Effects of Patient-Reported Outcome Tracking and Health Information Provision via Remote Patient Monitoring Software on Patient Outcomes in Oncology Care: A Systematic Review and Meta-Analysis.

OBJECTIVES: The authors sought to 1) review the literature on the remote care model that uses remote patient monitoring software (RPMS) as key mechanisms in oncology care for symptom tracking and health information provision and (2) compare the remote care model to standard care in terms of health-related quality of life, symptom burden, health management self-efficacy, anxiety, and depression. DATA SOURCES: The search was conducted on March 23, 2022, in the Cochrane Library, MEDLINE/PubMed, PsycINFO, and CINAHL databases. RESULTS: The primary strategies for applying digital technology in remote care models are patient-reported outcomes (PRO) tracking and health information delivery. Common PRO measurements applied in the RPMS include quality of life, symptom burden, self-efficacy, anxiety, and depression. Nine randomized controlled trials testing seven RPMS interventions were examined. Compared to standard care, remote patient monitoring via RPMS was related to greater quality of life and lower physical symptom burden during cancer therapy. The RPMS incorporated into routine clinical care with nurses providing remote monitoring performed better on PRO than that not integrated. CONCLUSION: The RPMS-based remote care model improves patient outcomes during cancer treatment, and it is not inferior to standard care until the RPMS function is more integrated with existing clinical care. IMPLICATIONS FOR NURSING PRACTICE: Nurses are well-positioned to engage patients in self-care skills via RPMS and can play a vital role in integrating such a model of remote patient care into routine care practices.

Estimating the burden of disease attributable to high ambient temperature across climate zones: methodological framework with a case study.

BACKGROUND: With high temperature becoming an increasing health risk due to a changing climate, it is important to quantify the scale of the problem. However, estimating the burden of disease (BoD) attributable to high temperature can be challenging due to differences in risk patterns across geographical regions and data accessibility issues. METHODS: We present a methodological framework that uses Köppen-Geiger climate zones to refine exposure levels and quantifies the difference between the burden observed due to high temperatures and what would have been observed if the population had been exposed to the theoretical minimum risk exposure distribution (TMRED). Our proposed method aligned with the Australian Burden of Disease Study and included two parts: (i) estimation of the population attributable fractions (PAF); and then (ii) estimation of the BoD attributable to high temperature. We use suicide and self-inflicted injuries in Australia as an example, with most frequent temperatures (MFTs) as the minimum risk exposure threshold (TMRED). RESULTS: Our proposed framework to estimate the attributable BoD accounts for the importance of geographical variations of risk estimates between climate zones, and can be modified and adapted to other diseases and contexts that may be affected by high temperatures. CONCLUSIONS: As the heat-related BoD may continue to increase in the future, this method is useful in estimating burdens across climate zones. This work may have important implications for preventive health measures, by enhancing the reproducibility and transparency of BoD research.

Hospitalization Costs of Respiratory Diseases Attributable to Temperature in Australia and Projections for Future Costs in the 2030s and 2050s under Climate Change.

This study aimed to estimate respiratory disease hospitalization costs attributable to ambient temperatures and to estimate the future hospitalization costs in Australia. The associations between daily hospitalization costs for respiratory diseases and temperatures in Sydney and Perth over the study period of 2010-2016 were analyzed using distributed non-linear lag models. Future hospitalization costs were estimated based on three predicted climate change scenarios-RCP2.6, RCP4.5 and RCP8.5. The estimated respiratory disease hospitalization costs attributable to ambient temperatures increased from 493.2 million Australian dollars (AUD) in the 2010s to more than AUD 700 million in 2050s in Sydney and from AUD 98.0 million to about AUD 150 million in Perth. The current cold attributable fraction in Sydney (23.7%) and Perth (11.2%) is estimated to decline by the middle of this century to (18.1-20.1%) and (5.1-6.6%), respectively, while the heat-attributable fraction for respiratory disease is expected to gradually increase from 2.6% up to 5.5% in Perth. Limitations of this study should be noted, such as lacking information on individual-level exposures, local air pollution levels, and other behavioral risks, which is common in such ecological studies. Nonetheless, this study found both cold and hot temperatures increased the overall hospitalization costs for respiratory diseases, although the attributable fractions varied. The largest contributor was cold temperatures. While respiratory disease hospitalization costs will increase in the future, climate change may result in a decrease in the cold attributable fraction and an increase in the heat attributable fraction, depending on the location.

