Glasgow Victoria Infirmary

BACKGROUND Risk stratification is a major challenge in bladder cancer (BC), and a biomarker is needed. Multiple studies have reported the neutrophil-to-lymphocyte ratio (NLR) as a promising candidate; however, these analyses have methodological limitations. Therefore, the authors performed a category B biomarker study to test whether NLR is prognostic for overall survival (OS) after curative treatment or is predictive for the survival benefit from neoadjuvant chemotherapy (NAC). METHODS This study is an unplanned secondary analysis of SWOG 8710, a randomized phase 3 trial that assessed cystectomy with or without NAC in 317 patients with muscle-invasive BC. NLR was calculated from prospectively collected complete blood counts. For the prognostic analysis, 230 patients were identified; for the predictive analysis, 263 were identified. NLR was evaluated with proportional hazards models including prespecified factors (age, sex, T-stage, lymphovascular invasion, and treatment arm). RESULTS With a median follow-up of 18.6 years, there were 172 and 205 deaths in the prognostic and predictive cohorts, respectively. In a multivariable analysis, NLR was not prognostic for OS (hazard ratio [HR], 1.04; 95% confidence interval [CI], 0.98-1.11; P = .24). Furthermore, NLR did not predict for the OS benefit from NAC (HR, 1.01; 95% CI, 0.90-1.14; P = .86). Factors associated with worse OS were older age (HR, 1.05; 95% CI, 1.04-1.07; P < .001) and surgery without NAC (HR, 1.39; 95% CI, 1.03-1.88; P = .03). CONCLUSIONS This is the first analysis of NLR in BC to use prospectively collected clinical trial data. In contrast to previous studies, it suggests that NLR is neither a prognostic nor predictive biomarker for OS in muscle-invasive BC. Cancer 2016. © 2016 American Cancer Society.

BackgroundIdiopathic pulmonary fibrosis (IPF) is an age-related, progressive and irreversible lung disease.1 The diagnosis of IPF is made using clinical history, pulmonary function testing (PFT), and radiological appearances of Usual Interstitial Pneumonia (UIP) on High Resolution CT (HRCT) Scanning provided other appearances have been excluded. The diagnosis is frequently made at MDT where the images are categorised into Definite UIP, Possible UIP, or Inconsistent with UIP using HRCT criteria.2 In the west of Scotland, patients demonstrating definite or possible UIP patterns on HRCT with a FVC < 80% are considered for antifibrotic therapy. The aim of this study was to assess whether response to antifibrotic therapy in IPF is correlated with the aforementioned categories. The presence of pleural plaques was also considered.MethodsWe retrospectively divided 170 patients into three categories: definite UIP pattern, possible UIP pattern, and UIP with pleural plaques. Serial pulmonary function test results were obtained and the change in FVC calculated. Treatment failure was defined as a change in FVC% predicted of >10% per year. The rate of treatment failure, overall mortality, 6-month and 12-month survival was compared between the three groups.Results116 patients out of 170 were started on antifibrotic therapy. The average duration of therapy was 256 days. There was a trend towards higher treatment failure in possible (n = 3 of 12 25%) versus definite UIP patterns (n = 6 of 55 11%), this was not statistically significant. Overall mortality rates were similar between possible and definite UIP patterns at 6- and 12-months (Figure 1). 5 patients with UIP and pleural plaques were started on therapy.ConclusionsMortality at 12 months was similar in possible UIP and UIP groups; there was a trend towards higher levels of treatment failure in patients with possible UIP. A different disease process may exist in some patients with possible UIP which is non-responsive to antifibrotic treatment. Numbers are relatively small and further observation is warranted.ReferencesKing TE, et al. Idiopathic pulmonary fibrosis. Lancet Elsevier 2011;378(9807):1949–61.Raghu G, et al. An official ATS/ERS/JRS/ALAT statement: Idiopathic pulmonary fibrosis: Evidence-based guidelines for diagnosis and management. AJRCCM 2011;183(6):788–824. P167 Figure 1Pirfenidone therapy and survival rates in definite UIP, and Possible UIP

Food bone perforation of the bowel is a relatively rare diagnosis. Its presentation is non-specific and often misdiagnosed. We present a case where a food bone perforation in both the large and small bowel was diagnosed on CT scan. A successful outcome was achieved with surgical treatment.

To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. Eight Scottish ICUs over a 12-month period. Mechanically ventilated patients. None. The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman ρ = 0.75) and were reliable in clinician-clinician (weighted kappa; κ = 0.66) and clinician-researcher (κ = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale (ρ = 0.24) and was reliable in clinician-clinician (κ = 0.58) and clinician-researcher (κ = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale (ρ = 0.54), and reliability in clinician-clinician (κ = 0.29) and clinician-researcher (κ = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time.

