Systematic Review Of Prognostic Factors Research Articles

87 a Systematic Review of Prognostic Factors in Patients with Cancer Receiving Palliative Radiotherapy: Evidence-Based Recommendations

87 a Systematic Review of Prognostic Factors in Patients with Cancer Receiving Palliative Radiotherapy: Evidence-Based Recommendations

A Systematic Review of Prognostic Factors in Patients with Cancer Receiving Palliative Radiotherapy: Evidence-Based Recommendations.

(1) Background: Prognostication in patients with cancer receiving palliative radiotherapy remains a challenge. To improve the process, we aim to identify prognostic factors in this population from the literature and offer evidence-based recommendations on prognostication in patients undergoing palliative radiotherapy for non-curable or advanced cancers. (2) Methods: A systematic review was performed on the medical literature from 2005 to 2023 to extract papers on the prognosis of palliative radiotherapy patients with advanced cancer. The initial selection was performed by at least two authors to determine study relevance to the target area. Studies were then classified based on type and evidence quality to determine final recommendations. (3) Results: The literature search returned 57 papers to be evaluated. Clinical and biological prognostic factors were identified from these papers to improve clinical decision making or construct prognostic models. Twenty prognostic models were identified for clinical use. There is moderate evidence supporting (i) evidence-based factors (patient, clinical, disease, and lab) in guiding decision making around palliative radiation; (ii) that certain biological factors are of importance; (iii) prognostication models in patients with advanced cancer; and that (iv) SBRT or re-irradiation use can be guided by predictions of survival by prognostic scores or clinicians. Patients with more favorable prognoses are generally better suited to SBRT or re-irradiation, and the use of prognostic models can aid in this decision making. (4) Conclusions: This evaluation has identified several factors or tools to aid in prognosis and clinical decision making. Future studies should aim to further validate these tools and factors in a clinical setting, including the leveraging of electronic medical records for data availability. To increase our understanding of how causal factors interact with palliative radiotherapy, future studies should also examine and include prediction of response to radiation as an outcome.

Predicting the outcome of plantar heel pain in adults: a systematic review of prognostic factors

BackgroundPlantar Heel Pain (PHP) is a common disorder with many treatment pathways and is not self-limiting, hence prognostic information concerning recovery or recalcitrance is needed to guide practice. In this systematic review, we investigate which prognostic factors are associated with favourable or unfavourable PHP outcomes.MethodsMEDLINE, Web of Science, EMBASE, Scopus and PubMed electronic bibliographic databases were searched for studies evaluating baseline patient characteristics associated with outcomes in prospective longitudinal cohorts or after specific interventions. Cohort, clinical prediction rule derivation and single arms of randomised controlled trials were included. Risk of bias was evaluated with method-specific tools and evidence certainty with GRADE.ResultsThe review included five studies which evaluated 98 variables in 811 participants. Prognostic factors could be categorised as demographics, pain, physical and activity-related. Three factors including sex and bilateral symptoms (HR: 0.49[0.30–0.80], 0.33[0.15–0.72], respectively) were associated with a poor outcome in a single cohort study. The remaining four studies reported twenty factors associated with a favourable outcome following shockwave therapy, anti-pronation taping and orthoses. Heel spur (AUC = 0.88[0.82–0.93]), ankle plantar-flexor strength (Likelihood ratio (LR): 2.17[1.20–3.95]) and response to taping (LR = 2.17[1.19–3.90]) were the strongest factors predicting medium-term improvement. Overall, the study quality was low. A gap map analysis revealed an absence of research that included psychosocial factors.ConclusionsA limited number of biomedical factors predict favourable or unfavourable PHP outcomes. High quality, adequately powered, prospective studies are required to better understand PHP recovery and should evaluate the prognostic value of a wide range of variables, including psychosocial factors.

