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Journal of Vascular Surgery Jul 2004We undertook a quantitative systematic review of randomized controlled trials (RCTs) and observational studies to determine the effectiveness of cerebrospinal fluid... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
We undertook a quantitative systematic review of randomized controlled trials (RCTs) and observational studies to determine the effectiveness of cerebrospinal fluid (CSF) drainage to prevent paraplegia in thoracic aneurysm (TA) and thoracoabdominal aortic aneurysm (TAAA) surgery.
METHODS
We included RCTs and cohort studies that met the following criteria: elective or emergent aneurysm surgery involving the thoracic or thoracoabdominal aorta, documentation of postoperative neurologic deficits, and patient age older than 18 years. We excluded studies that reported results in 10 or fewer patients and duplicate publications. We identified eligible studies by searching computerized databases, our own files, and the reference lists of relevant articles and review articles. Database searching, eligibility decisions, relevance and method quality assessments, and data extraction were performed in duplicate with prespecified criteria.
RESULTS
Of 372 publications identified in our search, 14 met our eligibility criteria. Three RCTs reported 289 patients with type I or type II TAAA. Lower limb neurologic deficits occurred in 12% of patients who underwent CSF drainage and 33% of control subjects (number needed to treat, 9; 95% confidence interval [CI], 5-50). The pooled odds ratio (OR) for development of paraplegia in patients in the CSF drainage group was 0.35 (P =.05; 95% CI, 0.12-0.99). Similar results were found in five cohort studies with a control group (pooled OR, 0.26; P =.0002; 95% CI, 0.13-0.53). When all studies were considered together the pooled OR of TA and TAAA was 0.3 (95% CI, 0.17-0.54). There was no statistical heterogeneity among studies included in the meta-analysis. In six cohort studies without a control group, the incidence of paraplegia in high-risk TA and TAAA was 7.6%.
CONCLUSIONS
Evidence from randomized and nonrandomized trials and from cohort studies support the use of CSF drainage as an adjunct to prevent paraplegia when this adjunct is used in centers with large experience in the management of TAAA.
Topics: Aged; Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Cerebrospinal Fluid; Drainage; Female; Humans; Male; Paraplegia; Treatment Outcome; Vascular Surgical Procedures
PubMed: 15218460
DOI: 10.1016/j.jvs.2004.03.017 -
Journal of Vascular Surgery Oct 2022Best medical therapy (BMT) should be recommended for treating uncomplicated Stanford type B aortic dissection (uSTBAD), whereas thoracic aortic endovascular repair... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Best medical therapy (BMT) should be recommended for treating uncomplicated Stanford type B aortic dissection (uSTBAD), whereas thoracic aortic endovascular repair (TEVAR) has been controversial for uSTBAD.
METHODS
In this paper, a meta-analysis was conducted on all available randomized controlled trials and observational studies that evaluated the relative benefits and harms of TEVAR and BMT for the management of patients suffering from uSTBAD. Primary endpoints consisted of early adverse events, long-term adverse events, and aortic remodeling. In addition, risk differences (RDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. The random-effects model or the fixed-effects model was used in accordance with the 50% heterogeneity threshold.
RESULTS
Seven observational studies and two randomized controlled studies from 11 articles that contained 15,066 patients with uSTBAD (1518 TEVARs) met the inclusion criteria. For early outcomes, no significant differences were found between the TEVAR group and the BMT group in aortic rupture, retrograde dissection, paraplegia/paraparesis, reintervention, aorta-related death, and all-cause death. In the long run, the TEVAR group was found to have a significantly lower incidence of adverse events, which included aortic rupture (OR, 0.26; 95% CI, 0.16-0.42; P < .05; heterogeneity: P = .90, I = 0%), reintervention (OR, 0.45; 95% CI, 0.26-0.75; P < .05; heterogeneity: P = .17, I = 41%), aorta-related death (OR, 0.27; 95% CI, 0.18-0.42; P < .05; heterogeneity: P = .61, I = 0%), and all-cause death (OR, 0.52; 95% CI, 0.42-0.66; P < .05; heterogeneity: P = .05, I = 53%) as compared with the BMT group. Moreover, in compared with BMT, TEVAR was found to significantly contribute to the complete thrombosis of thoracic false lumen (OR, 55.34; 95% CI, 34.32-89.21; P < .05; heterogeneity: P = .97, I = 0%), and aortic regression (true lumen expansion and false lumen shrinkage).
