Multidisciplinary protocol to reduce surgical readmissions in Australia: American College of Surgeons National Surgical Quality Improvement Program.

INTRODUCTION: Unplanned readmissions in general surgery are an important quality indicator of patient care and are associated with increased costs to healthcare services. This study aims to implement a multidisciplinary protocol in a single institution in a tertiary referral hospital to monitor and reduce unplanned readmission rates. METHODS: A prospective cohort study using an institution-based protocol was conducted over an 18-month period including patients undergoing a general surgical procedure. The protocol included: (i) implementation of a surgical readmissions nurse-patient liaison; (ii) access to a surgical walk-in clinic; and (iii) early post-discharge phone contact. Data included demographic details, index procedure, hospital length of stay (LOS), and whether contact between patient/nurse occurred upon discharge. The primary outcome was the cause and rate of 30-day readmissions. Secondary outcomes were mortality, use of surgical clinic, emergency department presentations, and complications. RESULTS: After protocol implementation, 874 patients underwent a general surgical procedure, with 354 (49%) being male and an overall median age of 53.0 years (interquartile range: 36.0-67.0). The overall readmission rate was 5.6% (n = 49), with a median LOS after readmission of 4 days. Compared with historical pre-protocol ACS-NSQIP data, this reflects a 30% reduction compared to that of readmission rate of 7.9%, P = 0.03. CONCLUSION: The multidisciplinary protocol was efficacious in significantly reducing unplanned readmissions. Continued audits and monitoring of factors associated with readmissions are required to help design targeted projects that may lead to improved outcomes, lower costs, increased patient satisfaction, and better efficiency within our healthcare system.

A clinical observation algorithm for anterior abdominal stab wound is safe in an Australian setting.

INTRODUCTION: We previously published the outcomes associated with the use of diagnostic laparoscopy to determine peritoneal breach for AASW patients without an immediate indication for laparotomy. Although this pathway was 100% sensitive there was a 54% non-therapeutic laparotomy rate. Another option that has been extensively reported is the clinical observation algorithm (COA) however, majority of the data originate from high-volume centres. We hypothesized that a COA would also be a safe option in an Australian setting, and reduce the rate of non-therapeutic operative intervention in managing AASW. METHODS: This was a prospective cohort study examining patients with AASW admitted to a level 1 trauma centre in Sydney, Australia, between June 2021 and August 2023. Patient, injury, management and outcome data were collected from electronic medical records and the hospital trauma registry. Data were then analysed to determine the diagnostic accuracy of the COA, complication rates and median hospital length-of-stay (LOS). RESULTS: A total of 48 patients presented with AASW. Of these patients, 11 (22.9%) proceeded to immediate laparotomy. Seven patients had a contraindication to COA and underwent diagnostic laparoscopy. Thirty patients were managed with the COA, with three (10%) patients subsequently requiring a laparotomy. Only one patient (3.3%) underwent a non-therapeutic laparotomy. There were no missed injuries. The COA sensitivity was 100%, specificity 92.7%, PPV 50% and NPV 100%. Patients managed with COA had no complications. Overall median hospital LOS was 1 day (1.0-2.3). CONCLUSION: A COA is a safe approach for evaluating patients with AASW in an Australian setting with adequate resources. It reduces the rate of non-therapeutic operative intervention and has acceptable outcomes compared with a diagnostic laparoscopy pathway.

Codesign of health technology interventions to support best-practice perioperative care and surgical waitlist management.

OBJECTIVES: This project aimed to determine where health technology can support best-practice perioperative care for patients waiting for surgery. METHODS: An exploratory codesign process used personas and journey mapping in three interprofessional workshops to identify key challenges in perioperative care across four health districts in Sydney, Australia. Through participatory methodology, the research inquiry directly involved perioperative clinicians. In three facilitated workshops, clinician and patient participants codesigned potential digital interventions to support perioperative pathways. Workshop output was coded and thematically analysed, using design principles. RESULTS: Codesign workshops, involving 51 participants, were conducted October to November 2022. Participants designed seven patient personas, with consumer representatives confirming acceptability and diversity. Interprofessional team members and consumers mapped key clinical moments, feelings and barriers for each persona during a hypothetical perioperative journey. Six key themes were identified: 'preventative care', 'personalised care', 'integrated communication', 'shared decision-making', 'care transitions' and 'partnership'. Twenty potential solutions were proposed, with top priorities a digital dashboard and virtual care coordination. DISCUSSION: Our findings emphasise the importance of interprofessional collaboration, patient and family engagement and supporting health technology infrastructure. Through user-based codesign, participants identified potential opportunities where health technology could improve system efficiencies and enhance care quality for patients waiting for surgical procedures. The codesign approach embedded users in the development of locally-driven, contextually oriented policies to address current perioperative service challenges, such as prolonged waiting times and care fragmentation. CONCLUSION: Health technology innovation provides opportunities to improve perioperative care and integrate clinical information. Future research will prototype priority solutions for further implementation and evaluation.

