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European Journal of Vascular and... Jun 2018The incidence of spinal cord ischaemia (SCI) and subsequent paraplegia after thoracic endovascular aneurysm repair (TEVAR) and thoraco-abdominal endovascular aneurysm... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
The incidence of spinal cord ischaemia (SCI) and subsequent paraplegia after thoracic endovascular aneurysm repair (TEVAR) and thoraco-abdominal endovascular aneurysm repair is estimated to be between 2.5% and 8%. The aim of this review is to provide an overview of SCI preventive strategies in TEVAR and thoraco-abdominal repair and recommend an optimal strategy.
METHODS
Medline, Embase, and the Cochrane Library were searched for studies on TEVAR, thoraco-abdominal endovascular repair, and the use of SCI preventive measures. The review was reported according to the PRISMA statement.
RESULTS
The final analysis included 43 studies (7168 patients). All studies are cohort studies (non-comparative cohorts n = 37, comparative cohorts n = 6) and largely performed retrospectively (n = 27). The included studies had an average MINORS score of 9 (range 6-13) for non-comparative studies and 15.5 (range 12-18) for comparative studies. Transient SCI occurred in 5.7% (450/7,168, 95% CI 4.5-6.9%), permanent SCI in 2.2% (232/7,168, 95% CI 1.6-2.8%). There was a trend towards increased SCI incidence for more "high risk" cohorts. Avoidance of hypotension resulted in a slightly lower permanent SCI rate 1.8% (102/4216, 95% CI 1.2-2.3%) than the overall cohort. A very low SCI estimate (transient and permanent) was found in the subgroup of studies (2 studies, n = 248) using (mild) peri-operative hypothermia (transient SCI 0.8%, permanent SCI 0.4%). In the subgroup using temporary permissive endoleak, there was a transient SCI estimate (15.4%), with a permanent SCI estimate of 4.8%. The remaining preventive measures did not significantly impact transient or permanent SCI estimates.
CONCLUSION
Low overall transient and permanent SCI rates are achieved during endovascular thoracic and thoraco-abdominal aortic repair. Based on the presented data, the use of selective spinal fluid drainage in high risk patients seems justified. Peri-operative hypotension should be avoided and treated where possible. The use of mild hypothermia is promising in small cohorts, but requires further evaluation. Further high quality data are essential to establish a definitive preventive strategy.
Topics: Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Endovascular Procedures; Epidemiologic Methods; Humans; Postoperative Complications; Spinal Cord Ischemia
PubMed: 29525741
DOI: 10.1016/j.ejvs.2018.02.002 -
Nutrition in Clinical Practice :... Jun 2018The aim of this study was to systematically review the effect of permissive underfeeding/trophic feeding on the clinical outcomes of critically ill patients. A...
Permissive or Trophic Enteral Nutrition and Full Enteral Nutrition Had Similar Effects on Clinical Outcomes in Intensive Care: A Systematic Review of Randomized Clinical Trials.
The aim of this study was to systematically review the effect of permissive underfeeding/trophic feeding on the clinical outcomes of critically ill patients. A systematic review of randomized clinical trials to evaluate the mortality, length of stay, and mechanical ventilation duration in patients randomized to either hypocaloric or full-energy enteral nutrition was performed. Data sources included PubMed and Scopus and the reference lists of the articles retrieved. Two independent reviewers participated in all phases of this systematic review as proposed by the Cochrane Handbook, and the review was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 7 randomized clinical trials that included a total of 1,717 patients were reviewed. Intensive care unit length of stay and mechanical ventilation duration were not statistically different between the intervention and control groups in all randomized clinical trials, and mortality rate was also not different between the groups. In conclusion, hypocaloric enteral nutrition had no significantly different effects on morbidity and mortality in critically ill patients when compared with full-energy nutrition. It is still necessary to determine the safety of this intervention in this group of patients, the optimal amount of energy provided, and the duration of this therapy.
Topics: Critical Care; Critical Illness; Enteral Nutrition; Humans; Length of Stay; Nutritional Status; Randomized Controlled Trials as Topic; Respiration, Artificial; Treatment Outcome
PubMed: 29377333
DOI: 10.1002/ncp.10001 -
The Journal of Trauma and Acute Care... May 2018Aggressive fluid resuscitation in trauma promotes deleterious effects such as clot disruption, dilutional coagulopathy and hypothermia. Animal studies suggest that... (Meta-Analysis)
Meta-Analysis
Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Aggressive fluid resuscitation in trauma promotes deleterious effects such as clot disruption, dilutional coagulopathy and hypothermia. Animal studies suggest that permissive hypotension maintains appropriate organ perfusion, reduces bleeding and improves mortality. This review assesses the efficacy and safety of permissive hypotension in adult trauma patients with hemorrhagic shock.
