Gender Differences in Authorship and Quality of Anesthesia Clinical Practice Guidelines From 2016 to 2020 Using the Appraisal of Guidelines for Research and Evaluation II Instrument

INTRODUCTION

Women continue to be underrepresented in academic anesthesiology. This study assessed guidelines in anesthesia journals over the past 5 years, evaluating differences in woman-led versus man-led guidelines in terms of author gender, quality, and changes over time. We hypothesized that anesthesia guidelines would be predominately man-led, and that there would be differences in quality between woman-led versus man-led guidelines.

METHODS

All clinical practice guidelines published in the top 10 anesthesia journals were identified as per Clarivate Analytics Impact Factor between 2016 and 2020. Fifty-one guidelines were included for author, gender, and quality analysis using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument. Each guideline was assessed across 6 domains and 23 items and given an overall score, overall quality score, and overall rating/recommendation. Stratified and trend analyses were performed for woman-led versus man-led guidelines.

RESULTS

Fifty out of 51 guidelines were included: 1 was excluded due to unidentifiable first-author gender. In total, 255 of 1052 (24%) authors were women, and woman-led guidelines (woman-first author) represented 12 of 50 (24%) overall guidelines. Eighteen percent (9 of 50) of guidelines had all-male authors, and a majority (26 of 50, 52%) had less than one-third of female authors. The overall number and percentage of woman-led guidelines did not change over time. There was a significantly higher percentage of female authors in woman-led versus man-led guidelines, median 39% vs 20% (P = .012), as well as a significantly higher number of female coauthors in guidelines that were woman-led median 3.5 vs 1.0, P = .049. For quality, there was no significant difference in the overall rating or objective quality of woman- versus man-led guidelines. However, there was a significant increase in the overall rating of all the guidelines over time (P = .010), driven by the increase in overall rating among man-led guidelines, P = .002. The overall score of guidelines did not increase over time; however, they increased in man-led but not woman-led guidelines. There was no significant correlation between the percentage of female authors per guideline and either overall score or overall rating.

CONCLUSIONS

There is a substantial disparity in the number of women leading and contributing to guidelines which has not improved over time. Woman-led guidelines included more women and a higher percentage of women. There was no difference in quality of guidelines by first-author gender or percentage of female authors. Further systematic and quota-driven sponsorship is needed to promote gender equity, diversity, and inclusion in anesthesia guidelines.

Lay Health Worker Interventions in Rheumatology: A Scoping Review

OBJECTIVE

To determine next steps for lay health worker (LHW) intervention research, specifically in patients with rheumatic musculoskeletal diseases (RMDs), there is a need to establish what strategies have been effective for chronic disease management thus far. The goal of this scoping review is to collate the literature of LHW interventions for adults with RMDs to inform next steps for LHW research.

METHODS

A comprehensive literature search was performed in the following databases from inception to September 2021: Ovid Medline, Ovid Embase, CINAHL, PsycINFO, and The Cochrane Library. Studies retrieved were then screened for eligibility against predefined inclusion and exclusion criteria.

RESULTS

Twenty-two articles were eligible and included in this review. The most common RMDs studied, not mutually exclusive, were osteoarthritis (n = 13), rheumatoid arthritis (n = 9), and unspecified or other RMD (n = 14). Most studies had a homogenous patient population, enrolling White, non-Hispanic, or Latina women over the age of 60 (n = 13). Eight studies observed statistically significant results in the intervention arm compared with the control. Only one of these studies exhibited sustained treatment effects past one year.

CONCLUSION

There are not enough data to conclude if LHW interventions have a positive, null, or negative effect on patients with RMDs. Future LHW interventions should specify a priori hypotheses, be powered to detect statistical significance for primary outcomes, employ a theoretical framework, include an active control, describe training protocols for LHWs, and increase minority representation to establish the effectiveness of LHWs for patients with RMDs.

Volume outcome relationship in postesophagectomy leak: a systematic review and meta-analysis

BACKGROUND

Anastomotic leak after esophagectomy carries important short- and long-term sequelae. The authors conducted a systematic review and meta-analysis to determine its association with surgical volume.

MATERIALS AND METHODS

A systematic literature review was performed to identify all studies reporting on anastomotic leak after esophagectomy. Studies with less than 100 cases were excluded. The primary outcome was postesophagectomy anastomotic leak, while secondary outcomes were operative mortality overall and after anastomotic leak. Pooled event rates (PER) were calculated, and the association with annual esophagectomy volume by center was investigated.

RESULTS

Of the 3932 retrieved articles, 472 were included ( n =177 566 patients). The PER of anastomotic leak was 8.91% [95% CI=8.32; 9.53%]. The PER of early mortality overall and after an anastomotic leak was 2.49% [95% CI=2.27; 2.74] and 11.39% [95% CI=9.66; 13.39], respectively. Centers with less than 37 annual esophagectomies had a higher leak rate compared to those with greater than or equal to 37 annual esophagectomies (9.58% vs. 8.34%; P =0.040). On meta-regression, surgical volume was inversely associated with the PER of esophageal leak and of early mortality.

CONCLUSIONS

The frequency of anastomotic leaks after esophagectomy, perioperative, and leak associated mortality are inversely associated with esophagectomy volume.

Subclinical hypothyroidism and clinical outcomes after cardiac surgery: A systematic review and meta-analysis

Background

Subclinical hypothyroidism (SCH) is associated with major adverse cardiovascular events. Despite the recognized negative impact of SCH on cardiovascular health, research on cardiac postoperative outcomes with SCH has yielded conflicting results, and patients are not currently treated for SCH before cardiac surgery procedures.

Methods

We performed a study-level meta-analysis on the impact of SCH on patients undergoing nonurgent cardiac surgery, including coronary artery bypass grafting and valve and aortic surgery. The primary outcome was operative mortality. Secondary outcomes were hospital length of stay (LOS), intensive care unit (ICU) stay, postoperative atrial fibrillation (POAF), intra-aortic balloon pump (IABP) use, renal complications, and long-term all-cause mortality.

Results

Seven observational studies, with a total of 3445 patients, including 851 [24.7%] diagnosed with SCH and 2594 [75.3%] euthyroid patients) were identified. Compared to euthyroid patients, the patients with SCH had higher rates of operative mortality (odds ratio [OR], 2.57; 95% confidence interval [CI], 1.09-6.04; P = .03), prolonged hospital LOS (standardized mean difference, 0.32; 95% CI, 0.02-0.62; P = .04), a higher rate of renal complications (OR, 2.53; 95% CI, 1.74-3.69; P < .0001), but no significant differences in ICU stay, POAF, or IABP use. At mean follow-up of 49.3 months, the presence of SCH was associated with a higher rate of all-cause mortality (incidence rate ratio, 1.82; 95% CI, 1.18-2.83; P = .02).

Conclusions

Patients with SCH have higher operative mortality, prolonged hospital LOS, and increased renal complications after cardiac surgery. Achieving and maintaining a euthyroid state prior to and after cardiac surgery procedures might improve outcomes in these patients.

Thorax support vest to prevent sternal wound infections in cardiac surgery patients-a systematic review and meta-analysis

OBJECTIVES

Midline sternotomy is the main surgical access for cardiac surgeries. The most prominent complication of sternotomy is sternal wound infection (SWI). The use of a thorax support vest (TSV) that limits thorax movement and ensures sternal stability has been suggested to prevent postoperative SWI.

METHODS

We performed a meta-analysis to evaluate differences in clinical outcomes with and without the use of TSV after cardiac surgery in randomized trials. The primary outcome was deep SWI (DSWI). Secondary outcomes were superficial SWI, sternal wound dehiscence, and hospital length of stay (LOS). A trial sequential analysis was performed. Fixed (F) and random effects (R) models were calculated.

RESULTS

A total of 4 studies (3820 patients) were included. Patients who wore the TSV had lower incidence of DSWI [odds ratio (OR) = F: 0.24, 95% confidence interval (CI), 0.13-0.43, P < 0.01; R: 0.24, 0.04-1.59, P = 0.08], sternal wound dehiscence (OR = F: 0.08, 95% CI, 0.02-0.27, P < 0.01; R: 0.10, 0.00-2.20, P = 0.08) and shorter hospital LOS (standardized mean difference = F: -0.30, -0.37 to -0.24, P < 0.01; R: -0.63, -1.29 to 0.02, P = 0.15). There was no difference regarding the incidence of superficial SWI (OR = F: 0.71, 95% CI, 0.34-1.47, P = 0.35; R: 0.64, 0.10, 4.26, P = 0.42). The trial sequential analysis, however, showed that the observed decrease in DSWI in the TSV arm cannot be considered conclusive based on the existing evidence.

CONCLUSIONS

This meta-analysis suggests that the use of a TSV after cardiac surgery could potentially be associated with a reduction in sternal wound complications. However, despite the significant treatment effect in the available studies, the evidence is not solid enough to provide strong practice recommendations.

Survival difference among adult and pediatric mediastinal yolk sac tumors cases: A meta-analysis of case reports

BACKGROUND

Mediastinal Yolk sac tumors (YST) are rare and highly malignant extragonadal germ cell tumors with rapid growth and early metastases. We sought to conduct a meta-analysis of published case reports/case series to compare differences in survival, demographics, and treatment modalities between adult and pediatric patients with YST.

METHODS

Ovid Embase, Cochrane, and Ovid Medline databases were searched for primary mediastinal pure YST cases. The primary outcome was overall survival (OS). Log-rank and Cox regression were used. This study is registered on PROSPERO (CRD42022367586).

RESULTS

Among 846 studies, 87 met our inclusion criteria including 130 patients (Adults: 90 and Pediatrics: 40). About 41.5% of the patients were from the United States. The median age was 23.0 (Q1-Q3: 17.0-30.0), 88.5% were males, and (32.3%) were Asian. Stage II represented almost 40%. AFP was elevated in 96.9%. Respiratory distress was the presenting symptom in 65.4%. Chemotherapy, radiotherapy, and surgery were utilized in 84.6, 23.1, and 64.7% respectively. Median OS was 24 months (Adults: 23 months, Pediatrics: 25 months, P = 0.89). 3- and 5-year OS were 34.4% and 22.9% in adults and 41.5% and 41.5% in pediatrics, respectively. On multivariate analysis, anterior location of tumors, receipt of chemotherapy, and undergoing surgery were associated with better OS.

CONCLUSION

Primary mediastinal YSTs are rare, but lethal neoplasms. Our meta-analysis showed that mediastinal YSTs mimic other non-seminomatous mediastinal GCTs in terms of clinical characteristics and available treatment options. Early diagnosis, neoadjuvant chemotherapy, and surgical resection are the key points for effective management and improved outcomes.

