The modified frailty index predicts postoperative morbidity in elective hernia repair patients: analysis of the national inpatient sample 2015-2019

PURPOSE

Frailty has shown promise in predicting postoperative morbidity and mortality following hernia surgery. This study aims to evaluate the predictive capacity of the 11-item modified frailty index (mFI) in estimating postoperative outcomes following elective hernia surgery using the National Inpatient Sample (NIS) database.

METHODS

A retrospective analysis of the NIS from 2015 to 2019 was performed including adult patients who underwent elective hernia repair. The mFI was used to stratify patients as either frail (mFI ≥ 0.27) or robust (mFI < 0.27). The primary outcomes were in-hospital postoperative morbidity and mortality. The secondary outcomes were system-specific morbidity, length of stay (LOS), total in-hospital healthcare cost, and discharge disposition. Univariable and multivariable regressions were utilized.

RESULTS

In total, 14,125 robust patients and 1704 frail patients were included. Frailty was associated with an increased age (mean age 66.4 years vs. 52.6 years, p < 0.001) and prevalence of ventral hernias (51.9% vs. 44.4%, p < 0.001). Adjusted analyses demonstrated that frail patients had increased in-hospital mortality (adjusted odds ratio (aOR) 3.89, 95% CI 1.50, 10.11, p = 0.005), postoperative overall morbidity (aOR 1.98, 95% CI 1.72, 2.29, p < 0.001), postoperative LOS (adjusted mean difference (aMD) 0.78 days, 95% CI 0.51, 1.06, p < 0.001), total in-hospital healthcare costs (aMD $7562 95% CI 3292, 11,832, p = 0.001), and were less likely to be discharged home (aOR 0.61, 95% CI 0.53, 0.69, p < 0.001).

CONCLUSION

The mFI may be a reliable predictor of postoperative morbidity and mortality in elective hernia surgery. Utilizing this tool can aid in patient education and identifying high-risk patients who may benefit from tailored prehabilitation.

Short-term postoperative outcomes for obese versus non-obese inflammatory bowel disease patients undergoing bowel resection: a propensity score matched analysis

PURPOSE

Up to 40% of patients with inflammatory bowel disease (IBD) are obese. Obesity is a well-known risk factor for increased perioperative morbidity, but this risk has never been quantified in IBD patients undergoing abdominal surgery using the United States National Inpatient Sample (NIS) database. This study aims to compare postoperative morbidity between obese and non-obese patients undergoing bowel resection for IBD using recent NIS data.

METHODS

Adult patients who underwent bowel resection for IBD from 2015 to 2019 were identified in the NIS using ICD-10-CM coding. Patients were stratified into obese (BMI > 30 kg/m2) and non-obese groups, then propensity score matched (PSM) for demographic, operative, and hospital characteristics. The primary outcome was postoperative in-hospital morbidity. Secondary outcomes included postoperative in-hospital mortality, system-specific postoperative complications, total admission healthcare costs, and length of stay (LOS). Univariable and multivariable regressions were utilized.

RESULTS

Overall, 6601 non-obese patients and 671 obese patients were identified. The PSM cohort included 659 patients per group. Obese patients had significantly increased odds of experiencing postoperative in-hospital morbidity (aOR 1.50, 95% CI 1.10-2.03, p = 0.010) compared to non-obese patients. Specifically, obese patients experienced increased gastrointestinal complications (aOR 1.49, 95% CI 1.00-2.24, p = 0.050), and genitourinary complications (aOR 1.71, 95% CI 1.12-2.61, p = 0.013). There were no differences in total admission healthcare costs (MD - $2256.32, 95% CI - 19,144.54-14,631.9, p = 0.79) or LOS (MD 0.16 days, 95% CI - 0.93-1.27, p = 0.77).

CONCLUSIONS

Obese IBD patients are at greater risk of postoperative in-hospital morbidity than non-obese IBD patients. This supports targeted preoperative weight loss protocols for IBD patients to optimize surgical outcomes.

Total Abdominal Colectomy Versus Diverting Loop Ileostomy and Antegrade Colonic Lavage for Fulminant Clostridioides Colitis: Analysis of the National Inpatient Sample 2016-2019

BACKGROUND

When surgery is indicated for fulminant Clostridioides difficile infection (CDI), total abdominal colectomy (TAC) is the most common approach. Diverting loop ileostomy (DLI) with antegrade colonic lavage has been introduced as a colon-sparing surgical approach. Prior analyses of National Inpatient Sample (NIS) data suggested equivalent postoperative outcomes between groups but did not evaluate healthcare resource utilization. As such, we aimed to analyze a more recent NIS cohort to compare these two approaches in terms of both postoperative outcomes and healthcare resource utilization.

