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patiënten met diverticulitis en geïsoleerd pericolisch extraluminaal lucht initieel conservatief en laat de Overweeg patiënten met diverticulitis en geïsoleerd pericolisch extraluminaal lucht routinematig met antibiotica Overweeg bij patiënten met diverticulitis en geïsoleerd pericolisch extraluminaal lucht een routinematige Despite the frequent occurrence of pericolic extraluminal air in acute diverticulitis patients (up to ##%), little is known about the natural course and required treatment Current treatment is based on individual opinion and experiences and it is not clear whether extraluminal air should be considered mild diverticulitis with a benign disease course or complicated diverticulitis requiring more aggressive treatment Seven studies reported rates of need for emergency surgery during the initial episode of diverticulitis with pericolic extraluminal air Six of those studies reported crude data, yielding a pooled need for emergency surgery in #% of the patients (##% CI #% to ##%) <PERSOON> need for percutaneous abscess drainage was reported in # studies including only ## patients; no events were observed No adequate comparisons between uncomplicated patients and pericolic extraluminal air patients could be made Therefore, these results can only be compared with available rates from other literature including uncomplicated diverticulitis These rates of #% to #% need for emergency surgery in uncomplicated diverticulitis are slightly lower than the #% in pericolic interpretation of these results First, all studies were observational cohort studies and # out of the # studies were retrospective Second, most studies did not define the decision-making process for emergency surgery <PERSOON> presence of extraluminal air may lower the threshold for surgery because of the fear of progression into free perforation Consequently, the found rate of #% may be an overestimation Third, the need for percutaneous abscess drainage was only reported # studies including ## patients Since percutaneous interventions represent an increasing part of all interventions, the lack of reports about the need for percutaneous abscess drainage may have led to an underestimation of the actual need for interventions Fourth, since almost all studies treated the patients with Although the need for emergency surgery rate in pericolic extraluminal air patients is slightly higher than in uncomplicated patients, the vast majority has a benign course and does not need intervention This ##% success rate of non-operative treatment in these patients seems to justify a conservative approach Since evidence on non-antibiotic treatment of these patients is lacking, routine antibiotic treatment seems appropriate Also, due to the suggestion of a slightly more virulent course than uncomplicated diverticulitis patients, these patients seem not to be candidates for outpatient treatment Although approximately ##% of all acute diverticulitis patients have pericolic extraluminal air on computed tomography (CT), studies on the natural course in these patients are scarce and consensus about the treatment is lacking It is not clear whether these patients behave as mild uncomplicated diverticulitis or as severe diverticulitis needing more aggressive treatment Currently, these patients are treated based on personal.
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air may lower the threshold for surgery because of the fear of progression into free perforation Consequently, the found rate of #% may be an overestimation Third, the need for percutaneous abscess drainage was only reported # studies including ## patients Since percutaneous interventions represent an increasing part of all interventions, the lack of reports about the need for percutaneous abscess drainage may have led to an underestimation of the actual need for interventions Fourth, since almost all studies treated the patients with Although the need for emergency surgery rate in pericolic extraluminal air patients is slightly higher than in uncomplicated patients, the vast majority has a benign course and does not need intervention This ##% success rate of non-operative treatment in these patients seems to justify a conservative approach Since evidence on non-antibiotic treatment of these patients is lacking, routine antibiotic treatment seems appropriate Also, due to the suggestion of a slightly more virulent course than uncomplicated diverticulitis patients, these patients seem not to be candidates for outpatient treatment Although approximately ##% of all acute diverticulitis patients have pericolic extraluminal air on computed tomography (CT), studies on the natural course in these patients are scarce and consensus about the treatment is lacking It is not clear whether these patients behave as mild uncomplicated diverticulitis or as severe diverticulitis needing more aggressive treatment Currently, these patients are treated based on personal Ongeveer #% van de patiënten met diverticulitis en geïsoleerd pericolisch extraluminaal lucht De patiëntaantallen in de literatuur zijn vooralsnog te laag voor duidelijke conclusies ten aanzien Three prospective cohort studies (Lahat, ###; Mora, ###; Thorisson, ###) and # retrospective cohort studies Europe and # study in the United States of <PERSOON> Although all studies reported pericolic extraluminal air patients separately from distant free air patients, a wide variety of definitions for pericolic extraluminal air was used Only # studies clearly specified the location of the extraluminal air as within # centimetres of the inflamed bowel segment Other studies used definitions such as contained perforation, localized pericolic free air and air within the mesentery Since pericolic extraluminal air was not the primary aim of all studies, some studies applied inclusion criteria that may have caused selection bias in patients with pericolic extraluminal air <PERSOON> study particularly, only included patients without comorbidity and with absence of all systemic inflammatory response syndrome (SIRS) criteria (Mora, ###) Five studies treated all patients with antibiotics, # study (Thorisson, ###) only treated part of the patients with antibiotics and # study (Sallinen, ###) did not state anything about antibiotic treatment Need for emergency surgery was reported in # studies and need for percutaneous abscess drainage in # studies A control group was included in # studies Although, only # study (Mora, ###) compared the pericolic extraluminal air patients to uncomplicated diverticulitis patients <PERSOON> other two studies (Sallinen, ###; Thorisson, ###) made a comparison with a group of patients containing perforations or abscesses.
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in de literatuur zijn vooralsnog te laag voor duidelijke conclusies ten aanzien Three prospective cohort studies (Lahat, ###; Mora, ###; Thorisson, ###) and # retrospective cohort studies Europe and # study in the United States of <PERSOON> Although all studies reported pericolic extraluminal air patients separately from distant free air patients, a wide variety of definitions for pericolic extraluminal air was used Only # studies clearly specified the location of the extraluminal air as within # centimetres of the inflamed bowel segment Other studies used definitions such as contained perforation, localized pericolic free air and air within the mesentery Since pericolic extraluminal air was not the primary aim of all studies, some studies applied inclusion criteria that may have caused selection bias in patients with pericolic extraluminal air <PERSOON> study particularly, only included patients without comorbidity and with absence of all systemic inflammatory response syndrome (SIRS) criteria (Mora, ###) Five studies treated all patients with antibiotics, # study (Thorisson, ###) only treated part of the patients with antibiotics and # study (Sallinen, ###) did not state anything about antibiotic treatment Need for emergency surgery was reported in # studies and need for percutaneous abscess drainage in # studies A control group was included in # studies Although, only # study (Mora, ###) compared the pericolic extraluminal air patients to uncomplicated diverticulitis patients <PERSOON> other two studies (Sallinen, ###; Thorisson, ###) made a comparison with a group of patients containing perforations or abscesses Rates of emergency surgery were reported in ### patients and rates of percutaneous abscess drainage in ## patients Seven studies reported rates of emergency surgery Six studies provided crude data and could be pooled in a emergency surgery One study (Sallinen, ###) only reported an adjusted odds ratio for the need for emergency surgery (# ##, ##% CI # ## to # ##) However, since the control group consisted of all patients including free perforation, interpretation of this odds ratio is hampered A comparison of rates of emergency surgery between pericolic extraluminal air patients and uncomplicated diverticulitis patients was reported in # study (Mora, ###) In the pericolic extraluminal air group #% (#/##) underwent emergency surgery versus #% (#/##) in the Figure # Forest plot of pooled rate of need f or emergency surgery in pericolic extraluminal air <PERSOON> need for percutaneous abscess drainage was only reported in # studies From a combined total of ## patients, no patients underwent percutaneous abscess drainage Only # study compared the need for percutaneous abscess drainage between pericolic extraluminal air patients and uncomplicated diverticulitis De bewijskracht voor de uitkomstmaat noodzaak tot spoedoperatie begon op âlaagâ aangezien het bewijs afkomstig is uit observationeel onderzoek Vervolgens is de bewijskracht met één niveau verlaagd gezien De bewijskracht voor de uitkomstmaat noodzaak tot percutane abcesdrainage begon op âlaagâ aangezien het bewijs afkomstig is uit observationeel onderzoek Vervolgens is de bewijskracht met één niveau verlaagd gezien.
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of emergency surgery were reported in ### patients and rates of percutaneous abscess drainage in ## patients Seven studies reported rates of emergency surgery Six studies provided crude data and could be pooled in a emergency surgery One study (Sallinen, ###) only reported an adjusted odds ratio for the need for emergency surgery (# ##, ##% CI # ## to # ##) However, since the control group consisted of all patients including free perforation, interpretation of this odds ratio is hampered A comparison of rates of emergency surgery between pericolic extraluminal air patients and uncomplicated diverticulitis patients was reported in # study (Mora, ###) In the pericolic extraluminal air group #% (#/##) underwent emergency surgery versus #% (#/##) in the Figure # Forest plot of pooled rate of need f or emergency surgery in pericolic extraluminal air <PERSOON> need for percutaneous abscess drainage was only reported in # studies From a combined total of ## patients, no patients underwent percutaneous abscess drainage Only # study compared the need for percutaneous abscess drainage between pericolic extraluminal air patients and uncomplicated diverticulitis De bewijskracht voor de uitkomstmaat noodzaak tot spoedoperatie begon op âlaagâ aangezien het bewijs afkomstig is uit observationeel onderzoek Vervolgens is de bewijskracht met één niveau verlaagd gezien De bewijskracht voor de uitkomstmaat noodzaak tot percutane abcesdrainage begon op âlaagâ aangezien het bewijs afkomstig is uit observationeel onderzoek Vervolgens is de bewijskracht met één niveau verlaagd gezien extraluminaal lucht (eventueel met antibiotica) ten opzichte van een directe interventie, chirurgisch dan wel percutaan (eventueel met antibiotica) bij patiënten met diverticulitis met geïsoleerd pericolisch extraluminaal Interventie conservatieve behandeling van diverticulitis met pericolisch extraluminaal lucht (eventueel met De werkgroep achtte noodzaak tot spoedoperatie en/of percutane abcesdrainage voor de besluitvorming kritieke uitkomstmaten De werkgroep definieerde niet a priori de genoemde uitkomstmaten, maar hanteerde Verantwoording De literatuurzoekactie leverde ### treffers op Studies werden geselecteerd op grond van de Studies die een onderscheid maakten tussen de locatie van het extraluminale lucht waarbij voor deze uitgangsvraag studies die pericolisch extraluminaal lucht (of een verwant synoniem) apart beschreven Geïsoleerd pericolisch extraluminaal lucht (niet in combinatie met abces of lucht op afstand); Case reports en patiënten series van # patiënten of kleiner werden geëxcludeerd Op basis van titel en abstract werden in eerste instantie ### studies voorgeselecteerd Na raadpleging van de volledige tekst, werden vervolgens ### studies geëxcludeerd (zie exclusietabel onder het tabblad Zeven onderzoeken zijn opgenomen in de literatuuranalyse De belangrijkste studiekarakteristieken en resultaten <PERSOON> F, et al AVOD Study Group Randomized clinical trial of antibiotics in acute uncomplicated <PERSOON> A, et al Challenging a classic myth pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients A ##-year experience with a <PERSOON> SR, Birnbaum EH, et al <PERSOON> efficacy of nonoperative management of acute complicated diverticulitis <PERSOON> MK, Tomlin AM, Hayes IP, et al.
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directe interventie, chirurgisch dan wel percutaan (eventueel met antibiotica) bij patiënten met diverticulitis met geïsoleerd pericolisch extraluminaal Interventie conservatieve behandeling van diverticulitis met pericolisch extraluminaal lucht (eventueel met De werkgroep achtte noodzaak tot spoedoperatie en/of percutane abcesdrainage voor de besluitvorming kritieke uitkomstmaten De werkgroep definieerde niet a priori de genoemde uitkomstmaten, maar hanteerde Verantwoording De literatuurzoekactie leverde ### treffers op Studies werden geselecteerd op grond van de Studies die een onderscheid maakten tussen de locatie van het extraluminale lucht waarbij voor deze uitgangsvraag studies die pericolisch extraluminaal lucht (of een verwant synoniem) apart beschreven Geïsoleerd pericolisch extraluminaal lucht (niet in combinatie met abces of lucht op afstand); Case reports en patiënten series van # patiënten of kleiner werden geëxcludeerd Op basis van titel en abstract werden in eerste instantie ### studies voorgeselecteerd Na raadpleging van de volledige tekst, werden vervolgens ### studies geëxcludeerd (zie exclusietabel onder het tabblad Zeven onderzoeken zijn opgenomen in de literatuuranalyse De belangrijkste studiekarakteristieken en resultaten <PERSOON> F, et al AVOD Study Group Randomized clinical trial of antibiotics in acute uncomplicated <PERSOON> A, et al Challenging a classic myth pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients A ##-year experience with a <PERSOON> SR, Birnbaum EH, et al <PERSOON> efficacy of nonoperative management of acute complicated diverticulitis <PERSOON> MK, Tomlin AM, Hayes IP, et al a multicentre state-wide study <PERSOON> E, et al Acute diverticulitis a decade of prospective follow-up <PERSOON> L, <PERSOON> X, et al Application of a modified Neff classification to patients with uncomplicated Sallinen VJ, Mentula PJ, Leppaniemi AK Nonoperative management of perforated diverticulitis with extraluminal air is safe Sallinen VJ, Leppaniemi AK, Mentula PJ Staging of acute diverticulitis based on clinical, radiologic, and physiologic <PERSOON> MR, et al CT imaging for prediction of complications and recurrence in acute Is laparoscopische lavage en drainage zonder resectie een veilig alternatief voor Hinchey # patiënten? Overweeg bij een patiënt met purulente peritonitis door diverticulitis laparoscopische lavage te verrichten als alternatief voor een sigmoïdresectie maar weeg hierbij de klinische conditie, patiëntkarakteristieken, expertise van de operateur en patiëntvoorkeuren over gewenste uitkomsten mee; meer reïnterventies en morbiditeit op korte termijn; minder re-operaties, minder stomaâs en lagere kosten op lange termijn Overweeg om bij het verrichten van laparoscopische lavage het infiltraat niet te verwijderen of in grote mate te manipuleren om te voorkomen dat een gedekte perforatie alsnog een vrije perforatie wordt Following several observational studies with promising results of laparoscopic lavage in Hinchey stage # diverticulitis patients (success rate of ##%, mortality of #% and morbidity of ##% (Toorenvliet, ###), three randomized clinical could not confirm these success rates Laparoscopic lavage patients needed more shortterm (# month) reoperations (pooled ##% versus #%; RR #.
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a multicentre state-wide study <PERSOON> E, et al Acute diverticulitis a decade of prospective follow-up <PERSOON> L, <PERSOON> X, et al Application of a modified Neff classification to patients with uncomplicated Sallinen VJ, Mentula PJ, Leppaniemi AK Nonoperative management of perforated diverticulitis with extraluminal air is safe Sallinen VJ, Leppaniemi AK, Mentula PJ Staging of acute diverticulitis based on clinical, radiologic, and physiologic <PERSOON> MR, et al CT imaging for prediction of complications and recurrence in acute Is laparoscopische lavage en drainage zonder resectie een veilig alternatief voor Hinchey # patiënten? Overweeg bij een patiënt met purulente peritonitis door diverticulitis laparoscopische lavage te verrichten als alternatief voor een sigmoïdresectie maar weeg hierbij de klinische conditie, patiëntkarakteristieken, expertise van de operateur en patiëntvoorkeuren over gewenste uitkomsten mee; meer reïnterventies en morbiditeit op korte termijn; minder re-operaties, minder stomaâs en lagere kosten op lange termijn Overweeg om bij het verrichten van laparoscopische lavage het infiltraat niet te verwijderen of in grote mate te manipuleren om te voorkomen dat een gedekte perforatie alsnog een vrije perforatie wordt Following several observational studies with promising results of laparoscopic lavage in Hinchey stage # diverticulitis patients (success rate of ##%, mortality of #% and morbidity of ##% (Toorenvliet, ###), three randomized clinical could not confirm these success rates Laparoscopic lavage patients needed more shortterm (# month) reoperations (pooled ##% versus #%; RR # ## to # ##) and percutaneous reinterventions than patients that underwent immediate sigmoid resection Also serious morbidity rates were slightly higher in the laparoscopic lavage group after # months (pooled ##% versus ##%; RR # ##, ##% CI # ## to # ##), just as the slightly higher risk of mortality after # month (pooled #% versus #%; RR # ##, ##% CI # ## to # ##) In the long-term however, reoperation and mortality occurred slightly less often in the laparoscopic lavage # ## to # ## respectively) Although, the higher number of reoperations in the resection group is mostly caused by a higher number of stoma reversal surgeries Although this type of surgery cannot be considered as a outcome significantly in favour of laparoscopic lavage in long-term was the number of patients with a stoma at ## months (RR # ##; ##% CI # ## to # ##) Furthermore, the medical costs were lower in the laparoscopic lavage group with a mean costs savings of â¬#,### (##% CI â¬##,### - â¬###) Although the level of evidence is high since it is based on randomized clinical trials, some limitations should also be addressed <PERSOON> DILALA trial only reported per-protocol analyses of short-term outcomes This may have caused a bias with reference to the intention-to-treat analyses in the other trials Particularly the pooled # month reoperation risk may have been influenced by this limitation Furthermore, the SCANDIV trial included patients with an intraoperative diagnosis.
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# ##) and percutaneous reinterventions than patients that underwent immediate sigmoid resection Also serious morbidity rates were slightly higher in the laparoscopic lavage group after # months (pooled ##% versus ##%; RR # ##, ##% CI # ## to # ##), just as the slightly higher risk of mortality after # month (pooled #% versus #%; RR # ##, ##% CI # ## to # ##) In the long-term however, reoperation and mortality occurred slightly less often in the laparoscopic lavage # ## to # ## respectively) Although, the higher number of reoperations in the resection group is mostly caused by a higher number of stoma reversal surgeries Although this type of surgery cannot be considered as a outcome significantly in favour of laparoscopic lavage in long-term was the number of patients with a stoma at ## months (RR # ##; ##% CI # ## to # ##) Furthermore, the medical costs were lower in the laparoscopic lavage group with a mean costs savings of â¬#,### (##% CI â¬##,### - â¬###) Although the level of evidence is high since it is based on randomized clinical trials, some limitations should also be addressed <PERSOON> DILALA trial only reported per-protocol analyses of short-term outcomes This may have caused a bias with reference to the intention-to-treat analyses in the other trials Particularly the pooled # month reoperation risk may have been influenced by this limitation Furthermore, the SCANDIV trial included patients with an intraoperative diagnosis Since laparoscopic lavage may only be a promising treatment option in Hinchey stage # patients, this incorrect composition of the groups may have masked the true treatment effect in Hinchey # patients Consensus about the importance of the different outcomes in determining future treatment strategies is lacking, which is reflected by the differences in definition of primary endpoints in the trials Reinterventions and morbidity are important outcomes for patients, but a slightly higher rate may be accepted if mortality in the long-term is not increased as a result, especially in the type of patients with perforated diverticulitis (high age and present comorbidity) Percutaneous drainage may even be considered a part of the treatment strategy when performing laparoscopic lavage rather than a complication Patients may also consider the significantly higher stoma rates at long-term â that are therefore likely to be permanent â in the resection group an important factor impairing their quality of life On the other hand, the LADIES trial reported significantly more patients with a recurrent episode of acute diverticulitis within ## months in the laparoscopic lavage group; ##% (#/##) versus #% (#/##) in the resection group Based on these three randomized clinical trial, laparoscopic lavage seemed to result in more reverse However, most found associations were not significant which may be partially caused by the early termination of the LADIES trial <PERSOON> forthcoming data of the fourth randomized clinical trial (LapLAND trial) may increase the total sample size enabling more firm conclusions.
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may only be a promising treatment option in Hinchey stage # patients, this incorrect composition of the groups may have masked the true treatment effect in Hinchey # patients Consensus about the importance of the different outcomes in determining future treatment strategies is lacking, which is reflected by the differences in definition of primary endpoints in the trials Reinterventions and morbidity are important outcomes for patients, but a slightly higher rate may be accepted if mortality in the long-term is not increased as a result, especially in the type of patients with perforated diverticulitis (high age and present comorbidity) Percutaneous drainage may even be considered a part of the treatment strategy when performing laparoscopic lavage rather than a complication Patients may also consider the significantly higher stoma rates at long-term â that are therefore likely to be permanent â in the resection group an important factor impairing their quality of life On the other hand, the LADIES trial reported significantly more patients with a recurrent episode of acute diverticulitis within ## months in the laparoscopic lavage group; ##% (#/##) versus #% (#/##) in the resection group Based on these three randomized clinical trial, laparoscopic lavage seemed to result in more reverse However, most found associations were not significant which may be partially caused by the early termination of the LADIES trial <PERSOON> forthcoming data of the fourth randomized clinical trial (LapLAND trial) may increase the total sample size enabling more firm conclusions patient selection In the LADIES trial, one third of the patients in the resection group showed perforation at pathological examination Since patients with overt perforation are likely to fail laparoscopic lavage management, similar rates of perforation in the laparoscopic lavage may have worsened the outcomes in this group Better preoperative diagnostics may identify true Hinchey stage # patients more reliably Based on the results of the three randomized clinical trials, laparoscopic seems to be a safe alternative for sigmoid resection in Hinchey # patients <PERSOON> decision can be customised for each individual patient based on patient characteristics or patient preferences that determine the importance of better short-term results (less reinterventions and lower morbidity rates in the resection group), or better long-term results (less reoperations, less patients with (permanent) stomas and lower costs in de laparoscopic lavage group) Lastly, in these three randomized adhesions to the sigmoid were not to be dissected in the laparoscopic lavage group in order to prevent a covered perforation to become an overt perforation When performing laparoscopic lavage in daily Usually, perforated diverticulitis patients with purulent peritonitis undergo resection of the affected colon segment However, this is a relatively extensive procedure in patients that can be critically ill and are mostly elderly patients with comorbidities Laparoscopic lavage without resection may be a less burdensome procedure which has been subject of several randomised controlled trials in recent years Hoewel niet significant verschillend, lijken laparoscopische lavage patiënten op korte termijn (# maand) meer re-operaties nodig te hebben.
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one third of the patients in the resection group showed perforation at pathological examination Since patients with overt perforation are likely to fail laparoscopic lavage management, similar rates of perforation in the laparoscopic lavage may have worsened the outcomes in this group Better preoperative diagnostics may identify true Hinchey stage # patients more reliably Based on the results of the three randomized clinical trials, laparoscopic seems to be a safe alternative for sigmoid resection in Hinchey # patients <PERSOON> decision can be customised for each individual patient based on patient characteristics or patient preferences that determine the importance of better short-term results (less reinterventions and lower morbidity rates in the resection group), or better long-term results (less reoperations, less patients with (permanent) stomas and lower costs in de laparoscopic lavage group) Lastly, in these three randomized adhesions to the sigmoid were not to be dissected in the laparoscopic lavage group in order to prevent a covered perforation to become an overt perforation When performing laparoscopic lavage in daily Usually, perforated diverticulitis patients with purulent peritonitis undergo resection of the affected colon segment However, this is a relatively extensive procedure in patients that can be critically ill and are mostly elderly patients with comorbidities Laparoscopic lavage without resection may be a less burdensome procedure which has been subject of several randomised controlled trials in recent years Hoewel niet significant verschillend, lijken laparoscopische lavage patiënten op korte termijn (# maand) meer re-operaties nodig te hebben patiënten juist, voornamelijk door een lager aantal opheffen stoma operaties, minder reoperaties te ondergaan dan sigmoïd resectie patiënten Op korte termijn (# maand) hebben laparoscopische lavage patiënten vaker een percutane reïnterventie nodig dan patiënten die een sigmoïd resectie hebben ondergaan Hoewel niet significant verschillend, lijken laparoscopische lavage patiënten op korte termijn De mortaliteit is niet verschillend tussen laparoscopische lavage en sigmoïd resectie patiënten Three randomized clinical trials were included; the DILALA trial (Angenete, ###), the LADIES trial (<PERSOON>, ###) and the SCANDIV trial (<PERSOON>, ###) <PERSOON> DILALA trial and the SCANDIV trial reported long-term results in a ###) reported costs in separate papers <PERSOON> DILALA and LADIES trials only included patients with intraoperatively confirmed, as far as possible, Hinchey stage # diverticulitis (purulent peritonitis without faecal peritonitis or overt perforation) <PERSOON> SCANDIV trial included all patients with free air on computed tomography that needed urgent surgery due to clinical peritonitis Therefore, this study includes patients with intraoperative signs of Hinchey stage #, <DATUM> and # diverticulitis Patients with Hinchey stage #, # and # were distinguished from Hinchey stage # patients and were analyzed as a single group <PERSOON> laparoscopic lavage procedure was comparable in all three studies; lavage of all quadrants with saline after which a passive drain was placed under antibiotic treatment according to local routines Regarding the control group, the DILALA trial only performed <PERSOON>âs procedures (HP), the LADIES and SCANDIV trials performed a <PERSOON>âs procedure or resection with primary anastomosis.
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een lager aantal opheffen stoma operaties, minder reoperaties te ondergaan dan sigmoïd resectie patiënten Op korte termijn (# maand) hebben laparoscopische lavage patiënten vaker een percutane reïnterventie nodig dan patiënten die een sigmoïd resectie hebben ondergaan Hoewel niet significant verschillend, lijken laparoscopische lavage patiënten op korte termijn De mortaliteit is niet verschillend tussen laparoscopische lavage en sigmoïd resectie patiënten Three randomized clinical trials were included; the DILALA trial (Angenete, ###), the LADIES trial (<PERSOON>, ###) and the SCANDIV trial (<PERSOON>, ###) <PERSOON> DILALA trial and the SCANDIV trial reported long-term results in a ###) reported costs in separate papers <PERSOON> DILALA and LADIES trials only included patients with intraoperatively confirmed, as far as possible, Hinchey stage # diverticulitis (purulent peritonitis without faecal peritonitis or overt perforation) <PERSOON> SCANDIV trial included all patients with free air on computed tomography that needed urgent surgery due to clinical peritonitis Therefore, this study includes patients with intraoperative signs of Hinchey stage #, <DATUM> and # diverticulitis Patients with Hinchey stage #, # and # were distinguished from Hinchey stage # patients and were analyzed as a single group <PERSOON> laparoscopic lavage procedure was comparable in all three studies; lavage of all quadrants with saline after which a passive drain was placed under antibiotic treatment according to local routines Regarding the control group, the DILALA trial only performed <PERSOON>âs procedures (HP), the LADIES and SCANDIV trials performed a <PERSOON>âs procedure or resection with primary anastomosis studies, percutaneous abscess drainage was only reported by the LADIES and SCANDIV trial, patients with stoma and costs were only reported by the DILALA and LADIES trial Most analyses were done according to the intention-to-treat principle Only the DILALA trial reported results of reoperation and mortality up to # months from a per-protocol analysis <PERSOON> SCANDIV trial reported all results according to a modified intention-to-treat principle in which patients without an intraoperative perforation were excluded This modified intention-to-treat group is similar to the intention-to-treat groups from other studies since this filtered out the patients without intraoperatively confirmed perforated diverticulitis <PERSOON> DILALA and LADIES trial filtered out these patients similarly by just randomizing the patients intraoperatively <PERSOON> DILALA trial did not compare the included patients with patients that were eligible but not included <PERSOON> SCANDIV trial found only a slightly higher proportion of patients with an ASA score of # or higher (##% versus #%) in the not included patients <PERSOON> LADIES trial found no differences in baseline characteristics between the included and eligible but not included patients <PERSOON> LADIES trial was terminated early, after inclusion of ## out of the planned ### patients, for safety All three RCTâs reported rates of reoperation after laparoscopic lavage or sigmoid resection <PERSOON> risk of needing reoperation within # month was ##% higher but not significantly higher in the laparoscopic lavage group However, within a follow-up duration of ## months a trend towards less reoperations in the laparoscopic.
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reported by the LADIES and SCANDIV trial, patients with stoma and costs were only reported by the DILALA and LADIES trial Most analyses were done according to the intention-to-treat principle Only the DILALA trial reported results of reoperation and mortality up to # months from a per-protocol analysis <PERSOON> SCANDIV trial reported all results according to a modified intention-to-treat principle in which patients without an intraoperative perforation were excluded This modified intention-to-treat group is similar to the intention-to-treat groups from other studies since this filtered out the patients without intraoperatively confirmed perforated diverticulitis <PERSOON> DILALA and LADIES trial filtered out these patients similarly by just randomizing the patients intraoperatively <PERSOON> DILALA trial did not compare the included patients with patients that were eligible but not included <PERSOON> SCANDIV trial found only a slightly higher proportion of patients with an ASA score of # or higher (##% versus #%) in the not included patients <PERSOON> LADIES trial found no differences in baseline characteristics between the included and eligible but not included patients <PERSOON> LADIES trial was terminated early, after inclusion of ## out of the planned ### patients, for safety All three RCTâs reported rates of reoperation after laparoscopic lavage or sigmoid resection <PERSOON> risk of needing reoperation within # month was ##% higher but not significantly higher in the laparoscopic lavage group However, within a follow-up duration of ## months a trend towards less reoperations in the laparoscopic ##; ##% CI # ## to <DATUM> This effect is mostly caused by the higher number of stoma reversal operations in the resection group (Figure #) Figure # Forest plot f or the risk of needing reoperation within # or ## months <PERSOON> need for percutaneous abscess drainage was only reported in two studies at three different follow-up durations Therefore the number of patients per time point was low Laparoscopic lavage patients underwent significantly more percutaneous abscess drainages within # month This increased risk decreased and was no longer statistically significant at # months or ## months but remained in favour of the sigmoid resection group Figure # Forest plot f or the risk of needing percutaneous abscess drainage within # month, # All three studies reported morbidity rates at # months of follow-up These rates were defined as morbidity non-significantly higher risk for serious morbidity At ## months, only the LADIES trial and SCANDIV trial reported morbidity rates yielding a comparable increased risk (RR # ##; ##% CI # ## to # ##) Figure # Forest plot f or the risk of serious morbidity (Clavien-Dindo grade #b or higher) within # All three studies reported mortality rates, although the DILALA trial only reported per-protocol results at # month and # months follow-up At # month of follow-up the risk of mortality was slightly but non-significantly higher in the laparoscopic lavage group At # months and ## months however, the risk of mortality was.
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##) This effect is mostly caused by the higher number of stoma reversal operations in the resection group (Figure #) Figure # Forest plot f or the risk of needing reoperation within # or ## months <PERSOON> need for percutaneous abscess drainage was only reported in two studies at three different follow-up durations Therefore the number of patients per time point was low Laparoscopic lavage patients underwent significantly more percutaneous abscess drainages within # month This increased risk decreased and was no longer statistically significant at # months or ## months but remained in favour of the sigmoid resection group Figure # Forest plot f or the risk of needing percutaneous abscess drainage within # month, # All three studies reported morbidity rates at # months of follow-up These rates were defined as morbidity non-significantly higher risk for serious morbidity At ## months, only the LADIES trial and SCANDIV trial reported morbidity rates yielding a comparable increased risk (RR # ##; ##% CI # ## to # ##) Figure # Forest plot f or the risk of serious morbidity (Clavien-Dindo grade #b or higher) within # All three studies reported mortality rates, although the DILALA trial only reported per-protocol results at # month and # months follow-up At # month of follow-up the risk of mortality was slightly but non-significantly higher in the laparoscopic lavage group At # months and ## months however, the risk of mortality was Although, these differences were not Figure # Forest plot f or the risk of mortality within # month, # months and ## months Part of the patients in the resection group underwent a <PERSOON>âs procedure, therefore more patients in this group had a stoma during the study Since not all stomaâs were reversed, significantly less patients had a stoma Figure # Forest plot f or the risk of having a stoma at ## months f ollow-up duration <PERSOON> the DILALA and the LADIES trial reported the medical costs savings at a follow-up duration of ## months <PERSOON> showed costs savings in favour of laparoscopic lavage, resulting in a significant pooled costs savings of De bewijskracht voor de uitkomstmaat re-operaties begon op âhoogâ aangezien het bewijs afkomstig is uit gerandomiseerde klinische onderzoeken Vervolgens is de bewijskracht met # niveaus verlaagd gezien het De bewijskracht voor de uitkomstmaat percutane reïnterventies begon op âhoogâ aangezien het bewijs afkomstig is uit gerandomiseerde klinische onderzoeken Vervolgens is de bewijskracht met # niveau verlaagd gerandomiseerde klinische onderzoeken Vervolgens is de bewijskracht met # niveau verlaagd gezien het De bewijskracht voor de uitkomstmaat mortaliteit begon op âhoogâ aangezien het bewijs afkomstig is uit Wat zijn de (on)gewenste effecten van laparoscopische lavage en drainage (zonder resectie) ten opzichte van De werkgroep achtte re-operaties, percutane reïnterventies, complicaties en mortaliteit voor de besluitvorming kritieke uitkomstmaten en het aantal patiënten met stoma en kosten voor de besluitvorming belangrijke Verantwoording De literatuurzoekactie leverde ### treffers op Studies werden geselecteerd op grond van de.
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# Forest plot f or the risk of mortality within # month, # months and ## months Part of the patients in the resection group underwent a <PERSOON>âs procedure, therefore more patients in this group had a stoma during the study Since not all stomaâs were reversed, significantly less patients had a stoma Figure # Forest plot f or the risk of having a stoma at ## months f ollow-up duration <PERSOON> the DILALA and the LADIES trial reported the medical costs savings at a follow-up duration of ## months <PERSOON> showed costs savings in favour of laparoscopic lavage, resulting in a significant pooled costs savings of De bewijskracht voor de uitkomstmaat re-operaties begon op âhoogâ aangezien het bewijs afkomstig is uit gerandomiseerde klinische onderzoeken Vervolgens is de bewijskracht met # niveaus verlaagd gezien het De bewijskracht voor de uitkomstmaat percutane reïnterventies begon op âhoogâ aangezien het bewijs afkomstig is uit gerandomiseerde klinische onderzoeken Vervolgens is de bewijskracht met # niveau verlaagd gerandomiseerde klinische onderzoeken Vervolgens is de bewijskracht met # niveau verlaagd gezien het De bewijskracht voor de uitkomstmaat mortaliteit begon op âhoogâ aangezien het bewijs afkomstig is uit Wat zijn de (on)gewenste effecten van laparoscopische lavage en drainage (zonder resectie) ten opzichte van De werkgroep achtte re-operaties, percutane reïnterventies, complicaties en mortaliteit voor de besluitvorming kritieke uitkomstmaten en het aantal patiënten met stoma en kosten voor de besluitvorming belangrijke Verantwoording De literatuurzoekactie leverde ### treffers op Studies werden geselecteerd op grond van de (<PERSOON> procedure dan wel resectie met primaire anastomose) bij volwassen patiënten met Op basis van titel en abstract werden in eerste instantie ## studies voorgeselecteerd Na raadpleging van de volledige tekst, werden vervolgens # studies geëxcludeerd (zie exclusietabel onder het tabblad Zeven onderzoeken, waarin resultaten van # gerandomiseerde onderzoeken werden gerapporteerd, zijn evidence-tabellen De beoordeling van de individuele studieopzet (risk of bias) is opgenomen in de risk of bias <PERSOON> J, et al Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis <PERSOON> first results from the randomized controlled trial DILALA Annals of <PERSOON> I, et al Health economic analysis of laparoscopic lavage versus <PERSOON>'s procedure for <PERSOON> C, et al Laparoscopic Lavage versus Primary Resection for <PERSOON> L, et al One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage <PERSOON> T, et al Laparoscopic lavage for perforated diverticulitis with purulent peritonitis <PERSOON> JW, et al Laparoscopic peritoneal lavage for perforated colonic diverticulitis a <PERSOON-##> IM, et al Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with <PERSOON-##> BC, et al Cost analysis of laparoscopic lavage compared with sigmoid resection for Dient bij resectie een <PERSOON> procedure te worden uitgevoerd of kan een primaire anastomose aangelegd.
