Normal saline instillation before suctioning: A meta-analysis of randomized controlled trials.

BACKGROUND: For airway management of intensive care unit (ICU) patients who are intubated, a 5-10-mL bolus of sterile normal saline (NS) solution is commonly instilled into an endotracheal or tracheostomy tube before suctioning. However, NS instillation has been associated with adverse events such as dyspnea, increasing heart rate, decreasing of oxygenation, blood pressure, and other vital parameters. OBJECTIVE: To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the necessity of NS instillation before suctioning in ICU patients. DATA SOURCES: The PubMed, Embase, Cochrane Library, and Scopus databases and the ClinicalTrials.gov registry were searched for studies published before May 2016. REVIEW METHODS: RCTs evaluating the outcome of NS instillation before suctioning in ICU patients undergoing endotracheal intubation or tracheostomy were included. Individual effect sizes were standardised, and a meta-analysis was conducted to calculate the pooled effect size by using a random-effect model. The primary outcome was the oxygen saturation immediately and 2 and 5min after suctioning. The secondary outcomes were the heart rate and blood pressure after suctioning. RESULTS: We reviewed 5 RCTs including 337 patients. Oxygen saturation was significantly higher in the non-NS group than in the NS group 5min after suctioning. The pooled mean difference in oxygen saturation was -1.14 (95% confidence interval: -2.25 to -0.03). The heart rate and blood pressure did not differ significantly between the non-NS and NS groups. CONCLUSION: NS instillation before suctioning does not benefit patients undergoing endotracheal intubation or tracheostomy. Moreover, it reduces oxygen saturation 5min after suction. However, our reviewed studies had a low methodological quality. Thus, additional studies involving large-scale RCTs are warranted.

Effect of Glyceryl Trinitrate Ointment on Pain Control After Hemorrhoidectomy: A Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Hemorrhoidectomy is associated with postoperative pain and prolonged wound healing. Glyceryl trinitrate has been shown to decrease muscle spasm and increase anodermal blood flow. A meta-analysis of randomized controlled trials was conducted to evaluate the efficacy of topical glyceryl trinitrate application in pain relief after hemorrhoidectomy. METHODS: PubMed, EMBASE, Cochrane Library, Scopus, and ClinicalTrials.gov registries were searched for studies published before August 2015. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate a pooled effect size using random effects models. Pain was assessed using a visual analog scale on days 1, 3, 7, and 14 after operation. Secondary outcomes included time taken to resume routine activities, wound healing at 3 weeks after operation, complication, and headache incidence. RESULTS: A total of 12 trials with 1095 patients were reviewed. Significant pain reduction was observed on days 1, 3, 7, and 14 after hemorrhoidectomy in the glyceryl trinitrate groups. Glyceryl trinitrate-treated patients appeared to resume routine activities earlier than those in the control group (weight mean difference -7.52; 95% confidence interval: 16.13-1.08). The wound healing rates 3 weeks after operation were significant higher in the glyceryl trinitrate-treated groups than in the control group (risk ratio 1.79; 95% confidence interval: 1.38-2.33). However, the incidence of headache significantly increased in the glyceryl trinitrate group (risk ratio 3.68; 95% confidence interval: 1.62-8.34). CONCLUSION: Topical application of glyceryl trinitrate effectively relieves pain and promotes wound healing after hemorrhoidectomy; however, the substantial headache incidence may limit extensive application.

Concordance correlation coefficients estimated by modified variance components and generalized estimating equations for longitudinal overdispersed Poisson data.

For longitudinal overdispersed Poisson data sets, estimators of the intra-, inter-, and total concordance correlation coefficient through variance components have been proposed. However, biased estimators of quadratic forms are used in concordance correlation coefficient estimation. In addition, the generalized estimating equations approach has been used in estimating agreement for longitudinal normal data and not for longitudinal overdispersed Poisson data. Therefore, this paper proposes a modified variance component approach to develop the unbiased estimators of the concordance correlation coefficient for longitudinal overdispersed Poisson data. Further, the indices of intra-, inter-, and total agreement through generalized estimating equations are also developed considering the correlation structure of longitudinal count repeated measurements. Simulation studies are conducted to compare the performance of the modified variance component and generalized estimating equation approaches for longitudinal Poisson and overdispersed Poisson data sets. An application of corticospinal diffusion tensor tractography study is used for illustration. In conclusion, the modified variance component approach performs outstandingly well with small mean square errors and nominal 95% coverage rates. The generalized estimating equation approach provides in model assumption flexibility of correlation structures for repeated measurements to produce satisfactory concordance correlation coefficient estimation results.

