Prevalence and incidence of venous leg ulcers—A systematic review and meta-analysis

Venous leg ulcers (VLU) represent a major public health challenge. Little is known about the prevalence and incidence of VLU internationally. Published studies are usually reporting different estimates because of disparities in study designs and measurement methods. Therefore, we conducted a systematic literature review and meta-analysis to identify the prevalence and incidence of VLU internationally and to characterise the population as reported in these studies. Studies were identified from searches in Medline (PubMed), CINAHL Complete (EBSCOhost), Embase, Scopus, Web of Science, LiSSa (Littérature Scientifique en Santé), Google Scholar and Cochrane Database of Systematic Reviews up to November 2022. Studies were included if their primary outcomes were reported as a period prevalence or point prevalence or cumulative incidence or incidence VLU rate. Fourteen studies met the inclusion criteria, 10 reporting estimates of prevalence, three reporting both prevalence and incidence estimates and one incidence. All were included in meta-analyses. The results show a pooled prevalence of 0.32% and a pooled incidence of 0.17%. Our results highlighted an extreme heterogeneity across effect sizes for both prevalence and incidence, which prevent a meaningful interpretation of pooled indexes and argue for further studies with specific prevalence-type reported and target population under study.     

Does VATS provide optimal treatment of empyema in children? A systematic review

Purpose

The surgical literature is replete with studies describing methods of treatment for pediatric empyema. The purpose of this report was to perform an evidence-based review of the literature to determine the most effective and appropriate treatment for empyema in infants and children.

Methods

The MEDLINE database was searched for English- and Spanish-language articles published from 1987 through 2002 on the treatment of thoracic empyema in children. Additional unpublished data were obtained by contacting individual study authors. There were no multiinstitutional prospective studies; all were retrospective, institutional series. A true meta-analysis could not be performed because of inherent institutional bias and variability in outcome measures among studies. A Kruskal-Wallis nonparametric test was used to compare methods detailed in the individual studies.

Results

Forty-four retrospective studies with a total of 1,369 patients were available for analysis. Four treatment strategies were compared: chest tube drainage alone (16 studies, 611 patients), chest tube drainage with fibrinolytic instillation (10 studies, 83 patients), thoracotomy (13 studies, 226 patients), and video-assisted thoracoscopic decortication (VATS; 22 studies, 449 patients). Outcome measures common to the majority of studies included length of stay, fever duration, l of antibiotic therapy duration, and duration of chest tube drainage. Patients undergoing early VATS or thoracotomy had shorter length of stay (P = .003). There was a trend for shorter duration of postoperative fever compared with chest tube alone or with fibrinolytic therapy, but this did not reach statistical significance (P = .055). There was no statistical difference in chest tube duration between methods. There was no trend correlating antibiotic use with treatment methods, length of hospital stay, duration of fever, or length of chest tube requirement.

Conclusions

Early VATS or thoracotomy leads to shorter hospitalization. The duration of chest tube placement and antibiotic use is variable and does not correlate with treatment method. A carefully designed, multiinstitutional, randomized study would lead to the development of evidence-based standards that may optimize the treatment of thoracic empyema in children.     

Factors affecting mortality in older trauma patients—A systematic review and meta-analysis

