Re-resection Rates and Disease Recurrence in Crohn's Disease - A Population-Based Study Using Individual-Level Patient Data.

BACKGROUND AND AIMS: Despite advances in the medical treatment of Crohn's disease (CD), many patients will still need bowel resections and face the subsequent risk of recurrence and re-resection. We describe contemporary re-resection rates and identify disease-modifying factors and risk factors for re-resection. METHODS: We conducted a retrospective, population-based, individual patient data cohort study covering 47.4% of the Danish population, including all CD patients who underwent a primary resection between 2010 and 2020. RESULTS: Among 631 primary resected patients, 24.5% underwent a second resection, and 5.3% a third. Re-resection rates after one, five, and 10 years were 12.6%, 22.4%, and 32.2%, respectively. Reasons for additional resections were mainly disease activity (57%) and stoma reversal (40%). Disease activity-driven re-resection rates after one, five, and 10 years were 3.6%, 10.1%, and 14.1%, respectively. Most stoma reversals occurred within one year (80%). The median time to recurrence was 11.0 months. Biologics started within one year of the first resection revealed protective effect against re-resection for stenotic and penetrating phenotypes. Prophylactic biologic therapy at primary ileocecal resection reduced disease recurrence and re-resection risk (HR 0.58, 95% CI (0.34-0.99), p=0.047). Risk factors for re-resection were location of resected bowel segments at the primary resection, disease location, disease behavior, smoking, and perianal disease. CONCLUSION: Re-resection rates, categorized by disease activity, are lower than those reported in other studies and are closely associated with disease phenotype and localization. Biological therapy may be disease-modifying for certain subgroups when initiated within one year of resection.

Characterisation of South African field Ehrlichia ruminantium using multilocus sequence typing.

Heartwater, one of the major tick-borne diseases of some domestic and wild ruminants in Africa, is caused by Ehrlichia ruminantium. The genetic diversity of E. ruminantium isolates renders the available vaccine ineffective against certain virulent isolates. To better understand the E. ruminantium genotypes in South Africa, a total of 1004 Amblyomma hebraeum tick deoxyribonucleic acid (DNA) samples from cattle in three South African provinces were tested by pCS20 Sol1 real-time polymerase chain reaction (qPCR) and characterised by multilocus sequence typing (MLST) using five housekeeping genes. Out of 1004 samples tested, 222 (22%) were positive for E. ruminantium. The occurrence of E. ruminantium in Mpumalanga, KwaZulu-Natal and Limpopo provinces was 19%, 22% and 27%, respectively. The E. ruminantium positive samples were screened for housekeeping genes and sequenced. Phylogenetic analysis revealed three main lineages: clade 1 made up of worldwide isolates (eastern, southern Africa, and Caribbean isolates), clade 2 comprised only West African isolates and clade 3 consisted of Omatjenne, Kümm2 and Riverside. Some study sample sequences were not identical to any of the reference isolates. However, they could all be grouped into the worldwide clade. Genetic variation in the sequenced regions was observed in the form of single nucleotide polymorphisms (SNPs). Using MLST to characterise E. ruminantium field isolates allowed the South African genotypes to be clearly distinguished from the distinct West African isolates.Contribution: Characterisation of E. ruminantium field isolates is important for the control of heartwater and contributes to preliminary knowledge required for the development of a more practical vaccine against heartwater.

Post-prandial secretion of glucagon-like peptide-2 (GLP-2) after carbohydrate-, fat- or protein enriched meals in healthy subjects.

