Measuring quality in colorectal cancer surgery in low- and middle-income countries: The Clavien-Dindo classification in a Sri Lankan cohort

Background

The colorectal cancer (CRC) incidence is increasing in low- and middle-income countries (LMICs) as part of an ongoing epidemiological transition. Surgery is the main treatment and surgical services are scaled up to meet the need. This warrants the establishment of frugal systems to measure safety and quality of surgical care that are tailored for low-resource settings. The aim of this study was to test the applicability of the Clavien-Dindo classification (CDC) for measurement of surgical complications in an LMIC setting where medical records are paper-based.

Material and methods

88 patients who underwent CRC resection at Colombo South Teaching Hospital, Sri Lanka, from January 2017 to January 2020 were included. Medical records were retrospectively reviewed for postoperative complications and the severity was graded using the CDC.

Results

One or more postoperative complications (CDC ≥ grade II) occurred in 45.5% (n = 40) of the patients. The complications were distributed as grade II n = 46, grade III n = 3, grade IV n = 2 and grade V n = 0. The most common complication (22.7%, n = 20) was postoperative anemia treated with blood transfusion. The second most common complication was incisional surgical site infection (11.4%, n = 10).

Conclusion

Postoperative outcome could be evaluated by using the CDC in a Sri Lankan facility based on retrospective review of medical records. This suggests that the CDC is a feasible standardized system appropriate for measuring surgical quality also in other LMICs. Identified fields for possible quality improvement at the study site were to limit blood transfusions and minimize treatment with antibiotics.

•

Global health is putting focus on not only access to surgery, but also surgical quality and safety.

•

The Clavien-Dindo Classification may be a standardized way of evaluating surgical quality in low-resource settings.

•

The feasibility of Clavien-Dindo Classification in a retrospective cohort in Sri Lanka is demonstrated.

Automatic Tuning of Spatially Varying Transfer Functions for Blood Vessel Visualization

Computed Tomography Angiography (CTA) is commonly used in clinical routine for diagnosing vascular diseases. The procedure involves the injection of a contrast agent into the blood stream to increase the contrast between the blood vessels and the surrounding tissue in the image data. CTA is often visualized with Direct Volume Rendering (DVR) where the enhanced image contrast is important for the construction of Transfer Functions (TFs). For increased efficiency, clinical routine heavily relies on preset TFs to simplify the creation of such visualizations for a physician. In practice, however, TF presets often do not yield optimal images due to variations in mixture concentration of contrast agent in the blood stream. In this paper we propose an automatic, optimization-based method that shifts TF presets to account for general deviations and local variations of the intensity of contrast enhanced blood vessels. Some of the advantages of this method are the following. It computationally automates large parts of a process that is currently performed manually. It performs the TF shift locally and can thus optimize larger portions of the image than is possible with manual interaction. The method is based on a well known vesselness descriptor in the definition of the optimization criterion. The performance of the method is illustrated by clinically relevant CT angiography datasets displaying both improved structural overviews of vessel trees and improved adaption to local variations of contrast concentration.

Short-term effects of 1-alpha-hydroxy-vitamin D3 in patients on corticosteroid treatment and in patients with senile osteoporosis

Six patients with bronchial asthma undergoing long-term corticosteroid treatment and six patients with senile osteoporosis were given the same oral dose of 1-alpha-hydroxy-vitamin D3 (1alpha-OH-D3) and calcium. The immediate effect on blood and urine chemistry and on the intestinal calcium absorption rate were studied. Hypercalcaemia occurred frequently among the patients treated with corticosteroids but not among those with senile osteoporosis. We conclude that corticosteroids do not counteract the effects of 1alpha-OH-D3. No correlation was found between the calcium absorption rate and the degree of osteoporosis, nor did the serum PTH levels show any differences that could be attributed to the treatment.

Ethanol administration potentiates cocaine-induced dopamine levels in the rat nucleus accumbens

Ethanol and cocaine are frequently co-abused, and the drug combination has been reported to produce an increased and prolonged subjective euphoria as compared to when either drug is administered alone. Acute administration of ethanol or cocaine increases the extracellular dopamine (DA) concentration in the nucleus accumbens (NAcc), a terminal region of the mesolimbic dopaminergic pathway. In the present study, the effects of separate and concurrent administration of cocaine and ethanol on DA concentrations in the NAcc were studied in rats pretreated with ethanol. Four groups of rats received either ethanol (2 g/kg, i.p.) or saline twice daily for 6 consecutive days. Thereafter, rats were given injections of saline or cocaine for another 2 days (i.e. treatment days 7 and 8) using a 'binge' administration pattern (three i.p. injections of 15 mg/kg each with 1-h interval starting 40 min after the first of the two daily doses of ethanol/saline). Stereotypic behavior was scored after each 'binge' of cocaine or saline on days 7 and 8. The DA and DA metabolite concentrations were measured using microdialysis on day 8. Ethanol enhanced the effect of cocaine on DA concentration in the NAcc as compared to a single administration of cocaine. The DA levels increased and reached their maximum values within 20-40 min after the cocaine administration, then gradually declined until the next injection 1-h later. Cocaine-induced stereotypic behavior was significantly increased in both saline and ethanol pretreated groups, though there was no significant difference between the two groups. The results of this study suggest that the enhanced DA transmission may be related to the experience produced by concurrent abuse of ethanol and cocaine in humans.

