Patient-reported outcomes after oesophagectomy in the multicentre LASER study.

BACKGROUND: Data on the long-term symptom burden in patients surviving oesophageal cancer surgery are scarce. The aim of this study was to identify the most prevalent symptoms and their interactions with health-related quality of life. METHODS: This was a cross-sectional cohort study of patients who underwent oesophageal cancer surgery in 20 European centres between 2010 and 2016. Patients had to be disease-free for at least 1 year. They were asked to complete a 28-symptom questionnaire at a single time point, at least 1 year after surgery. Principal component analysis was used to assess for clustering and association of symptoms. Risk factors associated with the development of severe symptoms were identified by multivariable logistic regression models. RESULTS: Of 1081 invited patients, 876 (81.0 per cent) responded. Symptoms in the preceding 6 months associated with previous surgery were experienced by 586 patients (66.9 per cent). The most common severe symptoms included reduced energy or activity tolerance (30.7 per cent), feeling of early fullness after eating (30.0 per cent), tiredness (28.7 per cent), and heartburn/acid or bile regurgitation (19.6 per cent). Clustering analysis showed that symptoms clustered into six domains: lethargy, musculoskeletal pain, dumping, lower gastrointestinal symptoms, regurgitation/reflux, and swallowing/conduit problems; the latter two were the most closely associated. Surgical approach, neoadjuvant therapy, patient age, and sex were factors associated with severe symptoms. CONCLUSION: A long-term symptom burden is common after oesophageal cancer surgery.

Achieving good-quality consent: review of literature, case law and guidance.

BACKGROUND: Informed consent is an integral part of clinical practice. There is widespread agreement amongst health professionals that obtaining procedural consent needs to move away from a unidirectional transfer of information to a process of supporting patients in making informed, self-determined decisions. This review aimed to identify processes and measures that warrant consideration when engaging in consent-based discussions with competent patients undergoing elective procedures. METHODS: Formal written guidance from the General Medical Council and Royal College of Surgeons of England, in addition to peer-reviewed literature and case law, was considered in the formulation of this review. RESULTS: A framework for obtaining consent is presented that is informed by the key tenets of shared decision-making (SDM), a model that advocates the contribution of both the clinician and patient to the decision-making process through emphasis on patient participation, analysis of empirical evidence, and effective information exchange. Moreover, areas of contention are highlighted in which further guidance and research are necessary for improved enhancement of the consent process. CONCLUSION: This SDM-centric framework provides structure, detail and suggestions for achieving meaningful consent.

ANTECEDENTES: El consentimiento informado es una parte integral de la práctica clínica. Existe un acuerdo generalizado entre los profesionales de la salud en que lograr el consentimiento del procedimiento no debe ser una transferencia unidireccional de información, sino un proceso de apoyo a los pacientes en la toma de decisiones informadas y autodeterminadas. Esta revisión tiene como objetivo identificar procesos y medidas que deban ser considerados al hablar sobre el consentimiento con pacientes autosuficientes sometidos a procedimientos quirúrgicos electivos. MÉTODOS: Al planear esta revisión se tuvo en cuenta la recomendación formal por escrito del Consejo Médico General y del Royal College of Surgeons of England, además de la literatura revisada por pares y de la jurisprudencia. RESULTADOS: Se presenta un marco para lograr el consentimiento que se basa en los principios clave de la toma de decisiones compartida (Shared Decision-Making, SDM); un modelo que aboga por la contribución, tanto del médico como del paciente, al proceso de toma de decisiones a través del énfasis en la participación del paciente, el análisis de la evidencia empírica y el intercambio efectivo de información. Además, se destacan áreas de contención en las que se necesitan más recomendaciones y más investigación para mejorar aún más el proceso del consentimiento. CONCLUSIÓN: Este marco centrado en la SDM proporciona estructura, detalles y sugerencias sobre cómo se puede lograr un consentimiento informado satisfactorio.

Avoidable 30-day readmissions in patients undergoing vascular surgery.

Background: Vascular surgery has one of the highest unplanned 30-day readmission rates of all surgical specialties. The degree to which these may be avoidable and the optimal strategies to reduce their occurrence are unknown. The aim of this study was to identify and classify avoidable 30-day readmissions in patients undergoing vascular surgery in order to plan targeted interventions to reduce their occurrence, improve outcomes and reduce cost. Methods: A retrospective analysis of discharges over a 12-month period from a single tertiary vascular unit was performed. A multidisciplinary panel conducted a manual case-note review to identify and classify those 30-day unplanned emergency readmissions deemed avoidable. Results: An unplanned 30-day readmission occurred in 72 of 885 admissions (8·1 per cent). These unplanned readmissions were deemed avoidable in 36 (50 per cent) of these 72 patients, and were most frequently due to unresolved medical issues (19 of 36, 53 per cent) and inappropriate admission with the potential for outpatient management (7 of 36, 19 per cent). A smaller number were due to inadequate social care provision (4 of 36, 11 per cent) and the occurrence of other avoidable adverse events (4 of 36, 11 per cent). Conclusion: Half of all 30-day readmissions following vascular surgery are potentially avoidable. Multidisciplinary coordination of inpatient care and the transition from hospital to community care after discharge need to be improved.

