Long-term outcomes in surgically intervened empyema patients: a systematic review.

BACKGROUND: Pleural empyema is significant cause of morbidity and mortality. Debate in the literature exists regarding the best initial and definitive therapy, with recent research demonstrating superior short-term outcomes with initial surgical intervention. Despite this, the impact of surgical intervention on long-term outcomes has been incompletely described. A systematic review was undertaken to assess the current evidence evaluating the long-term impact of surgical intervention. METHODS: A systematic review was undertaken according to PRISMA guidelines utilizing three databases. Articles included all papers where patients received surgical intervention for empyema with outcomes evaluated beyond 90 days. Two reviewers extracted and reviewed the articles. Grey literature was included. RESULTS: Eleven studies and two abstracts were extracted. One study and two abstracts evaluated the quality of life outcomes, two studies evaluated dyspnoea outcomes, seven studies evaluated long-term lung function and two studies evaluated mortality and re-admissions. 60-65% of patients had no dyspnoea between 2 and 7 years follow-up. In six of seven studies, normal lung function was achieved in patients with chronic fibrothorax with FEV1% and FVC% improvements between 14-30% and 13-50%, respectively. The results from such biased cohorts could not be extrapolated to conclude that surgical intervention results in better outcomes than ICC drainage. Risk of bias was severe for all 11 studies. CONCLUSION: Surgical intervention potentially improves post-operative lung function, long-term dyspnoea, and mortality. The impact this has on quality of life remains unknown. Future prospective trials with homogenous comparative groups are required to better define the role of surgery and its impact on long-term outcomes.

Creating ANZTHOR-A Thoracic Database for Australia and Aotearoa New Zealand.

The increasing complexity and scope of thoracic surgery warrants tools to monitor and improve the quality of surgical care provided to patients. Few data on the volume or outcome of thoracic surgical procedures are currently collected in Australasia. The Australia and Aotearoa New Zealand Thoracic Registry (ANZTHOR) Steering Group have sought to rectify this by designing a REDCap-based thoracic clinical quality registry with improved patient care as its central goal. This centralised thoracic registry will benefit patients, clinicians, trainees, and the practise of thoracic surgery in Australia and Aotearoa New Zealand. With time, the registry will also facilitate high quality thoracic research.

Does surgical fixation improve pain and quality of life in patients with non-flail rib fractures? A best evidence topic review.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'does surgical stabilization of rib fractures improve pain and quality of life in patients with non-flail rib fractures?'. Altogether >300 papers were found using the reported search, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Whilst several non-randomized cohort studies demonstrate superior pain and quality of life outcomes with surgical fixation as compared to conservative management, this is not replicated by the findings of a recent randomized trial which found worse pain, but early return to work in those treated with surgical stabilization of rib fractures. Given this, clinicians will need to carefully consider the indications for treating painful non-flail rib fractures as surgical fixation represents a reasonable treatment option in only appropriately selected candidates.

Outcomes for minimally invasive parathyroidectomy: widening inclusion criteria based on preoperative imaging results.

BACKGROUND: Primary hyperparathyroidism is caused by a single adenoma in at least 80% of cases. Minimally invasive parathyroidectomy (MIP) has overtaken bilateral neck exploration as the gold standard for treatment in cases with adequate preoperative localization. There is evidence that, following careful review of preoperative imaging by the surgeon, increasing numbers of patients can successfully undergo MIP. METHODS: We conducted a retrospective review of 225 consecutive cases performed by a single surgeon. Outcomes for patients with disease reported as localized by radiologists and nuclear medicine physicians using sestamibi and ultrasound were compared with patients with negative or indeterminate localization studies, in which the surgeon reviewed the sestamibi, performed an ultrasound study and identified likely single adenomas and planned MIP. RESULTS: One hundred and sixty patients with radiologist-localized disease and an additional 29 patients with surgeon-localized disease underwent MIP. The surgeon-localized group had higher rates of conversion to bilateral neck exploration (21% compared with 4%, P = 0.004), but rates of failure to cure were comparable between the two groups (4.3% compared with 2.8%). CONCLUSION: Careful review of preoperative sestamibi and ultrasound studies by an experienced surgeon can increase the number of patients that can successfully undergo MIP for the treatment of primary hyperparathyroidism. Offering MIP to these patients does not result in increased rates of failure or recurrence.

