Outcomes after liver transplantation using deceased after circulatory death donors: A comparison of outcomes in the UK and the US.

BACKGROUND AND AIMS: Identifying international differences in utilization and outcomes of liver transplantation (LT) after donation after circulatory death (DCD) donation provides a unique opportunity for benchmarking and population-level insight. METHODS: Adult (≥18 years) LT data between 2008 and 2018 from the UK and US were used to assess mortality and graft failure after DCD LT. We used time-dependent Cox-regression methods to estimate hazard ratios (HR) for risk-adjusted short-term (0-90 days) and longer-term (90 days-5 years) outcomes. RESULTS: One-thousand five-hundred-and-sixty LT receipts from the UK and 3426 from the US were included. Over the study period, the use of DCD livers increased from 15.7% to 23.9% in the UK compared to 5.1% to 7.6% in the US. In the UK, DCD donors were older (UK:51 vs. US:33 years) with longer cold ischaemia time (UK: 437 vs. US: 333 min). Recipients in the US had higher Model for End-stage Liver Disease (MELD) scores, higher body mass index, higher proportions of ascites, encephalopathy, diabetes and previous abdominal surgeries. No difference in the risk-adjusted short-term mortality or graft failure was observed between the countries. In the longer-term (90 days-5 years), the UK had lower mortality and graft failure (adj.mortality HR:UK: 0.63 (95% CI: 0.49-0.80); graft failure HR: UK: 0.72, 95% CI: 0.58-0.91). The cumulative incidence of retransplantation was higher in the UK (5 years: UK: 11.9% vs. 4.6%; p < .001). CONCLUSIONS: For those receiving a DCD LT, longer-term post-transplant outcomes in the UK are superior to the US, however, significant differences in recipient illness, graft quality and access to retransplantation were seen between the two countries.

Patients' satisfaction with the reconstructive options provided to them measured 18 months after mastectomy surgery for breast cancer.

INTRODUCTION: Mastectomy patients' satisfaction with reconstructive options has not been examined. METHODS: A national study measured 18-month satisfaction with reconstructive options and collected case-mix and reconstructive offer and uptake data on breast cancer patients having mastectomy with or without immediate reconstruction (IR) in England between January 2008 and March 2009. Multivariable logistic regression examined the relationship between satisfaction, age, IR offer and uptake, and clinical suitability. RESULTS: Of 4796 patients, 1889 were not offered IR, 1489 declined an offer and 1418 underwent it. Women not offered IR were more likely older, obese or smokers and had higher ASA grades, ECOG scores, tumour burdens and adjuvant chemotherapy and radiotherapy likelihoods (9% of lowest suitability group offered IR; 81% in highest suitability group). 83.7% were satisfied with their reconstructive options, varying significantly by IR offer and uptake (76.1% for those not offered IR; 85.8% for those who declined IR; 91.7% following IR). Older women and women deemed more suitable for IR were more often satisfied (p-values <0.001). CONCLUSIONS: Satisfaction varied by offer and uptake status, age and suitability score. Clinicians should target equity for women deemed unsuitable by exploring their needs and desired outcomes, standardising operative fitness assessments and utilising shared decision-making aids.

The association between complications and quality of life after mastectomy and breast reconstruction for breast cancer.

BACKGROUND: Medical treatment for breast cancer is associated with substantial toxicity and patient burden. There is less known about the impact of surgical complications. Understanding this impact could provide important information for patients when they are considering surgical options. METHODS: Between 2008 and 2009, the UK National Mastectomy and Breast Reconstruction Audit recorded surgical complications for a prospective cohort of 17,844 women treated for breast cancer at 270 hospitals; 6405 of these women were surveyed about their quality of life 18 months after surgery. Breast appearance, emotional well-being, and physical well-being were quantified on 0- to 100-point scales. Linear multiple regression models, controlling for a range of baseline prognostic factors, were used to compare the scores of patients who had complications with the scores of those who did not. RESULTS: The overall complication rate was 10.2%. Complications were associated with little or no impairment in women undergoing mastectomy without reconstruction or with delayed reconstruction. The association was much larger for flap-related complications suffered during immediate reconstruction. The breast-appearance scores (adjusted mean difference, -23.8; 95% confidence interval [CI], -31.0 to -16.6) and emotional well-being scores (adjusted mean difference, -14.0; 95% CI, -22.0 to -6.0) of these patients were much lower than those of any other patient group. Implant-related complications were not associated with a lower quality of life in any surgical group. CONCLUSIONS: There is a strong case for prospectively collecting flap-complication rates at the surgeon and surgical unit level and for allowing patients to access these data when they make choices about their breast cancer surgery. Cancer 2017;123:3460-7. © 2017 American Cancer Society.