METHODS

A retrospective analysis of the NIS from 2016 to 2019 was conducted. The primary outcome was postoperative in-hospital morbidity. Secondary outcomes included postoperative in-hospital mortality, system-specific postoperative complications, total admission cost, and length of stay (LOS). Univariable and multivariable regressions were utilized to compare the two operative approaches.

RESULTS

In total, 886 patients underwent TAC and 409 patients underwent DLI with antegrade colonic lavage. Adjusted analyses demonstrated no difference between groups in postoperative in-hospital morbidity (aOR 0.96, 95%CI 0.64-1.44, p = 0.851) or in-hospital mortality (aOR 1.15, 95%CI 0.81-1.64, p = 0.436). Patients undergoing TAC experienced significantly decreased total admission cost (MD $79,715.34, 95%CI 133,841-25,588, p = 0.004) and shorter postoperative LOS (MD 4.06 days, 95%CI 6.96-1.15, p = 0.006).

CONCLUSIONS

There are minimal differences between TAC and DLI with antegrade colonic lavage for fulminant CDI in terms of postoperative morbidity and mortality. Healthcare resource utilization, however, is significantly improved when patients undergo TAC as evidenced by clinically important decreases in total admission cost and postoperative LOS.

Diffusive process under Lifshitz scaling and pandemic scenarios

We here propose to model active and cumulative cases data from COVID-19 by a continuous effective model based on a modified diffusion equation under Lifshitz scaling with a dynamic diffusion coefficient. The proposed model is rich enough to capture different aspects of a complex virus diffusion as humanity has been recently facing. The model being continuous it is bound to be solved analytically and/or numerically. So, we investigate two possible models where the diffusion coefficient associated with possible types of contamination are captured by some specific profiles. The active cases curves here derived were able to successfully describe the pandemic behavior of Germany and Spain. Moreover, we also predict some scenarios for the evolution of COVID-19 in Brazil. Furthermore, we depicted the cumulative cases curves of COVID-19, reproducing the spreading of the pandemic between the cities of São Paulo and São José dos Campos, Brazil. The scenarios also unveil how the lockdown measures can flatten the contamination curves. We can find the best profile of the diffusion coefficient that better fit the real data of pandemic.

Bedside Optic Nerve Ultrasonography for Diagnosing Increased Intracranial Pressure: A Systematic Review and Meta-analysis

BACKGROUND

Optic nerve ultrasonography (optic nerve sheath diameter sonography) has been proposed as a noninvasive, quick method for diagnosing increased intracranial pressure.

PURPOSE

To examine the accuracy of optic nerve ultrasonography for diagnosing increased intracranial pressure in children and adults.

DATA SOURCES

13 databases from inception through May 2019, reference lists, and meeting proceedings.

STUDY SELECTION

Prospective optic nerve ultrasonography diagnostic accuracy studies, published in any language, involving any age group or reference standard.

DATA EXTRACTION

3 reviewers independently abstracted data and performed quality assessment.

DATA SYNTHESIS

Of 71 eligible studies involving 4551 patients, 61 included adults, and 35 were rated as having low risk of bias. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of optic nerve ultrasonography in patients with traumatic brain injury were 97% (95% CI, 92% to 99%), 86% (CI, 74% to 93%), 6.93 (CI, 3.55 to 13.54), and 0.04 (CI, 0.02 to 0.10), respectively. Respective estimates in patients with nontraumatic brain injury were 92% (CI, 86% to 96%), 86% (CI, 77% to 92%), 6.39 (CI, 3.77 to 10.84), and 0.09 (CI, 0.05 to 0.17). Accuracy estimates were similar among studies stratified by patient age, operator specialty and training level, reference standard, sonographer blinding status, and cutoff value. The optimal cutoff for optic nerve sheath dilatation on ultrasonography was 5.0 mm.

LIMITATION

Small studies, imprecise summary estimates, possible publication bias, and no evaluation of effect on clinical outcomes.

CONCLUSION

Optic nerve ultrasonography can help diagnose increased intracranial pressure. A normal sheath diameter measurement has high sensitivity and a low negative likelihood ratio that may rule out increased intracranial pressure, whereas an elevated measurement, characterized by a high specificity and positive likelihood ratio, may indicate increased intracranial pressure and the need for additional confirmatory tests.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42017055485).

Role of physical exercise on hepatic insulin, glucocorticoid and inflammatory signaling pathways in an animal model of non-alcoholic steatohepatitis

AIMS

Pro-inflammatory mediators, glucocorticoids and transforming growth factor (TGF)-β are implicated in the pathogenesis of non-alcoholic steatohepatitis (NASH)-related insulin resistance. As physical activity is beneficial against NASH, we analyzed the voluntary physical activity (VPA) and endurance training (ET) (preventive and therapeutic strategies) effects on hepatic insulin, pro-inflammatory and glucocorticoid signaling regulators/mediators in high-fat (Lieber-DeCarli) diet (HFD)-induced NASH.

