Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages

Introduction

The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes.

Methods

Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 – July 2009) and after (August 2009 – July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality.

Results

There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann– Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008–2009 to 6 (16.7%) in 2009–2010 (chi-squared test, p<0.0001).

Conclusions

The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.     

Physical therapists' perceptions of family involvement in the rehabilitation process

The purpose of this qualitative study was to describe how physical therapists working in rehabilitation settings involved families in the patient's rehabilitation program and what factors facilitated or impeded this involvement. Forty physical therapists practicing in the eastern United States were individually interviewed on their involvement of families in a patient's rehabilitation. The interview data were transcribed, coded, and analyzed for main themes. Family involvement was found to be a significant aspect of a patient's rehabilitation. Factors pertaining to the family, the patient, the healthcare organization and the physical therapist were identified. Factors, such as the family's knowledge, attitudes and skills of the family, their relationship with the patient prior to the injury or disability, the availability and opportunity of family members to be involved, and their physical capabilities, all influenced the degree to which the family participated. Therapists also perceived the cognitive status of the patient as a factor which dictated the proper amount of family participation. The health-care organization was an important factor which needed to encourage and support the family participation. With decreased lengths of stay there is less time for families to be independent in caring for their loved one. The organization of the department could be instrumental in this by providing multiple formal and informal avenues for family training, such as support groups, home visits, ‘open door’ policy visiting hours, and scheduling changes. Finally, the physical therapists might have been the single most significant factor in facilitating family involvement. It was important for them to establish open and honest communication and be pro-activists for their patients and their families. The findings were consistent with the existing literature base in relation to the patient and family. Additional findings present physical therapists and healthcare organizations with suggestions for improving family education. Copyright © 1996 Whurr Publishers Ltd.     

User and Healthcare Professional Perspectives on Do-It-Yourself Artificial Pancreas Systems: A Need for Guidelines

A growing number of individuals with type 1 diabetes are choosing to use “do-it-yourself” artificial pancreas systems (DIY APS) to support their diabetes self-management. Observational and self-report data of glycemic benefits of DIY APS are promising; however, without rigorous clinical trials or regulation from governing bodies, liability and user safety continue to be central concerns for stakeholders. Despite DIY APS having been used for several years now, there are no guidelines to assist users and healthcare professionals in addressing DIY APS use in routine clinical care. This commentary reports key stakeholders’ perspectives presented at the annual Advanced Technologies and Treatments in Diabetes conference in February 2020. Important considerations to inform the development of clinical care guidelines are also presented to generate further debate.     

Allergic contact stomatitis from a gold alloy--fixed partial denture

Allergic contact stomatitis to gold is rare. To our knowledge, seven cases caused by dental restorations have been previously reported. Each of the patients was female. This report documents an allergic reaction to gold in a fixed prosthesis. A female patient, previously sensitized to gold earrings, experienced an itching and burning pain sensation and ulceration of the oral tissues adjacent to the gold restoration. Patch tests confirmed the allergy to gold. The dentist needs to be aware of the symptoms that are characteristic of the allergic manifestations of gold. Inquiries about allergies to metals and jewelry should be a part of the medical history. Any patient experiencing pain, itching, burning, and ulceration of the mucosa adjacent to a cast gold restoration should be suspected of an allergic contact stomatitis.     

Response of Pulmonary Vein Potentials to Burst Pacing

BACKGROUND: Pulmonary vein potentials recorded at the ostia of pulmonary veins (PV) are a useful guide for segmental isolation of the PV in patients with atrial fibrillation (AF). Even during coronary sinus pacing at 600 ms, atrial (A) and PV potentials can overlap in 50-60% of patients making the accurate identification of PV potentials very difficult. METHODS: Nineteen patients (M:F 15:4) with paroxysmal AF underwent segmental isolation of one or more PV. Coronary sinus (CS) pacing was performed at cycle lengths of 600/550/500/450/400/350/300 ms and bipolar electrograms were recorded from the 10 or 20 pole Lasso catheter placed at the atrial-PV junction in 27 pulmonary veins. Stimulus (S) to A, S-PVP and A-PVP intervals were measured during CS pacing at the different cycle lengths at sweep speed of 200 mm/sec. RESULTS: During CS pacing at 600 ms the A and PV potentials were significantly overlapped (A-PVP < or = 25 ms) in 15 of 27 (55%) veins. During pacing at 300 ms, the A and PV potentials were significantly separated (A-PVP > or = 25 ms) in 9 of the 15 veins where A and PV potentials overlapped and 21 of all 27 (78%) veins. In two patients pacing at 300 ms was associated with 2:1 conduction block from atrial to PV fascicle. CONCLUSIONS: Coronary sinus pacing at cycle length of 300 ms demonstrated better separation of A and PV potentials compared to pacing at 600 ms. This strategy is easier and less time consuming compared to extrastimuli testing. It also confirms that the electrophysiological properties of PV fascicles are different from that of the adjacent atrial musculature.     

