Metabolic syndrome and surgical complications: a systematic review and meta-analysis of 13 million individuals.

BACKGROUND: Metabolic syndrome (MetS) is characterised by the presence of at least three of the five following components: insulin resistance, obesity, chronic hypertension, elevated serum triglycerides, and decreased high-density lipoprotein cholesterol concentrations. It is estimated to affect 1 in 3 people around the globe and is reported to affect 46% of surgical patients. For people with MetS who undergo surgery, an emerging body of literature points to significantly poorer postoperative outcomes compared with nonaffected populations. The aim of this study is to review the current evidence on the risks of surgical complications in patients with MetS compared to those without MetS. METHODS: Systematic review and meta-analysis using PRISMA and AMSTAR reporting guidelines. RESULTS: The meta-analysis included 63 studies involving 1 919 347 patients with MetS and 11 248 114 patients without MetS. Compared to individuals without the condition, individuals with MetS were at an increased risk of mortality (OR 1.75 95% CI: 1.36-2.24; P <0.01); all surgical site infection types as well as dehiscence (OR 1.64 95% CI: 1.52-1.77; P <0.01); cardiovascular complications (OR 1.56 95% CI: 1.41-1.73; P <0.01) including myocardial infarction, stroke, cardiac arrest, cardiac arrythmias and deep vein thrombosis; increased length of hospital stay (MD 0.65 95% CI: 0.39-0.9; P <0.01); and hospital readmission (OR 1.55 95% CI: 1.41-1.71; P <0.01). CONCLUSION: MetS is associated with a significantly increased risk of surgical complications including mortality, surgical site infection, cardiovascular complications, increased length of stay, and hospital readmission. Despite these risks and the high prevalence of MetS in surgical populations there is a lack of evidence on interventions for reducing surgical complications in patients with MetS. The authors suggest prioritising interventions across the surgical continuum that include (1) preoperative screening for MetS; (2) surgical prehabilitation; (3) intraoperative monitoring and management; and (4) postoperative rehabilitation and follow-up.

The Use of Evaluation Panels During the Development of a Digital Intervention for Veterans Based on Cognitive Behavioral Therapy for Insomnia: Qualitative Evaluation Study.

BACKGROUND: Individuals enrolling in the Veterans Health Administration frequently report symptoms consistent with insomnia disorder. Cognitive behavioral therapy for insomnia (CBT-I) is a gold standard treatment for insomnia disorder. While the Veterans Health Administration has successfully implemented a large dissemination effort to train providers in CBT-I, the limited number of trained CBT-I providers continues to restrict the number of individuals who can receive CBT-I. Digital mental health intervention adaptations of CBT-I have been found to have similar efficacy as traditional CBT-I. To help address the unmet need for insomnia disorder treatment, the VA commissioned the creation of a freely available, internet-delivered digital mental health intervention adaptation of CBT-I known as Path to Better Sleep (PTBS). OBJECTIVE: We aimed to describe the use of evaluation panels composed of veterans and spouses of veterans during the development of PTBS. Specifically, we report on the methods used to conduct the panels, the feedback they provided on elements of the course relevant to user engagement, and how their feedback influenced the design and content of PTBS. METHODS: A communications firm was contracted to recruit 3 veteran (n=27) and 2 spouse of veteran (n=18) panels and convene them for three 1-hour meetings. Members of the VA team identified key questions for the panels, and the communications firm prepared facilitator guides to elicit feedback on these key questions. The guides provided a script for facilitators to follow while convening the panels. The panels were telephonically conducted, with visual content displayed via remote presentation software. The communications firm prepared reports summarizing the panelists' feedback during each panel meeting. The qualitative feedback described in these reports served as the raw material for this study. RESULTS: The panel members provided markedly consistent feedback on several elements of PTBS, including recommendations to emphasize the efficacy of CBT-I techniques; clarify and simplify written content as much as possible; and ensure that content is consistent with the lived experiences of veterans. Their feedback was congruent with previous studies on the factors influencing user engagement with digital mental health interventions. Panelist feedback influenced multiple course design decisions, including reducing the effort required to use the course's sleep diary function, making written content more concise, and selecting veteran testimonial videos that emphasized the benefits of treating chronic insomnia symptoms. CONCLUSIONS: The veteran and spouse evaluation panels provided useful feedback during the design of PTBS. This feedback was used to make concrete revisions and design decisions consistent with existing research on improving user engagement with digital mental health interventions. We believe that many of the key feedback messages provided by these evaluation panels could prove useful to other digital mental health intervention designers.

