Effect of hospital-admission volume on outcomes following acute non-variceal upper gastrointestinal bleeding.

INTRODUCTION: Treatment-requiring acute non-variceal upper gastrointestinal bleeding (NVUGIB) is a common, potentially life-threatening emergency. This study investigated whether hospital admittance volume of patients with NVUGIB was associated with reduced mortality, reduced lasting failure of haemostatic procedures defined as rate of re-endoscopy with repeated haemostasis intervention (ReWHI), transfusion requirements and conversion to surgery. METHODS: Data on Danish nationwide admissions of patients with acute NVUGIB from 2011-2013 were analysed to estimate 30-day mortality, re-bleeding (ReWHI), transfusion rates and rates of conversion to surgery. Data were analysed by regression modelling while controlling for confounders including age, admission haemoglobin, the American College of Anesthesiologists score, comorbidities and the Forrest classification. RESULTS: A total of 3,537 patients with acute non-variceal upper gastrointestinal bleeding were included in the study. The hospital admission volume of patients with NVUGIB was positively associated with a significant increase in ReWHI with an odds ratio of 1.27; p = 1.91 × 10-6. There was no significant association between admission volume and conversion to surgery, 30-day mortality or transfusion rates. CONCLUSIONS: A positive association between admission volumes of patients with NVUGIB and ReWHI was identified. No association between admission volumes and 30-day mortality or other failure of haemostasis events could be identified. FUNDING: none. TRIAL REGISTRATION: not applicable.

Self-evaluated competence in trauma reception.

INTRODUCTION: No formal training requirements exist for trauma teams in Denmark. The aim of this study was to investigate the point prevalence level of training and the self-evaluated competence of doctors involved in trauma care. METHODS: On two nights, all doctors on call at departments involved in trauma care were interviewed and answered a structured questionnaire pertaining to their level of training and self-evaluated level of competence in relevant skills. These skills included the ability to perform diagnostics and interventions as mandated by the Advanced Trauma Life Support and Definitive Surgical Trauma Care curriculums. RESULTS: All contacted doctors replied to the questionnaire. 58% of doctors were specialists; most often anaesthesiologists (AN) (86%) and doctors working at hospitals with a dedicated trauma centre designation (100%). In total, 45% of orthopaedic (OS) and gastrointestinal surgeons (GS) were specialists. In terms of self-evaluated competence, 95% of AN felt competent performing damage control resuscitation, 82% of OS felt competent performing damage control surgery on extremities, whereas 55% of GS felt competent performing damage control surgery in the abdomen. A total of 20% of the respondents had not attended any relevant trauma course, the majority of these were GS. CONCLUSIONS: The results indicate that, at the point of sampling, trauma reception in Denmark was handled by AN specialists in the majority of cases, but by surgical trainees. Self-perceived competencies evaluation revealed preparedness to perform damage control resuscitation, but discrepancies in the ability to perform surgical damage control procedures. FUNDING: none. TRIAL REGISTRATION: not relevant.

Self-perceived readiness to perform at the attending level following surgical specialist training in Denmark.

INTRODUCTION: Great effort has been invested in improving the educational aspect of the Danish five-year national surgical residency programme. Among other initiatives, an updated logbook containing specific objectives was implemented in 2015. The effect of current and prior educational efforts has not previously been studied. In the present study, we aim to investigate the role of supervision in the national surgical residency programme and the self-perceived readiness to undertake the role of a specialist doctor in gastrointestinal surgery in a cohort of gastrointestinal surgeons graduating in 2012 and 2013. METHODS: A retrospective study was conducted, and questionnaires matching the categories from the American Accreditation Council for Graduate Medical Education were distributed to all Danish surgical residents graduating from the national surgery residency programme in 2012 or 2013. RESULTS: A total of 30 graduated residents (55%) responded to the Danish survey. Among those, 14 (47%) felt ready to be a specialist in surgery. A total of 25 (83%) answered that increased supervision would have increased their selfperceived competencies to serve as a surgical specialist. Self -perceived readiness was significantly associated with level of supervision during surgical training (p = 0.02), whereas no association with operative volume could be established. CONCLUSIONS: A worryingly high number of graduates did not feel ready to undertake their role as a gastrointestinal surgical specialist. Adequate supervision seems to play a crucial role in education. FUNDING: none. TRIAL REGISTRATION: not relevant.

