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Annals of Emergency Medicine Oct 2015The aim of this systematic review and meta-analysis is to determine the diagnostic accuracy of D-dimer as a rule-out test for acute aortic dissection. Previous... (Meta-Analysis)
Meta-Analysis Review
STUDY OBJECTIVE
The aim of this systematic review and meta-analysis is to determine the diagnostic accuracy of D-dimer as a rule-out test for acute aortic dissection. Previous meta-analyses have had methodological problems with conflicting conclusions, and new diagnostic accuracy studies have been published since.
METHODS
All prospective cross-sectional analytic studies of D-dimer as a diagnostic test for acute aortic dissection were included where diagnosis was confirmed by an accepted reference standard. Studies were identified with MEDLINE, EMBASE, Medion, Google Scholar, Web of Science, and bibliographies of relevant articles and previous systematic reviews. Two reviewers independently screened articles for inclusion, assessed study quality, and extracted data.
RESULTS
Abstracts from 800 articles were reviewed, yielding 30 potentially relevant studies that were reviewed in full text. Five studies met all eligibility criteria. Data from 4 studies (1,557 participants) that used a D-dimer cutoff of 0.50 μg/mL were pooled to estimate sensitivity, specificity, and positive and negative likelihood ratios. Overall, sensitivity and negative likelihood ratio were 98.0% (95% confidence interval [CI] 96.3% to 99.1%) and 0.05 (95% CI 0.03 to 0.09), respectively. These measurements had little statistical heterogeneity. Specificity (41.9%; 95% CI 39.0% to 44.9%) and positive likelihood ratio (2.11; 95% CI 1.46 to 3.05) showed significant statistical heterogeneity. When applied to a low-risk population as defined by the American Heart Association (prevalence 6%), the posttest probability for acute aortic dissection was 0.3%.
CONCLUSION
This meta-analysis suggests that a negative D-dimer result may be useful to help rule out acute aortic dissection in low-risk patients.
Topics: Aortic Dissection; Aortic Aneurysm; Biomarkers; Fibrin Fibrinogen Degradation Products; Humans
PubMed: 25805111
DOI: 10.1016/j.annemergmed.2015.02.013 -
Management and Outcomes of Aortic Dissection in Pregnancy with Marfan Syndrome: A Systematic Review.Current Vascular Pharmacology 2020In Marfan Syndrome (MFS), aortic dilatation is one of the main cardiovascular manifestations which deteriorate due to the physiological changes during pregnancy. We...
BACKGROUND
In Marfan Syndrome (MFS), aortic dilatation is one of the main cardiovascular manifestations which deteriorate due to the physiological changes during pregnancy. We aimed to assess the up-to-date management and outcomes of aortic root dilation and dissection (AoD) in pregnancy with MFS.
PATIENTS AND METHODS
A systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Original studies published between January 1, 2001 and December 31, 2018 and which described the management and/or outcomes of AoD during or after pregnancy in women with MFS were included. Literature searches were conducted. The PubMed search was performed using terms "Marfan Syndrome" [Mesh] and "Pregnancy" [Mesh] whereas the Google Scholar search was for "Marfan" and "Pregnancy", all words anywhere in the article.
RESULTS
The literature search yielded 177 articles on PubMed and 13,900 articles on Google Scholar. Assessment of full-text articles for eligibility after removal of duplicates from both databases yielded 12 eligible studies to be included in the final review.
CONCLUSION
Women with MFS are at high risk of aortic dissection during pregnancy and women with aortic root 41-45 mm should consider avoiding pregnancy. Guideline-specific management of aortic aneurysms in pregnancy will reduce the risk of dissection. Diagnosis and Management of MFS need a multidisciplinary approach and team that should start working early in pregnancy. Further studies are needed to optimize medical and surgical approaches in addition to preconception counselling in highrisk subjects.
Topics: Aortic Dissection; Aortic Aneurysm; Blood Vessel Prosthesis Implantation; Female; Heart Valve Prosthesis Implantation; Humans; Marfan Syndrome; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Risk Assessment; Risk Factors; Treatment Outcome
PubMed: 30963974
DOI: 10.2174/1570161117666190408164612 -
Journal of Vascular Surgery Oct 2022Best medical therapy (BMT) should be recommended for treating uncomplicated Stanford type B aortic dissection (uSTBAD), whereas thoracic aortic endovascular repair... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Best medical therapy (BMT) should be recommended for treating uncomplicated Stanford type B aortic dissection (uSTBAD), whereas thoracic aortic endovascular repair (TEVAR) has been controversial for uSTBAD.
