Clinical Quality Improvement Research Articles

The impact of the European Association of Endoscopic Surgery research grant scheme-a mixed qualitative quantitative methodology study protocol.

The European Association of Endoscopic Surgery (EAES) is a surgical society who promotes the development and expansion of minimally invasive surgery to surgeons and surgical trainees. It does so through its activities in education, training, and research. The EAES research committee aims to promote the highest quality clinical research in endoscopic and minimally invasive surgery. They have provided grant funding since 2009 in education, surgery, and basic science. Despite the success and longevity of the scheme, the academic and non-academic impact of the research funding scheme has not been evaluated. The primary aim of this project is to assess the short, long term academic and real world impact of the EAES funding scheme. The secondary aims are to identify barriers and facilitators for achieving good impact. This will be a mixed qualitative and quantitative study. Semi-structured interviews will be performed with previous grant recipients. The questions for the interviews will be selected after a consensus is achieved amongst the members of the steering committee of this project. The responses will be transcribed and thematic analysis will be applied. The results of the thematic analysis will be used to populate a questionnaire which will be disseminated to grant recipients. This study is kindly funded by the EAES. The first question this project is expected to answer is whether the EAES research funding scheme had a significant positive impact on research output, career progression but also non-academic output such as change in clinical guidelines, healthcare quality and cost-effectiveness improvement. This project however is also expected to identify facilitators and barriers to successful completion of projects and to achieving high impact. This will inform EAES and the rest of the surgical and academic communities as to how clinicians would like to be supported when conducting research. There should also be a positive and decisive change towards removing factors that hinder the timely and successful completion of projects.

#4606 INNOVATIVE METHOD TO EVALUATE MATURATION OF NEWLY CREATED ARTERIO-VENOUS FISTULAS: INSIGHTS FROM A QUALITY IMPROVEMENT PROJECT

Abstract Background and Aims Recently, we introduced central-venous oxygen saturation (ScvO2) and estimated upper-body blood flow (eUBBF) to monitor the maturation of newly created arterio-venous fistulas (AVF) in hemodialysis (HD) patients [1]. The approach was implemented in a clinical quality improvement project (QIP). Method The QIP involved two Renal Research Institute dialysis centers in New York City that use the Crit-Line monitor (CLM, Fresenius Medical Care, Waltham, MA, USA) as part of the standard of care. CLM measures automatically and non-invasively hematocrit and oxygen saturation (i.e., ScvO2 in patients with central venous catheter as vascular access). eUBBF was computed as described previously [1]. Patients with a with a newly created AVF were included, irrespective of their HD vintage. The QIP team comprised a registered nurse per clinic, two research physicians, and two data analysts. The team met weekly to assess the AVF maturation progress based on eUBBF and ScvO2 data that were displayed on a specific dashboard. Successful AVF maturation is typically accompanied by a rise in cardiac output and eUBBF that starts immediately after AVF creation. However, it is unknown what degree of eUBBF increase indicates a subsequently successful AVF maturation. To identify predictive eUBBF thresholds, we correlated eUBBF changes with the progress of AVF maturation in the six weeks following AVF creation. We defined maturation as unsuccessful when the newly created AVF required an intervention (e.g., angioplasty) or was abandoned. Results We studied 39 patients (age 56 ±18 years; 25 males). Twenty-eight of them were incident patients. Two patients had a second AVF created. In 15 patients AVF maturation was unsuccessful. In these patients, eUBBF increased to an average of 119.2% (SD 35.2) compared to pre-AFV creation. In patients with successful AFV maturation (N = 24), eUBBF increased to an average of 153.7% (SD 31.6) (Figure 1). The difference between the groups is 34.4 percentage points (95% CI: 12.4 to 56.4; p = 0.003). Using eUBBF as a diagnostic measure to discriminate successful vs. failed AVF maturation, an area under the receiver operating characteristics curve of 0.824 (95% CI: 0.673 to 0.925; p<0.0001) was obtained. An eUBBF increase of 25% had a sensitivity of 59% and a specificity of 92% to predict AVF maturation outcomes. Conclusion Computation of eUBBF provides a simple and non-invasive means to track AVF maturation and predict its outcomes.

