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Background Individuals who participate in outdoor sports are subject to an increased risk of developing skin cancer. To date, there has been no review examining skin cancer and sun protective behaviours specific to outdoor, water based sports. Therefore, this scoping reviews objectives were to (1) summarise volume and type of scientific literature available relating to skin cancer, (2) examine current sun protective behaviours and (3) identify knowledge gaps to inform future research. Method A scoping review was conducted to address the objectives following the PRISMA guidelines. Seven databases were searched; identified studies were screened based on title, abstract and full-text for outdoor water based sports which examined skin cancer and/or sun protective behaviours. Data was extracted, synthesised and critically appraised using a modified AXIS tool. Percentage frequencies were calculated, and key results were placed in tabular or graphical presentation. Results Nine cross sectional studies were identified, all defined as low level evidence. A combined sample of 4,377 participants across six countries and five water based sports showed BCC (71%) was the most common skin cancer, followed by melanoma (18%) and SCC (10%). The head (41%) and upper-limbs (27%) were the most common location. Conclusion This review highlights the minimal research available and demonstrates those in water based sports are at high risk of developing skin cancer. Due to difficulty adhering to sun protective behaviours, the most prevalent location is the upper body. Included studies were of low level evidence, providing opportunity for future research to expand upon the gaps in the current literature.

Pulmonary embolism (PE) is a common emergency presenting among high risk patients. It is important to have a structured approach to clinical assessment, diagnosis and management of this potentially life-threatening emergency. Clinical and management pathways have improved over the last 10 years as clear guidelines have emerged. Newer diagnostic modalities have become available and will hopefully improve the pick-up rate of PE and reduce the morbidity and mortality. High level evidence presented by the American Society of Haematology and the European Society of Cardiology forms the basis for this review.

The objective of this study is to summarize literature from the past 10 years on pediatric stone management with a focus on evidence generated from meta-analysis, systematic reviews, and randomized controlled trials (RCTs). Systematic literature search was performed on May 26, 2020. The search was on publications from the past 10 years and limited to meta-analysis, systematic reviews, and relevant RCTs on pediatric urolithiasis. Summary of literature was clustered to stone etiology, diagnostics, medical management, and surgical management. Summary of evidence was extracted with GRADE criteria used to standardize the level and quality of evidence reported. A total of 32 articles (19 systematic reviews with meta-analysis, 4 systematic reviews, and 9 relevant RCTs) were included. We summarized the genetic association with pediatric stone formation, diagnostics, medical management such as dissolution and medical expulsion therapy, procedural efficacy, as well as safety for extracorporeal lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy. We also evaluated each article’s approach to the comparison of outcome measures. Most of the available evidence was determined to be “very low” to “low” quality. Heterogeneity and low precision of the included studies led to downgrading using GRADE criteria. Relevant RCTs qualified as “high” to “uncertain” risk of bias in several domains of the study implementation and analysis. In the past decade, several systematic reviews, meta-analysis, and relevant RCTs that were mostly “very low” to “low” quality of evidence are available, and no definitive recommendations can be given to guide a pediatric urologist. We strongly recommend an individualized approach in the management of pediatric urolithiasis.

This study investigates the existence of convergence in public-expenditures and its nine different sub-categories to reveal regional disparities in Turkey. To this end, we employ a club convergence analysis proposed by Phillips and Sul (in Econometrica 75(6):1771–1855, 2007) for 81 provinces of Turkey over the period between 2004 and 2018. The findings show that (i) except for social and environmental protection expenditures, total public expenditures and its seven sub-categories have multiple equilibria; (ii) there are major disparities across regions, especially between the eastern and western regions; (iii) spendings on education, health, and economic affairs expenditures might pose serious challenges for long-term development; (iv) expenditures on defense and economic affairs are the most important components of multiple equilibria found in total public expenditures. The existence of club convergence and the distribution of provinces across clubs propose some important policies which might help policymakers to reduce regional disparities amongst provinces.

Introduction: Physical therapists are required to perform tasks that predispose them to developing work related musculoskeletal disorders. The physical therapists personal and professional life can be affected by work related musculoskeletal disorders. High level evidence is lacking regarding work related musculoskeletal disorders. The purpose of this study was to combine information on prevalence, risk factors and the consequences of work-related musculoskeletal disorders in physical therapists. Material & Methods: A systematic review was conducted according to PRISMA guidelines.Three members independently searched the databases PubMed and other online sources including google scholar for relevant data from July 2014 to September 2020. Cross-sectional studies published in English language which reported work related musculoskeletal disorders in physical therapists were included. Studies involving physical therapy students and internees, having insufficient information about past or current work-related musculoskeletal disorders, sample size of physical therapists less than 50 and not published in peer reviewed journals were excluded. Results: Twenty one articles were included in current systematic review. The 1-year prevalence of workrelated musculoskeletal disorders among physical therapists ranged from 38.5% to 97.6%. The low back was the commonest affected body part. Treating large number of patients and manual therapy were the leading risk factors for developing work related musculoskeletal disorders. The most common consequences were modifying treatment techniques and reducing work hours. Conclusion: Prevalence of work related musculoskeletal disorders are high among physical therapists. The nature of physical therapy job presents significant risk factors which can lead to work related musculoskeletal disorders.

