Post-operative morbidity after neoadjuvant chemotherapy and resection for gallbladder cancer: A national surgical quality improvement program analysis

BACKGROUND Gallbladder cancer is the most common malignancy of the biliary tract.Neo-adjuvant chemotherapy(NACT)has improved overall survival by enabling R0 resection.Currently,there is no consensus of guidelines for neoadjuvant therapy in gallbladder cancer.As investigations continue to analyze the regimen and benefit of NACT for ongoing care of gallbladder cancer patients,we examined American College of Surgeons National Surgical Quality Improvement Program(NSQIP)database to determine if there was higher morbidity among the neo-adjuvant group within the 30-day post-operative period.We hypothesized patients who underwent NACT were more likely to have higher post-operative morbidity.AIM To investigate the 30-day post-operative morbidity outcomes between patients who received NACT and underwent surgery and patients who only had surgery.METHODS A retrospective analysis of the targeted hepatectomy NSQIP data between 2015 and 2019 was performed to determine if NACT in gallbladder cancer increased the risk for post-operative morbidity(bile leak,infection rate,rate of converting to open surgery,etc.)compared to the group who only had surgery.To calculate the odds ratio for the primary and secondary outcomes,a crude logistic regression was performed.RESULTS Of the 452 patients,52 patients received NACT prior to surgery.There were no statistically significant differences in the odds of morbidity between the two groups,including bile leak[odds ratio(OR),0.69;95%confidence interval(95%CI):0.16-2.10;P=0.55],superficial wound infection(OR,0.58;95%CI:0.03-3.02;P=0.61),and organ space wound infection(OR,0.63;95%CI:0.18-1.63;P=0.61).CONCLUSION There was no significant difference in the risk of 30-day post-operative morbidity between the NACT and surgery group and the surgery only group.

Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy

Objective:We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre-and peri-operative variables associated with length of stay(LOS)greater than 3 days and readmission within 30 days.Methods:Records from 2008 to 2018 for“laparoscopy,surgical;partial nephrectomy”for prolonged LOS and readmission cohorts were compiled.Univariate analysis with Chi-square,t-tests,and multivariable logistic regression analysis with odds ratios(ORs),p-values,and 95%confidence intervals assessed statistical associations.Results:Totally,20306 records for LOS greater than 3 days and 15854 for readmission within 30 days were available.Univariate and multivariable analysis exhibited similar results.For LOS greater than 3 days,undergoing non-elective surgery(OR=5.247),transfusion of greater than four units within 72 h prior to surgery(OR=5.072),pre-operative renal failure or dialysis(OR=2.941),and poor pre-operative functional status(OR=2.540)exhibited the strongest statistically significant associations.For hospital readmission within 30 days,loss in body weight greater than 10%in 6 months prior to surgery(OR=2.227)and bleeding disorders(OR=2.081)exhibited strongest statistically significant associations.Conclusion:Multiple pre-and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data.Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection,optimization strategies,and patient education.

