMJ Open 2021; 11:e054704. [PMID: 34645666 PMCID: PMC8515468 DOI: 10.1136/bmjopen-2021-054704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Gastrointestinal recovery after surgery is of worldwide significance. Postoperative gastrointestinal dysfunction is multifaceted and known to represent a major source of postoperative morbidity, however, its significance to postoperative care across all surgical procedures is unknown. The complexity of postoperative gastrointestinal recovery is poorly defined within gastrointestinal surgery, and even less so outside this field. To inform the clinical care of surgical patients worldwide, this systematic review and meta-analysis will aim to characterise the duration of postoperative gastrointestinal recovery that can be expected across all surgical procedures and determine the associations between factors that may affect this. METHODS AND ANALYSIS MEDLINE, Embase, Cochrane Library and CINAHL will be searched for studies reporting the time to first postoperative passage of stool after any surgical procedure. We will screen records, extract data and assess risk of bias in duplicate. Forest plots will be constructed for time to postoperative gastrointestinal recovery, as assessed by various outcome measures. Because of potential heterogeneity, a random-effects model will be used throughout the meta-analysis. Funnel plots will be used to test for publication bias. Meta-regressions will be undertaken where the outcome is the mean time to first postoperative passage of stool, with potential predictors and confounders being patient characteristics, postoperative outcomes and surgical factors. ETHICS AND DISSEMINATION This study will not involve human or animal subjects and, thus, does not require ethics approval. The outcomes will be disseminated via publication in peer-reviewed scientific journal(s) and presentations at scientific conferences. PROSPERO REGISTRATION NUMBER CRD42021256210.
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Affiliation(s)
- Joshua G Kovoor
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Australian Safety and Efficacy Register of New Interventional Procedures-Surgical, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Brandon Stretton
- Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Jonathan Henry W Jacobsen
- Australian Safety and Efficacy Register of New Interventional Procedures-Surgical, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- University of Adelaide, Discipline of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher D Ovenden
- University of Adelaide, Discipline of Surgery, Women's and Children's Hospital Adelaide, Adelaide, South Australia, Australia
- Department of Neurosurgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Joseph N Hewitt
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - John M Glynatsis
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- Adelaide Health Technology Assessment, The University of Adelaide, Adelaide, South Australia, Australia
| | - Kaitryn Campbell
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gayatri P Asokan
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - David R Tivey
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Wendy J Babidge
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Christopher K Rayner
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adrian A Anthony
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Michael Horowitz
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Peter J Hewett
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Karen L Jones
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Guy J Maddern
- University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
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15
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Reid JL, Kanhere HA, Hewett PJ, Price TJ, Maddern GJ, Trochsler MI. Can pressurised intraperitoneal aerosol chemotherapy with oxaliplatin (PIPAC-O+) be added to standard treatment for resectable high-risk gastric cancer patients? A study protocol. Pleura Peritoneum 2021; 6:151-154. [PMID: 35071735 PMCID: PMC8722176 DOI: 10.1515/pp-2021-0132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 09/02/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives Gastric cancer remains one of the most fatal cancers, despite an intensive treatment regime of chemotherapy–surgery–chemotherapy. Peritoneal metastatic disease is commonly diagnosed post treatment regime and once established, patients are likely to die in 3–9 months. Systemic chemotherapy does not increase survival for these patients due to the poor vascularisation of this area. We are proposing the addition of pressurised intraperitoneal aerosol chemotherapy (PIPAC) to the treatment regime for curative patients as a preventive measure to reduce the risk of peritoneal metastases occurring. Methods This is a prospective, single centre, non-randomised, open-label pilot trial evaluating the addition of PIPAC to the standard multimodal treatment pathway. Patients will undergo standard neoadjuvant chemotherapy with four cycles of fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT), then PIPAC, followed by gastrectomy. Four cycles of FLOT will be administered post-surgery. Primary outcome is safety and feasibility, assessed by perioperative morbidity and possible interruptions of the standard multimodal treatment pathway.
