-
Integrative Cancer Therapies 2021Branched-chain amino acids (BCAAs; leucine, isoleucine, and valine) are essential amino acids involved in immune responses, and may have roles in protein malnutrition... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Branched-chain amino acids (BCAAs; leucine, isoleucine, and valine) are essential amino acids involved in immune responses, and may have roles in protein malnutrition and sarcopenia. Furthermore, certain liver diseases have been associated with a decreased Fischer's ratio (BCAAs to aromatic amino acids; phenylalanine, tyrosine, and tryptophan). We aimed to evaluate the safety and efficacy of BCAAs use in patients with cancer undergoing surgery.
METHODS
MEDLINE, Embase, and CENTRAL were searched (inception to July 24, 2020) for randomized controlled trials (RCTs) and comparative observational studies in English evaluating BCAAs (alone or in combinations) during the oncological peri-operative period. Study selection, data extraction, and quality appraisal were done in duplicate. RCT risk-of-bias was appraised using Cochrane Risk-of-Bias tool, and observational studies' quality assessment was conducted with Newcastle-Ottawa Scale. Meta-analyses were conducted when appropriate.
RESULTS
20 articles were included comprising 13 RCTs and 6 observational cohort studies in 7 reports and 2019 total participants overall. Among 13 RCTs, 77% involved liver cancer. Methodological study quality scored substantial risk-of-bias across most RCTs. Meta-analysis of RCTs found a 38% decreased risk of post-operative infections in BCAAs group compared to controls (RR = 0.62; 95% CI = 0.44 to 0.87; = .006; number of RCTs, = 6; total sample size, N = 389; = 0%). BCAAs were also found to be beneficial for ascites (RR = 0.55; 95% CI = 0.35 to 0.86; = .008; = 4; N = 296; = 0%), body weight (MD = 3.24 kg; 95% CI = 0.44 to 6.04; = .02; = 3; N = 196; = 24%), and hospitalization length (MD = -2.07 days; 95% CI = -3.97 to -0.17; = .03; = 5; N = 362; = 59%). No differences were found between BCAAs and controls for mortality, recurrence, other post-operative complications (liver failure, edema, pleural effusion), blood loss, quality of life, ammonia level, and prothrombin time. No serious adverse events were related to BCAAs; however, serious adverse events were reported due to intravenous catheters. No safety concerns from observational studies were identified.
CONCLUSIONS
Branched-chain amino acids during the oncological surgical period demonstrated promise in reducing important post-operative morbidity from infections and ascites compared to controls. Blinded, placebo-controlled confirmatory trials of higher methodological quality are warranted, especially using oral, short-term BCAAs-enriched supplements within the context of recent ERAS programs.
PROSPERO REGISTRATION
CRD42018086168.
Topics: Amino Acids, Branched-Chain; Dietary Supplements; Humans; Neoplasm Recurrence, Local; Postoperative Complications; Quality of Life
PubMed: 33648360
DOI: 10.1177/1534735421997551 -
Seizure Feb 2018Although the majority of adult epilepsy patients respond well to the current antiepileptic drug treatment, 20-40% of them are drug-resistant. In these patients,... (Review)
Review
PURPOSE
Although the majority of adult epilepsy patients respond well to the current antiepileptic drug treatment, 20-40% of them are drug-resistant. In these patients, resective epilepsy surgery is a curative treatment option, for which, however, only a limited number of patients is eligible. The purpose is to summarize the outcome of radiotherapy for drug-resistant non-neoplastic focal epilepsy and to elucidate its efficacy for seizure outcome and long-term toxicity in adults.
METHOD
A systematic literature search was performed in Pubmed, Ovid Medline, Cochrane library, Embase and Web of Science. The methodological quality was evaluated using an adapted QUADAS checklist.
RESULTS
Sixteen out of 170 initially identified studies were included in this systematic literature study (n = 170 patients). Twelve of the 16 studies described a positive effect of radiotherapy on seizure frequency reduction, with 98 of the patients (on average 58%, range 25%-95%) reporting no or rare seizures (defined as radiotherapy-adapted Engel class [RAEC] I and II. In total, 20% (34 patients) of the patients needed subsequent surgery due to radionecrosis, cysts formation, edema, and intracranial hypertension or remaining seizures. A dose-effect model was fitted to the available response data in an attempt to derive a relationship between prescribed dose and RAEC frequency.
