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CNS Drugs Sep 2023Although one of the major presentations of vestibular migraine is dizziness with/without unsteady gait, it is still classified as one of the migraine categories.... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Although one of the major presentations of vestibular migraine is dizziness with/without unsteady gait, it is still classified as one of the migraine categories. However, in contrast to ordinary migraine, vestibular migraine patients have distinct characteristics, and the detailed treatment strategy for vestibular migraine is different and more challenging than ordinary migraine treatment. Currently, there is no conclusive evidence regarding its management, including vestibular migraine prophylaxis.
AIM
The objective of this current network meta-analysis (NMA) was to compare the efficacy and acceptability of individual treatment strategies in patients with vestibular migraine.
METHODS
The PubMed, Embase, ScienceDirect, ProQuest, Web of Science, ClinicalKey, Cochrane Central, and ClinicalTrials.gov databases were systematically searched for randomized controlled trials (RCTs), with a final literature search date of 30 December 2022. Patients diagnosed with vestibular migraine were included. The PICO of the current study included (1) patients with vestibular migraine; (2) intervention: any active pharmacologic or non-pharmacologic intervention; (3) comparator: placebo-control, active control, or waiting list; and (4) outcome: changes in migraine frequency or severity. This NMA of RCTs of vestibular migraine treatment was conducted using a frequentist model. We arranged inconsistency and similarity tests to re-examine the assumption of NMA, and also conducted a subgroup analysis focusing on RCTs of pharmacological treatment for vestibular migraine management. The primary outcome was changes in the frequency of vestibular migraines, while the secondary outcomes were changes in vestibular migraine severity and acceptability. Acceptability was set as the dropout rate, which was defined as the participant leaving the study before the end of the trial for any reason. Two authors independently evaluated the risk of bias for each domain using the Cochrane risk-of-bias tool.
RESULTS
Seven randomized controlled trials (N = 828, mean age 37.6 years, 78.4% female) and seven active regimens were included. We determined that only valproic acid (standardized mean difference [SMD] -1.61, 95% confidence interval [CI] -2.69, -0.54), propranolol (SMD -1.36, 95% CI -2.55, -0.17), and venlafaxine (SMD -1.25, 95% CI -2.32, -0.18) were significantly associated with better improvement in vestibular migraine frequency than the placebo/control groups. Furthermore, among all the investigated pharmacologic/non-pharmacologic treatments, valproic acid yielded the greatest decrease in vestibular migraine frequency among all the interventions. In addition, most pharmacologic/non-pharmacologic treatments were associated with similar acceptability (i.e. dropout rate) as those of the placebo/control groups.
CONCLUSIONS
The current study provides evidence that only valproic acid, propranolol, and venlafaxine might be associated with beneficial efficacy in vestibular migraine treatment.
TRIAL REGISTRATION
CRD42023388343.
Topics: Adult; Female; Humans; Male; Migraine Disorders; Network Meta-Analysis; Propranolol; Valproic Acid; Venlafaxine Hydrochloride
PubMed: 37676473
DOI: 10.1007/s40263-023-01037-0 -
European Urology Jul 2023The optimal management for men with prostate cancer (PCa) with unconventional histology (UH) is unknown. The outcome for these cancers might be worse than for...
Impact of Epithelial Histological Types, Subtypes, and Growth Patterns on Oncological Outcomes for Patients with Nonmetastatic Prostate Cancer Treated with Curative Intent: A Systematic Review.
CONTEXT
The optimal management for men with prostate cancer (PCa) with unconventional histology (UH) is unknown. The outcome for these cancers might be worse than for conventional PCa and so different approaches may be needed.
OBJECTIVE
To compare oncological outcomes for conventional and UH PCa in men with localized disease treated with curative intent.
EVIDENCE ACQUISITION
A systematic review adhering to the Referred Reporting Items for Systematic Reviews and Meta-Analyses was prospectively registered on PROSPERO (CRD42022296013) was performed in July 2021.
EVIDENCE SYNTHESIS
We screened 3651 manuscripts and identified 46 eligible studies (reporting on 1 871 814 men with conventional PCa and 6929 men with 10 different PCa UHs). Extraprostatic extension and lymph node metastases, but not positive margin rates, were more common with UH PCa than with conventional tumors. PCa cases with cribriform pattern, intraductal carcinoma, or ductal adenocarcinoma had higher rates of biochemical recurrence and metastases after radical prostatectomy than for conventional PCa cases. Lower cancer-specific survival rates were observed for mixed cribriform/intraductal and cribriform PCa. By contrast, pathological findings and oncological outcomes for mucinous and prostatic intraepithelial neoplasia (PIN)-like PCa were similar to those for conventional PCa. Limitations of this review include low-quality studies, a risk of reporting bias, and a scarcity of studies that included radiotherapy.