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Affiliation(s)
- Jessica L. Reid
- Discipline of Surgery , The University of Adelaide, The Queen Elizabeth Hospital , Adelaide , SA , Australia
| | - Harsh A. Kanhere
- Discipline of Surgery , The University of Adelaide, The Queen Elizabeth Hospital , Adelaide , SA , Australia
| | - Peter J. Hewett
- Discipline of Surgery , The University of Adelaide, The Queen Elizabeth Hospital , Adelaide , SA , Australia
| | - Timothy J. Price
- Department of Oncology, The Queen Elizabeth Hospital , Adelaide , SA , Australia
- Adelaide Medical School , The University of Adelaide , Adelaide , SA , Australia
| | - Guy J. Maddern
- Discipline of Surgery , The University of Adelaide, The Queen Elizabeth Hospital , Adelaide , SA , Australia
| | - Markus I. Trochsler
- Discipline of Surgery , The University of Adelaide, The Queen Elizabeth Hospital , Adelaide , SA , Australia
- Department of Surgery, Royal Adelaide Hospital , Adelaide , SA , Australia
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16
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Farfus AW, Trochsler MI, Maddern GJ, Kuan LL. First case of liver resection in Australia for recurrent intrahepatic stones post Kasai procedure. ANZ J Surg 2021; 91:E623-E624. [PMID: 33529463 DOI: 10.1111/ans.16620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Anthony W Farfus
- Department of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Woodville, Australia, 5011, Australia
| | - Guy J Maddern
- Department of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Li Lian Kuan
- Department of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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17
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Kirana C, Smith E, Ngo DT, Trochsler MI, Hewett PJ, Stubbs RS, Hardingham JE, Maddern GJ, Hauben E. High preoperative levels of circulating SFRP5 predict better prognosis in colorectal cancer patients. Future Oncol 2020; 16:2499-2509. [PMID: 33048585 DOI: 10.2217/fon-2020-0356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The purpose of this research was to investigate the diagnostic and prognostic value of circulating SFRP5 (cSFRP5) in colorectal cancer (CRC). We evaluated preoperative cSFRP5 levels in CRC patients and controls (n = 208). We found significantly higher cSFRP5 levels in CRC patients compared with non-CRC controls (p < 0.001). Levels of cSFRP5 were significantly lower in CRC patients with either vascular invasion (p = 0.001) or liver metastasis (p = 0.016). High cSFRP5 levels were associated with longer disease-free survival in both univariate (p = 0.024) and multivariate (p = 0.015) analyses. Analysis of an independent tissue cohort from The Cancer Genome Atlas database revealed significantly lower SFRP5 RNA expression in CRC tumor tissue compared with adjacent normal mucosa (n = 590 vs 47; p < 0.0001). Our findings confirm the role of cSFRP5 as a physiologic tumor suppressor and demonstrate its potential diagnostic and prognostic value in CRC.
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Affiliation(s)
- Chandra Kirana
- Liver Metastasis Research Group, Discipline of Surgery, The University of Adelaide, The Basil Hetzel Institute for Translational Health Research, Woodville South, South Australia, 5011, Australia.,Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Woodville South, South Australia, 5011, Australia
| | - Eric Smith
- Solid Tumour Group, The Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, 5011, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, 5005, Australia
| | - Doan T Ngo
- School of Biomedical Sciences & Pharmacy, University of Newcastle, New South Wales, 2308, Australia
| | - Markus I Trochsler
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Woodville South, South Australia, 5011, Australia
| | - Peter J Hewett
- Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Woodville South, South Australia, 5011, Australia
| | - Richard S Stubbs
- The Wakefield Clinic for Gastrointestinal Diseases, Wellington, 6242, New Zealand
| | - Jennifer E Hardingham
- Solid Tumour Group, The Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, 5011, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, 5005, Australia
| | - Guy J Maddern
- Liver Metastasis Research Group, Discipline of Surgery, The University of Adelaide, The Basil Hetzel Institute for Translational Health Research, Woodville South, South Australia, 5011, Australia.,Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Woodville South, South Australia, 5011, Australia
| | - Ehud Hauben
- Liver Metastasis Research Group, Discipline of Surgery, The University of Adelaide, The Basil Hetzel Institute for Translational Health Research, Woodville South, South Australia, 5011, Australia.,Department of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Woodville South, South Australia, 5011, Australia
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18
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Hummel R, Ha NH, Lord A, Trochsler MI, Maddern G, Kanhere H. Centralisation of oesophagectomy in Australia: is only caseload critical? AUST HEALTH REV 2019; 43:15-20. [PMID: 29032792 DOI: 10.1071/ah17095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/03/2017] [Indexed: 01/05/2023]
Abstract
