Background
Since the advent of laparoscopic cholecystectomy (LC) there has been continued debate regarding the management of acute cholecystitis with either early or delayed LC. Nearly all studies ...have demonstrated that early LC has a significantly shorter total length of hospital stay compared with delayed LC. Although previous randomized controlled trials and meta-analysis have shown clinical outcomes to favour early surgery, clinical practice continues to vary significantly worldwide. In addition, there is much confusion in the optimal timing for early LC with definitions of early varying from 72 h to 7 days. There have been numerous case–control studies investigating the timing of LC in acute cholecystitis. The aim of this paper is to pool the results from all case–control studies to investigate outcomes including mortality rates, complication rates, length of hospital stay and conversion rates to open procedures.
Methods
A search of electronic databases was performed for case–control studies published between 1985–February 2015.
Results
Results from 77 case–control studies showed statistically significant reductions in mortality, complications, bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital stay and blood loss associated with early LC. Although LC within the 72-h window is optimal, patients operated after this window still benefit from early surgery compared to delayed surgery. The duration of symptoms in acute cholecystitis should not influence the surgeons’ willingness to operate acutely.
Conclusions
Early LC is clearly superior to delayed LC in acute cholecystitis. The most recent evidence-based practice strongly suggests that early LC should be standard of care in the management of acute cholecystitis.
Virus-like particles resemble infectious virus particles in size, shape, and molecular composition; however, they fail to productively infect host cells. Historically, the presence of virus-like ...particles has been inferred from total particle counts by microscopy, and infectious particle counts or plaque-forming-units (PFUs) by plaque assay; the resulting ratio of particles-to-PFUs is often greater than one, easily 10 or 100, indicating that most particles are non-infectious. Despite their inability to hijack cells for their reproduction, virus-like particles and the defective genomes they carry can exhibit a broad range of behaviors: interference with normal virus growth during co-infections, cell killing, and activation or inhibition of innate immune signaling. In addition, some virus-like particles become productive as their multiplicities of infection increase, a sign of cooperation between particles. Here, we review established and emerging methods to count virus-like particles and characterize their biological functions. We take a critical look at evidence for defective interfering virus genomes in natural and clinical isolates, and we review their potential as antiviral therapeutics. In short, we highlight an urgent need to better understand how virus-like genomes and particles interact with intact functional viruses during co-infection of their hosts, and their impacts on the transmission, severity, and persistence of virus-associated diseases.
Introduction
The timing of laparoscopic cholecystectomy for acute cholecystitis remains an issue for debate amongst general surgeons. The aim of this study was to compare clinical outcomes between ...early and delayed cholecystectomy for acute cholecystitis. The primary outcome measures included mortality rates, complication rates, length of hospital stay and conversion rates to open procedures.
Materials and Methods
A search of electronic databases was performed for randomised controlled trials. Fifteen studies were included.
Results
Early surgery has a decreased risk of wound infections (RR 0.57, 95 % CI 0.35–0.93,
p
= 0.01) compared with delayed surgery but no difference in mortality, bile duct injuries, bile duct leaks and the risk of conversion to open surgery. Of patients in the delayed group, 9.7 % failed initial non-operative management and underwent emergency LC. Early surgery had a significantly reduced total hospital stay and mean hospital costs compared with delayed surgery.
Conclusion
Early laparoscopic cholecystectomy in acute cholecystitis demonstrated decreased incidence of wound infections, a shorter total length of stay and decreased costs with no difference in the rates of mortality, bile duct injuries, bile leaks and conversions. These results support that early laparoscopic cholecystectomy is the best care and should be considered a routine in patients presenting with acute cholecystitis.
Background
The operative management of symptomatic cholelithiasis during pregnancy is either laparoscopic cholecystectomy (LC) or open cholecystectomy (OC). The aim of this systematic review and ...meta-analysis is to compare the outcomes of the laparoscopic and open approach for cholecystectomy during pregnancy.
Method
A literature search was conducted using MEDLINE, PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL and Current Contents Connect using appropriate search terms. All comparative studies reporting maternal, fetal, and/or surgical complications were included.
Results
Eleven comparative studies, with a total of 10,632 patients, were included. The laparoscopic approach was performed at mean 18-week gestation and the open approach at mean 24-week gestation. LC was associated with decreased risks for fetal (OR 0.42; 95 % CI 0.28–0.63;
p
< 0.001), maternal (OR 0.42; 95 % CI 0.33–0.53;
p
< 0.001) and surgical (OR 0.45; 95 % CI 0.25–0.82,
p
= 0.01) complications. The average length of hospital stay (LOS) was: LC 3.2 days and OC 6.0 days (
p
= 0.02). The conversion rate from LC to OC was 3.8 %.
Conclusion
The results of this first meta-analysis suggest that LC is associated with fewer maternal and fetal complications than OC during pregnancy. However, 91 % of included patients were in the first or second trimester at the time of surgery. These findings do not account for gestational age during pregnancy, which may be a significant confounding factor. The results support intervention for symptomatic gallstones in the first and second trimester with a laparoscopic approach.
