Preoperative Optimization of Promotility in Robotic Prostatectomy and Minimally Invasive Kidney Surgery

INTRODUCTION

Patients are routinely discharged postoperative day 1 following minimally invasive surgery (MIS) for prostate cancer and kidney cancer. Delays in discharge are often related to gastrointestinal symptoms such as nausea, abdominal pain and vomiting; however, the role of baseline constipation in these symptoms and resultant delays in discharge is unclear. We conducted a prospective observational study to describe the incidence of baseline constipation among patients undergoing MIS prostate and kidney surgery, and its relationship to length of stay (LOS).

METHODS

Consenting adult patients undergoing MIS procedures for kidney and prostate cancer completed constipation symptom questionnaires perioperatively. Clinicopathological data were collected prospectively. Delay in discharge, defined as LOS >2 days, was the primary outcome. Patients were stratified by the primary outcome and preoperative Patient Assessment of Constipation Symptoms (PAC-SYM) scores were compared.

RESULTS

A total of 97 patients enrolled, of whom 29 underwent radical nephrectomy, 34 underwent robotic partial nephrectomy and 34 underwent robotic prostatectomy. Constipation symptoms were reported in 67/97 patients (69%). A total of 17/97 patients (18%) had a delay in discharge. Patients who discharged on time had a median PAC-SYM score of 2 (IQR 2-9) compared to 4 (IQR 0-7.5) for those with a delay (p=0.021). Patients who had a delay with gastrointestinal symptoms had a median PAC-SYM score of 5 (IQR 1.5-11.5, p=0.032).

CONCLUSIONS

Seven out of 10 patients undergoing routine MIS procedures report constipation symptoms, which may represent a target for preoperative interventions to reduce LOS after surgery.

Intensive preoperative ostomy education for the radical cystectomy patient

OBJECTIVES

Patients undergoing radical cystectomy with ileal conduit formation usually receive training on the use of their stoma during their initial hospitalization - while actively recovering from surgery - often with little follow-up or reinforcement. Many of these patients are not equipped to deal with these significant body changes, which can lead to additional clinic visits, stoma-related complications, and decreased patient satisfaction/health-related quality of life (HRQOL). In an effort to improve patient education, we sought to evaluate the feasibility of implementing a preoperative comprehensive stoma education session termed the "stoma bootcamp" for patients scheduled for a radical cystectomy and ileal conduit (RCIC). We tracked patient related outcomes to determine its impact.

METHODS

We performed a longitudinal, quality-improvement feasibility study at the University of Kansas Health System. All patients who were scheduled to undergo a RCIC for bladder cancer were offered enrollment into the study at their preoperative clinic visit. The "stoma boot camp" consisted of a 3-hour group session within 2 weeks of the surgery date. Patients were given a short presentation by residents and advanced practice providers regarding the operation, recovery, and expectations for their post-operative care. Ostomy nurses then demonstrated basic urostomy care - pouching, sizing, emptying - along with trouble-shooting tips for common ostomy problems. Measurements of HRQOL questionnaires were completed at the initial visit, after "boot camp," and at defined time points after surgery for 12 weeks. This included using an ostomy adjustment score. Length of stay, unplanned stoma-related interventions, and re-admissions within 30 days were also tracked.

RESULTS

In this initial pilot program, 51 patients participated in the stoma bootcamp. The patients had an average ostomy adjustment score (OAS) of 150.4 (95% CI 142.0, 158.8) at discharge from the hospital, and these high OAS levels persisted throughout the 12 weeks of follow-up data without any significant decline. Short-form 36 (SF-36) scores demonstrated numerical improvements in each individual category at the 6-week mark above baseline. These improvements persisted at the 12-week mark.

CONCLUSIONS

In this study we were able to establish the feasibility of implementing a preoperative comprehensive stoma education session for patients scheduled for a RCIC. Additionally, we were able to document favorable HRQOL data and improved ostomy adjustment scores surrounding the education session.

