2019 Chitranjan S. Ranawat Award: Elective joint arthroplasty outcomes improve in malnourished patients with nutritional intervention

2019 ◽  
Vol 101-B (7_Supple_C) ◽  
pp. 17-21 ◽  
Author(s):  
W. C. Schroer ◽  
A. R. LeMarr ◽  
K. Mills ◽  
A. L. Childress ◽  
D. J. Morton ◽  
...  
Keyword(s):  
Elective Surgery ◽  
Admission Rate ◽  
Nutritional Intervention ◽  
Joint Arthroplasty ◽  
High Protein ◽  
Postoperative Outcomes ◽  
Hospital Length Of Stay ◽  
Data Set ◽  
Anti Inflammatory ◽  
Study Hospital

Aims To date, no study has demonstrated an improvement in postoperative outcomes following elective joint arthroplasty with a focus on nutritional intervention for patients with preoperative hypoalbuminaemia. In this prospective study, we evaluated differences in the hospital length of stay (LOS), rate of re-admission, and total patient charges for a malnourished patient study population who received a specific nutrition protocol before surgery. Patients and Methods An analytical report was extracted from the electronic medical record (EMR; Epic, Verona, Wisconsin) of a five-hospital network joint arthroplasty patient data set between 2014 and 2017. A total of 4733 patients underwent joint arthroplasty and had preoperative measurement of albumin levels: 2220 at four hospitals and 2513 at the study hospital. Albumin ≤ 3.4 g/l, designated as malnutrition, was found in 543 patients (11.5%). A nutritional intervention programme focusing on a high-protein, anti-inflammatory diet was initiated in January 2017 at one study hospital. Hospital LOS, re-admission rate, and 90-day charges were compared for differential change between patients in study and control hospitals for all elective hip and knee arthroplasty patients, and for malnourished patients over time as the nutrition intervention was implemented. Results Malnourished patients with nutritional intervention at the study hospital had shorter hospital LOS beginning in 2017 than malnourished patients at control hospitals during the same period (p = 0.04). Similarly, this cohort had significantly lower primary hospitalization charges, charges associated with hospital re-admissions, and 90-day total charges (p < 0.001). Inclusion of covariant potential confounders (age, anaemia, diabetes, and obesity) did not alter the conclusions of the primary statistical analysis. Conclusion Joint arthroplasty outcomes were positively affected in study patients with low albumin when a high-protein, anti-inflammatory diet was encouraged. Elective surgery was neither cancelled nor delayed with a malnutrition designation. While the entire network population experienced improved postoperative outcomes, malnourished control patients did not experience this improvement. This study demonstrated that education on malnutrition can benefit patients. Cite this article: Bone Joint J 2019;101-B(7 Supple C):17–21

scholarly journals Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis

BMJ Open ◽  
2021 ◽  
Vol 11 (9) ◽  
pp. e050806
Author(s):  
Rachel Perry ◽  
Georgia Herbert ◽  
Charlotte Atkinson ◽  
Clare England ◽  
Kate Northstone ◽  
...  
Keyword(s):  
Systematic Review ◽  
Elective Surgery ◽  
Meta Analysis ◽  
Pulmonary Complications ◽  
Postoperative Outcomes ◽  
Hospital Length Of Stay ◽  
Cochrane Library ◽  
Pool Data ◽  
High Dependency

