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The Cochrane Database of Systematic... Jan 2024Balancing the risk of bleeding and thrombosis after acute myocardial infarction (AMI) is challenging, and the optimal antithrombotic therapy remains uncertain. The... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Balancing the risk of bleeding and thrombosis after acute myocardial infarction (AMI) is challenging, and the optimal antithrombotic therapy remains uncertain. The potential of non-vitamin K antagonist oral anticoagulants (NOACs) to prevent ischaemic cardiovascular events is promising, but the evidence remains limited.
OBJECTIVES
To evaluate the efficacy and safety of non-vitamin-K-antagonist oral anticoagulants (NOACs) in addition to background antiplatelet therapy, compared with placebo, antiplatelet therapy, or both, after acute myocardial infarction (AMI) in people without an indication for anticoagulation (i.e. atrial fibrillation or venous thromboembolism).
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science, and two clinical trial registers in September 2022 with no language restrictions. We checked the reference lists of included studies for any additional trials.
SELECTION CRITERIA
We searched for randomised controlled trials (RCTs) that evaluated NOACs plus antiplatelet therapy versus placebo, antiplatelet therapy, or both, in people without an indication for anticoagulation after an AMI.
DATA COLLECTION AND ANALYSIS
Two review authors independently checked the results of searches to identify relevant studies, assessed each included study, and extracted study data. We conducted random-effects pairwise analyses using Review Manager Web, and network meta-analysis using the R package 'netmeta'. We ranked competing treatments by P scores, which are derived from the P values of all pairwise comparisons and allow ranking of treatments on a continuous 0-to-1 scale.
MAIN RESULTS
We identified seven eligible RCTs, including an ongoing trial that we could not include in the analysis. Of the six RCTs involving 33,039 participants, three RCTs compared rivaroxaban with placebo, two RCTs compared apixaban with placebo, and one RCT compared dabigatran with placebo. All participants in the six RCTs received concomitant antiplatelet therapy. The available evidence suggests that rivaroxaban compared with placebo reduces the rate of all-cause mortality (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.69 to 0.98; number needed to treat for an additional beneficial outcome (NNTB) 250; 3 studies, 21,870 participants; high certainty) and probably reduces cardiovascular mortality (RR 0.83, 95% CI 0.69 to 1.01; NNTB 250; 3 studies, 21,870 participants; moderate certainty). There is probably little or no difference between apixaban and placebo in all-cause mortality (RR 1.09, 95% CI 0.88 to 1.35; number needed to treat for an additional harmful outcome (NNTH) 334; 2 studies, 8638 participants; moderate certainty) and cardiovascular mortality (RR 0.99, 95% CI 0.77 to 1.27; number needed to treat not applicable; 2 studies, 8638 participants; moderate certainty). Dabigatran may reduce the rate of all-cause mortality compared with placebo (RR 0.57, 95% CI 0.31 to 1.06; NNTB 63; 1 study, 1861 participants; low certainty). Dabigatran compared with placebo may have little or no effect on cardiovascular mortality, although the point estimate suggests benefit (RR 0.72, 95% CI 0.34 to 1.52; NNTB 143; 1 study, 1861 participants; low certainty). Two of the investigated NOACs were associated with an increased risk of major bleeding compared to placebo: apixaban (RR 2.41, 95% CI 1.44 to 4.06; NNTH 143; 2 studies, 8544 participants; high certainty) and rivaroxaban (RR 3.31, 95% CI 1.12 to 9.77; NNTH 125; 3 studies, 21,870 participants; high certainty). There may be little or no difference between dabigatran and placebo in the risk of major bleeding (RR 1.74, 95% CI 0.22 to 14.12; NNTH 500; 1 study, 1861 participants; low certainty). The results of the network meta-analysis were inconclusive between the different NOACs at all individual doses for all primary outcomes. However, low-certainty evidence suggests that apixaban (combined dose) may be less effective than rivaroxaban and dabigatran for preventing all-cause mortality after AMI in people without an indication for anticoagulation.
