Consequences of bed rest:

To Shrink or Not to Shrink? An Objective Assessment of Free Gracilis Muscle Volume Change in Lower-Extremity Defect Reconstruction

Background: The use of free gracilis muscle flaps in reconstructive surgery of the lower leg is common practice to cover defects. However, there is still a lack of understanding of the morphometric changes that occur in the transferred muscle and area of interest over time, particularly the characteristic volume decrease that is observed over the course of the first year. This study aimed to assess volume changes in patients with free gracilis muscle flap reconstruction following infection, trauma, or malignancies of the lower extremity. Methods: Three-dimensional surface imaging was performed intraoperatively after 2 weeks, 6 months, and 12 months with the Vectra H2 system. A total of 31 patients were included in this study and analyzed. Results: There was an average volume increase of 146.67 ± 29.66% 2 weeks after reconstruction. Compared to this volume increase, there was a reduction of 108.44 ± 13.62% after 12 months (p < 0.05). Overall, we found a shrinkage to 85.53 ± 20.14% of the intraoperative baseline volume after 12 months. Conclusions: The use of non-invasive 3D surface imaging is a valuable tool for volume monitoring after free flap reconstruction of the lower extremity. The free gracilis muscle flap undergoes different phases of volume change over the first year, with the greatest influence on overall change being the development and decongestion of edema. Precise initial surgical tailoring is crucial for optimal long-term functional and cosmetic results.

Establishing an artificial intelligence-based predictive model for long-term health-related quality of life for infected patients in the ICU

Objective

To develop a model using a Chinese ICU infection patient database to predict long-term health-related quality of life (HRQOL) in survivors.

Methods

A patient database from the ICU of the Fourth People's Hospital in Zigong was analyzed, including data from 2019 to 2020. The subjects of the study were ICU infection survivors, and their post-discharge HRQOL was assessed through the SF-36 survey. The primary outcomes were the physical component summary (PCS) and mental component summary (MCS). We used artificial intelligence techniques for both feature selection and model building. Least absolute shrinkage and selection operator regression was used for feature selection, extreme gradient boosting (XGBoost) was used for model building, and the area under the receiver operating characteristic curve (AUROC) was used to assess model performance.

Results

The study included 917 ICU infection survivors. The median follow-up was 507.8 days. Their SF-36 scores, including PCS and MCS, were below the national average. The final prognostic model showed an AUROC of 0.72 for PCS and 0.63 for MCS. Within the sepsis subgroup, the predictive model AUROC values for PCS and MCS were 0.76 and 0.68, respectively.

Conclusions

This study established a valuable prognostic model using artificial intelligence to predict long-term HRQOL in ICU infection patients, which supports clinical decision making, but requires further optimization and validation.

Risks of serious adverse events with non-steroidal anti-inflammatory drugs in gastrointestinal surgery: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended for perioperative opioid-sparing multimodal analgesic treatments. Concerns regarding the potential for serious adverse events (SAEs) associated with perioperative NSAID treatment are especially relevant following gastrointestinal surgery. We assessed the risks of SAEs with perioperative NSAID treatment in patients undergoing gastrointestinal surgery.

METHODS

We conducted a systematic review of randomised clinical trials assessing the harmful effects of NSAIDs versus placebo, usual care or no intervention in patients undergoing gastrointestinal surgery. The primary outcome was an incidence of SAEs. We systematically searched for eligible trials in five major databases up to January 2024. We performed risk of bias assessments to account for systematic errors, trial sequential analysis (TSA) to account for the risks of random errors, performed meta-analyses using R and used the Grading of Recommendations Assessment, Development and Evaluation framework to describe the certainty of evidence.

RESULTS

We included 22 trials enrolling 1622 patients for our primary analyses. Most trials were at high risk of bias. Meta-analyses (risk ratio 0.78; 95% confidence interval [CI] 0.51-1.19; I2 = 4%; p = .24; very low certainty of evidence) and TSA indicated a lack of information on the effects of NSAIDs compared to placebo on the risks of SAEs. Post-hoc beta-binomial regression sensitivity analyses including trials with zero events showed a reduction in SAEs with NSAIDs versus placebo (odds ratio 0.73; CI 0.54-0.99; p = .042).

CONCLUSION

In adult patients undergoing gastrointestinal surgery, there was insufficient information to draw firm conclusions on the effects of NSAIDs on SAEs. The certainty of the evidence was very low.

Efficacy and Safety of Paragastric Neural Blockade in Controlling Pain, Nausea, and Vomiting After Sleeve Gastrectomy: A Randomized Controlled Trial

BACKGROUND

There are difficulties in controlling the symptoms of pain, nausea, and vomiting after laparoscopic sleeve gastrectomy (LSG). This study aimed to evaluate the efficacy and safety of PGNB on pain and nausea and vomiting in the early postoperative period in patients who underwent LSG.

METHODS

In this prospective, randomized, controlled, double-blind study, the patients were divided into two equally formed groups: patients who underwent PGNB after LSG and the control group. Postoperative pain symptoms were evaluated using the visual analog scale (VAS) scores, and nausea and vomiting symptoms were evaluated using the postoperative nausea and vomiting (PONV) scores.

RESULTS

The study was completed with 90 patients, 45 patients in each group. The VAS scores measured at postoperative hours 1, 6, and 12 were statistically significantly lower in the PGNB group. There was no significant difference between the two groups in terms of the 24th hour VAS scores. The mean PONV scores of the PGNB and control groups were 0.47 ± 0.89 and 1.67 ± 1.95, respectively, revealing a significantly higher value for the controls. The mean time to first mobilization in the postoperative period was significantly shorter in the PGNB group. Upon the evaluation of patient satisfaction, it was determined that the satisfaction score of the PGNB group was significantly higher.

CONCLUSIONS

PGNB is an effective and safe method for managing pain, nausea, and vomiting that occur in the early period after LSG.

Early In-Bed Cycle Ergometry in Mechanically Ventilated Patients

BACKGROUND

Critical illness requiring invasive mechanical ventilation can precipitate important functional disability, contributing to multidimensional morbidity following admission to an intensive care unit (ICU). Early in-bed cycle ergometry added to usual physiotherapy may mitigate ICU-acquired physical function impairment.

METHODS

We randomly assigned 360 adult ICU patients undergoing invasive mechanical ventilation to receive 30 minutes of early in-bed Cycling + Usual physiotherapy (n=178) or Usual physiotherapy alone (n=182). The primary outcome was the Physical Function ICU Test-scored (PFIT-s) at 3 days after discharge from the ICU (the score ranges from 0 to 10, with higher scores indicating better function).

RESULTS

Cycling began within a median (interquartile range) of 2 (1 to 3) days of starting mechanical ventilation; patients received 3 (2 to 5) cycling sessions for a mean (±standard deviation) of 27.2 ± 6.6 minutes. In both groups, patients started Usual physiotherapy within 2 (2 to 4) days of mechanical ventilation and received 4 (2 to 7) Usual physiotherapy sessions. The duration of Usual physiotherapy was 23.7 ± 15.1 minutes in the Cycling + Usual physiotherapy group and 29.1 ± 13.2 minutes in the Usual physiotherapy group. No serious adverse events occurred in either group. Among survivors, the PFIT-s at 3 days after discharge from the ICU was 7.7 ± 1.7 in the Cycling + Usual physiotherapy group and 7.5 ± 1.7 in the Usual physiotherapy group (absolute difference, 0.23 points; 95% confidence interval, -0.19 to 0.65; P=0.29).

CONCLUSIONS

Among adults receiving mechanical ventilation in the ICU, adding early in-bed Cycling to usual physiotherapy did not improve physical function at 3 days after discharge from the ICU compared with Usual physiotherapy alone. Cycling did not cause any serious adverse events. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov numbers, NCT03471247 [full randomized clinical trial] and NCT02377830 [CYCLE Vanguard 46-patient internal pilot].).

