A Systematic Review of Adjuvant Chemotherapy in Localized Dedifferentiated Chondrosarcoma.

Dedifferentiated chondrosarcoma (DDCS) is a high-grade subtype of chondrosarcoma with the bimorphic histological appearance of a conventional chondrosarcoma component with abrupt transition to a high-grade, non-cartilaginous sarcoma. DDCS can be radiographically divided into central and peripheral types. Wide resection is currently the main therapeutic option for localized DDCS. Moreover, the effectiveness of adjuvant chemotherapy remains controversial. Therefore, we performed a systematic review of available evidence to evaluate the effect of adjuvant chemotherapy on localized DDCS. The purpose was to compare the 5-year survival rate among patients treated with surgery plus adjuvant chemotherapy or surgery alone for localized DDCS. The search was conducted in PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Of the 217 studies shortlisted, 11 retrospective non-randomized studies (comprising 556 patients with localized DDCS) were selected. The 5-year survival rates were similar between the two treatment groups (28.2% (51/181) vs. 24.0% (90/375), respectively). The overall pooled odds ratio was 1.25 (95% confidence interval: 0.80-1.94; p = 0.324), and heterogeneity I2 was 2%. However, when limited to peripheral DDCS, adjuvant chemotherapy was associated with prolonged survival (p = 0.03). Due to the paucity of included studies and the absence of prospective comparative studies, no conclusions can be drawn regarding the effectiveness or ineffectiveness of adjuvant chemotherapy for localized DDCS.

Influences of comorbidities on perioperative rehabilitation in patients with gastrointestinal cancers: a retrospective study.

BACKGROUND: Older patients are more likely to have comorbidities than younger patients, and multiple comorbidities are associated with mortality in patients with cancer. Therefore, we hypothesized that a functional comorbidity index could predict the therapeutic effects of rehabilitation. OBJECTIVES: In this study, we investigate whether the comorbidities influenced the execution and therapeutic effects of rehabilitation. METHODS: A consecutive cohort of 48 patients with gastrointestinal cancer who underwent surgery between January 1 and November 30, 2020, was analyzed. Charlson Comorbidity Index (CCI) scores were calculated based on data derived from medical records. The primary outcomes were ambulation status, duration (days) from the start of postoperative rehabilitation, and length of hospital stay. We investigated the relationship between CCI scores and primary outcomes. RESULTS: The CCI did not correlate with the duration of rehabilitation or the length of hospital stay. Subsequently, patients with functional recovery problems were evaluated, and we identified the conditions that were not included in the list using CCI scores. Most conditions are associated with surgical complications. Furthermore, using the Clavien-Dindo classification (CDC), we assessed the clinical features of the severity of complications. We found that the length of stay and the duration to start rehabilitation were significantly longer in the patients with higher severity of surgical complications (CDC≧III) than in those with lower severity (CDC≦II). CONCLUSIONS: Treatment-related conditions may significantly impact the perioperative period more than the original comorbidities. In addition to original comorbidities, events related to surgical complications should be assessed to determine the therapeutic effects of rehabilitation in patients with gastrointestinal cancer.

Megaprosthetic reconstruction of the distal femur with a short residual proximal femur following bone tumor resection: a systematic review.

BACKGROUND: To investigate the risk of postoperative function and complications associated with reconstruction methods in patients with short residual proximal femurs (< 12 cm) after resection of distal femoral bone tumors, we performed a systematic review of studies reporting postoperative function and complications in these patients. METHODS: Of the 236 studies identified by systematic searches using the Medline, Embase, and Cochrane Central Register of Controlled Trials databases, eight were included (none were randomized controlled trials). In these studies, 106 (68.4%), 12 (7.7%), and 37 (23.9%) patients underwent reconstruction with custom-made megaprostheses with extracortical plates or cross-pins, allograft prosthetic composite (APC), and Compress® compliant pre-stress (CPS) implants, respectively. RESULTS: Aseptic loosening occurred slightly more frequently in the APC group than in the other reconstruction methods (APC group, 21%; custom-made megaprosthesis group, 0-17%; CPS implant group, 14%). No differences were noted in the frequencies of implant breakage, fractures, or infections between the three reconstruction methods. Mechanical survival, where endpoint was set as implant removal for any reason, was 80% at seven years in the APC group, 70-77% at 10 years in the custom-made megaprosthesis group, and 68% at nine years in the CPS implant group. Therefore, there appeared to be no difference among the three reconstruction methods with respect to mechanical survival. CONCLUSIONS: During megaprosthetic reconstruction of the distal femur with a short residual proximal femur after bone tumor resection, similar results were obtained using custom-made megaprostheses, APCs, and CPS implants.

