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Scandinavian Journal of Pain Jan 2018Treatment of pain following major limb amputations is often a clinical challenge in a patient population consisting mainly of elderly with underlying diseases....
BACKGROUND AND AIMS
Treatment of pain following major limb amputations is often a clinical challenge in a patient population consisting mainly of elderly with underlying diseases. Literature on management of acute post-amputation pain is scarce. We performed a systematic review on this topic to evaluate the efficacy and safety of analgesic interventions for acute pain following major limb amputation.
METHODS
A literature search was performed in PubMed, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews using the following key words: [(amputation) AND (pain OR analgesi* OR pain relief)] AND (acute OR postoperative). Randomized controlled studies (RCTs) and observational studies investigating treatment of acute pain following major amputations for any indication (peripheral vascular disease, malignant disease, trauma) were included. The review was performed according to the standards described in the PRISMA statement. The Cochrane quality assessment tool was used to evaluate the risk of bias in the RCTs.
RESULTS
Nineteen studies with total of 949 patients were included. The studies were generally small and heterogeneous on outcomes, study designs and quality. There were 16 studies on epidural or continuous perineural analgesia (CPI). Based on five RCTs (n=268) and two observational studies (n=49), epidural analgesia decreased the intensity of acute stump pain as compared to systemic analgesics, during the first 24 h after the operation. Based on one study epidural analgesia caused more adverse effects like sedation, nausea and motor block than continuous perineural local anesthetic infusion. Based on one RCT (n=21) and eight observational studies (n=501) CPI seemed to decrease opioid consumption as compared to systemic analgesics only, on the first three postoperative days, and was well tolerated. Only three trials investigated systemic analgesics (oral memantine, oral gabapentine, iv ketamine). Ketamine did not decrease acute pain or opioid consumption after amputation as compared to other systemic analgesics. Gabapentin did not decrease acute pain when combined to epidural analgesia as compared to epidural analgesia and opioid treatment, and caused adverse effects.
CONCLUSIONS
The main finding of this systematic review is that evidence regarding pain management after major limb amputation is very limited. Epidural analgesia may be effective, but firm evidence is lacking. Epidural causes more adverse effects than CPI. The results on efficacy of CPI are indecisive. The data on adjuvant medications combined to epidural analgesia or CPI is limited. Studies on efficacy and adverse effects of systemic analgesics for amputation pain, especially concentrating on elderly patients, are needed.
Topics: Acute Pain; Amputation, Surgical; Analgesia, Epidural; Analgesics; Chemotherapy, Adjuvant; Humans; Pain Management; Pain, Postoperative
PubMed: 29794290
DOI: 10.1515/sjpain-2017-0170 -
British Journal of Anaesthesia Feb 2017Dexmedetomidine has been proposed as a perineural local anaesthetic (LA) adjunct to prolong peripheral nerve block duration; however, results from our previous... (Meta-Analysis)
Meta-Analysis Review
Evidence basis for using perineural dexmedetomidine to enhance the quality of brachial plexus nerve blocks: a systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Dexmedetomidine has been proposed as a perineural local anaesthetic (LA) adjunct to prolong peripheral nerve block duration; however, results from our previous meta-analysis in the setting of brachial plexus block (BPB) did not support its use. Many additional randomized trials have since been published. We thus conducted an updated meta-analysis.
METHODS
Randomized trials investigating the addition of dexmedetomidine to LA compared with LA alone (Control) in BPB for upper extremity surgery were sought. Sensory and motor block duration, onset times, duration of analgesia, analgesic consumption, pain severity, patient satisfaction, and dexmedetomidine-related side-effects were analysed using random-effects modeling. We used ratio-of-means (lower confidence interval [point estimate]) for continuous outcomes.
RESULTS
We identified 32 trials (2007 patients), and found that dexmedetomidine prolonged sensory block (at least 57%, P < 0.0001), motor block (at least 58%, P < 0.0001), and analgesia (at least 63%, P < 0.0001) duration. Dexmedetomidine expedited onset for both sensory (at least 40%, P < 0.0001) and motor (at least 39%, P < 0.0001) blocks. Dexmedetomidine also reduced postoperative oral morphine consumption by 10.2mg [-15.3, -5.2] (P < 0.0001), improved pain control, and enhanced satisfaction. In contrast, dexmedetomidine increased odds of bradycardia (3.3 [0.8, 13.5](P = 0.0002)), and hypotension (5.4 [2.7, 11.0] (P < 0.0001)). A 50-60µg dexmedetomidine dose maximized sensory block duration while minimizing haemodynamic side-effects. No patients experienced any neurologic sequelae. Evidence quality for sensory block was high according to the GRADE system.
