Comparison of low versus high (standard) intraabdominal pressure during laparoscopic colorectal surgery: systematic review and meta-analysis.

BACKGROUND: To evaluate outcomes of low with high intraabdominal pressure during laparoscopic colorectal resection surgery. METHODS: A systematic search of multiple electronic data sources was conducted, and all studies comparing low with high (standard) intraabdominal pressures were included. Our primary outcomes were post-operative ileus occurrence and return of bowel movement/flatus. The evaluated secondary outcomes included: total operative time, post-operative haemorrhage, anastomotic leak, pneumonia, surgical site infection, overall post-operative complications (categorised by Clavien-Dindo grading), and length of hospital stay. Revman 5.4 was used for data analysis. RESULTS: Six randomised controlled trials (RCTs) and one observational study with a total of 771 patients (370 surgery at low intraabdominal pressure and 401 at high pressures) were included. There was no statistically significant difference in all the measured outcomes; post-operative ileus [OR 0.80; CI (0.42, 1.52), P = 0.50], time-to-pass flatus [OR -4.31; CI (-12.12, 3.50), P = 0.28], total operative time [OR 0.40; CI (-10.19, 11.00), P = 0.94], post-operative haemorrhage [OR 1.51; CI (0.41, 5.58, P = 0.53], anastomotic leak [OR 1.14; CI (0.26, 4.91), P = 0.86], pneumonia [OR 1.15; CI (0.22, 6.09), P = 0.87], SSI [OR 0.69; CI (0.19, 2.47), P = 0.57], overall post-operative complications [OR 0.82; CI (0.52, 1.30), P = 0.40], Clavien-Dindo grade ≥ 3 [OR 1.27; CI (0.59, 2.77), P = 0.54], and length of hospital stay [OR -0.68; CI (-1.61, 0.24), P = 0.15]. CONCLUSION: Low intraabdominal pressure is safe and feasible approach to laparoscopic colorectal resection surgery with non-inferior outcomes to standard or high pressures. More robust and well-powered RCTs are needed to consolidate the potential benefits of low over high pressure intra-abdominal surgery.

Hepatojugular 'reflex' or 'reflux'? A tale of two vowels.

SUMMARY: Hepatojugular reflux is an important, prognostic clinical sign in the field of medicine. The majority of medical students or clinicians may attempt to elicit this sign during abdominal or cardiovascular examinations. However, some individuals may incorrectly call it the hepatojugular 'reflex' rather than a 'reflux'. In the first instance, that may not pose a problem to either patient or clinician-however, it may reflect a lack of basic understanding of how the human body works.

Evaluation of National Anaesthetics Teaching in Undergraduate Medicine (ENATUM).

BACKGROUND: During a global pandemic where anaesthetists play a pertinent role in treating coronavirus 2019 (COVID-19), it is crucial to inspire medical students to consider a career in anaesthetics and perioperative care. Where anaesthetic skills are vital for all surgical foundation doctors, regardless of whether they have a rotation in anaesthetics, this study seeks to establish the current level of exposure to anaesthetics in the UK medical schools' curriculum and evaluate if the current anaesthetic undergraduate curriculum is sufficient to prepare students to pass their exams and perform the duties expected of them as future junior doctors. METHODS: A 35-item structured questionnaire, registered at University College London Hospital Research & Development (R&D), was distributed amongst foundation doctors who had graduated from UK universities within the previous 3 years between August and October 2020. RESULTS: In total, 239 participants completed the questionnaire from 34 UK medical schools. Despite 90.0% of participants being allocated an 'anaesthesia' placement, 54.0% spent <15 hours shadowing an anaesthetist throughout their medical school. Of participants, 38.5% agreed that their anaesthetic teaching was sufficient compared to teaching of other specialities, with 48.6% of students not satisfied with the teaching provided to meet anaesthetic learning outcomes set by The Royal College of Surgeons of England; 72.4% said they would have benefited from additional anaesthetic teaching, with 80.7% stating it would have increased understanding into the speciality; and 71.5% stated a short course in anaesthetics alongside undergraduate training would have been beneficial. CONCLUSIONS: Our results demonstrate that there is a lack of standardization in undergraduate anaesthetics teaching nationally and an additional undergraduate anaesthetic teaching programme is required to increase understanding and provide further insight into anaesthetics. Key messages:  The emergence of the coronavirus 2019 (COVID-19) pandemic has halted undergraduate medical education, in particular perioperative medicine and surgery.Exposure to anaesthesia is already limited in the medical undergraduate curriculum, with a limited number of anaesthesia-themed foundation rotations available for junior doctors.Recent UK graduates feel that undergraduate anaesthetics education is inadequate at medical school, reporting a lack of confidence in applying undergraduate anaesthesia learning outcomes.Additional anaesthetic teaching and online teaching methods are suggested ways of improving the delivery of undergraduate anaesthetic education.Can a national, standardized anaesthetics teaching curriculum improve the undergraduate knowledge base of anaesthesia?

