Effectiveness of Rifaximin on the Outcomes of Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Irritable bowel syndrome (IBS) is a prevalent gastrointestinal disorder that impacts the lives of many individuals worldwide. We conducted a systemic review and meta-analysis of randomized controlled trials (RCTs) to assess both the effectiveness of rifaximin in alleviating IBS symptoms and its potential adverse effects. PubMed, Web of Science, Embase, the Cochrane Library, Scopus, and Google Scholar were searched from inception until August 20, 2023, for studies comparing rifaximin with placebo in the resolution of symptoms among IBS patients. Risk ratios (RRs) and their corresponding 95% confidence intervals (CIs) were derived for all the outcomes of interest. Six RCTs were pooled in this analysis. The results showed improved abdominal distension with rifaximin over the control group. Overall symptom relief at the end of the treatment period and follow-up period was also observed in the patients receiving rifaximin. However, no significant differences were found between the rifaximin group and the control group for the outcomes of abdominal pain, nausea, headache, vomiting, diarrhea, sinusitis, bronchitis, and upper respiratory tract infection. The results of our meta-analysis support the use of rifaximin in the treatment of IBS, owing to its safety and effectiveness. Future RCTs should be conducted to assess this topic of interest more extensively.

Comparison of Long-Term Outcomes of Patients With Myocardia Infarction (MI) With Non-obstructive Coronary Arteries and MI With Obstructive Coronary Arteries: A Systematic Review and Meta-Analysis

The aim of this study was to compare long-term outcomes in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) and patients with myocardial infarction with obstructive coronary arteries (MIOCA). This meta-analysis was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The literature search was conducted in online databases including PubMed and Web of Science from 2010 onwards. Primary outcomes assessed in this meta-analysis included major adverse cardiovascular events (MACE) and all-cause mortality. Secondary outcomes included cardiovascular mortality and myocardial infarction. A total of 16 studies were included in the meta-analysis. Pooled analysis showed that the risk of MACE was higher in MIOCA patients (risk ratio (RR): 1.47, 95%CI: 1.43-1.52, p-value: 0.001) compared to MINOCA patients. Additionally, the risk of all-cause mortality was also significantly higher in MIOCA patients compared to MINOCA (RR: 1.33, 95%CI: 1.14-1.56, p-value: 0.001). Our findings also indicate that patients with MIOCA are at a significantly higher risk of recurrent myocardial infarction and cardiovascular-related mortality compared to patients with MINOCA. Overall, the insights gained from this meta-analysis have significant clinical implications, guiding decision-making in the management of patients with MINOCA.

Comparing Efficacy and Safety of Different Doses of Tirzepatide for the Treatment of Type 2 Diabetes Mellitus: A Meta-Analysis of Randomized Controlled Trials

Our study assessed the efficacy and safety of the three primary tirzepatide (TZP) doses, 5 mg, 10 mg, and 15 mg using network meta-analysis to assess their relative impact on type 2 diabetes mellitus (T2DM) treatment. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Two authors independently screened online databases, including PubMed, Cochrane Library, and Embase. We employed the keywords "Type 2 diabetes OR T2DM or diabetes" AND "Tirzepatide OR LY3298176 OR twincretin OR dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist" AND "randomized controlled trial". The outcomes evaluated in this study comprised changes in hemoglobin (Hb)A1c levels from baseline (%), changes in weight from baseline (Kg), changes in fasting serum glucose from baseline (mg/dL), and occurrences of serious adverse events (SAE), adverse events (AE) and major adverse cardiovascular events (MACE). A total of eight studies met the inclusion criteria and were included in this meta-analysis. Our findings suggest that among the evaluated doses, TZP at 15 mg demonstrated superior effectiveness in reducing HbA1c, weight, and fasting serum glucose compared to doses of 10 mg and 5 mg. Notably, the reduction in HbA1c and weight showed a dose-dependent trend, with the 15 mg dose achieving the most substantial benefits. The safety analysis indicated that while serious adverse events and major adverse cardiovascular events (MACE) did not significantly differ among the three doses, the risk of overall adverse events was notably higher in the 10 mg and 15 mg TZP groups compared to the 5 mg group.

