Evidence-based Medicine Level Research Articles

Cost Analysis in Shoulder Surgery: A Systematic Review.

Background:Cost analysis studies in medicine were uncommon in the past, but with the rising importance of financial considerations, it has become increasingly important to use available resources most efficiently.Purpose:To analyze the current state of cost-effectiveness analyses in shoulder surgery.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review of the current literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All full economic analyses published since January 1, 2010 and including the terms “cost analysis” and “shoulder” were checked for usability. The methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine levels of evidence and established health economic criteria (Quality of Health Economic Studies [QHES] instrument).Results:A total of 34 studies fulfilled the inclusion criteria. Compared with older studies, recent studies were of better quality: one level 1 study and eight level 2 studies were included. The mean QHES score was 87 of 100. The thematic focus of most studies (n = 13) was rotator cuff tears, with the main findings as follows: (1) magnetic resonance imaging is a cost-effective imaging strategy, (2) primary (arthroscopic) rotator cuff repair (RCR) with conversion to reverse total shoulder arthroplasty in case of failure is the most cost-effective strategy, (3) the platelet-rich plasma augmentation of RCR seems not to be cost-effective, and (4) the cost-effectiveness of double-row RCR remains unclear. Other studies included shoulder instability (n = 3), glenohumeral osteoarthritis (n = 3), proximal humeral fractures (n = 4), subacromial impingement (n = 4), and other shoulder conditions (n = 7).Conclusion:Compared with prior studies, the quality of recently available studies has improved significantly. Current studies could help decision makers to appropriately and adequately allocate resources. The optimal use of financial resources will be of increasing importance to improve medical care for patients. However, further studies are still necessary.

The evidence for switching dibenzazepines in people with epilepsy.

The dibenzazepines particularly carbamazepine are associated with known adverse effects (AEs) and drug to drug interactions. Eslicarbazepine acetate (ESL) is structurally distinct from other members of the dibenzazepine family and has the advantage of once daily dosing. Observational and trial data report successful switching from older dibenzazepines to ESL. The evidence base for doing so is unclear and not standardized. This is a literature review following the PRISMA scoping guidelines identifying the evidence of switching dibenzazepines. Transition methods, ratios, tolerance to change, adverse effects and retention post-change were evaluated. Study quality was assessed using the Oxford Centre for Evidence Based Medicine levels of evidence. Seven studies investigated the outcome of transition between carbamazepine and or oxcarbazepine to ESL, with specific data on the transition dose ratio and scheduling. The available data suggest that the overnight transition between oxcarbazepine and ESL in a 1:1 ratio (most common) is generally well tolerated with high retention rates. The transition showed improvement in adverse events associated with oxcarbazepine across a variety of domains. Almost 60% transitioned because of adverse events experienced no further symptoms at 12months. There is less data on the transition from carbamazepine to ESL. The evidence available suggests an overnight transition in the ratio of 1:1.3-1.5. The retention rate following transition from carbamazepine to ESL was 69% (follow-up of 4months) with almost half of those transitioned because of adverse events experiencing no further symptoms. There is Grade C evidence available to help guide clinicians in the transition.

Factors Influencing "Face" in People With Dementia: A Systematic Review of the Literature

