Ninety-day mortality and clinical outcomes of patients with solid tumours and COVID-19 infection during the first pandemic outbreak in Catalonia, Spain: A multicentre retrospective study.

To describe the clinical outcomes and risk factors for 90-day mortality in patients with solid tumours (ST) and coronavirus disease 2019 (COVID-19) during the first outbreak in Catalonia. This is a multicentre retrospective study including adults with ST and COVID-19 confirmed by real time reverse transcription polymerase chain reaction between 13 March and 30 April 2020. Clinical and survival data were collected. Follow-up ended on 30 July 2020. Multivariate and survival analysis were performed. A hundred and fifteen patients were included. In all, 42.6% had advanced disease and were receiving anticancer treatment; 7% were admitted to the ICU and 22.6% died during hospitalisation. Thirty-day mortality was 27.8%, which increased to 33.9% at 90 days. Ninety-day mortality was associated with current smoker status (hazard ratio [HR]: 2.91, 95% CI [confidence interval]: 1.03-8.33, P = .044), baseline ECOG-PS 2 to 3 (HR: 3.88, 95% CI: 1.77-8.46, P < .001]), dyspnoea (HR: 3.02, 95% CI: 1.31-6.96, P = .009), a respiratory rate ≥ 24 (HR: 2.24, 95% CI: 1.02-4.92, P = .046) and sepsis (HR: 3.97, 95% CI: 1.78-8.88, P < .001). Of the 76 survivors, 73.6% had a follow-up visit. Of those, 33.9% had their cancer controlled and 23.2% had progressed. Thirty-five survivors were receiving anticancer treatment before COVID-19 diagnosis though 14 had to discontinue the treatment. Eight survivors without previous anticancer therapy started therapy. The median time to start anticancer therapy after COVID-19 was 45 days (interquartile range: 28-61). In conclusion, 90-day mortality in patients with ST and COVID-19 was 33.9%; current smoker status, poor ECOG-PS, dyspnoea, respiratory rate ≥24 and sepsis were independent risk factors for mortality; and survivors did not restart their anticancer treatment until 1.5 months after COVID-19 diagnosis.

Thyroid cancer overdiagnosis and overtreatment: a cross- sectional study at a thyroid cancer referral center in Ecuador.

BACKGROUND: In contrast to the rapid increase in thyroid cancer incidence, the mortality has remained low and stable over the last decades. In Ecuador, however, thyroid cancer mortality has increased. The objective of this study is to determine possible drivers of high rates of thyroid cancer mortality, through a cross-sectional analysis of all patients attending a thyroid cancer referral center in Ecuador. METHODS: From June 2014 to December 2017, a cross-sectional study was conducted at the Hospital de Especialidades Eugenio Espejo, a regional reference public hospital for endocrine neoplasia in adults in Quito, Ecuador. We identified the mechanism of detection, histopathology and treatment modalities from a patient interview and review of clinical records. RESULTS: Among 452 patients, 74.8% were young adults and 94.2% (426) were female. 13.7% had a family history of thyroid cancer, and patients' median tumor size was 2 cm. The incidental finding was 54.2% whereas 45.8% was non-incidental. Thyroid cancer histology reported that 93.3% had papillary thyroid cancer (PTC), 2.7% follicular, 1.5% Hurtle cells, 1.6% medullary, 0.7% poor differentiated, and 0.2% anaplastic carcinoma. The mean MACIS (metastasis, age, completeness, invasion, and size) score was 4.95 (CI 4.15-5.95) with 76.2% of the thyroid cancer patients having MACIS score less than or equal to 6. The very low and low risk of recurrence was 18.1% (79) and 62% (271) respectively. An analysis of 319 patients with non-metastatic thyroid cancer showed that 10.7% (34) of patients had surgical complications. Moreover, around 62.5% (80 from 128 patients with thyroglobulin laboratory results) of TC patients had a stimulated-thyroglobulin value equal or higher than 2 ng/ml. Overall, a poor surgical outcome was present in 35.1% (112) patients. Out of 436 patients with differentiated thyroid carcinoma, 86% (375) received radioactive iodine. CONCLUSION: Thyroid cancer histological characteristics and method of diagnosis are like those described in other reports without any evidence of the high frequency of aggressive thyroid cancer histology. However, we observed evidence of overtreatment and poor surgical outcomes that demand additional studies to understand their association with thyroid cancer mortality in Ecuador.

