Laparoscopic appendectomy is amongst the most common general surgical procedures performed in the developed world. Arguably, the most critical part of this procedure is effective closure of the ...appendix stump to prevent catastrophic intra-abdominal complications from a faecal leak into the abdominal cavity. A variety of methods to close the appendix stump are used worldwide; these can be broadly divided into traditional ligatures (such as intracorporeal or extracorporeal ligatures or Roeder loops) and mechanical devices (such as stapling devices, clips, or electrothermal devices). However, the optimal method remains unclear.
To compare all surgical techniques now used for appendix stump closure during laparoscopic appendectomy.
In June 2017, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6) in the Cochrane Library, MEDLINE Ovid (1946 to 14 June 2017), Embase Ovid (1974 to 14 June 2017), Science Citation Index - Expanded (14 June 2017), China Biological Medicine Database (CBM), the World Health Organization International Trials Registry Platform search portal, ClinicalTrials.gov, Current Controlled Trials, the Chinese Clinical Trials Register, and the EU Clinical Trials Register (all in June 2017). We searched the reference lists of relevant publications as well as meeting abstracts and Conference Proceedings Citation Index to look for additional relevant clinical trials.
We included all randomised controlled trials (RCTs) that compared mechanical appendix stump closure (stapler, clips, or electrothermal devices) versus ligation (Endoloop, Roeder loop, or intracorporeal knot techniques) for uncomplicated appendicitis.
Two review authors identified trials for inclusion, collected data, and assessed risk of bias independently. We performed the meta-analysis using Review Manager 5. We calculated the odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).
We included eight randomised studies encompassing 850 participants. Five studies compared titanium clips versus ligature, two studies compared an endoscopic stapler device versus ligature, and one study compared an endoscopic stapler device, titanium clips, and ligature. In our analyses of primary outcomes, we found no differences in total complications (OR 0.97, 95% CI 0.27 to 3.50, 8 RCTs, very low-quality evidence), intraoperative complications (OR 0.93, 95% CI 0.34 to 2.55, 8 RCTs, very low-quality evidence), or postoperative complications (OR 0.80, 95% CI 0.21 to 3.13, 8 RCTs, very low-quality evidence) between ligature and all types of mechanical devices. However, our analyses of secondary outcomes revealed that use of mechanical devices saved approximately nine minutes of total operating time when compared with use of a ligature (mean difference (MD) -9.04 minutes, 95% CI -12.97 to -5.11 minutes, 8 RCTs, very low-quality evidence). However, this finding did not translate into a clinically or statistically significant reduction in inpatient hospital stay (MD 0.02 days, 95% CI -0.12 to 0.17 days, 8 RCTs, very low-quality evidence). Available information was insufficient for reliable comparison of total hospital costs and postoperative pain/quality of life between the two approaches. Overall, evidence across all analyses was of very low quality, with substantial potential for confounding factors. Given the limitations of all studies in terms of bias and the low quality of available evidence, a clear conclusion regarding superiority of any one particular type of mechanical device over another is not possible.
Evidence is insufficient at present to advocate omission of conventional ligature-based appendix stump closure in favour of any single type of mechanical device over another in uncomplicated appendicitis.
Background
The impact of hemoglobin levels and anemia on stroke mortality remains controversial. We aimed to systematically assess this association and quantify the evidence.
Methods and Results
We ...analyzed data from a cohort of 8013 stroke patients (mean±SD, 77.81±11.83 years) consecutively admitted over 11 years (January 2003 to May 2015) using a UK Regional Stroke Register. The impact of hemoglobin levels and anemia on mortality was assessed by sex‐specific values at different time points (7 and 14 days; 1, 3, and 6 months; 1 year) using multiple regression models controlling for confounders. Anemia was present in 24.5% of the cohort on admission and was associated with increased odds of mortality at most of the time points examined up to 1 year following stroke. The association was less consistent for men with hemorrhagic stroke. Elevated hemoglobin was also associated with increased mortality, mainly within the first month. We then conducted a systematic review using the Embase and Medline databases. Twenty studies met the inclusion criteria. When combined with the cohort from the current study, the pooled population had 29 943 patients with stroke. The evidence base was quantified in a meta‐analysis. Anemia on admission was found to be associated with an increased risk of mortality in both ischemic stroke (8 studies; odds ratio 1.97 95% CI 1.57–2.47) and hemorrhagic stroke (4 studies; odds ratio 1.46 95% CI 1.23–1.74).
