The effect of consultant outcome publication on surgeon behaviour: a systematic review and narrative synthesis.

Introduction Surgeon-specific outcome data, or consultant outcome publication, refers to public access to named surgeon procedural outcomes. Consultant outcome publication originates from cardiothoracic surgery, having been introduced to US and UK surgery in 1991 and 2005, respectively. It has been associated with an improvement in patient outcomes. However, there is concern that it may also have led to changes in surgeon behaviour. This review assesses the literature for evidence of risk-averse behaviour, upgrading of patient risk factors and cessation of low-volume or poorly performing surgeons. Materials and methods A systematic literature review of Embase and Medline databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Original studies including data on consultant outcome publication and its potential effect on surgeon behaviour were included. Results Twenty-five studies were identified from the literature search. Studies suggesting the presence of risk-averse behaviour and upgrading of risk factors tended to be survey based, with studies contrary to these findings using recognised regional and national databases. Discussion and conclusion Our review includes instances of consultant outcome publication leading to risk-averse behaviour, upgrading of risk factors and cessation of low-volume or poorly performing surgeons. As UK data on consultant outcome publication matures, further research is essential to ensure that high-risk patients are not inappropriately turned down for surgery.

Efficacy of ß-mannanase on broiler growth performance and energy utilization in the presence of increasing dietary galactomannan.

An experiment was conducted to investigate the impact of ß-mannanase inclusion on growth performance, viscosity, and energy utilization in broilers fed diets varying in galactomannan (GM) concentrations. Treatments were arranged as a 3 (GM concentration) × 3 (ß-mannanase inclusion) factorial randomized complete block design with 12 replicates of 29 male broilers per replicate for a 42-d experiment. Efforts were made to reduce the amount of soybean meal, and thus GM, in the basal diet with guar gum included at 0, 0.21, or 0.42% to achieve a GM supplementation of 1,500 and 3,000 ppm, respectively. Beta-mannanase was included at 0, 200, or 400 g/ton. Broilers were fed a starter (d 0 to 14), grower (d 15 to 28), and finisher diets (d 29 to 42). Growth performance was monitored and ileal contents collected on d 14, 28, and 42 to determine ileal digestible energy (IDE) and intestinal viscosity. Increasing levels of GM negatively (P < 0.05) influenced body weight (BW) following the starter and grower periods and increased (P < 0.01) mortality corrected feed conversion ratio (FCR) throughout the study. Reduced growth performance was associated with increased (P < 0.05) intestinal viscosity and decreased (P < 0.05) IDE when GM inclusion was increased. Inclusion of ß-mannanase in diets containing supplemental GM on d 28, increased average BW to levels similar to diets without supplemental GM. Improvements in FCR were also observed with ß-mannanase inclusion in diets containing supplemental GM. Ileal digestible energy was increased (P < 0.05) with the addition of ß-mannanase on d 28 of age. Multiple interactions in growth performance, intestinal viscosity, and IDE were associated with ß-mannanase administration. In conclusion, ß-mannanase improved IDE, reduced intestinal viscosity, and improved growth performance; however, the observed benefit was dependent upon dietary GM concentration.

Evaluation of increasing levels of a microbial phytase in phosphorus deficient broiler diets via live broiler performance, tibia bone ash, apparent metabolizable energy, and amino acid digestibility.

The objective was to investigate increasing concentrations of an evolved microbial phytase on male broiler performance, tibia bone ash, AME, and amino acid digestibility when fed diets deficient in available phosphorus (aP). Experiment 1 evaluated the effects of phytase during a 21 d battery cage study and Experiment 2 was a 42 d grow-out. Experiment 1 included six treatments; negative control (NC) with an aP level of 0.23% (starter) and 0.19% (grower), two positive controls (PC) consisting of an additional 0.12% and 0.22% aP (PC 1 and PC 2), and the NC supplemented with three levels of phytase (250, 500, and 2,000 U/kg). The NC diet reduced (P < 0.05) FC, BW, and bone ash. Phytase increased (P < 0.05) BW with 2,000 U/kg phytase yielding similar results to the PC2, and improved FCR and increased bone ash was observed at all phytase levels. Amino acid digestibility coefficients were increased (P < 0.05) with phytase at 250 U/kg. Phytase at all rates increased (P < 0.05) AME to levels similar level as PC diets. Linear regression analysis indicated average P equivalency values for BW and bone ash of 0.137, 0.147, and 0.226 for phytase inclusion of 250, 500, and 2000 U/kg, respectively. Experiment 2 included a PC consisting of 0.45%, 0.41%, and 0.38% aP for the starter, grower, and finisher, respectively; NC with reduced aP of 0.17%; and phytase at 500 and 2,000 U/kg. Phytase increased BW (P < 0.05) compared to the NC as 2,000 U/kg phytase resulted in further BW increases compared to the PC (starter and grower). Phytase improved FCR to levels comparable to the PC, with supplementation at 2,000 U/kg resulting in improvements beyond the PC in the starter phase. Amino acid digestibility coefficients were increased with phytase at 2,000 U/kg to levels comparable to that of the PC. These data confirm that the inclusion of phytase improves broiler performance and bone mineralization in aP reduced diets and levels beyond the traditional 500 U/kg can result in further improvements.

