Improving Gastrointestinal Cancer Care by Enhanced Recovery Protocol Implementation

Background

Enhanced recovery protocols (ERPs) have become the standard of care for patients undergoing elective small bowel surgeries but have not yet been adequately studied in community hospitals. In this study, a multidisciplinary ERP was developed and implemented at a community hospital to include minimal anesthesia, early ambulation and enteral alimentation, and multimodal analgesia. The aim of this study was to determine the effects of the ERP on postoperative length of stay (LOS), readmission (RA) rates following bowel surgery, and postoperative outcomes.

Methods

The study design was a retrospective review of patients undergoing major bowel resection at Holy Cross Hospital (HCH) from January 1, 2017 to December 31, 2017. Patient charts for diagnostic-related group (DRG) 329, 330, and 331 were retrospectively reviewed at HCH in 2017 to compare outcomes in ERP versus non-ERP cases. The Medicare claims database (CMS) was also retrospectively reviewed to compare HCH data to the national average LOS and RA for the same DRG codes. Mean values for LOS and RA were statistically compared to determine significant differences between ERP versus non-ERP patients at HCH and national CMS data versus HCH patients.

Results

LOS was analyzed for each DRG at HCH. At HCH, for DRG 329, the mean LOS for non-ERP was 13.0833 days (n = 12) versus 3.375 days (n = 8) (P ≤ 0.001) for ERP. For DRG 330, the mean LOS for non-ERP was 10.861 days (n = 36) versus 4.583 days (n = 24) (P ≤ 0.001) for ERP. For DRG 331, the mean LOS for non-ERP was 7.272 days (n = 11) versus 3.348 days (n = 23) (P = 0.004) for ERP. LOS was also compared to national CMS data. The LOS at HCH for DRG 329 improved from the 10th to 90th percentile (n = 238,907); DRG 330 improved from the 10th to the 72nd percentile (n = 285,423); DRG 331 improved from 10th to 54th percentile (n = 126,941) (P < 0.001). The RA at HCH in ERP and non-ERP cases was 3% at 30 and 90 days. CMS RA for DRG 329 was 25.1% at 90 days and 9.9% at 30 days; DRG 330 RA was 18.3% at 90 days and 6.6% at 30 days; DRG 331 RA was 11% at 90 days and 3.9% at 30 days.

Conclusion

Implementation of ERP following bowel surgery at HCH significantly improved outcomes, in comparison to non-ERP cases, national CMS data, and Humana data. Further research on ERP for other fields and its impact on outcomes in other community settings is recommended.

Angiotensin converting enzyme gene polymorphism studies: A case-control study

Mild gestational hyperglycemia (MGH) is a very common complication of pregnancy that is characterized by intolerance to glucose. The association of angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism to MGH has been previously reported. In this study, we evaluated the association between ACE polymorphism and the risk of MGH in a Saudi population. We conducted a case-control study in a population of 100 MGH patients and 100 control subjects. ACE gene polymorphism was analyzed by the novel approach of tetraprimer amplification refractory mutation system (ARMS)-polymerase chain reaction (PCR). The frequency of ACE polymorphism was not associated with either alleles or genotypes in MGH patients. Glucose concentration was found to be significantly associated with the MGH group. Our study suggests that ACE genotypes were not associated with ACE polymorphism in a Saudi population.

Delayed diagnosis in children with intracranial germ cell tumors

OBJECTIVE

To review symptoms and provider history in a large cohort of patients with germ cell tumors (GCTs) to highlight the variety of manifestations and assess the effect of delayed diagnosis on outcomes.

STUDY DESIGN

Patients treated for intracranial pure germinoma and nongerminomatous GCTs at Massachusetts General Hospital between 1998 and 2012 were included (n = 70). The primary outcome was time from onset of symptoms to diagnostic imaging. Delay was defined as an interval of ≥ 6 months.

