Total Knee Arthroplasty With or Without Prior Bariatric Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Studies comparing the outcomes of bariatric surgery followed by total knee arthroplasty (TKA) versus TKA alone in obese patients have disparate results. This systematic review and meta-analysis sought to compare TKA with and without prior bariatric surgery in obese patients. METHODS: MEDLINE, PubMed, and Embase were searched from inception to April 9, 2023. There were twelve included studies that yielded 2,876,547 patients, of whom 62,818 and 2,813,729 underwent TKA with and without prior bariatric surgery, respectively. Primary outcomes were medical complications (ie, urinary tract infection, pneumonia, renal failure, respiratory failure, venous thromboembolism [VTE], arrhythmia, myocardial infarction, and stroke); surgical complications (ie, wound complications [eg, infection, hematoma, dehiscence, delayed wound healing, and seroma], periprosthetic joint infection, mechanical complications, periprosthetic fracture, knee stiffness, and failed hardware); revision, and mortality. Secondary outcomes were blood transfusion, length of stay (day), and readmission. RESULTS: The odds ratios (OR) of 90-day VTE (OR = 0.75 [0.66, 0.85], P < .00001), 90-day stroke (OR = 0.58 [0.41, 0.81], P = .002), and 1-year periprosthetic fracture (OR = 0.74 [0.55, 0.99], P = .04) were lower in those who underwent bariatric surgery before TKA. Although the mean difference in hospital stays (-0.19 days [-0.23, -0.15], P < .00001) was statistically less in those who underwent bariatric surgery before TKA, it was not clinically relevant. The other outcomes were similar between the groups. CONCLUSIONS: Bariatric surgery before TKA is beneficial in terms of a lower risk of VTE, stroke, and periprosthetic fracture. This analysis suggests surgeons consider discussing bariatric surgery before TKA in obese patients, especially those who are at risk of VTE and stroke.

Awake Versus Asleep Craniotomy for Patients With Eloquent Glioma: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Awake vs asleep craniotomy for patients with eloquent glioma is debatable. This systematic review and meta-analysis sought to compare awake vs asleep craniotomy for the resection of gliomas in the eloquent regions. METHODS: MEDLINE and PubMed were searched from inception to December 13, 2022. Primary outcomes were the extent of resection (EOR), overall survival (month), progression-free survival (month), and rates of neurological deficit, Karnofsky performance score, and seizure freedom at the 3-month follow-up. Secondary outcomes were duration of operation (minute) and length of hospital stay (LOS) (day). RESULTS: Fifteen studies yielded 2032 patients, from which 800 (39.4%) and 1232 (60.6%) underwent awake and asleep craniotomy, respectively. The meta-analysis concluded that the awake group had greater EOR (mean difference [MD] = MD = 8.52 [4.28, 12.76], P < .00001), overall survival (MD = 2.86 months [1.35, 4.37], P = .0002), progression-free survival (MD = 5.69 months [0.75, 10.64], P = .02), 3-month postoperative Karnofsky performance score (MD = 13.59 [11.08, 16.09], P < .00001), and 3-month postoperative seizure freedom (odds ratio = 8.72 [3.39, 22.39], P < .00001). Furthermore, the awake group had lower 3-month postoperative neurological deficit (odds ratio = 0.47 [0.28, 0.78], P = .004) and shorter LOS (MD = -2.99 days [-5.09, -0.88], P = .005). In addition, the duration of operation was similar between the groups (MD = 37.88 minutes [-34.09, 109.86], P = .30). CONCLUSION: Awake craniotomy for gliomas in the eloquent regions benefits EOR, survival, postoperative neurofunctional outcomes, and LOS. When feasible, the authors recommend awake craniotomy for surgical resection of gliomas in the eloquent regions.

Endovascular Thrombectomy versus Endovascular Thrombectomy Preceded by Intravenous Thrombolysis: A Systematic Review and Meta-Analysis.

