Furthermore, patients with deep surgical site infection following a hip hemiarthroplasty have a 50% in-hospital mortality.4 These differences are why we concentrated on the early effects of deep ...surgical site infection in the WHiTE 8 trial. ...we involved a large number of surgeons, including supervised surgeons in training. Regarding the subgroup analyses proposed by Chu and colleagues, given the much smaller numbers of participants in these subgroups, any such analyses would have been underpowered to detect differences in the rate of deep surgical site infection. ...we did not include such analyses in our pre-specified statistical analysis plan for the WHiTE 8 trial.
Given their relatively small area, mangroves and their organic sediments are of disproportionate importance to global carbon sequestration and carbon storage. Peat deposition and preservation allows ...some mangroves to accrete vertically and keep pace with sea-level rise by growing on their own root remains. In this study we show that mangroves in desert inlets in the coasts of the Baja California have been accumulating root peat for nearly 2,000 y and harbor a belowground carbon content of 900–34,00 Mg C/ha, with an average value of 1,130 (± 128) Mg C/ha, and a belowground carbon accumulation similar to that found under some of the tallest tropical mangroves in the Mexican Pacific coast. The depth–age curve for the mangrove sediments of Baja California indicates that sea level in the peninsula has been rising at a mean rate of 0.70 mm/y (± 0.07) during the last 17 centuries, a value similar to the rates of sea-level rise estimated for the Caribbean during a comparable period. By accreting on their own accumulated peat, these desert mangroves store large amounts of carbon in their sediments. We estimate that mangroves and halophyte scrubs in Mexico’s arid northwest, with less than 1% of the terrestrial area, store in their belowground sediments around 28% of the total belowground carbon pool of the whole region.
Controversy exists over the use of bone cement in hip fractures treated with hemiarthroplasty. Only limited data on quality of life after cemented as compared with modern uncemented ...hemiarthroplasties are available.
We conducted a multicenter, randomized, controlled trial comparing cemented with uncemented hemiarthroplasty in patients 60 years of age or older with an intracapsular hip fracture. The primary outcome was health-related quality of life measured with the use of utility scores on the EuroQol Group 5-Dimension (EQ-5D) questionnaire at 4 months after randomization (range of scores, -0.594 to 1, with higher scores indicating better quality of life; range for minimal clinically important difference, 0.050 to 0.075).
A total of 610 patients were assigned to undergo cemented hemiarthroplasty and 615 to undergo modern uncemented hemiarthroplasty; follow-up data were available for 71.6% of the patients at 4 months. The mean EQ-5D utility score was 0.371 in patients assigned to the cemented group and 0.315 in those assigned to the uncemented group (adjusted difference, 0.055; 95% confidence interval CI, 0.009 to 0.101; P = 0.02). The between-group difference at 1 month was similar to that at 4 months, but the difference at 12 months was smaller than that at 4 months. Mortality at 12 months was 23.9% in the cemented group and 27.8% in the uncemented group (odds ratio for death, 0.80; 95% CI, 0.62 to 1.05). Periprosthetic fractures occurred in 0.5% and 2.1% of the patients in the respective groups (odds ratio uncemented vs. cemented, 4.37; 95% CI, 1.19 to 24.00). The incidences of other complications were similar in the two groups.
Among patients 60 years of age or older with an intracapsular hip fracture, cemented hemiarthroplasty resulted in a modestly but significantly better quality of life and a lower risk of periprosthetic fracture than uncemented hemiarthroplasty. (Funded by the National Institute for Health Research; WHiTE 5 ISRCTN number, ISRCTN18393176.).
Purpose
The primary aim of this systematic review was to examine the hypothesis that meniscal allograft transplantation is chondroprotective by identifying and appraising studies that have assessed ...the progression of osteoarthritis following meniscal allograft transplantation. The secondary aim was to identify and appraise radiological measures of meniscal allograft integrity following surgery.
Methods
Clinical studies on human participants undergoing meniscal allograft transplantation with a minimum follow-up of 6 months were included. The primary outcome measure was any radiological osteoarthritis progression measure. Secondary outcomes included magnetic resonance measures of meniscal integrity including meniscal size, shape, healing, extrusion and signal intensity.