CONCLUSIONS
Radiotherapy is a possible non-invasive treatment option for patients with drug-resistant focal non-neoplastic epilepsy. This systematic review showed that there is only level 4 evidence of primary radiotherapy reducing seizure frequency in adult patients. Prospective randomized trials are needed to determine its exact value compared to other treatment approaches.
Topics: Adult; Drug Resistant Epilepsy; Epilepsies, Partial; Humans; Radiosurgery; Treatment Outcome
PubMed: 29414140
DOI: 10.1016/j.seizure.2018.01.009 -
The Cochrane Database of Systematic... Apr 2018The combination of steroid and anti-vascular endothelial growth factor (VEGF) intravitreal therapeutic agents could potentially have synergistic effects for treating... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The combination of steroid and anti-vascular endothelial growth factor (VEGF) intravitreal therapeutic agents could potentially have synergistic effects for treating diabetic macular oedema (DMO). On the one hand, if combined treatment is more effective than monotherapy, there would be significant implications for improving patient outcomes. Conversely, if there is no added benefit of combination therapy, then people could be potentially exposed to unnecessary local or systemic side effects.
OBJECTIVES
To assess the effects of intravitreal agents that block vascular endothelial growth factor activity (anti-VEGF agents) plus intravitreal steroids versus monotherapy with macular laser, intravitreal steroids or intravitreal anti-VEGF agents for managing DMO.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 1); Ovid MEDLINE; Ovid Embase; LILACS; the ISRCTN registry; ClinicalTrials.gov and the ICTRP. The date of the search was 21 February 2018.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) of intravitreal anti-VEGF combined with intravitreal steroids versus intravitreal anti-VEGF alone, intravitreal steroids alone or macular laser alone for managing DMO. We included people with DMO of all ages and both sexes. We also included trials where both eyes from one participant received different treatments.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures recommended by Cochrane.Two authors independently reviewed all the titles and abstracts identified from the electronic and manual searches against the inclusion criteria. Our primary outcome was change in best corrected visual acuity (BCVA) between baseline and one year. Secondary outcomes included change in central macular thickness (CMT), economic data and quality of life. We considered adverse effects including intraocular inflammation, raised intraocular pressure (IOP) and development of cataract.
MAIN RESULTS
There were eight RCTs (703 participants, 817 eyes) that met our inclusion criteria with only three studies reporting outcomes at one year. The studies took place in Iran (3), USA (2), Brazil (1), Czech Republic (1) and South Korea (1). Seven studies used the unlicensed anti-VEGF agent bevacizumab and one study used licensed ranibizumab. The study that used licensed ranibizumab had a unique design compared with the other studies in that included eyes had persisting DMO after anti-VEGF monotherapy and received three monthly doses of ranibizumab prior to allocation. The anti-VEGF agent was combined with intravitreal triamcinolone in six studies and with an intravitreal dexamethasone implant in two studies. The comparator group was anti-VEGF alone in all studies; two studies had an additional steroid monotherapy arm, another study had an additional macular laser photocoagulation arm. Whilst we judged these studies to be at low risk of bias for most domains, at least one domain was at unclear risk in all studies.When comparing anti-VEGF/steroid with anti-VEGF monotherapy as primary therapy for DMO, we found no meaningful clinical difference in change in BCVA (mean difference (MD) -2.29 visual acuity (VA) letters, 95% confidence interval (CI) -6.03 