P259 Systematic review of prognostic factors affecting the acquisition of transition readiness skills in patients with inflammatory bowel disease

Abstract Background Around 25% of patients with inflammatory bowel disease (IBD) are diagnosed before the age of 20, meaning transition from paediatric to adult healthcare is inevitable for some. Good transition is important to maintain quality of care, and poor transition can result in adverse outcomes such as clinic and medication non-adherence. Certain skills are required in order for someone to be ready to transition, and the aim of this study was to identify modifiable and non-modifiable factors affecting the development of these skills in young people with IBD. Methods This review was registered on the PROSERO database (CRD42019152272) and conducted in line with PRISMA guidelines. Studies were included if they (1) explored factors affecting the acquisition of transition readiness skills in IBD patients 2) were written in English (3) were published since 1999. The databases MEDLINE, CINAHL and PsychINFO were searched from September - October 2019. Bias was assessed using the Quality in Prognostic Studies tool. Results Searches identified 822 papers and 27 full texts were retrieved. Sixteen papers were included in the final review, reporting on 1770 patients ranging from 10–29 years of age. Fourteen studies were cross-sectional and two longitudinal. Six assessed transition readiness, five self-management, two disease knowledge, one medication knowledge, one health literacy, and one both disease knowledge and self-management. Modifiable factors found were increased provider-communication about transition, transition duration, and health care satisfaction. Participant self-efficacy was found to be significant for three studies, and increased parent autonomy granting was related to higher disease knowledge in one study. Non-modifiable factors identified were age, sex, socioeconomic score, participant educational level and ethnicity. Nine studies showed increased age as a positive prognostic factor, and two additional papers found an effect for certain domains assessed. Four studies showed higher scores for females, and one study demonstrated higher self-rated self-efficacy scores for males. Disease-related non-modifiable factors identified were IBD family history, age at diagnosis, and absence from school. Conclusion This study identified five potentially modifiable factors. Strategies or interventions to address these in the IBD population transitioning to adult care might lead to improved experience and outcomes. This review also identified eight non-modifiable factors. This may allow healthcare and allied professionals to identify those at an increased risk of not developing the necessary competencies for transition and adapting the way in which they approach transition for each individual.

