Research Spotlight

Posted October 15th 2018

Volume-Based vs Rate-Based Enteral Nutrition in the Intensive Care Unit: Impact on Nutrition Delivery and Glycemic Control.

Susan Roberts D.C.N.

Susan Roberts D.C.N.

Roberts, S., R. Brody, S. Rawal and L. Byham-Gray (2018). “Volume-Based vs Rate-Based Enteral Nutrition in the Intensive Care Unit: Impact on Nutrition Delivery and Glycemic Control.” JPEN J Parenter Enteral Nutr Sep 19. [Epub ahead of print].

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BACKGROUND: Underfeeding with enteral nutrition (EN) is prevalent in intensive care units (ICUs) and associated with negative outcomes. This study evaluated the impact of volume-based EN (VBEN) vs rate-based EN (RBEN) on delivery of prescribed energy and protein, and glycemic control (GC). METHODS: This retrospective study included adult patients who require mechanical ventilation within 48 hours of ICU admission and with an RBEN (n = 85) or VBEN (n = 86) order for >/=3 consecutive days during the first 12 ICU days. RESULTS: Patients receiving VBEN, vs RBEN, received more prescribed energy (RBEN, 67.6%; VBEN, 79.6%; P < .001) and protein (RBEN, 68.6%; VBEN, 79.3%; P < .001). Multiple linear regression analyses confirmed VBEN was significantly associated with an 8.9% increase in energy (P = .002) and 7.7% increase in protein (P = .004) received, after adjusting for age, Acute Physiology and Chronic Health Evaluation II score, duration of and initiation day for EN, and ICU admission location. Presence of hyperglycemia (P = .40) and glycemic variability (GV) (P = .99) were not different between the 2 groups. After adjusting for age, body mass index, diabetes history, primary diagnosis, and percent of days receiving corticosteroids, GC outcomes (presence of hyperglycemia, P = .27; GV, P = .67) remained unrelated to EN order type in multivariable regression models. CONCLUSION: VBEN, compared with RBEN, was associated with increased energy and protein delivery without adversely affecting GC. These results suggest VBEN is an effective, safe strategy to enhance EN delivery in the ICU.


Posted October 15th 2018

Examining the relationship between obesity and mental health outcomes among individuals admitted to a level I trauma centre.

Ann M. Warren Ph.D.

Ann M. Warren Ph.D.

Reynolds, M., S. Driver, M. Bennett, S. Patel, E. Rainey and A. M. Warren (2018). “Examining the relationship between obesity and mental health outcomes among individuals admitted to a level I trauma centre.” Clin Obes 8(5): 337-344.

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The increased incidence of obesity in the general population translates into clinicians caring for an increased number of trauma patients with obesity. Previous research has documented the unique anatomical and physiological challenges that clinicians face when caring for trauma patients with obesity; however, little is known about psychological challenges that trauma patients with obesity may also experience in the months following injury. The aim of this study is to determine the relationship between obesity and (i) mental health, (ii) demographic and injury-related variables and (iii) quality-of-life outcomes among trauma patients between hospitalization and 3-months post-injury. This is a prospective, longitudinal study conducted between March 2012 and May 2014 at a single, level I trauma centre in the southwest United States. Inclusion criteria for this convenience sample consisted of patients who were admitted to the trauma or orthopaedic trauma service >/=24 h, medically stable, spoke English or Spanish and >/=18 years of age. In total, 455 eligible patients were consented and enrolled; 343 (70.87%) completed 3-month follow-up. The objective of this study is to investigate the relationship between obesity and mental health among trauma patients in the months following injury. Demographic and injury-related data were also collected; patients’ height and weight were used to determine body mass index. Health outcomes were assessed during initial hospitalization and at 3-month follow-up and included depression, post-traumatic stress symptoms, pain and return to work. Prior to data collection, it was hypothesized that obesity would have a negative effect on mental health outcomes among patients 3 months post-injury. The final sample consisted of 343 participants; average age was 46.4 +/- 17.3 years; majority male (n = 213, 63%) and Caucasian (n = 231, 69%). Patients with obesity had higher odds of screening positive for depression (odds ratio [OR] = 2.36, P = 0.02) and overweight patients had lower odds of returning to work (OR = 0.31, P = 0.01) 3 months post-injury compared to patients of normal weight (65% vs. 40%). No other significant differences were found. Results of the current study are novel in that they identify psychological challenges that overweight and trauma patients with obesity may experience. These results demonstrate the need for mental health professionals to be involved in follow-up care to extending in the months following injury.


Posted October 15th 2018

Totally Thorascopic Closure of the Left Atrial Appendage.

James R. Edgerton M.D.

James R. Edgerton M.D.

Ramlawi, B., K. Bedeir and J. R. Edgerton (2018). “Totally Thorascopic Closure of the Left Atrial Appendage.” Ann Thorac Surg Sep 18. [Epub ahead of print].