Proactive outcome monitoring and standardisation of physiotherapy stroke rehabilitation- A retrospective functional outcomes analysis of Accelerated Stroke Ambulation Programme (ASAP).

A clinical quality improvement programme named Accelerated Stroke Ambulation Programme (ASAP) was piloted in Physiotherapy Department of Tai Po Hospital from 1st October 2019 to 30th September 2020 and executed as a standard practice afterwards. The goal of ASAP was to facilitate early maximal walking ability of stroke patients in early rehabilitation phase. ASAP featured (1) proactive outcome monitoring and standardised process compliance monitoring by a patient database - Stroke Registry; (2) standardised mobility prediction by Reference Modified Rivermead Mobility Index (MRMI) Gain and (3) standardised intervention database - Stroke Treatment Library. To investigate the effectiveness of ASAP in an inpatient rehabilitation setting for stroke patients in terms of functional outcomes. The design was a retrospective comparative study to analyse the difference in functional outcomes of Pre-ASAP Group (1st October 2018 - 30th September 2019) and Post-ASAP Group (1st October 2020-30th September 2021). The primary outcome measures were MRMI, Berg's Balance Scale (BBS), Modified Barthel Index (MBI), MRMI Gain, BBS Gain, MBI Gain, MRMI Efficiency, BBS Efficiency and MBI Efficiency. There 348 subjects in Pre-ASAP Group and 281 subjects in Post-ASAP Group. Both groups had highly significant within-group improvement in MRMI, BBS and MBI (). The MRMI Gain of Pre-ASAP Group and Post-ASAP Group was 6.32 and 7.42, respectively; and the difference was significant (). The BBS Gain of Pre-ASAP Group and Post-ASAP Group was 8.17 and 9.70, respectively; and the difference was in margin of significance (). The MBI Gain of Pre-ASAP Group and Post-ASAP Group was 10.69 and 11.96, respectively; but the difference was non-significant (). The MRMI Efficiency, BBS Efficiency and MBI Efficiency of Post-ASAP Group were higher than Pre-ASAP Group but the difference was non-significant. The results of this study reflected that stroke rehabilitation programme with proactive outcome monitoring, standardised process compliance monitoring, standardised mobility prediction and standardised intervention database was practical in real clinical practice with better functional outcomes than traditional physiotherapy practice which were dominated by personal preference and experience of therapists. Proactive outcome monitoring, standardised process compliance monitoring, standardised mobility prediction and standardised intervention database may enhance the effectiveness in terms of functional outcomes of stroke rehabilitation programme.

Clinical efficacy of cognitive behavioral therapy combined with pinaverium bromide tablets on irritable bowel syndrome.

To investigate the clinical efficacy of cognitive behavioral therapy combined with pinaverium bromide tablets in admitted patients with irritable bowel syndrome (IBS). This is a retrospective study. A total of 60 patients with IBS admitted to Beijing Hospital of Integrated Traditional Chinese and Western Medicine between June 2021 and June 2022 were selected and randomly divided into two groups. Patients in the control group were treated with pinaverium bromide tablets, and those in the observation group were treated with cognitive behavior therapy combined with pinaverium bromide tablets. The improvement of clinical symptoms and quality of life before and after treatment was compared for the two groups, IBS-SSS scale and IBS-QOL scale were used to compare the improvement of clinical symptoms and quality of life between the two groups of patients before and after treatment. SAS score and SDS score were used to evaluate the psychology of the two groups. Adverse reactions occurring during the treatment were recorded, such as nausea and vomiting, dizziness and headache, etc. The efficacy of the observation group was higher than that of the control group and the difference was significant (P<0.05). After treatment, the IBS-SSS score in the observation group and the control group decreased and the IBS-QOL score increased. The SDS score and SAS score in the observation group were better than those in the control group (P< 0.05). After treatment, there was no significant difference in adverse reactions between the observation group and the control group (P > 0.05). Cognitive behavioral therapy combined with pinaverium bromide tablets is significantly effective in the treatment of patients with IBS, which can effectively relieve symptoms such as diarrhea and abdominal pain, and reduce irritable bowel reactions.

