Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis.

Left-sided colonic diverticulitis is a common condition with significant morbidity and health care costs in Western countries. Acute uncomplicated diverticulitis which is characterized by the absence of organ dysfunction, abscesses, fistula, or perforations accounts for around 80% of the cases. In the last decades, several traditional paradigms in the management of acute uncomplicated diverticulitis have been replaced by evidence-based routines. This review provides a comprehensive evidence-based and clinical-oriented overview of up-to-date diagnostics with computer tomography, non-antibiotic treatment, outpatient treatment, and surgical strategies as well as follow-up of patients with acute uncomplicated diverticulitis.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon.

AIM: The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons. METHODS: The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements. RESULTS: This guideline contains 38 evidence based consensus statements on the management of diverticular disease. CONCLUSION: This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

Risk of colorectal cancer following CT-verified acute diverticulitis: a nationwide population-based cohort study.

AIM: Routine colonoscopy to exclude colorectal cancer (CRC) after CT-verified acute diverticulitis is controversial. This study aimed to compare the incidence of CRC in patients with acute diverticulitis with that in the general population. METHOD: Patients with an emergency admission for diverticular disease to any Norwegian hospital between 1 January 2008 and 31 December 2010 were included through identification in the Norwegian Patient Registry using International Classification of Diseases (ICD-10) codes K57.1-9. To estimate the age-specific distribution of CT-verified acute uncomplicated diverticulitis (AUD) and acute complicated diverticulitis (ACD) in this nationwide study population, numbers from the largest Norwegian emergency hospital were used. Patients diagnosed with CRC within 1 year following their admission for acute diverticulitis were detected through cross-matching with the Cancer Registry of Norway. Based on both Norwegian age-specific incidence of CRC and estimated age-specific distribution of CT-verified diverticulitis, standard morbidity ratios (SMRs) were calculated. RESULTS: A total of 7473 patients with emergency admissions for diverticular disease were identified (estimated CT-verified AUD n = 3523, ACD n = 1206); of these 155 patients were diagnosed with CRC within 1 year. Eighty had a CT-verified diverticulitis at index admission [41 AUD (51.3%); 39 ACD (49.7%)]. Compared with the general population, the SMR was 6.6 following CT-verified AUD and 16.3 following ACD, respectively. CONCLUSION: In the first year after CT-verified acute diverticulitis, especially after ACD, the risk of CRC is higher than in the general population. This probably represents misdiagnosis of CRC as acute diverticulitis. Follow-up colonoscopy should be recommended to all patients admitted with acute diverticulitis.

Demographic histories and genetic diversity across pinnipeds are shaped by human exploitation, ecology and life-history.

A central paradigm in conservation biology is that population bottlenecks reduce genetic diversity and population viability. In an era of biodiversity loss and climate change, understanding the determinants and consequences of bottlenecks is therefore an important challenge. However, as most studies focus on single species, the multitude of potential drivers and the consequences of bottlenecks remain elusive. Here, we combined genetic data from over 11,000 individuals of 30 pinniped species with demographic, ecological and life history data to evaluate the consequences of commercial exploitation by 18th and 19th century sealers. We show that around one third of these species exhibit strong signatures of recent population declines. Bottleneck strength is associated with breeding habitat and mating system variation, and together with global abundance explains much of the variation in genetic diversity across species. Overall, bottleneck intensity is unrelated to IUCN status, although the three most heavily bottlenecked species are endangered. Our study reveals an unforeseen interplay between human exploitation, animal biology, demographic declines and genetic diversity.

One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis.

