Significant Difference In Treatment Success Research Articles

Outcomes in Patients With Vogt–Koyanagi–Harada Disease From the First-Line Antimetabolites for Steroid-Sparing Treatment Uveitis Trial

PurposeTo compare the effectiveness of methotrexate (MTX) and mycophenolate mofetil (MMF) in achieving corticosteroid-sparing control of uveitis in patients with Vogt-Koyanagi-Harada (VKH) disease. MethodsA subanalysis of patients with VKH from the First-line Antimetabolites as Steroid-sparing Treatment (FAST) Uveitis Trial, a randomized, observer-masked, comparative effectiveness trial, with comparisons by treatment (MTX versus MMF) and disease stage (acute versus chronic). Individuals with noninfectious uveitis were placed on a standardized corticosteroid taper and block randomized 1:1 to either 25mg weekly oral MTX or 1.5g twice daily oral MMF. The primary outcome was treatment success defined by corticosteroid-sparing control of uveitis at 6 months. Additional outcomes included change in best spectacle-corrected visual acuity (BSCVA), retinal central subfield thickness (CST), and resolution of serous retinal detachment (SRD). ResultsNinety-three out of 216 enrolled patients had VKH; 49 patients were randomized to MTX and 44 to MMF, of which 85 patients (46 on MTX, 39 on MMF) contributed to the primary outcome. There was no significant difference in treatment success by antimetabolite (80.4% for MTX compared to 64.1% for MMF; P=.12) or in BSCVA improvement (P=.78). Methotrexate was superior to MMF in reducing CST (P=.003) and resolving SRD (P=.02). There was no significant difference in treatment success by disease stage (P=.25), but patients with acute VKH had greater improvement in BSCVA (P<.001) and reduction of CST (P=.02) than chronic VKH patients. ConclusionsMTX and MMF have comparable outcomes as corticosteroid-sparing immunosuppressive therapies for VKH. Visual acuity improvement was greater in acute vs chronic VKH. Trial RegistrationClinicalTrials.gov Identifier: NCT 0182929

Diabetic Osteomyelitis: Oral versus Intravenous Antibiotics at a Single Level 1 Academic Medical Trauma Center

Residual osteomyelitis is a frequent problem following surgical intervention for diabetic foot infection. The Infectious Disease Society of America guidelines recommend a prolonged course of antibiotics for treatment of residual osteomyelitis. Recent literature suggests oral antibiotic therapy is not inferior to IV therapy. The primary aim of this study was to evaluate treatment success in 128 patients receiving oral versus IV antibiotics for residual osteomyelitis in the diabetic foot after amputation at a Level 1 academic medical trauma center. Treatment success was defined as completion of at least 4 weeks of antibiotic therapy, complete surgical wound healing, and no residual infection requiring further debridement or amputation within 1 year of the initial surgery. Patients with peripheral arterial disease were excluded. A retrospective chart review was performed, and we found no statistically significant difference in treatment success between these two groups (p = .2766). The median time to healing for oral antibiotic treatment was 3.17 months compared to 4.06 months for IV treatment (p = .1045). Furthermore, there was no significant difference in group demographics or comorbidities, aside from more patients in the IV group having coronary artery disease (p = .0416). The type of closure and whether the infection was single or polymicrobial were also not associated with a difference in outcomes between the two treatment arms. The results of the present study suggest oral antibiotics for treatment of residual osteomyelitis are not inferior to IV therapy and may be more efficacious for certain patients regarding cost and ease of administration.

Treatment of Multidrug-resistant or Rifampicin-resistant Tuberculosis With an All-oral 9-month Regimen Containing Linezolid or Ethionamide in South Africa: A Retrospective Cohort Study.

