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To the Editor As academic hand surgeons, we were delighted that JAMA published a comprehensive Review article on 4 common hand conditions. Understanding that the article had a broad scope and was not focused on the epidemiology of carpal tunnel syndrome (CTS), we were nevertheless surprised that genetics was conspicuously missing as a risk factor for CTS, and an entire section was dedicated to “occupational risks.”
In Reply In their Letter about our article on common hand conditions, Dr Wiberg and colleagues describe the genetic component of CTS etiology, citing twin and genome-wide association studies that provide convincing data supporting heritability of CTS. Because our article was not a comprehensive review, we prioritized occupational risks that are frequently encountered by primary care physicians who evaluate and counsel these patients.
Introduction
The increasing ageing population has become a substantial challenge for both healthcare and social services in many Asian countries. There is a high incidence of chronic diseases and comorbidities in older populations, leading to impairments and functional disability. Functional disability may result in loss of independence, reduced quality of life and increased care needs. Community-based rehabilitation (CBR) provides rehabilitation to improve physical, mental and social outcomes. However, there is limited evidence regarding the effectiveness of CBR for improving older adults’ physical fitness. The aim of this systematic review is to synthesise the evidence for the effectiveness of interventions delivered by CBR centres on physical fitness of community-dwelling older adults in Asian countries.
Methods and analysis
A search on four English databases (CINAHL, Medline, Scopus and Proquest) and two Chinese databases (China National Knowledge Internet and Wanfang Database) will be conducted from inception to 15 November 2021. Both English and Chinese publications will be included. Studies conducted in Asian countries using either experimental or quasi-experimental designs, with any type of control group, will be included. The primary outcomes are physical fitness (capacity to perform activities and tasks). Secondary outcomes are performance of activities of daily living and health-related quality of life. The quality of all included studies will be assessed using the Joanna Briggs Institute standardised critical appraisal tools. Two reviewers will independently complete study screening, selection, quality appraisal and data extraction. Quantitative data where possible will be pooled in statistical meta-analysis. All statistical analyses will be performed using Review Manager (Rev Man) V.5.3 software.
Ethics and dissemination
Ethical approval is not required for this review. Findings of the review will be disseminated electronically through a peer-reviewed publication and conference presentations. This review will provide high-quality evidence for CBR in Asian countries with growing ageing populations. Clinical and research recommendations will provide guidance for policy makers and clinical programmes in Asian healthcare systems. Findings will also inform healthcare systems in other countries that use CBR.
PROSPERO registration number
CRD42021292088.
Introduction
Mechanical thrombectomy (MT) using stent retrievers or a direct aspiration first-pass technique has proven to yield better results over intravenous thrombolysis in treating acute ischaemic stroke caused by large vessel occlusion (LVO). However, the treatment of intracranial atherosclerotic stenosis-related LVO remains unclear and has been a critical problem in daily clinical practice, as it can cause a relatively high failure rate for MT. Whether direct angioplasty and/or stenting is clinically feasible and shows advantage in reducing delay to revascularisation with better functional outcome compared with MT with rescue angioplasty and/or stenting remains unclear. This study seeks to provide direct and practical clinical evidence for clinicians.
Methods and analysis
The main databases of PubMed, the Cochrane library, Embase and Web of Science will be screened for related studies published after1 January 2015. Primary outcomes include successful recanalisation and 90-day favourable outcome. Secondary outcomes include puncture to revascularisation time, vascular complication (perforation, dissection and vasospasm), intracerebral haemorrhage, hospital-related complications and 90-day mortality. The Newcastle-Ottawa Scale will be adopted to assess risk bias of observational studies. The I2 statistic will be used to assess heterogeneity.
Ethics and dissemination
No primary data of patients are needed. Therefore, ethics approval is unnecessary. The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.
PROSPERO registration number
CRD42021268061.
