Safe Pathway Research Articles

A prospective observational concordance study to evaluate computational model-driven clinical practice guidelines for Type 2 diabetes mellitus

Background: Clinical Practice Guidelines (CPGs) provide healthcare professionals with performance and decision-making support during the treatment of patients. Sometimes, however, they are poorly implemented. The IDE4ICDS platform was developed and validated with CPGs for type 2 diabetes mellitus (T2DM). Objective: The main objective of this paper is to present the results of the clinical validation of the IDE4ICDS platform in a real clinical environment at two health clinics in the Andalusian Public Health System (SSPA) in the southern Spanish region of Andalusia. Methods: National and international knowledge sources on T2DM were selected and reviewed and used to define a diabetes CPG model on the IDE4ICDS platform. Once the diabetes CPG was configured and deployed, it was validated. A total of 506 patients were identified as meeting the inclusion criteria, of whom 130 could be recruited and 89 attended the appointment. Results: A concordance analysis was performed with the kappa value. Overall agreement between the recommendations provided by the system and those recorded in each patient's EHR was good (0.61 - 0.80) with a total kappa index of 0.701, leading to the conclusion that the system provided appropriate recommendations for each patient and was therefore well-functioning. Conclusions: A series of possible improvements were identified based on the limitations for the recovery of variables related to the quality of these recolected variables, the detection of duplicate recommendations based on different input variables for the same patient, and clinical usability, such as the capacity to generate reports based on the recommendations generated. Nevertheless, the project resulted in the IDE4ICDS platform: a Clinical Decision Support System (CDSS) capable of providing appropriate recommendations for improving the management and quality of patient care and optimizing health outcomes. The result of this validation is a safe and effective pathway for developing and adopting digital transformation at the regional scale of the use of biomedical knowledge in real healthcare.

Assessment of routine same-day discharge surgery for robot-assisted radical prostatectomy.

It is important for robotic surgery to be cost-effective, especially by reducing the length of stay (LOS). Therefore, we developed a protocol for day-case robot-assisted radical prostatectomy (RARP). This study aimed to validate this as a safe practice of care and to assess the potential benefits to the hospital and patient. In this single-centre study, all patients booked for RARP between April 2022 and October 2022 were screened for suitability for day case. All tumour types were included. Exclusion criteria were a history of complex abdominal surgeries, salvage prostatectomy, body mass index (BMI) > 35 and patient living alone or > 150km away from the hospital. All day-case RARPs were performed as a morning case with a protocol for review throughout the day with evening discharge if mobilising independently and eating/drinking well. The primary outcome of the study was success rate of discharge home on day of surgery (DOS) with secondary outcomes of readmissions and complications. A patient questionnaire was completed at home including both visual analogue scale (VAS) for pain and satisfaction rating. Forty-five patients underwent day-case RARP over a 6-month period with minimum of 30days of follow-up. 41/45 (91%) had successful DOS discharge home. The four admissions overnight were due to dizziness, low oxygen saturation, intraoperative complications and a diagnosis of COVID-19. There were no readmissions and no 30-day complications. The most common issues at home were catheter discomfort and constipation with low mean VAS pain score and low nausea reported. The overall patient satisfaction rating was very high at 4.8/5, and 97% said they would recommend to a family member. The cost saving for the hospital was 400 pounds per patient. Day-case procedure is a viable, safe and efficient pathway for appropriately selected and counselled patients undergoing RARP.

1052 Safety of Drain-Less Anterior Cervical Discectomy and Fusion (ACDF) and Effects on Length of Stay

Abstract Aim The use of drain in ACDF surgery is to avoid post-operative catastrophic haematomas compressing the airway. However, studies associate drains with dysphagia, infection and longer inpatient stays. This study assesses whether drain-less ACDF could avoid drain-site morbidity and reduce length of stay (LoS) without increasing complications. Method All consecutive adult patients who had ACDF under a single surgeon over a 4-year period were identified, where routine post-operative care did not involve drain placement when meticulous intra-operative haemostasis was achieved. Data was collected using electronic patient records. From Autumn 2020, patients were pre-operatively counselled on potential same-day discharge. This group of patients (PC) was compared with those without counselling (Control) for assessing secondary outcomes, including LoS and GP or A&E attendance. Results Seventy-four patients were included in this study. None had post-operative drain placement and there were no reports of post-operative haematoma or return to theatre. There were 12 and 15 patients for PC and Control groups respectively. For same-day discharge, there were two patients in the PC group and none in Control group. Median LoS was also shorter in PC (1.0 day; IQR:1-1.3) compared to Control (2.0 days; IQR:1-3.5). Three patients from each group had persistent mild radicular symptoms, but none required GP or A&E attendance within 6 weeks post-operatively. Conclusions Our results support that routine drain placement may not be required for safe ACDF surgery. Additionally, with appropriate counselling, shorter LoS can be achieved. This could help develop safe daycase surgery pathways, easing bed demands while improving access to treatment.

