Multidisciplinary Day Surgery Unit: a Health Technology Assessment

Issue

The aim of this study was to improve effectiveness, efficiency and quality of healthcare provided in Day Surgery (DS) setting at “Villa Malta” Hospital in Sarno (Italy). Health Technology Assessment (HTA) was used to compare two organisational models: the first one, in force at the beginning of the study, was characterized by a decentralisation of care activities at the individual Surgery Units; the other one provided for a centralisation of care activities in one unit, named the Multidisciplinary Day Surgery Unit (MDSU).

Description of the Problem

We evaluated economical (cost-minimisation analysis), performance (effectiveness, efficiency, appropriateness, quality and safety) and ethical-social aspects. The cost-minimisation analysis took into account costs incurred and revenues received (DRG-based reimbursement). The perceived quality and the ethical and social impacts were assessed by reference to the voluntary interruption of pregnancy (VIP) and the increasing offer of the Otorhinolaryngology services.

Results

MDSU has resulted in a net gain of €1,261,097 per year. This is a result of the increase in hospitalisation production of €1,235,869 and the savings on staff costs of €30,476. The new model also shown an improvement in efficiency through standardisation of the number of DS admissions and in perceived quality concerning VIP, ensuring greater privacy and humanisation for the patients. Finally, the introduction of the Otorhinolaryngology services in DS has increased the quality of healthcare on offer, without the need to transfer the surgical candidates to other hospitals.

Lessons

The centralised model has shown definite advantages over the decentralised one. MDSU was adopted to provide DS services at “Villa Malta” Hospital and this organisational model could be chosen by other hospitals to improve quality of healthcare.

Key messages

MDSU has advantages especially in economic, ethical and social terms. MDSU increases hospitalisation production, improves humanisation of patients and increases quality of healthcare on offer.

Barbed suture in oral cavity reconstruction: preliminary results

The purpose of this study is to evaluate the efficacy and safety of unidirectional barbed suture (V-Loc) compared to a standard monofilament stitch (Vicryl) in suturing of a free flap to local tissue after head and neck surgery for squamous cell carcinoma of the oral cavity. Complication rates, operative closure time, length of hospitalisation and costs were evaluated. The study cohort (group A) of 20 consecutive patients reconstructed using barbed stitches for suturing was prospectively compared to a control cohort (group B) of 20 consecutive patients reconstructed using conventional vicryl stitches. All patients were affected by squamous cell carcinoma of the tongue and underwent different types of glossectomy and reconstruction with free flaps. This analysis demonstrates the efficacy of the barbed suture compared with a standard monofilament stitch in terms of lower complication rate (15% group A, 30% group B), intra-operative closure times (486 minutes group A, 517 minutes group B), and length of hospitalisation (average length of hospitalisation 14.60 days group A, 16.85 days group B). These factors coupled with the use of a lower number of stitches compared with the standard stitches may compensate the increased cost of the barbed suture. In conclusion, this study demonstrates that the use of unidirectional barbed stitches for suturing of a free flap to the recipient site reduces the complication rate, principally in terms of dehiscence and fistula incidence, and reduces intra-operative time and length of hospitalisation. Based on these results and on the literature, the use of unidirectional barbed stitches can be considered as a safe and efficient alternative to conventional stitches for suturing of free flaps to local tissue.

