Impact of perioperative hyperglycemia in patients undergoing microvascular reconstruction

Continuous Interstitial Glucose Measurement for Flap Venous Occlusion Monitoring in a Diabetic Model

ABSTRACT

Glucose has been used in the monitoring of transplanted flaps. However, few studies have focused on the effect of diabetes on the decrease in flap glucose levels. The purpose of this study was to evaluate the application of continuous interstitial glucose monitoring to detect flap venous occlusion in a diabetic rat model. The flap interstitial glucose level was measured by transcutaneous sensors in the bilateral vertical rectus abdominis myocutaneous flaps of each rat. interstitial glucose values in the bilateral flaps were recorded every 5 minutes after the venous occlusion of 1 flap. Forty-one rats were divided into the control group (n = 13), diabetic group (n = 15, established by the intraperitoneal injection of streptozotocin), and insulin-treated diabetic group (n = 13, systemic glucose well controlled by insulin before surgery). Results indicated that flap interstitial glucose decreased to the lowest level in all flaps with venous occlusion. The time from venous occlusionto the lowest interstitial glucose level was significantlylongerinthe diabetic group than the control group (120.8 ± 5.7 minutes versus 56.5 ± 6.7 min-minutes, P < 0.001), but was similar in the insulin-treated diabetic and control groups (56.5 ± 6.7 minutes versus 56.0 ± 6.6 minutes, P = 0.876). The change in interstitial glucose in both the diabetic and insulin-treated diabetic groups began with a plateau period or a slow decline before decreasing for 49.0 ± 6.4 minutes and 24.4 ± 4.3 min-minutes, respectively. in a diabetic rat model, impaired glucose metabolism prolongs the required monitoring time and dulls the reaction of flap interstitial glucose to venous congestion. Insulin restores the prolonged monitoring time, but not the reaction of flap interstitial glucose. Therefore, care is needed during application of the technique in diabetic patients.

Consumer Wearables for Patient Monitoring in Otolaryngology: A State of the Art Review

OBJECTIVE

Consumer wearables, such as the Apple Watch or Fitbit devices, have become increasingly commonplace over the past decade. The application of these devices to health care remains an area of significant yet ill-defined promise. This review aims to identify the potential role of consumer wearables for the monitoring of otolaryngology patients.

DATA SOURCES

PubMed.

REVIEW METHODS

A PubMed search was conducted to identify the use of consumer wearables for the assessment of clinical outcomes relevant to otolaryngology. Articles were included if they described the use of wearables that were designed for continuous wear and were available for consumer purchase in the United States. Articles meeting inclusion criteria were synthesized into a final narrative review.

CONCLUSIONS

In the perioperative setting, consumer wearables could facilitate prehabilitation before major surgery and prediction of clinical outcomes. The use of consumer wearables in the inpatient setting could allow for early recognition of parameters suggestive of poor or declining health. The real-time feedback provided by these devices in the remote setting could be incorporated into behavioral interventions to promote patients' engagement with healthy behaviors. Various concerns surrounding the privacy, ownership, and validity of wearable-derived data must be addressed before their widespread adoption in health care.

IMPLICATIONS FOR PRACTICE

Understanding how to leverage the wealth of biometric data collected by consumer wearables to improve health outcomes will become a high-impact area of research and clinical care. Well-designed comparative studies that elucidate the value and clinical applicability of these data are needed.

The Utility of Comorbidity Indices in Assessing Head and Neck Surgery Outcomes: A Systematic Review

OBJECTIVE

To evaluate the utility of comorbidity index (CI) scores in predicting outcomes in head and neck surgery (HNS). The CIs evaluated were the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Kaplan-Feinstein Index (KFI), American Society of Anesthesiologists Physical Status (ASA-PS), Adult Comorbidity Evaluation-27 (ACE-27), National Cancer Institute Comorbidity Index (NCI-CI), and the Washington University Head and Neck Comorbidity Index (WUHNCI).

METHODS

We report a systematic review according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases (PubMed, Cochrane, and Embase) and manual search of bibliographies identified manuscripts addressing how CI scores related to HNS outcomes.

RESULTS

A total of 116 studies associated CI scores with HNS outcomes. CIs were represented in the literature as follows: ASA-PS (70/116), CCI (39/116), ACE-27 (24/116), KFI (7/116), NCI-CI (3/116), ECI (2/116), and WUHNCI (1/116). The most frequently cited justification for calculating each CI (if provided) was: CCI for its validation in other studies, ACE-27 for its utility in cancer patients, and ECI for its comprehensive design. In general, the CCI and ACE-27 were predictive of mortality in HNS. The ECI was most consistent in predicting >1-year mortality. The ACE-27 and KFI were most consistent in predicting medical complications.

CONCLUSION

Despite inconsistencies in the literature, CIs provide insights into the impact of comorbidities on outcomes in HNS. These scores should be employed as an adjunct in the preoperative assessment of HNS patients. Comparative studies are needed to identify indices that are most reliable in predicting HNS outcomes.

LEVEL OF EVIDENCE

NA Laryngoscope, 2021.

