Guy Haller

[(18)F]Fluoroethyltyrosine- positron emission tomography-guided radiotherapy for high-grade glioma.

BackgroundTo compare morphological gross tumor volumes (GTVs), defined as pre- and postoperative gadolinium enhancement on T1-weighted magnetic resonance imaging to biological tumor volumes (BTVs), defined by the uptake of 18F fluoroethyltyrosine (FET) for the radiotherapy planning of high-grade glioma, using a dedicated positron emission tomography (PET)-CT scanner equipped with three triangulation lasers for patient positioning.MethodsNineteen patients with malignant glioma were included into a prospective protocol using FET PET-CT for radiotherapy planning. To be eligible, patients had to present with residual disease after surgery. Planning was performed using the clinical target volume (CTV = GTV ∪ BTV) and planning target volume (PTV = CTV + 20 mm). First, the interrater reliability for BTV delineation was assessed among three observers. Second, the BTV and GTV were quantified and compared. Finally, the geometrical relationships between GTV and BTV were assessed.ResultsInterrater agreement for BTV delineation was excellent (intraclass correlation coefficient 0.9). Although, BTVs and GTVs were not significantly different (p = 0.9), CTVs (mean 57.8 ± 30.4 cm3) were significantly larger than BTVs (mean 42.1 ± 24.4 cm3; p < 0.01) or GTVs (mean 38.7 ± 25.7 cm3; p < 0.01). In 13 (68%) and 6 (32%) of 19 patients, FET uptake extended ≥ 10 and 20 mm from the margin of the gadolinium enhancement.ConclusionUsing FET, the interrater reliability had excellent agreement for BTV delineation. With FET PET-CT planning, the size and geometrical location of GTVs and BTVs differed in a majority of patients.

Rate of undesirable events at beginning of academic year: retrospective cohort study

Objective To determine whether an increase in the rate of undesirable events occurs after care provided by trainees at the beginning of the academic year. Design Retrospective cohort study using administrative and patient record data. Setting University affiliated hospital in Melbourne, Australia. Participants 19 560 patients having an anaesthetic procedure carried out by first to fifth year trainees starting work for the first time at the hospital over a period of five years (1995-2000). Main outcome measures Absolute event rates, absolute rate reduction, and rate ratios of undesirable events. Results The rate of undesirable events was higher at the beginning of the academic year compared with the rest of the year (absolute event rate 137 v 107 per 1000 patient hours, relative rate reduction 28%, P<0.001). The overall adjusted rate ratio for undesirable events was 1.40, 95% confidence interval 1.24 to 1.58. This excess risk was seen for all residents, regardless of their level of seniority. The excess risk decreased progressively after the first month, and the trend disappeared fully after the fourth month of the year (rate ratio for fourth month 1.21, 0.93 to 1.57). The most important decreases were for central and peripheral nerve injuries (relative difference 82%), inadequate oxygenation of the patient (66%), vomiting/aspiration in theatre (53%), and technical failures of tracheal tube placement (49%). Conclusions The rate of undesirable events was greater among trainees at the beginning of the academic year regardless of their level of clinical experience. This suggests that several additional factors, such as knowledge of the working environment, teamwork, and communication, may contribute to the increase.

Quality and safety indicators in anesthesia: a systematic review.

Clinical indicators are increasingly developed and promoted by professional organizations, governmental agencies, and quality initiatives as measures of quality and performance. To clarify the number, characteristics, and validity of indicators available for anesthesia care, the authors performed a systematic review. They identified 108 anesthetic clinical indicators, of which 53 related also to surgical or postoperative ward care. Most were process (42%) or outcome (57%) measures assessing the safety and effectiveness of patient care. To identify possible quality issues, most clinical indicators were used as part of interhospital comparison or professional peer-review processes. For 60% of the clinical indicators identified, validity relied on expert opinion. The level of scientific evidence on which prescriptive indicators (“how things should be done”) were based was high (1a–1b) for 38% and low (4–5) for 62% of indicators. Additional efforts should be placed into the development and validation of anesthesia-specific quality indicators.

