An assessment of sustainable transport infrastructure in a national healthcare system

INTRODUCTION

Healthcare contributes significantly to carbon dioxide emissions, which can be reduced by promoting sustainable mobility amongst staff commuting. This study aims to investigate the national sustainable transport infrastructure for staff of healthcare facilities and utilise this data to develop a novel scoring and ranking system.

METHODS

This was an empirical retrospective observational study. Data was collected on all 47 hospitals sustainable transport infrastructure. A working group calculated the weighted scores for each sustainable transport data point. These scores were used to calculate the Total and Active Sustainability Scores for each hospital, allowing a ranking to be formed.

RESULTS

7 of 47 (15 %) hospitals had EV charging on campus. 17 of 47 (36 %) hospitals had secure bike parking. 2 of 47 (4 %) hospitals had a "bike hub". 18 of 47 (38 %) hospitals had a bike lane. 13 of 22 (59 %) city hospitals had bike sharing facilities. 42 of 47 (89 %) hospitals had one public transport route. City hospitals ranked higher in both Total & Active Sustainability Scores.

DISCUSSION

This study explored a new concept of measuring sustainable transport infrastructure. Frameworks examining sustainability are available, however, none allowed for ranking of hospitals. This study highlights the lack of both research in this field and sustainable transport infrastructure in hospitals.

Recurrent venous thromboembolism in cancer patients treated with direct oral anticoagulants

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Background: Malignancy associated thrombosis places a significant clinical and financial burden on all major oncology services worldwide. Cancer patients are at an increased risk of thrombosis and large studies have suggested a subsequent increased mortality. (1) Some studies have recorded higher risk associated with certain chemotherapy regimens such as platinum-based agents and gemcitabine. (2) Guidelines for anticoagulation often recommend low molecular weight heparin (LMWH) as first line for malignancy associated thrombosis. (3) In recent years ASCO guidelines have added DOACs as an option for VTE treatment. (4) We herein describe eight cases of recurrent venous thromboembolism despite direct oral anticoagulation. Methods: Data was gathered from electronic patient records for cancer patients attending a single centre in Western Australia between 2016 and 2021. Radiology and medication records were used to confirm VTE diagnoses and subsequent treatment. This data was recorded on an excel file and analysed accordingly. Results: We identified 8 patients with recurrent VTE on DOACs. Median age of patients was 61 years (range 50-72). The most common associated malignancy was pancreatic cancer (n = 3). Other associated cancer types were ovarian (n = 2), lung adenocarcinoma (n = 2) and colorectal cancer(n = 1). Most patients had metastatic disease at time of first VTE(n = 5). The most common site of thrombosis was in the upper limb with 3 cases of initial VTE and 4 cases of recurrent VTE. All of these occurred in patients with peripherally inserted central catheters. (PICC) One patient had a left central retinal vein thrombosis resulting in complete loss of vision in that eye. All but one patient had received either platinum based chemotherapy or gemcitabine. Median time to initial thrombotic event was 4 months from diagnosis. Median time to recurrent thrombotic event was 3.5 months. Rivaroxaban was the most common DOAC used with initial VTE (n = 5). All other patients received apixaban (n = 3). All patients were switched to either LMWH (n = 6) or unfractionated heparin (n = 2) following recurrent VTE. 75% of patients did not have further thrombosis after switch to heparin. One patient had chronic thrombosis on subsequent scans and another patient had recurrent pulmonary embolism despite unfractionated heparin and vena cava filter insertion. Conclusions: Venous thromboembolism is a common complication of malignancy with significant associated morbidity and mortality. A high index of suspicion is needed in patients with clinical signs of recurrent VTE while on a DOAC, especially for those with PICCs. While DOACs are common for patient preference, the differing rates of VTE recurrences should be further investigated and considered in oncology prescribing practice going forward.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Cancer associated thrombosis in patients taking direct oral anticoagulants (DOACs): Retrospective review of a single institutional series

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Background: Venous thromboembolism (VTE) is a common and often serious complication for patients with malignancy. Even though low molecular weight heparin (LMWH) is recommended as first line therapy for initial and long term anticoagulation, patient choice may demand oral anticoagulants. This retrospective review illustrates the repeated observation of recurrent thromboembolic disease in patients taking the new class of oral anticoagulant, DOAC. Methods: The pharmacy database at our institution was searched to identify oncology patients who had received a prescription for a DOAC (rivaroxaban or apixiban). Sixtyfive patients were identified and case records were then examined for evidence of venous thromboembolism. Results: Five seperate episodes of recurrent venous thromboembolism were identified in four patients in our cohort., one patient having two seperate episodes of pulmonary embolus. All were on recommended therapeutic doses of DOAC at the time of thromboembolic event. Two patients experienced proven pulmonary embolus on CT pulmonary angiography (1 twice), one lower limb deep vein thrombosis and one upper limb deep vein thrombosis. Conclusions: This retrosepctive review reinforces the clinical guidelines stated by the Cochrane review and ASCO that LMWH should always be first line for the initial and continuation treatment of a VTE. The guidelines did not focus on the suboptimal anticoagulation aspect of the newer oral anticoagulants but more on the safety issues. Research has been mainly focused on comparing LMWH with unfractionated heparin (UFH) or oral warfarin. Comparisons between DOAC versus Warfarin as an oral form of therapy have also been made. In the available published literature, there is a paucity of research comparing DOACs to LMWH. We have identified four patients out of sixtyfive treated with therapeutic doses of DOAC who developed subsequent thromboembolism. This is additional supportive evidence that newer oral anticoagulant agents may not be efficacious in malignancy driven VTE and that LMWH should remain the standard of care. Patients specifically requesting DOAC for cancer associated VTE should be made aware of this data.

An electron beam lithography and digital image acquisition system for scanning electron microscopes

A low-cost microcontroller based control and data acquisition unit for digital image recording of scanning electron microscope (SEM) images and scanning electron microscope based electron beam lithography (EBL) is described. The developed microcontroller low-level embedded software incorporates major time critical functions for image acquisition and electron beam lithography and makes the unit an intelligent module which communicates via USB with the main computer. The system allows recording of images with up to 4096 x 4096 pixel size, different scan modes, controllable dwell time, synchronization with main power frequency, and other user controllable functions. The electron beam can be arbitrary positioned with 12-bit precision in both dimensions and this is used to extend the scanning electron microscope capabilities for electron beam lithography. Hardware and software details of the system are given to allow its easy duplication. Performance of the system is discussed and exemplary results are presented.