Influence of preoperative nutritional state on inflammatory response after surgery

Spinal infection after vertebral augmentation: a covert complication with serious havoc

INTRODUCTION

Vertebral augmentation, including percutaneous vertebroplasty (PVP) or kyphoplasty (PKP), is the current least invasive surgical option and has been widely used to treat the painful osteoporotic vertebral compression fractures (OVCF). However, the postoperative infections could be life-threatening, even though they rarely occur. Our studies aim to clarify the causation and outcomes of spinal infections following augmentation and meanwhile to identify the risk factors.

METHODS

A retrospective study was conducted on patients with OVCF who underwent PVP or PKP, and were subsequently admitted to our institution with postoperative spinal infection between January 2010 and December 2022. A total of 33 patients were finally included.

RESULTS

The rate of spinal infection after augmentation in our single institute was 0.05% (2/3893). In addition to these 2 patients, the remaining 31 were referred from other hospitals. All 33 patients exhibited elevated inflammatory parameters, 14 patients presented with fever, and 9 patients experienced neurological deficits. Additionally, 29 patients had comorbidity and risk factors. Pathogens were identified in 26 patients, while only 7 patients were examined as culture negative. 27 patients underwent revision surgery and 6 patients only received conservative therapy. Anterior surgery was performed in 2 patients, while posterior surgery was performed in 20 patients. A combined anterior-posterior surgery was performed in 5 patients. At the final follow-up, 18 patients had unrestricted mobility, 10 patients required assistance from crutches or a walker for ambulation, 4 patients needed a wheelchair, and 1 patients died after revision surgery.

CONCLUSIONS

Spinal infection after vertebral augmentation is rare, but it cannot be ignored. Surgeons should make every effort to detect the potential preoperative spondylitis or discitis. Once postoperative spinal infection is confirmed, a prompt intravenous antibiotic therapy is warranted. If medication therapy fails, revision surgery involving debridement and spinal reconstruction should be considered.

Independent predictors of systemic inflammatory response syndrome for intramedullary nailing of femoral shaft fractures: Analysis of national inpatient sample database

Background

The systemic inflammatory response syndrome (SIRS) is a clinical reaction that can occur due to a variety of stimuli. Reamed intramedullary femoral nailing is a common orthopedic surgery that has been shown to induce SIRS. To date, no nationwide analyses have been performed to evaluate the incidence, risk factors, and economic burdens of SIRS following intramedullary femoral nailing for femoral shaft fractures. The objective of this study is to investigate the independent predictors, incidence, post-operative, and economic burden of SIRS among patients treated with intramedullary nailing for femoral shaft fractures.

Methods

We utilized the 2016-2019 National Inpatient Sample (NIS) to identify patients who underwent intramedullary femoral nailing and were diagnosed with non-infectious SIRS (NI-SIRS) based on ICD-10-CM coding. Identified patients who underwent intramedullary femoral nailing were dichotomized into SIRS and Non-SIRS groups to assess independent predictors of SIRS development, and to compare post-operative complications and costs.

Results

A total of 65,240 patients with femur shaft fractures underwent IMFN, of which 665 (1.0 %) developed NI-SIRS. Patients with NI-SIRS had a higher incidence of laparotomy (OR = 13.97, p < 0.001), initial treatment with external fixation (OR = 1.845, p < 0.001), and late application of external fixation (OR = 4.884, p = 0.005). Routine discharge (OR = 0.491, p < 0.001) was less likely in patients with NI-SIRS. Length of stay (12.38 days vs 7.16 days, p < 0.001) and total charges ($278, 590 vs $145,118, p < 0.001) were both increased in patients with NI-SIRS.

Conclusion

NI-SIRS is associated with increasing injury severity and post-operative complications. Those that developed NI-SIRS experienced higher healthcare resource utilization. Risk factors associated with development of NI-SIRS warrant further investigation.

Changes in spinal alignment one month post abdominal surgery: A prospective cohort study

Following abdominal surgery, many patients assume a bending or stooping posture to protect the surgical wound. Such postural changes are known to induce side effects, but the improvement and persistence of these effects are unknown. Therefore, the purpose of this study was to clarify the nature of postural changes in patients undergoing abdominal surgery. In this prospective cohort study, we enrolled 25 patients who underwent abdominal surgery from February 2019 to January 2020. Measurements were obtained during the preoperative, pre-discharge, and first outpatient stages. The sacral tilt, lumbar lordotic, thoracic kyphosis, and overall tilt angles were measured in the static standing position in a private room. Wound pain was measured using a Visual Analogue Scale. Repeated measures analysis of variance was applied to compare spine measurements for each measurement period, followed by the Bonferroni method for each level. Pearson's product-moment correlation coefficient was performed to examine the relationship between wound pain and spinal column angle. The lumbar kyphosis angle was lower before discharge (-7.2 ± 7.4°) compared to preoperatively (-11.1 ± 7.5°) (95% CI 0.76, 7.08; P < .01, η2 = 0.21). Regarding the overall tilt angle, the anterior tilt angle increased before discharge (3.4 ± 3.9°) compared to preoperatively (1.1 ± 4.1°) (95% CI 0.86, 3.78; P < .01, η2 = 0.33). No statistically significant correlation with pain was observed. Compared to the preoperative period, the patients had an anterior tilt, mainly due to lumbar spine changes, prior to discharge from the hospital. Changes in spinal alignment were not associated with wound pain.

