Repatriation General Hospital

Modern advances in medicine and technology have led to an increase in robotic-assisted surgery (RAS) cases. However, concerns have been raised about the potential environmental impact of RAS. Despite this, only limited quantitative evidence is currently available. Therefore, this study aims to objectively quantify the environmental impact of a multi-specialty RAS caseload at an Australian public tertiary hospital. An analysis was performed to quantify the amount of waste produced on a consecutive multi-specialty RAS caseload performed between August 2016 and March 2023 at a major public hospital. The weight of each instrument and consumable was measured and the total weight of discarded waste was calculated for each RAS case. A total of 671 patients underwent RAS using the da Vinci Xi System, including Urology (n = 341, 50.8%), Cardiothoracic (n = 158, 23.5%), Gynaecology (n = 107, 16.0%), and Colorectal (n = 65, 9.7%). Overall, the amount of waste was 2,948.9 kg, with single-use items contributing the largest volume (93.9%). Cardiothoracic generated the lowest average weight of waste per case (3.04 kg) while Colorectal generated the highest (5.27 kg). Overall, the da Vinci Xi instrument arm drape was the single item with the largest contribution to the total weight of waste (32.9%). RAS generates substantial waste, primarily from single-use items. These findings underscore the need for strategies to mitigate the environmental footprint of RAS as its adoption continues to grow.

ObjectivesThe lupus low disease activity state (LLDAS) allows for certain clinical and/or serological activity of SLE, provided overall disease activity does not exceed predefined cut-offs. This study aimed to evaluate the outcomes of patients who achieved LLDAS with clinical activity, serological activity only or neither clinical nor serological activity.MethodsPatients with SLE enrolled in a prospective multinational cohort from March 2013 to December 2020 who were in LLDAS at least once were included. Visits that fulfilled both LLDAS and Definition of Remission in SLE (DORIS) criteria were excluded.Results2099 patients were included, with median follow-up of 3.5 (IQR 1.3–5.8) years. At 6150 visits, patients were in LLDAS but not DORIS criteria; of these 1280 (20.8%) had some clinical activity, 3102 (50.4%) visits had serological activity only and 1768 (28.8%) visits had neither clinical nor serological activity. Multivariable regression analysis showed that compared with non-LLDAS, all three subsets of LLDAS had a protective association with flares in the ensuing 6 months and damage accrual in the ensuing 36 months. LLDAS with no clinical or serological activity had a significantly stronger protective association with severe flares in the ensuing 6 months compared with LLDAS with clinical activity (HR 0.47, 95% CI (0.27 to 0.82), p=0.007).ConclusionsLLDAS without any clinical activity accounted for almost 80% of LLDAS visits. This study confirms that all subsets of LLDAS are associated with reduced flare and damage accrual. However, LLDAS without any clinical or serological activity has the strongest protective association with severe flares.

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2024_09_23_CJASNSeptember19992.mp3.

Purpose:PARP inhibitors (PARPi) have demonstrated efficacy in tumors with germline breast cancer susceptibility genes (gBRCA) 1 and 2 mutations, but further factors influencing response to PARPi are poorly understood.Experimental Design:Breast cancer tumor tissue from patients with gBRCA1/2 mutations from the phase III EMBRACA trial of the PARPi talazoparib versus chemotherapy was sequenced using FoundationOne CDx.Results:In the evaluable intent-to-treat population, 96.1% (296/308) had ≥1 tumor BRCA (tBRCA) mutation and there was strong concordance (95.3%) between tBRCA and gBRCA mutational status. Genetic/genomic characteristics including BRCA loss of heterozygosity (LOH; identified in 82.6% of evaluable patients), DNA damage response (DDR) gene mutational burden, and tumor homologous recombination deficiency [assessed by genomic LOH (gLOH)] demonstrated no association with talazoparib efficacy.Conclusions:Overall, BRCA LOH status, DDR gene mutational burden, and gLOH were not associated with talazoparib efficacy; however, these conclusions are qualified by population heterogeneity and low patient numbers in some subgroups. Further investigation in larger patient populations is warranted.

A 53-year-old woman presented in the early hours of the morning with generalised abdominal pain and features of hypovolaemic shock, following a dilatation of an enterostomy stricture 12 hours prior. Dilatation of this stricture was indicated by ongoing dysphagia, which had been successfully dilated twice before without incident. Standard resuscitative measures and confirmation of the endoscopically-caused splenic injury by CT scan were followed promptly by a splenectomy to control ongoing blood loss. The strictured enterostomy was revised to mitigate further need for endoscopic dilatation. The patient recovered well and was discharged shortly after on a soft diet.

