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Minerva Anestesiologica 2023Strategies that blunt noxious stimuli and stabilize hemodynamics may reduce perioperative cardiovascular complications and enhance recovery after craniotomy. (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Strategies that blunt noxious stimuli and stabilize hemodynamics may reduce perioperative cardiovascular complications and enhance recovery after craniotomy.
EVIDENCE ACQUISITION
Our systematic literature review and meta-analysis investigated whether scalp nerve block (SNB) reduces the acute hemodynamic response compared with non-SNB (scalp infiltration or control) in adult patients undergoing elective craniotomy. We searched MEDLINE, EMBASE, CENTRAL, and two Chinese databases for randomized trials. Primary outcomes included mean arterial pressure and heart rate during skull pin insertion and surgical incision in craniotomy. Secondary outcomes included incidence of hypertension and dosage of intraoperative analgesic opioids used. Random-effects models were used for meta-analyses.
EVIDENCE SYNTHESIS
SNB significantly reduced the mean arterial pressure (mean difference: -14.00 mmHg; 95% confidence interval [CI]: -19.71 to -8.28) and heart rate (mean difference: -11.55 beat/min; 95% CI: -19.31 to -3.80), when compared with non-SNB during skull pin insertion. A similar trend was observed during skin incisions (SNB vs. non-SNB, mean difference in mean arterial pressure: -9.46 mmHg; 95% CI: -14.53 to -4.38; mean difference in heart rate: -9.34 beat/min; 95% CI: -15.40 to -3.28). Subgroup analysis showed that, compared with scalp infiltration, SNB reduced mean arterial pressure and heart during pin insertion but not during skin incisions. SNB also reduced the incidence of intraoperative hypertension, but no difference was observed in intraoperative opioid consumption when compared with non-SNB.
CONCLUSIONS
SNB alleviated the craniotomy-associated hemodynamic response. SNB may be superior to scalp infiltration in maintaining hemodynamic stability during pin insertion. However, high-quality trials are still needed to provide more conclusive evidence.
Topics: Adult; Humans; Anesthetics, Local; Scalp; Randomized Controlled Trials as Topic; Hemodynamics; Nerve Block; Craniotomy; Analgesics, Opioid; Hypertension; Pain, Postoperative
PubMed: 36448987
DOI: 10.23736/S0375-9393.22.16775-1 -
Surgical Neurology International 2022Cranial vault lymphomas are rare and their clinical features are often similar to those of cranial vault meningiomas. The objective of this review was to identify the... (Review)
Review
BACKGROUND
Cranial vault lymphomas are rare and their clinical features are often similar to those of cranial vault meningiomas. The objective of this review was to identify the features helpful for differentiating lymphomas of the cranial vault, from meningiomas which were the most common diagnosis before the definitive pathological diagnosis.
METHODS
The inclusion criterion was a histologically proven malignant lymphoma initially appearing in the calvarium. We conducted a literature search of the electronic PubMed and Ichushi-Web databases up to June 1, 2020. Cranial vault lymphoma that was diagnosed after an original diagnosis of lymphoma in a nodal or soft-tissue site was excluded from the study. Descriptive analyses were used to present the patient characteristics.
RESULTS
A total of 111 patients were found in 98 eligible articles. Almost all studies were case reports. The most common symptom was a growing subcutaneous scalp mass (84%) present for a mean duration of 5.9 months before the patient presented for treatment in analyzable cases; this fast growth may distinguish lymphomas from meningiomas. The tumor vascularization was often inconspicuous or poor, unlike well-vascularized meningiomas. A disproportionately small amount of skull destruction compared with the soft-tissue mass was observed in two-thirds of the analyzable cases.
CONCLUSION
This qualitative systematic review identified several features of cranial vault lymphomas that may be useful in differentiating them from meningiomas, including a rapidly growing subcutaneous scalp mass, poor vascularization, and limited skull destruction relative to the size of the soft-tissue mass.
