Search

Abstract: Aim: There is increasing awareness of hypogonadism in men with type 2 diabetes but limited data from Primary Care. Subjects and methods: The anonymised records of 6457 male patients aged 18–80 years with diabetes were accessed. Within the last 2 years 391 men (6.0% of total) underwent measurement of serum testosterone. Data search was performed through the centralised data facility afforded by EMIS®, the majority GP systems provider in Cheshire. Results: 4.4% of type 2 diabetes men screened were frankly hypogonadal with a serum total testosterone of less than 8.0nmol/l. For borderline hypogonadism (serum total testosterone 8–11.99nmol/l) the proportion of type 2 diabetes men rose to 32.1%. Age adjusted mean (geometric) testosterone was lower in men with type 2 diabetes (13.6nmol/l 95%CI: 13.1–14.2) vs type 1 diabetes (17.9nmol/l; 95%CI 15.2–21.0), F =10.3; p =0.0014. For those screened age adjusted body mass index (BMI) was greater in type 2 diabetes at 30.7 (30.1–31.3) vs 28.4 (26.1–30.6)kg/m2 in type 1 diabetes (F =4.3; p =0.04). Multiple linear regression analysis indicated that there was a statistically significant interaction (P =0.014) between BMI and diabetes type in their relation with log testosterone. For persons with type 1 DM and type 2 DM, testosterone can be expected to decrease by 6% (P =0.002) and by 1% (P =0.002) respectively, for every one unit increment in BMI. Conclusions: There is manifestly a subset of men with diabetes and androgen deficiency who could benefit from testosterone replacement. BMI has an independent influence on androgen status. [Copyright &y& Elsevier]

Abstract: Background: Mortality after oesophagectomy is lower in high-volume than in low-volume surgical units. Case series from cardiothoracic surgeons report lower mortality rates than those from general surgeons. We therefore used a national data set to investigate the effects of surgical specialty and volume on mortality after oesophagectomy. Methods: We analysed Hospital Episode Statistics for oesophagectomy for cancer (n =9034 cases), linked to data from death certificates, in England from 1998 to 2003. Results: After adjustment for patients'' age, sex and deprivation score, the odds ratio (OR) for death of general surgeons'' (GS) patients, compared with cardiothoracic surgeons'' (CTS) patients, was significantly high: 1.62 [95% CI 1.34–1.96] at 30 days and 1.38 [1.18–1.61] at 90 days. The odds ratio for high-volume GS patients was not significantly different from that for high-volume CTS patients. However, the odds ratio for low-volume GS patients compared with high-volume CTS patients was significantly high: 1.72 (1.40–2.11) at 30 days and 1.48 (1.26–1.74) at 90 days. Conclusion: Patients treated by general surgeons in low-volume hospitals had worse mortality outcomes than those treated by general surgeons in high-volume hospitals or by cardiothoracic surgeons. This is important because a majority of patients who underwent oesophagectomy for cancer were in this high-mortality risk group. [Copyright &y& Elsevier]

Problem: Emergency surgical patients are at high risk for harm because of errors in care. Quality improvement methods that involve process redesign, such as “Lean,” appear to improve service reliability and efficiency in healthcare., Design: Interrupted time series., Setting: The emergency general surgery ward of a university hospital in the United Kingdom., Key Measures for Improvement: Seven safety relevant care processes., Strategy for Change: A Lean intervention targeting five of the seven care processes relevant to patient safety., Effects of Change: 969 patients were admitted during the four month study period before the introduction of the Lean intervention (May to August 2007), and 1114 were admitted during the four month period after completion of the intervention (May to August 2008). Compliance with the five process measures targeted for Lean intervention (but not the two that were not) improved significantly (relative improvement 28% to 149%; P<0.007). Excellent compliance continued at least 10 months after active intervention ceased. The proportion of patients requiring transfer to other wards fell from 27% to 20% (P<0.000025). Rates of adverse events and potential adverse events were unchanged, except for a significant reduction in new safety events after transfer to other wards (P<0.028). Most adverse events and potential adverse events were owing to delays in investigation and treatment caused by factors outside the ward being evaluated., Lessons Learnt: Lean can substantially and simultaneously improve compliance with a bundle of safety related processes. Given the interconnected nature of hospital care, this strategy might not translate into improvements in safety outcomes unless a system-wide approach is adopted to remove barriers to change.

