A Systematic Review of the Quality of Clinical Practice Guidelines for Chronic Limb-Threatening Ischemia.

BACKGROUND: To assess the quality of clinical practice guidelines (CPGs) for chronic limb-threatening ischemia (CLTI) using the Appraisal of Guidelines for Research and Evaluation II instrument. METHODS: A systematic review of Medline, Embase, and online CPG databases was carried out. Four CPGs on CLTI were identified: Global Vascular Guidelines (GVG), European Society of Cardiology (ESC), American College of Cardiology, and National Institute for Health and Care Excellence guidelines on lower limb peripheral arterial disease. Two independent appraisers analyzed the 4 CPGs using the Appraisal of Guidelines for Research and Evaluation II instrument. CPGs were ranked across 6 domains with 23 items that ranged from 1 (strongly disagree) to 7 (strongly agree). A scaled domain score was calculated as a percentage of the maximum possible score achievable. A domain score of ≥50% and an overall average domain score of ≥80% reflected a CPG of adequate quality recommended for use. RESULTS: GVG had the highest overall score (82.9%), as an average of all domains, and ESC had the lowest score (50.2%). GVG and National Institute for Health and Care Excellence guidelines had all domains scoring >50%, while American College of Cardiology had 5 and ESC had 3. Two domains, rigor of development and applicability, scored the lowest among the CPGs. There was a lack of detail in describing systematic methods used in the literature review, how guidelines were formulated with minimal bias, and the planned procedure for updating the guidelines. Implications of guideline application and monitoring of outcomes after implementations were not explicitly discussed. CONCLUSIONS: The GVG guideline published in 2019 discussing CLTI is assessed to be of high quality and recommended for use. This review helps to improve clinical decision-making and quality of future CPGs for CLTI.

Increased risk of diaphragmatic herniation following esophagectomy with a minimally invasive abdominal approach.

OBJECTIVE: Diaphragmatic herniation is a rare complication following esophagectomy, associated with risks of aspiration pneumonia, bowel obstruction, and strangulation. Repair can be challenging due to the presence of the gastric conduit. We performed this systematic review and meta-analysis to determine the incidence and risk factors associated with diaphragmatic herniation following esophagectomy, the timing and mode of presentation, and outcomes of repair. METHODS: A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was performed using four major databases. A meta-analysis of diaphragmatic herniation incidence following esophagectomies with a minimally invasive abdominal (MIA) approach compared with open esophagectomies was conducted. Qualitative analysis was performed for tumor location, associated symptoms, time to presentation, and outcomes of postdiaphragmatic herniation repair. RESULTS: This systematic review consisted of 17,052 patients from 32 studies. The risk of diaphragmatic herniation was 2.74 times higher in MIA esophagectomy compared with open esophagectomy, with pooled incidence of 6.0% versus 3.2%, respectively. Diaphragmatic herniation was more commonly seen following surgery for distal esophageal tumors. Majority of patients (64%) were symptomatic at diagnosis. Presentation within 30 days of operation occurred in 21% of cases and is twice as likely to require emergent repair with increased surgical morbidity. Early diaphragmatic herniation recurrence and cardiorespiratory complications are common sequelae following hernia repair. CONCLUSIONS: In the era of MIA esophagectomy, one has to be cognizant of the increased risk of diaphragmatic herniation and its sequelae. Failure to recognize early diaphragmatic herniation can result in catastrophic consequences. Increased vigilance and decreased threshold for imaging during this period is warranted.

Trans-hiatal repair for Oesophageal and Junctional perforation: a case series.

