The conundrum of differentiating Cushing's syndrome from non-neoplastic hypercortisolism: a systematic review and meta-analysis.

CONTEXT: Once hypercortisolemia is confirmed, differential diagnosis between Cushing's syndrome (CS) due to neoplastic endogenous hypercortisolism and non-neoplastic hypercortisolism (NNH, pseudo-Cushing's syndrome) is crucial. Due to worldwide corticotropin-releasing hormone (CRH) unavailability, accuracy of alternative tests to dexamethasone (Dex)-CRH, is clearly needed. OBJECTIVE: Assess the diagnostic accuracy of Dex-CRH test, desmopressin stimulation test, midnight serum cortisol (MSC), and late-night salivary cortisol (LNSC) levels to distinguish CS from NNH. METHODS: Articles through March 2022 were identified from Scopus, Web of Science, MEDLINE, EMBASE, and PubMed. All steps through the systematic review were performed independently and in duplicate and strictly adhered to the updated PRISMA-DTA checklist. DATA SYNTHESIS: A total of 24 articles (1900 patients) were included. Dex-CRH had a pooled sensitivity and specificity of 91% (95%CI 87-94%; I2 0%) and 82% (73-88%; I2 50%), desmopressin test 86% (81-90%; I2 28%) and 90% (84-94%; I2 15%), MSC 91% (85-94%; I2 66%) and 81% (70-89%; I2 71%), and LNSC 80% (67-89%; I2 57%) and 90% (84-93%; I2 21%), respectively. Summary receiver operating characteristics areas under the curve were Dex-CRH 0.949, desmopressin test 0.936, MSC 0.942, and LNSC 0.950 without visual or statistical significance. The overall risk of studies bias was moderate. CONCLUSION: Dex-CRH, the desmopressin stimulation test, and MSC have similar diagnostic accuracy, with Dex-CRH and MSC having slightly higher sensitivity, and the desmopressin test being more specific. LNSC was the least accurate, probably due to high heterogeneity, intrinsic variability, different assays, and lack of consistent reported cutoffs. When facing this challenging differential diagnosis, the results presented here should increase clinicians' confidence when deciding which test to perform.

Rotator Interval vs Posterior Approach Ultrasound-guided Corticosteroid Injections in Primary Frozen Shoulder: A Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: To compare the efficacy of rotator interval (RI) vs posterior approach (PA) ultrasound (US) guided corticosteroid injections into the glenohumeral (GH) joint in primary frozen shoulder (PFS). DATA SOURCES: A systematic literature search for all relevant studies on Medline, Scopus, Embase, Web of Science, and Cochrane Central, up to January 2023 was conducted. STUDY SELECTION: Randomized controlled trials that directly compared the US-guided corticosteroid injection into the RI and GH joint using PA in patients clinically and radiographically diagnosed with PFS. DATA EXTRACTION: The primary outcome was pain, and the secondary outcomes were function, and range of motion (ROM). Two authors independently assessed the risk of bias using the Cochrane risk-of-bias tool version 2. A random-effects model and generic inverse variance method were performed. Effect sizes were estimated using mean difference (MD) and standardized mean difference (SMD). DATA SYNTHESIS: A total of 5 clinical trials involving 323 subjects were included for the meta-analysis. US-guided corticosteroid injections into the RI revealed significant pain relief (MD 1.33 [95% confidence interval (CI) 0.20 to 2.46]; P=.02) and significant functional improvement (SMD 1.31 [95% CI 0.11 to 2.51]; P=.03) compared with the PA after 12 weeks. CONCLUSION: The results suggest the injection of corticosteroid into RI space is more effective than PA after 12 weeks in improving both pain and functional scores in patients with PFS.

Anthropometric parameters to estimate body frame size in children and adolescents: A systematic review.

OBJECTIVE: To determine the most frequently body frame size (BFS) measurement and to compare the cut-off values used for classifying body size in children and adolescents. METHODS: This systematic review focused on primary studies and scientific reports published in Medline Ovid, EMBASE, Web of Science, or Scopus between January 1, 2007 and March 31, 2021. Eligible studies must have included at least one BFS parameter measured in healthy children or adolescents. A descriptive analysis and graphic comparison were performed when values of the body frame were available. RESULTS: A total of 26 studies involving 317 202 children and adolescents from all over the world were included. The report of Frame index predominated (46%). It was followed by the biacromial diameter single or combined with the bitrochanteric and biiliocristal diameter (27%), the wrist circumference (19%), and the grant index (12%). Fourteen studies reported percentile values of the BFS measurement, but only four presented cut-off values. CONCLUSIONS: There was no unified BFS measurement in children and adolescents neither reference cut-off values for categorization. The Frame index was the most frequently used. It is difficult to compare BFS statistics due to the diversity of measurements. It is necessary to standardize the use of the methods for measuring BFS.

Interventions supporting cost conversations between patients and clinicians: A systematic review.

