Summary Background & aims The aim of the Enhanced Recovery After Surgery (ERAS) pathway is to attenuate the stress response to surgery and enable rapid recovery. The objective of this meta-analysis ...was to study the differences in outcomes in patients undergoing major elective open colorectal surgery within an ERAS pathway and those treated with conventional perioperative care. Methods Medline, Embase and Cochrane database searches were performed for relevant studies published between January 1966 and November 2009. All randomized controlled trials comparing ERAS with conventional perioperative care were selected. The outcome measures studied were length of hospital stay, complication rates, readmission rates and mortality. Results Six randomized controlled trials with 452 patients were included. The number of individual ERAS elements used ranged from 4 to 12, with a mean of 9. The length of hospital stay weighted mean difference (95% confidence interval): −2.55 (−3.24, −1.85) and complication rates relative risk (95% confidence interval): 0.53 (0.44, 0.64) were significantly reduced in the enhanced recovery group. There was no statistically significant difference in readmission and mortality rates. Conclusion ERAS pathways appear to reduce the length of stay and complication rates after major elective open colorectal surgery without compromising patient safety.
Background
Uncomplicated acute appendicitis has been managed traditionally by early appendicectomy. However, recently, there has been increasing interest in the potential for primary treatment with ...antibiotics, with studies finding this to be associated with fewer complications than appendicectomy. The aim of this study was to compare outcomes of antibiotic therapy with appendicectomy for uncomplicated acute appendicitis.
Method
This meta-analysis of randomised controlled trials included adult patients presenting with uncomplicated acute appendicitis treated with antibiotics or appendicectomy. The primary outcome measure was complications. Secondary outcomes included treatment efficacy, hospital length of stay (LOS), readmission rate and incidence of complicated appendicitis.
Results
Five randomised controlled trials with a total of 1430 participants (727 undergoing antibiotic therapy and 703 undergoing appendicectomy) were included. There was a 39 % risk reduction in overall complication rates in those treated with antibiotics compared with those undergoing appendicectomy (RR 0.61, 95 % CI 0.44–0.83,
p
= 0.002). There was no significant difference in hospital LOS (mean difference 0.25 days, 95 % CI −0.05 to 0.56,
p
= 0.10). In the antibiotic cohort, 123 of 587 patients initially treated successfully with antibiotics were readmitted with symptoms suspicious of recurrent appendicitis. The incidence of complicated appendicitis was not increased in patients who underwent appendicectomy after “failed” antibiotic treatment (10.8 %) versus those who underwent primary appendicectomy (17.9 %).
Conclusion
Increasing evidence supports the primary treatment of acute uncomplicated appendicitis with antibiotics, in terms of complications, hospital LOS and risk of complicated appendicitis. Antibiotics should be prescribed once a diagnosis of acute appendicitis is made or considered.
OBJECTIVE:To define the impact of perioperative treatment with probiotics or synbiotics on postoperative outcome in patients undergoing abdominal surgery.
BACKGROUND:Postoperative surgical infection ...accounts for a third of all cases of sepsis, and is a leading cause of morbidity and mortality. Probiotics, prebiotics, and synbiotics (preparations that combine probiotics and prebiotics) are nutritional adjuncts that are emerging as novel therapeutic modalities for preventing surgical infections. However, current evidence on their effects is conflicting.
METHODS:A comprehensive search of the PubMed, Embase, and WHO Global Index Medicus electronic databases was performed to identify randomized controlled trials evaluating probiotics or synbiotics in adult patients undergoing elective colorectal, upper gastrointestinal, transplant, or hepatopancreaticobiliary surgery. Bibliographies of studies were also searched. The primary outcome measure was incidence of postoperative infectious complications. Secondary outcomes included incidence of noninfectious complications, mortality, length of hospital stay, and any treatment-related adverse events. Quantitative pooling of the data was undertaken using a random effects model.
