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Neurocritical Care Jun 2023Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this...
BACKGROUND
Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors.
METHODS
A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: "When counseling surrogates of comatose adult survivors of cardiac arrest, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of poor functional outcome assessed at 3 months or later?" Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format.
RESULTS
Eleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors.
CONCLUSIONS
These guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.
Topics: Adult; Humans; Coma; Heart Arrest; Hypothermia, Induced; Prognosis; Reproducibility of Results; Survivors
PubMed: 36949360
DOI: 10.1007/s12028-023-01688-3 -
Journal of Neuroengineering and... Aug 2022This systematic review and meta-analysis aim to summarize and analyze the available evidence of non-invasive brain stimulation/spinal cord stimulation on gait, balance... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
This systematic review and meta-analysis aim to summarize and analyze the available evidence of non-invasive brain stimulation/spinal cord stimulation on gait, balance and/or lower limb motor recovery in stroke patients.
METHODS
The PubMed database was searched from its inception through to 31/03/2021 for randomized controlled trials investigating repetitive transcranial magnetic stimulation or transcranial/trans-spinal direct current/alternating current stimulation for improving gait, balance and/or lower limb motor function in stroke patients.
RESULTS
Overall, 25 appropriate studies (including 657 stroke subjects) were found. The data indicates that non-invasive brain stimulation/spinal cord stimulation is effective in supporting recovery. However, the effects are inhomogeneous across studies: (1) transcranial/trans-spinal direct current/alternating current stimulation induce greater effects than repetitive transcranial magnetic stimulation, and (2) bilateral application of non-invasive brain stimulation is superior to unilateral stimulation.
CONCLUSIONS
The current evidence encourages further research and suggests that more individualized approaches are necessary for increasing effect sizes in stroke patients.
Topics: Brain; Gait; Humans; Lower Extremity; Stroke; Stroke Rehabilitation; Transcranial Direct Current Stimulation; Transcranial Magnetic Stimulation
PubMed: 35922846
DOI: 10.1186/s12984-022-01062-y -
The Cochrane Database of Systematic... Sep 2013Benign masseter muscle hypertrophy is an uncommon clinical phenomenon of uncertain aetiology which is characterised by a soft swelling near the angle of the mandible.... (Review)
Review
BACKGROUND
Benign masseter muscle hypertrophy is an uncommon clinical phenomenon of uncertain aetiology which is characterised by a soft swelling near the angle of the mandible. The swelling may on occasion be associated with facial pain and can be prominent enough to be considered cosmetically disfiguring. Varying degrees of success have been reported for some of the treatment options for masseter hypertrophy, which range from simple pharmacotherapy to more invasive surgical reduction. Injection of botulinum toxin type A into the masseter muscle is generally considered a less invasive modality and has been advocated for cosmetic sculpting of the lower face. Botulinum toxin type A is a powerful neurotoxin which is produced by the anaerobic organism Clostridium botulinum and when injected into a muscle causes interference with the neurotransmitter mechanism producing selective paralysis and subsequent atrophy of the muscle.This review is an update of a previously published Cochrane review.
OBJECTIVES
To assess the efficacy and safety of botulinum toxin type A compared to placebo or no treatment, for the management of benign bilateral masseter hypertrophy.
SEARCH METHODS
We searched the following databases from inception to April 2013: the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (via PubMed); EMBASE (via embase.com); Web of Science; CINAHL; Academic Search Premier (via EBSCOhost); ScienceDirect; LILACS (via BIREME); PubMed Central and Google Scholar (from 1700 to 19 April 2013). We searched two bibliographic databases of regional journals (IndMED and Iranmedex) which were expected to contain relevant trials. We also searched reference lists of relevant articles and contacted investigators to identify additional published and unpublished studies.