MAIN METHODS

Adult male Sprague-Dawley rats were divided in standard diet (SD) or HFD, with sedentary, VPA and ET animals in both diet regimens. Plasma glucose and insulin concentrations were analyzed; plasma insulin sensitivity index (ISI) was calculated. Hepatic insulin, pro-inflammatory and glucocorticoid signaling regulators/mediators were evaluated by Western blot or reverse transcriptase-PCR.

KEY FINDINGS

ET improved ISI in both diet regimens. HFD-feeding increased interleukin-1β and induced a similar pattern on interleukin-6 and TGF-β, which were globally reduced by physical exercise. ET decreased HFD leukemia inhibitory factor level, SD+VPA animals presenting higher values than HFD+VPA animals. HFD increased the ratio of IRS-1(Ser307)/total IRS-1, which was completely mitigated by physical exercise. Physical exercise reduced total ERK and JNK (total and activated) expression in HFD. In SD vs. HFD, VPA presented higher activated JNK and ET presented higher total JNK. Generally, in HFD, the ratio (activated/total) of AKT, and each separately, decreased with exercise and also for activated AKT in SD. Overall, in both diets, exercise reduced 11β-hydroxysteroid dehydrogenase type 1. ET increased glucocorticoid receptor and reduced PTP1B in HFD.

SIGNIFICANCE

Physical exercise mitigates the expression of pro-inflammatory mediators and positively modulates insulin and glucocorticoid signaling in NASH.

Tourniquet use for peripheral vascular injuries in the civilian setting

BACKGROUND

Haemorrhage in peripheral vascular injuries may cause life-threatening exsanguination. Tourniquets are used extensively by the military, with increased interest in the civilian setting to prevent deaths. This is a retrospective study of trauma patients at two large Canadian trauma centres with arterial injury after isolated extremity trauma. We hypothesized that tourniquet use may decrease mortality rate and transfusion requirements if applied early.

METHODS

The study group was all adult patients at two Level 1 Trauma Centres in two Canadian cities in Canada, who had arterial injuries from extremity trauma. The study period was from January 2001 to December 2010. We excluded patients with significant associated injuries. The intervention in this study was prehospital tourniquet use. The main outcome was in-hospital mortality. Secondary outcomes were length of stay, compartment syndrome, amputation, and blood product transfusion.

RESULTS

190 patients were included in the study, and only 4 patients had a prehospital tourniquet applied. They arrived directly from the scene of injury, had improvised tourniquets by police or bystanders, and showed a trend to be more hypotensive and acidotic. Four other patients had tourniquets applied in the trauma bay within 1h of injury. There were no differences in age, sex, injury severity or physiologic presentation between patients who had an early tourniquet applied and those who died without a tourniquet. However, six patients died without a tourniquet, and all bled to death. Of the eight patients who had early tourniquets applied, none died.

CONCLUSIONS

Tourniquets may prevent exsanguination in the civilian setting for patients suffering either blunt or penetrating trauma to the extremity. Future studies will help determine the utility of deploying tourniquets in the civilian setting, given the rarity of exsanguinating haemorrhage from isolated extremity trauma in this setting.

Modulation of cardiac mitochondrial permeability transition and apoptotic signaling by endurance training and intermittent hypobaric hypoxia

BACKGROUND

Modulation of the mitochondrial permeability transition pore (MPTP) and inhibition of the apoptotic signaling are critically associated with the cardioprotective phenotypes afforded by both intermittent hypobaric-hypoxia (IHH) and endurance-training (ET). We recently proposed that IHH and ET improve cardiac function and basic mitochondrial capacity, although without showing addictive effects. Here we investigate whether a combination of IHH and ET alters cardiac mitochondrial vulnerability to MPTP and related apoptotic signaling.

METHODS

Male Wistar rats were divided into normoxic-sedentary (NS), normoxic-exercised (NE, 1h/day/5 week treadmill-running), hypoxic-sedentary (HS, 6000 m, 5h/day/5 weeks) and hypoxic-exercised (HE) to study susceptibility to calcium-induced cardiac MPTP opening. Mitochondrial cyclophilin D (CypD), adenine nucleotide translocator (ANT), Bax and Bcl-2 protein contents were semi-quantified by Western blotting. Cardiac caspase 3-, 8- and 9-like activities were measured. Mitochondrial aconitase and superoxide dismutase (MnSOD) activity and malondialdehyde (MDA) and sulphydryl group (-SH) content were determined.

