Patient-reported outcomes 6 months after enhanced recovery after colorectal surgery.

BackgroundEnhanced recovery after surgery (ERAS) programs have been established as perioperative strategies associated with improved outcomes. However, intermediate and long-term patient-reported outcome data for patients undergoing ERAS interventions remain limited. We utilized an automated telephone survey 6 months post-colorectal surgery from patients who participated in an ERAS program to determine 6-month patient-reported outcomes and associated predictive factors.MethodsWe conducted a prospective observational study, using an automated telephone survey and researcher-administered telephone questionnaire 6 months after patients underwent abdominal colorectal surgery. Six-month significant outcomes were defined by persistent pain, hospital readmission, and patient satisfaction. Patients reporting these outcome variables were compared with patients who met none of these criteria. Additionally, analysis was performed to determine differences between patients that did and did not respond to the 6-month survey. A chi-square test was used to determine any relationship for categorical variables, a two independent sample t test for length of procedure/stay, and a Wilcoxon-Mann-Whitney test for pain scores.ResultsOne hundred fifty-four of 324 patients contacted 6 months after surgery completed the automated telephone survey (47.53%). There was no statistical difference between patient populations completing and not completing the survey. Hospital 6-month readmission was associated with patients with a diagnosis of cancer (P = .049) and with a longer mean length of index procedure (282 vs. 206 minutes, P = .006). Median 6-month pain scores were higher for patients that underwent an open procedure compared to laparoscopic (Z = - 2.06, P = .04).ConclusionsLong-term benefits of an ERAS program were mostly confirmed. Longer procedure time and patients with cancer correlated with an increased likelihood of hospital 6-month readmission, suggesting that perioperative outcomes in complex cancer patients need to be evaluated over a longer time frame. In addition, invasiveness of procedure continues to have a significant effect on pain scores even 6 months later

Is incident rheumatoid arthritis interstitial lung disease associated with methotrexate treatment? Results from a multivariate analysis in the ERAS and ERAN inception cohorts

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.Objectives To assess predictive factors for rheumatoid arthritis interstitial lung disease (RA-ILD) in two early RA inception cohorts with a focus on methotrexate (MTX) exposure. Design Multicenter prospective early RA inception cohort studies; the early RA study (ERAS) and the early RA network (ERAN) Setting Secondary care, ERAS 9 centers, ERAN 23 centers in England, Wales and the Republic of Ireland Participants Patients with new diagnosis of RA, n=2701.Standardised data including demographics, drug therapies and clinical outcomes including the presence of RA-ILD were collected at baseline, within 3- 6 months, at 12 months and annually thereafter. Primary and secondary outcome measures Primary outcome was the association of MTX exposure on RA-ILD diagnosis. Secondary outcomes were the association of demographic, comorbid and RA specific factors on RA-ILD diagnosis and the association of MTX exposure on time to RA-ILD diagnosis. Results Of 92 eligible ILD cases, 39 occurred in 1578 (2.5%) MTX exposed and 53 in 1114 (4.8%) non-MTX exposed cases. The primary analysis of RA-ILD cases only developing after any csDMARD treatment (n=67) showed MTX exposure not to be associated with incident RA-ILD (O.R. 0.85 CI 0.49, 1.49 p=0.578) and a non-significant trend for delayed ILD diagnosis (O.R. 0.54 CI 0.28, 1.06 p=0.072). In an extended analysis including RA-ILD cases present at RA diagnosis (n=92), MTX exposure was associated with a significantly reduced risk of incident RA-ILD (O.R. 0.48, CI 0.3, 0.79 p=0.004) and longer time to ILD diagnosis (O.R. 0.41, CI 0.23, 0.75 p=0.004). Other independent baseline associations with incident RA-ILD were higher age of RA onset, ever smoking, male gender, rheumatoid nodules and longer time from first RA symptom to first out-patient visit. Conclusions MTX treatment was not associated with an increased risk of RA-ILD diagnosis. On the contrary evidence suggested that MTX may delay the onset of ILD.Peer reviewe

Does Preoperative Ostomy Education Decrease Anxiety in the New Ostomy Patient?

