Enhanced Recovery After Surgery (ERAS) in gynecologic oncology: System-wide implementation and audit leads to improved value and patient outcomes.

OBJECTIVE: Enhanced recovery pathways have been shown to reduce length of stay without increasing readmission or complications in numerous areas of surgery. Uptake of gynecologic oncology ERAS guidelines has been limited. We describe the effect of ERAS guideline implementation in gynecologic oncology on length of stay, patient outcomes, and economic impact for a province-wide single-payer system. METHODS: We compared pre- and post-guideline implementation outcomes in consecutive staging and debulking patients at two centers that provide the majority of surgical gynecologic oncology care in Alberta, Canada between March 2016 and April 2017. Clinical outcomes and compliance were obtained using the ERAS Interactive Audit System. Patients were followed until 30 days after discharge. Negative binomial regression was employed to adjust for patient characteristics. RESULTS: We assessed 152 pre-ERAS and 367 post-ERAS implementation patients. Mean compliance with ERAS care elements increased from 56% to 77.0% after implementation (p < 0.0001). Median length of stay for all surgeries decreased from 4.0 days to 3.0 days post-ERAS (p < 0.0001), which translated to an adjusted LOS decrease of 31.4% (95% CI = [21.7% - 39.9%], p < 0.0001). In medium/high complexity surgery median LOS was reduced by 2.0 days (p = 0.0005). Complications prior to discharge decreased from 53.3% to 36.2% post-ERAS (p = 0.0003). There was no significant difference in readmission (p = 0.6159), complications up to 30 days (p = 0.6274), or mortality (p = 0.3618) between the cohorts. The net cost savings per patient was $956 (95%CI: $162 to $1636). CONCLUSIONS: Systematic implementation of ERAS gynecologic oncology guidelines across a healthcare system improves patient outcomes and saves resources.

First nations people's perspectives on barriers and supports for enhancing HPV vaccination: Foundations for sustainable, community-driven strategies.

OBJECTIVE: In Canada, Indigenous people have higher human papillomavirus (HPV) infection rates, lower screening rates for cervical cancer, and higher rates of invasive cancer, leading to worse cervical cancer-related outcomes than observed in non-Indigenous Canadian women. Lingering harms from European colonization drive these health inequities and create public health challenges. Policy guidance is needed to optimize HPV vaccination rates and, thereby, decrease the burden of HPV-related illness, including high-morbidity surgical procedures and chemo-radiotherapy. The Enhancing HPV Vaccination In First Nations Populations in Alberta (EHVINA) project focuses on First Nations, a diverse subset of recognized Indigenous people in Canada, and seeks to increase HPV vaccination among girls and boys living in First Nation communities. METHODS: Developing an effective strategy requires partnership with affected communities to better understand knowledge and perceptions about cancer, healthcare, and the HPV vaccine. A 2017 community gathering was convened to engage First Nations community members, health directors, and health services researchers in dialogue around unique barriers and supports to HPV vaccination in Alberta. Voices of community Elders, parents, health directors, and cancer survivors (n=24) are presented as qualitative evidence to help inform intervention design. RESULTS: Key findings from discussions indicate barriers to HPV vaccination include resource constraints and service infrastructure gaps, historical mistrust in healthcare systems, impacts of changing modes of communication, and community sensitivities regarding sexual health promotion. Supports were identified as strengthened inter-generational relationships in communities. CONCLUSIONS AND FUTURE DIRECTION: Ongoing dialogue and co-development of community-based strategies to increase HPV vaccine uptake are required. The identification of possible barriers to HPV vaccination in a Canadian Indigenous population contributes to limited global literature on this subject and may inform researchers and policy makers who work with Indigenous populations in other regions.

The Arabidopsis NPR1/NIM1 protein enhances the DNA binding activity of a subgroup of the TGA family of bZIP transcription factors.

The Arabidopsis NPR1 gene is essential in activating systemic, inducible plant defense responses. To gain a better understanding of NPR1 function, we conducted a yeast two-hybrid screening procedure and identified a differential interaction between NPR1 and all known members of the Arabidopsis TGA family of basic leucine zipper transcription factors. In the electrophoretic mobility shift assay, NPR1 substantially increased the binding of TGA2 to its cognate promoter element (as-1) as well as to a positive salicylic acid-inducible element (LS7) and a negative element (LS5) in the promoter of the pathogenesis-related PR-1 gene. Proteins encoded by npr1 mutants interacted poorly with TGA2 and did not substantially increase TGA2 binding to the as-1, LS5, or LS7 elements, thus establishing a link between the loss of disease resistance and the loss of TGA2 interaction and NPR1-enhanced DNA binding. Coupled with observations that the DNA binding activity of TGA factors is deregulated in npr1 plants, the results suggest that NPR1-mediated DNA binding of TGA2 is critical for activation of defense genes.

A starch-branching enzyme gene in wheat produces alternatively spliced transcripts.

