Recovery Pathways Research Articles

Comparison of the Outcomes of Enhanced Recovery After Surgery and Traditional Recovery Pathway in Robotic Hysterectomy for Benign Indications: A Randomized Controlled Trial

ObjectiveThe present study aimed to evaluate the impact of implementation of the ERAS program in patients undergoing robotic hysterectomy for benign indications in comparison with conventional management DesignRandomized controlled trial SettingNorth Indian tertiary care hospital ParticipantsPatients aged 40-60 years willing to sign the informed written consent were included while cases with contraindications for neuraxial anesthesia were excluded. 130 subjects undergoing robotic hysterectomy, divided into ERAS (N=65) and conventional (non-ERAS) (N=65) groups. InterventionsComponents of the ERAS protocol included preoperative counselling, carbohydrate loading, early removal of catheter, and early ambulation. Both groups underwent optimization of medical conditions, standardized anesthesia, and venous thromboembolism prophylaxis. ResultsOutcome measures included length of hospital stay (LOHS), time to tolerance of diet, postoperative complications, readmission rates, and quality of life assessed by WHO-QOL BREF. Baseline characteristics were comparable between groups. ERAS group showed significantly lower docking time (4.82±0.73 versus 5.31±0.92 minutes), faster tolerance of diet (0.14±0.35 versus 1.14±0.35 days), and earlier resumption of ambulation (0.42±0.5 versus 1.26±0.44 days). Time for 'fit for discharge' (1.43±0.61 versus 2.97±1.1 days) and LOHS (2.85±1.09 versus 3.78±1.29 days) were significantly lower in the ERAS group. Postoperative complications and readmission rates were comparable. Quality of life scores favoured the ERAS group at postoperative day 1 and 30. ConclusionThe combination of ERAS and robotic surgery improves patient outcomes, shortens hospital stay, and enhances postoperative recovery without increasing complications. This research serves as a pioneering effort in assessing ERAS impact on robotic hysterectomy for benign indications, providing valuable insights for future multicentric studies and supporting the integration of ERAS protocols to enhance patient outcomes and quality of life.Clinical trial registration: Clinical trial registry of India: https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NjczODM=&Enc=&userName=)

Clinical Milestone Recovery Pathway for Low-Risk Patients

Clinical Milestone Recovery Pathway for Low-Risk Patients

Structural outcomes of climate adaptation treatments in two contrasting northern temperate forests

Forest managers require climate adaptation strategies that are regionally relevant and translatable into planning processes. Adaptation frameworks, such as the resistance, resilience, transition framework, can guide the development of these strategies. However, there are limited examples of how these concepts can be operationalized with concomitant estimates of changes in forest structural complexity and diversity, which may support adaptive capacity. To address this knowledge gap, two operational-scale, replicated experiments were studied to understand how application of the resistance, resilience, transition framework influences stand structure in two contrasting northern forests: mixed pine and mesic hardwoods. We found that treatments corresponding to each adaptation approach (resistance, resilience, transition) manifested differently in each forest type. In mixed-pine, there were greater differences in structural diversity metrics among treatments; there were fewer differences among treatments in the mesic hardwood forest, which had comparatively greater pre-treatment structural variation. In both forests, our analyses demonstrate that management strategies associated with greater emphasis on change and adaptation (i.e., resilience and transition) created a quantifiably more heterogeneous arrangement of structural elements across treatment units, supporting shifts in stand-scale understory resource patterning. These results underscore the importance of accounting for the influence of pre-treatment stand conditions on outcomes of adaptation treatments and that stand-wide averaging of plot measurements may serve to obscure stand-scale diversity metrics. The variation in structural conditions across stands that we found is expected to contribute to forest response to novel disturbances by providing multiple recovery pathways. Based on these findings, application of adaptive silvicultural treatments can generate varying levels of structural heterogeneity at the stand-scale which in turn can confer adaptation potential; however, ecological memory strongly influences post-management stand conditions.

