Outcomes In Surgical Patients Research Articles

Co-developing a theory of change for a personalised multimodal cancer prehabilitation programme in South Wales

BackgroundEvidence suggests that prehabilitation interventions, which optimise physical and mental health prior to treatment, can improve outcomes for surgical cancer patients and save costs to the health system through faster recovery and fewer complications. However, robust, theory-based evaluations of these programmes are needed. Using a theory of change (ToC) approach can guide evaluation plans by describing how and why a programme is expected to work. Theories of Change have not been developed for cancer prehabilitation programmes in the literature to date. This paper aims to provide an overview of the methodological steps we used to retrospectively construct a ToC for Prehab2Rehab (P2R), a cancer prehabilitation programme being implemented by the Cardiff and Vale University Health Board.MethodsWe used an iterative, participatory approach to develop the ToC. Following a literature review and document analysis, we facilitated a workshop with fourteen stakeholders from across the programme using a ‘backwards mapping’ approach. After the workshop, stakeholders had three additional opportunities to refine and validate a final working version of the ToC.ResultsOur process resulted in the effective and timely development of a ToC. The ToC captures how P2R’s interventions or activities are expected to bring about short, medium and long-term outcomes that, collectively, should result in the overarching desired impacts of the programme, which were improved patient flow and reduced costs to the health system. The process of developing a ToC also enabled us to have a better understanding of the programme and build rapport with key stakeholders.ConclusionsThe ToC has guided the design of an evaluation that covers the complexity of P2R and will generate lessons for policy and clinical practice on supporting surgical cancer patients in Wales and beyond. We recommend that evaluators apply a ToC development process at the outset of evaluations to bring together stakeholders and enhance the utilisation of the findings. This paper details a pragmatic, efficient and replicable process that evaluators could adopt to develop a ToC. Theory-informed evaluations may provide better evidence to develop and refine cancer prehabilitation interventions and other complex public health interventions.

Early Surgical Outcomes in Infective Endocarditis Before and During COVID-19 Pandemic.

Infective endocarditis (IE) is associated with extremely high surgical mortality. During the SARS-CoV-2 pandemic, hospitals restructured their intensive care units and outpatient services to prioritize COVID-19 care, which may have affected the outcomes of patients requiring urgent procedures. This study aimed to evaluate the impact of the pandemic on surgical outcomes of IE patients in Southern Germany. This observational, community-based study compared two cohorts of surgical candidates: a pandemic cohort from March 2020 to November 2021 (n=84) and a pre-pandemic cohort from August 2018 to March 2020 (before the lockdown, n=94). Preoperative status and postoperative in-hospital complications were analyzed and compared between groups. The pandemic cohort experienced longer symptom onset to diagnosis intervals (14.5 vs. 8 days, p = 0.529). A higher incidence of definite IE was observed after the lockdown according to the modified Duke criteria (82.1% vs. 68.1%, p = 0.035). Patients presented with more severe symptoms post-lockdown (NYHA Class III: 50% vs. 33%; Class IV: 22.6% vs. 11.7%, p = 0.001). Postoperative complications, such as re-thoracotomy due to bleeding and hemofiltration for acute renal failure, were significantly more frequent after the lockdown (p < 0.05). However, in-hospital survival rates did not differ significantly between the groups. The COVID-19 pandemic and related lockdown measures were associated with delayed diagnoses and worse perioperative outcomes for surgical IE patients, highlighting the need for improved management strategies during public health crises.

Isolation of Candida Species Is Associated with Comorbidities, Prolonged Mechanical Ventilation, and Treatment Outcomes in Surgical ICU Patients, a Cross-Sectional Study.

The isolation of Candida may be related to comorbidity, prolonged mechanical ventilation, and survival during intensive care unit (ICU) stay, especially with non-albicans Candida (NAC). To examine the frequency of Candida isolation, associated comorbidities and outcomes in the surgical ICU in Osijek University Hospital, Croatia, the data from the electronic database from May 2016 to 30 June 2023 were analyzed. In a cross-sectional study examining 15,790 microbiological samples, different strains of Candida were observed in 581 samples from 236 patients. The control group (N = 261) was 130 consecutive patients from March to May 2019 and 131 in the same months in 2020 (pre- and post-COVID-19). Comorbidities, duration of mechanical ventilation, and survival were compared. Patients with isolated Candida were more often non-elective and had significantly more heart, kidney, and liver diseases and sepsis than the control group (p < 0.001). The duration of mechanical ventilation was 9.2 [2.2-9.24], 96 [24-146], 160 [19.5-343], and 224 [73.5-510] hours in the controls, in patients with Candida albicans, in patients with NAC, and in patients with ≥2 Candida species isolated, respectively. The mortality was significantly higher (42%) in patients with isolated Candida than in the control group (19%, p < 0.001). In a multivariate analysis adjusted for patients' age, the Simplified Acute Physiology Score II, days of ICU, and type of admission, only sepsis on admission was an independent predictor of mortality (odds ratio = 2.27).

