Does prophylactic therapy with antioxidant vitamins have an effect on atrial fibrillation following cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether prophylactic therapy with antioxidant vitamins reduces the incidence of postoperative atrial fibrillation (AF). One hundred and fifty-four papers were found using the reported search, of which five were judged to represent the best evidence to answer the question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results were tabulated. Four of the five studies found antioxidant vitamins to significantly reduce the incidence of postoperative AF. Two of the studies show that prophylactic treatment with adjuvant vitamin C and β-blockers is more effective than β-blocker therapy alone. The quality of these studies was assessed using a Jadad scoring system, which identified four of the studies to be of low and one to be of high methodological quality. We conclude that although preliminary evidence suggests that prophylactic antioxidant vitamins may be effective in reducing the incidence of postoperative AF, there is a lack of high-quality data. Additional large-scale, adequately powered clinical studies are warranted before antioxidant vitamins can be considered for routine use in this setting.     

Behavioural interventions for smoking cessation in patients hospitalised for a major cardiovascular event

The impact of cigarette smoking on progression of atherosclerosis in patients with known cardiovascular disease suggests a strong need for effective cessation interventions in this group. This letter compares and discusses smoking cessation outcomes following behavioural smoking cessation interventions versus usual care in hospitalised cardiovascular patients using meta-analysis of randomised controlled peer-reviewed publications. It particularly focuses on the impact of intensity and duration of intervention on outcome.     

Primary Resection With Anastomosis vs. Hartmann’s Procedure in Nonelective Surgery for Acute Colonic Diverticulitis: A Systematic Review

Purpose This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis. Methods Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed. Results Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome. Conclusions Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.     

A Comparison of Adverse Events and Functional Outcomes After Restorative Proctocolectomy for Familial Adenomatous Polyposis and Ulcerative Colitis

Purpose Restorative proctocolectomy is the procedure of choice for patients undergoing proctocolectomy for familial adenomatous polyposis or ulcerative colitis. This meta-analysis was designed to identify differences in adverse events and functional outcomes between these two groups. Methods Studies published between 1986 and 2003 that compared outcomes between patients with familial adenomatous polyposis and ulcerative colitis were included. Meta-analytical techniques using random effect models were used to compare short-term and long-term adverse events as well as functional outcomes between the groups. Results Nineteen studies comprising 5,199 patients (familial adenomatous polyposis, 782; ulcerative colitis, 4,417) were analyzed. There were no significant differences in immediate postoperative adverse events between the two groups. Pouch-related fistulation was significantly increased in the ulcerative colitis group (10.5 percent vs. familial adenomatous polyposis 4.8 percent; odds ratio 2.31; P < 0.001). There was no significant difference in pouch failure between the two groups (ulcerative colitis 5.8 percent vs. familial adenomatous polyposis 4.5 percent; odds ratio 1.22; P = 0.43). The incidence of pouchitis was significantly greater in the ulcerative colitis group (30.1 vs. 5.5 percent; odds ratio 6.44; P < 0.001). Patients with familial adenomatous polyposis had a significant advantage in stool frequency with one less motion per 24 hours (95 percent confidence interval, 0.21–1.76; P = 0.01). Conclusions In contrast to studies reporting similar outcomes for patients undergoing restorative proctocolectomy for familial adenomatous polyposis or ulcerative colitis, the present meta-analysis suggested that patients with ulcerative colitis are at greater risk of pouch-related fistulation and pouchitis. Although there was an increase in the 24-hour stool frequency in the ulcerative colitis group, this may be accounted for by the younger age at surgery in the familial adenomatous polyposis group. Henry S. Tilney is sponsored by a research grant from The Royal College of Surgeons of England. Read at the meeting of the Association of Surgeons of Great Britain and Ireland, Edinburgh, Scotland, May 3 to 5, 2006.     

An unusual case of brucellar spondylitis involving both the cervical and lumbar spine

We report an unusual case of brucellar spondylitis, involving both the cervical and lumbar spine. Diagnosis was established using magnetic resonance imaging (MRI). An initial plain radiograph of the lumbar spine, showing mild degenerative lesions, was misleading. Therefore, institution of a proper treatment was delayed.     

Systemic leukofiltration does not attenuate pulmonary injury after cardiopulmonary bypass

Pulmonary injury mediated by activated leukocytes is a recognized complication of cardiopulmonary bypass. The aim of this paper is to systematically analyze the effects of systemic leukofiltration within the cardiopulmonary bypass circuit on pulmonary injury and related clinical outcomes. We performed a systematic search to identify randomized controlled trials reporting on the effects of systemic leukofiltration on respiratory parameters. Random effect meta-analytical techniques were applied to identify differences in outcomes between the two groups. Sensitivity and subgroup analyses were undertaken to evaluate study heterogeneity. Incorporating 995 patients, 21 studies satisfied the inclusion criteria. Systemic leukofiltration significantly increased the PaO2/FiO2 ratio within 12 hours of bypass cessation, (weighted mean difference (WMD), 25.97; 95% confidence interval (CI), 3.41-48.53; p = 0.02) but this effect was lost by 24 hours (WMD, 12.98; 95% CI, -7.93-33.89; p = 0.22). Leukofiltration significantly reduced the duration of ventilatory support postoperatively (WMD, -2.11 hours; 95% CI, -0.65 to -3.58; p = 0.005), but had no impact on postoperative chest infection, intensive care length of stay or hospital length of stay. The heterogeneity of the included studies was high, due to poor quality study design and failure to include patients at high risk of pulmonary complications. Systemic leukofiltration may attenuate bypass-related lung injury in the early postoperative period, but this does not seem to translate to clinically significant differences in outcomes.     

Assessment of the cerebral cortex during motor task behaviours in adults: a systematic review of functional near infrared spectroscopy (fNIRS) studies

Functional near infrared spectroscopy (fNIRS) is an emerging tool for non-invasively monitoring the haemodynamic response to brain activation. The technique has been widely adopted to investigate cortical responses during motor tasks in health and disease. This systematic review provides a critical analysis of the research findings in the hope of summating relevant information, identifying consistent outcomes acquired using different spectrometers, clarifying data inconsistencies, and learning from the common challenges across disciplines. The spatiotemporal characteristics, reliability, repeatability and modulation of typical cortical response evoked by motor stimulation are all evaluated in detail. The review assesses the contribution of the technique to advancing our understanding of motor skill learning and control in the context of tasks of everyday living, athletic performance, and recovery from neurological illness. Finally, the limitations of current fNIRS technologies are examined and a series of recommendations for future studies are provided based upon the reviewed literature.