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Background: Enhanced Recovery After Surgery (ERAS) protocols for bariatric surgery improve clinical outcomes. However, the impact of ERAS protocols on patient satisfaction is unknown. Virtual reality has been implemented as an effective adjunct to standard analgesic regimens. This study seeks to find out if immersive virtual reality in the immediate postoperative period could improve the subjective quality of recovery and further reduce opioid requirements for bariatric surgery patients compared with ERAS care alone. Methods: This is a single-centre, randomised clinical trial of patients recovering from laparoscopic bariatric surgery. Once in the post-anaesthesia care unit (PACU), participants will receive either an immersive virtual reality plus ERAS protocol or ERAS protocol alone. The primary outcome will be the Quality of Recovery-15 (QoR-15) score at PACU discharge. Secondary outcomes include PACU opioid requirements, length of PACU stay, PACU pain scores, QoR-15 score on postoperative day 1, hospital length of stay, opioid requirements, and opioid-related adverse effects until hospital discharge. Conclusions: Positive findings from this study could introduce virtual reality as a non-pharmacological adjunct during PACU care that improves subjective recovery for patients undergoing bariatric surgery. Clinical trial registration: NCT04754165.

Background: Deep brain stimulation (DBS) and other neuromodulatory techniques are being increasingly utilized to treat refractory neurologic and psychiatric disorders. Objective: /Hypothesis: To better understand the circuit-level pathophysiology of treatment-resistant depression (TRD) and treat the network-level dysfunction inherent to this challenging disorder, we adopted an approach of inpatient intracranial monitoring borrowed from the epilepsy surgery field. Methods: We implanted 3 patients with 4 DBS leads (bilateral pair in both the ventral capsule/ventral striatum and subcallosal cingulate) and 10 stereo-electroencephalography (sEEG) electrodes targeting depression-relevant network regions. For surgical planning, we used an interactive, holographic visualization platform to appreciate the 3D anatomy and connectivity. In the initial surgery, we placed the DBS leads and sEEG electrodes using robotic stereotaxy. Subjects were then admitted to an inpatient monitoring unit for depression-specific neurophysiological assessments. Following these investigations, subjects returned to the OR to remove the sEEG electrodes and internalize the DBS leads to implanted pulse generators. Results: Intraoperative testing revealed positive valence responses in all 3 subjects that helped verify targeting. Given the importance of the network-based hypotheses we were testing, we required accurate adherence to the surgical plan (to engage DBS and sEEG targets) and stability of DBS lead rotational position (to ensure that stimulation field estimates of the directional leads used during inpatient monitoring were relevant chronically), both of which we confirmed (mean radial error 1.2±0.9 mm; mean rotation 3.6±2.6°). Conclusion: This novel hybrid sEEG-DBS approach allows detailed study of the neurophysiological substrates of complex neuropsychiatric disorders.

Malignant melanoma continues to be a fatal disease for which novel and long-term curative breakthroughs are desired. One such innovative idea would be to assess combination therapeutic treatments – by way of combining two potentially effective and very different therapy. Previously, we have shown that DHODH inhibitors, A771726 and Brequinar sodium (BQR) induced cell growth impairment in melanoma cells. Similar results were seen with DHODH RNA interference (shRNA). In the present study, we showed that combination of BQR with doxorubicin resulted in synergistic and additive cell growth inhibition in these cells. In addition, in vivo studies with this combination of drugs demonstrated an almost 90% tumor regression in nude mice bearing melanoma tumors. Cell cycle regulatory proteins, cyclin B1 and its binding partner pcdc-2 and p21 were significantly downregulated and upregulated respectively following the combined treatment. Given that we have observed synergistic effects with BQR and doxorubicin, both in vitro and in vivo, these drugs potentially represent a new combination in the targeted therapy of melanoma.