The pharmacist's role in optimizing medication management before, during, and after minimally invasive and bariatric surgery.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Minimally invasive surgery (MIS) with integrated enhanced recovery pathways (ERPs) helps reduce length of stay and improve surgical outcomes. As these procedures have become more prevalent over time, pharmacists are in key positions to manage medications in the perioperative space to help optimize transitions of care and reduce safety events. Here we identify several clinical areas across phases of care for these procedures in which the knowledge and guidance of pharmacists, as members of the interprofessional team, are paramount. Perioperative pharmacy expertise is often required for MIS procedures in the areas of acid suppression, antithrombotic management, blood glucose control, drug formulation, immunosuppressant optimization, pain mitigation, and postoperative nausea and vomiting prevention and treatment. For each MIS procedure, pharmacists should identify and consider diet and anatomical changes as well as patient- and surgery-specific risk factors. Pharmacists can then utilize their knowledge of the pharmacokinetics and pharmacodynamics of individual medications along with evidence-based medicine to recommend selection of appropriate agents. Pharmacist contributions to perioperative medication management for MIS procedures can improve care as surgical patients navigate transitions through the perioperative setting. Pharmacists can further incorporate medication expertise through development and implementation of institutional MIS protocols within the context of ERPs. As such, any pharmacist should feel empowered to aid in the care of surgical patients.

Efficacy of Erector Spinae Plane (ESP) Block for Non-cardiac Thoracic and Upper Abdominal Surgery: A Single Institute Comparative Retrospective Case Series.

Introduction Erector spinae plane (ESP) block was first introduced for the management of thoracic pain but has become increasingly popular for the treatment of abdominal surgical pain. Previous studies have shown the ESP block can be easily adapted to abdominal procedures at the corresponding dermatome level and provide postoperative analgesia. Though the versatility, simplicity, and safety of the ESP block have been demonstrated, there is a gap in the literature regarding its comparison between thoracic and abdominal surgeries. This study aims to evaluate the efficacy of the ESP block in treating acute postoperative pain in patients undergoing thoracic and abdominal surgeries. Methods This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Data was obtained via the acute pain service records at a tertiary care center from 2018 to 2022.All patients received bilateral ESP blocks, performed under ultrasound guidance. Various parameters were evaluated including oral morphine equivalents (OMEs) and visual analog scale (VAS) scores during post-anesthesia care unit (PACU), 6, 12, and 24 hours postop. The use of abortive antiemetic medications within 24 hours was also measured to evaluate the incidence of nausea and vomiting. The results were analyzed and compared. No control group is included, as all patients at our institution receive a peripheral nerve block as a part of the institution's enhanced recovery pathway (ERP). Results This retrospective study included 50 patients in the non-cardiac thoracic surgery group (bilateral breast mastectomy with reconstruction) and 50 patients in the abdominal surgery group (robotic or laparoscopic sleeve gastrectomy). Compared to the thoracic group, the abdominal group had a statistically higher VAS score in PACU with mean difference (MD)1.3 VAS, 95% confidence interval (CI) 0.03-2.56, p-value 0.0443, statistically higher OME consumption in the PACU (difference 13.35 OME, 95% CI 4.97-21.73, p-value 0.0003), and requiredsignificantly more antiemetic pharmacotherapy (mean 1.4 antiemeticsadministered, 95% CI 0.84-2.04, p-value <0.0001). Despite the abdominal group having more OME utilization in the PACU, there was no difference in cumulative OME use in the first 24hours (95% CI-9.745-24.10, p-value 0.4021). Conclusion In this study, we demonstrated that ESP blocks are an effective regional anesthesia technique to reduce postoperative pain and opioid consumption. The ESP block can serve as a useful and safe alternative to either thoracic epidural or paravertebral blocktechniques in thoracic and upper abdominal surgeries for perioperative pain management.

Pushing the Limits of Minimally Invasive Spine Surgery-From Preoperative to Intraoperative to Postoperative Management.

The introduction of minimally invasive surgery ushered in a new era of spine surgery by minimizing the undue iatrogenic injury, recovery time, and blood loss, among other complications, of traditional open procedures. Over time, technological advancements have further refined the care of the operative minimally invasive spine patient. Moreover, pre-, and postoperative care have also undergone significant change by way of artificial intelligence risk stratification, advanced imaging for surgical planning and patient selection, postoperative recovery pathways, and digital health solutions. Despite these advancements, challenges persist necessitating ongoing research and collaboration to further optimize patient care in minimally invasive spine surgery.

