Increased Elastase and Matrix Metalloproteinase Levels in the Pulmonary Arteries of Infants With Congenital Diaphragmatic Hernia.

BACKGROUND: Pulmonary vascular disease (PVD) complicated with pulmonary hypertension (PH) is a leading cause of mortality in congenital diaphragmatic hernia (CDH). Unfortunately, CDH patients are often resistant to PH therapy. Using the nitrogen CDH rat model, we previously demonstrated that CDH-associated PVD involves an induction of elastase and matrix metalloproteinase (MMP) activities, increased osteopontin and epidermal growth factor (EGF) levels, and enhanced smooth muscle cell (SMC) proliferation. Here, we aimed to determine whether the levels of the key members of this proteinase-induced pathway are also elevated in the pulmonary arteries (PAs) of CDH patients. METHODS: Neutrophil elastase (NE), matrix metalloproteinase-2 (MMP-2), epidermal growth factor (EGF), tenascin-C, and osteopontin levels were assessed by immunohistochemistry in the PAs from the lungs of 11 CDH patients and 5 normal age-matched controls. Markers of proliferation (proliferating cell nuclear antigen (PCNA)) and apoptosis (cleaved (active) caspase-3) were also used. RESULTS: While expressed by both control and CDH lungs, the levels of NE, MMP-2, EGF, as well as tenascin-C and osteopontin were significantly increased in the PAs from CDH patients. The percentage of PCNA-positive PA SMCs were also enhanced, while those positive for caspase-3 were slightly decreased. CONCLUSIONS: These results suggest that increased elastase and MMPs, together with elevated tenascin-C and osteopontin levels in an EGF-rich environment may contribute to the PVD in CDH infants. The next step of this study is to expand our analysis to a larger cohort, and determine the potential of targeting this pathway for the treatment of CDH-associated PVD and PH. TYPE OF STUDY: Therapeutic. LEVEL OF EVIDENCE: LEVEL III.

Anterograde venous bullet embolism from the left facial vein to the right ventricle.

A young man presented to the emergency department reporting he had been recently shot in the face and chest with an unknown weapon. Initial physical examination only found bruising by the left hemimandible, but CT angiography of the thorax revealed a BB in the right ventricle. A subsequent CT angiography of the head and neck showed no major arterial injury but noted stranding and irregularity of the left facial vein directly deep to the injury site. The findings favoured anterograde venous bullet embolism from the left facial vein to the right ventricle. To our knowledge, this is the first report of a relatively small diameter and superficial vein of the face resulting in this phenomenon.

Impact of distance on postoperative follow-up in patients of pediatric surgery: a retrospective review.

Objective: Centralization of medical services in Canada has resulted in patients travelling long distances for healthcare, which may compromise their health. We hypothesized that children living farther from a children's hospital were offered and attended fewer follow-up appointments. Methods: We reviewed children less than 17 years of age referred to the general surgery clinic at a tertiary children's hospital during a 2-year period who underwent surgery. Descriptive statistics were performed. Results: We identified 723 patients. The majority were male (61%) with a median age of 7 years (range 18 days to16 years) and were from the major urban center (MUC) (56.3%). The median distance travelled to hospital for MUC patients was 8.9 km (range 0.9-22 km) vs 119.5 km (range 20.3-1950 km) for non-MUC patients. MUC children were offered more follow-up appointments (72.7% vs 60.8%, p<0.05). No significant differences existed in follow-up attendance rates (MUC 88.5% vs non-MUC 89.1%, p=0.84) or postoperative complications (9.8% vs 9.2%, p=0.78). There were no deaths. Conclusions: Patients living farther from a hospital were offered fewer follow-up appointments, but attended an equivalent rate of follow-ups when offered one. Telemedicine and remote follow-up are underused approaches that can permit follow-up appointments while reducing associated travel time and expenses.

Improving quality through process change: a scoping review of process improvement tools in cancer surgery.

