Douglas M. Overbey

Fecal microbiota transplant in patients with Clostridium difficile infection: A systematic review.

BACKGROUND Fecal microbiota transplantation (FMT) restores a diverse bacterial profile to the gastrointestinal tract and may effectively treat patients with Clostridium difficile infection (CDI). The objective of this systematic review was to evaluate the effectiveness of FMT in the treatment of CDI. METHODS Ovid MEDLINE, EMBASE, Web of Science, and Cochrane database were used. The authors searched studies with 10 or more patients examining the resolution of symptoms after FMT in patients with CDI. Reviews, letters to the editors, and abstracts were excluded. Participants were patients with CDI. Intervention used was FMT. Quality assessment was performed using the Cochrane risk of bias assessment tool. Results were synthesized using a narrative approach. RESULTS Retrospective and uncontrolled prospective cohort studies suggest that FMT is a highly effective therapy for recurrent/refractory CDI, with clinical success rates ranging from 83% to 100%, which is similar to rates published by two randomized controlled trials. Fecal microbiota transplantation may be effectively administered via antegrade (upper gastrointestinal) or retrograde (lower gastrointestinal) routes of delivery. Fecal microbiota transplantation rarely results in major adverse events. However, diarrhea, cramping, and bloating commonly occur and are typically self-limited. Most studies were uncontrolled retrospective studies. CONCLUSION Fecal microbiota transplantation should be considered in patients with recurrent episodes of mild to moderate CDI who have failed conventional antimicrobial therapy. There is insufficient evidence to recommend FMT for the treatment of severe CDI. LEVEL OF EVIDENCE Systematic review, level III.

Clinical Utility of Chest Computed Tomography in Patients with Rib Fractures CT Chest and Rib Fractures

Background Chest CT is more sensitive than a chest X-ray (CXR) in diagnosing rib fractures; however, the clinical significance of these fractures remains unclear. Objectives The purpose of this study was to determine the added diagnostic use of chest CT performed after CXR in patients with either known or suspected rib fractures secondary to blunt trauma. Methods Retrospective cohort study of blunt trauma patients with rib fractures at a level I trauma center that had both a CXR and a CT chest. The CT finding of ≥ 3 additional fractures in patients with ≤ 3 rib fractures on CXR was considered clinically meaningful. Student’s t-test and chi-square analysis were used for comparison. Results We identified 499 patients with rib fractures: 93 (18.6%) had CXR only, 7 (1.4%) had chest CT only, and 399 (79.9%) had both CXR and chest CT. Among these 399 patients, a total of 1,969 rib fractures were identified: 1,467 (74.5%) were missed by CXR. The median number of additional fractures identified by CT was 3 (range, 4 - 15). Of 212 (53.1%) patients with a clinically meaningful increase in the number of fractures, 68 patients underwent one or more clinical interventions: 36 SICU admissions, 20 pain catheter placements, 23 epidural placements, and 3 SSRF. Additionally, 70 patients had a chest tube placed for retained hemothorax or occult pneumothorax. Overall, 138 patients (34.5%) had a change in clinical management based upon CT chest. Conclusions The chest X-ray missed ~75% of rib fractures seen on chest CT. Although patients with a clinical meaningful increase in the number of rib fractures were more likely to be admitted to the intensive care unit, there was no associated improvement in pulmonary outcomes.

How Hemostatic Agents Interact With the Coagulation Cascade

Hemostasis is a critical component of the preservation of hemodynamic stability and operative visibility during surgery. Initially, hemostasis is achieved via the careful application of direct pressure to allow time for the coagulation cascade to create a fibrin and platelet plug. Other first-line methods of hemostasis in surgery include repair or ligation of the bleeding vessel with sutures, clips, or staples and coagulation of the bleeding site with a thermal energy-based device. When these methods are insufficient to provide adequate hemostasis, topical hemostatic agents can be used to augment the creation of a clot during surgery. A basic understanding of how and where these products interact with the coagulation cascade is essential to achieving optimal hemostasis outcomes.

Surgical management of colonic perforation due to ulcerative colitis during pregnancy: Report of a case

This report describes a young female in her second trimester of pregnancy with known ulcerative colitis on maintenance medical therapy. She was admitted for abdominal pain, and workup revealed a colonic stricture and ulceration with contained perforation. After multidisciplinary discussion she was managed with colectomy and end ileostomy. She delivered a healthy newborn 18 wk after surgery. Only a few prior reports described surgical management of inflammatory bowel disease during pregnancy, with recent results indicating low risk of adverse outcomes.

Chapter 47 – Acid Peptic Ulcer Disease

3. Explain the pathophysiology of PUD. Gastric or duodenal epithelial cells secrete mucus and bicarbonate in response to irritation of the lining or cholinergic stimulation and prostaglandin stimulation respectively. The mucous acts as an impermeable barrier to acid, while the bicarbonate serves as a proximity buffer. Disruptive factors such as Helicobacter pylori infection and nonsteroidal antiinflammatory drugs (NSAIDs) can disrupt this equilibrium, leading to epithelial injury and ulceration. Other risk factors include cigarette smoking, blood group O, chronic pancreatitis, cirrhosis, emphysema, and α-1 antitrypsin deficiency.

Impact of neoadjuvant chemoradiation on perioperative outcomes in patients with rectal cancer

Neoadjuvant chemoradiation for rectal cancer is associated with lower local recurrence rates. The objective of this study is to assess the impact of neoadjuvant therapy on perioperative complications in patients with rectal cancer.