IntroductionMajor trauma in older people is a significant health burden in the developed world. The aging of the population has resulted in larger numbers of older patients suffering serious injury. Older trauma patients are at greater risk of death from major trauma, but the reasons for this are less well understood. The aim of this review was to identify the factors affecting mortality in older patients suffering major injury.Materials and methodsA systematic review of Medline, Cinhal and the Cochrane database, supplemented by a manual search of relevant papers was undertaken, with meta-analysis.Multi-centre cohort studies of existing trauma registries that reported risk-adjusted mortality (adjusted odds ratios, AOR) in their outcomes and which analysed patients aged 65 and older as a separate cohort were included in the review.Results3609 papers were identified from the electronic databases, and 28 from manual searches. Of these, 15 papers fulfilled the inclusion criteria. Demographic variables (age and gender), pre-existing conditions (comorbidities and medication), and injury-related factors (injury severity, pattern and mechanism) were found to affect mortality.The ‘oldest old’, aged 75 and older, had higher mortality rates than younger patients, aged 65–74 years. Older men had a significantly higher mortality rate than women (cumulative odds ratio 1.51, 95% CI 1.37–1.66). Three papers reported a higher risk of death in patients with pre-existing conditions. Two studies reported increased mortality in patients on warfarin (cumulative odds ratio 1.32, 95% CI 1.05–1.66). Higher mortality was seen in patients with lower Glasgow coma scores and systolic blood pressures. Mortality increased with increased injury severity and number of injuries sustained. Low level falls were associated with higher mortality than motor vehicle collisions (cumulative odds ratio 2.88, 95% CI 1.26–6.60).ConclusionsMultiple factors contribute to mortality risk in older trauma patients. The relation between these factors and mortality is complex, and a fuller understanding of the contribution of each factor is needed to develop a better predictive model for trauma outcomes in older people. More research is required to identify patient and process factors affecting mortality in older patients.     

Current practice and future perspectives in the treatment of short bowel syndrome in children—a systematic review

Purpose

Short bowel syndrome (SBS) is a malabsorption disorder of the intestine, which leads to an inadequate alimentary supply. A number of therapeutic approaches are already in use, but research advances may provide new options in the future. The purpose of this paper was to provide an overview of the established therapeutic approaches together with a discussion of the future perspectives in the treatment of patients with SBS. We review those studies dealing with the treatment of SBS patients and discuss both surgical and non-surgical approaches together with tissue engineering.

Methods

A systemic review of Medline-cited studies dealing with current practice and future perspectives in the treatment of short bowel in children was performed.

Results

Surgical approaches, non-surgical approaches, and tissue engineering which was used in the treatment of SBS were analyzed. Among the surgical approaches, the bowel lengthening procedures and small bowel transplantation are prevalent. Stimulants are most important concerning non-surgical approaches. Tissue engineering seems to be more experimental and was also evaluated.

Conclusion

The treatment of SBS patients remains very complex. It is eminent to find the best therapeutic option for each patient and to individualize and modify the different possible types of applied techniques frequently.     

Surgical versus conservative treatment for ankle fractures in adults – A systematic review and meta-analysis of the benefits and harms

IntroductionDespite fractures of the ankle being very common, there is a lack of clarity regarding the relative effectiveness of conservative versus surgical treatment.The purpose of this systematic review and meta-analysis was to investigate the clinical effects, benefits, and harms of surgical versus conservative treatment of ankle fractures in adults.MethodsA systematic search strategy was conducted in the databases: Pubmed, Embase, Web of Science, and Cochrane up until the 16th of August 2017. Eight available randomized controlled trials, regardless of fracture type, reported on patient-reported ankle-specific functional outcome and were included. Analyses were based on random effects models.ResultsThe 8 included studies randomly allocated 1237 patients to either surgical or conservative treatment. Mean age of patients ranged from 38.1 to 71.4 years. Five studies evaluated short-term patient-reported ankle function, with no significant difference between surgery and conservative treatment (SMD = ?0.14, 95%CI = ?0.57 to 0.29, P = 0.51, I² = 84%). Three studies evaluated health-related quality of life, with no significant difference in treatment effect between surgery or conservative treatment (SMD = 0.13, 95%CI = ?0.01 to 0.27, P = 0.06, I² = 0%).ConclusionsThe best available current evidence supports that clinicians can manage ankle fractures by both surgical and conservative means with equal short-term results in selected patient groups with stable and unstable nondisplaced ankle fractures. However, more research is needed including high-quality RCTs investigating the long-term effects. This is especially the case in younger patients, before making significant interpretations about clinical practice.     

Intracranial pressure monitoring in posterior fossa lesions—systematic review and meta-analysis

Neurosurgical Review - Elevated intracranial pressure (ICP) with reduced cerebral perfusion pressure is a well-known cause of secondary brain injury. Previously, there have been some reports...     