Circulation, Volume 146, Issue Suppl_1, Page A15248-A15248, November 8, 2022. Hypothesis:Transcatheter aortic valve replacement (TAVR) serves as a less-invasive treatment option for high-risk patients with severe aortic stenosis. Given the coexistence of obstructive coronary artery disease in patients with high-grade aortic stenosis (estimated to be 40-75%), there is inconsistent clinical data regarding potential mortality benefits of paired percutaneous coronary intervention (PCI) with TAVR procedures.Methods:We performed a literature search using PubMed, Embase, and Cochrane Library from inception through April 2022 to assess the mortality impact of preceding/concomitant PCI in patients undergoing transcatheter aortic valve replacement. The primary outcomes were 30-day all-cause mortality, 30-day cardiovascular mortality, and 6 months-1 year all-cause mortality. Secondary outcomes included 30-day myocardial infarction, stroke, major bleeding/vascular complications, and acute kidney injury.Results:11 studies (10 retrospective cohort studies, 1 randomized control trial) involving 2791 patients were included in the meta-analysis. Compared to patients undergoing TAVR alone, the TAVR+PCI group showed no significant difference in 30-day all-cause mortality (RR 0.90, CI 0.66, 1.22, p =0.49), 30-day cardiovascular mortality (RR 0.71 CI 0.44, 1.14, p =0.16), or 6 months-1 year all-cause mortality (RR 0.94, CI 0.75, 1.18, p =0.57). Regarding secondary outcomes, 30-day myocardial infarction was higher in the TAVR+PCI group compared to the TAVR group (RR 3.09, CI 1.26, 7.57, p =0.01), while no significant differences were found in rates of 30-day stroke (RR 1.14, CI 0.56, 2.33, p =0.72), major bleeding/vascular complications (RR 1.11, CI 0.79, 1.56, p =0.55), and acute kidney injury (RR 1.07, CI 0.75, 1.54, p =0.71).Conclusion:Concomitant/preceding percutaneous coronary intervention does not confer any additional mortality benefit, and may increase the risk of 30-day myocardial infarction, in patients with high-grade aortic stenosis undergoing transcatheter aortic valve replacement. Further trials with large sample sizes are needed to confirm our findings.
Circulation, Volume 146, Issue Suppl_1, Page A11599-A11599, November 8, 2022. Introduction:Oral anticoagulants (OAC) (e.g., warfarin, rivaroxaban, dabigatran) and salicylates (e.g., aspirin) can trigger the occurrence of bleeding events when used alone or in combination.Objective:The objective of this study was to conduct a systematic review and meta-analysis to examine the risk of bleeding in individuals exposed to a combination of OAC and aspirin, compared to those taking OAC monotherapy.Methods:PubMed, EMBASE, Scopus, and Web of Science were queried in January 2021. Studies that described combined exposure to OAC and salicylates, had a control arm of monotherapy of OAC and reported the number of bleeding events in each arm were included. After studies were identified for potential inclusion, first, the title and abstract were screened, followed by a review of the full text. The following information was extracted from the included studies: citation, drug and dose of medication, the average age of participants, number of patients and bleeding events in each group, and population of interest. Pooled odds ratios were calculated using a random-effects model. Heterogeneity was evaluated with Cochran’s Q and I2 statistics.Results:A total of 509 studies were identified, of which 35 met the inclusion criteria for the meta-analysis. Studies were further categorized into two groups based on the design of the study (randomized control trial or observational studies). Out of 35 studies, 16 randomized control trials compared combined OAC and salicylates vs warfarin monotherapy and combination therapy was associated with an increased odds [OR: 1.37, (95% CI 1.17 to 1.61)] of bleeding compared to warfarin monotherapy. The second group consisted of 19 observational studies comparing combined OAC and salicylates vs warfarin monotherapy. The results suggested that combination therapy was associated with an increased odds [OR: 1.42, (95% CI 1.09 to 1.87)] of bleeding compared to aspirin monotherapy.Conclusion:Risk of bleeding is significantly increased among patients taking salicylates and OAC together as compared with those taking warfarin alone.