Conclusions
Strong evidence suggests that patients with anemia have increased mortality with stroke. Targeted interventions in this patient population may improve outcomes and require further evaluation.
Objectives
To determine the risk factor profiles associated with post‐acute ischaemic stroke (AIS) myocardial infarction (MI) over long‐term follow‐up.
Methods
This observational study includes ...prospectively identified AIS patients (n = 9840) admitted to a UK regional centre between January 2003 and December 2016 (median follow‐up: 4.72 years). Predictors of post‐stroke MI during follow‐up were examined using logistic and Cox regression models for in‐hospital and post‐discharge events, respectively. MI incidence was determined using a competing risk non‐parametric estimator. The influence of post‐stroke MI on mortality was examined using Cox regressions.
Results
Mean age (SD) of study participants was 77.3 (12.2) years (48% males). Factors associated with in‐hospital MI (OR 95% CI) were increasing blood glucose (1.80 1.17‐2.77 per 10 mmol/L), total leucocyte count (1.25 1.01‐1.54 per 10 × 109/L) and CRP (1.05 1.02‐1.08 per 10 mg/L increase). Age (HR 95% CI = 1.03 1.01‐1.06), coronary heart disease (1.59 1.01‐2.50), chronic kidney disease (2.58 1.44‐4.63) and cancers (1.76 1.08‐2.89) were associated with incident MI between discharge and one‐year follow‐up. Age (1.02 1.00‐1.03), diabetes (1.96 1.38‐2.65), congestive heart failure (2.07 1.44‐2.99), coronary heart disease (1.81 1.31‐2.50), hypertension 1.86 (1.24‐2.79) and peripheral vascular disease (2.25 1.40‐3.63) were associated with incident MI between 1 and 5 years after discharge. Diabetes (2.01 1.09‐3.72), hypertension (3.69 1.44‐9.45) and peripheral vascular disease (2.46 1.02‐5.98) were associated with incident MI between 5 and 10 years after discharge. Cumulative MI incidence over 10 years was 5.4%. MI during all follow‐up periods (discharge‐1, 1‐5, 5‐10 years) was associated with increased risk of death (respective HR 95% CI = 3.26 2.51‐4.15, 1.96 1.58‐2.42 and 1.92 1.26‐2.93).
Conclusions
In conclusion, prognosis is poor in post‐stroke MI. We highlight a range of potential areas to focus preventative efforts.
Background
Idiopathic gynecomastia is a benign breast disorder characterized by overdevelopment of male breast tissue. It can cause discomfort and concern, resulting in patients seeking diagnosis and ...treatment. We aimed to evaluate the efficacy of tamoxifen therapy in resolving this condition.
Methods
We undertook a prospective cohort study of all male patients who presented to our breast clinic, were diagnosed with primary gynecomastia, and were treated with a trial of tamoxifen 10 mg daily therapy, over a 10‐year period from October 2004 to October 2015. All patients underwent routine investigations to exclude secondary causes of gynecomastia. The end point of interest was the complete resolution of gynecomastia.
Results
We included 81 patients in this study. The mean age was 42.8 years (SD 19.5 years). Of these, 28.4% were bilateral gynecomastia and 71.6% were unilateral. The majority (87.7%) of cases presented with accompanying mastalgia. Following treatment, 90.1% (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. Only eight patients did not have a complete resolution following tamoxifen therapy, of which two underwent subsequent surgical resection of their symptomatic gynecomastia.
Conclusion
Our study is the largest to date examining the role of tamoxifen in idiopathic gynecomastia, and our results show approximately nine in every 10 men treated with tamoxifen therapy had successful resolution of their symptoms. We support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits.