PubMed: 35855149
DOI: 10.25259/SNI_28_2022 -
Journal of Plastic, Reconstructive &... Dec 2021Microtia is a rare disorder characterized by malformation or even complete absence of the auricle. Reconstruction is often performed using autologous costal cartilage...
BACKGROUND
Microtia is a rare disorder characterized by malformation or even complete absence of the auricle. Reconstruction is often performed using autologous costal cartilage (ACC) or porous polyethylene implants (PPE). However, the long-term outcomes of both methods are unclear.
OBJECTIVE
This systematic review aimed to analyze long-term complications and suggest minimal reporting criteria for future original data studies.
METHODS
A systematic literature search was conducted in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials from inception through October 14, 2020. Articles on auricular reconstruction in patients with microtia using ACC or PPE were included provided that the follow-up period was at least one year. This publication focused on long-term complications reported in patients with a postoperative follow-up period of at least one year.
RESULTS
Twenty-nine publications reported on complications during long-term follow-up. Overall long-term complication rates were not reported. The incidence of individual complications during long-term follow-up was less than 10% after ACC reconstruction and less than 15% in PPE reconstruction. Framework resorption and wire exposure were reported even after an extended follow-up of more than five years after ACC reconstruction, while reports on the extended long-term results of PPE reconstruction are limited. Data synthesis was limited due to heterogeneity and poor study quality.
CONCLUSIONS
Future studies should report on long-term complications including framework exposure or extrusion, graft loss, framework resorption, wire exposure and scalp and auricular scar complications. We recommend a surgical follow-up of at least five years.
Topics: Congenital Microtia; Costal Cartilage; Humans; Postoperative Complications; Prostheses and Implants; Plastic Surgery Procedures
PubMed: 34481742
DOI: 10.1016/j.bjps.2021.08.001 -
Plastic and Reconstructive Surgery.... Oct 2016Large complex scalp wounds that have traditionally required free vascularized tissue transfer have been successfully reconstructed with skin substitutes such as Integra....
BACKGROUND
Large complex scalp wounds that have traditionally required free vascularized tissue transfer have been successfully reconstructed with skin substitutes such as Integra. Although there are multiple reports of Integra-based reconstructions of scalp wounds, there has not been a comprehensive assessment of this body of literature that critically examines this method. Our goal was to conduct a systematic review to determine the effectiveness of Integra-based reconstructions of scalp wounds, with emphasis on large defects.
METHODS
A comprehensive systematic review was completed using key search terms, including Integra, dermal regeneration template, bovine collagen, skin substitute, forehead, and scalp. Selected articles reported characteristics of patients and their reconstructions. The primary outcome measures were wound complications and percent graft take.
RESULTS
Thirty-four articles were included in this systematic review. Wound sizes ranged from 5.7 to 610 cm, with 35.3% of articles reporting a mean defect size >100 cm. Thirty-two articles reported mean percent take of skin graft ≥90%. Sixteen articles reported a minor complication. There were no major complications associated with the reconstructions.
CONCLUSIONS
There is a substantial evidence base for the use of Integra to reconstruct scalp wounds. To date, the dermal regeneration template is generally reserved for salvage procedures or when the patient cannot tolerate free tissue transfer. Based on the findings of this systematic review and the authors' clinical experience, Integra can be used to achieve predictable results in large complex scalp defects.
PubMed: 27826471
DOI: 10.1097/GOX.0000000000001074 -
Dermatology and Therapy Jun 2020Cyclosporine is commonly used in treatment for alopecia areata. It can be administered as a monotherapy or in combination with systemic corticosteroids, with various... (Review)
Review
INTRODUCTION
Cyclosporine is commonly used in treatment for alopecia areata. It can be administered as a monotherapy or in combination with systemic corticosteroids, with various outcomes.
METHODS
Efficacy of cyclosporine with and without systemic corticosteroids for alopecia areata was evaluated by a systematic review. Cochrane, EBSCOhost, Pubmed, Scopus and Web of Science databases were searched. Only studies published before January 2020 were included.
