Author: Dr.S.Harsha Vardhan

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No Reduction in SSIs With Strict Surgical Attire Policy

Implementing policies that require surgical staff to wear surgical jackets and bouffants in the operating room (OR) does not decrease the risk for surgical site infections (SSIs), according to a study published online today in JAMA Surgery.

“[T]he results of this study suggest that surgical jackets and bouffants are neither beneficial nor cost-effective in preventing SSIs,” write Bradley W. Wills, MD, University of Alabama at Birmingham, and colleagues.

Approximately 300,000 SSIs occur annually in the United States, accounting for one fifth of all hospital-acquired infections and costing the US healthcare system an estimated $10 billion each year.

Although some evidence supports implementation of certain OR attire policies (such as use of gloves and impermeable surgical gowns) to help prevent SSIs, data are lacking on the association between use of surgical jackets and bouffants and infections.

Wills and colleagues performed a retrospective cohort study to investigate whether mandating use of surgical jackets and bouffants in the OR was linked to a lower incidence of SSIs.

The study included 34,042 inpatient surgical encounters at a large academic tertiary care hospital between January 2017 and October 2018. The researchers compared three periods within this time.

During the first period (8 months), no bouffants or surgical jackets were required. During the second period (6 months), surgical jackets were mandated, and during the third period (8 months), surgical jackets and bouffants were required.

Despite the dress code changes, SSI risk remained relatively constant throughout the time frame, with no significant difference between the three periods (1.01% vs 0.99% vs 0.83%; P = .28).

Similarly, the investigators found no significant difference between the periods in risk for mortality (1.83% vs 2.05% vs 1.92%; P = .54), postoperative sepsis (6.60% vs 6.24% vs 6.54%; P = .54), or wound dehiscence (1.07% vs 0.84% vs 1.06%; P = .20).

The researchers calculated that use of surgical jackets during the 14 months of the second and third study periods cost an additional $264,760.78.

“The results add to the growing body of research that there is no clear benefit to bouffants and surgical jackets in the quest to decrease the incidence of SSIs,” the authors conclude.

“Institutions should evaluate their own data to determine whether recommendations by outside governing organizations are beneficial and cost-effective.”

In an accompanying editorial, Radwan Dipp Ramos, MD, and Kamal M. F. Itani, MD, both from the Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, agree that sufficient evidence now exists to show that these policies, although well-intentioned, do not reduce SSI risk and raise hospital expenditure.

Ramos and Itani, who is also with Boston University and Harvard Medical School, also stress the need to remember common-sense recommendations regarding OR attire. These include frequent laundering of cloth caps, they say.

Staff must remove headgear, mask, and shoe covers outside restricted areas and use new ones if they return to the OR. When leaving restricted areas for another case, staff should also change scrubs or cover them with a protective coat. And they should not be allowed to enter the OR wearing scrubs from home.

“Short of having best evidence in any of those areas, myth and reality will continue to coexist, and our common sense augmented by available evidence should prevail over emotions and careless practices,” the editorialists conclude.

Source : Medscape

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Tramadol Linked to Increased Hip Fracture Risk in Elderly

Older patients treated with the pain medication tramadol show significant increases in the risk of hip fracture compared with those using codeine or commonly used nonsteroidal anti-inflammatory drugs (NSAIDs), new research shows.

“Considering the significant impact of hip fracture on morbidity, mortality, and healthcare cost, our results point to the need to consider tramadol’s associated risk of fracture in clinical practice and treatment guidelines,” first author Jie Wei, PhD, an associate professor of epidemiology at Xiangya Hospital, Central South University, China, told Medscape Medical News.

In commenting on the research, Shailendra Singh, MD, noted that the “article clearly reinforces [prior] knowledge…that opiates are associated with an increased risk of falls and fractures.”

The American Geriatric Society BEERS criteria for inappropriate drugs for the elderly, for instance, lists tramadol and opiates as drugs to avoid in patients with increased risk of falls and fractures, added Singh, who is rheumatology medical director of the White River Medical Center in Batesville, Arkansas, and was not involved with the current study.

Increased Risk of Hip Fracture With Tramadol Even Compared With Codeine  

The new study, published this month in the Journal of Bone and Mineral Research, involved data on 146,956 patients in the United Kingdom who were age 50 years and older and enrolled in The Health Improvement Network (THIN).

The patients had initiated treatment with tramadol between 2000 and 2017 for noncancer-related pain, and had no history of hip fracture, cancer, or opioid use disorder.

In the propensity-matching analysis, those initiating tramadol were matched 1:1 with well-balanced characteristics to patients identified as initiating codeine during the same period (146,956 in each group).

Equal-numbered groups were also matched between tramadol and naproxen (115,109 in each group) or ibuprofen (107,438 per group), both NSAIDs, or celecoxib (43,130 per group) or etoricoxib (27,689 per group), which are both cyclooxygenase‐2 inhibitors.