Tunable Gas-Gas Reactions through Nanobubble Pathway.

Combustible gas-gas reactions usually do not occur spontaneously upon mixing without ignition or other triggers to lower the activation energy barrier. Nanobubbles, however, could provide such a possibility in solution under ambient conditions due to high inner pressure and catalytic radicals within their boundary layers. Herein, a tunable gas-gas reaction strategy via bulk nanobubble pathway is developed by tuning the interface charge of one type of bulk nanobubble and promoting its fusion and reaction with another, where the reaction-accompanied size and number concentration change of the bulk nanobubbles and the corresponding thermal effect clearly confirm the occurrence of the nanobubble-based H2 /O2 combustion. In addition, abundant radicals can be detected during the reaction, which is considered to be critical to ignite the gas reaction during the fusion of nanobubbles in water at room temperature. Therefore, the nanobubble-based gas-gas reactions provide a safe and efficient pathway to produce energy and synthesize new matter inaccessible under mild or ambient conditions.

Ultrasound-Driven Piezoelectrocatalytic Immunoactivation of Deep Tumor.

Tumor heterogeneity makes routine drugs difficult to penetrate solid tumors, limiting their therapy efficacies. Based on high tissue penetrability of hydrogen molecules (H2 ) and ultrasound (US) and the immunomodulation effects of H2 and lactic acid (LA), this work proposes a novel strategy of US-driven piezoelectrocatalytic tumor immunoactivation for high-efficacy therapy of deep tumors by piezoelectrocatalytic hydrogen generation and LA deprivation. A kind of US-responsive piezoelectric SnS nanosheets (SSN) is developed to realize US-triggered local hydrogen production and simultaneous LA deprivation in deep tumors. The proof-of-concept experiments which are executed on an orthotopic liver cancer model have verified that intratumoral SSN-medicated piezoelectrocatalytically generated H2 liberates effector CD8+ T cells from the immunosuppression of tumor cells through down-regulating PD-L1 over-expression, and simultaneous LA deprivation activates CD8+ T cells by inhibiting regulatory T cells, efficiently co-activating tumor immunity and achieving a high outcome of liver tumor therapy with complete tumor eradication and 100% mice survival. The proposed strategy of US-driven piezoelectrocatalytic tumor immunoactivation opens a safe and efficient pathway for deep tumor therapy.

Using microneedle array electrodes for non-invasive electrophysiological signal acquisition and sensory feedback evoking.

Introduction: Bidirectional transmission of information is needed to realize a closed-loop human-machine interaction (HMI), where electrophysiological signals are recorded for man-machine control and electrical stimulations are used for machine-man feedback. As a neural interface (NI) connecting man and machine, electrodes play an important role in HMI and their characteristics are critical for information transmission. Methods: In this work, we fabricated a kind of microneedle array electrodes (MAEs) by using a magnetization-induced self-assembly method, where microneedles with a length of 500-600μm and a tip diameter of ∼20μm were constructed on flexible substrates. Part of the needle length could penetrate through the subjects' stratum corneum and reach the epidermis, but not touch the dermis, establishing a safe and direct communication pathway between external electrical circuit and internal peripheral nervous system. Results: The MAEs showed significantly lower and more stable electrode-skin interface impedance than the metal-based flat array electrodes (FAEs) in various testing scenarios, demonstrating their promising impedance characteristics. With the stable microneedle structure, MAEs exhibited an average SNR of EMG that is more than 30% higher than FAEs, and a motion-intention classification accuracy that is 10% higher than FAEs. The successful sensation evoking demonstrated the feasibility of the MAE-based electrical stimulation for sensory feedback, where a variety of natural and intuitive feelings were generated in the subjects and thereafter objectively verified through EEG analysis. Discussion: This work confirms the application potential of MAEs working as an effective NI, in both electrophysiological recording and electrical stimulation, which may provide a technique support for the development of HMI.