Is There Synergistic Effect Between Obesity and Hypoalbuminemia on Postoperative Outcomes Among Primary Total Shoulder Arthroplasty Recipients?

Background

Malnutrition and obesity are established predictors of complications following joint replacement surgery. However, the effect of obesity in the setting of albumin deficiency has not been explored in non-weight-bearing upper-extremity joint arthroplasty.

Purpose

We sought to determine whether there is a synergistic effect between obesity and hypoalbuminemia among patients undergoing primary total shoulder arthroplasty (TSA) with respect to postoperative outcomes, including (1) mortality rates, (2) composite surgical complications, (3) length of hospitalization, and (4) hospital readmission.

Methods

We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database to find patients who underwent primary TSA from January 1, 2006, to December 31, 2019. We grouped these patients as obese (body mass index [BMI] ≥ 30 kg/m2) or nonobese (BMI = 18.5-29.9 kg/m2) and by serum albumin level (hypoalbuminemia < 3.5 mg/dL or normoalbuminemia ≥ 3.5 mg/dL). We gathered data on readmission and mortality rates, and NSQIP complications were organized into 3 composite variables: wound infection, systemic infection, and cardiac/pulmonary complication. For each outcome, multivariate logistic regression analysis evaluated its association with obesity and hypoalbuminemia, as well as with the interaction of BMI and albumin, while adjusting for covariates.

Results

Of 12,881 patients, 51.8% were obese and 7.0% had hypoalbuminemia; 7.6% of obese patients had hypoalbuminemia versus 6.3% of those who were not obese. Patients with hypoalbuminemia had the longest hospital stays and the highest rates of mortality and systemic infection of all subgroups. Multivariate logistic regression analysis did not show higher complication rates due to obesity or evidence of additive interaction between hypoalbuminemia and obesity.

Conclusion

Unlike previous reports in weight-bearing arthroplasty, in this retrospective study of a cohort of patients who underwent TSA, we did not observe greater complications due to obesity alone, nor did we find evidence of additive interaction between obesity and hypoalbuminemia. This distinction may be due to the non-weight-bearing nature of TSA, in which excessive BMI may be less relevant for postoperative healing.

Effect of Preoperative Serum Transthyretin Levels on Postoperative Clinical Results and Morbidity in Patients Undergoing Spinal Surgery

Introduction This study aims to investigate the effects of preoperative serum transthyretin (TTR) levels on surgical success, pain scores, and postoperative morbidity.

Methods Note that, in our clinic, 188 patients who were operated for spinal pathologies between June 2010 and January 2011 were included in this study. Blood samples were drawn from all patients on the morning of surgery and then serum TTR measurements were made. Demographic data of all patients were collected, and then their preoperative and postoperative neurological examinations, Karnofsky scores, visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, postoperative infection and wound healing status, hospital stay, and morbidity levels were recorded and TTR levels were compared.

Results When preoperative TTR level of patients were low, their Karnofsky scores decreased, ODI scores increased, the early postoperative VAS and late postoperative VAS values increased, and the length of hospital stay was increased. Moreover, in patients with low TTR levels, postoperative Karnofsky scores were lower, postoperative ODI levels were higher, postoperative early and late VAS scores were higher, hospital stays were longer, peroperative complication rates were higher, wound infection rates were higher, the delay in wound site healing was higher, and the morbidity rate was higher.

Conclusion Consequently, preoperative low TTR levels have been reported to be an effective parameter that can be used to predict surgical results, wound infection and wound site healing status, perioperative complications, and morbidity in spinal surgery.

The impact of pre-operative biologic therapy on post-operative surgical outcomes in ulcerative colitis: a systematic review and meta-analysis

BACKGROUND AND AIMS

Biologic therapy has emerged as an effective modality amongst the medical treatment options available for ulcerative colitis (UC). However, its impact on post-operative care in patients with UC is still debatable. This review evaluates the risk of post-operative complications following biologic treatment in patients with UC.

METHODS

A systematic search of the relevant databases was conducted with the aim of identifying studies that compared the post-operative complication rates of UC patients who were either exposed or not exposed to a biologic therapy prior to their surgery. Outcomes of interest included both infection-related complications and overall surgical morbidity. Pooled odds-ratio (OR) and 95% confidence intervals (CI) were calculated using Review Manager 5.3.

RESULTS

In all, 20 studies, reviewing a total of 12,494 patients with UC, were included in the meta-analysis. Of these, 2254 patients were exposed to a biologic therapy prior to surgery. The pooled ORs for infection-related complications (n = 8067) and overall complications (n = 11,869) were 0.98 (95% CI 0.66-1.45) and 1.14 (95% CI 1.04-1.28), respectively, which suggested that there was no significant association between the use of pre-operative biologic therapy and post-operative complications. Interestingly, the interval between the last dose of biologic therapy and surgery did not influence the risk of having a post-operative infection.

CONCLUSIONS

This meta-analysis suggests that pre-operative biologic therapy does not increase the overall risk of having post-operative infection-related or other complications. PROSPERO registration id-CRD42019141827.

Serum albumin levels and their correlates among individuals with motor disorders at five institutions in Japan

BACKGROUND/OBJECTIVES

The level of serum albumin is an index of nourishment care and management. However, the distribution and correlates of serum albumin levels among individuals with motor disorders have not been reported until now. Therefore, we examined the distribution and correlates of serum albumin levels among individuals with motor disorders.