Why the NHS needs adult generalists: A call for single certification in general internal medicine

As the UK NHS faces growing challenges of the ageing population and escalating healthcare costs, we examine the role of the general internal medicine (GIM) consultant in inpatient medicine. We argue that the reintroduction of GIM could provide a sustainable and valuable contribution to high-quality, cost-effective inpatient care drawing on parallels from the GIM hospitalist model in the USA. Additionally, GIM expansion could contribute to improved outcomes for complex medical patients and surgical patients, as well as safety and quality initiatives.

Venous Thromboembolism after Hospital Discharge: Temporal Trends in Baseline Characteristics, Prevention, Treatment, and 90-day Outcomes.

Venous thromboembolism (VTE) after hospital discharge poses a serious health risk. Assessments of patient characteristics, prophylaxis, treatment, outcomes, and over time changes lack consistency. Data on 16,901 hospitalized patients in the Registro Informatizado Enfermedad TromboEmbolica registry (2003-2022) were analyzed to evaluate trends in baseline characteristics, prophylaxis, treatments, and 90-day outcomes among medical (6,218) and surgical (10,683) patient cohorts. Multivariable logistic regression was used to assess the risks of the composite of fatal pulmonary embolism (PE) or recurrent VTE and major bleeding. The proportion of patients who presented with PE increased among medical (from 54 to 72%) and surgical patients (from 55 to 58%). Prophylaxis use increased in medical patients (from 53 to 71%), while decreasing in surgical patients (from 67 to 58%). Notably, the 90-day composite of fatal PE or recurrent VTE decreased in medical (from 3.9 to 1.8%) and surgical patients (from 2.9 to 1.2%; p < 0.001 for both). Conversely, major bleeding increased (3.1 to 4.5%) in medical patients (p = 0.008), with no change in surgical patients (from 2.5 to 2.4%). Risk-adjusted analysis showed a yearly decrease in the risk for the composite outcome (subhazard ratio [sHR]: 0.95; 95% confidence interval [CI]: 0.93-0.98) in medical and surgical patients and an increase in the risk for major bleeding in medical patients only (sHR: 1.04; 95% CI: 1.01-1.07). Results were consistent after excluding coronavirus disease 2019 patients. Over 20 years, the composite of fatal PE or recurrent VTE within 90 days had significantly decreased in VTE patients after hospitalization for medical or surgical care. Medical patients, however, exhibited an increase in major bleeding.

The role of preoperative immunonutrition on morbidity and immune response after cystectomy: protocol of a multicenter randomized controlled trial (INCyst Trial)

IntroductionCancer, malnutrition, and surgery negatively impact patient’s immune system. Despite standardized surgical technique and the development of new perioperative care protocols, morbidity after cystectomy remains a serious challenge for urologists. Most common postoperative complications, such as infections and ileus, often lead to longer length of stay and worse survival. The immune system and its interaction with the gut microbiota play a pivotal role in cancer immunosurveillance and in patient’s response to surgical stress. Malnutrition has been identified as an independent and modifiable risk factor for both mortality and morbidity. Immunonutrition (IN) may improve the nutritional status, immunological function, and clinical outcome of surgical patients. Aims of the study are (1) to evaluate the impact of IN on morbidity and mortality at 30 and 90 days after cystectomy and (2) to determine immune and microbiota signature that would predict IN effect.MethodsThis is a randomized, multicentric, controlled, pragmatic, parallel-group comparative study, supported by the Swiss National Science Foundation. A total of 232 patients is planned to be enrolled between April 2023 and June 2026. Three participating centers (Lausanne, Bern, and Riviera-Chablais) have been selected. All patients undergoing elective radical and simple cystectomy will be randomly assigned to receive 7 days of preoperative IN (Oral Impact®, Nestlé, Switzerland) versus standard of care (control group) and followed for 90 days after surgery. For the exploratory outcomes, blood, serum, urine, and stool samples will be collected in patients treated at Lausanne. In order to determine the impact of IN on immune fitness, patients enrolled at Lausanne will be vaccinated against influenza and the establishment of the vaccine-specific immune response will be followed. Analysis of the microbiota and expression of argininosuccinate synthetase 1 as potential biomarker will also be performed.Discussion and conclusionStrengths of the INCyst study include the randomized, multicenter, prospective design, the large number of patients studied, and the translational investigation. This study will challenge the added value of preoperative IN in patients undergoing cystectomy, assessing the clinical effect of IN on the onset of postoperative morbidity and mortality after cystectomy. Furthermore, it will provide invaluable data on the host immune response and microbiota composition.Trial registrationClinicalTrials.gov NCT05726786. Registered on March 9, 2023.