Reconstruction after Talar Tumor Resection: A Systematic Review.

This systematic review investigated the functional outcomes and complications of reconstruction methods after talar tumor resection. A systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases identified 156 studies, of which 20 (23 patients) were ultimately included. The mean Musculoskeletal Tumor Society scores in the groups reconstructed using tibiocalcaneal fusion (n = 17), frozen autograft (n = 1), and talar prosthesis (n = 5) were 77.6 (range 66-90), 70, and 90 (range 87-93), respectively. Regarding complications, sensory deficits were observed in one patient (6%) and venous thrombosis in two patients (12%) in the tibiocalcaneal fusion group, while osteoarthritis was observed in one patient (100%) in the frozen autograft group. No complications were observed in the talar prosthesis group. Reconstruction with talar prosthesis seems preferable to conventional tibiocalcaneal fusion after talar tumor resection because it offers better function and fewer complications. However, as this systematic review included only retrospective studies with a small number of patients, its results require re-evaluation in future randomized controlled trials with larger numbers of patients.

The Effect of Adjuvant Chemotherapy on Localized Extraskeletal Osteosarcoma: A Systematic Review.

(1) Background: Extraskeletal osteosarcoma (ESOS) is a malignant tumor characterized by the production of bone or bone matrix by tumor cells without any continuity into the skeletal bones. The standard treatment for localized ESOS is wide resection; however, the effect of (neo)adjuvant chemotherapy remains unclear. To investigate the effect of (neo)adjuvant chemotherapy for localized ESOS, we conducted a systematic review of studies comparing the 5-year disease-free survival rate between patients who underwent surgery combined with (neo)adjuvant chemotherapy and those who underwent surgery alone. (2) Methods: Of the 210 studies identified by systematically searching the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases, 12 were included in the final analysis. These 12 articles were not randomized controlled trials, but retrospective studies. In total, 761 patients with localized ESOS were included in this study. (3) Results: The 5-year disease-free survival rate was 47.9% (187 of 390 patients) in the surgery and (neo)adjuvant chemotherapy group and 40.4% (150 of 371 patients) in the surgery alone group. The overall pooled odds ratio was 1.23 (95% confidence interval, 0.69-2.19; p = 0.479) and the heterogeneity I2 was 37%. (4) Conclusions: The effect of adjuvant chemotherapy on localized ESOS seems to be limited. Therefore, routine use of adjuvant chemotherapy for localized ESOS should be avoided. However, further randomized controlled trials are required to confirm these results.

Effect of adjuvant chemotherapy on periosteal osteosarcoma: a systematic review.

BACKGROUND AND OBJECTIVE: The effects of adjuvant chemotherapy on periosteal osteosarcoma are controversial. Therefore, we conducted a systematic review of studies comparing mortality, local recurrence, distant metastasis and secondary malignancy incidence among patients who underwent surgery and (neo-) adjuvant chemotherapy or surgery alone for periosteal osteosarcoma without distant metastases at diagnosis. METHODS: Of the 210 studies identified in the search, 13 were included in this study, involving 291 patients with periosteal osteosarcoma in total. RESULTS: The mortality rates in the surgery and (neo-) adjuvant chemotherapy and surgery alone groups were 11.3% (8/71) and 16.3% (16/98), respectively. The overall pooled odds ratio was 0.89 (P = 0.800). The local recurrence rate in the surgery and (neo-) adjuvant chemotherapy group was 12.1% (8/66), while that in the surgery alone group was 17.6% (13/74). The overall pooled odds ratio was 1.31 (P = 0.601). The distant metastasis rate in the surgery and (neo-) adjuvant chemotherapy group was 15.2% (10/66) and that in the surgery alone group was 10.8% (8/74). The overall pooled odds ratio was 1.51 (P = 0.444). The incidence of secondary malignancy in the surgery and (neo-) adjuvant chemotherapy group was 7.6% (9/118) and that in the surgery alone group was 2.7% (2/74). The overall pooled odds ratio was 2.29 (P = 0.187). CONCLUSIONS: Adjuvant chemotherapy did not appear to improve the prognosis of patients with periosteal osteosarcoma. No association was found between the use of adjuvant chemotherapy and development of secondary malignancies.