BACKGROUND: Randomized controlled trials comparing endovascular thrombectomy (EVT) versus EVT preceded by intravenous thrombolysis (EVT + IVT) for acute ischemic stroke due to large artery occlusion remain controversial. This systematic review and meta-analysis seek to compare these 2 modalities. METHODS: Online Protocol is available at PROSPERO (york.ac.uk) (registration# CRD42022357506). MEDLINE, PubMed, and Embase were searched. The primary outcome was 90-day modified Rankin scale (mRS) ≤2. Secondary outcomes were 90-day mRS ≤1, 90-day mean mRS, National Institutes of Health Stroke Scale (NIHSS) at 1-3 and 3-7 days, 90-day Barthel Index, 90-day EQ-5D-5L (EuroQoL Group 5-Dimension 5-Level), the volume of infarction (mL), successful reperfusion, complete reperfusion, recanalization, 90-day mortality, any intracranial hemorrhage (ICH), symptomatic ICH, embolization in new territory, new infarction, puncture site complications, vessel dissection, and contrast extravasation. The certainty in the evidence was determined by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. RESULTS: Six randomized controlled trials yielding 2332 patients were included, of which 1163 and 1169 underwent EVT and EVT + IVT, respectively. The relative risk (RR) of 90-day mRS ≤2 was similar between the groups (RR = 0.96[0.88, 1.04]; P = 0.28). EVT was non-inferior to EVT + IVT because the lower bond of 95% confidence interval of the risk difference (RD = -0.02 [-0.06, 0.02]; P = 0.36) exceeded the -0.1 non-inferiority margin. The certainty in the evidence was high. The RR of successful reperfusion (RR = 0.96 [0.93, 0.99]; P = 0.006), any ICH (RR = 0.87 [0.77, 0.98]; P = 0.02), and puncture site complications (RR = 0.47 [0.25, 0.88]; P = 0.02) were lower with EVT. For EVT + IVT, the number needed to treat for successful reperfusion was 25, and the number needed to harm for any ICH was 20. The 2 groups were similar in other outcomes. CONCLUSION: EVT is non-inferior to EVT + IVT. In centers capable of both EVT and IVT, if timely EVT is feasible, it is reasonable to skip bridging IVT and keep rescue thrombolysis at the discretion of the interventionist for patients presenting within 4.5 hours of anterior ischemic stroke.

Laparoscopic Versus Open Pancreatoduodenectomy in Patients With Periampullary Tumors: A Systematic Review and Meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis of randomized controlled trials compared laparoscopic pancreatoduodenectomy (LPD) versus open pancreatoduodenectomy (OPD) in patients with periampullary tumors. BACKGROUND: LPD has gained attention; however, its safety and efficacy versus OPD remain debatable. METHODS: We searched PubMed and Embase. Primary outcomes were the length of hospital stay (LOS) (day), Clavien-Dindo grade ≥III complications, and 90-day mortality. Secondary outcomes were blood loss (milliliter), blood transfusion, duration of operation (minute), readmission, reoperation, comprehensive complication index score, bile leak, gastrojejunostomy or duodenojejunostomy leak, postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, surgical site infection, intra-abdominal infection, number of harvested lymph nodes, and R0 resection. Pooled odds ratio (OR) or mean difference (MD) of data was calculated using the random-effect model. The grading of recommendations, assessment, development and evaluation approach was used for grading the level of evidence. RESULTS: Four randomized controlled trials yielding 818 patients were included, of which 411 and 407 patients underwent LPD and OPD, respectively. The meta-analysis concluded that 2 approaches were similar, except in the LPD group, the LOS tended to be shorter [MD=-2.54 (-5.17, 0.09), P =0.06], LOS in ICU was shorter [MD=-1 (-1.8, -0.2), P =0.01], duration of operation was longer [MD=75.16 (23.29, 127.03), P =0.005], blood loss was lower [MD=-115.40 (-152.13, -78.68), P <0.00001], blood transfusion was lower [OR=0.66 (0.47, 0.92), P =0.01], and surgical site infection was lower [OR=0.35 (0.12, 0.96), P =0.04]. The overall certainty of the evidence was moderate. CONCLUSIONS: Within the hands of highly skilled surgeons in high-volume centers, LPD is feasible and as safe and efficient as OPD.

Primary Balloon Angioplasty Versus Hydrostatic Dilation for Arteriovenous Fistula Creation in Patients with Small-Caliber Cephalic Veins: A Systematic Review and Meta-Analysis.