Circulation, Volume 146, Issue Suppl_1, Page A11716-A11716, November 8, 2022. Introduction:Cardiac papillary fibroelastomas (CPF) are rare, benign endocardial tumors with embolic complications like cerebrovascular events. The objective of this systematic review is to identify the clinical profile, diagnostic approach, tumor characteristics, and treatment modalities of patients with CPF presenting with stroke or TIA.Methods:We performed a systematic review using PUBMED and EMBASE databases involving all the published case reports and case series of CPF with TIA or stroke as presentation until April 2022. Viewpoints, editorials, and review articles were excluded.Results:A total of 161 cases were identified from 133 case reports and 11 case series. The mean age was 54.8 ± 15.6 years with 53.4% females. The proportion of patients with TIA and stroke was 32.3% and 67.8% respectively. Neuroimaging demonstrated the involvement of multiple sites (36.6%) and middle cerebral artery territory (35.6%) as major sites of stroke. The primary imaging tool for the diagnosis of CPF was echocardiogram. The size of the tumor varied from 2 to 47 mm (mean 11.8 ± 7.1). Left-sided valves were the most common location of the tumor (73.2%). Mitral valve was the most common valve involved (38.9%) with the anterior leaflet being the more common site (61.3%). The aortic valve was involved in 32.5% with non-coronary cusp being the more common site (37.5%). About 10.6% of cases were missed by TTE (mean size of valvular tumors missed by TTE was 5.6 ± 1.9 mm). Most of the tumors (91.4%) showed independent mobility. Surgical excision was performed in 89.5% cases with histopathological confirmation. Medical management prior to surgery included antiplatelets (87.9%) and anticoagulation (12.1%). Simple excision, excision with valve repair and excision with valve replacement were done in 66.7%, 16.7% and 16.7% respectively. Most patients (97.8%) had uneventful post-operative course.Conclusions:CPFs are potential differential diagnosis for cryptogenic stroke. TEE serves as a better diagnostic modality for cardiac workup of cryptogenic stroke if the initial TTE is negative. While the consensus for CPF management remains controversial, the results of our study support surgical management as the primary approach for left-sided tumors presenting as stroke/TIA.
Circulation, Volume 146, Issue Suppl_1, Page A14753-A14753, November 8, 2022. Introduction:Impact of time savings with the use of automated left ventricular volume measurements has not been systematically quantified.Hypothesis:Automated measurement of left ventricular volumes will lead to significant time savings.Methods:Electronic search of MEDLINE and EMBASE was performed. Inclusion criteria included 1) LVEF (either 2D or 3D) quantification using completely automated software, 2) comparator group of manual measurements and 3) stated mean and standard deviation of measurement time. Meta-analysis was performed with studies weighted by DerSimonian-Laird method and pooled using random-effects model.Results:6 studies of automated 3D-LVEF measurement were identified with total of 697 pts. Time savings for 3D-LVEF automation was -371.0 seconds per study (95%CI -754.6 to +12.6 seconds, p = 0.058, Q (df=5) 2104.3, I2 99.9%), which was non-significant. HeartModel (Phillips) was used in 4 studies with 550 patients with non-significant time savings of -452.3 seconds (95%CI -1029.5 to +124.9 seconds, p=0.12, Q(df=3) 1954.1, I2 99.9%). 4D AutoLVQ (GE) was used in 1 study of 103 patients with significant time savings (142±30 sec vs. 226±114 sec, p
Circulation, Volume 146, Issue Suppl_1, Page A11548-A11548, November 8, 2022. Background:Evidence demonstrated gender disparities after transcatheter aortic valve replacement (TAVR) with early generation transcatheter heart valves (THV)s. However, it is unclear whether gender-related differences persist with the newer generation THVs. We conducted this meta-analysis and systematic review to assess gender disparities after TAVR with newer generation THVsMethods:We searched MEDLINE, and Embase databases from inception to May 2022 to identify studies that reported gender-specific outcomes after TAVR with newer generation THVs (Sapien 3, Corevalve Evolut R, and Evolut Pro). Outcomes of interests included 30-day mortality, 1-year mortality and vascular complications. Data were pooled using random-effects models to calculate pooled odds ratio (OR) and 95% conference interval (CI).Results:Four studies with a total of 47,933 patients (21,073 in females and 26,860 in males) were included. Ninety-six percent received TAVR via transfemoral approach. Females had higher 30-day mortality (OR = 1.53, 95%CI 1.31-1.79, p-value (p) < 0.001) and vascular complications (OR=1.43, 95%CI 1.23-1.65, p< 0.001). However, 1-year mortality was similar between 2 groups (OR=0.83, 95%CI 0.67-1.04, p=0.33).Conclusions:Higher 30-day mortality after TAVR in females may be attributed from higher vascular complications. Further research is needed to explore potential causes of increased mortality. While vascular complications may be an etiology, other patient characteristics or procedure-related issues should be evaluated.
