Risk factors of microtia: A systematic review and meta-analysis

Background

The pathogenesis of microtia is still unclear. Various risk factors have been studied but they remain inconclusive. We conducted the first ever systematic review and meta-analysis to look for the association between microtia and various environmental risk factors.

Methods

Relevant case-control studies published between January 2000 to October 2014 were identified through a systematic search in PubMed and EMBASE. Reference lists from relevant review articles were also searched. Studies were included if they meet our selection criteria. Out of 1706 potential articles, 12 were included in the systematic review and 8 in the meta-analysis.

Results

Risk factors which showed significant positive association with microtia were: cold-like syndrome during pregnancy (OR?=?2.15; 95 % CI?=?1.36, 3.41, P?=?0.001); multiple gestation (OR?=?1.55; 95 % CI?=?1.05, 2.29, P?=?0.03); and gestational diabetes (OR?=?1.48; 95 % CI?=?1.04, 2.10, P?=?0.03). Risk factors which showed positive association but statistically insignificant were: threatened abortion (OR?=?1.22; 95 % CI?=?0.69, 2.15, P?=?0.50); smoking during pregnancy (OR?=?1.05; 95 % CI?=?0.63, 1.77, P?=?0.84); alcohol during pregnancy (OR?=?1.08; 95 % CI?=?0.65,1.80 P?=?0.77); urinary tract infection (OR?=?1.04; 95 % CI?=?0.59, 1.84, P?=?0.89); essential hypertension (OR?=?1.04; 95 % CI?=?0.74, 1.47, P?=?0.82); maternal diabetes (OR?=?3.98; 95 % CI?=?0.72, 21.96, P?=?0.11); respiratory tract infection (OR?=?1.26,95 % CI?=?0.84,1.88, P?=?0.26); chronic disease during pregnancy (OR?=?1.29,95 % CI?=?0.99,1.69, P?=?0.06); severe nausea/vomiting (OR?=?1.16; 95 % CI?=?0.66, 2.04, P?=?0.61); NSAIDs during pregnancy (OR?=?1.17, 95 % CI?=?0.61,2.22, P?=?0.64); antihypertensives during pregnancy (OR?=?1.84,95 % CI?=?0.94,3.62, P?=?0.08); and illegal drugs during pregnancy (OR?=?1.69; 95 % CI?=?0.65, 4.39, P?=?0.28). Reduced risk for microtia was found with these factors: folic acid (OR?=?0.55; 95 % CI?=?0.33, 0.92, P?=?0.02); advanced maternal age (OR?=?0.94; 95 % CI?=?0.79, 1.11, P?=?0.45); ampicillin during pregnancy (OR?=?0.80,95 % CI?=?0.50, 1.28, P?=?0.35); and metronidazole during pregnancy (OR?=?0.77,95 % CI?=?0.40, 1.48 P?=?0.44).

Conclusions

Our study indicates cold-like syndrome, multiple gestation, and gestational diabetes as significant risk factors for microtia; whereas folic acid consumption during pregnancy is shown to be a protective factor. Studies on risk factors for microtia are still very limited to establish the definitive risk factors. Further large-scale and multicentre studies are needed to clarify the role of key risk factors for the development of microtia.Level of Evidence: Level II, risk / prognostic study.

     

Ethanol lock is effective on reducing the incidence of tunneled catheter-related bloodstream infections in hemodialysis patients: a systematic review and meta-analysis

Purpose

The purpose of this meta-analysis is to evaluate the effect of ethanol lock on the incidence of catheter-related bloodstream infection (CRBSI) in patients with central venous catheters.

Methods

RCTs comparing ethanol lock with another solution lock for prevention of CRBSI were obtained by searching databases of PubMed, Embase, Web of Science and Cochrane Central Register of clinical trials for eligible randomized controlled trials (inception to December 2017). Two researchers separately selected the RCTs and assessed their quality. Data on patient characteristics and ethanol protocols were collected. The primary outcome was the incidence of CRBSI, and the secondary outcomes were catheter colonization, exit infection and thrombosis.

Results

A total of 2575 patients with 3375 catheters from 7 eligible RCTs were included. Overall, ethanol lock significantly decreased the risk of CRBSI, with RR 0.54 (95% CI 0.38–0.78; I²?=?0%; p?=?0.001); no obvious heterogeneity was observed in the fixed-effects model (I²?=?0%). Of note, subgroup analysis demonstrated that ethanol lock conferred significant benefit in studies with tunneled catheters (RR 0.46; 95% CI 0.30–0.72) but not in studies with untunneled catheters. Only two studies provided data regarding catheter colonization, and no significant difference was found (RR, 1.09; 95% CI, 0.87–1.38; I²?=?41%; p?=?0.45). Moreover, pooled data did not show significant differences between ethanol and control groups with regard to the incidence of thrombosis (RR 1.05; 95% CI 0.91–1.22; I²?=?0%; p?=?0.48).

Conclusions

Our meta-analysis suggests that ethanol lock is effective on reducing the incidence of CRBSI in hemodialysis patients with tunneled central venous catheters.

     

Postoperative Peritonitis After Digestive Tract Surgery: Surgical Management and Risk Factors for Morbidity and Mortality,a Cohort of 191 Patients

Background

Postoperative peritonitis (POP) following gastrointestinal surgery is associated with significant morbidity and mortality, with no clear management option proposed. The aim of this study was to report our surgical management of POP and identify pre- and perioperative risk factors for morbidity and mortality.

Methods

All patients with POP undergoing relaparotomy in our department between January 2004 and December 2013 were included. Pre- and perioperative data were analyzed to identify predictors of morbidity and mortality.

Results

A total of 191 patients required relaparotomy for POP, of which 16.8% required >1 reinterventions. The commonest cause of POP was anastomotic leakage (66.5%) followed by perforation (20.9%). POP was mostly treated by anastomotic takedown (51.8%), suture with derivative stoma (11.5%), enteral resection and stoma (12%), drainage of the leak (8.9%), stoma on perforation (8.4%), duodenal intubation (7.3%) or intubation of the leak (3.1%). The overall mortality rate was 14%, of which 40% died within the first 48 h. Major complications (Dindo–Clavien >?2) were seen in 47% of the cohort. Stoma formation occurred in 81.6% of patients following relaparotomy. Independent risk factors for mortality were: ASA?>?2 (OR?=?2.75, 95% CI?=?1.07–7.62, p?=?0.037), multiorgan failure (MOF) (OR?=?5.22, 95% CI?=?2.11–13.5, p?=?0.0037), perioperative transfusion (OR?=?2.7, 95% CI?=?1.05–7.47, p?=?0.04) and upper GI origin (OR?=?3.55, 95% CI?=?1.32–9.56, p?=?0.013). Independent risk factors for morbidity were: MOF (OR?=?2.74, 95% CI?=?1.26–6.19, p?=?0.013), upper GI origin (OR?=?3.74, 95% CI?=?1.59–9.44, p?=?0.0034) and delayed extubation (OR?=?0.27, 95% CI?=?0.14–0.55, p?=?0.0027).

Conclusion

Mortality following POP remains a significant issue; however, it is decreasing due to effective and aggressive surgical intervention. Predictors of poor outcomes will help tailor management options.

     

LBP rs2232618 polymorphism contributes to risk of sepsis after trauma

Background

Previous study revealed that rs2232618 polymorphism (Phe436Leu) within LBP gene is a functional variant and associated with susceptibility of sepsis in traumatic patients. Our aim was to confirm the reported association by enlarging the population sample size and perform a meta-analysis to find additional evidence.

Methods

Traumatic patients from Southwest (n?=?1296) and Southeast (n?=?445) of China were enrolled in our study. After genotyping, the relationship between rs2232618 and the risk of sepsis was analyzed. Furthermore, we proceeded with a comprehensive literature search and meta-analysis to determine whether the rs2232618 polymorphism conferred susceptibility to sepsis.

Results

Significance correlation was observed between rs2232618 and risk of sepsis in Southwest patients (P?=?0.002 for the dominant model, P?=?0.006 for the recessive model). The association was confirmed in Southeast cohort (P?=?0.005 for the dominant model) and overall combined cohorts (P =?4.5?×?10^?4, P?=?0.041 for the dominant and recessive model). Multiple logistical regression analyses suggested that rs2232618 polymorphism was related to higher risk of sepsis (OR?=?1.77, 95% CI?=?1.26–2.48, P?=?0.001 in Southwest patients; OR?=?2.11, 95% CI?=?1.24–3.58, P?=?0.006 in Southeast cohort; OR?=?1.54, 95% CI?=?1.34–2.08, P?=?0.006 in overall cohort). Furthermore, meta-analysis of four studies (including the present study) confirmed that rs2232618 within LBP increased the risk of sepsis (OR?=?1.75, P?<?0.001 for the dominant model; OR?=?6.08, P?=?0.003 for the recessive model; OR?=?2.72, P?<?0.001 for the allelic model).

Conclusions

The results from our replication study and meta-analysis provided firm evidence that rs2232618T allele significantly increased the risk of sepsis.

     

Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors

Background

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.

Methods

This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.

Results

Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N?=?2,799, 76.1 %) and had resection for malignancy (N?=?2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR?=?1.01, 95 % CI?=?1.01–1.02, p?=?0.001), preoperative malnutrition (OR?=?1.65, 95 % CI?=?1.35–2.02, p?<?0.001), total gastrectomy (OR?=?1.63, 95 % CI?=?1.31–2.03, p?<?0.001), benign indication for resection (OR?=?1.60, 95 % CI?=?1.29–1.97, p?<?0.001), blood transfusion (OR?=?2.57, 95 % CI?=?2.10–3.13, p?<?0.001), and intraoperative placement of a feeding tubes (OR?=?1.28, 95 % CI?=?1.00–1.62, p?=?0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR?=?1.23, 95 % CI?=?0.99–1.53, p?=?0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p?<?0.001).

