Systematic review of enhanced recovery after gastro-oesophageal cancer surgery

Introduction

Fast track methodology or enhanced recovery schemes have gained increasing popularity in perioperative care. While evidence is strong for colorectal surgery, its importance in gastric and oesophageal surgery has yet to be established. This article reviews the evidence of enhanced recovery schemes on outcome for this type of surgery.

Methods

A systematic literature search was conducted up to March 2014. Studies were retrieved and analysed using predetermined criteria.

Results

From 34 articles reviewed, 18 eligible studies were identified: 7 on gastric and 11 on oesophageal resection. Three randomised controlled trials, five case-controlled studies and ten case series were identified. The reported protocols included changes to each stage of the patient journey from pre to postoperative care. The specific focus following oesophageal resections was on early mobilisation, a reduction in intensive care unit stay, early drain removal and early (or no) contrast swallow studies. Following gastric resections, the emphasis was on reducing epidural anaesthesia along with re-establishing oral intake in the first three postoperative days and early removal of nasogastric tubes.In the papers reviewed, mortality rates following fast track surgery were 0.8% (9/1,075) for oesophageal resection and 0% (0/329) for gastric resection. The reported morbidity rate was 16.5% (54/329) following gastric resection and 38.6% (396/1,075) following oesophageal resection. Length of stay was reduced in both groups compared with conventional recovery groups in comparative studies.

Conclusions

The evidence for enhanced recovery schemes following gastric and oesophageal resection is weak, with only three (low volume) published randomised controlled trials. However, the enhanced recovery approach appears safe and may be associated with a reduction in length of stay.     

Autoantibodies against the platelet glycoprotein IIb/IIIa complex in patients with chronic ITP

Chronic idiopathic thrombocytopenic purpura (ITP) is caused by an antibody reactive with platelet-associated antigens. The present studies provide direct evidence that some patients with chronic ITP have autoantibodies against the platelet glycoprotein (GP) IIb/IIIa complex. Microtiter wells, coated with a monoclonal antibody (2G12) specific for GPIIb/GPIIIa were reacted with GPIIb/GPIIIa contained in a platelet extract. Control wells containing the same antibody were reacted with a cell extract containing no GPIIb/GPIIIa. After washing, the wells were reacted with patient or control plasma, and IgG binding was detected using 125I-Fab2-anti-human IgG. Assay values were expressed as binding ratios (cpm GPIIb/GPIIIa wells/cpm control wells). Plasma from 5 of 56 patients with chronic ITP had ratios (1.36-3.14) greater than 3 standard deviations above the mean (+/- SD) of control plasmas--0.93 +/- 0.12. Elevated values were also noted in two patients with anti-P1A1 antibody (ratios greater than 30) and in one patient with Hodgkin's disease and an ITP-like syndrome (ratio 1.53). Normal values were noted in 34 patients with a variety of immune and nonimmune diseases. Plasma from two of the positive ITP patients was reacted with 125I-surface-labeled platelets and, after solubilization, the IgG and bound antigen were precipitated with Staph-A. Autoradiographs from SDS- PAGE electrophoresis of the Staph-A-bound proteins shows two radioactive bands consistent in size with GPIIb and GPIIIa.     

A randomised controlled trial of the effectiveness of soft silicone multi‐layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial

The prevention of hospital acquired pressure ulcers in critically ill patients remains a significant clinical challenge. The aim of this trial was to investigate the effectiveness of multi‐layered soft silicone foam dressings in preventing intensive care unit (ICU) pressure ulcers when applied in the emergency department to 440 trauma and critically ill patients. Intervention group patients (n = 219) had Mepilex^® Border Sacrum and Mepilex^® Heel dressings applied in the emergency department and maintained throughout their ICU stay. Results revealed that there were significantly fewer patients with pressure ulcers in the intervention group compared to the control group (5 versus 20, P = 0·001). This represented a 10% difference in incidence between the groups (3·1% versus 13·1%) and a number needed to treat of ten patients to prevent one pressure ulcer. Overall there were fewer sacral (2 versus 8, P = 0·05) and heel pressure ulcers (5 versus 19, P = 0·002) and pressure injuries overall (7 versus 27, P = 0·002) in interventions than in controls. The time to injury survival analysis indicated that intervention group patients had a hazard ratio of 0·19 (P = 0·002) compared to control group patients. We conclude that multi‐layered soft silicone foam dressings are effective in preventing pressure ulcers in critically ill patients when applied in the emergency department prior to ICU transfer.     