National trends in resection of the distal pancreas

AIM:To investigate national trends in distal pancreatectomy(DP) through query of three national patient care databases.METHODS:From the Nationwide Inpatient Sample(NIS,2003-2009),the National Surgical Quality Improvement Project(NSQIP,2005-2010),and the Surveillance Epidemiology and End Results(SEER,2003-2009) databases using appropriate diagnostic and procedural codes we identified all patients with a diagnosis of a benign or malignant lesion of the body and/or tail of the pancreas that had undergone a partial or distal pancreatectomy.Utilization of laparoscopy was defined in NIS by the International Classification of Diseases,Ninth Revision correspondent procedure code;and in NSQIP by the exploratory laparoscopy or unlisted procedure current procedural terminology codes.In SEER,patients were identified by the International Classification of Diseases for Oncology,Third Edition diagnosis codes and the SEER Program Code Manual,third edition procedure codes.We analyzed the databases with respect to trends of inpatient outcome metrics,oncologic outcomes,and hospital volumes in patients with lesions of the neck and body of the pancreas that underwent operative resection.RESULTS:NIS,NSQIP and SEER identified 4242,2681 and 11 082 DP resections,respectively.Overall,laparoscopy was utilized in 15%(NIS) and 27%(NSQIP).No significant increase was seen over the course of the study.Resection was performed for malignancy in 59%(NIS) and 66%(NSQIP).Neither patient Body mass index nor comorbidities were associated with operative approach(P = 0.95 and P = 0.96,respectively).Mortality(3% vs 2%,P = 0.05) and reoperation(4% vs 4%,P = 1.0) was not different between laparoscopy and open groups.Overall complications(10% vs 15%,P < 0.001),hospital costs [44 741 dollars,interquartile range(IQR) 28 347-74 114 dollars vs 49 792 dollars,IQR 13 299-73 463,P = 0.02] and hospital length of stay(7 d,IQR 4-11 d vs 7 d,IQR 6-10,P < 0.001) were less when laparoscopy was utilized.One and two year survival after resection for malignancy were unchanged over the course of the study(ductal adenocarinoma 1-year 63.6% and 2-year 35.1%,P = 0.53;intraductal papillary mucinous neoplasm and nueroendocrine 1-year 90% and 2-year 84%,P = 0.25).The majority of resections were performed in teaching hospitals(77% NIS and 85% NSQIP),but minimally invasive surgery(MIS) was not more likely to be used in teaching hospitals(15% vs 14%,P = 0.26).Hospitals in the top decile for volume were more likely to be teaching hospitals than lower volume deciles(88% vs 43%,P < 0.001),but were no more likely to utilize MIS at resection.Complication rate in teaching and the top decile hospitals was not significantly decreased when compared to non-teaching(15% vs 14%,P = 0.72) and lower volume hospitals(14% vs 15%,P = 0.99).No difference was seen in the median number of lymph nodes and lymph node ratio in N1 disease when compared by year(P = 0.17 and P = 0.96,respectively).CONCLUSION:There appears to be an overall underutilization of laparoscopy for DP.Centralization does not appear to be occurring.Survival and lymph node harvest have not changed.

Teaching Reform and Practice of Traditional Chinese Medicine Course Based on National Standard and Ideological and Political Theories Teaching in All Courses

Under the new situation,how to integrate the ideological and political theories teaching in all courses for Chinese medicine major and meet the requirements of national standards for teaching quality,improve the training quality of Chinese medicine talents and strengthen the connotative development of Chinese medicine higher education are urgent issues to be solved in Chinese medicine colleges.This paper introduces the practical experience of teaching reform of traditional Chinese medicine courses based on national standards of teaching quality and ideological and political theories teaching in all courses from the aspects of curriculum setting,teaching content,teaching methods and teaching practice,which can provide reference for teaching reform of other professional courses based on national standards of teaching quality and ideological and political theories teaching in all courses.

National Quality Supervision & Inspection Center for Refractories

National Quality Supervision ＆ Inspection Center for Refractories （NRQS） was set up in 1986 and was authorized in 1990 by State Bureau of Quality and Technical Supervision （SBQTS） as the state supervision ＆ inspection center （Certificate SBQTS No. 101）. In 1993, NRQS was granted Import ＆ Export Authorized Laboratory for national refractories by the State Administration for Entry Exit Inspection and Quarantine （Certificate No. 5302）. In 1995, NRQS was granted the national testing organization by State Committee of Science ＆ Technology and SBQTS. In September 2000,

Compare the model of Iran national quality award and the EFQM model

Nowadays, there are a lot of challenges for global processing in countries economic companies. One of the important reasons is lack of changes that must be with world-class technology for making a competition in industry, and another important reason is lack of organized distinction for managers. Most of high rank managers don＇t have good points for charging and worry about it. In this essay, there have been excellence organized model of EFQM and Iran national quality award which are compared by a case study, and finally, it has suggested using a native model.

Discussion on Ideological and Political Theories Teaching in Traditional Chinese Medicine Courses Based on National Standard for Teaching Quality

This paper analyzes the necessity and existing problems of ideological and political theories teaching in traditional Chinese medicine courses,and puts forward some suggestions,such as improving the ideological and political ability of professional teachers,perfecting the evaluation mechanism,and exploring ideological and political elements based on the characteristics of courses,so as to provide the basis for ideological and political theories teaching in traditional Chinese medicine courses under the National Standard for Teaching Quality.

