Effect of high-protein peptide-based formula compared with isocaloric isonitrogenous polymeric formula in critically ill surgical patient.

BACKGROUND: Malnutrition is common in critically ill patients, and it is associated with an increased risk of complications. Early enteral nutrition with adequate caloric and protein intake is critical nevertheless it is difficult to achieve. Peptide-based formulas have been shown to be beneficial in patients with feeding intolerance. However, there are limited studies showing the efficacy and safety of high-protein peptide-based formula in critically ill surgical patients. AIM: To determine the effects of a high-protein peptide formulation on gastrointestinal tolerance, nutritional status, biochemical changes, and adverse events in patients in the surgery intensive care unit (SICU) compared to an isocaloric isonitrogenous standard polymeric formulation. METHODS: This study was a multi-center double-blind, randomized controlled trial. We enrolled adult patients in the surgical intensive care unit, age ≥ 15 years and expected to receive enteral feeding for at least 5-14 d post-operation. They were randomly assigned to receive either the high-protein peptide-based formula or the isocaloric isonitrogenous standard formula for 14 d. Gastric residual volume (GRV), nutritional status, body composition and biochemical parameters were assessed at baseline and on days 3, 5, 7, 9, 11, and 14. RESULTS: A total of 19 patients were enrolled, 9 patients in the peptide-based formula group and 10 patients in the standard formula group. During the study period, there were no differences of the average GRV, body weight, body composition, nutritional status and biochemical parameters in the patients receiving peptide-based formula, compared to the standard regimen. However, participants in the standard formula lost their body weight, body mass index (BMI) and skeletal muscle mass significantly. While body weight, BMI and muscle mass were maintained in the peptide-based formula, from baseline to day 14. Moreover, the participants in the peptide-based formula tended to reach their caloric target faster than the standard formula. CONCLUSION: The study emphasizes the importance of early nutritional support in the SICU and showed the efficacy and safety of a high-protein, peptide-based formula in meeting caloric and protein intake targets while maintaining body weight and muscle mass.

Clinical prediction score for superficial surgical site infection after appendectomy in adults with complicated appendicitis.

Background: Superficial surgical site infection (SSI) is common after appendectomy. This study aims to determine a clinical prediction score for SSI after appendectomy in complicated appendicitis. Methods: Data from randomized controlled trial of delayed versus primary wound closures in complicated appendicitis was used. Nineteen patient- and operative-related predictors were selected in the logit model. Clinical prediction score was then constructed using coefficients of significant predictors. Risk stratification was done by receiver operating characteristic (ROC) curve analysis. Bootstrap technique was used to internal validate the score. Results: Among 607 patients, the SSI incidence was 8.7% (95% CI 6.4, 11.2). Four predictors were significantly associated with SSI, i.e., presence of diabetes, incisional length > 7 cm, fecal contamination, and operative time > 75 min with the odds ratio of 2.6 (95% CI 1.2, 5.9), 2.8 (1.5, 5.4), 3.6 (1.9, 6.8), and 3.4 (1.8, 6.5), respectively. Clinical prediction score ranged from 0 to 4.5 with its discrimination concordance (C) statistic of 0.74 (95% CI 0.66, 0.81). Risk stratification classified patients into very low, low, moderate, and high risk groups for SSI when none, one, two, and more than two risk factors were presented with positive likelihood ratio of 1.00, 1.45, 3.32, and 9.28, respectively. A bootstrap demonstrated well calibration and thus good internal validation. Conclusions: Diabetes, incisional length, fecal contamination, and operative time could be used to predict SSI with acceptable discrimination. This clinical risk prediction should be useful in prediction of SSI. However, external validation should be performed. Trial registration: ClinicalTrials.gov (ID NCT01659983), registered August 8, 2012.

Comparison of Superficial Surgical Site Infection Between Delayed Primary Versus Primary Wound Closure in Complicated Appendicitis: A Randomized Controlled Trial.

OBJECTIVE: To compare superficial surgical site infection (SSI) rates between delayed primary wound closure (DPC) and primary wound closure (PC) for complicated appendicitis. BACKGROUND: SSI is common in appendectomy for complicated appendicitis. DPC is preferentially used over PC, but its efficacy is still controversial. METHODS: A multicenter randomized controlled trial was conducted in 6 hospitals in Thailand, enrolling patients with gangrenous and ruptured appendicitis. Patients were randomized to PC (ie, immediately wound closure) or DPC (ie, wound closure at postoperative days 3-5). Superficial SSI was defined by the Center for Disease Control criteria. Secondary outcomes included postoperative pain, length of stay, recovery time, quality of life, and cost of treatment. RESULTS: In all, 303 and 304 patients were randomized to PC and DPC groups, and 5 and 4 patients were lost to follow-up, respectively, leaving 300 and 298 patients in the modified intention-to-treat analysis. The superficial SSI rate was lower in the PC than DPC groups [ie, 7.3% (95% confidence interval 4.4, 10.3) vs 10% (95% CI 6.6, 13.3)] with a risk difference (RD) of -2.7% (-7.1%, 1.9%), but this RD was not significant. Postoperative pain, length of stay, recovery times, and quality of life were nonsignificantly different with corresponding RDs of 0.3 (-2.5, 3.0), -0.1 (-0.5, 0.3), -0.2 (-0.8, 0.4), and 0.02 (-0.01, 0.04), respectively. However, costs for PC were 2083 (1410, 2756) Baht cheaper than DPC (∼$60 USD). CONCLUSIONS: Superficial SSI rates for the PC group were slightly lower than DPC group, but this did not reach statistical significance. Costs were significantly lower for the PC group.

