A Targeted Discharge Pathway to Reduce Hospital Readmission and Dying in Hospital in Cancer Patients at the End of Life.

OBJECTIVES: There is a need for better information exchange between primary and secondary care healthcare professionals in cancer patients with limited life expectancy, most of whom prefer to be at home but are admitted frequently at the end of life (EoL). We conducted a file search to assess this among our patients and developed a discharge pathway to decrease readmission rate and dying in hospital. DATA SOURCES: We performed an in-depth file search among 150 patients who died within 1 month after hospital admission (July 2013 to January 2014); 60 were admitted once, and 90 were admitted twice or more. Mean time spent in hospital at EoL was 12 days; 37% died in hospital, and 49% died at home. We included 31 admitted cancer patients at the EoL in whom home-discharge was planned for the intervention (February 2017 to December 2018). Median survival was 24 days, time spent in hospital decreased from 15.5 to 2.5 days, and number of readmissions fell from 2.8 to 0.57. One patient (3.1%) died in hospital, and 77% died at home. And 78% of general practitioners found the provided information useful. CONCLUSION: A proactive discharge pathway may reduce hospital readmission rates, time spent in hospital, and in-hospital death. IMPLICATIONS FOR NURSING PRACTICE: Ever more patients with complex care needs at the EoL are being discharged early. Being informed about patients' wishes, preferences, and treatment options for symptom management at home is essential for doctors and nurses in primary care. A systematic discharge pathway can be useful for information transfer when admitted patients are discharged home.

First Experience with Three-Dimensional Thoracolaparoscopy in Esophageal Cancer Surgery.

INTRODUCTION: Endoscopic techniques are rapidly gaining interest in esophageal cancer surgery due to lower pulmonary complication rates and faster postoperative recovery. Conventional two-dimensional endoscopic surgery has two main limitations: lack of depth perception and limited dexterity due to the use of rigid instruments. Theoretically, three-dimensional (3D) endoscopy can overcome these limitations, but to date, its use has not been reported in the context of esophageal cancer surgery. We studied our first series of 3D thoracolaparoscopic esophagectomies to document the safety and feasibility of implementing this technique. METHODS: Patients who underwent a thoracolaparoscopic esophagectomy using a glasses-based 3D system with a 100° angulating camera tip were included. Continuity of the digestive tract was restored with gastric tube reconstruction and a cervical anastomosis. RESULTS: All 13 resections were completed thoracolaparoscopically. Median duration of surgery was 360 minutes (range: 245-590 minutes), and median blood loss was 170 mL (range: 50-230 mL). A median of 20 lymph nodes was resected, and all resections were microscopically radical. Median hospital stay was 9 days. Two patients developed pneumonia (15%), and three patients experienced an anastomotic leakage (23%). All postoperative complications were managed on the ward. CONCLUSION: In this series, the newest generation glasses-based 3D systems proved safe and useful for the thoracolaparoscopic resection of esophageal cancer. Besides better visualization, dexterity seemed to be improved using the 100° flexible 3D camera. Implementation was without significant problems, and the first results are promising.

The palliative performance scale applied in high-care residential hospice: a retrospective study.

BACKGROUND: The Palliative Performance Scale (PPS) is a tool that is widely used to predict end of life. In Ontario, Canada, the PPS is used to mark the terminal phase of life and eligibility for terminal care. OBJECTIVE: The aim of this retrospective study was to confirm that a PPS level of 40% can be used as a marker for the terminal phase of life. METHOD: PPS levels from 78 patients were calculated based on the intake reports made at admission to an inpatient hospice. RESULTS: Although 77 patients passed away within a period of 3 months, PPS levels at admission varied from 10% to 70%. Fifty-six percent of all patients had a PPS level of 40% or less. Regarding survival, three significant PPS profiles, consisting of two or more PPS levels could be distinguished.

Growth hormone analysis and treatment in Ellis-van Creveld syndrome.

Little is known on growth, growth hormone (GH) levels and GH treatment in patients with Ellis-van Creveld syndrome (EvC). The aim of the present study was to assess growth, growth hormone status and the possible effectiveness of GH treatment in literature and in a small series of EvC patients. A review of literature indicated retarded growth for most EvC patients (-2 to -4.5 SDS) and minimal data on GH levels or treatment which did not allow any conclusion. We studied eight EvC patients, seven of whom were treated with GH. Four were GH deficient (GHD) and four were GH sufficient. In all patients treated with GH, first year growth velocity increased. In three of the four GHD and in one GH-sufficient patient a gain in height SDS was noted. In the present small EvC series GHD occurred more often than expected. Patient acquisition through the Growth Hormone Database will have caused a significant bias, but the present results indicate that GH treatment may improve growth in at least some patients with EvC. Therefore we conclude that EvC patients may benefit from being tested for GHD and, if indicated, treated. In addition a prospective study to evaluate GH status and linear growth in patients with EvC as well as the potential effectiveness of GH treatment is warranted.