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dan wel resectie met primaire anastomose) bij volwassen patiënten met Op basis van titel en abstract werden in eerste instantie ## studies voorgeselecteerd Na raadpleging van de volledige tekst, werden vervolgens # studies geëxcludeerd (zie exclusietabel onder het tabblad Zeven onderzoeken, waarin resultaten van # gerandomiseerde onderzoeken werden gerapporteerd, zijn evidence-tabellen De beoordeling van de individuele studieopzet (risk of bias) is opgenomen in de risk of bias <PERSOON> J, et al Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis <PERSOON> first results from the randomized controlled trial DILALA Annals of <PERSOON> I, et al Health economic analysis of laparoscopic lavage versus <PERSOON>'s procedure for <PERSOON> C, et al Laparoscopic Lavage versus Primary Resection for <PERSOON> L, et al One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage <PERSOON> T, et al Laparoscopic lavage for perforated diverticulitis with purulent peritonitis <PERSOON> JW, et al Laparoscopic peritoneal lavage for perforated colonic diverticulitis a <PERSOON> IM, et al Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with <PERSOON-##> BC, et al Cost analysis of laparoscopic lavage compared with sigmoid resection for Dient bij resectie een <PERSOON> procedure te worden uitgevoerd of kan een primaire anastomose aangelegd ondergaan wegens geperforeerde acute diverticulitis en weeg hierbij de klinische conditie van de patiënt en expertise van de operateur mee Overweeg bij overige patiënten de <PERSOON> procedure Following several observational studies that showed clear benefits of primary anastomosis compared to a <PERSOON>âs procedure for perforated diverticulitis, three randomized clinical trials have been conducted and published thus far A major limitation of these trials is the premature termination of all three trials due to difficulties to recruit patients Studies were terminated at only ##% to ##% of the intended sample size resulting in seriously underpowered studies Another limitation is the randomisation by regular envelopes in two out of three studies <PERSOON> unequal distribution of patients among groups in <PERSOON-##> (## patients in the primary anastomosis group versus ## in the <PERSOON> group) could be a sign of a dysfunctional randomisation process, although this could also be explained by chance due to the lack of stratification Furthermore, follow-up durations were not described appropriately for several outcomes Outcomes were assessed after resection without description of the actual follow-up length or in-hospital hampering comparison of outcomes between Complicated acute diverticulitis is associated with considerable mortality which is therefore the most important outcome when comparing treatment strategies Although earlier meta-analyses of mostly observational studies showed a significant reduction in mortality in primary anastomosis patients compared to <PERSOON> patients, three randomised clinical trials demonstrated no difference in mortality rates Furthermore, performing a primary.
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wegens geperforeerde acute diverticulitis en weeg hierbij de klinische conditie van de patiënt en expertise van de operateur mee Overweeg bij overige patiënten de <PERSOON> procedure Following several observational studies that showed clear benefits of primary anastomosis compared to a <PERSOON>âs procedure for perforated diverticulitis, three randomized clinical trials have been conducted and published thus far A major limitation of these trials is the premature termination of all three trials due to difficulties to recruit patients Studies were terminated at only ##% to ##% of the intended sample size resulting in seriously underpowered studies Another limitation is the randomisation by regular envelopes in two out of three studies <PERSOON> unequal distribution of patients among groups in <PERSOON> (## patients in the primary anastomosis group versus ## in the <PERSOON> group) could be a sign of a dysfunctional randomisation process, although this could also be explained by chance due to the lack of stratification Furthermore, follow-up durations were not described appropriately for several outcomes Outcomes were assessed after resection without description of the actual follow-up length or in-hospital hampering comparison of outcomes between Complicated acute diverticulitis is associated with considerable mortality which is therefore the most important outcome when comparing treatment strategies Although earlier meta-analyses of mostly observational studies showed a significant reduction in mortality in primary anastomosis patients compared to <PERSOON> patients, three randomised clinical trials demonstrated no difference in mortality rates Furthermore, performing a primary complications but all three trials did not show an increase in complications in these patients Another important outcome that may affect patientsâ quality of life is the number of patients that end up with a permanent stoma Two studies showed significantly less patients with a stoma at the end of follow-up in the primary anastomosis group Some patients never had a stoma and ileostomies were reversed more often than colostomies A primary anastomosis seems to be a safe alternative to a <PERSOON>âs procedure for perforated acute diverticulitis Although, the methodological limitations of these RCTâs should be taken into account In most primary anastomosis patients a diverting ileostomy was created In only one trial this decision was left to the discretion of the surgeon and in only ten primary anastomosis patients no diverting ileostomy was created Therefore, although omitting a diverting ileostomy may actually be safe, this could not be concluded from these trials In patients that are considered to be unfit for any stoma reversal, a <PERSOON>âs procedure with definitive end colostomy may be preferred Furthermore, the included RCTâs may have suffered from selection bias by including clinically stable patients rather than critically ill patients On the other hand, ##% of patients that underwent a <PERSOON>âs procedure ended up with a definitive stoma This rate could be decreased considerably Perforated diverticulitis is traditionally treated by sigmoid resection with end colostomy (<PERSOON>âs procedure) However, the reversal of a colostomy is associated with higher morbidity than ileostomy reversal and literature.
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in complications in these patients Another important outcome that may affect patientsâ quality of life is the number of patients that end up with a permanent stoma Two studies showed significantly less patients with a stoma at the end of follow-up in the primary anastomosis group Some patients never had a stoma and ileostomies were reversed more often than colostomies A primary anastomosis seems to be a safe alternative to a <PERSOON>âs procedure for perforated acute diverticulitis Although, the methodological limitations of these RCTâs should be taken into account In most primary anastomosis patients a diverting ileostomy was created In only one trial this decision was left to the discretion of the surgeon and in only ten primary anastomosis patients no diverting ileostomy was created Therefore, although omitting a diverting ileostomy may actually be safe, this could not be concluded from these trials In patients that are considered to be unfit for any stoma reversal, a <PERSOON>âs procedure with definitive end colostomy may be preferred Furthermore, the included RCTâs may have suffered from selection bias by including clinically stable patients rather than critically ill patients On the other hand, ##% of patients that underwent a <PERSOON>âs procedure ended up with a definitive stoma This rate could be decreased considerably Perforated diverticulitis is traditionally treated by sigmoid resection with end colostomy (<PERSOON>âs procedure) However, the reversal of a colostomy is associated with higher morbidity than ileostomy reversal and literature A resection with primary anastomosis could be a one stage operation (without diverting ileostomy) <PERSOON> if a diverting ileostomy is created, reversal is less burdensome and is more frequently performed compared to a colostomy On the other hand, surgical morbidity may be higher when creating a primary anastomosis in an inflamed area and during emergency Het aanleggen van een primaire anastomose (met of zonder deviërend ileostoma) in plaats van het verrichten van een <PERSOON> procedure lijkt niet tot een hogere of lagere mortaliteit te het verrichten van een <PERSOON> procedure lijkt niet tot een hogere of lagere morbiditeit te Het aanleggen van een primaire anastomose (met of zonder deviërend ileostoma) lijkt het aantal permanente stomaâs te verminderen in vergelijking met het initieel te verrichten van een <PERSOON> procedure bij patiënten met Hinchey # of # diverticulitis ###) All studies included perforated acute diverticulitis patients with purulent of faecal peritonitis, although only two included intra-operatively verified peritonitis patients (<PERSOON>, ###; <PERSOON> and Oberkofler created a diverting ileostomy in every primary anastomosis <PERSOON> left this decision to the discretion of the surgeon All three studies were prematurely terminated due to low accrual rates; <PERSOON> only randomised ##% of the intended sample size, Bridoux randomised ##% of patients and Oberkofler terminated the trial at ##% of the intended sample size Mortality and overall morbidity was reported in all trials, serious morbidity was only reported by Bridoux and Oberkofler but with different definitions (Clavien Dindo # to # and Clavien Dindo #b to #).
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anastomosis could be a one stage operation (without diverting ileostomy) <PERSOON> if a diverting ileostomy is created, reversal is less burdensome and is more frequently performed compared to a colostomy On the other hand, surgical morbidity may be higher when creating a primary anastomosis in an inflamed area and during emergency Het aanleggen van een primaire anastomose (met of zonder deviërend ileostoma) in plaats van het verrichten van een <PERSOON> procedure lijkt niet tot een hogere of lagere mortaliteit te het verrichten van een <PERSOON> procedure lijkt niet tot een hogere of lagere morbiditeit te Het aanleggen van een primaire anastomose (met of zonder deviërend ileostoma) lijkt het aantal permanente stomaâs te verminderen in vergelijking met het initieel te verrichten van een <PERSOON> procedure bij patiënten met Hinchey # of # diverticulitis ###) All studies included perforated acute diverticulitis patients with purulent of faecal peritonitis, although only two included intra-operatively verified peritonitis patients (<PERSOON>, ###; <PERSOON> and Oberkofler created a diverting ileostomy in every primary anastomosis <PERSOON> left this decision to the discretion of the surgeon All three studies were prematurely terminated due to low accrual rates; <PERSOON> only randomised ##% of the intended sample size, Bridoux randomised ##% of patients and Oberkofler terminated the trial at ##% of the intended sample size Mortality and overall morbidity was reported in all trials, serious morbidity was only reported by Bridoux and Oberkofler but with different definitions (Clavien Dindo # to # and Clavien Dindo #b to #) the studies from Bridoux and <PERSOON> reported follow-up durations differed per study <PERSOON> reported all outcomes within ## days and additionally reported a combined mortality rate during the first ## days after resection and after the stoma reversal surgery Bridoux reported outcomes after the resection but did not state the length of follow-up and additionally reported outcomes at ## months Oberkofler reported outcomes after resection and after resection plus stoma reversal combined but did not state the exact length of follow-up Mortality rates were not different between primary anastomosis and <PERSOON>âs procedure on short-term (after resection within ## days or in-hospital); RR for primary anastomosis # ## (##% CI # ## to # ##), pooled rate primary anastomosis #% versus <PERSOON> #% (Figure #) When also mortality after stoma reversal surgery is taken into account, comparable results were found; RR for primary anastomosis # ## (##% CI # ## to # ##), Figure # Forest plot of mortality af ter resection and stoma reversal surgery Short-term overall morbidity was reported by all three studies which revealed no differences among groups (Figure #) Also morbidity on long-term, which was reported by two studies, was not different in Bridoux ##% after resection and stoma reversal surgery combined; p=# ###) Two studies reported serious morbidity rates as well Bridoux defined serious morbidity as Clavien Dindo # or # and found comparable results among groups; primary ##% versus <PERSOON> ##% (p=# ###) on short-term after resection and primary ##% versus.
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from Bridoux and <PERSOON> reported follow-up durations differed per study <PERSOON> reported all outcomes within ## days and additionally reported a combined mortality rate during the first ## days after resection and after the stoma reversal surgery Bridoux reported outcomes after the resection but did not state the length of follow-up and additionally reported outcomes at ## months Oberkofler reported outcomes after resection and after resection plus stoma reversal combined but did not state the exact length of follow-up Mortality rates were not different between primary anastomosis and <PERSOON>âs procedure on short-term (after resection within ## days or in-hospital); RR for primary anastomosis # ## (##% CI # ## to # ##), pooled rate primary anastomosis #% versus <PERSOON> #% (Figure #) When also mortality after stoma reversal surgery is taken into account, comparable results were found; RR for primary anastomosis # ## (##% CI # ## to # ##), Figure # Forest plot of mortality af ter resection and stoma reversal surgery Short-term overall morbidity was reported by all three studies which revealed no differences among groups (Figure #) Also morbidity on long-term, which was reported by two studies, was not different in Bridoux ##% after resection and stoma reversal surgery combined; p=# ###) Two studies reported serious morbidity rates as well Bridoux defined serious morbidity as Clavien Dindo # or # and found comparable results among groups; primary ##% versus <PERSOON> ##% (p=# ###) on short-term after resection and primary ##% versus ###) on short-term after surgery and primary ##% versus <PERSOON> ##% (p=# ###) on long-term after resection and stoma reversal surgery In the primary anastomosis group, significantly less patients were alive with a (probably permanent) stoma at the end of follow-up which was ## months in Bridoux and unknown in Oberkofler; RR primary anastomosis # ## gerandomiseerde klinische onderzoeken Vervolgens is de bewijskracht met # niveaus verlaagd gezien beperkingen in de onderzoeksopzet (enveloprandomisatie in # van de # studies met aanwijzingen voor foutieve randomisatie en onduidelijke follow-up tijden), waarschijnlijke patiëntselectie (zieke patiënten en/of nachtelijke operaties niet geïncludeerd) en het voortijdig afbreken van alle # geïncludeerde RCTâs De bewijskracht voor de uitkomstmaat morbiditeit begon op âhoogâ aangezien het bewijs afkomstig is uit De bewijskracht voor de uitkomstmaat patiënten met stoma begon op âhoogâ aangezien het bewijs afkomstig is uit gerandomiseerde klinische onderzoeken Vervolgens is de bewijskracht met # niveaus verlaagd gezien operaties mogelijk niet geïncludeerd) en het voortijdig afbreken van alle # geïncludeerde RCTâs Wat zijn de (on)gewenste effecten van het aanleggen van een primaire anastomose met of zonder deviërend Verantwoording De literatuurzoekactie leverde ### treffers op Studies werden geselecteerd op grond van de volledige tekst, werden vervolgens ## studies geëxcludeerd (zie exclusietabel onder het tabblad <PERSOON> GA, Karas JR, Serventi A, et al Primary anastomosis versus nonrestorative resection for perforated diverticulitis with peritonitis a prematurely terminated randomized controlled trial Colorectal disease the official journal of the <PERSOON> JM, Ouaissi M, et al.
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after surgery and primary ##% versus <PERSOON> ##% (p=# ###) on long-term after resection and stoma reversal surgery In the primary anastomosis group, significantly less patients were alive with a (probably permanent) stoma at the end of follow-up which was ## months in Bridoux and unknown in Oberkofler; RR primary anastomosis # ## gerandomiseerde klinische onderzoeken Vervolgens is de bewijskracht met # niveaus verlaagd gezien beperkingen in de onderzoeksopzet (enveloprandomisatie in # van de # studies met aanwijzingen voor foutieve randomisatie en onduidelijke follow-up tijden), waarschijnlijke patiëntselectie (zieke patiënten en/of nachtelijke operaties niet geïncludeerd) en het voortijdig afbreken van alle # geïncludeerde RCTâs De bewijskracht voor de uitkomstmaat morbiditeit begon op âhoogâ aangezien het bewijs afkomstig is uit De bewijskracht voor de uitkomstmaat patiënten met stoma begon op âhoogâ aangezien het bewijs afkomstig is uit gerandomiseerde klinische onderzoeken Vervolgens is de bewijskracht met # niveaus verlaagd gezien operaties mogelijk niet geïncludeerd) en het voortijdig afbreken van alle # geïncludeerde RCTâs Wat zijn de (on)gewenste effecten van het aanleggen van een primaire anastomose met of zonder deviërend Verantwoording De literatuurzoekactie leverde ### treffers op Studies werden geselecteerd op grond van de volledige tekst, werden vervolgens ## studies geëxcludeerd (zie exclusietabel onder het tabblad <PERSOON> GA, Karas JR, Serventi A, et al Primary anastomosis versus nonrestorative resection for perforated diverticulitis with peritonitis a prematurely terminated randomized controlled trial Colorectal disease the official journal of the <PERSOON> JM, Ouaissi M, et al to <PERSOON>) Journal of the American College of <PERSOON> DA, et al A multicenter randomized clinical trial of primary anastomosis or <PERSOON>'s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis Annals of surgery Welke bijzondere patiëntengroepen vereisen een aangepaste behandeling van gecompliceerde diverticulitis? Er is geen wetenschappelijke onderbouwing om het beleid van gecompliceerde diverticulitis aan te passen enkel op basis van leeftijd, immuunstatus of op basis van medicatie (NSAIDâs, acetylsalicylzuur, opioïden of Although all patient subgroups have been studied for their association with the occurrence of complicated diverticulitis and to a lesser extent for their association with the need for interventions during the disease course, no studies were found that assessed the effect of these patient characteristics on the disease course when the diverticulitis episode is already complicated Therefore, no recommendations could be made for altered management of complicated diverticulitis for young patients, immunocompromised patients and patients on Immuungecompromitteerde patiënten met acute diverticulitis lijken een verhoogde kans te Two systematic reviews that both included a meta-analysis of part of the data and # observational studies were the cases by âextracolonic sepsis from diverticular diseaseâ <PERSOON> controls were drawn from a variety of groups systematic review of <PERSOON>, only results from this additional study were extracted patients (OR # ##; ##% CI # ## to <DATUM> (<PERSOON> need for percutaneous abscess drainage was only (##% versus #%, p(#.
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<PERSOON>) Journal of the American College of <PERSOON> DA, et al A multicenter randomized clinical trial of primary anastomosis or <PERSOON>'s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis Annals of surgery Welke bijzondere patiëntengroepen vereisen een aangepaste behandeling van gecompliceerde diverticulitis? Er is geen wetenschappelijke onderbouwing om het beleid van gecompliceerde diverticulitis aan te passen enkel op basis van leeftijd, immuunstatus of op basis van medicatie (NSAIDâs, acetylsalicylzuur, opioïden of Although all patient subgroups have been studied for their association with the occurrence of complicated diverticulitis and to a lesser extent for their association with the need for interventions during the disease course, no studies were found that assessed the effect of these patient characteristics on the disease course when the diverticulitis episode is already complicated Therefore, no recommendations could be made for altered management of complicated diverticulitis for young patients, immunocompromised patients and patients on Immuungecompromitteerde patiënten met acute diverticulitis lijken een verhoogde kans te Two systematic reviews that both included a meta-analysis of part of the data and # observational studies were the cases by âextracolonic sepsis from diverticular diseaseâ <PERSOON> controls were drawn from a variety of groups systematic review of <PERSOON>, only results from this additional study were extracted patients (OR # ##; ##% CI # ## to <DATUM> (<PERSOON> need for percutaneous abscess drainage was only (##% versus #%, p(# ###) After adjustment (###) performed a meta-analysis including # studies, yielding comparable risks between the groups (pooled volgende zoekvragen (zoekstrategie is uitgevoerd voor alle stadia van diverticulitis waarna in de overwegingen gecompliceerde presentatie of beloop, kans op recidief, bij patiënten met gecompliceerde diverticulitis? <PERSOON> G, et al Benefits of sonography in diagnosing suspected Journal of gastrointestinal surgery official journal of the Society for Surgery of the Alimentary Tract ###;##(##) ###-## Recidief diverticulitis en/of persisterende klachten preventie middels dieet en De werkgroep beveelt aan leefstijladviezen te geven aan patiënten die een diverticulitis hebben doorgemaakt, die zijn gericht op gewichtsvermindering, stoppen met roken en meer lichaamsbeweging De werkgroep adviseert een vezelverrijkt dieet aan patienten die een diverticulitis hebben doorgemaakt Er zijn geen studies die gewichtsreductie, meer lichaamsbeweging of stoppen met roken hebben onderzocht om een recidief diverticulitis te voorkomen Epidemiologische studies maken een verband tussen deze factoren en de kans op diverticulitis echter aannemelijk De werkgroep is daarom van mening dat een advies voor gewichtsvermindering bij overgewicht, stoppen met roken en meer lichaamsbeweging op zijn plaats is Uit epidemiologische studies is aannemelijk gemaakt dat mensen die een vezelrijke voeding gebruiken minder kans hebben om een diverticulitis te krijgen De werkgroep adviseert daarom patiënten die een diverticulitis Hoewel wetenschappelijk onderzoek over levensstijl en het voorkomen van een recidief diverticulitis ontbreekt, is het aannemelijk dat de preventieve maatregelen genoemd in module 'Preventie' ook van toepassing zijn op.
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adjustment (###) performed a meta-analysis including # studies, yielding comparable risks between the groups (pooled volgende zoekvragen (zoekstrategie is uitgevoerd voor alle stadia van diverticulitis waarna in de overwegingen gecompliceerde presentatie of beloop, kans op recidief, bij patiënten met gecompliceerde diverticulitis? <PERSOON> G, et al Benefits of sonography in diagnosing suspected Journal of gastrointestinal surgery official journal of the Society for Surgery of the Alimentary Tract ###;##(##) ###-## Recidief diverticulitis en/of persisterende klachten preventie middels dieet en De werkgroep beveelt aan leefstijladviezen te geven aan patiënten die een diverticulitis hebben doorgemaakt, die zijn gericht op gewichtsvermindering, stoppen met roken en meer lichaamsbeweging De werkgroep adviseert een vezelverrijkt dieet aan patienten die een diverticulitis hebben doorgemaakt Er zijn geen studies die gewichtsreductie, meer lichaamsbeweging of stoppen met roken hebben onderzocht om een recidief diverticulitis te voorkomen Epidemiologische studies maken een verband tussen deze factoren en de kans op diverticulitis echter aannemelijk De werkgroep is daarom van mening dat een advies voor gewichtsvermindering bij overgewicht, stoppen met roken en meer lichaamsbeweging op zijn plaats is Uit epidemiologische studies is aannemelijk gemaakt dat mensen die een vezelrijke voeding gebruiken minder kans hebben om een diverticulitis te krijgen De werkgroep adviseert daarom patiënten die een diverticulitis Hoewel wetenschappelijk onderzoek over levensstijl en het voorkomen van een recidief diverticulitis ontbreekt, is het aannemelijk dat de preventieve maatregelen genoemd in module 'Preventie' ook van toepassing zijn op Er zijn aanwijzingen dat roken een risicofactor vormt voor het ontstaan van diverticulitis en Brodribb voerde in ### de eerste gerandomiseerde dubbel-blind gecontroleerde trial uit bij patiënten met symptomatische diverticulitis De diagnose symptomatische diverticulitis was gebaseerd op een samengestelde symptoomscore bij patiënten met radiologisch bevestigde diverticulitis Hoe dit radiologisch werd bevestigd werd niet uitgelegd De symptomen werden verzameld door middel van een gedetailleerde vragenlijst Deze richtte zich op dyspepsie, buikpijn, defecatieproblemen en het gebruik van laxantia De ## geïncludeerde patiënten werden gerandomiseerd in # groepen Groep # kreeg dagelijks #,# g vezels, groep <DATUM> # g per dag De patiënten werden # maanden gevolgd en maandelijks geïnterviewd De patiënten die vezelrijke voeding kregen hadden significant minder symptomen dan de andere groep De groep die vezelrijke voeding kreeg had significant minder pijn, maar dyspeptische klachten kwamen in beide groepen even vaak voor Een andere gerandomiseerde, cross-over, dubbel-blind gecontroleerde trial, gepubliceerd in ### (Ornstein et al), includeerde ## patiënten met symptomatische, ongecompliceerde diverticulitis De diagnose werd gesteld met een X-coloninloop De patiënten werden at random verdeeld over # groepen die respectievelijk #, # of #,# (placebogroep) gram vezels per dag kregen gedurende ## weken De patiënten hielden maandelijks een vagenlijst bij en verzamelden gedurende # dagen faeces aan het einde van elke behandelperiode Er werden geen verschillen gevonden tussen de verschillende groepen wat betreft buikpijn, defeacatie, samenstelling van Leahy et al (###) evalueerde ## patiënten die in de periode ###-### opgenomen waren ## patiënten werden conservatief behandeld.
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ontstaan van diverticulitis en Brodribb voerde in ### de eerste gerandomiseerde dubbel-blind gecontroleerde trial uit bij patiënten met symptomatische diverticulitis De diagnose symptomatische diverticulitis was gebaseerd op een samengestelde symptoomscore bij patiënten met radiologisch bevestigde diverticulitis Hoe dit radiologisch werd bevestigd werd niet uitgelegd De symptomen werden verzameld door middel van een gedetailleerde vragenlijst Deze richtte zich op dyspepsie, buikpijn, defecatieproblemen en het gebruik van laxantia De ## geïncludeerde patiënten werden gerandomiseerd in # groepen Groep # kreeg dagelijks #,# g vezels, groep <DATUM> # g per dag De patiënten werden # maanden gevolgd en maandelijks geïnterviewd De patiënten die vezelrijke voeding kregen hadden significant minder symptomen dan de andere groep De groep die vezelrijke voeding kreeg had significant minder pijn, maar dyspeptische klachten kwamen in beide groepen even vaak voor Een andere gerandomiseerde, cross-over, dubbel-blind gecontroleerde trial, gepubliceerd in ### (Ornstein et al), includeerde ## patiënten met symptomatische, ongecompliceerde diverticulitis De diagnose werd gesteld met een X-coloninloop De patiënten werden at random verdeeld over # groepen die respectievelijk #, # of #,# (placebogroep) gram vezels per dag kregen gedurende ## weken De patiënten hielden maandelijks een vagenlijst bij en verzamelden gedurende # dagen faeces aan het einde van elke behandelperiode Er werden geen verschillen gevonden tussen de verschillende groepen wat betreft buikpijn, defeacatie, samenstelling van Leahy et al (###) evalueerde ## patiënten die in de periode ###-### opgenomen waren ## patiënten werden conservatief behandeld ziekenhuis, ## kregen een vezelverrijkt dieet met een minimaal ## gram vezels per dag voorgeschreven ## patiënten volgden dit advies op, ## niet De ## patiënten die een vezelverrijkt dieet volgden werden vergeleken met de ## die een vezelarm dieet volgden De groep met het vezelverrijkte dieet had significant minder complicaties en onderging minder operaties (p (#,##) Tijdens de follow-up bleek de groep met het vezelverrijkte dieet ook significant minder buikklachten te hebben (P (#,##) De enige twee gepubliceerde gerandomiseerde studies over een vezelverrijkt dieet bij patiënten met diverticulitis lieten inconsistente resultaten zien Brodribb et al (###) vonden een significante daling in pijn en een vermindering van klachten, terwijl Ornstein et al (###) geen verbetering vonden behalve minder obstipatie Ondanks het gebrek aan wetenschappelijk bewijs, wordt een vezelverrijkt dieet als behandeling voor Overgewicht vormt in toenemende mate een probleem in de gezondheidszorg Er zijn aanwijzingen dat patiënten met overgewicht een verhoogd risico hebben op een acute diverticulitis Om die reden zou Dobbins et al (###) beschrijft een retrospectieve, case control studie bij ## patiënten die opgenomen waren recidief, eerste periode diverticultis en ongecompliceerde diverticulose De patiënten met een perforatie (p=#,###) of een recidief diverticulitis (p=#,###) bleken een significant hogere BMI te hebben dan de overige Roken worden ook als riscofactoren genoemd, wellicht is om die reden stoppen met roken gunstig bij het Turunen et al (###) beschrijft een retrospectieve studie bij ### patiënten die electief geopereerd werden gedurende een periode van <LEEFTIJD> jaar in het ziekenhuis van Helsinki.
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met een minimaal ## gram vezels per dag voorgeschreven ## patiënten volgden dit advies op, ## niet De ## patiënten die een vezelverrijkt dieet volgden werden vergeleken met de ## die een vezelarm dieet volgden De groep met het vezelverrijkte dieet had significant minder complicaties en onderging minder operaties (p (#,##) Tijdens de follow-up bleek de groep met het vezelverrijkte dieet ook significant minder buikklachten te hebben (P (#,##) De enige twee gepubliceerde gerandomiseerde studies over een vezelverrijkt dieet bij patiënten met diverticulitis lieten inconsistente resultaten zien Brodribb et al (###) vonden een significante daling in pijn en een vermindering van klachten, terwijl Ornstein et al (###) geen verbetering vonden behalve minder obstipatie Ondanks het gebrek aan wetenschappelijk bewijs, wordt een vezelverrijkt dieet als behandeling voor Overgewicht vormt in toenemende mate een probleem in de gezondheidszorg Er zijn aanwijzingen dat patiënten met overgewicht een verhoogd risico hebben op een acute diverticulitis Om die reden zou Dobbins et al (###) beschrijft een retrospectieve, case control studie bij ## patiënten die opgenomen waren recidief, eerste periode diverticultis en ongecompliceerde diverticulose De patiënten met een perforatie (p=#,###) of een recidief diverticulitis (p=#,###) bleken een significant hogere BMI te hebben dan de overige Roken worden ook als riscofactoren genoemd, wellicht is om die reden stoppen met roken gunstig bij het Turunen et al (###) beschrijft een retrospectieve studie bij ### patiënten die electief geopereerd werden gedurende een periode van <LEEFTIJD> jaar in het ziekenhuis van Helsinki sigmoidoscopie dan niet rokers (p=#,###), hadden meer perforaties (p=#,###) en recidief <PERSOON> and treatment of diverticular disease Results of a consensus development conference <PERSOON> scientific committee of the european association for endoscopic surgery Surg Leahy, A L , <PERSOON> fibre diet in symptomatic diverticular disease of the colon <PERSOON> of American Society of Colon and <PERSOON> and management of diverticular disease of the colon in adults <PERSOON> hoc incidence of complicated diverticular disease of the sigmoid colon (###) Scand J surg; ## ##, <DATUM> Recidief diverticulitis en/of persisterende klachten preventie middels medicatie Wat zijn medicamenteuze opties om recidieven en/of persisterende klachten te voorkomen? Rather than waiting for a potential recurrent episode of acute diverticulitis when the initial episode is in remission, clinicians would like to treat patients medically to prevent recurrent episodes Diverticulitis researchers focussed on three candidates; poorly absorbed antibiotics (mainly rifaximin), anti-inflammatory agents (mainly mesalazine) and probiotics Despite the attention to this topic, many trials suffer from methodological limitations and low <PERSOON> effect of # to ## days a month rifaximin was assessed in one RCT (rifaximin versus placebo) and two observational studies (rifaximin versus mesalazine).
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(p=#,###), hadden meer perforaties (p=#,###) en recidief <PERSOON> and treatment of diverticular disease Results of a consensus development conference <PERSOON> scientific committee of the european association for endoscopic surgery Surg Leahy, A L , <PERSOON> fibre diet in symptomatic diverticular disease of the colon <PERSOON> of American Society of Colon and <PERSOON> and management of diverticular disease of the colon in adults <PERSOON> hoc incidence of complicated diverticular disease of the sigmoid colon (###) Scand J surg; ## ##, <DATUM> Recidief diverticulitis en/of persisterende klachten preventie middels medicatie Wat zijn medicamenteuze opties om recidieven en/of persisterende klachten te voorkomen? Rather than waiting for a potential recurrent episode of acute diverticulitis when the initial episode is in remission, clinicians would like to treat patients medically to prevent recurrent episodes Diverticulitis researchers focussed on three candidates; poorly absorbed antibiotics (mainly rifaximin), anti-inflammatory agents (mainly mesalazine) and probiotics Despite the attention to this topic, many trials suffer from methodological limitations and low <PERSOON> effect of # to ## days a month rifaximin was assessed in one RCT (rifaximin versus placebo) and two observational studies (rifaximin versus mesalazine) at ## weeks in the intention-to-treat analysis, although some benefit of rifaximin was seen in additional analyses that were adjusted for several confounders Furthermore, this study was terminated early because of low accrual rates and the intention of the study was therefore changed to proof-of-concept One of the # observational studies found results in favour of mesalazine rather than rifaximin treatment but this study compared a #-day per month rifaximin treatment with a continuous and daily mesalazine treatment Although the same author published a study which showed a significantly better effect of daily treatment than intermittent treatment in diverticular disease patients (Tursi, ###) Therefore, a comparison between a daily mesalazine treatment with an intermittent rifaximin treatment seems to be irrelevant <PERSOON> other study found opposite results; rifaximin yielded lower risks for recurrent diverticulitis than mesalazine treatment In summary, current evidence on the effect of rifaximin is scarce, contradictory and of mostly of low quality Although rifiximin may be a promising treatment in the future, current evidence is far from sufficient to make firm conclusions about its effectivity and <PERSOON> effect of mesalazine was studied in # randomized and placebo controlled trials At both ## months and ## months after initiation of treatment no differences in rates of recurrent diverticulitis were seen Different dosages of mesalazine were assessed in one RCT but also higher dosages did not show a beneficial effect on recurrence rates Although not only imaging proven acute diverticulitis patients were included in all trials, the results of all.
