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Cureus Feb 2023There is a rising incidence of coronary artery diseases and myocardial infarction (MI). Mortality associated with acute MI (AMI) is directly linked to the time to... (Review)
Review
There is a rising incidence of coronary artery diseases and myocardial infarction (MI). Mortality associated with acute MI (AMI) is directly linked to the time to receive treatment and missed diagnoses. Although health professionals are aware of typical AMI presentation, atypical MI is difficult to diagnose, which on the other hand, is likely to have an impact on morbidity and mortality. Therefore, it is prudent to know such atypical presentations, especially for emergency and primary care physicians. We aimed to systematically evaluate the clinical presentations of atypical MI and analyze them to characterize the common clinical presentations of atypical MI. We researched the PubMed database, did citation tracking, and performed Google Scholar advanced search to find the cases reported on the atypical presentation of MI published from January 2000 to September 2022. Articles of all languages were included; Google Translate was used to translate articles published in languages other than English. A total of 496 (56 PubMed articles, 340 citations from included PubMed articles, and 100 articles from Google Scholar advanced search) were screened; 52 case reports were evaluated, and their data were analyzed. Atypical presentations of myocardial infarction are vast; patients may have chest pain without typical characteristics of angina pain or may not have chest pain. No typical characterization could be done. Most patients were in their fifth decade or above of their life and commonly presented with pain and discomfort in the abdomen, head, and neck regions. Prodromal symptoms were consistent findings, and many patients had two to three comorbidities out of four common comorbidities, i.e., diabetes, hypertension, dyslipidemia, and substance abuse. A patient who is 50 years old or more, having comorbidities such as diabetes, hypertension, dyslipidemia, history of tobacco or marijuana usage, presenting with prodromal symptoms like shortness of breath, dizziness, fatigue, syncope, gastrointestinal discomfort or head/neck pain should be suspected for atypical MI.
PubMed: 36999116
DOI: 10.7759/cureus.35492 -
The Cochrane Database of Systematic... Jun 2018The use of surgical drains has been considered mandatory after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The use of surgical drains has been considered mandatory after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial.
OBJECTIVES
To assess the benefits and harms of routine abdominal drainage after pancreatic surgery, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal.
SEARCH METHODS
For the last version of this review, we searched CENTRAL (2016, Issue 8), and MEDLINE, Embase, Science Citation Index Expanded, and Chinese Biomedical Literature Database (CBM) to 28 August 2016). For this updated review, we searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and CBM from 2016 to 15 November 2017.
SELECTION CRITERIA
We included all randomized controlled trials that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included randomized controlled studies that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery.
DATA COLLECTION AND ANALYSIS
We identified six studies (1384 participants). Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we used the random-effects model.
MAIN RESULTS
Drain use versus no drain useWe included four studies with 1110 participants, who were randomized to the drainage group (N = 560) and the no drainage group (N = 550) after pancreatic surgery. There was little or no difference in mortality at 30 days between groups (1.5% with drains versus 2.3% with no drains; RR 0.78, 95% CI 0.31 to 1.99; four studies, 1055 participants; moderate-quality evidence). Drain use probably slightly reduced mortality at 90 days (0.8% versus 4.2%; RR 0.23, 95% CI 0.06 to 0.90; two studies, 478 participants; moderate-quality evidence). We were uncertain whether drain use reduced intra-abdominal infection (7.9% versus 8.2%; RR 0.97, 95% CI 0.52 to 1.80; four studies, 1055 participants; very low-quality evidence), or additional radiological interventions for postoperative complications (10.9% versus 12.1%; RR 0.87, 95% CI 0.79 to 2.23; three studies, 660 participants; very low-quality evidence). Drain use may lead to similar amount of wound infection (9.8% versus 9.9%; RR 0.98 , 95% CI 0.68 to 1.41; four studies, 1055 participants; low-quality evidence), and additional open procedures for postoperative complications (9.4% versus 7.1%; RR 1.33, 95% CI 0.79 to 2.23; four studies, 1055 participants; low-quality evidence) when compared with no drain use. There was little or no difference in morbidity (61.7% versus 59.7%; RR 1.03, 95% CI 0.94 to 1.13; four studies, 1055 participants; moderate-quality evidence), or length