Quality Indicators in Ambulatory Surgery: A Literature Review Comparing Portuguese and International Systems

Introduction: According to several studies conducted in North America and Europe, ambulatory surgery is a practice that has grown over the years, and both the number of more complex surgical procedures deemed suitable for ambulatory surgery and the number of patients with different co-morbidities which are now suitable for this type of procedure have been increasing. In order to respond to the increased number of day surgeries, as well as to avoid a potential proportional increase in perioperative morbidity, quality control systems must be adopted to enable continuous improvement and minimise predicted risks. The purpose of this study is to review global quality indicators used in ambulatory surgery and compare them with those used in Portugal. Material and Methods: The authors conducted a comprehensive search of medical databases, using MeSH words. Limits were applied to include only studies published after 1998 written in Portuguese, English and Spanish. Ambulatory surgery indicators for Portugal were also obtained. Results: Twenty-one different quality indicators for ambulatory surgery were identified. The Portuguese Healthcare Regulation Authority has defined seven quality indicators for ambulatory surgery. Discussion: The Portuguese quality indicators for ambulatory surgery are generally well adapted to current international practices. Nevertheless, after analysing the relevant international literature based on this study, it is important to consider two additional indicators for ambulatory surgery – same day surgery cancellations and patient satisfaction. Conclusion: On the literature review, same day surgery cancellations and patient satisfaction should be included in the National Health Assessment System created by the Portuguese Healthcare Regulation Authority

TOWARDS THE DEVELOPMENT OF SKILLS IN MEDICAL EDUCATION: "THE VIRTUAL QUIZ IDENTIFICATION STATION"

In 2007, the teaching staff of Clinical Anatomy of the Faculty of Medicine of the University of Porto (FMUP) and the Office of Support for New Technologies in Education of the University of Porto (UP), engaged in a project of building a virtual tool that could allow students to practice and develop identification skills of anatomic structures, in the computer. Later, this "Virtual Quiz" was to be integrated in the learning management system of UP-WebCT VISTA. The purpose of the virtual tool is to allow a specific imaging and sectional anatomy training, aiming to improve both active learning and skills for practical identification of anatomical structures, being this last procedure of great impact to medical students. The e-learning tool was available to the students attending Clinical Anatomy (2nd year/2nd semester), starting the 2007/08 academic year. This Curricular Unit is of most relevance in medical curricula, since it allows to develop "critical anatomical reasoning", known as crucial to the acquisition of "clinical reasoning".The "Virtual Quiz" is based on an animation built in Adobe Flash, which loads randomly 40 images of a total of 2500. Each image is linked to a respective correct answer. Each set of 2 images is to be answered in a minute, in the end of which a sonorous sign is heard, with automatic advancement of the page for the following set. After viewing and identifying the 40 images the final result is displayed. The student has the possibility to review the image with the correct answer, as well as his/her own response. This tool is exported to a SCORM package and the final grade is transposed to the Learning Management System, which allows the faculty to have individualized student's information. The "Virtual Quiz" is a tool that can work dissociated from a LMS and can be used online and offline.A statistical analysis was performed correlating the use of the "Virtual Quiz" and the performance achieved at the assessment proofs. It was demonstrated that students using the "Virtual Quiz" have significant better performance at the identification of anatomical structures in the "real" situation of examination.This work demonstrates the adequacy and importance of developing new tools - directed to real situations and within the context of teaching/learning situations. If we link these important issues to the demonstrated improvement of academic performance, this makes this tool an important resource in the teaching/learning programs. Besides, it is extremely flexible to be used in other learning contexts. A specific version of this tool is now to be transferred as a tool for skills training transfer in a University Network created under the scope of EDULINK Project "A NAME for Health", with the involvement of FMUP, Faculty of Medicine of the University Agostinho Neto, Luanda and Faculty of Medicine of University Eduardo Mondlane an University Lúrio, in Mozambique. (supported by EDULINK -contract nº 9-ACP-RPR-118 #29