METHODS
In this paper, a meta-analysis was conducted on all available randomized controlled trials and observational studies that evaluated the relative benefits and harms of TEVAR and BMT for the management of patients suffering from uSTBAD. Primary endpoints consisted of early adverse events, long-term adverse events, and aortic remodeling. In addition, risk differences (RDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. The random-effects model or the fixed-effects model was used in accordance with the 50% heterogeneity threshold.
RESULTS
Seven observational studies and two randomized controlled studies from 11 articles that contained 15,066 patients with uSTBAD (1518 TEVARs) met the inclusion criteria. For early outcomes, no significant differences were found between the TEVAR group and the BMT group in aortic rupture, retrograde dissection, paraplegia/paraparesis, reintervention, aorta-related death, and all-cause death. In the long run, the TEVAR group was found to have a significantly lower incidence of adverse events, which included aortic rupture (OR, 0.26; 95% CI, 0.16-0.42; P < .05; heterogeneity: P = .90, I = 0%), reintervention (OR, 0.45; 95% CI, 0.26-0.75; P < .05; heterogeneity: P = .17, I = 41%), aorta-related death (OR, 0.27; 95% CI, 0.18-0.42; P < .05; heterogeneity: P = .61, I = 0%), and all-cause death (OR, 0.52; 95% CI, 0.42-0.66; P < .05; heterogeneity: P = .05, I = 53%) as compared with the BMT group. Moreover, in compared with BMT, TEVAR was found to significantly contribute to the complete thrombosis of thoracic false lumen (OR, 55.34; 95% CI, 34.32-89.21; P < .05; heterogeneity: P = .97, I = 0%), and aortic regression (true lumen expansion and false lumen shrinkage).
CONCLUSIONS
Although early endovascular repair of uSTBAD does not outperform BMT, its implementation is found to be necessary to facilitate the long-term prognosis. Accordingly, if early TEVAR is to be deferred, close follow-up is critical to allow for timely reintervention.
Topics: Aortic Dissection; Aortic Aneurysm, Thoracic; Aortic Rupture; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Observational Studies as Topic; Retrospective Studies; Treatment Outcome
PubMed: 35390485
DOI: 10.1016/j.jvs.2022.03.876 -
Current Problems in Cardiology Mar 2024Despite guideline recommendations, strategies for implementing cardiac rehabilitation (CR) in patients with acute aortic dissection (AAD) are not well established with... (Review)
Review
Despite guideline recommendations, strategies for implementing cardiac rehabilitation (CR) in patients with acute aortic dissection (AAD) are not well established with little evidence to risk stratify prudent and effective guidelines for the many required variables. We conducted a systematic review of studies (2004-2023) reporting CR following type A (TA) and type B (TB) AAD. Our review is limited to open surgical repair for TA and medical treatment for TB. A total of 5 studies were included (4 TA-AAD and 1 TB-AAD) in the qualitative analysis. In general, observational data included 311 patients who had an overall favorable effect of CR in AAD consisting of a modestly improved exercise capacity and work load during cycle cardiopulmonary exercise test (TB-AAD), and improved quality of life (QoL). No adverse events were reported during symptom limited pre-CR treadmill or cycle exercise VO max or CR. Given the overall potential in this high risk population without adequate evidence for important variables such as safe time from post-op to CR, intensity of training, duration and frequency of sessions and followup it is time for a moderate sized well designed safe trial for patients' post-op surgery for TA-AAD and medically treated TB-AAD who are treated with standardized evidence based medical therapy and physical therapy from discharge randomized to CR versus usual care. PROSPERO registry ID: CRD42023392896.
Topics: Humans; Cardiac Rehabilitation; Quality of Life; Evidence Gaps; Treatment Outcome; Aortic Dissection; Randomized Controlled Trials as Topic
PubMed: 38246318
DOI: 10.1016/j.cpcardiol.2023.102348 -
Annals of Gastroenterology 2022Esophagogastric junction adenocarcinomas (EGJAs) include esophageal and gastric cardia adenocarcinomas (GCAs). These tumors are currently regarded as a single entity,...
BACKGROUND
Esophagogastric junction adenocarcinomas (EGJAs) include esophageal and gastric cardia adenocarcinomas (GCAs). These tumors are currently regarded as a single entity, with similar surgical and oncological therapies, although they originate from different organs. Endoscopy allows an early-stage diagnosis, where both subtypes can be differentiated. With this review we aimed to describe the outcomes of endoscopic submucosal dissection for the treatment of esophageal adenocarcinomas (EAs) and GCAs.
