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Journal of the American Geriatrics... Oct 2021To compare the effectiveness of single, multiple, and multifactorial interventions to prevent falls and fall-related fractures in community-dwelling older persons. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To compare the effectiveness of single, multiple, and multifactorial interventions to prevent falls and fall-related fractures in community-dwelling older persons.
METHODS
MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) evaluating the effectiveness of fall prevention interventions in community-dwelling adults aged ≥65 years, from inception until February 27, 2019. Two large RCTs (published in 2020 after the search closed) were included in post hoc analyses. Pairwise meta-analysis and network meta-analysis (NMA) were conducted.
RESULTS
NMA including 192 studies revealed that the following single interventions, compared with usual care, were associated with reductions in number of fallers: exercise (risk ratio [RR] 0.83; 95% confidence interval [CI] 0.77-0.89) and quality improvement strategies (e.g., patient education) (RR 0.90; 95% CI 0.83-0.98). Exercise as a single intervention was associated with a reduction in falls rate (RR 0.79; 95% CI 0.73-0.86). Common components of multiple interventions significantly associated with a reduction in number of fallers and falls rate were exercise, assistive technology, environmental assessment and modifications, quality improvement strategies, and basic falls risk assessment (e.g., medication review). Multifactorial interventions were associated with a reduction in falls rate (RR 0.87; 95% CI 0.80-0.95), but not with a reduction in number of fallers (RR 0.95; 95% CI 0.89-1.01). The following single interventions, compared with usual care, were associated with reductions in number of fall-related fractures: basic falls risk assessment (RR 0.60; 95% CI 0.39-0.94) and exercise (RR 0.62; 95% CI 0.42-0.90).
CONCLUSIONS
In keeping with Tricco et al. (2017), several single and multiple fall prevention interventions are associated with fewer falls. In addition to Tricco, we observe a benefit at the NMA-level of some single interventions on preventing fall-related fractures.
Topics: Accidental Falls; Accidents, Home; Aged; Aged, 80 and over; Environment Design; Exercise Therapy; Female; Fractures, Bone; Humans; Independent Living; Male; Network Meta-Analysis; Randomized Controlled Trials as Topic; Risk Assessment; Self-Help Devices
PubMed: 34318929
DOI: 10.1111/jgs.17375 -
Health Technology Assessment... Jun 2020Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture.
BACKGROUND
Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture.
OBJECTIVES
The objectives were to evaluate the clinical effectiveness, safety and cost-effectiveness of non-bisphosphonates {denosumab [Prolia; Amgen Inc., Thousand Oaks, CA, USA], raloxifene [Evista; Daiichi Sankyo Company, Ltd, Tokyo, Japan], romosozumab [Evenity; Union Chimique Belge (UCB) S.A. (Brussels, Belgium) and Amgen Inc.] and teriparatide [Forsteo; Eli Lilly and Company, Indianapolis, IN, USA]}, compared with each other, bisphosphonates or no treatment, for the prevention of fragility fracture.
DATA SOURCES
For the clinical effectiveness review, nine electronic databases (including MEDLINE, EMBASE and the World Health Organization International Clinical Trials Registry Platform) were searched up to July 2018.
REVIEW METHODS
A systematic review and network meta-analysis of fracture and femoral neck bone mineral density were conducted. A review of published economic analyses was undertaken and a model previously used to evaluate bisphosphonates was adapted. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years for a simulated cohort of patients with heterogeneous characteristics. This was done for each non-bisphosphonate treatment, a strategy of no treatment, and the five bisphosphonate treatments previously evaluated. The model was populated with effectiveness evidence from the systematic review and network meta-analysis. All other parameters were estimated from published sources. An NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net monetary benefit was estimated using non-parametric regression. A probabilistic sensitivity analysis and scenario analyses were used to assess uncertainty.