A Path to High-Value Gastric Cancer Surgery Care Delivery.

To evaluate the feasibility, safety, and effectiveness of a comprehensive regional program, including the Minimally Invasive Recovery and Empowerment Care (MIREC) pathway, that can significantly reduce hospital stays after laparoscopic gastrectomy without increasing adverse events. Cost-effectiveness and improving patient outcomes are crucial in providing quality gastric cancer care worldwide. To compare the outcomes of gastric cancer surgery using 2 different models of care within an integrated healthcare system from February 2012 to March 2023. The primary endpoint was the length of hospital stay. The secondary endpoints were the need for intensive care unit care, emergency room (ER) visits, readmission, reoperation, and death within 30 days after surgery. There were 553 patients, 167 in the pre-(February 2012-April 2016) and 386 in the post-MIREC period (May 2016-March 2023). Perioperative chemotherapy utilization increased from 31.7% to 76.4% (P < 0.0001). Laparoscopic gastrectomy increased from 17.4% to 97.7% (P < 0.0001). Length of hospitalization decreased from 7 to 2 days (P < 0.0001), with 32.1% and 88% of patients discharged home on postoperative day 1 and postoperative day 2, respectively. When comparing pre- and post-MIREC, intensive care unit utilization (10.8% vs. 2.9%, P < 0.0001), ER visits (34.7% vs. 19.7%, P = 0.0002), and readmission (18.6% vs. 11.1%, P = 0.019) at 30 days were also considerably lower. In addition, more patients received postoperative adjuvant chemotherapy (31.4% to 63.5%, P < 0.0001), and the time between gastrectomy and starting adjuvant chemotherapy was also less (49-41 days; P = 0.002). This comprehensive regional program, which encompasses regionalization care, laparoscopic approach, modern oncologic care, surgical subspecialization, and the MIREC pathway, can potentially improve gastric cancer surgery outcomes. These benefits include reduced hospital stays and lower complication rates. As such, this program can revolutionize how gastric cancer surgery is delivered, leading to a higher quality of care and increased value to patients.

Same-Day Ileostomy Closure Discharge Reduces Costs without Compromising Outcomes: An Economic Analysis.

This study aims to assess the costs of a Same-Day Discharge Enhanced Recovery Pathway (SDD) for diverting loop ileostomy closure compared to a standard institutional enhanced recovery protocol (ERP). Every year, 50,155 patients in the United States undergo temporary stoma reversal. While ambulatory stoma closure has shown promise, widespread adoption remains slow. This study builds on previous research, focusing on the costs of a novel SDD protocol introduced in 2020. A retrospective case-control study was conducted at Mayo Clinic, Rochester, Minnesota, and Mayo Clinic, Jacksonville, Florida, comparing patients undergoing same-day discharge diverting loop ileostomy closure (SDD) from August 2020 to February 2023 to those in a matched cohort receiving standard inpatient ERP. Patients were matched based on age, sex, ASA score, surgery period, and hospital. Primary outcomes included direct hospitalization and additional costs in the 30 days post-discharge. The SDD group (n=118) demonstrated a significant reduction in median index episode hospitalization and 30-day post-operative costs compared to the inpatient group (n=236), with savings of $4,827 per patient. Complication rates were similar, and so were readmission and reoperation rates. Implementation of the SDD for diverting loop ileostomy closure is associated with substantial cost savings without compromising patient outcomes. The study advocates for a shift towards same-day discharge protocols, offering economic benefits and potential improvements in healthcare resource utilization.

An Interdisciplinary, Comprehensive Recovery Pathway Improves Microsurgical Breast Reconstruction Delivery.