AUTHORS' CONCLUSIONS
Compared with placebo, rivaroxaban reduces all-cause mortality and probably reduces cardiovascular mortality after AMI in people without an indication for anticoagulation. Dabigatran may reduce the rate of all-cause mortality and may have little or no effect on cardiovascular mortality. There is probably no meaningful difference in the rate of all-cause mortality and cardiovascular mortality between apixaban and placebo. Moreover, we found no meaningful benefit in efficacy outcomes for specific therapy doses of any investigated NOACs following AMI in people without an indication for anticoagulation. Evidence from the included studies suggests that rivaroxaban and apixaban increase the risk of major bleeding compared with placebo. There may be little or no difference between dabigatran and placebo in the risk of major bleeding. Network meta-analysis did not show any superiority of one NOAC over another for our prespecified primary outcomes. Although the evidence suggests that NOACs reduce mortality, the effect size or impact is small; moreover, NOACs may increase major bleeding. Head-to-head trials, comparing NOACs against each other, are required to provide more solid evidence.
Topics: Humans; Dabigatran; Rivaroxaban; Network Meta-Analysis; Platelet Aggregation Inhibitors; Anticoagulants; Myocardial Infarction; Hemorrhage
PubMed: 38264795
DOI: 10.1002/14651858.CD014678.pub2 -
Zeitschrift Fur Rheumatologie Mar 2024Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is a major driver of premature mortality in patients with rheumatoid arthritis (RA). Detection of... (Review)
Review
OBJECTIVE
Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is a major driver of premature mortality in patients with rheumatoid arthritis (RA). Detection of RA-ILD is crucial but requires awareness among the treating physicians. To date, however, there is no international recommendation concerning screening for ILD in RA patients.
METHODS
After a systematic literature review, the modified Delphi technique in combination with the nominal group technique was used to provide a Delphi consensus statement elaborated by an expert panel of pneumonologists, rheumatologists, and a radiologist. Based on the available evidence, several clusters of questions were defined and discussed until consent was reached.
RESULTS
A screening algorithm for ILD in patients with RA based on clinical signs, respiratory symptoms, and risk factors has been developed. Further, the recommendations address diagnostic tools for RA-ILD and the follow-up of RA patients qualifying for ILD screening.
Topics: Humans; Arthritis, Rheumatoid; Lung Diseases, Interstitial; Risk Factors
PubMed: 38240817
DOI: 10.1007/s00393-023-01464-w -
Canadian Association of Radiologists... Jan 2024Pneumothorax is a common acute presentation in healthcare settings. A chest radiograph (CXR) is often necessary to make the diagnosis, and minimizing the time between...
BACKGROUND
Pneumothorax is a common acute presentation in healthcare settings. A chest radiograph (CXR) is often necessary to make the diagnosis, and minimizing the time between presentation and diagnosis is critical to deliver optimal treatment. Deep learning (DL) algorithms have been developed to rapidly identify pathologic findings on various imaging modalities.
PURPOSE
The purpose of this systematic review and meta-analysis was to evaluate the overall performance of studies utilizing DL algorithms to detect pneumothorax on CXR.
METHODS
A study protocol was created and registered a priori (PROSPERO CRD42023391375). The search strategy included studies published up until January 10, 2023. Inclusion criteria were studies that used adult patients, utilized computer-aided detection of pneumothorax on CXR, dataset was evaluated by a qualified physician, and sufficient data was present to create a 2 × 2 contingency table. Risk of bias was assessed using the QUADAS-2 tool. Bivariate random effects meta-analyses and meta-regression modeling were performed.
RESULTS
Twenty-three studies were selected, including 34 011 patients and 34 075 CXRs. The pooled sensitivity and specificity were 87% (95% confidence interval, 81%, 92%) and 95% (95% confidence interval, 92%, 97%), respectively. The study design, use of an institutional/public data set and risk of bias had no significant effect on the sensitivity and specificity of pneumothorax detection.
CONCLUSIONS
The relatively high sensitivity and specificity of pneumothorax detection by deep-learning showcases the vast potential for implementation in clinical settings to both augment the workflow of radiologists and assist in more rapid diagnoses and subsequent patient treatment.
PubMed: 38189265
DOI: 10.1177/08465371231220885 -
European Radiology Jul 2024Cytotoxic lesions of the corpus callosum (CLOCC) are a common magnetic resonance imaging (MRI) finding associated with various systemic diseases including COVID-19.... (Review)
Review
OBJECTIVES
Cytotoxic lesions of the corpus callosum (CLOCC) are a common magnetic resonance imaging (MRI) finding associated with various systemic diseases including COVID-19. Although an increasing number of such cases is reported in the literature, there is a lack of systematic evidence summarizing the etiology and neuroimaging findings of these lesions. Thus, the aim of this systematic review was to synthesize the applied nomenclature, neuroimaging and clinical features, and differential diagnoses as well as associated disease entities of CLOCC.
