Acceptability and barriers to adopting physical therapy and rehabilitation as standard of care in hernia disease: a prospective national survey of providers and preliminary data

PURPOSE

Physical therapy (PT) and rehabilitation are widely utilized in a variety of disease processes to improve function, return to activities of daily living (ADLs), and promote overall recovery. However, hernia repair has struggled to adopt this practice despite operations occurring in one of the most dynamic parts of the body - the abdominal core. This study sought to understand perspectives and perceived barriers regarding the incorporation of PT and rehabilitation in hernia care.

METHODS

A standardized rehabilitation protocol was developed by the Abdominal Core Health Quality Collaborative (ACHQC), a national quality improvement initiative specific to hernia disease, and launched in 2019. Empiric data from the ACHQC was then obtained to describe preliminary utilization. A prospective electronic survey was then deployed to all surgeons participating in the ACHQC to aid in interpreting the identified trends. The survey included questions regarding the current use of PT in their practice, as well as further opinions on the functionality, benefit, and barriers to its use.

RESULTS

We identified 1,544 patients who were listed as receiving some form of postoperative rehabilitation, of which 992 (64.2%) had a primary diagnosis of ventral hernia and 552 (35.8%) had an inguinal hernia. Among patients who had a ventral hernia, 863 (87.0%) received self-directed rehabilitation exercises compared to 488 (88.4%) of inguinal hernia patients. The subsequent survey exploring these trends was completed by 46 ACHQC surgeons (10.2%). More than half (52%) reported using PT for hernia patients, primarily in abdominal wall reconstruction cases (92%). Of those who did not report using PT, 50% cited unknown clinical benefit and another 27% cited unknown PT resources. PT utilization was typically concentrated to the postoperative period (58%), while 42% reported also using it preoperatively. Despite 72% of respondents citing a perceived benefit of PT in hernia patients, overall use of PT was primarily reported as 'occasional' by 42%, with another 27% reporting 'rarely.' Perceived benefits of PT included increased core strength, stability, mobility, patient satisfaction, education, independence, earlier return to work and ADLs, overall improved recovery, and decreased risk of postoperative issues. Reported barriers to implementing PT in practice or adapting the ACHQC Rehabilitation Protocol included lack of education, lack of evidence of clinical benefit, and difficulties operationalizing the protocol.

CONCLUSION

A national survey of hernia surgeons demonstrated willingness to adopt PT and rehabilitation protocols in their clinical practices and noted a high perceived benefit to patients. However, lack of education and evidence regarding the protocol may represent important barriers to overcome in widely disseminating these resources to patients. These gaps can be addressed through dedicated educational venues and additional studies establishing PT and rehabilitation as critical future adjuncts for the recovery of hernia repair patients.

Radiofrequency ablation for the treatment of haemorrhoidal disease: a minimally invasive and effective treatment modality

BACKGROUND

Haemorrhoidal disease (HD) is a common colorectal condition that often requires surgical treatment. Less invasive procedures are usually more acceptable to patients. The aim of this study was to report the outcome of a novel and minimally invasive technique employing a radiofrequency ablation (RFA) energy (Rafaelo^®) to treat HD.

METHODS

A total number of 27 patients who had RFA for the treatment of HD were recruited to this study. The procedure was performed under deep sedation and local anaesthesia. Patients' demographics; haemorrhoid severity score (HSS); quality of life; pain and satisfaction scores; and recurrence rate were recorded.

