Strategies to prevent suppurative chondritis following auricular burns: a systematic review.

OBJECTIVE: Suppurative chondritis is a potentially devastating complication of burns to the ear. The infection and inflammation can liquify cartilage, leading to significant aesthetic deformities which are difficult to treat. This article reviews published measures for preventing post-burn chondritis. METHOD: A comprehensive search of all available literature up to September 2020 was performed, according to PRISMA guidelines, for studies assessing preventive measures for post-burn chondritis. Randomised controlled trials (RCT), cohort studies, case-control studies, case reports and series were eligible for inclusion. RESULTS: A total of 10 studies, including one RCT and nine retrospective observational analyses, were included, incorporating 1369 patients with burns to the ear. The most common interventions were pressure avoidance (70%), daily cleansing (60%), topical mafenide acetate (60%) and targeted debridement (30%). Packages of measures which included pressure avoidance were the most effective, all of which achieved a chondritis incidence of <6%. CONCLUSION: Low-level but strong published evidence suggests that important treatment principles include prevention by pressure relief, targeted debridement, prophylactic local antibiotics, local antisepsis and the avoidance of desiccation.

State of the art regarding the management of multiligamentous injuries of the knee.

Multiligamentous knee injuries are rare but serious injuries that can threaten limb viability. As such, they require careful management to give patients the best chance of immediate and ultimate functional recovery. However, as these injuries are rare, there is paucity in prospective comparative studies large enough to provide high level evidence for best practice. This lack of comprehensive and convincing evidence has made the management of multiligamentous knee injuries an area of active debate and controversy. The debate on whether surgical management leads to better outcomes than non-operative management, the optimal timing of surgery after injury and whether repair is better than reconstruction is still ongoing. Using the Oxford Levels of Evidence, this review summarises the latest high level evidence to provide answers to these issues. Recommendations for practice have also been offered and assigned a grade using a published scale.

External cardiac compression during cardiopulmonary resuscitation of patients with left ventricular assist devices.

A best evidence topic was written according to a structured protocol to determine whether there is evidence that cardiopulmonary resuscitation (CPR) by compressing the chest is safe and effective in patients with left ventricular assist devices (LVADs). Manufacturers warn of a possible risk of device dislodgement if the chest is compressed. AMED, EMBASE, MEDLINE, BNI and CINAHL were searched from inception to March 2014. Animal studies, case reports, case series, case-control studies, randomized controlled studies and systematic reviews were eligible for inclusion. Opinion articles with no reference to data were excluded. Of 45 unique results, 3 articles merited inclusion. A total of 10 patients with LVADs received chest compression during resuscitation. There was no report of device dislodgement as judged by postarrest flow rate, autopsy and resumption of effective circulation and/or neurological function. The longest duration of chest compression was 150 min. However, there are no comparisons of the efficacy of chest compressions relative to alternative means of external CPR, such as abdominal-only compressions. The absence of high-quality data precludes definitive recommendation of any particular form of CPR, in patients with LVADs. However, data identified suggest that chest compression is not as unsafe as previously thought. The efficacy of chest compressions in this patient population has not yet been investigated. Further research is required to address both the safety and efficacy of chest compressions in this population. Urgent presentation and publication of further evidence will inform future guidance.

Enteral immunonutrition versus standard enteral nutrition for patients undergoing oesophagogastric resection for cancer.

A best evidence topic in surgery was written according to a structured protocol. The question addressed was "In cancer patients undergoing oesophageal or gastric resection for cancer and requiring postoperative nutritional support, does enteral immunonutrition confer additional clinical benefits as compared to standard enteral nutrition? Two hundred and fifty-eight papers were identified by a search of the MEDLINE and EMBASE databases, of which six randomized controlled trials represented the best evidence to answer this clinical question. The authors, journal, date and country of publication, patient group, study group, relevant outcomes and results of these papers were tabulated. All six of these randomised controlled trials compared the clinical benefits of standard enteral nutrition with those of enteral nutrition supplemented with a variety of immune-modulating substances. The studies failed to demonstrate consistent differences in patients' postoperative clinical course, complications, length of hospital stay and inflammatory marker levels. Hence although there is reasonable evidence to suggest that immunonutrition improves humoral immunity as opposed to cellular immunity, this improvement does not result in reductions in infection rates or reduced hospital stay. There is currently not enough evidence to recommend routine immunonutrition in all patients undergoing oesophageal or gastric resection for cancer.

Are head bandages required post-pinnaplasty?

A best evidence topic in ear, nose and throat surgery was written according to a structured protocol. The question addressed was: In patients who are undergoing pinnaplasty for prominent ears, does the use of post-operative head bandages as compared to not using post-operative head bandages improve clinical outcomes? A total of 121 papers were identified using the reported search protocol, of which five articles represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All five studies showed that no advantage exists in using head bandages with patients who have undergone pinnaplasty. Four of the five studies concluded that head bandages should not be utilised at all, whereas two of the five studies suggested that there is little reason to use head bandages after the first 24 h post-pinnaplasty. Therefore, the clinical bottom line is that provided the pinnaplasty result is good at time of surgery, there is reasonable evidence to suggest that head bandages have no effect on complications or patient satisfaction, so at best they are unnecessary and at worst, their physical drawbacks may actually outweigh any of their perceived benefits.