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Academic Emergency Medicine : Official... Mar 2016Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the emergency setting, the diagnosis of AHF in ED patients with undifferentiated dyspnea can be challenging.
OBJECTIVES
The primary objective of this study was to perform a systematic review and meta-analysis of the operating characteristics of diagnostic elements available to the emergency physician for diagnosing AHF. Secondary objectives were to develop a test-treatment threshold model and to calculate interval likelihood ratios (LRs) for natriuretic peptides (NPs) by pooling patient-level results.
METHODS
PubMed, EMBASE, and selected bibliographies were searched from January 1965 to March 2015 using MeSH terms to address the ability of the following index tests to predict AHF as a cause of dyspnea in adult patients in the ED: history and physical examination, electrocardiogram, chest radiograph (CXR), B-type natriuretic peptide (BNP), N-terminal proB-type natriuretic peptide (NT-proBNP), lung ultrasound (US), bedside echocardiography, and bioimpedance. A diagnosis of AHF based on clinical data combined with objective test results served as the criterion standard diagnosis. Data were analyzed using Meta-DiSc software. Authors of all NP studies were contacted to obtain patient-level data. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was utilized to evaluate the quality and applicability of the studies included.
RESULTS
Based on the included studies, the prevalence of AHF ranged from 29% to 79%. Index tests with pooled positive LRs ≥ 4 were the auscultation of S3 on physical examination (4.0, 95% confidence interval [CI] = 2.7 to 5.9), pulmonary edema on both CXR (4.8, 95% CI = 3.6 to 6.4) and lung US (7.4, 95% CI = 4.2 to 12.8), and reduced ejection fraction observed on bedside echocardiogram (4.1, 95% CI = 2.4 to 7.2). Tests with low negative LRs were BNP < 100 pg/mL (0.11, 95% CI = 0.07 to 0.16), NT-proBNP < 300 pg/mL (0.09, 95% CI = 0.03 to 0.34), and B-line pattern on lung US LR (0.16, 95% CI = 0.05 to 0.51). Interval LRs of BNP concentrations at the low end of "positive" results as defined by a cutoff of 100 pg/mL were substantially lower (100 to 200 pg/mL; 0.29, 95% CI = 0.23 to 0.38) than those associated with higher BNP concentrations (1000 to 1500 pg/mL; 7.12, 95% CI = 4.53 to 11.18). The interval LR of NT-proBNP concentrations even at very high values (30,000 to 200,000 pg/mL) was 3.30 (95% CI = 2.05 to 5.31).
CONCLUSIONS
Bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis.
Topics: Acute Disease; Diagnosis, Differential; Dyspnea; Echocardiography; Electrocardiography; Emergency Service, Hospital; Heart Failure; Humans; Lung; Natriuretic Peptide, Brain; Peptide Fragments; Physical Examination; Radiography, Thoracic
PubMed: 26910112
DOI: 10.1111/acem.12878 -
JAMA Network Open Mar 2019Standard tools used to diagnose pulmonary edema in acute decompensated heart failure (ADHF), including chest radiography (CXR), lack adequate sensitivity, which may... (Meta-Analysis)
Meta-Analysis
Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis.
IMPORTANCE
Standard tools used to diagnose pulmonary edema in acute decompensated heart failure (ADHF), including chest radiography (CXR), lack adequate sensitivity, which may delay appropriate diagnosis and treatment. Point-of-care lung ultrasonography (LUS) may be more accurate than CXR, but no meta-analysis of studies directly comparing the 2 tools was previously available.
OBJECTIVE
To compare the accuracy of LUS with the accuracy of CXR in the diagnosis of cardiogenic pulmonary edema in adult patients presenting with dyspnea.
DATA SOURCES
A comprehensive search of MEDLINE, Embase, and Cochrane Library databases and the gray literature was performed in May 2018. No language or year limits were applied.
STUDY SELECTION
Study inclusion criteria were a prospective adult cohort of patients presenting to any clinical setting with dyspnea who underwent both LUS and CXR on initial assessment with imaging results compared with a reference standard ADHF diagnosis by a clinical expert after either a medical record review or a combination of echocardiography findings and brain-type natriuretic peptide criteria. Two reviewers independently assessed the studies for inclusion criteria, and disagreements were resolved with discussion.
