Intravesical hyaluronic acid and chondroitin sulfate for recurrent urinary tract infections: systematic review and meta-analysis

Introduction and hypothesis

The objective was to assess the efficacy of intravesical hyaluronic acid (HA) and chondroitin sulfate (CS), alone or in combination, for recurrent urinary tract infections (RUTIs) in adult female patients using a systematic review and meta-analysis.

Methods

English-language articles were obtained from the MEDLINE, Embase, and Cochrane databases through November 2016, by manual searching and cross-referencing. Randomized and nonrandomized trials of adult female patients with a documented history of RUTIs who received HA, CS or HA plus CS were included. The random effects model was applied to all pooled analyses. Risk of bias was assessed for individual studies and across studies.

Results

Two randomized (n = 85) and six nonrandomized (n = 715) studies met the inclusion criteria. These studies assessed HA ± CS; studies of CS alone were not identified in the search. HA ± CS decreased the UTI rate per patient-year (pooled mean difference [MD] –2.56; 95% confidence interval [CI] –3.86, ?1.26; p < 0.001) and increased the time to first UTI recurrence (pooled MD 130.05 days; 95% CI 5.84, 254.26; p = 0.04). There was heterogeneity in most outcomes considered, and publication bias in many studies. The standard of trial reporting was low. The patient population size, and the number of studies included, were small.

Conclusions

HA ± CS appears to reduce the rate of UTI and increase the time to recurrence in women with RUTI. As randomized controlled studies are available only for HA plus CS, the quality of evidence is higher for the combination than for HA alone.

     

A meta-analysis comparing tacker mesh fixation with suture mesh fixation in laparoscopic incisional and ventral hernia repair

Objective

To systematically compare the tacker mesh fixation (TMF) with the suture mesh fixation (SMF) in laparoscopic incisional and ventral hernia (LIVH) repair.

Methods

Trials evaluating the TMF with the SMF in LIVH repair were analysed using the statistical tool RevMan^®. Combined dichotomous and continuous data were expressed as odds ratio (OR) and mean difference (MD), respectively.

Results

Four trials (2 randomised and 2 non-randomised) encompassing 207 patients undergoing LIVH repair with TMF versus SMF were retrieved from the standard electronic databases and analysed systematically. Ninety-nine patients underwent TMF and 108 patients underwent SMF in LIVH repair. There was no statistically significant heterogeneity (p = 0.27)] among trials. In the fixed-effects model, LIVH repair with TMF was associated with shorter operation time (MD, ?23.65; 95 % CI, ?31.06, ?16.25; z = 6.26; p < 0.00001). Four- to six-week postoperative pain score was significantly lower (MD, ?0.69; 95 % CI, ?1.16, ?0.23; z = 2.92; p < 0.004) following TMF. Peri-operative complications (p = 0.65), length of hospital stay (p = 1) and risk of hernia recurrence (OR, 1.54; 95 % CI, 0.38, 6.27; z = 0.61; p = 0.54) following TMF and SMF were statistically not different.

Conclusion

TMF in LIVH repair is associated with shorter operative time and lesser postoperative pain. TMF is comparable with SMF in terms of peri-operative complications, length of hospital stay and hernia recurrence. Therefore, TMF may be used in LIVH repair. However, further randomised trials recruiting higher number of patients are required to validate these findings.     

Lipopolysaccharide-binding protein: a potential marker of febrile urinary tract infection in childhood

Background

Urinary tract infections (UTIs) are encountered frequently in children, and their early diagnosis and treatment are important. This study evaluates the diagnostic value of serum concentrations of lipopolysaccharide-binding protein (LBP), an acute-phase protein, in children with febrile UTI and compares it to those of the total white blood cell count (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6).

Methods

The study population comprised 77 consecutive patients with a first-episode febrile UTI (33 boys) with a median age of 11 months [interquartile range (IQR), 5.5–33 months], 21 healthy controls (11 boys) with a median age of 10 months (IQR, 5–20.5 months) and 58 febrile controls with a fever due to other causes (28 boys) with a median age of 12.5 months (IQR, 7–30 months). LBP, IL-6, PCT, and CRP were measured for both patients and control groups.

