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Journal of Cardiothoracic and Vascular... Jun 2018This study was planned to pool existing data on outcome and to evaluate the efficacy of postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) in... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This study was planned to pool existing data on outcome and to evaluate the efficacy of postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adult patients.
DESIGN
Systematic review of the literature and meta-analysis.
SETTING
Multi-institutional study.
PARTICIPANTS
Adult patients with acute heart failure immediately after cardiac surgery.
INTERVENTIONS
VA-ECMO after cardiac surgery. Studies evaluating only heart transplant patients were excluded from this analysis.
MEASUREMENTS AND MAIN RESULTS
A literature search was performed to identify studies published since 2000. Thirty-one studies reported on 2,986 patients (mean age, 58.1 years) who required postcardiotomy VA-ECMO. The weaning rate from VA-ECMO was 59.5% and hospital survival was 36.1% (95% CI 31.5-40.8). The pooled rate of reoperation for bleeding was 42.9%, major neurological event 11.3%, lower limb ischemia 10.8%, deep sternal wound infection/mediastinitis 14.7%, and renal replacement therapy 47.1%. The pooled mean number of transfused red blood cell units was 17.7 (95% CI 13.3-22.1). The mean stay in the intensive care unit was 13.3 days (95% CI 10.2-16.4). Survivors were significantly younger (mean, 55.7 v 63.6 years, p = 0.015) and their blood lactate level before starting VA-ECMO was lower (mean, 7.7 v 10.7 mmol/L, p = 0.028) than patients who died. One-year survival rate was 30.9% (95% CI 24.3-37.5).
CONCLUSIONS
Pooled data showed that VA-ECMO may salvage one-third of patients unresponsive to any other resuscitative treatment after adult cardiac surgery.
Topics: Adult; Cardiac Surgical Procedures; Extracorporeal Membrane Oxygenation; Heart Failure; Humans; Postoperative Complications; Survival Rate; Treatment Outcome
PubMed: 29158060
DOI: 10.1053/j.jvca.2017.08.048 -
JAMA Apr 2014The association between red blood cell (RBC) transfusion strategies and health care-associated infection is not fully understood. (Meta-Analysis)
Meta-Analysis Review
IMPORTANCE
The association between red blood cell (RBC) transfusion strategies and health care-associated infection is not fully understood.
OBJECTIVE
To evaluate whether RBC transfusion thresholds are associated with the risk of infection and whether risk is independent of leukocyte reduction.
DATA SOURCES
MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cochrane Database of Sytematic Reviews, ClinicalTrials.gov, International Clinical Trials Registry, and the International Standard Randomized Controlled Trial Number register were searched through January 22, 2014.
STUDY SELECTION
Randomized clinical trials with restrictive vs liberal RBC transfusion strategies.
DATA EXTRACTION AND SYNTHESIS
Twenty-one randomized trials with 8735 patients met eligibility criteria, of which 18 trials (n = 7593 patients) contained sufficient information for meta-analyses. DerSimonian and Laird random-effects models were used to report pooled risk ratios. Absolute risks of infection were calculated using the profile likelihood random-effects method.
MAIN OUTCOMES AND MEASURES
Incidence of health care-associated infection such as pneumonia, mediastinitis, wound infection, and sepsis.
RESULTS
The pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I2 = 0%; τ2 <.0001). The number needed to treat (NNT) with restrictive strategies to prevent serious infection was 38 (95% CI, 24-122). The risk of infection remained reduced with a restrictive strategy, even with leukocyte reduction (RR, 0.80 [95% CI, 0.67-0.95]). For trials with a restrictive hemoglobin threshold of <7.0 g/dL, the RR was 0.82 (95% CI, 0.70-0.97) with NNT of 20 (95% CI, 12-133). With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery and 0.51 (95% CI, 0.28-0.95) in patients presenting with sepsis. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight.
CONCLUSIONS AND RELEVANCE
Among hospitalized patients, a restrictive RBC transfusion strategy was associated with a reduced risk of health care-associated infection compared with a liberal transfusion strategy. Implementing restrictive strategies may have the potential to lower the incidence of health care-associated infection.
Topics: Cross Infection; Erythrocyte Transfusion; Humans; Mediastinitis; Pneumonia; Randomized Controlled Trials as Topic; Risk; Sepsis; Surgical Wound Infection
PubMed: 24691607
DOI: 10.1001/jama.2014.2726 -
Respiratory Investigation Jul 2020Sarcoidosis is a multisystemic granulomatous disorder of unknown etiology. Diagnosis of sarcoidosis is made by correlating clinical and radiological features along with...
