Predictive role of atrial fibrillation in cognitive decline: a systematic review and meta-analysis of 2.8 million individuals.

AIMS: To systematic review and meta-analyse the association and mechanistic links between atrial fibrillation (AF) and cognitive impairment. METHODS AND RESULTS: PubMed, EMBASE, and Cochrane Library were searched up to 27 March 2021 and yielded 4534 citations. After exclusions, 61 were analysed; 15 and 6 studies reported on the association of AF and cognitive impairment in the general population and post-stroke cohorts, respectively. Thirty-six studies reported on the neuro-pathological changes in patients with AF; of those, 13 reported on silent cerebral infarction (SCI) and 11 reported on cerebral microbleeds (CMB). Atrial fibrillation was associated with 39% increased risk of cognitive impairment in the general population [n = 15: 2 822 974 patients; hazard ratio = 1.39; 95% confidence interval (CI) 1.25-1.53, I2 = 90.3%; follow-up 3.8-25 years]. In the post-stroke cohort, AF was associated with a 2.70-fold increased risk of cognitive impairment [adjusted odds ratio (OR) 2.70; 95% CI 1.66-3.74, I2 = 0.0%; follow-up 0.25-3.78 years]. Atrial fibrillation was associated with cerebral small vessel disease, such as white matter hyperintensities and CMB (n = 8: 3698 patients; OR = 1.38; 95% CI 1.11-1.73, I2 = 0.0%), SCI (n = 13: 6188 patients; OR = 2.11; 95% CI 1.58-2.64, I2 = 0%), and decreased cerebral perfusion and cerebral volume even in the absence of clinical stroke. CONCLUSION: Atrial fibrillation is associated with increased risk of cognitive impairment. The association with cerebral small vessel disease and cerebral atrophy secondary to cardioembolism and cerebral hypoperfusion may suggest a plausible link in the absence of clinical stroke. PROSPERO CRD42018109185.

Clinical factors leading to a change in management in chronic hepatitis B patients managed in a tertiary setting.

BACKGROUND: Newer antiviral agents for chronic hepatitis B (CHB) are highly effective, with minimal risks of complications and development of resistance. AIM: To identify the proportion of patients with CHB on treatment who will not require alteration of management and the clinical factors of those who will require closer monitoring. METHODS: Patients with CHB who were on entecavir and/or tenofovir between January 2011 and December 2016 were retrospectively studied. According to the initial treatment plan provided by the managing physician, any deviation in the interval of follow up, choice of investigations and alteration of medical therapy were considered a change in CHB management. We also evaluated the predictability of these changes, factors associated with higher frequency of change and the additional cost of managing stable patients with CHB in a tertiary setting. RESULTS: Of the patients, 75.7% (n = 87/115) did not have a change in CHB management; 85.6% of the changes in management were predictable based on liver function tests, hepatitis B virus DNA polymerase chain reaction levels and liver ultrasound. Interpreter use (OR (95% CI) = 2.41 (1.01-5.76)), liver cirrhosis (OR (95% CI) = 4.11 (1.44-11.75)) and immunosuppression (OR (95% CI) = 3.81 (1.2-12.06)) were associated risk factors. Overall, there was an incremental annual cost of AU$60 166 to manage patients who did not require alteration of their CHB management in our institution. CONCLUSION: The majority of stable CHB patients on highly potent antiviral treatment do not require alteration of management. While additional investigations are required, this study highlights the potential for a shared primary care approach in highly selected CHB patients.

Testicular Appendage Torsion-To Explore the Other Side or Not?

OBJECTIVE: To investigate and compare the risks vs benefits of synchronous contralateral scrotal compartment exploration when testicular appendage torsion is diagnosed intra-operatively. METHODS: Emergency scrotal explorations performed at the Women's and Children's Hospital between 2002 and 2017 were retrospectively analysed to identify patients with testicular appendage torsion. Primary outcome measures were metachronous acute scrotum re-presentations and returns to theatre. Outcomes were compared between groups that underwent unilateral and bilateral scrotal compartment exploration. RESULTS: Testicular appendage torsion was diagnosed intra-operatively in 575 patients and 90.4% underwent unilateral scrotal exploration. Re-presentations with metachronous acute scrotum on the non-index side occurred in 8.5% of unexplored and 3.6% of previously explored sides (P = .29). Non-index side returns to theatre occurred in 5.4% of unexplored and 0% previously explored sides (P = .097). Future metachronous contralateral testicular appendage torsion was diagnosed in 4.2%. Post-operative complications were comparably low in both groups. The number needed to treat to prevent a return to theatre for metachronous contralateral testicular appendage torsion is 24. CONCLUSION: The low morbidity of exploring the contralateral side is justifiable, but confers only limited benefit of preventing low likelihood future metachronous contralateral pathology. In balancing these risks, we recommend contralateral exploration as advisable but not a necessity.