BACKGROUND AND AIM: Discussing cost during medical encounters may decrease the financial impact of medical care on patients and align their treatment plans with their financial capacities. We aimed to examine which interventions exist and quantify their effectiveness to support cost conversations. METHODS: Several databases were queried (Embase; Ovid MEDLINE(R); Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily; the Cochrane databases; and Scopus) from their inception until January 31, 2020 using terms such as "clinician*", "patient*", "cost*", and "conversation*". Eligibility assessment, data extraction and risk of bias assessment were performed independently and in duplicate. We extracted study setting, design, intervention characteristics and outcomes related to patients, clinicians and quality metrics. RESULTS: We identified four studies (1327 patients) meeting our inclusion criteria. All studies were non-randomised and conducted in the United States. Three were performed in a primary care setting and the fourth in an oncology. Two studies used decision aids that included cost information; one used a training session for health care staff about cost conversations, and the other directly delivered information regarding cost conversations to patients. All interventions increased cost-conversation frequency. There was no effect on out-of-pocket costs, satisfaction, medication adherence or understanding of costs of care. CONCLUSION: The body of evidence is small and comprised of studies at high risk of bias. However, an increase in the frequency of cost conversations is consistent. Studies with higher quality are needed to ascertain the effects of these interventions on the acceptability, frequency and quality of cost conversations.

Localized gallbladder perforation: a systematic review of treatment and prognosis.

BACKGROUND: The optimal management of localized gallbladder perforation (Neimeier type II) has yet to be defined. The aim of this systematic review was to identify factors associated with improved patient outcomes. METHODS: Systematic review of studies that described the management of Neimeier type II perforation, reported complications of the first intervention, necessity of added interventions, resolution of the pathology, and days of hospital stay were included. The search strategy was conducted in EMBASE, Mayo Journals, MEDLINE, SCOPUS, and Web of Science (December 2020) RESULTS: A total of 122 patients (53% male) from case reports, series, and cohorts were included for analysis. In total 56 (46%) and 44 (36%)patients were treated with open and laparoscopic cholecystectomy respectively. Overall risk of bias was moderate. The need for another intervention was higher in the laparoscopic group (5 vs 17, p=<0.001) as well as prevalence of complications (4 vs 16, p=<0.001), but lower for days of hospital stay (median days 5. vs 15, p = 0.008) against open cholecystectomy. Preoperative percutaneous catheter drainage did not influence outcome. CONCLUSION: Open cholecystectomy has a lower need for further surgical procedures and postoperative complications, but a longer hospital stay. These outcomes did not vary with preoperative percutaneous drainage. The effect of timing of cholecystectomy did not influence the outcomes.

Acanthosis nigricans in middle-age adults: A highly prevalent and specific clinical sign of insulin resistance.

BACKGROUND: Insulin resistance (IR) precedes the diagnosis of many metabolic and non-metabolic illnesses, including type 2 diabetes mellitus (T2DM). Acanthosis nigricans (AN) is a clinical sign associated with IR. However, AN prevalence and diagnostic accuracy in middle-age adults before or at the time of prediabetes/diabetes diagnosis remain uncertain. METHODS: With the aim to define AN prevalence and diagnostic accuracy, adults between 40 and 60 years of age were consecutively invited to participate in the study. Participants were categorised into one of two main groups: individuals with normoglycaemia (group 1) and hyperglycaemia (group 2 [ie, prediabetes/diabetes]). Demographic, clinical, anthropometric characteristics, homeostasis model assessment of IR, homeostatic model assessment of ß-cell function, as well as the presence of AN on the neck, axillae, elbows and knuckles were assessed. RESULTS: A total of 320 consecutive participants with a mean age of 49.3 years (59.4% women) were included. Overall, AN prevalence was 46.3%, while AN in group 1 and group 2 was 36.3% and 49.6%, respectively (P = .04). The most common affected sites in group 1 (n = 80) were the knuckles (21.2%) and the neck (17.5%), while in group 2 (n = 240), the neck (29.6%) followed by the knuckles (26.7%). The specificity and positive predictive value of AN for IR were 0.85 and 0.86 in group 1 and 0.90 and 0.96 in group 2, respectively. CONCLUSIONS: In middle-age adults, within the entire spectrum of carbohydrate tolerance, AN is highly prevalent and specific. This finding supports its assessment as a reliable and convenient clinical sign of IR. The understanding of AN behaviour through different carbohydrate tolerance strata, and its different locations, could lead to early detection of individuals at high metabolic risk or help direct a more pathophysiological treatment approach in patients with T2DM.

Does glitazone treatment have a role on the prevention of Parkinson's disease in adult diabetic population? A systematic review.

