To drain or not to drain in colorectal anastomosis: a meta-analysis

Background

Currently, many surgeons place a prophylactic drain in the abdominal or pelvic cavity after colorectal anastomosis as a conventional treatment. However, some trials have demonstrated that this procedure may not be beneficial to the patients.

Objective

To determine whether prophylactic placement of a drain in colorectal anastomosis can reduce postoperative complications.

Methods

We systematically searched all the electronic databases for randomized controlled trials (RCTs) that compared routine use of drainage to non-drainage regimes after colorectal anastomosis, using the terms “colorectal” or “colon/colonic” or “rectum/rectal” and “anastomo*” and “drain or drainage.” Reference lists of relevant articles, conference proceedings, and ongoing trial databases were also screened. Primary outcome measures were clinical and radiological anastomotic leakage. Secondary outcome measures included mortality, wound infection, re-operation, and respiratory complications. We assessed the eligible studies for risk of bias using the Cochrane Risk of Bias Tool. Two authors independently extracted data.

Results

Eleven RCTs were included (1803 patients in total, 939 patients in the drain group and 864 patients in the no drain group). Meta-analysis showed that there was no statistically significant differences between the drain group and the no drain group in (1) overall anastomotic leakage (relative risk (RR)?=?1.14, 95 % confidence interval (CI) 0.80–1.62, P?=?0.47), (2) clinical anastomotic leakage (RR?=?1.39, 95 % CI 0.80–2.39, P?=?0.24), (3) radiologic anastomotic leakage (RR?=?0.92, 95 % CI 0.56–1.51, P?=?0.74), (4) mortality (RR?=?0.94, 95 % CI 0.57–1.55, P?=?0.81), (5) wound infection (RR?=?1.19, 95 % CI 0.84–1.69, P?=?0.34), (6) re-operation (RR?=?1.18, 95 % CI 0.75–1.85, P?=?0.47), and (7) respiratory complications (RR?=?0.82, 95 % CI 0.55–1.23, P?=?0.34).

Conclusions

Routine use of prophylactic drainage in colorectal anastomosis does not benefit in decreasing postoperative complications.

     

Obstructive sleep apnea increases the risk of cardiac events after percutaneous coronary intervention: a meta-analysis of prospective cohort studies

Purpose

Recent studies have shown an association between obstructive sleep apnea (OSA) and coronary artery disease; however, the association between OSA and cardiac outcomes in patients after percutaneous coronary intervention (PCI) remains undetermined.

Methods

PubMed, EMBASE, and CENTRAL were searched from inception to July 2016 for cohort studies that followed up with patients after PCI, and evaluated their overnight sleep patterns within 1 month for major adverse cardiac events (MACEs) as primary outcomes including cardiac death, non-fatal myocardial infarction (MI), and coronary revascularization and secondary outcomes including re-admission for heart failure and stroke. Outcomes data were pooled using fixed-effect meta-analysis, and heterogeneity was assessed with the I ² statistics. The methodological quality of the studies was assessed using the Newcastle-Ottawa Scale checklist, and publication bias was evaluated by a visual investigation of funnel plots.

Results

We identified seven pertinent studies including 2465 patients from 178 related articles. OSA was associated with MACEs (odds ratio [OR], 1.52, 95% confidence interval [CI], 1.20–1.93, I ² = 29%), which included cardiac death (OR 2.05, 95% CI, 1.15–3.65, I ² = 0%), non-fatal MI (OR 1.59, 95% CI, 1.14–2.23, I ² = 15%), and coronary revascularization (OR 1.69, 95% CI, 1.28–2.23, I ² = 0%). However, OSA was not associated with re-admission for heart failure (OR 1.71, 95% CI, 0.99–2.96, I ² = 0%) and/or stroke (OR 1.68, 95% CI, 0.91–3.11, I ² = 0%) according to the pooled results.

Conclusions

In patients after PCI, OSA appears to increase the risk of cardiac death, non-fatal MI, and coronary revascularization.

     

Age,overweight and physical inactivity increase the risk of latent autoimmune diabetes in adults: results from the Nord-Trøndelag health study

Aims/hypothesis

Latent autoimmune diabetes (LADA) is a common form of diabetes, yet the risk factors are poorly characterised. The aim of this study was to investigate the influence of age, overweight and physical activity on the risk of LADA.