Will focal therapy become a standard of care for men with localized prostate cancer?

The current treatment choice for men with localized prostate cancer lies between active surveillance and radical therapy. The difference between these two extremes of care is 5% in terms of cancer-related absolute mortality at 8 years. It is generally accepted that this small difference will decrease for men diagnosed in the prostate-specific-antigen era. Radical therapy is associated with considerable adverse effects (e.g. incontinence, impotence, rectal problems) because it treats the whole gland, and damages surrounding structures in up to half of men. Men are being diagnosed at a younger age with lower-risk disease, and many have unifocal or unilateral disease. We propose a new concept whereby only the tumor focus and a margin of normal tissue are treated. This paradigm might decrease adverse effects whilst, at the same time, retaining effective cancer control. The arguments for and against active surveillance and radical therapy are reviewed in this article, with focal therapy presented as a means for bridging these two approaches.

Adult orthotopic liver transplantation in the United Kingdom and Ireland between 1994 and 2005.

BACKGROUND: The UK and Ireland Liver Transplant Audit collects information on all liver transplantations that are carried out in both countries. In this paper, we describe these transplantations and their outcomes in adult patients according to primary liver disease diagnosis, type of transplantation and period. METHODS: A prospective cohort study of 7906 orthotopic liver transplantations carried out between April 1994 and June 2005 in the United Kingdom and Ireland. Multivariable logistic regression was used to investigate improvements in mortality according to period of transplantation adjusted for recipient and donor characteristics. RESULTS: A total of 6,850 transplantations were done in adults (patients 16 years or older). Of these, 836 (12.2%) were first super-urgent procedures (33.7% men; median age 36 years), and 5,072 (74.0%) first elective procedures (60.0% men; median age 52 years). The percentage of patients who received a donor organ with abnormal appearance gradually increased, especially in patients receiving an elective transplant. Mortality at 90 days after first super-urgent transplant decreased from 29.6% (95% confidence interval: 23.5% to 36.9%) before October 1, 1996 to 16.0% (11.7% to 21.7%) after October 1, 2002. Considering the same time periods, mortality at 90 days after first elective transplant decreased from 10.6% (8.9% to 12.7%) to 7.7% (6.3% to 9.3%). Multivariable analysis demonstrated that these improvements cannot be explained by changes in the risk profile of recipients and donors. CONCLUSIONS: Patients undergoing a liver transplantation in the most recent years had a better survival than patients with similar characteristics transplanted 10 years earlier. Posttransplant survival has improved despite a deteriorating quality of donor organs.

Surgical Determinants of Patient-Reported Outcomes following Postmastectomy Reconstruction in Women with Breast Cancer.

BACKGROUND: This national prospective cohort study compared the patient-reported outcomes of breast cancer patients undergoing postmastectomy autologous reconstruction to those who had breast implants, in terms of aesthetic appearance; levels of psychological, physical, and sexual well-being; and overall satisfaction. METHODS: Of 5063 women who underwent immediate reconstruction (n = 3349) or delayed reconstruction (n = 1714) between January 1, 2008, and March 31, 2009, in England, 2923 women who gave informed consent were sent validated, procedure-specific, 18-month follow-up questionnaires. Outcome scale scores ranged from 0 (poor) to 100 (excellent); multiple linear regression was used to adjust scores for patient and treatment characteristics. RESULTS: Two thousand two hundred eighty-nine women (78 percent) returned completed questionnaires (immediate reconstruction, n = 1528; delayed reconstruction, n = 761). For immediate reconstruction, mean overall satisfaction scores for the various techniques ranged from 67 to 85 (median, 67 to 93). For delayed reconstruction, mean overall satisfaction scores ranged from 70 to 85 (median, 75 to 100). For both groups, similar gradients were observed for the other outcome scales across techniques. Reconstruction using patients' own tissues tended to have higher mean adjusted scores compared with those techniques using implants alone (p < 0.0001 for aesthetic appearance, psychological well-being, sexual well-being, and satisfaction with outcomes for immediate and delayed reconstruction groups). CONCLUSIONS: Women who underwent autologous reconstruction tended to report greater satisfaction than those who underwent implant reconstruction. These results can inform patients of the anticipated outcomes of their selected surgery, but further research is required to confirm whether autologous reconstruction is superior in general. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Developing a prognostic model for 90-day mortality after liver transplantation based on pretransplant recipient factors.