Association between delta anion gap/delta bicarbonate and outcome of surgical patients admitted to intensive care unit

BackgroundPatients undergoing high-risk surgeries with acid-based disorders are associated with poor outcomes. The screening of mixed acid-based metabolic disorders by calculating delta anion gap (AG)/delta bicarbonate (Bic) has a clinically relevant role in patients with high AG metabolic acidosis (MA), however its utility in individuals facing high-risk surgical procedures remains unclear.ObjectiveCharacterize metabolic acidosis using delta-AG/delta-Bic and its associations in patients undergoing high-risk surgeries with possible outcome-related complications.DesignProspective observational multicentric study.SettingThree tertiary hospitals in Brazil.PatientsPatients undergoing high-risk surgeries, aged 18 years or older, requiring postoperative critical care.Main outcome measuresPatients undergoing high-risk surgeries monitored during the postoperative phase across three distinct intensive care units (ICUs), with assessment encompassing laboratory analyses upon admission and 24 h thereafter. Patients with MA and with elevated AG within 24 h were separated into 3 subgroups: [G1 – delta-AG/delta-Bic < 1.0] MA associated with hyperchloremia; [G2 – delta-AG/delta-Bic between 1.0 and 1.6] MA and no mixed disorders; and [G3 – delta-AG/delta-Bic > 1.6] MA associated with alkalosis. Primary endpoint was 30-day mortality. The secondary endpoints were cardiovascular, respiratory, renal, neurological, coagulation and infective complications.ResultsFrom the 621 surgical patients admitted to ICU, 421 (51.7%) had any type of acidosis. After 24 h, 140 patients remained with MA with elevated AG (G1: 101, G2: 18, and G3: 21). When compared to patients from subgroups 1 and 3, the subgroup with no mixed disorders 2 showed higher 30-day mortality (adjusted HR = 3.72; 95% CI 1.11–12.89, p = 0.001), cardiovascular complications (p = 0.001), ICU mortality (p = 0.03) and sum of all complications during the ICU period (p = 0.021).ConclusionIn the postoperative time, patients with metabolic acidosis and no mixed disorders present higher ICU-Mortality and higher cardiovascular postoperative complications when compared with patients with combined hyperchloremia or alkalosis. Delta-AG/delta-Bic can be a useful tool to evaluate major clinical outcomes in this population.

Impact of rapid response system in mortality and complications post-orthopedic surgery: a retrospective cohort study

BackgroundRapid response systems (RRSs) are used in hospitals to identify and treat deteriorating patients. However, RRS implementation and outcomes in orthopedic and surgical patients remain controversial. We aimed to investigate whether the RRS affects mortality and complications after orthopedic surgery.MethodsThe National Health Insurance Service of South Korea provided the data for this population-based cohort study. Individuals who were admitted to the hospital that implemented RRS were categorized into the RRS group and those admitted to a hospital that did not implement the RRS were categorized into the non-RRS group. In-hospital mortality and postoperative complications were the endpoints.ResultsA total of 931,774 adult patients were included. Among them, 93,293 patients underwent orthopedic surgery in a hospital that implemented RRS and were assigned to the RRS group, whereas 838,481 patients were assigned to the non-RRS group. In multivariable logistic regression analysis, the RRS group was not associated with in-hospital mortality after orthopedic surgery compared with the non-RRS group (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.80, 1.08; P = 0.350). However, the RRS group was associated with a 14% lower postoperative complication rate after orthopedic surgery than the non-RRS group (OR 0.86, 95% CI 0.84, 0.86; P < 0.001).ConclusionsThe RRS was not associated with in-hospital mortality following orthopedic surgery in South Korea. However, RRS deployment was related to a decreased risk of postoperative complications in patients undergoing orthopedic surgery.

