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The Journal of Foot and Ankle Surgery :... 2017Acute Achilles tendon ruptures can be treated with surgical and nonsurgical treatment. However, the optimal intervention for acute Achilles tendon rupture remains... (Comparative Study)
Comparative Study Meta-Analysis Review
Acute Achilles tendon ruptures can be treated with surgical and nonsurgical treatment. However, the optimal intervention for acute Achilles tendon rupture remains controversial. The aim of the present study was to compare the clinical outcomes of surgical treatment versus conservative management for acute Achilles tendon rupture. Eight randomized controlled studies involving 762 patients were included in the meta-analysis. In general, re-rupture occurred in 14 of 381 surgically treated patients (3.7%) and 37 of 377 nonsurgically treated patients (9.8%). Pooled results showed that the total re-rupture rate was significantly lower in surgical group than that in the nonsurgical group (risk ratio 0.38, 95% confidence interval 0.21 to 0.68; p = .001). No significant differences were found between the 2 treatment groups in the incidence of deep venous thrombosis, the number who returned to sport, ankle range of motion (dorsiflexion, plantarflexion), Achilles tendon total rupture score, or physical activity scale. Surgical treatment can effectively reduce the re-rupture rate and might be a better choice for the treatment of acute Achilles tendon rupture. Multicenter, double-blind randomized controlled trials with stratification and long-term follow-up are needed to obtain a higher level of evidence and to guide clinical practice, especially in the comparison and selection of different treatments.
Topics: Achilles Tendon; Conservative Treatment; Female; Humans; Male; Orthopedic Procedures; Postoperative Complications; Randomized Controlled Trials as Topic; Range of Motion, Articular; Recovery of Function; Recurrence; Rupture; Tendon Injuries; Treatment Outcome
PubMed: 29079238
DOI: 10.1053/j.jfas.2017.05.036 -
Frontiers in Neurology 2022Cerebral venous sinus thrombosis (CVST) is increasingly being recognized in the setting of traumatic brain injury (TBI), but its effect on TBI patients and its...
Cerebral venous sinus thrombosis in traumatic brain injury: A systematic review of its complications, effect on mortality, diagnostic and therapeutic management, and follow-up.
OBJECTIVE
Cerebral venous sinus thrombosis (CVST) is increasingly being recognized in the setting of traumatic brain injury (TBI), but its effect on TBI patients and its management remains uncertain. Here, we systematically review the currently available evidence on the complications, effect on mortality and the diagnostic and therapeutic management and follow-up of CVST in the setting of TBI.
METHODS
Key clinical questions were posed and used to define the scope of the review within the following topics of complications; effect on mortality; diagnostics; therapeutics; recanalization and follow-up of CVST in TBI. We searched relevant databases using a structured search strategy. We screened identified records according to eligibility criteria and for information regarding the posed key clinical questions within the defined topics of the review.
RESULTS
From 679 identified records, 21 studies met the eligibility criteria and were included, all of which were observational in nature. Data was deemed insufficiently homogenous to perform meta-analysis and was narratively synthesized. Reported rates of venous infarctions ranged between 7 and 38%. One large registry study reported increased in-hospital mortality in CVSP and TBI compared to a control group with TBI alone in adjusted analyses. Another two studies found midline CVST to be associated with increased risk of mortality in adjusted analyses. Direct data to inform the optimum diagnostic and therapeutic management of the condition was limited, but some data on the safety, and effect of anticoagulation treatment of CVST in TBI was identified. Systematic data on recanalization rates to guide follow-up was also limited, and reported complete recanalization rates ranged between 41 and 86%. In the context of the identified data, we discuss the diagnostic and therapeutic management and follow-up of the condition.
CONCLUSION
Currently, the available evidence is insufficient for evidence-based treatment of CVST in the setting of TBI. However, there are clear indications in the presently available literature that CVST in TBI is associated with complications and increased mortality, and this indicates that management options for the condition must be considered. Further studies are needed to confirm the effects of CVST on TBI patients and to provide evidence to support management decisions.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/, identifier: PROSPERO [CRD42021247833].