Sarcoidosis is a multisystemic granulomatous disorder of unknown etiology. Diagnosis of sarcoidosis is made by correlating clinical and radiological features along with the histopathological demonstration of non-necrotizing granulomas in tissue samples. Diagnosis is often challenging as the clinical profile may mimic other granulomatous disorders, including infections, inflammatory diseases, and lymphoid malignancies. Differentiation from tuberculosis is especially crucial in endemic regions where exclusion of mediastinal tuberculosis is necessary before any immunosuppressant treatment can be initiated for symptomatic sarcoidosis. Identification of biomarkers, which can aid in diagnosis as well as prognosis, can be helpful in clinical decision making. MicroRNAs are small non-coding regulatory RNAs that serve as post-transcriptional regulators of gene expression and have been studied as emerging biomarkers in many other respiratory diseases, including lung cancer, asthma, idiopathic pulmonary fibrosis, and chronic obstructive pulmonary disease. In the context of sarcoidosis, miRNA expression has been studied in the lungs, lymph nodes, bronchoalveolar lavage fluid, and peripheral blood mononuclear cells. A comprehensive search of the PubMed database was performed by two authors independently, and relevant studies were retrieved for review. This systematic review summarizes the current information on miRNAs in sarcoidosis, the biological mechanisms involved in CD4 T-helper 1 and macrophage polarization, and the use of exhaled breath condensate as an alternative, noninvasive and potential source of miRNAs.
Topics: Biomarkers; Breath Tests; Bronchoalveolar Lavage Fluid; CD4-Positive T-Lymphocytes; Diagnosis, Differential; Gene Expression; Humans; Leukocytes, Mononuclear; Lung; Lymph Nodes; Macrophages; MicroRNAs; Sarcoidosis, Pulmonary; T-Lymphocytes, Helper-Inducer
PubMed: 32305227
DOI: 10.1016/j.resinv.2020.02.008 -
Canadian Journal of Anaesthesia =... Mar 2009This systematic review aimed to evaluate the efficacy and safety of topical application of antifibrinolytic drugs to reduce postoperative bleeding and transfusion... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
This systematic review aimed to evaluate the efficacy and safety of topical application of antifibrinolytic drugs to reduce postoperative bleeding and transfusion requirements in patients undergoing on-pump cardiac surgery.
METHODS
We searched The Cochrane Library, MEDLINE, EMBASE and SCI-EXPANDED for all randomized controlled trials on the topic. Trial inclusion, quality assessment, and data extraction were performed independently by two authors. Standard meta-analytic techniques were applied.
RESULTS
Eight trials (n = 622 patients) met our inclusion criteria. The medication/placebo was applied into the pericardial cavity and/or mediastinum at the end of cardiac surgery. Seven trials compared antifibrinolytic agents (aprotinin or tranexamic acid) versus placebo. They showed that, on average, topical use of antifibrinolytic agents reduced the amount of 24-h postoperative chest tube (blood) loss by 220 ml (95% confidence interval: -318 to -126, P < 0.00001, I (2) = 93%) and resulted in a saving of 1 unit of allogeneic red blood cells per patient (95% confidence interval: -1.54 to -0.53, P < 0.0001, I (2) = 55%). The incidence of blood transfusion was not significantly changed following topical application of the medications. One study comparing topical versus intravenous administration of aprotinin found comparable results between the two methods of administration for the above-mentioned outcomes. No adverse effects were reported following topical use of the medications.
CONCLUSION
This review suggests that topical application of antifibrinolytics can reduce postoperative bleeding and transfusion requirements in patients undergoing on-pump cardiac surgery. These promising findings need to be confirmed by more trials with large sample size using patient-related outcomes and more assessments regarding the systemic absorption of the medications.
Topics: Administration, Topical; Aged; Antifibrinolytic Agents; Aprotinin; Blood Loss, Surgical; Blood Transfusion; Clinical Trials as Topic; Coronary Artery Bypass; Female; Hemostatics; Humans; Male; Middle Aged; Randomized Controlled Trials as Topic; Research Design; Tranexamic Acid; Treatment Outcome
PubMed: 19247741
DOI: 10.1007/s12630-008-9038-x -
The Cochrane Database of Systematic... Oct 2007The nature and indications for thyroid surgery vary and a perceived risk of haemorrhage post-surgery is one reason why wound drains are frequently inserted. However when... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The nature and indications for thyroid surgery vary and a perceived risk of haemorrhage post-surgery is one reason why wound drains are frequently inserted. However when a significant bleed occurs, wound drains may become blocked and the drain does not obviate the need for surgery or meticulous haemostasis. The evidence in support of the use of drains post-thyroid surgery is unclear therefore and a systematic review of the best available evidence was undertaken.
