Implementation of a standardised perioperative nutrition care pathway in upper gastrointestinal cancer surgery: A multisite pilot study.

BACKGROUND: Perioperative nutrition support is recommended for patients undergoing upper gastrointestinal (UGI) cancer surgery; however, limited evidence exists regarding implementation of a nutrition care pathway in clinical practice. The aims of this pilot study were to determine whether implementation of a standardised perioperative nutrition pathway for patients undergoing UGI cancer surgery improves access to dietetics care, as well as to evaluate study feasibility, fidelity, resource requirements and effect on clinical outcomes. METHODS: Patients with newly diagnosed UGI cancer from four major metropolitan hospitals in Melbourne, planned for curative intent surgery, were included in the prospective pilot study (n = 35), with historical controls (n = 35) as standard care. Outcomes were dietetics care (dietetics contacts) nutritional status, hand grip strength, weight change, preoperative hospital admissions, complications and length of stay, recruitment feasibility, fidelity and adherence, and resource requirements. Continuous data were analysed using independent samples t test accounting for unequal variances or a Mann-Whitney U test. Dichotomous data were analysed using Fisher's exact test. RESULTS: The percentage of participants receiving preoperative dietetic intervention increased from 55% to 100% (p < 0.001). Mean ± SD dietetics contacts increased from 2.2 ± 3.7 to 5.9 ± 3.9 (p < 0.001). Non-statistically significant decreases in preoperative nutrition-related hospital admissions, and surgical complications were demonstrated in patients who underwent neoadjuvant therapy. Recruitment rate was 81%, and adherence to the nutrition pathway was high (> 70% for all stages of the pathway). The mean ± SD estimated resource requirement for the preoperative period was 3.7 ± 2.8 h per patient. CONCLUSIONS: Implementation of this standardised nutrition pathway resulted in improved access to dietetics care. Recruitment feasibility and high fidelity to the intervention suggest that a larger study would be viable.

Implementing a standardised perioperative nutrition care pathway in upper gastrointestinal cancer surgery: a mixed-methods analysis of implementation using the Consolidated Framework for Implementation Research.

BACKGROUND: Implementation studies of complex interventions such as nutrition care pathways are important to health services research, as they support translation of research into practice. There is limited research regarding implementation of a nutrition care pathway in an upper gastrointestinal (UGI) cancer population. The aim of this study was to comprehensively evaluate the implementation process of a perioperative nutrition care pathway in UGI cancer surgery using The Consolidated Framework for Implementation Research (CFIR). METHODS: This was a mixed methods implementation study conducted during a pilot study of a standardised nutrition care pathway across four major hospitals between September 2018 to August 2019. Outcome measures included five focus groups among study dietitians (n = 4-8 per group), and quantitative satisfaction surveys from multi-disciplinary team (MDT) members (n = 14) and patients (n = 18). Focus group responses were analysed thematically using the CFIR constructs, which were used as a priori codes. Survey responses were summarised using means and standard deviations. A convergent parallel mixed methods approach according to CFIR domains and constructs was used to integrate qualitative and quantitative data. RESULTS: Qualitative data demonstrated that dietitian perceptions primarily aligned with five CFIR constructs (networks and communications, structural characteristics, adaptability, compatibility and patient needs/resources), indicating a complex clinical and implementation environment. Challenges to implementation mostly related to adapting the pathway, and the compatibility of nutrition coordination to existing aspects of care within each setting. Identified benefits from dietitian qualitative data and MDT survey responses included increased engagement between the dietitian and MDT, and a more proactive approach to nutrition care. Patients were highly satisfied with the service, with the majority of survey items being rated highly (≥4 of a possible 5 points). CONCLUSIONS: The nutrition care pathway was perceived to be beneficial by key stakeholders. Based on the findings, sustainability and compliance to this model of care may be achieved with improved systems level coordination and communication.

The complement inhibitors Crry and factor H are critical for preventing autologous complement activation on renal tubular epithelial cells.

Congenital and acquired deficiencies of complement regulatory proteins are associated with pathologic complement activation in several renal diseases. To elucidate the mechanisms by which renal tubular epithelial cells (TECs) control the complement system, we examined the expression of complement regulatory proteins by the cells. We found that Crry is the only membrane-bound complement regulator expressed by murine TECs, and its expression is concentrated on the basolateral surface. Consistent with the polarized localization of Crry, less complement activation was observed when the basolateral surface of TECs was exposed to serum than when the apical surface was exposed. Furthermore, greater complement activation occurred when the basolateral surface of TECs from Crry(-/-)fB(-/-) mice was exposed to normal serum compared with TECs from wild-type mice. Complement activation on the apical and basolateral surfaces was also greater when factor H, an alternative pathway regulatory protein found in serum, was blocked from interacting with the cells. Finally, we injected Crry(-/-)fB(-/-) and Crry(+/+)fB(-/-) mice with purified factor B (an essential protein of the alternative pathway). Spontaneous complement activation was seen on the tubules of Crry(-/-)fB(-/-) mice after injection with factor B, and the mice developed acute tubular injury. These studies indicate that factor H and Crry regulate complement activation on the basolateral surface of TECs and that factor H regulates complement activation on the apical surface. However, congenital deficiency of Crry or reduced expression of the protein on the basolateral surface of injured cells permits spontaneous complement activation and tubular injury.