MDCT of retractor-related hepatic injury following laparoscopic surgery: appearances, incidence, and follow-up.

AIMS: To investigate the postoperative computed tomography (CT) features resulting from the use of Nathanson retractors during laparoscopic upper gastro-intestinal surgery. MATERIALS AND METHODS: A 3-year retrospective study of 176 patients who had undergone laparoscopic upper gastro-intestinal surgery for bariatric or malignant disease was performed. Postoperative CT images [divided into early (≤ 30 days) and late (>30 days)] were assessed by a consultant radiologist and liver abnormalities recorded. RESULTS: The features of a retractor injury were a hypodense lesion, abutting the liver edge, usually triangular or linear in shape. Late postoperative features included focal subcapsular retraction and associated liver atrophy. Sixty-eight percent (52/77) of patients undergoing surgery for malignancy underwent postoperative CT, compared with 11% (11/99) of those undergoing bariatric surgery. Patients with malignancy were more likely to have retraction-related liver abnormalities (14/52, 27%) at postoperative CT than those in the bariatric group (2/11, 18%). CONCLUSION: Retractor-related liver injuries at MDCT are common following laparoscopic upper gastro-intestinal surgery. Recognition of the characteristic triad of features, a hypodense lesion abutting the liver edge with a triangular or linear shape, should allow confident diagnosis. CT follow-up reveals that over time these lesions may disappear, remain unchanged, or result in a focal subcapsular scar with associated atrophy.

Practical applications of digital tomosynthesis of the chest.

Digital tomosynthesis is a radiographic technique that generates a number of coronal raw images of a patient from a single pass of the x-ray tube. Tomosynthesis provides some of the tomographic benefits of computed tomography (CT), but at a much lower dose of radiation and cost when compared to CT. This review illustrates the range of practical applications of digital tomosynthesis of the chest.

Pancreatic splenosis demonstrated by contrast-enhanced sonography.

Pancreatic splenosis is a very rare condition whose features on contrast-enhanced ultrasound (CEUS) have not, to our knowledge, been previously reported. We present the imaging findings in a case of pancreatic splenosis, in which a confident diagnosis was achieved with the use of CEUS and confirmed by a labeled heat denatured red cell scan. Accumulation of ultrasound contrast microbubbles in splenic tissue can be readily visualized on late-phase CEUS and this technique has already been used to confirm the nature of intrapancreatic accessory spleens. This case shows that it can also confirm the diagnosis of splenosis.

Littoral cell angioma in a splenunculus: a case report.

Littoral cell angioma (LCA) is a rare primary splenic vascular tumour that arises from the littoral cells that line the red pulp sinuses. It is usually asymptomatic and is discovered incidentally on imaging for other pathologies. Radiologists should be aware of these lesions as they may be mistaken for malignant lesions and lead to unnecessary surgery. We present a case of LCA recurrence within a splenunculus that was discovered incidentally in a 60-year-old patient being investigated for right upper quadrant pain.

Sand aspiration: a case report and review of the radiological features and management.

We report a case of severe sand aspiration in association with near-drowning, which led to respiratory failure secondary to the acute respiratory distress syndrome, necessitating mechanical ventilation, repeated therapeutic bronchoscopic lavage, and a stay in the intensive care unit that exceeded one month.

Imaging the pericardium: appearances on ECG-gated 64-detector row cardiac computed tomography.

Multidetector row computed tomography (MDCT) with its high spatial and temporal resolution has now become an established and complementary method for cardiac imaging. It can now be used reliably to exclude significant coronary artery disease and delineate complex coronary artery anomalies, and has become a valuable problem-solving tool. Our experience with MDCT imaging suggests that it is clinically useful for imaging the pericardium. It is important to be aware of the normal anatomy of the pericardium and not mistake normal variations for pathology. The pericardial recesses are visible in up to 44% of non-electrocardiogram (ECG)-gated MDCT images. Abnormalities of the pericardium can now be identified with increasing certainty on 64-detector row CT; they may be the key to diagnosis and therefore must not be overlooked. This educational review of the pericardium will cover different imaging techniques, with a significant emphasis on MDCT. We have a large research and clinical experience of ECG-gated cardiac CT and will demonstrate examples of pericardial recesses, their variations and a wide variety of pericardial abnormalities and systemic conditions affecting the pericardium. We give a brief relevant background of the conditions and reinforce the key imaging features. We aim to provide a pictorial demonstration of the wide variety of abnormalities of the pericardium and the pitfalls in the diagnosis of pericardial disease.