Safety and Efficacy of Istaroxime in Patients With Acute Heart Failure: A Meta-Analysis of Randomized Controlled Trials

The aim of this study was to assess the efficacy and safety of istaroxime in patients with heart failure. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, a search was conducted on the EMBASE and Medline databases to identify articles related to the safety and efficacy of istaroxime in patients with heart failure. The search covered the period from inception to May 31st, 2023, without any restrictions on the year of publication. The search strategy utilized relevant terms such as "istaroxime," "heart failure", "efficacy," and other related terms, along with their corresponding Medical Subject Headings (MeSH) terms. The outcomes assessed in this meta-analysis included the change in left ventricular ejection fraction (LVEF), E to A ratio (a marker of left ventricle function), cardiac index in L/min/m2, systolic blood pressure (SBP) in mmHg, left ventricular end-systolic volume (LVESV) in ml, and left ventricular end-diastolic volume (LVDSV) in ml. For safety analysis, gastrointestinal events and cardiovascular events were assessed. A total of three randomized controlled trials (RCTs) were included in this meta-analysis encompassing 211 patients with heart failure. Pooled analysis showed that istaroxime was effective in increasing LVEF (MD: 1.26, 95% CI: 0.91 to 1.62, p-value: 0.001), reducing E to A ratio (MD: -0.39, 95% CI: -0.60 to -0.19, p-value: 0.001), increasing cardiac index (MD: 0.22, 95% CI: 0.18 to 0.25, p-value: 0.001), reducing LVESV (MD: -11.84, 95% CI: -13.91 to -9.78, p-value: 0.001), reducing LVEDV (MD: -12.25, 95% CI: -14.63 to -9.87, p-value: 0.001) and increasing SBP (MD: 8.41, 95% CI: 5.23 to 11.60, p-value: 0.001) compared to the placebo group. However, risk of gastrointestinal events was significantly higher in patients receiving istaroxime compared to the placebo group (RR: 2.64, 95% CI: 1.53 to 4.57, p-value: 0.0005). These findings support the enhancement of heart function with istaroxime administration, aligning with previous clinical and experimental evidence.

Thomas Eshelby (1769-1811), Nelson's Surgeon

Horatio Nelson is an icon of British naval history. His above-elbow amputation by Thomas Eshelby remains one of the most famous surgical procedures ever performed. Yet the surgeon himself remains relatively obscure and uncelebrated. We present a vignette of this young Yorkshireman and reflect on his life and times. Eshelby was a competent and conscientious surgeon and was certainly held in high regard by Nelson. Quite a few documents pertaining to his tour of duty in the Mediterranean and to his later appointment at Plymouth have been archived. These shed valuable light on his professional life, betraying his clinical acumen, his conscientious and pragmatic nature and his demeanour toward both his peers and his superiors. Eshelby was also the patriarch of an enterprising family including three generations of surgeons and others with eponymous discoveries in the fields of geography and science.

Cemented Thompson's hemiarthroplasty in patients with intracapsular neck of femur fractures: survival analysis of 1,670 procedures

Cemented Thompson's prostheses have been used to treat elderly patients with displaced intracapsular hip fractures at our two units for the last 15 years, amid growing support for the use of newer implant designs for hip hemiarthroplasty. This provided us with an opportunity to investigate survival of the Thompson's stem in our patients. A retrospective cohort study was set up to review previously collected data on patients who underwent Thompson's hemiarthroplasty over a 7-year period. These were linked to surgical notes, clinical letters and radiographs to record post-operative course and subsequent admissions and procedures. The identifiers were then linked to mortality data from the Office of 'National Statistics. Kaplan-Meier survival analyses were done for implants and patients. A total of 1,632 patients (mean age 82.7 years) underwent 1,670 procedures. Five-year implant survival was 95.4 %. A total of 36 stems were revised, including 14 revisions to total hip arthroplasty and 22 excision arthroplasties. Reasons for revision included infection (2.1 %), dislocation (1.1 %) and aseptic loosening (0.5 %). Symptomatic aseptic loosening and acetabular erosion occurred late (mean time 3.2 and 5.7 years, respectively following surgery). Aseptic loosening and erosion following hemiarthroplasty are relatively late complications.

