Diagnostic accuracy of chest X-ray and CT using artificial intelligence for osteoporosis: systematic review and meta-analysis.

INTRODUCTION: Artificial intelligence (AI)-based systems using chest images are potentially reliable for diagnosing osteoporosis. METHODS: We performed a systematic review and meta-analysis to assess the diagnostic accuracy of chest X-ray and computed tomography (CT) scans using AI for osteoporosis in accordance with the diagnostic test accuracy guidelines. We included any type of study investigating the diagnostic accuracy of index test for osteoporosis. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and IEEE Xplore Digital Library on November 8, 2023. The main outcome measures were the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) for osteoporosis and osteopenia. We described forest plots for sensitivity, specificity, and AUC. The summary points were estimated from the bivariate random-effects models. We summarized the overall quality of evidence using the Grades of Recommendation, Assessment, Development, and Evaluation approach. RESULTS: Nine studies with 11,369 participants were included in this review. The pooled sensitivity, specificity, and AUC of chest X-rays for the diagnosis of osteoporosis were 0.83 (95% confidence interval [CI] 0.75, 0.89), 0.76 (95% CI 0.71, 0.80), and 0.86 (95% CI 0.83, 0.89), respectively (certainty of the evidence, low). The pooled sensitivity and specificity of chest CT for the diagnosis of osteoporosis and osteopenia were 0.83 (95% CI 0.69, 0.92) and 0.70 (95% CI 0.61, 0.77), respectively (certainty of the evidence, low and very low). CONCLUSIONS: This review suggests that chest X-ray with AI has a high sensitivity for the diagnosis of osteoporosis, highlighting its potential for opportunistic screening. However, the risk of bias of patient selection in most studies were high. More research with adequate participants' selection criteria for screening tool will be needed in the future.

Ultrasonography for confirmation of gastric tube placement.

BACKGROUND: Gastric tubes are commonly used for the administration of drugs and tube feeding for people who are unable to swallow. Feeding via a tube misplaced in the trachea can result in severe pneumonia. Therefore, the confirmation of tube placement in the stomach after tube insertion is important. Recent studies have reported that ultrasonography provides good diagnostic accuracy estimates in the confirmation of appropriate tube placement. Hence, ultrasound could provide a promising alternative to X-rays in the confirmation of tube placement, especially in settings where X-ray facilities are unavailable or difficult to access. OBJECTIVES: To assess the diagnostic accuracy of ultrasound alone or in combination with other methods for gastric tube placement confirmation in children and adults. SEARCH METHODS: This systematic review is an update of a previously published Cochrane review. For this update, we searched the Cochrane Library (2021, Issue 6), MEDLINE (to April 2023), Embase (to April 2023), five other databases (to July 2021), and reference lists of articles, and contacted study authors. SELECTION CRITERIA: We included studies that evaluated the diagnostic accuracy of naso- and orogastric tube placement confirmed by ultrasound visualization using X-ray visualization as the reference standard. We included cross-sectional studies and case-control studies. We excluded case series or case reports. We excluded studies if X-ray visualization was not the reference standard or if the tube being placed was a gastrostomy or enteric tube. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the methodological quality and extracted data from each of the included studies. We contacted the authors of the included studies to obtain missing data. There were sparse data for specificity. Therefore, we performed a meta-analysis of only sensitivity using a univariate random-effects logistic regression model to combine data from studies that used the same method and echo window. MAIN RESULTS: We identified 12 new studies in addition to 10 studies included in the earlier version of this review, totalling 1939 participants and 1944 tube insertions. Overall, we judged the risk of bias in the included studies as low or unclear. No study was at low risk of bias or low concern for applicability in every QUADAS-2 domain. There were limited data (152 participants) for misplacement detection (specificity) due to the low incidence of misplacement. The summary sensitivity of ultrasound on neck and abdomen echo windows were 0.96 (95% confidence interval (CI) 0.92 to 0.98; moderate-certainty evidence) for air injection and 0.98 (95% CI 0.83 to 1.00; moderate-certainty evidence) for saline injection. The summary sensitivity of ultrasound on abdomen echo window was 0.96 (95% CI 0.65 to 1.00; very low-certainty evidence) for air injection and 0.97 (95% CI 0.95 to 0.99; moderate-certainty evidence) for procedures without injection. The certainty of evidence for specificity across all methods was very low due to the very small sample size. For settings where X-ray was not readily available and participants underwent gastric tube insertion for drainage (8 studies, 552 participants), sensitivity estimates of ultrasound in combination with other confirmatory tests ranged from 0.86 to 0.98 and specificity estimates of 1.00 with wide CIs. For studies of ultrasound alone (9 studies, 782 participants), sensitivity estimates ranged from 0.77 to 0.98 and specificity estimates were 1.00 with wide CIs or not estimable due to no occurrence of misplacement. AUTHORS' CONCLUSIONS: Of 22 studies that assessed the diagnostic accuracy of gastric tube placement, few studies had a low risk of bias. Based on limited evidence, ultrasound does not have sufficient accuracy as a single test to confirm gastric tube placement. However, in settings where X-ray is not readily available, ultrasound may be useful to detect misplaced gastric tubes. Larger studies are needed to determine the possibility of adverse events when ultrasound is used to confirm tube placement.

