Autologous fat transfer for breast augmentation: a systematic review.

BACKGROUND: The role of autologous fat transfer (AFT) for cosmetic breast augmentation is uncertain due to ongoing concerns regarding its safety and efficacy compared with other breast augmentation techniques. OBJECTIVES: The aim of this systematic review was to assess the safety and efficacy of AFT for cosmetic breast augmentation in comparison with saline and cohesive silicone gel implants. METHODS: A systematic search of several electronic databases, including PubMed and EMBASE, was used to identify relevant studies for inclusion. The inclusion of studies was established through the application of a predetermined protocol by two independent reviewers. RESULTS: There were no comparative studies available, necessitating that all comparisons be indirect. Eighteen studies were included, 11 of which reported outcomes for AFT. Complications associated with AFT occurred in only a small proportion of patients, with fat necrosis, cysts and lumps most commonly reported. No data examining the effect of complications such as microcalcification on long-term mammographic and cancer-related outcomes were identified. Reabsorption of fat occurred to varying degrees, usually during the first 12 months following the procedure. Patient satisfaction following AFT was high. Limitation in breast volume increase was the main complaint associated with this procedure. CONCLUSIONS: Based on the limited evidence available, AFT was considered to be at least as safe as the nominated comparator procedures in regard to complications; however, its safety in regard to cancer detection could not be determined. The efficacy of AFT could not be determined.

Lumbar artificial intervertebral disc replacement: a systematic review.

BACKGROUND: Low back pain represents a significant disease burden in Australia. Lumbar artificial intervertebral disc replacement (AIDR) has emerged as an alternative surgical option to lumbar fusion for patients suffering from axial low back pain as a result of degenerative disc disease. OBJECTIVES: The aim of this review was to assess the safety and effectiveness of lumbar AIDR for patients suffering from significant axial back pain and/or radicular (nerve root) pain, secondary to disc degeneration or prolapse, who have failed non-operative treatment. METHODS: A systematic search of several electronic databases was conducted between January 2005 and April 2012 to identify relevant randomized controlled trials and non-randomized comparative studies. Inclusion of studies was established through the application of a predetermined protocol by two independent reviewers. RESULTS: Six randomized controlled trials (comprising nine studies) and one non-randomized comparative study comparing lumbar AIDR with lumbar fusion were included in this review. For the majority of adverse events reported, there were no obvious differences in incidence rates between the two treatment groups, and serious adverse events were rare in both groups. Following lumbar AIDR, effectiveness outcomes including Oswestry Disability Index scores, procedural success rates, pain scores, narcotic medication use and patient satisfaction were generally significantly better than, or equivalent to, outcomes achieved following lumbar fusion. CONCLUSIONS: In the short to medium term, the safety and effectiveness of lumbar AIDR appears to be comparable to that of lumbar fusion.

Cost-effectiveness of lumbar artificial intervertebral disc replacement: driven by the choice of comparator.

BACKGROUND: Lower back pain is a common and costly condition in Australia. This paper aims to conduct an economic evaluation of lumbar artificial intervertebral disc replacement (AIDR) compared with lumbar fusion for the treatment of patients suffering from significant axial back pain and/or radicular (nerve root) pain, secondary to disc degeneration or prolapse, who have failed conservative treatment. METHODS: A cost-effectiveness approach was used to compare costs and benefits of AIDR to five fusion approaches. Resource use was based on Medicare Benefits Schedule claims data and expert opinion. Effectiveness and re-operation rates were based on published randomized controlled trials. The key clinical outcomes considered were narcotic medication discontinuation, achievement of overall clinical success, achievement of Oswestry Disability Index success and quality-adjusted life-years gained. RESULTS: AIDR was estimated to be cost-saving compared with fusion overall ($1600/patient); however, anterior lumbar interbody fusion and posterolateral fusion were less costly by $2155 and $807, respectively. The incremental cost-effectiveness depends on the outcome considered and the comparator. CONCLUSIONS: AIDR is potentially a cost-saving treatment for lumbar disc degeneration, although longer-term follow-up data are required to substantiate this claim. The incremental cost-effectiveness depends on the outcome considered and the comparator, and further research is required before any firm conclusions can be drawn.

Consumer perspectives in surgical research and audit.

OBJECTIVES: The aim was to learn about perspectives of consumers contributing to the work of the Division of Research, Audit and Academic Surgery of the Royal Australasian College of Surgeons. The research arm of the Division has worked with consumers since it was formed in 1998. METHODS: Nine consumers who worked with the Division over the past 5 years completed (1) a written survey focused on their background and past experience, and (2) a semi-structured phone interview focused on their motivations for becoming involved in this work; their role; the evolution of the role of consumers in healthcare research; and what health information for consumers should contain. RESULTS: Participants came from various backgrounds and had different motivations for being involved. A common theme was concern about uncertainties in surgery and the need to provide consumers with information about potential benefits and risks of a procedure. Participants believed that a consumer presence was vital in research on surgical procedures, and that the content and wording of consumer information must be chosen carefully in order for the public to use it in a meaningful way. They also acknowledged the changing role of the consumer, who was rapidly becoming a partner in the doctor-patient relationship. CONCLUSIONS: In surgical research and audit, the consumer perspective is unique and informed by a wealth of experience. The findings of this study may be of interest to other health technology assessment and associated agencies seeking to involve consumers within their own research process.