Role of prophylactic antiepileptic drugs in chronic subdural hematoma—a systematic review and meta-analysis

Neurosurgical Review - Chronic subdural hematoma is a common neurosurgical pathology, which is more commonly seen in the elderly age group. Few patients with chronic subdural hematoma (cSDH) can...     

Does birthweight predict bone mass in adulthood? A systematic review and meta-analysis

Summary  

This systematic review and meta-analysis assessed the strength and magnitude of the association between birthweight and adult bone mass. Higher birthweight was associated with higher bone mineral content of the spine and hip in adult men and women at ages between 18 and 80 years across a range of settings.     

Is interposition arthroplasty a viable option for treatment of moderate to severe hallux rigidus? — A systematic review and meta-analysis

IntroductionWhen conservative therapy for hallux rigidus fails, surgical options such as arthrodesis and interposition arthroplasty can be considered. Although arthrodesis of MTP joint is the gold standard treatment. However patients desiring MTP joint movement may opt for either interposition arthroplasty or implant arthroplasty to avoid the movement restrictions of arthrodesis. The purpose of this systematic review was to investigate clinical outcomes and complications following interposition arthroplasty for moderate to severe hallux rigidus, for patietns who would prefer to maintain range of motion in the MTP joint.MethodsA systematic search on MEDLINE, EMBASE and Cochrane library database was performed during February 2018. Demographics, surgical techniques, clinical outcomes, radiological outcomes and complications were recorded from each included study. Pooled statistics performed for variables with homogenous data across the studies. A linear regression model used to compare the clinical outcomes between autogenous vs allogenous material interposition arthroplasty.ResultsFifteen articles were included in the systematic review. Mean AOFAS scores improved from preoperative 41.35 to postoperative 83.17. Mean pain, function, and alignment score improved from preoperative values of 14.9, 24.9, and 10 to postoperative values of 33.3, 35.8, and 14.5. Mean dorsiflexion increased from 21.27° (5–30) to 42.03° (25–71). Mean ROM improved from 21.06° to 46.43°. Joint space increased from 0.8 mm to 2.5 mm. The most common postoperative complications included metatarsalgia (13.9%), loss of ground contact (9.7%), osteonecrosis (5.4%), great toe weakness (4.8%), hypoesthesia (4.2%), decreased push off power (4.2%), and callous formation (4.2%).ConclusionInterposition arthroplasty is an effective treatment option with acceptable clinical outcomes in patients with moderate-severe hallux rigidus who prefer to maintain range of motion and accept the risk of future complications.Level of Evidence: IV.     

Is fusion superior to non-fusion for the treatment of thoracolumbar burst fracture? A systematic review and meta-analysis

Objective

The purpose of this meta-analysis was to compare the efficacy and safety between patients with thoracolumbar burst fracture who underwent posterior fixation alone (non-fusion) and supplemented with fusion.

Surgical versus non-surgical treatment for acute Achilles’ tendon rupture. A systematic review of literature and meta-analysis

BackgroundAchilles’ tendon injury affect 31.17 per 100,000 yearly, it has a major impact on quality of life of affected patients, mostly active young individuals. Different management options exist ranging from conservative treatment, to operative repair either open or percutaneous repair. No consensus has been reached on which treatment modality is preferred for each patient. In this study we systematically reviewed the literature for available evidence regarding management of acute Achilles’ tendon rupture.MethodsThis systematic review consisted of 9 studies, including a systematic search of literature (PubMed, SCOPUS, and The Cochrane Library), selection of studies, extraction of study characteristics, assessment of methodological quality and bias and extraction of data on clinical outcomes and their comparisons between different surgical groups.ResultsA total of 9 studies were included, 822 patients were extracted from the included studies. Of the 822 patients, 415 (50.4%) had undergone surgical intervention and 407 (49.6%) had received non-surgical treatment. The minimum follow-up duration was 12 months. The left Achilles' tendon was relatively more prone to rupture. The interval from injury to treatment was within 2 to 14 days. Five 5 different surgical techniques were used; end to end, modified Kessler, augmented repair, Krackow type and interrupted circumferential stitch. Operative repair was found to significantly decrease rupture rate (Risk Ratio of 0.36, 95% CI 0.21–0.64; P = 0.0005) with higher risk of wound complications. No statistically significant difference between the two groups in functional outcome scores and range of motion.ConclusionWe concluded that surgical technique lowers the risk of rerupture rate but associated with higher complication rate which can be reduced by using the minimally invasive techniques. Multicenter randomized clinical trials are needed to obtain a high-quality level of evidence for the comparison between the different modified surgical techniques and the gap effect on making different decision of managements.     