SUBJECTS/METHODS

A cross-sectional study on 249 individuals with motor disabilities (144 men, mean age: 51.4 years; 105 women, mean age: 51.4 years) was conducted at five institutions in Ibaraki Prefecture, Japan in 2008. The results were compared with data from the National Health and Nutrition Survey.

RESULTS

The mean serum albumin levels were 4.0 ± 0.4 g/dL for men and 3.8 ± 0.5 g/dL for women. Overall, 17 (11.8%) men and 25 (23.8%) women had hypoalbuminemia (serum albumin level ≤ 3.5 g/dL); these proportions were greater than those among healthy Japanese adults (≤ 1%). Low serum albumin level was related with female sex, older age, low calf circumference, low relative daily energy intake, low hemoglobin (Hb), low blood platelet count, low high-density lipoprotein cholesterol (HDL-C), low HbA_1c, and high C-reactive protein (CRP) levels. The strongest correlates, based on standardized betas, were Hb (0.321), CRP (-0.279), and HDL-C (0.279) levels.

CONCLUSIONS

These results indicate that the prevalence of hypoalbuminemia is higher in individuals with motor disabilities than in healthy individuals and that inflammation is a strong negative correlate of serum albumin levels. Therefore, inflammation should be examined for the assessment of hypoalbuminemia among institutionalized individuals with motor disabilities.

Influence of preoperative peripheral parenteral nutrition with micronutrients after colorectal cancer patients

BACKGROUND

The inflammatory reactions are stronger after surgery of malnourished preoperative patients. Many studies have shown vitamin and trace element deficiencies appear to affect the functioning of immune cells. Enteral nutrition is often inadequate for malnourished patients. Therefore, total parenteral nutrition (TPN) is considered an effective method for providing preoperative nutritional support. TPN needs a central vein catheter, and there are more risks associated with TPN. However, peripheral parenteral nutrition (PPN) often does not provide enough energy or nutrients.

PURPOSE

This study investigated the inflammatory response and prognosis for patients receiving a modified form of PPN with added fat emulsion infusion, multiple vitamins (MTV), and trace elements (TE) to assess the feasibility of preoperative nutritional support. Methods. A cross-sectional design was used to compare the influence of PPN with or without adding MTV and TE on malnourished abdominal surgery patients.

RESULTS

Both preoperative groups received equal calories and protein, but due to the lack of micronutrients, patients in preoperative Group B exhibited higher inflammation, lower serum albumin levels, and higher anastomotic leak rates and also required prolonged hospital stays.

CONCLUSION

Malnourished patients who receive micronutrient supplementation preoperatively have lower postoperative inflammatory responses and better prognoses. PPN with added fat emulsion, MTV, and TE provides valid and effective preoperative nutritional support.

Is potential malnutrition associated with septic failure and acute infection after revision total joint arthroplasty?

BACKGROUND

Although malnutrition has been hypothesized to increase the risk of periprosthetic joint infection (PJI), strong evidence linking the two is lacking.

QUESTIONS/PURPOSES

The purposes of this study were to determine (1) if one or more laboratory values suggestive of malnutrition is independently associated with being revised for an infected joint arthroplasty as opposed to for an aseptic failure; (2) the relationship between laboratory parameters suggestive of malnutrition and obesity; and (3) if one or more laboratory parameters suggestive of malnutrition is independently associated with acute PJI complicating an aseptic revision procedure.

METHODS

Between 2002 and 2010, one surgeon performed 600 revision total joint arthroplasties in 547 patients; during that time, nutritional parameters (including serum albumin, total lymphocyte count, and transferrin) were routinely obtained preoperatively; complete data sets were available on 454 patients (501 procedures [84%]). We compared the frequency of having one or more laboratory parameters suggestive of malnutrition between patients undergoing a revision for septic reasons and aseptic reasons as well as between obese and nonobese patients. The 375 aseptic revisions were then assessed for the incidence of acute postoperative infection (within 90 days, diagnosed with Musculoskeletal Infection Society criteria). Multivariate logistic regression modeling was used to evaluate factors independently associated with (1) a septic as opposed to an aseptic mode of failure; and (2) acute postoperative infection after an aseptic revision.

RESULTS

Patients in 67 of 126 (53%) revisions for PJI had one or more laboratory parameters suggestive of malnutrition compared with 123 of 375 (33%) undergoing revision for a noninfectious etiology (odds ratio [OR], 2.3 [95% confidence interval, 1.5-3.5]; p<0.001). Patients who were of normal weight at the time of revision had the highest frequency of laboratory parameters suggestive of malnutrition (42 of 82 [51%]), although this was common in obese patients as well (76 of 238 [32%]) (p=0.002). Among the 375 aseptic revisions, 12 developed an acute postoperative infection (3%). The frequency of infection was nine of 123 in the group having one or more laboratory parameters suggestive of malnutrition and three of 252 in the group not having such laboratory parameters (7% versus 1%; p=0.003). Multivariate regression revealed that having laboratory parameters suggestive of malnutrition is independently associated with both chronic PJI (p=0.003; OR, 2.1) and an acute postoperative infection complicating an aseptic revision arthroplasty (p=0.02; OR, 5.9).

CONCLUSIONS

Having one or more laboratory parameters suggestive of malnutrition is common among patients undergoing revision arthroplasty and is independently associated with both chronic septic failure and acute postoperative infection complicating a revision performed for a noninfectious etiology. Future studies should assess the impact of a standardized screening protocol with subsequent correction of abnormal laboratory parameters suggestive of malnutrition on the risk of PJI to determine a potential causal relationship between the two.