Face (self-esteem) is an issue that involves socially endowed status, identity roles, and self-image management and maintenance. People with dementia and their family members often experience social isolation due to diminished self-image, which affects disease progression. Better understanding the factors that influence the self-image of people with dementia may promote the ability of caregivers to maintain self-image and promote public understanding and empathy toward people with dementia. The aim of this study was to explore the factors influencing self-image in people with dementia using a systematic review of the literature. A systematic review was used. Articles were retrieved from electronic databases including PubMed, CINAHL, Airiti Library, and Cochrane Library. The following keywords and MeSH terms were used to search for articles on dementia, face, self-esteem, respect, and self-concept. A total of 3,050 articles published prior to September 2018 that matched the search criteria were extracted. After screening the topics, deleting repetitions, and doing critical appraisals, eight articles were selected for analysis. Research quality was appraised using the Joanna Briggs Institute and the Melnyk and Fineout-Overholt for Evidence-Based Medicine Level of Evidence. Two themes related to the factors influencing self-image in people with dementia were extracted from the selected articles. The first theme was "loss of self-identity". As people with dementia gradually lose their cognitive function and memory ability, they are increasingly incapable of handling and managing their current role tasks. The second theme was "negative public perception". The public believes that people with dementia are at risk to others and that their behaviors are unpredictable, resulting in the deprivation of the rights to which people with dementia are entitled. Because of disease progression, people with dementia gradually lose their self-identity and become unable to perform their life-role tasks. This is accompanied by negative perceptions of the disease among the public, which, in turn, damages the self-image of people with dementia and their families. The results of this review may provide a reference for caregivers planning future person-centered care approaches for people with dementia. In addition, these results may help facilitate the establishment of a more friendly environment for people with dementia in both public and private spaces.

Voice and Swallowing Outcomes Following Airway Reconstruction in Adults: A Systematic Review.

ObjectivesLaryngotracheal stenosis is a rare condition characterized by upper airway narrowing. Reconstructive surgical treatment aims to manage the area of stenosis to improve dyspnea and can impact voice and swallowing function. This article critically evaluates the literature about voice and swallowing outcomes in adults with laryngotracheal stenosis who undergo reconstructive surgery.Study DesignSystematic review.MethodsSix databases were searched for articles referring to voice and swallowing outcome measures following reconstruction procedures in adults with laryngotracheal stenosis. Screening was completed using predefined inclusion/exclusion criteria.ResultsA total of 143 abstracts were reviewed, with 67 articles selected for full‐text review. Twenty studies met the inclusion criteria. Data extraction was completed with the Strengthening Reporting of Observational Studies in Epidemiology checklist with Oxford Centre for Evidence‐Based Medicine Level of Evidence used to indicate quality. Risk of bias was assessed using the Risk of Bias Assessment Tool for Non‐Randomized Studies. All studies scored a high risk of bias in at least one of the domains. Selection and timing of outcome measures was heterogenous, and there was limited information provided about rationale or reliability.ConclusionsThe literature acknowledges the importance of voice and swallowing outcomes following airway reconstruction. Studies show correlation between reconstructive surgery and deterioration in vocal function; there are no consistent data about swallowing outcomes. The lack of a core outcome measures set for adults with laryngotracheal stenosis limits the findings of this review. Further research is needed to establish clear criteria for robust and clinically relevant outcome measurement. Laryngoscope, 131:146–157, 2021

Salivary biomarkers for diagnosis of systemic diseases and malignant tumors. A systematic review

Background Saliva evaluation could be a possible alternative to blood and/or tissue analyses, for researching specific molecules associated to the presence of systemic diseases and malignancies. The present systematic review has been designed in order to answer to the question “are there significant associations between specific salivary biomarkers and diagnosis of systemic diseases or malignancies?”. Material and Methods The Preferred Reporting Item for Systematic Reviews and Meta-analysis (PRISMA) statement was used to guide the review. The combinations of “saliva” and “systemic diseases” or “diagnosis” or “biomarkers” or “cancers” or “carcinoma” or “tumors”, were used to search Medline, Scopus and Web of Science databases. Endpoint of research has been set at May 2019. Studies were classified into 3 groups according to the type of disease investigated for diagnosis: 1) malignant tumors; 2) neurologic diseases and 3) inflammatory/metabolic/cardiovascular diseases. Assessment of quality has been assigned according to a series of questions proposed by the National Institute of Health. Level of evidence was assessed using the categories proposed in the Oxford Center for Evidence-Based medicine (CEMB) levels for diagnosis (2011). Results Seventy-nine studies met the inclusion and exclusion criteria. Fifty-one (64%) investigated malignant tumors, 14 (17.5%) neurologic and 14 (18.5%) inflammatory/cardiovascular/metabolic diseases. Among studies investigating malignant tumors, 12 (23.5%) were scored as “good” and 11 of these reported statistically significant associations between salivary molecules and pathology. Two and 5 studies were found to have a good quality, among those evaluating the association between salivary biomarkers and neurologic and inflammatory/metabolic/cardiovascular diseases, respectively. Conclusions The present systematic review confirms the existence of some “good” quality evidence to support the role of peculiar salivary biomarkers for diagnosis of systemic diseases (e.g. lung cancer and EGFR). Key words:Salivary diagnostics, biomarkers, systemic diseases, malignant tumors, early diagnosis.