"VIRTUAL QUIZ": A TOOL FOR ACTIVE LEARNING AND ASSESSMENT IN CLINICAL ANATOMY

Clinical Anatomy, introduced in different medical curricula around the world, is considered of relevance for future physicians, since it allows the integration of anatomical knowledge with clinical activity developed by health professionals. Besides helping to develop the essential "critical anatomical reasoning" identified as crucial to the acquisition of "clinical reasoning", this area of knowledge contributes to the translation between the basic and the clinical areas in Medical Education.In 2007 the teacher's group of Clinical Anatomy of the Faculty of Medicine of Universidade do Porto (FMUP) and the Office of Support for New Technologies in Education engaged in a project of building a virtual tool that could allow the students to practice the identification skills of anatomic structures in the computer. Later, this "Virtual Quizz" was to be integrated in the e-learning management system of the University.And so, this e-learning tool was available to the students attending Clinical Anatomy (2nd year/2nd semester), during the 2007/08 academic year.The purpose of the virtual tool is to permit a specific imaging and sectional anatomy training that allows improving both active learning and training for practical assessment of identification of anatomical structures, being this last procedure of great impact to medical students.Technically, the "Virtual Quiz" is based on an animation built in Adobe Flash 8 that loads, randomly, 40 images of a total of 2500. To each one of these images there is the respective correct answer. The student has a minute to answer each group of 2 images, in the end of which a sonorous sign is heard (similar to what students listen during their "real" practical examination), with automatic advancement of the page for the following group. After viewing and identifying the 40 images the final result is shown, being possible for the student to review the image with the correct answer as well as his/her own response. As this tool is exported to a SCORM package, the final grade is transposed to the Learning Management System, which allows the teachers to have individualized information. The "Virtual Quiz" is a tool that can work dissociated from a LMS and can be used online and offline.A statistical analysis was performed correlating the use of the "Virtual Quiz" and the performance achieved at the assessment proofs. It was demonstrated that students using the "Virtual Quiz" have significant better performance at the identification of anatomical structures in the "real" situation of examination.This work demonstrates the adequacy and importance of developing new tools - directed to real situations and within the context of teaching/learning situations - even in a field where a huge offer of materials is available. The "Virtual Quiz" is shown to be an important tool as referred by the students, who consider its value as far active learning is promoted, and feed-back is quickly available. Besides, it is extremely flexible to be used in other learning contexts and also to be offered to Master and PhD programs that include identification of anatomical structures. If we link these important issues to the proved correlation with improvement of academic performance, this makes this tool an important resource in the teaching/learning programs of gross morphology in the Medical Course

Angiomiolipoma duodenal

Angiomyolipoma is a rare benign mesenchymal tumor. Usually located in the kidney, with an incidence of 0.3-3%. Extra-renal angiomyolipomas are extremely rare, with not much more than fifty cases having been described. We report a case of a healthy 50 year-old man, who presented with episodes of melena. Routine blood tests showed a hypochromic and microcytic anemia. An endoscopy showed an extrinsic lesion compressing the transition of the gastric body and antrum. A CT-scan of the abdomen revealed an intraluminal pedunculated tumor that originated in the third part of the duodenum and extended to the Treitz region. The patient underwent to a laparotomy with duodenotomy and excision of the pedunculated tumor. Histopathological examination revealed an angiomyolipoma. There appears to be only one previous report of duodenal angiomyolipoma in the literature. Keywords: Angiomyolipoma; duodenum; mesenchymal tumor Os angiomiolipomas são tumores mesenquimatosos benignos raros. Atingem preferencialmente o rim, com uma incidência entre 0,3-3%. A sua localização extra-renal é extremamente rara, havendo pouco mais de 50 casos descritos. Os autores apresentam um caso clínico de um homem de 50 anos de idade, previamente saudável, que recorreu ao seu médico assistente por melenas. Analiticamente apresentava anemia hipocrómica e microcítica. A Endoscopia Digestiva Alta (EDA) mostrou uma área de compressão extrínseca na transição do corpo para o antro gástrico. A TAC efectuada revelou uma lesão pediculada que se iniciava na terceira porção do duodeno e se estendia até à região do ângulo de Treitz. Foi realizada laparotomia exploradora e exérese de um tumor pediculado dependente da parede livre da 3a porção do duodeno. O exame histológico identificou um angiomiolipoma submucoso do duodeno. Na revisão da literatura, encontrou-se apenas um caso de angiomiolipoma duodenal. Palavras-chave: Angiomiolipoma; duodeno; tumor mesenquimatoso

Saturated fatty acid-enriched small extracellular vesicles mediate a crosstalk inducing liver inflammation and hepatocyte insulin resistance