A Culture of Early Mobilization in Adult Intensive Care Units: Perspective and Competency of Physicians

BACKGROUND

Early mobility (EM) is vital in the intensive care unit (ICU) to counteract immobility-related effects. A multidisciplinary approach is key, as it requires precise initiation knowledge. However, physicians' understanding of EM in adult ICU settings remains unexplored. This study was conducted to investigate the knowledge and clinical competency of physicians working in adult ICUs toward EM.

METHODS

This cross-sectional study enrolled 236 physicians to assess their knowledge of EM. A rigorously designed survey comprising 30 questions across the demographic, theoretical, and clinical domains was employed. The criteria for knowledge and competency were aligned with the minimum passing score (70%) stipulated for physician licensure by the medical regulatory authority in Saudi Arabia.

RESULTS

Nearly 40% of the respondents had more than 5 years of experience. One-third of the respondents received theoretical knowledge about EM as part of their residency training, and only 4% of the respondents attended formal courses to enhance their knowledge. Almost all the respondents (95%) stated their awareness of EM benefits and its indications and contraindications and considered it safe to mobilize patients on mechanical ventilators. However, 62.3% of the respondents did not support EM for critically ill patients on mechanical ventilators until weaning. In contrast, 51.7% of respondents advised EM for agitated patients with RASS > 2. Only 113 (47.9%) physicians were competent in determining the suitability of ICU patients for EM. For critically ill patients who should be mobilized, nearly 60% of physicians refused to initiate EM.

CONCLUSIONS

This study underscores insufficient practical knowledge of ICU physicians about EM criteria, which leads to suboptimal decisions, particularly in complex ICU cases. These findings emphasize the need for enhanced training and education of physicians working in adult ICU settings to optimize patient care and outcomes in critical care settings.

All day in bed, all night in the wheelchair: Unmet attendant care needs of people with spinal cord injury

CONTEXT

Having dependable attendant care is essential to the health and well-being of those most severely impacted by a spinal cord injury (SCI). Our objective was to identify how often people with SCI who require assistance for transfers either spend a full day in bed or all night in a wheelchair because they do not have paid or unpaid assistance.

FINDINGS

Of the 918 respondents, 319 (34.7%) indicated they needed someone's help for basic activities of daily living and 229 (24.9%) relied on someone's assistance for wheelchair-to-bed transfers. Nearly a quarter of participants (22.2%) reported staying in bed all day for at least one once on during the past year, with a median of 10 times among those with at least one day. Men reported a higher rate than women (25.6%, 13.6%) and nonwhites-Hispanics (33.3%) reported a higher percentage than non-Hispanic whites (18.6%). Just over one in every 20 participants (5.3%) reported staying in the wheelchair at least one night because they did not have attendant care, with a median of 2.5 times among those with at least one night. Over one in 10 (11.7%) nonwhites and Hispanics reported at least one overnight in the wheelchair compared with only (3.1%) for non-Hispanic whites.

CONCLUSION/CLINICAL RELEVANCE

Staying in bed all day and staying in the chair all night due to lack of attendant care represents a breakdown in the attendant care system and a threat to the well-being of those with SCI, particularly nonwhites and Hispanics, and men.

Bed rest impairs the vestibular control of balance

Prolonged bed rest impairs standing balance but the underlying mechanisms are uncertain. Previous research suggests strength loss is not the cause, leaving impaired sensorimotor control as an alternative. Here we examine vestibular control of posture in 18 male volunteers before and after 60 days of bed rest. Stochastic vestibular stimulation (SVS) was used to evoke sway responses before, 1 and 6 days after bed rest under different head yaw orientations. The directional accuracy and precision of these responses were calculated from ground reaction force vectors. Bed rest caused up to 63% increases in spontaneous standing sway and 31% reductions in leg strength, changes which were uncorrelated. The increase in sway was exacerbated when the eyes were closed. Mean directions of SVS-evoked sway responses were unaffected, being directed towards the anodal ear and rotating in line with head orientation in the same way before and after bed rest. However, individual trial analysis revealed 25%-30% increases in directional variability, which were significantly correlated with the increase in spontaneous sway (r = 0.48-0.71; P ≤ 0.044) and were still elevated on day 6 post-bed rest. This reveals that individual sway responses may be inappropriately oriented, a finding masked by the averaging process. Our results confirm that impaired balance following prolonged bedrest is not related to loss of strength. Rather, they demonstrate that the sensorimotor transformation process which converts vestibular feedback into appropriately directed balance responses is impaired. KEY POINTS: Prolonged inactivity impairs balance but previous research suggests this is not caused by loss of strength. Here we investigated vestibular control of balance before and after 60 days of bed rest using electrical vestibular stimulation (EVS) to evoke sway responses. Spontaneous sway significantly increased and muscle strength reduced following bed rest, but, in keeping with previous research, these two effects were not correlated. While the overall accuracy of EVS-evoked sway responses was unaffected, their directional variability significantly increased following bed rest, and this was correlated with the increases in spontaneous sway. We have shown that the ability to transform head-centred vestibular feedback into an appropriately directed body sway response is negatively affected by prolonged inactivity; this may contribute to the impaired balance commonly observed following bed rest.

Randomized comparative study of negative pressure wound therapy versus compression dressing on split-thickness skin grafts of the lower limbs in an elderly population

INTRODUCTION

Failure to adequately secure the skin graft to the lower limbs recipient bed can result in loss of the graft. Our objective was to compare the healing of split-thickness skin grafts three weeks postoperatively, using either negative pressure wound therapy (NPWT) or conventional compression bandaging.

METHODS

In this multicenter randomized controlled study, patients with tissue loss ranging from 50 cm2 to 600 cm2 on the lower limbs and treated with split-thickness skin grafts were included in three French hospitals. A digital photographic evaluation was performed at 3 weeks.

RESULTS

During 9 years, 70 patients were included in the study and allocated to a treatment group. The grafted area was similar in both groups. Loss of graft was significantly reduced in the NPWT group with 14.6 cm2 compared to 29 cm2 in the control group (p = 0.0003). The hospital stay was also significantly reduced in the NPWT group, at 4 days versus 6.5 days in the control group (p = 0.0284). In the NPWT group, 60% reported pain compared to 22.9% in the control group (p = 0.0048).

CONCLUSIONS

The use of NPWT dressings improves skin graft take by reducing necrosis, improving the graft's adherence to the recipient site, and reducing hospital length-of-stay.

Physical and Cognitive Impairment in Acute Respiratory Failure

Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.

Efficacy of the "Start to move" protocol on functionality, ICU-acquired weakness and delirium: A randomized clinical trial

OBJECTIVE

To evaluate the efficacy of the Start to move protocol compared to conventional treatment in subjects over 15 years of age hospitalized in the ICU on an improvement in functionality, decrease in ICU-acquired weakness (DAUCI), incidence of delirium, days of mechanical ventilation (MV), length of stay in ICU and mortality at 28 days.

DESIGN

randomized controlled clinical trial.

SETTING

Intensive Care Unit.

PARTICIPANTS

Includes adults older than 15 years with invasive mechanical ventilation more than 48h, randomized allocation.

INTERVENTIONS

Start to move protocol and conventional treatment.

MAIN VARIABLES OF INTEREST

Functionality, incidence of ICU-acquired weakness, incidence of delirium, days on mechanical ventilation, ICU stay and mortality-28 days, ClinicalTrials.gov number, NCT05053724.

RESULTS

69 subjects were admitted to the study, 33 to the Start to move group and 36 to conventional treatment, clinically and sociodemographic comparable. In the "Start to move" group, the incidence of IUCD at ICU discharge was 35.7% vs. 80.7% in the "conventional treatment" group (p=0.001). Functionality (FSS-ICU) at ICU discharge corresponds to 26 vs. 17 points in favor of the "Start to move" group (p=0.001). The difference in Barthel at ICU discharge was 20% in favor of the "Start to move" group (p=0.006). There were no significant differences in the incidence of delirium, days of mechanical ventilation, ICU stay and 28-day mortality. The study did not report adverse events or protocol suspension.

CONCLUSIONS

The application of the "Start to move" protocol in ICU showed a reduction in the incidence of IUAD, an increase in functionality and a smaller decrease in Barthel score at discharge.