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intention-to-treat analysis, although some benefit of rifaximin was seen in additional analyses that were adjusted for several confounders Furthermore, this study was terminated early because of low accrual rates and the intention of the study was therefore changed to proof-of-concept One of the # observational studies found results in favour of mesalazine rather than rifaximin treatment but this study compared a #-day per month rifaximin treatment with a continuous and daily mesalazine treatment Although the same author published a study which showed a significantly better effect of daily treatment than intermittent treatment in diverticular disease patients (Tursi, ###) Therefore, a comparison between a daily mesalazine treatment with an intermittent rifaximin treatment seems to be irrelevant <PERSOON> other study found opposite results; rifaximin yielded lower risks for recurrent diverticulitis than mesalazine treatment In summary, current evidence on the effect of rifaximin is scarce, contradictory and of mostly of low quality Although rifiximin may be a promising treatment in the future, current evidence is far from sufficient to make firm conclusions about its effectivity and <PERSOON> effect of mesalazine was studied in # randomized and placebo controlled trials At both ## months and ## months after initiation of treatment no differences in rates of recurrent diverticulitis were seen Different dosages of mesalazine were assessed in one RCT but also higher dosages did not show a beneficial effect on recurrence rates Although not only imaging proven acute diverticulitis patients were included in all trials, the results of all Mesalazine showed some improvement in physical quality of life in one study but failed to show an effect on recurrence rates in all studies Therefore prophylactic treatment of mesalazine after an One randomized controlled trial studied the effect of probiotics on rates of recurrent diverticulitis and persistent gastrointestinal complaints However, this study only included a combined probiotics and mesalazine treatment group and compared this group with a mesalazine and a placebo treatment group Rates of recurrent diverticulitis were highest in the probiotics/mesalazine group and mesalazine monotherapy was superior to combined treatment with probiotics regarding persistent gastrointestinal complaints In summary, evidence on the effect of probiotics is very limited and the available evidence did not show a beneficial effect Further studies are needed to draw any conclusion about the effectivity of probiotics Meanwhile, treatment with probiotics In summary, all three medical interventions (rifaximin, mesalazine and probiotics) have not been proven beneficial for acute diverticulitis patients regarding the prevention of recurrent diverticulitis or persistent complaints and can therefore not be advocated However, the quality of evidence is relatively low (particularly for rifaximin and probiotics) These medical interventions could be considered for individual patients who are no Approximately ##% of acute diverticulitis patients develops one or more episodes of recurrent diverticulitis Several studies have focussed on the medical treatment in the prevention of these recurrences <PERSOON> main De effectiviteit van rifaximine ter preventie van recidief diverticulitis en/of persisterende.
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Mesalazine showed some improvement in physical quality of life in one study but failed to show an effect on recurrence rates in all studies Therefore prophylactic treatment of mesalazine after an One randomized controlled trial studied the effect of probiotics on rates of recurrent diverticulitis and persistent gastrointestinal complaints However, this study only included a combined probiotics and mesalazine treatment group and compared this group with a mesalazine and a placebo treatment group Rates of recurrent diverticulitis were highest in the probiotics/mesalazine group and mesalazine monotherapy was superior to combined treatment with probiotics regarding persistent gastrointestinal complaints In summary, evidence on the effect of probiotics is very limited and the available evidence did not show a beneficial effect Further studies are needed to draw any conclusion about the effectivity of probiotics Meanwhile, treatment with probiotics In summary, all three medical interventions (rifaximin, mesalazine and probiotics) have not been proven beneficial for acute diverticulitis patients regarding the prevention of recurrent diverticulitis or persistent complaints and can therefore not be advocated However, the quality of evidence is relatively low (particularly for rifaximin and probiotics) These medical interventions could be considered for individual patients who are no Approximately ##% of acute diverticulitis patients develops one or more episodes of recurrent diverticulitis Several studies have focussed on the medical treatment in the prevention of these recurrences <PERSOON> main De effectiviteit van rifaximine ter preventie van recidief diverticulitis en/of persisterende De combinatie van probiotica met mesalazine is niet effectief One randomised placebo controlled trial (RCT) that confirmed the acute diverticulitis diagnosis by imaging or colonoscopy and two observational cohort studies (# prospective and # retrospective) that confirmed the Tursi, ###) All studies employed an intermittent antibiotic treatment protocol with rifaximin (a poorly absorbed antibiotic which is therefore mainly used in gastrointestinal diseases); Festa ## days a month, Lanas and Tursi # days a month Festa treated all patients with probiotics simultaneously (Festa, ###) In both observational studies, the control group consisted of patients treated with mesalazine (anti-inflammatory agent) Festa treated patients with mesalazine ## days a month (similar to the rifaximin treatment), Tursi treated the patients in the control group with mesalazine continuously (daily) in contrast with the # days a month rifaximin treatment Lanas treated and followed patients for ## weeks Festa reported results from a median follow-up duration ## months and accounted for different follow-up durations between the treatment groups using hazard ratios Tursi on the other hand, did not state anything about the exact follow-up duration That study only reported a maximum follow-up duration of ## months but no information on what percentage of patients reached that ## months of follow-up Festa reported rates and hazard ratios for diverticulitis recurrences Tursi only provided the proportion of patients that were in clinical remission However, no exact results were reported but figures only Three papers including four randomized controlled trials (Parente, ###; Raskin, ###; Stollmann, ###) were included.
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randomised placebo controlled trial (RCT) that confirmed the acute diverticulitis diagnosis by imaging or colonoscopy and two observational cohort studies (# prospective and # retrospective) that confirmed the Tursi, ###) All studies employed an intermittent antibiotic treatment protocol with rifaximin (a poorly absorbed antibiotic which is therefore mainly used in gastrointestinal diseases); Festa ## days a month, Lanas and Tursi # days a month Festa treated all patients with probiotics simultaneously (Festa, ###) In both observational studies, the control group consisted of patients treated with mesalazine (anti-inflammatory agent) Festa treated patients with mesalazine ## days a month (similar to the rifaximin treatment), Tursi treated the patients in the control group with mesalazine continuously (daily) in contrast with the # days a month rifaximin treatment Lanas treated and followed patients for ## weeks Festa reported results from a median follow-up duration ## months and accounted for different follow-up durations between the treatment groups using hazard ratios Tursi on the other hand, did not state anything about the exact follow-up duration That study only reported a maximum follow-up duration of ## months but no information on what percentage of patients reached that ## months of follow-up Festa reported rates and hazard ratios for diverticulitis recurrences Tursi only provided the proportion of patients that were in clinical remission However, no exact results were reported but figures only Three papers including four randomized controlled trials (Parente, ###; Raskin, ###; Stollmann, ###) were included treated diverticulitis patients between mesalazine treatment and placebo treatment Stollmann treated patients daily for # months with a total follow-up of ## months Parente treated patients daily during the entire follow-up duration of ## months Raskin reported results from # identical and worldwide RCTâs (PREVENT # and PREVENT #) with daily mesalazine or placebo treatment during # years In addition, Raskin divided mesalazine patients in # subgroups (<DATUM> /d, <DATUM> /d and <DATUM> /d) of different dosages Therefore the study included a total of # groups in which patients were randomised to in a <DATUM> ratio Outcome measures were recurrent diverticulitis at the end of follow-up (clinical recurrence in the study of Stollmann and imaging proven recurrence in the study of Parente and Raskin) Stollmann additionally evaluated Global Symptom Scores (GSS) at # and ## months <PERSOON> GSS is a composite score made of the sum of the scores from ## individual gastrointestinal symptoms (on a scale from # (none) to # (severe)) most commonly associated with diverticular disease This score was created by the authors of the study since no validated instrument existed Parente additionally assessed quality of life using a Therapy Impact Questionnaire (TIQ) One randomized controlled trial (Stollman, ###) that confirmed the diverticulitis diagnosis using computed tomography was included This study included # treatment groups; a mesalazine monotherapy group, a mesalazine plus probiotics group and a placebo group Patients were treated for three months after which all.
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and placebo treatment Stollmann treated patients daily for # months with a total follow-up of ## months Parente treated patients daily during the entire follow-up duration of ## months Raskin reported results from # identical and worldwide RCTâs (PREVENT # and PREVENT #) with daily mesalazine or placebo treatment during # years In addition, Raskin divided mesalazine patients in # subgroups (<DATUM> /d, <DATUM> /d and <DATUM> /d) of different dosages Therefore the study included a total of # groups in which patients were randomised to in a <DATUM> ratio Outcome measures were recurrent diverticulitis at the end of follow-up (clinical recurrence in the study of Stollmann and imaging proven recurrence in the study of Parente and Raskin) Stollmann additionally evaluated Global Symptom Scores (GSS) at # and ## months <PERSOON> GSS is a composite score made of the sum of the scores from ## individual gastrointestinal symptoms (on a scale from # (none) to # (severe)) most commonly associated with diverticular disease This score was created by the authors of the study since no validated instrument existed Parente additionally assessed quality of life using a Therapy Impact Questionnaire (TIQ) One randomized controlled trial (Stollman, ###) that confirmed the diverticulitis diagnosis using computed tomography was included This study included # treatment groups; a mesalazine monotherapy group, a mesalazine plus probiotics group and a placebo group Patients were treated for three months after which all All three groups suffered from high withdrawal numbers; ##% of all patients completed their ##-week treatment and only ##% completed the ##-week study Main reasons for withdrawal were adverse events, voluntary withdrawal and recurrent diverticulitis requiring surgery Also, the number of withdrawals differed between groups Global Symptom Scores (GSS) were reported at ## weeks and ## weeks Furthermore, rates of recurrent diverticulitis Lanas found no differences in rates of recurrent diverticulitis at ## weeks between the rifaximin group and the regression and cox regression analyses adjusting for age, sex, duration and localization of illness, time from last episode and centre recruitment rate demonstrated a beneficial effect of rifaximin compared to placebo Festa found <DATUM> recurrent diverticulitis (#/##) in the rifaximin group versus <DATUM> (##/##) in the mesalazine group This resulted in an unadjusted hazard ratio of # ## (##% CI # ## to # ##) for the rifaximin group opposed to the mesalazine group Adjusting this result for age and gender in a multivariable analysis revealed comparable results (adjusted HR # ##; ##% CI # ## to # ##) <PERSOON> estimated cumulative proportion of patients free of recurrence at ## months was #<DATUM> in the rifaximin group and #<DATUM> in the mesalazine group Tursi found opposite results; significantly more patients treated with rifaximin had a recurrent episode of diverticulitis (p=# ###) However, this study reported no exact results but figures and p-values only.
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withdrawal numbers; ##% of all patients completed their ##-week treatment and only ##% completed the ##-week study Main reasons for withdrawal were adverse events, voluntary withdrawal and recurrent diverticulitis requiring surgery Also, the number of withdrawals differed between groups Global Symptom Scores (GSS) were reported at ## weeks and ## weeks Furthermore, rates of recurrent diverticulitis Lanas found no differences in rates of recurrent diverticulitis at ## weeks between the rifaximin group and the regression and cox regression analyses adjusting for age, sex, duration and localization of illness, time from last episode and centre recruitment rate demonstrated a beneficial effect of rifaximin compared to placebo Festa found <DATUM> recurrent diverticulitis (#/##) in the rifaximin group versus <DATUM> (##/##) in the mesalazine group This resulted in an unadjusted hazard ratio of # ## (##% CI # ## to # ##) for the rifaximin group opposed to the mesalazine group Adjusting this result for age and gender in a multivariable analysis revealed comparable results (adjusted HR # ##; ##% CI # ## to # ##) <PERSOON> estimated cumulative proportion of patients free of recurrence at ## months was #<DATUM> in the rifaximin group and #<DATUM> in the mesalazine group Tursi found opposite results; significantly more patients treated with rifaximin had a recurrent episode of diverticulitis (p=# ###) However, this study reported no exact results but figures and p-values only of treatment Pooled results showed comparable risks for the mesalazine group and the placebo group (RR # ##; ##% CI # #<DATUM> (Figure #) (Parente, ###; Stollmann, ###) Also two trials reported ## months followup results showing comparable risks as well (pooled RR <DATUM> ##% CI # ## to # ##) (<PERSOON> physical condition quality of life (according to a Therapy Impact Questionnaire) was Figure # Forest plot of risk ratios f or recurrent diverticulitis at ## months in mesalazine and Figure # Forest plot of risk ratios f or recurrent diverticulitis at ## months in mesalazine and Clinical recurrent diverticulitis was reported in ## #% of patients in the placebo group, <DATUM> in the mesalazine significant differences were found between the treatment groups At both ## weeks and ## weeks, the placebo group reported the highest symptom scores, followed by the mesalazine/probiotics group and the mesalazine group <PERSOON> proportion of GSS responders (patients that scores # or # for all ## symptoms) at ## weeks was highest in the mesalazine group (##%), followed by the mesalazine/probiotics group (##%) and the placebo group (##%) At ## weeks the higher proportion of GSS responders was again highest in the mesalazine group De bewijskracht voor de uitkomstmaat aantal recidieven en/of persisterende klachten bij behandeling met antibiotica afkomstig uit de gerandomiseerde studie begon op âhoogâ, en werd vervolgens met # niveaus verlaagd gezien beperkingen in de onderzoeksopzet (proof of concept studie) en het geringe aantal patiënten (imprecisie).
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group (RR # ##; ##% CI # #<DATUM> (Figure #) (Parente, ###; Stollmann, ###) Also two trials reported ## months followup results showing comparable risks as well (pooled RR <DATUM> ##% CI # ## to # ##) (<PERSOON> physical condition quality of life (according to a Therapy Impact Questionnaire) was Figure # Forest plot of risk ratios f or recurrent diverticulitis at ## months in mesalazine and Figure # Forest plot of risk ratios f or recurrent diverticulitis at ## months in mesalazine and Clinical recurrent diverticulitis was reported in ## #% of patients in the placebo group, <DATUM> in the mesalazine significant differences were found between the treatment groups At both ## weeks and ## weeks, the placebo group reported the highest symptom scores, followed by the mesalazine/probiotics group and the mesalazine group <PERSOON> proportion of GSS responders (patients that scores # or # for all ## symptoms) at ## weeks was highest in the mesalazine group (##%), followed by the mesalazine/probiotics group (##%) and the placebo group (##%) At ## weeks the higher proportion of GSS responders was again highest in the mesalazine group De bewijskracht voor de uitkomstmaat aantal recidieven en/of persisterende klachten bij behandeling met antibiotica afkomstig uit de gerandomiseerde studie begon op âhoogâ, en werd vervolgens met # niveaus verlaagd gezien beperkingen in de onderzoeksopzet (proof of concept studie) en het geringe aantal patiënten (imprecisie) # niveau verlaagd gezien het geringe aantal patiënten (imprecisie) De bewijskracht voor de uitkomstmaat aantal recidieven en/of persisterende klachten bij behandeling met antiinflammatoire medicatie begon op âhoogâ, aangezien het bewijs afkomstig is uit gerandomiseerd gecontroleerd probiotica begon op âhoogâ, aangezien het bewijs afkomstig is uit gerandomiseerd gecontroleerd onderzoek Vervolgens is de bewijskracht met # niveaus verlaagd gezien beperkingen in de extrapoleerbaarheid (bias ten gevolge van indirectheid - alle vergelijkingen zijn gecombineerd met mesalazine) en het geringe aantal patiënten Wat zijn de (on)gunstige effecten van slecht-resorbeerbare antibiotica ten opzichte van geen of een andere medicamenteuze behandeling bij patiënten met een doorgemaakte acute diverticulitis episode? Wat zijn de (on)gunstige effecten van anti-inflammatoire medicatie ten opzichte van geen of een andere Wat zijn de (on)gunstige effecten van probiotica ten opzichte van geen of een andere medicamenteuze De werkgroep achtte recidief diverticulitis en persisterende klachten voor de besluitvorming kritieke uitkomstmaten en kwaliteit van leven een voor de besluitvorming belangrijke uitkomstmaten naar gerandomiseerde klinische onderzoeken, observationele cohortstudies, systematische reviews en/of metaanalyses Voor de deelvraag over anti-inflammatoire medicatie werden alleen gerandomiseerde onderzoeken literatuurzoekactie leverde ### treffers op Studies werden geselecteerd op grond van de volgende Op basis van titel en abstract werden in eerste instantie ## studies voorgeselecteerd Na raadpleging van de volledige tekst, werden vervolgens ## studies geëxcludeerd (zie exclusietabel onder het tabblad Zes onderzoeken zijn opgenomen in de literatuuranalyse De belangrijkste studiekarakteristieken en resultaten <PERSOON> F, et al Retrospective comparison of long-term ten-day/month rifaximin or mesalazine in prevention of relapse in acute diverticulitis.
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voor de uitkomstmaat aantal recidieven en/of persisterende klachten bij behandeling met antiinflammatoire medicatie begon op âhoogâ, aangezien het bewijs afkomstig is uit gerandomiseerd gecontroleerd probiotica begon op âhoogâ, aangezien het bewijs afkomstig is uit gerandomiseerd gecontroleerd onderzoek Vervolgens is de bewijskracht met # niveaus verlaagd gezien beperkingen in de extrapoleerbaarheid (bias ten gevolge van indirectheid - alle vergelijkingen zijn gecombineerd met mesalazine) en het geringe aantal patiënten Wat zijn de (on)gunstige effecten van slecht-resorbeerbare antibiotica ten opzichte van geen of een andere medicamenteuze behandeling bij patiënten met een doorgemaakte acute diverticulitis episode? Wat zijn de (on)gunstige effecten van anti-inflammatoire medicatie ten opzichte van geen of een andere Wat zijn de (on)gunstige effecten van probiotica ten opzichte van geen of een andere medicamenteuze De werkgroep achtte recidief diverticulitis en persisterende klachten voor de besluitvorming kritieke uitkomstmaten en kwaliteit van leven een voor de besluitvorming belangrijke uitkomstmaten naar gerandomiseerde klinische onderzoeken, observationele cohortstudies, systematische reviews en/of metaanalyses Voor de deelvraag over anti-inflammatoire medicatie werden alleen gerandomiseerde onderzoeken literatuurzoekactie leverde ### treffers op Studies werden geselecteerd op grond van de volgende Op basis van titel en abstract werden in eerste instantie ## studies voorgeselecteerd Na raadpleging van de volledige tekst, werden vervolgens ## studies geëxcludeerd (zie exclusietabel onder het tabblad Zes onderzoeken zijn opgenomen in de literatuuranalyse De belangrijkste studiekarakteristieken en resultaten <PERSOON> F, et al Retrospective comparison of long-term ten-day/month rifaximin or mesalazine in prevention of relapse in acute diverticulitis ###;## ###<DATUM> <PERSOON> A, et al One year intermittent rifaximin plus fibre supplementation versus fibre supplementation alone to prevent diverticulitis recurrence A proof-of-concept study Digestive and <PERSOON> A, et al Intermittent treatment with mesalazine in the prevention of diverticulitis recurrence A randomised multicentre pilot double-blind placebo-controlled study of ##-month duration International journal of Raskin JB, Kamm MA, <PERSOON> MM, et al Mesalamine did not prevent recurrent diverticulitis in phase # controlled trials <PERSOON> F, et al A randomized controlled study of mesalamine after acute diverticulitis <PERSOON> GM, et al Effectiveness of different therapeutic strategies in preventing diverticulitis recurrence Overweeg een electieve sigmoïdresectie bij patiënten met recidiverende diverticulitis of langdurig persisterende klachten na een episode van acute diverticulitis, en weeg hierbij patiëntkarakteristieken en patiëntvoorkeuren in Het aantal recidieven is niet bepalend voor de indicatie tot electieve sigmoïdresectie Voer een electieve resectie uit bij symptomatische stenosering of fistels ten gevolge van (recidiverende) Traditionally patients underwent elective sigmoid resection after one or two episodes of acute diverticulitis At the time, it was thought that most acute diverticulitis patients would develop recurrences and that these recurrences would be more complicated than the previous episode(s) <PERSOON> elective sigmoid resection was performed to prevent these recurrences and particularly to prevent complicated diverticulitis and with that emergency surgery.
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<PERSOON> A, et al One year intermittent rifaximin plus fibre supplementation versus fibre supplementation alone to prevent diverticulitis recurrence A proof-of-concept study Digestive and <PERSOON> A, et al Intermittent treatment with mesalazine in the prevention of diverticulitis recurrence A randomised multicentre pilot double-blind placebo-controlled study of ##-month duration International journal of Raskin JB, Kamm MA, <PERSOON> MM, et al Mesalamine did not prevent recurrent diverticulitis in phase # controlled trials <PERSOON> F, et al A randomized controlled study of mesalamine after acute diverticulitis <PERSOON> GM, et al Effectiveness of different therapeutic strategies in preventing diverticulitis recurrence Overweeg een electieve sigmoïdresectie bij patiënten met recidiverende diverticulitis of langdurig persisterende klachten na een episode van acute diverticulitis, en weeg hierbij patiëntkarakteristieken en patiëntvoorkeuren in Het aantal recidieven is niet bepalend voor de indicatie tot electieve sigmoïdresectie Voer een electieve resectie uit bij symptomatische stenosering of fistels ten gevolge van (recidiverende) Traditionally patients underwent elective sigmoid resection after one or two episodes of acute diverticulitis At the time, it was thought that most acute diverticulitis patients would develop recurrences and that these recurrences would be more complicated than the previous episode(s) <PERSOON> elective sigmoid resection was performed to prevent these recurrences and particularly to prevent complicated diverticulitis and with that emergency surgery (Peppas, ###) Furthermore, instead of more complicated recurrences, more recent literature shows that the primary episode is likely to be the most complicated one and that subsequent episodes have a milder clinical course (Ritz, ###; Chapman, ###) Because of these developments in literature, the number of elective sigmoid resections decreased as they are performed on individual grounds rather than routinely Only chronic complications of acute diverticulitis such as fistula and colonic obstruction are generally accepted routine indications for elective surgery Although patients with recurrent diverticulitis or persistent complaints after an episode of acute diverticulitis do not routinely undergo elective surgery anymore, a selection of these patients may actually benefit from an elective sigmoid resection However, it has been proven difficult to set a threshold of number of recurrences or amount of complaints from which surgery will benefit patients Also, a direct comparison of quality of life outcome after surgical or conservative treatment has been lacking until recently (<PERSOON>, ###) <PERSOON> Dutch randomised DIRECT trial looked in to the effect of elective surgery compared to conservative treatment in patients that went through at least # episodes of acute diverticulitis within # years or experienced persistent abdominal complaints during at least # months (Van de Wall, ###) Despite the early termination of the study because of difficulties in recruiting patients, the quality of life (according to the GIQLI, EQ-#D and physical component of the SF-## questionnaire) appeared to be significantly better in the surgical group compared to the conservative group at ## months Also pain scores on a visual analogue scale at ##.
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the primary episode is likely to be the most complicated one and that subsequent episodes have a milder clinical course (Ritz, ###; Chapman, ###) Because of these developments in literature, the number of elective sigmoid resections decreased as they are performed on individual grounds rather than routinely Only chronic complications of acute diverticulitis such as fistula and colonic obstruction are generally accepted routine indications for elective surgery Although patients with recurrent diverticulitis or persistent complaints after an episode of acute diverticulitis do not routinely undergo elective surgery anymore, a selection of these patients may actually benefit from an elective sigmoid resection However, it has been proven difficult to set a threshold of number of recurrences or amount of complaints from which surgery will benefit patients Also, a direct comparison of quality of life outcome after surgical or conservative treatment has been lacking until recently (<PERSOON>, ###) <PERSOON> Dutch randomised DIRECT trial looked in to the effect of elective surgery compared to conservative treatment in patients that went through at least # episodes of acute diverticulitis within # years or experienced persistent abdominal complaints during at least # months (Van de Wall, ###) Despite the early termination of the study because of difficulties in recruiting patients, the quality of life (according to the GIQLI, EQ-#D and physical component of the SF-## questionnaire) appeared to be significantly better in the surgical group compared to the conservative group at ## months Also pain scores on a visual analogue scale at ## Although statistically significant, the lower bound of the difference in GIQLI score among groups crossed the minimum clinically important difference Therefore, the quality of life was significantly better in the surgical group but it was not proven whether this difference is clinically relevant This improved quality of life after surgery however comes at the price of postoperative morbidity including ##% (#/##) anastomotic leakage and ##% (##/##) of patients that needed one or more reinterventions Also, some patients may have to live with a stoma for a few months or even end up with a permanent stoma after an elective sigmoid resection In the conservative group ##% (##/##) eventually did undergo elective surgery due to ongoing abdominal complaints within the follow-up duration of # months Furthermore, the long-term results and cost-effectiveness have not been published yet In summary, the DIRECT trial is the first high-quality study that demonstrates a potential benefit of surgery in selected patients However, the benefits of surgery should be weighted up to the surgery-related morbidity <PERSOON> relatively small but potentially clinically relevant improvement of quality of life could be considered too small by some patients to risk the potential surgical morbidity Furthermore, even after a sigmoid resection, patients can develop recurrent acute diverticulitis episodes (up to ##% in literature) and cure of persistent abdominal complaints is not warranted In this decision making process, the patient should be informed about the potential benefits of.
| 603 | fms |
Although statistically significant, the lower bound of the difference in GIQLI score among groups crossed the minimum clinically important difference Therefore, the quality of life was significantly better in the surgical group but it was not proven whether this difference is clinically relevant This improved quality of life after surgery however comes at the price of postoperative morbidity including ##% (#/##) anastomotic leakage and ##% (##/##) of patients that needed one or more reinterventions Also, some patients may have to live with a stoma for a few months or even end up with a permanent stoma after an elective sigmoid resection In the conservative group ##% (##/##) eventually did undergo elective surgery due to ongoing abdominal complaints within the follow-up duration of # months Furthermore, the long-term results and cost-effectiveness have not been published yet In summary, the DIRECT trial is the first high-quality study that demonstrates a potential benefit of surgery in selected patients However, the benefits of surgery should be weighted up to the surgery-related morbidity <PERSOON> relatively small but potentially clinically relevant improvement of quality of life could be considered too small by some patients to risk the potential surgical morbidity Furthermore, even after a sigmoid resection, patients can develop recurrent acute diverticulitis episodes (up to ##% in literature) and cure of persistent abdominal complaints is not warranted In this decision making process, the patient should be informed about the potential benefits of or absolute prevention of recurrences cannot be guaranteed Patient characteristics and patients preferences therefore play an important role in deciding whether or not to perform an elective sigmoid resection and in Recurrent diverticulitis and persistent complaints are seen in up to ##% of patients after an episode of acute diverticulitis <PERSOON> elective sigmoid resection could cure persisting complaints and prevent future (complicated) recurrences However, this effect is not warranted and the potential gains of an operation should be weighted up against the surgical morbidity Therefore, the selection of patients that are likely to benefit from an operation De kwaliteit van leven van patiënten met recidiverende diverticulitis of persisterende klachten na een acute diverticulitis is beter (### versus ### op de GIQLI quality of life score) # maanden na Het aantal patiënten dat een recidief diverticulitis ontwikkelt lijkt na # maanden hoger te zijn in een conservatief behandelde groep in vergelijking met de groep die een electieve Er is geen literatuur over de kosten van chirurgische dan wel conservatieve behandeling van A randomised clinical trial, taking place in ## hospitals in the Netherlands, included patients with frequently recurring diverticulitis or ongoing abdominal complaints after an episode of acute diverticulitis <PERSOON> initial acute diverticulitis was to be confirmed by computed tomography (CT), ultrasound or colonoscopy Frequently recurring diverticulitis was defined by three of more presentations with clinical signs of acute diverticulitis within # years Ongoing abdominal complaints was defined by ongoing lower left-sided abdominal pain or persistent.
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Patient characteristics and patients preferences therefore play an important role in deciding whether or not to perform an elective sigmoid resection and in Recurrent diverticulitis and persistent complaints are seen in up to ##% of patients after an episode of acute diverticulitis <PERSOON> elective sigmoid resection could cure persisting complaints and prevent future (complicated) recurrences However, this effect is not warranted and the potential gains of an operation should be weighted up against the surgical morbidity Therefore, the selection of patients that are likely to benefit from an operation De kwaliteit van leven van patiënten met recidiverende diverticulitis of persisterende klachten na een acute diverticulitis is beter (### versus ### op de GIQLI quality of life score) # maanden na Het aantal patiënten dat een recidief diverticulitis ontwikkelt lijkt na # maanden hoger te zijn in een conservatief behandelde groep in vergelijking met de groep die een electieve Er is geen literatuur over de kosten van chirurgische dan wel conservatieve behandeling van A randomised clinical trial, taking place in ## hospitals in the Netherlands, included patients with frequently recurring diverticulitis or ongoing abdominal complaints after an episode of acute diverticulitis <PERSOON> initial acute diverticulitis was to be confirmed by computed tomography (CT), ultrasound or colonoscopy Frequently recurring diverticulitis was defined by three of more presentations with clinical signs of acute diverticulitis within # years Ongoing abdominal complaints was defined by ongoing lower left-sided abdominal pain or persistent Patients were randomised to an elective sigmoid resection or conservative treatment according to the daily practice in the Netherlands Primary outcome was quality of life according to the GIQLI questionnaire (a questionnaire assessing gastro-intestinal complaints in which a higher score indicated a better quality of life) at ## months after inclusion (conservative group) or surgery (surgical group) Secondary outcomes were the proportion of patients that reported an improved quality of life higher than the level indicating a minimum clinically important difference in the GIQLI questionnaire, and additional quality of life assessments (EQ-#D, VAS-pain and SF-##), morbidity and mortality <PERSOON> minimum clinically important difference was set to half an effect size (# # times the standard deviation) from previously published studies A total of ### patients was randomised to an elective sigmoid resection (n=##) or conservative treatment strategy (n=##) <PERSOON> trial was terminated early because of increasing difficulty to recruit patients Therefore, only ### patients were included instead of the initially intended sample size of ### All outcomes were reported at a follow-up duration of # months Nineteen patients were lost to follow-up (## (##%) in the surgical group and # (##%) in the conservative group) No mortality was recorded <PERSOON> GIQLI score at # months was significantly higher in the surgical group (surgery mean #<DATUM> ± <DATUM> versus conservative ### # ± <DATUM> p(# ###) Also the minimum clinically important improvement of ## points was achieved by more patients in the surgical group (surgery ##/## (##%) versus conservative ##/## (##%); p(# ###).
| 661 | fms |
to the daily practice in the Netherlands Primary outcome was quality of life according to the GIQLI questionnaire (a questionnaire assessing gastro-intestinal complaints in which a higher score indicated a better quality of life) at ## months after inclusion (conservative group) or surgery (surgical group) Secondary outcomes were the proportion of patients that reported an improved quality of life higher than the level indicating a minimum clinically important difference in the GIQLI questionnaire, and additional quality of life assessments (EQ-#D, VAS-pain and SF-##), morbidity and mortality <PERSOON> minimum clinically important difference was set to half an effect size (# # times the standard deviation) from previously published studies A total of ### patients was randomised to an elective sigmoid resection (n=##) or conservative treatment strategy (n=##) <PERSOON> trial was terminated early because of increasing difficulty to recruit patients Therefore, only ### patients were included instead of the initially intended sample size of ### All outcomes were reported at a follow-up duration of # months Nineteen patients were lost to follow-up (## (##%) in the surgical group and # (##%) in the conservative group) No mortality was recorded <PERSOON> GIQLI score at # months was significantly higher in the surgical group (surgery mean #<DATUM> ± <DATUM> versus conservative ### # ± <DATUM> p(# ###) Also the minimum clinically important improvement of ## points was achieved by more patients in the surgical group (surgery ##/## (##%) versus conservative ##/## (##%); p(# ###) (SF-## physical component, VAS-pain and EQ-#D) were significantly better in the surgical group Only the mental component score from the SF-## questionnaire was comparable among treatment groups Rates of serious morbidity were comparable among groups (surgery ##/## (##%) versus conservative ##/## (##%); p=# ###) Thirteen per cent of patients (#/##) in the conservative group developed a recurrent episode within # months compared to nil recurrences (#/##) in the surgical group (p=# ###) From the ## patients that were randomised to conservative treatment, ## patients (##%) underwent sigmoid resection within # months after randomisation because of worsening symptoms In total, ## stomas were created (## in the surgical group and # in the initially conservative group) of which # were reversed within # months One stoma remained in the surgical group and # stoma remained at # months in the initially conservative group De bewijskracht voor de uitkomstmaat kwaliteit van leven begon op âhoogâ, aangezien het bewijs afkomstig is uit gerandomiseerd onderzoek Vervolgens is de bewijskracht met één niveaus verlaagd gezien het geringe De bewijskracht voor de uitkomstmaat recidief diverticulitis begon op âhoogâ, aangezien het bewijs afkomstig is uit gerandomiseerd onderzoek Vervolgens is de bewijskracht met twee niveaus verlaagd gezien beperkingen in de extrapoleerbaarheid (bias ten gevolge van indirectheid gezien de korte follow-up duur); het geringe aantal De bewijskracht voor de uitkomstmaat kosten kon niet worden beoordeeld aangezien literatuur hierover Wat zijn de (on)gunstige effecten van een electieve sigmoïdresectie op de klachten en het aantal recidieven Patiënt.
| 731 | fms |
component, VAS-pain and EQ-#D) were significantly better in the surgical group Only the mental component score from the SF-## questionnaire was comparable among treatment groups Rates of serious morbidity were comparable among groups (surgery ##/## (##%) versus conservative ##/## (##%); p=# ###) Thirteen per cent of patients (#/##) in the conservative group developed a recurrent episode within # months compared to nil recurrences (#/##) in the surgical group (p=# ###) From the ## patients that were randomised to conservative treatment, ## patients (##%) underwent sigmoid resection within # months after randomisation because of worsening symptoms In total, ## stomas were created (## in the surgical group and # in the initially conservative group) of which # were reversed within # months One stoma remained in the surgical group and # stoma remained at # months in the initially conservative group De bewijskracht voor de uitkomstmaat kwaliteit van leven begon op âhoogâ, aangezien het bewijs afkomstig is uit gerandomiseerd onderzoek Vervolgens is de bewijskracht met één niveaus verlaagd gezien het geringe De bewijskracht voor de uitkomstmaat recidief diverticulitis begon op âhoogâ, aangezien het bewijs afkomstig is uit gerandomiseerd onderzoek Vervolgens is de bewijskracht met twee niveaus verlaagd gezien beperkingen in de extrapoleerbaarheid (bias ten gevolge van indirectheid gezien de korte follow-up duur); het geringe aantal De bewijskracht voor de uitkomstmaat kosten kon niet worden beoordeeld aangezien literatuur hierover Wat zijn de (on)gunstige effecten van een electieve sigmoïdresectie op de klachten en het aantal recidieven Patiënt De werkgroep achtte kwaliteit van leven een voor de besluitvorming kritieke uitkomstmaat en recidief naar gerandomiseerde klinische onderzoeken Tevens zijn de gerelateerde artikelen handmatig doorzocht De zoekverantwoording is weergegeven onder het tabblad Verantwoording De literatuurzoekactie leverde ### Op basis van titel en abstract werden in eerste instantie ## studies geselecteerd Na raadpleging van de volledige tekst, werden ## studies geëxcludeerd (zie exclusietabel onder het tabblad Verantwoording) en# Dit onderzoek zijn opgenomen in de literatuuranalyse De belangrijkste studiekarakteristieken en resultaten zijn <PERSOON>CS, Berg R, Staal> JB, et al Patient-reported Outcomes After Conservative or Surgical Management of Recurrent and Chronic Complaints of Diverticulitis Systematic Review and <PERSOON>-analysis Clinical gastroenterology and hepatology <PERSOON> B, et al Complicated diverticulitis is it time to rethink the rules? <PERSOON> MA, et al Indications for elective sigmoid resection in diverticular disease <PERSOON> IA, Oikonomaki D, et al Outcomes after medical and surgical treatment of diverticulitis a systematic van de <PERSOON> WA, et al Surgery versus conservative management for recurrent and ongoing Welke bijzondere patiëntengroepen vereisen een aangepaste behandeling van acute diverticulitis? Voer een electieve resectie ter preventie van recidief diverticulitis of persisterende klachten als regel niet Er is geen aanbeveling voor de immuungecompromitteerde patiënt met recidiverende episoden van diverticulitis Overweeg per individuele patiënt of de immuungecompromitteerde status van de patiënt een.