In 2019, the South African tuberculosis program replaced ethionamide with linezolid as part of an all-oral 9-month regimen. We evaluated treatment outcomes for patients assigned to regimens including linezolid in 2019 and ethionamide in 2017. This retrospective cohort study included patients treated for multidrug-resistant/rifampicin-resistant tuberculosis throughout South Africa between 1 January and 31 December 2017 and 1 January to 31 December 2019. The cohort treated with a 9-month regimen containing ethionamide for four months, was compared with a cohort treated with a 9-month regimen containing linezolid for 2 months. The regimens were otherwise identical. Inverse probability weighting of propensity scores was used to adjust for potential confounding. A log-binomial regression model was used to estimate adjusted relative risk (aRR) comparing 24-month outcomes between cohorts including treatment success, death, loss to follow up, and treatment failure. Adverse event data were available for the linezolid cohort. In total, 817 patients were included in the cohort receiving ethionamide and 4244 in the cohort receiving linezolid. No evidence for a difference was observed between linezolid and ethionamide regimens for treatment success (aRR = 0.96, 95% confidence interval [CI] .91-1.01), death (aRR = 1.01, 95% CI .87-1.17) or treatment failure (aRR = 0.87, 95% CI .44-1.75). Loss to follow-up was more common in the linezolid group, although estimates were imprecise (aRR = 1.22, 95% CI .99-1.50). No significant differences in treatment success and survival were observed with substitution of linezolid for ethionamide as a part of an all-oral 9-month regimen. Linezolid is an acceptable alternative to ethionamide in this shorter regimen for treatment of multidrug-resistant/rifampicin-resistant tuberculosis.

Digital Health Interventions to Enhance Tuberculosis Treatment Adherence: Scoping Review.

Digital health technologies are widely used for disease management, with their computing platforms, software, and sensors being used for health care. These technologies are developed to manage chronic diseases and infectious bacterial diseases, including tuberculosis (TB). This study aims to comprehensively review the literature on the use of digital health interventions (DHIs) for enhancing TB treatment adherence and identify major strategies for their adoption. We conducted a literature search in the PubMed, Cochrane Library, Ovid Embase, and Scopus databases for relevant studies published between January 2012 and March 2022. Studies that focused on web-based or mobile phone-based interventions, medication adherence, digital health, randomized controlled trials, digital interventions, or mobile health and ubiquitous health technology for TB treatment and related health outcomes were included. We identified 27 relevant studies and classified them according to the intervention method, a significant difference in treatment success, and health outcomes. The following interventions were emphasized: SMS text messaging interventions (8/27, 30%), medicine reminders (6/27, 22%), and web-based direct observation therapy (9/27, 33%). Digital health technology significantly promoted disease management among individuals and health care professionals. However, only a few studies addressed 2-way communication therapies, such as interactive SMS text messaging and feedback systems. This scoping review classified studies on DHIs for patients with TB and demonstrated their potential for the self-management of TB. DHIs are still being developed, and evidence on the impact of digital technologies on enhancing TB treatment adherence remains limited. However, it is necessary to encourage patients' participation in TB treatment and self-management through bidirectional communication. We emphasize the importance of developing a communication system.

Efficacy and safety of probiotics and synbiotics for functional constipation in children: A systematic review and meta-analysis of randomized clinical trials

We aimed to evaluate the efficacy and safety of probiotics and synbiotics in childhood functional constipation. PubMed, Embase, Cochrane Library, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP) were searched up to June 2023. Randomized controlled trials involving children diagnosed with FC with Rome III/IV criteria were included. Treatment success, defecation frequency, stool consistency, painful defecation, fecal incontinence, and adverse events were assessed as outcomes. Odds ratios (ORs) and standard mean difference (SMD) with 95% confidence intervals (CIs) were calculated for dichotomous and continuous variables as appropriate. Cochrane risk-of-bias tool version 2 assessed the risk of bias. Seventeen RCTs with 1504 patients were included. Compared to placebo, probiotics significantly improved defecation frequency (SMD 0.40, 95% CI 0.10 to 0.70, I2=0%) and fecal incontinence (OR 0.53, 95% CI 0.29 to 0.96, I2=0%). However, it did not significantly improve treatment success, painful defecation, and abdominal pain. Probiotics, as add-on therapy, failed to yield a significant difference in treatment success (OR 0.82, 95% CI 0.15 to 4.48, I2=52%), defecation frequency (SMD 0.13, 95% CI -0.13 to 0.39, I2=0%), defecation consistency (SMD -0.01, 95% CI -0.40 to 0.38, I2=1%), fecal incontinence (OR 0.95, 95% CI 0.48 to 1.90, I2=0%), and abdominal pain (OR, 0.60, 95% CI 0.24 to 1.53, I2=0%) versus laxatives monotherapy. Synbiotics plus laxatives showed no significant effect on defecation frequency (SMD -0.57; 95% CI -1.29 to 0.14, I2=74%) and painful defecation (OR, 3.39; 95% CI 0.74 to 15.55, I2=0%) versus laxatives alone. Current evidence did not advocate using probiotics and synbiotics in treating functional constipation in children. At this time, the effects of strain-specific probiotics, probiotics mixtures, and the optimal doses and treatment durations of the probiotics and synbiotics were unclear. Additional rigorous evidence is required to evaluate and establish the effectiveness and safety of probiotics and synbiotics for childhood functional constipation. CRD42020195869.