The impact of shift patterns on junior doctors' perceptions of fatigue, training, work/life balance and the role of social support

BACKGROUND

The organisation of junior doctors' work hours has been radically altered following the partial implementation of the European Working Time Directive. Poorly designed shift schedules cause excessive disruption to shift workers' circadian rhythms.

METHOD

Interviews and focus groups were used to explore perceptions among junior doctors and hospital managers regarding the impact of the European Working Time Directive on patient care and doctors' well-being.

RESULTS

Four main themes were identified. Under "Doctors shift rotas", doctors deliberated the merits and demerits of working seven nights in row. They also discussed the impact on fatigue of long sequences of day shifts. "Education and training" focused on concerns about reduced on-the-job learning opportunities under the new working time arrangements and also about the difficulties of finding time and energy to study. "Work/life balance" reflected the conflict between the positive aspects of working on-call or at night and the impact on life outside work. "Social support structures" focused on the role of morale and team spirit. Good support structures in the work place counteracted and compensated for the effects of negative role stressors, and arduous and unsocial work schedules.

CONCLUSIONS

The impact of junior doctors' work schedules is influenced by the nature of specific shift sequences, educational considerations, issues of work/life balance and by social support systems. Poorly designed shift rotas can have negative impacts on junior doctors' professional performance and educational training, with implications for clinical practice, patient care and the welfare of junior doctors.

Variants of the TCF7L2 gene are associated with beta cell dysfunction and confer an increased risk of type 2 diabetes mellitus in the ULSAM cohort of Swedish elderly men

AIMS/HYPOTHESIS

In a population-based cohort of elderly men with well-defined phenotypes and biochemical markers related to type 2 diabetes mellitus, we analysed two single nucleotide polymorphisms (SNPs), rs7903146 and rs12255372, in the transcription factor 7-like 2 gene (TCF7L2), which are associated with an increased risk of type 2 diabetes mellitus.

MATERIALS AND METHODS

The 1,142 subjects were from the population-based Uppsala Longitudinal Study of Adult Men cohort study (see http://www.pubcare.uu.se/ULSAM/, last accessed in May 2007). Insulin sensitivity was assessed using a euglycaemic-hyperinsulinaemic clamp; fasting intact and 32-33 split proinsulin, immunoreactive insulin and specific insulin were measured in plasma samples. The SNPs rs7903146 and rs12255372 were genotyped using a fluorescent homogeneous single base extension assay. The SNP genotypes were analysed against diabetes prevalence at age 70 using logistic regression and against quantitative biochemical measures using linear regression analysis.

RESULTS

We replicated the association with type 2 diabetes mellitus for both SNPs in this cohort of elderly males. The highest significant odds ratio (2.15, 95% CI 1.20-3.85) was found for SNP rs7903146. The odds ratio for SNP rs12255372 was 1.69 (95% CI 1.20-2.39). Both TCF7L2 SNPs were found to be significantly associated with plasma proinsulin when adjusting for insulin sensitivity, both in the whole cohort and when the diabetic subjects were excluded. Analysis for fasting plasma insulin or insulin sensitivity did not give significant results.

CONCLUSIONS/INTERPRETATION

The association between the risk alleles of the two SNPs studied and levels of proinsulin in plasma, identified when adjusting for insulin sensitivity using euglycaemic-hyperinsulinaemic clamp measurements in this study, is an important novel finding.

Activity performance and upper extremity function in cervical spinal cord injury patients according to the Klein-Bell ADL Scale

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

(1) To examine whether the Klein-Bell ADL Scale (K-B Scale) discriminates cervical spinal cord injury (SCI) patients in daily activities and to explore its applicability in this group of patients. (2) To examine the association between basic ADL and upper extremity function. (3) To investigate if grip ability can be discerned in the scale.

SETTING

Spinal Cord Injury Unit, Sahlgrenska University Hospital, Göteborg, Sweden.