AQSIQ Sends Working Groups to Implement the Spirit of National Quality Working Conference

On August 1st, the General Administration of Quality Supervision, Inspection and Quarantine (AQSIQ) convened a conference to transmit the spirit of national quality work and study an important speech regarding standards from Wen Jiabao,Premier of the State Council.……

Food Safety Detection Methods Applied to National Special Rectification of Product Quality and Food Safety

Afour-month period of national special rectification for product quality and food safety officially started on August 25, and was focused on eight fields, including those of agricultural products and processed foods.……

Radiation therapy prior to a pancreaticoduodenectomy for adenocarcinoma is associated with longer operative times and higher blood loss

BACKGROUND Pancreatic adenocarcinoma is currently the fourth leading cause of cancer-related deaths in the United States.In patients with“borderline resectable”disease,current National Comprehensive Cancer Center guidelines recommend the use of neoadjuvant chemoradiation prior to a pancreaticoduodenectomy.Although neoadjuvant radiotherapy may improve negative margin resection rate,it is theorized that its administration increases operative times and complexity.AIM To investigate the association between neoadjuvant radiotherapy and 30-d morbidity and mortality outcomes among patients receiving a pancreaticoduodenectomy for pancreatic adenocarcinoma.METHODS Patients listed in the 2015-2019 National Surgery Quality Improvement Program data set,who received a pancreaticoduodenectomy for pancreatic adenocarcinoma,were divided into two groups based off neoadjuvant radiotherapy status.Multivariable regression was used to determine if there is a significant correlation between neoadjuvant radiotherapy,perioperative blood transfusion status,total operative time,and other perioperative outcomes.RESULTS Of the 11458 patients included in the study,1470(12.8%)underwent neoadjuvant radiotherapy.Patients who received neoadjuvant radiotherapy were significantly more likely to require a perioperative blood transfusion[adjusted odds ratio(aOR)=1.58,95%confidence interval(CI):1.37-1.82;P<0.001]and have longer surgeries(insulin receptor-related receptor=1.14,95%CI:1.11-1.16;P<0.001),while simultaneously having lower rates of organ space infections(aOR=0.80,95%CI:0.66-0.97;P=0.02)and pancreatic fistula formation(aOR=0.50,95%CI:0.40-0.63;P<0.001)compared to those who underwent surgery alone.CONCLUSION Neoadjuvant radiotherapy,while not associated with increased mortality,will impact the complexity of surgical resection in patients with pancreatic adenocarcinoma.

Chronic kidney disease prediction is an inexact science: The concept of “progressors” and “nonprogressors”

In 2002,the National Kidney Foundation Kidney Disease Outcomes Quality Initiative(NKF KDOQI)instituted new guidelines that established a novel chronic kidney disease(CKD)staging paradigm.This set of guidelines,since updated,is now very widely accepted around the world.Nevertheless,the authoritative United States Preventative Task Force had in August 2012acknowledged that we know surprisingly little about whether screening adults with no signs or symptoms of CKD improve health outcomes and that we deserve better information on CKD.More recently,the American Society of Nephrology and the American College of Physicians,two very well respected United States professional physician organizations were strongly at odds coming out with exactly opposite recommendations regarding the need or otherwise for"CKD screening"among the asymptomatic population.In this review,we revisit the various angles and perspectives of these conflicting arguments,raise unanswered questionsregarding the validity and veracity of the NKF KDOQI CKD staging model,and raise even more questions about the soundness of its evidence-base.We show clinical evidence,from a Mayo Clinic Health System Renal Unit in Northwestern Wisconsin,United States,of the pitfalls of the current CKD staging model,show the inexactitude and unpredictable vagaries of current CKD prediction models and call for a more cautious and guarded application of CKD staging paradigms in clinical practice.The impacts of acute kidney injury on CKD initiation and CKD propagation and progression,the effects of such phenomenon as the syndrome of late onset renal failure from angiotensin blockade and the syndrome of rapid onset end stage renal disease on CKD initiation,CKD propagation and CKD progression to end stage renal disease all demand further study and analysis.Yet more research on CKD staging,CKD prognostication and CKD predictions are warranted.Finally and most importantly,cognizant of the very serious limitations and drawbacks of the NKF K/DOQI CKD staging model,the need to individualize CKD care,both in terms of patient care and prognostication,cannot be overemphasized.