Impact of endoprosthesis type on inflammatory response in patients undergoing endoscopic drainage of pancreatic fluid collections.

To study the impact of endoprosthesis type on inflammatory response in patients undergoing endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFC). Patients undergoing EUS-guided PFC drainage and treated using lumen-apposing metal stents (LAMS) or plastic endoprostheses constituted the study cohort. The primary outcome was the presence of systemic inflammatory response syndrome (SIRS) after index intervention. Secondary outcomes were persistent organ failure, new onset organ failure, duration of hospitalization, and treatment success. In all, 303 patients were treated using LAMS (n = 247) or plastic stents (n = 56). At 48 h postintervention, the presence of SIRS (25.0 vs. 14.2%, P = 0.047), new onset SIRS (10.0 vs. 1.8%, P = 0.017), and new organ failure (5.4 vs. 0.4%, P = 0.003) were significantly higher in the plastic stent cohort compared to LAMS. On multivariable logistic regression analysis, the use of plastic stents (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.2-6.0, P = 0.014), patients receiving high-acuity care (OR 5.1, 95% CI 2.5-10.4, P < 0.001) and the presence of ≥33% of necrosis (OR 4.5, 95% CI 2.0-10.0, P < 0.001) were significantly associated with the presence of SIRS or new organ failure. While there was no significant difference in treatment success (96.4 vs. 95.5%, P = 0.77), duration of hospitalization was significantly longer for the plastic stent cohort (mean [standard deviation] 12.5 [17.8] vs. 7.9 [10.1] days, P = 0.009). Use of plastic stents as compared to LAMS was associated with a higher proportion of SIRS and new organ failure that prolonged hospital stay. Therefore, placement of LAMS is recommended in sick patients and those with ≥33% necrosis to minimize inflammatory response.

Impact of customized add-on nighttime bracing in full-time brace treatment of adolescent idiopathic scoliosis.

Retrospective cohort study. Bracing is an accepted standard therapy for idiopathic scoliosis at Cobb angle ranges between 25° and 40°. However, it is unclear, if a specifically tailored regimen of daytime and nighttime braces (= double brace) yields superior results compared to the standard treatment (single brace for day and night). One-hundred-fifteen patients with adolescent idiopathic scoliosis (AIS) were assessed before initiation of bracing treatment and at the final follow-up 2 years after deposition of the brace. They were divided into two groups: double-brace group (n = 66, 4 male, 62 female, age 13.1 ± 1.9 (mean ± SD), primary curvature thoracic n = 35, lumbar n = 31) and single-brace group (n = 49, 8 male, 41 female, age 14.1 ± 1.9, primary curvature thoracic n = 18, lumbar n = 31). Each patient underwent clinical and radiological examinations and Cobb angles were measured. Both therapy regimens succeeded to either stop progression or improve scoliosis in over 85% of cases. The nighttime brace showed a significantly higher primary correction than the daytime brace. Nevertheless, there was no significant difference in treatment success in the 2-year follow-up (p = 0.58). It seems to be sufficient to treat idiopathic scoliosis with one well-tailored brace for day- and nighttime.

Intravenous to oral transition of antibiotics for gram-negative bloodstream infection at a University hospital in Thailand: Clinical outcomes and predictors of treatment failure

