Registry-Based Medical Research: Data Dredging or Value Building to Quality of Care?

Registry-based medical research is an important tool in assessing health care interventions in the general population. Observational studies are used to establish effectiveness whereas randomized clinical trials assess efficacy in an experimental manner targeting a carefully selected population of patients. Medical registries may be office or hospital based, state/provincial, national, or more recently, global. Their role in postmarketing pharmacosurveillance is effective in detecting early adverse events and long-term benefits. Surgical disciplines use registry data to discover early device or prosthesis failures. Payers and administrators depend on medical registries to measure cost effectiveness (value). Patients are the ultimate beneficiary in terms of quality care. Current medical registries benefit from the explosion in medical informatics. The growth in the electronic health record for individual patients and hospitals provides an online wealth of data. The pharmaceutical industry has accurate cost usage data in many jurisdictions. Device manufacturers have upgraded data generated by using unique identifiers and device-generated surveillance alerts. Measurement of surgical innovations by registry is a new challenge. Quality data entry will become more user friendly and at reduced cost. A futuristic medical registry will be Internet based and require a higher degree of collaboration and harmonization to meet societal demand for timely "real world" data in measuring value delivered and accountability. This type of medical registry will only enhance value for patients, for the pharmaceutical and device industries, and for payers and administrators in augmenting quality patient care.

Additional and repeated computed tomography in interfacility trauma transfers: Room for standardization.

BACKGROUND: Despite the recommendations of the Advanced Trauma Life Support course of the American College of Surgeons, patients undergo computed tomography (CT) in local hospitals before transfer to a trauma center. The problem of repeat CTs caused by technical and protocol issues is ongoing. The objective is to measure the importance of repeat CTs and CTs involving other body regions. METHODS: All secondary transfers to our level 1 facility with CT at the local hospital over 9 years were reviewed. Patients were considered to have had a repeat CT if the same body region or an another body region was scanned as a part of the initial assessment but not for reasons of clinical follow-up. RESULTS: Of 6,292 patients received from local hospitals, 685 (12%) had undergone 1097 CT scans at the local hospitals. Patients being scanned in local hospitals were sicker (injury severity score: 21 vs 13) and required more intensive care unit admissions (38% vs 29%) and more ventilation (32% vs 22%). Thirty-nine percent of CTs were repeated, and 55% of these patients required imaging of another body part. CONCLUSION: Repeat and additional images remain a major issue in trauma transfers. Improvement requires standardization of CT protocols and change in the approach of local hospitals from "finding and requiring need level 1 trauma center" to "not missing any injuries."

Defining and Measuring Decision-Making for the Management of Trauma Patients.

BACKGROUND: Effective management of trauma patients is heavily dependent on sound judgment and decision-making. Yet, current methods for training and assessing these advanced cognitive skills are subjective, lack standardization, and are prone to error. This qualitative study aims to define and characterize the cognitive and interpersonal competencies required to optimally manage injured patients. METHODS: Cognitive and hierarchical task analyses for managing unstable trauma patients were performed using qualitative methods to map the thoughts, behaviors, and practices that characterize expert performance. Trauma team leaders and board-certified trauma surgeons participated in semistructured interviews that were transcribed verbatim. Data were supplemented with content from published literature and prospectively collected field notes from observations of the trauma team during trauma activations. The data were coded and analyzed using grounded theory by 2 independent reviewers. RESULTS: A framework was created based on 14 interviews with experts (lasting 1-2 hours each), 35 field observations (20 [57%] blunt; 15 [43%] penetrating; median Injury Severity Score 20 [13-25]), and 15 literary sources. Experts included 11 trauma surgeons and 3 emergency physicians from 7 Level 1 academic institutions in North America (median years in practice: 12 [8-17]). Twenty-nine competencies were identified, including 17 (59%) related to situation awareness, 6 (21%) involving decision-making, and 6 (21%) requiring interpersonal skills. Of 40 potential errors that were identified, root causes were mapped to errors in situation awareness (20 [50%]), decision-making (10 [25%]), or interpersonal skills (10 [25%]). CONCLUSIONS: This study defines cognitive and interpersonal competencies that are essential for the management of trauma patients. This framework may serve as the basis for novel curricula to train and assess decision-making skills, and to develop quality-control metrics to improve team and individual performance.

