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Quality problem or issue The traditional variable life-adjusted display (VLAD) is a graphical display of the difference between expected and actual cumulative deaths. The VLAD assumes binary outcomes: death within 30 days of an operation or survival beyond 30 days. Full recovery and bedridden for life, for example, are considered the same outcome. This binary classification results in a great loss of information. Initial assessment Although there are many grades of survival, the binary outcomes are commonly used to classify surgical outcomes. Consequently, quality monitoring procedures are developed based on binary outcomes. With a more refined set of outcomes, the sensitivities of these procedures can be expected to improve. Choice of solution A likelihood ratio method is used to define a penalty-reward scoring system based on three or more surgical outcomes for the new VLAD. The likelihood ratio statistic W is based on testing the odds ratio of cumulative probabilities of recovery R. Two methods of implementing the new VLAD are proposed. Implementation We accumulate the statistic W-W¯R to estimate the performance of a surgeon where W¯R is the average of the W's of a historical data set. The accumulated sum will be zero based on the historical data set. This ensures that if a new VLAD is plotted for a future surgeon of performance similar to this average performance, the plot will exhibit a horizontal trend. Evaluation For illustration of the new VLAD, we consider 3-outcome surgical results: death within 30 days, partial and full recoveries. In our first illustration, we show the effect of partial recoveries on surgical results of a surgeon. In our second and third illustrations, the surgical results of two surgeons are compared using both the traditional VLAD based on binary-outcome data and the new VLAD based on 3-outcome data. A reversal in relative performance of surgeons is observed when the new VLAD is used. In our final illustration, we display the surgical results of four surgeons using the new VLAD based completely on 3-outcome data. Lessons learned Full recovery and bedridden for life are two completely different outcomes. There is a great loss of information when different grades of 'successful' operations are naively classified as survival. When surgical outcomes are classified more accurately into more than two categories, the resulting new VLAD will reveal more accurately and fairly the surgical results.

Additional file 1. Appendix 1. Complete inclusion and exclusion criteria for SingHEART study.

Clinico-pathologic characteristics of discovery and prevalence cohorts. (DOC 59 kb)

Copy number variation plot summary of 18 oral tongue squamous cell carcinoma patients in the discovery set. The samples are sorted according to smokers and never-smokers as indicated. Regions of gains and losses are color coded as per the legend. (PPT 662 kb)

a Mutational signatures for each sample in the discovery set. b Mutational signatures found in the discovery set grouped according to clinical characteristics (age, recurrence, gender, ethnicity, and smoking status). Signatures are displayed according to the 96 substitution classification defined by the substitution class and sequence context immediately 3â ˛ and 5â ˛ of the mutated base. The probability bars for the six types of substitutions are displayed in different colors. The mutation types are on the horizontal axes, whereas vertical axes depict the proportions of mutations attributed to a specific mutation type. All mutational signatures are displayed on the basis of the trinucleotide frequency of the human genome. (DOC 913 kb)

Mutation plot summary of 18 oral tongue squamous cell carcinoma patients examined in the â discovery setâ . The top plot shows the key clinical parameters, below which the mutation status of the recurrently mutated genes for each tumor is indicated. Somatic mutations are colored according to functional class and color coded according to the legend below the plot. Prevalence is indicated as number of mutations in the graph on the right and mutational frequency is given in the left of the mutation plot. (PPT 423 kb)

Top ten significantly mutated pathways in oral tongue squamous cell carcinoma (OTSCC), as determined by examination of the Molecular Signatures Database (MSigDB) by Gene Set Enrichment Analysis (GSEA) software and comparisons with well-recognized cancer-related pathways. (PPT 137 kb)

The term infantile colic though often used is poorly understood. This common affliction of early infancy, in which crying is the primary symptom, has been the subject of numerous publications over many decades. This appraisal of the literature reveals that lack of consensus on the definition of colic poses difficulties when assessing the outcome and validity of research. In addition, the numerous hypotheses, reviewed here, on the precise cause of infantile colic have resulted in various approaches to treatment and no clear strategy for management. The possibility that mechanical factors play a role in the aetiology of colic underlies the osteopathic approach to treatment which, despite anecdotal success, is poorly documented. This article is designed to appraise osteopaths with an overview of the field to better inform their practice. 2006 Published by Elsevier Ltd.