Laparoscopic sleeve gastrectomy in 108 obese children and adolescents aged 5 to 21 years.

OBJECTIVE: To report experience with laparoscopic sleeve gastrectomy (LSG) in 108 severely obese children and adolescents. BACKGROUND: Obesity during childhood and adolescence can be accompanied by serious long-term adverse health and longevity outcomes. With increased use of bariatric surgery to treat obesity in these patients, diverse guidelines have been published, most of which exclude children aged younger than 14 years. Few reports describe LSG in children and adolescents, delaying determining its safety and effectiveness and developing guidance regarding its use. METHODS: A retrospective review of LSG performed from March 2008 through February 2011 by a single surgeon at King Saud University Hospitals, Riyadh, Saudi Arabia, included 108 patients aged 5 through 21 years. RESULTS: Patients attending follow-up visits at 3 (n = 88), 6 (n = 76), 12 (n = 41), and 24 (n = 8) months postoperatively experienced median excess weight loss (EWL) of 28.9%, 48.1%, 61.3%, and 62.3%, respectively. At 6 and 12 months follow-up, 42.1% (n = 32) and 73.2% (n = 30) of patients achieved at least 50% EWL, whereas 7.9% (n = 6) and 4.9% (n = 2) had 25% or less EWL, respectively. There were no serious postoperative complications and no adverse sequelae developed during the current follow-up. Available comorbidity data indicate resolution of dyslipidemia, 21 of 30 (70.0%); hypertension, 27 of 36 (75.0%); prehypertension, 15 of 18 (83.3%); symptoms of obstructive sleep apnea, 20 of 22 (90.9%); diabetes, 15 of 16 (93.8%); and prediabetes, 11 of 11 (100.0%). CONCLUSIONS: LSG resulted in successful short-term weight loss in more than 90% of pediatric patients and 70% or more comorbidity resolution during up to 24 months of follow-up. Long-term data are necessary to evaluate persistence of weight loss and maturation to adulthood.

Quality and strength of evidence of the Infectious Diseases Society of America clinical practice guidelines.

OBJECTIVE: To describe the distribution and temporal trends of the quality and strength of evidence supporting recommendations in the Infectious Diseases Society of America (IDSA) clinical practice guidelines. METHODS: Guidelines either issued or endorsed by IDSA from March 1994 to July 2009 were evaluated using the IDSA-US Public Health Service Grading System. In this system, the letters A-E signify the strength of the recommendation, and numerals I-III indicate the quality of evidence supporting these recommendations. The distribution of the guideline recommendations among strength of recommendation and quality of evidence classes was quantified. Temporal changes between the first and current guideline version were evaluated. RESULTS: Approximately one-half (median, 50.0%; interquartile range [IQR], 38.1%-58.6%) of the recommendations in the current guidelines are supported by level III evidence (derived from expert opinion). Evidence from observational studies (level II) supports 31% of recommendations (median, 30.9%; IQR, 23.3%-43.2%), whereas evidence based on ≥ 1 randomized clinical trial (level I) constitutes 16% of the recommendations (median, 15.8%; IQR, 5.8%-28.3%). The strength of recommendation was mainly distributed among classes A (median, 41.5%; IQR, 28.7%-55.6%) and B (median, 40.3%; IQR, 27.1%-47.9%). Among guidelines with ≥ 1 revised version, the recommendations moved proportionately toward more level I evidence (+12.4%). Consequently, there was a proportional increase in class A recommendations (+11.1%) with a decrease in class C recommendations (-23.5%). CONCLUSIONS: The IDSA guideline recommendations are primarily based on low-quality evidence derived from nonrandomized studies or expert opinion. These findings highlight the limitations of current clinical infectious diseases research that can provide high-quality evidence. There is an urgent need to support high-quality research to strengthen the evidence available for the formulation of guidelines.

Cerebral venous thrombosis in Saudi Arabia. Clinical variables, response to treatment, and outcome.

