Postoperative nutrition practices in abdominal surgery patients in a tertiary referral hospital Intensive Care Unit: A prospective analysis

Background:Benefit of early enteral feeds in surgical patients admitted to Intensive Care Units (ICUs) has been emphasized by several studies. Apprehensions about anastomotic leaks in gastrointestinal surgical patients prevent initiation of early enteral nutrition (EN). The impact of these practices on outcome in Indian scenario is less studied.Aims:This study compares the impact of early EN (within 48 h after surgery) with late EN (48 h postsurgery) on outcomes in abdominal surgical ICU patients.Methods:Only patients directly admitted to ICU after abdominal surgery were included in this study. ICU stay>3 days was considered as prolonged; with average ICU length of stay (LOS) for this ICU being 3 days. The primary outcome was in-patient mortality. ICU LOS, hospital LOS, infection rates, and ventilator days were secondary outcome measures. Acute Physiology and Chronic Health Evaluation II scores were calculated. SPSS and Microsoft Excel were used for analysis.Results:Of 91 ICU patients included, 58 received early EN and 33 late EN. Hospital LOS and infection rates were less in early EN group. Use of parenteral nutrition (odds ratio [OR] 5.25, 95% confidence interval (CI); P = 0.003) and number of nil-per-oral days (OR 8.25, 95% CI; P ≤ 0.001) were other predictors of prolonged LOS.Conclusions:Early EN in postabdominal surgery ICU patients was associated with reduced hospital LOS and infection rates. ICU LOS, duration of mechanical ventilation and mortality rates did not vary.     

Impact of Workspace Design on Radiation Therapist Technicians’ Physical Stressors,Mental Workload,Situation Awareness,and Performance

PurposeOur purpose was to assess the effect of workspace configuration on radiation therapists’ (RTs) physical stressors, mental workload (WL), situational awareness (SA), and performance during routine treatment delivery tasks in a simulated environment.Methods and MaterialsFourteen RTs were randomized to 2 workspace configurations while performing 4 simulated scenarios: current (not ergonomically optimized; n = 7) and enhanced (ergonomically optimized, n = 7). Physical stressors were objectively assessed using a rapid upper limb assessment tool. Mental WL was measured at the end of each simulated scenario subjectively using the NASA Task-Load Index and objectively throughout the scenario using eye-tracking metrics (pupil diameter and blink rate). SA was measured at the end of each simulated scenario subjectively using the situation awareness and review technique. Performance was measured objectively via assessment of time-out compliance, error detection, and procedural compliance. Analysis of variance was used to test the effect of workspace configuration on physical stressors, mental WL, SA, and performance.ResultsThe enhanced configuration significantly reduced physical stressors (rapid upper limb assessment; P < .01) and resulted in a higher rate of time-out compliance (P = .01) compared with current workspace configuration. No significant effect on other metrics was measured.ConclusionsOur results suggest that an ergonomically designed workspace may minimize physical stressors and improve the performance of RTs.     

Influence of low-level laser on pain and inflammation in type 2 diabetes mellitus with diabetic dermopathy – A case report

Numerous skin lesions have been commonly observed in individuals with diabetes mellitus. The common skin manifestations of diabetes mellitus are erythrasma, xanthomatosis, xanthelasma, phycomycetes and cutaneous infections like furuncolosis, candidiasis, carbuncle, dermatophytosis, etc. Diabetic dermopathy is the most common skin lesion found in patients with diabetes. It is typically seen in men aged above 50 years. In low-level laser therapy (LLLT), the entire lower limb was illuminated with the frequency of 20 Hz and wavelength of 830 nm for 9 min, and the treatment was divided into four parts. With the continued sessions of LLLT, the skin manifestations and neuropathy conditions improved drastically. On the 21st day, the skin colour was found to be normal. Also, there were significant changes in clinical findings for diabetic peripheral neuropathy. LLLT with specific exercises can promote healing of skin manifestations in individuals with type 2 diabetes mellitus. It can be used as an effective treatment modality for treating diabetic dermopathy.     

Successful Voiding After Trial Without Catheter Is Not Synonymous With Recovery of Bladder Function After Colorectal Surgery

Purpose The need for monitoring postoperative urine output and the possibility of lower urinary tract dysfunction following colorectal surgery necessitates temporary urinary drainage. Current practice assumes recovery of lower urinary tract function to coincide with successful micturition after removal of urethral catheter. The aim of this study was to analyze the recovery of bladder function following colorectal surgery. Methods Patients undergoing colorectal operations underwent preoperative and postoperative uroflowmetry and residual urine estimation. All patients were catheterized suprapubically at surgery. Uroflowmetry and postvoid residual volumes were recorded postoperatively until recovery of bladder function was complete. Results Thirty consecutive patients underwent suprapubic catheterization, 25 of whom completed the study. Seventeen (68 percent) patients were able to pass urine within 72 hours of surgery. Recovery of lower urinary tract function was delayed in patients undergoing rectal vs. colonic resections (median, 6 vs. 3 days, P = 0.0015). Postvoid residual volumes greater than 200 ml were noted in three (20 percent) patients following rectal resections beyond the tenth postoperative day, with complete emptying achieved by six weeks. Conclusions Apparent successful micturition following rectal resections does not always indicate recovery of bladder function. The use of suprapubic catheters, in addition to being safe and effective, allows assessment of residual volumes postoperatively and smoothes the path to full recovery of lower urinary tract function. Presented at the Tripartite Colorectal Meeting, Melbourne, Australia, October 27 to 30, 2002.     