Free-flap (autologous) breast reconstruction demonstrates superiority over alloplastic approaches but is offered infrequently. Enhanced recovery protocols can address postoperative challenges, but most literature is limited to inpatient interventions and outcomes. This study describes an adoptable, longitudinally comprehensive and multidisciplinary recovery pathway for autologous reconstruction which adds to the current guidelines. The authors aimed to allow perioperative outcomes comparable to alloplastic reconstructions. All autologous Comprehensive Recovery Pathway (CRP) subjects from a single surgeon were retrospectively included. A comparator group of equal size was randomly selected from institutional subpectoral and dual-plane tissue expander patients having Enhanced Recovery After Surgery guideline-directed care. All subjects in both cohorts received preoperative paravertebral regional blocks. Operative detail, inpatient recovery, longitudinal morphine equivalents (MEs) required, and complications were compared. Each cohort included 71 cases (99 breasts). Despite longer operations, intraoperative MEs were fewer in autologous cases ( P = 0.02). Morphine equivalents during inpatient stay were similar between cohorts, with both being discharged on median day 2. Multivariate regression demonstrated a 0.8-day increased stay for autologous subjects with additional contribution from bilateral cases, body mass index, and age ( P < 0.05). Autologous subjects were regularly discharged postoperative day 1 (17%) and postoperative day 2 (39%), with trend toward earlier discharge ( P < 0.01). Outpatient MEs were significantly fewer in autologous subjects, corresponding to a 30- to 150-mg oxycodone difference ( P < 0.01). Major complication occurred in 12.7% of autologous and 22.5% of alloplastic subjects ( P = 0.11). Flap loss occurred in 1 autologous subject versus 11 alloplastic failures ( P < 0.01). This study details partnership between the plastic surgery service, regional and acute pain anesthesia services, and dedicated nursing with longitudinal optimizations allowing perioperative outcomes improved over current literature. Patients in the CRP used fewer opioids from operation through follow-up with comparable length of stay and significantly fewer reconstructive failures than alloplastic subjects. The pathway may be quickly adopted into academic practice patterns and mitigates traditional barriers, allowing extension of autologous reconstruction offerings.

Optimization of the end‐of‐life tire repartition within the European treatment system to minimize its environmental impacts

AbstractThis study contrasts two different approaches to inform European‐scale decision‐making to mitigate the environmental impacts of the end‐of‐life tires (ELT) management system. The first analysis is a traditional life cycle assessment (LCA) that compares the environmental performances of the 12 main available European end‐of‐life (EOL) technologies in ELT processing while restricting the boundaries to the EOL stage. The second analysis has a broader scope, addressing the optimization of the ELT distribution within the 12 considered pathways to minimize the environmental impacts of the total tire use in Europe under present capacity and constraints. The results of the traditional LCA show that, except for landfill, all the tested EOL routes present environmental benefits. Material recovery pathways bring the most environmental credits, whereas civil engineering pathways are the least promising. The LCA results that emerged from the optimization of ELT management technologies yield two optimal technological mixes that maximize the quantity of ELT recycled in molded objects production: such results represent a hypothetical case with no constraints. When considering constraints, that is, limitations on maximum quantities of ELT that can undergo retreading, pyrolysis, or recycling in synthetic turfs, in molded objects and in production, the number of optimal technology mixes increases to five. The type of technologies favored depends on the minimized impact categories (climate change, fossil and nuclear energy use, human health, and ecosystem quality). A comparison between constrained and unconstrained scenarios shows that achieving the best environmental performances is conditional to the accessibility of the EOL technologies as well as their individual environmental impacts.

Endothelial ELABELA improves post-ischemic angiogenesis by upregulating VEGFR2 expression

BackgroundPost-ischemic angiogenesis is critical for perfusion recovery and tissue repair. ELABELA (ELA) plays an essential role in embryonic heart development and vasculogenesis. However, the mechanism of ELA on post-ischemic angiogenesis is poorly characterized. MethodsWe first assessed ELA expression after hind limb ischemia (HLI) in mice. We then established a HLI model in tamoxifen-inducible endothelial-ELA-specific knockout mice (ELAECKO) and assessed the rate of perfusion recovery, capillary density, and VEGFR2 pathway. Knockdown of ELA with lentivirus or siRNA and exogenous addition of ELA peptides were employed to analyze the effects of ELA on angiogenic capacity and VEGFR2 pathway in endothelial cells in vitro. The serum levels of ELA in healthy people and patients with type 2 diabetes mellitus (T2DM) and diabetic foot ulcer (DFU) were detected by a commercial ELISA kit. ResultsIn murine HLI models, ELA was significantly up-regulated in the ischemic hindlimb. Endothelial-specific deletion of ELA impaired perfusion recovery and angiogenesis. In physiologic conditions, no significant difference in VEGFR2 expression was found between ELAECKO mice and ELAWT mice. After ischemia, the expression of VEGFR2, p-VEGFR2, and p-AKT was significantly lower in ELAECKO mice than in ELAWT mice. In cellular experiments, the knockdown of ELA inhibited endothelial cell proliferation and tube formation, and the addition of ELA peptides promoted proliferation and tube formation. Mechanistically, ELA upregulated the expression of VEGFR2, p-VEGFR2, and p-AKT in endothelial cells under hypoxic conditions. In clinical investigations, DFU patients had significantly lower serum levels of ELA compared to T2DM patients. ConclusionOur results indicated that endothelial ELA is a positive regulator of post-ischemic angiogenesis via upregulating VEGFR2 expression. Targeting ELA may be a potential therapeutic option for peripheral arterial diseases.