[Background & Aims]: Lipotoxicity triggers non-alcoholic fatty liver disease (NAFLD) progression owing to the accumulation of toxic lipids in hepatocytes including saturated fatty acids (SFAs), which activate pro-inflammatory pathways. We investigated the impact of hepatocyte- or circulating-derived small extracellular vesicles (sEV) secreted under NAFLD conditions on liver inflammation and hepatocyte insulin signalling. [Methods]: sEV released by primary mouse hepatocytes, characterised and analysed by lipidomics, were added to mouse macrophages/Kupffer cells (KC) to monitor internalisation and inflammatory responses. Insulin signalling was analysed in hepatocytes exposed to conditioned media from sEV-loaded macrophages/KC. Mice were i.v. injected sEV to study liver inflammation and insulin signalling. Circulating sEV from mice and humans with NAFLD were used to evaluate macrophage–hepatocyte crosstalk. [Results]: Numbers of sEV released by hepatocytes increased under NAFLD conditions. Lipotoxic sEV were internalised by macrophages through the endosomal pathway and induced pro-inflammatory responses that were ameliorated by pharmacological inhibition or deletion of Toll-like receptor-4 (TLR4). Hepatocyte insulin signalling was impaired upon treatment with conditioned media from macrophages/KC loaded with lipotoxic sEV. Both hepatocyte-released lipotoxic sEV and the recipient macrophages/KC were enriched in palmitic (C16:0) and stearic (C18:0) SFAs, well-known TLR4 activators. Upon injection, lipotoxic sEV rapidly reached KC, triggering a pro-inflammatory response in the liver monitored by Jun N-terminal kinase (JNK) phosphorylation, NF-κB nuclear translocation, pro-inflammatory cytokine expression, and infiltration of immune cells into the liver parenchyma. sEV-mediated liver inflammation was attenuated by pharmacological inhibition or deletion of TLR4 in myeloid cells. Macrophage inflammation and subsequent hepatocyte insulin resistance were also induced by circulating sEV from mice and humans with NAFLD. [Conclusions]: We identified hepatocyte-derived sEV as SFA transporters targeting macrophages/KC and activating a TLR4-mediated pro-inflammatory response enough to induce hepatocyte insulin resistance.This work was supported by grants PID2021-122766OB-I00 (AMV), PID2019-105989RB-I00 (JB), PID2020-113238RB-I00 (LB), PID2019-106581RB-I00 (MAM), PID2020-114148RB-I00 (MI), PID2019-107036RB-I00 (RF), and RD21/0006/0001 (ISCIII) (IL) funded by Ministerio de Ciencia e Innovación/Agencia Estatal de Investigación/10.13039/501100011033 and ERDF ‘A way of making Europe’ by the European Union (MICINN/AEI/FEDER, EU), grant EFSD/Boehringer Ingelheim European Research Programme on ‘Multi-System Challenges in Diabetes’ from the European Foundation for the Study of Diabetes (AMV), P2022/BMD-7227 (Comunidad de Madrid, Spain) (AMV), Fundación Ramón Areces (Spain) (AMV), CIBERdem (AMV and JB), CIBERhed (RF), and CIBERcv (LB) (ISCIII, Spain). LB and AMV belong to the Spanish National Research Council’s (CSIC’s) Cancer Hub. We also acknowledge the Spanish Ministry of Economy and Competitiveness (MINECO) postdoctoral contract IJCI-2015-24758 to IGM and the Spanish Ministry of Education, Culture and Sport (MECD) FPU17/02786 grant to RA

Cancellation on the Day of Surgery in an Ambulatory Setting Due to Patient Factors: A Preliminary Study

info:eu-repo/semantics/publishedVersio

SINAS: Impacto na Melhoria da Qualidade em Cirurgia de Ambulatório num Centro Integrado de Cirurgia Ambulatório

Introduction: The National Health Assessment System is a system designed by the Portuguese Health Regulatory Entity in order to evaluate the overall quality of the health care institutions. One of the key areas evaluated by the National Health Assessment System is ambulatory surgery. The aim of this study is to demonstrate that the introduction of the National Health Assessment System evaluation at our ambulatory centre not only improved the overall quality of ambulatory surgery but also the quality of the clinical record entries. Material and methods: A retrospective analysis was performed from the hospital's clinical database. The study was carried out at the ambulatory centre of the Hospital and University Centre of Porto, and included 100 consecutive surgical procedures, across all surgical specialties, previously selected by the National Health Assessment System audit performed in 2015 in our ambulatory surgery centre and other 46 surgical procedures performed in 2008 at our hospital, before the National Health Assessment System was implemented. The main outcome measure was the validation and record of the seven indicators of National Health Assessment System for ambulatory surgery. Results: We have seen an improvement in all indicators after the National Health Assessment System implementation, except for criterion 4. Discussion: Our study demonstrates that the introduction of the National Health Assessment System in our ambulatory centre resulted in the improvement in the quality of both of clinical practice, and clinical record keepingConclusion: We can conclude that the application of evaluation of quality indicators and benchmarking practices can be used to enhance healthcare outcomes.info:eu-repo/semantics/publishedVersio