Objective High caseload is considered one of the most important factors for good outcomes after high-risk surgeries such as oesophagectomy. However, many Australian centres perform low volumes of oesophagectomies due to demographics. The aim of the present study was to audit outcome after oesophagectomy in an Australian low-volume centre over a period of 13 years and to discuss potential contributors to outcome other than just case volume. Methods Perioperative and long-term outcomes of all oesophagectomies over a 13-year period in a low-volume Australian tertiary care centre were analysed retrospectively. Data were compared in subgroups of patients in two separate time periods: 2000-05 (n=23) and 2006-12 (n=24). Results There were two perioperative deaths over the entire 13-year period with no postoperative mortality in the last decade. The complication and long-term survival rates for each of the two separate time periods were similar to those from high-volume centres, more so in the second half of the study period. Conclusions The data suggest that under specific conditions, oesophagectomies can be safely performed even in smaller- or low-volume centres in Australia. The policy of centralisation for these procedures in Australia needs to be carefully tailored to the needs of the population, clinical outcomes, cost-effectiveness and optimal utilisation of existing facilities rather than on caseload alone. What is known about the topic? High caseload is considered one of the most important factors for good outcomes after oesophagectomy and a driving force behind centralisation of this procedure. However, other factors may also affect outcome - such as availability of experienced surgeons, specialist nurses, interventional radiology, gastroenterology, etc. What does this paper add? With the availability of appropriate levels of expertise, infrastructure and specialist nursing staff as is the case in most Australian tertiary centres, good perioperative outcomes can be obtained despite low volumes. Case load only should not be used as a surrogate marker of quality. What are the implications for practitioners? The policy of centralisation for oesophagectomy in Australia needs to be carefully thought out on the basis of population demographics, outcomes and cost-effectiveness, with the appropriate use of existing facilities, rather than on a caseload basis alone.
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Affiliation(s)
- Richard Hummel
- Department of Surgery, The Queen Elizabeth Hospital, 8 Woodville Road, Woodville South, SA 5011, Australia. ; ;
| | - Ngoc Hoang Ha
- Department of Surgery, The Queen Elizabeth Hospital, 8 Woodville Road, Woodville South, SA 5011, Australia. ; ;
| | - Andrew Lord
- Department of Surgery, The Queen Elizabeth Hospital, 8 Woodville Road, Woodville South, SA 5011, Australia. ; ;
| | - Markus I Trochsler
- Department of Surgery, The Queen Elizabeth Hospital, 8 Woodville Road, Woodville South, SA 5011, Australia. ; ;
| | - Guy Maddern
- Department of Surgery, The Queen Elizabeth Hospital, 8 Woodville Road, Woodville South, SA 5011, Australia. ; ;
| | - Harsh Kanhere
- Department of Surgery, The Queen Elizabeth Hospital, 8 Woodville Road, Woodville South, SA 5011, Australia. ; ;
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19
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Hewitt JN, Gupta AK, Maddern GJ, Trochsler MI. Adrenaline in local anaesthetics: do students and junior doctors still believe the myth? A survey. ANZ J Surg 2019; 89:1367-1368. [PMID: 31760695 DOI: 10.1111/ans.15468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/13/2019] [Accepted: 08/18/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Joseph N Hewitt
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
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20
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Gupta AK, Kanhere HA, Maddern GJ, Trochsler MI. Response to Re: Liver resection in octogenarians: are the outcomes worth the risk? ANZ J Surg 2019; 89:132. [PMID: 30756488 DOI: 10.1111/ans.14974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 10/25/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Aashray K Gupta
- Faculty of Health and Medical Sciences, University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Harsh A Kanhere
- University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Guy J Maddern
- University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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21
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Gupta AK, Kanhere HA, Maddern GJ, Trochsler MI. Liver resection in octogenarians: are the outcomes worth the risk? ANZ J Surg 2018; 88:E756-E760. [DOI: 10.1111/ans.14475] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/15/2018] [Accepted: 02/17/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Aashray K. Gupta
- Faculty of Health and Medical Sciences; The University of Adelaide Medical School; Adelaide South Australia Australia
| | - Harsh A. Kanhere
- The University of Adelaide Discipline of Surgery; The Queen Elizabeth Hospital; Adelaide South Australia Australia
| | - Guy J. Maddern
- The University of Adelaide Discipline of Surgery; The Queen Elizabeth Hospital; Adelaide South Australia Australia
| | - Markus I. Trochsler
- The University of Adelaide Discipline of Surgery; The Queen Elizabeth Hospital; Adelaide South Australia Australia
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22