Early Discharge after Enhanced Recovery Colectomy Does Not Increase Emergency Department Visits and Readmissions: A Single Institution Analysis.

Same-day discharge after colorectal surgery in enhanced recovery pathways is increasing. This study aimed to determine if discharge on postoperative days (POD) one or two is associated with increased rates of emergency department (ED) visits and hospital readmissions after left and right colectomy. Single institution retrospective analysis of prospective institutional colorectal surgery database between 07/01/2018 and 07/15/2022. Primary outcomes were ED visit and readmission rates for enhanced recovery open and minimally invasive right and left colectomy using logistic regressions models. 820 patients met inclusion criteria. There were significant differences in discharge-day by diagnosis-58.5% of patients with Crohn's disease were discharged on POD ≥4 and 21.6% with benign colon neoplasia were discharged on POD-0-1 (P < .001). ED visits occurred in 12.9% of the study population and were not significantly different between discharge-day groups (P = .096). Overall readmission rate was 8.5% and significantly different between discharge-day groups (0% POD-0 vs 8.3% POD-1 vs 5.8% POD-2 vs 6.9% POD-3 vs 12.9% POD ≥4, P = .041). Logistic regression showed that ED visits and readmissions for longer discharge-days (POD-2, POD-3, POD ≥4) were not significantly different than POD-0-1. Readmission diagnoses for the study population were higher for ileus (17.1%) and surgical site infection (SSI) type-III (22.9%) than for acute kidney injury (1.4%) and SSI type-I/II (1.4%). Early discharge after left and right colectomy is not associated with increased rates of ED visits and readmissions. Same-day discharge may be feasible in selected enhanced recovery patients. Standardized post-discharge resources that safely allow same-day discharge require further investigation.

Abstract 5846: Inhibiting elements of the proteasome recovery pathway sensitizes glioblastoma to proteasome inhibitors

Abstract Bacground: Glioblastoma (GBM) is the most common primary brain tumor, accounting for 15% of all central nervous system related tumors. Despite the aggressive standard of care treatment including chemotherapy, radiotherapy, and maximally safe surgical resection, patient outcomes are abysmal: with 95% of patients relapsing and a median overall survival of 15 months. Thus, this necessitates the rapid query for personalized therapeutics and agents that can potentiate the clinical effects of currently approved treatments. One such pathway that demonstrates aberrant functioning in cancer and is a targetable mechanism is the ubiquitin-proteosome pathway (UPP). Studies have shown that UPP related proteolysis remains constitutively active in cancer cells leading to the rapid degradation of proteins that regulate tumor suppressor genes and oncogenes. Despite robust preclinical evaluations for the usage of proteosome inhibitors against GBM, most tested proteosome inhibitors failed in phase II and III trials, indicating resistance. Methods: We conducted an unbiased genome wide CRISPR-Cas9 screen in human HAP1 cells treated with the proteosome inhibitor, Bortezomib (BTZ), to identify genes that may lead to a BTZ-resistant phenotype. We identified several genes that when perturbed, sensitized cells to BTZ including N-glycanase-1 (NGLY-1), Nuclear factor Erythroid 2-Like-1 (NFE2L1), and DNA damage inducible 1 homolog 2 (DDI2). Herein we sought to evaluate the effects of perturbing components of the proteosome rescue pathway in our Singh lab patient derived GBM cell lines by utilizing CRISPR/Cas9 knockout technology in vitro and in vivo. Results: The generation of NGLY-1, DDI2, and NFE2L1 KO cell lines demonstrated functional sensitivity to the proteosome inhibitor Marizomib (MZB) as observed through a significant reduction of the IC50 in the KO cell lines compared to a control. Functional evaluation also revealed a reduction in proliferation capacity as well as sphere formation in these genetically modified GBM lines. Ongoing in vivo work will aim to evaluate the mitigation of this resistant pathway in our NSG mouse models orthotopically transplanted with these patient derived KO cell lines. In an ongoing collaborative effort, we are working to identify and functionally assess a novel small molecule NGLY-1 inhibitor to evaluate preclinical sensitivity to MZB in our in vitro and in vivo models. Citation Format: Alisha Anand, Muhammad Vaseem Shaikh, Chirayu Chokshi, Benjamin Brakel, William Maich, Shan Grewal, Chitra Venugopal, Sheila Singh. Inhibiting elements of the proteasome recovery pathway sensitizes glioblastoma to proteasome inhibitors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5846.

