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The Cochrane Database of Systematic... 2004Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks which may be lessened by performing the operation under local rather than general anaesthetic.
OBJECTIVES
The aim of this review was to assess the risks of endarterectomy under local compared with general anaesthetic.
SEARCH STRATEGY
We searched the Stroke Group trials register (April 2003), MEDLINE (1966 to April 2003), EMBASE (1980 to 2002), and Index to Scientific and Technical Proceedings (1980 to 1994). We handsearched 13 relevant journals up to 2002, and searched the reference lists of articles identified. We also advertised the review in Vascular News (a newspaper for European vascular specialists) in August 2001.
SELECTION CRITERIA
Randomised trials and non-randomised studies comparing carotid endarterectomy under local versus general anaesthetic.
DATA COLLECTION AND ANALYSIS
One reviewer selected studies for inclusion and another independently checked the decisions. Two reviewers assessed trial quality and independently extracted the data.
MAIN RESULTS
Seven randomised trials involving 554 operations, and 41 non-randomised studies involving 25622 operations were included. The methodological quality of the non-randomised trials was questionable. Eleven of the non-randomised studies were prospective and 29 reported on a consecutive series of patients. In nine non-randomised studies the number of arteries, as opposed to the number of patients, was unclear. Meta-analysis of the non-randomised studies showed that the use of local anaesthetic was associated with significant reductions in the odds of death (35 studies), stroke (31 studies), stroke or death (26 studies), myocardial infarction (22 studies), and pulmonary complications (7 studies), within 30 days of the operation. Meta-analysis of the randomised studies showed that the use of local anaesthetic was associated with a significant reduction in local haemorrhage (OR = 0.31, 95% CI = 0.12 to 0.79) within 30 days of the operation, but there was no evidence of a reduction in the odds of operative stroke. However, the trials were too small to allow reliable conclusions to be drawn, and in some studies intention-to-treat analyses were not possible because of exclusions.
REVIEWERS' CONCLUSIONS
There is insufficient evidence from randomised trials comparing carotid endarterectomy performed under local and general anaesthetic. Non-randomised studies suggest potential benefits with the use of local anaesthetic, but these studies may be biased. More randomised studies are needed.
Topics: Anesthesia, General; Anesthesia, Local; Clinical Trials as Topic; Endarterectomy, Carotid; Humans
PubMed: 15106144
DOI: 10.1002/14651858.CD000126.pub2 -
The Cochrane Database of Systematic... 2000Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks... (Review)
Review
BACKGROUND
Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks which may be lessened by performing the operation under local rather than general anaesthetic.
OBJECTIVES
The objective of this review was to assess the effect of endarterectomy under local compared with general anaesthetic.
SEARCH STRATEGY
We searched the Cochrane Stroke Group trials register, Medline (1966 to 1995), Embase (1980 to 1995), and Index to Scientific and Technical Proceedings (1980 to 1994). We handsearched Annals of Surgery (1981 to 1995), British Journal of Surgery (1985 to 1995), European Journal of Vascular Surgery (1988 to 1995) and World Journal of Surgery (1978 to 1995). Reference lists of articles were searched.
SELECTION CRITERIA
Randomised trials and non-randomised studies comparing carotid endarterectomy under local versus general anaesthetic.
DATA COLLECTION AND ANALYSIS
One reviewer selected studies for inclusion and another independently checked the decisions. Two reviewers assessed trial quality and independently extracted the data.
MAIN RESULTS
Three randomised trials involving 143 patients, and 17 non-randomised studies involving about 5970 patients were included. The methodological quality of the randomised trials was questionable. Two of the non-randomised studies were prospective and 12 reported on a consecutive series of patients. In nine non-randomised studies the number of patients, as opposed to the number of arteries, was unclear. There were insufficient data to enable conclusions to be drawn from the randomised trials. In 15 non-randomised studies, no significant difference was shown between local and general anaesthetic in deaths within 30 days of operation (odds ratio 0.61, 95% confidence interval 0.32 to 1.16). Non-randomised studies showed that local anaesthetic was associated with a significant reduction in the odds of stroke (15 studies), stroke or death (14 studies), myocardial infarction (12 studies), and pulmonary complications (five studies), within 30 days of the operation. Patient and surgeon satisfaction were not reported in any study.
REVIEWER'S CONCLUSIONS
There is not enough evidence from randomised trials comparing carotid endarterectomy performed under local as opposed to general anaesthetic. Non-randomised studies suggest potential benefits with local anaesthetic. However these studies are likely to be significantly biased.
