Three-dimensional versus two-dimensional imaging during laparoscopic cholecystectomy: a systematic review and meta-analysis of randomised controlled trials (2020)

Type of publication:
Systematic Review

Author(s):
*Davies S.; Ghallab M.; Hajibandeh S.; Hajibandeh S.; Addison S.

Citation:
Langenbeck’s Archives of Surgery; 2020

Abstract:
Objectives: To evaluate the comparative outcomes of three-dimensional (3D) versus two-dimensional (2D) imaging during laparoscopic cholecystectomy.
Method(s): We conducted a systematic search of electronic information sources and bibliographic reference lists and applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits. Procedure time, Calot’s triangle dissection time, gallbladder removal time, gallbladder perforation, intraoperative bleeding, postoperative complications, conversion to open and intraoperative errors were the evaluated outcome parameters.
Result(s): We identified 6 randomised controlled trials (RCT) reporting a total of 577 patients who underwent laparoscopic cholecystectomy using 3D (n = 282) or 2D (n = 295) imaging. The 3D imaging was associated with significantly shorter procedure time (MD – 4.23, 95% CI – 8.14 to – 0.32, p = 0.03), Calot’s triangle dissection time (MD – 4.19, 95% CI – 6.52 to – 1.86, p = 0.0004) and significantly lower risk of gallbladder perforation (RR 0.50, 95% CI 0.28-0.88, p = 0.02) compared to the 2D approach. No significant difference was found in gallbladder removal time (MD – 0.79, 95% CI – 2.24 to 0.66, p = 0.28), intraoperative bleeding (RR 1.14, 95% CI 0.68-1.90, p = 0.61), postoperative complications (RD – 0.01, 95% CI – 0.06 to 0.05, p = 0.85), conversion to open (RD 0.00, 95% CI – 0.02 to 0.03, p = 0.70) or intraoperative errors (RR 0.96, 95% CI 0.79-1.17, p = 0.70) between the two groups.
Conclusion(s): Although our findings suggest that the use of 3D imaging during laparoscopic cholecystectomy may be associated with significantly shorter procedure time, Calot’s triangle dissection time and gallbladder injury compared to the 2D imaging, the differences seem to be clinically insignificant. Moreover, both approaches carry s similar risk of postoperative morbidities. The impact of the surgeon’s level of experience and difficulty of the procedure on the outcomes of each imaging modality remains unknown.

Routine Use of Swallowing Outcome Measures Following Head and Neck Cancer in a Multidisciplinary Clinic Setting (2020)

Type of publication:
Journal article

Author(s):
*Annette C. Zuydam, Simon N. Rogers, Kate Grayson, *Clare F. Probert

Citation:
International Archives of Otorhinolaryngology, May 2020 [epub ahead of print]

Abstract:
Introduction: Chemoradiotherapy treatment for head and neck cancer (HNC) can have a major impact on swallowing function and health-related quality of life. The use of outcome measures in early detection of patients with swallowing problems provides the opportunity for targeting speech and language therapy (SLT) interventions to aid adaption and promote better clinical outcomes.
Objective: The purpose of the present study was to assess relationships between four outcomes measures over time, in a cohort of HNC patients, treated by (chemo-) radiotherapy.
Methods: Data were collected at 3 months and 12 months, on 49 consecutive patients with primary squamous cell cancer of the oropharynx, nasopharynx or hypopharynx stage T1–4, N0–2b, M0 disease.
Results: Out of 49 eligible patients, 45 completed assessment at 3 months and 20 at 12 months. The 3-month outcomes gave a strong indication of performance at 1 year. There were several strong correlations found between measures. The strongest was between the 3-month Performance Status Scale for Head and Neck Cancer (PSSHN) and the 12-month PSSHN (rs ¼ 0.761, n ¼ 17), the 12-month PSSHN and the 12-month
Functional Oral Intake Scale (FOIS) (rs ¼ 0.823, n ¼ 20), and the 12-month University of Washington Head and Neck Quality of Life (UWQoL) swallow and the 12-month Water Swallow Test (WST) capacity (rs ¼ 0.759, n ¼ 17).
Conclusion: The UW-QoL swallow item and WST are easy to incorporate into routine care and should be used as part of a standard assessment of swallow outcome. These measures can serve to help screen patients for dysfunction and focus allocation of resources for those who would benefit from more comprehensive assessment and intervention by SLT.