A systematic qualitative study investigating why individuals attend, and what they like, dislike, and find most helpful about, smart recovery, alcoholics anonymous, both, or neither

BackgroundSome individuals seeking recovery from alcohol use disorder (AUD) attend Alcoholics Anonymous (AA) while others choose newer alternatives such as Self-Management and Recovery Training (“SMART” Recovery). Some even attend both, while some choose not to attend either. Little is known about why people choose which pathway(s), and what they like, dislike, and find helpful. Greater knowledge could provide insights into the phenomenology of recovery experiences and enhance the efficiency of clinical linkage to these resources. MethodsCross-sectional, qualitative, investigation (N = 80; n = 20 per condition; 50%female) of individuals attending either AA-only, SMART-only, both, or neither. Participants were asked why they initially chose that pathway, what they like and dislike, and what helps. Responses were coded using an inductive grounded theory approach with utterances recorded and categorized into superordinate domains and rank-ordered in terms of frequency across each question and recovery pathway. ResultsAA participants reported attending due to, as well as liking and finding most helpful, the common socio-community aspects, whereas SMART attendees went initially due to, as well as found most helpful, the different format as well as the CBT/science-based approach. Similar to AA, however, SMART participants liked the socio-community aspects most. “Both” participants reported liking and finding helpful these perceived relative strengths of each organization. “Neither” participants reported reasons for non-attendance related to lower problem severity – perceiving no need to attend, and anxiety about privacy, but reported using recovery-related change strategies similar to those prescribed by AA, SMART and treatment (e.g., stimulus control, competing behaviors). Common dislikes for AA and SMART centered around irritation due to other members behaviors, a need for more SMART meetings, and negative experiences with SMART facilitators. ConclusionCommon impressions exist among individuals selecting different recovery pathway choices, but also some differences in keeping with the group dynamics and distinct approaches inherent in AA and SMART. AA attendees appear to go initially for the recovery buoyancy derived from the social ethos and camaraderie of lived experience and may end up staying for the same reason; those choosing SMART, in contrast, appear to attend initially for the CBT/science-based content and different approach but, like AA participants, may end up staying due to the same camaraderie of lived experience. Those participating in both AA and SMART appear to capitalize on the strengths of each organization, suggesting that some can psychologically accommodate and make use of theoretically distinct, and sometimes opposing, philosophies and practices.

The recovery potential and utilization pathway of chemical energy from wastewater pollutants during wastewater treatment in China

Research on the potential for chemical energy recovery and the optimization of recovery pathways in different regions of China is still lacking. This study aimed to address this gap by evaluating the potential and optimize the utilization pathways for chemical energy recovery in various regions of China for achieving sustainable wastewater treatment. The results showed that the eastern and northeastern regions of China exhibited higher chemical energy levels under the existing operating conditions. Key factors affecting chemical energy recovery included chemical oxygen demand removal (ΔCOD), treatment scale, and specific energy consumption (μ) of wastewater treatment plants (WWTPs). Furthermore, the average improvement in the chemical energy recovery rate with an optimized utilization pathway was approximately 40% in the WWTPs. The use of the net-zero energy consumption (NZE) model proved effective in improving the chemical energy recovery potential, with an average reduction of greenhouse gas (GHG) emissions reaching next to 95% in the investigated WWTPs.