Glucagon-like peptide 2 (GLP-2) is an important regulator of intestinal growth and function. In adherable mixed meals the macronutrient composition with the best potential for stimulating GLP-2 secretion is not known. We compared the effect of 3 iso-energetic meals, where approximately 60 % of the energy ratio was provided as either carbohydrate, fat, or protein, respectively, on the post-prandial endogenous GLP-2 secretion. The responses were compared to secretion profiles of peptide YY (PYY), and glucose-dependent insulinotropic peptide (GIP). Ten healthy subjects were admitted on three occasions, at least a week apart, after a night of fasting. In an open-label, crossover design, they were randomized to receive a high carbohydrate (HC), high fat (HF) or high protein (HP) meal. The meals were approximately ∼3.9 MJ. Venous blood was collected for 240 min, and plasma concentrations of GLP-2, GIP and PYY were measured with specific radioimmunoassays. Mean GLP-2 levels peaked already at 30 min for the HC meal, however the HP meal induced the highest mean GLP-2 peaking levels, resulting in significantly higher mean GLP-2 area under the curve (AUC) from baseline of 7279 pmol*min/L, 95 %-CI [6081;8477] compared to the HC meal: 4764 pmol*min/L, 95 %-CI [3498;6029], p = 0.020 and the HF meal: 4796 pmol*min/L, [3385;6207], p = 0.011. Findings were similar for the PYY. The HC meal provided a greater AUC for GIP compared to the HP- and HF meals. The HP meal was most effective with respect to stimulation of the postprandial GLP-2 and PYY secretion, whereas the HC meal was more effective for GIP.

Survival in patients initiating home parenteral support due to nonmalignant short bowel syndrome compared with background population.

BACKGROUND: Survival has frequently been studied and reported in patients with long term intestinal failure (IF). However, studies comparing the survival and mortality rates with the background population are rare. This study compares the survival in an adult IF, non-malignant, short bowel syndrome (SBS) cohort with a control group and with age- and sex-specific background mortality rates. DESIGN: Patients with SBS, defined by a small bowel length of 200 cm or less, due to non-malignant disease, were included and followed until death or censoring on 31 December 2017. Causes of deaths occurring during home parenteral support (HPS) were assessed by review of the charts. Each case was matched with ten controls from the background population according to year of HPS initiation, age, and sex, and their survival was compared. Furthermore, age- and sex-specific mortality rates of the background population were used to calculate the standardized mortality ratio (SMR) and excess mortality. RESULTS: After five years, patients who initiated HPS had a relative survival of 76%. The SMR was 5.0 and the excess mortality was 50 per 1000 years. HPS-related deaths were assessed to account for 11% of deaths during HPS and occurred with an incidence of 10 per 1000 years. The excess mortality was as low as 15 per 1000 years in cases aged less than 40 years. Patients weaning off HPS had a mortality rate closer to that expected in the background population. CONCLUSIONS: In adult patients with a non-malignant cause of SBS-IF, the excess mortality was 50 per 1000 years. However, HPS related deaths were rarely registered with an incidence of 10 HPS related deaths per 1000 HPS treatment years.

Postoperative Rehabilitation of Ulnar Collateral Ligament Reconstruction: A Systematic Review.

The incidence of ulnar collateral ligament injuries has increased over the past few decades with greater participation in overhead throwing sports; however, optimal postoperative management following surgery remains unclear. This systematic review summarizes the latest evidence, on postoperative rehabilitation protocols for patients undergoing ulnar collateral ligament reconstruction (UCLR). Studies published in the English language from the year 2000 to 2019 with a level 1 to 4 grade of evidence and examined rehabilitation protocols following UCLR were eligible for inclusion. A multidatabase search was conducted. Two blinded reviewers screened and graded articles for inclusion and a third independent reviewer resolved any conflicts. Ten of the original 139 studies identified were used for analysis. Surgical techniques as well as rehabilitation protocols varied across studies. Analysis gave strong evidence that a 4-phase postoperative rehabilitation protocol utilizing milestone-based goals is effective in returning athletes back to preinjury levels of activity and sport within 1 year following UCLR.

High Parenteral Support Volume Is Associated With Reduced Quality of Life Determined by the Short-Bowel Syndrome Quality of Life Scale in Nonmalignant Intestinal Failure Patients.

