Application of MALDI-TOF MS to assess clinical characteristics, risk factors, and outcomes associated with anaerobic bloodstream infection: a retrospective observational study.

BACKGROUND: Correctly identifying anaerobic bloodstream infections (BSIs) is difficult. However, a new technique, matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), enables more accurate identification and appropriate treatment. Anaerobic BSIs identified by MALDI-TOF MS were retrospectively analyzed to determine the clinical and microbiological features and patient outcomes based on the anaerobic genera or group. METHODS: Medical records of patients with anaerobic BSIs were used to conduct a single-center retrospective cohort study from January 2016 to December 2020 in Nagoya, Japan. Multivariate logistic regression analysis was performed to determine the independent risk factors for in-hospital mortality. RESULTS: Of the 215 patients with anaerobic BSIs, 31 had multiple anaerobic organisms in the blood culture, including 264 total episodes of anaerobic BSIs. Bacteroides spp. were isolated the most (n = 74), followed by gram-positive non-spore-forming bacilli (n = 57), Clostridium spp. (n = 52), gram-positive anaerobic cocci (GPAC) (n = 27), and gram-negative cocci (n = 7). The median patient age was 76 years; 56.7% were male. The most common focal infection site was intra-abdominal (36.7%). The in-hospital mortality caused by anaerobic BSIs was 21.3%, and was highest with Clostridium spp. (36.5%) and lowest with GPAC (3.7%). Age, solid tumors, and Clostridium spp. were independent risk factors for in-hospital mortality. CONCLUSIONS: We identified current anaerobic BSI trends using MALDI-TOF MS and reported that mortality in patients with anaerobic BSIs patients was highest with Clostridium spp. infections.

Clinical characteristics of bloodstream infection by Parvimonas micra: retrospective case series and literature review.

BACKGROUND: Gram-positive anaerobic (GPA) bacteria inhabit different parts of the human body as commensals but can also cause bacteremia. In this retrospective observational study, we analyzed GPA bacteremia pathogens before (2013-2015) and after (2016-2018) the introduction of the matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). METHOD: We conducted a retrospective observational study by searching the microbiology database to identify all positive GPA blood cultures of patients with GPA bacteremia diagnosed using the new technique, MALDI-TOF MS, between January 1, 2016 and December 31, 2018; and using a conventional phenotypic method between January 1, 2013 and December 31, 2015 at a single tertiary center in Japan. Parvimonas micra (P. micra) (17.5%) was the second most frequently identified GPA (MALDI-TOF MS); we then retrospectively reviewed electronic medical records for 25 P. micra bacteremia cases at our hospital. We also conducted a literature review of published cases in PubMed from January 1, 1980, until December 31, 2019; 27 cases were retrieved. RESULTS: Most cases of P. micra bacteremia were identified after 2015, both, at our institute and from the literature review. They were of mostly elderly patients and had comorbid conditions (malignancies and diabetes). In our cases, laryngeal pharynx (7/25, 28%) and gastrointestinal tract (GIT; 6/25, 24%) were identified as the most likely sources of bacteremia; however, the infection source was not identified in 9 cases (36%). P. micra bacteremia were frequently associated with spondylodiscitis (29.6%), oropharyngeal infection (25.9%), intra-abdominal abscess (14.8%), infective endocarditis (11.1%), septic pulmonary emboli (11.1%), and GIT infection (11.1%) in the literature review. Almost all cases were treated successfully with antibiotics and by abscess drainage. The 30-day mortalities were 4 and 3.7% for our cases and the literature cases, respectively. CONCLUSIONS: Infection sites of P. micra are predominantly associated with GIT, oropharyngeal, vertebral spine, intra-abdominal region, pulmonary, and heart valves. Patients with P. micra bacteremia could have good prognosis following appropriate treatment.

Evidence-based clinical practice guidelines for inflammatory bowel disease.

Inflammatory bowel disease (IBD) is a chronic disorder involving mainly the intestinal tract, but possibly other gastrointestinal and extraintestinal organs. Although etiology is still uncertain, recent knowledge in pathogenesis has accumulated, and novel diagnostic and therapeutic modalities have become available for clinical use. Therefore, the previous guidelines were urged to be updated. In 2016, the Japanese Society of Gastroenterology revised the previous versions of evidence-based clinical practice guidelines for ulcerative colitis (UC) and Crohn's disease (CD) in Japanese. A total of 59 clinical questions for 9 categories (1. clinical features of IBD; 2. diagnosis; 3. general consideration in treatment; 4. therapeutic interventions for IBD; 5. treatment of UC; 6. treatment of CD; 7. extraintestinal complications; 8. cancer surveillance; 9. IBD in special situation) were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases. The guidelines were developed with the basic concept of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Recommendations were made using Delphi rounds. This English version was produced and edited based on the existing updated guidelines in Japanese.

