Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

1492 The Age of Trainees When Joining the Specialist List – What Are the Differences Across Specialties?

Introduction

Those wishing to pursue a career in surgery will be aware of stereotypes that exist within each specialty, including how long it takes to attain a certificate of completion of training (CCT). These perceptions are often historic, and whilst may be based on elements of truth, are rarely backed by robust data. Oral & maxillofacial surgery (OMFS) for example is plagued by the stigma of necessitating a second degree which gives the assumption the age of being appointed a consultant is somewhat above average. We aim to dispel (or prove, depending on one’s predisposition) such myths by analysing the age of surgeons when appointed to the General Medical Council’s specialist list.

Method

Information on the age of entry onto the surgical specialist lists between 1997 and 2018 was obtained from the General Medical Council (GMC). Data was suitably statistically analysed.

Results

19,135 surgeons joined surgical specialist lists during the study period. General and trauma and orthopaedic surgery accounted for 60% of all surgeons (n = 11,444). The age on joining surgical specialist lists ranged from 27–83 years, with a mean of 41.4 years. Neurosurgeons most frequently joined the specialist list in the youngest age bracket. OMF surgeons, along with their cardiothoracic and vascular colleagues, are joint eldest by 1.3 years.

Conclusions

Since the creation of the specialist list, training has seen several upheavals. This data shows that despite each specialty’s specific requirements and individuals’ varying paths, there is little difference in the age when the consultant destination is reached.

Bewertung des Gesprächsverhaltens nach Schädel-Hirn-Trauma mit dem La Trobe Communication Questionnaire (LCQ): Erste Ergebnisse der deutschen Replikationsstudie an neurologisch gesunden Kontrollprobanden

Der La Trobe Communication Questionnaire (LCQ) ist ein Verfahren, um Veränderungen des Gesprächsverhaltens nach Schädelhirntrauma zu erheben. Die vorliegende Version des LCQ ist im deutschsprachigen Raum derzeit der einzige psychometrisch untersuchte Fragebogen, mit dem kognitive Kommunikationsstörungen bei SHT sowohl aus der Perspektive von Betroffenen als auch Bezugspersonen bewertet werden können. Ziel der direkten Replikationsstudie war es zu prüfen, ob die deutsche Adaptation des LCQ zu vergleichbaren Ergebnissen in der Selbst- und Fremdeinschätzung führt wie die australische Originalversion. In dieser Pilotstudie wurde an einer Stichprobe von 160 Probanden (= 80 Dyaden) überprüft, ob sich bei neurologisch gesunden Probanden in Bezug auf die Selbst- und Fremdeinschätzung ähnliche Resultate zeigen wie in der Originalversion: Die Selbstauskunft sollte im Vergleich zur Fremdauskunft kritischer ausfallen, was sich in einem höheren Punktwert im LCQ widerspiegeln sollte. Zudem sollten keine signifikanten Mittelwertsunterschiede für die Selbst- bzw. Fremdbeurteilung zwischen der Originalversion und der deutschsprachigen Version vorliegen. In der vorliegenden Studie konnten die wichtigsten Ergebnisse der Originalstudie repliziert werden, was die Validität des LCQ untermauert.

Performance demands in the endurance rider

Endurance is one of the fastest growing equestrian disciplines worldwide. Races are long distance competitions (40-160 km), organised into loops, over variable terrain usually within one day. Horse and rider combinations in endurance races have to complete the course in good condition whilst also aiming to win. Horse welfare is paramount within the sport and horses are required to ‘pass’ a veterinary check prior to racing, after each loop of the course and at the end of the race. Despite the health, fitness and welfare of both athletes within the horse-rider dyad being essential to achieve success, few equivalent measures assessing the wellbeing of the endurance rider are implemented. This review considers evidence from ultra-endurance sports and rider performance in other equestrian disciplines, to consider physiological and psychological strategies the endurance rider could use to enhance their competition performance. Successful endurance riding requires an effective partnership to be established between horse and rider. Within this partnership, adequate rider health and fitness are key to optimal decision-making to manage the horse effectively during training and competition, but just as importantly riders should manage themselves as an athlete. Targeted management for superior rider performance can underpin more effective decision-making promoting ethical equitation practices and optimising competition performance. Therefore, the responsible and competitive endurance rider needs to consider how they prepare themselves adequately for participation in the sport. This should include engaging in appropriate physiological training for fitness and musculoskeletal strength and conditioning. Alongside planning nutritional strategies to support rider performance in training and within the pre-, peri- and post-competition periods to promote superior physical and cognitive performance, and prevent injury. By applying an evidence informed approach to self-management, the endurance athlete will support the horse and rider partnership to achieve to their optimal capacity, whilst maximising both parties physical and psychological wellbeing.