Topics: Anesthesia, General; Anesthesia, Local; Endarterectomy, Carotid; Humans
PubMed: 10796302
DOI: 10.1002/14651858.CD000126 -
BMJ Global Health 2018Pulmonary tuberculosis (TB) is an important risk factor for chronic respiratory disease due to residual lung damage. Yet, the WHO End TB strategy does not mention...
INTRODUCTION
Pulmonary tuberculosis (TB) is an important risk factor for chronic respiratory disease due to residual lung damage. Yet, the WHO End TB strategy does not mention post-TB chronic lung disorders (PTBLDs) and programmatic interventions to address PTBLD are lacking. This study assessed the scope of current guidelines and evidence on PTBLD to inform policy and research action.
METHODS
A systematic literature search was conducted following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Eight databases (TRIP, International Guideline Library, MEDLINE/PubMed, EMBASE, Web of Science, Global Health, Cochrane Library) were searched for records on PTBLD published between 1 January 1990 and 1 December 2017. Non-English records, case series, conference abstracts and letters to editors were excluded. Data were extracted and charted on publication year, location, PTBLD condition(s) and main study outcome.
RESULTS
A total of 212 guidelines and 3661 articles were retrieved. After screening, only three international TB guidelines mentioned TB sequelae, but none described how to identify or manage the condition. A total of 156 articles addressed PTBLD: 54 (35%) mentioned unspecified TB sequelae; 47 (30%) specific post-TB conditions including aspergillosis, bronchial stenosis or bronchiectasis; 52 (33%) post-TB obstructive disorders or lung function impairment; and 20 (13%) post-TB respiratory symptoms or chest X-ray abnormalities. The first two groups mostly assessed surgery or ventilation techniques for patient management, while the last two groups typically assessed prevalence or predictors of disease.
CONCLUSION
This is the first review to provide a comprehensive overview of the current literature on PTBLD. The scope of evidence around the burden of PTBLD warrants inclusion and recognition of the problem in international TB guidelines. Research is now needed on early detection of PTBLD and patient management options that are suitable for high-burden TB countries.
PubMed: 30057796
DOI: 10.1136/bmjgh-2018-000745 -
Health Technology Assessment... Nov 2008To determine the safety, clinical effectiveness and cost-effectiveness of radio frequency catheter ablation (RCFA) for the curative treatment of atrial fibrillation (AF)... (Comparative Study)
Comparative Study Meta-Analysis Review
OBJECTIVES
To determine the safety, clinical effectiveness and cost-effectiveness of radio frequency catheter ablation (RCFA) for the curative treatment of atrial fibrillation (AF) and typical atrial flutter.
DATA SOURCES
For the systematic reviews of clinical studies 25 bibliographic databases and internet sources were searched in July 2006, with subsequent update searches for controlled trials conducted in April 2007. For the review of cost-effectiveness a broad range of studies was considered, including economic evaluations conducted alongside trials, modelling studies and analyses of administrative databases.
REVIEW METHODS
Systematic reviews of clinical studies and economic evaluations of catheter ablation for AF and typical atrial flutter were conducted. The quality of the included studies was assessed using standard methods. A decision model was developed to evaluate a strategy of RFCA compared with long-term antiarrhythmic drug (AAD) treatment alone in adults with paroxysmal AF. This was used to estimate the cost-effectiveness of RFCA in terms of cost per quality-adjusted life-year (QALY) under a range of assumptions. Decision uncertainty associated with this analysis was presented and used to inform future research priorities using the value of information analysis.