DATA EXTRACTION AND SYNTHESIS
Reporting adhered to the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy and the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Two authors independently extracted data and assessed the risk of bias using a customized QUADAS-2 tool. The pooled sensitivity and specificity of LUS and CXR were determined using a hierarchical summary receiver operating characteristic approach.
MAIN OUTCOMES AND MEASURES
The comparative accuracy of LUS and CXR in diagnosing ADHF as measured by the differences between the 2 modalities in pooled sensitivity and specificity.
RESULTS
The literature search yielded 1377 nonduplicate titles that were screened, of which 43 articles (3.1%) underwent full-text review. Six studies met the inclusion criteria, representing a total of 1827 patients. Pooled estimates for LUS were 0.88 (95% Cl, 0.75-0.95) for sensitivity and 0.90 (95% Cl, 0.88-0.92) for specificity. Pooled estimates for CXR were 0.73 (95% CI, 0.70-0.76) for sensitivity and 0.90 (95% CI, 0.75-0.97) for specificity. The relative sensitivity ratio of LUS, compared with CXR, was 1.2 (95% CI, 1.08-1.34; P < .001), but no difference was found in specificity between tests (relative specificity ratio, 1.0; 95% CI, 0.90-1.11; P = .96).
CONCLUSIONS AND RELEVANCE
The findings suggest that LUS is more sensitive than CXR in detecting pulmonary edema in ADHF; LUS should be considered as an adjunct imaging modality in the evaluation of patients with dyspnea at risk of ADHF.
Topics: Aged; Aged, 80 and over; Female; Heart Failure; Humans; Lung; Male; Middle Aged; Point-of-Care Systems; Predictive Value of Tests; Radiography, Thoracic; Ultrasonography
PubMed: 30874784
DOI: 10.1001/jamanetworkopen.2019.0703 -
Journal of the American Heart... Jul 2023Background To study the prevalence and types of hypertension-mediated organ damage and the prognosis of patients presenting to the emergency department (ED) with... (Meta-Analysis)
Meta-Analysis
Background To study the prevalence and types of hypertension-mediated organ damage and the prognosis of patients presenting to the emergency department (ED) with hypertensive emergencies. Methods and Results PubMed was queried from inception through November 30, 2021. Studies were included if they reported the prevalence or prognosis of hypertensive emergencies in patients presenting to the ED. Studies reporting data on hypertensive emergencies in other departments were excluded. The extracted data were arcsine transformed and pooled using a random-effects model. Fifteen studies (n=4370 patients) were included. Pooled analysis demonstrates that the prevalence of hypertensive emergencies was 0.5% (95% CI, 0.40%-0.70%) in all patients presenting to ED and 35.9% (95% CI, 26.7%-45.5%) among patients presenting in ED with hypertensive crisis. Ischemic stroke (28.1% [95% CI, 18.7%-38.6%]) was the most prevalent hypertension-mediated organ damage, followed by pulmonary edema/acute heart failure (24.1% [95% CI, 19.0%-29.7%]), hemorrhagic stroke (14.6% [95% CI, 9.9%-20.0%]), acute coronary syndrome (10.8% [95% CI, 7.3%-14.8%]), renal failure (8.0% [95% CI, 2.9%-15.5%]), subarachnoid hemorrhage (6.9% [95% CI, 3.9%-10.7%]), encephalopathy (6.1% [95% CI, 1.9%-12.4%]), and the least prevalent was aortic dissection (1.8% [95% CI, 1.1%-2.8%]). Prevalence of in-hospital mortality among patients with hypertensive emergency was 9.9% (95% CI, 1.4%-24.6%). Conclusions Our findings demonstrate a pattern of hypertension-mediated organ damage primarily affecting the brain and heart, substantial cardiovascular renal morbidity and mortality, as well as subsequent hospitalization in patients with hypertensive emergencies presenting to the ED.
Topics: Humans; Emergencies; Hypertension; Hospitalization; Heart Failure; Subarachnoid Hemorrhage; Emergency Service, Hospital
PubMed: 37421281
DOI: 10.1161/JAHA.122.029355 -
European Journal of Medical Research Nov 2023Alzheimer's disease (AD) is a worldwide public health problem and is difficult to cure. Drugs aimed at slowing the progression of the disease have been developed, with... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Alzheimer's disease (AD) is a worldwide public health problem and is difficult to cure. Drugs aimed at slowing the progression of the disease have been developed, with the Food and Drug Administration (FDA) granting accelerated approval for aducanumab on June 21, 2021 and a new accelerated approval for lecanemab on January 22, 2023. We performed this systematic review and meta-analysis to assess the efficacy and safety of FDA-approved anti-amyloid-β (anti-Aβ) monoclonal antibodies (mabs) for the treatment of AD.
