Measurements between the hepatic veins and portal venous system, in human cirrhotic liver: a cast study.

PURPOSE: To measure the distance between the right and middle hepatic veins and portal vein branches, in human cirrhotic liver casts. Was this measure actually smaller in the cirrhotic liver than in normal one? MATERIALS AND METHODS: This study was authorized by an area Research Ethics Committee, and each study subject or legal representative granted signed informed consent. Acrylic corrosion casts of 21 resected cirrhotic livers were generated. Diameters of hepatic veins and portal branches and pertinent intervening distances were measured. To assess differences in estimated average (relative to reference values), Student's t test for one sample was applied. RESULTS: Mean distances from right hepatic vein to the right portal branch and to portal vein bifurcation were 33 ± 6.4 and 36 ± 7.4 mm, respectively, both significantly less than published reference values in healthy human livers (p < 0.0001 and p < 0.0002, respectively). Mean distances from middle hepatic vein to right and left branches of portal vein were 36 ± 6.8 and 26 ± 8.8 mm, respectively. CONCLUSION: Distances separating right hepatic vein and portal vein (right branch and bifurcation) are diminished in cirrhotic livers compared to healthy ones. Given its caliber and proximity to portal branches, the middle hepatic vein remains as a reasonable alternative for TIPS procedures.

Positive end-expiratory pressure (PEEP) during anaesthesia for prevention of mortality and postoperative pulmonary complications.

BACKGROUND: General anaesthesia causes atelectasis, which can lead to impaired respiratory function. Positive end-expiratory pressure (PEEP) is a mechanical manoeuvre that increases functional residual capacity (FRC) and prevents collapse of the airways, thereby reducing atelectasis. It is not known whether intraoperative PEEP alters the risks of postoperative mortality and pulmonary complications. This review was originally published in 2010 and was updated in 2013. OBJECTIVES: To assess the benefits and harms of intraoperative PEEP in terms of postoperative mortality and pulmonary outcomes in all adult surgical patients. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 10, part of The Cochrane Library, as well as MEDLINE (via Ovid) (1966 to October 2013), EMBASE (via Ovid) (1980 to October 2013), CINAHL (via EBSCOhost) (1982 to October 2013), ISI Web of Science (1945 to October 2013) and LILACS (via BIREME interface) (1982 to October 2010). The original search was performed in January 2010. SELECTION CRITERIA: We included randomized clinical trials assessing the effects of PEEP versus no PEEP during general anaesthesia on postoperative mortality and postoperative respiratory complications in adults, 16 years of age and older. DATA COLLECTION AND ANALYSIS: Two review authors independently selected papers, assessed trial quality and extracted data. We contacted study authors to ask for additional information, when necessary. We calculated the number of additional participants needed (information size) to make reliable conclusions. MAIN RESULTS: This updated review includes two new randomized trials. In total, 10 randomized trials with 432 participants and four comparisons are included in this review. One trial had a low risk of bias. No differences were demonstrated in mortality, with risk ratio (RR) of 0.97 (95% confidence interval (CI) 0.20 to 4.59; P value 0.97; 268 participants, six trials, very low quality of evidence (grading of recommendations assessment, development and evaluation (GRADE)), and in pneumonia, with RR of 0.40 (95% CI 0.11 to 1.39; P value 0.15; 120 participants, three trials, very low quality of evidence (GRADE)). Statistically significant results included the following: The PEEP group had higher arterial oxygen pressure (PaO2)/fraction of inspired oxygen (FiO2) on day one postoperatively, with a mean difference of 22.98 (95% CI 4.40 to 41.55; P value 0.02; 80 participants, two trials, very low quality of evidence (GRADE)), and postoperative atelectasis (defined as an area of collapsed lung, quantified by computerized tomography scan) was less in the PEEP group (standard mean difference -1.2, 95% CI -1.78 to -0.79; P value 0.00001; 88 participants, two trials, very low quality of evidence (GRADE)). No adverse events were reported in the three trials that adequately measured these outcomes (barotrauma and cardiac complications). Using information size calculations, we estimated that a further 21,200 participants would have to be randomly assigned to allow a reliable conclusion about PEEP and mortality. AUTHORS' CONCLUSIONS: Evidence is currently insufficient to permit conclusions about whether intraoperative PEEP alters risks of postoperative mortality and respiratory complications among undifferentiated surgical patients.

Neuraxial anaesthesia for lower-limb revascularization.