to 1.45; 3 RCTs; 188 eyes; low-certainty evidence) or change in CMT (MD 0.20 μm, 95% CI -37.14 to 37.53; 3 RCTs; 188 eyes; low-certainty evidence) at one year. There was very low-certainty evidence on intraocular inflammation from 8 studies, with one event in the anti-VEGF/steroid group (313 eyes) and two events in the anti-VEGF group (322 eyes). There was a greater risk of raised IOP (Peto odds ratio (OR) 8.13, 95% CI 4.67 to 14.16; 635 eyes; 8 RCTs; moderate-certainty evidence) and development of cataract (Peto OR 7.49, 95% CI 2.87 to 19.60; 635 eyes; 8 RCTs; moderate-certainty evidence) in eyes receiving anti-VEGF/steroid compared with anti-VEGF monotherapy. There was low-certainty evidence from one study of an increased risk of systemic adverse events in the anti-VEGF/steroid group compared with the anti-VEGF alone group (Peto OR 1.32, 95% CI 0.61 to 2.86; 103 eyes).One study compared anti-VEGF/steroid versus macular laser therapy. At one year investigators did not report a meaningful difference between the groups in change in BCVA (MD 4.00 VA letters 95% CI -2.70 to 10.70; 80 eyes; low-certainty evidence) or change in CMT (MD -16.00 μm, 95% CI -68.93 to 36.93; 80 eyes; low-certainty evidence). There was very low-certainty evidence suggesting an increased risk of cataract in the anti-VEGF/steroid group compared with the macular laser group (Peto OR 4.58, 95% 0.99 to 21.10, 100 eyes) and an increased risk of elevated IOP in the anti-VEGF/steroid group compared with the macular laser group (Peto OR 9.49, 95% CI 2.86 to 31.51; 100 eyes).One study provided very low-certainty evidence comparing anti-VEGF/steroid versus steroid monotherapy at one year. There was no evidence of a meaningful difference in BCVA between treatments at one year (MD 0 VA letters, 95% CI -6.1 to 6.1, low-certainty evidence). Likewise, there was no meaningful difference in the mean CMT at one year (MD - 9 μm, 95% CI -39.87μm to 21.87μm between the anti-VEGF/steroid group and the steroid group. There was very low-certainty evidence on raised IOP at one year comparing the anti-VEGF/steroid versus steroid groups (Peto OR 0.75, 95% CI 0.16 to 3.55).No included study reported impact of treatment on patients' quality of life or economic data. None of the studies reported any cases of endophthalmitis.
AUTHORS' CONCLUSIONS
Combination of intravitreal anti-VEGF plus intravitreal steroids does not appear to offer additional visual benefit compared with monotherapy for DMO; at present the evidence for this is of low-certainty. There was an increased rate of cataract development and raised intraocular pressure in eyes treated with anti-VEGF plus steroid versus anti-VEGF alone. Patients were exposed to potential side effects of both these agents without reported additional benefit. The majority of the evidence comes from studies of bevacizumab and triamcinolone used as primary therapy for DMO. There is limited evidence from studies using licensed intravitreal anti-VEGF agents plus licensed intravitreal steroid implants with at least one year follow-up. It is not known whether treatment response is different in eyes that are phakic and pseudophakic at baseline.
Topics: Bevacizumab; Dexamethasone; Diabetic Retinopathy; Drug Therapy, Combination; Glucocorticoids; Humans; Intraocular Pressure; Intravitreal Injections; Macula Lutea; Macular Edema; Randomized Controlled Trials as Topic; Ranibizumab; Receptors, Vascular Endothelial Growth Factor; Triamcinolone; Vascular Endothelial Growth Factor A; Visual Acuity
PubMed: 29669176
DOI: 10.1002/14651858.CD011599.pub2 -
Frontiers in Neurology 2021IgA vasculitis/Henoch-Schoenlein purpura (IgAV/HSP) is a systemic small vessel vasculitis of unknown pathogenesis predominantly affecting children. While skin, GI...
Focal Seizures and Posterior Reversible Encephalopathy Syndrome as Presenting Signs of IgA Vasculitis/Henoch-Schoenlein Purpura-An Educative Case and Systematic Review of the Literature.