SELECTION CRITERIA
Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing intra-masseteric injections of botulinum toxin versus placebo administered for cosmetic facial sculpting in individuals of any age with bilateral benign masseter hypertrophy, which had been self-evaluated and confirmed by clinical and radiological examination were considered for inclusion. We excluded participants with unilateral or compensatory contralateral masseter hypertrophy resulting from head and neck radiotherapy.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened the search results. For future updates, two authors will independently extract data and assess trial quality using the Cochrane risk of bias tool. Risk ratios (RR) and corresponding 95% confidence intervals (CI) will be calculated for all dichotomous outcomes and the mean difference (MD) and 95% CI will be calculated for continuous outcomes.
MAIN RESULTS
We retrieved 683 unique references to studies. After screening these references 660 were excluded for being non-applicable. We assessed 23 full text articles for eligibility and all of these studies were excluded from the review.
AUTHORS' CONCLUSIONS
We were unable to identify any RCTs or CCTs assessing the efficacy and safety of intra-masseteric injections of botulinum toxin for people with bilateral benign masseter hypertrophy. The absence of high level evidence for the effectiveness of this intervention emphasises the need for well-designed, adequately powered RCTs.
Topics: Botulinum Toxins, Type A; Humans; Hypertrophy; Injections, Intramuscular; Masseter Muscle; Neuromuscular Agents
PubMed: 24018587
DOI: 10.1002/14651858.CD007510.pub3 -
The Cochrane Database of Systematic... Sep 2021The clinical management of intermittent exotropia (X(T)) has been discussed extensively in the literature, yet there remains a lack of clarity regarding indications for... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The clinical management of intermittent exotropia (X(T)) has been discussed extensively in the literature, yet there remains a lack of clarity regarding indications for intervention, the most effective form of treatment, and whether there is an optimal time in the evolution of the disease at which any given treatment should be carried out.
OBJECTIVES
The objective of this review was to analyze the effects of various surgical and non-surgical treatments in randomized controlled trials (RCTs) of participants with intermittent exotropia, and to report intervention criteria and determine whether the treatment effect varies by age and subtype of X(T).
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 1), which contains the Cochrane Eyes and Vision Trials Register; Ovid MEDLINE; Ovid Embase; Latin American and Caribbean Health Science Information database (LILACS); the ISRCTN registry; ClinicalTrials.gov, and the WHO ICTRP. The date of the search was 20 January 2021. We performed manual searches of the British Orthoptic Journal up to 2002, and the proceedings of the European Strabismological Association (ESA), International Strabismological Association (ISA), and American Association for Pediatric Ophthalmology and Strabismus meeting (AAPOS) up to 2001.
SELECTION CRITERIA
We included RCTs of any surgical or non-surgical treatment for intermittent exotropia.
DATA COLLECTION AND ANALYSIS
We followed standard Cochrane methodology.
MAIN RESULTS
We included six RCTs, four of which took place in the United States, and the remaining two in Asia (Turkey, India). A total of 890 participants with basic or distance X(T) were included, most of whom were children aged 12 months to 10 years. Three of these six studies were from the 2013 version of this review. Overall, the included studies had a high risk of performance bias as masking of participants and personnel administering treatment was not possible. Two RCTs compared bilateral lateral rectus recession versus unilateral lateral rectus recession with medial rectus resection, but only one RCT (n = 197) reported on the primary outcomes of this review. Bilateral lateral rectus recession likely results in little difference in motor alignment at near (MD 1.00, 95% CI -2.69 to 4.69) and distance (MD 2.00, 95% CI -1.22 to 5.22) fixation as measured in pupillary distance using PACT (moderate-certainty evidence). Bilateral lateral rectus recession may result in little to no difference in stereoacuity at near fixation (risk ratio (RR) 0.77, 95% CI 0.35 to 1.71), adverse events (RR 7.36, 95% CI 0.39 to 140.65), or quality of life measures (low-certainty evidence). We conducted a meta-analysis of two RCTs comparing patching (n = 249) with active observation (n = 252), but were unable to conduct further meta-analyses due to the clinical and methodological heterogeneity in the remaining trials. We found evidence that patching was clinically more effective than active observation in improving motor alignment at near (mean difference (MD) -2.23, 95% confidence interval (CI) -4.02 to -0.44) and distance (MD -2.00, 95% CI -3.40 to -0.61) fixation as measured by prism and alternate cover test (PACT) at six months (high-certainty evidence). The evidence suggests that patching results in little to no difference in stereoacuity at near fixation (MD 0.00, 95% CI -0.07 to 0.07) (low-certainty evidence). Stereoacuity at distance, motor fusion test, and quality of life measures were not reported. Adverse events were also not reported, but study authors explained that they were not anticipated due to the non-surgical nature of patching. One RCT (n = 38) compared prism adaptation test with eye muscle surgery versus eye muscle surgery alone. No review outcomes were reported. One RCT (n = 60) compared lateral rectus recession and medial rectus plication versus lateral rectus recession and medial rectus resection. Lateral rectus recession and medial rectus plication may not improve motor alignment at distance (MD 0.66, 95% CI -1.06 to 2.38) (low-certainty evidence). The evidence for the effect of lateral rectus recession and medial rectus plication on motor fusion test performance is very uncertain (RR 0.92, 95% CI 0.48 to 1.74) (very low-certainty evidence).