Virtual reality in spinal endoscopy: a paradigm shift in education to support spine surgeons.

Minimally invasive spine surgery (MISS) and endoscopic spine surgery have continually evolving indications in the cervical, thoracic, and lumbar spine. Endoscopic spine surgery entails treatment of disc disease, stenosis, spondylolisthesis, radiculopathy, and deformity. MISS involves complex motor skills in regions of variable anatomy. Simulator use has been proposed to aid in training and skill retention, preoperative planning, and intraoperative use. A systematic review of five databases was performed for publications pertaining to the use of virtual (VR), augmented (AR), and mixed (MR) reality in MISS and spinal endoscopic surgery. Qualitative data analysis was undertaken with focus of study design, quality, and reported outcomes. Study quality was assessed using the Medical Education Research Quality Instrument (MERSQI) score and level of evidence (LoE) by a modified Oxford Centre for Evidence-Based Medicine (OCEBM) level for simulation in medicine. Thirty-eight studies were retained for data collection. Studies were of intervention-control, clinical application, and pilot or cross-sectional design. Identified articles illustrated use of VR, AR, and MR in all study designs. Procedures included pedicle cannulation and screw insertion, vertebroplasty, kyphoplasty, percutaneous transforaminal endoscopic discectomy (PTED), lumbar puncture and facet injection, transvertebral anterior cervical foraminotomy (TVACF) and posterior cervical laminoforaminotomy. Overall MERSQI score was low-to-medium [M =9.71 (SD =2.60); range, 4.5-13.5], and LoE was predominantly low given the number of purely descriptive articles, or low-quality randomized studies. The current scope of VR, AR, and MR surgical simulators in MISS and spinal endoscopic surgery was described. Studies demonstrate improvement in technical skill and patient outcomes in short term follow-up. Despite this, overall study quality and levels of evidence remain low. Cohesive study design and reporting with focus on transfer validity in training scenarios, and patient derived outcome measures in clinical studies are required to further advance the field.

Clinical indications for image guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part III, nerves of the upper limb.

Image-guided interventional procedures of the nerves are commonly performed by physicians from different medical specialties, although there is a lack of clinical indications for these types of procedures. This Delphi-based consensus provided a list of indications on image-guided interventional procedures for nerves of the upper limb based on updated published evidence. An expert panel of 45 members of the Ultrasound and Interventional Subcommittees of the ESSR participated in this Delphi-based consensus study. After revision of the published papers on image-guided interventional procedures for nerves of the upper limb updated to September 2018, the experts drafted a list of statements according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus on statements regarding clinical indications was considered as strong when more than 95% of experts agreed, and broad if more than 80% agreed. Ten statements were drafted on procedures for nerves of the upper limb. Only two statements reached the highest level of evidence (ultrasound guidance is a safe and effective method for brachial plexus block; ultrasound-guided non-surgical approaches are safe and effective methods to treat carpal tunnel syndrome in the short term, but there is sparse evidence on the mid- and long-term effectiveness of these interventions). Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%). This Delphi-based consensus study reported poor evidence on image-guided interventional procedures for nerves of the upper limb. Sixty percent of statements on clinical indications provided by the expert board reached a strong consensus. • An expert panel of the ESSR provided 10 evidence-based statements on clinical indications for image-guided interventional procedures for nerves of the upper limb • Two statements reached the highest level of evidence • Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%).