Application of enhanced recovery after surgery (ERAS) protocols in adrenal surgery: A retrospective, preliminary analysis

BACKGROUND

The present study was conducted to evaluate the impact of enhanced recovery after surgery (ERAS) pathway in patients undergoing laparoscopic adrenalectomy (LA) for primary and secondary adrenal disease, in reducing the length of primary hospital stay and return to daily activities.

MATERIALS AND METHODS

This retrospective study was carried out on 61 patients who underwent LA. A total of 32 patients formed the ERAS group. A total of 29 patients received conventional perioperative care and were assigned as the control group. Groups were compared in terms of patient's characteristics (sex, age, pre-operative diagnosis, side of tumour, tumour size and co-morbidities), post-operative compliance (anaesthesia time, operative time, post-operative stay, post-operative numeric rating scale (NRS) score, analgesic assumption and days to return to daily activities) and post-operative complications.

RESULTS

No significant differences in anaesthesia time ( P = 0.4) and operative time ( P = 0.6) were reported. NRS score 24 h postoperatively was significantly lower in the ERAS group ( P < 0.05). The analgesic assumption in post-operative period in the ERAS group was lower ( P < 0.05). ERAS protocol led to a significantly shorter length of post-operative stay ( P < 0.05) and to return to daily activities ( P < 0.05). No differences in peri-operative complications were reported.

DISCUSSION

ERAS protocols seem safe and feasible, potentially improving perioperative outcomes of patients undergoing LA, mainly improving pain control, hospital stay and return to daily activities. Further studies are needed to investigate overall compliance with ERAS protocols and their impact on clinical outcomes.

Effect of 60 days of head down tilt bed rest on amplitude and phase of rhythms in physiology and sleep in men

Twenty-four-hour rhythms in physiology and behaviour are shaped by circadian clocks, environmental rhythms, and feedback of behavioural rhythms onto physiology. In space, 24 h signals such as those associated with the light-dark cycle and changes in posture, are weaker, potentially reducing the robustness of rhythms. Head down tilt (HDT) bed rest is commonly used to simulate effects of microgravity but how HDT affects rhythms in physiology has not been extensively investigated. Here we report effects of -6° HDT during a 90-day protocol on 24 h rhythmicity in 20 men. During HDT, amplitude of light, motor activity, and wrist-temperature rhythms were reduced, evening melatonin was elevated, while cortisol was not affected during HDT, but was higher in the morning during recovery when compared to last session of HDT. During recovery from HDT, time in Slow-Wave Sleep increased. EEG activity in alpha and beta frequencies increased during NREM and REM sleep. These results highlight the profound effects of head-down-tilt-bed-rest on 24 h rhythmicity.

Efficacy and Safety of Pericapsular Nerve Group Block for Hip Fracture Surgery under Spinal Anesthesia: A Meta-Analysis

Objective

To evaluate the effectiveness and safety of pericapsular nerve group (PENG) block for hip fracture surgery under spinal anesthesia.

Methods

This meta-analysis was registered on INPLASY (INPLASY202270005). PubMed, Embase, Cochrane, CNKI, and Wanfang databases were searched to collect the randomized controlled trials of the PENG block applied to hip fracture surgery in the setting of spinal anesthesia, with the search period from inception to 1 May 2023. Two independent researchers gradually screened the literature, evaluated the quality, extracted the data, and eventually pooled data using RevMan 5.4.

Results

Fifteen articles with 890 patients were enrolled. The combined results showed that the PENG block reduced pain scores during position placement (SMD = -0.35; 95% CI [-0.67, 0.02]; P=0.04; I2 = 0%). Subgroup analyses showed that compared to the unblocked group, the PENG block reduced pain scores at 12 h, 24 h, and 48 h postoperatively. The incidence of postoperative hypokinesia was reduced (RR = 0.11; 95% CI [0.01, 0.86]; P=0.04; I2 = 0.00%). The time to first walking was advanced (SMD = -0.90; 95% CI [-1.17, 0.63]; P < 0.00001; I2 = 0%).

Conclusion

The PENG block can reduce postoperative pain and pain during spinal anesthesia positioning, which is helpful to improve the operability and comfort of spinal anesthesia and facilitate postoperative muscle strength recovery and early activity.

Optimizing Early Recovery Through Timely Mobilization in Nephrectomy Patients: A Case Report

Nephrectomy, a surgical method involving the partial or complete removal of one or both kidneys, is performed if there is the presence of a tumor or many other reasons. In the above case, a 60-year-old female patient with a history of recurring symptoms, stomach pain, and fever, as well as a previous history of tuberculosis was brought to a tertiary care hospital. The patient underwent a left-sided nephrectomy. An X-ray and a complete blood count (CBC) were done during the investigations. Patients experienced various post-operative complications like respiratory discomfort, secretions, early fatigue, and intensive care unit-acquired weakness (ICUAW). The patient was referred for physiotherapy. Throughout the intervention, outcome assessments showed progressive improvement in lung capacity, inspiratory pressure, and quality of life scores. Goal-oriented physiotherapy was planned according to the severity of the symptoms of the patient. The physical therapy rehabilitation program in the above case was planned for six weeks focusing on symptoms like shortness of breath, early fatigue, secretions, respiratory discomfort, difficulty in maintaining good posture because of pain at the incision site, reduced mobility, and various post-operative complications. The study focuses on the efficacy of an integrated physiotherapy strategy in increasing lung compliance, secretion clearance, and overall respiratory health. Early mobilization strategies were crucial in reducing post-surgery problems, hastening functional recovery, and shortening hospital stays.

Muscle stiffness indicating mission crew health in space

Muscle function is compromised by gravitational unloading in space affecting overall musculoskeletal health. Astronauts perform daily exercise programmes to mitigate these effects but knowing which muscles to target would optimise effectiveness. Accurate inflight assessment to inform exercise programmes is critical due to lack of technologies suitable for spaceflight. Changes in mechanical properties indicate muscle health status and can be measured rapidly and non-invasively using novel technology. A hand-held MyotonPRO device enabled monitoring of muscle health for the first time in spaceflight (> 180 days). Greater/maintained stiffness indicated countermeasures were effective. Tissue stiffness was preserved in the majority of muscles (neck, shoulder, back, thigh) but Tibialis Anterior (foot lever muscle) stiffness decreased inflight vs. preflight (p < 0.0001; mean difference 149 N/m) in all 12 crewmembers. The calf muscles showed opposing effects, Gastrocnemius increasing in stiffness Soleus decreasing. Selective stiffness decrements indicate lack of preservation despite daily inflight countermeasures. This calls for more targeted exercises for lower leg muscles with vital roles as ankle joint stabilizers and in gait. Muscle stiffness is a digital biomarker for risk monitoring during future planetary explorations (Moon, Mars), for healthcare management in challenging environments or clinical disorders in people on Earth, to enable effective tailored exercise programmes.

Severe starvation and restraint in a 47-year-old woman: Clinical, autopsy and histopathological evidence of abuse and neglect

The recognition of abuse and/or neglect still represents a challenge for both clinicians and forensic pathologists. Whereas abusive behaviors have been largely described among pediatric and elderly populations, adults' abuse and neglect is less frequently encountered, and therefore investigated. We report a case of a middle-aged woman without any known organic or psychiatric disorders who died of a multiple organ failure (MOF) due to extreme cachexia and bed-resting syndrome. The integration of all clinical, autopsy and histopathological data highlighted a picture of severe malnutrition, restraint, and widespread traumatic injuries related to abuse and neglect. We believe that the case here presented could be useful for both clinicians and forensic pathologists as it underlines once again the importance of collecting and integrating all medical evidence (both in the ante- and post-mortem settings) for reconstructing the most probable pathophysiology of disorders and injuries, comparing that reconstruction with the allegations of the caregivers, and thus identifying any potential abuse and/or neglect behaviors.

