Reducing Lung Injury from Blind Insertion of Small-Bore Feeding Tubes.

ABSTRACT: Using a blind insertion technique to insert small-bore feeding tubes can result in inadvertent placement in the lungs, leading to lung perforation and even mortality. In a Magnet-designated, 500-bed, level 2 trauma center, two serious patient safety events occurred in a four-week period due to nurses blindly inserting a small-bore feeding tube. A patient safety event review team convened and conducted an assessment of reported small-bore feeding tube insertion events that occurred between March 2019 and July 2021. The review revealed six lung perforations over this two-year period. These events prompted the creation of a multidisciplinary team to evaluate alternative small-bore feeding tube insertion practices. The team reviewed the literature and evaluated several evidence-based small-bore feeding tube placement methods, including placement with fluoroscopy, a two-step X-ray, electromagnetic visualization, and capnography. After the evaluation, capnography was selected as the most effective method to mitigate the complications of blind insertion. In this article, the authors describe a quality improvement project involving the implementation of capnography-guided small-bore feeding tube placement to reduce complications and the incidence of lung perforation. Since the completion of the project, which took place from December 13, 2021, through April 18, 2022, no lung injuries or perforations have been reported. Capnography is a relatively simple, noninvasive, and cost-effective technology that provides nurses with a means to safely and effectively insert small-bore feeding tubes, decrease the incidence of adverse events, and improve patient care.

Thoracic irrigation for prevention of secondary intervention after thoracostomy tube drainage for hemothorax: A Western Trauma Association multi-center study.

BACKGROUND: Retained hemothorax (rHTX) requiring intervention occurs in up to 20% of patients who undergo chest tube (TT) placement for a hemothorax (HTX). Thoracic irrigation at the time of TT placement decreases the need for secondary intervention in this patient group but those findings are limited because of the single center design. A multi-center study was conducted to evaluate the effectiveness of thoracic irrigation. METHODS: A multi-center, prospective, observational study was conducted between June 2018 and July 2023. Eleven sites contributed patients. Patients were included if they had a TT placed for a HTX and were excluded if: age < 18 years, TT for pneumothorax, thoracotomy or VATS performed within 6 hours of TT, TT >24 hours after injury, TT removed <24 hours, or death within 48 hours. Thoracic irrigation was performed at the discretion of the attending. Each hemithorax was considered separately if bilateral HTX. The primary outcome was secondary intervention for HTX-related complications (rHTX, effusion, or empyema). Secondary intervention was defined as: TT placement, instillation of thrombolytics, VATS, or thoracotomy. Irrigated and non-irrigated hemithoraces were compared using a propensity weighted analysis with age, sex, mechanism of injury, Abbreviated Injury Scale (AIS) chest and TT size as predictors. RESULTS: 493 patients with 462 treated hemothoraces were included, 123 (25%) had thoracic irrigation at TT placement. There were no significant demographic differences between the cohorts. Fifty-seven secondary interventions were performed, 10 (8%) and 47 (13%) in the irrigated and non-irrigated groups, respectively (p = 0.015). Propensity weighted analysis demonstrated a reduction in secondary interventions in the irrigated cohort (Odds Ratio 0.56 (0.34-0.85); p = 0.005). CONCLUSION: This Western Trauma Association multi-center study demonstrates a benefit of thoracic irrigation at the time of TT placement for a HTX. Thoracic irrigation reduces the odds of a secondary intervention for rHTX-related complications by 44%. LEVEL OF EVIDENCE: Therapeutic Study, Level II.

Appropriate Imaging for Geriatric Trauma.