ObjectiveTo determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery.DesignSystematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished). We searched Medline, Embase, CENTRAL, DARE, HTA and NHS EED, The Cochrane Library, CINAHL, PsychINFO and ISI Web of Science (June 2020).SettingSecondary care.ParticipantsPatients (≥18 years) undergoing major elective surgery (curative or palliative).InterventionsAny intervention administered in the preoperative period with the aim of improving postoperative outcomes.Outcomes and measuresPrimary outcomes were 30-day mortality, hospital length of stay (LoS) and postoperative complications. Secondary outcomes included LoS in intensive care unit or high dependency unit, perioperative morbidity, hospital readmission, postoperative pain, heath-related quality of life, outcomes specific to the intervention, intervention-specific adverse events and resource use.Review methodsTwo authors independently extracted data from eligible RCTs and assessed risk of bias and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Random-effects meta-analyses were used to pool data across trials.Results178 RCTs including eight types of intervention were included. Inspiratory muscle training (IMT), immunonutrition and multimodal interventions reduced hospital LoS (mean difference vs usual care: −1.81 days, 95% CI −2.31 to −1.31; −2.11 days, 95% CI −3.07 to −1.15; −1.67 days, 95% CI −2.31 to −1.03, respectively). Immunonutrition reduced infective complications (risk ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise reduced postoperative pulmonary complications (RR 0.55, 95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75, respectively). Smoking cessation interventions reduced wound infections (RR 0.28, 95% CI 0.12 to 0.64).ConclusionsSome prehabilitation interventions may reduce postoperative LoS and complications but the quality of the evidence was low.PROSPERO registration numberCRD42015019191.

scholarly journals Anti-inflammatory genes in PBMCs post-spontaneous intracerebral hemorrhage

2021 ◽  
Vol 12 (1) ◽  
pp. 58-66
Author(s):  
Doan Nguyen ◽  
Vi Tran ◽  
Alireza Shirazian ◽  
Cruz Velasco-Gonzalez ◽  
Ifeanyi Iwuchukwu
Keyword(s):  
Intracerebral Hemorrhage ◽  
Negative Correlation ◽  
Mononuclear Cells ◽  
Inflammatory Cells ◽  
Favorable Outcome ◽  
Hospital Length Of Stay ◽  
Spontaneous Intracerebral Hemorrhage ◽  
Hematoma Volume ◽  
Peripheral Blood Mononuclear ◽  
Anti Inflammatory

Abstract Background Neuroinflammation is important in the pathophysiology of spontaneous intracerebral hemorrhage (ICH) and peripheral inflammatory cells play a role in the clinical evolution and outcome. Methodology Blood samples from ICH patients (n = 20) were collected at admission for 5 consecutive days for peripheral blood mononuclear cells (PBMCs). Frozen PBMCs were used for real-time PCR using Taqman probes (NFKB1, SOD1, PPARG, IL10, NFE2L2, and REL) and normalized to GAPDH. Data on hospital length of stay and modified Rankin score (MRS) were collected with 90-day MRS ≤ 3 as favorable outcome. Statistical analysis of clinical characteristics to temporal gene expression from early to delayed timepoints was compared for MRS groups (favorable vs unfavorable) and hematoma volume. Principle findings and results IL10, SOD1, and REL expression were significantly higher at delayed timepoints in PBMCs of ICH patients with favorable outcome. PPARG and REL increased between timepoints in patients with favorable outcome. NFKB1 expression was not sustained, but significantly decreased from higher levels at early onset in patients with unfavorable outcome. IL10 expression showed a negative correlation in patients with high hematoma volume (>30 mL). Conclusions and significance Anti-inflammatory, pro-survival regulators were highly expressed at delayed time points in ICH patients with a favorable outcome, and IL10 expression showed a negative correlation to high hematoma volume.

Preoperative nutritional status impacts clinical outcome and hospital length of stay in pelvic exenteration patients – a retrospective study

2021 ◽  
pp. 026010602110090
Author(s):  
Sophie Hogan ◽  
Daniel Steffens ◽  
Kenneth Vuong ◽  
Anna Rangan ◽  
Michael Solomon ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Nutritional Status ◽  
Pelvic Exenteration ◽  
Postoperative Outcomes ◽  
Hospital Length Of Stay ◽  
Major Surgery ◽  
High Morbidity ◽  
Nutrition Screening ◽  
Patient Cohort ◽  
Post Surgery