Conclusions

Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

     

ORIF versus arthroplasty for open proximal humerus fractures: Nationwide Inpatient Sample data between 1998 and 2013

Background

Limited data exists in analyzing open reduction and internal fixation (ORIF) and arthroplasty in the management of open proximal humerus fractures. We analyzed differences in hospital course between these procedures, patient demographics, complication rate, length of stay, hospital charges, and mortality rate.

Materials and methods

This is a retrospective review of the Nationwide Inpatient Sample database. ICD-9 codes identified patients hospitalized for open proximal humerus fractures from 1998 to 2013 who underwent ORIF or shoulder arthroplasty (hemi-, total, or reverse). Demographics and in-hospital complications were compared. Logistic regression controlling for age, gender, and Deyo index tested the impact of ORIF vs ARTH on any complications.

Results

Seven hundred thirty patients were included (ORIF, n?=?662 vs ARTH, n?=?68). ORIF patients were younger (p?<?0.001), more likely to be males (p?<?0.001), and had a lower Deyo score (p?=?0.012). Both groups had comparable complication rates (21.4% vs 18.0%, p?=?0.535), lengths of stay (7.86 days vs 7.44 days, p?=?0.833), hospital charges ($76,998 vs $64,133, p?=?0.360), and mortality rates (0.2% vs 0%, p?=?0.761). Type of surgery was not a predictor of any complications (OR?=?0.67 [95% CI 0.33–1.35], p?=?0.266), extended length of stay (OR?=?1.01 [95% CI 0.58–1.78], p?=?0.967), or high hospital charges (OR?=?1.39 [95% CI 0.68–2.86], p?=?0.366).

Conclusion

We revealed no differences in hospital course between ORIF and arthroplasty for management of open proximal humerus fractures. Although differences in demographics existed, no differences in complication rates, length of stay, hospital charges and mortality rates were noted. Future studies can evaluate the long-term outcomes of these procedures.

Level of evidence

Level III.

     

Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis

Background

Although mandatory laparotomy has been standard of care for patients with abdominal gunshot wounds (GSWs) for decades, this approach is associated with non-therapeutic operations, morbidity, and long hospital stays. This systematic review and meta-analysis sought to summarize outcomes of selective nonoperative management (SNOM) of civilian abdominal GSWs.

Methods

We searched electronic databases (March 1966–April 1, 2017) and reference lists of articles included in the systematic review for studies reporting outcomes of SNOM of civilian abdominal GSWs. We meta-analyzed the associated risks of SNOM-related failure (defined as laparotomy during hospital admission), mortality, and morbidity across included studies using DerSimonian and Laird random-effects models. Between-study heterogeneity was assessed by calculating I² statistics and conducting tests of homogeneity.

Results

Of 7155 citations identified, we included 41 studies [n?=?22,847 patients with abdominal GSWs, of whom 6777 (29.7%) underwent SNOM]. The pooled risk of failure of SNOM in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis was 7.0% [95% confidence interval (CI)?=?3.9–10.1%; I² =?92.6%, homogeneity p?<?0.001] while the pooled mortality associated with use of SNOM in this patient population was 0.4% (95% CI?=?0.2–0.6%; I² =?0%, homogeneity p?>?0.99). In patients who failed SNOM, the pooled estimate of the risk of therapeutic laparotomy was 68.0% (95% CI?=?58.3–77.7%; I² =?91.5%; homogeneity p?<?0.001). Risks of failure of SNOM were lowest in studies that evaluated patients with right thoracoabdomen (3.4%; 95% CI?=?0–7.0%; I² =?0%; homogeneity p?=?0.45), flank (7.0%; 95% CI?=?3.9–10.1%), and back (3.1%; 95% CI?=?0–6.5%) GSWs and highest in those that evaluated patients with anterior abdomen (13.2%; 95% CI?=?6.3–20.1%) GSWs. In patients who underwent mandatory abdominopelvic computed tomography (CT), the pooled risk of failure was 4.1% versus 8.3% in those who underwent selective CT (p?=?0.08). The overall sample-size-weighted mean hospital length of stay among patients who underwent SNOM was 6 days versus 10 days if they failed SNOM or developed an in-hospital complication.

Conclusions

SNOM of abdominal GSWs is safe when conducted in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis. Failure of SNOM may be lower in patients with GSWs to the back, flank, or right thoracoabdomen and be decreased by mandatory use of abdominopelvic CT scans.

     

Flexible versus rigid endoscopy in the management of esophageal foreign body impaction: systematic review and meta-analysis

Background

Foreign body (FB) impaction accounts for 4% of emergency endoscopies in clinical practice. Flexible endoscopy (FE) is recommended as the first-line therapeutic option because it can be performed under sedation, is cost-effective, and is well tolerated. Rigid endoscopy (RE) under general anesthesia is less used but may be advantageous in some circumstances. The aim of the study was to compare the efficacy and safety of FE and RE in esophageal FB removal.

Methods

PubMed, MEDLINE, Embase, and Cochrane databases were consulted matching the terms “Rigid endoscopy AND Flexible endoscopy AND foreign bod*”. Pooled effect measures were calculated using an inverse-variance weighted or Mantel-Haenszel in random effects meta-analysis. Heterogeneity was evaluated using I² index and Cochrane Q test.