[Diet consisting mainly of sunflower seeds and chicken as the cause of small bowel obstruction in a bodybuilder].

Diet-induced small bowel obstruction is a rare condition in young, healthy patients. We describe a case of a 26-year-old man, who presented with acute small bowel obstruction. During a period of eight days prior to admission the patient had been eating an extremely restricted diet along with a regulated intake of fluids. The diet was part of a preparation for a major fitness contest. We chose a conservative treatment of IV fluids and laxatives, and the patient recovered uneventfully.

National variation in transfusion strategies in patients with upper gastrointestinal bleeding.

INTRODUCTION: An optimal transfusion strategy for patients with upper gastrointestinal bleeding (UGIB) has yet to be established. The national guidelines contain recommendations for patients with life-threating bleeding in general, but no specific recommendations for patients with UGIB. We hypothesised that there are variations in transfusion strategies for patients with UGIB across the Danish regions. METHODS: We performed a retrospective, register-based, analysis on transfusions given to all patients with non-variceal UGIB in Denmark in 2011-2013. We compared the results from the five regions in Denmark in order to discover regional differences. RESULTS: A total of 5,292 admissions with treatment for non-variceal UGIB were identified, and analysis was made for the total group and a massive transfusions group (330 admissions). In the Capital Region, transfusion of platelets was more likely than in any other region for all patients (p < 0.01) including the massive transfusion group (p = 0.03). In the North Region, transfusion of fresh frozen plasma was more likely for the massive transfusion group (p = 0.01). CONCLUSION: The observed differences warrant further prospective cohort studies in order to provide a foundation for transfusion recommendations for patients with UGIB. FUNDING: none. TRIAL REGISTRATION: not relevant.

Histone deactylase gene expression profiles are associated with outcomes in blunt trauma patients.

BACKGROUND: Treatment with histone deacetylase (HDAC) inhibitors, such as valproic acid, increases survival in animal models of trauma and sepsis. Valproic acid is a pan-inhibitor that blocks most of the known HDAC isoforms. Targeting individual HDAC isoforms may increase survival and reduce complications, but little is known of the natural history of HDAC gene expression following trauma. We hypothesized that distinct HDAC isoform gene expression patterns would be associated with differences in outcomes following trauma. METHODS: Twenty-eight-day longitudinal HDAC leukocyte gene expression profiles in 172 blunt trauma patients were extracted from the Inflammation and the Host Response to Injury (Glue Grant) data set. Outcome was classified as complicated (death or no recovery by Day 28, n = 51) or uncomplicated (n = 121). Mixed modeling was used to compare the HDAC expression trajectories between the groups, corrected for Injury Severity Score (ISS), base deficit, and volume of blood products transfused during the initial 12 hours following admission. Weighted gene correlation network analysis identified modules of genes with significant coexpression, and HDAC genes were mapped to these modules. Biologic function of these modules was investigated using the Gene Ontology database. RESULTS: Elevated longitudinal HDAC expression trajectories for HDAC1, HDAC3, HDAC6, and HDAC11 were associated with complicated outcomes. In contrast, suppressed expression of Sirtuin 3 (SIRT3) was associated with adverse outcome (p < 0.01). Weighted gene correlation network analysis identified significant coexpression of HDAC and SIRT genes with genes involved in ribosomal function and down-regulation of protein translation in response to stress (HDAC1), T-cell signaling, and T-cell selection (HDAC3) as well as coagulation and hemostasis (SIRT3). No coexpression of HDAC11 was identified. CONCLUSION: Expression trajectories of HDAC1, HDAC3, HDAC6, HDAC11, and SIRT3 correlate with outcomes following trauma and may potentially serve as biomarkers. They may also be promising targets for pharmacologic intervention. The effects of HDAC and SIRT gene expression in trauma may be mediated through pathways involved in ribosomal and T-cell function as well as coagulation and hemostasis. LEVEL OF EVIDENCE: Prognostic study, level III.