CONCLUSIONS
Although early endovascular repair of uSTBAD does not outperform BMT, its implementation is found to be necessary to facilitate the long-term prognosis. Accordingly, if early TEVAR is to be deferred, close follow-up is critical to allow for timely reintervention.
Topics: Aortic Dissection; Aortic Aneurysm, Thoracic; Aortic Rupture; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Observational Studies as Topic; Retrospective Studies; Treatment Outcome
PubMed: 35390485
DOI: 10.1016/j.jvs.2022.03.876 -
Technology and Health Care : Official... 2012Research and development in the art of cycling using functional electrical stimulation (FES) of the paralysed leg muscles has been going on for around thirty years. A... (Review)
Review
Research and development in the art of cycling using functional electrical stimulation (FES) of the paralysed leg muscles has been going on for around thirty years. A range of physiological benefits has been observed in clinical studies but an outstanding problem with FES-cycling is that efficiency and power output are very low. The present work had the following aims: (i) to provide a tutorial introduction to a novel framework and methods of estimation of metabolic efficiency using example data sets, and to propose benchmark measures for evaluating FES-cycling performance; (ii) to systematically review the literature pertaining specifically to the metabolic efficiency of FES-cycling, to analyse the observations and possible explanations for the low efficiency, and to pose hypotheses for future studies which aim to improve performance. We recommend the following as benchmark measures for assessment of the performance of FES-cycling: (i) total work efficiency, delta efficiency and stimulation cost; (ii) we recommend, further, that these benchmark measures be complemented by mechanical measures of maximum power output, sustainable steady-state power output and endurance. Performance assessments should be carried out at a well-defined operating point, i.e. under conditions of well controlled work rate and cadence, because these variables have a strong effect on energy expenditure. Future work should focus on the two main factors which affect FES-cycling performance, namely: (i) unfavourable biomechanics, i.e. crude recruitment of muscle groups, non-optimal timing of muscle activation, and lack of synergistic and antagonistic joint control; (ii) non-physiological recruitment of muscle fibres, i.e. mixed recruitment of fibres of different type and deterministic constant-frequency stimulation. We hypothesise that the following areas may bring better FES-cycling performance: (i) study of alternative stimulation strategies for muscle activation including irregular stimulation patterns (e.g. doublets, triplets, stochastic patterns) and variable frequency stimulation trains, where it appears that increasing frequency over time may be profitable; (ii) study of better timing parameters for the stimulated muscle groups, and addition of more muscle groups: this path may be approached using EMG studies and constrained numerical optimisation employing dynamic models; (iii) development of optimal stimulation protocols for muscle reconditioning and FES-cycle training.
Topics: Bicycling; Biomechanical Phenomena; Electric Stimulation Therapy; Energy Metabolism; Energy Transfer; Humans; Leg; Muscle, Skeletal; Nervous System Diseases; Paraplegia; Spinal Cord Injuries
PubMed: 23079945
DOI: 10.3233/THC-2012-0689 -
Parkinsonism & Related Disorders Jun 2017Parkinsonian-Pyramidal syndrome (PPS), defined as the combination of both pyramidal and parkinsonian signs is a concept that recently emerged. PPS may manifest itself in... (Review)
Review
INTRODUCTION
Parkinsonian-Pyramidal syndrome (PPS), defined as the combination of both pyramidal and parkinsonian signs is a concept that recently emerged. PPS may manifest itself in numerous neurodegenerative diseases, many of these being inherited. Their diagnosis is a major challenge for the clinical management, for the prognosis, for genetic counselling and, in a few cases, which should not be neglected, for specific treatment.