Results

Five observational cohort studies, published between 1993 and 2015, matched the inclusion criteria. One thousand four hundred and two patients were included; FE was performed in 736 patients and RE in 666. Overall, 101 (7.2%) complications occurred. The most frequent complications were mucosal erosion (26.7%), mucosal edema (18.8%), and iatrogenic esophageal perforations (10.9%). Compared to FE, the estimated RE pooled success OR was 1.00 (95% CI 0.48–2.06; p?=?1.00). The pooled OR of iatrogenic perforation, other complications, and overall complications were 2.87 (95% CI 0.96–8.61; p?=?0.06), 1.09 (95% CI 0.38–3.18; p?=?0.87), and 1.50 (95% CI 0.53–4.25; p?=?0.44), respectively. There was no mortality.

Conclusions

FE and RE are equally safe and effective for the removal of esophageal FB. To provide a tailored or crossover approach, patients should be managed in multidisciplinary centers where expertise in RE is also available. Formal training and certification in RE should probably be re-evaluated.

     

Discontinuation of antiviral prophylaxis increased the risk of hepatitis B virus reactivation in glomerulonephritis patients under immunotherapy: a real-life observation

Purpose

Antiviral prophylaxis is proved to be effective in reducing the risk of hepatitis B virus (HBV) reactivation in hepatitis B surface antigen (HBsAg)-positive patients under immunotherapy. But outcomes referring to discontinuation of antiviral prophylaxis in these patients are lacking.

Methods

We performed a retrospective study of 105 HBsAg-positive patients under immunotherapy for glomerulonephritis and evaluated the incidence and risk factors for HBV reactivation.

Results

Among 105 patients, 55.24% completed antiviral prophylaxis, while 20.00% discontinued and 24.76% rejected antiviral prophylaxis. HBV reactivation was significantly different among completion, discontinuation, and rejection of antiviral prophylaxis: 5.17% versus 38.10% versus 15.38% in the incidence of HBV reactivation (P?=?0.001), 3.45% versus 23.81% versus 11.54% in HBV DNA?≥?5 Log copies/ml (P?=?0.023), and 0 versus 14.29% versus 3.85% in hepatitis B e antigen seroconversion from negative to positive (P?=?0.014). Survival curve showed the median occurrence time of HBV reactivation in discontinuation group was 32 months (95% CI 24–39 months), earlier than 69 months (95% CI 65–72 months) of completion group and 43 months (95% CI 37–49 months) of rejection group (χ²?=?13.780, P?=?0.001). Univariate and multivariate analysis identified two independent risk factors for HBV reactivation: baseline HBV DNA detectable (OR 5.009, 95% CI 1.717–16.335, P?=?0.012) and discontinuation of antiviral prophylaxis (OR 5.213, 95% CI 1.688–18.105, P?=?0.011).

Conclusions

Discontinuation of antiviral prophylaxis increased the risk of HBV reactivation in HBsAg-positive patients under immunotherapy for glomerulonephritis.

     

Extranodal Extension of Nodal Metastases Is a Poor Prognostic Indicator in Gastric Cancer: a Systematic Review and Meta-analysis

Introduction

The extranodal extension (ENE) of nodal metastases (the extension of neoplastic cells through the nodal capsule into the perinodal soft tissue) is a histological feature that has been considered a prognostic factor in several cancers, but the role in gastric cancer was not yet investigated. We aimed to investigate the prognostic role of ENE in patients affected by gastric cancer through a systematic review and meta-analysis.

Material and Methods

Two independent authors searched major databases until 09/30/2015 to identify studies providing data on gastric cancer patients’ prognostic parameters and comparing patients with ENE (ENE+) vs intra-nodal extension (ENE?). The data were summarized using risk ratios (RRs) for the number of deaths/recurrences and hazard ratios (HRs) with 95 % confidence intervals (CI), adjusted for potential confounders.

Results

Nine studies followed up 3250 patients with gastric cancer (1064 ENE+ and 2186 ENE?). ENE+ was associated with a significantly higher risk of all-cause mortality (RR?=?1.70; 95 % CI: 1.43–2.03, I ²?=?66 %; HR?=?2.14; 95 % CI: 1.66–2.75, I ²?=?0 %), cancer-specific mortality (RR?=?1.59; 95 % CI: 1.42–1.79; HR?=?1.52; 95 % CI: 1.19–1.96), and disease recurrence (RR?=?3.43, 95 % CI: 1.80–6.54, I ²?=?0 %).

Discussion

Judging from our results, ENE in gastric cancer patients should be considered for prognostic purposes from the gross sample to the pathology report.

     

Predictors of vaginal mesh exposure after midurethral sling placement: a case–control study

Introduction and hypothesis

Female stress urinary incontinence is highly prevalent, and synthetic midurethral sling placement is the most common type of anti-incontinence surgery performed in the USA. We aimed to identify risk factors associated with surgery used to treated vaginal mesh exposure after midurethral sling placement for stress urinary incontinence.