BACKGROUND: Recent randomized trials demonstrated that laparoscopic lavage compared with resection for Hinchey III perforated diverticulitis was associated with similar mortality, less stoma formation but a higher rate of early reintervention. The aim of this study was to compare 1-year outcomes in patients who participated in the randomized Scandinavian Diverticulitis (SCANDIV) trial. METHODS: Between February 2010 and June 2014, patients from 21 hospitals in Norway and Sweden presenting with suspected perforated diverticulitis were enrolled in a multicentre RCT comparing laparoscopic lavage and sigmoid resection. All patients with perforated diverticulitis confirmed during surgery were included in a modified intention-to-treat analysis of 1-year results. RESULTS: Of 199 enrolled patients, 101 were assigned randomly to laparoscopic lavage and 98 to colonic resection. Perforated diverticulitis was confirmed at the time of surgery in 89 and 83 patients respectively. Within 1 year after surgery, neither severe complications (34 versus 27 per cent; P = 0·323) nor disease-related mortality (12 versus 11 per cent) differed significantly between the lavage and surgery groups. Among the 144 patients with purulent peritonitis, the rate of severe complications (27 per cent (20 of 74) versus 21 per cent (15 of 70) respectively; P = 0·445) and disease-related mortality (8 versus 9 per cent) were similar. Laparoscopic lavage was associated with more deep surgical-site infections (32 versus 13 per cent; P = 0·006) but fewer superficial surgical-site infections (1 versus 17 per cent; P = 0·001). More patients in the lavage group underwent unplanned reoperations (27 versus 10 per cent; P = 0·010). Including stoma reversals, a similar proportion of patients required a secondary operation (28 versus 29 per cent). The stoma rate at 1 year was lower in the lavage group (14 versus 42 per cent in the resection group; P < 0·001); however, the Cleveland Global Quality of Life score did not differ between groups. CONCLUSION: The advantages of laparoscopic lavage should be weighed against the risk of secondary intervention (if sepsis is unresolved). Assessment to exclude malignancy (although uncommon) is advised. Registration number: NCT01047462 ( http://www.clinicaltrials.gov).

Management of acute uncomplicated diverticulitis without antibiotics: a single-centre cohort study.

AIM: This study aimed to evaluate the implementation of nonantibiotic management of acute uncomplicated diverticulitis at a large university hospital in Norway with regard to management failure, disease recurrence and complications. METHOD: On 1 January 2013 we implemented a new policy for the management of acute uncomplicated diverticulitis without antibiotics. Antibiotic treatment was only provided in the case of defined criteria. All patients admitted from 1 January 2013 to 30 June 2014 with a CT-verified, left-sided, acute uncomplicated diverticulitis were included in the study and evaluated retrospectively, with 12 months' follow-up. RESULTS: Of 244 admissions with acute uncomplicated diverticulitis, 177 (73%) were managed without antibiotics. Among these there were seven (4%) management failures, including five patients in whom a deteriorating clinical picture prompted antibiotic treatment and two readmissions within 1 month due to persisting symptoms. The only complication in this group was one fistula (< 1%). Eight (5%) patients had a recurrence of acute diverticulitis requiring hospital care and two (1%) underwent elective surgery within the first year. Twenty (8%) patients met predefined exemption criteria and received antibiotics from admission, six (30%) of whom developed complications. The recurrence rate in this group was 10% and none had surgery performed. The 47 (20%) policy violators treated with antibiotics from admission had no complications. Their recurrence rate was 11% and one (2%) patient underwent elective surgery. CONCLUSION: This study confirms that nonantibiotic management of acute uncomplicated diverticulitis is safe and feasible. Most complications occurred in a small group of high-risk patients treated with antibiotics.

Global phylogeography and seascape genetics of the lemon sharks (genus Negaprion).

Seascapes are complex environments, and populations are often isolated by factors other than distance. Here we investigate the role of coastal habitat preference and philopatry in shaping the distribution and population structure of lemon sharks. The genus Negaprion comprises the amphiatlantic lemon shark (N. brevirostris), with a relict population in the eastern Pacific, and its Indo-West Pacific sister species, the sicklefin lemon shark (N. acutidens). Analyzing 138 individuals throughout the range of N. brevirostris (N = 80) and N. acutidens (N = 58) at microsatellite loci (nine and six loci, respectively) and the mitochondrial control region, we find evidence of allopatric speciation corresponding to the Tethys Sea closure (10-14 million years ago) and isolation of the eastern Pacific N. brevirostris population via the emergence of the Isthmus of Panama (approximately 3.5 million years ago). There is significant isolation by oceanic distance (R(2) = 0.89, P = 0.005), defined as the maximum distance travelled at depths greater than 200 m. We find no evidence for contemporary transatlantic gene flow (m, M = 0.00) across an oceanic distance of approximately 2400 km. Negaprion acutidens populations in Australia and French Polynesia, separated by oceanic distances of at least 750 km, are moderately differentiated (F(ST) = 0.070-0.087, P < or = 0.001; Phi(ST) = 0.00, P = 0.99), with South Pacific archipelagos probably serving as stepping stones for rare dispersal events. Migration between coastally linked N. brevirostris populations is indicated by nuclear (m = 0.31) but not mitochondrial (m < 0.001) analyses, possibly indicating female natal site fidelity. However, philopatry is equivocal in N. acutidens, which has the lowest control region diversity (h = 0.28) of any shark yet studied. Restricted oceanic dispersal and high coastal connectivity stress the importance of both local and international conservation efforts for these threatened sharks.

