Objectives
To determine the effect of integrating informal caregivers into discharge planning on postdischarge cost and resource use in older adults.
Design
A systematic review and metaanalysis of ...randomized controlled trials that examine the effect of discharge planning with caregiver integration begun before discharge on healthcare cost and resource use outcomes. MEDLINE, EMBASE, and the Cochrane Library databases were searched for all English‐language articles published between 1990 and April 2016.
Setting
Hospital or skilled nursing facility.
Participants
Older adults with informal caregivers discharged to a community setting.
Measurements
Readmission rates, length of and time to post‐discharge rehospitalizations, costs of postdischarge care.
Results
Of 10,715 s identified, 15 studies met the inclusion criteria. Eleven studies provided sufficient detail to calculate readmission rates for treatment and control participants. Discharge planning interventions with caregiver integration were associated with a 25% fewer readmissions at 90 days (relative risk (RR) = 0.75, 95% confidence interval (CI) = 0.62–0.91) and 24% fewer readmissions at 180 days (RR = 0.76, 95% CI = 0.64–0.90). The majority of studies reported statistically significant shorter time to readmission, shorter rehospitalization, and lower costs of postdischarge care among discharge planning interventions with caregiver integration.
Conclusion
For older adults discharged to a community setting, the integration of caregivers into the discharge planning process reduces the risk of hospital readmission.
Prolonged postoperative incontinence is a major drawback of RRP. Age, scars in the rhabdosphincter, nonnerve sparing surgery and postoperative sphincter insufficiency can cause temporary or ...definitive urinary incontinence. We believe that sphincter deficiency is the main cause of early incontinence. Urinary leakage results from the shortening of anatomical and functional sphincter length due to caudal retraction of the urethral sphincteric complex and disruption of the median posterior fibrous raphe. We describe a modification of the Walsh RRP that overcomes caudal retraction, reconstructs the posterior fibrous raphe and decreases time to continence. The primary study end point was early continence rate assessment. Long-term continence (1 year) and erectile function assessment were secondary end points.
To avoid caudal retraction of the urethrosphincteric complex, before completing the vesicourethral anastomosis the posterior semicircumference of the sphincter is joined to the residuum of Denonvilliers’ fascia and fixed to the posterior bladder wall 1 to 2 cm cranial and dorsal to the new bladder neck. Vesicourethral anastomosis is subsequently performed with care taken not to involve the neurovascular bundles. A total of 161 patients with clinically confined disease underwent modified RRP (group 1). They were compared with a historical series of 50 patients who underwent standard RRP (group 2). Early continence was defined as no pad use but patients using 1 diaper were also considered continent. Continence, assessed prospectively as the number of pads daily, was evaluated 3, 30 and 90 days, and 1 year after catheter removal. The continence state was assessed by a multivariate logistic model. Erectile function was evaluated using the International Index of Erectile Function questionnaire preoperatively and after 18 months in patients younger than 65 years who underwent nerve sparing surgery.
In group 1, 116 (72%), 127 (78.8%) and 139 patients (86.3%) were continent 3, 30 and 90 days after catheter removal compared with 7 (14%), 15 (30%) and 23 (46%), respectively, in group 2. One-year continence rates were 96% and 90%, respectively. Erectile function was similar in groups 1 and 2 (46% and 42%, respectively). Multivariate analysis showed that continence was significantly influenced by operation type, stage and patient age.
Careful reconstruction of the posterior aspect of the rhabdosphincter markedly shortens time to continence.
After the Counter-Reformation, the Papal State of Bologna became a hub for the flourishing of female artistic talent. The eighteenth-century biographer Luigi Crespi recorded over twenty-eight women ...artists working in the city, although many of these, until recently, were ignored by modern art criticism, despite the fame they attained during their lifetimes. What were the factors that contributed to Bologna's unique confluence of women with art, science, and religion? The Devout Hand explores the work of two generations of Italian women artists in Bologna, from Lavinia Fontana (1552–1614), whose career emerged during the aftermath of the Counter Reformation, to her brilliant successor, Elisabetta Sirani (1638–1665), who organized the first school for women artists. Patricia Rocco further sheds light on Sirani's students and colleagues, including the little-known engraver Veronica Fontana and the innovative but understudied etcher Giuseppe Maria Mitelli. Combining analysis of iconography, patronage, gender, and reception studies, Rocco integrates painting, popular prints, book illustration, and embroidery to open a wider lens onto the relationship between women, virtue, and the visual arts during a period of religious crisis and reform. A reminder of the lasting power of images, The Devout Hand highlights women's active role in sixteenth- and seventeenth-century Christian reform and artistic production.