The Best Practice Tariff helps improve management of neck of femur fractures: a completed audit loop

BACKGROUND

The Best Practice Tariff incentivizes hospitals in the UK to improve the care they deliver, and includes a requirement to deliver multiprofessional care to patients with neck of femur fractures. The Best Practice Tariff for 2010-11 included six targets: (1) surgery within 36 hours, (2) admission under consultant-led joint orthopaedic-geriatric care, (3) admission using a multidisciplinary assessment protocol, (4) review by a geriatrician within 72 hours, (5) geriatrician-directed multi-professional rehabilitation, and (6) assessment for falls and bone protection. The authors chose to audit their Trust's compliance with these targets.

METHODS

A retrospective audit was conducted in 2011 at the authors' university-affiliated tertiary care hospital, which is a regional major trauma centre. Only patients 65 years or older, with fragility-type neck of femur fractures who were treated surgically at the authors' unit and were eligible for geriatric review and multiprofessional rehabilitation, were included. The results of this audit (2010-11 Best Practice Tariff targets) were analysed and a series of procedural and logistical measures were introduced. A re-audit was performed in April 2012 for 2011-12, and the results for the 2 years were compared using appropriate statistics (Chi square tests and analysis of variance). Thirty-day mortality was compared using the summary hospital-level mortality indicator.

RESULTS

A total of 410 patients were eligible for Best Practice Tariff in 2010-11, which increased to 463 in 2011-12. The changes from the first year's audit helped increase the rates for 36-hour surgery from 48.3% to 73.4% and for 72-hour geriatric review from 68.8% to 81.8% (P<0.05). The annual Best Practice Tariff achievement increased from 31.7% to 61.3% (P<0.05). The summary hospital-level mortality indicator declined from 96.5 to 61.3.

CONCLUSIONS

Focusing on poorly satisfied Best Practice Tariff indicators can produce a significant improvement in the per capita Best Practice Tariff achievement. Further studies are needed to assess the health and financial gain in detail.

Peroneal artery pseudoaneurysm after surgical stabilisation of a Weber C trimalleolar ankle fracture: A case report and review of literature

A case of post-traumatic pseudoaneurysm of the peroneal artery is presented. This occurred after standard open reduction and internal fixation of a Weber type C trimalleolar fracture of the left ankle in a 33-year-old man. The pseudoaneurysm was diagnosed 12 weeks post-operatively when the patient attended the pre-assessment clinic for the removal of the syndesmosis screw. Diagnosis was confirmed on ultrasonography, and the anatomical site was confirmed by a digital subtraction angiogram. The pseudoaneurysm was coiled successfully, and the syndesmosis screw was removed in theatre the next day, without any post-operative complications. We explore the aetiology of post-traumatic peroneal pseudoaneurysms, with emphasis on the pathoanatomy and management as described in literature. This is a rare complication, but is easily manageable provided an index of suspicion is maintained.

Successful repair of an isolated osteochondral fracture of the patella presenting with locking of the knee

A 15-year-old boy presented with a locked knee after a football injury. Sudden valgus impact to the planted right leg caused a patellar osteochondral fracture diagnosed by magnetic resonance imaging. The 2.5-cm fragment had avulsed off the medial facet without damage to the medial retinaculum or the medial patellofemoral ligament. The fracture was stabilised with headless compression screws. It had healed at 8 weeks, with the patient being able to bear full weight, and with a full range of active knee movement. At 4 months, he had returned to playing football for his school team.

Normally, such a fracture occurs due to sheering force on the patella against the femur during the relocation phase of an acute patellar dislocation. In this case, the patella may have subluxed and then reduced spontaneously, without causing a true dislocation or damage to the medial soft tissue restraints. The energy dissipated at contact with the femur would however be sufficient to sheer the fragment off the patella. We believe this is the first report of successful repair of an osteochondral patellar fracture sustained by this mechanism.

The influence of process and patient factors on the recall of consent information in mentally competent patients undergoing surgery for neck of femur fractures

INTRODUCTION

Informed consent is an ethical and legal prerequisite for major surgical procedures. Recent literature has identified 'poor consent' as a major cause of litigation in trauma cases. We aimed to investigate the patient and process factors that influence consent information recall in mentally competent patients (abbreviated mental test score [AMTS] ≥6) presenting with neck of femur (NOF) fractures.