Audit-based corrective and preventive actions to reduce wastage of blood components at a single blood center: A quality improvement study.

The rate of discarded blood components or "wastage rate" reflects on the whole process, preparation, and production of blood and its quality control. It is the ratio of blood and blood components discarded to the total number of collections. The discard or unusability of blood products are many, and the ones that can be monitored and regarded as indicators to be improvised on are QC failure rate, transfusion-transmitted infection (TTI) positivity, and component discards (other than TTI), including those that caused transfusion reactions. These were studied over four intervention cycles to see if they could be improved. This was a clinical audit and quality improvement study. The clinical audit was conducted over four cycles over 16 months. Each cycle included three stages wherein the data required for calculating those key performance indicators (KPIs) of the blood center were studied and analyzed, and causes for the poorly performing ones were identified; a corrective plan was drawn and implemented, followed by data collection and interpretation of the same in the next cycle for improvement. The data were compiled using a Microsoft Excel spreadsheet and analyzed using SPSS version 19 (IBM Corporation, New York, USA). The overall discard rates due to all cumulative causes mentioned were at about 5% at the start of the first cycle. The various factors comprising preparatory, preparation, and the management of inventory and issue were analyzed, and corrective interventions were performed in every cycle. The discard rates were reduced to about 3% by the end of the four cycles. The difference was statistically significant, with a P < 0.05. The implementation of Corrective and preventive action measures can rectify the deviations in KPIs. The blood center director, staff, and doctors should be responsible for maintaining and continuously improving the quality indicators.

Current status of colon capsule endoscopy in clinical practice.

Colon capsule endoscopy (CCE) is used for restricted indications only. Growing demand for out-of-hospital treatment combined with technical and clinical improvements in quality has made a wider use plausible. Artificial intelligence-supported footage analysis and quality assessment might further improve quality and reduce the price of CCE to a competitive level.

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The role of upadacitinib in the treatment of ulcerative colitis.

The JAK signaling pathway plays a major role in the immunopathology of autoimmune diseases, including inflammatory bowel disease. JAK enzymes provide novel targets for rapidly effective inflammatory bowel disease therapy, particularly in ulcerative colitis. Upadacitinib is a targeted JAK1 inhibitor. In multiple phase III clinical trials, upadacitinib has demonstrated significant improvement in clinical and endoscopic outcomes and quality of life for patients with moderate-to-severe ulcerative colitis. In this drug evaluationwe describe the role of the JAK signaling pathway in ulcerative colitis, the mechanism of action of upadacitinib and the current clinical evidence for its use in ulcerative colitis; we also review its safety and tolerability, including for special populations.

Construction and Practice of Teaching Staff and Teaching Quality Monitoring System in University Affiliated Hospitals Under the Background of Education Informatization

Objective: To build a set of teaching staff construction and teaching quality monitoring system suitable for clinical practice teaching in affiliated hospitals of medical colleges, achieve continuous improvement of clinical education and teaching level, and ensure the quality of medical education talent cultivation. Methods: A modern clinical practice teaching quality monitoring system is constructed based on organizational structure construction, teaching staff system construction, quality control system construction, and information platform construction, combined with external audit and evaluation. Results: The hospital has established a Faculty Development and Teaching Evaluation Office specifically responsible for the cultivation of clinical teachers and the evaluation and supervision of teaching quality. A relatively complete teacher construction and teaching quality monitoring system has also been established for clinical practice teaching, thus achieving integration with the school’s quality control system in terms of management mechanism. At the same time, a set of teaching quality control mode based on the “Internet +” platform has been created by means of informatization. At present, this mode has won three national computer software copyrights and two second prizes for school-level teaching achievements. Conclusion: Through five years of practice, an “Internet +” teaching quality evaluation and monitoring system with the characteristics of teaching hospitals affiliated to local medical colleges has been established. In order to further standardize the training system of clinical teachers in affiliated hospitals, achieve self-monitoring and self-improvement in terms of teaching quality, and ensure the continuous improvement of clinical teaching quality, we will continue to promote the development of clinical teachers with quality and excellence, enrich the main team of quality monitoring, guide the transformation of the education mode from being “centered on teachers” to being “centered on students,” and realize the integration of internal and external quality monitoring systems.

