Enhanced recovery programme after colorectal surgery in high-income and low-middle income countries: a systematic review and meta-analysis.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols strive to optimise outcomes following elective surgery; however, there is a dearth of evidence to support its equitable application and efficacy internationally. MATERIALS AND METHODS: The authors performed a systematic review and meta-analysis of studies on the uptake and impact of ERAS with the aim of highlighting differences in implementation and outcomes across high-income countries (HICs) and low-middle income countries (LMICs). The primary outcome was characterisation of global ERAS uptake. Secondary outcomes included length of hospital stay (LOS), 30-day readmission, 30-day mortality and postoperative complications. RESULTS: Three hundred thirty-seven studies with considerable heterogeneity were included in the analysis (291 from HICs, and 46 from LMICs) with a total of 110 190 patients. The weighted median number of implemented elements were similar between HICs and LMICs ( P =0·94), but there was a trend towards greater uptake of less affordable elements across all aspects of the ERAS pathway in HICs. The mean LOS was significantly shorter in patient cohorts in HICs (5·85 days versus 7·17 days in LMICs, P <0·001). The 30-day readmission rate was higher in HICs (8·5 vs. 4·25% in LMICs, P <0·001, but no overall world-wide effect when ERAS compared to controls (OR 1·00, 95% CI: 0·88-1·13). There were no reported differences in complications ( P =0·229) or 30-day mortality ( P =0·949). CONCLUSION: Considerable variation in the structure, the implementation and outcomes of ERAS exists between HICs and LMICs, where affordable elements are implemented, contributing towards longer LOS in LMICs. Global efforts are required to ensure equitable access, effective ERAS implementation and a higher standard of perioperative care world-wide.

Catecholamine Mega Storm Triggered by Cocaine Use and Thyrotoxicosis Crisis.

Takotsubo cardiomyopathy (TCM) is a well-recognized non-ischemic complication of physical and emotional stressors leading to heart dysfunction. Both thyroid storm and cocaine have been implicated with TCM to varying degrees. We present the case of a 26-year-old male with Graves' disease and cocaine abuse who was hospitalized with thyroid storm resulting in takotsubo cardiomyopathy and cardiogenic shock. The patient had a long and complicated hospital course, requiring advanced therapies including extracorporeal membrane oxygenation and other medical and mechanical circulatory support therapies. With treatment for thyroid storm using antithyroid medications and steroids, the patient eventually had complete recovery of his left ventricular function and was ultimately weaned from pressors, inotropes and mechanical support.

Healthcare provider's perspectives on home blood pressure management in Peru and Cameroon: Findings from the BPMONITOR study.

Home blood pressure management, including self-monitoring and medication self-titration, is an efficient and cost-effective tool. Although its use is increasing globally, little is known about the feasibility of such interventions in low and middle-income countries. Further, the perspectives and experiences of healthcare providers who play a big role in ensuring the success of home blood pressure management interventions have not been documented. This qualitative study was conducted with a total of 35 healthcare providers (60% female, mean [SD] age = 37.3 [6.9 years] years), through 4 in-depth interviews from Peru, and 8 in-depth interviews and 4 focus groups from Cameroon. Study participants (healthcare providers) include physicians (primary care physicians), specialists (cardiologists and geriatricians), and nurses that were purposively recruited from two hospitals in two of the largest cities in both countries. Results were thematically analyzed by two researchers. Themes derived were related to feasibility and acceptability, and largely reflected providers in both countries endorsing home blood pressure management. Providers' concerns were in three main areas; 1) safety of patients when they self-titrate medications, 2) resources such as healthcare financing, local hospital policies that support communications with patients for home blood pressure management, and 3) sustainability through patient adherence, incorporating home blood pressure management within clinical guidelines and hospital policies, and complementing with continued health education and lifestyle modifications. According to providers, home blood pressure management may be feasible and acceptable if tailored multi-faceted protocols were introduced bearing in mind local contexts.

Safety and effectiveness of live broadcast of surgical procedures: systematic review.

