Can post-sternotomy mediastinitis be prevented by a closed incision management system?

Post-sternotomy mediastinitis is a serious complication after cardiothoracic surgery and contribute significantly to post-operative morbidity, mortality, and healthcare costs. Negative pressure wound therapy is today’s golden standard for post-sternotomy mediastinitis treatment. A systematic literature search was conducted at PubMed until October 2012 to analyse whether vacuum-assisted closure technique prevents mediastinitis after clean surgical incisions closure. Today’s studies showed reduction of post-sternotomy mediastinitis including a beneficial socio-economic impact. Current studies, however included only high-risk patients, hence furthermore, larger randomised controlled trials are warranted to clarify the benefit for using surgical incision vacuum management systems in the general patient population undergoing sternotomy and clarify risk factor interaction.     

Does nutritional intervention in protein-energy malnutrition improve morbidity or mortality?

Although there is an association between malnutrition and a poor clinical outcome, it does not necessarily follow that providing nutrients to such patients will improve the outcome. In fact, a number of prospective randomized controlled trials have not been able to demonstrate that nutritional support does, in general, improve morbidity or mortality. Very few such trials have been performed in patients with renal disease. Three studies in patients with acute renal failure have suggested that patients receiving parenteral nutrition using essential amino acids as the nitrogen source have better outcomes than do patients receiving equicaloric amounts of glucose, but these studies cannot exclude the possibility that the intravenous infusion of high concentrations of dextrose is detrimental. Small studies have suggested that the provision of perdialytic nutrient infusions or enteral nutrient supplements can improve measurements of nutritional status, but none of these trials described the effect of the nutritional intervention on morbidity or mortality. Two small trials have raised the possibility that supplemental ketoacids may retard the progression of chronic renal failure. There is a need for large randomized controlled trials to establish or refute the efficacy of nutritional support in renal disease. Such trials should include a control group that is not receiving any nutritional support.     

How much disease burden can be prevented by environmental interventions?

There is very little systematically collected evidence on the overall contribution of environmental risk factors to the global burden of disease. The World Health Organization (WHO) recently completed a comprehensive, systematic, and transparent estimate of the disease burden attributable to the environment highlighting the full potential for environmental interventions to improve human health.This report is the result of a systematic literature review on environmental risks completed by a survey of expert opinion using a variant of the Delphi method. More than 100 experts provided quantitative estimates on the fractions of 85 diseases attributable to the environment. They were asked to consider only the contributions of the "reasonably modifiable environment"-that is, the part of environment that can plausibly be changed by existing interventions.The report estimates that 24% of the global burden of disease was due to environmental risk factors. Environmental factors were judged to play a role in 85 of the 102 diseases taken into account. Major diseases were, for example, diarrheal diseases with fractions attributable to the environment of 94%, lower respiratory infections with 41%, malaria with 42%, and unintentional injuries with 42%. The evidence shows that a large proportion of this "environmental disease burden" could be averted by existing cost-effective interventions such as clean water, clean air, and basic safety measures. In children, 34% of the disease burden is attributable to the environment, and much of this burden is in developing countries.     

Can knee replacements be assessed by post?

The audit of knee replacement surgery requires long-term follow-up. The aim of this Bristol study was to examine whether an accurate assessment of knee replacement surgery could be undertaken by post, thus obviating the need for patients to visit hospital. A patient's questionnaire was designed to complement the clinic therapist's assessment form currently in use, and this was completed by 73 patients without supervision prior to the therapist's assessment. A comparison of the two assessments shows a significant discrepancy between their results, particularly in the assessment of pain, walking distance, and range of movement. The authors conclude that postal follow-up of knee replacements should be viewed with caution.     

Can gender differences in psychosocial factors be explained by socioeconomic status?

AIMS: The aims of this study were to examine (1) if associations between gender and psychosocial factors could be explained by socioeconomic status (SES) and (2) if associations between gender and psychosocial factors are more salient at lower levels of SES. METHODS: Psychosocial factors such as decision latitude and social integration were studied in a cross-sectional study in two steps. In a public health survey, 4,086 randomly selected men and women aged 30-64 participated. Of these, 257 men and women also participated in an in-depth study. SES was measured in terms of education and occupation. Linear regression models were used to test associations between gender, SES, and a broad range of psychosocial factors. RESULTS: Women reported lower scale scores on decision latitude, coping, and self-esteem, as well as more job strain, depression, and vital exhaustion, while men reported more cynicism (all p<0.05). Observed gender differences were still significant after control for effect of education, while after control for occupational status the effect of gender was lost for decision latitude and job strain. Significant interaction factors were found between gender and educational status for psychological demands, decision latitude, social integration, coping, and hopelessness. CONCLUSIONS: Gender differences, found for a broad range of psychosocial factors, could not be explained by SES. However, associations between gender and psychosocial factors were more salient at lower levels of SES. Psychosocial factors, especially decision latitude and social integration, may help explain why women with low SES experience poorer health.     

Can bioelectrical impedance analysis identify malnutrition in preoperative nutrition assessment?

OBJECTIVE: Malnutrition is characterized by changes in cellular membrane integrity and alterations in fluid balance, both of which can be detected by bioelectrical impedance analysis (BIA). We investigated whether BIA-measured variables could detect malnutrition, as defined by the Subjective Global Assessment (SGA), in preoperative surgical patients. METHODS: We prospectively evaluated 279 patients hospitalized for elective gastrointestinal surgery during the first 72 h after admission. BIA estimates were used to derive body cell mass, ratio of extracellular mass to body cell mass, and phase angle. Malnutrition diagnosed with these measures was compared with the SGA score. Receiver operating characteristic curves also were formulated to explore alternative cutoff points for one measure, phase angle. RESULTS: A linear trend for means across SGA categories was found for all indicators used, except percentage of body cell mass. However, there was only fair overall agreement between SGA and BIA estimates. The receiver operating characteristic curves for phase angle suggested that the test was too sensitive or too specific. No alternative cutoff points resulted in suitable tests that could provide an alternative to SGA. CONCLUSIONS: Although not in close agreement with SGA, the results suggested that there are some alterations in tissue electrical properties with malnutrition that can be detected by BIA. New cutoff points may be needed for application of BIA as a complementary method in the nutrition assessment of surgical patients.