BAOMS QOMS: findings from the pilot phase and lessons learned in the feasibility evaluation of a national quality improvement initiative.

The BAOMS QOMS pilot was developed and run in six England OMFS units between December 2019 - April 2020. The aims of this pilot project were: to evaluate feasibility of the questionnaires developed for the audit and how effective they were with regards to quality improvement, to test the processes associated with the data collection system and finally, to provide baseline data to support patient data collection without the requirement of prospective consent. The pilot included a series of six audits (oral and dentoalveolar [ODA], oncology, orthognathic, reconstruction, trauma, and skin). Data entry was clinician-led in five OMFS units and in one unit (EKHU), it was additionally supported by members of the clinical coding team. One hundred and twenty-eight REDCap account user details were issued and of these, 45 (35%) completed registration and 22 (17%) were active users who participated in the pilot data entry. Disproportionate focus on individual audits within QOMS was seen, though not all units offered the full range of service audited. Users suggest the skin and ODA audits were sufficiently clear, but improvement is required in the oncology and reconstruction questionnaire particularly. The pilot was successful in aiding the project team identify areas of weaknesses and strength in the design of the REDCap registry and implementation of the next phase of the initiative. The information and experience gained has to date enabled a successful application for section 251 approval from the HRA and progress for the next phase of national data collection.

Machine learning methods applied to audit of surgical margins after curative surgery for head and neck cancer.

Most surgical specialties have attempted to address concerns about the unfair comparison of outcomes by 'risk-adjusting' data to benchmark specialty-specific outcomes that are indicative of quality of care. We explore the ability to predict for positive margin status so that effective benchmarking that will account for complexity of case mix is possible. A dataset of care episodes recorded as a clinical audit of margin status after surgery for head and neck squamous cell carcinoma (n=1316) was analysed within the Waikato Environment for Knowledge Analyisis (WEKA) machine learning programme. The outcome was a classification model that can predict for positivity of tumour margins (defined as less than 1mm) using data on preoperative demographics, operations, functional status, and tumour stage. Positive resection margins of less than 1mm were common, and varied considerably between treatment units (19%-29%). Four algorithms were compared to attempt to risk-adjust for case complexity. The 'champion' model was a Naïve Bayes classifier (AUROC 0.72) that suggested acceptable discrimination. Calibration was good (Hosmer-Lemershow goodness-of-fit test p=0.9). Adjusted positive margin rates are presented on a funnel plot. Subspecialty groups within oral and maxillofacial surgery are seeking metrics that will allow for meaningful comparison of the quality of care delivered by surgical units in the UK. To enable metrics to be effective, we argue that they can be modelled so that meaningful benchmarking, which takes account of variation in complexity of patient need or care, is possible.

Machine learning methods applied to audit of surgical outcomes after treatment for cancer of the head and neck.

Most surgical specialties have attempted to address concerns about unfair comparison of outcomes by "risk-adjusting" data to benchmark specialty-specific outcomes that are indicative of the quality of care. We are building on previous work in head and neck surgery to address the current need for a robust validated means of risk adjustment. A dataset of care episodes, which were recorded as a clinical audit of complications after operations for squamous cell carcinoma (SCC) of the head and neck (n=1254), was analysed with the Waikarto Environment for Knowledge Analysis (WEKA) machine learning tool. This produced 4 classification models that could predict complications using data on the preoperative demographics of the patients, operation, functional status, and tumour stage. Three of them performed acceptably: one that predicted "any complication" within 30 days (area under the receiver operating characteristic curve (AUROC) 0.72), one that predicted severe complications (Clavien-Dindo grade 3 or above) within 30 days (AUROC 0.70), and one that predicted a prolonged duration of hospital stay of more than 15 days, (AUROC 0.81). The final model, which was developed on a subgroup of patients who had free tissue transfer (n=443), performed poorly (AUROC 0.59). Subspecialty groups within oral and maxillofacial surgery are seeking metrics that will allow a meaningful comparison of the quality of care delivered by surgical units in the UK. For these metrics to be effective they must show variation between units and be amendable to change by service personnel. Published baseline data must also be available. They should be modelled effectively so that meaningful comparison, which takes account of variations in the complexity of the patients' needs or care, is possible.

Validating a risk stratification tool for audit of early outcome after operations for squamous cell carcinoma of the head and neck.