Methods

We analysed age, overweight and physical inactivity and the incidence of LADA in 38,800 men and women, observed between 1984 and 1986 and 1995 and 1997 as part of the Nord-Trøndelag Health Survey. We also compared such factors with incident cases of type 2 (n?=?738) and ‘classic’ type 1 diabetes (n?=?18). Patients classified as LADA (n?=?81) had antibodies against GAD and were insulin independent at diagnosis.

Results

The proportion of those who were older, overweight and inactive before diagnosis was almost identical in LADA and type 2 diabetes patients. BMI ≥30 kg/m² was strongly associated with LADA incidence (relative risk [RR]?=?15.0, 95% CI 7.51–29.97). The association was similar for type 2 diabetes (RR?=?15.37, 95% CI 12.07–19.57) but not for type 1 diabetes. Similarly, age (≥60 years) was an important risk factor for LADA (RR?=?5.62, 95% CI 2.36–13.4) as well as for type 2 diabetes (RR?=?6.78, 95% CI 5.07–9.06) in contrast to type 1 diabetes. Physical inactivity was associated with an increased risk of both LADA and type 2 diabetes.

Conclusions/interpretation

This study suggests that increased age, overweight and physical inactivity are as strong risk factors for LADA as for type 2 diabetes. These findings suggest a role for insulin resistance in the pathogenesis of LADA.

     

Infliximab versus cyclosporine as rescue therapy in acute severe steroid-refractory ulcerative colitis: a systematic review and meta-analysis

Purpose

Acute severe colitis affects 25 % of patients with ulcerative colitis (UC). Up to 30–40 % of these patients are resistant to intensive steroid therapy and therefore require rescue therapy to prevent emergent colectomy. Data comparing rescue therapy using infliximab and cyclosporine are limited and equivocal. This study evaluates the outcomes of UC patients receiving infliximab or cyclosporine as rescue therapy in acute severe steroid-refractory exacerbations.

Methods

Electronic databases (PubMed, EMBASE, and Cochrane database) were searched for studies directly comparing infliximab and cyclosporine in UC, and references of included studies were screened. Two independent reviewers identified relevant studies and extracted data. Meta-analyses were performed using the random effect model. Outcome measures included 3- and 12-month colectomy rates, adverse drug reactions, and postoperative complications.

Results

Six retrospective cohort studies describing 321 patients met the inclusion criteria. The meta-analysis did not show significant differences between infliximab and cyclosporine in the 3-month colectomy rate (odds ratio (OR)?=?0.86, 95 % confidence interval (CI)?=?0.31–2.41, p?=?0.775), in the 12-month colectomy rate (OR?=?0.60, 95 % CI?=?0.19–1.89, p?=?0.381), in adverse drug reactions (OR?=?0.76, 95 % CI?=?0.34–1.70, p?=?0.508), and in postoperative complications (OR?=?1.66, 95 % CI?=?0.26–10.50, p?=?0.591). Funnel plot revealed no publication bias.

Conclusions

Infliximab and cyclosporine are comparable when used as rescue therapy in acute severe steroid-refractory UC. Randomized trials are required to further evaluate these agents.

     

Colchicine in addition to conventional therapy for pericarditis recurrence

Background

Randomized controlled trials (RCTs) have investigated the use of colchicine and conventional therapy for reducing the recurrence of pericarditis in patients with acute pericarditis or post-pericardiotomy syndrome. However, the benefits of these treatments are variable.

Methods

Studies were retrieved from PubMed, the Cochrane Library, and the EMBASE database.

Results

We identified nine RCTs with 1832 patients and a mean follow-up of 13.1 months. Overall, colchicine therapy significantly decreased the risk of pericarditis recurrence (odds ratio, OR 0.42; 95?% confidence interval, CI 0.33–0.52; P?<?0.001; I²?=?17.0?%). Colchicine therapy was associated with significantly lower rates of pericarditis-associated rehospitalization (OR 0.29; 95?% CI 0.16–0.53; P?<?0.0001; I²?=?0.0?%) and persistence of symptoms (OR 0.29; 95?% CI, 0.21–0.41; P?=?0.000; I²?=?0.0?%) at 72 h. Adverse events were higher in the colchicine group (relative risk, RR 1.48; 95?% CI, 1.06–2.07; P?=?0.02; I²?=?0.0?%). Subgroup analysis showed that recurrence of pericarditis was significantly lower in the colchicine therapy group, irrespective of prednisone use and the cause of pericarditis.

Conclusion

Colchicine significantly decreases the rate of pericarditis recurrence, regardless of prednisone use and the cause of pericarditis. Larger studies are needed to confirm this effect.

