Comparison of Surgical Intervention and Mortality for Seven Surgical Emergencies in England and the United States.

OBJECTIVE: To examine differences between England and the USA in the rate of surgical intervention and in-hospital mortality for 7 index surgical emergencies. BACKGROUND: Considerable international variation exists in the configuration, provision, and outcomes of emergency healthcare. METHODS: Patients aged <80 years hospitalized with 1 of 7 surgical emergencies (ruptured abdominal aortic aneurysm, aortic dissection, appendicitis, perforated esophagus, peptic ulcer, small bowel or large bowel, and incarcerated or strangulated hernias) were identified from English Hospital Episode Statistics and the USA Nationwide Inpatient Sample (2006-2012) and classified by whether they received a corrective surgical intervention. The rates of surgical intervention and population mortality were compared between England and the USA after adjustment for patient demographic factors. RESULTS: From 2006 to 2012, there were 136,047 admissions in English hospitals and 1,863,626 admissions in US hospitals due to the index surgical emergencies.Proportion of patients receiving no surgical intervention, for all 7 conditions was greater in the England (OR 4.25, 1.55, 8.53, 1.92, 2.06, 2.42, 1.75) and population in-hospital mortality was greater in England (OR 1.34, 1.67, 2.22, 1.65, 2.7, 4.46, 3.22) for ruptured abdominal aortic aneurysm, aortic dissection, appendicitis, perforated esophagus, peptic ulcer, small bowel or large bowel, and incarcerated or strangulated hernias respectively.In England (where follow-up was available), lack of utilization of surgery was also associated with increased in-hospital and long-term mortality for all conditions. CONCLUSION: England and US hospitals differ in the threshold for surgical intervention, which may be associated with increases in mortality in England for these 7 general surgical emergencies.

Point-of-Care Ultrasound Use, Accuracy, and Impact on Clinical Decision Making in Rwanda Hospitals.

OBJECTIVES: Few studies of point-of-care ultrasound training and use in low resource settings have reported the impact of examinations on clinical management or the longer-term quality of trainee-performed studies. We characterized the long-term effect of a point-of-care ultrasound program on clinical decision making, and evaluated the quality of clinician-performed ultrasound studies. METHODS: We conducted point-of-care ultrasound training for physicians from Rwandan hospitals. Physicians then used point-of-care ultrasound and recorded their findings, interpretation, and effects on patient management. Data were collected for 6 months. Trainee studies were reviewed for image quality and accuracy. RESULTS: Fifteen participants documented 1158 ultrasounds; 590 studies (50.9%) had matched images and interpretations for review. Abdominal ultrasound for free fluid was the most frequently performed application. The mean image quality score was 2.36 (95% confidence interval, 2.28-2.44). Overall sensitivity and specificity for trainee-performed examinations was 94 and 98%. Point-of-care ultrasound use most commonly changed medications administered (42.4%) and disposition (30%). CONCLUSIONS: A point-of-care ultrasound training intervention in a low-resource setting resulted in high numbers of diagnostic-quality studies over long-term follow-up. Ultrasound use routinely changed clinical decision making.

Intensive point-of-care ultrasound training with long-term follow-up in a cohort of Rwandan physicians.

OBJECTIVE: We delivered a point-of-care ultrasound training programme in a resource-limited setting in Rwanda, and sought to determine participants' knowledge and skill retention. We also measured trainees' assessment of the usefulness of ultrasound in clinical practice. METHODS: This was a prospective cohort study of 17 Rwandan physicians participating in a point-of-care ultrasound training programme. The follow-up period was 1 year. Participants completed a 10-day ultrasound course, with follow-up training delivered over the subsequent 12 months. Trainee knowledge acquisition and skill retention were assessed via observed structured clinical examinations (OSCEs) administered at six points during the study, and an image-based assessment completed at three points. RESULTS: Trainees reported minimal structured ultrasound education and little confidence using point-of-care ultrasound before the training. Mean scores on the image-based assessment increased from 36.9% (95% CI 32-41.8%) before the initial 10-day training to 74.3% afterwards (95% CI 69.4-79.2; P < 0.001). The mean score on the initial OSCE after the introductory course was 81.7% (95% CI 78-85.4%). The mean OSCE performance at each subsequent evaluation was at least 75%, and the mean OSCE score at the 58-week follow up was 84.9% (95% CI 80.9-88.9%). CONCLUSIONS: Physicians providing acute care in a resource-limited setting demonstrated sustained improvement in their ultrasound knowledge and skill 1 year after completing a clinical ultrasound training programme. They also reported improvements in their ability to provide patient care and in job satisfaction.

