Yuu Tanaka

Measurement of quality of recovery using the QoR-40: a quantitative systematic review

BACKGROUND Several rating scales have been developed to measure quality of recovery after surgery and anaesthesia, but the most extensively used is the QoR-40, a 40-item questionnaire that provides a global score and subscores across five dimensions: patient support, comfort, emotions, physical independence, and pain. It has been evaluated in a variety of settings, but its overall psychometric properties (validity, reliability, ease of use, and interpretation) and clinical utility are uncertain. METHODS We undertook a quantitative systematic review of studies evaluating psychometric properties of the QoR-40. Data were combined in meta-analyses using random effects models. This resulted in a total sample of 3459 patients from 17 studies originating in nine countries. RESULTS We confirmed content, construct, and convergent [pooled r=0.58, 95% confidence interval (CI): 0.51-0.65] validity. Reliability was confirmed by excellent intraclass correlation (pooled α=0.91, 95% CI: 0.88-0.93), test-retest reliability (pooled r=0.90, 95% CI: 0.86-0.92), and inter-rater reliability (intraclass correlation=0.86). The clinical utility of the QoR-40 instrument was supported by high patient recruitment into evaluation studies (97%), and an excellent completion and return rate (97%). The mean time to complete the QoR-40 was 5.1 (95% CI: 4.4-5.7) min. CONCLUSIONS The QoR-40 is a widely used and extensively validated measure of quality of recovery. The QoR-40 is a suitable measure of postoperative quality of recovery in a range of clinical and research situations.

Influence of room heating on ambulatory blood pressure in winter: a randomised controlled study

Background Previous studies have proposed that higher blood pressure (BP) in winter is an important cause of increased mortality from cardiovascular disease during the winter. Some observational and physiological studies have shown that cold exposure increases BP, but evidence from a randomised controlled study assessing the effectiveness of intensive room heating for lowering BP was lacking. Objectives The present study aimed to determine whether intensive room heating in winter decreases ambulatory BP as compared with weak room heating resulting in a 10°C lower target room temperature when sufficient clothing and bedclothes are available. Methods We conducted a parallel group, assessor blinded, simple randomised controlled study with 1:1 allocation among 146 healthy participants in Japan from November 2009 to March 2010. Ambulatory BP was measured while the participants stayed in single experimental rooms from 21:00 to 8:00. During the session, participants could adjust the amount of clothing and bedclothes as required. Compared with the weak room heating group (mean temperature±SD: 13.9±3.3°C), systolic morning BP (mean BP 2 h after getting out of bed) of the intensive room heating group (24.2±1.7°C) was significantly lower by 5.8 mm Hg (95% CI 2.4 to 9.3). Sleep-trough morning BP surges (morning BP minus lowest night-time BP) in the intensive room heating group were significantly suppressed to about two thirds of the values in the weak room heating group (14.3 vs 21.9 mm Hg; p<0.01). Conclusions Intensive room heating decreased morning BP and the morning BP surge in winter.

Tracheal intubation by trainees does not alter the incidence or duration of postoperative sore throat and hoarseness: a teaching hospital-based propensity score analysis

BACKGROUND Postoperative throat complications, such as sore throat and hoarseness, are frequent complications of tracheal intubation. To assess whether severity of throat complications is related to the experience of physicians performing tracheal intubation, we compared the incidence and duration of postoperative sore throat and hoarseness and patient satisfaction between tracheal intubation performed by trainees and experienced consultant anaesthetists. METHODS This is a retrospective review of an institutional registry containing records of 21 606 patients undergoing general anaesthesia and was conducted with ethics board approval. All tracheal intubations by trainees were performed under the supervision of consultant anaesthetists. To avoid channel bias, the propensity score analysis was used to generate a set of matched cases (intubations by trainees) and controls (intubations by anaesthetists), yielding 3465 (sore throat) and 3267 (hoarseness) matched patient pairs. The incidence and sustained rate of symptoms were compared as primary outcomes. We also compared patient satisfaction with perioperative care. RESULTS After propensity score matching, there was no difference between tracheal intubation by trainees and tracheal intubation by consultant anaesthetists in the incidences of sore throat (32.9 vs 32.6%, P=0.84) or hoarseness (35.8 vs 35.2%, P=0.60). Odds ratios and 95% confidence intervals for tracheal intubation by trainees were 1.01 (0.91-1.12) for sore throat and 1.03 (0.93-1.14) for hoarseness. The rates of sustained sore throat and hoarseness over the course were low (P=0.85 and P=0.67, respectively). Hazard ratios and 95% confidence intervals for tracheal intubation by trainees were 0.99 (0.94-1.05) for sustained sore throat and 0.99 (0.93-1.05) for sustained hoarseness. Patient satisfaction did not differ between matched groups (P=0.66 and P=0.83). CONCLUSIONS Tracheal intubation by trainees under the supervision of consultant anaesthetists did not worsen the postoperative airway outcomes, such as sore throat and hoarseness.