OBJECTIVES
To determine the effects of inserting a wound drain during thyroid surgery, on wound complications, respiratory complications and mortality.
SEARCH STRATEGY
We searched the following databases: Cochrane Wounds Group Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2007); MEDLINE (2005 to February 2007); EMBASE (2005 to February 2007); CINAHL (2005 to February 2007) using relevant search strategies.
SELECTION CRITERIA
Only randomised controlled trials were eligible for inclusion. Quasi randomised studies were excluded. Studies with participants undergoing any form of thyroid surgery, irrespective of indications, were eligible for inclusion in this review. Studies involving people undergoing parathyroid surgery and lateral neck dissections were excluded. At least 80% follow up (till discharge) was considered essential.
DATA COLLECTION AND ANALYSIS
Studies were assessed for eligibility and data were extracted by two authors independently, differences were resolved by discussion. Studies were assessed for validity including criteria on whether they used a robust method of random sequence generation and allocation concealment. Missing and unclear data were resolved by contacting the study authors.
MAIN RESULTS
13 eligible studies were identified (1646 participants). 11 studies compared drainage with no drainage and found no significant difference in re-operation rates; incidence of respiratory distress and wound infections. Post-operative wound collections needing aspiration or drainage were significantly reduced by drains (RR 0.51, 95% CI 0.27 to 0.97), but a further analysis of the 4 high quality studies showed no significant difference (RR 1.82, 95% CI 0.51 to 6.46). Hospital stay was significantly prolonged in the drain group (WMD 1.18 days, 95% CI 0.73 to 1.63).Eleven studies compared suction drain with no drainage and found no significant difference in re-operation rates; incidence of respiratory distress and wound infection rates. The incidence of collections that required aspiration or drainage without formal re-operation was significantly less in the drained group (RR 0.48, 95% CI 0.25 to 0.92). However, further analysis of only high quality studies showed no significant difference (RR 1.78, 95% CI 0.44 to 7.17). Hospital stay was significantly prolonged in the drain group (WMD 1.20 days, 95% CI 0.77 to 1.63). One study compared open drain with no drain. No participant in either group required re-operation. No data were available regarding the incidence of respiratory distress, wound infection and pain. The incidence of collections needing aspiration or drainage without re-operation was not significantly different between the groups and there was no significant difference in length of hospital stay. One study compared suction drainage with passive closed drainage. None of the participants in the study needed re-operation and data regarding other outcomes were not available. Two studies (180 participants) compared open drainage with suction drainage. One study reported wound infections and minor wound collections, both were not significantly different. The other study reported wound collections requiring intervention and hospital stay; both were not significantly different. None of the participants in either study required re-operation. Data regarding other outcomes were not available.
AUTHORS' CONCLUSIONS
There is no clear evidence that using drains in patients undergoing thyroid operations significantly improves patient outcomes and drains may be associated with an increased length of hospital stay. The existing evidence is from trials involving patients having goitres without mediastinal extension, normal coagulation indices and the operation not involving any lateral neck dissection for lymphadenectomy.
Topics: Drainage; Hematoma; Humans; Length of Stay; Pain, Postoperative; Postoperative Hemorrhage; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Seroma; Surgical Wound Infection; Thyroid Diseases; Thyroidectomy
PubMed: 17943885
DOI: 10.1002/14651858.CD006099.pub2 -
Florence Nightingale Journal of Nursing Oct 2022Blood product administration is a vital and possibly life-threatening issue that may increase the risk of clinical damage in patients. This review aims to provide a...
AIM
Blood product administration is a vital and possibly life-threatening issue that may increase the risk of clinical damage in patients. This review aims to provide a comprehensive review of the ways to improve blood transfusion safety.
METHOD
In order to conduct this systematic review, electronic databases, including PubMed/MEDLINE, EMBASE, Web of Science, Cochrane CENTRAL, Scopus, and Google Scholar, were searched for data of the last 30 years using keywords including patient safety, blood transfusion, risk management, safety management, and transfusion reaction. The inclusion criteria set for the selection of quantitative articles were articles written in English and published in peer-reviewed journals during the mentioned period. In this study the publications are reviewed in line with the PRISMA guide checklist.