Safety and Toxicity Profiles of CAR T Cell Therapy in Non-Hodgkin Lymphoma: A Systematic Review and Meta-Analysis

BACKGROUND

The application of CD19-directed chimeric antigen receptor T (CAR T) cell therapy has improved outcomes for thousands of patients with non-Hodgkin B cell lymphoma (NHL). The toxicities associated with various CAR T cell products, however, can be severe and difficult to anticipate.

METHODS

In this systematic review and meta-analysis, we set out to determine whether there are measurable differences in common toxicities, including cytokine release syndrome (CRS), immune effector cell associated neurotoxicity syndrome (ICANS), cytopenias, and infections, between CAR T products that are commercially available for the treatment of NHL.

RESULTS

After a stringent study selection process, we used a cohort of 1364 patients enrolled in 15 prospective clinical trials investigating the use of axicabtagene ciloleucel (axi-cel), lisocabtagene maraleucel (liso-cel), and tisagenlecleucel (tisa-cel). We found that the rates of CRS and ICANS were significantly higher with axi-cel as compared to both liso-cel and tisa-cel. Conversely, we demonstrated that rates of all-grade and severe neutropenia were significantly greater with liso-cel. Febrile neutropenia and all-grade infection rates did not differ significantly between products though rates of severe infection were increased with axi-cel.

CONCLUSIONS

Overall, this study serves as the first to delineate toxicity profiles associated with various available CAR T products. By better understanding associated toxicities, it may become possible to tailor therapies towards individual patients and anticipate the development of toxicities at earlier stages.

Efficacy and Toxicity of CD19 Chimeric Antigen Receptor T Cell Therapy for Lymphoma in Solid Organ Transplant Recipients: A Systematic Review and Meta-Analysis

The safety and efficacy of chimeric antigen receptor (CAR) T cell therapy in solid organ transplant recipients is poorly understood, given the paucity of available data in this patient population. There is a theoretical risk of compromising transplanted organ function with CAR T cell therapy; conversely, organ transplantation-related immunosuppression can alter the function of CAR T cells. Given the prevalence of post-transplantation lymphoproliferative disease, which often can be difficult to treat with conventional chemoimmunotherapy, understanding the risks and benefits of delivering lymphoma-directed CAR T cell therapy in solid organ transplant recipients is of utmost importance. We sought to determine the efficacy of CAR T cell therapy in solid organ transplant recipients as well as the associated adverse effects, including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and compromised solid organ transplant function. We conducted a systematic review and meta-analysis of adult recipients of solid organ transplant who received CAR T cell therapy for non-Hodgkin lymphoma. Primary outcomes included efficacy, defined as overall response (OR), complete response (CR), progression-free survival, and overall survival, as well as rates of CRS and ICANS. Secondary outcomes included rates of transplanted organ loss, compromised organ function, and alterations to immunosuppressant regimens. After a systematic literature review and 2-reviewer screening process, we identified 10 studies suitable for descriptive analysis and 4 studies suitable for meta-analysis. Among all patients, 69% (24 of 35) achieved a response to CAR T cell therapy, and 52% (18 of 35) achieved a CR. CRS of any grade occurred in 83% (29 of 35), and CRS grade ≥3 occurred in 9% (3 of 35). Sixty percent of the patients (21 of 35) developed ICANS, and 34% (12 of 35) developed ICANS grade ≥3. The incidence of any grade 5 toxicity among all patients was 11% (4 of 35). Fourteen percent of the patients (5 of 35) experienced loss of the transplanted organ. Immunosuppressant therapy was held in 22 patients but eventually restarted in 68% of them (15 of 22). Among the studies included in the meta-analysis, the pooled OR rate was 70% (95% confidence interval [CI], 29.2% to 100%; I2 = 71%) and the pooled CR rate was 46% (95% CI, 25.4% to 67.8%; I2 = 29%). The rates of any grade CRS and grade ≥3 CRS were 88% (95% CI, 69% to 99%; I2 = 0%) and 5% (95% CI, 0% to 21%; I2 = 0%), respectively. The rates of any grade ICANS and ICANS grade ≥3 were 54% (95% CI, 9% to 96%; I2 = 68%) and 40% (95% CI, 3% to 85%; I2 = 63%), respectively. The efficacy of CAR T cell therapy in solid organ transplant recipients is comparable to that in the general population as reported in prior investigational studies, with an acceptable toxicity profile in terms of CRS, ICANS, and transplanted organ compromise. Further studies are needed to determine long-term effects on organ function, sustained response rates, and best practices peri-CAR T infusion period in this patient population.

"Healthcare Disparities in the Care of Children with Craniosynostosis in the United States: A Systematic Review"

BACKGROUND

Healthcare inequity is a pressing concern in pediatric populations with craniofacial conditions. Little is known about the barriers to care affecting children with craniosynostosis. This systematic review investigates disparities impacting care for children with craniosynostosis in the U.S.

METHODS

A comprehensive literature search was performed in the following databases from inception to December 2022: Ovid MEDLINE, Ovid EMBASE, and The Cochrane Library. Studies were screened for eligibility by two authors. All original articles that focused on disparities in access, treatment, or outcomes of craniosynostosis surgery were included. Studies describing disparities in other countries, those not written English, and review articles were excluded (Figure 1).

RESULTS

An initial database search revealed 607 citations of which 21 met inclusion criteria (Figure 1). All included studies were retrospective reviews of databases or cohorts of patients. The results of our study demonstrate that barriers to access in treatment for craniosynostosis disproportionally affect minority children, children of non-English speaking parents and those of lower socioeconomic status or with Medicaid. Black and Hispanic children, non-English speaking patients, and children without insurance or with Medicaid were more likely to present later for evaluation, ultimately undergoing surgery at an older age. These patients were also more likely to experience complications and require blood transfusions compared to their more privileged, white peers.

CONCLUSIONS

There is a discrepancy in treatment received by minority patients, patients with Medicaid, and those who are non-English speaking. Further research is needed to describe the specific barriers that prevent equitable care for these patients.

Coronary Artery Bypass Surgery to Treat Anomalous Origin of Coronary Arteries in Adults: A Systematic Review

OBJECTIVE

To review the available literature on the use of coronary artery bypass grafting (CABG) as a treatment option for anomalous origin of coronary artery in adults.

METHODS

A systematic literature search was performed in March 2023 (including Ovid MEDLINE, Ovid Embase, and the Cochrane Library databases) to identify studies reporting the use of CABG in adult patients with anomalous origin of coronary artery.

RESULTS

A total of 31 studies and 62 patients were included, 32 patients (52%) were women, and the mean age was 45.1±16.1 years. The most common coronary anomaly was the right coronary artery arising from the left coronary sinus in 26 patients (42%), followed by an anomalous left coronary artery from the pulmonary artery in 23 patients (37%). A total of 65 conduits were used in 61 patients, and 1 case report did not report conduit type. Reported grafts included saphenous vein (23 of 65 [35.4%]), left internal thoracic artery (15 of 65 [23.1%]), right internal thoracic artery (23 of 65 [35.4%]), and radial artery (2 of 65 [3.1%]); right gastroepiploic artery and basilic vein were used once (1.5%) each. Ligation of the native coronary artery was performed in 42 (67.7%) patients. Patient follow-up was available in 19 studies with a mean of 31.2 months. Only 1 operative mortality was reported.

CONCLUSIONS

Based on the limited available data, CABG can be performed with good early results. Use of arterial conduits and ligation of the native coronary artery may improve long-term graft patency.

Coronary Plaque Characteristics Associated With Major Adverse Cardiovascular Events in Atherosclerotic Patients and Lesions: A Systematic Review and Meta-Analysis

BACKGROUND

The clinical value of high-risk coronary plaque characteristics (CPCs) to inform intensified medical therapy or revascularization of non-flow-limiting lesions remains uncertain.

OBJECTIVES

The authors performed a systematic review and meta-analysis to study the prognostic impact of CPCs on patient-level and lesion-level major cardiovascular adverse events (MACE).

METHODS

Thirty studies (21 retrospective, 9 prospective) with 30,369 patients evaluating the association of CPCs with MACE were included. CPCs included high plaque burden, low minimal lumen area, thin cap fibroatheroma, high lipid core burden index, low-attenuation plaque, spotty calcification, napkin ring sign, and positive remodeling.

RESULTS

CPCs were evaluated with the use of intracoronary modalities in 9 studies (optical coherence tomography in 4 studies, intravascular ultrasound imaging in 3 studies, and near-infrared spectroscopy intravascular ultrasound imaging in 2 studies) and by means of coronary computed tomographic angiography in 21 studies. CPCs significantly predicted patient-level and lesion-level MACE in both unadjusted and adjusted analyses. For most CPCs, accuracy for MACE was modest to good at the patient level and moderate to good at the lesion level. Plaques with more than 1 CPC had the highest accuracy for lesion-level MACE (AUC: 0.87). Because the prevalence of CPCs among plaques was low, estimated positive predictive values for lesion-level MACE were modest. Results were mostly consistent across imaging modalities and clinical presentations, and in studies with prevailing hard outcomes.

CONCLUSIONS

Characterization of CPCs identifies high-risk atherosclerotic plaques that place lesions and patients at risk for future MACE, albeit with modest sensitivity and positive predictive value (Coronary Plaque Characteristics Associated With Major Adverse Cardiovascular Events Among Atherosclerotic Patients and Lesions; CRD42021251810).

Quality of Life After Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting

BACKGROUND

Differences in quality of life (QoL) after coronary artery bypass grafting (CABG) compared with percutaneous coronary intervention (PCI) are not well characterized. We aimed to compare the short- and long-term effects of CABG versus PCI on QoL.

METHODS AND RESULTS

We performed a systematic review and meta-analysis of randomized controlled trials comparing CABG versus PCI using the Seattle Angina Questionnaire (SAQ)-Angina Frequency, SAQ-QoL, SAQ-Physical Limitations, EuroQoL-5D, and Short-Form Questionnaire. We calculated mean changes within each group from baseline to 1, 6, 12, and 36 to 60 months (latest follow-up) and the weighted mean differences between groups using inverse-variance methods. A total of 10 760 patients were enrolled in 5 trials. From baseline to 12 months and 36 to 60 months, the mean change in SAQ-Angina Frequency was >22 points (95% CI, 21.0-25.6) after both PCI and CABG. The mean difference in SAQ-Angina Frequency was similar between procedures at 1 month and at 36 to 60 months but favored CABG at 12 months (1.97 [95% CI, 0.68-3.26]). SAQ-QoL favored PCI at 1 month (-2.92 [95% CI, -4.66 to -1.18]) and CABG at 6 (2.50 [95% CI, 1.02-3.97]), 12 (3.30 [95% CI, 1.78-4.82]), and 36 to 60 months (3.17 [95% CI, 0.54 5.80). SAQ-Physical Limitations (-12.61 [95% CI, -16.16 to -9.06]) and EuroQoL-5D (-0.07 [95% CI, -0.08 to -0.07) favored PCI at 1 month. Short-Form Questionnaire-Physical Component favored CABG at 12 months (1.18 [95% CI, 0.46-1.90]).