IgA vasculitis/Henoch-Schoenlein purpura (IgAV/HSP) is a systemic small vessel vasculitis of unknown pathogenesis predominantly affecting children. While skin, GI tract, joints, and kidneys are frequently affected and considered, central nervous system (CNS) involvement of this disease is underestimated. We provide a case report and systematically review the literature on IgAV, collecting data on the spectrum of neurological manifestations. We report on a 7-year-old girl with IgAV who presented with diplopia and afebrile focal seizures, which preceded the onset of purpura. Cranial magnetic resonance imaging was consistent with posterior reversible encephalopathy syndrome (PRES), showing typical focal bilateral parietal swelling and cortical and subcortical high signal intensities on T2-fluid attenuated inversion recovery (FLAIR) images predominantly without diffusion restriction. Cerebrospinal fluid analysis and blood tests excluded systemic inflammation or vasculitis. Interestingly, hypertension was not a hallmark of the developing disease in the initial phase of PRES manifestation. Renal disease and other secondary causes for PRES were also excluded. Supportive- and steroid treatment resulted in restitution . Reviewing the literature, we identified 28 other cases of IgAV with CNS involvement. Severe CNS involvement includes seizures, cerebral edema, or hemorrhage, as well as PRES. Thirteen patients fulfilled all diagnostic criteria of PRES. The mean age was 11.2 years (median 8.0, range 5-42 years), with no reported bias toward gender or ethnic background. Treatment regimens varied from watchful waiting to oral and intravenously steroids up to plasmapheresis. Three cases showed permanent CNS impairment. Collectively, our data demonstrate that (I) severe CNS involvement such as PRES is an underappreciated feature of IgAV, (II) CNS symptoms may precede other features of IgAV, (III) PRES can occur in IgAV, and differentiation from CNS vasculitis is challenging, (IV) pathogenesis of PRES in the context of IgAV remains elusive, which hampers treatment decisions. We, therefore, conclude that clinical awareness and the collection of structured data are necessary to elucidate the pathophysiological connection of IgAV and PRES.
PubMed: 34867743
DOI: 10.3389/fneur.2021.759386 -
Indian Journal of Pharmacology 2021Till now, no meta-analysis is available to address the clinical profile, risk factors, different interventions, and outcomes among COVID-19-associated... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Till now, no meta-analysis is available to address the clinical profile, risk factors, different interventions, and outcomes among COVID-19-associated rhino-orbito-cerebral mucormycosis (C-ROCM) cases.
MATERIALS AND METHODS
Eight literature databases were screened using appropriate keywords from November 1, 2019, to June 30, 2021. The objectives were to analyze the clinical and microbiological profile, risk factor/comorbidity, intervention, and outcome. "R-metafor package" was used for analysis.
RESULTS
A total of 23 studies were included. The mean age of presentation of C-ROCM was 54.6 years. The most common presentation was ptosis (72.7%), lid edema (60.6%), proptosis (60.6%), ophthalmoplegia (57.3%), loss of vision (53.7%), facial edema (34.7%), and nasal-blockage (11.8%). Evidence of intracranial spread was seen in 42.8% of cases. Rhizopus was the most common fungus (57.1%) isolated in fungal culture. Among C-ROCM patients, diabetes was the commonest comorbid condition, and the use of corticosteroids related to COVID-19 treatment was the most common risk factor (85.75%). Compared to controlled diabetics, C-ROCM was significantly higher among uncontrolled diabetics (odds ratio [OR] 0.15, 95% confidence interval [C.I.] 0.041-0.544, P = 0.0010). However, no significant association was seen between C-ROCM and COVID-19 severity (OR 0.930, 95% C.I. 0.212-4.087, P = 0.923). For treatment, amphotericin-B was the most common antifungal drug used which was followed by surgical options. However, mortality was high (prevalence 0.344, 95% C.I. 0.205-0.403) despite treatment.
CONCLUSION
Although local rhino-orbito symptoms were the first to appear, rapid intracranial extension was seen in a significant number of C-ROCM cases. Uncontrolled diabetes and excessive use of corticosteroid were the most common risk factors present among the C-ROCM cases. High index clinical suspicion is imperative (specifically among COVID-19 patients with diabetes), and routine screening may be helpful.
Topics: Amphotericin B; Antifungal Agents; Brain Diseases; COVID-19; Humans; Mucormycosis; Nose Diseases; Orbital Diseases; Regression Analysis; Risk Factors; SARS-CoV-2
PubMed: 34975140
DOI: 10.4103/ijp.ijp_839_21 -
Frontiers in Neurology 2020As not all ischemic stroke patients benefit from currently available treatments, there is considerable need for neuroprotective co-therapies. Therapeutic hypothermia is...