The Use of Platelet-Rich Plasma for Conservative Treatment of Partial Ulnar Collateral Ligament Tears in Overhead Athletes: A Critically Appraised Topic.

Clinical Scenario: Rates of ulnar collateral ligament (UCL) injuries continue to rise in overhead athletes of all ages. Surgical interventions require minimally 6 months and up to 2 years of rehabilitation. Younger athletes and those with partial tears have seen positive results with conservative treatment approaches. Platelet-rich plasma (PRP) continues to be studied with various orthopedic injuries, and its use has the potential to improve return-to-sport rates and reduce recovery time. Focused Clinical Question: Do PRP injections improve conservative treatment outcomes in overhead athletes with partial tears of the UCL compared with conservative treatment alone regarding return to participation? Summary of Search, Best Evidence Appraised, and Key Findings: A literature search was performed to locate all studies investigating outcomes when PRP is included in a conservative treatment program for overhead athletes with partial UCL tears. Three case series qualified and were reviewed. Clinical Bottom Line: Current evidence suggests that including PRP in a conservative treatment program can improve outcomes in overhead athletes with partial UCL tears. Athletes whose treatment included PRP show higher return-to-competition rates and shorter recovery times compared with athletes who used rehabilitation alone. Athletes with grade-1 and proximal-based grade-2 injuries returned to competition at rates comparable with athletes undergoing surgical intervention. For optimal conservative management outcomes, PRP injections should be recommended for treatment of partial UCL tears. Strength of Recommendation: The studies qualifying for inclusion are level 4 evidence based on the 2011 Oxford Centre for Evidence-Based Medicine levels of evidence. The studies are well designed and show consistent results, but higher level studies need to demonstrate similar results to improve the body of evidence. The strength of recommendation is C.

A Critically Appraised Topic on the Tuck Jump Assessment: Does the Tuck Jump Assessment Demonstrate Interrater and Intrarater Reliability in Healthy Individuals?

Clinical Scenario: Lower-extremity injuries in the United States costs millions of dollars each year. Athletes should be screened for neuromuscular deficits and trained to correct them. The tuck jump assessment (TJA) is a plyometric tool that can be used with athletes. Clinical Question: Does the TJA demonstrate both interrater and intrarater reliability in healthy individuals? Summary of Key Findings: Four of the 5 articles included in this critically appraised topic showed good to excellent reliability; however, caution should be taken in interpreting these results. Although composite scores of the TJA were found to be reliable, individual flaws do not demonstrate reliability on their own, with the exception of knee valgus at landing. Aspects of the TJA itself, including rater training, scoring system, playback speed, volume, and number of views allotted, need to be standardized before the reliability of this clinical assessment can be further researched. Clinical Bottom Line: The TJA has shown varying levels of reliability, from poor to excellent, for both interrater and intrarater reliability, given current research. Strength of Recommendation: According to the Centre for Evidence Based Medicine levels of evidence, there is level 2b evidence for research into the reliability of the TJA. This evidence has been demonstrated in elite, adolescent, and college-level athletics in the United Kingdom, Spain, and the United States. The recommendation of level 2b was chosen because these studies utilized cohort design for interrater and intrarater reliability across populations. An overall grade of B was recommended because there were consistent level 2 studies.

Treatment of calcinosis cutis in systemic sclerosis and dermatomyositis: A review of the literature

We have limited data on the treatment of calcinosis cutis associated with systemic sclerosis and dermatomyositis. To assess the efficacy and tolerance of available treatments for calcinosis cutis based on previously published studies. We performed a systematic review of studies published in Medline, Embase, and the Cochrane library during 1980-July 2018. The strength of clinical data was graded according to the modified Oxford Centre for Evidence-Based Medicine levels of evidence. In all, 30 studies (288 patients) were included. Eleven therapeutic classes, surgery, and physical treatments were identified as potential treatment options for calcinosis cutis. On the basis of results of a small randomized controlled trial and 4 retrospective studies, low-dose warfarin should not be used for calcinosis cutis (level IB evidence). The results of several studies suggest diltiazem and bisphosphonates might be useful treatment options (level IV). Considering biologic therapies, rituximab has shown promising results in treating both dermatomyositis and systemic sclerosis, whereas tumor necrosis factor inhibitors might be useful for treating juvenile dermatomyositis (level IV). Intralesional sodium thiosulfate might be a promising alternative (level IV). Few included studies had a high level of evidence. This study highlights the efficacy and tolerance profiles of available treatments for calcinosis cutis, with a focus on level of evidence.