CONCLUSIONS

Both PCI and CABG improved long-term disease-specific and generic QoL.

The VEST External Support for Saphenous Vein Grafts in Coronary Surgery: A Review of Randomized Clinical Trials

Saphenous vein grafts (SVGs) are the most frequently used conduits in coronary artery bypass grafting (CABG), but their higher rate of occlusion compared to arterial conduits remains a concern. Previous studies have shown that SVG failure is mainly driven by intimal hyperplasia, an adaptative response to higher pressures of the arterial circulation. The VESTTM device (Vascular Graft Solutions, Tel Aviv, Israel), an external support designed to mitigate intimal hyperplasia in SVGs, has been tested in few clinical trials (RCTs). Herein, we descriptively evaluated the randomized evidence on the VEST device.

Differences in Postoperative Atrial Fibrillation Incidence and Outcomes After Cardiac Surgery According to Assessment Method and Definition: A Systematic Review and Meta-Analysis

BACKGROUND

Postoperative atrial fibrillation (POAF) is the most frequent complication of cardiac surgery. Despite clinical and economic implications, ample variability in POAF assessment method and definition exist across studies. We performed a study-level meta-analysis to evaluate the influence of POAF assessment method and definition on its incidence and association with clinical outcomes.

METHODS AND RESULTS

A systematic literature search was conducted to identify studies comparing the outcomes of patients with and without POAF after cardiac surgery that also reported POAF assessment method. The primary outcome was POAF incidence. The secondary outcomes were in-hospital mortality, stroke, intensive care unit length of stay, and postoperative length of stay. Fifty-nine studies totaling 197 774 patients were included. POAF cumulative incidence was 26% (range: 7.3%-53.1%). There were no differences in POAF incidence among assessment methods (27%, [range: 7.3%-53.1%] for continuous telemetry, 27% [range: 7.9%-50%] for telemetry plus daily ECG, and 19% [range: 7.8%-42.4%] for daily ECG only; P>0.05 for all comparisons). No differences in in-hospital mortality, stroke, intensive care unit length of stay, and postoperative length of stay were found between assessment methods. No differences in POAF incidence or any other outcomes were found between POAF definitions. Continuous telemetry and telemetry plus daily ECG were associated with higher POAF incidence compared with daily ECG in studies including only patients undergoing isolated coronary artery bypass grafting.

CONCLUSIONS

POAF incidence after cardiac surgery remains high, and detection rates are variable among studies. POAF incidence and its association with adverse outcomes are not influenced by the assessment method and definition used, except in patients undergoing isolated coronary artery bypass grafting.

Spinal cord injury after open and endovascular repair of descending thoracic aneurysm and thoracoabdominal aortic aneurysm: an updated systematic review and meta-analysis

Background

Spinal cord injury (SCI) is a rare but severe complication after open or endovascular repair of descending thoracic aneurysms (DTAs) or thoracoabdominal aortic aneurysms (TAAAs). This meta-analysis aims to provide a comprehensive assessment of SCI rates and factors associated with SCI.

Methods

A systematic literature search was performed in September 2022 looking for studies on open and/or endovascular repair of DTA and/or TAAA published after 2018, to update the results of our previously published meta-analysis. The primary outcome was permanent SCI. Secondary outcomes were temporary SCI, 30-day and in-hospital mortality, follow-up mortality, postoperative stroke, and cerebrospinal fluid (CSF) drain-related complications. Data were pooled as proportions using inverse-variance weighting.

Results

A total of 239 studies (71 new studies and 168 from our previous meta-analysis) and 61,962 patients were included. The overall pooled rate of permanent SCI was 3.3% [95% confidence interval (CI), 2.9-3.8%]. Open repair was associated with a permanent SCI rate of 4.0% (95% CI, 3.3-4.8%), and endovascular repair was associated with a permanent SCI rate of 2.9% (95% CI, 2.4-3.5%). Permanent SCI was 2.0% (95% CI, 1.2-3.3%) after DTA repair, and 4.7% (95% CI, 3.9-5.6%) after TAAA repair; permanent SCI rate was 3.8% (95% CI, 2.9-5.0%) for Crawford extent I, 13.4% (95% CI, 9.0-19.5%) for extent II, 7.1% (95% CI, 5.7-8.9%) for extent III, 2.3% (95% CI, 1.6-3.5%) for extent IV, and 6.7% (95% CI, 1.7-23.1%) for extent V TAAA aneurysms. The pooled rate of CSF drain related complications was 1.9% (95% CI, 0.8-4.7%) for severe, 0.4% (95% CI, 0.0-4.0%) for moderate, and 1.8% (95% CI, 0.6-5.6%) for minor complications.

Conclusions

Permanent SCI occurs after both endovascular and open DTA or TAAA repairs. Open repairs and TAAA repairs have higher risk of SCI compared with endovascular or DTA repairs. In particular, extent II aneurysms present the highest overall risk of SCI.

Psychiatric Comorbidities and Outcomes in Palliative and End-of-Life Care: A Systematic Review

BACKGROUND

Although psychiatric comorbidities are common among individuals at end of life, their impact on outcomes is poorly understood.

METHODS

We conducted a systematic literature review of six databases following preferred reporting items for systematic reviews and meta-analyses guidelines and aimed at assessing the relationship between psychiatric comorbidities and outcomes in palliative and end-of-life care. Six databases were included in our search. This review is registered on PROSPERO (CRD42022335922).

RESULTS

Our search generated 7472 unique records. Eighty-eight full texts were reviewed for eligibility and 43 studies were included in the review. Clinically, psychiatric comorbidity was associated with poor quality of life, increased physical symptom burden, and low function. The impact of psychiatric comorbidity on health utilization varied, though many studies suggested that psychiatric comorbidity increased utilization of palliative care services. Quality of evidence was limited by lack of consistent approach to confounding variables as well as heterogeneity of the included studies.

CONCLUSION

Psychiatric comorbidity is associated with significant differences in care utilization and clinical outcome among patients at end of life. In particular, patients with psychiatric comorbidity and serious illness are at high risk of poor quality of life and high symptom burden. Our finding that psychiatric comorbidity is associated with increased utilization of palliative care likely reflects the complexity and clinical needs of patients with serious illness and mental health needs. These data suggest that greater integration of mental health and palliative care services may enhance quality-of-life among patients at end of life.

Comparison of SYNTAX score strata effects of percutaneous and surgical revascularization trials: A meta-analysis

OBJECTIVES

The evidence supporting the use of the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) score for risk stratification is controversial. We performed a systematic review and meta-analysis of all the randomized controlled trials comparing percutaneous coronary intervention versus coronary artery bypass grafting that reported their outcomes stratified by SYNTAX score, focusing on between-strata comparisons.

METHODS

A systematic review of MEDLINE, EMBASE, Cochrane Library databases was performed. Incidence rate ratios were pooled with a random effect model. Between-group statistical heterogeneity according to accepted SYNTAX score tertiles was computed in the main analysis. Ratios of incidence rate ratios were computed to appraise between-strata effect, as sensitivity analysis. Primary and secondary outcomes were major adverse cardiac and cerebrovascular events and all-cause mortality, respectively. Separate sub-analyses were performed for left main and multivessel disease.

RESULTS

From 425 citations, 6 trials were eventually included (8269 patients [4134 percutaneous coronary interventions, 4135 coronary artery bypass graftings]; mean follow-up: 6.2 years [range: 3.8-10]). Overall, percutaneous coronary intervention was associated with a significant increase in major adverse cardiac and cerebrovascular events (incidence rate ratio, 1.39, 95% confidence interval, 1.27-1.51) and nonsignificant increase in all-cause mortality (incidence rate ratio, 1.17, 95% confidence interval, 0.98-1.40). There was no significant statistical heterogeneity of treatment effect by SYNTAX score for major adverse cardiac and cerebrovascular events or mortality (P = .40 and P = .34, respectively). Results were consistent also for patients with left main and multivessel disease (major adverse cardiac and cerebrovascular events: P = .85 in left main, P = .78 in multivessel disease 0.78; mortality: P = .12 in left main; P = .34 in multivessel disease). Results of analysis based on ratios of incidence rate ratios were consistent with the main analysis.

CONCLUSIONS

No significant association was found between SYNTAX score and the comparative effectiveness of percutaneous coronary intervention and coronary artery bypass grafting. These findings have implications for clinical practice, future guidelines, and the design of percutaneous coronary intervention versus coronary artery bypass grafting trials.

Coronary artery bypass with single versus multiple arterial grafts in women: A meta-analysis

OBJECTIVE

The study objective was to investigate the impact of multiple arterial grafting on long-term all-cause mortality in women undergoing isolated coronary artery bypass grafting.

METHODS

A comprehensive search was performed to identify observational studies reporting outcomes after coronary artery bypass grafting reported by sex and stratified into multiple arterial grafting versus single arterial grafting strategies. Articles were considered for inclusion if they were written in English and were propensity-matched observational studies. Included studies were then pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was long-term all-cause mortality. Secondary outcomes were operative mortality and spontaneous myocardial infarction. Meta-regression was used to explore the effects of preoperative and intraoperative variables on the primary outcome.

RESULTS

A total of 6 studies with 32,793 women (25,714 single arterial grafting and 7079 multiple arterial grafting) were included. Women who received multiple arterial grafting had lower long-term mortality (incidence rate ratio, 0.86; 95% confidence interval, 0.76-0.96; P = .007) and spontaneous myocardial infarction (incidence rate ratio, 0.80; 95% confidence interval, 0.68-0.93; P = .003) compared with women who received single arterial grafting, but the difference in mortality disappeared when including only the 3 largest studies. There was no difference between groups in operative mortality (odds ratio, 0.99; 95% confidence interval, 0.84-1.17; P = .91). Meta-regression did not identify any associations with the incidence rate ratio for long-term mortality.