Barriers to Respiratory Care Research in the United States.

Respiratory therapists (RTs) are in a unique position to positively impact patient outcomes through respiratory care research. Research plays a key role in evidence-based medicine; however, few RTs perform and publish research. Identification of barriers experienced by RTs may help increase RT-driven research. Thus, we aimed to identify barriers and research interests for RTs. American Association for Respiratory Care (AARC) members were invited to anonymously complete a survey via an electronic link posted on AARC Connect. Survey domains included research training, experience, reasons for doing research, important respiratory topics, and barriers to conduct research. Responses from 82 surveys were analyzed. The majority were female (56%), and most had a graduate degree (61%), with a mean working experience of 25.3 ± 13.6 y. Fifty-seven percent of respondents reported at least one publication in a peer-reviewed journal. The desire to improve patient outcomes was the top-ranked reason for doing research. Most received research training through a graduate-level program (56%), but few had a formal research mentor (26%). Clinical research (67%) and quality improvement (63%) were the most common types of research. Data collection was the most common research role (51%). Invasive ventilation, advanced monitoring, and airway clearance were identified as the most important research topics. The primary barriers for RTs to conduct research were lack of protected time for research, opportunities to participate, training, departmental support, and mentorship. Lack of time, resources, and opportunities were identified as the primary barriers to RT research, and many RTs have not received formal research training. Resources such as formal mentorship, funding, and protected time may help increase RT participation in research.

Building Resident Quality Improvement Knowledge and Engagement Through a Longitudinal, Mentored, and Experiential Learning-Based Quality Improvement Curriculum.

Quality improvement (QI) training is an essential component of resident medical education and a part of the ACGME core competencies. We present our residency's evidence-based QI curriculum, which outlines key components identified in the literature for successful QI education. Our curriculum included a mandatory five-part longitudinal educational series during ambulatory education sessions for second-year residents. Modeled after the Institute for Healthcare Improvement model for improvement and taught by a chief resident, our curriculum introduced residents to key QI concepts through case-based, just-in-time didactics and applied experiential learning via concurrent resident-led longitudinal QI projects. Residents received structured, multilayer mentorship from a faculty mentor in their field of interest and the chief resident of quality and patient safety. Their work-in-progress projects were presented to faculty QI experts and institutional leadership for additional feedback and mentorship. Since 2016, a total of 234 internal medicine residents have completed our QI curriculum and developed 67 QI projects, which have been presented at various local, regional, and national conferences. In the 2 most recent academic years, Quality Improvement Knowledge Application Tool Revised (QIKAT-R) scores significantly increased from 4.6 precurriculum to 6.3 postcurriculum (p < .001). A longitudinal, experiential, and mentored QI curriculum teaches residents QI skill sets through incorporating mechanisms associated with successful educational initiatives and adult learning theory. Our QIKAT-R results and project output show that our curriculum is associated with improved trainee QI knowledge and systems-level improvements.

Mobilizing registry data for quality improvement: A convergent mixed-methods analysis and application to spinal cord injury.

