Extubation time, hemodynamic stability, and postoperative pain control in patients undergoing coronary artery bypass surgery: an evaluation of fentanyl, remifentanil, and nonsteroidal antiinflammatory drugs with propofol for perioperative and postoperative management

STUDY OBJECTIVE: To compare three anesthetic strategies with respect to the time of extubation after coronary artery bypass graft (CABG) surgery and to assess patient satisfaction with the procedure. DESIGN: Prospective, randomized, clinical study. SETTING: Tertiary-care referral center. PARTICIPANTS: 180 cardiac surgical patients undergoing primary CABG from January through June 2004. INTERVENTIONS: After induction of general anesthesia, patients were allocated to one of three groups. All three groups received a continuous infusion of intravenous (IV) propofol perioperatively and postoperatively. Group 1 (fentanyl infusion group, n = 60) received continuous IV fentanyl infusion perioperatively and postoperatively for analgesia. Group 2 (diclofenac group, n = 60) received fentanyl bolus doses intraoperatively and diclofenac suppository postoperatively. Group 3 (remifentanil group, n = 60) received continuous infusion of IV remifentanil perioperatively and IV fentanyl as an immediate postoperative bolus followed by continuous fentanyl infusion. Duration of postoperative ventilation up to the time of extubation, inotrope requirement, time at which analgesic infusion was discontinued, postextubation arterial blood gas analysis, pain evaluation via visual analog scale, need for rescue analgesia, awareness during surgery, and length of postcardiac surgical unit stay, were evaluated in each patient. MAIN RESULTS: The diclofenac group exhibited the shortest time to extubation, the least inotrope use, and the fewest rescue doses of analgesic than did patients of the other two groups. CONCLUSION: Intravenous propofol with bolus doses of IV fentanyl intraoperatively in combination with postoperative nonsteroidal antiinflammatory drugs had the best recovery profile in patients undergoing primary CABG than did the other two regimens studied.     

Dextrose prolotherapy in knee osteoarthritis: A systematic review and meta-analysis

ObjectiveTo summarize the evidence for dextrose prolotherapy in knee osteoarthritis.Data sourcesThe authors searched PubMed and Embase from inception to September 2020. All publications in the English language were included without demographic limits.Study selectionRandomized clinical trials comparing the effects of any active interventions or placebo versus dextrose prolotherapy in patients with knee osteoarthritis were included.Data extractionPotential articles were screened for eligibility, and data was extracted independently. The risk of bias was assessed using the Cochrane Risk of Bias tool. Meta-analysis was performed on clinical trials with similar parameters. The Strength of Recommendation Taxonomy (SORT) was used for evaluating the strength of recommendations.Data synthesisIn total, eleven articles (n = 837 patients) met the search criteria and were included. The risk-of-bias analysis revealed two studies to be of low risk. The overall effectiveness was calculated using a meta-analysis method. Prolotherapy was no different from platelet-rich plasma on the pain subscale at the 6-month time point. Prolotherapy was inferior to platelet-rich plasma at 6 months (MD 0.45, 95% CI 0.06–0.85, p = 0.03) on the stiffness subscale. Prolotherapy was found to be safe with no major adverse effects.ConclusionProlotherapy in knee osteoarthritis confers potential benefits for pain but the studies are at high risk of bias. Based on two well-designed studies, dextrose prolotherapy may be considered in knee osteoarthritis (strength of recommendation B). This treatment is safe and may be considered in patients with limited alternative options (strength of recommendation C).     

The effect of osteoarthritis definition on prevalence and incidence estimates: a systematic review

Objective

To understand the differences in prevalence and incidence estimates of osteoarthritis (OA), according to case definition, in knee, hip and hand joints.

Method

A systematic review was carried out in PUBMED and SCOPUS databases comprising the date of publication period from January 1995 to February 2011. We attempted to summarise data on the incidence and prevalence of OA according to different methods of assessment: self-reported, radiographic and symptomatic OA (clinical plus radiographic). Prevalence estimates were combined through meta-analysis and between-study heterogeneity was quantified.

Results

Seventy-two papers were reviewed (nine on incidence and 63 on prevalence). Higher OA prevalences are seen when radiographic OA definition was used for all age groups. Prevalence meta-analysis showed high heterogeneity between studies even in each specific joint and using the same OA definition. Although the knee is the most studied joint, the highest OA prevalence estimates were found in hand joints. OA of the knee tends to be more prevalent in women than in men independently of the OA definition used, but no gender differences were found in hip and hand OA. Insufficient data for incidence studies didn’t allow us to make any comparison according to joint site or OA definition.