     

Clinical patterns,epidemiology and risk factors of community-acquired urinary tract infection caused by extended-spectrum beta-lactamase producers: a prospective hospital case-control study

Purpose

To assess incidence rate, risk factors and susceptibility patterns associated with extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli or Klebsiella pneumoniae in community-acquired urinary tract infections (CA-UTIs).

Methods

A prospective, case-control study was conducted at a tertiary teaching hospital from Jan 2015 to Dec 2016. The results of microbiology cultures were initially screened to include only patients with positive E. coli or K. pneumoniae urine cultures. Afterwards, clinical symptoms were assessed to confirm the UTI. To investigate the risk factors, patients with a positive urine culture for ESBL-producing isolates were assigned as cases, while patients with non-ESBL were assigned as controls.

Results

Out of 591 patients included in this study, 57.5% (n?=?340) were included in the control group and 42.5% (n?=?251) were in the case group. The incidence rate of ESBL-producing isolates was 3.465 cases per 1000-patient hospital admissions. Male gender (OR?=?1.856, 95% CI?=?1.192–2.889, p?=?0.006), pediatrics (OR?=?1.676, 95% CI?=?1.117–2.517, p?=?0.013), patients with comorbidity (OR?=?1.542, 95% CI?=?1.029–2.312, p?=?0.036) and UTI in the previous 12 months (OR?=?1.705, 95% CI?=?1.106–2.628, p?=?0.016) were independently associated with a higher risk of infection. The resistance rate for most commonly prescribed antibiotics was high.

Conclusions

Our results suggest that the incidence of ESBL producers among CA-UTIs is high. Male gender, pediatrics, comorbidity and UTI in the previous 12 months were associated with a higher risk for infection. Continuous surveillance and prudent antibiotic use by healthcare professionals are important factors for effective control of ESBL associated infections.

     

Ticagrelor vs. clopidogrel in non-ST-elevation acute coronary syndromes

Aim

The aim of this study was to evaluate the bradyarrhythmic events associated with ticagrelor combination therapy in the management of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI).

Patients and methods

The study comprised 300 patients with NSTEMI who were treated via percutaneous coronary intervention (PCI). Patients were randomly assigned to two groups: the clopidogrel group (initial dose of 300 mg and then maintenance dose of 75 mg once daily, n?=?151) and the ticagrelor group (initial dose of 180 mg and then maintenance dose of 90 mg twice daily, n?=?149). All patients were followed up in the outpatient clinic. Follow-up included 12-lead electrocardiography and 24-h Holter monitoring performed 1, 6, and 12 months after the revascularization procedure.

Results

Of the 300 patients, 112 patients (36.7?%) had a decrease in heart rate at the 12-month follow-up. Of these, 80 patients were in the ticagrelor group (53.3?%) vs. 32 patients in the clopidogrel group (24.7?%; p?<?0.05). However, the difference was not statistically significant at the 1-month and 6-month follow-up visits. After adjusting for potential confounders, the reduction in heart rate with ticagrelor combination therapy remained independently associated with a reduced risk of major adverse cardiovascular events (hazard ratio, 2.1; 95?% CI, 1.90–2.23), while ticagrelor therapy reduced the risk to a level equivalent to that of patients in the clopidogrel group.

Conclusion

Ticagrelor can lower the resting heart rate of patients and cause bradyarrhythmias in the 12th month after PCI.

     

Association of peripheral arterial disease with all-cause and cardiovascular mortality in hemodialysis patients: a meta-analysis

Background

Recent studies have shown an association between peripheral arterial disease (PAD) and increased risk of mortality in hemodialysis (HD) patients; however, the estimates vary widely and are inconsistent. It is necessary to elucidate the degree of mortality risk for PAD patients in HD population.

Methods

PubMed, EMBASE, Web of Science and Cochrane Library (from inception to September 4th, 2016) were systematically searched for cohort studies assessing the association between PAD and mortality in HD patients. We calculated the pooled risk ratios (RRs) with 95% confidence intervals (CI) of all-cause and cardiovascular (CV) mortality using random effects models. Subgroup analyses were conducted to explore the source of heterogeneity.

Results

The search identified 2,973 potentially eligible records and 10 studies (n?=?32,864) were included. Our meta-analysis revealed that PAD significantly increased the risk of all-cause mortality (RR 2.15, 95 % CI 1.67–2.77, n?=?32,864) and CV mortality (RR 2.99, 95 % CI 1.66-5.38, n?=?31,794) in HD patients after multivariate adjustment. Subgroup analyses showed the study design and follow-up time might be two sources of heterogeneity.