Results

The serum levels of LBP (p? < ?0.001), CRP (p? < ?0.001), PCT (p? = ?0.001), IL-6 (p? = ?0.002), ESR (p? = ?0.020), and WBC (p? < ?0.001) were higher in patients with febrile UTI than in the healthy and febrile control groups. The LPB cut-off value for best sensitivity and specificity in patients with febrile UTI was >43.23 mg/l. Furthermore, the area under the receiver operating characteristic curve was significantly greater for LBP than for CRP (p? = ?0.014), PCT (p? < ?0.001), ESR (p? < ?0.001), WBC (p? = ?0.002) and IL-6 (p? = ?0.006).

Conclusions

The results of this study suggest that the serum LBP concentration constitutes a reliable biologic marker for the diagnosis of a febrile UTI in children.     

Effectiveness of intravesical hyaluronic acid/chondroitin sulfate in recurrent bacterial cystitis: a randomized study

Introduction and hypothesis

The glycosaminoglycan hyaluronic acid (HA) protects the urothelium; damage may increase bacterial adherence and infection risk. This study evaluated the effect of intravesical HA in recurrent bacterial cystitis (RBC).

Methods

Women with RBC were randomized to intravesical HA 800?mg and chondroitin sulfate (CS) 1?g (IALURIL^?, IBSA) in 50?mL of saline solution once weekly for 4?weeks then once every 2?weeks twice more (group 1) or long term antibiotic prophylaxis using sulfamethoxazole 200?mg and trimethoprim 40?mg once weekly for 6?weeks (group 2; control). Evaluations included: cystitis recurrence at 2 and 12?months; subjective pain symptoms (visual analog scale [VAS]); 3?day voiding; sexual function; quality of life (King's Health Questionnaire [KHQ]); frequency symptoms/frequency symptoms (PUF symptom scale); and maximum cystometric capacity (MCC). Means ± standard deviations were reported, with Mann-Whitney test for between-group comparison (significance P?<?.05).

Results

Of 28 women (mean age 60?±?13?y) randomized, 26 completed follow-up (mean follow-up 11.5?mo). Group 1 showed a significant improvement in all evaluations; cystitis recurrence (1?±?1.2 versus 2.3?±?1.4, P?=?.02); 3-day voiding (mean 17.8?±?3.5 vs 24.2?±?8.3, P?=?.04); symptom VAS (1.6?±?0.8 vs 7.8?±?1.6, P?<?.001); PUF score (11.2?±?2.7 vs 19.6?±?2.2, P?<?.001), KHQ score (18.4?±?7.2 vs 47.3?±?13.6, P?<?.001), and MCC (380?±?78 vs 229?±?51?mL, P?<?.001) vs group 2 at 12?mo. No adverse effects were recorded.

Conclusions

Intravesical HA and CS in combination significantly reduced cystitis recurrence and improved urinary symptoms, quality of life, and cystometric capacity in RBC patients at 12?mo follow-up versus antibiotic prophylaxis. Study limitations include a small sample and relatively short follow-up.     

Long-Term Patient Outcomes After Laparoscopic Anti-Reflux Procedures

Background

Laparoscopic anti-reflux surgery with or without large hiatal hernia has been shown to have good short-term outcomes. However, limited data are available on long-term outcomes of greater than 5 years. The aim of this study is to review functional and symptomatic outcomes of anit-reflux surgery in a large tertiary referral medical center.

Methods

Two hundred ninety-seven patients who underwent anti-reflux surgery at the University of Nebraska Medical Center between 2002 and 2013 were included in this study. Patient data including pre- and post-operative studies and symptom questionnaires were prospectively collected and the database was used to analyze postoperative outcomes.

Results

A total of 297 Nissen fundoplications, 35 redo fundoplications and 22 Toupet procedures were performed. Mean BMI was 30.0?±?6.2. The median follow-up was 70 (6–135)?months. There were three reoperations (0.9 %) for recurrent symptoms. Mesh was used in 210 cases where hiatal hernia was larger than 2 cm. Median preoperative DeMeester score was 50.8?±?46. There was a statistically significant improvement in composite heartburn score (83 % (CI 78.2, 87.7); p?<?0.05), regurgitation (81.1 % (CI 76.1, 86.1); p?<?0.05), and belching (63 % (CI 56.7, 69.3); p?<?0.05). Atypical presentation such as pulmonary (e.g., aspiration (25.8 % (CI 20, 31.6), wheezing (20.3 % (CI 15, 25.6); p?<?0.05), and throat symptoms (e.g., laryngitis 28 % (CI 22.1, 33.9); p?<?0.05) also improved. Available radiographic studies for patients more than 3 years follow-up show an overall recurrence of 33.9 % (47.8 % in hiatal hernia?>?5 cm repaired with mesh). Of those with recurrence, over 84 % were asymptomatic at follow-up.

