The Effect of Pedal Pump Lymphatic Technique Versus Passive Recovery Following Maximal Exercise: A Randomized Cross-Over Trial

Context Muscle damage and delayed onset muscle soreness (DOMS) can occur following intense exercise. Various modalities have been studied to improve blood lactate accumulation, which is a primary reason for DOMS. It has been well established that active recovery facilitates blood lactate removal more rapidly that passive recovery due to the pumping action of the muscle. The pedal pump is a manual lymphatic technique used in osteopathic manipulative medicine to increase lymphatic drainage throughout the body. Pedal pump has been shown to increase lymphatic flow and improve immunity. This may improve circulation and improve clearance of metabolites post-exercise. Objective This study compared the use of pedal pump lymphatic technique to passive supine recovery following maximal exercise. Methods 17 subjects (male n = 10, age 23 ± 3.01; female n = 7, age 24 ± 1.8), performed a maximal volume O2 test (VO2 max) using a Bruce protocol, followed by a recovery protocol using either pedal pump technique or supine passive rest for 10 min, followed by sitting for 10 min. Outcome measures included blood lactate concentration (BL), heart rate (HR), systolic blood pressure (SBP) and VO2. Subjects returned on another day to repeat the VO2 max test to perform the other recovery protocol. All outcomes were measured at rest, within 1- minute post-peak exercise, and at minutes 4, 7, 10 and 20 of the recovery protocols. A 2 × 6 repeated measures ANOVA was used to compare outcome measures (p ≤ 0.05). Results No significant differences were found in VO2, HR, or SBP between any of the recovery protocols. There was no significant difference in BL concentrations for recovery at minutes 4, 7, or 10 (p > 0.05). However, the pedal pump recovery displayed significantly lower BL concentrations at minute 20 of recovery (p = 0.04). Conclusion The pedal pump significantly decreased blood lactate concentrations following intense exercise at recovery minute 20. The use of manual lymphatic techniques in exercise recovery should be investigated further.

P-OGC91 Significance of the number, size and type of drains used for intercostal drainage after oesophagectomy for cancer

Background Pleural space drainage with intercostal drains (ICD) is performed after oesophagectomy to allow the lung to reinflate, remove excess fluid post-operatively, and signal chyle or enteric content. Enhanced recovery protocols encourage the use of the minimum number of drains for the shortest duration to facilitate rapid recovery after surgery. There is wide variability in the type, number and size of drains inserted at operation. This study sought to identify the most effective drain pattern insertion, using the need for respiratory reintervention as the primary end point and secondary outcome of the presence of pleural effusions. Methods All patients undergoing oesophagectomy for cancer in one unit were included between November 2014 and December 2020. The operation performed, drain sizes, sides and type were recorded. Respiratory reintervention was defined as replacement of an ICD, bronchoscopy, pleural aspiration or reintubation. The primary and secondary end points, and potential confounders such as age, histology, pre-operative stage of disease, neoadjuvant therapy, pre-existing lung disease, and anastomotic or chyle leak were recorded. Results The study period encompassed 258 patients who underwent oesophagectomy for cancer. Median age 69 (range 32-82), 211 male, 226 ACA:32 SCC, 224 neoadjuvant therapy, 212 right-sided thoracic operations, 46 left thoracoabdominal approach. Post-operative respiratory reinterventions occurred in 47 patients (18.2%). At least one post-operative pleural effusion was present in 52 patients (20.2%): 9 bilateral; 26 contralateral; 17 ipsilateral to the side of thoracic surgery. 67% of effusions were contralateral to the operated side. The use of two or three ICDs (HR 371683269, p < 1), one or two operative side ICDs (HR 0, p < 1), Blake’s drains in place of rigid ICDs (HR 0.938 [0.422-2.085], p < 0.875), and size 24F compared to 28F drains (HR 0, p < 0.999) are not significantly associated with post-operative respiratory reinterventions. Similarly, the presence of post-operative pleural effusions is not significantly associated with the use of two or three ICDs (HR 240242843, p < 1), one or two operative side ICDs (HR 0, p < 1), Blake’s drains in place of rigid ICDs (HR 1.505 [0.665-3.405], p < 0.327), and size 24F compared to 28F drains (HR 1.055 [0.109-10.2], p < 0.963). Conclusions This study supports the use of contralateral pleural space drainage as two thirds of effusions were contralateral to the operated side. It shows no correlation between the size of drains, number of drains or use of Blakes drains and the likelihood of requiring a post-operative respiratory intervention or development of post-operative pleural effusion. Therefore the ERAS principles of the fewest number of drains for the shortest duration should be adopted.

