PURPOSE: The objective was to determine if particular magnetic resonance, clinical and demographic findings were associated with functional status prior to surgery and predictive of functional outcomes at follow-up. RESULTS: The study included 65 consecutive CSM patients. The modified Japanese Orthopaedic Association Scale (mJOA) was used as the primary outcome measure. Higher baseline mJOA scores were associated with younger age, shorter duration of symptoms, fewer compressed segments and less severe cord compression. Better post-operative mJOA scores were associated with younger age, shorter duration of symptoms and higher baseline scores. Using multivariate analysis, baseline and follow-up mJOA scores adjusted for baseline mjOA score were best predicted by age. CONCLUSION: Age and clinical severity scores at admission can both provide valuable information. However, MR imaging features of the spinal cord before surgery cannot accurately predict the functional prognosis for patients with CSM and hence alternative imaging approaches may be required.

PURPOSE: The objective was to determine if particular magnetic resonance, clinical and demographic findings were associated with functional status prior to surgery and predictive of functional outcomes at follow-up. RESULTS: The study included 65 consecutive CSM patients. The modified Japanese Orthopaedic Association Scale (mJOA) was used as the primary outcome measure. Higher baseline mJOA scores were associated with younger age, shorter duration of symptoms, fewer compressed segments and less severe cord compression. Better post-operative mJOA scores were associated with younger age, shorter duration of symptoms and higher baseline scores. Using multivariate analysis, baseline and follow-up mJOA scores adjusted for baseline mjOA score were best predicted by age. CONCLUSION: Age and clinical severity scores at admission can both provide valuable information. However, MR imaging features of the spinal cord before surgery cannot accurately predict the functional prognosis for patients with CSM and hence alternative imaging approaches may be required.

PURPOSE: To investigate relationships between preoperative and intraoperative characteristics with outcome variables in patients suffering from primary rhegmatogenous retinal detachment (RRD) or traction retinal detachment (TRD) complicated by serous choroidal detachment (CD). Choroidal detachment is a rare complication of retinal detachment and the current literature cites generally poor visual outcome variables. By investigating a retrospective case series, we hope to elucidate new relationships and embolden existing ones so that future physicians can make more educated decisions regarding the care for these complicated patients. METHODS: A retrospective case series analyzed 18 patient’s medical records (18 eyes) who had been diagnosed and surgically treated for RRD or TRD associated with a CD at the Longwood Medical Eye Center at Beth Israel Deaconess Medical Center. Patients with RDCD who had undergone 23-gauge pars plana vitrectomy with silicone oil tamponade were selected. Exclusionary criteria included ocular complications such as phthisis bulbi and open globe trauma. Patients experienced a variety of surgical procedures including by not limited to relaxing retinotomy (n=12 eyes), choroidal drainage (n=10 eyes), endoscopy-assisted PPV (n=10 eyes), and ERM peeling (n=8 eyes). Primary outcome variables tabulated were primary and final anatomic success, defined as successful reattachment of the retina to the underlying choroid, and final visual acuity. RESULTS: The mean age of the sample group was 69 with 8 patients (44%) diagnosed with preoperative hypotony (IOP <= 6 mmHg). A total of 12 patients were pseudophakic (67%). With a mean follow-up of 21.6 months, patients exhibited expected visual outcomes with 6 patients (33%) improving visual acuity and 7 patients (39%) decreasing visual acuity. Final anatomic success was seen in 17 cases (94%). A significant correlation was found between decreased number of previous surgeries and better visual outcomes (change in BCVA). Another significant relationship correlates choroidal drainage with worse visual outcomes (change in BCVA). Finally, patients who received ERM peeling had better rates of primary anatomic success. CONCLUSION: The advanced age of the sample lends itself to increased risk for cataracts and thus pseudophakia. In addition, high rates of diabetes and macular degeneration follow. The pathophysiology of RDCD in relation to the risk factors of hypotony and macular holes is possibly based on the Starling forces and favorable fluid transudation into the suprachoroidal space. Although the outcomes of this study were similar to previous literature, the visual outcomes are still poor at best. Reducing the number of previous, invasive, ocular surgeries was seen to be correlated with better visual outcomes. In addition, performing ERM peels is seen to be correlated with improved rates of primary anatomic success. More research is required on the etiology of the disease process and a case-controlled longitudinal study may be helpful in determining more relationships with outcome variables.