BACKGROUND: Aim was to investigate the association between quality of life (QoL), bowel anatomy, and the need for home parenteral support (HPS) volume in patients with nonmalignant short-bowel syndrome (SBS) and intestinal failure (IF). METHODS: The SBS-QoL scale was used in a cross-sectional study of 95 nonmalignant SBS-IF patients. Sum QoL scores (0: best, 170: worst) were calculated. Patients were defined as having a small bowel (≤200 cm), and patients with jejunostomy or ileostomy were subclassified based on functional small-bowel length (cm) into 4 anatomy subgroups: 1a-1d (0-49, 50-99, 100-149, 150-200 cm, respectively). Multiple linear regression analyses explored associations between QoL, patient groups, and HPS volume, adjusting for age, sex, body mass index, and education. RESULTS: Complete data were obtained from 60 patients. HPS volume was associated with a worse SBS-QoL score (L/d, ß = 7.91; SE = 3.90; P = .048), but male sex associated with improvement (ß = -26.28; SE = 11.06; P = .021). No differences in sum QoL were seen between the benign SBS-IF subgroups 1a-d (P = .210). Multivariate regression analyses showed that patients with a small-bowel stoma, a small-bowel length <50 cm was associated with a significantly worse/higher SBS-QoL score compared with a length >50 cm. CONCLUSION: In patients with benign SBS-IF, high HPS volume was associated with poor QoL. Also, jejunostomy or ileostomy with small-bowel length <50 cm was associated with impaired QoL. These findings support rehabilitation strategies that reduce fecal losses and decrease HPS needs.

Risk Factors for Wound Infection in Outpatients With Lower Extremity Burns.

BACKGROUND: We sought to evaluate risk factors for wound infection in patients with lower extremity (LE) burn. METHODS: Adults presenting with LE burn from January 2014 to July 2015 were included. Data regarding demographics, injury characteristics, and outcomes were obtained. The primary outcome was wound infection. Multivariate logistic regression analysis was performed to identify independent risk factors for wound infection. RESULTS: 317 patients were included with a mean age of 43 years and median total body surface area of .8%; 22 (7%) patients had a component of full-thickness (FT) burn; and 212 (67%) patients had below-the-knee (BTK) burn. The incidence of wound infection was 15%. The median time to infection was 5 days, and majority (61%) of the patients developed wound infection by day 5. Patients who developed wound infection were more likely to have an FT burn (22% vs. 5%, P < .001) and BTK burn (87% vs. 64%, P = .002), without a difference in other variables. Multivariate logistic regression analysis showed age (Odds ratio (OR) 1.02 and CI 1.00-1.04), presence of FT burn (OR 5.33 and CI 2.09-13.62), and BTK burn (OR 3.42 and CI 1.37-8.52) as independent risk factors for wound infection (area under the curve = .72). CONCLUSION: Age, presence of FT burn, and BTK burn are independent risk factors for wound infection in outpatients with LE burns.

Hospitalizations in Patients With Nonmalignant Short-Bowel Syndrome Receiving Home Parenteral Support.

BACKGROUND: The objective of this retrospective cohort study was to assess the frequency, duration, and causes of hospitalizations in patients receiving home parenteral support (HPS) due to short-bowel syndrome (SBS) of nonmalignant causes. Furthermore, we aimed to investigate potential risk factors and hypothesized that patients with the shortest remnant, functional, small bowel-hence, the highest need for HPS-would have the highest incidence of hospitalizations. METHODS: Patients with nonmalignant SBS who initiated HPS in the period from 1970 to 2016 from the Department of Gastroenterology, Rigshospitalet, Copenhagen, Denmark, were included. Information about demography, hospitalizations at the department, and duration of HPS was obtained from the Copenhagen intestinal failure database. RESULTS: Patients (n = 331) received HPS for a total of 1409.9 years in the period. Hospitalizations accounted for 6.6% of the time registered as HPS-dependent. The average patient was hospitalized for 5.7% (range 0%-82%) of the registered HPS days. The incidence of admissions was 2.5 per HPS year. The median length of stay was 7 days (range; 0-387). Catheter-related complications were the most frequently registered causes of admissions (35.2%), subsequently accounting for 31.3% of the total admission time. A Cox regression of admissions showed no significant influence of the remnant-bowel anatomy but identified the ability to administer HPS unaided as associated with a significantly reduced hazard. CONCLUSIONS: This retrospective study illustrated that 6.6% of the provided HPS days were, in fact, spent hospitalized. Since admissions elsewhere were not accounted for, this may be an underestimation.