PURPOSE: The life expectancy for people with spina bifida has increased, thus resulting in greater need for guidelines in urologic care in order to protect normal renal function, to develop strategies for urinary continence, and to advance independence through adult years. METHODS: The English literature was assessed from 2002–2015; greater than 300 publications identified. Case reports and opinion pieces were eliminated leaving 100 for in depth review. Clinical questions were then established for each age group that allowed for focused assessment. RESULTS: There was no Level 1 evidence for any of the defined clinical questions. This resulted in group consensus for all questions throughout all age groups. Guidelines were provided for identifying a symptomatic urinary infection, the role of urodynamic bladder testing and identification of bladder hostility, determining methods of renal function assessment and surveillance, the initiation of continence control, and transitioning to self-care through the teen and adult years. CONCLUSION: Urologic guidelines continue to be based on clinical consensus due to the lack of high level evidence-based research. Further research is required in all aspects of urologic management. While not the “Standard of Care,” these guidelines should be considered “Best Practice”.

OBJECTIVES: To determine the: 1) quality of articles cited in systematic reviews (SRs); 2) methodological quality of the SRs; and 3) impact of quality on level 1A evidence. METHODS: SRs related to musculoskeletal physical therapy interventions were identified. The methodological quality of the SRs and articles cited by the SRs were assessed by two blinded reviewers. Data analysis was performed by a third blinded researcher. Additional comparisons were made based on the Journal Impact Factor, spin, financial bias, and conflict of interest. RESULTS: Twenty-four SRs were identified; 21/24 SRs had ‘critically low’ quality on the AMSTAR 2. Thirty-four percent of included studies were ‘low quality,’ and 58% of SRs included studies that had unreported external validity. One-half of the SRs represented ‘spin,’ and one-third of the SRs generated conclusions based on low-quality clinical trials. DISCUSSION: The ‘critically low’ SRs methodological quality was exacerbated by low-quality research inclusion. Most SRs failed to follow best practices, including prospective registration and integration of professional librarians in the search process. Based on the high proportion of SRs that include low-quality trials and overall low methodological quality, further discussion regarding practice recommendations on level vs. quality of evidence is warranted. LEVEL OF EVIDENCE: 1a

Radical nephroureterectomy is the mainstay of surgical treatment for upper tract urothelial carcinoma (UTUC), a disease which comprises approximately 5% of urothelial malignancies. Minimally-invasive and nephron-sparing interventions have been explored, although thus far have not shown comparable oncologic outcomes except in a relatively narrow set of patients. Due to the relative rarity of the disease, it has taken decades and multi-disciplinary efforts to sufficiently identify prognostic factors of oncologic outcomes. Despite these efforts, however, oncologic outcomes of nephroureterectomy have remained remarkably stable over the past 30 years. New techniques, such as laparoscopic and robotic surgery, have been applied to this procedure. High level evidence regarding equivalent oncologic outcomes is lacking and open surgery remains the standard of care for high-stage disease, although there is a role for laparoscopic and robotic nephroureterectomy. The importance of bladder cuff removal in improving oncologic outcomes has been broadly accepted, although there is no consensus as to the most oncologically appropriate technique. There does appear to be evidence that endoscopic techniques confer worse oncologic control. The role of lymphadenectomy remains controversial, although there is evidence that increased nodal yield could have oncologic benefit. Given disease heterogeneity and varied technical approaches to the procedure, no consensus standardized template has been identified. There is level 1 evidence for the use of intravesical chemotherapy peri-operatively and that this intervention can improve the risk of intravesical recurrence. Advances in systemic neoadjuvant and adjuvant chemotherapy have yielded promising results and are likely to become standard of care for patients without contraindications. Immunotherapy and targeted biologic agents are also likely to improve the surgical efficacy of radical nephroureterectomy as well. Ultimately, more high level evidence is needed to identify successful surgical and medical approaches to UTUC and multi-institutional collaboration is critical to this progress.

Microglia and non-parenchymal macrophages are increasingly recognized to play critical roles in the central nervous system (CNS) health and disease. Accumulating evidence suggests that these mononuclear phagocytes do not constitute stereotypical cell populations, but rather polarize into a variety of phenotypes at different stages of CNS development, stresses, and diseases. This commentary aims to discuss our current consensus and controversy on microglia/macrophage phenotypes. Collective single-cell level evidence validates the concept of microglia/macrophage polarization, while suggests multi-polarity instead of dichotomic polarization. Characterizing the functions of a specific microglia/macrophage phenotype is challenging yet essential to translate our scientific discoveries into clinical application.

The foot is commonly affected in systemic diseases such as rheumatoid arthritis and diabetes mellitus. Treating patients who suffer with foot pathology secondary to systemic diseases requires a multidisciplinary approach, following the principles outlined within this review. There is little high level evidence in this field, such as prospective controlled clinical trials, hence much of what we know and practise is based upon the expert opinion of key individuals in specialist centres, to whom we owe a great debt.

Chinese gastrointestinal surgeons are building up our own high level evidence in evidence-based medicine, With tremendous clinical trials carrying out in gastrointestinal cancers. Besides, Standardized procedure of diagnosis and treatment should be promoted. More personalized schemes are needed. The model of multidisciplinary team can be more widely and deeply applied. In order to further optimize the surgical pathways and promote the clinical application of ERAS in surgery, it is important to raise awareness of the ERAS concept, advocate multi-disciplinary cooperation model, including surgery, anesthesiology, nursing, clinical nutrition, etc. to improve the application of ERAS in gastrointestinal surgery, promote medical and health management performance. And the concept of enhanced recovery after surgery should be more operable. To keep pace with the times, the gastrointestinal surgeons have to seek for innovative technology and new ideas.Read Complete Article at ijSciences: V82019011920 AND DOI: http://dx.doi.org/10.18483/ijSci.1920

The management of symptomatic osteochondral lesions of the talus (OLTs) can be challenging. The number of ways of treating these lesions has increased considerably during the last decade, with published studies often providing conflicting, low-level evidence. This paper aims to present an up-to-date concise overview of the best evidence for the surgical treatment of OLTs. Management options are reviewed based on the size of the lesion and include bone marrow stimulation, bone grafting options, drilling techniques, biological preparations, and resurfacing. Although many of these techniques have shown promising results, there remains little high level evidence, and further large scale prospective studies and systematic reviews will be required to identify the optimal form of treatment for these lesions. Cite this article: Bone Joint J 2021;103-B(2):207–212.