Conclusions

Radiographic case definition of OA presented the highest prevalences. Within each joint site, self-reported and symptomatic OA definitions appear to present similar estimates. The high heterogeneity found in the studies limited further conclusions.     

Key Steps in Conducting Systematic Reviews for Underpinning Clinical Practice Guidelines: Methodology of the European Association of Urology

Context

The findings of systematic reviews (SRs) and meta-analyses (MAs) are used for clinical decision making. The European Association of Urology has committed increasing resources into the development of high quality clinical guidelines based on such SRs and MAs.

Efficacy and safety of intraarticular hyaluronic acid in the treatment of hip osteoarthritis: a systematic review

OBJECTIVE: This study sought to use a systematic review to ascertain the efficacy and safety of hyaluronic acid (HA) in the treatment of hip osteoarthritis (OA). DESIGN: A protocolized search was made of a number of electronic databases, including Medline, EMBASE, Cochrane Library and Health Technology Assessment (HTA) among others. Two independent reviewers applied a series of inclusion and exclusion criteria to the studies located in the search, and selected only those that included more than 20 patients; had a follow-up period of more than 1 week; and exclusively assessed the efficacy and/or effectiveness of HA in patients with confirmed hip OA. RESULTS: A total of eight studies, comprising clinical trials and one review, met the inclusion criteria, and had study populations ranging from 22 to 104 patients. Only two of the trials were controlled: one compared two HAs of different molecular weights; and the other compared HA with corticoids and a placebo. Relief of pain was estimated to be around 40-50% by most studies, though the duration of this post-treatment effect was not known. CONCLUSIONS: Based on available evidence, HA treatment should only be used under careful supervision by the clinician and just in those cases where other treatments have failed in hip OA. There are methodologic limitations displayed in the literature, which were mainly the absence of a control group in most of the studies, overly short follow-up periods, and different ways of measuring outcomes.     

Distraction arthroplasty in the management of osteoarthritis of the ankle: A systematic review

BackgroundThis study aimed to evaluate the use of distraction arthroplasty for ankle osteoarthritis, with respect to patient reported outcome measures (PROMs), complications, range of motion and radiographic outcomes.MethodsA computer-based search was performed in PubMed, Cinahl, Embase, Scopus and ISI Web of Science. Two reviewers independently performed title/abstract and full-text screening. Quality assessment was performed using The Methodological Index for Non-Randomised Studies (MINORS) and Joanna Briggs Institute criteria.ResultsWhilst all studies evaluating PROMs reported significant (P < 0.05) improvement, these were either below or only slightly above the minimally clinically important difference. The rate of conversion to arthrodesis or total ankle arthroplasty was high, with failure rates of up to 52% reported.ConclusionDue to the inconsistent improvements in PROMs, which are likely overestimated due to substantial bias, and the high failure rate, this review suggests that distraction arthroplasty is not currently an effective treatment option for ankle arthritis.Level of evidenceLevel IV, systematic review of level I to IV studies.     

Identifying Bone-Mass-Related Risk Factors for Fracture to Guide Bone Densitometry Measurements: A Systematic Review of the Literature

Available evidence suggests that fracture prediction with bone densitometry may improve when used on people at high risk of osteoporotic fractures. The objectives of this literature review were: (1) to identify risk factors for fracture that are associated with the development of a low bone mass for both men and women; (2) to describe and assess the relationship between these factors and the risk of fracture; and (3) to classify them according to the strength of their association with fracture incidence. Studies were identified from MEDLINE (1982-1997), HealthSTAR (1975-1997) and The Cochrane Library (1997) databases. Pre-stated inclusion criteria (original analytic studies assessing risk factors for osteoporotic fractures in men and women) and methodologic quality were assessed by two independent investigators. Information on the study design and analysis, characteristics of participants, exposure (risk factor) and outcome measures (relative risk and odds ratios for fracture incidence), control for potential confounding factors and risk estimates was extracted using a standardized protocol. Qualitative and meta-analytic techniques were used for data synthesis. As a result, risk factors were classified into three groups according to their strength of association with fracture: high risk (RR > or = 2), moderate risk (1 < RR < 2) and no risk or protective (RR < or = 1). Of approximately 80 risk factors identified from 94 cohort and 72 case-control studies, 15% were classified in the high-risk group, including low body weight, loss of weight, physical inactivity, the consumption of corticosteroids or anticonvulsants, primary hyperparathyroidism, diabetes mellitus type 1, anorexia nervosa, gastrectomy, pernicious anemia, and aging (> 70-80 years). Eighteen percent and 8% of risk factors were classified in the moderate and no risk group respectively, whereas 60% showed either a lack of scientific evidence confirming their association with fracture or contradictory results. An efficient strategy for bone densitometry provision may thus be its selective use in those individuals who present with several strong or moderate risk factors for fracture related to bone mass loss.     