STUCK IN TRANSIT: LOOMING DISASTER IN A PATIENT WITH A PATENT FORAMEN OVALE-ADHERENT THROMBUS

SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/23/2019 8:45 AM - 9:45 AM INTRODUCTION: The diagnosis of an impending paradoxical embolism, defined as a thrombus adherent to a patent foramen ovale (PFO), is very rare with the first reported case in 1985 [1]. This phenomenon is increasingly diagnosed due to improved availability of echocardiography and advances in imaging technology, although fewer than 200 cases to date have been reported [2,3]. Impending paradoxical embolism carries a high 30-day mortality rate of 18.4-29% [3,4]. CASE PRESENTATION: Our patient is a 64-year-old male with tobacco use, former alcohol and methamphetamine abuse, who presents with 1-month of progressive exertional dyspnea, lower extremity swelling, and 1-week of left-sided pleuritic chest pain. He was tachycardic and tachypneic on admission, with a blood pressure of 111/78 and SpO2 of 89% on room air. Significant laboratory values include a BNP of 1937 (5-99), troponin 0.03 (<0.03), and an EKG showing sinus tachycardia and right axis deviation. Admission transthoracic echocardiogram (TTE) revealed a reduced left ventricular ejection fraction of 20-25% with global hypokinesis, a moderately dilated right ventricle with severely reduced systolic function, elevated estimated pulmonary artery systolic pressure (PASP) of 63-73 mmHg, and a mobile mass in the right atrium (RA). A CT chest angiogram showed extensive chronic/subacute-appearing thrombi involving the main pulmonary arteries with extension into the right and left lower lobe segmental branches, and a 4.6 cm heterogeneous RA mass. A transesophageal echocardiogram showed a 4.1 x 4.5 cm RA mass traversing a newly noted PFO. Lower extremity dopplers showed bilateral deep venous thromboses extending from the iliac to popliteal veins. Coronary angiogram was without significant obstructive coronary artery disease. His treatment included a continuous heparin infusion, oxygen supplementation, and progressive diuresis. The patient was transferred to a tertiary referral center for pulmonary thromboendarterectomy with PFO closure. The removed mass from the pulmonary arteries was consistent with chronic clot and the final pathology of the atrial mass was organizing thrombus. DISCUSSION: Despite the increasing frequency of detection of an impending paradoxical embolism, the diagnosis is still rare and there are no established treatment guidelines. There is a trend towards improved outcomes with surgical endarterectomy over thrombolysis or anticoagulation alone [5]. CONCLUSIONS: Our patient underwent successful endarterectomy without evidence of systemic embolization. At 1-year follow up, he has normal cardiac function and normal PASP by TTE, with no perfusion abnormalities on VQ scan. His hypercoagulable work-up was non-diagnostic, although anticoagulation for life is recommended. Reference #1: 1. U. Nellessen, W. Daniel, G. Matheis, et al.Impending paradoxical embolism from atrial thrombus: correct diagnosis by transeosophageal echocardiography and prevention by surgery. J Am Coll Cardiol, 5 (1985), pp. 1002-1004. Reference #2: 2. Podroužková H, Horváth V, Hlinomaz O, et al. Embolus entrapped in patent foramen ovale: impending paradoxical embolism. The Annals Of Thoracic Surgery. 2014;98(6):e151-e152. https://doi.org/10.1016/j.athoracsur.2014.08.072. Reference #3: 3. Myers P. O., Bounameaux H., Panos A., Lerch R., Kalangos A. Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest. 2010;137(1):164–170. https://doi.org/10.1378/chest.09-0961. 4. Shepherd F, White-Stern A, Rahaman O, Kurian D, Simon K. Saddle Pulmonary Embolism with Thrombus in Transit across a Patent Foramen Ovale. Case Rep Cardiol. 2017;2017:6752709. 5. Fauveaua E., Cohen A., Bonnet N., Gacem K., Lardoux H. Surgical or medical treatment for thrombus straddling the patent foramen ovale: Impending paradoxical embolism? Report of four clinical cases and literature review. Archives of Cardiovascular Diseases. 2008;101(10):637–644. https://doi.org/10.1016/j.acvd.2008.08.011. DISCLOSURES: No relevant relationships by Jenifer Lentz, source=Web Response

A mini systematic review of prognostic factors in elderly patients with tuberculosis.

While advanced age has been suggested as a prognostic factor in patients with tuberculosis, the characteristics associated with a poor outcome in elderly patients have remained unclear. The aim of this systematic review was to describe the risk factors for a poor outcome in elderly patients with tuberculosis. We identified 1255 studies published between 1919 and 2017 from the PubMed database by using combinations of the keywords "tuberculosis [Title/Abstract]" and "elderly [Title/Abstract]". Full texts of the studies that met the inclusion criteria were further evaluated by two independent investigators. even retrospective cohort studies were included in this systematic review. More advanced age, comorbidities, and nutritional status were likely to be prognostic factors in Taiwan (aging country) and Japan (super-aged country), while human immunodeficiency virus infection and severe tuberculosis were associated with a poor outcome in low-income countries. Two studies from Taiwan investigated the prognostic factors of tuberculosis-specific death and non-tuberculosis-specific death separately, but no significant differences were found in the factors between the two types of death. The prognostic factors of tuberculosis in elderly patients varied according to the income levels of the countries. The factors in Taiwan and Japan were mainly associated with host factors, irrespective of the cause of death, which may reflect senile deterioration due to old age.

A Systematic Review of Prognostic Factors for Sensory Recovery After Digital Nerve Reconstruction.