Genetics of epilepsy: The testimony of twins in the molecular era.

OBJECTIVE: Analysis of twins with epilepsy to explore the genetic architecture of specific epilepsies, to evaluate the applicability of the 2010 International League Against Epilepsy (ILAE) organization of epilepsy syndromes, and to integrate molecular genetics with phenotypic analyses. METHODS: A total of 558 twin pairs suspected to have epilepsy were ascertained from twin registries (69%) or referral (31%). Casewise concordance estimates were calculated for epilepsy syndromes. Epilepsies were then grouped according to the 2010 ILAE organizational scheme. Molecular genetic information was utilized where applicable. RESULTS: Of 558 twin pairs, 418 had confirmed seizures. A total of 534 twin individuals were affected. There were higher twin concordance estimates for monozygotic (MZ) than for dizygotic (DZ) twins for idiopathic generalized epilepsies (MZ = 0.77; DZ = 0.35), genetic epilepsy with febrile seizures plus (MZ = 0.85; DZ = 0.25), and focal epilepsies (MZ = 0.40; DZ = 0.03). Utilizing the 2010 ILAE scheme, the twin data clearly demonstrated genetic influences in the syndromes designated as genetic. Of the 384 tested twin individuals, 10.9% had mutations of large effect in known epilepsy genes or carried validated susceptibility alleles. CONCLUSIONS: Twin studies confirm clear genetic influences for specific epilepsies. Analysis of the twin sample using the 2010 ILAE scheme strongly supported the validity of grouping the "genetic" syndromes together and shows this organizational scheme to be a more flexible and biologically meaningful system than previous classifications. Successful selected molecular testing applied to this cohort is the prelude to future large-scale next-generation sequencing of epilepsy research cohorts. Insights into genetic architecture provided by twin studies provide essential data for optimizing such approaches.

Genetics of febrile seizure subtypes and syndromes: a twin study.

PURPOSE: Febrile seizures (FS) are the most common seizure syndrome. A strong genetic component has been well established through family and twin studies; however, such studies have not examined the genetics of different FS types (simple, complex, febrile status epilepticus) and sub-syndromes (true FS, febrile seizures plus (FS+), 'FS with later epilepsy'). Here we used a community-based twin sample to analyze genetic factors within different FS subtypes and FS syndromes. METHODS: Twin pairs were ascertained from the twin database of the Epilepsy Research Centre. A retrospective chart review was conducted and follow-up attempted for all subjects. Casewise concordance values were calculated for the different subgroups and intra-pair variation was analyzed. KEY FINDINGS: One hundred and seventy-nine twin pairs with FS were identified. Overall casewise concordance for FS in monozygotic (MZ) twins (0.62) was greater than in dizygotic (DZ) twins (0.16, p<0.0001). A greater concordance amongst MZ pairs than DZ twin pairs was also observed for all FS subtypes and FS sub-syndromes, particularly in twins with FS+. Within concordant MZ pairs, we did not observe the co-occurrence of FS and FS+. SIGNIFICANCE: These results suggest a strong genetic contribution to different FS subtypes and sub-syndromes. They also support the existence of distinct genetic factors for different FS subtypes and sub-syndromes, especially FS+. This information is important for the strategic planning of next generation sequencing studies of febrile seizures.

Obstetric events as a risk factor for febrile seizures: a community-based twin study.

Adverse events during the perinatal period have traditionally been thought to contribute to the risk of febrile seizures although an association has not been found in large epidemiological studies. Disease-discordant twins provide a means to assess the role of non-shared environmental factors while matching for confounding factors and avoiding difficulties of epidemiological studies in singletons. This study aimed to examine the association of obstetric events and febrile seizures in a community-based twin study. Twenty-one twin pairs discordant for febrile seizures were ascertained from a community-based twin register. Obstetric events were scored using the McNeil-Sjöström Scale for Obstetric Complications and expressed as a summary score (OC score). The frequency of individual obstetric events in affected and unaffected twins, the within-pair differences in OC scores and other markers of perinatal risk including birthweight, birth order and Apgar scores were examined. No significant difference was found in the frequency of individual obstetric events, nor in OC scores between affected and unaffected twins. No differences in birth weight, birth order, 1- or 5-minute Apgar scores were observed. Our results confirm previous findings that obstetric events are not associated with the risk of febrile seizures.