The Canterbury Charity Hospital: an update (2010-2012) and effects of the earthquakes.

AIM: To update activities of the Canterbury Charity Hospital (CCH) and its Trust over the 3 years 2010-2012, during which the devastating Christchurch earthquakes occurred. METHODS: Patients' treatments, establishment of new services, expansion of the CCH, staffing and finances were reviewed. RESULTS: Previously established services including general surgery continued as before, some services such as ophthalmology declined, and new services were established including colonoscopy, dentistry and some gynaecological procedures; counselling was provided following the earthquakes. Teaching and research endeavours increased. An adjacent property was purchased and renovated to accommodate the expansion. The Trust became financially self-sustaining in 2010; annual running costs of $340,000/year were maintained but were anticipated to increase soon. Of the money generously donated by the community to the Trust, 82% went directly to patient care. Although not formally recorded, hundreds of appointment request were rejected because of service unavailability or unmet referral criteria. CONCLUSIONS: This 3-year review highlights substantial, undocumented unmet healthcare needs in the region, which were exacerbated by the 2010/2011 earthquakes. We contend that the level of unmet healthcare in Canterbury and throughout the country should be regularly documented to inform planning of public healthcare services.

Long-term outcomes of the australasian randomized clinical trial comparing laparoscopic and conventional open surgical treatments for colon cancer: the Australasian Laparoscopic Colon Cancer Study trial.

OBJECTIVE: : We report a multicentered randomized controlled trial across Australia and New Zealand comparing laparoscopic-assisted colon resection (LCR) with open colon resection (OCR) for colon cancer. BACKGROUND: : Colon cancer is a significant worldwide health issue. This trial investigated whether the short-term benefits associated with LCR for colon cancer could be achieved safely, without survival disadvantages, in our region. METHODS: : A total of 601 patients with potentially curable colon cancer were randomized to receive LCR or OCR. Primary endpoints were 5-year overall survival, recurrence-free survival, and freedom from recurrence rates, compared using an intention-to-treat analysis. RESULTS: : On April 5, 2010, 587 eligible patients were followed for a median of 5.2 years (range, 1 week-11.4 years) with 5-year confirmed follow-up data for survival and recurrence on 567 (96.6%). Significant differences between the 2 trial groups were as follows: LCR patients were older at randomization, and their pathology specimens showed smaller distal resection margins; OCR patients had some worse pathology parameters, but there were no differences in disease stages. There were no significant differences between the LCR and OCR groups in 5-year follow-up of overall survival (77.7% vs 76.0%, P = 0.64), recurrence-free survival (72.7% vs 71.2%, P = 0.70), or freedom from recurrence (86.2% vs 85.6%, P = 0.85). CONCLUSIONS: : In spite of some differences in short-term surrogate oncological markers, LCR was not inferior to OCR in direct measures of survival and disease recurrence. These findings emphasize the importance of long-term data in formulating evidence-based practice guidelines.

Ethical issues with the disclosure of surgical trial short-term data.

BACKGROUND: This paper describes the distinctions between major surgical and pharmaceutical trials and questions the application of a common ethical paradigm to guide their conduct and reporting. METHODS: Surgical trials differ from other trials in cumulative therapeutic effects, operator dependence, the clinical setting, interdependence of short- and long-term outcomes, and equipoise. A principal tenant of randomized controlled trial management is the maintenance of interim data confidentiality. Its application to complete surgical short-term data is examined across a variety of common clinical trial circumstances that influence data integrity and the reliability of conclusions regarding the benefit-to-risk profile of experimental interventions. RESULTS: Complete perioperative results describe important treatment ends that cannot influence primary outcomes. These short-term results may inform patient consent, teaching and provide valuable procedural insights to surgeons outside trial precincts. CONCLUSION: Structured experimentation standards are necessary. But, the common paradigm applied across all clinical trials and the prohibition on short term data reporting may not serve the achievement of safe and effective advancements in surgery.

Patients "falling through the cracks". The Canterbury Charity Hospital: initial progress report.