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos).

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis.

We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos).

The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1st edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Effectiveness of Helicobacter pylori eradication in the prevention of primary gastric cancer in healthy asymptomatic people: A systematic review and meta-analysis comparing risk ratio with risk difference.

BACKGROUND: Helicobacter pylori infection is strongly associated with gastric cancer occurrence. However, it is unclear whether eradication therapy reduces the risk of gastric cancer occurrence. We evaluated whether H. pylori eradication reduces the risk of primary gastric cancer by using both risk ratio (RR) and risk difference (RD). METHODS: Searches of PubMed, EMBASE, Google scholar, the Cochrane Library, and the Japan Medical Abstracts Society as well as those registered in databases of the Cochrane Central Register of Controlled Trials, metaRegister of Controlled Trials, ClinicalTrials.gov, controlled-trials.com, UMIN-CTR, JMACCT-CTR, and JAPIC-CTI between January 1965 and March 2017, supplemented with manual screening. Randomized controlled trials (RCTs) in which eradication therapy were implemented for the interventional group but not for the control group, and assessed the subsequent occurrence of primary gastric cancer as the main outcome. Two authors independently reviewed articles and extracted data. Integrated results for all data were presented as RR and RD. RESULTS: Seven studies met inclusion criteria. The reductions in risk of primary gastric cancer occurrence in terms of overall RR and RD were 0.67 (95% CI: 0.48 to 0.95) and -0.00 ([95% CI: -0.01 to 0.00]; number needed to treat: 125.5 [95% CI: 70.0 to 800.9]), respectively. CONCLUSIONS: The effectiveness of H. pylori eradication therapy in suppressing the occurrence of primary gastric cancer was significant and comparable to that of previous studies in terms of the estimated RR. However, the estimated RD was slight and not statistically significant.

Systematic review of motor evoked potentials monitoring during thoracic and thoracoabdominal aortic aneurysm open repair surgery: a diagnostic meta-analysis.

Motor evoked potential (MEP) monitoring has been used to prevent neurological complications such as paraplegia in patients who underwent thoracic or thoracoabdominal aortic aneurysm (TAA/TAAA) surgery. The object of this study was making a systematic review to survey the performance of MEP monitoring during TAA/TAAA open repair surgery. We searched electronic databases for relevant studies. We summarized the diagnostic data with summary sensitivity, summary specificity and forest plots of pooled sensitivity, and conducted sub-group analysis. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We also surveyed the reporting rate of clinical key factors such as methods of anesthesia, surgery, and success rate of MEP. Nineteen studies met our criteria. The results of meta-analysis showed 89.1 % summary sensitivity (95 % confidence interval 47.9-98.6 %) and 99.3 % summary specificity (95 % confidence interval 96.1-99.9 %). Sub-group analysis of pooled sensitivity and specificity by all-or-none cut-off point were better than other cut-off points. The results of the QUADAS-2 were not good. The performance of MEP monitoring was good for detecting postoperative paraplegia in TAA/TAAA open repair surgery. The cut-off point of all-or-none may be the best, according to our review.

Evidence of surgical outcomes fluctuates over time: results from a cumulative meta-analysis of laparoscopic versus open appendectomy for acute appendicitis.

BACKGROUND: In surgical trials, complex variables such as equipment development and surgeons' learning curve are involved. The evidence obtained in these trials can thus fluctuate over time. We explored the stability of the evidence obtained during surgery by conducting a cumulative meta-analysis of randomized controlled trials for open and laparoscopic appendectomy. METHODS: We conducted a cumulative meta-analysis of randomized controlled trials comparing laparoscopic appendectomy with open appendectomy for acute appendicitis, a topic with the greatest number of trials in the gastroenterological surgical field. We searched the MEDLINE (PubMed), EMBASE, and CINAHL databases up to September 2014 and reviewed the bibliographies. Outcomes were the incidence of intra-abdominal abscess, incidence of wound infection, operative time, and length of hospital stay. We used the 95 % confidence interval (95 % CI) of effect size for the significance test. RESULTS: Sixty-four trials were included in this analysis. Of the 51 trials addressing intra-abdominal abscesses, our cumulative meta-analysis of trials published up to and including 2001 demonstrated statistical significance in favor of open appendectomy (cumulative odds ratio [OR] 2.35, 95 % CI 1.30-4.25). The effect size in favor of open procedures began to disappear after 2001, leading to an insignificant result with an overall cumulative OR of 1.32 (95 % CI 0.84-2.10) when laparoscopic appendectomy was compared with open appendectomy. CONCLUSIONS: The evidence regarding treatment effectiveness changed over time, after treatment effectiveness became significant in trials comparing laparoscopic and open appendectomy. Observing only the 95 % confidence interval of effect size from a meta-analysis may not provide conclusive results.

