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Emergency Radiology Jun 2024Head computed tomography (CT) is the preferred imaging modality for mild traumatic brain injury (mTBI). The routine use of head CT in low-risk individuals with mild TBI... (Review)
Review
Head computed tomography (CT) is the preferred imaging modality for mild traumatic brain injury (mTBI). The routine use of head CT in low-risk individuals with mild TBI offers no clinical benefit but also causes notable health and financial burden. Despite the availability of related guidelines, studies have reported considerable rate of non-indicated head CT requests. The objectives were to provide an overall estimate for the head CT overutilization rate and to identify the factors contributing to the overuse. A systematic review of PubMed, Scopus, Web of Science, and Embase databases was conducted up to November 2023, following PRISMA and MOOSE guidelines. Two reviewers independently selected eligible articles and extracted data. Quality assessment was performed using a bias risk tool, and a random-effects model was used for data synthesis. Fourteen studies, encompassing 28,612 patients, were included, with 27,809 undergoing head CT scans. Notably, 75% of the included studies exhibited a moderate to high risk of bias. The overutilization rate for pediatric and adult patients was 27% (95% CI: 5-50%) and 32% (95% CI: 21-44%), respectively. An alternative rate, focusing on low-risk pediatric patients, was 54% (95% CI: 20-89%). Overutilization rates showed no significant difference between teaching and non-teaching hospitals. Patients with mTBI from falls or assaults were less likely to receive non-indicated scans. There was no significant association between physician specialty or seniority and overuse, nor between patients' age or sex and the likelihood of receiving a non-indicated scan. Approximately one-third of head CT scans in mTBI cases are avoidable, underscoring the necessity for quality improvement programs to reduce unnecessary imaging and its associated burdens.
PubMed: 38844658
DOI: 10.1007/s10140-024-02247-9 -
Journal of Medical Internet Research Jun 2024The internet has become a prevalent source of health information for patients. However, its accuracy and relevance are often questionable. While patients seek... (Review)
Review
BACKGROUND
The internet has become a prevalent source of health information for patients. However, its accuracy and relevance are often questionable. While patients seek physicians' expertise in interpreting internet health information, physicians' perspectives on patients' information-seeking behavior are less explored.
OBJECTIVE
This review aims to understand physicians' perceptions of patients' internet health information-seeking behavior as well as their communication strategies and the challenges and needs they face with internet-informed patients.
METHODS
An initial search in PubMed, Scopus, CINAHL, Communication and Mass Media Complete, and PsycINFO was conducted to collect studies published from January 1990 to August 1, 2022. A subsequent search on December 24, 2023, targeted recent studies published after the initial search cutoff date. Two reviewers independently performed title, abstract, and full-text screening, adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines. Thematic analysis was then used to identify key themes and systematically categorize evidence from both qualitative and quantitative studies under these themes.
RESULTS
A total of 22 qualifying articles were identified after the search and screening process. Physicians were found to hold diverse views on patients' internet searches, which can be viewed as a continuous spectrum of opinions ranging from positive to negative. While some physicians leaned distinctly toward either positive or negative perspectives, a significant number expressed more balanced views. These physicians recognized both the benefits, such as increased patient health knowledge and informed decision-making, and the potential harms, including misinformation and the triggering of negative emotions, such as patient anxiety or confusion, associated with patients' internet health information seeking. Two communicative strategies were identified: the participative and defensive approaches. While the former seeks to guide internet-informed patients to use internet information with physicians' expertise, the latter aims to discourage patients from using the internet to seek health information. Physicians' perceptions were linked to their strategies: those holding positive views tended to adopt a participative approach, while those with negative views favored a defensive strategy. Some physicians claimed to shift between the 2 approaches depending on their interaction with a certain patient. We also identified several challenges and needs of physicians in dealing with internet-informed patients, including the time pressure to address internet-informed patient demands, a lack of structured training, and being uninformed about trustworthy internet sites that can be recommended to internet-informed patients.
