Test Characteristics of Emergency Medicine-Performed Point-of-Care Ultrasound for the Diagnosis of Acute Cholecystitis: A Systematic Review and Meta-analysis.

Acute cholecystitis accounts for up to 9% of hospital admissions for acute abdominal pain, and best practice entails early surgical management. Ultrasound is the standard modality used to confirm diagnosis. Our objective was to perform a systematic review and meta-analysis to determine the diagnostic accuracy of emergency physician-performed point-of-care ultrasound for the diagnosis of acute cholecystitis when compared with a reference standard of final diagnosis (informed by available surgical pathology, discharge diagnosis, and radiology-performed ultrasound). We completed a systematic review and meta-analysis, registered in PROSPERO, in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched 7 databases as well as gray literature in the form of select conference abstracts from inception to February 8, 2023. Two independent reviewers completed study selection, data extraction, and risk of bias (QUADAS-2) assessment. Disagreements were resolved by consensus with a third reviewer. Data were extracted from eligible studies to create 2 × 2 tables for diagnostic accuracy meta-analysis. Hierarchical Summary Receiver Operating Characteristic models were constructed. Of 1855 titles/abstracts, 40 were selected for full-text review. Ten studies (n=2356) were included. Emergency physician-performed point-of-care ultrasound with final diagnosis as the reference standard (7 studies, n=1,772) had a pooled sensitivity of 70.9% (95% confidence interval [CI] 62.3 to 78.2), specificity of 94.4% (95% CI 88.2 to 97.5), positive likelihood ratio of 12.7 (5.8 to 27.5), and negative likelihood ratio of 0.31 (0.23 to 0.41) for the diagnosis of acute cholecystitis. Emergency physician-performed point-of-care ultrasound has high specificity and moderate sensitivity for the diagnosis of acute cholecystitis in patients with clinical suspicion. This review supports the use of emergency physician-performed point-of-care ultrasound to rule in a diagnosis of acute cholecystitis in the emergency department, which may help expedite definitive management.

Early detection and prevention of head and neck cancers.

Squamous cell carcinoma forms the vast majority of head and neck malignancies, with advanced disease incurring poor long-term survival. Early detection and prompt specialist referral allows the patient a greater chance of cure. Furthermore, basal cell carcinoma is the most common malignancy in humans, with the vast majority presenting in the head and neck region. Dentists have a unique opportunity to assess for cutaneous malignancies during routine visits.Cancer screening should be common practice within dental professionals. In addition to enquiring about common red flag symptoms, a comprehensive and systematic extra- and intra-oral examination should be undertaken at each new and check-up appointment. Urgent referral to an appropriate secondary care provider should be made at the earliest opportunity where concern for cancer exists.

A regional effort: the current landscape of inguinal hernia repair and postoperative opioid prescription practices in Eastern Ontario.

Inguinal hernia repairs are commonly performed by general surgeons in academic and community centres. The optimal strategy for postoperative analgesia is evolving, particularly because of concerns over opioid prescribing given the current opioid crisis. Efforts to address opioid overprescribing have been emphasized in our academic hospital system. Our survey of general surgeons in Eastern Ontario shows similarities in postoperative prescriptions of nonopioid and opioid analgesics across practice environments. Importantly, awareness of opioid-reduction initiatives was similar between academic and community surgeons. This regional effort is a result of local and national communities of practice fostered by organizations such as the Canadian Association of General Surgeons.

Timing of pharmacologic venous thromboembolism prophylaxis initiation for trauma patients with nonoperatively managed blunt abdominal solid organ injury: a systematic review and meta-analysis.

