Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias

Introduction

In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias.

Methods

A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type.

Results

The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03–2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04–6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher’s exact test).

Conclusions

Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk.     

Validation of a Novel Surgical Data Capturing System Following Total Hip Arthroplasty

Background

The OrthoMiDaS (Orthopedic Minimal Data Set) Episode of Care (OME) database was developed in an effort to advance orthopedic outcome measurements on a national scale. This study was designed to evaluate if the OME data capture system would increase the quality of data collected in the context of primary and revision total hip arthroplasty (THA) compared to conventional operative notes.

Connective Tissue Growth Factor Modulates Adult β-Cell Maturity and Proliferation to Promote β-Cell Regeneration in Mice

Stimulation of endogenous β-cell expansion could facilitate regeneration in patients with diabetes. In mice, connective tissue growth factor (CTGF) is expressed in embryonic β-cells and in adult β-cells during periods of expansion. We discovered that in embryos CTGF is necessary for β-cell proliferation, and increased CTGF in β-cells promotes proliferation of immature (MafA⁻) insulin-positive cells. CTGF overexpression, under nonstimulatory conditions, does not increase adult β-cell proliferation. In this study, we tested the ability of CTGF to promote β-cell proliferation and regeneration after partial β-cell destruction. β-Cell mass reaches 50% recovery after 4 weeks of CTGF treatment, primarily via increased β-cell proliferation, which is enhanced as early as 2 days of treatment. CTGF treatment increases the number of immature β-cells but promotes proliferation of both mature and immature β-cells. A shortened β-cell replication refractory period is also observed. CTGF treatment upregulates positive cell-cycle regulators and factors involved in β-cell proliferation, including hepatocyte growth factor, serotonin synthesis, and integrin β1. Ex vivo treatment of whole islets with recombinant human CTGF induces β-cell replication and gene expression changes consistent with those observed in vivo, demonstrating that CTGF acts directly on islets to promote β-cell replication. Thus, CTGF can induce replication of adult mouse β-cells given a permissive microenvironment.     

In-Room Ultraviolet Air Filtration Units Reduce Airborne Particles During Total Joint Arthroplasty

Reducing airborne bioburden in total joint arthroplasty (TJA) is of critical importance. The efficacy of crystalline ultraviolet-C (C-UVC) filtration in reducing bioburden in a dynamic operating room (OR) environment has not been evaluated. We assessed whether C-UVC filtration reduced (i) total particle counts (TPC); (ii) viable particle counts (VPC); and (iii) colony-forming units (CFUs). Fifty primary TJA cases were performed in a positive-pressure OR; 25 cases with the C-UVC unit and 25 cases without. The air was sampled by a particle counter and an impact air sampler to measure particle counts and CFUs, respectively. To compare TPC, VPC, and CFU/m³ between groups, independent t tests and multivariate regression, adjusted for number of OR staff and door openings, were performed. The C-UVC group had significantly lower TPC (2.6 × 10⁶ vs. 4.7 × 10⁶ particles, p = 0.001) and VPC (18,605 vs. 27,516 particles, p = 0.001). There were fewer CFUs in the C-UVC group (10.9 CFU/m³ vs. 13.7 CFU/m³, p = 0.163). Multivariate analysis identified C-UVC filtration as a significant predictor of decreased TPC (β = −0.44, p = 0.002) and VPC (β = −0.47, p = 0.001) after accounting for door openings and number of OR staff. The reduction in CFUs was not significant on multivariate analysis. In this prospective pilot study, a C-UVC air disinfection and recirculation unit led to a significant reduction in both TPC and VPC and a non-significant reduction in CFU. Statement of clinical significance: Further studies are needed to investigate the effects of C-UVC filtration units on surgical-site infection rates. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:431-437, 2020     

Role of Resveratrol as Radiosensitizer by Targeting Cancer Stem Cells in Radioresistant Prostate Cancer Cells (PC-3)

Aim of Work: Here, we examined the role of resveratrol as a radiosensitizer by targeting cancer stem cells in radioresistant prostate cancer cells (PC-3) using stem cell markers CD44, CD49b and CD29, SOX2, OCT4, CXCR4, DCLK1 and EMT markers such as VIM and E-cadherin. Material and Methods: This study was an in vitro study involving PC-3 cell line which was dividing into four groups. Group I (CO): Control group composed of cells grown in the same medium without treatment with ionizing radiation or resveratrol. Group II (IR): Cells were treated with ionizing radiation alone. Group III (RV): Cells were treated with resveratrol alone. Group VI (IR&RV): The cells were treated with ionizing radiation and resveratrol in combination. The viability of cells was assessed by MTT assay. Genes of interest were measured by RT-PCR and the radiosensitizing efficacy of RV on proliferating cancer cells was determined by clonogenic assay. Results: Ionizing radiation significantly reduced PC-3 viability, lowered stem cell markers and affected epithelial to mesenchymal transition (EMT) genes expression at all doses (2, 4, 6 and 8 Gray). Resveratrol significantly decreased PC-3 viability and lowered stem cell markers and EMT genes expression at concentrations 35, 70 and 140 µM. Combining resveratrol treatment with ionizing radiation leads to significant reduction in cell viability and stem cell markers genes which was noticed with increasing the radiation dose when compared to ionizing radiation alone treated group. Conclusion: Resveratrol has a radiosensitizing effect, that ability is triggered by reducing the expression of cancer stem cell markers and affecting EMT markers. Resveratrol showed to be a good candidate for further studies as anticancer drug in the treatment of human prostate cancer.     