Background: Preoperative malnutrition is common in surgical oncology patients and can have negative effects on postoperative outcomes. Pelvic exenteration is major surgery associated with high morbidity rates. Associations between preoperative malnutrition, determined using the patient-generated subjective global assessment, and postoperative outcomes in this patient cohort has not yet been investigated. Aim: To determine if preoperative nutritional status is associated with postoperative surgical and quality of life (QoL) outcomes after pelvic exenteration surgery. Methods: A retrospective cohort study was conducted at a quaternary hospital investigating 123 patients who had pelvic exenteration surgery from January 2017 to August 2019. Preoperative nutritional status and postoperative surgical and QoL outcomes were collected and analysed to determine any associations. Results: Overall, 49.6% of patients were female with a median age of 59 years. Forty patients (32.5%) were malnourished and 83 (67.5%) were well nourished before surgery. Well-nourished patients had a shorter length of hospital stay ( p = 0.034) and at 6 months post-surgery, presented with a significantly better physical and mental QoL score ( p = 0.038 and p = 0.001 respectively). The regression analyses showed that intensive care unit (ICU) readmission rates were 7.19 times more likely to occur in malnourished patients ( p = 0.022). Conclusions: Preoperative malnutrition is associated with increased length of stay, ICU readmissions and poorer QoL following pelvic exenteration. Nutrition screening, assessment and optimisation of management are essential in this patient cohort to improve patient outcomes. Future studies are needed to measure the effect of interventions and identify the most beneficial model of care for this complex patient group.

scholarly journals 427 The Effect of Malnutrition on Early Outcomes after Cancer Surgery: An International Prospective Cohort Study in 82 Countries

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
A Riad ◽  
S Knight ◽  
E Harrison
Keyword(s):  
Colorectal Cancer ◽  
Cohort Study ◽  
Elective Surgery ◽  
Final Analysis ◽  
Cancer Surgery ◽  
Postoperative Outcomes ◽  
Disease Stage ◽  
Severe Malnutrition ◽  
Colorectal Cancer Surgery ◽  
After Cancer

Abstract Background Malnutrition is a state linked to worse postoperative outcomes, and cancer patients are particularly vulnerable due to cachexia. We aimed to explore the effect of malnutrition on 30-day mortality following gastric and colorectal cancer surgery. Method GlobalSurg3 was multicentre international cohort study which collected data from consecutive patients undergoing emergency or elective surgery for gastric and colorectal cancer. Malnutrition was defined using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Multilevel variable regression approaches determined the relationship between malnutrition and early postoperative outcomes. Results 6438 patients were included in the final analysis (1184 gastric cancer; 5254 colorectal cancer). Severe malnutrition was common across all income-strata, affecting 1 in 4 patients overall, with a higher burden in low and lower-middle income countries (64%). In patients undergoing elective surgery (n = 5709), severe malnutrition was independently associated with increased mortality (aOR = 1.62 (1.07-2.48, P = 0.024) after accounting for patient factors, disease stage and country effects. Conclusions Severe malnutrition represents a high global burden in cancer surgery, particularly within lower income settings. Malnutrition is an independent risk-factor for 30-day mortality following elective surgery for gastric and colorectal cancer, suggesting perioperative nutritional interventions may improve outcomes after cancer surgery.

scholarly journals Coronary Revascularization and Postoperative Outcomes in People With and Without Alzheimer’s Disease

2021 ◽  
Author(s):  
Mai Vu ◽  
Marjaana Koponen ◽  
Heidi Taipale ◽  
Raimo Kettunen ◽  
Sirpa Hartikainen ◽  
...  
Keyword(s):  
Alzheimer’S Disease ◽  
Alzheimer's Disease ◽  
Coronary Revascularization ◽  
Admission Rate ◽  
Postoperative Outcomes ◽  
Hospital District ◽  
Emergency Procedures ◽  
Risk Increase ◽  
Cox Proportional Hazard Models ◽  
Matched Comparison