The aim of this study was to validate a case-mix adjustment tool (neural network) for the audit of postoperative outcomes. We tested its calibration and discrimination on two unseen groups of patients being treated for squamous cell carcinoma (SCC) of the head and neck and compared observed complication rates with predicted rates. A total of 196 patients who were treated at two UK NHS institutions between 2016 and 2018 were audited. Preoperative data pertaining to risk (T classification, complexity of operation, and "high-risk" status) were collected, together with data on postoperative complications. Diagnostic test statistics and receiver operating curves (ROC) were used to test the performance of the tool. The score was well calibrated (predicted and observed complication rates both 43%), but discrimination suggested only fair accuracy (ROC 0.66 - 0.68). Adjustment of case mix for the audit of postoperative complications is difficult, although our model suggests that departmental audit is possible, and its accuracy is equivalent to that of other national audits. Further work may elucidate key variables that have not yet been assessed.

Case-mix adjustment in audit of length of hospital stay in patients operated on for cancer of the head and neck.

Patients treated surgically for squamous cell carcinoma (SCC) of the head and neck form a heterogeneous group, and it is difficult to take this variation into account when measuring the quality of care. We have tested the feasibility of mathematical models that allow for the adjustment for case mix when auditing the length of hospital stay as a proxy indicator of the quality of care. We completed a case-note audit of 733 surgical episodes of care for SCC of the head and neck in five cancer networks, and used logistic regression and decision tree analysis to adjust for case mix using pertinent preoperative variables. Risk adjustment models of length of stay included age, alcohol, T classification, performance status, tracheostomy, high-risk status, and complexity of operation. The risk-adjusted length of stay differed significantly between the cancer networks studied (p<0.001). The models performed acceptably for the purpose of audit when this was under 15 days. Length of stay is a measurable outcome that can be used as a benchmark of surgical care. Audits of this after operations for cancer of the head and neck, if reported in national clinical audits, should take case mix into account.

Subjective perception of paraesthesia of the lower lip after bilateral sagittal split osteotomy at a district general hospital.

Our aim was to assess patients' perception of paraesthesia of the lower lip after bilateral sagittal split osteotomy (BSSO) at a district general hospital. Patients who had BSSO between August 2013 and August 2014 (n=46) were asked to score their perception of numbness between 0-10 (0=normal sensation. 10=complete loss of sensation/total numbness) one day postoperatively and then weekly for seven weeks, and at three months, 6 months, and one year. Data was collected on score sheets and by regular contact by telephone. Of the 46 operated on, 31 were female and 15 male. Data were available one year postoperatively for 43 patients. Ten of the 92 sides were reported as feeling normal on day 1 postoperatively, three-quarters as feeling normal at six months, and 79 at one year. On multivariate analysis there was no significant difference in postoperative sensation at one year between sides operated on by the registrar (left) and consultant (right) operated (p=0.76). Our results compared favourably with the limited data available in similarly designed studies.

Validating a benchmarking tool for audit of early outcomes after operations for head and neck cancer.

INTRODUCTION In 2013 all UK surgical specialties, with the exception of head and neck surgery, published outcome data adjusted for case mix for indicator operations. This paper reports a pilot study to validate a previously published risk adjustment score on patients from separate UK cancer centres. METHODS A case note audit was performed of 1,075 patients undergoing 1,218 operations for head and neck squamous cell carcinoma under general anaesthesia in 4 surgical centres. A logistic regression equation predicting for all complications, previously validated internally at sites A-C, was tested on a fourth external validation sample (site D, 172 operations) using receiver operating characteristic curves, Hosmer-Lemeshow goodness of fit analysis and Brier scores. RESULTS Thirty-day complication rates varied widely (34-51%) between the centres. The predictive score allowed imperfect risk adjustment (area under the curve: 0.70), with Hosmer-Lemeshow analysis suggesting good calibration. The Brier score changed from 0.19 for sites A-C to 0.23 when site D was also included, suggesting poor accuracy overall. CONCLUSIONS Marked differences in operative risk and patient case mix captured by the risk adjustment score do not explain all the differences in observed outcomes. Further investigation with different methods is recommended to improve modelling of risk. Morbidity is common, and usually has a major impact on patient recovery, ward occupancy, hospital finances and patient perception of quality of care. We hope comparative audit will highlight good performance and challenge underperformance where it exists.

Sudden cardiac death in postmyocardial-infarction patients.