The impact of busulfan on the testicular structure in prepubertal rats: A histological, ultrastructural and immunohistochemical study.

Busulfan is a widely used cancer chemotherapeutic agent. Temporary or permanent sterility in male patients is one of the most common side effects of this drug. The present study was performed to evaluate the changes in the microscopic structure of the testes of prepubertal rats, as well as the changes in PCNA and caspase-3 immune expression, at different durations after busulfan administration. The rats were 5 weeks old and were divided into two main groups. Control group and busulfan treated group. Busulfan treated group received a single dose of busulfan (40 mg/kg), then animals were subdivided to three subgroups; IIa, IIb, IIc which were sacrificed after four, ten and twenty weeks, respectively, from the beginning of the experiment. Light and electron microscopic studies were done. Serum testosterone level and relative testes weight were assessed. Immunohistochemical staining for anti-proliferating cell nuclear antigen (PCNA) and anti-caspase-3 antigen was also done. Morphometric and statistical studies were carried out. Group II revealed histological and ultrastructural degenerative changes including congested blood vessels and degenerated spermatogenic epithelium, Sertoli cells, and Leydig cells. These changes were more evident after 10 weeks of busulfan administration and were accompanied by absence of mature sperms in the lumen of seminiferous tubules. These changes were associated with a significant reduction in relative testes weight, testosterone level, germinal epithelial height and seminiferous tubule diameter. Moreover, PCNA and caspase-3 immune expression was significantly altered in busulfan treated group. Mild improvement in testicular structure was observed 20 weeks after busulfan treatment.

Do Hypoalbuminaemia Increase the Risk of Surgical Site Infection in Neck of Femur Fracture Patients: A Systematic Review and Meta-Analysis.

Serum albumin plays an important role in physiological and inflammatory haemostasis, and low serum levels are linked with an increased incidence of surgical site infections (SSI). Although this has been demonstrated in the spine and elective arthroplasty settings, there is a paucity of evidence with regard to the effect of low serum albumin on rates of SSI following surgery for adult patients suffering from traumatic and acute hip fractures. A systematic review was conducted using the PRISMA guidelines. Four databases were searched for randomised controlled trials (RCTs), cohort studies, and case-controlled studies. The risk of bias was assessed using the Newcastle-Ottawa Score (NOS). Data was collected and pooled using RevMan Web software. Results were reported as odds ratios (OR) with 95% confidence intervals (CI) and statistical significance of p <0.05. An inverse variance model was used in the meta-analysis. Six retrospective studies (five cohorts and one case-control) with a total of 43,059 patients were included. 45.3% (n=19 496) had low serum albumin (<3.5 g/dL). Hypoalbuminemia was associated with a significantly higher risk of any form of SSI (OR 1.25, p=0.008) and deep SSI (OR 1.76, p=0.05). There was no statistical significance between hypoalbuminemia and the incidence of superficial SSI (OR 1.06, p=0.77). Organ-space SSI was associated with hypoalbuminemia, although one study reported this with poor statistical significance (OR 8.74, p<0.054). Hypoalbuminemia increases the risk of most forms of surgical site infections, both superficial and deep. There is a weak conclusion to draw between the incidence of deep-space organ infections and low serum albumin.

Optimized neural network-based model to predict the shear strength of trapezoidal-corrugated steel webs.

Beam-like members use corrugated webs to increase their shear strength, stability, and efficiency. The corrugation positively affects the members' structural characteristics, especially those governed by the web parameters, such as the shear strength, while reducing the total weight. Existing code and analytical models for predicting the shear strength of trapezoidal corrugated steel webs (TCSWs) are summarized. This paper presents an optimized Artificial Neural Network (ANN)-based model to estimate the shear strength of steel girders with a TCSW subjected to a concentrated force. A database of 206 experimental results from the literature is used to feed the ANNs. Six geometrical and material parameters were identified as input variables, and the experimental shear strength at failure was considered the output variable. Four hyperparameter optimization techniques are applied to refine the ANN models: Bayesian Optimization (BO), Limited-memory Broyden-Fletcher-Goldfarb-Shanno (L-BFGS), Firefly Algorithm (FA), and African Buffalo Optimization (ABO). The performance metrics indicate that the ABO-ANN model is the most effective among these. The predictions of the developed ML model were also compared with those of existing code and analytical models. The comparisons illustrated that the ANN-based model outperforms the other existing models. The sensitivity analysis using the proposed ANN-based model captured the relationships and interactions among the geometric and material parameters and their impact on shear strength. One main finding is that the corrugation angle in the 35-45° range maximized the TCSW shear strength.