BACKGROUND: For arteriovenous fistula (AVF) presence of a venous segment with adequate diameter is essential which is lacking in many patients. To find the optimal augmentation technique in patients with small-caliber cephalic vein (i.e., cephalic vein diameter <3 mm), studies compared primary balloon angioplasty (PBA) versus hydrostatic dilation (HD); however, it remained debatable. This systematic review seeks to determine which technique is preferable. METHODS: We searched MEDLINE, PubMed, Embase, and Google Scholar. Primary outcomes were 6-month primary patency, reintervention, and working AVF. Secondary outcomes were immediate success, the AVF's maturation time (day), and surgical site infection. RESULTS: Three randomized controlled trials yielding 180 patients were included, of which 89 patients were in the PBA group. The odds ratio (OR) of primary patency was significantly higher in the PBA group (OR 6.09, 95% confidence interval [CI], 2.36-15.76, P = 0.0002), the OR of reintervention was significantly lower in the PBA group (OR 0.16, 95% CI, 0.06-0.42, P = 0.0002), and the OR of working AVF was greater in PBA group (OR 4.22, 95% CI, 1.31-13.59, P = 0.02). The OR of immediate success was significantly greater in the PBA group (OR 11.42, 95% CI, 2.54-51.42, P = 0.002), and the AVF maturation time was significantly shorter in patients who underwent PBA (mean difference -20.32 days, 95% CI, -30.12 to -10.52, P = 0.0001). The certainty of the evidence was high. CONCLUSIONS: PBA of small cephalic veins with diameter ≤2.5 cm is a safe, feasible, and efficacious augmentation method for AVF creation. This technique achieves favorable maturation outcomes, and PBA is superior to the standard hydrostatic dilatation technique.

Desmopressin Acetate in Percutaneous Ultrasound-Guided Native Kidney Biopsy in Patients with Reduced Kidney Function: A Double-Blind Randomized Controlled Trial.

INTRODUCTION: Bleeding events are the most common complications after kidney biopsy. This study aims to evaluate the effect of desmopressin administration on bleeding complication, in native kidney biopsy candidates with reduced kidney function. METHODS: This double-blind randomized clinical trial enrolled 18 to 80 years old patients with 15 < eGFR < 90 mL/min/ 1.73m² from July 2017 to August 2020. Patients were randomly assigned to receive either 3 µg/kg of intranasal desmopressin acetate or 1 mL/kg of intranasal sodium chloride 0.65%, one hour before ultrasound-guided, percutaneous native kidney biopsy. The primary outcome was the post-biopsy bleeding complications, and secondary outcomes were the volume of perirenal hematoma, and changes of post-biopsy hemoglobin and hematocrit level, plasma sodium and blood pressure (Clinical Trial Registration ID: IRCT20090701002112N3). RESULTS: A total of 120 patients (58 men and 62 women), 60 patients in each group, were analyzed. The mean age and eGFR of the patients were 45.29 ± 15.95 years and 51.77 ± 18.02 ml/min/ 1.73m², respectively. Desmopressin administration significantly decreased post-biopsy perirenal hematoma compared to placebo (7/60 [11.6%]) vs. 33/60 [40%]; P < .05), and the hematoma volume was significantly smaller in the desmopressin group, in case of hematoma formation (2.31 ± 1.17 vs. 7.72 ± 5.45 mm³, P < .05). CONCLUSION: Desmopressin administration before kidney biopsy is a safe and effective strategy to prevent bleeding complications. Considering absolute risk reduction of about 28%, the number needed to treat is about 4 procedures. We recommend considering desmopressin administration before percutaneous native kidney biopsy.  DOI: 10.52547/ijkd.6966.

Dorsal Approach in the Surgical Treatment of Complex Dorsal Dislocation of Index Metacarpophalangeal Joint; a Case Report.

Complex metacarpophalangeal (MCP) joint dislocation is an uncommon entity, which occurs following a hyperextension injury. Closed reduction is not feasible due to entrapped volar plate and/or coexisting fractures. Various approaches and techniques have been proposed for treatment of complex MCP dislocation; however, controversies exist over which one is superior. This study describes a right-handed 14-year-old boy who fell on the outstretched hand and sustained a dorsal dislocation of the left index MCP joint. The dislocation was complicated by an epiphyseal metacarpal head fracture with dorsal-ulnar displacement of the osteochondral fragment. The patient underwent open reduction through the dorsal approach, and the metacarpal head was fixed via the two-screw technique. The patient resumed left-hand function after six weeks. At the two-year follow-up, the range of motion and grip strength were normal, the patient was pain-free, and no sign of growth disturbance or joint stiffness was detected. Dorsal surgical approach with screw fixation is a feasible technique for the treatment of complex MCP dislocation, especially when it is complicated by a large epiphyseal head fracture.