Factors associated with functional disability or mortality after elective noncardiac surgery: a prospective cohort study.

PURPOSE: Preoperative prediction of functional status after surgery is essential when practicing patient-centered medicine. We aimed to evaluate the incidence and factors associated with postoperative functional disability or all-cause mortality. Secondarily, we sought to describe the trajectory of disability in this population. METHODS: Adults aged ≥ 55 yr who underwent elective noncardiac surgery under general anesthesia in a tertiary care hospital were followed up one year after surgery. Pre- and intraoperative factors associated with a composite outcome of postoperative functional disability or all-cause mortality were assessed using a multiple logistic regression. The sequential changes in the 12-item World Health Organization Disability Assessment Schedule (WHODAS) 2.0 score were described and stratified by surgical invasiveness. RESULTS: Of the 2,921 patients included, 293 experienced postoperative functional disability (10.0%; 95% confidence interval [CI], 8.9 to 11.1) and 124 died (4.2%; 95% CI, 3.5 to 5.0). In a multiple regression model, the potentially modifiable risk factors, body mass index ≥ 30 kg·m-2 and poor preoperative nutritional status, were significantly associated with the primary composite outcome, as well as nonmodifiable factors such as age, preoperative comorbidities, and blood loss volume. Changes in the 12-item WHODAS 2.0 disability score varied between different levels of surgical invasiveness and types of surgery. CONCLUSION: Within one year after surgery, one in ten patients experienced postoperative functional disability and one in 20 died. We identified potentially modifiable factors (obesity, poor nutritional status) associated with these adverse outcomes. STUDY REGISTRATION: University Hospital Medical Information Network (UMIN000021671); registered 31 December 2015.

RéSUMé: OBJECTIF: La prédiction préopératoire du statut fonctionnel après chirurgie est essentielle dans la pratique d'une médecine centrée sur le patient. Nous avons cherché à évaluer l'incidence et les facteurs associés à l'incapacité fonctionnelle ou à la mortalité toutes causes confondues en postopératoire. En deuxième lieu, nous avons cherché à décrire la trajectoire de l'incapacité dans cette population. MéTHODE: Les adultes âgés de ≥ 55 ans qui ont subi une chirurgie non cardiaque non urgente sous anesthésie générale dans un hôpital de soins tertiaires ont été suivis jusqu'à un an après leur chirurgie. Les facteurs pré- et peropératoires associés à un devenir composite d'incapacité fonctionnelle postopératoire ou de mortalité toutes causes confondues ont été évalués à l'aide d'une régression logistique multiple. Les changements séquentiels dans le score de l'outil d'évaluation de l'invalidité de l'Organisation mondiale de la Santé (WHODAS - World Health Organization Disability Assessment Schedule) version 2.0 en 12 éléments ont été décrits et stratifiés en fonction du degré invasif de la chirurgie. RéSULTATS: Sur les 2921 patients inclus, 293 ont présenté une incapacité fonctionnelle postopératoire (10,0 %; intervalle de confiance [IC] à 95 %, 8,9 à 11,1) et 124 personnes sont décédées (4,2 %; IC 95 %, 3,5 à 5,0). Dans un modèle de régression multiple, les facteurs de risque potentiellement modifiables, un indice de masse corporelle ≥ 30 kg·m-2 et un mauvais état nutritionnel préopératoire étaient significativement associés au critère d'évaluation composite principal, ainsi qu'à des facteurs non modifiables tels que l'âge, les comorbidités préopératoires et le volume de perte de sang. Les changements dans le score d'incapacité WHODAS 2.0 à 12 éléments variaient entre les différents degrés invasifs de la chirurgie et les types de chirurgie. CONCLUSION: Dans l'année qui a suivi la chirurgie, un patient sur dix a présenté une incapacité fonctionnelle postopératoire et un sur 20 est décédé. Nous avons identifié des facteurs potentiellement modifiables (obésité, mauvais état nutritionnel) associés à ces effets indésirables. ENREGISTREMENT DE L'éTUDE: University Hospital Medical Information Network (UMIN000021671); enregistré le 31 décembre 2015.

Precisión de la prueba diagnóstica de acentuación de la cefalea mediante sacudidas cefálicas para el diagnóstico de meningitis aguda en urgencias / Diagnostic test accuracy of jolt accentuation for headache in acute meningitis in the emergency setting

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Effect of Adjuvant Chemotherapy on Localized Malignant Giant Cell Tumor of Bone: A Systematic Review.

