Tutorial: Development and Implementation of a Multidisciplinary Preoperative Nutrition Optimization Clinic

Although much is known about surgical risk, little evidence exists regarding how best to proactively address preoperative risk factors to improve surgical outcomes. Preoperative malnutrition is a widely prevalent and modifiable risk factor in patients undergoing surgery. Malnutrition prior to surgery portends significantly higher postoperative mortality, morbidity, length of stay, readmission rates, and hospital costs. Unfortunately, perioperative malnutrition is poorly screened for and remains largely unrecognized and undertreated—a true “silent epidemic” in surgical care. To better address this silent epidemic of surgical nutrition risk, here we describe the rationalization, development, and implementation of a multidisciplinary, registered dietitian–driven, preoperative nutrition optimization clinic program designed to improve perioperative outcomes and reduce cost. Implementation of this novel Perioperative Enhancement Team (POET) Nutrition Clinic required a collaboration among many disciplines, as well as an identified need for multidimensional scheduling template development, data tracking systems, dashboard development, and integration of electronic health records. A structured malnutrition risk score (Perioperative Nutrition Screen score) was developed and is being validated. A structured malnutrition pathway was developed and is under study. Finally, the POET Nutrition Clinic has established a novel role for a perioperative registered dietitian as the integral point person to deliver perioperative nutrition care. We hope this structured model of perioperative nutrition assessment and optimization will allow for wide implementation and generalizability in other centers worldwide to improve recognition and treatment of perioperative nutrition risk.     

Exome sequencing of synchronously resected primary colorectal tumours and colorectal liver metastases to inform oncosurgical management

Background

Next generation sequencing technology has facilitated mapping of the colorectal cancer genotype and furthered our understanding of metastogenesis. The aim of this study was to investigate for conserved and different mutations in the exomes of synchronously resected primary colorectal tumour and liver metastases. This information could potentially be utilised to guide the treatment of advanced disease with the help of biological information from the primary tumour.

Obesity management in primary care: assessment of readiness to change among 284 family practice patients

BACKGROUND: Most adults in primary care are overweight or obese; two thirds of patients with weight problems have other obesity-related conditions. The study objective was to explore the feasibility of a primary care obesity intervention based on the transtheoretical model (TM) of behavior change and principles of chronic disease (CD) care. METHODS: A prospective study of the initial version of the TM-CD intervention with obese family practice patients (n = 284) yielded cross-sectional data on baseline stage of change for six target behaviors: dietary fat, portion control, vegetable intake, fruit intake, usual physical activity, and planned exercise. The sample consisted of obese patients scheduled for an office visit during times when recruitment and informed consent did not conflict with acute care. RESULTS: Obese patients volunteering for a TM-CD program are in different stages of change for six target behaviors. Preparation was the most frequently reported stage for increased exercise (49%) or activity (34%), decreased dietary fat consumption (44%), and increased portion control (51%). Patients in a particular stage for one behavior were distributed across all five stages for another behavior. Stage of change for five target behaviors was associated with body mass index or waist girth (P < .05) in a manner consistent with stage-of-change theory. CONCLUSIONS: Using the transtheoretical model of behavior change will allow physicians to recognize when obese patients are receptive to specific behavioral interventions.     

Tuberculosis isolation: comparison of written procedures and actual practices in three California hospitals.