Pain management for unilateral orchidopexy in children: an effective regimen.

BACKGROUND: The reported high incidence of 30-60% postoperative pain after an elective day surgical orchidopexy is undesirable. We evaluated the efficacy of our analgesic regimen for unilateral orchidopexy in preschool children performed as a day surgical procedure. METHODS: Between January 2004 and December 2006, 247 children (mean age: 3.3 +/- 1.6 years) underwent a unilateral orchidopexy as a day surgical procedure. They were prospectively analyzed for postoperative pain during a period of 48 h by using the Visual Analogue Scale (VAS). After standardized general anesthesia, all children had a 0.25% levo-bupivacaine hydrochloride ilio-inguinal block and a rectal diclofenac sodium suppository. Orchidopexy was performed through transverse inguinal and scrotal incisions. The wounds were infiltrated with 0.25% levo-bupivacaine hydrochloride at the end of the operation. Postoperatively acetaminophen and ibuprofen were given orally at regular intervals for 48 h. RESULTS: On first assessment in the recovery room, 148 out of 247 (60%) patients were pain-free, and 99 of 247 (40%) patients had pain: VAS score ranged from 3 to 10. By 3 h, 27 (11%) had mild-to-moderate pain, with VAS scores between 3 and 7. All children were discharged home at 4 h with no pain. At home, 95% were pain-free at 10 h and 97% by 24 h, with a declining pain score. All children were pain-free at 32, 40, and 48 h. Pain scores were unrelated to the duration of surgery (r (s) = 0.54). CONCLUSION: Clinical effectiveness of our institution analgesic regime justifies the performance of unilateral orchidopexy as a day-case procedure.

Open pyeloplasty in children: experience with an improved stenting technique.

OBJECTIVE: To describe the use of an alternative and improved nephrostostent in open pyeloplasty procedures. MATERIALS AND METHODS: A series of 27 consecutive patients (between 4 months and 14 years of age) undergoing an open pyeloplasty procedure had their urinary system drained via a nephrostostent which passes from the ureteric anastomosis to the skin and which unlike other described nephrostostents does not cross the vesico-ureteric junction. All children received an ultrasound and MAG3 scan 3 months post-operatively and were followed up for 18-24 months. RESULTS: The use of this stent was associated with no serious complications. There was a decreased incidence of vesico-ureteric reflux, post-operative urinary tract infection and stent displacement compared to previously described methods of drainage. CONCLUSION: This method of open pyeloplasty drainage, which has not been described before, could be associated with fewer complications than existing stenting techniques.

A laboratory batch reactor test for assessing nonspeciated volatile organic compound biodegradation in activated sludge.

The relative rates of biodegradation and stripping and volatilization of nonspeciated volatile organic compounds (VOCs) in wastewater treated with aerobic activated-sludge processes can be quantified using a newly developed procedure. This method was adapted from the original aerated draft tube reactor test that was developed to measure biodegradation rate constants for specific volatile pollutants of interest. The original batch test has been modified to include solid-phase microextraction (SPME) fibers for sampling in the gas phase. The experimental procedure using SPME fibers does not require specific identification and quantitation of individual pollutants and can be used to evaluate wastewater with multiple VOCs. To illustrate use of this procedure, laboratory experiments were conducted using biomass and wastewater or effluent from three activated-sludge treatment systems. Each experiment consisted of two trials: a stripping-only trial without biomass and a stripping plus biodegradation trial using biomass from the activated-sludge unit of interest. Data from the two trials were used to quantify the rates of biodegradation by difference. The activated-sludge systems tested were a laboratory diffused-air reactor treating refinery wastewater, a full-scale surface aerated reactor treating a petrochemical wastewater, and a full-scale diffused-air reactor treating a variety of industrial effluents. The biodegradation rate constant data from each laboratory batch experiment were used in model calculations to quantify the fraction emitted (fe) and the fraction biodegraded (fbio) for each system. The fe values ranged from a maximum of 0.01 to a maximum of 0.32, whereas fbio values ranged from a minimum of 0.40 to a minimum 0.95. Two of these systems had been previously tested using a more complicated experimental approach, and the current results were in good agreement with previous results. These results indicate that biodegradation rate constant data from this laboratory method can be successfully used to predict the fate of VOCs in field-scale treatment units, and thus could potentially be used for demonstration of compliance with wastewater VOC emission regulations.