PubMed: 36698879
DOI: 10.3389/fneur.2022.1079579 -
Journal of Vascular Surgery. Venous and... Nov 2021Venous injury to the inferior vena cava or iliac veins is rare but can result in high mortality rates. Traditional treatment by repair or ligation can be technically...
OBJECTIVE
Venous injury to the inferior vena cava or iliac veins is rare but can result in high mortality rates. Traditional treatment by repair or ligation can be technically demanding. A relatively new treatment modality is the use of a covered stent to cover the venous defect. The aim of the present systematic review was to assess the techniques, results, and challenges of covered stent graft repair of traumatic injury to the inferior vena cava and iliac veins.
METHODS
The PubMed (Medline) and Embase databases were systematically searched up to September 2020 by two of us (R.R.S. and D.D.) independently for studies reporting on covered stenting of the inferior vena cava or iliac veins after traumatic or iatrogenic injury. A methodologic quality assessment was performed using the modified Newcastle-Ottawa scale. Data were extracted for the following parameters: first author, year of publication, study design, number of patients, type and diameter of the stent graft, hemostatic success, complications, mortality, postoperative medication, follow-up type and duration, and venous segment patency. The main outcome was clinical success of the intervention, defined as direct hemostasis, with control of hemorrhage, hemodynamic recovery, and absence of contrast extravasation.
RESULTS
From the initial search, which yielded 1884 records, a total of 28 studies were identified for analysis. All reports consisted of case reports, except for one retrospective cohort study and one case series. A total of 35 patients had been treated with various covered stent grafts, predominantly thoracic or abdominal aortic endografts. In all patients, the treatment was technically successful. The 30-day mortality rate for the entire series was 2.9%. Three perioperative complications were described: one immediate stent occlusion, one partial thrombosis, and one pulmonary embolism. Additional in-stent thrombus formation was seen during follow-up in three patients, leading to one stent graft occlusion (asymptomatic). The postoperative anticoagulation strategy was highly heterogeneous. The median follow-up was 3 months (range, 0.1-84 months). However, follow-up with imaging studies was not performed in all cases.
CONCLUSIONS
In selected cases of injury to the inferior vena cava and iliac veins, covered stent grafts can be successful for urgent hemostasis with good short-term results. Data on long-term follow-up are very limited.
Topics: Humans; Iliac Vein; Prosthesis Design; Stents; Vascular Surgical Procedures; Vena Cava, Inferior
PubMed: 33771733
DOI: 10.1016/j.jvsv.2021.03.008 -
Wound Repair and Regeneration :... Sep 2019Use of complementary and alternative medicine for wound healing is influencing mainstream medical practice. This systematic review evaluates the role of Calendula...
Use of complementary and alternative medicine for wound healing is influencing mainstream medical practice. This systematic review evaluates the role of Calendula officinalis flower extract as monotherapy compared to control for wound healing in vivo. Searches were conducted in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus (up to April 2018) with 14 studies meeting the inclusion criteria, comprising 7 animal experiments and 7 clinical trials. Findings from the review on acute wound healing showed faster resolution of the inflammation phase with increased production of granulation tissue in the test groups treated with extract. These findings were consistent in five animal studies and one randomized clinical trial. Chronic wound healing studies were varied. Two clinical control studies on venous ulcers demonstrated decreased ulcer surface area compared to controls. Another randomized clinical trial demonstrated no improvement for the calendula group in diabetic leg ulcer healing. Burn healing similarly showed mixed results. Two animal studies demonstrated a prophylactic effect for the administration of calendula extract prior to burn injury. A randomized clinical trial of patients suffering from partial to full thickness burns demonstrated no benefit for topical application of calendula extract compared to controls. Two randomized clinical trials assessed the potential for extract to prevent acute post radiation dermatitis, with one study showing improvements compared to trolamine, while the other found no improvement compared to aqua gel cream. Animal studies provide moderate evidence for improved recovery from the inflammation phase and increased production of granulation tissue in calendula extract treatment groups. This review identified some evidence for the beneficial effects of C. officinalis extract for wound healing, consistent with its role in traditional medicine. There is a need for larger, well-designed randomized control trials to assess the effect of calendula on wound healing including complications.
