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Intensive physical therapy after emergency laparotomy: Pilot phase of the Incidence of Complications following Emergency Abdominal surgery Get Exercising randomized controlled trial. J Trauma Acute Care Surg 2022; 92:1020-1030. [PMID: 35609291 DOI: 10.1097/ta.0000000000003542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative pneumonia and delayed physical recovery are significant problems after emergency laparotomy. No randomized controlled trial has assessed the feasibility, safety, or effectiveness of intensive postoperative physical therapy in this high-risk acute population. METHODS The internal pilot phase of the Incidence of Complications after Emergency Abdominal Surgery: Get Exercising (ICEAGE) trial was a prospective, randomized controlled trial that evaluated the feasibility, safety, and clinical trial processes of providing intensive physical therapy immediately following emergency laparotomy. Fifty consecutive patients were recruited at the principal participating hospital and randomly assigned to standard-care or intensive physical therapy of twice daily coached breathing exercises for 2 days and 30 minutes of daily supervised rehabilitation over the first 5 postoperative days. RESULTS Interventions were provided exactly as per protocol in 35% (78 of 221 patients) of planned treatment sessions. Main barriers to protocol delivery were physical therapist unavailability on weekends (59 of 221 patients [27%]), awaiting patient consent (18 of 99 patients [18%]), and patient fatigue (26 of 221 patients [12%]). Despite inhibitors to treatment delivery, the intervention group still received twice as many breathing exercise sessions and four times the amount of physical therapy over the first 5 postoperative days (23 minutes [interquartile range, 12-29 minutes] vs. 86 minutes [interquartile range, 53-121 minutes]; p < 0.001). One adverse event was reported from 78 rehabilitation sessions (1.3%), which resolved fully on cessation of activity without escalation of medical care. CONCLUSION Intensive postoperative physical therapy can be delivered safely and successfully to patients in the first week after emergency laparotomy. The ICEAGE trial protocol resulted in intervention group participants receiving more coached breathing exercises and spending significantly more time physically active over the first 5 days after surgery compared with standard care. It was therefore recommended to progress into the multicenter phase of ICEAGE to definitively test the effect of intensive physical therapy to prevent pneumonia and improve physical recovery after emergency laparotomy. LEVEL OF EVIDENCE Therapeutic/Care Management; Level II.
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Di Luca NM, Del Rio A. Information obligation in surgery. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021072. [PMID: 34487102 PMCID: PMC8477101 DOI: 10.23750/abm.v92i4.10318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/25/2020] [Indexed: 12/14/2022]
Abstract
The following article aims to clarify the guidelines needed for the gaining of informed consent in surgery treatments. Legal dispositions in the provisions of law n. 219/2017, written according to the regulatory mechanism uphold by the Italian Supreme Court and medical code of practice have been properly analyzed in order answer the questions unanswered by the law. Who is supposed to inform the patient? About which risks? Does the patient's characteristics affect information obligation? Is necessary to add more information than those required by the law? How do emergency and urgency affect information obligation? Can the patient give consent in advance to an additional operation during the undergoing surgery, if needed? The answers provided by the law and by the Italian Supreme Court picture a state of obligation, where the single physician risks to encounter several responsibilities. It's important to face this problem inside sanitary facilities, creating a suitable informed consent form and planning surgeries to allow the usage of personal data according to the patient's need.
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Affiliation(s)
- Natale Mario Di Luca
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, "Sapienza" University of Rome";}.
| | - Alessandro Del Rio
- Section of Legal Medicine, Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, "Sapienza" University of Rome, Rome, Italy.