Background:Idiopathic toe walking (ITW) is a diagnosis of exclusion and represents a spectrum of severity. Treatment for ITW includes observation and a variety of conservative treatment methods, with surgical intervention often reserved for severe cases. Previous studies reviewing treatment outcomes are often difficult to interpret secondary to a mixture of case severity. The goal of this study was to review surgical outcomes in patients with severe ITW who had failed prior conservative treatment, as well as determine differences in outcomes based on the type of surgery performed.Methods:After IRB approval, all patients with surgical management of severe ITW at a single institution were identified. Zone II or zone III plantar flexor lengthenings were performed in all subjects. Clinical, radiographic, and motion analysis data were collected preoperatively and at 1 year following surgery.Results:Twenty-six patients (46 extremities) with a diagnosis of severe ITW from 2002 to 2017 were included. Zone II lengthenings were performed in 25 extremities (mean age=9.9 y) and zone III lengthenings were performed in 21 extremities (mean age=8.6 y). At the most recent follow-up, 100% of zone III lengthening extremities and 88% of zone II lengthening demonstrated decreased severity of ITW. Six extremities required additional treatment, all of which were initially managed with zone II lengthenings.Conclusions:Severe ITW or ITW that has not responded to conservative treatment may benefit from surgical intervention. More successful outcomes, including continued resolution of toe walking, were observed in subjects treated with zone III lengthenings.Level of Evidence:Level III - case series.

INTRODUCTION: Unplanned hospital visits have emerged as a quality metric encompassing many aspects of postoperative morbidity and deficiencies in the transition from inpatient to outpatient care. This study aims to identify patient, encounter, and organizational factors that may influence Emergency Department (ED) visits and readmissions following bariatric surgery. METHODS: A modified version of a framework initially proposed by Vest et al. in their systematic review of the determinants of preventable readmissions was used as a conceptual framework for this study. The Michigan Bariatric Surgery Collaborative (MBSC) database was used to identify patients undergoing all primary bariatric procedures at 40 centers with >100 patients in the database from 2006–2015. Multivariate logistic regression modeling was used to identify factors associated with unplanned hospital visits. Using an indirect standardization process, each sites’ observed to expected ratio for 30-day readmission was calculated. The association between each site’s adjusted readmission rate with their rate of ED visits, Emergency Department-Sourced readmissions (EDSR), major complications, and compliance with best practices were calculated with Pearson’s correlation coefficients. RESULTS: Younger age, greater comorbidities, increased length of stay, procedure type, and Medicaid/Medicare insurance were significantly associated with readmissions in a multivariate logistic regression model. There was significant variation among sites’ adjusted rates of readmission, EDSR, best practice compliance, and major complications. There was a moderately strong association between each sites’ adjusted readmission rate with their rate of EDSR (r=0.53), major complications (r=0.53), and ED visits (r=0.55). However, the association between bariatric centers’ compliance with best practices to reduce unplanned hospital visits and their readmission rates was fairly weak (r= -0.14). CONCLUSION: Several individual, encounter, and organization-level characteristics are associated with an increased risk of unplanned visits after bariatric surgery. Bariatric centers are more likely to have higher readmission rates if their site has higher rates of major complications and if their ED is less likely to treat and then discharge bariatric patients. Further examination of organizational characteristics of bariatric programs that affect postoperative readmissions, including ED practices, is needed to better guide future initiatives aimed at improving this quality metric.