Abstract Background Little is known on the incidence and postoperative outcomes of revascularizations according to electivity in persons with Alzheimer’s disease (AD). Methods The Medication Use and Alzheimer’s disease (MEDALZ) cohort includes 70 718 community dwellers diagnosed with incident AD during 2005–2011 in Finland. For each person with AD, 1–4 age-, sex-, and hospital district-matched comparison persons without AD were identified. Altogether 448 persons with AD and 5909 without AD underwent revascularization during the follow-up. The outcomes were 30-day and 90-day re-admission rate after discharge, and all-cause 1-year and 3-year mortality. Risk of outcomes in persons with AD were compared to those without AD using Cox proportional hazard models adjusted with age, sex, comorbidities, statin use, revascularization type, length of stay, and support at discharge. Result People with AD had less revascularizations (adjusted hazard ratio 0.24, 95% confidence interval 0.22–0.27). Emergency procedures were more common (42.6% vs 33.1%) than elective procedures (34.2% vs 48.6%) among people with AD. There was no difference in 30-day readmissions (0.97, 0.80–1.17) or 1-year mortality (1.04, 0.75–1.42) and 90 days readmission risk was lower in persons with AD (0.85, 0.74–0.98). People with AD had higher 3-year mortality (1.42, 1.15–1.74), but the risk increase was observed only for emergency (1.71, 1.27–2.31), not for elective procedures (0.96, 0.63–1.46). Conclusion People with AD did not have worse readmission and mortality outcomes following elective revascularization. These findings in conjunction with lower revascularization rate especially for elective procedures raise questions on the threshold for elective procedures in people with AD.

scholarly journals Absence of Association between Preoperative Estimated Glomerular Filtration Rates and Postoperative Outcomes following Elective Gastrointestinal Surgeries: A Prospective Cohort Study

2018 ◽  
Vol 2018 ◽  
pp. 1-7
Author(s):  
Sivesh K. Kamarajah ◽  
Behrad Barmayehvar ◽  
Mustafa Sowida ◽  
Amirul Adlan ◽  
Christina Reihill ◽  
...  
Keyword(s):  
Risk Stratification ◽  
Glomerular Filtration ◽  
Elective Surgery ◽  
Gastrointestinal Surgery ◽  
Major Complication ◽  
Postoperative Outcomes ◽  
Queen Elizabeth Hospital ◽  
Complication Rates ◽  
Significant Difference ◽  
The Impact

Background. Preoperative risk stratification and optimising care of patients undergoing elective surgery are important to reduce the risk of postoperative outcomes. Renal dysfunction is becoming increasingly prevalent, but its impact on patients undergoing elective gastrointestinal surgery is unknown although much evidence is available for cardiac surgery. This study aimed to investigate the impact of preoperative estimated glomerular filtration rate (eGFR) and postoperative outcomes in patients undergoing elective gastrointestinal surgeries. Methods. This prospective study included consecutive adult patients undergoing elective gastrointestinal surgeries attending preassessment screening (PAS) clinics at the Queen Elizabeth Hospital Birmingham (QEHB) between July and August 2016. Primary outcome measure was 30-day overall complication rates and secondary outcomes were grade of complications, 30-day readmission rates, and postoperative care setting. Results. This study included 370 patients, of which 11% (41/370) had eGFR of <60 ml/min/1.73 m2. Patients with eGFR < 60 ml/min/1.73 m2 were more likely to have ASA grade 3/4 (p<0.001) and >2 comorbidities (p<0.001). Overall complication rates were 15% (54/370), with no significant difference in overall (p=0.644) and major complication rates (p=0.831) between both groups. In adjusted models, only surgery grade was predictive of overall complications. Preoperative eGFR did not impact on overall complications (HR: 0.89, 95% CI: 0.45–1.54; p=0.2). Conclusions. Preoperative eGFR does not appear to impact on postoperative complications in patients undergoing elective gastrointestinal surgeries, even when stratified by surgery grade. These findings will help preassessment clinics in risk stratification and optimisation of perioperative care of patients.