A WINNING COMBINATION: WOMEN,LITERACY, AND PARTICIPATION IN HEALTH CARE

Health information materials written at the appropriate reading level help individuals manage their own health care. In this study, we assessed the reading ability of clients and readability of the patient information materials at a rural women's health clinic. We administered a reading comprehension test to 50 subjects and tested the patient education materials using a readability formula. More than one in six women could not read all of the patient information, which could limit their understanding, and achievement of good health care. Commercially available materials can be checked readily for reading level using software installed in most computers. This software also allows clinicians who prepare their own materials for their patients to generate versions that are appropriate for different reading levels.     

The challenge of evaluating annual mammography screening for young women with a family history of breast cancer

It has been recommended that women aged 40-49 years with a significant family history of breast cancer should be offered annual mammography screening (http://www.nice.org.uk). An observational study known as FH01 (http://www.screeningservices.org/btw/fh01/index.asp) is evaluating this policy in a cohort of 6000 women at moderately increased risk of breast cancer due to family history. The main aims are to assess the likely impact on breast cancer mortality and cost-effectiveness. Measuring these outcomes is challenging in an environment where a randomized trial is not feasible and there is no natural comparison group. In this paper, we present some approaches to estimating effectiveness and the planned analyses. These involve comparison of disease stage and likely consequent breast cancer mortality in the cohort offered screening with that estimated in the absence of screening. The estimation uses observed outcomes in external populations and estimated outcomes for the hypothetical situation where screening had not taken place.     

Improving Adult Immunization Practices Using a Team Approach in the Primary Care Setting

Objectives. The objective of this study was to improve the immunization rates of primary care practices using a team approach.Methods. Practices performed 35 random chart abstractions at 2 time points and completed a survey about immunizations at baseline and 12 months after intervention. Data were collected for the following immunizations: influenza, pneumococcal, tetanus diphtheria (Td)/tetanus diphtheria pertussis (Tdap), hepatitis A, hepatitis B, meningococcal, varicella, herpes zoster, and human papilloma virus. Between baseline and after intervention, practice teams were given feedback reports and access to an online educational tool, and attended quality improvement coaching conference calls.Results. Statistically significant improvements were seen for Td/Tdap (45.6% pre-intervention, 55.0% post-intervention; P ≤ .01), herpes zoster (12.3% pre-intervention, 19.3% post-intervention; P ≤ .01), and pneumococcal (52.2% pre-intervention, 74.5% post-intervention; P ≤ .01) immunizations. Data also revealed an increase in the number of physicians who discussed herpes zoster and pneumococcal vaccinations with their patients (23.2% pre-intervention, 43.3% post-intervention; P ≤ .01 and 19.9% pre-intervention, 43.0% post-intervention; P ≤ .01, respectively) as well as an increase in physicians using the Centers for Disease Control and Prevention immunization schedule (52.9% pre-intervention, 88.2% post-intervention; P ≤ .02).Conclusions. The immunization rates of the primary care practices involved in this study improved.The need for improving quality is pervasive in the primary care setting, involving physicians, their practice teams, and administrative staff. The issue of low quality is well documented1–3 and is not partial to any 1 disease condition.4–15 Poor quality is a result of our medical system’s orientation to the urgent, its focus on acute and not chronic care, lack of adherence to evidence-based guidelines, and an increasing number of patients with complex medical conditions.2 Quality is characterized as a systems issue rather than an individual one,16 which has led efforts to focus on the practice team. Practice teams have been shown to improve quality in primary care.17,18 The issues with poor quality in primary care extend to the practice of adult immunizations.19 It is estimated that between 50 000 and 70 000 US adults die each year because of diseases that could be prevented by vaccination.20 For example, influenza is the sixth leading cause of death for adults and contributes to at least 200 000 hospitalizations and 36 000 deaths annually.21,22 Economic costs associated with influenza are projected to be $87.1 billion.23Adult vaccination guidelines, such as those published by the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices,24 are increasingly evidence-based and are a good reference for practices to measure themselves against when doing immunization practice redesign work. Although childhood vaccinations have become a public health success, adult vaccination rates are low, prompting the movement toward “lifespan immunizations.”20,25 However, quality gaps and missed opportunities for vaccination exist between the number of patients who are recommended to receive vaccinations and those who actually receive them.26–30 A variety of barriers at the practice, patient, economic, and social level help explain these missed opportunities. For instance, only 60% of physicians reported using CDC and Advisory Committee on Immunization Practice guidelines as their reference for adult immunizations, and most often reported recommending vaccinations at well visits compared with sick visits.31 Physicians also reported multiple barriers to vaccinating patients, including lack of health insurance, fear of needles, and misconception of the safety and efficacy of vaccinations.31 In turn, patients consistently reported that their physicians do not recommend vaccinations.31,32A comprehensive quality approach was considered to be more effective than mere guideline dissemination because the latter has not been shown to be successful alone in changing practice patterns.33,34 The American College of Physicians (ACP) developed this quality improvement program to help physicians and practice teams learn about the current recommendations and best practices for adult immunization. The goal of this prospective study was to improve the immunization practices of primary care practices by using a team approach.