The impact of post-operative enteral nutrition on duodenal injury outcomes: A post hoc analysis of an EAST multicenter trial.

BACKGROUND: Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os(NPO) treatment. Parenteral nutrition(PN) has known morbidity; however, duodenal leak(DL) patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition(EN). We hypothesized EN alone would be associated with 1)shorter duration until leak closure and 2)less infectious complications and shorter hospital length of stay(HLOS) compared to PN. METHODS: This was a post-hoc analysis of a retrospective, multicenter study from 35 Level-1 trauma centers, including patients >14 years-old who underwent surgery for duodenal injuries(1/2010-12/2020) and endured post-operative DL. The study compared nutrition strategies: EN vs PN vs EN + PN using Chi-Square and Kruskal-Wallis tests; if significance was found pairwise comparison or Dunn's test were performed. RESULTS: There were 113 patients with DL: 43 EN, 22 PN, and 48 EN + PN. Patients were young(median age 28 years-old) males(83.2%) with penetrating injuries(81.4%). There was no difference in injury severity or critical illness among the groups, however there were more pancreatic injuries among PN groups. EN patients had less days NPO compared to both PN groups(12 days[IQR23] vs 40[54] vs 33[32],p = <0.001). Time until leak closure was less in EN patients when comparing the three groups(7 days[IQR14.5] vs 15[20.5] vs 25.5[55.8],p = 0.008). EN patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups(all p < 0.05). HLOS was shorter among EN patients vs both PN groups(27 days[24] vs 44[62] vs 45[31],p = 0.001). When controlling for predictors of leak, regression analysis demonstrated EN was associated with shorter HLOS(ß -24.9, 95%CI -39.0 to -10.7,p < 0.001). CONCLUSION: EN was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible. LEVEL OF EVIDENCE: IV.

Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial.

BACKGROUND: Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS: A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA. CONCLUSION: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Five-year publication rate of podium presentations at SICOT Annual Conference: an observational study and new objective proposal of conference power.

INTRODUCTION: The SICOT Conference Committee continually tries to improve the quality of presentations at their annual international meetings. However to the author's best knowledge, no previous study has been undertaken to determine abstract quality. This study aimed to determine the five-year publication rate of presentations made at the 2009 SICOT Annual International Conference (AIC), recognise predictors of full-text publication, identify inconsistencies between presentations and publications, and determine presentation-publication delay. METHODS: We retrieved all 329 oral presentation abstracts from the 2009 SICOT Conference, recorded fundamental study details and conducted a comprehensive, electronic search of Medline and PubMed to determine publication status. For subsequent publications, we examined for inconsistencies between presentation abstracts and full-text publications, whether there were retrospectively identifiable publication predictors and calculated presentation-publication delay. RESULTS: The five-year publication rate for all presentations was 31.3%, for oral presentations. The average presentation-publication delay was 23.4 months. Observational studies were the most commonly published studies. Publications most commonly resulted from studies related to hip and knee subspecialties. CONCLUSION: Our study shows that almost one third of all abstracts presented at SICOT led to a full-text publication. This is a positive outcome particularly when made in comparison to similar studies of other reputable international conferences such as European Federation of Orthopaedics and Traumatology (EFORT) and American Academy of Orthopaedic Surgeons (AAOS). This study re-enforces SICOT's reputation as a world leading international conference with a strict peer-review process yielding high-quality presentations.

Neuronavigation-Assisted Aspiration and Electro-Acupuncture for Hypertensive Putaminal Hemorrhage: A Suitable Technique on Hemiplegia Rehabilitation.

AIM: To identify whether neuronavigation-assisted aspiration (NA) combined with electro-acupuncture (EA) provides better motor recovery in events of hypertensive putaminal hematoma (HPH) sized 30 to 50 ml. This study aims to examine whether neuronavigation-assisted aspiration and electro-acupuncture have additional value to cerebral hemorrhage motor rehabilitation. MATERIAL AND METHODS: 240 patients with HPH sized 30 to 50 ml and admitted within 6 to 10 hours after stroke ictus were included in this study. Group 1 contained 60 patients who underwent neuronavigation-assisted aspiration and electro-acupuncture (NAEA), group 2 contained 60 patients who underwent neuronavigation-assisted aspiration (NA), group 3 contained 60 patients who underwent electro-acupuncture (EA), and group 4 contained 60 patients who received conservative therapy consisting solely of medications. All the patients received the same therapeutic plan on admission and functional exercises three days after stroke onset. Electro-acupuncture was performed on the third day of admission; motor recovery was examined on weeks zero and eight by blinded assessors. Outcome measures included Fugl-Meyer assessment, modified Ashworth Scale and Functional Independence Measure. RESULTS: Group one showed significantly improved motor outcomes compared to group four (p < 0.01). Group one also showed significant motor improvement when pre-and post- therapy functioning was examined (p < 0.01). Cerebral edema and ischemia were significantly decreased in group one compared to group 3 and 4 (p < 0.05). While not as effective as group one treatment, group two and group three patients had significant motor recovery after intervention when compared to group four (p < 0.05). Muscular tension secondary to stroke was considerably improved between group one and group four, group two and group four, group three and group four respectively (p < 0.05). Activities of daily living (ADL) improved a lot with EA together with NA. CONCLUSION: Neuronavigation-assisted aspiration and electro-acupuncture of HPH at the early stage can provide improved motor recovery with fewer complications. Significant motor recovery can be achieved by neuronavigation-assisted aspiration with acupuncture. Based on our findings, we recommend early intervention with NA and EA in order to promote early rehabilitation of hemiplegia secondary to HPH.