Patients who survive a myocardial infarction are at increased risk for sudden death, owing largely to ventricular arrhythmia. In this article, we will review the epidemiology of sudden cardiac death in postmyocardial-infarction patients, arrhythmia mechanisms and substrate leading to cardiac arrest, identifying possible risk factors for sudden cardiac death (SCD) in high risk population and apply risk stratification strategies for prevention of SCD. We will also review relevant major trials and evidence-based therapy currently used, in addition to the indications and role of implantable cardioverter-defibrillators in this population. We will end this review with a summary of the current guidelines recommendations and a look into the future of this domain.

Diagnostic investigation of parotid neoplasms: a 16-year experience of freehand fine needle aspiration cytology and ultrasound-guided core needle biopsy.

This study aimed to examine the diagnostic yield of fine needle aspiration cytology (FNAC) and ultrasound-guided core needle biopsy (USCB) in the diagnosis of parotid neoplasia. A 16-year retrospective analysis was performed of patients entered into our pathology database with a final diagnosis of parotid neoplasia. FNAC and USCB data were compared to surgical excision where available. One hundred and twenty FNAC, 313 USCB, and 259 surgical specimens were analyzed from 397 patients. Fifty-six percent of FNAC and 4% of USCB were non-diagnostic. One hundred and thirty-two (33%) patients had a final diagnosis made by USCB and did not undergo surgery. Surgery was performed in 257 (65%) patients, 226 (88%) of whom had a preoperative biopsy. Most lesions were benign, but there were 62 parotid and 13 haematological malignancies diagnosed; false-negative results were obtained in three FNAC and two USCB samples. The sensitivity and specificity of FNAC were 70% and 89%, respectively, and for USCB were 93% and 100%, respectively. This study represents the largest series of patients with a parotid neoplasm undergoing USCB for diagnosis. USCB is highly accurate with a low non-diagnostic rate and should be considered an integral part of parotid assessment.

Identification of appropriate outcome indices in head and neck cancer and factors influencing them.

Audit of early postoperative outcomes adjusted for patient case mix is still in its infancy in head and neck surgery. Nevertheless the role for audit of early postoperative outcomes is obvious. The primary outcome measure of this study was to identify factors that are associated with early mortality or morbidity after surgery for head and neck squamous cell carcinoma (HNSCC). The secondary outcome measure was to develop a pilot score that allows for risk-adjustment of outcome data to facilitate departmental audit. In this series the mortality rate was low (2.8%), in keeping with other published series. Complications, including those causing death, occurred after 38.1% of operations. Independent risk factors for mortality on logistic regression were shown to be previous HNSCC (P=0.03), estimated blood loss (l) (P=0.03), and extracapsular spread (P=0.05). Age (P=0.01), tracheostomy (P<0.01), estimated blood loss (l) (P=0.05), and duration of anaesthesia (P<0.01) were independent predictors of complications. Models predicting for risk demonstrated good discrimination (area under the curve statistics) for mortality (0.86) and morbidity (0.81). These pilot scores need external validation and may herald a means of facilitating risk-adjustment in the audit of early outcomes, allowing meaningful comparison of surgeons and their units over time.

Pulmonary lymphangitic carcinomatosis from head and neck squamous cell carcinoma.

Pulmonary lymphangitic carcinomatosis (PLC) secondary to mucosal head and neck squamous cell carcinoma (HNSCC) is extremely rare, difficult to diagnose in the pre-symptomatic phase, and is rapidly fatal. We describe two cases of fatal PLC secondary to squamous cell carcinoma in whom a review of pre-treatment imaging (computed tomography of the chest) changes reported as unspecific were retrospectively felt to be consistent with pre-symptomatic PLC. Case 1, a 73-year-old male with T2N2bMx poorly differentiated squamous cell carcinoma of the right tonsil, died 6 weeks after chemoradiotherapy with curative intent. Case 2, a 65-year-old female with T4aN2bMx of the right body of the mandible, died within 6 weeks of radical surgery including free tissue transfer. A review of the literature showed that PLC secondary to HNSCC occurs in an older cohort of patients: mean age 69 years vs. other tumour groups 50 years. PLC secondary to HNSCC can behave in distinctly different ways, demonstrating similarity to either gastric adenocarcinoma or bronchogenic squamous cell carcinomas.

Maternal hypothyroidism decreases progesterone receptor expression in the cortical subplate of foetal rat brain.