BACKGROUND: Current statistical prognostic models for mortality after liver transplantation do not have good discriminatory ability. Furthermore, the methodology used to develop these models is often flawed. The objective of this paper is to develop a prognostic model for 90-day mortality after liver transplantation based on pretransplant recipient factors, employing a rigorous model development method. METHODS: We used data on 4,829 patient that were prospectively collected for the UK & Ireland Liver Transplant Audit. Switching regression was employed to impute missing values combined with a bootstrapping approach for variable selection. RESULTS: In all, 452 patients (9.4%) died within 90 days of their transplantation. The final prognostic model was well calibrated and discriminated moderately well between patients who did and who did not die (c-statistic 0.65, 95% CI [0.63, 0.68]). Although discrimination was not excellent overall, the results showed that those patients with a "low" chance of dying within 90 days of their transplant and those with a "high" chance of dying could be differentiated from patients with a "intermediate" chance. CONCLUSIONS: Our model can provide transplant candidates with predictions of their early posttransplantation prospects before any donor information is known, which is essential information for patients with end-stage liver disease for whom liver transplantation is a treatment option.

Complications of surgery for nasal polyposis and chronic rhinosinusitis: the results of a national audit in England and Wales.

OBJECTIVE: The objective of this study was to determine the rate of complications of surgery for nasal polyposis and chronic rhinosinusitis as well as their risk factors. STUDY DESIGN, SETTING, PARTICIPANTS, AND OUTCOME MEASURES: The authors conducted a prospective study of 3,128 patients who underwent sinonasal surgery during 2000 and 2001 in 87 National Health Service hospitals in England and Wales. Patients completed a preoperative questionnaire that included the Sino-Nasal Outcome Test, a measure of sinonasal symptoms severity and health-related quality of life. Surgeons provided information about polyp extent, opacity of the sinuses on computed tomography (Lund-Mackay score), comorbidity (American Society of Anesthesiologists score), and the occurrence of perioperative complications. RESULTS: Major complications (orbital or intracranial complications, bleeding requiring ligation or orbital decompression, or return to the operating room) occurred in 11 patients (0.4%). Minor complications (all other untoward events) occurred in 207 patients (6.6%). Most frequently reported minor complications were excessive perioperative hemorrhage bleeding (5.0%) as well as postoperative hemorrhage requiring treatment (0.8%). Multivariate analysis indicated that the complication rate was linked to the extent of disease measured in terms of symptom severity and health-related quality of life, the extent of polyposis, level of opacity of the sinuses on computed tomography, and the presence of comorbidity, but not surgical characteristics (extent of surgery, use of endoscope or microdebrider, grade of surgeon, and adjunctive turbinate surgery). CONCLUSIONS: The risk of complications depended on patient characteristics rather than on the surgical technique used. Measures of the extent of disease and comorbidity may help in identifying patients at high risk of complications.

Functional status of patients before liver transplantation as a predictor of posttransplant mortality.

BACKGROUND: Risk models for mortality after liver transplantation have poor predictive ability. We examined whether the performance of these risk models can be improved by including information about patients' functional status (i.e., their ability to carry out activities of daily living) in addition to conventional clinical risk factors. METHODS: The UK and Ireland Liver Transplant Audit has data on all liver transplantations carried out in both countries since 1994. We examined the association of functional status measures taken immediately before transplantation on a 5-point scale (modified version of the Eastern Cooperative Oncology Group performance status) and mortality 90 days after transplantation. Logistic regression was used to adjust for other risk factors. RESULTS: Posttransplant mortality increased from 5.3% in patients able to carry out normal activity without restriction (functional status 1) to 24.8% in patients completely reliant on nursing and medical care (functional status 5; P for trend 0.003). This association remained after adjustment for conventional risk factors (adjusted P for trend 0.003). Adjusted odds ratios with functional status 3 (the most frequent functional status) as baseline category were 0.60 (95% confidence interval 0.29-1.25) for functional status 1, 0.70 (0.50-0.97) for functional status 2, 1.00 (0.71-1.41) for functional status 4, and 1.85 (1.07-3.19) for functional status 5. CONCLUSIONS: Considering a patient's functional status or more general measures of a patient's health status before transplantation in addition to conventional clinical factors may help to improve our ability to predict posttransplant survival.