Kidney Transplantation Outcomes From Uncontrolled Donation After Circulatory Death: A Systematic Review and Meta-analysis.

BACKGROUND: Uncontrolled donation after circulatory death (uDCD) is a potential additional source of donor kidneys. This study reviewed uDCD kidney transplant outcomes to determine if these are comparable to controlled donation after circulatory death (cDCD). METHODS: MEDLINE, Cochrane, and Embase databases were searched. Data on demographic information and transplant outcomes were extracted from included studies. Meta-analyses were performed, and risk ratios (RR) were estimated to compare transplant outcomes from uDCD to cDCD. RESULTS: Nine cohort studies were included, from 2178 uDCD kidney transplants. There was a moderate degree of bias, as 4 studies did not account for potential confounding factors. The median incidence of primary nonfunction in uDCD was 12.3% versus 5.7% for cDCD (RR, 1.85; 95% confidence intervals, 1.06-3.23; P = 0.03, I 2 = 75). The median rate of delayed graft function was 65.1% for uDCD and 52.0% for cDCD. The median 1-y graft survival for uDCD was 82.7% compared with 87.5% for cDCD (RR, 1.43; 95% confidence intervals, 1.02-2.01; P = 0.04; I 2 = 71%). The median 5-y graft survival for uDCD and cDCD was 70% each. Notably, the use of normothermic regional perfusion improved primary nonfunction rates in uDCD grafts. CONCLUSIONS: Although uDCD outcomes may be inferior in the short-term, the long-term outcomes are comparable to cDCD.

Quality of life and mental health measurements among patients with type 2 diabetes mellitus: a systematic review.

BACKGROUND: Over the past few decades the benefits of assessing Quality of Life (QoL) and mental health in patients with Type 2 Diabetes Mellitus (T2DM) have steadily increased with limited studies relating to the most useful method to assess these patients. This study aims to identify, review, summarise, and evaluate the methodological quality for the most validated commonly used health-related QoL and mental health assessment measurements in diabetic patients. METHODS: All original articles published on PubMed, MedLine, OVID, The Cochrane Register, Web of Science Conference Proceedings and Scopus databases were systematically reviewed between 2011 and 2022. A search strategy was developed for each database using all possible combinations of the following keywords: "type 2 diabetes mellitus", "quality of life", mental health", and "questionnaires". Studies conducted on patients with T2DM of ≥ 18 years with or without other clinical illnesses were included. Articles designed as a literature or systematic review conducted on either children or adolescents, healthy adults and/or with a small sample size were excluded. RESULTS: A total of 489 articles were identified in all of the electronic medical databases. Of these articles, 40 were shown to meet our eligibility criteria to be included in this systematic review. Approximately, 60% of these studies were cross-sectional, 22.5% were clinical trials, and 17.5% of cohort studies. The top commonly used QoL measurements are the SF-12 identified in 19 studies, the SF-36, included in 16 studies, and the EuroQoL EQ-5D, found in 8 studies. Fifteen (37.5%) studies used only one questionnaire, while the remaining reviewed (62.5%) used more than one questionnaire. Finally, the majority (90%) of studies reported using self-administered questionnaires and only 4 used interviewer mode of administration. CONCLUSION: Our evidence highlights that the commonly used questionnaire to evaluate the QoL and mental health is the SF-12 followed by SF-36. Both of these questionnaires are validated, reliable and supported in different languages. Moreover, using single or combined questionnaires as well as the mode of administration depends on the clinical research question and aim of the study.

Improving Quality Metrics with a Day-only Skin Abscess Protocol: Experience from Australia.

