Varying negative appendectomy rates after laparoscopic appendectomy: a systematic review and meta-analysis.

PURPOSE: Appendicitis is a common cause of acute abdominal pain, and treatment with laparoscopy has become increasingly common during the past two decades. Guidelines recommend that normal appendices are removed if operated for suspected acute appendicitis. It is unclear how many patients are affected by this recommendation. The aim of this study was to estimate the rate of negative appendectomies in patients undergoing laparoscopic surgery for suspected acute appendicitis. METHODS: This study was reported following the PRISMA 2020 statement. A systematic search was conducted in PubMed and Embase for retrospective or prospective cohort studies (with n ≥ 100) including patients with suspected acute appendicitis. The primary outcome was the histopathologically confirmed negative appendectomy rate after a laparoscopic approach with a 95% confidence interval (CI). We performed subgroup analyses on geographical region, age, sex, and use of preoperative imaging or scoring systems. The risk of bias was assessed using the Newcastle-Ottawa Scale. Certainty of the evidence was assessed using GRADE. RESULTS: In total, 74 studies were identified, summing up to 76,688 patients. The negative appendectomy rate varied from 0% to 46% in the included studies (interquartile range 4-20%). The meta-analysis estimated the negative appendectomy rate to be 13% (95% CI 12-14%) with large variations between the individual studies. Sensitivity analyses did not change the estimate. The certainty of evidence by GRADE was moderate due to inconsistency in point estimates. CONCLUSION: The overall estimated negative appendectomy rate after laparoscopic surgery was 13% with moderate certainty of evidence. The negative appendectomy rate varied greatly between studies.

A novel and practical technique to facilitate lead insertion at the His bundle region.

BACKGROUND: His bundle (HB) pacing techniques are challenging and time-consuming. This is primarily due to the limitations in locating the relatively small area of the HB body for pacing. METHODS: Permanent HB pacing was performed in 133 consecutive patients with symptomatic bradycardia. A right atrial septo-gram (RAS) was performed in all patients to locate the HB. Briefly, 8-10 cc of contrast was injected through the Medtronic C315HIS delivery sheath while fluoroscopy cine runs were obtained in the RAO 15-20° projection. The images obtained provided the visualization of an approximately 90° angle composed by the medial aspect of the tricuspid valve annulus (TVA) anteriorly and the superior aspect of the interatrial septum superiorly. The apex of this angle coincides with the tip of the triangle of Koch (TK), where the HB body is usually located. A Medtronic SelectSecure™ MRI SureScan™ Model 3830 lead was then advanced and directed towards this area. The HB was mapped using pace mapping and unipolar recordings from the lead tip. RESULTS: Localization of the apex of the TK/HB body with the RAS was successful in all patients. The overall acute success of inserting the lead at the HB was 95%. CONCLUSION: This study demonstrated that our method of utilizing a RAS to facilitate the localization the HB body proved to be safe and efficient in achieving permanent HB pacing with a success rate higher than previously reported.

Cocaine Positivity in ST-Elevation Myocardial Infarction: A True or False Association.

INTRODUCTION: Every year, more than 500,000 US Emergency Department visits are associated with cocaine use. People who use cocaine tend to have a lower incidence of true ST-elevation myocardial infarction (STEMI). OBJECTIVE: To identify the factors associated with true STEMI in patients with cocaine-positive (CPos) findings. METHODS: We retrospectively analyzed 1144 consecutive patients with STEMI between 2008 and 2013. True STEMI was defined as having a culprit lesion on coronary angiogram. Multivariate and univariate analyses were used to identify risk factors and create a predictive model. RESULTS: A total of 64 patients with suspected STEMI were CPos (mean age 53.1 ± 11.2 years; male = 80%). True STEMI was diagnosed in 34 patients. Patients with CPos true STEMI were more likely to be uninsured than those with false STEMI (61.8% vs 34.5%, p = 0.03) and have higher peak troponin levels (21.1 ng/mL vs 2.12 ng/mL, p = < 0.01) with no difference in mean age between the 2 groups (p = 0.24). In multivariate analyses, independent predictors of true STEMI in patients with CPos findings included age older than 65 years (odds ratio [OR] = 19.3, 95% confidence iterval [CI] = 1.2-318.3), lack of health insurance (OR = 4.9, 95% CI = 1.2-19.6), and troponin level higher than 0.05 (OR = 24.0, 95% CI = 2.6-216.8) (all p < 0.05). A multivariate risk score created with a C-statistic of 82% (95% CI = 71-93) significantly improved the identification of patients with true STEMI. CONCLUSION: Among those with suspected STEMI, patients with CPos findings had a higher incidence of false STEMI. Older age, lack of health insurance, and troponin levels outside of defined limits were associated with true STEMI in this group.