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Highlights • Awake prone positioning is a promising intervention to improve patient's oxygenation and likely to reduce the need for intubation. Despite reports of its use during the COVID-19 pandemic, controlled evidence is lacking. • A meta-trial, with harmonized inclusion and outcome criteria and a global interim analysis plan, may enable to get a high level of evidence within the short period of time required by the pandemic, through performing a prospective meta-analysis of the generated data across countries. • Clinicians and researchers around the world are invited to join the “Meta-trial of awake prone positioning with nasal high flow therapy” project by contacting the core investigator group: Awake.Prone.Meta.Trial@gmail.com

Introduction Management of spontaneous intracerebral hemorrhage (ICH) remains controversial despite efforts to produce high level evidence in the past few years. We systematically examined the pooled literature data on the natural history and surgical management of ICH. Evidence acquisition A systematic review was performed using the PubMed and Embase databases, encompassing English, full-text articles, reporting treatment outcomes for the conservative and surgical management of ICH. Evidence synthesis A total of 91 studies met the eligibility criteria (total of 16,411 ICH cases). The most common locations for an ICH were the basal ganglia for both the conservative (68.7%) and surgical cohorts (58.4%). Patients in the non-operative group (40.5%) were older (mean age 62.9 years; range 12.0-94.0), had a higher Glasgow Coma Scale (GCS) score at presentation (mean GCS 10.2; range 3-15) and lower ICH volume (mean 36.9 mL). When managed non-operatively, a favorable functional outcome was encountered in 25.7% (95% CI 16.9-34.5) of patients, with a 22.2% (95% CI 16.6-27.8) mortality rate. Patients who underwent surgery (59.5%) were younger (mean age 58.8 years; range 12.0-94.0), had a lower GCS at presentation (mean GCS 8.2; range 3-15) and larger ICH volume (mean 58.3 mL; range 8.2-140.0). Craniotomy with hematoma evacuation was the preferred surgical technique (38.6%). A favorable functional outcome was encountered in 29.8% (95% CI 23.8-35.8) of operated patients, with a 21.3% (95% CI 16.3-26.3) mortality rate. Conclusions For many ICH cases, the reviewed literature allows to define surgical and conservative candidates. However, there are still some ICH-cases where management remains controversial.

Objective: To describe a low-cost, accessible, reproducible ankle arthroscopy simulator model which, after validation, will allow the development and improvement of technical skills required in arthroscopic surgical practice. Methods: This study describes the production of an ankle arthroscopy model that simulates camera, arthroscope, and ankle joint. Results: The simulator works properly when connected to a monitor, television, computer, or cell phone. Conclusion: A reproducible, accessible, low-cost ankle arthroscopy simulator can be developed using components available from local and online stores, with an approximate cost of R$232.00. Level Evidence V; Economic and Decision Analyses – Development of an Economic or Decision Model; Expert Opinion.

National Comprehensive Cancer Network (NCCN) guidelines are the most comprehensive and widely used standard for clinical care, financial reimbursements and quality improvement initiatives in oncology. We studied the distribution of categories of evidence and consensus (EC) in the guidelines for the common cancers in the United States. We evaluated the EC categories in staging, therapy and surveillance recommendations in 2019 guidelines and compared them with the same in 2010. The latest 2019 version of NCCN guidelines were obtained. The definitions for various categories of EC used were, Category 1 (high level evidence, uniform consensus), Category 2A (lower level of evidence [LOE], uniform consensus), Category 2B (lower LOE, no uniform consensus but with no major disagreement) and Category 3 (any LOE, major disagreement). We compared our results with previously published results from 2010 guidelines. Total number of recommendations increased by 77% from 1023 (2010) to 1818 (2019). Of the 1818 recommendations, Category 1, 2A, 2B and 3 EC were 7%, 87%, 6% and 0%, respectively, while in 2010 they were 6%, 83%, 10% and 1%. Breast (30%), lung (10%) and kidney (10%) cancer had the highest proportions of Category 1 therapeutic recommendations in their respective guidelines. No Category 1 recommendations were found in screening or surveillance guidelines or in pancreatic and uterine cancer guidelines. Recommendations in 2019 NCCN guidelines are largely Category 2A (lower levels of evidence, uniform expert opinion), unchanged from the previous study in 2010.

With the health care environment becoming increasingly patient centric and cost-conscious, interest levels in spinal endoscopy are at an all-time high. Patient demand for the least invasive procedures combined with surgeon desire to maximally shorten the postoperative recovery period has further driven this surgical evolution. Mounting scientific evidence demonstrates the noninferiority and perhaps even superiority of endoscopic techniques to more conventional spinal surgery for the treatment of spinal stenosis and disc herniations. Although higher level evidence is much needed to support the clinical utility of the latest endoscopic techniques and surgical indications, it appears that the entrance of spinal endoscopy into the mainstream arena of spinal surgery is inevitable.

