A systematic review of dermal fillers for age-related lines and wrinkles.

BACKGROUND: Dermal fillers are gaining popularity for rapid aesthetic improvement. Long-term efficacy and safety have not been well documented. The aim of this systematic review was to assess the safety and efficacy of injectable dermal fillers compared with other facial augmentation techniques for the management of age-related lines and wrinkles. METHODS: Studies including patients receiving injectable semi-permanent or permanent dermal fillers for age-related lines and wrinkles were included in this review. Efficacy outcomes (including changes in skin thickness and patient satisfaction) and safety outcomes (including mortality, lumps and infections) were examined. RESULTS: Three randomized control trials and six case series were included. Permanent and semi-permanent dermal fillers improved subjective ratings of appearance and resulted in higher patient satisfaction than temporary fillers. Long-term efficacy appeared good in the few studies that reported it. Short-term safety appeared favourable. Lumps were reported in all but one study but received little follow-up. Long-term safety data were limited. CONCLUSIONS: The treatment of age-related lines and wrinkles with permanent and semi-permanent dermal fillers is more efficacious compared with temporary fillers in those studies that compared them. Case series evidence suggests that these fillers achieve their objective, which is to decrease the visible effects of age-related changes. These fillers appear at least as safe as temporary fillers in the short term in those studies that compared them. Long-term safety could not be determined.

Effects of fatigue on surgeon performance and surgical outcomes: a systematic review.

BACKGROUND: Sleep deprivation and disturbances in circadian rhythms generally lead to poor performance, but is there a link in surgery? This review aimed to determine whether fatigue has an impact on surgeon performance or surgical outcomes. METHODS: Studies were identified by searching EMBASE, CINAHL, PubMed, The Cochrane Library, Current Contents and clinical trials databases. Inclusion of relevant studies was by application of a predetermined protocol and independent assessment by two reviewers. Each included study was critically appraised for its study quality according to the methods used for Cochrane Reviews. Data from included studies were extracted by one researcher using standardized data extraction tables developed a priori and checked by a second researcher. RESULTS: From 823 potentially relevant studies, a total of 16 studies were included in this review: two randomized controlled trials, five non-randomized comparative studies and nine case series. Of five studies that directly measure clinical performance, three studies reported no significant difference as a result of sleep deprivation, while two studies found increases in complications or errors. Eleven studies assessed psychomotor skill performance using a variety of simulation-based methods when a participant was rested and/or fatigued. Two randomized controlled trials reported no significant differences, while the nine remaining studies reported mixed results. Surgical residents with less surgical training/experience appeared to be more affected than more senior residents. CONCLUSION: There is little evidence, as yet, to inform the issue of the effect of fatigue on surgical performance.

Systematic review of the impact of volume of oesophagectomy on patient outcome.

PURPOSE: This systematic review aims to assess whether overall survival, mortality, morbidity, length of stay and cost of performing oesophagectomy are related to surgical volume. METHODS: A systematic search strategy from 1997 until December 2006 was used to retrieve relevant studies. Inclusion of articles was established through application of a predetermined protocol, independent assessment by two reviewers and a final consensus decision. RESULTS: A total of 55 studies were identified of which 27 studies, representing 68 882 patients, met the inclusion criteria. Twenty-one of these solely examined hospital volume, 5 examined both hospital and surgeon volume, and 1 examined surgeon volume in isolation. All but one of the studies were retrospective in nature, and because of the heterogeneity of the literature, no meta-analysis could be performed. Of the studies exploring the relationship between hospital volume and mortality, 20 reported a statistically significant benefit to large volume centres. Five of six included studies showed significant evidence for a reduced mortality risk with greater surgeon volume. CONCLUSIONS: Based on the evidence from these retrospective studies, oesophagectomy performed in high volume centres would appear to be associated with better outcome compared with low volume centres.

Radical prostatectomy: a systematic review of the impact of hospital and surgeon volume on patient outcome.

BACKGROUND: To assess the impact of hospital and surgeon volume on mortality, morbidity, length of hospital stay and costs of radical prostatectomy (RP). METHODS: This systematic review identified relevant studies published between 1997 and June 2007. Inclusion of papers was established through application of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. RESULTS: Compared with low volume hospitals, the included studies showed high volume hospitals demonstrated lower rates of mortality, postoperative complications and readmissions, and lower overall hospital costs. High volume surgeons similarly showed lower rates of postoperative complications and shorter length of stay compared with low volume surgeons, but no difference in mortality. CONCLUSIONS: From the literature obtained, patients undergoing RP performed by high volume providers may have better outcomes compared to low volume providers; however, any move to centralize RP must be further evaluated.