BACKGROUND: Blunt abdominal solid organ injury is common and is often managed nonoperatively. Clinicians must balance risk of both hemorrhage and thrombosis. The optimal timing of pharmacologic venous thromboembolism prophylaxis (VTEp) initiation in this population is unclear. The objective was to evaluate early (< 48 h) compared to late initiation of VTEp in adult trauma patients with blunt abdominal solid organ injury managed nonoperatively. METHODS: Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception to March 2021. Studies comparing timeframes of VTEp initiation were considered. The primary outcome was failure of nonoperative management (NOM) after VTEp initiation. Secondary outcomes included risk of transfusion, other bleeding complications, risk of deep vein thrombosis (DVT) and pulmonary embolism, and mortality. RESULTS: Ten cohort studies met inclusion criteria, with a total of 4642 patients. Meta-analysis revealed a statistically significant increase in the risk of failure of NOM among patients receiving early VTEp (OR 1.76, 95% CI 1.01-3.05, p = 0.05). There was no significant difference in risk of transfusion. Odds of DVT were significantly lower in the early group (OR 0.36, 95% CI 0.22-0.59, p < 0.0001). There was no difference in mortality (OR 1.50, 95% CI 0.82-2.75, p = 0.19). All studies were at serious risk of bias due to confounding. CONCLUSIONS: Initiation of VTEp earlier than 48 h following hospitalization is associated with an increased risk of failure of NOM but a decreased risk of DVT. Absolute failure rates of NOM are low. Initiation of VTEp at 48 h may balance the risks of bleeding and VTE.

Intraoperative balloon occlusion of the aorta for blood management in sacral and pelvic tumor resection: A systematic review and meta-analysis.

BACKGROUND: Neoplasms of the sacrum and pelvis are challenging to manage due to their complex vascularity and size and are at high risk of bleeding during resection. Intra-aortic balloon occlusion (IABO) has been used in trauma to control massive blood loss, but its efficacy and safety in oncologic sacral and pelvic surgery are unknown. The primary objective of this systematic review and meta-analysis was to assess the effectiveness of IABO in providing hemorrhage control during resection of sacral and pelvic tumors. METHODS: This PROSPERO pre-registered study meta-analyzed all studies reporting on the use of IABO in the setting of pelvic and sacral tumour resection, in accordance with the PRISMA guidelines. The primary outcome of the meta-analysis was intraoperative blood loss, with secondary outcomes consisting of transfusion volume, post-operative blood loss, operative time, complication rate, and mortality. RESULTS: Across studies, IABO was associated with a large, significant reduction in intraoperative blood loss (SMD -0.81, 95% CI -1.01 to -0.60, P < 0.0001) and transfused red blood cell volume (SMD 0.92, 95% CI -1.30 to -0.53, P < 0.0001). Two studies reported that complication rates were comparable between patients receiving IABO and patient receiving conventional surgery (Odds ratio = 1.29, 95% CI: 0.59 to 2.83, P = 0.52). All studies descriptively reported improved visualization of the operative field with IABO. CONCLUSIONS: Our findings demonstrated that IABO is an effective technique to decrease blood loss and transfusion requirements during sacral and pelvic tumor surgery. Future clinical trials should be conducted to establish the safety of this method and explore potential contraindications.

Financial implications of trauma patients at a Canadian level 1 trauma center: a retrospective cohort study.

BACKGROUND: Trauma is a cause of significant morbidity and mortality globally, and patients with major trauma require specialized settings for multidisciplinary care. We sought to enumerate the variability of costs of caring for patients at a Canadian level 1 trauma center. METHODS: A retrospective analysis of all adult patients admitted to The Ottawa Hospital trauma service between June 2013 and June 2018 was conducted. Hospital costs and clinical data were collected. Descriptive statistics and multivariable regression analysis using generalized linear model were performed to assess cost variation with patient characteristics. Quintile-based analyses were used to characterize patients in different cost categories. Hospital costs were reported in 2018 Canadian dollars. RESULTS: A total of 2381 admissions were identified in the 5-year cohort. The mean age of patients was 50.2 years, the mean Injury Severity Score (ISS) was 18.7, the mean Charlson Comorbidity Index (CCI) score was 0.35, and the median total cost was $10 048.54. ISS and CCI score were associated with higher costs (ISS >15; p<0.0001). The most expensive mechanisms of injury (MOIs) were those involving heavy machinery (median total cost $24 074.38), pedestrians involved in road traffic collisions ($20 965.45), patients in motor vehicle collisions ($17 621.01) and motorcycle collisions ($16 220.89), and acts of self-injury ($13 903.69). Patients who experienced in-hospital adverse events were associated with higher costs (p<0.0001). Our multivariable regression analysis showed variation in costs related to male gender, penetrating/violent MOI, ISS, adverse hospital events, CCI score, urgent admission status, hospital 1-year mortality risk score, and alternate level of care designation (p<0.05). Quintile-based analyses demonstrated clinically significant differences between the highest and lowest cost groups. DISCUSSION: Major trauma was associated with high hospital costs. Modifiable and non-modifiable patient factors were shown to correlate with differing total hospital costs. These findings can aid in the development of funding strategies and resource allocation for this complex patient population. LEVEL OF EVIDENCE: Level III evidence for economic and value-based evaluations.