Development of the Japanese 15D Instrument of Health-Related Quality of Life: Verification of Reliability and Validity among Elderly People

Objective The 15D is a self-administered questionnaire for assessment of health-related quality of life, which contains 15 questions with 5 response options each. This study was conducted to evaluate the reliability and validity of the Japanese 15D. Methods The subjects were 430 community-dwelling elderly people. Each item of the 15D was scored on a 5-point Likert scale, with level 1 being the best, score 1. Reliability was assessed by determination of the internal consistency and test-retest reliability. Criterion-based validity was assessed using the Japanese version of the Nottingham Health Profile (NHP) and Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG index). Acceptability was assessed by inquiring about the time required to complete the questionnaire and the burden felt in responding to it. Results The answers of 423 individuals who responded to all items were analyzed. The median time required to complete the questionnaire was 5.0 minutes, and the proportion of subjects who indicated that the questionnaire was easy to complete was 98.3%. The Cronbach’s alpha coefficients for all 15 items in the 2 surveys were 0.793 and 0.792, respectively. The intraclass correlation coefficients for the 15 items ranged from 0.44 to 0.72. In the relationship between the 15D and the NHP, the correlation coefficients between the corresponding domains were higher than those between non-corresponding domains. The prevalence of disability in higher-level functional capacity was higher in the “level 2 to 5” group than in the “level 1” group. Conclusions The Japanese version of the 15D showed sufficient internal consistency and moderate repeatability. Because of the short time required to complete the Japanese 15D and the significant relationships between the scores on the 15D and the NHP, and between the 15D and higher-level functional capacity, the acceptability and validity of the Japanese 15D were considered to be sufficient.

Combined use of transesophageal echocardiography and basket catheter can prevent tumor embolism in a patient with renal cell carcinoma.

MASSIVE pulmonary tumor embolism is one of the serious complications that can occur during surgical treatment for renal cell carcinoma, especially tumors that extend into the inferior vena cava (IVC) Therefore, the prevention of pulmonary embolism is important. We describe a case in which transesophageal echocardiography (TEE) and a basket catheter were used during thrombectomy and radical nephrectomy for renal carcinoma that invaded into the IVC to prevent massive tumor embolization.

Multivariate analyses of Ki-67, cytokeratin 13 and cytokeratin 17 in diagnosis and prognosis of oral precancerous lesions

BACKGROUND Ki-67, cytokeratin 13, and/or cytokeratin 17 detection by immunohistochemistry has been reported to be useful for the diagnosis of oral precancerous lesions. However, the use of these markers remains controversial because of the lack of appropriately designed statistical studies. We assessed the hypothesis that Ki-67, cytokeratin 13, or cytokeratin 17 immunohistochemistry could facilitate the diagnosis of oral precancerous lesions and/or predict prognosis. METHODS Epithelial dysplasia was classified as low grade (none or mild dysplasia) or high grade (moderate dysplasia, severe dysplasia, or carcinoma in situ). This study included 58 low-grade and 36 high-grade dysplasia cases. We used logistic regression to assess the diagnostic values of Ki-67, cytokeratin 13, and cytokeratin 17 for high-grade dysplasia. Correlations between these markers and the prognosis of oral atypical epithelium were assessed using the Cox proportional hazards model. RESULTS Ki-67 overexpression and cytokeratin 13 loss were independent diagnostic markers for high-grade dysplasia (odds ratios, 1.92 and 2.53; 95% confidence intervals, 1.03-3.58, and 1.19-5.38, respectively). The area under the curve of Ki-67 was 0.73 and that of cytokeratin 13 was 0.72. However, the combination of Ki-67 and cytokeratin 13 yielded the area under the curve of 0.78. Ki-67 overexpression was significantly associated with recurrence and/or malignant transformation of oral atypical epithelium (hazard ratio, 7.25; 95% confidence interval, 1.07-48.92). CONCLUSIONS Ki-67 overexpression and cytokeratin 13 loss may be useful for distinguishing oral precancerous lesions from reactive atypical epithelium. Moreover, Ki-67 overexpression may be a risk factor for recurrence and/or malignant transformation of oral atypical epithelium.