Economic Impact of an Enhanced Recovery Pathway for Lung Resection.

BACKGROUND: Multimodal enhanced recovery pathways (ERP) improve clinical outcomes and hospital length of stay for patients undergoing lung resection. However, data supporting their economic impact is lacking. This study evaluated the effect of an ERP on costs of lung resection. METHODS: Adult patients undergoing elective lung resection from August 2011 to August 2013 at a single university-affiliated institution were prospectively recruited. Pneumonectomies and extended resections were excluded. Beginning in September 2012, patients were enrolled in a multimodal ERP. Outcomes were recorded until 90 days after discharge. Total costs from institutional, health care system, and societal perspectives are reported in 2016 Canadian dollars, with uncertainty expressed as 95% confidence intervals derived using bootstrapped estimates (10,000 repetitions). RESULTS: The study included 133 patients (conventional care: n = 58; ERP: n = 75). Patient and operative characteristics were similar between the groups. The ERP group had shorter median (interquartile range) length of stay (4 [3 to 6] days vs 6 [4 to 9] days, p < 0.01), decreased total complications (32% vs 52%, p = 0.02), and decreased pulmonary complications (16% vs 34%, p = 0.01), with no difference in readmissions. After discharge, there was a trend towards less caregiver burden for the ERP group (53 ± 90 hours vs 101 ± 252 hours, p = 0.17). Overall societal costs were lower in the ERP group (mean difference per patient: -$4,396 Canadian; 95% confidence interval -$8,674 to $618 Canadian). CONCLUSIONS: A multidisciplinary ERP is associated with improved clinical outcomes and societal cost savings compared with conventional perioperative management for elective lung resection.

Epidural analgesia for traumatic rib fractures is associated with worse outcomes: a matched analysis.

BACKGROUND: The optimal method of pain control for patients with traumatic rib fractures is unknown. The aim of this study was to determine the effect of epidural analgesia on respiratory complications and in-hospital mortality in patients with rib fractures. METHODS: Adult patients at a level I trauma center with ≥1 rib fracture from blunt trauma were included (2004-2013). Those with a blunt-penetrating mechanism, traumatic brain injury, or underwent a laparotomy or thoracotomy were excluded. Patients who were treated with epidural analgesia (EPI) were compared with those were not treated with epidural analgesia (NEPI) using coarsened exact matching. Primary outcomes were respiratory complications (pneumonia, deep vein thrombosis/pulmonary embolus, and respiratory failure) and 30-d in-hospital mortality. Secondary outcomes were total hospital and intensive care unit length of stay, and duration of ventilator support. RESULTS: About 1360 patients (EPI: 329 and NEPI: 1031) met inclusion criteria (mean age: 54.2 y; standard deviation [SD]: 19.7; 68% male). The mean number of rib fractures was 4.8 (SD: 3.3; 21% bilateral) with a high total burden of injury (mean Injury Severity Score: 19.9 [SD: 8.9]). The overall incidence of respiratory complications was 13% and mortality was 4%. After matching, 204 EPI patients were compared with 204 NEPI patients, with no differences in baseline characteristics. EPI patients experienced more respiratory complications (19% versus 10%, P = 0.009), but no differences in 30-d mortality (5% versus 2%, P = 0.159), duration of mechanical ventilation (EPI: 148 h [SD: 167] versus NEPI: 117 h [SD: 187], P = 0.434), or duration of intensive care unit length of stay (6.5 d [SD: 7.6] versus 5.8 d [SD: 9.1], P = 0.626). Hospital stay was higher in the EPI group (16.6 d [SD: 19.6] vs 12.7 d [SD: 15.2], P = 0.026). CONCLUSIONS: Epidural analgesia is associated with increased respiratory complications without providing mortality benefit after traumatic rib fractures. Alternate analgesic strategies should be investigated to treat these severely injured patients.