An analysis of the Research Fellowship Scheme of the Royal College of Surgeons of England.

BACKGROUND: The Research Fellowship Scheme of the Royal College of Surgeons of England commenced in 1993 with the aim of exposing selected surgical trainees to research techniques and methodology, with the hope of having an impact on surgical research and increasing the cadre of young surgeons who might decide to pursue an academic career in surgery. Over 11 million pounds sterling (approximately US 20 million dollars) has been invested in 264 fellowships. The College wished to evaluate the impact of the Scheme on the careers of research fellows, surgical research, and patient care. As the 10th anniversary of the Scheme approached. STUDY DESIGN: Two-hundred and sixty research fellows whose current addresses were available were sent a questionnaire. Two-hundred and thirty-eight (91.5%) responded. RESULTS: Three-quarters of the research fellows conducted laboratory-based research, with most of the remainder conducting patient-based clinical research. One-third of the fellows who have reached consultant status have an academic component to their post. The total number of publications based on fellowship projects was 531, with a median impact factor of 3.5. Almost all fellows had been awarded a higher degree or were working toward this. Half of the fellows received subsequent funding for research, mostly awarded by national or international funding bodies. CONCLUSIONS: The Research Fellowship Scheme of the Royal College of Surgeons of England has successfully supported many trainee surgeons in the initial phase of their research career. It has helped surgical research by increasing the pool of surgeons willing to embark on an academic career. Indirectly, patient care has benefited by promoting an evidence-based culture among young surgeons. Such schemes are relevant to surgical training programs elsewhere if more young surgeons are to be attracted into academic surgery.

Assessing the quality of the data in a transplant registry: the European Liver Transplant Registry.

The usefulness of a clinical database depends strongly on the quality of the collected data. Data quality assurance should start with deciding in advance the uses to which the database is going to be put, developing an explicitly defined minimum data set, and setting up a user-friendly interface. The quality of the collected data can be assessed by computer validation, during which computerized range and consistency checks are based on information within the database itself. Also, note validation can be used, which implies a comparison of the original database against medical records. A number of related methodological issues are discussed in this article.

Findings of a national comparative audit of mastectomy and breast reconstruction surgery in England.

OBJECTIVES: This paper summarises the findings of a national audit of mastectomy and breast reconstruction surgery carried out in England. It describes patterns of treatment, and the clinical and patient-reported quality of life outcomes associated with these types of procedure. DESIGN: Prospective cohort study. SETTING: All 150 National Health Service hospital groups (NHS trusts) in England that provided mastectomy or breast reconstruction surgery, along with six NHS trusts in Wales and Scotland and 114 independent hospitals. PARTICIPANTS: Women aged 16 years and over undergoing mastectomy with or without immediate breast reconstruction, or primary delayed breast reconstruction, between 1st January 2008 and 31st March 2009. MAIN OUTCOME MEASURES: Reconstructive utilisation, post-operative complications and sequelae, and patient-reported satisfaction and quality of life. RESULTS: Overall, 21% of the 16,485 women who had mastectomy underwent immediate reconstruction. However, the proportion varied between regions from 9% to 43% (p < 0.001). Levels of patient satisfaction with information, choice and the quality of care were high. The proportion of women who experienced local complications was 10.30% (95% CI 9.78-10.84) for mastectomy surgery, ranged from 11.02% (9.31-12.92) to 18.24% (14.80-22.10) for different immediate reconstructive procedures, and from 5.00% (2.76-8.25) to 19.86% (16.21-23.94) for types of delayed reconstruction. Breast appearance and overall well-being scores reported 18 months after surgery were higher among women having immediate breast reconstruction compared to mastectomy only. Postoperative outcomes were similar across providers.. CONCLUSIONS: The Audit found women were highly satisfied with their peri-operative care, with hospital providers achieving similar outcomes. English providers should examine how to reduce the variation in rates of immediate reconstruction.