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kwaliteit van leven een voor de besluitvorming kritieke uitkomstmaat en recidief naar gerandomiseerde klinische onderzoeken Tevens zijn de gerelateerde artikelen handmatig doorzocht De zoekverantwoording is weergegeven onder het tabblad Verantwoording De literatuurzoekactie leverde ### Op basis van titel en abstract werden in eerste instantie ## studies geselecteerd Na raadpleging van de volledige tekst, werden ## studies geëxcludeerd (zie exclusietabel onder het tabblad Verantwoording) en# Dit onderzoek zijn opgenomen in de literatuuranalyse De belangrijkste studiekarakteristieken en resultaten zijn <PERSOON>CS, Berg R, Staal> JB, et al Patient-reported Outcomes After Conservative or Surgical Management of Recurrent and Chronic Complaints of Diverticulitis Systematic Review and <PERSOON>-analysis Clinical gastroenterology and hepatology <PERSOON> B, et al Complicated diverticulitis is it time to rethink the rules? <PERSOON> MA, et al Indications for elective sigmoid resection in diverticular disease <PERSOON> IA, Oikonomaki D, et al Outcomes after medical and surgical treatment of diverticulitis a systematic van de <PERSOON> WA, et al Surgery versus conservative management for recurrent and ongoing Welke bijzondere patiëntengroepen vereisen een aangepaste behandeling van acute diverticulitis? Voer een electieve resectie ter preventie van recidief diverticulitis of persisterende klachten als regel niet Er is geen aanbeveling voor de immuungecompromitteerde patiënt met recidiverende episoden van diverticulitis Overweeg per individuele patiënt of de immuungecompromitteerde status van de patiënt een Since pharmacological therapies have not been proven to prevent recurrent diverticulitis or persistent complaints sufficiently for diverticulitis patients in general, no specific recommendations could be made for patient subgroups as young patients <PERSOON> main role age may play in the management of recurrent diverticulitis and persistent complaints is in whether or not to perform elective surgery and the timing of surgery Young patients do not suffer from a more virulent disease course of the initial acute diverticulitis episode Although this association has not been studied sufficiently for subsequent acute diverticulitis episodes, it is not likely that young patients suffer from more virulent recurrences Therefore, the threshold for elective surgery is mainly determined by the risk of developing recurrent episodes Traditionally, young patients are suggested to suffer from higher recurrent diverticulitis rates However, this understanding is mainly based on population based studies that lack an imaging confirmation of the diverticulitis diagnosis and lack proper description of follow-up durations in which the recurrences could have occurred <PERSOON>-analysis of crude data on recurrent diverticulitis showed a significant ##% higher risk of recurrent diverticulitis for young patients However, description of followup duration per age group was lacking in all but one studies For an outcome measure that relies mostly on the time in which an event could have occurred, equal follow-up durations are essential Three studies with the most reliable design by taking follow-up duration into account â using survival analysis â found no association or even.
| 547 | fms |
not been proven to prevent recurrent diverticulitis or persistent complaints sufficiently for diverticulitis patients in general, no specific recommendations could be made for patient subgroups as young patients <PERSOON> main role age may play in the management of recurrent diverticulitis and persistent complaints is in whether or not to perform elective surgery and the timing of surgery Young patients do not suffer from a more virulent disease course of the initial acute diverticulitis episode Although this association has not been studied sufficiently for subsequent acute diverticulitis episodes, it is not likely that young patients suffer from more virulent recurrences Therefore, the threshold for elective surgery is mainly determined by the risk of developing recurrent episodes Traditionally, young patients are suggested to suffer from higher recurrent diverticulitis rates However, this understanding is mainly based on population based studies that lack an imaging confirmation of the diverticulitis diagnosis and lack proper description of follow-up durations in which the recurrences could have occurred <PERSOON>-analysis of crude data on recurrent diverticulitis showed a significant ##% higher risk of recurrent diverticulitis for young patients However, description of followup duration per age group was lacking in all but one studies For an outcome measure that relies mostly on the time in which an event could have occurred, equal follow-up durations are essential Three studies with the most reliable design by taking follow-up duration into account â using survival analysis â found no association or even Therefore, age should not be considered a factor in the decision making process for elective sigmoid resection in the prevention of recurrent diverticulitis Obviously, younger patient can have different demands because of working activities or physically demanding hobbies than elderly patients, meaning that more recurrent episodes may actually be a reason for elective resection in these patients These kinds of individual patient related factors can lower the threshold for elective surgery but young age itself should not be a reason for more invasive treatment immunocompromised patients Also, rates of emergency surgery are slightly higher than numbers of nonimmunocompromised patients in literature These results do not specifically consider subsequent episodes Also, the risk of recurrent diverticulitis in these patients is unknown Although an increased risk of complicated diverticulitis may be a reason to perform elective surgery to prevent subsequent episodes, some studies show an increased risk of complications or mortality after surgery in these immunocompromised patients Therefore, the risk of subsequent diverticulitis episodes versus complications after elective surgery should be weighted for of complicated diverticulitis NSAIDs, aspirin and opioids have been suggested to increase the risk of diverticular perforation, calcium channel antagonists have been suggested to protect against diverticular perforation Only for two of these a possible underlying mechanism is known, NSAIDs may affect the inflammation process and calcium channel antagonists may have a protective effect because of smooth muscle relaxation A meta-analysis of mostly case-control studies showed that patients with prior use or use at the time of presentation of NSAIDs.
| 548 | fms |
a factor in the decision making process for elective sigmoid resection in the prevention of recurrent diverticulitis Obviously, younger patient can have different demands because of working activities or physically demanding hobbies than elderly patients, meaning that more recurrent episodes may actually be a reason for elective resection in these patients These kinds of individual patient related factors can lower the threshold for elective surgery but young age itself should not be a reason for more invasive treatment immunocompromised patients Also, rates of emergency surgery are slightly higher than numbers of nonimmunocompromised patients in literature These results do not specifically consider subsequent episodes Also, the risk of recurrent diverticulitis in these patients is unknown Although an increased risk of complicated diverticulitis may be a reason to perform elective surgery to prevent subsequent episodes, some studies show an increased risk of complications or mortality after surgery in these immunocompromised patients Therefore, the risk of subsequent diverticulitis episodes versus complications after elective surgery should be weighted for of complicated diverticulitis NSAIDs, aspirin and opioids have been suggested to increase the risk of diverticular perforation, calcium channel antagonists have been suggested to protect against diverticular perforation Only for two of these a possible underlying mechanism is known, NSAIDs may affect the inflammation process and calcium channel antagonists may have a protective effect because of smooth muscle relaxation A meta-analysis of mostly case-control studies showed that patients with prior use or use at the time of presentation of NSAIDs Aspirin and calcium channel antagonists were not associated with complicated diverticulitis rates and the effect of paracetamol has not been studied at all Although an association between NSAIDs or opioids and diverticular perforation was found, due to the methodological limitations of the studies it is not possible to conclude whether this is a causal relationship Due to the <INSTELLING> that NSAIDs have been studies most extensively and a possible underlying mechanism is known, the association between NSAIDs and diverticular perforation seems most reliable These results do not specifically consider subsequent episodes Although, it is likely that chronic use of NSAIDs could increase the risk of complicated diverticulitis for subsequent episodes as well Therefore, cessation of NSAIDs should be considered to decrease the risk of complicated diverticulitis at a potential subsequent episode For paracetamol, opioids, aspirin and calcium channel antagonists current evidence is insufficient to conclude anything on their diverticulitis and complicated diverticulitis associated mortality (Oor, ###) This review included ## prospective case control study and # prospective cohort study (Kvasnovsky, ###) Reported medications were studies and calcium channel antagonists in # studies Most studies included patients that used the medication systematic review of <PERSOON>, only results from this additional study were extracted patient characteristics <PERSOON> systematic review of Kvasnovsky (###) performed a meta-analysis of studies describing individual medications used at the time of diverticular complication This meta-analysis, included #.
| 549 | fms |
Aspirin and calcium channel antagonists were not associated with complicated diverticulitis rates and the effect of paracetamol has not been studied at all Although an association between NSAIDs or opioids and diverticular perforation was found, due to the methodological limitations of the studies it is not possible to conclude whether this is a causal relationship Due to the <INSTELLING> that NSAIDs have been studies most extensively and a possible underlying mechanism is known, the association between NSAIDs and diverticular perforation seems most reliable These results do not specifically consider subsequent episodes Although, it is likely that chronic use of NSAIDs could increase the risk of complicated diverticulitis for subsequent episodes as well Therefore, cessation of NSAIDs should be considered to decrease the risk of complicated diverticulitis at a potential subsequent episode For paracetamol, opioids, aspirin and calcium channel antagonists current evidence is insufficient to conclude anything on their diverticulitis and complicated diverticulitis associated mortality (Oor, ###) This review included ## prospective case control study and # prospective cohort study (Kvasnovsky, ###) Reported medications were studies and calcium channel antagonists in # studies Most studies included patients that used the medication systematic review of <PERSOON>, only results from this additional study were extracted patient characteristics <PERSOON> systematic review of Kvasnovsky (###) performed a meta-analysis of studies describing individual medications used at the time of diverticular complication This meta-analysis, included # (###) performed a meta-analyses including # studies, yielding comparable risks between the groups (pooled De bewijskracht voor de uitkomstmaat gecompliceerde presentatie of beloop initiële episode is âlaagâ aangezien het bewijs afkomstig is van observationeel onderzoek Vervolgens is de bewijskracht één niveau verlaagd gezien tegenstrijdige resultaten (inconsistentie); hoge heterogeniteit tussen de uitkomsten van studies Dient de behandeling van diverticulitis te worden aangepast bij een jonge patiënt? Dient de behandeling van diverticulitis te worden aangepast bij een immuungecompromitteerde patiënt? Dient de behandeling van diverticulitis te worden aangepast bij een patiënt met medicatie? De literatuurzoekactie leverde voor de deelvraag over de jonge patiënt ### treffers op Studies werden Minimaal # leeftijdsgroepen of leeftijd als continue variabele in regressie of survivalanalyse; De literatuurzoekactie leverde voor de deelvraag over de immuungecompromitteerde patiënt ### treffers op De literatuurzoekactie leverde voor de deelvraag over de patiënt met medicatie ### treffers op Studies werden Dient na een episode diverticulitis een colonscopie ter uitsluiting van maligniteit of ander onderliggend lijden Een colonoscopie ter uitsluiting van een maligniteit lijkt niet geïndiceerd bij patiënten die een episode van gecompliceerde diverticulitis (abces of perforatie), bij patiënten met persisterende klachten of anderszins een Sixteen observational studies reported rates of advanced colorectal neoplasm (ACN) or colorectal carcinoma (CRC) However, only two studies included a control group of asymptomatic individuals These two studies demonstrated comparable rates of ACN (diverticulitis pooled <DATUM> versus control pooled <DATUM> ; RR # ##, ##% More evidence is available from studies including only acute diverticulitis patients, eight studies on ACN rates (##% CI <DATUM> to <DATUM> ).
| 620 | fms |
between the groups (pooled De bewijskracht voor de uitkomstmaat gecompliceerde presentatie of beloop initiële episode is âlaagâ aangezien het bewijs afkomstig is van observationeel onderzoek Vervolgens is de bewijskracht één niveau verlaagd gezien tegenstrijdige resultaten (inconsistentie); hoge heterogeniteit tussen de uitkomsten van studies Dient de behandeling van diverticulitis te worden aangepast bij een jonge patiënt? Dient de behandeling van diverticulitis te worden aangepast bij een immuungecompromitteerde patiënt? Dient de behandeling van diverticulitis te worden aangepast bij een patiënt met medicatie? De literatuurzoekactie leverde voor de deelvraag over de jonge patiënt ### treffers op Studies werden Minimaal # leeftijdsgroepen of leeftijd als continue variabele in regressie of survivalanalyse; De literatuurzoekactie leverde voor de deelvraag over de immuungecompromitteerde patiënt ### treffers op De literatuurzoekactie leverde voor de deelvraag over de patiënt met medicatie ### treffers op Studies werden Dient na een episode diverticulitis een colonscopie ter uitsluiting van maligniteit of ander onderliggend lijden Een colonoscopie ter uitsluiting van een maligniteit lijkt niet geïndiceerd bij patiënten die een episode van gecompliceerde diverticulitis (abces of perforatie), bij patiënten met persisterende klachten of anderszins een Sixteen observational studies reported rates of advanced colorectal neoplasm (ACN) or colorectal carcinoma (CRC) However, only two studies included a control group of asymptomatic individuals These two studies demonstrated comparable rates of ACN (diverticulitis pooled <DATUM> versus control pooled <DATUM> ; RR # ##, ##% More evidence is available from studies including only acute diverticulitis patients, eight studies on ACN rates (##% CI <DATUM> to <DATUM> ) patients found lower rates of ACN and CRC Three studies found <DATUM> ACN in these uncomplicated patients Since most studies did not include a control group, these rates can only be compared to rates in literature <PERSOON> incidence of ACN in studies including asymptomatic screening colonoscopy populations varies between <DATUM> ###; <PERSOON>, ###) <PERSOON> <DATUM> in the present review seems to be comparable to these rates in literature <PERSOON> incidence of CRC however seems to be higher in acute diverticulitis patients, which was <DATUM> in the present review In literature, asymptomatic screening populations demonstrate slightly lower CRC rates from # #% to ###; <PERSOON>, ###) Although these screening patients were not matched to the acute diverticulitis patients from the studies included in the present review, patients in literature seem to be comparable <PERSOON> screening studies included asymptomatic patients from a general population mostly aged between ## and ## years, whereas patients with a familial history of colorectal cancer were mostly excluded Although the overall incidence of CRC in acute diverticulitis seems to be slightly higher, the rate of CRC in patients with uncomplicated acute diverticulitis appeared to be only # #% which is similar to the rates in asymptomatic screening populations Therefore, routine colonoscopy after an uncomplicated diverticulitis episode seems not necessary, whereas a colonoscopy after a conservatively treated episode of complicated It should be noted that all patients included in the present study were diagnosed with acute diverticulitis based on CT.
| 633 | fms |
patients found lower rates of ACN and CRC Three studies found <DATUM> ACN in these uncomplicated patients Since most studies did not include a control group, these rates can only be compared to rates in literature <PERSOON> incidence of ACN in studies including asymptomatic screening colonoscopy populations varies between <DATUM> ###; <PERSOON>, ###) <PERSOON> <DATUM> in the present review seems to be comparable to these rates in literature <PERSOON> incidence of CRC however seems to be higher in acute diverticulitis patients, which was <DATUM> in the present review In literature, asymptomatic screening populations demonstrate slightly lower CRC rates from # #% to ###; <PERSOON>, ###) Although these screening patients were not matched to the acute diverticulitis patients from the studies included in the present review, patients in literature seem to be comparable <PERSOON> screening studies included asymptomatic patients from a general population mostly aged between ## and ## years, whereas patients with a familial history of colorectal cancer were mostly excluded Although the overall incidence of CRC in acute diverticulitis seems to be slightly higher, the rate of CRC in patients with uncomplicated acute diverticulitis appeared to be only # #% which is similar to the rates in asymptomatic screening populations Therefore, routine colonoscopy after an uncomplicated diverticulitis episode seems not necessary, whereas a colonoscopy after a conservatively treated episode of complicated It should be noted that all patients included in the present study were diagnosed with acute diverticulitis based on CT These suspected lesions could have been missed on ultrasound and therefore the incidence of malignancy may be slightly higher in patients who did not undergo CT Although an earlier Dutch study (Van de Wall, ###) including both CT-proven and ultrasound-proven diverticulitis patients, found comparable prevalences (ACN in # out of ### patients (<DATUM> ) and CRC in # out of ### patients (# #%)) Furthermore, patients with persistent complaints after an episode of acute diverticulitis may not have been included in the studies when they underwent surgery before colonoscopy or were excluded in studies since such patients underwent colonoscopy on indication rather than a mere screening colonoscopy after a period of diverticulitis Routine colonoscopy seems appropriate for patients with persistent complaints after an episode of acute diverticulitis and may be considered to rule out malignancy in patients with non-surgical treatment of complicated diverticulitis In contrast, patients with uncomplicated acute diverticulitis do not appear to have an increased risk for ACN or CRC and routine colonoscopy may be omitted These patients can be referred back Routine colonoscopy to exclude an underlying malignancy has been considered mandatory for decades, based on studies that showed increased rates of colorectal malignancies in acute diverticulitis patients In recent years this strategy has been topic of debate because computed tomography (CT) increased the diagnostic accuracy of acute diverticulitis and decreased the number of misclassifications of colorectal malignancy as acute diverticulitis If acute diverticulitis patients do not have a higher risk for colorectal malignancy or advanced.
| 603 | fms |
suspected lesions could have been missed on ultrasound and therefore the incidence of malignancy may be slightly higher in patients who did not undergo CT Although an earlier Dutch study (Van de Wall, ###) including both CT-proven and ultrasound-proven diverticulitis patients, found comparable prevalences (ACN in # out of ### patients (<DATUM> ) and CRC in # out of ### patients (# #%)) Furthermore, patients with persistent complaints after an episode of acute diverticulitis may not have been included in the studies when they underwent surgery before colonoscopy or were excluded in studies since such patients underwent colonoscopy on indication rather than a mere screening colonoscopy after a period of diverticulitis Routine colonoscopy seems appropriate for patients with persistent complaints after an episode of acute diverticulitis and may be considered to rule out malignancy in patients with non-surgical treatment of complicated diverticulitis In contrast, patients with uncomplicated acute diverticulitis do not appear to have an increased risk for ACN or CRC and routine colonoscopy may be omitted These patients can be referred back Routine colonoscopy to exclude an underlying malignancy has been considered mandatory for decades, based on studies that showed increased rates of colorectal malignancies in acute diverticulitis patients In recent years this strategy has been topic of debate because computed tomography (CT) increased the diagnostic accuracy of acute diverticulitis and decreased the number of misclassifications of colorectal malignancy as acute diverticulitis If acute diverticulitis patients do not have a higher risk for colorectal malignancy or advanced minority of patients, the discomfort, costs and possible morbidity of a colonoscopy could be avoided in most Het aantal patiënten na een episode van acute diverticulitis waarbij een advanced adenoom Het aantal patiënten na een episode van acute diverticulitis waarbij een colorectaal carcinoom Na een episode van acute diverticulitis wordt bij #,#% van de patiënten een advanced Na een episode van acute diverticulitis wordt bij #,#% van de patiënten een colorectaal Sixteen observational cohort studies were included Ten studies were conducted in Europe, # in Canada, # in Australia, # in the USA and # in Korea (from which only left-sided diverticulitis patients were included in the present review) From five studies only left-sided diverticulitis patients could be included and the other studies did not report the proportion of left-sided diverticulitis but were from Western origin Most studies only included patients treated conservatively and excluded patients who had undergone a colonoscopy in the year(s) prior to the acute diverticulitis episode Six of ## studies reported outcomes of either only uncomplicated diverticulitis patients or reported outcomes only in subgroups of uncomplicated diverticulitis (Alexandersson, ###; colonoscopy were included in the present review Most follow-up colonoscopies were performed within a few months after the acute diverticulitis episode, although also colonoscopies performed later but within # year after the episode were included Only two studies included a control group of healthy individuals (<PERSOON>, ###; <PERSOON> study (<PERSOON>, ###) included control patients from a general population screening.
| 597 | fms |
of patients, the discomfort, costs and possible morbidity of a colonoscopy could be avoided in most Het aantal patiënten na een episode van acute diverticulitis waarbij een advanced adenoom Het aantal patiënten na een episode van acute diverticulitis waarbij een colorectaal carcinoom Na een episode van acute diverticulitis wordt bij #,#% van de patiënten een advanced Na een episode van acute diverticulitis wordt bij #,#% van de patiënten een colorectaal Sixteen observational cohort studies were included Ten studies were conducted in Europe, # in Canada, # in Australia, # in the USA and # in Korea (from which only left-sided diverticulitis patients were included in the present review) From five studies only left-sided diverticulitis patients could be included and the other studies did not report the proportion of left-sided diverticulitis but were from Western origin Most studies only included patients treated conservatively and excluded patients who had undergone a colonoscopy in the year(s) prior to the acute diverticulitis episode Six of ## studies reported outcomes of either only uncomplicated diverticulitis patients or reported outcomes only in subgroups of uncomplicated diverticulitis (Alexandersson, ###; colonoscopy were included in the present review Most follow-up colonoscopies were performed within a few months after the acute diverticulitis episode, although also colonoscopies performed later but within # year after the episode were included Only two studies included a control group of healthy individuals (<PERSOON>, ###; <PERSOON> study (<PERSOON>, ###) included control patients from a general population screening <PERSOON> study (Lecleire, ###) included sex and age matched control patients with a familial history of colorectal cancer or neoplasia (not occurring below the age of ##) that underwent screening colonoscopy in the same hospitals as the diverticulitis patients All ## studies reported rates of colorectal carcinoma (of which # studies reported results in an uncomplicated diverticulitis subgroup) and # studies reported rates of advanced colorectal neoplasms (of which # studies reported results in an uncomplicated diverticulitis subgroup) Advanced colorectal neoplasm was defined by colorectal carcinoma or another advanced neoplasm (adenoma of ##mm or larger, ##% or more villous features (also classified as tubulovillous or villous histology), or with high-grade dysplasia) Only two studies compared rates of ACN between acute diverticulitis patients and healthy controls ACN was found non-significantly less in diverticulitis patients (diverticulitis patients pooled <DATUM> versus controls pooled <DATUM> ; RR # ##, ##% CI # ## to <DATUM> (Figure #) Eight studies reported ACN rates in only diverticulitis patients, yielding a pooled rate of <DATUM> (Figure #) <PERSOON>-analysis of uncomplicated diverticulitis subgroup from # studies Figure # Forest plot of studies reporting rates of ACN in CT-proven acute diverticulitis patients compared with healthy patients f rom a screening ref erence population Figure # Forest plot of studies reporting rates of ACN in all CT-proven acute diverticulitis patients Figure # Forest plot of studies reporting rates of ACN in CT-proven uncomplicated acute.
| 624 | fms |
###) included sex and age matched control patients with a familial history of colorectal cancer or neoplasia (not occurring below the age of ##) that underwent screening colonoscopy in the same hospitals as the diverticulitis patients All ## studies reported rates of colorectal carcinoma (of which # studies reported results in an uncomplicated diverticulitis subgroup) and # studies reported rates of advanced colorectal neoplasms (of which # studies reported results in an uncomplicated diverticulitis subgroup) Advanced colorectal neoplasm was defined by colorectal carcinoma or another advanced neoplasm (adenoma of ##mm or larger, ##% or more villous features (also classified as tubulovillous or villous histology), or with high-grade dysplasia) Only two studies compared rates of ACN between acute diverticulitis patients and healthy controls ACN was found non-significantly less in diverticulitis patients (diverticulitis patients pooled <DATUM> versus controls pooled <DATUM> ; RR # ##, ##% CI # ## to <DATUM> (Figure #) Eight studies reported ACN rates in only diverticulitis patients, yielding a pooled rate of <DATUM> (Figure #) <PERSOON>-analysis of uncomplicated diverticulitis subgroup from # studies Figure # Forest plot of studies reporting rates of ACN in CT-proven acute diverticulitis patients compared with healthy patients f rom a screening ref erence population Figure # Forest plot of studies reporting rates of ACN in all CT-proven acute diverticulitis patients Figure # Forest plot of studies reporting rates of ACN in CT-proven uncomplicated acute Rates of CRC were comparable among groups (diverticulitis patients pooled # #% versus controls pooled # #%; RR # ##, ##% CI # ## to # ##) (Figure #) Sixteen studies reported CRC rates in only diverticulitis patients, yielding a pooled rate of <DATUM> (Figure #) <PERSOON>-analysis of uncomplicated diverticulitis subgroup from # studies demonstrated a lower rate of # #% (Figure #) Colorectal carcinomas were located at the site of the acute diverticulitis segment in the vast majority of cases <PERSOON> studies, including ## cases of CRC, reported locations Figure # Forest plot of studies reporting rates of CRC in CT-proven acute diverticulitis patients Figure # Forest plot of studies reporting rates of CRC in all CT-proven acute diverticulitis patients Figure # Forest plot of studies reporting rates of CRC in CT-proven uncomplicated acute De bewijskracht voor de uitkomstmaat advanced adenoom begon op âlaagâ aangezien het bewijs afkomstig is uit observationeel onderzoek Vervolgens is de bewijskracht met # niveau verlaagd gezien het gering aantal De bewijskracht voor de uitkomstmaat colorectaal carcinoom begon op âlaagâ aangezien het bewijs afkomstig is Is de kans op het hebben van colorectale neoplasmata verhoogd in patiënten die een episode acute diverticulitis De werkgroep achtte advanced adenoom en colorectaal carcinoom voor de besluitvorming kritieke Verantwoording De literatuurzoekactie leverde ### treffers op Studies werden geselecteerd op grond van de Minimaal ##% linkszijdige diverticulitis, indien proportie linkszijdige diverticulitis niet beschrijven alleen Westerse studies (zeer aannemelijk dat hierin de grote meerderheid linkszijdige diverticulitis betreft) Follow-up colonoscopie na diagnose acute diverticulitis en maximaal <LEEFTIJD> jaar na acute diverticulitis.
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controls pooled # #%; RR # ##, ##% CI # ## to # ##) (Figure #) Sixteen studies reported CRC rates in only diverticulitis patients, yielding a pooled rate of <DATUM> (Figure #) <PERSOON>-analysis of uncomplicated diverticulitis subgroup from # studies demonstrated a lower rate of # #% (Figure #) Colorectal carcinomas were located at the site of the acute diverticulitis segment in the vast majority of cases <PERSOON> studies, including ## cases of CRC, reported locations Figure # Forest plot of studies reporting rates of CRC in CT-proven acute diverticulitis patients Figure # Forest plot of studies reporting rates of CRC in all CT-proven acute diverticulitis patients Figure # Forest plot of studies reporting rates of CRC in CT-proven uncomplicated acute De bewijskracht voor de uitkomstmaat advanced adenoom begon op âlaagâ aangezien het bewijs afkomstig is uit observationeel onderzoek Vervolgens is de bewijskracht met # niveau verlaagd gezien het gering aantal De bewijskracht voor de uitkomstmaat colorectaal carcinoom begon op âlaagâ aangezien het bewijs afkomstig is Is de kans op het hebben van colorectale neoplasmata verhoogd in patiënten die een episode acute diverticulitis De werkgroep achtte advanced adenoom en colorectaal carcinoom voor de besluitvorming kritieke Verantwoording De literatuurzoekactie leverde ### treffers op Studies werden geselecteerd op grond van de Minimaal ##% linkszijdige diverticulitis, indien proportie linkszijdige diverticulitis niet beschrijven alleen Westerse studies (zeer aannemelijk dat hierin de grote meerderheid linkszijdige diverticulitis betreft) Follow-up colonoscopie na diagnose acute diverticulitis en maximaal <LEEFTIJD> jaar na acute diverticulitis Op basis van titel en abstract werden in eerste instantie ### studies voorgeselecteerd Na raadpleging van de volledige tekst, werden vervolgens ### studies geëxcludeerd (zie exclusietabel onder het tabblad Alexandersson BT, Hreinsson JP, Stefansson T, et al <PERSOON> risk of colorectal cancer after an attack of uncomplicated <PERSOON> R, et al Routine Colonoscopy after Acute Uncomplicated Diverticulitis - Challenging a <PERSOON> H, et al Prevalence of colorectal cancer and its precursor lesions in symptomatic and asymptomatic patients undergoing total colonoscopy results of a large prospective, multicenter, controlled endoscopy <PERSOON> D, et al Screening colonoscopy for colorectal cancer prevention results from a <PERSOON> PB, et al Colonoscopy following nonoperative management of uncomplicated diverticulitis may not <PERSOON> S, et al CT-colonography in the follow-up of acute diverticulitis patient acceptance and <PERSOON> YH, Koh SJ, <PERSOON-##> JW, et al Do we need colonoscopy following acute diverticulitis detected on computed tomography <PERSOON-##> TR, et al Yield of colonoscopy after recent CT-proven uncomplicated acute diverticulitis <PERSOON-##> SS, Pargaonkar V, et al Is early colonoscopy beneficial in patients with CT-diagnosed diverticulitis? <PERSOON-##> SJ, et al <PERSOON> association of colonoscopy quality indicators with the detection of screenrelevant lesions, adverse events, and postcolonoscopy cancers in an asymptomatic Canadian colorectal cancer screening.
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Op basis van titel en abstract werden in eerste instantie ### studies voorgeselecteerd Na raadpleging van de volledige tekst, werden vervolgens ### studies geëxcludeerd (zie exclusietabel onder het tabblad Alexandersson BT, Hreinsson JP, Stefansson T, et al <PERSOON> risk of colorectal cancer after an attack of uncomplicated <PERSOON> R, et al Routine Colonoscopy after Acute Uncomplicated Diverticulitis - Challenging a <PERSOON> H, et al Prevalence of colorectal cancer and its precursor lesions in symptomatic and asymptomatic patients undergoing total colonoscopy results of a large prospective, multicenter, controlled endoscopy <PERSOON> D, et al Screening colonoscopy for colorectal cancer prevention results from a <PERSOON> PB, et al Colonoscopy following nonoperative management of uncomplicated diverticulitis may not <PERSOON> S, et al CT-colonography in the follow-up of acute diverticulitis patient acceptance and <PERSOON> YH, Koh SJ, <PERSOON> JW, et al Do we need colonoscopy following acute diverticulitis detected on computed tomography <PERSOON> TR, et al Yield of colonoscopy after recent CT-proven uncomplicated acute diverticulitis <PERSOON-##> SS, Pargaonkar V, et al Is early colonoscopy beneficial in patients with CT-diagnosed diverticulitis? <PERSOON-##> SJ, et al <PERSOON> association of colonoscopy quality indicators with the detection of screenrelevant lesions, adverse events, and postcolonoscopy cancers in an asymptomatic Canadian colorectal cancer screening CT colonography versus colonoscopy in the follow-up of patients after diverticulitis - a <PERSOON-##> Y, et al <PERSOON> feasibility and risk of early colonoscopy in acute diverticulitis a prospective <PERSOON-##> Y, et al Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis can colorectal cancer be confidently excluded? Diseases of the colon and rectum ###;##(##) ###-## <PERSOON-##> A, et al Diagnostic impact of routine colonoscopy following acute diverticulitis A multicenter Lisi D, <PERSOON-##> M, et al Participation in colorectal cancer screening with FOBT and colonoscopy an <PERSOON-##> R, <PERSOON-##> Z, et al Screening colonoscopy for colorectal cancer in asymptomatic people a meta-analysis <PERSOON-##> J, et al Colonoscopy after CT-diagnosed acute diverticulitis Is it really necessary? <PERSOON-##> L, et al Colonoscopy versus fecal immunochemical testing in colorectal-cancer screening <PERSOON-##> J, et al Colonoscopy after CT diagnosis of diverticulitis to exclude colon cancer a systematic <PERSOON-##> E, et al Early colonoscopy in patients with acute diverticulitis results of a prospective pilot <PERSOON-##> of colon cancer after computed tomography-diagnosed acute diverticulitis is <PERSOON-##> E, <PERSOON-##> M, et al <PERSOON-##> a colonoscopy after acute diverticulitis affect its management? a single.
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De z e ric htlijn is to t stand ge ko me n o p initiatie f van Ne de rlandse Ve re niging vo o r Tho raxc hirurgie Operative interventions to reduce the incidence of atrial fibrillation Anticoagulation for patients with de novo atrial fibrillation after cardiac surgery Additional benefit of magnesium in patients having antiarrhythmic treatment for atrial fibrillation Deze richtlijn richt zich op wat volgens de huidige maatstaven de beste zorg is om boezemfibrilleren te voorkomen of te behandelen bij patiënten die een operatie aan hart en/of longen ondergaan In de richtlijn De beste behandeling van boezemfibrilleren bij patiënten die een hartoperatie hebben ondergaan De rol van antistollende medicijnen op boezemfibrilleren bij patiënten die een hartoperatie hebben De best te gebruiken lokatie van de plakker als boezemfibrilleren moet worden behandeld met een De rol van magnesium in de behandeling van boezemfibrilleren bij patiënten die een hartoperatie Deze richtlijn is bestemd voor alle zorgverleners die betrokken zijn bij de zorg voor patiënten met Het hart bestaat uit vier holtes De bovenste twee holtes worden boezems (atriums) genoemd, de onderste twee kamers (ventrikels) Het bloed komt het hart binnen via de boezems, stroomt de kamers in en wordt dan het lichaam weer ingepomt Normaal gesproken ligt het hartritme tussen de ## en ### slagen per minuut boezemfribrilleren is het ritme vaak onregelmatig en sneller dan normaal Soms is dit voelbaar voor patiënten Dit kan angst of onrust geven Ook kan duizeligheid en vermoeidheid optreden Boezemfibrilleren kan kortdurend maar ook langer aanwezig zijn Er bestaan verschillende oorzaken Een van deze oorzaken is het ondergaan van een operatie Cardio-thoracale operaties zijn operaties waarbij wordt geopereerd aan het hart en/of de longen Bij ## tot ## procent van alle patiënten die worden geopereerd aan het hart en/of de longen Meer informatie over boezemfibrilleren is ook te vinden op de website van de Hartstichting Het initiatief voor deze richtlijn is afkomstig van de Nederlandse Vereniging voor Thoraxchirurgie (NVT) De <PERSOON> Jr JJ, Cohn LH, Burstin HR Predictors of atrial fibrillation after coronary artery surgery Current trends and impact on hospital resources Circulation ###;#<DATUM> # [see <PERSOON> JL Hazards of postoperative atrial arrhythmias <PERSOON> AC, Aggarwal A, <PERSOON> TE, <PERSOON> AL, Sethi GK, Grover FL, Hammermeister KE Atrial fibrillation after cardiac surgery a major morbid event? <PERSOON> ###;#<DATUM> <PERSOON> DT, Browner WS, Multicenter Study of Perioperative Ischemia Research Group Atrial fibrillation following coronary artery bypass graft surgery predictors, outcomes, and <PERSOON> DL, Goldberg RJ Clinical recommendations using levels of evidence for <PERSOON> evidence-based medicine in cardiothoracic surgery best BETS.