OBJECTIVE
Our objective is to provide a review of PPS and an algorithm in order to guide their diagnosis in clinical practice.
METHODS
We performed an exhaustive PubMed and OMIM research matching the following key words: "Parkinsonism and pyramidal signs" or "Parkinsonism and spasticity" or "pallido-pyramidal syndrome" or "Parkinsonism and spastic paraplegia". English publications from the last ten years were included.
RESULTS
We propose a pragmatic presentation based on several established classifications and we will distinguish inherited PPS found in complex hereditary spastic paraplegia, young onset parkinsonism, neurodegeneration with brain iron accumulation, primary familial brain calcifications, inborn errors of metabolism, and few rare others inherited neurodegenerative diseases, then non-inherited neurodegenerative PPS. We therefore suggest guidelines (based on age at onset, family history, associated clinical signs, brain MRI findings as well as certain laboratory investigations), for the diagnosis and the management of PPS. Many pathophysiological pathways may underlie PPS but the most frequent are those usually involved in both inherited Parkinson's disease and spastic paraplegia, i.e. mitochondrial pathway, vesicular trafficking including endosomal and lysosomal pathways as well as autophagy.
Topics: Blepharospasm; Brain; Databases, Bibliographic; Globus Pallidus; Humans; Magnetic Resonance Imaging; Parkinson Disease, Secondary; Parkinsonian Disorders
PubMed: 28256436
DOI: 10.1016/j.parkreldis.2017.02.025 -
Interactive Cardiovascular and Thoracic... Aug 2022Consensus regarding optimal cerebral protection strategy in aortic arch surgery is lacking. We therefore performed a systematic review and meta-analysis to assess... (Meta-Analysis)
Meta-Analysis
Consensus regarding optimal cerebral protection strategy in aortic arch surgery is lacking. We therefore performed a systematic review and meta-analysis to assess outcome differences between unilateral antegrade cerebral perfusion (ACP), bilateral ACP, retrograde cerebral perfusion (RCP) and deep hypothermic circulatory arrest (DHCA). A systematic literature search was performed in Embase, Medline, Web of Science, Cochrane and Google Scholar for all papers published till February 2021 reporting on early clinical outcome after aortic arch surgery utilizing either unilateral, bilateral ACP, RCP or DHCA. The primary outcome was operative mortality. Other key secondary endpoints were occurrence of postoperative disabling stroke, paraplegia, renal and respiratory failure. Pooled outcome risks were estimated using random-effects models. A total of 222 studies were included with a total of 43 720 patients. Pooled postoperative mortality in unilateral ACP group was 6.6% [95% confidence interval (CI) 5.3-8.1%], 9.1% (95% CI 7.9-10.4%), 7.8% (95% CI 5.6-10.7%), 9.2% (95% CI 6.7-12.7%) in bilateral ACP, RCP and DHCA groups, respectively. The incidence of postoperative disabling stroke was 4.8% (95% CI 3.8-6.1%) in the unilateral ACP group, 7.3% (95% CI 6.2-8.5%) in bilateral ACP, 6.4% (95% CI 4.4-9.1%) in RCP and 6.3% (95% CI 4.4-9.1%) in DHCA subgroups. The present meta-analysis summarizes the clinical outcomes of different cerebral protection techniques that have been used in clinical practice over the last decades. These outcomes may be used in advanced microsimulation model. These findings need to be placed in the context of the underlying aortic disease, the extent of the aortic disease and other comorbidities. Prospero registration number: CRD42021246372 METC: MEC-2019-0825.
