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Systematic review analyzing the treatment outcomes of cracked teeth that received endodontic treatment is unavailable. The purpose of this study was to examine the treatment outcome of cracked teeth that received root canal treatment and to determine factors that influenced outcome. The specific PIO questions were as follows: Population: patients who were healthy individuals ≥ 18 years old and required root canal treatment due to cracked tooth; Intervention: root canal treatment with at least 1 year in occlusal function; Outcomes: survival rate and pre-operative factors. Ovid, PubMed, and Cochrane databases were searched in conjunction with hand searching. Pooled survival rates were determined from a meta-analysis of the data retrieved from the articles. All statistics were performed by the Comprehensive Meta-Analysis software. Four articles met the inclusion criteria. The overall tooth survival at 60 months was 84.1% (95%CI, 72.3–91.5%). Although no pre-operative factors had statistical significance, 4 factors had possible clinical significance. Teeth with single crack and teeth with cracks contained within crowns exhibited lower extraction risk, while teeth with pre-treatment periodontal probing > 3 mm and teeth that were terminal abutments showed a greater risk of extraction. This systematic review determined the survival rate of endodontically treated cracked teeth to be moderately high. More studies in this area are, however, warranted before definitive conclusions can be derived. In view of the relatively high survival rate, endodontic treatment rather than extraction should be considered for cracked teeth.

Therapeutic vaccines may be promising treatments for chronic hepatitis B (CHB), but their clinical efficacy and safety are unclear. We conducted a systematic review of the evidence for the efficacy and safety of therapeutic vaccines in CHB patients. We searched PubMed, EMBASE and Google Scholar from 1990 until present and abstracts from EASL, APASL and AASLD from 2012 to 2017 and selected randomized controlled trials of CHB patients, comparing therapeutic vaccines with no treatment or standard of care. The Cochrane Risk of Bias tool v2.0 and GRADE method were used. Analyses were stratified by hepatitis B e antigen (HBeAg) status and the comparator (therapeutic vaccines vs no treatment, or therapeutic vaccines + standard of care vs standard of care). Efficacy outcomes were HBeAg seroconversion, hepatitis B virus DNA reduction and hepatitis B virus surface antigen (HBsAg) loss, measured at the end of treatment or end of follow-up. Effects were reported as risk differences with 95% confidence intervals using a random effects model. Fifteen studies were included. A wide variety of therapeutic vaccines were tested. For HBeAg clearance at the end of follow-up, when comparing therapeutic vaccines vs no therapy, RD = 0.01, 95% CI -0.05 to 0.07, and when comparing therapeutic vaccines + standard of care vs standard of care, RD = 0.03, 95% CI -0.03 to 0.09. For HBVDNA reduction at the end of follow-up, when comparing therapeutic vaccines vs no therapy, RD = -0.03, 95% CI -0.08 to 0.02, and when comparing therapeutic vaccines + standard of care, RD = 0.15, 95% CI 0.02-0.28. There were only a few studies on HBsAg loss, and hence, the findings were inconclusive. The only efficacy finding was HBVDNA reduction at the end of follow-up for therapeutic vaccines + standard of care vs standard of care; otherwise, therapeutic vaccines do not appear to be efficacious for the treatment of CHB, but were limited by few RCTs, suboptimal therapeutic vaccines and patient selection.

BACKGROUND Atopic dermatitis (AD) is a common skin condition in childhood. AD management can be complex, and caregivers may have inadequate information on the disease, aggravating factors, and management. Comprehensive therapeutic education has been closely associated with increased compliance and is recommended for all patients. There are, as yet, no studies on the impact of a pharmacist-led eczema counseling service. OBJECTIVES The primary objective was to assess the impact of a pharmacist-led eczema counseling service on improving caregivers' knowledge. The secondary objective was to evaluate caregivers' satisfaction of the service and their confidence in handling the patient's condition after counseling. METHODS This was a prospective, questionnaire-based observational study. After obtaining informed consent, caregivers were required to complete questionnaire A, containing items on demographics and knowledge assessment. Caregivers then underwent a counseling session by a dermatology-trained pharmacist. After counseling, caregivers were required to complete questionnaire B containing items on satisfaction and confidence level. A follow-up phone call was conducted after initial counseling session, during which knowledge-based questionnaire C would be completed. RESULTS Data from 32 participants were included in the analysis. There was a significant improvement in caregivers' knowledge score after receiving counseling, with mean precounseling score of 8.38 ± 3.92 and mean postcounseling score of 13.88 ± 3.65 (P