A statistical study of postmortem heart weight in Chinese adults

INTRODUCTION

Objective assessment of cardiac hypertrophy in forensic pathology practice is of great significance for forensic pathologists, for whom reference values for normal heart weights are needed. Developed regions such as Europe, the United States, and Japan recalculate the weight of human organs at regular intervals, but in China, there has been no systematic calculation of the weights of human organs since 2006.

AIMS

To statistically analyse the heart weight of Chinese adults postmortem and obtain a reference range.

MATERIALS AND METHODS

4170 adult autopsy reports were collected from 12 forensic departments in 10 provinces in China. The causes of death were classified by sex, and heart weight and the heart weight/body height ratio reference values were further calculated according to different body mass index and body heights. Finally, the cutoff value of cardiac hypertrophy in Chinese adults was calculated.

RESULTS

In the group of non-cardiovascular disease causes of death, the cardiac weight of the electric death group was higher, while the heart weight of the prolonged bed-rest group was significantly reduced. After the electric death and prolonged bed-rest groups were excluded, heart weight, the heart weight/body height ratio, and cutoff values for cardiac hypertrophy were further classified and analysed according to body mass index. The mean reference values for heart weight in men and women with normal weight status were 325.82 ± 41.60 g and 286.39 ± 44.84 g, and the heart weight/body height ratios were 1.95 ± 0.23 in men and 1.82 ± 0.27, respectively. The cutoff values for cardiac hypertrophy were 387.35 g for men and 346.80 g for women.

CONCLUSION

The heart weight reference values of both sexes in this study were significantly higher than those in 2006, which is considered related to the development of China's economy and the improvement of people's living standards. This study also suggests the need for a new round of statistical surveys and updated data on the weight of other organs.

Protocol for the PORT study: short-term perioperative rehabilitation to improve outcomes in cardiac valvular surgery - a randomised control trial

INTRODUCTION

Perioperative rehabilitation (PORT) has shown a positive effect on patients undergoing cardiac surgery. However, there are minimal data on the impact of short-term PORT in cardiac surgery, which is associated with higher postoperative morbidity and mortality. The trial will assess the efficacy of short-term PORT in reducing in-hospital mortality, postoperative pulmonary complications and length of stay, compared with the usual care in cardiac surgical patients.

METHODS AND ANALYSIS

This is a single-centre prospective, randomised, open, controlled trial with a 1:1 ratio. Consecutive 800 adult patients undergoing elective valve surgery will be randomised to either usual care or in-hospital short-term PORT that consists of education, inspiratory muscle training, active cycle of breathing techniques and early mobilisation. The primary outcome of this study will be a composite of in-hospital all-cause mortality, incidence of postoperative pulmonary complications and the ratio of postoperative hospitalisation >7 days.

ETHICS AND DISSEMINATION

The PORT study was granted by the Medical Research Ethics Committee of Guangdong Provincial People's Hospital in August 2018. Findings will be disseminated to patients, clinicians and commissioning groups through peer-reviewed publication.

TRIAL REGISTRATION NUMBER

NCT03709511.

Attitude and influencing factors on exercise in patients with moderately to severely active inflammatory bowel disease: a qualitative study

OBJECTIVES

To explore the attitudes towards exercise, factors influencing exercise and exercise-related needs of patients with moderately to severely active inflammatory bowel disease.

DESIGN

A qualitative phenomenological research.

SETTING

The study was conducted at a comprehensive tertiary hospital in Suzhou, China, which is a secondary care facility.

PARTICIPANTS

The study included 17 participants who met specific inclusion criteria: aged between 16 and 70 years, diagnosed with inflammatory bowel disease and in a state of moderate to severe disease activity. Participants were required to be capable of clear self-expression and provide voluntary consent. Exclusion criteria included the presence of cancer or severe physical illness, cognitive impairment or mental illness.

INTERVENTIONS

Semistructured interviews were used to collect data.

RESULTS

The exercise experiences of participants with moderate to severe inflammatory bowel disease yielded three themes: attitudes towards exercise, factors influencing exercise and exercise-related needs.

CONCLUSION

The majority of participants had negative attitudes towards exercise during periods of moderate to severe activity, largely influenced by disease activity, symptom management, inadequate knowledge of exercise and uncertainty about the value of exercise. Of particular note, professional guidance was generally recognised as stimulating a willingness to exercise positively, and participants demonstrated a strong need for professional guidance. Therefore, it is recommended that clear exercise guidelines for inflammatory bowel disease be constructed to ensure that patients receive safe and effective guidance to develop a healthy lifestyle in order to maximise the benefits of exercise.

Early Ambulation is Associated with Improved Outcomes Following Colorectal Surgery

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) society lists early mobilization as one of their recommendations for improving patient outcomes following colorectal surgery. The level of supporting evidence, however, is relatively weak, and furthermore, the ERAS guidelines do not clearly define "early" mobilization. In this study, we define mobilization in terms of time to first ambulation after surgery and develop an outcome-based cutoff for early mobilization.

METHODS

This is a retrospective cohort study comprised of 291 patients who underwent colorectal operations at a large, academic medical center from June to December 2019. Three cutoffs (12 hours, 24 hours, and 48 hours) were used to divide patients into early and late ambulation groups for each cutoff, and statistical analysis was performed to determine differences in postoperative outcomes between the corresponding groups.

RESULTS

Multivariate analysis showed no difference between the early and late ambulation groups for the 12-hour and 48-hour cutoffs; however, ambulation before 24 hours was associated with a decreased rate of severe complications as well as fewer adverse events overall. Patients who ambulated within 24 hours had a 4.1% rate of severe complications and a 22.1% rate of experiencing some adverse event (complication, return to the emergency department, and/or readmission). In comparison, 11.8% of patients who ambulated later experienced a severe complication (P = 0.026), while 36.1% of patients experienced some adverse event (P = 0.011).

CONCLUSIONS

Ambulation within 24 hours after colorectal surgery is associated with improved postoperative outcomes, particularly a decreased rate of severe complications.

In defence of falling: the onomastics and ethics of "therapeutic" falls in rehabilitation

Aim: Despite efforts towards a more just culture, rehabilitation providers still experience shame and trauma when their patients fall. This paper proposes a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls in rehab are not seen as something to be avoided at all costs, but rather as part of the recovery journey for some patients.Methods: Patients who understand and are willing to take on the risks of falling are more likely to collaborate with their care team to practice higher-risk activities, such as walking to the bathroom independently at night, as part of their recovery. If a fall takes place in this context, we argue that it should be considered a "therapeutic" fall.Results: This paper details some of the clinical and ethical approaches to supporting a care environment where values-and potential conflicts-about the benefits and challenges of risk-taking are recognized. An expanded concept of a therapeutic fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Conclusion: The goal of this work is to offer rehabilitation patients greater opportunities to make autonomous decisions about their mobility, and lay the groundwork for a more successful transition home.IMPLICATIONS FOR REHABILITATIONDespite best efforts, patients are often less active than they or their rehabilitation team might wish them to be.An expanded concept of a "therapeutic" fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Rehabilitation is the right environment to support shared decision-making about risk that better prepares patients and families for the often challenging transition back to community living.This works represents a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls are not something to be avoided at all costs, but can instead be part of the journey to recovery.

Enhanced perioperative care in emergency general surgery: the WSES position paper

Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

Comparison of postoperative mobilization measurements by activPAL versus Johns Hopkins Highest Level of Mobility scale after major abdominal surgery

BACKGROUND

The Johns Hopkins Highest Level of Mobility scale is a validated tool for assessing patient mobility in the hospital. It has excellent inter-rater and test-retest reliabilities, but it is unknown how accurately Johns Hopkins Highest Level of Mobility documentation reflects the patients' mobility performance in the immediate postoperative period compared to objective measures such as accelerometers.

METHODS

In this single-center observational study, consented adults undergoing open abdominal surgery wore a research-grade accelerometer, activPAL, starting immediately postoperatively until hospital discharge or up to 7 days. We collected the Johns Hopkins Highest Level of Mobility scores documented by hospital staff via retrospective chart review and evaluated their accuracy in describing the type, frequency, and volume of postoperative out-of-bed mobilization using the activPAL as the criterion.