Successful digital nerve repair is crucial in preventing painful neuroma formation and restoring sensory function after traumatic hand injury. The purpose of this study is to identify prognostic factors affecting sensory recovery following digital nerve reconstruction. A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines including studies reporting patients 18 years and older, greater than 10 reconstructed digital nerves, and greater than or equal to 3 months follow-up. Studies with proximal nerve injuries in the same distribution or inadequate sensory data were excluded. Included studies were evaluated by methodological index for nonrandomized studies score. Possible predictors were examined using the t test and 1-way analysis of variance with α ≤ 0.05. Twenty-five studies met the inclusion criteria, consisting of 818 surgically reconstructed digital nerves (mean age, 38 years; 78% male) with a mean ± SD defect length of 1.5 ± 0.5 cm. Mean follow-up time was 22 months. Fifty-six percent of patients presented with concomitant injuries to tendons (31%) and the digital artery (13%). Mean ± SD time to surgical repair was 36 ± 73.8 days. Reconstructive techniques included 35% end-to-end primary neurorrhaphy, 31% nerve grafts, and 11% synthetic conduits. Postoperatively, 81% of the patients demonstrated sensory recovery of S3+/S4, with 45% complaining of hyperesthesia. Nerve reconstructions performed within 15 days of injury had significantly better static 2-point discrimination than delayed procedures (P = 0.02). Static 2-point discrimination measurements were also significantly better for shorter defect lengths (<1.3 cm, P = 0.05). No significant functional differences were found across age, follow-up time, injured digit or side, nor reconstructive technique. Digital nerve reconstruction has good to excellent sensory recovery in up to 81% of patients with improved results in nerve gaps less than 1.3 cm. Performing the reconstruction within 15 days of injury is also correlated with improved sensory recovery.

A systematic review of prognostic factors at the end of life for people with a hematological malignancy

BackgroundAccurate prognosticating is needed when patients are nearing the end of life to ensure appropriate treatment decisions, and facilitate palliative care provision and transitioning to terminal care. People with a hematological malignancy characteristically experience a fluctuating illness trajectory leading to difficulties with prognosticating. The aim of this review was to identify current knowledge regarding ‘bedside’ prognostic factors in the final 3 months of life for people with a hematological malignancy associated with increased risk of mortality.MethodsA systematic review of the literature was performed across: PubMed; CINAHL; PsycINFO; and Cochrane with set inclusion criteria: 1) prognostic cohort studies; 2) published 2004–2014; 3) sample ≥ 18 years; 4) >50% sample had a hematological malignancy; 5) reported ‘bedside’ prognostic factors; 6) median survival of <3 months; and 7) English language. Quality appraisal was performed using the Quality In Prognostic Studies (QUIPS) tool. Results are reported in line with PRISMA guidelines.ResultsThe search returned 4860 studies of which 28 met inclusion criteria. Twenty-four studies were rated moderate quality, three were high quality and one study was deemed to be of low quality. Most studies were set in the ICU (n = 24/28) and were retrospective (n = 25/28). Forty ‘bedside’ prognostic factors were identified as associated with increased risk of mortality encompassing the following broad categories: 1) demographics; 2) physiological complications or conditions; 3) disease characteristics; 4) laboratory blood values; and 5) interventions.ConclusionsThe literature on prognosticating in the final months of life was predominantly focused on people who had experienced acute physiological deterioration and were being treated aggressively in the in-patient setting. A significant gap in the literature exists for people who are treated less aggressively or are on a palliative trajectory. Findings did not report on, or confirm the significance of, many of the key prognostic factors associated with increased risk of mortality at the end of life in the solid tumour population, demonstrating key differences in the two populations.Trial registrationThis systematic review was not registered.

De novo degenerative lumbar scoliosis: a systematic review of prognostic factors for curve progression.

To identify prognostic factors for curve progression in de novo degenerative lumbar scoliosis (DNDLS) by performing a systematic review of the literature. Studies were selected for inclusion following a systematic search in the bibliographic databases PubMed and EMBASE prior to September 2015 and hand searches of the reference lists of retrieved articles. Two authors independently assessed methodological quality. Data were extracted and presented according to a best evidence synthesis. The literature search generated a total of 2696 references. After removing duplicates and articles that did not meet inclusion criteria, 12 studies were included. Due to the lack of statistical analyses, pooling of data was not possible. Strong evidence indicates that increasing intervertebral disk degeneration, lateral vertebral translation ≥6mm, and an intercrest line through L5 (rather than L4) are associated with DNDLS curve progression. Moderate evidence suggests that apical vertebral rotation Grade II or III is associated with curve progression. For the majority of other prognostic factors, we found limited, conflicting, or inconclusive evidence. Osteoporosis, a coronal Cobb angle <30°, lumbar lordosis, lateral osteophytes difference of ≥5mm, and degenerative spondylolisthesis have not been shown to be risk factors. Clinical risk factors for progression were not identified. This review shows strong evidence that increased intervertebral disk degeneration, an intercrest line through L5, and apical lateral vertebral translation ≥6mm are associated with DNDLS curve progression. Moderate evidence was found for apical vertebral rotation (Grade II/III) as a risk factor for curve progression. These results, however, may not be directly applicable to the individual patient.