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kan kortdurend maar ook langer aanwezig zijn Er bestaan verschillende oorzaken Een van deze oorzaken is het ondergaan van een operatie Cardio-thoracale operaties zijn operaties waarbij wordt geopereerd aan het hart en/of de longen Bij ## tot ## procent van alle patiënten die worden geopereerd aan het hart en/of de longen Meer informatie over boezemfibrilleren is ook te vinden op de website van de Hartstichting Het initiatief voor deze richtlijn is afkomstig van de Nederlandse Vereniging voor Thoraxchirurgie (NVT) De <PERSOON> Jr JJ, Cohn LH, Burstin HR Predictors of atrial fibrillation after coronary artery surgery Current trends and impact on hospital resources Circulation ###;#<DATUM> # [see <PERSOON> JL Hazards of postoperative atrial arrhythmias <PERSOON> AC, Aggarwal A, <PERSOON> TE, <PERSOON> AL, Sethi GK, Grover FL, Hammermeister KE Atrial fibrillation after cardiac surgery a major morbid event? <PERSOON> ###;#<DATUM> <PERSOON> DT, Browner WS, Multicenter Study of Perioperative Ischemia Research Group Atrial fibrillation following coronary artery bypass graft surgery predictors, outcomes, and <PERSOON> DL, Goldberg RJ Clinical recommendations using levels of evidence for <PERSOON> evidence-based medicine in cardiothoracic surgery best BETS European Society of Cardiology Committee for Practice Guidelines and Policy Conferences ACC/AHA/ESC Guidelines for the Management of <PERSOON-##> ###;#<DATUM> âlxx <PERSOON-##> J Are prophylactic b-blockers of benefit in reducing the incidence of atrial fibrillation Andrews TC, Reimold SC, Berlin JA, Antman EM Prevention of supraventricular arrhythmias after coronary artery bypass Kowey PR, <PERSOON-##> JE, Rials SJ, Marinchak RA <PERSOON-##>-analysis of the effectiveness of prophylactic drug therapy in preventing supraventricular arrhythmia early after coronary artery bypass grafting <PERSOON-##> ###;#<DATUM> # <PERSOON-##> SJ, Sleik K, <PERSOON-##> TJ, <PERSOON-##> on prevention of postoperative atrial fibrillation in patients Wurdeman RL, Mooss AN, Mohiuddin SM, Lenz TL Amiodarone vs sotalol as prophylaxis against atrial fibrillation /flutter <PERSOON-##> SN <PERSOON-##>-analysis of antiarrhythmic therapy in the prevention of postoperative atrial fibrillation and the effect on hospital length of stay, costs, cerebrovascular accidents, andmortality in patients undergoing cardiac surgery <PERSOON-##> ###;##(#) ###â# # <PERSOON-##> MS, Connolly SS, <PERSOON-##> TT, Sleik K, <PERSOON-##> SS Interventions for preventing postoperative atrial fibrillation in patients undergoing heart surgery <PERSOON-##> ED Society of Thoracic Surgeons National Adult Cardiac Surgery Database Preoperative B-blocker use and mortality and morbidity following CABG surgery in <PERSOON-##>.
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Cardiology Committee for Practice Guidelines and Policy Conferences ACC/AHA/ESC Guidelines for the Management of <PERSOON> ###;#<DATUM> âlxx <PERSOON> J Are prophylactic b-blockers of benefit in reducing the incidence of atrial fibrillation Andrews TC, Reimold SC, Berlin JA, Antman EM Prevention of supraventricular arrhythmias after coronary artery bypass Kowey PR, <PERSOON> JE, Rials SJ, Marinchak RA <PERSOON>-analysis of the effectiveness of prophylactic drug therapy in preventing supraventricular arrhythmia early after coronary artery bypass grafting <PERSOON> ###;#<DATUM> # <PERSOON> SJ, Sleik K, <PERSOON> TJ, <PERSOON> on prevention of postoperative atrial fibrillation in patients Wurdeman RL, Mooss AN, Mohiuddin SM, Lenz TL Amiodarone vs sotalol as prophylaxis against atrial fibrillation /flutter <PERSOON> SN <PERSOON>-analysis of antiarrhythmic therapy in the prevention of postoperative atrial fibrillation and the effect on hospital length of stay, costs, cerebrovascular accidents, andmortality in patients undergoing cardiac surgery <PERSOON> ###;##(#) ###â# # <PERSOON-##> MS, Connolly SS, <PERSOON> TT, Sleik K, <PERSOON-##> SS Interventions for preventing postoperative atrial fibrillation in patients undergoing heart surgery <PERSOON-##> ED Society of Thoracic Surgeons National Adult Cardiac Surgery Database Preoperative B-blocker use and mortality and morbidity following CABG surgery in <PERSOON-##> Oâ<PERSOON-##> WL, <PERSOON-##> G, <PERSOON-##> Jr SC ACC/AHA guidelines for coronary artery bypass graft surgery A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee to revise the ### <PERSOON-##> J Is Sotalol more effective than standard beta-blockers for prophylaxis of atrial fibrillation during cardiac <PERSOON-##> JH, Tijon <PERSOON-##> Gin RM, van Hemel <PERSOON-##> EM, Defauw JA, <PERSOON-##> AJ, <PERSOON-##> SM Efficacy and safety of low and high dose sotalol versus propranolol in the prevention of supraventricular tachyarrhythmias early after coronary <PERSOON-##> JG, van Hemel NM, Defauw JA, <PERSOON-##> SM Effectiveness of sotalol in preventing supraventricular tachyarrhythmias shortly after coronary artery bypass grafting <PERSOON-##> of prevention of postoperative atrial fibrillation A comparison between oral antiarrhythmic drugs in the prevention of atrial fibrillation after cardiac surgery the pilot study of prevention of postoperative atrial fibrillation (SPPAF), a randomised, <PERSOON-##> use of sotalol versus atenolol <PERSOON-##> and treatment of.
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<PERSOON> WL, <PERSOON> G, <PERSOON> Jr SC ACC/AHA guidelines for coronary artery bypass graft surgery A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee to revise the ### <PERSOON> J Is Sotalol more effective than standard beta-blockers for prophylaxis of atrial fibrillation during cardiac <PERSOON> JH, Tijon <PERSOON> Gin RM, van Hemel <PERSOON> EM, Defauw JA, <PERSOON> AJ, <PERSOON> SM Efficacy and safety of low and high dose sotalol versus propranolol in the prevention of supraventricular tachyarrhythmias early after coronary <PERSOON-##> JG, van Hemel NM, Defauw JA, <PERSOON> SM Effectiveness of sotalol in preventing supraventricular tachyarrhythmias shortly after coronary artery bypass grafting <PERSOON-##> of prevention of postoperative atrial fibrillation A comparison between oral antiarrhythmic drugs in the prevention of atrial fibrillation after cardiac surgery the pilot study of prevention of postoperative atrial fibrillation (SPPAF), a randomised, <PERSOON-##> use of sotalol versus atenolol <PERSOON-##> and treatment of a randomised open trial <PERSOON-##> of sotalol and metoprolol in the prevention of atrial <PERSOON-##> sotalol reduces the incidence of atrial fibrillation after coronary artery bypass surgery Thorac Cardiovasc Surg ###;## ##â# <PERSOON-##> O, <PERSOON-##> HT, <PERSOON-##> comparative value of low dose sotalol vs <PERSOON-##> amiodarone effectively prevents postoperative atrial fibrillation Interactive <PERSOON-##> EG, Strickberger SA, <PERSOON-##> amiodarone as prophylaxis against atrial fibrillation after heart surgery <PERSOON-##> J Med ###;### ###â<DATUM> [see <PERSOON-##> amiodarone for prevention of atrial fibrillation after open heart surgery, the Atrial Fibrillation Suppression Trial (AFIST) a randomised <PERSOON-##> M, <PERSOON-##> intravenous and oral amiodarone perioperatively for the prevention of postoperative atrial fibrillation in patients undergoing coronary artery bypass surgery <PERSOON-##> prophylaxis for tachycardias after coronary artery surgery a <PERSOON-##> G, <PERSOON-##> and antiarrhythmic effects of intravenous amiodarone.
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a randomised open trial <PERSOON> of sotalol and metoprolol in the prevention of atrial <PERSOON> sotalol reduces the incidence of atrial fibrillation after coronary artery bypass surgery Thorac Cardiovasc Surg ###;## ##â# <PERSOON> O, <PERSOON> HT, <PERSOON> comparative value of low dose sotalol vs <PERSOON> amiodarone effectively prevents postoperative atrial fibrillation Interactive <PERSOON> EG, Strickberger SA, <PERSOON> amiodarone as prophylaxis against atrial fibrillation after heart surgery <PERSOON> J Med ###;### ###â<DATUM> [see <PERSOON-##> amiodarone for prevention of atrial fibrillation after open heart surgery, the Atrial Fibrillation Suppression Trial (AFIST) a randomised <PERSOON-##> M, <PERSOON-##> intravenous and oral amiodarone perioperatively for the prevention of postoperative atrial fibrillation in patients undergoing coronary artery bypass surgery <PERSOON-##> prophylaxis for tachycardias after coronary artery surgery a <PERSOON-##> G, <PERSOON-##> and antiarrhythmic effects of intravenous amiodarone Am Heart J <PERSOON-##> J Bi-atrial pacing significantly reduces the incidence of atrial fibrillation post cardiac surgery <PERSOON-##> magnesium prophylaxis reduce the incidence of atrial fibrillation following coronary Miller S, <PERSOON-##> SJ Effects of Magnesium on atrial fibrillation after cardiac Alghamdi <INSTELLING>, Al-<PERSOON-##> OO, Latter DA Intravenous magnesium for prevention of atrial fibrillation after coronary artery <PERSOON-##> prophylaxis for arrhythmia after cardiac surgery a meta-analysis of <PERSOON-##> infusion dramatically decreases the incidence of atrial fibrillation after coronary artery bypass grafting <PERSOON-##> S, De <PERSOON-##> of sotalol and magnesium prevents atrial fibrillation after coronary artery bypass grafting <PERSOON-##> SR, Boley TM, Cetindag IB, Moulton KP, Trammell GL, Polancic JE, Shawgo TS, <PERSOON-##> JA, <PERSOON-##> efficacy of supplemental magnesium in reducing atrial fibrillation after coronary artery bypass grafting <PERSOON-##> <INSTELLING>, Ascione R, <PERSOON-##> AJ, Angelini GD Magnesium-supplemented warm blood <PERSOON-##> AK A beta-blocker, not magnesium, is effective prophylaxis for atrial tachyarrhythmias after coronary artery bypass graft surgery <PERSOON-##> ###;<DATUM> #.
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J <PERSOON> J Bi-atrial pacing significantly reduces the incidence of atrial fibrillation post cardiac surgery <PERSOON> magnesium prophylaxis reduce the incidence of atrial fibrillation following coronary Miller S, <PERSOON> SJ Effects of Magnesium on atrial fibrillation after cardiac Alghamdi <INSTELLING>, Al-<PERSOON> OO, Latter DA Intravenous magnesium for prevention of atrial fibrillation after coronary artery <PERSOON> prophylaxis for arrhythmia after cardiac surgery a meta-analysis of <PERSOON> infusion dramatically decreases the incidence of atrial fibrillation after coronary artery bypass grafting <PERSOON> S, De <PERSOON> of sotalol and magnesium prevents atrial fibrillation after coronary artery bypass grafting <PERSOON> SR, Boley TM, Cetindag IB, Moulton KP, Trammell GL, Polancic JE, Shawgo TS, <PERSOON-##> JA, <PERSOON-##> efficacy of supplemental magnesium in reducing atrial fibrillation after coronary artery bypass grafting <PERSOON-##> <INSTELLING>, Ascione R, <PERSOON-##> AJ, Angelini GD Magnesium-supplemented warm blood <PERSOON-##> AK A beta-blocker, not magnesium, is effective prophylaxis for atrial tachyarrhythmias after coronary artery bypass graft surgery <PERSOON-##> magnesium sulfate prophylaxis for atrial fibrillation after coronary <PERSOON-##> G Is there a role for prophylaxis against atrial fibrillation for patients undergoing <PERSOON-##> ME, <PERSOON-##> DH, Downey RJ, Ginsberg RJ Effects of diltiazem versus digoxin on dysrhythmias and cardiac function after pneumonectomy <PERSOON-##> as prophylactic Van <PERSOON-##> LM, Deneffe GJ, Demedts MG Amiodarone and the development of <PERSOON-##> of arrhythmias by flecainide after <PERSOON-##> of arrhythmias after non cardiac thoracic <PERSOON-##> EB Perioperative metoprolol reduces the frequency of atrial fibrillation after thoracotomy for lung resection <PERSOON-##> CD, Massel <PERSOON-##> RI, Malthaner RA, <PERSOON-##> SD, Powell FS, Kennedy RS Propranolol for the prevention of <PERSOON-##> epidural bupivacaine attenuates supraventricular tachyarrhythmias after pulmonary <PERSOON-##> VS Prevention of atrial tachyarrhythmias after non-cardiac thoracic surgery by infusion of magnesium sulfate Cardiovasc Surg ###;#<DATUM> # [see comment].
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Intravenous magnesium sulfate prophylaxis for atrial fibrillation after coronary <PERSOON> G Is there a role for prophylaxis against atrial fibrillation for patients undergoing <PERSOON> ME, <PERSOON> DH, Downey RJ, Ginsberg RJ Effects of diltiazem versus digoxin on dysrhythmias and cardiac function after pneumonectomy <PERSOON> as prophylactic Van <PERSOON> LM, Deneffe GJ, Demedts MG Amiodarone and the development of <PERSOON> of arrhythmias by flecainide after <PERSOON> of arrhythmias after non cardiac thoracic <PERSOON> EB Perioperative metoprolol reduces the frequency of atrial fibrillation after thoracotomy for lung resection <PERSOON> CD, Massel <PERSOON-##> RI, Malthaner RA, <PERSOON-##> SD, Powell FS, Kennedy RS Propranolol for the prevention of <PERSOON-##> epidural bupivacaine attenuates supraventricular tachyarrhythmias after pulmonary <PERSOON-##> VS Prevention of atrial tachyarrhythmias after non-cardiac thoracic surgery by infusion of magnesium sulfate Cardiovasc Surg ###;#<DATUM> # [see comment] <PERSOON-##> off-pump coronary artery surgery reduce the incidence of postoperative atrial Reston JT, Tregear SJ, Turkelson CM <PERSOON-##>-analysis of short-term and mid-term outcomes following off-pump coronary <PERSOON-##> EWL, Grobbee DE Metaanalysis on the effect of off-pump coronary bypass <PERSOON-##> AM, Nathoe HM, Grobbee DE, de <PERSOON-##> CJ, Octopus Study Group Cognitive outcome after off-pump and on-pump coronary <PERSOON-##> WH, <PERSOON-##> KE, <PERSOON-##> RJ, <PERSOON-##> DE, <PERSOON-##> EM, Weintraub WS, Guyton RA Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay a prospective randomised comparison of two hundred unselected patients undergoing off-pump versus conventional <PERSOON-##> JD, <PERSOON-##> WT, Popper J, <PERSOON-##> A, <PERSOON-##> D, <PERSOON-##> CR Benefits of off-pump bypass on neurologic and clinical morbidity a prospective randomised trial <PERSOON-##> GD, <PERSOON-##> FC, Reeves <PERSOON-##> and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS # and #) a pooled analysis of two randomised controlled trials <PERSOON-##> R Off-pump versus on-pump.
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surgery reduce the incidence of postoperative atrial Reston JT, Tregear SJ, Turkelson CM <PERSOON>-analysis of short-term and mid-term outcomes following off-pump coronary <PERSOON> EWL, Grobbee DE Metaanalysis on the effect of off-pump coronary bypass <PERSOON> AM, Nathoe HM, Grobbee DE, de <PERSOON> CJ, Octopus Study Group Cognitive outcome after off-pump and on-pump coronary <PERSOON> WH, <PERSOON> KE, <PERSOON> RJ, <PERSOON> DE, <PERSOON> EM, Weintraub WS, Guyton RA Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay a prospective randomised comparison of two hundred unselected patients undergoing off-pump versus conventional <PERSOON-##> JD, <PERSOON-##> WT, Popper J, <PERSOON-##> A, <PERSOON-##> D, <PERSOON-##> CR Benefits of off-pump bypass on neurologic and clinical morbidity a prospective randomised trial <PERSOON-##> GD, <PERSOON-##> FC, Reeves <PERSOON-##> and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS # and #) a pooled analysis of two randomised controlled trials <PERSOON-##> R Off-pump versus on-pump final results from a prospective randomised study <PERSOON-##> DE, Robles De <PERSOON-##> EO, de Jaegere PP, Octopus Study Group Early outcome after off-pump versus on-pump coronary <PERSOON-##> Off-pump coronary artery bypass surgery technique for total arterial myocardial revascularization a prospective randomised study <PERSOON-##> LA, <PERSOON-##> JN Off-pump versus on-pump myocardial revascularization in low-risk patients with one or two vessel disease perioperative results in a multicenter randomised <PERSOON-##> pericardiotomy reduces the incidence of supraventricular arrhythmias and pericardial effusion after coronary artery bypass grafting <PERSOON-##> of ventral cardiac denervation as a prophylaxis against AF after coronary artery bypass <PERSOON-##> HK Aortic fat pad destruction and post operative AF <PERSOON-##> H, <PERSOON-##> cardiac denervation reduces the incidence of AF after coronary artery bypass grafting <PERSOON-##> B.
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final results from a prospective randomised study <PERSOON> DE, Robles De <PERSOON> EO, de Jaegere PP, Octopus Study Group Early outcome after off-pump versus on-pump coronary <PERSOON> Off-pump coronary artery bypass surgery technique for total arterial myocardial revascularization a prospective randomised study <PERSOON> LA, <PERSOON> JN Off-pump versus on-pump myocardial revascularization in low-risk patients with one or two vessel disease perioperative results in a multicenter randomised <PERSOON> pericardiotomy reduces the incidence of supraventricular arrhythmias and pericardial effusion after coronary artery bypass grafting <PERSOON> of ventral cardiac denervation as a prophylaxis against AF after coronary artery bypass <PERSOON> HK Aortic fat pad destruction and post operative AF <PERSOON> H, <PERSOON-##> cardiac denervation reduces the incidence of AF after coronary artery bypass grafting <PERSOON-##> B atrial fibrillation after their operation? Interactive Cardiovasc Thorac Surg ###;##â ## Gavaghan TP, Feneley MP, Campbell TJ, <PERSOON-##> JJ Atrial tachyarrhythmias after cardiac surgery results of disopyramide <PERSOON-##> GA, el <PERSOON-##> GS, Wheatley DJ Arrhythmia prophylaxis after coronary artery surgery <PERSOON-##>-disordered breathing a novel predictor of atrial fibrillation after coronary <PERSOON-##> RE, Hayes DL Expanding indications for permanent pacemakers <PERSOON-##> M, <PERSOON-##> R, <PERSOON-##> effects and safety of sotalol in the prevention of supraventricular arrhythmias after coronary artery bypass surgery <PERSOON-##> BB A comparison of amiodarone and digoxin for treatment of supraventricular arrhythmias after cardiac surgery <PERSOON-##> amiodarone vs propafenone for atrial <PERSOON-##> AD, <PERSOON-##> DJ, Pullan DM, Dihmis WC, <PERSOON-##> BM Coronary surgery in patients with peripheral vascular disease effect of avoiding cardiopulmonary bypass <PERSOON-##> TA, Schaff HV, Pluth JR, Danielson GK, Puga FJ, Ilstrup DM, <PERSOON-##> risk of stroke in the early Groh MA, Sutherland SE, Burton III HG, <PERSOON-##> AM, Ely SW.
| 457 | fms |
Interactive Cardiovasc Thorac Surg ###;##â ## Gavaghan TP, Feneley MP, Campbell TJ, <PERSOON> JJ Atrial tachyarrhythmias after cardiac surgery results of disopyramide <PERSOON> GA, el <PERSOON> GS, Wheatley DJ Arrhythmia prophylaxis after coronary artery surgery <PERSOON>-disordered breathing a novel predictor of atrial fibrillation after coronary <PERSOON> RE, Hayes DL Expanding indications for permanent pacemakers <PERSOON> M, <PERSOON> R, <PERSOON> effects and safety of sotalol in the prevention of supraventricular arrhythmias after coronary artery bypass surgery <PERSOON> BB A comparison of amiodarone and digoxin for treatment of supraventricular arrhythmias after cardiac surgery <PERSOON-##> amiodarone vs propafenone for atrial <PERSOON-##> AD, <PERSOON-##> DJ, Pullan DM, Dihmis WC, <PERSOON-##> BM Coronary surgery in patients with peripheral vascular disease effect of avoiding cardiopulmonary bypass <PERSOON-##> TA, Schaff HV, Pluth JR, Danielson GK, Puga FJ, Ilstrup DM, <PERSOON-##> risk of stroke in the early Groh MA, Sutherland SE, Burton III HG, <PERSOON-##> AM, Ely SW technique and Campbell TJ, Gavaghan TP, <PERSOON> JJ Intravenous sotalol for the treatment of atrial fibrillation and flutter after cardiopulmonary bypass Comparison with disopyramide and digoxin in a randomised trial <PERSOON-##> circadian variation in heart rate variability before surgery in patients developing postoperative AF <PERSOON-##> AG, Archbold RA, Helft G, <PERSOON-##> EA, Curzen NP, Mills PG Atrial fibrillation after coronary artery bypass surgery a <PERSOON-##> KB, <PERSOON-##> PC, Hicks Jr GL Patterns of referral and recovery in women and men undergoing coronary artery bypass <PERSOON-##> and risk factors of atrial fibrillation in a surgical <PERSOON-##> TW, <PERSOON-##> care after minimally invasive and conventional coronary surgery a prospective comparison <PERSOON-##> substitution in elective coronary artery surgery a double-blind clinical study <PERSOON-##> SM What is the optimal anticoagulation management of patients postcardiac surgery who go into atrial fibrillation? Interactive Cardiovasc Thorac Surg ###;###â# Hart <PERSOON-##> LA.
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TJ, Gavaghan TP, <PERSOON> JJ Intravenous sotalol for the treatment of atrial fibrillation and flutter after cardiopulmonary bypass Comparison with disopyramide and digoxin in a randomised trial <PERSOON> circadian variation in heart rate variability before surgery in patients developing postoperative AF <PERSOON> AG, Archbold RA, Helft G, <PERSOON> EA, Curzen NP, Mills PG Atrial fibrillation after coronary artery bypass surgery a <PERSOON> KB, <PERSOON> PC, Hicks Jr GL Patterns of referral and recovery in women and men undergoing coronary artery bypass <PERSOON> and risk factors of atrial fibrillation in a surgical <PERSOON> TW, <PERSOON> care after minimally invasive and conventional coronary surgery a prospective comparison <PERSOON-##> substitution in elective coronary artery surgery a double-blind clinical study <PERSOON-##> SM What is the optimal anticoagulation management of patients postcardiac surgery who go into atrial fibrillation? Interactive Cardiovasc Thorac Surg ###;###â# Hart <PERSOON-##> LA a <PERSOON-##> NG, Henault LE, Selby JV, Singer DE Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation <PERSOON-##> B, <PERSOON-##> A, <PERSOON-##> atrial fibrillation and mortality after coronary artery bypass surgery <PERSOON-##> after coronary artery bypass <PERSOON-##> role of anticoagulation in the development of pericardial effusion and late tamponade after cardiac surgery Eur Heart J ###;## ###â# [erratum in Eur Heart J ### Apr;##(#) ###â# ] <PERSOON-##> EG Management of atrial fibrillation in the post-cardiac surgery setting Cardiol Clin ###;<DATUM> [review, ## Nagarajan DV, Dunning J Is antero-posterior position superior to antero-lateral position for placement of electrodes for external cardioversion of atrial fibrillation? <PERSOON-##> magnesium offer any additional benefit in patients having anti-arrhythmic treatment for atrial fibrillation following cardiac surgery? Interactive Cardiovasc Thorac Surg ###;<DATUM> # Kalus JS, <PERSOON-##> AP, Tsikouris JP Impact of prophylactic iv magnesium on the efficacy of ibutilide for conversion of atrial.
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a <PERSOON> NG, Henault LE, Selby JV, Singer DE Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation <PERSOON> B, <PERSOON> A, <PERSOON> atrial fibrillation and mortality after coronary artery bypass surgery <PERSOON> after coronary artery bypass <PERSOON> role of anticoagulation in the development of pericardial effusion and late tamponade after cardiac surgery Eur Heart J ###;## ###â# [erratum in Eur Heart J ### Apr;##(#) ###â# ] <PERSOON> EG Management of atrial fibrillation in the post-cardiac surgery setting Cardiol Clin ###;<DATUM> [review, ## Nagarajan DV, Dunning J Is antero-posterior position superior to antero-lateral position for placement of electrodes for external cardioversion of atrial fibrillation? <PERSOON> magnesium offer any additional benefit in patients having anti-arrhythmic treatment for atrial fibrillation following cardiac surgery? Interactive Cardiovasc Thorac Surg ###;<DATUM> # Kalus JS, <PERSOON> AP, Tsikouris JP Impact of prophylactic iv magnesium on the efficacy of ibutilide for conversion of atrial Magnesium therapy in new onset atrial Hays JV, Gilman JK, Rubal BJ Effect of magnesium sulfate on ventricular rate control in atrial fibrillation <PERSOON-##> M Effect of intravenous magnesium on heart rate and heart rate variability in patients with Chiladakis JA, <PERSOON-##> AS Intravenous magnesium sulfate versus diltiazem in paroxysmal <PERSOON-##> magnesium sulfate versus amiodarone in the therapy of atrial tachyarrhythmias a prospective, randomised study <PERSOON-##> effect of magnesium versus verapamil on supraventricular <PERSOON-##> AE, Hirsch GM, Pearson GJ Assessment of new onset post coronary artery bypass surgery atrial fibrillation current practice pattern review and the development of treatment guidelines <PERSOON-##> of atrial fibrillation after coronary artery bypass graft <PERSOON-##> ###;##(#A) ##â## [review, ## <PERSOON> EG Management of atrial fibrillation in the post-cardiac surgery setting Cardiol Clin ###;##(#) ###â<DATUM> [review, ## Prystowsky EN Management of atrial fibrillation therapeutic options and clinical decisions <PERSOON-##> WH, Rawn JD, Stevenson WG Atrial fibrillation after cardiac surgery <PERSOON-##> Med ###;##<DATUM> ## [review, ### Hogue Jr CW, Hyder ML Atrial fibrillation after cardiac operation risks, mechanisms, and treatment <PERSOON-##> LL, <PERSOON-##> Jr RJ.
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JK, Rubal BJ Effect of magnesium sulfate on ventricular rate control in atrial fibrillation <PERSOON> M Effect of intravenous magnesium on heart rate and heart rate variability in patients with Chiladakis JA, <PERSOON> AS Intravenous magnesium sulfate versus diltiazem in paroxysmal <PERSOON> magnesium sulfate versus amiodarone in the therapy of atrial tachyarrhythmias a prospective, randomised study <PERSOON> effect of magnesium versus verapamil on supraventricular <PERSOON> AE, Hirsch GM, Pearson GJ Assessment of new onset post coronary artery bypass surgery atrial fibrillation current practice pattern review and the development of treatment guidelines <PERSOON> of atrial fibrillation after coronary artery bypass graft <PERSOON> ###;##(#A) ##â## [review, ## <PERSOON> EG Management of atrial fibrillation in the post-cardiac surgery setting Cardiol Clin ###;##(#) ###â<DATUM> [review, ## Prystowsky EN Management of atrial fibrillation therapeutic options and clinical decisions <PERSOON> WH, Rawn JD, Stevenson WG Atrial fibrillation after cardiac surgery <PERSOON-##> Med ###;##<DATUM> ## [review, ### Hogue Jr CW, Hyder ML Atrial fibrillation after cardiac operation risks, mechanisms, and treatment <PERSOON-##> LL, <PERSOON-##> Jr RJ an old problem crying out for new solutions <PERSOON-##> JW Atrial fibrillation after coronary bypass aetiology and pharmacologic prevention Hill LL, De <PERSOON-##> Jr CW Management of atrial fibrillation after cardiac surgery Part II Prevention and treatment <PERSOON-##> DB, Kowey PR Management and prevention of atrial fibrillation after cardiovascular surgery AmJ Cardiol Reiffel JA Drug choices in the treatment of atrial fibrillation <PERSOON> ###;##(##A) ##Dâ# D [review, ## refs ] <PERSOON-##> SK Arrhythmias and conduction disturbances after coronary artery bypass graft <PERSOON-##> National Collaborating Centre for Chronic Conditions for the National Institute for Health and <PERSOON-##> conversion of acute atrial fibrillation after open-heart surgery compared with digoxin treatment <PERSOON-##> SS,<PERSOON-##> DE, Parker DJ, Camm AJ Efficacy of flecainide acetate for atrial arrhythmias following coronary artery <PERSOON-##> versus ibutilide for post operative atrial fibrillation following cardiac surgery neither strategy improves outcomes compared with rate control alone (the PIPAF study) Med Sci Monit ###;# I##â<DATUM> <PERSOON-##> EO, Schmid ER, <PERSOON-##> versus amiodarone in atrial fibrillation a Mooss AN, Wurdeman RL, Mohiuddin SM, Reyes AP, Sugimoto JT, <PERSOON-##> DE, Seyedroudbari A.
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old problem crying out for new solutions <PERSOON> JW Atrial fibrillation after coronary bypass aetiology and pharmacologic prevention Hill LL, De <PERSOON> Jr CW Management of atrial fibrillation after cardiac surgery Part II Prevention and treatment <PERSOON> DB, Kowey PR Management and prevention of atrial fibrillation after cardiovascular surgery AmJ Cardiol Reiffel JA Drug choices in the treatment of atrial fibrillation <PERSOON> ###;##(##A) ##Dâ# D [review, ## refs ] <PERSOON> SK Arrhythmias and conduction disturbances after coronary artery bypass graft <PERSOON> National Collaborating Centre for Chronic Conditions for the National Institute for Health and <PERSOON> conversion of acute atrial fibrillation after open-heart surgery compared with digoxin treatment <PERSOON> SS,<PERSOON> DE, Parker DJ, Camm AJ Efficacy of flecainide acetate for atrial arrhythmias following coronary artery <PERSOON-##> versus ibutilide for post operative atrial fibrillation following cardiac surgery neither strategy improves outcomes compared with rate control alone (the PIPAF study) Med Sci Monit ###;# I##â<DATUM> <PERSOON-##> EO, Schmid ER, <PERSOON-##> versus amiodarone in atrial fibrillation a Mooss AN, Wurdeman RL, Mohiuddin SM, Reyes AP, Sugimoto JT, <PERSOON-##> DE, Seyedroudbari A diltiazem in the treatment of postoperative atrial fibrillation/atrial flutter after open heart surgery <PERSOON-##> GE, <PERSOON-##> M, <PERSOON-##> of propafenone versus procainamide for the acute treatment of atrial fibrillation after cardiac surgery <PERSOON-##> JE, Padhi ID, Goldberg AD, Silverman NA, Webb CR, Higgins RS, Paone G, <PERSOON-##> DM, Borzak S A randomised, double-blind comparison of intravenous diltiazem and digoxin for atrial fibrillation after coronary artery bypass surgery <PERSOON-##> and safety of dofetilide, a new class III antiarrhythmic agent, in acute termination of atrial fibrillation or flutter after coronary McAlister HF, <PERSOON-##> WM Intravenous amiodarone bolus versus oral quinidine for atrial flutter and <PERSOON-##> BW Randomised placebo-controlled trial of propafenone for treatment <PERSOON-##> efficacy and safety of intravenous propafenone versus intravenous amiodarone in the conversion of atrial fibrillation or flutter after cardiac surgery <PERSOON-##> DM, Dias VC, Kleiger RE, Tschida VH, Sung RJ, <PERSOON-##>-AF/Flutter Study Group Efficacy and safety of intravenous diltiazem for treatment of atrial fibrillation and atrial flutter <PERSOON> ###;##(##) ###â## <PERSOON-##> GJ, Krahn AD, <PERSOON-##> A.
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the treatment of postoperative atrial fibrillation/atrial flutter after open heart surgery <PERSOON> GE, <PERSOON> M, <PERSOON> of propafenone versus procainamide for the acute treatment of atrial fibrillation after cardiac surgery <PERSOON> JE, Padhi ID, Goldberg AD, Silverman NA, Webb CR, Higgins RS, Paone G, <PERSOON> DM, Borzak S A randomised, double-blind comparison of intravenous diltiazem and digoxin for atrial fibrillation after coronary artery bypass surgery <PERSOON> and safety of dofetilide, a new class III antiarrhythmic agent, in acute termination of atrial fibrillation or flutter after coronary McAlister HF, <PERSOON> WM Intravenous amiodarone bolus versus oral quinidine for atrial flutter and <PERSOON> BW Randomised placebo-controlled trial of propafenone for treatment <PERSOON> efficacy and safety of intravenous propafenone versus intravenous amiodarone in the conversion of atrial fibrillation or flutter after cardiac surgery <PERSOON-##> DM, Dias VC, Kleiger RE, Tschida VH, Sung RJ, <PERSOON-##>-AF/Flutter Study Group Efficacy and safety of intravenous diltiazem for treatment of atrial fibrillation and atrial flutter <PERSOON-##> ###;##(##) ###â## <PERSOON-##> GJ, Krahn AD, <PERSOON-##> A postoperative atrial fibrillation trial design and pilot study results Card Electrophysiol Rev ###;<DATUM> <PERSOON-##> GJ, Krahn AD, <PERSOON-##>-control versus conversion strategy in Hilleman DE, Reyes AP, Mooss AN, Packard KA Esmolol versus diltiazem in atrial fibrillation following coronary artery <PERSOON-##> LK, <PERSOON-##> KT, Kowey PR Efficacy and safety of ibutilide fumarate for the conversion of atrial arrhythmias after cardiac surgery Circulation ###;### ###â## b-Blockers should routinely be used as first choice for the prophylaxis of AF in all patients If the patient is on b-blockers, these should be continued up to the morning of surgery and Evidence was sought for b-blockers as prophylaxis against AF during cardiac surgery This search is fully documented in the ICVTS (Omorphos et al [#]) together with a summary of all identified papers We identified ### papers using the presented search strategy From these papers, # represented the best evidence on this Included were five meta-analyses, two systematic reviews and a cohort study of ###,### patients from the STS All the identified meta-analyses concluded that bblockers significantly reduced the incidence of AF [#â##] <PERSOON-##> largest meta-analysis was by <PERSOON-##> et al [##], published in ### in Circulation They reported that across ## randomised controlled trials (RCTs) with #,### patients, controls had an incidence of AF of ##% but patients.
