Self-rated health scores predict mortality among people with type 2 diabetes differently across three different country groupings: findings from the ADVANCE and ADVANCE-ON trials.

AIMS: To explore whether there is a different strength of association between self-rated health and all-cause mortality in people with type 2 diabetes across three country groupings: nine countries grouped together as 'established market economies'; Asia; and Eastern Europe. METHODS: The ADVANCE trial and its post-trial follow-up were used in this study, which included 11 140 people with type 2 diabetes from 20 countries, with a median follow-up of 9.9 years. Self-rated health was reported on a 0-100 visual analogue scale. Cox proportional hazard models were fitted to estimate the relationship between the visual analogue scale score and all-cause mortality, controlling for a range of demographic and clinical risk factors. Interaction terms were used to assess whether the association between the visual analogue scale score and mortality varied across country groupings. RESULTS: The visual analogue scale score had different strengths of association with mortality in the three country groupings. A 10-point increase in visual analogue scale score was associated with a 15% (95% CI 12-18) lower mortality hazard in the established market economies, a 25% (95% CI 21-28) lower hazard in Asia, and an 8% (95% CI 3-13) lower hazard in Eastern Europe. CONCLUSIONS: Self-rated health appears to predict 10-year all-cause mortality for people with type 2 diabetes worldwide, but this relationship varies across groups of countries.

A stratified analysis of the perioperative outcome of 17623 patients undergoing major head and neck cancer surgery in England over 10 years: Towards an Informatics-based Outcomes Surveillance Framework.

OBJECTIVES: To perform a national analysis of the perioperative outcome of major head and neck cancer surgery to develop a stratification strategy and outcomes assessment framework using hospital administrative data. DESIGN: A Hospital Episode Statistics N = near-all analysis. SETTINGS: The English National Health Service. MAIN OUTCOME MEASURES: Local audit data were used to assess and triangulate the quality of the administrative dataset. Within the national dataset, cancer sites, morbidities, social deprivation, treatment, complications, and in-hospital mortality were recorded. RESULTS: Within local audit datasets, the accuracy of assigning newly-derived Cancer Site Strata and Resection Strata were 92.3% and 94.2%, respectively. Accuracy of morbidities assignment was 97%. Within the national dataset, we identified 17 623 major head and neck cancer resections between 2002 and 2012. There were 12 413 males and mean age at surgery was 63 ± 12 years. The commonest cancer site strata were oral cavity (42%) and larynx-hypopharynx (32%). The commonest resection site was the larynx (n = 4217), and 13 211 and 11 841 patients had neck dissection and flap-based reconstruction, respectively. There were prognostically significant baseline differences between patients with oromandibular and pharyngolaryngeal malignancy. Patients with pharyngolaryngeal malignancies had a greater burden of morbidities, lower socio-economic status, fewer primary resections, and a sixfold increased risk of undergoing their major resection during an emergency hospital admission. Mean length of stay was 25 days and each complication linearly increased it by 9.6 days. There were 609 (3.5%) in-hospital deaths and a basket of seven medical and three surgical complications significantly increased the risk of in-hospital death. At least one potentially lethal complication occurred in 26% of patients. The risk of in-hospital death in a patient with no potentially lethal complication was 1.1% and this increased to 6% with one potentially lethal complication, and to 15.1% if two potentially lethal complications occurred in one patient. Complex oral-pharyngeal resections and pharyngolaryngectomies had the highest risks of complications and mortality. CONCLUSION: Mortality following head and neck cancer surgery shows variation across different resection strata. We propose an Informatics-based Framework for Outcomes Surveillance (IFOS) in Head and Neck Surgery for perpetual quality assurance, using the local hospital coding data or its collated destination, the national administrative dataset.

Predicting mortality in people with type 2 diabetes mellitus after major complications: a study using Swedish National Diabetes Register data.

