Modified 2-stage IPAA has similar postoperative complication rates and functional outcomes compared to 3-stage IPAA

INTRODUCTION

Reconstructive ileal-pouch anal anastomosis (IPAA) for ulcerative colitis (UC) is often created in 3-stages: colectomy ​+ ​ileostomy, proctectomy ​+ ​pouch creation with diverting loop ileostomy, then subsequent ileostomy closure. Modified 2-stage IPAA is without pouch diversion, thus avoiding a third operation. This study compares perioperative complications, quality of life (QOL) and functional outcomes of 3- versus modified 2-stage IPAA.

METHODS

Charts were reviewed for adult UC patients undergoing IPAA between 2010 and 2020. QOL and function were assessed with EQ-5D-3L Quality of Life and Pouch Functional Score questionnaires.

RESULTS

152 patients were identified. 43 modified 2-stage and 109 3-stage IPAA were similar for anastomotic leak (9.3% vs. 1.8%, p ​= ​0.06), SSI (34.9% vs. 29.7%, p ​= ​0.51) and ileus (32.6% vs. 33%, p ​= ​0.96). Modified 2-stage had less bowel obstruction than 3-stage IPAA (7.0% vs. 30.1%, p ​= ​0.006). 92 patients returned questionnaires with similar QOL and pouch function.

CONCLUSIONS

Perioperative complications, QOL and function are similar for 3-stage IPAA and modified 2-stage IPAA. Modified 2-stage IPAA in select patients is safe and has less postoperative bowel obstruction than 3-stage IPAA.

Testing an educational intervention to improve health care providers' preparedness to care for victims of elder abuse: a mixed method pilot study

BACKGROUND

Elder abuse is prevalent and associated with ill-health. However, health care providers often lack education about elder abuse and older patients' victimization often remains unknown to them. In this pilot study we performed initial testing of an educational model aiming at improving health care providers' preparedness to care for older adults subjected to abuse, or more specifically their self-reported propensity to ask older patients questions about abuse and perceived ability to manage the response.

METHODS

The educational model consisted of a full training day about elder abuse, including theory, group discussions and forum theatre. Forum theatre is an interactive form of drama in which participants are not only observers, but rather spect-actors, urged to participate in the scene. They are thereby given the opportunity to discuss and practise difficult health care encounters. Medical interns (intervention group n = 16, control group n = 14) in Sweden participated in the study and a mixed method convergent parallel design was used. Quantitative data was collected at baseline and 6 months post-intervention using a questionnaire (the REAGERA-P). Qualitative interviews were conducted with four of the participants in the intervention group and data was analysed using qualitative content analysis.

RESULTS

The reported frequency of asking older patients questions about abuse increased in the intervention group (p = 0.047), but not the control group (p = 0.38) post-intervention. Potential mediators for the improvement were an increased awareness of elder abuse and higher self-efficacy for asking questions about elder abuse. Participants also reported a higher perceived ability to manage cases of elder abuse, even though uncertainties concerning how to provide the best possible care remained. The qualitative interviews indicated that learning from each other in group discussions and forum theatre likely was an important contributor to the positive results.

CONCLUSION

This pilot test indicated that the educational model may be effective in improving health care providers' preparedness to care for older adults subjected to abuse. However, uncertainties about how to handle elder abuse cases remained post-intervention. In a future full-scale test of the model more focus needs to be put on how to manage cases of elder abuse.

Responding to Elder Abuse in GERiAtric care (REAGERA) educational intervention for healthcare providers: a non-randomised stepped wedge trial

INTRODUCTION

Elder abuse is prevalent and associated with different forms of ill health. Despite this, healthcare providers are often unaware of abusive experiences among older patients and many lack training about elder abuse. The overall aim of this study is to determine the effectiveness of an educational intervention on healthcare providers' propensity to ask older patients questions about abusive experiences.

METHODS AND ANALYSIS

Healthcare providers at hospital clinics and primary healthcare centres in Sweden will undergo full-day education about elder abuse between the fall of 2021 and spring of 2023. The education consists of (1) theory and group discussions; (2) forum theatre, a form of interactive theatre in which participants are given the opportunity to practise how to manage difficult patient encounters; and (3) post-training reflection on changing practices.The design is a non-randomised cluster, stepped wedge trial in which all participants (n=750) gradually transit from control group to intervention group with 6-month interval, starting fall 2021. Data are collected using the Responding to Elder Abuse in GERiAtric care-Provider questionnaire which was distributed to all clusters at baseline. All participants will also be asked to answer the questionnaire in conjunction with participating in the education as well as at 6-month and 12-month follow-up. Main outcome is changes in self-reported propensity to ask older patients questions about abuse post-intervention compared with pre-intervention. Linear mixed models including cluster as a random effect will be used to statistically evaluate the outcome.

ETHICS AND DISSEMINATION

The study has been approved by the Swedish Ethical Review Authority. The results will be published in peer-reviewed journals and conference proceedings. If the intervention is successful, a manual of the course content will be published so that the education can be disseminated to other clinics.

TRIAL REGISTRATION NUMBER

NCT05065281.

Factors associated with health care providers speaking with older patients about being subjected to abuse

Health care providers have difficulties responding to elder abuse. This study aimed to investigate factors associated with health care providers speaking with older patients about being subjected to abuse, and what facilitating measures staff preferred to help them achieve this. A cross-sectional questionnaire survey was conducted among hospital health care providers (n = 154) in Sweden. Half of the respondents had experience of speaking about elder abuse. A high sense of professional responsibility (OR 3.23) and being less concerned about inflicting damage to the therapeutic relationship (OR 3.97) were associated with having spoken with older patients about being subjected to abuse. Written guidelines about elder abuse and a patient information sheet were the most preferred facilitating measures. Our findings indicate that increasing care providers' sense of responsibility and addressing concerns about damaging the therapeutic relationship might be important factors to target in future interventions to improve health care response to elder abuse.

Increased levels of neutrophil extracellular trap remnants in the circulation of patients with small vessel vasculitis, but an inverse correlation to anti-neutrophil cytoplasmic antibodies during remission

OBJECTIVES

Neutrophil extracellular traps (NETs) have been visualized at the site of ANCA-associated vasculitis (AAV) lesions. Increased levels of NET remnants in the circulation have been reported in some AAV patients with active disease. The aim of the present study was to analyse NET remnants in a larger cohort of AAV patients with varying degrees of disease activity and to elucidate possible factors responsible for remnant variation.

METHODS

Levels of NET remnants in the circulation of healthy controls (HCs; n = 31) and AAV patients (n = 93) were determined with ELISA. NET remnants were then correlated with ANCA levels, spontaneous and induced cell death (NETosis/necrosis) in vitro, neutrophil count and corticosteroid therapy.

RESULTS

Patients with active disease showed higher levels of circulating NET remnants compared with patients in remission (P = 0.026) and HCs (P = 0.006). From patients sampled during both remission and active disease, we found increased levels during active disease (P = 0.0010). In remission, ANCA-negative patients had higher levels of NET remnants than ANCA-positive patients and a negative correlation was observed between NET remnants and PR3-ANCA (rs = -0.287, P = 0.048). NET remnants correlated with neutrophil count in HCs (rs = 0.503, P = 0.014) but not in patients during remission. Neutrophils from patients showed enhanced spontaneous cell death (P = 0.043).

CONCLUSION

We found increased levels of circulating NET remnants in patients with active AAV. Furthermore, AAV patients exhibited an increased propensity for spontaneous cell death. NET remnant levels seem to be positively related to disease activity and neutrophil count, but inversely related to ANCA at least during remission.