LEVEL OF EVIDENCE

Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Nutritional Effect of Oral Supplement Enriched in ω-3 Fatty Acids, Arginine, RNA on Immune Response and Leukocyte-platelet Aggregate Formation in Patients Undergoing Cardiac Surgery

The aim of the present study was to investigate the influence of a supplement enriched in ω-3 fatty acids on immune responses and platelet–leukocyte complex formation in patients undergoing cardiac surgery. Patients in the supplement group (n = 7) took a supplement enriched in ω-3 fatty acids (Impact^®) in addition to a hospital diet for five successive days before surgery; those in the control group (n = 7) took only hospital diet and did not take Impact^®. Blood samples in both groups were collected at same time points. Before surgery, samples were collected five days before surgery, at the start of supplementation (baseline), and the end of supplementation (postoperative day (POD)-0). After surgery, samples were collected on POD-1 and POD-7. The expression of human leukocyte antigen (HLA)-DR, the ratio of CD4-/CD8-positive cells, the production of interferon (IFN)-γ by CD4-positive cells, plasma levels of cytokines, and leukocyte–platelet aggregates were measured. Before surgery (POD-0), the supplement caused significant increases in HLA-DR expression, CD4/CD8 ratio, and plasma levels of IFN-γ; these levels were significantly higher compared to those in the control group (P < 0.05, respectively). After surgery (POD-1), all values dramatically decreased in comparison with those of POD-0; however, the values in the supplement group were significantly higher compared to their respective markers in the control group (P < 0.05, respectively). Significant differences of HLA-DR expression and CD4/CD8 ratio persisted through POD-7. Before surgery (POD-0), plasma levels of interleukin (IL)-10 in the supplement group decreased significantly compared with those in the control group (P < 0.05). After surgery (POD-1), plasma levels of IL-10 in both the control and supplement groups increased; these levels in the supplement group were significantly lower than those in the control group (P < 0.05). Significant decreases in the percentage of leukocyte–platelet aggregates were found after supplementation; the difference between the supplement and the control groups was found on POD-0 and POD-1 (P < 0.05, respectively). In conclusion, the dietary supplement increased HLA-DR expression, the CD4/CD8 ratio, and the production of IFN-γ by CD4-positive cells; conversely, the levels of IL-10 and the formation of leukocyte–platelet aggregates before and after surgery were suppressed. These beneficial effects may decrease the incidence of complications after surgery.

Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends

Pressure ulcers in spinal cord injury represent a challenging problem for patients, their caregivers, and their physicians. They often lead to recurrent hospitalizations, multiple surgeries, and potentially devastating complications. They present a significant cost to the healthcare system, they require a multidisciplinary team approach to manage well, and outcomes directly depend on patients' education, prevention, and compliance with conservative and surgical protocols. With so many factors involved in the successful treatment of pressure ulcers, an update on their comprehensive management in spinal cord injury is warranted. Current concepts of local wound care, surgical options, as well as future trends from the latest wound healing research are reviewed to aid medical professionals in treating patients with this difficult problem.

Quality of life and protein-energy wasting in kidney transplant recipients

PURPOSE

Chronic kidney disease has profound effects on the health-related quality of life (HRQoL) of patients, with serious physiological, psychological and socio-economic implications. The co-occurrence of protein-energy wasting and inflammation in end-stage renal disease patients is associated with worse HRQoL and increased mortality. We designed this study to examine the relationship between nutritional and inflammatory status and HRQoL in kidney transplant recipients.

METHODS

Data from 100 randomly selected kidney transplant patients were analyzed in a cross-sectional survey. Socio-demographic parameters, laboratory results, transplantation-related data, comorbidities, medication and malnutrition-inflammation score (MIS) (Kalantar Score) were tabulated at baseline. Patients completed the Kidney Disease Quality of Life-SF (KDQoL-SF™) self-administered questionnaire.

RESULTS

Mean age was 51 ± 13 years, median (interquartile range, IQR) time since transplantation 66 (83) months, 57% were men, and 19% had diabetes. The median (IQR) MIS was 3 (3). The MIS significantly and negatively correlated with almost all HRQoL domains analyzed, and this association remained significant in multivariate linear regression analysis for the log-transformed scores on energy/fatigue (β = -0.059 P < 0.001), bodily pain (β = -0.056 P = 0.004), physical functioning (β = -0.029, P = 0.022) and symptoms/problems (β = -0.023 P = 0.005) domains after statistical correction for age, gender, eGFR, dialysis vintage, Charlson Comorbidity Index and occupational status. Additionally, cubic spline analyses revealed linearly increasing, "dose-response" relationship between almost all domains of KDQoL-SF™ and the MIS.

CONCLUSIONS

Malnutrition-inflammation score is independently associated with different dimensions of HRQoL in kidney transplant recipients.

Prealbumin levels as a useful marker for predicting infectious complications after gastric surgery

BACKGROUND/OBJECTIVES

Preoperative nutritional status is associated with postoperative complications. Prealbumin, a visceral protein, is sensitive to protein malnutrition. The objective of this study is to evaluate the role of preoperative prealbumin levels as a marker for predicting complications after gastric surgery.

METHODS

An observational study was performed on 183 patients who underwent gastric surgery due to benign or malignant gastric disease at Seoul National University Hospital (SNUH) between August 2009 and October 2010. Preoperative prealbumin levels were also measured. Nutritional variables such as prealbumin (cutoff value, 18 mg/dL), albumin, body mass index (BMI), and clinicopathologic data were collected. Postoperative hospital stay, 30-day complications and mortality rate were obtained to investigate outcomes.

