Haemoprotozoa in wild short-beaked echidnas (Tachyglossus aculeatus).

The occurrence and clinical significance of the protozoal parasite reported as Hepatozoon tachyglossi in wild short-beaked echidnas (Tachyglossis aculeatus) have long been uncertain, as has its potential as a prognostic indicator. This retrospective survey of free-ranging short-beaked echidnas admitted to a wildlife hospital used morphological evidence to identify a H. tachyglossi prevalence of 56%, with parasitaemias affecting 0%-36% of monocytes. There was no statistical association between H. tachyglossi intensity and clinical status (P-value = 0.12; 95% confidence interval = 0.1 to 1.3), nor between the presence of H. tachyglossi and age, reason for admission, outcome, season or location. Piroplasms, presumed to be Theileria tachyglossi, were concurrently identified in the erythrocytes of 88% of short-beaked echidnas with no association between age, outcome, season or location, but a statistical association with the location where the animal was found (either on a road, airport runway, exposed urban area, or entangled). Given the current results, intracellular parasitism due to H. tachyglossi may be considered as an incidental finding on haematologic examination of short-beaked echidnas and is likely not an effective prognostic indicator. Further research using molecular tools is required to resolve the uncertain identity of H. tachyglossi which has been based on morphologic characteristics alone.

Interventional treatments for prolapsing haemorrhoids: network meta-analysis.

BACKGROUND: Multiple treatments for early-moderate grade symptomatic haemorrhoids currently exist, each associated with their respective efficacy, complications, and risks. The aim of this study was to compare the relative clinical outcomes and effectiveness of interventional treatments for grade II-III haemorrhoids. METHODS: A systematic review was conducted according to PRISMA criteria for all the RCTs published between 1980 and 2020; manuscripts were identified using the MEDLINE, Embase, and CENTRAL databases. Inclusion criteria were RCTs comparing procedural interventions for grade II-III haemorrhoids. Primary outcomes of interest were: symptom recurrence at a minimum follow-up of 6 weeks, postprocedural pain measured on a visual analogue scale (VAS) on day 1, and postprocedural complications (bleeding, urinary retention, and bowel incontinence). After bias assessment and heterogeneity analysis, a Bayesian network meta-analysis was performed. RESULTS: Seventy-nine RCTs were identified, including 9232 patients. Fourteen different treatments were analysed in the network meta-analysis. Overall, there were 59 RCTs (73 per cent) judged as being at high risk of bias, and the greatest risk was in the domain measurement of outcome. Variable amounts of heterogeneity were detected in direct treatment comparisons, in particular for symptom recurrence and postprocedural pain. Recurrence of haemorrhoidal symptoms was reported by 54 studies, involving 7026 patients and 14 treatments. Closed haemorrhoidectomy had the lowest recurrence risk, followed by open haemorrhoidectomy, suture ligation with mucopexy, stapled haemorrhoidopexy, and Doppler-guided haemorrhoid artery ligation (DG-HAL) with mucopexy. Pain was reported in 34 studies involving 3812 patients and 11 treatments. Direct current electrotherapy, DG-HAL with mucopexy, and infrared coagulation yielded the lowest pain scores. Postprocedural bleeding was recorded in 46 studies involving 5696 patients and 14 treatments. Open haemorrhoidectomy had the greatest risk of postprocedural bleeding, followed by stapled haemorrhoidopexy and closed haemorrhoidectomy. Urinary retention was reported in 30 studies comparing 10 treatments involving 3116 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had significantly higher odds of urinary retention than rubber band ligation and DG-HAL with mucopexy. Nine studies reported bowel incontinence comparing five treatments involving 1269 participants. Open haemorrhoidectomy and stapled haemorrhoidopexy had the highest probability of bowel incontinence. CONCLUSION: Open and closed haemorrhoidectomy, and stapled haemorrhoidopexy were associated with worse pain, and more postprocedural bleeding, urinary retention, and bowel incontinence, but had the lowest rates of symptom recurrence. The risks and benefits of each treatment should be discussed with patients before a decision is made.

Tick paralysis in Australian birds caused by Ixodes holocyclus.