The rising prevalence of complex chronic conditions and growing intricacies of healthcare systems emphasizes the need for interdisciplinary partnerships to advance coordination and quality of rehabilitation care. Registry databases are increasingly used for clinical monitoring and quality improvement (QI) of health system change. Currently, it is unclear how interdisciplinary partnerships can best mobilize registry data to support QI across care settings for complex chronic conditions. We employed spinal cord injury (SCI) as a case study of a highly disruptive and debilitating complex chronic condition, with existing registry data that is underutilized for QI. We aimed to compare and converge evidence from previous reports and multi-disciplinary experts in order to outline the major elements of a strategy to effectively mobilize registry data for QI of care for complex chronic conditions. This study used a convergent parallel-database variant mixed design, whereby findings from a systematic review and a qualitative exploration were analyzed independently and then simultaneously. The scoping review used a three-stage process to review 282 records, which resulted in 28 articles reviewed for analysis. Concurrent interviews were conducted with multidisciplinary-stakeholders, including leadership from condition-specific national registries, members of national SCI communities, leadership from SCI community organizations, and a person with lived experience of SCI. Descriptive analysis was used for the scoping review and qualitative description for stakeholder interviews. There were 28 articles included in the scoping review and 11 multidisciplinary-stakeholders in the semi-structured interviews. The integration of the results allowed the identification of three key learnings to enhance the successful design and use of registry data to inform the planning and development of a QI initiative: enhance utility and reliability of registry data; form a steering committee lead by clinical champions; and design effective, feasible, and sustainable QI initiatives. This study highlights the importance of interdisciplinary partnerships to support QI of care for persons with complex conditions. It provides practical strategies to determine mutual priorities that promote implementation and sustained use of registry data to inform QI. Learnings from this work could enhance interdisciplinary collaboration to support QI of care for rehabilitation for persons with complex chronic conditions.

Reporting of scar outcomes in the hand and wrist; a state-of-the-art literature review

ObjectivesThe aim of this literature review was to synthesise and report current practice in evaluation and reporting of scar outcomes in hand and wrist clinical research.MethodsA systematic search from inception to 2022 was conducted using three electronic databases. English language randomized controlled trials and observational cohort studies reporting standardised scar outcome measures and/or scar symptoms, appearance, impairment, function, or mental health outcomes in patients with hand and wrist scars were included. Two independent reviewers determined study eligibility and performed data extraction of a priori identified scar outcome domains. Data analysis included descriptive statistics and identification of discordance in taxonomy.ResultsFifty-nine studies were included. Elective surgery cohorts were the most frequently included clinical population (n = 28; 47%) followed by burns (n = 16; 27%). Six different standardised scar outcome measures were reported by 25% of studies however only 7% of studies utilised a patient-reported measure. Scar symptoms were the most frequently reported outcome domain (81%); but taxonomy was incongruous, constructs lacked working definitions required for generalisability and outcome measurement was variable and unreported. Nineteen different measures of scar appearance and structure were reported by 30 (51%) of studies however only nine (23%) were patient-reported. Seven different hand function PROMs were reported by 25 (43%) studies. Person-centred domains including scar acceptability (12%), mental health impact (5%), and social participation (4%) were rarely reported.ConclusionsThis review highlights that evaluation and reporting of hand and wrist scar outcomes is not standardised, assessment methods and measures are under-reported and there is discordance in taxonomy. Evaluation is not person-centred, rather it is dependent on clinician assessment. Domains including scar acceptability, mental health, and social participation are rarely addressed. A stakeholder consensus derived hand and wrist scar core outcome measurement set will promote standardisation and underpin improvements in clinical research quality, transparency, and rigour.

Efforts to Optimize Clinical Trial Management by Revising Deviation Reports and Classifying Deviation Cases for Efficient Clinical Trial Quality Improvement at Asahikawa Medical University Hospital

Face-to-face communication during on-site monitoring is important for clinical trial quality assurance. However, with the coronavirus disease early 2020 pandemic, medical institutions placed restrictions on hospital visits to secure their medical systems.

A collaborative approach to engaging undergraduate students in learning and developing evidence-based practice

Background: Students often have difficulty engaging with evidenced-based practice (EBP) courses that are largely theoretical and lack clinical relevance. This may result in graduates lacking vital skills to critique practice and participate in quality improvement. Approach: This paper describes the development and implementation of a collaborative academic and healthcare industry-based course that linked theoretical aspects of EBP. Students undertook a quality improvement project during clinical practice experience. Course assessments were designed to provide feedback on the progression of projects, the integration of theoretical and practical aspects of EBP and dissemination of findings. Conclusions: The course required substantial collaboration between the university and industry partners to identify clinically relevant projects and coordinate academic and clinical mentorship to support the students. The course demonstrated a significant level of clinical and academic partnership that resulted in relevant clinical quality improvements and increased student engagement with learning about, producing and implementing EBP.