CONCLUSIONS

The use of multiple arterial grafting in women undergoing coronary artery bypass grafting is associated with lower long-term mortality, although the difference is mostly driven by small series. Further studies, including randomized trials, are needed to evaluate the efficacy of multiple arterial grafting in women undergoing coronary artery bypass grafting.

Comparison of meta-analytical estimates of outcomes after Alfieri or neochordal repair in isolated anterior mitral prolapse

OBJECTIVES

Repair of the isolated degenerative anterior mitral leaflet has been considered more challenging and associated with compromised durability compared with isolated posterior leaflet in major series. Implantation of neochordae or Alfieri edge-to-edge is the most employed repair technique for isolated anterior repair currently, but little data exist comparing their relative durability. We sought to investigate this issue with this meta-analysis.

METHODS

A literature search was performed (Ovid MEDLINE, Ovid Embase and The Cochrane Library). The primary outcome was the incidence rate (IR) of reoperation, the secondary outcomes were recurrent moderately severe/severe mitral regurgitation (MR), in-hospital/30-day reoperation and mortality and follow-up mortality. A random-effect model was used. Leave-one-out, subgroup analysis (Alfieri versus neochordae) and meta-regression were done.

RESULTS

Seventeen studies (including 1358 patients) were included. At a weighted mean follow-up of 5.56 ± 3.31 years, the IR for reoperation was 14.45 event per 1000 person-year and significantly lower in Alfieri than neochordae repair (9.40 vs 18.61, P = 0.04) on subgroup analysis. The IR of follow-up moderately severe/severe MR was 19.89 event per 1000 person-year and significantly lower in Alfieri than neochordae repair (10.68 and 28.63, P = 0.01). In a sensitivity analysis comparing homogenous studies, a significant difference in the recurrence of regurgitation in favour of the Alfieri approach remained. There were no differences in operative outcomes or survival. There were significant associations between increased incidence of late reoperation and New York Heart Association class III/IV and associated coronary artery bypass graft procedure for whole cohort.

CONCLUSIONS

Alfieri repair may be associated with a lower incidence of recurrent MR compared with neochordae-based repair in the setting of isolated degenerative anterior mitral pathology. This is the first such meta-analysis and further inquiry into this area is needed.

Difference in spontaneous myocardial infarction and mortality in percutaneous versus surgical revascularization trials: A systematic review and meta-analysis

OBJECTIVES

It has been hypothesized that the survival benefit of coronary artery bypass (CABG) compared with percutaneous interventions (PCI) may be associated with the reduction in spontaneous myocardial infarction (SMI) achieved by surgery. This, however, has not been formally investigated. The present meta-analysis aims to evaluate the association between the difference in SMI and in survival in PCI versus CABG randomized controlled trials (RCTs).

METHODS

A systematic search was performed to identify all RCTs comparing PCI with CABG for the treatment of coronary artery disease and reporting SMI outcomes. Generic inverse variance method was used to pool outcomes as natural logarithms of the incident rate ratios across studies. Subgroup analysis and interaction test were used to compare the difference of the primary outcome among trials that did and did not report a significant reduction in SMI- in the patients treated by CABG. Primary outcome was all-cause mortality; secondary outcome was SMI.

RESULTS

Twenty RCTs were included in the meta-analysis. A statistically significant difference in SMI in favor of CABG was found in 7 of the included trials (35%). Overall, PCI was associated with significantly greater all-cause mortality (incident rate ratio, 1.13; 95% confidence interval, 1.01-1.28). At subgroup analysis, a significant difference in survival in favor of CABG was seen only in trials that reported a significant reduction in SMI in the surgical arm (P for interaction 0.02).

CONCLUSIONS

In the published PCI versus CABG trials, the reduction in all-cause mortality in the surgical arm is associated with the protective effect of CABG against SMI.

Deep Sternal Wound Infection and Mortality in Cardiac Surgery: A Meta-analysis

BACKGROUND

Deep sternal wound infection (DSWI) is a rare but severe complication after cardiac surgical procedures and has been associated with increased early morbidity and mortality. Studies reporting long-term outcomes in patients with DSWI have shown contradictory results. We performed a study-level meta-analysis evaluating the impact of DSWI on short- and long-term clinical outcomes.

METHODS

A systematic literature search was conducted to identify studies comparing short- and long-term outcomes of patients submitted to cardiac surgical procedures who developed DSWI and patients who did not. The primary outcome was overall mortality. Secondary outcomes were in-hospital mortality, follow-up mortality, major adverse cardiovascular events, myocardial infarction, and repeat revascularization. Postoperative outcomes were also investigated.

RESULTS

Twenty-four studies totaling 407 829 patients were included. Overall, 6437 (1.6%) patients developed DSWI. Mean follow-up was 3.5 years. DSWI was associated with higher overall mortality (incidence rate ratio [IRR], 1.99; 95% CI, 1.66-2.38; P < .001), in-hospital mortality (odds ratio, 3.30; 95% CI, 1.88-5.81; P < .001), follow-up mortality (IRR, 2.02; 95% CI, 1.39-2.94; P = .001), and major adverse cardiovascular events (IRR, 2.04; 95% CI, 1.60-2.59; P < .001). No differences in myocardial infarction and repeat revascularization were found, but limited studies reported those outcomes. DSWI was associated with longer postoperative hospitalization, stroke, myocardial infarction, and respiratory and renal failure. Sensitivity analyses on isolated coronary artery bypass grafting studies and by adjustment method were consistent with the main analysis.

CONCLUSIONS

Compared with patients who did not develop DSWI, patients with DSWI after cardiac surgical procedures had increased risk of death as well as short- and long-term adverse clinical outcomes.

Effect of posterior pericardiotomy in cardiac surgery: A systematic review and meta-analysis of randomized controlled trials

Background

Posterior pericardiotomy (PP) has been shown to reduce the incidence of pericardial effusion and postoperative atrial fibrillation (POAF) after cardiac surgery. However, the procedure and the totality of its effects are poorly known in the cardiac surgery community. We performed a study-level meta-analysis of randomized controlled trials (RCTs) to evaluate the impact of PP in cardiac surgery patients.

Methods

A systematic literature search was conducted on three medical databases (Ovid MEDLINE, Ovid Embase, Cochrane Library) to identify RCTs reporting outcomes of patients that received a PP or no intervention after cardiac surgery. The primary outcome was the incidence of POAF. Key secondary outcomes were operative mortality, incidence of pericardial and pleural effusion, cardiac tamponade, length of stay (LOS), pulmonary complications, amount of chest drainage, need for intra-aortic balloon pump, and re-exploration for bleeding.

Results

Eighteen RCTs totaling 3,531 patients were included. PP was associated with a significantly lower incidence of POAF (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.32-0.64, P < 0.0001), early (OR 0.18, 95% CI 0.10-0.34, P < 0.0001) and late pericardial effusion (incidence rate ratio 0.13, 95% CI 0.06-0.29, P < 0.0001), and cardiac tamponade (risk difference -0.02, 95% CI -0.04 to -0.01, P = 0.001). PP was associated with a higher incidence of pleural effusion (OR 1.42, 95% CI 1.06-1.90, P = 0.02), but not pulmonary complications (OR 0.82, 95% CI 0.56-1.19; P = 0.38). No differences in other outcomes, including operative mortality, were found.

Conclusions

PP is a safe and effective intervention that significantly decreases the incidence of POAF and pericardial effusion following cardiac surgery.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=261485, identifier: CRD42021261485.

Association of liver dysfunction with outcomes after cardiac surgery-a meta-analysis

OBJECTIVES

The aim of this study was to perform a meta-analysis of studies reporting outcomes in patients with liver dysfunction addressed by the model of end-stage liver disease and Child-Turcotte-Pugh scores undergoing cardiac surgery.

METHODS

A systematic literature search was conducted to identify contemporary studies reporting short- and long-term outcomes in patients with liver dysfunction compared to patients with no or mild liver dysfunction undergoing cardiac surgery (stratified in high and low score group based on the study cut-offs). Primary outcome was perioperative mortality. Secondary outcomes were perioperative neurological events, prolonged ventilation, sepsis, bleeding and/or need for transfusion, acute kidney injury and long-term mortality.

RESULTS

A total of 33 studies with 48 891 patients were included. Compared with the low score group, being in the high score group was associated with significantly higher risk of perioperative mortality [odds ratio (OR) 3.72, 95% confidence interval (CI) 2.75-5.03, P < 0.001]. High score group was also associated with a significantly higher rate of perioperative neurological events (OR 1.49, 95% CI 1.30-1.71, P < 0.001), prolonged ventilation (OR 2.45, 95% CI 1.94-3.09, P < 0.001), sepsis (OR 3.88, 95% CI 2.07-7.26, P < 0.001), bleeding and/or need for transfusion (OR 1.95, 95% CI 1.43-2.64, P < 0.001), acute kidney injury (OR 3.84, 95% CI 2.12-6.98, P < 0.001) and long-term mortality (incidence risk ratio 1.29, 95% CI 1.14-1.46, P < 0.001).

CONCLUSIONS

The analysis suggests that liver dysfunction in patients undergoing cardiac surgery is independently associated with higher risk of short and long-term mortality and also with an increased occurrence of various perioperative adverse events.

Sex differences in saphenous vein graft patency: A systematic review and meta-analysis

BACKGROUND

Saphenous vein grafts (SVG) are the most commonly used conduits in coronary artery bypass grafting (CABG). Graft failure is observed in up to 50% of SVG at 10 years after surgery. Whether a difference in SVG patency rates exists between men and women remains unclear.

METHODS

We performed a study-level meta-analysis to evaluate sex-related differences in follow-up patency rates of SVG after CABG. A systematic literature search was conducted to identify studies on CABG that reported follow-up SVG patency rates in men and women. The primary outcome was SVG patency rates by sex at follow-up.

RESULTS

Seventeen studies totaling 8235 patients and 14,781 SVG grafts were included. There was no significant difference in follow-up SVG patency rates between men and women (incidence rate ratio 0.96, 95% confidence interval 0.90-1.03, p = .24), with mean angiographic follow-up of 33.5 months (standard deviation 29.2). Leave-one-out and cumulative analysis were consistent with the main analysis. We concluded that follow-up SVG patency rate is similar between men and women undergoing CABG.

Mortality after sternal reconstruction with pectoralis major flap vs omental flap for postsurgical mediastinitis: A systematic review and meta-analysis

BACKGROUND

Deep sternal wound infections are rare but severe complications after median sternotomy and can be managed with sternal reconstruction. The use of pectoralis major flap (PMF) has traditionally been the first-line approach for flap reconstruction but the advantage in patients' survival when compared to the omental flap (OF) transposition is still not clear. We performed a study-level meta-analysis evaluating the association of the type of flap on postoperative outcomes.

