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Radiology Sep 2010To report an updated, systematic review of medical literature from January 2003 to July 2008, on endovascular treatment (EVT) of intracranial unruptured aneurysms (UAs)... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To report an updated, systematic review of medical literature from January 2003 to July 2008, on endovascular treatment (EVT) of intracranial unruptured aneurysms (UAs) (a) to assess the morbidity and case fatality rate of EVT of UAs, (b) to understand how bias can affect results, and (c) to estimate the efficacy of EVT by using reported digital subtraction angiographic (DSA) results and clinical follow-up events.
MATERIALS AND METHODS
This article was prepared in accordance with the Meta-Analysis of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The literature was searched by using PubMed and the EMBASE and Cochrane Library databases. Eligibility criteria were (a) explicit procedural mortality and morbidity rates; (b) at least 10 patients; (c) saccular, intradural, nondissecting UAs; (d) original study published in English or French between January 2003 and July 2008; and (e) a methodological quality score higher than 6, according to Strengthening the Reporting of Observational Studies in Epidemiology criteria. End points included procedural mortality and morbidity, defined as a modified Rankin scale score of 3-6 at 1 month, and efficacy, estimated by using immediate and follow-up digital subtraction angiographic results, as well as delayed hemorrhagic events.
RESULTS
Seventy-one studies were included. Procedural unfavorable outcome was found in 4.8% (random-effect weighted average; 189 of 5044) of patients (99% confidence interval [CI]: 3.9%, 6.0%). Immediate angiographic results showed satisfactory occlusion in 86.1% (2660 of 3089) of UAs. Recurrences were shown in 321 (24.4%) of 1316 patients followed up for 0.4-3.2 years. Retreatment was performed in 9.1% (random-effect weighted average; 166 of 1699) of patients (99% CI: 6.2%, 13.1%). The annual risk of bleeding after EVT was 0.2% (random-effect weighted average; nine of 1395) of patients (99% CI: 0.1%, 0.3%), but clinical follow-up was short, limited to the first 6 months for 76.7% (n = 1071) of reported patients.
CONCLUSION
EVT of UAs can be performed with relative safety. The efficacy of treatment as compared with observation has not been rigorously documented.
Topics: Angiography, Digital Subtraction; Cerebral Angiography; Embolization, Therapeutic; Humans; Intracranial Aneurysm; Outcome and Process Assessment, Health Care
PubMed: 20634431
DOI: 10.1148/radiol.10091982 -
Retina (Philadelphia, Pa.) Sep 2018Obstructive sleep apnea (OSA) has been associated with an array of ocular disorders. This systematic review aims to investigate the association of OSA with central... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Obstructive sleep apnea (OSA) has been associated with an array of ocular disorders. This systematic review aims to investigate the association of OSA with central serous chorioretinopathy (CSCR) and subfoveal choroidal thickness changes on enhanced depth imaging optical coherence tomography.
METHODS
Systematic review and meta-analysis of all articles published up to November 2017 examining rate of OSA in patients with CSCR versus controls or examining subfoveal choroidal thickness measurements on enhanced depth imaging optical coherence tomography in patients with OSA versus controls. Pooled odds ratios and weighted mean difference with 95% confidence intervals (CIs) were calculated.
RESULTS
For the CSCR/OSA analysis, 7,238 patients (1,479 with CSCR and 5,759 controls) from 6 studies were eligible. For the choroidal thickness/OSA analysis, 778 eyes of 778 patients (514 with OSA and 264 controls) from 9 studies were eligible. Patients with CSCR had a 1.56 increased odds of having OSA than controls (odds ratio, 1.56; 95% CI, 1.16-2.10). There was no statistically significant difference in choroidal thickness between mild OSA subjects and controls (weighted mean difference = -3.17; 95% CI, -19.10 to 12.76). Patients with moderate OSA (weighted mean difference = -24.14; 95% CI, -42.16 to -6.12) and severe OSA (weighted mean difference = -51.19; 95% CI, -99.30 to -3.08) had thinner choroidal thickness measurements than controls.