A systematic review of prognostic factors for distal upper limb pain.

Musculoskeletal pain in the distal upper limb is relatively common, can be a cause of disability, presents a high cost to society and is clinically important. Previous reviews of prognostic factors have focused on pain in the proximal upper limb, whole upper extremity or isolated regions of the distal upper limb. To identify factors that predict outcome of distal upper limb pain. Systematic review. Eight bibliographic databases were searched from inception to March 2014. Eligible articles included adults with pain anywhere in the distal upper limb at baseline from randomised controlled trials with a waiting list, expectant policy or usual care group, or observational studies where no treatment or usual care was provided. Data describing the association between a putative prognostic factor and pain or functional outcome at follow-up were required. Quality was assessed using the Quality in Prognostic Studies tool. Seven articles reporting on six studies were identified. Heterogeneity of study populations and outcome measures prevented a meta-analysis so a narrative synthesis of results was undertaken. Three factors (being female, a longer duration of the complaint at initial presentation and having musculoskeletal pain in multiple locations) were significantly associated with poor pain outcome in more than one study. Being female was the only factor significantly associated with poor functional outcome in more than one study. A range of sociodemographic, pain-related, occupational and psychosocial prognostic factors for distal upper limb pain outcomes were investigated in studies included in the review. However, due to the lack of commonality of factors investigated and lack of consistency of results across studies, there is limited evidence for predictors of distal upper limb pain outcomes. Further research is required to identify prognostic factors of distal upper limb pain, particularly modifiable factors that may influence management.

Prognostic factors for progression of clinical osteoarthritis of the knee: a systematic review of observational studies.

IntroductionWe performed a systematic review of prognostic factors for the progression of symptomatic knee osteoarthritis (OA), defined as increase in pain, decline in physical function or total joint replacement.MethodWe searched for available observational studies up to January 2015 in Medline and Embase according to a specified search strategy. Studies that fulfilled our initial inclusion criteria were assessed for methodological quality. Data were extracted and the results were pooled, or if necessary summarized according to a best evidence synthesis.ResultsOf 1,392 articles identified, 30 met the inclusion criteria and 38 determinants were investigated. Pooling was not possible due to large heterogeneity between studies. The best evidence synthesis showed strong evidence that age, ethnicity, body mass index, co-morbidity count, magnetic resonance imaging (MRI)-detected infrapatellar synovitis, joint effusion and baseline OA severity (both radiographic and clinical) are associated with clinical knee OA progression. There was moderate evidence showing that education level, vitality, pain-coping subscale resting, MRI-detected medial femorotibial cartilage loss and general bone marrow lesions are associated with clinical knee OA progression. However, evidence for the majority of determinants was limited (including knee range of motion or markers) or conflicting (including age, gender and joint line tenderness).ConclusionStrong evidence was found for multiple prognostic factors for progression of clinical knee OA. A large variety in definitions of clinical knee OA (progression) remains, which makes it impossible to summarize the evidence through meta-analyses. More research on prognostic factors for knee OA is needed using symptom progression as an outcome measure. Remarkably, only few studies have been performed using pain progression as an outcome measure. The pathophysiology of radiographic factors and their relation with symptoms should be further explored.

Systematic review of prognostic factors for mortality in dogs with immune-mediated hemolytic anemia.