Civilian Airway Trauma: A Single-Institution Experience.

BACKGROUND: Injuries to the airway in the neck and thorax are uncommon, but may be potentially life threatening. The objective of this study is to determine the clinical characteristics and outcomes for patients with airway injury. METHODS: From 1974 to 2014, a prospectively entered trauma database at a Level 1 trauma center was accessed to identify patients with injuries to the larynx, cervical trachea, or thoracic airway. Hospital charts were reviewed to obtain data on demographics, presentation, injury management, in-hospital and long-term morbidity and in-hospital mortality. Multivariate logistic regression was used to estimate predictors of mortality and long-term vocal cord morbidity. Data are expressed as N (%). RESULTS: One hundred and twenty patients were included (median injury severity score: 19 [interquartile range: 10-27]). There were 65 (54 %) blunt and 55 (46 %) penetrating injuries, with 90 (75 %) suffering multiple injuries. Sixteen (13 %) patients died from associated injuries (7: in ER; 9: after admission). Injuries were located in the cervical airway [101 (84 %)], thoracic airway [21 (18 %)], or both [2 (2 %)]. Eighty-six (72 %) patients were managed surgically. Predictors of in-hospital mortality included hemodynamic instability (OR 6.54, 95 % CI 1.11-37.14), GCS < 8 upon presentation (OR 4.35, 95 % CI 3.24-5.41), and head trauma (OR 4.10, 95 % CI 1.91-6.30). Fracture of cricoid or thyroid cartilages was a strong predictor of long-term vocal cord injury (OR 3.93, 95 % CI 1.25-12.59). CONCLUSIONS: Airway trauma remains a major challenge for early diagnosis, airway control, and management of both acute life-threatening injury and long-term morbidity.

Dr Anthony Dobell, Legendary McGill Trailblazer: May 7, 1927, to June 17, 2015.

Anthony R. C. Dobell died on June 17, 2015, at the age of 88. Dobell was the first Canadian president of the Society of Thoracic Surgeons. He was a pioneer in the development of pediatric and adult cardiac surgery at McGill University. He was inspired by Dr John Gibbon during his residency training at Jefferson Medical College in Philadelphia. He developed a McGill-based residency in Cardiothoracic Surgery and always took pride in the legacy of more than 40 residents scattered throughout North America.

An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy.

BACKGROUND: Few studies have investigated the effectiveness of enhanced recovery pathways (ERP) for lung resection. This study estimates the impact of an ERP for lobectomy on duration of stay, complications, and readmissions. METHODS: Patients undergoing open lobectomy were identified from an OR database between 2011 and 2013. Beginning September 2012, all patients were managed according to a 4-day multidisciplinary ERP with written daily patient education treatment plans, multimodal analgesia, early diet, structured mobilization and standardized drain management. Pre-pathway (PRE) and post-pathway (POST) patients were compared in terms of duration of stay, complications, and readmissions. RESULTS: We identified 234 patients (PRE, 127; POST, 107). Groups were similar with respect to age, gender, American Society of Anesthesiologists score, and baseline pulmonary function. Compared with the PRE group, the POST group had decreased duration of stay (median, 6 [interquartile range (IQR), 5-7] vs 7 [6-10] days; P < .05), total complications (40 [37%] vs 64 [50%]; P < .05), urinary tract infections (3 [3%] vs 15 [12%]; P < .05), and chest tube duration (median, 4 [IQR, 3-6] vs 5 [4-7] days; P < .05), with no difference in readmissions (7 [7%] vs 6 [5%]; P < .05) or chest tube reinsertion (4 [4%] vs 6 [5%]; P < .05). Decreased duration of stay was driven by patients without complications (median, 5 [IQR, 4-6] vs 6 [5-7] days; P < .05). CONCLUSION: Implementation of a multimodal ERP for lobectomy was associated with decreased duration of stay and complications with no difference in readmissions.