WITHDRAWN: Decongestants and antihistamines for acute otitis media in children.

BACKGROUND: Acute otitis media (AOM) is a common and important source of morbidity in children, although most cases resolve spontaneously. While frequently recommended, decongestant and antihistamine therapy is of unclear benefit. OBJECTIVES: To determine the efficacy of decongestant and antihistamine therapy in children with AOM on outcomes of AOM resolution, symptom resolution, medication side effects, and complications of AOM. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2003); MEDLINE (January 1966 to December 2003), EMBASE (January 1990 to July 2003) and reference lists of articles for this updated review. We also contacted study authors and pharmaceutical companies. SELECTION CRITERIA: Randomized controlled trials evaluating decongestant or antihistamine treatment for children with AOM were included. Patient-oriented outcomes were considered most relevant. There were no quality or language restrictions. DATA COLLECTION AND ANALYSIS: Investigators independently evaluated studies for inclusion, performed validity assessments, and completed data extraction. Dichotomous data were pooled to generate relative risks; homogeneity was assessed using approximate chi-square tests. MAIN RESULTS: Fifteen trials involving 2695 people were included. Only the combined decongestant-antihistamine group demonstrated statistically lower rates of persistent AOM at the two week period (fixed relative risk (RR) 0.76; 95% confidence interval (CI) 0.60 to 0.96; number needed to treat (NNT) 10). No benefit was found for early cure rates, symptom resolution, prevention of surgery or other complications. There was a five to eight -fold increased risk of side effects for those receiving an intervention, which reached statistical significance for all decongestant groupings. Validity sub analyses demonstrated that lower quality studies found benefit, while analysis of those studies with higher validity scores found no benefit of treatment. AUTHORS' CONCLUSIONS: Given lack of benefit and increased risk of side effects, these data do not support the use of decongestant treatment in children with AOM. There was a small statistical benefit from combination medication use but the clinical significance is minimal and study design may be biasing the results. Thus, the routine use of antihistamines for treating AOM in children cannot be recommended.

Antihistamines and/or decongestants for otitis media with effusion (OME) in children.

BACKGROUND: Otitis media with effusion (OME) is common and may cause hearing loss with associated developmental delay. Treatment remains controversial. The effectiveness of antihistamines, decongestants and antihistamine/decongestant combinations in promoting the resolution of effusions has been assessed by randomized controlled trials. OBJECTIVES: The objective of this review is to determine whether antihistamine, decongestant, or combination therapy is effective in treating children who present with OME. SEARCH STRATEGY: The Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2006), EMBASE (1974 to 2006), MEDLINE (1951 to 2006) and a gray literature database were searched using a search strategy created by an experienced medical librarian. The date of the last search was March 2006. Reference lists from included studies and relevant reviews were searched by hand; pharmaceutical manufacturers of antihistamines and decongestants and first authors of included studies were contacted to identify other potentially relevant studies. SELECTION CRITERIA: Randomized controlled trials (RCTs) using antihistamines, decongestants or antihistamine/decongestant combinations as treatment for OME in children were selected. We excluded trials that randomized on the basis of acute otitis media (AOM) even though OME was also studied in follow up. DATA COLLECTION AND ANALYSIS: Data were extracted from the published reports by two authors independently using standardized data extraction forms and methods. The methodological quality of the included studies was independently assessed by two authors. Dichotomous results were expressed as a relative risk with 95% confidence intervals using a fixed-effect model when homogeneous and a random-effects model when heterogeneous. Nearly all outcomes analysed were homogeneous. Continuous results were discussed qualitatively. Statistical analysis was conducted using RevMan software. MAIN RESULTS: No statistical or clinical benefit was found for any of the interventions or outcomes studied. However, treated study subjects experienced 11% more side effects than untreated subjects (number needed to treat to harm = 9). AUTHORS' CONCLUSIONS: Because the pooled data demonstrate no benefit and some harm from the use of antihistamines or decongestants alone or in combination in the management of OME, we recommend against their use.

Decongestants and antihistamines for acute otitis media in children.