RESULTS
Fifty-two randomised controlled trials of non-bisphosphonates were included in the clinical effectiveness systematic review and an additional 51 randomised controlled trials of bisphosphonates were included in the network meta-analysis. All treatments had beneficial effects compared with placebo for vertebral, non-vertebral and hip fractures, with hazard ratios varying from 0.23 to 0.94, depending on treatment and fracture type. The effects on vertebral fractures and the percentage change in bone mineral density were statistically significant for all treatments. The rate of serious adverse events varied across trials (0-33%), with most between-group differences not being statistically significant for comparisons with placebo/no active treatment, non-bisphosphonates or bisphosphonates. The incremental cost-effectiveness ratios were > £20,000 per quality-adjusted life-year for all non-bisphosphonate interventions compared with no treatment across the range of QFracture and FRAX scores expected in the population eligible for fracture risk assessment. The incremental cost-effectiveness ratio for denosumab may fall below £30,000 per quality-adjusted life-year at very high levels of risk or for high-risk patients with specific characteristics. Raloxifene was dominated by no treatment (resulted in fewer quality-adjusted life-years) in most risk categories.
LIMITATIONS
The incremental cost-effectiveness ratios are uncertain for very high-risk patients.
CONCLUSIONS
Non-bisphosphonates are effective in preventing fragility fractures, but the incremental cost-effectiveness ratios are generally greater than the commonly applied threshold of £20,000-30,000 per quality-adjusted life-year.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42018107651.
FUNDING
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 24, No. 29. See the NIHR Journals Library website for further project information.
Topics: Bone Density Conservation Agents; Clinical Trials as Topic; Cost-Benefit Analysis; Denosumab; Diphosphonates; Humans; Osteoporotic Fractures; Quality-Adjusted Life Years; Raloxifene Hydrochloride; Teriparatide; Treatment Outcome
PubMed: 32588816
DOI: 10.3310/hta24290 -
The Journal of Surgical Research Aug 2022Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been treated conservatively, there is increasing interest in the benefits of surgical fixation. However, strong evidence that supports surgical rib fixation and identifies the most appropriate patients for its application is currently sparse.
METHODS
A systematic review and meta-analysis following PRISMA guidelines was performed to identify all peer-reviewed papers that examined surgical compared to conservative management of rib fractures. We undertook a subgroup analysis to determine the specific effects of rib fracture type, age, the timing of fixation and study design on outcomes. The primary outcomes were the length of hospital and ICU stay, and secondary outcomes included mechanical ventilation time, rates of pneumonia, and mortality.
RESULTS
Our search identified 45 papers in the systematic review, and 40 were included in the meta-analysis. There was a statistical benefit of surgical fixation compared to conservative management of rib fractures for length of ICU stay, mechanical ventilation, mortality, pneumonia, and tracheostomy. The subgroup analysis identified surgical fixation was most favorable for patients with flail chest and those who underwent surgical fixation within 72 h. Patients over 60 y had a statistical benefit of conservative management on length of hospital stay and mechanical ventilation.
CONCLUSIONS
Surgical fixation of flail and multiple rib fractures is associated with a reduction in morbidity and mortality outcomes compared to conservative management. However, careful selection of patients is required for the appropriate application of surgical rib fixation.
Topics: Flail Chest; Fracture Fixation, Internal; Humans; Length of Stay; Pneumonia; Retrospective Studies; Rib Fractures; Ribs; Spinal Fractures
PubMed: 35390577
DOI: 10.1016/j.jss.2022.02.055 -
The Journal of Trauma and Acute Care... Mar 2023Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully... (Meta-Analysis)
Meta-Analysis
Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society.
BACKGROUND
Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia.
METHODS
Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used.
RESULTS
Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality.
CONCLUSION
We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia.
LEVEL OF EVIDENCE
Systematic Review/Meta-analysis; Level IV.
Topics: Humans; Aged; Rib Fractures; Ketamine; Pain; Analgesia, Epidural; Thoracic Injuries; Pneumonia; Neck Injuries; Length of Stay
PubMed: 36730672
DOI: 10.1097/TA.0000000000003830 -
Scandinavian Journal of Medicine &... May 2020Globally, populations are ageing. Typically, physical activity levels decline and health worsens as we age; however, estimates of the impact of physical inactivity for...
BACKGROUND
Globally, populations are ageing. Typically, physical activity levels decline and health worsens as we age; however, estimates of the impact of physical inactivity for population health often fail to specifically focus on older adults.