Results
Thirty-eight studies with 1056 allografts were included. The weighted mean joint space loss was 0.032 mm at 4.5 years across 11 studies. Other radiological classification systems were reported in small numbers and with variable progression rates. Meniscal extrusion was present in nearly all cases, but was not associated with clinical or other radiological outcomes. Meniscal healing rates were high, although the size, shape and signal intensity were commonly altered from that of the native meniscus. The quality of the included studies was low, with a high risk of bias.
Conclusion
There is some evidence to support the hypothesis that meniscal allograft transplantation reduces the progression of osteoarthritis, although it is unlikely to be as effective as the native meniscus. If this is proven, there may be a role for prophylactic meniscal allograft transplantation in selected patients. Well-designed randomised controlled trials are needed to further test this hypothesis.
Level of evidence
Systematic review of studies, Level IV.
Objectives To determine whether the use of total hip arthroplasty (THA) among individuals with a displaced intracapsular fracture of the femoral neck is based on national guidelines or if there are ...systematic inequalities.Design Observational cohort study using the National Hip Fracture Database (NHFD).Setting All hospitals that treat adults with hip fractures in England, Wales, and Northern Ireland.Participants Patients within the national database (all aged ≥60) who received operative treatment for a non-pathological displaced intracapsular hip fracture from 1 July 2011 to 31 April 2015.Main outcome measures Provision of THA to patients considered eligible under criteria published by the National Institute for Health and Care Excellence (NICE).Results 114 119 patients with hip fracture were included, 11 683 (10.2%) of whom underwent THA. Of those who satisfied the NICE criteria, 32% (6780)received a THA. Of patients who underwent THA, 42% (4903) did not satisfy the NICE criteria. A recursive partitioning algorithm found that the NICE eligibility criteria did not optimally explain which patients underwent THA. A model with superior explanatory power drew distinctions that are not supported by NICE, which were an age cut off at 76 and a different ambulation cut off. Among patients who satisfied the NICE eligibility, the use of THA was less likely with higher age (odds ratio 0.88, 95% confidence interval 0.87 to 0.88), worsening abbreviated mental test scores (0.49 (0.41 to 0.58) for normal cognition v borderline cognitive impairment)), worsening American Society of Anesthesiologists score (0.74, 0.66 to 0.84), male sex (0.85, 0.77 to 0.93), worsening ambulatory status (0.32, 0.28 to 0.35 for walking with a stick v independent ambulation), and fifths of worsening socioeconomic area deprivation (0.76 (0.66 to 0.88) for least v most deprived fifth). Patients receiving treatment during the working week were more likely to receive THA than at the weekend (0.90, 0.83 to 0.98).Conclusions There are wide disparities in the use of THA among individuals with hip fractures, and compliance with NICE guidance is poor. Patients with higher levels of socioeconomic deprivation and those who require surgery at the weekend were less likely to receive THA. Inconsistent compliance with NICE recommendations means that the optimal treatment for older adults with hip fractures can depend on where and when they present to hospital.
Injection therapies for Achilles tendinopathy Kearney, Rebecca S; Parsons, Nick; Metcalfe, David ...
Cochrane database of systematic reviews,
05/2015, Letnik:
2015, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Background
Achilles tendinopathy is a common condition, often with significant functional consequences. As a wide range of injection treatments are available, a review of randomised trials evaluating ...injection therapies to help inform treatment decisions is warranted.
Objectives
To assess the effects (benefits and harms) of injection therapies for people with Achilles tendinopathy.
Search methods
We searched the following databases up to 20 April 2015: the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, CINAHL and SPORTDiscus. We also searched trial registers (29 May 2014) and reference lists of articles to identify additional studies.
Selection criteria
We included randomised and quasi‐randomised controlled trials evaluating injection therapies in adults with an investigator‐reported diagnosis of Achilles tendinopathy. We accepted comparison arms of placebo (sham) or no injection control, or other active treatment (such as physiotherapy, pharmaceuticals or surgery). Our primary outcomes were function, using measures such as the VISA‐A (Victorian Institute of Sport Assessment‐Achilles questionnaire), and adverse events.
Data collection and analysis
Two review authors independently extracted data from the included studies. We assessed treatment effects using mean differences (MDs) and 95% confidence intervals (CIs) for continuous variables and risk ratios (RRs) and 95% CIs for dichotomous variables. For follow‐up data, we defined short‐term as up to six weeks, medium‐term as up to three months and longer‐term as data beyond three months. We performed meta‐analysis where appropriate.
