Inodilators are commonly used in critically ill patients, but their effect on survival has not been properly studied to date. The objective of this work was to conduct a network meta-analysis on the ...effects of inodilators on survival in adult cardiac surgery patients, and to compare and rank drugs that have not been adequately compared in head-to-head trials.
Relevant studies were independently searched in BioMedCentral, MEDLINE/PubMed, Embase, and the Cochrane Central Register of clinical trials (updated on May 1, 2014). The criteria for inclusion were: random allocation to treatment with at least one group receiving dobutamine, enoximone, levosimendan, or milrinone and at least another group receiving the above inodilators or placebo, performed in cardiac surgical patients. The endpoint was to identify differences in mortality at longest follow-up available.
The 46 included trials were published between 1995 and 2014 and randomised 2647 patients. The Bayesian network meta-analysis found that only the use of levosimendan was associated with a decrease in mortality when compared with placebo (posterior mean of OR=0.48, 95% CrI 0.28 to 0.80). The posterior distribution of the probability for each inodilator to be the best and the worst drug showed that levosimendan is the best agent to improve survival after cardiac surgery. The sensitivity analyses performed did not produce different interpretative result.
Levosimendan seems to be the most efficacious inodilator to improve survival in cardiac surgery.
Traumatic brain injury (TBI) has drawn national attention for its high incidence and mechanistic complexity. The majority of TBI cases are “mild” in nature including concussions and mild TBI (mTBI). ...Concussions are a distinct form of mTBI where diagnosis is difficult, quantification of the incidence is challenging and there is greater risk for subsequent injuries. While concussions occur in the general population, it has become a hallmark injury consistently observed among adolescent and young adult athletes and the risks for repeat TBI (rTBI) is significant. Clinical and experimental evidence shows that the magnitude and duration of deficits is dependent on the number and the interval between injuries. Several studies suggest that metabolic vulnerabilities after injury may contribute to the window for cerebral vulnerability from rTBI. In addition to metabolism, this review addresses how age, sex and hormones also play an important role in the response to repeat concussions. Understanding how these factors collectively contribute to concussion and rTBI recovery is critically important in establishing age/sex appropriate return to play guidelines, injury prevention, therapeutic interventions and mitigation of long-term consequences of rTBI.
Inotropes and vasopressors are frequently administered to critically ill patients in order to improve haemodynamic function and restore adequate organ perfusion. However, some studies have suggested ...a possible association between inotrope administration and increased mortality. We therefore performed a meta-analysis of randomized trials published in the last 20 yr to investigate the effect of these drugs on mortality.
BioMedCentral, PubMed, Embase and the Cochrane Central Register were searched (all updated April 8th, 2015). Inclusion criteria were: random allocation to treatment, at least one group receiving an inotropic or vasopressor drug compared with at least one group receiving a non-inotropic/vasopressor treatment, study published after 1st January 1994, and systemic drug administration. Exclusion criteria were overlapping populations, studies published as abstract only, crossover studies, paediatric studies and lack of data on mortality.
A total of 28 280 patients from 177 trials were included. Overall, pooled estimates showed no difference in mortality between the group receiving inotropes/vasopressors and the control group 4255/14 036 (31.7%) vs 4277/14 244 (31.8%), risk ratio=0.98 (0.96–1.01), P for effect=0.23, P for heterogeneity=0.30, I2=6%. A reduction in mortality was associated with inotrope/vasopressor therapy use in settings of vasoplegic syndromes, sepsis and cardiac surgery. Levosimendan was the only drug associated with improvement in survival. Subgroup analysis did not identify any groups with increased mortality associated with inotrope/vasopressor therapy.
Our systematic review found that inotrope/vasopressor therapy is not associated with differences in mortality in the overall population and in the majority of subsettings.
The IlluminOss® System (IS) based on photodynamic bone stabilization (PBS) is a recent option in between the minimally invasive surgical techniques available to treat bone metastases when medical or ...radiation therapy is neither effective nor indicated, and major surgery is not possible. In this study, the results obtained using IS in the treatment of impending fractures or bone metastases of the upper limb have been analyzed in terms of improvement in pain, quality of life and recovery of function.
Between January 2017 and October 2019, 8 patients over 65 years old with impending fractures or pathological fractures or myeloma of the upper limb have been treated in our institute with IS. All patients were assessed about pain, general health and function of the affected limb before surgery and 1, 3, 6 (consistent with survival) months after the procedure.
Mean VAS score improved from 8.88 before surgery to 1.00 six months after surgery, mean Karnofsky index improved at 1 and 3 months post-operative follow-up, and Musculoskeletal Tumor Society Score (MSTS) raised from 44.6 before surgery to 74.7 six months after surgery. Moreover, good reduction and stable fixation of the osteolytic lesion were achieved in all patients, and no complications were found.
Numerous studies have been reported in the literature on the use of this system in osteoporotic elderly fractures, whereas only few articles are currently available regarding its use in the treatment of bone metastases or pathological fractures. From our study PBS seems to be an effective solution in the management of bone metastases or myeloma in both pathological fractures and impending upper limb fractures in patients with low life expectancy.
Meta-analysis: pitfalls and hints Greco, T; Zangrillo, A; Biondi-Zoccai, G ...