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.

World Health Organization (WHO) antibiotic regimen against other regimens for the treatment of leprosy: a systematic review and meta-analysis.

BACKGROUND: To evaluate the effectiveness and safety of the World Health Organization antibiotic regimen for the treatment of paucibacillary (PB) and multibacillary (MB) leprosy compared to other available regimens. METHODS: We performed a search from 1982 to July 2018 without language restriction. We included randomized controlled trials, quasi-randomized trials, and comparative observational studies (cohorts and case-control studies) that enrolled patients of any age with PB or MB leprosy that were treated with any of the leprosy antibiotic regimens established by the WHO in 1982 and used any other antimicrobial regimen as a controller. Primary efficacy outcomes included: complete clinical cure, clinical improvement of the lesions, relapse rate, treatment failure. Data were pooled using a random effects model to estimate the treatment effects reported as relative risk (RR) with 95% confidence intervals (CI). RESULTS: We found 25 eligible studies, 11 evaluated patients with paucibacillary leprosy, while 13 evaluated patients with MB leprosy and 1 evaluated patients of both groups. Diverse regimen treatments and outcomes were studied. Complete cure at 6 months of multidrug therapy (MDT) in comparison to rifampin-ofloxacin-minocycline (ROM) found RR of 1.06 (95% CI 0.88-1.27) in five studies. Whereas six studies compare the same outcome at different follow up periods between 6 months and 5 years, according to the analysis ROM was not better than MDT (RR of 1.01 (95% CI 0.78-1.31)) in PB leprosy. CONCLUSION: Not better treatment than the implemented by the WHO was found. Diverse outcome and treatment regimens were studied, more statements to standardized the measurements of outcomes are needed.

Patient Experiences and Perceptions Associated with the Use of Desiccated Thyroid Extract.

Background and objectives: It is unclear why many patients with hypothyroidism prefer the use of desiccated thyroid extract (DTE) as a thyroid hormone replacement formulation over levothyroxine (LT4) treatment, as recommended by clinical practice guidelines. We analyzed patient-reported information from patient online forums to better understand patient preferences for and attitudes toward the use of DTE to treat hypothyroidism. Materials and Methods: We conducted a mixed-methods study by evaluating the content of online posts from three popular hypothyroidism forums from patients currently taking DTE (n = 673). From these posts, we extracted descriptive information on patient demographics and clinical characteristics and qualitatively analyzed posts' content to explore patient perceptions on DTE and other therapies further. Results: Nearly half (46%) of the patients reported that a clinician initially drove their interest in trying DTE. Patients described many reasons for switching from a previous therapeutic approach to DTE, including lack of improvement in hypothyroidism-related symptoms (58%) and the development of side effects (22%). The majority of patients described DTE as moderately to majorly effective overall (81%) and more effective than the previous therapy (77%). The most frequently described benefits associated with DTE use were an improvement in symptoms (56%) and a change in overall well-being (34%). One-fifth of patients described side effects related to the use of DTE. Qualitative analysis of posts' content supported these findings and raised additional issues around the need for individualizing therapy approaches for hypothyroidism (e.g., a sense of each patient has different needs), as well as difficulties obtaining DTE (e.g., issues with pharmacy availability). Conclusions: Lack of individualized treatment and a feeling of not been listened to were recurrent themes among DTE users. A subset of patients may prefer DTE to LT4 for many reasons, including perceived better effectiveness and improved overall well-being, despite the risks associated with DTE.

Can Patients Trust Online Health Information? A Meta-narrative Systematic Review Addressing the Quality of Health Information on the Internet.

BACKGROUND: The Internet has become a leading source of health information accessed by patients and the general public. It is crucial that this information is reliable and accurate. OBJECTIVES: The purpose of this systematic review was to evaluate the overall quality of online health information targeting patients and the general public. METHODS: The systematic review is based on a pre-established protocol and is reported according to the PRISMA statement. Eleven databases and Internet searches were performed for relevant studies. Descriptive statistics were used to synthesize data. The NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess the methodological quality of the included studies. RESULTS: Out of 3393 references, we included 153 cross-sectional studies evaluating 11,785 websites using 14 quality assessment tools. The quality level varied across scales. Using DISCERN, none of the websites received a category of excellent in quality, 37-79% were rated as good, and the rest were rated as poor quality. Only 18% of websites were HON Code certified. Quality varied by affiliation (governmental was higher than academic, which was higher than other media sources) and by health specialty (likely higher in internal medicine and anesthesiology). CONCLUSION: This comprehensive systematic review demonstrated suboptimal quality of online health information. Therefore, the Internet at the present time does not provide reliable health information for laypersons. The quality of online health information requires significant improvement which should be a mandate for policymakers and private and public organizations.