Conclusion

PAD may be a prognostic marker of all-cause and CV mortality in HD patients. More attention should be paid to diagnosis and management of PAD in HD patients.

     

Systematic review assessing the effectiveness of dietary intervention on gut microbiota in adults with type 2 diabetes

Aims/hypothesis

Despite improved understanding of the pathophysiology of type 2 diabetes mellitus, explanations for individual variability in disease progression and response to treatment are incomplete. The gut microbiota has been linked to the pathophysiology of type 2 diabetes mellitus and may account for this variability. We conducted a systematic review to assess the effectiveness of dietary and physical activity/exercise interventions in modulating the gut microbiota and improving glucose control in adults with type 2 diabetes mellitus.

Methods

A systematic search was conducted to identify studies reporting on the effect of dietary and physical activity/exercise interventions on the gut microbiota and glucose control in individuals with a confirmed diagnosis of type 2 diabetes mellitus. Study characteristics, methodological quality and details relating to interventions were captured using a data-extraction form. Meta-analyses were conducted where sufficient data were available, and other results were reported narratively.

Results

Eight studies met the eligibility criteria of the systematic review. No studies were found that reported on the effects of physical activity/exercise on the gut microbiota and glucose control. However, studies reporting on dietary interventions showed that such interventions were associated with modifications to the composition and diversity of the gut microbiota. There was a statistically significant improvement in HbA_1c (standardised mean difference [SMD] ?2.31 mmol/mol [95% CI ?2.76, ?1.85] [0.21%; 95% CI ?0.26, ?0.16]; I²?=?0%, p?<?0.01), but not in fasting blood glucose (SMD ?0.25 mmol/l [95% CI ?0.85, 0.35], I²?=?87%, p?>?0.05), fasting insulin (SMD ?1.82 pmol/l [95% CI ?7.23, 3.60], I²?=?54%, p?>?0.05) or HOMA-IR (SMD ?0.15 [95% CI ?0.63, 0.32], I²?=?69%, p?>?0.05) when comparing dietary interventions with comparator groups. There were no significant changes in the relative abundance of bacteria in the genera Bifidobacterium (SMD 1.29% [95% CI ?4.45, 7.03], I²?=?33%, p?>?0.05), Roseburia (SMD ?0.85% [95% CI ?2.91, 1.21], I²?=?79%, p?>?0.05) or Lactobacillus (SMD 0.04% [95% CI ?0.01, 0.09], I²?=?0%, p?>?0.05) when comparing dietary interventions with comparator groups. There were, however, other significant changes in the gut microbiota, including changes at various taxonomic levels, including phylum, family, genus and species, Firmicutes:Bacteroidetes ratios and changes in diversity matrices (α and β). Dietary intervention had minimal or no effect on inflammation, short-chain fatty acids or anthropometrics.

Conclusions/interpretation

Dietary intervention was found to modulate the gut microbiota and improve glucose control in individuals with type 2 diabetes. Although the results of the included studies are encouraging, this review highlights the need for further well-conducted interventional studies to inform the clinical use of dietary interventions targeting the gut microbiota.

     

Genetic evidence of a causal effect of insulin resistance on branched-chain amino acid levels

Aims/hypothesis

Fasting plasma levels of branched-chain amino acids (BCAAs) are associated with insulin resistance, but it remains unclear whether there is a causal relation between the two. We aimed to disentangle the causal relations by performing a Mendelian randomisation study using genetic variants associated with circulating BCAA levels and insulin resistance as instrumental variables.

Methods

We measured circulating BCAA levels in blood plasma by NMR spectroscopy in 1,321 individuals from the ADDITION-PRO cohort. We complemented our analyses by using previously published genome-wide association study (GWAS) results from the Meta-Analyses of Glucose and Insulin-related traits Consortium (MAGIC) (n?=?46,186) and from a GWAS of serum BCAA levels (n?=?24,925). We used a genetic risk score (GRS), calculated using ten established fasting serum insulin associated variants, as an instrumental variable for insulin resistance. A GRS of three variants increasing circulating BCAA levels was used as an instrumental variable for circulating BCAA levels.