Acute Colonic Pseudo-Obstruction.

Acute colonic pseudo-obstruction (ACPO) is a functional disorder of the large intestine distinguished by colonic dysmotility resulting in colonic distension in the absence of mechanical obstruction. The underlying pathophysiology of ACPO remains unclear despite technological advances in understanding the physiology of colonic motility, such as spatio-temporal mapping and high-resolution manometry. In many ways, the management of ACPO has remained relatively unchanged for 40 years. Patients with perforation or suspected ischemia undergo operative intervention, while patients without undergo initial conservative management with bowel rest, correction of electrolyte disturbances, and mobilization. Patients who fail conservative management or have prominent cecal dilatation undergo decompression with either neostigmine or colonoscopy. A subset of patients with ACPO will have recurrent symptoms despite endoscopic and medical management. For these patients who are difficult to manage, an underlying colonic functional disorder, such as slow-transit dysmotility or chronic intestinal pseudo-obstruction may be considered. The following review of ACPO aims to provide a concise update of the causes, diagnosis, and management of this emergency surgical condition.

Serum Fatty Acid Latent Classes Are Associated With Suicide in a Large Military Personnel Sample.

OBJECTIVE: Fatty acids (FAs) are involved in the functioning of biological systems previously associated with suicidal behavior (eg, monoamine signaling and the immune system). We sought to determine (1) whether observed FA levels in a sample of military suicide decedents and living matched controls were consistent with latent classes having distinctive FA profiles and (2) whether those latent classes were associated with suicide and mental health diagnoses. METHODS: Serum samples from 800 US military suicide decedents who died between 2002 and 2008 and 800 demographically matched living controls were selected at random from a large military serum repository and assayed for 22 different FAs. A latent class cluster analysis was performed using values of 6 FAs previously individually associated with suicide. Once the latent classes were identified, they were compared in terms of suicide decedent proportion, demographic variables, estimated FA enzyme activity, diagnoses, and mental health care usage. RESULTS: A 6-latent class solution best characterized the dataset. Suicide decedents were less likely to belong to 2 of the classes and more likely to belong to 3 of the classes. The low-decedent classes differed from the high-decedent classes on 9 FAs and on estimated indices of activity for 3 FA enzymes: 14:0, 24:0, 18:1 n-9, 24:1 n-9, 22:5 n-3, 22:6 n-3, 20:2 n-6, 20:4 n-6, 22:5 n-6, elongation of very long chain fatty acids protein 1 (ELOVL1), ELOVL6, and Δ9 desaturase. The FA profiles of the latent classes were consistent with biological abnormalities previously associated with suicidal behavior. CONCLUSIONS: This study suggests the utility of methods that simultaneously examine multiple FAs when trying to understand their relationship with suicide and psychiatric illness.

Can normal inflammatory markers rule out acute appendicitis? The reliability of biochemical investigations in diagnosis.

