Accuracy of surgical complication rate estimation using ICD-10 codes.

BACKGROUND: The ICD-10 codes are used globally for comparison of diagnoses and complications, and are an important tool for the development of patient safety, healthcare policies and the health economy. The aim of this study was to investigate the accuracy of verified complication rates in surgical admissions identified by ICD-10 codes and to validate these estimates against complications identified using the established Global Trigger Tool (GTT) methodology. METHODS: This was a prospective observational study of a sample of surgical admissions in two Norwegian hospitals. Complications were identified and classified by two expert GTT teams who reviewed patients' medical records. Three trained reviewers verified ICD-10 codes indicating a complication present on admission or emerging in hospital. RESULTS: A total of 700 admissions were drawn randomly from 12 966 procedures. Some 519 possible complications were identified in 332 of 700 admissions (47·4 per cent) from ICD-10 codes. Verification of the ICD-10 codes against information from patients' medical records confirmed 298 as in-hospital complications in 141 of 700 admissions (20·1 per cent). Using GTT methodology, 331 complications were found in 212 of 700 admissions (30·3 per cent). Agreement between the two methods reached 83·3 per cent after verification of ICD-10 codes. The odds ratio for identifying complications using the GTT increased from 5·85 (95 per cent c.i. 4·06 to 8·44) to 25·38 (15·41 to 41·79) when ICD-10 complication codes were verified against patients' medical records. CONCLUSION: Verified ICD-10 codes strengthen the accuracy of complication rates. Use of non-verified complication codes from administrative systems significantly overestimates in-hospital surgical complication rates.

A rare missense mutation in CHRNA4 associates with smoking behavior and its consequences.

Using Icelandic whole-genome sequence data and an imputation approach we searched for rare sequence variants in CHRNA4 and tested them for association with nicotine dependence. We show that carriers of a rare missense variant (allele frequency=0.24%) within CHRNA4, encoding an R336C substitution, have greater risk of nicotine addiction than non-carriers as assessed by the Fagerstrom Test for Nicotine Dependence (P=1.2 × 10(-4)). The variant also confers risk of several serious smoking-related diseases previously shown to be associated with the D398N substitution in CHRNA5. We observed odds ratios (ORs) of 1.7-2.3 for lung cancer (LC; P=4.0 × 10(-4)), chronic obstructive pulmonary disease (COPD; P=9.3 × 10(-4)), peripheral artery disease (PAD; P=0.090) and abdominal aortic aneurysms (AAAs; P=0.12), and the variant associates strongly with the early-onset forms of LC (OR=4.49, P=2.2 × 10(-4)), COPD (OR=3.22, P=2.9 × 10(-4)), PAD (OR=3.47, P=9.2 × 10(-3)) and AAA (OR=6.44, P=6.3 × 10(-3)). Joint analysis of the four smoking-related diseases reveals significant association (P=6.8 × 10(-5)), particularly for early-onset cases (P=2.1 × 10(-7)). Our results are in agreement with functional studies showing that the human α4ß2 isoform of the channel containing R336C has less sensitivity for its agonists than the wild-type form following nicotine incubation.

Impact of the World Health Organization's Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study.

BACKGROUND: Positive changes in safety culture have been hypothesized to be one of the mechanisms behind the reduction in mortality and morbidity after the introduction of the World Health Organization's Surgical Safety Checklist (SSC). We aimed to study the checklist effects on safety culture perceptions in operating theatre personnel using a prospective controlled intervention design at a single Norwegian university hospital. METHODS: We conducted a study with pre- and post-intervention surveys using the intervention and control groups. The primary outcome was the effects of the Norwegian version of the SSC on safety culture perceptions. Safety culture was measured using the validated Norwegian version of the Hospital Survey on Patient Safety Culture. Descriptive characteristics of operating theatre personnel and checklist compliance data were also recorded. A mixed linear regression model was used to assess changes in safety culture. RESULTS: The response rate was 61% (349/575) at baseline and 51% (292/569) post-intervention. Checklist compliance ranged from 77% to 85%. We found significant positive changes in the checklist intervention group for the culture factors 'frequency of events reported' and 'adequate staffing' with regression coefficients at -0.25 [95% confidence interval (CI), -0.47 to -0.07] and 0.21 (95% CI, 0.07-0.35), respectively. Overall, the intervention group reported significantly more positive culture scores-including at baseline. CONCLUSIONS: Implementation of the SSC had rather limited impact on the safety culture within this hospital.