Results

Fasting plasma BCAA levels were associated with higher HOMA-IR in ADDITION-PRO (β 0.137 [95% CI 0.08, 0.19] p?=?6?×?10^?7). However, the GRS for circulating BCAA levels was not associated with fasting insulin levels or HOMA-IR in ADDITION-PRO (β ?0.011 [95% CI ?0.053, 0.032] p?=?0.6 and β ?0.011 [95% CI ?0.054, 0.031] p?=?0.6, respectively) or in GWAS results for HOMA-IR from MAGIC (β for valine-increasing GRS ?0.012 [95% CI ?0.069, 0.045] p?=?0.7). By contrast, the insulin-resistance-increasing GRS was significantly associated with increased BCAA levels in ADDITION-PRO (β 0.027 [95% CI 0.005, 0.048] p?=?0.01) and in GWAS results for serum BCAA levels (β 1.22 [95% CI 0.71, 1.73] p?=?4?×?10^?6, β 0.96 [95% CI 0.45, 1.47] p?=?3?×?10^?4, and β 0.67 [95% CI 0.16, 1.18] p?=?0.01 for isoleucine, leucine and valine levels, respectively) and instrumental variable analyses in ADDITION-PRO indicated that HOMA-IR is causally related to higher circulating fasting BCAA levels (β 0.73 [95% CI 0.26, 1.19] p?=?0.002).

Conclusions/interpretation

Our results suggest that higher BCAA levels do not have a causal effect on insulin resistance while increased insulin resistance drives higher circulating fasting BCAA levels.

     

Efficacy of Nucleoside Analogs for Chronic Hepatitis B Virus-Related Hepatocellular Carcinoma After Curative Treatment: A Meta-Analysis

Background and Aim

The efficacy of nucleoside analogs (NAs) for hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) after curative treatment remains unclear. The present study aimed to evaluate the efficacy of these agents by conducting a comprehensive meta-analysis of available studies.

Methods

We searched several databases including Pubmed, Embase, Cochrane Library, Clinical Trials, and Web of Science, according to PRISMA guidelines. We considered all randomized controlled trials and cohort studies that met the inclusion criteria. Statistical analyses were conducted using Review Manager 5.3 and Stata 14.0.

Results

Twenty-one studies with 8752 participants were included in the final analysis. The pooled data showed that patients treated with NAs had significantly lower 1- and 3-year HCC recurrence rates (relative risk [RR] 0.76, 95% confidence interval [CI] 0.65–0.90; P?=?0.001 and RR 0.79, 95% CI 0.71–0.88; P?<?0.001, respectively), but there was no difference in 5-year recurrence rates (RR 0.87, 95% CI 0.74–1.03; P?=?0.10). Regarding overall survival (OS), patients treated with NAs had significantly higher 1-, 3-, and 5-year OS rates (RR 1.05, 95% CI 1.02–1.08; P?=?0.003; RR 1.25, 95% CI 1.16–1.34; P?<?0.001; and RR 1.28, 95% CI 1.18–1.39; P?<?0.001, respectively).

Conclusion

NA therapy has the potential to reduce the risk of early recurrence and improve OS in patients with HBV-related HCC after curative treatment, compared with placebo or no treatment. Further research including more homogeneous studies with large sample sizes is required to improve the reliability of these conclusions.

     

Sex and ethnic/racial-specific risk factors for gallbladder disease

Background

Gallbladder disease (GBD) is a highly prevalent condition; however, little is known about potential differences in risk factors by sex and ethnicity/race. Our aim was to evaluate dietary, reproductive and obesity-related factors and GBD in multiethnic populations.

Methods

We performed a prospective analysis from the Multiethnic Cohort study who self-identified as non-Hispanic White (n?=?32,103), African American (n?=?30,209), Japanese (n?=?35,987), Native Hawaiian (n?=?6942) and Latino (n?=?39,168). GBD cases were identified using Medicare and California hospital discharge files (1993–2012) and self-completed questionnaires. We used exposure information on the baseline questionnaire to identify exposures of interest. Associations were estimated by hazard ratios and 95% confidence intervals using Cox models adjusted for confounders.

Result

After a median 10.7 years of follow-up, there were 13,437 GBD cases. BMI over 25 kg/m², diabetes, past and current smoking, red meat consumption, saturated fat and cholesterol were significant risk factors across ethnic/racial populations (p-trends?<?0.01). Protective factors included vigorous physical activity, alcohol use, fruits, vegetables and foods rich in dietary fiber (p-trends?<?0.01). Carbohydrates were inversely associated with GBD risk only among women and Latinos born in South America/Mexico (p-trend?<?0.003). Parity was a significant risk factor among women; post-menopausal hormones use was only associated with an increased risk among White women (estrogen-only: HR?=?1.24; 95% CI?=?1.07–1.43 and estrogen?+?progesterone: HR?=?1.23; 95% CI?=?1.06–1.42).