Understanding current and projected emergency department presentations and associated healthcare costs in a changing thermal climate in Adelaide, South Australia.

BACKGROUND: Exposure to extreme temperatures is associated with increased emergency department (ED) presentations. The resulting burden on health service costs and the potential impact of climate change is largely unknown. This study examines the temperature-EDs/cost relationships in Adelaide, South Australia and how this may be impacted by increasing temperatures. METHODS: A time series analysis using a distributed lag nonlinear model was used to explore the exposure-response relationships. The net-attributable, cold-attributable and heat-attributable ED presentations for temperature-related diseases and costs were calculated for the baseline (2014-2017) and future periods (2034-2037 and 2054-2057) under three climate representative concentration pathways (RCPs). RESULTS: The baseline heat-attributable ED presentations were estimated to be 3600 (95% empirical CI (eCI) 700 to 6500) with associated cost of $A4.7 million (95% eCI 1.8 to 7.5). Heat-attributable ED presentations and costs were projected to increase during 2030s and 2050s with no change in the cold-attributable burden. Under RCP8.5 and population growth, the increase in heat-attributable burden would be 1.9% (95% eCI 0.8% to 3.0%) for ED presentations and 2.5% (95% eCI 1.3% to 3.7%) for ED costs during 2030s. Under the same conditions, the heat effect is expected to increase by 3.7% (95% eCI 1.7% to 5.6%) for ED presentations and 5.0% (95% eCI 2.6% to 7.1%) for ED costs during 2050s. CONCLUSIONS: Projected climate change is likely to increase heat-attributable emergency presentations and the associated costs in Adelaide. Planning health service resources to meet these changes will be necessary as part of broader risk mitigation strategies and public health adaptation actions.

Evaluating cost benefits from a heat health warning system in Adelaide, South Australia.

OBJECTIVE: To examine the cost benefits of a heat health warning system (HHWS) in South Australia. METHODS: Information from key agencies was used to estimate the costs associated with the South Australian HHWS, including for three targeted public health interventions. Health cost savings were estimated based on previously reported HHWS-attributable reductions in hospital and emergency department (ED) admissions and ambulance callouts. RESULTS: The estimated cost for a one-week activation of the HHWS was AU$593,000. Activation costs compare favourably with the potential costs averted through HHWS-attributable reductions in hospital admissions and ambulance callouts with an estimated benefit-cost ratio of 2.0-3.3. CONCLUSIONS: On the basis of estimated cost benefit, the South Australian HHWS is a no-regret public health response to heatwaves. IMPLICATIONS FOR PUBLIC HEALTH: As global temperatures rise there are likely to be significant health impacts from more frequent and intense heatwaves. This study indicates that HHWSs incorporating targeted supports for vulnerable groups are likely to be cost-effective public health interventions.

Assessment of pharyngeal motor function using a novel velopharyngeal squeeze maneuver and a novel endoscopic pharyngeal contraction grade scale in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma.

BACKGROUND: To investigate a novel velopharyngeal squeeze maneuver (VPSM) and novel endoscopic pharyngeal contraction grade (EPCG) scale for the evaluation of pharyngeal motor function. METHODS: During endoscopic examination of 77 post-irradiated nasopharyngeal carcinoma patients and control subjects, VPSM was rated and lateral pharyngeal wall movement graded with EPCG scale during swallowing. Pharyngeal constriction ratio (PCR) measured by videofluoroscopy was used for correlation. RESULTS: VPSM and EPCG scale showed almost perfect intra-rater and inter-rater reliability (Kappa: >0.90). VPSM was present in 61% of patients suggesting good pharyngeal motor function. VPSM was predictive of EPCG scale (Wald statistic = 29.99, p < 0.001). EPCG scale also correlated strongly with PCR (r: 0.812) and was predictive for aspiration (odds ratio: 22.14 [95% CI 5.01-97.89, p < 0.001]). CONCLUSIONS: VPSM and EPCG scale are two novel tools to assess pharyngeal motor function, and both correlate well with pharyngeal contractility and aspiration.

Increasing impacts of temperature on hospital admissions, length of stay, and related healthcare costs in the context of climate change in Adelaide, South Australia.