A malignant giant cell tumor of the bone (GCTB) is a rare primary malignant tumor classified as primary or secondary. Wide resection of the primary tumor is recommended for localized malignant GCTB, but the effect of adjuvant chemotherapy is unclear. A systematic review was performed to compare the mortality associated with wide resection with that of wide resection plus adjuvant chemotherapy for primary and secondary localized malignant GCTB. Among the 745 studies identified, 9 were included. A total of 112 cases of localized malignant GCTB were included, with 39 and 73 cases being primary and secondary malignant GCTB. In primary localized malignant GCTB, the mortality rates were 40% (6/15 patients) and 33% (8/24 patients) in the surgery plus adjuvant chemotherapy and surgery-only groups, respectively. Overall pooled odds ratio was 1.07 (95% confidence interval, 0.26-4.37; p = 0.92). In secondary localized malignant GCTB, the mortality rates were 30.6% (11/36 patients) and 62.2% (23/37 patients) in the surgery plus adjuvant chemotherapy and surgery-only groups, respectively. The overall pooled odds ratio was 0.31 (95% confidence interval, 0.10-0.95; p = 0.04). The effect of adjuvant chemotherapy remains unclear for primary localized malignant GCTB, but adjuvant chemotherapy improved the survival of patients with secondary localized malignant GCTB.

Denosumab Does Not Decrease Local Recurrence in Giant Cell Tumor of Bone Treated With En Bloc Resection.

We performed a systematic analysis of existing studies to determine whether preoperative denosumab reduces the risk of local recurrence for patients with giant cell tumor of bone treated with en bloc resection and to address the optimal duration of preoperative denosumab with respect to the risk of local recurrence after en bloc resection. Denosumab did not decrease the risk of local recurrence after en bloc resection; the proportion of patients with local recurrence was 3.6% (2 of 56) in the en bloc resection with preoperative denosumab group vs 14.2% (40 of 280) in the en bloc resection alone group, with an overall pooled odds ratio of 0.76 (P=.67). Meta-regression models revealed no association between the duration of preoperative denosumab and the odds of local recurrence after en bloc resection (P=.83). Administration of denosumab for 3 months before en bloc resection is appropriate for sufficient bone hardening to reduce tumor cell spillage and does not result in denosumab-related complications. [Orthopedics. 2021;44(6):326-332.].

Metastasectomy Versus Non-Metastasectomy for Giant Cell Tumor of Bone Lung Metastases.

Approximately 2% to 9% of giant cell tumor of bone (GCTB) metastasizes systemically, mainly to the lungs. The biological behaviors and clinical courses of lung metastases are difficult to predict, and their treatment recommendations vary, including metastasectomy and non-metastasectomy with chemotherapy (denosumab, interferon-alfa, bisphosphonates), with radiation therapy, or with observation alone. However, it is unclear whether metastasectomy for GCTB lung metastases decreases the mortality rate of these patients. Therefore, the authors performed this systematic review to compare metastasectomy and non-metastasectomy for GCTB patients with operable lung metastasis. Of the 919 relevant studies, 16 studies (138 patients) were included for analysis; 61.6% of patients had metastasectomy and 38.4% had non-metastasectomy. Analysis showed that mortality rates were similar for the patients who had metastasectomy compared with those who did not; the proportion of patients who died of disease was 7.1% in the metastasectomy group and 17.0% in the non-metastasectomy group, with an overall pooled odds ratio of 0.64 (P=.36). Therefore, physicians should reconsider the potential risks and benefits of metastasectomy for patients with GCTB and lung metastasis, because metastasectomy does not reduce the mortality rate in these patients. [Orthopedics. 2021;44(6):e707-e712.].

Translation and validation of the Japanese Version of the Quality of Recovery-15 Questionnaire.

