Background
Antibiotics are advised in most guidelines on acute diverticulitis, despite a lack of evidence to support their routine use. This trial compared the effectiveness of a strategy with or ...without antibiotics for a first episode of uncomplicated acute diverticulitis.
Methods
Patients with CT‐proven, primary, left‐sided, uncomplicated, acute diverticulitis were included at 22 clinical sites in the Netherlands, and assigned randomly to an observational or antibiotic treatment strategy. The primary endpoint was time to recovery during 6 months of follow‐up. Main secondary endpoints were readmission rate, complicated, ongoing and recurrent diverticulitis, sigmoid resection and mortality. Intention‐to‐treat and per‐protocol analyses were done.
Results
A total of 528 patients were included. Median time to recovery was 14 (i.q.r. 6–35) days for the observational and 12 (7–30) days for the antibiotic treatment strategy, with a hazard ratio for recovery of 0·91 (lower limit of 1‐sided 95 per cent c.i. 0·78; P = 0·151). No significant differences between the observation and antibiotic treatment groups were found for secondary endpoints: complicated diverticulitis (3·8 versus 2·6 per cent respectively; P = 0·377), ongoing diverticulitis (7·3 versus 4·1 per cent; P = 0·183), recurrent diverticulitis (3·4 versus 3·0 per cent; P = 0·494), sigmoid resection (3·8 versus 2·3 per cent; P = 0·323), readmission (17·6 versus 12·0 per cent; P = 0·148), adverse events (48·5 versus 54·5 per cent; P = 0·221) and mortality (1·1 versus 0·4 per cent; P = 0·432). Hospital stay was significantly shorter in the observation group (2 versus 3 days; P = 0·006). Per‐protocol analyses were concordant with the intention‐to‐treat analyses.
Conclusion
Observational treatment without antibiotics did not prolong recovery and can be considered appropriate in patients with uncomplicated diverticulitis. Registration number: NCT01111253 (http://www.clinicaltrials.gov).
Antibiotics not needed
Previous studies have suggested that sigmoidectomy with primary anastomosis is superior to Hartmann's procedure. The likelihood of stoma reversal after primary anastomosis has been reported to be ...higher and reversal seems to be associated with lower morbidity and mortality. Although promising, results from these previous studies remain uncertain because of potential selection bias. Therefore, this study aimed to assess outcomes after Hartmann's procedure versus sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy, for perforated diverticulitis with purulent or faecal peritonitis (Hinchey III or IV disease) in a randomised trial.
A multicentre, randomised, open-label, superiority trial was done in eight academic hospitals and 34 teaching hospitals in Belgium, Italy, and the Netherlands. Patients aged between 18 and 85 years who presented with clinical signs of general peritonitis and suspected perforated diverticulitis were eligible for inclusion if plain abdominal radiography or CT scan showed diffuse free air or fluid. Patients with Hinchey I or II diverticulitis were not eligible for inclusion. Patients were allocated (1:1) to Hartmann's procedure or sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy. Patients were enrolled by the surgeon or surgical resident involved, and secure online randomisation software was used in the operating room or by the trial coordinator on the phone. Random and concealed block sizes of two, four, or six were used, and randomisation was stratified by age (<60 and ≥60 years). The primary endpoint was 12-month stoma-free survival. Patients were analysed according to a modified intention-to-treat principle. The trial is registered with the Netherlands Trial Register, number NTR2037, and ClinicalTrials.gov, number NCT01317485.
Between July 1, 2010, and Feb 22, 2013, and June 9, 2013, and trial termination on June 3, 2016, 133 patients (93 with Hinchey III disease and 40 with Hinchey IV disease) were randomly assigned to Hartmann's procedure (68 patients) or primary anastomosis (65 patients). Two patients in the Hartmann's group were excluded, as was one in the primary anastomosis group; the modified intention-to-treat population therefore consisted of 66 patients in the Hartmann's procedure group (46 with Hinchey III disease, 20 with Hinchey IV disease) and 64 in the primary anastomosis group (46 with Hinchey III disease, 18 with Hinchey IV disease). In 17 (27%) of 64 patients assigned to primary anastomosis, no stoma was constructed. 12-month stoma-free survival was significantly better for patients undergoing primary anastomosis compared with Hartmann's procedure (94·6% 95% CI 88·7-100 vs 71·7% 95% CI 60·1-83·3, hazard ratio 2·79 95% CI 1·86-4·18; log-rank p<0·0001). There were no significant differences in short-term morbidity and mortality after the index procedure for Hartmann's procedure compared with primary anastomosis (morbidity: 29 44% of 66 patients vs 25 39% of 64, p=0·60; mortality: two 3% vs four 6%, p=0·44).
In haemodynamically stable, immunocompetent patients younger than 85 years, primary anastomosis is preferable to Hartmann's procedure as a treatment for perforated diverticulitis (Hinchey III or Hinchey IV disease).
Netherlands Organisation for Health Research and Development.