Insomnia and obstructive sleep apnoea (OSA) frequently co-occur and may be causally related through sleep fragmentation and/or hyperarousal mechanisms. Previous studies suggest that OSA treatment can improve insomnia severity. However, the effect of insomnia treatment on OSA severity has not been investigated. We performed a randomised controlled trial to investigate the effect of cognitive behavioural therapy for insomnia (CBTi) on OSA severity, controlling for potential sleep-stage and posture effects.145 patients with comorbid insomnia (International Classification of Sleep Disorders, 3rd Edn) and untreated OSA (apnoea–hypopnoea index (AHI) ≥15 events·h−1 sleep) were randomised to a four-session CBTi programme or to a no-treatment control. Overnight sleep studies were completed pre- and post-treatment to measure AHI, arousal index and sleep architecture, to investigate the effect of intervention group, time, sleep stage (N1–3 or REM) and posture (supine or nonsupine) on OSA severity.The CBTi group showed a 7.5 event·h−1 greater AHI difference (mean (95% CI) decrease 5.5 (1.3–9.7) events·h−1, Cohen's d=0.2, from 36.4 events·h−1 pre-treatment) across sleep-stages and postures, compared to control (mean increase 2.0 (−2.0–6.1) events·h−1, d=0.01, from 37.5 events·h−1 at pre-treatment; interaction p=0.012). Compared to control, the CBTi group also had a greater reduction in total number (mean difference 5.6 (0.6–10.6) greater overall reduction; p=0.029) and duration of nocturnal awakenings (mean difference 21.1 (2.0–40.3) min greater reduction; p=0.031) but showed no difference in the arousal index, or sleep architecture.CBTi consolidates sleep periods and promotes a 15% decrease in OSA severity in patients with comorbid insomnia and OSA. This suggests that insomnia disorder may exacerbate OSA and provides further support for treating insomnia in the presence of comorbid OSA.

To determine the antiseptic efficacy on bacterial colony counts of a 5- vs 10-minute surgical site scrub in urologic surgery. A prospective cohort study was conducted in 101 patients presenting for elective urological procedures. Patients were randomized to a 5- or 10-minute groin scrub with Betadine (povidone-iodine). Skin swabs were taken immediately after skin clipping and following routine painting with Betadine. A third swab was taken after the betadine skin scrub. Bacterial colony counts were reported as a number of colony-forming units (CFUs). The primary outcome measure was a quantitative comparison of CFUs in the two arms. Fifty-three patients were randomized to a 5-minute scrub and 48 to a 10-minute scrub. After Betadine painting, CFUs were present in 38% of patients in the 5-minute group (mean, 33.5 CFU) and in 27% of the 10-minute group (mean, 45.4 CFU). Following the surgical scrub, only 7.5% of the 5-minute group and 8.3% of the 10-minute group had a measurable CFU count of greater than or equal to 1, and colony counts were low in both groups (5- minute group: mean, 1.5 CFU; 10-minute group: mean, 2.0 CFU). There was no significant difference in CFUs following a 5- or 10-minute scrub (P = 0.28). The addition of a surgical skin scrub leads to a fourfold reduction in the skin CFU count compared with Betadine painting. However, there is no difference between the antibacterial effects of a 5- and 10-minute scrub. A 5-minute scrub may be sufficient in urologic prosthetic surgery.

ObjectiveIn Australia and other countries, participation in colorectal cancer (CRC) screening using fecal occult blood testing is low. Previous research suggests that fecal sampling induces disgust, so approaches not involving feces may increase participation. This study aimed to determine population preferences for CRC screening tests that utilize different sample collections (stool, blood, and saliva) and the extent to which specific attributes (convenience, performance, and cost) impact this preference.Materials and methodsPeople aged 50–74 years completed a survey. Preference for screening for CRC through stool, blood, and saliva was judged through ranking of preference and attributes critical to preference and confirmed via a discrete choice experiment (DCE) where test attributes were described as varying by performance, cost, and sample type. Participants also completed a measure of aversion to sample type.ResultsA total of 1,282 people participated in the survey. The DCE and ranking exercise confirmed that all test attributes had a statistically significant impact on respondents’ preferences (P < 0.001). Blood and saliva were equally preferred over stool; however, test performance was the most influential attribute. In multivariable analyses, those who preferred blood to stool collection exhibited higher aversion to fecal (OR = 1.17; P ≤ 0.001) and saliva (OR = 1.06; P ≤ 0.05) sampling and perceived that they had less time for home sample collection (OR = 0.72, P ≤ 0.001). Those who preferred saliva to stool had higher aversion to fecal (OR = 1.15; P ≤ 0.001) and blood (OR = 1.06, P ≤ 0.01) sampling and less time for home sample collection (OR = 0.81, P ≤ 0.5).ConclusionAversion to sample type and perceived inconvenience of sample collection are significant drivers of screening preference. While blood and saliva sampling were the most preferred methods, test performance was the most important attribute of a screening test, regardless of sample type. Efforts to increase CRC screening participation should focus on a test, or combination of tests, that combines the attributes of high performance, low aversion, and convenience of use.