Validation of the perioperative nutrition screen for prediction of postoperative outcomes.

BACKGROUND: Preoperative nutrition risk is often underrecognized and undertreated. The perioperative nutrition screen (PONS) was recently introduced as an efficient tool to rapidly screen for preoperative nutrition risk. The relationship between identification of "nutrition risk" via PONS and adverse postoperative outcomes remains undescribed. METHODS: Preoperative nutrition risk was assessed via PONS from 01/01/2019 to 09/30/2020. Key clinical outcomes were compared with individual and composite PONS components. RESULTS: A total of 3151 patients with PONS evaluations were analyzed. Multivariate regression adjusted for key covariates demonstrated positive responses for specific PONS questions was associated with adverse clinical outcomes as follows. (1) Unplanned weight loss (>10% in 6-months preoperatively) associated with a 22.4% increased length of stay (LOS) (P < 0.0001) and increased 30-day readmission rate (odds ratio [OR], 2.44, 95% CI, 1.73-3.44, P < 0.001). (2) History of <50% of previous oral intake in past week associated with a 25% increased LOS (P < 0.001). (3) Preoperative serum albumin level <3.0 g/L associated with a 29.9% increased LOS (P < 0.001) and increased 30-day readmission rate (OR, 2.66, 95% CI, 1.63-4.35, P < 0.001). (4) Low body mass index was not associated with increased LOS by adjusted analysis although was predictive by univariate analysis. CONCLUSIONS: The PONS and its individual components appear to predict risk of adverse postoperative outcomes, even independent of a validated malnutrition diagnosis. Further studies are needed to assess the impact of specific preoperative nutrition interventions on adverse outcomes predicted by PONS when delivered to patients identified via PONS screen.

Tutorial: Development and Implementation of a Multidisciplinary Preoperative Nutrition Optimization Clinic.

Although much is known about surgical risk, little evidence exists regarding how best to proactively address preoperative risk factors to improve surgical outcomes. Preoperative malnutrition is a widely prevalent and modifiable risk factor in patients undergoing surgery. Malnutrition prior to surgery portends significantly higher postoperative mortality, morbidity, length of stay, readmission rates, and hospital costs. Unfortunately, perioperative malnutrition is poorly screened for and remains largely unrecognized and undertreated-a true "silent epidemic" in surgical care. To better address this silent epidemic of surgical nutrition risk, here we describe the rationalization, development, and implementation of a multidisciplinary, registered dietitian-driven, preoperative nutrition optimization clinic program designed to improve perioperative outcomes and reduce cost. Implementation of this novel Perioperative Enhancement Team (POET) Nutrition Clinic required a collaboration among many disciplines, as well as an identified need for multidimensional scheduling template development, data tracking systems, dashboard development, and integration of electronic health records. A structured malnutrition risk score (Perioperative Nutrition Screen score) was developed and is being validated. A structured malnutrition pathway was developed and is under study. Finally, the POET Nutrition Clinic has established a novel role for a perioperative registered dietitian as the integral point person to deliver perioperative nutrition care. We hope this structured model of perioperative nutrition assessment and optimization will allow for wide implementation and generalizability in other centers worldwide to improve recognition and treatment of perioperative nutrition risk.

Force during functional exercises on land and in water in older adults with and without knee osteoarthritis: Implications for rehabilitation.

BACKGROUND: Closed kinetic chain and plyometric exercises are commonly used in aquatic rehabilitation because they are believed to reduce joint loading whilst replicating functional tasks. However, the forces and relationship to land-based functional movement is unknown. This study aims to compare vertical ground reaction force during squats, calf raises and jumping in older adults with and without knee osteoarthritis on land and in water. METHODS: Forty one participants (Healthy n = 21; Knee osteoarthritis n = 20; Age 68.5 (4.4) years) completed squats and calf raises at slow, medium and maximal speeds and jumping at maximal speed on land and in waist and chest depth water. Vertical ground reaction force and pain rating was measured in each environment. RESULTS: Force in all exercises was significantly greater on land than in chest depth water (p < 0.005). Peak force was significantly greater at maximal speed compared to slow speed (p < 0.001). The pattern of force in squats at slow speed in water was different to on land, with force highest at the start and end of the exercise and decreasing in the central phase. Pain ratings were significantly lower (p < 0.001) in water compared to on land in squats. CONCLUSIONS: Closed kinetic chain exercises offer inherently different loading in an aquatic environment. Body weight squats and calf raises in water could be defined as either neuromotor or low load, high velocity training. Maximal speed exercise in water produces higher relative load compared to slow speed and minimal pain providing an opportunity for clinicians to use greater speed to address power deficits.

Early aquatic physical therapy improves function and does not increase risk of wound-related adverse events for adults after orthopedic surgery: a systematic review and meta-analysis.

OBJECTIVES: To investigate whether early postoperative aquatic physical therapy is a low-risk and effective form of physical therapy to improve functional outcomes after orthopedic surgery. DATA SOURCES: Databases MEDLINE, CINAHL, AMED, Embase, and PEDro were searched from the earliest date available until October 2011. Additional trials were identified by searching reference lists and citation tracking. STUDY SELECTION: Controlled trials evaluating the effects of aquatic physical therapy on adverse events for adults <3 months after orthopedic surgery. Two reviewers independently applied inclusion and exclusion criteria, and any disagreements were discussed until consensus could be reached. Searching identified 5069 potentially relevant articles, of which 8 controlled trials with 287 participants met inclusion criteria. DATA EXTRACTION: A predefined data extraction form was completed in detail for each included study by 1 reviewer and checked for accuracy by another. Methodologic quality of included trials was assessed independently by 2 reviewers using the PEDro scale. DATA SYNTHESIS: Pooled analyses were performed using random effects model with inverse variance methods to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs) (continuous outcomes) and risk difference and 95% CIs (dichotomous outcomes). When compared with land-based physical therapy, early aquatic physical therapy does not increase the risk of wound-related adverse events (risk difference=.01, 95% CI -.05 to .07) and results in improved performance of activities of daily living (SMD=.33, 95% CI=.07-.58, I(2)=0%). There were no significant differences in edema (SMD=-.27, 95% CI=-.81 to .27, I(2)=58%) or pain (SMD=-.06, 95% CI=-.50 to .38, I(2)=32%). CONCLUSIONS: After orthopedic surgery aquatic physical therapy improves function and does not increase the risk of wound-related adverse events and is as effective as land-based therapy in terms of pain, edema, strength, and range of motion in the early postoperative period.