Topics: Aorta, Thoracic; Aortic Diseases; Cerebrovascular Circulation; Circulatory Arrest, Deep Hypothermia Induced; Humans; Perfusion; Retrospective Studies; Stroke; Treatment Outcome
PubMed: 35512204
DOI: 10.1093/icvts/ivac128 -
Frontiers in Neurology 2019The term hereditary spastic paraplegia (HSP) embraces a clinically and genetically heterogeneous group of neurodegenerative diseases characterized by progressive...
The term hereditary spastic paraplegia (HSP) embraces a clinically and genetically heterogeneous group of neurodegenerative diseases characterized by progressive spasticity and weakness of the lower limbs. There currently exist no specific therapies for HSP, and treatment is exclusively symptomatic, aimed at reducing muscle spasticity, and improving strength and gait. The authors set out to perform a comprehensive systematic review of the available scientific literature on the treatment of HSP, applying Cochrane Collaboration methods. The Google Scholar, PubMed and Scopus electronic databases were searched to find relevant randomized control trials (RCTs) and open-label interventional studies, prospective, and retrospective observational studies of supplements, medications, and physical therapy, as well as case reports and case series. Two authors independently analyzed 27 articles selected on the basis of a series of inclusion criteria. Applying a best-evidence synthesis approach, they evaluated these articles for methodological quality. A standardized scoring system was used to obtain interrater assessments. Disagreements were resolved by discussion. The 27 articles focused on pharmacological treatment ( = 17 articles), physical therapy ( = 5), surgical treatment ( = 5). The drugs used in the 17 articles on pharmacological therapy were: gabapentin, progabide, dalfampridine, botulinum toxin, L-Dopa, cholesterol-lowering drugs, betaine, and folinic acid. Gabapentin, progabide, dalfampridine, and botulinum toxin were used as antispastic agents; the study evaluating gabapentin efficacy was well-designed, but failed to demonstrate any significant improvement. L-Dopa, cholesterol-lowering drugs, betaine, and folinic acid were only used in specific HSP subtypes. Two of the three studies evaluating cholesterol-lowering drugs (in SPG5 patients) were well-designed and showed a significant reduction of specific serum biomarkers (oxysterols), but clinical outcomes were not evaluated. The articles focusing on physical treatment and surgical therapy were found to be of low/medium quality and, accordingly, failed to clarify the role of these approaches in HSP. Despite recent advances in understanding of the pathogenesis of HSP and the possibility, in several centers, of obtaining more precise and rapid molecular diagnoses, there is still no adequate evidence base for recommending the various published therapies. Well-designed RCTs are needed to evaluate the efficacy of both symptomatic and pathogenetic treatments.
PubMed: 30723448
DOI: 10.3389/fneur.2019.00003 -
Journal of Neurosurgery. Spine Apr 2022Secondary health conditions (SHCs) are long-term complications that frequently occur due to traumatic spinal cord injury (tSCI) and can negatively affect quality of life...
OBJECTIVE
Secondary health conditions (SHCs) are long-term complications that frequently occur due to traumatic spinal cord injury (tSCI) and can negatively affect quality of life in this patient population. This study provides an overview of the associations between the severity and level of injury and the occurrence of SHCs in tSCI.
METHODS
A systematic search was conducted in PubMed and Embase that retrieved 44 studies on the influence of severity and/or level of injury on the occurrence of SHCs in the subacute and chronic phase of tSCI (from 3 months after trauma). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.
RESULTS
In the majority of studies, patients with motor-complete tSCI (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade A or B) had a significantly increased occurrence of SHCs in comparison to patients with motor-incomplete tSCI (AIS grade C or D), such as respiratory and urogenital complications, musculoskeletal disorders, pressure ulcers, and autonomic dysreflexia. In contrast, an increased prevalence of pain was seen in patients with motor-incomplete injuries. In addition, higher rates of pulmonary infections, spasticity, and autonomic dysreflexia were observed in patients with tetraplegia. Patients with paraplegia more commonly suffered from hypertension, venous thromboembolism, and pain.