of hospital stay (MD -0.66 days, 95% CI -1.60 to 0.29; three studies, 711 participants; moderate-quality evidence) between groups. There was one drain-related complication in the drainage group (0.2%). Health-related quality of life was measured with the pancreas-specific quality-of-life questionnaire (FACT-PA; a scale of 0 to 144 with higher values indicating a better quality of life). Drain use may lead to similar quality of life scores, measured at 30 days after pancreatic surgery, when compared with no drain use (105 points versus 104 points; one study, 399 participants; low-quality evidence). Hospital costs and pain were not reported in any of the studies.Type of drainWe included one trial involving 160 participants, who were randomized to the active drain group (N = 82) and the passive drain group (N = 78) after pancreatic surgery. An active drain may lead to similar mortality at 30 days (1.2% with active drain versus 0% with passive drain; low-quality evidence), and morbidity (22.0% versus 32.1%; RR 0.68, 95% CI 0.41 to 1.15; low-quality evidence) when compared with a passive drain. We were uncertain whether an active drain decreased intra-abdominal infection (0% versus 2.6%; very low-quality evidence), wound infection (6.1% versus 9.0%; RR 0.68, 95% CI 0.23 to 2.05; very low-quality evidence), or the number of additional open procedures for postoperative complications (1.2% versus 7.7%; RR 0.16, 95% CI 0.02 to 1.29; very low-quality evidence). Active drain may reduce length of hospital stay slightly (MD -1.90 days, 95% CI -3.67 to -0.13; one study; low-quality evidence; 14.1% decrease of an 'average' length of hospital stay). Additional radiological interventions, pain, and quality of life were not reported in the study.Early versus late drain removalWe included one trial involving 114 participants with a low risk of postoperative pancreatic fistula, who were randomized to the early drain removal group (N = 57) and the late drain removal group (N = 57) after pancreatic surgery. There was no mortality in either group. Early drain removal may slightly reduce morbidity (38.6% with early drain removal versus 61.4% with late drain removal; RR 0.63, 95% CI 0.43 to 0.93; low-quality evidence), length of hospital stay (MD -2.10 days, 95% CI -4.17 to -0.03; low-quality evidence; 21.5% decrease of an 'average' length of hospital stay), and hospital costs (MD -EUR 2069.00, 95% CI -3872.26 to -265.74; low-quality evidence; 17.0% decrease of 'average' hospital costs). We were uncertain whether early drain removal reduced additional open procedures for postoperative complications (0% versus 1.8%; RR 0.33, 95% CI 0.01 to 8.01; one study; very low-quality evidence). Intra-abdominal infection, wound infection, additional radiological interventions, pain, and quality of life were not reported in the study.
AUTHORS' CONCLUSIONS
It was unclear whether routine abdominal drainage had any effect on the reduction of mortality at 30 days, or postoperative complications after pancreatic surgery. Moderate-quality evidence suggested that routine abdominal drainage probably slightly reduced mortality at 90 days. Low-quality evidence suggested that use of an active drain compared to the use of a passive drain may slightly reduce the length of hospital stay after pancreatic surgery, and early removal may be superior to late removal for people with low risk of postoperative pancreatic fistula.
Topics: Abdomen; Device Removal; Drainage; Humans; Length of Stay; Pancreas; Postoperative Complications; Randomized Controlled Trials as Topic; Time Factors
PubMed: 29928755
DOI: 10.1002/14651858.CD010583.pub4 -
The Lancet. Global Health Mar 2016Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well... (Review)
Review
Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data.
BACKGROUND
Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures--caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair--to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety.
METHODS
We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates.
FINDINGS
From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs.
INTERPRETATION
All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care.
FUNDING
None.
Topics: Adult; Appendectomy; Appendicitis; Cesarean Section; Developing Countries; Female; Groin; Hernia; Herniorrhaphy; Humans; Male; Postoperative Period; Pregnancy
PubMed: 26916818
DOI: 10.1016/S2214-109X(15)00320-4 -
Journal of Cardiovascular Ultrasound Sep 2017Ultrasound imaging devices are becoming popular in clinical and teaching settings, but there is no systematic information on their use in medical education. We conducted... (Review)
Review
BACKGROUND
Ultrasound imaging devices are becoming popular in clinical and teaching settings, but there is no systematic information on their use in medical education. We conducted a systematic review of hand-held ultrasound (HHU) devices in undergraduate medical education to delineate their role, significance, and limitations.
