True benefit or selection bias: an analysis of laparoscopic versus open splenectomy from the ACS-NSQIP

Background

By virtue of the benefits associated with minimally invasive approaches, laparoscopic splenectomy (LS) is believed to have better patient-related outcomes compared to open splenectomy (OS). However, there are limited data directly comparing the two techniques.

Methods

Patients who underwent elective LS and OS between 2005 and 2010 were identified from the public use file of the ACS-NSQIP database using the Current Procedural Terminology codes 38120 and 38100. Patients who had concomitant procedures were excluded. Because of the nonrandom assignment of surgical techniques, a selection bias could have been responsible for the differences in patient outcomes. Therefore, patient characteristics and comorbidities that were available and could have been potential confounders were compared and regression analysis was performed to determine independent risk factors associated with serious and overall morbidity as well as mortality.

Results

During the study period 1,644 and 851 patients underwent LS and OS, respectively. Compared to patients who underwent LS, patients who had OS had a longer median length of hospital stay (3 vs. 6 days, P < 0.0001) and higher incidences of serious (7 vs. 17 %, P < 0.0001) and overall morbidity (12 vs. 25 %, P < 0.0001) and mortality (1.4 vs. 3.3 %, P = 0.02). However, there were certain significant differences in the characteristics and comorbidities of the patients that could have confounded outcomes. On regression analysis, OS was not associated with higher mortality (OR = 1.43, 95 % CI 0.7–2.7, P = 0.28) but was associated with higher serious morbidity (OR = 1.8, 95 % CI 1.4–2.3, P = 0.001) and overall morbidity (OR = 2.0, 95 % CI 1.6–2.4, P = 0.0001).

Conclusion

After adjusting for available confounders, patients who underwent LS had lower morbidity and similar mortality rates. Although certain confounders such as previous surgical history, underlying pathology, and spleen size could still have potentially influenced outcomes, the data suggest that patient outcomes after LS are excellent and when technically possible a minimally invasive technique should be the preferred approach for splenectomy.     

Changes in sleep architecture after burn injury: ‘Waking up’ to this unaddressed aspect of postburn rehabilitation in the developing world

BACKGROUND:

Changes in sleep architecture are common phenomena observed in post-traumatic patients; such altered sleeping patterns have negative implications on various phases of rehabilitation. Sleep is an essential process, without which one cannot function effectively and, hence, any aberrations in the quality of sleep in such patients need to be critically analyzed.

OBJECTIVE:

To probe the quality of sleep in postburn patients at one year compared with a group of adequately matched controls.

METHODS:

Quality of sleep in postburn patients at one year was measured using the Pittsburg Sleep Quality Index questionnaire and compared with a group of adequately matched controls. Data were tabulated and subjected to statistical analysis using Pearson’s χ² test.

RESULTS:

The relationship between the postburn state and sleep disturbances was found to be statistically significant. Other relevant parameters are also highlighted and discussed.

DISCUSSION:

Sleep is one of aspect of functioning that may be least taken into account by professionals during the phase of postburn rehabilitation because more obvious threats receive preferred treatment. Unless these problems are dealt with in the postburn period, rehabilitation can never be complete.

CONCLUSION:

Postburn patients experience significant changes in sleep architecture, which need to be taken into account to enable complete rehabilitation of the patient.     

Health and wellbeing of Victorian adults with intellectual disability compared to the general Victorian population

Multiple measures of health and wellbeing of people with intellectual disability (ID) and the general Victorian population were compared using representative population level data. The sample consisted of adults with ID (N = 897) and the general Victorian population (N = 34,168) living in the state of Victoria in Australia. Proxy respondents were interviewed on behalf of people with ID, while respondents from the general Victorian population were interviewed directly. The data were weighted to reflect the age/sex/geographic distribution of the population. Results revealed that adults with ID reported higher prevalence of poor social determinants of health, behavioural risk factors, depression, diabetes, poor or fair health. A higher proportion of people with ID reported blood pressure and blood glucose checks, while a lower proportion reported cervical and breast cancer screening, compared with the general Victorian population. The survey identified areas where targeted approaches may be undertaken to improve the health outcomes of people with ID and provide an important understanding of the health and wellbeing of these Victorians.     

High performance p-channel and ambipolar OFETs based on imidazo[4,5-f]-1,10-phenanthroline-triarylamines

A series of phenanthroline functionalized triarylamines (TAA) has been designed and synthesised to evaluate their OFET characteristics. Solution processed OFET devices have exhibited p-channel/ambipolar behaviour with respect to the substituents, in particular methoxyphenyl substitution resulted with highest mobility (μ_h) up to 1.1 cm² V⁻¹ s⁻¹ with good I_on/off (10⁶) ratio. These compounds can be potentially utilized for the fabrication of electronic devices.

A series of phenanthroline functionalized triarylamines (TAA) has been designed and synthesised to evaluate their OFET characteristics. Solution processed OFET devices have exhibited p-channel/ambipolar behaviour with respect to the substituents.     