Functional outcomes and quality of life after proximal gastrectomy with esophagogastrostomy using a narrow gastric conduit.

BACKGROUND: The best surgical approach for tumors of the proximal stomach remains controversial. For proximal gastrectomy (PG), the evidence regarding quality of life (QoL) and functional outcomes is controversial. Moreover, there are limited data from non-Asian settings. METHODS: All patients who underwent PG from September 2005 to July 2013 were identified from an institutional database. Demographic, perioperative and pathologic characteristics were retrieved. Symptom scores (0 = best/4 = worst) for reflux symptoms, dysphagia and validated QoL metrics (FACT scale, where a higher score is better) were assessed during early and late follow-up. Eligible patients for analysis were those with no evidence of recurrence. RESULTS: Of 465 upper gastrointestinal cancer resections, 50 were PG for adenocarcinoma (42; 84%), neuroendocrine carcinoma (5; 10%) or other pathologies (3; 6%). R0 resection was achieved in 44 (89.8%) of 49 patients with malignant tumors. Median lymph node collection was 32 (range 7-57). QoL scores did not differ from preoperative to early follow-up but increased compared to both at late follow-up [preoperative, 125 (interquartile range 105-140); early follow-up, 122.5 (97-142); late follow-up, 147 (132-159); p < 0.05]. At early and late follow-up, 9 (21.4%) of 42 and 10 (33.3%) of 30 patients reported reflux symptoms, but most were mild. Endoscopic signs of esophagitis were found in 7 (29%) of 24 patients, but only two of these reported reflux symptoms. Conversely only three of eight patients with reflux symptoms had esophagitis on endoscopy. CONCLUSIONS: Global QoL is not reduced early after PG, and increases compared to baseline at late follow-up. Although reflux symptoms are reported by a quarter of patients, most are mild, and there is little correlation with esophagitis. PG should remain a viable option in the management of proximal gastric tumors.

Validity of the EuroQol-5 dimensions as a measure of recovery after pulmonary resection.

BACKGROUND: Surgical innovations advocated to improve patient recovery are often costly. Economic evaluation requires preference-based measures that reflect the construct of patient recovery. We investigated the responsiveness and construct validity of the EuroQol-5 dimensions (EQ-5D) as a measure of postoperative recovery after planned pulmonary resection for suspected malignant tumors. METHODS: Patients undergoing pulmonary resection completed the EQ-5D questionnaire and visual analog scales (VAS) for pain and fatigue at baseline (preoperatively) and at 1 and 3 mo postoperatively. Responsiveness and construct validity (discriminant and convergent) were investigated by testing a priori hypotheses. RESULTS: Fifty-five patients were analyzed (45% male, 62 ± 12 y, 29% video-assisted). There was no significant difference between median EQ-5D scores obtained at baseline (0.83 [interquartile range {IQR 0.80-1}]) compared to scores at 1 mo (0.83 [0.80-1], P = 0.86) and 3 mo after surgery (1 [0.83-1]; P = 0.09). At 1 mo after surgery, EQ-5D scores were significantly lower in patients undergoing thoracotomy versus video-assisted surgery (0.82 [IQR 0.77-0.89] versus 1 [0.83-1], P = 0.003), but there were no significant differences between patients ≥ 70-y old versus younger (0.95 [IQR 0.82-1] versus 0.83 [0.77-1], P = 0.09) or between patients with versus without complications (0.82 [IQR 0.79-0.95] versus 0.83 [0.80-1], P = 0.10). There was a low but significant correlation between EQ-5D and VAS scores of pain and fatigue (Rho -0.30 to -0.47, P ≤ 0.01). CONCLUSIONS: Despite evidence of convergent validity, the EQ-5D was not sensitive to the hypothesized trajectory of postoperative recovery and showed limited discriminant validity. This study suggests that the EQ-5D may not be appropriate to value recovery after lung resection.