Comparison of anatomy-based, fluence-based and aperture-based treatment planning approaches for VMAT

Volumetric modulated arc therapy (VMAT) has the potential to reduce treatment times while producing comparable or improved dose distributions relative to fixed-field intensity-modulated radiation therapy. In order to take full advantage of the VMAT delivery technique, one must select a robust inverse planning tool. The purpose of this study was to evaluate the effectiveness and efficiency of VMAT planning techniques of three categories: anatomy-based, fluence-based and aperture-based inverse planning. We have compared these techniques in terms of the plan quality, planning efficiency and delivery efficiency. Fourteen patients were selected for this study including six head-and-neck (HN) cases, and two cases each of prostate, pancreas, lung and partial brain. For each case, three VMAT plans were created. The first VMAT plan was generated based on the anatomical geometry. In the Elekta ERGO++ treatment planning system (TPS), segments were generated based on the beam's eye view (BEV) of the target and the organs at risk. The segment shapes were then exported to Pinnacle TPS followed by segment weight optimization and final dose calculation. The second VMAT plan was generated by converting optimized fluence maps (calculated by the Pinnacle TPS) into deliverable arcs using an in-house arc sequencer. The third VMAT plan was generated using the Pinnacle SmartArc IMRT module which is an aperture-based optimization method. All VMAT plans were delivered using an Elekta Synergy linear accelerator and the plan comparisons were made in terms of plan quality and delivery efficiency. The results show that for cases of little or modest complexity such as prostate, pancreas, lung and brain, the anatomy-based approach provides similar target coverage and critical structure sparing, but less conformal dose distributions as compared to the other two approaches. For more complex HN cases, the anatomy-based approach is not able to provide clinically acceptable VMAT plans while highly conformal dose distributions were obtained using both aperture-based and fluence-based inverse planning techniques. The aperture-based approach provides improved dose conformity than the fluence-based technique in complex cases.     

Improved HIV-related outcomes associated with implementation of a novel public health information exchange

PurposeThe purpose of this study was to evaluate HIV-related outcomes associated with use of a novel public health information exchange that was designed to identify out of care HIV-infected individuals seen within a large, integrated delivery network (IDN).MethodsA novel, secure, bidirectional health care delivery-public health information exchange, the Louisiana Public Health Information Exchange (LaPHIE) was developed between a multi-geographical IDN and the Louisiana public health authority in response to the high proportion of out of care HIV-infected persons. The system provides real-time provider alerts when any HIV-infected person who has not had CD4 or HIV viral load (VL) monitoring in >1 year receives non-HIV care within the IDN, allowing immediate linkage to HIV specialty care. Persons identified over the first 30 months of the system's implementation were characterized using a case-cohort approach to compare out-of-care individuals with randomly sampled, time-matched in-care controls.ResultsBetween 2/1/09 and 7/31/11, 549 alerts identified 419 unduplicated HIV-infected individuals without a CD4 count or VL in >1 year. Patients were identified at 60 clinics and alerts shown to 223 clinicians in 7 participating facilities. A quarter (24%) of those identified had not had a CD4 count or VL conducted since their initial diagnosis. Of the remaining 76% who had been in care previously, over half (55%) had been out of care for ≥18 months, with a median time of 19.4 months [IQR 15.0–32.5] since their previous visit. Following LaPHIE identification, 42% had CD4 counts < 200 cells/mm³ and 62% had VL > 10,000 RNA copies/mL. Of the 344 patients with at least 6 months of follow up, 85% had at least one CD4 and/or VL test after being identified.ConclusionsThe results of this study demonstrate that an information exchange can effectively facilitate engagement, re-engagement, and retention of out-of care HIV-infected persons in HIV specialty care. Within two years, we were able to observe significant improvements in HIV-related utilization and disease progression indices. Future programs should consider adopting this innovative strategy to improve HIV care at both the individual and population levels.     

Blockade of SK-type Ca2+-activated K+ channels uncovers a Ca2+-dependent slow afterdepolarization in nigral dopamine neurons

Sharp electrode current-clamp recording techniques were used to characterize the response of nigral dopamine (DA)-containing neurons in rat brain slices to injected current pulses applied in the presence of TTX (2 microM) and under conditions in which apamin-sensitive Ca2+-activated K+ channels were blocked. Addition of apamin (100-300 nM) to perfusion solutions containing TTX blocked the pacemaker oscillation in membrane voltage evoked by depolarizing current pulses and revealed an afterdepolarization (ADP) that appeared as a shoulder on the falling phase of the voltage response. ADP were preceded by a ramp-shaped slow depolarization and followed by an apamin-insensitive hyperpolarizing afterpotential (HAP). Although ADPs were observed in all apamin-treated cells, the duration of the response varied considerably between individual neurons and was strongly potentiated by the addition of TEA (2-3 mM). In the presence of TTX, TEA, and apamin, optimal stimulus parameters (0.1 nA, 200-ms duration at -55 to -68 mV) evoked ADP ranging from 80 to 1,020 ms in duration (355.3 +/- 56.5 ms, n = 16). Both the ramp-shaped slow depolarization and the ensuing ADP were markedly voltage dependent but appeared to be mediated by separate conductance mechanisms. Thus, although bath application of nifedipine (10-30 microM) or low Ca2+, high Mg2+ Ringer blocked the ADP without affecting the ramp potential, equimolar substitution of Co2+ for Ca2+ blocked both components of the voltage response. Nominal Ca2+ Ringer containing Co2+ also blocked the HAP evoked between -55 and -68 mV. We conclude that the ADP elicited in DA neurons after blockade of apamin-sensitive Ca2+-activated K+ channels is mediated by a voltage-dependent, L-type Ca2+ channel and represents a transient form of the regenerative plateau oscillation in membrane potential previously shown to underlie apamin-induced bursting activity. These data provide further support for the notion that modulation of apamin-sensitive Ca2+-activated K+ channels in DA neurons exerts a permissive effect on the conductances that are involved in the expression of phasic activity.     

Do we practice evidence based medicine with regard to drain usage in knee arthroplasty? Results of a questionnaire of BASK members

Clinical governance requires our clinical practice to be evidence based. We wished to see if British Orthopaedic surgeons are using the current evidence with regards to the use of drains in knee arthroplasty. A questionnaire was faxed to all UK members of BASK to ascertain their current practice regarding the use of drains in knee arthroplasty and the rationale for their drain policy. The study suggests that the majority of practising members of BASK do not practice evidence based medicine with regard to the use of drains in knee arthroplasty.