Literature search parameters marginally improved the pooled estimate accuracy for ultrasound in detecting deep venous thrombosis

Surgical treatment of acromegaly according to the 2010 remission criteria: systematic review and meta-analysis

BACKGROUND

In 2010, the Acromegaly Consensus Group revised the criteria for cure of acromegaly and thus rates of surgical remission need to be revised in light of these new thresholds. Two subgroups consisted of patients with discordant GH and IGF-1 levels and patients in remission according to the 2000 criteria, but not to the 2010 criteria, have been reported after adenomectomy and for these subgroups the precise incidence and management has not been established. The objective of the study was to update rates of surgical remission and complications and to evaluate the incidence, management, and long-term outcome of the two previously described subgroups of patients.

METHODS

Systematic review and meta-analysis of surgical series that defined remission according to the 2010 biochemical criteria.

RESULTS

We included 13 studies (1105 patients). The pooled rate of overall surgical remission was 54.8 % (95 % CI 44.4-65.2 %), and 72.2 % with previous criteria. Remission was achieved in 77.9 % (95 % CI 68.1-87.6 %) of microadenomas; 52.7 % (95 % CI 41-64.4 %) of macroadenomas; 29 % (95 % CI 20.1-37.8 %) of invasive and 68.8 % (95 % CI 60-77.6 %) of non-invasive adenomas. Complication rates were 1.2 % (95 % CI 0.6-1.9 %) for CSF leak, 1.3 % (95 % CI 0.6-2.1 %) for permanent diabetes insipidus, 8.7 % (95 % CI 4.8-12.5 %) for new anterior pituitary dysfunction and 0.6 % (95 % CI 0.1-1.1 %) for severe intraoperative hemorrhage. We identified an intermediate group of patients, defined as: (1) Remission according to one, but not the other biochemical criteria (GH or IGF-1) or 2010 criteria (14.3 % and 47.1 % cases), (2) Remission according to 2000, but not 2010 criteria (13.2-58.8 % cases). Two studies reported a remission rate of 56.5 % and 100 %, in the two subgroups respectively, in a long-term outcome without adjuvant therapy.

CONCLUSIONS

Overall remission with transsphenoidal surgery is achieved in ∼55 % of patients. For the intermediate group of patients, future prospective studies with long-term follow-up are required to determine the long-term biochemical remission rates and clinical implications.

The role of nurses in HIV screening in health care facilities: A systematic review

OBJECTIVE

To examine nurse-driven HIV screening in various health care settings in terms of its impact on test offering, acceptance and delivery rates, nursing responsibilities, staff perceptions and long-term implementation.

DESIGN

Systematic review.

REVIEW METHODS

The systematic review conducted in September 2014 adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Two independent reviewers extracted and summarised the eligible studies using a standardised form.

STUDY ELIGIBILITY CRITERIA

All studies published from 2004 to 2014 that explored nurse-driven HIV screening practice in health care facilities in countries with comparable concentrated HIV epidemics were included.

DATA SOURCES

MEDLINE, EBSCO CINAHL.

RESULTS

Overall, 30 quantitative, qualitative and mixed methods studies fulfilled the eligibility criteria. The studies showed a trend in higher test offering, better acceptance and higher delivery rates with the implementation of nurse-driven HIV screening. However, among the 23 studies (77%) that evaluated these aims, only 13 studies (56%) had a control group, and 4 studies (17%) were randomised controlled trials (RCT) in few centres (i.e., 1 or 2). In 2 studies that compared nurse-driven HIV test offering to physician intervention, the participation of nurses was higher than that of physicians (85% vs. 54%, p<0.001; 47% vs. 28%, p<0.05). In a third study, the intervention of a dedicated nurse increased the test offering from 96.5% to 99.5% (OR=7.27, 95% CI=1.02-316.9). Acceptance rates increased with the nurse intervention in 2 RCTs (75% vs. 71%, p=0.025; 45% vs. 19%, p<0.05) and in a cohort study (74.8% vs. 84.3%, OR=1.82, 95% CI=1.14-2.88), whereas it decreased in 2 other studies. The testing rates increased in 7 out of 10 studies, with a maximum absolute increase of 65.9%. Nurse-driven HIV screening was evaluated at the time of routine HIV screening implementation in 27 studies (90%) and provided nurses with new responsibilities in 9 studies (30%). The few studies (23%) that explored how health care professionals, including nurses, perceived the strategy showed that this approach was well received. However, several operational barriers, such as lack of time, prevented its long-term implementation.