Overweight in polycystic ovary syndrome. An update on evidence based advice on diet, exercise and metformin use for weight loss.

AIM: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in premenopausal women affecting 5-10%. Nearly 50% are overweight or obese, which result in a more severe phenotype of PCOS. Weight loss is therefore considered the first line treatment in overweight women with PCOS. The aim of this study was to appoint evidence based and clinically applicable advises on weight loss in overweight women with PCOS. METHODS: A review of the existing literature on weight loss through lifestyle modification and/or metformin treatment in overweight women with PCOS. The primary outcome was weight loss. The clinical manifestations of hyperandrogenism and menstrual cyclicity were secondary outcomes. Metabolic parameters were not included in the present review. RESULTS: Weight loss is most effectively achieved through a 12-1500 kcal/day diet, which results in a clinically relevant weight loss. The type of diet has no implications for degree of weight loss. Physical activity has no significant additive effect on weight loss. Metformin combined with a low calorie diet has subtle additive effect on weight loss and level of androgens when compared to diet alone. CONCLUSION: Weight loss through life style changes, preferably a low calorie diet, should be the first line treatment in overweight/obese women with PCOS. Metformin can be considered as an additional treatment but has subtle additive effect.

The prognosis of self-reported paresthesia and weakness in disc-related sciatica.

PURPOSE: To explore how patients with sciatica rate the 'bothersomeness' of paresthesia (tingling and numbness) and weakness as compared with leg pain during 2 years of follow-up. METHODS: Observational cohort study including 380 patients with sciatica and lumbar disc herniation referred to secondary care. Using the Sciatica Bothersomeness Index paresthesia, weakness and leg pain were rated on a scale from 0 to 6. A symptom score of 4-6 was defined as bothersome. RESULTS: Along with leg pain, the bothersomeness of paresthesia and weakness both improved during follow-up. Those who received surgery (n = 121) reported larger improvements in both symptoms than did those who were treated without surgery. At 2 years, 18.2% of the patients reported bothersome paresthesia, 16.6% reported bothersome leg pain, and 11.5% reported bothersome weakness. Among patients with no or little leg pain, 6.7% reported bothersome paresthesia and 5.1% bothersome weakness. CONCLUSION: During 2 years of follow-up, patients considered paresthesia more bothersome than weakness. At 2 years, the percentage of patients who reported bothersome paresthesia was similar to the percentage who reported bothersome leg pain. Based on patients' self-report, paresthesia and weakness are relevant aspects of disc-related sciatica.

Molecular characterization of a cancer-related single nucleotide polymorphism in the pro-inflammatory interleukin-1B gene.

Interleukin-1ß is a key pro-inflammatory cytokine that has been associated with chronic inflammation and inflammation-related cancer initiation and progression. There are inter-individual differences in IL1B expression which may be due to single nucleotide polymorphisms (SNPs) in the regulatory regions of the gene. We have previously shown that a SNP located in the promoter of the IL1B gene (the IL1B T-31C SNP) was associated with lung cancer risk. Interestingly, the presence of the C allele was also associated with reduced IL1B expression in normal lung tissue of lung cancer patients. In the present study, we found that differential binding patterns of nuclear proteins to oligonucleotide probes containing the IL1B -31C allele compared to those with the T allele were due to specific binding of the transcription factor Yin Yang 1 (YY1). We further found evidence that specific recruitment of YY1 to the -31C region of the IL1B promoter regulated IL1B gene expression using siRNA directed towards YY1. The results indicate that the presence of a C allele at the -31 position may lead to decreased expression of the IL1B gene due to a specific binding of YY1 in lung epithelial cells. Our study provides functional significance of allelic variation at a single locus in the IL1B promoter and contributes to understanding the regulation of IL1B in inflammation-related carcinogenesis.

