Combining failure modes and effects analysis and cause-effect analysis: a novel method of risk analysis to reduce anaphylaxis due to contrast media.

BACKGROUND: Contrast media agents are essential for computed tomography (CT)-based diagnoses. However, they can cause fatal adverse effects such as anaphylaxis in patients. Although it is rare, the chances of anaphylaxis increase with the number of examinations. OBJECTIVE: We aimed to design a quality improvement initiative to reduce patient risk to contrast media agents. METHODS: We analysed CT processes using contrast iodine in a tertiary-care academic hospital that performs approximately 14 000 CT scans per year in Japan. We applied a combination of failure modes and effects analysis (FMEA) and cause-effect analysis to reduce the risk of patients developing allergic reactions to iodine-based contrast agents during CT imaging. RESULTS: Our multidisciplinary team comprising seven professionals analysed the data and designed a 56-process flowchart of CT imaging with iodine. We obtained 177 failure modes, of which 15 had a risk-probability number higher than 100. We identified the two riskiest processes and developed cause-and-effect diagrams for both: one was related to the exchange of information between the radiation and hospital information system regarding the patient's allergy, the other was due to education and structural deficiencies in observation following the exam. CONCLUSION: The combined method of FMEA and cause-and-effect analysis reveals high-risk processes and suggests measures to reduce these risks. FMEA is not well-known in healthcare but has significant potential for improving patient safety. Our findings emphasise the importance of adopting new techniques to reduce patient risk and carry out best practices in radiology.

Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety.

OBJECTIVE: This study aimed to determine if introducing nontechnical skills to surgical trainees during surgical education can reduce the operation time and contribute to patient safety. DESIGN: Quality improvement initiatives using the KAIZEN as a problem-solving method. SETTING: Department of surgery in a referral and educational hospital. PARTICIPANTS: Surgical team and quality management team. INTERVENTION: The KAIZEN was used as a problem-solving method between 2015 and 2018 to reduce the operation time. First, baseline measurement was performed to understand the current situations in our department. To achieve continuous improvement, periodical feedback of the current status was obtained from all staff. Bundles, including nontechnical skills, were established. Briefing and debriefing were performed by the surgical team. MAIN OUTCOME MEASURES: Excessively long operation rates with a standard procedure. RESULTS: We included 1573 operations in this initiative. Excessively long operation rates were reduced in all types of surgeries, from 27.1% to 15.2% for herniorrhaphy (P = 0.005), 58.3-40.0% for gastrectomy (P = 0.03), 50.0-4.1% for total gastrectomy (P = 0.12), 65.6-45.0% for colectomy (P = 0.004), 67.8-43.2% for high anterior resection (P = 0.02) and 69.6-47.9% for low anterior resection (P = 0.03). The adherence to briefing and debriefing were improved, and majority of the surgeons favored the bundle elements. CONCLUSIONS: The KAIZEN initiative was effective in clinical healthcare settings. In the event of scaling-up this initiative, the educational program for physicians should include project management strategies and leadership skills.

[CHANGES IN MAC ANTIBODY LEVELS BEFORE AND AFTER SURGERY AND AT THE TIME OF RELAPSE/RECURRENCE IN MAC LUNG DISEASE--Can MAC Antibodies Be an Indicator of Postoperative Relapse/Recurrence?].

BACKGROUND: Patients receiving surgical treatment for Mycobacterium avium complex (MAC), lung disease should be followed up with careful attention paid to relapse/recurrence, but there is some debate regarding the findings based on which relapse/recurrence should be diagnosed. PURPOSE AND METHODS: We hypothesized that we might be able to use anti-GPL core IgA antibodies (MAC antibodies), which have been attracting attention as a factor that may support diagnosis of MAC lung disease, to diagnose postoperative relapse/recurrence. Therefore, we compared the levels of these antibodies before and at the time of relapse/recurrence, and also compared antibody titers before and after surgery. RESULT: MAC antibody titers were elevated by an average of about 50% at the time of relapse/recurrence compared to those before relapse/recurrence for 6 patients. In contrast, MAC antibody titers were about 30% lower after surgery compared to those before surgery for 37 patients. CONCLUSION: It may be possible to use MAC antibodies as an indicator of postoperative relapse/recurrence for MAC lung disease.

[SURGICAL TREATMENT FOR TWENTIES PATIENTS WITH PULMONARY NONTUBERCULOUS MYCOBACTERIOSIS RESISTING CHEMOTHERAPY].

SUBJECTS AND METHODS: We report five cases of surgical treatment for pulmonary nontuberculous mycobac- teriosis (NTM) resisting chemotherapy in twenties. Of the five, one was male and four were female. They had cavitary or nodular lesion in their lung. After chemotherapy, partial resection or lobectomy was performed. RESULT: Though postoperative chemotherapy had contin- ued for only 6 months or 1 year, there was no relapse/recurrence at more than 86 months in average after surgery. Consideration. In younger patients, NTM lesions in the lung are sometimes more localized than senior patients, therefore they can be removed as a smaller portion by the operation, and we can sometimes keep more pulmonary function of the patient. CONCLUSION: Surgical treatment for twenties patients with pulmonary nontuberculous mycobacteriosis resisting chemo- therapy should be carried out aggressively at an early stage to resect a smaller portion of the lung and also decrease relapse/ recurrence after surgery.