AIM: To predict mortality risk and life expectancy for patients with type 2 diabetes after a major diabetes-related complication. METHODS: The study sample, taken from the Swedish National Diabetes Register, consisted of 20 836 people with type 2 diabetes who had their first major complication (myocardial infarction, stroke, heart failure, amputation or renal failure) between January 2001 and December 2007. A Gompertz proportional hazards model was derived which determined significant risk factors associated with mortality and was used to estimate life expectancies. RESULTS: Risk of death changed over time according to type of complication, with myocardial infarction initally having the highest initial risk of death, but after the first month, the risk was higher for heart failure, renal failure and amputation. Other factors that increased the risk of death were male gender (hazard ratio 1.06, 95% CI 1.02-1.12), longer duration of diabetes (hazard ratio 1.07 per 10 years, 95% CI 1.04-1.10), smoking (hazard ratio 1.51, 95% CI 1.40-1.63) and macroalbuminuria (hazard ratio 1.14, 95% CI 1.06-1.22). Low BMI, low systolic blood pressure and low estimated GFR also increased mortality risk. Life expectancy was highest after a stroke, myocardial infarction or heart failure, lower after amputation and lowest after renal failure. Smoking and poor renal function were the risk factors which had the largest impact on reducing life expectancy. CONCLUSIONS: Risk of death and life expectancy differs substantially among the major complications of diabetes, and factors significantly increasing risk included smoking, low estimated GFR and albuminuria.

UKPDS outcomes model 2: a new version of a model to simulate lifetime health outcomes of patients with type 2 diabetes mellitus using data from the 30 year United Kingdom Prospective Diabetes Study: UKPDS 82.

AIMS/HYPOTHESIS: The aim of this project was to build a new version of the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model (UKPDS-OM1), a patient-level simulation tool for predicting lifetime health outcomes of people with type 2 diabetes mellitus. METHODS: Data from 5,102 UKPDS patients from the 20 year trial and the 4,031 survivors entering the 10 year post-trial monitoring period were used to derive parametric proportional hazards models predicting absolute risk of diabetes complications and death. We re-estimated the seven original event equations and estimated new equations for diabetic ulcer and some second events. The additional data permitted inclusion of new risk factor predictors such as estimated GFR. We also developed four new equations for all-cause mortality. Internal validation of model predictions of cumulative incidence of all events and death was carried out and a contemporary patient-level dataset was used to compare 10 year predictions from the original and the new models. RESULTS: Model equations were based on a median 17.6 years of follow-up and up to 89,760 patient-years of data, providing double the number of events, greater precision and a larger number of significant covariates. The new model, UKPDS-OM2, is internally valid over 25 years and predicts event rates for complications, which are lower than those from the existing model. CONCLUSIONS/INTERPRETATION: The new UKPDS-OM2 has significant advantages over the existing model, as it captures more outcomes, is based on longer follow-up data, and more comprehensively captures the progression of diabetes. Its use will permit detailed and reliable lifetime simulations of key health outcomes in people with type 2 diabetes mellitus.

Infanticide and reproductive restraint in a polygynous social mammal.

Alpha male chacma baboons experience uncontested access to individual estrus females. Consequently, alpha male paternity certainty is high and underpins significant levels of infanticide by immigrant males that, in turn, has selected for male defense of infants. There is also, however, a high probability that alpha males will be absent during the period when their own offspring are vulnerable, suggesting selection for additional countermeasures. We use data from a long-term study to test the prediction that alpha male chacma baboons cede reproductive opportunities to subordinate males and that this leads to the presence of other fathers that can serve as a buffer against infanticidal attack. We found that subordinate males obtained significantly more conceptive opportunities than predicted by priority of access alone, and that this occurred because alpha males did not consort all receptive periods. There was no evidence that this was due to energetic constraint, large male cohorts, alpha male inexperience, or the competitive strength of queuing subordinates. The number of males who benefited from concession and the length of time that they were resident relative to those who did not benefit in this way greatly reduced the probability that infants of alpha males would face immigrant males without a surrogate father whose own offspring were vulnerable. The absence of such males was associated with observed infanticide as well as, unexpectedly, an increased likelihood of takeover when alpha males with vulnerable infants were present.

A national analysis of the outcome of major head and neck cancer surgery: implications for surgeon-level data publication.

