Subtotal vs total cholecystectomy for difficult gallbladders: A systematic review and meta-analysis.

INTRODUCTION: With severely inflamed gallbladders, laparoscopic cholecystectomy can be difficult and may require procedures like subtotal cholecystectomy (SC). Few studies exist comparing SC and total cholecystectomy (TC) in the setting of severe biliary inflammation. This meta-analysis aims to compare SC and TC for difficult gallbladders. METHODS: Medline-OVID, Embase-OVID, and Cinahl were searched including only studies comparing SC to TC for difficult gallbladders. Primary outcome was CBD injury. Secondary outcomes included bile leak, duodenal injury, retained stone, bleeding, intraabdominal collection, wound infection, reoperation, and mortality. RESULTS: Ten studies were included. Compared to TC, SC significantly lowered the risk for CBD injury (0 â€‹% vs. 1.6 â€‹%, RR 0.30, 95%CI 0.10-0.87) but increased risk of bile leaks (RR 3.5, 95%CI 1.79-6.84), postoperative ERCP (RR 2.86, 95%CI 1.53-5.35), intraabdominal collections (RR 2.55, 95%CI 1.32-4.93), and reoperation (RR 2.92, 95%CI 1.14-7.47). CONCLUSION: SC is a reasonable alternative to difficult gallbladders that may decrease the risk of CBD injuries. Knowing both approaches is crucial to manage the difficult gallbladder while minimizing harm. Further studies are needed to understand the value of SC for difficult cholecystectomy.

Benefit of hospital admission for detecting serious adverse events among emergency department patients with syncope: a propensity-score-matched analysis of a multicentre prospective cohort.

BACKGROUND: The benefit of hospital admission after emergency department evaluation for syncope is unclear. We sought to determine the association between hospital admission and detection of serious adverse events, and whether this varied according to the Canadian Syncope Risk Score (CSRS). METHODS: We conducted a secondary analysis of a multicentre prospective cohort of patients assessed in the emergency department for syncope. We compared patients admitted to hospital and discharged patients, using propensity scores to match 1:1 for risk of a serious adverse event. The primary outcome was detection of a serious adverse event in hospital for admitted patients or within 30 days after emergency department disposition for discharged patients. RESULTS: We included 8183 patients, of whom 743 (9.1%) were admitted; 658/743 (88.6%) were matched. Admitted patients had higher odds of detection of a serious adverse event (odds ratio [OR] 5.0, 95% confidence interval [CI] 3.3-7.4), nonfatal arrhythmia (OR 5.1, 95% CI 2.9-8.8) and nonarrhythmic serious adverse event (OR 6.3, 95% CI 2.9-13.5). There were no significant differences between the 2 groups in death (OR 1.0, 95% CI 0.4-2.7) or detection of ventricular arrhythmia (OR 2.0, 95% CI 0.7-6.0). Differences between admitted and discharged patients in detection of serious adverse events were greater for those with a CSRS indicating medium to high risk (p = 0.04). INTERPRETATION: Patients with syncope were more likely to have serious adverse events identified within 30 days if they were admitted to hospital rather than discharged from the emergency department. However, the benefit of hospital admission is low for patients at low risk of a serious adverse event.

Do four or more antenatal care visits increase skilled birth attendant use and institutional delivery in Bangladesh? A propensity-score matched analysis.

BACKGROUND: With Bangladesh's adoption of the third Sustainable Development Goal to reduce maternal mortality, the impetus for Bangladesh to continue to improve uptake of maternal healthcare is strong. METHODS: Using a propensity-score matched analysis, the present study utilized data from the 2014 Bangladesh Demographic Health survey to examine the impact of four or more antenatal care visits on skilled birth attendant use and institutional delivery. RESULTS: The results revealed a significant and positive impact of four or more antenatal care visits on skilled birth attendant use and institutional delivery after matching treated and untreated mothers on included socio-demographic characteristics. CONCLUSIONS: Implementation of policies to provide at least four antenatal care visits may serve as an effective strategy to increase SBA use and institutional delivery in Bangladesh, which could contribute to the reduction of maternal mortality.