Trends in hospitalization and in-hospital mortality of patients with heart failure in Spain. A population-based study (2003–2015)

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
J.L Bonilla Palomas ◽  
M.P Anguita-Sanchez ◽  
F.J Elola ◽  
J.L Bernal ◽  
C Fernandez-Perez ◽  
...  
Keyword(s):  
Heart Failure ◽  
Mortality Rate ◽  
Hospital Mortality ◽  
National Health System ◽  
Admission Rate ◽  
Population Data ◽  
Principal Diagnosis ◽  
Data Set ◽  
Discharge Rates ◽  
Mortality Ratio

Abstract Background Heart failure (HF) is one of the most pressing current public health concerns. However, in Spain there is a lack of population data. Purpose To investigate trends in HF hospitalization and in-hospital mortality rates. Methods We conducted a retrospective observational study of patients discharged with the principal diagnosis of HF from The National Health System' acute hospitals during 2003–2015. The source of the data was the Minimum Basic Data Set of the Ministry of Health, Consumer and Social Welfare. We analyzed trends in hospital discharge rates for HF (discharge rates were weighted by age and gender) an in-hospital mortality. The risk-standardized in-hospital mortality ratio (RSMR) was defined as the ratio between predicted mortality (which individually considers the performance of the hospital where the patient is attended) and expected mortality (which considers a standard performance according to the average of all hospitals) multiplied by the crude rate of mortality. RSMR was calculated using a risk adjustment multilevel logistic regression models developed by the Medicare and Medicaid Services. Temporal trend during the observed period was modelled using Poisson regression analysis with year as the only independent variable. In this model, the incidence rate ratio (IRR) and their 95% confidence intervals (95% CI) was calculated. Results A total of 1 254 830 episodes of HF were selected. Throughout 2003–2015 the number of hospital discharges with principal diagnosis of HF increased by 61% (IRR: 1.04; CI: 1.03–1.04; p&lt;0.001), meanwhile the crude mortality rate and the mean length of stay (LOS) diminished significantly (IRR: 0.99; CI: 0.98–1; and IRR: 1.04; CI: 0.99–0.99; p&lt;0.001, for both). Discharge rates weighted by age and sex showed a statistically significant increase during the period (IRR: 1.03; CI: 1.03–1.03; p&lt;0.001); however, whereas discharge rates increased significantly in older groups of age (≥75 years old) (IRR: 1–1.02; p&lt;0.001) they diminished in younger groups of age (45–74 years old) (IRR: 0.99; p&lt;0.001 and there was not a significant trend in the discharge rates for the group of 35–44 years old (Figure). The risk-standardized in-hospital mortality ratio did not significantly change throughout 2003–2015 (IRR: 0.997; CI: 0.992–1; p=0.32), however the risk-standardized LOS ratio diminished from 1.07 in 2003 to 0.97 in 2015 (IRR: 0.98: IC: 0.98–0.99; p&lt;0.001). Conclusions From 2003 to 2015, HF admission rate increased significantly in Spain as a consequence of the sustained increase of hospitalization in the population over 75. The crude in-hospital mortality rate diminished significantly for the same period, but the risk-standardized in-hospital mortality ratio did not significantly change. Figure 1 Funding Acknowledgement Type of funding source: None

Abstract 16009: Y RNA Fragments Enriched in Exosomes From Cardiosphere-derived Cells Mediate Cardioprotection and Macrophage Polarization

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Linda Cambier ◽  
Geoffrey de Couto ◽  
Ahmed Ibrahim ◽  
Eduardo Marbán
Keyword(s):  
Oxidative Stress ◽  
Gene Expression ◽  
Noncoding Rna ◽  
Neonatal Rat ◽  
Target Cells ◽  
Therapeutic Effects ◽  
Data Set ◽  
Rna Content ◽  
Rna Fragments ◽  
Anti Inflammatory