METHOD
PubMed, Embase, and Cochrane Library were systematically searched to identify relevant studies published before May 2023. Efficacy outcomes included Aβ, neuroimaging, and biomarker outcomes. Safety outcomes included amyloid-related imaging abnormalities with edema or effusions (ARIA-E) and ARIA with cerebral microhemorrhages, cerebral macrohemorrhages, or superficial siderosis (ARIA-H). Review Manager 5.4 software was used to assess the data. The standard mean differences (SMDs) or odds ratio (OR) with 95% confidence interval (95% CI) were analyzed and calculated with a random effect model or a fixed effect model.
RESULT
Overall, 4471 patients from 6 randomized controlled trials (RCTs), with 2190 patients in the treatment group and 2281 patients in the placebo group meeting the inclusion criteria. FDA-approved anti-Aβ mabs showed statistically significant improvements in clinical outcomes, including CDR-SB (P = 0.01), ADCS-ADL-MCI (P = 0.00003), ADCOMS (P < 0.00001), ADAS-Cog (P < 0.00001). Moreover, FDA-approved anti-Aβ mabs increased cerebrospinal fluid (CSF) Aβ1-42 (P = 0.002) and plasma Aβ42/40 ratios (P = 0.0008). They also decreased CSF P-Tau (P < 0.00001), CSF T-Tau (P < 0.00001), and plasma p-tau181 (P < 0.00001). FDA-approved anti-Aβ mabs perform neuroimaging changes in amyloid Positron Emission Tomography Standardized Uptake Value ratio (PET SUVr) (P < 0.00001). However, compared with placebo, FDA-approved anti-Aβ mabs had higher risk of ARIA-E (P < 0.00001) and ARIA-H (P < 0001).
CONCLUSION
FDA-approved anti-Aβ mabs have a role in slowing disease progression in patients with AD, at the cost of an increased probability of side effects.
Topics: United States; Humans; Alzheimer Disease; United States Food and Drug Administration; Randomized Controlled Trials as Topic; Amyloid beta-Peptides; Biomarkers
PubMed: 38017568
DOI: 10.1186/s40001-023-01512-w -
Parkinsonism & Related Disorders Nov 2016Deep brain stimulation (DBS) is effective for some neurological and psychiatric conditions. Idiopathic delayed-onset edema (IDE) surrounding the leads has been... (Review)
Review
INTRODUCTION
Deep brain stimulation (DBS) is effective for some neurological and psychiatric conditions. Idiopathic delayed-onset edema (IDE) surrounding the leads has been anecdotally reported. The etiology, predisposing factors and prognosis of this complication are unknown. We present a multicenter case series of patients with IDE, and a systematic literature review, aimed at defining the pathophysiology and identifying appropriate treatment strategies.
METHODS
IDE was defined as edema along the DBS lead, occurring ≥72 h postoperatively, in absence of trauma, vascular events or infection. Information on patients with IDE was collected in a standardized way. A systematic search was performed in Pubmed.
RESULTS
Twelve new patients presenting with 14 episodes of IDE are described. From the literature, 38 patients were identified. No common surgical aspects or patient-related factors were identified as risk predictors for the onset of IDE. Symptoms included deterioration of the stimulation effect, seizures and focal neurological signs. Although the condition is self-limiting, with symptoms resolution in 28.5 days on average, three patients underwent surgical revision and seven received antibiotics.
CONCLUSIONS
IDE is a rare complication of DBS procedures, presenting from few days to months after surgery. Symptoms can be mild and not-specific, and the condition is self-limiting. The diagnosis of IDE is made after exclusion of vascular events or infections. The pathophysiology is still unexplained. The recognition of this complication can help avoiding unnecessary surgical procedures (system explantation) and antibiotic treatment.