Exploring youth and caregiver preferences for asthma education video content

Objective: This study examines (1) whether youth and their caregivers have different preferences for asthma education video topics and (2) if education topic preferences vary by youth and caregiver sociodemographic characteristics. Methods: Youth (n?=?83) ages 7–17 years with persistent asthma and their caregivers were recruited at two pediatric practices in North Carolina. Sociodemographic information and youth and caregiver preferences for nine asthma video education topics were collected during in-person interviews. Bonferroni-corrected Chi-square or McNemar tests (α?=?0.0056) were used to compare youth and caregivers differences in topic preferences and topic preferences by youth and caregiver sociodemographic characteristics, including gender, race, ethnicity, and age. Results: Youth were primarily male (52%) and from low-income families (74%; caregiver annual income less than $30 000) and many were Hispanic (45%). Youth and parents expressed the most interest in the following two topics: “how to deal with triggers” (90% and 95%, respectively) and “how to keep asthma under control” (87% and 96%, respectively). Caregivers and children were discordant for two topics: “the difference between a rescue and controller medicine” and “how to [help your child] talk to your [his/her] friends about asthma.” No differences were found between youth and caregiver sociodemographic characteristics and video topic preferences. Conclusions: Youth with persistent asthma and their caregivers differed in their asthma education topic preferences, but preferences did not vary by caregiver or youth sociodemographic characteristics. Studies examining the effectiveness of interventions tailored to differences in educational preferences of youth with asthma and their caregivers are needed.     

Towards theory‐driven therapies for aphasic verb impairments: A review of current theory and practice

Background: This review is intended for both theoretically and clinically motivated audiences with an interest in aphasic verb impairments.

Aims: Building from previous reviews, our aim is to provide a concise summary of the relevant theoretical research and perspectives on verbs, and from this theoretical foundation to explore which aspects have been incorporated and tested in therapy studies.

Main Contribution: In the theoretical domain, the review first considers the patterns of verb and noun impairments in aphasic syndromes. Second, an overview of the linguistic differences between verbs and nouns is provided, differences that occur at various levels of linguistic analysis: phonological, morphological, semantic, and syntactic. This is followed by a detailed account of the psycholinguistic perspective on verb–noun differences. Specifically, this section examines the role of variables such as imageability and frequency, and the issue of depiction of actions in static picture versus dynamic video format. Evidence from neuroimaging studies as well as neurodegenerative conditions such as semantic dementia is also reviewed. Finally, the psycholinguistic account further discusses the question of whether verbs (and nouns) serve as primary ordering principles in the cognitive architecture of language processing or whether they should be more accurately viewed as points on an overarching psycholinguistic continuum. Also within the psycholinguistic discussion, event perception is described as a theoretical account with implications for verb processing. Despite the importance of verbs in their pivotal role in connected speech, there is a very limited body of literature on verb therapies and only a small number of the theoretical issues/perspectives have penetrated approaches to treating verb impairments. Ten published papers are described. Two of these directly compare verb and noun therapies, reflecting the many comparisons of noun vs verb impairments in the theoretical literature. The remaining eight consist of purely verb‐focused therapies, which also examined the effects of increased verb retrieval skills on related sentence production (reflecting the pivotal role of verbs in connected speech). These eight studies are subdivided between four that targeted verb retrieval only and four that also investigated aspects of verb argument structure and sentence production.

Conclusions: The general discussion notes possible new approaches to the treatment of verb deficits that arise from the many factors noted in the theoretical literature which are yet to be fully explored in therapy studies.