METHODS

A systematic search of the literature was performed to identify all studies comparing the postoperative outcomes of PMF versus OF for sternal reconstruction. The primary outcome was postoperative mortality. Secondary outcomes were the occurrence of sepsis, pneumonia, operative time, and length of stay. Binary outcomes were pooled using an inverse variance method and reported as odds ratio (OR) with corresponding 95% confidence interval (CI). Continuous outcomes were pooled using an inverse variance method and reported as standardized mean difference (SMD) with corresponding 95% CI.

RESULTS

Four studies with a total of 528 patients were included in the analysis. Overall, 443 patients had PMF reconstruction, and 85 patients had OF reconstruction. Baseline characteristics were similar in both groups. There were no statistically significant differences between PMF patients and OF patients in mortality (OR 0.6 [0.16; 2.17]; p = .09), sepsis (OR 1.1 [0.49; 2.47]; p = .43), pneumonia (OR 0.72 [0.18; 2.8]; p = .11), length of stay (SMD -0.59 [-2.03; 0.85]; p < .01), and operative time (SMD 0.08 [-1.21; 1.57]; p < .01).

CONCLUSION

Our analysis found no association between the type of flap and postoperative mortality, the incidence of pneumonia, sepsis, operation time, and length of stay.

Evaluation of the Quality of COVID-19 Guidance Documents in Anaesthesia using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) Instrument

Background

Methods

Results

Conclusions

Strategies to optimize comprehension of numerical medication instructions: A systematic review and concept map

OBJECTIVE

To develop evidence-based recommendations for improving comprehension of quantitative medication instructions.

METHODS

This review included a literature search from inception to November 2021. Studies were included for the following: 1) original research; 2) compared multiple formats for presenting quantitative medication information on dose, frequency, and/or time; 3) included patients/lay-people; 4) assessed comprehension-related outcomes quantitatively. To classify the studies, we developed a concept map. We weighed 3 factors (risk of bias in individual studies, consistency of findings among studies, and homogeneity of the interventions tested) to generate 3 levels of recommendations.

RESULTS

Twenty-one studies were included. Level 1 recommendations are: 1) use visualizations of medication doses for liquid medications, and 2) express instructions in time-periods rather than times per day. Level 2 recommendations include: validate icons, use panels or tables with explanatory text, use visualizations for non-English speaking populations and for those with low health literacy and limited English proficiency.

CONCLUSIONS

Visualized liquid medication doses and time period-based administration instructions improve comprehension of numerical medication instructions. Use of visualizations for those with limited health literacy and English proficiency could result in improved outcomes.

PRACTICE IMPLICATIONS

Practitioners should use visualizations for liquid medication instructions and time period-based instructions to improve outcomes.

The great vessel freeze-out: A meta-analysis of conventional versus frozen elephant trunks in aortic arch surgery

Background

The optimal treatment strategy for complex aortic arch and proximal descending aortic pathologies remains controversial. Despite the frozen elephant trunk (FET) technique's increasing popularity, its use over the conventional elephant trunk (CET) remains a matter of physician preference and outcomes are varied.

Methods

This meta‐analysis of available comparative studies of FET versus CET sought to examine differences in survival, reintervention, and adverse events. The following databases were searched from inception—May 2020: Ovid MEDLINE, Ovid EMBASE, and The Cochrane Library. Studies retrieved were then screened for eligibility against predefined inclusion/exclusion criteria with a protocol registered on Open Science Framework at https://osf.io/hrfze/.

Results

The search identified 1911 citations, with five studies included. The resultant meta‐analysis included 313 CET and 292 FET cases. FET had lower perioperative mortality (risk ratio [RR]: 0.50, 95% confidence interval [CI]: [0.42; 0.60], p < .001) and improved 1‐year survival compared to CET (hazard ratio: 0.63, 95% CI: [0.42; 0.95], p = .03). There were no significant differences in rates of overall or open reinterventions following FET versus CET, but FET did yield a significantly higher rate of endovascular reintervention (RR: 2.32, 95% CI: [1.17; 4.61], p = .03). No significant differences were observed in the incidences of postoperative stroke, spinal cord injury, or renal failure between groups.

Conclusions

The FET technique yields superior rates of perioperative and medium‐term survival with no significant increase in overall reinterventions. There was no significant difference in the rate of spinal cord injury between groups, providing further large‐scale evidence that the FET is an acceptable, safe alternative to the CET.

Quality of recent clinical practice guidelines in anaesthesia publications using the Appraisal of Guidelines for Research and Evaluation II instrument

Clinical practice guidelines are a valuable resource aiding medical decision-making based on scientific evidence. In anaesthesia, guidelines are increasing in both number and scope, influencing individual practice and shaping local departmental policy. The aim of this review is to assess the quality of clinical practice guidelines published in high impact anaesthesia journals over the past 5 yr using the internationally validated Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. A literature search was conducted in Scopus to identify all guidelines published in the top 10 anaesthesia journals as per Clarivate Analytics Impact Factor from 2016 and 2020. Fifty-one guidelines were included for analysis by five independent appraisers using AGREE II. Each guideline was assessed across six domains and 23 items. Individual domain scores were calculated with a threshold agreed via consensus to represent high-quality guidelines. There was a significant increase in overall score over time (P=0.041), driven by Domain 3 (Rigour of Development, P=0.046). The raw overall score for Domain 3, however, was low. The other domains performed as expected based on previous studies, with Domains 1, 4, and 6 achieving high scores and Domains 2 and 5 incurring poor ratings. Most guidelines studied involved international collaboration but emerged from a single professional society. Use of an appraisal tool was stated as high but poorly detailed. The improvement in the overall score of guidelines and rigour of development is promising; however, only seven guidelines met high-quality criteria, suggesting room for improvement for the overall integrity of guidelines in anaesthesia.

Executive Summary of Recommendations and Expert Consensus for Plasma and Platelet Transfusion Practice in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding (TAXI-CAB)

OBJECTIVES

Critically ill children frequently receive plasma and platelet transfusions. We sought to determine evidence-based recommendations, and when evidence was insufficient, we developed expert-based consensus statements about decision-making for plasma and platelet transfusions in critically ill pediatric patients.

DESIGN

Systematic review and consensus conference series involving multidisciplinary international experts in hemostasis, and plasma/platelet transfusion in critically ill infants and children (Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding [TAXI-CAB]).

SETTING

Not applicable.

PATIENTS

Children admitted to a PICU at risk of bleeding and receipt of plasma and/or platelet transfusions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of 29 experts in methodology, transfusion, and implementation science from five countries and nine pediatric subspecialties completed a systematic review and participated in a virtual consensus conference series to develop recommendations. The search included MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020, using a combination of subject heading terms and text words for concepts of plasma and platelet transfusion in critically ill children. Four graded recommendations and 49 consensus expert statements were developed using modified Research and Development/UCLA and Grading of Recommendations, Assessment, Development, and Evaluation methodology. We focused on eight subpopulations of critical illness (1, severe trauma, intracranial hemorrhage, or traumatic brain injury; 2, cardiopulmonary bypass surgery; 3, extracorporeal membrane oxygenation; 4, oncologic diagnosis or hematopoietic stem cell transplantation; 5, acute liver failure or liver transplantation; 6, noncardiac surgery; 7, invasive procedures outside the operating room; 8, sepsis and/or disseminated intravascular coagulation) as well as laboratory assays and selection/processing of plasma and platelet components. In total, we came to consensus on four recommendations, five good practice statements, and 44 consensus-based statements. These results were further developed into consensus-based clinical decision trees for plasma and platelet transfusion in critically ill pediatric patients.

CONCLUSIONS

The TAXI-CAB program provides expert-based consensus for pediatric intensivists for the administration of plasma and/or platelet transfusions in critically ill pediatric patients. There is a pressing need for primary research to provide more evidence to guide practitioners.

Angiographic Patency of Coronary Artery Bypass Conduits: An Updated Network Meta-Analysis of Randomized Trials

Introduction

The second best conduit for coronary artery bypass grafting is uncertain. The objective of this study is to determine the second best conduit according to graft patency results from randomized controlled trials using a network meta-analysis.

Methods

A systematic literature search was conducted for randomized controlled trials comparing the angiographic patency rate of the no-touch saphenous vein (NT-SV), the radial artery (RA), the right internal thoracic artery (RITA), and the gastroepiploic artery (GEA) in reference to the conventionally harvested saphenous vein (CON-SV). The primary outcome was graft occlusion, and the secondary outcome was all-cause mortality.

Results

A total of 859 studies were retrieved, of which 18 were included. A total of 6,543 patients and 8,272 grafts were analyzed. The weighted mean angiographic follow-up time was 3.5 years. Compared with CON-SV, RA (incidence rate ratio [IRR] 0.56; 95% confidence interval [CI], 0.43-0.74) and NT-SV (IRR 0.56; 95% CI, 0.44-0.70) demonstrated lower graft occlusion. NT-SV and RA were ranked as the best conduits (rank score for NT-SV 0.88 vs. 0.87 for RA, 0.29 for GEA, 0.27 for CON-SV, and 0.20 for RITA). There was no significant difference in late mortality between different conduit types.

Conclusion

RA and NT-SV are associated with significantly lower graft occlusion rates and are comparably ranked as the best conduit for patency.

A survey of retractions in the cardiovascular literature

BACKGROUND

Retractions of erroneous and fraudulent papers from the biomedical literature continue to be a major concern. The aim of this analysis is to summarize trends of retractions in the cardiovascular literature over the past four decades.

METHODS

A review of the Retraction Watch database for retracted articles published between 1978 and 2020 in the cardiovascular literature was performed. Retractions with the term "medicine" in the subject code were selected. Titles and abstracts were reviewed and only retractions of articles in cardiovascular medicine and surgery were included.

RESULTS

459 retraction notices published in 228 journals were identified. The number of retractions increased with time from 1 in 1991 to 48 at the end of 2019 (P < 0.001). Overall, the yearly percentage of retraction increased during the study period (P < 0.001) but decreased after 2015. China had the highest percentage of retractions when compared to other countries (P < 0.001). The majority of articles were retracted for scientific misconduct (n = 289, 63.0%); retractions due to scientific misconduct increased significantly over the study period (P = 0.04) but decreased after 2015. The median time from publication to retraction was 1.4 years (interquartile range [IQR]: 0.6-3.8) and decreased significantly over time (P < 0.001). The median number of citations of retracted articles was 8.0.