Views and experiences of healthcare professionals and patients on the implementation of a 23-hour accelerated enhanced recovery programme: a mixed-method study

BackgroundAn accumulating body of research suggests that an accelerating enhanced recovery after colon surgery protocol is beneficial for patients, however, to obtain these effects, adherence to all elements of the protocol is important. The implementation of complex interventions, such as the Enhanced Recovery After Surgery protocol (ERAS), and their strict adherence have proven to be difficult. The same challenges can be expected in the implementation of the accelerated Enhanced Recovery Pathways (ERPs). This study aimed to understand the perspectives of both healthcare professionals (HCPs) and patients on the locally studied acCelerated enHanced recovery After SurgEry (CHASE) protocol.MethodsFor this mixed-method study, HCPs who provided CHASE care and patients who received CHASE care were recruited using purposive sampling. Ethical approval was obtained by the Medical Ethical Committee of the Zuyderland Medical Centre (NL71804.096.19, METCZ20190130, October 2022). Semi-structured, in-depth, one-on-one interviews were conducted with HCPs (n = 13) and patients (n = 11). The interviews consisted of a qualitative and quantitative part, the protocol evaluation and the Measurement Instrument or Determinant of Innovations-structured questionnaire. We explored the perspectives, barriers, and facilitators of the CHASE protocol implementation. The interviews were audiotaped, transcribed verbatim and analysed independently by two researchers using direct content analysis.ResultsThe results showed that overall, HCPs support the implementation of the CHASE protocol. The enablers were easy access to the protocol, the relevance of the intervention, and thorough patient education. Some of the reported barriers included the difficulty of recognizing CHASE patients, the need for regular feedback, and the updates on the implementation progress. Most patients were enthusiastic about early discharge after surgery and expressed satisfaction with the care they received. On the other hand, the patients sometimes received different information from different HCPs, considered the information to be too extensive and few experienced some discomfort with CHASE care.ConclusionBringing CHASE care into practice was challenging and required adaptation from HCPs. The experiences of HCPs showed that the protocol can be improved further, and the mostly positive experiences of patients are a motivation for this improvement. These results yielded practical implications to improve the implementation of accelerated ERPs.

The economics of waste oil recycling in the EU

ABSTRACT In 2018, 1.6 million tonnes of waste oil were collected in the European Union. About 61% of the waste oil was regenerated – i.e. it was turned into base oil again – and 39% followed energy recovery pathways either in the form of conversion to fuel or via direct incineration. Although the life-cycle literature largely agrees that regeneration outperforms energy recovery in the EU in terms of greenhouse gas emissions and societal costs, policies to boost regeneration and their socio-economic impacts remain underexplored. We fill this gap by discussing policies for managing waste oil flows and by systematically assessing their socio-economic impacts. We analyse different policies that would induce an increase in the regeneration rate of waste oil from the current 61% to either 70% or 85% and assess how the type and magnitude of impacts as well as their distribution across different actors varies, depending on the policy design. The policies lead to a net saving in terms of avoided societal costs and to moderate gains in employment. However, when accounting for estimated administrative costs, these benefits are likely insufficient to justify regulatory intervention.

