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Journal of Vascular Surgery Mar 2019Acute carotid stent thrombosis (ACST) occurring in the first hours after the procedure is an exceedingly rare complication of carotid artery stenting, but it is... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Acute carotid stent thrombosis (ACST) occurring in the first hours after the procedure is an exceedingly rare complication of carotid artery stenting, but it is potentially devastating. This review aimed to evaluate current literature, identifying all reported cases during the last two decades, with the final purpose of reporting predictive factors and early management.
METHODS
A systematic review and meta-analysis was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.
RESULTS
A total of 464 potentially relevant articles were selected. After review of records at title and abstract level, 29 articles with 60 patients were included. Twelve studies reported on ACST incidence rate in their cohorts, ranging from 0.36% to as high as 33%. In considering etiology, antiplatelet noncompliance or resistance is the most frequently reported risk factor. Emergency procedures seemed to be associated with greater risk for ACST, reaching 5.6% to 33% incidence. Dual-layer stents were also associated with greater risk (45% vs 3.7%; P = .0001; odds ratio, 21.3). Use of an overlapping stent as a bailout procedure because of dissection, malposition, or long lesions was correlated with increased risk (7.3% vs 0.002%), as were long stenotic lesions (22.9 ± 6.83 mm vs 14.2 ± 6.42 mm; P = .0034) and stent length (3.8 ± 0.4 cm vs 2.8 ± 0.86 cm; P = .0055). ACST was associated with neurologic status deterioration in 56.7% of cases. Time to symptoms or ACST diagnosis had a median of 1.5 hours, with 30% occurring intraprocedurally. In asymptomatic ACST, conservative management was unanimous. Endovascular treatment was the most common approach to intraprocedural ACST. Surgical options included carotid endarterectomy with stent explantation (n = 9), which was also a bailout after failed endovascular treatment in two cases.
CONCLUSIONS
ACST incidence is higher in emergent, neurologically unstable patients. Antiplatelet noncompliance, antiplatelet resistance, long stenotic lesions, use of more than one stent, and dual-layer stents are also associated with increased risk. The decision as to the best approach depends on whether ACST occurs intraprocedurally or afterward, the development of neurologic status deterioration, and the center's experience. However, additional studies must be undertaken to better define optimal management.
Topics: Acute Disease; Aged; Aged, 80 and over; Carotid Stenosis; Early Diagnosis; Endovascular Procedures; Female; Humans; Incidence; Male; Middle Aged; Risk Factors; Stents; Thrombosis; Time Factors; Treatment Outcome
PubMed: 30798846
DOI: 10.1016/j.jvs.2018.09.053 -
PloS One 2018Total Shoulder Arthroplasty (TSA) anatomical, reverse or both is an increasingly popular procedure but the glenoid component is still a weak element, accounting for... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Total Shoulder Arthroplasty (TSA) anatomical, reverse or both is an increasingly popular procedure but the glenoid component is still a weak element, accounting for 30-50% of mechanical complications and contributing to the revision burden. Component mal-positioning is one of the main aetiological factors in glenoid failure and thus Patient-Specific Instrumentation (PSI) has been introduced in an effort to optimise implant placement. The aim of this systematic literature review and meta-analysis is to compare the success of PSI and Standard Instrumentation (STDI) methods in reproducing pre-operative surgical planning of glenoid component positioning.
MATERIAL AND METHODS
A search (restricted to English language) was conducted in November 2017 on MEDLINE, the Cochrane Library, EMBASE and ClinicalTrials.gov. Using the search terms "Patient-Specific Instrumentation (PSI)", "custom guide", "shoulder", "glenoid" and "arthroplasty", 42 studies were identified. The main exclusion criteria were: no CT-scan analysis results; studies done on plastic bone; and use of a reusable or generic guide. Eligible studies evaluated final deviations from the planning for version, inclination, entry point and rotation. Reviewers worked independently to extract data and assess the risk of bias on the same studies.
RESULTS
The final analysis included 12 studies, comprising 227 participants (seven studies on 103 humans and five studies on 124 cadaveric specimens). Heterogeneity was moderate or high for all parameters. Deviations from the pre-operative planning for version (p<0.01), inclination (p<0.01) and entry point (p = 0.02) were significantly lower with the PSI than with the STDI, but not for rotation (p = 0.49). Accuracy (deviation from planning) with PSI was about 1.88° to 4.96°, depending on the parameter. The number of component outliers (>10° of deviation or 4mm) were significantly higher with STDI than with PSI (68.6% vs 15.3% (p = 0.01)).