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Clarke NAR, Kanhere HA, Trochsler MI, Maddern GJ. Liver resection for non-colorectal non-neuroendocrine metastases. ANZ J Surg 2016; 88:E313-E317. [PMID: 27490345 DOI: 10.1111/ans.13700] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/30/2016] [Accepted: 05/31/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Liver resections for non-colorectal non-neuroendocrine liver metastases (NCNELM) are gaining popularity. This study examines the outcomes of liver resections in patients with NCNELM in an Australian hospital. METHOD A database search identified 21 attempted liver resections on 20 patients (12 men, eight women, mean age: 63.1) from 1998 to 2013. A retrospective analysis considered patient demographics and primary malignancy details. Complication rates were compared to those for colorectal metastases at the same institution. Kaplan-Meier curves were used to plot overall survival. RESULTS Complete resection was achieved in 16 of the 21 operations with 13 cases having proven metastases (three cases were benign lesions on final histology). Primary cancers were gastric (n = 4), gall bladder/bile duct (n = 3), renal (n = 3), soft tissue sarcoma (n = 3), melanoma (n = 2), pancreatic (n = 2), anal (n = 2), breast (n = 1) and unknown (n = 1). Primary histology types were adenocarcinoma (n = 10), sarcoma (n = 3), renal cell (n = 3), squamous cell (n = 2), melanoma (n = 2) and gastrointestinal stromal tumour (n = 1). There was no peri-operative mortality. Significant post-operative complications (Clavien-Dindo Grade III or more) occurred in six patients (28.5%). Overall survival at 2 and 5 years was 46.2% and 30.8%, respectively, for all 21 cases of attempted resection, and 51.9% and 34.6%, respectively, for the 13 cases of complete resection of malignant metastases. CONCLUSIONS This study produced comparable 5-year survival rates to those reported after liver resection for colorectal metastases and in other studies on NCNELM. Complication rates were comparable to those for colorectal liver metastasis resection at the same institution.
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Affiliation(s)
- Nicholas A R Clarke
- Faculty of Health Sciences, University of Adelaide School of Medicine, Adelaide, South Australia, Australia.,University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Harsh A Kanhere
- University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Markus I Trochsler
- University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Guy J Maddern
- University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
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23
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Matthews TJ, Trochsler MI, Bridgewater FH, Maddern GJ. Systematic review of congenital and acquired portal-systemic shunts in otherwise normal livers. Br J Surg 2014; 101:1509-17. [PMID: 25200002 DOI: 10.1002/bjs.9619] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 06/11/2014] [Accepted: 06/27/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Portal-systemic shunts (PSSs) are rarely seen in healthy individuals or patients with non-cirrhotic liver disease. They may play an important role in hepatic metabolism as well as in the spread of gastrointestinal metastatic tumours to specific organs. Small spontaneous PSSs may be more common than generally thought. However, epidemiological data are scarce and inconclusive. This systematic review examined the prevalence of reported PSSs and the associated detection methods. METHODS Literature up to 2011 was reviewed for adult patients with proven congenital or acquired PSSs. Only PSSs in normal livers were analysed for the methods of diagnosis. Eligible studies were identified by searching relevant databases, including PubMed, Embase, MEDLINE and the Cochrane Library. The selection of eligible articles was carried out using predefined inclusion criteria (adult, non-surgical PSS) and a set of search terms that were established before the articles were identified. RESULTS Eighty studies were included describing 112 patients with congenital or acquired PSSs. The majority were diagnosed incidentally using Doppler ultrasound imaging and CT. CONCLUSION Congenital and acquired PSSs are rare. They are usually clinically asymptomatic and discovered incidentally by radiological techniques. They may be clinically relevant owing to drug, tumour cell, metabolic and pathogen shunting.
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Affiliation(s)
- T J Matthews
- Discipline of Surgery, University of Adelaide, Queen Elizabeth Hospital, 28 Woodville Road, Woodville, South Australia 5011, Australia
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Abstract
Mycobacterial infections are rare in developed countries. Isolated involvement of the liver and biliary tree by mycobacterial infection is extremely rare. We report a case of a 45-year-old Caucasian female presenting with obstructive jaundice with a common bile duct stricture and multiple hypodense liver lesions raising suspicion of a metastatic cholangiocarcinoma. Percutaneous core biopsies of the liver lesions however suggested granulomatous process and histology at surgical excision confirmed this finding. Atypical mycobacteria (M. abcessus) sensitive to Amikacin were cultured from the surgical specimen proving the diagnosis. With the resurgence of tubercular and atypical mycobacterial infections in the developed world, it is important not to overlook these in differential diagnosis of various malignancies.
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Affiliation(s)
- Harsh A Kanhere
- Division of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Markus I Trochsler
- Division of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, SA, Australia
| | - John Pierides
- Department of Surgical Pathology, Institute of Medical and Veterinary Sciences, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Guy J Maddern
- Division of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, SA, Australia
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