BACKGROUND: A growing number of studies have investigated the effect of increasing temperatures on morbidity and health service use. However, there is a lack of studies investigating the temperature-attributable cost burden. OBJECTIVES: This study examines the relationship of daily mean temperature with hospital admissions, length of hospital stay (LoS), and costs; and estimates the baseline temperature-attributable hospital admissions, and costs and in relation to warmer climate scenarios in Adelaide, South Australia. METHOD: A daily time series analysis using distributed lag non-linear models (DLNM) was used to explore exposure-response relationships and to estimate the aggregated burden of hospital admissions for conditions associated with temperatures (i.e. renal diseases, mental health, diabetes, ischaemic heart diseases and heat-related illnesses) as well as the associated LoS and costs, for the baseline period (2010-2015) and different future climate scenarios in Adelaide, South Australia. RESULTS: During the six-year baseline period, the overall temperature-attributable hospital admissions, LoS, and associated costs were estimated to be 3915 cases (95% empirical confidence interval (eCI): 235, 7295), 99,766 days (95% eCI: 14,484, 168,457), and AU$159 million (95% eCI: 18.8, 269.0), respectively. A climate scenario consistent with RCP8.5 emissions, and including projected demographic change, is estimated to lead to increases in heat-attributable hospital admissions, LoS, and costs of 2.2% (95% eCI: 0.5, 3.9), 8.4% (95% eCI: 1.1, 14.3), and 7.7% (95% eCI: 0.3, 13.3), respectively by mid-century. CONCLUSIONS: There is already a substantial temperature-attributable impact on hospital admissions, LoS, and costs which are estimated to increase due to climate change and an increasing aged population. Unless effective climate and public health interventions are put into action, the costs of treating temperature-related admissions will be high.

Dynamic Assessment of Pulmonary Artery Pulsatility Index Provides Incremental Risk Assessment for Early Right Ventricular Failure After Left Ventricular Assist Device.

BACKGROUND: The pulmonary artery pulsatility index (PAPi) has been studied to predict right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation, but only as a single time point before LVAD implantation. Multiple clinical factors and therapies impact RV function in pre-LVAD patients. Thus, we hypothesized that serial PAPi measurements during cardiac intensive care unit (CICU) optimization before LVAD implantation would provide incremental risk stratification for early RVF after LVAD implantation. METHODS AND RESULTS: Consecutive patients who underwent sequential pulmonary artery catherization with cardiac intensive care optimization before durable LVAD implantation were included. Serial hemodynamics were reviewed retrospectively across the optimization period. The optimal PAPi was defined by the initial PAPi + the PAPi at optimized hemodynamics. RVF was defined as need for a right ventricular assist device or prolonged inotrope use (>14 days postoperatively). Patients with early RVF had significantly lower mean optimal PAPi (3.5 vs 7.5, P < .001) compared with those who did not develop RVF. After adjusting for established risk factors of early RVF after LVAD implantation, the optimal PAPi was independently and incrementally associated with early RVF after LVAD implantation (odds ratio 0.64, 95% confidence interval 0.532-0.765, P < .0001). CONCLUSIONS: Optimal PAPi achieved during medical optimization before LVAD implantation provides independent and incremental risk stratification for early RVF, likely identifying dynamic RV reserve.

Daily Temperature and Bacillary Dysentery: Estimated Effects, Attributable Risks, and Future Disease Burden in 316 Chinese Cities.

BACKGROUND: Bacillary dysentery (BD) remains a significant public health issue, especially in developing countries. Evidence assessing the risk of BD from temperature is limited, particularly from national studies including multiple locations with different climatic characteristics. OBJECTIVES: We estimated the effect of temperature on BD across China, assessed heterogeneity and attributable risks across cities and regions, and projected the future risk of BD under climate change. METHODS: Daily BD surveillance and meteorological data over 2014-2016 were collected from the Chinese Center for Disease Control and Prevention and the China Meteorology Administration, respectively. A two-stage statistical model was used to estimate city-specific temperature-BD relationships that were pooled to derive regional and national estimates. The risk of BD attributable to temperature was estimated, and the future burden of BD attributable to temperature was projected under different climate change scenarios. RESULTS: A positive linear relationship for the pooled effect was estimated at the national level. Subgroup analyses indicate that the estimated effect of temperature on BD was similar by age (≤5y or >5y) and gender. At baseline, estimated attributable risks for BD due to average daily mean temperatures above the 50th percentile were highest for the Inner Mongolia (16%), Northeast China (14%), and Northern China (13%). Most of the individual cities in the same regions and most of the cities in the Northwest, Southern, and Southwest regions, had high attributable risks (≥5%). The Northern, Northeast, Inner Mongolia, Northwest, and Southern China regions were identified as high risk for future BD, with estimated increases by the 2090s compared with baseline of 20% (95% confidence interval: 11%, 27%), 15% (6%, 20%), 15% (-1%, 22%), 12% (1%, 19%), and 11% (5%, 15%), respectively, under Representative Concentration Pathway 8.5. CONCLUSIONS: The positive association between temperature and BD in different climatic regions of China, and the projection for increased risk due to climate change, support efforts to mitigate future risks. https://doi.org/10.1289/EHP5779.