Assessing neuropathic pain in patients with low back-related leg pain: Comparing the painDETECT Questionnaire with the 2016 NeuPSIG grading system.

BACKGROUND: Low back-related leg pain with nerve root involvement is conceptually regarded as a neuropathic condition. However, it is uncertain to what extent patients with this condition can be formally classified with neuropathic pain. METHOD: First, we used the 2016 revision of the IASP Special Interest Group on Neuropathic Pain (NeuPSIG) grading system for neuropathic pain to grade patients suffering from low back-related leg pain and a corresponding disc herniation with either unlikely, possible, probable or definite neuropathic pain. Examination included bedside quantitative sensory testing. Next, we used the clinical classification based on the 2016 NeuPSIG grading system as a reference standard to assess the ability of the painDETECT Questionnaire to identify patients with neuropathic pain. RESULTS: Of the 50 included patients, six (12%) fulfilled the clinical classification criteria for probable and 44 (88%) for definite neuropathic pain, while none were graded unlikely or possible. According to painDETECT, 23 patients (46%) were classified with unlikely neuropathic pain, 18 patients (36%) had an uncertain condition and in nine patients (18%) neuropathic pain was likely. Among the 44 patients graded as having definite neuropathic pain by the clinical classification, eight were classified as likely neuropathic pain by painDETECT, resulting in an agreement of 18%. Of these 44 patients graded with definite neuropathic pain, painDETECT classified 21 patients (48%) as unlikely and 15 (34%) as uncertain. CONCLUSION: Our results do not support the use of painDETECT as a screening tool to classify or grade neuropathic components in patients with low back-related leg pain. SIGNIFICANCE: The painDETECT Questionnaire performed poorly at detecting neuropathic pain among patients with low back-related leg pain, compared to clinical examination based on the 2016 NeuPSIG grading system as a reference standard. Our results do not support the use of painDETECT as a screening tool to classify or grade neuropathic components in this population.

Transmission electron microscopy of fetal rat brain cells during neoplastic transformation in cell culture.

Fetal rat brain cells were investigated by transmission electron microscopy during neoplastic transformation in long-term cell culture. Before transfer of the cells to culture, BD IX rat fetuses were treated with a single transplacental pulse of N-ethyl-N-nitrosourea (75 micrograms/g body wt) on the 18th day of gestation. During the early stages (3--4 mo), both glia-like and neuron-like cells were present in the culture, and after 2 months they formed complex aggregates ("nodules"). In contrast, corresponding secondary control cultures consisted of flat, epithelioid neural cells without neuron or astrocyte differentiation. After 3 months, cells with neuron morphology gradually disappeared. Some of the remaining cells contained many autophagosomes. After 5 months, rapid proliferation of rather homogeneous, glia-like populations was accompanied by reduction of microfilament bundles and microtubules, as well as atypical nuclei. Ability to form tumors upon sc implantation into syngeneic hosts was not observed until about 3 months later.

Surface structure of fetal rat brain cells during neoplastic transformation in cell culture.

The surface microstructure of fetal rat brain cells undergoing neoplastic transformation in long-term cell culture after a single transplacental pulse of 75 microgram N-ethyl-N-nitrosourea/g body weight to the fetal (18th day of gestation) BD IX rat was investigated by scanning electron microscopy. After about 3 weeks of culture, N-ethyl-N-nitrosourea-pretreated fetal rat brain cells showed focal proliferation of neural cells on an underlayer of flat, epithelioid cells. The neural cells exhibited varying forms of numerous dorsal ruffles and an increased number of other surface microprojections. Between the 40th and the 100th day, nodules of bipolar and multipolar neural cells were observed with a complex surface microstructure including many blebs and ruffles and an increased number of microvilli. After 100-210 days, more rapidly proliferating, morphologically altered cells formed "piled-up" foci, which resulted in a homogeneous population of cells with numerous long microvilli, large ruffles, and blebs over the whole surface. The cells retained the same altered surface structure until tumorigenicity after reimplantation into the syngeneic host was first observed (approximately 273 days). Surface alterations characteristic of the neoplastic cells were thus observable more than 100 days before the cells became tumorigenic.