To the Editor, Since its original description in 2016,1 the ultrasound-guided erector spinae plane (ESP) block, a regional anaesthesia technique, has become increasingly popular and the potential clinical applications have been increasing.2 A popular indication is analgesia for rib fracture management. Although randomised controlled trial (RCT) -level evidence for the ESP block is lacking in rib fractures, a recent retrospective cohort study3 has shown increased incentive spirometry values and reduced pain scores in the first 24 hours after implementation of the ESP block compared with before block administration. Alternative techniques, such as thoracic epidurals and paravertebral blockade, have greater potential for complications and steeper learning curves. The serratus anterior plane block’s efficacy has been questioned in patients with posterior rib fractures, with potential technical challenges if surgical emphysema or chest drains are present.3 This makes the ESP block an attractive proposition in management of these challenging patients. At our institution, a survey of senior anaesthetic trainees highlighted the need for training in ESP blockade as a tool in their armamentarium for rib fracture analgesia when a thoracic epidural was not feasible or practical. …

Contains fulltext : 222298.pdf (Publisher’s version ) (Open Access) This paper is a commentary on: McInerney, M. S., Reddihough, D. S., Carding, P. N., Swanton, R., Walton, C. M., Imms, C. (2019). Behavioral interventions to treat drooling in children with neurodisability: A systematic review. Developmental Medicine & Child Neurology, 61, 39-48. doi: 10.1111/dmcn.14048 7 p.

While video-assisted thoracoscopic surgery (VATS) has gained acceptance as the recommended approach in the surgical management of resectable early stage non-small cell lung cancer (NSCLC), newer minimally invasive techniques continue to evolve and show promise as viable alternatives. The increasingly popular robotic platform, praised for its improved dexterity and visualization, has advanced the ongoing debate regarding superiority among the minimally invasive approaches. A review of the best available literature comparing robotic and thoracoscopic lung resection in the treatment of early stage lung cancer was thus performed to determine the optimal approach. Although high level evidence remains limited to date, the results of the reviewed studies suggest that patients with early stage non-small cell lung cancer can safely undergo either robotic or VATS lung resection with no compromise in morbidity, oncologic effectiveness, or survival. Robotic lobectomy was shown to have an increased cost; however, this variable may be reduced with increased technical proficiency and decreased operative times. Therefore, apart from the cost discrepancy favoring a VATS approach, the two minimally invasive techniques should be considered equivalent in regard to patient outcomes.

Objective This study aimed to describe the conceptualization, development, and implementation processes of the newly established Korean Cardiac Arrest Resuscitation Consortium (KoCARC) to improve out-of-hospital cardiac arrest (OHCA) outcomes. Methods The KoCARC was established in 2014 by recruiting hospitals willing to participate voluntarily. To enhance professionalism in research, seven research committees, the Epidemiology and Preventive Research Committee, Community Resuscitation Research Committee, Emergency Medical System Resuscitation Research Committee, Hospital Resuscitation Research Committee, Hypothermia and Postresuscitation Care Research Committee, Cardiac Care Resuscitation Committee, and Pediatric Resuscitation Research Committee, were organized under a steering committee. The KoCARC registry was developed with variables incorporated in the currently existing regional OHCA registries and Utstein templates and were collected via a web-based electronic database system. The KoCARC study population comprises patients visiting the participating hospitals who had been treated by the emergency medical system for OHCA presumed to have a cardiac etiology. Results A total of 62 hospitals volunteered to participate in the KoCARC, which captures 33.0% of the study population in Korea. Web-based data collection started in October 2015, and to date (December 2016), there were 3,187 cases compiled in the registry collected from 32 hospitals. Conclusion The KoCARC is a self-funded, voluntary, hospital-based collaborative research network providing high level evidence in the field of OHCA and resuscitation. This paper will serve as a reference for subsequent KoCARC manuscripts and for data elements collected in the study.

Oropharyngeal cancer (OPC) has traditionally been managed by radiotherapy (RT)-based approaches. Minimally invasive surgery [transoral robotic surgery (TORS)/transoral laser microsurgery (TLMS)] is gaining popularity in T1-T2 HPV+ OPC. However, there is lack of high level evidence to guide practice. We summarize ongoing research regarding outcomes and investigational strategies for TORS/TLM- and RT-based treatments for this disease. Literature published in 2012–2017 demonstrated comparable exemplary outcomes with TORS/TLM and IMRT for selected HPV+ T1-T2 OPC. However, many TORS/TLM-treated patients also require adjuvant treatment, which impacts quality of life. Emerging RT-based de-intensification trial data suggest promising results. Ongoing investigation include indications for postoperative (chemo-)radiotherapy following TORS/TLM- and optimal RT-based de-intensification strategies. A contemporary literature review demonstrates equal efficacy for TORS/TLM and IMRT as primary treatment for selected HPV+ T1-T2 OPC. TORS/TLM is an attractive approach when the opportunity for single modality treatment is high.

Vesico-vaginal fistula is a global healthcare problem that has a high prevalence in sub-Saharan Africa, where obstetric complications lead to the development of this condition. Despite this, comparatively few fistula repairs are performed in well-resourced countries, where iatrogenic injury is the leading aetiological factor. As a consequence, much of our knowledge results from the experience of relatively few fistula surgeons in areas of high prevalence borne out of large case series or retrospective cohorts rather than high level evidence. At present, debate surrounds the exact timing of repair and the most appropriate surgical approach for this condition. Certain fistulae can be selected for conservative management, while those that do not demonstrate factors associated with spontaneous closure can be selected for surgery. Fistula surgeons should be aware of several potential repair options and the principles of contemporary fistula surgery, as the first attempt at repair is likely to be the best opportunity to achieve a successful outcome. We review the available literature and provide evidence on the optimal timing of repair, the appropriate surgical approach and the use of tissue interpositioning in fistula surgery. Keywords: Martius flap, Reconstructive urology, Urogenital fistula, Vesico-vaginal fistula

Eustachian tube dysfuntion intends to describe a variety of signs, symptoms, and physical findings that result from the impairment of ET function. A large variety of methods have been employed to assess ET function in the literature. Due to the lack of high level evidence, it is difficult to draw conclusions on the effectiveness of medical and surgical treatments. There are various medical and surgical interventions available for chronic obstructive ET dysfunction including balloon Eustachian tuboplasty (BET) and laser or microdebrider tuboplasty. Consensus on diagnostic criteria for ETD is required to define inclusion criteria of future trials. There is however emerging work with reassuring, but preliminary, results that suggest evidence for safety in the surgical management of ETD. Like many newly introduced techniques the current data remains limited to non-controlled case-series, with heterogeneous data collection methods and lacking substantial long-term outcomes. Nevertheless, short-term data provide favorable results. Current treatment options comprising BET and patulous ET surgery may be offered as a treatment possibility to selected patients.

