Incisional negative pressure wound therapy for the prevention of surgical site infection: an up-to-date meta-analysis and trial sequential analysis

Background

The evidence on prophylactic use of negative pressure wound therapy on primary closed incisional wounds (iNPWT) for the prevention of surgical site infections (SSI) is confusing and ambiguous. Implementation in daily practice is impaired by inconsistent recommendations in current international guidelines and published meta-analyses. More recently, multiple new randomised controlled trials (RCTs) have been published. We aimed to provide an overview of all meta-analyses and their characteristics; to conduct a new and up-to-date systematic review and meta-analysis and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment; and to explore the additive value of new RCTs with a trial sequential analysis (TSA).

Methods

PubMed, Embase and Cochrane CENTRAL databases were searched from database inception to October 24, 2022. We identified existing meta-analyses covering all surgical specialties and RCTs studying the effect of iNPWT compared with standard dressings in all types of surgery on the incidence of SSI, wound dehiscence, reoperation, seroma, hematoma, mortality, readmission rate, skin blistering, skin necrosis, pain, and adverse effects of the intervention. We calculated relative risks (RR) with corresponding 95% confidence intervals (CI) using a Mantel-Haenszel random-effects model. We assessed publication bias with a comparison-adjusted funnel plot. TSA was used to assess the risk of random error. The certainty of evidence was evaluated using the Cochrane Risk of Bias-2 (RoB2) tool and GRADE approach. This study is registered with PROSPERO, CRD42022312995.

Findings

We identified eight previously published general meta-analyses investigating iNPWT and compared their results to present meta-analysis. For the updated systematic review, 57 RCTs with 13,744 patients were included in the quantitative analysis for SSI, yielding a RR of 0.67 (95% CI: 0.59-0.76, I2 = 21%) for iNPWT compared with standard dressing. Certainty of evidence was high. Compared with previous meta-analyses, the RR stabilised, and the confidence interval narrowed. In the TSA, the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, confirming the robustness of the summary effect estimate from the meta-analysis.

Interpretation

In this up-to-date meta-analysis, GRADE assessment shows high-certainty evidence that iNPWT is effective in reducing SSI, and uncertainty is less than in previous meta-analyses. TSA indicated that further trials are unlikely to change the effect estimate for the outcome SSI; therefore, if future research is to be conducted on iNPWT, it is crucial to consider what the findings will contribute to the existing robust evidence.

Funding

Dutch Association for Quality Funds Medical Specialists.

Efficacy of different preoperative skin antiseptics on the incidence of surgical site infections: a systematic review, GRADE assessment, and network meta-analysis

BACKGROUND

Surgical site infection (SSI) is the most common postoperative complication and substantially increases health-care costs. Published meta-analyses and international guidelines differ with regard to which preoperative skin antiseptic solution and concentration has the highest efficacy. We aimed to compare the efficacy of different skin preparation solutions and concentrations for the prevention of SSIs, and to provide an overview of current guidelines.

METHODS

This systematic review and network meta-analysis compared different preoperative skin antiseptics in the prevention of SSIs in adult patients undergoing surgery of any wound classification. We searched for randomised controlled trials (RCTs) in MEDLINE, Embase, and Cochrane CENTRAL, published up to Nov 23, 2021, that directly compared two or more antiseptic agents (ie, chlorhexidine, iodine, or olanexidine) or concentrations in aqueous and alcohol-based solutions. We excluded paediatric, animal, and non-randomised studies, and studies not providing standard preoperative intravenous antibiotic prophylaxis. Studies with no SSIs in both groups were excluded from the quantitative analysis. Two reviewers screened and reviewed eligible full texts and extracted data. The primary outcome was the occurrence of SSI (ie, superficial, deep, and organ space). We conducted a frequentist random effects network meta-analysis to estimate the network effects of the skin preparation solutions on the prevention of SSIs. A risk-of-bias and Grading of Recommendations, Assessment, Development, and Evaluation assessment were done to determine the certainty of the evidence. This study is registered with PROSPERO, CRD42021293554.

