Epistemic Injustice in Incident Investigations: A Qualitative Study.

Serious incident investigations-often conducted by means of Root Cause Analysis methodologies-are increasingly seen as platforms to learn from multiple perspectives and experiences: professionals, patients and their families alike. Underlying this principle of inclusiveness is the idea that healthcare staff and service users hold unique and valuable knowledge that can inform learning, as well as the notion that learning is a social process that involves people actively reflecting on shared knowledge. Despite initiatives to facilitate inclusiveness, research shows that embracing and learning from diverse perspectives is difficult. Using the concept of 'epistemic injustice', pointing at practices of someone's knowledge being unjustly disqualified or devalued, we analyze the way incident investigations are organized and executed with the aim to understand why it is difficult to embrace and learn from the multiple perspectives voiced in incident investigations. We draw from 73 semi-structured interviews with healthcare leaders, managers, healthcare professionals, incident investigators and inspectors, document analyses and ethnographic observations. Our analysis identified several structures in the incident investigation process, that can promote or hinder an actor's epistemic contribution in the process of incident investigations. Rather than repeat calls to 'involve more' and 'listen better', we encourage policy makers to be mindful of and address the structures that can cause epistemic injustice. This can improve the outcome of incident investigations and can help to do justice to the lived experiences of the involved actors in the aftermath of a serious incident.

How incident reporting systems can stimulate social and participative learning: A mixed-methods study.

Incident reporting systems (IRSs) have been widely adopted in healthcare, calling for the investigation of serious incidents to understand what causes patient harm. In this article, we study how the Dutch IRS contributed to social and participative learning from incidents. We integrate quantitative and qualitative data in a mixed-methods design. Between 1 July 2013 and 31 March 2019, Dutch hospitals reported and investigated 4667 incidents. Healthcare inspectors scored all investigations to assess hospitals' learning process following incidents. We analysed if and on what aspects hospitals improved over time. Additionally, we draw from semi-structured interviews with incident investigators, quality managers, healthcare inspectors and healthcare professionals. Healthcare inspectors score incident investigation reports better over time, suggesting that hospitals conduct better investigations or have become adept at writing reports in line with inspectors' expectations. Our qualitative data suggests the IRS contributed to practices that support social and participative learning-the professionalisation of incident investigation teams, the increased involvement of patients and families in investigations-and practices that do not-not linking learning from the investigation teams to that of professionals, not consistently monitoring the recommendations that investigations identify. The IRS both hits and misses the mark. We learned that IRSs need to be responsive to the (developing) capabilities of healthcare providers to investigate and learn from incidents, if the IRS is to stimulate social and participative learning from incidents.

Disruptive life event or reflexive instrument? On the regulation of hospital mergers from a quality of care perspective.

PURPOSE: Despite the continuation of hospital mergers in many western countries, it is uncertain if and how hospital mergers impact the quality of care. This poses challenges for the regulation of mergers. The purpose of this paper is to understand: how regulators and hospitals frame the impact of merging on the quality and safety of care and how hospital mergers might be regulated, given their uncertain impact on quality and safety of care. DESIGN/METHODOLOGY/APPROACH: This paper studies the regulation of hospital mergers in The Netherlands. In a qualitative study design, it draws on 30 semi-structured interviews with inspectors from the Dutch Health and Youth Care Inspectorate (Inspectorate) and respondents from three hospitals that merged between 2013 and 2015. This paper draws from literature on process-based regulation to understand how regulators can monitor hospital mergers. FINDINGS: This paper finds that inspectors and hospital respondents frame the process of merging as potentially disruptive to daily care practices. While inspectors emphasise the dangers of merging, hospital respondents report how merging stimulated them to reflect on their care practices and how it afforded learning between hospitals. Although the Inspectorate considers mergers a risk to quality of care, their regulatory practices are hesitant. ORIGINALITY/VALUE: This qualitative study sheds light on how merging might affect key hospital processes and daily care practices. It offers opportunities for the regulation of hospital mergers that acknowledges rather than aims to dispel the uncertain and potentially ambiguous impact of mergers on quality and safety of care.

Regional Anesthesia for Pediatric Ophthalmic Surgery: A Review of the Literature.