Risk of Surgical Site Infection Varies Based on Location of Disease and Segment of Colorectal Resection for Cancer.

BACKGROUND: Current quality-monitoring initiatives do not accurately evaluate surgical site infections based on type of surgical procedure. OBJECTIVE: This study aimed to characterize the effect of the anatomical site resected (right, left, rectal) on wound complications, including superficial, deep, and organ space surgical site infections, in patients who have cancer. SETTINGS: Data were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database. DESIGN: This study was designed to determine the independent risk associated with the anatomical location of cancer resection for all subtypes of surgical site infection. Statistical methods included the Fisher exact test, the χ test, and univariable and multivariable analyses for each outcome of interest. PATIENTS: All colon and rectal resections for colorectal cancer between 2006 and 2012 were selected. Included were 45,956 patients: 17,993 (39.2%) underwent right colectomy, 11,538 (25.1%) underwent left colectomy, and 16,425 (35.7%) underwent rectal resections. RESULTS: The overall surgical site infection rate was 12.3%: 3.7% organ space, 1.4% deep, and 7.2% superficial. On multivariable analysis, rectal resection was associated with the greatest odds of overall surgical site infections in comparison with left- or right-sided resections (rectal OR, 1.51; 95% CI, 1.35-1.69 vs left OR, 1.09; 95% CI, 0.97-1.23 vs right OR, 1). Rectal resections were also associated with greater odds of developing a deep surgical site infection than either right (rectal OR, 1.45; 95% CI, 1.06-1.99) or left (OR, 0.89; 95% CI, 0.62-1.27). The likelihood of organ space surgical site infection followed a similar pattern (rectal OR, 1.83; 95% CI 1.49-2.25; left colon, OR, 0.95; 95% CI, 0.75-1.19). Rectal and left resections had increased odds of superficial surgical site infections compared with right resections (rectal OR, 1.31; 95% CI, 1.14-1.51; left OR, 1.19; 95% CI, 1.03-1.37). LIMITATIONS: This is a retrospective observational study. CONCLUSIONS: Rectal resections for cancer are independently associated with an increased likelihood of superficial, deep, and organ space infections. The policy on surgical site infections as a quality measure currently in place requires modification to adjust for the location of pathology and, hence, the anatomical segment resected when assessing the risk for type of surgical site infection.

Risk of anastomotic leak after laparoscopic versus open colectomy.

BACKGROUND: Anastomotic leak following colorectal surgery is associated with significant morbidity and mortality. With the widespread adoption of laparoscopy, data from initial clinical trials evaluating the efficacy of laparoscopic when compared to open surgery may not currently be generalizable. We assess the risk of anastomotic leak after laparoscopic versus open colorectal resection using a nationwide database with standardized definitions. METHODS: The 2012-2013 ACS-NSQIP targeted colectomy data were queried for all elective colorectal resections. Characteristics were compared for those patients undergoing laparoscopic versus open operations. Univariable and multivariable analyses, followed by a propensity score-matched analysis, were performed to assess the impact of laparoscopy on the development of an anastomotic leak. RESULTS: Of 23,568 patients, 3.4 % developed an anastomotic leak. Laparoscopic surgery was associated with a leak rate of 2.8 % (n = 425) and open surgery, 4.5 % (n = 378, p < 0.0001). Patients who developed a leak were more likely to die within 30 days of surgery (5.7 vs. 0.6 %, p < 0.0001). Patients who underwent laparoscopic surgery compared to open were younger (61 vs. 63 years, p = 0, p = 0.045) and with fewer comorbidities. On univariable analysis laparoscopic surgery was associated with reduced odds of developing an anastomotic leak (OR 0.60, p < 0.0001), and this remained after adjusting for all significant preoperative and disease-related confounders (OR 0.69, 95 % CI 0.58-0.82). A propensity score-matched analysis confirmed benefit of laparoscopic surgery over open surgery for anastomotic leak. CONCLUSION: Laparoscopic colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy when controlling for patient-, disease- and procedure-related factors.

Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery.

OBJECTIVES: To clarify whether bowel preparation use or its individual components [mechanical bowel preparation (MBP)/oral antibiotics] impact specific outcomes after colorectal surgery. METHODS: National Surgical Quality Improvement Program-targeted colectomy data initiated in 2012 capture information on the use/type of bowel preparation and colorectal-specific complications. For patients undergoing elective colorectal resection, the impact of preoperative MBP and antibiotics (MBP+/ABX+), MBP alone (MBP+/ABX-), and no bowel preparation (no-prep) on outcomes, particularly anastomotic leak, surgical site infection (SSI), and ileus, were evaluated using unadjusted/adjusted logistic regression analysis. RESULTS: Of 8442 patients, 2296 (27.2%) had no-prep, 3822 (45.3%) MBP+/ABX-, and 2324 (27.5%) MBP+/ABX+. Baseline characteristics were similar; however, there were marginally more patients with prior sepsis, ascites, steroid use, bleeding disorders, and disseminated cancer in no-prep. MBP with or without antibiotics was associated with reduced ileus [MBP+/ABX+: odds ratio (OR) = 0.57, 95% confidence interval (CI): 0.48-0.68; MBP+/ABX-: OR = 0.78, 95% CI: 0.68-0.91] and SSI [MBP+/ABX+: OR = 0.39, 95% CI: 0.32-0.48; MBP+/ABX-: OR = 0.80, 95% CI: 0.69-0.93] versus no-prep. MBP+/ABX+ was also associated with lower anastomotic leak rate than no-prep [OR = 0.45 (95% CI: 0.32-0.64)]. On multivariable analysis, MBP with antibiotics, but not without, was independently associated with reduced anastomotic leak (OR = 0.57, 95% CI: 0.35-0.94), SSI (OR = 0.40, 95% CI: 0.31-0.53), and postoperative ileus (OR = 0.71, 95% CI: 0.56-0.90). CONCLUSIONS: These data clarify the near 50-year debate whether bowel preparation improves outcomes after colorectal resection. MBP with oral antibiotics reduces by nearly half, SSI, anastomotic leak, and ileus, the most common and troublesome complications after colorectal surgery.

A practical guide to self-sustaining point-of-care ultrasound education programs in resource-limited settings.

The value of point-of-care ultrasound education in resource-limited settings is increasingly recognized, though little guidance exists on how to best construct a sustainable training program. Herein we offer a practical overview of core factors to consider when developing and implementing a point-of-care ultrasound education program in a resource-limited setting. Considerations include analysis of needs assessment findings, development of locally relevant curriculum, access to ultrasound machines and related technological and financial resources, quality assurance and follow-up plans, strategic partnerships, and outcomes measures. Well-planned education programs in these settings increase the potential for long-term influence on clinician skills and patient care.

SonoGames: an innovative approach to emergency medicine resident ultrasound education.

SonoGames was created by the Academy of Emergency Ultrasound for the 2012 annual meeting of the Society for Academic Emergency Medicine. The assessment of resident knowledge and of the performance of point-of-care ultrasound examinations is an integral component of ultrasound education and is required in emergency medicine residency training. With that in mind, game organizers sought to assess and improve emergency medicine residents' point-of-care ultrasound knowledge, hands-on skills, and integration of knowledge into clinical decision making. SonoGames is an annual 4-hour competition consisting of 3 rounds. In this article, we provide a description of SonoGames and provide a blueprint for an effective and successful educational event.

Faculty staff-guided versus self-guided ultrasound training for internal medicine residents.