Contribution of Gestational Weight Gain to Childhood Asthma Phenotypes: A Prospective Cohort Study.

BACKGROUND: The contribution of prenatal anthropometric measures to the development of specific childhood asthma phenotypes is not known. OBJECTIVE: We aimed to evaluate associations between prepregnancy body mass index (BMI) and gestational weight gain (GWG) with allergic and nonallergic asthma phenotypes in childhood. METHODS: Our study population included term, healthy infants in the middle Tennessee region of the United States. Prepregnancy BMI and GWG were ascertained from questionnaires administered during early infancy and categorized based on World Health Organization and Institute of Medicine recommendations, respectively. Allergic asthma was defined as 5-year current asthma and a positive skin test or specific IgE to aeroallergen(s). We used multivariable logistic regression models for asthma and multinomial logistic regression models for nonasthma, allergic asthma, and nonallergic asthma. RESULTS: A total of 1266 children were included. At the 5-year follow-up, 194 (15.3%) had asthma; among them, 102 (52.6%) had allergic asthma. Both inadequate and excessive GWG, compared with adequate GWG, were associated with increased odds of asthma (inadequate: adjusted odds ratio [aOR]: 1.76 [95% confidence interval (CI): 1.03-2.98]; excessive: aOR: 1.70 [95% CI: 1.12-2.57]) and increased odds of allergic asthma compared with no asthma (inadequate: aOR: 3.49 [95% CI: 1.66-7.32]; excessive: aOR: 2.55 [95% CI: 1.34-4.85]). Prepregnancy BMI was not associated with asthma nor with asthma phenotypes. CONCLUSIONS: Both inadequate and excessive GWG were associated with allergic asthma risk. These results support the benefits of optimal GWG during pregnancy on child health outcomes.

Joint associations of air pollutants during pregnancy, infancy, and childhood with childhood persistent asthma: Nationwide database study in Japan.