Characterising the Burden of Work-Related Injuries in South Australia: A 15-Year Data Analysis.

To characterise the burden of work-related injuries in South Australia, workers' compensation claim data were obtained from SafeWork South Australia between 2000 and 2014. Descriptive analyses were performed to investigate the burden of work-related injuries by age, gender, occupation, industry, and nature and mechanism of injury. Dunn's test was used to compare the injury costs and working days lost by industry and occupation. Ordinary linear regression was used to investigate the age-injury cost association. A total of 464,139 workers' compensation claims were reported during the 15-year period in South Australia, with an overall rate of 4.6 claims per 100 employees, resulting in a total of 20,861,001 working days lost and AU$14.9 billion dollars of compensation payment. Between 2000 to 2014, the annual claim rates, compensation payments, working days lost, and number of work-related death reduced by 59.3, 73.8, 87.1, and 78.6 percent, respectively, while the median compensation payment increased by 67.3% from AU$968 to AU$1620. A 1-year increase in age was associated with a 2.1% (Rate Ratio, RR = 1.021, 95% CI: 1.020-1.022) increase in compensation costs and a 1.3% (RR = 1.013, 95% CI: 1.012-1.020) increase in working days lost. Work-related injury rates are declining in most sectors, however some workers, especially young male technicians and labourers in the community services industry, remain at higher risk. Challenges for workers' health and safety include the aging labour force, vehicle incidents, and severe injuries among new and foreign-born workers.

Microplegia vs 4:1 Blood Cardioplegia: Effectiveness and Cost Savings in Complex Cardiac Operations.

BACKGROUND: Microplegia has been studied during isolated coronary artery bypass grafting and valve surgery but not in more complex operations. Objectives of this study were to demonstrate safety and effectiveness of microplegia relative to Buckberg cardioplegia during these operations. METHODS: From January 2012 to January 2017, 242 patients underwent multicomponent operations with simplified microplegia delivered via syringe pump and 10,512 with modified Buckberg cardioplegia. Operations included aortic root, arch, or ascending aorta replacement in 424 (94%) patients, aortic valve surgery in 324 (72%) patients, and concomitant coronary artery bypass grafting in 47 (10%) patients. Outcomes were compared in 226 propensity-matched pairs. RESULTS: There was no difference in median postoperative troponin T between groups after adjusting for aortic clamp time. Microplegia patients received significantly less crystalloid with their cardioplegia (mean 27 ± 8.0 mL/operation vs 735 ± 357 mL/operation; P < .001) and had lower peak intraoperative glucose (196 ± 40 mg/dL vs 248 ± 69 mg/dL; P < .001). Microplegia and Buckberg groups had similar in-hospital mortality (2.7% [n = 6] vs 2.2% [n = 5]; P = .8), stroke (2.2% [n = 5] vs 3.6% [n = 8]; P = .4), renal failure (8% [n = 18] vs 5.8% [n = 13]; P = .4), prolonged ventilation (23% [n = 51] vs 24% [n = 54]; P = .7), median postoperative length of stay (both 8.1 days; P > .9), and median red cell units administered to patients requiring transfusion (4 units vs 3 units; P = .14). The mean cost of cardioplegia per case with microplegia was 1/26th that of Buckberg cardioplegia. CONCLUSIONS: Our simplified microplegia technique offers several advantages over Buckberg cardioplegia without compromising myocardial protection or safety in complex, multicomponent operations with extended aortic clamp times.

Impact of Multidisciplinary Pulmonary Embolism Response Team Availability on Management and Outcomes.