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The left atrial appendage (LAA) is a major site of clot formation in atrial fibrillation. Stand-alone thoracoscopic LAA complete closure can decrease stroke risk and may be an alternative to life-long oral anticoagulation.(1) We describe our technique for totally thoracoscopic LAA exclusion with an epicardial clip device. This approach provides a safe and likely more effective alternative to LAA management than other endocardial devices.


Posted October 15th 2018

Defining Proficiency for Society of Thoracic Surgeons Participants Performing Thoracoscopic Lobectomy.

Mitchell J. Magee M.D.

Mitchell J. Magee M.D.

Puri, V., H. A. Gaissert, D. W. Wormuth, E. L. Grogan, W. R. Burfeind, A. C. Chang, C. W. Seder, F. G. Fernandez, L. Brown, M. J. Magee, A. S. Kosinski, D. P. Raymond, S. R. Broderick, R. J. Welsh, M. M. DeCamp, F. Farjah, M. A. Edwards and B. D. Kozower (2018). “Defining Proficiency for Society of Thoracic Surgeons Participants Performing Thoracoscopic Lobectomy.” Ann Thorac Surg Sep 28. [Epub ahead of print].

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BACKGROUND: Parameters defining attainment and maintenance of proficiency in thoracoscopic (VATS) lobectomy remain unknown. To address this knowledge gap, we investigated the institutional performance curve for VATS lobectomy using risk-adjusted Cusum analysis. METHODS: Using the STS General Thoracic Surgery Database, we identified centers that had performed a total of 30 or more VATS lobectomies. Major morbidity, mortality, and blood transfusion were each deemed a primary outcome, with expected incidence derived from risk adjusted regression models. Acceptable and unacceptable failure rates for outcomes were set a priori based upon clinical relevance and informed by regression model output. RESULTS: Between 2001 and 2016, 24196 patients underwent VATS lobectomy at 159 centers with a median volume of 103 (range 30-760). Overall rates of operative mortality, major morbidity, and transfusion were 1% (244/24189), 17.1% (4145/24196), and 4% (975/24196) respectively. Of the highest volume centers (>/=100 cases), 84% (65/77) and 82 % (63/77) (p=0.48) were proficient by major morbidity standards by their 50(th) and 100(th) cases, respectively. Similarly, 92% (71/77) and 90% (69/77) (p=0.41) of centers showed proficiency by transfusion standards by their 50(th) and 100(th) cases. Three performance patterns were observed: A) Initial and sustained proficiency; B) Crossing unacceptability thresholds with subsequent improved performance; and C) Crossing unacceptability thresholds without subsequent improved performance. CONCLUSIONS: VATS lobectomy outcomes have improved with lower mortality and transfusion rates. The majority of high-volume centers demonstrate proficiency after 50 cases; however, maintenance of proficiency is not assured. Cusum provides a simple yet powerful tool that can trigger internal audits and performance improvement initiatives.


Posted October 15th 2018

Impact of a Novel Surgical Wound Protection Device on Observed versus Expected Surgical Site Infection Rates after Colectomy Using the National Surgical Quality Improvement Program Risk Calculator.

Harry T. Papaconstantinou M.D.

Harry T. Papaconstantinou M.D.

Papaconstantinou, H. T., E. H. Birnbaum, R. Ricciardi, D. A. Margolin, R. C. Moesinger, W. E. Lichliter, J. S. Thomas and R. Bergamaschi (2018). “Impact of a Novel Surgical Wound Protection Device on Observed versus Expected Surgical Site Infection Rates after Colectomy Using the National Surgical Quality Improvement Program Risk Calculator.” Surg Infect (Larchmt) Sep 20. [Epub ahead of print].

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BACKGROUND: Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. A novel surgical device that combines barrier surgical wound protection and continuous surgical wound irrigation was evaluated in a cohort of elective colorectal surgery patients. A retrospective analysis was performed comparing rates of SSI observed in a prospective cohort study with the predicted rate of SSI using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator. PATIENTS AND METHODS: A prospective multi-center study of colectomy patients was conducted using a study device for surgical site retraction and protection, as well as irrigation of the incision. Patients were followed for 30 days after the surgical procedure to assess for SSI. After completion of the study, patients’ characteristics were inserted into the ACS-NSQIP Risk Calculator to determine the predicted rate of SSI for the given patient population and compared with the observed rate in the study. RESULTS: A total of 108 subjects were enrolled in the study. The observed rate of SSI in the prospective study using the novel device was 3.7% (4/108). The predicted rate of SSI in the same patient population utilizing the ACS-NSQIP Risk Calculator was estimated to be 9.5%. This demonstrated a 61% difference (3.7% vs. 9.5%, p = 0.04) in SSI from the NSQIP predicted rate with the use of the irrigating surgical wound protection and retraction device. CONCLUSIONS: These data suggest the use of a novel surgical wound protection device seems to reduce the rate of SSIs in colorectal surgery.