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Renal transplantation is common worldwide, with >25,000 procedures performed in 2022. Usage of prophylactic perinephric drains is variable in renal transplantation; drains are associated with risks, and there is a lack of consensus regarding benefit of routine drain placement in these patients. This meta-analysis assessed whether prophylactic drainage reduced need for reintervention postoperatively. This systematic review and meta-analysis was carried out using the Preferred Reporting Items in Systematic Reviews and Meta-Analysis, and prospectively registered on PROSPERO. Summary statistics for outcomes of interest underwent meta-analyses to a confidence interval (CI) of 95% and are presented as Forest Plots for Odds Ratio (OR). A systematic literature search in June 2023 revealed 1,540 unique articles across four databases. Of these, four retrospective cohort studies were selected. Meta-analysis of three studies showed no significant reduction in reintervention rate with pre-emptive drain placement, OR = 0.59 (95% CI: 0.16-2.23), p = 0.44. Meta-analysis did not show a significant reduction in perinephric collections with prophylactic drain insertion OR = 0.55 (95% CI: 0.13-2.37), p = 0.42. Finally, there is not good evidence that drain placement reduces superficial wound complications or improves 12-month graft survival. Further work is needed, including well-designed, prospective studies to assess the risks and benefits of drain placement in these patients. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023422685, Identifier PROSPERO CRD42021255795.
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Drenagem , Transplante de Rim , Humanos , Complicações Pós-Operatórias/prevenção & controle , ReoperaçãoRESUMO
Procedural sedation and analgesia (PSA) are a common practice in emergency departments (EDs), aiming to alleviate pain, anxiety, and discomfort during various medical procedures. We have undertaken a systematic review and meta-analysis with the aim of assessing the incidence of adverse events associated with PSA, including those related to individual drugs and various drug combinations. The study adhered to PRISMA guidelines for a systematic review and meta-analysis of adverse events in ED sedation. A comprehensive search strategy was employed across ten databases, supplemented by searches on clinicaltrials.gov and manual reviews of reference lists. Data extraction focused on medication administration and adverse events. The study considered four types of adverse events: cardiac, respiratory, gastrointestinal, and neurological. Only randomized controlled trials (RCTs) focusing on PSA administered to adult patients within the ED setting were included. The statistical analysis employed OpenMeta Analyst to conduct a one-arm meta-analysis, with findings presented alongside their corresponding 95% Confidence Intervals. Forest plots were constructed to combine and evaluate results, and sensitivity analyses were performed to identify sources of heterogeneity. From a literature search of 4246 records, 32 RCTs were deemed suitable for this meta-analysis. The analysis included 6377 procedural sedations. The most common adverse event was hypoxia, with an incidence rate of 78.5 per 1000 sedations (95% CI = 77.5-133.5). This was followed by apnea and hypotension, with incidence rates of 31 (95% CI = 19.5-41.8) and 28.1 (95% CI = 17.4-38.9) per 1,000 sedations, respectively. Agitation and vomiting each occurred in 15.6 per 1,000 sedations (95% CI = 8.7-22.6). Severe adverse events were rare, with bradycardia observed in 16.7 per 1,000 sedations, laryngospasm in 2.9 per 1,000 sedations (95% CI = - 0.1 to 6), intubation in 10.8 per 1,000 sedations (95% CI = 4-17), and aspiration in 2.7 per 1,000 sedations (95% CI = - 0.3 to 5.7). Ketamine is found to be the safest option in terms of respiratory adverse events, with the lowest rates of apnea and hypoxia, making it the least respiratory depressant among the evaluated drugs. Etomidate has the least occurrence of hypotension when used alone. Propofol has the highest incidence of hypotension when used alone and ranks second in hypoxia-related adverse events after midazolam. Using combinations of sedating agents, such as propofol and ketamine, has been found to offer several advantages over single drugs, especially in reducing adverse events like vomiting, intubation difficulty, hypotension, bradycardia, and laryngospasm. The combination significantly reduces the incidence of hypotension compared to using propofol or ketamine individually. Despite the regular use of procedural sedation, it can sometimes lead to serious adverse events. Respiratory issues like apnea and hypoxia, while not common, do occur more often than cardiovascular problems such as hypotension. However, the least frequent respiratory complications, which can also pose a threat to life, include laryngospasm, aspiration, and intubation. These incidents are extremely rare.