Background
There is lack of data on the association between infective endocarditis (IE) and outcomes of mortality and complications in stroke. We aimed to compare characteristics and outcomes of ...stroke patients with and without IE.
Methods
We retrospectively examined the above association using data obtained from an insurance database which covers ~75% of the Thai population. All hospitalised strokes between 8 January 2003 and 31 December 2013 were included in the current study. Characteristics and outcomes were compared between stroke patients with or without IE, and then between two main stroke types. Multiple logistic regression models including propensity score‐matched analyses were constructed to assess study outcomes controlling for age, sex, stroke type and comorbidities.
Results
A total of 590 115 stroke patients (mean (SD) age = 64.2 ± 13.7 years; ischaemic = 51.7%; haemorrhagic = 32.6%; undetermined = 15.7%) were included, of whom 2129 (0.36%) had stroke associated with IE. After adjustment, we found that IE was significantly associated with the following complications: arrhythmias (adjusted odds ratio (95% CI) 6.94 (6.29‐7.66)), sepsis (1.24 (1.01‐1.52)), pneumonia (1.34 (1.17‐1.53)), respiratory failure (1.43 (1.24‐1.66)) and in‐hospital mortality (1.29 (1.13‐1.47)) (P for all <.001). Patients with haemorrhagic stroke with IE had poorer outcomes for in‐hospital mortality and respiratory failure compared with their counterparts with ischaemic stroke. Propensity score‐matched analysis showed similar results.
Conclusions
Our results suggest that stroke patients with IE differ from that of the general stroke population and these patients have worse outcomes. Future studies are needed to determine the best treatment strategies for stroke patients with IE.
Abstract Background Individually, diabetes mellitus and dementia are associated with poorer outcomes after stroke. However, the combined impact of these pre-existing factors on acute ischemic stroke ...(AIS) outcomes has not been examined. Methods All consecutive patients with AIS admitted to Norfolk and Norwich University Hospitals between 2003 and 2016 (catchment population ~ 900,000) were divided into four groups: those with neither diabetes nor dementia (reference), with diabetes without dementia, with dementia without diabetes, and with both co-morbidities. In-hospital mortality, length of hospital stay (LoS), and disability outcomes were analysed using logistic regressions. Post-discharge mortality and recurrence were assessed using Cox regressions. Additionally, interaction terms were added to the models for the short-term outcomes and long-term mortality to test for synergistic effects of diabetes and dementia. Models were adjusted for age, sex, Oxfordshire Community Stroke Project classification, comorbidities, hematological and biochemical measures, and antithrombotic medications. Results The cohort was 10,812 patients with 52% females and a median age of 80. The median follow-up was 3.8 years for stroke recurrence and 5.5 years for mortality. No significant differences between the four groups existed for in-hospital mortality and post-stroke disability. Patients with dementia had significantly longer LoS (OR 2.25 95% CI: 1.34–3.77 and 1.31 1.02–1.68 with and without diabetes, respectively). Patients with both comorbidities had the highest risk of stroke recurrence (HR 2.06 1.12–3.77), followed by those with only dementia (1.59 1.15–2.20) and only diabetes (1.25 1.06–1.49). Similarly, the patient group with both diabetes and dementia had the highest long-term mortality risk (1.76 1.33–2.37). The hazard ratios for patients with only dementia and only diabetes were 1.71 1.46–2.01 and 1.19 1.08–1.32, respectively. No significant interactions were seen between diabetes and dementia with regards to their effects on the outcomes. Conclusion Individual and cumulative impacts of the two conditions on long-term mortality and stroke recurrence were notable. However, no synergistic impact of the two comorbidities were seen on the stroke outcomes tested in our study. Therefore, tailoring the management of stroke patients based on additional requirements associated with each pre-existing condition will be more impactful towards improving outcomes.