Risk of Adverse Vascular Events in Patients with Malignant Glioma Treated with Bevacizumab Plus Irinotecan: A Systematic Review and Meta-Analysis

Bevacizumab plus irinotecan is a new beneficial chemotherapy strategy for patients with malignant glioma. The purpose of this systematic review and meta-analysis was to comprehensively assess the risk of adverse vascular events in adults with malignant glioma treated with bevacizumab plus irinotecan. The Cochrane Library, Embase and PubMed were searched, and relevant trials were identified up to June 2018. Two investigators screened all titles and abstracts for possible inclusion and extracted data independently. Six studies were included, and 5 of them in the control group using bevacizumab alone or bevacizumab with temozolomide. Three systems were used to assess the quality of evidence and the level of recommendation. The Oxford Centre for Evidence-Based Medicine Levels of Evidence (2009) system was used to classify the evidence into 5 levels (classes I-V). The star system from the Newcastle-Ottawa Scale was used to assess methodological quality. The GRADE profiler was used to evaluate the overall body of evidence. Our data show that bevacizumab plus irinotecan therapy does not significantly affect the risk of systemic adverse events (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.43-3.18). Patients treated with bevacizumab plus irinotecan had a similar risk of hematotoxicity (OR, 1.06; 95% CI, 0.26-4.38), thrombocytopenia (OR, 1.07; 95% CI, 0.25-4.63), and hypertension (OR,1.34; 95% CI, 0.28-6.36) compared with the control group (those treated without irinotecan). Thrombosis occurred more frequently in patients treated with bevacizumab plus irinotecan compared with the control group (OR, 3.23; 95% CI, 1.47-7.12). The risk of systemic adverse events was not significantly different between patients with malignant glioma treated with bevacizumab plus irinotecan and the control group. The risks of hematotoxicity, thrombocytopenia, and hypertension were similar in the 2 groups. The risk of thrombosis was higher in patients treated with bevacizumab plus irinotecan. Monitoring for thrombosis and administering anticoagulant therapy as necessary merit promotion for patients with malignant glioma receiving treatment with bevacizumab plus irinotecan.

Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM): Introduction of a Strength-of-evidence Approach Based on a Methodological Systematic Review (P13-023-19)

ObjectivesTo characterize strength of evidence (SOE) tools in recent use, identify their application to lifestyle medicine, and to assess implications of the findings. MethodsThe search strategy was created in PubMed and modified as needed for four additional databases: Embase, AnthropologyPlus, PsycINFO, and Ageline. Systematic reviews and meta-analyses were included if they used a specified SOE tool. There were seven interventions or exposures of interest: diet, exercise, stress, social relationships/support, addiction(s), sleep, and genetic-based factors with potential for epigenetic modification. Data was collected for each SOE tool and summarized in narrative form with regard to the conditions necessary for assigning the highest SOE grading and treatment of prospective cohort studies within each SOE rating framework was qualitatively summarized. The expert panel convened to discuss the findings and their implication for assessing evidence in the domain of lifestyle medicine. ResultsA total of 15 unique tools were identified. All tools rated SOE using three to five levels of evidence, with the exception of one that uses two levels. Ten were tools developed and used by governmental agencies or other equivalent professional bodies and were applicable in a variety of settings. Five require consistent results from RCTs of high quality to award the highest rating of evidence. Except for the Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence, specific mention of cohort studies was made only to note their secondary contribution to overall SOE as compared to RCTs, unless RCTs were methodologically flawed. A new construct, Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM), was developed to evaluate SOE for the lifetime effects of health behaviors. ConclusionsThe best metric for SOE varies with research questions and the methods required to answer them. Assessment of evidence relevant to lifestyle medicine requires a potential adaptation of SOE approaches when outcomes and/or exposures obviate exclusive or preferential reliance on RCTs. Funding SourcesSupported by the American College of Lifestyle Medicine, with additional funding from the Centers for Disease Control, grant 5U48DP005023–04. Supporting Tables, Images and/or Graphs▪