Participants in the matched groups had a mean age of 65 and 56.9% were women.

For the primary outcome of the incidence of hip fracture over 1 year, the risk was higher for tramadol compared with codeine (hazard ratio [HR], 1.28), with 518 cases of hip fracture (3.7 per 1000 person-years) in the tramadol cohort and 401 (2.9 per 1000 person-years) in the codeine cohort.

Likewise, the risk was higher with tramadol compared with naproxen (HR, 1.69), ibuprofen (HR, 1.65), celecoxib (HR, 1.85), and etoricoxib (HR, 1.96).

A sensitivity analysis restricted to individuals aged 60 or older showed no major differences in the associations for all of the drug groups.

“The sensitivity analyses had similar results, indicating that the observed associations were robust and raising a concern on the potential risk of hip fracture among initiators of tramadol use,” the authors say.

The increased risk compared with the initiation of codeine is particularly notable, as codeine is regarded as a weak opioid and often used in a similar context as tramadol, Wei noted.

“The risk of incident hip fracture among tramadol initiators was not only higher than that among NSAIDs initiators, but also higher than that among codeine initiators, suggesting that the confounding by indication may not substantially account for an increased risk of hip fracture for tramadol,” she observed.

She added that “this was further supported by the evidence that risk factor profiles between initial prescription of tramadol and that of codeine were similar even before propensity-matching, except a few (for instance BMI was higher among tramadol than codeine prescriptions).”

“Nevertheless, as in all observational studies, we can’t rule out the impact of potential residual confounders when comparing the risk of hip fracture between initial prescription of tramadol and other pain-relief medications,” Wei stressed.

Tramadol Seen as Beneficial NSAID Alternative for Pain

Tramadol is seen as a valuable analgesic alternative to NSAIDs, with perceived lower cardiovascular and gastrointestinal effects while providing a reduced risk of addiction and respiratory depression compared with traditional opioids, the authors note.

Guidelines of professional organizations recommend tramadol for pain under various conditions, including the most recent guidelines of the American College of Rheumatology (ACR), which conditionally recommend tramadol for the treatment of knee or hip osteoarthritis, “including when patients may have contraindications to NSAIDs, find other therapies ineffective, or have no available surgical options.”

Use of the drug has been on the rise worldwide in recent decades, with one survey showing a 22.8% increase in tramadol prescriptions in the US from 2012 to 2015.

The authors note that important limitations of the study include the fact that the THIN database does not include measures on two potentially important confounders — bone density and frailty.

Singh said it’s unknown whether propensity score matching can adjust for important factors, such as the severity of disease: “(For instance), people with severe osteoporosis are at a higher risk of fracture, compared to moderate…the lower the T-score, the higher the risk of fracture.”

Link Between Increased Risk of Falls and Tramadol?
Don’t Prescribe It First-Line

As reported by Medscape Medical News, Wei and her colleagues showed an association between tramadol use and a higher risk of all-cause mortality among patients in the THIN network in a study published last year.

The specific mechanisms linking tramadol use to an increased risk of mortality remain unclear, however.

And that study, which — as opposed to the current one — was limited to patients with osteoarthritis pain, showed the increased mortality risk did not extend to those treated with codeine.

Although the mechanisms that may explain the increased risk of fracture are not known, Wei and colleagues note previous research suggesting an effect of tramadol in activating mu-opioid receptors while suppressing central serotonin and norepinephrine reuptake, which can be linked to the risk of seizures, dizziness, and/or delirium — all of which could increase the risk of fall.

“In fact, several studies have reported that tramadol use was indeed associated with a higher risk of fall, which is a critical risk factor for fracture,” they note.

“All these studies appear to suggest that relation of tramadol to the risk of hip fracture may be, at least partly, through its effect on fall,” they surmise.

“In this population-based cohort study, the initiation of tramadol was associated with a higher risk of hip fracture than initiation of codeine and commonly used NSAIDs, suggesting a need to revisit several guidelines on tramadol use in clinical practice.”

Singh agrees. While underscoring that further studies are needed to determine the mechanism of action in the increased hip fracture risk, he concluded that “opiates of any kind, including tramadol, should not be used as a first line drug for pain management in any setting.”

Source : Medscape

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How does it look like to drain the entire Ocean ?

Three fifths of the Earth’s surface is under the ocean, and the ocean floor is as rich in detail as the land surface with which we are familiar. This animation simulates a drop in sea level that gradually reveals this detail. As the sea level drops, the continental shelves appear immediately. They are mostly visible by a depth of 140 meters, except for the Arctic and Antarctic regions, where the shelves are deeper. The mid-ocean ridges start to appear at a depth of 2000 to 3000 meters. By 6000 meters, most of the ocean is drained except for the deep ocean trenches, the deepest of which is the Marianas Trench at a depth of 10,911 meters.