Bochdalek hernia in a symptomatic adult.

Bochdalek hernias usually present in neonates with respiratory failure, need to be operated early and are associated with a high mortality. We describe an adult patient who came to the emergency department with nonspecific recurrent chest and abdominal pain. A computed tomography scan showed a large posterolateral diaphragmatic defect and an oversized spleen. The hernia was repaired by a thoracoabdominal approach and Gore-Tex patch. Congenital diaphragmatic hernias are rare and are associated with nonspecific symptoms in adults. With suspicious chest or abdominal radiographs, a computed tomography scan is essential to plan an individualized surgical intervention.

Cost-effectiveness of minimally invasive versus open esophagectomy for esophageal cancer.

BACKGROUND: A recent randomized trial comparing minimally invasive (MIE) and open esophagectomy for esophageal cancer reported improved short-term outcomes. However, MIE has increased operative costs, and it is unclear whether the short-term benefits of MIE outweigh the increased operative costs. Therefore, the objective of this study was to determine the cost-effectiveness of MIE compared to open esophagectomy for esophageal cancer. METHODS: A decision-analysis model was developed to estimate the expected costs and outcomes after MIE and open esophagectomy from a health care system perspective with a time horizon of 1 year. Costs were represented in 2012 Canadian dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). Probabilistic sensitivity analysis assessed parameter uncertainty. RESULTS: MIE was estimated to cost $1641 (95% confidence interval 1565, 1718) less than open esophagectomy, with an incremental gain of 0.022 QALYs (95% confidence interval 0.021, 0.023). MIE was therefore dominant over open esophagectomy. On deterministic sensitivity analyses, the results were most sensitive to variations in length of stay. Probabilistic sensitivity analysis demonstrated the robustness of the base case result, with 66, 77, and 82% probabilities of cost-effectiveness at willingness-to-pay thresholds of $0/QALY, $50,000/QALY, and $100,000/QALY, respectively. CONCLUSIONS: MIE is cost-effective compared to open esophagectomy in patients with resectable esophageal cancer.

Predicting lymph node metastases in early esophageal adenocarcinoma using a simple scoring system.

BACKGROUND: Endoscopic resection is an organ-sparing option for early esophageal adenocarcinoma, but should be used only in patients with a negligible risk of lymph node metastases (LNM). The objective was to develop a simple scoring system to predict LNM in T1 esophageal adenocarcinoma. STUDY DESIGN: All primary esophagectomies performed for T1 esophageal adenocarcinoma without neoadjuvant therapy at 5 university institutions from 2000 to 2011 were analyzed. Patient and pathologic characteristics were compared between patients with LNM at the time of surgical resection and those without. Univariate and multivariate analyses were performed to establish a simple scoring system that estimated the risk of LNM, using variables from the final surgical pathology. RESULTS: A total of 258 patients were included for analysis (mean age 65.2 years [SD 10.3 years], 88% male). The incidence of LNM was 7% (9 of 122) for T1a and 26% (35 of 136) for T1b. Tumor size (odds ratio [OR] 1.35 per cm, 95% CI 1.07 to 1.71) and lymphovascular invasion (OR 7.50, 95% CI 3.30 to 17.07) were the strongest independent predictors of LNM. A weighted scoring system was devised from the final multivariate model and included size (+1 point per cm), depth of invasion (+2 for T1b), differentiation (+3 for each step of dedifferentiation), and lymphovascular invasion (+6 if present). Total number of points estimated the probability of LNM (low risk [0 to 1 point], ≤ 2%; moderate risk [2 to 4 points], 3% to 6%; and high risk [5+ points], ≥ 7%). CONCLUSIONS: We devised a simple scoring system that accurately estimates the risk of LNM to aid in decision-making in patients with T1 esophageal adenocarcinoma undergoing endoscopic resection.

Training future surgeons for management roles: the resident-surgeon-manager conference.