RESULTS
Among 6105 articles found during the initial search, 16 articles were finalized for further investigation. Fifty percent of the included articles discussed the use of modern technology including patient identification system, barcode technology, portable computer systems, and databases. Moreover, 31% of the studies evaluated the use of alternative methods for transfusion of blood products including mediastinal blood transfusion, the use of autologous blood in adult patients, the use of cord blood in children, the use of hemoglobin-based oxygen carrier-201, and the injection of fresh whole blood. About 18% of articles drew attention to indications and thresholds as an essential factor increasing patient safety.
CONCLUSION
It was concluded from this study that the use of technology leads to fewer human errors and complications caused by these errors. In addition, some alternative methods can be used in a cost-effective way to reduce serious adverse events caused by common strategies.
PubMed: 36106812
DOI: 10.5152/FNJN.2022.21214 -
Blood Transfusion = Trasfusione Del... Jan 2017Deep sternal wound infection and bleeding are devastating complications following cardiac surgery, which may be reduced by topical application of autologous platelet... (Meta-Analysis)
Meta-Analysis Review
Deep sternal wound infection and bleeding are devastating complications following cardiac surgery, which may be reduced by topical application of autologous platelet gel. Systematic review identified seven comparative studies involving 4,692 patients. Meta-analysis showed significant reductions in all sternal wound infections (odds ratio 3.48 [1.08-11.23], p=0.04) and mediastinitis (odds ratio 2.69 [1.20-6.06], p=0.02) but not bleeding. No adverse events relating to the use of topical platelet-rich plasma were reported. The use of autologous platelet gel in cardiac surgery appears to provide significant reductions in serious sternal wound infections, and its use is unlikely to be associated with significant risk.
Topics: Cardiac Surgical Procedures; Humans; Platelet-Rich Plasma; Sternum; Surgical Wound Infection; Treatment Outcome; Wound Healing
PubMed: 27177403
DOI: 10.2450/2016.0231-15 -
Journal of Cardiothoracic Surgery Oct 2020The standard for clinical staging of lung cancer is the use of CT and PET scans, however, these may underestimate the burden of the disease. The use of serum tumor... (Meta-Analysis)
Meta-Analysis
Elevated preoperative CEA is associated with subclinical nodal involvement and worse survival in stage I non-small cell lung cancer: a systematic review and meta-analysis.
BACKGROUND
The standard for clinical staging of lung cancer is the use of CT and PET scans, however, these may underestimate the burden of the disease. The use of serum tumor markers might aid in the detection of subclinical advanced disease. The aim of this study is to review the predictive value of tumor markers in patients with clinical stage I NSCLC.
METHODS
A comprehensive search was performed using the Medline, EMBASE, Scopus data bases. Abstracts included based on the following inclusion criteria: 1) adult ≥18 years old, 2) clinical stage I NSCLC, 3) Tumor markers (CEA, SCC, CYFRA 21-1), 4) further imaging or procedure, 5) > 5 patients, 6) articles in English language. The primary outcome of interest was utility of tumour markers for predicting nodal involvement and oncologic outcomes in patients with clinical stage I NSCLC. Secondary outcomes included sub-type of lung cancer, procedure performed, and follow-up duration.
RESULTS
Two hundred seventy articles were screened, 86 studies received full-text assessment for eligibility. Of those, 12 studies were included. Total of 4666 patients were involved. All studies had used CEA, while less than 50% used CYFRA 21-1 or SCC. The most common tumor sub-type was adenocarcinoma, and the most frequently performed procedure was lobectomy. Meta-analysis revealed that higher CEA level is associated with higher rates of lymph node involvement and higher mortality.
CONCLUSION
There is significant correlation between the CEA level and both nodal involvement and survival. Higher serum CEA is associated with advanced stage, and poor prognosis. Measuring preoperative CEA in patient with early stage NSCLC might help to identify patients with more advanced disease which is not detected by CT scans, and potentially identify candidates for invasive mediastinal lymph node staging, helping to select the most effective therapy for patients with potentially subclinical nodal disease. Further prospective studies are needed to standardize the use of CEA as an adjunct for NSCLC staging.
Topics: Biomarkers, Tumor; Carcinoembryonic Antigen; Carcinoma, Non-Small-Cell Lung; Humans; Lung Neoplasms; Neoplasm Staging; Predictive Value of Tests; Survival Analysis
PubMed: 33059696
DOI: 10.1186/s13019-020-01353-2 -
Journal of Robotic Surgery Mar 2024The role of robotic surgery in the curative-intent treatment of esophageal cancer patients is yet to be defined. To compare short-term outcomes between conventional... (Meta-Analysis)
Meta-Analysis Review
Short-term outcomes of robot-assisted versus conventional minimally invasive esophagectomy for esophageal cancer: a systematic review and meta-analysis of 18,187 patients.