BACKGROUND: Oesophageal perforation is a life-threatening condition that requires urgent intervention. Surgical repair is recommended within 24 h of onset to minimise mortality risk, traditionally via an open thoracotomy or a laparotomy. Primary oesophageal repair via a laparoscopic trans-hiatal approach has been seldomly reported due to concerns of inadequate eradication of soilage in the mediastinum and pleural space, as well as poor access and an increased operative time in an unwell population. CASE PRESENTATION: We report a case series of 3 oesophageal and junctional perforations with varying presentations, demonstrating how the laparoscopic trans-hiatal approach can be used successfully to manage oesophageal perforations. CONCLUSIONS: Laparoscopic trans-hiatal repair is an attractive option for oesophageal and junctional perforations, in haemodynamically stable surgical candidates, in the absence of gross contamination of the thoracic cavity.

Laparoscopic management of chylous ascites posthiatal hernia repair with Toupet fundoplication.

We present a case of chylous ascites in a 69-year-old man 5 months after a laparoscopic Toupet fundoplication (posterior 270°). This was successfully treated with laparoscopic ligation of tissue adjacent to the right crus. Laparoscopic ligation is a management option that should be considered after this rare complication, offering rapid results.

Severe pancreatitis complicated by abdominal compartment syndrome managed with decompressive laparotomy: a case report.

BACKGROUND: Abdominal compartment syndrome (ACS) is an uncommon complication of severe pancreatitis. It is defined as a sustained intraabdominal pressure (IAP) > 20 mmHg (with or without an abdominal perfusion pressure (APP) < 60 mmHg), associated with new organ dysfunction/failure. ACS confers a poor prognosis and should be promptly diagnosed and managed. However, it is often missed on clinical examination, leading to a delay of diagnosis. CASE PRESENTATION: A 38-year old Sri Lankan man presented with severe alcohol-induced pancreatitis associated with abdominal compartment syndrome. Diagnosis was delayed due to false reassurance from clinical examination. The patient was managed with a decompressive laparotomy, after which he required treatment with continuous renal replacement therapy (CRRT), total parenteral nutrition (TPN) and broad-spectrum antibiotics for a prolonged period of time. Despite significant post-operative multi-organ failure, the patient survived. CONCLUSIONS: Early trans-bladder measurement of IAP is important for severe pancreatitis. Serial measurements of IAP should be implemented early when any known risk factor for ACS is present in a critically ill patient.

Influence of Cultural Beliefs on Infant Feeding, Postpartum and Childcare Practices among Chinese-American Mothers in New York City.

As one of the fastest growing communities in the United States, Chinese-Americans receive relatively little research attention on their rates of breastfeeding versus formula feeding, and what factors influence that choice. This research aims to examine the influence of elders and cultural beliefs on postpartum, infant feeding, and childcare practices. Semi-structured interviews with 22 recently postpartum mothers who met the recruiting criteria were conducted between July 2012 and February 2013. The traditional postpartum practice, zuo yuezi, presented negative physical and emotional outcomes and maternal reporting of delay in lactation. Early introduction of solids for traditional reasons was reported. The support from husbands and elders were necessary for breastfeeding success, while some mothers had to first negotiate with elders for breastfeeding. The practice of sending infants back to China to be taken care of by extended families presented cultural implications related to grandparents' involvement in raising grandchildren. With the respect and appreciation for elders and traditions, it is likely that Chinese mothers negotiate between cultural traditions and societal expectation in the western home.

Pleural small cell lung cancer masquerading as malignant mesothelioma: A case report.

Nodular soft tissue pleural thickening on imaging is highly suggestive of malignancy, of which pleural malignant mesothelioma and metastatic disease are differentials. We present the case of a 71-year-old male who presented with acute worsening of shortness of breath associated with a recurrent left pleural effusion post-pleurocentesis. He was an ex-smoker with previous asbestos exposure. Computed tomography performed demonstrated left-sided pleural thickening in the hemithorax and hemidiaphragm with complex pleural effusion. 18F-2-deoxy-d-glucose whole body PET scan revealed extensive uptake throughout the left hemithorax in multiple pleural masses. The imaging findings and clinical case were typical of malignant mesothelioma. However, histopathology results revealed small cell lung cancer. We need to be cognisant of this atypical presentation of a common disease entity. Even when all clinical and imaging findings point towards a certain diagnosis, histopathological assessment cannot be ignored.