BackgroundLimited studies evaluate the outcome of intravenous antibiotics to oral transition in Gram-negative bloodstream infection (GN-BSI), particularly GN-BSI originating outside the urinary tract. This study aimed to evaluate treatment success in patients with GN-BSI treated with either intravenous therapy or intravenous to oral transition and to identify factors associated with treatment failure in those undergoing intravenous to oral transition.MethodsA retrospective cohort study was conducted at King Chulalongkorn Memorial Hospital, Thailand. Patients were included if they were ≥18 years of age, hospitalized in general medical wards with GN-BSI between August 1, 2015, to July 31, 2020, received intravenous antibiotic agents and had a functioning gastrointestinal tract.ResultsOf 955 patients, 545 (57.1%) were in the intravenous to oral transition group. The urinary tract was the most common source of infection (38.8%). Ciprofloxacin was the most prescribed oral antibiotic (53%). Treatment success occurred in 94.3% in the intravenous antibiotic to oral transition group. There was no significant difference in treatment success between the two groups (P = 0.790) with a concordant result after using propensity score matching (P = 0.223). Independent predictors of treatment failure in the intravenous to oral transition group included metastatic solid cancer (aOR = 4.355), HIV infection with CD4 < 200 cells/mm3 (aOR = 8.452), qSOFA score ≥ 2 (aOR = 2.545), multidrug-resistant infection (aOR = 2.849), and respiratory tract infection (aOR = 8.447). Hospital length of stay in the intravenous to oral transition group was shorter than in the intravenous group (P < 0.001).ConclusionsIntravenous to oral transition may be a practical approach in GN-BSI. Patients with Gram-negative bacteremia who have HIV infection with CD4 < 200 cells/mm3, multidrug-resistant infections, and respiratory tract sources of infection may not be ideal candidates for this approach. Future research is needed from a randomized controlled trial.

Non-surgical management of tubal ectopic pregnancy: A systematic review and meta-analysis.

Background:Ectopic pregnancy (EP) is a common cause of acute abdominal pain in the field of gynecology. Because the majority of women with EP are hemodynamically stable, non-surgical therapy is a viable option. The goal of this study was to determine the most effective non-surgical therapy for hemodynamically stable EP.Methods:We performed a systematic review and meta-analysis. We searched PubMed, LILACS, SciELO, CINAHL, Embase, and the Cochrane library in May 2020, with no starting date restrictions.Studies were restricted to randomized controlled trials, which were included if the target population contained women with tubal EP and the intervention was non-surgical management. The primary outcome measure was treatment success defined by a decrease in serum hCG to a level ranging from five mIU/mL to 50 mIU/mL. Secondary outcome measures were side effects, time needed to treat, number of injections and operative rate.Results:We conducted a meta-analysis of 15 studies that included 1573 women who were diagnosed with EP and managed non-surgically. There was no significant difference in treatment success in the matched groups; however, single-dose MTX was associated with fewer side effects than multiple-dose (relative risk 0.48, 95% confidence interval 0.28–0.80, P = .006) and two-dose therapies (relative risk 0.74, 95% confidence interval 0.55–1.00, P = .05).Conclusions:We highly recommend that single-dose MTX without mifepristone be used first-line in patients who require conservative therapy due to the inherent negative effects of mifepristone. An EP woman with a low -hCG level that is falling or plateauing should receive expectant treatment to reduce adverse effects.

Effect of Premature Tube Extrusion for Simple Congenital Nasolacrimal Duct Obstruction: A Comparison of Monocanalicular and Bicanalicular Intubation.

The objective of this article is to compare the incidence of premature dislocation of silicone tubes and the effect on treatment success between monocanalicular (MCI) and bicanalicular (BCI) intubation in pediatric patients with simple congenital nasolacrimal duct obstruction. Retrospective comparative case series of 108 eyes of 78 pediatric patients with simple congenital nasolacrimal duct obstruction who underwent probing with either BCI (n = 38 eyes) or MCI (n = 70 eyes) from 2017 to 2020. Premature tube extrusion was defined as any tube removed prior to the 3 month postoperative appointment. Success was defined as resolution of tearing 3 months post tube removal. Ages ranged from 10 months to 5.35 years (mean, 1.95 years; Standard deviation (SD), 0.91). Premature tube extrusion occurred in 15 eyes with BCI and 29 eyes with MCI. Success rates were not significantly different regardless of intubation type between the planned tube removal (90.6%) and the premature tube extrusion cohorts (84.1%), P = 0.89. There was no significant difference in treatment success between the planned tube removal (92.7% MCI, 87% BCI) and the premature tube extrusion cohorts (86.2% MCI, 80% BCI). Complications included 2 infections (1 MCI, 1 BCI) and 2 cases of tube related keratopathy (1 MCI, 1 BCI) that all resolved with tube removal. There were 2 BCI patients that presented to the emergency department for premature tube extrusion. Silicone intubation regardless of stent type is an effective treatment for simple congenital nasolacrimal duct obstruction. There was no significant difference in treatment success between tubes that extrude prematurely, and tubes removed at term based on type of intubation.

Relationship between Higher Order Aberrations and Astigmatism in Hyperopic Amblyopia

Aim. To study the dynamics of changes in the values of higher order aberrations in amblyopia treatment and the correlation between higher-order aberrations and astigmatism in patients with hyperopic amblyopia.Methods. This cohort prospective study included 36 patients (36 eyes) with refractive amblyopia aged 4 to 16 years. All patients had anisometropia: emmetropia in one eye and hyperopic astigmatism combined with refractive amblyopia of varying degrees in the other eye. Patients were divided into two groups depending on the degree of astigmatism. Astigmatism greater than 1.5 D was detected in 20 patients (55.5%) and astigmatism less than 1.5 D was detected in 16 patients (44.5%). All patients underwent a complex treatment, including twenty half-hour sessions of videocomputer autotraining using “Amblyotron” device during 20 days, in addition to constant wearing of glasses. Higher order aberrations were measured using the WaveScan Wavefront System aberrometer at the first visit and at 3-, 6 - and 12-month follow-up. A correlation analysis was performed to assess the relationship between higher order aberrations and astigmatism.Results. There was a statistically significant difference in treatment success between groups with high and low astigmatism. In both groups, higher order aberrations were reduced during the treatment of amblyopia. When comparing the two groups, a significant difference in coma was found at 12-month follow-up (p = 0.043). At 12-month follow-up, coma showed a statistically significant correlation with astigmatism, and a stronger correlation with astigmatism was found in the group of patients with high astigmatism.Conclusions. In patients with refractive amblyopia associated with astigmatism, the decrease in visual acuity is directly dependent on the values of higher-order aberrations, especially on the values of coma, which should be considered as the cause of the development of amblyopia.

Comparison of radioiodine ablation rates between low versus high dose, and according to the surgeon's expertise in the low-risk group of differentiated thyroid cancer.

Radioiodine ablation following surgery is the accepted treatment for patients with differentiated thyroid cancer (DTC). Since that surgical volume and radioiodine dose can have impact on treatment outcome, we aimed to evaluate them on the treatment outcome of low-risk DTC patients. Low-risk DTC patients were classified into four groups, including (1) thyroidectomy was performed by thyroid surgeon and low-dose (1850 MBq [30 mCi]) radioiodine was administered (n = 17), (2) thyroidectomy was performed by thyroid surgeon and high-dose (3700 MBq [100 mCi]) radioiodine was administered (n = 10), (3) thyroidectomy was performed by general surgeon and low-dose radioiodine was administered (n = 22), and (4) thyroidectomy was performed by general surgeon and high-dose radioiodine was administered (n = 29). All patients were followed at least for 6 months and also for evaluation of treatment success, neck sonography, thyroid-stimulating hormone-off, thyroglobulin (Tg)-off, and anti-Tg-off tests were performed. Furthermore, two common radioiodine treatment-associated side effects, including dry mouth, and nausea/vomiting were assessed for all patients. Seventy-eight low-risk DTC patients (female: 70 [89.7%]; male: 8 [10.3%]) aged from 18 to 78 years old with mean of 41.96 ± 13.42 years were enrolled in this study. In total, the treatment was successful in 96.2% of patients. There was no significant difference in treatment success among groups (P > 0.05), while there was a significant association among administered activity and side effects. In low dose patients, only one patient complained from dry mouth; however, 11/39 patients who received high dose of iodine complained from dry mouth (P = 0.002). In addition, 9/39 high dose patients suffered from vomiting/nausea, while none of low-dose patients suffered from vomiting/nausea (P = 0.001). In low-risk DTC patients, surgical volume and amounts of radioiodine had no significant impact on treatment results; therefore, low dose radioiodine following thyroidectomy may be preferable to low-risk DTC patients to avoid side effects.

Maternal Beslenmeye Eklenen Probiyotiklerin İnfantil Kolik Üzerine Etkisi: Sistematik Bir İnceleme ve Meta-analiz