RESULTS
A total of 2104 studies were initially examined, of which 14 were eligible for the systematic review. Among 340 reported cases, 213 had focal, multifocal or ophiasis form of alopecia areata, 60 were diagnosed with alopecia totalis and 67 with alopecia universalis. The mean response rate in the whole group of patients at the end of treatment was 65.00% (221/340; range 25-100%). Hair regrowth rate was higher in the group with cases of alopecia areata limited to scalp (124/165; mean 75.15%; range 40-100%) than in the cases with alopecia totalis (30/46; mean 65.22%; range 25-100%) or alopecia universalis (24/52; mean 46.15%; range 25-100%). The combined therapy with systemic corticosteroids was superior to the monotherapy (152/219; mean 69.41%; 0-80% vs. 69/121; mean 57.02%; range 6.67-100%) and had a lower recurrence rate (39/108; mean 36.11% vs. 34/46; mean 73.91%, respectively). The combined treatment with methylprednisolone was significantly more effective when compared to the cyclosporine monotherapy (124/183; mean 67.76%; range 0-80% vs. 69/121; mean 57.02%; range 6.67-100%). The mean time of treatment was 6.75 months (range 2-36).
LIMITATIONS
Limitations of our study were the retrospective character of included studies, differences in doses of prescribed drugs, and duration of the treatment and follow-up times.
CONCLUSION
Cyclosporine in combination with oral systemic corticosteroids is more effective than in monotherapy for severe alopecia areata.
PubMed: 32270396
DOI: 10.1007/s13555-020-00370-2 -
Frontiers in Neuroscience 2023Delirium is an acute alteration of consciousness marked by confusion, inattention, and changes in cognition. Some speculate that delirium may be a disorder of functional... (Review)
Review
OBJECTIVE
Delirium is an acute alteration of consciousness marked by confusion, inattention, and changes in cognition. Some speculate that delirium may be a disorder of functional connectivity, but the requirement to lay still may limit measurement with existing functional imaging modalities in this population. Electroencephalography (EEG) may allow for a more feasible approach to the study of potential connectivity disturbances in delirium. We conducted a systematic review to investigate whether there are EEG-measurable differences in brain functional connectivity in the resting state associated with delirium.
METHODS
Medline, PubMed, PsychInfo, Embase and CINAHL were searched for relevant articles containing original data studying EEG functional connectivity measures in delirium.
RESULTS
The search yielded 1,516 records. Following strict inclusion criteria, four studies were included in the review. The studies used a variety of EEG measures including phase lag index, coherence, entropy, shortest path length, minimum spanning tree, and network clustering coefficients to study functional connectivity between scalp electrodes. Across connectivity measures, delirium was associated with decreased brain functional connectivity. All four studies found decreased alpha band connectivity for patients with delirium. None of the studies directly compared the different motor subtypes of delirium.
SIGNIFICANCE
This systematic review provides converging evidence for disturbances in oscillatory-based functional connectivity in delirium.
PubMed: 38033553
DOI: 10.3389/fnins.2023.1274837 -
The Cochrane Database of Systematic... Mar 2019Electroconvulsive therapy (ECT) involves the induction of a seizure by the administration of an electrical stimulus via electrodes usually placed bilaterally on the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Electroconvulsive therapy (ECT) involves the induction of a seizure by the administration of an electrical stimulus via electrodes usually placed bilaterally on the scalp and was introduced as a treatment for schizophrenia in 1938. However, ECT is a controversial treatment with concerns about long-term side effects such a memory loss. Therefore, it is important to determine its clinical efficacy and safety for people with schizophrenia who are not responding to their treatment.
OBJECTIVES
Our primary objective was to assess the effects (benefits and harms) of ECT for people with treatment-resistant schizophrenia.Our secondary objectives were to determine whether ECT produces a differential response in people: who are treated with unilateral compared to bilateral ECT; who have had a long (more than 12 sessions) or a short course of ECT; who are given continuation or maintenance ECT; who are diagnosed with well-defined treatment-resistant schizophrenia as opposed to less rigorously defined treatment-resistant schizophrenia (who would be expected to have a greater affective component to their illness).