Ophthalmic pediatric regional anesthesia has been widely described, but infrequently used. This review summarizes the available evidence supporting the use of conduction anesthesia in pediatric ophthalmic surgery. Key anatomic differences in axial length, intraocular pressure, and available orbital space between young children and adults impact conduct of ophthalmic regional anesthesia. The eye is near adult size at birth and completes its growth rapidly while the orbit does not. This results in significantly diminished extraocular orbital volumes for local anesthetic deposition. Needle-based blocks are categorized by relation of the needle to the extraocular muscle cone (ie, intraconal or extraconal) and in the cannula-based block, by description of the potential space deep to the Tenon capsule. In children, blocks are placed after induction of anesthesia by a pediatric anesthesiologist or ophthalmologist, via anatomic landmarks or under ultrasonography. Ocular conduction anesthesia confers several advantages for eye surgery including analgesia, akinesia, ablation of the oculocardiac reflex, and reduction of postoperative nausea and vomiting. Short (16 mm), blunt-tip needles are preferred because of altered globe-to-orbit ratios in children. Soft-tip cannulae of varying length have been demonstrated as safe in sub-Tenon blockade. Ultrasound technology facilitates direct, real-time visualization of needle position and local anesthetic spread and reduces inadvertent intraconal needle placement. The developing eye is vulnerable to thermal and mechanical insults, so ocular-rated transducers are mandated. The adjuvant hyaluronidase improves ocular akinesia, decreases local anesthetic dosage requirements, and improves initial block success; meanwhile, dexmedetomidine increases local anesthetic potency and prolongs duration of analgesia without an increase in adverse events. Intraconal blockade is a relative contraindication in neonates and infants, retinoblastoma surgery, and in the presence of posterior staphylomas and buphthalmos. Specific considerations include pertinent pediatric ophthalmologic topics, block placement in the syndromic child, and potential adverse effects associated with each technique. Recommendations based on our experience at a busy academic ophthalmologic tertiary referral center are provided.

Protocols and pitfalls in obtaining fatty acid-binding proteins for biophysical studies of ligand-protein and protein-protein interactions.

Adipocyte fatty acid-binding protein (AFABP: FABP4) is a member of the intracellular lipid-binding protein family that is thought to target long-chain fatty acids to nuclear receptors such as peroxisome proliferator-activated receptor gamma (PPARγ), which in turn plays roles in insulin resistance and obesity. A molecular understanding of AFABP function requires robust isolation of the protein in liganded and free forms as well as characterization of its oligomerization state(s) under physiological conditions. We report development of a protocol to optimize the production of members of this protein family in pure form, including removal of their bound lipids by mixing with hydrophobically functionalized hydroxypropyl dextran beads and validation by two-dimensional NMR spectroscopy. The formation of self-associated or covalently bonded protein dimers was evaluated critically using gel filtration chromatography, revealing conditions that promote or prevent formation of disulfide-linked homodimers. The resulting scheme provides a solid foundation for future investigations of AFABP interactions with key ligand and protein partners involved in lipid metabolism.

Otocephaly Complex: Case Report, Literature Review, and Ethical Considerations.

Otocephaly complex is a rare and usually lethal syndrome characterized by a set of malformations consisting of microstomia, mandibular hypoplasia/agnathia, and ventromedial malposition of the ears. Those cases that have been diagnosed prenatally have used an ex utero intrapartum treatment procedure to establish a definitive airway. However, prenatal diagnosis continues to be challenging, primarily because of poor diagnostic sensitivity associated with ultrasonography. We present a case of a newborn with an unanticipated otocephaly complex requiring emergent airway management. In this report, we discuss the medical and ethical issues related to the care of a newborn with this frequently fatal condition.

Survival Impact of Initial Therapy in Patients with T1-T2 Glottic Squamous Cell Carcinoma.