INTRODUCTION: Live Broadcast of Surgical Procedures (LBSP) has gained popularity in conferences and educational meetings in the past few decades. This is due to rapid advancement in both Minimally Invasive Surgery (MIS) that enable transmission of the entire operative field and transmission ease and technology to help broadcast the operation to a live audience. The aim of this study was to update the evidence with specific emphasis on the patient safety issues related to LBSP in MIS. METHODS: A systematic review of the literature was performed using Medline, Embase and Pubmed using defined search terms related to LBSP in educational events across all surgical specialities, in accordance with the PRISMA guidelines. We also consolidated the prior guidelines and position statements on this topic. Outcomes included reports on the educational value of LBSP as well as patient safety outcomes and ethical issues that were captured by clinical outcomes. RESULTS: A total 1230 abstracts were identified with 27 papers meeting the inclusion criteria (13 original articles and 14 position statements/guidelines). All studies highlighted the educational benefits of LBSP but without clear measure of these benefits. Clinical outcomes were not compromised in 9 studies but were inferior in the remaining 4, including lower completion rate of endoscopic surgery and higher rate of re-operation. Only nine studies complied with dedicated consent forms for LBSP with no consistent approach of reporting on maintaining patient confidentiality during LBSP. There was a lack of recommendation on standardised approach of reporting on LBSP including the outcomes across the 14 published guidelines and positions statements. CONCLUSIONS: Live Broadcast of Surgical Procedures can be of educational value but patient safety may be compromised. A standardised framework of reporting on LBSP and its outcomes is required from an ethical and patient safety perspective. PROSPERO REGISTRATION: CRD42021256901.

Efficacy of retinoids alone or in combination with other remedies in the management of warts: A systematic review and network meta-analysis.

The use of combined systemic retinoids and intralesional immunotherapy in the management of warts is still debatable without straightforward evidence. Through network meta-analysis, the current study evaluated the efficacy and safety of systemic retinoids alone or combined with other remedies in the treatment of warts. We searched six literature databases for clinical trials that compared systemic retinoids to local treatments or placebo in wart management. Outcomes were calculated as odds ratios (OR) with 95% confidence-interval. We used the R software to perform conventional and network meta-analyses (with a frequentist approach). Network meta-analysis of eight trials showed that oral acitretin plus intralesional Candida Ag (OR = 367.71), INF-α plus oral isotretinoin (OR = 223.77), oral acitretin (OR = 117), Candida Ag (OR = 91.93), oral isotretinoin (OR = 62.26) and topical isotretinoin (OR = 17.69) had higher complete recovery rates than placebo. Regarding the P-score, oral acitretin plus intralesional Candida Ag had the highest efficacy in achieving complete response (P-score = 0.88), followed by INF-α plus oral isotretinoin (P-score = 0.79), then oral acitretin (P-score = 0.60). Variable baseline characteristics and lack of data on some outcomes. The current study shows the efficacy for systemic retinoids in the treatment of warts, especially reluctant or recurrent types. Moreover, combinations of systemic retinoids with intralesional immunotherapy yield higher rates of complete clearance with lower recurrence.

Correction: Simultaneous administration of imipenem/cilastatin/relebactam with selected intravenous antimicrobials, a stewardship approach.

[This corrects the article DOI: 10.1371/journal.pone.0233335.].

Treatment options for autoimmune bullous dermatoses other than systemic steroids: A systematic review and network meta-analysis.

Autoimmune blistering diseases can eventually cause life-threatening complications if left untreated. Although there is no cure for these bullous diseases; their therapy is based on suppressing the immune system to cease the de novo formation of the generated antibodies. The current study aimed to assess the safety and efficacy of using standing alone alternative therapies beyond systemic steroids for management of autoimmune bullous diseases. We searched six literature databases for both randomized and quasi-randomized clinical trials that assessed the efficacy of drugs other than systemic steroids in autoimmune bullous diseases. Outcomes were calculated as odds ratios with 95% confidence-interval. We used the R software to perform conventional and network meta-analyses with a frequentist approach. The network ranking order for 629 bullous pemphigoid patients, from the best to the worst was, clobetasol propionate cream (40 mg; (P-score = .87), clobetasol propionate cream (10-30 mg; P-score = .77), nicotinamide plus tetracycline (P-score = .56), steroids (P-score = .29) and doxycycline (P-score = .01). Limitations of this study are the small sample of the included studies except for blister trial and lack of randomization in most trials. To conclude, Combined doxycycline and nicotinamides are safer and more effective option for extensive bullous pemphigoid patients than the usual use of systemic steroids. For limited disease, topical corticosteroid (40 mg/d) use provides a safer and better response modality than the other proposed treatments.