RESULTS

We analyzed data from 56 participants. The activPAL showed that participants spent 97.7% of their time lying in bed or sitting in a chair. Meanwhile, the Johns Hopkins Highest Level of Mobility documentation of preambulatory activities (scores 1-5) was rare. The activPAL detected 4 times more out-of-bed mobilization than routine Johns Hopkins Highest Level of Mobility documentation. Whereas the frequency of activPAL-measured out-of-bed mobilization increased steadily to a median of 9 sessions by postoperative day 6, the number of Johns Hopkins Highest Level of Mobility documentation remained around twice daily. ActivPAL measurements demonstrated that Johns Hopkins Highest Level of Mobility documentation of ambulatory sessions (scores 6-8) was accurate.

CONCLUSIONS

We found that routine Johns Hopkins Highest Level of Mobility documentation did not accurately detect preambulatory activities or the overall frequency of out-of-bed mobility sessions, poorly reflecting the highly sedentary behaviors of the acute postoperative inpatients and highlighting the need to improve clinical documentation or use alternative methods to track postoperative mobilization.

The impact of sarcopenia on esophagectomy for cancer: a systematic review and meta-analysis

BACKGROUND

Esophagectomy is the gold-standard treatment for locally advanced esophageal cancer but has high morbimortality rates. Sarcopenia is a common comorbidity in cancer patients. The exact burden of sarcopenia in esophagectomy outcomes remains unclear. Therefore, this systematic review and meta-analysis were performed to establish the impact of sarcopenia on postoperative outcomes of esophagectomy for cancer.

METHODS

We performed a systematic review and meta-analysis comparing sarcopenic with non-sarcopenic patients before esophagectomy for cancer (Registration number: CRD42021270332). An electronic search was conducted on Embase, PubMed, Cochrane, and LILACS, alongside a manual search of the references. The inclusion criteria were cohorts, case series, and clinical trials; adult patients; studies evaluating patients with sarcopenia undergoing esophagectomy or gastroesophagectomy for cancer; and studies that analyze relevant outcomes. The exclusion criteria were letters, editorials, congress abstracts, case reports, reviews, cross-sectional studies, patients undergoing surgery for benign conditions, and animal studies. The meta-analysis was synthesized with forest plots.

RESULTS

The meta-analysis included 40 studies. Sarcopenia was significantly associated with increased postoperative complications (RD: 0.08; 95% CI: 0.02 to 0.14), severe complications (RD: 0.11; 95% CI: 0.04 to 0.19), and pneumonia (RD: 0.13; 95% CI: 0.09 to 0.18). Patients with sarcopenia had a lower probability of survival at a 3-year follow-up (RD: -0.16; 95% CI: -0.23 to -0.10).

CONCLUSION

Preoperative sarcopenia imposes a higher risk for overall complications and severe complications. Besides, patients with sarcopenia had a lower chance of long-term survival.

Effects of Bone Cross-Link Bridging on Fracture Mechanism and Surgical Outcomes in Elderly Patients with Spine Fractures

STUDY DESIGN

This study adopted a cross-sectional study design.

PURPOSE

This study was designed to investigate the effects of bone cross-link bridging on fracture mechanism and surgical outcomes in vertebral fractures using the maximum number of vertebral bodies with bony bridges between adjacent vertebrae without interruption (maxVB).

OVERVIEW OF LITERATURE

The complex interplay of bone density and bone bridging in the elderly can complicate vertebral fractures, necessitating a better understanding of fracture mechanics.

METHODS

We examined 242 patients (age >60 years) who underwent surgery for thoracic to lumbar spine fractures from 2010 to 2020. Subsequently, the maxVB was classified into three groups: maxVB (0), maxVB (2-8), and maxVB (9-18), and parameters, including fracture morphology (new Association of Osteosynthesis classification), fracture level, and neurological deficits were compared. In a sub-analysis, 146 patients with thoracolumbar spine fractures were classified into the three aforementioned groups based on the maxVB and compared to determine the optimal operative technique and evaluate surgical outcomes.

RESULTS

Regarding the fracture morphology, the maxVB (0) group had more A3 and A4 fractures, whereas the maxVB (2-8) group had less A4 and more B1 and B2 fractures. The maxVB (9-18) group exhibited an increased frequency of B3 and C fractures. Regarding the fracture level, the maxVB (0) group tended to have more fractures in the thoracolumbar transition region. Furthermore, the maxVB (2-8) group had a higher fracture frequency in the lumbar spine area, whereas the maxVB (9-18) group had a higher fracture frequency in the thoracic spine area than the maxVB (0) group. The maxVB (9-18) group had fewer preoperative neurological deficits but a higher reoperation rate and postoperative mortality than the other groups.

CONCLUSIONS

The maxVB was identified as a factor influencing fracture level, fracture type, and preoperative neurological deficits. Thus, understanding the maxVB could help elucidate fracture mechanics and assist in perioperative patient management.

Erector spinae plane block in laparoscopic colorectal surgery for reducing opioid requirement and facilitating early ambulation: a double-blind, randomized trial

Various techniques have been formulated to reduce pain and ensure early recovery after surgery, as these are major concerns among surgeons, anesthesiologists, and patients. Erector spinae plane block (ESPB), the injection of local anesthetic into the fascial plane, is a simple and novel analgesia technique widely used due to its minimal risk of complications. ESPB has been tried in various surgeries; however, no study has reported its use in colorectal surgery. This study investigated whether ESPB could promote early recovery following laparoscopic colorectal surgery (LCS) by reducing opioid consumption and pain intensity. After randomization into the ESPB or control groups, an ultrasound-guided ESPB was performed at the thoracic 10^th-11th level with 40 mL of 0.25% bupivacaine or normal saline. The ESPB group used less fentanyl during the initial 24 h after surgery (P = 0.004) and experienced less pain (P < 0.05 at all-time points) than the control group. The time to the first ambulation and the length of hospital stay were shorter in the ESPB group than in the control group (P = 0.015 and P = 0.008, respectively). In conclusion, ESPB could promote early recovery by reducing opioid consumption and pain intensity in patients receiving LCS.

Impact of Early Out-of-Bed Mobilization on Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study

BACKGROUND

Effects of early mobilization are not well documented in patients with aneurysmal subarachnoid hemorrhage (aSAH). Only a few studies have investigated it through progressive mobilization protocols and suggested that it is safe and feasible. This study aimed to determine the impact of early out-of-bed mobilization (EOM) on 3-month functional outcome and cerebral vasospasm (CVS) occurrence in patients with aSAH.

METHODS

A retrospective review of consecutive patients admitted to the intensive care unit with a diagnosis of aSAH was performed. EOM was defined as out-of-bed (OOB) mobilization performed before or on day 4 after aSAH onset. The primary outcome was 3-month functional independence (i.e., a modified Rankin Scale below 3) and the occurrence of CVS.

RESULTS

A total of 179 patients with aSAH met the inclusion criteria. Thirty-one patients constituted the EOM group, and 148 patients were in the delayed out-of-bed mobilization group. Functional independence was more frequent in the EOM group than in the delayed out-of-bed mobilization group (n = 26 [84%] vs. n = 83 [56%], P = 0.004). In a multivariable analysis, EOM was an independent predictor of functional independence (adjusted odds ratio = 3.11; 95% confidence interval, 1.11-10.36; P < 0.05). The delay between bleeding and first OOB mobilization was also identified as an independent risk factor for the occurrence of CVS (adjusted odds ratio = 1.12; 95% confidence interval = 1.06-1.18, P < 0.001).

CONCLUSIONS

EOM was independently associated with favorable functional outcome after aSAH. The delay between bleeding and OOB mobilization was an independent risk factor for reduced functional independence and CVS occurrence. Prospective randomized trials are necessary to confirm these results and improve clinical practice.

Critical Care Cycling to Improve Lower Extremity Strength (CYCLE): protocol for an international, multicentre randomised clinical trial of early in-bed cycling for mechanically ventilated patients

INTRODUCTION

In-bed leg cycling with critically ill patients is a promising intervention aimed at minimising immobility, thus improving physical function following intensive care unit (ICU) discharge. We previously completed a pilot randomised controlled trial (RCT) which supported the feasibility of a large RCT. In this report, we describe the protocol for an international, multicentre RCT to determine the effectiveness of early in-bed cycling versus routine physiotherapy (PT) in critically ill, mechanically ventilated adults.