CONCLUSIONS
Intraductal, cribriform, and ductal UHs may have worse oncological outcomes than for conventional and mucinous or PIN-like PCa. Alternative treatment approaches need to be evaluated in men with these cancers.
PATIENT SUMMARY
We reviewed the literature to explore whether prostate cancers with unconventional growth patterns behave differently to conventional prostate cancers. We found that some unconventional growth patterns have worse outcomes, so we need to investigate if they need different treatments. Urologists should be aware of these growth patterns and their clinical impact.
Topics: Humans; Male; Prostate; Prostate-Specific Antigen; Prostatectomy; Prostatic Intraepithelial Neoplasia; Prostatic Neoplasms
PubMed: 37117107
DOI: 10.1016/j.eururo.2023.03.014 -
Canadian Family Physician Medecin de... Sep 2023To provide an overview and approach to common nail bed injuries seen by primary care practitioners. (Review)
Review
OBJECTIVE
To provide an overview and approach to common nail bed injuries seen by primary care practitioners.
SOURCES OF INFORMATION
An Ovid MEDLINE literature search was performed using search terms and studies were graded based on level of evidence.
MAIN MESSAGE
Nail trauma is common in primary care practice and requires proper and prompt treatment to avoid lasting effects on finger function and cosmesis. When presented with a fingernail injury, primary care physicians should perform a thorough physical examination to determine extent of injury; take a history to rule out notable risk factors; perform a comprehensive neurovascular examination to assess pulp capillary refill, to do a 2-point discrimination, and to compare with an uninjured digit; and evaluate range of motion. Clinical evaluation may require local anesthesia and a tourniquet. Nail bed trauma can present in different ways and includes subungual hematomas, distal phalanx fractures, Seymour fractures, and-in more severe cases-fragmentation or avulsion of the nail bed. Treatment for subungual hematomas where the nail plate is intact does not require nail plate removal and nail bed exploration; however, exploration and repair are indicated for a nail plate injury, a proximal fracture involving the germinal matrix, and a distal phalanx fracture requiring stabilization.
CONCLUSION
Fingertips are essential to normal hand function. Nail trauma is common and can be managed by primary care physicians. Shared decision making concerning management is based on the mechanism and extent of the injury and aims to prevent secondary deformities.
Topics: Humans; Nails; Physicians, Primary Care; Fractures, Bone; Fingers; Nail Diseases
PubMed: 37704235
DOI: 10.46747/cfp.6909609 -
Journal of Orthopaedic Surgery and... Aug 2023Internal fixation with cephalomedullary nails has been widely used in the treatment of intertrochanteric femoral fractures (IFF). Yet, the difference in efficacy and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Internal fixation with cephalomedullary nails has been widely used in the treatment of intertrochanteric femoral fractures (IFF). Yet, the difference in efficacy and safety between the commonly used integrated dual-screw cephalomedullary nail (InterTAN) and single-screw cephalomedullary nail remains inconclusive. Thus we performed the present systematic review and meta-analysis.
METHODS
Randomized controlled trials (RCTs) or observational studies comparing InterTAN with proximal femoral nail anti-rotation (PFNA), the Asian PFNA (PFNA-II), or the Gamma3 nail in treating IFF were searched on PubMed, EMBASE, Web of Science and Cochrane Library from inception to April 30, 2023. The differences in perioperative parameters and clinical and radiological outcomes were evaluated by mean difference (MD) with 95% confidence interval (95%CI). The risks of various complications and mortality were assessed by risk ratio (RR) with 95%CI.
RESULTS
Twenty-three studies comprising 3566 patients were included. Compared with single-screw cephalomedullary nails (PFNA/PFNA-II, Gamma3), InterTAN conferred significantly reduced risk of implant failures (RR = 0.37, 95%CI 0.26 to 0.51, P < 0.001), hip and thigh pain (RR = 0.70, 95%CI 0.55 to 0.90, P = 0.006) and all-cause revision/reoperation (RR = 0.38, 95%CI 0.26 to 0.57, P < 0.001). Moreover, patients treated with InterTAN had significantly higher 1-year Harris Hip Score (MD = 0.82, 95%CI 0.20-1.44, P = 0.010) and shorter time to union/healing (MD = - 0.66 days, 95%CI - 1.16 to - 0.16, P = 0.009). Femoral neck shortening, time to full bearing, and incidences of non-union, infection, deep venous thrombosis, and mortality were comparable between both groups.