METHODS
We searched Cochrane, PubMed, Embase, and Medline using the strategy: [(Hand-held OR Portable OR Pocket OR "Point of Care Systems") AND Ultrasound] AND (Education OR Training OR Undergraduate OR "Medical Students" OR "Medical School"). We retained 12 articles focusing on undergraduate medical education. We summarised the patterns of HHU use, pooled and estimated sensitivity, and specificity of HHU for detection of left ventricular dysfunction.
RESULTS
Features reported were heterogeneous: training time (1-25 hours), number of students involved (1-an entire cohort), number of subjects scanned (27-211), and type of learning (self-directed vs. traditional lectures + hands-on sessions). Most studies reported cardiac HHU examinations, but other anatomical areas were examined, e.g. abdomen and thyroid. Pooled sensitivity 0.88 [95% confidence interval (CI) 0.83-0.92] and specificity 0.86 (95% CI 0.81-0.90) were high for the detection of left ventricular systolic dysfunction by students.
CONCLUSION
Data on HHU devices in medical education are scarce and incomplete, but following training students can achieve high diagnostic accuracy, albeit in a limited number of (mainly cardiac) pathologies. There is no consensus on protocols best-suited to the educational needs of medical students, nor data on long-term impact, decay in proficiency or on the financial implications of deploying HHU in this setting.
PubMed: 29093769
DOI: 10.4250/jcu.2017.25.3.75 -
Brain Sciences Feb 2020Most available large animal extracranial aneurysm models feature healthy non-degenerated aneurysm pouches with stable long-term follow-ups and extensive healing... (Review)
Review
BACKGROUND
Most available large animal extracranial aneurysm models feature healthy non-degenerated aneurysm pouches with stable long-term follow-ups and extensive healing reactions after endovascular treatment. This review focuses on a small subgroup of extracranial aneurysm models that demonstrated growth and potential rupture during follow-up.
METHODS
The literature was searched in Medline/Pubmed to identify extracranial in vivo saccular aneurysm models featuring growth and rupture, using a predefined search strategy in accordance with the PRISMA guidelines. From eligible studies we extracted the following details: technique and location of aneurysm creation, aneurysm pouch characteristics, time for model creation, growth and rupture rate, time course, patency rate, histological findings, and associated morbidity and mortality.
RESULTS
A total of 20 articles were found to describe growth and/or rupture of an experimentally created extracranial saccular aneurysm during follow-up. Most frequent growth was reported in rats ( = 6), followed by rabbits ( = 4), dogs ( = 4), swine ( = 5), and sheep ( = 1). Except for two studies reporting growth and rupture within the abdominal cavity (abdominal aortic artery; = 2) all other aneurysms were located at the neck of the animal. The largest growth rate, with an up to 10-fold size increase, was found in a rat abdominal aortic sidewall aneurysm model.
CONCLUSIONS
Extracranial saccular aneurysm models with growth and rupture are rare. Degradation of the created aneurysmal outpouch seems to be a prerequisite to allow growth, which may ultimately lead to rupture. Since it has been shown that the aneurysm wall is important for healing after endovascular therapy, it is likely that models featuring growth and rupture will gain in interest for preclinical testing of novel endovascular therapies.
PubMed: 32069946
DOI: 10.3390/brainsci10020101 -
Biophysical Reviews Jun 2021In low-income countries, pregnant women do not have easy access to health care, especially in rural and peri-urban areas. In this context, they can be surprised by the... (Review)
Review
BACKGROUND
In low-income countries, pregnant women do not have easy access to health care, especially in rural and peri-urban areas. In this context, they can be surprised by the uterine contractions that precede childbirth and sometimes find themselves giving birth at home or on the way to the nearest health facility (located miles away from their home). In view of the development of an external uterine electrohysterogram acquisition system for labour prediction, a review of the literature on electrodes and their characteristics is necessary.
METHODS
A comprehensive literature review was conducted to collate information on the use of electrodes in external EHG recording and their characteristics.
RESULTS
Wet electrodes based on Ag/AgCl redox chemistry are the most common type of electrodes for EHG, employed in different configurations on the pregnant woman's abdomen. All positioning configurations are around the vertical median axis if they are not placed directly on it. Positioning below the navel seems to be the most efficient. The number of source, reference, and ground electrodes used varies from one author to another, as does the distance between the electrodes.