Diffuse descending necrotising mediastinitis and pleural empyema secondary to acute odontogenic infection resulting in severe dysphagia.

We report a case of acute odontogenic sepsis in a 59-year-old man, presenting with diffuse, descending necrotising mediastinitis complicated by pleural empyema. Despite surviving the odds, his recovery was complicated by severe dysphagia, resulting in gastrostomy feeding for 6 months. Until now, severe dysphagia following descending necrotising mediastinitis has been unreported.

The Web-based CanMEDS Resident Learning Portfolio Project (WEBCAM): how we got started.

SUMMARY: The CanMEDS framework is ubiquitous in Canadian postgraduate medical education; however, training programs do not have a universal method of assessing competence. We set out to develop a novel portfolio that allowed trainees to generate a longitudinal record of their training and development within the framework. The portfolio provided an objective means for the residency program director to document and evaluate resident progress within the CanMEDS roles.

Simple interventions can greatly improve clinical documentation: a quality improvement project of record keeping on the surgical wards at a district general hospital.

Clinical documentation is an integral part of the healthcare professional's job. Good record keeping is essential for patient care, accurate recording of consultations and for effective communication within the multidisciplinary team. Within the surgical department at the Great Western Hospital, Swindon, the case notes were deemed to be bulky and cumbersome, inhibiting effective record keeping, potentially putting patients' at risk. The aim of this quality improvement project was therefore to improve the standard of documentation, the labelling of notes and the overall filing. A baseline audit was firstly undertaken assessing the notes within the busiest surgical ward. A number of variables were assessed, but notably, only 12% (4/33) of the case notes were found to be without loose pages. Furthermore, less than half of the pages with entries written within the last 72 hours contained adequate patient identifiers on them. When assessing these entries further, the designation of the writer was only recorded in one third (11/33) of the cases, whilst the printed name of the writer was only recorded in 65% (21/33) of the entries. This project ran over a 10 month period, using a plan, do study, act methodology. Initial focus was on simple education. Afterwards, single admission folders were introduced, to contain only information required for that admission, in an attempt to streamline the notes and ease the filing. This saw a global improvement across all data subsets, with a sustained improvement of over 80% compliance seen. An educational poster was also created and displayed in clinical areas, to remind users to label their notes with patient identifying stickers. This saw a 4-fold increase (16%-68%) in the labelling of notes. In conclusion, simple, cost effective measures in streamlining medical notes, improves the quality of documentation, facilitates the filing and ultimately improves patient care.

Partial versus complete fundoplication for the correction of pediatric GERD: a systematic review and meta-analysis.

BACKGROUND: There is no consensus as to what extent of "wrap" is required in a fundoplication for correction of gastroesophageal reflux disease (GERD). OBJECTIVE: To evaluate if a complete (360 degree) or partial fundoplication gives better control of GERD. METHODS: A systematic search of MEDLINE and Scopus identified interventional and observational studies of fundoplication in children. Screening identified those comparing techniques. The primary outcome was recurrence of GERD following surgery. Dysphagia and complications were secondary outcomes of interest. Meta-analysis was performed when appropriate. Study quality was assessed using the Cochrane Risk of Bias Tool. RESULTS: 2289 abstracts were screened, yielding 2 randomized controlled trials (RCTs) and 12 retrospective cohort studies. The RCTs were pooled. There was no difference in surgical success between partial and complete fundoplication, OR 1.33 [0.67,2.66]. In the 12 cohort studies, 3 (25%) used an objective assessment of the surgery, one of which showed improved outcomes with complete fundoplication. Twenty-five different complications were reported; common were dysphagia and gas-bloat syndrome. Overall study quality was poor. CONCLUSIONS: The comparison of partial fundoplication with complete fundoplication warrants further study. The evidence does not demonstrate superiority of one technique. The lack of high quality RCTs and the methodological heterogeneity of observational studies limits a powerful meta-analysis.