CONCLUSIONS

The number of retractions and the yearly percentage of retraction in the cardiovascular literature increased significantly during the study period, although a decrease was seen after 2015. Scientific misconduct represents the most common reason for retraction, although a reduction has been observed in the last five years.

Assessing the long-term safety and efficacy of gamma knife and linear accelerator radiosurgery for vestibular schwannoma: A systematic review and meta-analysis

Background

Differences in long-term outcomes of single-fraction stereotactic radiosurgery (SRS) between gamma knife (GK) and linear accelerator (LINAC) systems for vestibular schwannoma (VS) management remain unclear. To investigate differences in safety and efficacy between modalities, we conducted a meta-analysis of studies over the past decade.

Methods

MEDLINE, EMBASE, and Cochrane databases were queried for studies with the following inclusion criteria: English language, published between January 2010 and April 2020, cohort size ≥30, and mean/median follow-up ≥5 years. Odds ratios (OR) compared rates of tumor control, hearing preservation, and cranial nerve toxicities before and after SRS.

Results

Thirty-nine studies were included (29 GK, 10 LINAC) with 6516 total patients. Tumor control rates were 93% (95% CI 91-94%) and 94% (95% CI 91-97%) for GK and LINAC, respectively. Both GK (OR 0.06, 95% CI 0.02-0.13) and LINAC (OR 0.47, 95% CI 0.29-0.76) reduced odds of serviceable hearing. Neither GK (OR 0.71, 95% CI 0.41-1.22) nor LINAC (OR 1.13, 95% CI 0.64-2.00) impacted facial nerve function. GK decreased odds of trigeminal nerve (TN) impairment (OR 0.55, 95% CI 0.32-0.94) while LINAC did not impact TN function (OR 1.45, 95% CI 0.81-2.61). Lastly, LINAC offered decreased odds of tinnitus (OR 0.15, 95% CI 0.03-0.87) not observed with GK (OR 0.70, 95% CI 0.48-1.01).

Conclusions

VS tumor control and hearing preservation rates are comparable between GK and LINAC SRS. GK may better preserve TN function, while LINAC decreases tinnitus rates. Future studies are warranted to investigate the efficacy of GK and LINAC SRS more directly.

Effect of coronary artery bypass grafting on quality of life: a meta-analysis of randomized trials

AIMS

We conducted a systematic review and meta-analysis to evaluate temporal trends in quality of life (QoL) after coronary artery bypass grafting (CABG) surgery in randomized clinical trials, and a quantitative comparison from before surgery to up to 5 years after surgery.

METHODS AND RESULTS

We searched MEDLINE, CINAHL, EMBASE, Cochrane Library, and PsycINFO from 2010 to 2020 to identify studies that included the measurement of QoL in patients undergoing CABG. The primary outcome was the Seattle Angina Questionnaire (SAQ), and secondary outcomes were the 36-item Short Form Health Survey (SF-36) and EuroQol Questionnaire (EQ-5D). We pooled the means and the weighted mean differences over the follow-up period. In the meta-analysis, 2586 studies were screened and 18 full-text studies were included. There was a significant trend towards higher QoL scores from before surgery to 1 year post-operatively for the SAQ angina frequency (AF), SAQ QoL, SF-36 physical component (PC), and EQ-5D, whereas the SF-36 mental component (MC) did not improve significantly. The weighted mean differences from before surgery to 1 year after was 24 [95% confidence interval (CI): 21.6-26.4] for the SAQ AF, 31 (95% CI: 27.5-34.6) for the SAQ QoL, 9.8 (95% CI: 7.1-12.8) for the SF-36 PC, 7.1 (95% CI: 4.2-10.0) for the SF-36 MC, and 0.1 (95% CI: 0.06-0.14) for the EQ-5D. There was no evidence of publication bias or small-study effect.

CONCLUSION

CABG had both short- and long-term improvements in disease-specific QoL and generic QoL, with the largest improvement in angina frequency.

Percutaneous coronary intervention versus coronary artery surgery for left main disease according to lesion site: A meta-analysis

BACKGROUND

Comparative data after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for unprotected left main coronary artery (ULMCA) disease according to lesion site (ostial/shaft vs distal) are scant. The aim of this meta-analysis was to investigate outcomes after PCI or CABG for ULMCA disease according to lesion site.

METHODS

Randomized controlled trials (RCTs) and adjusted observational studies that compared PCI versus CABG in patients with ULMCA disease and reported outcomes according to lesion site were systematically identified. Major adverse cardiovascular events (MACE; a composite of all-cause death, myocardial infarction, stroke, and repeat revascularization) and all-cause death were the co-primary end points. Individual components of MACE were secondary end points. Sensitivity analysis including RCTs only were performed for each outcome.

RESULTS

Nine studies (3 RCTs, 6 adjusted observational), encompassing 6296 patients (2274 and 4022 treated for ostial/shaft or distal ULMCA, respectively) were included. At the 5-year follow-up, there were no significant differences between CABG and PCI for MACE, death, or any other secondary outcome for ostial/shaft ULMCA lesions (MACE: hazard ratio [HR], 1.0 [95% confidence interval (CI), 0.79-1.27]; death: HR, 1.10 [95% CI, 0.84-1.46]). For distal ULMCA, PCI was associated with an increased risk of MACE (HR, 1.32; 95% CI, 1.10-1.58), death (HR, 1.56; 95% CI, 1.19-2.04), and revascularization (HR, 2.07; 95% CI, 1.5-2.84). The benefit of CABG for MACE and revascularization was confirmed in the analysis limited to RCTs, whereas the benefit for mortality was not.

CONCLUSIONS

Among patients with distal ULMCA disease, CABG is associated with lower incidence of MACE and revascularization compared with PCI, whereas no differences in outcomes were observed for ostial/shaft ULMCA disease.

Sex differences in outcomes after coronary artery bypass grafting: a pooled analysis of individual patient data

AIMS

Data suggest that women have worse outcomes than men after coronary artery bypass grafting (CABG), but results have been inconsistent across studies. Due to the large differences in baseline characteristics between sexes, suboptimal risk adjustment due to low-quality data may be the reason for the observed differences. To overcome this limitation, we undertook a systematic review and pooled analysis of high-quality individual patient data from large CABG trials to compare the adjusted outcomes of women and men.

METHODS AND RESULTS

The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events, MACCE). The secondary outcome was all-cause mortality. Multivariable mixed-effect Cox regression was used. Four trials involving 13 193 patients (10 479 males; 2714 females) were included. Over 5 years of follow-up, women had a significantly higher risk of MACCE [adjusted hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.04-1.21; P = 0.004] but similar mortality (adjusted HR 1.03, 95% CI 0.94-1.14; P = 0.51) compared to men. Women had higher incidence of MI (adjusted HR 1.30, 95% CI 1.11-1.52) and repeat revascularization (adjusted HR 1.22, 95% CI 1.04-1.43) but not stroke (adjusted HR 1.17, 95% CI 0.90-1.52). The difference in MACCE between sexes was not significant in patients 75 years and older. The use of off-pump surgery and multiple arterial grafting did not modify the difference between sexes.

CONCLUSIONS

Women have worse outcomes than men in the first 5 years after CABG. This difference is not significant in patients aged over 75 years and is not affected by the surgical technique.

Effects of Experimental Interventions to Improve the Biomedical Peer-Review Process: A Systematic Review and Meta-Analysis

Background

Quality of the peer‐review process has been tested only in small studies. We describe and summarize the randomized trials that investigated interventions aimed at improving peer‐review process of biomedical manuscripts.

Methods and Results

All randomized trials comparing different peer‐review interventions at author‐, reviewer‐, and/or editor‐level were included. Differences between traditional and intervention‐modified peer‐review processes were pooled as standardized mean difference (SMD) in quality based on the definitions used in the individual studies. Main outcomes assessed were quality and duration of the peer‐review process. Five‐hundred and seventy‐five studies were retrieved, eventually yielding 24 randomized trials. Eight studies evaluated the effect of interventions at author‐level, 16 at reviewer‐level, and 3 at editor‐level. Three studies investigated interventions at multiple levels. The effects of the interventions were reported as mean change in review quality, duration of the peer‐review process, acceptance/rejection rate, manuscript quality, and number of errors detected in 13, 11, 5, 4, and 3 studies, respectively. At network meta‐analysis, reviewer‐level interventions were associated with a significant improvement in review quality (SMD, 0.20 [0.06 to 0.33]), at the cost of increased duration of the review process (SMD, 0.15 [0.01 to 0.29]), except for reviewer blinding. Author‐ and editor‐level interventions did not significantly impact peer‐review quality and duration (respectively, SMD, 0.17 [−0.16 to 0.51] and SMD, 0.19 [−0.40 to 0.79] for quality, and SMD, 0.17 [−0.16 to 0.51] and SMD, 0.19 [−0.40 to 0.79] for duration).

Conclusions

Modifications of the traditional peer‐review process at reviewer‐level are associated with improved quality, at the price of longer duration. Further studies are needed.

Registration

URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42020187910.

Applications of augmented reality in the neurosurgical operating room: A systematic review of the literature

Advancements in imaging techniques are key forces of progress in neurosurgery. The importance of accurate visualization of intraoperative anatomy cannot be overemphasized and is commonly delivered through traditional neuronavigation. Augmented Reality (AR) technology has been tested and applied widely in various neurosurgical subspecialties in intraoperative, clinical use and shows promise for the future. This systematic review of the literature explores the ways in which AR technology has been successfully brought into the operating room (OR) and incorporated into clinical practice. A comprehensive literature search was performed in the following databases from inception-April 2020: Ovid MEDLINE, Ovid EMBASE, and The Cochrane Library. Studies retrieved were then screened for eligibility against predefined inclusion/exclusion criteria. A total of 54 articles were included in this systematic review. The studies were sub- grouped into brain and spine subspecialties and analyzed for their incorporation of AR in the neurosurgical clinical setting. AR technology has the potential to greatly enhance intraoperative visualization and guidance in neurosurgery beyond the traditional neuronavigation systems. However, there are several key challenges to scaling the use of this technology and bringing it into standard operative practice including accurate and efficient brain segmentation of magnetic resonance imaging (MRI) scans, accounting for brain shift, reducing coregistration errors, and improving the AR device hardware. There is also an exciting potential for future work combining AR with multimodal imaging techniques and artificial intelligence to further enhance its impact in neurosurgery.