The joint effect of air pollutants at relatively low levels requires further investigation. Here, a database study was performed to evaluate the effects of exposure to mixtures of air pollutants during pregnancy, infancy, and childhood on childhood persistent asthma. We used the Japan Medical Data Center database, which provides access to family linkages and healthcare provider addresses, and included child-mother dyads in which the child was born between January 2010 and January 2017. The exposure of interest was ground-level air pollutants, and the primary outcome was childhood persistent asthma at 45 years of age, as defined based on outpatient and inpatient asthma disease codes and/or asthma medication dispensing claims. The weighted quantile sum (WQS) regression was used to evaluate the effects of air pollutant mixtures on 52,526 child-mother dyads from 1149 of 1907 municipalities (60.3 %) in Japan. The WQS regression models showed that with every 10th percentile increase in the WQS index, ground-level air pollutants during pregnancy, infancy, and childhood increased the risk of childhood persistent asthma by an odds ratio of 1.04 (95 % CI: 1.02-1.05; p<0.001), 1.02 (95 % CI: 1.01-1.03; p<0.001), and 1.03 (95 % CI: 1.01-1.04; p<0.001), respectively. Moreover, particulate matter with an aerodynamic diameter ≤ 2.5 µm was assigned the highest weight across all three exposure periods. Relatively high weights were assigned to suspended particulate matter and photochemical oxidants during pregnancy, carbon monoxide during infancy, and photochemical oxidants during childhood. Our study showed that a mixture of low-level air pollutants has a detrimental association with childhood persistent asthma.

The impact of continuity correction methods in Cochrane reviews with single-zero trials with rare events: A meta-epidemiological study.

Meta-analyses examining dichotomous outcomes often include single-zero studies, where no events occur in intervention or control groups. These pose challenges, and several methods have been proposed to address them. A fixed continuity correction method has been shown to bias estimates, but it is frequently used because sometimes software (e.g., RevMan software in Cochrane reviews) uses it as a default. We aimed to empirically compare results using the continuity correction with those using alternative models that do not require correction. To this aim, we reanalyzed the original data from 885 meta-analyses in Cochrane reviews using the following methods: (i) Mantel-Haenszel model with a fixed continuity correction, (ii) random effects inverse variance model with a fixed continuity correction, (iii) Peto method (the three models available in RevMan), (iv) random effects inverse variance model with the treatment arm continuity correction, (v) Mantel-Haenszel model without correction, (vi) logistic regression, and (vii) a Bayesian random effects model with binominal likelihood. For each meta-analysis we calculated ratios of odds ratios between all methods, to assess how the choice of method may impact results. Ratios of odds ratios <0.8 or <1.25 were seen in ~30% of the existing meta-analyses when comparing results between Mantel-Haenszel model with a fixed continuity correction and either Mantel-Haenszel model without correction or logistic regression. We concluded that injudicious use of the fixed continuity correction in existing Cochrane reviews may have substantially influenced effect estimates in some cases. Future updates of RevMan should incorporate less biased statistical methods.

Association between Empirical Anti-Pseudomonal Antibiotics and Progression to Thoracic Surgery and Death in Empyema: Database Research.

Evidence on the optimal antibiotic strategy for empyema is lacking. Our database study aimed to evaluate the effectiveness of empirical anti-pseudomonal antibiotics in patients with empyema. We utilised a Japanese real-world data database, focusing on patients aged ≥40 diagnosed with empyema, who underwent thoracostomy and received intravenous antibiotics either upon admission or the following day. Patients administered intravenous vasopressors were excluded. We compared thoracic surgery and death within 90 days after admission between patients treated with empirical anti-pseudomonal and non-anti-pseudomonal antibiotics. Cause-specific hazard ratios for thoracic surgery and death were estimated using Cox proportional hazards models, with adjustment for clinically important confounders. Subgroup analyses entailed the same procedures for patients exhibiting at least one risk factor for multidrug-resistant organisms. Between March 2014 and March 2023, 855 patients with empyema meeting the inclusion criteria were enrolled. Among them, 271 (31.7%) patients received anti-pseudomonal antibiotics. The Cox proportional hazards models indicated that compared to empirical non-anti-pseudomonal antibiotics, empirical anti-pseudomonal antibiotics were associated with higher HRs for thoracic surgery and death within 90 days, respectively. Thus, regardless of the risks of multidrug-resistant organisms, empirical anti-pseudomonal antibiotics did not extend the time to thoracic surgery or death within 90 days.

Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis.

