Search

Aims Our objective was to compare the efficacy of pre-treatment with different classes of anti-arrhythmic drugs (AADs) in patients with atrial fibrillation (AF) undergoing electrical cardioversion. Methods and results We performed a systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing different AADs in patients with AF undergoing electrical cardioversion. We grouped AADs into five network nodes: no treatment or rate control, Class Ia, Class Ic, Class III, and amiodarone. Outcomes were (i) acute restoration and (ii) maintenance of sinus rhythm. We searched MEDLINE and EMBASE from inception until June 2020. We used Python 3.8.3 and R 3.6.2 for data analysis. We evaluated the overall certainty of evidence with the GRADE framework. We included 28 RCTs. Compared with no treatment or rate control, Class III AADs [odds ratio (OR): 2.41; 95% credible interval (CrI): 1.37 to 4.62, high certainty] and amiodarone (OR: 2.58; 95% CrI: 1.54 to 4.37, high certainty) improved restoration of sinus rhythm. Amiodarone improved long-term maintenance of sinus rhythm when compared with no treatment or rate control (OR: 5.37; 95% CrI: 4.00–7.39, high certainty), Class Ic (OR: 1.89; 95% CrI: 1.05–3.45, moderate certainty) and Class III AADs (OR: 2.19; 95% CrI: 1.39–3.26, high certainty). Conclusion Before electrical cardioversion of AF, treatment with Class III AADs or amiodarone improves the acute restoration of sinus rhythm. Amiodarone is most likely to improve the maintenance of sinus rhythm after electrical cardioversion, but Class Ic and Class III AADs are also effective.

To assess the effects of blue-light (BL)-enhanced transurethral resection of bladder tumour (TURBT) compared to white-light (WL)-based TURBT in the treatment of non-muscle-invasive bladder cancer (NMIBC).Based on a published protocol, we performed a systematic search of multiple databases from their inception to March 2021. We included randomized controlled trials (RCTs) comparing blue-light (BL) TURBT to white-light (WL) TURBT. Our meta-analysis was based on a random-effects model. We assessed the quality of evidence on a per-outcome basis according to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.We included 16 RCTs involving a total of 4325 participants in this review. BL TURBT may reduce the risk of disease recurrence over time (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.54-0.81; low-certainty evidence) depending on baseline risk. For participants with low-, intermediate- and high-risk NMIBC, this corresponded to 48 (66 fewer to 27 fewer), 109 (152 fewer to 59 fewer) and 147 (211 fewer to 76 fewer) fewer recurrences per 1000 participants when compared to WL TURBT, respectively. BL TURBT may also reduce the risk of disease progression over time (HR 0.65, 95% CI 0.50-0.84; low-certainty evidence) depending on baseline risk. For participants with low-, intermediate- and high-risk NMIBC, this corresponded to 1 (1 fewer to 0 fewer), 17 (25 fewer to 8 fewer), and 56 (81 fewer to 25 fewer) fewer progressions per 1000 participants when compared to WL TURBT, respectively.Our findings suggest a favourable impact of BL TURBT on the risk of disease recurrence and progression; however, whether this risk reduction is clinically relevant greatly depends on the baseline risk of patients. We did not find an increase in severe surgical complications with BL cystoscopy, and we did not find any trial evidence on other, non-surgical adverse events.

Randomized controlled trials (RCTs) are the most robust study design for evaluating the safety and efficacy of a therapeutic intervention. However, their internal validity are at risk when evaluating surgical interventions. This review summarizes existing expertise- based trials in surgery and related methodological concepts to guide surgeons performing this work. We provide caseloads required to reach the learning curve for various surgical interventions and report criteria for expertise from published and unpublished expertise-based trials. In addition, we review design and implementation concepts of expertise-based trials, including recruitment of surgeons, crossover, ethics, generalizability, sample size and definitions for learning curve. Several RCTs have used an expertise-based design. We found that the majority of definitions used for expertise were vague, heterogeneous, and inconsistent across trials evaluating the same surgical intervention. Statistical methods exist to adjust for the learning curve; however, there is limited guidance. We developed the following criteria for surgical expertise for future trials: 1) decide on the proxy to be used for the learning curve, and 2) assess eligible surgeons by comparing their performance to the previously defined expertise criteria.

Cardiogenic shock carries high morbidity and mortality. The purpose of this review was to determine the safety and efficacy of pulmonary artery catheterization (PAC) in adult patients hospitalized with cardiogenic shock. We performed a systematic review and meta-analysis of observational studies and randomized controlled trials comparing PAC vs no PAC in cardiogenic shock. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and grey literature. We screened articles, abstracted data, and evaluated risk of bias in duplicate. We pooled data using a random-effects model and evaluated the quality of evidence using the GRADE framework. Outcomes of interest were mortality, length of stay, and procedural complications. We identified 19 eligible observational studies (≥ 2,716,287 patients) and no randomized controlled trials; 14 studies were at high risk of bias (lack of adjustment for prognostic variables and/or co-interventions). When pooling adjusted results, PAC was associated with improved survival to hospital discharge (relative risk [RR], 0.77; 95% confidence interval [CI], 0.64 to 0.91, I2 = 98%; very low-quality evidence) and at longest available follow-up (RR, 0.72; 95% CI, 0.60 to 0.87; I2 = 99%; very low-quality evidence). Unadjusted length of stay was 3.5 days longer (95% CI, 1.49 to 5.54; I2 = 100%; very low-quality evidence) with PAC. Procedural complications were inconsistently reported. Very low-quality observational evidence suggests PAC use in patients with cardiogenic shock is associated with lower mortality. Overall, these results support consideration of PAC for hemodynamic assessment in cardiogenic shock. Prospective randomized clinical trials are needed to further characterize the role of PAC in this population.

Topic To evaluate the safety and efficacy of transepithelial corneal cross-linking in comparison with the established epithelium-off technique for corneal ectasia. Clinical Relevance Considerable debate exists regarding whether transepithelial and epithelium-off cross-linking are comparable in their safety and efficacy. Methods We searched 16 electronic databases, including Medline, Embase, Web of Science, and the grey literature, current to July 8, 2020, for randomized controlled trials comparing transepithelial and epithelium-off cross-linking for corneal ectasia. We excluded studies evaluating cross-linking for nonectatic indications, as well as non–randomized controlled trials. Our primary outcome was the change in maximal keratometry (Kmax) at 12 months after cross-linking, and we considered additional topographic, visual, and safety outcomes. We summarized our analyses by calculating weighted mean differences (MDs) with associated 95% confidence intervals (CIs) for continuous outcomes and relative risks (RRs) with corresponding 95% CIs for dichotomous outcomes. We conducted trial sequential analysis to determine whether the required information size was met for each outcome. The quality of individual trials was evaluated using the Cochrane Collaboration’s risk of bias assessment tool, and the evidence was assessed at an outcome level using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Results Twelve studies totaling 966 eyes were eligible. A significant difference was found between transepithelial and epithelium-off cross-linking groups in the change in Kmax at 12 months (MD, 0.75; 95% CI, 0.23–1.28; P = 0.004; primary outcome) and at longest follow-up (MD, 1.20; 95% CI, 0.62–1.77; P Discussion The efficacy of transepithelial cross-linking remains inferior to the epithelium-off approach, although it is significantly safer.

To estimate the rates of technical success and adverse events of vascular closure devices (VCDs) in the brachial artery, and compare rates of adverse events with manual compression.Medline and Embase were searched for observational studies examining VCDs in the brachial artery. Meta-analyses were performed using random-effects for the following outcomes: technical success, hematoma at the access site, pseudoaneurysm, local neurological adverse events, and the total number of adverse events. A pairwise meta-analysis compared VCD versus manual compression for the outcomes of hematoma and the total number of adverse events.Of 1761 eligible records, 16 studies including 510 access sites were included. Primary procedures performed were peripheral arterial disease interventions, percutaneous coronary intervention, and endovascular thrombectomy for ischemic stroke. Technical success rate was 93% (95% CI 87-96%, IDespite being off-label, studies suggest that VCDs in the brachial artery have a high technical success rate. There was no significant difference detected in adverse events between VCDs and manual compression in the brachial artery.