OBJECTIVE: Laryngeal cancer most commonly arises from the glottis. Comparable outcomes in survival have been shown in patients with early glottic squamous cell carcinoma treated with either surgery or radiotherapy. STUDY DESIGN AND SETTING: Administrative database study. SUBJECTS AND METHODS: The US National Cancer Institute's SEER database (Surveillance, Epidemiology, and End Results) was queried for cases of early glottic cancer (T1-T2N0M0, 1988-2012). We identified 13,312 qualifying cases. Patient demographics, therapeutic measures, and survival outcomes were examined with appropriate univariate and multivariate analyses. RESULTS: Early glottic cancer has a mean age at diagnosis of 64.8 ± 11.6 years and a male:female ratio of 6.9:1. The most common treatment modality was radiotherapy alone (51.6%), followed by combination therapy with surgery first (31.5%). Overall, the 5-year disease-specific survival (DSS) rate was 88.4%. When stratified by treatment modality and stage, 5-year DSS for T1 tumors was 93.2% with surgery alone and 89.0% with radiation alone (P < .0001). With combination therapy, the 5-year DSS was 91.3% for surgery first and 84.9% for radiation first (P = .0239). In T2 tumors, 5-year DSS was improved with single-modality therapy versus multimodality therapy (81.1% vs 76.4; P = .0255). CONCLUSION: In T1 disease, surgery alone shows improved 5-year DSS versus radiation alone, but this difference was not observed in T2 tumors. Additionally, surgery, rather than radiation, shows improved 5-year DSS when implemented as a first-line therapy. Combination therapy does not show improved 5-year DSS for early glottic cancer.

Emergent Airway Management of an Uncooperative Child with a Large Retropharyngeal and Posterior Mediastinal Abscess.

Retropharyngeal abscesses are deep neck space infections that can lead to life-threatening airway emergencies and other catastrophic complications. Retropharyngeal abscesses demand prompt diagnosis and early establishment of a definitive airway when there is airway compromise. This can be difficult in an uncooperative patient. We present the case of a 12-year-old girl with mediastinitis and tracheal compression and anterior displacement from a large retropharyngeal and posterior mediastinal abscess secondary to traumatic esophageal perforation, who received successful awake nasal fiberoptic intubation. Anesthesiologists must be prepared for airway emergencies in uncooperative patients, especially children, but there is controversy concerning the use of sedation.

Incidence of Suicide in Patients With Head and Neck Cancer.

IMPORTANCE: Suicide rates among patients with cancer in the US are significantly higher than those of the general population. To our knowledge, large cohort studies examining suicide rates among patients with head and neck cancer have not been performed. OBJECTIVE: To identify incidence rate, trends, and risk factors of suicide in patients with cancer of the head and neck. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study of geographic areas served by the Surveillance, Epidemiology, and End Results (SEER) program. In total, 350,413 cases of patients with head and neck cancer were recorded within the SEER registry between 1973 and 2011. Data analyses were performed in 2014. Incidence data were calculated from the subset of that population that had the cause of death category coded as "suicide and self-inflicted injury." EXPOSURES: Patients diagnosed as having a primary cancer of the head and neck region. MAIN OUTCOMES AND MEASURES: Influence of demographic factors, anatomic site of tumor, disease stage, and time since diagnosis on risk for suicide. RESULTS: Among 350,413 SEER registry patients with head and neck cancer, observed for 2,263,376 person-years, 857 suicides were identified with an age-, sex-, and race-adjusted suicide rate of 37.9/100,000 person-years. In contrast, the US general population suicide rate was 11.8 per 100,000 person-years. Suicide rates were higher in those treated with radiation alone (standardized mortality ratio [SMR], 5.12; 95% CI, 3.83-6.41) compared with those treated with surgery alone (SMR, 2.57; 95% CI, 1.66-3.49). The highest suicide risk was seen in patients with cancers of the hypopharynx (SMR, 13.91; 95% CI, 11.78-16.03) and larynx (SMR, 5.48; 95% CI, 4.14-6.81). CONCLUSIONS AND RELEVANCE: Patients with head and neck cancer have more than 3 times the incidence of suicide compared with the general US population. Furthermore, suicide rates were highest among those with cancers of the larynx and hypopharynx.

Laryngeal Verrucous Carcinoma: A Population-Based Analysis.