Outcomes of patients with metastatic phaeochromocytoma and paraganglioma: A systematic review and meta-analysis.

OBJECTIVE: The outcomes of patients with metastatic phaeochromocytoma (PHEO) and paraganglioma (PGL) are unclear. We performed a systematic review and meta-analysis of baseline characteristics and mortality rates of patients with metastatic PHEO and PGL (PPGL). DESIGN: Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Scopus, Web of Science, and references of key articles were searched from inception to 2016. PATIENTS: Studies comprised ≥20 patients with metastatic PPGL and reported baseline characteristics and follow-up data. MEASUREMENTS: Reviewers extracted standardized data and assessed risk of bias using a modified Newcastle-Ottawa tool. Random-effects meta-analysis was used to pool event rates across studies. RESULTS: Twenty retrospective noncomparative studies reported on 1338 patients with metastatic PHEO (685/1296, 52.9%) and PGL (611/1296, 47.1%), diagnosed at a mean age of 43.9 ± 5.2 years. Mean follow-up was 6.3 ± 3.2 years. Of 532 patients with reported data, 40.4% had synchronous metastases. Five-year (7 studies, n = 738) and 10-year (2 studies, n = 55) mortality rates for patients with metastatic PPGL were 37% (95% CI, 24%-51%) and 29% (95% CI, 17%-42%), respectively. Higher mortality was associated with male sex (RR 1.50; 95% CI, 1.11-2.02) and synchronous metastases (RR 2.43; 95% CI, 1.01-5.85). CONCLUSIONS: Available low-quality evidence from heterogeneous studies suggests low mortality rates of patients with metastatic PPGL. Male sex and synchronous metastases correlated with increased mortality. The outcomes of patients with metastatic PPGL have been inadequately assessed, indicating the need for carefully planned prospective studies.

What does expert opinion in guidelines mean? a meta-epidemiological study.

Guidelines often use the term expert opinion (EO) to qualify recommendations. We sought to identify the rationale and evidence type in EO recommendations. We searched multiple databases and websites for contemporary guidelines published in the last decade that used the term EO. We identified 1106 references, of which 69 guidelines were included (2390 recommendations, of which 907 were qualified as EO). A rationale for using EO designation was not provided in most (91%) recommendations. The most commonly cited evidence type was extrapolated from studies that did not answer guideline question (40% from randomised trials, 38% from observational studies and 2% from case reports or series). Evidence extrapolated from populations that were different from those addressed in the guideline was found in 2.5% of EO recommendations. We judged 5.6% of EO recommendations as ones that could have been potentially labelled as good practice statements. None of the EO recommendations were explicitly described as being solely dependent on the clinical experience of the panel. The use of EO as a level of evidence in guidelines remains common. A rationale for such use is not explicitly provided in most instances. Most of the time, evidence labelled as EO was indirect evidence and occasionally was very low-quality evidence derived from case series. We posit that the explicit description of evidence type, as opposed to using the label EO, may add clarity and transparency and may ultimately improve uptake of recommendations.

Plasmodium vivax malaria at households: spatial clustering and risk factors in a low endemicity urban area of the northwestern Peruvian coast.