Sutureless aortic valve replacement (SuAVR) is gaining popularity for the treatment of aortic stenosis. We aimed to describe Canadian cardiac surgeons' practice patterns and perceptions regarding SuAVR.Content experts (clinicians and methodologists) developed the survey. Domains in the questionnaire include: respondent characteristics, factors influencing the decision to implant a SuAVR, barriers to SuAVR use, and interest in participating in a trial.A total of 66 cardiac surgeons (median duration of practice: 15 years; range 8-20 years) from 18 hospitals across Canada responded to the survey for a response rate of 84%. Surgeons reported that the following patient characteristics increased the likelihood they would choose SuAVR: hostile root (73%), small annular size (55%), high Society of Thoracic Surgery risk score (42%), older age (40%), to support minimally invasive surgery (25%) and redo-operation (23%). The following patient characteristics made surgeons less likely to pursue SuAVR: young age (73%), low STS score (40%), and large annular size (30%). Reported barriers to SuAVR use included: cost (33%), permanent pacemaker risk (27%) and uncertain durability (12%). Of respondents, 73% were interested in participating in a randomized controlled trial comparing SuAVR with transcatheter aortic valve replacement.The primary reasons for surgeons selecting SuAVR were high surgical risk and anatomical challenges. Cost is a primary factor limiting SuAVR use.

BACKGROUND Delayed parenthood, by both women and men, has become more common in developed countries. The adverse effect of advanced maternal age on embryo aneuploidy and reproductive outcomes is well known. However, whether there is an association between paternal age (PA) and embryonic chromosomal aberrations remains controversial. Oocyte donation (OD) is often utilized to minimize maternal age effects on oocyte and embryo aneuploidy, thus providing an optimal model to assess the effect of PA. Several studies have revealed a higher than expected rate of aneuploidy in embryos derived from young oocyte donors, which warrants examination as to whether this may be attributed to advanced PA (APA). OBJECTIVE AND RATIONALE The objective of this systematic review and individual patient data (IPD) meta-analysis is to evaluate existing evidence regarding an association between PA and chromosomal aberrations in an OD model. SEARCH METHODS This review was conducted according to PRISMA guidelines for systematic reviews and meta-analyses. Medline, Embase and Cochrane databases were searched from inception through March 2020 using the (MeSH) terms: chromosome aberrations, preimplantation genetic screening and IVF. Original research articles, reporting on the types and/or frequency of chromosomal aberrations in embryos derived from donor oocytes, including data regarding PA, were included. Studies reporting results of IVF cycles using only autologous oocytes were excluded. Quality appraisal of included studies was conducted independently by two reviewers using a modified Newcastle-Ottawa Assessment Scale. A one-stage IPD meta-analysis was performed to evaluate whether an association exists between PA and aneuploidy. Meta-analysis was performed using a generalized linear mixed model to account for clustering of embryos within patients and clustering of patients within studies. OUTCOMES The search identified 13 032 references, independently screened by 2 reviewers, yielding 6 studies encompassing a total of 2637 IVF-OD cycles (n = 20 024 embryos). Two ‘low’ quality studies using FISH to screen 12 chromosomes on Day 3 embryos (n = 649) reported higher total aneuploidy rates and specifically higher rates of trisomy 21, 18 and 13 in men ≥50 years. One ‘moderate’ and three ‘high’ quality studies, which used 24-chromosome screening, found no association between PA and aneuploidy in Day 5/6 embryos (n = 12 559). The IPD meta-analysis, which included three ‘high’ quality studies (n = 10 830 Day 5/6 embryos), found no significant effect of PA on the rate of aneuploidy (odds ratio (OR) 0.97 per decade of age, 95% CI 0.91–1.03), which was robust to sensitivity analyses. There was no association between PA and individual chromosome aneuploidy or segmental aberrations, including for chromosomes X and Y (OR 1.06 per decade of age, 95% CI 0.92–1.21). Monosomy was most frequent for chromosome 16 (217/10802, 2.01%, 95% CI 1.76–2.29%) and trisomy was also most frequent for chromosome 16 (194/10802, 1.80%, 95% CI 1.56–2.06%). WIDER IMPLICATIONS We conclude, based on the available evidence, that APA is not associated with higher rates of aneuploidy in embryos derived from OD. These results will help fertility practitioners when providing preconception counselling, particularly to older men who desire to have a child.

Aims To evaluate the long-term outcomes of sacral neuromodulation (SNM), and patient characteristics that may predict long-term success or complications. Methods A single-center retrospective cohort study was performed of all patients who underwent SNM testing and implantation. Outcome results, resolution of symptoms, and device removal were reported. Multivariable logistic regression was used to identify predictors of success. Cox proportional hazards model was used to identify predictors for device removal. Results Four hundred and thrity four patients underwent SNM test phase of which 241 (median age 48.0 years, 91.7% [221/241] female) had device implantation and were followed up for median [range] time of 4.0 (3 months-20.5 years) years. Multivariable logistic regression showed that male gender (odds ratio: 0.314; 95% confidence interval: 0.164-0.601, p = .0005) was independently associated with decreased peripheral nerve evaluation success. At final follow-up for patients who originally had device implantation, median (interquartile range) percent of symptoms resolution of all patients was 60.0% (0%-90%) and 69.3% (167/241) had SNM successful outcomes. Cox proportional hazards model showed no difference for time to SNM device removal with respect to patient age, gender, or diagnosis. 69.3% (167/241) patients had at least 1 surgical re-intervention. The most common reason at first surgical re-intervention was lead change only (26.3%, 44/167). Conclusion SNM is a minimally invasive procedure with good long-term success rates. There is a high revision rate but overall, SNM has a good safety profile and excellent long-term outcomes.

Objective To investigate a possible correlation between chromosomal aberrations and paternal age, analyzing embryos derived from young oocyte donors, with available preimplantation genetic testing for aneuploidy results from day 5/6 trophectoderm biopsy obtained by next-generation sequencing for all 24 chromosomes. Design Retrospective cohort study. Setting Canadian fertility centre. Patient(s) A total of 3,118 embryos from 407 male patients, allocated into three paternal age groups: group A, ≤39 years (n = 203); group B, 40–49 years (n = 161); group C, ≥50 years (n = 43). Intervention(s) None. Main Outcome Measure(s) The primary outcomes were aneuploidy, euploidy, mosaicism, and blastocyst formation rates. Secondary endpoints were comparison of specific chromosome aneuploidy, segmental and complex (involving two chromosomes + mosaicism >50%) aneuploidy, and analysis of overall percentage of chromosomal gains and losses within each group. Result(s) The study included 437 in vitro fertilization (IVF) antagonist cycles using 302 oocyte donors in which preimplantation genetic testing for aneuploidy was performed. Overall, 70.04% of embryos were euploid, 13.9% were aneuploid, and 16.06% were mosaic. No significant differences among paternal age groups A, B, and C were found in euploidy rates (69.2%, 70.6%, 71.4%, respectively), aneuploidy rates (14.7%, 12.8%, 13.9%, respectively) or mosaicism rates (16.1%, 16.6%, 13.6%; respectively). The fertilization rate was lower in group C compared with group B (76.35% vs. 80.09%). No difference was found in blastocyst formation rate between the study groups (median 52% [interquartile range, 41%, 67%] vs. 53% [42%, 65%] vs. 52% [42%, 64%], respectively). A generalized linear mixed model regression analysis for embryo ploidy rates found older oocyte donor age to be independently associated with embryo aneuploidy (odds ratio=1.041; 95% CI, 1.009–1.074). The rate of segmental aneuploidies was significantly higher in the older versus younger paternal age group (36.6% vs. 19.4%). Conclusion(s) No association was found between paternal age and aneuploidy rates in embryos derived from IVF cycles using young oocyte donors, after adjusting for donor, sperm, and IVF cycle characteristics. Advanced paternal age ≥ 50, compared with younger paternal ages, was associated with a lower fertilization rate and increased rate of segmental aberrations.