FINDINGS

Overall, 2326 articles were identified, 33 studies were eligible for the systematic review, and 27 studies with 17 735 patients reporting 2144 SSIs (overall incidence of 12·1%) were included in the quantitative analysis. Only 2·0-2·5% chlorhexidine in alcohol (relative risk 0·75, 95% CI 0·61-0·92) and 1·5% olanexidine (0·49, 0·26-0·92) significantly reduced the rate of SSIs compared with aqueous iodine. For clean surgery, we found no difference in efficacy between different concentrations of chlorhexidine in alcohol. Seven RCTs were at high risk of bias, 24 had some concerns, and two had low risk of bias. Heterogeneity across the studies was moderate (I²=27·5%), and netsplitting did not show inconsistencies between direct and indirect comparisons. Five of ten studies that mentioned adverse events related to the skin preparation solutions reported no adverse events, and five reported a total of 56 mild events (mainly erythema, pruritus, dermatitis, skin irritation, or mild allergic symptoms); none reported a substantial difference in adverse events between groups.

INTERPRETATION

For adult patients undergoing a surgical procedure of any wound classification, skin preparation using either 2·0-2·5% chlorhexidine in alcohol or 1·5% olanexidine is most effective in the prevention of SSIs. For clean surgery, no specific concentration of chlorhexidine in alcohol can be recommended. The efficacy of olanexidine was established by a single randomised trial and further investigation is needed.

FUNDING

Dutch Association for Quality Funds Medical Specialists.

A Network Meta-Analysis and GRADE Assessment of the Effect of Preoperative Oral Antibiotics with and Without Mechanical Bowel Preparation on Surgical Site Infection Rate in Colorectal Surgery

Objective

To compare the effect of different methods of bowel preparation on the incidence of surgical site infections (SSI), anastomotic leakage (AL), and mortality in patients undergoing elective colorectal surgery.

Background

Recent guidelines advise mechanical bowel preparation with oral antibiotics (MBP-OA) for the prevention of SSI in colorectal surgery. Recent trials suggest oral antibiotics (OA) alone may be sufficient.

Methods

PubMed, MEDLINE, and Embase were searched from inception until 10-08-2021. We included randomized controlled trials (RCTs) comparing multiple methods of bowel preparation (mechanical bowel preparation [MBP], OA, MBP-OA, or no preparation) with regards to clinical outcomes such as incidence of SSI, AL, and mortality rates. A frequentist random-effects network meta-analysis was conducted to estimate the network effects of the different treatment options.

Results

We included 48 studies with 13,611 patients. Compared to no preparation, combined direct and indirect network estimates showed a relative risk (RR) for SSI of 0.57 (95% confidence interval [CI], 0.45-0.72) for MBP-OA, 0.68 (95% CI, 0.49-0.95) for OA, and 1.05 (95% CI, 0.87-1.26) for MBP. The RR for MBP-OA compared to OA was 0.84 (95% CI, 0.60-1.19); in sensitivity analysis of mainly laparoscopic procedures this effect of MBP-OA was more profound (RR, 0.56; 95% CI, 0.31-0.99).

Conclusions

This network meta-analysis of RCTs finds that both mechanical bowel preparation with oral antibiotics and oral antibiotics alone are comparably effective in the prevention of SSI. The evidence is uncertain about the relative benefit of MBP-OA compared to OA alone. Therefore, it seems justified to use either of the 2 for the prevention of SSI in colorectal surgery.