PURPOSE: Patient-reported outcomes after surgery and anaesthesia have recently attracted attention. A recent systematic review and a consensus guideline recommend that patients' recovery can be adequately measured using the quality of recovery-15 (QoR-15) during the perioperative period; however, the Japanese version of the QoR-15 (QoR-15J) is not available. We aimed to translate the QoR-15 into Japanese and assess its validity. METHODS: After translating into Japanese, 205 patients who underwent various types of surgery under general anaesthesia were enrolled in the study. QoR-15J was evaluated before surgery and 24 h and 48 h after surgery. Additionally, 30 patients answered the QoR-15J at 25 h after surgery. We assessed the feasibility, reliability, validity, and responsiveness of the QoR-15J. RESULTS: One patient who did not undergo surgery and two patients who were discharged within 24 h were excluded. One hundred and eighty-seven patients answered the QoR-15J at 24 h after surgery (completion rate, 92.6%) and 183 patients with complete data were included in the final analysis. The Cronbach's alpha coefficient for internal reliability and Spearman rank correlation coefficient for test-retest reliability were 0.84 and 0.91, respectively. The Cohen effect size for all items was 1.42. CONCLUSIONS: QoR-15 was translated into Japanese and the Japanese version's validity was assessed in patients undergoing various types of surgery under general anaesthesia. Our results suggest that QoR-15J is feasible, reliable, valid, and responsive.

Effects of exercise on kidney and physical function in patients with non-dialysis chronic kidney disease: a systematic review and meta-analysis.

Patients with non-dialysis chronic kidney disease (CKD) are at greater risk of early mortality and decreased physical function with an advance in the stage of CKD. However, the effect of exercise in these patients is unclear. This meta-analysis aimed to determine the effects of physical exercise training on the risk of mortality, kidney and physical functions, and adverse events in patients with non-dialysis CKD. The meta-analysis conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement and the Cochrane Handbook recommendations. On 16 August 2019, the PubMed, CINAHL, Cochrane Library databases, and Embase were electronically searched, with no restrictions for date/time, language, document type, or publication status, for eligible randomized controlled trials (RCTs) investigating the effects of exercise on mortality and kidney and physical function in patients with non-dialysis CKD. Eighteen trials (28 records), including 848 patients, were analyzed. The effects of exercise on all-cause mortality and estimated glomerular filtration rate were not significantly different from that of usual care. Exercise training improved peak/maximum oxygen consumption compared to usual care. Regular exercise improves physical and walking capacity for patients with non-dialysis CKD. Effect on leg muscle strength was unclear.

Diagnostic test accuracy of jolt accentuation for headache in acute meningitis in the emergency setting.

BACKGROUND: Meningitis is inflammation of the meninges, the layers that protect the brain and spinal cord. Acute meningitis is an emergent disease that develops over the course of hours to several days. Delay in treatment can lead to serious outcomes. Inflammation of the meninges is assessed by analysing cerebrospinal fluid. Identifying the pathogen in cerebrospinal fluid is another way to diagnose meningitis. Cerebrospinal fluid is collected by doing a lumbar puncture, which is an invasive test, and can be avoided if a physical examination excludes the diagnosis of meningitis. However, most physical examinations, such as nuchal rigidity, Kernig's test, and Brudzinski's test, are not sufficiently sensitive to exclude meningitis completely. Jolt accentuation of headache is a new and less well-recognised physical examination, which assesses meningeal irritation. It is judged as positive if the headache is exacerbated by rotating the head horizontally two or three times per second. A 1991 observational study initially reported high sensitivity of this examination to predict pleocytosis. Pleocytosis, an abnormally high cerebrospinal fluid sample white cell count, is an accepted indicator of nervous system infection or inflammation. Jolt accentuation of headache may therefore accurately rule out meningitis without the use of lumbar puncture. However, more recent cross-sectional studies have reported variable diagnostic accuracy. OBJECTIVES: To estimate the diagnostic accuracy of jolt accentuation of headache for detecting acute meningitis in emergency settings. Secondary objectives: to investigate the sources of heterogeneity, including study population, patient condition, and types of meningitis. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), and Embase (Elsevier) to 27 April 2020. We searched ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and Ichushi-Web Version 5.0 to 28 April 2020. SELECTION CRITERIA: We included cross-sectional studies that assessed the diagnostic accuracy of jolt accentuation of headache for people with suspected meningitis in emergency settings. We included participants of any age and any severity of illness. Meningitis should be diagnosed with any reference standard, such as cerebrospinal fluid pleocytosis, proof of causative agents, or autopsy. DATA COLLECTION AND ANALYSIS: Two review authors independently collated study data. We assessed methodological quality of studies using QUADAS-2 criteria. We used a bivariate random-effects model to determine summary estimates of sensitivity and specificity where meta-analysis was possible. We performed sensitivity analyses to validate the robustness of outcomes. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included nine studies (1161 participants). Five studies included only adults. Four studies included both adults and children; however, the proportion was not reported in three of these studies. The youngest child reported in the studies was aged 13 years. There was no study including only children. The reference standard was pleocytosis in eight studies, and the combination of pleocytosis and increased protein in the cerebrospinal fluid in one study. Two studies also used smear or positive culture of cerebrospinal fluid. Risk of bias and concern about applicability was high in the participant selection domain for all included studies and the consciousness subgroup. Overall, pooled sensitivity was 65.3% (95% confidence interval (CI) 37.3 to 85.6), and pooled specificity was 70.4% (95% CI 47.7 to 86.1) (very low-certainty evidence). We established the possibility of heterogeneity from visual inspection of forest plots. However, we were unable to conduct further analysis for study population, types of meningitis, and participants' condition, other than disturbance of consciousness (a secondary outcome). Amongst participants whose consciousness was undisturbed (8 studies, 921 participants), pooled sensitivity and specificity were 75.2% (95% CI 54.3 to 88.6) and 60.8% (95% CI 43.4 to 75.9), respectively (very low-certainty evidence). AUTHORS' CONCLUSIONS: Jolt accentuation for headache may exclude diagnoses of meningitis in emergency settings, but high-quality evidence to support use of this test is lacking. Even where jolt accentuation of headache is negative, there is still the possibility of acute meningitis. This review identified the possibility of heterogeneity. However, factors that contribute to heterogeneity are incompletely understood, and should be considered in future research.