CONCLUSIONS
This review highlights the diverse perceptions that physicians hold toward internet-informed patients, as well as the interplay between their perceptions, communication strategies, and their interactions with individual patients. Incorporating elements into the medical teaching curriculum that introduce physicians to reliable internet health resources for patient guidance, coupled with providing updates on technological advancements, could be instrumental in equipping physicians to more effectively manage internet-informed patients.
TRIAL REGISTRATION
PROSPERO CRD42022356317; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=356317.
Topics: Humans; Internet; Physicians; Physician-Patient Relations; Information Seeking Behavior; Attitude of Health Personnel; Communication
PubMed: 38842920
DOI: 10.2196/47620 -
The Cochrane Database of Systematic... Jun 2024Persistent visceral pain is an unpleasant sensation coming from one or more organs within the body. Visceral pain is a common symptom in those with advanced cancer.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Persistent visceral pain is an unpleasant sensation coming from one or more organs within the body. Visceral pain is a common symptom in those with advanced cancer. Interventional procedures, such as neurolytic sympathetic nerve blocks, have been suggested as additional treatments that may play a part in optimising pain management for individuals with this condition.
OBJECTIVES
To evaluate the benefits and harms of neurolytic sympathetic nerve blocks for persistent visceral pain in adults with inoperable abdominopelvic cancer compared to standard care or placebo and comparing single blocks to combination blocks.
SEARCH METHODS
We searched the following databases without language restrictions on 19 October 2022 and ran a top-up search on 31 October 2023: CENTRAL; MEDLINE via Ovid; Embase via Ovid; LILACS. We searched trial registers without language restrictions on 2 November 2022: ClinicalTrials.gov; WHO International Clinical Trials Registry Platform (ICTRP). We searched grey literature, checked reference lists of reviews and retrieved articles for additional studies, and performed citation searches on key articles. We also contacted experts in the field for unpublished and ongoing trials. Our trial protocol was preregistered in the Cochrane Database of Systematic Reviews on 21 October 2022.
SELECTION CRITERIA
We searched for randomised controlled trials (RCTs) comparing any sympathetic nerve block targeting sites commonly used to treat abdominal pelvic pain from inoperable malignancies in adults to standard care or placebo.
DATA COLLECTION AND ANALYSIS
We independently selected trials based on predefined inclusion criteria, resolving any differences via adjudication with a third review author. We used a random-effects model as some heterogeneity was expected between the studies due to differences in the interventions being assessed and malignancy types included in the study population. We chose three primary outcomes and four secondary outcomes of interest. We sought consumer input to refine our review outcomes and assessed extracted data using Cochrane's risk of bias 2 tool (RoB 2). We assessed the certainty of evidence using the GRADE system.
MAIN RESULTS
We included 17 studies with 1025 participants in this review. Fifteen studies with a total of 951 participants contributed to the quantitative analysis. Single block versus standard care Primary outcomes No included studies reported our primary outcome, 'Proportion of participants reporting no worse than mild pain after treatment at 14 days'. The evidence is very uncertain about the effect of sympathetic nerve blocks on reducing pain to no worse than mild pain at 14 days when compared to standard care due to insufficient data (very low-certainty evidence). Sympathetic nerve blocks may provide small to 'little to no' improvement in quality of life (QOL) scores at 14 days after treatment when compared to standard care, but the evidence is very uncertain (standardised mean difference (SMD) -0.73, 95% confidence interval (CI) -1.70 to 0.25; I² = 87%; 4 studies, 150 participants; very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events as defined in our review as only one study contributed data to this outcome. Sympathetic nerve blocks may have an 'increased risk' to 'no additional risk' of harm compared with standard care (very low-certainty evidence). Secondary outcomes Sympathetic nerve blocks showed a small to 'little to no' effect on participant-reported pain scores at 14 days using a 0 to 10 visual analogue scale (VAS) for pain compared with standard care, but the evidence is very uncertain (mean difference (MD) -0.44, 95% CI -0.98 to 0.11; I² = 56%; 5 studies, 214 participants; very low-certainty evidence). There may be a 'moderate to large' to 'little to no' reduction in daily consumption of opioids postprocedure at 14 days with sympathetic nerve blocks compared with standard care, but the evidence is very uncertain (change in daily consumption of opioids at 14 days as oral milligrams morphine equivalent (MME): MD -41.63 mg, 95% CI -78.54 mg to -4.72 mg; I² = 90%; 4 studies, 130 participants; very low-certainty evidence). The evidence is very uncertain about the effect of sympathetic nerve blocks on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to insufficient data. Combination block versus single block Primary outcomes There is no evidence about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on the proportion of participants reporting no worse than mild pain after treatment at 14 days because no studies reported this outcome. There may be a small to 'little to no' effect on QOL score at 14 days after treatment, but the evidence is very uncertain (very low-certainty evidence). The evidence is very uncertain about the risk of serious adverse events with combination sympathetic nerve blocks compared with single sympathetic nerve blocks due to limited reporting in the included studies (very low-certainty evidence). Secondary outcomes The evidence is very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks on participant-reported pain score and change in daily consumption of opioids postprocedure, at 14 days. There may be a small to 'little to no' effect, but the evidence is very uncertain (very low-certainty evidence). There is no evidence about the effect on participant satisfaction with procedure at 0 to 7 days and time to need for retreatment or treatment effect failure (or both) due to these outcomes not being measured by the studies. Risk of bias The risk of bias was predominately high for most outcomes in most studies due to significant concerns regarding adequate blinding. Very few studies were deemed as low risk across all domains for any outcome.
AUTHORS' CONCLUSIONS
There is limited evidence to support or refute the use of sympathetic nerve blocks for persistent abdominopelvic pain due to inoperable malignancy. We are very uncertain about the effect of combination sympathetic nerve blocks compared with single sympathetic nerve blocks. The certainty of the evidence is very low and these findings should be interpreted with caution.
Topics: Humans; Randomized Controlled Trials as Topic; Autonomic Nerve Block; Adult; Bias; Pelvic Neoplasms; Abdominal Neoplasms; Cancer Pain; Abdominal Pain; Pain Management; Nerve Block; Quality of Life
PubMed: 38842054
DOI: 10.1002/14651858.CD015229.pub2 -
Virology Journal Jun 2024Limited data is available regarding the severity and mortality of Mpox in individuals with immunocompromised conditions. Therefore, we performed this meta-analysis to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Limited data is available regarding the severity and mortality of Mpox in individuals with immunocompromised conditions. Therefore, we performed this meta-analysis to understand the impact of HIV- or non-HIV-associated immunosuppression on the severity of Mpox requiring hospitalization and mortality.
METHODS
A thorough literature search was performed from 2022 up to January 2024. The results were presented as odds ratios (ORs). We only included patients who required hospitalization for severity rather than isolation.
RESULTS
A total of 34 studies were included in this analysis. Our analysis did not find a significant difference in the hospitalization risk between HIV-positive individuals and those who were HIV-negative (OR = 1.03; P = 0.85; 7 studies; CD4 count of fewer than 200 cells/µL was less than 0.5% across all studies). Patients with a CD4 count lower than 200 cells/µL or an unsuppressed RNA viral load (> 200 copies/ml) had a significantly higher hospitalization risk (OR = 5.3, P < 0.001) and (OR = 3, P < 0.001), respectively. Most of the reported deaths were reported in patients with HIV with CD4 counts below 200 cells/µL, with some fatal cases occurring in non-HIV immunosuppressed patients, particularly organ transplant recipients. Based on the autopsy findings, Mpox was confirmed in multiple organs, particularly the digestive tract, lung, and testes. Furthermore, some studies documented cases of death that were suspected to be related to hemophagocytic lymphohistiocytosis (HLH) and immune reconstitution inflammatory syndrome (IRIS). Most of the death reports showed concomitant non-Mpox infections at the time of hospitalization and death CONCLUSIONS: Our finding shows that Mpox acts as an opportunistic pathogen in immunocompromised individuals. These individuals should be prioritized for early care and closely monitored for signs of deteriorating clinical conditions. Clinical manifestations and autopsy findings strongly suggest Mpox dissemination to multiple organs, particularly the digestive tract, and lungs. However, the presence of concomitant non-Mpox infections complicates the assessment of the attribution of Mpox to death. Caution should be exercised when interpreting data suggesting poorer outcomes in individuals with non-HIV immunosuppression, as current evidence is scarce and further research is needed.
