Abstract Background We aim to develop a risk stratification tool to preoperatively predict conversion (CONV) from a laparoscopic to open cholecystectomy. Methods Multiple risk factors were analyzed ...with multivariate logistic regression and presented as probability nomograms. Results Of 732 patients, 47 (6.4%) required CONV. Among 40 preoperative risk factors evaluated, 5 variables were found to have significant association with CONV: 2 clinical variables, previous upper abdominal surgery (odds ratio OR 95.2) and obesity defined as body mass index greater than 30 kg/m2 (OR 12.3), and 3 ultrasound parameters, visible choledocholithiasis (OR 19.8), impacted stone at the neck of the gallbladder (OR 5.9), and gallbladder wall width in millimeters (OR 2.1). Nomograms based on this multivariate model demonstrate the individual preoperative probability of CONV. Internal validation using receiver operator curve analysis showed an area under the curve of .97. Conclusion Four probability nomograms were developed as a practical individual risk stratification tool to predict probability of CONV.
Abstract
Background
Community pharmacies in Wales delivered an NHS-funded sore throat test and treat (STTT) service during the period of increased invasive Group A Streptococcus (iGAS) incidents in ...winter 2022–23. Service users were screened using FeverPAIN/CENTOR scores, offered GAS rapid antigen detection tests (RADT) if appropriate, and antibiotics if indicated.
Objectives
To evaluate the service’s response to a substantial rise in sore throat presentations during a period of heightened public anxiety.
Methods
Cross-sectional study with anonymized individual-level data from electronic pharmacy records of all eligible STTT service users, between January 2022 and March 2023.
Results
Antibiotics were supplied to 24% (95% CI: 23–24) of people who used the STTT service and 31% (95% CI: 31–32) of those who met the threshold for an RADT. Of 27 441 STTT consultations, 9308 (33.9%) occurred during December 2022. In the week commencing 2 December 2022, following the announcements of increased iGAS incidents, we observed a statistically significant increase of 1700 consultations (95% CI: 924–2476) and a statistically significant decrease in supply rate of 13.9 antibiotics per 100 RADT (95% CI: −18.40 to −9.40). Antibiotic supply rates increased thereafter to those observed before the announcements of iGAS incidents. Referral rates to other primary care or emergency settings remained below 10% throughout the study period.
Conclusions
Our findings suggest that, despite a dramatic increase in sore throat consultation rates in response to media reports, the pre-specified pathway followed by pharmacists ensured appropriate use of antibiotics, and absorbed a substantial workload that would otherwise end up in other healthcare settings.
Summary
Short and long sleep patterns in children have been associated with a range of poor health outcomes. However, there is no consensus regarding the definitions of these abnormal sleep ...parameters in childhood for use in paediatric research. Given that there is a clear lack of definitions for sleep duration throughout paediatric sleep literature, this review aimed to establish recommendations for standard cut‐offs of short and long sleep for children aged 1–16 years to enable homogeneity in future studies of paediatric sleep duration. Four databases were systematically searched to identify prospective studies that defined short or long sleep patterns in children. Included papers (38) were assessed for methodological quality, and their definitions were extracted to examine the current applied cut‐offs in the literature for short or long sleep duration. The definitions were analysed in a regression model to summarize applied cut‐offs from subjective data into cut‐offs for short and long sleep duration. These models were fitted to reference values of three commonly cited paediatric population studies to establish new definitions of sleep duration for future use in research. Across the age groups there was little consensus in applied cut‐offs for short and long sleep duration. This study found the best compromise for short sleep was defined as the 2.5th centile (hours = 0.25*age + 11) and long sleep as the 97.5th centile (hours = 0.017*age2 − 0.68*age + 16) of sleep duration in children. Recommendations for the hourly cut‐offs of short and long sleep duration based on these percentiles were described.
Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI despite many other ...potential causes. This leads to significant overdiagnosis of UTI, inappropriate antibiotic use and potential harmful outcomes. This problem is particularly prevalent in nursing home settings.
