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Australian Journal of General Practice Nov 2023In Australia, mortality rates for hepatocellular carcinoma (HCC) are rising. Targeted surveillance is recommended to increase early diagnosis. The aim of this study was...
BACKGROUND AND OBJECTIVES
In Australia, mortality rates for hepatocellular carcinoma (HCC) are rising. Targeted surveillance is recommended to increase early diagnosis. The aim of this study was to synthesise evidence regarding HCC surveillance in primary care and identify barriers and facilitators to surveillance.
METHOD
A systematic review was performed, with searches conducted in five biomedical databases, the Centre for Reviews and Dissemination website and the grey literature. Study quality was assessed using the National Institute for Heath and Care Excellence (NICE) quality appraisal checklists.
RESULTS
In all, 32 studies, focusing on viral hepatitis and cirrhosis patients, were included in the review. HCC surveillance rates were lower for patients managed by primary care providers (PCPs) than for those managed by gastroenterologists/hepatologists. HCC surveillance rates increased when additional support was provided to PCPs (eg reminder systems, nurse follow-up). Key barriers were a lack of awareness of HCC risks and surveillance recommendations, as well as competing priorities PCPs must address when working with patients with multimorbidity.
DISCUSSION
HCC surveillance programs in primary care should be accompanied by additional support for PCPs and strategies to increase awareness of clinical recommendations.
Topics: Humans; Liver Neoplasms; Carcinoma, Hepatocellular; Liver Cirrhosis; Early Detection of Cancer; Primary Health Care
PubMed: 37935142
DOI: 10.31128/AJGP-11-22-6619 -
BMC Primary Care Nov 2023Primary care clinicians (PCCs) are typically the first practitioners to detect cognitive impairment in their patients, including those with Alzheimer's disease or...
Understanding barriers to and facilitators of clinician-patient conversations about brain health and cognitive concerns in primary care: a systematic review and practical considerations for the clinician.
BACKGROUND
Primary care clinicians (PCCs) are typically the first practitioners to detect cognitive impairment in their patients, including those with Alzheimer's disease or related dementias (ADRD). However, conversations around cognitive changes can be challenging for patients, family members, and clinicians to initiate, with all groups reporting barriers to open dialogue. With the expanding array of evidence-based interventions for ADRD, from multidomain care management to novel biotherapeutics for early-stage AD, incorporating conversations about brain health into routine healthcare should become a standard of care. We conducted a systematic review to identify barriers to and facilitators of brain health conversations in primary care settings.
METHODS
We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Library for qualitative or quantitative studies conducted in the US between January 2000 and October 2022 that evaluated perceptions of cognition and provider-patient brain health conversations prior to formal screening for, or diagnosis of, mild cognitive impairment or ADRD. We assessed the quality of the included studies using the Mixed Methods Appraisal Tool.
RESULTS
In total, 5547 unique abstracts were screened and 22 articles describing 19 studies were included. The studies explored perceptions of cognition among laypersons or clinicians, or provider-patient interactions in the context of a patient's cognitive concerns. We identified 4 main themes: (1) PCCs are hesitant to discuss brain health and cognitive concerns; (2) patients are hesitant to raise cognitive concerns; (3) evidence to guide clinicians in developing treatment plans that address cognitive decline is often poorly communicated; and (4) social and cultural context influence perceptions of brain health and cognition, and therefore affect clinical engagement.
CONCLUSIONS
Early conversations about brain health between PCCs and their patients are rare, and effective tools, processes, and strategies are needed to make these vital conversations routine.
Topics: Humans; Alzheimer Disease; Cognitive Dysfunction; Brain; Cognition; Primary Health Care
PubMed: 37932666
DOI: 10.1186/s12875-023-02185-4 -
Health Technology Assessment... Oct 2023Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.
BACKGROUND
Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.
REVIEW QUESTIONS
(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?
METHODS
A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases ( = 9), trial registries ( = 6), grey literature databases ( = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.
RESULTS
- 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect size = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect size = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect size = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.
LIMITATIONS
Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.
CONCLUSION
The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.
FUTURE WORK
There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.
STUDY REGISTRATION
This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).
FUNDING
This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.
Topics: Humans; Shoulder Pain; Feasibility Studies; Exercise Therapy; Tendinopathy; Treatment Outcome
PubMed: 37929629
DOI: 10.3310/TFWS2748 -
JSES Reviews, Reports, and Techniques Nov 2023Currently, recurrent anterior shoulder instability in patients with a Hill-Sachs lesion managed using the Bankart repair showed higher recurrent instability compared... (Review)
Review
Bankart repair with remplissage vs. Latarjet procedure on recurrence, postoperative pain scores, external rotation, and Rowe score in patients with a Hill-Sachs lesion. A systematic review.