RESULTS
A total of 4858 studies were retrieved for the review of clinical effectiveness. Of these, eight controlled studies and 53 case series of AF were included. Two controlled studies and 23 case series of typical atrial flutter were included. For atrial fibrillation, freedom from arrhythmia at 12 months in case series ranged from 28% to 85.3% with a weighted mean of 76%. Three RCTs suggested that RFCA is more effective than long-term AAD therapy in patients with drug-refractory paroxysmal AF. Single RCTs also suggested superiority of RFCA over electrical cardioversion followed by long-term AAD therapy and of RFCA plus AAD therapy over AAD maintenance therapy alone in drug-refractory patients. The available RCTs provided insufficient evidence to determine the effectiveness of RFCA beyond 12 months or in patients with persistent or permanent AF. Adverse events and complications were generally rare. Mortality rates were low in both RCTs and case series. Cardiac tamponade and pulmonary vein stenosis were the most frequently recorded complications. For atrial flutter, freedom from arrhythmia at 12 months in case series ranged from 85% to 92% with a weighted mean of 88%. Neither of the atrial flutter RCTs reported freedom from arrhythmia at 12 months. One RCT found a statistically significant benefit favouring ablation over AADs in terms of freedom from arrhythmia at a mean follow-up of 22 months. A second RCT reported a more modest effect favouring ablation in terms of freedom from atrial flutter at follow-up in older patients (mean age 78 years) after their first episode of flutter. In the atrial flutter case series, mortality was rare and the most frequent complications were atrioventricular block and haematomas. Complications in the RCTs were similar, except for those events likely to have been caused by AAD therapy (e.g. thyroid dysfunction). The review of cost-effectiveness evidence found one relevant study, which from a UK NHS perspective had a number of important limitations. The base-case analysis in the decision model demonstrated that if the quality of life benefits of RFCA are maintained over the remaining lifetime of the patient then the cost-effectiveness of RFCA appears clear. These findings were robust over a wide range of alternative assumptions, being between 7763 and 7910 pounds per additional QALY with very little uncertainty. If the quality of life benefits of RFCA are assumed to be maintained for no more than 5 years, cost-effectiveness of RFCA is dependent on a number of factors. Estimates of cost-effectiveness that explored the influence of these factors ranged from 23,000 to 38,000 pounds per QALY.
CONCLUSIONS
RFCA is a relatively safe and efficacious procedure for the therapeutic treatment of AF and typical atrial flutter. There is some randomised evidence to suggest that RFCA is superior to AADs in patients with drug-refractory paroxysmal AF in terms of freedom from arrhythmia at 12 months. RFCA appears to be cost-effective if the observed quality of life benefits are assumed to continue over a patient's lifetime. However, there remain uncertainties around longer-term effects of the intervention and the extent to which published effectiveness findings can be generalised to 'typical' UK practice. All catheter ablation procedures for the treatment of AF or atrial flutter undertaken in the UK should be recorded prospectively and centrally and measures to increase compliance in recording RFCA procedures may be needed. This would be of particular value in establishing the long-term benefits of RFCA and the true incidence and impact of any complications. Collection of appropriate quality of life data within any such registry would also be of value to future clinical and cost-effectiveness research in this area. Any planned multicentre RCTs comparing RFCA against best medical therapy for the treatment of AF and/or atrial flutter should be conducted among 'non-pioneering' centres using the techniques and equipment typically employed in UK practice and should measure relevant outcomes.
Topics: Adult; Anti-Arrhythmia Agents; Atrial Fibrillation; Atrial Flutter; Catheter Ablation; Cost-Benefit Analysis; Databases, Bibliographic; Humans; Quality-Adjusted Life Years; Safety; Technology Assessment, Biomedical; Treatment Outcome; United Kingdom
PubMed: 19036232
DOI: 10.3310/hta12340 -
Medicine Jul 2022Safe and effective arteriovenous fistula (AVF) puncture techniques must be used to reduce harm to hemodialysis patients. The relative benefits of buttonhole (BH)... (Meta-Analysis)
Meta-Analysis
Effect of buttonhole cannulation versus rope-ladder cannulation in hemodialysis patients with vascular access: A systematic review and meta-analysis of randomized/clinical controlled trials.
BACKGROUND
Safe and effective arteriovenous fistula (AVF) puncture techniques must be used to reduce harm to hemodialysis patients. The relative benefits of buttonhole (BH) cannulation over those of rope ladder (RL) cannulation for AVF remain unclear and inconsistent.
METHODS
This systematic review and meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Literature searches were conducted in June 2020 in multiple scientific databases including Cochrane library, CINAHL, PubMed/ Medline, Airiti Library, National Digital Library of Theses and Dissertations in Taiwan, Google scholar, Embase, and ProQuest. We included all randomized controlled trials (RCTs) and clinical controlled trials (CCTs) that explored the efficacy of BH cannulation in hemodialysis patients. These included reports published in either English or Chinese that enrolled adults aged 18 years or older who underwent hemodialysis using an autogenous AVF. Studies that showed poor design, such as use of a self-control group or no control group, were excluded from analysis. The critical appraisal skills program checklist for RCTs were used to assess the quality of the evidence and RevMan software were used to perform the meta-analysis.