[Experiences from the county of Norrbotten: screening of hearing at the age of four crucial for detecting mild hearing impairment]

Since the eighties the formerly well established hearing screening performed at the age of four has been debated, partly for economic reasons. One quarter of Sweden's counties have since then abolished it. But how many children do we detect by this screening? What significance does it have for a child that those around it are aware of a mild hearing impairment? In Norrbotten, in all, we found 123 children born 1989-1992 with a hearing impairment. The prevalence was 7.9 per thousand. 30 percent of the children were detected at the 4-years hearing screening, and of these 0.9/1,000 had a hearing impairment that was bilateral, 1.0/1,000 unilateral and 0.5/1,000 impairment only in the high frequencies. Also children with mild bilateral or unilateral hearing impairment can experience difficulties in school and among friends, especially in noisy surroundings, and benefit by knowing early about their hearing impairment.

The selective kappa-opioid receptor agonist U50,488H attenuates voluntary ethanol intake in the rat

Non-selective opioid receptor antagonists are increasingly used in the treatment of alcohol dependence. The clinical effects are significant but the effect size is rather small and unpleasant side effects may limit the benefits of the compounds. Ligands acting at mu- and/or delta- receptors can alter the voluntary intake of ethanol in various animal models. Therefore, the attenuating effects of selective opioid receptor ligands on ethanol intake may be of clinical interest in the treatment of alcoholism. The objective of this study was to examine the effects of a selective kappa-receptor agonist, U50,488H on voluntary ethanol intake in the rat. We used a restricted access model with a free choice between an ethanol solution (10% v/v) and water. During the 3-days baseline period, the rats received a daily saline injection (1 ml/kg, i.p.) 15 min before the 2 h access to ethanol. The animals had free access to water at all times. The control group received a daily saline injection during the 4-days treatment-period, whereas the treatment groups received a daily dose of U50,488H (2.5, 5.0 or 10 mg/kg per day). Animals treated with U50,488H dose-dependently decreased their ethanol intake. The effect of the highest dose of U50,488H was reduced by pre-treatment with the selective kappa-antagonist nor-binaltorphimine (nor-BNI). These results demonstrate that activation of kappa-opioid receptors can attenuate voluntary ethanol intake in the rat, and the data suggest that the brain dynorphin/kappa-receptor systems may represent a novel target for pharmacotherapy in the treatment of alcohol dependence.

Effects of middle ear pressure changes on clinical symptoms in patients with Ménière's disease--a clinical multicentre placebo-controlled study

Different medical and surgical methods have been tried in attempting to reduce endolymphatic pressure in Ménière's disease. Pressure treatment has a role on the treatment staircase, after pharmacological treatment and before destructive methods. Pressure chamber treatment has shown that some patients respond well to the treatment with diminishing inner ear symptoms and also some hearing improvement. Earlier studies have shown that electrocochlear measurements improve after local pressure treatment in the ear. The present study was a prospective randomized placebo controlled, multicentre clinical trial. 56 patients with active Ménière's disease, age 20-65 years, with a hearing loss of 20-65 dB PTA participated. A total of 31 patients completed 2 weeks use with an active apparatus (Meniett) and 25 patients completed the 2 weeks with the placebo gadget. Both machines were produced by Pascal Medical, Halmstad, Sweden. Two weeks before the start of treatment a grommet was placed in the tympanic membrane. A significant improvement concerning frequency and intensity of vertigo, dizziness, aural pressure and tinnitus was reported by the active group on the visual analogue scales (VAS) questionnaire. In the placebo group no change was the most common finding, followed by worsening of the symptoms and a few improvements. The function in professional and family life improved during active treatment and did not during placebo treatment. Pure-tone audiometry did not improve after placebo treatment, but improved at the frequencies 500 Hz and 1,000 Hz after active treatment. The study showed an improvement in the inner ear symptoms after Meniett treatment. The mechanism may be explained by the influence on the round window membrane pressure receptors or an endolymphatic flow out through the pressure release points, such as the endolymphatic duct and sac, thus activating the longitudinal flow. Other mechanisms are also possible.