BACKGROUND: Lower-limb revascularization is a surgical procedure that is performed to restore an adequate blood supply to the limbs. Lower-limb revascularization surgery is used to reduce pain and sometimes to improve lower-limb function. Neuraxial anaesthesia is an anaesthetic technique that uses local anaesthetics next to the spinal cord to block nerve function. Neuraxial anaesthesia may lead to improved survival. This systematic review was originally published in 2010 and was first updated in 2011 and again in 2013. OBJECTIVES: To determine the rates of death and major complications associated with spinal and epidural anaesthesia as compared with other types of anaesthesia for lower-limb revascularization in patients aged 18 years or older who are affected by obstruction of lower-limb vessels. SEARCH METHODS: The original review was published in 2010 and was based on a search until June 2008. In 2011 we reran the search until February 2011 and updated the review. For this second updated version of the review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, CINAHL and Web of Science from 2011 to April 2013. SELECTION CRITERIA: We included randomized controlled trials comparing neuraxial anaesthesia (spinal or epidural anaesthesia) versus other types of anaesthesia in adults (18 years or older) with arterial vascular obstruction undergoing lower-limb revascularization surgery. DATA COLLECTION AND ANALYSIS: Two review authors independently performed data extraction and assessed trial quality. We pooled the data on mortality, myocardial infarction, lower-limb amputation and pneumonia. We summarized dichotomous data as odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. MAIN RESULTS: In this updated version of the review, we found no new studies that met our inclusion criteria. We included in this review four studies that compared neuraxial anaesthesia with general anaesthesia. The total number of participants was 696, of whom 417 were allocated to neuraxial anaesthesia and 279 to general anaesthesia. Participants allocated to neuraxial anaesthesia had a mean age of 67 years, and 59% were men. Participants allocated to general anaesthesia had a mean age of 67 years, and 66% were men. Four studies had an unclear risk of bias. No difference was observed between participants allocated to neuraxial or general anaesthesia in mortality rate (OR 0.89, 95% CI 0.38 to 2.07; 696 participants; four trials), myocardial infarction (OR 1.23, 95% CI 0.56 to 2.70; 696 participants; four trials), and lower-limb amputation (OR 0.84, 95% CI 0.38 to 1.84; 465 participants; three trials). Pneumonia was less common after neuraxial anaesthesia than after general anaesthesia (OR 0.37, 95% CI 0.15 to 0.89; 201 participants; two trials). Evidence was insufficient for cerebral stroke, duration of hospital stay, postoperative cognitive dysfunction, complications in the anaesthetic recovery room and transfusion requirements. No data described nerve dysfunction, postoperative wound infection, patient satisfaction, postoperative pain score, claudication distance and pain at rest. AUTHORS' CONCLUSIONS: Available evidence from included trials that compared neuraxial anaesthesia with general anaesthesia was insufficient to rule out clinically important differences for most clinical outcomes. Neuraxial anaesthesia may reduce pneumonia. No conclusions can be drawn with regard to mortality, myocardial infarction and rate of lower-limb amputation, or less common outcomes.

Cyclophosphamide versus methylprednisolone for treating neuropsychiatric involvement in systemic lupus erythematosus.

BACKGROUND: Neuropsychiatric involvement in systemic lupus erythematosus (SLE) is complex and it is an important cause of morbidity and mortality. Management of nervous system manifestations of SLE remains unsatisfactory. This is an update of a Cochrane review first published in 2000 and previously updated in 2006. OBJECTIVES: To assess the benefits and harms of cyclophosphamide and methylprednisolone in the treatment of neuropsychiatric manifestations of SLE. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, SCOPUS and WHO up to and including June 2012. We sought additional articles through handsearching in relevant journals as well as contact with experts. There were no language restrictions. SELECTION CRITERIA: We included all randomised controlled trials that compared cyclophosphamide to methylprednisolone in patients with SLE of any age and gender and presenting with any kind of neuropsychiatric manifestations. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted, assessed and cross-checked data. We produced a 'Summary of findings' table. We presented dichotomous data as risk ratios (RRs) with 95% confidence intervals (CIs). MAIN RESULTS: We did not include any new trials in this update. One randomised controlled trial of 32 patients is included. Concerning risk of bias, generation of the allocation sequence was at low risk; however, allocation concealment, blinding and selective reporting were at high risk. Treatment response, defined as 20% improvement from basal conditions by clinical, serological and specific neurological measures, was found in 94.7% (18/19) of patients using cyclophosphamide compared with 46.2% (6/13) in the methylprednisolone group at 24 months (RR 2.05, 95% CI 1.13 to 3.73). This was statistically significant and the number needed to treat for an additional beneficial outcome (NNTB) of treatment response is three. We found no statistically significant differences between the groups in damage index measurements (Systemic Lupus International Collaborating Clinics (SLICC)). The median SLE Disease Activity Index (SLEDAI) rating favoured the cyclophosphamide group. Cyclophosphamide use was associated with a reduction in prednisone requirements. All the patients in the cyclophosphamide group had electroencephalographic improvement but there was no statistically significant difference in decrease between groups in the number of monthly seizures. No statistically significant differences in adverse effects, including mortality, were reported between the groups. AUTHORS' CONCLUSIONS: This systematic review found one randomised controlled trial with a small number of patients in the different clinical subgroups of neurological manifestation. There is very low-quality evidence that cyclophosphamide is more effective in reducing symptoms of neuropsychiatric involvement in SLE compared with methylprednisolone. However, properly designed randomised controlled trials that involve large numbers of individuals, with explicit clinical and laboratory diagnostic criteria, sufficient duration of follow-up and description of all relevant outcome measures, are necessary to guide practice. As we did not find any new trials to include in this review at update, the conclusions of the review did not change.