Hypoalbuminemia associates with poor acute ischemic stroke (AIS) outcomes. We hypothesised a non-linear relationship and aimed to systematically assess this association using prospective stroke data ...from the Norfolk and Norwich Stroke and TIA Register. Consecutive AIS patients aged ≥40 years admitted December 2003-December 2016 were included. Outcomes: In-hospital mortality, poor discharge, functional outcome (modified Rankin score 3-6), prolonged length of stay (PLoS) > 4 days, and long-term mortality. Restricted cubic spline regressions investigated the albumin-outcome relationship. We updated a systematic review (PubMed, Scopus, and Embase databases, January 2020-June 2023) and undertook a meta-analysis. A total of 9979 patients were included; mean age (standard deviation) = 78.3 (11.2) years; mean serum albumin 36.69 g/L (5.38). Compared to the cohort median, albumin < 37 g/L associated with up to two-fold higher long-term mortality (HR
; 95% CI = 2.01; 1.61-2.49) and in-hospital mortality (RR
; 95% CI = 1.48; 1.21-1.80). Albumin > 44 g/L associated with up to 12% higher long-term mortality (HR
1.12; 1.06-1.19). Nine studies met our inclusion criteria totalling 23,597 patients. Low albumin associated with increased risk of long-term mortality (two studies; relative risk 1.57 (95% CI 1.11-2.22;
= 81.28)), as did low-normal albumin (RR 1.10 (95% CI 1.01-1.20;
= 0.00)). Strong evidence indicates increased long-term mortality in AIS patients with low or low-normal albumin on admission.
Social Determinants of Health (SDoH) are an increasingly important part of the broader research and public health efforts in understanding individuals' physical and mental well-being. Despite this, ...non-clinical factors affecting health are poorly recorded in electronic health databases and techniques to study how SDoH might relate to population outcomes are lacking. This paper proposes an approach to systematically identify and quantify associations between SDoH and health-related outcomes in a specific cohort of people by (1) leveraging published evidence from literature to build a knowledge graph of health and social factor associations and (2) analysing a large dataset of claims and medical records where those associations may be found. This work demonstrates how the proposed approach could be used to generate hypotheses and inform further research on SDoH in a data-driven manner.
Whilst stroke-associated pneumonia (SAP) is common and associated with poor outcomes, less is known about the determinants of these adverse clinical outcomes in SAP. To identify the factors that ...influence mortality and morbidity in SAP. Data for patients with SAP (
n
= 854) were extracted from a regional Hospital Stroke Register in Norfolk, UK (2003–2015). SAP was defined as pneumonia occurring within 7 days of admission by the treating clinicians. Mutlivariable regression models were constructed to assess factors influencing survival and the level of disability at discharge using modified Rankin Scale mRS. Mean (SD) age was 83.0 (8.7) years and ischaemic stroke occurred in 727 (85.0%). Mortality was 19.0% at 30 days and 44.0% at 6 months. Stroke severity assessment using National Institutes of Health Stroke Scale was not recorded in the data set although Oxfordshire Community Stroke Project was Classification. In the multivariable analyses, 30-day mortality was independently associated with age (OR 1.04, 95% CI 1.01–1.07,
p
= 0.01), haemorrhagic stroke (2.27, 1.07–4.78,
p
= 0.03) and pre-stroke disability (mRS 4–5 v 0–1: 6.45, 3.12–13.35,
p
< 0.001). 6-month mortality was independently associated with age (< 0.001), pre-stroke disability (
p
< 0.001) and certain comorbidities, including the following: dementia (6.53, 4.73–9.03,
p
< 0.001), lung cancer (2.07, 1.14–3.77,
p
= 0.017) and previous transient ischemic attack (1.94, 1.12–3.36,
p
= 0.019). Disability defined by mRS at discharge was independently associated with age (1.10, 1.05–1.16,
p
< 0.001) and plasma C-reactive protein (1.02, 1.01–1.03,
p
= 0.012). We have identified non-modifiable determinants of poor prognosis in patients with SAP. Further studies are required to identify modifiable factors which may guide areas for intervention to improve the prognosis in SAP in these patients.
PDF