Comparison of different methods for measurement of electrolytes in patients admitted to the intensive care unit

Objectives:

To investigate whether electrolyte levels measured by using blood gas analyzers (ABG) and auto-analyzers (AA) are equivalent and can be used interchangeably.

Methods:

This observational prospective study was conducted in 100 patients admitted to the Intensive Care Unit, Adnan Menderes University School of Medicine, Aydin, Turkey, between March and August 2014. Samples for both AA and ABG analyzers were collected simultaneously from invasive arterial catheters of patients. The electrolyte levels were measured by using 2 methods.

Results:

The mean sodium level measured by ABG was 136.1±6.3 mmol/L and 137.8±5.4 mmol/L for AA (p=0.001). The Pearson’s correlation coefficient was 0.561 (p<0.001). The Bland-Altman 95% limits of agreement were -9.4 to 12.6 mmol/L. The mean potassium levels measured by ABG was 3.4±0.7 mmol/L and AA was 3.8±0.7 mmol/L (p=0.001). The Bland-Altman comparison limits were -0.58 to 1.24 and the associated Pearson’s correlation coefficient was 0.812 (p<0.001).

Conclusion:

The results of the 2 analyzing methods, in terms of sodium, were not equivalent and could not be used interchangeably. However, according to the statistical analyses results, by including, but not blindly trusting these findings, urgent and vital decisions could be made by the potassium levels obtained from the BGA, but a simultaneous follow-up sample had to be sent to the central laboratory for confirmation.Electrolytes are very important for the continuation of the physiological functions of the human body. They play vital roles in: regulation of the cell membrane potential, steady process of neurohormonal pathways, energy transformation and the fluid, and acid-base balance in the body. Signs and symptoms of electrolyte disorders may be nonspecific in an intensive care unit (ICU) patient.1-3 The therapies directed for maintaining vital organ functions affect the electrolyte balance. Consequently, electrolyte disorders are more common in critically ill patients than non-critically ill patients.1 The incidence of electrolyte disorders is nearly 25% in ICU patients.2 In recent studies,4-6 it is shown that in ICU patients, serum sodium and potassium levels are significant predictors of mortality. Therefore, prompt and complete correction of electrolyte disorders in ICU patients is vitally important. Under these circumstances, the importance of obtaining the results of serum electrolyte levels at the earliest is obvious. In routine application, serum electrolytes are measured by the indirect ion-sensing (ISE) method using auto-analyzers (AA) located in the central laboratories of hospitals. In this analyzing method, the processing time is longer because of a delay in the transportation of the samples to the central laboratory on account of several reasons.7 Hence, point-of-care (POC) testing methods, such as, arterial blood gas (ABG) analyzers have been increasingly used in the daily assessments of ICU patients. Blood gas analyzers; use the direct ISE method with short processing time that provides time and rapidity to the physician in the patient’s treatment decisions.7,8 The United States Clinical Laboratory Improvement Amendments (US CLIA) accepts a 0.5 mmol/l difference in the measured potassium levels and a 4 mmol/l difference in the measured sodium levels, in the gold standard measure of the standard calibration solution.9 In some recent studies, the data revealed the difference in the electrolyte levels between the ABG and AA results.10,11 Furthermore, there are also studies that suggest that there is no significant difference between these measuring methods.12,13 Physicians want to trust the veracity of the ABG results of electrolytes such as sodium and potassium because, by this method, the delay in reaching the results is surpassed, and risks arising from this delay may be reduced. However, the results of the above-mentioned studies are confusing and still a diagnostic challenge for physicians. On account of the hesitation by the physicians, we decided to investigate whether the sodium and potassium levels measured by using ABG and AA were equivalent. We conducted a prospective study comparing the electrolyte level results measured in the arterial blood samples by 2 different methods. We tried to notice all limitations of previous similar studies and designed our study according to these points. Thereby, we aimed to improve the accuracy of our study results.     

Nuclear gyrB encodes a functional subunit of the Plasmodium falciparum gyrase that is involved in apicoplast DNA replication

The DNA replication machinery of the Plasmodium falciparum apicoplast is a validated drug target. Nuclear-encoded gyrase subunits are predicted to play a critical role in maintaining DNA topology during the D-loop/bi-directional ori replication process of the parasite. We show the presence of P. falciparum gyrase subunits in parasite lysates by using antibodies generated against recombinant gyrase A and B. The ATPase activity of PfGyrB was inhibited by novobiocin that also caused parasite death in culture. Reduction of apicoplast/nuclear DNA ratio in the presence of novobiocin indicated that the drug targets apicoplast DNA replication. Molecular modeling of gyrase A and B subunits revealed extensive fold conservation with the Escherichia coli counterparts as well as the presence of a long disordered loop adjacent to the ATPase domain of PfGyrB. Our results have implications for development of PfGyrB as a drug target against malaria.     

Pacemaker infection secondary to burkholderia pseudomallei

Infection is a relatively rare but devastating complication of intracardiac device implantation. Burkholderia pseudomallei is the organism which causes melioidosis, an endemic and lethal infection in the tropics. We describe a case of pacemaker infection secondary to Burkholderia pseudomallei, which was treated by explantation of the device and appropriate antimicrobial therapy.     

