Role of C-reactive protein in early detection of anastomotic leak in patients undergoing elective colorectal resection surgery with primary anastomosis

Introduction:Despite improvements in surgical technique and perioperative care anastomotic leaks (AL) are still present, causing increased morbidity, mortality, length of stay and costs.Aim: The aim of this article is to study the role of c-reactive protein in early detection of anastomotic leak in the studied group.Materials and Methods:Prospective study in the period January 2017 - December 2018 of all patients undergoing elective colorectal surgery for cancer with primary colonic anastomosis in the Clinic of Surgical Oncology, Dr. G. Stranski University Hospital – Pleven was conducted. All patients were treated according to the ERAS protocols for colorectal surgery. The incidence of anastomotic leaks, changes in CRP and leukocyte (WBC) levels were studied.Results:A total of 201 patients were subjected to colonic resection in the Clinic for the study period. In 123 of the interventions an intestinal anastomosis was performed and this is the group of interest. Fifty-two of all interventions were minimally invasive. Anastomotic leak was found in 7 cases (5.7%), of which 2 patients were conservatively treated, and 5 patients were reoperated.All patients with anastomotic insufficiency had serum levels of CRP above 130 mg/L. In five patients we found CRP levels above 130 mg/L without anastomotic leak. There were no patients with anastomotic insufficiency with CRP levels below 130 mg/L. The positive predictive value for these levels of CRP was 58.33% and the negative predictive value - 100%. In 85.7% of the patients with AL leukocyte (WBC) levels were in normal range at the time of AL detection.Conclusion:CRP is an early marker with excellent negative predictive value for the development of anastomotic leak after colorectal surgery

Comparison of Outcomes Between Suture Button Technique and Screw Fixation Technique in Patients With Acute Syndesmotic Diastasis: A Meta-analysis of Randomized Controlled Trials

Background: Our aim was to compare the outcome between suture button (SB) stabilization and syndesmotic screw fixation (SF) in patients with acute syndesmotic diastasis. Methods: A systematic literature search up to June 30, 2021, was performed to identify randomized controlled trials (RCTs) comparing outcomes of SB with SF techniques in patients with acute syndesmotic diastasis. We calculated mean differences for continuous outcomes, using the Hartung-Knapp-Sidik-Jonkman method, and odds ratio for dichotomous outcomes, using the Mantel-Haenszel method. Results: Eight RCTs involving 569 patients met the inclusion criteria, 1 RCT with level I evidence, and 7 RCTs with level II evidence. The meta-analysis showed that the SB technique had a higher AOFAS score <6 months and 12 months postoperatively (MD = 4.74, 95% CI 1.68-7.80, P = .01; and MD = 5.42, 95% CI 1.50-9.33, P = .02) and reduced the risk of implant irritation (OR = 0.31, 95% CI 0.11-0.89, P = .03), implant failure (OR = 0.06, 95% CI 0.02-0.23, P < .01), and reoperation (OR = 0.43, 95% CI 0.22-0.83, P = .01). The 2 approaches did not differ in further functional outcomes or postoperative complications. Conclusion: Because functional outcomes showed no relevant difference between both SB and SF, the advantage of SB appears to be in the lower risk for postoperative complications. The SB technique led to fewer cases of implant irritation, implant failure, and reoperation compared with SF. Level of Evidence: Level I, meta-analysis of RCTs

A meta-analysis on RCTs of direct anterior and conventional approaches in total hip arthroplasty

To conduct a systematic review and meta-analyses on short-term outcomes between total hip arthroplasty (THA) through direct anterior approach (DAA) compared to THA through conventional approaches (CAs) in treatment of hip diseases and fractures. We performed a systematic literature search up to March 1, 2021 to identify RCTs, comparing THA through DAA with THA through CAs. We calculated mean differences (MDs) with 95% confidence intervals (CIs) for continuous outcomes, using the DerSimonian and Laird method and a random effects model. We calculated odds ratios (ORs) with 95% CIs for dichotomous outcomes, using the Mantel–Haenszel method and a random effects model. Ten RCTs met the criteria for final meta-analysis, involving 1053 patients. Four studies were blinded RCTs with a level I evidence, the other 6 studies were non-blinded RCTs with a level II evidence. DAA had a longer operation time than CAs (MD = 17.8, 95% CI  4.8 to 30.8); DAA had similar results compared to CAs for incision length (MD = − 1.1, 95% CI − 4.1 to 1.8), for intraoperative blood loss (MD = 67.2, 95% CI − 34.8 to 169.1), for HHS 3 months postoperatively (MD = 2.4, 95% CI − 0.7 to 5.5), for HHS 6 months postoperatively (MD = 0.8, 95% CI − 1.9 to 3.5), for HHS 12 months postoperatively (MD = 0.9, 95% CI − 0.7 to 2.5), for pain VAS 1 day postoperatively (MD = − 0.9, 95% CI − 2.0 to 0.15), for acetabular cup anteversion angle (MD = − 4.3, 95% CI − 5.2 to − 3.5), for acetabular cup inclination angle (MD = − 0.5, 95% CI − 2.1 to 1.1) and for postoperative complications (OR = 2.4, 95% CI 0.5 to 12.4). Considering the overall results of our meta-analysis, we can conclude that THA through DAA showed similar short-term surgical, functional, radiological outcomes and postoperative complications compared to THA through CAs