Olecranon fractures and osteotomies are treated with either tension-band wiring or plate-screw fixation; however, these methods of fixation have high rates of symptomatic hardware, resulting in revision surgery. We describe the novel use of intramedullary noncannulated long screws to gain rigid internal fixation and allow early range of motion. Our procedure differs from traditional intramedullary olecranon fixation as the longer screws, which can commonly be found on many pelvic fixation sets, allow for endosteal purchase at the isthmus of the ulna, which increases the pull-out strength of the screw. This procedure can be done quickly and requires minimal exposure, which minimises anaesthetic exposure, blood loss, and tourniquet time. The construct is not palpable subcutaneously and therefore is less likely to result in symptomatic hardware and revision surgery. How to cite this article Oitment C, Koziarz A, Bozzo A, et al. Intramedullary Cancellous Screw Fixation of Simple Olecranon Fractures. Strategies Trauma Limb Reconstr 2019;14(3):163–167.

Purpose: To evaluate the technical success and complication rates of vascular closure devices (VCDs) in the axillary artery. Materials and Methods: MEDLINE and Embase were searched independently by two reviewers to identify observational studies from inception through October 2021. The following outcomes were meta-analyzed: technical success, hematoma, dissection, pseudoaneurysm, infection, and local neurological complications. Complications were also graded as mild, moderate, and severe. A logistic regression evaluating the influence of sheath size for the outcome of technical success rate was performed using individual patient–level data. Results: Of 1496 unique records, 20 observational studies were included, totaling 915 unique arterial access sites. Pooled estimates were as follows: technical success 84.8% (95% confidence interval [CI]: 78%–89.7%, I2=60.4%), hematoma 7.9% (95% CI: 5.8%–10.6%, I2=0%), dissection 3.1% (95% CI: 1.3%–7.3%, I2=0%), pseudoaneurysm 2.7% (95% CI: 1.3%–5.7%, I2=0%), infection 2=20.5%), and local neurological complications 2.7% (95% CI: 1.7%–4.4%, I2=0%). There was a significant negative association between sheath size and technical success rate (odds ratio [OR]: 0.87 per 1 French (Fr) increase in sheath size, 95% CI: 0.80–0.94, p=0.0005). Larger sheath sizes were associated with a greater number of access-site complications (adjusted odds ratio [aOR]: 1.21 per 1 Fr increase sheath size, 95% CI: 1.04–1.40, p=0.013). Conclusions: Off-label use of VCDs in the axillary artery provides an 85% successful closure rate and variable complication rate, depending on the primary procedure and sheath size. Larger sheaths were associated with a lower technical success and greater rate of access-related complications. Clinical Impact Safe arterial access is the foundation for arterial intervention. While the common femoral artery is a well established access site, alternative arterial access sites capable of larger sheath sizes are needed in the modern endovascular era. This article provides the largest synthesis to date on the use of vascular closure devices for percutaneous axillary artery access in endovascular intervention. It should serve clinicians with added confidence around this approach in terms of providing a reference for technical success and complications. Clinically, this data is relevant for patient consent purposes as well as for practice quality improvement in setting safety standards for this access site.

Background Left ventricular assist device has been shown to be a safe and effective treatment option for patients with end-stage heart failure. However, there is limited evidence showing the effect of the implantation approach on postoperative morbidities and mortality. We aimed to compare left ventricular assist device implantation using conventional sternotomy versus less-invasive surgery including hemi-sternotomy and the minithoracotomy approach. Methods Between January 2014 and December 2018, 342 consecutive patients underwent left ventricular assist device implantation at 2 high-volume centers. Patient characteristics were prospectively collected. The propensity score method was used to create 2 groups in a 1:1 fashion. A competing risk regression model was used to evaluate time to death adjusting for competing risk of heart transplantation. Results The unmatched cohort included 241 patients who underwent left ventricular assist device implantation with the conventional sternotomy technique and 101 patients who underwent left ventricular assist device implantation with the less-invasive surgery technique. Propensity matching produced 2 groups each including 73 patients. In the matched groups, reexploration rate for bleeding was necessary in 17.9% (12/67) in the conventional sternotomy group compared with 4.1% (3/73) the less-invasive surgery group (P = .018). Intensive care unit stay for the less-invasive surgery group was significantly lower than for the sternotomy group (10.5 [interquartile range, 2-25.75] days vs 4 [interquartile range, 2-9.25] days, P = .008), as was hospital length of stay (37 [interquartile range, 27-61] days vs 25.5 [interquartile range, 21-42] days, P = .007). Mortality cumulative incidence for conventional surgery was 24% (95% confidence interval, 14.3-34.8) at 1 year and 26% (95% confidence interval, 15.9-37.4) at 2 years for patients without heart transplantation. Mortality cumulative incidence for less-invasive surgery was 22.5% (95% confidence interval, 12.8-33.8) at 1 year and 25.2% (95% confidence interval, 14.5-37.4) at 2 years for patients without heart transplantation. There was no difference in cumulative mortality incidence when adjusting for competing risk of heart transplantation (subdistribution hazard, 0.904, 95% confidence interval, 0.45-1.80, P = .77). Conclusions The less-invasive surgery approach is a safe technique for left ventricular assist device implantation. Less-invasive surgery was associated with a significant reduction in the postoperative bleeding complications and duration of hospital stay, with no significant difference in mortality incidence.

Background Sutureless aortic valve replacement (SuAVR) is an alternative to surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). This study compares the effectiveness of SuAVR to SAVR and TAVR. Methods We searched MEDLINE and EMBASE from inception to July 2021 for studies evaluating SuAVR, SAVR, and TAVR in adults with aortic stenosis. We performed screening, full-text assessment, data collection, and risk of bias evaluation independently and in duplicate. We evaluated risk of bias using by Cochrane and CLARITY's tools, and certainty in evidence using the GRADE framework. Data were pooled using a random-effects model. Results We identified one randomized and 78 observational studies (n = 60,689; SuAVR vs. SAVR = 39,171, vs. TAVR = 21,518). All studies were at high or unclear risk of bias, with very-low certainty in effect estimates. Compared to TAVR, SuAVR demonstrates no significant difference in mortality at 30-days (odds ratio [OR]: 0.52, 95% confidence interval [CI: 0.85, 1.16], I2 = 0%), but decreased odds at 2-years (OR: 0.39, 95% CI [0.17, 0.88], I2 = 0%). SuAVR also reduced odds of mild paravalvular regurgitation (OR: 0.11, 95% CI [0.06, 0.21], I2 = 50%). Compared to SAVR, SuAVR was associated with a similar mortality at 30-days (OR: 0.99, 95% CI [0.85, 1.16], I2 = 0%) and 2-years (OR: 0.99, 95% CI [0.43-2.30], I2 = 7%). SuAVR significantly increased odds of permanent pacemaker implantation (OR: 2.5, 95% CI [2.25, 2.77], I2 = 0%). Pooled effect estimates were consistent with results from the randomized trial comparing SuAVR and SAVR. Conclusion Based on very-low quality evidence, SuAVR is associated with similar short- and midterm outcomes compared to TAVR and SAVR. Comparative randomized data with long-term follow-up are required to clarify the role of SuAVR.

Introduction: Preoperative alpha-blockers have been proposed to improve intraoperative outcomes and patient stone-free status after ureteroscopy for ureteral stones. Materials and Methods: We searc...