Trends in the use of bilateral mastectomy in England from 2002 to 2011: retrospective analysis of hospital episode statistics.

OBJECTIVES: For healthy women at high risk of developing breast cancer, a bilateral mastectomy can reduce future risk. For women who already have unilateral breast cancer, removing the contralateral healthy breast is more difficult to justify. We examined trends in the number of women who had a bilateral mastectomy in England between 2002 and 2011. DESIGN: Retrospective cohort study using the Hospital Episode Statistics database. SETTING: NHS hospital trusts in England. PARTICIPANTS: Women aged between 18 and 80 years who had a bilateral mastectomy (or a contralateral mastectomy within 24 months of unilateral mastectomy) with or without a diagnosis of breast cancer. MAIN OUTCOME MEASURES: Number and incidence of women without breast cancer who had a bilateral mastectomy; number and proportion who had a bilateral mastectomy as their first breast cancer operation, and the proportion of those undergoing bilateral mastectomy who had immediate breast reconstruction. RESULTS: Among women without breast cancer, the number who had a bilateral mastectomy increased from 71 in 2002 to 255 in 2011 (annual incidence rate ratio 1.16, 95% CI 1.13 to 1.18). In women with breast cancer, the number rose from 529 to 931, an increase from 2% to 3.1% of first operations (OR for annual increase 1.07, 95% CI 1.05 to 1.08). Across both groups, rates of immediate breast reconstruction roughly doubled and reached 90% among women without breast cancer in 2011. CONCLUSIONS: The number of women who had a bilateral mastectomy nearly doubled over the last decade, and more than tripled among women without breast cancer. This coincided with an increase in the use of immediate breast reconstruction.

Impact of route to diagnosis on treatment intent and 1-year survival in patients diagnosed with oesophagogastric cancer in England: a prospective cohort study.

OBJECTIVE: To investigate the relationship between the route to diagnosis, patient characteristics, treatment intent and 1 -year survival among patients with oesophagogastric (O-G) cancer. SETTING: Cohort study in 142 English NHS trusts and 30 cancer networks. PARTICIPANTS: Patients diagnosed with O-G cancer between October 2007 and June 2009. DESIGN: Prospective cohort study. Route to diagnosis defined as general practitioner (GP) referral-urgent (suspected cancer) or non-urgent, hospital consultant referral, or after an emergency admission. Logistic regression was used to estimate associations and adjust for differences in casemix. MAIN OUTCOME MEASURES: Proportion of patients diagnosed by route of diagnosis; proportion of patients selected for curative treatment; 1-year survival. RESULTS: Among 14 102 cancer patients, 66.3% were diagnosed after a GP referral, 16.4% after an emergency admission and 17.4% after a hospital consultant referral. Of the 9351 GP referrals, 68.8% were urgent. Compared to urgent GP referrals, a markedly lower proportion of patients diagnosed after emergency admission had a curative treatment plan (36% vs 16%; adjusted OR=0.62, 95% CI 0.52 to 0.74) and a lower proportion survived 1 year (43% vs 27%; OR 0.78; 95% CI 0.68 to 0.89). Urgency of GP referral did not affect treatment intent or survival. Routes to diagnosis varied across cancer networks, with the adjusted proportion of patients diagnosed after emergency admission ranging from 8.7 to 32.3%. CONCLUSIONS: Outcomes for cancer patients are worse if diagnosed after emergency admission. Primary care and hospital services should work together to reduce rates of diagnosis after emergency admission and the variation across cancer networks.

Outcomes of transplantation of livers from donation after circulatory death donors in the UK: a cohort study.