Acute lower respiratory tract infections (LRTIs) (e.g. pneumonia) are a major cause of morbidity and mortality and management focuses on early treatment. Chest radiographs (X-rays) are one of the ...commonly used strategies. Although radiological facilities are easily accessible in high-income countries, access can be limited in low-income countries. The efficacy of chest radiographs as a tool in the management of acute LRTIs has not been determined. Although chest radiographs are used for both diagnosis and management, our review focuses only on management.
To assess the effectiveness of chest radiographs in addition to clinical judgement, compared to clinical judgement alone, in the management of acute LRTIs in children and adults.
We searched CENTRAL 2013, Issue 1; MEDLINE (1948 to January week 4, 2013); EMBASE (1974 to February 2013); CINAHL (1985 to February 2013) and LILACS (1985 to February 2013). We also searched NHS EED, DARE, ClinicalTrials.gov and WHO ICTRP (up to February 2013).
Randomised controlled trials (RCTs) of chest radiographs versus no chest radiographs in acute LRTIs in children and adults.
Two review authors independently applied the inclusion criteria, extracted data and assessed risk of bias. A third review author compiled the findings and any discrepancies were discussed among all review authors. We used the standard methodological procedures expected by The Cochrane Collaboration.
Two RCTs involving 2024 patients (1502 adults and 522 children) were included in this review. Both RCTs excluded patients with suspected severe disease. It was not possible to pool the results due to incomplete data. Both included trials concluded that the use of chest radiographs did not result in a better clinical outcome (duration of illness and of symptoms) for patients with acute LRTIs. In the study involving children in South Africa, the median time to recovery was seven days (95% confidence interval (CI) six to eight days (radiograph group) and six to nine days (control group)), P value = 0.50, log-rank test) and the hazard ratio for recovery was 1.08 (95% CI 0.85 to 1.34). In the study with adult participants in the USA, the average duration of illness was 16.9 days versus 17.0 days (P value > 0.05) in the radiograph and no radiograph groups respectively. This result was not statistically significant and there were no significant differences in patient outcomes between the groups with or without chest radiograph.The study in adults also reports that chest radiographs did not affect the frequencies with which clinicians ordered return visits or antibiotics. However, there was a benefit of chest radiographs in a subgroup of the adult participants with an infiltrate on their radiograph, with a reduction in length of illness (16.2 days in the group allocated to chest radiographs and 22.6 in the non-chest radiograph group, P < 0.05), duration of cough (14.2 versus 21.3 days, P < 0.05) and duration of sputum production (8.5 versus 17.8 days, P < 0.05). The authors mention that this difference in outcome between the intervention and control group in this particular subgroup only was probably a result of "the higher proportion of patients treated with antibiotics when the radiograph was used in patient care".Hospitalisation rates were only reported in the study involving children and it was found that a higher proportion of patients in the radiograph group (4.7%) required hospitalisation compared to the control group (2.3%) with the result not being statistically significant (P = 0.14). None of the trials report the effect on mortality, complications of infection or adverse events from chest radiographs. Overall, the included studies had a low or unclear risk for blinding, attrition bias and reporting bias, but a high risk of selection bias. Both trials had strict exclusion criteria which is important but may limit the clinical practicability of the results as participants may not reflect those presenting in clinical practice.
Data from two trials suggest that routine chest radiography does not affect the clinical outcomes in adults and children presenting to a hospital with signs and symptoms suggestive of a LRTI. This conclusion may be weakened by the risk of bias of the studies and the lack of complete data available.
Background
Traditional siting of stomas, in the lower abdomen, has been guided by surgical dogma lacking evidence. In the lower abdomen, the combination of a thick and pendulous abdominal apron, can ...create a challenging and suboptimal site for a stoma. The anatomical determinant limiting delivery of a stoma to the abdominal skin is the distance of the SMA from the lower border of the pancreas. The aim of this cross‐sectional study was to compare the distance between the traditional stoma site, and upper abdominal stoma sites, to both the superior mesenteric artery (SMA) origin and SMA at the inferior border of the pancreas on abdominal computed tomography (CT).
Methods
A cross‐sectional study at a single academic university hospital of adult patients who underwent abdominal CT in Australia.
Results
Two hundred and thirteen patients were included. Stoma sites in the upper abdomen were 57‐76 mm shorter to the origin of the SMA and inferior border of the pancreas than those positioned at the traditional stoma site (P < 0.001). The mean panniculus thickness in the upper abdomen was 10 mm thinner than in the lower abdomen and increased with increasing BMI (P < 0.001). The ratio between the distance from the xiphisternum to umbilicus, and the umbilicus to pubic symphysis, was 1.10; this ratio increased with increasing BMI.
Conclusion
The distance of the SMA to the skin is always shorter in the upper abdomen compared to the traditional stoma site. Consideration should be given to placing stomas in the upper abdomen, particularly in overweight or obese patients.
Anatomical changes in abdominal wall topography occur as weight increases; including thickness of the abdominal wall and descent of the umbilicus. The skin of the upper abdominal wall is always closer to the origin of the superior mesenteric artery. Consideration, especially in the obese, should be given to positioning stomas in the upper abdomen.
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