Tick paralysis is an uncommon cause of neuromuscular paralysis affecting 0.12% of wild birds presented to Currumbin Wildlife Sanctuary, Queensland, with a strong seasonal predilection towards spring and summer. Clinical signs and progression of paralysis showed similarities to companion animals and were consistent across 20 species. Tick location, number of engorged ticks and number of clinical signs did not affect the outcome; however, all mortalities occurred within 4 days of admission. Treatment with canine-derived tick antiserum resulted in clinical improvement within 24 h and a recovery rate of 73%. Average time to resolution of clinical signs was 4.3 days, with juvenile birds recovering more quickly than adults. The treatment and release of wild birds affected by tick paralysis are both achievable and rewarding, further research is required to establish treatment guidelines in birds.

Symptom-based scoring for haemorrhoidal disease: a systematic review.

AIM: Haemorrhoidal disease can severely affect a patient's quality of life. Its classification is commonly based on morphology of the degree of prolapse; however, this does not take into account the symptoms and impact on the quality of life. The aim of this systematic review was to determine the most appropriate instruments that classify the severity of disease according to symptoms. METHOD: A PRISMA-compliant search was conducted in December 2019 to identify studies that described the validation of a haemorrhoidal symptom score. The measurement properties of the scoring systems were assessed based on the consensus-based standards for the selection of health status measurement instruments (COSMIN) methodology for systematic reviews for patient-reported outcome measures. RESULTS: A total of 5288 articles were identified, with five articles included. Three studies developed a scoring system based on a set of core symptoms for a cohort of patients and validated the score against treatment outcomes. One study developed a disease-specific quality of life questionnaire based on symptoms to evaluate disease burden. One study combined both quality of life and symptom measures and tested measurement properties on two cohorts of patients. Only one study demonstrated satisfactory valid, reliable and responsive measurement criteria. CONCLUSION: A single study demonstrated sufficient quality in measurement properties to be recommended for clinical use. Further studies in this area should utilize consensus-based standards for designing and reporting validation research to ensure that the appropriate evidence base is acquired if any further patient-reported outcome measures are to be recommended.

Risk factors associated with unplanned readmission following excisional haemorrhoidectomy.

AIM: Excisional haemorrhoidectomy is the gold standard for management of advanced symptomatic haemorrhoids. Although an effective treatment, it is associated with significant postoperative morbidity with pain, bleeding and a high readmission rate. This study seeks to investigate potential risk factors that may predict unplanned 30-day readmissions following excisional haemorrhoidectomy. METHOD: A retrospective cohort review of all haemorrhoidectomies performed at Counties Manukau District Health Board, Auckland, New Zealand, between January 2012 and December 2017 was performed. Baseline demographic data, readmission data and potential variables for readmission were recorded. Univariate and multivariate logistic regression analyses were performed to determine significant variables for readmission within 30 days. RESULTS: In total, 485 cases of excisional haemorrhoidectomy were included in the final analysis with 62 (12.8%) unplanned readmissions. The demographics between the no readmission and unplanned readmission groups were similar. Multivariate logistic regression analysis demonstrated that male gender (P = 0.018) and the use of non-diathermy devices (P = 0.017) were significant risk factors for readmission. Initial dispensing of opioid analgesia did not decrease the risk of readmission. CONCLUSION: This study suggests that male gender and surgical technique are associated with increased risk of readmission.

Is suturing of the bladder defect in benign Enterovesical fistula necessary?

BACKGROUND: Enterovesical fistula (EVF) is a abnormal connection between the intestine and the bladder. The aim of the study was to analyze whether closure of the defect in the bladder wall during surgery is always necessary. METHODS: Fifty-nine patients with benign EVF undergoing surgical treatment were enrolled. A one-stage surgical procedure was performed in all patients. After the separation of the diseased bowel segment, methylene blue was introduced. Through a catheter into the bladder. Only patients with urinary bladder leakage were sutured. RESULTS: The most common intestinal fistula involving the urinary bladder was colovesical fistula, observed in 53% of cases. Two-thirds of patients had diverticular disease as the underlying pathology. There was no relationship between suturing of the bladder and perioperative complications. Recurrent EVF was observed in one patient with bladder suturing and in two patients without suture. CONCLUSIONS: These findings suggest that closure of the bladder defect is not necessary in cases where a leak is not demonstrated from the bladder intraoperatively. This study is limited by its retrospective design and small numbers and a randomized controlled trial is recommended to answer this question definitively.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018.

BACKGROUND: This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS: A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS: All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS: The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Evidence-based management of pain after laparoscopic cholecystectomy: a PROSPECT review update.