BACKGROUND: Skin abscesses are a common emergency presentation often requiring incision and drainage; however, issues with theatre access lead to delays in management and high costs. The long-term impact in a tertiary centre of a standardised day-only protocol is unknown. The aim was to evaluate the impact of day-only skin abscess protocol (DOSAP) for emergency surgery of skin abscesses in a tertiary institution in Australia and to provide a blueprint for other institutions. METHODS: A retrospective cohort study analysed several time periods: Period A (July 2014 to 2015, n = 201) pre-DOSAP implementation, Period B (July 2016 to 2017, n = 259) post-DOSAP, and Period C (July 2018 to 2022, n = 1,625) prospectively analysed four 12-month periods to assess long-term utilisation of DOSAP. Primary outcomes were length of stay and delay to theatre. Secondary outcome measures included theatre start time, representation rates and total costs. Statistical analysis using nonparametric methods was used to analyse the data. RESULTS: There was a significant decrease in ward length of stay (1.25 days vs. 0.65 days, P < 0.0001), delay to theatre (0.81 days vs. 0.44 days, P < 0.0001) and theatre start time before 10AM (44 cases vs. 96 cases, P < 0.0001) after implementation of DOSAP. There was a significant decrease in median cost of admission of $711.74 after accounting for inflation. Period C reported 1,006 abscess presentations successfully managed by DOSAP over the four-year period. CONCLUSION: Our study demonstrates the successful implementation of DOSAP in an Australian tertiary centre. The ongoing utilisation of the protocol demonstrates the ease of applicability.

Comparison of breast cancer HER-2 receptor testing with immunohistochemistry and in situ hybridization.

PURPOSE: Human epidermal growth factor receptor-2 (HER2) status can be tested with immunohistochemistry (IHC) and in situ hybridization (ISH). The 2018 American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) HER2 testing guidelines suggest initial HER2 testing using IHC and further testing IHC equivocal cases with ISH. However, many institutions perform both IHC and ISH on the same specimen. This study aims to analyze the concordance between HER2 IHC and ISH in order to evaluate the benefit of repeating HER2 testing on the same breast cancer specimens. METHOD: Patients diagnosed with invasive breast cancer through BreastScreen NSW Sydney West program between January 2018 and December 2020 were identified and their HER2 IHC and HER2 ISH results on core needle biopsy (CNB) and surgical excisions (SE) were retrospectively collected. Specimens with both IHC and ISH results were then analyzed for agreement and concordance using unweighted kappa values. Equivocal IHC (2+) cases were excluded from concordance analysis. RESULTS: Overall, there were 240 invasive breast cancer specimens (CNB and SE) with both IHC and ISH recorded. Concordance between HER2 IHC and ISH was 100% (95% CI: 96.2-100%; κ = 1.00 (P < 0.001)). Of the IHC equivocal cases (n = 146), 94.5% were ISH negative. CONCLUSION: There was perfect positive concordance and agreement between non-equivocal IHC and ISH results. This reinforces that IHC alone can be utilized reliably for testing HER2 status of non-equivocal cases consistent with the 2018 ASCO/CAP guidelines.

Reducing unplanned general surgical readmissions: a review of the Australian and New Zealand National Surgical Quality Improvement Program Database.

BACKGROUND: Unplanned surgical readmissions are an important indicator of quality care and are a key focus of improvement programs. The aims of this study were to evaluate the factors that lead to unplanned hospital readmissions in patients undergoing general surgical procedures and to identify preventable readmissions. METHODS: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database from 2016 to 2020 at a tertiary hospital was conducted to identify patients undergoing a general surgical procedure. Various perioperative parameters were studied to identify risk factors and reasons for unplanned readmission. Preventable readmissions were identified. RESULTS: A total of 3069 patients underwent a general surgical procedure. Of these, the overall unplanned readmission rate was 8.8% (n = 247). The most common reason for readmission was associated with surgical site infections (n = 112, 44.3%) followed by pain (n = 50, 20.2%), with over 45% deemed as preventable readmissions. Factors associated with increased risk of readmission included older age, longer index length of stay, prolonged operative time, elective procedures, higher ASA score and contaminated procedures. CONCLUSION: Unplanned readmissions are more likely to occur in patients who develop postoperative complications. Understanding factors associated with readmissions may facilitate targeted quality improvement projects that reduce hospital readmission after surgery.