There has been much recent interest in the use of procalcitonin (PCT) as a marker of intra-abdominal infection (IAI) following colorectal surgery. However, the literature remains divided on the value of PCT in this setting. This meta-analysis aims to evaluate the value of PCT in predicting IAI after colorectal surgery.Systemic literature search was performed using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews to identify studies evaluating the diagnostic accuracy of PCT as a predictor for detecting IAI on postoperative days (POD) 3 to 5 following colorectal surgery. A meta-analysis was performed using random effect model and pooled predictive parameters as well as cut-off values for POD 3 to 5 were derived.Eight studies consisting 1629 patients were included. The pooled prevalence of IAI was 5.7% on POD 3, 9.7% on POD 4, and 6.3% on POD 5. The pooled AUC for POD 3 to 5 were 0.83 (95% CI 0.78-0.88), 0.79 (95% CI 0.64-0.93), and 0.94 (95% CI 0.91-0.97), respectively. The derived PCT cut-off values were 1.45 ng/ml on POD 3, 1.28 ng/ml on POD 4, and 1.26 ng/ml on POD 5. PCT had the highest diagnostic capability on POD 5 with diagnostic odds ratio of 32.9 (95% CI 15.01-69.88), sensitivity of 0.78 (95% CI 0.65-0.89), and specificity of 0.88 (95% CI 0.85-0.90).PCT is a useful diagnostic predictor of IAI after colorectal surgery. It has the greatest diagnostic accuracy on POD 5 and can help guide safe discharge of patients after colorectal surgery.

Objective Many trials incorporate induction chemotherapy (IC) in selecting for organ preservation in head and neck squamous cell carcinomas (HNSCC). However, few studies examine IC response in predicting for chemoradiation therapy (CRT) response. This meta-analysis aims to determine the predictive accuracy of IC for subsequent response to CRT and overall survival (OS). Data sources Medline, EMBASE, Cochrane register. Methods A systematic search identified studies from database inception to October 2016 that used IC prior to CRT as definitive treatment for advanced HNSCC. The sensitivities and specificities of IC response predicting for complete CRT response were calculated, and the results were pooled in a summary receiver operating curve. One-, 2- and 5-year OS data were extracted. Results Seven studies (n = 423 patients) were analyzed for response and six (n = 439) for OS. Pooled median sensitivity and specificity of IC response predicting CRT response were 0.95 (95% confidence interval [CI]: 0.72-0.98) and 0.43 (95% CI: 0.00-0.61), respectively. Patients were more likely to respond to CRT given previous response to IC (positive likelihood ratio = 1.6; 95% CI: 1.21-2.11) and less likely to respond to CRT if they failed to respond to IC (negative likelihood ratio = 0.16; 95% CI: 0.07-0.38). At 2 years, good response to IC was a statistically significant prognostic marker with a risk ratio of 1.35 (95% CI: 1.12-1.64). Conclusion Our data suggests that patients with poor IC response will have poorer response to CRT and should be directed to other modalities. In contrast, good IC response does not guarantee a favorable outcome to CRT; however, because these patients are likely to have better prognoses, they should be offered salvage therapies of curative intent despite treatment failure. Level of evidence NA. Laryngoscope, 128:1594-1601, 2018.

Background In out of hospital cardiac arrest (OHCA), the prognostic influence of conversion to shockable rhythms during resuscitation for initially non-shockable rhythms remains unknown. This study aimed to assess the relationship between initial and subsequent shockable rhythm and post-arrest survival and neurological outcomes after OHCA. Methodology This was a retrospective analysis of all OHCA cases collected from the Pan-Asian Resuscitation Outcomes Study (PAROS) registry in 7 countries in Asia between 2009 and 2012. We included OHCA cases of presumed cardiac etiology, aged 18-years and above and resuscitation attempted by EMS. We performed multivariate logistic regression analyses to assess the relationship between initial and subsequent shockable rhythm and survival and neurological outcomes. 2-stage seemingly unrelated bivariate probit models were developed to jointly model the survival and neurological outcomes. We adjusted for the clustering effects of country variance in all models. Results 40,160 OHCA cases met the inclusion criteria. There were 5356 OHCA cases (13.3%) with initial shockable rhythm and 33,974 (84.7%) with initial non-shockable rhythm. After adjustment of baseline and prehospital characteristics, OHCA with initial shockable rhythm (odds ratio/OR = 6.10, 95% confidence interval/CI = 5.06–7.34) and subsequent conversion to shockable rhythm (OR = 2.00,95%CI = 1.10–3.65) independently predicted better survival-to-hospital-discharge outcomes. Subsequent shockable rhythm conversion significantly improved survival-to-admission, discharge and post-arrest overall and cerebral performance outcomes in the multivariate logistic regression and 2-stage analyses. Conclusion Initial shockable rhythm was the strongest predictor for survival. However, conversion to subsequent shockable rhythm significantly improved post-arrest survival and neurological outcomes. This study suggests the importance of early resuscitation efforts even for initially non-shockable rhythms which has prognostic implications and selection of subsequent post-resuscitation therapy.