CONCLUSIONS
New evidence now indicates that perineural dexmedetomidine improves BPB onset, quality, and analgesia. However, these benefits should be weighed against increased risks of motor block prolongation and transient bradycardia and hypotension.
Topics: Anesthetics, Local; Brachial Plexus Block; Dexmedetomidine; Humans; Randomized Controlled Trials as Topic
PubMed: 28100520
DOI: 10.1093/bja/aew411 -
Annals of Surgical Oncology Jul 2024Improved systemic therapy has made long term (≥ 5 years) overall survival (LTS) after resection of pancreatic ductal adenocarcinoma (PDAC) increasingly common.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Improved systemic therapy has made long term (≥ 5 years) overall survival (LTS) after resection of pancreatic ductal adenocarcinoma (PDAC) increasingly common. However, a systematic review on predictors of LTS following resection of PDAC is lacking.
METHODS
The PubMed, Embase, Scopus, and Cochrane CENTRAL databases were systematically searched from inception until March 2023. Studies reporting actual survival data (based on follow-up and not survival analysis estimates) on factors associated with LTS were included. Meta-analyses were conducted by using a random effects model, and study quality was gauged by using the Newcastle-Ottawa Scale (NOS).
RESULTS
Twenty-five studies with 27,091 patients (LTS: 2,132, non-LTS: 24,959) who underwent surgical resection for PDAC were meta-analyzed. The median proportion of LTS patients was 18.32% (IQR 12.97-21.18%) based on 20 studies. Predictors for LTS included sex, body mass index (BMI), preoperative levels of CA19-9, CEA, and albumin, neutrophil-lymphocyte ratio, tumor grade, AJCC stage, lymphovascular and perineural invasion, pathologic T-stage, nodal disease, metastatic disease, margin status, adjuvant therapy, vascular resection, operative time, operative blood loss, and perioperative blood transfusion. Most articles received a "good" NOS assessment, indicating an acceptable risk of bias.
CONCLUSIONS
Our meta-analysis pools all true follow up data in the literature to quantify associations between prognostic factors and LTS after resection of PDAC. While there appears to be evidence of a complex interplay between risk, tumor biology, patient characteristics, and management related factors, no single parameter can predict LTS after the resection of PDAC.
Topics: Humans; Carcinoma, Pancreatic Ductal; Pancreatic Neoplasms; Survival Rate; Prognosis; Pancreatectomy
PubMed: 38710910
DOI: 10.1245/s10434-024-15281-1 -
Cancer Diagnosis & Prognosis 2022To systematically review the patient characteristics and management approaches of adenoid cystic carcinoma (ACC) infiltrating the skull base. (Review)
Review
BACKGROUND/AIM
To systematically review the patient characteristics and management approaches of adenoid cystic carcinoma (ACC) infiltrating the skull base.
MATERIALS AND METHODS
According to PRISMA guidelines, PubMed, Scopus, and Cochrane were searched to retrieve studies reporting management protocols and survival outcomes of patients with skull base ACCs. Patient characteristics, management strategies, and outcomes were investigated.
RESULTS
The review encompassed 17 studies involving 171 patients, with a female predominance (57.9%) and a mean age of 49±7.12 years. ACCs mostly infiltrated the paranasal sinus (22.2%), cavernous sinus (8.8%), and nasopharynx (7.1%). Perineural invasion was reported in 6.4% of cases. Facial pain, nasal obstruction, and facial paresthesia were the most common symptoms. Surgical resection (45.6%) was favored over biopsy (12.2%). Employing the free flap technique (4.7%), surgical reconstruction of the bony defect after resection was performed using abdominal and anterior thigh muscle grafts in 1.8% of patients each. As adjuvant management, 22.8% of cases had radiotherapy and 14.6% received chemotherapy. Recurrence of skull base ACCs occurred in 26.9% of cases during a mean follow up-time of 30.8±1.8 months.
CONCLUSION
Skull base ACCs pose a surgical challenge mainly due to their proximity to critical neurovascular structures and aggressive behavior. Surgical resection and radiotherapy are shown to be safe and effective treatment modalities. The dismal prognosis and limited data on non-surgical strategies highlight the need for further evaluation of the current management paradigm and upraising innovative therapies to improve patient mortality and quality of life.
