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The Cochrane Database of Systematic... Dec 2019Ascites is the accumulation of fluid within the abdominal cavity. Most women with advanced ovarian cancer and some women with advanced endometrial cancer need repeated... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Ascites is the accumulation of fluid within the abdominal cavity. Most women with advanced ovarian cancer and some women with advanced endometrial cancer need repeated drainage for ascites. Guidelines to advise those involved in the drainage of ascites are usually produced locally and are generally not evidence-based. Managing drains that improve the efficacy and quality of the procedure is key in making recommendations that could improve the quality of life (QoL) for women at this critical period of their lives.
OBJECTIVES
To evaluate the effectiveness and adverse events of different interventions for the management of malignant ascites drainage in the palliative care of women with gynaecological cancer.
SEARCH METHODS
We searched CENTRAL, MEDLINE, and Embase to 4 November 2019. We checked clinical trial registries, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) of women with malignant ascites with gynaecological cancer. If studies also included women with non-gynaecological cancer, we planned to extract data specifically for women with gynaecological cancers or request the data from trial authors. If this was not possible, we planned to include the study only if at least 50% of participants were diagnosed with gynaecological cancer.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected studies, extracted data, evaluated the quality of the included studies, compared results, and assessed the certainty of the evidence using Cochrane methodology.
MAIN RESULTS
In the original 2010 review, we identified no relevant studies. This updated review included one RCT involving 245 participants that compared abdominal paracentesis and intraperitoneal infusion of catumaxomab versus abdominal paracentesis alone. The study was at high risk of bias in almost all domains. The data were not suitable for analysis. The median time to the first deterioration of QoL ranged from 19 to 26 days in participants receiving paracentesis alone compared to 47 to 49 days among participants receiving paracentesis with catumaxomab infusion (very low-certainty evidence). Adverse events were only reported among participants receiving catumaxomab infusion. The most common severe adverse events were abdominal pain and lymphopenia (157 participants; very low-certainty evidence). There were no data on the improvement of symptoms, satisfaction of participants and caregivers, and cost-effectiveness.
AUTHORS' CONCLUSIONS
Currently, there is insufficient evidence to recommend the most appropriate management of drainage for malignant ascites among women with gynaecological cancer, as there was only very low-certainty evidence from one small RCT at overall high risk of bias.
Topics: Ascites; Drainage; Endometrial Neoplasms; Female; Humans; Ovarian Neoplasms; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 31825525
DOI: 10.1002/14651858.CD007794.pub3 -
Irish Journal of Medical Science May 2020In the management of bilateral fetal hydrothorax where the fetus is non-hydropic and apparently otherwise normal, we wished to determine if pleural-amniotic shunt...
OBJECTIVE
In the management of bilateral fetal hydrothorax where the fetus is non-hydropic and apparently otherwise normal, we wished to determine if pleural-amniotic shunt insertion was better than conservative management in terms of mortality.
METHODS
A systematic review was conducted between 1992 and 2017. Data extracted was inspected for heterogeneity. Where there was comparative data available, the odds ratio (OR) and confidence interval (CI) were calculated.
RESULTS
Seven studies were included in this systematic review. There was a paucity of comparative data where only 2 studies (28 cases) allowed for direct comparison. Within the limitations of the study, there was no difference between shunt insertion vs. conservative management in terms of stillbirth or miscarriage (OR = 1.00, 95% CI 0.12-8.34, heterogeneity I = 0%, p = 1.00).
CONCLUSION
There is insufficient data available to determine whether the outcome is improved by pleural-amniotic shunt insertion compared with conservative management in cases of bilateral fetal hydrothorax where the fetus is non-hydropic and otherwise normal.
Topics: Conservative Treatment; Female; Fetus; Humans; Hydrothorax; Pregnancy; Thoracentesis
PubMed: 31745722
DOI: 10.1007/s11845-019-02094-5 -
Gynecological Endocrinology : the... Mar 2020The aim of this study is to analyze the methods for reducing intra-abdominal pressure (IAP) in the management of the moderate and severe forms of ovarian...