METHODS
We searched the MEDLINE and EMBASE databases from inception to May 2017 for randomized controlled trials comparing permissive hypotension vs. conventional resuscitation following traumatic injury. We included preoperative and intraoperative resuscitation strategies. The primary outcome was 30-day or in-hospital mortality. Secondary outcomes included blood product utilization, estimated blood loss and in-hospital complications. Pooling was performed with a random-effects model.
RESULTS
We screened 722 abstracts, from which five randomized trials evaluating 1,158 patients were included. Blood pressure targets in the intervention arms varied from systolic BP 50 mm Hg to 70 mm Hg or mean arterial pressure of 50 mm Hg or higher as compared to systolic BP 65 mm Hg to 100 mm Hg or mean arterial pressure of 65 or higher in the control arms. Two studies evaluated only patients with penetrating injury while the remaining three additionally included blunt injuries. Four trials suggested a survival benefit for 30-day or in-hospital mortality with hypotensive resuscitation, although three studies were insufficiently powered to find statistical significance. Studies were of poor to moderate quality due to poor protocol reporting and lack of blinding. The pooled odds ratio was 0.70 (95% confidence interval, 0.53-0.92), suggesting a survival benefit for permissive hypotension. Those patients received fewer blood products and had lesser estimated blood loss.
CONCLUSION
Permissive hypotension may offer a survival benefit over conventional resuscitation for patients with hemorrhagic injury. It may additionally reduce blood loss and blood product utilization. However, the majority of studies were underpowered, thus reflecting a need for high quality, adequately powered trials.
PROSPERO REGISTRATION
Systematic Review, level II.CRD42017070526.
Topics: Adult; Blood Pressure; Fluid Therapy; Humans; Hypotension; Randomized Controlled Trials as Topic; Resuscitation; Shock, Hemorrhagic; Wounds, Penetrating
PubMed: 29370058
DOI: 10.1097/TA.0000000000001816 -
BMJ Open Nov 2017Current guidelines suggest limiting the use of vasopressors following traumatic injury; however, wide variations in practice exist. Although excessive vasoconstriction... (Review)
Review
OBJECTIVES
Current guidelines suggest limiting the use of vasopressors following traumatic injury; however, wide variations in practice exist. Although excessive vasoconstriction may be harmful, these agents may help reduce administration of potentially harmful resuscitation fluids. This systematic review aims to compare early vasopressor use to standard resuscitation in adults with trauma-induced shock.
DESIGN
Systematic review.
DATA SOURCES
We searched MEDLINE, EMBASE, ClinicalTrials.gov and the Central Register of Controlled Trials from inception until October 2016, as well as the proceedings of 10 relevant international conferences from 2005 to 2016.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Randomised controlled trials and controlled observational studies that compared the early vasopressor use with standard resuscitation in adults with acute traumatic injury.
RESULTS
Of 8001 citations, we retrieved 18 full-text articles and included 6 studies (1 randomised controlled trial and 5 observational studies), including 2 published exclusively in abstract form. Across observational studies, vasopressor use was associated with increased short-term mortality, with unadjusted risk ratios ranging from 2.31 to 7.39. However, the risk of bias was considered high in these observational studies because patients who received vasopressors were systematically sicker than patients treated without vasopressors. One clinical trial (n=78) was too imprecise to yield meaningful results. Two clinical trials are currently ongoing. No study measured long-term quality of life or cognitive function.
CONCLUSIONS
Existing data on the effects of vasopressors following traumatic injury are of very low quality according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. With emerging evidence of harm associated with aggressive fluid resuscitation and, in selected subgroups of patients, with permissive hypotension, the alternatives to vasopressor therapy are limited. Observational data showing that vasopressors are part of usual care would provide a strong justification for high-quality clinical trials of early vasopressor use during trauma resuscitation.
TRIAL REGISTRATION NUMBER
CRD42016033437.