BACKGROUND: Surgery is a common treatment option for patients with infective endocarditis. We present a large cohort of surgically managed patients with infective endocarditis and evaluate the long-term mortality of those with and without neurological complications. METHODS: We performed a retrospective review of patients surgically managed for infective endocarditis between 1994 and 2017. Demographic and outcome data were collected using a hospital database. Time-to-event analysis was performed with Kaplan-Meier curve and compared statistically with log-rank testing. RESULTS: At the time of admission, 680 (27.7%) patients with infective endocarditis showed neurological complications. The mean age was 62.6±14.0 years and 70% were male. Two thousand two hundred and sixty-one (92%) patients had left-sided valve endocarditis. Isolated aortic valve endocarditis was present in 59% of patients and 35% of patients had isolated infective endocarditis of the mitral valve. Mean logistic EuroSCORE was 21.2±21.6. Microbiologic cultures were positive in 1,939 patients (79%). The most common bacteria were Staphylococcus aureus (26%). In-hospital mortality in the group of patients with Staphylococcus aureus was significantly higher than in the group infected with other pathogens (18.2% vs. 13.4%, P=0.004). Patients with vegetations ≥1 cm had significantly more systemic embolization (P

Olecranon fractures are common upper-extremity fractures amenable to various surgical techniques. The authors conducted a systematic review and meta-analysis to evaluate surgical management strategies for olecranon fractures in adult patients. Two investigators independently screened articles from records obtained from MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Library databases. The authors compared tension-band wiring (TBW) with plate fixation (PF) for the outcomes of complications and hardware removal. Subgroup analyses were conducted comparing randomized controlled trials with observational studies for each outcome. In addition, the authors evaluated novel fixation techniques other than TBW and PF. Twenty-four studies were included in the systematic review and 10 studies were included in the meta-analysis of TBW vs PF. Compared with TBW (n=270), patients who underwent PF (n=369) had a significantly lower complication rate (relative risk, 0.48; 95% confidence interval, 0.36–0.64; P I 2 =16%). Plate fixation (41 of 332) also had less hardware removal compared with TBW (79 of 236; relative risk, 0.36; 95% confidence interval, 0.25–0.50; P I 2 =0%). Subgroup analyses showed no difference when comparing randomized controlled trials with observational studies for the outcomes of complication rate ( P =.45) and hardware removal ( P =.54). Qualitative analysis revealed novel methods of olecranon fixation: a modified cable pin system, tension banding through 2 cannulated screws, olecranon memory connector fixation, and cancellous screw TBW. This meta-analysis revealed significantly lower complication and hardware removal rates for PF compared with TBW. Several novel methods of olecranon fixation may represent viable alternatives. [ Orthopedics . 2019; 42(2):75–82.]

To provide a comprehensive overview of the literature assessing the safety and efficacy of uterine artery embolization (UAE) for patients with pedunculated subserosal fibroids.MEDLINE and Embase databases were searched without language or publication type restrictions for observational studies to estimate safety (adverse events) and efficacy (devascularization, fibroid volume reduction, and uterine volume reduction) outcomes. Case reports were included to qualitatively report adverse events. Meta-analysis was performed for single proportions and mean changes with random-effects modeling.Of 98 eligible articles, 11 studies were included in the final analysis. Of the adverse events detailed in these cases, 5 events were mild, 2 were moderate (torsion of pedunculated fibroid requiring laparoscopic myomectomy and persistent bleeding after embolization requiring hysterectomy), and 1 was severe (fibroid necrosis causing bowel obstruction requiring bowel resection and hysterectomy). There were no deaths reported in the literature. The pooled risk of adverse events was 1.7% (95% confidence interval [CI], 0.29%-9.2%; 4 of 181; IUAE for pedunculated subserosal fibroids has a low risk of adverse events and effectively reduces fibroid and uterine size.

OBJECTIVE The clinical consequences of alternative outflow cannula positioning in patients undergoing left ventricular assist device implantation are unknown. We evaluated clinical outcomes in patients who underwent implantation with the outflow cannula implanted from the right side into the ascending aorta versus the left side of the pericardium. METHODS Fifty consecutive patients with terminal left heart failure underwent implantation using the Medtronic Heartware Ventricular Assist Device at Toronto General Hospital. Patients were divided between left and right outflow cannula positioning during implantation where anastomosis occurred in the ascending aorta. Propensity score matching using exact matching on the following pre-specified covariates: Interagency Registry for Mechanically Assisted Circulatory Support score, previous cardiac surgery, and preoperative inotrope use. RESULTS Fifty consecutive patients (25 left implantation and 25 right implantation) were included in the unmatched cohort and 45 patients (25 left implantation and 20 right implantation) were included in the matched cohort. No significant differences in baseline demographics. Pump thrombosis occurred in 10% (n = 2) receiving right-sided implantation and 8% (n = 2) with left implantation (p = 1.00). Postoperative stroke occurred in 10% (2/20) with right implantation and 16% (4/25) with left implantation (p = .88). No difference in 1-year mortality between right 20% (5/25) and left 25% (5/20) implantation (p = .97). CONCLUSION No observed difference in mortality when adjusting for competing risk of heart transplantation. There was also no difference in stroke, pump thrombosis, driveline infection. Larger studies are required to confirm these findings. These preliminary data support the use of left-sided anastomoses to facilitate subsequent re-entry during heart transplantation.

Introduction UNAIDS has identified female sex workers (FSW) as a key HIV at‐risk population. FSW disproportionately experience gender‐based violence, which compounds their risk of HIV acquisition and may contribute to adverse mental health outcomes. Pre‐exposure prophylaxis (PrEP) is a powerful but underused HIV prevention tool for these women. This study explored the associations between intimate partner violence (IPV) and client‐perpetrated violence against FSW, mental health outcomes and PrEP use. Methods An anonymous questionnaire was administered to a convenience sample of 220 Nairobi FSW attending dedicated clinics from June to July 2019, where PrEP was available free of charge. A modified version of the WHO Violence Against Women Instrument assessed IPV and client‐perpetrated violence, and the Patient Health Questionnaire‐9 (PHQ‐9) and Generalized Anxiety Disorder‐7 (GAD‐7) assessed depressive and anxiety symptoms respectively. Multivariable logistic regressions evaluated predictors of depression, generalized anxiety and PrEP use. Results Of the total 220 women (median [IQR] age 32 [27‐39]), 56.8% (125/220) reported depression (PHQ‐9 ≥ 10) and 39.1% (86/220) reported anxiety (GAD‐7 ≥ 10). Only 41.4% (91/220) reported optimal use of PrEP (taken correctly six to seven days/week) despite the cohort pursuing sex work for a median of 7 (4 to 12) years. Most women reported experiencing any violence in the past 12 months (90%, 198/220). Any recent IPV was frequent (78.7%, 129/164), particularly emotional IPV (66.5%, 109/164), as was any client‐perpetrated violence in the past 12 months (80.9%, 178/220). Regression analyses found that violence was independently associated with depression (adjusted OR [aOR] 9.39, 95% CI 2.90 to 30.42, p = 0.0002) and generalized anxiety (aOR 3.47, 95% CI 1.10 to 10.88, p = 0.03), with the strongest associations between emotional IPV and both depression and anxiety. Recent client‐perpetrated emotional violence (aOR 0.23, 95% CI 0.07 to 0.71, p = 0.01) was associated with decreased PrEP use, whereas client‐perpetrated physical violence was associated with increased PrEP use (aOR 3.01, 95% CI 1.16 to 7.81, p = 0.02). Conclusions There was a high prevalence of recent violence by different perpetrators as well as depression and anxiety among FSW from Nairobi. PrEP use was relatively infrequent, and recent client‐perpetrated emotional violence was associated with PrEP non‐use. Interventions to reduce gender‐based violence may independently enhance HIV prevention and reduce the mental health burden in this community.