WITHDRAWN. Antibiotics for treating leptospirosis.

BACKGROUND: Leptospirosis is a parasitic disease transmitted by animals. Severe leptospirosis may result in hospitalisation and about five per cent of the patients die. In clinical practice, penicillin is widely used for treating leptospirosis. OBJECTIVES: To evaluate the effectiveness and safety of antibiotics versus placebo or other antibiotic regimens in treating leptospirosis. We addressed the following clinical questions: a) Are treatment regimens with antibiotics more efficient than placebo for leptospirosis? b) Are treatment regimens with antibiotics safe when compared to placebo for leptospirosis? c) Which antibiotic regimen is the most efficient and safest in treating leptospirosis? SEARCH STRATEGY: Electronic searches and searches of the identified articles were combined. STUDIES: Randomised clinical trials in which antibiotics were used as treatment for leptospirosis. Language, date, or other restrictions were not applied. PARTICIPANTS: Patients with clinical manifestations of leptospirosis. INTERVENTIONS: Any antibiotic regimen compared with a control group (placebo or another antibiotic regimen). DATA COLLECTION AND ANALYSIS: Data and methodological quality of each trial were independently extracted and assessed by two reviewers. The random effects model was used irrespective of significant statistical heterogeneity. MAIN RESULTS: Three trials met inclusion criteria. Allocation concealment and double blind methods were not clearly described in two. Of the patients enrolled, 75 were treated with placebo and 75 with antibiotics: 61 (81.3%) penicillin and 14 (18.6%) doxycycline. The patients assigned to antibiotics compared to placebo showed: a) Mortality: 1% (1/75) versus 4% (3/75); risk difference -2%, 95% confidence interval -8% to 4%. b) Duration of hospital stay (days): weighted mean difference 0.30, 95% confidence interval -1.26 to 1.86. c) Prolonged hospital stay (> seven days): 30% (7/23) versus 74% (14/19); risk difference -43%, 95% confidence interval -70% to -16%. Number needed-to-treat 3, 95% confidence interval 2 to 7. d) Period of disappearance of fever (days): weighted mean difference -4.04, 95% confidence interval -8.65 to 0.58. e) Leptospiruria: 5% (4/75) versus 40% (30/75); risk difference -46%, 95% confidence interval -88% to -3%. Number needed-to-treat 2, 95% confidence interval 1 to 33. AUTHORS' CONCLUSIONS: Antibiotic regimens for treatment of leptospirosis is a form of care for which the evidence is insufficient to provide clear guidelines for practice. The randomised trials suggest that antibiotics could be a useful treatment for leptospirosis. Because of the questionable quality of two of the three trials, the indication for general use of antibiotics is uncertain. However, the evidence suggest that penicillin may cause more good than harm.

Neuraxial anaesthesia for lower-limb revascularization.