Topics: Humans; Hospitalization; Immunocompromised Host; HIV Infections; CD4 Lymphocyte Count; Mpox (monkeypox); Disease Outbreaks; Immunosuppression Therapy; Viral Load
PubMed: 38840177
DOI: 10.1186/s12985-024-02392-0 -
PloS One 2024Up to 30% of diagnostic imaging (DI) tests may be unnecessary, leading to increased healthcare costs and the possibility of patient harm. The primary objective of this... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Up to 30% of diagnostic imaging (DI) tests may be unnecessary, leading to increased healthcare costs and the possibility of patient harm. The primary objective of this systematic review was to assess the effect of audit and feedback (AF) interventions directed at healthcare providers on reducing image ordering. The secondary objective was to examine the effect of AF on the appropriateness of DI ordering.
METHODS
Studies were identified using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov registry on December 22nd, 2022. Studies were included if they were randomized control trials (RCTs), targeted healthcare professionals, and studied AF as the sole intervention or as the core component of a multi-faceted intervention. Risk of bias for each study was evaluated using the Cochrane risk of bias tool. Meta-analyses were completed using RevMan software and results were displayed in forest plots.
RESULTS
Eleven RCTs enrolling 4311 clinicians or practices were included. AF interventions resulted in 1.5 fewer image test orders per 1000 patients seen than control interventions (95% confidence interval (CI) for the difference -2.6 to -0.4, p-value = 0.009). The effect of AF on appropriateness was not statistically significant, with a 3.2% (95% CI -1.5 to 7.7%, p-value = 0.18) greater likelihood of test orders being considered appropriate with AF vs control interventions. The strength of evidence was rated as moderate for the primary objective but was very low for the appropriateness outcome because of risk of bias, inconsistency in findings, indirectness, and imprecision.
CONCLUSION
AF interventions are associated with a modest reduction in total DI ordering with moderate certainty, suggesting some benefit of AF. Individual studies document effects of AF on image order appropriateness ranging from a non-significant trend toward worsening to a highly significant improvement, but the weighted average effect size from the meta-analysis is not statistically significant with very low certainty.
Topics: Humans; Diagnostic Imaging; Feedback; Practice Patterns, Physicians'; Randomized Controlled Trials as Topic; Medical Audit
PubMed: 38837994
DOI: 10.1371/journal.pone.0300001 -
Advances in Mind-body MedicinePeripheral neuropathies constitute a diverse array of disorders impacting the peripheral nervous system. Despite extensive research on the therapeutic potential of yoga... (Review)
Review
BACKGROUND
Peripheral neuropathies constitute a diverse array of disorders impacting the peripheral nervous system. Despite extensive research on the therapeutic potential of yoga for various health conditions, its specific effects on peripheral neuropathy remain underexplored.
OBJECTIVE
This review aims to comprehensively investigate the effects, including potential adverse events, of yoga on peripheral neuropathy.
METHODS
A systematic literature search was conducted using the PubMed/Medline electronic database from inception to March 5, 2024. The search strategy involved a combination of relevant Medical Subject Heading (MeSH) terms and keywords related to peripheral neuropathy and yoga. The primary outcome measures assessed in the included studies were the improvement in symptoms and clinical indicators of peripheral neuropathy following yoga interventions. Out of 101 articles initially screened, 16 were considered eligible for inclusion in this review.
RESULTS
The synthesized literature suggests that yoga may serve as a beneficial adjunct in the management of diabetic peripheral neuropathy, chemotherapy-induced peripheral neuropathy, lumbar disc herniation-induced neuropathy, Guillain-Barré Syndrome, and Carpal tunnel syndrome. However, caution is warranted as reported instances of yoga asanas precipitate adverse events such as progressive glaucomatous optic neuropathy, bilateral sciatic nerve neuropathy, and acute loss of motor function due to acute ulnar neuropathy.