OBJECTIVES: To undertake a national outcomes analysis following major head and neck cancer surgery in order to identify risk factors for complications and in-hospital mortality, as well as areas whose closer examination and formal benchmarking in the context of local and national quality assurance audits may lead to improved results for this condition. DESIGN: An analysis using Hospital Episode Statistics data. SETTINGS: All units undertaking major head and neck cancer surgery in England. MAIN OUTCOME MEASURES: Cancer sites, co-morbidities, social deprivation, surgical and non-surgical treatments, complications, and in-hospital mortality were recorded. Regression analysis was used for casemix adjustment and for identifying independent predictors of complications and mortality. Funnel plots were used for data visualisation. RESULTS: We identified 10,589 major head and neck cancer operations performed in England between 2006 and 2011. There were 7312 males, and mean age at surgery was 63 ± 13 years. Oral cavity (42%) and the larynx (28%) were the commonest cancer sites. At least one complication occurred in 33.1% of patients, and there were 322 (3.05%) in-hospital deaths. Variables associated with in-hospital mortality were trust volume, age, co-morbidities, performing emergency major surgery and performing a tracheostomy or reconstructive surgery. Occurrence of major medical complications including pulmonary infections (7%), major acute cardiovascular events (4.7%) and acute renal failure (0.6%) also increased mortality risk. The analysis identified units that were outside of crude and risk-adjusted 99.8% limits of confidence for complications and mortality. CONCLUSION: Mortality following head and neck cancer surgery shows significant national variation and is associated with fixed risk factors like age and co-morbidities, but also with modifiable risk factors like performing major surgery during an emergency admission, tracheostomy, reconstructive surgery and medical complications. We propose that the quality of tracheostomy care, reconstructive surgery, emergency major surgery rate, and occurrence and treatment of major medical complications should be closely examined and formally benchmarked as part of loco-regional and national quality improvement audits.

Risk equations to predict life expectancy of people with Type 2 diabetes mellitus following major complications: a study from Western Australia.

AIMS: To develop a model for predicting life expectancy following major diabetes-related complications and to summarize these results by age and gender in the form of a simple table. METHODS: Equations for forecasting mortality were derived using an observational cohort of 12,792 patients who had one of the following complications of diabetes: myocardial infarction, stroke, heart failure, amputation or renal failure, recorded in administrative health and mortality data from the state of Western Australia between 1990 and 1999. Logistic regression was used to estimate mortality within the first month post-event and a Gompertz proportional hazards model was used to estimate survival over the patients' remaining lifetime. After examining the internal validity over a 5-year period, these equations were used to estimate remaining life expectancy by age and sex following specific complications. RESULTS: Of the complications examined, renal failure had most impact on life expectancy at all ages, followed by heart failure; the best prognosis was following stroke, myocardial infarction and amputation. For a 60-year-old male, life expectancy immediately post-event ranged from 10.1 years (95% CI 9.4-10.8 years) for stroke to 4.3 years (95% CI 3.1-6.1 years) for renal failure. Life expectancies for women at 60 and 70 years of age were significantly lower than men following myocardial infarction and significantly higher than men following heart failure and amputation at 70 and 80 years of age. CONCLUSION: The model allows estimation of both survival probability and life expectancy post-event for men and women of any age. The summary table may provide a useful and simple reference for clinicians and diabetes specialists.

Pharyngolaryngectomy using a free jejunal graft: a new anastomosis technique.

We describe a technique of staple anastomosis for pharyngolaryngeal reconstruction using a free jejunal graft. Stapled anastomosis can be applied to both the upper and lower pharyngeal and oesophageal repair. Our series of 37 stapled anastomosis developed no post operative leaks. This technique allows an easier method for inferior anastomosis low down in the upper mediastinum where access is often difficult. Swallowing was established in all patients. Primary puncture into oesophagus below the anastomosis, gives good results with a low stricture rate of 11% all of which resolved with a single subsequent dilatation.

Impact of the method and success of pharyngeal reconstruction on the outcome of treating laryngeal and hypopharyngeal cancers with pharyngolaryngectomy: A national analysis.

BACKGROUND: Surgical treatment of cancers that arise from or invade the hypopharynx presents major reconstructive challenges. Reconstructive failure exposes the airway and neck vessels to digestive contents. METHODS: We performed a national N = near-all analysis of the administrative dataset to identify pharyngolaryngectomies in England between 2002 and 2012. Information about morbidity, pharyngeal closure method and post-operative complications was derived. RESULTS: There were 1589 predominantly male (78%) patients whose mean age at surgery was 62 years. The commonest morbidities were hypertension (24%) and ischemic heart disease (11%). For 232 (15%) patients, pharyngolaryngectomy was performed during an emergency admission. The pharynx was closed primarily in 551 patients, with skin or muscle free or pedicled flaps in 755 patients and with jejunum and gastric pull-up in 123 and 160 patients, respectively. In-hospital mortality rate was 6% and was significantly higher in the gastric pull-up group (11%). Reconstructive failure had an odds ratio of 6.2 [95% confidence interval (CI) 2.4-16.1] for in-hospital death. The five-year survival was 57% and age, morbidities, emergency surgery, gastric pull-up, major acute cardiovascular events, renal failure and reconstructive failure independently worsened prognosis. Patients who underwent pharyngeal reconstruction with radial forearm or anterolateral thigh flaps had lower mortality rates than patients who had jejunum flap reconstruction (hazard ratio = 1.50 [95% CI 1.03-2.19]) or gastric pull-up (hazard ratio = 1.92 [95% CI 1.32-2.80]). CONCLUSIONS: Pharyngolaryngectomy carries a high degree of risk of morbidity and mortality. Reconstructive failure worsens short- and long-term prognosis, and the use of cutaneous free flaps appears to improve survival.