Conclusions

This study shows that patients had excellent symptom control and low rates of complications and reoperations in long-term follow-up. We found that typical gastro intestinal symptoms responded better compared with atypical symptoms in spite of clear evidence of reflux on preoperative studies. Hiatal hernia was very commonly seen in our patient population and long-term radiographic follow-up suggest that asymptomatic recurrence may be high but rarely requires any surgical intervention. Anti-reflux surgery with correction of hiatal hernia if present is safe and effective in long-term follow-up.     

Staphylococcus aureus urinary tract infections in children are associated with urinary tract abnormalities and vesico-ureteral reflux

Background

Staphylococcus aureus is an uncommon cause of pediatric urinary tract infection (UTI). Data regarding urinary tract malformations in children with S. aureus UTI is limited.

Methods

The medical records of all children aged 0 to 16 years at Shaare Zedek Medical Center between 2001 and 2013 and who were diagnosed with S. aureus UTI were reviewed for demographic, clinical, and laboratory data. Patients with Escherichia coli UTIs during the same period were included as controls.

Results

S. aureus was the cause of UTI in 26 children, of whom six were bacteremic. Compared to children with E. coli UTI, children with S. aureus had higher rates of abnormal findings in ultrasound (77 vs. 22 %; p?<?0.001). Similarly, more patients with S. aureus UTI had abnormal voiding cystourethrogram (53 vs. 23 %; p?<?0.001) or vesicoureteral reflux (50 vs. 23 %; p?<?0.001). The median duration of hospitalization for patients with S. aureus UTI was significantly longer than for patients with E. coli UTI (8 vs. 2.3 days; p?=?0.0003).

Conclusions

S. aureus is an uncommon urinary pathogen among children. The finding of S. aureus UTI requires thorough search for urinary abnormalities.     

Prevention of recurrent urinary tract infections by intravesical administration of hyaluronic acid and chondroitin sulphate: a placebo-controlled randomised trial

Background

Urinary tract infection (UTI) is a prevalent condition in women during their lifetime with a high rate of recurrence within 3–6 mo.

Objectives

Our aim was to investigate the efficacy and tolerability of the intravesical administration of combined hyaluronic acid (HA) and chondroitin sulphate (CS) in female patients with a history of recurrent UTI.

Design, setting, and participants

We conducted a prospective, randomised, double-blind, placebo-controlled study comparing the intravesical instillation of HA-CS with placebo in women with recurrent UTI.

Intervention

Participants were randomised to receive 50 ml of sterile sodium HA 1.6% and CS 2.0% solution (IALURIL^®) weekly for 4 wk and then monthly for 5 mo.

Measurements

The primary end point of the study was defined as the mean number of UTI per patient per year. Participants were evaluated addressing UTI status/urinary symptoms and with a general health-related quality-of-life (QoL) questionnaire at baseline and after 3, 6, 9, and 12 mo.

Results and limitations

In the intention-to-treat analysis, 57 women were randomly allocated to HA-CS (n = 28) or placebo (n = 29). The UTI rate per patient per year at the end of the study (12 mo) (mean ± SD: −86.6% ± 47.6 vs −9.6% ± 24.6; mean difference: 77%; 95% confidence interval, 72.3–80.8; p = 0.0002) and the mean time to UTI recurrence (52.7 ± 33.4 vs 185.2 ± 78.7 d; p < 0.001) were significantly reduced after treatment with HA-CS compared with placebo. Overall urinary symptoms and QoL measured by questionnaires significantly improved compared with placebo (Pelvic Pain and Urgency/Frequency questionnaire symptom score: 14.53 ± 4.32 vs 9.88 ± 6.77; p = 0.004; SF-36 QoL score: 78.6 ± 6.44 vs 53.1 ± 4.72; p < 0.001). No serious adverse event was reported.

Conclusions

Compared with placebo, HA-CS intravesical instillations significantly reduced UTI rate without severe side effects while improving symptoms and QoL over a 12-mo period in patients with recurrent UTI.

Trial registration

ISRCTN 76354426.     

What is the Effect of Laparoscopic Colectomy on Pattern of Colon Cancer Recurrence? A Propensity Score and Competing Risk Analysis Compared with Open Colectomy

Background

Variability in colon cancer recurrence after laparoscopic colectomy (LAC) remains poorly understood. The aim of our study was to quantify the influence of LAC on colon cancer recurrence patterns.