MATERIALS AND METHODS
A comprehensive literature search in three biomedical databases identified 441 references, out of which 324 were eligible for a narrative summary including a total of 1353 patients.
RESULTS
Our PRISMA-conform systematic review identifies a broad panel of disease entities which are associated with CLOCC, among them toxic/drug-treatment-associated, infectious (viral, bacterial), vascular, metabolic, traumatic, and neoplastic entities in both adult and pediatric individuals. On MRI, CLOCC show typical high T2 signal, low T1 signal, restricted diffusion, and lack of contrast enhancement. The majority of the lesions were reversible within the follow-up period (median follow-up 3 weeks). Interestingly, even though CLOCC were mostly associated with symptoms of the underlying disease, in exceptional cases, CLOCC were associated with callosal neurological symptoms. Of note, employed nomenclature for CLOCC was highly inconsistent.
CONCLUSIONS
Our study provides high-level evidence for clinical and imaging features of CLOCC as well as associated disease entities.
CLINICAL RELEVANCE STATEMENT
Our study provides high-level evidence on MRI features of CLOCC as well as a comprehensive list of disease entities potentially associated with CLOCC. Together, this will facilitate rigorous diagnostic workup of suspected CLOCC cases.
KEY POINTS
• Cytotoxic lesions of the corpus callosum (CLOCC) are a frequent MRI feature associated with various systemic diseases. • Cytotoxic lesions of the corpus callosum show a highly homogenous MRI presentation and temporal dynamics. • This comprehensive overview will benefit (neuro)radiologists during diagnostic workup.
Topics: Humans; Corpus Callosum; Magnetic Resonance Imaging; COVID-19; Brain Diseases; Neuroimaging; Diagnosis, Differential
PubMed: 38147170
DOI: 10.1007/s00330-023-10524-3 -
Polish Journal of Radiology 2023Colorectal cancer (CRC) is one of the most common malignancies in the world. Nowadays many treatments are available to help control CRC, including surgery, radiation... (Review)
Review
Colorectal cancer (CRC) is one of the most common malignancies in the world. Nowadays many treatments are available to help control CRC, including surgery, radiation therapy, interventional radiology, and drug treatments. A multidisciplinary approach and the role of radiologists is needed to assist the surgeon in the management thanks to emerging technology and strategies. The Response Evaluation Criteria in Solid Tumours (RECIST) has been created to objectify and standardize cancer response assessment. Thus, in this article specific presumptions and practical aspects of evaluating responses according to the RECIST 1.1 are discussed. Furthermore, examples of possible response to systemic treatment of colorectal liver metastases (CRLM), including tumour necrosis, apparent diffusion coefficient (ADC) values, tumour calcification, tumour fibrosis and intratumoural fat deposition observed on cross-sectional imaging, are described. Disappearing liver metastases (DLM) presents a therapeutic dilemma. The optimal management of DLM remains controversial due to the uncertainty of residual microscopic disease and effective long-term outcomes. The article provides an overview of the CRLM phenomenon and current possible assessment methods of the response to systemic treatment.
PubMed: 38125815
DOI: 10.5114/pjr.2023.132884 -
CVIR Endovascular Dec 2023Splenic artery embolisation (SAE) has become a vital strategy in the modern landscape of multidisciplinary trauma care, improving splenic salvage rates in patients with... (Review)
Review
BACKGROUND
Splenic artery embolisation (SAE) has become a vital strategy in the modern landscape of multidisciplinary trauma care, improving splenic salvage rates in patients with high-grade injury. However, due to a lack of prospective data there remains contention amongst stakeholders as to whether SAE should be performed at the time of presentation (prophylactic or pSAE), or whether patients should be observed, and SAE only used only if a patient re-bleeds. This systematic review aimed to assess published practice management guidelines which recommend pSAE, stratified according to their quality.
METHODS
The study was registered and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Medline, PubMed, Cochrane, Embase, and Google Scholar were searched by the study authors. Identified guidelines were graded according to the Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument.
RESULTS
Database and internet searches identified 1006 results. After applying exclusion criteria, 28 guidelines were included. The use of pSAE was recommended in 15 guidelines (54%). This included 6 out of 9 guidelines that were high quality (66.7%), 4 out of 9 guidelines that were moderate quality (44.4%), and 3 out of 10 (30%) guidelines that were low quality, p = 0.275.
CONCLUSIONS
This systematic review showed that recommendation of pSAE is more common in guidelines which are of high quality. However, there is vast heterogeneity of recommended practice guidelines, likely based on individual trauma systems rather than the available evidence. This reflects biases with interpretation of data and lack of multidisciplinary system inputs, including from interventional radiologists.