So , how does it look like to drain the entire ocean ? Lets see ….

Source : NASA

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Handheld 3D Printer Delivers Skin-Precursor Sheets Directly to Full-Thickness Burns

A new handheld 3D printer can be used to deliver skin-precursor sheets directly to wound beds and improve healing in full-thickness burns, according to a preclinical study in a porcine model.

“The ability to consistently deliver (human) cells in a matrix and onto practically relevant wound surfaces, i.e., of arbitrary size and topology, has been a significant limitation that we believe has been overcome with our handheld instrument,” Dr. Alex Guenther of the University of Toronto, in Canada, told Reuters Health by email.

Large burn areas often leave insufficient healthy skin to use as autologous skin grafts. Acellular biodegradable scaffolds have been used as alternatives, and different cellular approaches using patient-derived autologous or donor-derived allogeneic cells are under development.

Dr. Guenther and colleagues developed a handheld 3D bioprinter designed to deliver a fibrinogen-based bioink containing mesenchymal stromal cells directly onto burn-wound surfaces of arbitrary size, shape and topography.

A burn area of 2,000 cm2 (similar to an average burn area of the human posterior trunk or about 10% of total body surface) would require about 40 mL of biomaterial with 40 million cells in total, with a deposition time of 70 minutes, the researchers report in Biofabrication.

The time required to cover a full-thickness burn wound size of 5×5 cm took an average of 0.89 min, using 480 uL of biomaterials with a total of 480,000 cells.

The researchers treated full-thickness burn wounds on four porcine models using the handheld instrument and found that the wounds were uniformly covered with the deposited material immediately after delivery.

After 28 days, the treated wounds showed superior healing profiles with a reduction in inflammation, scarring, and contraction, compared with untreated burns and burns treated with acellular materials.

Histologically, treated wounds showed epidermal cell repopulation in normal ranges, whereas burn controls and acellular treatments showed regions with poor cell repopulation in addition to localized areas with hyperplasia or hypoplasia.

“Cell delivery of bioprinting should in many clinical cases probably not be done with a printer that is scaled to patient dimensions,” Dr. Guenther said. “That would make for a very bulky instrument. In contrast, we believe the demonstrated handheld device is advantageous. Also, because its form is similar to another handheld instrument routinely used by burn surgeons for many decades: a dermatome.”

Co-author Dr. Marc G. Jeschke of Sunnybrook Health Sciences Centre, also in Toronto, told Reuters Health by email, “This could change the way we practice for burn patients and patients with large wounds as we could restore a patients skin with no scar, no pain as we avoid donor sites and a significantly shortened hospital stay from months to weeks.”

“We have not shown that printing can restore autologous skin of a patient yet,” he said. “The issue at this time is showing efficacy, but this is being studied.”

Source : Medscape

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Bariatric Surgery Tied to Lowered Risk of Colorectal Cancer

Bariatric surgery may lower patients’ risk of developing colorectal cancer, a research review suggests.

Obesity has long been linked to increased risk of colorectal tumors and other types of cancer, as well as a greater risk for chronic illnesses like diabetes and heart disease. Losing weight is thought to reduce these risks.

“Our findings further support . . . that these surgeries do in fact have an overall protective effect among the obese population in terms of reducing colorectal cancer,” said Dr. Sulaiman Almazeedi of Jaber Al-Ahmed Hospital in Kuwait, who led the study.

The researchers examined data from seven previous studies that followed more than 1.2 million patients for about seven years, on average. Colorectal cancer was rare, developing in just 638 people during the study.

Compared to obese individuals who didn’t get bariatric surgery, those who did were 35% less likely to develop colorectal cancer, the researchers report in the British Journal of Surgery.

“Obesity is one of the most preventable causes of early death and it, as an epidemic, should not be taken lightly,” Almazeedi told Reuters Health by email. “Although lifestyle modifications and medical therapy have long been the cornerstone of this problem, bariatric surgery is proving day by day to be of vital importance in this battle.”

The studies in the analysis used a variety of methods and none was designed to prove bariatric surgery directly affects colorectal cancer risk.

Researchers also lacked information on preoperative body mass index, postoperative weight loss, and type of bariatric surgery.

“The primary explanation for reduction in cancer including colorectal cancer following bariatric surgery is the extent of weight loss which occurs,” said Dr. Bruce Wolfe, a researcher at Oregon Health and Science University in Portland, who wasn’t involved in the study.

Earlier research suggests obese people need to lose 20% of their body weight to get the best outcome in terms of reducing the risk of cancer, Wolfe said by email. Bariatric surgery is the best way to accomplish this, he said.