BACKGROUND
Currently, recurrent anterior shoulder instability in patients with a Hill-Sachs lesion managed using the Bankart repair showed higher recurrent instability compared with the Latarjet technique. Addition of posterior capsulodesis with infraspinatus remplissage to the Bankart repair, known as Bankart with remplissage (BR), increases shoulder stability in patients with a Hill-Sachs lesion. BR can potentially match the low recurrence rates of the Latarjet procedure while being less invasive. This systematic review compares the Bankart repair with remplissage and Latarjet procedure on postoperative pain, external rotation range of motion, and recurrent instability in anterior shoulder instability patients with a Hill-Sachs lesion.
METHODS
A systematic search of the PubMed, Web of Science, and Cochrane Library databases was performed. Studies comparing BR and Latarjet on recurrent instability and/or visual analogue scale (VAS) pain score in anterior shoulder instability patients with a Hill-Sachs lesion were included. Expert opinion, conference presentations, editorials, abstracts, case reports, and nonclinical studies were excluded. Records were initially screened by title and abstract, during the second screening full text was consulted. Study quality was examined using the Methodological Index for Nonrandomized Studies criteria. Risk ratios were calculated for recurrent instability, and standardized mean difference (Cohen's d) were calculated for VAS pain, external rotation, and Rowe score.
RESULTS
Eight of the 146 studies were included in the analysis. The study population consisted of a total of 845 patients, of whom 450 patients underwent the Latarjet procedure and 395 patients underwent BR. Three studies included revision surgery patients; more revision surgery patients were allocated to the Latarjet group. Risk ratios for recurrent instability varied from 0.45 to 2.41. Effect size varied for VAS pain from -2.28 to 0.04, for external rotation from -1.44 to 1.12, and for Rowe score from -0.67 to 1.37. Limitations of the included studies were differences in baseline demographics and functional outcomes.
CONCLUSION
Recurrent instability seems equal between BR and Latarjet in patients with a Hill-Sachs lesion depth <10 mm. Latarjet showed superior external rotation than BR. Future research should examine patient demographics optimal for minimizing recurrent instability using BR.
PubMed: 37928988
DOI: 10.1016/j.xrrt.2023.08.001 -
Healthcare (Basel, Switzerland) Oct 2023Mothers in the postpartum period often experience musculoskeletal disorders and pain, impacting their ability to care for themselves and their infants. Conventional... (Review)
Review
Mothers in the postpartum period often experience musculoskeletal disorders and pain, impacting their ability to care for themselves and their infants. Conventional treatments have limitations, prompting interest in alternative options like herbal medicine. This systematic review aimed to confirm the effectiveness and safety of herbal medicine treatment to improve maternal health in patients with postpartum pain (puerperal wind syndrome). We searched eight electronic databases for randomized controlled trials (RCTs) to evaluate the effects of herbal medicines on puerperal wind syndrome. Nine RCTs, including 652 patients, were selected. Following a meta-analysis of RCTs, both herbal medicine and combination treatments improved the visual analog scale scores, total effective rate, scores of Traditional Chinese Medicine syndromes, Oswestry Disability Index, and quality of life in patients with role-emotional puerperal wind syndrome. All adverse events were minor, and the incidence rate was not high compared with that of the control group. In conclusion, herbal medicine supports the improvement in pain, other systemic symptoms, and the quality of life of patients with puerperal wind syndrome. Moreover, no serious side effects were observed; therefore, herbal medicines appear to be safe. It can be the preferred treatment option for puerperal wind syndrome, which is currently managed symptomatically.
PubMed: 37893817
DOI: 10.3390/healthcare11202743 -
Frontiers in Medicine 2023Coronary artery disease (CAD) management in the setting of immune thrombocytopenia (ITP) remains very challenging to clinicians as a reasonable balance between bleeding...
INTRODUCTION
Coronary artery disease (CAD) management in the setting of immune thrombocytopenia (ITP) remains very challenging to clinicians as a reasonable balance between bleeding and thrombosis risks needs to be achieved, and the evidence guiding such management is scarce.