The association between physical activity and delayed neurocognitive recovery in elderly patients: a mediation analysis of pro-inflammatory cytokines

BackgroundDelayed neurocognitive recovery (dNCR) can result in unfavorable outcomes in elderly surgical patients. Physical activity (PA) has been shown to improve cognitive function, potentially by reducing systemic inflammatory responses. However, there is a lack of supportive data indicating whether PA has a protective effect against dNCR.AimsTo examine the correlation between dNCR and PA, and to further analyze if pro-inflammatory cytokines mediate this relationship.MethodsThis study is a prospective nested case-control investigation of elderly patients who had knee replacement surgery. dNCR was defined as a decline in cognitive function compared with baseline by using a battery of neuropsychological tests. PA was assessed with the Physical Activity Scale for the Elderly (PASE). Enzyme-linked immunosorbent assay (ELISA) was used to measure the serum concentrations of IL-6, IL-1β, and TNF-α. Multivariable logistic regression analysis was conducted to assess the association between PA and dNCR. Mediation analysis was employed to evaluate whether pro-inflammatory cytokines mediate the relationship between them.ResultsA cohort of 152 patients was included, resulting in an incidence rate of dNCR of 23.68%. PA was associated with dNCR after full adjustment [OR = 0.199, (95% CI, 0.061; 0.649), P = 0.007]. Mediation analysis showed that the IL-6 mediated the statistical association between PA and dNCR, with mediation proportions (%) of 77.68 (postoperative concentration of IL-6) or 27.58 (the absolute change in IL-6 before and after surgery).ConclusionsPA serves as a protective factor against dNCR, possibly through the reduction of pro-inflammatory cytokine concentrations.The Chinese Clinical Trail Registry: www.http://chictr.org.cn, Registration No. ChiCTR2300070834, Registration date: April 24, 2023.

Work-Related Experiences and Challenges of Perioperative Nurses in Southwestern Nigeria

Background: Perioperative nursing is highly demanding due to the long hours of complex procedures, limited support, inadequate facilities, and staffing issues. These factors contribute to fatigue, frustration, and burnout. However, there is a paucity of data on challenges and experiences of perioperative nurses in Southwestern Nigeria.Purpose: This study explored work-related experiences and challenges of perioperative nurses in selected hospitals in in a south western state, Nigeria.Methods: This study adopted a qualitative phenomenological design. Twenty perioperative nurses that have spent minimum of six months in the operating theatres of the three public hospitals selected hospitals were purposively selected for the study. Data collection was done with through semi-structured interview using key informant interview guide. The qualitative data collected were transcribed verbatim, coded and analysed using content and thematic analysis.Results: The study identified two major themes: the experiences of perioperative nursing practitioners and the challenges faced in perioperative nursing practice. The findings highlighted perioperative nurses’ personal experiences, their motivational factors, and their professional aspirations. Additionally, the study uncovered several challenges, including inadequate infrastructure and equipment, obsolete theatre buildings, faulty and insufficient surgical instruments, a severe shortage of perioperative nurses, and underfunding of perioperative nursing services.Conclusion:The study concluded that perioperative nurses’ experiences were both educative and fulfilling, yet also challenging and frustrating due to the numerous obstacles they face in their professional roles. Therefore, there is a need for stakeholders to address these challenges to enable perioperative nurses to function optimally and improve outcomes for surgical patients.

A Mild Increase in Serum Creatinine after Surgery Is Associated with Increased Mortality.