Differences in methodology impact estimates of survival and dependence on home parenteral support of patients with nonmalignant short bowel syndrome.

BACKGROUND: In patients with intestinal failure (IF), who are receiving home parenteral support (HPS), variations between centers in estimates of survival and HPS dependency often reflect differences in population characteristics. However, variations in methodology and adherence to model assumptions may further contribute. OBJECTIVES: We investigated how differences in methodology affect estimates of outcomes in IF patients. METHODS: We applied different model assumptions and statistical methods to real-life outcome data from a well-characterized cohort of nonmalignant short bowel syndrome (SBS) patients. This retrospective study was based on extracts from the Copenhagen IF database and from the Danish death registry. RESULTS: Estimates of mortality varied substantially, depending on the study design and statistical method. The 5-y mortality rate obtained with the Kaplan-Meier (KM) method was estimated to be 10.1% higher if patients were only followed during HPS treatment, compared with follow-up regardless of HPS treatment. The 5-y cumulative incidence of weaning off HPS was overestimated by 4.4% when inappropriately using the KM method, instead of the cumulative incidence function. The 5-y survival rates in nonmalignant SBS-IF patients who initiated HPS were 89.1% for those aged younger than 40 y, 74.8% for patients aged 40-60 y, and 52.1% for those older than 60 y. A Cox regression analysis identified age and diagnoses other than inflammatory bowel disease as significant risk factors for mortality. For HPS dependency, bowel anatomy was significantly associated with the ability to wean off, and no patients without a colon and less than 100 cm remnant of the small bowel remained continuously weaned off and alive for one year. CONCLUSIONS: The large variations in outcomes illustrated in this study emphasize the importance of the appropriate selection of statistical methods. A comparison between studies is problematic, due to differences in the methods employed.

Efficiency of care and cost for common emergency general surgery conditions: Comparison by surgeon training and practice.

BACKGROUND: Our institutional emergency general surgery service is staffed by both trauma and critical care-trained surgeons and other boarded general surgeons and subspecialists. We compared efficiency of care for common emergency general surgery conditions between trauma and critical care-trained surgeons and boarded general surgeons and subspecialists. METHODS: Adults admitted between February 2014 and May 2017 with acute appendicitis, acute cholecystitis, intestinal obstruction, incarcerated hernia, or other acute abdominal diagnoses seen by emergency general surgery service were included. Demographic characteristics, consulting surgeon, operations, outcomes, and cost data were obtained. RESULTS: A total of 1,363 patients were included: 384 (28.2%) with acute appendicitis, 477 (35.0%) with acute cholecystitis, 406 (29.8%) with intestinal obstruction, 22 (1.6%) with incarcerated hernia, and 74 (5.4%) with other acute abdominal diagnoses. Trauma and critical care-trained surgeons saw 836 (61.3%) patients. There was no difference in operative management between the two groups, however, trauma and critical care-trained surgeons had significantly less time to the operative room (7.0 vs 12.9 hours; P < .001), without a difference in duration of stay or costs. The subgroups of acute appendicitis and acute cholecystitis when treated by trauma and critical care-trained surgeons had less time to the operative room (8.4 vs 17.4 hours; P < .001), shorter hospital stay (2.5 vs 2.8 days; P = .021), and less emergency department cost ($822 vs $876; P = .012). CONCLUSION: Compared with boarded general surgeons and subspecialists, trauma and critical care-trained surgeons provide more efficient care for common emergency general surgery conditions, with less time from consultation to the operative room.