Main results
We included 18 studies (732 participants). Seven trials exclusively studied athletic populations. The mean ages of the participants in the individual trials ranged from 20 years to 50 years. Fifteen trials compared an injection therapy with a placebo injection or no injection control, four trials compared an injection therapy with active treatment, and one compared two different concentrations of the same injection. Thus no trials compared different injection therapies. Two studies had three trial arms and we included them twice in two different categories. Within these categories, we further subdivided injection therapies by mode of action (injury‐causing versus direct repair agents).
The risk of bias was unclear (due to poor reporting) or high in six trials published between 1987 and 1994. Improved methodology and reporting for the subsequent trials published between 2004 and 2013 meant that these were at less risk of bias.
Given the very low quality evidence available from each of four small trials comparing different combinations of injection therapy versus active treatment and the single trial comparing two doses of one injection therapy, only the results of the first comparison (injection therapy versus control) are presented.
There is low quality evidence of a lack of significant or clinically important differences in VISA‐A scores (0 to 100: best function) between injection therapy and control groups at six weeks (MD 0.79, 95% CI ‐4.56 to 6.14; 200 participants, five trials), three months (MD ‐0.94, 95% CI ‐6.34 to 4.46; 189 participants, five trials) or between six and 12 months (MD 0.14, 95% CI ‐6.54 to 6.82; 132 participants, three trials). Very low quality evidence from 13 trials showed little difference between the two groups in adverse events (14/243 versus 12/206; RR 0.97, 95% CI 0.50 to 1.89), most of which were minor and short‐lasting. The only major adverse event in the injection therapy group was an Achilles tendon rupture, which happened in a trial testing corticosteroid injections. There was very low quality evidence in favour of the injection therapy group in short‐term (under three months) pain (219 participants, seven trials) and in the return to sports (335 participants, seven trials). There was very low quality evidence indicating little difference between groups in patient satisfaction with treatment (152 participants, four trials). There was insufficient evidence to conclude on subgroup differences based on mode of action given that only two trials tested injury‐causing agents and the clear heterogeneity of the other 13 trials, which tested seven different therapies that act directly on the repair pathway.
Authors' conclusions
There is insufficient evidence from randomised controlled trials to draw conclusions on the use, or to support the routine use, of injection therapies for treating Achilles tendinopathy. This review has highlighted a need for definitive research in the area of injection therapies for Achilles tendinopathy, including in older non‐athletic populations. This review has shown that there is a consensus in the literature that placebo‐controlled trials are considered the most appropriate trial design.
Background
Traumatic wounds (wounds caused by injury) range from abrasions and minor skin incisions or tears, to wounds with extensive tissue damage or loss as well as damage to bone and internal ...organs. Two key types of traumatic wounds considered in this review are those that damage soft tissue only and those that involve a broken bone, that is, open fractures. In some cases these wounds are left open and negative pressure wound therapy (NPWT) is used as a treatment. This medical device involves the application of a wound dressing through which negative pressure is applied and tissue fluid drawn away from the area. The treatment aims to support wound management, to prepare wounds for further surgery, to reduce the risk of infection and potentially to reduce time to healing (with or without surgical intervention). There are no systematic reviews assessing the effectiveness of NPWT for traumatic wounds.
Objectives
To assess the effects of NPWT for treating open traumatic wounds in people managed in any care setting.
Search methods
In June 2018 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations), Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta‐analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.
Selection criteria
Published and unpublished randomised controlled trials that used NPWT for open traumatic wounds involving either open fractures or soft tissue wounds. Wound healing, wound infection and adverse events were our primary outcomes.
Data collection and analysis
Two review authors independently selected eligible studies, extracted data, carried out a 'Risk of bias' assessment and rated the certainty of the evidence. Data were presented and analysed separately for open fracture wounds and other open traumatic wounds (not involving a broken bone).
Main results
Seven RCTs (1377 participants recruited) met the inclusion criteria of this review. Study sample sizes ranged from 40 to 586 participants. One study had three arms, which were all included in the review. Six studies compared NPWT at 125 mmHg with standard care: one of these studies did not report any relevant outcome data. One further study compared NPWT at 75 mmHg with standard care and NPWT 125mmHg with NPWT 75 mmHg.
Open fracture wounds (four studies all comparing NPWT 125 mmHg with standard care)
One study (460 participants) comparing NPWT 125 mmHg with standard care reported the proportions of wounds healed in each arm. At six weeks there was no clear difference between groups in the number of participants with a healed, open fracture wound: risk ratio (RR) 1.01 (95% confidence interval (CI) 0.81 to 1.27); moderate‐certainty evidence, downgraded for imprecision.