Background: Acute kidney injury (AKI), a prevalent postoperative complication, predominantly manifests as stage 1, characterized by a mild elevation in serum creatinine (SCr). There is yet to be a consensus regarding the association between stage 1 AKI and adverse outcomes in surgical patients. Methods: This retrospective study enrolled adult patients who underwent at least one surgery during hospitalization from the MIMIC IV database. AKI was diagnosed when the KDIGO creatinine criteria were satisfied within 7 days after surgery. Stage 1a AKI was defined as an absolute increase in SCr of 26.5 μmol/L, and stage 1b was defined as a 50% relative increase. Stage 1 AKI was also divided into transient and persistent substages based on whether the AKI recovered within 48 h after onset. The association between stage 1 AKI and its substages and in-hospital mortality was evaluated. Results: Among 49,928 patients enrolled, 9755 (19.5%) developed AKI within 7 days after surgery, of which 7659 (78.5%) presented with stage 1 AKI. The median follow-up was 369 (367, 372) days. Stage 1 AKI was significantly associated with in-hospital mortality after adjustment (aHR, 2.73; 95% CI, 2.29, 3.26). Subgroup analyses showed that the risk of stage 1 AKI on in-hospital mortality was attenuated by age ≥ 65 years (p for interaction = 0.017) or a baseline eGFR < 60 mL/min per 1.73 m2 (p for interaction = 0.001). Compared with non-AKI, patients with stage 1b (aHR, 3.06; 95% CI, 2.56, 3.66) and persistent stage 1 (aHR, 2.03; 95% CI, 1.61, 2.57) AKI had an increased risk of in-hospital mortality; however, this risk was not significant in those with stage 1a (aHR, 1.01; 95% CI, 0.68, 1.51) and transient stage 1 (aHR, 1.11; 95% CI, 0.79, 1.57) AKI. Conclusions: Stage 1 AKI exhibits an independent correlation with a heightened mortality risk among surgical patients. Consequently, a tailored adaptation of the KDIGO AKI classification may be necessitated for the surgical population, particularly those presenting with decreased baseline kidney function.

Health-related quality of life is a predictor of readmission following emergency laparotomy.

Health-related quality of life (HRQoL) is a multidimensional concept used to examine the impact of patient-perceived health status on quality of life. Patients' perception of illness affects outcomes in both medical and elective surgical patients; however, not much is known about how HRQoL effects outcomes in the emergency surgical setting. This study aimed to examine if patient-reported HRQoL was a predictor of unplanned readmission after emergency laparotomy. This study included 215 patients who underwent emergency laparotomy at the Copenhagen University Hospital, Herlev, between August 1, 2021, and July 31, 2022. Patient-reported HRQoL was assessed with the EuroQol group EQ5D index (EQ5D5L descriptive system and EQ-VAS). The population was followed from 0 to 180days after discharge, and readmissions and days alive and out of hospital were registered. A Cox proportional hazard model was used to examine HRQoL and the risk of readmission within 30 and 180days. Within 30days, 28.4% of patients were readmitted; within 180days, the number accumulated to 45.1%. Low self-evaluated HRQoL predicted 180-day readmission and was significantly associated with fewer days out of hospital within both 90 and 180days. Low HRQoL and discharge with rehabilitation were independent risk factors for short- (30-day) and long-term (180-day) emergency readmission. Patient-perceived quality of life is an independent predictor of 180-day readmission, and the number of days out of hospital was correlated to self-reported HRQoL.

Efficacy and safety of topical tranexamic acid in spinal surgery: a systematic review and meta-analysis.

This study aimed to assess the effects of topical tranexamic acid (tTXA) in spinal surgery to provide reliable clinical evidence for its usefulness. The PubMed, EMBASE, Medline, and Cochrane Central Register of Controlled Trials databases were comprehensively searched to identify randomized controlled trials and non-randomized controlled trials evaluating the effect of tTXA on blood loss during spine surgery. The observation indexes were intraoperative blood loss, total blood loss, output and duration of postoperative drainage, postoperative hematological variables, length of postoperative hospital stay, blood transfusion rate, and complication rate. A total of 21 studies involving 1774 patients were included. Our results showed that the use of tTXA during spinal surgery significantly reduced the total blood loss, postoperative drainage volume, postoperative transfusion rate, duration of postoperative drainage, and postoperative hospital stay, and increased the serum hemoglobin concentration, thereby providing better clinical outcomes for surgical patients. However, tTXA had no effect on intraoperative blood loss and associated complications. On the basis of the available evidence, the present results provide strong clinical evidence of the clinical value of tTXA in spinal surgery and provide an important reference for future research and clinical decision-making.

Identifying Frailty Using Point-of-Care Ultrasonography: Image Acquisition and Assessment.