Methods

We identified women who underwent anti-incontinence procedures from January 2002 through December 2012. Patients with vaginal mesh exposure undergoing surgical repair after midurethral sling placement were compared with a control group without mesh exposure in a 1:3 ratio. Patients with ObTape sling placement (Mentor Corporation) were excluded. Logistic regression models were used to evaluate associations between clinical risk factors and vaginal mesh exposure.

Results

Overall, 2,123 patients underwent primary sling placement, with 27 (1.3 %) having vaginal mesh exposure necessitating surgical repair. Patients with mesh exposure were more likely to have undergone previous bariatric surgery (P?=?0.008), hemoglobin <13 g/dL (P?=?0.006), premenopausal status (P?=?0.008), age <50 years (P?=?0.001), and the retropubic approach to sling placement (P?=?0.03). Multivariate analysis identified these risk factors: previous bariatric surgery (odds ratio [OR], 7.0; 95 % CI, 1.1–61.4), retropubic approach (OR, 5.7; 95 % CI, 1.1–107.0), preoperative hemoglobin <13 g/dL (OR, 2.8; 95 % CI, 1.1–7.5), and premenopausal status (OR, 2.6; 95 % CI, 1.0–7.3). Among postmenopausal patients, those with mesh exposure were significantly more likely to receive preoperative estrogen therapy (OR, 12.4; 95 % CI, 2.7–57.8).

Conclusions

Previous bariatric surgery, retropubic approach, premenopausal status, and lower preoperative hemoglobin were associated with a significantly increased risk of surgery for vaginal mesh exposure after midurethral sling placement. Recognizing these factors can improve preoperative patient counseling.

     

Acute kidney injury associated with concomitant vancomycin and piperacillin/tazobactam administration: a systematic review and meta-analysis

Background

As a tricyclic glycopeptide antibiotic used to treat acute infections, Vancomycin (VAN) is often administered with piperacillin/tazobactam (PT) to treat various infections in clinical practice. However, whether the combination of these two drugs, compared to VAN alone, can cause an increased risk of acute kidney injury (AKI) remains controversial.

Objectives

This study aims to identify the correlation between the development of AKI and the combined use of VAN and PT.

Methods

We conducted a meta-analysis of eight observational cohort studies (a total of 10727 participants received VAN and PT versus VAN and other β-lactams). PubMed, Chinese Biological Medicine Database (CBM), China National Knowledge Infrastructure (CNKI) Database, Wan Fang Digital Periodicals Database (WFDP), and China Science Citation Database (CSCD) were searched through April 2017 using “vancomycin” and “piperacillin” and “tazobactam” as well as “acute kidney injury” or “acute renal failure” or “AKI” or “ARF” or “nephrotoxicity.” Two reviewers extracted the data and assessed the risk of bias.

Results

A correlation was found between the development of AKI and concurrent use of VAN and PT compared with concomitant VAN and β-lactams (OR 1.57; 95% CI, 1.13–2.01; I²?=?76.4%, p?<?0.001). Similar findings were obtained in an analysis of studies comparing concurrent VAN and PT use with concurrent VAN and β-lactam (cefepime) use (OR 1.50; 95% CI, 1.07–1.93; I²?=?80.5%, p?<?0.001). Exclusion of fair-quality and low-quality articles did not change the results (OR 1.49; 95% CI, 1.06–1.92; I²?=?84.1%, p?<?0.001).

Conclusions

Regarding β-lactam therapy in clinical practice, an elevated risk of AKI due to the combined use of VAN and PT should be considered.

     

Lymphadenectomy for Intrahepatic Cholangiocarcinoma: Has Nodal Evaluation Been Increasingly Adopted by Surgeons over Time?A National Database Analysis

Background

Surgical management of intrahepatic cholangiocarcinoma routinely includes resection of the hepatic parenchyma, yet the role of lymphadenectomy (LND) is more controversial. The objective of the current study was to define overall utilization, as well as temporal trends, in the utilization of LND among patients undergoing curative-intent hepatectomy for ICC using a nationwide database.

Materials and Methods

One thousand four hundred ninety-six patients who underwent curative-intent resection for ICC were identified using the SEER database from 2000 to 2013. The utilization of LND was assessed over time and by geographic region. LND utilization and the incidence of lymph node metastasis (LNM) were evaluated relative to AJCC T categories.

Results

At the time of surgery, slightly over one-half of patients (n?=?784, 52.4%) had at least one LN evaluated. Specifically, 613 (41.0%) patients had 1–5 LNs evaluated, whereas 171 (11.4%) patients had ≥?6 LNs evaluated. The proportion of patients who had at least one LN evaluated at the time of surgery did not change with time (2000–2004: 50.5% vs. 2005–2009: 52.0% vs. 2010–2013: 53.7%) (p?=?0.636). In contrast, the proportion of patients who had ≥?6 LNs examined did increase (2000–2004: 6.9% vs. 2005–2009: 10.6% vs. 2009–2013: 14.3%) (p?=?0.003). The risk of LNM was higher among patients with advanced T category tumors (Referent T1; T2a: OR 4.2, 95% CI 2.0–8.8, p?<?0.001; T2b: OR 2.4, 95% CI 1.1–4.9, p?=?0.018; T3: OR 3.6, 95% CI 1.6–7.9, p?=?0.001; T4: OR 2.2, 95% CI 1.0–4.9, p?=?0.049). In addition, the portion of patients with LNM varied among the different T categories (T1, 23.2%, T2a, 55.3%, T2b, 42.0%, T3, 51.4%, and T4, 39.5%; p?=?0.001).