The current study examined the ability of pain-related catastrophizing to predict outcomes following non-surgical and surgical intervention for temporomandibular disorders (TMDs). The interpersonal context of pain-related catastrophizing, referred to as the communal coping model, was also examined to determine if patient perceptions of punishing and solicitous responses from significant others would moderate or mediate relations between pain catastrophizing and outcomes. The role of pain duration as a moderator of the relation between pain-related catastrophizing and perceived significant other responding was also examined. A total of 94 patients were identified for which 65 had follow-up outcomes that could be examined. Patient follow-up data were obtained at approximately two to three weeks, two to three months, and six months post-intervention. Results showed that pain-related catastrophizing was predictive of greater pain severity at all three follow-up time points after controlling for baseline levels of pain severity, depressive symptoms, sleep disturbance, and pain duration. Pain-related catastrophizing was predictive of poorer range of motion (ROM) at the initial follow-up after controlling for baseline levels of ROM, gender, and form of intervention. Pain-related catastrophizing was not associated with ROM at the second and third post-intervention follow-ups. There was no interaction between pain-related catastrophizing and perceptions of either solicitous or punishing responses in predicting post-intervention pain severity or ROM and any time point. Perceptions of significant other responses also did not mediate the relation between pain-related catastrophizing and post-intervention outcomes at any time point. Additionally, the interaction between pain duration and pain-related catastrophizing in the prediction of post-intervention pain severity or ROM was not significant at any follow-up time point. The findings indicate that pain related catastrophizing is an important predictor of pain severity following non-surgical and surgical interventions for TMDs both initially and in the long-term. Pain-related catastrophizing is related to ROM outcomes only in the short term. Perceptions of punishing and solicitous responses from significant others do not appear to play a role in these associations. The results suggest that patients with high levels of pre-intervention catastrophizing may benefit from adjunctive cognitive-behavioral intervention to attenuate post-intervention pain severity.

Background: Very occasionally, when a fetus is developing in the womb, problems occur with the normal processes controlling closure of the muscles of the abdominal wall and, as a result, some of the abdominal contents develop outside of the body. This is known as an abdominal wall defect. If the pregnancy continues to term, the newborn infant will need specialised surgical care. This situation occurs so infrequently that even a dedicated surgical centre will care for very few of these women and their babies in a year. Many centres have shared their experiences of managing these babies in the published literature but the majority of reports have included only a few infants. The focus of most previous studies has been to describe what happens to these newborn infants between birth and first discharge from hospital from a purely clinical perspective. Aim: To explore methodologies to holistically understand the short and longer-term outcomes of children born with abdominal wall defects and to use the information to improve the care of future affected infants. Methods: The quality of the published literature on short-term outcomes of children born with gastroschisis was scrutinised in a systematic review. The accompanying meta-analysis used published data as a means of identifying population outcome estimates. Two national population-based cohort studies were undertaken, exploring the short-term outcomes of children born with exomphalos and the outcomes at seven to ten years of children born with gastroschisis. The latter study included an assessment of childhood outcomes from the point of view of the children themselves, along with their parents. Further parental perspectives on experiences of care were explored in a qualitative analysis of in-depth interviews with parents of children born with exomphalos. Findings: Short-term outcomes of children born with gastroschisis have been published in a large number of small studies. Pooling the published data, where possible allowed the production of population estimates but heterogeneity between studies was marked. One in fourteen children born with gastroschisis died before their first birthday when managed in developed countries. Those who developed bowel complications in utero, had an increased risk of dying before one-year. The assessment of childhood outcomes for this latter group of children, who made up 11&percnt; of the population cohort, revealed a bleak outlook for many, of with one in three either dying or requiring complex surgery to gain allow them to be able to be fed via their gut, before their ninth birthday. Due to methodological limitations, the extent of neurological and gastrointestinal morbidity among survivors in the cohort is unclear, but the findings of both the highly selected responses from the parent report and those of the clinical study provide enough concern to suggest that alternative methodologies need to be explored to identify the extent of ongoing sequelae as children grow older. The live-born population of children with exomphalos is highly varied and a large burden of comorbidity was identified, however, two-thirds of infants were able to be have their abdominal wall defect surgically closed with a low-rate of early complications. A variety of techniques are employed by UK surgeons when the defect cannot be easily closed and evidence to guide management choice will be difficult to obtain using standard techniques due to the small number of these infants born annually in the UK. Parental experiences echoed the variability in management approach and in some cases highlighted a lack of respect for parental perspectives on management choice. Conclusion: Children born with abdominal wall defects represent a spectrum from those with severe comorbidity who will need ongoing care, to those who have a straightforward course and a relatively short stay in hospital. Methods of risk-stratifying infants for the purposes of outcome assessment have been explored. This approach is crucial to contextualising the progress of an individual infant and counselling their parents about their likely prognosis.