BACKGROUND: Surgery is a cornerstone of treatment for malignancy. However, significant variation has been reported in patterns and quality of cancer care for important health outcomes, including perioperative mortality. Surgical process improvement tools (SPITs) have been developed that focus on enhancing the processes of care at the point of care, as a means of quality improvement. This study describes SPITs and develops a conceptual framework by synthesizing the available literature on these novel quality improvement tools. METHODS: A scoping review was conducted based on instruments developed for quality improvement in surgery. The search was executed on electronically indexed sources (MEDLINE, EMBASE, and the Cochrane library) from January 1990 to March 2011. Data were extracted, tabulated and reported thematically using a narrative synthesis approach. These results were used to develop a conceptual framework that describes and classifies SPITs. RESULTS: 232 articles were reviewed for data extraction and analysis. SPITs identified were classified into 3 groups: clinical mapping tools, structure communication tools and error reduction instruments. The dominant instrument reported were clinical mapping tools, including: clinical pathways (113, 48%), fast track (46, 20%) and enhanced recovery after surgery protocols (36, 15%). Outcomes reported included: length of stay (174, 75%), readmission rates (116, 50%), morbidity (116, 50%), mortality (104, 45%), and economic (60, 26%). Many gaps in the literature were recognized. CONCLUSION: We have developed a conceptual framework of SPITs and identified gaps in current knowledge. These results will guide the design and development of new quality instruments in surgery.

Quality of narrative operative reports in pancreatic surgery.

BACKGROUND: Quality in health care can be evaluated using quality indicators (QIs). Elements contained in the surgical operative report are potential sources for QI data, but little is known about the completeness of the narrative operative report (NR). We evaluated the completeness of the NR for patients undergoing a pancreaticoduodenectomy. METHODS: We reviewed NRs for patients undergoing a pancreaticoduodenectomy over a 1-year period. We extracted 79 variables related to patient and narrator characteristics, process of care measures, surgical technique and oncology-related outcomes by document analysis. Data were coded and evaluated for completeness. RESULTS: We analyzed 74 NRs. The median number of variables reported was 43.5 (range 13-54). Variables related to surgical technique were most complete. Process of care and oncology-related variables were often omitted. Completeness of the NR was associated with longer operative duration. CONCLUSION: The NRs were often incomplete and of poor quality. Important elements, including process of care and oncology-related data, were frequently missing. Thus, the NR is an inadequate data source for QI. Development and use of alternative reporting methods, including standardized synoptic operative reports, should be encouraged to improve documentation of care and serve as a measure of quality of surgical care.

CONTEXTE: Il est possible d'évaluer la qualité des soins de santé au moyen d'indicateurs de qualité (IQ). Les éléments contenus dans les notes opératoires (NO) sont une source potentielle de renseignements pouvant servir d'IQ, mais on en sait peu sur leur exhaustivité. Nous avons voulu évaluer l'exhaustivité des NO dans les dossiers de patients soumis à une pancréatoduodénectomie. MÉTHODES: Nous avons passé en revue les NO dans les dossiers de patients soumisà une pancréatoduodénectomie sur une période d'un an. Par analyse des documents, nous avons extrait 79 variables liées aux caractéristiques des patients et aux rédacteurs des NO, aux mesures des protocoles opératoires, à la technique chirurgicale et aux résultats oncologiques. Nous avons encodé et évalué ces données en fonction de leur exhaustivité. RÉSULTATS: Nous avons analysé les NO pour 74 interventions. Le nombre médian de variables relevées était de 43,5 (entre 13 et 54). Les variables liées au protocole de soins et les variables oncologiques étaient souvent omises. L'exhaustivité des NO était proportionnelle à la durée de l'intervention. CONCLUSION: Les NO sont souvent incomplètes et leur qualité laisse à désirer. Des éléments importants, dont le protocole opératoire et les données oncologiques, étaient souvent manquants. Ainsi, les NO constituent une source inadéquate de données en ce qui concerne les IQ. Il faudra encourager la mise au point et l'utilisation d'autres types de rapports, dont des synopsis opératoires standardisés, pour mieux documenter les soins chirurgicaux prodigués et pour en évaluer la qualité.