Fibular fixation in mid and distal extra-articular tibia fractures – A systematic review and meta-analysis

BackgroundThe surgical management of extra-articular mid and distal tibia fractures has primarily focused on reducing rates of non-union and malunion, preserving hip-knee-ankle alignment and improving functional outcomes. Fibular fractures commonly accompany these injuries and the contributory role of fixation of these fractures has been increasingly studied. A systematic review and meta-analysis were performed to determine whether concurrent fibular fixation (FF) during extra-articular mid and distal tibia fracture fixation (AO/OTA 42 and 43-A) altered the risk of malunion, non-union and post-operative complications when compared to no fibular fixation (NF).MethodsA systematic search of literature in the databases of MEDLINE (via OvidSP), PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) from the dates of inception was performed for randomised and non-randomised controlled trials. All studies published in English were included. Risk of Bias in Non-randomised Studies (ROBINS-I) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework were utilised. Relative risk (RR) was used for dichotomous outcomes, while mean difference (MD) was used for continuous variables, with 95% confidence intervals. Alpha was set at 0.05.ResultsA total of ten studies with 1174 patients were included for analysis. There was a statistically significant reduced risk of overall malunion in the FF group compared to the NF group (11.8% vs 21.9%, RR 0.63, 95% CI: 0.41–0.98, p = 0.04) and this was supported through a sensitivity analysis of only randomised controlled trials (21.8% vs 40.3%, RR 0.37, 95% CI: 0.18–0.76, p = 0.006). There was no statistically significant difference in rates of non-union between groups (p > 0.05). Overall, there were similar incidences of diabetes, open fractures and smoking history between groups (p > 0.05). Detailed information regarding methods of tibial fixation were not available for subgroup analysis.ConclusionIn conclusion, in extra-articular mid and distal tibia (AO/OTA 42 and 43-A) fracture fixation, additional fibular fixation (FF) appears to significantly reduce the risk of overall malunion (RR, 0.37, 95% CI: 0.18–0.76, p = 0.006) without increasing the risk of non-union. These results should be interpreted with caution given the lack of subgroup analysis for methods of tibial fixation. Future high-quality randomised controlled trials should therefore delineate between types of tibial fixation.     

The role of statins in erectile dysfunction： a systematic review and meta-analysis

To evaluate the effect of statins for erectile dysfunction （ED）, a systematic review of the literature was conducted in the Cochrane Library, Embase and PubMed from the inception of each database to June 2013. Only randomized controlled trials （RCTs） comparing treatment for ED with statins were identified. Placebo RCTs with the International Index of Erectile Function （IIEF） as the outcome measure were eligible for meta-analysis. A total of seven RCTs including two statins with a total of 586 patients strictly met our criteria for systematic review and five of them qualified for the meta-analysis. A meta-analysis using a random effects model showed that statins were associated with a significant increase in IIEF-5 scores （mean difference （MD）： 3.27; 95% confidential interval （CI）：1.51 to 5.02; P〈 0.01） and an overall improvement of lipid profiles including total cholesterol （MD： -1.08; 95% Ch -1.68 to -0.48; P 〈 0.01）, low-density lipoprotein （LDL） cholesterol （MD： -1.43; 95% Ch -2.07 to -0.79; P 〈 0.01）, high-density lipoprotein （HDL） cholesterol （MD： 0.24; 95% Ch 0.13 to 0.35; P〈 0.01） and triglycerides （TGs） （MD. -0.55; 95% Ch -0.61 to -0.48; P 〈 0.01）. In summary, our study revealed positive consequences of these lipid-lowering drugs on erectile function, especially for nonresponders to phosphodiesterase type 5 inhibitors （PDE51s）. However, it has been reported that statin therapy may reduce levels of testosterone and aggravate symptoms of ED. Therefore, larger, well-designed RCTs are needed to investigate the double-edged role of statins in the treatment of ED.     