Attitudes Toward Communication and Collaboration After Participation in a Mock Page Program: A Pilot of an Interprofessional Approach to Surgical Residency Preparation.

OBJECTIVE: A source of insecurity among new physicians and new nurses is communicating and managing acute changes in patient condition. Mock page programs are an effective method for teaching communication and clinical decision-making skills to medical students. Joint participation in a mock page program provides a unique opportunity for medical and nursing students to practice communication, collaboration, and clinical decision-making in a low-risk learning environment. The purpose of this pilot study was to examine attitudes toward communication and collaboration among medical and nursing students after participation in a mock page program. DESIGN: Twenty-four medical students participating in a surgical residency preparatory course were paired with 24 senior level nursing students. Over a period of 3 weeks, nursing students delivered 5 mock pages to the medical students. Mock pages consisted of peer-reviewed, prescripted scenarios depicting patients experiencing common postoperative complications. A 12-question survey measuring attitudes toward communication and collaboration between physicians and nurses was administered prior to delivery of the first page and after delivery of the last page. A dependent sample t test was used to perform item analysis. RESULTS: Individual item analysis of medical student surveys indicated significant improvement in attitudes toward communication and collaboration with nurses in 12 out of 12 survey items (p < 0.05). Individual item analysis of nursing student surveys indicated significant improvement in attitudes toward communication and collaboration with physicians in 6 out of 10 survey items (p < 0.05). There was no decline in attitudes among any of the survey items. CONCLUSIONS: The results from this study suggest that an interprofessional mock page program improves attitudes toward communication and collaboration between medical and nursing students. This program has the potential to improve the quality of education and increase confidence among medical and nursing students as they prepare for their professional roles.

Catheter-related bloodstream infections in patients with intestinal failure receiving home parenteral support: risks related to a catheter-salvage strategy.

Background: In intestinal failure (IF) patients receiving home parenteral support (HPS), catheter-related bloodstream infections (CRBSIs) frequently result in replacement of their tunneled central venous catheters (CVCs), which may lead to future loss of central venous access. Objective: This observational study investigated the consequences of a catheter-salvage strategy related to CRBSIs. Design: All CRBSIs from 2002 to 2016 in the Copenhagen IF and microbiological databases were retrospectively analyzed. Catheter salvage was defined by successful antimicrobial therapy with a retained CVC at discharge. Re-occurrences of CRBSIs with the same microbial species and identical antibiogram were defined as a relapse (<30 d) or as a recurrent (30-100 d) infection. Cox regression analyses incorporated a frailty factor to account for recurrent events and overrepresentation by some patients. Cumulative incidence curves are presented with a competing risk model. Results: There were 2006 tunneled CVCs inserted in 715 adult HPS patients covering 2014.3 CVC years, with a CRBSI incidence rate of 1.83/1000 (n = 1350) and a mortality rate of 0.007/1000 CVC days (n = 5). The mean ± SD salvage rate was 55.3% ± 5.5%, varying according to infection type [monoinfections (62.9% ± 4.4%) and polyinfections (58.6% ± 17.3%)] and causative microorganism [coagulase-negative Staphylococci (CoNS) (68.1% ± 9.4%), Staphylococcus aureus (42.6% ± 17.5%), and Enterobacteriaceae (54.3% ± 16.7%)]. The overall risk of CRBSI relapse was 7.5%, and the risk of CRBSI recurrence was 7.3%. The HR for a subsequent CRBSI was 14% lower in a replaced than in a retained CVC (95% CI: 0.74, 0.99). The HR for a new CRBSI after catheter salvage was 36% higher after polyinfections than after monoinfections (95% CI: 1.03, 1.79). Enterobacteriaceae entailed an increased risk of CRBSI recurrence compared with CoNS (2.26; 95% CI; 1.08, 4.75) and S. aureus (4.45; 95% CI: 1.28, 15.5). Conclusions: High catheter-salvage rates related to CRBSIs were achievable and safe in HPS patients within a broad range of microorganisms but contributed to an increased risk of CRBSI relapse or recurrence.