Antecedentes: La cirugía vascular tiene una de las tasas más elevadas de reingresos no planificados a los 30 días de todas las especialidades quirúrgicas. Se desconoce hasta qué punto este problema puede ser evitable y las estrategias óptimas para su disminución. El objetivo de este estudio fue identificar y clasificar los reingresos evitables a los 30 días en pacientes sometidos a cirugía vascular para planificar intervenciones dirigidas a su disminución, mejorar los resultados y reducir el coste. Métodos: Se realizó un análisis retrospectivo de las altas hospitalarias durante un periodo de 12 meses en una unidad vascular terciaria. Un panel multidisciplinario realizó una revisión manual de los casos para identificar y clasificar aquellos reingresos urgentes no planificados a los 30 días que se considerasen evitables. Resultados: Se registró un reingreso no planificado a los 30 días en 72/885 (8,1%) ingresos. Estos reingresos no planificados fueron considerados evitables en el 50,0% (36/72) y fueron debidos con más frecuencia a cuestiones médicas sin resolver (19/36, 52,8%) y a un ingreso no apropiado con la posibilidad de tratamiento ambulatorio (7/36, 19,4%). En un número menor de casos se debió a una asistencia social inadecuada (4/36, 11,1%) y la aparición de otros eventos adversos evitables (4/36, 11,1%). Conclusión: La mitad de los reingresos a los 30 días en pacientes vasculares son potencialmente evitables. Tras el alta hospitalaria debe mejorarse la coordinación multidisciplinaria de la atención hospitalaria y la transición desde el hospital a la atención comunitaria.

Acoustic reflectors are visible in the right heart during radiofrequency ablation of varicose veins.

OBJECTIVE: Cerebrovascular events have been noted after foam sclerotherapy for varicose veins. One hypothesis is migration of microemboli to the brain through a cardiac septal defect. The aim of this study was to identify whether acoustic reflectors are found in the right side of the heart during radiofrequency ablation of varicose veins, as neurological events are not reported during these procedures. METHODS: Transthoracic echocardiography was performed during local anaesthetic radiofrequency ablation (VNUS ClosureFast) of the great saphenous vein in 14 patients. An apical view was captured at the start of the procedure, during each cycle of heating and at 1 min post-treatment. Patients were monitored for 1 h. Video loops were read by an independent cardiologist. The presence of acoustic reflectors was classified as: 0 = absent, 1 = occasional, 2 = stream, 3 = complete opacification. RESULTS: Loops were of diagnostic quality in 11/14 (79%) patients. After the second cycle of heating, acoustic reflectors moving through the right heart were seen in 5/11 (45%) patients. These were classified as grade 1 in four patients and grade 2 in one patient. No acoustic reflectors were seen in the left heart. No neurological symptoms were reported. CONCLUSION: Acoustic reflectors in the right heart are a common finding during radiofrequency ablation of varicose veins. Considering the prevalence of cardiac septal defects (17%), more neurological events would be expected if these particles were indeed responsible for these events. Further work is required to elicit the mechanisms underlying neurological complications following sclerotherapy.

Aging techniques for deep vein thrombosis: a systematic review.

Deep vein thrombosis is common with an incidence of 1 in 1000. Acute thrombus removal for extensive proximal deep vein thrombosis using catheter-directed techniques highlights the need for accurate assessment of thrombus age. This systematic review summarises experimental and clinical evidence of imaging techniques for aging deep vein thrombosis. Ultrasound elastography and magnetic resonance imaging were highlighted as the most studied imaging modalities. Elastography was shown to distinguish between acute and chronic clots, despite demonstrating difficulty in accurate aging of clots older than 10 days in rat models. Elastography is noted as a feasible adjunct to current first-line imaging for deep vein thrombosis using duplex ultrasonography. Combinations of magnetic resonance imaging techniques can identify acute, sub-acute and chronic thrombi using endogenous contrast agents and provide objective standardisation of the diagnostic process, with reduced onus upon operator dependency. Further validation is required of these novel imaging techniques prior to clinical implementation for deep vein thrombosis aging.