METHODS
Multiple databases were searched for systematic reviews and/or meta-analyses of longitudinal observational studies, investigating the relationship between physical activity and any physical or mental health outcome in adults aged ≥60 years. Quality of included reviews was assessed using AMSTAR.
RESULTS
Twenty-four systematic reviews and meta-analyses were included. The majority of reviews were of moderate or high methodological quality. Physically active older adults (≥60 years) are at a reduced risk of all-cause and cardiovascular mortality, breast and prostate cancer, fractures, recurrent falls, ADL disability and functional limitation and cognitive decline, dementia, Alzheimer's disease, and depression. They also experience healthier ageing trajectories, better quality of life and improved cognitive functioning.
CONCLUSION
This review of reviews provides a comprehensive and systematic overview of epidemiological evidence from previously conducted research to assess the associations of physical activity with physical and mental health outcomes in older adults.
Topics: Aged; Chronic Disease; Exercise; Humans; Mental Health; Meta-Analysis as Topic; Middle Aged; Mortality; Quality of Life; Review Literature as Topic; Sedentary Behavior
PubMed: 32020713
DOI: 10.1111/sms.13616 -
The Cochrane Database of Systematic... Jan 2019At least one-third of community-dwelling people over 65 years of age fall each year. Exercises that target balance, gait and muscle strength have been found to prevent... (Meta-Analysis)
Meta-Analysis
BACKGROUND
At least one-third of community-dwelling people over 65 years of age fall each year. Exercises that target balance, gait and muscle strength have been found to prevent falls in these people. An up-to-date synthesis of the evidence is important given the major long-term consequences associated with falls and fall-related injuries OBJECTIVES: To assess the effects (benefits and harms) of exercise interventions for preventing falls in older people living in the community.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers up to 2 May 2018, together with reference checking and contact with study authors to identify additional studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) evaluating the effects of any form of exercise as a single intervention on falls in people aged 60+ years living in the community. We excluded trials focused on particular conditions, such as stroke.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls.
MAIN RESULTS
We included 108 RCTs with 23,407 participants living in the community in 25 countries. There were nine cluster-RCTs. On average, participants were 76 years old and 77% were women. Most trials had unclear or high risk of bias for one or more items. Results from four trials focusing on people who had been recently discharged from hospital and from comparisons of different exercises are not described here.Exercise (all types) versus control Eighty-one trials (19,684 participants) compared exercise (all types) with control intervention (one not thought to reduce falls). Exercise reduces the rate of falls by 23% (rate ratio (RaR) 0.77, 95% confidence interval (CI) 0.71 to 0.83; 12,981 participants, 59 studies; high-certainty evidence). Based on an illustrative risk of 850 falls in 1000 people followed over one year (data based on control group risk data from the 59 studies), this equates to 195 (95% CI 144 to 246) fewer falls in the exercise group. Exercise also reduces the number of people experiencing one or more falls by 15% (risk ratio (RR) 0.85, 95% CI 0.81 to 0.89; 13,518 participants, 63 studies; high-certainty evidence). Based on an illustrative risk of 480 fallers in 1000 people followed over one year (data based on control group risk data from the 63 studies), this equates to 72 (95% CI 52 to 91) fewer fallers in the exercise group. Subgroup analyses showed no evidence of a difference in effect on both falls outcomes according to whether trials selected participants at increased risk of falling or not.The findings for other outcomes are less certain, reflecting in part the relatively low number of studies and participants. Exercise may reduce the number of people experiencing one or more fall-related fractures (RR 0.73, 95% CI 0.56 to 0.95; 4047 participants, 10 studies; low-certainty evidence) and the number of people experiencing one or more falls requiring medical attention (RR 0.61, 95% CI 0.47 to 0.79; 1019 participants, 5 studies; low-certainty evidence). The effect of exercise on the number of people who experience one or more falls requiring hospital admission is unclear (RR 0.78, 95% CI 0.51 to 1.18; 1705 participants, 2 studies, very low-certainty