Reporting quality of statistical methods in surgical observational studies: protocol for systematic review.

BACKGROUND: Observational studies dominate the surgical literature. Statistical adjustment is an important strategy to account for confounders in observational studies. Research has shown that published articles are often poor in statistical quality, which may jeopardize their conclusions. The Statistical Analyses and Methods in the Published Literature (SAMPL) guidelines have been published to help establish standards for statistical reporting.This study will seek to determine whether the quality of statistical adjustment and the reporting of these methods are adequate in surgical observational studies. We hypothesize that incomplete reporting will be found in all surgical observational studies, and that the quality and reporting of these methods will be of lower quality in surgical journals when compared with medical journals. Finally, this work will seek to identify predictors of high-quality reporting. METHODS/DESIGN: This work will examine the top five general surgical and medical journals, based on a 5-year impact factor (2007-2012). All observational studies investigating an intervention related to an essential component area of general surgery (defined by the American Board of Surgery), with an exposure, outcome, and comparator, will be included in this systematic review. Essential elements related to statistical reporting and quality were extracted from the SAMPL guidelines and include domains such as intent of analysis, primary analysis, multiple comparisons, numbers and descriptive statistics, association and correlation analyses, linear regression, logistic regression, Cox proportional hazard analysis, analysis of variance, survival analysis, propensity analysis, and independent and correlated analyses. Each article will be scored as a proportion based on fulfilling criteria in relevant analyses used in the study. A logistic regression model will be built to identify variables associated with high-quality reporting. A comparison will be made between the scores of surgical observational studies published in medical versus surgical journals. Secondary outcomes will pertain to individual domains of analysis. Sensitivity analyses will be conducted. DISCUSSION: This study will explore the reporting and quality of statistical analyses in surgical observational studies published in the most referenced surgical and medical journals in 2013 and examine whether variables (including the type of journal) can predict high-quality reporting.

Ancillary testing for diagnosis of brain death: a protocol for a systematic review and meta-analysis.

BACKGROUND: The essential clinical diagnostic components of brain death must include evidence for an established etiology capable of causing brain death, two independent clinical confirmations of the absence of all brainstem reflexes and an apnea test, and exclude confounders that can mimic brain death. Numerous confounders can render the clinical neurological determination of death (NDD) virtually impossible. As such, clinicians must rely on additional ancillary testing. METHODS/DESIGN: We will conduct a systematic review and a meta-analysis of ancillary testing for the neurological determination of death. The primary objective of this systematic review is to evaluate the accuracy of these ancillary tests compared to the three accepted reference standards: (1) clinical diagnosis, (2) four-vessel angiography and (3) radionuclide imaging. This objective will be investigated using two different populations with different baseline risks of brain death: comatose patients and patients with a neurological determination of death. We will search MEDLINE, EMBASE and the Cochrane Central databases for retrospective and prospective diagnostic test studies and interventional studies. We will report study characteristics and assess methodological quality using QUADAS-2, which is used to assess the quality of diagnostic tests. If pooling is appropriate, we will compute parameter estimates using a bivariate model to produce summary receiver operating curves, summary operating points (pooled sensitivity and specificity), and 95% confidence regions around the summary operating point. Clinical and methodological subgroup and sensitivity analyses will be performed to explore heterogeneity. DISCUSSION: The results of this project will provide a critical evidence base for the neurological determination of death. The results will help clinicians to select ancillary tests based on the best available evidence. Our systematic review will also identify the strengths and weaknesses in the current evidence for the use of ancillary tests in diagnosing brain death. It will serve as a foundation for further research and the development of prospective studies on currently used or novel techniques for NDD. PROTOCOL REGISTRATION: PROSPERO Registration Number: CRD42013005907.