Recurrent pain after percutaneous vertebroplasty.

OBJECTIVE: The purposes of this review are to summarize the causes of recurrent pain after percutaneous vertebroplasty and to discuss the incidence, clinical symptoms, risk factors, image findings, treatment and prognosis, and prevention of such pain. CONCLUSION: Percutaneous vertebroplasty is widely used to treat patients with symptomatic osteoporotic compression fractures. Although the procedure relieves the pain of the compression fracture, recurrent back pain after percutaneous vertebroplasty is common.

The clinical influence of fluid sign in treated vertebral bodies after percutaneous vertebroplasty.

PURPOSE: To determine the association between fluid sign and clinical prognosis following percutaneous vertebroplasty (PV). MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained for this prospective study. Fifty-two patients (41 women, 11 men; mean age, 75.9 years; range, 56-95 years) were enrolled from August 2006 to August 2007. All patients underwent preoperative magnetic resonance (MR) imaging and assessment of mobility and pain scores. PV was performed and patients underwent 1-, 3-, and 6-month follow-up examinations. MR findings of fluid sign (a focal, linear, or triangular area of strong hyperintensity, which is isointense relative to cerebrospinal fluid on T2-weighted sagittal images) and vacuum cleft were analyzed with respect to clinical outcome. Data were analyzed by using a combination of independent Student t test, chi(2) test, analysis of variance, and Fisher exact test. RESULTS: Thirty-four (65%) patients showed vacuum cleft; 14 (27%) showed fluid sign at the bone-cement interface. Patients without fluid sign in the treated vertebral bodies had better mobility and pain improvement compared with patients with fluid sign at 1- and 3-month follow-up (P < .05). The adjacent fracture percentage (seven of 14, 50%) was higher in patients with fluid sign in the treated vertebral bodies than in those without (three of 38, 8%) (P = .002). Pain was similar in groups with and without fluid sign at 6-month follow-up. CONCLUSION: The fluid sign in the treated vertebral bodies had a high negative predictive value of 92% and a positive predictive value of 50% to develop a new adjacent compression fracture.

Immunoglobulin G4-Related Disease Presented as Recurrent Otitis Media and Mixed Hearing Loss Treated With Cyclophosphamide and Rituximab: A Case Report.

Immunoglobulin G4-related disease (IgG4-RD) is a systemic autoimmune disease; however, it rarely presents as recurrent otitis media and mixed hearing loss. In this article, we present a 43-year-old male patient who presented with recurrent otitis media and mixed hearing loss that is the 12th case of IgG4-RD with middle and inner ear involvement. We also report the clinical response of cyclophosphamide and rituximab therapy in IgG4- RD. These two drugs have never been used to treat otologic symptoms, but were used to treat other organs affected by IgG4-RD. One year later, the patient underwent mastoidectomy of the right ear and the pathological reports revealed IgG4-related disease. A rheumatologist administered immunosuppressive therapy comprising cyclophosphamide and rituximab. After therapy, patient's right-sided mixed hearing loss partially improved. We recorded all pure tone audiometry data to evaluate the clinical course and treatment effect. Finally, we concluded that pathological confirmation and further immunosuppressive therapy should be considered in a timely manner to prevent hearing impairment. We recommend cyclophosphamide and rituximab for the treatment of diseases involving the middle and inner ear.

Fluid sign in the treated bodies after percutaneous vertebroplasty.

INTRODUCTION: The aims of this study are to describe non-healing in the treated vertebral body after percutaneous vertebroplasty and analyze the influence of vacuum cleft, location, and severity of collapse on the development of nonunion cement. MATERIALS AND METHODS: Of 208 patients (266 treated vertebral bodies) who were treated with percutaneous vertebroplasty from September 2002 to May 2006, 23 patients (41 treated levels) with residual or recurrent pain underwent follow-up magnetic resonance imaging (MRI) study. Retrospective chart review with analysis of preoperative and postoperative MRIs were performed in these 23 patients. RESULTS: In the 41 treated vertebral bodies, 22 of 41 bodies had vacuum cleft found in the preoperative MRI study. Eight of the 22 treated vertebral bodies with preoperative vacuum clefts were found to have fluid between the interface of cement and the residual bone in the collapsed vertebral bodies on follow-up MRI. The adjacent discs of these treated vertebral bodies were upward/downward displaced. The endplate of the adjacent vertebral body exhibited fibrotic change. Treated bodies with vacuum clefts and level A location (T9, T11, T12, and L1) had higher probability of developing nonunion of the cement with statistical significance. The probability of nonunion cement in severe collapsed bodies might be higher than that of union cement in mild collapsed ones, but was not statistically significant. CONCLUSIONS: Fluid sign in the treated body represents unhealed bone-cement interface. The location of the treated vertebral body and existence of vacuum cleft in the treated bodies may be important factors influencing the nonunion of cement.

