Observational versus antibiotic therapy for acute uncomplicated diverticulitis: A non-inferiority meta-analysis based on a Delphi consensus

Comparison of Recombinant Human Thyroid-Stimulating Hormone and Thyroid Hormone Withdrawal for 131 I Therapy in Patients With Intermediate- to High-Risk Thyroid Cancer : A Systematic Review and Meta-analysis

BACKGROUND

This meta-analysis and systematic review aimed to evaluate the therapeutic efficacy and advantages associated with the use of recombinant human thyroid-stimulating hormone (rhTSH) for radioactive iodine (RAI) therapy in patients with intermediate- to high-risk differentiated thyroid cancer.

PATIENTS AND METHODS

MEDLINE, EMBASE, and Cochrane databases were searched to identify relevant articles reporting clinical outcomes of rhTSH compared with thyroid hormone withdrawal (THW) in patients with intermediate- to high-risk differentiated thyroid cancer published between January 2012 and June 2023. Meta-analyses were performed (PROSPERO registration number: CRD42022340915) to assess the success rate of radioiodine remnant ablation (RRA) in patients with intermediate to high risk and determine the disease control rate among patients with distant metastases, evaluated using the RECIST criteria.

RESULTS

Thirteen studies involving 1858 patients were included in the meta-analysis. Pooled analyses revealed significantly higher overall RRA success rate in the rhTSH group compared with the THW group, with a risk ratio (RR) of 1.12 (95% confidence interval [CI], 1.01-1.25). However, in the subgroup analysis of high-risk patients, pooled analyses showed no significant differences in RRA success rate between the rhTSH group compared with the THW group with a pooled RR of 1.05 (95% CI, 0.88-1.24). In patients with distant metastases, there were no significant differences in the disease control rate between groups, with a pooled RR of 1.06 (95% CI, 0.78-1.44).

CONCLUSIONS

rhTSH for RAI therapy is a practical option for RAI therapy in patients with intermediate- to high-risk thyroid cancer, including those with distant metastases.

Efficacy of antimicrobial therapy in patients with uncomplicated acute colonic diverticulitis: an updated systematic review and meta-analysis

The need for antimicrobial therapy for uncomplicated acute diverticulitis of the colon remains controversial. We conducted a systematic review of the efficacy of antimicrobial agents against this disease, including new randomized controlled trials (RCTs) reported in recent years, and evaluated their efficacy using a meta-analytic approach. RCTs were searched using PubMed, EMBASE, Google Scholar, Cochrane Library, Ichushi-Web, and eight registries. Keywords were 'colonic diverticulitis', 'diverticulitis', 'antimicrobial agents', ''antibiotics, 'complication', 'abscess', 'gastrointestinal perforation', 'gastrointestinal obstruction', 'diverticular hemorrhage', and 'fistula'. Studies with antimicrobial treatment in the intervention group and placebo or no treatment in the control group were selected by multiple reviewers using uniform inclusion criteria, and data were extracted. Prevention of any complication was assessed as the primary outcome, and efficacy was expressed as risk ratio (RR) and risk difference (RD). A meta-analysis was performed using 5 RCTs of the 21 studies that were eligible for scrutiny in the initial search and which qualified for final inclusion. Three of these studies were not included in the previous meta-analysis. Subjects included 1039 in the intervention group and 1040 in the control group. Pooled RR = 0.86 (95% confidence interval, 0.58-1.28) and pooled RD = -0.01 (-0.03 to 0.01) for the effect of antimicrobial agents in reducing any complications. Recurrences, readmissions, and surgical interventions did not significantly show the efficacies of using antimicrobial agents. A meta-analysis of recently reported RCTs did not provide evidence that antimicrobial therapy improves clinical outcomes in uncomplicated acute diverticulitis of the colon.

Treatment for acute uncomplicated diverticulitis without antibiotherapy: systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Use of antibiotics in selected cases of acute uncomplicated diverticulitis (AUD) has recently been questioned.

OBJECTIVE

The aim of this study is to examine the safety and efficacy of treatment regimens without antibiotics compared with that of traditional treatments with antibiotics in selected patients with AUD.

DATA SOURCES

PubMed, Medline, Embase, Web of Science, and the Cochrane Library.

METHODS

A systematic review was performed according to PRISMA and AMSTAR guidelines by searching through Medline, Embase, Web of Science, and the Cochrane Library for randomized clinical trials (RCTs) published before December 2022. The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis.

STUDY SELECTION

RCTs on treating AUD without antibiotics published in English before December 2022 were included.

INTERVENTION

Treatments without antibiotics were compared with treatments with antibiotics.

MAIN OUTCOME MEASURES

The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis.