Methods

We included 986 patients undergoing curative colectomy at our institution between 1992 and 2008. Kaplan–Meier, multivariable Cox regression, propensity score adjustment, and competing risks modeling were used to evaluate the influence of laparoscopic surgery on the site of colon cancer recurrence, including the following: liver metastasis, lung metastasis, local recurrence, peritoneal dissemination, other, and multiple sites. We estimated the risk factors for each recurrence site.

Results

Laparoscopic surgery was used in 419 (42.5 %) of 986 patients, with an overall median follow-up time of 5.0 years (interquartile range 3.5). The overall 5-year disease-free survival rate was 86.1 % (open surgery 81.8 % vs. laparoscopic surgery 92.0 %; p < 0.001). However, after covariates and propensity score adjustment, laparoscopic surgery was not a significant risk factor for each type of recurrence: liver hazard ratio (HR) 0.93 (95 % CI 0.45–1.89), p = 0.84; lung HR 0.67 (95 % CI 0.26–1.70), p = 0.39; local HR 0.56 (95 % CI 0.12–2.63), p = 0.46; peritoneal HR 2.49 (95 % CI 0.75–8.27), p = 0.14; others HR 0.47 (95 % CI 0.04–5.13), p = 0.53; multiple HR 0.88 (95 % CI 0.25–3.14), p = 0.84. The risk factors for each type of recurrence were variable and characterized by specific clinicopathological features.

Conclusion

Our study reveals that LAC and open colectomy demonstrate comparable overall colon cancer recurrence rates and recurrence sites. Specific clinicopathological characteristics may have a stronger influence on colon cancer recurrence site compared with the surgical technique.     

The effects of epidural/spinal opioids in labour analgesia on neonatal outcomes: a meta-analysis of randomized controlled trials

Purpose

Epidural/spinal opioids are increasingly used to relieve parturients’ pain in labour. Some studies indicate that opioids can induce side effects in neonates, such as respiratory depression and neurobehavioural changes. This meta-analysis aimed to clarify the effects of opioids in labour analgesia on neonates.

Source

PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE? were searched for relevant randomized controlled trials (RCTs). The neonatal data of Apgar scores, Neurological and Adaptive Capacity Scores (NACS), and umbilical cord pH values were extracted. Statistical analyses were carried out using Review Manager 5.2 and Stata^® 10.

Principal findings

Twenty-one trials with 2,859 participants were included in our meta-analysis. No difference in the incidence of Apgar scores < 7 was shown between the opioid and control groups at one minute (risk difference [RD] 0.0%, 95% confidence interval [CI]: ?3.0 to 2.0, P = 0.78; I ² = 0%, 95% CI: 0 to 50) and at five minutes (RD ?1.0%, 95% CI: ?2.0 to 1.0, P = 0.31; I ² = 0%, 95% CI: 0 to 50). No significant differences were found in the NACS at two hours (mean difference [MD] ?0.35, 95% CI: ?1.70 to 1.01, P = 0.62; I ² = 0%, 95% CI: 0 to 79) and at 24 hr (MD ?0.45, 95% CI: ?1.36 to 0.46, P = 0.33; I ² = 3%, 95% CI: 0 to 26). Also, no significant differences were found in umbilical cord artery pH (MD ?0.02, 95% CI: ?0.06 to 0.03, P = 0.48; I ² = 80%, 95% CI: 46 to 92) and vein pH (MD ?0.03, 95% CI: ?0.07 to 0.00, P = 0.08; I ² = 77%, 95% CI: 36 to 91). No significant publication bias was found.

Conclusion

The common doses of fentanyl and sufentanil used with an epidural/spinal technique in labour analgesia are safe for neonates up to 24 hr after delivery. In future studies, more attention should be paid to the long-term side effects in neonates.     

Direct inguinal hernias and anterior surgical approach are risk factors for female inguinal hernia recurrences

Purpose

The purpose of this study was to establish the risk of recurrence after direct and indirect inguinal hernia operation in a large-scale female population and to establish the relationship between the type of hernia at the primary and recurrent procedure.

Methods

Using data from the Danish Hernia Database (DHDB), a cohort was generated: all females operated on electively for a primary inguinal hernia by either Lichtenstein’s technique or laparoscopy from 1998 to 2012. Within this prospectively collected cohort, the hernia type at the primary procedure (direct inguinal hernia (DIH), indirect inguinal hernia (IIH), combination hernia), the hernia type at the recurrent procedure (DIH, IIH, combination hernia, femoral hernia), anesthesia type, and time from primary procedure to reoperation were registered.