A systematic review of the literature was conducted assessing the association between confusion and UTI in the elderly. PubMed, Scopus and PsychInfo were searched with the following terms: confusion, delirium, altered mental status, acute confusional state, urinary tract infection, urine infection, urinary infection and bacteriuria. Inclusion criteria and methods were specified in advance and documented in the protocol, which was published with PROSPERO (registration ID: CRD42015025804). Quality assessment was conducted independently by two authors. Data were extracted using a standardised extraction tool and a qualitative synthesis of evidence was made.
One thousand seven hunderd two original records were identified, of which 22 were included in the final analysis. The quality of these included studies varied, with frequent poor case definitions for UTI or confusion contributing to large variation in results and limiting their validity. Eight studies defined confusion using valid criteria; however, no studies defined UTI in accordance with established criteria. As no study used an acceptable definition of confusion and UTI, an association could not be reliably established. Only one study had acceptable definitions of confusion and bacteriuria, reporting an association with the relative risk being 1.4 (95% CI 1.0-1.7, p = 0.034).
Current evidence appears insufficient to accurately determine if UTI and confusion are associated, with estimates varying widely. This was often attributable to poor case definitions for UTI or confusion, or inadequate control of confounding factors. Future well-designed studies, using validated criteria for UTI and confusion are required to examine the relationship between UTI and acute confusion in the elderly. The optimal solution to clarify this clinical issue would be a randomized controlled trial comparing the effect of antibiotics versus placebo in patients with new onset or worsening confusion and presence of bacteriuria while lacking specific urinary tract symptoms.
Background
The emergency to elective surgery ratio is a proposed indicator for global access to surgical care. There is a well-established link between low socioeconomic status and increased ...morbidity and mortality. This study examined the emergency to elective surgery ratios for low socioeconomic patients utilising both self-reported unemployment and the neighbourhood Index of Economic Resources (IER).
Methods
A retrospective study was conducted at a regional tertiary care centre in Australia, including data over a ten-year period (2008–2018). Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, rurality, and if surgeries were due to trauma or injuries, was performed.
Results
84,014 patients underwent a surgical procedure in the period examined; 29.0% underwent emergency surgery, 5.31% were unemployed, and 26.6% lived in neighbourhoods with the lowest IER. Following multivariable testing, the rate of emergency surgery was higher for unemployed patients (OR 1.42 1.32–1.52,
p
< 0.001), and for those from the lowest IER (OR 1.13 1.08–1.19,
p
< 0.001). For unemployed patients, this disparity increased during the study period (OR 1.32 2008–2012, OR 1.48 2013–2018). When stratified by specialty, most (7/11) had significant disparities for unemployed patients: Cardiac/Cardiothoracic, Otolaryngology, Maxillofacial/Dental, Obstetrics/Gynaecology, Orthopaedics, Plastics, and Vascular surgery.
Conclusions
Unemployed Australians and those residing in the most disadvantaged IER neighbourhoods had higher emergency to elective surgery rates. The disparity in emergency to elective surgery rates for unemployed patients was found in most surgical specialties and increased over the period examined. This suggests a widespread and potentially increasing disparity in access to surgical care for patients of socioeconomic disadvantage, specifically for those who are unemployed.
Background
Diabetes and peripheral arterial disease (PAD) often synergistically lead to foot ulceration, infection, and gangrene, which may require lower limb amputation. Worldwide there are ...disparities in the rates of advanced presentation of PAD for vulnerable populations. This study examined rates of advanced presentations of PAD for unemployed patients, those residing in low Index of Economic Resources (IER) areas, and those in rural areas of Australia.
Methods
A retrospective study was conducted at a regional tertiary care centre (2008–2018). To capture advanced presentations of PAD, the proportion of operative patients presenting with complications (gangrene/ulcers), the proportion of surgeries that are amputations, and the rate of emergency to elective surgeries were examined. Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, and sociodemographic variables was performed.