Repeated ethanol administration induces short- and long-term changes in enkephalin and dynorphin tissue concentrations in rat brain

Recently, we have shown that rats repeatedly treated with ethanol and/or cocaine have decreased kappa-opioid receptor mRNA levels in the mesolimbic system. The aim of the present study was to investigate the short- and long-term effects of repeated ethanol administration on opioid peptide concentrations in brain tissue of male Sprague-Dawley rats. Dynorphin B (1-13) (Dyn B) and Met-enkephalinArg(6)Phe(7) (MEAP), endogenous ligands to kappa- and delta-opioid receptors, respectively, were measured using radioimmunoassays. The rats were given either ethanol [intraperitoneal (ip), twice daily, 2 g/kg bw/dose] or saline for 13 consecutive days. Thirty minutes after the last ethanol dose on Day 13, the Dyn B tissue concentration was significantly decreased in the cingulate cortex. The MEAP tissue concentration was decreased in the hippocampus 5 days after the last ethanol injection as compared to saline-treated controls. Furthermore, the Dyn B and the MEAP concentrations were increased in the periaqueductal grey area (PAG) at this time point. Of particular interest were the significant increases in Dyn B tissue concentrations found in the nucleus accumbens (NAcc) at 30 min and at 21 days after the last ethanol dose. The results suggest that repeated ethanol administration induces both short- and long-term changes in the tissue concentrations of opioids in certain brain regions associated with motivation and reward.

Downregulation of kappa opioid receptor mRNA levels by chronic ethanol and repetitive cocaine in rat ventral tegmentum and nucleus accumbens

The combination of ethanol and cocaine is commonly abused by human addicts which has serious clinical consequences. Here, the effects of separately and concurrently administered ethanol and 'binge' cocaine on kappa opioid receptor (KOR) mRNA in the ventral tegmental area (VTA) and nucleus accumbens (NAc) of rats were studied. KOR mRNA was down-regulated in both brain regions during concurrent as well as separate treatment with these drugs. In the VTA, the most pronounced decrease was obtained following combined treatment with ethanol and 'binge' cocaine. In the NAc, the strongest decrease was observed in the 'binge' cocaine group. This profound decrease of KOR mRNA in regions important for brain reward suggests a potential role of the KOR system in the abuse of cocaine and ethanol.

Modulation of volitional ethanol intake in the rat by central delta-opioid receptors

The acute effect of opioid antagonists on volitional ethanol intake was studied in unselected Sprague-Dawley rats using a two-bottle, free-choice model. The total daily intake of ethanol during saline treatment was 1.79 +/- 0.4 g/kg/day (n = 136). The rats were deprived of fluids for the last 4 hr of the light period. Saline or drug was given intraperitoneally 20 to 30 min before the onset of dark, and the ethanol and water intakes were measured during the following hour. The ethanol intake during this hour was 0.75 +/- 0.06 g/kg (n = 136). Naltrexone significantly reduced ethanol intake. There was also a significant reduction in ethanol intake following administration of ICI-174,864. Naloxonazine and naloxone methiodide lacked effect. None of the treatments had any effect on the water or food intake. The results suggest that central delta-opioid receptors modulate volitional ethanol intake in the rat.

[The use of bone morphogenetic proteins in delayed fracture healing, pseudoarthrosis and in ulna osteotomy carried out because of elbow joint diseases]

This study deals with the application of bone morphogenetic protein (BMP) as an osteoinductive factor in the treatment of fractures and elbow disease in the dog. Partially purified canine bone morphogenetic protein (cBMP) was used in the repair of a delayed union fracture and a pseudoarthrosis. The cBMP was applied in Biocoral and Tricalciumphosphate carriers using a subcortical grafting method. Two dogs suffering from incongruence and subluxation of the elbow joint were treated with a partially purified bone morphogenetic protein of moose bone origin placed in the gap produced by ulnar osteotomy.

Prevalence and predictive value of ECG findings in acute extremity ischemia

OBJECTIVE

To determine the prevalence and predictive value of ECG findings in patients treated surgically for acute extremity ischemia.

EXPERIMENTAL DESIGN

Retrospective study with follow-up for one month.

SETTING

Tampere University Hospital, Jyväskylä Central Hospital.

PATIENTS

114 patients with acute extremity ischemia treated surgically.

INTERVENTIONS

Emergency thromboembolectomy was performed to all patients.

MEASURES

ECGs, taken preoperatively at the emergency department, were analysed according to the Minnesota code. Death was regarded as the endpoint of the study.