CONCLUSION
In summary, our results suggest that patients with CSCR are more likely to have OSA, and that moderate/severe OSA is associated with smaller subfoveal choroidal measurements on enhanced depth imaging optical coherence tomography.
Topics: Central Serous Chorioretinopathy; Choroid; Disease Progression; Fluorescein Angiography; Fundus Oculi; Humans; Prognosis; Sleep Apnea, Obstructive; Tomography, Optical Coherence
PubMed: 29474303
DOI: 10.1097/IAE.0000000000002117 -
Medicina (Kaunas, Lithuania) Jul 2021bedside cardiac ultrasound is a widely adopted method in Emergency Departments (ED) for extending physical examination and refining clinical diagnosis. However, in the... (Review)
Review
bedside cardiac ultrasound is a widely adopted method in Emergency Departments (ED) for extending physical examination and refining clinical diagnosis. However, in the setting of hemodynamically-stable pulmonary embolism, the diagnostic role of echocardiography is still the subject of debate. In light of its high specificity and low sensitivity, some authors suggest that echocardiographic signs of right ventricle overload could be used to rule-in pulmonary embolism. In this study, we aimed to clarify the diagnostic role of echocardiographic signs of right ventricle overload in the setting of hemodynamically-stable pulmonary embolism in the ED. we performed a systematic review of literature in PubMed, Web of Science and Cochrane databases, considering the echocardiographic signs for the diagnosis of pulmonary embolism in the ED. Studies considering unstable or shocked patients were excluded. Papers enrolling hemodynamically stable subjects were selected. We performed a diagnostic test accuracy meta-analysis for each sign, and then performed a critical evaluation according to pretest probability, assessed with Wells' score for pulmonary embolism. 10 studies were finally included. We observed a good specificity and a low sensitivity of each echocardiographic sign of right ventricle overload. However, once stratified by the Wells' score, the post-test probability only increased among high-risk patients. signs of echocardiographic right ventricle overload should not be used to modify the clinical behavior in low- and intermediate- risk patients according to Wells' score classification. Among high-risk patients, however, echocardiographic signs could help a physician in detecting patients with the highest probability of pulmonary embolism, necessitating a confirmation by computed tomography with pulmonary angiography. However, a focused cardiac and thoracic ultrasound investigation is useful for the differential diagnosis of dyspnea and chest pain in the ED.
Topics: Angiography; Echocardiography; Emergency Service, Hospital; Humans; Pulmonary Embolism; Ultrasonography
PubMed: 34440972
DOI: 10.3390/medicina57080766 -
The Journal of Cardiovascular Nursing 2017Guidelines recommend that all non-ST-segment elevation acute coronary syndrome (NSTEACS) patients with high-risk features receive a coronary angiogram. We hypothesised... (Meta-Analysis)
Meta-Analysis Review
Systematic Review and Meta-analyses Investigating Whether Risk Stratification Explains Lower Rates of Coronary Angiography Among Women With Non-ST-Segment Elevation Acute Coronary Syndrome.
BACKGROUND
Guidelines recommend that all non-ST-segment elevation acute coronary syndrome (NSTEACS) patients with high-risk features receive a coronary angiogram. We hypothesised that the widely reported gender disparity in the use of angiography might be the result of women more frequently being stratified into the lower-risk category.
OBJECTIVES
The aim of the study was to review studies reporting risk stratification of NSTEACS patients by gender, compare risk profiles, and assess impact on use of coronary angiography.
METHODS
PubMed, Scopus, and EMBASE databases were searched on June 17, 2014, using MeSH terms/subheadings and/or key words with no further limits. The search revealed 1230 articles, of which 25 met our objective.
RESULTS
Among the 28 risk-stratified populations described in the 25 articles, women were more likely to be stratified as high-risk in 13 studies; men were more likely to be stratified as high-risk in 3 studies. After meta-analyses, women had a 23% higher odds of being stratified as high-risk than did men (P = .001). Lower-risk patients were more likely to receive an angiogram in 15 study populations.