CONCLUSION
Two well-positioned source electrodes on the vertical median axis, with ground electrode on the right side of the hip and reference one on the left side, are able to generate a good external EHG recording signal. The minimum allowed inter-electrode distance is approximately 17.5 to 25mm.
PubMed: 34178173
DOI: 10.1007/s12551-021-00805-w -
Journal of Robotic Surgery Apr 2023Robotically assisted operations are the state of the art in laparoscopic general surgery. They are established predominantly for elective operations. Since laparoscopy... (Review)
Review
Robotically assisted operations are the state of the art in laparoscopic general surgery. They are established predominantly for elective operations. Since laparoscopy is widely used in urgent general surgery, the significance of robotic assistance in urgent operations is of interest. Currently, there are few data on robotic-assisted operations in urgent surgery. The aim of this study was to collect and classify the existing studies. A two-stage, PRISMA-compliant literature search of PubMed and the Cochrane Library was conducted. We analyzed all articles on robotic surgery associated with urgent general surgery resp. acute surgical diseases of the abdomen. Gynecological and urological diseases so as vascular surgery, except mesenterial ischemia, were excluded. Studies and case reports/series published between 1980 and 2021 were eligible for inclusion. In addition to a descriptive synopsis, various outcome parameters were systematically recorded. Fifty-two studies of operations for acute appendicitis and cholecystitis, hernias and acute conditions of the gastrointestinal tract were included. The level of evidence is low. Surgical robots in the narrow sense and robotic camera mounts were used. All narrow-sense robots are nonautonomous systems; in 82%, the Da Vinci system was used. The most frequently published emergency operations were urgent cholecystectomies (30 studies, 703 patients) followed by incarcerated hernias (9 studies, 199 patients). Feasibility of robotic operations was demonstrated for all indications. Neither robotic-specific problems nor extensive complication rates were reported. Various urgent operations in general surgery can be performed robotically without increased risk. The available data do not allow a final evidence-based assessment.
Topics: Humans; Robotic Surgical Procedures; Robotics; Laparoscopy; Cholecystectomy; Hernia
PubMed: 35727485
DOI: 10.1007/s11701-022-01425-6 -
Journal of Pain Research 2021We set out to evaluate whether the instillation of bupivacaine versus a saline solution into the peritoneal cavity at time of laparoscopic gynecologic surgery will... (Review)
Review
OBJECTIVE
We set out to evaluate whether the instillation of bupivacaine versus a saline solution into the peritoneal cavity at time of laparoscopic gynecologic surgery will reduce postoperative pain and postoperative opioid consumption.
DATA SOURCES
We searched six databases: Web of Science, SCOPUS, Cochrane CENTRAL, ClinicalTrials.Gov, MEDLINE and PubMed. Our search strategy had no restriction on time or languages and included all studies that met our search algorithm up to March of 2021.
METHODS OF STUDY SELECTION
We included only randomized trials that met our search strategy for the outcomes of 1) pain intensity 24 hours after surgery, 2) pain intensity 6 hours after surgery, and 3) length of hospital stay.
TABULATION INTEGRATION AND RESULTS
We analyzed continuous data using mean difference (MD) with relative 95% confidence interval (CI). We included 8 randomized clinical trials. We found that intraperitoneal bupivacaine showed significant difference from the saline group regarding pain intensity 24 hours after surgery (MD= -0.73 [-1.10, -0.36]) (P = 0.01) and pain intensity 6 hours after surgery (MD= -1.12 [-2.22, -0.02]) (P = 0.05). Overall, patients allocated to the placebo group seemed to need other analgesics earlier than patients allocated to the bupivacaine group (MD=145.08 [51.37, 238.79] (P = 0.02)). There was no significant difference regarding the length of hospital stay (MD= -0.44 [-1.44, 0.56]) (P = 0.39).
CONCLUSION
Bupivacaine significantly reduced the visual analog pain score for pain compared with that of the placebo at 6 and 24 hours postoperatively. There was no significant difference in hospital stay.
PROSPERO REGISTRATION
CRD42021254268.