OBJECTIVES: Ultrasonography is of growing importance within internal medicine (IM), but the optimal method of training doctors to use it is uncertain. In this study, the authors provide the first objective comparison of two approaches to training IM residents in ultrasonography. METHODS: In this randomised trial, a simulation-based ultrasound training curriculum was implemented during IM intern orientation at a tertiary care teaching hospital. All 72 incoming interns attended a lecture and were given access to online modules. Interns were then randomly assigned to a 4-hour faculty-guided (FG) or self-guided (SG) ultrasound training session in a simulation laboratory with both human and manikin models. Interns were asked to self-assess their competence in ultrasonography and underwent an objective structured clinical examination (OSCE) to assess their competence in basic and procedurally oriented ultrasound tasks. The primary outcome was the score on the OSCE. RESULTS: Faculty-guided training was superior to self-guided training based on the OSCE scores. Subjects in the FG training group achieved significantly higher OSCE scores on the two subsets of task completion (0.9-point difference, 95% confidence interval [CI] 0.27-1.54; p = 0.008) and ultrasound image quality (2.43-point difference, 95% CI 1.5-3.36; p < 0.001). Both training groups demonstrated an increase in self-assessed competence after their respective training sessions and there was little difference between the groups. Subjects rated the FG training group much more favourably than the SG training group. CONCLUSIONS: Both FG and SG ultrasound training curricula can improve the self-reported competence of IM interns in ultrasonography. However, FG training was superior to SG training in both skills acquisition and intern preference. Incorporating mandatory ultrasound training into IM residencies can address the perceived need for ultrasound training, improve confidence and procedural skills, and may enhance patient safety. However, the optimal training method may require significant faculty input.

Is there a need for preoperative imaging of the internal mammary recipient site for autologous breast reconstruction?

Preoperative imaging of recipient-site vasculatur in autologous breast reconstruction may potentiate improved outcomes through the identification of individual variations in vascular architecture. There are a range of both normal and pathologic states which can substantially affect the internal mammary vessels in particular, and the identification of these preoperatively may significantly affect operative approach. There are a range of imaging modalities available, with ultrasound particularly useful, and computed tomography angiography (CTA) evolving as a useful option, albeit with radiation exposure. The benefits of CTA must be balanced against its risks, which include contrast nephrotoxicity and allergic reactions, and radiation exposure. The radiation risk with thoracic imaging is substantially higher than that for donor sites, such as the abdominal wall, with reasons including exposure of the contralateral breast to radiation (with a risk of contralateral breast cancer in this population 2 to 6 times higher than that of primary breast cancer, reaching a 20-year incidence of 15%), as well as proximity to the thyroid gland. Current evidence suggests that although many cases may not warrant such imaging because of risk, the benefits of preoperative CTA in selected patients may outweigh the risks of exposure, prompting an individualized approach.

The anatomy and variations of the internal thoracic (internal mammary) artery and implications in autologous breast reconstruction: clinical anatomical study and literature review.

BACKGROUND: The internal thoracic (IT) vessels (otherwise known as the thoracica interna or internal mammary vessels) are widely used as recipient vessels in autologous breast reconstruction. Despite this, normal and pathological variations in IT artery architecture have been described, and these have the potential to complicate dissection and the selection of suitable vessels. METHODS: A clinical anatomical study of 240 IT arteries (120 patients) and review of the literature was undertaken. Participants comprised 120 female patients undergoing preoperative imaging of the IT artery prior to autologous breast reconstruction, 42 with computed tomographic angiography (CTA) and 78 with ultrasound. RESULTS: There was complete concordance between surgical and radiological findings. An IT artery was present in 100% of cases, with a duplicate IT artery in two cases (1% overall). The position of the IT artery was between two IT veins most frequently (71.5% of cases), and was lateral to the vein(s) least frequently (6%). There were large IT perforators from the first and second intercostal spaces in 87 and 91% of cases, respectively, with the incidence of such perforators reducing in the lower spaces. The literature highlighted a range of cadaveric and clinical cases in which there was absence of a patent IT artery, variant course or size, and variant relationship to the IT vein. CONCLUSION: A range of congenital, pathological and iatrogenic variants in IT artery anatomy have the potential to limit the use of the IT artery in autologous breast reconstruction. Preoperative imaging with ultrasound or CTA may provide a clear and accurate method of identifying these anatomical variations pre-operatively.

The Challenges of Measuring and Valuing Quality of Life in Preschool Children: A Retrospective Review of NICE Appraisals.