Home Parenteral Nutrition in Adult Patients With Chronic Intestinal Failure: Catheter-Related Complications Over 4 Decades at the Main Danish Tertiary Referral Center.

BACKGROUND/AIMS: Catheter-related complications (CRCs) cause mortality and morbidity in patients dependent on parenteral support at home (HPN) due to intestinal failure (IF). This study describes the incidences of CRCs in an adult IF cohort over 40 years. It illustrates the evolution and consequences of CRCs, their association to demographic characteristics, and potential risk factors in an effort to provide the rationale for preventive precautions to the relevant patients with IF at risk. METHODS: All patients with IF discharged with HPN from 1970-2010 were included. Patient and treatment characteristics were extracted from the Copenhagen IF database. The incidences were given per 1000 central venous catheter (CVC) days. RESULTS: The 1715 CRCs occurred in 70% of the 508 patients with IF (56% of the 2191 CVCs). The incidence of catheter-related bloodstream infections (CRBSIs) was 1.43. Higher age, HPN administration by community home nurses, and prior CRBSIs significantly raised the hazard for CRBSIs. In the 1970s, catheters were generally replaced following CRBSIs, whereas catheter salvage was the norm in the 2000s. The incidences of mechanical complications, tunnel infections, and catheter-related venous thromboses were 0.80, 0.25, and 0.11, respectively. The overall CRC incidence was 2.58, decreasing the first 3 decades but peaking in the last (2.84). The deaths related to CRCs were low (0.018). CONCLUSION: Even in an experienced IF center of excellence, the incidence of CRCs increased over the 4 decades. This increase could be explained by the expansion of the indication of HPN to a more elderly and frail patient population.

Catheter-Related Bloodstream Infections in Adults Receiving Home Parenteral Nutrition: Substantial Differences in Incidence Comparing a Strict Microbiological to a Clinically Based Diagnosis.

BACKGROUND: A common complication in patients receiving home parenteral nutrition (HPN) is catheter-related bloodstream infections (CRBSIs). The CRBSI incidence has been advocated as an outcome parameter assessing the quality of care. This study aimed to illustrate how the use of different CRBSI definitions affects the reported incidence. MATERIALS AND METHODS: In an observational study based on the Copenhagen intestinal failure database, all clinically reported CRBSIs from 2002-2013 were compared with data from the affiliated microbiological database according to recommended CRBSI criteria. RESULTS: Clinically, 1034 CRBSIs were observed in 548 adults receiving HPN for 1410 catheter-years. Thus, the clinically assessed CRBSI incidence was 1.95/1000 catheter-days. However, based on the microbiological evaluation, only 47% of our episodes fulfilled the Centers for Disease Control and Prevention (CDC) and European Society for Clinical Nutrition (ESPEN) CRBSI criteria. Employing a catheter-salvaging strategy, 40% of the CRBSI diagnoses were supported by the paired blood culture positivity criteria and only 6% by a positive catheter tip. In 53%, CRBSIs were categorized as a clinical or "probable CRBSI" diagnosis. In 20% of all episodes, missing information/blood cultures hampered a CDC/ESPEN CRBSI diagnosis. Thereby, according to CDC/ESPEN CRBSI definitions, the incidence was 0.92/1000 days or 46% lower than clinically assessed. CONCLUSION: This study illustrates the practical and methodological challenges and great variability in reporting of the CRBSI incidence. Nonetheless, it is recommended as a marker of the quality of care. Consensus regarding CRBSI definitions is a prerequisite for a meaningful comparison of this important outcome parameter between HPN centers.

Effect of Liraglutide Treatment on Jejunostomy Output in Patients With Short Bowel Syndrome: An Open-Label Pilot Study.