A wheat gene, denoted Sbe1, encoding a type I starch-branching enzyme (SBEI) was isolated from a genomic library and shown to comprise 14 exons distributed over a 5.7 kb DNA region. Analyses of kernel RNA by 5' rapid amplification of cDNA ends (5'-RACE) and reverse transcription-polymerase chain reaction (RT-PCR) demonstrated a considerable sequence variation at the 5' ends of SBEI gene transcripts. DNA sequence alignments between the 5'-RACE products and the Sbe1 genomic DNA indicated that the first two exons and first intron were differentially processed to generate three classes of the mature transcript. One form of the SBEI gene transcript in 12-day old kernels contained the exon I+II+III combination at the 5' end, whereas other forms differed by inclusion of intron 1 or exclusion of exon II sequences. RT-PCR analysis of Sbe1-uidA::nptII chimeric mRNA produced in transgenic wheat cultured cells confirmed that the isolated Sbe1 was able to produce all three forms of SBEI gene transcripts by alternative splicing of the primary mRNA. The variants of processed Sbe1 mRNA were potentially translated into N-terminal variants of the SBEI precursor with different transit peptide sequences.

The AAPM/RSNA physics tutorial for residents. Typical patient radiation doses in diagnostic radiology.

Factors affecting patient dose in all x-ray imaging modalities include beam energy, filtration, collimation, patient size, and image processing. In conventional radiography, the most important determinant of acceptable patient dose is use of the highest peak kilovoltage that results in diagnostic images. Digital radiography allows a much wider range of exposures than conventional radiography for producing diagnostic images. However, operators must be aware of the subtle differences in techniques used with digital systems to avoid unnecessary increases in patient dose. Low-dose mammography requires lower ranges of peak kilovoltage; different target materials, filters, and screen-film combinations; special attention to breast thickness, composition, and compression during the study; and different standards for grids, magnification, and optical density. Although peak kilovoltage and tube current are important for controlling patient dose in fluoroscopy, collimation, source-to-skin and patient-to-image intensifier distances, and control of beam-on time have perhaps greater importance. Computed tomography (CT) involves greater patient dose than conventional radiography, and, although the primary radiation dose is delivered to smaller volumes, dose calculations must account for dose received by adjacent tissue sections. Many variables are involved in fetal exposure and fetal dose effects, but a solid understanding of them can help in developing responsible patient management practices.

Exposure rates during special procedures with C-arm type fluoroscopic systems.

PURPOSE: To test for regulatory compliance of free-in-air entrance air kerma rates (EAKR) in C-arm type fluoroscopic equipment, measurements are frequently made under minimum source-to-image receptor distance (SID) and at 300 mm from the image intensifier. However, this is not representative of normal patient geometry, and the automatic brightness controls on these units frequently increase tube output as SID increases. This study investigated effects of these circumstances on actual EAKRs. MATERIALS AND METHODS: Typical patient geometries were observed and recorded for 23 consecutive body vascular procedures. EAKRs were measured under compliance and normal patient geometries with use of five modern C-arm type systems for special procedures. RESULTS: SIDs of 1 m were typical when rapid film changers were employed and the patient's entrance skin surface was typically 500 mm from the image receptor. Actual EAKRs were found to be up to 2.5 times those measured under compliance geometry. CONCLUSION: Actual patient geometries should be used to ensure correct estimates of EAKRs.

Attenuation properties of lead composite aprons.

Traditionally, the absorption properties of protective aprons used in diagnostic radiology have been specified in units of lead equivalent thickness. This is appropriate and accurate when lead is the only high-atomic-numbered component in the apron. In an attempt to manufacture light-weight protective apparel, however, some manufacturers have included other elements with k absorption edges in the energy range of interest, to provide equivalent absorption properties with less weight. With these other high-atomic-numbered elements added, the lead equivalence of the apparel becomes a function of the photon energy. This must be recognized and specified by the supplier, because lead apparel is used in environments other than diagnostic radiology, where the shielding benefits may be substantially less than expected when specifications are based on the diagnostic x-ray energy range.

Effectiveness of radiation control program for Dornier HM3 lithotriptor.

Radiation exposure during extracorporeal shock-wave lithotripsy (ESWL) was calculated using a "worst-case method" in 135 randomly selected patients. The patients were divided into four groups according to body weight: small (less than 140 pounds), medium (141-180 pounds), large (181-220 pounds), and very large (greater than 220 pounds). Average skin exposure was found to be 15.2 R (from 1.2 to 95.6 R). After implementation of a "radiation awareness program" radiation exposure was calculated in 128 cases (matched for body weight and stone burden) and average exposure was 9.5 R (from 0.9 to 33.4 R) with a reduction of 20, 37, 33, and 62 percent for each group, respectively. Radiation exposure reduction was primarily due to a reduction in the number of radiographic "snapshots" taken as a result of preferential use of special-mode fluoroscopic "stills."

Patient and personnel exposure during extracorporeal lithotripsy.