Characteristics of Randomized Clinical Trials in Surgery From 2008 to 2020: A Systematic Review

IMPORTANCE

Randomized clinical trials (RCTs) provide the highest level of evidence to evaluate 2 or more surgical interventions. Surgical RCTs, however, face unique challenges in design and implementation.

OBJECTIVE

To evaluate the design, conduct, and reporting of contemporary surgical RCTs.

EVIDENCE REVIEW

A literature search performed in the 2 journals with the highest impact factor in general medicine as well as 6 key surgical specialties was conducted to identify RCTs published between 2008 and 2020. All RCTs describing a surgical intervention in both experimental and control arms were included. The quality of included data was assessed by establishing an a priori protocol containing all the details to extract. Trial characteristics, fragility index, risk of bias (Cochrane Risk of Bias 2 Tool), pragmatism (Pragmatic Explanatory Continuum Indicator Summary 2 [PRECIS-2]), and reporting bias were assessed.

FINDINGS

A total of 388 trials were identified. Of them, 242 (62.4%) were registered; discrepancies with the published protocol were identified in 81 (33.5%). Most trials used superiority design (329 [84.8%]), and intention-to-treat as primary analysis (221 [56.9%]) and were designed to detect a large treatment effect (50.0%; interquartile range [IQR], 24.7%-63.3%). Only 123 trials (31.7%) used major clinical events as the primary outcome. Most trials (303 [78.1%]) did not control for surgeon experience; only 17 trials (4.4%) assessed the quality of the intervention. The median sample size was 122 patients (IQR, 70-245 patients). The median follow-up was 24 months (IQR, 12.0-32.0 months). Most trials (211 [54.4%]) had some concern of bias and 91 (23.5%) had high risk of bias. The mean (SD) PRECIS-2 score was 3.52 (0.65) and increased significantly over the study period. Most trials (212 [54.6%]) reported a neutral result; reporting bias was identified in 109 of 211 (51.7%). The median fragility index was 3.0 (IQR, 1.0-6.0). Multiplicity was detected in 175 trials (45.1%), and only 35 (20.0%) adjusted for multiple comparisons.

CONCLUSIONS AND RELEVANCE

In this systematic review, the size of contemporary surgical trials was small and the focus was on minor clinical events. Trial registration remained suboptimal and discrepancies with the published protocol and reporting bias were frequent. Few trials controlled for surgeon experience or assessed the quality of the intervention.

POS1097 TREATMENT KNOWLEDGE AND PREFERENCES FOR BLACK PEOPLE WITH HIP AND KNEE OSTEOARTHRITIS: A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS

Background:

Black people are less likely to undergo total joint arthroplasties, despite reporting more severe symptoms. (1) While racial disparities exist in treatment utilization for osteoarthritis, comprehensive studies of the treatment preferences of Black people have not been conducted.

Objectives:

The purpose of this manuscript is to systematically review the literature and identify Black osteoarthritis patients’ treatment preferences to understand how they may contribute to racial differences in the utilization of different treatment options.

Methods:

Searches ran on April 8, 2019 and April 7, 2020 in the following databases: Ovid MEDLINE (ALL - 1946 to Present); Ovid EMBASE (1974 to present); and The Cochrane Library (Wiley). Using the Patient/Population-Intervention-Comparison/Comparator-Outcome (PICO) format, our population of interest was Black people with hip and/or knee osteoarthritis, our intervention was preferences and opinions about treatment options for osteoarthritis, our comparator was white people with hip and/or knee osteoarthritis, and our outcome was preferences of osteoarthritis therapies. The protocol was registered under the PROSPERO international register, and the Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed.

Results:

Searches across the chosen databases retrieved 10,894 studies after de-duplication, 182 full text, and 31 selected for inclusion in this review. Black people were less likely to use NSAIDs or narcotic analgesics compared to white people. (Figure 1) Black people were more likely than white people to use spirituality and prayer, as well as topical treatments. Utilization of meditation, supplement/vitamin use, and hot/cold treatments was not significantly different between groups. Black people were less willing than white people to consider or undergo joint replacements, even if the procedure was needed and recommended by a physician.

Conclusion:

Racial differences persist in OA care across the spectrum of options. Future interventions should focus on providing accessible information surrounding treatment options and targeting perceptions of the importance of joint health.

References:

[1]Suarez-Almazor ME, Souchek J, Kelly PA, et al. Ethnic Variation in Knee Replacement: Patient Preferences or Uninformed Disparity? Arch Intern Med. 2005;165(10):1117-1124. doi:10.1001/archinte.165.10.1117

Figure 1.

Meta-analysis describing the odds ratios of Black people using NSAIDs and Narcotic Analgesics compared to white people

Disclosure of Interests:

Collin Brantner: None declared, Diyu Pearce-Fisher: None declared, Carine Moezinia: None declared, Haley Tornberg: None declared, John FitzGerald: None declared, Michael Parks Consultant of: Zimmer Biomet, Peter Sculco Consultant of: EOS Imaging, Intellijoint Surgical, DePuy Synthes, Lima Corporate, Cynthia Kahlenberg: None declared, Curtis Mensah: None declared, Ajay Premkuar: None declared, Nicholas Williams: None declared, Michelle Demetres: None declared, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Horizon Therapeutics.

MRI surveillance of boys with X-linked adrenoleukodystrophy identified by newborn screening: Meta-analysis and consensus guidelines

BACKGROUND

Among boys with X-Linked adrenoleukodystrophy, a subset will develop childhood cerebral adrenoleukodystrophy (CCALD). CCALD is typically lethal without hematopoietic stem cell transplant before or soon after symptom onset. We sought to establish evidence-based guidelines detailing the neuroimaging surveillance of boys with neurologically asymptomatic adrenoleukodystrophy.

METHODS

To establish the most frequent age and diagnostic neuroimaging modality for CCALD, we completed a meta-analysis of relevant studies published between January 1, 1970 and September 10, 2019. We used the consensus development conference method to incorporate the resulting data into guidelines to inform the timing and techniques for neuroimaging surveillance. Final guideline agreement was defined as >80% consensus.

RESULTS

One hundred twenty-three studies met inclusion criteria yielding 1285 patients. The overall mean age of CCALD diagnosis is 7.91 years old. The median age of CCALD diagnosis calculated from individual patient data is 7.0 years old (IQR: 6.0-9.5, n = 349). Ninety percent of patients were diagnosed between 3 and 12. Conventional MRI was most frequently reported, comprised most often of T2-weighted and contrast-enhanced T1-weighted MRI. The expert panel achieved 95.7% consensus on the following surveillance parameters: (a) Obtain an MRI between 12 and 18 months old. (b) Obtain a second MRI 1 year after baseline. (c) Between 3 and 12 years old, obtain a contrast-enhanced MRI every 6 months. (d) After 12 years, obtain an annual MRI.

CONCLUSION

Boys with adrenoleukodystrophy identified early in life should be monitored with serial brain MRIs during the period of highest risk for conversion to CCALD.

Thoracotomy versus sternotomy? The effect of surgical approach on outcomes after left ventricular assist device implantation: A review of the literature and meta-analysis

BACKGROUND AND AIM

Thoracotomy approaches to left ventricular assist device (LVAD) implantation may reduce surgical morbidity and, through preservation of the pericardial restraint over the right heart, may reduce the incidence of right ventricular failure (RVF).

METHODS

A meta-analysis of all original studies describing the effect of the surgical approach on postoperative outcomes after LVAD implantation was performed. Postoperative outcomes analyzed.

RESULTS

Thirteen studies were included with 692 patients undergoing a sternotomy and 373 a thoracotomy approach. Patients undergoing a thoracotomy approach had a higher comorbid status (INTERMACS 1-2: 56% vs. 44%; p = .0004), but were less likely to undergo a concomitant procedure (4% vs. 15%; p = .0002) than patients undergoing a sternotomy approach. Patients undergoing a thoracotomy approach demonstrated a reduced incidence of RVF (OR, .47; CI, .23-.97; p = .04), reexploration for bleeding (OR, .55; CI, .32-.94; p = .03), perioperative blood transfusion (SMD, -.30; CI, -.49 to -.11; p = .002), LOS (-5.57; -10.56 to -.59; p = .03), and mortality (OR, .57; CI, .33-.98; p = .04), but no difference in RVAD requirement or stroke were noted. Metaregression demonstrated that the performance of a concomitant procedure did not modify the effect of the surgical approach on the primary endpoints of RVF or RVAD requirement.

CONCLUSIONS

In the current meta-analysis including over 1000 patients undergoing LVAD implantation, a thoracotomy approach was associated with a reduced incidence of RVF (but not RVAD requirement), bleeding, LOS, and mortality. No difference in stroke rates was noted. These findings not only offer additional support as to the feasibility of a thoracotomy approach for LVAD implantation but also suggest a potential superiority over a sternotomy approach.

Angiographic Patency of Coronary Artery Bypass Conduits: A Network Meta-Analysis of Randomized Trials

Background Several randomized trials have compared the patency of coronary artery bypass conduits. All of the published studies, however, have performed pairwise comparisons and a comprehensive evaluation of the patency rates of all conduits has yet to be published. We set out to investigate the angiographic patency rates of all conduits used in coronary bypass surgery by performing a network meta-analysis of the current available randomized evidence. Methods and Results A systematic literature search was conducted for randomized controlled trials comparing the angiographic patency rate of the conventionally harvested saphenous vein, the no-touch saphenous vein, the radial artery (RA), the right internal thoracic artery, or the gastroepiploic artery. The primary outcome was graft occlusion. A total of 4160 studies were retrieved of which 14 were included with 3651 grafts analyzed. The weighted mean angiographic follow-up was 5.1 years. Compared with the conventionally harvested saphenous vein, both the RA (incidence rate ratio [IRR] 0.54; 95% CI, 0.35-0.82) and the no-touch saphenous vein (IRR 0.55; 95% CI, 0.39-0.78) were associated with lower graft occlusion. The RA ranked as the best conduit (rank score for RA 0.87 versus 0.85 for no-touch saphenous vein, 0.23 for right internal thoracic artery, 0.29 for gastroepiploic artery, and 0.25 for the conventionally harvested saphenous vein). Conclusions Compared with the conventionally harvested saphenous vein, only the RA and no-touch saphenous vein grafts are associated with significantly lower graft occlusion rates. The RA ranks as the best conduit. Registration URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42020164492.

Effectiveness of Medical Treatment of Cushing's Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this systematic review was to evaluate the effectiveness and safety of pasireotide, cabergoline, ketoconazole, levoketoconazole, metyrapone, osilodrostat, and temozolomide for the treatment of Cushing's disease (CD).