The role of robotic surgery in the curative-intent treatment of esophageal cancer patients is yet to be defined. To compare short-term outcomes between conventional minimally invasive (cMIE) and robot-assisted minimally invasive esophagectomy (RAMIE) in esophageal cancer patients. PubMed, Web of Science and Cochrane Library were systematically searched. The included studies compared short-term outcomes between cMIE and RAMIE. Individual risk of bias was calculated using the MINORS and RoB2 scales. There were no statistically significant differences between RAMIE and cMIE regarding conversion to open procedure, mean number of harvested lymph nodes in the mediastinum, abdomen and along the right recurrent laryngeal nerve (RLN), 30- and 90-day mortality rates, chyle leakage, RLN palsy as well as cardiac and infectious complication rates. Estimated blood loss (MD - 71.78 mL, p < 0.00001), total number of harvested lymph nodes (MD 2.18 nodes, p < 0.0001) and along the left RLN (MD 0.73 nodes, p = 0.03), pulmonary complications (RR 0.70, p = 0.001) and length of hospital stay (MD - 3.03 days, p < 0.0001) are outcomes that favored RAMIE. A significantly shorter operating time (MD 29.01 min, p = 0.004) and a lower rate of anastomotic leakage (RR 1.23, p = 0.0005) were seen in cMIE. RAMIE has indicated to be a safe and feasible alternative to cMIE, with a tendency towards superiority in blood loss, lymph node yield, pulmonary complications and length of hospital stay. There was significant heterogeneity among studies for some of the outcomes measured. Further studies are necessary to confirm these results and overcome current limitations.
Topics: Humans; Esophagectomy; Lymph Node Excision; Robotics; Robotic Surgical Procedures; Postoperative Complications; Esophageal Neoplasms; Minimally Invasive Surgical Procedures; Treatment Outcome
PubMed: 38492067
DOI: 10.1007/s11701-024-01880-3 -
Journal of Cardiovascular... Jun 2018Atrioesophageal fistula (AEF) is a dire complication of atrial fibrillation ablation. The diagnostic yield of computed tomography (CT) chest, the role and timing of...
INTRODUCTION
Atrioesophageal fistula (AEF) is a dire complication of atrial fibrillation ablation. The diagnostic yield of computed tomography (CT) chest, the role and timing of repeat testing, and the value of other investigations in the diagnosis of AEF is uncertain.
METHODS
We systematically reviewed published AEF cases to evaluate radiological, bedside, and biochemical investigations for AEF (registered on PROSPERO [CRD42017077493]).
RESULTS
Eighty-seven articles with 126 patients (median age, 59 years; male, 71%) were included in the analysis. CT chest was performed in 88% (111/126) and was abnormal in 87%. A clear diagnosis of AEF (fistula/perforation) was only detected in 35% (34/97). Other major findings included free air in mediastinum (26%), left atrium (LA), or LA wall (24%). In 11 patients with normal/nonspecific initial CT chest, major abnormalities were detected in 91% (10/11) of repeat CT chest performed 6 days (median; range, 4-22) after initial scan. Initial CT head was normal in 51%; diffuse air emboli was identified in 79% (22/28). Initial transthoracic echocardiography was normal in 61% of cases. The spectrum of radiological abnormalities included Air (mediastinum/LA), Effusion (pleural/pericardial), Fistula/Perforation, and Thickening (esophagus/LA) - "AEF-Tests." Esophagram demonstrated contrast extravasation in 87% (13/15). Blood culture was consistently positive (100%; 28/28), particularly for streptococcus species (93%; 26/28).
CONCLUSION
The diagnosis of AEF remains challenging. Clinicians should be aware of the limitations in the yield of CT chest, the variety of major abnormalities reported, the need for repeat testing, unique brain imaging findings, and the importance of positive blood cultures and raised inflammatory markers.
Topics: Adult; Aged; Aged, 80 and over; Atrial Fibrillation; Biomarkers; Diagnosis, Differential; Echocardiography; Esophageal Fistula; Female; Fistula; Heart Atria; Heart Diseases; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Point-of-Care Testing; Predictive Value of Tests; Prognosis; Reproducibility of Results; Risk Factors; Tomography, X-Ray Computed
PubMed: 29603477
DOI: 10.1111/jce.13494