Endovascular repair of infected carotid pseudoaneurysm: A case report.

BACKGROUND: Pseudoaneurysm (PA) of the carotid artery is a rare but life-threatening complication following carotid endarterectomy (CEA). Management of carotid PAs is challenging due to the increased risk of stroke and nerve injury in an infected and re-operative field. Open surgery has been the mainstay for this complicated pathology however some patients have characteristics which make an endovascular approach more advantageous. Yet endovascular intervention for infected fields is scrutinized and used as a last option. HISTORY AND TREATMENT PLAN: 72 year old female with history of basilar artery aneurysm embolization and right internal carotid artery occlusion presented with a left carotid pseudoaneurysm after a CEA 6 months prior. She presented with 2 days of increasing left neck swelling, erythema, and a small ulcerated area with bloody discharge from incision site. A Computed Tomagraphy scan (CTA) showed hematoma surrounding the left ICA concerning for PA. Wound cultures were obtained which grew coagulase (-) staphylococcus. We elected to perform an endovascular procedure to temporize the bleeding by placing a stent graft (7 mm × 7.5 cm Gore Viabahn) across the left ICA. She remains asymptomatic with no recurrent symptoms 6 months postoperatively. CONCLUSION: Our experience in this patient indicates that endovascular stenting could be feasible and potentially effective intervention for infection-associated post-CEA PA in patients with an excessively high risk for stroke and nerve injury. We suggest each patient should be evaluated individually and all pertinent characteristics should be considered to make the best decision.

Insulin Resistance and Free Androgen as Predictors for Ovarian Hyperstimulation Syndrome in Non-PCOS Women.

We evaluated the effect of insulin resistance and free androgen index (FAI) in non-PCOS (polycystic ovary syndrome) infertile women following controlled ovarian hyperstimulation. A prospective study was done on 144 infertile non-PCOS women with regular menstrual cycle. At first, insulin resistance (IR), free androgen index (FAI), PCOM (polycystic ovary morphology), AFC (antral follicle count), and AMH (anti-Müllerian hormone) were assessed. The patients underwent assisted reproductive technology (ART), and then preovulatory follicles and oocytes retrieved were recorded. The variables of the study were compared between two groups of patients with ovarian hyperstimulation syndrome (OHSS) (n=66) and non-OHSS patients (n=78). Of the 9 variables: BMI, HOMA-IR, FAI, AFC, AMH, PCOM, and preovulatory follicles were risk factors, while the age and retrieved oocytes were not. The 7 variables that showed significance in the univariate analyses were determined as independent variables included in the multivariable logistic regression analysis, as a result, a total of 5 risk factors, BMI, HOMA-IR, FAI, PCOM, and preovulatory follicles entered the equation. The maximum contribution was HOMA-IR followed by PCOM, FAI, preovulatory follicles and BMI. Patients with OHSS had higher chance to have ovaries with polycystic morphology (74%), about three times more than patients who did not develop OHSS (29%) (p<0.001). The best cut-points for IR, FAI, AFC, AMH, and preovulatry follicles were 2.36, 3.9, 8, 3.3 ng/ml, and 10, respectively. Patients with a higher value of BMI, FAI, HOMA-IR, and preovulatory follicles and the presence of PCOM are more likely to develop OHSS, which are not confined to PCOS patients.

Endovascular Thoracic Aortic Repair for Catheter Associated Aortic Injury During Thoracostomy Tube Placement.

BACKGROUND: Aortic injuries during non-aortic related procedures are rare but potentially catastrophic. Endovascular aortic repair has been described as a viable option in similar circumstances. However, most reports involve aortic injury from orthopaedic hardware after spine surgery or trocar injury during abdominal surgery. REPORT: This is a report of a thoracic aortic injury during thoracostomy tube placement and summary of the management paradigm. The patient was treated with a thoracic stent graft and was seen at four-month follow up, with imaging showing the endograft in stable position. CONCLUSION: Endovascular stenting can increase the treatment scope for management of emergent thoracic aortic pathology.

