A review of perioperative immune-modulating and metabolic-modulating nutrition strategies for bowel resection surgery.

Focused perioperative nutrition strategies have proven benefits on the outcomes for patients undergoing major abdominal surgery. In this brief article, we will review these strategies and the evidence to support them with a focus on gastrointestinal anastomotic healing. We will elaborate the risks and benefits of enteral feeds, immune- and metabolic-modulating formulas, prebiotics and probiotics, and prehabilitation in preparation for surgery. Additionally, we will discuss the role of fish oils (eicosapentaenoic acid and docosahexaenoic acid) in the surgical patient and new data on specialized proresolving mediators in inflammation resolution. Finally, this article will consider the harmful impact surgical trauma has on the microbiome and the potential for perioperative dietary modulation to attenuate these negative effects.

Colorectal Neoplasia in the Setting of Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer (colorectal adenocarcinoma [CRC]) compared with the general population. IBD-related CRC is related to poorer outcomes than non-IBD-related CRC, and it accounts for 10% to 15% of death in patients with IBD. As such, screening guidelines have been made specific to this population recommending shorter intervals of endoscopic screening to detect dysplasia and CRC relative to the general population. Advances in endoscopic technology allow for improved visualization of dysplasia, which has led to widespread adoption of dye-spray chromoendoscopy with targeted biopsy.

Adoption of rescue colloid during burn resuscitation decreases fluid administered and restores end-organ perfusion.

INTRODUCTION: Traditionally, lactated Ringer's solution (LR) has been utilized for the resuscitation of thermally injured patients via the Parkland or Brooke formulas. Both of these formulas include colloid supplementation after 24 h of resuscitation. Recently, the addition of albumin within the initial resuscitation has been reported to decrease fluid creep and hourly fluids given. Our institution has previously advocated for a crystalloid-driven resuscitation. Given reports of improved outcomes with albumin, we pragmatically adjusted these practices and present our findings for doing so. METHODS: Our burn registry, consisting of prospectively collected patient data, was queried for those at least 18 years of age who, between July 2017 and December 2018, sustained a thermal injury and completed a formal resuscitation (24 h). At the attending physician's discretion, rescue colloid was administered using 25% albumin for those failing to respond to traditional resuscitation (patients with sustained urine output of <0.5 mL/kg over 2-3 h, or unstable vital signs and ongoing fluid administration). We compared the total volume of the crystalloid-only and rescue colloid resuscitation fluids given to patients. We also examined the in/out fluid balances during resuscitation. Statistical analysis was performed using Stata software. RESULTS: A total of 91 patients with thermal injuries were included: the median age was 40 (IQR 31-57), 73% were male, and 30 patients received rescue albumin. The percentage of total body surface area burned (%TBSA) was greater in those who received rescue albumin (40.3% vs. 34%; p = 0.047). Despite a higher %TBSA in the albumin group, the total LR given during resuscitation was not significantly different between groups (15,914.43 mL vs. 11,828.71 mL; p = 0.129) even when normalized for TBSA and weight (ml LR/kg/%TBSA: 4.31 vs. 3.66; p = 0.129. The average in/out fluid ratio for the rescue group was higher than for the crystalloid group (0.83 ± 0.05 vs. 0.59 ± 0.11; p = 0.06) and returned to normal after colloid administration. CONCLUSION: Rescue albumin administration decreases the amount of fluid administered per %TBSA during resuscitation, and also increases end organ function as evidenced by increased urinary output. These effects occurred in patients who sustained larger burns and failed to respond to traditional crystalloid resuscitation. Our findings led us to modify our current protocol and a related prospective study of clinical outcomes.

Neurologic injuries following road traffic accidents in the Dominican Republic: Examining causes and potential solutions.

Objective: Road traffic accidents (RTAs) are the number one cause of traumatic brain injuries (TBIs) worldwide. This study examines RTA-related TBIs in the Dominican Republic, a country in the Caribbean with the highest RTA fatality rate in the Western Hemisphere. Methods: We interviewed 117 adult patients or medical guardians of patients admitted to Hospital Traumatológico Dr. Ney Arias Lora in Santo Domingo following an RTA. Information regarding the type of accident, patient demographics, and injuries sustained was collected for each patient. Results: Most study participants were males (79.5%), and the most common method of transportation was motorized 2-wheeled vehicle (MTW; 74.4%). Of the 69 patients who suffered a TBI, 66.7% were classified as moderate-severe TBIs and 30.3% were classified as mild TBIs. The most common types of intracranial hemorrhage were subdural hemorrhage (12%) and subarachnoid hemorrhage (9.4%). Helmet use among admitted MTW riders was reported at 22.4%, and none of the 9 MTW riders who died in the hospital were wearing a helmet. Only 58.1% of patients lived in an area that offered 911 emergency response services at the time of the study. At 66.2%, the majority of people living within the 911 service area utilized emergency response services following an RTA. Multiple logistic regression determined that the utilization of 911 emergency response services was associated with a decrease in the likelihood of presenting with a moderate/severe TBI by a factor of 0.78 (adjusted odds ratio [OR]; P < .008; 95% confidence interval [CI], 0.65, 0.93). Nonuse of a helmet was associated with a 1.22 times increased risk of presenting with a moderate/severe TBI (adjusted OR; P < .04; 95% CI, 1.01, 1.61). Age and gender were not statistically significant in this model. Conclusions: The results of this study support 2 important avenues for reducing the burden of RTA-associated neurologic disease in the Dominican Republic. As with many other middle-income countries, MTWs represent an economical and efficient mode of transportation. Therefore, increasing helmet use may be the most effective way to reduce RTA-associated TBIs. In addition, continuing the expansion of postcrash emergency response services may mitigate the severity of RTA-associated neurologic disease.