Topics: Fluid Therapy; Humans; Observational Studies as Topic; Randomized Controlled Trials as Topic; Resuscitation; Shock, Traumatic; Vasoconstrictor Agents
PubMed: 29151048
DOI: 10.1136/bmjopen-2017-017559 -
European Journal of Trauma and... Apr 2018Permissive hypotensive resuscitation (PHR) is an advancing concept aiming towards deliberative balanced resuscitation whilst treating severely injured patients, and its... (Review)
Review
BACKGROUND
Permissive hypotensive resuscitation (PHR) is an advancing concept aiming towards deliberative balanced resuscitation whilst treating severely injured patients, and its effectiveness on the survival rate remains unexplored. This detailed systematic review aims to critically evaluate the available literature that investigates the effects of PHR on survival rate.
METHODS
A systematic review design searched for comparative and non-comparative studies using EMBASE, MEDLINE, PubMed, Web-of-Science and CENTRAL. Full-text articles on adult trauma patients with low blood pressure were considered for inclusion. The risk of bias and a critical appraisal of the identified articles were performed to assess the quality of the selected studies. Included studies were sorted into comparative and non-comparative studies to ease the process of analysis. Mortality rates of PHR were calculated for both groups of studies.
RESULTS
From the 869 articles that were initially identified, ten studies were selected for review, including randomised control trials (RCTs) and cohort studies. By applying the risk of bias assessment and critique tools, the methodologies of the selected articles ranged from moderate to high quality. The mortality rates among patients resuscitated with low volume and large volume in the selected RCTs were 21.5% (123/570) and 28.6% (168/587) respectively, whilst the total mortality rate of the patients enrolled in three non-comparative studies was 9.97% (279/2797).
CONCLUSIONS
The death rate amongst post-trauma patients managed with conservative resuscitation was lower than standard aggressive resuscitation, which indicates that PHR can create better survival rate among traumatised patients. Therefore, PHR is a feasible and safely practiced fluid resuscitative strategy to manage haemorrhagic shock in pre-hospital and in-hospital settings. Further trials on PHR are required to assess its effectiveness on the survival rate.
LEVEL OF EVIDENCE
Systematic review, level III.
Topics: Adult; Humans; Multiple Trauma; Resuscitation; Shock, Hemorrhagic; Survival Analysis
PubMed: 29079917
DOI: 10.1007/s00068-017-0862-y -
Drug and Alcohol Dependence Sep 2017It is unclear what effect parents' rules about their children's alcohol use have on drinking in adolescence. This review and meta-analysis investigated associations... (Review)
Review
BACKGROUND
It is unclear what effect parents' rules about their children's alcohol use have on drinking in adolescence. This review and meta-analysis investigated associations between prospectively measured parental alcohol rules and later adolescent risky drinking.
METHODS
Using the PRISMA guidelines, we searched eight electronic databases for a variety of terms up to 10 September 2016. We imposed no restrictions on publication year. We assessed the risk of bias and conducted a meta-analysis.
RESULTS
We identified 13 eligible studies in four groups of specific exposures for meta-analysis. The pooled overall estimate showed that when parents set rules concerning alcohol, their children were less likely to develop risky drinking and related problems (OR=0.64, 95% CI=0.48, 0.86). Pooled estimates illustrate that parental alcohol rules were significantly negatively associated with adolescent risky drinking and related problems (OR=0.73, 95% CI=0.53, 0.99), as was parental approval of alcohol use (inverse OR=0.41, 95% CI=0.34, 0.50). Neither parental permissiveness (inverse OR=0.83, 95% CI=0.59, 1.19) nor parental disapproval of alcohol use (OR=0.49, 95% CI=0.20, 1.20) was significantly associated with alcohol-related problems. However, the small number of studies and variability in the point estimates in these latter two groups of studies limits inferences.
CONCLUSIONS
Parents' restrictiveness of their children's drinking was associated with lower risky drinking, but the risk of bias in the existing literature precludes strong inferences about the association. Further longitudinal studies with prospective measurement of parent behaviour, low attrition, and control for likely confounders, are needed.
Topics: Alcohol Drinking; Child; Ethanol; Humans; Mental Disorders; Parent-Child Relations; Parents; Prospective Studies; Risk; Underage Drinking
PubMed: 28667942
DOI: 10.1016/j.drugalcdep.2017.05.011 -
JMIR Public Health and Surveillance May 2017Childhood obesity is a significant global public health problem due to increasing rates worldwide. Growing evidence suggests that nonresponsive parental feeding styles...