Treatment strategies for complex patients with pulmonary embolism (PE) are often debated given patient heterogeneity, multitude of available treatment modalities, and lack of consensus guidelines. Although multidisciplinary Pulmonary Embolism Response Teams (PERT) are emerging to address this lack of consensus, their impact on patient outcomes is not entirely clear. This analysis was conducted to compare outcomes of all patients with PE before and after PERT availability. We analyzed all adult patients admitted with acute PE diagnosed on computed tomography scans in the 18 months before and after the institution of PERT at a large tertiary care hospital. Among 769 consecutive inpatients with PE, PERT era patients had lower rates of major or clinically relevant nonmajor bleeding (17.0% vs 8.3%, p = 0.002), shorter time-to-therapeutic anticoagulation (16.3 hour vs 12.6 hour, p = 0.009) and decreased use of inferior vena cava filters (22.2% vs 16.4%, p = 0.004). There was an increase in the use of thrombolytics/catheter-based strategies, however, this did not achieve statistical significance (p = 0.07). There was a significant decrease in 30-day/inpatient mortality (8.5% vs 4.7%, p = 0.03). These differences in outcomes were more pronounced in intermediate and high-risk patients (mortality 10.0% vs 5.3%, p = 0.02). The availability of multidisciplinary PERT was associated with improved outcomes including 30-day mortality. Patients with higher severity of PE seemed to derive most benefit from PERT availability.

Overcoming developing world challenges of cochlear implantation: Chinese perspective.

PURPOSE OF REVIEW: Over a short period, China has adopted cochlear implants and emerged as a burgeoning market. This represents a valuable case study for emerging countries in terms of planning, initiating, and growing cochlear implant programs. RECENT FINDINGS: Although many challenges such as funding, establishing infrastructure, and recipient community support have been addressed, many more remain. Consistent rapid escalation in numbers has been driven by push-and-pull factors. Federal, state, and private funding have all played a role. SUMMARY: The review highlights the massive need for hearing rehabilitation that currently exists in China. The shortfall can only be addressed by a purposeful and coordinated approach involving government policy, The China Disabled Persons Federation, the industry partnering with hearing and medical professionals and the deaf community.

Sonographic assessment of swallowing in irradiated nasopharyngeal carcinoma patients.

OBJECTIVES/HYPOTHESIS: Ultrasonography is an emerging clinical tool to study the dysfunction of swallowing muscles. This was the first sonographic study to assess the relationship between suprahyoid muscle contraction, hyoid bone displacement, and penetration-aspiration status (PAS) during swallowing in nasopharyngeal carcinoma (NPC) patients treated with radiotherapy (RT). The study also aimed to establish reliability data for the sonographic technique described. STUDY DESIGN: Cross-sectional study. METHODS: Geniohyoid muscle contraction was quantified using brightness-mode ultrasonography in this study of 40 post-RT NPC patients. A series of physiological parameters and PAS were measured using videofluoroscopy. RESULTS: Intra- and inter-rater agreement values ranged from 0.75 to 0.96 across various sonographic measurements. Percentage increase in the cross-sectional area of the geniohyoid muscle correlated with anterior (r = 0.42, P < .05) but not superior (r = 0.27, P = .09) hyoid displacement. Anterior hyoid displacement and pharyngeal constriction ratio were significantly associated with PAS score. CONCLUSIONS: Sonographic measurement of suprahyoid muscles provides valuable information on muscle function and is potentially a useful clinical tool in swallowing assessment. Further research is needed to refine the role of this examination in dysphagia. LEVEL OF EVIDENCE: 2b. Laryngoscope, 2552-2559, 2018.

Economic evaluation of open vs endovascular repair of blunt traumatic thoracic aortic injuries.