OBJECTIVE To demonstrate that senior surgical residents would benefit from focused training by professionals with management expertise. Although managerial skills are recognized as necessary for the successful establishment of a surgical practice, they are not often emphasized in traditional surgical residency curricula. DESIGN Senior residents from all surgical subspecialties at McGill University were invited to participate in a 1-day management seminar. Precourse questionnaires aimed at evaluating the residents' perceptions of their own managerial knowledge and preparedness were circulated. The seminar was then given in the form of interactive lectures and case-based discussions. The questionnaires were readministered at the end of the course, along with an evaluation form. Precourse and postcourse data were compared using the Freeman-Halton extension of the Fisher exact test to determine statistical significance (P < .05). SETTING McGill University Health Centre in Montreal, Quebec, Canada. PARTICIPANTS A total of 43 senior residents. RESULTS Before the course, the majority of residents (27 of 43 [63%]) thought that management instruction only happened "from time to time" in their respective programs. After the course, 15 residents (35%) felt that management topics were "well addressed," and 19 (44%) felt that management topics have been "very well addressed" (P < .01). Residents noted a significant improvement in their ability to perform the following skills after the course: giving feedback, delegating duties, coping with stress, effective learning, and effective teaching. On the ensemble of all managerial skills combined, 26 residents (60%) rated their performance as "good" or "excellent" after the course vs only 21 (49%) before the course (P = .02). Residents also noted a statistically significant improvement in their ability to perform the managerial duties necessary for the establishment of a surgical practice. CONCLUSIONS Surgical residency programs have the responsibility of preparing their residents for leadership and managerial roles in their future careers. An annual seminar serves as a starting point that could be built on for incorporating formal management training in surgical residency curricula.

An enhanced recovery pathway decreases duration of stay after esophagectomy.

PURPOSE: Enhanced recovery pathways (ERP) decrease morbidity and duration of stay after colorectal surgery. There is little information about their role in complex procedures, such as esophagectomy. The purpose of this study was to determine the impact of an ERP on duration of stay, complications, and readmissions after esophagectomy. METHODS: Patients undergoing esophagectomy for cancer or high-grade dysplasia from June 2009 to December 2011 were identified from a prospectively maintained database. Beginning in June 2010, all patients were enrolled in a 7-day multidisciplinary ERP including written patient education with daily treatment plan, indications for intensive care admission, early structured mobilization, and diet and drain management. Short-term (30-day) outcomes were compared for patients undergoing esophagectomy pre- and post-pathway. Data are expressed as median values [interquartile range]. RESULTS: We identified 106 patients; 47 underwent esophagectomy before ERP implementation and 59 after. Patients were similar with respect to age, gender, diagnosis, and operative time. Hospital stay was shorter in the ERP group (8 [7-17] vs 10 [9-17] days; P = .01). There were no differences in rates of complications (59% vs 62%) or readmissions (6% vs 5%). CONCLUSION: Implementation of a multidisciplinary ERP for esophagectomy was associated with decreased duration of stay, without an increase in complications or readmissions.

Reconstruction after major chest wall resection: can rigid fixation be avoided?