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Serviço Hospitalar de Emergência , Adulto , Humanos , Sedação Consciente/métodos , Sedação Consciente/efeitos adversos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
This case report delves into the intricate diagnostic journey of a 42-year-old male presenting with jaundice, abdominal distension, and ascites, where medical imaging, including CT scans and ultrasound, played a central role. Noteworthy radiological findings, such as irregular nodular margins and caudate lobe hypertrophy, illuminated the distinctive pathophysiology of cryptogenic cirrhosis. The study underscores the pivotal role of medical imaging in elucidating complex liver pathologies, emphasizing the relevance of radiological approaches in diagnosing cryptogenic cirrhosis and guiding comprehensive management strategies.
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Introduction: Degenerative cervical myelopathy (DCM) is a form of chronic spinal cord injury, with a natural history of potential for progression over time. Whilst driven by mechanical stress on the spinal cord from degenerative and congenital pathology, the neurological phenotype of DCM is likely to be modified by multiple systemic factors. The role of metabolic factors is therefore of interest, particularly given that ischaemia is considered a key pathological mechanism of spinal cord injury. The objective was therefore to synthesise current evidence on the effect of metabolism on DCM susceptibility, severity, and surgical outcomes. Methods: A systematic review in MEDLINE and Embase was conducted following PRISMA guidelines. Full-text papers in English, with a focus on DCM and metabolism, including diabetes, cardiovascular disease, anaemia, and lipid profile, were eligible for inclusion. Risk of methodological bias was assessed using the Joanna Briggs Institute (JBI) critical assessment tools. Quality assessments were performed using the GRADE assessment tool. Patient demographics, metabolic factors and the relationships between metabolism and spinal cord disease, spinal column disease and post-operative outcomes were assessed. Results: In total, 8,523 papers were identified, of which 57 met criteria for inclusion in the final analysis. A total of 91% (52/57) of included papers assessed the effects of diabetes in relation to DCM, of which 85% (44/52) reported an association with poor surgical outcomes; 42% of papers (24/57) discussed the association between cardiovascular health and DCM, of which 88% (21/24) reported a significant association. Overall, DCM patients with diabetes or cardiovascular disease experienced greater perioperative morbidity and poorer neurological recovery. They were also more likely to have comorbidities such as obesity and hyperlipidaemia. Conclusion: Metabolic factors appear to be associated with surgical outcomes in DCM. However, evidence for a more specific role in DCM susceptibility and severity is uncertain. The pathophysiology and natural history of DCM are critical research priorities; the role of metabolism is therefore a key area for future research focus. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42021268814.
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INTRODUCTION: Degenerative cervical myelopathy (DCM) is a common and progressive neurological condition caused by injury of the cervical spinal cord by degenerative spinal pathology. Delayed diagnosis leading to avoidable and irreversible disability is a major current problem limiting patient outcomes. Lack of sufficient representation of DCM in undergraduate and postgraduate medical curricula may contribute to poor recognition of DCM by non-specialist doctors. The objective of this study was to assess the DCM teaching provision in UK medical schools and the DCM knowledge of UK medical students. METHODS: UK medical students completed a web-based survey distributed nationally through university social media pages, university email bulletins and the national student network of Myelopathy.org. The survey comprised a 19-item questionnaire capturing data on student demographics, myelopathy teaching and myelopathy knowledge. Advertisements were repeated monthly over a 12-month recruitment period and participation was incentivised by entry into an Amazon voucher prize draw. Ethical approval for the study was granted by the Psychology Research Ethics Committee, University of Cambridge (PRE.2018.099). RESULTS: A total of 751 medical students from 32 British medical schools completed the survey. Medical students from all year groups participated. Most students (520; 72%) had not received any medical school teaching about DCM. When students had received DCM teaching, the duration of teaching was minimal (75% < 1 h). A total of 350 students (47%) reported conducting private study on DCM. Modal student self-rating of their own knowledge of DCM was 'terrible' (356; 47%). There was no correlation between a student's subjective rating of their knowledge and their answers to objective questions. A total of 723 (96%) of students expressed interest in learning more about DCM, with lectures the preferred format. CONCLUSIONS: DCM appears to be a neglected condition in medical education which has implications for clinical practice. However, student enthusiasm to undertake private study suggests future teaching interventions will be well-received. Future work is necessary to characterise the format of DCM teaching that is most effective and to subsequently measure how educational interventions translate into clinical benefits.