Results

A total of 5,893 females with primary elective inguinal hernia operation on in the study period (61 % IIH, 37 % DIH, 2 % combined hernias) were included with a median follow-up time of 72 months (range 0 to 169). A total of 305 operations for suspected recurrences were registered (61 % inguinal recurrences, 38 % femoral recurrences, 1 % no hernias), which corresponded to an overall reoperation rate of 5.2 %. All femoral recurrences occurred after a previous open anterior operation. The crude reoperation rate after primary DIH operation was 11.0 %, 3.0 % after primary IIH operation and 0.007 % after combined hernia operation (p?<?0.001). The multivariate adjusted analysis found that DIH at primary operation was a substantial risk factor for recurrence with a hazard ratio of 3.1 (CI 95 % 2.4–3.9) compared with IIH at primary operation (p?<?0.001), and that laparoscopic operation gave a lower risk of recurrence with a hazard ratio of 0.57 (CI 95 % 0.43–0.75) compared with Lichtenstein’s technique (p?<?0.001). The risk of femoral recurrence was correlated to operation for DIH with a hazard ratio of 2.4 (CI 95 % 1.7–3.5) compared with operation for IIH.

Conclusion

In a female nationwide prospectively gathered cohort, we found that operation for a DIH resulted in a higher risk of reoperation than operation for an IIH. We found that femoral hernia recurrences exclusively existed after anterior open primary operation.     

Systematic Review and Meta-Analysis of Randomized Controlled Trials Comparing Single Incision versus Conventional Laparoscopic Appendectomy

Background

Single incision laparoscopic appendectomy (SILA) has been proposed as an alternative to conventional laparoscopic appendectomy (CLA).

Objective

The aim of this study was to evaluate the safety and efficacy of SILA when compared with CLA through a systematic review.

Methods

We performed an electronic search of EMBASE, PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) that compared SILA with CLA were included.

Results

Six RCTs met eligibility criteria, which included a total of 800 patients, 401 in the SILA group and 399 in the CLA group. There were no significant differences in terms of overall complications (odds ratio [OR] 0.93; 95 % confidence interval [CI] 0.59–1.47; p = 0.77). SILA had a higher technical failure rate (OR 3.30; 95 % CI 1.26–8.65; p = 0.01) and required a longer operative time (mean difference [MD] 4.67; 95 % CI 1.76–7.57; p = 0.002). SILA was associated with better cosmetic results (standardized MD –0.4; 95 % CI –0.64 to –0.16; p = 0.001) and earlier return to normal activity (MD –0.64; 95 % CI –1.09 to –0.20; p = 0.005), although these advantages should be taken with caution due to the small number of studies reporting these two items and the short follow-up in the evaluation of cosmetic results. There were no significant differences in terms of postoperative pain or length of hospital stay between groups.

Conclusions

SILA is comparable to CLA in selected patients, although it is associated with a higher technical failure rate and longer operative time. Further randomized trials are needed to determine if SILA really offers benefits over CLA.     

SHBG levels are associated with bone loss and vertebral fractures in patients with prostate cancer

Summary

Fractures are increased among prostate cancer patients. No data have been reported in patients with prostate cancer about the relation between serum sex hormone-binding globulin (SHBG) and bone metabolism. We found that SHBG levels were inversely related to bone mass and vertebral fractures in this population.

Introduction

Fractures are increased among prostate cancer patients, especially those on androgen deprivation therapy (ADT), but few data are available on the role of SHBG in their bone status. Our objective was to analyze the relation between serum SHBG and bone metabolism in prostate cancer patients.

Methods

This is a cross-sectional study including 91 subjects with prostate cancer (54 % with ADT). We measured serum levels of SHBG and sex steroids, bone mineral density (BMD) by dual-energy X-ray absorptiometry, and prevalent radiographic vertebral fractures.

Results

SHBG levels were inversely related to BMD (femoral neck: r?=??0.299, p?=?0.00; total hip: r?=??0.259, p?=?0.019). Subjects with osteoporosis had higher SHBG concentrations than patients without osteoporosis (60.97?±?39.56 vs 44.45?±?23.32 nmol/l, p?=?0.022). Patients with SHBG levels in the first quartile (>57.6 nmol/l) had an odds ratio (OR) for osteoporosis of 2.59 (95 % CI, 1.30–5.12; p?=?0.009) compared with patients with lower SHBG levels. In patients with SHBG >57.6 nmol/l, the OR for vertebral fractures was 2.34 (95 % CI, 1.15–4.78; p?=?0.034). The calculated OR was higher after adjustment for age (OR, 5.16; 95 % CI, 1.09–24.49; p?=?0.039), estrogens (OR, 6.45; 95 % CI, 1.44–28.95; p?=?0.023), and androgens (OR, 5.51; 95 % CI, 1.36–22.37; p?=?0.017).

