Overall readmissions and readmissions related to dehydration after creation of an ileostomy: a systematic review and meta-analysis.

BACKGROUND: Hospital readmissions after creation of an ileostomy are common and come with a high clinical and financial burden. The aim of this review with pooled analysis was to determine the incidence of dehydration-related and all-cause readmissions after formation of an ileostomy, and the associated costs. METHODS: A systematic literature search was conducted for studies reporting on dehydration-related and overall readmission rates after formation of a loop or end ileostomy between January 1990 and April 2021. Analyses were performed using R Statistical Software Version 3.6.1. RESULTS: The search yielded 71 studies (n = 82,451 patients). The pooled incidence of readmissions due to dehydration was 6% (95% CI 0.04-0.09) within 30 days, with an all-cause readmission rate of 20% (CI 95% 0.18-0.23). Duration of readmissions for dehydration ranged from 2.5 to 9 days. Average costs of dehydration-related readmission were between $2750 and $5924 per patient. Other indications for readmission within 30 days were specified in 15 studies, with a pooled incidence of 5% (95% CI 0.02-0.14) for dehydration, 4% (95% CI 0.02-0.08) for stoma outlet problems, and 4% (95% CI 0.02-0.09) for infections. CONCLUSIONS: One in five patients are readmitted with a stoma-related complication within 30 days of creation of an ileostomy. Dehydration is the leading cause for these readmissions, occurring in 6% of all patients within 30 days. This comes with high health care cost for a potentially avoidable cause. Better monitoring, patient awareness and preventive measures are required.

The effect of dietary protein depletion on hepatic 5-fluorouracil metabolism.

BACKGROUND: Protein calorie malnutrition, which is highly prevalent in tumor-bearing hosts, increases toxicity to 5-fluorouracil (5-FU), but the mechanisms are unclear. This study investigated the effects of protein depletion on 5-FU in vivo hepatic metabolism using F19-nuclear magnetic resonance spectroscopy (19F-NMRS). METHODS: Rats received normal (21.5%) or low (2.5%) protein diet for 25 days. 5-FU was injected intraperitoneally, and hepatic fluorine spectra were obtained. Parallel experiments were conducted to determine serum 5-FU pharmacokinetics using high-performance liquid chromatography (HPLC) and to measure hepatic dihydropyrimidine dehydrogenase (DPD) activity. RESULTS: The mean time of initial detection of fluoro-beta-alanine and the mean duration of the 5-FU signal in the liver were significantly prolonged in the low-protein group. 5-FU clearance and hepatic DPD activity were significantly lower in the low-protein group. Low-protein animals demonstrated increased toxicity, with diarrhea, weight loss, leukopenia (P < 0.001), and an 85% mortality, compared with regular diet animals, who had mild diarrhea and weight loss but no leukopenia and a 12% mortality. CONCLUSION: Protein depletion results in increased toxicity to 5-FU, which is associated with a significantly decreased rate of hepatic metabolism and clearance of 5-FU and a significant decrease in hepatic DPD activity. 19F-NMRS can noninvasively identify these alterations of 5-FU metabolism in vivo and may serve as a useful guide to determining chemotherapy dosage adjustments to reduce toxicity.

Integrated magnetic resonance imaging and phosphorus spectroscopy of soft tissue tumors.

Eighteen patients with soft tissue masses underwent integrated magnetic resonance imaging (MRI) and phosphorus spectroscopy (31P-MRS) to evaluate benign and malignant tumor morphology and metabolism. Spectra from soft tissue tumors had a significantly higher proportion of phosphate in the low-energy portion of the 31P spectrum (P less than 0.001) with a concomitant decrease in phosphocreatine (P less than 0.01) compared with 31P spectra from normal muscle. Malignant tumors had a mean pH of 7.35 +/- 0.13 which was greater than that of muscle tissue with a mean pH of 7.08 +/- 0.07 (P less than 0.001). All tumors had greater relative levels of phosphomonoesters, inorganic phosphate, and phosphodiesters compared with those in muscle tissue but considerable variability among tumors was noted due to tumor size, extent of tumor necrosis, and muscle contamination. Integrated MRI/MRS studies are necessary to provide exact localization of the tumor and a more correct interpretation of the 31P-MRS data.

Components of energy expenditure in tumor-bearing animals.