OBJECTIVES: During the last decade, endovascular repair (EV) has replaced open surgical repair (OSR) as the preferred method of treatment of blunt traumatic thoracic aortic injuries (BTAIs) at many trauma centers. This has resulted in reductions in mortality, length of stay, and major complications, including paraplegia, with the added expense of the initial endograft, subsequent surveillance, and reinterventions. The purpose of this study was to conduct an economic evaluation comparing these two methods of repair. METHODS: We performed an economic comparison of EV and OSR for the treatment of BTAI using a decision tree analysis with transition points derived from our institution's experience and through a review of the literature. Over a 15-year period (1991-2006), 28 patients with BTAI were treated at our center (15 EV, 13 OSR). Costs were obtained from our hospital's case costing center, the Ontario Case Costing Initiative, Ontario's Drug Benefit Formulary, and Ontario's Schedule of Benefits for physician costs. Our center's results were then combined with those from the literature to arrive at an economic model. RESULTS: These combined results revealed that EV, when compared to OSR, resulted in decreased early mortality (7.2% vs 22.5%), decreased composite outcome of mortality and paraplegia (7.7% vs 27.6%) and decreased composite outcome of mortality and major complication (42.5% vs 69.8%). Patients undergoing EV also had shorter intensive care unit stays (12.2 vs 15.3 days), total hospital length of stays (22.5 vs 28.6 days), and ventilator days (8.0 vs 9.2 days). Additionally, patients undergoing EV had decreased total 1-year costs compared with OSR ($70,442 vs $72,833). CONCLUSIONS: EV repair of BTAIs offers a survival advantage as well as a reduction in major morbidity, including paraplegia, compared with OSR, and results in a reduction in costs at 1 year. As a result, from the cost-effectiveness point of view, EV is the DOMINANT therapy over OSR for these injuries.

Endoscopic assessment of the nasopharynx: an objective score of abnormality to predict the likelihood of malignancy.

OBJECTIVES: We developed an objective endoscopic score of abnormality of the nasopharynx to predict the likelihood of malignancy. METHODS: A score sheet with 44 variables was developed to objectively quantify the bilateral endoscopic assessment of the nasopharynx. Patients scheduled to undergo nasopharyngeal biopsies were recruited. The nasopharynx was assessed endoscopically, photographed, and scored on 44 variables. The scores were compared to the biopsy results, and predictors of malignancy were modeled with regression analysis. The sensitivity and specificity of the novel scoring system were examined. RESULTS: Seventeen patients had carcinoma, and 60 had a benign lesion or no disease. Patients with a nasopharyngeal malignancy scored significantly higher than did patients with a benign lesion or no disease. No patient with a malignant lesion had a score of less than 12. With a receiver operating characteristic curve area of 0.917, the score demonstrated an excellent ability to discriminate between nasopharynges that were likely or unlikely to contain malignant disease. Independent predictors for both malignant disease and a score greater than 12 were modeled. CONCLUSIONS: A cutoff score above 12 on the novel objective endoscopic assessment of the nasopharynx measure was highly predictive of possible malignancy.

Development and validation of the functional assessment of cancer therapy nasopharyngeal cancer subscale.

BACKGROUND: We aimed to develop a quality-of-life subscale for nasopharyngeal carcinoma (NPC) and validate the functional assessment of cancer therapy-nasopharyngeal (FACT-NP). METHODS: The FACT-NP was tested cross-sectionally in survivors of postirradiated NPC (n = 357) and was administered to newly diagnosed patients (n = 160) before, at the end of, and 3 months after radiotherapy (RT). RESULTS: Each FACT-NP domain was internally consistent (Cronbach's alpha = 0.87-0.90). The test-retest reliability for each subscale was satisfactory (intraclass correlation coefficient = .73-.88). Concurrent validity was suggested by the moderate to strong correlations between the FACT-NP and the Quality of Life-Radiation Therapy Instrument-Head and Neck (QOL-RTI-H&N) subscales (Pearson r = .39-.84). The FACT-NP was responsive to clinical changes from pretreatment to 3 months after RT (effect sizes > 0.6 for clinically relevant subscales). The pooled data for multitrait scaling analysis showed satisfactory item internal consistency and item discriminant validity (100% and 90% scaling success, respectively). CONCLUSION: The FACT-NP is a reliable and valid instrument for measuring QOL in patients with NPC.

The roles and limitations of computed tomography in the preoperative assessment of sinonasal inverted papillomas.