Clinical practice involves making many treatment decisions for which only limited formal evidence exists. While the methodology of evidence-based medicine (EBM) has evolved tremendously, there is a need to better characterize lower-level evidence. This should enhance the ability to appropriately weigh the evidence against other considerations, and counter the temptation to think it is more robust than it actually is. A framework to categorize lower-level evidence is proposed, consisting of nonrandomized comparisons, extrapolation using indirect evidence, rationale, and clinical experience (ie, an accumulated general impression). Subtypes are recognized within these categories, based on the degree of confounding in nonrandomized comparisons, the uncertainty involved in extrapolation from indirect evidence, and the plausibility of a rationale. Categorizing the available evidence in this way can promote a better understanding of the strengths and limitations of using such evidence as the basis for treatment decisions in clinically relevant areas that are devoid of higher-level evidence.

Background: The management of rectal cancer has evolved over the years, including the recent rise of Transanal Total Mesorectal Excision (TaTME). TaTME addresses the limitations created by the bony confines of the pelvis, bulky tumours, and fatty mesorectum, particularly for low rectal cancers. However, guidance is required to ensure safe implementation and to avoid the pitfalls and potential major morbidity encountered by the early adopters of TaTME. We report a broad international consensus statement, which provides a basis for optimal clinical practice. Methods: Forty international experts were invited to participate based on clinical and academic achievements. The consensus statements were developed using Delphi methodology incorporating three successive rounds. Consensus was defined as agreement by 80% or more of the experts. Results: A total of 37 colorectal surgeons from 20 countries and 5 continents (Europe, Asia, North and South America, Australasia) contributed to the consensus. Participation to the iterative Delphi rounds was 100%. An expert radiologist, pathologist, and medical oncologist provided recommendations to maximize relevance to current practice. Consensus was obtained on all seven different chapters: patient selection and surgical indication, perioperative management, patient positioning and operating room set up, surgical technique, devices and instruments, pelvic anatomy, TaTME training, and outcomes analysis. Conclusions: This multidisciplinary consensus statement achieved more than 80% approval and can thus be graded as strong recommendation, yet acknowledging the current lack of high level evidence. It provides the best possible guidance for safe implementation and practice of Transanal Total Mesorectal Excision.

Cholangiocarcinoma, malignant tumor of epithelial cells of bile ducts has poor overall survival and prognosis. We report a case of non-resectable cholangiocarcinoma with a 57-month survival after incomplete R2 surgical margin resection of the tumor. A 52-year old man with generalized itching, jaundice, brownish urine, mild abdominal pain and weight loss of 8 kg in last two months presented. Imaging and surgical workups showed hilar cholangiocarcinoma (Klatskin tumor). Along with incomplete R2 margin resection we performed stent embedding and post-operative adjuvant chemotherapy. Based on current literature data there is no superiority of adjuvant chemotherapy after complete R0 resection compared to incomplete R2 resection. However, it seems that partial resection along with stent embedding and applied adjuvant chemotherapy in cases of locally advanced non-resectable cholangiocarcinoma may increase survival rate.

Although guidelines for the performance of an emergency department thoracotomy (EDT) are available, high level evidence remains scarce potentially leading to variation in decisions and practices among trauma surgeons. The National Trauma Databank was queried for all subjects who died in the emergency department (ED) between 2007 and 2011. Trauma centers were divided into four quartiles based on the rate of EDTamong ED deaths. A total of 31,623 subjects admitted to 729 trauma centers met inclusion criteria. Most of of these centers (n = 328, 53%) never performed an EDT during the study period. Very few outlier centers (1.1%) performed this procedure in 50.0 per cent or more of all patients who died in the ED. Trauma centers in the highest quartiles in performing EDT were more likely to intervene with both surgical and nonsurgical procedures in patients who died in the ED, independent of the performance of an EDT. There are significant variations among trauma centers in the management of trauma patients who expire in the ED. Further research at a national level toward standardizing the management of the trauma patient in extremis and the decision to perform an EDT is necessary, given the extremely low survival associated with this procedure.

This narrative review examines the changes required in dietary behaviours to address the current global burden of disease resulting from diet-associated cardiometabolic dysfunction. Beginning with known relationships between nutritional factors and health outcomes, the review identifies a number of problems with current dietary behaviours, using examples from the Australian context. Implications for practice are then discussed drawing on insights from research in dietary trials. From a concerted research effort across the globe, the effects of foods, food components and dietary patterns on cardiometabolic parameters have been reasonably well exposed. The evidence base for these effects underpins dietary guidelines, which aim to meet nutritional requirements and protect against cardiometabolic disease. Thus foods recommended in dietary guidelines tend to be consistent with research that identifies foods that appear protective and those that appear detrimental to health. The need for dietary behaviour change is apparent through analyses that have exposed increasing consumption of detrimental foods, despite the availability of healthy foods. However, behaviour change is a complex area, and where weight loss is also required, there is high level evidence that interdisciplinary efforts combining diet, physical activity and psychological support are warranted. Insights from dietary trials and research indicate that focussing on foods and dietary patterns is integral to the specific dietary change required for health outcomes, but social and behavioural factors will influence the achievement of these changes. Keywords: Diet, Nutritional quality, Lifestyle-related disease