CONCLUSION

The review supports the implementation of nurse-driven HIV screening. However, the evaluation of the impact of the nurse approach by RCTs was scarce, calling for additional research to better evaluate the impact of the nursing profession's contribution to HIV screening. Moreover, the perceptions of nurses and health care staff were seldom evaluated and require further exploration to improve nurse-driven HIV screening implementation.

Search strategies to identify diagnostic accuracy studies in MEDLINE and EMBASE

BACKGROUND

A systematic and extensive search for as many eligible studies as possible is essential in any systematic review. When searching for diagnostic test accuracy (DTA) studies in bibliographic databases, it is recommended that terms for disease (target condition) are combined with terms for the diagnostic test (index test). Researchers have developed methodological filters to try to increase the precision of these searches. These consist of text words and database indexing terms and would be added to the target condition and index test searches.Efficiently identifying reports of DTA studies presents challenges because the methods are often not well reported in their titles and abstracts, suitable indexing terms may not be available and relevant indexing terms do not seem to be consistently assigned. A consequence of using search filters to identify records for diagnostic reviews is that relevant studies might be missed, while the number of irrelevant studies that need to be assessed may not be reduced. The current guidance for Cochrane DTA reviews recommends against the addition of a methodological search filter to target condition and index test search, as the only search approach.

OBJECTIVES

To systematically review empirical studies that report the development or evaluation, or both, of methodological search filters designed to retrieve DTA studies in MEDLINE and EMBASE.

SEARCH METHODS

We searched MEDLINE (1950 to week 1 November 2012); EMBASE (1980 to 2012 Week 48); the Cochrane Methodology Register (Issue 3, 2012); ISI Web of Science (11 January 2013); PsycINFO (13 March 2013); Library and Information Science Abstracts (LISA) (31 May 2010); and Library, Information Science & Technology Abstracts (LISTA) (13 March 2013). We undertook citation searches on Web of Science, checked the reference lists of relevant studies, and searched the Search Filters Resource website of the InterTASC Information Specialists' Sub-Group (ISSG).

SELECTION CRITERIA

Studies reporting the development or evaluation, or both, of a MEDLINE or EMBASE search filter aimed at retrieving DTA studies, which reported a measure of the filter's performance were eligible.

DATA COLLECTION AND ANALYSIS

The main outcome was a measure of filter performance, such as sensitivity or precision. We extracted data on the identification of the reference set (including the gold standard and, if used, the non-gold standard records), how the reference set was used and any limitations, the identification and combination of the search terms in the filters, internal and external validity testing, the number of filters evaluated, the date the study was conducted, the date the searches were completed, and the databases and search interfaces used. Where 2 x 2 data were available on filter performance, we used these to calculate sensitivity, specificity, precision and Number Needed to Read (NNR), and 95% confidence intervals (CIs). We compared the performance of a filter as reported by the original development study and any subsequent studies that evaluated the same filter.

MAIN RESULTS

Ninteen studies were included, reporting on 57 MEDLINE filters and 13 EMBASE filters. Thirty MEDLINE and four EMBASE filters were tested in an evaluation study where the performance of one or more filters was tested against one or more gold standards. The reported outcome measures varied. Some studies reported specificity as well as sensitivity if a reference set containing non-gold standard records in addition to gold standard records was used. In some cases, the original development study did not report any performance data on the filters. Original performance from the development study was not available for 17 filters that were subsequently tested in evaluation studies. All 19 studies reported the sensitivity of the filters that they developed or evaluated, nine studies reported the specificities and 14 studies reported the precision.No filter which had original performance data from its development study, and was subsequently tested in an evaluation study, had what we defined a priori as acceptable sensitivity (> 90%) and precision (> 10%). In studies that developed MEDLINE filters that were evaluated in another study (n = 13), the sensitivity ranged from 55% to 100% (median 86%) and specificity from 73% to 98% (median 95%). Estimates of performance were lower in eight studies that evaluated the same 13 MEDLINE filters, with sensitivities ranging from 14% to 100% (median 73%) and specificities ranging from 15% to 96% (median 81%). Precision ranged from 1.1% to 40% (median 9.5%) in studies that developed MEDLINE filters and from 0.2% to 16.7% (median 4%) in studies that evaluated these filters. A similar range of specificities and precision were reported amongst the evaluation studies for MEDLINE filters without an original performance measure. Sensitivities ranged from 31% to 100% (median 71%), specificity ranged from 13% to 90% (median 55.5%) and precision from 1.0% to 11.0% (median 3.35%).For the EMBASE filters, the original sensitivities reported in two development studies ranged from 74% to 100% (median 90%) for three filters, and precision ranged from 1.2% to 17.6% (median 3.7%). Evaluation studies of these filters had sensitivities from 72% to 97% (median 86%) and precision from 1.2% to 9% (median 3.7%). The performance of EMBASE search filters in development and evaluation studies were more alike than the performance of MEDLINE filters in development and evaluation studies. None of the EMBASE filters in either type of study had a sensitivity above 90% and precision above 10%.