We pooled data on wound infection from four studies (596 participants). Follow‐up varied between studies but was approximately 30 days. On average, it is uncertain whether NPWT at 125 mmHg reduces the risk of wound infection compared with standard care (RR 0.48, 95% CI 0.20 to 1.13; I2 = 56%); very low‐certainty evidence downgraded for risk of bias, inconsistency and imprecision.
Data from one study shows that there is probably no clear difference in health‐related quality of life between participants treated with NPWT 125 mmHg and those treated with standard wound care (EQ‐5D utility scores mean difference (MD) ‐0.01, 95% CI ‐0.08 to 0.06; 364 participants, moderate‐certainty evidence; physical component summary score of the short‐form 12 instrument MD ‐0.50, 95% CI ‐4.08 to 3.08; 329 participants; low‐certainty evidence downgraded for imprecision).
Moderate‐certainty evidence from one trial (460 participants) suggests that NPWT is unlikely to be a cost‐effective treatment for open fractures in the UK. On average, NPWT was more costly and conferred few additional quality‐adjusted life years (QALYs) when compared with standard care. The incremental cost‐effectiveness ratio was GBP 267,910 and NPWT was shown to be unlikely to be cost effective at a range of cost‐per‐QALYs thresholds. We downgraded the certainty of the evidence for imprecision.
Other open traumatic wounds (two studies, one comparing NPWT 125 mmHg with standard care and a three‐arm study comparing NPWT 125 mmHg, NPWT 75 mmHg and standard care)
Pooled data from two studies (509 participants) suggests no clear difference in risk of wound infection between open traumatic wounds treated with NPWT at 125 mmHg or standard care (RR 0.61, 95% CI 0.31 to 1.18); low‐certainty evidence downgraded for risk of bias and imprecision.
One trial with 463 participants compared NPWT at 75 mmHg with standard care and with NPWT at 125 mmHg. Data on wound infection were reported for each comparison. It is uncertain if there is a difference in risk of wound infection between NPWT 75 mmHg and standard care (RR 0.44, 95% CI 0.17 to 1.10; 463 participants) and uncertain if there is a difference in risk of wound infection between NPWT 75 mmHg and 125 mmHg (RR 1.04, 95% CI 0.31 to 3.51; 251 participants. We downgraded the certainty of the evidence for risk of bias and imprecision.
Authors' conclusions
There is moderate‐certainty evidence for no clear difference between NPWT and standard care on the proportion of wounds healed at six weeks for open fracture wounds. There is moderate‐certainty evidence that NPWT is not a cost‐effective treatment for open fracture wounds. Moderate‐certainty evidence means that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. It is uncertain whether there is a difference in risk of wound infection, adverse events, time to closure or coverage surgery, pain or health‐related quality of life between NPWT and standard care for any type of open traumatic wound.
To describe the epidemiology of slipped capital femoral epiphysis (SCFE), to examine associations with childhood obesity and socioeconomic deprivation, and to explore factors associated with ...diagnostic delays.
Historic cohort study using linked primary and secondary care data from the Clinical Practice Research Datalink and Hospital Episode Statistics.
All contacts with healthcare services, including emergency presentations, outpatient appointments, inpatient admissions and primary care visits, within the UK National Health Service.
All individuals <16 years old with a diagnosis of SCFE and whose electronic medical record was held by one of 650 primary care practices in the UK between 1990 and 2013.
Annual incidence, missed opportunities for diagnosis and diagnostic delay.
Over the 23-year period the incidence remained constant at 4.8 (95% CI 4.4 to 5.2) cases per 100,000 0-16-year-olds. There was a strong association with socioeconomic deprivation. Predisease obesity was also strongly associated with SCFE; mean predisease z-score of body mass index was 1.43 (95% CI 1.20 to 1.68) compared with the UK reference mean. Diagnostic delays were common, with most children (75.4%) having multiple primary care contacts with relevant symptomatology, and those who presented with knee pain having significantly longer diagnostic delay (median 161 (IQR 27-278) days) than those with hip pain (20 (5-126)) or gait abnormalities (21 (7-72)).
SCFE has a strong association with both area-level socioeconomic deprivation and predisease obesity. The majority of patients with SCFE are initially misdiagnosed and those presenting with knee pain are particularly at risk.
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