BACKGROUND: Acute appendicitis is a common general surgical condition where diagnosis is predominantly clinical, with the aid of adjunct investigations. This study reviews the relationship between normal and elevated biochemical inflammatory markers, duration of symptoms and proven appendicitis. METHODS: A multicentre prospective observational study was performed across 27 centres and included a total of 949 patients with clinical suspicion of appendicitis, who had both white cell count (WCC) and C-reactive protein (CRP) recorded and underwent appendicectomy. RESULTS: A total of 90.4% of patients with raised WCC and CRP had appendicitis with a positive predictive value (PPV) of 0.9 and negative predictive value (NPV) of 0.4. Sensitivity and specificity of elevated WCC (sensitivity 66.5%, specificity 66.0%) and elevated CRP (sensitivity 77.3%, specificity 52.0%) lie within ranges identified by previous studies. A total of 39.8% of patients with normal CRP and WCC had appendicitis. Sensitivity and PPV for patients with elevated inflammatory markers were high until 48 h of symptoms (sensitivity 94%, PPV 0.87). NPV was elevated after 24 h (NPV 0.65 in patients with 24-48 h of symptoms, and 0.61 after 48 h), whilst those with symptoms less than 24 h had a lower NPV of 0.52. CONCLUSION: Whilst elevated inflammatory markers are a helpful aid in the diagnosis of appendicitis, they should not be relied on by themselves. Nor can normal inflammatory markers be used to exclude appendicitis, even in those with prolonged duration of symptoms. The diagnosis of appendicitis should be guided by a combination of clinical judgement with the assistance of inflammatory markers.

Variation in anti-microbial prescription and complications post emergency appendicectomy in Australia: do we follow recommended guidelines?

BACKGROUND: This study aims to establish compliance levels to prescription guidelines among Australian surgeons in the use of antibiotics in the surgical management of appendicitis. The secondary outcomes are predictors of post-operative infective complications; surgical site infection (SSI) and intra-abdominal abscess (IAA) at 30 days. METHODS: A multi-centre, prospective, observational study was conducted over a period of 2 months with a 30-day follow-up. Patients were eligible for recruitment if they underwent appendicectomy for suspected appendicitis. Antibiotics prescription practices were recorded and compared to national guidelines. RESULTS: A total of 1189 patients were recruited across 27 centres; 1081 (92.1%) patients were given prophylactic antibiotics at the time of appendicectomy. Patients with gangrenous appendicitis were more likely to receive prophylactic antibiotics (98.9%); lower rates of use were seen in the non-appendicitis group (85.7%). A total of 619 (53.3%) patients received antibiotics in the post-operative period. Despite recommendations, 300 (44.3%) patients with simple appendicitis received post-operative antibiotics. Only six (2.9%) patients with complicated appendicitis did not receive antibiotics. Overall, SSI and IAA rates were 1.9% and 2.7%, respectively. Aboriginal and Torres Strait Islanders (P = 0.02) and patients with converted operations (P = 0.001) were more likely to have a SSI. Patients with complicated appendicitis and those operated on by a consultant were more likely to increase the odds of IAA (odds ratio 3.8 and 5.1, respectively). CONCLUSION: This broad-based study shows mixed compliance with antibiotic guidelines in the surgical management of appendicitis in Australia. The use of post-operative antibiotics in patients with simple appendicitis should be a target for antimicrobial stewardship programmes to prevent antibiotic over-utilization.

Can Surgeons Identify Appendicitis Macroscopically? Results From a Multicentre Prospective Study.

PURPOSE: The primary outcome was to investigate the accuracy of intraoperative macroscopic diagnosis by the operating surgeon with the results of the subsequent histopathologic examination. The secondary outcome was to identify the predictors of discrepancies between these 2 groups. MATERIALS AND METHODS: A multicentre, prospective, observational study was conducted over a period of 2 months with a 30-day follow-up period. Patients who underwent surgery with the intention of appendicectomy were recruited in the study. RESULTS: A total of 1169 patients were recruited. False negatives (FNs) were defined as a normal macroscopic diagnosis but histopathologically appendicitis, whereas false positive otherwise. Overall, FN rates were 22.4%, whereas false positive rates were 8.2%. The seniority of the operating surgeons did not affect the ability to accurately diagnose appendicitis macroscopically (P=0.069). However, consultant surgeons had the lowest FN rate of 15.6%. Females and preoperative ultrasound scan increased odds of FN, whereas preoperative computed tomography decreased the odds of FN appendicectomy. CONCLUSION: Macroscopic identification intraoperatively is inaccurate with a FN rate of 22%.