Topics: Brain Edema; Databases, Bibliographic; Deep Brain Stimulation; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Retrospective Studies
PubMed: 27622967
DOI: 10.1016/j.parkreldis.2016.09.007 -
CNS Neuroscience & Therapeutics Mar 2022The compatibility of deep brain stimulation (DBS) hardware and MRI scans has greatly improved the diagnostic rate of postoperative peri-lead edema (PLE). However, the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The compatibility of deep brain stimulation (DBS) hardware and MRI scans has greatly improved the diagnostic rate of postoperative peri-lead edema (PLE). However, the etiology, incidence, and prognostic outcomes of this complication have not been established.
OBJECTIVE
The incidence of PLE and associated symptoms, the process of occurrence and progression of this complication, as well as treatment strategies were evaluated.
METHODS
We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses compliant systematic review of all studies that reported on incidences of PLE and associated symptoms after DBS implantation. Through systematic literature review, we evaluated its causes, neuropsychiatric symptoms, duration, treatment methods, and prognostic outcomes.
RESULTS
Our search retrieved 10 articles, including 5 articles on PLE and 10 articles on symptomatic PLE. The incidence of PLE was 35.8% (95% CI: 17.0%-54.6%), while the incidence of symptomatic PLE was 3.1% (95% CI: 1.5%-4.7%) accounting for 8.7% of PLE.
CONCLUSIONS
This complication is not as rare as previously reported. Therefore, it requires significant attention after DBS implantation. The correlation between its causes, duration, symptoms, and the area involved in edema should be assessed in long-term prospective clinical studies with large sample sizes.
Topics: Brain Edema; Deep Brain Stimulation; Edema; Humans; Magnetic Resonance Imaging; Prospective Studies
PubMed: 35044099
DOI: 10.1111/cns.13802 -
Frontiers in Neurology 2023The objective of this study is to systematically evaluate prediction models for post-thrombectomy brain edema in acute ischemic stroke (AIS) patients. This analysis aims...
OBJECTIVE
The objective of this study is to systematically evaluate prediction models for post-thrombectomy brain edema in acute ischemic stroke (AIS) patients. This analysis aims to equip clinicians with evidence-based guidance for the selection of appropriate prediction models, thereby facilitating the early identification of patients at risk of developing brain edema post-surgery.
METHODS
A comprehensive literature search was conducted across multiple databases, including PubMed, Web of Science, Embase, The Cochrane Library, CNKI, Wanfang, and Vip, aiming to identify studies on prediction models for post-thrombectomy brain edema in AIS patients up to January 2023. Reference lists of relevant articles were also inspected. Two reviewers independently screened the literature and extracted data. The Prediction Model Risk of Bias Assessment Tool (PROBAST) and the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) guidelines were employed to assess study bias and literature quality, respectively. We then used random-effects bivariate meta-analysis models to summarize the studies.
RESULTS
The review included five articles, yielding 10 models. These models exhibited a relatively high risk of bias. Random effects model demonstrated that the AUC was 0.858 (95% CI 0.817-0.899).
CONCLUSION
Despite the promising discriminative ability shown by studies on prediction models for post-thrombectomy brain edema in AIS patients, concerns related to a high risk of bias and limited external validation remain. Future research should prioritize the external validation and optimization of these models. There is an urgent need for large-scale, multicenter studies to develop robust, user-friendly models for real-world clinical application.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk, unique Identifier: CRD42022382790.
PubMed: 37719759
DOI: 10.3389/fneur.2023.1254090 -
Chinese Journal of Traumatology =... Nov 2021Hypertonic fluids such as mannitol and half-molar sodium lactate are given to treat intracranial hypertension in patients with severe traumatic brain injury (TBI). In...
PURPOSE
Hypertonic fluids such as mannitol and half-molar sodium lactate are given to treat intracranial hypertension in patients with severe traumatic brain injury (TBI). In this study, sodium lactate was compared to mannitol in patients with TBI to investigate the efficacy in reducing intracranial pressure (ICP).
METHODS
This study was a systematic review with literature research on articles published in any year in the databases of PubMed, ScienceDirect, Asian Journal of Neurosurgery, and Cochrane Central Register of Controlled Trials. The keywords were "half-molar sodium lactate", "mannitol", "cerebral edema or brain swelling", and "severe traumatic brain injury". The inclusion criteria were (1) studies published in English, (2) randomized control trials or retrospective/prospective studies on TBI patients, and (3) therapies including half-molar sodium lactate and mannitol and (4) sufficient data such as mean difference (MD) and risk ratio (RR). Data analysis was conducted using Review Manager 5.3.
