Subscribe
×

Preference: Surgery

1175

Stating best practice in breast cancer care

Although survival for women with breast cancer in Australia is among the highest in the world, there is evidence that not all patients are receiving the most appropriate care.

Cancer Australia has brought together evidence and expertise to support improved and informed practice in breast cancer. The Cancer Australia Statement — influencing best practice in breast cancer is based on the best available evidence and is supported by expert clinical and consumer advice. The statement represents agreed priority areas which, if implemented, will support effective, patient-centred breast cancer care and reduce unwarranted variations in practice.

The statement aims to encourage health professionals to reflect on their clinical practice to ensure that it is aligned with best practice. It also aims to encourage consumers to start conversations with their medical teams to improve their cancer experience and outcomes.

There are 12 practices in the breast cancer statement, from diagnosis across the continuum of care. The practices are identified as either appropriate or not appropriate.

A practice is appropriate if it is beneficial for patients, effective (based on valid evidence, including evidence of benefit), efficient (cost-effective) and equitable.

A practice is not appropriate if it is not consistent with the evidence, may cause potential harm or provides little benefit to patients.

The practices were chosen with the collaboration, participation and engagement of relevant clinical colleges, cancer and consumer organisations. The statement is intended to complement relevant clinical practice guidelines.

Supporting materials have been developed for the statement, including information on the value to patients, evidence base and references for each practice.

More information about the statement and recommended practices is available at canceraustralia.gov.au/statement.

[Comment] eTHoS piles pressure on haemorrhoidopexy

Surgical innovation strives to address the perceived shortcomings and potential pitfalls associated with traditional therapeutic techniques. New devices are often recommended to patients on the basis of incomplete clinical datasets that highlight specific short-term gains over standard treatment but may not confirm long-term benefit. Enthusiasm for new technology in surgery should be balanced by the requirement to undertake objective, high-quality studies to establish the overall clinical and economic effect of surgical therapies.

A new model to predict acute kidney injury requiring renal replacement therapy after cardiac surgery [Research]

Background:

Acute kidney injury after cardiac surgery is associated with adverse in-hospital and long-term outcomes. Novel risk factors for acute kidney injury have been identified, but it is unknown whether their incorporation into risk models substantially improves prediction of postoperative acute kidney injury requiring renal replacement therapy.

Methods:

We developed and validated a risk prediction model for acute kidney injury requiring renal replacement therapy within 14 days after cardiac surgery. We used demographic, and preoperative clinical and laboratory data from 2 independent cohorts of adults who underwent cardiac surgery (excluding transplantation) between Jan. 1, 2004, and Mar. 31, 2009. We developed the risk prediction model using multivariable logistic regression and compared it with existing models based on the C statistic, Hosmer–Lemeshow goodness-of-fit test and Net Reclassification Improvement index.

Results:

We identified 8 independent predictors of acute kidney injury requiring renal replacement therapy in the derivation model (adjusted odds ratio, 95% confidence interval [CI]): congestive heart failure (3.03, 2.00–4.58), Canadian Cardiovascular Society angina class III or higher (1.66, 1.15–2.40), diabetes mellitus (1.61, 1.12–2.31), baseline estimated glomerular filtration rate (0.96, 0.95–0.97), increasing hemoglobin concentration (0.85, 0.77–0.93), proteinuria (1.65, 1.07–2.54), coronary artery bypass graft (CABG) plus valve surgery (v. CABG only, 1.25, 0.64–2.43), other cardiac procedure (v. CABG only, 3.11, 2.12–4.58) and emergent status for surgery booking (4.63, 2.61–8.21). The 8-variable risk prediction model had excellent performance characteristics in the validation cohort (C statistic 0.83, 95% CI 0.79–0.86). The net reclassification improvement with the prediction model was 13.9% (p < 0.001) compared with the best existing risk prediction model (Cleveland Clinic Score).

Interpretation:

We have developed and validated a practical and accurate risk prediction model for acute kidney injury requiring renal replacement therapy after cardiac surgery based on routinely available preoperative clinical and laboratory data. The prediction model can be easily applied at the bedside and provides a simple and interpretable estimation of risk.

[Comment] Preventing postoperative delirium: all that glisters is not gold

Delirium is an important complication of surgery, affecting an estimated 30% of surgical patients in the intensive care unit (ICU).1 Postoperative delirium is distressing for patients and family members, and is associated with increased risk of further negative outcomes, including admission to institutions, dementia, and death.2 Unfortunately, many candidate pharmacological interventions to prevent postoperative delirium have failed.3 The cholinesterase inhibitor rivastigmine exemplifies the failures.