Metastasizing pleomorphic salivary adenoma.

OBJECTIVE: To address questions about the etiology, behavior, optimal treatment, and prognosis of metastasizing pleomorphic adenoma (MPA), we undertook a review of the literature (1953-2005) and constructed a virtual series of all identified cases of MPA, metastatic lesions that are very occasionally identified in patients with a history of pleomorphic salivary adenoma and, on detailed pathological evaluation, found to exhibit all the histological hallmarks of the preceding benign lesions. DATA SOURCES: A review of the English-language literature between 1953 and 2005 using MEDLINE, secondary references identified from bibliographies of pertinent articles, and a further case from one of our institutions. DATA SYNTHESIS: A virtual case series was constructed and quantitatively analyzed. Forty-two patients with an average age of 33 years were identified. There were 20 male and 22 female patients. There was an overwhelming history of incomplete surgery for pleomorphic salivary adenoma. Most patients had locoregional recurrences before metastasis, and the mean presentation-to-metastasis latency was 16 years. Bone was the most common site for metastases (45%), followed by the head and neck (43%) and lung (36%). There was significant morbidity and mortality from distant disease, with 5-year disease-specific and disease-free survival of 58% and 50%, respectively. Developing distant lesions within 10 years of the primary tumor and presence of metastases in multiple sites were independent predictors of survival on Cox regression analysis. Metastasectomy conferred significant survival advantage over nonoperative treatment (log-rank analysis, P<.02). Chemotherapy and radiotherapy were of limited value. CONCLUSIONS: Meticulous surgery is crucial in preventing MPA. Metastatic disease carries significant morbidity and mortality and should be treated surgically when feasible.

Myxoid liposarcoma metastatic to the thyroid gland: a case report and literature review.

We present the second reported case of a myxoid liposarcoma metastatic to the thyroid gland in a 51-year-old gentleman with previous liposarcoma of the right thigh. Myxoid liposarcoma has a relatively good prognosis but tends to recur locally. Metastases affecting the thyroid gland are a rare entity and most commonly arise from the kidney, lung or breast. Clinical presentation, patterns of recurrence and prognosis of myxoid liposarcoma and metastases to the thyroid gland are discussed.

Nose and paranasal sinus tumours: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. With only limited high-level evidence for management of nasal and paranasal sinus cancers owing to low incidence and diverse histology, this paper provides recommendations on the work up and management based on the existing evidence base. Recommendations • Sinonasal tumours are best treated de novo and unusual polyps should be imaged and biopsied prior to definitive surgery. (G) • Treatment of sinonasal malignancy should be carefully planned and discussed at a specialist skull base multidisciplinary team meeting with all relevant expertise. (G) • Complete surgical resection is the mainstay of treatment for inverted papilloma and juvenile angiofibroma. (R) • Essential equipment is necessary and must be available prior to commencing endonasal resection of skull base malignancy. (G) • Endoscopic skull base surgery may be facilitated by two surgeons working simultaneously, utilising both sides of the nose. (G) • To ensure the optimum oncological results, the primary tumour must be completely removed and margins checked by frozen section if necessary. (G) • The most common management approach is surgery followed by post-operative radiotherapy, ideally within six weeks. (R) • Radiation is given first if a response to radiation may lead to organ preservation. (G) • Radiotherapy should be delivered within an accredited department using megavoltage photons from a linear accelerator (typical energies 4-6 MV) as an unbroken course. (R).

Upper neck spinal accessory nerve identification during neck dissection.

Iatrogenic injury to the spinal accessory nerve (SAN) during neck dissection may result in significant and avoidable morbidity in the form of 'shoulder syndrome'. The authors describe a simple method, based on the anatomy of the sternocleidomastoid muscle (SCM), which allows consistent and rapid identification of the SAN in the upper neck during dissection, thereby facilitating its preservation.

A study of out-of-hours facilities in otolaryngology: current provision and problems.

