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Background Enhanced recovery after surgery (ERAS) protocols are known to potentially improve the management and outcomes of patients undergoing colorectal surgery, with limited evidence of their implementation in hospital networks and in a large population. We aimed to assess the impact of the implementation of an ERAS protocol in colorectal cancer surgery in the entire region of Piemonte, Italy, supported by an audit and feedback (A&F) intervention. Methods A large, stepped wedge, cluster randomised trial enrolled patients scheduled for elective surgery at 29 general surgery units (clusters). At baseline (first 3 months), standard care was continued in all units. Thereafter, four groups of clusters began to adopt the ERAS protocol successively. By the end of the study, each cluster had a period in which standard care was maintained (control) and a period in which the protocol was applied (experimental). ERAS implementation was supported by initial training and A&F initiatives. The primary endpoint was length of stay (LOS) without outliers (>94th percentile), and the secondary endpoints were outliers for LOS, postoperative medical and surgical complications, quality of recovery and compliance with ERAS items. Results Of 2626 randomised patients, 2397 were included in the LOS analysis (1060 in the control period and 1337 in the experimental period). The mean LOS without outliers was 8.5 days during the control period (SD 3.9) and 7.5 (SD 3.5) during the experimental one. The adjusted difference between the two periods was a reduction of 0.58 days (95% CI -1.07, -0.09; p=0.021). The compliance with ERAS items increased from 52.4% to 67.3% (estimated absolute difference +13%; 95% CI 11.4%, 14.7%). No difference in the occurrence of complications was evidenced (OR 1.22; 95% CI 0.89, 1.68). [ABSTRACT FROM AUTHOR]

Objective To identify factors acting as barriers or enablers to the process of healthcare consent for people with intellectual disability and to understand how to make this process equitable and accessible. Data sources Databases: Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL. Additional articles were obtained from an ancestral search and hand- searching three journals. Eligibility criteria Peer- reviewed original research about the consent process for healthcare interventions, published after 1990, involving adult participants with intellectual disability. Synthesis of results Inductive thematic analysis was used to identify factors affecting informed consent. The findings were reviewed by co- researchers with intellectual disability to ensure they reflected lived experiences, and an easy read summary was created. Results Twenty- three studies were included (1999 to 2020), with a mix of qualitative (n=14), quantitative (n=6) and mixed- methods (n=3) studies. Participant numbers ranged from 9 to 604 people (median 21) and included people with intellectual disability, health professionals, carers and support people, and others working with people with intellectual disability. Six themes were identified: (1) health professionals' attitudes and lack of education, (2) inadequate accessible health information, (3) involvement of support people, (4) systemic constraints, (5) person- centred informed consent and (6) effective communication between health professionals and patients. Themes were barriers (themes 1, 2 and 4), enablers (themes 5 and 6) or both (theme 3). Conclusions Multiple reasons contribute to poor consent practices for people with intellectual disability in current health systems. Recommendations include addressing health professionals' attitudes and lack of education in informed consent with clinician training, the coproduction of accessible information resources and further inclusive research into informed consent for people with intellectual disability. PROSPERO registration CRD42021290548. [ABSTRACT FROM AUTHOR]

Background High-quality antenatal care is important for ensuring optimal birth outcomes and reducing risks of maternal and fetal mortality and morbidity. The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. We aimed to characterise what quality would look like for remote antenatal care from the perspectives of those who use, provide and organise it. Methods This UK- wide study involved interviews and an online survey inviting free- text responses with: those who were or had been pregnant since March 2020; maternity professionals and managers of maternity services and system- level stakeholders. Recruitment used network-based approaches, professional and community networks and purposively selected hospitals. Analysis of interview transcripts was based on the constant comparative method. Free-text survey responses were analysed using a coding framework developed by researchers. Findings Participants included 106 pregnant women and 105 healthcare professionals and managers/ stakeholders. Analysis enabled generation of a framework of the domains of quality that appear to be most relevant to stakeholders in remote antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person- centredness and choice and continuity. Participants reported that remote care was not straightforwardly positive or negative across these domains. Care that was more transactional in nature was identified as more suitable for remote modalities, but remote care was also seen as having potential to undermine important aspects of trusting relationships and continuity, to amplify or create new forms of structural inequality and to create possible risks to safety. Conclusions This study offers a provisional framework that can help in structuring thinking, policy and practice. By outlining the range of domains relevant to remote antenatal care, this framework is likely to be of value in guiding policy, practice and research. [ABSTRACT FROM AUTHOR]