Is the Risk of Infection Lower with Sutures than with Staples for Skin Closure After Orthopaedic Surgery? A Meta-analysis of Randomized Trials.

BACKGROUND: Two previous meta-analyses comparing staples versus sutures have led to conflicting relative risks for surgical site infection between skin closure methods after orthopaedic surgery. Consequently, the choice of sutures or staples for skin closure continues to be a subject of conversation. Recently, additional randomized trials have been published, and an updated meta-analysis is needed to inform this debate. QUESTIONS/PURPOSES: To determine using a meta-analysis of randomized trials (1) whether there is a difference in surgical site infection (SSI) between staples and sutures for skin closure after orthopaedic surgery, and (2) whether that finding remains the same when the analysis is limited to randomized trials with a low risk of bias. METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) comparing staples with sutures for skin closure after orthopaedic surgery was conducted. We excluded barbed sutures, surgical zippers, and skin adhesives from this meta-analysis. Medline, Embase, CINAHL, Cochrane Library, and Global Index Medicus were searched from date of inception to October 18, 2017. The sole outcome of interest was SSI as defined by the original study authors, with preference given to Center for Disease Control and Prevention (CDC) definitions whenever possible, recognizing that this may result in the pooling of more common minor events with rarer, more severe events, and in so doing, overestimate between-group differences. Because of this, subgroup analysis was planned based on severity of infection. Relative risk was calculated using a random-effects model (relative risk [RR], 95% confidence interval [CI]). Heterogeneity was estimated using I. Publication bias was explored using visual inspection of the funnel plot and Egger's test. Subgroup analysis was planned for type of orthopaedic surgery, suture material, SSI category, and country development index. Subgroup interaction p values were calculated. The Cochrane risk of bias tool was used to assess study quality. Sensitivity analysis was planned to assess whether the results changed when the analysis was limited to studies with low risk of bias. In total, 17 RCTs (2446 patients) were eligible, of which five RCTs (501 patients) were at low risk of bias. RESULTS: In the primary analysis, patients randomized to staples had a higher risk of SSI versus those who received sutures for skin closure (RR, 2.05; 95% CI,1.38-3.06; I = 0%). However, most of the events were driven by superficial SSI, and only two deep infections were explicitly reported in total (one in each group). After a post-hoc sensitivity analysis excluded a highly influential trial with high risk of bias, the results were highly fragile, relying on a difference of only four additional events in the staples group. When we limited the analysis to RCTs with low risk of bias, no difference was found between sutures and staples in terms of SSI (RR, 1.45; 95% CI, 0.31-6.79; I = 46%). Effect sizes were consistent across subgroups (p value for subgroup interaction was not significant for elective versus trauma; hip versus knee arthroplasty; suture material; high versus middle- versus low-income settings). CONCLUSIONS: Even in this relatively large meta-analysis, existing RCTs do not provide definitive evidence of a difference in SSI risk when staples are used instead of sutures for skin closure after orthopaedic surgery. Currently, the total body of evidence remains weak and, even when limiting to only low risk of bias studies, it is not possible to rule in or rule out clinically important differences between staples and sutures. Until randomized studies of adequate power and followup duration are performed to definitively inform this issue, the choice between staples versus sutures should be based on other factors such as local availability, surgeon preference, and cost. LEVEL OF EVIDENCE: Level I, therapeutic study.

Outcomes of Cutaneous Squamous Cell Carcinoma in the Head and Neck Region With Regional Lymph Node Metastasis: A Systematic Review and Meta-analysis.