Tianjin Automotive Test Center & National Passenger Car Quality Supervision and Inspection Center——A State Testing and Universality Techniques Research Base in China

Tianiin Automotive Test Center has a test capability as well as a capability of conducting universality techniques research. With fixed assets of around RMB 76.44 million yuan and an architectural area of 11,200 sqm, test labs mainly include: auto emission test lab, full-scale vehicle crash test lab, auto safety test lab, auto lighting and view field test lab, engine test lab,

Machine learning predicts unpredicted deaths with high accuracy following hepatopancreatic surgery

Background:Machine learning to predict morbidity and mortality-especially in a population traditionally considered low risk-has not been previously examined.We sought to characterize the incidence of death among patients with a low estimated morbidity and mortality risk based on the National Surgical Quality Improvement Program(NSQIP)estimated probability(EP),as well as develop a machine learning model to identify individuals at risk for“unpredicted death”(UD)among patients undergoing hepatopancreatic(HP)procedures.Methods:The NSQIP database was used to identify patients who underwent elective HP surgery between 2012-2017.The risk of morbidity and mortality was stratified into three tiers(low,intermediate,or high estimated)using a k-means clustering method with bin sorting.A machine learning classification tree and multivariable regression analyses were used to predict 30-day mortality with a 10-fold cross validation.C statistics were used to compare model performance.Results:Among 63,507 patients who underwent an HP procedure,median patient age was 63(IQR:54-71)years.Patients underwent either pancreatectomy(n=38,209,60.2%)or hepatic resection(n=25,298,39.8%).Patients were stratified into three tiers of predicted morbidity and mortality risk based on the NSQIP EP:low(n=36,923,58.1%),intermediate(n=23,609,37.2%)and high risk(n=2,975,4.7%).Among 36,923 patients with low estimated risk of morbidity and mortality,237 patients(0.6%)experienced a UD.According to the classification tree analysis,age was the most important factor to predict UD(importance 16.9)followed by preoperative albumin level(importance:10.8),disseminated cancer(importance:6.5),preoperative platelet count(importance:6.5),and sex(importance 5.9).Among patients deemed to be low risk,the c-statistic for the machine learning derived prediction model was 0.807 compared with an AUC of only 0.662 for the NSQIP EP.Conclusions:A prognostic model derived using machine learning methodology performed better than the NSQIP EP in predicting 30-day UD among low risk patients undergoing HP surgery.

Spatial variance and assessment of nitrogen dioxide pollution in major cities of Pakistan along N5-Highway

This paper discusses the findings of the first car MAX-DOAS（multi-axis differential optical absorption spectroscopy） field campaign（300 km long） along the National Highway-05（N5-Highway） of Pakistan conducted on 13 and 14 November, 2012. The main objective of the field campaign was to assess the spatial distribution of tropospheric nitrogen dioxide（NO_2）columns and corresponding concentrations along the N5-Highway from Islamabad to Lahore.Source identification of NO_2 revealed that the concentrations were higher within major cities along the highway. The highest NO_2 vertical column densities（NO_2VCDs） were found around two major cities of Rawalpindi and Lahore. This study also presents a comparison of NO_2 VCDs measured by the ozone monitoring instrument（OMI） and car MAX-DOAS observations. The comparison revealed similar spatial distribution of the NO_2 columns with both car MAX-DOAS and satellite observations, but the car MAX-DOAS observations show much more spatial details. Maximum NO_2 VCD retrieved from car MAX-DOAS observations was up to an order of magnitude larger than the OMI observations in urban areas.

