Post-surgery length of stay using multi-criteria decision-making tool

Purpose Length of stay (LOS) in hospital after surgery varies for each patient depending on surgeon’s decision that considers criticality of the surgery, patient’s conditions before and after surgery, expected time to recovery and experience of the surgeon involved. Decision on patients’ LOS at hospital post-surgery affects overall healthcare performance as it affects both cost and quality of care. The purpose of this paper is to develop a model for deriving the most appropriate LOS after surgical interventions. Design/methodology/approach The study adopts an action research involving multiple stakeholders (surgeon, patients/patients’ relatives, hospital management and other medics). First, a conceptual model is developed using literature and experts’ opinion. Second, the model is applied in three surgical interventions in a public hospital in Malta to demonstrate the effectiveness of the model. Third, the policy alternatives developed are compared to a selection of current international standards for each surgical intervention. The proposed model analyses three LOS threshold policies for three procedures using efficiency and responsiveness criteria. The entire analysis is carried out using 325 randomly selected patient files along with structured interactions with more than 50 stakeholders (surgeon, patients/patients’ relatives, hospital management and other medics). A multiple criteria decision-making method is deployed for model building and data analysis. The method involves combining the analytic hierarchy process (AHP) for verbal subjective judgements on prioritizing the four predictors of surgical LOS—medical, financial, social and risk, with pairwise comparisons of the sub-criteria under each criterion in line with the concerned interventions—the objective data of which are obtained from the patients’ files. Findings The proposed model was successfully applied to decide on the best policy alternative for LOS for the three interventions. The best policy alternatives compared well to current international benchmarks. Research limitations/implications The proposed method needs to be tested for other interventions across various healthcare settings. Practical implications Multi-criteria decision-making tools enable resource optimization and overall improvement of patient care through the application of a scientific management technique that involves all relevant stakeholders while utilizing both subjective judgements as well as objective data. Originality/value Traditionally, the duration of post-surgery LOS is mainly based on the surgeons’ clinical but also arbitrary decisions, with, as a result, having insufficiently explicable variations in LOS amongst peers for similar interventions. According to the authors’ knowledge, this is the first attempt to derive post-surgery LOS using the AHP, a multiple criteria decision-making method

Competency level in radiotherapy across EU educational programmes: A cross-case study evaluating stakeholders' perceptions

Introduction: The education of Therapeutic Radiographers (TRs) is regulated in some countries but is not standardised across the EU, leading to differences in competencies between and within member states. This study aimed to explore stakeholders’ perceptions regarding underdeveloped competencies of TRs practising on the linear accelerator, identified in a previous study by the same research team.Methods: Interviews with stakeholders from four countries (selected based on the characteristics of their degrees) were performed as part of this cross-case study. Stakeholders were asked to provide their perception regarding the least developed competencies identified in a previous study.Results: The 27 stakeholders confirmed that Pharmacology, Quality Assurance (QA), Management and Leadership, Research (from the previous study) were underdeveloped and identified Image Verification and Critical Thinking as additional underdeveloped competencies. Suggested causes included: lack of regulation of required competencies at the national level, lack of training dedicated to radiotherapy (RT) (taught within generic modules) and lack of time within the degree programme. The ideal academic level to develop these competencies and whether they are essential varied between country and stakeholder.Conclusion: It is essential to regulate learning outcomes at the national level to ensure a high level of care is provided to all RT patients and, ideally, standardise it across Europe. Education institutions should review their curricula to ensure that sufficient time is dedicated to RT and that the essential competencies are developed. Due to time constraints within some programmes, some competencies must be developed after graduation.Implications for practice: Lack of regulation of learning outcomes (at European level and national level in many countries) and lack of RT-specific training lead to underdeveloped competencies that may compromise patient care.peer-reviewe

Evaluation of radiotherapy education across the EU and the impact on graduates’ competencies working on the linear accelerator.