Different susceptibility to smoking-induced DNA damage among male and female lung cancer patients.

The levels of aromatic/hydrophobic DNA adducts were analyzed in normal lung tissue from 63 lung cancer patients and examined in relation to exposure and genetic factors. Adduct levels were significantly higher in smokers than in nonsmokers, but among smokers the number of cigarettes smoked per day had only low significance for the variation in adduct levels. An inverse correlation was found between years of smoking and DNA adduct levels (r = 0.52, P = 0.001). Thus, patients with high adduct levels generally had shorter duration of smoking and/or lower smoking dose before the clinical onset of the disease, which fits expected behavior of cancer susceptible individuals. The data indicated an excess of individuals with glutathione S-transferase M1 deficiency among male patients with high adduct levels. Among females the DNA adduct levels were higher than in males when adjusted for smoking dose. There was a highly significant difference in the distribution of males and females when smokers were divided into quartile groups according to adducts per pack year (trend test: 2-sided P = 0.005). This may indicate that women are at greater risk of tobacco-induced lung cancer.

Detection of polycyclic aromatic hydrocarbon-DNA adducts in white blood cells from coke oven workers: correlation with job categories.

Polycyclic aromatic hydrocarbon (PAH)-DNA adducts were quantitatively determined by ultrasensitive radioimmunoassay (USERIA) and 32P postlabeling in 128 DNA samples from WBCs of 68 coke oven workers and a local control group of 13 workers. Forty-four samples had a detectable adduct level by USERIA, with a mean of 0.390 fmol adducts/micrograms DNA (12.9 adducts/10(8) nucleotides) in the exposed group compared to a mean of 0.316 fmol adducts/micrograms DNA (10.4 adducts/10(8) nucleotides) in the control group. The mean adduct level with 32P postlabeling was 0.05 fmol/micrograms DNA (1.67 adducts/10(8) nucleotides) for the exposed group and 0.046 fmol/microgram DNA (1.54 adducts/10(8) nucleotides for the control group. Based on job description the workers were divided in 4 groups: control, low-, medium-, and high-exposure group. Both methods produced a positive correlation coefficient between estimated exposure and PAH-DNA adduct levels. The significance levels determined with Kendall rank correlation were P = 0.0145 for USERIA and P = 0.0594 for 32P postlabeling. Adduct levels determined by 32P postlabeling showed a correlation with tobacco smoking in the control group. No significant correlation between PAH-DNA adduct levels measured by USERIA and 32P postlabeling was found. These results show that these methods recognize different parts of the complex exposures in a coke oven plant.

A hereditary genetic marker closely associated with microsatellite instability in lung cancer.

Alterations in 5 microsatellite loci were analyzed in tumors from 137 patients with primary non-small cell lung carcinomas that were also genotyped for the Hras1 variable number of tandem repeats (VNTR) locus. Twenty-nine patients (21%) had changes in at least one microsatellite locus. A majority of these cases (24 of 29, 83%) had VNTR alleles classified as rare in the population. The frequency of these rare alleles were significantly higher among lung cancer patients than in healthy controls (P = 0.016 or 1.80; 95% confidence interval = 1.13-2.85). Microsatellite alterations were significantly more frequent among patients with at least one rare Hras1 VNTR allele (24 of 40, 60%) compared to patients with two common alleles (5 of 97, 5%; P < 0.001 or 27.6; 95% confidence interval = 8.18-82.9). Microsatellite alterations were also more frequent among patients below 50 years of age (8 of 21, 38%) than for older patients (21 of 112, 19%).

Immortalization of normal human kidney epithelial cells by nickel(II).