The Role of Sodium-Glucose Cotransporter-2 Inhibitors in Heart Failure Management: The Continuing Challenge of Clinical Outcome Endpoints in Heart Failure Trials.

The introduction of sodium-glucose cotransporter-2 (SGLT2) inhibitors in the management of heart failure with preserved ejection fraction (HFpEF) may be regarded as the first effective treatment in these patients. However, this proposition must be evaluated from the perspective of the complexity of clinical outcome endpoints in heart failure. The major goals of heart failure treatment have been categorized as: (1) reduction in (cardiovascular) mortality, (2) prevention of recurrent hospitalizations due to worsening heart failure, and (3) improvement in clinical status, functional capacity, and quality of life. The use of the composite primary endpoint of cardiovascular death and hospitalization for heart failure in SGLT2 inhibitor HFpEF trials flowed from the assumption that hospitalization for heart failure is a proxy for subsequent cardiovascular death. The use of this composite endpoint was not justified since the effect of the intervention on both components was clearly distinct. Moreover, the lack of convincing and clinically meaningful effects of SGLT2 inhibitors on metrics of heart failure-related health status indicates that the effect of this class of drugs in HFpEF patients is essentially restricted to an effect on hospitalization for heart failure. In conclusion, SGLT2 inhibitors do not represent a substantial breakthrough in the management of HFpEF.

The Impact of Healthcare Delivery Complexity on Practices for Clinical Quality Improvement: A Case of Healthcare Workers’ Hand Hygiene Compliance

Healthcare providers often implement quality improvement (QI) practices to improve clinical quality, which may be measured as the extent to which healthcare workers (HCWs) comply with standardized procedures designed for ensuring patient safety. Unfortunately, the effectiveness of QI practices to improve clinical quality varies from facility to facility because of healthcare delivery complexity. In this paper, we consider the contextual complexity and the provider complexity arising from healthcare delivery processes, and we propose an exploratory study based on discrete choice experiments to examine their roles in the relationship between QI practices and clinical quality. By collecting and analyzing data from 320 HCWs at a university hospital in Taiwan, we found that healthcare delivery complexity significantly moderated the effectiveness of QI practices and how they improved clinical quality. We found that the contextual complexity influenced the level of effectiveness of the QI practices, whereas the provider complexity influenced whether a QI practice may be effective or not. We also studied the effect of implementing multiple QI practices simultaneously to counter the provider complexity. We found that implementing more QI practices does not necessarily lead to better outcomes, but implementing the right ones would. Our findings provide healthcare facilities with ex ante insights for designing QI practices to improve clinical quality. Funding: W. Chen was supported by the National Natural Science Foundation of China [Grant 71902017], and C.-L. Tseng was supported by the University of New South Wales UNOVA Knowledge Hub. Supplemental Material: The online appendix is available at https://doi.org/10.1287/serv.2023.0323 .

Rewards, recognition, and advancement for clinical pharmacists

AbstractClinical pharmacy has continually evolved, with significant expansion in clinical pharmacists' qualifications and roles. However, this growth has not necessarily correlated with improved job satisfaction among clinical pharmacists. A survey of practicing clinical pharmacists performed by the American College of Clinical Pharmacy (ACCP) Clinical Practice Affairs Committee A identified low satisfaction with the time allocated for clinical activities, quality improvement, research and scholarship, and teaching and mentorship. There was also low satisfaction with the recognition provided, despite a high desire for recognition and strong agreement that recognition affects job satisfaction. Rewards for workplace successes and advancement pathways are also not commonly provided. This white paper provides an update to the previous ACCP publications from 1995 and 2010 on the current state of rewards, recognition, and advancement for clinical pharmacists. Suggestions for the pharmacy profession and administrators on how to improve job satisfaction and retention and reduce burnout were developed by the committee and are provided as best practice recommendations.