Analgesic Effects of Locally Administered Ketorolac-based Analgesics After Breast Surgery: A Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: Reducing postoperative pain following breast surgery is crucial for rapid recovery and shortening hospital stay. Ketorolac, a nonsteroidal anti-inflammatory drug, has been used as a postoperative analgesic in many surgical procedures. We conducted a systemic review and meta-analysis on the efficacy of locally administered ketorolac-based analgesics in managing pain after breast surgery. METHODS: We searched the PubMed, Embase, Cochrane Library, Scopus, and ClinicalTrials.gov registry for randomized control trials (RCTs) published up to September 2016. The primary outcome was pain level assessed using a visual analog scale (VAS) at 1 and 6 hours following breast surgery. RESULTS: We reviewed 4 RCTs with 255 patients. For meta-analysis, VAS at 1 and 6 hours of 3 similar RCTs were compared. At 1 hour, VAS scores were significantly lower in patients administered a ketorolac solution [weighted mean difference (WMD)=-2.04; 95% confidence interval (CI): -3.08 to -1.00] or ketorolac-bupivacaine solution (WMD=-2.30; 95% CI, -4.07 to -0.54) than in controls. At 6 hours, the ketorolac-bupivacaine solution reduced VAS scores significantly (WMD=-1.40; 95% CI, -2.48 to -0.32) compared with controls. However, at 1 hour, the ketorolac solution was significantly more effective than the bupivacaine solution was (WMD=-1.70; 95% CI, -2.81 to -0.59). DISCUSSION: The effects of ketorolac-based analgesics vary as per the surgery and disease type. Locally administered ketorolac-based analgesics decreased postoperative pain in breast surgery patients, and the effect of local ketorolac was better than local bupivacaine. Therefore, ketorolac-based analgesics demonstrate considerable local infiltration during pain management after breast surgery.

Effect of acupuncture on aromatase inhibitor-induced arthralgia in patients with breast cancer: A meta-analysis of randomized controlled trials.

PURPOSE: Aromatase inhibitor (AI)-induced arthralgia (AIA) is a common side effect that may lead to premature discontinuation of effective hormonal therapy in patients with breast cancer. Acupuncture may relieve joint pain in patients with AIA. We conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the effectiveness of acupuncture in pain relief in AIA. METHODS: The PubMed, Embase, Cochrane Library, and Scopus databases and the ClinicalTrials.gov registry were searched for studies published before February 2017. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate the pooled effect size by using a random effect model. Pain was assessed using the Brief Pain Inventory (BPI) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 3-4, 6-8, and 12 weeks. Secondary outcomes included disability level, upper extremity function, physical performance, and quality of life. RESULTS: Five trials involving 181 patients were reviewed. Significant pain reduction was observed after 6-8 weeks of acupuncture treatment. Patients receiving acupuncture showed a significant decrease in the BPI worst pain score (weighted mean difference [WMD]: -3.81, 95% confidence interval [CI]: -5.15 to -2.47) and the WOMAC pain score (WMD: -130.77, 95% CI: -230.31 to -31.22) after 6-8 weeks of treatment. One of the 4 trials reported 18 minor adverse events in 8 patients during 398 intervention episodes. CONCLUSION: Acupuncture is a safe and viable nonpharmacologic treatment that may relieve joint pain in patients with AIA. Additional studies involving a higher number of RCTs are warranted.

Unusual magnetic resonance characteristics of a cerebellopontine angle epidermoid cyst with upper cervical spinal canal extension.

We present a 27-year-old woman with an epidermoid cyst at the cerebellopontine (CP) angle with caudal extension into the upper cervical spinal canal. The lesion showed unusual hyperintensity on T1-weighted images, and hypointensity on T2-weighted images. We used microneurosurgical techniques for tumour dissection and excision. To our knowledge, this is the fifth example in Index Medicus/MEDLINE of histopathologically proven CP angle epidermoid with cervical spine extension.

Hyperdense findings in sinus computed tomography of chronic rhinosinusitis.