The results of surgery, with or without radiotherapy, for primary spinal myxopapillary ependymoma: a retrospective study from the rare cancer network

PURPOSE The aim of this study was to assess the outcome of patients with primary spinal myxopapillary ependymoma (MPE). MATERIALS AND METHODS Data from a series of 85 (35 females, 50 males) patients with spinal MPE were collected in this retrospective multicenter study. Thirty-eight (45%) underwent surgery only and 47 (55%) received postoperative radiotherapy (RT). Median administered radiation dose was 50.4 Gy (range, 22.2-59.4). Median follow-up of the surviving patients was 60.0 months (range, 0.2-316.6). RESULTS The 5-year progression-free survival (PFS) was 50.4% and 74.8% for surgery only and surgery with postoperative low- (<50.4 Gy) or high-dose (>or=50.4 Gy) RT, respectively. Treatment failure was observed in 24 (28%) patients. Fifteen patients presented treatment failure at the primary site only, whereas 2 and 1 patients presented with brain and distant spinal failure only. Three and 2 patients with local failure presented with concomitant spinal distant seeding and brain failure, respectively. One patient failed simultaneously in the brain and spine. Age greater than 36 years (p = 0.01), absence of neurologic symptoms at diagnosis (p = 0.01), tumor size >or=25 mm (p = 0.04), and postoperative high-dose RT (p = 0.05) were variables predictive of improved PFS on univariate analysis. In multivariate analysis, only postoperative high-dose RT was independent predictors of PFS (p = 0.04). CONCLUSIONS The observed pattern of failure was mainly local, but one fifth of the patients presented with a concomitant spinal or brain component. Postoperative high-dose RT appears to significantly reduce the rate of tumor progression.

Validity of Unplanned Admission to an Intensive Care Unit as a Measure of Patient Safety in Surgical Patients

Background:An unplanned admission to the intensive care unit within 24 h of a procedure (UIA) is a recommended clinical indicator in surgical patients. Often regarded as a surrogate marker of adverse events, it has potential as a direct measure of patient safety. Its true validity for such use is currently unknown. Methods:The authors validated UIA as an indicator of safety in surgical patients in a prospective cohort study of 44,130 patients admitted to their hospital. They assessed the association of UIA with intraoperative incidents and near misses, increased hospital length of stay, and 30-day mortality as three constructs of patient safety. Results:The authors identified 201 patients with a UIA; 104 (52.2%) had at least one incident or near miss. After adjusting for confounders, these incidents were significantly associated with UIA in all categories of surgical procedures analyzed; odds ratios were 12.21 (95% confidence interval [CI], 6.33–23.58), 4.06 (95% CI, 2.74–6.03), and 2.13 (95% CI, 1.02–4.42), respectively. The 30-day mortality for patients with UIA was 10.9%, compared with 1.1% in non-UIA patients. After risk adjustment, UIA was associated with excess mortality in several types of surgical procedures (odds ratio, 3.89; 95% CI, 2.14–7.04). The median length of stay was increased if UIA occurred: 16 days (interquartile range, 10–31) versus 2 days (interquartile range, 0.5–9) (P < 0.001). For patients with a UIA, the likelihood of discharge from hospital was significantly decreased in most surgical categories analyzed, with adjusted hazard ratios of 0.41 (95% CI, 0.23–0.77) to 0.58 (95% CI, 0.37–0.93). Conclusions:These findings provide strong support for the construct validity of UIA as a measure of patient safety.