Cardiogenic shock carries high morbidity and mortality. The purpose of this review was to determine the safety and efficacy of pulmonary artery catheterization (PAC) in adult patients hospitalized with cardiogenic shock.We performed a systematic review and meta-analysis of observational studies and randomized controlled trials comparing PAC vs no PAC in cardiogenic shock. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and grey literature. We screened articles, abstracted data, and evaluated risk of bias in duplicate. We pooled data using a random-effects model and evaluated the quality of evidence using the GRADE framework. Outcomes of interest were mortality, length of stay, and procedural complications.We identified 19 eligible observational studies (≥ 2,716,287 patients) and no randomized controlled trials; 14 studies were at high risk of bias (lack of adjustment for prognostic variables and/or co-interventions). When pooling adjusted results, PAC was associated with improved survival to hospital discharge (relative risk [RR], 0.77; 95% confidence interval [CI], 0.64 to 0.91, IVery low-quality observational evidence suggests PAC use in patients with cardiogenic shock is associated with lower mortality. Overall, these results support consideration of PAC for hemodynamic assessment in cardiogenic shock. Prospective randomized clinical trials are needed to further characterize the role of PAC in this population.RéSUMé: OBJECTIF: Le choc cardiogénique entraîne une morbidité et une mortalité élevées. Le but de cette revue était de déterminer la sécurité et l’efficacité de l’utilisation d’un cathétérisme de l’artère pulmonaire (CAP) chez des patients adultes hospitalisés en choc cardiogénique.Nous avons réalisé une revue systématique et une méta-analyse d’études observationnelles et d’études randomisées contrôlées comparant l’utilisation vs la non-utilisation de CAP pour le traitement d’un choc cardiogénique. Nous avons effectué des recherches dans les bases de données MEDLINE, EMBASE, Cochrane CENTRAL et dans la littérature grise. Nous avons examiné les articles, résumé les données et évalué le risque de biais à deux reprises. Nous avons regroupé les données à l’aide d’un modèle à effets aléatoires et évalué la qualité des données probantes en nous appuyant sur le système GRADE. Les issues d’intérêt étaient la mortalité, la durée de séjour et les complications procédurales.Nous avons identifié 19 études observationnelles admissibles (≥ 2 716 287 patients) et aucune étude randomisée contrôlée; 14 études comportaient un risque élevé de biais (absence d’ajustement sur les variables pronostiques et/ou les interventions concomitantes). En regroupant les résultats ajustés, le CAP a été associé à une meilleure survie jusqu’au congé de l’hôpital (risque relatif [RR], 0,77; intervalle de confiance [IC] à 95 %, 0,64 à 0,91, I2 = 98 %; données probantes de très faible qualité) et jusqu’au point de suivi disponible rapporté le plus lointain dans le temps (RR, 0,72; IC 95 %, 0,60 à 0,87; I2 = 99 %; données probantes de très faible qualité). La durée de séjour non ajustée était 3,5 jours plus longue (IC 95 %, 1,49 à 5,54; I2 = 100 %; données probantes de très faible qualité) avec un CAP. Les complications procédurales n’étaient par rapportées de manière uniforme.Des données observationnelles de très faible qualité suggèrent que l’utilisation d’un CAP chez des patients en choc cardiogénique est associée à une réduction de la mortalité. Dans l’ensemble, ces résultats suggèrent de considérer le CAP pour l’évaluation hémodynamique en cas de choc cardiogénique. Des études cliniques randomisées prospectives sont nécessaires pour mieux caractériser le rôle du CAP dans cette population.

Background Shock wave lithotripsy (SWL) is a widely used method to treat renal and ureteral stone. It fragments stones into smaller pieces that are then able to pass spontaneously down the ureter and into the bladder. Alpha-blockers may assist in promoting the passage of stone fragments, but their effectiveness remains uncertain. OBJECTIVES: To assess the effects of alpha-blockers as adjuvant medical expulsive therapy plus usual care compared to placebo and usual care or usual care alone in adults undergoing shock wave lithotripsy for renal or ureteral stones. Search methods We performed a comprehensive literature search of the Cochrane Library, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, several clinical trial registries and grey literature for published and unpublished studies irrespective of language. The date of the most recent search was 27 February 2020. Selection criteria We included randomized controlled trials of adults undergoing SWL. Participants in the intervention group had to have received an alpha-blocker as adjuvant medical expulsive therapy plus usual care. For the comparator group, we considered studies in which participants received placebo. Data collection and analysis Two review authors independently selected studies for inclusion/exclusion, and performed data abstraction and risk of bias assessment. We conducted meta-analysis for the identified dichotomous and continuous outcomes using RevManWeb according to Cochrane methods using a random-effects model. We judged the certainty of evidence on a per outcome basis using GRADE. Main results We included 40 studies with 4793 participants randomized to usual care and an alpha-blocker versus usual care alone. Only four studies were placebo controlled. The mean age of participants was 28.6 to 56.8 years and the mean stone size prior to SWL was 7.1 mm to 13.2 mm. The most widely used alpha-blocker was tamsulosin; others were silodosin, doxazosin, terazosin and alfuzosin. Alpha-blockers may improve clearance of stone fragments after SWL (risk ratio (RR) 1.16, 95% confidence interval (CI) 1.09 to 1.23; I² = 78%; studies = 36; participants = 4084; low certainty evidence). Based on the stone clearance rate of 69.3% observed in the control arm, an alpha-blocker may increase stone clearance to 80.4%. This corresponds to 111 more (62 more to 159 more) participants per 1000 clearing their stone fragments. Alpha-blockers may reduce the need for auxiliary treatments after SWL (RR 0.67, 95% CI 0.45 to 1.00; I² = 16%; studies = 12; participants = 1251; low certainty evidence), but also includes the possibility of no effect. Based on a rate of auxiliary treatments in the usual care arm of 9.7%, alpha-blockers may reduce the rate to 6.5%. This corresponds 32 fewer (53 fewer to 0 fewer) participants per 1000 undergoing auxiliary treatments. Alpha-blockers may reduce major adverse events (RR 0.60, 95% CI 0.46 to 0.80; I² = 0%; studies = 7; participants = 747; low certainty evidence). Major adverse events occurred in 25.8% of participants in the usual care group; alpha-blockers would reduce this to 15.5%. This corresponds to 103 fewer (139 fewer to 52 fewer) major adverse events per 1000 with alpha-blocker treatment. None of the reported major adverse events appeared drug-related; most were emergency room visits or rehospitalizations. Alpha-blockers may reduce stone clearance time in days (mean difference (MD) -3.74, 95% CI -5.25 to -2.23; I² = 86%; studies = 14; participants = 1790; low certainty evidence). We found no evidence for the outcome of quality of life. For those outcomes for which we were able to perform subgroup analyses, we found no evidence of interaction with stone location, stone size or type of alpha-blocker. We were unable to conduct an analysis by lithotripter type. The results were also largely unchanged when the analyses were limited to placebo controlled studies and those in which participants explicitly only received a single SWL session. Authors' conclusions Based on low certainty evidence, adjuvant alpha-blocker therapy following SWL in addition to usual care may result in improved stone clearance, less need for auxiliary treatments, fewer major adverse events and a reduced stone clearance time compared to usual care alone. We did not find evidence for quality of life. The low certainty of evidence means that our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.

To evaluate the safety and efficacy of transepithelial corneal cross-linking in comparison with the established epithelium-off technique for corneal ectasia.Considerable debate exists regarding whether transepithelial and epithelium-off cross-linking are comparable in their safety and efficacy.We searched 16 electronic databases, including Medline, Embase, Web of Science, and the grey literature, current to July 8, 2020, for randomized controlled trials comparing transepithelial and epithelium-off cross-linking for corneal ectasia. We excluded studies evaluating cross-linking for nonectatic indications, as well as non-randomized controlled trials. Our primary outcome was the change in maximal keratometry (KTwelve studies totaling 966 eyes were eligible. A significant difference was found between transepithelial and epithelium-off cross-linking groups in the change in KThe efficacy of transepithelial cross-linking remains inferior to the epithelium-off approach, although it is significantly safer.

Background The aim of this study was to evaluate the results after stented porcine xenograft implantation (Epic, SJM, St Paul, MN) with Linx anticalcification treatment in elderly patients at our high-volume tertiary care center. Methods A total of 3825 patients undergoing aortic (AVR = 2441), mitral (MVR = 892), or double valve (DVR = 492) replacement between 11/2001 and 12/2017 with Epic xenografts were evaluated. Outcomes were assessed by reviewing the prospectively acquired hospital database results, and regular annual follow-up information was acquired from questionnaires or telephone interviews. Results For patients undergoing AVR, MVR, DVR, age at surgery were 76.4 ± 6, 71.2 ± 9, 72.9 ± 8 years; active endocarditis was an indication for valve surgery in 4.5%, 20.7%, 19.7%; and the predicted median (interquartile range [IQR]) mortality risk (EuroSCORE II) was 5.2% (3.1%-9.4%), 7.5% (3.9%-16.2%), 9.9% (6.0%-19.6%), respectively. Median follow-up was 3.04 (IQR: 0.18-5.21). Thirty-day survival was 91.2% ± 0.6%, 87.6% ± 0.1.1%, 84.7% ± 1.6%; and 10-year survival was 56.7% ± 1.0%, 59.4% ± 2.5%, 50.45% ± 3.1%, respectively. Patients who underwent MVR versus AVR were at significant increased risk for reoperation for endocarditis (adjusted odds ratio; 2.2, 95% confidence interval; 1.29-3.7; P = .003). There was no significant difference in all-cause mortality at midterm in AVR vs MVR in the matched cohort (P = .85). Conclusions Implantation of the Epic stented porcine xenograft is associated with acceptable survival and freedom from valve-related complications or reoperation due to structural valve disease at midterm follow-up.

Study Design: Systematic review and meta-analysis. Objectives: This study aims to evaluate the effects of anterior cervical decompression and fusion (ACDF) on axial neck pain in adult patients receiving surgery for myelopathy, radiculopathy, or a combination of both. Methods: Two independent reviewers completed a librarian-assisted search of 4 databases. Visual Analogue Scale (VAS) and Neck Disability Index (NDI) scores were extracted preoperatively and at 3, 6, 12, 24, 36, 48, and 48+ months postoperatively for ACDF groups and pooled using a random-effects model. Results: Of 17 850 eligible studies, 37 were included for analysis, totaling 2138 patients analyzed with VAS and 2477 with NDI score. Individual VAS mean differences were reduced at 6 weeks (−2.5 [95% confidence interval (CI): −3.5 to −1.6]), 3 months (−2.9 [−3.7 to −2.2]), 6 months (−3.2 [−3.9 to −2.6]), 12 months (−3.7 [−4.3 to −3.1]), 24 months (−4.0 [−4.4 to −3.5]), 48 months (−4.6 [−5.5 to −3.8]), and >48 months (−4.7 [−5.8 to −3.6]) follow-up ( P < .0001 for all endpoints). Individual NDI mean differences were reduced at 6 weeks (−26.7 [−30.9 to −22.6]), 3 months (−29.8 [−32.7 to −26.8]), 6 months (−31.2 [−35.5 to −26.8)], 12 months (−29.3 [−33.2 to −25.4]), 24 months (−28.9 [−32.6 to −25.2]), 48 months (−33.1 [−37.4 to −28.7]), and >48 months (−37.6 [−45.9 to −29.3]) follow-up ( P < .0001 for all endpoints). Conclusions: ACDF is associated with a significant reduction in axial neck pain compared with preoperative values in patients being treated specifically for myelopathy or radiculopathy. This influences the preoperative discussions surgeons may have with patients regarding their expectations for surgery. The effects seen are stable over time and represent a clinically significant reduction in axial neck pain.

BACKGROUND Many acceptable treatment options exist for distal radius fractures (DRFs); however, a simultaneous comparison of all methods is difficult using conventional study designs. QUESTIONS/PURPOSES We performed a network meta-analysis of randomized controlled trials (RCTs) on DRF treatment to answer the following questions: Compared with nonoperative treatment, (1) which intervention is associated with the best 1-year functional outcome? (2) Which intervention is associated with the lowest risk of overall complications? (3) Which intervention is associated with the lowest risk of complications requiring operation? METHODS Ten databases were searched from inception to July 25, 2019. Search and analysis reporting adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Included studies were English-language RCTs that assessed at least one surgical treatment arm for adult patients with displaced DRFs, with less than 20% loss to follow-up. We excluded RCTs reporting on patients with open fractures, extensive bone loss, or ipsilateral upper extremity polytrauma. Seventy RCTs (n = 4789 patients) were included. Treatments compared were the volar locking plate, bridging external fixation, nonbridging external fixation, dynamic external fixation, percutaneous pinning, intramedullary fixation, dorsal plating, fragment-specific plating, and nonoperative treatment. Subgroup analyses were conducted for intraarticular fractures, extraarticular fractures, and patients with an average age greater than 60 years. Mean (range) patient age was 59 years (56 to 63) and was similar across all treatment groups except for dynamic external fixation (44 years) and fragment-specific plating (47 years). Distribution of intraarticular and extraarticular fractures was approximately equal among the treatment groups other than that for intramedullary fixation (73% extraarticular), fragment-specific plating (66% intraarticular) [13, 70], and dorsal plating (100% intraarticular). Outcomes were the DASH score at 1 year, total complications, and reoperation. The minimum clinically important different (MCID) for the DASH score was set at 10 points. The analysis was performed using Bayesian methodology with random-effects models. Rank orders were generated using surface under the cumulative ranking curve values. Evidence quality was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology. Most studies had a low risk of bias due to randomization and low rates of incomplete follow-up, unclear risk of bias due to selective reporting, and high risk of bias due to lack of patient and assessor blinding. Studies assessing bridging external fixation and/or nonoperative treatment arms had a higher overall risk of bias while studies with volar plating and/or percutaneous pinning treatment arms had a lower risk of bias. RESULTS Across all patients, there were no clinically important differences in terms of the DASH score at 1 year; although differences were found, all were less than the MCID of 10 points. Volar plating was ranked the highest for DASH score at 1 year (mean difference -7.34 [95% credible interval -11 to -3.7) while intramedullary fixation, with low-quality evidence, also showed improvement in DASH score (mean difference -7.75 [95% CI -14.6 to -0.56]). The subgroup analysis revealed that only locked volar plating was favored over nonoperative treatment for patients older than 60 years of age (mean difference -6.4 [95% CI -11 to -2.1]) and for those with intraarticular fractures (mean difference -8.4 [95% CI -15 to -2.0]). However, its clinical importance was uncertain as the MCID was not met. Among all patients, intramedullary fixation (odds ratio 0.09 [95% CI 0.02 to 0.84]) and locked volar plating (OR 0.14 [95% CI 0.05 to 0.39]) were associated with a lower complication risk compared with nonoperative treatment. For intraarticular fractures, volar plating was the only treatment associated with a lower risk of complications than nonoperative treatment (OR 0.021 [95% CI < 0.01 to 0.50]). For extraarticular fractures, only nonbridging external fixation was associated with a lower risk of complications than nonoperative treatment (OR 0.011 [95% CI < 0.01 to 0.65]), although the quality of evidence was low. Among all patients, the risk of complications requiring operation was lower with intramedullary fixation (OR 0.06 [95% CI < 0.01 to 0.85) than with nonoperative treatment, but no treatment was favored over nonoperative treatment when analyzed by subgroups. CONCLUSION We found no clinically important differences favoring any surgical treatment option with respect to 1-year functional outcome. However, relative to the other options, volar plating was associated with a lower complication risk, particularly in patients with intraarticular fractures, while nonbridging external fixation was associated with a lower complication risk in patients with extraarticular fractures. For patients older than 60 years of age, nonoperative treatment may still be the preferred option because there is no reliable evidence showing a consistent decrease in complications or complications requiring operation among the other treatment options. Particularly in this age group, the decision to expose patients to even a single surgery should be made with caution. LEVEL OF EVIDENCE Level I, therapeutic study.