Health technology assessment agencies evaluate interventions across the lifespan. However, there is no consensus about best-practice methods to measure health-related quality of life (HRQoL) in preschool children (<5 years) and data are often scarce. We reviewed methods used to capture the HRQoL of preschool children in past National Institute for Health and Care Excellence (NICE) appraisals to establish whether there is a need for better methods in this area and if so, to identify priority research areas. We identified past NICE appraisals that included preschool children, examining the methods used to generate utility values and whether committees believed these captured HRQoL adequately. Of the 12 appraisals, most used generic HRQoL measures designed for adults. Measures were usually completed by adult patients or clinical experts. Committees frequently commented on limitations in the HRQoL data. While acknowledging that data collection may be challenging, committees would value evidence based on HRQoL data from parents or guardians collected as part of a clinical trial. We identified several research priorities including the psychometric properties of existing measures; the feasibility and validity of valuation studies; and mapping. Progress in these areas will help ensure that the aspects of HRQoL which matter to children and their families are captured in NICE evaluations.

Contemporary occupational therapy philosophy and practice in hospital settings.

BACKGROUND: Occupational therapists have sought to reconnect with the foundations of the profession for many years, and a key focus has been the place of occupation in practice. Existing literature suggests that therapists working in acute settings experience difficulties practicing in ways that centralise occupation. AIM/OBJECTIVE: This scoping review aimed to explore the existing literature on contemporary occupational therapy philosophy and practice in acute hospital settings. METHODS: A five step scoping review process was implemented. Four electronic databases were searched using a combination of search terms. Searching reference lists of papers was also completed. Results were summarised using numeric and thematic analysis. RESULTS: Twenty four publications were included. Four themes were identified; attitudes towards occupation-based practice, benefits of occupation-based approaches, challenges implementing occupation-based practice, and strategies to overcome challenges. CONCLUSION AND SIGNIFICANCE: Findings highlighted therapists value occupation as an important aspect of practice, however they experience many environmental and personal challenges in acute settings. Strategies to overcome these challenges related to individual's changing their practice to be more occupation-focussed and changes within the practice context including adapting environments, documentation and intervention protocols to focus on occupation. These strategies may support therapists to align practice with their professional values.

New geographic model of care to manage the post-COVID-19 elective surgery aftershock in England: a retrospective observational study.

OBJECTIVES: The suspension of elective surgery during the COVID-19 pandemic is unprecedented and has resulted in record volumes of patients waiting for operations. Novel approaches that maximise capacity and efficiency of surgical care are urgently required. This study applies Markov multiscale community detection (MMCD), an unsupervised graph-based clustering framework, to identify new surgical care models based on pooled waiting-lists delivered across an expanded network of surgical providers. DESIGN: Retrospective observational study using Hospital Episode Statistics. SETTING: Public and private hospitals providing surgical care to National Health Service (NHS) patients in England. PARTICIPANTS: All adult patients resident in England undergoing NHS-funded planned surgical procedures between 1 April 2017 and 31 March 2018. MAIN OUTCOME MEASURES: The identification of the most common planned surgical procedures in England (high-volume procedures (HVP)) and proportion of low, medium and high-risk patients undergoing each HVP. The mapping of hospitals providing surgical care onto optimised groupings based on patient usage data. RESULTS: A total of 7 811 891 planned operations were identified in 4 284 925 adults during the 1-year period of our study. The 28 most common surgical procedures accounted for a combined 3 907 474 operations (50.0% of the total). 2 412 613 (61.7%) of these most common procedures involved 'low risk' patients. Patients travelled an average of 11.3 km for these procedures. Based on the data, MMCD partitioned England into 45, 16 and 7 mutually exclusive and collectively exhaustive natural surgical communities of increasing coarseness. The coarser partitions into 16 and seven surgical communities were shown to be associated with balanced supply and demand for surgical care within communities. CONCLUSIONS: Pooled waiting-lists for low-risk elective procedures and patients across integrated, expanded natural surgical community networks have the potential to increase efficiency by innovatively flexing existing supply to better match demand.

Optic nerve sheath diameter correlates with the presence and severity of acute mountain sickness: evidence for increased intracranial pressure.

