Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials

Objective To compare the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis. Design Meta-analysis of randomised controlled trials. Population Randomised controlled trials of adult patients presenting with uncomplicated acute appendicitis, diagnosed by haematological and radiological investigations. Interventions Antibiotic treatment versus appendicectomy. Outcome measures The primary outcome measure was complications. The secondary outcome measures were efficacy of treatment, length of stay, and incidence of complicated appendicitis and readmissions. Results Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63% (277/438) success rate at one year. Meta-analysis of complications showed a relative risk reduction of 31% for antibiotic treatment compared with appendicectomy (risk ratio (Mantel-Haenszel, fixed) 0.69 (95% confidence interval 0.54 to 0.89); I2=0%; P=0.004). A secondary analysis, excluding the study with crossover of patients between the two interventions after randomisation, showed a significant relative risk reduction of 39% for antibiotic therapy (risk ratio 0.61 (0.40 to 0.92); I2=0%; P=0.02). Of the 65 (20%) patients who had appendicectomy after readmission, nine had perforated appendicitis and four had gangrenous appendicitis. No significant differences were seen for treatment efficacy, length of stay, or risk of developing complicated appendicitis. Conclusion Antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis

Volcano collapse promoted by progressive strength reduction: new data from Mount St. Helens

Rock shear strength plays a fundamental role in volcano flank collapse, yet pertinent data from modern collapse surfaces are rare. Using samples collected from the inferred failure surface of the massive 1980 collapse of Mount St. Helens (MSH), we determined rock shear strength via laboratory tests designed to mimic conditions in the pre-collapse edifice. We observed that the 1980 failure shear surfaces formed primarily in pervasively shattered older dome rocks; failure was not localized in sloping volcanic strata or in weak, hydrothermally altered rocks. Our test results show that rock shear strength under large confining stresses is reduced ∼20% as a result of large quasi-static shear strain, as preceded the 1980 collapse of MSH. Using quasi-3D slope-stability modeling, we demonstrate that this mechanical weakening could have provoked edifice collapse, even in the absence of transiently elevated pore-fluid pressures or earthquake ground shaking. Progressive strength reduction could promote collapses at other volcanic edifices

Simulations of Arctic ozone depletion with current and doubled levels of CO2

Results from idealized 3-D simulations of a dynamical-radiative-photochemical model of the stratosphere are presented for the Northern Hemisphere winter and spring. For a simulation of a quiescent winter, it is found that with current levels of CO2 only modest polar ozone depletion occurs, consistent with observations. For a second simulation with the same planetary wave amplitudes in the upper troposphere but with doubled CO2, the model predicts a northern hemisphere ozone hole comparable to that observed in Antarctica with almost complete ozone destruction at 20 km. Reasons for the marked difference between the simulations are identified

The use of intraoperative nitrous oxide leads to postoperative increases in plasma homocysteine

Hyperhomocysteinemia is an independent risk factor for coronary artery and cerebrovascular disease, but its significance in the perioperative period is unknown. Nitrous oxide inhibits methionine synthase, which aids in the conversion of homocysteine to methionine. In this prospective, controlled, randomized study, we determined the effect of intraoperative nitrous oxide exposure on postoperative plasma homocysteine concentrations. Twenty ASA physical status I-III patients, aged \u3e18 yr, presenting for elective craniotomy, were randomized to receive general anesthesia with or without nitrous oxide (inspired nitrous oxide \u3e50%). Plasma was sampled before the induction of anesthesia, on arrival in the postanesthesia care unit (PACU) after discontinuation of nitrous oxide, and 24 h after induction. There was a significant increase (22.6 ± 11.4 vs 13.0 ± 4.7 μmol/L; P = 0.0038 for postoperative versus preinduction values) in plasma homocysteine concentrations in the nitrous oxide group on arrival in the PACU and for 24 h. In the nonnitrous oxide group, mean plasma homocysteine concentrations did not change (9.5 ± 1.9 vs 9.8 ± 1.6 μmol/L; P = 0.86 for postoperative versus preinduction values). The change in plasma homocysteine concentrations in the nitrous oxide group was significantly different from that in the nonnitrous group (P = 0.0031). We conclude that the use of intraoperative nitrous oxide leads to significant increases in perioperative plasma homocysteine concentrations. Implications: Short-term exposure to nitrous oxide led to significant increases in plasma homocysteine. Further investigations are required to determine the clinical significance of this change