Robotic-assisted versus laparoscopic rectal surgery in obese and morbidly obese patients: ACS-NSQIP analysis.

Laparoscopic rectal surgery within the confines of a narrow pelvis may be associated with a high rate of open conversion. In the obese and morbidly obese patient, the complexity of laparoscopic surgery increases substantially. Robotic technology is known to reduce the risk of conversion, but it is unclear if it can overcome the technical challenges associated with obesity. The ACS NSQIP database was used to identify obese patients who underwent elective laparoscopic or robotic-assisted rectal resection from 2015 to 2016. Obesity was defined as a body mass index (BMI) greater than or equal to 30 kg/m2. Morbid obesity was defined as a BMI greater than or equal to 35 kg/m2. The primary outcome was unplanned conversions to open. Other outcomes measures assessed included anastomotic leak, operative time, surgical site infections, length of hospital stay, readmissions and mortality. Statistical analyses were performed using SPSS 22.0 (IBM SPSS, USA). 1490 patients had robotic-assisted and 4967 patients had laparoscopic rectal resections between 2015 and 2016. Of those patients, 561 obese patients had robotic-assisted rectal resections and 1824 patients underwent laparoscopic rectal surgery. In the obese cohort, the rate of unplanned conversion to open in the robotic group was 14% compared to 24% in the laparoscopic group (P < 0.0001). Median operative time was significantly longer in the robotic group (248 min vs. 215 min, P < 0.0001). There was no difference in anastomotic leak or systemic sepsis between the laparoscopic and robotic rectal surgery groups. In morbidly obese patients (BMI ≥ 35 kg/m2), the rate of unplanned conversion to open in the robotic group was 19% compared to 26% in the laparoscopic group (P < 0.027). There was no difference in anastomotic leak, systemic sepsis or surgical site infection rates between robotic and laparoscopic rectal resection. Multivariate analysis showed that robotic-assisted surgery was associated with fewer unplanned conversions to open (OR 0.28, P < 0.0001). Robotic-assisted surgery is associated with a decreased risk of conversion to open in obese and morbidly obese patients when compared to conventional laparoscopic surgery. However, robotic surgery was associated with longer operative time and despite improvement in the rate of conversion to open, there was no difference in complications or length of stay. Our findings are limited by the retrospective non-randomised nature of the study, demographic differences between the two groups, and the likely difference in surgeon experience between the two groups. Large randomised controlled studies are needed to further explore the role of robotic rectal surgery in obese and morbidly obese patients.

Concordance between core needle biopsy and surgical excision for breast cancer tumor grade and biomarkers.

PURPOSE: Histopathological biomarkers guide breast cancer management. Testing histopathological biomarkers on both core needle biopsy (CNB) and surgical excision (SE) in patients who are treated with upfront surgery is unnecessary and costly if there is high concordance between the two. This study investigated the concordance between CNB and SE for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor-2 (HER2), tumor grade and Ki-67. METHODS: Histopathological biomarker information were retrospectively collected from preoperative CNB and SE on patients diagnosed with breast cancer through the BreastScreen Sydney West program over a four-year period between January 2017 and December 2020. Data were then analyzed to calculate percentage of agreement and concordance using kappa values for ER, PR, HER2, tumor grade and Ki-67. RESULTS: A total of 504 cases of invasive breast cancers were analyzed. There was substantial level of concordance for ER 96.7% (κ = 0.687) and PR 93.2% (κ = 0.69). Concordance for HER2 negative (IHC 0, IHC 1 +) or positive (IHC 3 +) tumor on CNB was 100% (κ = 1.00). Grade and Ki-67 showed moderate level of concordance, 72.6% (κ = 0.545) and 70.5% (κ = 0.453), respectively. CONCLUSION: ER, PR and HER2 show high level of concordance. CNB is reliable in determining histopathological biomarkers for ER, PR positive and HER2 positive or negative tumors indicating that retesting these on SE may not be necessary.

Development and validation of a multivariable prediction model in open abdomen patients for entero-atmospheric fistula.