AUTHORS' CONCLUSIONS

None of the current methodological filters designed to identify reports of primary DTA studies in MEDLINE or EMBASE combine sufficiently high sensitivity, required for systematic reviews, with a reasonable degree of precision. This finding supports the current recommendation in the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy that the combination of methodological filter search terms with terms for the index test and target condition should not be used as the only approach when conducting formal searches to inform systematic reviews of DTA.

Meta-analysis of diagnostic test accuracy in neurosurgical practice

Comparative effectiveness research (CER) allows evidence to be evaluated on the effectiveness, benefits, and detriments of management options, diagnostic tests, or ways to deliver health care. This process can be achieved in different ways, such as with well-designed randomized controlled trials or by meta-analyses. Several medical subspecialties are increasingly using CER, but CER remains underused by the neurosurgical community. Meta-analysis is a highly accurate method that permits results from multiple well-designed research studies to be quantitatively compared. Meta-analysis can be performed in many settings, such as the evaluation of treatment or of a diagnostic test or prognostic factor. Meta-analyses of randomized controlled treatment trials are well known, but there is a paucity of papers describing the ways to perform a meta-analysis of a diagnostic test. The aim of this paper is to improve neurosurgeons' familiarity with the meta-analysis of diagnostic test accuracy by describing and detailing each stage leading to publication.

Nontraumatic spinal epidural hematoma during pregnancy: diagnosis and management concerns

OBJECTIVE

Nontraumatic spinal epidural hematoma (SEH) during pregnancy is rare. Therefore, appropriate management of this occurrence is not well defined. The aim of this study was to extensively review the literature on this subject, to propose some novel treatment guidelines.

METHODS

Electronic databases, manual reviews and conference proceedings up to December 2011 were systematically reviewed. Articles were deemed eligible for inclusion in this study if they dealt with nontraumatic SEH during pregnancy. Search protocols and data were independently assessed by two authors.

RESULTS

In all, 23 case reports were found to be appropriate for review. The mean patient age was 28 years and gestational age was 33.2 weeks. Thirteen cases presented with acute interscapular pain. The clinical picture consisted of paraplegia, which occurred approximately 63 h after pain onset. Spinal cord decompression was performed within an average time of 20 h after neurological deficit onset. Fifteen patients had cesarean deliveries, even when the gestational age was less than 36 weeks.

CONCLUSION

This review failed to identify articles, other than case reports, which could assist in the formation of new guidelines to treat SEH in pregnancy. However, we believe that SEH may be managed neurosurgically, without requiring prior, premature, cesarean section.

Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis

PURPOSE

To evaluate the diagnostic accuracy of ultrasonography of optic nerve sheath diameter (ONSD) for assessment of intracranial hypertension.

METHODS

Systematic review without language restriction based on electronic databases, with manual review of literature and conference proceedings until July 2010. Studies were eligible if they compared ultrasonography of ONSD with intracranial pressure (ICP) monitoring. Data were extracted independently by three authors. Random-effects meta-analysis and meta-regression were performed.

RESULTS

Six studies including 231 patients were reviewed. No significant heterogeneity was detected for sensitivity, specificity, positive and negative likelihood ratios or diagnostic odds ratio. For detection of raised intracranial pressure, pooled sensitivity was 0.90 [95% confidence interval (CI) 0.80-0.95; p for heterogeneity, p (het) = 0.09], pooled specificity was 0.85 (95% CI 0.73-0.93, p (het) = 0.13), and the pooled diagnostic odds ratio was 51 (95% CI 22-121). The area under the summary receiver-operating characteristic (SROC) curve was 0.94 (95% CI 0.91-0.96).

CONCLUSIONS

Ultrasonography of ONSD shows a good level of diagnostic accuracy for detecting intracranial hypertension. In clinical decision-making, this technique may help physicians decide to transfer patients to specialized centers or to place an invasive device when specific recommendations for this placement do not exist.