Background & objective(s) Obesity is a worldwide epidemic and a common medical condition associated with a variety of chronic diseases. Cereal beta-glucans are soluble fibers with potential health benefits. A number of randomized controlled trials (RCTs) have investigated the effect of cereal beta-glucan consumption on weight, but these results have not been summarized in a meta-analysis. The purpose of this study was to investigate the effect of cereal beta-glucan consumption on body weight, body mass index, waist circumference and a total energy intake. Methods Studies were identified using MEDLINE/PubMed, Scopus and Cochrane databases. Screening of relevant articles and references was carried out until December 2018. There were no language restrictions. This systematic review and meta-analysis was performed using the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results Twenty eligible studies were identified and analyzed. Our study found a significant reduction in body weight and body mass index (BMI) following beta-glucan consumption (weighted mean difference [WMD]: −0.77 kg, 95% CI: −1.49, −0.04) and (WMD: −0.62 kg/cm2, 95% CI: −1.04, −0.21), respectively. There was no significant effect on waist circumference and energy intake. A subgroup analysis showed that a beta-glucan dose of ≥ 4 g/day lead to an increase in energy intake. Conclusion The findings of this study indicates that cereal beta-glucan consumption seems to decrease body weight and BMI, but has no effect on waist circumference and energy intake.

Background Childbirth may cause the most severe pain some women experience in their lifetime. Epidural analgesia is an effective form of pain relief during labour and is considered to be the reference standard. Traditionally epidural analgesia has been delivered as a continuous infusion via a catheter in the epidural space, with or without the ability for the patient to supplement the analgesia received by activating a programmable pump to deliver additional top-up doses, known as patient-controlled epidural analgesia (PCEA). There has been interest in delivering maintenance analgesic medication via bolus dosing (automated mandatory bolus - AMB) instead of the traditional continuous basal infusion (BI); recent randomized controlled trials (RCTs) have shown that the AMB technique leads to improved analgesia and maternal satisfaction. Objectives To assess the effects of automated mandatory bolus versus basal infusion for maintaining epidural analgesia in labour. Search methods We searched CENTRAL, MEDLINE, Embase, the World Health Organization International Clinial Trials Registry Platform (WHO-ICTRP) and ClinicalTrials.gov on 16 January 2018. We screened the reference lists of all eligible trials and reviews. We also contacted authors of included studies in this field in order to identify unpublished research and trials still underway, and we screened the reference lists of the included articles for potentially relevant articles. Selection criteria We included all RCTs that compared the use of bolus dosing AMB with continuous BI for providing pain relief during epidural analgesia for labour in women. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: risk of breakthrough pain with the need for anaesthetic intervention; risk of caesarean delivery; risk of instrumental delivery. Secondary outcomes included: duration of labour; local anaesthetic consumption. We used GRADE to assess the certainty of evidence for each outcome. Main results We included 12 studies with a total of 1121 women. Ten studies enrolled healthy nulliparous women only and two studies enrolled healthy parous women at term as well. All studies excluded women with complicated pregnancies. There were variations in the technique of initiation of epidural analgesia. Seven studies utilized the combined spinal epidural (CSE) technique, and the other five studies only placed an epidural catheter without any intrathecal injection. Seven studies utilized ropivacaine: six with fentanyl and one with sufentanil. Two studies used levobupivacaine: one with sufentanil and one with fentanyl. Three used bupivacaine with or without fentanyl. The overall risk of bias of the studies was low. AMB probably reduces the risk of breakthrough pain compared with BI for maintaining epidural analgesia for labour (from 33% to 20%; risk ratio (RR) 0.60; 95% confidence interval (CI) 0.39 to 0.92, 10 studies, 797 women, moderate-certainty evidence). AMB may make little or no difference to the risk of caesarean delivery compared to BI (15% and 16% respectively; RR 0.92; 95% CI 0.70 to 1.21, 11 studies, 1079 women, low-certainty evidence). AMB may make little or no difference in the risk of instrumental delivery compared to BI (12% and 9% respectively; RR 0.75; 95% CI 0.54 to 1.06, 11 studies, 1079 women, low-certainty evidence). There is probably little or no difference in the mean duration of labour with AMB compared to BI (mean difference (MD) −10.38 min; 95% CI −26.73 to 5.96, 11 studies, 1079 women, moderate-certainty evidence). There is probably a reduction in the hourly consumption of local anaesthetic with AMB compared to BI for maintaining epidural analgesia during labour (MD −1.08 mg/h; 95% CI −1.78 to −0.38, 12 studies, 1121 women, moderate-certainty evidence). Five out of seven studies reported an increase in maternal satisfaction with AMB compared to BI for maintaining epidural analgesia for labour; however, we did not pool these data due to their ordinal nature. Seven studies reported Apgar scores, though there was significant heterogeneity in reporting. None of the studies showed any significant difference between Apgar scores between groups. Authors' conclusions There is predominantly moderate-certainty evidence that AMB is similar to BI for maintaining epidural analgesia for labour for all measured outcomes and may have the benefit of decreasing the risk of breakthrough pain and improving maternal satisfaction while decreasing the amount of local anaesthetic needed.