Lately, focus on the relation between Parkinson's disease (PD) and Diabetes has risen greatly, as neuroprotective properties have been attributed to insulin use. Several studies have assessed the effect of glitazones, an insulin-sensitizing agent, in diabetic population on PD future risk. However, reports on the effect of their use have been heterogeneous. We aimed to synthesize the available scientific evidence which assesses the effect of glitazone use in type 2 diabetes patients on PD incidence. A systematic review was performed on multiple electronic databases. Considered for inclusion were studies that assessed the incidence of PD in type 2 diabetes glitazone users. Two reviewers worked independently and in duplicate to assess all studies, extract information and assess the methodological quality in each included study. Four high quality retrospective cohorts fulfilled inclusion criteria. Comparison groups varied across studies. In each study, incidence of PD was lower in glitazone-exposed patients compared to their respective comparison group. Pooled analysis showed lesser risk of PD in ever versus never glitazone users (RR 0.75 [95% C.I. 0.67-0.85; p < .0001; I2 = 0]). Our pooled analysis showed lesser risk of PD in glitazone versus non glitazone users, however, we advise to take results with caution since results are non-adjusted to possible confounding variables, furthermore, different glitazone-exposure time, follow up and comparison groups are aspects that also need to be pointed out. More clinical research focused on glitazone use and its relation with PD is needed, as this could result in new potential treatment modalities.

Does axillary lymph node size predict better metastatic involvement than apparent diffusion coefficient (ADC) value in women with newly diagnosed breast cancer?

BACKGROUND: It has been demonstrated that the number of metastatic axillary lymph nodes (mALNs) influence disease-free and overall survival in patients with breast cancer. PURPOSE: To determine if the ALN size is more accurate than the ALN apparent diffusion coefficient (ADC) value to predict metastatic involvement in newly diagnosed breast cancer. MATERIAL AND METHODS: A total of 44 patients with breast cancer were included. Magnetic resonance imaging (MRI) examinations were performed on a 1.5-T system with sagittal T1-weighted fast spin-echo non-fat saturated, sagittal T2-weighted fast spin-echo non-fat saturated, axial diffusion-weighted imaging echo-planar (b values of 0 and 700 s/mm2), and non-contrast axial VIBRANT sequences. The size and the ADC value were obtained for ALN ipsilateral and contralateral to breast cancer. The reference standard was the histopathologic lymph node status. RESULTS: mALN had a greater cortical thickness compared to contralateral non-mALN (10.3 ± 5.32 mm vs. 4 ± 1.17 mm, P ≤ 0.001). The threshold of ≥6.7 mm for predicting axillary metastatic involvement had a sensitivity and a specificity of 80.0% and 97.7%, respectively. The ADC value of mALN was significantly higher than the contralateral non-mALN (0.90 ± 0.12 × 10-3mm2/s vs. 0.78 ± 0.12 × 10-3mm2/s; P = 0.001). The threshold of ≥0.86 × 10-3mm2/s had a sensitivity and a specificity of 66.7% and 76.7%, respectively. CONCLUSION: Our results indicate that the cortical thickness has a better diagnostic performance in the differentiation of metastatic and non-metastatic lymph nodes than the lymph node ADC.

[Association of family typology and dysfunction in families with adolescents from a Mexican population]. / Asociación de tipología familiar y disfuncionalidad en familias con adolescentes de una población mexicana.

OBJECTIVE: To determine the association between family typology and dysfunction in families with adolescents in a Mexican population. DESIGN: Cross-sectional observational study. SETTING AND POPULATION: A total of 437 families in a Mexican population with adolescents attending a public high school. MAIN MEASUREMENTS: Determination of family typology (Mexican Family Medicine Council and Consensus) and family function (family APGAR) in adolescents and their parents/guardians. Identification of families with concordant perceptions among members (Cohen kappa), in which the association between typology and perception of family dysfunction was determined (odds ratio [OR]). RESULTS: The types of families are associated with family function by kinship, physical presence in the home and the level of family poverty. From the perception of the adolescent, the types are associated with: simple nuclear (OR 0.5, 95% CI 0.3-0.8), extended single parent (OR 1.9, 95% CI 1.03-3.5), integrated nucleus (OR 0.6, 95% CI 0.4-0.9), low family poverty (OR 0.5, 95% CI 0.3-0.8), and high family poverty (OR 5.3, 95% CI 1.5-18.6). From the perception of the tutor: the single parent (OR 1.9, 95% CI 1.09-3.4), and high family poverty (OR 2.9, 95% CI 1.1-7.7). There were 259 families with concordant perception of family function/dysfunction with a κ=0.189, determining that the types associated are: simple nuclear (OR 0.4, 95% CI 0.2-0.7), single-parent (OR 1.7, 95% CI 0.80-3.8), integrated nucleus (OR 0.5, 95% CI 0.3-0.8), non-integrated nucleus (OR 1.9, 95% CI 1.09-3.5), and high family poverty (OR 13.8, 95% CI 1.7-108.5). CONCLUSION: The family types with adolescents associated with family dysfunction are single-parent families with a non-integrated nucleus and high family poverty, and as protective factors, the simple nuclear and integrated nucleus.