BackgroundTreatment of dogs with primary immune‐mediated hemolytic anemia (IMHA) is difficult and frequently unrewarding. Prognostic factors have been evaluated in a number of previous studies, and identification of such factors would be beneficial to enable selection of appropriate therapeutic regimens and supportive care.ObjectivesThe aim of the current study was to undertake a critical appraisal of the risk of bias in evidence relating to prognostic indicators for mortality in dogs with IMHA.AnimalsThree hundred and eighty client‐owned dogs with spontaneous primary idiopathic IMHA reported in 6 previous studies.MethodsA systematic review was conducted to evaluate evidence relating to prognostic factors for mortality in dogs with primary IMHA. Search tools were employed to identify articles and a validated appraisal tool was used to assess the quality of individual studies by considering inclusion and exclusion criteria, measurement of prognostic, outcome and confounding variables, and statistical methods.ResultsFew studies evaluated prognostic indicators for IMHA in dogs, and all of these suffered from methodologic flaws in at least 1 major area. Fifteen different variables were identified as prognostic indicators, with 2 variables identified by >1 study.Conclusions and Clinical ImportanceThere are few pieces of high‐quality evidence available to enable estimation of prognosis for dogs presenting with primary IMHA.

A systematic review of prognostic factors for return to work following work-related traumatic hand injury

Study designSystematic review. IntroductionTraumatic hand injuries are frequent cause of work related injuries and can result in prolonged durations of time loss from work. PurposeTo systematically review available evidence to determine which prognostic factors predict return-to-work (RTW) following work-related traumatic hand injuries. MethodsWe searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and PsycINFO from 1980 to September 2013 and reference lists of articles. Studies investigating any prognostic factors of RTW after traumatic hand injury were included. Two reviewers performed study selection, assessment of methodological quality and data extraction independently of each other. Identified factors were grouped into conceptual prognostic factor categories. ResultsWe assessed 8 studies, which addressed 11 potential prognostic factors (i.e., sociodemographic factors, occupation, work compensation status, treatment related factors, impairment severity, location of injury, etc.). The quality of the studies was low to moderate. Across all included studies, RTW (original or modified work) occurred in over 60% of individuals by 6 months. There was consistent low-moderate quality evidence that individuals with more severe impairments and lower pre-injury income were less likely to RTW, and low-moderate quality evidence that age, gender and level of education had no impact on RTW. Evidence on other commonly cited prognostic factors were limited in the literature. ConclusionImpairment severity and lower pre-injury income showed a consistent association with RTW following occupational hand injury, while other factors demonstrated no or variable effects across studies. Additional high-quality studies are warranted toward improving our understanding of the complex factors that mediate RTW following a traumatic work-related hand injury. Level of evidence2a.

Systematic review of prognostic factors predicting outcome in non‐surgically treated patients with sciatica

Identification of prognostic factors for surgery in patients with sciatica is important to be able to predict surgery in an early stage. Identification of prognostic factors predicting persistent pain, disability and recovery are important for better understanding of the clinical course, to inform patient and physician and support decision making. Consequently, we aimed to systematically review prognostic factors predicting outcome in non-surgically treated patients with sciatica. A search of Medline, Embase, Web of Science and Cinahl, up to March 2012 was performed for prospective cohort studies on prognostic factors for non-surgically treated sciatica. Two reviewers independently selected studies for inclusion and assessed the risk of bias. Outcomes were pain, disability, recovery and surgery. A best evidence synthesis was carried out in order to assess and summarize the data. The initial search yielded 4392 articles of which 23 articles reporting on 14 original cohorts met the inclusion criteria. High clinical, methodological and statistical heterogeneity among studies was found. Reported evidence regarding prognostic factors predicting the outcome in sciatica is limited. The majority of factors that have been evaluated, e.g., age, body mass index, smoking and sensory disturbance, showed no association with outcome. The only positive association with strong evidence was found for leg pain intensity at baseline as prognostic factor for subsequent surgery.

