Background: After the introduction of Electronic Health Record Systems (EHRS) (EPIC systems) in 2019, our Drinking, Eating, and Mobilising (DrEaMing) outcomes for prostatectomy patients had deteriorated when compared with historical PQIP data.1 This project therefore aimed to reintegrate these principles using the EHRS to increase pathway adherence. Methods: Using a multidisciplinary approach, a digital Enhanced Recovery After Surgery (ERAS) pathway for patients with Robot Assisted Laparoscopic Prostatectomy (RALP) was developed and implemented into the EHRS. Flowsheet completion rate was used as a process measure of adherence to DrEaMing and therefore effectiveness of the EHRS. Staff were also interviewed if not completing the flowsheet to identify barriers to its usage. Results: After the pathway was introduced, an audit of 20 patient charts was undertaken, and flowsheet completion rate was found to be less than 10%. From those who reported not using the flowsheet, reasons reported included missing training sessions (50%), finding it redundant (17%), being unaware of it (17%), or finding it too time consuming to complete (16%) (Fig. 7). Conclusions: Digital build does not automatically equate to clinical adoption. Conversion to EHRS may reduce the effectiveness of established ERAS pathways, at least in the short term. This risk must be considered during design and implementation to avoid the loss of established effective analogue pathways. End user training is vital for sustainable uptake of EHRS, alongside regular data visualisations to understand the importance and performance benefits that users accomplish through using the system. Effective implementation has potential to provide a standardised approach to DrEaMing across multiple specialties. PQIP data could be used elsewhere to examine nationwide patterns in processes of ERAS care as the NHS transitions to digital workflow. 1.Perioperative Quality Improvement Programme. Annual Report 2021. Available from https://pqip.org.uk/FilesUploaded/PQIP-Annual-Report_2021.pdf (accessed 28 March 2022)

High-frequency jet ventilation (HFJV) can reduce organ movement that otherwise complicates percutaneous image-guided ablation (IGA) procedures. This study describes feasibility and safety of the technique in routine use. We describe our method for the use of HFJV and present 169 consecutive cases, including IGA of tumors of the lung, liver, kidney, and pancreas. Intended oncological treatment was delivered in all cases and HFJV used for the duration of treatment in all except one case. We describe the characteristics of patients, procedures, and adverse events. It is feasible to use HFJV as the routine standard of care for IGA.

ObjectivesTo evaluate whether distance and estimated travel time to hospital for patients undergoing emergency laparotomy is associated with postoperative mortality.DesignNational cohort study using data from the National Emergency Laparotomy Audit.Setting171 National Health Service hospitals in England and Wales.Participants22 772 adult patients undergoing emergency surgery on the gastrointestinal tract between 2013 and 2016.Main outcome measuresMortality from any cause and in any place at 30 and 90 days after surgery.ResultsMedian on-road distance between home and hospital was 8.4 km (IQR 4.7–16.7 km) with a median estimated travel time of 16 min. Median time from hospital admission to operating theatre was 12.7 hours. Older patients live on average further from hospital and patients from areas of increased socioeconomic deprivation live on average less far away.We included estimated travel time as a continuous variable in multilevel logistic regression models adjusting for important confounders and found no evidence for an association with 30-day mortality (OR per 10 min of travel time=1.02, 95% CI 0.97 to 1.06, p=0.512) or 90-day mortality (OR 1.02, 95 % CI 0.97 to 1.06, p=0.472).The results were similar when we limited our analysis to the subgroup of 5386 patients undergoing the most urgent surgery. 30-day mortality: OR=1.02 (95% CI 0.95 to 1.10, p=0.574) and 90-day mortality: OR=1.01 (95% CI 0.94 to 1.08, p=0.858).ConclusionsIn the UK NHS, estimated travel time between home and hospital was not a primary determinant of short-term mortality following emergency gastrointestinal surgery.

BACKGROUND:Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups.METHODS:This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence.RESULTS:Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and least-deprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76-0.92]; Q3: 0.84 [0.76-0.92]; Q4: 0.87 [0.79-0.96]; Q5 [least deprived]: 0.77 [0.70-0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association.CONCLUSIONS:More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.

More than 25% of events reported to the Fourth National Audit Project (NAP4) were from ICU and EU.1 Analysis of these cases revealed deficiencies including planning and provision of skilled staff and equipment. The Difficult Airway Society (DAS) ‘Guidelines for the management of tracheal intubation in critically ill adults’ published in 20172 recommends using standardised equipment trolleys and a structured algorithm approach. Shadow boards and kit dump have been advocated for Rapid Sequence Induction (RSI) in non-theatre and pre-hospital environments,3 but current available designs do not match the most up-to-date guidelines. We have produced a shadow board incorporating the 2017 intubation checklist (Fig. 4). We advocate standardised use in non-theatre environments and have produced a simple design that we intend to make freely available for non-commercial purposes and fits on standard airway trolleys. We are currently trialling the design in our emergency department. Our local design has been scaled to fit on an Avalo Difficult Airway Trolley (Distinctive Medical, Runcorn, UK), and this can be printed on waterproof vinyl at a cost of approximately £15. The design is not endorsed by DAS or any other organisation but is reproduced within the terms of use (https://www.das.uk.com/content/permission-use-das-algorithms). 1.Katz JA. Anesthesiology 2012; 116: 4962.Higgs A, McGrath BA, Goddard C, et al. Br J Anaesth 2017; 120: 323–523.Leeuwenburg T. Crit Care Horizons 2015; 1: 1–10