Conclusions

In prostate cancer patients, SHBG levels were inversely related to bone mass and vertebral fractures. Determination of the serum SHBG level may constitute a useful and straightforward marker for predicting the severity of osteoporosis in these patients.     

Risk Factors Associated with 30-Day Postoperative Readmissions in Major Gastrointestinal Resections

Purpose

Preventable readmissions represent a major burden on the health care system and risk stratification of patients can help direct costly resources. This study examines patient characteristics, surgical factors, and postoperative complications associated with 30-day postoperative readmissions in gastrointestinal (GI) resections.

Methods

Inpatients undergoing major GI surgery were selected from the 2011 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Resections were classified into foregut, small bowel, colorectal, liver, and pancreatic using Current Procedural Terminology (CPT) codes. Postoperative complications were divided into pre- and post-discharge groups using time to complication and discharge. Univariate analysis compared patient and surgical characteristics and pre-discharge complications with 30-day unplanned readmission rates. Factors with a p value <0.1 were included in multivariate logistic regression. A p value <0.05 was considered statistically significant.

Results

For 42,609 patients undergoing GI resection, the overall 30-day unplanned readmission rate was 12.3 % ranging from 11.8 % for colorectal resections to 16.3 % for pancreatic resections. Major predictors of 30-day readmissions included pre-discharge major complications (odds ratio [OR]?=?1.28, 95 % confidence interval [CI] 1.18–1.39, p?<?0.0001), chronic steroid use (OR?=?1.67, 95 % CI 1.50–1.86, p?<?0.0001), operative time ≥4 h (OR?=?1.45, 95 % CI 1.35–1.56, p?<?0.0001) and discharge to a facility other than home (OR?=?1.37, 95 % CI 1.23–1.50, p?<?0.0001).

Conclusions

Unplanned 30-day readmissions represent a major clinical and financial concern, but some may be foreseeable and potentially modifiable. This model provides insight into factors that could inform resource utilization and postoperative care to help prevent readmissions in select GI surgical patients.     

Evaluating the porcine dermis graft InteXen® in three-compartment transvaginal pelvic organ prolapse repair

Introduction and hypothesis

The aim was to assess the efficacy of three-compartment pelvic organ prolapse (POP) vaginal repair using the InteXen® biocompatible porcine dermal graft as compared to traditional colporrhaphy with sacrospinous ligament suspension.

Methods

Preoperative, operative, postoperative and follow-up data were collected retrospectively. Objective recurrence was defined as POP quantification ≥ stage II and subjective recurrence as a symptomatic bulge.

Results

Each group consisted of 63 patients. Surgery time was longer using InteXen® (72?±?24.5 vs 55?±?23.5 min, p?=?0.0002). Length of hospital stay (4.6?±?1.6 vs 4.9?±?2.1 days, p?=?0.34) as well as duration of follow-up (37.1 vs 35.7 months, p?=?0.45) were equivalent between the two groups. No case of mesh erosion or infection was noted. The objective (17% vs 8%, p?=?0.12) and subjective recurrence rates (13% vs 5%, p?=?0.12) between the two groups were not statistically different.

Conclusions

InteXen® was well tolerated but had similar efficacy to traditional colporrhaphy and sacrospinous ligament suspension.     

Nodal recurrence in the lateral neck after total thyroidectomy with prophylactic central neck dissection for papillary thyroid cancer

Purpose

The aim of this study was to examine risk factors for nodal recurrence in the lateral neck (NRLN) in patients with papillary thyroid cancer (PTC) who underwent total thyroidectomy with prophylactic central neck dissection (TT + pCND).

Methods

This was a retrospective cohort study of patients with PTC who underwent TT + pCND. Data of all patients treated over a 10-year period (between 1998 and 2007) were analysed. The primary outcome was prevalence of NRLN within the 5-year follow-up after initial surgery. Predictors of NRLN were determined in the univariable and multivariable analysis.