P-OGC13 Chest drainage after oesophageal resection: A systematic review

Background Modern enhanced recovery protocols discourage drain use due to negative impacts on patient comfort, mobility, and recovery, and lack of proven clinical benefit. After oesophagectomy, however, drains are still routinely placed. This review aimed to assess the evidence for, and how best to use chest drains after oesophageal surgery. Methods A systematic literature search was performed in Medline, Embase and Cochrane collaboration databases. Studies reporting outcomes for different types or uses of thoracic drainage, or outcomes related to drains after trans-thoracic oesophagectomy were included. Studies were collated into domains based on variations in number, position, type, removal criteria, diagnostic use and complications of drains. Methodological quality was assessed with Newcastle-Ottawa and Jadad scores. Results Among 434 potentially relevant studies, 27 studies met the inclusion criteria and these included 2564 patients. Studies that examined the number of drains showed pain reduction with a single drain compared to multiple drains (3 studies, n = 103), and transhiatal placement compared to intercostal (6 studies, n = 425). Amylase levels may aid diagnosis of anastomotic leak (9 studies, n = 888). Narrow calibre Blake drains may effectively drain both air and fluid (2 studies, n = 163). Drain removal criteria by daily drainage volumes of up to 300ml did not impact subsequent effusion rates (2 studies, n = 130). Complications related directly to drains were reported by 3 studies (n = 59). Conclusions Available evidence on the impact of thoracic drainage after oesophagectomy is limited, but has the potential to negatively affect outcomes. Further research is required to determine optimum drainage strategies.

Patient Engagement in the Design of a Mobile Health App That Supports Enhanced Recovery Protocols for Cardiac Surgery: Development Study

Background Despite the importance of their perspectives, end users (eg, patients, caregivers) are not typically engaged by academic researchers in the development of mobile health (mHealth) apps for perioperative cardiac surgery settings. Objective The aim of this study was to describe a process for and the impact of patient engagement in the development of an mHealth app that supports patient and caregiver involvement with enhanced recovery protocols during the perioperative period of cardiac surgery. Methods Engagement occurred at the level of consultation and took the form of an advisory panel. Patients who underwent cardiac surgery (2017-2018) at St. Boniface Hospital (Winnipeg, Manitoba) and their caregivers were approached for participation. A qualitative exploration determined the impact of patient engagement on the development (ie, design and content) of the mHealth app. This included a description of (1) the key messages generated by the advisory panel, (2) how key messages were incorporated into the development of the mHealth app, and (3) feedback from the developers of the mHealth app about the key messages generated by the advisory panel. Results The advisory panel (N=10) generated 23 key messages to guide the development of the mHealth app. Key design-specific messages (n=7) centered around access, tracking, synchronization, and reminders. Key content-specific messages (n=16) centered around medical terms, professional roles, cardiac surgery procedures and recovery, educational videos, travel, nutrition, medications, resources, and physical activity. This information was directly incorporated into the design of the mHealth app as long as it was supported by the existing functionalities of the underlying platform. For example, the platform did not support the scheduling of reminders by users, identifying drug interactions, or synchronizing with other devices. The developers of the mHealth app noted that key messages resulted in the integration of a vast range and volume of information and resources instead of ones primarily focused on surgical information, content geared toward expectations management, and an expanded focus to include caregivers and other family members, so that these stakeholders may be directly included in the provision of information, allowing them to be better informed, prepare along with the patient, and be involved in recovery planning. Conclusions Patient engagement may facilitate the development of a detail-oriented and patient-centered mHealth app whose design and content are driven by the lived experiences of end users.