The aim of this study is to analyze the methods for reducing intra-abdominal pressure (IAP) in the management of the moderate and severe forms of ovarian hyperstimulation syndrome (OHSS). We carried out a systematic review of the literature. An evaluation of clinical trials, meta-analysis, case-reports, and reviews assessing the management of conditions associated with OHSS and intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) was made using the following data sources: MEDLINE Pubmed (from 1966 to July 2019) and the Cochrane Controlled Clinical Trials Register, Embase (up to July 2019). The principles of treatment of IAH syndrome can be considered in the treatment of moderate and severe forms of OHSS. Medical treatment of patients with increased IAP in OHSS should be started early to prevent further organ dysfunction and avoid a transition to a more severe stage of IAH and ACS. Some of the new, non-surgical methods, such as continuous negative extra-abdominal pressure, are a promising option in specific groups of patients with OHSS. This review provides suggestions for the management of OHSS based on the principles of therapy for IAH syndrome. Further well-designed studies are needed to confirm these initial data.
Topics: Analgesics; Decompression; Decompression, Surgical; Female; Fluid Therapy; Humans; Hypnotics and Sedatives; Intra-Abdominal Hypertension; Intubation, Gastrointestinal; Ovarian Hyperstimulation Syndrome; Paracentesis; Severity of Illness Index
PubMed: 31668111
DOI: 10.1080/09513590.2019.1683822 -
Alimentary Pharmacology & Therapeutics Nov 2019Few effective treatments are available for patients with cirrhosis and refractory ascites. New treatment modalities are needed for these patients. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Few effective treatments are available for patients with cirrhosis and refractory ascites. New treatment modalities are needed for these patients.
AIM
To synthesise the available evidence on the efficacy and safety of automated low-flow ascites pump therapy in patients with cirrhosis and refractory ascites.
METHODS
Electronic databases were searched for trials evaluating automated low-flow ascites pump therapy in patients with refractory ascites.
RESULTS
Nine studies were included. Eight were case series, one was a randomised controlled trial. Pooled estimate rates were 0.62 (95% CI = 0.49-0.74) for the absence of requirement of large volume paracentesis (LVP) after pump insertion, 0.30 (95% CI = 0.17-0.47) for acute kidney injury, 0.27 (95% CI = 0.13-0.49) for bacterial peritonitis and 0.20 (95% CI = 0.09-0.37) for urinary tract infection. There was high heterogeneity between studies which was often reduced or eliminated in sensitivity analyses by excluding studies of patients with a mean or median model for end-stage liver disease (MELD) score > 15. Results of sensitivity analyses were similar to those of overall analyses. Mean increase in serum creatinine level after pump insertion was 23 µmol/L (95% CI = 10-35) with no heterogeneity between studies. The pooled estimate rate for pump-related side effects was 0.77 (95% CI = 0.64-0.87) with low heterogeneity between studies.
CONCLUSION
This meta-analysis demonstrates that most patients treated with automated low-flow ascites pump therapy do not require LVP after pump insertion. Acute kidney injury occurs in 30% of patients and creatinine levels increase by a mean of 23 µmol/L after pump insertion. Bacterial peritonitis and urinary tract infection occur in 27% and 20% of patients respectively.
Topics: Ascites; Automation; Bacterial Infections; Humans; Liver Cirrhosis; Liver Function Tests; Paracentesis; Peritonitis; Treatment Failure; Treatment Outcome
PubMed: 31583729
DOI: 10.1111/apt.15502 -
The Cochrane Database of Systematic... Jun 2019Plasma volume expanders are used in connection to paracentesis in people with cirrhosis to prevent reduction of effective plasma volume, which may trigger deleterious... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Plasma volume expanders are used in connection to paracentesis in people with cirrhosis to prevent reduction of effective plasma volume, which may trigger deleterious effect on haemodynamic balance, and increase morbidity and mortality. Albumin is considered the standard product against which no plasma expansion or other plasma expanders, e.g. other colloids (polygeline , dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol have been compared. However, the benefits and harms of these plasma expanders are not fully clear.
OBJECTIVES
To assess the benefits and harms of any plasma volume expanders such as albumin, other colloids (polygeline, dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol versus no plasma volume expander or versus another plasma volume expander for paracentesis in people with cirrhosis and large ascites.
SEARCH METHODS
We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, CNKI, VIP, Wanfang, Science Citation Index Expanded, and Conference Proceedings Citation Index until January 2019. Furthermore, we searched FDA, EMA, WHO (last search January 2019), www.clinicaltrials.gov/, and www.controlled-trials.com/ for ongoing trials.