Results

Of 760 patients with PTC included in this study, 44 (6.0 %) developed NRLN. In the univariable analysis, the following factors were identified to be associated with an increased risk of NRLN: positive/negative lymph node ratio ≥0.3 (odds ratio (OR) 14.50, 95 % confidence interval (CI) 7.21 to 29.13; p?<?0.001), central lymph node metastases (OR 7.47, 95 % CI 3.63 to 15.38; p?<?0.001), number of level VI lymph nodes <6 in the specimen (OR 2.88, 95 % CI 1.21 to 6.83; p?=?0.016), extension through the thyroid capsule (OR 2.55, 95 % CI 1.21 to 5.37; p?=?0.013), localization of the tumour within the upper third of the thyroid lobe (OR 2.35, 95 % CI 1.27 to 4.34; p?=?0.006) and multifocal lesions (OR 1.85, 95 % CI 1.01 to 3.41; p?=?0.048).

Conclusions

Central lymph node metastases together with positive to negative lymph node ratio ≥0.3 represent the strongest independent prognostic factors for the PTC recurrence in the lateral neck.     

Does concomitant anterior/apical repair during midurethral sling improve the overactive bladder component of mixed incontinence?

Introduction and hypothesis

Midurethral sling (MUS) can improve overactive bladder (OAB) symptoms. It is unclear if anterior/apical prolapse (AA) repair provides additional benefit. We hypothesized that women with mixed urinary incontinence (MUI) experience greater improvement in the OAB component of their symptoms after concomitant MUS and AA repair compared with MUS alone.

Methods

This is a retrospective cohort study of women with bothersome MUI (defined by objective stress test and validated questionnaire) undergoing MUS alone (“MUS-only”) or concomitant MUS and AA repair (“MUS + AA”). Our primary outcome was the Overactive Bladder Questionnaire Symptom Severity (OAB-q SS) change score 6 weeks after surgery.

Results

Of 151 women, 67 (44 %) underwent MUS-only and 84 (56 %) underwent MUS + AA. The MUS-only cohort was younger and had less severe baseline prolapse (p?p?p?=?0.20), indicating similar improvements in OAB symptoms. Multivariate linear regression analysis revealed no difference in OAB-q SS change score between cohorts; however, OAB-q SS change scores were lower for women with a postoperative complication (β?=??19, 95 % CI ?31 to ?6; p?Conclusions In women with bothersome MUI, concomitant AA repair does not result in additional improvement in OAB symptoms over MUS alone. Patients with postoperative complications exhibit less improvement in OAB symptoms.     

Independent predictors for recurrence of chronic subdural hematoma

Background

Chronic subdural hematoma is characterized by blood in the subdural space that evokes an inflammatory reaction. Numerous factors potentially associated with recurrence of chronic subdural hematoma have been reported, but these factors have not been sufficiently investigated. In this study, we evaluated the independent risk factors of recurrence.

Methods

We analyzed data for 420 patients with chronic subdural hematoma treated by the standard surgical procedure for hematoma evacuation at our institution.

Results

Ninety-two (21.9?%) patients experienced at least one recurrence of chronic subdural hematoma during the study period. We did not identify any significant differences between chronic subdural hematoma recurrence and current antiplatelet therapy. The recurrence rate was 7?% for the homogeneous type, 21?% for the laminar type, 38?% for the separated type, and 0?% for the trabecular type. The rate of recurrence was significantly lower in the homogeneous and trabecular type than in the laminar and separated type. We performed a multivariate logistic regression analysis and found that postoperative midline shifting (OR, 3.6; 95?% CI, 1.618-7.885; p?=?0.001), diabetes mellitus (OR, 2.2; 95?% CI, 1.196-3.856; p?=?0.010), history of seizure (OR, 2.6; 95?% CI, 1.210-5.430; p?=?0.014), width of hematoma (OR, 2.1; 95?% CI, 1.287-3.538; p?=?0.003), and anticoagulant therapy (OR, 2.7; 95?% CI, 1.424-6.960; p?=?0.005) were independent risk factors for the recurrence of chronic subdural hematoma.

Conclusions

We have shown that postoperative midline shifting (≥5?mm), diabetes mellitus, preoperative seizure, preoperative width of hematoma (≥20?mm), and anticoagulant therapy were independent predictors of the recurrence of chronic subdural hematoma. According to internal architecture of hematoma, the rate of recurrence was significantly lower in the homogeneous and the trabecular type than the laminar and separated type.     