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postoperative atrial fibrillation trial design and pilot study results Card Electrophysiol Rev ###;<DATUM> <PERSOON> GJ, Krahn AD, <PERSOON>-control versus conversion strategy in Hilleman DE, Reyes AP, Mooss AN, Packard KA Esmolol versus diltiazem in atrial fibrillation following coronary artery <PERSOON> LK, <PERSOON> KT, Kowey PR Efficacy and safety of ibutilide fumarate for the conversion of atrial arrhythmias after cardiac surgery Circulation ###;### ###â## b-Blockers should routinely be used as first choice for the prophylaxis of AF in all patients If the patient is on b-blockers, these should be continued up to the morning of surgery and Evidence was sought for b-blockers as prophylaxis against AF during cardiac surgery This search is fully documented in the ICVTS (Omorphos et al [#]) together with a summary of all identified papers We identified ### papers using the presented search strategy From these papers, # represented the best evidence on this Included were five meta-analyses, two systematic reviews and a cohort study of ###,### patients from the STS All the identified meta-analyses concluded that bblockers significantly reduced the incidence of AF [#â##] <PERSOON> largest meta-analysis was by <PERSOON> et al [##], published in ### in Circulation They reported that across ## randomised controlled trials (RCTs) with #,### patients, controls had an incidence of AF of ##% but patients Of note, they have recently updated their findings as a Cochrane review [##] Ferguson et al [##] performed a large retrospective analysis of the STS surgical database containing ###,### patients to look at the mortality and morbidity associated with peri-operative b-blocker use After propensity analysis, they found a decrease in <PERSOON> American Heart Association [##] strongly recommends routine pre-operative or early post-operative bblocker therapy as the standard of care for coronary artery bypass grafting (CABG) Thus, there is very strong evidence that b-blockers reduce the incidence of AF In addition, there is evidence that b-blocker prophylaxis reduces length of stay, costs, mortality and morbidity Evidence for amiodarone prohylaxis is similar (see Section <DATUM> but this is based on fewer RCTs and many patients having heart surgery are already taking b-blockers with Sotalol may be more effective than standard b-blockers for the prevention of AF without causing an excess of Evidence was sought for whether sotalol might be superior to standard b-blockers for prophylaxis against AF during cardiac surgery This search is fully documented in the ICVTS (Patel and Dunning [##]) together with a summary of all identified papers We identified ## papers using the presented search strategy From these, # Seven RCTs compared sotalol to a conventional b-blocker Study sizes ranged from ### to ### patients All seven papers showed a greater reduction in the incidence of AF compared with conventional b-blockers although, two of these studies did not reach statistical significance.
| 638 | fms |
they have recently updated their findings as a Cochrane review [##] Ferguson et al [##] performed a large retrospective analysis of the STS surgical database containing ###,### patients to look at the mortality and morbidity associated with peri-operative b-blocker use After propensity analysis, they found a decrease in <PERSOON> American Heart Association [##] strongly recommends routine pre-operative or early post-operative bblocker therapy as the standard of care for coronary artery bypass grafting (CABG) Thus, there is very strong evidence that b-blockers reduce the incidence of AF In addition, there is evidence that b-blocker prophylaxis reduces length of stay, costs, mortality and morbidity Evidence for amiodarone prohylaxis is similar (see Section <DATUM> but this is based on fewer RCTs and many patients having heart surgery are already taking b-blockers with Sotalol may be more effective than standard b-blockers for the prevention of AF without causing an excess of Evidence was sought for whether sotalol might be superior to standard b-blockers for prophylaxis against AF during cardiac surgery This search is fully documented in the ICVTS (Patel and Dunning [##]) together with a summary of all identified papers We identified ## papers using the presented search strategy From these, # Seven RCTs compared sotalol to a conventional b-blocker Study sizes ranged from ### to ### patients All seven papers showed a greater reduction in the incidence of AF compared with conventional b-blockers although, two of these studies did not reach statistical significance [##,##], who performed a four-arm study comparing low or high doses of sotalol or propranolol in ### patients Sotalol ## mg tds resulted in an incidence of ##% of AF compared with ##% incidence of low dose propranolol ( p = ns) Auer et al [##] studied ### patients randomised to four regimes including sotalol or metoprolol <PERSOON> incidence of AF was ##% with sotalol and ##% with metoprolol, although this was again non-significant Sanjuan et al [##] found a significant reduction from ##% to ##% comparing atenolol with sotalol in ### patients <PERSOON> et al [##] studied ### patients randomised to sotalol, metoprolol or no therapy Only <DATUM> of patients receiving sotalol went into AF, compared with ##% in the metoprolol group and ##% of controls, which was a significant finding No serious side effects were reported in any group Parikka et al [##] randomised ### patients to either sotalol or metoprolol AF occurred in ##% of patients receiving sotalol compared with ##% of patients receiving metoprolol ( p ( # ##) Nystrom et al [##] randomised ### patients to high dose sotalol or (<DATUM> dose b-blockers <PERSOON> incidence of AF was ##% in the sotalol group compared with ##% in the b-blocker group ( p = # ###) <PERSOON> [##] studied ### patients randomised to sotalol or metoprolol <PERSOON> incidence <PERSOON> et al.
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a four-arm study comparing low or high doses of sotalol or propranolol in ### patients Sotalol ## mg tds resulted in an incidence of ##% of AF compared with ##% incidence of low dose propranolol ( p = ns) Auer et al [##] studied ### patients randomised to four regimes including sotalol or metoprolol <PERSOON> incidence of AF was ##% with sotalol and ##% with metoprolol, although this was again non-significant Sanjuan et al [##] found a significant reduction from ##% to ##% comparing atenolol with sotalol in ### patients <PERSOON> et al [##] studied ### patients randomised to sotalol, metoprolol or no therapy Only <DATUM> of patients receiving sotalol went into AF, compared with ##% in the metoprolol group and ##% of controls, which was a significant finding No serious side effects were reported in any group Parikka et al [##] randomised ### patients to either sotalol or metoprolol AF occurred in ##% of patients receiving sotalol compared with ##% of patients receiving metoprolol ( p ( # ##) Nystrom et al [##] randomised ### patients to high dose sotalol or (<DATUM> dose b-blockers <PERSOON> incidence of AF was ##% in the sotalol group compared with ##% in the b-blocker group ( p = # ###) <PERSOON> [##] studied ### patients randomised to sotalol or metoprolol <PERSOON> incidence <PERSOON> et al ##% compared with ##% in the b-blocker groups, which was a significant finding, and they showed that the number needed to treat with sotalol over standard b-blockers was ## to prevent an additional case of AF In these studies, either ## mg tds or ## mg bd were low in side effects but doses higher than this caused a higher Amiodarone should be used for prophylaxis of AF in all patients undergoing cardiac surgery in whom b-blocker In high-risk patients receiving b-blocker therapy for prophylaxis of AF, amiodarone may also be used as These patients should be protected from the complications of bradycardia with temporary pacing wires being Evidence was sought for whether amiodarone provided effective prophylaxis against AF during cardiac surgery This search is fully documented in the ICVTS (Dunning et al [##]) together with a summary of all identified papers A total of ## papers were identified using the presented search strategy From these, ## papers Eleven RCTs and one meta-analysis were identified <PERSOON> of the ## RCTs showed a significant reduction in the incidence of AF, and the remaining two studies showed nonsignificant trends in the reduction of AF Included in these papers were two very well conducted studies published in the NEJM and the Lancet <PERSOON> et al [##] randomised ### patients to either # days of pre-operative oral amiodarone or controls <PERSOON> incidence of AF was ##% in the amiodarone group and ##% in the control group Giri et al [##] randomised ### patients who were already receiving bblockers to either amiodarone or placebo.
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showed that the number needed to treat with sotalol over standard b-blockers was ## to prevent an additional case of AF In these studies, either ## mg tds or ## mg bd were low in side effects but doses higher than this caused a higher Amiodarone should be used for prophylaxis of AF in all patients undergoing cardiac surgery in whom b-blocker In high-risk patients receiving b-blocker therapy for prophylaxis of AF, amiodarone may also be used as These patients should be protected from the complications of bradycardia with temporary pacing wires being Evidence was sought for whether amiodarone provided effective prophylaxis against AF during cardiac surgery This search is fully documented in the ICVTS (Dunning et al [##]) together with a summary of all identified papers A total of ## papers were identified using the presented search strategy From these, ## papers Eleven RCTs and one meta-analysis were identified <PERSOON> of the ## RCTs showed a significant reduction in the incidence of AF, and the remaining two studies showed nonsignificant trends in the reduction of AF Included in these papers were two very well conducted studies published in the NEJM and the Lancet <PERSOON> et al [##] randomised ### patients to either # days of pre-operative oral amiodarone or controls <PERSOON> incidence of AF was ##% in the amiodarone group and ##% in the control group Giri et al [##] randomised ### patients who were already receiving bblockers to either amiodarone or placebo amiodarone group and ##% in the control group ( p = # ##) Ten of these RCTs were summarised by <PERSOON> et al [##], who reported an incidence of AF of <DATUM> in the amiodarone groups, and an incidence of ##% in control groups, giving a NNT of seven to prevent an additional case of AF Since our review, one additional study has been published in ### by Kerstein et al [##] They used a casecontrol design to study ## CABG patients receiving intravenous amiodarone peri-operatively to ## patients not receiving amiodarone during the same period <PERSOON> incidence of AF was #% in the amiodarone group compared with ##% in the controls There was no significant difference in complications Of note, most patients also <PERSOON> incidence of complications was low in all these RCTs except the studies by Butler et al [##], who found a significantly increased rate of bradycardias and pauses, and Hohnloser et al [##] who had to stop therapy in ##% of patients receiving amiodarone Also of note, the reported studies varied in their protocols with many of Biatrial pacing significantly reduces the incidence of AF in patients undergoing cardiac surgery Care must be taken in the placement of the wires in order to minimise avoidable complications A pacing strategy of ##â## beats/min is recommended for #â# days with the increased rate if the native rate.
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amiodarone group and ##% in the control group ( p = # ##) Ten of these RCTs were summarised by <PERSOON> et al [##], who reported an incidence of AF of <DATUM> in the amiodarone groups, and an incidence of ##% in control groups, giving a NNT of seven to prevent an additional case of AF Since our review, one additional study has been published in ### by Kerstein et al [##] They used a casecontrol design to study ## CABG patients receiving intravenous amiodarone peri-operatively to ## patients not receiving amiodarone during the same period <PERSOON> incidence of AF was #% in the amiodarone group compared with ##% in the controls There was no significant difference in complications Of note, most patients also <PERSOON> incidence of complications was low in all these RCTs except the studies by Butler et al [##], who found a significantly increased rate of bradycardias and pauses, and Hohnloser et al [##] who had to stop therapy in ##% of patients receiving amiodarone Also of note, the reported studies varied in their protocols with many of Biatrial pacing significantly reduces the incidence of AF in patients undergoing cardiac surgery Care must be taken in the placement of the wires in order to minimise avoidable complications A pacing strategy of ##â## beats/min is recommended for #â# days with the increased rate if the native rate Evidence was sought for whether atrial pacing reduces the incidence of post-operative AF in patients undergoing cardiac surgery This search is fully documented in the ICVTS (<PERSOON> and Dunning [##]) together with a summary of all identified papers Four hundred and fifty eight papers were identified using the presented search strategy From these, ## papers represented the best evidence on this topic We identified ## RCTs recruiting between ## and ### patients These varied markedly both in their placement of atrial pacing wires, pacing strategies and also in their definitions of AF Eleven studies looked at biatrial pacing Six found a significant benefit and five found no significant benefit Eight studies used right atrial pacing Two studies reported a significant benefit but six found no benefit Ten of the ## completed RCTs were identified in the meta-analysis by <PERSOON> et al [##] but we repeated the meta-analysis in order to update these data We found that there was a significant benefit shown for biatrial pacing (OR # ##, ##% CI # ##â# ##) but While there is a clear benefit in the use of biatrial pacing, several papers reported technical difficulties, with loss of sensing, diaphragmatic pacing and LV pacing, which led to a number of patients being withdrawn from their respective studies Thus, if biatrial pacing is contemplated, much care must be used when placing the wires In addition, many different pacing strategies were used, but most paced at a rate of ##â## beats/min with higher.
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in patients undergoing cardiac surgery This search is fully documented in the ICVTS (<PERSOON> and Dunning [##]) together with a summary of all identified papers Four hundred and fifty eight papers were identified using the presented search strategy From these, ## papers represented the best evidence on this topic We identified ## RCTs recruiting between ## and ### patients These varied markedly both in their placement of atrial pacing wires, pacing strategies and also in their definitions of AF Eleven studies looked at biatrial pacing Six found a significant benefit and five found no significant benefit Eight studies used right atrial pacing Two studies reported a significant benefit but six found no benefit Ten of the ## completed RCTs were identified in the meta-analysis by <PERSOON> et al [##] but we repeated the meta-analysis in order to update these data We found that there was a significant benefit shown for biatrial pacing (OR # ##, ##% CI # ##â# ##) but While there is a clear benefit in the use of biatrial pacing, several papers reported technical difficulties, with loss of sensing, diaphragmatic pacing and LV pacing, which led to a number of patients being withdrawn from their respective studies Thus, if biatrial pacing is contemplated, much care must be used when placing the wires In addition, many different pacing strategies were used, but most paced at a rate of ##â## beats/min with higher Finally, the number of days of pacing varied among the studies As the incidence of AF generally peaked around day # in these studies, #â# days of pacing seem Prophylaxis with magnesium is an effective strategy to minimise the incidence of AF for patients undergoing cardiac surgery This may safely be given in addition to other strategies to reduce the incidence of AF One acceptable strategy for effective prophylaxis with magnesium is # mmol magnesium sulphate infusion pre-operatively, just after cardiopulmonary bypass and once daily for # days after surgery Evidence was sought for whether magnesium reduces the incidence of post-operative AF in patients undergoing cardiac surgery This search is fully documented in the ICVTS (Rostron et al [##]) together with a summary of all identified papers One hundred and thirteen papers were identified using the presented search strategy Fromthese, ## papers represented the best evidence on this topic Two further meta-analyses were also We identified ## RCTs that addressed this issue and # meta-analyses One meta-analysis summarised data on ### patients from all but six of the RCTs that we identified <PERSOON> meta-analysis was performed by Shiga et al [##] in ###, summarising papers that contained magnesium alone as prophylaxis and compared it to placebo treatment Twenty three percent of patients in the magnesium groups suffered a supraventricular arrhythmia compared with ##% in the placebo group ( p = # ###) This gives a NNT of ## to prevent one episode of supraventricular tachyarrhythmia (SVT).
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varied among the studies As the incidence of AF generally peaked around day # in these studies, #â# days of pacing seem Prophylaxis with magnesium is an effective strategy to minimise the incidence of AF for patients undergoing cardiac surgery This may safely be given in addition to other strategies to reduce the incidence of AF One acceptable strategy for effective prophylaxis with magnesium is # mmol magnesium sulphate infusion pre-operatively, just after cardiopulmonary bypass and once daily for # days after surgery Evidence was sought for whether magnesium reduces the incidence of post-operative AF in patients undergoing cardiac surgery This search is fully documented in the ICVTS (Rostron et al [##]) together with a summary of all identified papers One hundred and thirteen papers were identified using the presented search strategy Fromthese, ## papers represented the best evidence on this topic Two further meta-analyses were also We identified ## RCTs that addressed this issue and # meta-analyses One meta-analysis summarised data on ### patients from all but six of the RCTs that we identified <PERSOON> meta-analysis was performed by Shiga et al [##] in ###, summarising papers that contained magnesium alone as prophylaxis and compared it to placebo treatment Twenty three percent of patients in the magnesium groups suffered a supraventricular arrhythmia compared with ##% in the placebo group ( p = # ###) This gives a NNT of ## to prevent one episode of supraventricular tachyarrhythmia (SVT) ventricular arrhythmias with a NNT of ## to prevent one episode of ventricular tachyarrhythmia (VT) Shiga et al also summarised the complications reported in ### patients They found no episodes of bradycardia or hypotension However, important differences were found between all these studies and no one prophylactic regime was found to be superior to another Regimes ranged from a single dose of # mmol in the cardioplegia <PERSOON> second meta-analysis published in ### [##] summarised ## studies with ### patients They found that summarised the effect on length of stay and mortality but found no significant difference Again, they did not <PERSOON> most recent meta-analysis summarised only eight RCTs that compared magnesium with placebo [##] They also found a highly significant reduction in relative risk with the addition of magnesium (RR # ##, ##% CI # ##â There were six studies that investigated over ### patients Toraman et al [##] in ### performed an RCT in ### patients, giving them either # mmol of magnesium both pre-operatively and post-operatively or placebo Only # (#%) of patients receiving magnesium went into AF compared with ## (##%) in the control group Forlani et al [##] performed an RCT in ###, separating ### patients into four groups Patients received either sotalol ## mg bd or magnesium <DATUM> g orally for # days postoperatively or both or neither treatment Only # of.
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a NNT of ## to prevent one episode of ventricular tachyarrhythmia (VT) Shiga et al also summarised the complications reported in ### patients They found no episodes of bradycardia or hypotension However, important differences were found between all these studies and no one prophylactic regime was found to be superior to another Regimes ranged from a single dose of # mmol in the cardioplegia <PERSOON> second meta-analysis published in ### [##] summarised ## studies with ### patients They found that summarised the effect on length of stay and mortality but found no significant difference Again, they did not <PERSOON> most recent meta-analysis summarised only eight RCTs that compared magnesium with placebo [##] They also found a highly significant reduction in relative risk with the addition of magnesium (RR # ##, ##% CI # ##â There were six studies that investigated over ### patients Toraman et al [##] in ### performed an RCT in ### patients, giving them either # mmol of magnesium both pre-operatively and post-operatively or placebo Only # (#%) of patients receiving magnesium went into AF compared with ## (##%) in the control group Forlani et al [##] performed an RCT in ###, separating ### patients into four groups Patients received either sotalol ## mg bd or magnesium <DATUM> g orally for # days postoperatively or both or neither treatment Only # of Hazelrigg et al [##] randomised ### patients to receive ## mg/kg of magnesium pre-operatively, then # mg/(kg h) post-operatively for ## h or placebo in ## patients Thirtytwo treatment patients went into AF compared with ## control patients, which was a non-significant trend towards benefit However, the reduction in AF was Yeatman et al [##] performed the largest study on magnesium prophylaxis, with ### patients randomised in a double blind fashion to receive ## mmol of # mmol/ml magnesium sulphate in the cardioplegia solution or controls They found that the incidence of AF was ##% in the magnesium group compared with ##% in controls, which was non-significant, although the findings were significant in a subset analysis of urgent patients <PERSOON> authors acknowledged that their dose of magnesium only produced a concentration of # mmol/l of cardioplegia, when actually they should have used a higher dose to obtain a concentration nearer ## mmol/l of <PERSOON> et al [##] performed a multi-arm study in ### patients randomised into six groups of prophylaxis including of magnesium had no beneficial effect as compared with b-blockers, digoxin or controls <PERSOON> et al [##] performed a study in ### patients, giving # g of magnesium intravenously pre-operatively and With regard to which regime should be employed, Yeatman et al [##], who performed the largest study, recommend ## mmol/l in the cardioplegia solution, although they used a dose smaller than this in their study Toraman et al [##] found the greatest beneficial effect in their large study of ### patients.
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magnesium pre-operatively, then # mg/(kg h) post-operatively for ## h or placebo in ## patients Thirtytwo treatment patients went into AF compared with ## control patients, which was a non-significant trend towards benefit However, the reduction in AF was Yeatman et al [##] performed the largest study on magnesium prophylaxis, with ### patients randomised in a double blind fashion to receive ## mmol of # mmol/ml magnesium sulphate in the cardioplegia solution or controls They found that the incidence of AF was ##% in the magnesium group compared with ##% in controls, which was non-significant, although the findings were significant in a subset analysis of urgent patients <PERSOON> authors acknowledged that their dose of magnesium only produced a concentration of # mmol/l of cardioplegia, when actually they should have used a higher dose to obtain a concentration nearer ## mmol/l of <PERSOON> et al [##] performed a multi-arm study in ### patients randomised into six groups of prophylaxis including of magnesium had no beneficial effect as compared with b-blockers, digoxin or controls <PERSOON> et al [##] performed a study in ### patients, giving # g of magnesium intravenously pre-operatively and With regard to which regime should be employed, Yeatman et al [##], who performed the largest study, recommend ## mmol/l in the cardioplegia solution, although they used a dose smaller than this in their study Toraman et al [##] found the greatest beneficial effect in their large study of ### patients magnesium sulphate infusion in ### ml # #% NaCl solution (at ## ml/h) the day before surgery, just after cardiopulmonary bypass and once daily for # days after surgery As this study demonstrates the largest benefit in a well-conducted study, perhaps this should be regarded as the optimal regime so far investigated There is currently inadequate evidence to recommend routine prophylaxis against AF for all patients undergoing If prophylaxis against AF is desired for patients undergoing lung surgery, individual studies have provided some Amiodarone is not recommended for prophylaxis against AF due to concerns over the development of adult Evidence was sought for whether there is a role for prophylaxis against AF for patients undergoing lung surgery This search is fully documented in the ICVTS (Shrivastava et al [##]) together with a summary of all identified papers A total of ### papers were identified using the presented search strategy From these, ## papers We identified ## RCTs that studied the prophylactic effects of diltiazem, b-blockers, digoxin, verapamil, flecainide, amiodarone, magnesium and epidural anaesthesia <PERSOON> quality and sizes of these studies varied greatly, ranging from### patients to only ## patients <PERSOON> strongest paperwas by <PERSOON> et al [##] and evaluated using a loading dose of # ## mg/kg of diltiazem administered over ## min followed by a continuous infusion (# # mg/(kg h)) for ##â## h, there were no significant increased adverse reactions to drug treatment This well conducted study gives a NNT of eight to prevent one episode of AF.
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### ml # #% NaCl solution (at ## ml/h) the day before surgery, just after cardiopulmonary bypass and once daily for # days after surgery As this study demonstrates the largest benefit in a well-conducted study, perhaps this should be regarded as the optimal regime so far investigated There is currently inadequate evidence to recommend routine prophylaxis against AF for all patients undergoing If prophylaxis against AF is desired for patients undergoing lung surgery, individual studies have provided some Amiodarone is not recommended for prophylaxis against AF due to concerns over the development of adult Evidence was sought for whether there is a role for prophylaxis against AF for patients undergoing lung surgery This search is fully documented in the ICVTS (Shrivastava et al [##]) together with a summary of all identified papers A total of ### papers were identified using the presented search strategy From these, ## papers We identified ## RCTs that studied the prophylactic effects of diltiazem, b-blockers, digoxin, verapamil, flecainide, amiodarone, magnesium and epidural anaesthesia <PERSOON> quality and sizes of these studies varied greatly, ranging from### patients to only ## patients <PERSOON> strongest paperwas by <PERSOON> et al [##] and evaluated using a loading dose of # ## mg/kg of diltiazem administered over ## min followed by a continuous infusion (# # mg/(kg h)) for ##â## h, there were no significant increased adverse reactions to drug treatment This well conducted study gives a NNT of eight to prevent one episode of AF A second large study was performed by Van Mieghem et al [##] in ### patients in an unblinded RCT They evaluated prophylactic verapamil and found that the incidence of AF reduced from ##% to #% This was a nonsignificant finding and, importantly, ##% of patients experienced bradycardia or hypotension as a result of verapamil and had to be withdrawn from the study Interestingly, Van Mieghemâs study was originally a threearm trial of verapamil, amiodarone and controls but was stopped early after three patients in the amiodarone group developed adult respiratory distress syndrome (ARDS), with two patients dying of this complication <PERSOON> authors then performed a retrospective review of ### lobectomies and pneumonectomies [##] and found ## patients who received amiodarone, of whom # developed ARDS (##%), but of ### patients who did not receive Flecainide was examined in two studies by Borgeat et al [##,##], with ## patients in each study <PERSOON> studies showed reductions in AF from ##% to less than ##%, but as there were only ## patients in each treatment b-Blockers have also been studied Jakobsen et al [##] randomised ## patients to metoprolol versus controls and showed a significant reduction in AF from ##% down to #% Bayliff et al [##] randomised ## patients to propranolol and ## to controls They only showed some trends towards effectiveness and the propranolol Oka et al [##] looked at morphine versus bupivacaine given by epidural in ## patients.
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A second large study was performed by Van Mieghem et al [##] in ### patients in an unblinded RCT They evaluated prophylactic verapamil and found that the incidence of AF reduced from ##% to #% This was a nonsignificant finding and, importantly, ##% of patients experienced bradycardia or hypotension as a result of verapamil and had to be withdrawn from the study Interestingly, Van Mieghemâs study was originally a threearm trial of verapamil, amiodarone and controls but was stopped early after three patients in the amiodarone group developed adult respiratory distress syndrome (ARDS), with two patients dying of this complication <PERSOON> authors then performed a retrospective review of ### lobectomies and pneumonectomies [##] and found ## patients who received amiodarone, of whom # developed ARDS (##%), but of ### patients who did not receive Flecainide was examined in two studies by Borgeat et al [##,##], with ## patients in each study <PERSOON> studies showed reductions in AF from ##% to less than ##%, but as there were only ## patients in each treatment b-Blockers have also been studied Jakobsen et al [##] randomised ## patients to metoprolol versus controls and showed a significant reduction in AF from ##% down to #% Bayliff et al [##] randomised ## patients to propranolol and ## to controls They only showed some trends towards effectiveness and the propranolol Oka et al [##] looked at morphine versus bupivacaine given by epidural in ## patients reduced from ##% in the morphine group to <DATUM> in the bupivacaine group and there was no excess of side Finally Terzi et al [##] in ### performed an unblinded RCT in ### patients, allocating ## patients to In summary, digoxin and verapamil do not reduce the incidence of AF Amiodarone may cause ARDS, and cannot be recommended Flecainide and b-blockers have been inadequately studied to make safe recommendations Single RCTs have demonstrated evidence for bupivacaine epidural, magnesium and Off-pump CABG reduces the incidence of AF compared with conventional (on-pump) CABG Evidence was sought for whether patients undergoing offpump CABG (OPCAB) are at lower risk from AF This search is fully documented in the ICVTS (<PERSOON> et al [##]) together with a summary of all identified papers One hundred and seven papers were identified using the presented search strategy From these, ## papers represented the best evidence on this topic We identified five meta-analyses, six RCTs not included in the meta-analyses and a large cohort study that provided direct evidence for this topic Of note, several studies split Reston et al [##] performed a comprehensive and wellbalanced meta-analysis in ### [##] of the short term and midterm outcomes of OPCAB versus conventional CABG Selecting ## studies, they found that there was a highly significant reduction in AF in the OPCAB group (odds ratio of # ## in favour of OPCAB) There was, however, significant heterogeneity between these studies that they could not account for.
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the morphine group to <DATUM> in the bupivacaine group and there was no excess of side Finally Terzi et al [##] in ### performed an unblinded RCT in ### patients, allocating ## patients to In summary, digoxin and verapamil do not reduce the incidence of AF Amiodarone may cause ARDS, and cannot be recommended Flecainide and b-blockers have been inadequately studied to make safe recommendations Single RCTs have demonstrated evidence for bupivacaine epidural, magnesium and Off-pump CABG reduces the incidence of AF compared with conventional (on-pump) CABG Evidence was sought for whether patients undergoing offpump CABG (OPCAB) are at lower risk from AF This search is fully documented in the ICVTS (<PERSOON> et al [##]) together with a summary of all identified papers One hundred and seven papers were identified using the presented search strategy From these, ## papers represented the best evidence on this topic We identified five meta-analyses, six RCTs not included in the meta-analyses and a large cohort study that provided direct evidence for this topic Of note, several studies split Reston et al [##] performed a comprehensive and wellbalanced meta-analysis in ### [##] of the short term and midterm outcomes of OPCAB versus conventional CABG Selecting ## studies, they found that there was a highly significant reduction in AF in the OPCAB group (odds ratio of # ## in favour of OPCAB) There was, however, significant heterogeneity between these studies that they could not account for RCTs are included, the difference was increased rather than decreased They did caution that most studies excluded patients such as non-elective surgery, reoperation, renal failure and impaired left ventricular function While Reston et al also found significant benefits in terms of stroke, myocardial infarction (MI) and mortality, a metaanalysis by <PERSOON> et al [##] in ### that assessed only RCTs disagreed with their meta-analysis, finding that there was no significant difference in the combined end-point of MI, death or stroke Although this study did not look at AF, it is interesting to note that this meta-analysis also included the Octopus study [##], the SMARTstudy [##] and an RCT from Hawaii [##] This calls into question whether the metaanalysis by Reston et Ascione and Angelini performed a pooled meta-analysis of the BHACAS # and # [##] They showed that the incidence of AF reduced from ##% to ##% This was a highly significant finding There was no difference in Of the recent randomised trials not included in the Reston meta-analysis, the SMART trial of ### patients randomised to either OPCAB or conventional CABG found no significant difference in AF but, with an incidence of ##% in the OPCAB group and ##% in the CABG group, there was a trend towards reduced incidence in OPCAB In contrast, the PRAGUE-# trial [##] that randomised ### patients to OPCAB or CABG found no difference at all in the incidence of AF.
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are included, the difference was increased rather than decreased They did caution that most studies excluded patients such as non-elective surgery, reoperation, renal failure and impaired left ventricular function While Reston et al also found significant benefits in terms of stroke, myocardial infarction (MI) and mortality, a metaanalysis by <PERSOON> et al [##] in ### that assessed only RCTs disagreed with their meta-analysis, finding that there was no significant difference in the combined end-point of MI, death or stroke Although this study did not look at AF, it is interesting to note that this meta-analysis also included the Octopus study [##], the SMARTstudy [##] and an RCT from Hawaii [##] This calls into question whether the metaanalysis by Reston et Ascione and Angelini performed a pooled meta-analysis of the BHACAS # and # [##] They showed that the incidence of AF reduced from ##% to ##% This was a highly significant finding There was no difference in Of the recent randomised trials not included in the Reston meta-analysis, the SMART trial of ### patients randomised to either OPCAB or conventional CABG found no significant difference in AF but, with an incidence of ##% in the OPCAB group and ##% in the CABG group, there was a trend towards reduced incidence in OPCAB In contrast, the PRAGUE-# trial [##] that randomised ### patients to OPCAB or CABG found no difference at all in the incidence of AF <PERSOON> OCTOPUS trial [##] found no difference in AF between the two groups with a ##% incidence in the OPCAB group and a ##% incidence in the CABG group Muneretto et al [##] performed an RCT in ### patients comparing total arterial OPCAB with total arterial CABG They found that the incidence of AF was ##% in the OPCAB group and ##% in the CABG group, which showed a strong trend towards a lower incidence in the Gerola et al [##] performed an RCT in ### in Brazil in ### patients and found a low incidence of AF in both groups <PERSOON> finding of #% in the OPCAB group and #% in the CABG group was far lower than other studies, and calls into question the measurement of AF in their study, which was not described in the protocol <PERSOON> et al [##] in ### performed a small RCT in ## patients, and found an incidence of AF of ##% in OPCAB In summary, three of the five meta-analyses directly assessedAF inOPCAB versus conventionalCABG They all found a significant reduction in AF with OPCAB Six further RCTs were identified that were published after several of these metaanalyses None of them identified a significant difference individually but their results can be summarised as follows there was a <DATUM> AF rate in the OPCAB group (#<DATUM> and a ##% rate of AF in the CABG group (##<DATUM> This corresponds to an odds ratio of # ## with a probability of #.
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AF between the two groups with a ##% incidence in the OPCAB group and a ##% incidence in the CABG group Muneretto et al [##] performed an RCT in ### patients comparing total arterial OPCAB with total arterial CABG They found that the incidence of AF was ##% in the OPCAB group and ##% in the CABG group, which showed a strong trend towards a lower incidence in the Gerola et al [##] performed an RCT in ### in Brazil in ### patients and found a low incidence of AF in both groups <PERSOON> finding of #% in the OPCAB group and #% in the CABG group was far lower than other studies, and calls into question the measurement of AF in their study, which was not described in the protocol <PERSOON> et al [##] in ### performed a small RCT in ## patients, and found an incidence of AF of ##% in OPCAB In summary, three of the five meta-analyses directly assessedAF inOPCAB versus conventionalCABG They all found a significant reduction in AF with OPCAB Six further RCTs were identified that were published after several of these metaanalyses None of them identified a significant difference individually but their results can be summarised as follows there was a <DATUM> AF rate in the OPCAB group (#<DATUM> and a ##% rate of AF in the CABG group (##<DATUM> This corresponds to an odds ratio of # ## with a probability of # results are non-significant These studies are, therefore, in broad agreement with the already performed metaanalyses that found significant differences Our summary of the recent RCTs gives a NNT of ## to avoid one Ventral cardiac denervation has not been convincingly shown to affect the incidence of postoperative AF in Posterior pericardiotomy has been shown to reduce the incidence of AF in a single randomised controlled trial but this finding requires confirmation in further clinical trials prior to use in routine clinical practise Several search strategies were employed to search for intra-operative interventions that might reduce the incidence of AF However, only four papers were found that documented any intra-operative intervention to reduce the incidence of post-operative AF [##â##] These include three papers investigating aortic fat pad removal, and one paper performing a posterior pericardiotomy in order to reduce the incidence of AF Thus, Melo et al [##] performed a ventral cardiac denervation in ### patients undergoing low risk coronary arterial surgery <PERSOON> fat pads that surround the superior vena cava, the aorta and the anterior and right lateral aspects of the main pulmonary artery were excised prior to cardiopulmonary bypass This took on average #min (_# min) A total of ### patients were identified to act as non-randomised controls Of the patients who had ventral CI ##â##%), which was a significant finding ( p ( # ##) This prospective cohort study was limited by a lack of.