BACKGROUND: Preoperative radiological assessment of sinonasal inverted papilloma (SNIP) is important in the planning of surgical treatment. This study investigates the roles and limitations of preoperative plain computed tomography (CT) scan in the preoperative assessment of SNIP. METHODS: Plain CT scans from 30 patients with SNIP were reviewed retrospectively by a radiologist who had no prior knowledge of the final surgical findings. Disease at each sinus was judged by the CT findings of opacity and additional signs. The overall disease was staged according to the staging system proposed by Krouse. All of the findings were compared with the final disease extent and staging confirmed by intraoperative and histological findings. RESULTS: Using opacity with additional signs for diagnosis, the range of accuracy of CT diagnosis for each sinus involvement was 83-97%. Staging by plain CT was concordant with postoperative staging in 80% of patients. Among the additional signs, focal hyperostosis or "bony strut" had the highest positive predictive value (100%) of tumor origin. CONCLUSION: Focal hyperostosis or bony strut is the most important CT sign predicting the origin of tumor. Although using multiple CT diagnostic signs provides a reasonable assessment of tumor origin and extent, accurate tumor mapping was still impossible because of inadequate differentiation of tumor from inflammatory pathologies. This drawback may be overcome by a complementary MRI scan. Since preoperative CT staging was inaccurate in 20% of cases, surgical planning should be flexible to provide for the need of the intraoperative findings.

Does the trainee's level of experience impact on patient safety and clinical outcomes in coronary artery bypass surgery?

BACKGROUND: There is a relative dearth of information on how the resident's level of training affects patient outcomes in cardiac surgery. We designed this study to determine if there were any significant differences in patient demographics and clinical outcomes of coronary artery bypass procedures (CABG) performed by residents of PGY 4/lower, residents of PGY 5/6, fellows, or consultants. METHODS: Standardized preoperative, intraoperative, and postoperative variables were prospectively collected and analyzed on 2906 isolated CABG procedures, performed between July 1999 and March 2006 with the primary surgeon prospectively classified as PGY4/lower, PGY5/6, fellow, and consultant. RESULTS: The number of cases performed by residents of PGY4/lower, PGY5/6, fellows and consultants were 179, 263, 301, and 2163, respectively. Preoperative demographics and comorbidities were similar except PGY4/lower group had more diabetics and consultant group had more patients requiring IABP. More non-LIMA arterial conduits were used in the consultant and fellow groups. However, there were neither significant differences in the mean number of grafts nor in the composite postoperative morbidity, median ICU, and hospital lengths of stay. Observed in-hospital mortality was 2.2%, 1.5%, 1.7%, and 2.7% (p = 0.49), respectively. CONCLUSIONS: Preoperative patient demographics and operative data were similar in all groups except that patients requiring IABP preoperatively were more likely operated on by consultants and arterial revascularization was performed more commonly by consultants and fellows. Postoperative mortality and morbidity rates were similar among all groups, thus demonstrating that with appropriate supervision, trainees of all levels can safely be taught CABG.

A benefit-risk assessment of ofloxacin otic solution in ear infection.

Ofloxacin is a fluoroquinolone antibacterial with potent bactericidal activities and the topical otological preparation of this drug has been clinically utilised since the late 1980s. The rate of eradication with ofloxacin ranges from 83.3% to 100% for all pathogens commonly isolated from middle ear effusions in cases of otitis media and otitis externa. Despite the significant length of its usage, emergence of resistant pathogens has been rarely encountered in clinical trials; only two strains of Pseudomonas aeruginosa have been documented with decreased susceptibility to ofloxacin following the use of the otic solution.Ear infections, including otitis externa, chronic suppurative otitis media and otorrhoea associated with tympanostomy tubes, are common problems in clinical practice. The potential complications associated with ear infection can be otological, extratemporal, or even psychosocial. They are sometimes fatal and the effect can be long-lasting and detrimental. The use of an effective topical antibacterial with high cost-effectiveness is definitely warranted. As regards various clinical aspects, including overall success rate, symptomatic relief of otalgia and otorrhoea, ofloxacin otic solution was found to be more effective than comparator agents, be it a topical antibacterial, a systemic antibacterial or combination drugs. The systemic absorption of fluoroquinolones is minimal after topical application. Ofloxacin otic solution 0.3% has been shown to have a low rate of adverse drug reactions. Adverse reactions to ofloxacin otic solution were generally mild. The lack of ototoxic effect from ofloxacin eardrops, even in the concentration higher than 0.3%, has been demonstrated in animal studies. In the clinical setting, no increase in bone-conduction threshold has been shown after the treatment of topical ofloxacin otic solution. There have not been any reports of ototoxicity with ofloxacin otic solution since its approval. To conclude, ofloxacin otic solution 0.3% is clinically effective in the treatment of otitis externa and chronic suppurative otitis media in particular with respect to the overall cure rate, relief of otalgia and otorrhoea. It is well tolerated, with minimal adverse effects. It is not associated with any ototoxicity both experimentally and clinically.