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Affiliation(s)
- Sally Kerr
- Department of Trauma and Orthopaedics, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - David Warwick
- Department of Orthopaedics, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Fares S Haddad
- The Bone & Joint Journal, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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Haddad FS. International perspectives are important. Bone Joint J 2019; 101-B:353-354. [PMID: 30929486 DOI: 10.1302/0301-620x.101b4.bjj-2019-0244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- F S Haddad
- The Bone & Joint Journal, Professor of Orthopaedic Surgery, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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Abstract
Informed consent is a very important part of surgical treatment. In this paper, we report a number of legal judgements in spinal surgery where there was no criticism of the surgical procedure itself. The fault that was identified was a failure to inform the patient of alternatives to, and material risks of, surgery, or overemphasizing the benefits of surgery. In one case, there was a promise that a specific surgeon was to perform the operation, which did not ensue. All of the faults in these cases were faults purely of the consenting process. In many cases, the surgeon claimed to have explained certain risks to the patient but was unable to provide proof of doing so. We propose a checklist that, if followed, would ensure that the surgeon would take their patients through the relevant matters but also, crucially, would act as strong evidence in any future court proceedings that the appropriate discussions had taken place. Although this article focuses on spinal surgery, the principles and messages are applicable to the whole of orthopaedic surgery. Cite this article: Bone Joint J 2019;101-B:355–360.
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Affiliation(s)
- N. V. Todd
- Newcastle Nuffield Hospital, Newcastle upon Tyne, UK
| | - N. C. Birch
- The Chris Moody Rehabilitation and Sports Injury Centre, Moulton, UK
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Fernandez MA, Costa ML. Clinical research in fragility fractures. Injury 2018; 49:1473-1476. [PMID: 29958685 DOI: 10.1016/j.injury.2018.06.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/17/2018] [Accepted: 06/21/2018] [Indexed: 02/02/2023]
Abstract
The Fragility Fracture Network is coordinating international initiatives to promote collaborative research, multidisciplinary care, and the secondary prevention of fragility fractures. This review discusses the use of national audit processes and the collection of common outcomes to facilitate research, as well as the key role played by patient and public involvement, and strategies to overcome research barriers.
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Affiliation(s)
- M A Fernandez
- Clinical Research Fellow in Orthopaedic Trauma, Oxford Trauma, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK; Specialty Registrar in Trauma & Orthopaedic Surgery, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.
| | - M L Costa
- Professor of Orthopaedic Trauma Surgery, Oxford Trauma, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
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Tutton E, Achten J, Lamb SE, Willett K, Costa ML. Participation in a trial in the emergency situation: a qualitative study of patient experience in the UK WOLLF trial. Trials 2018; 19:328. [PMID: 29941030 PMCID: PMC6019785 DOI: 10.1186/s13063-018-2722-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 06/06/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients can struggle to make sense of trials in emergency situations. This study examines patient experience of participating in the United Kingdom, Wound management of Open Lower Limb Fractures (UK WOLLF) study, a trial of standard wound management versus Negative Pressure Wound Therapy (NPWT). METHODS The aim of the study was to understand the patient's lived experience of taking part in a trial of wound dressings. Interviews drawing on Phenomenology were undertaken with a purposive sample of 20 patients, on average 12 days into their hospital stay from July 2012-July 2013. RESULTS The participants were vulnerable due to the emotional and physical impact of injury. They expressed their trial experience through the theme of being compromised identified in categories of being dependent, being trusting, being grateful and being without experience. Participants felt dependent on and trusted the team to make the right decisions for them and not cause them harm. Their hopes for future recovery were also invested within the expertise of the team. Despite often not being well enough to consent to the study prior to surgery, they wished to be involved as much as possible. In agreeing to take part they expressed gratitude for their care, wanted to be helpful to others and considered the trial interventions to be a small component in relation to the enormity of their injury and broader treatment. In making sense of the trial they felt they could not understand the interventions without experience of them but if they received NPWT they developed a strong technological preference for this intervention. CONCLUSIONS Patients prefer to be involved in studies within the limits of their capacity, despite not being able to provide informed consent. A variety of sources of knowledge may enable participants to feel that they have a better understanding of the interventions. Professional staff need to be aware of the situated nature of decision making where participants invest their hopes for recovery in the team. TRIAL REGISTRATION Current Controlled Trials, ID: ISRCTN33756652 . Registered on 24 February 2012.
