Background
Options for reconstruction after low anterior resection (LAR) for rectal cancer include straight or side‐to‐end coloanal anastomosis (CAA), colonic J pouch and transverse coloplasty. This ...systematic review compared these techniques in terms of function, surgical outcomes and quality of life.
Methods
A systematic literature search (MEDLINE, Embase and the Cochrane Library, from inception of the databases until November 2014) was conducted to identify randomized clinical trials comparing reconstructive techniques after LAR. Random‐effects meta‐analyses were carried out, and results presented as weighted odds ratios or mean differences with corresponding 95 per cent c.i. A network meta‐analysis was conducted for the outcome anastomotic leakage.
Results
The search yielded 965 results; 21 trials comprising data from 1636 patients were included. Colonic J pouch was associated with lower stool frequency and antidiarrhoeal medication use for up to 1 year after surgery compared with straight CAA. Transverse coloplasty and side‐to‐end CAA had similar functional outcomes to the colonic J pouch. No superiority was found for any of the techniques in terms of anastomotic leak rate.
Conclusion
Colonic J pouch and side‐to‐end CAA or transverse coloplasty lead to a better functional outcome than straight CAA for the first year after surgery.
Short‐term advantages to reservoir techniques
Many hands make tight work Silberzahn, Raphael; Uhlmann, Eric L
Nature (London),
10/2015, Letnik:
526, Številka:
7572
Journal Article
Recenzirano
In analyses run by a single team, researchers take on multiple roles: as inventors who create ideas and hypotheses; as optimistic analysts who scrutinize the data in search of confirmation; and as ...devil's advocates who try different approaches to reveal flaws in the findings.
Background
Photodynamic therapy is an effective treatment for actinic keratoses. Nevertheless, severe pain during the procedure is a serious adverse effect, which leads to interruption or even ...termination. Complete pain relief remains a difficult challenge.
Objective
To evaluate the effect of a nitrous oxide/oxygen mixture on pain intensity during photodynamic therapy.
Methods
This clinical trial has been designed as a prospective, single‐centre, explorative, controlled, observational study.
Results
We were able to detect a significant overall pain reduction of 55.2% after application of a nitrous oxide/oxygen mixture by means of an intra‐individual comparison. Furthermore, the total number of therapy interruption significantly decreased by 82% after the inhalation analgesia. Additionally, treatment satisfaction ranged from ‘extremely to very satisfied’.
Conclusions
This study shows that analgesia by means of a nitrous oxide/oxygen mixture is a very effective and well‐tolerated method for achieving significant pain reduction during photodynamic therapy.
Summary
Background
The Psoriasis Area and Severity Index (PASI) represents the gold standard for psoriasis severity assessments but is limited by its subjectivity and low intra‐ and inter‐rater ...consistency.
Objectives
To investigate the precision and reproducibility of automated, computer‐guided PASI measurements (ACPMs) in comparison with three trained physicians.
Methods
This was a comparative observational study assessing ACPMs attained by automated total‐body imaging and computerized digital image analysis in a cohort of 120 patients affected by plaque psoriasis of various severities. The level of agreement between ACPMs and physicians’ PASI measurements was calculated by the intraclass correlation coefficient (ICC). The reproducibility of ACPMs in comparison with physicians’ PASI measurements was investigated by performing two successive ‘repeat PASI calculations’ in the same patients.
Results
The agreement between ACPMs and physicians’ PASI calculations in 120 fully evaluable patients was high (ICC 0·86, 95% confidence interval 0·80–0·90, mean absolute difference 2·5 PASI points). Repeat ACPMs to measure the reproducibility showed an excellent ICC of 0·99 (95% confidence interval 0·98–0·99) with a mean absolute difference of 0·5 PASI points. The ACPMs thus outperformed the three physicians for intrarater reliability (mean ICC 0·86).
Conclusions
The results of this first clinical study investigating ACPMs in 120 patients with psoriasis indicate a similar precision and higher reproducibility in comparison with trained physicians. Limitations arise from poorly observable body sites and from patients unable to attain predefined postures during automated image acquisition.
What's already known about this topic?
The Psoriasis Area and Severity Index (PASI) is the standard for psoriasis severity assessments but is limited by its subjectivity and low reproducibility.
What does this study add?
Automated computer‐guided PASI measurements (ACPMs) agreed with the results of trained physicians and outperformed the physicians in terms of reproducibility.
ACPMs provide a first step towards a higher standardization and reproducibility of PASI measurements.
Linked Comment: Garcia‐Doval and Albrecht. Br J Dermatol 2019; 180:260–261.
Respond to this article
Endovascular therapy for acute ischemic stroke is often performed with the patient under conscious sedation. Emergent conversion from conscious sedation to general anesthesia is sometimes necessary. ...The aim of this study was to assess the functional outcome in converted patients compared with patients who remained in conscious sedation and to identify predictors associated with the risk of conversion.