Testing the effects of banking development, economic growth and foreign direct investment on renewable energy in South Africa

AbstractThe world's climate‐related policies need to be revised to combat environmental issues. Therefore, adopting renewable energy technologies in conjunction with energy efficiency measures are needed to make safe pathways to reduce over 90% of energy related CO2. In this context, this study intends to assess the influence of foreign direct investment (FDI), economic growth, and banking and development on renewable energy consumption in South Africa from 1970 to 2020. The study uses a novel ‘bootstrap Autoregressive Distributed Lag (ARDL)’ testing to empirically analyse the short and long links among the tested variables. The ARDL estimations demonstrate a FDI and economic growth have positive effect on renewable energy consumption. Furthermore, the outcomes reveal that banking sector development affects positively renewable energy use in long run. Therefore, it is suggested that government and playmakers of South Africa must make more efforts to link the economic and baking development with renewable energy by investing capital and funds in renewable energy infrastructure. It will not only boost the economy of the country but also provide an opportunity to clean and green the environment with decreasing rate of greenhouse gases emission like carbon dioxide.

Anticoagulation prescription among atrial fibrillation patients managed with and without an anticoagulant initiation pathway: a cohort study.

The Canadian Association of Emergency Physicians atrial fibrillation (AF) checklist advises that emergency physicians initiate anticoagulation therapy for patients with AF or flutter who are CHADS65 positive. The aim was to compare anticoagulation initiation rates between patients treated with and without an anticoagulation assessment pathway (the SAFE pathway). This was a retrospective cohort study. All emergency department patients were discharged home with a diagnosis of AF between June 2018 and May 2020 at two Canadian emergency departments. The SAFE pathway is a hard copy form which allows emergency physicians to document contraindications to anticoagulation, the positive components of the CHADS65 score, and details how to prescribe anticoagulation. Trained researchers abstracted data on the use of the SAFE pathway by the presence or absence of the completed, scanned pathway in the electronic medical chart. The exposure of interest was use of this pathway. Patients were followed forward in time for 90 days by electronic medical record review to document stroke, transient ischemic attack, arterial embolism and major bleeding events. All events were independently adjudicated. Adjusted odds ratios were calculated to compare outcomes between those managed with and without the SAFE pathway. In total, 766 patients were included, of whom 264 were already taking anticoagulation, 166 were CHADS65 negative and 65 had a contraindication to anticoagulation, leaving 271 patients eligible for anticoagulation prescription. Among the 271 eligible patients, 137/166 managed with the SAFE pathway were initiated on anticoagulation and 24/105 managed without the SAFE pathway started anticoagulation (adjusted odds ratio 25.9; 13.1-51.2). There was no statistically significant difference in the 90-day rate of stroke or bleeding. Use of the SAFE pathway was associated with a higher rate of anticoagulation prescription.

Impact of Introducing a PACU24 Concept on the Perioperative Outcome of Patients with Advanced Ovarian Cancer Treated with Cytoreductive Surgery.

Patients with ovarian cancer who undergo multivisceral surgery usually require intensive care monitoring postoperatively. In view of the ever-fewer numbers of high-care/intensive care beds and the introduction of fast-track treatment concepts, it is increasingly being suggested that these patients should be cared for postoperatively in 24-h Post Anesthesia Care Units (PACU24). No analyses have been carried out to date to investigate whether such a postoperative care concept might be associated with a potential increase in postoperative complications in this patient cohort. A PACU24 unit was set up in our institution in 2015 and it has become the primary postoperative care pathway for patients with ovarian cancer who have undergone cytoreductive (debulking) surgery. A structured, retrospective analysis of data from patients treated before (control group) and after (PACU group) the introduction of this care concept was carried out, with a particular focus on postoperative complications and secondary admission to an intensive care unit where necessary. The data of 42 patients were analyzed for the PACU group and 45 patients for the control group. According to the analysis, the preoperative and surgical data of both groups were comparable (age, ASA, BMI, FIGO stage, duration of surgery, blood loss). The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM score) as a measure for the risk of postoperative complications was higher in the PACU group (11.1% vs. 9.7%, p=0.001). Patients in the PACU group underwent bowel resection with anastomosis significantly more often (76.3% vs. 33.3%, p<0.001), although the extent of surgery was otherwise comparable. The total number, type and severity of postoperative complications and the duration of the overall stay in hospital did not differ between the two groups. None of the patients required secondary transfer from the PACU or normal ward to an intensive care unit (ICU). Our data support the assumption that the care concept of transferring patients to a PACU24 represents a safe and cost-saving care pathway for the postoperative care of patients even after complex gynecological-oncological procedures.