RESULTS:A total of 34 randomized controlled trials reporting on 2723 participants were included. In the intervention arm, 1354 patients received prebiotic or symbiotic preparations, whereas 1369 patients in the control arm received placebo or standard care. Perioperative administration of either probiotics or synbiotics significantly reduced the risk of infectious complications following abdominal surgery relative risk (RR) 0.56; 95% confidence interval (CI) 0.46–0.69; P < 0.00001, n = 2723, I = 42%. Synbiotics showed greater effect on postoperative infections compared with probiotics alone (synbiotics RR0.46; 95% CI0.33–0.66; P < 0.0001, n = 1399, I = 53% probiotics RR0.65; 95% CI0.53–0.80; P < 0.0001, n = 1324, I = 18%). Synbiotics but not probiotics also led to a reduction in total length of stay (synbiotics weighted mean difference−3.89; 95% CI−6.60 to −1.18 days; P = 0.005, n = 535, I = 91% probiotics RR−0.65; 95% CI−2.03–0.72; P = 0.35, n = 294, I = 65%). There were no significant differences in mortality (RR0.98; 95% CI0.54–1.80; P = 0.96, n = 1729, I = 0%) or noninfectious complications between the intervention and control groups. The preparations were well tolerated with no significant adverse events reported.
CONCLUSIONS:Probiotics and synbiotics are safe and effective nutritional adjuncts in reducing postoperative infective complications in elective abdominal surgery. The treatment effects are greatest with synbiotics.
Background
The aim of this study was to establish features of inflammation in histologically normal gallbladders with gallstones and compare the expression of inflammatory markers in acutely and ...chronically inflamed gallbladders.
Methods
Immunohistochemistry was performed on formalin‐fixed paraffin‐embedded gallbladders for tumor necrosis factor (TNF)‐α, interleukin (IL)‐6, IL‐2R, and substance p in three groups: Group I (n = 60) chronic cholecystitis, Group II (n = 57) acute cholecystitis and Group III (n = 45) histologically normal gallbladders with gallstones. Expression was quantified using the H‐scoring system.
Results
Median, interquartile range expression of mucosal IL‐2R in Groups I (2.65, 0.87–7.97) and II (12.30, 6.15–25.55) was significantly increased compared with group III (0.40, 0.10–1.35, p < 0.05). Submucosal IL‐2R expression in Groups I (2.0, 1.12–4.95) and II (10.0, 5.95–14.30) was also significantly increased compared with Group III (0.50, 0.15–1.05, p < 0.05). There was no difference in the lymphoid cell IL‐6 expression between Groups I (5.95, 1.60–18.15), II (6.10, 1.1–36.15) and III (8.30, 2.60–26.35, p > 0.05). Epithelial IL‐6 expression of Group III (8.3, 2.6–26.3) was significantly increased compared with group I (0.5, 0–10.2, p < 0.05) as was epithelial TNF‐α expression in Group III (85.0, 70.50–92.0) compared with Groups I (72.50, 45.25.0–85.50, p < 0.05) and II (61.0, 30.0–92.0, p < 0.05). Lymphoid cell Substance P expression in Groups I (1.90, 1.32–2.65) and II (5.62, 2.50–20.8) was significantly increased compared with Group III (1.0,1.0–1.30, p < 0.05). Epithelial cell expression of Substance P in Group III (121.7, 94.6–167.8) was significantly increased compared with Groups I (75.7, 50.6–105.3, p < 0.05) and II (78.9, 43.5–118.5, p < 0.05).
Conclusion
Histologically normal gallbladders with gallstones exhibited features of inflammation on immunohistochemistry.
Foodborne outbreaks of Salmonella remain a pressing public health concern. We recently detected a large outbreak of Salmonella enterica serovar Enteritidis phage type 14b affecting more than 30 ...patients in our hospital. This outbreak was linked to community, national and European-wide cases. Hospital patients with Salmonella are at high risk, and require a rapid response. We initially investigated this outbreak by whole-genome sequencing using a novel rapid protocol on the Illumina MiSeq; we then integrated these data with whole-genome data from surveillance sequencing, thereby placing the outbreak in a national context. Additionally, we investigated the potential of a newly released sequencing technology, the MinION from Oxford Nanopore Technologies, in the management of a hospital outbreak of Salmonella.
We demonstrate that rapid MiSeq sequencing can reduce the time to answer compared to the standard sequencing protocol with no impact on the results. We show, for the first time, that the MinION can acquire clinically relevant information in real time and within minutes of a DNA library being loaded. MinION sequencing permits confident assignment to species level within 20 min. Using a novel streaming phylogenetic placement method samples can be assigned to a serotype in 40 min and determined to be part of the outbreak in less than 2 h.