RESULTS

The complication rate was 52% in the abnormal prealbumin group (n = 23) and 24% in the normal prealbumin group (n = 160; p = 0.005). The complication rate was higher in patients with low preoperative albumin levels (<3.5 g/dL) and abnormal BMI (<18.5 kg/m(2)), but the differences were not statistically significant. Comorbidity of diabetes mellitus (DM), resection extent, combined resection, TNM stage and prealbumin levels were associated with complications. In multivariate analysis, DM and combined resection were significantly correlated with complications (p = 0.001 for each). In subgroup analysis, resection extent, approach, combined resection, TNM stage, and prealbumin levels were significantly associated with infectious complications. Multivariate analysis identified combined resection (p = 0.001) and prealbumin levels (p = 0.032) as independent variables.

CONCLUSIONS

Preoperative prealbumin levels could be a useful marker for predicting complications, especially infectious complications, after gastric surgery.

Preoperative Nutritional Status and Post-Operative Infection in Total Knee Replacements: A Prospective Study of 213 Patients

Purpose

To assess the potential relationship between preoperative nutritional status, including anthropometric parameters, and infection following total knee replacement surgery.

Methods

A total of 213 patients undergoing total knee replacement between December 2007 and May 2008 were prospectively studied. Patients with rheumatoid arthritis were excluded. For each patient we pre-operatively checked biochemical and anthropometric parameters of nutrition information about co-morbidities such as diabetes and high blood pressure, ASA score, age, and gender. Information about early infections, both superficial and deep, was collected. A descriptive statistical analysis and univariate/multivariate logistic regression model for risk factors were performed.

Results

Eleven patients (5.16%) had an infection, 5 deep and 6 superficial. Neither co-morbidities nor preoperatively biochemical parameters were associated with infection. However, in the univariate logistic regression model there was an inversely proportional relationship between triceps skinfold (TSF) and infection. After adjusting for age, ASA score and gender (multivariate logistic regression), TSF remained significantly associated with infection.

Conclusion

There was a statistically significant association between TSF and post-operative infection risk after TKR.

Level of evidence

Level I (Prospective prognostic study).

Is titanium mesh cage safe in surgical management of pyogenic spondylitis?

OBJECTIVE

To report our experience with pyogenic spondylitis treated with anterior radical debridement and insertion of a titanium mesh cage and to demonstrate the effectiveness and safety of the use of a titanium mesh cage in the surgical management of pyogenic spondylitis.

METHODS

We retrospectively analyzed the clinical characteristics of 19 patients who underwent surgical treatment in our department between January 2004 and December 2008. The average follow-up period was 11.16 months (range, 6-64 months). We evaluated risk factors, cultured organisms, lab data, clinical outcomes, and radiographic results. Surgical techniques for patients with pyogenic spondylitis were anterior radical debridement and reconstruction with titanium mesh cage insertion and screw fixation. All patients received intravenous antibiotics for at least 6 weeks postoperatively, and some patients received oral antibiotics.

RESULTS

The infections resolved in all of the patients as noted by normalization of their erythrocyte sedimentation rates and C-reactive protein levels. The mean pain score on a Visual Analog Scale was 7.8 (range, 4-10) before surgery and 2.4 (range, 1-5) after surgery. The Frankel grade was improved by one grade in seven patients. After surgery, the average difference of the angle was improved about 6.96° in all patients. At the last follow-up, the mean loss of correction was 4.86°.

CONCLUSION

Anterior radical debridement followed by the placement of instrumentation with a titanium mesh cage may be a safe and effective treatment for selected patients with pyogenic spondylitis. This surgical therapy does not lead to recurrent pyogenic spondylitis.

Lower albumin levels in African Americans at colon cancer diagnosis: a potential explanation for outcome disparities between groups?

BACKGROUND AND AIM

Colorectal cancer is the third most common cancer and 3rd leading cause of cancer-related death in the USA. African Americans (AA) have inferior outcomes when matched for diagnosis stage and socioeconomic situation. Nutritional status, at diagnosis and its contribution to the observed cancer outcome disparity, between AA and non-Hispanic whites (nHw) has not been evaluated to date. The aim of the investigation was to determine if differences in nutritional surrogate markers, such as serum albumin and body mass index (BMI), exist at the time of colorectal cancer diagnosis between AA and nHw.

METHODS

The University of Florida College of Medicine-Jacksonville endoscopy database was reviewed for all patients with a biopsied colorectal mass between January 2000 and December 2007. Patients were excluded if histology did not reveal colorectal adenocarcinoma or albumin/BMI was unavailable. Demographic data, tumor location, serum albumin within 60 days of diagnosis, presence of diabetes along with serum HbA1c were obtained.

RESULTS

During the study period, 321 patients had colorectal masses discovered and 156 met entry criteria. There was no difference between ethnic groups regarding gender distribution, tumor location, diabetes presence, or BMI. Mean albumin was significantly less in AA compared to nHw (p < 0.01). This persisted after adjustment for gender, presence/absence of diabetes, and BMI.

CONCLUSIONS

Lower albumin levels in AA indicate poorer nutritional status at colorectal cancer diagnosis compared to nHw. This may contribute to the outcome disparities observed between AA and nHw. Aggressive nutritional interventions to reverse this disparity should be evaluated.