Level 1a Evidence Comparing Use of Antibiotics Versus No Antibiotics in Management of Acute Left-Sided Uncomplicated Diverticulitis.

BACKGROUND: Acute uncomplicated diverticulitis (AUD) is a common cause of acute abdominal pain. Recent guidelines advise selective use of antibiotics in AUD patients. This meta-analysis aimed to compare the effectiveness of no antibiotics vs antibiotics in AUD patients. METHODS: This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify randomized controlled trials (RCTs) involving AUD patients which compared the use of antibiotics with no antibiotics. Pooled outcome data was calculated using random effects modeling with 95% confidence intervals (CIs). RESULTS: 5 RCTs with 1934 AUD patients were included. 979 patients were managed without antibiotics (50.6%). Patients in the no antibiotic and antibiotic groups had comparable demographics (age, sex, and body mass index) and presenting features (temperature, pain score, and C-reactive protein levels). There was no significant difference in rates of complicated diverticulitis (OR: .61, 95% CI: 0.27-1.36, P = .23), abscess (OR: .51, 95% CI: .08-3.25, P = .47) or fistula (OR: .33, 95% CI: .03-3.15, P = .33) formation, perforation (OR: .98, 95% CI: .32-3.07, P = .98), recurrence (OR: .96, 95% CI: .66-1.41, P = .85), need for surgery (OR: 1.36, 95% CI: .47-3.95, P = .37), mortality (OR: 1.27, 95% CI: .14-11.76, P = .82), or length of stay (MD: .215, 95% CI: -.43-.73, P = .61) between the 2 groups. However, the likelihood of readmission was higher in the antibiotics group (OR: 2.13, 95% CI: 1.43-3.18, P = .0002). CONCLUSION: There is no significant difference in baseline characteristics, clinical presentation, and adverse health outcomes between AUD patients treated without antibiotics compared to with antibiotics.

Toothpick perforates small bowel-mimicking diverticulitis.

Bowel perforation is an emergency condition that requires critical thinking and readily intervention; nevertheless, on occasions, its presentation can be challenging to diagnose. Several etiologies could cause bowel perforation, including obstruction, mass, inflammation, ischemia, etc. On rare occasions, a foreign body could be the cause of perforation, which mandates a detailed history and focused review of the images when the patient's condition allows. We report a case of ileal perforation caused by an ingested wooden toothpick that was suspected on the CT images, which the patient has no memory of ingesting.

Blood Group and Response to Bariatric Surgery in Morbidly Obese Patients: A Retrospective Study in Saudi Arabia.

OBJECTIVES: To explore the relationship between the blood group of patients and their response to bariatric surgery and to identify predictors of better outcomes. METHODS: This was a retrospective cross-sectional analysis of patients who underwent laparoscopic sleeve gastrectomy for morbid obesity between 2014 and 2020 at King Saud University Medical City in Riyadh, Saudi Arabia. RESULTS: This study included 1434 individuals. The mean change in BMI (pre- versus post-BMI) differed statistically significantly between blood groups (p ≤ 0.01). The greatest drop in body weight was seen in individuals with the AB-negative blood type (56.0 (21.4) kg), which corresponds to the greatest percentage of reduction from baseline (47.7% (14.8)). The mean BMI of the patients decreased by 34.7% (9.2) from a mean pre-operation BMI of 45.5 (8.4) kg/m2 to 29.7 (6.1) kg/m2 (p ≤ 0.001). After laparoscopic sleeve gastrectomy, male patients and those with the B-negative blood type are more likely to see a greater BMI reduction (pre-operation compared to post-operation) (p ≤ 0.05). CONCLUSIONS: For morbidly obese patients, laparoscopic sleeve gastrectomy demonstrated promising weight loss outcomes. Blood groups may be able to predict the success rate of bariatric surgery in morbidly obese patients.

Medication take-back programs in Qatar: Parental perceptions.