METHODS
We identified studies by screening PubMed, Embase and Web of Science. We included all 19 studies that mentioned at least one of the following criteria of interest: ; R0 resection; local recurrences; and/or overall survival.
RESULTS
We found an resection rate superior to 90% for both tumors. R0 resections rates were over 60% for most EAs, vs. 83% for most GCAs. We recorded less than 13% and 20% early and late adverse events for EA, and 10% and 7% for GCA. The local recurrence rate was 8% for EA and 3% for GCA. The overall survival was over 90%.
CONCLUSIONS
Endoscopic submucosal dissection is safe and effective for esophageal and GCAs. These data support the extension of the use of endoscopic submucosal dissection to all EGJAs, including early EAs.
PubMed: 35784626
DOI: 10.20524/aog.2022.0719 -
The American Journal of Emergency... Mar 2022Aortic dissection is a rare but potentially catastrophic condition. Misdiagnosis of aortic dissection is not uncommon as symptoms can overlap with other diagnoses.
BACKGROUND
Aortic dissection is a rare but potentially catastrophic condition. Misdiagnosis of aortic dissection is not uncommon as symptoms can overlap with other diagnoses.
OBJECTIVE
We conducted a systematic review to better understand the factors contributing to incorrect diagnosis of this condition.
METHODS
We searched MEDLINE and EMBASE for studies that evaluated the misdiagnosis of aortic dissection. The rate of misdiagnosis was pooled and results were narratively synthesized.
RESULTS
A total of 12 studies with were included with 1663 patients. The overall rate of misdiagnosis of aortic dissection was 33.8%. The proportion of patients presenting with chest pain, back pain and syncope were 67.5%, 24.8% and 6.8% respectively. The proportion of patients with pre-existing hypertension was 55.4%, 30.5% were smokers while the proportion of patients with coronary artery disease, previous cardiovascular surgery or surgical trauma and Marfan syndrome was 14.7%, 5.8%, and 3.7%, respectively. Factors related to misdiagnosis included the presence of symptoms and features associated with other diseases (such as acute coronary syndrome, stroke and pulmonary embolism), the absence of typical features (such as widened mediastinum on chest X-ray) or concurrent conditions such congestive heart failure. Factors associated with more accurate diagnosis included more comprehensive history taking and increased use of imaging.
CONCLUSIONS
Misdiagnosis in patients with an eventual diagnosis of aortic dissection affects 1 in 3 patients. Clinicians should consider aortic dissection as differential diagnosis in patients with chest pain, back pain and syncope. Imaging should be used early to make the diagnosis when aortic dissection is suspected.
Topics: Aortic Dissection; Back Pain; Chest Pain; Diagnostic Errors; Humans; Syncope
PubMed: 34968970
DOI: 10.1016/j.ajem.2021.11.047 -
International Journal of Cardiology Jan 2019To investigate the association between fluoroquinolones use and development of aortopathy. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To investigate the association between fluoroquinolones use and development of aortopathy.
METHODS
A systematic review and meta-analysis was conducted following PRISMA and MOOSE guidelines for reporting systematic reviews of observational studies. Multiple databases were searched and two authors independently screened studies for eligibility. Newcastle Ottawa scale was used to assessed the quality of included studies. Primary outcome of interest was development of aortic aneurysm or dissection among fluoroquinolones users in comparison to non-users. An inverse variance model meta-analysis was used to pool odds ratio or hazards ratio from included studies to calculate the overall effect estimate. Pre specified subgroups analyses were also conducted to explore sources of heterogeneity.
RESULTS
Three observational studies that enrolled 941,639 subjects met the inclusion criteria and were included in the final analysis. All studies were of a good methodological quality. Current use of fluoroquinolones, defined as within 60 days from development of the primary outcome, was associated with significantly elevated risk of developing aortic aneurysm and/or dissection in comparison to controls, (OR = 2.04; 95% CI [1.67, 2.48]). There was only a mild degree of between study heterogeneity, I = 33%. The association remains robust among all subgroups analyses.
CONCLUSION
Our findings indicate that current fluoroquinolone use was significantly associated with increased risk of aortic aneurysm and dissection. Health care providers need to be aware of this serious association and use fluoroquinolones judiciously in order to minimize the risk of the serious sequela of aortopathy.
Topics: Aortic Dissection; Anti-Bacterial Agents; Aortic Aneurysm; Bacterial Infections; Fluoroquinolones; Global Health; Humans; Incidence; Risk Assessment; Risk Factors
PubMed: 30309682
DOI: 10.1016/j.ijcard.2018.09.067 -
Annals of Vascular Surgery Sep 2022This study explored seasonal and monthly variations of the incidence of acute aortic dissection (AAD). (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This study explored seasonal and monthly variations of the incidence of acute aortic dissection (AAD).