METHODS
We conducted a systematic review following the PRISMA guidelines to summarize the available literature on the management and outcomes of CAD coexisting with ITP. We searched PubMed and Embase for studies published in English exploring CAD and ITP management until 05 October 2022. Two independent reviewers screened and assessed the articles for inclusion. Patients' characteristics, CAD treatment modalities, ITP treatment, and complications were reported.
RESULTS
We identified 32 CAD cases, among which 18 cases were revascularized with percutaneous coronary intervention (PCI), 12 cases underwent coronary artery bypass graft surgery (CABG), and two cases were managed conservatively. More than 50% were men, with a mean age of 61 ± 13 years and a mean baseline platelet count of 52 ± 59 × 10/L. Irrespective of the revascularization modality, most patients were treated with either corticosteroids alone, intravenous immunoglobulins (IVIG) alone, or in combination. Among those who underwent PCI, two patients had bleeding events, and one patient died. Similarly, among those with CABG, one patient developed bleeding, and one patient died.
CONCLUSION
We found that revascularization with either PCI or CABG with the concurrent use of corticosteroids and/or IVIG for ITP was feasible, with an existing non-negligible risk of bleeding and mortality.
PubMed: 37886354
DOI: 10.3389/fmed.2023.1213275 -
Medicine Oct 2023The concept of a weekend effect is that patients admitted to hospitals on the weekend tend to have poorer outcomes compared to those admitted on a weekday. Whether there... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The concept of a weekend effect is that patients admitted to hospitals on the weekend tend to have poorer outcomes compared to those admitted on a weekday. Whether there is a weekend effect among patients receiving spine surgery is not well described in the literature. We sought to perform a systematic review with meta-analysis to explore whether a weekend effect exists among patients experiencing spinal surgery.
METHODS
The Cochrane Library, PubMed, Embase, and MEDLINE electronic databases were searched for relevant articles. Meta-analyses were performed using functions available in the metafor package within the R software. We obtained adjusted odds ratios (OR) from included studies and pooled OR through an inverse variance method. A random-effects model was applied for meta-analysis and effect sizes were presented with their corresponding 95% confidence intervals (CI).
RESULTS
Our search strategy identified 316 references from electronic databases and eventually 6 studies were included in the analysis. The pooled result of 5 studies reporting overall complication rate indicated significant increased risk of complications among the weekend admission group (OR, 1.35; 95% CI, 1.01 to 1.80). The pooled results of 3 studies demonstrated no difference in overall mortality rates between these 2 groups of patients (OR, 1.18; 95% CI, 0.67 to 1.97).
CONCLUSIONS
In spinal surgical patients, the weekend effect significantly contributes to a higher complication rate. Knowledge of potential adverse events in patients admitted on weekends is necessary for spinal surgeons and caregivers to improve patient outcomes with spinal surgery.
Topics: Humans; Hospital Mortality; Hospitalization; Neurosurgical Procedures; Hospitals; Postoperative Period
PubMed: 37861527
DOI: 10.1097/MD.0000000000035640 -
The Journal of Medicine Access 2023Immunoglobulin replacement therapy (IgRT) benefits patients with primary immuno deficiency (PID) originating from the innate or polygenic defects in the immune system.... (Review)
Review
BACKGROUND
Immunoglobulin replacement therapy (IgRT) benefits patients with primary immuno deficiency (PID) originating from the innate or polygenic defects in the immune system. However, evidence supporting their therapeutic role is not as explicit in secondary immuno deficiency (SID) resulting from the treatment of haematological malignancies.
OBJECTIVES
This study aimed to (1) create a dataset of relevant research papers, which explore the use of IgRT in SID for analysis, (2) assess the risk of bias within this dataset and (3) study the characteristics of these papers.
DESIGN
This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. In addition to the risk of bias, the study characteristics explored in this article included study design, study geographical location and year of publication.
DATA SOURCES AND METHODS
To identify studies relevant to the research question, EMBASE and PubMed databases were searched. The Population, Intervention, Comparison and Outcome (PICO) framework was used to assess study quality. Risk of bias and quality of studies were assessed in accordance with the study design. As one model was not appropriate to assess bias in all articles, several tools were used.
RESULTS
A total of 43 studies were identified from the literature search as relevant to the research objective. The most common study design was a retrospective case-control cohort study ( = 16/43), and randomised trials were among the least commonly used approaches ( = 1). Research in this area is occurring around the globe including the United States ( = 7), Italy ( = 7), China, India, Japan and throughout Europe. The annual number of papers in this area has varied from 2012 ( = 1) to 2021 ( = 7). The studies in this article demonstrated a varied risk of bias, with 9 of the 20 cohort studies scoring less than 5 out of 9 stars.
