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Parenteral nutrition (PN) is a critical intervention for surgical patients who cannot meet nutritional needs via the gastrointestinal tract. This article explores the principles of PN through the lens of When, How, and Why, providing evidence-based guidance for timing, administration, and monitoring. Emphasis is placed on optimizing outcomes, minimizing complications, and addressing ethical considerations in resource-limited settings.
Importance Incisional negative pressure wound therapy (iNPWT) has been proposed as a nonantibiotic adjunct to standard dressings for preventing surgical site infection (SSI), but uncertainty remains regarding consistency across SSI subtypes and dressing-related harms. Objective To evaluate the efficacy and safety of iNPWT vs standard dressing in adults undergoing surgery. Data Sources PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception through March 7, 2026. Study Selection Randomized clinical trials (RCTs) enrolling adults in whom iNPWT was applied to primarily closed surgical incisions and compared with standard dressing. Data Extraction and Synthesis Two reviewers independently extracted data. Risk ratios (RRs) and mean differences with 95% CIs were pooled using random-effects models. Main Outcomes and Measures The primary outcome was overall SSI. Secondary outcomes included SSI subtypes, wound dehiscence, seroma, skin necrosis, reoperation, readmission, mortality, skin blistering, and device-related adverse events. Results Eighty-five RCTs comprising 16 980 patients (iNPWT, n = 8463; standard dressing, n = 8517) were included. The mean (SD) age was 48.3 (19.4) years (48.1 [19.5] years in the iNPWT group and 48.5 [19.4] years in the standard dressing group), and 5660 of 16 075 individuals (35.2%) were male (2889 [35.7%] in the iNPWT group and 2771 [34.7%] in the standard dressing group). iNPWT was associated with lower risk of overall SSI (RR, 0.64; 95% CI, 0.57-0.72), deep SSI (RR, 0.66; 95% CI, 0.51-0.86), superficial SSI (RR, 0.59; 95% CI, 0.49-0.72), wound dehiscence (RR, 0.73; 95% CI, 0.61-0.88), seroma (RR, 0.77; 95% CI, 0.63-0.94), reoperation (RR, 0.80; 95% CI, 0.64-0.99), and skin necrosis (RR, 0.38; 95% CI, 0.18-0.80). No significant differences were observed for organ-space SSI, readmission, or mortality. iNPWT was associated with higher risks of skin blistering (RR, 4.51; 95% CI, 2.37-8.58) and device-related adverse events (RR, 11.87; 95% CI, 4.74-29.74). The number needed to treat was 21 for SSI; the number needed to harm was 18 for skin blistering and 11 for device-related adverse events. Trial sequential analysis confirmed evidence for overall, deep, and superficial SSI. Certainty of evidence was moderate. Conclusions and Relevance In this systematic review and meta-analysis of 85 RCTs, iNPWT was associated with lower risks of overall, deep, and superficial SSI and several wound complications but potentially higher risks of skin blistering and device-related adverse events. These findings support selective rather than routine use, particularly in patients at elevated risk of incisional wound complications.
Importance:Incisional negative pressure wound therapy (iNPWT) has been proposed as a nonantibiotic adjunct to standard dressings for preventing surgical site infection (SSI), but uncertainty remains regarding consistency across SSI subtypes and dressing-related harms. Objective:To evaluate the efficacy and safety of iNPWT vs standard dressing in adults undergoing surgery. Data Sources:PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception through March 7, 2026. Study Selection:Randomized clinical trials (RCTs) enrolling adults in whom iNPWT was applied to primarily closed surgical incisions and compared with standard dressing. Data Extraction and Synthesis:Two reviewers independently extracted data. Risk ratios (RRs) and mean differences with 95% CIs were pooled using random-effects models. Main Outcomes and Measures:The primary outcome was overall SSI. Secondary outcomes included SSI subtypes, wound dehiscence, seroma, skin necrosis, reoperation, readmission, mortality, skin blistering, and device-related adverse events. Results:Eighty-five RCTs comprising 16 980 patients (iNPWT, n = 8463; standard dressing, n = 8517) were included. The mean (SD) age was 48.3 (19.4) years (48.1 [19.5] years in the iNPWT group and 48.5 [19.4] years in the standard dressing group), and 5660 of 16 075 individuals (35.2%) were male (2889 [35.7%] in the iNPWT group and 2771 [34.7%] in the standard dressing group). iNPWT was associated with lower risk of overall SSI (RR, 0.64; 95% CI, 0.57-0.72), deep SSI (RR, 0.66; 95% CI, 0.51-0.86), superficial SSI (RR, 0.59; 95% CI, 0.49-0.72), wound dehiscence (RR, 0.73; 95% CI, 0.61-0.88), seroma (RR, 0.77; 95% CI, 0.63-0.94), reoperation (RR, 0.80; 95% CI, 0.64-0.99), and skin necrosis (RR, 0.38; 95% CI, 0.18-0.80). No significant differences were observed for organ-space SSI, readmission, or mortality. iNPWT was associated with higher risks of skin blistering (RR, 4.51; 95% CI, 2.37-8.58) and device-related adverse events (RR, 11.87; 95% CI, 4.74-29.74). The number needed to treat was 21 for SSI; the number needed to harm was 18 for skin blistering and 11 for device-related adverse events. Trial sequential analysis confirmed evidence for overall, deep, and superficial SSI. Certainty of evidence was moderate. Conclusions and Relevance:In this systematic review and meta-analysis of 85 RCTs, iNPWT was associated with lower risks of overall, deep, and superficial SSI and several wound complications but potentially higher risks of skin blistering and device-related adverse events. These findings support selective rather than routine use, particularly in patients at elevated risk of incisional wound complications.
