Effect of angioembolisation versus surgical packing on mortality in traumatic pelvic haemorrhage: A systematic review and meta-analysis

BACKGROUND: The management of complex pattern of bleeding associated with pelvic trauma remains a big challenge for trauma surgeons. We aimed to conduct a comprehensive meta-analysis to compare the outcomes of angioembolisation and pelvic packing in patients with pelvic trauma.METHODS: We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the CENTRAL; the World Health Organization International Clinical Trials Registry; Clinical Trials.gov; ISRCTN Register, and bibliographic reference lists. The primary outcome was defined as mortality. Combined overall effect sizes were calculated using randomeffects models. Results are reported as the odds ratio(OR) and 95% confidence interval(CI).RESULTS: We identified 3 observational studies reporting a total of 120 patients undergoing angioembolisation(n=60) or pelvic packing(n=60) for pelvic trauma. Reporting of the Injury Severity Score(ISS) was variable, with higher ISS in the pelvic packing group. The risk of bias was low in two studies, and moderate in one. The pooled analysis demonstrated that angioembolisation did not significantly reduce mortality in patients with pelvic trauma compared to surgery(OR=1.99; 95% CI= 0.83–4.78, P=0.12). There was mild between-study heterogeneity(I^2=0%, P=0.65).CONCLUSION: Our analysis found no significant difference in mortality between angioembolisation and pelvic packing in patients with traumatic pelvic haemorrhage. The current level of evidence in this context is very limited and insufficient to support the superiority of a treatment modality. Future research is required.

Confirming longline position in neonates-Survey of practice in England and Wales

AIM To establish how neonatal units in England and Wales currently confirm longline tip position, immediately after insertion of a longline.METHODS We conducted a telephone survey of 170 neonatal units(37 special care baby units, 81 local neonatal units and 52 neonatal intensive care units) across England and Wales over the period from January to May 2016. Data was collected on specifically designed proformas. We gathered information on the following: Unit Level designation; whether the unit used longlines and specific type used? Modality used to confirm longline tip position? Whether guide wires were routinely removed and contrast injected to determine longline position? The responders were primarily senior nurses.RESULTS We had 100% response rate. Out of the total neonatal units surveyed(170) in England and Wales, 141 units(83%) used longlines. Fifty-five out of 81 local neonatal units(68%) using longlines, used ones that came with guide wires; a similar percentage of neonatal intensive care units, i.e., 31 out of 52 units(60%) did the same. All of those units used radiography, plain X-rays, to establish longline tip position. Out of 55 local neonatal units usinglonglines with guide wires, 42(76%) were not removing wire to use contrast while this figure was 58%(18 out of 31 units) for neonatal intensive care units. Overall, only 49 out of 141 units(35%) of the units using longlines were using contrast. However it was interesting to note that use of contrast increased as one moved from special care baby units(25%, 2 out of 8 units) to local neonatal units(28%, 23 out of 81 units) and neonatal intensive care units level(46%, 24 out of 52 units) designation. CONCLUSION Neonatal units in England and Wales are overwhelmingly relying on plain radiographs to assess longline tip position immediately after insertion. Despite evidence of its usefulness, and in the absence of perhaps more accurate methods of assessing longline tip position in a reliable and consistent way, i.e., ultrasonography, contrast is only used in a third of units.

Multiple Sclerosis in Pregnancy—A Practical Guide for the Obstetrician

Technological advances, a deeper understanding of disease processes and increased sophistication of therapeutic methods have all led to better outcomes in rare diseases which previously had devastating effects on many women’s lives. The inevitable result of this progress is that women, who in the past did not contemplate pregnancy because of significant morbidity, now get to adulthood and are reasonably “disease free” enough to have their own families. The ever expanding, but relatively new specialty of Obstetric medicine seeks to further improve the outcome in pregnant women with intercurrent disease by enhancing the literature base, thereby contributing to the creation of appropriate guidance in the management of these patients. This article is a brief but useful guide for the busy obstetrician who may have limited experience in dealing with multiple sclerosis in pregnant women.

Laser vs microdebrider eustachian tuboplasty for the treatment of chronic adult eustachian tube dysfunction: A systematic review

Objectives:Multiple treatments are described in the literature for the treatment of chronic Eustachian tube dysfunction but high-level quality evidence seems missing to support these treatments.This systematic review aimed to determine and compare the safety and efficacy of Laser Eustachian tuboplasty and Microdebrider Eustachian tuboplasty as a treatment for long-term Eustachian tube dysfunction.Data sources:A total of 12 electronic databases were searched up to April 2018 for published and unpublished literature in the English language.References of included studies were checked.Methods:A systematic review was undertaken.Outcomes assessed were:primary outcomes-subjective improvement in symptoms(ETDQ-7),audiometric improvement of hearing,improvement of negative middle ear pressure noticed in tympanometry,objective improvement of tympanic membrane retraction.Secondary outcomes were-the ability to auto-insufflate Eustachian tube i.e.Valsalva manoeuvre,improved quality of life,passive tubal opening,tubomanometry,swallowing test,reduction in mucosal inflammation of Eustachian tube orifice in the nose,complications from the procedure,the need for further procedures.Results are reported in a narrative synthesis as a meta-analysis was not possible due to heterogeneous data.Results:Three studies were included.All included studies were small-scale case series(13-38 par-ticipants).Studies were conducted outside the UK.Subjective and objective improvement of Eustachian tube function was reported in all studies.But all included studies were at high risk of bias and subject to multiple limitations.No major complications were reported in either study.Conclusions:Based on current evidence,it is not possible to recommend the clinical use of either of these two interventions i.e.Laser or Microdebrider Eustachian tuboplasty.Lack of controlled studies was identified as a gap in the evidence.Future research should be directed toward designing randomised controlled trials.These trials should use strict standard methodology and reporting criteria.Future trials should make use of consensus statement document about Eustachian tube dysfunction definition,diagnostic methods,and outcome assessment criteria to design clinical trials.