Simultaneous administration of imipenem/cilastatin/relebactam with selected intravenous antimicrobials, a stewardship approach.

Imipenem/cilastatin/relebactam is a ß-lactam/ß-lactamase inhibitor that has been recently FDA approved for complicated intra-abdominal and urinary tract infections under the brand name Recarbrio®. It has activity against imipenem non-susceptible Pseudomonas species as well as KPC-producing Enterobacteriaceae. Optimization of PK/PD of antimicrobials particularly in critically-ill patients is essential, but unfortunately, is hindered by separate administration that requires significant resources. The objective of the study is to investigate the compatibility of Y-site administration of imipenem/cilastatin/relebactam with a wide range of antimicrobials. After admixture, physical characteristics, pH changes and turbidity were measured for each 2-drug combination at a time. With the exception of amphotericin B deoxycholate, and posaconazole, imipenem/cilastatin/relebactam was compatible with a variety of antimicrobial agents. The compatibility profile described, will facilitate incorporation into hospital protocols, contribute to therapy optimization and guide clinicians to avoid successive administration, consequently resulting in reduction of total infusion time, optimization of PK/PD, economizing nursing time and cost containment.

Mental health in medical students: time to act.

BACKGROUND: Mental health problems are prevalent amongst medical students. However, many students delay seeking medical help or support from the medical school for a variety of reasons, including a fear of facing fitness to practice proceedings. Tackling this problem of awareness and delayed presentation will need a strong and dedicated focus at all stages, with prevention being of great importance. METHODS: A conference dedicated to mental health and well-being was organised for students of all years. The first part of the conference centred on well-being dilemmas and the second part focused on discussing important issues in small group sessions. RESULTS: Students were divided into eight groups and each group suggested improvements to the course that they felt would improve mental health and well-being. The main suggestions raised were: reassurance that the disclosure of mental health problems would not automatically result in fitness to practice proceedings; separate academic and pastoral roles of tutors; open up the topic of mental health and well-being more frequently during the programme; improve knowledge about the availability of support services; and have mentors who are at an earlier stage in postgraduate training (e.g. junior doctors). DISCUSSION: It is necessary to tackle the prevalent myths about this topic. Many students are unaware of the support services available. This conference has therefore sought to increase awareness of the topic. An approach is also now needed to identify those who need extra help. The authors strongly advocate opening up this topic throughout the course in the context of a dedicated conference, for example. Many students are unaware of the support services available The authors strongly advocate opening up this topic throughout the course in the context of a dedicated conference ….

Consensus views on the optimum training curriculum for advanced minimally invasive surgery: A delphi study.

INTRODUCTION: There has been a wide uptake in the use of Minimal Invasive Surgery (MIS) globally across different surgical specialties. Whilst evidence exists for a structured training curriculum for basic laparoscopic surgery, there is little agreement on a complete framework for an advanced MIS training curriculum, defining the essential elements of the curriculum including the optimal assessment methods. The aim of this study is to obtain a consensus on the essential elements of a training curriculum for advanced MIS. MATERIALS AND METHODS: A Delphi study was carried out involving 57 international experts in advanced MIS across different surgical specialties. A three round survey was conducted to reach consensus on the essential domains of a curriculum. This included defining the learners, trainers and training centres; curriculum content and competency based assessment. RESULTS: Unanimous agreement was reached for the completion of basic laparoscopic training before entry into advanced training. A trainer should have reached competency in advanced MIS and attended a 'Train the trainer' course. The curriculum should be delivered as modular training, including a multi-modal approach with a structured clinical proctorship programme. Formative assessment was considered as an integral part of learning and should be performed using objective work based assessment tools such as global assessment scale (GAS) forms. Accreditation in advanced MIS can be achieved by objective assessment of technical performance of unedited videos in addition to key clinical performance outcomes. CONCLUSION: A consensus on the framework of an advanced MIS training curriculum has been achieved defining the essential elements of entry criteria, selection of trainers and training units and curriculum content. Multimodal learning, clinical proctorship programme and competency based assessment are integral parts of the curriculum.

Zarxio (Filgrastim-sndz): The First Biosimilar Approved by the FDA.

Zarxio (filgrastim-sndz), a biosimilar for the treatment of severe chronic neutropenia.