Comparison of effects in randomized controlled trials with observational studies in digestive surgery.

OBJECTIVES: To compare the results of randomized controlled trials versus observational studies in meta-analyses of digestive surgical topics. SUMMARY BACKGROUND DATA: While randomized controlled trials have been recognized as providing the highest standard of evidence, claims have been made that observational studies may overestimate treatment benefits. This debate has recently been renewed, particularly with regard to pharmacotherapies. METHODS: The PubMed (1966 to April 2004), EMBASE (1986 to April 2004) and Cochrane databases (Issue 2, 2004) were searched to identify meta-analyses of randomized controlled trials in digestive surgery. Fifty-two outcomes of 18 topics were identified from 276 original articles (96 randomized trials, 180 observational studies) and included in meta-analyses. All available binary data and study characteristics were extracted and combined separately for randomized and observational studies. In each selected digestive surgical topic, summary odds ratios or relative risks from randomized controlled trials were compared with observational studies using an equivalent calculation method. RESULTS: Significant between-study heterogeneity was seen more often among observational studies (5 of 12 topics) than among randomized trials (1 of 9 topics). In 4 of the 16 primary outcomes compared (10 of 52 total outcomes), summary estimates of treatment effects showed significant discrepancies between the two designs. CONCLUSIONS: One fourth of observational studies gave different results than randomized trials, and between-study heterogeneity was more common in observational studies in the field of digestive surgery.

Single- versus two- layer intestinal anastomosis: a meta-analysis of randomized controlled trials.

BACKGROUND: To compare single- with two- layer intestinal anastomosis after intestinal resection: a meta-analysis of randomized controlled trials. METHODS: Randomized controlled trials comparing single- with two-layer intestinal anastomosis were identified using a systematic search of Medline, Embase and the Cochrane Library Databases covering articles published from 1966 to 2004. Outcome of primary interest was postoperative leak. A risk ratio for trial outcomes and weighted pooled estimates for data were calculated. A fixed-effect model weighted using Mantel-Haenszel methods and a random-effect model using DerSimonian-Laird methods were employed. RESULTS: Six trials were analyzed, comprising 670 participants (single-layer group, n = 299; two-layer group, n = 371). Data on leaks were available from all included studies. Combined risk ratio using DerSimonian-Laird methods was 0.91 (95% CI = 0.49 to 1.69), and indicated no significant difference. Inter-study heterogeneity was significant (chi2 = 10.5, d.f. = 5, p = 0.06). CONCLUSION: No evidence was found that two-layer intestinal anastomosis leads to fewer post-operative leaks than single layer. Considering duration of the anastomosis procedure and medical expenses, single-layer intestinal anastomosis appears to represent the optimal choice for most surgical situations.

A meta-analytic comparison of echocardiographic stressors.

BACKGROUND: The relative performance of alternative stressors for stress echocardiography for the diagnosis of coronary artery disease (CAD) is not well established. METHODS: All studies published between 1981 to December 2001 who met inclusion criteria were included in this analysis. We performed a summary receiver operator characteristic (SROC) analysis and calculated weighted mean of the likelihood ratio and sensitivity/specificity. A covariate analysis using meta-regression methods was also performed. RESULTS: Forty-four studies presented data on Exercise, 11 on Adenosine, 80 on Dobutamine, 40 on Dipyridamole, 16 on transatrial pacing transesophageal echocardiography (Tap-TEE), and 7 on transatrial pacing transthorasic echocardiography (Tap-TTE). SROC analysis showed that the following order of most discriminatory to least: Tap-TEE, Exercise, Dipyridamole, Dobutamine and Adenosine. Weighted means sensitivity/specificity were Exercise: 82.6/84.4%, Adenosine: 68.4/80.9%, Dobutamine: 79.6/85.1%, Dipyridamole: 71.0/92.2%, Tap-TTE: 90.7/86.1%, and Tap-TEE: 86.2/91.3%. Covariate analysis showed that the discriminatory power of Exercise decreased with increasing mean age. CONCLUSIONS: Tap-TEE is a very accurate test for both ruling in and ruling out CAD although its invasiveness may limit its clinical acceptability. Exercise is a well-balanced satisfactory test for both ruling in and ruling out but performance might be lower for the elderly. Dobutamine offers a reasonable compromise for Exercise. Dipyridamole might be good for ruling in but not for ruling out CAD. The incapability in ruling-out CAD was a major problem in clinical application of the stress. Adenosine was the least useful stressor in diagnosing CAD.