RESULTS

Susceptibility to MPTP decreased in NE and HS vs. NS and even further in HE. The ANT content increased in HE vs. NS. Bcl-2/Bax ratio increased in NE and HS compared to NS. Decreased activities in tissue caspase 3-like (HE vs. NS) and caspase 9-like (HS and HE vs. NS) were observed. Mitochondrial aconitase increased in NE and HS vs. NS. No alterations between groups were observed for caspase 8-like activity, MnSOD, CypD, MDA and -SH.

CONCLUSIONS

Data confirm that IHH and ET modulate cardiac mitochondria to a protective phenotype characterized by decreased MPTP induction and apoptotic signaling, although without visible addictive effects as initially hypothesized.

IV access in bleeding trauma patients: a performance review

BACKGROUND

Exsanguinating haemorrhage is a leading cause of death in severely injured trauma patients. Management includes achieving haemostasis, replacing lost intravascular volume with fluids and blood, and treating coagulopathy. The provision of fluids and blood products is contingent on obtaining adequate vascular access to the patient's venous system. We sought to examine the nature and timing of achieving adequate intravenous (IV) access in trauma patients requiring uncrossmatched blood in the trauma bay.

METHODS

We performed a retrospective chart review of all patients admitted to our trauma centre from 2005 to 2009 who were transfused uncrossmatched blood in the trauma bay. We examined the impact of IV access on prehospital times and time to first PRBC transfusion.

RESULTS

Of 208 study patients, 168 (81%) received prehospital IV access, and the on-scene time for these patients was 5 min longer (16.1 vs 11.4, p<0.01). Time to achieving adequate IV access in those without any prehospital IVs occurred on average 21 min (6.6-30.5) after arrival to the trauma bay. A central venous catheter was placed in 92 (44%) of patients. Time to first blood transfusion correlated most strongly with time to achieving central venous access (Pearson correlation coefficient 0.94, p<0.001) as opposed to time to achieving adequate peripheral IV access (Pearson correlation coefficient 0.19, p=0.12).

CONCLUSIONS

We found that most bleeding patients received a prehospital IV; however, we also found that obtaining prehospital IVs was associated with longer EMS on-scene times and longer prehospital times. Interestingly, we found that obtaining a prehospital IV was not associated with more rapid initiation of blood product transfusion. Obtaining optimal IV access and subsequent blood transfusion in severely injured patients continues to present a challenge.

In vitro salicylate does not further impair aging-induced brain mitochondrial dysfunction

Aging and drug-induced side effects may contribute to the deterioration of mitochondrial bioenergetics in the brain. One hypothesis is that the combination of both deleterious stimuli accelerates the process of mitochondrial degradation, leading to progressive bioenergetic disruption. The hypothesis was tested by analyzing the isolated and combined effect of aging and salicylate, a vastly used anti-inflammatory drug, on isolated brain fractions in rats. Male Wistar rats were divided according to age in two groups: adult (n=8, 19 weeks of age) and aged (n=8, 106 weeks of age). In vitro endpoints of brain mitochondrial function including oxygen consumption and transmembrane electric potential (ΔΨ) were evaluated in the absence and in the presence of salicylate (0.5mM). Brain mitochondrial susceptibility to calcium-induced permeability transition pore (MPTP) was also assessed. Mitochondrial oxidative stress was determined by measuring aconitase and manganese-superoxide dismutase (SOD) activity, and content in sulfhydryl groups (SH) and malondialdehyde (MDA). Mitochondrial content in apoptotic-related proteins Bax, Bcl-2 and cyclophilin D was determined by Western Blotting. Under basal, untreated, conditions, aging affected brain mitochondrial state 3 respiration, maximal ΔΨ developed, ADP phosphorylation lag phase and calcium-induced MPTP. Interestingly, MDA decreased and Mn-SOD activity increased in the aged group. Brain mitochondrial Bcl-2 content decreased and Bax/Bcl-2 ratio increased in aged group. Salicylate incubation for 20min increased lipid peroxidation in the aged group only and stimulated respiration during state 2, accompanied by decreased ΔΨ, although both effects were independent of the animal age. We confirmed that both aging and salicylate per se impaired brain mitochondrial bioenergetics, although the combination of both does not seem to worsen the mitochondrial end-points studied.

[Ethics in nursing]

Synopsis about the evolution of moral principles adopted by brazilian nursing since 1923 to nowadays. It indicates a metaphysical, abstract and spiritual tendencies in the codes of 1958 and 1975, and a change in the code of 1993, which searches to observe valuables of historic form and based on material conditions of existence.