OBJECTIVE: To investigate cerebral venous thrombosis (CVT) clinical presentations, risk factors, and response to treatment in Saudi Arabia. METHODS: Retrospective analysis of the King Fahad Medical City, Riyadh, acute stroke database from April 2005 through February 2008 revealed 22 patients with CVT. Hypercoagulable work-up and neuroimaging were performed. RESULTS: Sixteen patients were female (72.7%), and the median age was 35 years. Clinical presentations included: headache (77.3%), seizures (54.5%), focal neurological signs (54.5%), and decreased level of consciousness (50%). Over two-thirds (n=11; 69%) of female patients had a history of oral contraceptive use, which was the most common risk factor. Protein S deficiency (n=3), antiphospholipid antibody syndrome secondary to systemic lupus erythematosus (SLE) (n=1), rhinocerebral mucormycosis (n=1), leukemia (n=1), non-Hodgkin`s lymphoma (n=1), sepsis (n=1), and unknown (n=6) were causes. Affected areas included superior sagittal (n=13), transverse (n=16), sigmoid (n=14), straight (n=6), and cavernous sinus (n=1); internal cerebral vein (n=2); vein of Galen (n=3); cortical veins (n=10); and internal jugular vein (n=12). Two patients had quadriparesis, and 2 patients died. The remainder (n=18, 81.8%) improved. Bilateral hemorrhagic presentation or venous infarction, deep venous system thrombosis, and underlying malignancy had less favorable results. CONCLUSION: Presentations in our series were similar to those in other reports, although altered consciousness and seizures were more common. Cortical vein involvement was also higher than commonly reported. Oral contraceptive use was a primary risk factor in female patients. Outcomes were favorable in 81.8% of patients.

The role of valve surgery in infective endocarditis management: a systematic review of observational studies that included propensity score analysis.

BACKGROUND: The potential role of valve surgery in infective endocarditis (IE) management is controversial. No randomized trials have been conducted to date; accordingly, some studies use propensity score analysis (PSA) to minimize selection bias in observational studies. METHODS: A systematic review of the literature addressing the role of valve surgery in IE was performed. Studies in which PSA was applied to the management of IE were identified using Medline, Web of Science, Zetoc, and Article First from inception to June 2007. Cohort studies that compared valve surgery (combined with antimicrobial therapy) to antimicrobial therapy alone and used PSA to adjust for selection bias were eligible. Methodological details and outcomes were compared to assess methodological quality. RESULTS: Six cohort studies that enrolled a total of 3,409 patients with either native valve endocarditis (NVE) or prosthetic valve endocarditis (PVE) were eligible. The proportions of IE cases undergoing valve surgery ranged from 28.9% to 41.7% for PVE and from 20.8% to 49.3% for NVE. Two studies suggested a statistically significant survival benefit with surgery in patients with NVE. Data from 2 other patient cohorts (PVE and NVE) revealed conflicting results. No statistically significant associations were found in the remaining studies. CONCLUSIONS: There are several limitations of available cohort studies that assess the role of valve surgery in IE. Well-designed prospective studies that address these limitations are needed to further define the role of surgery in IE. Until then, careful scrutiny is warranted when making management decisions in complicated, left-sided IE.

Conclusion about the association between valve surgery and mortality in an infective endocarditis cohort changed after adjusting for survivor bias.

OBJECTIVE: Survivor bias commonly weakens observational studies, even those published in premier journals. It occurs because patients who live longer are more likely to receive treatment than those who die early. We sought to quantify the effect of survivor bias on the association between valve surgery and mortality in infective endocarditis (IE). STUDY DESIGN AND SETTING: The study cohort included 546 IE patients. We compared the hazard ratios (HR) resulting from two propensity score analysis approaches that adjusted for survivor bias (time-dependent variable and matching on follow-up time) with those achieved using the same models but without that adjustment (time-fixed variable). RESULTS: In the total cohort, the HR of surgery in the time-dependent model was 1.9 (95% confidence interval [CI] = 1.1-3.2; P = 0.03) vs. 0.9 (95% CI = 0.5-1.4; P = 0.53) in the time-fixed model. In the propensity score-matched subset, the HR of surgery was 1.3 (95% CI = 0.5-3.1; P = 0.56) and 0.8 (95% CI = 0.4-1.7; P = 0.57) in the subset with and without matching on follow-up time, respectively. CONCLUSION: Adjusting for survivor bias changed the conclusion about the association between valve surgery and mortality in IE. Researchers should be aware of this bias when evaluating observational studies of treatment efficacy.