evidence). Exercise may make little important difference to health-related quality of life: conversion of the pooled result (standardised mean difference (SMD) -0.03, 95% CI -0.10 to 0.04; 3172 participants, 15 studies; low-certainty evidence) to the EQ-5D and SF-36 scores showed the respective 95% CIs were much smaller than minimally important differences for both scales.Adverse events were reported to some degree in 27 trials (6019 participants) but were monitored closely in both exercise and control groups in only one trial. Fourteen trials reported no adverse events. Aside from two serious adverse events (one pelvic stress fracture and one inguinal hernia surgery) reported in one trial, the remainder were non-serious adverse events, primarily of a musculoskeletal nature. There was a median of three events (range 1 to 26) in the exercise groups.Different exercise types versus controlDifferent forms of exercise had different impacts on falls (test for subgroup differences, rate of falls: P = 0.004, I² = 71%). Compared with control, balance and functional exercises reduce the rate of falls by 24% (RaR 0.76, 95% CI 0.70 to 0.81; 7920 participants, 39 studies; high-certainty evidence) and the number of people experiencing one or more falls by 13% (RR 0.87, 95% CI 0.82 to 0.91; 8288 participants, 37 studies; high-certainty evidence). Multiple types of exercise (most commonly balance and functional exercises plus resistance exercises) probably reduce the rate of falls by 34% (RaR 0.66, 95% CI 0.50 to 0.88; 1374 participants, 11 studies; moderate-certainty evidence) and the number of people experiencing one or more falls by 22% (RR 0.78, 95% CI 0.64 to 0.96; 1623 participants, 17 studies; moderate-certainty evidence). Tai Chi may reduce the rate of falls by 19% (RaR 0.81, 95% CI 0.67 to 0.99; 2655 participants, 7 studies; low-certainty evidence) as well as reducing the number of people who experience falls by 20% (RR 0.80, 95% CI 0.70 to 0.91; 2677 participants, 8 studies; high-certainty evidence). We are uncertain of the effects of programmes that are primarily resistance training, or dance or walking programmes on the rate of falls and the number of people who experience falls. No trials compared flexibility or endurance exercise versus control.
AUTHORS' CONCLUSIONS
Exercise programmes reduce the rate of falls and the number of people experiencing falls in older people living in the community (high-certainty evidence). The effects of such exercise programmes are uncertain for other non-falls outcomes. Where reported, adverse events were predominantly non-serious.Exercise programmes that reduce falls primarily involve balance and functional exercises, while programmes that probably reduce falls include multiple exercise categories (typically balance and functional exercises plus resistance exercises). Tai Chi may also prevent falls but we are uncertain of the effect of resistance exercise (without balance and functional exercises), dance, or walking on the rate of falls.
Topics: Accidental Falls; Aged; Dance Therapy; Exercise; Exercise Therapy; Female; Fractures, Bone; Gait; Humans; Independent Living; Male; Middle Aged; Postural Balance; Quality of Life; Randomized Controlled Trials as Topic; Resistance Training; Tai Ji
PubMed: 30703272
DOI: 10.1002/14651858.CD012424.pub2 -
British Journal of Sports Medicine Jul 2015Recurrent instability following a first-time anterior traumatic shoulder dislocation may exceed 26%. We systematically reviewed risk factors which predispose this... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Recurrent instability following a first-time anterior traumatic shoulder dislocation may exceed 26%. We systematically reviewed risk factors which predispose this population to events of recurrence.
METHODS
A systematic review of studies published before 1 July 2014. Risk factors which predispose recurrence following a first-time traumatic anterior shoulder dislocation were documented and rates of recurrence were compared. Pooled ORs were analysed using random-effects meta-analysis.
RESULTS
Ten studies comprising 1324 participants met the criteria for inclusion. Recurrent instability following a first-time traumatic anterior shoulder dislocation was 39%. Increased risk of recurrent instability was reported in people aged 40 years and under (OR=13.46), in men (OR=3.18) and in people with hyperlaxity (OR=2.68). Decreased risk of recurrent instability was reported in people with a greater tuberosity fracture (OR=0.13). The rate of recurrent instability decreased as time from the initial dislocation increased. Other factors such as a bony Bankart lesion, nerve palsy and occupation influenced rates of recurrent instability.