Conclusions

Utilization of LND in the surgical management of ICC across the USA remained relatively low and did not change over the last decade. Selective utilization of LND may be problematic as T-stage was not a reliable predictor of nodal status with almost a quarter of patients with early stage disease having LNM.

     

Short- and Long-Term Oncological Outcome After Rectal Cancer Surgery: a Systematic Review and Meta-Analysis Comparing Open Versus Laparoscopic Rectal Cancer Surgery

Background

While several trials have compared laparoscopic to open surgery for colon cancer showing similar oncological results, oncological quality of laparoscopic versus open rectal resection is not well investigated.

Methods

A systematic literature search for randomized controlled trials was conducted in MEDLINE, the Cochrane Library, and Embase. Qualitative and quantitative meta-analyses of short-term (rate of complete resections, number of harvested lymph nodes, circumferential resection margin positivity) and long-term (recurrence, disease-free and overall survival) oncologic results were conducted.

Results

Fourteen randomized controlled trials were identified including 3528 patients. Patients in the open resection group had significantly more complete resections (OR 0.70; 95% CI 0.51–0.97; p?=?0.03) and a higher number of resected lymph nodes (mean difference ??0.92; 95% CI ??1.08 to 0.75; p?<?0.001). No differences were detected in the frequency of positive circumferential resection margins (OR 0.82; 95% CI 0.62–1.10; p?=?0.18). Furthermore, no significant differences of long-term oncologic outcome parameters after 5 years including locoregional recurrence (OR 0.95; 95% CI 0.44–2.05; p?=?0.89), disease-free survival (OR 1.16; 95% CI 0.84–1.58; p?=?0.36), and overall survival (OR 1.04; 95% CI 0.76–1.41; p?=?0.82) were found. Most trials exhibited a relevant risk of bias and several studies provided no information on the surgical expertise of the participating surgeons.

Conclusion

Differences in oncologic outcome between laparoscopic and open rectal surgery for rectal cancer were detected for the complete resection rate and the number of resected lymph nodes in favor of the open approach. No statistically significant differences were found in oncologic long-term outcome parameters.

     

The effects of intranasal dexmedetomidine premedication in children: a systematic review and meta-analysis

Purpose

Intranasal dexmedetomidine premedication is a newly introduced method for reducing stress and anxiety before general anesthesia in children. We performed a meta-analysis to identify the effects of intranasal dexmedetomidine premedication in children.

Source

We conducted a systematic review to find published randomized-controlled trials using intranasal dexmedetomidine as premedication. We searched databases in EMBASE?, MEDLINE®, and the Cochrane Controlled Trials Register using the Ovid platform. This study was conducted based on the Cochrane Review Methods.

Principal findings

This review included 1,168 participants in 13 studies. Intranasal dexmedetomidine premedication provided more satisfactory sedation at parent separation (relative risk [RR], 1.45; 95% confidence interval [CI], 1.19 to 1.76; P = 0.0002; I² = 80%) than other premedication regimes. In addition, it reduced the need for rescue analgesics (RR, 0.58; 95% CI, 0.40 to 0.83; P = 0.003; I² = 0%). Nevertheless, there were no differences in sedation at mask induction (RR, 1.25; 95% CI, 0.98 to 1.59; P = 0.08; I² =71%) or in the incidence of emergence delirium (RR, 0.52; 95% CI, 0.24 to 1.13; P = 0.10; I² = 67%). Intranasal dexmedetomidine was associated with a significantly lower incidence of nasal irritation (RR, 0.05; 95% CI, 0.01 to 0.36; P = 0.003; I² = 0%) and postoperative nausea and vomiting (RR, 0.63; 95% CI, 0.40 to 0.99; P = 0.04; I² = 0%) than other premedication treatments. It also showed significantly lower systolic blood pressure (weighted mean difference [WMD], ?6.7 mmHg; 95% CI, ?10.5 to ?2.9; P = 0.0006; I² = 96%) and heart rate (WMD, ?6.8 beats·min^?1; 95% CI, ?11.3 to ?2.6; P = 0.002; I² = 98%).

Conclusions

Intranasal dexmedetomidine provided more satisfactory sedation at parent separation and reduced the need for rescue analgesics and the incidence of nasal irritation and postoperative nausea and vomiting when compared with other premedication treatments.

     

Incisional Hernia Rates After Laparoscopic or Open Abdominal Surgery—A Systematic Review and Meta-Analysis

Background

Incisional hernias are one of the most common long-term complications associated with open abdominal surgery. The aim of this review and meta-analysis was to systematically assess laparoscopic versus open abdominal surgery as a general surgical strategy in all available indications in terms of incisional hernia occurrence.