Cross-cultural Comparison of Pharmacy Students’ Attitudes, Knowledge, Practice, and Barriers Regarding Evidence-based Medicine

Objective. To explore cultural influences on US and Japanese pharmacy students' evidence-based medicine (EBM) attitudes, knowledge, and behavior. Methods. A cross-sectional study was conducted using a self-administered survey. Senior students in one pharmacy school in the United States and two pharmacy schools in Japan were invited to complete a 33-item survey instrument. Results. Students in both countries reported having positive attitudes and understanding of EBM concepts. In their self-evaluation, American students rated their current EBM practice, EBM skills, and access to EBM resources higher than Japanese students rated themselves in these areas. The most common barriers to EBM for American students were lack of time (84.5%), lack of statistical knowledge (63.9%), and lack of critical appraisal skills (53.1%). The most common barriers to EBM for Japanese students were lack of training (92.6%), lack of clinical knowledge (90.4%), and lack of opportunity (88.8%). Conclusion. Although barriers to implementing EBM and confidence levels in using EBM differed between US and Japanese pharmacy students, both cohorts recognized EBM as an important skillset for the pharmacy profession. Culturally specific approaches to teaching EBM to pharmacy students are needed to improve EBM use in practice.

Herbal medicines and pregnancy: A narrative review and anaesthetic considerations.

The use of herbal medicines by pregnant women varies among different countries, ranging from 4.3% in Sweden to 69% in Russia. The aim of this narrative review is to evaluate the benefits and safety of common herbal medicines used during pregnancy. A systematic literature search (from 1995 to February 2018) was performed using a variety of electronic databases. The levels of evidence of the clinical studies were graded using the Oxford Centre for Evidence-Based Medicine levels of evidence guidelines. From the 736 articles retrieved, 69 articles were used for this review. Ginger has been investigated extensively and has been consistently found to decrease nausea and vomiting associated with pregnancy (Level 2). There is insufficient evidence concerning the efficacy of other herbal medicines such as garlic, cranberry and raspberry in pregnancy (Level 3–4). Much of the literature is based on case reports with limited pharmacodynamic/kinetic studies. There are no clear data on the adverse herb–drug interactions during anaesthesia. As the risks of these interactions are unknown, it would be prudent for anaesthetists to explicitly ask their patients about their use of herbal medicines before surgery and prior to labour and birth. The European Society of Anaesthesiology and American Society of Anesthesiologists recommend that patients cease taking herbal medicines two weeks before surgery.

Proprioceptive Training and Outcomes of Patients With Knee Osteoarthritis: A Meta-Analysis of Randomized Controlled Trials.

To describe the effects of proprioceptive training on pain, stiffness, function, and functional test outcomes among patients with knee osteoarthritis (OA). All studies completed from 1946 to 2017 were obtained from 4 databases (PubMed, MEDLINE, CINAHL, and SPORTDiscus). Three reviewers independently identified appropriate studies and extracted data. Methodologic quality and level of evidence were assessed using the Physiotherapy Evidence Database scale and Oxford Centre for Evidence-Based Medicine guidelines. The standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated for pain, stiffness, function, and functional test outcomes. Seven randomized controlled trials involving 558 patients with knee OA met the inclusion criteria. The selected studies had Physiotherapy Evidence Database scores of 6 to 8. All randomized controlled trials had an Oxford Centre for Evidence-Based Medicine level of evidence of 2. Meta-analysis of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale (SMD = -0.56; 95% CI = -1.06, -0.07; P = .026), function subscale (SMD = -0.40; 95% CI = -0.59, -0.21; P < .001), and non-WOMAC walking speed test (SMD = -1.07; 95% CI = -2.12, -0.01; P = .048) revealed that proprioceptive training had significant treatment effects. Proprioceptive training was not associated with reductions in WOMAC stiffness subscale scores and did not improve non-WOMAC get-up-and-go scores. Proprioceptive training effectively promoted pain relief and completion of functional daily activity among patients with knee OA and should be included in rehabilitation programs. Stiffness and other mobility measures were unchanged after proprioceptive training. Modified proprioceptive training programs are needed to target stiffness and improve additional physical function domains.