STUDY OBJECTIVE: We conducted a systematic review and network meta-analysis to evaluate the comparative efficacy of peripheral nerve block types for preoperative pain management of hip fractures. METHODS: We searched Cochrane, Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar for randomized clinical trials. We included participants aged more than 16 years with hip fractures who received peripheral nerve blocks or analgesics for preoperative pain management. The primary outcomes were defined as absolute pain score 2 hours after block placement, preoperative consumption of morphine equivalents, and length of hospital stay. We used a random-effects network meta-analysis conceptualized in the Bayesian framework. Confidence of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). RESULTS: We included 63 randomized controlled studies (4,778 participants), of which only a few had a low risk of bias. The femoral nerve block, 3-in-1 block, fascia iliaca compartment block, and pericapsular nerve group block yielded significantly lowered pain scores at 2 hours after block placement compared with those with no block (standardized mean differences [SMD]: -1.1; 95% credible interval [CrI]: -1.7 to -0.48, [confidence of evidence: low]; SMD: -1.8; 95% CrI: -3.0 to -0.55, [low]; SMD: -1.4; 95% CrI: -2.0 to -0.72, [low]; SMD: -2.3; 95% CrI: -3.2 to -1.4, [moderate], respectively). The pericapsular nerve group block, 3-in-1 block, fascia iliaca compartment block, and femoral nerve block resulted in lower pain scores than the no-block group. Additionally, the pericapsular nerve group block yielded a lower pain score than femoral nerve block or fascia iliaca compartment block (SMD: -1.21; 95% CrI: -2.18 to -0.23, [very low]: SMD: -0.92; 95% CrI: -1.70 to -0.16, [low]). However, both the fascia iliaca compartment block and femoral nerve block did not show a reduction in morphine consumption compared with no block. To our knowledge, no studies have compared the pericapsular nerve group block with other methods regarding morphine consumption. Furthermore, no significant difference was observed between peripheral nerve blocks and no block in terms of the length of hospital stay. CONCLUSIONS: Compared with no block, preoperative peripheral nerve blocks for hip fractures appear to reduce pain 2 hours after block placement. Comparing different blocks, pericapsular nerve group block might be superior to fascia iliaca compartment block and femoral nerve block for pain relief, though the confidence evidence was low in most comparisons because of the moderate to high risk of bias in many of the included studies and the high heterogeneity of treatment strategies across studies. Therefore, further high-quality research is needed.

Prognostic Factors for Discharge Directly Home in Patients With Thoracoscopic Surgery for Empyema: A Multicenter Retrospective Cohort Study.

Background: Video-assisted thoracoscopic surgery is a widely recommended treatment for empyema in advanced stages. However, only a few studies have evaluated prognostic factors among patients with empyema who underwent video-assisted thoracoscopic surgery. Furthermore, no studies have evaluated predictors of direct discharge home. Patients and Methods: This multicenter retrospective cohort study included 161 patients with empyema who underwent video-assisted thoracoscopic surgery in five acute-care hospitals. The primary outcome was the probability of direct discharge home. The secondary outcome was the length of hospital stay after surgery. We broadly assessed pre-operative factors and performed univariable logistic regression for the direct discharge home and univariable gamma regression for the length of hospital stay after surgery. Results: Of the 161 included patients, 74.5% were directly discharged home. Age (>70 years; -24.3%); altered mental status (-33.4%); blood urea nitrogen (>22.4 mg/dL; -19.4%); and pleural pH (<7.2; -17.6%) were associated with high probabilities of not being directly discharged home. Fever (15.2%) and albumin (> 2.7 g/dL; 20.2%) were associated with high probabilities of being directly discharged home. The median length of stay after surgery was 19 days. Age (>70 years; 6.2 days); altered mental status (5.6 days); purulence (2.7 days); pleural thickness (>2 cm; 5.1 days); bronchial fistula (14.6 days); albumin (>2.7 g/dL; 3.1 days); and C-reactive protein (>20 mg/dL; 3.6 days) were associated with a longer post-operation hospital stay. Conclusions: Physicians should consider using these prognostic factors to predict non-direct discharge to the home for patients with empyema.