BACKGROUND: Our study investigated the diagnostic value of the mineralization findings and high-density secretion features of sinus computed tomography (CT) images in cases of chronic rhinosinusitis (CRS) compared to histopathology and operative findings. METHODS: This was a prospective cohort study of 193 patients consecutively enrolled for endoscopic sinus surgery (ESS). Group 1 had mineralization in the sinus; group 2 had high-density secretions in the sinus but no mineralization; group 3 lacked both high-density secretions and evidence of mineralization. Intergroup comparisons were performed for histopathology (especially presence of fungus ball), CT scores, and gross operative appearance. RESULTS: Histopathologic evidence of fungus ball (FB) compared to presence of CT findings was significantly different between the groups, with the following percentages of patients demonstrating FB presence: 33% of group 1 (CT mineralization) (n = 48); 4% of group 2 (CT hyperdensity) patients (n = 25); and 2% of group 3 (no mineralization, no hyperdensity) patients (n = 120) (p < 0.05). Operative findings did not necessarily correlate with CT findings and all groups demonstrated varying amounts of dry cheesy (DCM) or wet clay-like (WCLM) material, though this was slightly higher in groups 1 and 2. CONCLUSION: A preoperative survey of sinus mineralization and high-density secretion features observed with CT was predictive of operative findings and histopathological results indicating a sinus FB.

Sac ligation in inguinal hernia repair: A meta-analysis of randomized controlled trials.

BACKGROUND: Traditionally, hernia sac ligation during inguinal hernia repair is considered mandatory to prevent postoperative development of hernia. However, ligation may induce postoperative pain. The aim of this study was to evaluate the outcomes of hernia sac ligation after inguinal hernia repair. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials to investigate the outcomes of hernia sac ligation for open or laparoscopic inguinal hernia repair. Incidence of hernia recurrence was assessed following the surgery. The secondary outcomes included pain scores and postoperative complications. RESULTS: Five trials were selected and their results were summarized. These 5 trials were published between 1984 and 2014, and the sample sizes ranged from 50 to 467 patients. Four trials had recruited patients with inguinal hernia who underwent open repair, and one study enrolled patients who underwent laparoscopic procedures. We observed no difference in the incidence of hernia recurrence and postoperative complications between the sac ligation and nonligation groups. Postoperatively, the intensity of pain was significantly higher in the ligation group than in the nonligation group at Day 7 (Weight mean difference 1.46; 95% confident interval: 0.98-1.95). CONCLUSION: Hernia sac ligation was associated with higher postoperative pain, and did not show any benefit over sac nonligation regarding the incidence of recurrence and postoperative complications in patients undergoing open tension-free mesh repair or laparoscopic procedures.

Effect of wound infiltration with ropivacaine or bupivacaine analgesia in breast cancer surgery: A meta-analysis of randomized controlled trials.

BACKGROUND: Although not completely painless, breast-conserving surgery is considerably less painful than modified radical mastectomy. Local anesthetics are speculated to reduce postoperative pain when placed at the surgical site. Thus, we conducted a systematic review of randomized controlled trials to evaluate the efficacy of bupivacaine or ropivacaine analgesia for pain relief in breast cancer surgery. METHODS: PubMed, Embase, the Cochrane Library, Scopus, and the ClinicalTrials.gov registry were searched for studies published up to July 2015. Individual effect sizes were standardized, and a meta-analysis was performed to calculate a pooled effect size by using random effects models. Pain was assessed using a visual analog scale at 1, 2, 12, and 24 h postoperatively. The secondary outcomes included complications and analgesic consumption. RESULTS: We reviewed 13 trials with 1150 patients. We found no difference in postoperative pain reduction at 1, 12, and 24 h after breast cancer surgery between the experimental and control groups. The severity of pain was significantly reduced in the experimental group (weighted mean difference -0.19; 95% confidence interval: -0.39-0.00) at 2 h postoperatively. Moreover, postoperative analgesic consumption did not differ significantly between the groups. No major drug-related complication was observed in any study. CONCLUSION: Administration of the local anesthetics bupivacaine or ropivacaine during breast cancer surgery decreased pain significantly at only 2 h but did not reduce pain at 12, and 24 h postoperatively.

Supraumbilical skin rash and fat necrosis after transcatheter arterial chemoembolization: a case report.

We report the case of a 63-year-old female who had chronic hepatitis C and who was diagnosed with hepatocellular carcinoma. Hepatic angiography showed one visible and tortuous falciform artery arising as the terminal branch of the left hepatic artery. Transcatheter arterial chemoembolization (TACE) was performed via the left hepatic artery. The patient developed supraumbilical skin rash with local tenderness on the following day. After supportive treatment by a dermatologist, the skin rash subsided gradually with sequelae of irregular skin surface and one small subcutaneous nodule. Skin biopsy of the lesion 1 year later showed fat necrosis with foreign body reaction and fibrosis. We discuss this rare complication of TACE and review the literature.