The occupational and environmental hazards of nickel exposure are of great concern in environmental medicine. Nickel workers have increased risk of cancer of the nose, lung, larynx, and possibly the kidney. In the present investigation we have studied the effects of nickel ions on fetal human kidney cortex explants. The explants were continuously exposed to 5 micrograms/ml NiSO4. After 70-100 days in culture foci of phenotypically altered cells appeared. Immortalized cell lines were established and demonstrated to be of human epithelial origin. Tumorigenicity was not induced, but the cells demonstrated decreased requirement for serum, increased plating efficiency and saturation density, and formation of colonies in soft agar. Chromosome changes in the treated cells were observed. Worth mentioning are change in ploidy (3n) and abnormalities of chromosomes 1, 7, 9, 11, 13, 14 and 20; increased numbers of chromosome 17; and loss of normal chromosomes 20 and 22.

Sex differences in lung CYP1A1 expression and DNA adduct levels among lung cancer patients.

Several epidemiological studies have indicated that female tobacco smokers may be at higher risk of lung cancer than males. In a study of lung cancer cases, we have found that female smokers had a significantly higher level of aromatic/hydrophobic DNA adducts in their nontumor lung tissue (15.39+/-9.47 adducts/10(8) nucleotides, n = 29) than male smokers (12.08+/-8.14, a = 93; P = 0.047). Females had significantly higher levels of adducts/pack-year (females 0.95+/-0.82 adducts/pack-year and males 0.46+/-0.46; P = 0.0004) and adducts/cigaret/day (females 1.48+/-1.29 and males 0.89+/-0.74, P = 0.015). By quantitative reverse transcription-PCR, it was found that female smokers exhibited a significantly higher expression level of lung CYP1A1 (494+/-334 CYP1A1 mRNA/10(6) glyceraldehyde-3-phophate dehydrogenase mRNA, n = 15) compared with males (210+/-208, n = 12; P = 0.016). Furthermore, for both sexes combined a significant correlation between CYP1A1 expression and DNA adduct level was found (r = 0.50, P = 0.009). In conclusion, the observed sex difference in aromatic/hydrophobic DNA adduct levels may at least in part be explained by different levels of CYP1A1 expression.

Determination of polycyclic aromatic hydrocarbons in the urine, benzo(a)pyrene diol epoxide-DNA adducts in lymphocyte DNA, and antibodies to the adducts in sera from coke oven workers exposed to measured amounts of polycyclic aromatic hydrocarbons in the work atmosphere.

Workers in coke oven plants have a higher incidence of lung cancer than the general population. They are exposed to a variety of chemicals, in particular the polycyclic aromatic hydrocarbons (PAH), including benzo(a)pyrene. To evaluate the genotoxic effects of PAH exposure, air samples and urine samples were analyzed for PAH by capillary gas chromatography and high-performance liquid chromatography, respectively. Since benzo(a)pyrene is activated to 7 beta,8 alpha-dihydroxy-(9 alpha,10 alpha)-epoxy-7,8,9,10-tetrahydrobenzo(a)pyrene (BPDE) and binds to DNA, we have used ultrasensitive enzymatic radioimmunoassay and synchronous fluorescence spectrophotometry to measure BPDE-DNA adducts in lymphocyte DNA. The results show that workers were exposed to high concentrations of atmospheric PAH. However, the mean PAH exposure levels are reduced 60% when the workers wore masks during work. When compared to exposure levels, the urinary excretion of PAH was relatively low. Approximately one-third of the workers had detectable putative BPDE-DNA adducts in lymphocytes by ultrasensitive enzymatic radioimmunoassay, and 10% of the samples had emission peaks at 379 nm by synchronous fluorescence spectrophotometry. The four most positive samples were the same in both of the assays. Antibodies to an epitope(s) on BPDE-DNA were found in the sera of approximately one-third of the workers. Detection of DNA adducts and antibodies to these adducts are internal indicators of exposure to benzo(a)pyrene.

Altered p53 gene structure and expression in human epithelial cells after exposure to nickel.