RESULTS
From 1499 studies, a total of 8 studies were eligible. Mannitol group reduced ICP of 0.65 times (MD 0.65; p = 0.64) and improved cerebral perfusion pressure of 0.61 times (MD 0.61; p = 0.88), better than the half-molar group of sodium lactate. But the half-molar group of sodium lactate maintained the mean arterial pressure level of 0.86 times, better than the mannitol group (MD 0.86; p = 0.09).
CONCLUSION
Half-molar sodium lactate is as effective as mannitol in reducing ICP in the early phase of brain injury, superior over mannitol in an extended period. It is able to prevent intracranial hypertension and give better brain tissue perfusion as well as more stable hemodynamics. Blood osmolarity is a concern as it increases serum sodium.
Topics: Brain Edema; Brain Injuries, Traumatic; Diuretics, Osmotic; Humans; Intracranial Hypertension; Intracranial Pressure; Mannitol; Prospective Studies; Retrospective Studies; Saline Solution, Hypertonic; Sodium Lactate
PubMed: 34344615
DOI: 10.1016/j.cjtee.2021.07.005 -
Annals of Palliative Medicine Oct 2015The morbidity and mortality associated with metastatic disease to brain make this problem a formidable challenge faced by health care providers and caregivers. The aim... (Review)
Review
BACKGROUND
The morbidity and mortality associated with metastatic disease to brain make this problem a formidable challenge faced by health care providers and caregivers. The aim of this review is to summarize management for patients with brain metastases with a particular focus on symptom management.
METHODS
A systematic review of the literature was performed. Outcomes of interest included survival, brain control (local in field and whole brain). In particular, symptom control (quality of life, neurological function and neurocognition) was examined.
RESULTS
Steroids provide relief of symptoms due to intra-cerebral edema. The steroid of choice is dexamethasone. Anti-seizure medications should not be given as prophylaxis but instead be given for treatment of seizures. Depending on patient, tumour and treatment factors, management for brain metastases range from optimal supportive care including the use of steroids, whole brain radiotherapy (WBRT), radiosurgery, surgery alone or in combination. Surgery or radiosurgery improves survival for selected patients with single brain metastasis as compared to WBRT alone. Ongoing research topics include focal postoperative cavity radiation, focal fractionated regimens, molecular targeted therapies, chemoprevention of brain metastases and neurocognitive protection (such as neuro-protective drugs and radiation techniques such as hippocampal sparing).
CONCLUSIONS
The management of brain metastases has evolved over the decades. Other than survival and brain control (local in-field and whole brain), the outcomes of quality of life and neurocognition are becoming increasingly important.
Topics: Brain Neoplasms; Breast Neoplasms; Humans; Lung Neoplasms; Melanoma; Meta-Analysis as Topic; Multicenter Studies as Topic; Palliative Care; Prognosis; Randomized Controlled Trials as Topic
PubMed: 26541403
DOI: 10.3978/j.issn.2224-5820.2015.09.01 -
Journal of Neuroinflammation Sep 2015Research focus in neuro-oncology has shifted in the last decades towards the exploration of tumor infiltration by a variety of immune cells and their products. T cells,... (Review)
Review
BACKGROUND
Research focus in neuro-oncology has shifted in the last decades towards the exploration of tumor infiltration by a variety of immune cells and their products. T cells, macrophages, B cells, and mast cells (MCs) have been identified.
METHODS
A systematic review of the literature was conducted by searching PubMed, EMBASE, Google Scholar, and Turning Research into Practice (TRIP) for the presence of MCs in meningiomas using the terms meningioma, inflammation and mast cells.
RESULTS
MCs have been detected in various tumors of the central nervous system (CNS), such as gliomas, including glioblastoma multiforme, hemangioblastomas, and meningiomas as well as metastatic brain tumors. MCs were present in as many as 90 % of all high-grade meningiomas mainly found in the perivascular areas of the tumor. A correlation between peritumoral edema and MCs was found.
INTERPRETATION
Accumulation of MCs in meningiomas could contribute to the aggressiveness of tumors and to brain inflammation that may be involved in the pathogenesis of additional disorders.
Topics: Animals; Databases, Bibliographic; Encephalitis; Humans; Mast Cells; Meningeal Neoplasms; Meningioma
PubMed: 26377554
DOI: 10.1186/s12974-015-0388-3