Use of quality of recovery score (QoR40) in the assessment of postoperative recovery and evaluation of enhanced recovery after surgery protocols.

Surgery has become less invasive with technological advances in surgical instruments and imaging. In addition, safer anesthesia has been achieved with the use of airway management tools including the video laryngoscope and supraglottic airway device, perioperative assessment by transesophageal echocardiography during noncardiac and cardiac surgery, and new anesthetic agents and muscle relaxants such as remifentanil and rocuronium bromide. Nowadays, there is an emphasis on the quality of postoperative recovery [1]. Quality of recovery, an important postoperative outcome, is classified into two categories [2]: doctor-reported outcome (DRO) and patient-reported outcome (PRO). DRO includes survival, adverse events, and length of hospital stay; PRO includes quality of life (QoL), quality of recovery, and patient satisfaction. The Food and Drug Administration defines PRO as ‘‘any report on the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else’’ [2]. Litwin et al. [3] showed that physician ratings of patient symptoms do not correlate well with patient self-assessment of health-related QoL, suggesting that both DRO and PRO are important. Donabedian’s classical model of quality of care consists of three components: structure, process, and outcomes [4]. The Donabedian model is applicable to perioperative medicine (Fig. 1). Monitoring and evaluation of both DRO and PRO are essential for improving quality of care.

Improving the safety and quality of surgical patient care: what can we learn from quality management of industries?

Perioperativemanagement of surgical patients includes pre-, intraand postoperative care, which has been disjointed and characterized by significant variability of care, depending on the individual experience and preference of the surgeon and anesthesiologist. However, varied and fragmented care by each physician may expose surgical patients to lapses in expected care, increase the chance of mistakes and accidents, and often result in unnecessary interventions. One way to reduce this variability is to manage patients undergoing surgery as one perioperative continuum of care, by the perioperative team [1, 2]. Recently, the concept of perioperative surgical home (PSH) has been advocated as a new model for the care of surgical patients. The American Society of Anesthesiologists strongly supports the development of PSH as the futuremodel of anesthesia practice [2– 5]. The PSH model is defined as a patient-centered and physician-led multidisciplinary and team-based system of coordinated care, which guides the patient throughout the entire surgical experience, from the minute the surgeon decides to operate until 30 days post-discharge. There are five major goals of PSH: (1) provide a portal of entry to perioperative care and ensure continuity, (2) identify and manage patients according to acuity, comorbidities and risk factors, (3) deliver evidence-based clinical care before, during and after the procedure, (4) manage, coordinate and follow up on perioperative care across specialty lines and (5) measure and improve performance and cost–efficiency [2–4]. The central idea is to optimize the patient for surgery based on risk stratification and predeveloped evidence-based protocols, and improve the outcome at the lowest cost. Standardization of perioperative management by a team of professionals is a critical component of PSH. Kain et al. [2] reported the process of developing PSH for primary joint replacement surgery at University of California, Irvine, CA, USA. Multidisciplinary teams consisting of anesthesiologists, surgeons, nurses, pharmacists, physical therapists, case managers, social workers and information technology experts met weekly during the implementation phase. Interestingly, all team leaders underwent training in Lean Six Sigma methodology and Lean Six Sigma was used as a cornerstone for PSH implementation. Lean Six Sigma is a management approach to performance improvement based on a combination of the different tools of Lean and Six Sigma. Lean methodology originated with Toyota, which revolutionized the car industry using rigorous standardization in its production lines. Lean focuses on speed, efficiency and taking waste out of a process, creating enhanced customer satisfaction and less wasted resources. Six Sigma methodology is a measurement-based strategy that focuses on process improvement and variation reduction to achieve Six Sigma quality with no more than 3.4 defects per million opportunities. When combined and implemented properly, it can be a powerful management tool that can greatly improve an organization’s performance, by providing a structured approach to resolving problems. Conceptually, the perioperative environment could be similar to a production line and standardization of all perioperative procedures could result in an error-free, high-quality process. There has been growing evidence of the efficacy of using quality improvement (QI) methodologies such as M. Kawaguchi (&) Y. Tanaka Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan e-mail: drjkawa@naramed-u.ac.jp