Changes in United Kingdom oral and maxillofacial surgical specialty trainees since 1995 - numbers, gender, first degrees, and nations of origin

Training in UK surgery has changed dramatically since 1995, from a relative lack of structure to time-limited and highly documented programmes. Training in oral and maxillofacial surgery (OMFS) has shared these changes and included some significant changes of its own. Minutes from the OMFS Specialty Advisory Committee (SAC) were reviewed over the last 25 years to record the number and location of newly approved posts. The General Medicine Council's (GMC) OMFS specialist list in 2019 was combined with the records of OMFS specialists' dental qualifications held by the General Dental Council (GDC) and augmented from a database of OMFS trainees and consultants in the UK. Data on demographics, location, and nature of the first medical or dental degree were noted for analysis. A total of 691 OMFS specialists and trainees were identified from GMC, OMFS SAC and consultant databases. Of these, 12 consultants held only dental qualification/registration. First degree data could not be obtained for 12 specialists (all male). A further 20 OMFS specialists, whose training was outside the UK, were also excluded from further analysis. In 1995 there were 95 national training posts, by 2013 there were 150. Over the last quarter of a century, there has been an increase in medicine first trainees, an increase in female trainees and specialists, and a relative decrease in OMFS trainees from the Indian subcontinent. The varied origins of the OMFS workforce has contributed to greater diversity and inclusion within the specialty. In the UK, OMFS appears to have produced the correct number of specialists whilst maintaining a high standard of training. The next change in OMFS training programmes is to deliver The Postgraduate Medical Education and Training Board's (PMETB) recommendations. As we move to achieve this it is imperative that as new doors open, we do not close others.

Workforce intelligence: what data do we need to collect to understand trends in substantive oral and maxillofacial surgery consultant posts? A retrospective review and plan for the future

Understanding workforce pressures within surgery is an inexact science. This paper assembles evidence regarding oral and maxillofacial surgery (OMFS) consultant appointments in the UK and plans for prospective data collection in the future. Information about the number of OMFS specialists joining the UK specialist list was obtained from the General Medical Council and compared to a database of substantive OMFS consultant posts. OMFS consultants were asked to contribute information about their training programmes and consultant appointments (date, interview experience, and sub-specialty interest). This information was collated on Excel© and analysed using WinStat©. Data on OMFS consultant posts advertised in 'NHS Jobs' and the British Medical Journal were collected. The mean (SD) number of specialists joining the specialist list per year is 24.1 (5.2) with a median of 24 and a range of 15 - 36. The number of trainees completing training and numbers joining the OMFS specialist list are in balance at present. The median delay between OMFS specialist listing and appointment as a consultant was 72 days and mean of 169 with the 25th centile of five days, standard deviation of 239 days and maximum of 5.2 years. Of those returning data, 135 (47%) candidates were the sole interviewee and 83 (29%) had one other candidate at their successful interview. The mean application ratio for each post was 1.9 and the median number of candidates was one, mean 1.6 and maximum candidates seven. About half of the posts were filled by trainees from their regional training rotation. Prospective data collection on advertised posts, interviews held, expected retirements/new posts, combined with a route for trainees approaching CCT to highlight their availability may streamline recruitment and allow a more rapid recognition of recruitment problems.

Duration of specialty training in Oral and Maxillofacial Surgery in the United Kingdom for trainees joining the OMFS specialist list between 2002 and 2019

INTRODUCTION

OMFS Specialty Training in the UK is usually 5 years and 'starts' at Specialty Training Year 3 (ST3). In 2007 a pilot of 'run-through' training started with Core Training (CT) posts linked to specialty training (ST1 posts). ST1 posts are usually 12 months but may be up to 24 months.

METHOD

UK OMFS consultants joining the OMFS specialist list between 2002 and 2019 were contacted regarding their training. If their training was extended beyond the expected date of completion, they were asked to give a primary and secondary reason from a simplified list. Results were analysed with Winstat©.