A systematic review and meta-analysis of surgical versus endovascular thrombectomy of thrombosed arteriovenous grafts in hemodialysis patients

BackgroundThe major pitfall of arteriovenous grafts (AVGs) for hemodialysis patients is thrombosis and occlusion. Prompt intervention with either surgical or endovascular therapy to salvage the vascular access is crucial in maintaining effective hemodialysis. The purpose of this systematic review and meta-analysis was to assess and compare the efficacy of open surgical vs wholly endovascular therapy for the treatment of thrombosed AVGs.MethodsThis review was conducted according to the PRISMA guidelines. Relative risks **(RRs) and pooled proportions for both primary and secondary outcomes were calculated.ResultsA total of eight randomized, controlled trials and two retrospective cohort studies were included, comprising 806 (63%) and 466 (37%) participants in the surgical and wholly endovascular treatment arms respectively. There were no significant differences between endovascular and surgical therapy in the 30-, 60-, and 90-day primary nonpatency rates. However, endovascular therapy reported a significantly higher 1-year primary nonpatency rate (rate ratio [RR], 1.22; 95% confidence interval [CI], 1.13-1.33; P < .01) and the 2-year primary nonpatency rate (RR, 1.26; 95% CI, 1.10-1.45; P < .01) as compared with surgical therapy. Similarly, the endovascular arm had a higher pooled proportion of primary nonpatency of 87.7% (95% CI, 81.5%-92.9%; P = .297), as compared with the surgical arm (72.1%; 95% CI, 66.4%-77.4%; P = .289). In terms of secondary nonpatency rates, there were no significant differences between endovascular and surgical procedures at 30, 60, and 90 days. Endovascular procedures reported a significantly higher technical failure rate as compared with surgical thrombectomy (RR, 1.58; 95% CI, 1.06-2.37; P = .03). There was no significant difference in terms of minor and major complications.ConclusionsOur data suggest that, for thrombectomy of AVGs, wholly endovascular therapy seems to be inferior to open surgery plus adjuncts based on the long-term patency and technical failure rates. However, further research in the form of a well-conducted randomized trial is warranted to establish a firmer conclusion.     

Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review

Background/purpose

Interval appendicectomy (IA) is commonly performed after successful nonoperative treatment of appendix mass (AM); although, this approach has recently been challenged. We systematically reviewed the pediatric literature with regard to the justification for this practice.

Methods

Using a defined search strategy, studies were identified and data were extracted independently by 2 reviewers. Incidences of recurrent appendicitis, complications after IA, and carcinoid tumor were estimated accounting for interstudy heterogeneity. Cost and length of stay of IA were analyzed.

Results

Three studies (127 cases) reporting routine nonsurgical treatment were identified; all were retrospective. There was marked interstudy heterogeneity and variable follow-up. After successful nonoperative treatment of AM, the risk of recurrent appendicitis is 20.5% (95% confidence interval [CI], 14.3%-28.4%). The incidence of complications after IA (23 studies, n = 1247) is 3.4% (95% CI, 2.2-5.1), and the incidence of carcinoid tumor found at IA (15 studies, n = 955) is 0.9% (95% CI, 0.5-1.8). No reports compared costs. Mean length of stay for IA was 3 days (range, 1-30 days).

Conclusions

Prospective studies comparing routine IA with nonoperative treatment without IA in children are lacking. Available data suggest that 80% of children with AM may not need IA. A prospective study to evaluate the natural history of this condition compared with the morbidity and costs of IA is warranted.