Topics: Administration, Topical; Animals; Calendula; Clinical Trials as Topic; Granulation Tissue; Humans; Models, Animal; Ointments; Phytotherapy; Plant Extracts; Treatment Outcome; Varicose Ulcer; Wound Healing
PubMed: 31145533
DOI: 10.1111/wrr.12737 -
The Journal of Trauma and Acute Care... Sep 2016Venous thromboembolism (VTE) is a common, potentially fatal complication after traumatic brain injury (TBI). The objective was to evaluate the effectiveness and safety... (Meta-Analysis)
Meta-Analysis Review
The effectiveness and safety of pharmacological prophylaxis against venous thromboembolism in patients with moderate to severe traumatic brain injury: A systematic review and meta-analysis.
BACKGROUND
Venous thromboembolism (VTE) is a common, potentially fatal complication after traumatic brain injury (TBI). The objective was to evaluate the effectiveness and safety of pharmacologic VTE prophylaxis in moderate to severe TBI patients, and its use in hospitals.
DATA SOURCES
A systematic review of the literature was conducted using Medline, Embase, Central database, Google scholar, and the SciELO from 1966 to 2014.
STUDY SELECTION & DATA EXTRACTION
All studies providing information on the following variables-use of VTE prophylaxis (both pharmacological and nonpharmacological), initiation of treatment, application of specific protocols, rates of VTE and hemorrhagic progression of the traumatic brain injury on computed tomographic scan-were included. The random effects model was used to calculate pooled effect estimates. Heterogeneity among studies was assessed using the Cochran Q homogeneity test. A forest plot was constructed, and aggregate odds ratio was computed. Potential publication bias was evaluated using funnel plots.
METHODS & MAIN RESULTS
A total of 12 retrospective observational studies were identified, totaling 8,747 patients. Six studies (3,325 patients) were used to analyze the safety and five (2,105 patients) to analyze the effectiveness of pharmacological versus nonpharmacological prophylaxis, without considering the timing of treatment. Four studies (1,371 patients) were used to evaluate early versus late pharmacologic prophylaxis, with results favoring early administration (odds ratio, 0.46; 95% confidence interval, 0.24-0.88; p < 0.05; I, 46%) and showing no significant differences regarding safety. Three studies (4,133 patients), used to analyze VTE prophylaxis protocols, showed significant heterogeneity (p < 0.01).
CONCLUSION
When we compared mechanical and pharmacological prophylaxis, the results were heterogeneous; and thus, their potential differences could not be assessed. In some studies, the introduction of prophylaxis protocols in neurocritical patient care improved their effectiveness. Early pharmacologic prophylaxis, in the first 72 hours after TBI, was more effective than late, when there was no hemorrhagic progression within 24 hours after injury; no significant differences were found regarding safety.
LEVEL OF EVEDINCE
Systematic review/meta-analysis, level III.
Topics: Anticoagulants; Brain Injuries, Traumatic; Humans; Venous Thromboembolism
PubMed: 27244574
DOI: 10.1097/TA.0000000000001134 -
European Journal of Vascular and... Nov 2023The objective was to compare technical success, complications, and quality of life after thermal vs. non-thermal endovenous ablation for the treatment of superficial... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The objective was to compare technical success, complications, and quality of life after thermal vs. non-thermal endovenous ablation for the treatment of superficial venous incompetence.
DATA SOURCES
Electronic bibliographic sources (Google Scholar, Pubmed, Cochrane Database, Scopus, Web of Science, and Embase).
REVIEW METHODS
A systematic review and meta-analysis of randomised controlled trials was conducted using terms to identify relevant studies to be included. The primary outcome was vein occlusion rate at up to four weeks and one to two years from procedure. Secondary outcome measures included peri-procedural pain, nerve injury, endothermal heat induced thrombosis, and quality of life.