As not all ischemic stroke patients benefit from currently available treatments, there is considerable need for neuroprotective co-therapies. Therapeutic hypothermia is one such co-therapy, but numerous issues have hampered its clinical use (e.g., pneumonia risk with whole-body cooling). Some problems may be avoided with brain-specific methods, such as intra-arterial selective cooling infusion (IA-SCI) into the arteries supplying the ischemic tissue. Our research question was about the efficacy of IA-SCI in animal middle cerebral artery occlusion models. We hypothesized that IA-SCI would be beneficial, but translationally-relevant study elements may be missing (e.g., aged animals). We completed a systematic review of the PubMed database following the PRISMA guidelines on May 21, 2020 for animal studies that administered IA-SCI in the peri-reperfusion period and assessed infarct volume, behavior (primary meta-analytic endpoints), edema, or blood-brain barrier injury (secondary endpoints). Our search terms included: "focal ischemia" and related terms, "IA-SCI" and related terms, and "animal" and related terms. Nineteen studies met inclusion criteria. We adapted a methodological quality scale from 0 to 12 for experimental design assessment (e.g., use of blinding/randomization, sample size calculations). Studies were relatively homogenous (e.g., all studies used young, healthy animals). Some experimental design elements, such as blinding, were common whereas others, such as sample size calculations, were infrequent (median methodological quality score: 5; range: 2-7). Our analyses revealed that IA-SCI provides benefit on all endpoints (mean normalized infarct volume reduction = 23.67%; 95% CI: 19.21-28.12; mean normalized behavioral improvement = 35.56%; 95% CI: 25.91-45.20; mean standardized edema reduction = 0.95; 95% CI: 0.56-1.34). Unfortunately, blood-brain barrier assessments were uncommon and could not be analyzed. However, there was substantial statistical heterogeneity and relatively few studies. Therefore, exploration of heterogeneity meta-regression using saline infusion parameters, study quality, and ischemic duration was inconclusive. Despite convincing evidence of benefit in ischemic stroke models, additional studies are required to determine the scope of benefit, especially when considering additional elements (e.g., dosing characteristics). As there is interest in using this treatment alongside current ischemic stroke therapies, more relevant animal studies will be critical to inform patient studies.
PubMed: 33488495
DOI: 10.3389/fneur.2020.588479 -
European Annals of Otorhinolaryngology,... May 2021There are emerging reports of the effectiveness of in-office awake vocal-fold corticosteroid injection in the treatment of exudative vocal-fold lesions. The aim of this...
OBJECTIVES
There are emerging reports of the effectiveness of in-office awake vocal-fold corticosteroid injection in the treatment of exudative vocal-fold lesions. The aim of this study was to review this therapy and specify indications, practical modalities and outcomes.
STUDY DESIGN
Systematic review of the literature without meta-analysis.
METHODS
A systematic review by PubMed search for the period January 2000 to December 2018 was carried out.
RESULTS
Nine articles were included, for a total of 502 lesions: nodules (46.4%), polyps (31.7%), and Reinke's edema (21.9%). Submucosal injection of low-dose triamcinolone acetonide (0.1 to 0.3mL) was transoral, transcutaneous or transnasal via flexible endoscope with operating channel. Lesion volume was significantly reduced in more than 90% of cases, with significant vocal improvement in all studies. Relapse rates ranged between 4% and 31%, with time to relapse of 1 to 40 months.
CONCLUSIONS
First-line treatment of exudative glottic lesions by submucosal corticosteroid injection provides at least transient significant reduction in lesion volume and vocal improvement. It is consensually reserved to moderate-sized mainly exudative lesions without fibrosis. In-office injection provides an immediate therapeutic response in case of vocal impairment, enabling surgery under general anesthesia to be postponed.
Topics: Adrenal Cortex Hormones; Humans; Laryngeal Edema; Polyps; Vocal Cords
PubMed: 33191161
DOI: 10.1016/j.anorl.2020.09.001 -
Journal of Personalized Medicine Sep 2023The objective of this manuscript was to review the indications, efficacy, and safety of a 585 nm pulsed dye laser (PDL) in non-malignant laryngeal lesions. Following the... (Review)
Review
The objective of this manuscript was to review the indications, efficacy, and safety of a 585 nm pulsed dye laser (PDL) in non-malignant laryngeal lesions. Following the PRISMA statement recommendations, three independent authors searched for articles published in PubMed/MEDLINE, the Cochrane Library, Google Scholar, Scielo, and Web of Science. A bias analysis was performed following NICE guidance tools. From the 506 identified publications, 19 observational studies met the inclusion criteria. The PDL improves vocal quality objectively and subjectively in vascular lesions ( < 0.005) and improves vocal quality in patients with dysplasia/leukoplasia without changing the natural history of the disease compared to other treatments. Reinke's edema and granulomas require an average of 1.5 PDL sessions for resolution. Treatment of recurrent respiratory papillomatosis requires multiple sessions, with complete remission achieved in 50-70% of patients. Regardless of the lesion, the tolerance of the procedure under local anesthesia is exceptional (84-97%), and the results in terms of regression and vocal quality are promising. The complication rate is minimal, and the procedure does not interfere with other treatment alternatives. There is no consensus on laser settings. The lack of consistent use in evaluating vocal outcomes, whether objective or subjective, prevents the comparability between studies. The 585 nm pulsed dye laser appears to be an effective and safe therapeutic option in patients with non-malignant laryngeal pathology. Future controlled studies are needed to compare the 585 nm pulsed dye laser with other lasers or cold instrument procedures.