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Educação de Graduação em Medicina , Doenças da Medula Espinal , Estudantes de Medicina , Humanos , Faculdades de Medicina , Estudos Transversais , Estudantes de Medicina/psicologia , Reino UnidoRESUMO
In this cadaveric study, we analysed digital images of dissected palms to define the location and length of superficial connections between the median and the ulnar nerves (Berrettini communicating branches). We found the connections present in 12 of 27 hands. We used a coordinate model to define their location relative to seven specified landmarks. The model revealed that the Berrettini communicating branches were positioned consistently, and we defined a high-risk zone in the palm that fully contained seven of the 12 connections, while others had minor projections outside the zone. We conclude that awareness of this high-risk zone in the palm can be of some help to reduce the risk of iatrogenic nerve injury, however, any operation in the palm must always be done with great care to visualize and protect any possible anatomically unusual structures.
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Nervo Mediano , Nervo Ulnar , Cadáver , Mãos/inervação , Mãos/cirurgia , Humanos , Nervo Mediano/cirurgia , Nervo Ulnar/anatomia & histologiaRESUMO
STUDY DESIGN: Survey. INTRODUCTION: AO Spine Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy (AO Spine RECODE-DCM) is an international initiative that aims to accelerate knowledge discovery and improve outcomes by developing a consensus framework for research. This includes defining the top research priorities, an index term and a minimum data set (core outcome set and core data elements set - core outcome set (COS)/core data elements (CDE)). OBJECTIVE: To describe how perspectives were gathered and report the detailed sampling characteristics. METHODS: A two-stage, electronic survey was used to gather and seek initial consensus. Perspectives were sought from spinal surgeons, other healthcare professionals and people with degenerative cervical myelopathy (DCM). Participants were allocated to one of two parallel streams: (1) priority setting or (2) minimum dataset. An email campaign was developed to advertise the survey to relevant global stakeholder individuals and organisations. People with DCM were recruited using the international DCM charity Myelopathy.org and its social media channels. A network of global partners was recruited to act as project ambassadors. Data from Google Analytics, MailChimp and Calibrum helped optimise survey dissemination. RESULTS: Survey engagement was high amongst the three stakeholder groups: 208 people with DCM, 389 spinal surgeons and 157 other healthcare professionals. Individuals from 76 different countries participated; the United States, United Kingdom and Canada were the most common countries of participants. CONCLUSION: AO Spine RECODE-DCM recruited a diverse and sufficient number of participants for an international PSP and COS/CDE process. Whilst PSP and COS/CDE have been undertaken in other fields, to our knowledge, this is the first time they have been combined in one process.