BACKGROUND: Laparostomy or Open Abdomen (OA) has matured into an effective strategy in the management of abdominal catastrophe. Single prognostic factors have been identified in a previous systematic review regarding entero-atmospheric fistula (EAF). Unfortunately, no prognostic multivariable model for EAF exist. The aim was to develop and validate a multivariable prediction model from a retrospective cohort study involving three hospital's databases. METHODS: Fifty-seven variables were evaluated to develop a multivariable model. Univariate and multivariable logistic regression analyses were performed for on a developmental data set from two hospitals. Receiver operator characteristics analysis with area under the curve (AUC) and 95% confidence intervals (CI) were performed on the developmental data set (internal validation) as well as on an additional validation data set from another hospital (external validation). RESULTS: Five-hundred and forty-eight patients managed with an OA. Two variables remained in the multivariable prediction model for EAF. The AUC for EAF on internal validation were 0.74 (95% CI: 0.58-0.86) and 0.79 (95% CI: 0.67-0.92) on external validation. CONCLUSIONS: A multivariable prediction model for EAF was externally validated and an easy-to-use probability nomogram was constructed using the two predictor variables. LEVEL OF EVIDENCE: III; prognostic.

The impact of variations in care and complications within a colorectal Enhanced Recovery After Surgery program on length of stay.

PURPOSE: Enhanced Recovery After Surgery (ERAS) has become standard of care in colorectal surgery. However, there is not a universally accepted colorectal ERAS protocol and significant variations in care exist between institutions. The aim of this study was to examine the impact of variations in ERAS interventions and complications on length of stay (LOS). METHODS: This study was a single-center review of the first 200 consecutive patients recruited into our prospectively collected ERAS database. The primary outcome of this study was to examine the rate of compliance to ERAS interventions and the impact of these interventions on LOS. The secondary outcome was to assess the impact of complications (anastomotic leak, ileus, and surgical site infections) on LOS. ERAS interventions, rate of adherence, LOS, readmissions, morbidity, and mortality were recorded, and statistical analysis was performed. RESULTS: ERAS variations and complications significantly influenced patient LOS on both univariate and multivariate analysis. ERAS interventions identified as the most important strategies in reducing LOS included laparoscopic surgery, mobilization twice daily postoperative day (POD) 0 to 1, discontinuation of intravenous fluids on POD 0 to 1, upgrading to solid diet by POD 0 to 2, removal of indwelling catheter by POD 0 to 2, avoiding nasogastric tube reinsertion and removing drains early. Both major and minor complications increased LOS. Anastomotic leak and ileus were associated with the greatest increase in LOS. CONCLUSION: Seven high-yield ERAS interventions reduced LOS. Major and minor complications increased LOS. Reducing variations in care and complications can improve outcomes following colorectal surgery.

Successful Expectant Management of Nonocclusive Thrombosis in Simultaneous Pancreas-Kidney Transplantation.

BACKGROUND: Simultaneous pancreas-kidney (SPK) transplantation can be complicated by thrombosis in the early post-transplant period. METHODS: We performed a single-center retrospective study examining risk factors, management, and outcomes of modern era SPK transplants. We reviewed 235 recipients over 10 years (January 1, 2008, to September 1, 2017). We used multivariate analysis to examine donor, recipient, and operative risk factors for thrombosis. RESULTS: Forty-one patients (17%) had a thrombosis diagnosed on postoperative imaging, but 61% of these patients (n = 25/41) did not lose their graft secondary to the thrombosis. Nine patients (22%) were managed with watchful waiting and serial imaging, 12 (29%) were managed with therapeutic anticoagulation, and 4 (10%) required laparotomy and graft thrombectomy. Sixteen of 235 pancreas grafts (6.8%) required pancreatectomy, and 10 of these cases occurred in the first half of the study, before 2012. The risk of thrombosis leading to graft loss increased 11.2-fold in recipients with a body mass index (calculated as weight in kilograms divided by height in meters squared) > 25 compared with others (odds ratio, 11.2; 95% CI, 1.1-116.7; P = .043). CONCLUSIONS: The majority of SPK transplants (61%) complicated by thrombosis of the pancreatic graft were salvaged by use of imaging, anticoagulation, and in select cases, laparotomy and graft thrombectomy.

Culture of Transplant Perfusate Using BACTEC Technology and Antibiotic Prophylaxis Influences Wound Complications Within a Kidney Transplant and SPK Transplant Cohort.