Background: Exosomes secreted by cardiosphere-derived cells (CDCs) are critical agents of regeneration and cardioprotection following ischemic injury, mediating the beneficial therapeutic effects of CDCs. Transfer of exosomal RNA to target cells is important for bioactivity. Objective: We sought to determine the RNA content of CDCs-secreted exosomes (CDC-exo), and to assess the contributions of selected small non-coding RNAs to the therapeutic efficacy of CDC-exo. Methods: Using next-generation sequencing (Illumina), we characterized the RNA content of CDC-exo. By direct transfection of fluorescently-labelled oligoribonucleotides, we delivered and tracked selected RNA fragments that are highly enriched in CDC-exo. In order to examine potential cytoprotective effects, neonatal rat ventricular myocytes (NRVMs) were pretreated with each of these fragments or a scrambled control fragment prior to H2O2-induced oxidative stress. Effects on gene expression were assessed by transfection of the fragments into bone marrow-derived macrophages. Results: Several noncoding RNA species were present in CDC-exo. Among these, Y RNAs (either whole or in fragments of the 5’ end) constituted 18% of all hits. From this data set, we selected two highly-enriched Y RNA fragments. Both fragments localized to the cytoplasm of CDC, NRVM and macrophages, and conferred augmented resistance to oxidative stress of NRVM (64.25±31.13% viability vs. 44±26.85%; p=0.06). Additionally, macrophages transfected with Y fragments exhibit rapid, robust polarization to a distinctive gene expression profile notable for upregulation of IL-10 (83.07 vs. 0.59 fold; p<0.0001), an anti-inflammatory cytokine. Conclusions: Here, we demonstrated that abundant noncoding RNA components of CDC-exo, Y RNA fragments, are bioactive components of CDC-exo. Two distinct fragments confer cardioprotection and also induce a strong anti-inflammatory response in macrophages. Although several components of the CDC-exo payload (including miRNA) contribute to functional efficacy, the present findings demonstrate the capacity of Y RNA fragments, an RNA species of previously-unknown function, to elicit therapeutic effects in vitro.

scholarly journals Variation in CT use for paediatric head injuries across different types of emergency departments in Australia and New Zealand

2020 ◽  
Vol 37 (11) ◽  
pp. 686-689
Author(s):  
Catherine L Wilson ◽  
Emma J Tavender ◽  
Natalie T Phillips ◽  
Stephen JC Hearps ◽  
Kelly Foster ◽  
...  
Keyword(s):  
New Zealand ◽  
Head Injury ◽  
North America ◽  
Emergency Departments ◽  
Head Injuries ◽  
Admission Rate ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Paediatric Head Injury ◽  
Tertiary Hospitals

ObjectivesCT of the brain (CTB) for paediatric head injury is used less frequently at tertiary paediatric emergency departments (EDs) in Australia and New Zealand than in North America. In preparation for release of a national head injury guideline and given the high variation in CTB use found in North America, we aimed to assess variation in CTB use for paediatric head injury across hospitals types.MethodsMulticentre retrospective review of presentations to tertiary, urban/suburban and regional/rural EDs in Australia and New Zealand in 2016. Children aged <16 years, with a primary ED diagnosis of head injury were included and data extracted from 100 eligible cases per site. Primary outcome was CTB use adjusted for severity (Glasgow Coma Scale) with 95% CIs; secondary outcomes included hospital length of stay and admission rate.ResultsThere were 3072 head injury presentations at 31 EDs: 9 tertiary (n=900), 11 urban/suburban (n=1072) and 11 regional/rural EDs (n=1100). The proportion of children with Glasgow Coma Score ≤13 was 1.3% in each type of hospital. Among all presentations, CTB was performed for 8.2% (95% CI 6.4 to 10.0) in tertiary hospitals, 6.6% (95% CI 5.1 to 8.1) in urban/suburban hospitals and 6.1% (95% CI 4.7 to 7.5) in regional/rural. Intragroup variation of CTB use ranged from 0% to 14%. The regional/rural hospitals admitted fewer patients (14.6%, 95% CI 12.6% to 16.9%, p<0.001) than tertiary and urban/suburban hospitals (28.1%, 95% CI 25.2% to 31.2%; 27.3%, 95% CI 24.7% to 30.1%).ConclusionsIn Australia and New Zealand, there was no difference in CTB use for paediatric patients with head injuries across tertiary, urban/suburban and regional/rural EDs with similar intragroup variation. This information can inform a binational head injury guideline.

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