Objective: This study thoroughly evaluates the available evidence examining the effect of probiotics and derivatives added to maternal nutrition on infantile colic. Material and Methods: A comprehensive, systematic search of PubMed, Web of Science, the Cochrane Library, CINAHL and ULAKBİM databases was completed. In the systematic review, we examined the evidence about probiotics that could potentially be included. Contrary to what is usual, our review included maternal nutrition, but not infant feeding. Outcomes data including treatment success and crying times of infantile colic were collected to conduct an analysis. Meta-analysis of study outcomes was performed using Review Manager. The Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) approach was used to assess the quality of the body of evidence for each outcome of this meta-analysis. PROSPERO; registration number CRD42020155237. Results: In the review, 4 studies (1,110 participants) were included. The agreement between the 2 researchers was excellent, with Cohen kappa scores [95% confidence interval (CI)]=0.95 (I0.88-1) for article selection and 0.97 (I0.92-1) for bias scoring. The end of the intervention did not find a significant difference in treatment success between the 2 groups [risk ratio (RR) 1.14; 95% CI (0.4, 2.71)]. In a sensitivity analysis using the fixed effect model, we found a significant difference in favor of probiotics [RR 0.92; 95% CI (0.60, 1.42)]. Conclusion: Research suggests that the addition of some probiotics in the diet of mothers is reasonable for the treatment of infantile colic. However, more research is needed.

Safety and efficacy of sofosbuvir and daclatasvir in the treatment of chronic HCV infection in elderly Egyptian patients Mohamad B. Bastawy, Mostafa A. Elhawary, Mohamed G. Mohamed and Mohamad R. Rashed, Department of Hepatogastroentrology and infectious diseases, Faculty of Medicine, Al-Azhar University-Cairo

Background: Chronic Hepatitis-C virus [HCV] infection is endemic in Egypt, with the highest prevalence worldwide. There are few studies on the effectiveness and safety of direct acting antivirals in treating geriatric patients with chronic HCV. Aim of the work: This study aimed to determine the efficacy and safety of sofosbuvir and daclatasvir with or without ribavirin in treating chronic HCV infection in geriatric Egyptian patients. Patients and Methods: In this study, we analyzed the medical files of 100 patients with chronic HCV, ≥ 65 years old, naive, and eligible for HCV treatment. Patients were classified into: Group I; 50 patients without cirrhosis and Group II; 50 patients with Cirrhosis. All patients were subjected to history taking, clinical and laboratory evaluation. Electrocardiogram [ECG] and echocardiography were also conducted. Polymerase chain reaction [PCR] for HCV- ribonucleic acid [RNA] was performed and compared between groups at baseline, at the end of treatment, and at 12 weeks later. All patients underwent an abdominal ultrasound and fibrosis-4 [FIB-4] score. Group I was treated with sofosbuvir 400 mg and daclatasvir 60 mg once daily for 12 weeks, while weight-based ribavirin was added in group II. Results: Overall, 95 patients achieved sustained virological response[SVR]-12, three had failed treatment, and two had relapse. There were no significant differences in treatment success between the groups after treatment completion [HCV RNA was below the detection limit in 49 patients in group I and 48 patients in group II] and 12 weeks later [HCV RNA was below the detection limit in 48 patients in group I and 47 patients in group II], with one patient in group I and two patients in group II had failed treatment. There was also a significant decrease in alanine transaminase [ALT] and aspartate transaminase [AST] in both groups after treatment completion. Some patient symptoms like easy fatigability and dyspepsia have been improved with no significant cardiac changes after therapy.Conclusions: Sofosbuvir and daclatasvir with or without ribavirin are safe and effective in treating elderly Egyptian patients with chronic HCV infection.

Outcomes of a Structured, Stepwise Approach to Endoscopic Necrosectomy.

Despite the increasing number of procedures being performed, there is no consensus on the optimal approach to performing direct endoscopic necrosectomy (DEN), which is a labor-intensive, nonstandardized intervention. We prospectively validated the usefulness of a predefined, structured, stepwise approach to DEN with the objective of improving procedural efficiency and resource use. A prospective study of patients with necrotizing pancreatitis who after endoscopic transluminal drainage did not have clinical improvement and required DEN. The study was undertaken in 2 phases. Phase I was a retrospective analysis of interventions performed using an unstructured, conventional approach. Median of 3 necrosectomy sessions (range, 2 to 3) were required to achieve 80% treatment success in 20 patients. On the basis of these observations, a structured approach that included 3 steps (debridement, necrosis extraction, and irrigation) was developed and validated prospectively in phase II in 39 patients. The main outcome was to compare procedural efficiency defined as a number of necrosectomy sessions to achieve treatment success. Although there was no significant difference in treatment success (phase I=80.0 vs. phase II=94.9%, P=0.17), the procedure was more efficient in phase II [median session, 2 (interquartile range=1 to 3) vs. 3 (interquartile range=2 to 3); P=0.003]. Multiple logistic regression analysis revealed that a structured, stepwise approach was associated with fewer necrosectomy sessions to achieve treatment success (odds ratio=4.7; 95% confidence interval=1.5-15.0; P=0.008) when adjusted for patient demographics, lab parameters, and disease characteristics. By decreasing the number of necrosectomy sessions, a structured, stepwise approach to endoscopic necrosectomy seems to improve procedural efficiency.