METHODS

A prospective study was conducted at a tertiary unit. Fifty NOF patients (cases) and fifty total hip replacement (THR) patients (controls) were assessed for process factors (adequacy and validity of consent) as well as patient factors (comprehension and retention) using consent forms and structured interview proformas.

RESULTS

The two groups were matched for ASA (American Society of Anesthesiologists) grade and AMTS. The consent forms were adequate in both groups but scored poorly for validity in the NOF group. Only 26% of NOF patients remembered correctly what surgery they had while only 48% recalled the risks and benefits of the procedure. These results were significantly poorer than in THR patients (p = 0.0001).

CONCLUSIONS

This study confirms that NOF patients are poor at remembering the information conveyed to them at the time of consent when compared with THR patients despite being intellectually and physiologically matched. We suggest using preprinted consent forms (process factors), information sheets and visual aids (patient factors) to improve retention and recall.

Changing antibiotic prophylaxis for primary joint arthroplasty affects postoperative complication rates and bacterial spectrum

BACKGROUND

The reduction of Clostridium difficile associated diarrhoea (CDAD) is a national priority. As part of the C. difficile improvement plan in our Trust, antibiotic prophylaxis for primary arthroplasty was changed from cefuroxime to gentamicin. Gentamicin was chosen following a review of the sensitivity profiles of all the organisms isolated from infected primary arthoplasties.

METHODS

From January 2002 to September 2007, 6094 patients (Group 1) undergoing primary hip and knee arthroplasty received three doses of Cefuroxime as prophylaxis; while from October 2007 to February 2009, 2101 patients (Group 2) received single dose Gentamicin (4.5 mg/kg). We studied the rate of CDAD as well as several other postoperative complications, including rate of return to theatre (RTT), before and after the change.

FINDINGS

There was an insignificant fall in CDAD from 0.18% to 0% (p=0.08) in Group 2, however there was a statistically significant increase in pneumonia (0.67-1.33%, p<0.01), acute renal failure (ARF) requiring HDU admission (0.07-0.33%, p<0.01) and RTT (1.08-1.95%, p<0.01) in this group. RTT for proven infection increased from 0.66% to 1.52% (p<0.01).

CONCLUSIONS

We conclude that Gentamicin 4.5 mg/kg alone should not be used as prophylaxis for primary joint arthroplasty as it does not reduce CDAD significantly but increases the risk of other postoperative complications. We have changed our prophylaxis to low dose gentamicin (3 mg/kg) combined with Teicoplanin 400 mg given once.

A national analysis of complications following hemiarthroplasty for hip fracture in older patients

BACKGROUND

There is emerging evidence that patients with fractured neck of femur (FNOF) aged >85 years have different demands on a health-care system when compared to younger patients.

AIM

We sought to better quantify this in terms of comorbidity and complication rates.

DESIGN

Retrospective review of national database.

METHODS

Data on all patients who underwent hip hemiarthroplasty for FNOF between January 2005 and December 2008 were extracted from the English hospital episode statistics database.

RESULTS

There were 41 770 patients aged 65-84 years and 35 321 patients aged ≥85 years. The older cohort was less likely to have diabetes, chronic obstructive pulmonary disease and rheumatoid arthritis. However, they exhibited a significantly higher risk of lower respiratory tract infection [odds ratio (OR) = 1.58, 95% confidence interval (CI) 1.50-1.67)], myocardial infarction (OR = 1.67, 1.52-1.83) and acute renal failure (OR = 1.54, 1.40-1.70) within 30 days of surgery with an inpatient mortality risk at 90 days, double that of the younger age group. Length of stay (LoS) was significantly longer in patients >85 years compared to younger patients (median 18 days vs. 15, P < 0.001).

CONCLUSION

Patients aged ≥85 years admitted for FNOF were found to have a lower incidence of major chronic disease but exhibited a greater incidence of acute events following hemiarthroplasty and their LoS was increased. Targeted medical interventions that focus upon this susceptible patient group may help reduce morbidity and improve survival.