Background Robotic-assisted neurointervention was recently introduced, with implications that it could be used to treat neurovascular diseases. Objective To evaluate the effectiveness and safety of the robotic-assisted platform CorPath GRX for treating cerebral aneurysms. Methods This prospective, international, multicenter study enrolled patients with brain aneurysms that required endovascular coiling and/or stent-assisted coiling. The primary effectiveness endpoint was defined as successful completion of the robotic-assisted endovascular procedure without any unplanned conversion to manual treatment with guidewire or microcatheter navigation, embolization coil(s) or intracranial stent(s) deployment, or an inability to navigate vessel anatomy. The primary safety endpoint included intraprocedural and periprocedural events. Results The study enrolled 117 patients (74.4% female) with mean age of 56.6 years from 10 international sites,. Headache was the most common presenting symptom in 40/117 (34.2%) subjects. Internal carotid artery was the most common location (34/122, 27.9%), and the mean aneurysm height and neck width were 5.7±2.6 mm and 3.5±1.4 mm, respectively. The overall procedure time was 117.3±47.3 min with 59.4±32.6 min robotic procedure time. Primary effectiveness was achieved in 110/117 (94%) subjects with seven subjects requiring conversion to manual for procedure completion. Only four primary safety events were recorded with two intraprocedural aneurysm ruptures and two strokes. A Raymond-Roy Classification Scale score of 1 was achieved in 71/110 (64.5%) subjects, and all subjects were discharged with a modified Rankin Scale score of ≤2. Conclusions This first-of-its-kind robotic-assisted neurovascular trial demonstrates the effectiveness and safety of the CorPath GRX System for endovascular embolization of cerebral aneurysm procedures. [ABSTRACT FROM AUTHOR]

Background Stent assisted coiling (SAC) and flow diverters (FDs) are common endovascular treatments for wide necked cerebral aneurysms, but studies comparing the new generation Atlas SAC and FDs are scarce. We performed a propensity score matched (PSM) cohort study to compare the Atlas SAC and the pipeline embolization device (PED) for proximal internal carotid artery (ICA) aneurysms. Methods Consecutive ICA aneurysms treated at our institution with either the Atlas SAC or PED were studied. PSM was used to control for age, sex, smoking, hypertension, and hyperlipidemia, and the rupture status, maximal diameter, and neck size of the aneurysm (aneurysms >15 mm and non-saccular aneurysms were excluded). Midterm outcomes and hospital costs were compared between these two devices. Results A total of 309 patients with 316 ICA aneurysms were included. Following PSM, 178 aneurysms treated with the Atlas SAC and PED were matched (n=89 in each group). Aneurysms treated with the Atlas SAC required a slightly longer procedure time, but had lower hospital costs than those treated with the PED (115.2±24.6 vs 102.4±40.8 min, P=0.012; $27 650.2±$6961.4 vs $34 107.0±$3707.2, P<0.001). Atlas SAC and PED treatments showed equivalent aneurysm occlusion rates (89.9% vs 86.5%, P=0.486), complication rates (5.6% vs 11.2%, P=0.177), and a favorable functional outcome (96.6% vs 97.8%, P=1.0) at follow-up (8.2±3.0 vs 8.4±4.2 months, P=0.652). Conclusion In this PSM study, midterm outcomes of the PED and Atlas SAC in the treatment of ICA aneurysms were similar. However, SAC required a longer operation time, and the PED may increase the economic cost of inpatients in Beijing, China. [ABSTRACT FROM AUTHOR]

Clinical tools for use in practice--such as medicine reconciliation charts, diagnosis support tools and track- and- trigger charts--are endemic in healthcare, but relatively little attention is given to how to optimise their design. User- centred design approaches and co- design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co- dESign of Clinical practice tOols or 'FRESCO') offering practical guidance based on user- centred methods and co- design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think- aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops. We applied the framework in a case study to support co- design of a prototype track- and- trigger chart for detecting and responding to possible fetal deterioration during labour. This started with establishing an advisory group of 22 members with varied expertise. Two initial draft prototypes were developed--one based on a version produced by national bodies, and the other with similar content but designed using human factors principles. Think- aloud usability evaluations of these prototypes were conducted with 15 professionals, and the findings used to inform co-design of an improved draft prototype. This was tested with 52 maternity professionals from five maternity units through clinical simulations. Analysis of these simulations and six workshops were used to co-design the final prototype to the point of readiness for large- scale testing. By codifying existing methods and principles into a single framework, FRESCO supported mobilisation of the expertise and ingenuity of diverse stakeholders to co- design a prototype track- and- trigger chart in an area of pressing service need. Subject to further evaluation, the framework has potential for application beyond the area of clinical practice in which it was applied. [ABSTRACT FROM AUTHOR]