Both approaches yielded reliable and actionable clinical information on the Salmonella outbreak in less than half a day. The rapid availability of such information may facilitate more informed epidemiological investigations and influence infection control practices.
Abstract
Every counselor–client interaction is an opportunity for mutual learning through inquiry, listening, exploring, and understanding about a client's experiences with development and ...well‐being. Given the convergence of multiple sociopolitical events and systems that impact mental health and well‐being, we issue a call to increase promotion and uptake of preventative mental health strategies by assessing the social determinants of mental health (SDMH) in counseling practice. We contend that counselors are uniquely prepared to assess the SDMH at the intrapersonal, interpersonal, and environmental levels. Therefore, we review the parallels between counseling frameworks and the SDMH with the aim of explaining why and how counselors should assess the SDMH. Specifically, we describe ways that counselors can use their foundational skills and expertise in assessment procedures to identify client needs, as well as potential individual and community interventions. We outline a four‐phased approach for assessing the SDMH in counseling practice and provide implications for improving counseling outcomes.
Older adults are susceptible to dehydration due to age-related pathophysiological changes. We aimed to investigate the prevalence of hyperosmolar dehydration (HD) in hospitalised older adults, aged ...≥65 years, admitted as an emergency and to assess the impact on short-term and long-term outcome.
This prospective cohort study was performed on older adult participants who were admitted acutely to a large U.K. teaching hospital. Data collected included the Charlson comorbidity index (CCI), national early warning score (NEWS), Canadian Study of Health and Aging (CSHA) clinical frailty scale and Nutrition Risk Screening Tool (NRS) 2002. Admission bloods were used to measure serum osmolality. HD was defined as serum osmolality >300 mOsmol/kg. Participants who were still in hospital 48 h after admission were reviewed, and the same measurements were repeated.
A total of 200 participants were recruited at admission to hospital, 37% of whom were dehydrated. Of those dehydrated, 62% were still dehydrated when reviewed at 48 h after admission. Overall, 7% of the participants died in hospital, 79% of whom were dehydrated at admission (P = 0.001). Cox regression analysis adjusted for age, gender, CCI, NEWS, CSHA and NRS demonstrated that participants dehydrated at admission were 6 times more likely to die in hospital than those euhydrated, hazards ratio (HR) 6.04 (1.64-22.25); P = 0.007.
HD is common in hospitalised older adults and is associated with poor outcome. Coordinated efforts are necessary to develop comprehensive hydration assessment tools to implement and monitor a real change in culture and attitude towards hydration in hospitalised older adults.
Background
Histologically normal appendices resected for right iliac fossa pain in children demonstrate immunohistochemical markers of inflammation. We aimed to establish if subclinical inflammation ...was present in histologically normal appendices resected from adults with right iliac fossa pain.
Methods
Immunohistochemistry was performed on formalin-fixed paraffin-embedded appendices for tumour necrosis factor (TNF)-α, interleukin (IL)-6, IL-2R and serotonin in four groups: Group I (
n
= 120): uncomplicated appendicitis, Group II (
n
= 118): complicated appendicitis (perforation or gangrene), Group III (
n
= 104): histologically normal appendices resected for right iliac fossa pain and Group IV (
n
= 106) appendices resected at elective colectomy. Expression was quantified using the H-scoring system.
Results
Median, interquartile range expression of TNF-α was increased in Groups I (5.9, 3.1–9.8), II (6.8, 3.6–12.1) and III (9.8, 6.2–15.2) when compared with Group IV (3.0, 1.4–4.7,
p
< 0.01). Epithelial expression of IL-6 in Groups II (44.0, 8.0–97.0) and III (71.0, 18.5–130.0) was increased when compared with Group IV (9.5, 1.0–60.2,
p
< 0.01). Expression of mucosal IL-2R in Groups I (47.4, 34.8–69.0), II (37.8, 25.4–60.4) and III (18.4, 10.1–34.7) was increased when compared with Group IV (2.8, 1.2–5.7,
p
< 0.01). Serotonin content in Groups I (3.0, 0–30.0) and II (0, 0–8.5) was decreased when compared with Groups III (49.7, 16.7–107.5) and IV (43.5, 9.5–115.8,
p
< 0.01).
Conclusion
Histologically normal appendices resected from symptomatic patients exhibited increased proinflammatory cytokine expression on immunohistochemistry suggesting the presence of an inflammatory process not detected on conventional microscopy.
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