Methods

A systematic literature search was performed to identify randomized controlled trials comparing incisional hernia rates after laparoscopic versus open abdominal surgery in all indications. Random effects meta-analyses were calculated and presented as risk differences (RD) with their corresponding 95 % confidence intervals (CI).

Results

24 trials (3490 patients) were included. Incisional hernias were significantly reduced in the laparoscopic group (RD ?0.06, 95 % CI [?0.09, ?0.03], p = 0.0002, I ² = 75). The advantage of the laparoscopic procedure persisted in the subgroup of total-laparoscopic interventions (RD ?0.14, 95 % CI [?0.22, ?0.06], p = 0.001, I ² = 87 %), whereas laparoscopically assisted procedures did not show a significant reduction of incisional hernias compared to open surgery (RD ?0.01, 95 % CI [?0.03, 0.01], p = 0.31, I ² = 35 %). Wound infections were significantly reduced in the laparoscopic group (RD ?0.06, 95 % CI [?0.09, ?0.03], p < 0.0001, I ² = 35 %); overall postoperative morbidity was comparable in both groups (RD ?0.06, 95 % CI [?0.13, 0.00], p = 0.06; I ² = 64 %). Open abdominal surgery showed a significantly longer hospital stay compared to laparoscopy (RD ?1.92, 95 % CI [?2.67, ?1.17], p < 0.00001, I ² = 87 %). At short-term follow-up, quality of life was in favor of laparoscopy.

Conclusions

Incisional hernias are less frequent using the total-laparoscopic approach instead of open abdominal surgery. Whenever possible, the less traumatic access should be chosen.

     

Nephrolithiasis,bone mineral density,osteoporosis, and fractures: a systematic review and comparative meta-analysis

Summary

Our meta-analysis demonstrates that people with nephrolithiasis have decreased bone mineral density, an increased odds of osteoporosis, and potentially an elevated risk of fractures.

Introduction

People with nephrolithiasis might be at risk of reduced bone mineral density (BMD) and fractures, but the data is equivocal. We conducted a meta-analysis to investigate if patients with nephrolithiasis have worse bone health outcomes (BMD), osteoporosis, and fractures versus healthy controls (HCs).

Methods

Two investigators searched major databases for articles reporting BMD (expressed as g/cm² or a T- or Z-score), osteoporosis or fractures in a sample of people with nephrolithiasis, and HCs. Standardized mean differences (SMDs), 95 % confidence intervals (CIs) were calculated for BMD parameters; in addition odds (ORs) for case-control and adjusted hazard ratios (HRs) in longitudinal studies for categorical variables were calculated.

Results

From 1816 initial hits, 28 studies were included. A meta-analysis of case-control studies including 1595 patients with nephrolithiasis (mean age 41.1 years) versus 3402 HCs (mean age 40.2 years) was conducted. Patients with nephrolithiasis showed significant lower T-scores values for the spine (seven studies; SMD?=??0.69; 95 % CI?=??0.86 to ?0.52; I ²?=?0 %), total hip (seven studies; SMD?=??0.82; 95 % CI?=??1.11 to ?0.52; I ²?=?72 %), and femoral neck (six studies; SMD?=??0.67; 95 % CI?=???1.00 to ?0.34; I ²?=?69 %). A meta-analysis of the case-controlled studies suggests that people with nephrolithiasis are at increased risk of fractures (OR?=?1.15, 95 % CI?=?1.12–1.17, p?<?0.0001, studies?=?4), while the risk of fractures in two longitudinal studies demonstrated trend level significance (HR?=?1.31, 95 % CI?=?0.95–1.62). People with nephrolithiasis were four times more likely to have osteoporosis than HCs (OR?=?4.12, p?<?0.0001).

Conclusions

Nephrolithiasis is associated with lower BMD, an increased risk of osteoporosis, and possibly, fractures. Future screening/preventative interventions targeting bone health might be indicated.

     

Predictors for persistent urodynamic stress incontinence following extensive pelvic reconstructive surgery with and without midurethral sling

Introduction and hypothesis

The objective of this study was to identify the predictors for persistent urodynamic stress incontinence (P-USI) in women following extensive pelvic reconstructive surgery (PRS) with and without midurethral sling (MUS).

Mmethods

A total of 1,017 women who underwent pelvic organ prolapse (POP) surgery from January 2005 to December 2013 in our institutions were analyzed. We included 349 USI women who had extensive PRS for POP stage III or more of whom 209 underwent concomitant MUS.

