The effect of intensified nonverbal facilitation of swallowing on dysphagia after severe acquired brain injury: A randomised controlled pilot study.

BACKGROUND: There is little high-level evidence for the effect of the nonverbal facilitation of swallowing on swallowing ability in the subacute stage of rehabilitation following severe acquired brain injury (ABI). OBJECTIVE: To pilot test a randomised controlled trial to determine the effect of an intensification of the nonverbal facilitation of swallowing on dysphagia. METHODS: Ten patients with severe ABI and dysphagia were randomised into two groups at a highly specialised neurorehabilitation clinic.The intervention group received an intensification of the nonverbal facilitation of swallowing and the control group received basic care of the face and mouth in addition to treatment as usual for two sessions of 20 minutes per day for three weeks.Outcomes were Functional Oral Intake Scale (FOIS), Penetration Aspiration Scale (PAS), and electrophysiological swallowing specific parameters (EMBI). RESULTS: The intensified intervention was feasible. PAS and FOIS scores improved in both groups, with no differences between groups. The swallowing specific parameters reflected clinically observed changes in swallowing. CONCLUSIONS: PAS and FOIS are feasible instruments to measure dysphagia. It is possible and valid to measure swallowing frequency and kinematics using electromyography and bioimpedance. The definitive study should have widened inclusion criteria and optimise intervention timing to maintain patient arousal.

Cyclo-oxygenase 2 inhibitors and the risk of anastomotic leakage after fast-track colonic surgery.

BACKGROUND: Anastomotic leakage occurs after 3-6 per cent of colonic resections. The influence of analgesic agents is largely unknown. This study determined the rate of anastomotic leakage in a series of patients who had colonic surgery over a 9-year period with or without use of a cyclo-oxygenase inhibitor for postoperative analgesia. METHODS: Patients with anastomotic leakage following a standard fast-track procotol between April 1997 and May 2006 were identified from a prospective, consecutive database. During this period there were two changes in perioperative management: cessation of preoperative oral bowel preparation in August 2002 and the use of celecoxib for postoperative analgesia between May 2003 and November 2004. Rates of anastomotic leakage during the various periods were determined and compared. RESULTS: Some 28 (5.6 per cent) of 502 patients had an anastomotic leak. The incidence of leakage increased significantly during the period of celecoxib use (15.1 per cent), versus 3.3 and 1.5 per cent respectively before and after celecoxib use (P < 0.001). Leakage rates were similar with or without oral bowel preparation (3.5 versus 1.7 per cent respectively; P = 0.346) when celecoxib was not used. CONCLUSION: A detrimental effect of celecoxib on anastomotic healing is suggested, and requires further evaluation.

Readmission rates after a planned hospital stay of 2 versus 3 days in fast-track colonic surgery.

BACKGROUND: Initial programmes of fast-track open colonic surgery with a planned 2-day postoperative hospital stay have had a high readmission rate (about 20 per cent). The aim of this large, consecutive series was to compare readmission rates after a fast-track open colonic surgery programme with a planned hospital stay of 2 versus 3 days. METHODS: The study included 541 consecutive colonic resections from one surgical department with a structured care programme, including well defined discharge criteria, between April 1997 and December 2005. The planned hospital stay was increased from 2 to 3 days from August 2004. All patients were examined 8 and 30 days after surgery. RESULTS: Readmission rates fell from 20.1 per cent in 408 patients with a planned 2-day hospital stay (period 1) to 11.3 per cent in 133 patients with a planned 3-day hospital stay (period 2) (P < 0.020). Median length of primary hospital stay was 2 and 3 days, median stay after readmission was 5 and 5.5 days, and median (mean) total stay was 3 (5.6) and 3 (5.7) days in periods 1 and 2 respectively. The readmission rate in period 2 was lower because there were fewer readmissions for short-term observation or social reasons. There was no difference in type and incidence of morbidity between the two periods. CONCLUSION: Readmission after fast-track open colonic resection was reduced by planning discharge 3 instead of 2 days after surgery, with the same discharge criteria.

Convalescence after colonic surgery with fast-track vs conventional care.