Urinary bacteria in adult women with urgency urinary incontinence

Introduction and hypothesis

This study’s aims were to detect and quantify bacterial DNA in the urine of randomized trial participants about to undergo treatment for urinary urgency incontinence (UUI) without clinical evidence of urinary tract infection (UTI) and to determine if the presence of bacterial DNA in baseline urine relates to either baseline urinary symptoms or UTI risk after urinary tract instrumentation.

Methods

Women without clinical evidence of baseline UTI were randomized to cystoscopic onabotulinum toxin A injection and oral placebo medication versus cystoscopic placebo injection and active oral medication. Bacterial DNA in participants’ catheterized urine was measured by quantitative polymerase chain reaction (qPCR).

Results

Bacterial DNA was detected in the urine of 38.7 % of participants (60 out of 155). In these 60 qPCR-positive participants, baseline daily UUI episodes were greater than in the 95 qPCR-negative participants (5.71 [±2.60] vs 4.72 [±2.86], p?=?0.004). Neither symptom severity by questionnaire nor treatment outcome was associated with qPCR status or with qPCR level in qPCR-positive subjects. In contrast, the presence of urinary bacterial DNA was associated with UTI risk: only 10 % of the qPCR-positive women developed a UTI post-treatment, while 24 % of the qPCR-negative women did so. The median qPCR level for qPCR-positive samples did not differ significantly by UTI status (UTI 2.58?×?10⁵ vs no UTI 1.35?×?10⁵ copies/mL, p?=?0.6).

Conclusions

These results may indicate a urinary bacterial contribution to both baseline UUI and the risk of post-treatment UTI.     

Klinisches Outcome (Median 5 Jahre) nach winkelstabiler Plattenosteosynthese von 228 Patienten mit dislozierter proximaler Humerusfraktur

Background

Aim of the study was to evaluate clinical outcomes 5 years following locked plating for proximal humeral fractures and to identify risk factors for a poor outcome.

Methods

467 patients with displaced proximal humeral fractures were treated by open reduction and locking plate fixation between 02/2002 and 02/2012. 228 patients (follow-up rate 48.8?%) were followed by use of the Constant and DASH score. Final follow-up was performed after a median of 5.7 years (95?% CI: 5.4; 6.1).

Results

Of 228 patients, 68.9?% female (mean age 65.7 years, 95?% CI: 63.6; 67.7) and 31.1?% male (mean age 55.5 years, 95?% CI: 52.3; 58.6) the absolute Constant Score (CS) five years after surgery was 75.5 (95?% CI: 72.6; 78.4). The normalized CS (nCS) was 85.5 (95?% CI: 81.6; 89.3) and the CS in percentage to the contralateral side (% CS) was 84.5?% (95?% CI: 81.1; 87.9). The shoulder function was rated “excellent” (100–86 points) in 41.7?%, “good” (85–71) 24.1?%, “moderate” (70–56) 19.3?% and “poor” (r?=???0.2, p?r?=???0.3, p?Conclusions Five years after locked plating of displaced proximal humeral fractures patients show good to excellent outcomes in 2/3 of cases. However, worse long-term outcomes are observed in 15?% of cases, particularly in patients of higher age that underwent revision surgery.     

Predicting Recurrence of C. difficile Colitis Using Bacterial Virulence Factors: Binary Toxin Is the Key

Background

Recurrent Clostridium difficile colitis is common, yet the ability to predict recurrence is poorly developed.

Methods

Patients ≥18 years of age treated at our institution for C. difficile of any severity were consecutively enrolled. C. difficile colitis was defined as symptoms of colitis with a positive PCR stool test. Each bacterial isolate was studied for virulence factors: tcdC mutations via PCR; the presence of genes for toxins A, B, and binary toxin using restriction fragment length polymorphism; and identification of ribotype 027 by PCR. Chi-squared tests, t tests, and logistic and linear regression were used to determine which virulence factors predicted recurrence.

Results

Sixty-nine patients (male, 57 %) were studied, with a mean age of 64?±?13 years. Twenty-one (30 %) patients were initially diagnosed as outpatients. There was no difference (p?>?0.05) between virulence factors among inpatients and outpatients. The presence of a binary toxin gene was the single virulence factor independently associated with recurrence (p?=?0.02). The combination of a tcdC mutation with binary toxin gene resulted in the highest odds of recurrence (OR, 5.3; 95 % CI, 3.52–6.09).

Conclusion

Binary toxin gene is a predictor of recurrent infection. Its presence may require longer antibiotic regimens in an effort to lower already elevated recurrence rates.