Stenotrophomonas maltophilia infections of intact skin: a systematic review of the literature.

To highlight the importance of intact skin infection syndromes caused by Stenotrophomonas maltophilia, we review 17 reported cases. Skin infection syndrome presentations included metastatic cellulitis (58%), primary cellulitis (23%), and ecthyma gangrenosum (17%). Associated risk factors were hematologic malignancies and chemotherapy (94%), neutropenia (94%), presence of central venous catheter (17%), and exposure to broad-spectrum antibiotics (84%). The diagnosis was supported by cultures of skin biopsy specimens (35%), blood cultures (24%), or both (41%). Trimethoprim-sulfamethoxazole was the treatment of choice (76%), and outcomes were favorable (71%).

Corticosteroid administration and outcome of adolescents and adults with acute bacterial meningitis: a meta-analysis.

OBJECTIVE: To systematically assess the effect of the adjunctive administration of corticosteroids in the treatment of acute bacterial meningitis. METHODS: We performed a systematic review and meta-analysis by searching several databases for reports (published from January 1966 through February 2008) of placebo-controlled randomized trials of corticosteroid use in the treatment of adolescents and adults with acute bacterial meningitis. We used random-effects models. Sources of heterogeneity were explored by preplanned subgroup analyses. RESULTS: The 4 eligible trials (published between 1999 and 2007) were of high methodological quality and included 1261 adult patients. Overall, the short-term mortality rate associated with corticosteroid administration was not significantly lower than that associated with placebo (relative risk [RR], 0.81; 95% confidence interval [CI], 0.54-1.20; I(2)=54%). A significant interaction was found between the effect of corticosteroids and the income status of the country (P=.02) and the prevalence of infection with human immunodeficiency virus (HIV) among study populations (P=.03). The administration of corticosteroids resulted in a lower short-term mortality rate than did the administration of placebo in high-income countries (pooled RR, 0.5; 95% CI, 0.27-0.92; I(2)=0%) and in the studies with a low prevalence of infection with HIV (RR, 0.66; 95% CI, 0.44-0.99; I(2)=0%). In studies from high-income countries, the number needed to treat with corticosteriods to prevent 1 death and 1 neurologic sequela was 12.5 (95% CI, 7.1-100.0) and 11.0 (95% CI, 5.6-100.0), respectively. CONCLUSION: Our meta-analysis suggests that the adjunctive administration of corticosteroids is beneficial in the treatment of adolescents and adults with bacterial meningitis in patient populations similar to those seen in high-income countries and in areas with a low prevalence of HIV infection.

Statins for the prevention and treatment of infections: a systematic review and meta-analysis.

BACKGROUND: Emerging epidemiological evidence suggests that statin use may reduce the risk of infections and infection-related complications. Our objective was to examine the association between statin use and the risk of infections and related outcomes. METHODS: We searched several electronic databases from inception through December 2007 for randomized trials and cohort studies that examined the association between statin use and the risk or outcome of infections. Data on study characteristics, measurement of statin use, outcomes (adjusted for potential confounders), and quality assessment were extracted. RESULTS: Sixteen cohorts were eligible and differed in representativeness, outcome assessment, and comparability of exposed (statin) and unexposed (nonstatin) groups. Nine cohorts addressed the role of statins in treating infections: bacteremia (n = 3), pneumonia (n = 3), sepsis (n = 2), and bacterial infection (n = 1). The pooled adjusted effect estimate was 0.55 (95% confidence interval, 0.36-0.83; I(2) = 76.5%) in favor of statins. Seven cohorts addressed infection prevention in patients with vascular diseases (n = 3), chronic kidney disease (n = 1), diabetes (n = 1), intensive care unit-acquired infections (n = 1), and in general practice (n = 1). The pooled effect estimate was 0.57 (95% confidence interval, 0.43-0.75; I(2) = 82%) in favor of statin use; there was some evidence of publication bias for this analysis (Egger test; P = .07). Meta-regression did not identify potential effect modifiers that explain the between-study heterogeneity. CONCLUSIONS: Results for our meta-analysis suggest that statin use may be associated with a beneficial effect in treating and preventing different infections. Given the presence of heterogeneity and publication bias, there is a need for randomized trials to confirm the benefit of statin use in this context.