ObjectivesWard round documentation provides one of the most important means of communication between healthcare professionals. We aimed to establish if the use of a problem based standardised proforma can improve documentation in acute surgical receiving.MethodsGold standards were established using the RCSE record keeping guidelines. We audited documentation for seven days using the following headings: patient name/identification number, subjective findings, objective findings, clinical impression/diagnosis, plan, diet status, discharge decision, discharge planning, signature, and grade.After the initial audit cycle, a ward round proforma was introduced using the above headings and re-audited over a seven day period.ResultsThe pre-intervention arm contained 50 patients and the post intervention arm contained 47. The following headings showed an improvement in documentation compliance to 100%: patient name/identification number vs 96%, subjective findings vs 84%, objective findings vs 48%, plan vs 98%, signature vs 96%, and grade vs 62%. Documentation of the clinical impression/diagnosis improved to 98% vs 30%, diet status rose to 83% vs 16%, discharge decision to 66% vs 16%, and discharge planning to 40% vs 20%.ConclusionsStandardised proformas improve the documentation of post-take ward round notes. This helps to clarify the onward management plan for all aspects of a patient's care and will help avoid adverse events and litigation. This should improve the quality and safety of Patient Care.

ABSTRACTIn this study, the construct and the role of distributed situation awareness (DSA) on the anaesthetic management of challenging major obstetric haemorrhage (MOH) cases is explored, specifically the anaesthetist's perception of the operating theatre elements, the understanding of their meaning and the anticipation of their progress in interaction with other people and artefacts. Eighteen anaesthetists from four Scottish Hospitals were asked to discuss a challenging MOH case from their experience, prompted by questions emanating from a critical decision method protocol. The majority of the described DSA references were attributed to gathering information and in interaction with external artefacts, including monitors, suction containers, the whiteboard and even swabs. For understanding and anticipating, the majority of DSA references emerged in interaction with other team members within and outside the operating theatre. Methods for improving practice and training in MOH should address the interactive nature of DSA, by going beyond monitoring anaesthetic displays.

Recent studies in the United Kingdom [1],[2] have highlighted serious shortfalls in the care of patients with a tracheostomy or laryngectomy. Such patients potentially require time-critical, decisive airway management, likely involving resident intensive care clinicians. However, previous regional studies identified critical care trainees as inadequately trained and experienced to confidently manage airway emergencies in neck breathers [3].

IntroductionPatients with inflammatory bowel disease (IBD) have an increased risk of colorectal cancer. In 2009 the British Society of Gastroenterology updated guidelines recommending chromoendoscopy with targeted biopsies of suspicious areas, Grade A; or 2–4 biopsies every 10cm, Grade C. A local audit in Forth Valley Royal Hospital (FVRH) looking at adherence to guidelines was carried out in 2009 showing adherence to guidelines in 27% (12/44) of cases. Subsequent to this, information regarding the current guidelines was disseminated to clinicians and three medical consultants took responsibility for performing chromoendoscopy. Practice was then re-audited.MethodsFVRH is a district general hospital with a catchment area of 300,000. The endosocpy reporting tool Unisoft was used to identify patients undergoing colonoscopy with the indication “follow up - colitis surveillance” during a 1 year period from 01/01/2012. The endoscopy report was reviewed noting the endoscopist, completeness of procedure, and adherence to a surveillance guideline. The pathology reports were accessed via the SCI store computer system.Results87 patients were identified (44 identified over 6 months during the previous audit) as having colitis surveillance colonoscopy. 60 (69%) procedures adhered to one of the recognised surveillance strategies (37 dye-spray, 23 biopsy protocol) compared to 27% (12/44) in 2009. There has also been a marked increase in the number of patients who had chromoendoscopy; 43% (37/87) versus 4.5% (2/44) in 2009. The other main difference in this audit was the type of endoscopist performing the procedure (medical 70% v 32%, nurse 22% v 43%, surgeon 25% v 8%). Medical gastroenterologists performed 34 of the 37 chromoendoscopic procedures. Compliance rates increased in medical endoscopies to 79% (v 32%), nurses 63% (v 37%) compared to the previous audit. Dysplasia was found in 10 of the 87 cases. 8 showed low grade dysplasia in tubular adenomas, 1 was high grade dysplasia in DALM discovered using chromoendoscopy and colectomy was performed. Low grade dysplasia was also identified in one patient and they are awaiting discussion about colectomy.ConclusionThere has been a significant improvement in adherence to current guidelines after dissemination of this information to the relevant clinicians. The use of chromoendoscopy has been successfully adopted in a significant number of patients. Streamlining of procedures to endoscopists with an interest in IBD surveillance has added to the improved compliance with guidelines but there are still a number of procedures performed outwith guidelines likely in part due to the ‘generic pooling’ of endoscopy lists. The setting up of specific surveillance lists may improve compliance and chromoendoscopy rates further.Disclosure of InterestNone Declared.