Protocol for a systematic review and individual patient data meta-analysis of prognostic factors of foot ulceration in people with diabetes: the international research collaboration for the prediction of diabetic foot ulcerations (PODUS)

BackgroundDiabetes–related lower limb amputations are associated with considerable morbidity and mortality and are usually preceded by foot ulceration. The available systematic reviews of aggregate data are compromised because the primary studies report both adjusted and unadjusted estimates. As adjusted meta-analyses of aggregate data can be challenging, the best way to standardise the analytical approach is to conduct a meta-analysis based on individual patient data (IPD).There are however many challenges and fundamental methodological omissions are common; protocols are rare and the assessment of the risk of bias arising from the conduct of individual studies is frequently not performed, largely because of the absence of widely agreed criteria for assessing the risk of bias in this type of review. In this protocol we propose key methodological approaches to underpin our IPD systematic review of prognostic factors of foot ulceration in diabetes.Review questions;1. What are the most highly prognostic factors for foot ulceration (i.e. symptoms, signs, diagnostic tests) in people with diabetes?2. Can the data from each study be adjusted for a consistent set of adjustment factors?3. Does the model accuracy change when patient populations are stratified according to demographic and/or clinical characteristics?MethodsMEDLINE and EMBASE databases from their inception until early 2012 were searched and the corresponding authors of all eligible primary studies invited to contribute their raw data. We developed relevant quality assurance items likely to identify occasions when study validity may have been compromised from several sources. A confidentiality agreement, arrangements for communication and reporting as well as ethical and governance considerations are explained.We have agreement from the corresponding authors of all studies which meet the eligibility criteria and they collectively possess data from more than 17000 patients. We propose, as a provisional analysis plan, to use a multi-level mixed model, using “study” as one of the levels. Such a model can also allow for the within-patient clustering that occurs if a patient contributes data from both feet, although to aid interpretation, we prefer to use patients rather than feet as the unit of analysis. We intend to only attempt this analysis if the results of the investigation of heterogeneity do not rule it out and the model diagnostics are acceptable.DiscussionThis review is central to the development of a global evidence-based strategy for the risk assessment of the foot in patients with diabetes, ensuring future recommendations are valid and can reliably inform international clinical guidelines.

Practical methodological strategies for individual patient data systematic reviews

BackgroundDiabetes-related leg amputations are associated with substantial morbidity and mortality and are usually preceded by foot ulceration. Annual assessment procedures are recommended to identify people with diabetes who are at risk of foot ulceration. Some evidence suggests the use of specific diagnostic tests, symptoms, signs, and elements from the patients' history, but the role of other contributory factors is unclear. Clinical guidelines for foot screening are largely based on consensus and on the findings from individual studies rather than on any systematic integration of all available data. Systematic reviews to integrate evidence of predictive factors exist, but are compromised because both adjusted and unadjusted estimates are present in the primary studies. Because adjusted meta-analyses of aggregate data can be challenging, the best way to standardise the analytical approach is to use individual patient data (IPD). There are many challenges associated with this type of systematic review including its time-consuming and costly nature. We will share the key methodological strategies that underpin our IPD systematic review of prognostic factors for foot ulceration in diabetes. We have three aims: (1) to systematically review individual patient data from cohort studies in a meta-analysis to estimate the predictive value of clinical characteristics and diagnostic tests for diabetic foot ulceration; (2) to develop a prognostic model of the risk factors for diabetic foot ulceration on the basis of data obtained worldwide; and (3) to test the robustness of the model in different demographic profiles (eg, age, duration of diabetes, control of diabetes [insulin, diet, or oral medication], and type of diabetes [type I or II]). MethodsWe searched Medline and Embase databases from inception until 2012 (appendix). We contacted the corresponding authors of eligible primary studies and invited them to contribute the data to an IPD analysis. The review protocol is available from PROSPERO. FindingsWe identified 14 eligible cohort studies of more than 20 000 patients worldwide, and all corresponding authors have given signed agreements to share their data. These datasets share common variables from which meta-analyses of predictive factors for foot ulceration in diabetes are feasible. Several key methodological strategies positively contributed to our review. Previous conduct and publication of an aggregate systematic review allowed us to develop search strategies and communicate with authors about their primary studies and resultant data; the absence of industry involvement meant that authors were in possession of their dataset; the continual involvement of the authors in the specialty of diabetes foot research sustained their interest in the review question; and a detailed protocol including items for an assessment of quality and ethical considerations helped to establish a contract between the collaborators. Importantly, the project has received funding to support research activity and international collaborations. InterpretationPractical methodological strategies have positively contributed to the conduct of this IPD systematic review, which is central to the development of a global evidence-based strategy for the risk assessment of the diabetic foot. IPD systematic reviewers should carefully consider practical effects in the preparatory stages of their work. FundingThe National Institute of Health Research Health Technology Assessment Clinical Evaluation and Trials Board (project: 10/57/08).