Brief reports: paravertebral block for anesthesia: a systematic review.

BACKGROUND: The objective of this review was to assess the safety and efficacy of thoracic and lumbar paravertebral blocks (PVBs) for surgical anesthesia through a systematic review of the peer-reviewed literature. PVBs for surgical anesthesia were compared with general anesthesia (GA) or other regional anesthetic techniques. METHODS: We searched literature databases including MEDLINE, EMBASE, and The Cochrane Library up to May 2008. Included studies were limited to eligible randomized controlled trials. Eight randomized controlled trials were included in this review, 6 of which used PVBs for anesthesia during breast surgery, and 2 trials used PVB for anesthesia during herniorrhaphy. RESULTS: The ability to obtain firm conclusions was limited by the diversity of outcomes and how they were measured, which varied across studies. The PVB failure rate was not >13%, and patients were more satisfied with PVB than with GA. There was some indication that PVB could achieve shorter hospital stays than GA. PVB for anesthesia substantially reduces nausea and vomiting in comparison with GA (relative risk: 0.25, 95% CI: 0.13-0.50; P < 0.05), although it does carry a risk of pleural puncture and epidural spread of local anesthetic. CONCLUSIONS: In conclusion, based on the current evidence, PVBs for surgical anesthesia at the level of the thoracic and lumbar vertebrae are associated with less pain during the immediate postoperative period, as well as less postoperative nausea and vomiting, and greater patient satisfaction compared with GA.

Safety and efficacy of nontherapeutic male circumcision: a systematic review.

PURPOSE: We wanted to assess the safety and efficacy of nontherapeutic male circumcision through a systematic review of the literature. METHODS: We systematically searched The York Centre for Reviews and Disseminations, Cochrane Library, PubMed, and EMBASE databases for randomized controlled trials published between January 1997 and August 2008. Studies reporting on circumcision in an operative setting in males of any age with no contraindications to or medical indications for circumcision were eligible for inclusion. The main comparator was intact genitalia. From 73 retrieved studies, 8 randomized controlled trials were ultimately included for analysis. RESULTS: Severe complications were uncommon. Analgesia/anesthesia during circumcision was promoted. The prevalence of self-reported genital ulcers was significantly lower in circumcised men than uncircumcised men (3.1% vs 5.8%; prevalence risk ratio 0.53; 95% confidence interval [CI], 0.43-0.64; P<.001). Circumcised sub-Saharan African men were at significantly lower risk of acquiring human immunodeficiency virus/acquired immune deficiency syndrome than were uncircumcised men (random effects odds ratio = 0.44, 95% CI, 0.32-0.59; P <.001). The evidence suggests that adult circumcision does not affect sexual satisfaction and function. CONCLUSIONS: Strong evidence suggests circumcision can prevent human immunodeficiency virus/acquired immune deficiency syndrome acquisition in sub-Saharan African men. These findings remain uncertain in men residing in other countries. The role of adult nontherapeutic male circumcision in preventing sexually transmitted infections, urinary tract infections, and penile cancer remains unclear. Current evidence fails to recommend widespread neonatal circumcision for these purposes.

Nontherapeutic male circumcision: tackling the difficult issues.

INTRODUCTION: Male circumcision is the most commonly performed surgical procedure in the world. Circumcision may be performed to treat an underlying pathological process ("therapeutic circumcision"). However there may be religious, cultural, and social indications. AIM: This article addresses the religious, cultural, social, and ethical issues surrounding nontherapeutic male circumcision (NTMC). MAIN OUTCOME MEASURES: Any religious, social, cultural, or ethical issues relating to NTMC. METHODS: Because of the absence of high level evidence, a concise literature review was undertaken to identify articles published between January 1990 and February 2009 summarizing current knowledge on NTMC. RESULTS: There are complex religious, cultural, social, and prophylactic incentives for NTMC. The procedure may have associated clinical and psychosocial adverse events and raises such ethical issues as bodily integrity and consent. Because of the strength of the incentives for NTMC, there may be important implications in denying patients the procedure. Several important issues must be considered when introducing mass circumcision as a preventative strategy for HIV/AIDS. CONCLUSION: When assessing whether NTMC will benefit or harm a patient, clinicians must take his religious, cultural, and social circumstances into account. Males requiring mandatory religious or cultural NTMC are likely to suffer significant harm if they do not receive circumcision and should be considered separately to males in general.