PubMed: 38103054
DOI: 10.1186/s42155-023-00414-6 -
European Radiology Jul 2024Scaphoid fractures are usually diagnosed using X-rays, a low-sensitivity modality. Artificial intelligence (AI) using Convolutional Neural Networks (CNNs) has been... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Scaphoid fractures are usually diagnosed using X-rays, a low-sensitivity modality. Artificial intelligence (AI) using Convolutional Neural Networks (CNNs) has been explored for diagnosing scaphoid fractures in X-rays. The aim of this systematic review and meta-analysis is to evaluate the use of AI for detecting scaphoid fractures on X-rays and analyze its accuracy and usefulness.
MATERIALS AND METHODS
This study followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and PRISMA-Diagnostic Test Accuracy. A literature search was conducted in the PubMed database for original articles published until July 2023. The risk of bias and applicability were evaluated using the QUADAS-2 tool. A bivariate diagnostic random-effects meta-analysis was conducted, and the results were analyzed using the Summary Receiver Operating Characteristic (SROC) curve.
RESULTS
Ten studies met the inclusion criteria and were all retrospective. The AI's diagnostic performance for detecting scaphoid fractures ranged from AUC 0.77 to 0.96. Seven studies were included in the meta-analysis, with a total of 3373 images. The meta-analysis pooled sensitivity and specificity were 0.80 and 0.89, respectively. The meta-analysis overall AUC was 0.88. The QUADAS-2 tool found high risk of bias and concerns about applicability in 9 out of 10 studies.
CONCLUSIONS
The current results of AI's diagnostic performance for detecting scaphoid fractures in X-rays show promise. The results show high overall sensitivity and specificity and a high SROC result. Further research is needed to compare AI's diagnostic performance to human diagnostic performance in a clinical setting.
CLINICAL RELEVANCE STATEMENT
Scaphoid fractures are prone to be missed secondary to assessment with a low sensitivity modality and a high occult fracture rate. AI systems can be beneficial for clinicians and radiologists to facilitate early diagnosis, and avoid missed injuries.
KEY POINTS
• Scaphoid fractures are common and some can be easily missed in X-rays. • Artificial intelligence (AI) systems demonstrate high diagnostic performance for the diagnosis of scaphoid fractures in X-rays. • AI systems can be beneficial in diagnosing both obvious and occult scaphoid fractures.
Topics: Humans; Scaphoid Bone; Fractures, Bone; Artificial Intelligence; Sensitivity and Specificity; Radiography
PubMed: 38097728
DOI: 10.1007/s00330-023-10473-x -
Biomedical Engineering Online Dec 2023This systematic review and meta-analysis were conducted to objectively evaluate the evidence of machine learning (ML) in the patient diagnosis of Intracranial Hemorrhage... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This systematic review and meta-analysis were conducted to objectively evaluate the evidence of machine learning (ML) in the patient diagnosis of Intracranial Hemorrhage (ICH) on computed tomography (CT) scans.
METHODS
Until May 2023, systematic searches were conducted in ISI Web of Science, PubMed, Scopus, Cochrane Library, IEEE Xplore Digital Library, CINAHL, Science Direct, PROSPERO, and EMBASE for studies that evaluated the diagnostic precision of ML model-assisted ICH detection. Patients with and without ICH as the target condition who were receiving CT-Scan were eligible for the research, which used ML algorithms based on radiologists' reports as the gold reference standard. For meta-analysis, pooled sensitivities, specificities, and a summary receiver operating characteristics curve (SROC) were used.
RESULTS
At last, after screening the title, abstract, and full paper, twenty-six retrospective and three prospective, and two retrospective/prospective studies were included. The overall (Diagnostic Test Accuracy) DTA of retrospective studies with a pooled sensitivity was 0.917 (95% CI 0.88-0.943, I = 99%). The pooled specificity was 0.945 (95% CI 0.918-0.964, I = 100%). The pooled diagnostic odds ratio (DOR) was 219.47 (95% CI 104.78-459.66, I = 100%). These results were significant for the specificity of the different network architecture models (p-value = 0.0289). However, the results for sensitivity (p-value = 0.6417) and DOR (p-value = 0.2187) were not significant. The ResNet algorithm has higher pooled specificity than other algorithms with 0.935 (95% CI 0.854-0.973, I = 93%).