Prevalence and Correlated Factors for Obesity, Overweight and Central Obesity in Southwest of Iran.

BACKGROUND: We assessed the prevalence of obesity, overweight, central obesity and their associated risk factors in an urban population in Ahvaz, southwest of Iran. METHODS: This population-based cross-sectional study was performed via random cluster sampling method in 6 health centers in Iran in 2015. A questionnaire was completed by each individual. RESULTS: Of 2575 participants, 1187 (46%) were men. Nearly 50% of the participants' level of education was high school or higher. About 82% of the population was married and about one-third had positive family history of parental obesity. The total prevalence of obesity, overweight, and central obesity were 26.5%, 38.7%, and 28.6%, respectively. The rate of obesity in men was lower than in women (P<0.001). The prevalence of obesity increased until the age of 60 yr in both genders and decreased thereafter except for central obesity in women, which increased without any lag. Low level of education, marriage, positive history of parental obesity and parity ≥five were associated with increased odds of obesity (OR=2.14(1.52, 3.00), OR=2.4(1.75, 2.99), OR=2.7(1.71, 3.2) and 4.16(2.17, 7.65), respectively). CONCLUSION: Obesity and overweight have a high prevalence in southwest of the country, increasing with age. Although several risk factors are associated with obesity, the prevalence of obesity and overweight can be reduced by controlling the risk factors in the community.

Prevention of Contrast-induced Nephropathy in Patients with Chronic Kidney Disease Undergoing Elective Coronary Angioplasty or Angiography with Sodium Potassium Citrate Solution, a Double Blind Randomized Clinical Trial.

INTRODUCTION: Contrast-induced nephropathy (CIN) is a frequent complication of contrast exposure. A recent study suggested that Na/K citrate might have a preventive role. We investigated the efficacy of Na/K citrate to prevent CIN in patients with renal dysfunction undergoing coronary intervention. METHODS: The randomized, double-blind, placebo-controlled trial included 201 patients with estimated creatinine clearance < 90 mL/ min, randomized to receive oral Na/K citrate plus saline infusion (treatment group, 104 patients) or oral water plus saline infusion (placebo group, 97 patients). CIN was defined as an absolute increase of serum creatinine ≥ 0.5 mg/dL or a relative increase ≥ 25% or a relative decrease of estimated GFR ≥ 25% within 5 days. RESULTS: CIN occurred in 22 patients (12.29%); 10 (11%) in treatment group and 12 (13.6%) in placebo group (P > .05). Post-exposure Cr values were not significantly different between the two groups (1.18 ± 0.28 mg/dL in the placebo vs. 1.15 ± 0.29 mg/dL in the treatment group, P > .05). CIN-negative patients in the treatment group showed a significantly higher increase in urine pH than that of CIN-positive patients (1.642 ± 0.577 vs. 1.20 ± 0.422, P < .05). CONCLUSION: Na/K citrate solution is not effective for prophylaxis of CIN in patients with renal dysfunction. However, a probable preventive effect might exist in a subgroup of patients with at least 1.6 units increase in urine pH values following Na/K citrate administration.

Sedative and Analgesic Effects of Entonox Gas Compared with Midazolam and Fentanyl in Synchronized Cardioversion.

The purpose of this study was to determine if the Entonox gas could cause adequate analgesic and sedative effects in patients who need cardioversion. In this randomized not blinded clinical trial, the sedative and analgesic effects of midazolam and fentanyl were compared with Entonox. Eligible patients who need synchronized cardioversion because of dysrhythmia were randomly divided into two groups. The first group received intravenous midazolam and fentanyl; the second group received Entonox through a blower-dependent mask. Onset and end of sedation, sedation level, and pain score were recorded. There were nonsignificant differences between the two groups (22 patients in each group) regarding age, gender, weight, sedation level, and frequency and level of shock. The pain score recorded in the first group was 5.05 ± 1.32, and 3.9 ± 0.7 in the second group (P = 0.002). Furthermore, sedation duration and time to full recovery consciousness were shorter in the second group (P < 0.001). In the first group, seven patients needed additional doses to induce and maintain sedation. In addition, as a result of apnoea, four patients required airway support. None of them occurred in the second group. Entonox is a suitable medication in rapid cardioversion, as it has minimal side effects and adequate analgesic and sedative effects.