RESULTS

The search yielded 1163 studies. Four RCTs with 1809 patients were included in the review. Among these patients, 50.1% were treated conservatively without antibiotics. The meta-analysis showed no significant differences between nonantibiotic and antibiotic treatment groups with respect to rates of readmission [odds ratio (OR)=1.39; 95% CI: 0.93-2.06; P =0.11; I2 =0%], change in strategy (OR=1.03; 95% CI: 0.52-2,02; P =0.94; I2 =44%), emergency surgery (OR=0.43; 95% CI: 0.12-1.53; P =0.19; I2 =0%), worsening (OR=0.91; 95% CI: 0.48-1.73; P =0.78; I2 =0%), and persistent diverticulitis (OR=1.54; 95% CI: 0.63-3.26; P =0.26; I2 =0%).

LIMITATIONS

Heterogeneity and a limited number of RCTs.

CONCLUSIONS

Treatment for AUD without antibiotic therapy is safe and effective in selected patients. Further RTCs should confirm the present findings.

Antibiotics vs observational therapy in acute uncomplicated diverticulitis, a systemic review and meta-analysis

PURPOSE

Antibiotics have long been recommended as a form of conservative therapy in patients with acute uncomplicated diverticulitis despite no supporting evidence. This meta-analysis aims to assess the difference in outcomes between observational therapy and antibiotics regime in patients with acute uncomplicated diverticulitis.

METHODS

Medline and Embase electronic databases were reviewed. A comparative meta-analysis in odds ratios (ORs) or mean difference (MD) was conducted using a random effects model for dichotomous and continuous outcomes, respectively. Randomized controlled trials comparing outcomes in patients with acute uncomplicated diverticulitis on observational therapy compared to antibiotics regime were selected. Outcomes of interest included all-cause mortality, complications, emergency surgery rates, length of stay, and recurrence.

RESULTS

A total of 7 articles looking at 5 different randomized controlled trials were included. A total of 2959 patients with acute uncomplicated diverticulitis comprising of 1485 patients on antibiotics therapy and 1474 patients on observational therapy were included in the comparison. We found that there was no statistically significant difference in all-cause mortality (OR = 0.98; 95% CI 0.53;1.81; p = 0.68), complications (OR = 1.04; 95% CI 0.36;3.02; p = 0.51), emergency surgery (OR = 1.24; 95% CI 0.70;2.19, p = 0.92), length of stay (M.D: -0.14, 95% CI -0.50;0.23, p < 0.001), and recurrent diverticulitis (OR 1.01; 95% CI 0.83;1.22, p < 0.91) between the two arms.

CONCLUSION

This systemic review and meta-analysis found that there is no statistically significant difference in outcomes between patients with acute uncomplicated diverticulitis who were put on observational therapy compared to the antibiotics regime. This suggests that observational therapy is an equally safe and effective therapy as compared to antibiotics therapy.

Impact of the Covid-19 pandemic on rates of emergency department utilization and hospital admission due to general surgery conditions

BACKGROUND

Recent literature reports a decrease in healthcare-seeking behaviours by adults during the Covid-19 pandemic. Given that emergency general surgery (GS) conditions are often associated with high morbidity and mortality if left untreated, the objective of this study was to describe and quantify the impact of the Covid-19 pandemic on rates of emergency department (ED) utilization and hospital admission due to GS conditions.

METHODS

This cohort study involved the analysis of an institutional database and retrospective chart review. We identified adult patients presenting to the ED in a network of three teaching hospitals in Montreal, Canada during the first wave of the Covid-19 pandemic (March13-May13, 2020) and a control pre-pandemic period (March13-May13, 2019). Patients with GS conditions were included in the analysis. ED utilization rates, admission rates and 30-day outcomes were compared between the two periods using multivariate regression analysis.

RESULTS

During the pandemic period, 258 patients presented to ED with a GS diagnosis compared to 351 patients pre-pandemically (adjusted rate ratio (aRR) 0.75; p < 0.001). Rate of hospital admission during the pandemic was also significantly lower (aRR = 0.77, p < 0.001). Patients had a significantly shorter ED stay during the pandemic (adjusted mean difference 5.0 h; p < 0.001). Rates of operative management during the pandemic were preserved compared to the pre-pandemic period. There were no differences in 30-day complications (adjusted odds ratio (aOR) 1.46; p = 0.07), ED revisits (aOR 1.10; p = 0.66) and (re)admissions (aOR 1.42; p = 0.22) between the two periods.

CONCLUSION

There was a decrease in rates of ED utilization and hospital admissions due to GS conditions during the first wave of the Covid -19 pandemic; however, rates of operative management, complications and healthcare reutilization were unchanged. Although our findings are not generalizable to patients who did not seek healthcare, it was possible to successfully uphold institutional standards of care once patients presented to the ED.