PubMed: 36060029
DOI: 10.21873/cdp.10134 -
PloS One 2020In this study, we sought to identify the potential impacts of disease characteristics on the prognosis of cutaneous squamous cell carcinoma (cSCC). We searched the... (Meta-Analysis)
Meta-Analysis
In this study, we sought to identify the potential impacts of disease characteristics on the prognosis of cutaneous squamous cell carcinoma (cSCC). We searched the PubMed, EmBase, and Cochrane Library databases from their inception until February 2020 to identify studies that investigated the prognosis of cSCC. The pooled effect estimates were applied using odds ratios (OR) and 95% confidence intervals (CI) and were calculated using the random-effects model. Forty-three studies including a total of 21,530 patients and reporting 28,627 cases of cSCC were selected for the final meta-analysis. Poor differentiation (OR, 3.54; 95% CI, 2.30-5.46; P < 0.001), perineural invasion (OR, 3.27; 95% CI, 1.60-6.67; P = 0.001), Breslow greater than 2 mm (OR, 5.47; 95% CI, 2.63-11.37; P < 0.001), diameter greater than 20 mm (OR, 4.62; 95% CI, 2.95-7.23; P < 0.001), and location on temple (OR, 3.20; 95% CI, 1.12-9.15; P = 0.030) were associated with an increased risk of recurrence, whereas immunosuppression status and location on cheek, ear, or lip were not associated with the risk of recurrence. Poor differentiation (OR, 6.82; 95% CI, 4.66-9.99; P < 0.001); perineural invasion (OR, 7.15; 95% CI, 4.73-10.83; P < 0.001); Breslow greater than 2 mm (OR, 6.11; 95% CI, 4.05-9.21; P < 0.001); diameter greater than 20 mm (OR, 5.01; 95% CI, 2.56-9.80; P < 0.001); and location on ear (OR, 2.38; 95% CI, 1.39-4.09; P = 0.002), lip (OR, 2.15; 95% CI, 1.26-3.68; P = 0.005), and temple (OR, 2.77; 95% CI, 1.20-6.40; P = 0.017) were associated with an increased risk of metastasis, whereas immunosuppression status and location on cheek did not affect the risk of metastasis. Finally, poor differentiation (OR, 5.97; 95% CI, 1.82-19.62; P = 0.003), perineural invasion (OR, 6.64; 95% CI, 3.63-12.12; P < 0.001), and Breslow greater than 2 mm (OR, 3.42; 95% CI, 1.76-6.66; P < 0.001) were associated with an increased risk of disease-specific death, whereas diameter; immunosuppression status; and location on ear, lip, and temple did not affect the risk of disease-specific death. We found that differentiation, perineural invasion, depth, diameter, and location could affect the prognosis of cSCC. The potential role of other patient characteristics on the prognosis of cSCC should be identified in further large-scale prospective studies.
Topics: Head and Neck Neoplasms; Humans; Immunosuppression Therapy; Prognosis; Risk Factors; Skin Neoplasms; Squamous Cell Carcinoma of Head and Neck
PubMed: 32991600
DOI: 10.1371/journal.pone.0239586 -
BMC Urology Feb 2018Although numerous studies have shown that perineural invasion (PNI) is linked to prostate cancer (PCa) risk, the results have been inconsistent. This study aimed to... (Meta-Analysis)
Meta-Analysis Review
Perineural invasion as an independent predictor of biochemical recurrence in prostate cancer following radical prostatectomy or radiotherapy: a systematic review and meta-analysis.
BACKGROUND
Although numerous studies have shown that perineural invasion (PNI) is linked to prostate cancer (PCa) risk, the results have been inconsistent. This study aimed to explore the association between PNI and biochemical recurrence (BCR) in patients with PCa following radical prostatectomy (RP) or radiotherapy (RT).
METHODS
According to the PRISMA statement, we searched the PubMed, EMBASE, Chinese National Knowledge Infrastructure (CNKI) and Wan Fang databases from inception to May 2017. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were extracted from eligible studies. Fixed or random effects model were used to calculate pooled HRs and 95% CIs according to heterogeneity. Publication bias was calculated by Begg's test.