OBJECTIVE: To compare convalescence after colonic surgery with a fast-track rehabilitation programme vs conventional care. BACKGROUND: Introduction of a multimodal rehabilitation programme (fast-track) with focus on epidural anaesthesia, minimal invasive surgical techniques, optimal pain control, and early nutrition and mobilization together with detailed patient information have led to a shorter hospital stay after colonic surgery. There are not much data on convalescence after discharge. METHODS: A prospective, controlled, non-randomized interview-based assessment in 160 patients undergoing an elective, uncomplicated, open colonic resection or the Hartmann reversal procedure with a fast-track or a conventional care programme in two university hospitals. A structured interview-based assessment was performed preoperatively, and day 14 and 30 postoperatively. RESULTS: Patients undergoing colonic surgery with a fast-track programme regained functional capabilities earlier with less fatigue and need for sleep compared with patients having conventional care. Despite early discharge of the fast-track patients (mean 3.4 days vs 7.5 days), no differences were found according to the need for home care, social care and visit to general practitioners, although the fast-track group had an increased number of visits at the outpatient clinic for wound care. More patients in the fast-track group were re-admitted, but the overall mean total hospital stay was 4.2 days vs 8.3 days in the conventional group. CONCLUSION: A fast-track rehabillitation programme led to a shorter hospital stay, less fatigue and earlier resumption of normal activities, without the increased need for support after discharge compared with conventionally treated patients after uncomplicated colonic resection.

Convalescence after colonic resection with fast-track versus conventional care.

BACKGROUND: Multi-modal rehabilitation programmes may improve early postoperative body composition, pulmonary function, exercise capacity, and reduce hospital stay. So far, no data are available on convalescence after discharge. AIM: The objectives were to compare convalescence data (fatigue, sleep, time to resume normal activities, and functional capabilities) and need for nursing care and contact to general practitioner with fast-track multi-modal rehabilitation compared with conventional care after colonic surgery. METHODS: Non-randomised, prospective controlled study in 30 consecutive patients undergoing fast-track rehabilitation with continuous epidural analgesia, enforced oral nutrition, mobilisation, planned early discharge, and 30 consecutive patients undergoing conventional care. Patients were interviewed preoperatively and 14 and 30 days postoperatively. RESULTS: Median hospital stay was 2 vs. 8 days in the fast-track vs. conventional care group, respectively (p < 0.01). Fourteen days postoperatively, total and mid-day sleep were increased in the conventional care group when compared with the fast-track group (p < 0.01). Fatigue was increased significantly at 14 days (p < 0.05) and throughout the study period compared with the fast-track group (p < 0.01). Similarly, ability to walking stairs, cooking, house keeping, shopping and walking outdoor was significantly less reduced at 14 days in the fast-track group, who also regained leisure activities earlier (p < 0.05). There was no significant difference between groups at 30 days or between need for nursing care and visits to general practitioners. Readmission for surgery-related events occurred more frequently (5 vs. 1 patient) in the fast-track group. CONCLUSION: Fast-track rehabilitation with early discharge after colonic surgery results in earlier resumption of normal activities with reduced fatigue and need for sleep postoperatively compared to conventional care, and without increased need for nursing care or visits to general practitioners. However, readmissions may occur more frequently.

Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition.

BACKGROUND: Postoperative organ dysfunction contributes to morbidity, hospital stay and convalescence. Multimodal rehabilitation with epidural analgesia, early oral feeding, mobilization and laxative use after colonic resection has reduced ileus and hospital stay. METHODS: Fourteen patients receiving conventional care (group 1) and 14 patients who had multimodal rehabilitation (group 2) were studied before and 8 days after colonic resection. Outcome measures included postoperative mobilization, body composition by whole-body dual X-ray absorptiometry, cardiovascular response to treadmill exercise, pulmonary function and nocturnal oxygen saturation. RESULTS: Defaecation occurred earlier (median day 1 versus day 4) and hospital stay was shorter (median 2 versus 12 days) in patients who had multimodal treatment. Lean body and fat mass decreased in group 1 but not in group 2. Exercise performance decreased by 44 per cent in group 1 but was unchanged in group 2. A postoperative increase in heart rate (HR) response to exercise was avoided in group 2. Pulmonary function decreased in group 1 but not in group 2. There was less nocturnal postoperative hypoxaemia in group 2. Cardiac demand-supply (HR/oxygen saturation ratio) increased in group 1 but not in group 2. CONCLUSION: Multimodal rehabilitation prevents reduction in lean body mass, pulmonary function, oxygenation and cardiovascular response to exercise after colonic surgery.