Introduction: In recent years, robot-assisted surgery has taken over as a first option in rectal cancer treatment. The overall perception is that robot-assisted surgery is a method with good surgical outcomes. Many current studies have focused on comparing robot-assisted surgery to conventional laparoscopy. To our knowledge, few studies have been conducted to compare surgical outcomes in rectal cancer over time in robot-assisted surgery as training and knowledge increases in the field. Aim: To examine the two most commonly used robot-assisted surgical procedures in rectal cancer, to compare surgical outcomes of each procedure over a ten-year period. Method: A retrospective comparative study design was used. The national Swedish Colorectal Cancer Registry (SCRCR) was used to identify patients who underwent robot-assisted rectal cancer surgery at Örebro University Hospital between 2013 and 2022. Two surgical procedures were assessed: anterior resection and abdomino-perineal resection. Studied outcomes included: console-time, operation time, blood loss, hospital stay and conversion rate. Group comparisons were performed. Results: In total 202 patients were included and grouped into two periods (2013-2017; 2018-2022). A statistically significant reduction was observed in both procedures regarding blood loss in the later period. No other statistically significant differences were identified. Patients operated with APR in the later period were less fit. Conclusion: The surgical procedures showed comparable clinical outcomes in both periods. Our study showed that more complex cases in the group operated with APR were selected in the second period, which could imply that a higher degree of surgical proficiency was obtained over time.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23793号 / 医博第4839号 / 新制||医||1057(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 大森 孝一, 教授 花川 隆, 教授 渡邊 直樹 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

The Institute of Medicine report "To Err is Human," released in late 1999, raised the issue of human error in medicine to a new level of attention. This study examines the frequency, severity, and type (FST) of errors associated with postoperative surgical complications at a tertiary care, university-based medical center, addressing the intersection of three domains: patient safety, graduate medical education, and simulation-based training. The study develops and validates a classification system for medical error that is specific to surgery, affirming reliability internally and externally. Baseline data on the FST of errors is collected over a 12-month period. A hybrid, simulation based training session is developed, validated, and applied to a cohort of surgical residents, focusing on the three most common types of errors identified from pilot data, namely judgment error, incomplete understanding of the problem, and inattention to detail, all human factor errors. The impact of the training is evaluated by measuring the FST of errors occurring during the 6-month period following the training sessions. The study demonstrates that there is a continuous decrement in the incidence of postoperative complications and a proportional decrease in error, which starts at the beginning of the baseline data collection and continues linearly throughout the 12 baseline months and subsequent 6 post-training months. There is no additional decrement in the rate of change following training, and no change in the rate of the index errors following the training. This study suggests that surgical error is frequent (>2%) and principally due to human factors rather than systems or communication. This study demonstrates that creating an environment where residents are continuously involved in identifying and characterizing errors results in a significant and sustained decrease in postoperative complications and the errors specifically associated with them. Contrary to expectations, a validated, well-designed, active-learning training module does not result in an additional identifiable improvement in patient outcome or in the incidence of index errors. These results are at variance with many recent studies addressing medical error and, if verified by additional studies, challenge several strongly held ideas related to patient safety training.