RESULTS
Ultimately, 19 cohort studies that met the eligibility criteria and that involved 13,412 patients (82-2,316 per study) were included in this meta-analysis. The results showed that PNI was associated with higher BCR rates in patients with PCa after RP (HR=1.23, 95% CI: 1.11, 1.36, p<0.001) or RT (HR=1.22, 95% CI: 1.12, 1.34, p<0.001). No potential publication bias was found among the included studies in the RP group (p-Begg = 0.124) or the RT group (p-Begg = 0.081).
CONCLUSIONS
This study suggests that the presence of PNI by histopathology is associated with higher risk of BCR in PCa following RP or RT, and could serve as an independent prognostic factor in patients with PCa.
Topics: Humans; Male; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Peripheral Nerves; Predictive Value of Tests; Prostatectomy; Prostatic Neoplasms
PubMed: 29390991
DOI: 10.1186/s12894-018-0319-6 -
Frontiers in Oncology 2021A significant number of recently published research has outlined the contribution of perineural invasion (PNI) to clinical outcomes in oral tongue squamous cell...
OBJECTIVES
A significant number of recently published research has outlined the contribution of perineural invasion (PNI) to clinical outcomes in oral tongue squamous cell carcinoma (OTSCC), but some results remain conflicting. This study aimed to determine whether patients with OTSCC with PNI have a worse prognosis than those without PNI.
MATERIALS AND METHODS
PubMed, Embase, and the Cochrane Library were queried for potentially eligible articles published up to December 2020. The primary outcomes were the hazard ratio (HR) for locoregional recurrence, overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS). The random-effect model was used in all analyses.
RESULTS
Seventeen studies (4445 patients) were included. Using adjusted HRs, the presence of PNI was associated with a higher risk of locoregional recurrence (HR=1.73, 95%CI: 1.07-2.79, P=0.025, I = 33.1%, P=0.224), worse OS (HR=1.94, 95%CI: 1.39-2.72, P<0.001, I = 0.0%, P=0.838), worse DFS (HR=2.13, 95%CI: 1.53-2.96, P<0.001, I = 48.4%, P=0.071), and worse CSS (HR=1.93, 95%CI: 1.40-2.65, P<0.001, I = 25.5%, P=0.251). PNI had an impact on locoregional recurrence in early-stage OTSCC but not in all stages, and on OS, DFS, and CSS in all-stage and early-stage OTSCC. The sensitivity analyses showed that the results were robust.
CONCLUSION
The presence of PNI significantly affects the locoregional recurrence and survival outcomes among patients with OTSCC.
PubMed: 34322385
DOI: 10.3389/fonc.2021.683825 -
Scientific Reports Mar 2022Colorectal cancer remains a significant cause of morbidity and mortality, even despite curative treatment. A significant proportion of patients present emergently and... (Meta-Analysis)
Meta-Analysis
Colorectal cancer remains a significant cause of morbidity and mortality, even despite curative treatment. A significant proportion of patients present emergently and have poorer outcomes compared to elective presentations, independent of TNM stage. In this systematic review and meta-analysis, differences between elective/emergency presentations of colorectal cancer were examined to determine which factors were associated with emergency presentation. A literature search was carried out from 1990 to 2018 comparing elective and emergency presentations of colon and/or rectal cancer. All reported clinicopathological variables were extracted from identified studies. Variables were analysed through either systematic review or, if appropriate, meta-analysis. This study identified multiple differences between elective and emergency presentations of colorectal cancer. On meta-analysis, emergency presentations were associated with more advanced tumour stage, both overall (OR 2.05) and T/N/M/ subclassification (OR 2.56/1.59/1.75), more: lymphovascular invasion (OR 1.76), vascular invasion (OR 1.92), perineural invasion (OR 1.89), and ASA (OR 1.83). Emergencies were more likely to be of ethnic minority (OR 1.58). There are multiple tumour/host factors that differ between elective and emergency presentations of colorectal cancer. Further work is required to determine which of these factors are independently associated with emergency presentation and subsequently which factors have the most significant effect on outcomes.
Topics: Colorectal Neoplasms; Emergencies; Ethnicity; Humans; Minority Groups; Rectal Neoplasms
PubMed: 35288664
DOI: 10.1038/s41598-022-08447-y -
Endocrine Jan 2020There are no clear histopathological parameters determining the risk of lymph node (LN) metastases and appropriateness of completion prophylactic right hemicolectomy... (Meta-Analysis)
Meta-Analysis
The risk of lymph node metastases and their impact on survival in patients with appendiceal neuroendocrine neoplasms: a systematic review and meta-analysis of adult and paediatric patients.