AUTHORS' CONCLUSIONS
Patching confers a clinical benefit in children aged 12 months to 10 years of age with basic- or distance-type X(T) compared with active observation. There is insufficient evidence to determine whether interventions such as bilateral lateral rectus recession versus unilateral lateral rectus recession with medial rectus resection; lateral rectus recession and medial rectus plication versus lateral rectus recession and medial rectus resection; and prism adaptation test prior to eye muscle surgery versus eye muscle surgery alone may confer any benefit.
Topics: Asia; Child; Exotropia; Humans; Oculomotor Muscles; Strabismus; Visual Acuity
PubMed: 34516656
DOI: 10.1002/14651858.CD003737.pub4 -
Sleep Medicine Reviews Dec 2021Obstructive Sleep Apnea (OSA) is often treated with Mandibular Advancement Devices (MADs). It is unclear whether particular design features are superior to others in... (Meta-Analysis)
Meta-Analysis Review
Obstructive Sleep Apnea (OSA) is often treated with Mandibular Advancement Devices (MADs). It is unclear whether particular design features are superior to others in terms of OSA alleviation. In order to facilitate clinical decision-making, this systematic review summarizes the objective and subjective outcomes of different available MAD designs. Studies comparing different MAD designs in OSA treatment were searched. After screening 1887 titles and abstracts, 20 original RCTs and six cohort studies were included. 14 articles were systematically reviewed in a meta-analysis. The decrease in AHI was significantly different between some of the MAD designs. The clinical relevance of the observed differences was however limited. Monoblock appliances performed more favorable, compared to bilateral thrust (effect size:-0.37; CI:-1.81 to 0.07). Midline traction appliances performed more favorable, compared to other designs. Custom appliances performed more favorable, compared to thermoplastic appliances (effect size:0.86; CI:-0.62 to 2.35). Furthermore, there were no clinically relevant differences between MAD designs in reduction of ESS, compliance, preference, side effects, and cost effectiveness. With respect to the included trials, presently there is not one superior custom MAD design in OSA treatment regarding the effect on AHI reduction, ESS improvement, compliance, preference, side effects, cost effectiveness, and other disease-related outcomes. We confirm custom MAD designs perform superior to thermoplastic MAD designs.