Early versus delayed cholecystectomy for acute cholecystitis: a meta-analysis of randomized controlled trials.

PURPOSE: We performed a meta-analysis of randomized controlled trials to determine the optimal timing of laparoscopic cholecystectomy and open cholecystectomy for acute cholecystitis. METHODS: We retrieved randomized controlled trials (RCTs) that compared early with delayed cholecystectomy for acute cholecystitis by systematically searching Medline and the Cochrane Library for studies published between 1966 and 2003. The outcomes of primary interest were mortality and morbidity. RESULTS: The ten trials we analyzed comprised 1 014 subjects; 534 were assigned to the early group and 480 assigned to the delayed group. The combined risk difference of mortality appeared to favor open cholecystectomy in the early period (risk difference, -0.02; 95% confidence interval, -0.44 to -0.00), but no differences were found among laparoscopic procedures or among all procedures. The combined risk difference of morbidity showed no differences between the open and laparoscopic procedures. The combined risk difference of the rate of conversion to open surgery showed no differences in the included laparoscopic studies; however, the combined total hospital stay was significantly shorter in the early group than in the delayed group. CONCLUSIONS: There is no advantage to delaying cholecystectomy for acute cholecystitis on the basis of outcomes in mortality, morbidity, rate of conversion to open surgery, and mean hospital stay. Thus, early cholecystectomy should be performed for patients with acute cholecystitis.

Treatment of acute pancreatitis with protease inhibitors: a meta-analysis.

OBJECTIVES: Protease inhibitors are used to treat acute pancreatitis, but their effectiveness remains unclear. We performed a meta-analysis to determine whether treatment with protease inhibitors reduces overall mortality or morbidity from acute pancreatitis. METHODS: Articles of randomized controlled trials evaluating effects of protease inhibitors for acute pancreatitis were retrieved by systematically searching Medline, the Cochrane Library and Journal@ovid databases published from January 1966 through December 2003. References of review articles were also searched manually. The main outcome in interest was the overall mortality rate from acute pancreatitis. RESULTS: Ten studies met the inclusion criteria. Treatment with protease inhibitors did not significantly reduce the mortality rate from acute pancreatitis (pooled risk difference, -0.03; 95% confidence interval, -0.07 to 0.01). Subgroup analyses showed that treatment with protease inhibitors significantly reduced the mortality rate in patients with moderate to severe pancreatitis (pooled risk difference, -0.07; 95% confidence interval, -0.13 to -0.01) as defined by mortality rate in the control group (control mortality rate > 0.10). The decrease in mortality rate was not significant in mild pancreatitis (pooled risk difference, 0.00; 95% confidence interval, -0.04 to 0.05). CONCLUSIONS: Treatment with protease inhibitors does not significantly reduce the mortality in patients with acute or mild pancreatitis, but may reduce the mortality in patients with moderate to severe pancreatitis.

Effects of timing of thoracoscopic surgery for primary spontaneous pneumothorax on prognosis and costs.

BACKGROUND: Primary spontaneous pneumothorax recurs frequently. Timing of video-assisted thoracoscopic surgery to prevent recurrence is controversial and long-term costs remain inconclusive. METHODS: We constructed a Markov model to assess the effect of different timings for surgery on health status, costs, and cost effectiveness from the payers' perspective in Japan. RESULTS: During 1-year follow-up, the proportions of patients who underwent surgery after the first and second drainage were 46% and 36%, respectively. Average 1-year cost for surgery at the first episode was highest (U.S. dollars 6556), followed by the second (U.S. dollars 2988) and the third (U.S. dollars 2532). Incremental cost for surgery at the first episode compared with the second and that at the second episode compared with the third were U.S. dollars 30564 and U.S. dollars 29915 per quality-adjusted life year, respectively. Sensitivity analyses showed utility and length of hospital stay for surgery have the strongest effect on incremental cost. CONCLUSIONS: Thoracoscopic surgery at the first episode significantly increased costs, but could be acceptable from a cost-effectiveness perspective.

The effects of cessation from cigarette smoking on the lipid and lipoprotein profiles: a meta-analysis.