The carcinogenicity of certain nickel compounds is well known. We have previously shown that human kidney epithelial cells were immortalized by treatment with Ni(II) and in cooperation with the v-Ha-ras oncogene transformed the cells to acquire tumorigenicity in athymic nude mice. Immunocytochemistry and sequence analysis of DNA from the nickel-immortalized cells revealed abnormal p53 expression and a T----C transition mutation in codon 238. These data are consistent with the hypothesis that Ni(II)-induced mutation in the p53 gene can be involved in the escape from senescence of kidney epithelial cells.

Quantitation of aflatoxin B1-modified DNA using monoclonal antibodies.

Five monoclonal antibodies were obtained after fusion of mouse P3 x 63 myeloma cells with spleen cells isolated from BALB/c mice that had been immunized with aflatoxin B1-adducted DNA complexes with methylated bovine serum albumin. Selected hybridomas were found to produce monoclonal antibodies specific for modified DNA containing both the 2,3-dihydro-2-(N7-guanyl)-3-hydroxyaflatoxin B1 and the putative 2,3-dihydro-2-(N5-formyl-2',5',6'-triamino-4'-oxo-N5-pyrimidyl)-3-hydroxyaflatoxin B1, suggesting that these DNA adducts share a common antigenic determinant. Enzyme immunoassay conditions using these monoclonal antibodies were optimized, and DNA isolated from the livers of rats given dosages of aflatoxin B1 ranging from 0.01 to 1.0 mg aflatoxin B1 per kg body weight was tested. A level of modification in DNA of 1 aflatoxin B1 residue per 1,355,000 nucleotides can be quantitatively measured. Monoclonal antibodies will be useful probes for studying the molecular interactions of aflatoxin B1 with DNA and the occurrence of aflatoxin B1:DNA adducts in tissues and cells of humans exposed to this environmental carcinogen.

Clonal growth of epithelial cells from normal adult human bronchus.

Normal primary epithelial cell cultures devoid of fibroblastic cells have been developed from tissue explants of adult human bronchi. Conditions for clonal growth of secondary cultures of bronchial epithelial cells were optimized by coculturing the human cells with mitomycin C growth-arrested Swiss 3T3 mouse feeder cells, lowering the calcium concentration of medium M199, and supplementing it with hydrocortisone, insulin, cholera toxin, epidermal growth factor, and 1.25% fetal bovine serum. The epithelial cells grew for an average of 35 population doublings and had the normal human karyotype, expressed keratin and blood group antigen epithelial cell markers, metabolized benzo(a)pyrene, and were capable of differentiating into both ciliated and squamous cells. This culture system makes it potentially possible to investigate various aspects of differentiation and carcinogenesis in human bronchial epithelial cells.

p53 mutations in lung tumors: relationship to putative susceptibility markers for cancer.

We have screened 108 non-small cell lung tumors for mutational alterations in the p53 gene (exons 5 through 8) using polymerase chain reaction and denaturing gel electrophoresis techniques. Thirty-four cases (32%) had aberrant band migrations. The following DNA-sequencing step confirmed the mutations in all these samples. Seventy-six % of the mutations were found at G:C base pairs. Of all the mutations found, 29% were GC to AT, 29% GC to TA, 15% AT to GC, 12% GC to CG, and 3% AT to CG. The other mutations (12%) were deletions or insertions of one base pair. The frequency of p53 mutations among heavy smokers was higher than in nonsmokers (P = 0.047; odds ratio, 6.75; 95% confidence interval, 0.80-57). We examined p53 mutations in relation to genotypes of GSTmu1 and H-ras1. Our data showed that nearly all heavy smokers with transversion mutations were homozygous for the GSTmu1 null allele (10 of 11). The frequency of such mutations was significantly higher for patients with two null alleles (10 of 25) than for those with at least one allele intact (1 of 18) (P = 0.011; odds ratio, 11.33; 95% confidence interval, 1.29-99.3). This study indicated that rare alleles at the variable number of tandem repeats region flanking the H-ras protooncogene are negatively associated to the presence of p53 mutations in the tumors (P = 0.009).