Unravelling the risk factors that underlie laryngeal surgery in elderly

Older patients are not considered good candidates to undergo more challenging therapeutic treatments, e.g. highly invasive surgery and complex chemotherapy. However, their exclusion from standard therapeutic options is not justifiable. Herein, we reviewed 212 patients aged ≥ 70, affected with laryngeal squamous cell carcinoma, and treated with transoral laser microsurgery or open neck (partial / total) laryngectomy with radical intent. The main aim was to compare patient outcomes to identify predictive factors that can be used by surgeons to choose the most appropriate treatment option. In our cohort, patients affected with more advanced tumour and hence treated by invasive open neck surgeries (above all TL) are more prone to develop complications and undergo fatal outcome than those with early disease treated by laser microsurgery, independently of age at surgery. In conclusion, elderly patients affected by laryngeal cancer can be treated similarly to younger patients, keeping in mind that more invasive surgeries are associated with a higher risk of developing complications. The advantages of mini-invasive surgery make it a possible first choice treatment in very old and frail patients suffering from laryngeal cancer, especially considering the recent success in treatment of some advanced stage tumours. Furthermore, comorbidities, by themselves, should not be used as exclusion criteria for subjecting an elderly patient to a different treatment that is from standard therapy.

Identification and developmental expression of three Distal-less homeobox containing genes in the ascidian Ciona intestinalis

Several homeobox-containing genes related to Drosophila Distal-less (Dll) have been isolated from a wide variety of organisms and have been shown to function as developmental regulators. While in Drosophila only one Dll gene has been described so far, in Vertebrates many components of the Dlx multigenic family have been characterized. This suggests that, during the evolution of the Chordate phylum, the Dlx genes arose from an ancestral Dll/Dlx gene via gene duplication. We have previously reported the isolation of two Dll-related homeoboxes from the protochordate Ciona intestinalis, and described their clustered arrangement (Gene 156 (1995) 253). Here we present the detailed genomic organization and spatial-temporal expression of these two genes, Ci-Dll-A and Ci-Dll-B, and describe the isolation and characterization of another member of the ascidian family of Dll-related genes, which we tentatively named Ci-Dll-C.

Role of distinct mitogen-activated protein kinase pathways and cooperation between Ets-2, ATF-2, and Jun family members in human urokinase-type plasminogen activator gene induction by interleukin-1 and tetradecanoyl phorbol acetate

We have investigated the in vivo and in vitro regulation of the human urokinase-type plasminogen activator (uPA) gene by interleukin-1 (IL-1) and analyzed the transcription factors and signalling pathways involved in the response of the -2.0-kb uPA enhancer to IL-1 induction and to tetradecanoyl phorbol acetate (TPA) induction. Mutational analysis showed the cooperative activity of the Ets-binding site (EBS) and the two AP-1 elements of the enhancer. The results reveal that the EBS is required for the response to both inducers mediated by Ets-2, which is regulated at a level subsequent to DNA binding, by an IL-1- and phorbol ester-inducible transactivation domain. Both the IL-1 and the TPA-mediated induction result in a drastic increase of AP-1 binding to the downstream site of the enhancer (uPA 3' TPA-responsive element), while a mostly qualitative change, resulting from the interplay between ATF-2 homodimers and c-Jun-ATF-2 heterodimers, takes place at the upstream AP-1 element. The analysis of two distinct mitogen-activated protein kinase pathways shows that stress-activated protein kinase-Jun N-terminal kinase activation, resulting in the phosphorylation of ATF-2, c-Jun, and JunD, is required not only for the IL-1- but also for the TPA-dependent induction, while the extracellular signal-related kinase 1 (ERK-1) and ERK-2 activation is involved in the TPA- but not in the IL-1-dependent stimulation of the uPA enhancer.

Specific cellular localization of tyrosinase mRNA during Ciona intestinalis larval development

A Ciona intestinalis cDNA clone that encodes a protein highly homologous to other tyrosinases was isolated. Northern blot analysis showed that expression of Ciona tyrosinase starts at the early neurula stage and continues throughout the tail-bud and tadpole larval stages. The earliest tyrosinase expression was detected, by in situ hybridization, at the neural plate stage, in pigment precursor cells located along the two neural folds, in the animal region of the embryo. In the course of embryonic development the strong hybridization signal was always localized, within the rostral part of the developing brain, in the pigment precursor cells and was later detected in the otolith and ocellus. These results are discussed in relation to tyrosinase as an early marker of neural induction.

