Search

Summary: Postoperative systemic inflammation is strongly associated with surgical outcomes, but its relationship with patient‐centred outcomes is largely unknown. Detection of excessive inflammation and patient and surgical factors associated with adverse patient‐centred outcomes should inform preventative treatment options to be evaluated in clinical trials and current clinical care. This retrospective cohort study analysed prospectively collected data from 3000 high‐risk, elective, major abdominal surgery patients in the restrictive vs. liberal fluid therapy for major abdominal surgery (RELIEF) trial from 47 centres in seven countries from May 2013 to September 2016. The co‐primary endpoints were persistent disability or death up to 90 days after surgery, and quality of recovery using a 15‐item quality of recovery score at days 3 and 30. Secondary endpoints included: 90‐day and 1‐year all‐cause mortality; septic complications; acute kidney injury; unplanned admission to intensive care/high dependency unit; and total intensive care unit and hospital stays. Patients were assigned into quartiles of maximum postoperative C‐reactive protein concentration up to day 3, after multiple imputations of missing values. The lowest (reference) group, quartile 1, C‐reactive protein ≤ 85 mg.l‐1, was compared with three inflammation groups: quartile 2 > 85 mg.l‐1 to 140 mg.l‐1; quartile 3 > 140 mg.l‐1 to 200 mg.l‐1; and quartile 4 > 200 mg.l‐1 to 587 mg.l‐1. Greater postoperative systemic inflammation had a higher adjusted risk ratio (95%CI) of persistent disability or death up to 90 days after surgery, quartile 4 vs. quartile 1 being 1.76 (1.31–2.36), p < 0.001. Increased inflammation was associated with increasing decline in risk‐adjusted estimated medians (95%CI) for quality of recovery, the quartile 4 to quartile 1 difference being ‐14.4 (‐17.38 to ‐10.71), p < 0.001 on day 3, and ‐5.94 (‐8.92 to ‐2.95), p < 0.001 on day 30. Marked postoperative systemic inflammation was associated with increased risk of complications, poor quality of recovery and persistent disability or death up to 90 days after surgery. [ABSTRACT FROM AUTHOR]

Summary: In some patients, the inflammatory‐immune response to surgical injury progresses to a harmful, dysregulated state. We posit that postoperative systemic inflammatory dysregulation forms part of a pathophysiological response to surgical injury that places patients at increased risk of complications and subsequently prolongs hospital stay. In this narrative review, we have outlined the evolution, measurement and prediction of postoperative systemic inflammatory dysregulation, distinguishing it from a healthy and self‐limiting host response. We reviewed the actions of glucocorticoids and the potential for heterogeneous responses to peri‐operative corticosteroid supplementation. We have then appraised the evidence highlighting the safety of corticosteroid supplementation, and the potential benefits of high/repeated doses to reduce the risks of major complications and death. Finally, we addressed how clinical trials in the future should target patients at higher risk of peri‐operative inflammatory complications, whereby corticosteroid regimes should be tailored to modify not only the a priori risk, but also further adjusted in response to markers of an evolving pathophysiological response. [ABSTRACT FROM AUTHOR]