RESULTS

The median duration of symptoms before diagnostic magnetic resonance imaging was 6 months (range, 2 days to 72 months). Thirty-eight of the 70 patients (54%) had a delayed diagnosis. Patients with suprasellar tumors presented with symptoms related to endocrinopathies, and patients with pineal region tumors presented with symptoms related to hydrocephalus. Most of the patients were evaluated by a general pediatrician (49%) and/or pediatric subspecialists (66%) before diagnosis. Patients with delayed diagnosis saw a greater number of physicians before diagnosis (P = .006). The majority of patients (63%) with delayed diagnosis were seen by 2 or more physicians, and many (40%) were seen by 2 or more subspecialists. Progression-free survival was similar in the patients with delayed diagnosis and those without delayed diagnosis (P = .90), but the former were more likely to present with disseminated disease at diagnosis (34% vs 6%; P = .007).

CONCLUSION

A significant proportion of patients with GCT experience a delay in time to diagnosis, in some cases despite evaluation by general pediatricians and specialists. This delay increases the risk of disseminated disease.

The association of bisphenol-A urinary concentrations with antral follicle counts and other measures of ovarian reserve in women undergoing infertility treatments

In this prospective cohort of women undergoing infertility treatments, we measured specific-gravity adjusted urinary BPA (SG-BPA) concentrations and used regression models to evaluate the association of BPA with antral follicle count (AFC), day-3 serum follicle stimulating hormone levels (FSH), and ovarian volume (OV). BPA, detected in >80% of women, had a geometric mean (±GSD) of 1.6±2.0, 1.7±2.1, and 1.5±1.8μg/L for the women contributing to the AFC (n=154), day-3 FSH (n=120), and OV (n=114) analyses, respectively. There was an average decrease in AFC of 12% (95% CI: -23%, -0.6%), 22% (95% CI: -31%, -11%), and 17% (95% CI: -27%, -6%), in the 2nd, 3rd, and 4th SG-BPA quartile compared to the 1st quartile, respectively (p-trend: <0.001). No association of SG-BPA with FSH or OV was observed. Among women from an infertility clinic, higher urinary BPA concentrations were associated with lower AFC, raising concern for possible accelerated follicle loss and reproductive aging.

Bisphenol A and human health: a review of the literature

There is growing evidence that bisphenol A (BPA) may adversely affect humans. BPA is an endocrine disruptor that has been shown to be harmful in laboratory animal studies. Until recently, there were relatively few epidemiological studies examining the relationship between BPA and health effects in humans. However, in the last year, the number of these studies has more than doubled. A comprehensive literature search found 91 studies linking BPA to human health; 53 published within the last year. This review outlines this body of literature, showing associations between BPA exposure and adverse perinatal, childhood, and adult health outcomes, including reproductive and developmental effects, metabolic disease, and other health effects. These studies encompass both prenatal and postnatal exposures, and include several study designs and population types. While it is difficult to make causal links with epidemiological studies, the growing human literature correlating environmental BPA exposure to adverse effects in humans, along with laboratory studies in many species including primates, provides increasing support that environmental BPA exposure can be harmful to humans, especially in regards to behavioral and other effects in children.

Which neuromuscular attributes are most associated with mobility among older primary care patients?

OBJECTIVE

To identify the neuromuscular attributes that are associated with self-reported mobility status among older primary care patients.

DESIGN

Cohort study.

SETTING

Metropolitan-based health care system.

PARTICIPANTS

Community-dwelling primary care patients aged ≥65 years (N=430), with self-reported modification of mobility tasks resulting from underlying health conditions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Basic and Advanced Lower Extremity Function as measured by the Late Life Function and Disability Instrument.

RESULTS

We constructed multivariable linear regression models evaluating both outcomes. For Basic Lower Extremity Function, leg strength, leg velocity, trunk extensor muscle endurance, and ankle range of motion (ROM) were statistically significant predictors (P<.001, R(2)=.21). For Advanced Lower Extremity Function, leg strength, leg strength asymmetry, leg velocity, trunk extensor muscle endurance, and knee flexion ROM were statistically significant predictors (P<.001, R(2)=.39). Sensitivity analyses conducted using multiple imputations to account for missing data confirmed these findings.

CONCLUSIONS

This analysis highlights the relevance and importance of 5 categories of neuromuscular attributes: strength, speed of movement, ROM, asymmetry, and trunk stability. It identifies novel attributes (leg velocity and trunk extensor muscle endurance) relevant to mobility and highlights that impairment profiles vary by the level of mobility assessed. These findings will inform the design of more thorough and potentially more effective disability prevention strategies.