BACKGROUND
Childhood obesity is a significant global public health problem due to increasing rates worldwide. Growing evidence suggests that nonresponsive parental feeding styles and practices are important influences on children's eating behaviors and weight status, especially during early childhood. Therefore, understanding parental factors that may influence nonresponsive parental feeding styles and practices is significant for the development of interventions to prevent childhood obesity.
OBJECTIVE
The objectives of this systematic review were to (1) identify and review existing research examining the associations between maternal depressive symptoms and use of nonresponsive feeding styles and practices among mothers of young children (2-8 years of age), (2) highlight the limitations of reviewed studies, and (3) generate suggestions for future research.
METHODS
Using the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) guidelines, six electronic academic databases were searched for peer-reviewed, full-text papers published in English between January 2000 and June 2016. Only studies with mothers 18+ years old of normally developing children between 2 and 8 years of age were included. Of the 297 citations identified, 35 full-text papers were retrieved and 8 were reviewed.
RESULTS
The reviewed studies provided mixed evidence for associations between maternal depressive symptoms and nonresponsive feeding styles and practices. Two out of three studies reported positive associations with nonresponsive feeding styles, in that mothers with elevated depressive symptoms were more likely than mothers without those symptoms to exhibit uninvolved and permissive or indulgent feeding styles. Furthermore, results of reviewed studies provide good evidence for association between maternal depressive symptoms and instrumental feeding (3 of 3 reviewed studies) and nonresponsive family mealtime practices (3/3), but mixed evidence for pressuring children to eat (3/6) and emotional feeding (1/3). In addition, evidence for the association between maternal depressive symptoms and restricting child food intake was mixed: one study (1/6) found a positive association; two studies (2/6) found a negative association; whereas one study (1/6) found no association.
CONCLUSIONS
This review indicates that the results of studies examining the associations between maternal depressive symptoms and parental feeding styles and practices are mixed. Limitations of studies included in this review should be noted: (1) the use of a diverse set of self-report questionnaires to assess parental feeding practices is problematic due to potential misclassification and makes it difficult to compare these outcomes across studies, thus caution must be taken in drawing conclusions; and (2) the majority of included studies (6/8) were cross-sectional. There is a need for additional longitudinal studies to disentangle the influence of depression on parental feeding styles and practices. Nevertheless, given that depressive symptoms and feeding styles and practices are potentially modifiable, it is important to understand their relationship to inform obesity prevention interventions and programs.
PubMed: 28550007
DOI: 10.2196/publichealth.6492 -
BMC Anesthesiology Feb 2017Oliguria is associated with a decreased kidney- and organ perfusion, leading to organ damage and increased mortality. While the effects of correcting oliguria on renal... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Oliguria is associated with a decreased kidney- and organ perfusion, leading to organ damage and increased mortality. While the effects of correcting oliguria on renal outcome have been investigated frequently, whether urine output is a modifiable risk factor for mortality or simply an epiphenomenon remains unclear. We investigated whether targeting urine output, defined as achieving and maintaining urine output above a predefined threshold, in hemodynamic management protocols affects 30-day mortality in perioperative and critical care.
METHODS
We performed a systematic review with a random-effects meta-analyses and meta-regression based on search strategy through MEDLINE, EMBASE and references in relevant articles. We included studies comparing conventional fluid management with goal-directed therapy and reporting whether urine output was used as target or not, and reporting 30-day mortality data in perioperative and critical care.
RESULTS
We found 36 studies in which goal-directed therapy reduced 30-day mortality (OR 0.825; 95% CI 0.684-0.995; P = 0.045). Targeting urine output within goal-directed therapy increased 30-day mortality (OR 2.66; 95% CI 1.06-6.67; P = 0.037), but not in conventional fluid management (OR 1.77; 95% CI 0.59-5.34; P = 0.305). After adjusting for operative setting, hemodynamic monitoring device, underlying etiology, use of vasoactive medication and year of publication, we found insufficient evidence to associate targeting urine output with a change in 30-day mortality (goal-directed therapy: OR 1.17; 95% CI 0.54-2.56; P = 0.685; conventional fluid management: OR 0.74; 95% CI 0.39-1.38; P = 0.334).
CONCLUSIONS
The principal finding of this meta-analysis is that after adjusting for confounders, there is insufficient evidence to associate targeting urine output with an effect on 30-day mortality. The paucity of direct data illustrates the need for further research on whether permissive oliguria should be a key component of fluid management protocols.