5-Hydroxyethyl-3-tetradecanoyltetramic acid represents a novel treatment for intravascular catheter infections due to Staphylococcus aureus.

Objectives: Biofilm infections of intravascular catheters caused by Staphylococcus aureus may be treated with catheter lock solutions (CLSs). Here we investigated the antibacterial activity, cytotoxicity and CLS potential of 5-hydroxyethyl-3-tetradecanoyltetramic acid (5HE-C14-TMA) compared with the related compounds 3-tetradecanoyltetronic (C14-TOA) and 3-tetradecanoylthiotetronic (C14-TTA), which are variants of quorum sensing signalling molecules produced by Pseudomonas aeruginosa . Methods: Antibacterial activity and mechanism of action of 5HE-C14-TMA, C14-TOA and C14-TTA were determined via MIC, bacterial killing, membrane potential and permeability assays. Susceptibility of S. aureus biofilms formed in the presence of plasma in vitro was investigated, MTT cytotoxicity testing was undertaken and cytokine release in human blood upon exposure to 5HE-C14-TMA and/or S. aureus biofilms was quantified. The effectiveness of 5HE-C14-TMA as CLS therapy in vivo was assessed using a rat intravascular catheter biofilm infection model. Results: MICs of 5HE-C14-TMA, C14-TOA and C14-TTA ranged from 2 to 4 mg/L. 5HE-C14-TMA and C14-TTA were bactericidal; all three compounds perturbed the staphylococcal membrane by increasing membrane permeability, depolarized the transmembrane potential and caused ATP leakage. Cytotoxicity and haemolytic activity were compound and target cell type-dependent. 5HE-C14-TMA reduced S. aureus biofilm viability in a dose-dependent manner in vitro and in vivo and did not trigger release of cytokines in human blood, but inhibited the high levels of IL-8 and TNF-α induced by S. aureus biofilms. Conclusions: 5HE-C14-TMA, C14-TOA and C14-TTA are membrane-active agents. 5HE-C14-TMA was the most potent, eradicating S. aureus biofilms at 512-1024 mg/L both in vitro and in vivo as a CLS.

Biotic inactivation of the Pseudomonas aeruginosa quinolone signal molecule.

In Pseudomonas aeruginosa, quorum sensing (QS) regulates the production of secondary metabolites, many of which are antimicrobials that impact on polymicrobial community composition. Consequently, quenching QS modulates the environmental impact of P. aeruginosa. To identify bacteria capable of inactivating the QS signal molecule 2-heptyl-3-hydroxy-4(1H)-quinolone (PQS), a minimal medium containing PQS as the sole carbon source was used to enrich a Malaysian rainforest soil sample. This yielded an Achromobacter xylosoxidans strain (Q19) that inactivated PQS, yielding a new fluorescent compound (I-PQS) confirmed as PQS-derived using deuterated PQS. The I-PQS structure was elucidated using mass spectrometry and nuclear magnetic resonance spectroscopy as 2-heptyl-2-hydroxy-1,2-dihydroquinoline-3,4-dione (HHQD). Achromobacter xylosoxidans Q19 oxidized PQS congeners with alkyl chains ranging from C1 to C5 and also N-methyl PQS, yielding the corresponding 2-hydroxy-1,2-dihydroquinoline-3,4-diones, but was unable to inactivate the PQS precursor HHQ. This indicates that the hydroxyl group at position 3 in PQS is essential and that A. xylosoxidans inactivates PQS via a pathway involving the incorporation of oxygen at C2 of the heterocyclic ring. The conversion of PQS to HHQD also occurred on incubation with 12/17 A. xylosoxidans strains recovered from cystic fibrosis patients, with P. aeruginosa and with Arthrobacter, suggesting that formation of hydroxylated PQS may be a common mechanism of inactivation.

Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: a prospective observational cohort study.

OBJECTIVE: To examine the association between the outcomes of a pre-operative comprehensive geriatric assessment (CGA) and the risk of severe post-operative complications in elderly patients electively operated for colorectal cancer. METHODS: One hundred seventy-eight consecutive patients ≥ 70 years electively operated for all stages of colorectal cancer were prospectively examined. A pre-operative CGA was performed, and patients were categorized as fit, intermediate, or frail. The main outcome measure was severe complications within 30 days of surgery. RESULTS: Twenty-one patients (12%) were categorized as fit, 81 (46%) as intermediate, and 76 (43%) as frail. Eighty-three patients experienced severe complications, including three deaths; 7/21 (33%) of fit patients, 29/81 (36%) of intermediate patients and 47/76 (62%) of frail patients (p=0.002). Increasing age and ASA classification were not associated with complications in this series. CONCLUSION: CGA can identify frail patients who have a significantly increased risk of severe complications after elective surgery for colorectal cancer.

Surgical risk and post-operative complications in older unfit cancer patients.

Surgeons have always dealt with elderly cancer patients, but understanding frailty and tailoring treatment is a new achievement endeavour. Mounting evidence is resulting in the introduction of geriatric assessment into clinical practice. Particularly, undernourishment should be assessed and corrected in order to avoid emergency situations whenever possible.

Sub-ballistic behavior in quantum systems with Lévy noise.

We investigate the quantum walk and the quantum kicked rotor in resonance subjected to noise with a Lévy waiting time distribution. We find that both systems have a sub-ballistic wave function spreading as shown by a power-law tail of the standard deviation.

Dynamical localization in quasiperiodic driven systems.

We investigate how the time dependence of the Hamiltonian determines the occurrence of dynamical localization (DL) in driven quantum systems with two incommensurate frequencies. If both frequencies are associated to impulsive terms, DL is permanently destroyed. In this case, we show that the evolution is similar to a decoherent case. On the other hand, if both frequencies are associated to smooth driving functions, DL persists although on a time scale longer than in the periodic case. When the driving function consists of a series of pulses of duration sigma, we show that the localization time increases as sigma(-2) as the impulsive limit, sigma-->0, is approached. In the intermediate case, in which only one of the frequencies is associated to an impulsive term in the Hamiltonian, a transition from a localized to a delocalized dynamics takes place at a certain critical value of the strength parameter. We provide an estimate for this critical value, based on analytical considerations. We show how, in all cases, the frequency spectrum of the dynamical response can be used to understand the global features of the motion. All results are numerically checked.

Proxen in the treatment of gonarthrosis. A controlled clinical double-blind study.

Forty patients of both sexes, aged between 25 and 65 years and suffering from gonarthrosis, took part in a controlled double-blind study of Proxen vs naproxen. Proxen was administered to 20 patients and the control drug to the other 20, in doses of 500 mg twice a day for 60 days. Both drugs demonstrated a good level of activity and tolerance. Proxen proved effective in 94% of the cases, while naproxen was effective in 80%.

Diuretic agents related to indapamide. II. Synthesis and pharmacological activity of 1-alkyl, 1-carboxyalkyl- and 1,3-dialkyl substituted 2-(4-chloro-3-sulfamoylbenzamido)isoindolines.

In pursuing earlier studies, the synthesis of a series of 1 and 1,3- substituted 2-(4-chloro-3-sulfamoylbenzamido)isoindolines (V a-e), related to indapamide, is described. These compounds were evaluated for diuretic and antihypertensive activities.