BACKGROUND
There are no clear histopathological parameters determining the risk of lymph node (LN) metastases and appropriateness of completion prophylactic right hemicolectomy (RHC) in patients with appendiceal neuroendocrine neoplasms (ANENs).
MATERIALS AND METHODS
The PubMed, Cochrane Library, Embase, Web of Science and SCOPUS databases were searched up to November 2018. Quality/risk of bias was assessed using the Newcastle-Ottawa Scale (NOS).
RESULTS
A total of 526 articles were screened. In 11 adult and 3 paediatric studies, 602 and 77 unique patients, respectively, with ANEN and undergoing RHC, were included. The rate of LN metastases for a cutoff size >10 mm was 48.6% (vs 12.1% for lesions <10 mm) among adult patients, with an odds ratio (OR) of 4.8 (95% CI, 1.5-15.8). For 20 mm size cutoff, these figures were 61% (vs 28.2% for lesions <20 mm) with an OR of 3.2 (95% CI, 1.3-7.8). Vascular-, lymph vessel- and perineural invasions were identified as predictive factors for LN metastases in adult patients. In paediatric patients, there were no strong morphological predictors for LN metastases. The 10-year disease-specific survival (DSS) for adult patients without LN metastases was 99.2% vs 95.6% in patients with LN (OR: 0.2; 95% CI, 0.02-2.4). The complication rate of prophylactic RHC was 11.4%.
CONCLUSIONS
This meta-analysis demonstrates that tumour size >20 mm as well as >10 mm and/or vascular-, lymph vessel- and perineural invasions are associated with increased risk for LN metastases in adult patients with ANEN. The prognostic value of LN positivity remains to be determined in further studies with long-term follow-up.
Topics: Adult; Appendiceal Neoplasms; Child; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Neuroendocrine Tumors; Prognosis; Retrospective Studies
PubMed: 31493274
DOI: 10.1007/s12020-019-02072-y -
Medicina Oral, Patologia Oral Y Cirugia... May 2022This study aimed to analyze whether immunohistochemistry (IHC) is more sensitive than hematoxylin-eosin (H&E) staining for identifying perineural invasion (PNI) or... (Meta-Analysis)
Meta-Analysis
Is immunohistochemistry more sensitive than hematoxylin-eosin staining for identifying perineural or lymphovascular invasion in oral squamous cell carcinoma? A systematic review and meta-analysis.
BACKGROUND
This study aimed to analyze whether immunohistochemistry (IHC) is more sensitive than hematoxylin-eosin (H&E) staining for identifying perineural invasion (PNI) or lymphovascular invasion (LVI) in oral squamous cell carcinoma (OSCC).
MATERIAL AND METHODS
In this systematic review and meta-analysis (Prospective Register of Systematic Reviews - CRD 42021256515), data were obtained from six databases (PubMed, Scopus, LILACS, Web of Science, EBSCO, LIVIVO, Embase) and the grey literature. Cross-sectional observational studies of the diagnostic sensitivity of IHC for PNI and LVI were included. Studies were selected in two phases: first collection and reference retrieval. The Quality Assessment of Diagnostic Accuracy Studies-2 tool assessed study quality, while the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach assessed evidence quality. The meta-analysis (random effects model) was performed using MedCalc 18.2.1 software (MedCalc®) (p<0.05).
RESULTS
Four studies (560 patients with 295 biopsies) were analyzed. The combined sensitivity was 76% (95% confidence interval [CI], 44.30-97.19%) and specificity was 42% (95% CI, 23.40-62.02%). The positive predictive value (PPV) and negative predictive value (NPV) were 61% (95% CI, 49.78-71.53%) and 70% (95% CI, 37.63-94.43%). The overall accuracy was 58% (95% CI, 45.17-70.65%). The risk of bias was low, and GRADE analysis showed a very low certainty of evidence.
CONCLUSIONS
Our data suggest that IHC staining to highlight PNI/LVI may be useful in cases in which H&E analysis results in a negative decrease in the prevalence of false-negative cases and underestimated treatment.
Topics: Carcinoma, Squamous Cell; Cross-Sectional Studies; Eosine Yellowish-(YS); Head and Neck Neoplasms; Hematoxylin; Humans; Immunohistochemistry; Lymphatic Metastasis; Mouth Neoplasms; Neoplasm Invasiveness; Squamous Cell Carcinoma of Head and Neck; Staining and Labeling
PubMed: 35420066
DOI: 10.4317/medoral.25114