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non-significant These studies are, therefore, in broad agreement with the already performed metaanalyses that found significant differences Our summary of the recent RCTs gives a NNT of ## to avoid one Ventral cardiac denervation has not been convincingly shown to affect the incidence of postoperative AF in Posterior pericardiotomy has been shown to reduce the incidence of AF in a single randomised controlled trial but this finding requires confirmation in further clinical trials prior to use in routine clinical practise Several search strategies were employed to search for intra-operative interventions that might reduce the incidence of AF However, only four papers were found that documented any intra-operative intervention to reduce the incidence of post-operative AF [##â##] These include three papers investigating aortic fat pad removal, and one paper performing a posterior pericardiotomy in order to reduce the incidence of AF Thus, Melo et al [##] performed a ventral cardiac denervation in ### patients undergoing low risk coronary arterial surgery <PERSOON> fat pads that surround the superior vena cava, the aorta and the anterior and right lateral aspects of the main pulmonary artery were excised prior to cardiopulmonary bypass This took on average #min (_# min) A total of ### patients were identified to act as non-randomised controls Of the patients who had ventral CI ##â##%), which was a significant finding ( p ( # ##) This prospective cohort study was limited by a lack of may, in <INSTELLING>, increase the incidence of AF They conducted a pilot study and subsequent cohort study in ### patients, with the treatment group protected from the standard procedures of aortic fat pad disruption They found that there was no difference between the groups in the incidence of AF and concluded that the aortic fat <PERSOON> and Guvendik [##] carried out a cohort study where ## consecutive patients undergoing CABG but also having ventral cardiac denervation were compared with ## consecutive patients who did not have this additional procedure Denervation took around # min to complete <PERSOON> AF rate was ##% in control patients compared with ##% in those patients who had ventral cardiac denervation, which was a nonsignificant finding ( p = # ##) Farsak et al [##] studied the impact of a posterior pericardiotomy, with a # cm incision made posterior to the left phrenic nerve <PERSOON> RCT was performed in ### patients undergoing CABG Seven of the ## patients receiving a posterior pericardiotomy (<DATUM> ) went into AF, compared with ## of ## controls (##%) In addition, the incidence of early and late pericardial effusion was significantly lower in the pericardiotomy group Of note, patients receiving b-blockers were excluded from this study (level #b study) What is the optimal medical treatment for stable cardiac surgical patients who go into AF after cardiac surgery? No drug has definitively been shown to be superior to any other Amiodarone, digoxin, b-blockers and diltiazem.
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They conducted a pilot study and subsequent cohort study in ### patients, with the treatment group protected from the standard procedures of aortic fat pad disruption They found that there was no difference between the groups in the incidence of AF and concluded that the aortic fat <PERSOON> and Guvendik [##] carried out a cohort study where ## consecutive patients undergoing CABG but also having ventral cardiac denervation were compared with ## consecutive patients who did not have this additional procedure Denervation took around # min to complete <PERSOON> AF rate was ##% in control patients compared with ##% in those patients who had ventral cardiac denervation, which was a nonsignificant finding ( p = # ##) Farsak et al [##] studied the impact of a posterior pericardiotomy, with a # cm incision made posterior to the left phrenic nerve <PERSOON> RCT was performed in ### patients undergoing CABG Seven of the ## patients receiving a posterior pericardiotomy (<DATUM> ) went into AF, compared with ## of ## controls (##%) In addition, the incidence of early and late pericardial effusion was significantly lower in the pericardiotomy group Of note, patients receiving b-blockers were excluded from this study (level #b study) What is the optimal medical treatment for stable cardiac surgical patients who go into AF after cardiac surgery? No drug has definitively been shown to be superior to any other Amiodarone, digoxin, b-blockers and diltiazem <PERSOON> role of potassium in the treatment of AF after cardiac surgery is not fully understood Standard practice after cardiac surgery is to maintain serum potassium at the upper half of the normal range (<DATUM> mmol/l) <PERSOON> traditionally accepted view is that hypokalaemia predisposes towards potentially fatal ventricular dysrhythmias and that avoiding the risk of hypokalaemia will increase the margin of safety Whether this helps avoid or treat AF has never been proven scientifically, and is unlikely to be proven in the future as the perceived risk of ventricular dysrhythmias will pose ethical obstacles to the conduction of any randomised trial in which cardiac surgical patients are allocated to a low potassium study arm In view of this, it seems sensible to continue to recommend correction of absolute or relative hypokalaemia to the upper half of the normal range Evidence was sought for the optimal medical treatment for stable patients going into AF after cardiac surgery This search is fully documented in the ICVTS (Dunning et al [##]) together with a summary of all identified papers We identified ### papers using the presented search strategy From these, ## papers represented the best evidence on this topic Of note, for this search, if two papers were found investigating the same drug, only the better paper was included Therefore, for this guideline, the search was repeated and all papers were tabulated (Table #) Several studies were found that were cohort studies without a control group and these were excluded [##â##].
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after cardiac surgery is not fully understood Standard practice after cardiac surgery is to maintain serum potassium at the upper half of the normal range (<DATUM> mmol/l) <PERSOON> traditionally accepted view is that hypokalaemia predisposes towards potentially fatal ventricular dysrhythmias and that avoiding the risk of hypokalaemia will increase the margin of safety Whether this helps avoid or treat AF has never been proven scientifically, and is unlikely to be proven in the future as the perceived risk of ventricular dysrhythmias will pose ethical obstacles to the conduction of any randomised trial in which cardiac surgical patients are allocated to a low potassium study arm In view of this, it seems sensible to continue to recommend correction of absolute or relative hypokalaemia to the upper half of the normal range Evidence was sought for the optimal medical treatment for stable patients going into AF after cardiac surgery This search is fully documented in the ICVTS (Dunning et al [##]) together with a summary of all identified papers We identified ### papers using the presented search strategy From these, ## papers represented the best evidence on this topic Of note, for this search, if two papers were found investigating the same drug, only the better paper was included Therefore, for this guideline, the search was repeated and all papers were tabulated (Table #) Several studies were found that were cohort studies without a control group and these were excluded [##â##] studied, the regimes, the number of studies, with the number of patients included in the studies and the findings Five studies assessed amiodarone for the treatment of AF [##â##] Regimes were broadly similar using # mg/kg intravenously over between # and ## min followed by a maintenance regime of ##â## mg/h No study used a placebo group and equivalence was demonstrated with digoxin, ibutilide and propafenone One study demonstrated that quinidine might be superior to amiodarone in a study of ## patients, although more complications occurred with quinidine Complications with amiodarone were relatively few with hypotension and Five studies assessed digoxin for the treatment of AF [##] Again, no placebo groups were included in these studies but complications with digoxin were particularly low, with three papers reporting no complications at all However, digoxin was shown to be less effective than procainamide, flecainide, diltiazem and possibly sotalol Four studies assessed b-blockers for the treatment of AF [##â##] <PERSOON> drugs studied were sotalol, esmolol and metoprolol High doses of b-blockade did cause a high incidence of hypotension and esmolol had to be withdrawn in nearly ##% of patients included in the study investigating this drug Again, no placebo groups were included which would allow a more objective assessment of the effect of b-blockers versus other treatments but Four studies investigated diltiazem [##â##] Regimes were broadly similar using # ## mg/kg over # min and then a # mg/h infusion <PERSOON> main complication was hypotension and this was around ##%.
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the number of studies, with the number of patients included in the studies and the findings Five studies assessed amiodarone for the treatment of AF [##â##] Regimes were broadly similar using # mg/kg intravenously over between # and ## min followed by a maintenance regime of ##â## mg/h No study used a placebo group and equivalence was demonstrated with digoxin, ibutilide and propafenone One study demonstrated that quinidine might be superior to amiodarone in a study of ## patients, although more complications occurred with quinidine Complications with amiodarone were relatively few with hypotension and Five studies assessed digoxin for the treatment of AF [##] Again, no placebo groups were included in these studies but complications with digoxin were particularly low, with three papers reporting no complications at all However, digoxin was shown to be less effective than procainamide, flecainide, diltiazem and possibly sotalol Four studies assessed b-blockers for the treatment of AF [##â##] <PERSOON> drugs studied were sotalol, esmolol and metoprolol High doses of b-blockade did cause a high incidence of hypotension and esmolol had to be withdrawn in nearly ##% of patients included in the study investigating this drug Again, no placebo groups were included which would allow a more objective assessment of the effect of b-blockers versus other treatments but Four studies investigated diltiazem [##â##] Regimes were broadly similar using # ## mg/kg over # min and then a # mg/h infusion <PERSOON> main complication was hypotension and this was around ##% to be better than placebo and digoxin Esmolol may be superior to diltiazem but with more complications Five studies looked at propafenone [##,##,##â##] Regimes used were either an iv bolus of #â# mg/kg over ##â## min, followed by an infusion of ## mg/kg over ## h or an oral dose of ### mg Propafenone caused a high incidence of hypotension and one study reported a mean drop in blood pressure of # mmHg Propafenone was found to be superior to procainamide and perhaps amiodarone, but not different from ibutilide <PERSOON> remaining drugs are summarised in Table # There are several weaknesses with the available studies in this area Very few use a placebo group and, therefore, it is impossible to compare results of the various drugs across studies against placebo as a baseline In addition, comparison across the studies is further hampered by a wide variation in the definition of success for each drug, with time spans from ## min to several days being used to define successful cardioversion Thus, it is currently impossible definitively to recommend one drug over another for the treatment of AF <PERSOON> complication profile is an important issue in the selection of a drug to use against AF, and in <INSTELLING> it may be more important to choose treatment in a particular hospital where there is widespread There are several questions that must be addressed for this topic.
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to be better than placebo and digoxin Esmolol may be superior to diltiazem but with more complications Five studies looked at propafenone [##,##,##â##] Regimes used were either an iv bolus of #â# mg/kg over ##â## min, followed by an infusion of ## mg/kg over ## h or an oral dose of ### mg Propafenone caused a high incidence of hypotension and one study reported a mean drop in blood pressure of # mmHg Propafenone was found to be superior to procainamide and perhaps amiodarone, but not different from ibutilide <PERSOON> remaining drugs are summarised in Table # There are several weaknesses with the available studies in this area Very few use a placebo group and, therefore, it is impossible to compare results of the various drugs across studies against placebo as a baseline In addition, comparison across the studies is further hampered by a wide variation in the definition of success for each drug, with time spans from ## min to several days being used to define successful cardioversion Thus, it is currently impossible definitively to recommend one drug over another for the treatment of AF <PERSOON> complication profile is an important issue in the selection of a drug to use against AF, and in <INSTELLING> it may be more important to choose treatment in a particular hospital where there is widespread There are several questions that must be addressed for this topic Is there an increased risk of stroke in patients with do novo AF after cardiac surgery? If stroke risk is increased, can anticoagulation reduce this incidence post cardiac surgery? <PERSOON> this reduction be achieved without undue increase in bleeding complications? After cardiac surgery, patients with AF should be anticoagulated while in AF and full anticoagulation should be started within ## h of the onset of AF due to a doubling of their risk of stroke This can be achieved with Immediate full anticoagulation in patients going into AF within ## h of their operation There is insufficient evidence to recommend whether patients who suffer from an episode of AF after cardiac surgery but who return to sinus rhythm will benefit from a further #â# weeks of Evidence was sought for whether anticoagulation is indicated for patients going into AF after cardiac surgery This search is fully documented in the ICVTS (Dunning et al [##]) together with a summary of all identified papers We identified ### papers using the presented search strategy From these, ## papers represented the Addressing the issue of reduction in stroke risk in patients with AF, Hart et al [##] analysed results from ## trials by meta-analysis They demonstrated that anticoagulation with warfarin reduced the relative risk of stroke both in comparison to placebo and aspirin and that warfarin is, therefore, by far the best long-term treatment in patients with AF <PERSOON> NNT to prevent one stroke per year was ## in the primary prevention group and ## in the.
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novo AF after cardiac surgery? If stroke risk is increased, can anticoagulation reduce this incidence post cardiac surgery? <PERSOON> this reduction be achieved without undue increase in bleeding complications? After cardiac surgery, patients with AF should be anticoagulated while in AF and full anticoagulation should be started within ## h of the onset of AF due to a doubling of their risk of stroke This can be achieved with Immediate full anticoagulation in patients going into AF within ## h of their operation There is insufficient evidence to recommend whether patients who suffer from an episode of AF after cardiac surgery but who return to sinus rhythm will benefit from a further #â# weeks of Evidence was sought for whether anticoagulation is indicated for patients going into AF after cardiac surgery This search is fully documented in the ICVTS (Dunning et al [##]) together with a summary of all identified papers We identified ### papers using the presented search strategy From these, ## papers represented the Addressing the issue of reduction in stroke risk in patients with AF, Hart et al [##] analysed results from ## trials by meta-analysis They demonstrated that anticoagulation with warfarin reduced the relative risk of stroke both in comparison to placebo and aspirin and that warfarin is, therefore, by far the best long-term treatment in patients with AF <PERSOON> NNT to prevent one stroke per year was ## in the primary prevention group and ## in the These results were consistent for disabling and non-disabling strokes It is interesting to note that, though the incidence of intracranial haemorrhage was twice that of placebo, the difference was not statistically significant <PERSOON> mean international normalised ratio (INR) achieved was # #â<DATUM> in primary prevention trials and <DATUM> in a single secondary prevention trial In addition, since the above meta-analysis was performed, Hylek et al [##] published a cohort study of ##,### patients in the New England Journal of Medicine, showing that an INR above # # significantly improved survival among patients with AF who suffer a stroke <PERSOON> next issue is whether AF after cardiac surgery significantly increases the risk of stroke Villareal et al [##] reported that in a cohort of ### patients undergoing CABG, patients who went into AF had a much higher incidence of stroke (<DATUM> vs <DATUM> ) and also an increased risk of short and long-term mortality These patients were, however, at significantly higher risk in a large range of categories including age, heart failure, chronic lung disease and underlying coronary arterial disease and thus, some caution should be used when analysing these Stamou et al [##] performed a retrospective analysis of ##,### patients who had undergone CABG, of whom ### had suffered a stroke Multivariate analysis showed that AF was an independent predictor of stroke, increasing the odds of stroke by <DATUM> However, multiple other high risk factors also predicted stroke and thus,.
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disabling and non-disabling strokes It is interesting to note that, though the incidence of intracranial haemorrhage was twice that of placebo, the difference was not statistically significant <PERSOON> mean international normalised ratio (INR) achieved was # #â<DATUM> in primary prevention trials and <DATUM> in a single secondary prevention trial In addition, since the above meta-analysis was performed, Hylek et al [##] published a cohort study of ##,### patients in the New England Journal of Medicine, showing that an INR above # # significantly improved survival among patients with AF who suffer a stroke <PERSOON> next issue is whether AF after cardiac surgery significantly increases the risk of stroke Villareal et al [##] reported that in a cohort of ### patients undergoing CABG, patients who went into AF had a much higher incidence of stroke (<DATUM> vs <DATUM> ) and also an increased risk of short and long-term mortality These patients were, however, at significantly higher risk in a large range of categories including age, heart failure, chronic lung disease and underlying coronary arterial disease and thus, some caution should be used when analysing these Stamou et al [##] performed a retrospective analysis of ##,### patients who had undergone CABG, of whom ### had suffered a stroke Multivariate analysis showed that AF was an independent predictor of stroke, increasing the odds of stroke by <DATUM> However, multiple other high risk factors also predicted stroke and thus, Almassi et al [#] also showed a #% stroke rate in patients with AF compared with <DATUM> in the sinus rhythm group, performing a similar study to Stamou in a cohort of ### patients Creswell et al [#] found that the incidence of stroke was <DATUM> if the patient was in AF compared with <DATUM> in those with sinus rhythm in a cohort of ### patients We found no studies that demonstrate that anticoagulation (immediate or delayed) of patients, who go into AF after cardiac surgery, significantly reduces this increased risk of stroke However, addressing the issue of the safety of immediate anticoagulation, Malouf et al [##] in a cohort study on ### cardiac surgical patients, performed an echocardiogram on all patients They found a ##% incidence of tamponade requiring drainage in patients receiving early warfarin, with no such tamponade in controls In addition, ##% of the anticoagulated patients had a large pericardial effusion on echocardiography compared with #% in controls As a caveat, these patients received warfarin not heparin, and a large proportion had a period of excessive anticoagulation at <PERSOON> American College of Cardiology, American Heart association and the European Society of Cardiology have joint guidelines for the management of patients with AF In general, they suggest managing post-CABG AF in a similar fashion to AF in non-surgical patients [#] They recommend the use of anticoagulant treatment in highrisk patients with a target INR of # #â# #.
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also showed a #% stroke rate in patients with AF compared with <DATUM> in the sinus rhythm group, performing a similar study to Stamou in a cohort of ### patients Creswell et al [#] found that the incidence of stroke was <DATUM> if the patient was in AF compared with <DATUM> in those with sinus rhythm in a cohort of ### patients We found no studies that demonstrate that anticoagulation (immediate or delayed) of patients, who go into AF after cardiac surgery, significantly reduces this increased risk of stroke However, addressing the issue of the safety of immediate anticoagulation, Malouf et al [##] in a cohort study on ### cardiac surgical patients, performed an echocardiogram on all patients They found a ##% incidence of tamponade requiring drainage in patients receiving early warfarin, with no such tamponade in controls In addition, ##% of the anticoagulated patients had a large pericardial effusion on echocardiography compared with #% in controls As a caveat, these patients received warfarin not heparin, and a large proportion had a period of excessive anticoagulation at <PERSOON> American College of Cardiology, American Heart association and the European Society of Cardiology have joint guidelines for the management of patients with AF In general, they suggest managing post-CABG AF in a similar fashion to AF in non-surgical patients [#] They recommend the use of anticoagulant treatment in highrisk patients with a target INR of # #â# # anticoagulant is appropriate when AF persists more than ## h However, they only quote two pre-### papers <PERSOON> [##] supported these recommendations in a review published in ###, stating that warfarin anticoagulation should be started after ## h He further recommends that in higher risk patients, even if sinus rhythm returns, warfarin should be continued for # weeks as there is a delay in return of atrial contractility after a <PERSOON> American Heart Association, supported by several authors, recommends warfarinisation while in AF, with an INR of #â# and anticoagulation within ## h of the onset of AF after cardiac surgery Chronic AF increases the risk of stroke and anticoagulation with warfarin provides the optimal protection from this risk, with a NNT of only ## to prevent a stroke; this number drops to ## if there is a history of stroke It is also clear that AF after cardiac surgery doubles the risk of stroke, but no studies have yet demonstrated a drop in this risk with immediate anticoagulation In addition, one study provides some evidence of increased risk of pericardial effusion and tamponade with early anticoagulation A further compounding factor is the <INSTELLING> that in many patients, AF after cardiac surgery can be of relatively short duration because of either spontaneous or therapeutic cardioversion These factors affect the choice of anticoagulant to be used in AF after cardiac surgery, not least because AF may have resolved by the time adequate anticoagulation with warfarin has been achieved.
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than ## h However, they only quote two pre-### papers <PERSOON> [##] supported these recommendations in a review published in ###, stating that warfarin anticoagulation should be started after ## h He further recommends that in higher risk patients, even if sinus rhythm returns, warfarin should be continued for # weeks as there is a delay in return of atrial contractility after a <PERSOON> American Heart Association, supported by several authors, recommends warfarinisation while in AF, with an INR of #â# and anticoagulation within ## h of the onset of AF after cardiac surgery Chronic AF increases the risk of stroke and anticoagulation with warfarin provides the optimal protection from this risk, with a NNT of only ## to prevent a stroke; this number drops to ## if there is a history of stroke It is also clear that AF after cardiac surgery doubles the risk of stroke, but no studies have yet demonstrated a drop in this risk with immediate anticoagulation In addition, one study provides some evidence of increased risk of pericardial effusion and tamponade with early anticoagulation A further compounding factor is the <INSTELLING> that in many patients, AF after cardiac surgery can be of relatively short duration because of either spontaneous or therapeutic cardioversion These factors affect the choice of anticoagulant to be used in AF after cardiac surgery, not least because AF may have resolved by the time adequate anticoagulation with warfarin has been achieved pad positioning for cardioversion, although if cardioversion fails in one of these positions, the alternative Evidence was sought for the optimal position of electrodes for patients undergoing external cardioversion for AF This search is fully documented in the ICVTS (Nagarajan and Dunning [##]) together with a summary of all identified papers We identified ### papers using the presented search strategy From these, # papers Five prospective RCTs were identified None of these were specifically regarding patients who had cardiac surgery Five studies were performed in a total of ### patients Two studies showed no difference between groups, one study showed a statistically significant benefit in favour of antero-lateral positioning and two studies showed a statistically significant benefit in favour of antero-posterior positioning If all these studies are combined, there was an ##% conversion rate with antero-posterior positioning and a ##% conversion rate with antero-lateral positioning ( p = # ##) Of note, all studies showed that if one position failed to convert the patient, success could still be achieved by alternating the paddle position Additional benefit of magnesium in patients having antiarrhythmic treatment for <PERSOON> magnesium offer additional benefit in patients having anti-arrhythmic treatment for AF after cardiac There is currently no evidence in cardiothoracic patients going into AF that addition of magnesium is of benefit in facilitating the return to sinus rhythm or controlling the ventricular rate (Grade E recommendation based on expert consensus in the absence of relevant clinical trials).
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in one of these positions, the alternative Evidence was sought for the optimal position of electrodes for patients undergoing external cardioversion for AF This search is fully documented in the ICVTS (Nagarajan and Dunning [##]) together with a summary of all identified papers We identified ### papers using the presented search strategy From these, # papers Five prospective RCTs were identified None of these were specifically regarding patients who had cardiac surgery Five studies were performed in a total of ### patients Two studies showed no difference between groups, one study showed a statistically significant benefit in favour of antero-lateral positioning and two studies showed a statistically significant benefit in favour of antero-posterior positioning If all these studies are combined, there was an ##% conversion rate with antero-posterior positioning and a ##% conversion rate with antero-lateral positioning ( p = # ##) Of note, all studies showed that if one position failed to convert the patient, success could still be achieved by alternating the paddle position Additional benefit of magnesium in patients having antiarrhythmic treatment for <PERSOON> magnesium offer additional benefit in patients having anti-arrhythmic treatment for AF after cardiac There is currently no evidence in cardiothoracic patients going into AF that addition of magnesium is of benefit in facilitating the return to sinus rhythm or controlling the ventricular rate (Grade E recommendation based on expert consensus in the absence of relevant clinical trials) treatment for AF after cardiac surgery This search is fully documented in the ICVTS (Patel et al [##]) together with a summary of all identified papers Four hundred and sixty six papers were identified using the presented search strategy From these, eight papers represented the best evidence on this topic Despite searching Medline, Embase, CINAHL, Cochrane and American Heart Association databases and guidelines, we found no studies that looked into the effect of using magnesium to treat patients going into AF after cardiac surgery We extended the search to papers that might aid in a decision as to whether magnesium may potentially aid rate control or cardioversion in cardiac surgical patients Shiga et al [##] performed a comprehensive metaanalysis in ###, looking at the benefit of prophylactic magnesium in the prevention of AF post cardiac surgery They identified ## RCTs, comprising ### patients In In addition, the incidence of ventricular tachycardia was also significantly lower, and the mean serum magnesium was significantly higher than in the control groups Magnesium reduced the incidence of AF by ##% across the In the general medical literature, we found seven papers that looked at either addition of magnesium or magnesium alone in the therapy of AF Four of the seven papers demonstrated a significant benefit Kalus et al [##] considered the efficacy of magnesium as an adjunct to ibutilide in ### medical patients in AF This was a retrospective multicenter cohort study where the authors reviewed the case notes of patients in atrial flutter or.
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in the ICVTS (Patel et al [##]) together with a summary of all identified papers Four hundred and sixty six papers were identified using the presented search strategy From these, eight papers represented the best evidence on this topic Despite searching Medline, Embase, CINAHL, Cochrane and American Heart Association databases and guidelines, we found no studies that looked into the effect of using magnesium to treat patients going into AF after cardiac surgery We extended the search to papers that might aid in a decision as to whether magnesium may potentially aid rate control or cardioversion in cardiac surgical patients Shiga et al [##] performed a comprehensive metaanalysis in ###, looking at the benefit of prophylactic magnesium in the prevention of AF post cardiac surgery They identified ## RCTs, comprising ### patients In In addition, the incidence of ventricular tachycardia was also significantly lower, and the mean serum magnesium was significantly higher than in the control groups Magnesium reduced the incidence of AF by ##% across the In the general medical literature, we found seven papers that looked at either addition of magnesium or magnesium alone in the therapy of AF Four of the seven papers demonstrated a significant benefit Kalus et al [##] considered the efficacy of magnesium as an adjunct to ibutilide in ### medical patients in AF This was a retrospective multicenter cohort study where the authors reviewed the case notes of patients in atrial flutter or <PERSOON> rate of conversion was #<DATUM> versus #<DATUM> for patients in AF and #<DATUM> versus #<DATUM> for those in atrial flutter (ibutilide and magnesium versus ibutilide only) resulting in a ##% reduction in the need for elective DC cardioversion <PERSOON> remaining studies were small randomised trials in general medical patients, with patient numbers ranging from ## to ## patients [##â ###] <PERSOON> literature on magnesium prophylaxis and non-cardiacsurgical literature on magnesium for AF suggests that magnesium may be of benefit, but there are currently no studies to support the use of # All patients in AF should have a ##-lead electrocardiogram performed to confirm the diagnosis and differentiate AF from atrial flutter ECG monitoring or recording (continuous or at intervals) should be performed to identify changes in ventricular rate and reversion to sinus rhythm # All stable patients going into AF should undergo venesection within # h to establish their haemoglobin, white cell count, serum sodium, potassium, urea and creatinine levels Any reversible abnormalities should be corrected and serum potassium should be tested daily and maintained above <DATUM> mmol/l # All patients going into AF should have their oxygenation assessed, and saturations should be maintained # All patients going into AF should have their fluid balance status assessed Hypovolaemia or fluid overload # All patients in post-operative AF should have daily serum electrolyte tests in order to minimise electrical.
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Algemene informatie over de kenmerken, oorzaken en gevolgen van een hypertensief spoedgeval De behandeling van patiënten met een hypertensief spoedgeval en adviezen voor behandeling van Aanbevelingen ten aanzien van organisatie van de zorg rondom patiënten met (verdenking op) een Hypertensie is de medische term voor (een bij herhaling vastgestelde) hoge bloeddruk Een hypertensief spoedgeval is een sterke verhoging van de bloeddruk met acute schade aan hersenen, hart, grote bloedvaten, Ongeveer één op de ### patiënten die zich presenteren op de spoedeisende hulp hebben een verdenking op een hypertensief spoedgeval Hiervan heeft ongeveer # op de # patiënten acute hypertensie gemedieerde orgaanschade Meer dan de helft van de patiënten die zich presenteert met een hypertensief spoedgeval is reeds bekend met hoge bloeddruk Daarnaast wordt een hypertensief spoedgeval gezien bij patiënten die nog niet eerder bekend of behandeld zijn voor hun hypertensie of met hun bloeddrukverlagende medicatie zijn Het initiatief voor deze richtlijn is afkomstig van de Nederlandse Internisten Vereniging (NIV) De richtlijn is Wat is het beleid voor personen die zich op de SEH met ernstige hypertensie met of zonder symptomen Welke patiënten hebben direct een verhoogd risico op mortaliteit of cardiovasculaire morbiditeit ten gevolge van ernstige hypertensie en moeten derhalve acuut intraveneus worden behandeld ? Sluit bij symptomatische patienten met een bloeddruk )###/### mmHg een hypertensief spoedgeval met retinopathie en/of trombotische microangiopathie uit indien andere andere aanwijzingen voor acute Behandel patiënten met acute hypertensieve orgaanschade zo spoedig mogelijk met intraveneuze Maak geen onderscheid in behandeling bij symptomatische of niet-symptomatische patiënten met ernstige hypertensie zonder acute hypertensieve orgaanschade (zie voor beleid de module 'Behandeling van ernstige Voor- en nadelen van de interventie en de kwaliteit van het bewijs De prognose van een hypertensief spoedgeval met retinopathie is de afgelopen jaren sterk verbeterd Door verschillende studies met verschillende definities en met inclusie in verschillende tijdsperioden is het moeilijk een conclusie te trekken over de prognose van hypertensief spoedgeval, voormalig urgentie en asymptomatische ernstige hypertensie De prognose van een spoedgeval hangt sterk af van het type orgaanschade (# tot ##% mortaliteit over een follow-upperiode van ## tot ## maanden), waarbij een hypertensief spoedgeval met alleen retinopathie van de hypertensieve spoedgevallen de meest gunstige prognose lijkt te hebben met een mortaliteit variërend van # tot ##% (# studies met een follow-up van ## tot ### maanden), maar een aanzienlijke morbiditeit lijkt te kennen met betrekking tot het voorkomen van nierfunctiestoornissen De prognose van patiënten die zich presenteren met ernstige ongecontroleerde hypertensie bij de huisarts (#% mortaliteit na twee jaar) Dit betreft echter maar één studie waar geen onderscheid is gemaakt tussen spoedgeval, urgentie en asymptomatische ernstige hypertensie; het grootste deel betrof echter asymptomatische hypertensie Voorzichtig kan wel geconcludeerd worden dat hypertensieve urgentie geen hoger cardiovasculair risico met zich Al met al lijkt de afwezigheid van klachten gecorreleerd met een lage kans op een hypertensief spoedgeval en een goede prognose Ten aanzien van voorspellers voor een hypertensief spoedgeval zijn geen studies beschreven die aan de selectiecriteria voldeden Door het ontbreken van vergelijkende studies waarbij.
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met ernstige hypertensie zonder acute hypertensieve orgaanschade (zie voor beleid de module 'Behandeling van ernstige Voor- en nadelen van de interventie en de kwaliteit van het bewijs De prognose van een hypertensief spoedgeval met retinopathie is de afgelopen jaren sterk verbeterd Door verschillende studies met verschillende definities en met inclusie in verschillende tijdsperioden is het moeilijk een conclusie te trekken over de prognose van hypertensief spoedgeval, voormalig urgentie en asymptomatische ernstige hypertensie De prognose van een spoedgeval hangt sterk af van het type orgaanschade (# tot ##% mortaliteit over een follow-upperiode van ## tot ## maanden), waarbij een hypertensief spoedgeval met alleen retinopathie van de hypertensieve spoedgevallen de meest gunstige prognose lijkt te hebben met een mortaliteit variërend van # tot ##% (# studies met een follow-up van ## tot ### maanden), maar een aanzienlijke morbiditeit lijkt te kennen met betrekking tot het voorkomen van nierfunctiestoornissen De prognose van patiënten die zich presenteren met ernstige ongecontroleerde hypertensie bij de huisarts (#% mortaliteit na twee jaar) Dit betreft echter maar één studie waar geen onderscheid is gemaakt tussen spoedgeval, urgentie en asymptomatische ernstige hypertensie; het grootste deel betrof echter asymptomatische hypertensie Voorzichtig kan wel geconcludeerd worden dat hypertensieve urgentie geen hoger cardiovasculair risico met zich Al met al lijkt de afwezigheid van klachten gecorreleerd met een lage kans op een hypertensief spoedgeval en een goede prognose Ten aanzien van voorspellers voor een hypertensief spoedgeval zijn geen studies beschreven die aan de selectiecriteria voldeden Door het ontbreken van vergelijkende studies waarbij orgaanschade werden onderzocht is geen conclusie te trekken of gecontroleerde bloeddruk verlaging middels Het uitsluiten van een hypertensief spoedgeval bij patiënten die geen symptomen hebben kost veel tijd, wat door de betrokken ervaringsdeskundigen als onprettig werd ervaren Een volstrekt asymptomatische presentatie bij patienten die zich met een sterk verhoogde bloeddruk presenteren lijkt op basis van de literatuur zeldzaam Daarom valt bij deze categorie patienten het te overwegen om niet direct tot SEH-beoordeling over te gaan, aangezien er geen bewijs is dat bloeddrukbehandeling met orale medicatie alleen in dit geval tot een slechtere Uitsluiten van een hypertensief spoedgeval of een hypertensieve urgentie betreft een SEH-bezoek met veel diagnostiek Het is dus ook economisch gunstig de drempel hiervoor iets hoger te leggen dan nu het geval is Bij minder opnames op een bewaakte afdeling zullen de kosten voor behandeling van ernstige hypertensie dalen De voorgestelde beleidsverandering waarbij patiënten vooral bij alarmsymptomen of klachten op de SEH beoordeeld moeten worden, is makkelijk in te voeren; in de praktijk vinden zowel huisartsen als internisten dat er nu te laagdrempelig SEH-beoordeling nodig is bij een patiënt zonder overige klachten Belangrijkste is dat zorgverleners (de bloeddruk wordt vaak door praktijkondersteuners gemeten) geschoold worden in Oogheelkundige screening op hypertensieve retinopathie werd de afgelopen jaren al vaak niet uitgevoerd wegens logistieke redenen In de praktijk lijkt dit niet tot grote problemen te hebben geleid bij patiënten met ernstige hypertensie waarbij geen funduscopie wordt uitgevoerd is de prognose niet slechter dan bij patiënten.