BACKGROUND: Significant pain can be experienced after laparoscopic cholecystectomy. This systematic review aims to formulate PROSPECT (PROcedure SPECific Postoperative Pain ManagemenT) recommendations to reduce postoperative pain after laparoscopic cholecystectomy. METHODS: Randomised controlled trials published in the English language from January 2006 (date of last PROSPECT review) to December 2017, assessing analgesic, anaesthetic, or operative interventions for laparoscopic cholecystectomy in adults, and reporting pain scores, were retrieved from MEDLINE and Cochrane databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) search protocols. PROSPECT methodology was used, and recommendations were formulated after review and discussion by the PROSPECT group (an international group of leading pain specialists and surgeons). RESULTS: Of 1988 randomised controlled trials identified, 258 met the inclusion criteria and were included in this review. The studies were of mixed methodological quality, and quantitative analysis was not performed because of heterogeneous study design and how outcomes were reported. CONCLUSIONS: We recommend basic analgesic techniques: paracetamol + NSAID or cyclooxygenase-2 specific inhibitor + surgical site local anaesthetic infiltration. Paracetamol and NSAID should be started before or during operation with dexamethasone (GRADE A). Opioid should be reserved for rescue analgesia only (GRADE B). Gabapentanoids, intraperitoneal local anaesthetic, and transversus abdominis plane blocks are not recommended (GRADE D) unless basic analgesia is not possible. Surgically, we recommend low-pressure pneumoperitoneum, postprocedure saline lavage, and aspiration of pneumoperitoneum (GRADE A). Single-port incision techniques are not recommended to reduce pain (GRADE A).

Systematic review of the systemic concentrations of local anaesthetic after transversus abdominis plane block and rectus sheath block.

BACKGROUND.: Safe and efficacious modalities of perioperative analgesia are essential for enhanced recovery after surgery. Truncal nerve blocks are one potential adjunct for analgesia of the abdominal wall, and in recent years their popularity has increased. Transversus abdominis plane block (TAPB) and rectus sheath block (RSB) have been shown to reduce morphine consumption and improve pain relief after abdominal surgery. These blocks typically require large volumes of local anaesthetic (LA). We aimed to synthesize studies evaluating systemic concentrations of LA after perioperative TAP and RSB to enhance our understanding of systemic LA absorption and the risk of systemic toxicity. METHODS.: An independent literature review was performed in accordance with the methods outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. An electronic search of four databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and PubMed) was conducted. Primary articles measuring systemic concentrations of LA after single-shot bolus TAPB or RSB were included. RESULTS.: Fifteen studies met the inclusion criteria. Rapid systemic LA absorption was observed in all studies. Of a total of 381 patients, mean peak concentrations of LA exceeded toxic thresholds in 33 patients, of whom three reported mild adverse effects. The addition of epinephrine reduced systemic absorption of LA. No instances of seizure or cardiac instability were observed. CONCLUSIONS.: Local anaesthetic in TAPB and RSB can lead to detectable systemic concentrations that exceed commonly accepted thresholds of LA systemic toxicity. Our study highlights that these techniques are relatively safe with regard to LA systemic toxicity.

Systematic review of the role of biomarkers in diagnosing anastomotic leakage following colorectal surgery.

BACKGROUND: Anastomotic leakage (AL) following colorectal surgery can be difficult to diagnose owing to varying clinical presentations. This systematic review aimed to assess biomarkers as potential diagnostic tests for preclinical detection of AL. METHODS: A comprehensive literature review was conducted according to PRISMA guidelines. All published studies evaluating biomarkers, both systemic and peritoneal, in the context of AL following colorectal surgery were included. Studies were sought in three electronic databases (MEDLINE, PubMed and Embase) from January 1990 to June 2016. RESULTS: Thirty-six studies evaluated 51 different biomarkers in the context of AL after colorectal surgery. Biomarkers included markers of ischaemia and inflammation, and microbiological markers, and were measured in both peritoneal drain fluid and the systemic circulation. The most commonly evaluated peritoneal drain fluid biomarkers were interleukin (IL) 6, IL-10 and tumour necrosis factor. Significantly raised drain levels in the early postoperative period were reported to be associated with the development of AL. C-reactive protein, procalcitonin and leucocytes were the most commonly evaluated systemic biomarkers with significant negative and positive predictive values. Associated area under the curve values ranged from 0·508 to 0·960. CONCLUSION: Peritoneal drain fluid and systemic biomarkers are poor predictors of AL after colorectal surgery. Combinations of these biomarkers showed improvement in predictive accuracy.