Intracerebral implantation of autologous peripheral blood stem cells in stroke patients: a randomized phase II study.

In our previous study, intracerebral implantation of peripheral blood stem cells (PBSCs) improved functional outcome in rats with chronic cerebral infarction. Based on this finding, a randomized, single blind controlled study was conducted in 30 patients [PBSC group (n = 15) and control group (n = 15)] with middle cerebral artery infarction confirmed on a T2-weighted MRI 6 months to 5 years after a stroke. Only subjects with neurological deficits of intermediate severity based on the National Institute of Health Stroke Scale (NIHSS; range: 9-20) that had been stable for at least 3 months were enrolled. Those in the PBSC group received subcutaneous G-CSF injections (15 µg/kg/day) for 5 consecutive days, and then stereotaxic implantation of 3-8 × 10(6) CD34(+) immunosorted PBSCs. All 30 patients completed the 12-month follow-up. No serious adverse events were noted during study period. Improvements in stroke scales (NIHSS, ESS, and EMS) and functional outcomes (mRS) from baseline to the end of the 12-month follow-up period were significantly greater in the PBSC than the control group. The fiber numbers asymmetry (FNA) scores based on diffusion tensor image (DTI) tractography were reduced in every PBSC-treated subject, but not in the control group. Reduction in the FNA scores correlated well with the improvement in NIHSS. Furthermore, a positive motor-evoked potential (MEP) response by transcranial magnetic stimulation (TMS) appeared in 9 of the 15 subjects in the PBSC group. This phase II study demonstrated that implantation of autologous CD34(+) PBSC was safe, feasible, and effective in improving functional outcome.

Reproducibility of corticospinal diffusion tensor tractography in normal subjects and hemiparetic stroke patients.

PURPOSE: The reproducibility of corticospinal diffusion tensor tractography (DTT) for a guideline is important before longitudinal monitoring of the therapy effects in stroke patients. This study aimed to establish the reproducibility of corticospinal DTT indices in healthy subjects and chronic hemiparetic stroke patients. MATERIALS AND METHODS: Written informed consents were obtained from 10 healthy subjects (mean age 25.8 ± 6.8 years), who underwent two scans in one session plus the third scan one week later, and from 15 patients (mean age 47.5 ± 9.1 years, 6-60 months after the onset of stroke, NIHSS scores between 9 and 20) who were scanned thrice on separate days within one month. Diffusion-tensor imaging was performed at 3T with 25 diffusion directions. Corticospinal tracts were reconstructed using fiber assignment by continuous tracking without and with motion/eddy-current corrections. Intra- and inter-rater as well as intra- and inter-session variations of the DTT derived indices (fiber number, apparent diffusion coefficient (ADC), and fractional anisotropy (FA)) were assessed. RESULTS: Intra-session and inter-session coefficients of variations (CVs) are small for FA (1.13-2.09%) and ADC (0.45-1.64%), but much larger for fiber number (8.05-22.4%). Inter-session CVs in the stroke side of patients (22.4%) are higher than those in the normal sides (18.0%) and in the normal subjects (14.7%). Motion/eddy-current correction improved inter-session reproducibility only for the fiber number of the infarcted corticospinal tract (CV reduced from 22.4% to 14.1%). CONCLUSION: The fiber number derived from corticospinal DTT shows substantially lower precision than ADC and FA, with infarcted tracts showing lower reproducibility than the healthy tissues.

Repeat percutaneous vertebroplasty at cemented vertebra with fluid sign and recurrent pain.

SUMMARY: Six patients (three females and three males) were referred from their clinicians for evaluation with complaints of recurrent pain. A followup MRI showed fluid at the cemented vertebral bodies. Repeat percutaneous vertebroplasty (PV) was performed in these six patients at the cemented vertebrae. Pain scores, mobility scores, and spine MRIs before the 1st PV, prior to the repeat PV, and 1 and 3 months after the repeat PV were obtained. One month after the repeat PV, the six patients had a mean pain score reduction of 6.2 points and a mean postoperative pain level reduction of 2.8 points. Four of the six patients demonstrated an improvement in mobility with a 1.7 point mean decrease one month after the repeat PV. There was decreased fluid and bone marrow edema in four of the six patients on the follow-up MRIs one and three months after the repeat PV. Repeat PV at cemented vertebrae with fluid signs may offer therapeutic benefits for recurrent pain.