Background: It is widely accepted that the COVID-19 pandemic has accelerated the era of online health care delivery, including within community palliative care. This study was part of a larger project involving a collaboration between universities, health care services, government agencies, and software developers that sought to enhance an existing telehealth (video call) platform with additional features to improve both patient and health care professional (HCP) experience in a palliative care context., Objective: The aim of this study was to understand palliative care patients' and HCPs' experiences of telehealth delivery in a palliative care context in Victoria, Australia. For the purposes of this study, telehealth included consultations by both video and telephone calls. By better understanding users' experiences and perceptions of telehealth, we hoped to determine users' preferences for new telehealth enhancement features., Methods: A total of 6 health care professionals and 6 patients were recruited from a major tertiary hospital network's palliative care unit in Victoria, Australia. Participants were asked to generate 3-5 photographs depicting their telehealth experiences. These photographs were used as visual aids to prompt discussion during subsequent one-on-one interviews. Intertextual analysis was conducted to identify key themes., Results: A total of 3 overarching themes emerged: comfort (or lack thereof) afforded by telehealth, connection considerations in telehealth, and care quality impacts of telehealth. Patients (n=6) described telehealth as supporting their physical and psychological comfort and maintaining connection with HCPs, yet there were specific situations where it failed to meet their needs or impacted care quality and delayed treatment. HCPs (n=6) recognized the benefit of telehealth for patients but reported several limitations of telehealth, in particular due to lack of physical examination opportunities. Participants indicated that 2 types of connection were imperative for effective telehealth delivery: technical connection (eg, good internet connectivity or clear phone line) and interpersonal connection (ie, good rapport and therapeutic alliance between the HCPs and patients). Often technical connection issues impeded the development of interpersonal connection between the HCPs and patients in telehealth., Conclusions: The findings presented in this study combined with other co-design activities, which are outside the scope of this paper, indicated the potential value of a telehealth enhancement feature that generates patient-facing clinical consultation summaries. Our team has developed a video telehealth enhancement feature (or "add-on"), which will enable clinicians to distill key actionable advice and self-management guidance discussed during teleconsultations for a take-home summary document for patients. The add-on's prototype has also been subjected to an initial simulation study, which will be reported in a future publication., (© Mahima Kalla, Teresa O'Brien, Olivia Metcalf, Rashina Hoda, Xiao Chen, Andy Li, Catriona Parker, Michael Edward Franco, Sam Georgy, Kit Huckvale, Christopher Bain, Peter Poon. Originally published in JMIR Human Factors (https://humanfactors.jmir.org).)

Background: This retrospective cohort study evaluated 584 cattle caesarean sections (C-sections) performed at a first opinion practice in Southwest England between 2015 and 2021., Methods: Outcomes were recorded contemporaneously, and procedures were followed up after 14 days., Results: Thirty-one dams died within 14 days of undergoing a C-section (94.7% survival rate). Dam parity and purpose did not significantly impact mortality. Dams were at 2.7 times greater odds of dying within 14 days if they delivered a stillborn calf (p < 0.05, 95% confidence interval [CI] = 1.20‒6.13), and at 2.9 times greater odds of dying within 14 days if they were recumbent for some, or all, of the C-section (p < 0.05, 95% CI = 1.02‒8.2). Among the 428 procedures where calf outcomes were recorded, 32.9% (n = 141) were stillborn, reflecting previous studies reporting perinatal mortality. Uterine torsion was anecdotally listed as the reason for operating in 34 cases, and 58.1% (n = 18) of these C-sections resulted in a dead calf., Limitations: Despite the large number of cases studied, all C-sections were carried out by a single veterinary practice. Individual operator(s) and farms were not recorded and could be undetected confounding variables., Conclusion: This study's results provide much needed relevant benchmarking for completing in-house practice audit cycles, ensuring improved clinical governance and outcomes., (© 2024 British Veterinary Association.)

Introduction: Recent developments in the field of large language models have showcased impressive achievements in their ability to perform natural language processing tasks, opening up possibilities for use in critical domains like telehealth. We conducted a pilot study on the opportunities of utilizing large language models, specifically GPT-3.5, GPT-4, and LLaMA 2, in the context of zero-shot summarization of doctor-patient conversation during a palliative care teleconsultation., Methods: We created a bespoke doctor-patient conversation to evaluate the quality of medical conversation summarization, employing established automatic metrics such as BLEU, ROUGE-L, METEOR, and BERTScore for quality assessment, and using the Flesch-Kincaid grade Level for readability to understand the efficacy and suitability of these models in the medical domain., Results: For automatic metrics, LLaMA2-7B scored the highest in BLEU, indicating strong n-gram precision, while GPT-4 excelled in both ROUGE-L and METEOR, demonstrating its capability to capture longer sequences and semantic accuracy. GPT-4 also led in BERTScore, suggesting better semantic similarity at the token level compared to others. For readability, LLaMA 7B and LLaMA 13B produced summaries with Flesch-Kincaid grade levels of 11.9 and 12.6, respectively, which are somewhat more complex than the reference value of 10.6. LLaMA 70B generated summaries closest to the reference in simplicity, with a score of 10.7. GPT-3.5's summaries were the most complex at a grade level of 15.2, while GPT-4's summaries had a grade level of 13.1, making them moderately accessible., Conclusion: Our findings indicate that all the models have similar performance for the palliative care consultation, with GPT-4 being slightly better at balancing understanding content and maintaining structural similarity to the source, which makes it a potentially better choice for creating patient-friendly medical summaries. Threats and limitations of such approaches are also embedded in our analysis., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)