Cluster randomized trial to evaluate the impact of team training on surgical outcomes

Background

The application of safety principles from the aviation industry to the operating room has offered hope in reducing surgical complications. This study aimed to assess the impact on major surgical complications of adding an aviation-based team training programme after checklist implementation.

Methods

A prospective parallel-group cluster trial was undertaken between September 2011 and March 2013. Operating room teams from 31 hospitals were assigned randomly to participate in a team training programme focused on major concepts of crew resource management and checklist utilization. The primary outcome measure was the occurrence of any major adverse event, including death, during the hospital stay within the first 30 days after surgery. Using a difference-in-difference approach, the ratio of the odds ratios (ROR) was estimated to compare changes in surgical outcomes between intervention and control hospitals.

Results

Some 22 779 patients were enrolled, including 5934 before and 16 845 after team training implementation. The risk of major adverse events fell from 8·8 to 5·5 per cent in 16 intervention hospitals (adjusted odds ratio 0·57, 95 per cent c.i. 0·48 to 0·68; P < 0·001) and from 7·9 to 5·4 per cent in 15 control hospitals (odds ratio 0·64, 0·50 to 0·81; P < 0·001), resulting in the absence of difference between arms (ROR 0·90, 95 per cent c.i. 0·67 to 1·21; P = 0·474). Outcome trends revealed significant improvements among ten institutions, equally distributed across intervention and control hospitals.

Conclusion

Surgical outcomes improved substantially, with no difference between trial arms. Successful implementation of an aviation-based team training programme appears to require modification and adaptation of its principles in the context of the the surgical milieu. Registration number: NCT01384474 (http://www.clinicaltrials.gov).

Serum levels of adhesion molecules ICAM-1 and VCAM-1 and tissue inhibitor of metalloproteinases, TIMP-1, are elevated in patients with autoimmune thyroid disorders: relevance to vascular inflammation

Serum levels of ICAM-1 (Inter Cellular Adhesion Molecule-1), VCAM-1 (Vascular cell Adhesion Molecule-1-I), TIMP-1 (tissue inhibitor of metalloproteinases 1) and MMP-9 (Metalloproteinase 9) are well established markers of inflammation. The physiopathological link between inflammation, atherosclerosis and autoimmunity is well demonstrated. However, serum levels of these biomarkers in patients with autoimmune-mediated dysthyroidism, including their evolution after improvement of the thyroid disorder have not been assessed. So, we evaluated the circulating levels of these markers in autoimmune and in non-autoimmune-mediated dysthyroid patients, and their evolution after treatment of thyroid disease. We conducted a prospective study to evaluate these markers before and after treatment in hyperthyroid patients (n = 33; 28 patients with autoimmune disease), hypothyroid patients (n = 38; 33 patients with autoimmune disease) and euthyroid subjects (n = 33). At baseline, serum levels of ICAM-1, VCAM-1 and TIMP-1 were significantly elevated in patients with hyperthyroidism as compared to euthyroid and hypothyroid patients (respectively p = 0.0005 and p < 0.0001). In multivariate analysis, the differences remained significant for VCAM-1 and TIMP-1. Median levels of ICAM-1, VCAM-1 and TIMP-1 were significantly higher in patients with autoimmune-mediated dysthyroidism compared to euthyroid patients (respectively p < 0.0001 and p = 0.002). In hyperthyroid patients, ICAM-1, VCAM-1 and TIMP-1 concentrations fell significantly after they had become euthyroid (respectively p = 0.0006; p < 0.0001 and p = 0.0009), although VCAM-1 values remained higher than those observed in the control group (p = 0.005). We found that autoimmune-mediated dysthyroidism were associated with increased peripheral blood concentrations of VCAM-1, ICAM-1 and TIMP-1. Whether these biological abnormalities translate into increase intima remodelling and atherosclerosis remains to be studied.

[Myocardial infarction and disseminated lupus erythematosus]

Myocardial infarction is an underestimated complication of disseminated lupus erythematosus (DLE). Its features, treatment and prognosis are poorly understood. From June 1988 to December 2002, out of 1572 consecutive patients admitted during the first hours of acute myocardial infarction with ST elevation, 7 (5 women, aged 38 +/- 7 years) had DLE. The commonest risk factor was smoking (N = 4). There was a higher incidence of anterior infarction (N = 5). The infarct occurred 7 +/- 5 years after diagnosis of DLE. There were other complications of DLE in all cases. Three patients had antiphospholipid syndromes. The culprit artery was usually the left anterior descending (N = 5). The lesions included stenosing atheroma (N = 5) and extensive thrombosis (N = 5). The coronary disease was usually limited to a single vessel (N = 5). Revascularisation procedures include pre-hospital thrombolysis (N = 3) followed by immediate angioplasty (N = 2) or primary angioplasty (N = 4). TIMI grade 3 flow was obtained in all cases, 278 +/- 162 min after the onset of symptoms. The clinical course was characterised by acute reocclusion in 3 patients, recurrent in 2 patients with an antiphospholipid syndrome, and death in 1 case. Acute myocardial infarction occurs in already complicated cases of DLE, in young patients, associating atherosclerosis and extensive thrombosis. The risk of early reocclusion after reperfusion is high, especially in cases with the antiphospholipid syndrome.

[Compression of the ulnar (cubital) nerve at the wrist by a supernumerary muscle]

The authors report a case of anomaly of the flexor digiti minimi muscle, which extended into the forearm to be inserted 10 centimetres proximal to the carpal flexion crease on flexor carpi radialis. This anomaly was responsible for ulnar nerve compression when grasping objects with the hand. Cases of ulnar nerve compression at the wrist appear to be rare and the great majority of cases are secondary. Anatomical variants of muscles and nerves at the wrist are not exceptional, hence the importance of systematically looking for such anomalies in patients with ulnar nerve compression at the wrist. Excision of the muscle anomaly eliminated nerve compression and the associated symptoms.

Pasteurella caballi infection following a horse bite

The isolation of Pasteurella caballi from an horse-bite wound in a 56-year-old man is reported. Biochemical characteristics are described and compared with the other species representing the genus Pasteurella. This strain probably represents the first human isolate of P. caballi in France.