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Affiliation(s)
- Elizabeth Tutton
- Warwick Research in Nursing, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL UK
- Kadoorie Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Juul Achten
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL UK
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, OX3 9DU UK
| | - Sarah E. Lamb
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL UK
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, OX3 9DU UK
| | - Keith Willett
- Kadoorie Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU UK
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, OX3 9DU UK
| | - Matthew L. Costa
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL UK
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, OX3 9DU UK
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX UK
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Abstract
Our aim in this paper was to investigate the guidelines and laws governing informed consent in the English-speaking world. We noted a recent divergence from medical paternalism within the United Kingdom, highlighted by the Montgomery v Lanarkshire Health Board ruling of 2015. We investigated the situation in the United Kingdom, Australia, New Zealand, Canada, and the United States of America. We read the national guidance regarding obtaining consent for surgical intervention for each country. We used the references from this guidance to identify the laws that helped inform the guidance, and reviewed the court documents for each case. There has been a trend towards a more patient-focused approach in consent in each country. Surgeons should be aware of the guidance and legal cases so that they can inform patients fully, and prevent legal problems if outdated practices are followed. Cite this article: Bone Joint J 2018;100-B:687-92.
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Affiliation(s)
- D J McCormack
- Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Leicester, UK
| | - A Gulati
- Sandwell and West Birmingham Hospitals NHS Trust, City Hospital Birmingham, UK
| | - J Mangwani
- Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Leicester, UK
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Affiliation(s)
- F S Haddad
- NIHR University College London Hospitals Biomedical Research Centre, UK
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Sims AL, Parsons N, Achten J, Griffin XL, Costa ML, Reed MR. A randomized controlled trial comparing the Thompson hemiarthroplasty with the Exeter polished tapered stem and Unitrax modular head in the treatment of displaced intracapsular fractures of the hip: the WHiTE 3: HEMI Trial. Bone Joint J 2018; 100-B:352-360. [PMID: 29589786 PMCID: PMC6413801 DOI: 10.1302/0301-620x.100b3.bjj-2017-0872.r2] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Aims This study aimed to compare the change in health-related quality of life of patients receiving a traditional cemented monoblock Thompson hemiarthroplasty compared with a modern cemented modular polished-taper stemmed hemiarthroplasty for displaced intracapsular hip fractures. Patients and Methods This was a pragmatic, multicentre, multisurgeon, two-arm, parallel group, randomized standard-of-care controlled trial. It was embedded within the WHiTE Comprehensive Cohort Study. The sample size was 964 patients. The setting was five National Health Service Trauma Hospitals in England. A total of 964 patients over 60 years of age who required hemiarthroplasty of the hip between February 2015 and March 2016 were included. A standardized measure of health outcome, the EuroQol (EQ-5D-5L) questionnaire, was carried out on admission and at four months following the operation. Results Of the 964 patients enrolled, 482 died or were lost to follow-up (50%). No significant differences were noted in EQ-5D between groups, with a mean difference at four months of 0.037 in favour of the Exeter/Unitrax implant (95% confidence interval (CI) 0.014 to 0.087, p = 0.156), rising to 0.045 (95% CI 0.007 to 0.098, p = 0.09) when patients who died were excluded. The minimum clinically important difference for EQ-5D-5L used in this study is 0.08, therefore any benefit between implants is unlikely to be noticeable to the patient. There was no difference in mortality or mobility score. Conclusion Allowing for the high rate of loss to follow-up, the use of the traditional Thompson hemiarthroplasty in the treatment of the displaced intracapsular hip fracture shows no difference in health outcome when compared with a modern cemented hemiarthroplasty. Cite this article: Bone Joint J 2018;100-B:352-60.
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Affiliation(s)
- A L Sims
- Health Education North East, Waterfront, 4 Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, UK
| | - N Parsons
- Statistics and Epidemiology, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - J Achten
- Department of Orthopaedic Trauma, Oxford Trauma, University of Oxford, Kadoorie Centre, Level 3, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - X L Griffin
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford and Oxford Trauma, Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Science, University of Oxford, OX3 9DU, UK
| | - M L Costa
- NDORMS, Oxford Trauma, Kadoorie Centre, University of Oxford, John Radcliffe Hospital, Windmill Road, Oxford, OX3 9DU, UK
| | - M R Reed
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, NE63 9JJ, UK
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