Frailty is a significant predictor of a range of adverse outcomes in surgical patients, including increased mechanical ventilation time, longer hospital stays, unplanned readmissions, stroke, delirium, and death. However, accessible tools for screening in clinical settings are limited. Computed tomography of the psoas muscle is the current standard imaging device for measuring frailty, but it is expensive, time-consuming, and exposes the patient to ionizing radiation. Recently, the use of point-of-care ultrasound (POCUS) has emerged as a potential tool to determine the presence of frailty and has been shown to accurately predict frailty and postoperative outcomes. In this article, we will describe the image acquisition of the quadriceps muscles and explain how they can be used to determine frailty and predict postoperative adverse events. We will present information on probe selection, patient positioning, and troubleshooting. Images from a demonstration will be used to present the POCUS technique and example results. The article will culminate in a discussion of the use of these images in medical decision-making and potential limitations.

Pulmonary artery catheter use and in-hospital outcomes in cardiac surgery: a systematic review and meta-analysis.

To determine the association of intraoperative pulmonary artery catheter (PAC) use with in-hospital outcomes in cardiac surgical patients. MEDLINE, Embase, and Cochrane Library (Wiley) databases were screened for studies that compared cardiac surgical patients receiving intraoperative PAC with controls and reporting in-hospital mortality. Secondary outcomes included intensive care unit length of stay, cost of hospitalization, fluid volume administered, intubation time, inotropes use, acute kidney injury (AKI), stroke, myocardial infarction (MI), and infections. Seven studies (25853 patients, 88.6% undergoing coronary artery bypass graft surgery) were included. In-hospital mortality was significantly increased with PAC use [odds ratio (OR) 1.57; 95% confidence interval (CI) 1.12-2.20, P = 0.04]; PAC use was also associated with greater intraoperative inotrope use (OR 2.61; 95% CI 1.54-4.41) and costs [standardized mean difference (SMD) = 0.20; 95% CI 0.16-0.23], longer intensive care unit stay (SMD = 0.29; 95% CI 0.25-0.33), and longer intubation time (SMD = 0.44; 95% CI 0.12-0.76). PAC use is associated with significantly increased odds of in-hospital mortality, but the amount and quality of the available evidence is limited. Prospective randomized trials testing the effect of PAC on the outcomes of cardiac surgical patients are urgently needed.

The role of a dedicated Oncology Nurse Navigator in the surgical oncology pathways: 1 year experience from a General Surgery Unit in central Italy with follow up.

The Nurse Navigator is a highly specialized nurse with technical and non-technical skills that offers individualized assistance to cancer patients, their family and caregivers to overcome health system barriers and facilitate access to care. This role was introduced in the General Surgery Unit of the Madonna del Soccorso Hospital in San Benedetto del Tronto from 1st January 2023. The primary endpoint is to compare the times taken for each step of the diagnostic-therapeutic pathway comparing the study group followed by Oncology Nurse Navigator (ONN) and the group not followed by this role. The secondary endpoints, only for the study group, were the number of patient contacts with the ONN and the time slots; the number of examinations and consultations organized by ONN; the evaluation of patient satisfaction at discharge; the number and type of problems noted during follow-up contact at 7 and 30days after discharge. A prospective court study with historical control was conducted from 1st January 2023 in Madonna del Soccorso Hospital, Italy. The study group consists of all cancer patients cared for by ONN. The control group was created by selecting the same number of patients as the study group but taken care of in the previous 3years (from 2020 to 2022) and, therefore, without the presence of the Nurse Navigator. The control group data come from clinical documentation. The number and time slots of contact with the ONN were recorded through the use of a company mobile phone active 24/7 through phone calls and messages. The number of examinations and consultations is known through online requests. The satisfaction assessment was carried out through the use of externally validated questionnaire Patient Satisfaction with Cancer Care (PSCC). The follow-up was performed by telephone and recorded on documentation according to established parameters. A total of 200 patients were analyzed. Both the study and control groups included 100 patients each. The average time between the first contact with the patient and the execution of the diagnostic test was 7days in the cases compared to 28days in the control group. The waiting time for the Multi-Disciplinary Team discussion (MDT) was 3 days for the study group compared to 6days in the control group. The average time taken for the first oncological visit was 3days in the study group compared to 18days in the controls. The time from first contact to the operating session was 20days compared to 45 in controls. Each patient had an average of 10 phone calls with the ONN. For all patients accompanied at the first diagnosis, at least 2 radiological and laboratory tests were organized. Oncology appointment for treatment evaluations after delivery of the histological report was communicated within a maximum of 3 working days. A patient satisfaction questionnaire achieved a response rate of 100%, with an average score of 87.0/90. The telephone follow-up had a response rate of 100% of patients and revealed a decrease in problems at the 30-day check-up compared to that of 7days after discharge. (Activity of Daily Living 20% vs 8%; nutritional problems 40% vs 21%, pain 18% vs 2%; surgical wounds 45% vs 1%; mobilization 8% vs 0%). The data demonstrate that ONN service improves the quality and outcomes of surgical oncology patients' pathway. The professional role of the ONN, with predefined technical and non-technical skills, should also be officially recognized by the healthcare system and hospital administration.