News briefs

Anti-Zika drugs on the way

Compounds that suppress Zika virus replication or prevent the death of cells infected by the virus have been reported online in Nature Medicine. Similar to dengue virus and chikungunya virus, Zika virus can cause flu-like symptoms in some individuals. Unlike dengue virus and chikungunya virus, Zika virus infection can also result in the congenital defect microcephaly in developing fetuses, and in Guillain–Barre disease in adults. Researchers from the Johns Hopkins University School of Medicine screened a library of approximately 6000 compounds that included US Food and Drug Administration-approved drugs and experimental therapies currently in clinical trials, and identified two classes of compounds: one inhibits the death of cells infected by Zika virus, the other blocks Zika virus replication in infected cells. The two classes of compounds showed activity in several relevant types of brain cells — including human neural progenitor cells and astrocytes — and in 3D brain organoid cultures. The compounds also worked when given either before or after exposure to Zika virus. Finally, the two classes of compounds showed even greater benefits when used together than when given individually. Further research is needed before these compounds can be considered for human treatment, especially of pregnant women. Essential next steps include testing the efficacy and safety of these lead compounds in animal models of adult and fetal Zika virus infection.

http://dx.doi.org/10.1038/nm.4184

Night surgery doubles risk of death

New research presented at the World Congress of Anaesthesiologists in Hong Kong late last month showed that patients who had surgery during the night were twice as likely to die as patients operated on during regular working hours. Patients operated on later in the working day or in the early evening also had a higher mortality risk, concluded the researchers from McGill University Health Centre in Montreal, Canada. A retrospective review of 30-day postoperative in-hospital mortality was carried out at the Jewish General Hospital in Montreal, which is also a teaching hospital. The study evaluated all surgical procedures for the past 5 years, from 1 April 2010 to 31 March 2015. A database was constructed collecting variables about surgical interventions. All elective and emergent surgical cases were included, except ophthalmic and local anaesthesia cases. The working day was divided into three time blocks (daytime, 07:30-15:29; evening, 15:30-23:29; nighttime, 23:30-07:29). The start time of the anaesthetic recorded by the circulating nurse was used to determine in which time block the operation began. There were 41 716 elective and emergency surgeries performed on 33 942 patients in 40 044 hospitalisations. Of these, 10 480 were emergency procedures; there were 3445, 4951, and 2084 emergency procedures with anaesthesia starting during the day, evening and night respectively. There were 226, 97 and 29 deaths during day, evening and night surgery respectively (79, 95, 29 mortalities for emergency surgery in the same time periods). The researchers found that after adjustment for age and ASA scores, the patients operated on at night were 2.17 times more likely to die than those operated on during regular daytime working hours, and patients operated on late in the day were 1.43 times more likely to die than those operated on during regular daytime working hours.

https://owncloud.wellbehavedsoftware.com/index.php/s/WcTAhN1rXCXPmwX#pdfviewer

[Perspectives] Prosthetic possibilities

The Body Extended: Sculpture and Prosthetics is an intriguing exhibition that provides a fresh perspective on the relationship between the human body, its replacements, and its augmentations, forcing us to consider what a body is and what are its limits. This show at the Henry Moore Institute in Leeds takes place within an ecology of recent displays in the UK: some (such as War, Art and Surgery at the Royal College of Surgeons of England or the recently opened Wounded at London’s Science Museum) prompted by the centenary of World War 1, others exploring the possibilities of the body in less obvious ways (such as the Wellcome Collection’s Superhuman, in 2012).

Electroacupuncture and splinting versus splinting alone to treat carpal tunnel syndrome: a randomized controlled trial [Research]

Background:

The effectiveness of acupuncture for managing carpal tunnel syndrome is uncertain, particularly in patients already receiving conventional treatments (e.g., splinting). We aimed to assess the effects of electroacupuncture combined with splinting.

Methods:

We conducted a randomized parallel-group assessor-blinded 2-arm trial on patients with clinically diagnosed primary carpal tunnel syndrome. The treatment group was offered 13 sessions of electroacupuncture over 17 weeks. The treatment and control groups both received continuous nocturnal wrist splinting.

Results:

Of 181 participants randomly assigned to electroacupuncture combined with splinting (n = 90) or splinting alone (n = 91), 174 (96.1%) completed all follow-up. The electroacupuncture group showed greater improvements at 17 weeks in symptoms (primary outcome of Symptom Severity Scale score mean difference [MD] –0.20, 95% confidence interval [CI] –0.36 to –0.03), disability (Disability of Arm, Shoulder and Hand Questionnaire score MD –6.72, 95% CI –10.9 to –2.57), function (Functional Status Scale score MD –0.22, 95% CI –0.38 to –0.05), dexterity (time to complete blinded pick-up test MD –6.13 seconds, 95% CI –10.6 to –1.63) and maximal tip pinch strength (MD 1.17 lb, 95% CI 0.48 to 1.86). Differences between groups were small and clinically unimportant for reduction in pain (numerical rating scale –0.70, 95% CI –1.34 to –0.06), and not significant for sensation (first finger monofilament test –0.08 mm, 95% CI –0.22 to 0.06).

Interpretation:

For patients with primary carpal tunnel syndrome, chronic mild to moderate symptoms and no indication for surgery, electroacupuncture produces small changes in symptoms, disability, function, dexterity and pinch strength when added to nocturnal splinting.

Trial registration:

Chinese Clinical Trial Register no. ChiCTR-TRC-11001655 (www.chictr.org.cn/showprojen.aspx?proj=7890); subsequently deposited in the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR-TRC-11001655).

[Comment] Improving outcomes in dialysis fistulae

One of the great medical successes in recent years has been the reduction in the number of patients waiting for a kidney transplant. In 2009, 7190 people were on the waiting list in the UK, and in June, 2016, this number had decreased to 5116.1 Nevertheless, many people on the list can expect to wait for years, and many patients with end-stage renal failure are never suitable for transplantation because of comorbidities and remain instead on dialysis. As such, a substantial demand exists for dialysis access surgery; in the USA, 105 923 patients initiate haemodialysis annually2 and in the UK, more than 4000 vascular access procedures are done each year to facilitate haemodialysis.