Is bridge to surgery stenting a safe alternative to emergency surgery in malignant colonic obstruction: a meta-analysis of randomized control trials.

BACKGROUND: Despite studies showing superior results in terms of reduced stoma rate and higher primary anastomosis rate, the safety of bridge to surgery stenting (BTS stent) for left-sided malignant colonic obstruction, especially in oncological terms, remains a concern. AIM: The aim of this meta-analysis was to evaluate whether BTS stent is a safe alternative to emergency surgery (EmS). METHODS: Randomized control trials (RCTs) comparing BTS stent and EmS for left-sided colonic obstruction caused by primary cancer of the colon, up to Sep 2018, were retrieved from the Pubmed, Embase database, clinical trials registry of U. S. National Library of Medicine and BMJ and Google Search. RESULTS: There were seven eligible RCTs, involving a total of 448 patients. Compared to EmS, BTS stent had a significantly lower risk of overall complications (RR = 0.605; 95% CI 0.382-0.958; p = 0.032). However, the overall recurrence rate was higher in the BTS stent group (37.0% vs. 25.9%; RR = 1.425; 95% CI 1.002-2.028; p = 0.049). BTS stent significantly increased the risk of systemic recurrence (RR = 1.627; 95% CI 1.009-2.621; p = 0.046). This did not translate into a significant difference in terms of 3-year disease-free survival or 3-year overall survival. CONCLUSION: BTS stent is associated with a lower rate of overall morbidities than EmS. However, BTS stent was associated with a greater chance of recurrence, especially systemic recurrence. Clinicians ought to be aware of the pros and cons of different interventions and tailor treatments for patients suffering from left-sided obstructing cancer of the colon.

Clips closure versus endoloop ligation in laparoscopic appendectomy: a systematic review and meta-analysis of comparative studies.

Introduction: Appendiceal stump closure (ASC) is a key step in performing laparoscopic appendicectomy. Currently, there is no gold standard method to achieve this goal. The ideal method should be safe, easily available, and have a short learning curve. Out of all those appendiceal stump closure methods, the use of hem-o-Lok demonstrates its feasibility in replacing the traditionally used endoloop. In this systematic review and meta-analysis, the authors aim to review the currently available evidence addressing the topic of interest. Method: The PubMed and Embase databases were searched with the paired search terms appendicitis, clip, and endoloop by two authors separately. The quality of the randomized controlled trials was assessed with the Cochrane risk of bias tool, and the quality of the observational studies was assessed with the Newcastle-Ottawa scale. Meta-analysis was conducted with Cochrane Review Manager version 5.4. Result: Eighteen studies were included for quantitative analysis. The appendiceal stump closure time was shortened by 2 min 7 s using a hem-o-lok with 95% CI 1 min 48 s-2 min 26 s, p less than 0.00001. The pooled results of 6 randomized controlled trials demonstrated a statistically significant reduction in operative time of 5.15 min from adopting the hem-o-lok approach (p=0.001, 95% CI -2.05 to -8.24 min). Both endoloop and hem-o-lok demonstrated a comparable postoperative hospital stay and infective complication profile. Conclusion: The application of Hem-o-Lok demonstrates a comparable to endoloop ligation in terms of operative time and a potential benefit on the complication. When considering financial and technical aspects, it serves as an alternative to endoloop.

2020 American College of Rheumatology Guideline for the Management of Gout.

OBJECTIVE: To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations. METHODS: Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional. RESULTS: Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended. CONCLUSION: Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

2020 American College of Rheumatology Guideline for the Management of Gout.

OBJECTIVE: To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations. METHODS: Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional. RESULTS: Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended. CONCLUSION: Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

The current management of acute uncomplicated appendicitis: should there be a change in paradigm? A systematic review of the literatures and analysis of treatment performance.

INTRODUCTION: Appendectomy has long been the mainstay of intervention for acute appendicitis, aiming at preventing perforation, peritonitis, abscess formation and recurrence. With better understanding of the disease process, non-operative management (NOM) with antibiotics alone has been proved a feasible treatment for uncomplicated appendicitis. This article aimed at systematically reviewing the available literatures and discussing the question whether NOM should replace appendectomy as the standard first-line treatment for uncomplicated appendicitis. METHOD: A search of the Embase, Pubmed and Cochrane Library was performed using the keywords 'acute appendicitis' and 'antibiotic therapy'. Meta-analysis with inverse variance model for continuous variable and Mantel Haenzel Model for dichotomous variable was performed to evaluate the one year treatment efficacy, morbidities rate, sick leave duration and length of hospital stay associated with emergency appendectomy and NOM. RESULTS: Six randomized control trials were identified out of 1943 publications. NOM had a significant lower treatment efficacy rate at one year, 0.10 (95% CI 0.03-0.36, p < 0.01), when compared to appendectomy. The morbidities rate was comparable between the two interventions. The length of hospital stay was longer, with a mean difference of 1.08 days (95% CI 0.09-2.07, p = 0.03), and the sick leave duration was shorter, a mean difference of 3.37 days (95% CI -5.90 to -0.85 days, p < 0.01) for NOM. CONCLUSION: The paradigm remains unchanged, that appendectomy is the gold standard of treatment for uncomplicated appendicitis, given its higher efficacy rate when compared to NOM.

Syndrome of cocaine-levamisole-induced cutaneous vasculitis and immune-mediated leukopenia.

OBJECTIVE: We describe 4 patients who presented with palpable purpura, arthralgia or arthritis, leukopenia, and antineutrophil cytoplasmic antigen (ANCA) positivity most likely as a result of a hypersensitivity reaction to cocaine-levamisole induced vasculopathy. METHODS: Cases were seen and reviewed in both the inpatient consult service and the outpatient clinics at Rhode Island Hospital from August 2009 to August 2010. Clinical characteristics as well as pertinent laboratory parameters were also reviewed and corroborated with a review of the present literature. RESULTS: We describe 3 cases of cocaine-levamisole-related cutaneous vasculitis with or without associated neutropenia, and 1 case of severe neutropenia with oral mucosal ulceration. Further serologic studies revealed maximum titers of ANCA mostly in a perinuclear pattern. Antimyeloperoxidase tested negative or mildly elevated in our cohort. Three patients with neutropenia had positive antigranulocyte IgM antibody. Nonsteroidal anti-inflammatory drugs were effective as first-line treatment for joint pain. The use of colchicine and systemic corticosteroid was employed to manage severe and persistent skin lesions. CONCLUSIONS: Cocaine-levamisole-related cutaneous vasculitis with leukopenia is a diagnosis of exclusion, but this diagnosis should be strongly considered in patients with a history of cocaine abuse who present with a tetrad of cutaneous manifestations consisting of palpable purpura or bullae with ear involvement, arthralgias, leukopenia, and positive ANCA in high titers and negative Antimyeloperoxidase, when other infectious or idiopathic vasculitic entities have been excluded.