PURPOSE: Routine screening for microbial contamination in organ recovery perfusion transport solution (ORPTS) is by microbiological culture without broth enrichment. Our aim was to examine the clinical utility of broth enrichment of perfusion solution, through use of BACTEC (Becton Dickinson) blood culture media, in preventing wound complications for transplant recipients in comparison with culture without enrichment. METHODS: We prospectively collected samples of ORPTS of 395 kidney (n = 250) or simultaneous pancreas-kidney (SPK, n = 145) donors over a 7-year period. Results of culture with and without broth enrichment (n = 285) using BACTEC blood culture media were examined to compare the sensitivity of BACTEC with non-BACTEC methods. We then conducted a paired analysis of 110 recipients with both BACTEC and non-BACTEC culture organ perfusion media. We examined the rates of wound infection and whether the use of targeted antimicrobials reduced infections in the BACTEC group and recipients with both types of cultures. RESULTS: Of 395 patients with cultures of ORPTS, first, the results of 79 cultures performed using BACTEC media only were compared with 206 non-BACTEC cultures (n = 285). Second, 110 cultures were performed using both methods. For the first part of the study, BACTEC media detected significantly greater microbial growth than non-BACTEC methods (n = 79, 64.6% vs n = 206, 14.6%; P < .001). In the 110 patients with both BACTEC (52.3%) and non-BACTEC cultures (9.9%), there was significantly higher sensitivity of the BACTEC method (P < .001); 68.2% of these patients had antimicrobial cover in the days immediately following transplant sufficient to cover the cultured organism. In the patients with appropriate antimicrobial cover, the rate of recipient wound infection was significantly reduced (P = .003). CONCLUSIONS: Routine screening of ORPTS with BACTEC broth enrichment should always be employed. When paired with antimicrobial prophylaxis, it has the potential to significantly reduce the risk of recipient wound infection.

Comparison of administrative data and the American College of Surgeons National Surgical Quality Improvement Program data in a New South Wales Hospital.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) is widely used in North America for benchmarking. In 2015, NSQIP was introduced to four New South Wales public hospitals. The aim of this study is to investigate the agreement between NSQIP and administrative data in the Australian setting; to compare the performance of models derived from each data set to predict 30-day outcomes. METHODS: The NSQIP and administrative data variables were mapped to select variables available in both data sets where coding may be influenced by interpretation of the clinical information. These were compared for agreement. Logistic regression models were fitted to estimate the probability of adverse outcomes within 30 days. Models derived from NSQIP and administrative data were compared by receiver operating characteristic curve analysis. RESULTS: A total of 2240 procedures over 21 months had matching records. Functional status demonstrated poor agreement (kappa 0.02): administrative data recorded only one (1%) patient with partial- or total-dependence as recorded by NSQIP data. The American Society of Anesthesiologists class demonstrated excellent agreement (kappa 0.91). Other perioperative variables demonstrated poor to fair agreement (kappa 0.12-0.61). Predictive model based on NSQIP data was excellent at predicting mortality but was less accurate for complications and readmissions. The NSQIP model was better in predicting mortality and complications (receiver operating characteristic curve 0.93 versus 0.87; P = 0.029 and 0.71 versus 0.64; P = 0.027). CONCLUSIONS: There is poor agreement between NSQIP data and administrative data. Predictive models associated with NSQIP data were more accurate at predicting surgical outcomes than those from administrative data. To drive quality improvement in surgery, high-quality clinical data are required and we believe that NSQIP fulfils this function.

Aspirin for prevention of venous thromboembolism in recipients of major lower-limb orthopedic surgery: a systematic review of Level I evidence.

INTRODUCTION: Major lower-limb orthopedic surgery recipients are at increased risk of venous thromboembolism (VTE). The optimal strategy for preventing VTE is a topic of ongoing debate. The use of aspirin has been implicated in reducing VTE events and is potentially advantageous compared to other agents in respect to cost, access, route of administration and reduced adverse effects such as bleeding. EVIDENCE ACQUISITION: A systematic search for Level I evidence (systematic reviews and meta-analyses of randomised-controlled trials) was performed in April 2019 to evaluate the use of aspirin for primary and secondary VTE prophylaxis compared to alternative chemical and mechanical strategies. This search encompassed three electronic databases (Pubmed, Embase and the Cochrane Database of Systematic Reviews). All references of included studies were screened for additional studies. Data was compiled and compared to the recommendations and guidelines published by major institutions. Included studies were appraised with the aid of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. EVIDENCE SYNTHESIS: In total, 21 studies were included. Interventions and outcomes identified were heterogeneous across studies. Most statistical tests applied found no difference between aspirin and other interventions in regards to deep vein thrombosis, pulmonary embolism, bleeding and mortality outcomes. CONCLUSIONS: Aspirin may be a viable alternative to established thromboprophylactic regimes for primary prevention of VTE, however in the setting of secondary prevention it is generally less efficacious. Future studies should have clearly identified and comparable outcome measures, with direct comparisons and assessment of intervention combination, dosing and treatment duration.