Phytochemical constituents,biological activities,and health‐promoting effects of the genus Origanum

Origanum species are mostly distributed around the Mediterranean, Euro‐Siberian, and Iran‐Siberian regions. Since time immemorial, the genus has popularly been used in Southern Europe, as well as on the American continent as a spice now known all over the world under the name “oregano” or “pizza‐spice.” Origanum plants are also employed to prepare bitter tinctures, wines, vermouths, beer, and kvass. The major components of Origanum essential oil are various terpenes, phenols, phenolic acids, and flavonoids with predominant occurrence of carvacrol and thymol (with reasonable amounts of p‐cymen and ‐terpinene) or of terpinene‐4‐ol, linalool, and sabinene hydrate. Many species of Origanum genus are used to treat kidney, digestive, nervous, and respiratory disorders, spasms, sore throat, diabetes, lean menstruation, hypertension, cold, insomnia, toothache, headache, epilepsy, urinary tract infections, etc. Origanum essential oil showed potent bioactivities owing to its major constituents' carvacrol, thymol, and monoterpenes. Several preclinical studies evidenced its pharmacological potential as antiproliferative or anticancer, antidiabetic, antihyperlipidemic, anti‐obesity, renoprotective, antiinflammatory, vasoprotective, cardioprotective, antinociceptive, insecticidal, and hepatoprotective properties. Its nanotechnological applications as a promising pharmaceutical in order to enhance the solubility, physicochemical stability, and the accumulation rate of its essential oils have been investigated. However, Origanum has been reported causing angioedema, perioral dermatitis, allergic reaction, inhibition of platelet aggregation, hypoglycemia, and abortion. Conclusive evidences are still required for its clinical applications against human medical conditions. Toxicity analyses and risk assessment will aid to its safe and efficacious application. In addition, elaborate structure–activity studies are needed to explore the potential use of Origanum‐derived phytochemicals as promising drug candidates.     

Reprint – Bipolar vs. monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction: A Cochrane review

IntroductionThere remains uncertainty regarding the differences in patient outcomes between monopolar transurethral resection of the prostate (MTURP) and bipolar TURP (BTURP) in the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO).MethodsA systematic literature search was carried out up to March 19, 2019. Methods in the Cochrane Handbook were followed. Certainty of evidence (CoE) was assessed using the GRADE approach.ResultsA total of 59 randomized controlled trials (RCTs) with 8924 participants were included. BTURP probably results in little to no difference in International Prostate Symptom Score (IPSS) at 12 months (mean difference −0.24, 95% confidence internal [CI] −0.39–−0.09; participants=2531; RCTs=16; moderate CoE) or health-related quality of life (HRQOL) at 12 months (mean difference −0.12, 95% CI −0.25–0.02; participants=2004, RCTs=11; moderate CoE), compared to MTURP. BTURP probably reduces TUR syndrome (relative risk [RR] 0.17, 95% CI 0.09–0.30; participants= 6,745, RCTs=44; moderate CoE) and blood transfusions (RR 0.42, 95% CI 0.30–0.59; participants=5727, RCTs=38; moderate CoE), compared to MTURP. BTURP may carry similar risk of urinary incontinence at 12 months (RR 0.20, 95% CI 0.01–4.06; participants=751; RCTs=4; low CoE), re-TURP (RR 1.02, 95% CI 0.44–2.40; participants=652, RCTs=6, I²=0%; low CoE) and erectile dysfunction (International Index of Erectile Function [IIEF-5]) at 12 months (mean difference 0.88, 95% CI −0.56–2.32; RCTs=3; moderate CoE), compared to MTURP.ConclusionsBTURP and MTURP probably improve urological symptoms to a similar degree. BTURP probably reduces TUR syndrome and blood transfusion slightly postoperatively. The moderate certainty of evidence available for primary outcomes suggests no need for further RCTs comparing BTURP and MTURP.     

Critical adjustments and trauma surgery trends in adaptation to COVID-19 pandemic in Malaysia

Malaysia has one of the highest total numbers of COVID-19 infections amongst the Southeast Asian nations, which led to the enforcements of the Malaysian “Movement Control Order” to prohibit disease transmission. The overwhelming increasing amount of infections has led to a major strain on major healthcare services. This leads to shortages in hospital beds, ventilators and critical personnel protective equipment. This article focuses on the critical adaptations from a general surgery department in Malaysia which is part of a Malaysian tertiary hospital that treats COVID-19 cases. The core highlights of these strategies enforced during this pandemic are: (1) surgery ward and clinic decongestions; (2) deferment of elective surgeries; (3) restructuring of medical personnel work force; (4) utilization of online applications for tele-communication; (5) operating room (OR) adjustments and patient screening; and (6)continuing medical education and updating practices in context to COVID-19. These adaptations were important for the continuation of emergency surgery services, preventing transmission of COVID-19 amongst healthcare workers and optimization of medical personnel work force in times of a global pandemic. In addition, an early analysis on the impact of COVID-19 pandemic and lockdown measures in Malaysia towards the reduction in total number of elective/emergent/trauma surgeries performed is described in this article.