CONCLUSIONS
This review suggests that patients with a motor-complete tSCI have an increased risk of developing SHCs during the subacute and chronic stage of tSCI in comparison with patients with motor-incomplete tSCI. Future studies should examine whether systematic monitoring during rehabilitation and the subacute and chronic phase in patients with motor-complete tSCI could lead to early detection and potential prevention of SHCs in this population.
Topics: Humans; Paraplegia; Quadriplegia; Quality of Life; Retrospective Studies; Spinal Cord Injuries; Spinal Injuries
PubMed: 34767527
DOI: 10.3171/2021.7.SPINE21537 -
Frontiers in Neuroscience 2023Among the brain-machine interfaces, neurofeedback is a non-invasive technique that uses sensorimotor rhythm (SMR) as a clinical intervention protocol. This study aimed...
BACKGROUND
Among the brain-machine interfaces, neurofeedback is a non-invasive technique that uses sensorimotor rhythm (SMR) as a clinical intervention protocol. This study aimed to investigate the clinical applications of SMR neurofeedback to understand its clinical effectiveness in different pathologies or symptoms.
METHODS
A systematic review study with meta-analysis of the clinical applications of EEG-based SMR neurofeedback performed using pre-selected publication databases. A qualitative analysis of these studies was performed using the Consensus tool on the Reporting and Experimental Design of Neurofeedback studies (CRED-nf). The Meta-analysis of clinical efficacy was carried out using Review Manager software, version 5.4.1 (RevMan 5; Cochrane Collaboration, Oxford, UK).
RESULTS
The qualitative analysis includes 44 studies, of which only 27 studies had some kind of control condition, five studies were double-blinded, and only three reported a blind follow-up throughout the intervention. The meta-analysis included a total sample of 203 individuals between stroke and fibromyalgia. Studies on multiple sclerosis, insomnia, quadriplegia, paraplegia, and mild cognitive impairment were excluded due to the absence of a control group or results based only on post-intervention scales. Statistical analysis indicated that stroke patients did not benefit from neurofeedback interventions when compared to other therapies (Std. mean. dif. 0.31, 95% CI 0.03-0.60, = 0.03), and there was no significant heterogeneity among stroke studies, classified as moderate = 46% -value = 0.06. Patients diagnosed with fibromyalgia showed, by means of quantitative analysis, a better benefit for the group that used neurofeedback (Std. mean. dif. -0.73, 95% CI -1.22 to -0.24, = 0.001). Thus, on performing the pooled analysis between conditions, no significant differences were observed between the neurofeedback intervention and standard therapy (0.05, CI 95%, -0.20 to -0.30, = 0.69), with the presence of substantial heterogeneity = 92.2%, -value < 0.001.
CONCLUSION
We conclude that although neurofeedback based on electrophysiological patterns of SMR contemplates the interest of numerous researchers and the existence of research that presents promising results, it is currently not possible to point out the clinical benefits of the technique as a form of clinical intervention. Therefore, it is necessary to develop more robust studies with a greater sample of a more rigorous methodology to understand the benefits that the technique can provide to the population.
PubMed: 38053609
DOI: 10.3389/fnins.2023.1195066 -
Disability and Rehabilitation.... Oct 2016Rehabilitation professionals have little information concerning lower limb exoskeletons for people with paraplegia. This study has four objectives: (1) Outline the... (Review)
Review
PURPOSE
Rehabilitation professionals have little information concerning lower limb exoskeletons for people with paraplegia. This study has four objectives: (1) Outline the characteristics of the exoskeletons' design and their usefulness evidence as assistive mobility devices in the community for the Rewalk™, Mina, Indego®, Ekso™ (previously known as the eLEGS™) and Rex®; (2) document functional mobility outcomes of using these exoskeletons; (3) document secondary skills and benefits achieved with these exoskeletons, safety, user satisfaction and applicability in the community; and (4) establish level of scientific evidence of the selected studies.