Thoroughbred Racehorses in Hong Kong Require Vitamin D Supplementation to Mitigate the Risk of Low Vitamin D Status.

There is a paucity of data relating to the vitamin D status of racehorses. We hypothesised that the management of racehorses in Hong Kong (HK) predisposes to low vitamin D status unless they receive dietary supplementation. Serum concentrations of 25-hydroxyvitamin D2 (25OHD2), 25-hydroxyvitamin D3 (25OHD3) and total 25-hydroxyvitamin D (total 25OHD) for 79 non-grazing HK racehorses were compared with those for 22 racehorses training in the United Kingdom (UK) that grazed for ≥1 h/d, and for which published data exists. A nested group of 41 HK horses was sampled twice to determine the effect of the duration in HK on vitamin D status. The HK horses had significantly lower serum concentrations of total 25OHD and 25OHD2 than the UK horses; 25OHD2 was undetectable in 15/79 HK sera and serum concentrations of 25OHD2 declined with the duration in HK. The main determinants of vitamin D status were assessed using linear regression; the retained variables were the 25OHD3 concentration and the duration in HK. The inverse relationship between the serum concentrations of 25OHD2 and 25OHD3, previously identified in humans, was observed for the first time in horses. In conclusion, HK racehorses have low serum 25OHD2 and total 25OHD concentrations and rely on D3 supplementation to maintain adequate vitamin D status. Further study is required to determine the optimal form of dietary vitamin D supplementation for Thoroughbred racehorses.

Pneumatosis intestinalis: Not always bowel ischemia.

Pneumatosis intestinalis or abnormal intramural gas within the digestive tract usually suggests bowel ischemia necessitating urgent surgery. We report the case of an 82-year-old female presenting with hypotension and nausea, with a past history of schizophrenia, low grade chronic lymphocytic leukemia, stroke, bronchitis and rheumatoid arthritis. Computed tomography performed demonstrated extensive submucosal gas within the entire small bowel, associated with free gas in the peritoneal cavity. Bowel ischemia was diagnosed radiologically. However, a benign diagnosis of fecal impaction was ultimately made due to the patient's stable clinical status. Clinical correlation and close monitoring of clinical status in this context is of greatest diagnostic assistance when encountered with this phenomenon, to prevent unnecessary harm to the patient.

Prognostic utility of inflammation-based biomarkers, neutrophil-lymphocyte ratio and change in neutrophil-lymphocyte ratio, in surgically resected lung cancers.

BACKGROUND/OBJECTIVE: Given the poor overall survival (OR) and progression-free survival (PFS) rates for lung cancers managed with surgical resection, there is a need to identify the prognostic markers that would improve the risk stratification of patients with operable lung cancer to inform treatment decisions. We investigate the prognostic utility of two established inflammation-based scores, the neutrophil-lymphocyte ratio (NLR) and the change in neutrophil-lymphocyte ratio (ΔNLR), throughout the operative period in a prospective cohort of patients with lung cancer who underwent surgical resection. METHODS: Demographic, clinical, and treatment details for 345 patients with lung cancer who underwent surgical resection between 2000 and 2019 at multiple centers across Melbourne, Victoria (Australia), were prospectively collected. Preoperative NLR and ΔNLR were calculated after which Cox univariate and multivariate analyses were conducted for OS and PFS against the known prognostic factors. RESULTS: Both univariate and multivariate analyses showed that preoperative NLR >4.54, as well as day 1 and day 2 postoperative NLR (P < 0.01), was associated with increased risk for postoperative mortality (hazard ratio 1.8; P < 0.01) and PFS (P < 0.05), whereas ΔNLR was not a significant predictor of OS or PFS. CONCLUSION: Elevated NLR among patients with lung cancer who underwent surgical resection was prognostic for poor OS and PFS, whereas ΔNLR was not found to be prognostic for either OS or PFS. Further research may yet reveal a prognostic value for ΔNLR when compared across a greater time period.