Vestibular disorders result in symptoms that significantly impact an individual’s quality of life. Vestibular rehabilitation therapy (VRT) has, for many years, been used as an effective means of treating patients and their vestibular-related symptoms. For clinicians, it is crucial to stay up to date with the current best evidence in VRT in order to optimize patient management. Current evidence is in support of VRT for treating patients with a variety of vestibular disorders, both central and peripheral. High level evidence studies support the use of treatment techniques of adaptation and substitution for gaze stabilization, habituation, balance and gait training, and canalith repositioning maneuvers. Recent evidence has also examined and found promising results with technological innovations that are targeted at those with bilateral vestibular hypofunction and insufficient gains with a standard exercise-based program. Nevertheless, factors such as anxiety overlay/depression, time when beginning therapy, and adherence may have an impact on how a patient will do with his/her VRT program and should be acknowledged. Quantifiable and evidence-based literature supports the use of VRT for patients with a variety of vestibular disorders and their associated symptoms. The clinician needs to become familiar with each patient’s complaints and goals, as well as any potential barriers to positive outcomes with VRT, and combine this with their knowledge of current evidence-based literature in order to develop the optimal program for each unique patient.

Cytoreduction and heated intraperitoneal chemotherapy (CS/HIPEC) is increasingly utilized as a treatment strategy for patients with peritoneal metastases from various primary tumor sites. For this heterogenous procedure, related to patient characteristics, patient selection, and the extent of surgical completeness of cytoreduction, high level evidence (ex: multiple randomized controlled trials) is not available to support efficacy. This review of the available literature supporting application of the procedure, focusing on colorectal cancer, provides a summary of current evidence for patient selection and treatment algorithms based on patient presentation.

C. difficile infections (CDI) have been a challenging disease to treat, much less to prevent, for decades. Efforts for primary prevention have mainly focused on improving infection control practices, but CDI outbreaks continue to plague healthcare facilities. Areas covered: A literature search from 1970-December 2016 found 13 facility-level and 2 patient-level strategies that were evidence-based. The aim of this manuscript is to assess the current state of the literature on primary prevention of CDI and offer insights into which strategies may be more effective. Expert commentary: The strongest evidence for primary prevention is based on multi-faceted infection control bundles, while there is promising moderate evidence involving facility-wide use of specific probiotics. Moderate-level evidence was found for patient-level use of specific probiotics and low level evidence for vaccines. Future suggestions include use of consistent outcome metrics, measurements of implementation compliance and program sustainability.

BackgroundGUIDE-IT, the largest trial to date, published in August 2017, evaluating the effectiveness of natriuretic peptide (NP)-guided treatment of heart failure (HF), was stopped early for futility on a composite outcome. However, the reported effect sizes on individual outcomes of all-cause mortality and HF admissions are potentially clinically relevant.ObjectiveThis systematic review and meta-analysis aims to combine all available trial level evidence to determine if NP-guided treatment of HF reduces all-cause mortality and HF admissions in patients with HF.Study selectionEight databases, no language restrictions, up to November 2017 were searched for all randomised controlled trials comparing NP-guided treatment versus clinical assessment alone in adult patients with HF. No language restrictions were applied. Publications were independently double screened and extracted. Fixed-effect meta-analyses were conducted.Findings89 papers were included, reporting 19 trials (4554 participants), average ages 62–80 years. Pooled risk ratio estimates for all-cause mortality (16 trials, 4063 participants) were 0.87, 95% CI 0.77 to 0.99 and 0.80, 95% CI 0.72 to 0.89 for HF admissions (11 trials, 2822 participants). Sensitivity analyses, restricted to low risk of bias, produced similar estimates, but were no longer statistically significant.ConclusionsConsidering all the evidence to date, the pooled effects suggest that NP-guided treatment is beneficial in reducing HF admissions and all-cause mortality. However, there is still insufficient high-quality evidence to make definitive recommendations on the use of NP-guided treatment in clinical practice.Trial registration numberSystematic Review Cochrane Database Number: CD008966.

Background: Terrorism is increasingly the aetiology of mass casualty incidents. Improved prehospital response capability targeted to the unique characteristics of high threat incidents is an area of urgent focus. Gaps in current knowledge coupled with inconsistent reporting and difficulties in accessing data create difficult conditions for capability enhancement. Methods: A systematic literature review was conducted to describe the characteristics of prehospital response to terrorism from 2011 -2017. Papers were included if they described a prehospital response to a terrorist incident, were in English or translatable to English and full text was available. Results: 6115 records were located in the initial search of grey and published literature, with 71 retrieved for full text after screening of title and abstract. 23 papers were included in the final analysis, describing 6 separate terrorist attacks. The majority of literature was published by physicians, all were from Western countries with advanced Emergency Medical Services(EMS) and a standard reporting template was not identified. The level of evidence was low to very low. Themes of tactical triage, coordinated activation and response, use of damage control resuscitation and tactical casualty care were common throughout the papers. Conclusions: The paucity of high level evidence and systematic reporting of lessons learned in the prehospital terrorism response field requires a renewed push for access to data and the establishment of reporting systems that are inclusive of all responders. Keywords: Terrorism, Pre-hospital, Response, Tactical Emergency Casualty Care, Tactical Combat Casualty Care

Trauma to the labia occurs in up to 49% of vaginal births1. Trauma to the perineal body resulting from childbirth is well defined using widely used categories, and recommended management of perineal body trauma is based on high level evidence. Currently no similar evidence exists to inform the classification or management of labial trauma. This is reflected in variation in clinical practice with some practitioners favouring suturing of labial trauma, whilst others favour healing by secondary intention. A survey of practice was undertaken in three NHS organisations, over a five-week period in 2019 with data collected on 332 vaginal births. Overall, 47.3% (n=157) of women sustained labial trauma, of whom 29.3% (n=46) sustained trauma described as involving skin and underlying tissues. Of the labial trauma which involved skin and underlying tissues 76.0% (n=35) was sutured and the remainder unsutured. The survey confirmed a lack of consistency in practice and the need for further research to inform care for women.