OBJECTIVE: Verrucous carcinoma of the larynx (VCL) is a rare entity with reportedly favorable prognosis. Current analyses are limited primarily to case reports and case series, thus making a population-based analysis useful in characterizing frequency, incidence, and survival trends to guide clinical diagnosis and decision making. STUDY DESIGN: Analysis of the National Cancer Institute's SEER (Surveillance, Epidemiology, and End Results) database. METHODS: Cases of VCL diagnosed between 1973 and 2011 were searched in the SEER database. Analysis was carried out with respect to patient demographics, tumor characteristics, incidence, treatment modality, and survival. RESULTS: In sum, 516 patients with VCL were identified. Males composed 88.4% of cases. Whites accounted for 88.4% of cases, with 8.1% of cases occurring in black patients. Most cases (79.7%) arose in the glottis, a statistically significant predilection when compared with other laryngeal malignancies (P < .0001). Incidence of VCL decreased from 2000 to 2011, with an annual percent change of -5.4%. Overall 1-, 5-, and 10-year disease-specific survival for VCL was 97.5%, 88.0%, and 77.4%, while 1-, 5-, and 10-year relative survival was 98.1%, 85.5%, and 74.2%, respectively. Surgery seemed to confer better prognosis when compared with other treatment modalities. CONCLUSIONS: This large population-based analysis of VCL demonstrates that this entity has a good prognosis, arises in the glottis, and is decreasing in incidence. Five-year survival seems highest when surgery is utilized. However, this finding may be subject to selection bias in high-stage lesions.

Laryngeal spindle cell carcinoma: A population-based analysis of incidence and survival.

OBJECTIVES/HYPOTHESIS: Laryngeal spindle cell carcinoma (LSpCC) is a rare variant of squamous cell carcinoma. Surgery is the reported mainstay of treatment, but previous analyses failed to demonstrate survival outcomes by therapeutic modality. This study aims to carry out the largest population-based analysis of this histology to determine tumor characteristics, incidence, survival, and prognostic indicators. METHODS: The National Cancer Institute's Surveillance, Epidemiology, and End Results database was queried for cases of LSpCC diagnosed between 1973 and 2011. Data was analyzed for patient demographics, incidence, treatment, and survival. RESULTS: A total of 312 cases of LSpCC were identified. Males comprised 87.2% of the cases, representing a male-to-female ratio of nearly 7:1. Whites accounted for 83.7% of LSpCC cases, whereas blacks represented 13.1%. Most cases (72.1%) arose in the glottis. The incidence of LSpCC from 2000 to 2011 was 0.023 per 100,000, with an annual percent change of -0.115%. One-, 5-, and 10-year disease-specific survival (DSS) rates for LSpCC were 90.9%, 74.1%, and 57.9%; whereas 1-, 5-, and 10-year relative survival rates were 91.0%, 77.7%, and 64.5%, respectively. Tumors of the glottis had a 5-year DSS of 84.0% compared to 51.9% for nonglottic tumors (P < 0.0001). High-stage (III/IV) LpSCC had lower 5-year DSS than low-stage (I/II) (36.8% and 91.8%, respectively) (P < 0.0001). Surgery imparted favorable 5-year survival, whereas radiotherapy did not impact survival rates. CONCLUSIONS: Laryngeal spindle cell carcinoma most commonly affects males and has a strong predilection for the glottis. Survival is best for glottic LSpCC. Surgery imparts a favorable prognosis compared to radiotherapy. LEVEL OF EVIDENCE: 4.

Sinonasal extramedullary plasmacytoma: a population-based incidence and survival analysis.

BACKGROUND: Sinonasal extramedullary plasmacytoma (SN-EMP) is a rare plasma cell neoplasm. Published literature on this tumor largely consists of case reports and case-series with small sample sizes. This study analyzed population-based data on SN-EMP patients to understand demographic and clinical features as well as incidence and survival trends. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was queried for SN-EMP and other head and neck EMP (HN-EMP) cases from 1973 to 2011. Cases were analyzed to determine patient demographics, initial treatment modality, and survival outcomes. RESULTS: Of 778 patients identified with EMP in the head and neck region, 367 patients had SN-EMP and 411 had other HN-EMP. There was a strong male predilection found, with a male-to-female ratio of 3.65:1 in the SN-EMP group and 1.87:1 in the other HN-EMP group. The majority of the patients presented with localized disease in both SN-EMP (84.4%) and other HN-EMP (81.0%) groups. The most common treatment modality reported in this database was surgery with adjuvant radiotherapy in both SN-EMP (46.3%) and other HN-EMP (38.9%) groups, followed by radiotherapy alone (SN-EMP: 40.7%; other HN-EMP: 34.2%). Five-year and 10-year disease-specific survival rates were comparable between SN-EMP (88.2% and 83.3%, respectively) and other HN-EMP (90.0% and 87.4%, respectively) (p = 0.6016 and p = 0.4015, respectively). CONCLUSION: This study analyzed the largest cohort of SN-EMP patients to date. There was no statistically significant survival advantage found for any 1 particular treatment modality over other treatment modalities in both SN-EMP and other HN-EMP.