IMPORTANCE: There is a need to summarize the available evidence and provide quantitative data of the most important prognostic factors for patients with metastatic cutaneous squamous cell carcinoma of the head and neck region with regional lymph node metastasis (McSCCHN). OBJECTIVE: To undertake a PRISMA-compliant systematic review and meta-analysis of all published studies on the risk factors for overall survival (OS), locoregional control (LRC), locoregional recurrence (LRR), and disease-specific survival (DSS) for patients with McSCCHN. DATA SOURCES: PubMed, CINAHL, and Embase were searched from 1946 to August 2018 for English-language articles. STUDY SELECTION: Inclusion criteria were randomized clinical trials or observational studies reporting on at least 10 patients with McSCCHN; studies analyzing 1 defined risk factor; reporting OS, LRC, LRR, or DSS; and clinical follow-up of 1 year of more. For the final analysis we included risk factors that were analyzed for the same outcome in at least 3 studies. Of the 2923 articles screened, 21 articles met the inclusion criteria. DATA EXTRACTION AND SYNTHESIS: PRISMA guidelines were used for abstracting the data. Two reviewers independently abstracted the data. Risk of bias was estimated with the Newcastle-Ottawa Scale. Meta-analysis was performed using the random-effects model. All analysis took place between January and October 2018. MAIN OUTCOMES AND MEASURES: The primary end point was OS. Secondary end points included LRC, LRR, and DSS. RESULTS: A total of 20 observational studies and 1 randomized clinical trial were identified, representing 3534 patients (some reviewed articles reported no demographic characteristics), and were included in the analysis. Significant risk factors associated with OS were immunosuppression (hazard ratio [HR] of death, 2.66; 95% CI, 2.26-3.13), extracapsular spread (HR, 1.90; 95% CI, 1.12-3.23), adjuvant radiotherapy (HR, 0.45; 95% CI, 0.27-0.78), lymph node ratio (HR, 1.91; 95% CI, 1.09-3.35), and advanced age (HR, 1.03; 95% CI, 1.00-1.07). Immunosuppression (HR, 3.82; 95% CI, 2.47-5.92) and adjuvant radiotherapy (HR, 0.52; 95% CI, 0.33-0.84) were also significant risk factors for DSS. CONCLUSIONS AND RELEVANCE: Immunosuppressed patients and those with extracapsular extension have poor prognosis. Adjuvant radiotherapy is associated with an improvement in OS. These risk factors will assist with better risk stratification and may also help to inform future clinical trials.

Sex-Specific Associations Between Alcohol Consumption and Incidence of Hypertension: A Systematic Review and Meta-Analysis of Cohort Studies.

BACKGROUND: Although it is well established that heavy alcohol consumption increases the risk of hypertension, the risk associated with low levels of alcohol intake in men and women is unclear. METHODS AND RESULTS: We searched Medline and Embase for original cohort studies on the association between average alcohol consumption and incidence of hypertension in people without hypertension. Random-effects meta-analyses and metaregressions were conducted. Data from 20 articles with 361 254 participants (125 907 men and 235 347 women) and 90 160 incident cases of hypertension (32 426 men and 57 734 women) were included. In people drinking 1 to 2 drinks/day (12 g of pure ethanol per drink), incidence of hypertension differed between men and women (relative riskwomen vs men=0.79; 95% confidence interval, 0.67-0.93). In men, the risk for hypertension in comparison with abstainers was relative risk=1.19 (1.07-1.31; I2=59%), 1.51 (1.30-1.76), and 1.74 (1.35-2.24) for consumption of 1 to 2, 3 to 4, and 5 or more standard drinks per day, respectively. In women, there was no increased risk for 1 to 2 drinks/day (relative risk=0.94; 0.88-1.01; I2=73%), and an increased risk for consumption beyond this level (relative risk=1.42; 1.22-1.66). CONCLUSIONS: Any alcohol consumption was associated with an increase in the risk for hypertension in men. In women, there was no risk increase for consumption of 1 to 2 drinks/day and an increased risk for higher consumption levels. We did not find evidence for a protective effect of alcohol consumption in women, contrary to earlier meta-analyses.