Steroid hormones exert profound effects on the development of brain areas controlling complex cognitive function in adulthood. One class, progestins, may contribute by acting on the progestin receptor (PR), which is transiently expressed in a critical layer of developing cortex: the subplate. PR expression in the subplate coincides with the establishment of ongoing cortical connectivity and may play an important organisational role. Identification of the factor(s) that regulate the precise timing of PR expression within subplate may help elucidate the function of PR. Thyroid hormone may interact with hormone response elements within the PR gene. The present study examined the effects of maternal hypothyroidism on levels of PR immunoreactivity (PR-IR) within the foetal subplate. Pregnant rats were made hypothyroid by the administration of methimazole and potassium perchlorate in drinking water. Maternal hypothyroidism significantly decreased PR-IR within the foetal subplate. Using the incorporation of 5-bromo-2'-deoxyuridine (BrDU) during subplate cell neurogenesis (embryonic day 13.5) to determine subplate cell survival in hypothyroid animals, we found that decreases in PR-IR cannot be attributed to significant subplate cell loss but are more likely the result of altered PR expression. Gestational thyroxine replacement to hypothyroid dams prevented the decrease in PR-IR within the subplate. These results identify thyroid hormone as a potential factor in the regulation of PR expression in the developing brain. These results are consistent with the idea that endocrine cross-talk between progesterone and thyroid hormone may be one mechanism by which maternal hypothyroidism alters normal cortical development.

With adequate supervision, the grade of the operating surgeon is not a determinant of outcome for patients undergoing urgent colorectal surgery.

INTRODUCTION: It is essential that higher surgical trainees (HSTs) obtain adequate emergency operative experience without compromising patient outcome. The aim of this study was to compare the outcomes of patients operated by HSTs with those operated by consultants and to look at the effect of consultant supervision. PATIENTS AND METHODS: A retrospective analysis of 362 patients who underwent urgent colorectal surgery was performed. The primary outcome was 30-day mortality. Secondary outcomes were intra-operative and postoperative surgery, specific and systemic complications, and delayed complications. RESULTS: Comparison of the patients operated by a consultant (n = 190) and a HST (n = 172) as the primary surgeon revealed no significant difference between the two groups for age, gender, ASA status or indication for surgery. There was a difference in the type of procedure performed (left-sided resections: consultants 122/190, HST 91/172; P = 0.050). There was no difference between the two groups for the primary and secondary outcomes. However, HSTs operating unsupervised performed significantly fewer primary anastomoses for left-sided resections (P = 0.019) and had more surgery specific complications (P = 0.028) than those supervised by a consultant. CONCLUSIONS: HSTs can perform emergency colorectal surgery with similar outcomes to their consultants, but adequate consultant supervision is vital to achieving these results.

CT-angiography for the detection of a lower gastrointestinal bleeding source.

The evaluation of lower gastrointestinal bleeding (LGIB) often involves the collaborative efforts of the gastroenterologist, radiologist, and surgeon. Efforts to localize the acute LGIB have traditionally involved colonoscopy, technetium-labeled red blood cell (RBC) scintigraphy, angiography, or a combination of these modalities. The sensitivity of each method of diagnosis is limited, with the most common cause of a negative study the spontaneous cessation of hemorrhage. Other technical factors include vasospasm, lack of adequate contrast volume or exposure time, a venous bleeding source, and a large surface bleeding area. We report the use of multidetector computed tomography (MDCT), or CT-angiography (CT-A), in the initial evaluation of LGIB, and speculate on the incorporation of this technique into a diagnostic algorithm to treat LGIB. MDCT may offer a very sensitive means to evaluate the source of acute LGIB, while avoiding some of the morbidity and intense resource use of contrast angiography, and may provide unique morphologic information regarding the type of pathology. Screening with the more rapid and available MDCT, followed by either directed therapeutic angiography or surgical management, may represent a reasonable algorithm for the early evaluation and management of acute LGIB in which an active bleeding source is strongly suspected.

Superior vena caval syndrome: color flow Doppler detection of collateral venous channels.

Thrombosis of the superior vena cava (SVC) is an important clinical problem that requires prompt diagnosis. Confirmation of suspected SVC syndrome requires the use of an imaging study to document the obstruction and presence of collateral venous channels. Echocardiography is often used to evaluate suspected SVC obstruction; however, previous methods have allowed only indirect detection of collateral flow. We describe 3 patients with SVC obstruction in whom color flow Doppler allowed direct demonstration of collateral venous channels.