3% polidocanol foam sclerotherapy versus hemorrhoidal artery ligation with recto anal repair in hemorrhoidal disease grades II-III: a randomized, pilot trial

Purpose: Polidocanol foam sclerotherapy (SP) versus doppler-guided hemorrhoidal artery ligation with recto-anal repair (HAL-RAR) in the treatment of hemorrhoidal disease (HD) was analyzed. Methods: A prospective, randomized study including patients with HD grades II and III was performed. Participants were randomly assigned (1:1) into SP or HAL-RAR, during a recruitment period between September 2019 and February 2020. Therapeutic success (Sodergren's and bleeding scores) was the primary outcome. Other outcomes evaluated included complications and implication in the professional life. Efficacy and safety outcomes were evaluated during the 8 weeks after surgery or the final SP session. Results: Forty-six patients were allocated either to SP (n=22) or HAL-RAR (n=24). Most patients achieved therapeutic success (SP 100% vs. HAL-RAR 90.9%, p=0.131). Complete success was higher in the SP group (91.7% vs. 68.2%, p=0.045) and SP patients had less complications (25% vs. 68.2%, p=0.003). HAL-RAR had a greater negative impact on work activity of the patient. Conclusion: SP was more effective and safer than HAL-RAR. SP patients had less impact on their work activity. Clinical trials identifier NCT04675177.info:eu-repo/semantics/publishedVersio

Re-education of tumor associated macrophages by trabectedin

Resumen del trabajo presentado al 63rd Annual Meeting Biophysical Society, celebrado en Baltimore, Maryland (USA) del 2 al 6 de marzo de 2019.Immune cells have an important role in the tumor-microenvironment. Macrophages may tune the immune response toward inflammatory or tolerance pathways. Tumor associated macrophages (TAM) have immunosuppressive functions and they are considered a therapeutic target in cancer. The aim of this study was to evaluate the effects of trabectedin, a new class of antitumor agent, on the tumor-microenvironment through the study of electrophysiological and molecular phenotype of macrophages. Experiments were performed using the whole-cell configuration of the patch-clamp technique in resident peritoneal mouse macrophages under different types of polarization. Trabectedin decreased macrophage viability and increased ROS production. Trabectedin does not directly interact with KV1.5 and KV1.3 channels, but treatment (16 h) of macrophages with sub-cytotoxic concentrations (0.1-5 nM) increased their KV current in a concentration-dependent manner due to an upregulation of KV1.3 channels. In vitro generated TAM (TAMiv), by a co-culture of ID8 cells and macrophages, exhibited a M2 phenotype. TAMiv generated a small KV current, similarly to M2 polarized macrophages, and expressed high levels of M2 markers. In this study, we demonstrated that TAMiv polarization could be re-educated by using sub-cytotoxic concentration of trabectedin. TAMiv treated with sub-cytotoxic concentration of trabectedin exhibited an upregulation of KV1.3 channels and their M2 phenotype changed towards M1 pro-inflammatory one.Funded by PharmaMar, CSIC 201820E104, CIBERCV and SAF2016-75021-R.Peer Reviewe

Trabectedin modulates macrophage polarization in the tumor-microenvironment. Role of KV1.3 and KV1.5 channels

Immune cells have an important role in the tumor-microenvironment. Macrophages may tune the immune response toward inflammatory or tolerance pathways. Tumor-associated macrophages (TAM) have a string of immunosuppressive functions and they are considered a therapeutic target in cancer. This study aimed to analyze the effects of trabectedin, an antitumor agent, on the tumor-microenvironment through the characterization of the electrophysiological and molecular phenotype of macrophages. Experiments were performed using the whole-cell configuration of the patch-clamp technique in resident peritoneal mouse macrophages. Trabectedin does not directly interact with KV1.5 and KV1.3 channels, but their treatment (16 h) with sub-cytotoxic concentrations of trabectedin increased their KV current due to an upregulation of KV1.3 channels. In vitro generated TAM (TAMiv) exhibited an M2-like phenotype. TAMiv generated a small KV current and express high levels of M2 markers. K+ current from TAMs isolated from tumors generated in mice is a mixture of KV and KCa, and in TAM isolated from tumors generated in trabectedin-treated mice, the current is mostly driven by KCa. We conclude that the antitumor capacity of trabectedin is not only due to its effects on tumor cells, but also to the modulation of the tumor microenvironment, due, at least in part, to the modulation of the expression of different macrophage ion channels