PURPOSE: To identify parental perception of a take-back program for medications. MATERIALS AND METHODS: A cross-sectional study using a questionnaire was conducted at Hamad Medical Corporation, the only tertiary pediatric hospital in the State of Qatar at the time of the study. Qatar is a rapidly developing country with limited national data on the awareness of medication misuse among adults living with children at home and on the safety practices regarding medication disposal. RESULTS: 305 questionnaires were completed (response rate = 90%). More than 80% of parents were in between 20 and 39 years of age, 70% of them were females, and 80% were college graduates. Approximately 90% of participants have immediate relatives who were taking medications for chronic diseases. Almost 60% of parents stated that they keep unused medications at home, whereas 10% were not aware of the fate of the left over medications. Approximately 95% of the parents dispose the expired medications. In terms of the mode of disposing the medications, 66% of caregivers dispose the medication bottle or package in the trash can, whereas 14% remove the medications from the bottles or packages and throw them in the trash, and 15% put them through the drain. When asked if participants read disposal measures in the medication pamphlet, only 10% answered "always," whereas 26% answered "sometimes." Participants were asked if they have heard of any medications take-back programs, 75% answered no, whereas 14% were not sure. However, almost 60% of them will use the take-back program if available and 18% were not sure. CONCLUSION: Parents residing in the State of Qatar have deficiencies in knowledge about medication disposal. Parent's attitudes and perceptions are considered indispensable targets for community health intervention. Our next step is to share our data with the ministry of health to spread awareness about the proper disposal of medicines and take-back programs in Qatar.

Parental perception of medications safe storage in the State of Qatar.

PURPOSE: The purpose of this study is to identify parental perception of household medication storage. METHODS: A prospective cross-sectional study utilizing a questionnaire was carried out at Hamad Medical Corporation, the solely tertiary pediatric hospital in the State of Qatar at the time of the study. Qatar is a young developing country with limited data on the awareness of medication storage among adults with children at home and on the safety practices regarding medication storage. RESULTS: Three hundred and five questionnaires were completed. The vast majority of parents were married, one-third of them were males, and more than three quarters were college graduates and younger than 40 years of age. Almost 80% of the parents had more than three children but less than seven. In addition, 23% of participants were health-care workers. Almost 90% of the participants stored medications in a place that is easy to reach. However, the same percentage stated that those medications were stored in a locked place and that children did not have access to them. Approximately 10% of caregivers store multiple medications in one bottle, and the same percentage of participants do not check the expiration date on the medication labels. In terms of the most common medications stored at home, antihypertensives were on top of the list. Our study has shown that parental education and being a health-care worker were each associated with the difficulty in reaching medications (P = 0.006 and P = 0.011, respectively). Moreover, the percentage of participants who shared medications was significantly higher among those who were not working in the health-care section compared to those who were (P = 0.004). In addition, being a female parent and a college graduate was associated with the possibility of keeping excess or leftover medications at home (P = 0.025). CONCLUSION: Parents residing in the State of Qatar have some deficiencies in knowledge about medication storage. Parent's attitudes and perceptions are deemed vital objectives for population's health intervention.

Effect of anodal versus cathodal transcranial direct current stimulation on stroke rehabilitation: a pilot randomized controlled trial.

OBJECTIVE: We compared the long-term effect of anodal versus cathodal transcranial direct current stimulation (tDCS) on motor recovery in patients after subacute stroke. METHODS: Forty patients with ischemic stroke undergoing rehabilitation were randomly assigned to 1 of 3 groups: Anodal, Cathodal (over-affected and unaffected hemisphere, respectively), and Sham. Each group received tDCS at an intensity of 2 mA for 25 minutes daily for 6 consecutive days over of the motor cortex hand area. Patients were assessed with the National Institutes of Health Stroke Scale (NIHSS), Orgogozo's MCA scale (OMCASS), the Barthel index (BI), and the Medical Research Council (MRC) muscle strength scale at baseline, after the sixth tDCS session and then 1, 2, and 3 months later. Motor cortical excitability was measured with transcranial magnetic stimulation (TMS) at baseline and after the sixth session. RESULTS: By the 3-month follow-up, all groups had improved on all scales with P values ranging from .01 to .0001. Improvement was equal in the Anodal and Cathodal groups. When these treated groups were combined and compared with Sham, significant interactions were seen for the OMCASS and BI scales of functional ability (P = .002 for each). There was increased cortical excitability of the affected hemisphere in all groups with the changes being greater in the real versus sham groups. There were borderline significant improvements in muscle strength. CONCLUSION: A brief course of 2 types of tDCS stimulation is superior to sham stimulation in enhancing the effect of rehabilitation training to improve motor recovery after stroke.