Background: The efficacy of psychiatric DBS is thought to be driven by the connectivity of stimulation targets with mood-relevant fronto-temporal networks, which is typically evaluated using diffusion-weighted tractography. Objective: Leverage intracranial electrophysiology recordings to better predict the circuit-wide effects of neuromodulation to white matter targets. We hypothesize strong convergence between tractography-predicted structural connectivity and stimulation-induced electrophysiological responses. Methods: Evoked potentials were elicited by single-pulse stimulation to two common DBS targets for treatment-resistant depression – the subcallosal cingulate (SCC) and ventral capsule/ventral striatum (VCVS) – in two patients undergoing DBS with stereo-electroencephalographic (sEEG) monitoring. Evoked potentials were compared with predicted structural connectivity between DBS leads and sEEG contacts using probabilistic, patient-specific diffusion-weighted tractography. Results: Evoked potentials and tractography showed strong convergence in both patients in orbitofrontal, ventromedial prefrontal, and lateral prefrontal cortices for both SCC and VCVS stimulation targets. Low convergence was found in anterior cingulate (ACC), where tractography predicted structural connectivity from SCC targets but produced no evoked potentials during SCC stimulation. Further, tractography predicted no connectivity to ACC from VCVS targets, but VCVS stimulation produced robust evoked potentials. Conclusion: The two connectivity methods showed significant convergence, but important differences emerged with respect to the ability of tractography to predict electrophysiological connectivity between SCC and VCVS to regions of the mood-related network. This multimodal approach raises intriguing implications for the use of tractography in surgical targeting and provides new data to enhance our understanding of the network-wide effects of neuromodulation.

Introduction: Acute kidney injury (AKI) is common in the perioperative setting and associated with poor outcomes. Whether clinical decision support improves early management and outcomes of AKI on surgical units is uncertain., Methods: In this cluster-randomized, stepped-wedge trial, 8 surgical units in Alberta, Canada were randomized to various start dates to receive an education and clinical decision support intervention for recognition and early management of AKI. Eligible patients were aged ≥18 years, receiving care on a surgical unit, not already receiving dialysis, and with AKI., Results: There were 2135 admissions of 2038 patients who met the inclusion criteria; mean (SD) age was 64.3 (16.2) years, and 885 (41.4%) were females. The proportion of patients who experienced the composite primary outcome of progression of AKI to a higher stage, receipt of dialysis, or death was 16.0% (178 events/1113 admissions) in the intervention group; and 17.5% (179 events/1022 admissions) in the control group (time-adjusted odds ratio, 0.76; 95% confidence interval [CI], 0.53-1.08; P  = 0.12). There were no significant differences between groups in process of care outcomes within 48 hours of AKI onset, including administration of i.v. fluids, or withdrawal of medications affecting kidney function. Both groups experienced similar lengths of stay in hospital after AKI and change in estimated glomerular filtration rate (eGFR) at 3 months., Conclusion: An education and clinical decision support intervention did not significantly improve processes of care or reduce progression of AKI, length of hospital stays, or recovery of kidney function in patients with AKI on surgical units., (© 2024 International Society of Nephrology. Published by Elsevier Inc.)