Appendiceal Mucocele Presenting as a Right Adnexal Mass: A Case Report

A 68-year-old female presented to the Gynecologic Oncology Clinic with a right-lower quadrant abdominal mass 3 × 4 cm in diameter palpable on pelvic examination. Her routine laboratory tests were normal. Transvaginal ultrasonography revealed a cystic mass in the right adnexa 3.9 cm in diameter, which was thought to arise in the ovary. At the time of laparoscopy, a 3 × 4 cm tumor arising from the distal end of the appendix was noted. A laparoscopic appendectomy with tumor removal was performed. Histologic examination of the surgical specimen revealed a mucocele of the appendix (AM). Although rare, this tumor should be considered in the differential diagnosis of a right adnexal mass. These tumors can be identified laparoscopically and removed by minimally invasive surgery

Efficacy dilution in randomized placebo-controlled vaginal microbicide trials

<p>Abstract</p> <p>Background</p> <p>To date different vaginal gel microbicides have been evaluated in phase 2b/3 trials, but none have demonstrated effectiveness for preventing HIV infection. Failure to demonstrate effectiveness however does not necessarily indicate that a product is truly inefficacious, as several sources of efficacy dilution may compromise our ability to identify products that may have been truly efficacious.</p> <p>Methods</p> <p>For four individual sources of dilution, we describe the dilution mechanisms and quantify the expected effectiveness. An overall expected effectiveness that combines all sources of dilution in a trial is derived as well.</p> <p>Results</p> <p>Under conditions that have been observed in recent microbicide trials, the overall expected effectiveness assuming an active gel with true efficacy of 50% and 75% are in the range of [16%; 33%] and [28%; 50%], respectively, when considering the four major sources of dilution. In contrast the diluting effect due to adherence alone (assuming an adherence of 80%) leads to higher expected effectiveness, 40% and 60% assuming an active gel with true efficacy of 50% and 75%, respectively. Individual sources of dilution may demonstrate a small effect when evaluated independently, but the overall dilution effect in a trial with several sources of dilution can be quite substantial.</p> <p>Conclusion</p> <p>Currently planned phase 2b/3 microbicide trials of new candidate vaginal microbicides are not immune from these shortcomings. A good understanding of dilution effects is necessary to properly interpret microbicide trial results and to identify products worthy of further development and evaluation. Greater attention should be devoted to reducing and assessing the impact of efficacy dilution and to carefully selecting the effect size in the design of future trials.</p

Population-Level Benefits from Providing Effective HIV Prevention Means to Pregnant Women in High Prevalence Settings

Background:HIV prevalence among pregnant women in Southern Africa is extremely high. Epidemiological studies suggest that pregnancy increases the risk of HIV sexual acquisition and that HIV infections acquired during pregnancy carry higher risk of mother-to-child transmission (MTCT). We analyze the potential benefits from extending the availability of effective microbicide to pregnant women (in addition to non-pregnant women) in a wide-scale intervention.Methods and Findings:A transmission dynamic model was designed to assess the impact of microbicide use in high HIV prevalence settings and to estimate proportions of new HIV infections, infections acquired during pregnancy, and MTCT prevented over 10 years. Our analysis suggests that consistent use of microbicide with 70% efficacy by 60% of non-pregnant women may prevent approximately 40% and 15% of new infections in women and men respectively over 10 years, assuming no additional increase in HIV risk to either partner during pregnancy (RRHIV/preg = 1). It may also prevent 8-15% MTCT depending on the increase in MTCT risk when HIV is acquired during pregnancy compared to before pregnancy (RRMTCT/preg). Extending the microbicides use during pregnancy may improve the effectiveness of the intervention by 10% (RRHIV/preg = 1) to 25% (RRHIV/preg = 2) and reduce the number of HIV infections acquired during pregnancy by 40% to 70% in different scenarios. It may add between 6% (RRHIV/preg = 1, RRMTCT/preg = 1) and 25% (RRHIV/preg = 2, RRMTCT/preg = 4) to the reduction in the residual MTCT.Conclusion:Providing safe and effective microbicide to pregnant women in the context of wide-scale interventions would be desirable as it would increase the effectiveness of the intervention and significantly reduce the number of HIV infections acquired during pregnancy. The projected benefits from covering pregnant women by the HIV prevention programs is more substantial in communities in which the sexual risk during pregnancy is elevated. © 2013 Dimitrov et al