Improvement of exercise capacity following neonatal respiratory failure: A randomized controlled trial

Exercise capacity deteriorates in school-aged children born with major anatomical foregut anomalies and/or treated with extracorporeal membrane oxygenation. The aim of the present study was to evaluate whether exercise capacity can be improved in the short term and long term in children born with anatomical foregut anomalies and/or treated with extracorporeal membrane oxygenation. Therefore, we evaluated two different interventions in this single-blinded randomized controlled trial. Forty participants were randomly assigned to group A: standardized anaerobic high-intensity interval training plus online lifestyle coaching program, B: online lifestyle coaching program only, or C: standard of care. Inclusion criteria were as follows: score ≤-1 standard deviation (SD) on the Bruce protocol. Exercise capacity was assessed at baseline (T0), after 3 months (T1), and after 12 months (T2). Exercise capacity improved over time: mean (SD) standard deviation score (SDS) endurance time: T0 -1.91 (0.73); T1 -1.35 (0.94); T2 -1.20 (1.03): both P < .001. No significant differences in maximal endurance time were found at T1 (group A-C: estimated mean difference (SDS): 0.06 P = .802; group B-C: -0.17 P = .733) or T2 (group A-C: -0.13 P = .635; group B-C: -0.18 P = .587). Exercise capacity improved significantly over time, irrespective of the study arm. Not only residual morbidities may be responsible for reduced exercise capacity. Parental awareness of reduced exercise capacity rather than specific interventions may have contributed. Monitoring of exercise tolerance and providing counseling on lifestyle factors that improve physical activity should be part of routine care, and aftercare should be offered on an individual basis.

Fatigue After Aneurysmal Subarachnoid Hemorrhage Is Highly Prevalent in the First-Year Postonset and Related to Low Physical Fitness: A Longitudinal Study

OBJECTIVE

The aim of the study was to investigate whether low physical fitness and inactive and sedentary lifestyles play a role in the severity of fatigue in patients with aneurysmal subarachnoid hemorrhage (a-SAH).

DESIGN

This is a prospective 1-yr follow-up study, including a total of 52 patients with a-SAH. Outcome measures included the Fatigue Severity Scale score, peak oxygen uptake (VO2peak), isokinetic knee muscle strength (peak torque), physical activity (% 24-hr period), and sedentary behavior (% waking hours) and were evaluated at 6 and 12 mos after onset.

RESULTS

Fatigue was highly prevalent in the first year and reported by 48% of the patients at 6 mos and by 52% at 12 mos after a-SAH. Fatigue was associated with the knee extension (P < 0.001) and flexion strength (P < 0.001). A nonsignificant trend for a relationship was found between fatigue and the aerobic capacity (P = 0.079). No relationships were found between fatigue and physical activity or sedentary behavior. Fatigue could not be predicted by disease-related characteristics.

CONCLUSIONS

Half of the patients were fatigued in the first year after a-SAH. Interventions are necessary to reduce fatigue and should consider exercise training as a potential contributor to a multimodal treatment, preventing debilitating conditions after a-SAH.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Recognize the association between fatigue and physical fitness in patients after aneurysmal subarachnoid hemorrhage; (2) Determine the severity of fatigue complaints in patient after aneurysmal subarachnoid hemorrhage; and (3) Discuss the role of physical deconditioning in the management of fatigue in patients after aneurysmal subarachnoid hemorrhage.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

People With Aneurysmal Subarachnoid Hemorrhage Have Low Physical Fitness and Can Be Predisposed to Inactive and Sedentary Lifestyles

BACKGROUND

Physical inactivity, sedentary lifestyles, and low functional outcome are thought to impact the level of physical fitness in patients with aneurysmal subarachnoid hemorrhage (a-SAH). However, changes in fitness over time and associated factors have not been studied in a-SAH.

OBJECTIVE

The objective was to evaluate the level of physical fitness in the first year after a-SAH and explore longitudinal relations with physical activity, sedentary behavior, and functional outcome. Additionally, we evaluated whether physical fitness could be predicted by disease-related characteristics (ie, severity of a-SAH, location of the aneurysm, treatment procedure, pituitary dysfunction, and complications).

DESIGN

This was a prospective 1-year follow-up study.

METHODS

Fifty-two participants performed exercise testing at 6 and 12 months after a-SAH. Cardiopulmonary exercise testing and isokinetic dynamometry were applied to determine the peak oxygen uptake $({\rm{\dot{V}}}{{\rm{o}}_{2{\rm{peak}}}})$ and the peak torque of the knee extensors (PText) and flexors (PTflex). In addition, physical activity and sedentary behavior were evaluated by accelerometer-based activity monitoring. The functional outcome was assessed by the Functional Independence Measure and Functional Assessment Measure. Disease-related characteristics were collected at hospital intake.

RESULTS

At both 6 and 12 months, all fitness parameters were lower compared with predicted values (ranging from 18% to 28%). Physical activity is related to both ${\rm{\dot{V}}}{{\rm{o}}_{{\rm{2peak}}}}$ and PTflex. The Functional Independence Measure and Functional Assessment Measure scores was related to PText and PTflex. Further, participants who underwent surgical clipping had lower ${\rm{\dot{V}}}{{\rm{o}}_{{\rm{2peak}}}}$ and PTflex.

LIMITATIONS

Longitudinal observations cannot confirm causality.

CONCLUSIONS

Levels of physical fitness remain low over the first year after a-SAH. Participants who were physically more active had higher levels of physical fitness, whereas participants with impaired functional outcome or who were treated with surgical clipping were at risk of low physical fitness. Exercise interventions are warranted and should focus on the promotion of physical activity and target patients with impaired functional outcome or those who have been treated with surgical clipping.

Inactive lifestyles and sedentary behavior in persons with chronic aneurysmal subarachnoid hemorrhage: evidence from accelerometer-based activity monitoring

BACKGROUND

Aneurysmal subarachnoid hemorrhage (a-SAH) is a potential life-threatening stroke. Because survivors may be at increased risk for inactive and sedentary lifestyles, this study evaluates physical activity (PA) and sedentary behavior (SB) in the chronic phase after a-SAH.

METHODS

PA and SB were objectively measured at six months post a-SAH with an accelerometer-based activity monitor, with the aim to cover three consecutive weekdays. Total time spent in PA (comprising walking, cycling, running and non-cyclic movement) and SB (comprising sitting and lying) was determined. Also, in-depth analyses were performed to determine the accumulation and distribution of PA and SB throughout the day. Binary time series were created to determine the mean bout length and the fragmentation index. Measures of PA and SB in persons with a-SAH were compared to those in sex- and age-matched healthy controls.

RESULTS

The 51 participants comprised 33 persons with a-SAH and 18 controls. None of the participants had signs of paresis or spasticity. Persons with a-SAH spent 105 min/24 h being physically active, which was 35 min/24 h less than healthy controls (p = 0.005). For PA, compared with healthy controls, the mean bout length was shorter in those with a-SAH (12.0 vs. 13.5 s, p = 0.006) and the fragmentation index was higher (0.053 vs. 0.041, p < 0.001). Total sedentary time during waking hours showed no significant difference between groups (514 min vs. 474 min, p = 0.291). For SB, the mean bout length was longer in persons with a-SAH (122.3 vs. 80.5 s, p = 0.024), whereas there was no difference in fragmentation index between groups (0.0032 vs 0.0036, p = 0.396).

CONCLUSIONS

Persons with a-SAH are less physically active, they break PA time into shorter periods, and SB periods last longer compared to healthy controls. Since inactive lifestyles and prolonged uninterrupted periods of SB are independent risk factors for poor cardiovascular health, interventions seem necessary and should target both PA and SB.

STUDY REGISTRATION

Dutch registry number: NTR 2085.

Developmental problems in patients with oesophageal atresia: a longitudinal follow-up study

OBJECTIVE

To longitudinally evaluate motor development and predictive factors in school-age children with oesophageal atresia.

DESIGN

Cohort study with prospective longitudinal follow-up.

SETTING

Outpatient clinic of a tertiary university paediatric hospital.

PATIENTS

Children with oesophageal atresia born between January 1999 and May 2006 were assessed at 5 and 8 years of age.

INTERVENTIONS

None.