RESULTS

A total of 382 consultants were contacted, 325 responding (86%) and of these 290 were appointed at ST3 and their mean extension of training time was 0.63 years. For those 35 who were appointed to ST1, their training was on average 0.77 years longer than planned. Undertaking a Fellowship (33%) was the commonest reason for extension, followed by administrative delay (24%), unsuccessful attempts at the FRCS exam (12%) and training reasons (10%). Female trainees (n=37) spent on average 1.28 years longer than planned in training compared to male trainees (288 - 0.67 years). Gender differences were also present in the main reasons for extension with 12% of female respondents giving family reasons as the main cause, whereas only 2% of males gave this reason. Problems with training was the main cause for extension for 19% of females compared to 8% of males.

CONCLUSIONS

Understanding factors which extend training and the length of these extensions could have the twin benefits of openness for new trainees and directing support to existing trainees. Differential attainment and Equality Diversity & Inclusion (EDI) are domains whose monitoring is required by the General Medical Council and undertaken by training authorities. The small numbers of trainees in OMFS programmes may not always allow training variance to be recognised.

A prospective study of hospital episodes of adults with intellectual disability

BACKGROUND

Previous research has shown poor hospital experiences and dire outcomes for people with intellectual disability. The main objective of this study was to prospectively track episodes for adults with intellectual disability (ID) in Australian hospitals, with a focus on indications of the quality of care provided.

METHODS

A prospective audit of hospital records over 35 months yielded quantitative data about patient characteristics, frequency and length of hospital episodes, diagnostic assessments and outcomes, post-emergency department (ED) destinations and post-discharge recommendations. Fifty participants were recruited largely by identification on hospital ED entry. An audit of patients' hospital records was conducted towards the end of hospital episodes, using a tool developed for the study.

RESULTS

Participants were mostly men (70%), aged 42.9 years on average, living mostly with family (46%) or in supported accommodation (44%). Of 157 recorded episodes, 96% started in ED,  85% required urgent or semi-urgent care and 62% were in the first 3 months of study participation. Average time in ED exceeded the 4-h national benchmark, met in 40% of episodes. One or more diagnostic assessments were conducted in 91% episodes and others in short stay units. Almost half (49%) resulted in a ward stay. With an extreme data point removed, <1-35 days were spent in wards. The most frequent diagnosis in 75% of episodes was for digestive problems, followed by nervous system problems then injuries. Median length of bed stays reflected data available for Australian refined diagnosis-related groups. High hospital re-presentations were found: for 67% of episodes in total, 26% (n = 12) of which were within 72 h and 59% (n = 23) within 30 days.

CONCLUSIONS

Adults with ID presented frequently to ED and often had lengthy stays. We found no indication of poor care practices in terms of hospital staff willingness to keep patients in ED and conduct of diagnostic assessments. Frequent re-presentations, however, indicated failed hospital care at some level.

SPREAD OF QUALITY IMPROVEMENT PROJECTS IMPLEMENTED IN A GERIATRICS WORKFORCE DEVELOPMENT PROGRAM

This project characterizes spread of quality improvement (QI) projects initiated in the U.S. Department of Veterans Affairs (VA) Geriatric Scholars Program (GSP) workforce development program. This mixed methods study analyzes a recent cross-sectional survey of GSP participants and program-level data on participant characteristics and QI project topics. We surveyed 578 scholars who had completed all program requirements to that point, and still worked for VA; 207 (35%) responded. The majority of respondents who had been in the program for at least six months (70%) reported sustainment of their QI project beyond initial implementation and nearly a third (30.4%) reported any spread beyond their own care team. QI project topics spanned many domains and percent of projects reporting spread varied across domains from 0% to 67%. A workforce development capstone activity in which participants demonstrate substantive and methodological competency can foster bottom-up QI activities in a large, diverse health care system.

In Vivo Measurements of Fibrin Formation and Fibrinolysis in Operable Breast Cancer

Fibrin formation and fibrinolysis were estimated in 89 breast cancer patients by measurement in plasma of Fibrin Fragment Bβ 15-42 and Fibrinopeptide A (FPA), serum Fibrin(ogen) Degradation Products (FDPs) and plasminogen activator by Fibrin Plate Lysis Assay. Results were compared with (a) 26 patients with benign breast diseases; and (b) 45 healthy factory workers. FPA, FDP and Bβ 15-42 Levels were elevated in both breast cancer patients and benign disease patients, but there were no significant differences between these two groups. Cancer stage, patient age and smoking habits did not affect these results, but Oestrogen Receptor (ER) positive patients had higher Bβ 15-42 values than ER negative patients (p = 0.017). These results show that fibrin formation is enhanced preoperatively in patients with either benign or malignant breast disease. The fibrinolytic response to activated coagulation may be relatively deficient in breast cancer. The roles of malignancy, stress and other factors in the causation of these abnormalities require further assessment.