Bispectral and spectral entropy indices at propofol-induced loss of consciousness in young and elderly patients

BACKGROUND Bispectral (BIS) and state/response entropy (SE/RE) indices have been widely used to estimate depth of anaesthesia and sedation. In adults, independent of age, adequate and safe depth of anaesthesia for surgery is usually assumed when these indices are between 40 and 60. Since the EEG is changing with increasing age, we investigated the impact of advanced age on BIS, SE, and RE indices during induction. METHODS BIS and SE/RE indices were recorded continuously in elderly (> or =65 yr) and young (< or =40 yr) surgical patients who received propofol until loss of consciousness (LOC) using stepwise increasing effect-site concentrations. LOC was defined as an observer assessment of alertness/sedation score <2, corresponding to the absence of response to mild prodding or shaking. RESULTS We analysed 35 elderly [average age, 78 yr (range, 67-96)] and 34 young [35 (19-40)] patients. At LOC, all indices were significantly higher in elderly compared with young patients: BIS(LOC), median 70 (range, 58-91) vs 58 (40-70); SE(LOC), 71 (31-88) vs 55.5 (23-79); and RE(LOC), 79 (35-96) vs 59 (25-80) (P<0.001 for all comparisons). With all three monitors, only a minority of elderly patients lost consciousness within a 40-60 index range: two (5.7%) with BIS and RE each, and seven (20%) with SE. In young patients, the respective numbers were 20 (58.8%) for BIS, 13 (38.2%) for SE, and nine (26.5%) for RE. CONCLUSIONS In adults undergoing propofol induction, BIS, SE, and RE indices at LOC are significantly affected by age.

Intra-operative awareness in children: the value of an interview adapted to their cognitive abilities

Intra‐operative awareness in paediatric patients has been little studied for many years because of the difficulties in relying on childrens testimony. Earlier questionnaires used to detect this complication were not adapted to childrens language and memory capacities. By using a qualitative method, a semi‐structured in‐depth interview adapted to their cognitive abilities, we have now conducted a prospective evaluation of the incidence and risk factors for intra‐operative awareness in children undergoing general anaesthesia. Data were obtained from interviews with 410 children (aged 6–16 years) which were conducted within 36 h of general anaesthesia for elective or emergency surgery. One month after surgery, 293 of these patients were interviewed again. Three independent adjudicators classified each potential case of awareness. We considered awareness to include both the ‘confirmed awareness’ and the ‘possible awareness’ cases. The accuracy of the childrens recall was calculated. The relationship between their awareness and the anaesthesia management was examined. There were five cases of confirmed awareness, and six cases of possible awareness. The incidence of confirmed awareness was 1.2%, but when the possible cases were also considered, the overall incidence of this complication was as high as 2.7% (95% confidence interval, 1.4–5.0%). The only predictive factor identified was the multiple manoeuvres with which the airways were secured (odds ratio, 8.4; 95% confidence interval, 2.4–29.07%). The present study confirms the existence of intra‐operative awareness in the paediatric population. The application of a semi‐structured in‐depth interview adapted to the cognitive capacities of the children appears to enhance the detection of awareness in this population.

Reappraisal of Acetazolamide for the Prevention of Acute Mountain Sickness: A Systematic Review and Meta-Analysis

Acetazolamide is used to prevent acute mountain sickness (AMS). We assessed efficacy and harm of acetazolamide for the prevention of AMS, and tested for dose-responsiveness. We systematically searched electronic databases (until April 2011) for randomized trials comparing acetazolamide with placebo for the prevention of AMS. For each dose, risk ratios were aggregated using a Mantel-Haenszel fixed effect model. Numbers needed to treat (NNT) to benefit one subject with each dose were calculated for different baseline risks. Modes of ascent were taken as proxies of baseline risks. Twenty-four trials were included; 1011 subjects received acetazolamide 250, 500, or 750 mg day⁻¹; 854 received placebo. When climbing, median speed of ascent was 14 m/h, average AMS rate in controls was 34%, and NNT to prevent AMS with acetazolamide 250, 500, and 750 mg/day compared with placebo was 6.5, 5.9, and 5.3. When ascending by transport and subsequent climbing (speed of ascent 133 m/h) or by transport alone (491 m/h), average AMS rate in controls was 60%, and NNT with acetazolamide 250, 500, and 750 mg/day was 3.7, 3.3, and 3.0. In hypobaric chambers, median speed of ascent was 4438 m/h, average AMS rate in controls was 86%, and NNT with acetazolamide 250, 500, and 750 mg/day was 2.6, 2.3, and 2.1. The risk of paresthesia was increased with all doses. The risk of polyuria and taste disturbance was increased with 500 and 750 mg/day. The degree of efficacy of acetazolamide for the prevention of AMS is limited when the baseline risk is low, and there is some evidence of dose-responsiveness.

