Management of multiple cervical neurofibromas with myelopathy in neurofibromatosis type 1: A systematic review, case report and technical note

Objective: Neurofibromatosis type 1 (NF1) is a common disorder in which affected individuals uncommonly develop cervical neurofibromas. The presentation of cervical neurofibroma with myelopathy is clinically challenging. Available data of NF1 patients with cervical cord compression secondary to multiple neurofibromas remain scarce in the literature. To this end, we sought to address this limitation. Methods: Case presentation: We report a case of a 22-year-old man, recently diagnosed with NF1, who presented with progressive cervical myelopathy over the course of 12 months. Imaging revealed multiple cervical neurofibromas with significant spinal cord compression. The patient underwent a C3 to C7 decompressive laminectomy and subtotal resection of the bilateral neurofibromas and instrumented fusion. During the postoperative period, he experienced transient bilateral weakness in C5 and C6 muscle groups that gradually resolved, and his weakness and spasticity significantly improved thereafter.Systematic review: We performed a systematic review of PubMed and Scopus in English-language literature dated between 1960 and December 2019 for studies that included cervical neurofibromas presenting with myelopathy in patients with NF1. Results: Fifty-seven articles were identified for full-text examination, of which 19 articles were included in the systematic review; 10 involved studies on surgical treatment, and nine on other treatment modalities. Twelve studies were retrospective, 3 involved prospective cohorts, and 4 were case reports. Most studies included various types of spinal cord tumors with or without neurofibromatosis. Only two studies exclusively involved neurofibromas in NF patients. There was wide variation in surgical and radiation therapy techniques and outcome measures reported. Conclusion: Surgical decompression is the primary treatment strategy for multiple cervical neurofibromas that cause a progressive neurological deficit. Fusion is recommended to avoid late kyphotic deformity. Data describing the management plan and long-term outcomes in this group of patients remain scarce in the literature, and no standardized treatment strategy is available

The impact of “early” versus “late” initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis

Background: The optimal timing of initiating renal replacement therapy (RRT) in critical illness complicated by acute kidney injury (AKI) is not clearly established. Trials completed on this topic have been marked by contradictory findings as well as quality and heterogeneity issues. Our goal was to perform a synthesis of the evidence regarding the impact of “early” versus “late” RRT in critically ill patients with AKI, focusing on the highest-quality research on this topic. Methods: A literature search using the PubMed and Embase databases was completed to identify studies involving critically ill adult patients with AKI who received hemodialysis according to “early” versus “late”/“standard” criteria. The highest-quality studies were selected for meta-analysis. The primary outcome of interest was mortality at 1 month (composite of 28- and 30-day mortality). Secondary outcomes evaluated included intensive care unit (ICU) and hospital length of stay (LOS). Results: Thirty-six studies (seven randomized controlled trials, ten prospective cohorts, and nineteen retrospective cohorts) were identified for detailed evaluation. Nine studies involving 1042 patients were considered to be of high quality and were included for quantitative analysis. No survival advantage was found with “early” RRT among high-quality studies with an OR of 0.665 (95 % CI 0.384–1.153, p = 0.146). Subgroup analysis by reason for ICU admission (surgical/medical) or definition of “early” (time/biochemical) showed no evidence of survival advantage. No significant differences were observed in ICU or hospital LOS among high-quality studies. Conclusions: Our conclusion based on this evidence synthesis is that “early” initiation of RRT in critical illness complicated by AKI does not improve patient survival or confer reductions in ICU or hospital LOS. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1291-8) contains supplementary material, which is available to authorized users

Additional file 2: Table S1. of The impact of “early” versus “late” initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis

Search terms used during literature review. (DOCX 15 kb

Additional file 4: Figure S3. of The impact of “early” versus “late” initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis

a Mortality forest plot of subgroup analysis of high-quality studies according to post-surgical ICU admission type (n = 3). b Mortality forest plot of subgroup analysis of high-quality studies according to medical ICU admission type (n = 6). (ZIP 120 kb

Additional file 1: Figure S1. of The impact of “early” versus “late” initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. (PDF 51 kb

Additional file 3: Figure S2. of The impact of “early” versus “late” initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis

Article selection process. (PDF 86 kb

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially