Role of regional anesthesia and analgesia in enhanced recovery after colorectal surgery: a systematic review of randomized controlled trials.

BACKGROUND: Effective analgesia is an important element of enhanced recovery after surgery (ERAS), but the clinical impact of regional anesthesia and analgesia for colorectal surgery remains unclear. OBJECTIVE: We aimed to determine the impact of regional anesthesia following colorectal surgery in the setting of ERAS. EVIDENCE REVIEW: We performed a systematic review of nine databases up to June 2020, seeking randomized controlled trials comparing regional anesthesia versus control in an ERAS pathway for colorectal surgery. We analyzed the studies with successful ERAS implementation, defined as ERAS protocols with a hospital length of stay of ≤5 days. Data were qualitatively synthesized. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. FINDINGS: Of the 29 studies reporting ERAS pathways, only 13 comprising 1170 patients were included, with modest methodological quality and poor reporting of adherence to ERAS pathways. Epidural analgesia had limited evidence of outcome benefits in open surgery, while spinal analgesia with intrathecal opioids may potentially be associated with improved outcomes with no impact on length of stay in laparoscopic surgery, though dosing must be further investigated. There was limited evidence for fascial plane blocks or other regional anesthetic techniques. CONCLUSIONS: Although there was variable methodological quality and reporting of ERAS, we found little evidence demonstrating the clinical benefits of regional anesthetic techniques in the setting of successful ERAS implementation, and future studies must report adherence to ERAS in order for their interventions to be generalizable to modern clinical practice. PROSPERO REGISTRATION NUMBER: CRD42020161200.

Impact of NPS MedicineWise general practitioner education programs and Choosing Wisely Australia recommendations on prescribing of proton pump inhibitors in Australia.

BACKGROUND: This study evaluated the impact of multifaceted NPS MedicineWise programs that targeted all general practitioners (GPs) in Australia in 2009 and 2015 with the aim of reducing unnecessary prescribing of proton pump inhibitors (PPIs) and encouraged stepping down to a lower strength PPI or to discontinue treatment. The 2015 intervention coincided with the release of Choosing Wisely Australia recommendations from the Royal Australian College of General Practitioners (RACGP). METHODS: Outcome measures included monthly dispensing rates of different strength PPIs prescribed by GPs to concessional patients in Australia. All PPIs were categorized according to the May 2019 revised classifications for standard and low strength PPIs except for esomeprazole 40 mg which was classified as a standard strength and esomeprazole 20 mg as low strength for this analysis. Time series analyses was conducted of the dispensing rates of PPI prescriptions for concessional patients between January 2006 and June 2016 using the Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) databases in Australia. Participants were GPs with dispensed PPI prescriptions to concessional patients between January 2006 and June 2016. RESULTS: Following the 2009 NPS MedicineWise program we observed a 6.7% reduction in the expected dispensing rate of standard strength PPIs for concessional patients between April 2006 and March 2015, and an 8.6% reduction between April 2009 and June 2016 following the 2015 program launch. We observed a significant increase of 5.6% in the dispensing rate of low strength PPIs for concessional patients between April 2009 and March 2015, and no significant change in trend following the 2015 program. CONCLUSIONS: The NPS MedicineWise programs were associated with reductions in the dispensing rate of standard strength PPIs by June 2016 and an increase in the dispensing rate of low-strength PPIs by March 2015 although this trend did not continue following the 2015 program. This suggests that GPs are stepping down patients to lower strength PPIs following the educational programs. However, lower strength PPIs are still not the majority of PPIs dispensed in Australian and regular interventions to sustain and improve PPI management by GPs may be warranted.

Visualisation of focal renal lesions on ultrasound: A review of 518 lesions with contrast CT correlation.

INTRODUCTION: Conventional ultrasound (US) is a common imaging investigation of the kidneys; however, the current diagnostic performance of US in the visualisation of focal renal lesions is unknown. METHODS: This study was a retrospective sequential review of 518 focal renal lesions (FRLs) in 200 patients aged 50 years or older who received an US of the kidneys followed by contrast-enhanced computed tomography (CECT). RESULTS: Patient's age ranged from 50 to 94 years. The majority were hospital inpatients. 518 FRLs were identified on CECT ranging from 3 to 165 mm (median 8 mm). The majority of FRLs (96.1%) were benign. The visualisation rate of FRLs on US was size-dependent: <5 mm, 10.2%; 5-9 mm, 22.3 mm; 10-14 mm, 48.0%; 15-19 mm, 82.1%; and 20-24 mm, 100%. The visualisation of simple cysts was 49.1% and hyperdense lesions 81.8%. Follow-up was available on 58% of lesions. Benign lesions generally remained stable. Seven patients had concerning heterogeneous hyperdense masses on CECT, and US had visualised six of these (85.7%). CONCLUSION: Visualisation of FRLs is size-dependent. High rate of visualisation is achieved once the lesion exceeds 15 mm in size. Small FRLs are associated with a low rate of visualisation on ultrasound; however, they are rarely concerning. Hyperdense lesions on CECT that carry high suspicion of malignancy are associated with a high rate of US visualisation.