The influence of process and patient factors on the recall of consent information in mentally competent patients undergoing surgery for neck of femur fractures

INTRODUCTION

Informed consent is an ethical and legal prerequisite for major surgical procedures. Recent literature has identified ‘poor consent’ as a major cause of litigation in trauma cases. We aimed to investigate the patient and process factors that influence consent information recall in mentally competent patients (abbreviated mental test score [AMTS] ≥6) presenting with neck of femur (NOF) fractures.

METHODS

A prospective study was conducted at a tertiary unit. Fifty NOF patients (cases) and fifty total hip replacement (THR) patients (controls) were assessed for process factors (adequacy and validity of consent) as well as patient factors (comprehension and retention) using consent forms and structured interview proformas.

RESULTS

The two groups were matched for ASA (American Society of Anesthesiologists) grade and AMTS. The consent forms were adequate in both groups but scored poorly for validity in the NOF group. Only 26% of NOF patients remembered correctly what surgery they had while only 48% recalled the risks and benefits of the procedure. These results were significantly poorer than in THR patients (p=0.0001).

CONCLUSIONS

This study confirms that NOF patients are poor at remembering the information conveyed to them at the time of consent when compared with THR patients despite being intellectually and physiologically matched. We suggest using pre-printed consent forms (process factors), information sheets and visual aids (patient factors) to improve retention and recall.

Lumbar vertebral haemangioma causing pathological fracture, epidural haemorrhage, and cord compression: a case report and review of literature

CONTEXT

Vertebral haemangiomas are recognized to be one of the commonest benign tumours of the vertebral column, occurring mostly in the thoracic spine. The vast majority of these are asymptomatic. Infrequently, these can turn symptomatic and cause neurological deficit (cord compression) through any of four reported mechanisms: (1) epidural extension; (2) expansion of the involved vertebra(e) causing spinal canal stenosis; (3) spontaneous epidural haemorrhage; (4) pathological burst fracture. Thoracic haemangiomas have been reported to be more likely to produce cord compression than lumbar haemangiomas.

FINDINGS

A forty-nine year old male with acute onset spinal cord compression from a pathological fracture in a first lumbar vertebral haemangioma. An MRI delineated the haemangioma and extent of bleeding that caused the cord compression. These were confirmed during surgery and the haematoma was evacuated. The spine was instrumented from T12 to L2, and a cement vertebroplasty was performed intra-operatively. Written consent for publication was obtained from the patient.

CLINICAL RELEVANCE

The junctional location of the first lumbar vertebra, and the structural weakness from normal bone being replaced by the haemangioma, probably caused it to fracture under axial loading. This pathological fracture caused bleeding from the vascularized bone, resulting in cord compression.

Deterioration of water quality of Surma river

Surma River is polluted day by day by human activities, poor structured sewerage and drainage system, discharging industrial and household wastes. The charas (natural channels) are responsible for surface runoff conveyance from its urban catchments to the receiving Surma River. Water samples have been collected from a part of Surma River along different points and analyzed for various water quality parameters during dry and monsoon periods. Effects of industrial wastes, municipal sewage, and agricultural runoff on river water quality have been investigated. The study was conducted within the Chattak to Sunamganj portion of Surma River, which is significant due to the presence of two major industries--a paper mill and a cement factory. The other significant feature is the conveyors that travel from India to Chattak. The river was found to be highly turbid in the monsoon season. But BOD and fecal coliform concentration was found higher in the dry season. The water was found slightly acidic. The mean values of parameters were Conductivity 84-805 micros; DO: dry-5.52 mg/l, monsoon-5.72 mg/l; BOD: dry-1mg/l, monsoon-0.878 mg/l; Total Solid: dry-149.4 mg/l, monsoon-145.7 mg/l. In this study, an effort has been taken to investigate the status of concentration of phosphate (PO(-4)) and ammonia-nitrogen (NH4-N) at four entrance points of Malnichara to the city, Guali chara, Gaviar khal and Bolramer khal. Data has been collected from March-April and September-October of 2004. Concentrations have been measured using UV Spectrophotometer. Although the phosphate concentration has been found within the limit set by DOE for fishing, irrigation and recreational purposes, however ammonia-nitrogen has been found to exceed the limit.