Increased intracranial pressure is suspected in the pathogenesis of acute mountain sickness (AMS), but no studies have correlated it with the presence or severity of AMS. We sought to determine whether increased optic nerve sheath diameter, a surrogate measure of intracranial pressure, is associated with the presence and severity of AMS. We performed a cross-sectional study of travelers ascending through Pheriche, Nepal (4,240 m), from March 3 to May 14, 2006. AMS was assessed using the Lake Louise score. Optic nerve sheath diameter was measured by ultrasound. Ultrasound exams were performed and read by separate blinded observers. Two-hundred eighty seven subjects were enrolled. Ten of these underwent repeat examination. Mean optic nerve sheath diameter was 5.34 mm [95% confidence interval (CI) 5.18-5.51 mm] in the 69 subjects with AMS vs. 4.46 mm (95% CI 4.39-4.54 mm) in the 218 other subjects (P < 0.0001). There was also a positive association between optic nerve sheath diameter and total Lake Louise score (P for trend < 0.0001). In a multivariate logistic regression model of factors associated with AMS, optic nerve sheath diameter was strongly associated with AMS (odds ratio 6.3; 95% CI, 3.7-10.8; P < 0.001). In 10 subjects with repeat examinations, change in Lake Louise score had a strong positive correlation with change in optic nerve sheath diameter (R(2) = 0.84, P < 0.001). Optic nerve sheath diameter, a proxy for intracranial pressure, is associated with the presence and severity of AMS.

Prevalence and Characteristics of Twitter Posts About Court-Ordered, Tobacco-Related Corrective Statements: Descriptive Content Analysis.

BACKGROUND: Three major US tobacco companies were recently ordered to publish corrective statements intended to prevent and restrain further fraud about the health effects of smoking. The court-ordered statements began appearing in newspapers and on television (TV) in late 2017. OBJECTIVE: The objective of this study was to examine the social media dissemination of the tobacco corrective statements during the first 6 months of the implementation of the statements. METHODS: We conducted a descriptive content analysis of Twitter posts using an iterative search strategy through Crimson Hexagon and randomly selected 19.74% (456/2309) of original posts occurring between November 1, 2017, and March 27, 2018, for coding and analysis. We assessed post volume over time, source or author, valence, linked content, and reference to the industry (eg, big tobacco, tobacco industry, and Philip Morris) and media outlet (TV or newspaper). Retweeted content was coded for source/author and prevalence. RESULTS: Most posts were published in November 2017, surrounding the initial release of the corrective statements. Content was generally neutral (58.7%, 268/456) or positive (33.3%, 152/456) in valence, included links to additional information about the statements (94.9%, 433/456), referred to the industry (87.7%, 400/456), and did not mention a specific media channel on which the statements were aired or published (15%). The majority of original posts were created by individual users (55.2%, 252/456), whereas the majority of retweeted posts were posted by public health organizations (51%). Differences by source are reported, for example, organization posts are more likely to include a link to additional information compared with individual users (P=.03). CONCLUSIONS: Conversations about the court-ordered corrective statements are taking place on Twitter and are generally neutral or positive in nature. Public health organizations may be increasing the prevalence of these conversations through social media engagement.

Optimizing Patient Selection for Laparoscopic and Open Colorectal Cancer Resections: A National Surgical Quality Improvement Program-Matched Analysis.

The aim of this study was to identify patients undergoing colorectal cancer (CRC) resection who might benefit specifically from either an open or laparoscopic approach. From the NSQIP database (2012-2013), patients who underwent laparoscopic colectomy (LC) or open colectomy (OC) for CRC were identified. The two groups were matched and compared in terms of any, medical, and surgical complications. A wide range of patient characteristics were collected and analyzed. Interaction analysis was performed in a multivariable regression model to identify risk factors that may make LC or OC more beneficial in certain subgroups of patients. Overall, OC (n = 6593) was associated with a significantly higher risk of any [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.87-2.20], surgical (OR 1.98, 95% CI 1.82-2.16), and medical (OR 1.71, 95% CI 1.51-1.94) complications than LC (n = 6593). No subgroup of patients benefited from an open approach. Patients with obesity (BMI > 30) (P = 0.03) and older age (>65 years) (P = 0.01) benefited more than average from a laparoscopic approach. For obese patients, LC was associated with less overall complications (OC vs LC: OR 1.92 obese vs 1.21 nonobese patients). For elderly patients, LC was more preferable regarding the risk of medical complications (OC vs LC OR of 1.91 vs 1.34 for younger patients). No subgroup of CRC patients benefited specifically more from an open colorectal resection. This supports that the laparoscopic technique should be performed whenever feasible. For the obese and elderly patients, the benefits of the laparoscopic approach were more pronounced.