Results
In the period examined, 1115 patients underwent a surgical procedure for PAD. Forty-nine per cent of patients had diabetes. Following multivariable testing, the rates of those requiring amputations were higher for unemployed (OR 1.99(1.05–3.79),
p
= 0.036) and rural patients (OR 1.83(1.21–2.76),
p
= 0.004). The rate of presentation with complications was higher for unemployed (OR 7.2(2.13–24.3),
p
= 0.001), disadvantaged IER (OR 1.91(1.2–3.04),
p
= 0.007), and rural patients (OR 1.73(1.13–2.65),
p
= 0.012). The rate of emergency to elective surgery was higher for unemployed (OR 2.32(1.18–4.54),
p
= 0.015) and rural patients (OR 1.92(1.29–2.86),
p
= 0.001).
Conclusions
This study found disparities in metrics capturing delayed presentations of PAD: higher rates of presentations with complications, higher amputation rates, and increased rates of emergency to elective surgery, for patients of low socioeconomic status and those residing in rural areas. This suggests barriers to appropriate, effective, and timely care exists for these patients.
Objective: The pathogenicity of beta-hemolytic Streptococcus group C (GCS) in patients attending for an uncomplicated acute sore throat is unknown and it was the objective to clarify this.
Design: ...Systematic literature review with meta-analysis. Setting Medline and Scopus were searched from inception to February 2019, with searches of reference lists, Subjects case-control studies stating prevalence of GCS in patients as well as healthy controls presented for children and adults separately. Studies including patients already treated with antibiotics and studies focused on patients with HIV, malignancy or immunosuppression were not included. Main outcome measures Pooled prevalence of GCS was compared between patients and controls using chi-square and was further explored by calculating the positive etiologic predictive value (P-EPV) showing the post-test probability of a link between a sore throat and the bacterial finding. P-EPV for GCS was compared with that for group A Streptococci (GAS) using figures from the same publications and patients.
Results: Eleven studies were included. The prevalence of GCS among patients versus controls was similar in children (3.15 versus 2.87%, p = .44) but for adults higher in patients (11%) than in controls (5.6%) (p < .0001). The P-EPV for finding GCS in children with a sore throat was 9.3% (0.0-41%). The corresponding P-EPV for GCS in adults with a sore throat was 53% (36-67%) while the corresponding P-EPV for GAS in adults was 94% (90-96%).
Conclusions: GCS do not seem associated with the uncomplicated acute sore throat in children but there is support for an association in adults being weaker than for GAS. A possible consequence is to ignore GCS in otherwise healthy patients at their first visit for an uncomplicated sore throat. This would enable a stronger focus on the use of modern point of care tests (POCTs) to detect GAS.
Key points
There is no current consensus on the pathogenicity of group C beta-hemolytic Streptococcus (GCS) in patients attending for an uncomplicated acute sore throat.
This systematic literature review concludes it is unlikely that GCS is involved in the uncomplicated sore throat in otherwise healthy children.
This meta-analysis found a moderate link between GCS and the uncomplicated sore throat in adults.
The link in adults between GCS and the sore throat is much weaker than the corresponding link for group A beta-hemolytic Streptococcus.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Background
Breast cancer is the most commonly diagnosed cancer in Aboriginal and/or Torres Strait Islander women. When compared to other Australians, Aboriginal and/or Torres Strait Islander women ...have a higher breast cancer mortality rate. This systematic literature review examined disparities in breast cancer surgical access and outcomes for Aboriginal and/or Torres Strait Islander women.
Methods
This systematic literature review, following the PRISMA guidelines, compared measures of breast cancer surgical care for Aboriginal and/or Torres Strait Islander people and other Australians.