Background Many individuals leave costly inpatient detoxification programs prematurely because of the severity of withdrawal symptoms experienced. In the absence of opioid-assisted detoxification in Singapore, diazepam is used to manage withdrawal. However since diazepam is addictive, there is a need to explore the effectiveness of alternative medications. Design and procedures The study aimed to examine the safety and efficacy of lofexidine, a non-opiate, non-addictive, alpha 2-adrenergic agonist in assisting opioid detoxification in Singapore, using a randomized, double-blind, investigator-initiated placebo-controlled trial comparing lofexidine against diazepam. Opioid dependent patients (n = 111) were randomized to receive a 10-day course of lofexidine (n = 56) or diazepam (n = 55). The primary endpoint was the Objective Opioid Withdrawal Scale (OOWS) score on days 3 and 4 and secondary outcomes were the Short Opioid Withdrawal Scale (SOWS) score, program retention rate, and ratings of opiate craving. Main findings The OOWS, SOWS and opiate craving scores were consistently lower in the lofexidine group relative to the diazepam group over the 14-day study period; however no statistically significant differences were found on days 3 and 4 (peak withdrawal). Changes in mean pupil size during peak withdrawal were significantly smaller in the lofexidine group and more participants in the lofexidine group remained in treatment and completed detoxification. Conclusions Lofexidine was at least as effective as diazepam in reducing the opioid withdrawal syndrome and increased treatment retention. In addition to its non-addictive and non-abuse properties, lofexidine has several clinical advantages over diazepam. The use of lofexidine is recommended when opioid-assisted medications are not available.

The Pan Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network (CRN) was established in collaboration with emergency medical services (EMS) agencies and academic centers in Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and UAE-Dubai and aims to report out-of-hospital cardiac arrests (OHCA) and provide a better understanding of OHCA trends in Asia.This is a prospective, international, multi-center cohort study of OHCA across the Asia-Pacific. Each participating country provided between 1.5 and 2.5 years of data from January 2009 to December 2012. All OHCA cases conveyed by EMS or presenting at emergency departments were captured. 66,780 OHCA cases were submitted to the PAROS CRN; 41,004 cases were presumed cardiac etiology. The mean age OHCA occurred varied from 49.7 to 71.7 years. The proportion of males ranged from 57.9% to 82.7%. Proportion of unwitnessed arrests ranged from 26.4% to 67.9%. Presenting shockable rhythm rates ranged from 4.1% to 19.8%. Bystander cardiopulmonary resuscitation (CPR) rates varied from 10.5% to 40.9%, however1.0% of these arrests received bystander defibrillation. For arrests that were with cardiac etiology, witnessed arrest and VF, the survival rate to hospital discharge varied from no reported survivors to 31.2%. Overall survival to hospital discharge varied from 0.5% to 8.5%. Survival with good neurological function ranged from 1.6% to 3%.Survival to hospital discharge for Asia varies widely and this may be related to patient and system differences. This implies that survival may be improved with interventions such as increasing bystander CPR, public access defibrillation and improving EMS.