RESULTS
Eight randomised controlled trials met the selection criteria. These comprised a total of 1 956 patients, of whom 1 042 underwent endovenous thermal ablation and 915 underwent endovenous non-thermal ablation. There was no statistically significant difference in occlusion rate at all time points. Relative risk at four weeks and one to two years was 0.99 (95% CI 0.96 - 1.02) and 0.95 (95% CI 0.88 - 1.01), respectively. Non-thermal ablation was tolerated better and had less risk of nerve injury. There was no statistically significant difference in risk of endothermal heat induced thrombosis (EHIT). There was improvement in quality of life scores post-procedure but there was no statistically significant difference in thermal vs. non-thermal ablation. The quality of evidence assessed using GRADE methodology showed high quality for occlusion rate at four weeks and one to two years, moderate quality for nerve injury and peri-procedural pain, and low quality for EHIT.
CONCLUSION
Vein occlusion rates after thermal vs. non-thermal endovenous ablation are similar. In the early post-operative period, non-thermal endovenous ablation demonstrated the advantages of less pain and less risk of nerve injury. Improvement in quality of life after both thermal and non-thermal endovenous ablation is similar.
Topics: Humans; Pain, Procedural; Quality of Life; Varicose Veins; Saphenous Vein; Thrombosis; Venous Insufficiency; Treatment Outcome; Laser Therapy; Randomized Controlled Trials as Topic
PubMed: 37295602
DOI: 10.1016/j.ejvs.2023.06.002 -
World Journal of Emergency Surgery :... Apr 2022Blunt abdominal solid organ injury is common and is often managed nonoperatively. Clinicians must balance risk of both hemorrhage and thrombosis. The optimal timing of... (Meta-Analysis)
Meta-Analysis
Timing of pharmacologic venous thromboembolism prophylaxis initiation for trauma patients with nonoperatively managed blunt abdominal solid organ injury: a systematic review and meta-analysis.
BACKGROUND
Blunt abdominal solid organ injury is common and is often managed nonoperatively. Clinicians must balance risk of both hemorrhage and thrombosis. The optimal timing of pharmacologic venous thromboembolism prophylaxis (VTEp) initiation in this population is unclear. The objective was to evaluate early (< 48 h) compared to late initiation of VTEp in adult trauma patients with blunt abdominal solid organ injury managed nonoperatively.
METHODS
Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception to March 2021. Studies comparing timeframes of VTEp initiation were considered. The primary outcome was failure of nonoperative management (NOM) after VTEp initiation. Secondary outcomes included risk of transfusion, other bleeding complications, risk of deep vein thrombosis (DVT) and pulmonary embolism, and mortality.
RESULTS
Ten cohort studies met inclusion criteria, with a total of 4642 patients. Meta-analysis revealed a statistically significant increase in the risk of failure of NOM among patients receiving early VTEp (OR 1.76, 95% CI 1.01-3.05, p = 0.05). There was no significant difference in risk of transfusion. Odds of DVT were significantly lower in the early group (OR 0.36, 95% CI 0.22-0.59, p < 0.0001). There was no difference in mortality (OR 1.50, 95% CI 0.82-2.75, p = 0.19). All studies were at serious risk of bias due to confounding.
CONCLUSIONS
Initiation of VTEp earlier than 48 h following hospitalization is associated with an increased risk of failure of NOM but a decreased risk of DVT. Absolute failure rates of NOM are low. Initiation of VTEp at 48 h may balance the risks of bleeding and VTE.
Topics: Abdominal Injuries; Adult; Anticoagulants; Blood Transfusion; Humans; Venous Thromboembolism; Wounds, Nonpenetrating
PubMed: 35468835
DOI: 10.1186/s13017-022-00423-1 -
Injury Apr 2022It is unclear which pharmacological agents, and at what dosage and timing, are most effective for venous thromboembolism (VTE) prophylaxis in patients with...
BACKGROUND
It is unclear which pharmacological agents, and at what dosage and timing, are most effective for venous thromboembolism (VTE) prophylaxis in patients with pelvic/acetabular fractures.
METHODS
We searched the Cochrane Database of Systematic Reviews, Embase, Web of Science, EBSCO, and PubMed on October 3, 2020, for English-language studies of VTE prophylaxis in patients with pelvic/acetabular fractures. We applied no date limits. We included studies that compared efficacy of pharmacological agents for VTE prophylaxis, timing of administration of such agents, and/or dosage of such agents. We recorded interventions, sample sizes, and VTE incidence, including deep vein thrombosis (DVT) and pulmonary embolism.