Systematic Review of Prognostic Factors Related to Overall Survival in Patients with Stage IV Colorectal Cancer and Unresectable Metastases

With the improvements in newer chemotherapeutic agents, the role of primary tumour resection in patients with stage IV colorectal cancer is controversial. In many cases primary tumour resection is still favoured as first-line management. However, a detailed understanding of independent prognostic factors related to survival is necessary before making this decision. A literature search was conducted using Medline and Embase. Studies that performed multivariate analysis on overall survival of patients with incurable stage IV colorectal cancer were included in this review. Fourteen retrospective studies involving 3209 patients were included. Clinical variables analysed to consistently have independent prognostic significance for long-term survival included the patients' performance status (<2), volume of liver metastases (<50%), nodal stage (N0), disease-free resection margins, and treatment with chemotherapy and/or primary tumour resection. Cancer antigen (CA) 19-9, low albumin, elevated ALP levels, apical lymph node involvement, presence of ascites, and postoperative transfusion were each assessed by only one study and found to be independently associated with survival. Factors inconsistently reported to have independent prognostic significance were age, ASA score, preoperative CEA levels, primary tumour location, tumour size and differentiation, peritoneal dissemination, and extrahepatic metastases. Each patient should be reviewed individually on the basis of the above independent prognostic factors before deciding to resect the primary tumour. Patients with a poor performance status, extensive hepatic metastases, and extensive nodal disease detected preoperatively are less likely to have a survival benefit. Nonsurgical approaches to manage these patients should be given careful consideration.

Predicting Prognosis in Thermal Burns With Associated Inhalational Injury: A Systematic Review of Prognostic Factors in Adult Burn Victims

Burn injuries are a significant problem with high associated morbidity and mortality. Those associated with inhalational trauma (IHT) may be associated with higher mortality, but studies on prognosis are small and underpowered. This study was designed to identify prognostic factors that increase the risk of death, to quantify this risk, and to identify existing prognostic models. An electronic search of English-language publications that identify prognostic risk factors in thermal burns including IHT was carried out. Each article was reviewed systematically, and data extraction, quality assessment, and summarization of the articles were performed. Thirteen articles that met the inclusion/exclusion criteria of this study were reviewed. Overall, the mortality rate among burn patients in this review was 13.9% (4-28.3%), with the mortality rate among those with IHT being 27.6% (7.8-28.3%). Those studies with multivariate analyses identified increasing %TBSA, presence of IHT, and increasing age as the strongest predictors for mortality in this patient population. It seems that %TBSA, presence of IHT, and age are the best predictors of mortality among the current published literature on burn prognosis.

Évaluation des facteurs pronostiques du synovialosarcome thoracique

Synovial sarcoma is an uncommon tumour and thoracic involvement is rare and of varying location. Clinical characteristics are dominated by pain, with a slow progression over years. Pathological and immuno-histochemical characteristics are helpful in the diagnosis but a specific translocation between chromosomes X and 18 is crucial for confirmation. Extensive surgical resection is required for cure, combined with adjuvant radiotherapy in the presence of adverse prognostic factors. We report a case of synovial sarcoma of the chest wall, responsible for chronic local pain for several years, presenting as an acute pleuropneumonitis in a 21-year-old patient. In view of the large size of the tumour, associated with a high proliferation index (Ki-67), a surgical resection was performed, together with local adjuvant radiotherapy. This case report reviews synovial sarcoma and underlines the difficulties and requirements of both diagnostic strategy and therapeutic management. Among them, an initial systematic review of prognostic factors (tumour size, mitotic activity, proliferation index, SYT-SSX type fusion, histological grade) is crucial to determine the therapeutic options.

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