BACKGROUND: Peru has presented a decreasing malaria trend during the last decade, particularly in areas on northwestern coast; however, a limited number of cases continues to be reported yearly mainly in malaria hotspots. METHODS: A two-phase study was conducted to identify spatial and temporal clusters of incident Plasmodium vivax malaria, as well as to determine risk factors associated with households (HH) presenting P. vivax malaria episodes in an urban area of the northwestern Peruvian Coast from June 2008 to May 2010. In the first stage, a full census of the study population was conducted, including geo-referencing of reported P. vivax episodes. In the second stage, a population-based case-control study allowed the identification of risk factors associated with HHs reporting episodes. A total of 117 case HHs with reported P. vivax and 117 control HHs without malaria episodes were assessed. A semi-structured questionnaire was used to interview the head of households and to collect data on HH location and structure, availability of public services, preventive malaria measures, family member with outdoor occupation (farmer, moto-taxi driver), and other HH characteristics. Univariate and multivariate logistic regression analyses were performed to determine case-HH risk factors. SaTScan was used to detect spatial and temporal P. vivax malaria clusters. RESULTS: The most likely spatial cluster of malaria incidence included 1,040 people (22.4% of total population) in 245 HHs (24.6% of total HHs) accounting for 283 malaria episodes (40.1% of total episodes) during the study period (RR = 2.3, p < 0.001). A temporal cluster was also identified from April 12, 2009 to July 4, 2009 accounting for 355 malaria episodes (50.4% of total episodes) (RR = 7.2, p = 0.001). Factors significantly associated with case HHs compared with control HHs were: proximity to water drain < 200 metres (OR = 2.3, 95% CI: 1.3, 4.0); HH size >5 individuals (OR = 1.8, 95% CI: 1.0, 3.2); lack of potable water (OR = 1.8, 95% CI: 1.1, 3.2); and having domestic and peridomestic animals (OR = 3.6, 95% CI: 1.3, 9.5). CONCLUSION: Plasmodium vivax malaria incidence is highly heterogeneous in space and time in the urban study area with important geographical and housing risk factors associated with symptomatic episodes.

Radiofrequency ablation for thyroid nodules in Ecuador: a cross-sectional study.

OBJECTIVES: To describe the demographic characteristics and clinical outcomes following the first cohort of patients with Bening Thyroid Nodule (BTN) and (Papillary Thyroid Microcarcinoma) (PTMC) treated with Radiofrequency Ablation (RFA)in Ecuador. METHODS: Single-center, cross-sectional study. We included adults undergoing RFA for BTN and PTMC between July 2019 and May 2022. Descriptive statistics and the Wilcoxon signed-rank test were used to compare some pre- and post-intervention outcomes. RESULTS: We included 44 patients with 36 BTNs and eight PTMCs. The median age was 45.80 years (IQR 16-79 years), and most patients had normal thyroid function (72.72%). The median follow-up time was 7.80 months (IQR1.0-34.0). Nodules were primarily solid (43.21%) or predominantly solid (56.81%). The pre-RFA median volume in the benign lesions group was 10.30 ml (IQR 1.86-18.97). After ablation, the 1-month, 3-month, 6-month, and 12-month median volumes were 6.90 (IQR 0.48-10.15; p < 0.01) mL, 5.72 (IQR 0.77-7.25; p = 0.045); 0.98 (IQR 0.25-3.64; p < 0.01), and 0.11 (IQR 0.07-11.26; p = 0.026), respectively. The volume rate reduction was 47.20%, 72.20%, 74.00%, and 96.20% at 1, 3, 6, and 12-month follow-ups, respectively. The pre-RFA median volume in the PTMC group was 0.25 ml (IQR 0.19-0.48). After ablation, the 1-month, 3-month, and 6-month mean volumes were 0.19 (range 0.12-0.31; p = 0.120) mL, 0.10 (IQR 0.05-0.15; p = 0.13), and 0.01 (IQR 0.005-0.04; p = 0.364), respectively. CONCLUSIONS: In this first report from Ecuador, we found that RFA may be a feasible alternative for treating benign and malignant thyroid nodules in the short term. Long-term data are needed to evaluate oncologic outcomes in PTMC patients.

Diffuse large B-cell lymphoma associated with papillary thyroid carcinoma: a case report and systematic review on management and outcomes.

Primary thyroid lymphoma is a rare thyroid cancer, comprising ˂5% of thyroid neoplasms. Most cases are diffuse large B-cell lymphoma (DLBCL). Coexistence with papillary thyroid cancer (PTC) is extremely rare. This study presents a case of a 55-year-old woman with DLBCL and micropapillary thyroid cancer who underwent lobectomy, chemotherapy, and radiotherapy. Additionally, we performed a systematic review of 10 cases, including the reported case. The risk of bias in case reports varied. DLBCL diagnoses were mainly made after surgery, with total thyroidectomy being the most common surgical procedure. Chemotherapy was administered in most cases, and radiotherapy was used in some cases. Long-term outcomes indicated a low recurrence rate. While some debate the role of surgery in thyroid lymphoma, this study suggests that surgery should be considered in selected cases. Further research is needed to determine optimal treatment strategies for DLBCL with PTC.