BACKGROUND: Lower-limb revascularization surgery is used to reduce pain and sometimes to improve lower-limb function. The type of anaesthesia used during lower-limb revascularization may affect the risks of both good and bad outcomes. OBJECTIVES: To determine the rates of death and major complications with spinal and epidural anaesthesia compared with other types of anaesthesia for lower-limb revascularization. SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library 2008, Issue 2); MEDLINE (1960 to 10th June 2008); EMBASE (1982 to 10th June 2008); LILACS (1982 to 10th June 2008); CINAHL (1982 to 10th June 2008) and ISI Web of Science (1900 to 10th June 2008). SELECTION CRITERIA: We included randomized controlled trials that evaluated the effect of anaesthetic type in adults aged 18 years or older undergoing lower-limb revascularization surgery. DATA COLLECTION AND ANALYSIS: Two authors independently performed the data extraction. Primary outcomes were mortality, cerebral stroke, myocardial infarction, nerve dysfunction and postoperative lower-limb amputation rate. The secondary outcome analysed was pneumonia. We judged risk of bias with four criteria: randomization and allocation concealment methods, blinding of treatment and outcome assessment and completeness of follow up. To assess heterogeneity we used the I(2) statistic. We summarized dichotomous data as odds ratio (OR) with 95% confidence interval (CI) using a random-effects model. MAIN RESULTS: We included four studies that compared neuraxial anaesthesia with general anaesthesia. The total number of participants was 696, of whom 417 were allocated to neuraxial anaesthesia and 279 to general anaesthesia. Participants allocated to neuraxial anaesthesia had a mean age of 67 years and 59% were men. Participants allocated to general anaesthesia had a mean age of 67 years and 66% were men. There was no difference between participants allocated to neuraxial or general anaesthesia in: mortality rate (OR 0.89, 95% CI 0.38 to 2.07; 696 participants, four trials); myocardial infarction (OR 1.23, 95% CI 0.56 to 2.70; 696 participants, four trials); and lower-limb amputation rate (OR 0.84, 95% CI 0.38 to 1.84; 465 participants, three trials). Pneumonia was less common following neuraxial anaesthesia than general anaesthesia (OR 0.37, 95% CI 0.15 to 0.89; 201 participants, two trials). AUTHORS' CONCLUSIONS: There was insufficient evidence available from the included trials that compared neuraxial anaesthesia with general anaesthesia to rule out clinically important differences for most clinical outcomes. Neuraxial anaesthesia may reduce pneumonia. No conclusions can be drawn with regard to mortality, myocardial infarction and rate of lower-limb amputation or less common outcomes.

WITHDRAWN: Antibiotics for preventing leptospirosis.

BACKGROUND: Leptospirosis is an infectious disease transmitted by animals. Death occurs in about five per cent of the patients. In clinical practice, doxycycline is widely used for prevention. OBJECTIVES: To evaluate the effectiveness and safety of any antibiotic regimen versus placebo or other antibiotic regimens in the prophylaxis of leptospirosis. SEARCH STRATEGY: The sources used were: EMBASE, LILACS, MEDLINE, SCISEARCH, The Cochrane Controlled Trials Register, The Cochrane Hepato-Biliary Group Controlled Trials Register, bibliographies of published papers, and personal communication with authors. There were no language or date restrictions in any of the searches. STUDIES: All randomised clinical trials in which antibiotics were used as prophylactic regimen for leptospirosis. PARTICIPANTS: People potentially exposed to leptospirosis, such as people in endemic areas during the rainy season, health professionals and other professionals with high risk of infection. INTERVENTION: Any antibiotic regimen compared with a control group (placebo or another antibiotic regimen). OUTCOMES: Infection (primary outcome) and adverse events (secondary outcome). DATA COLLECTION AND ANALYSIS: Data were independently extracted and methodological quality of each trial was assessed by two reviewers as well as cross-checked. Details of the randomisation (generation and concealment), blinding, and the number of patients lost to follow-up were recorded. The results of each trial were summarised on an intention-to-treat basis in 2 x 2 tables for each outcome. MAIN RESULTS: Two trials comparing doxycycline with placebo met the inclusion criteria. We did not find trials comparing doxycycline versus other antibiotics, or other antibiotics versus placebo. One of the trials had excellent methodological quality. In the other trial, the allocation concealment process, generation of allocation sequence, and blinding methods were not described.Of the 1022 participants enrolled, 509 were treated with doxycycline and 513 with placebo. Of these, 940 participants were soldiers included in one trial. The patients assigned to the antibiotics group compared with the ones assigned to the placebo group showed: Symptomatic, verified leptospirosis: 0.6% (3/509) versus 4.9% (25/ 513); risk difference (random effects model) -4.1%, 95% confidence interval -5.9% to -2.3%. Number needed-to-treat 24 (95% confidence interval 17 to 43). Adverse effects: 3% (13/469 participants) versus 0.2% (1/471 participants); random effects model 2.6%, 95% confidence interval 1.0% to 4.1%. Number needed-to-harm 39 (95% confidence interval 25 to 100). AUTHORS' CONCLUSIONS: Prophylaxis of leptospirosis may be achieved by administration of doxycycline to soldiers training in endemic areas with a high risk of exposure to leptospirosis. Whether these findings apply to other scenarios or not remains to be proven.

Incidence of lower limbs deep vein thrombosis after open and laparoscopic gastric bypass: a prospective study.