OBJECTIVE: To evaluate implementation of healthcare worker exposure control measures for tuberculosis (TB)-patient isolation, as specified by Centers for Disease Control and Prevention (CDC) guidelines and the hospital's TB-control policy. DESIGN: Prospective multihospital study comparing CDC guidelines and hospital policy for TB-patient isolation to once-weekly observations of TB-patient isolation practices over 14 consecutive weeks at each hospital. SETTING: Three urban hospitals (two county, one private community) in counties in California with a high incidence rate of TB. MEASUREMENTS: Work practices for TB-patient isolation were observed and ventilation performance of isolation rooms was assessed while patient rooms were in use for TB isolation. RESULTS: Of 170 TB-patient rooms observed, 119 (70%) involved a patient in a designated TB isolation room, the room was under negative pressure, the door was closed, and a "respiratory precautions" sign was on the door; 32 patient-room units (19%) were not under negative pressure or not designated as negative-pressure rooms. Of 151 patient-room units mechanically capable of negative pressure at a prior point in time, 16 (11%) were not under negative pressure at the time of use. Of 67 patient-room units equipped with continuous monitoring devices, 8 (12%) involved devices that did not accurately reflect the direction of airflow. Of the 62 healthcare workers observed using a respirator for TB, 40 (65%) did not don the respirator properly. CONCLUSIONS: Implementing CDC guidelines for TB-patient isolation was feasible but imperfect in the three hospitals. Day-to-day work practices deviated from hospital policy. Prospectively quantifying the implementation of a hospital TB isolation policy while the room is in use may lead to improved estimates of risk and may help to identify and thereby prevent avoidable healthcare worker exposures to Mycobacterium tuberculosis aerosol. Auditing practices and verifying equipment performance is likely to identify unexpected problems in implementation of the TB control program.     

Evaluation of five in-line hematocrit monitors

Monitoring the hematocrit is essential during cardiopulmonary bypass for efficacious administration of blood products. The purpose of this study was to evaluate five cardiopulmonary bypass in-line monitors designed to display continuous hematocrit or hemoglobin values. The devices were evaluated for accuracy using an in vitro circuit primed with human blood while randomizing hematocrit, blood flow rate, and temperature. Hematocrits correlated significantly with the error in all the devices (p < 0.01). Over evaluation time, the error of the CDI, Gish, IBC, and MX2 increased significantly (p < 0.05). Temperature correlated significantly with the error of the Gish device (r = -0.49, p < 0.01). Blood flow correlated significantly with the Gish error (r = -0.24, p < 0.01). The Cobe device had a significantly smaller overall error than the other devices (p < 0.001). Device evaluation, based on a low mean error, a low percent error, a high correlation with the actual hematocrit, low correlations between mean error, blood flow, and temperature, and insignificant correlation between time and error, suggests that the Cobe device is more accurate for the continuous monitoring of hematocrit during cardiopulmonary bypass.     

Fatal disseminated Rasamsonia infection in cystic fibrosis post-lung transplantation

Background

Disseminated fungal infections are a known serious complication in individuals with cystic fibrosis (CF) following orthotopic lung transplantation. Aspergillus fumigatus and Scedosporium species are among the more common causes of invasive fungal infection in this population. However, it is also important for clinicians to be aware of other emerging fungal species which may require markedly different antifungal therapies.

Inhibition of mitochondrial translocase SLC25A5 and histone deacetylation is an effective combination therapy in neuroblastoma

The mitochondrion is a gatekeeper of apoptotic processes, and mediates drug resistance to several chemotherapy agents used to treat cancer. Neuroblastoma is a common solid cancer in young children with poor clinical outcomes following conventional chemotherapy. We sought druggable mitochondrial protein targets in neuroblastoma cells. Among mitochondria-associated gene targets, we found that high expression of the mitochondrial adenine nucleotide translocase 2 (SLC25A5/ANT2), was a strong predictor of poor neuroblastoma patient prognosis and contributed to a more malignant phenotype in pre-clinical models. Inhibiting this transporter with PENAO reduced cell viability in a panel of neuroblastoma cell lines in a TP53-status-dependant manner. We identified the histone deacetylase inhibitor, suberanilohydroxamic acid (SAHA), as the most effective drug in clinical use against mutant TP53 neuroblastoma cells. SAHA and PENAO synergistically reduced cell viability, and induced apoptosis, in neuroblastoma cells independent of TP53-status. The SAHA and PENAO drug combination significantly delayed tumour progression in pre-clinical neuroblastoma mouse models, suggesting that these clinically advanced inhibitors may be effective in treating the disease.