PubMed: 37763142
DOI: 10.3390/jpm13091374 -
The Cochrane Database of Systematic... Oct 2018Diabetic macular oedema (DMO) is a complication of diabetic retinopathy and one of the most common causes of visual impairment in people with diabetes. Clinically... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Diabetic macular oedema (DMO) is a complication of diabetic retinopathy and one of the most common causes of visual impairment in people with diabetes. Clinically significant macular oedema (CSMO) is the most severe form of DMO. Intravitreal antiangiogenic therapy is now the standard treatment for DMO involving the centre of the macula, but laser photocoagulation is still used in milder or non-central DMO.
OBJECTIVES
To access the efficacy and safety of laser photocoagulation as monotherapy in the treatment of diabetic macular oedema.
SEARCH METHODS
We searched CENTRAL, which contains the Cochrane Eyes and Vision Trials Register; MEDLINE; Embase; LILACS; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 24 July 2018.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) comparing any type of focal/grid macular laser photocoagulation versus another type or technique of laser treatment and no intervention. We did not compare laser versus other interventions as these are covered by other Cochrane Reviews.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. Our primary outcomes were gain or loss of 3 lines (0.3 logMAR or 15 ETDRS letters) of best-corrected visual acuity (BCVA) at one year of follow-up (plus or minus six months) after treatment initiation. Secondary outcomes included final or mean change in BCVA, resolution of macular oedema, central retinal thickness, quality of life and adverse events, all at one year. We graded the certainty of the evidence for each outcome using the GRADE approach.
MAIN RESULTS
We identified 24 studies (4422 eyes). The trials were conducted in Europe (nine studies), USA (seven), Asia (four) and, Africa (one), Latin America (one), Europe-Asian (one) and Oceania (one). The methodological quality of the studies was difficult to assess as they were poorly reported, so the predominant classification of bias was unclear.At one year, people with DMO receiving laser were less likely to lose BCVA compared with no intervention (risk ratio (RR) 0.42, 95% confidence interval (CI) 0.20 to 0.90; 3703 eyes; 4 studies; I = 71%; moderate-certainty evidence). There were also favourable effects observed at two and three years. One study (350 eyes) reported on partial or complete resolution of clinically significant DMO and found moderate-certainty evidence of a benefit at three years with photocoagulation (RR 1.55, 95% CI 1.30 to 1.86). Data on visual improvement, final BCVA, central macular thickness and quality of life were not available. One study related minor adverse effects on the central visual field and another reported one case of iatrogenic premacular fibrosis.Nine studies compared subthreshold versus standard macular photocoagulation (517 eyes). Subthreshold treatment was achieved with different methods of photocoagulation: non-visible conventional (two studies), micropulse (four) or nanopulse (one).Only one small study (29 eyes) reported on improvement or worsening of BCVA and estimates were very imprecise (improvement: RR 0.31, 95% CI 0.01 to 7.09; worsening: RR 0.93, 95% CI 0.15 to 5.76; very low-certainty evidence). All studies reported on continuous BCVA at one year; there was low-certainty evidence of no important difference between subthreshold and standard photocoagulation (mean difference (MD) in logMAR BCVA -0.02, 95% CI -0.07 to 0.03; 385 eyes; 7 studies; I = 42%), and were possibly different for different techniques (P = 0.07 and I = 61.5% for subgroup heterogeneity), with better results achieved with micropulse photocoagulation (MD -0.08 logMAR, 95% CI -0.16 to 0.0) as compared to the results achieved with nanopulse (MD 0.0 logMAR, 95% CI -0.06 to 0.06) and non-visible conventional (MD 0.04 logMAR, 95% CI -0.03 to 0.11), all of them compared to the standard lasers. One study reported partial to complete resolution of macular oedema at one year. There was low-certainty evidence of some benefit with standard photocoagulation, but estimates