An NSQIP evaluation of practice patterns and outcomes following surgery for anorectal abscess and fistula in patients with and without Crohn’s disease

Background:Patients with Crohn’s disease(CD)are believed to have more aggressive anorectal abscess and fistula disease.We assessed the types of procedures performed and perioperative complications associated with the surgical management of anorectal abscess and fistula disease in patients with and without CD.Methods:The American College of Surgeons National Surgical Quality Improvement Program database(ACS-NSQIP,2005-2010)was used to calculate 30-day outcomes using regression modeling,accounting for demographics,comorbidities and surgical procedures.ICD-9 codes for anorectal abscess or fistula were used for initial selection.Patients were then stratified,based on the presence or absence of underlying CD.Local procedures included incision and drainage of abscesses,fistulotomy and seton placement.Cutaneous fistulas were considered simple,while all others were classified as complex(-vaginal,-urethral and-vesical).Results:A total of 7,218 patients(mean age 45 years;64%male)met inclusion criteria,with underlying CD in 345(4.8%).CD patients were more likely to have a seton placed(9.9 vs 8.2%,P<0.001)and be on steroids(15.4 vs 4.3%,P<0.001).Thirty-seven percent of CD patients underwent local procedures,while 46%had a proctectomy and8%underwent diversion.Fistulotomy was more common in those without underlying CD(16 vs 11%,P<0.001).The overall complication rate after local treatment was 4.9%,with no difference between patients with and without CD(7.7 vs 4.9%,P=0.144).This was not affected by fistula type-simple(7.9 vs 3.9%,P=0.194)vs complex(33 vs 7.1%,P=0.21)—or when stratified by wound(3.8 vs 2.4%;P=0.26)or systemic complications(3.8 vs 2.5%;P=0.53).Yet,complications following emergency procedures were higher in patients with CD(21.4 vs 5.9%,P=0.047).Factors significantly associated with increased complications were Crohn’s disease(OR=8.2),lack of functional independence(OR=2.0),pre-operative weight loss(OR=2.6)and pre-operative acute renal failure(OR=5.6).Steroids were also associated with a 1.7-fold increase in complications,independent from CD.Conclusions:While most patients with anorectal abscess/fistula are treated with local procedures,proctectomy and diversion use is fairly common in those with underlying CD.Although complication rates following elective local procedures for anorectal abscess/fistula are similar in patients with and without CD,they are higher in patients on steroids and in CD patients undergoing emergent procedures.

A propensity score matched analysis of obesity as an independent risk factor for postoperative complications in reduction mammaplasty

Aim:Reduction mammaplasty is a commonly performed procedure for the treatment of symptomatic macromastia and is increasingly desired by the obese population.With the increasing prevalence obesity in the population,it is imperative to understand its effect on postoperative outcomes.The purpose of this study is to evaluate obesity as an independent risk factor for postoperative complications in breast reduction surgery using 1:1 patient matching through propensity scores between obese patients and non-obese controls.Methods:Between 2005 and 2013,the National Surgical Quality Improvement Program dataset identified a total of 6,016 patients as having undergone primary reduction mammaplasty with 30-day postoperative follow-up.Patients were divided into obese[body mass index(BMI)of 30 or more]vs.not obese(BMI below 30).Patients were initially analyzed using standard multivariable analysis.Using propensity scores obtained from a logistic regression model,patients were subsequently matched 1:1 according to preoperative and operative variables to truly isolate the effect of obesity on surgical outcomes.Outcomes were compared between the matched cohorts using McNemar’s test and the Wilcoxon signed rank test.Results:In unmatched multivariable analysis,rates of overall complications(7.2%vs.5.3%,P=0.0024),wound complications(5.5%vs.3.6%,P=0.0004),superficial surgical site infection(4.1%vs.2.8%,P=0.0050),and wound dehiscence(0.3%vs.1.1%,P=0.0005)were found to be statistically different between obese vs.non-obese,respectively.However,when comparing 1:1 matched obese and non-obese patients,only wound complications(4.6%vs.3.1%,P=0.0334)were significantly increased in the obese cohort.Conclusion:Using the most robust statistical tools available,obesity was determined to affect wound complications after breast reduction without increased detriment on other major complications when compared to the non-obese.Obesity should be a considered with other preoperative comorbidities,rather than an independent contraindication to surgery.Breast reduction appears to be safe in the obese patient who is otherwise healthy.