METHODS

Fifty-five patients with cervical SCI with no prior reconstructive hand surgery were included in the study. Analyses of the patient's independence were made according to the K-B Scale. Three additional analyses were carried out, the first examined whether the use of assistive devices and house and car adaptations influenced independence. The last two used different approaches to investigate whether arm and grip function could be detected in the K-B scale.

RESULTS

Raw score in the K-B Scale can discriminate for independence in daily activities but the scale's weight scheme does not function for cervical SCI patients. Assistive devices and car and house adaptations can compensate for dependence in daily activities. Lack of grip function decreases the patient's ability to become independent. Diagnosis-related activities cannot be assessed in all items.

CONCLUSION

The K-B Scale's raw score was useful assessing daily activities in cervical SCI patients. Its reliability in conjunction with arm and grip function in patients with cervical SCI has yet to be proven.

The effects of double-shifts (15.5 hours) on sleep, fatigue and health

The aim of the present study was to investigate how "double-shifts" (15.5 hours) affects sleep, fatigue and self-rated health. The study was carried out on male construction workers of which 80% were long-distance commuters. The schedule involved two work periods and each work period involved two double shifts in a row. The subjects filled in a sleep/wake diary at 8 times across a year and a questionnaire at 3 times. They also wore an actigraph during one shift cycle. The results showed that sleepiness, and to a certain extent, mental fatigue increased during double shifts and accumulated across days. The short rest time (8.5 hours) between days caused insufficient sleep and approximately 5.5 hours of sleep was obtained between double shifts. Questionnaire data showed that complaints of insufficient sleep, exhaustion on awakening and pain symptoms increased across the year. It was concluded that a shift system involving double shifts has a negative effect on fatigue, recovery and health-related well-being.

A novel mutation in ribosomal protein S4 that affects the function of a mutated RF1

Release factors (RF) 1 and 2 trigger the hydrolysis of the peptide from the peptidyl-tRNA during translation termination. RF1 binds to the ribosome in response to the stop codons UAG and UAA, whereas RF2 recognizes UAA and UGA. RF1 and RF2 have been shown to bind to several ribosomal proteins. To study this interaction in vivo, prfA1, a mutant form of RF1 has been used. A strain with the prfA1 mutation is temperature sensitive (Ts) for growth at 42 degrees C and shows an increased misreading of UAG and UAA. In this work we show that a point mutation in ribosomal protein S4 can, on the one hand, make the RF1 mutant strain Ts(+); on the other hand, this mutation increases the misreading of UAG, but not UAA, caused by prfA1. The S4 mutant allele, rpsD101, is a missense mutation (Tyr51 to Asp), which makes the cell cold sensitive. The behaviour of rpsD101 was compared to the well-studied S4 alleles rpsD12, rpsD14, and rpsD16. These three mutations all confer both a Ts (44 degrees C) phenotype and show a ribosomal ambiguity phenotype, which rpsD101 does not. The three alleles were sequenced and shown to be truncations of the S4 protein. None of the three mutations could compensate for the Ts phenotype caused by the prfA1 mutation. Hence, rpsD101 differs in all studied characteristics from the three above mentioned S4 mutants. Because rpsD101 can compensate for the Ts phenotype caused by prfA1 but enhances the misreading of UAG and not UAA, we suggest that S4 influences the interaction of RF1 with the decoding center of the ribosome and that the Ts phenotype is not a consequence of increased readthrough.