Drug administration errors are a common problem; they contribute to unintended patient harm and may in part be due to distractions during the drug administration round. In this study, a prospective sample of 38 drug rounds on an acute surgical ward were observed, and their duration, time spent dealing with interruptions and nature of the interruptions were recorded. On average, 11% of each drug round was spent dealing with interruptions. There were one or more interruptions in two-thirds of the rounds studied (average 2.61 interruptions per round), with a mean duration of 1 minute per interruption. The interruptions came from doctors (21%), other nurses (17%), patients (11%), telephone enquiries (8%), relatives (3%) or were initiated by the nurse conducting the round (21%). This pattern contradicts the subjective impressions of nurses in previous questionnaire studies, but it was notable that the longest individual interruptions were from conversations with patients (mean 249 seconds) and phone calls (mean 212 seconds). The data confirm the frequency of interruptions, and their potential as a safety hazard. Objective information from direct observation will prove valuable in designing possible solutions to the problem. These will require local knowledge and frontline staff involvement to be sustainable.

Gentronix is an innovative biotechnology company with the aim of providing cell-based assays and systems to ease or remove some of the current bottlenecks in preclinical drug discovery and development. Gentronix's first product, GreenScreen trade mark GC, is a combined genotoxicity and cytotoxicity test designed for high-throughput screening of new pharmaceutical lead compounds, giving drug development scientists a cost-effective preview of the battery of mandatory regulatory genotoxicity tests. Future products based on the company's extensive intellectual property rights portfolio will combine the company's expertise in cellular biosensor systems with novel optical detection technology to deliver a range of products for other applications within drug discovery, as well as industrial and environmental monitoring of toxic chemicals.

Objective: To evaluate the effect of comorbidity and other risk factors on postoperative mortality and morbidity in patients undergoing major oesophageal and gastric surgery., Design: Multicentre cohort study with data on postoperative mortality and morbidity in hospital., Data Source and Methods: The ASCOT prospective database, comprising 2087 patients with newly diagnosed oesophageal and gastric cancer in 24 hospitals in England and Wales between 1 January 1999 and 31 December 2002. Multivariate logistic regression analysis was used to model the risk of death and postoperative complications., Results: 955 patients underwent oesophagectomy or gastrectomy. Of these, 253 (27%) were graded ASA III or IV, and 187 (20%) had a high physiological POSSUM score (>or= 20). Operative mortality was 12% (111/955). Physiological POSSUM score, surgeon's assessment, type of operation, hospital case volume, and tumour stage independently predicted operative mortality. Medical complications were associated with higher physiological POSSUM scores and ASA grade, oesophagectomy or total gastrectomy, thoracotomy, and radical nodal dissection. Stage and additional organ resection predicted surgical (technical) complications., Conclusions: Many patients undergoing surgery for gastro-oesophageal cancer have major comorbid disease, which strongly influences their risk of postoperative death. Technical complications do not seem to be influenced by preoperative factors but reflect the extent of surgery and perhaps surgical judgment. Detailed prospective multicentre cooperative audit, with appropriate risk adjustment, is fundamental in the evaluation of cancer care and must be properly resourced.

Objectives: To determine (a) whether doctors involved in the process of emergency surgical admission could agree about which patients should be admitted, (b) whether there were consistent differences between doctors in different specialty groups, and (c) whether these opinions were greatly influenced by non-clinical factors., Design: Independent assessment of summarised case histories by three "expert" clinicians (two consultant surgeons and one general practitioner (GP)), by a group of 10 GPs, and by a group of 10 junior and senior surgeons. Experts, but not other observers, scored admissions both independently and as a consensus group. Observers indicated for each patient whether they would admit, would not admit, or were unsure., Setting: An urban general hospital with teaching status., Subjects: Fifty consecutive patients admitted to the general surgical unit as emergencies during 1995., Main Outcome Measures: Proportion of admissions considered unnecessary or uncertain: agreement between observers on these proportions: effect of social and procedural factors on the admission decision., Results: Between 8 and 34% of admissions were considered unnecessary and 20-38% of unclear necessity. Agreement between the groups of clinicians was not good. GPs and consultant surgeons showed the poorest agreement (kappa = 0.08 to 0.25, 4 comparisons), and the GPs scored a higher percentage of admissions as unnecessary (34 v 8-12%). After discussion, the consensus group achieved good to very good agreement (kappa 0.61-0.84)., Conclusions: Different groups of doctors vary widely in their views about the need for emergency surgical admission. Good agreement can be reached by consensus discussion. GPs are less likely than surgeons to consider emergency surgical admission necessary.