CONCLUSION
This review supports the idea that PSI enhances glenoid component positioning, especially a decrease in the number of outliers. However, the findings are not definitive and further validation is required. It should be noted that no randomised clinical studies are available to confirm long-term outcomes.
Topics: Arthroplasty, Replacement, Shoulder; Glenoid Cavity; Humans; Imaging, Three-Dimensional; Patient Positioning; Patient-Specific Modeling; Precision Medicine; Printing, Three-Dimensional; Surgery, Computer-Assisted
PubMed: 30133482
DOI: 10.1371/journal.pone.0201759 -
The Cochrane Database of Systematic... Jul 2018The success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid... (Review)
Review
BACKGROUND
The success rate of correct endotracheal tube (ETT) placement for junior medical staff is less than 50% and accidental oesophageal intubation is common. Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes including hypoxaemia, death, pneumothorax and right upper lobe collapse.ETT position can be confirmed using chest radiography, but this is often delayed; hence, a number of rapid point-of-care methods to confirm correct tube placement have been developed. Current neonatal resuscitation guidelines advise that correct ETT placement should be confirmed by the observation of clinical signs and the detection of exhaled carbon dioxide (CO). Even though these devices are frequently used in the delivery room to assess tube placement, they can display false-negative results. Recently, newer techniques to assess correct tube placement have emerged (e.g. respiratory function monitor), which have been claimed to be superior in the assessment of tube placement.
OBJECTIVES
To assess various techniques for the identification of correct ETT placement after oral or nasal intubation in newborn infants in either the delivery room or neonatal intensive care unit compared with chest radiography.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 4), MEDLINE (January 1996 to June 2014), EMBASE (January 1980 to Juen 2014) and CINAHL (January 1982 to June 2014). We searched clinical trials registers and the abstracts of the Society for Pediatric Research and the European Society for Pediatric Research from 2004 to 2014. We did not apply any language restrictions.
SELECTION CRITERIA
We planned to include randomised and quasi-randomised controlled trials and cluster trials that compared chest radiography with clinical signs, respiratory function monitors, exhaled CO detectors or ultrasound for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit.
DATA COLLECTION AND ANALYSIS
Two review authors independently evaluated the search results against the selection criteria. We did not perform data extraction and 'Risk of bias' assessments because we identified no studies that met our inclusion criteria.
MAIN RESULTS
We did not identify any studies meeting the criteria for inclusion in this review.
AUTHORS' CONCLUSIONS
There is insufficient evidence to determine the most effective technique for the assessment of correct ETT placement either in the delivery room or the neonatal intensive care unit. Randomised clinical trials comparing either of these techniques with chest radiography are warranted.
Topics: Humans; Infant, Newborn; Intubation, Intratracheal
PubMed: 29975802
DOI: 10.1002/14651858.CD010221.pub3 -
Critical Care (London, England) Mar 2018Insertion of a central venous catheter (CVC) is common practice in critical care medicine. Complications arising from CVC placement are mostly due to a pneumothorax or... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Insertion of a central venous catheter (CVC) is common practice in critical care medicine. Complications arising from CVC placement are mostly due to a pneumothorax or malposition. Correct position is currently confirmed by chest x-ray, while ultrasonography might be a more suitable option. We performed a meta-analysis of the available studies with the primary aim of synthesizing information regarding detection of CVC-related complications and misplacement using ultrasound (US).
METHODS
This is a systematic review and meta-analysis registered at PROSPERO (CRD42016050698). PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Articles which reported the diagnostic accuracy of US in detecting the position of CVCs and the mechanical complications associated with insertion were included. Primary outcomes were specificity and sensitivity of US. Secondary outcomes included prevalence of malposition and pneumothorax, feasibility of US examination, and time to perform and interpret both US and chest x-ray. A qualitative assessment was performed using the QUADAS-2 tool.
