Matthew C. Bozeman

Nutrition therapy issues in esophageal cancer.

Esophageal cancer has traditionally been a disease with poor long term outcomes in terms of both survival and quality of life. In combination with surgical and pharmacologic therapy, nutrition support has been demonstrated to improve patient tolerance of treatment, quality of life, and longterm outcomes. An aggressive multi-disciplinary approach is warranted with nutrition support remaining a cornerstone in management. Historically, nutrition support has focused on adequate caloric provision to prevent weight loss and allow for tolerance of treatment regimens. Alterations in metabolism occur in these patients making their use of available calories inefficient and the future of nutritional support may lie in the ability to alter this deranged metabolism. The purpose of this article is to review the current literature surrounding the etiology, treatment, and role of nutrition support in improving outcomes in esophageal cancer.

The prevalence and impact of prescription controlled substance use among injured patients at a Level I trauma center

BACKGROUND There has been increasing attention focused on the epidemic of prescription drug use in the United States, but little is known about its effects in trauma. The purpose of this study was to define the prevalence of prescription controlled substance use among trauma patients and determine its effects on outcome. METHODS A retrospective review of all patients admitted to a Level 1 trauma center from January 1, 2011, to December 31, 2011, was performed. Patients dying within 24 hours or without home medication reconciliations were excluded. Data review included preexisting benzodiazepine or narcotic use, sex, age, mechanism of injury, Injury Severity Scores (ISSs), intensive care unit (ICU) and overall length of stay, ventilator days, and overall cost. SAS version 9.3 was used for the analysis, and p ⩽ 0.05 was considered significant. RESULTS A total of 1,700 patients met inclusion criteria. Of these, 340 (20.0%) were on prescription narcotics and/or benzodiazepines at the time of admission. Patients in the narcotic/benzodiazepine group were significantly older (48 years vs. 43 years) and more likely to be women (43.7% vs. 28.9%). There was no difference in mechanism, ISS, or the presence of head injury between groups. Both ICU length of stay (3.3 days vs. 2.1 days) and total length of stay (7.8 days vs. 6.1 days) were significantly longer in patients on outpatient narcotics and/or benzodiazepines. Excluding severely injured patients, the need for mechanical ventilation was also increased among outpatient controlled substance users (15.8% vs. 11.0%). CONCLUSION There is a substantial prevalence of preexisting controlled substance use (20%) among patients at our Level 1 trauma center. Preexisting controlled substance use is associated with longer total hospital and ICU stays. Among mildly to moderately injured patients, preinjury controlled substance is also associated with the need for mechanical ventilation. LEVEL OF EVIDENCE Prognostic study, level III.

Intra-Abdominal Hypertension and Abdominal Compartment Syndrome in Association with Ruptured Abdominal Aortic Aneurysm in the Endovascular Era: Vigilance Remains Critical

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are common complications of ruptured abdominal aortoiliac aneurysms (rAAAs) and other abdominal vascular catastrophes even in the age of endovascular therapy. Morbidity and mortality due to systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) are significant. Recognition and management of IAH are key critical care measures which may decrease morbidity and improve survival in these vascular patients. Two strategies have been utilized: expectant management with prompt decompressive laparotomy upon diagnosis of threshold levels of IAH versus prophylactic, delayed abdominal closure based upon clinical parameters at the time of initial repair. Competent management of the abdominal wound with preservation of abdominal domain is also an important component of the care of these patients. In this review, we describe published experience with IAH and ACS complicating abdominal vascular catastrophes, experience with ACS complicating endovascular repair of rAAAs, and techniques for management of the abdominal wound. Vigilance and appropriate management of IAH and ACS remains critically important in decreasing morbidity and optimizing survival following catastrophic intra-abdominal vascular events.

When Can Nutritional Therapy Impact Liver Disease

This article reviews the current literature regarding nutritional therapy in liver disease, with an emphasis on patients progressing to liver failure as well as surgical patients. Mechanisms of malnutrition and sarcopenia in liver failure patients as well as nutritional assessment, nutritional requirements of this patient population, and goals and methods of therapy are discussed. Additionally, recommendations for feeding, micronutrient, branched chain amino acid supplementation, and the use of pre- and probiotics are included. The impact of these methods can have on patients with advanced disease and those undergoing surgical procedures will be emphasized.

Parenteral Nutrition for Management of Malignant Bowel Obstruction

Purpose of ReviewThis review article focuses on the practice of providing parenteral nutrition in cases of malignant bowel obstruction (MBO) where the enteral route of feeding is unavailable.Recent FindingsParenteral nutrition is an option in patients with MBO in whom enteral nutrition cannot be provided. However, its use is associated with complications that should lead to careful patient selection in determining who will benefit from its use. MBO often represents the end stage of the disease process, and not all patient presentations will benefit from parental nutrition (PN). Recent research does indicate that certain subsets of patients (e.g., chemotherapy naïve patients, patients with good functional status) will experience longer, better quality of life with administration of PN.SummaryThose patients with expected survival on the order of weeks to months, as well as those able to undergo surgical therapies to relieve the obstruction, benefit most from administration of PN, in addition to their cancer-specific treatment.

Will Availability of SMOF Lipid Emulsions for Parenteral Nutrition Change Surgical Nutrition Practice

Purpose of ReviewParenteral nutrition (PN) is a widely accepted form of nutrition administration in patients in whom enteral feeding is contraindicated or insufficient. This is true in surgical patient populations, as well. As a component of PN, intravenous fat emulsions (IVFEs) are essential for the administration of essential fatty acids (EFAs) and adequate energy intake. The oils that make up standard IVFE formulations have evolved over time.Recent FindingsA newer formulation, known as SMOF, contains a combination of soybean oil, medium chain triglycerides, olive oil, and fish oil and is gaining popularity for its purported beneficial effects on liver function, inflammation, and anti-oxidant status.SummaryThis literature review examines the current data regarding the effects of SMOF in the patient receiving PN and examines the role SMOF may play in the future management of nutrition in the surgical population.

Traumatic injury may be a predisposing factor for cerebrovascular accident

The purpose of the study was to assess whether trauma may be an independent risk factor for stroke. Evidence has shown that trauma patients experience a hypercoagulable state postinjury, increasing the risk of thrombotic events. A case-controlled, retrospective analysis was performed on admitted trauma patients over a 2-year period. Results revealed that trauma patients are 1.6 times more likely to have a cerebrovascular accident (CVA) during their hospital admission, when compared with nontrauma patients with similar CVA risk factors. Several statistically significant differences between the groups were identified. On the basis of these results, trauma appears to be an independent, nonmodifiable risk factor for CVA.