Background: Pancreatic surgery is associated with considerable morbidity and, consequently, offers a large and complex field for research. To prioritize relevant future scientific projects, it is of utmost importance to identify existing evidence and uncover research gaps. Thus, the aim of this project was to create a systematic and living Evidence Map of Pancreatic Surgery. Methods: PubMed, the Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched for all randomized controlled trials and systematic reviews on pancreatic surgery. Outcomes from every existing randomized controlled trial were extracted, and trial quality was assessed. Systematic reviews were used to identify an absence of randomized controlled trials. Randomized controlled trials and systematic reviews on identical subjects were grouped according to research topics. A web-based evidence map modeled after a mind map was created to visualize existing evidence. Metaanalyses of specific outcomes of pancreatic surgery were performed for all research topics with more than 3 randomized controlled trials. For partial pancreatoduodenectomy and distal pancreatectomy, pooled benchmarks for outcomes were calculated with a 99% confidence interval. The evidence map undergoes regular updates. Results: Out of 30,860 articles reviewed, 328 randomized controlled trials on 35,600 patients and 332 systematic reviews were included and grouped into 76 research topics. Most randomized controlled trials were from Europe (46%) and most systematic reviews were from Asia (51%). A living meta-analysis of 21 out of 76 research topics (28%) was performed and included in the web-based evidence map. Evidence gaps were identified in 11 out of 76 research topics (14%). The benchmark for mortality was 2% (99% confidence interval: 1%e2%) for partial pancreatoduodenectomy and <1% (99% confidence interval: 0%e1%) for distal pancreatectomy. The benchmark for overall complications was 53% (99%confidence interval: 46%e61%) for partial pancreatoduodenectomy and 59% (99% confidence interval: 44%e80%) for distal pancreatectomy. Conclusion:The International Study Group of Pancreatic Surgery Evidence Map of Pancreatic Surgery, which is freely accessible via www.evidencemap.surgery and as a mobile phone app, provides a regularly updated overview of the available literature displayed in an intuitive fashion. Clinical decision making and evidence-based patient information are supported by the primary data provided, as well as by living meta-analyses. Researchers can use the systematic literature search and processed data for their own projects, and funding bodies can base their research priorities on evidence gaps that the map uncovers.
To the EditorLinezolid is frequently used to treat infections related to a variety of Gram-positive microorganisms, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. Lactic acidosis associated with Linezolid therapy has been already reported, mostly with prolonged use, but this complication is a rare cause of death. We report herein a life-threatening lactic acidosis after 15 days of linezolid exposure.A 70-year-old man was admitted to the intensive care unit (ICU) of our hospital for a severe metabolic acidosis in December 2013. He had a past medical history of tobacco use, alcoholic liver cirrhosis, hypertension, coronary disease, iliac angioplasty stenting, and rheumatoid arthritis treated with steroids.Three months before ICU admission, he suffered a severe aortic stenosis-related acute pulmonary edema, and underwent a surgical valve replacement in November 2013. Cardiac surgery was complicated by the occurrence of atrial fibrillation, gastroduodenal bleeding ulcer, and ischemic colitis requiring a left colectomy. The patient was febrile during the postoperative period. A sternal wound sample yielded Enterococcus faecium and Enterobacter aerogenes, whereas Staphylococcus hominis and Staphylococcus haemolyticus were recovered in blood cultures. A trans-esophageal echocardiography ruled out endocarditis. Vancomycin and imipenem were administered for 8 days. Five days after antibiotics discontinuation, the patient had chills and became febrile up to 40°C. A thoraco-abdominal CT scan showed ascites, of which culture remained negative. Vancomycin and imipenem were again administered for 20 further days for suspected sternal infection.On December 6, 2013, the patient was referred to the infectious disease ward of our hospital for persistent sepsis.There was a small dehiscence on the abdominal wound on physical examination, from which multidrug-resistant Enterobacter cloacae were isolated, while a blood culture was positive for normally susceptible Klebsiella pneumoniae. Laboratory tests showed hyperleukocytosis at 29.8
ObjectivesParaparesis due to oncologic lesions of the spine warrants swift neurosurgical intervention to prevent permanent disability and hence maintain independence of affected patients. Clinical parameters that predict a favorable outcome after surgical intervention could aid decision-making in emergency situations.MethodsPatients who underwent surgical intervention for paraparesis (grade of muscle strength <5 according to the British Medical Research Council grading system) secondary to spinal neoplasms between 2006 and 2020 were included in a single-center retrospective analysis. Pre- and postoperative clinical data were collected. The neurological status was assessed using the modified McCormick Disability Scale (mMcC) Score. In a univariate analysis, patients with favorable (discharge mMcC improved or stable at <3) and non-favorable outcome (discharge mMcC deteriorated or stable at >2) and different tumor anatomical compartments were statistically compared.Results117 patients with oncologic paraparesis pertaining to intramedullary lesions (n=17, 15%), intradural extramedullary (n=24, 21%) and extradural lesions (n=76, 65%) with a mean age of 65.3 ± 14.6 years were included in the analysis. Thoracic tumors were the most common (77%), followed by lumbar and cervical tumors (13% and 12%, respectively). Surgery was performed within a mean of 36±60 hours of admission across all tumors and included decompression over a median of 2 segments (IQR:1-3) and mostly subtotal tumor resection (n=83, 71%). Surgical and medical complications were documented in 9% (n=11) and 7% (n=8) of cases, respectively. The median hospital length-of-stay was 9 (7-13) days. Upon discharge, the median mMcC score had improved from 3 to 2 (p<0.0001). At last follow-up (median 180; IQR 51-1080 days), patients showed an improvement in their mean Karnofsky Performance Score (KPS) from 51.7±18.8% to 65.3±20.4% (p<0.001). Localization in the intramedullary compartment, a high preoperative mMcC score, in addition to bladder and bowel dysfunction were associated with a non-favorable outcome (p<0.001).ConclusionThe data presented on patients with spinal oncologic paraparesis provide a risk-benefit narrative that favors surgical intervention across all etiologies. At the same time, they outline clinical factors that confer a less-favorable outcome like intramedullary tumor localization, a high McCormick score and/or bladder and bowel abnormalities at admission.
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