Compiling life cycle inventories for wastewater-derived products

With the paradigm shift in wastewater management from pollutant removal to resource recovery, more wastewater-derived products are emerging from different recovery pathways. It is becoming increasingly important to understand the potential environmental impacts of these products through life cycle assessment (LCA). This study aims to compile life cycle inventories of wastewater-derived products from the perspective of the product end users (e.g., agricultural sector, packaging industry), and to explore the challenges of their compilation. Using inventories from wastewater resource recovery LCA literature, we compiled an attributional inventory (88 sets) and a consequential inventory (33 sets) of three categories of wastewater-derived products – phosphorus compounds, nitrogen compounds, and biopolymers. The two inventories differ by the choices of system boundary, how foreground systems are being modelled, and how co-products are being handled. We found that while there is a large body of literature related to wastewater resource recovery LCA, very few studies (29 out of 174 for the three categories of products) are suitable for end users to successfully compile inventories of derived products. The inventories were assessed by the technology readiness level assessment, the data quality assessment, and the cumulative energy demand indicator. The inventories can be used directly by end users or served as “screening” inventories for end users to prioritize data collection effort. The identified challenges of inventory compilation include diverse recovery settings, the absence of baseline scenarios, the multifunctional nature of wastewater treatment plants, the lack of inventory transparency and completeness, and low technology readiness level for some recovery pathways. While established or emerging approaches exist to address most of these challenges for end users, wastewater resource recovery LCA practitioners can enhance their assessments to be more end-user-oriented. This can be achieved by including baseline non-recovery scenarios, disclosing detailed life cycle inventory by system components, and assessing a wide variety of operating scenarios. Addressing some of these compilation challenges would enhance the comprehensiveness and quality of wastewater-derived product inventories.

Closing the Gap on Addiction Recovery Engagement with an AI-infused Convolutional Neural Network Technology Application—A Design Vision

Currently, real-time detection networks elaborate the technical details of the Faster Regional Convolution Neural Network (R-CNN) recognition pipeline. Within existing R-CNN literature, the evolution exhibited by R-CNN is most profound in terms of computational efficiency integrating each training stage to reduce test time and improvement in mean average precision (mAP), which can be infused into an artificially intelligent (AI), machine learning (ML), real-time, interactive, recovery capital application (app). This article introduces a Region Proposal Network (RPN) that shares full-image convolutional features with a real-time detection AI-ML infused network in an interactive, continuously self-learning wrist-wearable real-time recovery capital app for enabling cost-free region proposals (e.g., instantaneous body physiological responses, mapped connections to emergency services, sponsor, counselor, peer support, links to local and specific recovery capital assets, etc.). A fully merged RPN and Faster R-CNN deep convolutional unified network in the app can simultaneously train to aggregate and predict object bounds and objectness scores for implementing recovery capital real-time solutions (e.g., baseball card scoring dashboards, token-based incentive programs, etc.) A continuous training scheme alternates between fine-tuning RPN tasks (e.g., logging and updating personal client information, gamification orientation) and fine-tuning the detection (e.g., real-time biometric monitoring client’s behavior for self-awareness of when to connect with an addiction specialist or family member, quick response (QR) code registration for a 12-step program, advanced security encryption, etc.) in the interactive app. The very deep VGG-16 model detection system has a frame rate of 5fps within a graphic processing unit (GPU) while accomplishing sophisticated object detection accuracy on PASCAL Visual Object Classification Challenge (PASCAL VOC) and Microsoft Common Objects in Context (MS COCO) datasets. This is achieved with only 300 proposals per real-time retrieved data capture point, information bit or image. The app has real-time, infused cartographic and statistical tracking tools to generate Python Codes, which can enable a gamified addiction recovery-oriented digital conscience. Faster R-CNN and RPN can be the foundations of an interactive real-time recovery capital app that can be adaptable to multiple recovery pathways based on participant recovery plans and actions. This paper discusses some of the critical attributes and features to include in the design of a future app to support and close current gaps in needed recovery capital to help those who are dealing with many different forms of addiction recovery.

The dynamic capabilities approach and regional business resilience: an Australian case study

ABSTRACT The frequency and severity of major disruptions (e.g., disasters, epidemics/pandemics) are increasing, significantly impacting business survival in regional areas. Using the dynamic capabilities approach, this paper reports on the recovery pathways and resilience of Australian regional businesses during the recent COVID-19 pandemic. A case study approach is adopted to explore the capabilities through which regional businesses can plan for, recover from, and develop strategies for building resilience. Using the data from 18 semi-structured interviews with business owners operating in different industry sectors and a web-based forum with 10 key stakeholders in regional South Australia, a dynamic capabilities resilience framework is developed. Results suggest that the dynamic capabilities approach during crises can become integral to the long-term business recovery of regional Australian businesses. By revealing both the determinants of business survival and the constraints regional businesses face during major crises, the study contributes information that businesses, government and non-government agencies that support them can use to develop effective recovery pathways, which is central to the future sustainability of regional Australia.