METHOD
A systematic review of the literature (January 2004 to April 2014) was done using the databases PubMed, CINAHL and Embase and groups of keywords associated with "exoskeleton", "lower limb" and "paraplegia".
RESULTS
Seven articles were selected. Exoskeleton use is effective for walking in a laboratory but there are no training protocols to modify identified outcomes over the term usage (ReWalk™: 3 months, Mina: 2 months and Indego®: 1 session). Levels of evidence of selected papers are low.
CONCLUSIONS
The applicability and effectiveness of lower limb exoskeletons as assistive devices in the community have not been demonstrated. More research is needed on walking performance with these exoskeletons compared to other mobility devices and other training contexts in the community. Implications for rehabilitation Characteristics of the exoskeletons' design and their usefulness evidence as assistive mobility devices in the community are addressed for the Rewalk™, Mina, Indego®, Ekso™ and Rex® ReWalk™, Indego® and Mina lower limb exoskeletons are effective for walking in a laboratory for individuals with complete lower-level SCI. The ReWalk™ has the best results for walking, with a maximum speed of 0.51 m/s after 45 sessions lasting 60 to 120 min; it is comparable to the average speed per day or per week in a manual wheelchair. The level of scientific evidence is low. Other studies are needed to provide more information about performance over the longer term when walking with an exoskeleton, compared to wheelchair mobility, the user's usual locomotion, the use of different exoskeletons or the training context in which the exoskeleton is used.
Topics: Exoskeleton Device; Humans; Lower Extremity; Paraplegia; Patient Safety; Patient Satisfaction; Spinal Cord Injuries; Walking
PubMed: 26340538
DOI: 10.3109/17483107.2015.1080766 -
Medicina (Kaunas, Lithuania) Dec 2023: Provisional extension to induce complete attachment (PETTICOAT) is suggested as being associated with a lower incidence of aorta-related events and fewer... (Meta-Analysis)
Meta-Analysis Review
The Rate of Postoperative Complications in Complicated Acute, and Subacute Type B Aortic Dissections after TEVAR vs. PETTICOAT Procedures: Systematic Review and Meta-Analysis.
: Provisional extension to induce complete attachment (PETTICOAT) is suggested as being associated with a lower incidence of aorta-related events and fewer reinterventions compared to thoracic endovascular aortic repair (TEVAR) in patients with complicated acute, and subacute type B aortic dissections. : This article is a systematic review and meta-analysis following the PRISMA guidelines. The Medline, PubMed, Embase, and Cochrane databases were searched, starting on 21 February 2022 and ending on 22 June 2022, to identify studies that investigated the rate of postoperative complications in patients treated with the PETTICOAT compared to the TEVAR. A random effects meta-analysis was performed. Of 2350 studies, 5 studies involving 360 patients were included: 143 patients after the PETTICOAT procedure and 217 after the TEVAR. : The meta-analysis of all studies showed that the rate of secondary endovascular reinterventions was smaller in patients treated with the PETTICOAT ( = 3 studies; OR, 0.30; 95% CI, 0.10 to 0.94; = 0.04). The results of other postoperative complications (30-day mortality, mortality during follow-up, paraplegia, stroke, and occurrence of endoleak) were lower in the PETTICOAT group but were not statistically significant. The rate of postoperative renal failure was lower in patients treated with the TEVAR ( = 4; OR, 1.08; 95% CI, 0.46 to 2.51; = 0.86). : This meta-analysis suggests that the PETTICOAT procedure is related to the lower rate of secondary endovascular reinterventions for complicated acute, and subacute type B aortic dissections.
Topics: Humans; Blood Vessel Prosthesis; Endovascular Aneurysm Repair; Blood Vessel Prosthesis Implantation; Stents; Aortic Aneurysm, Thoracic; Endovascular Procedures; Treatment Outcome; Aortic Dissection; Postoperative Complications; Retrospective Studies; Risk Factors
PubMed: 38138253
DOI: 10.3390/medicina59122150