CONCLUSIONS
Sex, age at initial dislocation, time from initial dislocation, hyperlaxity and greater tuberosity fractures were key risk factors in at least two good quality cohort studies resulting in strong evidence as concluded in the GRADE criteria. Although bony Bankart lesions, Hill Sachs lesions, occupation, physiotherapy treatment and nerve palsy were risk factors for recurrent instability, the evidence was weak using the GRADE criteria-these findings relied on poorer quality studies or were inconsistent among studies.
Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Disease Susceptibility; Female; Humans; Joint Instability; Male; Middle Aged; Recurrence; Risk Factors; Sex Factors; Shoulder Dislocation; Young Adult
PubMed: 25900943
DOI: 10.1136/bjsports-2014-094342 -
Clinical Oral Implants Research Oct 2018The aim of the present review was to compare the outcomes, that is, survival and complication rates of zirconia-ceramic and/or monolithic zirconia implant-supported... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
The aim of the present review was to compare the outcomes, that is, survival and complication rates of zirconia-ceramic and/or monolithic zirconia implant-supported fixed dental prostheses (FDPs) with metal-ceramic FDPs.
MATERIALS AND METHODS
An electronic MEDLINE search complemented by manual searching was conducted to identify randomized controlled clinical trials, prospective cohort studies and retrospective case series on implant-supported FDPs with a mean follow-up of at least 3 years. Patients had to have been examined clinically at the follow-up visit. Assessment of the identified studies and data extraction was performed independently by two reviewers. Failure and complication rates were analyzed using robust Poisson regression models to obtain summary estimates of 5-year proportions.
RESULTS
The search provided 5,263 titles and 455 abstracts. Full-text analysis was performed for 240 articles resulting in 19 studies on implant FDPs that met the inclusion criteria. The studies reported on 932 metal-ceramic and 175 zirconia-ceramic FDPs. Meta-analysis revealed an estimated 5-year survival rate of 98.7% (95% CI: 96.8%-99.5%) for metal-ceramic implant-supported FDPs, and of 93.0% (95% CI: 90.6%-94.8%) for zirconia-ceramic implant-supported FDPs (p < 0.001). Thirteen studies including 781 metal-ceramic implant-supported FDPs estimated a 5-year rate of ceramic fractures and chippings to be 11.6% compared with a significantly higher (p < 0.001) complication rate for zirconia implant-supported FDPs of 50%, reported in a small study with 13 zirconia implant-supported FDPs. Significantly (p = 0.001) more, that is, 4.1%, of the zirconia-ceramic implant-supported FDPs were lost due to ceramic fractures compared to only 0.2% of the metal-ceramic implant-supported FDPs. Detailed analysis of factors like number of units of the FDPs or location in the jaws was not possible due to heterogeneity of reporting. No studies on monolithic zirconia implant-supported FDPs fulfilled the inclusion criteria of the present review. Furthermore, no conclusive results were found for the aesthetic outcomes of both FDP-types.
CONCLUSION
For implant-supported FDPs, conventionally veneered zirconia should not be considered as material selection of first priority, as pronounced risk for framework fractures and chipping of the zirconia veneering ceramic was observed. Monolithic zirconia may be an interesting alternative, but its clinical medium- to long-term outcomes have not been evaluated yet. Hence, metal ceramics seems to stay the golden standard for implant-supported multiple-unit FDPs.