Introduction: Regulation and education of the professionals administering radiotherapy treatments in the linear accelerator varies across the EU. However, how different programme characteristics affect the level of competency of these professionals has never been studied before. This study also aimed to assess which are the least and most developed competencies in radiotherapy across the EU. Methods: An online questionnaire was distributed to academic staff teaching radiotherapy across the EU. Staff were asked to identify the characteristics of the course programmes and to classify the level of competency of graduates regarding linear accelerator tasks. Results: Fifty respondents from 19 EU countries answered the questionnaire. The least developed competency theme was pharmacology followed by equipment quality assurance and management and leadership. The most developed competency was positioning and immobilisation, followed by radiotherapy treatment delivery and professional and ethical practice. Some competencies are developed at the same level across EU countries, while others vary considerably between member-states. Longer programmes, with more placements, and larger proportions of radiotherapy in the programme showed significant increase in the development of some competencies. Longer placements in skills labs was correlated with a decrease in competency. Conclusion: There is no harmonisation of radiotherapy eduction across the EU and the differences in programme characteristics are reflected in differences in competency levels of radiotherapy radiographers. This may hinder movement of professionals and create disparities in the level of care offered across the EU. Implications for practice: Longer programmes, with longer clinical practice and adequate proportion of radiotherapy in the course are essential to ensure that these professionals are competent at similar levels across the EU and to ensure patient safety.peer-reviewe

Coxsackie and adenovirus receptor is a modifier of cardiac conduction and arrhythmia vulnerability in the setting of myocardial ischemia.

OBJECTIVES: The aim of this study was to investigate the modulatory effect of the coxsackie and adenovirus receptor (CAR) on ventricular conduction and arrhythmia vulnerability in the setting of myocardial ischemia. BACKGROUND: A heritable component in the risk of ventricular fibrillation during myocardial infarction has been well established. A recent genome-wide association study of ventricular fibrillation during acute myocardial infarction led to the identification of a locus on chromosome 21q21 (rs2824292) in the vicinity of the CXADR gene. CXADR encodes the CAR, a cell adhesion molecule predominantly located at the intercalated disks of the cardiomyocyte. METHODS: The correlation between CAR transcript levels and rs2824292 genotype was investigated in human left ventricular samples. Electrophysiological studies and molecular analyses were performed using CAR haploinsufficient (CAR(+/-)) mice. RESULTS: In human left ventricular samples, the risk allele at the chr21q21 genome-wide association study locus was associated with lower CXADR messenger ribonucleic acid levels, suggesting that decreased cardiac levels of CAR predispose to ischemia-induced ventricular fibrillation. Hearts from CAR(+/-) mice displayed slowing of ventricular conduction in addition to an earlier onset of ventricular arrhythmias during the early phase of acute myocardial ischemia after ligation of the left anterior descending artery. Expression and distribution of connexin 43 were unaffected, but CAR(+/-) hearts displayed increased arrhythmia susceptibility on pharmacological electrical uncoupling. Patch-clamp analysis of isolated CAR(+/-) myocytes showed reduced sodium current magnitude specifically at the intercalated disk. Moreover, CAR coprecipitated with NaV1.5 in vitro, suggesting that CAR affects sodium channel function through a physical interaction with NaV1.5. CONCLUSIONS: CAR is a novel modifier of ventricular conduction and arrhythmia vulnerability in the setting of myocardial ischemia. Genetic determinants of arrhythmia susceptibility (such as CAR) may constitute future targets for risk stratification of potentially lethal ventricular arrhythmias in patients with coronary artery disease

The cardiac sodium channel displays differential distribution in the conduction system and transmural heterogeneity in the murine ventricular myocardium

Cardiac sodium channels are responsible for conduction in the normal and diseased heart. We aimed to investigate regional and transmural distribution of sodium channel expression and function in the myocardium. Sodium channel Scn5a mRNA and Na(v)1.5 protein distribution was investigated in adult and embryonic mouse heart through immunohistochemistry and in situ hybridization. Functional sodium channel availability in subepicardial and subendocardial myocytes was assessed using patch-clamp technique. Adult and embryonic (ED14.5) mouse heart sections showed low expression of Na(v)1.5 in the HCN4-positive sinoatrial and atrioventricular nodes. In contrast, high expression levels of Na(v)1.5 were observed in the HCN4-positive and Cx43-negative AV or His bundle, bundle branches and Purkinje fibers. In both ventricles, a transmural gradient was observed, with a low Na(v)1.5 labeling intensity in the subepicardium as compared to the subendocardium. Similar Scn5a mRNA expression patterns were observed on in situ hybridization of embryonic and adult tissue. Maximal action potential upstroke velocity was significantly lower in subepicardial myocytes (mean +/- SEM 309 +/- 32 V/s; n = 14) compared to subendocardial myocytes (394 +/- 32 V/s; n = 11; P < 0.05), indicating decreased sodium channel availability in subepicardium compared to subendocardium. Scn5a and Na(v)1.5 show heterogeneous distribution patterns within the cardiac conduction system and across the ventricular wall. This differential distribution of the cardiac sodium channel may have profound consequences for conduction disease phenotypes and arrhythmogenesis in the setting of sodium channel diseas