No Effect of Surgical Approach on Discharge Outcomes in Outpatient Total Hip Arthroplasty

Background: The interest in ambulatory total hip arthroplasty (THA) has increased recently due to a national focus on value-based care and improved rapid recovery protocols. Purpose: We sought to determine if surgical approach had an effect on discharge outcomes in outpatient THA. Methods: We performed a retrospective cohort study examining patients who underwent unilateral THA at a single institution using a standardized perioperative care pathway who were discharged home within 24 hours. In total, we compared 106 patients who underwent THA using the direct anterior approach (ATHA) and 90 patients who underwent THA using the posterior approach (PTHA). Univariate and multivariable analyses were used to compare time to ambulation, length of surgery, readmissions, and 90-day complications. Results:Time to ambulation in the ATHA and PTHA groups was 3.9 hours and 4.1 hours, respectively, and time to discharge was 5.9 hours and 6.0 hours, respectively. Length of surgery was shorter in the ATHA group than in the PTHA group (78 minutes vs 86 minutes, respectively). Complications occurred in 3 patients (3%) in the ATHA group vs 4 patients (4%) in PTHA group. In both groups, early ambulation (within 5 hours) predicted earlier time to discharge. Surgical approach was not associated with time to ambulation or time to discharge on multivariable analysis. Conclusion: In this retrospective study, outpatient THA was feasible in a well-selected population of patients undergoing anterior or posterior approaches. Further study is warranted.

RT-ZooKeeper: Taming the Recovery Latency of a Coordination Service

Fault-tolerant coordination services have been widely used in distributed applications in cloud environments. Recent years have witnessed the emergence of time-sensitive applications deployed in edge computing environments, which introduces both challenges and opportunities for coordination services. On one hand, coordination services must recover from failures in a timely manner. On the other hand, edge computing employs local networked platforms that can be exploited to achieve timely recovery. In this work, we first identify the limitations of the leader election and recovery protocols underlying Apache ZooKeeper, the prevailing open-source coordination service. To reduce recovery latency from leader failures, we then design RT-Zookeeper with a set of novel features including a fast-convergence election protocol, a quorum channel notification mechanism, and a distributed epoch persistence protocol. We have implemented RT-Zookeeper based on ZooKeeper version 3.5.8. Empirical evaluation shows that RT-ZooKeeper achieves 91% reduction in maximum recovery latency in comparison to ZooKeeper. Furthermore, a case study demonstrates that fast failure recovery in RT-ZooKeeper can benefit a common messaging service like Kafka in terms of message latency.

Microbiome Forensic Biobanking: A Step toward Microbial Profiling for Forensic Human Identification

In recent years many studies have highlighted the great potential of microbial analysis in human identification for forensic purposes, with important differences in microbial community composition and function across different people and locations, showing a certain degree of uncertainty. Therefore, further studies are necessary to enable forensic scientists to evaluate the risk of microbial transfer and recovery from various items and to further critically evaluate the suitability of current human DNA recovery protocols for human microbial profiling for identification purposes. While the establishment and development of microbiome research biobanks for clinical applications is already very structured, the development of studies on the applicability of microbiome biobanks for forensic purposes is still in its infancy. The creation of large population microbiome biobanks, specifically dedicated to forensic human identification, could be worthwhile. This could also be useful to increase the practical applications of forensic microbiology for identification purposes, given that this type of evidence is currently absent from most real casework investigations and judicial proceedings in courts.

TP10.1.13A model for safe elective liver resection during the SARS-CoV-2 (COVID-19) pandemic – lessons for enhanced recovery

Background The COVID-19 outbreak in January 2020 rapidly became a pandemic, adversely impacting elective cancer services in the UK. This study describes the pandemic-driven changes to existing admission and enhanced recovery protocols, which allowed the Unit to maintain a liver resection service, and evaluates their impact on patient safety. Methods During the pandemic, all patients undergoing liver resection in this Unit isolated for 14 days prior to their admission, with COVID-19 testing 48 hours pre-admission. Patients were admitted on the day of surgery to the day surgery unit, a designated COVID-free environment. They underwent liver surgery, recovery and post-operative care, all within the day surgery unit. Using a prospectively collected database, short-term outcomes of consecutive patients undergoing elective hepatectomy during the COVID-19 pandemic (April - June 2020) were retrospectively compared to patients during the same period in 2019. Results During the pandemic, 24 patients underwent hepatectomy compared to 34 patients in 2019. There was no statistical difference in demographics, indications for surgery, intra-operative parameters or complications between these periods. The median post-operative length of stay (LOS) was significantly shorter during the pandemic [3 (IQR: 3-4) days vs. 4 (IQR; 4-7) days, p = 0.015], as was the overall LOS [4 (IQR: 4-6) days vs. 6 (IQR; 5-9) days, p = 0.006]. No patient contracted COVID-19 per-operatively. Conclusions Patient pathway changes during a pandemic enabled safe liver surgery to be undertaken with improved outcomes – a model that is transferrable to other Units.