Spring fire effects on two Aristida/Bothriochloa native pastures in central Queensland, Australia

Controlled burns are commonly used to suppress woody plant regrowth and to remove accumulated unpalatable pasture from rangelands and occasionally to alter pasture composition in native pastures in central Queensland, Australia. Outcomes can be somewhat unpredictable and short-term, and reliable evidence is needed to confirm the likely long-term efficacy of such fires. We imposed a regime of repeated spring burns on native Aristida/Bothriochloa pastures growing in two contrasting eucalypt woodlands of central Queensland to determine the effects on pasture composition, ground cover, landscape stability and woody plant recruitment, all in the absence of grazing. The sites selected were a silver-leaved ironbark (Eucalyptus melanophloia F.Muell.) woodland and a poplar box (E. populnea F.Muell.) woodland. Weather conditions precluded spring burns in 3 years out of 7 at the silver-leaved ironbark site and in 2 years out of 8 at the poplar box site. The burn intensity was variable, and frequent fires produced a marked change in abundance of only a few pasture species. Depending on the site, fires significantly increased the frequency of Enneapogon spp., Bothriochloa bladhii (Retz.) S.T.Blake and Dichanthium sericeum (R.Br.) A.Camus and reduced the frequency of some minor components such as Cymbopogon spp., Panicum effusum R.Br., Cenchrus ciliaris L. and, ephemerally, that of some forbs. Contrary to expectation, only Aristida calycina R.Br. declined in abundance among the many Aristida species present, and the abundance of Heteropogon contortus (L.) P.Beauv. ex Roem. & Schult. barely increased under regular spring fires. The total germinable seeds of herbaceous species in the soil each spring was significantly reduced by burning in the previous spring. Repeated spring fires rarely reinforced any initial change induced by burning, and slightly lowered average ground cover as well as various indices of landscape stability and ecosystem functionality. Changes produced were not always consistent across the two communities. Though prescribed burning is often important for maintaining grazing productivity and landscape values, very regular use is not recommended.

De novo loss of function mutations in KIAA2022 are associated with epilepsy and neurodevelopmental delay in females

Intellectual disability (ID) affects about 3% of the population and has a male gender bias. Of at least 700 genes currently linked to ID, more than 100 have been identified on the X chromosome, including KIAA2022. KIAA2022 is located on Xq13.3 and is expressed in the developing brain. The protein product of KIAA2022, X‐linked Intellectual Disability Protein Related to Neurite Extension (XPN), is developmentally regulated and is involved in neuronal migration and cell adhesion. The clinical manifestations of loss‐of‐function KIAA2022 mutations have been described previously in 15 males, born from unaffected carrier mothers, but few females. Using whole‐exome sequencing, we identified a cohort of five unrelated female patients with de novo probably gene damaging variants in KIAA2022 and core phenotypic features of ID, developmental delay, epilepsy refractory to treatment, and impaired language, of similar severity as reported for male counterparts. This study supports KIAA2022 as a novel cause of X‐linked dominant ID, and broadens the phenotype for KIAA2022 mutations.

First report of monomicrobial Candida parapsilosis necrotizing fasciitis

Candida parapsilosis is an emerging pathogen worldwide. It commonly causes soft tissue infection; however, to our knowledge there has been no previous report of monomicrobial necrotizing soft tissue infection (NSTI) secondary to C. parapsilosis. We report the first case of NSTI caused by C. parapsilosis in an immunocompromised renal transplant patient, with the diagnosis proven both histologically and microbiologically. Our patient required aggressive surgical intervention and antifungal therapy, with postoperative survival at 90 days.

Culture-negative Bartonella endocarditis in a patient with renal failure: the value of molecular methods in diagnosis

Members of the genus Bartonella are increasingly recognised as a cause of culture-negative endocarditis, particularly in those patients with underlying risk factors (e.g., homelessness and alcoholism (B. quintana) or valvulopathy and cat ownership (B. henselae). The aortic and mitral-valves are most commonly involved. Here, a case is reported of culture-negative right-sided endocarditis, without any of the above risk factors, due to Bartonella sp. in a 69-year-old man who presented with acute renal failure. The diagnosis was made using a broad-range 16S rRNA polymerase chain reaction (PCR) technique and direct automated sequencing on a peripheral blood sample, which was subsequently confirmed serologically. A review of the literature on Bartonella endocarditis is also presented. Molecular laboratory methods using peripheral blood or blood cultures may be very useful in the diagnosis of causal agents in culture-negative endocarditis and add further support to the recently inclusion of molecular (PCR) diagnosis, as a major Duke's criterion, for the diagnosis of infective endocarditis.