Clinical consequences of head and neck free-flap reconstructions in the DM population

Diabetes mellitus (DM) is a common comorbidity and risk factor for postoperative complications in head and neck (H&N) microsurgical reconstructions. Our study focused on the association between DM and individual complications regarding both surgical and medical aspects. A meta-analysis of English-language articles comparing a series of complications between DM and non-DM H&N free-flap recipients was performed by comprehensive meta-analysis (CMA). Twenty-seven articles presented 14,233 H&N free-flap reconstructions, and a subset of 2329 analyses including diabetic cases was included for final analysis. Total postoperative (RR = 1.194, p < 0.001; OR = 1.506, p = 0.030) and surgical (RR = 1.550, p = 0.001; OR = 3.362, p < 0.001) complications were increased in DM subjects. Free-flap failure/necrosis (RR = 1.577, p = 0.001; OR = 1.999, p = 0.001) and surgical site infections (OR = 2.414, p < 0.001) were also increased in diabetic recipients. However, return to the operating room, dehiscence, fistulas, plate exposures, readmissions, and mortalities were not increased in DM patients. DM increased various complications in H&N free-flap reconstructions. Surgical indications should be cautiously evaluated, and aggressive treatments should be implemented for high-risk recipients.

[Outcomes of comanagement with Internal Medicine in Otolaryngology]

BACKGROUND AND OBJECTIVE

The age and comorbidity of patients admitted to Otolaryngology are increasing, leading to increased consultations/referrals to Internal Medicine, but do not reach the required effectiveness. An alternative is comanagement. A study is conducted on the effect of comanagement on Otolaryngology.

METHODS

A retrospective observational study was conducted on patients ≥16 years old admitted in Otolaryngology between 03 December 2017 and 03 December 2019, since 03/12/2018 with comanagement with Internal Medicine since 03 December 2018. An analysis was performed on age, gender, type of admission, and whether the patient had surgery, administrative weight associated with (diagnosis-related group) DRG, total number of diagnoses at discharge, Charlson comorbidity index, deaths, urgent readmissions, and length of stay.

RESULTS

Comanaged patients were younger (3.1 years, 95% confidence interval [95% CI] 1.4 to 4.8), but with higher Charlson comorbidity index (0.2; 95% CI; 0.1 to 0.3), number of diagnoses (0.9; 95% CI; 0.6 to 1.2), and administrative weight (0.04; 95% CI; 0 to 0.09). On adjustment, comanagement reduced Otolaryngology length of stay by 26.7%, 0.8 days (95% CI; 0.3 to 1.3), 50% of urgent readmissions, and 60% mortality, both non-significant. The decrease in length of stay implies an Otolaryngology savings of at least € 320,476.5.

CONCLUSIONS

Patients admitted to Otolaryngology are increasing in age and comorbidity. Comanagement is associated with reduced length of stay and costs similar to those observed in other surgical services.

The impact of diabetes in head and neck cancer

PURPOSE OF REVIEW

A strong association between diabetes mellitus and carcinogenesis has been reported in different organs. The purpose of this review is to summarize the new evidences in relation to diabetes mellitus and its association with the development, prognosis, and therapeutic strategies of head and neck squamous cell carcinomas (HNSCC).

RECENT FINDINGS

Recent publications suggest that glycemic metabolism is altered in HNSCC. Elevated blood glucose levels, before or around the time of diagnosis, have been reported to reduce survival rates in HNSCC. Also, the homeostasis model assessment-insulin resistance has been independently associated with disease-free survival, suggesting that improving the glycemic control may improve the prognosis in this group of patients.Epidemiological studies revealed that cancer patients with diabetes mellitus have less cancer-related mortality after antiglycemic treatment, opening the option to include antiglycolytic agents, such as metformin, in the therapeutic plan. This finding is in accordance with in-vitro studies that demonstrated a decrease in tumor-cell proliferation with antidiabetic medications.

SUMMARY

Recent findings highlight the importance of glucose metabolism in the pathogenesis and progression of cancer cells. The knowledge of these altered pathways gives us an opportunity to design target treatments aimed to modulate glucose catabolism.

Free Flaps for Advanced Oral Cancer in the "Older Old" and "Oldest Old": A Retrospective Multi-Institutional Study

Introduction: Surgery followed by adjuvant therapy represents the most adequate treatment for advanced oral squamous cell carcinoma (OSCC). Free flaps are considered the best reconstructive option after major oral surgery. In the last decades, OSCC has increased in the elderly due to an augmented life span. The aim of this work is to evaluate the feasibility of microvascular surgery in patients older than 75 years, focusing on clinical and surgical prognosticators.

Methods: “Older old” (aged ≥ 75) and “oldest old” (>85) patients who underwent microvascular reconstruction for OSCC from 2002 to 2018 were retrospectively evaluated in three referral Head and Neck Departments. Demographic, clinical, and surgical data were collected and analyzed. Pre-operative assessment was performed by ASA and ACE-27 scores. Complications were grouped as medical or surgical, and major or minor according to the Clavien-Dindo scale.

Results: Eighty-four patients (72 “older old” and 12 “oldest old”) were treated with a free flap success rate of 94.1%. Thirty-seven (44.7%) and nine (10.7%) patients had minor and major medical complications, respectively; 18 (21.4%) and 17 (20.2%) had minor and major surgical complications, respectively. Twenty-one (25%) patients had both medical and surgical complications (with a statistically significant association, p = 0.018). Overall, 52 (61.9%) patients had at least one complication: ASA score, diabetes mellitus, and duration of general anesthesia (DGA) significantly impacted the complication rate at multivariate analysis.

Conclusion: Our data confirm the feasibility of free flaps for OSCC reconstruction in appropriately selected elderly patients. Pre-operative assessment and aggressive management of glycemia in patients with diabetes is mandatory. DGA should be reduced as much as possible to prevent post-surgical complications. Comprehensive geriatric assessment is of paramount importance in this subset of patients.