Value-based surgical care: a view from the surgeon's knife.

NHS trusts across the country are facing unprecedented financial pressures, along with rising levels of demand and widespread variation in surgical quality and cost. There is a moral and financial imperative to provide the most efficient use of resources in order to ensure sustainability of a system that is free at the point of use, and provide consistently high-value care for patients across the country. Delivering 'value' does not mean any reduction in the quality of care - it means achieving the same or higher quality at the same or lower cost. Avoidable and costly incidents in surgery occur every day: patients do not receive the right care, procedures or tests are performed without real benefit, complications lead to prolonged hospital stays, to readmissions and re-interventions. Put simply: poor quality surgical care is expensive. The concept of value-based health care is well known in the UK, yet its principles are not yet fully embedded in the health-care system, surgical training or practice. The shift towards better value-based care with a focus on delivery system reform (Getting It Right First Time), outcomes-based commissioning and payment reform (accountable care systems and integrated care systems) provides an opportunity to make significant improvements in surgical care. Radical and immediate change is required, and everyone, from trainees at the frontline, to clinical leaders, trust chief executives, local commissioners and policy-makers, has vital roles to play. The health-care system needs to be designed, organized and paid for differently to deliver better surgical value for patients.

Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema.

BACKGROUND: The comet-tail technique of chest ultrasonography has been described for the diagnosis of cardiogenic pulmonary edema. This is the first report describing its use for the diagnosis and monitoring of high-altitude pulmonary edema (HAPE), the leading cause of death from altitude illness. METHODS: Eleven consecutive patients presenting to the Himalayan Rescue Association clinic in Pheriche, Nepal (4,240 m) with a clinical diagnosis of HAPE underwent one to three chest ultrasound examinations using the comet-tail technique to determine the presence of extravascular lung water (EVLW). Seven patients with no evidence of HAPE or other altitude illness served as control subjects. All examinations were read by a blinded observer. RESULTS: HAPE patients had higher comet-tail score (CTS) [mean +/- SD, 31 +/- 11 vs 0.86 +/- 0.83] and lower oxygen saturation (O(2)Sat) [61 +/- 9.2% vs 87 +/- 2.8%] than control subjects (p < 0.001 for both). Mean CTS was higher (35 +/- 11 vs 12 +/- 6.8, p < 0.001) and O(2)Sat was lower (60 +/- 11% vs 84 +/- 1.6%, p = 0.002) at hospital admission than at discharge for the HAPE patients with follow-up ultrasound examinations. Regression analysis showed CTS was predictive of O(2)Sat (p < 0.001), and for every 1-point increase in CTS O(2)Sat fell by 0.67% (95% confidence interval, 0.41 to 0.93%, p < 0.001). CONCLUSIONS: The comet-tail technique effectively recognizes and monitors the degree of pulmonary edema in HAPE. Reduction in CTS parallels improved oxygenation and clinical status in HAPE. The feasibility of this technique in remote locations and rapid correlation with changes in EVLW make it a valuable research tool.

Treatment of high altitude pulmonary edema at 4240 m in Nepal.

High altitude pulmonary edema (HAPE) is the leading cause of death from altitude illness and rapid descent is often considered a life-saving foundation of therapy. Nevertheless, in the remote settings where HAPE often occurs, immediate descent sometimes places the victim and rescuers at risk. We treated 11 patients (7 Nepalese, 4 foreigners) for HAPE at the Himalayan Rescue Association clinic in Pheriche, Nepal (4240 m), from March 3 to May 14, 2006. Ten were admitted and primarily treated there. Seven of these (6 Nepalese, 1 foreigner) had serious to severe HAPE (Hultgren grades 3 or 4). Bed rest, oxygen, nifedipine, and acetazolamide were used for all patients. Sildenafil and salmeterol were used in most, but not all patients. The duration of stay was 31 +/- 16 h (range 12 to 48 h). Oxygen saturation was improved at discharge (84% +/- 1.7%) compared with admission (59% +/- 11%), as was ultrasound comet-tail score (11 +/- 4 at discharge vs. 33 +/- 8.6 at admission), a measure of pulmonary edema for which admission and discharge values were obtained in 7 patients. We conclude it is possible to treat even serious HAPE at 4240 m and discuss the significance of the predominance of Nepali patients seen in this series.