Entwicklung, Analyse und Bewertung einer Methodik zur Bestimmung der Mikroplastik-Belastung von Küstensedimenten

Regelrechte Müllstrudel existieren in den Weltmeeren, mit Tonnen von überwiegend aus Kunststoff bestehenden Müllteilchen. Mit der Zeit werden die Kunststoffe dabei mechanisch und chemisch zerkleinert und schwimmen dann in Größenfraktionen des sog. Mikroplastiks (u.a. in Plankton-Größe) im Ozean. Die Meeresstrategie-Rahmenrichtlinie (MSRL) der EU gibt vor, dass auch derlei Müll im Meer und (angeschwemmt) an den Küsten quantitativ und qualitativ untersucht werden soll und macht ein Monitoring erforderlich. Derzeit fehlen jedoch einheitliche und gut durchführbare Separations-Methoden. Die vorliegende Arbeit stellt einen Ansatz samt Erprobung des Verfahrens vor. Mithilfe eines Absinkzylinders wurden aus realen Sandproben (Flutmarke, letztes Hochwasser) die mengenmäßige Anteile Kunststoffpartikel (g/kg Trockenmasse) bestimmt

A cruise ship emergency medical evacuation triggered by handheld ultrasound findings and directed by tele-ultrasound

Cruise ships travel far from shoreside medical care and present a unique austere medical environment. For the cruise ship physician, decisions regarding emergency medical evacuation can be challenging. In the event that a passenger or crew member becomes seriously ill or is injured, the use of point-of-care ultrasound may assist in clarifying the diagnosis and stratifying the risk of a delayed care, and at times expedite an emergent medical evacuation. In this report we present the first case reported in the literaturę of an emergency medical evacuation from a cruise ship triggered by handheld ultrasound. A point-of-care ultrasound performed by a trained cruise ship physician, reviewed by a remote telemedical consultant with experience in point-of-care ultrasound, identified an ectopic pregnancy with intraabdominal free fluid in a young female patient with abdominal pain and expedited emergent helicopter evacuation from a cruise ship to a shoreside facility, where she immediately underwent successful surgery. The case highlights a medical evacuation that was accurately triggered by utilising a handheld ultrasound and successfully directed via a tele-ultrasound consultation. American College of Emergency Physicians (ACEP) health care guidelines for cruise ship medical facilities should be updated to include guidelines for point-of-care ultrasound, including training and telemedical support

Telepsychiatric assessment of a mariner expressing suicidal ideation

This case report highlights the successful use of telepsychiatric consultation by secure video chat to remotely assess a mariner expressing suicidal ideation. As a result of this intervention, telemedicine providers initiated psychiatric stabilisation while the mariner was still aboard the vessel, determined that he was safe for repatriation under the care of qualified medical escorts, and facilitated admission to a psychiatric facility near his home in the United States. Mental health emergencies are a significant cause of morbidity and mortality among mariners. Telepsychiatry is a validated method of establishing a psychiatric diagnosis and disposition as well as assessing risk of suicidality and the potential for violent decompensation. It has the potential to be a valuable adjunct to any traditional maritime telemedicine service

Telepsychiatric assessment of a mariner expressing suicidal ideation.

This case report highlights the successful use of telepsychiatric consultation by secure video chat to remotely assess a mariner expressing suicidal ideation. As a result of this intervention, telemedicine providers initiated psychiatric stabilisation while the mariner was still aboard the vessel, determined that he was safe for repatriation under the care of qualified medical escorts, and facilitated admission to a psychiatric facility near his home in the United States. Mental health emergencies are a significant cause of morbidity and mortality among mariners. Telepsychiatry is a validated method of establishing a psychiatric diagnosis and disposition as well as assessing risk of suicidality and the potential for violent decompensation. It has the potential to be a valuable adjunct to any traditional maritime telemedicine service