Conclusion

Overall, dietary, reproductive and obesity-related factors are strong risk factors for GBD affecting men and women of different ethnicities/races; however some risk factors appear stronger in women and certain ethnic groups.

     

Withdrawal of biologic agents in rheumatoid arthritis: a systematic review and meta-analysis

The aim of this study is to assess the efficacy of withdrawing biologics from patients with rheumatoid arthritis in sustained remission or low disease activity. This is a systematic review of clinical trials that randomized withdrawal or continuation of biologics. We searched MEDLINE, Embase, and other databases. Three authors independently selected and extracted the data from the studies. The GRADE approach was employed to assess the quality of the evidence. We calculated meta-analyses of random effects model and estimated the heterogeneity by I ². The number needed to treat (NNT) was calculated for significant outcomes. We included six trials (N?=?1927 patients), most were industry-sponsored. Compared to withdrawing, continuing biologics increased the probability of low disease activity (relative risk [RR]?=?0.66, 95 % CI 0.51–0.84, I ²?=?91 %, NNT?=?4, low quality), remission (0.57, 0.44–0.74, I ²?=?82 %, NNT?=?3, low quality), and radiographic progression (RR?=?0.91, 95 % CI 0.85–0.98, I ²?=?13 %, NNT?=?12, moderate quality). No significant difference was detected in the incidence of serious adverse events, serious infection, malignancy, and scores of improvement of tender and swollen joints between these strategies (low quality). A worse profile of outcomes was experienced by those patients when compared to the ones that continued biologics, but almost half of patients maintained low disease activity after withdrawal. As the quality of evidence was low, the conclusions may change as new results become available. The potential harms and benefits of this decision must be discussed with patients.     

Relation of intraoperative temperature to postoperative mortality in open colon surgery—an analysis of two randomized controlled trials

Introduction

The open surgical wound is exposed to cold and dry ambient air resulting in heat loss mainly through radiation and convection. This cools the wound and promotes local vasoconstriction and hypoxia. Carbon dioxide (CO₂) and water vapor are greenhouse gases with a warming effect. The aim was to evaluate if warm humidified CO₂ insufflated in surgical wound can affect long-term overall mortality

Methods

This is a retrospective study of two clinical trials, where patients were randomized to warm humidified CO₂ (n?=?80) or not (n?=?78). All patients underwent elective major open colon surgery. Patients in the treatment group received insufflation of warm humidified CO₂ into the open wound cavity via a gas diffuser to create a local atmosphere of 100 % CO₂. Temperature in the wound cavity was measured with a heat-sensitive infrared camera. Core temperature was measured at the tympanic membrane. Median follow-up was 70.9 months.

Results

A multivariate analysis adjusted for age (p?=?0.001) and cancer (p?=?0.165) showed that the larger the temperature difference between final core temperature and wound edge temperature, the lower the overall survival rate (p?=?0.050). Patients receiving insufflation of warm humidified CO₂ had a tendency to a better overall survival compared with control patients (p?=?0.508). End-of-operation wound edge temperature was negatively associated with mortality (OR?=?0.80, 95 % CI?=?0.68-0.95, p?=?0.011), whereas mortality was positively associated with age (10-year increase, OR?=?1.78, 95 % CI?=?1.37-2.33, p?<?0.001) and cancer (OR?=?8.1, 95 % CI?=?1.95–33.7, p?=?0.004).

Conclusions

A small end-of-operation temperature difference between final core and wound edge temperature was positively associated with patient survival in open colon surgery.

     

Antiviral therapy with nucleotide/nucleoside analogues in chronic hepatitis B: A meta-analysis of prospective randomized trials