[Accelerated rehabilitation after colon resection]. / Accelereret rehabilitering efter colonresektion.

INTRODUCTION: The stay in hospital after colonic resection is usually 7-12 days, with a complication rate of 20%. A multi-modal rehabilitation regimen, comprising epidural analgesia, early mobilisation, and oral nutrition, reduced the hospital stay to 2-3 days after colonic resection. METHODS: One hundred patients underwent elective colonic resection with a planned postoperative stay of two days in hospital and a regimen with epidural analgesia, oral nutrition, and mobilisation. Anaesthesia, the surgical technique, and nursing care programme were standardised. Postoperative follow-up visits were arranged for day 8 and day 30. RESULTS: The median age was 73 years. Forty patients were at high risk, ASA III-IV. Gastrointestinal function (defecation) occurred within 48 hours, except for five patients, and the median hospital stay was two days. The readmission rate was 18% with no acute, potentially lethal conditions. The total hospital stay was three days. None of the patients had cardiopulmonary complications, except for one patient, who died from cardiac failure 36 hours after surgery. Three patients had anastomotic dehiscence, two of whom were treated conservatively. CONCLUSION: The usual postoperative ileus, "medical complications", and hospital stay were reduced in high-risk patients undergoing colonic resection with a multi-modal rehabilitation programme. These results call for further comparative studies with conventional care programmes and laparoscopic colonic resection.

A clinical pathway to accelerate recovery after colonic resection.

OBJECTIVE: To investigate the feasibility of a 48-hour postoperative stay program after colonic resection. SUMMARY BACKGROUND DATA: Postoperative hospital stay after colonic resection is usually 6 to 12 days, with a complication rate of 10% to 20%. Limiting factors for early recovery include stress-induced organ dysfunction, paralytic ileus, pain, and fatigue. It has been hypothesized that an accelerated multimodal rehabilitation program with optimal pain relief, stress reduction with regional anesthesia, early enteral nutrition, and early mobilization may enhance recovery and reduce the complication rate. METHODS: Sixty consecutive patients undergoing elective colonic resection were prospectively studied using a well-defined postoperative care program including continuous thoracic epidural analgesia and enforced early mobilization and enteral nutrition, and a planned 48-hour postoperative hospital stay. Postoperative follow-up was scheduled at 8 and 30 days. RESULTS: Median age was 74 years, with 20 patients in ASA group III-IV. Normal gastrointestinal function (defecation) occurred within 48 hours in 57 patients, and the median hospital stay was 2 days, with 32 patients staying 2 days after surgery. There were no cardiopulmonary complications. The readmission rate was 15%, including two patients with anastomotic dehiscence (one treated conservatively, one with colostomy); other readmissions required only short-term observation. CONCLUSION: A multimodal rehabilitation program may significantly reduce the postoperative hospital stay in high-risk patients undergoing colonic resection. Such a program may also reduce postoperative ileus and cardiopulmonary complications. These results may have important implications for the care of patients after colonic surgery and in the future assessment of open versus laparoscopic colonic resection.

[Psychiatric security units in Norway. Patients and activity]. / Norske psykiatriske sikkerhetsenheter. Pasienter og virksomhet.

The authors briefly discuss past and present reasons for the psychiatric security unit system in Norway. They describe the patients in these units at the beginning of 1993 (N = 123). Of these patients, 16% were females, 78% had a main diagnosis of schizophrenia, and 12% were admitted because of personality disorders. Physical restraints had been used for 25%, pharmacological restraints for 17%, and forced pharmacological treatment had been necessary for 26% of the patients during the last six months. There were high rates of behaviour problems related to criminality, abuse, violence and auto-aggression. Nearly all the patients were committed involuntarily, and additional legal restrictions were imposed for one third of them. The majority (63%) of the patients had been in security units for more than one year. The highest levels of security within the security unit system were used for those with the most serious criminality or behaviour problems prior to admission.