Objective: First, to demonstrate that B-level evidence exists for the use of hyperbaric oxygen therapy (HBOT) as an effective treatment in mild to moderate traumatic brain injury/persistent postconcussion syndrome (mTBI/PPCS). Second, to alert readers and researchers that currently used pressurized air controls (≥21% O 2 , >1.0 ATA) are therapeutically active and cannot be utilized as sham controls without further validation. Method: Review of published, peer-reviewed articles of HBOT prospective and controlled clinical trials of mTBI/PPCS symptoms. Results: Published results demonstrate that HBOT is effective in the treatment of mTBI/PPCS symptoms. Doses of oxygen that are applied at ≥21% O 2 and at pressures of >1.0 ATA produce improvements from baseline measures. Some of the recently published clinical trials are mischaracterized as sham-controlled clinical trials (i.e., sham = 21% O 2 /1.2–1.3 ATA), but are best characterized as dose-varying (variation in oxygen concentration, pressure applied, or both) clinical trials. Conclusions: Hyperbaric oxygen and hyperbaric air have demonstrated therapeutic effects on mTBI/PPCS symptoms and can alleviate posttraumatic stress disorder symptoms secondary to a brain injury in 5 out of 5 peer-reviewed clinical trials. The current use of pressurized air (1.2–1.3 ATA) as a placebo or sham in clinical trials biases the results due to biological activity that favors healing.

This review provides a summary and appraisal commentary on the treatment review by Gantasala, S., Sullivan, P.B., & Thomas, A.G. (2013) Gastrostomy feeding versus oral feeding alone for children with cerebral palsy. Cochrane Database of Systematic Reviews, 7. doi:10.1002/14651858.CD003943.pub3Source of funding and disclosure of interests: This work was supported by the National Health and Medical Research Council [grant number 1105008], [grant number 607315].

Musculoskeletal disorders are a common cause of morbidity in our healthcare system today. The field of regenerative medicine (RM) has become an emerging treatment option in the musculoskeletal rehabilitation practice. Regenerative interventions include multiple injections prolotherapy, platelet rich plasma, autologous whole blood, hyaluronic acid, and mesenchymal stem cells. We review the highest level evidence to date in each of the aforementioned treatments. Early studies have provided encouraging results in treating a variety of injuries and conditions. Specific outcomes are variable and depend on interventions and outcome measures. RM is a rapidly expanding field, and with continued research efforts to determine mechanisms, indications, and dosing, it may become a more widely accepted treatment option.

Cholangiocarcinoma (CC) accounts for about 3% of all gastrointestinal tumors and is the second most common primary liver tumor. Quality guidelines on CC are needed to guide hepatobiliary surgeons. Here, current guidelines on CC were reviewed to provide useful information and suggestions to help institutes and organizations all around the world to draft better guidelines on CC. Literature databases were electronically searched to identify guidelines or consensus statements regarding CC published from 2002-2016. Nine guidelines were included in this review. Comparison of the current guidelines revealed several inconsistencies. Signs of conflicting views indicated a lack of high level evidence. More studies need to be conducted in areas of contention to help update the guidelines. Organizations and medical societies need to be encouraged to use standard evaluation measures, to restrict tumors to CC or iCC, pCC, or dCC specifically, to give recommendations in accordance with the equipment that is available for diagnosis and treatment in different counties, and to use an appropriate and consistent structure when establishing and drafting guidelines for CC.

Background The coronavirus (SARS-COV-2) is now a global concern because of its higher transmission capacity and associated adverse consequences including death. The reproductive number of coronavirus provides an estimate of the possible extent of the transmission. This study aims to provide a summary reproductive number of coronavirus based on available global level evidence. Methods A total of three databases were searched on September 15, 2020: PubMed, Web of Science, and Science Direct. The searches were conducted using a pre-specified search strategy to record studies reported the reproductive number of coronavirus from its inception in December 2019. It includes keywords of coronavirus and its reproductive number, which were combined using the Boolean operators (AND, OR). Based on the included studies, we estimated a summary reproductive number by using the meta-analysis. We used narrative synthesis to explain the results of the studies where the reproductive number was reported, however, were not possible to include in the meta-analysis because of the lack of data (mostly due to confidence interval was not reported). Results Total of 42 studies included in this review whereas 29 of them were included in the meta-analysis. The estimated summary reproductive number was 2.87 (95% CI, 2.39–3.44). We found evidence of very high heterogeneity (99.5%) of the reproductive number reported in the included studies. Our sub-group analysis was found the significant variations of reproductive number across the country for which it was estimated, method and model that were used to estimate the reproductive number, number of case that was considered to estimate the reproductive number, and the type of reproductive number that was estimated. The highest reproductive number was reported for the Diamond Princess Cruise Ship in Japan (14.8). In the country-level, the higher reproductive number was reported for France (R, 6.32, 95% CI, 5.72–6.99) following Germany (R, 6.07, 95% CI, 5.51–6.69) and Spain (R, 3.56, 95% CI, 1.62–7.82). The higher reproductive number was reported if it was estimated by using the Markov Chain Monte Carlo method (MCMC) method and the Epidemic curve model. We also reported significant heterogeneity of the type of reproductive number- a high-value reported if it was the time-dependent reproductive number. Conclusion The estimated summary reproductive number indicates an exponential increase of coronavirus infection in the coming days. Comprehensive policies and programs are important to reduce new infections as well as the associated adverse consequences including death.