Nucleotide/nucleoside analogues (antiviral therapy) are used in the therapy of HBeAg positive and HBeAg negative chronic hepatitis B. We analyzed ten selected randomized controlled with 2557 patients to estimate the effect of antiviral drugs in chronic hepatitis B with compared to placebo. Virological response, biochemical response, histological response, seroconversion of HBeAg, and loss of HBeAg were estimated as primary efficacy measures. The included studies were subjected for heterogeneity and publication bias. The heterogeneity was assessed with χ2 and I² statistics. Publication bias was assessed by funnel plot. Greater rates of improvement obtained in antiviral group for virological response [43.96 % vs. 3.15 %, RR?=?0.57, 95 % CI?=?0.54–0.61, p-value <0.00001], biochemical response [58.37 % vs. 21.87 %, RR?=?0.52, 95 % CI?=?0.48–0.56, p-value <0.00001], histological response [58.99 % vs. 27.13 %, RR?=?0.56, 95 % CI?=?0.50–0.63, p-value <0.0001], seroconversion of HBeAg [10.66 % vs. 5.56 %, RR?=?0.94, 95 % CI?=?0.91–0.97, p-value?=?0.0005], and HBeAg loss [14.59 % vs. 9.64 %, RR?=?0.92, 95 % CI?=?0.88–0.96, p-value?=?0.0002]. The safety analysis were carried out for adverse events such as headache [17.22 % vs. 17.34 %, OR?=?1.09, 95 % CI?=?0.81–1.46, p-value?=?0.58], abdominal pain [16.46 % vs. 14.34 %, OR?=?1.24, 95 % CI?=?0.90–1.72, p-value?=?0.19], and pharyngitis [22.22 % vs. 18.23 %, OR?=?1.12, 95 % CI?=?0.86–1.45, p-value?=?0.40]. Excluding adverse events, all primary efficacy measures shown statistical significant result for chronic hepatitis treatment (p-value <0.05). Antiviral therapy provided significant benefit for the treatment of chronic hepatitis B with no measurable adverse effects.     

Risk factors for surgical site infection following colorectal resection: a multi-institutional study

Introduction

Surgical site infection (SSI) is an infection occurring in an incisional wound within 30 days of surgery and significantly affects patients undergoing colorectal surgery. This study examined a multi-institutional dataset to determine risk factors for SSI following colorectal resection.

Methods

Data on 386 patients who underwent colorectal resection in three institutions were accrued. Patients were identified using a prospective SSI database and hospital records. Data are presented as median (interquartile range), and logistic regression analysis was used to identify risk factors.

Results

Patients (21.5 %) developed a postoperative SSI. The median time to the development of SSI was 7 days (5–10). Of all infections, 67.5 % were superficial, 22.9 % were deep and 9.6 % were organ space. In univariate analysis, an ASA grade of II (RR 0.6, CI 0.3–0.9, P?=?0.019), having an elective procedure (RR 0.4, CI 0.2–0.6, P?<?0.001), using a laparoscopic approach (RR 0.5, CI 0.3–0.9, P?=?0.019), having a daytime procedure (RR 0.3, CI 0.1–0.7, P?=?0.006) and having a clean/contaminated wound (RR 0.4, CI 0.2–0.7, P?=?0.001) were associated with reduced risk of SSI. In multivariate analysis, an ASA grade of IV (RR 3.9, CI 1.1–13.7, P?=?0.034), a procedure duration over 3 h (RR 4.3, CI 2.3–8.2, P?<?0.001) and undergoing a panproctocolectomy (RR 6.5, CI 1.0–40.9, P?=?0.044) were independent risk factors for SSI. Those who developed an SSI had a longer duration of inpatient stay (22 days [16–31] vs 15 days [10–26], P?<?0.001).

Conclusions

Patients who develop an SSI have a longer duration of inpatient stay. Independent risk factors for SSI following colorectal resection include being ASA grade IV, having a procedure duration over 3 h, and undergoing a panproctocolectomy.

     

Management of acute uncomplicated diverticulitis without antibiotics: a systematic review,meta-analysis,and meta-regression of predictors of treatment failure

Background

Diverticulitis is a common complication of diverticular disease of the colon. While complicated diverticulitis often warrants intervention, acute uncomplicated diverticulitis (AUD) is usually managed conservatively. The aim of the present review was to evaluate the efficacy and safety of conservative treatment of AUD without antibiotics compared to standard antibiotic treatment.

Methods

A systematic literature review in compliance with PRISMA guidelines was conducted. Electronic databases including PubMed/Medline, Scopus, Embase and Cochrane central register of controlled trials were searched. Studies that assessed efficacy and safety of treatment of AUD without antibiotics were included. Outcome parameters were rates of treatment failure, recurrence of diverticulitis, complications and mortality, readmission to hospital, and need for surgery.

Results

Nine studies including 2565 patients were included to the review. Of these patients, 65.1% were treated conservatively without antibiotics. Treatment failure was observed in 5.1% of patients not-given-antibiotic treatment versus 3.4% of those given antibiotic treatment. Recurrent diverticulitis occurred in 9.3% of patients in the non-antibiotic group versus 12.1% of patients in the antibiotic group. On meta-analysis of the studies, there were no significant differences between non-antibiotic and antibiotic treatment groups regarding rates of treatment failure (OR?=?1.5, p?=?0.06), recurrence of diverticulitis (OR?=?0.81, p?=?0.2), complications (OR?=?0.56, p?=?0.25), readmission rates (OR?=?0.97, p?=?0.91), need for surgery (OR?=?0.59, p?=?0.28), and mortality (OR?=?0.64, p?=?0.47). The only variable that was significantly associated with treatment failure in the non-antibiotic treatment group was associated comorbidities (standard error (SE) = ??0.07, 95% CI ??0.117 ??0.032; p?<?0.001).