Morbidity in anaesthesia: Today and tomorrow

Based on results recorded of perioperative mortality, anaesthetic care is often cited as a model for its improvements with regard to patient safety. However, anaesthesia-related morbidity represents a major burden for patients as yet in spite of major progresses in this field since the early 1980s. More than 1 out of 10 patients will have an intraoperative incident and 1 out of 1000 will have an injury such as a dental damage, an accidental dural perforation, a peripheral nerve damage or major pain. Poor preoperative patient evaluation and postoperative care often contribute to complications. Human error and inadequate teamwork are frequently identified as major causes of failures. To further improve anaesthetic care, high-risk technical procedures should be performed after systematic training, and further attention should be focussed on preoperative assessment and post-anaesthetic care. To minimise the impact of human errors, guidelines and standardised procedures should be widely implemented. Deficient teamwork and communication should be addressed through specific programmes that have been demonstrated to be effective in the aviation industry: crew resource management (CRM) and simulation. The impact of the overall safety culture of health-care organisations on anaesthesia should not be minimised, and organisational issues should be systematically addressed.

A clinical pathway in a post-anaesthesia care unit to reduce length of stay, mortality and unplanned intensive care unit admission.

Context The immediate post-operative period is critical with regard to post-operative outcomes. Objective To assess the impact of a clinical pathway implemented in a post-anaesthesia care unit on post-operative outcomes. Design A retrospective cohort study based on electronic patient records. Setting A post-anaesthesia care unit in a Swiss University Hospital. Patients Adult patients after elective and non-elective surgery. Intervention Implementation of a clinical pathway with a nurse-driven fast-track programme for uncomplicated patients (systematic use of Aldrete score and systematic discharge without physician) and a physician-driven slow-track programme for complicated patients (systematic handover between operating theatre and post-anaesthesia care unit, and between post-anaesthesia care unit and ward, systematic rounds, systematic use of standardised care for post-operative events, strict discharge criteria). Main outcome measures Post-anaesthesia care unit length of stay, in-hospital mortality and unplanned admission to the ICU after post-anaesthesia care unit stay. Methods Comparison of the periods before and after implementation using median and interquartile range (IQR) and rates (%). Statistical analysis: unpaired Students t-test, &khgr;2 test, Wilcoxon rank test. Differences were adjusted through multivariate analyses with linear and logistic regression (level of significance: P < 0.05) and expressed as odds ratio (OR) with 95% confidence interval (95% CI). Results After implementation, the median post-anaesthesia care unit length of stay decreased for all patients from 163 min (IQR 103–291) to 148 min (IQR 96–270; P < 0.001); in the American Society of Anaesthesiologists 1–2 patients, it decreased from 152 min (IQR 102–249) to 135 min (IQR 91–227; P < 0.001). In-hospital mortality decreased for all patients from 1.7 to 0.9% [adjusted OR 0.36 (95% CI 0.22–0.59), P < 0.001]. The number of unplanned admissions to the ICU decreased from 113 (2.8%) to 91 (2.1%) [adjusted OR 0.73 (95% CI 0.53–0.99), P = 0.04]. Conclusion A clinical pathway in a post-anaesthesia care unit can significantly reduce length of stay and can improve post-operative outcome.