METHODS

The primary outcomes were the proportion of CD control, adverse events (AE), and reduction of urinary free cortisol. Search strategies were applied to Embase, Medline, and CENTRAL. Independent reviewers assessed the study eligibility, extracted data, and evaluated risk of bias. Standardized mean difference was calculated with 95% confidence interval (CI) for continuous data (i.e., pre- and post-intervention). Random meta-analyses for the proportion of CD control and AE were conducted.

RESULTS

Twenty-nine controlled and non-controlled studies were included. No study with temozolomide and levoketoconazole and one study with osilodrostat fulfilled the inclusion criteria. The meta-analyses of proportion of CD control was 35% for cabergoline (95% CI: 27-43%, six studies, 141 participants), 44% for pasireotide (95% CI: 25-35%, eight studies, 522 participants), 41% for ketoconazole (95% CI: 36-46%, six studies, 450 participants), 66% for metyrapone (95% CI: 46-87%, four studies, 66 participants), and of 66.4% for osilodrostat (95% CI: 57.9, 74.3, 97 participants, one study). One study compared two different treatments (cabergoline vs. ketoconazole), and no statistical difference was observed in CD control (RR: 0.53, 95% CI: 0.15 to 1.87, 14 participants, very low certainty of evidence). The most frequent AE associated with pasireotide was hyperglycemia, dizziness and nausea with cabergoline and metyrapone, and elevated transaminases with ketoconazole.

CONCLUSION

The superiority of one drug over another could not be determined due to lack of controlled studies, but the proportion of disease control identified in our meta-analysis may support clinical decision. New therapeutic options should be investigated due to the limited efficacy and tolerability of the currently available medical treatment for patients with Cushing's disease.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020205567, identifier CRD42020205567.

The adverse health effects of punitive immigrant policies in the United States: A systematic review

BACKGROUND

Immigrants in the United States (US) today are facing a dynamic policy landscape. The Trump administration has threatened or curtailed access to basic services for 10.5 million undocumented immigrants currently in the US. We sought to examine the historical effects that punitive laws have had on health outcomes in US immigrant communities.

METHODS

In this systematic review, we searched the following databases from inception-May 2020 for original research articles with no language restrictions: Ovid MEDLINE, Ovid EMBASE, Cochrane Library (Wiley), Web of Science Core Collection (Clarivate), CINAHL (EBSCO), and Social Work Abstracts (Ovid). This study is registered with PROSPERO, CRD42019138817. Articles with cohort sizes >10 that directly evaluated the health-related effects of a punitive immigrant law or policy within the US were included.

FINDINGS

6,357 studies were screened for eligibility. Of these, 32 studies were selected for inclusion and qualitatively synthesized based upon four themes that appeared throughout our analysis: (1) impact on healthcare utilization, (2) impact on women's and children's health, (3) impact on mental health services, and (4) impact on public health. The impact of each law, policy, mandate, and directive since 1990 is briefly discussed, as are the limitations and risk of bias of each study.

INTERPRETATION

Many punitive immigrant policies have decreased immigrant access to and utilization of basic healthcare services, while instilling fear, confusion, and anxiety in these communities. The federal government should preserve and expand access for undocumented individuals without threat of deportation to improve health outcomes for US citizens and noncitizens.

Overall and Cause-Specific Mortality in Randomized Clinical Trials Comparing Percutaneous Interventions With Coronary Bypass Surgery: A Meta-analysis

IMPORTANCE

Mortality is a common outcome in trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG). Controversy exists regarding whether all-cause mortality or cardiac mortality is preferred as a study end point, because noncardiac mortality should be unrelated to the treatment.

OBJECTIVE

To evaluate the difference in all-cause and cause-specific mortality in randomized clinical trials (RCTs) comparing PCI with CABG for the treatment of patients with coronary artery disease.

DATA SOURCES

MEDLINE (1946 to the present), Embase (1974 to the present), and the Cochrane Library (1992 to the present) databases were searched on November 24, 2019. Reference lists of included articles were also searched, and additional studies were included if appropriate.

STUDY SELECTION

Articles were considered for inclusion if they were in English, were RCTs comparing PCI with drug-eluting or bare-metal stents and CABG for the treatment of coronary artery disease, and reported mortality and/or cause-specific mortality. Trials of PCI involving angioplasty without stenting were excluded. For each included trial, the publication with the longest follow-up duration for each outcome was selected.

DATA EXTRACTION AND SYNTHESIS

For data extraction, all studies were reviewed by 2 independent investigators, and disagreements were resolved by a third investigator in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Data were pooled using fixed- and random-effects models.

MAIN OUTCOMES AND MEASURES

The primary outcomes were all-cause and cause-specific (cardiac vs noncardiac) mortality. Subgroup analyses were performed for PCI trials using drug-eluting vs bare-metal stents and for trials involving patients with left main disease.

RESULTS

Twenty-three unique trials were included involving 13 620 unique patients (6829 undergoing PCI and 6791 undergoing CABG; men, 39.9%-99.0% of study populations; mean age range, 60.0-71.0 years). The weighted mean (SD) follow-up was 5.3 (3.6) years. Compared with CABG, PCI was associated with a higher rate of all-cause (incidence rate ratio, 1.17; 95% CI, 1.05-1.29) and cardiac (incidence rate ratio, 1.24; 95% CI, 1.05-1.45) mortality but also noncardiac mortality (incidence rate ratio, 1.19; 95% CI, 1.00-1.41).

CONCLUSIONS AND RELEVANCE

Percutaneous coronary intervention was associated with higher all-cause, cardiac, and noncardiac mortality compared with CABG at 5 years. The significantly higher noncardiac mortality associated with PCI suggests that even noncardiac deaths after PCI may be procedure related and supports the use of all-cause mortality as the end point for myocardial revascularization trials.

Treatment strategies in ischaemic left ventricular dysfunction: a network meta-analysis

OBJECTIVES

The optimal revascularization strategy for patients with ischaemic left ventricular systolic dysfunction (iLVSD) remains controversial. We aimed to compare percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical therapy (MT) in a network meta-analysis.

METHODS

All randomized controlled trials and observational studies comparing any combination of PCI, CABG and MT in patients with iLVSD were analysed in a frequentist network meta-analysis (generic inverse variance method). Primary outcome was mortality at longest available follow-up. Secondary outcomes were cardiac death, stroke, myocardial infarction (MI) and repeat revascularization (RR).

RESULTS

Twenty-three studies were included (n = 23 633; 4 randomized controlled trials). Compared to CABG, PCI was associated with higher mortality [incidence rate ratio (IRR) 1.32, 95% confidence interval (CI) 1.13-1.53], cardiac death (IRR 1.65, 95% CI 1.18-2.33), MI (IRR 2.18, 95% CI 1.70-2.80) and RR (IRR 3.75, 95% CI 2.89-4.85). Compared to CABG, MT was associated with higher mortality (IRR 1.52, 95% CI 1.26-1.84), cardiac death (IRR 3.83, 95% CI 2.12-6.91), MI (IRR 3.22, 95% CI 1.52-6.79) and RR (IRR 3.37, 95% CI 1.67-6.79). Compared to MT, PCI was associated with lower cardiac death (IRR 0.43, 95% CI 0.24-0.78). CABG ranked as the best revascularization strategy for mortality, cardiac death, MI and RR; MT ranked as the strategy associated with the lowest incidence of stroke. Left ventricular ejection fraction, year of study, use of drug-eluting stents did not affect relative treatment effects.

CONCLUSIONS

CABG appears to be the best therapy for iLVSD, although mainly based on observational data. Definitive randomized controlled trials comparing CABG and PCI in iLVSD are required.

PROSPERO REGISTRATION ID

132414.

A pairwise meta-analytic comparison of aortic valve area determined by planimetric versus hemodynamic methods in aortic stenosis

BACKGROUND

Aortic valve area (AVA) is commonly determined from 2-dimensional transthoracic echocardiography (2D TTE) by the continuity equation; however, this method relies on geometric assumptions of the left ventricular outflow tract which may not hold true. This study compared mean differences and correlations for AVA by planimetric (2-dimensional transesophageal echocardiography [2D TEE], 3-dimensional transesophageal echocardiography [3D TEE], 3-dimensional transthoracic echocardiography [3D TTE], multi-detector computed tomography [MDCT], and magnetic resonance imaging [MRI]) with hemodynamic methods (2D TTE and catheterization) using pairwise meta-analysis.

METHOD

Ovid MEDLINE®, Ovid EMBASE, and The Cochrane Library (Wiley) were queried for studies comparing AVA measurements assessed by planimetric and hemodynamic techniques. Pairwise meta-analysis for mean differences (using random effect model) and for correlation coefficients (r) were performed.

RESULTS

Forty-five studies (3014 patients) were included. Mean differences between planimetric and hemodynamic techniques were 0.12 cm² (95%CI 0.10-0.15) for AVA (pooled r = 0.84; 95%CI 0.76-0.90); 1.36cm² (95%CI 1.03-1.69) for left ventricular outflow tract area; and 0.13 cm (95%CI 0.07-0.20) for annular diameter (pooled r = 0.76; 95% CI 0.64-0.94); 0.67 cm² (95%CI 0.59-0.76) for annular area (pooled r = 0.74; 95%CI 0.55-0.86).

CONCLUSIONS

Planimetric techniques slightly, but significantly, overestimate AVA when compared to hemodynamic techniques.

Systematic Reviews and Meta-Analyses in Cardiac Surgery: Rules of the Road - Part 1

The number of cardiac surgical meta-analyses and systematic reviews published in the last decades has constantly increased, paralleling the exponential growth observed in virtually all other medical fields. Meta-analyses are open to methodological flaws, however, if best practices are not strictly followed. Assessment of the appropriateness of the research question is a crucial first step. Once a protocol has been developed, this should be registered before the work is initiated. The cornerstone of any systematic review or meta-analysis is a rigorous, comprehensive, and most of all reproducible, search that follows a prespecified and clear strategy. Eligibility criteria must be discussed and agreed upon in advance to guide final study selection, which ultimately lays the foundation for subsequent data extraction. In case of missing or partially reported data, the authors of the original papers should be contacted. Adherence to rigorous methodological rules at each of these stages will warrant availability of good quality data for formal statistical analyses. The aim of the first part of this expert review is to discuss the limits and pitfalls of the meta-analytic approach and provide guidance on how to perform trial-level meta-analyses, with particular reference to the identification of an appropriate research question, the definition and registration of the protocol, the search strategy, the study selection, and the data abstraction.