When people lose weight after bariatric surgery, many changes happen that impact cancer risk, said Dr. Daniel Schauer of the University of Cincinnati College of Medicine, in Ohio.

“Perhaps most importantly for colorectal cancer risk, the body has less inflammation and many of the (tumor) growth factors associated with obesity are decreased,” Schauer, who also wasn’t involved in the study, said by email. “These are strongly related to the amount of weight loss.”

Data from this study were presented at the XXIV World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders, Madrid, Spain, September 2019.

Source : Medscape

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Biopsy Kidneys From Live Donors to Predict Transplant Success

Subclinical structural features in kidneys from living donors that can only be seen with a microscope modestly contribute to predicting the long-term success of a transplant, new research suggests.

In an analysis that involved 2293 living donor-recipient pairs, intraoperative biopsy of the renal cortex of the donated kidney was performed to identify factors that predicted future graft failure — independent of donor and recipient risk factors, including age and kidney function.

These came down to interstitial fibrosis/tubular atrophy, larger cortical nephron size (although not nephron number), and smaller medullary volume.

“We think that these subtle abnormalities in the living kidney donor may make the kidney more susceptible to fail in the future in recipients,” lead investigator Naim Issa, MD, Mayo Clinic, Rochester, Minnesota, said in a statement from his institution. The study was published online January 23 in the Journal of the American Society of Nephrology.

“These important findings may provide insights into unrecognized predictors of kidney transplant failure in recipients,” Issa added.

However, he and his colleagues stress that even if these subtle structural abnormalities are detected in a living donor kidney, the findings should not deter anyone’s decision to donate his or her kidney to a patient who needs one.

Patients who receive a live donor kidney generally have better outcomes than those who receive a deceased donor organ, largely because kidneys from living donors tend to last longer than those from deceased donors.

Aging Kidney Anatomy Study

In the United States last year, nearly 7400 living donor transplants were performed, according to the United Network for Organ Sharing; it was a record year for living organ donation in the US but still a far cry from the nearly 95,000 organs needed for patients who are still awaiting a donor kidney.

Living kidney donation has become the preferred therapeutic option for patients with end-stage renal disease. A thorough clinical evaluation with laboratory testing is required to ensure the donor has healthy kidneys.

Despite this, certain live donor clinical characteristics (particularly older age and lower glomerular filtration rate) predict an increased risk of death-censored graft failure in the recipient.  

These clinical characteristics may reflect underlying structural features in the kidney that are predictive of longevity of the graft, so the researchers set out to examine kidney structural predictors of death-censored graft failure.

The study took place in 3 transplant centers involved in the Aging Kidney Anatomy study — donor and recipient pairs at Mayo Clinic Minnesota (n = 1585), Mayo Clinic Arizona (n = 436), and Cleveland Clinic in Ohio (n = 272) — examining organs donated between May 1999 and December 2017.

“All kidney donors underwent a thorough medical evaluation prior to donation that included a prescheduled series of tests,” including a CT scan, the researchers note. And an intraoperative needle core biopsy of the renal cortex of the donated kidney was performed during transplantation.

During follow-up, 12.5% of recipients developed death-censored graft failure and 18.5% of donor recipients died.

The mean time to death-censored graft failure or last follow-up was 6.3 years, the authors note.

“Each kidney structural feature on biopsy or CT scan at the time of transplantation was evaluated as a predictor of death-censored graft failure,” they explain.

Findings Support Biopsies to ID Grafts at Higher Risk of Failure

After adjusting for both donor and recipient clinical characteristics, the structural features that appeared to affect the life span of a posttransplant kidney were the percentage of interstitial fibrosis/tubular atrophy (IF/TA) in the allograft (an IF/TA >5%); arteriolar hyalinosis as detected by the pathologist on biopsy slides; larger glomeruli and tubules; and smaller medulla at the time of donation.

These all modestly predicted for death-censored graft failure, the authors elaborate.

“[These findings] provide important insights into the factors that define the ‘intrinsic quality’ of the living kidney donor graft at the time of donation and support the use of intraoperative biopsies to identify kidney allografts that are at higher risk for failure,” they emphasize.

The investigators point out that intraoperative kidney biopsy has very low risk for harm, with any bleeding easily controlled by the surgeon.

However, they reiterate that even with the abnormalities detected on biopsy,

“Availability of a willing person with acceptable health for kidney donation will generally supersede concerns regarding graft quality.”

“And if the biopsy shows arteriolar hyalinosis, IF/TA >5% or enlarged nephrons…[transplant recipients] may benefit from non-CNI (calcineurin inhibitor)-based immunosuppression or more aggressive management of blood pressure to prevent worsening arteriolar hyalinosis or nephron enlargement,” they indicate.

However, the researchers also caution, “Further studies are needed to determine if recipient management benefits from modifications based on the living donor biopsy findings.”

Source : Medscape