Heterodimerization of c-Jun with ATF-2 and c-Fos is required for positive and negative regulation of the human urokinase enhancer

Dimerization plays a pivotal role in modulating the activity of the c-Jun proto-oncogene product. Heterodimerization with activating transcription factor-2 (ATF-2) alters the DNA-binding specificity of c-Jun, allowing its targeting to several cAMP responsive element (CRE)-related sequences, which control a subset of AP-1-responsive genes. Here we show that a c-Jun/ATF-2 heterodimer binds to the AP-1 site (uPA 5'-TRE) essential for the activity of the human urokinase enhancer, conferring on this element several distinctive regulatory properties. The c-Jun/ATF-2 heterodimer was identified by binding competition assays, u.v. cross linking, and monospecific antibodies. In vitro binding studies revealed that the uPA 5'-TRE sequence is recognized by the cyclic AMP-unresponsive ATF-2 factor, but not by the cyclic AMP-inducible CREB. In addition, in vivo studies suggest that ATF-2 can mediate, at the same time, the activation of the c-Jun/ATF-2 site and the repression of the canonical collagenase AP-1 site. We report that heterodimerization with c-Fos does not increase the binding of c-Jun to the uPA 5'-TRE, in contrast to the increased binding at a consensus AP-1 site. Our data further suggest that c-Fos can act as a repressor of the c-Jun/ATF-2 binding site, revealing an important functional difference, with respect to canonical AP-1 elements.

Patient-ventilator interaction during synchronized intermittent mandatory ventilation. Effects of flow triggering

Synchronized intermittent mandatory ventilation (SIMV) intermixes assisted and spontaneous breaths. Its ability as a weaning technique has been questioned on the basis that patients show little adaptation to ventilator assistance. We studied inspiratory effort and patient-ventilator interaction at different levels (SIMV, 100, 50, and 0%) of flow-triggered SIMV versus pressure-triggered SIMV in patients during the weaning period. The two triggering systems were evaluated during constant flow and constant pressure mandatory SIMV breaths. Inspiratory effort was estimated as the esophageal pressure time product (PTP) per breath (PTP/b) and per minute (PTP/min). The PTP/b and PTP/min of both mandatory and spontaneous breaths were significantly lower during flow triggering than during pressure triggering SIMV, irrespective of the ventilatory mode. During pressure-triggered SIMV PTP/b and PTP/min were identical for mandatory and spontaneous breaths, whereas during flow-triggered SIMV PTP/b and PTP/min were significantly lower for mandatory than for spontaneous breaths. This difference was greatest when flow triggering and constant pressure ventilation were associated. These data show that flow triggering reduces inspiratory effort during both mandatory and spontaneous SIMV breaths and obtains a better patient-ventilator interaction.

A regulatory element that mediates co-operation between a PEA3-AP-1 element and an AP-1 site is required for phorbol ester induction of urokinase enhancer activity in HepG2 hepatoma cells

We have characterized a transcriptional enhancer of the human urokinase-type plasminogen activator (uPA) gene and found a regulatory element required for co-operation between a PEA3--AP-1 element and an AP-1 site in the enhancer. We designated this regulatory element co-operation mediator (COM). Both the PEA3--AP-1 element, the AP-1 site and the COM are required for efficient phorbol ester induction of transcription from the uPA promoter in the HepG2 hepatoma cell line. We show that the COM is also required for co-operation between the PEA3--AP-1 element and a glucocorticoid response element, both in the presence or absence of TPA, indicating that the COM is generally capable of mediating synergism between inducible enhancer elements. The COM contains multiple overlapping binding sites for nuclear proteins, designated uPA enhancer factors 1-4 (UEF-1-4). We have identified putative binding sites for UEF-1, -2 and -3. The UEF-1 and -3 sites in the uPA enhancer are highly conserved between species. We demonstrate the binding of UEF-3 to the NIP element, a previously characterized regulatory element in the human interleukin-3 and stromelysin promoters, suggesting that this factor plays a role in regulation of a variety of genes.