Echinocandins versus non-echinocandins for empirical antifungal therapy in patients with hematological disease with febrile neutropenia: A systematic review and meta-analysis

Empirical antifungal therapy is recommended in high-risk patients who have persistent febrile neutropenia (FN) despite broad-spectrum antibiotic therapy. Based on high-quality evidence, most guidelines recommend caspofungin. The aim of this study was to clarify whether echinocandins, including micafungin, are associated with improved clinical outcomes in patients with persistent FN. We conducted a meta-analysis of randomized controlled trials (RCTs) of empirical therapy with echinocandins and non-echinocandins for FN in patients with hematological disease. The primary outcome was all-cause mortality within 7 days after completion of therapy. Secondary outcomes included treatment success, and discontinuation of therapy because of adverse events. For subgroup analysis, we compared RCTs of echinocandins with liposomal amphotericin B. Six RCTs (four that evaluated caspofungin and two that evaluated micafungin) were included in the meta-analysis. Mortality and adverse events in echinocandin-treated patients were significantly lower than in those treated with non-echinocandins [risk ratio (RR) 0.70, 95% confidence interval (CI) 0.49–0.99; RR 0.48, 95% CI 0.33–0.71, respectively]. There was no significant difference in treatment success (RR 1.09, 95% CI 0.87–1.36). Mortality and adverse events in echinocandin-treated patients were significantly lower than in those treated with liposomal amphotericin B (RR 0.68, 95% CI 0.46–0.99; RR 0.53, 95% CI 0.37–0.74, respectively). In conclusion, patients with persistent FN treated with echinocandins had decreased risk of death and adverse events. Both caspofungin and micafungin may be recommended as first-line empirical antifungal therapy in these patients. However, the small number of enrolled patients and the lack of RCTs involving pediatric patients should be considered when using micafungin.

Assessment of three pharmacological agents following arthrocentesis for the treatment of internal derangement of the temporomandibular joint; a clinical study

Temporomandibular disorder (TMD) includes disorders of the temporomandibular joint (TMJ) and masticatory muscles and their associated structures. It is characterized by pain, joint sounds and restricted mandibular movement. Pharmacological agents commonly used for the treatment of TMDs include non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids, muscle relaxants, antidepressants, anticonvulsants and benzodiazepines.Objectives: In the present study, we compared the clinical outcome of intra-articular injections of NSAIDs, corticosteroids, Hyaluronic acid given after temporomandibular joint arthrocentesis. Materials and methods: Twenty-seven patients suffering internal derangement of the temporomandibular joint and not responding to conservative therapy were randomly classified into three equal groups. In group A joint lavage was followed by 1ml of piroxicam injection. In group B joint lavage followed by 1 ml of dexamethasone injection and in group C joint lavage was followed by 1 ml of Hyalgan injection. The treatment outcome was evaluated clinically by measuring the maximal mouth opening in mm at 2 weeks and 3 months postoperatively. Pain was measured using the Visual Analogue Scale at the study intervals. These data were statistically analyzed. Results: All drugs were able to demonstrate a reduction in pain intensity and improvement in mouth opening at 2 weeks and 3 months postoperatively. No significant differences in treatment success were found among the three groups (P > 0.05) through the study intervals. Conclusion: We concluded that arthrocentesis with Piroxicam, dexamethasone or Hyalgan are similarly effective and are promising methods in relieving the symptoms of TMJ with non-reducing disc displacement. Additional prospective studies are required to confirm the adequate dosage of each treatment protocol, frequency of the injections required and combination between those protocols and other modalities in order to achieve long-term results.

Prosthetic joint infections: is guideline-consistent surgical treatment beneficial?