Many trials incorporate induction chemotherapy (IC) in selecting for organ preservation in head and neck squamous cell carcinomas (HNSCC). However, few studies examine IC response in predicting for chemoradiation therapy (CRT) response. This meta-analysis aims to determine the predictive accuracy of IC for subsequent response to CRT and overall survival (OS).Medline, EMBASE, Cochrane register.A systematic search identified studies from database inception to October 2016 that used IC prior to CRT as definitive treatment for advanced HNSCC. The sensitivities and specificities of IC response predicting for complete CRT response were calculated, and the results were pooled in a summary receiver operating curve. One-, 2- and 5-year OS data were extracted.Seven studies (n = 423 patients) were analyzed for response and six (n = 439) for OS. Pooled median sensitivity and specificity of IC response predicting CRT response were 0.95 (95% confidence interval [CI]: 0.72-0.98) and 0.43 (95% CI: 0.00-0.61), respectively. Patients were more likely to respond to CRT given previous response to IC (positive likelihood ratio = 1.6; 95% CI: 1.21-2.11) and less likely to respond to CRT if they failed to respond to IC (negative likelihood ratio = 0.16; 95% CI: 0.07-0.38). At 2 years, good response to IC was a statistically significant prognostic marker with a risk ratio of 1.35 (95% CI: 1.12-1.64).Our data suggests that patients with poor IC response will have poorer response to CRT and should be directed to other modalities. In contrast, good IC response does not guarantee a favorable outcome to CRT; however, because these patients are likely to have better prognoses, they should be offered salvage therapies of curative intent despite treatment failure.NA. Laryngoscope, 128:1594-1601, 2018.

Hepatocellular carcinoma (HCC) is one of the most commonly diagnosed cancers worldwide. Majority of patients with HCC are diagnosed in the advanced stages of disease and hence they are only suitable for palliative therapy. TACE (transarterial chemoembolization) is the most commonly used treatment for unresectable HCC. It is however unclear if TACE improves the quality of life (QoL) in patients with HCC. The aim of this review is to evaluate the impact of TACE on QoL of HCC patients.

BackgroundVancomycin is the standard first-line treatment for methicillin-resistant Staphylococcus aureus bacteremia. However, recent consensus guidelines recommend that clinicians consider using alternative agents such as daptomycin when the vancomycin minimum inhibitory concentration is greater than 1 ug/ml. To date however, there have been no head-to-head randomized trials comparing the safety and efficacy of daptomycin and vancomycin in the treatment of such infections. The primary aim of our study is to compare the efficacy of daptomycin versus vancomycin in the treatment of bloodstream infections due to methicillin-resistant Staphylococcus aureus isolates with high vancomycin minimum inhibitory concentrations (greater than or equal to 1.5 ug/ml) in terms of reducing all-cause 60-day mortality.Methods/DesignThe study is designed as a multicenter prospective open label phase IIB pilot randomized controlled trial. Eligible participants will be inpatients over 21-years-old with a positive blood culture for methicillin-resistant Staphylococcus aureus with vancomycin minimum inhibitory concentration of greater than or equal to 1.5ug/ml. Randomization into intervention or active control arms will be performed with a 1:1 allocation ratio. We aim to recruit 50 participants over a period of two years. Participants randomized to the active control arm will receive vancomycin dose-while those randomized to the intervention arm will receive daptomycin. Participants will receive a minimum of 14 days study treatment.The primary analysis will be conducted on the intention-to-treat principle. The Fisher’s exact test will be used to compare the 60-day mortality rate from index blood cultures (primary endpoint) between the two treatment arms, and the exact two-sided 95% confidence interval will be calculated using the Clopper and Pearson method. Primary analysis will be conducted using a two sided alpha of 0.05.DiscussionIf results from this pilot study suggest that daptomycin shows significant efficacy in the treatment of bloodstream infections due to methicillin-resistant Staphylococcus aureus isolates with high vancomycin minimum inhibitory concentrations, we aim to proceed with a larger scale confirmatory study. This would help guide clinicians and inform practice guidelines on the optimal treatment for such infections.Trial registrationThe trial is listed on clinicaltrials.gov (NCT01975662, date of registration: 29 October 2013).