Link to full-text [Open access, no password required]

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial (2020)

Type of publication:
Randomised controlled trial

Author(s):
The HALT-IT Trial Collaborators (including *John Jones and *Charlotte Owen)

Citation:
Lancet, 2020; Vol. 395: pp. 1927–36

Abstract:
Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding.
Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124.
Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid
(5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11952 (99·5%) received the first dose of the allocated
treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the
tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18).
Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and
placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein
thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of
5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98).
Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our
results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a
randomised trial.

Link to full-text [Open access, no password required]

Altmetrics:

The Prevalence of Thyroid Dysfunction and Autoimmunity in Women With History of Miscarriage or Subfertility (2020)

Type of publication:
Journal article

Author(s):
Rima K Dhillon-Smith, Aurelio Tobias, Paul P Smith, Lee J Middleton, Kirandeep K Sunner, Krystyna Baker, Samantha Farrell-Carver, Ruth Bender-Atik, Rina Agrawal, Kalsang Bhatia, Justin J Chu, Edmond Edi-Osagie, Ayman Ewies, Tarek Ghobara, Pratima Gupta, Davor Jurkovic, Yacoub Khalaf, Khashia Mulbagal, Natalie Nunes, Caroline Overton, Siobhan Quenby, Raj Rai, Nick Raine-Fenning, Lynne Robinson, Jackie Ross, Andrew Sizer, Rachel Small, *Martyn Underwood, Mark D Kilby, Jane Daniels, Shakila Thangaratinam, Shiao Chan, Kristien Boelaert, Arri Coomarasamy

Citation:
The Journal of Clinical Endocrinology & Metabolism, Volume 105, Issue 8, August 2020

Abstract:
Objective: To describe the prevalence of and factors associated with different thyroid dysfunction phenotypes in women who are asymptomatic preconception.
Design: Observational cohort study.
Setting: A total of 49 hospitals across the United Kingdom between 2011 and 2016.
Participants: Women aged 16 to 41 years with history of miscarriage or subfertility trying for a pregnancy.
Methods: Prevalences and 95% confidence intervals (CIs) were estimated using the binomial exact method. Multivariate logistic regression analyses were conducted to identify risk factors for thyroid disease.
Intervention: None.
Main Outcome Measure: Rates of thyroid dysfunction.
Results: Thyroid function and thyroid peroxidase antibody (TPOAb) data were available for 19213 and 19237 women, respectively. The prevalence of abnormal thyroid function was 4.8% (95% CI, 4.5-5.1); euthyroidism was defined as levels of thyroid-stimulating hormone (TSH) of 0.44 to 4.50 mIU/L and free thyroxine (fT4) of 10 to 21 pmol/L. Overt hypothyroidism (TSH > 4.50 mIU/L, fT4 < 10 pmol/L) was present in 0.2% of women (95% CI, 0.1-0.3) and overt hyperthyroidism (TSH < 0.44 mIU/L, fT4 > 21 pmol/L) was present in 0.3% (95% CI, 0.2-0.3). The prevalence of subclinical hypothyroidism (SCH) using an upper TSH concentration of 4.50 mIU/L was 2.4% (95% CI, 2.1-2.6). Lowering the upper TSH to 2.50 mIU/L resulted in higher rates of SCH, 19.9% (95% CI, 19.3-20.5). Multiple regression analyses showed increased odds of SCH (TSH > 4.50 mIU/L) with body mass index (BMI) ≥ 35.0 kg/m2 (adjusted odds ratio [aOR] 1.71; 95% CI, 1.13-2.57; P = 0.01) and Asian ethnicity (aOR 1.76; 95% CI, 1.31-2.37; P < 0.001), and increased odds of SCH (TSH ≥ 2.50 mIU/L) with subfertility (aOR 1.16; 95% CI, 1.04-1.29; P = 0.008). TPOAb positivity was prevalent in 9.5% of women (95% CI, 9.1-9.9).
Conclusions: The prevalence of undiagnosed overt thyroid disease is low. SCH and TPOAb are common, particularly in women with higher BMI or of Asian ethnicity. A TSH cutoff of 2.50 mIU/L to define SCH results in a significant proportion of women potentially requiring levothyroxine treatment.