Acute Upper Limb Ischemia Due to Delayed Presentation of a Brachial Artery Pseudoaneurysm Post-Venipuncture.

Brachial artery pseudoaneurysms (BAPs) are rare but could lead to complications of high morbidity. We report a case of a BAP presenting with hand ischemia and median nerve neuropathy nearly a decade after the inciting iatrogenic trauma, successfully treated with excision and direct repair. This report highlights that untreated pseudoaneurysms can be indolent and present late with both symptoms of embolization and local compression.

Review of research output of Australian and New Zealand colorectal surgeons over the past 20 years.

OBJECTIVES: High-quality research has a tangible impact on patient care and should inform all medical decision-makings. Appraising and benchmarking of research is necessary in evidence-based medicine and allocation of funding. The aim of this review is to demonstrate how evidence may be gathered by quantifying the amount and type of research by a group of surgeons over a 20-year period. METHODS: Members of the Colorectal Surgical Society of Australia and New Zealand were identified in April 2020. A search of the Scopus database was conducted to quantify each surgeon's research output from 1999 to 2020. Authorship details such as the Hirsch index and number of papers published were recorded, as were publication-related details. RESULTS: 226 colorectal surgeons were included for analysis, producing a total of 5053 publications. The most frequent colorectal topics were colorectal cancer (32%, n = 1617 of all publications), followed by pelvic floor disorders (4.3%, n = 217) and inflammatory bowel disease (3.5%, n = 177). 56% (n = 2830) of all publications were case series audits (21%, n = 1061), expert opinion pieces (20%, n = 1011) and cohort studies (15%, n = 758). 7% (n = 354) were randomised control or non-randomised control trials, 3% (n = 152) were systematic reviews and 1% (n = 50) were meta-analyses. The top 10% (n = 23) of authors accounted for more than half (54%, n = 2729) of manuscripts published. CONCLUSION: Australasian colorectal surgeons made a significant contribution to the medical literature over the past 20 years and the number of publications is increasing over time. A greater output of higher-level evidence research is needed. This information may be used to better allocate researcher funding and grants for future projects.

Is there a difference in adenoma detection rates between gastroenterologists and surgeons?

AIM: To compare the adenoma detection rate (ADR) between gastroenterologists and colorectal surgeons at Box Hill Hospital, Melbourne, Australia. METHODS: A total of 300 colonoscopies performed by gastroenterologists and colorectal surgeons at Box Hill Hospital were retrospectively reviewed from May 2016 to June 2017. Exclusion criteria were: Patients ≤ 50 years old, colonoscopies with failure of caecal intubation, patients who previously had colon cancer and/or a colonic resection, history of polyposis syndromes or inflammatory bowel disease, or a colonoscopy within the last 10 years. Patient demographics, indications, symptoms and procedural-related outcomes were measured. RESULTS: The ADR was not significantly different between gastroenterologists and colorectal surgeons (34% vs 34.67%; P = 0.90). The adjusted odds ratio correcting for gender, age, 1st degree relative with colorectal cancer, previous colonoscopy, trainee involvement and caecal or terminal ileum intubation rate was 1.19 (0.69-2.05). CONCLUSION: Both specialties at our institution exceed benchmark standards suggested by published Australian and American guidelines. An association between endoscopist specialty and ADR was not observed.

First molecular epidemiology study of Mycobacterium tuberculosis in Kiribati.