[A STUDY OF SURGICAL TREATMENT FOR PATIENTS WITH MYCOBACTERIUM ABSCESSUS PULMONARY DISEASE AND A COMPARATIVE EXAMINATION OF MYCOBACTERIUM AVIUM COMPLEX DISEASE].

OBJECTIVE: This is a retrospective study on six surgical cases of Mycobacterium abscessus pulmonary disease, including a comparison with M. avium complex (MAC) disease. SUBJECTS AND METHODS: We performed surgery for six cases of M. abscessus pulmonary disease between July 2012 and June 2014. In all the cases, video-assisted thoracic surgery alone was performed. Age, sex, bacillus identification method, disease type, preoperative anti-glycopeptidolipid core immunoglobulin A antibody value, preoperative chemotherapy, preoperative chemotherapy period, adaptation of the operation, surgical method, result of the bacillus culture of an organization that was extracted at operation, postoperative hospitalization period, surgical complications, and postoperative relapse were examined for the six cases of M. abscessus pulmonary disease. In addition, the cases were compared with 36 cases of MAC disease for which operation was performed during the same period. RESULT: None of the patients had major surgical complications or in-hospital death. Although three patients survived for more than 1 postoperative year and completed chemotherapy, relapses are not accepted in all cases at present. In the comparison with MAC disease, the mean preoperative chemotherapy period for M. abscessus pulmonary disease was 5.5 months, which was 18.9 months shorter than that for MAC disease, with a statistically significant difference. CONCLUSION AND CONSIDERATION: Surgery for M. abscessus pulmonary disease may be considered a safe and effective therapeutic procedure. Moreover, some physicians believe that surgical treatment is required at an earlier stage of M. abscessus pulmonary disease compared with MAC disease.

[A study of relapse/recurrence cases after surgical treatment for patients with pulmonary nontuberculous mycobacteriosis].

PURPOSE: This is a retrospective study on relapse/recurrence of surgical cases of pulmonary nontuberculous mycobacteriosis (NTM). Surgical treatment was performed at one hospital and by one surgeon. METHOD: Fifty patients had undergone surgical treatment from August 2004 to July 2011 in hospital. From this group, 37 patients were selected after one year, and of these, 9 patients had a relapse/recurrence (group A) and the others (28 patients without relapse/recurrence, group B). Data was recorded about their age, gender, pre-operative image score, cavernous lesions, residual lesions after operation, drugs of pre-operative chemotherapy, the duration of pre-operative chemotherapy, the duration of any follow-up after operation, type of mycobacteria, the results of bacterial cultivation of surgical specimens, type of mycobacterium and operative procedure. RESULT: Three factors, the result of bacterial cultivation of surgical specimens, duration of chemotherapy before operation and existence of residual lesions, showed a significant difference statistically. No case with major surgical complication and hospital death was recognized. CONCLUSION: The visible foci should be removed as thoroughly as possible. Pre-operative chemotherapy should not be continued unnecessarily, and surgical treatment should be chosen at an early stage. The results of bacterial cultures of surgical specimens could be very useful for predicting the possibility of relapse/recurrence after operation. Surgical treatments of our patients were carried out safely. However, as the patients have a risk of relapse/recurrence, they require careful monitoring and post-operative chemotherapy over along period.

[Secondary pulmonary hypertension due to pulmonary tumor thrombotic microangiopathy diagnosed by open lung biopsy].

A 67-year-old woman was admitted with progressive exertional dyspnea. Arterial blood gas analysis showed severe hypoxia. A chest radiograph and a computed tomography showed bilateral interstitial infiltrations and patchy ground-grass opacities. Initially, she was given antibiotics with no effect. Since transthoracic echocardiography revealed right ventricular overload, cardiac catheterization was performed, which showed pulmonary hypertension. Pulmonary angiography revealed irregular filling defects along with pulmonary peripheral sites. Open lung biopsy was performed to establish a definitive diagnosis and to treat the diffuse lung disease. Microscopically, multiple tumor thrombi of mucinous adenocarcinoma were found in small sized pulmonary artery. Primary sites of malignancy has not been found in spite of postoperative examinations.

In vitro culture of chondrocytes in a novel thermoreversible gelation polymer scaffold containing growth factors.

In this study we examined the potential of a novel thermoreversible gelation polymer (TGP) to act as a 3-D hydrogel scaffold and deliver both chondrocytes and growth factors. Chondrocytes obtained from bovine articular cartilage were studied as a suspension in TGP chilled to 4 degrees C, in the presence or absence of the growth factors IGF-1 and/or TGF beta2. The cold cell/aqueous suspensions were injected into a cylindrical mold and cultured at 37 degrees C for up to 16 weeks. Specimens obtained at 12 and 16 weeks were semitranslucent and elastic. The matrices surrounding the chondrocytes were histologically positive to Safranin-O staining and type II collagen staining. The glycosaminoglycan and hydroxyproline contents in the specimens increased as a function of time and because of the presence of growth factors; those cultured with growth factors produced significantly more of these substances than those cultured without. We have concluded that TGP has potential as a scaffold material in the generation of tissue-engineered cartilage in vitro.