RESULTS
Two studies (3604 patients) compared pharmacological agents, reporting that patients who received direct oral anticoagulants (DOACs) were less likely to develop DVT than those who received low molecular weight heparin (LMWH) (p < 0.01). Compared with unfractionated heparin (UH), LMWH was associated with lower odds of VTE (odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.63) and death (OR = 0.27, 95% CI: 0.10-0.72). Three studies (3107 patients) compared timing of VTE prophylaxis, reporting that late prophylaxis was associated with higher odds of VTE (OR = 1.9, 95% CI: 1.2-3.2) and death (OR = 4.0, 95% CI: 1.5-11) and higher rates of symptomatic DVT (9.2% vs. 2.5%, p = 0.03; and 22% vs. 3.1%, p = 0.01). One study (31 patients) investigated dosage of VTE prophylaxis, reporting that a higher proportion of patients with acetabular fractures were underdosed (23% of patients below range of anti-Factor Xa [aFXa] had acetabular fractures vs. 4.8% of patients within adequate range of aFXa, p<0.01).
CONCLUSIONS
Early VTE chemoprophylaxis (within 24 or 48 h after injury) was better than late administration in terms of VTE and death. Many patients with acetabular fractures are underdosed with LMWH, with inadequate aFXa levels. Compared with UH, LMWH was associated with lower odds of VTE and death. DOACs were associated with lower risk of DVT compared with LMWH.
LEVEL OF EVIDENCE
III, systematic review of retrospective cohort studies.
Topics: Anticoagulants; Chemoprevention; Heparin; Heparin, Low-Molecular-Weight; Humans; Pulmonary Embolism; Retrospective Studies; Venous Thromboembolism
PubMed: 35148902
DOI: 10.1016/j.injury.2022.01.045 -
The Canadian Journal of Neurological... Jul 2018Patients suffering from traumatic brain injury (TBI) are at increased risk of venous thromboembolism (VTE). However, initiation of pharmacological venous...
BACKGROUND
Patients suffering from traumatic brain injury (TBI) are at increased risk of venous thromboembolism (VTE). However, initiation of pharmacological venous thromboprophylaxis (VTEp) may cause further intracranial hemorrhage. We reviewed the literature to determine the postinjury time interval at which VTEp can be administered without risk of TBI evolution and hematoma expansion.
METHODS
MEDLINE and EMBASE databases were searched. Inclusion criteria were studies investigating timing and safety of VTEp in TBI patients not previously on oral anticoagulation. Two investigators extracted data and graded the papers' levels of evidence. Randomized controlled trials were assessed for bias according to the Cochrane Collaboration Tool and Cohort studies were evaluated for bias using the Newcastle-Ottawa Scale. We performed univariate meta-regression analysis in an attempt to identify a relationship between VTEp timing and hemorrhagic progression and assess study heterogeneity using an I 2 statistic.
RESULTS
Twenty-one studies were included in the systematic review. Eighteen total studies demonstrated that VTEp postinjury in patients with stable head computed tomography scan does not lead to TBI progression. Fourteen studies demonstrated that VTEp administration 24 to 72 hours postinjury is safe in patients with stable injury. Four studies suggested that administering VTEp within 24 hours of injury in patients with stable TBI does not lead to progressive intracranial hemorrhage. Overall, meta-regression analysis demonstrated that there was no relationship between rate of hemorrhagic progression and VTEp timing.
CONCLUSIONS
Literature suggests that administering VTEp 24 to 48 hours postinjury may be safe for patients with low-hemorrhagic-risk TBIs and stable injury on repeat imaging.
Topics: Anticoagulants; Brain Injuries, Traumatic; Databases, Bibliographic; Humans; Venous Thromboembolism
PubMed: 29895339
DOI: 10.1017/cjn.2017.275 -
The Cochrane Database of Systematic... Aug 2019Hospital-acquired infection is a frequent adverse event in patient care; it can lead to longer stays in the intensive care unit (ICU), additional medical complications,...