Ablation techniques or active surveillance compared to surgical resection in patients with low-risk papillary thyroid cancer: a systematic review and meta-analysis.

BACKGROUND: The global prevalence of thyroid cancer is on the rise. About one-third of newly diagnosed thyroid cancer cases comprise low-risk papillary thyroid cancer (1.5 cm or more minor). While surgical removal remains the prevailing approach for managing low-risk papillary thyroid cancer (LPTC) in patients, other options such as active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) are also being considered as viable alternatives. This study evaluated and compared surgical thyroid resection (TSR) versus non-surgical (NS) methods for treating patients with LPTC. METHODS: The study encompassed an analysis of comparisons between surgical thyroid resection (TSR) and alternative approaches, including active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), or laser ablation (LA). The focus was on patients with biopsy-confirmed low-risk papillary thyroid cancer (LPTC) of less than 1.5 cm without preoperative indications of local or distant metastasis. The primary outcomes assessed were recurrence rates, disease-specific mortality, and quality of life (QoL). Data were collected from prominent databases, including Cochrane Database, Embase, MEDLINE, and Scopus, from inception to June 3rd, 2020. The CLARITY tool was utilized to evaluate bias risk. The analysis involved odds ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes, as well as mean differences (MD) and standardized mean differences (SMD) for continuous outcomes. The study is registered on PROSPERO under the identifier CRD42021235657. RESULTS: The study incorporated 13 retrospective cohort studies involving 4034 patients. Surgical thyroid resection (TSR), active surveillance (AS), and minimally invasive techniques like radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) were performed in varying proportions of cases. The analysis indicated that specific disease mortality rates were comparable among AS, MWA, and TSR groups. The risk of recurrence, evaluated over different follow-up periods, showed no significant differences when comparing AS, RFA, MWA, or LA against TSR. Patients undergoing AS demonstrated better physical health-related quality of life (QoL) than those undergoing TSR. However, no substantial differences were observed in the overall mental health domain of QoL when comparing AS or RFA with TSR. The risk of bias was moderate in nine studies and high in four. CONCLUSION: Low-quality evidence indicates comparable recurrence and disease-specific mortality risks among patients with LPTC who underwent ablation techniques or active surveillance (AS) compared to surgery. Nevertheless, individuals who opted for AS exhibited enhanced physical quality of life (QoL). Subsequent investigations are warranted to validate these findings.

Assessing malaria transmission in a low endemicity area of north-western Peru.

BACKGROUND: Where malaria endemicity is low, control programmes need increasingly sensitive tools for monitoring malaria transmission intensity (MTI) and to better define health priorities. A cross-sectional survey was conducted in a low endemicity area of the Peruvian north-western coast to assess the MTI using both molecular and serological tools. METHODS: Epidemiological, parasitological and serological data were collected from 2,667 individuals in three settlements of Bellavista district, in May 2010. Parasite infection was detected using microscopy and polymerase chain reaction (PCR). Antibodies to Plasmodium vivax merozoite surface protein-119 (PvMSP119) and to Plasmodium falciparum glutamate-rich protein (PfGLURP) were detected by ELISA. Risk factors for exposure to malaria (seropositivity) were assessed by multivariate survey logistic regression models. Age-specific antibody prevalence of both P. falciparum and P. vivax were analysed using a previously published catalytic conversion model based on maximum likelihood for generating seroconversion rates (SCR). RESULTS: The overall parasite prevalence by microscopy and PCR were extremely low: 0.3 and 0.9%, respectively for P. vivax, and 0 and 0.04%, respectively for P. falciparum, while seroprevalence was much higher, 13.6% for P. vivax and 9.8% for P. falciparum. Settlement, age and occupation as moto-taxi driver during previous year were significantly associated with P. falciparum exposure, while age and distance to the water drain were associated with P. vivax exposure. Likelihood ratio tests supported age seroprevalence curves with two SCR for both P. vivax and P. falciparum indicating significant changes in the MTI over time. The SCR for PfGLURP was 19-fold lower after 2002 as compared to before (λ1 = 0.022 versus λ2 = 0.431), and the SCR for PvMSP119 was four-fold higher after 2006 as compared to before (λ1 = 0.024 versus λ2 = 0.006). CONCLUSION: Combining molecular and serological tools considerably enhanced the capacity of detecting current and past exposure to malaria infections and related risks factors in this very low endemicity area. This allowed for an improved characterization of the current human reservoir of infections, largely hidden and heterogeneous, as well as providing insights into recent changes in species specific MTIs. This approach will be of key importance for evaluating and monitoring future malaria elimination strategies.