Intraoperative breast problem--focused sonography a valuable tool in the training of surgical residents

INTRODUCTION: In surgical residency education, "hands-on" learning is important in the operating room. Mastering the interpretation of preoperative data is a must for intraoperative decisions. Because preoperative evaluations of breast masses by ultrasound are performed and interpreted in the Department of Radiology, our study aimed to assess and improve surgical residents' ability to perform ultrasound and to interpret their results before performing breast mass biopsies. METHODS: Between January 2000 and May 2007, 128 female patients found to have palpable breast masses were scheduled for biopsy. An on-table ultrasound was performed by a surgical resident under the supervision of an attending surgeon. The resident was unaware of the result reported by the Department of Radiology. The parameters used to evaluate on-table ultrasound were the echogenicity, diameter (transverse vs vertical), and margins (regular vs irregular) of patients' lesions. Based on these criteria, residents classified lesions as benign, malignant, or indeterminate. The results were compared with the preoperative ultrasound evaluations provided by the Department of Radiology and pathology reports. RESULTS: Eliminating the 10 indeterminate lesions on ultrasound, the residents found that 87 lesions were benign and 31 lesions were malignant. The residents' assessment of the breast lumps had a sensitivity of 90.32% and a specificity of 96.55%, with a positive predictive value of 90.32% and a negative predictive value of 96.55%. CONCLUSIONS: The residents' overall accuracy of 94.91% approximates that of the radiologists in differentiating between benign and malignant lesions. The study allowed us to assess the knowledge and skills of residents who responded as required by Accreditation Council for Graduate Medical Education core competencies.     

A quantitative framework and strategies for management and evaluation of metabolic drug-drug interactions in oncology drug development: new molecular entities as object drugs

This article outlines general strategies for the management and evaluation of pharmacokinetic drug-drug interactions (DDIs) resulting from perturbation of clearance of investigational anticancer drug candidates by concomitantly administered agents in a drug development setting, with a focus on drug candidates that cannot be evaluated in first-in-human studies in healthy subjects. A risk level classification is proposed, based on quantitative integration of knowledge derived from preclinical drug-metabolism studies evaluating the projected percentage contribution [f(i)(%)] of individual molecular determinants (e.g. cytochrome P450 isoenzymes) to the overall human clearance of the investigational agent. The following classification is proposed with respect to susceptibility to DDIs with metabolic inhibitors: a projected maximum DDI expected to result in a ≤1.33-fold increase in exposure, representing a low level of risk; a projected maximum DDI expected to result in a >1.33-fold but <2-fold increase in exposure, representing a moderate level of risk; and a projected maximum DDI expected to result in a ≥2-fold increase in exposure, representing a potentially high level of risk. For DDIs with metabolic inducers, the following operational classification is proposed, based on the sum of the percentage contributions of enzymes that are inducible via a common mechanism to the overall clearance of the investigational drug: <25%, representing a low level of risk; <50%, representing a moderate level of risk; and ≥50%, representing a potentially high level of risk. To ensure patient safety and to minimize bias in determination of the recommended phase II dose (RP2D), it is recommended that strong and moderate inhibitors and inducers of the major contributing enzyme are excluded in phase I dose-escalation studies of high-risk compounds, whereas exclusion of strong inhibitors and inducers of the contributing enzyme(s) is recommended as being sufficient for moderate-risk compounds. For drugs that will be investigated in diseases such as glioblastoma, where there may be relatively frequent use of enzyme-inducing antiepileptic agents (EIAEDs), a separate dose-escalation study in this subpopulation is recommended to define the RP2D. For compounds in the high-risk category, if genetic deficiencies in the activity of the major drug-metabolizing enzyme are known, it is recommended that poor metabolizers be studied separately to define the RP2D for this subpopulation. Whereas concomitant medication exclusion criteria that are utilized in the phase I dose-escalation studies will probably also need to be maintained for high-risk compounds in phase II studies unless the results of a clinical DDI study indicate the absence of a clinically relevant interaction, these exclusion criteria can potentially be relaxed beyond phase I for moderate-risk compounds, if supported by the nature of clinical toxicities and the understanding of the therapeutic index in phase I. Adequately designed clinical DDI studies will not only inform potential relaxation of concomitant medication exclusion criteria in later-phase studies but, importantly, will also inform the development of pharmacokinetically derived dose-modification guidelines for use in clinical practice when coupled with adequate safety monitoring, as illustrated in the prescribing guidance for many recently approved oncology therapeutics.