Laryngeal Papillary Squamous Cell Carcinoma: A Population-Based Analysis of Incidence and Survival.

OBJECTIVE: Papillary squamous cell carcinoma has emerged as a distinct entity from the more common keratinizing squamous cell carcinoma. The basis behind this distinction relates not only to its histologic variation but also to its overall prognosis and survival. The objective of this study was to demonstrate the incidence, demographics, and long-term survival of laryngeal papillary squamous cell carcinoma (LPSCC) and how it relates to other laryngeal malignancies using a population-based database. STUDY DESIGN: Analysis of a population-based tumor registry. METHODS: The United States National Cancer Institute's Surveillance, Epidemiology, and End Results registry was used to perform a retrospective analysis. Patients diagnosed with LPSCC from 1973 to 2011 were identified. Data endpoints extracted included patient demographics, incidence, and survival. RESULTS: Three-hundred seventy cases of LPSCC were identified, corresponding to 0.5% of all laryngeal tumors. There was a 3:1 male predilection, without a significant racial preference. Most tumors identified were localized (T1) and at stage 1. The 1-year, 5-year, and 10-year disease-specific survival (DSS) for LPSCC was 97.1%, 83.1%, and 73.9%, respectively, compared with 87.9%, 64.5%, and 50.5% for other laryngeal malignancies (P values <.0001). Surgery was associated with a higher overall DSS in both LPSCC (87.4% vs 78.8%) and other laryngeal malignancies (70% vs 59.4%) when compared with other treatment modalities. CONCLUSION: This analysis of the largest sample of LPSCC demonstrates a better prognosis for this pathology compared with other laryngeal malignancies.

The changing face of trauma management and its impact on surgical resident training.

BACKGROUND: The management of trauma patients has become increasingly nonoperative, especially for solid abdominal organ injuries. However, the Residency Review Committee (RRC) still requires an operative trauma experience deemed essential for graduating general surgical residents. The purpose of this study was to review the trauma volume and mix of patients at two trauma centers and determine the major operative trauma cases available to residents involved in the care of these patients. METHODS: A retrospective chart review was conducted at the two trauma centers used by the Michigan State University surgery residency. Both of the trauma centers are American College of Surgeons verified. Surgical residents are involved with the care of every trauma patient at each of the hospitals. Cumulative data were collected and analyzed from January 1, 1997, through December 31, 1999. Age, gender, mechanism of injury (blunt vs. penetrating), Injury Severity Score, length of stay, operative interventions, and patients managed nonoperatively were reviewed. RESULTS: There were 434 patients selected for this study from 2,340 patients admitted to the trauma services. Male patients accounted for 66% of patients and female patients accounted for 34% of patients. Blunt trauma was the mechanism in 89% of patients, with penetrating trauma accounting for the other 11% of patients. Of the total number of patients, motor vehicle crashes accounted for the majority of cases, 325 of 434 (75%). Overall, 85% (370 of 434) of patients were managed without an index trauma surgical procedure according to RRC guidelines. Only 14.7% (64 of 434) of patients underwent operative intervention that qualified as index trauma surgical cases identified by the RRC. The spleen and small bowel were the two most commonly injured organs found at laparotomy. Nonoperative intervention of many patients with solid abdominal organ injuries did not meet the operation requirements expected by the RRC. CONCLUSION: Our residency program had 10 graduating chief residents over the 3-year time period. With only 64 operative trauma cases, this yields an average of 6.4 trauma cases per resident. This falls significantly short of the 16-case minimum requirement in trauma surgery established by the RRC. The operative trauma requirements established by the RRC for graduating residents may be unattainable in many residency programs because of the high incidence of blunt trauma and the changing patterns of trauma management.