Otomastoiditis is the infection and inflammation of both the otitis media (middle ear) and the mastoid air cells. Involvement of the mastoid air cells can occur if the infection extends past the middle ear to affect contiguous structures. Fungal mastoiditis is very rare and almost exclusively seen in immunocompromised patients. We present an unusual case of a type 2 diabetic with fungal otomastoiditis manifesting as left-sided ear pain, as well as neuropathies of the left cranial nerve VII and right cranial nerve III. While facial nerve paralysis is often attributed to idiopathic causes, it is important that physicians maintain a high index of suspicion, especially when multiple cranial nerves are involved.
Abstract Background Leadless pacemakers (LPs) represent a potential alternative pacing strategy after extraction of infected cardiac implantable electronic devices (CIEDs) Preliminary studies have suggested that LP implantation may be safe in an infectious environment; however, evidence remains sparse. Methods The "LEadless pacemaker implantation after device eXtraction – a multIcenter retrospective regiStry (LEXIS)" that included 430 patients from 19 centers worldwide who underwent LP implantation following CIED extraction due to infection. Leadless pacemaker systems included devices with passive tine fixation (PTF) and active helix fixation (AHF). Indications for extraction included systemic infection, pocket infection, or both. LP implantation was performed either concomitantly (concomitant group) during the extraction procedure or as a staged intervention (staged group). Major and minor complications related to transvenous lead extraction were assessed according to the EHRA consensus document. In addition, LP procedural complications were recorded. Outcomes were evaluated at 1 and 12 months of follow-up. Results A total of 430 patients from 19 centers were included in the analysis(Table 1). The majority of devices were PTF systems (n = 210; 81.1%). Concomitant LP- implantation was performed in 48.0% of patients. Minor complications occurred in 7.6% of procedures, while major complications related to the extraction procedure were rare, affecting 8 (2.0%) patients in total (pericardial tamponade requiring pericardiocentesis n=3, intraprocedural cardiac arrests n=2, flail tricuspid leaflet n=1, postprocedural, procedure-related death n=2). There were no significant differences on early major complications (p= 0.17), while procedure time differed significantly between concomitant(90 min) and staged implantation(75min) (p=0.01). At 1-month follow-up, mortality was 6.5% (n=23). Active infection was still present in 5 patients (2.0%). Importantly, no vegetation at a LP was observed. Twelve months FU was completed in 243/403 (60.2 %) pts. At 12 months, mortality was 17,6% (n=52), and n=1 (0.4%) LP reinfections occurred, which was managed by extraction. Reimplantation of a transvenous system was required in 16 patients (6.5%), most frequently due to pacemaker syndrome (43.7%), followed by heart failure (31.3%) and defibrillator indication (25.0%). Among these, 7 LPs (44.8%) were extracted, and 9 (53.2%) were left in situ and turned off. Conclusion LP implantation after extraction for CIED infection was feasible and safe, with low periprocedural complication rates and only one reinfection during 12-month follow-up. Concomitant implantation during extraction was as safe as a staged approach. The need for later reimplantation of a transvenous system was infrequent. These findings support leadless pacing as a reliable strategy in patients requiring device removal for infection.Baseline characteristics