SELECTION CRITERIA
Randomised clinical trials, no matter their design or year of publication, publication status, and language, assessing the use of any type of plasma expander versus placebo, no intervention, or a different plasma expander in connection with paracentesis for ascites in people with cirrhosis. We considered quasi-randomised, retrieved with the searches for randomised clinical trials only, for reports on harms.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. We calculated the risk ratio (RR) or mean difference (MD) using the fixed-effect model and the random-effects model meta-analyses, based on the intention-to-treat principle, whenever possible. If the fixed-effect and random-effects models showed different results, then we made our conclusions based on the analysis with the highest P value (the more conservative result). We assessed risks of bias of the individual trials using predefined bias risk domains. We assessed the certainty of the evidence at an outcome level, using GRADE, and constructed 'Summary of Findings' tables for seven of our review outcomes.
MAIN RESULTS
We identified 27 randomised clinical trials for inclusion in this review (24 published as full-text articles and 3 as abstracts). Five of the trials, with 271 participants, assessed plasma expanders (albumin in four trials and ascitic fluid in one trial) versus no plasma expander. The remaining 22 trials, with 1321 participants, assessed one type of plasma expander, i.e. dextran, hydroxyethyl starch, polygeline, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus another type of plasma expander, i.e. albumin in 20 of these trials and polygeline in one trial. Twenty-five trials provided data for quantitative meta-analysis. According to the Child-Pugh classification, most participants were at an intermediate to advanced stage of liver disease in the absence of hepatocellular carcinoma, recent gastrointestinal bleeding, infections, and hepatic encephalopathy. All trials were assessed as at overall high risk of bias. Ten trials seemed not to have been funded by industry; twelve trials were considered unclear about funding; and five trials were considered funded by industry or a for-profit institution.We found no evidence of a difference in effect between plasma expansion versus no plasma expansion on mortality (RR 0.52, 95% CI 0.06 to 4.83; 248 participants; 4 trials; very low certainty); renal impairment (RR 0.32, 95% CI 0.02 to 5.88; 181 participants; 4 trials; very low certainty); other liver-related complications (RR 1.61, 95% CI 0.79 to 3.27; 248 participants; 4 trials; very low certainty); and non-serious adverse events (RR 1.04, 95% CI 0.32 to 3.40; 158 participants; 3 trials; very low certainty). Two of the trials stated that no serious adverse events occurred while the remaining trials did not report on this outcome. No trial reported data on health-related quality of life.We found no evidence of a difference in effect between experimental plasma expanders versus albumin on mortality (RR 1.03, 95% CI 0.82 to 1.30; 1014 participants; 14 trials; very low certainty); serious adverse events (RR 0.89, 95% CI 0.10 to 8.30; 118 participants; 2 trials; very low certainty); renal impairment (RR 1.17, 95% CI 0.71 to 1.91; 1107 participants; 17 trials; very low certainty); other liver-related complications (RR 1.10, 95% CI 0.82 to 1.48; 1083 participants; 16 trials; very low certainty); and non-serious adverse events (RR 1.37, 95% CI 0.66 to 2.85; 977 participants; 14 trials; very low certainty). We found no data on heath-related quality of life and refractory ascites.
AUTHORS' CONCLUSIONS
Our systematic review and meta-analysis did not find any benefits or harms of plasma expanders versus no plasma expander or of one plasma expander such as polygeline, dextrans, hydroxyethyl starch, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus albumin on primary or secondary outcomes. The data originated from few, small, mostly short-term trials at high risks of systematic errors (bias) and high risks of random errors (play of chance). GRADE assessments concluded that the evidence was of very low certainty. Therefore, we can neither demonstrate or discard any benefit of plasma expansion versus no plasma expansion, and differences between one plasma expander versus another plasma expander.Larger trials at low risks of bias are needed to assess the role of plasma expanders in connection with paracentesis. Such trials should be conducted according to the SPIRIT guidelines and reported according to the CONSORT guidelines.
Topics: Humans; Ascites; Liver Cirrhosis; Paracentesis; Plasma Substitutes; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 31251387
DOI: 10.1002/14651858.CD004039.pub2 -
BMJ Supportive & Palliative Care Mar 2020Malignant pleural effusion (MPE) results in breathlessness and impairment of health-related quality of life (HRQOL). This study reviews the existing literature on HRQOL...