SEARCH METHODS
We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials including clinical trial registries on 9 September 2015 and 4 August 2017. There were no limitations on language, date, document type, or publication status for the inclusion of records in the register. We also inspected references of all the included records to identify further relevant studies.
SELECTION CRITERIA
Randomised controlled trials investigating the effects of ECT in people with treatment-resistant schizophrenia.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data. For binary outcomes, we calculated the risk ratio (RR) and its 95% confidence intervals (CIs), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between the groups and its 95% CIs. We employed the fixed-effect model for all analyses. We assessed risk of bias for the included studies and created 'Summary of findings' tables using the GRADE framework.
MAIN RESULTS
We included 15 studies involving 1285 participants (1264 completers with an average age of 18 to 46 years) with treatment-resistant schizophrenia. We rated most studies (14/15, 93.3%) as at high risk of bias due to issues related to the blinding of participants and personnel. Our main outcomes of interest were: (i) clinically important response to treatment; (ii) clinically important change in cognitive functioning; (iii) leaving the study early; (iv) clinically important change in general mental state; (v) clinically important change in general functioning; (vi) number hospitalised; and (vii) death. No trial reported data on death.The included trials reported useable data for four comparisons: ECT plus standard care compared with sham-ECT added to standard care; ECT plus standard care compared with antipsychotic added to standard care; ECT plus standard care compared with standard care; and ECT alone compared with antipsychotic alone.For the comparison ECT plus standard care versus sham-ECT plus standard care, only average endpoint BPRS (Brief Psychiatric Rating Scale) scores from one study were available for mental state; no clear difference between groups was observed (short term; MD 3.60, 95% CI -3.69 to 10.89; participants = 25; studies = 1; very low-quality evidence). One study reported data for service use, measured as number readmitted; there was a clear difference favouring the ECT group (short term; RR 0.29, 95% CI 0.10 to 0.85; participants = 25; studies = 1; low-quality evidence).When ECT plus standard care was compared with antipsychotics (clozapine) plus standard care, data from one study showed no clear difference for clinically important response to treatment (medium term; RR 1.23, 95% CI 0.95 to 1.58; participants = 162; studies = 1; low-quality evidence). Clinically important change in mental state data were not available, but average endpoint BPRS scores were reported. A positive effect for the ECT group was found (short-term BPRS; MD -5.20, 95% CI -7.93 to -2.47; participants = 162; studies = 1; very low-quality evidence).When ECT plus standard care was compared with standard care, more participants in the ECT group had a clinically important response (medium term; RR 2.06, 95% CI 1.75 to 2.42; participants = 819; studies = 9; moderate-quality evidence). Data on clinically important change in cognitive functioning were not available, but data for memory deterioration were reported. Results showed that adding ECT to standard care may increase the risk of memory deterioration (short term; RR 27.00, 95% CI 1.67 to 437.68; participants = 72; studies = 1; very low-quality evidence). There were no clear differences between groups in satisfaction and acceptability of treatment, measured as leaving the study early (medium term; RR 1.18, 95% CI 0.38 to 3.63; participants = 354; studies = 3; very low-quality evidence). Only average endpoint scale scores were available for mental state (BPRS) and general functioning (Global Assessment of Functioning). There were clear differences in scores, favouring ECT group for mental state (medium term; MD -11.18, 95% CI -12.61 to -9.76; participants = 345; studies = 2; low-quality evidence) and general functioning (medium term; MD 10.66, 95% CI 6.98 to 14.34; participants = 97; studies = 2; very low-quality evidence).For the comparison ECT alone versus antipsychotics (flupenthixol) alone, only average endpoint scale scores were available for mental state and general functioning. Mental state scores were similar between groups (medium-term BPRS; MD -0.93, 95% CI -6.95 to 5.09; participants = 30; studies = 1; very low-quality evidence); general functioning scores were also similar between groups (medium-term Global Assessment of Functioning; MD -0.66, 95% CI -3.60 to 2.28; participants = 30; studies = 1; very low-quality evidence).
