Nutrition Support During Prone Positioning: An Old Technique Reawakened by COVID-19.

Acute respiratory distress syndrome (ARDS) is a complex disease characterized by inflammation, resulting in diffuse alveolar damage, proliferation, and fibrosis, and carries a high mortality rate. Recently, the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has overwhelmed healthcare systems worldwide, as many patients have required hospitalization for the management of respiratory failure similar in nature to ARDS. In addition to lung-protective ventilation strategies aimed to maintain an oxygen saturation >90%, a ratio of partial pressure of oxygen to fraction of inspired oxygen >200, a pH of 7.25-7.40, and a plateau pressure <35 cm H2 O, prone positioning has emerged as an effective treatment strategy for severe ARDS by improving oxygenation and secretion clearance. Although early nutrition assessment and intervention are recommended for acutely and critically ill patients, rotational therapy may present challenges in providing this care. Here, we will describe the pathophysiology of ARDS and the rationale for use of prone positioning and review the considerations and challenges of providing nutrition therapy for patients in the prone position.

Hospital Volume Threshold for the Treatment of Retroperitoneal Sarcoma.

BACKGROUND: Retroperitoneal sarcomas (RPS) are rare, histologically heterogeneous, and anatomically complex tumors. National Comprehensive Cancer Network guidelines recommend evaluation and management by multidisciplinary teams with experience in sarcoma. Our aim was to determine an appropriate hospital volume threshold for the treatment of RPS. PATIENTS AND METHODS: Patients undergoing resection of RPS were identified from the National Cancer Data Base (1998-2012). Multivariable modeling with restricted cubic splines was employed to examine the association between hospital volume and survival and identify possible hospital volume threshold. RESULTS: The study included 5,340 patients who underwent surgery at 909 different hospitals. Median annual volume was two cases per year. After adjustment, hospital volume was associated with improved survival (p=0.01), without cutoff. The cohort was then grouped into: Low-volume (≤5 cases/year), intermediate-volume (6-10 cases/year), and high-volume (>10 cases/year). The majority of patients were treated in low-volume hospitals (86%), compared to 9% in intermediate- and 5% in high-volume centers; 44% of patients were treated in hospitals that performed one case per year. Compared to low-volume, high-volume hospitals more often had patients with high-grade and larger tumors. Adjusted 90-day mortality was significantly lower in high- vs. low-volume hospitals (odds ratio(OR)=0.25, p=0.02). With adjustment, treatment in high- vs. low-volume hospitals was associated with lower odds of margin positivity (OR=0.58, p=0.001), and improved overall survival (hazard ratio(HR)=0.61, p=0.002). CONCLUSION: Treatment of RPS in high-volume centers is associated with significant reduction in short-term mortality and improved long-term survival. Hospital volume may be a surrogate for the infrastructure and support necessary for the optimal management of these complex malignancies.