The Potential Cost-Effectiveness of HIV Vaccines: A Systematic Review

OBJECTIVE: The aim of this paper was to review and compare HIV vaccine cost-effectiveness analyses and describe the effects of uncertainty in model, methodology, and parameterization. METHODS: We systematically searched MEDLINE (1985 through May 2016), EMBASE, the Tufts Cost-Effectiveness Analysis (CEA) Registry, and the reference lists of articles following Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligibility criteria included peer-reviewed manuscripts with economic models estimating the cost-effectiveness of preventive HIV vaccines. Two reviewers independently assessed study quality and extracted data on model assumptions, characteristics, input parameters, and outcomes. RESULTS: The search yielded 71 studies, 11 of which met the inclusion criteria. Populations included low-income (n = 7), middle-income (n = 4), and high-income countries (n = 2). Model structure varied, including decision tree (n = 1), Markov (n = 5), compartmental (n = 4), and microsimulation (n = 1). Most studies measured outcomes in quality-adjusted life-years (QALYs) gained (n = 6), whereas others used unadjusted (n = 3) or disability-adjusted life-years (n = 2). The range of HIV vaccine costs were $US1.54–75 in low-income countries,$US55–100 in middle-income countries, and $US500–1000 in the USA. Base-case incremental cost-effectiveness ratios (ICERs) ranged from dominant (cost offsetting) to$US91,000 per QALY gained. CONCLUSION: Most models predicted HIV vaccines would be cost-effective. Model assumptions about vaccine price, HIV treatment costs, epidemic context, and willingness to pay influenced results more consistently than did assumptions on HIV transmission dynamics. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s41669-016-0009-9) contains supplementary material, which is available to authorized users

SQUAMOUS CELL CARCINOMA OF THE SKIN: A STUDY OF CLINICOHISTOPATHOLOGICAL CORRELATIONS PREDICTIVE FOR RECURRENCE, METASTASIS AND MORTALITY

Introduction: The incidence of Squamous cell carcinoma of the skin (SCCs) increases annually, and this process will likely be continued because of sun exposure, outdoor activities and the aging population. Objectives: The aim of our study is to analyse clinicohistopathological features, recurrence, metastasis and mortality rates of SCCs in Pleven, Lovech region, Bulgaria. Methods: We investigated 355 patients with histologically confirmed SCCs for the period 2016 – 2022 and carried out a detailed histopathological analysis of 100 tumors. They were divided into two groups according to their macroscopic diameter: with low risk for recurrence and metastases (20mm). We studied the localisation, histological subtype, tumor cell differentiation, microscopic depth of invasion, perineural and lymphovascular invasion, stromal lymphocyte infiltration. Results: We revealed that 73,3% of the patients with SCCs reported severe sunburns, and 1,13% of them underwent immunosuppressive treatment. Head and Neck localisation is the most common – 72,7%. We established a mean histological depth of SCCs of 5,92mm, lymphovascular invasion in 7% and perineural invasion in 5% of the cases. We found that tumors with a macroscopic diameter >20mm have a greater depth of invasion in comparison to SCCs with a smaller diameter. We found an incidence of local recurrence of 4,8%, lymph node metastases at 5,1%, far metastases in internal organs at 2,25% and mortality at 1,97%. Conclusion: Clinicohistopathological features of SCCs with related to recurrence, metastasis and mortality are localisation on the scalp, ears or lips, tumor size >20mm, depth of invasion >6mm, poor tumor cell differentiation, perineural and lymphovascular invasion, low or absent stromal lymphocyte infiltration

The future role of rectal and vaginal microbicides to prevent HIV infection in heterosexual populations: implications for product development and prevention.

Objectives. To compare the potential impact of rectal (RMB), vaginal (VMB) and bi-compartment (RVMB) (applied vaginally and protective during vaginal and anal intercourse) microbicides to prevent HIV in various heterosexual populations. To understand when a RMB is as useful than a VMB for women practicing anal intercourse (AI). Methods. Mathematical model was used to assess the population-level impact (cumulative fraction of new HIV infections prevented (CFP)) of the three different microbicides in various intervention scenarios and prevalence settings. We derived the break-even RMB efficacy required to reduce a female’s cumulative risk of HIV infection by the same amount than a VMB. Results. Under optimistic coverage (fast roll-out, 100% uptake), a 50% efficacious VMB used in 75% of sex acts in population without AI may prevent -33% (27, 42%) new total (men and women combined) HIV infections over 25 years. The 25-year CFP reduces to -25% (20, 32%) and 17% (13, 23%) if uptake decreases to 75% and 50%, respectively. Similar loss of impact (by 25% - 50%) is observed if the same VMB is introduced in populations with 5% - 10% AI and for RRRAI=4-20. A RMB is as useful as a VMB (ie, break-even) in populations with 5% AI if RRRAI=20 and in populations with 15% - 20% AI if RRRAI=4, independently of adherence as long as it is the same with both products. The 10-year CFP with a RVMB is twofold larger than for a VMB or RMB when AI=10% and RRRAI=10. Conclusions. Even low AI frequency can compromise the impact of VMB interventions. RMB and RVMB will be important prevention tools for heterosexual populations