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.

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."

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.

Dosimeter placement in the Rando phantom.

Each section of the Alderson Rando phantom contains a tissue-equivalent plastic coating layer approximately 2 mm thick, applied to both faces. This compensates for material removed in the sawing process. Conventional use of thermoluminescent dosimeters positions them totally or partially within the coating layer. Analysis shows that, in the lung region, dosimeters placed in this layer received a dose averaging 39% lower than those placed at midsection. Where bony structures interfere, some dosimeters in the coating layer received an 18% higher dose than those at midsection. Therefore, positioning dosimeters at the center of a section is recommended.

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.

Interpatient microbiological cross-contamination after dental radiographic examination.

Pairs of patients were evaluated for microbiological cross-contamination after radiographic examination. In 30 of these pairs of patients there was the possibility of transference of S pyogenes, S aureus, or D pneumoniae. Such transference was observed in 23 (77%) of these 30 pairs of patients. The vectors for such transfer include the hands of the X-ray technician and the radiographic equipment. Further, it was found that each of these organisms would survive for at least 48 hours after being placed on an X-ray tube. Since interpatient microbiological cross-contamination can occur after routine radiographic examination, in some cases, disinfection of the radiographic equipment is indicated.

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.

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.

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.

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.

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.