Canal wall up versus canal wall down mastoidectomy techniques in the pediatric population with cholesteatoma: A systematic review and meta-analysis of comparative studies.

IMPORTANCE: The optimal surgical management of cholesteatoma remains controversial. Within pediatric otolaryngology, one of the most vital points of contention is the selection of canal wall-up (CWU) versus canal wall-down (CWD) procedures. Pediatric cholesteatoma has high rates of recurrence (16%-54%). In adults, there is evidence that the selection of surgical techniques affects recurrence rates. This has not been shown in children. OBJECTIVES: 1. To systematically review the literature on recurrent and residual cholesteatoma after CWU and CWD in children and perform a meta-analysis of the data. 2. To assess the rates of recurrent and residual cholesteatoma between CWU and CWD techniques in pediatric patients. 3. To assess hearing outcomes by evaluating postoperative differences in the air-bone gap (ABG) between CWU and CWD techniques. DATA SOURCES: A systematic search of PubMed, Embase, Scopus, and Cochrane Collaboration was performed from inception to May 1st, 2020, to identify studies that compared CWU and CWD procedures for acquired cholesteatoma in children. STUDY SELECTION: Search records were screened in duplicate by four reviewers. Inclusion criteria consisted of comparative randomized clinical trials and observational studies assessing outcomes of CWU and CWD techniques in the pediatric population. Studies involving patients with congenital cholesteatoma were excluded. DATA EXTRACTION AND SYNTHESIS: Four reviewers working independently and in duplicate systematically reviewed and extracted study data. Dichotomous variables were analyzed as risk ratios (RR), while continuous variables were compared using weighted mean differences (MD). The risk of bias was assessed using the CLARITY Scale. PRIMARY OUTCOMES AND MEASURES: The outcomes were recurrence, residual disease, air-bone gap (ABG), and air conductive (AC) thresholds. RESULTS: After screening 1036 publications, 17 retrospective cohort studies were selected. 1333 children were included; the overall mean age was ten years (SD 7.9), and the overall mean follow-up time was 5.9 years (SD 6.6). CWU and CWD techniques were performed in 60% (796) and 40% (537) cases. We did not find differences in cholesteatoma recurrence (RR: 1.50, 95% CI 0.94; 2.40; n = 544; I2 0%; Tau [2]: 0.00), or rates of residual cholesteatoma (RR 1.51, 95% CI 0.96; 2.38, n = 506; I2: 0%; Tau [2]: 0.00) in patients who underwent CWU and CWD mastoidectomy. The mean air-bone gap was lower with CWU than CWD (mean difference: 7.60, 95% CI -10.65; -4.54; n = 242; I2: 71%; Tau [2]: 5.98). CONCLUSION: and relevance: We show similar rates of recurrence and residual disease after either CWU or CWD tympanoplasty. Our results challenge the fundamental principle of CWD surgery as a standard technique, as there is no difference in rates of recurrence and residual disease in CWU and CWD. Moreover, audiometric results support CWU with improved hearing outcomes. TRIAL REGISTRATION: PROSPERO identifier: CRD42020184029.

Safe management of carotid body tumor resection without preoperative embolization: an Ecuadorian high-altitude cities experience.