RESULTS
Fifteen studies (11 RCTs and 4 CCTs) met the inclusion criteria and were used for the meta-analysis. Meta-analysis showed that BH cannulation significantly reduced aneurysm formation (RR = 0.18, 95% confidence interval [CI] [0.1, 0.32]), stenosis (RR = 0.44, 95% CI [0.25, 0.77]), thrombosis formation (RR = 0.4, 95% CI [0.2, 0.8]), and hematoma (RR = 0.63, 95% CI [0.40, 0.99]) and showed no differences in AVR infection (≦6 months, RR = 2.17, 95% CI [0.76, 6.23]; >6 months, RR = 2.7, 95% CI [0.92, 7.92]) compared to RL cannulation.
CONCLUSIONS
Given the benefits of BH, this meta-analysis found that BH cannulation should be recommended as a routine procedure for hemodialysis but that hospitals and hemodialysis clinics should strengthen staff knowledge and skills of BH cannulation to reduce the risk of AVF infection.
Topics: Adult; Arteriovenous Fistula; Arteriovenous Shunt, Surgical; Catheterization; Humans; Kidney Failure, Chronic; Randomized Controlled Trials as Topic; Renal Dialysis
PubMed: 35866782
DOI: 10.1097/MD.0000000000029597 -
American Journal of Therapeutics 2018
Comparative Study Meta-Analysis
Topics: Angioplasty; Atrial Fibrillation; Humans; Radiofrequency Ablation; Recurrence; Stenosis, Pulmonary Vein; Stents; Treatment Outcome
PubMed: 30188876
DOI: 10.1097/MJT.0000000000000675 -
Acta Obstetricia Et Gynecologica... Mar 2024We aimed to investigate the incidence, prenatal factors and outcomes of twin-to-twin transfusion (TTTS) with right ventricular outflow tract obstruction (RVOTO). (Review)
Review
INTRODUCTION
We aimed to investigate the incidence, prenatal factors and outcomes of twin-to-twin transfusion (TTTS) with right ventricular outflow tract obstruction (RVOTO).
MATERIAL AND METHODS
A systematic search was conducted to identify relevant studies published until February 2023 in English using the databases PubMed, Scopus and Web of Science. Studies reporting on pregnancies with TTTS and RVOTO were included. The random-effect model pooled the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals. Heterogeneity was assessed using the I value.
RESULTS
A total of 17 studies encompassing 4332 TTTS pregnancies, of which 225 cases had RVOTO, were included. Incidence of RVOTO at time of TTTS diagnosis was 6%. In all, 134/197 (68%) had functional pulmonary stenosis and 62/197 (32%) had functional pulmonary atresia. Of these, 27% resolved following laser and 55% persisted after birth. Of those persisting, 27% required cardiac valve procedures. Prenatal associations were TTTS stage III (53% vs 39% in no-RVOTO), stage IV TTTS (28% in RVOTO vs 12% in no-RVOTO) and ductus venosus reversed a-wave (60% in RVOTO vs 19% in no-RVOTO). Gestational age at laser and gestational age at delivery were comparable between groups. Survival outcomes were also comparable between groups, including fetal demise of 26%, neonatal death of 12% and 6-month survival of 82% in RVOTO group. Findings were similar when subgroup analysis was done for studies including head-to-head analysis.
CONCLUSIONS
RVOT occurs in about 6% of the recipient twins with TTTS, especially in stages III and IV and those with reversed ductus venosus a-wave. The findings from this systematic review support the need for a thorough cardiac assessment of pregnancies complicated by TTTS, both before and after laser, to maximize perinatal outcome, and the importance of early diagnosis of TTTS and timely management.
PubMed: 38482999
DOI: 10.1111/aogs.14825 -
Interactive Cardiovascular and Thoracic... Nov 2014A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether preservation of the pleura during internal... (Review)
Review
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether preservation of the pleura during internal mammary artery (IMA) harvesting improved clinical outcomes after coronary artery bypass graft surgery. More than 210 papers were found using the reported search, of which 18 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studies, relevant outcomes, results and study weakness of these papers are tabulated. Most studies dealt with investigating the radiographic changes, pulmonary function tests, ventilation time and also clinical consequences, such as bleeding, the need for blood transfusion, pain scores and the length of hospital stay. There is still no meta-analysis and systematic review regarding this surgical problem. Eighteen articles were found, of which 6 were prospective randomized, controlled trials and 12 were cohort studies. In these studies, some beneficial clinical outcomes were reported including: pleural effusion (15 studies), atelectasis (11 studies), pulmonary function tests (9 studies), arterial blood gases (5 studies), postoperative pain (6 studies), tamponade (2 studies), ventilation time (12 studies with), blood loss (9 studies), transfusion (4 studies), intensive care unit stay (5 studies) and hospital stay (12 studies). Based on our findings, preservation of pleural integrity seems to contribute to decreased pulmonary complications and improved clinical outcomes, such as bleeding, pain and length of hospital stay.