BACKGROUND
Malignant pleural effusion (MPE) results in breathlessness and impairment of health-related quality of life (HRQOL). This study reviews the existing literature on HRQOL following invasive interventions in MPE.
METHODS
Five electronic databases were systematically searched and assessed three times during the review process and last completed on 15 June 2018. We included all studies evaluating HRQOL outcomes for the following interventions: therapeutic thoracocentesis, talc slurry (TS) pleurodesis, indwelling pleural catheter (IPC) insertion and thoracoscopic talc poudrage (TTP) pleurodesis. Meta-analysis was not performed due to substantial heterogeneity in the published data.
RESULTS
17 studies were included in the review reporting HRQOL outcomes in 2515 patients. TTP, TS and IPC were associated with modest but inconsistent improvements in HRQOL up to 12 weeks. No intervention was significantly different from another in HRQOL outcomes at any time point. The attrition to follow-up was 48.3% (664/1374) at 3 months. The overall quality of studies was inadequate.
CONCLUSION
TTP, TS and IPC seem to improve HRQOL in MPE over 4-12 weeks, but there are insufficient longer term data due to high attrition rates. Evidence on the most effective treatment strategy is limited by the small number of randomised or comparative studies.
TRIAL REGISTRATION NUMBER
CRD42016051003.
Topics: Aged; Catheterization; Catheters, Indwelling; Female; Humans; Male; Middle Aged; Pleural Effusion, Malignant; Pleurodesis; Quality of Life; Talc; Thoracentesis; Thoracoscopy; Treatment Outcome
PubMed: 31243020
DOI: 10.1136/bmjspcare-2018-001610 -
Diagnostics (Basel, Switzerland) Jun 2019The aim of this study was to review the scientific literature available on the comparison of hand-held ultrasound devices with high-end systems for abdominal and pleural... (Review)
Review
The aim of this study was to review the scientific literature available on the comparison of hand-held ultrasound devices with high-end systems for abdominal and pleural applications. PubMed, Embase, Web of Science and Cochrane were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Original research describing hand-held ultrasound devices compared with high-end systems was included and assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2. The search was limited to articles published since 1 January 2012. A total of 2486 articles were found and screened by title and abstract. A total of 16 articles were chosen for final review. All of the included articles showed good overall agreement between hand-held and high-end ultrasound systems. Strong correlations were found when evaluating ascites, hydronephrosis, pleural cavities, in detection of abdominal aortic aneurysms and for use with obstetric and gynaecological patients. Other articles found good agreement for cholelithiasis and for determining the best site for paracentesis. QUADAS-2 analysis suggested few risks of bias and almost no concerns regarding applicability. For distinct clinical questions, hand-held devices may be a valuable supplement to physical examination. However, evidence is inadequate, and more research is needed on the abdominal and pleural use of hand-held ultrasound with more standardised comparisons, using only blinded reviewers.
PubMed: 31208078
DOI: 10.3390/diagnostics9020061 -
Respiratory Medicine Jul 2019As many as 25% of all patients undergoing invasive pulmonary procedures are receiving at least one antiplatelet or anticoagulant agent. For those undergoing elective...
As many as 25% of all patients undergoing invasive pulmonary procedures are receiving at least one antiplatelet or anticoagulant agent. For those undergoing elective procedures, the decision-making process is uncomplicated and the procedure may be postponed until the antiplatelet or anticoagulant agent may be safely held. However, many invasive pulmonary procedures are semi-elective or emergent in nature in which case a risk-benefit calculation and discussion occur between the provider and patient or surrogate decision-maker. Therefore, it is critical for providers to have an awareness of the risk of bleeding complications with different pulmonary procedures on various antiplatelet and anticoagulant agents. This systematic review summarizes the bleeding complications associated with different pulmonary procedures in patients on various antiplatelet or anticoagulant agents in the literature and reveals a paucity of high-quality evidence across a wide spectrum of pulmonary procedures and antiplatelet or anticoagulant agents. The results of this review can help inform providers of the bleeding risk in these patients to aid in the shared decision-making process and risk vs benefit discussion.