Exploring the Relationship Between Schizophrenia and Cardiovascular Disease:A Genetic Correlation and Multivariable Mendelian Randomization Study

Individuals with schizophrenia have a reduced life-expectancy compared to the general population, largely due to an increased risk of cardiovascular disease (CVD). Clinical and epidemiological studies have been unable to unravel the nature of this relationship. We obtained summary-data of genome-wide-association studies of schizophrenia (N = 130 644), heart failure (N = 977 323), coronary artery disease (N = 332 477), systolic and diastolic blood pressure (N = 757 601), heart rate variability (N = 46 952), QT interval (N = 103 331), early repolarization and dilated cardiomyopathy ECG patterns (N = 63 700). We computed genetic correlations and conducted bi-directional Mendelian randomization (MR) to assess causality. With multivariable MR, we investigated whether causal effects were mediated by smoking, body mass index, physical activity, lipid levels, or type 2 diabetes. Genetic correlations between schizophrenia and CVD were close to zero (−0.02–0.04). There was evidence that liability to schizophrenia causally increases heart failure risk. This effect remained consistent with multivariable MR. There was also evidence that liability to schizophrenia increases early repolarization pattern, largely mediated by BMI and lipids. Finally, there was evidence that liability to schizophrenia increases heart rate variability, a direction of effect contrasting clinical studies. There was weak evidence that higher systolic blood pressure increases schizophrenia risk. Our finding that liability to schizophrenia increases heart failure is consistent with the notion that schizophrenia involves a systemic dysregulation of the body with detrimental effects on the heart. To decrease cardiovascular mortality among individuals with schizophrenia, priority should lie with optimal treatment in early stages of psychosis

Common genetic variants improve risk stratification after the atrial switch operation for transposition of the great arteries

Background: Clinical factors are used to estimate late complication risk in adults after atrial switch operation (AtrSO) for transposition of the great arteries (TGA), but heterogeneity in clinical course remains. We studied whether common genetic variants are associated with outcome and add value to a clinical risk score in TGA-AtrSO patients. Methods and results: This multicenter study followed 133 TGA-AtrSO patients (aged 28 [IQR 24–35] years) for 13 (IQR 9–16) years and examined the association of genome-wide single-nucleotide polymorphisms (SNPs) with a composite endpoint of symptomatic ventricular arrhythmia, heart failure hospitalization, ventricular assist device implantation, heart transplantation, or mortality. Thirty-two patients (24%) reached the endpoint. The genome-wide association study yielded one genome-wide significant (p 20%) risk. Stratified by the combined score, observed 5-year event-free survival was 100%, 79% and 31% for low, intermediate, and high-risk patients, respectively. Conclusions: Common genetic variants may explain some variation in the clinical course in TGA-AtrSO and improve risk stratification over clinical factors alone, especially in patients at intermediate clinical risk. These findings support the hypothesis that including genetic variants in risk assessment may be beneficial

Activation of Ventral Tegmental Area 5-HT2C Receptors Reduces Incentive Motivation

FUNDING AND DISCLOSURE The research was funded by Wellcome Trust (WT098012) to LKH; and National Institute of Health (DK056731) and the Marilyn H. Vincent Foundation to MGM. The University of Michigan Transgenic Core facility is partially supported by the NIH-funded University of Michigan Center for Gastrointestinal Research (DK034933). The remaining authors declare no conflict of interest. ACKNOWLEDGMENTS We thank Dr Celine Cansell, Ms Raffaella Chianese and the staff of the Medical Research Facility for technical assistance. We thank Dr Vladimir Orduña for the scientific advice and technical assistance.Peer reviewedPublisher PD