METHODS AND ANALYSIS

We report a parallel group RCT of 360 patients in 17 medical-surgical ICUs and three countries. We include adults (≥18 years old), who could ambulate independently before their critical illness (with or without a gait aid), ≤4 days of invasive mechanical ventilation and ≤7 days ICU length of stay, and an expected additional 2-day ICU stay, and who do not fulfil any of the exclusion criteria. After obtaining informed consent, patients are randomised using a web-based, centralised system to either 30 min of in-bed cycling in addition to routine PT, 5 days per week, up to 28 days maximum, or routine PT alone. The primary outcome is the Physical Function ICU Test-scored (PFIT-s) at 3 days post-ICU discharge measured by assessors blinded to treatment allocation. Participants, ICU clinicians and research coordinators are not blinded to group assignment. Our sample size estimate was based on the identification of a 1-point mean difference in PFIT-s between groups.

ETHICS AND DISSEMINATION

Critical Care Cycling to improve Lower Extremity (CYCLE) is approved by the Research Ethics Boards of all participating centres and Clinical Trials Ontario (Project 1345). We will disseminate trial results through publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT03471247 (Full RCT); NCT02377830 (CYCLE Vanguard 46 patient internal pilot).

Scraping Therapy Improved Muscle Regeneration through Regulating GLUT4/Glycolytic and AMPK/mTOR/4EBP1 Pathways in Rats with Lumbar Multifidus Injury

Background

High morbidity of nonspecific low back pain (NLBP) and large consumption of medical resources caused by it have become a heavy social burden. There are many factors inducing NLBP, among which the damage and atrophy of multifidus (MF) are most closely related to NLBP. Scraping therapy can have significant treatment effects on NLBP with fewer adverse reactions and less medical fund input than other modalities or medications. However, the mechanism of scraping therapy treating NLBP remains unclarified. Here, we wanted to investigate the effects of scraping therapy on promoting MF regeneration and the underlying mechanisms.

Methods

A total of 54 male rats (SD, 6-7 weeks old) were randomly divided into nine groups, namely, K, M6h, M1d, M2d, M3d, G6h, G1d, G2d, and G3d, with six rats in each group. They were injected with bupivacaine (BPVC) to intentionally induce MF injury. We then performed scraping therapy on the rats that had been randomly chosen and compared treatment effects at different time points. In vitro data including skin temperature and tactile allodynia threshold were collected and histological sections were analyzed. mRNA sequencing was applied to distinguish the genes or signaling pathways that had been altered due to scraping therapy, and the results were further verified through reverse transcription polymerase chain reaction and Western blot analysis.

Results

Transitory petechiae and ecchymosis both on and beneath the rats' skin raised by scraping therapy gradually faded in about 3 d. Cross-sectional area (CSA) of MF was significantly smaller 30 h, 2 d, and 4 d after modeling (P=0.007, P=0.001, and P=0.015, respectively, vs. the blank group) and was significantly larger in the scraping group 1 d after treatment (P=0.002 vs. the model 1d group). Skin temperature significantly increased immediately after scraping (P < 0.001) and hindlimb pain threshold increased on the 2nd day after scraping (P=0.046 and P=0.028, respectively). 391 differentially expressed genes and 8 signaling pathways were characterized 6 h after scraping; only 3 differentially expressed genes and 3 signaling pathways were screened out 2 d after treatment. The amounts of mRNAs or proteins for GLUT4, HK2, PFKM, PKM, LDHA (which belong to the GLUT4/glycolytic pathway), p-mTOR, p-4EBP1 (which belong to the AMPK/mTOR/4EBP1 pathway), and BDH1 were enhanced, and p-AMPKα was decreased after scraping therapy.

Conclusions

Scraping therapy has therapeutic effects on rats with multifidus injury by promoting muscle regeneration via regulating GLUT4/glycolytic and AMPK/mTOR/4EBP1 signaling pathways.

Critical Care Rehabilitation of the Burn Patient

Despite the fact that modern burn care has significantly reduced the mortality associated with severe burn injuries, the rehabilitation and community reintegration of survivors continues to be a challenge. An interprofessional team approach is essential for optimal outcomes. This includes early occupational and physical therapy, beginning in the intensive care unit (ICU). Burn-specific techniques (edema management, wound healing, and contracture prevention) are successfully integrated into the burn ICU. Research demonstrates that early intensive rehabilitation of critically ill burn patients is safe and effective. Further work on the physiologic, functional, and long-term impact of this care is needed.

Skeletal muscle gene expression dysregulation in long-term spaceflights and aging is clock-dependent

The circadian clock regulates cellular and molecular processes in mammals across all tissues including skeletal muscle, one of the largest organs in the human body. Dysregulated circadian rhythms are characteristic of aging and crewed spaceflight, associated with, for example, musculoskeletal atrophy. Molecular insights into spaceflight-related alterations of circadian regulation in skeletal muscle are still missing. Here, we investigated potential functional consequences of clock disruptions on skeletal muscle using published omics datasets obtained from spaceflights and other clock-altering, external (fasting and exercise), or internal (aging) conditions on Earth. Our analysis identified alterations of the clock network and skeletal muscle-associated pathways, as a result of spaceflight duration in mice, which resembles aging-related gene expression changes observed in humans on Earth (e.g., ATF4 downregulation, associated with muscle atrophy). Furthermore, according to our results, external factors such as exercise or fasting lead to molecular changes in the core-clock network, which may compensate for the circadian disruption observed during spaceflights. Thus, maintaining circadian functioning is crucial to ameliorate unphysiological alterations and musculoskeletal atrophy reported among astronauts.

Precision pain management in interventional radiology

Pain is a common manifestation of several benign and malignant conditions. Inadequate response to conservative therapies is often succeeded by incremental use of analgesics and opioids; however, such an approach is often ineffective, not well tolerated by patients, and carries the risk of addiction leading to the opioid crisis. Implementing minimally invasive percutaneous procedures, performed by interventional radiologists has proven to be successful in providing safe, effective, and patient-specific therapies across a wide range of painful conditions. In the present narrative review, we will review the repertoire of minimally invasive imaging guided interventions, which have been successfully used to treat common painful benign and malignant conditions. We briefly describe each technique, common indications, and expected results.

Impact of postoperative physical activity on the development of pneumonia in the subacute phase after esophagectomy in patients with esophageal cancer: A retrospective cohort study

PURPOSE

Physical activity is important to improve recovery following surgery. This study investigated the impact of physical activity on the development of pneumonia after radical esophagectomy in patients with thoracic esophageal cancer in the subacute phase from postoperative day 11 to hospital discharge.

METHODS

This retrospective cohort study included 83 patients who underwent radical esophagectomy for esophageal cancer between 2016 and 2022. Physical activity was measured using an activity tracker, and the average number of steps between postoperative days 8 and 10 was examined. The primary outcome was pneumonia (Clavien-Dindo classification 2 or higher) developing between postoperative day 11 and hospital discharge. We used the receiver operating characteristic (ROC) curve analysis to calculate the optimal cutoff value of physical activity that can predict the development of pneumonia and define low physical activity. We used logistic regression analysis to investigate the impact of low physical activity on postoperative pneumonia.

RESULTS

Pneumonia developed in 10 patients (12.0%) during the observation period. The optimal cutoff value of physical activity for predicting pneumonia was 1494 steps per day (sensitivity: 60.0%, specificity: 89.0%, area under the curve: 0.743). In multivariate analysis, low physical activity was an independent predictor of incident pneumonia [odds ratio: 12.10, 95% confidence interval: 2.21-65.90, p = 0.004], with adjustment for age, gastric tube reconstruction route, and postoperative recurrent nerve palsy.

CONCLUSIONS

Physical activity following radical esophagectomy in patients with thoracic esophageal cancer was an independent predictor of the development of pneumonia in the subacute phase after radical esophagectomy.