BACKGROUND: Acute otitis media (AOM) is a common and important source of morbidity in children, although most cases resolve spontaneously. While frequently recommended, decongestant and antihistamine therapy is of unclear benefit. OBJECTIVES: To determine the efficacy of decongestant and antihistamine therapy in children with AOM on outcomes of AOM resolution, symptom resolution, medication side effects, and complications of AOM. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2003); MEDLINE (January 1966 to December 2003), EMBASE (January 1990 to July 2003) and reference lists of articles for this updated review. We also contacted study authors and pharmaceutical companies. SELECTION CRITERIA: Randomized controlled trials evaluating decongestant or antihistamine treatment for children with AOM were included. Patient-oriented outcomes were considered most relevant. There were no quality or language restrictions. DATA COLLECTION AND ANALYSIS: Investigators independently evaluated studies for inclusion, performed validity assessments, and completed data extraction. Dichotomous data were pooled to generate relative risks; homogeneity was assessed using approximate chi-square tests. MAIN RESULTS: Fifteen trials involving 2695 people were included. Only the combined decongestant-antihistamine group demonstrated statistically lower rates of persistent AOM at the two week period (fixed relative risk (RR) 0.76; 95% confidence interval (CI) 0.60 to 0.96; number needed to treat (NNT) 10). No benefit was found for early cure rates, symptom resolution, prevention of surgery or other complications. There was a five to eight -fold increased risk of side effects for those receiving an intervention, which reached statistical significance for all decongestant groupings. Validity sub analyses demonstrated that lower quality studies found benefit, while analysis of those studies with higher validity scores found no benefit of treatment. REVIEWERS' CONCLUSIONS: Given lack of benefit and increased risk of side effects, these data do not support the use of decongestant treatment in children with AOM. There was a small statistical benefit from combination medication use but the clinical significance is minimal and study design may be biasing the results. Thus, the routine use of antihistamines for treating AOM in children cannot be recommended.

Enhancing partner support to improve smoking cessation.

BACKGROUND: While many cessation programs are available to assist smokers in quitting, research suggests that partner involvement may encourage long-term abstinence. OBJECTIVES: The purpose of this review was to determine if an intervention to enhance partner support helps smoking cessation when added as an adjunct to a smoking cessation program. SEARCH STRATEGY: The search was performed in: Cochrane Tobacco Addiction Group specialized register (Apr 2004), Cochrane controlled trials register (Apr 2004), CDC and Prevention-Tobacco Information and Prevention Database (Jul 2000), MEDLINE (1966-Apr 2004), Cancer Lit (1966-Apr 2004), EMBASE (1974-Apr 2004), CINAHL (1966-Jul 2000), PsycInfo (1861-Apr 2004), ERIC, PsycLit, & Dissertation Abstracts (1861-Dec 1999), SSCI (1972-Apr 2004) and HealthStar (1975-Jul 2000). The search terms used were smoking (prevention, control, therapy), smoking cessation, and support (family, marriage, spouse, partner, sexual partner, buddy, friend, co-habitees, and co-worker). The search was also limited to English language. SELECTION CRITERIA: Randomized controlled trials of smoking cessation interventions that compared an intervention that included a partner support component with an otherwise identical intervention and reported follow-up of 6 months or greater. DATA COLLECTION AND ANALYSIS: Two reviewers independently identified the included studies and extracted data using a structured form. A third reviewer was consulted to aid in the resolution of discrepancies. Abstinence and biochemical assessment were the primary outcome measures and were analyzed at two post-treatment intervals: 6-9 months and >12 months. The scores of PIQ (partner interaction questionnaire) were also analyzed to assess partner support. A fixed-effects model was used to assess the summary effect of the studies. MAIN RESULTS: A total of 40 articles were identified for this review. Only eight articles (nine studies) met the inclusion criteria. The definition of partner varied among the studies. All studies included data on self reported smoking cessation rates, but there was limited biochemical validation of abstinence rates. The odds ratio for self-reported abstinence at 6-9 months was 1.08 (CI 95%, 0.81 -1.44); and at 12 months post-treatment was 1.0 (CI 95%, 0.75 - 1.34). Of the six studies that measured partner support at follow-up, only two studies reported significant increase in partner support in the intervention groups. REVIEWERS' CONCLUSIONS: In this review of the randomized controlled trials of interventions designed to enhance partner support for smokers in cessation programs, we failed to detect an increase in quit rates. Limited data from several of the trials suggest that these interventions did not increase partner support either. No conclusions can be made about the impact of partner support on smoking cessation. More systematic intervention to affect partnership significantly should be delivered if partner support were part of an existing cessation program.