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orgaanschade werden onderzocht is geen conclusie te trekken of gecontroleerde bloeddruk verlaging middels Het uitsluiten van een hypertensief spoedgeval bij patiënten die geen symptomen hebben kost veel tijd, wat door de betrokken ervaringsdeskundigen als onprettig werd ervaren Een volstrekt asymptomatische presentatie bij patienten die zich met een sterk verhoogde bloeddruk presenteren lijkt op basis van de literatuur zeldzaam Daarom valt bij deze categorie patienten het te overwegen om niet direct tot SEH-beoordeling over te gaan, aangezien er geen bewijs is dat bloeddrukbehandeling met orale medicatie alleen in dit geval tot een slechtere Uitsluiten van een hypertensief spoedgeval of een hypertensieve urgentie betreft een SEH-bezoek met veel diagnostiek Het is dus ook economisch gunstig de drempel hiervoor iets hoger te leggen dan nu het geval is Bij minder opnames op een bewaakte afdeling zullen de kosten voor behandeling van ernstige hypertensie dalen De voorgestelde beleidsverandering waarbij patiënten vooral bij alarmsymptomen of klachten op de SEH beoordeeld moeten worden, is makkelijk in te voeren; in de praktijk vinden zowel huisartsen als internisten dat er nu te laagdrempelig SEH-beoordeling nodig is bij een patiënt zonder overige klachten Belangrijkste is dat zorgverleners (de bloeddruk wordt vaak door praktijkondersteuners gemeten) geschoold worden in Oogheelkundige screening op hypertensieve retinopathie werd de afgelopen jaren al vaak niet uitgevoerd wegens logistieke redenen In de praktijk lijkt dit niet tot grote problemen te hebben geleid bij patiënten met ernstige hypertensie waarbij geen funduscopie wordt uitgevoerd is de prognose niet slechter dan bij patiënten Verder gaven patiënten in een focusgroep aan dat de diagnostiek op de SEH vaak lang duurde; dit kan in een deel gereduceerd worden Rationale/ balans tussen de argumenten voor en tegen de interventie Het risico is dat patiënten met orale medicatie behandeld worden en een te snelle, ongecontroleerde bloeddrukdaling ontstaat die kan leiden tot een herseninfarct of overlijden in aanwezigheid van een gestoorde autoregulatie In de praktijk wordt op de SEH vaak ook al orale medicatie gegeven voordat de oogarts heeft beoordeeld of retinopathie aanwezig is, een situatie vergelijkbaar bij de huisarts Het risico op complicaties lijkt laag (hoewel nooit prospectief onderzocht) en is consistent met de studie van Patel (###) die laat zien dat bij een grote groep patienten met een sterk verhoogde bloeddruk op het spreekuur (bij # ## was de bloeddruk )###/### mmHg) de prognose gunstig is Gezien de hoge frequentie van patienten die vanwege (verdenking op) een hypertensief spoedgeval worden verwezen is het voor de belasting van de SEH een voordeel als in geval van ernstige hypertensie zonder alarmsymptomen of klachten, geen uitgebreid onderzoek hoeft plaats te vinden en behandeling kan worden gestart Aangezien in de verschillende cohorten patiënten met hypertensieve retinopathie meestal een bloeddruk hebben boven de ###/### mmHg en een asymptomatische presentatie zeldzaam is lijkt het, in lijn met eerdere aanbevelingen van de richtlijn uit ###, de richtlijn cardiovasculair risicomanagement uit ### en het recente positiedocument van de ESC en ESH, raadzaam om alleen bij patienten met een bloeddruk )###/### mmHg en symptomen aanvullend onderzoek te verrichten naar acute.
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in een focusgroep aan dat de diagnostiek op de SEH vaak lang duurde; dit kan in een deel gereduceerd worden Rationale/ balans tussen de argumenten voor en tegen de interventie Het risico is dat patiënten met orale medicatie behandeld worden en een te snelle, ongecontroleerde bloeddrukdaling ontstaat die kan leiden tot een herseninfarct of overlijden in aanwezigheid van een gestoorde autoregulatie In de praktijk wordt op de SEH vaak ook al orale medicatie gegeven voordat de oogarts heeft beoordeeld of retinopathie aanwezig is, een situatie vergelijkbaar bij de huisarts Het risico op complicaties lijkt laag (hoewel nooit prospectief onderzocht) en is consistent met de studie van Patel (###) die laat zien dat bij een grote groep patienten met een sterk verhoogde bloeddruk op het spreekuur (bij # ## was de bloeddruk )###/### mmHg) de prognose gunstig is Gezien de hoge frequentie van patienten die vanwege (verdenking op) een hypertensief spoedgeval worden verwezen is het voor de belasting van de SEH een voordeel als in geval van ernstige hypertensie zonder alarmsymptomen of klachten, geen uitgebreid onderzoek hoeft plaats te vinden en behandeling kan worden gestart Aangezien in de verschillende cohorten patiënten met hypertensieve retinopathie meestal een bloeddruk hebben boven de ###/### mmHg en een asymptomatische presentatie zeldzaam is lijkt het, in lijn met eerdere aanbevelingen van de richtlijn uit ###, de richtlijn cardiovasculair risicomanagement uit ### en het recente positiedocument van de ESC en ESH, raadzaam om alleen bij patienten met een bloeddruk )###/### mmHg en symptomen aanvullend onderzoek te verrichten naar acute Om vast te stellen welke diagnostiek nodig is bij ernstige hypertensie, is het van belang te weten wat de prognose is van ernstige hypertensie met of zonder symptomen Hierop kan worden bepaald wanneer uitgebreidere aanvullende diagnostiek nodig is om vast te stellen of acute intraveneuze behandeling nodig is Als een ernstig verhoogde bloeddruk wordt vastgesteld, moet de huisarts of andere zorgverlener die deze bloeddruk meet vaststellen of de patiënt verwezen moet worden naar de spoedeisende hulp (SEH) om een hypertensief spoedgeval uit te sluiten In de richtlijn van ### onderscheidt men een hypertensieve urgentie, waarbij snelwerkende orale medicatie werd geadviseerd, van "ernstige hypertensie zonder symptomen of acute eindorgaanschade" Het is de vraag of een urgentie een aparte entiteit is, of dat deze categorie een andere prognose heeft dan patiënten met een, vaak per toeval gemeten, ernstig verhoogde bloeddruk zonder Acute ernstige hypertensie kan gepaard gaan met ernstige eindorgaanschade en een verhoogde morbiditeit en mortaliteit Aanvullend onderzoek op de SEH richt zich onder andere op aanwijzingen voor ernstige hypertensieve retinopathie In de richtlijn van ### wordt geadviseerd gecontroleerde bloeddrukregulatie met intraveneuze middelen toe te passen bij ernstige hypertensieve retinopathie vanwege een gestoorde cerebrale autoregulatie Maar bepaalt het hebben van ernstige hypertensieve retinopathie de prognose van de patiënt? De mortaliteit is waarschijnlijk hoger bij een hypertensief spoedgeval vergeleken met een spoedgeval met alleen bilaterale retinopathie graad <DATUM> een urgentie of ernstige Vanwege het verschil in de wijze waarop cardiovasculaire morbiditeit werd gerapporteerd is.
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Om vast te stellen welke diagnostiek nodig is bij ernstige hypertensie, is het van belang te weten wat de prognose is van ernstige hypertensie met of zonder symptomen Hierop kan worden bepaald wanneer uitgebreidere aanvullende diagnostiek nodig is om vast te stellen of acute intraveneuze behandeling nodig is Als een ernstig verhoogde bloeddruk wordt vastgesteld, moet de huisarts of andere zorgverlener die deze bloeddruk meet vaststellen of de patiënt verwezen moet worden naar de spoedeisende hulp (SEH) om een hypertensief spoedgeval uit te sluiten In de richtlijn van ### onderscheidt men een hypertensieve urgentie, waarbij snelwerkende orale medicatie werd geadviseerd, van "ernstige hypertensie zonder symptomen of acute eindorgaanschade" Het is de vraag of een urgentie een aparte entiteit is, of dat deze categorie een andere prognose heeft dan patiënten met een, vaak per toeval gemeten, ernstig verhoogde bloeddruk zonder Acute ernstige hypertensie kan gepaard gaan met ernstige eindorgaanschade en een verhoogde morbiditeit en mortaliteit Aanvullend onderzoek op de SEH richt zich onder andere op aanwijzingen voor ernstige hypertensieve retinopathie In de richtlijn van ### wordt geadviseerd gecontroleerde bloeddrukregulatie met intraveneuze middelen toe te passen bij ernstige hypertensieve retinopathie vanwege een gestoorde cerebrale autoregulatie Maar bepaalt het hebben van ernstige hypertensieve retinopathie de prognose van de patiënt? De mortaliteit is waarschijnlijk hoger bij een hypertensief spoedgeval vergeleken met een spoedgeval met alleen bilaterale retinopathie graad <DATUM> een urgentie of ernstige Vanwege het verschil in de wijze waarop cardiovasculaire morbiditeit werd gerapporteerd is Vanwege het verschil in de wijze waarop nierinsufficiëntie werd gerapporteerd is het niet mogelijk een conclusie te trekken over prognose voor nierfalen bij verschillende patiënten Vanwege het ontbreken van gegevens over progressie naar een spoedgeval of over orgaanschade is het niet mogelijk een conclusie te trekken over prognose voor patiënten Guiga (###) vergeleek kortetermijn- en langetermijnprognose van patiënten met een hypertensief spoedgeval en een hypertensieve urgentie Volwassen die zich met een acute ernstige hypertensie (bloeddruk systolisch â¥### en/of diastolisch ⥠###mmHg) op de SEH in ### presenteerden, werden geïncludeerd Patiënten met acuut nierfalen en patiënten met (pre)eclampsie werden niet geïncludeerd aangezien deze patiënten naar een <INSTELLING> werden verwezen Eindorgaanschade werd door de auteurs gedefinieerd als encefalopathie, ischemische beroerte, intracerebrale bloeding, subarachnoïdale bloeding, acuut hartfalen, acuut coronair syndroom of aorta dissectie; retinopathie werd niet apart vermeld hoewel er wel een aantal patiënten gescoord werden benaderd om gegevens over mortaliteit na ## maanden te verzamelen In totaal werden ### patiënten ### (##%) met een urgentie Van ### en ### patiënten met respectievelijk een spoedgeval of een urgentie Roubsanthisuk (###) verrichtte een retrospectieve studie naar de uitkomst van patiënten die op een medische afdeling van het universitaire ziekenhuis in Bangkok kwamen met een hypertensief spoedgeval, gedefinieerd als ernstige hypertensie (SBP ) ### of DBP ) ### mmHg en acute of progressieve orgaanschade) In totaal waren er, over een termijn van één jaar (###), ### opnames in verband met hypertensieve spoedgevallen van ### patiënten (### patiënten werden eenmaal opgenomen en ## werden meer dan eenmalig opgenomen) De.
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werd gerapporteerd is het niet mogelijk een conclusie te trekken over prognose voor nierfalen bij verschillende patiënten Vanwege het ontbreken van gegevens over progressie naar een spoedgeval of over orgaanschade is het niet mogelijk een conclusie te trekken over prognose voor patiënten Guiga (###) vergeleek kortetermijn- en langetermijnprognose van patiënten met een hypertensief spoedgeval en een hypertensieve urgentie Volwassen die zich met een acute ernstige hypertensie (bloeddruk systolisch â¥### en/of diastolisch ⥠###mmHg) op de SEH in ### presenteerden, werden geïncludeerd Patiënten met acuut nierfalen en patiënten met (pre)eclampsie werden niet geïncludeerd aangezien deze patiënten naar een <INSTELLING> werden verwezen Eindorgaanschade werd door de auteurs gedefinieerd als encefalopathie, ischemische beroerte, intracerebrale bloeding, subarachnoïdale bloeding, acuut hartfalen, acuut coronair syndroom of aorta dissectie; retinopathie werd niet apart vermeld hoewel er wel een aantal patiënten gescoord werden benaderd om gegevens over mortaliteit na ## maanden te verzamelen In totaal werden ### patiënten ### (##%) met een urgentie Van ### en ### patiënten met respectievelijk een spoedgeval of een urgentie Roubsanthisuk (###) verrichtte een retrospectieve studie naar de uitkomst van patiënten die op een medische afdeling van het universitaire ziekenhuis in Bangkok kwamen met een hypertensief spoedgeval, gedefinieerd als ernstige hypertensie (SBP ) ### of DBP ) ### mmHg en acute of progressieve orgaanschade) In totaal waren er, over een termijn van één jaar (###), ### opnames in verband met hypertensieve spoedgevallen van ### patiënten (### patiënten werden eenmaal opgenomen en ## werden meer dan eenmalig opgenomen) De De gemiddelde systolische/ diastolische bloeddruk bij inclusie was ###,# (SD ##,#)/###,# (SD ##,#) mmHg Door overlijden, overplaatsing en ##% lost to follow-up wegens andere redenen was slechts ##% van de gevallen nog steeds onder controle tot het einde van ### #,#) (diastolisch) mmHg Deze patiënten hadden een gemiddelde follow-upduur van maximaal ## (SD #,#) <PERSOON> (###) beschrijft in een registerstudie de initiële kenmerken van opnames in verband met maligne hypertensie (bloeddruk â¥###/### mmHg en orgaanschade) om vroege herkenning van deze patiënten en kennis over orgaanschade te verbeteren Het Bordeaux-register van patiënten met maligne hypertensie werd in ### opgericht op de hypertensieafdeling van het European Society of Hypertension Excellence Center in Bordeaux Patiënten werden doorverwezen vanaf de afdeling spoedeisende hulp, ICU, neurologische afdeling of door hun huisarts naar deze hypertensie-afdeling Gedurende de eerste <LEEFTIJD> jaar was de opname van patiënten in het register gebaseerd op de combinatie van hoge bloeddruk (â¥###/### mmHg) en maligne hypertensieve retinopathie (MHR) volgens de klassieke definitie Sinds ### werden patiënten volgens de aangepaste definitie van maligne hypertensie geïncludeerd met een hoge bloeddruk en acute orgaanschade van minstens drie organen (niet noodzakelijkerwijs retinopathie) Tussen ### en ### werden ### patiënten geïncludeerd Van deze patiënten hadden ### de diagnose hypertensieve retinopathie, en ## hadden een normale oculaire fundus maar met ten minste drie andere vormen van orgaanschade Deze laatste groep wordt verder buiten (SD ##) mmHg Voor ##% (#<DATUM> van het totaal aantal patiënten gold dat ze niet bekend waren met.
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systolische/ diastolische bloeddruk bij inclusie was ###,# (SD ##,#)/###,# (SD ##,#) mmHg Door overlijden, overplaatsing en ##% lost to follow-up wegens andere redenen was slechts ##% van de gevallen nog steeds onder controle tot het einde van ### #,#) (diastolisch) mmHg Deze patiënten hadden een gemiddelde follow-upduur van maximaal ## (SD #,#) <PERSOON> (###) beschrijft in een registerstudie de initiële kenmerken van opnames in verband met maligne hypertensie (bloeddruk â¥###/### mmHg en orgaanschade) om vroege herkenning van deze patiënten en kennis over orgaanschade te verbeteren Het Bordeaux-register van patiënten met maligne hypertensie werd in ### opgericht op de hypertensieafdeling van het European Society of Hypertension Excellence Center in Bordeaux Patiënten werden doorverwezen vanaf de afdeling spoedeisende hulp, ICU, neurologische afdeling of door hun huisarts naar deze hypertensie-afdeling Gedurende de eerste <LEEFTIJD> jaar was de opname van patiënten in het register gebaseerd op de combinatie van hoge bloeddruk (â¥###/### mmHg) en maligne hypertensieve retinopathie (MHR) volgens de klassieke definitie Sinds ### werden patiënten volgens de aangepaste definitie van maligne hypertensie geïncludeerd met een hoge bloeddruk en acute orgaanschade van minstens drie organen (niet noodzakelijkerwijs retinopathie) Tussen ### en ### werden ### patiënten geïncludeerd Van deze patiënten hadden ### de diagnose hypertensieve retinopathie, en ## hadden een normale oculaire fundus maar met ten minste drie andere vormen van orgaanschade Deze laatste groep wordt verder buiten (SD ##) mmHg Voor ##% (#<DATUM> van het totaal aantal patiënten gold dat ze niet bekend waren met Redenen voor opname waren hoge bloeddruk bij ## (##%) patiënten Voor de resterende ##% was de opname het gevolg van een bijkomende complicatie (visusstoornis n=## (##%), beroerte n=## (##%), hartfalen n=## (##%) of niet-specifieke symptomen zoals hoofdpijn of duizeligheid (n=## Amraoui (###) had als doel de renale uitkomsten van patiënten met maligne hypertensie te kwantificeren bij in totaal ### patiënten met maligne hypertensie, die waren opgenomen tussen ### en ### Inclusiecriteria waren een diastolische bloeddruk van ### mmHg of hoger met graad # of # retinopathie Patiënten jonger dan <LEEFTIJD> jaar en zwangere vrouwen werden geëxcludeerd Patiënten verwezen vanuit een <INSTELLING> werden geëxcludeerd om referral bias te voorkomen Gemiddeld genomen waren patiënten <LEEFTIJD> jaar oud en ##% was vrouw Patiënten hadden een gemiddelde follow-up duur van ## maanden (IQR <DATUM> Follow-up gegevens waren beschikbaar van ## van de ### patiënten (##%) Tijdens follow-up overleden ## patienten (##%) Nierfunctievervangende therapie werd gestart in ## patienten (##%) tijdens de follow-up periode maligne hypertensie (gedefinieerd als hoge bloeddruk met bij funduscopie beiderzijds bloedingen en/of exsudaten) tussen ### en ### Het was onbekend wat onder een hoge bloeddruk werd verstaan De gemiddelde leeftijd was ## (SD ##) jaar en ##% was man ##% (#<DATUM> van de patiënten was bekend met Lane (###) onderzocht in een retrospectieve cohortstudie ### patiënten met maligne hypertensie, gedefinieerd als ernstige hypertensie met bij fundoscopie beiderzijds bloedingen en/of exsudaten De gemiddelde leeftijd was ## (bereik ## tot ##) jaar en ##% was man.
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waren hoge bloeddruk bij ## (##%) patiënten Voor de resterende ##% was de opname het gevolg van een bijkomende complicatie (visusstoornis n=## (##%), beroerte n=## (##%), hartfalen n=## (##%) of niet-specifieke symptomen zoals hoofdpijn of duizeligheid (n=## Amraoui (###) had als doel de renale uitkomsten van patiënten met maligne hypertensie te kwantificeren bij in totaal ### patiënten met maligne hypertensie, die waren opgenomen tussen ### en ### Inclusiecriteria waren een diastolische bloeddruk van ### mmHg of hoger met graad # of # retinopathie Patiënten jonger dan <LEEFTIJD> jaar en zwangere vrouwen werden geëxcludeerd Patiënten verwezen vanuit een <INSTELLING> werden geëxcludeerd om referral bias te voorkomen Gemiddeld genomen waren patiënten <LEEFTIJD> jaar oud en ##% was vrouw Patiënten hadden een gemiddelde follow-up duur van ## maanden (IQR <DATUM> Follow-up gegevens waren beschikbaar van ## van de ### patiënten (##%) Tijdens follow-up overleden ## patienten (##%) Nierfunctievervangende therapie werd gestart in ## patienten (##%) tijdens de follow-up periode maligne hypertensie (gedefinieerd als hoge bloeddruk met bij funduscopie beiderzijds bloedingen en/of exsudaten) tussen ### en ### Het was onbekend wat onder een hoge bloeddruk werd verstaan De gemiddelde leeftijd was ## (SD ##) jaar en ##% was man ##% (#<DATUM> van de patiënten was bekend met Lane (###) onderzocht in een retrospectieve cohortstudie ### patiënten met maligne hypertensie, gedefinieerd als ernstige hypertensie met bij fundoscopie beiderzijds bloedingen en/of exsudaten De gemiddelde leeftijd was ## (bereik ## tot ##) jaar en ##% was man van Zuid-Aziatische afkomst Patiënten werden tussen ### en ### geïncludeerd; alleen de gegevens van de periode ###-### werden beschreven vanwege het verandering in prognose over tijd De retrospectieve cohortstudie van Ayalon-Dangur (###) includeerde patiënten van ) <LEEFTIJD> jaar die werden ontslagen van de SEH van een groot ziekenhuis in <PERSOON> met een primaire diagnose van hypertensie Verhoogde bloeddruk werd gedefinieerd als een systolische bloeddruk ⥠### mmHg of diastolische bloeddruk ⥠## mmHg Patiënten werden uitgesloten als ze werden verwezen naar de SEH vanwege orgaanschade zoals acuut coronair syndroom (ACS), longoedeem, cerebrovasculair accident, acuut nierfalen, encefalopathie of een overduidelijke geschiedenis van hypertensiegeassocieerde groep van patiënten die de SEH bezocht voor een willekeurige oorzaak Gegevens van deze controlegroep werden buiten beschouwing gelaten In totaal werden ### patiënten geïdentificeerd Binnen de studiegroep hadden ### patiënten (##%) een systolische bloeddruk ⥠### Guiga (###) voor de beschrijving van de studie zie hierboven bij hypertensief spoedgeval Patel (###) beschreef de prevalentie van hypertensieve urgentie Alle patiënten die zich bij een poli of praktijk presenteerde met een hypertensieve urgentie werden geïncludeerd Daarvoor werd gebruik gemaakt van een lokaal systeem die alle gegevens van deze patiënten verzamelde Patiënten werden tussen <DATUM> en <DATUM> geïncludeerd De auteurs definieerde een hypertensieve urgentie als een systolische bloeddruk van ### mmHg of hoger en/of een diastolische bloeddruk van ### mmHg of hoger Zwangere vrouwen en patiënten doorverwezen naar het ziekenhuis anders dan voor hypertensie werden geëxcludeerd Patiënten.
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Zuid-Aziatische afkomst Patiënten werden tussen ### en ### geïncludeerd; alleen de gegevens van de periode ###-### werden beschreven vanwege het verandering in prognose over tijd De retrospectieve cohortstudie van Ayalon-Dangur (###) includeerde patiënten van ) <LEEFTIJD> jaar die werden ontslagen van de SEH van een groot ziekenhuis in <PERSOON> met een primaire diagnose van hypertensie Verhoogde bloeddruk werd gedefinieerd als een systolische bloeddruk ⥠### mmHg of diastolische bloeddruk ⥠## mmHg Patiënten werden uitgesloten als ze werden verwezen naar de SEH vanwege orgaanschade zoals acuut coronair syndroom (ACS), longoedeem, cerebrovasculair accident, acuut nierfalen, encefalopathie of een overduidelijke geschiedenis van hypertensiegeassocieerde groep van patiënten die de SEH bezocht voor een willekeurige oorzaak Gegevens van deze controlegroep werden buiten beschouwing gelaten In totaal werden ### patiënten geïdentificeerd Binnen de studiegroep hadden ### patiënten (##%) een systolische bloeddruk ⥠### Guiga (###) voor de beschrijving van de studie zie hierboven bij hypertensief spoedgeval Patel (###) beschreef de prevalentie van hypertensieve urgentie Alle patiënten die zich bij een poli of praktijk presenteerde met een hypertensieve urgentie werden geïncludeerd Daarvoor werd gebruik gemaakt van een lokaal systeem die alle gegevens van deze patiënten verzamelde Patiënten werden tussen <DATUM> en <DATUM> geïncludeerd De auteurs definieerde een hypertensieve urgentie als een systolische bloeddruk van ### mmHg of hoger en/of een diastolische bloeddruk van ### mmHg of hoger Zwangere vrouwen en patiënten doorverwezen naar het ziekenhuis anders dan voor hypertensie werden geëxcludeerd Patiënten Voor deze vraag werd alleen de groep doorverwezen naar het ziekenhuis meegenomen en beschreven Gemiddeld genomen waren patiënten was onbekend hoe hypertensie gedefinieerd was Patiënten werden geïdentificeerd uit een database met geanonimiseerde data van alle SEH-bezoeken in de provincie Ontario in Canada, de Canadian Institutes of Health Information National Ambulatory Care Reporting System De inclusieperiode liep van <DATUM> tot <DATUM> In totaal werden #<DATUM> patiënten geïncludeerd met een mediane leeftijd van <LEEFTIJD> jaar en ##% vrouw In een sample van # sites is ook de triage bloeddruk gerapporteerd, de mediane bloeddruk op de SEH Merlo (###) onderzocht in een prospectief observationele studie patiënten die zich presenteerden bij de prospectief gerekruteerd uit ## algemene praktijken in de grotere agglomeratie van de steden Luzern en Basel in Zwitserland tussen maart ### en juli ### In totaal voldeden ### patiënten aan de inclusiecriteria waarvan ##% man was met een gemiddelde leeftijd van <LEEFTIJD> jaar (SD <LEEFTIJD> jaar) De gemiddelde systolische/ diastolische twaalf uur na de eerste presentatie verkregen en na # (±#) dagen en na # (±#) maanden Uiteindelijk werd een onderverdeling gemaakt in patiënten met een hypertensief spoedgeval (n=## (#%)), urgentie (n=## (##%)) of asymptomatische bloeddrukverhoging (n= ## (##%)) Mortaliteit werd alleen apart voor de groep met De studies van <PERSOON> (###) rapporteerden data over mortaliteit Patel (###) (hypertensieve.
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Voor deze vraag werd alleen de groep doorverwezen naar het ziekenhuis meegenomen en beschreven Gemiddeld genomen waren patiënten was onbekend hoe hypertensie gedefinieerd was Patiënten werden geïdentificeerd uit een database met geanonimiseerde data van alle SEH-bezoeken in de provincie Ontario in Canada, de Canadian Institutes of Health Information National Ambulatory Care Reporting System De inclusieperiode liep van <DATUM> tot <DATUM> In totaal werden #<DATUM> patiënten geïncludeerd met een mediane leeftijd van <LEEFTIJD> jaar en ##% vrouw In een sample van # sites is ook de triage bloeddruk gerapporteerd, de mediane bloeddruk op de SEH Merlo (###) onderzocht in een prospectief observationele studie patiënten die zich presenteerden bij de prospectief gerekruteerd uit ## algemene praktijken in de grotere agglomeratie van de steden Luzern en Basel in Zwitserland tussen maart ### en juli ### In totaal voldeden ### patiënten aan de inclusiecriteria waarvan ##% man was met een gemiddelde leeftijd van <LEEFTIJD> jaar (SD <LEEFTIJD> jaar) De gemiddelde systolische/ diastolische twaalf uur na de eerste presentatie verkregen en na # (±#) dagen en na # (±#) maanden Uiteindelijk werd een onderverdeling gemaakt in patiënten met een hypertensief spoedgeval (n=## (#%)), urgentie (n=## (##%)) of asymptomatische bloeddrukverhoging (n= ## (##%)) Mortaliteit werd alleen apart voor de groep met De studies van <PERSOON> (###) rapporteerden data over mortaliteit Patel (###) (hypertensieve Vanwege een verschil in definitie en follow-upduur is besloten de resultaten niet te poolen, maar weer te geven in tabel # en figuur # Tabel # Overzicht van studies met gegevens over mortaliteit bekend staande als maligne hypertensie); Urgentie, hypertensieve urgentie zonder orgaanschade; De mortaliteit is hoger bij een hypertensief spoedgeval vergeleken met een spoedgeval met alleen retinopathie, hypertensieve urgentie en ernstige hypertensie De gemiddelde leeftijd van de verschillende patiëntengroepen Van de tien geïncludeerde studies beschreven zeven studies de uitkomst cardiovasculaire morbiditeit Geen van de studies die patiënten met een hypertensief spoedgeval beschreven de uitkomst cardiovasculaire morbiditeit Dit zal waarschijnlijk te maken hebben met het feit dat deze groep al orgaanschade heeft (waaronder voor een groot deel hart- en vaatziekten zoals hersen- of hartinfarct) wat de definitie spoedgeval heeft bepaald Van de vier studies met patiënten met retinopathie rapporteerde drie studies gegevens over cardiovasculaire morbiditeit De twee studies onder patiënten met ongecontroleerde ernstige hypertensie beschreven allebei de De uitkomstmaat werd door de studies op verschillende wijze gedefinieerd De gegevens zijn daarom in tabel # weergegeven Gezien het weinige overlap in gegevens tussen de studies is het niet mogelijk om een conclusie Tabel # Overzicht van studies met gegevens over cardiovasculaire morbiditeit events; # MI; #Gedef inieerd als MI, onstabiele angina, hartf alen, atriumf ibrilleren en beroerte; # Gedef inieerd als acuut coronair syndroom, beroerte of TIA, ongecontroleerde werd verstaan; # Eindstadium nierziekte; # Incl # patiënten die waren overleden ten gevolge van.
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besloten de resultaten niet te poolen, maar weer te geven in tabel # en figuur # Tabel # Overzicht van studies met gegevens over mortaliteit bekend staande als maligne hypertensie); Urgentie, hypertensieve urgentie zonder orgaanschade; De mortaliteit is hoger bij een hypertensief spoedgeval vergeleken met een spoedgeval met alleen retinopathie, hypertensieve urgentie en ernstige hypertensie De gemiddelde leeftijd van de verschillende patiëntengroepen Van de tien geïncludeerde studies beschreven zeven studies de uitkomst cardiovasculaire morbiditeit Geen van de studies die patiënten met een hypertensief spoedgeval beschreven de uitkomst cardiovasculaire morbiditeit Dit zal waarschijnlijk te maken hebben met het feit dat deze groep al orgaanschade heeft (waaronder voor een groot deel hart- en vaatziekten zoals hersen- of hartinfarct) wat de definitie spoedgeval heeft bepaald Van de vier studies met patiënten met retinopathie rapporteerde drie studies gegevens over cardiovasculaire morbiditeit De twee studies onder patiënten met ongecontroleerde ernstige hypertensie beschreven allebei de De uitkomstmaat werd door de studies op verschillende wijze gedefinieerd De gegevens zijn daarom in tabel # weergegeven Gezien het weinige overlap in gegevens tussen de studies is het niet mogelijk om een conclusie Tabel # Overzicht van studies met gegevens over cardiovasculaire morbiditeit events; # MI; #Gedef inieerd als MI, onstabiele angina, hartf alen, atriumf ibrilleren en beroerte; # Gedef inieerd als acuut coronair syndroom, beroerte of TIA, ongecontroleerde werd verstaan; # Eindstadium nierziekte; # Incl # patiënten die waren overleden ten gevolge van Vijf studies rapporteerden gegevens over nierinsufficiëntie (Tabel #) Ook hier was er verschil in de definitie en wijze van rapportage <PERSOON> (###) rapporteerde bijvoorbeeld dat # (#%) patiënten met een spoedgeval en alleen retinopathie eindstadium nierziekte kregen Amraoui (###) vermeldde dat # patiënten met een spoedgeval en alleen retinopathie waren overleden ten gevolge van nierfalen en dat ## patiënten nierfunctievervangende therapie nodig hadden tijdens follow-up <PERSOON> (###) beschreef het aantal patiënten met een spoedgeval en alleen retinopathie die dialyse afhankelijk werden, in totaal # (##%) Onder patiënten met een hypertensieve urgentie hadden # van ### patiënten, doorverwezen naar het ziekenhuis, acute nierschade (Patel, ###) Tot slot, onder ### ziekenhuisopnames was voor ### (#%) opnames nierfalen de Deze uitkomstmaat is alleen relevant voor studies die patiënten met een hypertensieve urgentie of ernstige hypertensie hebben geïncludeerd Geen van de studies rapporteerde de uitkomstmaat In de studie van Merlo (###) werd ##% van de ### patiënten ingedeeld als asymptomatische hypertensie Deze patiënten werden allen behandeld in de huisartsenpraktijk; er was geen verwijzing naar het ziekenhuis gedurende follow-up nodig Alleen Patel (###) rapporteerde onder patiënten beoordeeld op de SEH in verband met hypertensieve urgentie de uitkomstmaat âorgaanschadeâ ondanks afwezigheid van klachten passend bij een hypertensief spoedgeval Het domein van deze uitgangsvraag is therapeutisch met een prognostische zoekvraag Observationele studies Mortaliteit De bewijskracht voor de uitkomstmaat mortaliteit is met twee niveaus verlaagd gezien beperkingen in studieopzet (het ontbreken van een beschrijving van follow-up) en ernstige indirectheid Cardiovasculaire morbiditeit Vanwege het verschil in definitie van cardiovasculaire morbiditeit is het niet mogelijk.
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verschil in de definitie en wijze van rapportage <PERSOON> (###) rapporteerde bijvoorbeeld dat # (#%) patiënten met een spoedgeval en alleen retinopathie eindstadium nierziekte kregen Amraoui (###) vermeldde dat # patiënten met een spoedgeval en alleen retinopathie waren overleden ten gevolge van nierfalen en dat ## patiënten nierfunctievervangende therapie nodig hadden tijdens follow-up <PERSOON> (###) beschreef het aantal patiënten met een spoedgeval en alleen retinopathie die dialyse afhankelijk werden, in totaal # (##%) Onder patiënten met een hypertensieve urgentie hadden # van ### patiënten, doorverwezen naar het ziekenhuis, acute nierschade (Patel, ###) Tot slot, onder ### ziekenhuisopnames was voor ### (#%) opnames nierfalen de Deze uitkomstmaat is alleen relevant voor studies die patiënten met een hypertensieve urgentie of ernstige hypertensie hebben geïncludeerd Geen van de studies rapporteerde de uitkomstmaat In de studie van Merlo (###) werd ##% van de ### patiënten ingedeeld als asymptomatische hypertensie Deze patiënten werden allen behandeld in de huisartsenpraktijk; er was geen verwijzing naar het ziekenhuis gedurende follow-up nodig Alleen Patel (###) rapporteerde onder patiënten beoordeeld op de SEH in verband met hypertensieve urgentie de uitkomstmaat âorgaanschadeâ ondanks afwezigheid van klachten passend bij een hypertensief spoedgeval Het domein van deze uitgangsvraag is therapeutisch met een prognostische zoekvraag Observationele studies Mortaliteit De bewijskracht voor de uitkomstmaat mortaliteit is met twee niveaus verlaagd gezien beperkingen in studieopzet (het ontbreken van een beschrijving van follow-up) en ernstige indirectheid Cardiovasculaire morbiditeit Vanwege het verschil in definitie van cardiovasculaire morbiditeit is het niet mogelijk Vanwege het verschil in definitie van nierfalen is het niet mogelijk de bewijskracht te Progressie naar een spoedgeval vanwege het ontbreken van gegevens was het niet mogelijk om de Orgaanschade vanwege het ontbreken van gegevens was het niet mogelijk om de bewijskracht van deze Er zijn geen studies beschreven aangezien geen studie voldeed aan de selectiecriteria # Wat is de cardiovasculaire morbiditeit en mortaliteit bij patiënten met een hypertensief spoedgeval? P# patiënten met hypertensief spoedgeval en aanwezigheid van acute orgaanschade (aan hart, hersenen, # Wat is de prognose voor mortaliteit, cardiovasculaire morbiditeit, progressie naar spoedgeval of Additionele criteria voor zoekvraag # en # follow-upduur (een tot vijf jaar of tot aan ontslag uit het ziekenhuis) # Wat zijn voorspellers voor een slechte uitkomst bij patiënten die zich op de SEH met een hoge bloeddruk O mortaliteit (binnen ## dagen), morbiditeit van hart- en vaatziekten (binnen ## dagen), ernstige orgaanschade De werkgroep achtte mortaliteit en cardiovasculaire morbiditeit, progressie naar spoedgeval en orgaanschade Mortaliteit en cardiovasculaire morbiditeit De werkgroep definieerde #% verschil in relatief risico binnen <LEEFTIJD> jaar Progressie naar spoedgeval De werkgroep definieerde #% verschil in relatief risico binnen drie maanden als een klinisch relevante prognose voor patiënten met hypertensieve urgentie of ernstige hypertensie Nierinsufficiëntie De werkgroep definieerde nierinsufficiëntie als halvering van eGFR of noodzaak tot nierfunctievervangende therapie als klinisch relevant eindpunt voor alle benoemde patiëntenpopulaties In de databases Medline (via OVID) en Embase (via Embase.
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