BACKGROUND: Trauma is the leading cause of preventable death in the United States. Early detection of life-threatening injuries leads to improved survival. Computed tomography (CT) scanning has become the modality of choice for early detection of injuries in the stable patient. Some studies have associated selective imaging (Selective-CT) with equivalent outcomes compared to whole body imaging (Pan-CT) with lower costs and radiation exposure. Within the geriatric population, however, the utility of Pan-CT remains controversial. Therefore, the aim of this study was to determine if a difference exists between Selective-CT and Pan-CT imaging in the geriatric trauma patient. METHODS: A retrospective analysis of Level 3 (G60) trauma activations presenting to our urban Level I trauma center between June 2016 and June 2019 was performed. Pan-CT was defined by ICD-10 codes indicating a head, cervical spine, chest, abdomen, and pelvis CT series. Patients with missing images and those who were transferred from other institutions were excluded. Logistic regression controlling for age, gender, injury type, severity, and Glasgow Coma Score was performed. RESULTS: A total of 1014 patients met inclusion criteria. Of these, 30.9% underwent Pan-CT (n = 314), 48.9% had Selective-CT (n = 497), and 20.2% received no CT imaging (n = 203). After logistic regression, no clinically significant variations in emergency department length of stay (LOS), hospital LOS, ICU LOS, ventilator days, discharge disposition, missed injury rate, or mortality rate were observed between imaging strategies. CONCLUSIONS: Pan-CT provides no clinically significant advantage over Selective-CT in the geriatric trauma patient.

Robotic Diagnosis and Management of Acute Cholecystocolonic Fistula.

Cholecystocolonic fistula (CCF) is a rare complication of biliary tract disease. Increased use of imaging has aided in diagnosing these fistulae preoperatively and has established laparoscopy as a safe alternative to laparotomy. Here, we present a 79-year-old male who presented to the emergency room with abdominal pain and was diagnosed with choledocholithiasis. CT scan revealed a CCF, and he underwent endoscopic retrograde cholangiopancreatography (ERCP). He was followed closely to allow maturation of the fistula, and then, da Vinci® Xi robotic cholecystectomy and ligation were performed. Although current comparisons to laparoscopy have yet to demonstrate a clinical advantage, robotic assistance enhances dexterity, visualization, and ergonomics. Our case is one of the first documented successful operative management of CCF using the da Vinci® Xi robot.

The Relationship Between Dietary Intake and Dietary-Focused Lifestyle Interventions on Risk Factors Associated with Cardiovascular Disease in Firefighters.

PURPOSE OF REVIEW: Cardiovascular disease (CVD) is the leading cause of death to on-duty firefighters and is a substantial health concern. Preventative measures, including dietary interventions, may improve CVD in firefighters. The purpose of this review is to examine the literature on the relationship between dietary intake, dietary lifestyle interventions, and risk of CVD in firefighters. RECENT FINDINGS: Existing evidence, albeit limited, suggests that firefighters do not meet dietary guidelines. Lifestyle modifications featuring dietary interventions are effective in improving risk factors associated with CVD in firefighters. Unfortunately, no consistent nutrition-related trend was identified across the retrieved studies and only a limited number of randomized controlled trials have examined the efficacy of lifestyle intervention studies on CVD in firefighters. Although this review suggests dietary lifestyle interventions may facilitate decreases in risk factors associated with CVD in firefighters, current evidence is limited, and additional research is needed.

Predictors of retained hemothorax in trauma: Results of an Eastern Association for the Surgery of Trauma multi-institutional trial.

BACKGROUND: The natural history of traumatic hemothorax (HTX) remains unclear. We aimed to describe outcomes of HTX following tube thoracostomy drainage and to delineate factors that predict progression to a retained hemothorax (RH). We hypothesized that initial large-volume HTX predicts the development of an RH. METHODS: We conducted a prospective, observational, multi-institutional study of adult trauma patients diagnosed with an HTX identified on computed tomography (CT) scan with volumes calculated at time of diagnosis. All patients were managed with tube thoracostomy drainage within 24 hours of presentation. Retained hemothorax was defined as blood-density fluid identified on follow-up CT scan or need for additional intervention after initial tube thoracostomy placement for HTX. RESULTS: A total of 369 patients who presented with an HTX initially managed with tube thoracostomy drainage were enrolled from 17 trauma centers. Retained hemothorax was identified in 106 patients (28.7%). Patients with RH had a larger median (interquartile range) HTX volume on initial CT compared with no RH (191 [48-431] mL vs. 88 [35-245] mL, p = 0.013) and were more likely to be older with a higher burden of thoracic injury. After controlling for significant differences between groups, RH was independently associated with a larger HTX on presentation, with a 15% increase in risk of RH for each additional 100 mL of HTX on initial CT imaging (odds ratio, 1.15; 95% confidence interval, 1.08-1.21; p < 0.001). Patients with an RH also had higher rates of pneumonia and longer hospital length of stay than those with successful initial management. Retained hemothorax was also associated with worse functional outcomes at discharge and first outpatient follow-up. CONCLUSION: Larger initial HTX volumes are independently associated with RH, and unsuccessful initial management with tube thoracostomy is associated with worse patient outcomes. Future studies should use this experience to assess a range of options for reducing the risk of unsuccessful initial management. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