Cost-Related Underuse of Medicines for Asthma-Opportunities for Improving Adherence.

BACKGROUND: In asthma, underuse of cost-effective preventive treatments increases morbidity and mortality. The cost of medicines contributes to underuse ("nonadherence"), but the extent to which people with asthma skip or reduce doses or let prescriptions go unfilled when faced with cost pressures is unknown. OBJECTIVE: To estimate the extent of cost-related underuse behaviors and associated factors. METHODS: Using previously validated summary indicators, we conducted an online cross-sectional survey of adults and parents of children 5 to 17 years with asthma in Australia (a high-income country) and developed logistic regression models for adults and children with asthma, controlling for key clinical and demographic factors. RESULTS: The survey was completed by n = 792 adults (mean age, 47 [standard deviation, 17] years, male 47%, concession 60%) and n = 609 parents of children (5-10 years 51%, male 60%, concession 59%) with asthma. Cost-related underuse was reported by 52.9% adults and 34.3% parents, predominantly decreasing or skipping doses to make medicines last longer. Higher odds of cost-related underuse were observed with younger adults (adults: odds ratio [OR]: 1.19; 95% confidence interval [CI]: 1.12, 1.27), males (adults: OR: 1.49; 95% CI: 1.06, 2.08), having concerns about medicines (adults: OR: 3.12; 95% CI: 2.17, 4.35; parents: OR: 2.63; 95% CI: 1.56, 4.55), less comfortable talking to prescribers about cost (parents: OR: 1.22; 95% CI: 1.12, 1.33) or changing medicines (adults: OR: 1.12; 95% CI: 1.03, 1.22), feeling less engaged with prescribers about medicine decisions (parents: OR: 1.11; 95% CI: 1.01, 1.23), and with poorer asthma control (adults, poor control: OR: 1.87; 95% CI: 1.13, 3.09; parents, poor control: OR: 3.87; 95% CI: 1.99, 7.54), and requiring specialist (parents: OR: 1.83; 95% CI: 1.16, 2.87) or urgent health care visits (adults: OR: 1.54; 95% CI: 1.06, 2.23). Income and concession card status were not associated with cost-related underuse. CONCLUSIONS: Adults and parents of children with asthma indicate high rates of cost-related underuse of asthma medicines, even in the context of national medicines subsidies. Urgent targeting of interventions to promote discussion of medicines and costs between doctor and patients, particularly young adult males, is needed.

'All by myself': interns' reports of their experiences taking consent in Irish hospitals.

BACKGROUND: Obtaining patient consent is a fundamental process in surgical practice and is integral in respecting and safeguarding patient autonomy. It has been reported that the task of consenting patients frequently lies with junior doctors, who have the least experience of the procedure. AIM: To examine the role of interns in the consent process in the Irish context as well as to identify their concerns. METHODS: A 12-point questionnaire, assessing interns' experience with surgical consent, was circulated to interns in three Irish university teaching hospitals based in different geographical locations. Interns who had never worked in a surgical team were excluded from the analysis. RESULTS: Out of 104 interns, 60 interns returned questionnaires. Of these, 58 (96.7%) had consented a patient for a surgical procedure. Forty-four interns (73.3%) had never been supervised by a senior doctor. Of the 58 interns who had obtained surgical consent, six interns (10.3%) reported knowledge of 'all' the steps of the procedure. Only five interns (8.6%) reported that they were aware of all the risks of the procedures and 34 interns (58.6%) reported they knew 'most' of the risks. Twenty-five interns (43%) reported that they had, at some point, been explained the risks of the procedures by a senior colleague. CONCLUSION: The majority of interns reported that they had taken consent for a procedure without full knowledge of the procedure and its complications. Supervision or instruction from a senior colleague was reported by a minority.

Does a Patient-Directed Financial Incentive Affect Patient Choices About Controller Medicines for Asthma? A Discrete Choice Experiment and Financial Impact Analysis.