Enhancing partner support to improve smoking cessation.

BACKGROUND: While many cessation programs are available to assist smokers in quitting, research suggests that partner involvement may encourage long-term abstinence. OBJECTIVES: The purpose of this review was to determine if an intervention to enhance partner support helps smoking cessation when added as an adjunct to a smoking cessation program. SEARCH STRATEGY: The search was performed in: Cochrane Tobacco Addiction Group specialized register (Aug 2001), Cochrane controlled trials register (Apr 2000), CDC and Prevention-Tobacco Information and Prevention Database (Jul 2000), MEDLINE (1966-Jul 2000), Cancer Lit (1966-Jul 2000), EMBASE (1974-Apr 2000), CINAHL (1966-Jul 2000), PsycInfo (1861-Oct 2000), ERIC, PsycLit, & Dissertation Abstracts (1861-Dec 1999), SSCI (1972-Jul 2000) and HealthStar (1975-Jul 2000). The search terms used were smoking (prevention, control, therapy), smoking cessation, and support (family, marriage, spouse, partner, sexual partner, buddy, friend, co-habitees, and co-worker). The search was also limited to English language. SELECTION CRITERIA: Randomized controlled trials of smoking cessation interventions that compared an intervention that included a partner support component with an otherwise identical intervention and reported follow-up of 6 months or greater. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data using a structured form. A third reviewer was consulted to aid in the resolution of discrepancies. Abstinence and biochemical assessment were the primary outcome measures and were analyzed at two post-treatment intervals: 6-9 months and >12 months. The scores of PIQ (partner interaction questionnaire) were also analyzed to assess partner support. A fixed-effects model was used to assess the summary effect of the studies. MAIN RESULTS: A total of 31 articles were identified for this review. Only eight articles (nine studies) met the inclusion criteria. The definition of partner varied among the studies. All studies included data on self reported smoking cessation rates, but there was limited biochemical validation of abstinence rates. The odds ratio for self-reported abstinence at 6-9 months was 1.08 (CI 95%, 0.81 -1.44); and at 12 months post-treatment was 1.0 (CI 95%, 0.75 - 1.34). Of the six studies that measured partner support at follow-up, only two studies reported significant increase in partner support in the intervention groups. REVIEWER'S CONCLUSIONS: We conclude that interventions designed to enhance partner support for smokers in cessation programs did not increase quit rates. Limited data from several of the RCTs suggest that these interventions did not increase partner support either. No conclusions can be made about the impact of partner support on smoking cessation. More systematic intervention to affect partnership significantly should be delivered if partner support were part of an existing cessation program.

Are fluid-based cytologies superior to the conventional Papanicolaou test? A systematic review.

OBJECTIVE: We compared fluid-based cytologies (FBC) with conventional Papanicolaou (Pap) tests (CT) to determine if either is superior. STUDY DESIGN: This was a systematic review of original research reports evaluating both CT and FBC with respect to specimen adequacy, comparison with a reference standard, or both. Two reviewers independently reviewed the titles, abstracts, and full articles to determine inclusion status, with differences resolved by consensus with a third author. Risk differences (RD) between occurrence rates for FBC and CT were used for the specimen adequacy data. Sensitivity and specificity were pooled independently and weighted by the inverse of the variance using a random effects model. DATA SOURCES: Studies published between 1985 and November 1999 were identified from MEDLINE, Best Evidence, EMBASE, Biological Abstracts/RRM, and The Cochrane Library. OUTCOMES MEASURED: Sensitivity, specificity, area under the receiver operating characteristic curve (AuROC), and the proportion of satisfactory, unsatisfactory, and "satisfactory but limited by" test results were measured. RESULTS: There was no significant difference in AuROC (P = .37). FBC specimens were more likely to be satisfactory (RD=0.06; 95% confidence interval [CI], 0.03-0.09) or to have absent endocervical cells (RD=0.06; 95% CI, 0.02-0.10) but had 10% fewer "satisfactory but limited by - other" reports (RD = -0.10; 95% CI, -0.14 to -0.06). There was no difference in unsatisfactory Pap test results. CONCLUSIONS: For most women there is no reason to replace CT with FBC. For women at high risk of cervical cancer or who are screened infrequently, the possible increase in FBC sensitivity may outweigh the potential harms from additional false positives.