JMIR perioperative medicine最新文献

Background: The clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics.

Objective: We aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection.

Methods: The enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice a day compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival.

Results: Patients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were £9538.279 (£1=US $1.60) for ERP and £14,793.05 for standard treatment. This results in a cost-effectiveness ratio of -£6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91% (42/46) for patients receiving ERP versus 73% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery.

Conclusions: ERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings.

Background: The frequency and timing of assessing patient symptoms and discomfort during postoperative recovery are goals. Therefore, real-time recovery evaluation has been suggested to identify specific deficits in patient recovery.

Objective: This study aimed to psychometrically evaluate the Swedish Web Version of the Quality of Recovery (SwQoR) Scale adapted for patients undergoing local and peripheral nerve block (SwQoR-LA).

Methods: This was a secondary analysis of a psychometric evaluation of 107 patients aged ≥18 years undergoing day surgery under local or peripheral nerve block anesthesia at 4 different day surgery departments in Sweden. The SwQoR-LA, available through a mobile app called Recovery Assessment by Phone Points (RAPP), was completed daily on postoperative days 1-7.

Results: Some evidence of construct validity was supported, and discriminant validity was found in 7 of 8 items related to general anesthesia. The internal consistency was acceptable (.87-.89), and the split-half reliability was 0.80-0.86. Cohen d effect size was 0.98, and the percentage of change from baseline was 43.4%. No floor nor ceiling effects were found.

Conclusions: The SwQoR-LA is valid, reliable, responsive, and clinically feasible for digital real-time recovery assessment of patient recovery to identify specific deficits in patient recovery and detect those patients who might benefit from a timely intervention.

Trial registration: ClinicalTrials.gov NCT02492191; https://clinicaltrials.gov/ct2/show/NCT02492191.

International registered report identifier (irrid): RR2-10.1136/bmjopen-2015-009901.

Background: Hospital stays after major surgery are shorter than ever before. Although enhanced recovery and early discharge have many benefits, some complications will now first manifest themselves in home settings. Remote patient monitoring with wearable sensors in the first days after hospital discharge may capture clinical deterioration earlier but is largely uncharted territory.

Objective: This study aimed to assess the technical feasibility of patients, discharged after esophagectomy, being remotely monitored at home with a wireless patch sensor and the experiences of these patients. In addition, we determined whether observing vital signs with a wireless patch sensor influences clinical decision making.

Methods: In an observational feasibility study, vital signs of patients were monitored with a wearable patch sensor (VitalPatch, VitalConnect Inc) during the first 7 days at home after esophagectomy and discharge from hospital. Vital signs trends were shared with the surgical team once a day, and they were asked to check the patient's condition by phone each morning. Patient experiences were evaluated with a questionnaire, and technical feasibility was analyzed on a daily basis as the percentage of data loss and gap durations. In addition, the number of patients for whom a change in clinical decision was made based on the results of remote vital signs monitoring at home was assessed.

Results: Patients (N=20) completed 7 days each of home monitoring with the wearable patch sensor. Each of the patients had good recovery at home, and remotely observed vital signs trends did not alter clinical decision making. Patients appreciated that surgeons checked their vital signs daily (mean 4.4/5) and were happy to be called by the surgical team each day (mean 4.5/5). Wearability of the patch was high (mean 4.4/5), and no reports of skin irritation were mentioned. Overall data loss of vital signs measurements at home was 25%; both data loss and gap duration varied considerably among patients.

Conclusions: Remote monitoring of vital signs combined with telephone support from the surgical team was feasible and well perceived by all patients. Future studies need to evaluate the impact of home monitoring on patient outcome as well as the cost-effectiveness of this new approach.

Background: The American College of Surgeons reports 88,320 intraoperative needlestick injuries (NSIs) per year, resulting in US $376 to US $2456 in costs per NSI. Engineered sharps injury prevention (ESIP) devices protect against NSIs. To our knowledge, no study has been published to date to demonstrate clinical effectiveness of an intraoperative ESIP device. Operative Armour is a wearable arm cuff that can be donned during surgical closure to allow surgeons to keep a suture pack and sharps protection container on their forearm.