Emergency appendicectomy in Australia: findings from a multicentre, prospective study.

BACKGROUND: Emergency appendicectomy is the most common emergency surgical procedure performed in Australia. Despite this frequency, there is a relative paucity of contemporary, broad-based, local data that examine how emergency appendicectomies are currently performed and what are the outcomes from these operations. METHODS: A multicentre, prospective, observational study was performed. Patients were recruited by local investigators for a period of 2 months with 30-day follow-up. Patients were eligible for study inclusion if they underwent an emergency appendicectomy for suspected acute appendicitis. The primary outcome of the study was the negative appendicectomy rate (NAR), with secondary outcomes including 30-day complication rates, method of operation and conversion rates. RESULTS: A total of 1189 patients were recruited across 27 centres. The NAR across all centres was 19.0%. 98.2% of appendicectomies were performed with a laparoscopic-first approach. The rate of conversion from laparoscopy to open operation was 2.4%. 9.4% of patients were recorded as having one or more of the following complications: readmission (6.6%), surgical site infection (1.9%), intra-abdominal abscess (2.7%) or further intervention (1.5%). Patients who had an open operation had higher rates of readmission and surgical site infection. CONCLUSION: The NAR found in this study is within the traditional measures of acceptance; however, this rate is high when measured against modern international benchmarks.

Changing stigma through a consumer-based stigma reduction program.

This study assessed the Anti-Stigma Project workshop, a contact/education intervention developed by On Our Own of Maryland, Inc. and the Maryland Mental Hygiene Administration. Two separate randomized controlled trials administered pre- and post-test questionnaire assessments. One included people with mental illness (N = 127) and a second included mental health providers (N = 131). Post-intervention, people with mental illness were more aware of stigma, had lower levels of prejudice, and increased belief in recovery. Providers were more aware of stigma, had lower levels of prejudice, and increased concurrence in self-determination of people with mental illness. Increasing providers' stigma awareness and recognition can promote higher quality service delivery. Increasing stigma awareness and recognition for people with mental illness can foster confidence in overcoming psychiatric disabilities. Using a participatory action research team, our protocol included extant and newly developed stigma change tools. Organizations seeking to conduct effective evaluation studies should consider collaborative processes including the expertise of affected constituents.

The nectarine pit as a cause for small bowel obstruction and perforation: a case report.

Ingestion of a foreign body is a rare cause of small bowel obstruction. Ingested foreign bodies will usually pass without clinical sequelae, however on occasion can contribute to significant morbidity. Here we present an unusual case of small bowel obstruction and perforation as a result of accidental ingestion of a nectarine pit.

Developing a cultural competence assessment tool for people in recovery from racial, ethnic and cultural backgrounds: the journey, challenges and lessons learned.

In 1997, Maryland implemented a new managed care mental health system. Consumer satisfaction, evaluation and cultural competency were considered high priorities for the new system. While standardized tools for measuring consumer satisfaction were readily available, no validated, reliable and standardized tool existed to measure the perception of people from minority groups receiving mental health services. The MHA*/MHP* Cultural Competency Advisory Group (CCAG) accepted the challenge of developing a consumer assessment tool for cultural competency. The CCAG, composed of people in recovery, clinicians and administrators used their collective knowledge and experiences to develop a 52-item tool that met standards for validity and reliability. Consultation from a researcher helped to further develop the tool into one possessing tremendous potential for statewide implementation within Maryland's Public Mental Health System. Recognizing the limitations of the study and the need for further research, this instrument is a work in progress. Strategies to improve the instrument are currently underway with the Mental Hygiene Administration's Systems Evaluation Center of the University of Maryland and several national researchers.