'Action on ENT' has recently published advice as to the minimum requirements for equipment required to provide a safe and suitable out-of-hours service in ENT. Our objectives were to determine the availability of a dedicated ENT treatment room for seeing patients out of hours, appropriately maintained specialized ENT equipment and availability of appropriate assistance. In addition, the mechanism for disinfection of nasoendoscopes out of hours was determined. Telephone questionnaires of 106 ENT units in England, which provide an out-of-hours ENT service, were taken. At each unit the standard questionnaire was answered by the first on-call ENT doctor. One hundred and one units (95 percent) had access to a dedicated treatment room out of hours. The number of units with a microscope was 91 (86 percent), headlight/lamp and mirror was 105 (99 percent), flexible nasoendoscope was 86 (81 percent) and cautery (electrical or chemical) was 105 (99 percent). Seventy-nine units (75 percent) found that their treatment rooms were adequately stocked, and 62 units (58 per cent) had assistance available when needed. Twenty-four units (23 percent) sterilized their scopes adequately, 22 units (21 percent) used endosheaths, 26 units (24 percent) used a variety of inadequate cleaning methods, and 34 respondents (32 percent) were unsure how their scopes were cleaned. This survey has shown that not all ENT units have appropriately equipped out-of-hours facilities. There is a need for nationally agreed guidelines stating the minimum equipment and assistance required to provide a safe, adequate and suitable out-of-hours service. National guidelines on out-of-hours disinfection of flexible nasoendoscopes are also required.

Role of reconstructive surgery in the management of head and neck cancer: a national outcomes analysis of 11,841 reconstructions.

BACKGROUND: The quality of head and neck cancer reconstruction in England is not known. Hospital administrative data provides details of treatment within the English National Health Service and may be used for national outcomes analysis. METHODS: An algorithm for identifying head and neck surgery with flap-based reconstruction from administrative data was constructed and validated against information from three cancer units. The validated algorithm was applied to 2003-2013 national activity. RESULTS: The algorithm was 91% sensitive and over 99% specific. Its application to administrative data identified 11,841 patients and demonstrated an increase of 52% in reconstruction-containing head and neck cancer surgery in the past decade. There were 7776 males and mean treatment age was 62 years. Oral cavity was the commonest primary site (n = 7567; 64%) and 7575 patients (64%) underwent primary surgery. The commonest procedure was floor-of-mouth excision (n = 3614) and 9749 patients had a neck dissection. The most commonly used flap was the radial forearm (n = 4429). Flap failure occurred in 496 (4.2%) patients. It increased the mean length of stay from 22 to 41 days (P < 0.00001), and the odds ratio of in-hospital death to 2.37 [95% confidence interval 1.66-3.38; P < 0.0001]. Lethality of reconstructive failure was not uniform and was highest when a pharyngolaryngeal flap failed. CONCLUSIONS: Reconstructive surgery is central to the multidisciplinary management of head and neck cancer. Its quality directly influences patient morbidity and survival. We recommend that analysis of hospital administrative data should be periodically carried out as part of an over-arching quality assurance programme and, particularly for pharyngolaryngeal reconstructions, surgery should be undertaken in units with the best reconstructive outcomes.

Cost-benefit analysis and mammographic screening: a travel cost approach.

This study describes the methodology and presents preliminary results of an economic appraisal of a program to use mobile mammographic screening units in rural areas of Australia. The benefits of the project are measured using the travel cost method. Since mammograms are a 'binary good', conventional welfare analysis must be modified and discrete choice models used to estimate the demand for screening. The results suggest that the level of welfare benefits depends on the distance a town is from the nearest fixed screening unit. In the 10 towns studied, the economic benefits of mobile screening outweighed the economic costs if a rural town is situated 29 km or more from a fixed mammographic screening unit.

A comparison of active anterior rhinomanometry and nasometry in the objective assessment of nasal obstruction.

Nasometry is an objective technique that was originally devised for assessing nasality of speech. It is based on a comparison of the acoustic output from the nose and the mouth for a given spoken word or phrase. Subjects with nasal obstruction tend to have "hyponasal" speech and this study compares the standard technique of active anterior rhinomanometry with nasometry in the objective assessment of nasal obstruction. There was a significant association between the Total Nasal Resistance (TNR) and the nasality measurements using nasophonemically enhanced test phrases in 15 adult subjects. This test has obvious advantages over rhinomanometry which can be difficult, time consuming and unreliable particularly in the younger and severely congested patient.

Hazardous party trick (infolding of the pinna).

Two cases of habitual pinna folding are reported. One case was complicated by the development of bilateral haematoma auris as a direct result of the trauma caused by the folding.