Sutured point-fixation versus Jaboulay fixation for salvaged testicular torsion in children.

BACKGROUND: Surgical techniques for fixation of the testis are varied and subject to ongoing debate. Non-sutured techniques may avoid the theoretical morbidities of sutured fixation of the testis yet are criticized for insufficient prophylaxis against future torsion. This study aims to compare outcomes between sutured (point-fixation) versus Jaboulay fixation. METHODS: Emergency scrotal explorations performed at a tertiary hospital in the state of South Australia between February 2002 and December 2017 were analyzed to identify cases of testicular torsion. Primary outcome measures included future testicular torsions and return to theater episodes following initial testicular fixation. Secondary outcome measures included re-presentations and post-operative complications. RESULTS: A total of 482 scrotal compartments were explored in 244 boys with acute testicular torsion. Testis fixation was performed using sutured point-fixation in 58.4% and Jaboulay tunica plication in 41.6%. No future testicular torsion occurred regardless of fixation technique. There were no significant differences in returns to theater (0.4% versus 1.2%, p = 0.12), re-presentations (6.9% versus 6.0%, p = 0.83), and post-operative complications (1.7% versus 1.8%, p = 1.0) in testes that previously underwent sutured or Jaboulay fixation, respectively. CONCLUSION: Jaboulay testicular fixation techniques are comparable with sutured point-fixation techniques in effectiveness and morbidity. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.

Surveillance colonoscopies frequently booked earlier than the National Health and Medical Research Council guidelines: findings of a single centre audit.

BACKGROUND: To assess the adherence rate of surveillance colonoscopy booking intervals to recommended National Health and Medical Research Council guidelines at The Queen Elizabeth Hospital, Adelaide, Australia. METHODS: Patients on The Queen Elizabeth Hospital colorectal unit surveillance colonoscopy waiting list were included in this audit. Patient demographics, colonoscopy findings, follow-up plans and pathology results were analysed. Patients were categorized as normal/non-neoplastic finding, low-risk adenomas, high-risk adenomas, personal history of colorectal cancer (CRC) and family history of CRC. Booked colonoscopy within 2 months of guideline recommended interval was considered correct. RESULTS: A total of 467 patients were included (59.1% male; mean age 60 years). Two hundred and fifty-one (53.7%) patients had an incorrect surveillance colonoscopy booking. Twenty-seven patients with a normal/non-neoplastic previous colonoscopy not requiring surveillance colonoscopy were incorrectly booked for a colonoscopy. For the 222 patients booked incorrectly and requiring surveillance colonoscopy, 88.7% were early and 11.3% were late. The proportions of incorrect bookings were highest in the low-risk finding (66.1%) and history of CRC (67.6%) groups. For the 186 patients requiring a 3-year surveillance interval, 38.7% were booked incorrectly. For the 197 patients requiring a 5-year surveillance interval, 63.5% were booked incorrectly, of which 99.2% were early. More 5-year surveillance interval patients were booked at 3 years (n = 79), than at the correct interval of 5 years (n = 72). CONCLUSION: Adherence to the National Health and Medical Research Council guidelines for surveillance colonoscopy is poor. The majority of deviations represent early follow-up, which is most common among patients with low-risk findings or history of CRC. There is a tendency towards 3-year surveillance among low-risk patients.

Early onset necrotising enterocolitis in association with congenital diaphragmatic hernia in a term baby.

We report a case of a male, term newborn with known left congenital diaphragmatic hernia (CDH) who presented with circulatory compromise requiring maximal inotropic support in the first 24 hours of life. Repeat X-ray at 24 hours showed pneumatosis intestinalis. Emergency laparotomy was performed for suspected necrotising enterocolitis. The terminal ileum to the sigmoid colon were frankly necrotic with multiple perforations. Subtotal colectomy was performed. Although the recovery was protracted, the baby had a favourable outcome with progressive weight gain on follow-up at 3, 6 and 9 months of age.This case of CDH had a postnatal systemic instability that was more severe than predicted, and as well as assessing for persistent pulmonary hypertension of newborn should trigger immediate suspicion for other organ involvement.