Background Endoscopic third ventriculostomy (ETV) is a safe and effective treatment for hydrocephalus. An entry point located 4 cm anterior to the coronal suture, 3 cm anterior to Kocher point, and approximately 9 cm from the pupil at the midpupillary line has been used successfully for the last 20 years in our center. We aimed to evaluate this alternative anterior entry point routinely used for ETV, with or without concurrent endoscopic biopsy. Methods Patients undergoing this proposed entry point were examined to evaluate its safety and efficacy. Factors such as patients' age, sex, hydrocephalus etiology, tumor location and pathology, and complication rate were examined through regression analyses to evaluate their impact on tumor biopsy and ETV success rates, and the need for subsequent ventricular shunting. Results A total of 131 patients were included in the study. ETV was successful in 125 (95.4%) patients. Of these, 26 (19.8%) patients required a biopsy, which was successful in 21 (80.8%) cases. A complication was observed in 10 (7.6%) patients, with a trend toward complications occurring after ETV failure. There was no association between ETV success rate and patients' age (P = 0.5) or sex (P = 0.99). Conclusions The anterior entry point is a safe and effective method for ETV, especially when considering concurrent ventricular tumor biopsy. This entry point may be considered as a more minimally invasive procedure when using rigid endoscopy and may also eliminate the need for a flexible scope.

Background and importance Myxoid liposarcoma is not an uncommon form of sarcoma. However, it usually affects the lower extremity long bones. Scapular involvement is extremely rare, as is a metastasis to the parasellar region. We present a case of liposarcoma of the skull base originating in the scapular region and metastasizing to the sellar and parasellar regions and provide a review of the pertinent literature. Clinical presentation A 43-year-old female patient diagnosed with left scapular myxoid liposarcoma was treated with surgical resection. She had clear resection margins and was treated pre- and postoperatively with radiotherapy to the region. She remained asymptomatic for 2 years following surgery, after which she abruptly developed diplopia with right lateral gaze. There were no symptoms of raised intracranial pressure or impaired vision. Her examination was normal apart from complete right sixth nerve palsy. Imaging studies of the brain showed a large mass in the clivus eroding into the floor of the sella, encircling the right internal carotid artery in the cavernous sinus. The mass also displaced the sellar contents superiorly. An endonasal, endoscopic skull base approach was undertaken, and a subtotal resection was performed in an effort to avoid multiple cranial nerve pareses. Conclusion Our literature search revealed that this case report is the first to document liposarcoma metastasis to the skull base originating from the scapular region. Subtotal surgical resection resulted in minimal improvement of the patient's sixth nerve palsy. Postoperative radiation was undertaken. A multidisciplinary approach on an individual patient basis is recommended.

Background Cardiogenic shock carries high morbidity and mortality. Pulmonary artery catheterization (PAC) allows invasive hemodynamic assessment and tailored therapy; however, evidence supporting this practice is sparse. Methods We performed a systematic review and meta-analysis of observational studies and randomized controlled trials comparing PAC versus no PAC in cardiogenic shock. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and grey literature. We screened references, abstracted data and evaluated risk of bias in duplicate. We pooled data using a random-effects model and evaluated the quality of evidence using GRADE. Outcomes of interest were mortality and length of stay (LOS). Results We identified 13 observational studies (1,982,047 patients) and no randomized controlled trials; 12 studies were at high risk of bias. When pooling adjusted results, PAC was associated with reduced mortality at hospital discharge (RR 0.64; 95% CI 0.50–0.82) and at longest available follow-up (RR 0.65; 95% CI 0.49–0.87). Unadjusted LOS was 5.0 days longer (95% CI 4.93–5.07) with PAC. Quality of evidence was very low for all outcomes. Conclusion Based on very low quality evidence, PAC use in patients with cardiogenic shock may be associated with lower mortality. The observed increase in hospital LOS may represent survivor bias or relate to more aggressive management with PAC. Overall, these results support consideration of PAC for hemodynamic assessment and tailored therapy in cardiogenic shock. Funding Acknowledgement Type of funding source: None

Purpose of review A thorough understanding of the modes of bioprosthetic valve failure is critical as clinicians will be facing an increasing number of patients presenting with failed bioprostheses in coming years. The purpose of this article is to review modes of bioprosthestic valve degeneration, their management, and identify gaps for future research. Recent findings Guidelines recommend monitoring hemodynamic performance of prosthetic valves using serial echocardiograms to determine valve function and presence of valve degeneration. Modes of bioprosthetic valve failure may be categorized as structural degeneration (calcification, tears, fibrosis, flail), nonstructural degeneration (pannus), thrombosis, and endocarditis. Calcification is the most common form of structural valve degeneration. Predictors of bioprosthetic valve failure include valves implanted in the mitral position, younger age, and type of valve (porcine versus bovine pericardial). Failed bioprosthetic valves are managed with either redo surgical replacement or transcatheter valve-in-valve implantation. Summary Several modes of bioprosthetic valve failure exist, which vary based on patient, implant position, and valve characteristics. Further research is required to characterize factors associated with early failure to delay structural valve degeneration and improve patient prognosis.

Context: Vitamin D supplementation is important in military research because of its role in musculoskeletal health. Objective: This systematic review examined the effects of vitamin D supplementation on serum 25-hydroxyvitamin D (25(OH)D) concentrations and musculoskeletal health outcomes in military personnel. Data Sources: A comprehensive search was conducted using MEDLINE, EMBASE, CINAHL, SportDiscus, and the Cochrane Library databases and the reference lists of existing review articles and relevant studies. Study Selection: Reviewers independently screened titles, abstracts, and full texts of the articles using predefined criteria. Study Design: Systematic review of randomized controlled trials (RCTs) using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Level of Evidence: Level 3. Data Extraction: Three reviewers independently extracted data and assessed the methodological quality. Mean differences with 95% CI in serum 25(OH)D concentrations between the vitamin D and placebo arms were calculated. Results: Four RCTs were included in the qualitative analyses. The 25(OH)D concentrations were improved with 2000 IU/d supplementation (mean difference, 3.90 ng/mL; 95% CI, 0.22-7.58). A trial on female Navy recruits showed a significant decrease in stress fractures (risk ratio, 0.77; 95% CI, 0.62-0.95), particularly tibial fractures, from daily supplementation of 800 IU vitamin D and 2000 mg calcium. Conclusion: There was a positive trend in 25(OH)D concentrations from higher doses of supplementary vitamin D in military submariners and a possible benefit to bone health when vitamin D was combined with calcium.

Objective We conducted a meta-analysis to estimate the risk of adverse events, life expectancy, and event-free life expectancy after the Ross procedure in adults. Methods We searched databases for reports evaluating the Ross procedure in patients aged more than or equal to 16 years of age. A microsimulation model was used to evaluate age- and gender-specific life expectancy for patients undergoing the Ross procedure. Results Data were pooled from 63 articles totaling 19 155 patients from 20 countries. Perioperative mortality was 2.5% (95% confidence interval [CI]: 1.9-3.1; N = 9978). We found a mortality risk of 5.9% (95% CI: 4.8-7.2) at a mean follow-up of 7.2 years (N = 7573). The rate of perioperative clinically significant bleeding was 1.0% (95% CI: 0.1-3.0); re-exploration for bleeding 4.6% (95% CI: 3.1-6.3); postoperative clinically significant bleeding from 30 days until a mean of 7.1 years was 0.5% (95% CI: 0.2-1.0). At a mean of 6.9 years of follow-up, reintervention rate of any operated valve was 7.9% (95% CI: 5.7-10.3). The risk of valve thrombosis was 0.3% (95% CI: 0.2-0.5) at 7.6 years; peripheral embolism 0.3% (95% CI: 0.2-0.4) at 6.4 years; stroke 0.9% (95% CI: 0.7-1.2) at 6.5 years; and endocarditis 2.1% (95% CI: 1.6-2.6) at 8.0 years. Microsimulation reported a 40-year-old undergoing the Ross procedure to have a life expectancy of 35.4 years and event-free life expectancy of 26.6 years. Conclusions Ross procedure in nonelderly adults is associated with low mortality and low risk of adverse events both at short- and long-term follow-up. The surgical community must prioritize a large, expertize-based randomized controlled trial to definitively address the risks and benefits of the Ross procedure compared to conventional aortic valve replacement.