To compare intra and early postoperative outcomes between pulsed-wave and continuous-wave Thulium Fiber Laser Enucleation of the Prostate (PW-ThuFLEP vs CW-ThuFLEP) for the treatment of benign ...prostatic hyperplasia.
238 patients with lower urinary tract symptoms due to benign prostatic hyperplasia underwent PW-ThuFLEP (118 patients) vs CW-ThuFLEP (120 patients). Preoperative prostate volume, adenoma volume, prostate-specific antigen (PSA), and hemoglobin values were recorded. International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), post-void residual volume, and International Index of Erectile Function-5 score (IIEF-5) were assessed. Operative time, enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin drop, and postoperative complications were recorded. Micturition improvements and sexual outcomes were evaluated 3months after surgery.
CW-ThuFLEP showed shorter operative time (61.5 vs 67.4 minutes, P = .04). Enucleation time (50.2 vs 53.3 minutes, P = .12), enucleation efficiency (0.8 vs 0.7 g/min, P = .38), catheterization time (2.2 vs 2.1days, P = .29), irrigation volume (32.9 vs 32.8L, P = .71), hospital stay (2.8 vs 2.6days, P = .29) and hemoglobin drop (0.38 vs 0.39 g/dL, P = .53) were comparable. No significant difference in complication rate was observed. At 3-month follow-up, the procedures did not show any significant difference in IPSS, Qmax, post-void residual volume, IIEF-5, and PSA value.
PW-ThuFLEP and CW-ThuFLEP both relieve lower urinary tract symptoms equally, with high efficacy and safety. Operative time was significantly shorter with CW-ThuFLEP, but with a small difference with low clinical impact. Enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin and PSA drop, complication rate, and sexual outcomes showed no differences.
Abstract Background To report the perioperative, functional and oncological outcomes of salvage robot-assisted laparoscopic prostatectomy (s-RARP) in a propensity score-matched analysis. Study design ...53 patients underwent s-RARP at our institution. Perioperative, functional and oncological outcomes were compared between propensity matched cohorts. Results Patients in the s-RARP group were at significantly higher risk based on the D'Amico classification system ( p = 0.010). Estimated blood loss, complication rate, hospital stay, BCR risk, persistent cancer and time to return of potency were similar between groups (full nerve spare NS n = 22). In the s-RARP cohort there was a higher prevalence of lymphovascular invasion (26.4% versus 13.2%; p = 0.032), time to catheter removal and a higher prevalence of anastomotic leaks in the postoperative period (34.0% vs 5.7%, p < 0.010). The hazard ratio for return to potency regardless of nerve sparing in the s-RARP group was 0.47 (95% CI 0.25–0.88). Significantly more patients undergoing primary RARP with partial nerve sparing (NS) recovered continence (p < 0.001) and potency (p = 0.043) compared to partial NS s-RARP patients. The return to continence and potency did not differ between full NS cases (n = 22; p = 0.616). Conclusions Salvage RARP patients undergoing surgery have more high risk disease. Patients should be counseled that they are more likely to demonstrate anastomotic leakage on cystogram, and prolonged catheterization times. The time to potency and continence in s-RARP undergoing partial and no NS was significantly delayed (n = 49). The proportion of patients returning to potency and continence was also lower in our s-RARP group.
Purpose
To assess the learning curve of Thulium laser enucleation of the prostate (ThuLEP) of a single surgeon.
Methods
Hundred patients suffering from benign prostatic hyperplasia were treated by ...the same surgeon. In all cases, a well-trained urologist was present in the operating room. Patients urinary function was assessed preoperatively using the International Prostate Symptoms Score (IPSS), maximum flow rate and Post-Void Residual volume. Preoperative prostate volume was recorded. Enucleation and morcellation efficiency and complication rate were evaluated. Patients were divided into 5 cohorts of 20 consecutive cases to assess changes in outcomes through time.
Results
Mean age of patients was 73.1 years (SD 17.5) and mean prostate volume was 89.7 ml (SD 55.1). Overall, mean enucleation and morcellation efficiency were 1.7 (SD 2.9) and 5.1 (SD 2.7) g/min. A statistically significant increase in enucleation efficiency was observed when comparing cohort 1 vs 2 (0.9 vs 1.3 g/min,
p
= 0.03) and cohort 2 vs 3 (1.3 vs 1.7 g/min,
p
= 0.02). A statistically significant increase in morcellation efficiency was observed when comparing cohort 1 vs 2 (2.8 vs 3.7 g/min,
p
= 0.02) and cohort 2 vs 3 (3.7 vs 4.9 g/min,
p
= 0.03). In both cases, no significant differences were observed when comparing the following cohorts. Complication rate showed no significant differences throughout the caseload.