Upper Cervical Epidural Abscess in Clinical Practice: Diagnosis and Management.

Study Design Narrative review. Objective Upper cervical epidural abscess (UCEA) is a rare surgical emergency. Despite increasing incidence, uncertainty remains as to how it should initially be managed. Risk factors for UCEA include immunocompromised hosts, diabetes mellitus, and intravenous drug use. Our objective is to provide a comprehensive overview of the literature including the history, clinical manifestations, diagnosis, and management of UCEA. Methods Using PubMed, studies published prior to 2015 were analyzed. We used the keywords "Upper cervical epidural abscess," "C1 osteomyelitis," "C2 osteomyelitis," "C1 epidural abscess," "C2 epidural abscess." We excluded cases with tuberculosis. Results The review addresses epidemiology, etiology, imaging, microbiology, and diagnosis of this condition. We also address the nonoperative and operative management options and the relative indications for each as reviewed in the literature. Conclusion A high index of suspicion is required to diagnose this rare condition with magnetic resonance imaging being the imaging modality of choice. There has been a shift toward surgical management of this condition in recent times, with favorable outcomes.

Astrocyte-conditioned medium attenuates glutamate-induced apoptotic cell death in primary cultured spinal cord neurons of rats.

OBJECTIVES: To better understand the neuroprotective role of astrocytes in spinal cord injury (SCI), we investigated whether astrocyte-conditioned medium (ACM) can attenuate glutamate-induced apoptotic cell death in primary cultured spinal cord neurons. METHODS: Spinal cord neurons were pretreated with ACM for 24 hours. Subsequently, they were exposed to glutamate (125 µM) for 1 hour. The neurons were then incubated for 24 hours. Following that, measurements assessing cell viability and lactate dehydrogenase (LDH) release were performed. Apoptosis was confirmed through cell morphology using Hoechst 33342 staining and terminal deoxynucleotidyl transferase dUTP-mediated nicked end labeling (TUNEL) assay. Assessment for expression of apoptotic enzymes, including Caspase-3, Bcl-2 and Bax, was performed using Western Blot Analysis. RESULTS: Astrocyte-conditioned medium pretreatment of neurons showed both an increase in spinal cord neuron viability and a decrease in LDH release in a dose-dependent pattern. Moreover, pretreatment seems to attenuate glutamate-induced apoptotic cell death, antagonise glutamate-induced up-regulation of Caspase-3 expression and downregulate Bcl-2/Bax protein expression ratio. CONCLUSIONS: By attenuating glutamate-induced apoptotic cell death in primary cultured spinal cord neurons of rats, ACM seems to provide a neuroprotective effect by regulating apoptosis-related protein expression. Our results provide an experimental basis for clinical applications and potential therapeutic use of ACM in SCI.

Complement dependency of cardiomyocyte release of mediators during sepsis.

We have recently shown that antibody-induced blockade of C5a, C5a receptors, or IL-17A greatly reduced the harmful outcomes of sepsis. In the current study, normal cardiomyocytes from young (300 g) male Sprague-Dawley rats responded in vitro to C5a (ED(50)=55 nM) with release of IL-6 and TNFα, peaking between 2 to 8 h. Neutralizing antibodies to mouse C5a or IL-17A (ED(50)=40 µg for each, based on improved survival) reduced spontaneous in vitro release of cardiosuppressive cytokines and chemokines in cardiomyocytes obtained from mice with polymicrobial sepsis. A non-neutralizing C5a antibody had no such effects. Cardiomyocytes from septic mice (C57Bl/6) showed increased mRNA for TNFR1, IL-6 (gp80), and C5aR at 6 h after sepsis. Cardiomyocytes from septic C5aR(-/-) or C5L2(-/-) mice did not show spontaneous in vitro release of cytokines and chemokines. These data suggest that cardiomyocytes from septic mice release suppressive cytokines in a C5a-, C5aR-, and IL-17A-dependent manner, followed by mediator reactivity with receptors on cardiomyocytes, resulting in defective contractility and relaxation. These data may be relevant to a strategy for the treatment of heart dysfunction developing during sepsis.