Objective: We characterize Operative Armour's ESIP device effectiveness in a tertiary hospital, hypothesizing that this device will decrease NSI risk by decreasing behaviors associated with NSIs: needle passing and handling.

Methods: A prospective case-control study was conducted with institutional review board quality improvement designation in which authors observed skin closures of plastic surgery procedures. To ensure accuracy, one surgeon was observed at a time. Control surgeries were purely observational; intervention cases involved surgeon use of the device during skin closure. Outcomes of interest included needle passing, needle handling, lost needles, and loaded waiting needles.

Results: Surgeons were observed in 50 control and 50 intervention cases. Operative Armour eliminated needle passing during skin closure. One NSI occurred in one control case; no NSIs were observed in intervention cases (P=.36). The mean number of loaded and unprotected waiting needles was also significantly decreased in the intervention group from 2.3 to 0.2 (P<.001). Furthermore, a multivariable linear regression established that Operative Armour significantly decreased the number of needle adjustments by hand per stitch observed (F_{4, 21.68}=3.72; P=.01). In fact, needle adjustments by hand decreased overall (1 adjustment per 10 stitches vs 1 adjustment per 5 stitches, P=.004), and adjustments occurred half as frequently with use of Operative Armour in free flap reconstruction (1 adjustment per 10 stitches vs 1 adjustment per 5 stitches, P=.03) and a quarter as frequently in other breast reconstruction cases such as mastopexy (1 adjustment per 20 stitches vs 1 adjustment per 5 stitches, P=.002).

Conclusions: Operative Armour effectively functions as an ESIP device by decreasing intraoperative needle passing and handling. Although sample size prohibits demonstrating a decrease in NSIs during observed cases, by decreasing behaviors that drive NSI risk, we anticipate an associated decrease in NSIs with use of the device.

Background: Hernia repairs account for millions of general surgical procedures performed each year worldwide, with a notable shift to outpatient settings over the last decades. As technical possibilities such as smartphones, tablets, and different kinds of probes are becoming more and more available, such systems have been evaluated for applications in various clinical settings. However, there have been few studies conducted in the surgical field, especially in general surgery.

Objective: We aimed to assess the feasibility of a tablet-based follow up to monitor activity levels after repair of abdominal wall hernias and to evaluate a possible reduction of adverse events by their earlier recognition.

Methods: Patients scheduled for elective surgical repair of minor abdominal wall hernias (eg, inguinal, umbilical, or trocar hernias) were equipped with a telemonitoring system, including a tablet, pulse oximeter, and actimeter, for a monitoring phase of 7 days before and 30 days after surgery. Descriptive statistical analyses were performed.

Results: We enrolled 16 patients with a mean overall age of 48.75 (SD 16.27) years. Preoperative activity levels were reached on postoperative day 12 with a median of 2242 (IQR 0-4578) steps after plunging on the day of surgery. The median proportion of available activity measurements over the entire study period of 38 days was 69% (IQR 56%-81%). We observed a gradual decrease in the proportion of available data for all parameters during the postoperative course. Six out of ten patients (60%) regained preoperative activity levels within 3 weeks after surgery. Overall, patients rated the usability of the system as relatively easy.

Conclusions: Tablet-based follow up is feasible after surgical repair of minor abdominal wall hernias, with good adherence rates during the first couple of weeks after surgery. Thus, such a system could be a useful tool to supplement or even replace traditional outpatient follow up in selected general surgical patients.

Background: There is a great unmet clinical need to provide patients undergoing spinal surgery and their caregivers with ongoing, high-quality care before and after surgery in an efficiency-focused health care environment.

Objective: The objective of this study is to design, develop, and evaluate the acceptability and feasibility of a novel planning-, outcomes-, and analytics-based smartphone app called ManageMySurgery (MMS) in patients undergoing elective spine surgery (MMS-Spine).