Results
The 13 included studies were largely state-based retrospective reviews of data collected prior to the year 2012. Eight studies reported more advanced breast cancer presentation among Aboriginal and/or Torres Strait Islander women. Despite the increased distance to a multidisciplinary, specialist team, there were no disparities in seeing a surgeon, or in the time from diagnosis to surgical treatment. Two studies reported disparities in the receipt of surgery and two reported no variations. Three studies reported disparities in the receipt of mastectomy versus breast conserving surgery, whilst four studies reported no variations. No studies examined postoperative surgical outcomes.
Conclusions
Aboriginal and/or Torres Strait Islander women present with more advanced breast cancer. There may be disparities in the receipt of surgery and the type of surgery. However, the metrics tested were not related to optimal care guidelines, and the databases utilised contain limited data on individual factors contributing to surgical care decisions. It is therefore difficult to determine whether the reported differences in the receipt of surgical care reflect disparate or appropriate care.
•Streptococcus pyogenes is found in throat swabs from patients and healthy carriers.•Carriers of S. pyogenes ill from a virus makes the usefulness of swabs unclear.•This study clarifies post-test ...probabilities of a throat swab.•Finding SP has a 92%/63% probability that SP is the aetiology in adults/children.•Swabbing children with 3-4 Centor criteria alone boosts the probability to 83%.
The objective was to estimate the probability that finding a Streptococcus pyogenes (Group A Streptococcus) in a throat swab in a patient with a sore throat reflects the aetiology. We also investigated to what extent this is influenced by age, carrier rates of S. pyogenes and climate zone.
We conducted a comprehensive search of Medline and Scopus up until October 2023 for case-control studies reporting the prevalence of S. pyogenes in patients with a sore throat and healthy controls. We only included studies with separate data for children and adults. We used the positive and negative etiologic predictive values (P-EPV and N-EPV) to estimate the probability of a link between a sore throat and a finding of S. pyogenes.
We included 15 studies in our meta-analysis. The overall P-EPV for children and adults were 63% (49-74%) and 92% (87-95%), respectively. The P-EPV rose to 83% (64-93%) for children and 94% (90-97%) for adults when only patients with 3-4 Centor criteria were included. The overall N-EPV was 97% (96-98%) for children and 96% (95-97%) for adults.
Detecting S. pyogenes in adult patients with an uncomplicated acute sore throat is useful to rule in S. pyogenes as the likely aetiologic agent. The P-EPV significantly increased for children when those with 3-4 Centor criteria were selected. A negative throat swab is always useful for both children and adults to rule out S. pyogenes as the cause of sore throat.
Acquired Megacolon (AMC) is a condition involving persistent dilatation and lengthening of the colon in the absence of organic disease. Diagnosis depends on subjective radiological, endoscopic or ...surgical findings in the context of a suggestive clinical presentation. This review sets out to investigate diagnostic criteria of AMC.
The literature was searched using the databases - PubMed, Medline via OvidSP, ClinicalKey, Informit and the Cochrane Library. Primary studies, published in English, with more than three patients were critically appraised based on study design, methodology and sample size. Exclusion criteria were studies with the following features: post-operative; megarectum-predominant; paediatric; organic megacolon; non-human; and failure to exclude organic causes.
A review of 23 articles found constipation, abdominal pain, distension and gas distress were predominant symptoms. All ages and both sexes were affected, however, symptoms varied with age. Changes in anorectal manometry, histology and colonic transit are consistently reported. Studies involved varying patient numbers, demographics and data acquisition methods.
Outcome data investigating the diagnosis of AMC must be interpreted in light of the limitations of the low-level evidence studies published to date. Proposed diagnostic criteria include: (1) the exclusion of organic disease; (2) a radiological sigmoid diameter of ~ 10 cm; (3) and constipation, distension, abdominal pain and/or gas distress. A proportion of patients with AMC may be currently misdiagnosed as having functional gastrointestinal disorders. Our conclusions are inevitably tentative, but will hopefully stimulate further research on this enigmatic condition.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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