CONCLUSIONS
Yoga holds promise as an adjunctive therapy for the management of peripheral neuropathy. Nonetheless, discrepancies in sample size, type of yoga, and intervention duration across studies underscore the need for larger-scale investigations incorporating standardized long-term yoga interventions and objective outcome measures. To mitigate risks of adverse events, patients should practice yoga under the supervision and guidance of institutionally qualified yoga physicians.
Topics: Yoga; Humans; Peripheral Nervous System Diseases
PubMed: 38837778
DOI: No ID Found -
Inflammatory Bowel Diseases Jun 2024Inflammatory bowel disease (IBD)-associated peripheral spondyloarthritis (pSpA) decreases quality of life and remains poorly understood. Given the prevalence of this...
BACKGROUND
Inflammatory bowel disease (IBD)-associated peripheral spondyloarthritis (pSpA) decreases quality of life and remains poorly understood. Given the prevalence of this condition and its negative impact, it is surprising that evidence-based disease definitions and diagnostic strategies are lacking. This systematic review summarizes available data to facilitate development and validation of diagnostics, patient-reported outcomes, and imaging indices specific to this condition.
METHODS
A literature search was conducted. Consensus or classification criteria, case series, cross-sectional studies, cohort studies, and randomized controlled trials related to diagnosis were included.
RESULTS
A total of 44 studies reporting data on approximately 1500 patients with pSpA were eligible for analysis. Data quality across studies was only graded as fair to good. Due to large heterogeneity, meta-analysis was not possible. The majority of studies incorporated patient-reported outcomes and a physical examination. A total of 13 studies proposed or validated screening tools, consensus, classification, or consensus criteria. A total of 28 studies assessed the role of laboratory tests, none of which were considered sufficiently accurate for use in diagnosis. A total of 17 studies assessed the role of imaging, with the available literature insufficient to fully endorse any imaging modality as a robust diagnostic tool.
CONCLUSIONS
This review highlights existing inconsistency and lack of a clear diagnostic approach for IBD-associated pSpA. Given the absence of an evidence-based approach, a combination of existing criteria and physician assessment should be utilized. To address this issue comprehensively, our future efforts will be directed toward pursuit of a multidisciplinary approach aimed at standardizing evaluation and diagnosis of IBD-associated pSpA.
PubMed: 38836521
DOI: 10.1093/ibd/izae114 -
BMC Musculoskeletal Disorders Jun 2024The use of reverse total shoulder arthroplasty (RTSA) has increased at a greater rate than other shoulder procedures. In general, clinical and functional outcomes after...
BACKGROUND
The use of reverse total shoulder arthroplasty (RTSA) has increased at a greater rate than other shoulder procedures. In general, clinical and functional outcomes after RTSA have been favorable regardless of indication. However, little evidence exists regarding patient specific factors associated with clinical improvement after RTSA. Predicting postoperative outcomes after RTSA may support patients and physicians to establish more accurate patient expectations and contribute in treatment decisions. The aim of this study was to determine predictive factors for postoperative outcomes after RTSA for patients with degenerative shoulder disorders.
METHODS
EMBASE, PubMed, Cochrane Library and PEDro were searched to identify cohort studies reporting on predictive factors for postoperative outcomes after RTSA. Authors independently screened publications on eligibility. Risk of bias for each publication was assessed using the QUIPS tool. A qualitative description of the results was given. The GRADE framework was used to establish the quality of evidence.
RESULTS
A total of 1986 references were found of which 11 relevant articles were included in the analysis. Risk of bias was assessed as low (N = 7, 63.6%) or moderate (N = 4, 36.4%). According to the evidence synthesis there was moderate-quality evidence indicating that greater height predicts better postoperative shoulder function, and greater preoperative range of motion (ROM) predicts increased postoperative ROM following.
CONCLUSION
Preoperative predictive factors that may predict postoperative outcomes are: patient height and preoperative range of motion. These factors should be considered in the preoperative decision making for a RTSA, and can potentially be used to aid in preoperative decision making.
LEVEL OF EVIDENCE
Level I; Systematic review.