OBJECTIVES: Outcomes of liver transplantations from donation after circulatory death (DCD) donors may be inferior to those achieved with donation after brain death (DBD) donors. The impact of using DCD donors is likely to depend on specific national practices. We compared risk-adjusted graft loss and recipient mortality after transplantation of DCD and DBD livers in the UK. DESIGN: Prospective cohort study. Multivariable Cox regression and propensity score matching were used to estimate risk-adjusted HR. SETTING: 7 liver transplant centres in the National Health Service (NHS) hospitals in England and Scotland. PARTICIPANTS: Adults who received a first elective liver transplant between January 2005 and December 2010 who were identified in the UK Liver Transplant Audit. INTERVENTIONS: Transplantation of DCD and DBD livers. OUTCOMES: Graft loss and recipient mortality. RESULTS: In total, 2572 liver transplants were identified with 352 (14%) from DCD donors. 3-year graft loss (95% CI) was higher with DCD livers (27.3%, 21.8% to 33.9%) than with DBD livers (18.2%, 16.4% to 20.2%). After adjustment with regression, HR for graft loss was 2.3 (1.7 to 3.0). Similarly, 3-year mortality was higher with DCD livers (19.4%, 14.5% to 25.6%) than with DBD livers (14.1%, 12.5% to 16.0%) with an adjusted HR of 2.0 (1.4 to 2.8). Propensity score matching gave similar results. Centre-specific adjusted HRs for graft loss and recipient mortality seemed to differ among transplant centres, although statistical evidence is weak (p value for interaction 0.08 and 0.24, respectively). CONCLUSIONS: Graft loss and recipient mortality were about twice as high with DCD livers as with DBD livers in the UK. Outcomes after DCD liver transplantation may vary between centres. These results should inform policies for the use of DCD livers.

Trends in adult heart transplantation: a national survey from the United Kingdom Cardiothoracic Transplant Audit 1995-2007.

OBJECTIVE: The management of heart failure (HF), peri-transplant care and immunosuppression has changed in the last decade. Here we describe the changes that have occurred in the UK national programme of adult heart transplantation (HTx). METHODS: Using the data accrued with the UK Cardiothoracic Transplant Audit we undertook a prospective cohort study of 2958 consecutive adult patients listed for HTx and 2005 adult orthotopic HTx performed in three time periods - Era-1 (July 1995-March 1999, 1321 listed, 907 transplanted), Era-2 (April 1999-March 2003, 842 listed, 600 transplanted) and Era-3 (April 2003-March 2007, 795 listed, 498 transplanted). RESULTS: The median time on the waiting list reduced from 109 days in Era-1 to 40 days in Era-3. The proportion of HTx in non-ambulatory HF patients requiring inotropic or circulatory support increased from 12% in Era-1 to 35% in Era-3. The proportion undergoing HTx for non-ischaemic dilated cardiomyopathy increased from 40% in Era-1 to 58% in Era-3 while ischaemic cardiomyopathy decreased. Survival after HTx remained constant (81% (95% CI: 78-83%) at 1 year in Era-1 and 80% (95% CI: 77-84%) in Era-3). There was an increase in the use of mycophenolate and induction therapy and a reduction in rejection episodes over the eras. CONCLUSIONS: Although waiting list and HTx activity have declined, HTx continues to have an important role in the management of advanced HF, especially for patients on inotropic or circulatory support. Despite a deterioration of donor organ quality, survival after HTx has remained unchanged.

Continuous monitoring of long-term outcomes with application to hip prostheses.

The CUSUM continuous monitoring method could be a valuable tool in evaluating the performance (revision experience) of prostheses used in hip replacement surgery. The dilemma when applying the CUSUM in this context is the choice of statistical model for the outcome (revision). The Bernoulli model is perhaps the most straightforward approach but the Poisson model is a plausible, and could be argued, preferable alternative for long-term outcomes such as this, provided the rate of revision with time from surgery can be assumed to be constant. However, a rate (or hazard) varying according to the Weibull distribution appears to be a better representation of a prosthesis lifetime. We show how to adapt the Poisson approach to allow for the hazard to vary according to the Weibull model as well as other parametric survival models. Application to data on a known poorly performing prosthesis shows both the Poisson and Weibull CUSUMs could have given early warning of the poor performance, with the Weibull chart alerting before the Poisson. Simulation work to investigate the robustness of the Poisson and Weibull CUSUM to departures from the underlying survival model highlights the need for correct specification of the model for the outcome.

Continuous monitoring tools for pediatric surgical outcomes: an example using biliary atresia.