A Low Glycemic Index and Glycemic Load Diet Decreases Insulin-like Growth Factor-1 among Adults with Moderate and Severe Acne: A Short-Duration, 2-Week Randomized Controlled Trial.

BACKGROUND: A high glycemic index (GI) and glycemic load (GL) diet may stimulate acne proliferative pathways by influencing biochemical factors associated with acne. However, few randomized controlled trials have examined this relationship, and this process is not completely understood. OBJECTIVE: This study examined changes in biochemical factors associated with acne among adults with moderate to severe acne after following a low GI and GL diet or usual eating plan for 2 weeks. DESIGN: This study utilized a parallel randomized controlled design to compare the effect of a low GI and GL diet to usual diet on biochemical factors associated with acne (glucose, insulin, insulin-like growth factor [IGF]-1, and insulin-like growth factor binding protein [IGFBP]-3) and insulin resistance after 2 weeks. PARTICIPANTS: Sixty-six participants were randomly allocated to the low GI and GL diet (n=34) or usual eating plan (n=32) and included in the analyses. MAIN OUTCOME MEASURES: The primary outcomes were biochemical factors of acne and insulin resistance with dietary intake as a secondary outcome. STATISTICAL ANALYSES: Independent sample t tests assessed changes in biochemical factors associated with acne, dietary intake, and body composition pre- and postintervention, comparing the two dietary interventions. RESULTS: IGF-1 concentrations decreased significantly among participants randomized to a low GI and GL diet between pre- and postintervention time points (preintervention=267.3±85.6 mg/mL, postintervention=244.5±78.7 ng/mL) (P=0.049). There were no differences in changes in glucose, insulin, or IGFBP-3 concentrations or insulin resistance between treatment groups after 2 weeks. Carbohydrate (P=0.019), available carbohydrate (P<0.001), percent energy from carbohydrate (P<0.001), GI (P<0.001), and GL (P<0.001) decreased significantly among participants following a low GI/GL diet between the pre- and postintervention time points. There were no differences in changes in body composition comparing groups. CONCLUSIONS: In this study, a low GI and GL diet decreased IGF-1 concentrations, a well-established factor in acne pathogenesis. Further research of a longer duration should examine whether a low GI and GL diet would result in a clinically meaningful difference in IGF-1 concentrations leading to a reduction in acne. This trial was registered at clinicaltrials.gov as NCT02913001.

Differences in Dietary Glycemic Load and Hormones in New York City Adults with No and Moderate/Severe Acne.

