Background Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non‐steroidal anti‐inflammatory drugs (NSAIDs) for reducing ileus after surgery. Methods A prospective multicentre cohort study was delivered by an international, student‐ and trainee‐led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre‐specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury. Results A total of 4164 patients were included, with a median age of 68 (i.q.r. 57–75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1–3, of whom 1061 (92·0 per cent) received non‐selective cyclo‐oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001). Conclusion NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.
Giant cell reparative granuloma accounts for 1–7% of all benign lesions of the jaw. It often arises in the maxilla followed by mandible and affects children and young adults. It is usually a slow-growing lesion. The fast growing lesions are rare and despite the innocent histological appearance, has an aggressive behavior mimicking a malignant lesion. In the present report, the clinical features, diagnosis, and surgical treatment of an unusually large aggressive variety of reparative giant cell granuloma found in the cheek with extensions into maxilla, antrum, and infratemporal region in a 23-year-old female is described. The impact of delay in correct diagnosis on massive enlargement of the lesion, the importance of computed tomography-guided biopsy in the diagnosis of such inaccessible lesions, and the role of a general dentist in the early detection are also emphasized.
These cases provide a unique insight into an additional feature of HCC and usefulness of recognizing the ITPAs on imaging studies. Although de novo ITPAs in HCC are uncommon, occurring with an incidence rate of 0.24%, their presence in hypervascular hepatic lesion may point towards the diagnosis of HCC. Additionally, they should be accounted for in management planning as they can lead to complications of rupture and hemorrhage.
Castleman disease (CD) is a disorder characterized by lymphoid proliferation. It is not usually the first differential for pyrexia of unknown origin (PUO) because of the extremely rare incidence worldwide. We report the case of a 24-year-old man with PUO for six months. He had been previously investigated for infective, rheumatological, and immunological causes. Extrapulmonary tuberculosis was considered as the most likely diagnosis because of his clinical presentation and locality. Based on this, he was given a trial of anti-tuberculous therapy. However, he did not show any signs of improvement despite being compliant with the medications. His condition was further complicated by the development of ascites. Upon treatment failure, the patient presented to our tertiary care hospital and was investigated for a possible revision of diagnosis. Based on clinical assessment and histopathology of the lymph nodes, he was diagnosed with idiopathic multicentric CD overlapping with systemic lupus erythematosus. He was started on azathioprine and prednisone and showed a positive response, indicated by a decreasing erythrocyte sedimentation rate and C-reactive protein. The patient continues to be healthy and in remission to date.
Background Postoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies. Methods The Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surgery (2011–2015). Multivariable logistic regression was used to predict risk of AKI, with multiple imputation used to account for data missing at random. Prognostic accuracy was assessed for patients at high risk (greater than 20 per cent) of postoperative AKI. Results In the validation cohorts, 12.9 per cent of patients (661 of 5106) in IMAGINE and 14.7 per cent (106 of 719 patients) in Tayside developed 7-day postoperative AKI. Using the OAKS model, 558 patients (9.6 per cent) were classified as high risk. Less than 10 per cent of patients classified as low-risk developed AKI in either cohort (negative predictive value greater than 0.9). Upon external validation, the OAKS model retained an area under the receiver operating characteristic (AUC) curve of range 0.655–0.681 (Tayside 95 per cent c.i. 0.596 to 0.714; IMAGINE 95 per cent c.i. 0.659 to 0.703), sensitivity values range 0.323–0.352 (IMAGINE 95 per cent c.i. 0.281 to 0.368; Tayside 95 per cent c.i. 0.253 to 0.461), and specificity range 0.881–0.890 (Tayside 95 per cent c.i. 0.853 to 0.905; IMAGINE 95 per cent c.i. 0.881 to 0.899). Conclusion The OAKS prognostic model can identify patients who are not at high risk of postoperative AKI after gastrointestinal surgery with high specificity. Presented to Association of Surgeons in Training (ASiT) International Conference 2018 (Edinburgh, UK), European Society of Coloproctology (ESCP) International Conference 2018 (Nice, France), SARS (Society of Academic and Research Surgery) 2020 (Virtual, UK).
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