BACKGROUND: In Australia, many patients who are initiated on asthma controller inhalers receive combination inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) despite having asthma of sufficiently low severity that ICS-alone would be equally effective and less costly for the government. METHODS: We conducted a discrete choice experiment (DCE) in a nationally representative sample of adults (n = 792) and parents of children (n = 609) with asthma. Mixed multinomial models were estimated and calibrated to reflect the estimated market shares of ICS-alone, ICS/LABA and no controller. We then simulated the impact of varying patient co-payment on demand and the financial impact on government pharmaceutical expenditure. RESULTS: Preference for inhaler decreased with increasing costs to the patient or government, increasing chance of a repeat visit to the doctor, and if fewer symptoms were present. Adults preferred high-strength controllers, but parents preferred low-strength inhalers for children (general beneficiaries only). The DCE predicted a higher proportion choosing controller treatment (89%) compared to current levels (57%) at the current co-payment level, with proportionately higher uptake of ICS-alone and a lower average cost per patient [32.73 Australian dollars (AU$) c.f. AU$38.54]. Reducing the co-payment on ICS-alone by 50% would increase its market share to 50%, whilst completely removing the co-payment would only have a small marginal impact on market share, but increased average cost of treatment to the government to AU$41.04 per person. CONCLUSIONS: Patient-directed financial incentives are unlikely to encourage much switching of medicines, and current levels of under-treatment are not explained by patient preferences. Interventions directed at prescribers are more likely to promote better use of asthma medicines.

Relationship between antimicrobial-resistance programs and antibiotic dispensing for upper respiratory tract infection: An analysis of Australian data between 2004 and 2015.

Objective NPS MedicineWise aims to ensure that medicines are prescribed and used in a manner consistent with current evidence-based best practice. A series of nationwide educational and advertising interventions for general practitioners and consumers were implemented in Australia between 2009 and 2015 with the aim of reducing antibiotic prescriptions for upper respiratory tract infections (URTIs). The work described in this paper quantifies the change in antibiotic dispensing following these interventions. Methods Antibiotic dispensing data between 2004 and 2015 were obtained from a national claims database. A Bayesian structural time series model was used to forecast a series of antibiotic dispensing volumes expected to have occurred if the interventions had not taken place. These were compared with the volumes that were actually observed to estimate the intervention effect. Results On average, 126,536 fewer antibiotics were dispensed each month since the intervention programs began in 2009 (95% Bayesian credible interval = 71,580-181,490). This change represents a 14% total reduction in dispensed scripts after the series of intervention programs began in 2009. Conclusions Continual educational intervention programs that emphasise the judicious use of antibiotics may effectively reduce inappropriate prescribing of antibiotics for the treatment of URTIs at a national level.

HEALTH TECHNOLOGY PERFORMANCE ASSESSMENT: REAL-WORLD EVIDENCE FOR PUBLIC HEALTHCARE SUSTAINABILITY.

OBJECTIVES: Health technology financing is often based on randomized controlled trials (RCTs), which are often the same ones used for licensing. Because they are designed to show the best possible results, typically Phase III studies are conducted under ideal and highly controlled conditions. Consequently, it is not surprising that technologies do not always perform in real life in the same way as controlled conditions. Because financing (and price paid) decisions can be made with overestimated results, health authorities need to ask whether health systems achieve the results they expect when they choose to pay for a technology. The optimal way to answer this question is to assess the performance of financed technologies in real-world settings. Health technology performance assessment (HTpA) refers to the systematic evaluation of the properties, effects, and/or impact of a health intervention or health technology in the real world to provide information for investment/disinvestment decisions and clinical guideline updates. The objective is to describe the development and principal aspects of the Guideline for HTpA commissioned by the Brazilian Ministry of Health. METHODS: Our methods used include extensive literature review, refinement with experts across countries, and public consultation. RESULTS: A comprehensive guideline was developed, which has been adopted by the Brazilian government. CONCLUSION: We believe the guideline, with its particular focus on disinvestment, along with the creation of a specific program for HTpA, will allow the institutionalization and continuous improvement of the scientific methods to use real-world evidence to optimize available resources not only in Brazil but across countries.

Anaesthestic Management of Removal of Aspirated Hypodermic Needle in Trachea: A Case Report.

Aspiration of foreign body is a very common emergency in paediatric age group. It is very rare in adult population. Moreover common foreign body in adults are food materials. Aspiration of hypodermic needle is very rarely reported. But this can happen accidentally during use of hypodermic needle for dental block. We hereby report such a case of aspiration of hypodermic needle accidentally aspirated during performing a dental block. Aspiration of sharp foreign body and its bronscopic removal can lead to injury to airway. We report successful management of such a case where needle was removed under general anaesthesia successfully using rigid bronchoscope.

A review of short bowel syndrome and palliation: a case report and medication guideline.

While patients with short bowel syndrome are not common in palliative care, they can present challenges for palliative care professionals. The case presented highlights a specific difficulty encountered. Many medications are poorly absorbed from a short bowel and alternative routes of administration need to be considered. A search was conducted to identify reviews, reports, and other articles from January 1960 to February 2004. MEDLINE, Cochrane Library, and CINAHL (Cumulative Index of Nursing and Allied Health Library) and MIMs (Medimedia Australia) databases were searched. A review of major textbooks was also conducted. Information on the site of absorption, time to peak plasma concentration, alternate routes, and pharmacokinetic information is summarized and presented in table form. This case report and review should assist practitioners with the palliative management of patients with short bowel syndrome.