PURPOSE: Continuous monitoring tools can be used to monitor surgical outcomes over time. We illustrate the use of CUmulative SUM (CUSUM) charts in monitoring outcomes of Kasai portoenterostomy for treatment of biliary atresia at a supraregional unit. METHODS: Data on 57 consecutive infants who underwent a Kasai portoenterostomy performed by a single surgeon between June 1994 and June 2006 were collected. A procedure was defined as successful if clearance of jaundice (plasma bilirubin level <20 micromol/l) was achieved within 6 months of surgery. We applied cumulative observed-minus-expected, sequential probability ratio test (SPRT), and zero-resetting SPRT CUSUM charts and compared the results with those of standard aggregate data analyses. An expected failure rate of 43.0%, based on the national average failure rate, was used. RESULTS: The failure rate observed after 57 operations was 29.8%. The zero-resetting SPRT chart indicated a lower-than-expected failure rate earlier than did the aggregate data analyses and any of the other continuous monitoring techniques. CONCLUSIONS: The CUSUM chart method provides ongoing feedback that can be used for continuous monitoring of the outcome of a procedure to ensure that standards of care are maintained. Its use as a routine monitoring tool in pediatric surgery deserves wider recognition.

Mortality in men admitted to hospital with acute urinary retention: database analysis.

OBJECTIVES: To investigate mortality in men admitted to hospital with acute urinary retention and to report on the effects of comorbidity on mortality. DESIGN: Analysis of the hospital episode statistics database linked to the mortality database of the Office for National Statistics. SETTING: NHS hospital trusts in England, 1998-2005. PARTICIPANTS: All men aged over 45 who were admitted to NHS hospitals in England with a first episode of acute urinary retention. MAIN OUTCOME MEASURES: Mortality in the first year after acute urinary retention and standardised mortality ratio against the general population. RESULTS: During the study period, 176 046 men aged over 45 were admitted to hospital with a first episode of acute urinary retention. In 100 067 men with spontaneous acute urinary retention, the one year mortality was 4.1% in men aged 45-54 and 32.8% in those aged 85 and over. In 75 979 men with precipitated acute urinary retention, mortality was 9.5% and 45.4%, respectively. In men with spontaneous acute urinary retention aged 75-84, the most prevalent age group, the one year mortality was 12.5% in men without comorbidity and 28.8% in men with comorbidity. The corresponding figures for men with precipitated acute urinary retention were 18.1% and 40.5%. Compared with the general population, the highest relative increase in mortality was in men aged 45-54 (standardised mortality ratio 10.0 for spontaneous and 23.6 for precipitated acute urinary retention) and the lowest for men 85 and over (1.7 and 2.4, respectively). CONCLUSIONS: Mortality in men admitted to hospital with acute urinary retention is high and increases strongly with age and comorbidity. Patients might benefit from multi-disciplinary care to identify and treat comorbid conditions.

The thermo-expandable metallic stent for managing benign prostatic hyperplasia: a systematic review.

OBJECTIVES: To systematically review published reports of the safety, effectiveness and durability of a self-expanding metallic prostatic stent (Memokath, Engineers & Doctors A/S Ltd., Denmark) in patients with benign prostatic hyperplasia (BPH) who are unfit for surgery. METHODS: We systematically searched the Medline and Embase databases from 1992. The reference lists of included studies and the bibliographies of review articles were also searched. We contacted the manufacturer of Memokath for additional information. The primary outcomes were treatment failure (stent removal, replacement or repositioning) and urological symptom scores. Secondary outcomes were urodynamic indices and minor complications. Two reviewers independently assessed the methodological quality of the studies and extracted data. Data were synthesized using narrative techniques. RESULTS: In all, 14 case series described the use of the Memokath stent in 839 men with BPH. All patients were at high operative risk. Most studies were of poor quality with an inadequate follow-up. Treatment failure rates were 0-48% but the duration of follow-up was often unclear. Five studies reported International Prostate Symptom Scores and found reductions of 11-19 points after stent insertion. All seven studies that reported on maximum urinary flow rates found that these increased, and the four that described residual urine volumes found that these decreased. Minor complications were inconsistently reported. CONCLUSIONS: The Memokath stent can provide an effective treatment for BPH in men at high operative risk; it also appears to be safe, but inadequate follow-up does not allow firm conclusions on stent durability.