Measuring the quality of cancer care in the Barwon South Western region, Victoria, Australia.

OBJECTIVE: The implementation of clinical quality indicators for monitoring cancer care in regional, rural and remote areas. DESIGN: Retrospective data from a population-based Clinical Quality Registry for lung, colorectal and breast cancers. SETTING: All major health services in the Barwon South Western region, Victoria, Australia. PARTICIPANTS: All patients who were diagnosed with cancer and who presented to a health service. INTERVENTION(S): Clinical subgroups to review variations. MAIN OUTCOME MEASURES(S): Clinical quality indicators for lung, colorectal and breast cancers. RESULTS: Clinical indicators included the following: discussion at multidisciplinary meetings, the timeliness of care provided and the type of care for different stages of the disease and survival outcomes. Many of the derived clinical indicator targets were reached. However, variations led to an improvement in the tumour stage being recorded in the medical record; an improved awareness of the need for adjuvant chemotherapy for colorectal cancer; a reduction in time to treatment for lung cancer and a reduced time to surgery for breast cancer, and the 30-day mortality post-treatment for all of the tumour streams was highlighted. CONCLUSIONS: Clinical quality indicators allow for valuable insights into patterns of care. These indicators are easily reproduced and may be of use to other cancer centres and health services.

A trial of nebulised heparin to limit lung injury following cardiac surgery.

Cardiac surgery with cardiopulmonary bypass triggers an acute inflammatory response in the lungs. This response gives rise to fibrin deposition in the microvasculature and alveoli of the lungs. Fibrin deposition in the microvasculature increases alveolar dead space, while fibrin deposition in alveoli causes shunting. We investigated whether prophylactic nebulised heparin could limit this form of lung injury. We undertook a single-centre double-blind randomised trial. Forty patients undergoing elective cardiac surgery with cardiopulmonary bypass were randomised to prophylactic nebulised heparin (50,000 U) or placebo. The primary endpoint was the change in arterial oxygen levels over the operative period. Secondary endpoints included end-tidal CO2, the alveolar dead space fraction and bleeding complications. We found nebulised heparin did not improve arterial oxygen levels. Nebulised heparin was, however, associated with a lower alveolar dead space fraction (P <0.05) and lower tidal volumes at the end of surgery (P <0.01). Nebulised heparin was not associated with bleeding complications. In conclusion, prophylactic nebulised heparin did not improve oxygenation, but was associated with evidence of better alveolar perfusion and CO2elimination at the end of surgery.

Acute copper toxicity following copper glycinate injection.

We present a patient who developed multi-organ failure due to severe copper toxicity following attempted suicide by s.c. injection of copper glycinate. Acute copper toxicity is rare in the developed world, although it occurs more frequently in developing world countries, where it is a common mode of suicide. Acute toxicity usually results from oral ingestion and there are several local and systemic effects. Specific management can be difficult as there is little evidence regarding the efficacy of chelating agents in acute toxicity.

Palliation of advanced gastric cancer by laparoscopic gastrojejunostomy.

Palliation of unresectable gastric carcinoma by conventional gastrojejunostomy is associated with significant morbidity and mortality. Laparoscopic gastrojejunostomy may be an alternative as it can achieve the same results with less morbidity. This is a case report of a 68-year-old man with an obstructed, unresectable gastric carcinoma that has metastasized to the lungs and liver. Attempt at laser boring was unsuccessful. Laparoscopic assessment revealed an immobile tumour fixed to the pancreas. A totally intraabdominal laparoscopic gastrojejunostomy was fashioned with endoGIAs (USSC Norwalk, CT). Operation time was 85 minutes. He was able to tolerate feeds on the 3rd postoperative day (POD), diet on the 5th POD and was discharged on the 8th POD. Satisfactory palliation at home was achieved for ten weeks before death. Laparoscopic gastrojejunostomy is thus a good option for palliation of obstructed advanced gastric cancer.

Pulmonary lymphoma or pseudolymphoma: a diagnostic dilemma.

The clinical significance of pulmonary pseudolymphoma remains unresolved. We report a case which highlights the lymphoma versus pseudolymphoma dilemma. An elderly lady followed up for more than ten years with a slowly enlarging right lung mass had on biopsy, lymphoid hyperplasia consistent with a lymphoma or pseudolymphoma. Laboratory investigations revealed hyperglobulinemia due to a biclonal gammopathy with elevated serum immunoglobulin M and G fractions. Monoclonal production of immunoglobulin is today considered more indicative of a neoplasia than a hyperplasia.