Topics: Humans; Arthroplasty, Replacement, Shoulder; Range of Motion, Articular; Treatment Outcome; Shoulder Joint
PubMed: 38835042
DOI: 10.1186/s12891-024-07500-3 -
Reproductive Toxicology (Elmsford, N.Y.) Jun 2024The primary route of mercury exposure for the general population is through consumption of contaminated seafood. There is a biological basis for an adverse effect of... (Review)
Review
The primary route of mercury exposure for the general population is through consumption of contaminated seafood. There is a biological basis for an adverse effect of mercury exposure on human fertility. The goal of this review was to evaluate the existing literature on the association between mercury and pregnancy, among men and women attempting to conceive with and without assisted reproductive technology (ART). Systematic searches were performed in PubMed, EMBASE, Scopus and Web of Science for papers published up to March 2023 with no early date restriction, only including studies with a biomarker measurement of mercury exposure. We identified 11 studies examining mercury and natural fertility and 12 studies examining mercury and outcomes of assisted reproduction (implantation or clinical pregnancy). The accumulated evidence provides some support for a null association between bodily mercury concentrations and natural fertility among women, however, a large proportion of studies did not report adjusted estimates or were extremely imprecise. The majority of studies of natural fertility were also cross-sectional in nature. There was no evidence for an inverse or null association between mercury and natural fertility among men, or mercury and ART outcomes among men or women. In spite of biological plausibility, the existing evidence includes studies that are imprecise and often conflicting and does not allow us to make definitive conclusions on the associations of mercury exposure with successful pregnancy. Additional, larger studies are warranted, especially among individuals with high concentrations of mercury exposure as these individuals may be underrepresented in the current literature.
PubMed: 38830454
DOI: 10.1016/j.reprotox.2024.108613 -
Neurology Jul 2024Clinical trials in neurodegenerative diseases often encounter selective enrollment and under-representation of certain patient populations. This delays drug development... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND OBJECTIVES
Clinical trials in neurodegenerative diseases often encounter selective enrollment and under-representation of certain patient populations. This delays drug development and substantially limits the generalizability of clinical trial results. To inform recruitment and retention strategies, and to better understand the generalizability of clinical trial populations, we investigated which factors drive participation.
METHODS
We reviewed the literature systematically to identify barriers to and facilitators of trial participation in 4 major neurodegenerative disease areas: Alzheimer disease, Parkinson disease, amyotrophic lateral sclerosis, and Huntington disease. Inclusion criteria included original research articles published in a peer-reviewed journal and evaluating barriers to and/or facilitators of participation in a clinical trial with a drug therapy (either symptomatic or disease-modifying). The Critical Appraisal Skills Program checklist for qualitative studies was used to assess and ensure the quality of the studies. Qualitative thematic analyses were employed to identify key enablers of trial participation. Subsequently, we pooled quantitative data of each enabler using meta-analytical models.
RESULTS
Overall, we identified 36 studies, enrolling a cumulative sample size of 5,269 patients, caregivers, and health care professionals. In total, the thematic analysis resulted in 31 unique enablers of trial participation; the key factors were patient-related (own health benefit and altruism), study-related (treatment and study burden), and health care professional-related (information availability and patient-physician relationship). When meta-analyzed across studies, responders reported that the reason to participate was mainly driven by (1) the relationship with clinical staff (70% of the respondents; 95% CI 53%-83%), (2) the availability of study information (67%, 95% CI 38%-87%), and (3) the use or absence of a placebo or sham-control arm (53% 95% CI 32%-72%). There was, however, significant heterogeneity between studies (all < 0.001).
DISCUSSION
We have provided a comprehensive list of reasons why patients participate in clinical trials for neurodegenerative diseases. These results may help to increase participation rates, better inform patients, and facilitate patient-centric approaches, thereby potentially reducing selection mechanisms and improving generalizability of trial results.
Topics: Humans; Neurodegenerative Diseases; Clinical Trials as Topic; Patient Participation; Patient Selection
PubMed: 38830181
DOI: 10.1212/WNL.0000000000209503