MAIN OUTCOME

Motor performance was evaluated at 5 and 8 years using the Movement Assessment Battery for Children (M-ABC). Additionally, we evaluated perinatal characteristics, duration of anaesthesia within the first 24 months, socioeconomic status, sports participation and school performance at time of follow-up and intelligence and sustained attention at the age of 8 years.

RESULTS

In 5-year-olds (n=54), the mean (SD) z-score M-ABC was slightly, but significantly lower than age-predicted normative values (-0.75 (0.83), p<0.001). In 8-year-olds (n=49), the z-score M-ABC was -0.53 (0.91) (p<0.001), intelligence was normal, but sustained attention was impaired: z-score speed (-1.50 (1.73)) and raw score attentional fluctuation (3.99 (1.90)) (both p<0.001). Motor problems mainly concerned gross motor performance. Duration of anaesthesia and sustained attention were negatively associated with motor development; sports participation was positively associated.

CONCLUSIONS

Longer duration of anaesthesia and sustained attention problems were associated with gross motor problems in school-age patients with oesophageal atresia. Parental awareness of risks for motor problems may provide the opportunity to offer timely intervention.

The six-minute walk test predicts cardiorespiratory fitness in individuals with aneurysmal subarachnoid hemorrhage

BACKGROUND

Peak oxygen uptake (VO_2peak) established during progressive cardiopulmonary exercise testing (CPET) is the "gold-standard" for cardiorespiratory fitness. However, CPET measurements may be limited in patients with aneurysmal subarachnoid hemorrhage (a-SAH) by disease-related complaints, such as cardiovascular health-risks or anxiety. Furthermore, CPET with gas-exchange analyses require specialized knowledge and infrastructure with limited availability in most rehabilitation facilities.

OBJECTIVES

To determine whether an easy-to-administer six-minute walk test (6MWT) is a valid clinical alternative to progressive CPET in order to predict VO_2peak in individuals with a-SAH.

METHODS

Twenty-seven patients performed the 6MWT and CPET with gas-exchange analyses on a cycle ergometer. Univariate and multivariate regression models were made to investigate the predictability of VO_2peak from the six-minute walk distance (6MWD).

RESULTS

Univariate regression showed that the 6MWD was strongly related to VO_2peak (r = 0.75, p < 0.001), with an explained variance of 56% and a prediction error of 4.12 ml/kg/min, representing 18% of mean VO_2peak. Adding age and sex to an extended multivariate regression model improved this relationship (r = 0.82, p < 0.001), with an explained variance of 67% and a prediction error of 3.67 ml/kg/min corresponding to 16% of mean VO_2peak.

CONCLUSIONS

The 6MWT is an easy-to-administer submaximal exercise test that can be selected to estimate cardiorespiratory fitness at an aggregated level, in groups of patients with a-SAH, which may help to evaluate interventions in a clinical or research setting. However, the relatively large prediction error does not allow for an accurate prediction in individual patients.

A Mirror Therapy–Based Action Observation Protocol to Improve Motor Learning After Stroke

Background. Mirror therapy is a priming technique to improve motor function of the affected arm after stroke. Objective. To investigate whether a mirror therapy–based action observation (AO) protocol contributes to motor learning of the affected arm after stroke. Methods. A total of 37 participants in the chronic stage after stroke were randomly allocated to the AO or control observation (CO) group. Participants were instructed to perform an upper-arm reaching task as fast and as fluently as possible. All participants trained the upper-arm reaching task with their affected arm alternated with either AO or CO. Participants in the AO group observed mirrored video tapes of reaching movements performed by their unaffected arm, whereas participants in the CO group observed static photographs of landscapes. The experimental condition effect was investigated by evaluating the primary outcome measure: movement time (in seconds) of the reaching movement, measured by accelerometry. Results. Movement time decreased significantly in both groups: 18.3% in the AO and 9.1% in the CO group. Decrease in movement time was significantly more in the AO compared with the CO group (mean difference = 0.14 s; 95% confidence interval = 0.02, 0.26; P = .026). Conclusion. The present study showed that a mirror therapy–based AO protocol contributes to motor learning after stroke.