Tuberculosis incidence rates in Kiribati are among the highest in the Western Pacific Region, however the genetic diversity of circulating Mycobacterium tuberculosis complex strains (MTBC) and transmission dynamics are unknown. Here, we analysed MTBC strains isolated from culture positive pulmonary tuberculosis (TB) cases from the main TB referral centre between November 2007 and October 2009. Strain genotyping (IS6110 typing, spoligotyping, 24-loci MIRU-VNTR and SNP typing) was performed and demographic information collected. Among 73 MTBC strains analysed, we identified seven phylogenetic lineages, dominated by Beijing strains (49%). Beijing strains were further differentiated in two main branches, Beijing-A (n = 8) and -B (n = 28), that show distinct genotyping patterns and are characterized by specific deletion profiles (Beijing A: only RD105, RD207 deleted; Beijing B: RD150 and RD181 additionally deleted). Many Kiribati strains (59% based on IS6110 typing of all strains) occurred in clusters, suggesting ongoing local transmission. Beijing-B strains and over-crowded living conditions were associated with strain clustering (likely recent transmission), however little evidence of anti-tuberculous drug resistance was observed. We suggest enhanced case finding amongst close contacts and continued supervised treatment of all identified cases using standard first-line drugs to reduce TB burden in Kiribati. Beijing strains can be subdivided in different principle branches that might be associated with differential spreading patterns in the population.

Universal extraction method for gastrointestinal pathogens.

A universal stool extraction method for recovery of nucleic acids (NAs) from gastrointestinal pathogens was developed to support rapid diagnostics for the London 2012 Olympics. The method involved mechanical disruption (bead beating) of the stools, followed by automated extraction and detection using real-time PCR. This method had been used extensively in the Second Infectious Intestinal Disease Study (IID2) for the isolation of NA from bacteria and parasites (and was effective for the robust recovery of Cryptosporidium spp.) but had not been used for enteric viruses. To ensure this method was universally suitable, panels of samples known to contain target bacteria, viruses or parasites were processed in triplicate using the pre-treatment method routinely used for each target and the new extraction method (bead beating). The extracts were tested using real-time PCR and the cycle threshold values were compared. The results from this study showed that bead beating improved yields for the bacterial and parasitic targets and was suitable for the viral targets. The implementation of this universal method should confer cost- and time-saving benefits and streamline the processes required for the characterization of an array of pathogens from faecal samples.

Comparative evaluation of the QIAGEN QIAsymphony® SP system and bioMérieux NucliSens easyMAG automated extraction platforms in a clinical virology laboratory.

BACKGROUND: The QIAGEN QIAsymphony(®) SP is an automated system that can process a variety of different sample types for nucleic acid extraction. OBJECTIVES: To compare this system against the bioMérieux NucliSens easyMAG using a range of common clinical sample types. STUDY DESIGN: Nucleic acid extracts were tested on 6 in-house real time viral PCR assays: quantitative cytomegalovirus (CMV); respiratory and enteric multiplex (10 viruses); influenza A H1N1 2009 specific H1 and N1 assays (sH1/N1); herpes simplex virus (HSV) 1, HSV 2 and varicella zoster virus (VZV) multiplex; norovirus genogroups I and II (Noro GI/II) multiplex. RESULTS: Extraction of the clinical sample by either QIAsymphony(®) SP or NucliSens easyMAG gave similar results for each PCR; CMV viral loads, 52 plasma samples had a mean difference (easyMAG-QIAsymphony(®)) of 0.002 log(10)copies/ml (s.d. 0.536), 52 whole blood samples had a mean difference of -0.232 log(10)copies/ml (s.d. 0.490). Concordance for the qualitative assays were; 64/67 (95.5%) for the respiratory and enteric multiplex, all 28 (100%) for the sH1, sN1 and influenza A matrix multiplex, 33/34 (97%) for the HSV1/HSV2/VZV multiplex and all 15 (100%) for the Noro GI/II. Inter- and intra-run variation, determined for a 10-fold dilution series of CMV (5.20-3.20 log(10)copies/ml), was less than 0.63 log(10)copies/ml. CONCLUSIONS: Our evaluation found the performance of the QIAsymphony(®) SP comparable to the NucliSens easyMAG for a range of sample types commonly extracted in a clinical virology laboratory. In total, 331/343 (96.5%) PCR results were concordant on samples extracted by both platforms.