Methods: The development process of the MMS app was conducted over 2 sequential stages: (1) an evidence-based intervention design with refinement from surgeon and patient feedback and (2) feasibility testing in a clinical pilot study. We developed a novel, mobile-based, Health Insurance Portability and Accountability Act-compliant platform for interventional and surgical procedures. It is a patient-centric mobile health app that streamlines patients' interactions with their care team. MMS divides the patient journey into phases, making it feasible to provide customized care pathways that meet patients' unique needs. Patient-reported outcomes are easily collected and conform to the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) standard.

Results: We tested the feasibility of the MMS-Spine app with patients undergoing elective spine surgery at a large academic health system. A total of 47 patients undergoing elective spine surgery (26 cervical spine and 21 lumbar spine surgeries) downloaded and used MMS-Spine to navigate their surgical journey, quantify their baseline characteristics and postoperative outcomes, and provide feedback on the utility of the app in preparing for and recovering from their spinal surgery. The median age was 59.0 (range 33-77) years, 22 of the 47 patients (47%) were women, and 26 patients (55%) had commercial insurance. Of the 47 patients, a total of 33 (70%) logged in on an iOS device, 11 (23%) on an Android device, and 3 (6%) on a computer or tablet. A total of 17 of the 47 patients (36%) added a caregiver, of which 7 (41%) logged in. The median number of sign-ins was 2. A total of 38 of 47 patients (81%) completed their baseline preoperative PROMIS-29 outcomes, and 14 patients (30%) completed at least one PROMIS-29 survey during the postoperative period. Of the 24 patients who completed the MMS survey, 21 (88%) said it was helpful during preparation for their procedure, 16 (67%) said it was helpful during the postoperative period, and 23 (96%) said that they would recommend MMS to a friend or family member.

Conclusions: We used a patient-centered approach based on proven behavior change techniques to develop a comprehensive smartphone app for patients undergoing elective spine surgery. The optimized version of the app is ready for formal testing in a larger randomized clinical study

Background: Picture archiving and communication systems (PACS) are ubiquitously used to store, share, and view radiological information for preoperative planning across surgical specialties. Although traditional PACS software has proven reliable in terms of display accuracy and ease of use, it remains limited by its inherent representation of medical imaging in 2 dimensions. Augmented reality (AR) systems present an exciting opportunity to complement traditional PACS capabilities.

Objective: This study aims to evaluate the technical feasibility of using a novel AR platform, with holograms derived from computed tomography (CT) imaging, as a supplement to traditional PACS for presurgical planning in complex surgical procedures.

Methods: Independent readers measured objects of predetermined, anthropomorphically correlated sizes using the circumference and angle tools of standard-of-care PACS software and a newly developed augmented reality presurgical planning system (ARPPS).

Results: Measurements taken with the standard PACS and the ARPPS showed no statistically significant differences. Bland-Altman analysis showed a mean difference of 0.08% (95% CI -4.20% to 4.36%) for measurements taken with PACS versus ARPPS' circumference tools and -1.84% (95% CI -6.17% to 2.14%) for measurements with the systems' angle tools. Lin's concordance correlation coefficients were 1.00 and 0.98 for the circumference and angle measurements, respectively, indicating almost perfect strength of agreement between ARPPS and PACS. Intraclass correlation showed no statistically significant difference between the readers for either measurement tool on each system.

Conclusions: ARPPS can be an effective, accurate, and precise means of 3D visualization and measurement of CT-derived holograms in the presurgical care timeline.

Background: Deep diaphragmatic breathing, also called belly breathing, is a popular behavioral intervention that helps children cope with anxiety, stress, and their experience of pain. Combining physiological monitoring with accessible mobile technology can motivate children to comply with this intervention through biofeedback and gaming. These innovative technologies have the potential to improve patient experience and compliance with strategies that reduce anxiety, change the experience of pain, and enhance self-regulation during distressing medical procedures.

Objective: The aim of this paper was to describe a simple biofeedback method for quantifying breathing compliance in a mobile smartphone app.