Retrospective review of medication allergy labeling among patients admitted to a tertiary hospital in Qatar.

Background: Timely access to accurate, up-todate drug allergy information is critical to avoid potentially life-threatening adverse drug reactions (ADRs). However, the completeness and accuracy of allergy documentation remain a challenge. Inappropriate allergy documentation usually necessitates alternative treatments, increases costs, and may negatively impact patients' outcomes. Objectives: Review medication allergy labeling documentation, identify the most reported medication class, and describe allergic reactions based on the reported severity. Methods: A retrospective cross-sectional audit including all medication allergy labeling documentation for patients admitted to Hamad General Hospital (HGH) from January-December 2022 was conducted. A list of patients with medication allergies was generated from the pharmacy system, which included patients' demographics, medication names, documented allergy severity, and any other comments. The list was reviewed, and medications were categorized into different classes. Results: 2856 allergy documentation for 2431 unique patients were identified and included in the analyses. The mean age of included patients was 43 years old, with 73.2% (1780) being females. Among the reported allergic reactions, 11.8% (336) were documented as severe allergic reactions, 51.1% (1457) were moderate, and 37.1% (1060) were mild. Antibiotics were the most common documented allergens, representing 42.1% of all reported allergies, followed by non-steroidal anti-inflammatory drugs (20.7%, n=591), and paracetamol (5.3%, n=151). Of all the reported allergies, only 6 (0.21%) cases had documented confirmatory allergy tests done. Further analysis of the reported allergies revealed that 1.2% (34) of the allergies had documentation to counteract the allergy labeling through either revised patient history or re-challenging. Despite such, allergy labeling was kept in the medical profile without proper de-labeling. Conclusion: Allergy labeling documentation is a key to safe medication prescribing. However, standardized allergy documentation should be implemented to include a brief description and onset of the symptoms. Additionally, a safe de-labeling pathway should be adopted. Most of the allergy documentation was based on patients' or family/parents' reports, while actual allergies observed by a healthcare provider were limited.

One-stop autologous breast reconstruction: A safe and effective cost-saving pathway

Patients undergoing autologous breast reconstruction usually require further operations as part of their reconstructive journey. This involves contralateral breast symmetrization and nipple-areola complex (NAC) reconstruction. Restrained access to elective operating space led us to implement a one-stop breast reconstruction pathway. Patients undergoing contemporaneous contralateral breast symmetrization and immediate NAC reconstruction with free nipple grafts between July 2020 and June 2021 were identified. A retrospective review of our prospectively maintained database was conducted, to retrieve surgical notes, postoperative complications, and length of inpatient stay. A cost analysis was performed considering savings from contralateral symmetrization. A total of 50 eligible cases were identified, which had unilateral one-stop breast reconstructions. Complication rates and length of stay were not affected by this approach, with only one free flap being lost for this cohort. This approach resulted in £181,000 being saved for our service over a calendar year. A one-stop breast reconstruction pathway has proven to be safe and effective in our unit. During these uncertain times, it has streamlined the management of eligible patients, while releasing capacity for other elective operations. Patients avoid having to wait for secondary procedures, finishing their reconstructive pathway earlier. We plan to continue providing this service which has shown to be beneficial clinically and financially.