BACKGROUND: Glycemic index (GI) and glycemic load (GL) may be implicated in acne pathogenesis. OBJECTIVE: This cross-sectional study examined differences between GI/GL and biological factors associated with acne among adults with and without moderate/severe acne. Secondary objectives included examining differences between food-aggravated acne beliefs and acne-specific quality of life among adults with and without moderate/severe acne. DESIGN: As part of a cross-sectional study, participants completed a 5-day food record; blood draw to measure biological factors associated with acne (ie, glucose, insulin, insulin-like growth factor-1, insulin-like growth factor binding protein-3, and sex hormone-binding globulin concentrations); body composition assessment; and questionnaire to evaluate food-aggravated acne beliefs and acne-specific quality of life. Food records were analyzed using Nutrition Data Services for Research. PARTICIPANTS: Sixty-four participants (no acne, n=32; moderate/severe acne, n=32) from New York City, NY, were included in this study. STATISTICAL ANALYSIS: Independent sample t tests and Mann-Whitney tests examined differences in anthropometric measurements, dietary intakes, biological factors associated with acne, insulin resistance, and acne-specific quality of life between acne groups. A χ2 test for independence assessed differences in food-aggravated acne beliefs between acne groups. RESULTS: Participants with moderate/severe acne consumed greater total carbohydrate (P=0.003), available carbohydrate (P<0.001), percent energy from carbohydrate (P<0.001), and GL (P<0.001) compared to participants without acne. Participants with moderate/severe acne had greater insulin (P=0.002) and insulin-like growth factor-1 (P=0.009) concentrations, greater insulin resistance (P=0.001), and lower sex hormone-binding globulin (P=0.015) concentrations compared to participants without acne. Although there were no differences between groups, 61% of participants reported food-influenced acne. Participants with moderate/severe acne reported a lower quality of life compared to participants without acne (P<0.001). CONCLUSIONS: The results from this cross-sectional study suggest a relationship between dietary carbohydrate, including GL, and acne. Future research is necessary to determine the effect of medical nutrition therapy on biological factors associated with acne and acne severity.

Reduction of erosion risk in adult patients with implanted venous access ports.

One of the most common venous access devices used in patients with cancer is the implanted venous access port. Although incidences of infection and thrombosis are the most commonly reported complications, erosion rates of venous access ports are estimated at almost 1%. This article describes how evidence-based interdisciplinary interventions decreased port erosions for a regional health center from 3.2% to less than 1%.

Relationships of self-reported dietary factors and perceived acne severity in a cohort of New York young adults.

BACKGROUND: Recent observational and experimental evidence suggests that diet may contribute to acne prevalence. OBJECTIVES: To examine the differences in select dietary factors (glycemic index [GI], total sugar, added sugar, fruit/fruit juice, fruit/vegetables, vegetables, saturated fat, trans fat, and number of milk and fish servings per day) between groups of self-reported acne severity. Secondary objectives were to investigate the differences in food-aggravated acne beliefs and acne-specific quality-of-life between groups of self-reported acne severity. DESIGN: This study utilized a cross-sectional design. PARTICIPANTS/SETTING: A total of 248 (115 male, 133 female) participants, age 18 to 25 years, completed questionnaires designed to measure self-reported acne severity, select dietary factors, food-aggravated acne beliefs, acne-specific quality-of-life, and anthropometric and demographic characteristics. The Block fat/sugar/fruit/vegetable food frequency questionnaire assessed usual dietary intake. Data were collected in New York City between January and May 2012. STATISTICAL ANALYSES PERFORMED: One-way between groups analysis of variance examined differences in dietary factors, anthropometric characteristics, and acne-specific quality-of-life between groups of self-reported acne. χ² tests compared food-aggravated acne beliefs and demographic characteristics between groups of self-reported acne. RESULTS: Compared with participants with no or mild acne, participants with moderate to severe acne reported greater dietary GI (P<0.001), added sugar (P<0.001), total sugar (P<0.001), number of milk servings per day (P<0.001), saturated fat (P<0.001), and trans-fatty acids (P<0.001), and fewer servings of fish per day (P=0.002). Among all participants, 58.1% perceived diet to aggravate or influence acne. CONCLUSIONS: This study suggests that diet, particularly dietary GI, saturated fat, trans fat, milk, and fish may influence or aggravate acne development. Future research is necessary to elucidate the proposed mechanisms linking diet and acne and determine the impact of medical nutrition therapy on acne development.

Acne: the role of medical nutrition therapy.