Heart, lung and vessels,
2013, Letnik:
5, Številka:
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Journal Article
Odprti dostop
The present work is an overview of the main pitfalls which may occur when a researcher performs a meta-analysis. The main goal is to help clinicians evaluate published research results. Organizing ...and carrying out a meta-analysis is hard work, but the findings can be significant. Meta-analysis is a powerful tool to cumulate and summarize the knowledge in a research field, and to identify the overall measure of a treatment's effect by combining several conclusions. However, it is a controversial tool, because even small violations of certain rules can lead to misleading conclusions. In fact, several decisions made when designing and performing a meta-analysis require personal judgment and expertise, thus creating personal biases or expectations that may influence the result. Meta-analysis' conclusions should be interpreted in the light of various checks, discussed in this work, which can inform the readers of the likely reliability of the conclusions. Specifically, we explore the principal steps (from writing a prospective protocol of analysis to results' interpretation) in order to minimize the risk of conducting a mediocre meta-analysis and to support researchers to accurately evaluate the published findings.
Many studies have compared desflurane, isoflurane, sevoflurane, total i.v. anaesthesia (TIVA), or all in cardiac surgery to assess their effects on patient survival.
We performed standard pairwise ...and Bayesian network meta-analyses; the latter allows indirect assessments if any of the anaesthetic agents were not compared in head-to-head trials. Pertinent studies were identified using BioMedCentral, MEDLINE/PubMed, Embase, and the Cochrane Library (last updated in June 2012).
We identified 38 randomized trials with survival data published between 1991 and 2012, with most studies (63%) done in coronary artery bypass grafting (CABG) patients with standard cardiopulmonary bypass. Standard meta-analysis showed that the use of a volatile agent was associated with a reduction in mortality when compared with TIVA at the longest follow-up available 25/1994 (1.3%) in the volatile group vs 43/1648 (2.6%) in the TIVA arm, odds ratio (OR)=0.51, 95% confidence interval (CI) 0.33–0.81, P-value for effect=0.004, number needed to treat 74, I2=0% with results confirmed in trials with low risk of bias, in large trials, and when including only CABG studies. Bayesian network meta-analysis showed that sevoflurane (OR=0.31, 95% credible interval 0.14–0.64) and desflurane (OR=0.43, 95% credible interval 0.21–0.82) were individually associated with a reduction in mortality when compared with TIVA.
Anaesthesia with volatile agents appears to reduce mortality after cardiac surgery when compared with TIVA, especially when sevoflurane or desflurane is used. A large, multicentre trial is warranted to confirm that long-term survival is significantly affected by the choice of anaesthetic.
After a comprehensive review and meta-analysis, radiotherapy and chemotherapy appeared to be similarly effective overall in clinical stage (CS) IIA and IIB seminoma, but chemotherapy demonstrated a ...trend toward lower incidence of side-effects and RR in CS IIB disease.
Outcomes of radiotherapy (RT) compared with chemotherapy (CT) remain poorly defined for clinical stage (CS) IIA and IIB seminoma. We aimed to evaluate the current role of the two treatment modalities in this setting of testicular seminoma.
A systematic review and meta-analysis (MA) was carried out to identify all evaluable studies. Search was limited to studies published after 1990 and included the Medline, Embase databases, and abstracts from ASCO (GU), ESMO, AUA, and ASTRO meetings up to April 2014. Sensitivity analyses were applied including the following: CSIIA and CSIIB, paraortic + iliac RT only in both stages, RT dose (≥30 versus <30 Gy), and PEB/EP regimens only.
Thirteen studies have been selected for MA on relapse outcome. No randomized trials compared RT and CT. There were 4 prospective and 9 retrospective studies, with a total of 607 patients receiving RT and 283 patients CT. The pooled relapse rate (RR) was similar between the RT 0.11, 95% confidence interval (CI) 0.08–0.14, P for heterogeneity = 0.096, I2 = 38% and CT groups (0.08, 95% CI 0.01–0.15, P for heterogeneity <0.001, I2 = 82.5%). However, in the sensitivity analysis, the pooled RR for RT in CSIIB was 0.12 (95% CI 0.06–0.17) while it was 0.05 (95% CI 0–0.11) for CT. Long-term side-effects and incidence of second cancers were more frequently reported following RT. The overall incidence of nontesticular second malignancies was 0.04 (95% CI 0.01–0.02) in the RT group and 0.02 (95% CI 0.003–0.04) in the CT group.
Although RT and CT appeared to be equal options in CSIIA and IIB seminoma, a trend in favor of CT for a lower incidence of side-effects and RR in CSIIB was found. This evidence is limited by the retrospective quality of studies and their small sample size.
Most patients with advanced or metastatic cancer experience pain and despite several guidelines, undertreatment is well documented. A multicenter, open-label, prospective, non-randomised study was ...launched in Italy in 2006 to evaluate the epidemiology, patterns and quality of pain care of cancer patients. To assess the adequacy of analgesic care, we used a standardised measure, the pain management index (PMI), that compares the most potent analgesic prescribed for a patient with the reported level of the worst pain of that patient together with a selected list of clinical indicators. A total of 110 centres recruited 1801 valid cases. 61% of cases were received a WHO-level III opioid; 25.3% were classified as potentially undertreated, with wide variation (9.8-55.3%) according to the variables describing patients, centres and pattern of care. After adjustment with a multivariable logistic regression model, type of recruiting centre, receiving adjuvant therapy or not and type of patient recruited (new or already on follow-up) had a significant association with undertreatment. Non-compliance with the predefined set of clinical indicators was generally high, ranging from 41 to 76%. Despite intrinsic limitations of the PMI that may be considered as an indicator of the poor quality of cancer pain care, results suggest that the recourse to WHO third-level drugs still seems delayed in a substantial percentage of patients. This delay is probably related to several factors affecting practice in participating centres and suggests that the quality of cancer pain management in Italy deserves specific attention and interventions aimed at improving patients' outcomes.
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