METHODS
MEDLINE, EMBASE, and the Cochrane Library databases were searched up to July 2021. Temporal variation in the incidence of AAD was analyzed including all studies analyzing seasonal and monthly aggregations. Then, we performed subgroup analyses according to the type of AAD. Two authors independently reviewed and extracted data.
RESULTS
Twenty-seven studies for a total of 128,101 patients were included. Our results showed that the incidence of AAD was highest in winter and lowest in summer. Regardless of type A or type B, the incidence of AAD was significantly higher in winter than in summer and autumn. Nonetheless, there was no significant difference between spring and winter, and between summer and autumn. Results may be limited by the quality of the included articles. However, in the sensitivity analysis that excluded low-quality studies, results did not change significantly. In addition, the pooled incidence was highest in January and lowest in August.
CONCLUSIONS
Our data strongly support the presence of distribution patterns in the incidence of AAD, characterized by significantly higher risk in winter and in January. These distribution patterns of AAD incidence may help to develop better prevention strategies.
Topics: Aortic Dissection; Humans; Incidence; Seasons; Treatment Outcome
PubMed: 35461996
DOI: 10.1016/j.avsg.2022.04.008 -
Journal of Otolaryngology - Head & Neck... Mar 2021Neck dissection has a central role in the management of head and neck cancers. This systematic review aimed to compare the intraoperative and postoperative parameters... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Neck dissection has a central role in the management of head and neck cancers. This systematic review aimed to compare the intraoperative and postoperative parameters between conventional and LigaSure Small Jaw (LSJ)-assisted neck dissection.
METHODS
PubMed (MEDLINE), Embase, and the Cochrane Library were searched. independently by two authors for relevant articles comparing the outcomes of conventional and LSJ-assisted neck dissection. Data from each study were extracted, and a random-effects model was used in the pooled analysis.
RESULTS
Compared with conventional techniques, LSJ-assisted neck dissection was associated with a significantly reduced operative time. The rates of postoperative hematoma, infection, amount of intraoperative blood loss, the length of hospital stay and the drainage amount showed no significant intergroup differences.
CONCLUSIONS
The meta-analysis provides evidence that properly using LSJ may reduce the operative time compared with that of conventional techniques. Surgeons may consider using LSJ in neck dissection according to personal experiences.
Topics: Equipment Design; Head and Neck Neoplasms; Hemostasis, Surgical; Humans; Ligation; Neck Dissection; Operative Time; Postoperative Complications
PubMed: 33781344
DOI: 10.1186/s40463-021-00504-2 -
Plastic and Reconstructive Surgery Jul 2016There is conflicting evidence on the effectiveness of the various strategies to prevent postoperative seroma. Many high-quality studies have been performed to evaluate... (Review)
Review
BACKGROUND
There is conflicting evidence on the effectiveness of the various strategies to prevent postoperative seroma. Many high-quality studies have been performed to evaluate those strategies, but the numbers of patients included in those studies have been small. The authors' goal was to perform a systematic review of all Level I and II studies on the prevention of postoperative seroma.
METHODS
A PubMed search was performed of all Level I and II studies that evaluated strategies for the prevention of postoperative seroma. Only English-language comparative studies on humans, defining seroma as a postoperative serous fluid collection detectable on physical examination, were included. Data from all the studies were compiled, and a systematic review was performed to evaluate the effectiveness of each strategy.
RESULTS
Seventy-five studies comprising 7173 patients were included. Effective strategies for seroma prevention included the use of closed-suction drains; keeping the drains until their output volume was minimal; maintaining a high pressure gradient in the drains; using sharp or ultrasonic dissection rather than cautery; dissecting the abdomen in a place superficial to the Scarpa fascia; ligating blood vessels with sutures or clips; using quilting or progressive tension sutures; using fibrin, thrombin, or talc; and immobilizing the surgical site postoperatively. Surgical-site compression did not prevent seroma accumulation. The use of sclerosants at the initial operation actually increased the risk of seroma.
CONCLUSIONS
Seroma is a common and frustrating complication in plastic surgery. This study demonstrates that simple strategies can be used to lower the risk of seroma.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, II.
Topics: Drainage; Fibrin Tissue Adhesive; Humans; Postoperative Complications; Practice Guidelines as Topic; Plastic Surgery Procedures; Seroma
PubMed: 27348657
DOI: 10.1097/PRS.0000000000002245