AUTHORS' CONCLUSIONS
Moderate-quality evidence indicates that relative to standard care, ECT has a positive effect on medium-term clinical response for people with treatment-resistant schizophrenia. However, there is no clear and convincing advantage or disadvantage for adding ECT to standard care for other outcomes. The available evidence was also too weak to indicate whether adding ECT to standard care is superior or inferior to adding sham-ECT or other antipsychotics to standard care, and there was insufficient evidence to support or refute the use of ECT alone. More good-quality evidence is needed before firm conclusions can be made.
Topics: Adult; Antipsychotic Agents; Brief Psychiatric Rating Scale; Electroconvulsive Therapy; Female; Flupenthixol; Humans; Male; Memory Disorders; Patient Readmission; Piperazines; Randomized Controlled Trials as Topic; Schizophrenia; Standard of Care; Thiazoles; Treatment Outcome
PubMed: 30888709
DOI: 10.1002/14651858.CD011847.pub2 -
Cureus Jun 2020Scalp defects with exposed calvaria that have previously been irradiated present a unique reconstructive challenge. Patients with previously radiated scalp defects often...
Scalp defects with exposed calvaria that have previously been irradiated present a unique reconstructive challenge. Patients with previously radiated scalp defects often have few reconstructive options due to poor health or personal choice. The aim of this study was to evaluate the results of non-operative management for patients with prior radiotherapy to the scalp who developed exposed calvaria. The outcomes of interest were major and minor complications related to exposed calvaria with a time frame of follow-up of greater than one year or death from any cause. A retrospective chart review was performed to identify patients with prior radiotherapy and surgery for skin cancer to the scalp who subsequently developed exposed calvaria. Data from four surgeons from 2008 to 2019 was collected. Next, a systematic review of PubMed, EMBASE, Cochrane Library, and CINAHL was conducted to identify articles in which non-operative management was utilized for exposed calvaria post-radiotherapy. Nineteen patients were identified who received radiotherapy either before developing recurrent malignancy requiring operation or requiring radiation postoperatively because of close or involved margins and who subsequently developed exposed calvaria. Six of these patients had an additional attempt at local flap or skin grafting that failed. All patients had an American Society of Anesthesiologists score of three or four. All were managed with local wound care. Ten patients had near-complete healing with wound care alone. Eight patients are still alive from one to six years after the presentation. One patient, who remains alive, developed an intracranial abscess requiring long-term antibiotics but was medically compromised by concomitant myelodysplastic syndrome, mantle cell lymphoma on chemotherapy, atrial fibrillation on anticoagulation, and heart failure. Three patients developed new malignancies requiring re-operation with watchful waiting. Two of the three cases resulted in failure to control disease, but control of malignancy occurred in one case with resection of recurrent cancer and exposed bone. The systematic review of the literature yielded three studies that met the inclusion criteria. None of the studies encountered cases of meningitis, encephalitis, or death due to the non-operative treatment of exposed calvaria post radiation. Coverage of the calvaria with well-vascularized tissue is the reconstructive goal in the majority of circumstances. This case series and systematic review found that non-operative management of exposed calvaria post-radiotherapy can be an option for patients who are either not candidates for aggressive surgical treatment or who refuse surgery.
PubMed: 32714689
DOI: 10.7759/cureus.8751 -
Frontiers in Oncology 2022Primary intracranial ependymomas (IE) are rare brain tumors rarely metastasizing outside the central nervous system. We systematically reviewed the literature on...
BACKGROUND
Primary intracranial ependymomas (IE) are rare brain tumors rarely metastasizing outside the central nervous system. We systematically reviewed the literature on extra-neural metastases from primary IEs.
METHODS
PubMed, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA guidelines to include studies of extra-neural metastases from primary IEs. Clinical features, management strategies, and survival were analyzed.