Results

Of the women who underwent extensive PRS without MUS, 64.3 % (90/140) developed P-USI compared to only 10.5 % (22/209) of those who had concomitant MUS. Those with concomitant MUS and PRS alone were at higher risk of developing P-USI if they had overt USI [odds ratio (OR) 2.2, 95 % confidence interval (CI) 1.3–4.0, p?=?0.014 and OR 4.7, 95 % CI 2.0–11.3, p?<?0.001, respectively], maximum urethral closure pressure (MUCP) of?<?60 cm H₂O (OR 5.0, 95 % CI 3.0–8.1, p?<?0.001 and OR 5.3, 95 % CI 2.7–10.4, p?<?0.001, respectively), and functional urethral length (FUL) of?<?2 cm (OR 5.4, 95 % CI 2.7–8.8, p?<?0.001 and OR 3.9, 95 % CI 2.4–6.9, p?<?0.001, respectively). Parity?≥?6 (OR 3.9, 95 % CI 1.7–5.2, p?<?0.001) and Prolift T (OR 3.1, 95 % CI 1.9–4, p?<?0.001) posed a higher risk of P-USI in those with concomitant surgery. Perigee and Avaulta A seemed to be protective against P-USI in those without MUS.

Conclusions

Overt USI with advanced POP together with low MUCP and FUL values have a higher risk of developing P-USI. Therefore, counseling these women is worthwhile while considering the type of mesh used.

     

Comparison of the efficacy of tension-free vaginal tape obturator (TVT-O) and single-incision tension-free vaginal tape (Ajust™) in the treatment of female stress urinary incontinence: a 1-year follow-up randomized trial

Introduction and hypothesis

The aim of this study was to compare the efficacy of the tension-free vaginal tape obturator (TVT-O) and single-incision tension-free vaginal tape (Ajust?) in the treatment of stress urinary incontinence in a randomized two-arm study with a 1-year follow-up.

Methods

This single-centre randomized trial compared the objective and subjective cure rates of TVT-O and Ajust using objective criteria (cough test) and subjective criteria (International Consultation on Incontinence Questionnaire short form, ICIQ-UI SF). The objective cure rate was defined as the number of patients with a negative cough stress test. Subjective cure was defined as no stress leakage of urine after surgery based on the ICIQ-UI SF. The primary outcome was to establish differences in objective and subjective cure rates between the TVT-O and Ajust groups. We also compared postoperative pain profiles using a visual analogue scale (VAS), improvement in quality of life using the ICIQ- UI SF and the Incontinence Quality of Life questionnaire, and overall satisfaction with the surgical procedure using a VAS and a five-item Likert scale. Inclusion criteria were age over 18 years, signed informed consent, and urodynamic stress urinary incontinence. Following a power calculation, 50 patients were enrolled into each group (Ajust and TVT-O).

Results

The mean follow-up after surgery was 445 days (SD 157.6 days) in the TVT-O group and 451.8 days (SD 127.6 days) in the Ajust group (p?=?76.6 %). At 1 year, 47 patients were evaluated in the TVT-O group and 49 in the Ajust group. No differences in subjective cure rates or objective cure rates were observed. In the Ajust and TVT-O groups, the rates for no subjective stress leakage were 89.8 % and 91.5 %, respectively (p?=?1.0, OR 1.22, 95 % CI 0.24 – 6.58), and the rates for a negative stress test were 89.8 % and 87.2 %, respectively (p?=?0.76, OR 0.77, 95 % CI 0.17 – 3.32). In the Ajust group two patients reported de novo pain during sexual intercourse.

Conclusions

After a 1-year-follow-up, no significant differences were found with regard to subjective and objective outcomes between the single-incision tape Ajust and TVT-O.

     

Factors associated with urinary incontinence in middle-aged women: a population-based household survey

Introduction and hypothesis

The objective was to determine the prevalence of urinary incontinence (UI) and factors associated in a sample of Brazilian middle-aged women.

Methods

A cross-sectional study was conducted between September 2012 and June 2013 with 749 women. UI was defined as any complaint of involuntary loss of urine. The independent variables were sociodemographic data and health-related habits and problems. Statistical analysis was carried out using Chi-squared test and Poisson regression.

Results

The mean age was 52.5 (±4.4) years. The prevalence of UI was 23.6 %. Of these, 48 (6.4 %) had stress urinary incontinence, 59 (7.8 %) urinary urgency, and 70 (9.5 %) had mixed urinary incontinence. In the final statistical model, self-perception of health as fair/poor/very poor (PR: 1.90; 95 % CI, 1.45–2.49; P?<?0.001), ≥1 vaginal deliveries (PR: 1.84; 95 % CI, 1.35–2.50; P?<?0.001), higher body mass index (PR: 1.04; 95 % CI, 1.02–1.06; P?=?0.001), vaginal dryness (PR: 1.60; 95 % CI, 1.23–2.08; P?=?0.001), current or previous hormone therapy (PR: 1.38; 95 % CI, 1.06–1.81; P?=?0.019), pre-/perimenopause (PR: 1.42; 95 % CI, 1.06–1.91; P?=?0.021), and previous hysterectomy (PR: 1.41; 95 % CI, 1.03–1.92; P?=?0.031) were associated with a greater prevalence of UI. Current or previous use of soy products to treat menopausal symptoms was associated with a lower prevalence of UI (PR: 0.43; 95 % CI, 0.24–0.78; P?=?0.006).

Conclusions

Several factors are associated with UI in middle-aged Brazilian women. The results highlight the importance of carrying out interventions aimed at reducing modifiable factors.