[Update on fast-track concepts in operative medicine : Improved outcome and higher patient satisfaction through interdisciplinary multimodal treatment concepts]

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have been propagated in general surgery since the mid-1990s due to medical and health economic advantages for patients as well as hospitals. A comprehensive implementation in Germany is not yet established, although the demographic change requires more than ever concepts for the safe treatment of multimorbid frail patients. The aim of this review is to present modern ERAS concepts, to discuss an extension to prehabilitation measures for frail patients and to present aspects of structural feasibility.

MATERIAL AND METHOD

A selective literature search in the PubMed database was performed and national as well as international guidelines up to the cut-off date of 1 July 2022 were considered.

RESULTS

From an anesthesiological point of view, preoperative optimization, individual anesthesia management and postoperative analgesia are prioritized. The implementation of ERAS protocols requires a high degree of interdisciplinarity and needs in addition to medical know-how, appropriate information systems and structures. Modern ERAS concepts can reduce hospital costs and improve patient outcome.

CONCLUSION

The implementation of ERAS protocols is beneficial for patients as well as economically and should be further promoted. In addition, the benefit of an extension of ERAS concepts, e.g. in older multimorbid patients, should be further scientifically analyzed.

Early passive orthostatic training prevents diaphragm atrophy and dysfunction in intensive care unit patients on mechanical ventilation: A retrospective case‒control study

BACKGROUND

Intensive care unit (ICU) patients on mechanical ventilation (MV), who are always bedridden, easily develop diaphragm atrophy and dysfunction. However, few studies have assessed diaphragmatic thickness and functional changes after early passive orthostatic training.

OBJECTIVES

This is the first study to investigate the efficacy of early passive orthostatic training in preventing diaphragm atrophy and dysfunction in ICU patients on MV.

METHODS

In this randomized retrospective case‒control study, 81 ICU patients on MV for 8 days or longer were enrolled. Forty-four patients received early passive orthostatic training initiated within 72 h of MV initiation (training group), and 37 patients did not receive training (no-training group). The protocol was performed for seven days, once a day for 30 min. The primary outcomes were diaphragmatic thickness and diaphragm contractile fraction (TFdi). The ventilatory parameters were secondary outcomes.

RESULTS

This study included 81 (45 male) ICU patients on MV [(mean ± SD) age = (60.63 ± 7.88) years]. The training group had a larger diaphragmatic thickness at end-expiration (Tdi_,ee) and a smaller magnitude of decrease in Tdi_,ee and TFdi (p = 0.001, 0.029, and <0.001, respectively) than the no-training group after 7 days of training. The mean arterial pressure, fraction of inspired oxygen, and white blood cell levels were decreased in the training group compared with the no-training group (p = 0.003, 0.001, and 0.026, respectively), but lactic acid levels decreased slightly in the training group with no significant difference (p = 0.708).

CONCLUSIONS

Early passive orthostatic training is suitable to ameliorate diaphragm atrophy and dysfunction in ICU patients on MV.

Activity Restriction and Hospitalization in Pregnancy: Can Bed-Rest Exercise Prevent Deconditioning? A Narrative Review

Evidence suggests that exercise during pregnancy is beneficial to both parent and fetus. However, there are high-risk pregnancy conditions that may warrant hospitalization. In our narrative review, we first describe the clinical implications for activity restriction in pregnancy, the effects of hospitalization, and the impact of bed rest on non-pregnant individuals. We provide examples of a 30 min bed-rest exercise program for hospitalized pregnant patients using the principal of suggested frequency, intensity, time (duration) of activity, and type of activity (FITT) using a resistance tool while in bed. If the individual is able to ambulate, we recommend short walks around the ward. Every minute counts and activity should be incorporated into a program at least 3 times per week, or every day if possible. As in all exercise programs, motivation and accountability are essential. Flexibility in timing of the exercise intervention is important due to the scheduling of medical assessments that may occur throughout the day for these hospitalized patients. Evidence suggests that by improving physical and emotional health through a bed-rest exercise program during a hospitalized pregnancy may help the individual resume demanding daily activity in the postpartum period and improve quality of life once birth has occurred. More research is necessary to improve the health of those individuals who are hospitalized during pregnancy, with follow up and support into the postpartum period.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.

METHODS

A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.

RESULTS

A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.

CONCLUSIONS

These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

Impact of structured physical therapy protocol among heart transplant recipients while on intra-aortic balloon pump in the pretransplant period

BACKGROUND

Use of prolonged femoral intra-aortic balloon pump support limits the mobility of patients awaiting heart transplant. We assessed the safety and outcomes of a structured, tilting physical therapy protocol in patients supported by intra-aortic balloon pumps while awaiting transplant.

METHODS

We retrospectively reviewed five years of transplant patients. Eighteen patients received femoral intra-aortic balloon support, a heart transplant, and met all eligibility criteria. We compared complications and outcomes between patients who received the structured, tilting physical therapy (Protocol Group) and those that received standard of care (Control Group).

RESULTS

Complications were not significantly different between groups. The majority of the Protocol Group were discharged to home (10/12), while half (3/6) of the Control Group were discharged to a rehabilitation facility. Post-transplant length of stay was significantly less in the Protocol Group (median 16 vs. 28 days, p = 0.03).

CONCLUSION

Despite the small number analyzed, the data indicates that the structured, tilting physical therapy protocol led to a significantly reduced length of stay post-transplantation. Importantly, use of the protocol did not result in access site complications, thrombosis, or arrhythmias in the majority of the patients.

Upper limb function of individuals hospitalized in intensive care: A 6-month cohort study

BACKGROUND

Impaired physical function is a common complication in intensive care unit (ICU) patients. However, specific upper limb (UL) function is still poorly studied in this population.

OBJECTIVE

To evaluate UL function at discharge and after a 6-month follow-up of individuals hospitalized in the ICU.

METHODS

This was a longitudinal prospective 6-month multicentre cohort study with forty-six individuals hospitalized in the ICU undergoing mechanical ventilation for ≥ 48 h (ICU Group) and forty-six healthy individuals matched by sex, age, and socioeconomic status (control Group). The primary outcomes were measurements of UL disability using the Jebsen-Taylor Hand Function Test (JTT) and the Nine Hole Peg Test (NHPT). Secondary outcomes were physical function (Barthel index), muscle strength (Medical Research Council scale and hand grip strength), and quality of life (EuroQol-5 Dimension). All measurements were assessed after ICU discharge and at a 6-month follow-up.

RESULTS

The JTT performance time in the ICU group after discharge was worse than that in the control group [121 s (86-165) vs. 54 s (49-61), median (IQR), p<0,001] and was reduced after 6 months [62 s (54-81), p<0,01]. The NHPT performance time at discharge in the ICU group was worse than that in the controls [39 s (33-59) vs. 21 s (20-23), p<0,001] and was reduced after 6 months of follow-up [24 s (21-27), p<0,01]. Physical function, muscle strength and quality of life were reduced after ICU discharge.

CONCLUSION

Individuals hospitalized in the ICU presented with reduced UL function at discharge and at the 6-month follow-up.

Safety and efficacy of electrical stimulation for lower-extremity muscle weakness in intensive care unit 2019 Novel Coronavirus patients: A phase I double-blinded randomized controlled trial

Background

Intensive care unit (ICU) prolonged immobilization may lead to lower-extremity muscle deconditioning among critically ill patients, particularly more accentuated in those with 2019 Novel Coronavirus (COVID-19) infection. Electrical stimulation (E-Stim) is known to improve musculoskeletal outcomes. This phase I double-blinded randomized controlled trial examined the safety and efficacy of lower-extremity E-Stim to prevent muscle deconditioning.

Methods

Critically ill COVID-19 patients admitted to the ICU were randomly assigned to control (CG) or intervention (IG) groups. Both groups received daily E-Stim (1 h) for up to 14 days on both gastrocnemius muscles (GNMs). The device was functional in the IG and non-functional in the CG. Primary outcomes included ankle strength (Ankle_s) measured by an ankle-dynamometer, and GNM endurance (GNM_e) in response to E-Stim assessed with surface electromyography (sEMG). Outcomes were measured at baseline, 3 and 9 days.