Surgical treatment for delayed pyogenic spondylitis after percutaneous vertebroplasty and kyphoplasty. Report of 4 cases

Only 6 cases of pyogenic spondylitis following vertebroplasty or kyphoplasty have been reported, and their causes remained unclear. The authors report on 4 cases of delayed pyogenic spondylitis (DPS) following vertebroplasty or kyphoplasty for osteoporotic compression fractures and metastatic disease. Four patients presented with DPS after vertebroplasty or kyphoplasty and underwent surgical treatment. Clinical history, laboratory examination, and MR imaging confirmed the diagnosis of DPS. Anterior debridement, reconstruction, and posterior instrumented fusion were performed. The mean interval for the delayed occurrence of pyogenic spondylitis after surgery was 12.3 months. The infections were primarily bacterial in origin, but most patients also suffered diverse medical comorbidities. Despite successful treatment of the infections, comorbidity was and is a factor that compromises good results. Medical comorbidities associated with compromised immunity may increase susceptibility to DPS after vertebroplasty or kyphoplasty. In cases of incapacitating back pain after a pain-free period following either of these surgeries, evaluation of the erythrocyte sedimentation rate and C-reactive protein level and examination of contrast-enhanced MR imaging studies are essential to rule out delayed vertebral infection. Surgical treatment requires cement removal and anterior reconstruction with or without additional posterior instrumented fusion.

Factors predicting postoperative infectious complications and early induction of inflammatory mediators in ulcerative colitis patients

BACKGROUND

Positive outcomes after restorative proctocolectomy are compromised by a number of specific septic complications. However, there is no useful perioperative marker predicting postoperative infectious complications (PICs) in steroid overdosed patients with ulcerative colitis (UC).

METHODS

To determine factors associated with PICs and their relation to circulating levels of pro- and anti-inflammatory cytokines and neutrophil elastase (NE), we obtained perioperative blood samples from 60 UC patients.

RESULTS

Postoperative infectious complications were identified in 47% of cases. Patients who developed PICs had significantly longer disease duration, had been administered a greater total preoperative dosage of prednisolone, and had a higher body mass index. Logistic regression analysis showed that the total preoperative dosage of prednisolone was independently associated with the development of PICs. These patients showed suppressed systemic inflammation and pro- and anti-inflammatory cytokine induction. An early increase in the NE level was found to be predictive of PICs in the high-dose group, whereas there was no significant difference in neutrophil counts between the high- and low-dose groups.

CONCLUSIONS

Circulating NE levels in the early postoperative period might be a useful predictor of PICs in immune-controlled UC patients who received high doses of steroids.

Relation between nutritional state and postoperative complications in patients with oral and maxillofacial malignancy

PURPOSE

To evaluate the role of nutrition in the development of postoperative complications in patients with oral and maxillofacial malignancy.

PATIENTS AND METHODS

Ninety-six patients treated surgically for oral and maxillofacial malignancy, 27 of whom developed postoperative complications; the remaining 69 recovered uneventfully. Nutritional state and clinical variables in the two groups were compared.

RESULTS

The incidence of poor nutrition was greater in the complication group (56%) than in the uncomplicated group (20%) (p<0.001); the values for body weight, triceps skinfold thickness, arm circumference, arm muscle circumference, and creatinine-height index decreased more in the complicated than in the uncomplicated group (p<0.001); nitrogen and calorie intake during the first postoperative week was less in the complicated than in the uncomplicated group (p<0.001).

CONCLUSIONS

Poor nutrition plays an important part in the development of postoperative complications, and perioperative nutritional support of patients with oral and maxillofacial cancer must be properly managed.

Nutritional assessment using prealbumin as an objective criterion to determine whom should not undergo primary radical cytoreductive surgery for ovarian cancer

BACKGROUND

The purpose of this study was to determine if serum prealbumin could be used to objectively determine which patients could not safely undergo cytoreductive surgery.

METHODS

Patients with suspected ovarian cancer in a 24-month period underwent nutritional assessment during their preoperative workup and were followed for development of postoperative complications.

RESULTS

One hundred and eight of 114 patients underwent surgical cytoreduction. Of the 108 surgical patients, 88 patients had prealbumin levels <18 mg/dl and 24 patients had prealbumin levels <10 mg/dl. Postoperative complications increased with lower prealbumin levels. All complications occurred in group of patients with prealbumin <18 mg/dl (P=0.013). A significantly increased number of complications occurred in patients with prealbumin <10 mg/dl (61.5% vs. 6.4%, P<0.001, RR 9.6). All postoperative mortality in this series occurred in patients with prealbumin <10 mg/dl (23.1% vs. 0%, P<0.001). Patients whose prealbumin started low but was able to be raised to >10 mg/dl by TPN did not have significantly increased complications or EBL compared to patients whose initial prealbumin was >10 mg/dl (18.2% vs. 4.8%, P=0.95 and 570 vs. 600 ml, P=0.87).

CONCLUSIONS

Significantly more blood loss, morbidity, and mortality occurred in patients with abnormal preoperative prealbumin. This was especially true in patients with a prealbumin <10 mg/dl. With these significantly increased risks, patients with extremely poor nutritional status (prealbumin <10 mg/dl) may be better served by neoadjuvant chemotherapy with interval cytoreductive surgery if nutrition improves.