RESULTS
We included 25 studies with a total of 2548 patients and 2602 CVC placements. Analysis yielded a pooled specificity of 98.9 (95% confidence interval (CI): 97.8-99.5) and sensitivity of 68.2 (95% CI: 54.4-79.4). US examination was feasible in 96.8% of the cases. The prevalence of CVC malposition and pneumothorax was 6.8% and 1.1%, respectively. The mean time for US performance was 2.83 min (95% CI: 2.77-2.89 min) min, while chest x-ray performance took 34.7 min (95% CI: 32.6-36.7 min). US was feasible in 97%. Further analyses were performed by defining subgroups based on the different utilized US protocols and on intra-atrial and extra-atrial misplacement. Vascular US combined with transthoracic echocardiography was most accurate.
CONCLUSIONS
US is an accurate and feasible diagnostic modality to detect CVC malposition and iatrogenic pneumothorax. Advantages of US over chest x-ray are that it can be performed faster and does not subject patients to radiation. Vascular US combined with transthoracic echocardiography is advised. However, the results need to be interpreted with caution since included studies were often underpowered and had methodological limitations. A large multicenter study investigating optimal US protocol, among other things, is needed.
Topics: Catheterization, Central Venous; Central Venous Catheters; Humans; Iatrogenic Disease; Medical Errors; Pneumothorax; Point-of-Care Systems; Reproducibility of Results; Ultrasonography
PubMed: 29534732
DOI: 10.1186/s13054-018-1989-x -
Anaesthesia Aug 2018Double-lumen intubation is more difficult than single-lumen tracheal intubation. Videolaryngoscopes have many advantages in airway management. However, the advantages of... (Comparative Study)
Comparative Study Meta-Analysis
Double-lumen intubation is more difficult than single-lumen tracheal intubation. Videolaryngoscopes have many advantages in airway management. However, the advantages of videolaryngoscopy for intubation with a double-lumen tube remain controversial compared with traditional Macintosh laryngoscopy. In this study, we searched MEDLINE, Embase, Cochrane Library and the Web of Science for randomised controlled trials comparing videolaryngoscopy with Macintosh laryngoscopy for double-lumen tube intubation. We found that videolaryngoscopy provided a higher success rate at first attempt for double-lumen tube intubation, with an odds ratio (95%CI) of 2.77 (1.92-4.00) (12 studies, 1215 patients, moderate-quality evidence, p < 0.00001), as well as a lower incidence of oral, mucosal or dental injuries during double-lumen tube intubation, odds ratio (95%CI) 0.36 (0.15-0.85) (11 studies, 1145 patients, low-quality evidence, p = 0.02), and for postoperative sore throat, odds ratio (95%CI) 0.54 (0.36-0.81) (7 studies, 561 patients, moderate-quality evidence, p = 0.003), compared with Macintosh laryngoscopy. There were no significant differences in intubation time, with a standardised mean difference (95%CI) of -0.10 (-0.62 to 0.42) (14 studies, 1310 patients, very low-quality evidence, p = 0.71); and the incidence of postoperative voice change, odds ratio (95%CI) 0.53 (0.21-1.31) (7 studies, 535 patients, low-quality evidence, p = 0.17). Videolaryngoscopy led to a higher incidence of malpositioned double-lumen tube, with an odds ratio (95%CI) of 2.23 (1.10-4.52) (six studies, 487 patients, moderate-quality evidence, p = 0.03).
Topics: Humans; Intubation, Intratracheal; Laryngoscopes; Laryngoscopy; Postoperative Complications; Thoracic Surgery; Thoracic Surgical Procedures
PubMed: 29405258
DOI: 10.1111/anae.14226 -
Journal of Orthopaedic Surgery and... Sep 2017Quadriceps-sparing (QS) approach is considered to be the most minimally invasive surgery for total knee arthroplasty (TKA). We perform this meta-analysis to evaluate... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Quadriceps-sparing (QS) approach is considered to be the most minimally invasive surgery for total knee arthroplasty (TKA). We perform this meta-analysis to evaluate whether malalignment and malposition are more biased towards the QS approach compared to the traditional medial parapatellar (MP) approach, which is still controversial.
METHODS
According to the PRISMA guidelines, a comprehensive search was conducted in the databases of PubMed, the Cochrane library, and Embase. Relevant measures were extracted independently by two investigators.
