Survival, mortality and morbidity outcomes after oesophagogastric cancer surgery in New South Wales, 2001-2008.

OBJECTIVES: To examine the relationship between hospital volume and patient outcomes for New South Wales hospitals performing oesophagectomy and gastrectomy for oesophagogastric cancer. DESIGN, SETTING AND PATIENTS: A retrospective, population-based cohort study of NSW residents diagnosed with a new case of invasive oesophageal or gastric cancer who underwent oesophagectomy or gastrectomy between 2001 and 2008 in NSW hospitals using linked de-identified data from the NSW Central Cancer Registry, the National Death Index and the NSW Admitted Patient Data Collection. A higher-volume hospital was defined as one performing > 6 relevant procedures per year. MAIN OUTCOME MEASURES: Odds ratios for > 21-day length of stay, 28-day unplanned readmission, 30-day mortality and 90-day mortality, and hazard ratios (HRs) for 5-year absolute and conditional survival. RESULTS: Oesophagectomy (908 patients) and gastrectomy (1621 patients) were undertaken in 42 and 84 hospitals, respectively, between 2001 and 2008. Median annual hospital volume ranged from 2 to 4 for oesophagectomies and ranged from 2 to 3 for gastrectomies. Controlling for known confounders, no associations between hospital volume and > 21-day length of stay and 28-day unplanned readmission were found. Overall 30-day mortality was 4.1% and 4.4% for oesophagectomy and gastrectomy, respectively. Five-year absolute survival was significantly better for patients who underwent oesophagectomy in higher-volume hospitals (adjusted HR for lower-volume hospitals, 1.28 [95% CI, 1.10-1.49]; P = 0.002) and for those with localised gastric cancer who underwent gastrectomy in higher-volume hospitals (adjusted HR for lower-volume hospitals, 1.83 [95% CI, 1.28-2.61]; P = 0.001). CONCLUSIONS: These data support initial surgery for oesophagogastric cancer in higher-volume hospitals.

Effect of immunosuppressive doses of cyclosporine on pancreatic beta cell function in pigs.

OBJECTIVE: To evaluate whether immunosuppressive doses of cyclosporine (CsA) have an adverse effect on the liver, kidney, and pancreatic beta cells of pigs. ANIMALS: 8 juvenile 8-week-old Landrace X Large White crossbred pigs. PROCEDURE: CsA (100 to 140 mg/kg) was administered orally to euglycemic pigs to reach whole blood trough concentrations of approximately 1500 ng/mL. To determine pancreatic beta cell function, plasma C-peptide and insulin concentrations were measured in response to i.v. administration of glucose, glucagon, arginine, and oral administration of glucose. Effects on liver and kidney were determined by monitoring serum measurements of liver function and serum creatinine concentrations, respectively. RESULTS: Plasma concentrations of C-peptide were significantly lower in euglycemic CsA-treated pigs, compared with control pigs, following i.v. administration of glucose, glucagon, arginine, and oral administration of glucose. Furthermore, the glucose clearance rate was decreased in euglycemic CsA-treated pigs, compared with control pigs. Serum creatinine concentrations and 4 of 7 serum measurements of liver function were not adversely affected by CsA administration. Serum concentrations of bilirubin and albumin were significantly increased, and serum alanine aminotransferase activity was significantly decreased in CsA-treated pigs, compared with control pigs. Histologic evaluation of liver and kidney sections revealed no pathologic findings in CsA-treated or control pigs. CONCLUSIONS AND CLINICAL RELEVANCE: In our study, immunosuppressive doses of CsA caused an impairment of porcine pancreatic beta cell function, but did not have toxic effects on the kidney. However, on the basis of changes in serum bilirubin and albumin concentrations and alanine aminotransferase activity, subclinical toxic effects on the liver did occur when immunosuppressive doses of CsA were administered.

Safety and viability of microencapsulated human islets transplanted into diabetic humans.

OBJECTIVE: Transplantation of insulin-producing cells placed inside microcapsules is being trialled to overcome the need for immunosuppressive therapy. RESEARCH DESIGN AND METHODS: Four type 1 diabetic patients with no detectable C-peptide received an intraperitoneal infusion of islets inside microcapsules of barium alginate (mean 178,200 islet equivalents on each of eight occasions). RESULTS: C-peptide was detected on day 1 post-transplantation, and blood glucose levels and insulin requirements decreased. C-peptide was undetectable by 1-4 weeks. In a multi-islet recipient, C-peptide was detected at 6 weeks after the third infusion and remains detectable at 2.5 years. Neither insulin requirements nor glycemic control was affected. Capsules recovered at 16 months were surrounded by fibrous tissue and contained necrotic islets. No major side effects or infection occurred. CONCLUSIONS: While allografting of encapsulated human islets is safe, efficacy of the cells needs to improve for the therapy to make an impact on the clinical scene.

Australian Curriculum Framework for Junior Doctors.

The Confederation of Postgraduate Medical Education Councils launched the Australian Curriculum Framework for Junior Doctors in October 2006. The curriculum framework: balances the major areas of clinical management, communication and professionalism, and highlights the importance of an integrated approach to prevocational learning and teaching; supports practice-based, opportunistic and continuous learning, and specifies performance and supervision requirements for junior doctors; and has been published in both Internet and printable versions, to make the document accessible and easily usable by junior doctors and supervisors. The implementation of the curriculum framework will be overseen by a steering group that includes representatives from key stakeholder groups, including junior doctors and medical students.

Residents as teachers: outcomes of a brief training programme.

INTRODUCTION: Residents (RMOs) teach medical students in hospital wards, yet little evidence of efficacy is available for this activity. This study undertook to test the effectiveness of RMO teaching, and to delineate the principal barriers encountered. METHODS: Medical students in their fourth year were assessed at baseline for clinical examination skills in ophthalmoscopy, neurological examination of the legs, and rheumatological examination of the hands. One group of RMOs (n=6) taught ophthalmoscopy to the students attached to their unit, while the second group of RMOs (n=6) taught leg examination to their students. The third examination skill was not taught, but was used as a control intervention. The students were evaluated in all three skills by an observed, structured clinical examination at the beginning and end of their six-week attachments. RESULTS: There was a significant improvement in the skill of ophthalmoscopy in the intervention group (p<0.02), while the control group of students showed a decline in their abilities. The skill of examination of the legs improved after being taught, but not significantly. The RMOs universally reported that difficulty in finding time was a major barrier to their ability to teach medical students, and most set up additional teaching sessions rather than incorporate the teaching into their routine ward work. CONCLUSIONS: RMO teaching of medical students is effective, particularly for a skill which is novel. The difficulties arise in finding a suitable time for these important clinical teachers to transfer their skills.