CONCLUSIONS
The integrated dual-screw InterTAN construct has superior performance in reducing risks of complications and improving clinical and functional outcomes in the treatment of IFF. More well-designed, high-quality RCTs are warranted to confirm these findings.
Topics: Humans; Hip Fractures; Femur Neck; Wound Healing; Bone Screws; Femur
PubMed: 37599361
DOI: 10.1186/s13018-023-04103-x -
JBJS Essential Surgical Techniques 2023The all-dorsal scapholunate reconstruction technique is indicated for the treatment of scapholunate injuries in cases in which the carpus is reducible and there is no...
BACKGROUND
The all-dorsal scapholunate reconstruction technique is indicated for the treatment of scapholunate injuries in cases in which the carpus is reducible and there is no arthrosis present. The goal of this procedure is to reconstruct the torn dorsal portion of the scapholunate ligament in order to stabilize the scaphoid and lunate.
DESCRIPTION
A standard dorsal approach to the wrist, extending from the third metacarpal distally to the distal radioulnar joint, is utilized. The extensor pollicis longus is transposed and retracted radially, and the second and fourth extensor compartments are retracted ulnarly. A Berger ligament-sparing capsulotomy is utilized to visualize the carpus. Volarly, an extended open carpal tunnel release is also utilized to relieve any median nerve compression and to aid in reduction. The contents of the carpal tunnel can be retracted radially, allowing for visualization of the carpal bones. Joystick pins are placed in order to reduce the scaphoid and lunate. Reduction is held provisionally by clamping the pins until 4 pins can be placed across the carpal bones. For scapholunate reconstruction, 3 holes are made: in the lunate, proximal scaphoid, and distal scaphoid. Suture tape is then utilized to hold the scaphoid and lunate in their proper position. The dorsal wrist capsule and extensor retinaculum are repaired during closure. The pins are cut near the skin and are removed in 8 to 12 weeks.
ALTERNATIVES
Several other methods of scapholunate reconstruction have been described, including capsulodesis, tenodesis, and bone-tissue-bone repairs. Additionally, in patients who are poor candidates for scapholunate reconstruction, wrist-salvage procedures can be utilized as the primary treatment.
RATIONALE
Scapholunate reconstruction has the advantage of preserving the native physiologic motion of the wrist, in contrast to the many different wrist-salvage procedures that include arthrodesis or arthroplasty. Avoiding arthrodesis is specifically advantageous in patients who have not yet developed arthrosis of the wrist bones.
EXPECTED OUTCOMES
Outcomes of scapholunate reconstruction vary widely; however, there is a nearly universal decrease in range of motion and strength of the wrist. Wrist range of motion is typically 55% to 75% of the contralateral side, and grip strength is typically approximately 65% of the contralateral side. In a prior study, 50% to 60% of patients whose work involved physical labor were able to return to their same level of full-time work. Disabilities of the Arm, Shoulder and Hand scores average between 24 and 30. Specific patients at risk for inferior outcomes are those with delayed surgical treatment, poor carpal alignment following reduction, or open injuries.
IMPORTANT TIPS
Patients are counseled preoperatively regarding the likelihood of permanent wrist stiffness and the possibility of scapholunate diastasis even in the setting of technically successful repair.Traction and dorsally directed pressure on the lunate through an extended carpal tunnel incision can aid in reduction of the lunate.The joystick pin position in the dorsal scaphoid is angulated from distal to proximal and that in the lunate is angulated from proximal to distal in order to help correct flexion of the scaphoid and extension of the lunate by clamping together the Kirschner wires. Modifying the distance of the clamp from the carpus can allow precision in the degree of scapholunate angle fixation.Intercarpal Kirschner wire fixation of the scapholunate, lunotriquetral, and midcarpal joints (scaphocapitate and triquetrohamate) is best performed with 0.062-in (1.6-mm) Kirschner wires. The insertion angle is best visualized when the Kirschner wire is introduced from inside the incision through the skin, "inside out," in order to best envision the trajectory on the dorsal carpus and define the starting point on the bone. The Kirschner wire is then advanced through the carpus from outside-in at a slightly more volarly translated (but not angulated) position. The Kirschner wires are then cut beneath the skin at a depth that will allow them to be retrieved but will not cause them to become exposed once swelling decreases.The wrist is generally immobilized until the pins are removed at 3 months postoperatively.