BACKGROUND:Socioeconomic deprivation is a potentially important factor influencing surgical outcomes. This systematic review aimed to summarize the evidence for any association between socioeconomic group and mortality after colorectal surgery, and to report the definitions of deprivation used and the approaches taken to adjust for co-morbidity in this patient population.METHODS:MEDLINE, Embase, the Cochrane Library and Web of Science were searched for studies up to November 2016 on adult patients undergoing major colorectal surgery, which reported on mortality according to socioeconomic group. Risk of bias and study quality were assessed by extracting data relating to study size, and variations in inclusion and exclusion criteria. Quality was assessed using a modification of a previously described assessment tool.RESULTS:The literature search identified 59 studies published between 1993 and 2016, reporting on 2 698 403 patients from eight countries. Overall findings showed evidence for higher mortality in more deprived socioeconomic groups, both in the perioperative period and in the longer term. Studies differed in how they defined socioeconomic groups, but the most common approach was to use one of a selection of multifactorial indices based on small geographical areas. There was no consistent approach to adjusting for co-morbidity but, where this was considered, the Charlson Co-morbidity Index was most frequently used.CONCLUSION:This systematic review suggests that socioeconomic deprivation influences mortality after colorectal surgery.

Improvements in outcome measurement are needed to produce quality improvement in perioperative care. However, problems with the collection and use of outcome data persist in research and clinical practice. This is being addressed by several national programmes and initiatives to standardize and integrate outcome measurement. The use of different outcome measures is changing and there has been a transition towards patient-focused measures. Traditional measures of quality in perioperative care include mortality, morbidity and resource utilization measures. Patient-focused measures include patient-reported outcome measures and measures of patient experience. Each of these has advantages and disadvantages in different situations. The routine collection, analysis and dissemination of data relating to perioperative outcome is beneficial to patients, clinicians, hospitals, commissioners, regulators and researchers.

Background: Calcineurin (CaN) is a phosphatase involved in synaptic plasticity. A haplotype of the PPP3CC gene, which encodes the gamma isoform of the catalytic subunit (CaN A), has been associated with schizophrenia. However, the distribution of CaN A gamma is not established, nor whether its expression changes in schizophrenia.Methods: CaN A expression was analyzed in the hippocampal formation of 13 patients with schizophrenia and 12 controls. All three isoforms were examined, using in situ hybridization histochemistry, RT-PCR, and laser-assisted microdissection. CaN A protein was assessed using ELISA and immunohistochemistry. CaN A mRNAs were also measured in rats treated with haloperidol or chlorpromazine.Results: CaN was prominent in excitatory neurons. CaN Act and A beta isoforms were abundant in all subfields, but CaN A gamma was not reliably detected in CA1. CaN A protein, and all three mRNAs, were decreased in schizophrenia. The mRNA reductions were present in all subfields measured, except CA1. CaN A mRNAs were unaltered in the antipsychotic-treated rats.Conclusions: Decreased CaN expression extends the evidence for aberrant hippocampal synaptic plasticity in schizophrenia, which particularly affects glulamatergic transmission, and which leaves CA1 relatively unaffected. Reduced expression of PPP3CC may underlie its genetic involvement in the disorder.

Calcineurin (protein phosphatase 2B) is a calcium-dependent serine-threonine phosphatase. It has diverse roles and is centrally involved in synaptic plasticity. The catalytic A subunit of calcineurin has three isoforms, alpha, beta and gamma. Their expression and ontogeny in the brain has not been systematically investigated; such data become important with a report that PPP3CC, the gene encoding calcineurin A gamma, is a susceptibility gene for schizophrenia, and the finding that its expression is decreased in the disorder. We used in situ hybridization histochemistry to measure the relative transcript abundance of calcineurin A gamma and the other catalytic isoforms, A alpha and A beta, during development of the Sprague-Dawley rat hippocampus and cerebellum. All three isoforms are present in both regions at all time points [embryonic day 19 (E19) to postnatal day 42 (P42)] and undergo developmental regulation, but differ in their ontogenic profile. Calcineurin A alpha and A beta mRNAs increased from E19 through to adulthood, whereas A gamma mRNA was most highly expressed during early developmental stages. Calcineurin A alpha and A beta mRNAs positively correlated with synaptophysin mRNA (a synaptic marker), whilst A gamma mRNA was either unrelated to, or negatively correlated, with this transcript. These data confirm that all three calcineurin A subunits are expressed in the rodent brain, and indicate that calcineurin A gamma may have different roles than A alpha and A beta. The data also suggest a potential importance of calcineurin A gamma in neurodevelopment, and in the genetically influenced neurodevelopmental disturbance that is thought to underlie schizophrenia.