Systematic review of outcomes and meta-analysis of risk factors for prognosis after liver resection for hepatocellular carcinoma without cirrhosis

Long-term overall survival (OS) after liver resection for non-cirrhotic hepatocellular carcinoma (NCHCC) has been reported recently. The aim of this study was to review outcomes systematically and analyze risk factors for survival after surgical resection for HCC without cirrhosis. A literature search was performed of the PubMed and Embase databases for papers published between January 1995 and October 2012, which focused on hepatic resection for HCC without underlying cirrhosis. Cochrane systematic review methodology was used for this review. Outcomes were OS, operative mortality and disease-free survival (DFS). Pooled hazard ratios (HR) were calculated using the random effects model for parameters considered as potential prognostic factors. Totally, 26 retrospective case series were eligible for inclusion. The 1-, 3- and 5-year OS rate after surgical resection of NCHCC ranged from 62% to 100%, 46.3%–78.0%, and 30%–64%, respectively. The corresponding DFS rates ranged from 48.7% to 84%, 31.0%–66.0%, and 24.0%–58.0%, respectively. Five variables were related to poor survival: multiple tumors (HR 1.68, 95%CI 1.25–2.11); larger tumor size (HR 2.66, 95%CI 1.69–3.63); non-clear resection margin (R0 resection) (HR 3.52, 95%CI 1.63–5.42); poor tumor stage (HR 2.61, 95%CI 1.64–3.58); and invasion of the lymphatic vessels (HR 4.85, 95%CI 2.67–7.02). In sum, hepatic resection provides excellent OS rates for patients with NCHCC, and results have tended to improve recently. Risk factors for poor prognosis comprise multiple tumors, lager tumor size, non-R0 resection and invasion of the lymphatic vessels.     

Poor results of distal trapezium resection for trapeziometacarpal-1 osteoarthritis

Eleven patients (mean age 54 years, range 46–67 years) with osteoarthritis limited to the trapeziometacarpal-1 joint underwent a distal trapezium resection. In nine cases the palmaris longus tendon and in two cases a Swanson condylar implant was used as interposition material. The results were very disappointing. Only one patient was satisfied. Nine patients were reoperated upon (mean interval period 43 months, range 3–110) because of pain. In two cases, the cause was dislocation of the Swanson condylar implant. In the other seven cases, prominent bone on the trapezium, ulnar osteophytes, scaphotrapezial osteoarthritis, sclerosis of the trapezium remnant, and impingement were causal factors. In future, the selection of patients for this operation will be performed with even greater care. Despite these poor results, a definitive conclusion about the indication for this procedure can only be made after evaluation of an improved operative procedure. Received: 7 June 1999 / Accepted: 6 July 1999     

Differences between systematic reviews/meta-analyses of hyaluronic acid/hyaluronan/hylan in osteoarthritis of the knee

OBJECTIVE: To explore reasons for discrepant results between systematic reviews (SR)/meta-analyses (MA) of the efficacy and safety of hyaluronic acid/hyaluronan/hylan (HA) therapy in the treatment of osteoarthritis (OA) of the knee. METHODS: A decision algorithm was utilised to identify reasons for discordance among six SR. Sources of discordance such as clinical question, trial selection and inclusion, data extraction, assessment of study quality, assessment of the ability to combine trials, and statistical methods for data synthesis were examined. RESULTS: A similar question was asked in all six SR. Different trials were selected for inclusion in the reviews mainly because of differences in the search strategies and selection criteria. Although similar methods for data extraction were utilised, differences were found both in the outcome measures and time-points selected for extraction. Methodological quality was not always formally assessed. Different statistical methods for data synthesis resulted in conflicting estimates of therapeutic effect. CONCLUSIONS: Reasons for the inconsistency of results reported in the six SR were identified. Using the principles of the GRADE approach for estimating the therapeutic effect of HA in the treatment of OA of the knee, there is moderate evidence suggesting that further research is unlikely to change our confidence in the estimate of the effect. In the balance of benefit to harm, the trade-off is probable benefit with respect to pain reduction and physical function improvement with low risk of harm.