Is Treatment with Denosumab Associated with Local Recurrence in Patients with Giant Cell Tumor of Bone Treated with Curettage? A Systematic Review.

BACKGROUND: Denosumab, a monoclonal antibody that binds to receptor activation of nuclear factor-kappa ß ligand (RANKL), has been used as a drug to treat aggressive giant cell tumors of bone. It is unclear whether preoperative denosumab therapy is associated with the local recurrence risk in patients with giant cell tumors of bone treated with curettage. Early evidence suggests that denosumab treatment is associated with a reduction in local recurrence, but other studies have questioned that premise. Curettage after a short course of denosumab (3 to 4 months) has been recommended, especially for large, aggressive giant cell tumors in which complete curettage is difficult to achieve. No randomized studies have documented the benefit of this approach, and some investigators have reported higher local recurrence after denosumab treatment. Due to this confusion, we performed a systematic analysis of existing reports to attempt to answer this question and determine whether the appropriate preoperative denosumab therapy duration could be established. QUESTIONS/PURPOSES: (1) Is the use of preoperative denosumab associated with local recurrence risk in patients with giant cell tumors of bone treated with curettage compared with those treated with curettage alone? (2) Is the preoperative denosumab therapy duration associated with local recurrence after curettage? METHODS: We searched the PubMed, EMBASE, and CENTRAL databases on April 26, 2019 and included both randomized and non-randomized studies that compared local recurrence between patients who had giant cell tumors of bone and were treated with curettage after preoperative denosumab and patients treated with curettage alone. Two authors independently screened the studies. There were no randomized studies dealing with denosumab in giant cell tumors of bone, and generally, denosumab was used for more aggressive tumors. We assessed the quality of the included studies using the Risk of Bias Assessment tool for Non-randomized Studies, with a moderate overall risk of bias. We registered our protocol in PROSPERO (registration number CRD42019133288). We selected seven eligible studies involving 619 patients for the final analysis. RESULTS: The proportion of patients with local recurrence ranged from 20% to 100% in the curettage with preoperative denosumab group and ranged from 0% to 50% in the curettage-alone group. The odds ratio of local recurrence ranged from 1.07 to 37.80 in no more than 6 months of preoperative denosumab duration group and ranged from 0.60 to 28.33 in more than 6 months of preoperative denosumab duration group. CONCLUSIONS: The available evidence for the benefit of denosumab in more aggressive giant cell tumors is inconclusive, and denosumab treatment may even be associated with an increase in the proportion of patients experiencing local recurrence. Because there are no randomized studies and the existing studies are of poor quality due to indication bias (the most aggressive Campanacci 3 lesions or those where even a resection would be difficult and result in morbidity are generally the patients who are treated with denosumab), the evidence to suggest a disadvantage is weak. Denosumab treatment should be viewed with caution until more definitive, randomized studies documenting a benefit (or not) have been conducted. Furthermore, we could not find evidence to suggest an appropriate length of preoperative denosumab before curettage.