BACKGROUND: Rigid fixation is advocated as the best method to achieve good respiratory outcomes after chest wall resection at the expense of a high complication rate. The following study aims to examine the role of myocutaneous pedicled flaps, with or without soft prosthesis, in the reconstruction of small and large chest wall defects. METHODS: All patients who underwent resection of chest wall tumors between 2003-2010 were identified from a prospectively entered database. Operative and postoperative outcomes were documented. Patients were stratified into 2 separate groups based on the size of the residual chest wall defect; the Small Defect (SD) group (<60 cm(2)) and the Large Defect (LD) group (>60 cm(2)). RESULTS: Thirty-seven patients were identified over a 7-year period: 9 in the SD group and 28 in the LD group. Primary sarcoma was the most common indication for resection (57%). The mean size of the chest wall defect was 50.8 cm(2) in the SD group and 149.4 cm(2) in the LD group (P = .001). All patients underwent reconstruction with autologous tissue, nonrigid prosthesis, or a combination of the two. Prosthesis was used in 11% of patients in the SD group and 61% of patients in the LD group (P = .018). The rate of immediate postoperative extubation was 100% in the SD group and 89% in the LD group (P = .42). The rate of postoperative pneumonia was 7% in the LD group vs 0% in the SD group. The rate of surgical site infection was 7% in the LD group and 0% in the SD group. A subgroup analysis of the LD group demonstrated no statistical differences in any of the measured outcomes between patients in whom mesh prosthesis was used and patients in whom a myocutaneous flap alone was used. However, there was a clinical suggestion of prolonged ventilation in the subgroup where mesh was not used and of higher infection rates in the subgroup where mesh was used. CONCLUSION: Small chest wall defects can be reconstructed with pedicled myocutaneous flaps alone without compromising respiratory outcomes. In carefully selected patients with moderate size defects larger than 60 cm(2), reconstruction with pedicled myocutaneous flap alone offers similar postoperative outcomes as reconstruction with nonrigid prosthesis, at the expense of a possible need for a short period of mechanical ventilation.

Estimating the risk of prolonged air leak after pulmonary resection using a simple scoring system.

BACKGROUND: The high rate of prolonged air leak (PAL) after pulmonary resection has prompted interest in surgical adjuncts designed to prevent this complication. However, these adjuncts are costly and might not be beneficial if used routinely. Identification of patients at highest risk might allow for more effective use of these adjuncts. Therefore, we sought to develop a simple scoring system to predict PAL. STUDY DESIGN: A derivation set of 580 patients was identified from a prospectively entered database of consecutive pulmonary resections at a single institution from 2002 to 2007. Patient and operative characteristics were compared using Student's t-test and chi-square tests. Significant variables on univariate analysis were entered into a stepwise logistic regression to establish a simple predictive model to estimate the risk of PAL. This scoring system was then validated in a consecutive set of 381 patients operated at the same institution from 2007 to 2009. RESULTS: The rate of PAL was 14% in the derivation set and 18% in the validation set. Poor pulmonary function (forced expiratory volume in 1 second and carbon monoxide diffusing capacity, percent predicted) and pleural adhesions were significantly associated with PAL in the derivation set. A weighted scoring system was devised using pleural adhesions (+2 points), forced expiratory volume in 1 second (+1 per 10% below 100%), and carbon monoxide diffusing capacity (+1 per 20% below 100%). Total number of points estimated the probability of PAL. Hosmer-Lemeshow goodness-of-fit test confirmed validity (p > 0.2) of this scoring system in the validation set. CONCLUSIONS: We have devised and validated a simple scoring system to predict the probability of PAL after pulmonary resection.

An 18-year review of sports groin injuries in the elite hockey player: clinical presentation, new diagnostic imaging, treatment, and results.

OBJECTIVE: This is a retrospective study of 98 hockey players who underwent 107 surgical explorations for refractory lower abdominal and groin pain that prevented them from playing hockey at an elite level. DESIGN: Retrospective chart review combined with a complete follow-up examination and questionnaire. SETTING: The players were treated in an ambulatory care university tertiary care centre. PATIENTS: A total of 98 elite hockey players underwent 107 surgical groin explorations for intractable groin pain preventing their play. Follow-up was 100%. INTERVENTION: Each player had repair of a tear of the external oblique muscle and fascia reinforced by a Goretex mesh. The ilioinguinal nerve was resected in each patient. OUTCOME MEASURES: There was absence of groin pain on the return to play hockey at an elite level. RESULTS: In all, 97 of 98 players returned to play after the surgical procedures. No morbidity was attributed to division of the ilioinguinal nerve. CONCLUSIONS: Surgical exploration of the involved groin with repair of the torn external oblique muscle and division of the ilioinguinal nerve has resulted in resolution of refractory groin pain and return to play in the elite hockey player. The surgical procedure is associated with a low morbidity. Recent observations on dynamic ultrasound show promise in accurately diagnosing this injury.