BACKGROUND: An impaired hormonal "ileo-colonic brake" may contribute to rapid gastric emptying, gastric hypersecretion, high ostomy losses, and the need for parenteral support in end-jejunostomy short bowel syndrome (SBS) patients with intestinal failure (IF). Liraglutide, a glucagon-like peptide 1 receptor agonist, may reduce gastric hypersecretion and dampen gastric emptying, thereby improving conditions for intestinal absorption. MATERIALS AND METHODS: In an 8-week, open-label pilot study, liraglutide was given subcutaneously once daily to 8 end-jejunostomy patients, aged 63.4 ± 10.9 years (mean ± SD) and with small bowel lengths of 110 ± 66 cm. The 72-hour metabolic balance studies were performed before and at the end of treatment. Food intake was unrestricted. Oral fluid intake and parenteral support volume were kept constant. The primary end point was change in the ostomy wet weight output. RESULTS: Liraglutide reduced ostomy wet weight output by 474 ± 563 g/d from 3249 ± 1352 to 2775 ± 1187 g/d (P = .049, Student t test). Intestinal wet weight absorption tended to increase by 464 ± 557 g/d (P = .05), as did urine production by 765 ± 759 g/d (P = .02). Intestinal energy absorption improved by 902 ± 882 kJ/d (P = .02). CONCLUSION: Liraglutide reduced ostomy wet weight output in end-jejunostomy patients with SBS-IF and increased their intestinal wet weight and energy absorption. If larger, randomized, placebo-controlled studies confirm these effects, it adds to the hypothesis that many ileo-colonic brake hormones in conjunction may be involved in the process of intestinal adaptation. By identification of key hormones and addressing their potential synergistic effects, better treatments may be provided to patients with SBS-IF. This trial was registered at clinicaltrialsregister.eu as 2013-005499-16.

A surgical residency preparatory course for senior medical students leads to earlier independence in ACGME competencies.

BACKGROUND: It is unknown whether surgery residency preparatory courses lead to earlier independent practice. METHODS: A four-week surgical residency preparatory course was offered to graduating medical students. Upon entering residency, participants reported supervised and unsupervised performance of patient management and procedural competencies. Those who participated in the course (Group A) were compared with graduates from our institution who did not participate but entered surgery residency (Group B) and with residents from other medical schools in the same program as Group A (Group C). Time to independence was observed. RESULTS: Group A achieved independence earlier than Group B in 15/18 (83.3%), earlier than Group C in 14/18 (77.8%) and earlier than both in 12/16 (75%) competencies. Independence occurred 43.6 days earlier than Group B (range 6-112 days) and 49 days earlier than Group C (range 11.5-165 days). CONCLUSION: A surgical residency preparatory course led to earlier independent performance of the ACGME recommended patient management and procedural competencies compared to students from our institution and others who did not participate in such a course.

Utility of Sequential Organ Failure Assessment score in predicting bacteremia in critically ill burn patients.

BACKGROUND: We evaluated whether qSOFA ≥2 and an increase in SOFA (ΔSOFA) ≥2 can help predict bacteremia in a critically ill burn population. METHODS: Patients age ≥15 and TBSA ≥15% admitted between 2009 and 2015 were included. All blood cultures were recorded, and positive and negative blood culture days were defined based on the culture results. SOFA and qSOFA scores were compared between positive and negative blood culture days. RESULTS: There were 50 patients in our study with a mean age of 47yrs and mean TBSA burn of 37%. Bacteremic patients had larger TBSA and full thickness burns, higher revised Baux score, and longer hospital LOS, without a difference in mortality, compared to non-bacteremic patients. There was no difference in qSOFA and SOFA scores between positive and negative blood culture days. A ΔSOFA ≥5 was highly specific for positive blood culture days. CONCLUSIONS: SOFA and qSOFA have limited ability to predict bacteremia in critically ill burn patients.