CONCLUSIONS
Randomised controlled trials are less frequently used to assess access and use of immunoglobulins. More commonly, a retrospective case-control cohort study was used which correlates with the higher risk of bias seen in the studies in this article. Most of the research concerning immunoglobulin use and access occurs in higher-income countries.
PubMed: 37846344
DOI: 10.1177/27550834231197315 -
Journal of the Intensive Care Society Nov 2023Oxygen is the commonest intervention provided to critically ill patients requiring mechanical ventilation. Despite this, it is unclear how much oxygen should be...
BACKGROUND
Oxygen is the commonest intervention provided to critically ill patients requiring mechanical ventilation. Despite this, it is unclear how much oxygen should be administered to patients in order to promote the best clinical outcomes and it has been suggested that a strategy of conservative oxygen therapy (COT) may be advantageous. We therefore sought to answer the question of whether COT versus usual or liberal oxygen therapy was beneficial to adult patients receiving mechanical ventilation on an intensive care unit (ICU) by performing a systematic review and meta-analysis.
METHODS
Studies were included if they were randomised controlled trials comparing COT to liberal or usual oxygen therapy strategies in acutely ill adults (aged ⩾18 years) admitted to an ICU, and reported an outcome of interest. Studies were excluded if they were limited to a specific single disease diagnosis. The review was registered on PROSPERO (CRD42022308436). Risk of bias was assessed using a modified Cochrane Risk of Bias assessment tool. Effect estimates were pooled using a random effects model with the between study variance estimated using restricted maximum likelihood and standard errors calculated using the method of Hartung-Knapp/Sidik-Jonkman. Between study heterogeneity was quantified using the statistic. The certainty in the body of evidence was assessed using GRADE criteria.
RESULTS
Nine eligible studies with 5727 participants fulfilled all eligibility criteria. Trials varied in their definitions of COT and liberal or usual oxygen therapy. The pooled estimate of risk ratio for 90 day mortality for COT versus comparator was 0.99 (95% confidence interval 0.88-1.12, 95% prediction interval 0.82-1.21). There was low heterogeneity among studies ( = 22.4%). The finding that mortality was similar for patients managed with COT or usual/liberal oxygen therapy was graded as moderate certainty.
CONCLUSIONS
In critically ill adults admitted to an ICU, COT is neither beneficial nor harmful when compared to usual or liberal oxygen therapy. Trials to date have been inconsistent in defining both COT and liberal or usual oxygen therapy, which may have had an impact on the results of this meta-analysis. Future research should focus on unifying definitions and outcome measures.
PubMed: 37841302
DOI: 10.1177/17511437231192385 -
European Journal of Cardio-thoracic... Oct 2023Literature is scarce on the management of patients using direct oral anticoagulants (DOACs) undergoing elective, urgent and emergency surgery. Therefore, we summarize... (Review)
Review
OBJECTIVES
Literature is scarce on the management of patients using direct oral anticoagulants (DOACs) undergoing elective, urgent and emergency surgery. Therefore, we summarize the current evidence and provide literature-based recommendations for the management of patients on DOACs in the perioperative phase.
METHODS
A general literature review was conducted on the pharmacology of DOACs and for recommendations on the management of cardiac surgical patients on DOACs. Additionally, we performed a systematic review for studies on the use of direct DOAC reversal agents in the emergency cardiac surgical setting.
RESULTS
When surgery is elective, the DOAC cessation strategy is relatively straightforward and should be adapted to the renal function. The same approach applies to urgent cases, but additional DOAC activity drug level monitoring tests may be useful. In emergency cases, idarucizumab can be safely administered to patients on dabigatran in any of the perioperative phases. However, andexanet alfa, which is not registered for perioperative use, should not be administered in the preoperative phase to reverse the effect of factor Xa inhibitors, as it may induce temporary heparin resistance. Finally, the administration of (activated) prothrombin complex concentrate may be considered in all patients on DOACs, and such concentrates are generally readily available.
CONCLUSIONS
DOACs offer several advantages over vitamin K antagonists, but care must be taken in patients undergoing cardiac surgery. Although elective and urgent cases can be managed relatively straightforwardly, the management of emergency cases requires particular attention.
Topics: Humans; Administration, Oral; Anticoagulants; Cardiac Surgical Procedures; Dabigatran; Hemorrhage; Heparin
PubMed: 37812245
DOI: 10.1093/ejcts/ezad340