CONCLUSIONS
Contrary to our hypothesis, this review showed that women with NSTEACS are more likely than men to be considered high-risk when stratified using a range of risk assessment methods. Lower rates of angiography in women form part of a broader treatment-risk paradox, which may involve gender bias in the selection of patients for invasive therapy.
Topics: Acute Coronary Syndrome; Coronary Angiography; Female; Humans; Non-ST Elevated Myocardial Infarction; Risk Assessment; Sex Factors
PubMed: 26544171
DOI: 10.1097/JCN.0000000000000300 -
Health Technology Assessment... Dec 2014Age-related macular degeneration is the most common cause of sight impairment in the UK. In neovascular age-related macular degeneration (nAMD), vision worsens rapidly... (Review)
Review
Optical coherence tomography for the diagnosis, monitoring and guiding of treatment for neovascular age-related macular degeneration: a systematic review and economic evaluation.
BACKGROUND
Age-related macular degeneration is the most common cause of sight impairment in the UK. In neovascular age-related macular degeneration (nAMD), vision worsens rapidly (over weeks) due to abnormal blood vessels developing that leak fluid and blood at the macula.
OBJECTIVES
To determine the optimal role of optical coherence tomography (OCT) in diagnosing people newly presenting with suspected nAMD and monitoring those previously diagnosed with the disease.
DATA SOURCES
Databases searched: MEDLINE (1946 to March 2013), MEDLINE In-Process & Other Non-Indexed Citations (March 2013), EMBASE (1988 to March 2013), Biosciences Information Service (1995 to March 2013), Science Citation Index (1995 to March 2013), The Cochrane Library (Issue 2 2013), Database of Abstracts of Reviews of Effects (inception to March 2013), Medion (inception to March 2013), Health Technology Assessment database (inception to March 2013).
REVIEW METHODS
Types of studies: direct/indirect studies reporting diagnostic outcomes.
INDEX TEST
time domain optical coherence tomography (TD-OCT) or spectral domain optical coherence tomography (SD-OCT).
COMPARATORS
clinical evaluation, visual acuity, Amsler grid, colour fundus photographs, infrared reflectance, red-free images/blue reflectance, fundus autofluorescence imaging, indocyanine green angiography, preferential hyperacuity perimetry, microperimetry. Reference standard: fundus fluorescein angiography (FFA). Risk of bias was assessed using quality assessment of diagnostic accuracy studies, version 2. Meta-analysis models were fitted using hierarchical summary receiver operating characteristic curves. A Markov model was developed (65-year-old cohort, nAMD prevalence 70%), with nine strategies for diagnosis and/or monitoring, and cost-utility analysis conducted. NHS and Personal Social Services perspective was adopted. Costs (2011/12 prices) and quality-adjusted life-years (QALYs) were discounted (3.5%). Deterministic and probabilistic sensitivity analyses were performed.
RESULTS
In pooled estimates of diagnostic studies (all TD-OCT), sensitivity and specificity [95% confidence interval (CI)] was 88% (46% to 98%) and 78% (64% to 88%) respectively. For monitoring, the pooled sensitivity and specificity (95% CI) was 85% (72% to 93%) and 48% (30% to 67%) respectively. The FFA for diagnosis and nurse-technician-led monitoring strategy had the lowest cost (£ 39,769; QALYs 10.473) and dominated all others except FFA for diagnosis and ophthalmologist-led monitoring (£ 44,649; QALYs 10.575; incremental cost-effectiveness ratio £ 47,768). The least costly strategy had a 46.4% probability of being cost-effective at £ 30,000 willingness-to-pay threshold.
LIMITATIONS
Very few studies provided sufficient information for inclusion in meta-analyses. Only a few studies reported other tests; for some tests no studies were identified. The modelling was hampered by a lack of data on the diagnostic accuracy of strategies involving several tests.