RESULTS
We collected 48 patients from 43 studies. Median age was 13 years (range, 2-65). Primary IEs were frequently located in the parietal (22.9%) and frontal (16.7%) lobes, and mostly treated with resection (95.8%) and/or radiotherapy (62.5%). Most IEs were of grade-III (79.1%), and few of grade-I (6.3%) or grade-II (14.6%). 45 patients experienced intracranial recurrences, mostly treated with resection (86.7%), radiotherapy (60%), and/or chemotherapy (24.4%). Median time-interval from primary IEs was 28 months (range, 0-140). Most extra-neural metastases were diagnosed at imaging (37.5%) or autopsy (35.4%). Extra-neural metastases were multifocal in 38 patients (79.1%), mostly involving cervical or hilar lymph-nodes (66.7%), lung/pleura (47.9%), and/or scalp (29.1%). Surgical resection (31.3%), chemotherapy (31.3%) and locoregional radiotherapy (18.8%) were the most common treatments for extra-neural metastases, but 28 (58.3%) patients were not treated. At last follow-up, 37 patients died with median overall-survivals from primary IEs of 36 months (range, 1-239), and from extra-neural metastases of 3 months (range, 0.1-36). Overall-survival was significantly longer in patients with grade-I and II IEs (P=0.040).
CONCLUSION
Extra-neural metastases from primary IEs are rare, but mostly occur at later disease stages. Multidisciplinary management strategies should be intended mostly for palliation.
PubMed: 35574408
DOI: 10.3389/fonc.2022.831016 -
Annals of Translational Medicine Dec 2022This study used a network meta-analysis to evaluate the efficacy of various different acupuncture types and language rehabilitation training on post-stroke dysarthria...
The treatment of post-stroke dysarthria with a combination of different acupuncture types and language rehabilitation training: a systematic review and network meta-analysis.
BACKGROUND
This study used a network meta-analysis to evaluate the efficacy of various different acupuncture types and language rehabilitation training on post-stroke dysarthria (PSD), and examined the possible mechanisms involved. There are often clinical studies comparing the effects of different acupuncture methods on dysarthria after stroke. The efficacy of these methods can be ranked by network meta-analysis. This is necessary for clinical acupoints selection. The results of this study illustrated the comparison of the therapeutic effects of 6 different acupuncture types, which can provide some reference for clinical acupoints selection and research.
METHODS
A comprehensive search for clinical studies related to the use of acupuncture to treat PSD was conducted in eight English and Chinese databases. Patients were divided into six groups based on the acupoints selected, namely, tongue, neck, scalp, body, combination, and traditional acupuncture. The recovery of neurological function in the patients was assessed based on the curative impact and the National Institutes of Health Stroke Scale (NIHSS) score. The quality of the included studies was evaluated using the Cochrane risk bias assessment tool and the STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) criteria. A network meta-analysis was performed using the network-meta package of Stata 15.1 software based on frequency. The heterogeneity test, consistency test, head-to-head mixed comparison, efficacy ranking, and publication bias study were all performed.
RESULTS
A total of 47 studies were finally included. There was a total of 4,197 patients in the eligible studies. The model for network meta-analysis proved robust, with minimal heterogeneity and high consistency. Combined acupuncture combined with language rehabilitation training was the most effective in treating dysarthria symptoms, followed by tongue acupuncture (TA) and nape acupuncture (NA). In addition, the combined effect of acupuncture and language training was superior to that of acupuncture alone. In terms of recovery of nerve function, traditional acupuncture and body acupuncture were more effective. To facilitate the recovery of nerve function, increasing the frequency of acupoints is necessary.
CONCLUSIONS
Combined acupuncture may have the most beneficial healing effect on PSD, followed by acupuncture of the tongue and the nape of the neck. In terms of recovery of nerve function, traditional acupuncture and body acupuncture may have more effective.
PubMed: 36618810
DOI: 10.21037/atm-22-5583