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INTRODUCTION: Degenerative cervical myelopathy (DCM) is the commonest cause of adult spinal cord impairment worldwide, encompassing chronic compression of the spinal cord, neurological disability and diminished quality of life. Evidence on the contribution of environmental factors is sparse; in particular, the role of nutrition in DCM is unknown. The objective of this review was to assess the effect of nutrition on DCM susceptibility, severity and surgical outcome. METHODS: A systematic review in MEDLINE and Embase was conducted following PRISMA guidelines. Full-text papers in English papers, focussing on cervical myelopathy and nutrition, published before January 2020 were considered eligible. Quality assessments were performed using the GRADE assessment tool. Patient demographics, nutritional factor and DCM outcomes measures were recorded. Relationships between nutritional factors, interventions and disease prognosis were assessed. RESULTS: In total, 5835 papers were identified of which 44 were included in the final analysis. DCM patients with pathological weight pre-operatively were more likely to see poorer improvements post-surgically. These patients experienced poorer physical and mental health improvements from surgery compared to normal weight patients and were more likely to suffer from post-operative complications such as infection, DVT, PE and hospital readmissions. Two trials reporting benefits of nutritional supplements were identified, with 1 suggesting Cerebrolysin to be significant in functional improvement. An unbalanced diet, history of alcohol abuse and malnourishment were associated with poorer post-operative outcome. CONCLUSION: Although the overall strength of recommendation is low, current evidence suggests nutrition may have a significant role in optimising surgical outcome in DCM patients. Although it may have a role in onset and severity of DCM, this is a preliminary suggestion. Further work needs to be done on how nutrition is defined and measured, however, the beneficial results from studies with nutritional interventions suggest nutrition could be a treatment target in DCM.
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Microorganisms that inhabits human digestive tract affect global health and enteric disorders. Previous studies have documented the effectiveness and mode of action of probiotics and classified as human-friendly biota and a competitor to enteric pathogens. Statistical studies reported more than 1.5 billion cases of gastrointestinal infections caused by enteric pathogens and their long-term exposure can lead to mental retardation, temporary or permanent physical weakness, and leaving the patient susceptible for opportunistic pathogens, which can cause fatality. We reviewed previous literature providing evidence about therapeutic approaches regarding probiotics to cure enteric infections efficiently by producing inhibitory substances, immune system modulation, improved barrier function. The therapeutic effects of probiotics have shown success against many foodborne pathogens and their therapeutic effectiveness has been exponentially increased using genetically engineered probiotics. The bioengineered probiotic strains are expected to provide a better and alternative approach than traditional antibiotic therapy against enteric pathogens, but the novelty of these strains also raise doubts about the possible untapped side effects, for which there is a need for further studies to eliminate the concerns relating to the use and safety of probiotics. Many such developments and optimization of the classical techniques will revolutionize the treatments for enteric infections.
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INTRODUCTION: Degenerative cervical myelopathy (DCM) is a common, disabling and progressive neurological condition triggered by chronic compression of the cervical spinal cord by surrounding degenerative changes. Early diagnosis and specialist management are essential to reduce disability, yet time to diagnosis is typically prolonged. Lack of sufficient representation of DCM in undergraduate and postgraduate medical curricula may contribute to the poor recognition of DCM by non-specialist doctors in clinical practice.In this study, our objective, therefore, is to assess DCM teaching provision in medical schools throughout the UK and to assess the impact of teaching on the DCM knowledge of UK medical students. METHODS AND ANALYSIS: A 19-item questionnaire capturing data on medical student demographics, myelopathy teaching and myelopathy knowledge was designed. Ethical approval was granted by the Psychology Research Ethics Committee, University of Cambridge. An online survey was hosted on Myelopathy.org, an international myelopathy charity. Students studying at a UK medical school are eligible for inclusion. The survey is advertised nationally through university social media pages, university email bulletins and the national student network of Myelopathy.org. Advertisements are scheduled monthly over a 12-month recruitment period. Participation is incentivised by entering consenting participants of completed surveys to an Amazon voucher prize draw. Responses are anonymised using participant-chosen unique identifier codes. A participant information sheet followed by an explicit survey question captures participant informed consent. Regular updates on the progress of the study will be published on Myelopathy.org. ETHICS AND DISSEMINATION: Ethical approval for the study was granted by the Psychology Research Ethics Committee, University of Cambridge (PRE.2018.099). The findings of the study described in this protocol, and all other related work, will be submitted for publication in a peer-reviewed journal and will be presented at scientific conferences.