Conclusions
In our single-surgeon experience, we observed a learning curve of nearly 60 cases for the ThuLEP procedure in presence of a well-trained surgeon. Complication rate was low from the beginning of surgical experience.
COVID‐19 and dermatology: a comprehensive guide for dermatologists Fahmy, D.H.; El‐Amawy, H.S.; El‐Samongy, M.A. ...
JEADV. Journal of the European Academy of Dermatology and Venereology/Journal of the European Academy of Dermatology and Venereology,
July 2020, Letnik:
34, Številka:
7
Journal Article
Abstract Introduction and objectives Our goal was to evaluate the perioperative, functional and intermediate term oncological outcomes of robot assisted radical prostatectomy (RARP) in patients ≥70 ...years. Materials and methods The study population (N = 3241) consisted of consecutive patients who underwent RARP for localized prostate cancer by a single surgeon (VP) from January 2008 through February 2012. A query of our Institutional Review Board approved registry identified 400 men ≥70 years of age, with good functional status (Charlson co-morbidity index <3). These patients were propensity score matched to younger patients. Perioperative and postoperative functional and oncologic outcomes for the two groups were compared. Results Full nerve sparing as well as the ease of nerve sparing were similar in 2 groups. Intra-operative complications were comparable. Postoperative complication occurrence rates were similar. At mean follow up of 34.1 months and 37.2 months respectively in younger and older patients, the continence rate was comparable in 2 groups (91.3% and 87.3%).Average time to continence and potency were similar in 2 groups. A greater proportion of younger patients became potent than elderly (52.3% vs 33.5%,p < 0.001).The biochemical recurrence (BCR) rate was comparable in 2 groups (7.8% vs 8.3%; p = 0.79). The mean time to BCR was also comparable in 2 groups (16 months vs 22.6 months; p = 0.07). Conclusions In appropriately selected patients (minimal comorbidities with CCI ≤2, life expectancy >10 years, localized prostate cancer) RARP is a reasonable option in patients ≥70 years and provides comparable perioperative, functional and intermediate term oncologic outcomes as compared to younger patients.
Summary Introduction Minimally invasive pyeloplasty (MIP) for ureteropelvic junction (UPJ) obstruction in children has gained popularity over the past decade as an alternative to open surgery. The ...present study aimed to identify the factors affecting complication rates of MIP in children, and to compare the outcomes of laparoscopic (LP) and robotic-assisted laparoscopic pyeloplasty (RALP). Materials and methods The perioperative data of 783 pediatric patients (<18 years old) from 15 academic centers who underwent either LP or RALP with an Anderson Hynes dismembered pyeloplasty technique were retrospectively evaluated. Redo cases and patients with anatomic renal abnormalities were excluded. Demographics and operative data, including procedural factors, were collected. Complications were classified according to the Satava and modified Clavien systems. Failure was defined as any of the following: obstructive parameters on diuretic renal scintigraphy, decline in renal function, progressive hydronephrosis, or symptom relapse. Univariate and multivariate analysis were applied to identify factors affecting the complication rates. All parameters were compared between LP and RALP. Results A total of 575 children met the inclusion criteria. Laparoscopy, increased operative time, prolonged hospital stay, ureteral stenting technique, and time required for stenting were factors influencing complication rates on univariate analysis. None of those factors remained significant on multivariate analysis. Mean follow-up was 12.8±9.8 months for RALP and 45.2±33.8 months for LP ( P =0.001). Hospital stay and time for stenting were shorter for robotic pyeloplasty ( P <0.05 for both). Success rates were similar between RALP and LP (99.5% vs 97.3%, P =0.11). The intraoperative complication rate was comparable between RALP and LP (3.8% vs 7.4%, P =0.06). However, the postoperative complication rate was significantly higher in the LP group (3.2% for RALP and 7.7% for LP, P =0.02). All complications were of no greater severity than Satava Grade IIa and Clavien Grade IIIb. Discussion This was the largest multicenter series of LP and RALP in the pediatric population. Limitations of the study included the retrospective design and lack of surgical experience as a confounder. Conclusions Both minimally invasive approaches that were studied were safe and highly effective in treating UPJ obstruction in children in many centers globally. However, shorter hospitalization time and lower postoperative complication rates with RALP were noted. The aims of the study were met.
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