CONCLUSION
This meta-analysis on DTA of ML algorithms for detecting ICH by assessing non-contrast CT-Scans shows the ML has an acceptable performance in diagnosing ICH. Using ResNet in ICH detection remains promising prediction was improved via training in an Architecture Learning Network (ALN).
Topics: Humans; Prospective Studies; Sensitivity and Specificity; Retrospective Studies; Algorithms; Machine Learning; Diagnostic Tests, Routine
PubMed: 38049809
DOI: 10.1186/s12938-023-01172-1 -
World Journal of Emergency Surgery :... Nov 2023An updated overview of ultrasound (US) for diagnosis of acute cholecystitis (AC) remains lacking. This systematic review was conducted to evaluate the diagnostic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
An updated overview of ultrasound (US) for diagnosis of acute cholecystitis (AC) remains lacking. This systematic review was conducted to evaluate the diagnostic performance of US for AC.
METHODS
A systematic review was conducted following PRISMA guidelines. We meticulously screened articles from MEDLINE, Embase, and the Cochrane Library, spanning from inception to August 2023. We employed the search strategy combining the keywords "bedside US", "emergency US" or "point-of-care US" with "AC". Two reviewers independently screened the titles and abstracts of the retrieved articles to identify suitable studies. The inclusion criteria encompassed articles investigating the diagnostic performance of US for AC. Data regarding diagnostic performance, sonographers, and sonographic findings including the presence of gallstone, gallbladder (GB) wall thickness, peri-GB fluid, or sonographic Murphy sign were extracted, and a meta-analysis was executed. Case reports, editorials, and review articles were excluded, as well as studies focused on acalculous cholecystitis. The study quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool.
RESULTS
Forty studies with 8,652 patients were included. The majority of studies had a low risk of bias and applicability concerns. US had a pooled sensitivity of 71% (95% CI, 69-72%), a specificity of 85% (95% CI, 84-86%), and an accuracy of 0.83 (95% CI, 0.82-0.83) for the diagnosis of AC. The pooled sensitivity and specificity were 71% (95% CI, 67-74%) and 92% (95% CI, 90-93%) performed by emergency physicians (EPs), 79% (95% CI, 71-85%) and 76% (95% CI, 69-81%) performed by surgeons, and 68% (95% CI 66-71%) and 87% (95% CI, 86-88%) performed by radiologists, respectively. There were no statistically significant differences among the three groups.
CONCLUSION
US is a good imaging modality for the diagnosis of AC. EP-performed US has a similar diagnostic performance to radiologist-performed US. Further investigations would be needed to investigate the impact of US on expediting the management process and improving patient-centered outcomes.
Topics: Humans; Cholecystitis, Acute; Ultrasonography; Sensitivity and Specificity
PubMed: 38037062
DOI: 10.1186/s13017-023-00524-5 -
PLOS Digital Health Nov 2023The exponential growth of artificial intelligence (AI) in the last two decades has been recognized by many as an opportunity to improve the quality of patient care....
The exponential growth of artificial intelligence (AI) in the last two decades has been recognized by many as an opportunity to improve the quality of patient care. However, medical education systems have been slow to adapt to the age of AI, resulting in a paucity of AI-specific education in medical schools. The purpose of this systematic review is to evaluate the current evidence-based recommendations for the inclusion of an AI education curriculum in undergraduate medicine. Six databases were searched from inception to April 23, 2022 for cross sectional and cohort studies of fair quality or higher on the Newcastle-Ottawa scale, systematic, scoping, and integrative reviews, randomized controlled trials, and Delphi studies about AI education in undergraduate medical programs. The search yielded 991 results, of which 27 met all the criteria and seven more were included using reference mining. Despite the limitations of a high degree of heterogeneity among the study types and a lack of follow-up studies evaluating the impacts of current AI strategies, a thematic analysis of the key AI principles identified six themes needed for a successful implementation of AI in medical school curricula. These themes include ethics, theory and application, communication, collaboration, quality improvement, and perception and attitude. The themes of ethics, theory and application, and communication were further divided into subthemes, including patient-centric and data-centric ethics; knowledge for practice and knowledge for communication; and communication for clinical decision-making, communication for implementation, and communication for knowledge dissemination. Based on the survey studies, medical professionals and students, who generally have a low baseline knowledge of AI, have been strong supporters of adding formal AI education into medical curricula, suggesting more research needs to be done to push this agenda forward.
PubMed: 38011214
DOI: 10.1371/journal.pdig.0000255