Improvement in clinical outcome and quality of life after arthroscopic ankle arthrodesis in paralytic foot drop

BackgroundParalytic foot-drop is a disabling deformity that results from nerve or direct muscle injuries. Palliative surgeries such as tendon transfer and ankle arthrodesis are reserved for permanent deformity, with the arthroscopic technique had not been widely studied before. This study aims to evaluate the clinical outcome and quality of life after arthroscopic ankle fusion of paralytic foot-drop deformity.Materials and MethodsThe patients who were retrospectively enrolled in this study underwent arthroscopic ankle fusion for paralytic foot-drop deformity between March 2017 and December 2021. The American Orthopedic Foot and Ankle Society (AOFAS) ankle–hindfoot score and Cumberland Ankle Instability Tool (CAIT) were the measures used for clinical assessment. To judge the union, serial plain radiographs of the ankle were obtained. The preoperative and postoperative means were analyzed utilizing a two-tailed paired t-test, with a p value of less than 0.05 indicating statistical significance.ResultsThis study included 21 consecutive patients with a mean follow-up of 35.09 ± 4.5 months and a mean age of 41.5 ± 6.1 years. Highly significant improvements were observed between the preoperative and final follow-up means of the AOFAS score (from 57.6 ± 4.6 to 88.3 ± 2.7) and CAIT (from 12.1 ± 2.2 to 28.9 ± 1.01; p ˂ 0.00001 for both). All patients attained radiographic union and resumed their previous occupations without reporting serious adverse effects.ConclusionsArthroscopic ankle fusion is an effective, minimally invasive palliative surgery for patients suffering from permanent paralytic foot-drop deformity. This technique was shown to provide good functional and radiologic outcomes without significant complications.Level of evidenceRetrospective cohort; level of evidence (IV).

Efficacy of gargling with Licorice extract, Ketamine, and Magnesium Sulfate before Laryngoscopy: Tracheal Intubation in Prevention of Sore Throat, Hoarseness, and Cough; a Randomized Clinical Trial

Background and objective: Tracheal intubation is considered to represent a major cause of trauma to the airway mucosa, which can give rise to a postoperative sore throat. This randomized clinical quality improvement trial on the well-established benefit of gargling with licorice extract, ketamine, and magnesium sulfate before laryngoscopy and tracheal intubation was undertaken to address how to prevent throat soreness, hoarseness, and cough. Patients and methods: In a prospective, double-blind randomized controlled trials, 105 patients who were undergoing laryngoscopy and endotracheal intubation under general anesthesia were recruited. They were assigned into one of three intervention groups, including ketamine, licorice, and magnesium sulfate, using block randomization and requested to gargle twice for 15 seconds and 20 minutes before anesthesia induction and to spit out. Postoperative sore throat, cough, and hoarseness were recorded from endotracheal extubation at baseline (T0) every 10 minutes during recovery until T45 (45 minutes) and at initial 24-hour time points (2, 4, 8, 12, and 24 hours) later. Analysis of variance (ANOVA) and chi-squared tests was used for data analysis at a significance level of p = 0.05 in Statistical Package for the Social Sciences (SPSS) v20 (Chicago, Illinois, United States of America) software. Results: The mean age of patients was 48.21 ± 9.21 years, and 57.1% were male. No statistically significant intergroup difference was observed in the study groups for oxygen saturation (SpO2), heart rate, blood pressure, and duration of surgery. Our results showed that less sore throat was found in the ketamine group at T8/T12 (8 and 12 hours after recovery (p &lt; 0.05). In addition, no statistically significant intergroup difference was revealed in cough and hoarseness during the times studied (p &gt; 0.05). Conclusion: Our evidence confirmed that ketamine, licorice, and magnesium sulfate appeared to be able to effectively reduce pain, cough, and hoarseness and to be associated with similar hemodynamic changes, while the ketamine-treated subjects manifested a marked decrease in sore throat pain intensity with postoperative times of T8 and T12. Consequently, gargling with ketamine continues to demonstrably be put forward as a promising candidate to control postoperative sore throat but is as equal as other intervention drugs in terms of effectively controlling cough or hoarseness. Ultimately, the final choice relies on both patient acceptance and anesthesiologist preference.