Evaluating midwife-led antenatal care: choice, experience, effectiveness, and preparation for pregnancy.

OBJECTIVE: to evaluate midwife-led care (MLC) antenatal care compared with antenatal care provided in traditional obstetric-led hospital antenatal clinics (usual care). DESIGN: a mixed methods approach involving a chart audit, postal survey, focus group and in-depth interviews. SETTING: data were collected at a large maternity hospital and satellite clinics in Dublin from women attending for antenatal care between June 2011 and May 2012. PARTICIPANTS: 300 women with low-risk pregnancy who attended midwife-led antenatal care or usual clinics during the study period were randomly selected to participate. MEASUREMENTS: data were collected from 292 women׳s charts and from 186 survey participants (63% response rate). Nine women participated in in-depth interviews and a focus group. FINDINGS: MLC was as effective as usual care in relation to number of antenatal visits and ultrasound scans, referral to other clinicians, women׳s health in pregnancy, gestation at childbirth, and birth weight. Women attending MLC booked significantly earlier, fewer women attending MLC were admitted to hospital antenatally and more women breast fed their infant. Women attending MLC reported better choice and that shorter waiting times and having more time for discussion were important reasons for choosing MLC. Women attending MLC reported a better experience overall, and recorded better outcomes in relation to how they were treated, along with easier access to antenatal care and shorter waiting times to see a midwife. Although women attending MLC clinics reported higher satisfaction with the information that they received, they also identified that antenatal education could be improved in relation to labour, breast-feeding, depression and emotional well-being, and caring for the infant. KEY CONCLUSIONS: midwife-led antenatal care was as effective as usual care for women with low-risk pregnancy and better in relation to choice, breast feeding and women׳s experience of care.

Evaluating midwifery-led antenatal care: using a programme logic model to identify relevant outcomes.

BACKGROUND: a range of initiatives has been introduced in Ireland and internationally in recent years to establish midwifery-led models of care, generally aimed at increasing the choices available for women for maternity care. A midwifery-led antenatal clinic was first established at the study site (a large urban maternity hospital in Dublin) and extended over recent years. This paper reports on the design of an evaluation of these midwives clinics, in particular the use of a programme logic model to select outcomes to be included in the evaluation. AIMS AND OBJECTIVES: the programme logic model is used to identify the theory of a programme and is an integrative framework for the design and analysis of evaluations using qualitative and quantitative methods. Through an inclusive approach, the aim was to identify the most relevant outcomes to be included in the evaluation, by identifying and linking programme (midwifery-led antenatal clinic) outcomes to the goals, inputs and processes involved in the production of these outcomes. METHODS: the process involved a literature review, a review of policy documents and previous reviews of the clinics, interviews with midwives, obstetricians and managers to identify possible outcomes, a focus group with midwives, obstetricians, managers and women who had attended the clinics to refine and prioritise outcomes, and a follow-up survey to refine and prioritise the outcomes identified and to identify sources of data on each outcome. FINDINGS: seven categories of outcomes were identified: (1) choice, (2) relationship/interaction with caregiver, (3) experience of care, (4) preparation and education for childbirth and parenthood, (5) effectiveness of care, (6) organisational outcomes, and (7) programme viability. A range of sources of information was identified for each outcome, including existing documentation and data, chart audit, survey of women, and interviews and focus groups with midwives, obstetricians, managers and women. CONCLUSIONS: the programme logic model provided an inclusive, systematic and transparent approach to identifying relevant outcomes to be included in the evaluation. The information obtained has been used since to design the evaluation project, which is currently being concluded.

Outcomes of digital zone IV and V and thumb zone TI to TIV extensor tendon repairs using a running interlocking horizontal mattress technique.

PURPOSE: Biomechanical evidence has demonstrated that the running interlocking horizontal mattress (RIHM) repair for extensor tendon lacerations is significantly stronger, with higher ultimate load to failure and less tendon shortening compared with other techniques. We investigated the efficacy and safety of primary extensor tendon repair using the RIHM repair technique in the fingers followed by the immediate controlled active motion protocol, and in the thumb followed by a dynamic extension protocol. METHODS: We conducted a retrospective review of all patients undergoing extensor tendon repair from August 2009 to April 2012 by single surgeon in an academic hand surgery practice. The inclusion criteria were simple extensor tendon lacerations in digital zones IV and V and thumb zones TI to TIV and primary repair performed using the RIHM technique. We included 8 consecutive patients with 9 tendon lacerations (3 in the thumb). One patient underwent a concomitant dorsal hand rotation flap for soft tissue coverage. We used a 3-0 nonabsorbable braided suture to perform a running simple suture in 1 direction to obtain a tension-free tenorrhaphy, followed by an RIHM corset-type suture using the same continuous strand in the opposite direction. Average time to surgery was 10 days (range, 3-33 d). Mean follow-up was 15 weeks (range, 10-26 wk). We applied the immediate controlled active motion protocol to all injuries except those in the thumb, where we used a dynamic extension protocol instead. RESULTS: Using the criteria of Miller, all 9 tendon repairs achieved excellent or good results. There were no tendon ruptures or extensor lags. No patients required secondary surgery for tenolysis or joint release. No wound complications occurred. CONCLUSIONS: The RIHM technique for primary extensor tendon repairs in zone IV and V and T1 to TIV is safe, allows for immediate controlled active motion in the fingers and an immediate dynamic extension protocol in the thumb, and achieves good to excellent functional outcomes. These clinical outcomes support prior biomechanical data. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.