Circulation, Volume 146, Issue Suppl_1, Page A13426-A13426, November 8, 2022. Objective:Randomized control trials (RCT) conducted on myocardial infarction (MI) patients regarding the efficacy of therapeutic hypothermia (TH) as an adjunct to percutaneous coronary intervention (PCI) have shown inconsistent results. This study aims to compare the use of TH in patients with MI undergoing PCI with control groups.Methods:We systematically searched four databases; PubMed, Scopus, Web of Science, and Cochrane for studies conducted until March 2022. The inclusion criteria were any study design that compared TH in patients with MI undergoing PCI with a control group. Infarct size percentage and recurrent MI were primary efficacy outcomes. Mortality, major adverse cardiovascular events (MACE), and overall bleeding complications were primary safety outcomes. The risk of bias assessment of the included RCTs was conducted through Cochrane tool, while the quality of the included cohort studies was assessed by the NIH tool. The meta-analysis was performed on RevMan.Results:A total of 19 studies were included; 15 RCTs, one case-control, and three cohort studies. Infarct size percentage was significantly reduced in TH group as compared to control (MD= -1.76, 95% CI [-3.04, -0.47), p=0.007), but the TH group had a higher incidence of bleeding complications (OR= 1.88, 95% CI [1.11, 3.18), p=0.02). There were no significant differences between TH and control groups in mortality (OR= 1.06, 95% CI [0.75, 1.50), p=0.73) or recurrent MI (OR= 1.21, 95% CI [0.64, 2.30), p=0.56).Conclusion:In patients with MI, TH reduces infarct size while increasing bleeding complications. Mortality and recurrent MI outcomes are not significantly reduced.
Circulation, Volume 146, Issue Suppl_1, Page A14772-A14772, November 8, 2022. Introduction:Vascular closure devices have shown marked improvement in patient comfort and time to ambulation after undergoing atrial fibrillation (AF) and atrial flutter (AFL) radiofrequency ablation. They have been proven superior to manual closure and Figure of 8 suture in terms of pain control and time to ambulate. However, data comparing different vascular closure devices is sparse.Hypothesis:To compare the efficacy of venous closure devicesMethods:We retrospectively reviewed 100 patients at our institution who underwent AF and AFL radiofrequency ablation. We aimed to assess the difference in time to ambulation, device failure, pain control and vascular complication rate between the two commonly used venous closure devices (VASCADE and PERCLOSE).Results:A total of 100 patients (50 in each arm) were included in the study. The mean age was 67.6+9.3 years and 73% patients were men. The two groups were well balanced with respect to baseline demographics and clinical characteristics except for coronary artery disease (24%VASCADE vs. 14% PERCLOSE, p
Circulation, Volume 146, Issue Suppl_1, Page A15820-A15820, November 8, 2022. Background:There continues to be emerging data about the benefits of Sodium-glucose co-transporter 2 inhibitor (SGLT2i) in patients with heart failure. This has led to the addition of this medication to guideline-directed medical therapy for heart failure with reduced ejection fraction. There is a discrepancy in whether the use of SGLT2i is beneficial in patients hospitalized for decompensated heart failure.Methods:In this study, a search was completed through PubMed, Scopus, Cochrane Library, ProQuest for randomized