RESULTS

ST-J depression (60.5%) and T-wave inversion (71.9%) were the most common single findings. The ECG was considered suggestive of ischemic heart disease in 64.0% of patients. The prevalence of atrial fibrillation was 37.7%. Atrial fibrillation was found in 25.0% of patients with acute thrombotic occlusion and in 43.6% of patients with embolic occlusion (chi 2 = 3.6, df = 1, p = 0.057). The ECG was suggestive of ischemic heart disease in 87.5% of patients who died within a month compared to 60.2% in those still alive (chi 2 = 4.4, df = 1, p = 0.034). In logistic regression analysis atrial fibrillation was found to increase the risk of mortality (B = 0.93, df = 1, p = 0.002); odds ratio 2.6 (95% CI 1.4-4.7).

CONCLUSION

Most patients with acute extremity ischemia had significant ECG findings with low prevalence of AF reflecting increased ratio of thrombotic occlusions. AF and ECG suggestive of ischemic heart disease were also associated to poor short-term prognosis. We think that acute thrombosis should be suspected in most patients with acute extremity ischemia.

Glass-ceramic-coated titanium hip endoprosthesis. Experimental study in rabbits

Titanium alloy hip endoprostheses coated with a bioactive glass ceramic (BGC) were followed in rabbits. All test endoprostheses remained stable, and image analysis showed an average of 78% bonding of the BGC-coated implants to bone at 52 weeks. The uncoated Ti-alloy controls demonstrated an average of 37% bone coverage after 52 weeks. By scanning electron microscopy the thickness of the BGC reaction layer was found to stabilize at 60 microns after bioactive bone bonding. The results indicate that the BGC coating must be thicker than the reaction layer to prevent detachment from the core metal.

Revision of cemented hip arthroplasties. 101 hips followed for 5 (4-9) years

101 hips were revised with cemented Lubinus prostheses after failed primary cemented arthroplasty, and followed for 5 (4-9) years. Radiographically, 41 hips (36 femoral stems and 13 acetabular components) had become loose. The use of an intramedullary plug at the revision did not prevent sinking of the prosthesis. No difference was found between conventional or pressure-injection cementation techniques. In cases where the stem was inserted in varus or the acetabular component was in malposition there was increased loosening. Patients below 50 years of age had oftener more than 5 mm sinking of the stem and more prosthesis loosenings.

A comparison between cemented and cementless implants in revision arthroplasty of the hip following resection arthroplasty

Twenty patients underwent hip re-arthroplasty following resection arthroplasty due to former prosthetic infection, aseptic loosening, or TBC coxitis. In 9 cases Gentamycin-loaded cement was used. In 11 the re-arthroplasty was cementless. The overall results, evaluated by the Mayo and Harris scoring systems, were moderately good. Seventy-five per cent of patients reported relief from pain and improved hip function. However, in the previously infected cases significantly better results were found in the cementless group, while major complications such as deep infection, luxation, or loosening of the implant were mainly concentrated in the cementless re-arthroplasties following aseptic loosening and cemented re-arthroplasties following septic as well as aseptic failures.

Revision of aggressive granulomatous lesions in hip arthroplasty

Fourteen patients had revision arthroplasty for aggressive granulomatosis in 16 previously replaced cemented total hips. The revision was performed on average 8 years (range, 6-13 years) after the primary arthroplasty. Twelve patients had multifocal granulomatous lesions. Pain was the first clinical sign of the aggressive granulomatosis, beginning on average 1.7 years (range, 0.8-3.8 years) after the primary operation. One patient had a fracture of the femur due to large granulomas while waiting for revision. The patients were under follow-up evaluation for an average of 5.4 years (range, 4-7 years) after revision. Two patients had recurrence of aggressive granulomatosis at the original sites 4.5 and 6.5 years after revision. Eleven patients had good or excellent results of revision.

Diffuse pigmented villonodular synovitis in association with Paget's disease of bone: report of a case

A 73-year-old patient with Paget's disease of bone was found to have associated diffuse pigmented villonodular synovitis (PVNS) of the right knee joint. Paget's disease has been reported in association with bone sarcoma, benign giant-cell tumor of bone, myeloma and a single case of giant-cell tumor of tendon sheath. the tendency for Paget's disease to be associated with giant-cell-rich lesions of bone and joint, which includes PVNS, merits further investigation, particularly since the recent observation of intranuclear viral-like inclusions in the osteoclast of all patients with this disease.

Fixation of osteochondral fragments in the knee joint. A clinical survey

In 20 patients with osteochondral joint fragments (chiefly osteochondritis dissecans), followed for an average of five years, excellent or good results were obtained in 15 treated by transfixation with autologous cortical bone pegs.