Immediate Reconstruction of Complex Spinal Wounds Is Associated with Increased Hardware Retention and Fewer Wound-related Complications: A Systematic Review and Meta-analysis.

Patients undergoing surgeries involving extensive posterior spine instrumentation and fusion often have multiple risk factors for wound healing complications. We performed a systematic review and meta-analysis of the available evidence on immediate (proactive/prophylactic) and delayed (reactive) spinal wound reconstruction. We hypothesized that immediate soft-tissue reconstruction of extensive spinal wounds would be associated with fewer postoperative surgicalsite complications than delayed reconstruction. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a PubMed database search was performed to identify English-language, human-subject literature published between 2003 and 2018. Data were summarized, and the pooled prevalence of various wound complications was calculated, weighted by study size, using the generic inverse variance method. A subgroup analysis of all studies with a comparison group (Oxford Centre for Evidence-based Medicine level 3 or better) was performed, and Forest plots were created. The database search yielded 16 articles including 828 patients; 428 (51.7%) received an immediate spinal wound reconstruction and 400 (48.3%) had a delayed reconstruction. Spinal neoplasm was the most common index diagnosis. Paraspinous muscle flap reconstruction was performed in the majority of cases. Pooled analysis of all studies revealed immediate reconstruction to be associated with decreased rates of overall wound complications (28.5% versus 18.8%), hardware loss (10.7% versus 1.8%), and wound infections (10.7% versus 7.6%) compared with delayed reconstruction. Immediate soft-tissue reconstruction of high-risk spinal wounds is associated with fewer wound healing complications and increased hardware retention.

Prevalence of cervical HPV infection in women with systemic lupus erythematosus: A systematic review and meta-analysis.

The objectives of this systematic review and meta-regression were: 1) to compare the prevalence of cervical HPV infection between SLE patients and healthy controls and 2) to evaluate the relationship between cervical HPV infection and traditional and SLE-related risk factors for cervical HPV infection in these patients. We conducted a systematic literature review (PubMed, Cochrane Library, Embase, Virtual Health Library and SciELO databases) following PRISMA guidelines and using meta-regression to investigate the pooled prevalence of cervical HPV infection in adult women with SLE. The articles included were independently evaluated by two investigators who extracted information on study characteristics, defined outcomes, risk of bias and summarized strength of evidence [Quality of evidence using the Oxford Centre for evidence-based medicine (EBM) Levels of Evidence]. Using meta-regression, we further analyzed whether factors such as multiple sexual partners and immunosuppressive therapy were associated with HPV prevalence. We evaluated the quality of evidence included using the Oxford Centre for EBM levels of evidence. Pooled odds ratios (ORs) and 95% confidence intervals (CI) were calculated for studies providing data on HPV prevalence in women with SLE and in healthy controls. A total of 687 articles were identified; 9 full-text articles examining the prevalence of cervical HPV infection in SLE women were included, comprising 751 SLE women. Eight studies employed PCR using general primers. The HPV prevalence varied from 3.1% to 80.7%. In the random effects meta-analysis, the pooled prevalence of cervical HPV infection in SLE vs. controls was 34.15% (95% CI: 19.6%-52.5%) vs. 15.3% (95% CI 0.79-27.8%), OR = 2.87 (95% CI: 2.20-3.76) p < .0001, with large between-study heterogeneity (I2 = 95.4%). When only SLE women were evaluated, meta-regression showed no significant differences between patients with and without a background of multiple sexual partners and any immunosuppressive therapy. In addition, the prevalence of cervical HPV infection did not significantly differ between SLE patients on azathioprine or cyclophosphamide. This meta-analysis suggests that the prevalence of cervical HPV infection is higher in SLE women than in healthy controls. However, multiple sexual partners and any immunosuppressive therapy or specific immunosuppressive treatment (azathioprine and cyclophosphamide) were not associated with the prevalence of cervical HPV infection.