Background: There are approximately 100,000 patients with new ileostomies and colostomies created in the United States each year. These patients have specialized needs that include acceptance of altered body image, psychological stress, learning of difficult tasks, and occasionally an ominous diagnosis leading to the need for surgery. In addition to pre-surgical stoma site marking on the abdomen, ostomy nurses have identified early education to be an important factor in long-term success and management of the patient . Early education and stoma site marking may assist with a better-situated stoma leading to fewer complications related to appliance adherence and leakage. New ostomy patients that are well prepared may be able to adapt to the new body image and are more successful in management following ostomy surgery. Problem: Psychologists and sociologists have identified a link between anxiety levels and memory. Anxiety can affect learning by interfering with the attention process of the brain. This interference can hinder the ability of ostomy patients to effectively listen, learn, and perform ostomy care for themselves which places an increased demand on family, caregivers, and home health nurses. Pre-surgical education may offer reduced anxiety levels in post-operative patients, which may provide an improved environment for learning. Methods: Participants considered for study inclusion were those scheduled for ostomy surgery. Patients in Group 1 were provided with pre-surgical ostomy education and routine pre-surgical education, whereas patients in Group 2 were provided with routine pre-operative education only. The Hospital Anxiety and Depression Scoring tool (HADS) was administered during the post- operative period. The surveys were administered by a certified wound, ostomy, continence nurse practitioner. Analysis of Variance (ANOVA) was used to compare changes in anxiety scores between the two groups. Results: Of the 30 participants in the study, 22 were male (73.3%) and 8 were female (26.7%). The mean age was 65.27 ± 9.97 for Group 1 and 61.87 ± 17.56 for group 2. This difference was not statistically significant (p\u3e0.05). Both groups had an equal number of males (n=11) and females (n=4). Group 1 consisted of 9 colostomy patients, 4 ileostomy patients, and 2 urostomy patients. Group 2 consisted of 10 colostomy patients, 4 ileostomy patients and 1 urostomy patient. Patients who had pre-surgical ostomy education had statistically significant lower post surgical anxiety scores than patients who had standard education (p\u3c0.001). Conclusions: The findings of this study suggest that offering pre-operative ostomy education in addition to routine pre-operative education, significantly lowers anxiety when compared with patients who do not receive the pre-operative ostomy education

Diminishing Use of Liver Biopsy among Liver Transplant Recipients for Hepatitis C.

Background and Aims: Hepatitis C virus (HCV) cirrhosis is the leading indication for liver transplantation in the United States and recurrent HCV following liver transplantation is a major cause of allograft loss and mortality. Liver biopsies are commonly used to identify recurrent HCV and determine the need for antiviral therapy. The introduction of direct-acting antiviral agents (DAAs) has changed the management of recurrent HCV infection. This study aimed to describe the role of liver biopsies in liver transplant recipients with HCV after the introduction of DAAs. Methods: A retrospective analysis was performed looking at the rate of liver biopsies post-liver transplantation for HCV. The analysis included 475 adult liver transplants for hepatitis C performed at the University of California, Los Angeles from January 1, 2006 to October 1, 2015. Patients were divided into two eras, pre- and post-introduction of DAAs on December 1, 2013. Results: In the era before the introduction of DAAs, the percentage of patients biopsied was significantly higher compared to the era after the introduction of DAAs (56.1% vs. 26.9%, p < 0.001). Conclusions: The introduction of DAAs has changed the management of liver biopsy following liver transplantation and the management of recurrent HCV. Given that DAAs are well tolerated and have high efficacy, liver biopsies are no longer routinely used to justify the use antiviral therapy following liver transplantation

The Design, Construction and Commissioning of a Small Scale Dynamic Calibrated Hot Box (CHB)

Sustainable construction and in particular the sustainability of materials is a global issue with legislation on material properties and product performance at the forefront. In traditional constructed buildings however, it can be extremely challenging to get accurate data on performance. The variability of building materials design, manufacture and construction from different eras is substantial, even within local areas due to the vernacular nature of construction from these periods. Material properties testing can be expensive and is not always readily available when required and is therefore often ignored, particularly in the retrofitting of historic buildings. This can have major adverse effects on the building fabric and for its inhabitant’s health if the appropriate material interventions are not chosen. An inexpensive environmental chamber for testing such materials has been designed and built at the Dublin Institute of Technology, (DIT) Ireland, adopting comparable standards from EN ISO 8990 and ASTM C1363. This paper describes the design requirements for the construction of an affordable and mobile calibrated hot box (CHB) for the testing of historic materials. A characterisation panel has been used to carry out early calibration testing and the results of this are discussed. Improvements and tweaking of the first test are also discussed

Risk stratification by pre-operative cardiopulmonary exercise testing improves outcomes following elective abdominal aortic aneurysm surgery : a cohort study