The Hitchhiker's Guide to Spine Awake Surgery. The Oxford SAS Protocol and Early Outcomes

Spine awake surgery (SAS) aims to achieve faster recovery times, better outcomes, and a lesser economic impact on society. Our drive to establish SAS was to improve patient outcomes and health economics during the COVID-19 pandemic. After a systematic review and to the best of our knowledge, SAS, the Oxford Protocol, is the first protocolized pathway that aims to train bespoke teams performing SAS safely, efficiently, and in a standardized repeatable fashion. A pilot study wasdesigned around newly derived protocols and simulated training to determine if SAS is a safe and implementable pathway to improve patient outcomes and health economics. We assessed a cohort of 10 patients undergoing one-level lumbar discectomies and decompressions, analyzing the related costs, length of stay, complications, pain management, and patient satisfaction. The age range of our patients was 46-84years. Three discectomies and 7 central canal stenosis decompressions were performed. Eight patients were discharged on the same day. All patients gave positive feedback about their experience of SAS. A significant cost saving was made compared to a general anesthesia (GA) overnight stay across the group. No on day cancellations occurred due to lack of bed availability. No patient needed analgesia in the recovery room or needed additional analgesia over and above the SAS e-prescription take home package. Our early experience and journey reinforce our drive to push forward and expand on this process. It aligns with the international literature which highlights this approach as safe, efficient, and economical.

Ultrafast microwave heated form-stable thermal package providing operating temperature for PEO all-solid-state batteries

All-solid-state batteries (ASSBs) have been regarded as satisfying future energy storage devices owing to the advantages of notably high energy density and outstanding safety. However, their attainable energy density, especially in poly(ethylene oxide) (PEO)-based ASSBs, is limited by low operating ambient temperature due to sluggish lithium-ion transport of solid electrolyte. Herein, a functional anti-leakage skeleton (alumina ceramic and boron nitride) with efficient graphene-modified phase change material (GPCM) and microwave thermal energy storage system is proposed for providing the operating temperature of ASSBs. The composite, prepared by alumina ceramic fiber, boron nitride, and GPCM, presenting excellent thermal properties such as great enhancement of thermal conductivity (64.6%) and low enthalpy loss (11.27%). The superior thermal effect is confirmed by experiments and simulations of microwave absorption. Through microwave irradiating the ASSBs wrapped with the composite, ASSBs can realize cold-starting in 1 min from room temperature in a fast, safe and low-power heating pathway. Significantly, the combination of multi-scale characteristics in graphene increases the thermal energy generated by the composite during microwave processing. Furthermore, the composite material (GPBC), used as portable auxiliary heating equipment, enables the ASSB to exhibit 92% capacity of those ASSBs placed in 55 °C ovens at 1C. This work provides a distinctive route to achieve efficient and extensive applications of ASSBs through external preheating.

Remote limb ischemic postconditioning attenuates myocardial dysfunction induced by testicular torsion/detorsion in rats.

Torsion of the spermatic cord is a urological emergency that must be treated immediately with surgery, yet detorsion of the testis can cause testicular tissue damage because of ischemia‒reperfusion (I/R) injury. I/R injury is a complex pathophysiological process that may affect the functions of distant organs. Here, we examined whether testicular torsion/detorsion causes myocardial dysfunction. We next investigated the potential beneficial effect and underlying mechanisms of remote ischemic postconditioning (RIPost) on cardiac function after testicular torsion/detorsion. Male Sprague Dawley rats were assigned to three different sets of experimental groups. Testicular I/R was induced by rotating the right testis to 1080 degrees clockwise for 3 hours followed by 3 h of detorsion. RIPost was induced at the onset of testicular detorsion by four cycles of 5-min bilateral femoral artery occlusion with 5-min reperfusion. Cardiac function was determined postdetorsion, and the cardioprotective effect of RIPost was examined. Testicular torsion/detorsion-treated rats had reduced serum testosterone levels, impaired systemic hemodynamics, elevated systemic inflammatory responses and increased serum levels of LDH, CK-MB, α-HBDH and cTnI. Healthy rats transfused with testicular torsion/detorsion-treated plasma presented impaired cardiac function. However, RIPost attenuated remote heart dysfunction induced by testicular torsion/detorsion. Furthermore, RIPost enhanced the phosphorylation of ventricular STAT-3, which is a key component of the SAFE signaling pathways. Inhibition of STAT-3 with Ag490 abolished the RIPost-induced cardioprotection and STAT-3 phosphorylation. Testicular torsion followed by detorsion resulted in impairment of cardiac function. RIPost effectively attenuates this remote cardiac dysfunction. RIPost-induced protective effects may be mediated by the STAT-3 signaling pathway.