AIM: To present the early experience of establishing a community-funded and volunteer-staffed hospital in Christchurch, New Zealand. This was to provide free selected elective healthcare services to patients in the Canterbury region who were otherwise unable to access treatment in the public health system or afford private healthcare. METHODS: Data were reviewed relating to the establishment, financing, staffing and running of the Canterbury Charity Hospital. Details were provided of patients referred by their general practitioners who were seen and treated during the first two and a half years of function. RESULTS: Canterbury Charity Hospital Trust, established in 2004, completed the purchase of a residential villa in 2005 and converted it into the Canterbury Charity Hospital, which performed its first operations in 2007. By the end of December 2009, 115 volunteer health professionals and 79 non-medical volunteers had worked at the Hospital, provided a total of 966 outpatient clinic appointments, of which 609 were initial assessments, and performed 610 surgical procedures. Funding of $NZ4.3 million (end of last financial year) came from fundraising events, donations, grants and interest from investments. There has been no government funding. CONCLUSIONS: There is a substantial unmet need for elective healthcare in Canterbury, and this has, in part, been addressed by the recently established Canterbury Charity Hospital. The overwhelming community response we have experienced in Canterbury raises the question of whether the current public health system needs attention to be re-focused on unmet need. We contend that unless this occurs it might be necessary to establish charity-type hospitals elsewhere throughout the country.

Australian and New Zealand study comparing laparoscopic and open surgeries for colon cancer in adults: organization and conduct.

This article describes the initiation and implementation of the multicentre Australia and New Zealand prospective randomized controlled clinical study comparing laparoscopic and conventional open surgical treatments of right-sided and left-sided potentially curable colon cancer (Australasian Laparoscopic Colon Cancer Study). Six hundred and one adult patients were admitted with a clinical diagnosis of a single adenocarcinoma based on a physical examination and colonoscopy, barium enema or computed tomography scan and randomly allocated to either laparoscopic or open surgery. The primary aim of the study is to compare 5-year mortality and tumour recurrence rates between the two groups. Secondary aims include comparisons of safety (intraoperative and early postoperative complications, wound site recurrence, postoperative recovery and 30-day mortality), quality of life, in-hospital costs and short-term mortality and tumour recurrence. The data for 592 patients have been collected. There are currently 3141 person years of follow up. In all 370 patients have been assessed at 5 years. This study shows that large cooperative Australia-New Zealand surgical trials can and should be carried out to address significant clinical issues. When possible, coherence with similar, concurrent international trial protocols ensures broader analyses and applicability of results. It is important to recognize that special attention to sustained funding, surgeon credentialing, clinical protocol standardization, data management, publication policy and the protection of study credibility is required from the outset. The Australasian Laparoscopic Colon Cancer Study will achieve its aims with 5-year assessments of all entered patients in March 2010.

Short-term outcomes of the Australasian randomized clinical study comparing laparoscopic and conventional open surgical treatments for colon cancer: the ALCCaS trial.

BACKGROUND: Laparoscopy has revolutionized many abdominal surgical procedures. Laparoscopic colectomy has become increasingly popular. The short- and long-term benefits and satisfactory surgical oncological treatment of colorectal cancer by laparoscopic-assisted resection remain topical. The long-term outcomes of all international randomized controlled trials are still awaited, and short-term outcomes are important in the interim. METHODS: Between January 1998 and April 2005, a multicenter, prospective, randomized clinical trial in patients with colon cancer was conducted. Six hundred and one eligible patients were recruited by 33 surgeons from 31 Australian and New Zealand centers. Patients were allocated to colectomy by either laparoscopic-assisted surgery (n = 294) or open surgery (n = 298). Patient demographics and secondary end-points, such as operative and postoperative complications, length of hospital stay, and histopathological data, will be presented in this article. Analysis was by intention-to-treat. Survival will be reported only as the study matures. RESULTS: Histopathological parameters were similar between the two groups, except in regard to distal resection margins. There was no statistically significant difference found in postoperative complications, reoperation rate, or perioperative mortality. Statistically significant differences in quicker return of gastrointestinal function and shorter hospital stay were identified in favor of laparoscopic-assisted resection. A statistically significant increased rate of infective complications was seen in cases converted from laparoscopic-assisted to open procedures but with no difference in reoperation or in-hospital mortality. CONCLUSIONS: Laparoscopic-assisted colonic resection gives significant improvements in return of gastrointestinal function and length of stay, with an increased operative time and no difference in the postoperative complication rate.