Mentoring needs of distributed medical education faculty at a Canadian medical school: a mixed-methods descriptive study.

INTRODUCTION: The Schulich School of Medicine & Dentistry in London, Ontario, has a mentorship program for all full-time faculty. The school would like to expand its outreach to physician faculty located in distributed medical education sites. The purpose of this study was to determine what, if any, mentorship distributed physician faculty currently have, to gauge their interest in expanding the mentorship program to distributed physician faculty and to determine their vision of the most appropriate design of a mentorship program that would address their needs. METHODS: We conducted a mixed-methods study. The quantitative phase consisted of surveys sent to all distributed faculty members that elicited information on basic demographic characteristics and mentorship experiences/needs. The qualitative phase consisted of 4 focus groups of distributed faculty administered in 2 large and 2 small centres in both regions of the school's distributed education network: Sarnia, Leamington, Stratford and Hanover. Interviews were 90 minutes long and involved standardized semistructured questions. RESULTS: Of the 678 surveys sent, 210 (31.0%) were returned. Most respondents (136 [64.8%]) were men, and almost half (96 [45.7%]) were family physicians. Most respondents (197 [93.8%]) were not formal mentors to Schulich faculty, and 178 (84.8%) were not currently being formally mentored. Qualitative analysis suggested that many respondents were involved in informal mentoring. In addition, about half of the respondents (96 [45.7%]) wished to be formally mentored in the future, but they may be inhibited owing to time constraints and geographical isolation. Consistently, respondents wished to have mentoring by a colleague in a similar practice, with the most practical being one-on-one mentoring. CONCLUSION: Our analysis suggests that the school's current formal mentoring program may not be applicable and will require modification to address the needs of distributed faculty.

INTRODUCTION: L'École de médecine et de dentisterie Schulich, à London en Ontario, offre un programme de mentorat à tout le personnel enseignant à temps plein. L'École aimerait étendre son programme aux médecins enseignants des établissements de formation médicale décentralisée. Le but de cette étude était de déterminer à quel mentorat, le cas échéant, ces médecins ont accès actuellement et d'établir leur intérêt pour le programme de mentorat de l'École et leur vision du programme le plus approprié pour répondre à leurs besoins. METHODS: Nous avons mené une étude en méthodologie mixte. Lors de la phase quantitative, nous avons envoyé des questionnaires à tous les médecins des établissements de formation médicale décentralisée afin d'obtenir des renseignements sur les caractéristiques démographiques de base ainsi que les expériences et besoins de mentorat. La phase qualitative comprenait quatre groupes de discussion composés de médecins enseignants décentralisés dans deux grands et deux petits centres des deux régions du réseau de formation décentralisée de l'École, soit Sarnia, Leamington, Stratford et Hanover. Les entrevues étaient d'une durée de 90 minutes et se composaient de questions semi-structurées normalisées. RESULTS: Sur les 678 questionnaires distribués, 210 (31 %) ont été retournés. La plupart des répondants (136 [64,8 %]) étaient des hommes et presque la moitié (96 [45,7 %]) étaient des médecins de famille. La plupart des répondants (197 [93,8 %]) n'agissaient pas comme mentors officiels auprès du personnel enseignant de l'École de médecine et de dentisterie Schulich et 178 (84,8 %) ne recevaient pas de mentorat officiel actuellement. L'analyse qualitative suggère que plusieurs répondants participaient à une forme quelconque de mentorat informel. De plus, environ la moitié des répondants (96 [45,7 %]) souhaitaient recevoir un mentorat officiel à l'avenir, mais avaient possiblement des contraintes liées au manque de temps et à l'isolement géographique. Les répondants ont systématiquement exprimé le désir d'obtenir un mentorat d'un collègue dans une pratique similaire et un mentorat individualisé, de façon pratique. CONCLUSION: Notre analyse suggère que le programme actuel de mentorat de l'École n'est peut-être pas applicable et nécessitera des modifications pour répondre aux besoins du personnel enseignant décentralisé.