Percutaneous vacuum-assisted excision (VAE) of breast lesions of uncertain malignant potential (B3 lesions): a preliminary single-centre Italian experience.

In recent years vacuum-assisted excision (VAE) has been described as an alternative treatment for some B3 lesions. This study aims to assess the effectiveness of using VAE to manage selected B3 lesions by quantifying the number of B3 lesions undergoing VAE, the malignant upgrade rate, and the complications encountered. Our department evaluated all B3 lesions diagnosed between January 2019 and October 2021 and treated them with VAE. The data were collected during the initial biopsy and final histology based on VAE image guidance, also considering initial lesions and complications. The exclusion criteria were: B3 lesion of size > 20mm, presence of a concomitant malignant lesion, lesion < 5.0mm distant from the skin, nipple or pectoral muscle, phyllodes tumours or indeterminate B3 lesions. Lesions that upgraded to malignancy underwent surgical excision, while benign lesions performed radiological follow-ups. From 416 B3 lesions diagnosed, 67 (16.1%) underwent VAE. VAE was performed under X-ray (50/67) or ultrasound guidance (17/67). Five cases (7.5%) upgraded to a malignant lesion, 2 ADH, 2 LIN and one papillary lesion that underwent surgery. No malignancy or new lesions has occurred at the site of the VAE, with an average radiological follow-up of 14.9months. VAE could be a safe and effective pathway for managing selected B3 lesions. Lesions initially subjected to CNB with ADH and LN outcome, before undergoing VAE, should perform a VAB for better tissue characterization and management.

High-density electroanatomic activation mapping to guide slow pathway modification in patients with persistent left superior vena cava

Slow pathway (SP) mapping and modification can be challenging in patients with persistent left superior vena cava (PLSVC) due to anatomic variance of the Koch triangle (KT) and coronary sinus (CS) dilation. Studies using detailed 3-dimensional (3D) electroanatomic mapping (EAM) to investigate conduction characteristics and guide ablation targets in this condition are lacking. The purpose of this study was to describe a novel technique of SP mapping and ablation in sinus rhythm using 3D EAM in patients with PLSVC after validation in a cohort with normal CS anatomy. Seven patients with PLSVC and dual atrioventricular (AV) nodal physiology who underwent SP modification with the use of 3D EAM were included. Twenty-one normal heart patients with AV nodal reentrant tachycardias formed the validation group. High-resolution, ultra-high-density local activation timing mapping of the right atrial septum and proximal CS in sinus rhythm was performed. SP ablation targets were consistently identified by an area in the right atrial septum with the latest activation time and multicomponent atrial electrogram adjacent to a region with isochronal crowding (deceleration zone). In PLSVC patients, these targets were located at or within 1 cm of the midanterior CS ostium. Ablation in this area led to successful SP modification, reaching standard clinical endpoints with a median of 43 seconds of radiofrequency energy or 14 minutes of cryoablation without complications. High-resolution activation mapping of the KT in sinus rhythm can facilitate localization and safe SP ablation in patients with PLSVC.

CT Scan-Guided Fine Needle Aspiration Cytology for Lung Cancer Diagnosis through the COVID-19 Pandemic: What We Have Learned.

Novel coronavirus-related disease (COVID-19) has profoundly influenced hospital organization and structures worldwide. In Italy, the Lombardy Region, with almost 17% of the Italian population, rapidly became the most severely affected area since the pandemic beginning. The first and the following COVID-19 surges significantly affected lung cancer diagnosis and subsequent management. Much data have been already published regarding the therapeutic repercussions whereas very few reports have focused on the consequences of the pandemic on diagnostic procedures. We, here, would like to analyze data of novel lung cancer diagnosis performed in our Institution in Norther Italy where we faced the earliest and largest outbreaks of COVID-19 in Italy. We discuss, in detail, the strategies developed to perform biopsies and the safe pathways created in emergency settings to protect lung cancer patients in subsequent therapeutic phases. Quite unexpectedly, no significant differences emerged between cases enrolled during the pandemic and those before, and the two populations were homogeneous considering the composition and diagnostic and complication rates. By pointing out the role of multidisciplinarity in emergency contexts, these data will be of help in the future for designing tailored strategies to manage lung cancer in a real-life setting.