BACKGROUND
Hospital-acquired infection is a frequent adverse event in patient care; it can lead to longer stays in the intensive care unit (ICU), additional medical complications, permanent disability or death. Whilst all hospital-based patients are susceptible to infections, prevalence is particularly high in the ICU, where people who are critically ill have suppressed immunity and are subject to increased invasive monitoring. People who are mechanically-ventilated are at infection risk due to tracheostomy and reintubation and use of multiple central venous catheters, where lines and tubes may act as vectors for the transmission of bacteria and may increase bloodstream infections and ventilator-associated pneumonia (VAP). Chlorhexidine is a low-cost product, widely used as a disinfectant and antiseptic, which may be used to bathe people who are critically ill with the aim of killing bacteria and reducing the spread of hospital-acquired infections.
OBJECTIVES
To assess the effects of chlorhexidine bathing on the number of hospital-acquired infections in people who are critically ill.
SEARCH METHODS
In December 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies, and checked reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) that compared chlorhexidine bathing with soap-and-water bathing of patients in the ICU.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed study eligibility, extracted data and undertook risk of bias and GRADE assessment of the certainty of the evidence .
MAIN RESULTS
We included eight studies in this review. Four RCTs included a total of 1537 individually randomised participants, and four cluster-randomised cross-over studies included 23 randomised ICUs with 22,935 participants. We identified one study awaiting classification, for which we were unable to assess eligibility.The studies compared bathing using 2% chlorhexidine-impregnated washcloths or dilute solutions of 4% chlorhexidine versus soap-and-water bathing or bathing with non-antimicrobial washcloths.Eight studies reported data for participants who had a hospital-acquired infection during the ICU stay. We are uncertain whether using chlorhexidine for bathing of critically ill people reduces the rate of hospital-acquired infection, because the certainty of the evidence is very low (rate difference 1.70, 95% confidence interval (CI) 0.12 to 3.29; 21,924 participants). Six studies reported mortality (in hospital, in the ICU, and at 48 hours). We cannot be sure whether using chlorhexidine for bathing of critically-ill people reduces mortality, because the certainty of the evidence is very low (odds ratio 0.87, 95% CI 0.76 to 0.99; 15,798 participants). Six studies reported length of stay in the ICU. We noted that individual studies found no evidence of a difference in length of stay; we did not conduct meta-analysis because data were skewed. It is not clear whether using chlorhexidine for bathing of critically ill people reduced length of stay in the ICU, because the certainty of the evidence is very low. Seven studies reported skin reactions as an adverse event, and five of these reported skin reactions which were thought to be attributable to the bathing solution. Data in these studies were reported inconsistently and we were unable to conduct meta-analysis; we cannot tell whether using chlorhexidine for bathing of critically ill people reduced adverse events, because the certainty of the evidence is very low.We used the GRADE approach to downgrade the certainty of the evidence of each outcome to very low. For all outcomes, we downgraded evidence because of study limitations (most studies had a high risk of performance bias, and we noted high risks of other bias in some studies). We downgraded evidence due to indirectness, because some participants in studies may have had hospital-acquired infections before recruitment. We noted that one small study had a large influence on the effect for hospital-acquired infections, and we assessed decisions made in analysis of some cluster-randomised cross-over studies on the effect for hospital-acquired infections and for mortality; we downgraded the evidence for these outcomes due to inconsistency. We also downgraded the evidence on length of stay in the ICU, because of imprecision. Data for adverse events were limited by few events and so we downgraded for imprecision.
AUTHORS' CONCLUSIONS
Due to the very low-certainty evidence available, it is not clear whether bathing with chlorhexidine reduces hospital-acquired infections, mortality, or length of stay in the ICU, or whether the use of chlorhexidine results in more skin reactions.
Topics: Anti-Infective Agents, Local; Baths; Central Venous Catheters; Chlorhexidine; Critical Illness; Cross Infection; Humans; Pneumonia, Ventilator-Associated; Randomized Controlled Trials as Topic; Sepsis
PubMed: 31476022
DOI: 10.1002/14651858.CD012248.pub2