CONCLUSIONS
Based on a small body of evidence of variable quality, OCT had high sensitivity and moderate specificity for diagnosis, and relatively high sensitivity but low specificity for monitoring. Strategies involving OCT alone for diagnosis and/or monitoring were unlikely to be cost-effective. Further research is required on (i) the performance of SD-OCT compared with FFA, especially for monitoring but also for diagnosis; (ii) the performance of strategies involving combinations/sequences of tests, for diagnosis and monitoring; (iii) the likelihood of active and inactive nAMD becoming inactive or active respectively; and (iv) assessment of treatment-associated utility weights (e.g. decrements), through a preference-based study.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42012001930.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Cost-Benefit Analysis; Fluorescein Angiography; Humans; Macular Degeneration; Models, Econometric; Quality-Adjusted Life Years; Tomography, Optical Coherence; Visual Acuity
PubMed: 25436855
DOI: 10.3310/hta18690 -
Medical Care Mar 2012To examine the relationship between overuse of healthcare services and geographic variations in medical care. (Review)
Review
OBJECTIVE
To examine the relationship between overuse of healthcare services and geographic variations in medical care.
DESIGN
Systematic Review.
DATA SOURCES
Articles published in Medline between 1978, the year of publication of the first framework to measure quality, and January 1, 2009.
STUDY SELECTION
Four investigators screened 114,830 titles and 2 investigators screened all selected abstracts and articles for possible inclusion and extracted all data.
DATA EXTRACTION
We extracted data on rates of overuse in different geographic areas. We also extracted data on underuse, if available, for the same population in which overuse was measured.
RESULTS
Five papers examined the relationship between geographic variations and overuse of healthcare services. One study in 2008 compared the appropriateness of coronary angiography (CA) for acute myocardial infarction in high-cost areas versus low cost areas in the Medicare population and found largely similar rates of inappropriateness (12.2% vs. 16.2%). A study in 2000 using national data concluded that overuse of CA explained little of the geographic variations in the use of this procedure in the Medicare program. An older study of Medicare patients found similar rates of inappropriate use of CA (15% to 17% vs. 18%), endoscopy (15% vs. 18% 19%), and carotid endarterectomy (29% vs. 30%) in low-use and high-use regions. A small area reanalysis of data from this study of 3 procedures found no evidence of a relationship between inappropriate use of procedures and volume in 23 adjacent counties of California. Another 2008 study found that inappropriate chemotherapy for stage I cancer was less common in low-cost areas compared with high-cost areas (3.1% vs. 6.3%).
CONCLUSIONS
The limited available evidence does not lend support to the hypothesis that inappropriate use of procedures is a major source of geographic variations in intensity and/or costs of care. More research is needed to improve our understanding of the relationship between geographic variations and the quality of care.
Topics: Coronary Angiography; Endarterectomy, Carotid; Endoscopy, Gastrointestinal; Geography; Health Care Costs; Health Services Misuse; Humans; Medicare; Quality of Health Care; United States
PubMed: 22329997
DOI: 10.1097/MLR.0b013e3182422b0f -
BMJ Open Feb 2022Distinguishing type 2 (T2MI) from type 1 myocardial infarction (T1MI) in clinical practice can be difficult, and the management and prognosis for T2MI remain uncertain. (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Distinguishing type 2 (T2MI) from type 1 myocardial infarction (T1MI) in clinical practice can be difficult, and the management and prognosis for T2MI remain uncertain.
OBJECTIVE
To compare precipitating factors, risk factors, investigations, management and outcomes for T2MI and T1MI.
DATA SOURCES
Medline and Embase databases as well as reference list of recent articles were searched January 2009 to December 2020 for term 'type 2 myocardial infarction'.
STUDY SELECTION
Studies were included if they used a universal definition of MI and reported quantitative data on at least one variable of interest.
DATA EXTRACTION AND SYNTHESIS
Data were pooled using random-effect meta-analysis. Risk of bias was assessed using Newcastle-Ottawa quality assessment tool. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. All review stages were conducted by two reviewers.