Relaxin gene family in teleosts: phylogeny, syntenic mapping, selective constraint, and expression analysis.

BACKGROUND: In recent years, the relaxin family of signaling molecules has been shown to play diverse roles in mammalian physiology, but little is known about its diversity or physiology in teleosts, an infraclass of the bony fishes comprising approximately 50% of all extant vertebrates. In this paper, 32 relaxin family sequences were obtained by searching genomic and cDNA databases from eight teleost species; phylogenetic, molecular evolutionary, and syntenic data analyses were conducted to understand the relationship and differential patterns of evolution of relaxin family genes in teleosts compared with mammals. Additionally, real-time quantitative PCR was used to confirm and assess the tissues of expression of five relaxin family genes in Danio rerio and in situ hybridization used to assess the site-specific expression of the insulin 3-like gene in D. rerio testis. RESULTS: Up to six relaxin family genes were identified in each teleost species. Comparative syntenic mapping revealed that fish possess two paralogous copies of human RLN3, which we call rln3a and rln3b, an orthologue of human RLN2, rln, two paralogous copies of human INSL5, insl5a and insl5b, and an orthologue of human INSL3, insl3. Molecular evolutionary analyses indicated that: rln3a, rln3b and rln are under strong evolutionary constraint, that insl3 has been subject to moderate rates of sequence evolution with two amino acids in insl3/INSL3 showing evidence of positively selection, and that insl5b exhibits a higher rate of sequence evolution than its paralogue insl5a suggesting that it may have been neo-functionalized after the teleost whole genome duplication. Quantitative PCR analyses in D. rerio indicated that rln3a and rln3b are expressed in brain, insl3 is highly expressed in gonads, and that there was low expression of both insl5 genes in adult zebrafish. Finally, in situ hybridization of insl3 in D. rerio testes showed highly specific hybridization to interstitial Leydig cells. CONCLUSIONS: Contrary to previous studies, we find convincing evidence that teleosts contain orthologues of four relaxin family peptides. Overall our analyses suggest that in teleosts: 1) rln3 exhibits a similar evolution and expression pattern to mammalian RLN3, 2) insl3 has been subject to positive selection like its mammalian counterpart and shows similar tissue-specific expression in Leydig cells, 3) insl5 genes are highly represented and have a relatively high rate of sequence evolution in teleost genomes, but they exhibited only low levels of expression in adult zebrafish, 4) rln is evolving under very different selective constraints from mammalian RLN. The results presented here should facilitate the development of hypothesis-driven experimental work on the specific roles of relaxin family genes in teleosts.

A survey of general dental practitioners in Merseyside regarding urgent appointments and suspected cancer referrals.

AIMS: The aims of this study were to investigate the current situation regarding unregistered patients in the Mersey region who seek an urgent dental appointment, and to gather information on suspected oral cancer cases seen by dentists in the previous two years and about how such cases are referred. METHODS: The survey took the form of a short questionnaire sent in May 2006 to all general dental practitioners (GDPs) in the Mersey region who were registered with the regional postgraduate dental office. RESULTS: A total of 904 GDPs were identified and 572 (63%) returned completed survey responses. Half (276/572; 48%) reported that they could see new patients urgently under the National Health Service (NHS) and two-thirds (365/571; 64%) that they could see them either under the NHS or privately. Nineteen per cent reported that they would not see any new patients. Those in the most deprived areas were more likely to see a patient on the NHS. The waiting time for an urgent appointment, if it was offered, was over one week for nearly one-third (32%) of the dentists offering NHS care. Most dentists (84%) said that a patient suspected of having oral cancer would be referred the same day as the decision had been made to refer. CONCLUSION: Access to dental care has been a high-profile issue over the past few years. This survey indicated that in Merseyside, just under half of the dentists who responded were willing to see new patients with urgent problems under the NHS. It is suggested that this difficulty in access, together with some reported delays in obtaining appointments and the methods of onward referral, may cause additional barriers to early detection of oral cancer, especially for those in the most at-risk groups, who are also very frequently hard to reach.