Topics: Critical Care; Fluid Therapy; Humans; Oliguria; Regression Analysis
PubMed: 28187752
DOI: 10.1186/s12871-017-0316-4 -
Obesity Reviews : An Official Journal... Mar 2017Parenting style may be an important determinant of an individual's future weight status. However, reviews that evaluate the relationship between parenting style and... (Review)
Review
BACKGROUND
Parenting style may be an important determinant of an individual's future weight status. However, reviews that evaluate the relationship between parenting style and weight-related outcomes have not focused on prospective studies.
METHODS
We systematically searched PubMed, Embase and PsychInfo for studies published between 1995 and 2016 that evaluated the prospective relationship between parenting style experienced in childhood and subsequent weight outcomes.
RESULTS
We identified 11 prospective cohort studies. Among the eight studies that categorized parenting style into distinct groups (i.e. authoritative, authoritarian, permissive and neglectful), five provided evidence that authoritative parenting was associated with lower body mass index gains. Among the six highest quality studies, four suggested a protective role of authoritative parenting style against adverse weight-related outcomes. However, only one study controlled for a comprehensive set of confounders, and the small number of studies conducted within certain age groups precluded our ability to ascertain critical periods when parenting style is most strongly related to child weight.
CONCLUSIONS
The present literature supports the idea that authoritative parenting may be protective against later overweight and obesity, although findings are mixed. More prospective cohort studies of longer durations, with more sophisticated methods that examine age-varying relationships, and that control for a comprehensive set of confounders, are needed.
Topics: Authoritarianism; Body Mass Index; Body Weight; Databases, Factual; Humans; Obesity; Observational Studies as Topic; Overweight; Parent-Child Relations; Parenting; Parents; Permissiveness
PubMed: 28086262
DOI: 10.1111/obr.12497 -
Journal of Clinical Anesthesia Dec 2016This article reviews if a restrictive fluid management policy reduces the complication rate if compared to liberal fluid management policy during elective surgery. The... (Comparative Study)
Comparative Study Meta-Analysis Review
This article reviews if a restrictive fluid management policy reduces the complication rate if compared to liberal fluid management policy during elective surgery. The PubMed database was explored by 2 independent researchers. We used the following search terms: "Blood transfusion (MESH); transfusion need; fluid therapy (MESH); permissive hypotension; fluid management; resuscitation; restrictive fluid management; liberal fluid management; elective surgery; damage control resuscitation; surgical procedures, operative (MESH); wounds (MESH); injuries (MESH); surgery; trauma patients." A secondary search in the Medline, EMBASE, Web of Science, and Cochrane library revealed no additional results. We selected randomized controlled trials performed during elective surgeries. Patients were randomly assigned to a restrictive fluid management policy or to a liberal fluid management policy during elective surgery. The patient characteristics and the type of surgery varied. All but 3 studies reported American Society of Anaesthesiologists groups 1 to 3 as the inclusion criterion. The primary outcome of interest is total number of patients with a complication and the complication rate. Secondary outcome measures are infection rate, transfusion need, postoperative rebleeding, hospital stay, and renal function. In total, 1397 patients were analyzed (693 restrictive protocol, 704 liberal protocol). Meta-analysis showed that in the restrictive group as compared with the liberal group, fewer patients experienced a complication (relative risk [RR], 0.65; 95% confidence interval [CI], 0.55-0.78). The total complication rate (RR, 0.57; 95% CI, 0.52-0.64), risk of infection (RR, 0.62; 95% CI, 0.48-0.79), and transfusion rate (RR, 0.81; 95% CI, 0.66-0.99) were also lower. The postoperative rebleeding did not differ in both groups: RR, 0.76 (95% CI, 0.28-2.06). We conclude that compared with a liberal fluid policy, a restrictive fluid policy in elective surgery results in a 35% reduction in patients with a complication and should be advised as the preferred fluid management policy.
Topics: Blood Loss, Surgical; Blood Transfusion; Elective Surgical Procedures; Fluid Therapy; Humans; Intraoperative Care; Length of Stay; Odds Ratio; Postoperative Complications; Postoperative Hemorrhage; Randomized Controlled Trials as Topic
PubMed: 27871539
DOI: 10.1016/j.jclinane.2016.07.010