Background
The prevalence of symptoms of allergic diseases has increased significantly during the last decades. However, studies into time trends of atopic sensitization among children are limited ...and have focused on aeroallergen sensitization. We aimed to investigate time trends in the prevalence and degree of atopic sensitization to inhalant and food allergens among children (0‐17 years) with symptoms of allergic disease.
Methods
Sensitization data of all children tested in our clinical laboratory during 1994‐2014 were analyzed. Sensitization was detected using the ImmunoCAP system and defined as a specific IgE level of ≥0.35 kU/L. Trends in sensitization rates to 5 food and 5 aeroallergens for different age categories were investigated with logistic regression, adjusted for age and sex.
Results
Sensitization data of 18 199 children were analyzed. Between 1994 and 2014, a steady and statistically significant increase in overall sensitization rate was found (from 40.5% in 1994 to 48.9% in 2014, adjusted odds ratio aOR 1.01 per year, 95% confidence interval CI 1.00 to 1.01, P = .003). This increase in sensitization rate was mainly explained by increasing aeroallergen sensitization among 4‐ to 11‐year‐old children (aOR 1.02, 95% CI 1.01 to 1.02, P < .001). We found no increase in sensitization rates to food and aeroallergens in other age categories. The degree of sensitization did not change significantly during the study period (all tests P > .15).
Conclusion
We observed a statistically significant increase in sensitization rate between 1994 and 2014 among children with symptoms of allergic disease. This was mainly explained by increasing aeroallergen sensitization among 4‐ to 11‐year‐olds.
Themes and Texts in Luke-Acts Lietaert Peerbolte, Bert Jan; Vander Stichele, Caroline H. C. M; van Wieringen, L
2024, Letnik:
31
eBook
This volume offers readings of Luke-Acts varying from an economic perspective to cultic influences and the reception of Luke-Acts in Cyprian's treatise on prayer. It contains insightful studies from ...leading scholars and forms a valuable addition to any academic library.
To investigate the reliability of a weighted version of the Functional Comorbidity Index (w-FCI) compared with that of the original Functional Comorbidity Index (FCI) and to test its usability.
...Sixteen physicians collected data from 102 residents who lived in 16 different nursing homes in the Netherlands. A multicenter, prospective observational study was carried out in combination with a qualitative part using the three-step test interview, in which participants completed the w-FCI while thinking aloud and being observed, and were then interviewed afterward. To analyze inter-rater reliability, a subset of 41 residents participated. The qualitative part of the study was completed by eleven elderly care physicians and one advanced nurse practitioner.
The w-FCI was composed of the original FCI supplemented with a severity rating per comorbidity, ranging from 0 (disease absent) to 3 (severe impact on daily function). The w-FCI was filled out at baseline by 16 physicians and again 2 months later to establish intra-rater reliability (intraclass correlations; ICCs). For inter-rater reliability, four pairs of raters completed the w-FCI independently from each other.
The ICCs were 0.90 (FCI) and 0.94 (w-FCI) for intra-rater reliability, and 0.61 (FCI) and 0.55 (w-FCI) for inter-rater reliability. Regarding usability of the w-FCI, five meaningful themes emerged from the qualitative data: 1) sources of information; 2) deciding on the presence or absence of disease; 3) severity of comorbidities; 4) usefulness; and 5) content.
The intra-rater reliability of the FCI and the w-FCI was excellent, whereas the inter-rater reliability was moderate for both indices. Based on the present results, a modified w-FCI is proposed that is acceptable and feasible for use in older patients and requires further investigation to study its (predictive) validity.
The 'MHC-I (major histocompatibility complex class I)-opathy' concept describes a family of inflammatory conditions with overlapping clinical manifestations and a strong genetic link to the MHC-I ...antigen presentation pathway. Classical MHC-I-opathies such as spondyloarthritis, Behçet's disease, psoriasis and birdshot uveitis are widely recognised for their strong association with certain MHC-I alleles and gene variants of the antigen processing aminopeptidases ERAP1 and ERAP2 that implicates altered MHC-I peptide presentation to CD8+T cells in the pathogenesis. Progress in understanding the cause and treatment of these disorders is hampered by patient phenotypic heterogeneity and lack of systematic investigation of the MHC-I pathway.Here, we discuss new insights into the biology of MHC-I-opathies that strongly advocate for disease-overarching and integrated molecular and clinical investigation to decipher underlying disease mechanisms. Because this requires transformative multidisciplinary collaboration, we introduce the EULAR study group on MHC-I-opathies to unite clinical expertise in rheumatology, dermatology and ophthalmology, with fundamental and translational researchers from multiple disciplines such as immunology, genomics and proteomics, alongside patient partners. We prioritise standardisation of disease phenotypes and scientific nomenclature and propose interdisciplinary genetic and translational studies to exploit emerging therapeutic strategies to understand MHC-I-mediated disease mechanisms. These collaborative efforts are required to address outstanding questions in the etiopathogenesis of MHC-I-opathies towards improving patient treatment and prognostication.
BOOKREVIEWS Beentjes, P. C.; Koet, B. J.; Ottenheijm, Eric ...
Bijdragen tijdschrift voor filosofie en theologie,
01/2009, Letnik:
70, Številka:
3
Journal Article
PDF