Quality of life after great saphenous vein ablation in Thai patients with great saphenous vein reflux.

BACKGROUND/OBJECTIVE: To determine the quality of life (QoL) in Thais after intervention for great saphenous vein (GSV) reflux. METHODS: Patients with Clinical Etiologic Anatomic Pathophysiologic classes 2 and 3 were enrolled in this study. QoL was measured using the EuroQol descriptive system (EQ-5D) questionnaire, and patients chose to receive either endovenous treatment or surgery after consulting with their surgeons. The QoL before the intervention, at 1 week, and at 1 month after the intervention were evaluated. Patients who reported "no problem" in each domain of the EQ-5D questionnaire before and 1 month after the intervention were compared. Utility gain was estimated from the questionnaire and compared between clinical classes. The proportion of worsening QoL at 1 week after the intervention was compared between patients receiving endovenous procedures and surgery. RESULTS: A total of 83 patients-56 received endovenous procedures [23 received ultrasound-guided foam sclerotherapy (UGFS) and 33 received radiofrequency ablation (RFA)] and 27 received surgery-were enrolled. QoLs were significantly better in all domains after the intervention: pain/discomfort (58%), mobility (42%), anxiety/depression (38%), usual activities (19%), and self-care (9%). Utility gain was 0.255 (95% confidence interval: 0.197-0.313) and higher in class 3. At 1 week after the intervention, surgery had significantly higher patients with worse mobility scores. Among endovenous procedures, UGFS had higher patients with worse pain/discomfort scores than RFA at 1 week after the intervention (16% vs. 0%, p = 0.025). CONCLUSION: GSV ablation for GSV reflux in Thai patients with CEAP C2 and C3 categories significantly improves both physical and mental QoL; patients who received endovenous procedures were found to have better early physical QoL.

Cost-utility analysis of great saphenous vein ablation with radiofrequency, foam and surgery in the emerging health-care setting of Thailand.

OBJECTIVES: To conduct economic evaluations of radiofrequency ablation, ultrasound-guided foam sclerotherapy and surgery for great saphenous vein ablation. METHOD: A cost-utility and cohort analysis from societal perspective was performed to estimate incremental cost-effectiveness ratio. Transitional probabilities were from meta-analysis. Direct medical, direct non-medical, indirect costs, and utility were from standard Thai costings and cohort. Probabilistic sensitivity analysis was performed to assess parameter uncertainties. RESULTS: Seventy-seven patients (31 radiofrequency ablation, 19 ultrasound-guided foam sclerotherapy, and 27 surgeries) were enrolled from October 2011 to February 2013. Compared with surgery, radiofrequency ablation costed 12,935 and 20,872 Baht higher, whereas ultrasound-guided foam sclerotherapy costed 6159 lower and 1558 Bath higher for outpatient and inpatient, respectively. At one year, radiofrequency ablation had slightly lower quality-adjusted life-year, whereas ultrasound-guided foam sclerotherapy yielded additional 0.025 quality-adjusted life-year gained. Because of costing lower and greater quality-adjusted life-year than other compared alternatives, outpatient ultrasound-guided foam sclerotherapy was an option being dominant. Probabilistic sensitivity analysis resulted that at the Thai ceiling threshold of 160,000 Baht/quality-adjusted life-year gained, ultrasound-guided foam sclerotherapy had chances of 0.71 to be cost-effective. CONCLUSIONS: Ultrasound-guided foam sclerotherapy seems to be cost-effective for treating great saphenous vein reflux compared to surgery in Thailand at one-year results.

A systematic review and meta-analysis of randomised controlled trials of delayed primary wound closure in contaminated abdominal wounds.

A systematic review and meta-analysis was conducted to compare surgical site infection (SSI) between delayed primary (DPC) and primary wound closure (PC) in complicated appendicitis and other contaminated abdominal wounds. Medline and Scopus were searched from their beginning to November 2013 to identify randomised controlled trials (RCTs) comparing SSI and length of stay between DPC and PC. Studies' selection, data extraction, and risk of bias assessment were done by two independent authors. The risk ratio and unstandardised mean difference were pooled for SSI and length of stay, respectively. Among 8 eligible studies, 5 studies were done in complicated appendicitis, 2 with mixed complicated appendicitis and other types of abdominal operation and 1 with ileostomy closure. Most studies (75%) had high risk of bias in sequence generation and allocation concealment. Among 6 RCTs of complicated appendicitis underwent open appendectomy, the SSI between PC and DPC were not significantly different with a risk ratio of 0.89 (95% CI: 0.46, 1.73). DPC had a significantly 1.6 days (95% CI: 1.41, 1.79) longer length of stay than PC. Our evidence suggested there might be no advantage of DPC over PC in reducing SSI in complicated appendicitis. However, this was based on a small number of studies with low quality. A large scale RCT is further required.