Purpose Single, postoperative instillation of prophylactic intravesical chemotherapy (pIVC) is effective in reducing bladder cancer recurrences following radical nephroureterectomy (RNU). Despite high level evidence, pIVC is underutilized. Intraoperative pIVC (I-pIVC) may be easier and safer to implement than postoperative pIVC (P-pIVC). We aimed to evaluate the efficacy of I-pIVC during RNU. Materials and methods Retrospective analysis of patients undergoing RNU and I-pIVC or postoperative pIVC (P-pVC) with 20 to 40 mg mitomycin-C or 1 to 2 g gemcitabine. Recurrence rates were evaluated using the Kaplan-Meier curves and log rank test. Cox regression was used for univariable and multivariable analysis. Results One hundred and thirty-seven patients were included in the final analysis. 81% (111/137) had I-pIVC and 19% (26/137) had P-pIVC. In the I-pIVC group higher rates of HG, muscle invasive disease and gemcitabine use were observed. Overall, 74% (101/137) and 26% (36/137) had mitomycin-C and gemcitabine instillations, respectively. Within 12 months 14% (19/137) of the patients experienced bladder recurrence. Median time to bladder recurrence was 7 months (range 3–27). Twelve months bladder recurrence-free survival rates were 82% for the I-pIVC group, and 72% for the P-pIVC group ((log rank P = 0.365). Conclusions I-pIVC during RNU may reduce bladder recurrence rates. Bladder recurrence rates are comparable to those reported using postoperative instillations. Intraoperative instillations may be easier to implement and may increase usage rates.

BACKGROUND: Fracture non-union is a significant problem with a wide range demographic and massive socioeconomic elements, as well as the clinical difficulties it presents. Conventional treatments with autograft and allograft bone grafting pose serious difficulties, thus, it is necessary to develop novel techniques with our ever increasing knowledge of bioengineering using natural materials. OBJECTIVE: To search for current evidence regarding the treatment of fracture non-union or bone defects using mesenchymal stem cells (MSCs). RESULTS: The results presented in this review show that the use of mesenchymal stem cells for the treatment of non-union and bone defects is optimistic. Several papers had positive outcomes to report. There is a need for higher level evidence. CONCLUSION: A strong need of clinical results is required to further progress in cell therapy. Launched trials will hopefully provide this information in the near future. If clinical trials are positive, further development of complex tissue engineering techniques may be developed to treat large bone defects.

Objective: The aim of this systematic review was to assess the long term remineralizing potential of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) only in paste form compared with fluoride varnish, and or placebo in both naturally occurring and post-orthodontic white spot lesions in vivo. Data Sources: The literature search covered the electronic databases: PubMed and Google scholar from 2005-2016. Only articles published in English were included. Randomized control trials in which CPP-ACP delivered by paste form were included. All studies which met inclusion criteria underwent two independent reviews. Study Selection: Two ninety five articles were identified from the search after excluding duplications. Abstracts of forty one articles were reviewed independently. Twenty nine articles were excluded after reading abstract. Full text articles were retrieved for fifteen relevant studies. After reviewing articles independently, three articles were excluded after full text reading. Finally twelve studies were selected based on the eligibility criteria. The remineralizing effect of CPP-ACP were compared with placebo and fluoridated toothpaste and fluoride varnish in randomized control trial. Conclusion: A high level evidence of remineralizing potential of CPP-ACP on naturally occurring white spot lesion and WSL post orthodontic treatment was found in comparison with placebo/fluoridated toothpaste and fluoride varnish without any statistically significant difference. Well-designed RCTs are, therefore, required to improve the level of evidence in this area.

Background Evidence-based medicine has been increasingly applied in clinical practice. The objective of this study was to identify the trends of levels of evidence and the relevant factors of higher level evidence in external auricular defects literature over 3 decades. Methods The publications of external auricular defects published on 10 plastic surgery journals with higher impact factors from 1980 to 2011 were reviewed. Articles were appraised for level of evidence and other characteristics. Results Of 245 eligible articles reviewed, no level I study was identified, 1 (0.41%) was level II, 10 (4.1%) were level III, 152 (62%) were level IV, 82 (33.5%) were level V. There was an increase of the levels of evidence (P ≈ 0) from 1980 to 2011. Studies with larger sample size (P = 0.014) and the application of P values or confidence intervals (P ≈ 0.000), those related to prevalence questions (P = 0.000004) were significantly associated with higher levels of evidence. Conclusions In the last 3 decades, the levels of evidence have increased significantly in external auricular defects literature. However, the predominant study remained levels IV and V.

After studying this article, the participant should be able to: 1. Understand the indications for metacarpal fixation. 2. Understand the rationale for various surgical treatment options, based on high-level evidence where available. 3. Describe selected operative techniques and their postoperative management. Metacarpal fractures are extremely common, constituting one in five fractures that present to the emergency department. Although many metacarpal fractures can be treated nonoperatively, some require surgery. The purpose of this CME article is to present a practical, up-to-date guide to the management of these common injuries. A review of nonoperative management, surgical indications, and selected surgical techniques is provided. The authors reviewed the literature related to the treatment of metacarpal fractures, and the highest level evidence available to help guide decision-making is presented. Metacarpal fractures can often be treated nonoperatively, although some fractures will benefit from surgical treatment. Although there is some high-level evidence to guide decision-making, there are many clinical scenarios for which there is little high-quality applicable research. As a general principle, the treatment option that achieves the desired reduction and degree of fixation, allows early motion, and minimizes soft-tissue injury should be preferred.