Effects of atorvastatin and aspirin combined therapy on inflammatory responses in patients undergoing coronary artery bypass grafting

This study was conducted to compare the effects of atorvastatin plus aspirin combined therapy on inflammatory responses, endothelial cell function, and blood coagulation system in patients undergoing coronary artery bypass grafting (CABG) to aspirin monotherapy. The patients were randomized into atorvastatin plus aspirin combined therapy group and aspirin monotherapy group. Reduced total cholesterol in the combined therapy group was found in a short term of medication for 14 days. On postoperative day (POD)-14, inhibitory effects of the combined therapy on whole blood aggregation as well as platelet activation assessed by flow cytometry were stronger than those of the monotherapy. Furthermore, cytokine, cytokine receptors, c-reactive protein and alpha1-acid glycoprotein in the combined therapy group were down-regulated on POD-14. At the same time, circulating levels of thromboxane A(2), vascular endothelial growth factor and thrombin-antithrombin III complex as well as P-selectin, L-selectin and intercellular adhesion molecule-1 were down-regulated, while E-selectin and transforming growth factor-beta1 was up-regulated. Atorvastatin plus aspirin combined therapy may improve inflammatory responses, accelerated platelet function, vascular endothelial cell function, blood coagulation system at the early stage such as 14th day after CABG. In conclusion, atorvastatin and aspirin combined therapy may bring beneficial effects to the patient after CABG.

Effect of tacrolimus and partial hepatectomy on transthyretin metabolism in rats

Liver transplantation, which serves as treatment of familial amyloidotic polyneuropathy (FAP), and domino liver transplantation, which utilizes resected livers from patients with FAP for treatment of liver diseases, may induce changes in transthyretin (TTR), a pathogenic FAP-related protein. To evaluate this possibility, we performed a 70% hepatectomy or administered tacrolimus to Dark Agouti (DA) rats for 7 days and then measured changes in liver TTR mRNA levels and changes in serum TTR concentrations. After hepatectomy, TTR mRNA levels decreased by 77%; at day 3, they returned to preoperative levels. Except for slightly elevated serum TTR concentrations 12 h after operation, serum TTR levels remained unchanged. Thus, partial hepatectomy did not influence serum TTR concentrations. After tacrolimus administration, TTR mRNA declined by 56% 12 h after the experiment started; however, after day 3, a rebound phenomenon occurred until day 7. Tacrolimus may facilitate serum TTR degradation, although production of TTR in the liver also increased. This finding -- that TTR, the source of FAP-inducing amyloid, did not increase after transplantation -- may help post-transplantation treatment of patients who have FAP and other liver diseases.

Influence of preoperative administration of omega-3 fatty acid-enriched supplement on inflammatory and immune responses in patients undergoing major surgery for cancer

OBJECTIVE

Polyunsaturated fatty acid supplementation may produce beneficial effects after surgery. We investigated the influence of preoperative administration of a supplement rich in arginine, omega-3 fatty acids, and RNA, Impact (Japan), on inflammatory and immune responses in patients undergoing major surgery for cancer.

METHODS

Patients in the supplement group (n = 12) received 1 L/d of Impact (Japan) for 5 d before surgery, and those in the control group (n = 14) received an ordinary diet without Impact (Japan) before surgery. Plasma levels of omega-3 and omega-6 fatty acids, thromboxane B(2), prostaglandin E(2), inflammatory markers, nutritional markers, cytokines, and cytokine receptors were obtained 5 d before the operation at the starting point of supplementation in the supplement group. Samples were collected on postoperative days (PODs) 0, 1, 3, and 7.

RESULTS

After taking the supplement, significant increases in omega-3 fatty acids and rapid turnover proteins were found the day after ending supplementation (POD-0), whereas thromboxane B(2) levels and the ratio of omega-6 fatty acids to omega-3 fatty acids were significantly lower than before supplementation (P < 0.001). On POD-0 only, inflammatory markers and cytokine receptors in the supplement group showed low levels in comparison with the control group (P < 0.05). On POD-1 and POD-3, remarkable decreases in polymorphonuclear leukocyte-elastase and interleukin-8 in the supplement group were observed.

CONCLUSION

Our findings suggest that oral administration of a supplement rich in omega-3 fatty acids for 5 d before surgery may improve not only preoperative nutritional status but also preoperative and postoperative inflammatory and immune responses in patients who have cancer.

Role of perioperative parenteral nutrition in severely malnourished patients with Crohn’s disease

AIM: To evaluate the effect of perioperative parenteral nutrition on serum immunoglobulin, weight change, and post-operative outcome in severely malnourished patients with Crohn’s disease.

METHODS: Thirty-two severely malnourished patients with Crohn’s disease who had undergone surgery in our hospital were reviewed. Sixteen patients who received perioperative parenteral nutrition were enrolled in the study group, and the other 16 patients who did not receive parenteral nutrition were enrolled in the control group. Serum immunoglobulin, body mass index (BMI), liver function, weight change, and postoperative complications were evaluated.

RESULTS: Serum IgM levels elevated 1 wk before surgery in both groups, and decreased to normal value (from 139 ± 41 to 105 ± 29 mg/dL, P = 0.04) 4 wk after operation in the study group, while no significant changes was noted in the control group (from 133 ± 16 to 129 ± 13 mg/dL, P = 0.34). There were no significant changes in concentrations of IgG and IgA. The BMI of the study group increased from 13.9 ± 0.6 to 15.3 ± 0.7 kg/m² (P = 0.02) with no significant change in the control group (14.1 ± 0.7 and 14.5 ± 0.5, respectively, P = 0.81). The percentage of resuming work was higher in the study group than in the control group.