Topics: Coronary Angiography; Coronary Artery Bypass; Coronary Stenosis; Humans; Male; Mammary Arteries; Middle Aged; Pleura; Postoperative Complications; Tissue and Organ Harvesting
PubMed: 25082837
DOI: 10.1093/icvts/ivu254 -
International Journal of Cardiology Dec 2008In the large and expanding population of adults with congenital heart disease, little is known about their long-term outcome. By means of a systematic literature search,... (Review)
Review
BACKGROUND
In the large and expanding population of adults with congenital heart disease, little is known about their long-term outcome. By means of a systematic literature search, we aimed to assess the quantity and quality of data on long-term survival and morbidity in adults with common congenital heart defects.
METHODS
All literature on MEDLINE from January 1980 to January 2007 was searched, using a broad range of keywords for atrial septal defect, ventricular septal defect, pulmonary stenosis, tetralogy of Fallot, aortic coarctation, and transposition of the great arteries. After study selection using pre-specified criteria and quality assessment, data were extracted and weighed according to number of patients. Pooled estimates were obtained.
RESULTS
We identified 322 articles. Selection yielded 35 articles comprising 7894 patients. Data on survival were mainly available up until 40 years of age. In this young population, survival varied from 87.4% in aortic coarctation to 99.6% in atrial septal defect. Data on morbidity were sparse. Based on these data, morbidity was substantial.
CONCLUSIONS
Until the age of 40 years, survival is decreased in patients with congenital heart defects, albeit most pronounced among patients with complex heart defects. Moreover, morbidity is considerable in all defects. Sufficient data on long-term survival and morbidity beyond the age of 40 years are lacking, yet crucial for optimal clinical care.
Topics: Clinical Trials as Topic; Follow-Up Studies; Heart Defects, Congenital; Humans; Prognosis; Survival Rate; Time
PubMed: 18687485
DOI: 10.1016/j.ijcard.2008.06.023 -
Interdisciplinary Cardiovascular and... Jun 2024Transannular patch (TAP) repair of tetralogy of Fallot (ToF) relieves right ventricular tract obstruction but may lead to pulmonary regurgitation. Valve-sparing (VS)...
OBJECTIVES
Transannular patch (TAP) repair of tetralogy of Fallot (ToF) relieves right ventricular tract obstruction but may lead to pulmonary regurgitation. Valve-sparing (VS) procedures can avoid this but there is potential for residual pulmonic stenosis. We aimed to evaluate clinical and echocardiographic outcomes of TAP and VS repair for ToF.
METHODS
A systematic search of the PubMed, Embase, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases was carried out to identify articles comparing conventional TAP repair and VS repair for ToF. Clinical and echocardiographic outcomes were meta-analyzed using random-effects models.
RESULTS
40 studies were included in this meta-analysis with data on 11,723 participants (TAP: 6,171; VS: 5,045). Participants that underwent a VS procedure experienced a significantly lower cardiopulmonary bypass time (MD: -14.97; 95% CI: -22.54, -7.41), shorter ventilation duration (MD: -15.33; 95% CI: -30.20, -0.46), and shorter lengths of both ICU (MD: -0.67; 95% CI: -1.29, -0.06) and hospital stay (MD: -2.30; 95% CI: [-4.08, -0.52). There was also a lower risk of mortality (RR: 0.40; 95% CI: [0.27, 0.60]) and pulmonary regurgitation (RR: 0.35; 95% CI: [0.26, 0.46]) associated with the VS group. Most other clinical and echocardiographic outcomes were comparable in the two groups.
CONCLUSIONS
This meta-analysis confirms the well-established increased risk of pulmonary insufficiency following TAP repair, while also demonstrating that VS repairs are associated with several improved clinical outcomes. Continued research can identify the criteria for adopting a VS approach as opposed to a traditional TAP repair.
PubMed: 38924512
DOI: 10.1093/icvts/ivae124