Objective: To describe the steps, hurdles, and recommendations for implementation of the immediately sequential bilateral cataract surgery (ISBCS) evidence-based protocol at a high-volume Canadian tertiary care centre., Design: Quality-improvement study., Participants: A total of 406 patients who underwent ISBCS from July 2020 to December 2020. Patients were selected based on specific inclusion and exclusion criteria including psychosocial factors, refractive error and consent. This initiative impacted staff at all levels involved with cataract surgery., Methods: The Model of Improvement framework was used and involved numerous discussions with multidisciplinary teams of ophthalmologists, nursing and support staff, management, pharmacists, and medical device reprocessing teams. This initiative was created and refined via a thorough review of the literature and current best practices. It was implemented in July 2020 after a nursing "huddle." Any adverse outcomes and overall impact were collected from various levels of staff involved., Results: Each eye was treated as a separate surgery with a double time-out per bilateral case. Additional measures were taken to ensure different lot numbers for medications, equipment, and materials. This practice increased surgical volume by approximately 25% and reduced the number of patient visits by 50%, reducing potential COVID-19 exposure., Conclusions: The resulting protocol from our study may be useful to other centres wishing to integrate ISBCS as one example of successful implementation. Of the 406 cases of ISBCS performed, we report zero cases of toxic anterior segment syndrome or endophthalmitis. In times of decreased elective surgeries, ISBCS is a safe and effective option to supplement surgical volume and provide significant patient benefits., (Crown Copyright © 2021. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Quality Improvement (QI) science is a burgeoning component of healthcare systems and the practice of pharmacy. There is limited published literature on the implementation of QI training in undergraduate pharmacy education. We describe the development and implementation of QI training in an experiential course., Educational Activity and Setting: A QI curriculum was developed for an existing eight-week pharmacy practice elective experience for year four pharmacy students. The curriculum was divided into two, four-week blocks, combining didactic instruction and applied learning activities. A partnership between university departments and a local health organization provided a QI preceptor along with an interdisciplinary clinical team in an acute care setting to improve clinical services., Findings: Six students have completed the elective along with completing three QI projects. The Kirkpatrick 4 level model guided course evaluation. A curriculum strength was no additional cost or educational burden on the faculty of pharmacy and pharmaceutical sciences. Students recognized benefit from (1) course flexibility and independence to learn, (2) clear expectations and weekly guidance from the preceptor, (3) alignment of weekly readings and real-time application of QI concepts, and (4) the Institute for Healthcare Improvement education modules. Reducing the number of assigned tasks per week and improving availability of the clinical QI team to support student learning were identified as areas for improvement., Summary: This elective course demonstrated a starting point from which QI education can be formally included in pharmacy undergraduate education., Competing Interests: Declaration of Competing Interest None, (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Pregnant women with suspected or diagnosed preeclampsia receive laboratory investigations. Our institutional protocols were outdated and not evidence based. However, guidelines lack clear direction to support cost-effective use. We aimed to reduce unnecessary laboratory tests, while supporting physicians with investigation selection., Methods: A quality improvement (QI) approach was used to analyze the ordering process in the obstetrics wards of a tertiary care centre. Health care providers were surveyed on their laboratory ordering practices, and their responses corroborated with chart reviews. An algorithm for ordering preeclampsia investigations was developed by a multidisciplinary team, implemented, and posted on the wards. Pocket aides were also distributed, and the algorithm tool was supported by educational seminars. Laboratory usage volume and costs were analyzed pre- and post-intervention. Post-intervention impact surveys, informal interviews, and chart reviews were performed in plan-do-study-act (PDSA) cycles., Results: Most health care providers ordered broad panels of investigations and re-evaluated patients at inconsistent intervals. Almost none were aware of the laboratory costs associated with this testing. Most respondents acknowledged that some of the investigations they ordered did not affect patient care. Baseline data (Sept 2016-Aug 2017) showed 2923 tests ordered monthly (CAD$18 306). Post-intervention data (Sept 2017-Aug 2019) revealed a 39.9% reduction in costs related to blood tests (a savings of CAD$7304/mo), particularly those tests of lower clinical utility. The performance of essential investigations, such as measurement of creatinine levels, were similar pre- and post-intervention, and thus acted a control measure. The effects of this intervention were sustained., Conclusions: This simple and inexpensive intervention reduced unnecessary ordering of preeclampsia investigations. This resulted in annualized savings of CAD$87 643 and reduced iatrogenic blood loss, with no evidence of harm. Efforts to scale and spread this clinical tool will further improve health care delivery for pregnant patients., (Copyright © 2020 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: To develop a standardized process for reviewing daily patient lists and identifying potential risks of misidentification. Our goal was to develop a proactive approach to identify and eliminate risks of patient misidentification., Methods: Assessment of current patient identification practices took place over a period of 4 weeks. Using a process map, a patient survey was developed to determine the encounter points when patient identification was confirmed. This information was used to develop a standardized protocol for review of daily appointment lists., Results: Review of daily appointment lists was completed to identify potential similar/same name risks. A standardized manual process of chart review, flagging, and tracking was developed., Conclusions: The name alert process resulted in a simple manual process for identifying which patients have a higher name risk and allowed care providers to take preventative action to decrease potential risk of incorrect diagnostic testing, procedure, or medication administration., (Copyright © 2017 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Background: Ophthalmology residents on call at the Royal Alexandra Hospital identified workplace disorganization and lack of standardization in emergency eye examination rooms as an impediment to efficient patient treatment., Objective: The aim of the study was to use the "6S Lean" model to improve workflow in eye examination rooms at the Royal Alexandra Hospital., Methods: With the assistance of quality improvement consultants, the "6S Lean" model was applied to the current operation of the emergency eye clinic examination rooms. This model, considering 8 waste categories, was then used to recommend and implement changes to the examination rooms and to workplace protocols to enhance efficiency and safety., Results: Eye examination rooms were improved with regards to setup, organization of supplies, inventory control, and maintenance. All targets were achieved, and the 5S audit checklist score increased by 33 points from 44 to 77., Conclusions: Implementation of the 6S methodology is a simple approach that removes inefficiencies from the workplace. The ophthalmology clinic removed waste from all 8 waste categories, increased audit results, mitigated patient and resident safety risks, and ultimately redirected resident time back to patient care delivery., (Copyright © 2017 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)