Centralization and the relationship between volume and outcome in knee arthroplasty procedures.

BACKGROUND: Centralization aims to reduce adverse patient outcomes by concentrating complex surgical procedures in specified hospitals. OBJECTIVES: This review assessed the efficacy of centralization for knee arthroplasty by examining the relationship between hospital and surgeon volume and patient outcomes. DATA SOURCES AND REVIEW METHODS: The systematic review identified studies using multiple databases, including Medline and Embase. Two independent researchers ensured studies met the inclusion criteria. Morbidity, mortality, length of stay, financial outcomes and statistical rigour were examined. Correlations between volume and outcome were reported. RESULTS: Twelve primary knee arthroplasty studies examined hospital volume, which was significantly associated with decreased morbidity (five of seven studies), mortality (two of five studies) and length of stay (two of three studies). Three primary knee arthroplasty studies examined surgeon volume, which was significantly associated with decreased morbidity (two of three studies), mortality (zero of two studies) and length of stay (one of one study). Two revision knee arthroplasty studies examined hospital volume. One study examined but did not test for significance between hospital volume and patient morbidity; both studies examined volume and patient mortality reporting inconclusive results; and one study reported no significant association between volume and length of stay. None of the revision knee arthroplasty studies examined surgeon volume. CONCLUSIONS: Significant associations between increased hospital and surgeon volume and improved patient outcomes were reported. However, when these results were separated by arthroplasty type, the association appeared tenuous. Judgements regarding centralization of knee arthroplasty should be made with caution until further evidence is published.

A systematic review of permanent and semipermanent dermal fillers for HIV-associated facial lipoatrophy.

The objective of this study was to assess the safety and efficacy of injectable semipermanent and permanent dermal fillers, compared to other facial augmentation techniques, for the management of facial lipoatrophy as a result of highly active antiretroviral therapy (HAART) for HIV infection through a systematic review of the literature. A systematic search strategy was used to retrieve relevant studies. Inclusion of articles was by the application of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. One randomized controlled trial (RCT), one pseudo-RCT, two nonrandomized comparative studies, and seven case series were included for review. Injections with permanent and semipermanent dermal fillers improved subjective ratings of appearance and resulted in high patient satisfaction. Although short-term safety appeared favorable, of the seven studies that reported lumps, three studies reported these events in more than 40% of patients. Long-term safety data were lacking. Evidence suggests that permanent and semipermanent dermal fillers achieve their objective, which is to decrease the visible effects of HIV-associated facial lipoatrophy, with high patient satisfaction. Safety appears favorable in the short term, but further studies are required to determine long-term outcomes.

Damage control surgery and angiography in cases of acute mesenteric ischaemia.

BACKGROUND: Acute mesenteric arterial occlusion typically presents late and has an estimated mortality of 60-80%. This report examines the evolution of a novel management approach to this difficult surgical problem at a teaching hospital in rural Australia. METHODS: A retrospective review of 20 consecutive cases that presented to Lismore Base Hospital, Lismore, New South Wales, between 1995 and 2003 was performed. RESULTS: Of the 16 patients who were actively treated, 10 survived. Mortality was associated with attempting an emergency operative revascularisation and not performing a second-look laparotomy. All three patients who had a damage control approach at the initial operation survived and in four cases endovascular intervention successfully achieved reperfusion of acutely ischaemic bowel. CONCLUSIONS: Evidence from the series of patients described suggests that damage control surgery and early angiography improve survival in patients suffering acute mesenteric ischaemia. A damage control approach involves emergency resection of ischaemic bowel with no attempt to restore gastrointestinal continuity and formation of a laparostomy. Patients are stabilised in the intensive care unit (ICU) and angiography can be arranged to either plan a definitive bypass procedure or alternatively endovascular therapies can be carried out in an attempt to arrest gastrointestinal infarction. Definitive surgery is then considered after 2-3 days. This approach is particularly attractive if immediate specialist vascular expertise is not available.