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Implementation of an early manual lymphatic drainage program on post-op head/neck patients to decrease secondary edema.

It is estimated that 300 million surgical procedures take place annually throughout the globe (Gillespie et al., 2021). However, the incidence of surgical site infections (SSI) developing in surgical patients within 30 days of surgery have been estimated to be upwards of 11% (Gillespie et al., 2021). The purpose of this evidence-based practice project was to address the PICOT question: In patients who have undergone cardiothoracic or vascular surgery (P) does implementation of an evidence based post-operative care bundle (I) as compared to current clinical agency practice standards (C) result in a decrease of SSI (O) over a 12-week period (T)? The project was completed at a community hospital in Northern Indiana. There was a total of 26 participants, comprised mostly of males aged 49-88 years old. The surgical wounds were assessed for SSIs utilizing the National Healthcare Safety Network/Centers for Disease Control (NHSN/CDC) assessment tool. A Pearson Chi-Square test was used to compare data between two surgical groups to analyze if there was a difference between participants who had received a post-operative care bundle and those who had not. Data between the groups were analyzed and found there was not a statistical relationship between the two groups and whether an SSI was present after the intervention (p= 0.443). Findings from this project may help guide future post-operative care standards in the cardiothoracic and vascular surgical population.

Abstract: Hippocampal sclerosis (HS) is an important predictor of surgical outcome in temporal lobe epilepsy (TLE). High-resolution (1 mm isotropic) diffusion tensor imaging (DTI) of the hippocampus in TLE patients has shown patterns of hippocampal subfield diffusion abnormalities which were consistent with HS subtype on surgical histology in a pilot sample of four patients. T2 relaxometry has also demonstrated focal hippocampal abnormalities which correlated with HS pathological features of neuron loss, gliosis, and granule cell dispersion. The objectives of this thesis were to determine the stability of focal hippocampus diffusion changes over time in TLE patients, compare diffusion and quantitative T2 abnormalities of the sclerotic hippocampus and correlate pre-surgical mean diffusivity (MD) and T2 maps with post-surgical histology. To address these objectives, 19 TLE patients and 19 controls underwent two high-resolution (1 × 1 × 1 mm3) DTI and (1.1 × 1.1 × 1 mm3) T2 relaxometry scans (in a subset of 16 TLE patients and 9 controls) of the hippocampus at 3T, with a 2.6±0.8 year inter-scan interval. Within-participant hippocampal volume, MD and T2 were compared between the scans. Contralateral hippocampal changes 2.3±1.0 years after surgery and ipsilateral pre-operative MD maps versus post-operative subfield histopathology were evaluated in 8 patients who underwent surgical resection of the hippocampus. The results showed significantly reduced volume and elevated MD and T2 of sclerotic hippocampi compared to healthy and non-HS hippocampi. These whole-hippocampus measures remained unchanged between the longitudinal scans. Focal regions of elevated MD and T2 in bilateral hippocampi of HS TLE were detected consistently at both scans. Regions of high MD and T2 correlated and remained consistent over time. Volume, MD and T2 remained unchanged in post-operative contralateral hippocampus. Regional elevations of MD identified subfield neuron loss on post-surgical histology with 88% sensitivity and 88% specificity. Focal T2 elevations identified subfield neuron loss with 75% sensitivity and 88% specificity. The findings of this work suggest no significant change in diffusion and T2 abnormalities in ipsilateral and contralateral hippocampi between the two scans, suggesting permanent micro-structural alterations. While both MD and T2 accurately predicted HS subtypes, MD was more sensitive than T2 in detecting neuron loss on post-surgical histology. Both DTI and T2 acquisitions were acquired using a clinically feasible protocol (at 3T in under 6 minutes each), potentially providing the opportunity to diagnose precise HS subtypes as well as detect subtle or regional contralateral hippocampal abnormalities, which may aide in predicting surgical outcomes preoperatively.