RESULTS

The mean age of the patients was 46 (SD 14) years, 18 (67%) males and 9 (33%) females. The mean body mass index was 25 (SD 4) kg/m². The predominant symptom of all patients was per-rectal bleeding. HSS improved from 7.2 (SD 1.9) before the procedure to 1.6 (SD 1) after the procedure (p < 0.0001). Postoperative pain scores on a scale of 0-10 were 0, 2 (SD 2), 1 (SD 2), and 0 on immediate, day-1, day-3, and 2-month follow-up questionnaire. The mean satisfacion score was 9 (SD 1.5) out of 10 on 2-month follow-up. Mean time until patients returned to normal daily activity was 3 (SD 1) days following the procedure. Quality-of-life assessments including: visual analogue scale scores (before: mean 70, SD 23; after: mean 82, SD 16; p < 0.001) and EQ-5D-5L (before: mean 0.84, SD 0.15; after: mean 0.94, SD 0.13; p < 0.05) were significantly improved. The mean length of follow-up for recurrence of symptoms was 20 months (range 12-32 months). One patient (4%) reported the recurrence of rectal bleeding 12 months after the procedure.

CONCLUSIONS

RFA for the treatment of HD is safe and effective in achieving symptomatic relief. It is associated with minimal postoperative pain and low incidence of recurrence.

Logistic regression model to predict acute uncomplicated and complicated appendicitis

INTRODUCTION

While patients with acute uncomplicated appendicitis may be treated conservatively, those who suffer from complicated appendicitis require surgery. We describe a logistic regression equation to calculate the likelihood of acute uncomplicated appendicitis and complicated appendicitis in patients presenting to the emergency department with suspected acute appendicitis.

MATERIALS AND METHODS

A cohort of 895 patients who underwent appendicectomy were analysed retrospectively. Depending on the final histology, patients were divided into three groups; normal appendix, acute uncomplicated appendicitis and complicated appendicitis. Normal appendix was considered the reference category, while acute uncomplicated appendicitis and complicated appendicitis were the nominal categories. Multivariate and univariate regression models were undertaken to detect independent variables with significant odds ratio that can predict acute uncomplicated appendicitis and complicated appendicitis. Subsequently, a logistic regression equation was generated to produce the likelihood acute uncomplicated appendicitis and complicated appendicitis.

RESULTS

Pathological diagnosis of normal appendix, acute uncomplicated appendicitis and complicated appendicitis was identified in 188 (21%), 525 (59%) and 182 patients (20%), respectively. The odds ratio from a univariate analysis to predict complicated appendicitis for age, female gender, log2 white cell count, log2 C-reactive protein and log2 bilirubin were 1.02 (95% confidence interval, CI, 1.01, 1.04), 2.37 (95% CI 1.51, 3.70), 9.74 (95% CI 5.41, 17.5), 1.57 (95% CI 1.40, 1.74), 2.08 (95% CI 1.56, 2.76), respectively. For the same variable, similar odds ratios were demonstrated in a multivariate analysis to predict complicated appendicitis and univariate and multivariate analysis to predict acute uncomplicated appendicitis.

CONCLUSIONS

The likelihood of acute uncomplicated appendicitis and complicated appendicitis can be calculated by using the reported predictive equations integrated into a web application at www.appendistat.com. This will enable clinicians to determine the probability of appendicitis and the need for urgent surgery in case of complicated appendicitis.

Perioperative outcomes and adverse events of robotic colorectal resections for inflammatory bowel disease: a systematic literature review