Enhanced recovery after colorectal surgery is a safe and effective pathway for older patients: a pooling up analysis

The current study aimed to explore the efficacy and safety of Enhanced Recovery after surgery (ERAS) in older patients undergoing colorectal surgery. Three databases including PubMed, Embase, Medline, and the Cochrane Library were used for searching eligible studies on Jun 8th,2022. To evaluate the effect of ERAS, we focused on the short-term outcomes including postoperative complications and recovery. Subgroup analysis was also conducted for patients undergoing colorectal cancer (CRC) surgery. All the data processing and analyses were carried out by Stata (V.16.0) software. Finally, there were fourteen studies involving 5961 patients enrolled in this study. As for surgical outcomes, we found that the older group had more overall complications (OR = 1.41, I2 = 36.59%, 95% CI = 1.20 to 1.65, P = 0.00), more obstruction (OR = 1.462, I2 = 0.00%, 95% CI = 1.037 to 2.061, P = 0.0304), more respiratory complications (OR = 1.721, I2 = 0.00%, 95% CI = 1.177 to 2.515, P = 0.0051), more cardiovascular complications (OR = 3.361, I2 = 57.72%, 95% CI = 1.072 to 10.542, P = 0.0377), more urinary complications (OR = 1.639, I2 = 37.63%, 95% CI = 1.168 to 2.299, P = 0.0043), less readmission (OR = 0.662, I2 = 44.48%, 95% CI = 0.484 to 0.906, P = 0.0100), higher mortality (OR = 0.662, I2 = 44.48%, 95% CI = 0.484 to 0.906, P = 0.0100), and longer overall survival (OS) (HR = 1.21, I2 = 0.00%, 95% CI = 0.566 to 1.859, P = 0.0002)). Subgroup analysis also found that older CRC patients had a higher risk of overall complications (OR = 1.37, I2 = 37.51%, 95% CI = 1.06 to 1.78, P < 0.05). Although ERAS could accelerate postoperative recovery and reduce postoperative complications, older patients who received ERAS still had higher complication incidence than younger patients. Although the proportion of re-hospitalizations was lower and the OS was better, doctors could not rely too much on ERAS. More measures were needed to improve the outcomes of colorectal surgery in older patients.

Mitigating the impacts of racism on Indigenous wellbeing through human rights, legislative and health policy reform.

Mitigating the impacts of racism on Indigenous wellbeing through human rights, legislative and health policy reform.

Ambulatory vascular clinics provide a safe and effective pathway for management of chronic limb threatening ischaemia

Introduction: The management of chronic limb threatening ischaemia (CLTI) has changed rapidly over recent years. The outcomes of lower limb revascularisation, despite improvements since centralisation, remain poor. Ambulatory emergency care has emerged in several surgical subspecialties as the optimal pathway to ensure timely access to specialist services whilst avoiding unnecessary urgent hospital admission and lengthy inpatient stays. This study aims to describe the outcomes of such a service for those with CLTI. Methods: This study includes all patients with suspected CLTI presenting to the Guy’s and St Thomas’ (GSTT) Emergency Vascular Clinic (EVC) between 31 July 2017 and 19 April 2021. Demographic, clinical and admission data were gathered from a prospectively maintained database. Operative details, in hospital and mid-term outcomes were gathered retrospectively from electronic hospital records. Frailty data were calculated using the Edmonton Frailty Scoring (EFS) System. Results: There were 799 encounters at the EVC for suspected CLTI. 375 (46.9%) of these encounters resulted in a confirmed diagnosis of CLTI and admission, either the same day as an emergency (187 (23.4%)) or as a planned urgent admission (188 (23.5%)). Time from referral to EVC review was a median of 1 day (interquartile range (IQR) 1–3 days) and median time from EVC review to revascularisation or amputation (in cases where this was the primary treatment strategy) was 8 days (IQR 4–16 days). Median time to admission was 1 day (IQR 0–13 days and length of stay was a median of 7 days (IQR 2–15 days). Amputation-free survival (AFS) from the first patient encounter (with presentations for each leg taken separately) was 95% at one month and 78% at one year. Overall survival was 98% at one month and 84% at one year. Frailty was significantly associated with mortality (p=0.03), but not AFS (p=0.085). Conclusion: These data suggest that an EVC pathway provides a safe method of treating CLTI with minimal delays to urgent planned admission, revascularisation and AFS, in keeping with nationally reported data.