Canadian Urological Association Best Practice Report: Diagnosis and management of radiation-induced hemorrhagic cystitis.

Methodology A comprehensive review of studies examining radiation-induced hemorrhagic cystitis was performed using PubMed, Medline, and the Cochrane Library database. The bibliographies of relevant articles were searched to avoid exclusion of meaningful articles. Where available, focus was given to systematic reviews and comparative studies; however, due to a lack of high-quality evidence, case series were included and made up the majority of articles included. All articles were reviewed using the evidence-based medicine levels, with a modified Oxford grading system for recommendations.

The Effect of Age of Initiation of Cannabis Use on Psychosis, Depression, and Anxiety among Youth under 25 Years

This study was conducted to review the current state of evidence on the association between age of initiation of cannabis use and symptoms of psychosis, depression, or anxiety among youth under 25 years of age. We conducted a systematic review of articles published prior to March 2018 by searching OVID MEDLINE, PsycINFO, EMBASE, and the references of included studies. We included comparative studies (cohort, case-control, cross-sectional) that reported on cannabis use in persons <25 years of age (exposure) and symptoms of psychosis, depression, or anxiety (outcome). We narratively synthesized the studies according to design (cohort, etc.) and psychiatric outcome. We used the Newcastle-Ottawa Scale to assess risk of bias. Of the 534 citations identified through the literature search, 23 met the eligibility criteria and were included in this review. With psychosis as the outcome, all except one study found that earlier cannabis use was generally associated with higher risks. With depression/anxiety as the outcome, 6 of the 11 included studies reported findings indicating that earlier use of cannabis was linked to higher symptom levels. In persons <25 years old, greater cannabis use is associated with more psychological symptoms, especially among those with a predisposition or existing vulnerability to such outcomes (Oxford Centre for Evidence-Based Medicine level 3 or 4). Policy makers need to consider the adverse effects of cannabis use in youth when planning a public health approach to cannabis legalization.

Supratotal resection in glioma: a systematic review.

Emerging evidence suggests survival benefit from resection beyond all MRI abnormalities present on T1-enhanced and T2‒fluid attenuated inversion recovery (FLAIR) modalities in glioma (supratotal resection); however, the quality of evidence is unclear. We addressed this question via systematic review of the literature. EMBASE, MEDLINE, Scopus, and Web of Science databases were queried. Case studies, reviews or editorials, non-English, abstract-only, brain metastases, and descriptive works were excluded. All others were included. Three hundred and nine unique references yielded 41 studies for full-text review, with 7 included in the final analysis. Studies were mostly of Oxford Center for Evidence-Based Medicine Level 4 quality. A total of 88 patients underwent supratotal resection in a combined cohort of 492 patients (214 males and 278 females, age 18 to 82 years). Fifty-one supratotal resections were conducted on high-grade gliomas, and 37 on low-grade gliomas. Karnofsky performance status, overall survival, progression-free survival, neurological deficits postoperatively, and anaplastic transformation were the main measured outcomes. No randomized controlled trials were identified. Preliminary low-quality support was found for supratotal resection in increasing overall survival and progression-free survival for both low-grade and high-grade glioma. The literature suggests insufficient evidence for carte blanche application of supratotal resection, particularly in lower-grade gliomas where neurological deficits can result in long-term disability. While the preliminary studies discussed here, containing data from only a few centers, have reported increased progression-free and overall survival, these claims require validation in prospective research studies involving larger patient populations with clearly defined appropriate outcome metrics in order to reduce potential bias.