Assessment of recurrent laryngeal nerve function during thyroid surgery

INTRODUCTION

There is disparity in the reported incidence of temporary and permanent recurrent laryngeal nerve (RLN) palsy following thyroidectomy. Much of the disparity is due to the method of assessing vocal cord function. We sought to identify the incidence and natural history of temporary and permanent vocal cord palsy following thyroid surgery. The authors wanted to establish whether intraoperative nerve monitoring and stimulation aids in prognosis when managing vocal cord palsy.

METHODS

Prospective data on consecutive thyroid operations were collected. Intraoperative nerve monitoring and stimulation, using an endotracheal tube mounted device, was performed in all cases. Endoscopic examination of the larynx was performed on the first postoperative day and at three weeks.

RESULTS

Data on 102 patients and 123 nerves were collated. Temporary and permanent RLN palsy rates were 6.1% and 1.7%. Most RLN palsies were identified on the first postoperative day with all recognised at the three-week review. No preoperative clinical risk factors were identified. Although dysphonia at the three-week follow-up visit was the only significant predictor of vocal cord palsy, only two-thirds of patients with cord palsies were dysphonic. Intraoperative nerve monitoring and stimulation did not predict outcome in terms of vocal cord function.

CONCLUSIONS

Temporary nerve palsy rates were consistent with other series where direct laryngoscopy is used to assess laryngeal function. Direct laryngoscopy is the only reliable measure of cord function, with intraoperative monitoring being neither a reliable predictor of cord function nor a predictor of eventual laryngeal function. The fact that all temporary palsies recovered within four months has implications for staged procedures.

Serum total hCGβ level is an independent prognostic factor in transitional cell carcinoma of the urothelial tract

Background:

Serum total human chorionic gonadotrophin β subunit (hCGβ) level might have prognostic value in urothelial transitional cell carcinoma (TCC) but has not been investigated for independence from other prognostic variables.

Methods:

We utilised a clinical database of patients receiving chemotherapy between 2005 and 2011 for urothelial TCC and an independent cohort of radical cystectomy patients for validation purposes. Prognostic variables were tested by univariate Kaplan–Meier analyses and log-rank tests. Statistically significant variables were then assessed by multivariate Cox regression. Total hCGβ level was dichotomised at < vs ⩾2 IU l⁻¹.

Results:

A total of 235 chemotherapy patients were eligible. For neoadjuvant chemotherapy, established prognostic factors including low ECOG performance status, normal haemoglobin, lower T stage and suitability for cisplatin-based chemotherapy were associated with favourable survival in univariate analyses. In addition, low hCGβ level was favourable when assessed either before (median survival not reached vs 1.86 years, P=0.001) or on completion of chemotherapy (4.27 vs 0.42 years, P=0.000002). This was confirmed in multivariate analyses and in patients receiving first- and second-line palliative chemotherapy, and in a radical cystectomy validation set.

Conclusions:

Serum total hCGβ level is an independent prognostic factor in patients receiving chemotherapy for urothelial TCC in both curative and palliative settings.

Wing shape and size of the western corn rootworm (Coleoptera: Chrysomelidae) is related to sex and resistance to soybean-maize crop rotation

The western corn rootworm, Diabrotica virgifera virgifera LeConte, is a major pest of maize in the United States and more recently, Europe. Understanding the dispersal dynamics of this species will provide crucial information for its management. This study used geometric morphometric analysis of hind wing venation based on 13 landmarks in 223 specimens from nine locations in Illinois, Nebraska, Iowa, and Missouri, to assess whether wing shape and size differed between rotated and continuously grown maize where crop rotation-resistant and susceptible individuals are found, respectively. Before assessing differences between rotation-resistant and susceptible individuals, sexual dimorphism was investigated. No significant difference in wing (centroid) size was found between males and females; however, females had significantly different shaped (more elongated) wings compared with males. Wing shape and (centroid) size were significantly larger among individuals from rotated maize where crop-rotation resistance was reported; however, cross-validation of these results revealed that collection site resistance status was an only better than average predictor of shape in males and females. This study provides preliminary evidence of wing shape and size differences in D. v. virgifera from rotated versus continuous maize. Further study is needed to confirm whether wing shape and size can be used to track the movement of rotation-resistant individuals and populations as a means to better inform management strategies.