Patients' satisfaction with fast‐track surgery in gynaecological oncology

This study investigates the experience and satisfaction with care of fast‐tracked gynaecological patients. The Sydney Gynaecological Oncology Group, New South Wales, Australia, has previously shown the benefits of a fast‐track surgery programme for gynaecology patients with both complex benign gynaecological pathology and gynaecological malignancy. The question of whether these benefits translate into a positive experience for fast‐tracked patients, in the context of their hospital stay and healthcare team care, has not been previously explored in detail. A self‐administered satisfaction questionnaire incorporating the European Organisation for Research and Treatment of Cancer (EORTC) cancer in‐patient satisfaction with care measure (INPATSAT‐32) questionnaire with additional questions was administered to 106 gynaecology participants at Royal Prince Alfred Hospital. Participants reported high levels of satisfaction with patient care and support received from doctors, ward nurses and the hospital as a service and care organisation, within the context of a fast‐track surgical programme. Early hospital discharge after gynaecological surgery results in both enhanced recovery after surgery (ERAS) and high levels of patient satisfaction.     

Student reflective groups at a Scottish College of Nursing

In this paper student views on reflective groups, set up as an important element of the new Project 2000 course in a Scottish College of Nursing, are reported. A random sample of 19 students were interviewed. While the reflective groups were very popular with students because they provided support, there was little evidence of a linkage between theory and practice. It was clear that the ambitious objective of stimulating reflection-on-action was not attained. Practice certainly was discussed, but it tended to be dominated by dramatic and emotionally charged aspects of care rather than the more frequent routine concerns. There were, however, indications that the original aim of the reflective groups could be achieved if tutors could establish a common understanding of the purpose of the groups and of reflection, and if the practices on which students reflected consisted less of single day visits where the students saw themselves as non-participant outsiders.     

Evaluation of collateral circulation of the hand

In 1929, Edgar V. Allen described a noninvasive evaluation of the patency of the arterial supply to the hand of patients with thromboangitis obliterans (Am J Med Sci 1929;178:237). In the early 1950s, Allen's test was modified (Wright I. Vascular diseases in clinical practice. Chicago: Year Book Medical Publishers, 1952) for use as a test of collateral circulation prior to arterial cannulation. This test involves the examiner occluding the patient's ulnar and radial arteries while the patient makes a fist, causing the hand to blanch. The patient is then asked to extend the fingers. After the hand is open, the examiner releases the ulnar artery while continuing to maintain pressure on the radial artery. Adequate collateral circulation is felt to be indicated by return of normal color to the hand. The patient is instructed not to hyperextend the fingers when opening the hand. Hyperextension may cause a decrease in perfusion to the arch, possibly resulting in a false interpretation of the Allen test (Anesthesiology 1972;37:356). The modified Allen's test can be performed quickly and easily, but it is susceptible to error. (With Allen's original test, both hands were tested simultaneously. The patient clenched both fists tightly for 1 minute while the examiner compressed one artery of each hand. This method helps diagnose complete occlusion, just as Allen intended. The test was later modified, however, to evaluate the adequacy of collateral circulation. To perform the modified Allen's test, the examiner compresses both arteries while the patient's fists are clenched. The patient then opens the hand, and the adequacy of circulation is evaluated when the examiner releases one of the arteries.) This study was designed to combine the modified Allen's test with the sensitivity of oximetry and plethysmography to provide a quantifiable and reproducible evaluation of the palmar collateral circulation with or without the subject's cooperation. Superficial palmar arches of 90 normal volunteers (aged 22–45 years) were evaluated with the modified Allen's test. These results were compared with the flow patterns demonstrated by plethysmography and pulse oximetry. All of the modified Allen's tests were normal, with the palmar blush occurring in an average of 2.3 seconds (range, 2–5 s). Results were recorded independently by two observers, with agreement in all cases. Four of the 90 (4.4%) palmar arches were found to have abnormal circulatory patterns. Plethysmography clearly demonstrated the dominant arterial supply to the hand and, in appropriate cases, indicated the existence of an incomplete arch. The four abnormal circulatory patterns (two incomplete palmar arches and two other aberrant arterial communications) were clearly shown by plethysmography. Pulse oximetry was found to be too sensitive. Significant changes in flow did not result in a decrease in saturation. Only the incomplete superficial palmar arches resulted in a change in saturation. The two abnormal arterial communications were not detected by pulse oximetry. Pulse oximetry also could not show dominant flow patterns. Our findings indicate that plethysmography can be used to demonstrate palmar collateral circulation, but that pulse oximetry cannot.This work was funded by the Anesthesiology Research Foundation and the Samuel J. Roessler Research Scholarship.This paper was presented at the Society of Critical Care Medicine's 19th Annual Education and Scientific Symposium, San Francisco, California, May, 1990.     

晚期胰腺癌的内科治疗进展

近年来,胰腺癌发病率呈逐年上升趋势,早诊率低,手术切除率低,恶性程度高,预后极差,发病人数与死亡人数的比值接近1。目前放化疗联合姑息性手术的综合治疗是局部晚期及转移性胰腺癌的主要治疗手段,主要目的在于提高生活质量,延长生命。吉西他滨是目前的标准治疗,以其为主的联合方案的疗效亦有越来越多的循证医学证据支持。与靶向药物联合有一定的疗效。随着新的化疗药物和靶向药物的涌现,给晚期胰腺癌的治疗带来新的希望。