Topics: Ceramics; Databases, Factual; Dental Implants; Dental Materials; Dental Prosthesis Design; Dental Prosthesis, Implant-Supported; Dental Restoration Failure; Denture, Partial, Fixed; Esthetics, Dental; Humans; Metal Ceramic Alloys; Survival Analysis; Zirconium
PubMed: 30328185
DOI: 10.1111/clr.13277 -
Radiology Jul 2022Background Patients with fractures are a common emergency presentation and may be misdiagnosed at radiologic imaging. An increasing number of studies apply artificial... (Meta-Analysis)
Meta-Analysis
Background Patients with fractures are a common emergency presentation and may be misdiagnosed at radiologic imaging. An increasing number of studies apply artificial intelligence (AI) techniques to fracture detection as an adjunct to clinician diagnosis. Purpose To perform a systematic review and meta-analysis comparing the diagnostic performance in fracture detection between AI and clinicians in peer-reviewed publications and the gray literature (ie, articles published on preprint repositories). Materials and Methods A search of multiple electronic databases between January 2018 and July 2020 (updated June 2021) was performed that included any primary research studies that developed and/or validated AI for the purposes of fracture detection at any imaging modality and excluded studies that evaluated image segmentation algorithms. Meta-analysis with a hierarchical model to calculate pooled sensitivity and specificity was used. Risk of bias was assessed by using a modified Prediction Model Study Risk of Bias Assessment Tool, or PROBAST, checklist. Results Included for analysis were 42 studies, with 115 contingency tables extracted from 32 studies (55 061 images). Thirty-seven studies identified fractures on radiographs and five studies identified fractures on CT images. For internal validation test sets, the pooled sensitivity was 92% (95% CI: 88, 93) for AI and 91% (95% CI: 85, 95) for clinicians, and the pooled specificity was 91% (95% CI: 88, 93) for AI and 92% (95% CI: 89, 92) for clinicians. For external validation test sets, the pooled sensitivity was 91% (95% CI: 84, 95) for AI and 94% (95% CI: 90, 96) for clinicians, and the pooled specificity was 91% (95% CI: 81, 95) for AI and 94% (95% CI: 91, 95) for clinicians. There were no statistically significant differences between clinician and AI performance. There were 22 of 42 (52%) studies that were judged to have high risk of bias. Meta-regression identified multiple sources of heterogeneity in the data, including risk of bias and fracture type. Conclusion Artificial intelligence (AI) and clinicians had comparable reported diagnostic performance in fracture detection, suggesting that AI technology holds promise as a diagnostic adjunct in future clinical practice. Clinical trial registration no. CRD42020186641 © RSNA, 2022 See also the editorial by Cohen and McInnes in this issue.
Topics: Algorithms; Artificial Intelligence; Fractures, Bone; Humans; Sensitivity and Specificity
PubMed: 35348381
DOI: 10.1148/radiol.211785 -
The Journal of Clinical Endocrinology... May 2020Atypical femur fractures (AFFs) are serious adverse events associated with bisphosphonates and often show poor healing.
CONTEXT
Atypical femur fractures (AFFs) are serious adverse events associated with bisphosphonates and often show poor healing.
EVIDENCE ACQUISITION
We performed a systematic review to evaluate effects of teriparatide, raloxifene, and denosumab on healing and occurrence of AFF.
EVIDENCE SYNTHESIS
We retrieved 910 references and reviewed 67 papers, including 31 case reports, 9 retrospective and 3 prospective studies on teriparatide. There were no RCTs. We pooled data on fracture union (n = 98 AFFs on teriparatide) and found that radiological healing occurred within 6 months of teriparatide in 13 of 30 (43%) conservatively managed incomplete AFFs, 9 of 10 (90%) incomplete AFFs with surgical intervention, and 44 of 58 (75%) complete AFFs. In 9 of 30 (30%) nonoperated incomplete AFFs, no union was achieved after 12 months and 4 (13%) fractures became complete on teriparatide. Eight patients had new AFFs during or after teriparatide. AFF on denosumab was reported in 22 patients, including 11 patients treated for bone metastases and 8 without bisphosphonate exposure. Denosumab after AFF was associated with recurrent incomplete AFFs in 1 patient and 2 patients of contralateral complete AFF. Eight patients had used raloxifene before AFF occurred, including 1 bisphosphonate-naïve patient.
CONCLUSIONS
There is no evidence-based indication in patients with AFF for teriparatide apart from reducing the risk of typical fragility fractures, although observational data suggest that teriparatide might result in faster healing of surgically treated AFFs. Awaiting further evidence, we formulate recommendations for treatment after an AFF based on expert opinion.
Topics: Bone Density Conservation Agents; Denosumab; Diphosphonates; Europe; Femoral Fractures; Humans; Osteoporotic Fractures; Practice Patterns, Physicians'; Raloxifene Hydrochloride; Risk Assessment; Risk Factors; Societies, Medical; Teriparatide
PubMed: 31867670
DOI: 10.1210/clinem/dgz295