The rapid evaluation of bacterial growth and antibiotic susceptibility in blood cultures by selected ion flow tube mass spectrometry.

We have measured the production of volatile organic compounds (VOCs) by selected ion flow tube mass spectrometry (SIFT-MS) in the headspaces of conventional BacT/ALERT blood culture bottles (Biomerieux, Durham, NC) artificially infected with 5 bacterial strains. Uninfected blood samples were inoculated with Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, and Neisseria meningitidis. Growth and species identification were determined at 6 h by measuring a panel of 9 VOC products. Two species, E. coli and S. aureus, were also incubated in the presence of gentamicin or flucloxacillin, respectively, above or below their demonstrated MIC. The concentration-dependent antibiotic susceptibility of both strains was demonstrated by the inhibition of VOC production at 22 h (P < .05). These results suggest incorporating SIFT-MS detection of microbial VOCs as a sensitive method for bacterial detection, identification, and determination of antibiotic susceptibility in a conventional blood culture system.

Detection of volatile metabolites produced by bacterial growth in blood culture media by selected ion flow tube mass spectrometry (SIFT-MS).

To achieve faster bacteremia diagnosis, selected ion flow tube mass spectrometry (SIFT-MS) measured metabolic gases in the headspaces of BacT/ALERT blood culture bottles. Pseudomonas aeruginosa, Streptococcus pneumoniae, Escherichia coli, Staphylococcus aureus and Neisseria meningitidis growth and trace gas patterns were detected from 10 colony forming units after 6 h.

SIFT-MS measurement of VOC distribution coefficients in human blood constituents and urine.

The new technique of selected ion flow tube-mass spectrometry (SIFT-MS) has been applied to the measurement of Henry's Law constants for the volatile organic chemicals o-xylene and trichloroethylene that both have low solubility in aqueous solvents. The method is validated by measurements in water at 298 K using the equilibrium partitioning in closed systems (EPICS) methodology in which the equilibrium headspace concentrations for the volatile organic compounds (VOCs) are measured in two sealed bottles containing different liquid volumes of very dilute solutions of the VOC. The range of solvents is then extended to human body fluids at 309 K including urine, saline, whole blood, red cells in saline, and plasma. The dimensionless distribution coefficients for these solvents vary markedly in the different fluids. For o-xylene they range from k(H) = 0.12-0.15 for water, saline, and urine; 0.53 for red cells in saline; 1.9 for whole blood; to 2.4 for plasma. For trichloroethylene the distribution coefficients range from k(H) = 0.070-0.091 for water, saline, and urine; 0.28 for red cells in saline; 0.35 for plasma; to 0.48 in whole blood. The very different solubilities of organic solvents in body fluids influence the uptake of solvents in workers exposed to VOCs. Some implications of these measurements are briefly discussed.

In situ analysis of solvents on breath and blood: a selected ion flow tube mass spectrometric study.

We report measurements of residual vapour levels of xylenes and trimethylbenzenes, present following a floor re-surfacing procedure, using the technique of selected ion flow tube mass spectrometry (SIFT-MS). A subject exposed to controlled amounts of xylene and mesitylene was monitored by direct breath exhalation over a 4-hour period after exposure to the volatile organic compounds (VOCs) had stopped. The headspace gases above 5 mL blood samples taken over this period were also monitored. The decays of the solvent levels with time were fitted to a two-compartment model with residence times for xylene and mesitylene of 0.37 h and 0.38 h, respectively (compartment one) and 2.5 h and 2.8 h, respectively (compartment two).