ACRONYMS AND ABBREVIATIONS
ROM = range of motionK-wire = Kirschner wireDASH = Disabilities of the Arm, Shoulder and HandDISI = dorsal intercarpal ligament instability.
PubMed: 38357468
DOI: 10.2106/JBJS.ST.23.00031 -
Molecular Medicine Reports Sep 2023Glucocorticoid receptor (GR) is expressed in normal renal podocytes; however, its expression differs among renal diseases. The expression of GR as well as its epigenetic...
Glucocorticoid receptor (GR) is expressed in normal renal podocytes; however, its expression differs among renal diseases. The expression of GR as well as its epigenetic regulators microRNA (miR)30a, miR24 and miR370 was studied in the renal tissues of patients with systemic lupus nephritis (LN), minimal changes disease (MCD) and pauci-immune glumeronephritis (PIN). A total of 51 patients undergoing renal biopsy and 22 nephrectomised controls with no history of parenchymal renal disease were recruited from the Clinic of Nephrology and Renal Transplantation of General Laikon hospital between November 2016 and March 2019. All patients were newly-diagnosed and they were naïve of any treatment. The mRNA and protein expression were analyzed through reverse transcription-quantitative PCR and immunohistochemistry respectively. Written consent was obtained from all participants. mRNA expression was significantly reduced in all pathological samples compared with the 'normal' renal tissues used as controls (P=0.023 for LN, P=0.05 for MCD and P=0.004 for PIN). Similarly, GR protein expression was lower in all pathological samples (>6 GR positive podocytes/glomerulus in 50% of patients with LN and MCD and 18% with PIN) compared with controls (>6 positive podocytes/glomerulus in all the controls). PIN samples presented significantly lower mRNA and protein expression compared with LN and MCD samples. No significant differences were observed in the miR30a expression when comparing pathological with 'normal' renal samples. miR24 and miR370 expression demonstrated statistically significant difference in all pathological compared with 'normal' tissues. Moreover, expression was not significantly associated with either LN disease activity score or the response to the treatment. and miR24 expression was significantly reduced whereas miR370 significantly increased in all pathological compared with 'normal' renal tissues implying their protentional role in nephritis pathogenesis and treatment. Analysis of larger samples are required for more robust statistical analysis.
Topics: Humans; Receptors, Glucocorticoid; Kidney; Lupus Nephritis; Nephrosis, Lipoid; MicroRNAs; RNA, Messenger
PubMed: 37477126
DOI: 10.3892/mmr.2023.13056 -
Gels (Basel, Switzerland) Aug 2023Pin site infections arise from the use of percutaneous pinning techniques (as seen in skeletal traction, percutaneous fracture pinning, and external fixation for...
Pin site infections arise from the use of percutaneous pinning techniques (as seen in skeletal traction, percutaneous fracture pinning, and external fixation for fracture stabilization or complex deformity reconstruction). These sites are niduses for infection because the skin barrier is disrupted, allowing for bacteria to enter a previously privileged area. After external fixation, the rate of pin site infections can reach up to 100%. Following pin site infection, the pin may loosen, causing increased pain (increasing narcotic usage) and decreasing the fixation of the fracture or deformity correction construct. More serious complications include osteomyelitis and deep tissue infections. Due to the morbidity and costs associated with its sequelae, strategies to reduce pin site infections are vital. Current strategies for preventing implant-associated infections include coatings with antibiotics, antimicrobial polymers and peptides, silver, and other antiseptics like chlorhexidine and silver-sulfadiazine. Problems facing the development of antimicrobial coatings on orthopedic implants and, specifically, on pins known as Kirschner wires (or K-wires) include poor adhesion of the drug-eluting layer, which is easily removed by shear forces during the implantation. Development of highly adhesive drug-eluting coatings could therefore lead to improved antimicrobial efficacy of these devices and ultimately reduce the burden of pin site infections. In response to this need, we developed two types of gel coatings: synthetic poly-glycidyl methacrylate-based and natural-chitosan-based. Upon drying, these gel coatings showed strong adhesion to pins and remained undamaged after the application of strong shear forces. We also demonstrated that antibiotics can be incorporated into these gels, and a K-wire with such a coating retained antimicrobial efficacy after drilling into and removal from a bone. Such a coating could be invaluable for K-wires and other orthopedic implants that experience strong shear forces during their implantation.
PubMed: 37623093
DOI: 10.3390/gels9080639