Squamous cell carcinoma with hepatic metastasis in a saltwater crocodile (Crocodylus porosus).

BACKGROUND: Squamous cell carcinomas (SCC) are uncommon in reptiles and there have been few reports of neoplasia in Australian crocodiles, despite increased numbers being raised in captivity. CASE REPORT: We report a locally invasive SCC in the hindlimb of a wild-caught saltwater crocodile (Crocodylus porosus) with hepatic metastasis. The gross appearance was soft tissue swelling adjacent to the nail bed, progressing to abscessation incorporating multiple toes. Diagnosis was achieved by biopsy during amputation of the affected toes. Hepatic metastasis was identified at necropsy, with a similar gross appearance resembling an abscess. CLINICAL SIGNIFICANCE: Neoplasia is an uncommon finding in crocodilians and metastatic neoplasia is rarely documented. This is the first report of SCC in a crocodilian.

Acanthocephalan infection and sparganosis in a green tree snake (Dendrelaphis punctulata).

Acanthocephalan and spargana parasites were identified within a body wall mass during exploratory surgery in a wild green tree snake. Acanthocephalan parasites have not previously been reported in this species. Surgical excision, the treatment of choice, could not be achieved because of the extensive infiltration of the coelomic cavity.

Efficacy of patient-initiated follow-up clinics in secondary care: a systematic review.

Patient-initiated follow up (PIFU) is an initiative that allows patients to initiate hospital follow-up appointments on an 'as required' basis compared with the traditional 'physician-initiated' model. The main principle is to reduce inappropriate regular follow-up appointments. In this systematic review, we attempt to address its efficacy for outpatient secondary level care. Using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, an electronic literature search was performed independently by two authors using pre-defined search terms across EMBASE, Ovid MedLine, PubMed, PSYCINFO and the Cochrane Library databases. Articles were included if they specifically evaluated any aspect of PIFU. Studies evaluating non-outpatient-based, primary level-based and nurse-led clinic appointments were excluded. A total of 747 articles was reviewed, and six were finally included for the systematic review. Three studies analysed efficacy of PIFU with regards to rheumatological disease and found that there was no deleterious clinical effect and a trend towards increased satisfaction and quality of life including lower costs in the PIFU group. Two studies looked at PIFU and inflammatory bowel disease and identified some clinical benefit and lower costs and equivalent satisfaction and QoL with the PIFU group. A further study looked at PIFU in stage 1 breast cancer and did not find any significant differences in outcomes. There is evidence to suggest that PIFU systems result in fewer overall outpatient appointments in secondary care led services while maintaining equivalent if not better patient satisfaction, quality of life and clinical outcomes across a range of chronic conditions.

Association between preoperative glucocorticoids and long-term survival and cancer recurrence after colectomy: follow-up analysis of a previous randomized controlled trial.

BACKGROUND: The effect of anaesthetic drugs on long-term oncological outcomes after cancer surgery is an area of current interest. Dexamethasone is widely used in anaesthetic practice; however, its effect on long-term survival and cancer outcomes is not known. This study presents the results of a 5-yr follow-up of patients receiving dexamethasone before elective colectomy as part of a previous randomized clinical trial. METHODS: Sixty patients who underwent elective open colonic resection for any indication between June 2006 and March 2008 were randomized to receive either 8 mg i.v. dexamethasone or placebo before surgery. A 5-yr follow-up analysis was conducted to evaluate overall survival, disease-free survival and recurrence specifically for patients undergoing resection for Stage I-III colon cancer. Kaplan-Meier analysis was performed and log-rank test was used to evaluate difference in survival between groups. RESULTS: Forty-three of the 60 subjects had Stage I-III colon cancer and were included in the follow-up analysis. Twenty received preoperative dexamethasone and 23 received placebo. There were no significant differences between groups in baseline or disease characteristics. No differences were found between groups for overall or disease-free survival. In the dexamethasone group, there was a significantly higher rate of distant recurrence (6 compared with 1, P=0.04). CONCLUSIONS: Preoperative dexamethasone was associated with a higher rate of distant recurrence in patients undergoing colectomy for colon cancer. Given the small sample size, this finding should be interpreted with caution, but warrants further investigation in a prospective study.

Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery.

BACKGROUND: Several recent studies have investigated the role of C-reactive protein (CRP) as an early marker of anastomotic leakage following colorectal surgery. The aim of this systematic review and meta-analysis was to evaluate the predictive value of CRP in this setting. METHODS: A systematic literature search was performed using MEDLINE, Embase and PubMed to identify studies evaluating the diagnostic accuracy of postoperative CRP for anastomotic leakage following colorectal surgery. A meta-analysis was carried out using a random-effects model and pooled predictive parameters were determined along with a CRP cut-off value at each postoperative day (POD). RESULTS: Seven studies, with a total of 2483 patients, were included. The pooled prevalence of leakage was 9·6 per cent and the median day on which leakage was diagnosed ranged from POD 6 to 9. The serum CRP level on POD 3, 4 and 5 had comparable diagnostic accuracy for the development of an anastomotic leak with a pooled area under the curve of 0·81 (95 per cent confidence interval 0·75 to 0·86), 0·80 (0·74 to 0·86) and 0·80 (0·73 to 0·87) respectively. The derived CRP cut-off values were 172 mg/l on POD 3, 124 mg/l on POD 4 and 144 mg/l on POD 5; these corresponded to a negative predictive value of 97 per cent and a negative likelihood ratio of 0·26-0·33. All three time points had a low positive predictive value for leakage, ranging between 21 and 23 per cent. CONCLUSION: CRP is a useful negative predictive test for the development of anastomotic leakage following colorectal surgery.

A systematic review to assess cost effectiveness of enhanced recovery after surgery programmes in colorectal surgery.

AIM: Enhanced recovery after surgery (ERAS) programmes have been shown to reduce length of stay and peri-operative morbidity. However, there are comparatively few data on their cost effectiveness. The object of this systematic review was to appraise the current literature to determine the cost effectiveness of ERAS and to characterize how cost is reported and evaluated. METHOD: An electronic database search identified studies comparing ERAS with standard peri-operative care in colorectal surgery where an evaluation of cost effectiveness was a primary or secondary outcome. Cost data were converted to euros to enable a more standardized comparison of the studies. There were no limits on study design. RESULTS: Seven articles were included in the analysis. The reporting and evaluation of cost data were inconsistent. Reported cost for ERAS ranged from €1989 to €12,805 per patient. Although not all statistically significant, all studies demonstrated cost reductions with ERAS compared with non-ERAS although they were highly variable, ranging from €153 to €6537 per patient. CONCLUSION: Although the review has shown ERAS to be cost effective, there are some important inconsistencies and deficiencies regarding the reporting of data. Authors should therefore be encouraged to report cost data to supplement the literature detailing clinical efficacy.

Systematic review and meta-analysis of oesophageal Doppler-guided fluid management in colorectal surgery.

BACKGROUND: Oesophageal Doppler monitor (ODM)-guided fluid therapy has been recommended for routine use in patients undergoing colorectal surgery. However, recent trials have suggested either equivalent or inferior results for patients randomized to ODM-guided fluid management, especially when compared with fluid restriction or within the context of optimized perioperative care. Hence, an updated systematic review and meta-analysis was conducted. METHODS: A systematic review and meta-analysis was conducted of all randomized trials exploring ODM-guided fluid management in major colorectal surgery with the endpoints total complications and length of hospital stay (LOS). Subset analyses were planned a priori specifically to investigate the role of the ODM in the context of fluid restriction or optimized perioperative care. RESULTS: Six high-quality trials comprising a total of 691 patients were included in the final analysis. ODM-guided fluid therapy did not influence the incidence of complications (odds ratio 0·74, 95 per cent confidence interval (c.i.) 0·50 to 1·11; P = 0·15), with moderate heterogeneity in the results (I(2) = 33 per cent; P = 0·19). There was no difference in mean LOS between patients receiving ODM-guided fluid therapy and controls: mean difference -0·88 (95 per cent c.i. -2·89 to 1·13) days (P = 0·39). There was no difference in complications or LOS when ODM-guided fluid therapy was compared with fluid restriction or used within an otherwise optimized perioperative environment. CONCLUSION: ODM-guided fluid therapy did not influence LOS or complications in patients undergoing colorectal surgery. Results favouring the ODM were seen only in early studies, whereas newer trials did not show any benefit from such monitoring.