Conclusions

Treatment of AUD without antibiotics is feasible, safe, and effective. Adding broad-spectrum antibiotics to the treatment regimen did not serve to decrease treatment failure, recurrence, complications, hospital readmissions, and need for surgery significantly compared to non-antibiotic treatment.

     

Atrial resynchronization therapy in patients with atrial fibrillation and heart failure with and without systolic left ventricular dysfunction: a pilot study

Purpose

The superiority of catheter ablation (CA) for persistent (and long-standing persistent) atrial fibrillation (AF) is currently not well defined. We performed a meta-analysis of randomized controlled trials (RCTs) to assess the clinical outcomes of CA compared with medical therapy in persistent AF patients.

Methods

We systematically searched PubMed, EMBASE, the Cochrane Library, and clinicaltrials.gov for RCTs comparing CA with medical therapy in patients with persistent AF. For CA vs medical rhythm control, the primary outcome was freedom from atrial arrhythmia. For CA vs medical rate control, the primary outcome was the change in the left ventricular ejection fraction (LVEF).

Results

Eight studies with a total of 809 patients were included in the final analysis. Compared with medical rhythm control, CA was superior in achieving freedom from atrial arrhythmia (RR 2.08, 95% CI [1.67, 2.58]; P?<?0.00001). Similar result was found in CA arm without antiarrhythmic drug use after operation (RR 1.82, 95%CI [1.33, 2.49]; P?=?0.0002). CA was also superior in reducing the probability of cardioversion (RR 0.59, 95%CI [0.46, 0.76]; P?<?0.0001) and hospitalization (RR 0.54, 95%CI [0.39, 0.74]; P?=?0.0002). Compared with the medical rate control in persistent AF patients with heart failure (HF), CA significantly improved the LVEF (MD 7.72, 95%CI [4.78, 10.67]; P?<?0.00001) and reduced Minnesota Living with Heart Failure Questionnaire scores (MD 11.1395% CI [2.52–19.75]; P?=?0.01).

Conclusions

CA appeared to be superior to medical therapy in persistent AF patients and might be considered as a first-line therapy for some persistent AF patients especially for those with HF.

     

Exposure to Stress-Dose Steroids and Lethal Septic Shock After In-Hospital Cardiac Arrest: Individual Patient Data Reanalysis of Two Prior Randomized Clinical Trials that Evaluated the Vasopressin–Steroids–Epinephrine Combination Versus Epinephrine Alone

Purpose

Low-dose steroids may reduce the mortality of severely ill patients with septic shock. We sought to determine whether exposure to stress-dose steroids during and/or after cardiopulmonary resuscitation is associated with reduced risk of death due to postresuscitation septic shock.

Methods

We analyzed pooled, individual patient data from two prior, randomized clinical trials (RCTs). RCTs evaluated vasopressin, steroids, and epinephrine (VSE) during resuscitation and stress-dose steroids after resuscitation in vasopressor-requiring, in-hospital cardiac arrest. In the second RCT, 15 control group patients received open-label, stress-dose steroids. Patients with postresuscitation shock were assigned to a Steroids (n?=?118) or No Steroids (n?=?73) group according to an “as-treated” principle. We used cumulative incidence competing risks Cox regression to determine cause-specific hazard ratios (CSHRs) for pre-specified predictors of lethal septic shock (primary outcome). In sensitivity analyses, data were analyzed according to the intention-to-treat (ITT) principle (VSE group, n?=?103; control group, n?=?88).

Results

Lethal septic shock was less likely in Steroids versus No Steroids group, CSHR, 0.40, 95% confidence interval (CI), 0.20–0.82; p?=?0.012. ITT analysis yielded similar results: VSE versus Control, CSHR, 0.44, 95% CI, 0.23–0.87; p?=?0.019. Adjustment for significant, between-group baseline differences in composite cardiac arrest causes such as “hypotension and/or myocardial ischemia” did not appreciably affect the aforementioned CSHRs.

Conclusions

In this reanalysis, exposure to stress-dose steroids (primarily in the context of a combined VSE intervention) was associated with lower risk of postresuscitation lethal septic shock.