Carotid body tumors (CBTs) are a neoplasm that affects the carotid glomus. This study aims to improve the management of CBTs in Ecuador. This single-center, retrospective observational study was conducted at the Instituto de la Tiroides y Enfermedades de Cabeza y Cuello (ITECC). We included adults with CBTs, between January 2019 and August 2022. A total of 15 patients with CBTs were included. All patients were females living at high altitudes (>2500 m). In the Shamblin classification, 12 tumors were type II, and 3 were type III. Complete tumor resection was performed in all patients without pre-operative embolization. All patients had benign CBTs with a mean follow-up of 17, 73 months. In a time when the medical cost is high mainly in low-income countries such as Ecuador, further investigation should be undertaken in the form of randomized prospective trials to answer who would benefit from the pre-TAE procedure.

Robotic Living Donor Right Hepatectomy: A Systematic Review and Meta-Analysis.

The introduction of robotics in living donor liver transplantation has been revolutionary. We aimed to examine the safety of robotic living donor right hepatectomy (RLDRH) compared to open (ODRH) and laparoscopic (LADRH) approaches. A systematic review was carried out in Medline and six additional databases following PRISMA guidelines. Data on morbidity, postoperative liver function, and pain in donors and recipients were extracted from studies comparing RLDRH, ODRH, and LADRH published up to September 2020; PROSPERO (CRD42020214313). Dichotomous variables were pooled as risk ratios and continuous variables as weighted mean differences. Four studies with a total of 517 patients were included. In living donors, the postoperative total bilirubin level (MD: −0.7 95%CI −1.0, −0.4), length of hospital stay (MD: −0.8 95%CI −1.4, −0.3), Clavien−Dindo complications I−II (RR: 0.5 95%CI 0.2, 0.9), and pain score at day > 3 (MD: −0.6 95%CI −1.6, 0.4) were lower following RLDRH compared to ODRH. Furthermore, the pain score at day > 3 (MD: −0.4 95%CI −0.8, −0.09) was lower after RLDRH when compared to LADRH. In recipients, the postoperative AST level was lower (MD: −0.5 95%CI −0.9, −0.1) following RLDRH compared to ODRH. Moreover, the length of stay (MD: −6.4 95%CI −11.3, −1.5) was lower after RLDRH when compared to LADRH. In summary, we identified low- to unclear-quality evidence that RLDRH seems to be safe and feasible for adult living donor liver transplantation compared to the conventional approaches. No postoperative deaths were reported.

Impact of the Surgical Approach to Thymectomy Upon Complete Stable Remission Rates in Myasthenia Gravis: A Meta-analysis.

OBJECTIVES: To determine whether the available operative techniques for thymectomy in myasthenia gravis (MG) confer variable chances for achieving complete stable remission (CSR), we performed a meta-analysis of comparative studies of surgical approaches to thymectomy. METHODS: Meta-analysis was done of all studies providing comparative data on thymectomy approaches, with CSR reported and minimum 3-year mean follow-up. RESULTS: Twelve cohort studies and 1 randomized clinical trial, containing 1,598 patients, met entry criteria. At 3 years, CSR from MG was similar after video-assisted thoracoscopic (VATS) extended vs both basic (relative risk [RR] 1.00, p = 1.00, 95% confidence interval [CI] 0.39-2.58) and extended (RR 0.96, p = 0.74, 95% CI 0.72-1.27) transsternal approaches. CSR at 3 years was also similar after extended transsternal vs combined transcervical-subxiphoid (RR 1.08, p = 0.62, 95% CI 0.8-1.44) approaches. VATS extended approaches remained statistically equivalent to extended transsternal approaches through 9 years of follow-up (RR 1.51, p = 0.05, 95% CI 0.99-2.30). The only significant difference in CSR rate between a traditional open and a minimally invasive approach was seen at 10 years when the now-abandoned basic (non-sternum-lifting) transcervical approach was compared to the extended transsternal approach (RR 0.4, p = 0.01, 95% CI 0.2-0.8). CONCLUSIONS: A significant difference in the rate of CSR among various surgical approaches for thymectomy in MG was identified only at long-term follow-up and only between what might be considered the most aggressive approach (extended transsternal thymectomy) and the least aggressive approach (basic transcervical thymectomy). Extended minimally invasive approaches appear to have CSR rates equivalent to those of extended transsternal approaches and are therefore appropriate in the hands of experienced surgeons.

The validity of cost-effectiveness analyses of tight glycemic control. A systematic survey of economic evaluations of pharmacological interventions in patients with type 2 diabetes.