The use of metabolic balance studies in the objective discrimination between intestinal insufficiency and intestinal failure.

Background: In research settings that use metabolic balance studies (MBSs) of stable adult patients with short bowel syndrome, intestinal failure (IF) and dependence on parenteral support (PS) have been defined objectively as energy absorption <84% of calculated basal metabolic rate (BMR), wet weight (WW) absorption <23 g · kg body weight-1 · d-1, or both. Objective: This study aimed to explore and validate these borderlines in the clinical setting.Design: Intestinal absorption was measured from April 2003 to March 2015 in 175 consecutive patients with intestinal insufficiency (INS) in 96-h MBSs. They had not received PS 3 mo before referral.Results: To avoid the need for PS, the minimum absorptive requirements were energy absorption of ≥81% of BMR and WW absorption of ≥21 g · kg body weight-1 · d-1, which were equivalent to findings in research settings (differences of 3.6% and 8.7%; P = 0.65 and 0.60, respectively). Oral failure defined as energy intake <130% of calculated BMR or WW intake <40 g · kg body weight-1 · d-1 was seen in 71% and 82% of the 10% of patients with the lowest energy absorption and WW absorption, respectively.Conclusions: In clinical settings, the borderlines between INS and IF were not significantly different from those in research settings, even in an unselected patient population in which oral failure was also a predominant cause of nutritional dyshomeostasis. MBSs may be recommended to identify the individual patient in the spectrum from INS to IF, to objectivize the cause of nutritional dyshomeostasis (oral failure, malabsorption, or both), and to quantify the effects of treatment.

Taurolidine-citrate-heparin lock reduces catheter-related bloodstream infections in intestinal failure patients dependent on home parenteral support: a randomized, placebo-controlled trial.

Background: In patients with intestinal failure who are receiving home parenteral support (HPS), catheter-related bloodstream infections (CRBSIs) inflict health impairment and high costs.Objective: This study investigates the efficacy and safety of the antimicrobial catheter lock solution, taurolidine-citrate-heparin, compared with heparin 100 IE/mL on CRBSI occurrence.Design: Forty-one high-risk patients receiving HPS followed in a tertiary HPS unit were randomly assigned in a double-blinded, placebo-controlled trial. External, stratified randomization was performed according to age, sex, and prior CRBSI incidence. The prior CRBSI incidence in the study population was 2.4 episodes/1000 central venous catheter (CVC) days [95% Poisson confidence limits (CLs): 2.12, 2.71 episodes/1000 CVC days]. The maximum treatment period was 2 y or until occurrence of a CRBSI or right-censoring because of CVC removal. The exact permutation tests were used to calculate P values for the log-rank tests.Results: Twenty patients received the taurolidine-citrate-heparin lock and 21 received the heparin lock, with 9622 and 6956 treatment days, respectively. In the taurolidine-citrate-heparin arm, no CRBSIs occurred, whereas 7 CRBSIs occurred in the heparin arm, with an incidence of 1.0/1000 CVC days (95% Poisson CLs: 0.4, 2.07/1000 CVC days; P = 0.005). The CVC removal rates were 0.52/1000 CVC days (95% Poisson CLs: 0.17, 1.21/1000 CVC days) and 1.72/1000 CVC days (95% Poisson CLs: 0.89, 3.0/1000 CVC days) in the taurolidine-citrate-heparin and heparin arm, respectively, tending to prolong CVC survival in the taurolidine arm (P = 0.06). Costs per treatment year were lower in the taurolidine arm (€2348) than in the heparin arm (€6744) owing to fewer admission days related to treating CVC-related complications (P = 0.02).Conclusions: In patients with intestinal failure who are life dependent on HPS, the taurolidine-citrate-heparin catheter lock demonstrates a clinically substantial and cost-beneficial reduction of CRBSI occurrence in a high-risk population compared with heparin. This trial was registered at clinicaltrials.gov as NCT01948245.