PubMed: 34512009
DOI: 10.2147/JPR.S326145 -
Journal of Cardiothoracic Surgery Aug 2023Approximately one third of patients with Acute Type A Aortic Dissection (ATAAD) present with pre-operative malperfusion syndromes (MPS). Of these, mesenteric... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Approximately one third of patients with Acute Type A Aortic Dissection (ATAAD) present with pre-operative malperfusion syndromes (MPS). Of these, mesenteric malperfusion represents the greatest risk to patients with respect to increased short-term mortality. In select patients, it may be feasible to offer a staged approach by treating the mesenteric malperfusion first, optimizing the patient in the intensive care setting and then, following with a central aortic repair. The aim of this systematic review is to summarize cohort studies assessing the role of pre-operative interventions for mesenteric malperfusion.
METHODS
An electronic literature search of five databases was performed to identify all relevant studies providing studies examining short-term mortality on patients who underwent either endovascular or open revascularisation of mesenteric ischemia prior to central aortic repair. The primary outcome was all-cause, short-term mortality. Secondary outcomes were comparative mortality between a delayed repair vs. aortic repair first strategy, rates of postoperative laparotomy, bowel resection, and mortality following delayed aortic repair.
RESULTS
The search strategy identified 8 studies qualifying for inclusion, with a total of 180 patients who underwent delayed aortic surgery in the setting of mesenteric MPS. The weighted short-term mortality following a mesenteric revascularisation first, delayed aortic surgery strategy was 22.5%. This strategy was also associated with a significantly lower mortality than a central repair first strategy (OR 0.07, 95% CI 0.02-0.27), and a significantly lower rate of postoperative laparotomy/bowel resection (OR 0.05, 95% CI 0.02-0.14). If patients survive to receive central repair, the weighted short-term mortality postoperatively is low (2.1%).
CONCLUSION
A summary of this evidence reveals a lower short-term mortality in hemodynamically stable patients with mesenteric malperfusion, along with a reduction in postoperative laparotomy/bowel resections. Of those patients who survive to receive central repair, short-term mortality remains very low in the select group of hemodynamically stable patients. Further high-quality studies with randomized or propensity matched data are required to verify these results.
Topics: Humans; Aortic Dissection; Mesenteric Ischemia; Mesentery; Syndrome; Aorta; Treatment Delay; Angioplasty
PubMed: 37596605
DOI: 10.1186/s13019-023-02341-y -
International Journal of Surgery... Sep 2023To compare the safety and efficacy of robotic-assisted retroperitoneal lymph node dissection (RA-RPLND) versus non-robotic retroperitoneal lymph node dissection in... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To compare the safety and efficacy of robotic-assisted retroperitoneal lymph node dissection (RA-RPLND) versus non-robotic retroperitoneal lymph node dissection in testicular cancer.
METHODS
The statistical analysis software used Stata 17. The weighted mean difference (WMD) represents the continuous variable, and the dichotomous variable chooses the odds ratio, and calculates the 95% CI. This systematic review and cumulative meta-analysis was performed according to PRISMA criteria, and AMSTAR guidelines (assessing the methodological quality of systematic reviews). The Embase, PubMed, Cochrane Library, Web of Science, and Scopus databases were searched. The upper limit of the search time frame was February 2023, and no lower limit was set.
RESULTS
Seven studies involving 862 patients. Compared with open retroperitoneal lymph node dissection, RA-RPLND appears to have a shorter length of stay [WMD=-1.21, 95% CI (-1.66, -0.76), P <0.05], less estimated blood loss [WMD=-0.69, 95% CI (-1.07, -0.32), P <0.05], and lower overall complications [odds ratio=0.45, 95% CI (0.28, 0.73), P <0.05]. RA-RPLND appears to have more lymph node yields than laparoscopic retroperitoneal lymph node dissection [WMD=5.73, 95% CI (1.06, 10.40), P <0.05]. However, robotic versus open/laparoscopic retroperitoneal lymph node dissection had similar results in operation time, lymph node positivity rate, recurrence during follow-up, and postoperative ejaculation disorders.
CONCLUSION
RA-RPLND appears to be safe and effective for testicular cancer, but longer follow-up and more studies are needed to confirm this.
Topics: Male; Humans; Testicular Neoplasms; Robotic Surgical Procedures; Retroperitoneal Space; Retrospective Studies; Lymph Node Excision; Treatment Outcome; Laparoscopy
PubMed: 37222676
DOI: 10.1097/JS9.0000000000000520