Risk for lung cancer in workers exposed to benzidine and/or beta-naphthylamine: a protocol for systematic review and meta-analysis

BackgroundRisk for lung cancer in workers exposed to benzidine (BZ) and/or beta-naphthylamine (BNA), which are well-known bladder carcinogens, has been examined in many epidemiological studies, but individual epidemiological studies generally lack the power to examine the association between BZ/BNA exposure and lung cancer. We conduct a systematic review and meta-analysis to determine the risk for lung cancer among workers exposed to BZ/BNA occupationally.Methods/designStudies will be identified by a MEDLINE, EMBASE, CDSR, and CINAHL search and by the reference lists of articles/relevant reviews. Eligible studies will be cohort and case-control studies that report occupational BZ/BNA exposure and the outcome of interest (lung cancer death/incidence). The method of meta-analysis will be used to combine standardized mortality ratios (SMRs) and/or standardized incidence ratios (SIRs) from retrospective and prospective cohort studies and odds ratios (ORs) from case-control studies. Two reviewers will independently screen articles, extract data, and assess scientific quality using standardized forms and published quality assessment tools tailored for each study design. Overall pooled risk estimates and their corresponding 95% confidence intervals (CIs) will be obtained using random effects model. This systematic review and meta-analysis will be conducted following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines, and results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.DiscussionThis review will identify and synthesize studies of the association between occupational BZ/BNA exposure and lung cancer. The findings will help to identify whether BZ/BNA could cause lung cancer and might indicate whether workers with exposure to BZ/BNA have a need for preventive measures against non-urological cancer besides bladder cancer.Systematic review registrationPROSPERO CRD42014010250

In reply: MEP monitoring during aortic surgery

1. Sutedja NA, Hollands AWH, Jacobs MJ. MEP monitoring during aortic surgery: what we truly know. J Anesth. 2017;. doi:10.1007/ s00540-017-2367-6. 2. Tanaka Y, Kawaguchi M, Noguchi Y, Yoshitani K, Kawamata M, Masui K, Nakayama T, Yamada Y. Systematic review of motor evoked potentials monitoring during thoracic and thoracoabdominal aortic aneurysm open repair surgery: a diagnostic metaanalysis. J Anesth. 2016;30:1037–50. 3. Jacobs MJ, Mess W, Mochtar B, Nijenhuis RJ, Statius van Eps RG, Schurink GW. The value of motor-evoked potentials in reducing paraplegia during thoracoabdominal aneurysm repair. J Vasc Surg. 2006;43:239–46. To the Editor: We thank Studia and colleagues [1] for their comments on our manuscript [2]. Our group regularly double-check data obtained from independent researchers, and we hold paramount the accuracy of information that we present. Because of this, we deeply regret our inadvertent inclusion of poorly vetted data from the Jacobs 2006 study [3]. The issue centers around the debate about whether or not it is appropriate to consider a transient decline in motor evoked potential (MEP) as a true positive. Our critics maintain that only declines in MEP at surgical termination should be regarded as true-positive MEPs. Consequently, we reconsider our original analyses in light of our amended definition, i.e., MEP is to be regarded as ‘true positive’ only if it declines at the end of surgery. As a consequence of this recalculation, our MEP data have changed (ESM Table 1). However, our recalculations did not change our original conclusion. An ‘all-or-none’ MEP cut-off point may be best for detecting postoperative paraplegia following TAA/TAAA open repair surgery. To circumvent these issues in the future, we recommend that scientists and researchers with expertise in MEP