Topics: Adult; Anticoagulants; Awareness; Bronchoscopy; Clinical Decision-Making; Diagnostic Techniques and Procedures; Hemorrhage; Humans; Lung Diseases; Male; Platelet Aggregation Inhibitors; Pleural Diseases; Postoperative Hemorrhage; Thoracentesis; Tracheostomy
PubMed: 31176274
DOI: 10.1016/j.rmed.2019.05.018 -
Liver International : Official Journal... Sep 2019The incidence and mortality from end-stage liver disease is increasing, with a minority eligible for liver transplantation. Ascites is the commonest complication of...
BACKGROUND & AIMS
The incidence and mortality from end-stage liver disease is increasing, with a minority eligible for liver transplantation. Ascites is the commonest complication of end-stage liver disease and large volume paracentesis (LVP) the accepted management strategy where refractory to medical treatment. In malignant ascites, permanent indwelling peritoneal catheters (PIPC) are an established palliative intervention. The aims are to describe available data using permanent indwelling peritoneal catheters in refractory ascites due to end-stage liver disease.
METHODS
Using systematic review methodology, databases were searched (MEDLINE, EMBASE, CINAHL [The Cumulative Index to Nursing and Allied Health Literature], Google Scholar and Cochrane Database of Systematic Reviews from inception-March 2018), for studies combining ascites and palliative care. Inclusion and exclusion criteria were applied to results.
RESULTS
Following initial and updated searches, 225 studies were identified for full text review, 18 were eligible for final analysis. The studies displayed heterogeneity in design, reported on different indwelling catheters and were overall of low quality. Only one pilot randomised controlled trial was identified, of PIPC versus LVP, recruiting one patient into each arm. Technical insertion success was 100%, with low rates of non-infectious complications (<12%), none life threatening. Rates of bacterial peritonitis were not unacceptably high (12.7%), considering this was an end-stage liver disease population and only a minority utilising long-term prophylactic antibiotics. Only one study attempted quality-of-life assessments; none addressed potential health economic benefits.
CONCLUSIONS
Despite lack of well-designed studies, preliminary data suggests low significant complication rates; however safety and efficacy of permanent indwelling peritoneal catheters in end-stage liver disease remains to be confirmed. Further prospective randomised controlled trials are warranted, potentially translating permanent indwelling peritoneal catheters into improved palliative care in end-stage liver disease.
Topics: Antibiotic Prophylaxis; Ascites; Bacterial Infections; Catheters, Indwelling; Drainage; End Stage Liver Disease; Humans; Palliative Care; Paracentesis; Peritonitis; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 31152623
DOI: 10.1111/liv.14162 -
Paediatric Respiratory Reviews Apr 2019The ideal surgical approach for empyema in children (≤18 years) remains controversial. Video assisted thoracoscopic surgery (VATS) and chest drain with fibrinolysis... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
The ideal surgical approach for empyema in children (≤18 years) remains controversial. Video assisted thoracoscopic surgery (VATS) and chest drain with fibrinolysis (CDF) are both accepted methods. The aim of this study was to clarify which of these two techniques provides the best clinical outcome.
METHODS
A systematic review and meta-analysis (1997-2018) was conducted. We used the random-effect model to produce risk ratio (RR) for categorical variables, and standard difference in means (SDM) for continuous variables, along with 95% confidence intervals [CI]. I value was used to assess heterogeneity. P values <0.05 were considered significant.
RESULTS
We identified 707 studies: 10 studies were included in the final analysis. The incidence of total peri-operative complications was not different between the two groups (RR 0.6 [CI: 0.3-1.2], p = 0.2; I = 0.0%; p = 0.6). Need for re-intervention was significantly lower in the VATS group (RR 0.55 [CI: 0.34-0.88], p = 0.01; I = 14.4%; p = 0.3). Post-operative length of hospital stay was significantly shorter in the VATS group (SDM -0.45 [CI: -0.78 to -0.12], p = 0.007; I = 88%; p = 0.001).
CONCLUSIONS
Current evidence suggests that VATS and CDF for empyema in children have a similar incidence of peri-operative complications. However, VATS seems associated with reduced need for re-intervention and shorter post-operative hospital stay.
Topics: Chest Tubes; Child; Empyema, Pleural; Fibrinolytic Agents; Humans; Thoracentesis; Thoracic Surgery, Video-Assisted
PubMed: 31130425
DOI: 10.1016/j.prrv.2018.09.001