Background: In 2009, the NHS evidence adoption center and National Institute for Health and Care Excellence (NICE) published a review of the use of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). They recommended the development of a risk-assessment tool to help identify AAA patients with greater or lesser risk of operative mortality and to contribute to mortality prediction. A low anaerobic threshold (AT), which is a reliable, objective measure of pre-operative cardiorespiratory fitness, as determined by pre-operative cardiopulmonary exercise testing (CPET) is associated with poor surgical outcomes for major abdominal surgery. We aimed to assess the impact of a CPET-based risk-stratification strategy upon perioperative mortality, length of stay and non-operative costs for elective (open and endovascular) infra-renal AAA patients. Methods: A retrospective cohort study was undertaken. Pre-operative CPET-based selection for elective surgical intervention was introduced in 2007. An anonymized cohort of 230 consecutive infra-renal AAA patients (2007 to 2011) was studied. A historical control group of 128 consecutive infra-renal AAA patients (2003 to 2007) was identified for comparison. Comparative analysis of demographic and outcome data for CPET-pass (AT ≥ 11 ml/kg/min), CPET-fail (AT < 11 ml/kg/min) and CPET-submaximal (no AT generated) subgroups with control subjects was performed. Primary outcomes included 30-day mortality, survival and length of stay (LOS); secondary outcomes were non-operative inpatient costs. Results: Of 230 subjects, 188 underwent CPET: CPET-pass n = 131, CPET-fail n = 35 and CPET-submaximal n = 22. When compared to the controls, CPET-pass patients exhibited reduced median total LOS (10 vs 13 days for open surgery, n = 74, P < 0.01 and 4 vs 6 days for EVAR, n = 29, P < 0.05), intensive therapy unit requirement (3 vs 4 days for open repair only, P < 0.001), non-operative costs (£5,387 vs £9,634 for open repair, P < 0.001) and perioperative mortality (2.7% vs 12.6% (odds ratio: 0.19) for open repair only, P < 0.05). CPET-stratified (open/endovascular) patients exhibited a mid-term survival benefit (P < 0.05). Conclusion: In this retrospective cohort study, a pre-operative AT > 11 ml/kg/min was associated with reduced perioperative mortality (open cases only), LOS, survival and inpatient costs (open and endovascular repair) for elective infra-renal AAA surgery

Collaborative Academic Library Digital Collections Post- Cambridge University Press, HathiTrust and Google Decisions on Fair Use

Academic libraries face numerous stressors as they seek to meet the needs of their users through technological advances while adhering to copyright laws. This paper seeks to explore one specific proposal to balance these interests, the impact of recent decisions on its viability, and the copyright challenges that remain after these decisions

The Economics of a Centralized Judiciary: Uniformity, Forum Shopping and the Federal Circuit

In 1982, the US Congress established the Court of Appeals for the Federal Circuit (CAFC) as the sole appellate court for patent cases. Ostensibly, this court was created to eliminate inconsistencies in the application and interpretation of patent law across federal courts, and thereby mitigate the incentives of patentees and alleged infringers to "forum shop" for a preferred venue. We perform the first econometric study of the extent of non-uniformity and forum shopping in the pre-CAFC era and of the CAFC's impact on these phenomena. We find that in patentee-plaintiff cases the pre-CAFC era was indeed characterized by significant non-uniformity in patent validity rates across circuits and by forum shopping on the basis of validity rates. We find weak evidence that the CAFC has increased uniformity of validity rates and strong evidence that forum shopping on the basis of validity rates ceased several years prior to the CAFC's establishment. In patentee-defendant cases, we find that validity rates are lower on average, but do not find either significant non-uniformity of validity rates across circuits or significant forum shopping.

Retirement and Household Expenditure in Turbulent Times

We examine the impact of own and spousal retirement on household expenditure during a period of financial deterioration. We use detailed household data covering the period 2009-2016 in Greece, during which the country experienced a severe financial crisis that affected retirees in ways that were not anticipated. Similar to Moreau and Stancanelli (2015) our empirical strategy allows for the household expenditure to depend on both own and spousal retirement status. We employ an instrumental variable identification strategy by exploiting variation coming from the early retirement age threshold. Our Two-Stage Least Squares estimates show that, even after controlling for income, total expenditure drops significantly when the husband retires and as he becomes older. The reduction is stronger in 2010, when the first wave of austerity plans, including measures affecting pensioners were announced, and after 2014 when horizontal pension cuts were implemented. Expenditure does not change significantly when the wife retires neither the older she gets. A drop-in expenditure for clothing, transport, housing and communication drives the overall reduction in expenditure. Overall, our results can have significant policy implications in the design of structural pension reforms in a period of financial hardship