Background. Postoperative complications resulting in unplanned hospital readmission are common and avoidable. Discharge education enables general surgery (GS) patients to manage their recovery and seek professional help when required, but evidence gaps in this education exist. Aims. The purpose of this thesis was 1) to develop an evidence-based discharge education program using web-based technology for GS patients to self-manage their postdischarge recovery and 2) to test the feasibility of implementing the web-based education program. Methods. This research was guided by the Knowledge-to-Action (KTA) framework and UK Medical Research Council (MRC) guidance for developing and evaluating complex interventions. Phase 1 was a systematic mixed studies review (MSR) to identify the who, what, when and how relevant to discharge education being given to GS patients. Phase 2 included a qualitative study using individual and focus group interviews with patients and health care providers. The aim was to gain an understanding of the problem and the barriers and enablers in delivering discharge education. Phase 3 described the comprehensive approach used to develop the web-based education intervention. Phase 4 involved a pilot randomised controlled trial (RCT) to assess the feasibility of implementing the web-based discharge education intervention. Results. In Phase 1, the MSR of seven studies identified four themes: 1) the quality of discharge education influences its uptake, 2) health care professionals’ perceptions of their role in the delivery of discharge education to patients, 3) patients’ preferences for education delivery, and 4) patients’ participation in their self-care. In Phase 2, telephone interviews with 13 patients uncovered four themes: 1) the quality of discharge information influences patients’ postdischarge experience, 2) the negative impact of contextual influences on delivery of discharge education, 3) patients actively participating in their surgical journey, and 4) patients’ preferences with the delivery of discharge education. Interviews with 21 nurses revealed four themes: 1) assuming responsibility for patient education in the absence of discharge communication; 2) supporting patients to participate in self-management after hospitalisation; 3) variability in the resources, content, and delivery of discharge education; and 4) meeting operational demands compromises the quality of patients’ discharge education. Five themes emerged from the individual interviews with 10 doctors: 1) challenges of delivering quality discharge education, 2) complexities of the discharge planning process, 3) production pressures imposed by the organisation impede delivery of discharge education, 4) anticipating patients’ needs and preferences, and 5) coordinating the discharge process requires a team effort. In Phase 3, a logic model was used in the co-design of the intervention, which was underpinned by the concept of patient activation and Knowles theory of andragogy. It included three components:1) warning signs of potential postoperative complications, 2) information on postdischarge care, and 3) video on surgical wound care and signs of wound complication. In Phase 4, 85 GS patients were recruited and randomised to receive the web-based education intervention or standard education. Feasibility criteria of recruitment, randomisation was met although participants’ loss to follow up was high (27%). Patients in the intervention arm accessed the education an average of three times (SD 3.14) with 4 minutes (SD 16) spent on the website. Most patients were satisfied with its content and found it useful and straightforward. Patient activation, self-care ability, and unplanned health care utilisations improved for patients in the intervention arm, although were only statistically significant for patient activation (F[1,60] = 9.347, p = .003). Conclusions. This web-based discharge education intervention is easily accessed and is an additional support for GS patients to support their recovery after hospital discharge.

Abstract: Lung cancer has the highest mortality rates of all cancers worldwide, with a 5-year survival rate less than 15%. Screening methods are in need for the high risk population, as lung cancer is asymptomatic in its early stages. Proper screening methods would allow earlier diagnosis and curative intent treatment. microRNAs (miRNAs) are small, non-coding strands of ribonucleic acid (RNA) that are shown to lead to carcinogenesis when dysregulated. They are stable and detectable in small quantities, thus are promising candidates for biomarkers. miRNAs are also expressed in a tissue specific manner and measurable in small quantities of different biological fluids. In chapters 2 and 3, we show that in our nested case control study, a risk score analysis comparing miRNAs 21, 150, 210 and 223 in early stage non-small cell lung cancers (NSCLC) matched with similar age and smoking history controls, showed that miRNA profiling could be used as a screening method when measured in blood plasma. We also showed that pre-operative and post-operative NSCLC miRNA levels stay dysregulated 5-8 months post tumour resection, regardless of cancer recurrence or metastasis. In chapter 4 we discuss the results, which demonstrate the benefits of using miRNAs as a screening method for NSCLC, but also that it is not viable to be used as a test on its own. We suggest, in order to improve miRNAs screening capabilities, that the test be combined with another method, such as low-dose computed tomography (CT) scanning, to improve early detection in the high-risk population.

Social support and resilience have been shown to reduce recovery times after major operations, as well as predict levels of post-operative pain. This study aims to determine whether social support and resilience modulate medical outcomes parameters and perceptions of recovery after a surgical intervention. Post-operative patients were recruited from an inner-city, safety net, level 1 trauma center prior to discharge. They completed questionnaires on social support (Medical Outcomes Study - Social Support Survey MOS-SSS), resilience (Brief Resilience Scale BRS), and overall health (Medical Outcomes Study – Short Form 36 MOS-SF36). Patients then completed the MOS-SF36 questionnaire approximately six and twelve weeks after surgical treatment. Preliminary results from recruited patients offer no conclusion regarding social support and outcome measures, but a significant positive relationship between resilience and patient-reported quality of life was seen (Spearman's Rho = 0.606). Resilience was also highest among patients in the surgical oncology service, relative to the other two surgical cohorts.