The purpose of this study was to assess outcome measures and cost-effectiveness of robotic colorectal resections in adult patients with inflammatory bowel disease. The Cochrane Library, PubMed/Medline and Embase databases were reviewed, using the text "robotic(s)" AND ("inflammatory bowel disease" OR "Crohn's" OR "Ulcerative Colitis"). Two investigators screened abstracts for eligibility. All English language full-text articles were reviewed for specified outcomes. Data were presented in a summarised and aggregate form, since the lack of higher-level evidence studies precluded meta-analysis. Primary outcomes included mortality and postoperative complications. Secondary outcomes included readmission rate, length of stay, conversion rate, procedure time, estimated blood loss and functional outcome. The tertiary outcome was cost-effectiveness. Eight studies (3 case-matched observational studies, 4 case series and 1 case report) met the inclusion criteria. There was no reported mortality. Overall, complications occurred in 81 patients (54%) including 30 (20%) Clavien-Dindo III-IV complications. Mean length of stay was 8.6 days. Eleven cases (7.3%) were converted to open. The mean robotic operating time was 99 min out of a mean total operating time of 298.6 min. Thirty-two patients (24.7%) were readmitted. Functional outcomes were comparable among robotic, laparoscopic and open approaches. Case-matched observational studies comparing robotic to laparoscopic surgery revealed a significantly longer procedure time; however, conversion, complication, length of stay and readmission rates were similar. The case-matched observational study comparing robotic to open surgery also revealed a longer procedure time and a higher readmission rate; postoperative complication rates and length of stay were similar. No studies compared cost-effectiveness between robotic and traditional approaches. Although robotic resections for inflammatory bowel disease are technically feasible, outcomes must be interpreted with caution due to low-quality studies.

Lifetime prevalence of non-suicidal self-injury in patients with eating disorders: a systematic review and meta-analysis

BACKGROUND

Against a backdrop of increasing research, clinical and taxonomic attention in non-suicidal self-injury (NSSI), evidence suggests a link between NSSI and eating disorders (ED). The frequency estimates of NSSI in ED vary widely. Little is known about the sources of this variation, and no meta-analysis has quantified the association between ED and NSSI.

METHOD

Using random-effects meta-analyses, meta-regression analyses, and 1816-6466 unique participants with various ED, we estimated the weighted average percentage of individuals with ED, those with anorexia nervosa (AN) and those with bulimia nervosa (BN) who are reported to have a lifetime history of NSSI across studies. We further examined predictors of NSSI in ED.

RESULTS

The weighted average percentage of patients with a lifetime history of NSSI was 27.3% [95% confidence interval (CI) 23.8-31.0%] for ED, 21.8% (95% CI 18.5-25.6%) for AN, and 32.7% (95% CI 26.9-39.1%) for BN. The difference between BN and AN was statistically significant [odds ratio (OR) 1.77, 95% CI 1.14-2.77, p = 0.013]. The odds of NSSI increased by 24% for every 10% increase in the percentage of participants with histories of suicide attempts (OR 1.24, 95% CI 1.04-1.48, p = 0.020) and decreased by 26% for every 10% increase in the percentage of participants with histories of substance abuse (OR 0.74, 95% CI 0.58-0.95, p = 0.023).

CONCLUSIONS

In the specific context of ED, NSSI is highly prevalent and correlates positively with attempted suicide, urging for NSSI-focused treatments. A novel finding is that NSSI is potentially antagonized by substance abuse.

Delivery of high energy Er:YAG pulsed laser light at 2.94 µm through a silica hollow core photonic crystal fibre

In this paper the delivery of high power Er:YAG laser pulses through a silica hollow core photonic crystal fibre is demonstrated. The Er:YAG wavelength of 2.94 µm is well beyond the normal transmittance of bulk silica but the unique hollow core guidance allows silica to guide in this regime. We have demonstrated for the first time the ability to deliver high energy pulses through an all-silica fibre at 2.94 µm. These silica fibres are mechanically and chemically robust, biocompatible and have low sensitivity to bending. A maximum pulse energy of 14 mJ at 2.94 µm was delivered through the fibre. This, to our knowledge, is the first time a silica hollow core photonic crystal fibre has been shown to transmit 2.94 μm laser light at a fluence exceeding the thresholds required for modification (e.g. cutting and drilling) of hard biological tissue. Consequently, laser delivery systems based on these fibres have the potential for the realization of novel, minimally-invasive surgical procedures.

The effect of bilirubin on the assay of gentamicin

An experiment was set up to examine the effect of ;jaundiced' serum on the estimation of gentamicin levels in serum. Varying amounts of gentamicin were assayed in the presence of a range of bilirubin concentrations and compared with assayed levels in normal serum.