RESULTS
Five randomized controlled trials (RCTs) and eight retrospective studies including a total of 1261 cases were identified. The QS approach was associated with more outliers of hip-knee-ankle (HKA) angle (p = 0.03), coronal tibial component angle (p = 0.03), and femoral notch (p = 0.05). However, the differences of the outlier of the coronal femoral component angle between the two groups were not statistically significant.
CONCLUSIONS
This meta-analysis indicates that the QS approach is related to the high risk of malalignment and malposition. However, different studies reported different indicators resulting in small samples for analyzing the radiological outcomes. In addition, both of the relatively long learning curve and the present instruments might increase the risk of malalignment and malposition of the QS approach, which needs further study and improvement.
Topics: Arthroplasty, Replacement, Knee; Bone Malalignment; Humans
PubMed: 28874195
DOI: 10.1186/s13018-017-0627-7 -
Medicine Jul 2017Incidence of complications and reoperations between pedicle screw (PS) and hybrid instrumentations (HI) are still controversial in adolescent idiopathic scoliosis (AIS)... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Incidence of complications and reoperations between pedicle screw (PS) and hybrid instrumentations (HI) are still controversial in adolescent idiopathic scoliosis (AIS) patients. A systematic review and meta-analysis were performed to compare overall complications, reoperations, and radiographic outcomes between the 2 constructs.
METHODS
Strictly followed the PRISMA 2009 guidelines, the MEDLINE, EMBASE, and the Cochrane Library databases were used to search for literatures up to April 2016, addressing PS versus HI in AIS patients. The Newcastle-Ottawa scale was adopted to assess the quality of the studies. Data on complications, reoperations, Cobb angle of major curve, thoracic kyphosis, and proximal junctional measurement were extracted from the included studies. RevMan 5.3 and SPSS 21.0 were used for statistical analysis.
RESULTS
Twenty-four case-control studies with a total of 3042 AIS patients (1582 PS, 1460 HI) were included, consisting of 1 randomized controlled trial, 1 prospective study, and 22 retrospective studies. Decreased overall complications (95% CI 0.42-0.87, P = .007; I = 38%) and reoperations (95% CI 0.22-0.62, P = .0001; I = 0%) were found in PS group compared with HI group. As regard to reasons for reoperations, increased incidence of pseudarthrosis (P = .005), dislodged instrumentation (P = .005), and deep infection (P = .016) occurred in HI group. PS group achieved a better coronal correction (95% CI -7.06 to -4.54, P < .00001; I = 34%), but HI group was more powerful in restoring thoracic kyphosis (95% CI -7.88 to -3.70, P < .00001; I = 60%), and no significant differences were found in proximal junctional measurement (95% CI -0.88 to 1.54, P = .59; I = 0%) between the 2 constructs.
CONCLUSION
Compared with hybrid instrumentation, pedicle screw construct provides better coronal correction but less thoracic kyphosis restoring, with decreased incidence of overall complications and reoperations in AIS patients. As regard to the pedicle screw construct, the most common reasons for reoperation are malposition, deep infection, pseudarthrosis, and prominent implant.
Topics: Adolescent; Humans; Orthopedic Procedures; Pedicle Screws; Postoperative Complications; Reoperation; Scoliosis
PubMed: 28682881
DOI: 10.1097/MD.0000000000007337 -
Critical Care Medicine Apr 2017We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of... (Meta-Analysis)
Meta-Analysis Review
Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis.
OBJECTIVE
We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography.
DATA SOURCES
PubMed, Embase, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and ClinicalTrials.gov.
STUDY SELECTION
Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2 × 2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, interrater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position.
DATA EXTRACTION
Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio.
DATA SYNTHESIS
Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high.
CONCLUSIONS
Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.
Topics: Catheterization, Central Venous; Critical Illness; Humans; Jugular Veins; Pneumothorax; Point-of-Care Systems; Radiography, Thoracic; Subclavian Vein; Ultrasonography
PubMed: 27922877
DOI: 10.1097/CCM.0000000000002188 -
Plastic and Reconstructive Surgery.... Nov 2015Economic, cultural, and regulatory phenomena may explain recent popularization of implant-based augmentation in Asia; but the collective Eastern experience remains...