BACKGROUND: Lower limbs deep vein thrombosis (DVT) and pulmonary embolism (PE) are major causes of morbidity and mortality and are even higher in bariatric patients. The longer operative time and higher immobility in these patients increase the DVT risk. Although deaths after bariatric surgery have been reported, there is no consensus regarding the prophylaxis of DVT. This study's objective is to determine the incidence of lower limbs DVT in patients submitted to Roux-en-Y-gastric bypass (RYGBP) under prophylaxis by enoxaparin. METHODS: Patients with body mass index (BMI) equal to or higher than 35 kg/m(2) who submitted to RYGBP by laparotomy or laparoscopy using 40 mg/day of enoxaparin for 15 days were recruited between October 2004 and August 2005. Individuals with previous DVT and heparin allergy were excluded. Patients were tested for DVT using color Doppler ultrasound performed before surgery and on the second and fifth weeks after surgery. RESULTS: The study population included 136 patients, with 126 concluding the protocol. There were 79% (100/126) of female patients aged 19 to 65 years old, with mean of 40 years SD = 10 and BMI between 35 and 61 kg/m(2), mean of 43 kg/m(2) (SD = 5). All patients who submitted to RYGBP were divided as 55% (69/126) by laparoscopy and 45% (57/126) by laparotomy. The incidence rate of lower limbs DVT was 0.79% (1/126). CONCLUSION: The low incidence rate of DVT found in our study suggests that obesity might not be a major risk factor for venous thromboembolism in patients submitted to RYGBP.

Colony-stimulating factors for chemotherapy-induced febrile neutropenia: a meta-analysis of randomized controlled trials.

PURPOSE: Current treatment for febrile neutropenia (FN) includes hospitalization for evaluation, empiric broad-spectrum antibiotics, and other supportive care. Clinical trials have reported conflicting results when studying whether the colony-stimulating factors (CSFs) improve outcomes in patients with FN. This Cochrane Collaboration review was undertaken to further evaluate the safety and efficacy of the CSFs in patients with FN. METHODS: An exhaustive literature search was undertaken including major electronic databases (CANCERLIT, EMBASE, LILACS, MEDLINE, SCI, and the Cochrane Controlled Trials Register). All randomized controlled trials that compare CSFs plus antibiotics versus antibiotics alone for the treatment of established FN in adults and children were sought. A meta-analysis of the selected studies was performed. RESULTS: More than 8,000 references were screened, with 13 studies meeting eligibility criteria for inclusion. The overall mortality was not influenced significantly by the use of CSF (odds ratio [OR] = 0.68; 95% CI, 0.43 to 1.08; P = .1). A marginally significant result was obtained for the use of CSF in reducing infection-related mortality (OR = 0.51; 95% CI, 0.26 to 1.00; P = .05). Patients treated with CSFs had a shorter length of hospitalization (hazard ratio [HR] = 0.63; 95% CI, 0.49 to 0.82; P = .0006) and a shorter time to neutrophil recovery (HR = 0.32; 95% CI, 0.23 to 0.46; P < .00001). CONCLUSION: The use of the CSFs in patients with established FN caused by cancer chemotherapy reduces the amount of time spent in hospital and the neutrophil recovery period. The possible influence of the CSFs on infection-related mortality requires further investigation.

Clinical value of preoperative mechanical bowel cleansing in elective colorectal surgery: a systematic review.

PURPOSE: This study was designed to establish scientific evidence for and clinical results of preoperative mechanical bowel cleansing before elective colorectal surgery. METHODS: Systematic literature searches in electronic databases, conference proceedings, and hand searches of reference lists of previously retrieved literature without any language restrictions were used. Only randomized trials were included. A quality assessment of each retrieved trial was performed. Outcome measures were surgical infections, mortality, and anastomotic dehiscence. Meta-analyses of the selected trials were performed using the Peto odds ratio. RESULTS: The results of each outcome were as follows. 1). Overall anastomotic leakage-six studies: 5.5 percent with cleansing compared with 2.9 percent without cleansing; odds ratio 1.94, 95 percent confidence interval: 1.09 to 3.43 (P = 0.02). 2). Peritonitis-three studies: 5.1 percent with cleansing compared with 2.8 percent without cleansing; odds ratio 1.90, 95 percent confidence interval: 0.78 to 4.64 (not significant). 3). Wound infection-six studies: 7.4 percent with cleansing compared with 5.7 percent without cleansing; odds ratio 1.34, 95 percent confidence interval: 0.85 to 2.13 (not significant). CONCLUSIONS: There is no evidence in the literature for beneficial effects from the use of bowel cleansing before elective colorectal surgery. Cleansing seems to be associated with an increased risk of more anastomotic dehiscence. Further studies stratifying between rectal and colonic surgery are warranted.