Data from 368 patients, included in 3 trials randomizing between conscious sedation and general anesthesia before endovascular therapy (SIESTA, ANSTROKE, and GOLIATH) constituted the study cohort. Twenty-one (11%) of 185 patients randomized to conscious sedation were emergently converted to general anesthesia.
Absence of hyperlipidemia seemed to be the strongest predictor of conversion to general anesthesia, albeit a weak predictor (area under curve = 0.62). Sex, hypertension, diabetes, smoking status, atrial fibrillation, blood pressure, size of the infarct, and level and side of the occlusion were not significantly associated with conversion to general anesthesia. Neither age (mean age, 71.3 ± 13.8 years for conscious sedation versus 71.6 ± 12.3 years for converters,
= .58) nor severity of stroke (mean NIHSS score, 17 ± 4 versus 18 ± 4, respectively,
= .27) were significantly different between converters and those who tolerated conscious sedation. The converters had significantly worse outcome with a common odds ratio of 2.67 (
= .015) for a shift toward a higher mRS score compared with the patients remaining in the conscious sedation group.
Patients undergoing conversion had significantly worse outcome compared with patients remaining in conscious sedation. No factor was identified that predicted conversion from conscious sedation to general anesthesia.
Background
The Psoriasis Area and Severity Index (PASI) is the standard for psoriasis severity assessment. However, PASI measurement is complex and subjective, frequently leading to a high intra‐ and ...interobserver variability. To date, the precise extent of variability in PASI measurements and its underlying causes remain unknown.
Objective
To determine the inter‐ and intrarater variability of image‐based PASI measurements by calculating Intra‐Class‐Correlation‐Coefficients (ICCs) and to investigate the impact of the different PASI components and specific anatomic regions on the extent of variability.
Methods
First, the methodology of ‘image‐based’ vs. commonly used ‘live’ PASI measurements was validated in a pilot study. Next, in an observational cohort study, PASI scores of 120 patients affected by plaque psoriasis were prospectively evaluated by three formally trained physicians by means of total body images (TBI). Each observer independently performed two rounds of image‐based PASI calculations in all patients at two different time points.
Results
Overall, 720 image‐based PASI scores were calculated with a mean PASI of 8.8 (range 0.7–34.8). An interrater variability with an ICC of 0.895 and mean absolute difference (MAD) of 3.3 PASI points were observed. Intrarater variability showed a mean ICC of 0.877 and a MAD of 2.2 points. When considering specific PASI components, the highest agreement was found for the assessment of the involved body surface area (BSA), while the lowest ICCs were calculated for severity scoring of ‘scaling’ and ‘induration’. As BSA scores serve as a multiplier in the calculation of PASI, minor inaccuracies were capable of inducing a large share of variability.
Conclusion
The overall inter‐ and intrarater reliability of image‐based PASI measurements in this study was good. However, physicians were formally trained and experienced, which frequently is not the case in a real‐life clinical setting. Therefore, new strategies for higher standardization and objectivity of PASI calculations are needed.
Background
The anaesthetic conserving device, AnaConDa®, allows use of inhaled anaesthetics for sedation in the intensive care unit. We prospectively measured cerebral and cardiopulmonary parameters ...in patients with acute stroke or subarachnoid haemorrhage during a switch from i.v. to inhalative sedation.
Methods
25 patients were switched from i.v. to an indefinite period of inhaled sedation with sevoflurane. Mean arterial (MAP), intracranial (ICP), and cerebral perfusion pressure (CPP), middle cerebral artery mean flow velocity (MFV) and fractional tissue oxygen extraction (FTOE), systemic cardiopulmonary parameters, and administered drugs were assessed before and after the change (−6 to +12 h).
Results
In 8 patients, critically reduced MAP or ICP crisis led to premature termination of sevoflurane sedation. In the other 17 patients, after the first hour, mean ICP increased 2.4 (4.5) mm Hg; P=0.046, MAP decreased 7.8 (14.1) mm Hg; P=0.036 and thus CPP decreased also −10.2 (15.1) mm Hg; P=0.014. MFV and FTOE did not change. Over a 12 hour post switch observational period, PaCO2 increased slightly 0.3 (0.8) kPa; P=0.104, ICP did not change 0.2 (3.9) mm Hg; P=0.865, but MAP −6 (6.9) mm Hg; P=0.002 and thus CPP decreased −6 (8.5) mm Hg; P=0.010.
Conclusion
Sevoflurane led to sufficient sedation, but decreased MAP and CPP in a selected cerebrovascular neurocritical care population. In about a third of these patients, severe adverse reactions, including intolerable ICP increases, were observed.
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