Extracorporeal shock wave lithotripsy (ESWL) has provided a nonsurgical approach to treatment of renal stones. The Dornier lithotripter uses dual image intensified x-ray systems to center the stone before treatment. Three imaging modes are offered: a fluoroscopic mode and two video spot filming modes. The average entrance exposure to the stone side of the typical patient at our facility is 2.6 X 10(-3) C kg-1 (10 R) [range: 0.5-7.7 X 10(-3) C kg-1 (2-30 R)] which is comparable and often much less than that reported for percutaneous lithotripsy. Recommendations are made for minimizing patient exposure. Scattered radiation levels in the lithotripter room are presented. We have determined that Pb protective apparel is not required during this procedure provided x-ray operation is temporarily halted should personnel be required to lean directly over the tub to attend to the patient. If the walls of the ESWL room are greater than 1.83 m (6 feet) from the tub, shielding in addition to conventional construction is not required.

Defects in new protective aprons.

Upon careful examination, several defects have been detected in new protective aprons . The nature of the defects is identified and described. Although the occurrence of such defects has not exceeded 5%, they are significant enough to warrant return of the lead apron to the supplier. It is recommended that the integrity of all new protective aprons be verified upon receipt as well as at yearly intervals.

Radiographic workload and use factors for orthopedic facilities.

Observations of technique factors at 9 radiographic installations dedicated to orthopedic radiography have been made. Monthly area radiation measurements with thermoluminescent dosimeters were made at three of these facilities. The results of these observations and measurements suggest that current NCRP recommended assumptions utilized in protective barrier computations result in considerably more shielding than is necessary. We observed an average workload of 224 mA min/wk and a maximum weekly average of 670 mA min/wk. The use factor for the chest wall averaged 5%. That for all other vertical barriers was less than 1%. The average operating potential was 75 kVp. Room radiation measurements confirm the suggestion that at least two of the walls and the control booth barrier in an orthopedic radiographic facility may be considered secondary barriers.

A computer-assisted procedure for estimating patient exposure and fetal dose in radiographic examinations.

A computer program for calculating patient entrance exposure and fetal dose for 11 common radiographic examinations was developed. The output intensity measured at 70 kVp and a 30-inch (76-cm) source-to-skin distance was entered into the program. The change in output intensity with changing kVp was examined for 17 single-phase and 12 three-phase x-ray units. The relationships obtained from a least squares regression analysis of the data, along with the technique factors for each examination, were used to calculate patient exposure. Fetal dose was estimated using published fetal dose in mrad (10(-5) Gy) per 1,000 mR (258 microC/kg) entrance exposure values. The computations are fully automated and individualized to each radiographic unit. The information provides a ready reference in large institutions and is particularly useful at smaller facilities that do not have available physicians who can make the calculations immediately.

CT alignment probe for the dose profile insert.

One of the most accepted methods of characterizing the dose in computed tomography (CT) is by measuring the dose profile. Thermoluminescent dosimeters (TLD's) arranged in a stack are scanned in a plexiglass phantom. Unfortunately with this system there is no assurance that the scan properly intercepts the stack. Mispositioning will not be apparent until the TLD's are read, entailing at least a 24 h delay before rescanning. We have designed a simple alignment probe that insures that the scan will be centered on the stack to within 1 mm.

Computer-assisted quality assurance for radiographic equipment.

A quality assurance procedure which includes a computer program has been implemented to facilitate measurement of some of the parameters normally tested on diagnostic radiographic equipment. These include: reproducibility of output, linearity of mA settings, filtration, kVp calibration, timer error, SID indication, light field--x-ray field coincidence and effective focal spot size. The user may omit those sections which are not applicable to his needs. Full use is made of the data reducing the number of field measurements needed.

Patient radiation dose in conventional and xerographic cephalography.

A comparison of the radiation doses for xeroradiographic and conventional film screen cephalography was made. Alderson tissue-equivalent phantoms were used for patient stimulation. An optimum technique in terms of patient dose and imaqe quality was established for the xeroradhe data indicated that the dose for the Xerox process ranged from five to eleven times greater than that for the conventional process for entrance and exit exposures, respectively. The most commonly reported dose, the entrance dose, was found to be 206 mrad, which is five Imes that for the conventional cephalogram. This dose, however, falls within an acceptable range for other dental and medical radiation doses. It is recommended that conventional cephalography be used for routine purposes and that xeroradiography be reserved for situations requiring the increased image quality that the process affords.

Radiation dose in neurological computed tomographic scanning.

Patient dose and dose distribution during neurological computed tomography examinations were determined with five different computed tomography scanners. Maximum intracranial doses ranged from 1.17 to 2.67 rads. Doses to the lens of the eye ranged from 0.23 to 2.81 rads. These levels are considered and compared with patient doses reported for other computed tomography studies and for conventional tomographic examinations. In general, patient dose during computer tomographic examinations is less than one quarter of that during conventional tomography of the head.