Protection of the deltoid to triceps tendon transfer repair sites

The posterior deltoid muscle was used to replace lost elbow extension in 11 patients with C5 or C6 level tetraplegia. During surgery stainless steel sutures were inserted into the donor muscle, graft, and tendon insertion sites. Over the succeeding time periods (1 month to 2 years) the distances between the various markers were measured. Significant tendon elongation of 23.1 +/- 4.8 mm (mean +/- SEM; n = 6) was observed in patients receiving traditional postoperative care. To reduce the tendon elongation observed, a specially designed armrest was developed and applied the first postoperative day. The armrest was designed to maintain the elbow in 20 degrees flexion and to prevent shoulder adduction. The addition of this armrest to the traditional postoperative protocol resulted in a dramatic decrease of tendon elongation to only 8.4 +/- 3.0 mm (n = 5). Elongation occurred within the first 6 postoperative weeks in the armrest group; in the nonprotected group, elongation continued for several additional months. The majority of the elongation in both groups occurred in the proximal portion of the tendon-graft-tendon unit. Although this study did not explicitly measure strength, we conclude that preventing excessive muscle length change is required to protect repair sites in posterior deltoid to triceps transfer. (J Hand Surg 2000; 25A:144-149.

Organobismuth compounds: activity against Helicobacter pylori

BACKGROUND AND METHODS

The antibacterial activity of originally devised and synthesized organobismuth compounds was tested against fresh clinical isolates of Helicobacter pylori and compared with clinically well-established inorganic bismuth salts currently used in triple antibacterial treatment to eradicate H. pylori. The test conditions in vitro were standard for determination of minimum inhibitory concentrations (MICs).

RESULTS

Organic compounds with covalently bound bismuth showed stronger and more consistent antibacterial activity than inorganic bismuth salts. Whereas the most active among the standard therapeutic inorganic compounds showed MICs against the test organisms of 4-8 mg/l (bismuth salicylate) and 0.5-64 mg/l, the most active neosynthesized organic substance, tris(2.6-dimethylphenyl)-bismuthine, consistently showed an MIC of 4 mg/l against all bacterial strains.

CONCLUSIONS

The new line of organobismuth compounds might offer a therapeutic potential against the bacteria causing peptic ulcer disease.

Slipping on ice and snow--elderly women and young men are typical victims

Slipping on ice or snow during winter caused 3.5 injuries per 1000 inhabitants per year in the Umeå health district; the injury rate was highest among the elderly. Most injured were elderly women, but also many young men in the age group 20-29 years were injured. Half of all injuries were fractures; for women 50 years and over two-thirds were fractures, mostly of an upper extremity. The 'cost' of medical care of these slipping injuries was almost the same as the 'cost' of all traffic injuries in the area during the same time. Injury reducing measures, such as more effective snow clearing, sand and salt spreading in strategic areas, better slip preventive aids on shoes, and 'padding' of older women, would reduce the injuries and their consequences.

Genivir (DIP-253) 1% cream versus placebo cream in the treatment of recurrent genital herpes: a double-blind study

A total of 100 heterosexual adults of either sex with frequent episodes of recurrent genital herpes were allocated to treatment with either Genivir (DIP-253) 1% cream or placebo cream. All patients had genital herpes previously verified by a positive viral culture. The study was carried out as a double-blind parallel group trial. Fifty patients were allocated to each of the two treatment groups. The treatment was initiated within 24 hours after the first sign of a recurrence, and at the pretreatment examination all patients had developed typical lesions with blisters and/or sores. At baseline a sample for herpes virus culture and typing was obtained. The creams were applied four times daily for five days. Follow-up examinations were carried out on days 1, 2, 4 and if needed on days 7, 10 and 14. The major factor used for assessment of efficacy was the time to complete healing of all lesions. Duration of pruritus and pain were also recorded. In the group of patients treated with Genivir cream the time to complete healing was 3.3 days and in the placebo group 6.1 days. The difference was statistically significant (P less than 0.001). The mean duration of pain was 1.3 days in the Genivir group and 2.5 days in the placebo group: this difference also reached significance (P less than 0.01). The duration of pruritus was about the same in both groups. The active agent in Genivir, DIP-253, is a heterocyclic aromatic complex with confirmed anti-herpetic activity and with evidence of a local immunomodulatory effect. It was concluded that the efficacy of topical application of DIP-253 may be due to combined antiviral and immunomodulatory activities.