BACKGROUND: Cross-sectional studies revealed that cigarette smokers have lower high-density lipoprotein cholesterol (HDL-C) levels and higher levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and triglycerides (TG) than nonsmokers. But prospective studies on the effects of cigarette smoking cessation on lipid profile have yielded inconclusive results. METHODS: Relevant English articles were retrieved by keyword searches of MEDLINE (1966-October 2000), Cochrane Library (2000, Issue 2), and cited references. Twenty-seven studies met the following inclusion criteria: (1) prospective cohort study including clinical trials, (2) measuring smoking status and lipid profile of HDL-C, TC, LDL-C, and TG, (3) reporting the changes of lipid concentrations in abstinent smokers, and (4) not using adjuvant antihyperlipidemic drugs. RESULTS: Overall Q statistics for net change of HDL-C, TC, LDL-C, and TG showed heterogeneity. Using a random-effects model, HDL-C level increased significantly [0.100 (CI 0.074 to 0.127) mmol/L] after smoking cessation. However, levels of TC [+0.003 (CI -0.042 to 0.048)], LDL-C [-0.064 (CI -0.149 to 0.021)], and TG [+0.028 (CI -0.014 to 0.071)] did not change significantly after smoking cessation. CONCLUSIONS: Cigarette smoking cessation increases serum levels of HDL-C but not of TC, LDL-C, and TG.

Diagnostic value of adenosine deaminase in tuberculous pleural effusion: a meta-analysis.

BACKGROUND: Many studies have investigated the usefulness of adenosine deaminase activity (ADA) in pleural fluid for the early diagnosis of tuberculous pleurisy. To summarize the diagnostic characteristics of ADA we undertook a meta-analysis using a summary receiver operating characteristic (SROC) curve method. METHODS: Data sources were MEDLINE (1966-1999), the Cochrane Library and bibliographies of review and original articles. Studies were included if the absolute numbers of true positive, false negative, true negative and false positive observations were available or could be derived from the data presented; gold standards were described explicitly; and the criteria for a positive ADA result were reported. We constructed an SROC curve based on these extracted data to estimate the test characteristics. RESULTS: Forty articles were available for analysis. The gold standards used were pleural biopsy histology, microbiological examination of pleural fluid, pleural biopsy and sputum and the patient's clinical course or combinations of these. The sensitivity of ADA reported in the articles ranged from 47.1% to 100% and the specificity from 50.0% to 100%. The summary measure of test characteristics derived from the SROC curve was 92.2% for both sensitivity and specificity. CONCLUSIONS: The test performance of ADA in tuberculous pleural effusion is reasonably good. Measurement of pleural ADA is thus likely to be a useful diagnostic tool for tuberculous pleurisy.

Optimal strategy for the first episode of primary spontaneous pneumothorax in young men. A decision analysis.

OBJECTIVE: Primary spontaneous pneumothorax (PSP) is not uncommon in young men and is associated with frequent recurrence. The frequent recurrence after conservative treatment and resultant anxiety for recurrence are sources of disability. We explored which procedure is more appropriate as the initial therapy in terms of quality-adjusted life expectancy (QALE). DESIGN: Decision analysis using a Markov model. DATA SOURCES: Structured literature review for clinical probability. Utility derived from patients and medical staff using time trade-off method. SETTING: Hypothetical cohort. PATIENTS: Twenty-year-old men with a first episode of PSP for which simple aspiration was ineffective. INTERVENTIONS: One of the following treatment options: 1) thoracoscopic surgery, 2) pleural drainage followed by thoracoscopic surgery for recurrence, 3) pleural drainage followed by thoracoscopic surgery for the second recurrence, 4) pleurodesis followed by thoracoscopic surgery for recurrence, 5) pleurodesis followed by thoracoscopic surgery for the second recurrence, 6) pleural drainage followed by pleurodesis for the first recurrence and thoracoscopic surgery for the second recurrence. MEASUREMENTS AND MAIN RESULTS: During the 1-year period after one of the initial treatments, the QALE was 9.49 months for thoracoscopic surgery, 9.47 for pleurodesis, and 7.80-7.99 for pleural drainage. The QALE for thoracoscopic surgery was the longest among the 6 strategies during the period from 5 to 24 months. None of the variables in sensitivity analyses altered the main results except for thoracoscopic surgical death rate. When it exceeds 0.3%, pleurodesis becomes the preferred strategy. CONCLUSION: On the basis of the current best available data and patients' preference, thoracoscopic surgery can be considered the treatment of choice for the first episode of PSP.