Effect of the American College of Surgeons Oncology Group Z0011 trial on axillary management in breast cancer patients in the Australian setting.

The American College of Surgeons Oncology Group Z0011 Trial demonstrated that early breast cancer patients with positive axillary sentinel lymph nodes treated with breast-conserving surgery and breast radiotherapy had no additional oncologic benefit of proceeding to an axillary lymph node dissection (ALND). The extent to which practice has changed in Australia remains unclear. The aim of this study was to investigate the effect of the Z0011 trial on the management of positive axillary sentinel nodes at an Australian institutional level. We reviewed all breast cancer cases treated at the Sydney Adventist Hospital over a 10-year period from 1 January 2008 to 31 December 2017. Patients who fulfilled the Z0011 trial criteria were selected. These patients were divided into two groups according to the year of surgery, before and after 1 January 2011 when the Z0011 study was published. Clinicopathologic data and axillary surgical management were compared. Of the 237 patients fulfilling the Z0011 trial criteria, there were 73 patients before and 158 patients after 1 January 2011. In the earlier group the rate of proceeding to an ALND following a positive sentinel node was 78.1% compared to 43.7% in the latter group (P < 0.0001). There was a significant decline in the rate of ALND over this 10-year period (r = -0.79, P = 0.006). The Z0011 trial has influenced the surgical management of the axilla leading to a significant reduction in the rate of an ALND in patients fulfilling the Z0011 trial criteria at our institution.

Meta-analysis - perineural invasion as prognostic factor in rectal cancer / Metanálise -invasão perineural como fator prognóstico no câncer retal

ABSTRACT Objectives: The aim of this analysis was to determine prognostic value of perineural invasion in rectal cancer. Methods: Medline (PubMed, Ovid), Embase and Cochrane Library were searched for relevant reports published from January 1980 up to December 2017. All clinical trials which studied perineural invasion in rectal cancer, prospective observational studies, clinical registry data and retrospective case series which reported perineural invasion as an outcome were included. Case reports, abstracts, letters and comments were excluded. hazard ratio (HR) with 95% confidence interval (CI) was used to determine the prognostic value. Results: Nineteen studies comprising 6438 patients with rectal cancer were analysed. The results indicate that perineural invasion is a negative prognostic factor as evident from the overall survival (HR = 1.30, 95% CI 1.13-1.50, p < 0.01) and disease-free survival (HR = 2.14, 95% CI 2.06-2.22, p < 0.01). Conclusion: This study shows that presence of perineural invasion is associated with poor prognosis in rectal cancer.

RESUMO Objetivo: Este estudo buscou determinar o valor prognóstico da invasão perineural no câncer retal. Métodos: Relatos relevantes publicados entre janeiro de 1980 e dezembro de 2017 foram buscados nas bases de dados Medline (PubMed, Ovid), Embase e Cochrane Library. Todos os ensaios clínicos que avaliaram a IPN no câncer de reto, estudos observacionais prospectivos, dados de registro clínico e séries de casos retrospectivos que relataram IPN como um desfecho foram incluídos. Relatos de casos, resumos, cartas e comentários foram excluídos. A razão de risco (hazard ratio [HR]) com intervalo de confiança (IC) de 95% foi usada para determinar o valor prognóstico. Resultados: Foram analisados 19 estudos compreendendo 6.438 pacientes com câncer retal. Os resultados indicam que a invasão perineural é um fator prognóstico negativo, conforme demonstrado pela sobrevida global (HR = 1,30; IC 95%: 1,13-1,50; p < 0,01) e sobrevida livre de doença (HR = 2,14; IC 95%: 2,06-2,22, p < 0,01). Conclusão: O estudo demonstrou que a presença de invasão perineural está associada a um prognóstico ruim no câncer retal.