Background: The diagnosis and treatment of prosthetic joint infection (PJI) remains challenging. In 2013, both the Infectious Diseases Society of America (IDSA) guidelines and an international consensus’ recommendation on PJI were published, providing a consistent approach to PJI management. We undertook a study to compare outcomes of PJI managed in accordance with IDSA versus those managed outside of the same. Methods: This retrospective cohort study of a consecutive series of patients who had total joint replacement (TJR) with subsequent deep PJI was undertaken to determine historical clinical variation relative to recently established management guidelines. All operations were completed at one arthroplasty center over a 5-year period predating IDSA guideline development. Results: Of 8505 patients who had TJR, 267 (3.1%) were diagnosed with subsequent PJI. Of these, 42/8505 (0.5%) had culture positive deep PJI, with 38/42 (90.5%) managed surgically. The odds of treatment failure among cases not managed in accordance with IDSA were 11 times greater as compared to guideline-accordant cases (OR 11, 95%CI 1.84-65.7; P=0.006). This difference was most pronounced among those who had irrigation and debridement. We could not demonstrate any significant difference in treatment success or failure for one-stage or two-stage exchange. Conclusions: Surgical management of PJI in accordance with existing guidelines can optimize success of PJI treatment. In particular, aggressive surgical treatment (including prosthesis removal) is likely warranted in patients who had symptoms of PJI for longer than 3 wk. In a patient in whom deviation from existing guidelines is considered, it is important for physicians to weigh the risk of inferior outcome and counsel the patient accordingly.

Systematic review and meta-analysis of the effect of probiotic supplementation on functional constipation in children.

To evaluate the effect of probiotic supplementation on functional constipation in children. We performed electronic searches in PubMed, Embase, and Cochrane Library without language restriction to identify relevant studies from the time of inception of these databases to March 2018. The relative risk or weighted mean difference was calculated to evaluate the treatment effect of probiotics using random-effects model. We included 4 trials reporting data on 382 children with functional constipation. Overall, there were no significant differences in treatment success (P = .697), spontaneous bowel movements per week (P = .571), fecal soiling episodes per week (P = .642), straining at defecation (P = .408), use of lactulose (P = .238), use of laxatives (P = .190), fecal incontinence (P = .139), pain during defecation (P = .410), flatulence (P = .109), and adverse events (P = .979) between probiotics and placebo. Further, the use of probiotics was associated with lower frequency of glycerin enema use (weighted mean difference -2.40, P = .004) and abdominal pain (weighted mean difference -4.80, P < .001). The findings of this study suggested that the use of probiotics was associated with significant improvement in glycerin enema use and abdominal pain but did not affect the treatment success and other function indices.

The optimal duration of alarm therapy use in children with primary monosymptomatic nocturnal enuresis

The prevalence of primary monosymptomatic nocturnal enuresis (PMNE) has a range of 1.6-5.3% in adolescents and 7.5-12.4% in children of 5-10 years. Alarm intervention has been well known for more than 30 years. This method is a reliable and safe means of treating primary monosymptomatic nocturnal enuresis, being effective in 60-80% of cases. The objective of this study was to determine the efficacy of alarm intervention prolongation after the cure in order to reduce the risk of disease recurrence. Two hundred ninety-four boys and 161 girls (455 persons in total) of age 9-14 years (average 11.4 years) took part in the prospective randomized study. After preselection and establishing diagnosis, all patients were randomly divided in three groups. In group А (n=139) alarm system treatment was carried out within 12 weeks, in group В (n=136) 16 weeks, and in group С (n=139) 20 weeks. The percentage of patients who no longer wet the bed (for 2 weeks or more) immediately after treatment in groups B (80.7%) and C (85.5%) was higher than in group A (67.4%) if the probability of error is pB/A<0.05; pC/A<0.05. There was no statistically significant difference in treatment success between groups B and C immediately after treatment. The percentage of patients who no longer wet the bed 3 months after the end of treatment in groups B (71.2%) and C (77.1%) was higher than in the group A (45.9%) if the probability of error is pB/A<0.05; pC/A<0.05. There was no statistically significant difference in treatment success between groups B and C 3 months after treatment. During the year this ratio did not change. These data suggest that the effective duration of alarm intervention is found in the range 16-20 weeks and involves an uninterrupted course of treatment. Perhaps this range of time is optimal for the formation of a neuroreflexive mechanism that creates a habit for independent awakening in children with primary monosymptomatic nocturnal enuresis. The effective duration of alarm intervention is likely to be 16-20 weeks of an uninterrupted course of treatment. This time interval ensures the maximum effectiveness of treatment and the stability of long-term results.