controlled trials from 2020 to 2022 that evaluated the impact of the use of SGLT-2 inhibitors (Empagliflozin, Sotagliflozin) in patients admitted with acute HF. After screening for our preset inclusion and exclusion criteria, three randomized controlled clinical trials were eligible for inclusion. We carried out a Meta-analysis of the relative odds on the basis of the random effect model using the Mantel-Haenszel method for the major outcome of the incidence of death from any cause, the number of heart failure events, rehospitalization for heart failure, and time to first heart failure event in the acute setting. Comprehensive Meta-analysis version 3 software was used for analysis.Results:A total of 2,532 patients from the EMPULSE, SOLOIST-WHF, EMPA-RESPONSE-AHF trials were included. After analysis, it was found that the P-value was 0.000, Z-value was -4.103, and the OR 0.508 (95% CI 0.368; 0.702) for the patients on either Empagliflozin or Sotagliflozin.Conclusions:The systematic review and meta-analysis we conducted show that patients who received SGLT-2i (Empagliflozin, Sotagliflozin) during hospitalization within 24 hours or more had a statistically significant decreased odds of all-cause of death, number of heart failure events, and rehospitalization for heart failure.
Circulation, Volume 146, Issue Suppl_1, Page A9568-A9568, November 8, 2022. Introduction:Although the preventive effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors for new-onset diabetes was investigated as secondary analyses of recent randomized controlled trials (RCTs), the synthesized evidence is lacking. We thus aimed to summarize the effects of SGLT2 inhibitors on preventing new-onset diabetes.Hypothesis:We assessed the hypothesis that SGLT2 inhibitors reduce the incidence of diabetes among patients with prediabetes and heart failure or chronic kidney disease.Methods:In this systematic review and meta-analysis of RCTs, MEDLINE and EMBASE were searched through February 11, 2022. Two independent authors screened the search results and extracted data from eligible RCTs (including both original and post hoc analyses) comparing SGLT2 inhibitors and placebo for the risk of new-onset diabetes among adults with prediabetes. No restrictions on publication date and language were applied. Meta-analysis was conducted using random-effects models to calculate risk ratios and 95% confidence intervals (CIs).Results:We included 4 RCTs with 5655 participants who had prediabetes. All studies had a low risk of bias and were conducted for treatments of heart failure or chronic kidney disease. Based on the random-effects meta-analysis, SGLT2 inhibitors were significantly associated with a lower risk of new-onset diabetes (relative risk, 0.79; 95% CI, 0.68 to 0.93, I2 =0·0%). The relative risks of new-onset diabetes in dapagliflozin and empagliflozin were 0.68 (95% CI, 0.52 to 0.89) and 0.87 (95% CI, 0.72 to 1.04), respectively (p-for-heterogeneity =0.14). The frequency of severe hypoglycemia was not elevated in the SGLT2 inhibitors group compared to the placebo group.Conclusions:In this meta-analysis, SGLT2 inhibitors were associated with a reduced risk of new-onset type 2 diabetes among adults with prediabetes and heart failure or chronic kidney disease. These findings indicate the potential usefulness of SGLT2 inhibitors as a pharmaceutical approach to prevent diabetes in conjunction with lifestyle modification among high-risk adults with prediabetes.