Impact of Clinical Decision Support with Mandatory versus Voluntary Venous Thromboembolism Risk Assessment in Hospitalized Patients.

Background Venous thromboembolism (VTE) causes significant preventable morbidity and mortality in hospitalized patients. Assessing VTE risk is essential to initiating appropriate prophylaxis and reducing VTE outcomes. Studies show that computerized clinical decision support (CDS) can improve VTE risk assessment (RA), prophylaxis, and outcomes but few examined the effectiveness of specific design features. From 2008 to 2016, University of Michigan Health implemented CDS for VTE prevention in four stages, which alternated between voluntary and mandatory RA using the 2005 Caprini model and generated inpatient orders for risk-appropriate prophylaxis based on CHEST guidelines. This cross-sectional study evaluated the impact of mandatory versus voluntary RA on VTE prophylaxis and outcomes for adult medical and surgical patients admitted to the health system. Methods Interrupted time series analysis was conducted to evaluate the trend in smart order set-recommended VTE prophylaxis by CDS stage. Logistic regression with CDS stage as the primary independent variable was used in pairwise comparisons of VTE during hospitalization and within 90 days post-discharge for mandatory versus voluntary RA. Adjusted odd ratios (ORs) were calculated for total, in-hospital, and post-discharge VTE. Results In this study of 223,405 inpatients over 8 years, smart order set-recommended prophylaxis increased from 65 to 79%; it increased significantly when voluntary RA in Stage 1 became mandatory in Stage 2 (10.59%, p < 0.001) and decreased significantly when it returned to voluntary in Stage 3 (-11.24%, p < 0.001). The rate increased slightly when mandatory RA was reestablished in Stage 4 (0.23%, p = 0.935). Adjusted ORs for VTE were lower for mandatory RA versus adjacent stages with voluntary RA. The adjusted OR for Stage 2 versus Stage 1 was 14% lower ( p < 0.05) and versus Stage 3 was 11% lower ( p < 0.05). The adjusted OR for Stage 4 versus Stage 3 was 4% lower ( p = 0.60). These results were driven by changes in in-hospital VTE. By contrast, the incidence of post-discharge VTE increased in each successive stage. Conclusion Mandatory RA was more effective in improving smart order set-recommended prophylaxis and VTE outcomes, particularly in-hospital VTE. Post-discharge VTE increased despite high adherence to risk-appropriate prophylaxis, indicating that guidelines for extended, post-discharge prophylaxis are needed to further reduce VTE for hospitalized patients.

Serum tumor marker and CT body composition scoring system predicts outcomes in colorectal cancer surgical patients

ObjectiveTo investigate the prognostic value of preoperative body composition and serum tumor markers (STM) in patients undergoing surgical treatment for colorectal cancer (CRC) and to establish the prognostic score for patients with CRC.MethodsThis study enrolled 365 patients (training set 245, validation set 120) with CRC who underwent surgical resection. The predictive value of various body composition features and STM for determining CRC prognosis were compared. A novel index score based on the independent risk factors from Cox regression for CRC patients was established and evaluated for its usefulness.ResultsMultivariate Cox regression showed that low skeletal muscle radiodensity (SMD) (p = 0.020), low subcutaneous fat area (SFA) (p = 0.029), high carcinoembryonic antigen (CEA) (p = 0.008), and high alpha-fetoprotein (AFP) (p = 0.039) were all independent prognostic factors for poor overall survival (OS). The multifactorial analysis indicated that high intermuscular fat area (IMFA) (p = 0.033) and high CEA (p = 0.009) were independent prognostic factors for poor disease-free survival (DFS). Based on these findings, two scoring systems for OS and DFS were established in the training datasets. CRC patients who scored higher on the new scoring systems had lower OS and DFS (both p < 0.001) as shown in the Kaplan–Meier survival curves in the training and validation datasets.ConclusionIn predicting the prognosis of CRC patients, SFA and SMD are superior to other body composition measurements. A scoring system based on body composition and STM can have prognostic value and clinical applicability.Clinical relevance statementThis scoring system, combining body composition and serum tumor markers, may help predict postoperative survival of CRC patients and help clinicians make well-informed decisions regarding the treatment of patients.Key PointsColorectal cancer prognosis can be related to body composition.High intermuscular fat area and CEA were independent prognostic factors for poor disease-free survival.This scoring system, based on body composition and tumor markers, can prognosticate for colorectal cancer patients.