MAIN OUTCOMES AND MEASURES
Risk factors, presenting symptoms, cardiac investigations such as troponin and angiogram, management and outcomes such as mortality.
RESULTS
40 cohort studies comprising 98 930 patients with T1MI and 13 803 patients with T2MI were included. Compared with T1MI, patients with T2MI were: more likely to have pre-existing chronic kidney disease (OR 1.87; 95% CI 1.53 to 2.28) and chronic heart failure (OR 2.35; 95% CI 1.82 to 3.03), less likely to present with typical cardiac symptoms of chest pain (OR 0.19; 95% CI 0.13 to 0.26) and more likely to present with dyspnoea (OR 2.64; 95% CI 1.86 to 3.74); more likely to demonstrate non-specific ST-T wave changes on ECG (OR 2.62; 95% CI 1.81 to 3.79) and less likely to show ST elevation (OR 0.22; 95% CI 0.17 to 0.28); less likely to undergo coronary angiography (OR 0.09; 95% CI 0.06 to 0.12) and percutaneous coronary intervention (OR 0.06; 95% CI 0.04 to 0.10) or receive cardioprotective medications, such as statins (OR 0.25; 95% CI 0.16 to 0.38) and beta-blockers (OR 0.45; 95% CI 0.33 to 0.63). T2MI had greater risk of all cause 1-year mortality (OR 3.11; 95% CI 1.91 to 5.08), with no differences in short-term mortality (OR 1.34; 95% CI 0.63 to 2.85).
CONCLUSION AND RELEVANCE
This review has identified clinical, management and survival differences between T2MI and T1MI with greater precision and scope than previously reported. Differential use of coronary revascularisation and cardioprotective medications highlight ongoing uncertainty of their utility in T2MI compared with T1MI.
Topics: Cohort Studies; Coronary Angiography; Humans; Myocardial Infarction; Percutaneous Coronary Intervention; Prognosis
PubMed: 35177458
DOI: 10.1136/bmjopen-2021-055755 -
Microsurgery Sep 2013Preoperative CT-angiography (CTA) has shown to reduce operative time in deep inferior epigastric perforator (DIEP) flap breast reconstruction compared to Doppler... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Preoperative CT-angiography (CTA) has shown to reduce operative time in deep inferior epigastric perforator (DIEP) flap breast reconstruction compared to Doppler ultrasonography (US). Although decreased flap loss has been suggested, statistical significant reduction remains indeterminate. The purpose of this review is to evaluate flap loss after preoperative CTA and Doppler US in DIEP-flap breast reconstruction.
METHODS
A systematic literature search was performed in MEDLINE, EMBASE, and Cochrane libraries. All articles comparing CTA to Doppler US were selected and critically appraised; data on flap loss were extracted.
RESULTS
From 678 studies, eight were selected for appraisal. Six case-control studies were included in the final analysis. Pooled analysis showed CTA resulted in a significant reduction in partial necrosis (odds ratio/OR 0.15; 95% confidence interval/CI 0.07-0.32, P < 0.0001) and decreased flap loss (OR 0.28; 95% CI 0.10-0.79, P = 0.02).
CONCLUSIONS
Studies included in this meta-analysis have several limitations. However, most studies find a large clinical advantage of CTA over Doppler US, which reaches statistical significance when combined. As results show that CTA prior to DIEP flap breast reconstruction offers significant clinical benefits, we suggest the routine use of preoperative CTA.
Topics: Angiography; Humans; Mammaplasty; Necrosis; Perforator Flap; Preoperative Period; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler; Ultrasonography, Mammary
PubMed: 23836386
DOI: 10.1002/micr.22119 -
The Journal of Vascular Access Jul 2022A comprehensive comparison of available data in terms of vascular complications between distal and conventional transradial access is still partial and a net benefit of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
A comprehensive comparison of available data in terms of vascular complications between distal and conventional transradial access is still partial and a net benefit of such approach has not yet been clearly demonstrated.