Acne is a common disease in Westernized nations, particularly among adolescents and young adults. Acne has substantial effects on quality of life, making treatment essential. Medical nutrition therapy as a potential treatment for acne is not new, although the literature examining diet and acne during the past 100 years is mixed. During the late 1800s and early 1900s, diet was commonly used as an adjunct treatment for acne. During the 1960s, however, the diet-acne connection fell out of favor. In recent years, dermatologists and registered dietitians have revisited the idea and become increasingly interested in the role of medical nutrition therapy in acne treatment. This article reviews the history and existing literature examining the association between diet and acne. Although the total number of studies conducted within the past 40 years is relatively small, the growing body of epidemiologic and experimental evidence suggests a relationship between diet and acne. Compared with other dietary factors, more research examines dietary glycemic load. The evidence is more convincing for high glycemic load diets, compared with other dietary factors. To date there are no randomized controlled trials investigating the relationship between frequent dairy or milk consumption and acne. Similarly, the number of research studies examining the relationship between dietary fat and/or n-3 fatty acids is sparse and the evidence is less robust. Taken together, several methodologic limitations need to be addressed, and additional research, preferably randomized controlled trials, is warranted before comprehensive evidence-based guidelines can be established. While dermatologists and registered dietitians continue to debate and research the potential relationship between diet and acne, the best dietary approach is to address each acne patient individually, carefully considering the possibility of dietary counseling.

Perioperative atrial arrhythmias in noncardiothoracic patients: a review of risk factors and treatment strategies in the veteran population.

BACKGROUND: Perioperative atrial arrhythmias (PAAs) in noncardiothoracic patients have poorly defined risk factors and management. METHODS: The surgical intensive care unit database was queried for patients who developed PAAs from 2008 to 2009. Demographics, comorbidities, preoperative data (electrocardiography, chest x-rays, laboratory results), medications, intraoperative variables, management, and outcomes of atrial arrhythmias were collected. Controls were randomly chosen in a 3:1 ratio. Comparisons were performed using χ² tests, Student's t tests, or nonparametric comparisons as appropriate. Multivariate logistic regression was performed. RESULTS: Five hundred sixty-one patients were admitted to the surgical intensive care unit. Three hundred fifty-four (63%) had noncardiothoracic surgery, and 30 (8.5%) developed PAAs. The mean age of patients with PAAs was 66 ± 7.3 years, compared with 64 ± 11 years for controls (P = NS), with most patients undergoing general (60%) and vascular (33%) surgery. PAA patients were more likely to have coronary artery disease (P = .029), cardiomegaly (P = .011), and premature atrial contractions (P = .016) and to take aspirin (P = .010). On multivariate logistic regression, predictors of atrial arrhythmias were premature atrial contractions, preoperative hypokalemia, intraoperative adverse events, and cardiomegaly. Most PAA patients received amiodarone (63%). Ten percent required electrical cardioversion, and 26% received anticoagulation. PAA patients had significantly longer intensive care unit lengths of stay (P = .032). CONCLUSION: Coronary artery disease, cardiomegaly, hypokalemia, and premature atrial contractions were significantly associated with PAAs in noncardiothoracic patients. Prospective studies are needed to define treatment guidelines.

Emergent embolization of the gastroduodenal artery in the treatment of upper gastrointestinal bleeding. The experience from a surgeon-initiated interventional program.

BACKGROUND: Intractable nonvariceal upper gastrointestinal bleeding (UGIB) is associated with significant morbidity and mortality. Endovascular therapy is an alternative to surgery for high-risk patients. MATERIALS AND METHODS: Review of prospectively collected data from patients who underwent emergent gastroduodenal artery embolization for UGIB. RESULTS: Eight patients (mean age 68.5 years) were identified. They all had significant comorbidities and were deemed to be at high risk for surgical intervention. Endoscopy was performed in 7 patients. Active extravasation was present at the time of embolization in 5 (62.5%) patients. The technical success and clinical response rates were each 100%. The 30-day mortality rate was 12.5%. [corrected] There were no procedure-related complications. During mean follow-up of 9 months, 1 patient developed recurrent bleeding that was managed conservatively. COMMENTS: Endovascular embolization is a safe alternative to open surgical intervention after failed endoscopic treatment for UGIB. Surgeons with endovascular skills can perform this procedure with superior results.