Current peri-operative and surgical management of bladder paraganglioma

Introduction: In this article, we provide a narrative review of current peri-operative and surgical management of paraganglioma of the urinary bladder (PUB). Methods: Key articles relating to peri-operative optimisation, intra-operative considerations and post-operative follow-up of patients with PUB were identified for review. Discussion: Although the majority of PUBs are functionally active with potential for catecholamine release, typical catecholaminergic symptoms are often overshadowed by the presence of lower urinary tract symptoms such as painless visible haematuria. Consequently, many cases are diagnosed based on post-operative histopathology, resulting in inferior short- and long-term outcomes. Accurate pre-operative diagnosis is crucial as this informs pre-operative optimisation and choice of surgical approach. Partial cystectomy is the mainstay of treatment, but transurethral resection may be appropriate for non-functional tumours &lt;3 cm. The presence of succinate dehydrogenase ( SDH) subunit B (SDHB) pathogenic variants may prompt upfront radical cystectomy. Long-term outcomes of surgical patients remain incompletely characterised and lifelong follow-up is recommended to exclude tumour recurrence. Conclusion: Patients with PUBs require meticulous peri-operative optimisation under the care of an experienced multidisciplinary team. A pre-operative diagnosis is crucial to ensure optimal outcomes and guide surgical decision-making. Level of evidence: 4

Association of Preoperative Red Cell Distribution Width with Postoperative Outcomes in Liver Transplantation Recipients

Background: The 1-year mortality rate after liver transplantation is approximately 8%-20%. It is important to explore risk factors associated with postoperative outcomes in liver transplantation recipients (LTRs). Red cell distribution width (RDW) is an indicator that assesses the variability in the volume of red blood cells in circulation. RDW is not only related to inflammatory levels and nutritional status but also associated with postoperative outcomes in surgical patients. However, the relationship between preoperative RDW and postoperative outcomes in LTRs remains unclear. Therefore, we designed a retrospective observational study to investigate the impact of preoperative RDW levels on postoperative outcomes in LTRs. Methods: We retrospectively collected clinical data of patients who underwent allogeneic liver transplantation at West China Hospital, Sichuan University, from January 2016 to December 2020. The primary outcome was 1-year mortality. Secondary outcomes included 30-day mortality, long-term survival, early postoperative graft dysfunction, acute kidney injury, renal replacement therapy, pulmonary complications, duration of postoperative mechanical ventilation, length of ICU stay, and length of hospital stay. Patients were divided into two groups: RDW ≤ 14.5% and RDW &gt; 14.5%. We selected 14 covariates and used propensity score matching (PSM) to adjust for baseline characteristics. Postoperative outcomes and long-term survival were analyzed after PSM. Receiver operating characteristics (ROC) curves and subgroup analyses were also performed. Results: A total of 661 patients who underwent liver transplantation surgery were screened for this study. Finally, 438 patients were included in the statistical analysis. After PSM, there were no statistically significant differences in postoperative mortality and complications between the RDW ≤ 14.5% group and the RDW &gt; 14.5% group (P &gt; 0.05). The comparison of long-term survival between the two groups also showed no statistical difference (hazard ratio = 0.67, 95% confidence interval: 0.28-1.61, P = 0.358). Subgroup analyses showed consistent results. The ROC curve indicated that the predictive ability of preoperative RDW levels for 1-year mortality is moderate (area under the ROC curve 0.661). Conclusion: Preoperative RDW levels do not affect postoperative mortality and the incidence of complications in LTRs. However, these results still need further research for verification.