Topics: Continuous Positive Airway Pressure; Humans; Mandibular Advancement; Occlusal Splints; Sleep Apnea, Obstructive; Treatment Outcome
PubMed: 34662769
DOI: 10.1016/j.smrv.2021.101557 -
Journal of Affective Disorders Apr 2022Background We evaluated the efficacy and safety of repetitive transcranial magnetic stimulation (rTMS) for obsessive-compulsive disorder (OCD), and ranked the relative... (Meta-Analysis)
Meta-Analysis Review
Background We evaluated the efficacy and safety of repetitive transcranial magnetic stimulation (rTMS) for obsessive-compulsive disorder (OCD), and ranked the relative efficacy of different stimulation protocols. Methods We performed a search for randomised, sham-controlled trials of rTMS for OCD. The primary analysis included both a pairwise meta-analysis and a series of frequentist network meta-analyses (NMA) of OCD symptom severity. Secondary analyses were carried out on relevant clinical factors and safety. Results 21 studies involving 662 patients were included. The pairwise meta-analysis showed that rTMS for OCD is efficacious across all protocols (Hedges' g=-0.502 [95%CI= -0.708, -0.296]). The first NMA, with stimulation protocols clustered only by anatomical location, showed that both dorsolateral prefrontal cortex (dlPFC) stimulation and medial frontal cortex stimulation were efficacious. In the second NMA, considering each unique combination of frequency and location separately, low frequency (LF) pre-supplementary motor area (preSMA) stimulation, high frequency (HF) bilateral dlPFC stimulation, and LF right dlPFC stimulation were all efficacious . LF right dlPFC was ranked highest in terms of efficacy, although the corresponding confidence intervals overlapped with the other two protocols. Limitations Evidence base included mostly small studies, with only a few studies using similar protocols, giving a sparse network. Studies were heterogeneous, and a risk of publication bias was found. Conclusions rTMS for OCD was efficacious compared with sham stimulation. LF right dlPFC, HF bilateral dlPFC and LF preSMA stimulation were all efficacious protocols with significant and comparable clinical improvements. Future studies should further investigate the relative merits of these three protocols.
Topics: Humans; Motor Cortex; Network Meta-Analysis; Obsessive-Compulsive Disorder; Prefrontal Cortex; Transcranial Magnetic Stimulation; Treatment Outcome
PubMed: 35041869
DOI: 10.1016/j.jad.2022.01.048 -
Diagnostic and Interventional Radiology... 2017We systematically reviewed the role of bronchial artery embolization (BAE) in hemoptysis. Literature search was done for studies on BAE published between 1976 and 2016.... (Review)
Review
We systematically reviewed the role of bronchial artery embolization (BAE) in hemoptysis. Literature search was done for studies on BAE published between 1976 and 2016. Twenty-two studies published in English, with sample size of at least 50 patients, reporting indications, technique, efficacy, and follow-up were included in the final analysis. Common indications for BAE included tuberculosis (TB), post-tubercular sequelae, bronchiectasis, and aspergillomas. Most common embolizing agent used was polyvinyl alcohol (size, 300-600 μm) with increasing use of glue in recent years. Overall immediate clinical success rate of BAE, defined as complete cessation of hemoptysis, varied from 70%-99%. However, recurrence rate remains high, ranging from 10%-57%, due to incomplete initial embolization, recanalization of previously embolized arteries, and recruitment of new collaterals. Presence of nonbronchial systemic collaterals, bronchopulmonary shunting, aspergillomas, reactivation TB, and multidrug resistant TB were associated with significantly higher recurrence rates (P < 0.05). Rate of major complications remained negligible and stable over time with median incidence of 0.1% (0%-6.6%). Despite high hemoptysis recurrence rates, BAE continues to be the first-line, minimally invasive treatment of hemoptysis in emergency settings, surgically unfit patients, or in patients with diffuse or bilateral lung disease.
Topics: Bronchial Arteries; Embolization, Therapeutic; Hemoptysis; Humans; Polyvinyl Alcohol; Treatment Outcome
PubMed: 28703105
DOI: 10.5152/dir.2017.16454 -
International Journal of Implant... Jul 2023The purpose of this systematic review was to assess the evidence regarding the indications for placement of zygomatic implants to rehabilitate edentulous maxillae. (Review)
Review
PURPOSE
The purpose of this systematic review was to assess the evidence regarding the indications for placement of zygomatic implants to rehabilitate edentulous maxillae.