CONCLUSION: Perioperative parenteral nutrition possibly ameliorates the humoral immunity, reverses malnutrition, and facilitates rehabilitation.

Alterations in the Systemic Inflammatory Response after Early Total Care and Damage Control Procedures for Femoral Shaft Fracture in Severely Injured Patients

BACKGROUND

Recently, there has been a move away from early total care in patients with severe, multiple injuries to damage control orthopedics (DCO) in an attempt to limit the physiologic insult resulting from operative treatment after trauma. For femoral shaft fracture, this entails initial external fixation and subsequent conversion to an intramedullary nail (IMN). We sought to quantify the inflammatory response to initial surgery and conversion and link this to subsequent organ dysfunction and complications.

METHODS

Patients with femoral shaft fracture and a New Injury Severity Score of 20 or more were included. Data were retrospectively collected for 4 days at admission and at exchange procedure (external fixation to intramedullary nail), and the Systemic Inflammatory Response Syndrome (SIRS) score and the Marshall multiorgan dysfunction score were calculated.

RESULTS

One hundred seventy-four patients met the inclusion criteria. The DCO group had significantly more severe injuries (New Injury Severity Score of 25.4 vs. 36.2, p < 0.0001) and significantly more head and thoracic injuries (both p < 0.0001). The mean SIRS score was significantly higher in the IMN group, from 12 hours until 72 hours postoperatively (p < 0.05). The mean peak postoperative SIRS score was significantly higher in the IMN group than in the DCO group, at the primary procedure and at conversion, as was the time with an SIRS score greater than 1. At conversion in the DCO group, the preoperative SIRS score correlated with magnitude and duration of elevation in the SIRS and multiorgan dysfunction scores (p < 0.0001).

CONCLUSION

It would appear that despite more severe injuries in the DCO group, patients had a smaller, shorter postoperative SIRS and did not suffer significantly more pronounced organ failure than the IMN group. DCO patients undergoing conversion while their SIRS score was raised suffered the most pronounced subsequent inflammatory response and organ failure. According to these data, DCO treatment was associated with a lesser systemic inflammatory response than early total care for femur fractures. The inflammatory status of the patient may be a useful adjunct in clinical decision making regarding the timing of conversion to an intramedullary device.

Study of the clinical effects of postoperative parenteral nutrition in 15 horses

Several clinical variables were compared in two groups of 15 horses recovering from resection and anastomosis of a strangulated small intestine; 15 were treated with parenteral nutrition and 15 were starved routinely. There was some evidence that parenteral nutrition had a short-lived adverse effect on both the catheter sites and gastric emptying, but there were no marked adverse clinical effects and no evidence of any improvement in the horses' condition.

Assessment of nutritional status on hospital admission: nutritional scores

Malnutrition is still a largely unrecognized problem in hospitals. Malnutrition in hospitalized patients is generally related to increasing morbidity and mortality, and costs and length of stay. The aim of this study was to assess the nutritional status of patients on admission to a general hospital using different nutritional scores and to test the sensitivity and specificity of these scores. Sample population included 60 patients (55% male; 45% female) selected (aged 65.6+/-15.9 y) at random by using a computer software program. The nutritional state assessment was performed within 48 h of admission, using different nutritional indices (Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Gassull classification, Instant Nutritional Assessment (INA) and a combined index). About 78.3% of patients were found to be malnourished on admission. The frequency of malnutrition degree varied from 63.3% as assessed by the SGA to 90% with the NRI. Malnutrition severity was not related to the diagnosis. However, an elderly population was associated with a higher prevalence of malnutrition. INA was the best single score to identify patients who are malnourished or at risk of malnutrition and who may benefit from nutrition support.

Early evolution of nutritional status and body composition after kidney transplantation

BACKGROUND

Previous series have dealt with nutritional status after kidney transplantation. However, few studies have described the outcome of body composition after kidney transplantation.

METHODS

A total of 44 cadaver kidney transplant recipients (28 men and 16 women) were followed prospectively during the first post-transplant year. Biochemical nutritional markers, dietary records, anthropometric measurements, and body composition were assessed at kidney transplantation and 3, 6, and 12 months later.

RESULTS

By the end of the first year, serum albumin level was not significantly different from initial values. Prealbumin and retinol binding protein decreased from 42.3 +/- 10.2 mg/dL to 30.4 +/- 6.3 mg/dL and from 1.96 +/- 0.61 g/dL to 0.65 +/- 0.2 g/dL (P < 0.0001). Separating patients by gender showed that dietary caloric and protein intake increased in women only. At the end of the follow-up period, mean weight change was +5.4 kg in women (P = 0.009) and -0.9 kg in men (not significant). Body composition analyses showed that in women total fat and lean masses increased (+2.1 kg, P = 0.05, and +2.4 kg, P = 0.006), whereas in men total fat mass decreased (-1.4 kg, P = 0.04), and total lean mass tended to increase (+0.5 kg, not significant). Percentage change in total bone mass was +1.4% in women (not significant) and -2.1% in men (P = 0.05). In multivariate analyses, an independent impact of female gender on weight gain was observed, although increased fat mass was related only to energy intake. Increased total lean mass was related to low steroid doses and the absence of acute rejection and delayed graft function. Bone loss was related to male gender and high steroid doses.

CONCLUSION

Changes in body composition during the first year after kidney transplantation are modulated by gender, energy intake, steroid doses, the occurrence of acute rejection, and delayed graft function.