Circulation, Volume 146, Issue Suppl_1, Page A13429-A13429, November 8, 2022. Background:Post-CABG Atrial Fibrillation (PCAF) is linked to higher mortality, morbidity, and healthcare costs. Obstructive Sleep Apnea (OSA) has been studied as a risk factor for PCAF in a few studies. In this study, we sought to review and analyze the association between OSA and PCAF.Methods:We systematically searched PubMed, Scopus, and EMBASE for studies on OSA as predictors of PCAF using relevant keywords through June 2022. Random effects models were used to estimate pooled rates of PCAF with subgroup analysis. I2statistics were used to report inter-study heterogeneity. Leave-one-out meta-analysis was performed to evaluate the effect of each study on the overall estimate.Results:A total of 15 (N= 534387) studies were included between 2008-2021 in our Systematic review/Meta-analysis (Median follow-up duration: 29 days; mean age: 59-72 years; Males: 68.4%). 8 US-based studies, with the rest from Europe and South Asia, were included. A total of 34654 PCAF events were recorded. Pooled analysis of unadjusted (OR 1.23, 95%CI 1.07-1.42, p
Circulation, Volume 146, Issue Suppl_1, Page A13462-A13462, November 8, 2022. Introduction:Valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) and redo surgical mitral valve replacement (redo-SMVR) are two treatment strategies for patients with bioprosthetic mitral valve dysfunction. We conducted a systematic review and meta-analysis to compare the outcomes of ViV-TMVR versus redo-SMVR.Methods:We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of ViV-TMVR versus redo-SMVR in degenerated bioprosthetic mitral valves. We used a random effects model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 1-year, and 2-year mortality, stroke, bleeding and vascular complications, acute kidney injury (AKI), arrhythmias, and hospital length of stay (LOS).Results:Six observational studies with a total of 1,339 subjects were included. Median follow-up was 2 years. Compared to redo-SMVR, ViV-TMVR was associated with significantly lower in-hospital (RR 0.42; 95% CI 0.25-0.70; p=0.001) and 30-day mortality (RR 0.49; 95% CI 0.24-0.98; p=0.04) but similar 1-year (RR 0.97; 95% CI 0.64-1.47; p=0.89) and 2-year mortality (RR 1.14; 95% CI 0.71-1.81; p=0.59). Stroke, bleeding, AKI, and arrhythmias were less frequent and hospital LOS was shorter with ViV-TMVR, however vascular complications were similar between both strategies.Conclusion:In patients with degenerated bioprosthetic mitral valves, ViV-TMVR is associated with better outcomes compared to redo-SMVR including lower in-hospital and 30-day mortality, lower complication rates, and shorter hospital LOS. Given these findings and the ongoing advances in transcatheter therapeutics, ViV-TMVR may be preferred over redo-SMVR, particularly in individuals at intermediate-to-high surgical risk.
Circulation, Volume 146, Issue Suppl_1, Page A11771-A11771, November 8, 2022. Background:Obesity is usually associated with worse cardiovascular outcomes. However, fewer studies have evaluated its impact on long-term major adverse cardiovascular events (MACE) following CTO PCI. We conducted a meta-analysis to assess the same.Methods:PUBMED, Scopus, and EMBASE were systematically searched for studies reporting long-term (at least >1 year) outcomes with obesity vs no obesity in patients with CTO PCI. MACE events [all-cause mortality, cardiac mortality, revascularization, restenosis/reocclusion, recurrent angina pectoris (RAP), target-vessel myocardial infarction (MI), heart failure, cardiac death, or ischemia-driven target-vessel revascularization (TVR) were the primary endpoint. Pooled odds ratios (OR) and heterogeneity were assessed with random-effects models and I2 statistics respectively. Subgroup analysis was performed to assess the risk by age group and follow-up duration. The leave-one-study-out method was used for sensitivity analysis.Results:After an initial electronic search of thirty-two studies, five studies were selected, and between 2016 to 2021 selected were included in the final analysis. The sample size consisted of 5022 patients with a median age of 63. No significant impact of higher BMI/obesity was seen overall on a median duration of 2.6 yrs [OR(95% CI)= 0.95 (0.82-1.11), p=0.53, I2= 90.86%)](Fig 1).However, on a subgroup analysis, the geriatric age group (≥65 yrs) demonstrated an “Obesity Paradox” effect on MACE after CTO PCI, [OR (95%CI)=0.64 (0.47-0.88), I2=42.13, p