Results

Thirty-two (IG = 16, CG = 16) lower extremities in 16 patients were independently assessed. The mean time between ICU admission and E-Stim therapy delivery was 1.8 ± 1.9 days (p = 0.29). At 3 days, the IG showed an improvement compared to the CG with medium effect sizes for Ankle_s (p = 0.06, Cohen's d = 0.77) and GNM_e (p = 0.06, d = 0.69). At 9 days, the IG GNM_e was significantly higher than the CG (p = 0.04, d = 0.97) with a 6.3% improvement from baseline (p = 0.029). E-Stim did not alter vital signs (i.e., heart/respiratory rate, blood saturation of oxygen), showed no adverse events (i.e., pain, skin damage, discomfort), nor interfere with ICU standard of care procedures (i.e., mechanical ventilation, prone rotation).

Conclusion

This study supports the safety and efficacy of early E-Stim therapy to potentially prevent deterioration of lower-extremity muscle conditions in critically ill COVID-19 patients recently admitted to the ICU. If confirmed in a larger sample, E-Stim may be used as a practical adjunctive therapy.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT04685213].

Absolute Bed Rest Duration of 3 Days for Osteoporotic Vertebral Fractures: A Retrospective Study

STUDY DESIGN

Retrospective case-control study.

PURPOSE

To reduce unnecessary absolute bed rest (ABR), this study sought to determine the optimal aimed length of ABR in older patients getting conservative treatment for osteoporotic vertebral fractures (OVFs).

OVERVIEW OF LITERATURE

OVFs are quite common in elderly patients. ABR is a vital part of conservative treatment for OVFs, although the length of ABR may increase patient. No recommendations regarding how long ABR should last.

METHODS

This study was conducted in 134 patients with OVFs initially treated conservatively. The patients were split into two groups: 3-day and 7-day ABR. From the time of injury to 1, 4, and 12 weeks after injury, compression rate (CR) and local kyphotic angle (LKA) were assessed and compared between the two groups. Any complications such as pneumonia, deep vein thrombosis, delirium, and urinary tract infection known to be related to ABR were examined based on the electronic medical record.

RESULTS

Forty-four patients underwent ABR for 3 days and 90 underwent ABR for 7 days. There was no significant difference in CR and LKA between the two groups at the time of injury versus 1, 4, and 12 weeks after injury. The patients were divided into two groups: those who received a 3-day ABR and those who received a 7-day ABR. CR and LKA were measured and compared between the two groups from the time of damage to 1, 4, and 12 weeks after injury. The ABR-related complication rate was 43.4% in the 7-day ABR group and 22.7% in 3-day ABR group (p=0.02). The duration of hospital stay was significantly shorter in the 3-day ABR group (12.8 days) than in the 7-day group (16 days) (p=0.01).

CONCLUSIONS

Considering radiological outcomes, prognosis, complications, patient convenience, and economic impact, a 3-day ABR period is appropriate for the conservative treatment of OVFs.

A review of the current ERAS guidelines for liver resection, liver transplantation and pancreatoduodenectomy

In perioperative care after liver resection, transplantation and pancreatoduodenectomy, ERAS (Enhanced Recovery After Surgery) recommendations are based on the reducing invasiveness of procedures and the severity of the surgical stress, which results in decreasing complications and enhanced recovery. Recommendations for all three operations can be classified into five groups: recommended for all patients, recommended for special patient groups, rejected for all patients, controversial recommendations, specific recommendations for all three operations. Preoperative counselling and psychological support, nutritional support, smoking and alcohol cessation, pre- and intraoperative antibiotic prophylaxis, thrombosis prevention, limiting of preoperative hunger and thirst to 4 and 6 h, preoperative intaking carbohydrate rich drink, alcohol-based antiseptics for skin preparation, a goal-directed infusion therapy, providing normothermia, early removal of the drainage tube, glycemic control, dual antiemetic therapy, multimodal analgesia strategies, early oral feeding and activation, audit recommend for all patients. Postoperative antibiotic prophylaxis, enteral and parenteral nutrition, short-acting anxiolytics are recommended for individual patients. It is recommended to avoid Mercedes type incision, use of long-acting anxiolytics and postoperative nasogastric tube. The benefits of preoperative physical exercise, immunonutrition and probiotics are controversial. There are no specific recommendations for thoracic epidural anesthesia, preventing delayed gastric emptying and intestinal paresis in liver surgery.

Why does patients’ discharge delay after vertebral augmentation? A factor analysis of 1,442 patients

Objective

Vertebral augmentation techniques are widely used to treat osteoporotic vertebral compression fractures (OVCFs). Superior analgesic effects and shortened bed rest time means patients recover quickly, but prolonged unscheduled hospitalization can increase medical expenses and the risk of bed rest complications. The aim of this study was to investigate the reasons for prolonged hospitalization after vertebral augmentation surgery and to determine the relative risk factors.

Methods

A single-center retrospective study was conducted to enroll patients with OVCFs and accepted vertebral augmentation surgery from January 2017 to December 2017. Clinical information was collected from the Hospital Information System (HIS). The criterion of delayed discharge was postoperative hospitalization more than 3 days. Telephone interviews and medical history evaluations were conducted to confirm the exact reason for retention. The risk factors were analyzed by multiple logistic regression.

Results

Overall, 1,442 patients were included, and 191 (13.2%) stayed in the hospital for more than 3 days postoperatively. The reasons for delayed discharge were psychological factors (37.2%), residual pain (32.5%), cardiopulmonary complications (15.7%), nonspecific symptoms (8.4%), incision abnormalities (2.6%), thrombosis (2.1%), and postanesthesia reactions (1.6%). The multiple logistic model was significant; age (OR 1.028; 95% CI 1.009–1.046), preoperative stay (OR 1.192; 95% CI 1.095–1.298), operation type (OR 1.494; 95% CI 1.019–2.189), and the number of surgical segments (OR 2.238; 95% CI 1.512–3.312) showed statistical significance. In contrast, gender (P > 0.1) and chronic comorbidities (P > 0.1) were not predictors in this model.

Conclusion

Overall, 13.2% of OVCF patients who underwent vertebral augmentation surgery were not discharged within 3 days postoperatively, and several predictors were found. Preoperative communication and comprehensive evaluations are calling for more attention; physicians should adopt an appropriate medical process to enhance rehabilitation in geriatric orthopedics.

Considering care: A traumatic obturator fracture dislocation of the hip in a middle-aged man from Gaelic Medieval Ballyhanna, Co. Donegal, Ireland

OBJECTIVE

This article explores the potential care provided to a middle-aged man who had a suite of injuries evident in his skeleton, most notably an obturator fracture dislocation in his left hip.

MATERIALS

The skeleton derived from the Late Medieval Gaelic population buried at Ballyhanna, Co. Donegal, Ireland.

METHODS

A transdisciplinary bioarchaeology of care approach was adopted to undertake a phenomenological study of an individual with an acquired disability.

RESULTS

The man would have required intensive nursing care in the months following the initial injury, and longer-term accommodations may have been made by the wider community to support him.

CONCLUSIONS

Use of a transdisciplinary bioarchaeology of care approach enables important insights to be gained concerning the social impact of disability on the affected individual, his kin, and wider community.

SIGNIFICANCE

This study achieves a new level of integration of bioarchaeological findings with archaeological, historical, and ethno-historical sources, thereby enabling a phenomenological approach to interpretation of life after acquired disability. This is the first study to allow such an intimate insight into lived experience and it provides a model for bioarchaeology of care analysis of individuals from historical eras.

LIMITATIONS

These include difficulties in identifying the nature of a long-standing complex injury.

SUGGESTIONS FOR FUTURE RESEARCH

Further explorations of the bioarchaeology of care in historical time periods should incorporate a similarly wide range of transdisciplinary sources to enrich interpretations of the lived experiences of individuals, their care-givers and broader communities.