Effect of Transfusion Strategy in Acute Non-variceal Upper Gastrointestinal Bleeding: A Nationwide Study of 5861 Hospital Admissions in Denmark.

BACKGROUND: Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is a common cause of admissions as well as aggressive transfusion of blood products. Whether the transfusion strategy in NVUGIB impacts on hemostasis is unknown and constitutes the focus of this study. METHOD: Retrospective analysis of all hospital admissions in Denmark between 2011 and 2013 where hemostatic endoscopic interventions in either the stomach or duodenum had been employed. Regression modeling was used to predict the effect of units transfused of packed red blood cells (PRBC), fresh frozen plasma (FFP), and platelets (PLT) on primary outcome 30-day mortality as well as secondary hemostasis-related outcomes and need for re-endoscopy and conversion to surgery. The model was corrected for confounders, including transfusion of other blood products (PRBC, FFP, and PLT, respectively), patient age as well as pre-existing medical conditions. RESULTS: 5107 patients received 10783 therapeutic endoscopic interventions. Units of PRBC transfused were identified as a predictor of re-endoscopy, surgery, and 30-day mortality with odds ratio (OR) 1.08 (1.06-1.09, p < 0.01), 1.05 (1.03-1.07, p < 0.01), and 1.04 (1.01-1.06, p < 0.01), respectively. Units of FFP transfused were associated with a higher risk of surgery and 30-day mortality with OR 1.05 (1.02-1.08, p < 0.01) and 1.04 (1.02-1.07, p < 0.01), respectively. Units of PLTs transfused were independently associated with a reduction in risk of re-endoscopy 0.93 (0.87-0.98, p = 0.02). A high ratio of PRBC:FFP:PLT (1:1:1) was associated with reduced need for re-endoscopy OR 0.23 (0.06-0.67, p = 0.01) but increased mortality with OR 3.60 (1.34-11.38, p = 0.02). CONCLUSION: PRBC transfusion was associated with adverse events, including 30-day mortality and failure of hemostasis. In contrast, transfusion of PLT was associated with a reduction in need for re-endoscopy.

Outcome of negative-pressure wound therapy for open abdomen treatment after nontraumatic lower gastrointestinal surgery: analysis of factors affecting delayed fascial closure in 101 patients.

BACKGROUND: Few studies have focused on the risk factors for failure to achieve fascial closure after use of negative-pressure wound therapy (NPWT) in an open abdomen (OA). We aimed at analyzing possible risk factors for failure of fascial closure and the risk of fistulas after nontrauma lower gastrointestinal (GI) tract surgery treated with OA. METHODS: This retrospective study included 101 nontrauma patients treated with OA from 2007 to 2011. Multivariate analyses of risk factors were performed. RESULTS: Indications for OA were diffuse peritonitis (n = 47), need for second look (n = 26), failure to achieve fascial closure (e.g., bowel edema) at primary laparotomy (n = 24), and fascial necrosis (n = 4). Of the 101 patients, 61 (60 %) were alive at discharge, with one death possibly related to OA (fistula from an iatrogenic perforation). Delayed fascial closure was obtained in 40 (66 %) of the surviving patients, with 80 % when the indications for OA was need for second look and 72 % in cases of diffuse peritonitis. Compared with need for second look [hazard ratio (HR = 1), 95 % CI], proportional HR for failure of delayed fascial closure were peritonitis 1.96 (1.10-3.49) and failure to achieve fascial closure at primary laparotomy 4.70 (2.17-10.2). In the presence of a stoma the HR was 2.02 (1.13-3.63). CONCLUSIONS: OA using NPWT seems to be a safe procedure, with few procedure-related complications. Failure of fascial closure is related to the indication of OA and the presence of a stoma. Prospective multicenter studies are needed to establish which patients with lower GI surgery benefit from OA.

Promising results after vacuum-assisted wound closure and mesh-mediated fascial traction.