OBJECTIVE
To provide an updated comparison of complications between distal and conventional transradial access used to perform coronary angiography and/or percutaneous coronary intervention performing a systematic review and meta-analysis.
DATA SOURCES
Data were obtained searching MEDLINE, Scopus, and Web of Science for all investigations published any time to December 22, 2020 reporting a comparison between distal and conventional transradial access. The occurrence of radial artery occlusion was chosen as the primary outcome while the hematoma at access site and spasm as secondary and tertiary outcome, respectively.
STUDY ELIGIBILITY CRITERIA
Case-control studies comparing distal and conventional transradial access for coronary angiography and/or percutaneous coronary intervention. All studies included adult patients aged at least 18 years.
STUDY APPRAISAL AND SYNTHESIS METHODS
Overall, 7073 patients (mean age 57.9 and 58.4 years for distal and conventional transradial access, respectively), were analyzed. The rate of radial artery occlusion was significantly lower in the distal compared with the conventional group (2.1% vs 4.6%, < 0.001). The pooled analysis, based on a fixed effect model confirmed a lower relative risk of occlusion when distal access is used (RR: 0.46, 95% CI: 0.31-069, = 0.002, = 0%). Conversely, no differences in the risk of developing a hematoma at the access site or in the occurrence of a radial artery spasms were observed comparing the two groups (RR: 0.65, 95% CI: 0.37-1.13, = 0.12, = 0% and RR: 0.88, 95% CI: 0.48-1.63, = 0.001, = 0%, respectively).
LIMITATIONS
Only eight case-control studies met inclusion criteria.
CONCLUSION
This metanalysis confirmed a lower risk of radial artery occlusion using distal access and comparable performance in terms of hematoma, and radial artery spam risk.
Topics: Adolescent; Adult; Arterial Occlusive Diseases; Coronary Angiography; Hematoma; Humans; Middle Aged; Percutaneous Coronary Intervention; Radial Artery
PubMed: 33789519
DOI: 10.1177/11297298211005256 -
Heart & Lung : the Journal of Critical... 2023Computational tomography coronary angiography (CTCA) is increasingly the diagnostic test of choice for investigating patients with stable anginal symptoms. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Computational tomography coronary angiography (CTCA) is increasingly the diagnostic test of choice for investigating patients with stable anginal symptoms.
OBJECTIVES
We sought to conduct a systematic review and meta-analysis comparing CTCA with invasive coronary angiography (ICA) with regards to major adverse cardiovascular events (MACE), procedural complications and rates of revascularisation.
METHODS
We conducted a systematic review and meta-analysis in line with the PRISMA statement. A literature search was conducted using PubMed, MEDLINE Ovid and Embase, with three studies included in meta-analysis. Statistical analysis was undertaken using Review Manager 5.3 for MacOS software and outcomes expressed as odds ratio, with 95% confidence intervals and sensitivity analysis was conducted.
RESULTS
A total of 5662 patients were included in this study level meta-analysis. There was no difference in MACE between CT and angiography [2.97% v 3.45%, fixed-effect model, OR: 0.84 (0.62-1.14), p = 0.26, I 0%] and no difference found in rates of myocardial infarction, death or stroke. CTCA was associated with a reduced rate of revascularisation [12.6% v 18.3%, fixed-effects model, OR: 0.64 (0.55-0.75), p<0.00001, I =0%]. However, CTCA was not associated with a significantly lower complication rate [0.5% v 1.72%, random effects model, OR: 0.52 (0.06-4.38), p = 0.55, I 52%].
CONCLUSION
CTCA is a safe strategy for investigating patients with stable angina with no associated increase in MACE but a reduction in revascularisation rates.
Topics: Humans; Computed Tomography Angiography; Coronary Artery Disease; Coronary Angiography; Myocardial Infarction; Heart
PubMed: 36257218
DOI: 10.1016/j.hrtlng.2022.09.018