Methods: A smartphone app was developed that combined pulse oximetry with an animated protocol for paced deep breathing. We collected photoplethysmogram data during spontaneous and subsequently paced deep breathing in children. Two measures, synchronized respiratory sinus arrhythmia (RSA_sync) and the corresponding relative synchronized inspiration/expiration heart rate ratio (HR-I:E_sync), were extracted from the photoplethysmogram.

Results: Data collected from 80 children aged 5-17 years showed a positive RSA_sync effect in all participants during paced deep breathing, with a median (IQR; range) HR-I:E_sync ratio of 1.26 (1.16-1.35; 1.01-1.60) during paced deep breathing compared to 0.98 (0.96-1.02; 0.82-1.18) during spontaneous breathing (median difference 0.25, 95% CI 0.23-0.30; P<.001). The measured HR-I:E_sync values appeared to be independent of age.

Conclusions: An HR-I:E_sync level of 1.1 was identified as an age-independent threshold for programming the breathing pattern for optimal compliance in biofeedback.

Background: Mobile health (mHealth) apps are increasingly used postoperatively to monitor, educate, and rehabilitate. The usability of mHealth apps is critical to their implementation.

Objective: This systematic review evaluates the (1) methodology of usability analyses, (2) domains of usability being assessed, and (3) results of usability analyses.

Methods: The A Measurement Tool to Assess Systematic Reviews checklist was consulted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline was adhered to. Screening was undertaken by 2 independent reviewers. All included studies were assessed for risk of bias. Domains of usability were compared with the gold-standard mHealth App Usability Questionnaire (MAUQ).

Results: A total of 33 of 720 identified studies were included for data extraction. Of the 5 included randomized controlled trials (RCTs), usability was never the primary end point. Methodology of usability analyses included interview (10/33), self-created questionnaire (18/33), and validated questionnaire (9/33). Of the 3 domains of usability proposed in the MAUQ, satisfaction was assessed in 28 of the 33 studies, system information arrangement was assessed in 11 of the 33 studies, and usefulness was assessed in 18 of the 33 studies. Usability of mHealth apps was above industry average, with median System Usability Scale scores ranging from 76 to 95 out of 100.

Conclusions: Current analyses of mHealth app usability are substandard. RCTs are rare, and validated questionnaires are infrequently consulted. Of the 3 domains of usability, only satisfaction is regularly assessed. There is significant bias throughout the literature, particularly with regards to conflicts of interest. Future studies should adhere to the MAUQ to assess usability and improve the utility of mHealth apps.

Background: The internet has become an important medium within health care, giving patients the opportunity to search for information, guidance, and support to manage their health and well-being needs. Online forums and internet-based platforms appear to have changed the way many patients undergoing bariatric surgery view and engage with their health, before and after weight loss surgery. Given that significant health improvements result from sustained weight loss, ensuring patient adherence to recommended preoperative and postoperative guidance is critical for bariatric surgery success. In a patient cohort with high information needs preoperatively, and notoriously high attrition rates postoperatively, online forums may present an underutilized method of support.

Objective: The aim of this study was to conduct a narrative review focusing on the developing roles that online forums can play for patients with bariatric conditions preoperatively and postoperatively.

Methods: A literature search was conducted in October-November 2019 across 5 electronic databases: Scopus, EMBASE, PsycINFO, CINAHL, and MEDLINE. Qualitative or mixed methods studies were included if they evaluated patients undergoing bariatric surgery (or bariatric surgery health care professionals) engaging with, using, or analyzing online discussion forums or social media platforms. Using thematic analysis, themes were developed from coding patterns within the data to identify the roles and challenges of online forums for patients undergoing bariatric surgery.

Results: A total of 8 studies were included in this review, with 5 themes emerging around (1) managing expectations of a new life; (2) decision making and signposting; (3) supporting information seeking; (4) facilitating connectedness: peer-to-peer social and emotional support; and (5) enabling accessibility and connectivity with health care professionals.

Conclusions: Online forums could offer one solution to improving postoperative success by supporting and motivating patients. Future research should consider how best to design and moderate online forums for maximal effectiveness and the sharing of accurate information. The surgical multidisciplinary team may consider recommendations of online peer-support networks to complement care for patients throughout their surgical journey.