PURPOSE: Currently available randomized trial evidence has shown no reductions in type 2 diabetes (T2D) complications important to patients with tight glycemic control. Yet, economic analyses consistently find tight glycemic control to be cost-effective. To understand this apparent paradox, we systematically identified and appraised economic analyses of tight glycemic control for T2D. METHODS: We searched multiple databases from January 2016 to January 2018 for cost-effectiveness or cost-utility analyses of any glucose-lowering treatments for adults with T2D using simulations with long-40 years to lifetime-time horizons. Reviewers selected and appraised each study independently and in duplicate with good reproducibility. RESULTS: We found 30 analyses, most comparing the glycemic impact of glucose-lowering drugs and applying their impact on HbA1c to model (most commonly IMS CORE or Cardiff T2DM) their impact on the incidence of diabetes-related complication. Models drew from observational evidence of the correlation of HbA1c levels and diabetes-related complication rates; none used estimates of the effect of lowering HbA1c on these outcomes from systematic reviews of randomized trials. Sensitivity analyses, when conducted, demonstrate substantial loss of cost-effectiveness as simulations approach the results seen in these trials. CONCLUSIONS: Reliance on the association between glycemic control and diabetes-related complications evident in observational studies but not apparent in randomized trial bias the estimates of the cost-effectiveness of interventions to improve glycemic control.

Understanding treatment-subgroup effect in primary and secondary prevention of cardiovascular disease: An exploration using meta-analyses of individual patient data.

BACKGROUND AND OBJECTIVE: Recommendations for preventing cardiovascular (CV) disease are currently separated into primary and secondary prevention. We hypothesize that relative effects of interventions for CV prevention are not different across primary and secondary prevention cohorts. Our aim was to test for differences in relative effects on CV events in common preventive CV interventions across primary and secondary prevention cohorts. METHODS AND RESULTS: A systematic search was performed to identify individual patient data (IPD) meta-analyses that included both primary and secondary prevention populations. Eligibility assessment, data extraction, and risk of bias assessment were conducted independently and in duplicate. We extracted relative risks (RR) with 95% confidence intervals (95% CI) of the interventions over patient-important outcomes and estimated the ratio of RR for primary and secondary prevention populations. We identified five eligible IPDs representing 524,570 participants. Quality assessment resulted in overall low-to-moderate methodological quality. We found no subgroup effect across prevention categories in any of the outcomes assessed. CONCLUSION: In the absence of significant treatment-subgroup interactions between primary and secondary CV prevention cohorts for common preventive interventions, clinical practice guidelines could offer recommendations tailored to individual estimates of CV risk without regard to membership to primary and secondary prevention cohorts. This would require the development of reliable ASCVD risk estimators that apply across both cohorts.

Triggers of thyroid cancer diagnosis: a systematic review and meta-analysis.

PURPOSE: Understanding the method of thyroid cancer detection has potential implications on interpreting incidence rates, the diagnosis and management of thyroid cancer. We conducted a systematic review of studies reporting methods of thyroid cancer detection to estimate the frequency of incidentally found cancers and classify triggers of incidental thyroid cancer diagnosis. METHODS: We searched multiple bibliographic databases from inception to June 2020. A pair of reviewers, working independently and in duplicate selected studies for inclusion, extracted data, and evaluated each trial's risk of bias. Studies enrolling patients older than 18 years with thyroid cancer confirmed histologically were included. RESULTS: In total, 17 cohorts and 1 cross-sectional study, conducted between 1991 and 2018, enrolling 4668 patients with thyroid cancer were included: 88% had papillary thyroid cancer and 23% had papillary thyroid microcarcinoma. The proportion of patients with non-incidental and incidental thyroid cancer was similar: 49% [95% confidence interval (CI): 40-58%]. Subgroup analysis showed that most patients with incidental thyroid cancers had tumor size <10 mm (76%; 95% CI: 56-92%), age >45 (61%; 95% CI: 56-67%), and were detected through imaging (35%; 95% CI: 26-45%), of which ultrasound was the most common modality (27%; 95% CI: 14-43%). The heterogeneity for all the effect sizes was large and significant. CONCLUSIONS: About half of thyroid cancers were found incidentally through the use of imaging studies, in particular neck ultrasound. These incidentally found cancers were mostly small papillary thyroid cancer. These results highlight opportunities for interventions aimed at reducing drivers of overdiagnosis.