MATERIAL AND METHODS
A focused question using the PIO format was developed, questioning "in patients in need of an implant-supported rehabilitation of the edentulous maxillae, what are the indications for the use of zygomatic implants''. The primary information analyzed and collected was a clear description of the indication for the use of zygomatic implants.
RESULTS
A total of 1266 records were identified through database searching. The full-text review was conducted for 117 papers, and 10 were selected to be included in this review. Zygomatic implant indications were extreme bone atrophy or deficiency secondary to different factors. The quad zygoma concept (two zygomatic implants bilaterally placed and splinted) was applied to 107 patients, the classic zygoma concept (one zygomatic implant bilaterally placed and splinted to standard anterior implants) was used in 88 patients, and the unilateral concept (one zygomatic implant on one side, splinted with one or more conventional implants) was employed in 14 patients.
CONCLUSIONS
The main indication for the use of zygomatic implants was considered extreme maxillary bone atrophy, resulting from many factors. The clear definition of what was considered "extreme bone atrophy" is not uniquely defined in each paper. Further studies are needed to develop clear indications for zygomatic implants.
Topics: Humans; Dental Implants; Atrophy; Databases, Factual; Medicine; Mouth, Edentulous
PubMed: 37391575
DOI: 10.1186/s40729-023-00480-4 -
Hernia : the Journal of Hernias and... Dec 2021To systematically review technical aspects and treatment regimens of botulinum toxin A (BTA) injections in the lateral abdominal wall musculature. We also investigated... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To systematically review technical aspects and treatment regimens of botulinum toxin A (BTA) injections in the lateral abdominal wall musculature. We also investigated the effect of BTA on abdominal muscle- and hernia dimensions, and clinical outcome.
METHODS
PubMed, EMBASE, CENTRAL, and CINAHL were searched for studies that investigate the injection of BTA in the lateral abdominal wall muscles. Study characteristics, BTA treatment regimens, surgical procedures, and clinical outcomes are presented descriptively. The effect of BTA on muscle- and hernia dimensions is analyzed using random-effects meta-analyses, and exclusively for studies that investigate ventral incisional hernia patients.
RESULTS
We identified 23 studies, comprising 995 patients. Generally, either 500 units of Dysport or 200-300 units of Botox are injected at 3-5 locations bilaterally in all three muscles of the lateral abdominal wall, about 4 weeks prior to surgery. No major procedural complications are reported. Meta-analyses show that BTA provides significant elongation of the lateral abdominal wall of 3.2 cm per side (95% CI 2.0-4.3, I = 0%, p < 0.001); 6.3 cm total elongation, and a significant but heterogeneous decrease in transverse hernia width (95% CI 0.2-6.8, I = 94%, p = 0.04). Furthermore, meta-analysis shows that BTA pretreatment in ventral hernia patients significantly increases the fascial closure rate [RR 1.08 (95% CI 1.02-1.16, I = 0%, p = 0.02)].
CONCLUSION
The injection technique and treatment regimens of botulinum toxin A as well as patient selection require standardization. Bilateral pretreatment in hernia patients significantly elongates the lateral abdominal wall muscles, making fascial closure during surgical hernia repair more likely.
STUDY REGISTRATION
A review protocol for this meta-analysis was registered at PROSPERO (CRD42020198246).
Topics: Abdominal Muscles; Abdominal Wall; Botulinum Toxins, Type A; Hernia, Ventral; Herniorrhaphy; Humans; Neuromuscular Agents; Preoperative Care; Surgical Mesh
PubMed: 34546475
DOI: 10.1007/s10029-021-02499-1 -
Intensive Care Medicine Oct 2020To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC)... (Review)
Review
PURPOSE
To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3-5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA).
METHODS
PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013-April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed.
RESULTS
Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2-5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors.
CONCLUSION
In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169).
Topics: Adult; Coma; Evoked Potentials, Somatosensory; Heart Arrest; Humans; Hypothermia, Induced; Prognosis; Survivors
PubMed: 32915254
DOI: 10.1007/s00134-020-06198-w