Altmetrics:

Unscheduled Emergency Department Revisits in a Tertiary Care Hospital – A Quality Improvement Study (2020)

Type of publication:
Journal article

Author(s):
Mohammed Nazim Kt, Nithyanand M, *Dodiy Herman, Sourabh M Prakash, Shahana Sherin, *Benita Florence

Citation:
Indian Journal of Clinical Practice, Vol. 30, No. 10, p. 931-933, March 2020

Abstract:
Patients who revisit the emergency department (ED) within 72 hours constitute an integral key performance indicator of quality emergency care. The number of patient footfalls to the ED in a tertiary care hospital in a rural area of a district in India from December 1, 2018 to May 31, 2019 was 7,808 and the average re-attendances recorded during that period was 0.32%. With increase in the number of healthcare setups, rising standards of the healthcare industry and increase in the expectations of the population visiting hospitals, ED re-attendance within 72 hours has been considered as an important key performance indicator of emergency patient care. The early ED revisit rate at this tertiary care hospital for 6 months was found to be only 0.32% (at an average of 4 cases per month). This is less when compared to many other international hospitals where it ranges from 1.5% to 2.5%. Since readmissions cause unnecessary overcrowding in ED, it would be best if each hospital evaluated their rate of readmission and its causes, and then tried to address the problems found. This can be effective in better management of ED, reduction of treatment costs, increasing patient satisfaction and prevention of ED overcrowding.

Link to full-text [no password required]

Acute appendicitis secondary to endometriosis of the appendix: A case series (2019)

Type of publication:
Conference abstract

Author(s):
Argyriou O.; Wall M.; Johnson M.; Sutton P.A.; *Tamvakeras P.

Citation:
Colorectal Disease; 2019; vol. 21, S2, p. 36-37

Abstract:
Purpose: To review the clinical presentation, laboratory results, imaging and operative findings of patients subsequently found to have histological evidence of endometriosis of the appendix in a District General Hospital (DGH) between 2016-2018. Method(s): Ten histological reports containing the search term “endometriosis of the appendix” were identified. Four were excluded as planned gynaecological resections for known endometriosis. The case notes, laboratory and imaging reports of six patients were reviewed. Result(s): In three patients, a 72-h or less history of right iliac fossa (RIF) pain was present (24-h or less in two), whereas on two occasions there was a 3-week history of intermittent RIF pain. Three patients reported nausea and vomiting and two were pyrexial. No history of diarrhoea was reported. Inflammatory markers (white cell count-WCC, C-reactive protein-CRP) were raised on three occasions. In five patients, available imaging (CT/USS) was suggestive of an inflammatory process in the right iliac fossa, with principle diagnosis being acute appendicitis, and in one the diagnosis was solely clinical. In all six cases, acute appendicitis was found intraoperatively. The Alvarado score ranged from 4-7. Conclusion(s): Endometriosis of the appendix may present to surgical teams as acute appendicitis. Surgeons should be aware that a longer history of intermittent RIF pain and normal inflammatory markers does not exclude appendicitis secondary to endometriosis. An appendicectomy should be performed, as the aetiology does not appear to otherwise affect the natural history of this condition.

Link to full-text [no password required]

Transanal endoscopic microsurgery for early rectal cancer-can it be done safely with good outcomes at a in a UK district general hospital (2019)

Type of publication:
Conference abstract

Author(s):
*Vidyasankar V.; *Chakrabarthy A.; *McCloud J.; *Clarke R.

Citation:
Colorectal Disease; Sep 2019; vol. 21, S3, p. 54

Abstract:
Aim: Randomised controlled trials have demonstrated advantages of Transanal endoscopic microsurgery (TEMS) for early rectal cancer resections. The aim of our study was to assess the safety and outcome of TEMS for early rectal cancer at a U.K district general hospital. Method(s): Between July 2011 to January 2017, 27 patients, 13 men and 14 women, Mean age 77 years, underwent TEMS. Mean lesion diameter was 49 mm. Patient selection was based on multidisciplinary decision. Follow up included colonoscopy, MRI and CT according to standard protocol. Patients were admitted for overnight observation and discharged the following day. Result(s): Mean operative time was 60 minutes. Average hospital stay was 24 hours. One patient (3.7%) had bleeding, three (11%) developed perforation, which were identified and repaired immediately. Two (7.4%) developed pyrexia, One patient (3.7%) developed minor stricture. One (3.7%) developed a recto-vaginal fistula. R0 resection was achieved in 81% and R1 resection was achieved in 19% of cancer cases. One patient (3.7%) developed local recurrence. No mortality. Conclusion(s): Our study demonstrates that TEMS for early rectal cancer can be safely performed in selected patients at a district general hospital, with outcomes comparable with international data.