BACKGROUND
Economic, cultural, and regulatory phenomena may explain recent popularization of implant-based augmentation in Asia; but the collective Eastern experience remains limited. Asian surgeons and their patients rely on evidence-based medicine that originates elsewhere and may not be entirely relevant. Distinct anatomic and cultural features of Asian women warrant a tailored approach to breast augmentation. We explore the Asian experience with a thorough exploration of the recent literature.
METHODS
A literature search was performed for articles written after 2000, of Asian women who underwent augmentation mammoplasty using MEDLINE, Embase, and Pubmed Databases. Technique and outcomes data were summarized.
RESULTS
Twelve articles reported outcomes of 2089 women. Korea contributed most series (English language, 7), followed by China (3), Taiwan (1), and Japan (1). Silicone implants were used in 82.1% of women studied, and almost exclusively after 2009. More round (68.9%) than anatomic implants (31.1%) were placed. Non-inframammary (axillary, areolar, and umbilical) incisions were used in 96.9% of cases. Nearly all implants were positioned below the muscle or fascia; subglandular placement accounted for 1.1% of cases. Implant/nipple malposition (1.3%), capsular contracture (1.9%), hematoma (0.6%), and infection (0.2%) rates were reported in most series. Undesirable scarring was the most frequent complication (7.3%), but was reported only in 4 of 12 series.
CONCLUSIONS
Studies of Asian women undergoing augmentation mammoplasty are limited, often with ill-defined outcomes and inadequate follow-up. As experience accumulates, an expanding literature relevant to Asian women will provide evidence-based guidelines that improve outcomes and patient satisfaction, and foster innovation.
PubMed: 26893980
DOI: 10.1097/GOX.0000000000000528 -
The Cochrane Database of Systematic... Dec 2014Manual rotation is commonly performed to increase the chances of normal vaginal delivery and is perceived to be safe. Manual rotation has the potential to prevent... (Review)
Review
BACKGROUND
Manual rotation is commonly performed to increase the chances of normal vaginal delivery and is perceived to be safe. Manual rotation has the potential to prevent operative delivery and caesarean section, and reduce obstetric and neonatal complications.
OBJECTIVES
To assess the effect of prophylactic manual rotation for women with malposition in labour on mode of delivery, and maternal and neonatal outcomes.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2014), the Australian and New Zealand Clinical Trials Registry (ANZCTR), ClinicalTrials.gov, Current Controlled Trials and the WHO International Clinical Trials Registry Platform (ICTRP) (all searched 23 February 2014), previous reviews and, references of retrieved studies.
SELECTION CRITERIA
Randomised, quasi-randomised or cluster-randomised clinical trials comparing prophylactic manual rotation in labour for fetal malposition versus expectant management, augmentation of labour or operative delivery. We defined prophylactic manual rotation as rotation performed without immediate assisted delivery.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed study eligibility and quality, and extracted data.
MAIN RESULTS
We included only one small pilot study (involving 30 women). The study, which we considered to be at low risk of bias, was conducted in a tertiary referral hospital in Australia, and involved women with cephalic, singleton pregnancies. The primary outcome was operative delivery (instrumental delivery or caesarean section).In the manual rotation group, 13/15 women went on to have an instrumental delivery or caesarean section, whereas in the control group, 12/15 women had an operative delivery. The estimated risk ratio was 1.08 (95% confidence interval 0.79 to 1.49). There were no maternal or fetal mortalities in either groupThere were no clear differences for any of the secondary maternal or neonatal outcomes reported (e.g. perineal trauma, analgesia use duration of labour).In terms of adverse events, there were no reported cases of umbilical cord prolapse or cervical laceration and a single case of a non-reassuring or pathological cardiotocograph during the procedure.
AUTHORS' CONCLUSIONS
Currently, there is insufficient evidence to determine the efficacy of prophylactic manual rotation early in the second stage of labour for prevention of operative delivery. One additional study is ongoing. Further appropriately designed trials are required to determine the efficacy of manual rotation.
Topics: Adult; Analgesia, Obstetrical; Cesarean Section; Extraction, Obstetrical; Female; Humans; Labor Presentation; Obstetric Labor Complications; Perineum; Pilot Projects; Pregnancy; Version, Fetal
PubMed: 25532081
DOI: 10.1002/14651858.CD009298.pub2