INTRODUCTION: Patients with an open abdomen (OA) present a major challenge to the surgeon. High mortality and associated complication rates have been reported depending on the specific method of temporary abdominal closure, the primary disorder and any co-morbidity. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) is a novel technique recently introduced for late fascial closure of the OA. In previous studies, the disease aetiologies were mainly vascular and visceral surgical disease and trauma. We report our results using VAWCM in a non-trauma patient population treated with an OA due to visceral surgical disease. MATERIAL AND METHODS: Medical records of all patients in our department treated with VAWCM during the period from 1 August 2009 to 31 May 2011 were reviewed. All sixteen patients were non-trauma patients. The initial treatment was vacuum-assisted closure (VAC) (Abdominal Dressing System KCI, San Antonio, Texas, USA). VAWCM treatment was initiated if complete fascial closure could not be obtained with VAC. RESULTS: Two patients died of multiple organ failure that was not associated with the VAWCM treatment. In one patient, treatment was terminated due to a very short life expectancy. We achieved a complete fascial closure rate in seven out of 16 patients. One patient had a pancreatic fistula at discharge that was not associated with the VAWCM treatment. No enteric fistulas occurred. CONCLUSION: It seems that VAWCM can improve the rate of complete fascial closure after treatment with OA without increasing the mortality or the occurrence of enteric fistula compared with other kinds of temporary abdominal closure. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Treatment of pilonidal sinuses in Denmark is not optimal.

INTRODUCTION: The standard treatments of chronic pilonidal sinuses (PS) were previously wide excision with primary midline closure or open treatment by non-specialist surgeons resulting in high rates of unhealed wounds and recurrences. An evidence-based shift from the now obsolete midline procedures towards off-line procedures seems to have occurred over the past 3-4 years. We decided to analyse the present state of PS treatment in Denmark. MATERIAL AND METHODS: A questionnaire was sent to all public hospitals and private clinics potentially treating PS. It included questions on the volume of procedures, experience of surgeons, and methods of anaesthesia and procedures in different cases. RESULTS: The questionnaire was answered by 37 departments (response rate 95%) in public hospitals and by 92 private clinics (response rate 84%). Off-midline closure was performed in 75% of the public departments, but some of these are also still performing midline surgery in some case. A total of 54% of the public departments are still performing midline surgery in some cases. Local analgesia is used in only 41% of the departments, and in 58% of these departments, local analgesia is used in fewer than 10% of the cases. In 11 (39%) departments, elective PS is performed by one or two surgeons, and there is a significant relation (p = 0.033) between low experience and large number of PS surgeons per department. Midline surgery seems to be performed in departments with more PS surgeons. CONCLUSION: Too many surgeons are still performing obsolete midline surgery. National guidelines are needed. The number of cases treated under local analgesia is unsatisfactorily low.

Better backs by better beds?

STUDY DESIGN: A "randomized"/stratified, single-blinded, parallel-group study. OBJECTIVE.: To evaluate 3 structurally different mattresses relative influence on patients with chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA: In several advertisements, it is proclaimed that certain mattresses have a positive effect on LBP, and especially a hard mattress is commonly believed to have a positive effect. METHODS: One hundred sixty CLBP patients were randomized to 1 of 3 groups, having a mattress/bed mounted in their sleeping room for 1 month. The beds were: (1) waterbed (Akva), (2) body-conforming foam mattress (Tempur), and (3) a hard mattress (Innovation Futon). At baseline and after 4 weeks, a blinded observer interviewed the patients on LBP levels (0-10), daily function (activities of daily living, 0-30), and on the amount of sleeping hours/night. RESULTS: Because of dropout of 19 patients before baseline, the analyses were performed on 141 patients. During the 1-month trial period another 27 patients stopped ahead of time, which were accounted for by "worse case" as well as "no-change" analyses. Both the waterbed and the foam mattress seemed superior to the hard mattress, especially when using the probably most relevant "worst case" data. There were no relevant difference between the effects of the water bed and the foam bed. CONCLUSION: The Waterbed and foam mattress' did influence back symptoms, function and sleep more positively as apposed to the hard mattress, but the differences were small.