Background Collagen cross-linking (CXL) is an evolving procedure that enhances the biomechanical rigidity of the cornea and can slow or halt ectatic disease. CXL requires delivery of 5.4 J/cm2 of ultraviolet A (UVA) radiation to a cornea saturated with riboflavin in order to induce cross-link formation. The conventional CXL procedure achieves this fluence by exposing the cornea to a 3 mW/cm2 UVA lamp for 30 min; however, some surgeons have proposed accelerated protocols which achieve the same fluence in a shorter period of time by using a higher power light source. Whether accelerated protocols are as effective in arresting ectasia as the established conventional procedure remains unclear. Accordingly, this study will systematically review and synthesise the evidence on accelerated CXL and compare it to the conventional approach across an array of clinical outcomes. Methods We will search 16 electronic databases, including MEDLINE, Embase, and the Cochrane Library, from inception to February 1, 2019. We will include all randomised controlled trials comparing accelerated and conventional CXL for any corneal ectatic disease. Two reviewers will independently screen search results to identify eligible articles, complete data collection, and conduct quality assessment. The quality of individual trials will be assessed using the Cochrane Collaboration’s Risk of Bias Assessment Tool. Our primary outcome will be the change in maximal keratometry (K max) at 12 months following treatment. Additional outcomes will include: incidence of disease progression, incidence of serious adverse events, as well as change in K max at longest follow-up, mean stromal demarcation line depth, mean uncorrected distance visual acuity, mean corrected distance visual acuity, mean K max, mean endothelial cell density, mean central corneal thickness, mean spherical equivalent, mean intraocular pressure, and mean corneal power, at 12 months following treatment. We will calculate relative risks and 95% confidence intervals (CIs) for dichotomous outcomes and weighted mean differences and corresponding 95% CIs for continuous outcomes. Prespecified subgroup analyses will be performed to investigate heterogeneity. We will rate the overall quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Discussion This review will provide a comprehensive evaluation of the evidence on accelerated and conventional CXL approaches and serve to inform clinical practice, medical device design, and future research. Evaluating variations of the CXL protocol aimed at reducing treatment duration is of critical importance and a prerequisite to expanding treatment availability to more patients. Systematic review registration PROSPERO CRD42018104151

Objective The aim of this systematic review and meta-analysis is to evaluate whether duct stenting is associated with better survival and other clinical outcomes compared with the modified Blalock–Taussig shunt in infants with duct-dependent pulmonary flow. Methods A systematic search of the Medline, Embase, and Cochrane databases was performed by 4 independent reviewers from inception to March 2019. Meta-analysis was performed using the DerSimonian and Laird method with inverse-variance weighting. The quality of evidence was summarized using the Grading of Recommendations, Assessment, Development, and Evaluation framework. Results Six comparative observational studies were included, of which 3 were rated low risk of bias. There was no difference in 30-day mortality between the Blalock–Taussig shunt and duct stenting groups (risk ratio, 1.02; 95% confidence interval, 0.46-2.27; P = .96; I2 = 0%). However, there was benefit in favor of duct stenting for medium-term mortality (risk ratio, 0.63; 95% confidence interval, 0.40-0.99; P = .05; I2 = 0%). Duct stenting demonstrated a reduced risk for procedural complications compared with the Blalock–Taussig shunt (risk ratio, 0.50; 95% confidence interval, 0.31-0.81; P = .005; I2 = 0%). However, there was an increased risk for unplanned reintervention for duct stenting (risk ratio, 1.77; 95% confidence interval, 1.39-2.26; P Conclusions Duct stenting demonstrated comparable early mortality, lower medium-term mortality, lower risk of procedural complications, and higher risk of reintervention compared with the Blalock–Taussig shunt.

This meta-analysis of 71 studies examines the accuracy of bedside optic nerve ultrasonography for diagnosing increased intracranial pressure in persons with either traumatic or nontraumatic brain i...

AIMS Clinicians frequently pre-treat patients with amiodarone to increase the efficacy of electrical cardioversion for atrial fibrillation (AF). Our objective was to determine the precise effects of amiodarone pre- and post-treatment on conversion efficacy and sinus rhythm maintenance. METHODS AND RESULTS We conducted a systematic review and meta-analysis of trials comparing pre- and post-treatment for electrical cardioversion with amiodarone vs. no therapy on (i) acute restoration and (ii) maintenance of sinus rhythm after 1 year. We searched MEDLINE and EMBASE from inception to July 2018 for randomized controlled trials. We evaluated the risk of bias for individual studies with the Cochrane tool and overall quality of evidence with the GRADE framework. We identified eight eligible studies (n = 1012). Five studies were deemed to have unclear or high risk of selection bias. We found the evidence to be of high quality based on GRADE. Treatment with amiodarone (200-800 mg daily for 1-6 weeks pre-cardioversion; 0-200 mg daily post-cardioversion) was associated with higher rates of acute restoration [relative risk (RR) 1.22, 95% confidence interval (CI) 1.07-1.39, P = 0.004, n = 1012, I2 = 65%] and maintenance of sinus rhythm over 13 months (RR 4.39, 95% CI 2.99-6.45, P

Background The role of the extent of surgical resection (EOR) in clinical outcomes for patients with low-grade glioma requires further examination. The goal of the present study was to evaluate the association between variable degrees of EOR and clinical outcomes for patients with low-grade glioma. Methods We conducted a systematic review and meta-analysis and searched databases for reports of low-grade glioma EOR. Eligible studies compared patient outcomes, including ≥2 categories of EOR (biopsy, resection of any extent, subtotal resection [STR], or gross total resection [GTR]). Treatment effects were evaluated using pooled estimates, mean differences, or risk ratios (RRs) with corresponding 95% confidence intervals (CIs) using random effects modeling. Results Our literature search yielded 60 studies with 13,289 patients. Pooled estimates of overall survival (OS) showed an increase from 3.79 years in the biopsy group to 6.68 years in STR to 10.65 years in GTR. OS was favorable with resection of any extent compared with (mean difference, 3.24; 95% CI, 0.64–5.84; P = 0.015). Pooled estimates of seizure control showed an improvement from 47.8% with biopsy to 54.2% with STR and 81.0% with GTR. Compared with STR, GTR delayed malignant transformation (RR, 0.43; 95% CI, 0.20–0.93; P = 0.032), without increasing postoperative mortality (RR, 0.38; 95% CI, 0.07–1.97; P = 0.250) or morbidity (RR, 1.22; 95% CI, 0.65–2.28; P = 0.540). Conclusion Among patients with low-grade gliomas, greater degrees of safe EOR were associated with longer OS and progression-free survival, better seizure control, and delayed malignant transformation, without increasing mortality or morbidity.

Left atrial appendage occlusion (LAAO) is a proposed alternative to oral anticoagulation in reducing stroke in patients with atrial fibrillation. It is suggested that LAAO is most suitable in patients at increased risk of stroke or bleeding or with contraindication to pharmacologic intervention. Despite the increase in evidence evaluating LAAO, the relative safety and efficacy of the procedure remains uncertain. Presently, several ongoing randomized trials are comparing various devices to each other and to pharmacologic anticoagulation. The objectives of this narrative review were to present the evidence on percutaneous and surgical LAAO devices, review current guidelines, and summarize landmark trials.

Summary Background Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles. Methods In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546. Findings We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1–13·3) in the conventional needle group to 4·2% (3·3–5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34–0·47, p I 2 =45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29–0·64; p Interpretation Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture. Funding None.