Single snapshot measurements of resting energy expenditure (REE) suggest that hypermetabolism contributes to cancer cachexia, but tumor impact on total 24-hr energy expenditure (TEE) is unknown. Automated multicage indirect calorimetry was employed to measure daily energy expenditure in adult Buffalo rats (n = 16) randomized to tumor inoculation or controls. Measurements included baseline REE, activity EE (AEE), thermic response to food (TEF), and TEE. Rats (n = 16) were randomized. Metabolic measurements, tumor size, and body weight were recorded weekly. Animals were sacrificed at Week 5 for analysis of host and tumor composition. Significant depletion of total lean body mass occurred in TB rats (greater than 15% wt loss, ANOVA P less than 0.001) which inversely correlated with tumor growth (r = -0.81, P less than 0.001). REE, TEF, AEE, and TEE did not change in controls (ANOVA P = n.s.). In TB rats, a 19.5% increase in REE occurred (119.4 +/- 3.3 to 138.7 +/- 1.8 kcal/kg LBM/day, P less than 0.01). TEE remained unchanged (157.3 +/- 5.6 vs 152.9 +/- 3.6 kcal/kg LBM/day, P = n.s.) due to a 66% decrease in AEE (32.9 +/- 3.1 to 10.5 +/- 1.7 kcal/kg LBM/day, P = 0.01). TEF did not change (4.7 +/- 0.8 vs 5.0 +/- 0.3 kcal/kg LBM/day, P = n.s.). Both TB and controls demonstrated a decreased REE in response to a 24-hr fast (7.9% vs 4.8%, P = n.s.). Respiratory quotient decreased in both groups when comparing fed to fasted values: TB (0.86 to 0.76) and controls (0.86 to 0.71), but the decline was greater in controls (P = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Combined MR imaging and spectroscopy of bone and soft tissue tumors.

Twenty-three patients with bone and soft tissue tumors were studied with combined magnetic resonance (MR) imaging and spectroscopy. The MR examinations were utilized to determine the size, internal characteristics, and relationships of the tumor to the surrounding tissues. They also determined the optimal placement of the surface coil. The surface coil profile was the localization technique utilized. Four patients were also studied with one-dimensional chemical shift localization. Tumors were grouped according to histologic type, degree of muscle contamination, size, and extent of necrosis. Quantitative comparison among the groups was carried out by comparing the mean ratios of the low-energy phosphate portion of the spectra [phosphomonoester (PME), Pi, phosphodiester (PDE)] to beta-nucleotide triphosphate (NTP). Tumor spectra typically showed a relative elevation in PME, Pi, and PDE and a relative decrease in phosphocreatinine. No characteristic spectra were observed for individual tumor types. Contamination of the tumor spectra from surrounding muscle impaired interpretation of the spectral data. Tumor size and extent of necrosis were important determinants of the relative degree of abnormally elevated metabolite peaks (PME, Pi, PDE). A trend toward a higher mean PME/beta-NTP ratio was observed among high-grade lesions. Combined MR imaging and spectroscopy is a useful way to study tumor metabolism. Muscle contamination is a significant problem in analysis of the spectra. Better localization techniques are required.

Magnetic resonance imaging and magnetic resonance spectroscopy of bone tumors and bone marrow disease.

The authors have made use of an integrated magnetic resonance imaging/spectroscopy (MRI/MRS) examination to study seven patients with a variety of bone tumors. The spatial localization method used in the 31P portion of the examination was surface coil localization and a one-dimensional chemical shift imaging method (3 cases). The authors found that the precision of spatial localization was critical in many of these cases, since most of these bone tumors were surrounded by muscle tissue that contained high concentrations of phosphocreatine (PCr). For this reason, they suggest that the metabolite ratios should be referenced to the adenosine triphosphate (beta-NTP) resonance rather than PCr. The phosphate monoester (PME) to beta-NTP ratio was elevated as compared with normal muscle in all of the bone tumors studied. The authors found that all of these tumors exhibited pHs between 7.0 and 7.2, which are similar to the values found for normal muscle. They also show the feasibility of using a line-selective proton chemical shift imaging sequence with high spatial resolution for investigating changes in the fatty composition of bone marrow. This method is illustrated in an example of a patient with advanced avascular necrosis in the femoral heads.

Digital subtraction cholangiography: a new technique for visualising the common bile duct during cholecystectomy.

Operative cholangiography is for most surgeons a routine part of every cholecystectomy. Computerised digital subtraction angiography was adapted for operative cholangiography using a portable machine. After cannulation of the cystic duct the background image was subtracted before injecting contrast. Only the contrast within the bile duct appears on the monitor and resolution is high. A permanent record was made on 10 X 10 cm spot films. Eighteen pre-exploratory cholangiograms were performed using this method. In 12 no stones were demonstrated on digital subtraction cholangiography (DSC), nor were there clinical indications of common bile duct stones. These patients underwent cholecystectomy only. Stones were demonstrated on DSC in 3 patients and all had stones at exploration of the common bile duct (CBD). Three patients had no stones demonstrated on DSC but were explored on clinical grounds. No stones were found. Postoperative T-tube cholangiograms confirmed the absence of stones in 5 patients. A retained stone was present in one patient who had not had a postexploratory examination at operation and was not related to the use of this cholangiographic technique. DSC combines the benefits of image intensification and still radiography and has been accurate in both predicting and excluding common bile duct stones.

Optical and nuclear magnetic resonance studies of hypoxia in human tissue and tumors.

Correlations of energy state with response to therapy are more difficult to analyze because of the large effect of tumor clearing and oxygenation upon the tumor energy state as detected by PMRS alone. The combination of time-resolved hemoglobinometry using picosecond laser technology and localized PMRS seems appropriate to unravel the complexities of therapeutic intervention, tumor energetics, and oxygenation.