of effect were imprecise (RR 0.47, 95% CI 0.21 to 1.03; 29 eyes; 1 study). Studies also reported on the change in central macular thickness at one year and found moderate-certainty evidence of no important difference between subthreshold and standard photocoagulation (MD -9.1 μm, 95% CI -26.2 to 8.0; 385 eyes; 7 studies; I = 0%). There were no important adverse effects recorded in the studies.Nine studies compared argon laser versus another type of laser (997 eyes). There was moderate-certainty evidence of a small reduction or no difference between the interventions, with respect to improvement (RR 0.87, 95% CI 0.62 to 1.22; 773 eyes; 6 studies) and worsening of BCVA (RR 0.83, 95% CI 0.57 to 1.21; 773 eyes; 6 studies). Three studies reported few cases of subretinal fibrosis and neovascularization with argon laser and one study found subretinal fibrosis in the krypton group.One study (323 eyes) compared the modified ETDRS (mETDRS) grid technique with the mild macular grid (MMG), which uses mild, widely spaced burns throughout the macula. There was low-certainty evidence of an increased chance of visual improvement with MMG, but the estimate was imprecisely measured and the CIs include an increased risk or decreased risk of visual improvement at one year (RR 1.43, 95% CI 0.56 to 3.65; visual worsening: RR 1.40, 95% CI 0.64 to 3.05; change of logMAR visual acuity: MD -0.04 logMAR, 95% CI -0.01 to 0.09). There was a more significant reduction of central macular thickness with the mETDRS compared to the MMG technique (MD -34.0 µm, -59.8 to -8.3) in the MMG group. The study did not record important adverse effects.
AUTHORS' CONCLUSIONS
Laser photocoagulation reduces the chances of visual loss and increases those of partial to complete resolution of DMO compared to no intervention at one to three years. Subthreshold photocoagulation, particularly the micropulse technique, may be as effective as standard photocoagulation and RCTs are ongoing to assess whether this minimally invasive technique is preferable to treat milder or non-central cases of DMO.
Topics: Diabetic Retinopathy; Humans; Laser Coagulation; Lasers, Gas; Macular Edema; Randomized Controlled Trials as Topic; Treatment Outcome; Visual Acuity
PubMed: 30320466
DOI: 10.1002/14651858.CD010859.pub2 -
Medical Ultrasonography Nov 2019To define and score finger soft tissue oedema in psoriatic dactylitis by ultrasound.
AIM
To define and score finger soft tissue oedema in psoriatic dactylitis by ultrasound.
MATERIAL AND METHODS
A systematic literature review (SLR) on ultrasound-detected finger soft tissue oedema was performed. Subsequently, based on the SLR, a Delphi survey was developed and circulated among a group of 13 expert sonographers, in order to obtain agreement on detection, definition and scoring of finger oedema by B-mode and power Doppler ultrasound. Agreement was considered achieved when each statement was approved by >75% of participants.
RESULTS
At the first Delphi round, 91 % agreement was obtained for the scanning technique to adopt, including the most appropriate area to evaluate. At the second round, 76% agreement was achieved on the definition of soft tissue finger oedema. At the third round, 76% agreement was obtained for B-mode and power Doppler scores. The volar aspect of the finger and comparisons with the contralateral side were agreed to be the most appropriate in terms of scanning technique. Agreed ultrasound definition of finger soft tissue oedema was "abnormal hypoechoic/anechoic areas, diffused or localized within the subcutaneous tissue between the epidermidis and the tendon-related anatomic structures (i.e. flexor tendon sheath, peritenonium, tendon pulleys), with local thickening, with or without local abnormal Doppler signal, visualised in two perpendicular planes and not evident on the contralateral side". Semiquantitative (0-3) scores for both B-mode and power Doppler were agreed to be the most appropriate to be used.
CONCLUSION
Our work produced, for the first time, technical indications, definition and scoring for the ultrasound assessment of soft tissue oedema in psoriatic dactylitis.
Topics: Arthritis, Psoriatic; Edema; Fingers; Humans; Ultrasonography
PubMed: 31765449
DOI: 10.11152/mu-2258