Link to full-text [no password required]

Childbirth-related pelvic floor trauma in women at-risk: A survey of the current obstetric management of short stature primigravid women (2019)

Type of publication:
Conference abstract

Author(s):
*Rachaneni S.; Freeman R.

Citation:
International Urogynecology Journal; September 2019; vol. 30 (no. 1 Supplement)

Abstract:
Objective: To assess the antenatal and intrapartum management of short statured primigravid women in relation to the awareness of the increased risk of long-term pelvic floor morbidity from childbirth, by Obstetricians and Gynaecologists in the UK. Method(s):We carried out a questionnaire survey with 15 questions about the antenatal and intrapartum management of short statured primigravid women with a clinically large fetus, their timing and mode of delivery and discussion with the women about their risk of long-term pelvic floor morbidity following spontaneous and instrumental vaginal deliveries, their choice of instruments and episiotomy. Result(s): The survey was completed by 424 Members and Fellows of Royal College of Obstetricians and Gynaecologists (UK). We created a scenario of a short stature primigravid woman who presented with a clinically large baby around 38 weeks gestation. Sixty five percent of the responders stated that they would scan for estimated fetal weight, 48% would offer induction of labo-r at 40 weeks gestation and 13% would offer an elective caesarean section at 39-40 weeks. Only 59% of the responders said that would discuss the risks of obstructed labo-r, shoulder dystocia, instrumental delivery and Obstetric anal sphincter injury. Seventy percent of the responders said they would not discuss the long term risks of urinary, fecal incontinence and prolapse during antenatal or intrapartum management. For intrapartum management with failure to progress in the second stage of labo-r, 69% would attempt a rotational instrumental delivery, and only 5% would offer an emergency caesarean section. Manual rotation followed by ‘straight’ forceps application (59%) was the most frequent rotational delivery offered followed by Ventouse (40%) and Keillands forceps rotation. Thirty four percent stated that do not routinely perform an episiotomy in this scenario. The choice of instrument was not based on the long-term risk of pelvic floor dysfunction in 73% of the responses. Conclusion(s): The survey reveals a poor level of counselling of primigravid women of short stature who are known to be at higher risk of long-term pelvic floor trauma and consequent incontinence and prolapse.

Role of flavonoids in the management of acutely symptomatic haemorrhoids: A systematic review and meta-analysis of randomized, controlled trials (2019)

Type of publication:
Conference abstract

Author(s):
*Rehman S.; Miles W.; Sains P.; Sajid M.

Citation:
British Journal of Surgery; Sep 2019; vol. 106, S5, p. 110

Abstract:
Aims: The objective of this article is to assess the role of role of flavonoids in the management of acutely
symptomatic haemorrhoids.
Method(s): The data retrieved from the published randomized, controlled trials (RCT) regarding the role of flavonoids in the management of acutely symptomatic haemorrhoids was analysed using the principles of metaanalysis. The summated outcome of dichotomous variables was expressed in odds ratio (OR).
Result(s): Ten RCTs on 1478 patients comparing the surgical outcomes in patients having clinically and endoscopically diagnosed acute symptomatic haemorrhoids after using flavonoids versus placebo preparation were analysed. In the random effects model analysis using the statistical software Review Manager 5.3, the symptomatic relief (OR, 0.48; 95% CI, 0.16, 1.3928; z = 1.36; P = 0.18), satisfaction on pain relief (OR, 0.30; 95% CI, 0.08, 1.07; z = 1.86; P = 0.06), recurrence (OR, 0.48; 95% CI, 0.14, 1.63; z = 1.17; P = 0.24) and complications rate (OR, 1.31; 95% CI, 0.49, 3.54; z = 0.54; P = 0.59) were statistically similar in both groups. However, symptomatic haemorrhoidal bleeding control rate was higher in flavonoids group (OR, 0.33; 95% CI, 0.13, 0.84; z = 2.33; P = 0.02).
Conclusion(s): Use of flavonoids to treat symptomatic acute haemorrhoids failed to demonstrate better effectiveness over traditional placebo remedies except better bleeding control.

Link to full-text [NHS OpenAthens account required]