Conclusiveness of Cochrane Reviews in physiotherapy: a systematic search and analytical review.

Numerous Cochrane Reviews (CRs) in the field of physiotherapy have been published, but their conclusiveness has not been investigated. The purpose of this study was to provide an overview and describe the conclusiveness of evidence from CRs regarding physiotherapy. We conducted a systematic search using the Cochrane Database of Systematic Reviews in the Cochrane Library from 2008 through 2017 in the field of physiotherapy, the Physical Rehabilitation Evidence Database, and the CRs list on the Cochrane Rehabilitation website. Reviewers extracted the following data: year of publication, editorial group, number of articles meeting the criteria, number of patients enrolled, conclusiveness, and need for additional studies. Linear regression was used to determine whether the percentage of conclusive reviews was affected by the year of publication. Reviewers found 283 CRs in the field of physiotherapy, and only 16 (5.7%) of which were conclusive. The number of trials and participants enrolled in conclusive reviews were significantly higher than those in inconclusive reviews (P < 0.001). The percentage of conclusive reviews was significantly correlated with year of publication (P = 0.03). Almost all reviews recognized the need for additional studies. Most CRs in physiotherapy are inconclusive, and most emphasize the need for further research. The ability of a Cochrane Review to reach a conclusion is affected by the cumulative patient sample size and number of trials included in the analysis.

Prevalence and associated factors of preoperative functional disability in elective surgical patients over 55 years old: a prospective cohort study.

PURPOSE: In preoperative settings, patients may have functional disabilities due to the disease for which surgery is being performed or comorbidities, but the associated and predictive factors remain unknown. This study examined the prevalence of preoperative functional disability and clarified the associated factors. METHODS: Individuals aged ≥ 55 years who were scheduled to undergo surgery in a tertiary-care hospital in Japan between April 2016 and September 2016 were eligible for enrolment in the study. Patients with the diseases requiring psychiatric treatment and patients unable to complete the questionnaire without help were excluded. After obtaining informed consent, each patient was asked to complete the 12-item World Health Organization Disability Assessment Schedule-2.0, which is a standardized evaluation tool for assessing comprehensive living function. Data from these questionnaires and the patients' characteristics were evaluated. Multiple logistic regression analysis was conducted to determine independent factors associated with preoperative functional disability. RESULTS: Of 1201 recruited patients, 912 (75.9%) were included in our analysis. The prevalence of preoperative functional disability was 29.2%. Regression analysis identified six independent associated factors for preoperative functional disability: body mass index ≥ 30 kg m-2, mixed lung disease, serum albumin values, malnutrition, risk of malnutrition, and preoperative use of corticosteroids. CONCLUSIONS: In total, 29.2% of preoperative patients had functional disability. Obesity, nutritional deficiency, respiratory complications, and low serum albumin values were determined as potentially modifiable factors.

Clinical Utility of Intraoperative Motor-Evoked Potential Monitoring to Prevent Postoperative Spinal Cord Injury in Thoracic and Thoracoabdominal Aneurysm Repair: An Audit of the Japanese Association of Spinal Cord Protection in Aortic Surgery Database.

BACKGROUND: Spinal cord ischemic injury is the most devastating sequela of descending and thoracoabdominal aortic surgery. Motor-evoked potentials (MEPs) have been used to intraoperatively assess motor tract function, but it remains unclear whether MEP monitoring can decrease the incidence of postoperative motor deficits. Therefore, we reviewed multicenter medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open surgery and endovascular repair) to assess the association of MEP monitoring with postoperative motor deficits. METHODS: Patients included in the study underwent descending or thoracoabdominal aortic repair at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery between 2000 and 2013. Using multivariable mixed-effects logistic regression analysis, we investigated whether intraoperative MEP monitoring was associated with postoperative motor deficits at discharge after open and endovascular aortic repair. RESULTS: We reviewed data from 1214 patients (open surgery, 601 [49.5%]; endovascular repair, 613 [50.5%]). MEP monitoring was performed in 631 patients and not performed in the remaining 583 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. Multivariable logistic regression analysis revealed that postoperative motor deficits at discharge did not have a significant association with MEP monitoring (adjusted odds ratio [OR], 1.13; 95% confidence interval [CI], 0.69-1.88; P = .624), but with other factors: history of neural deficits (adjusted OR, 6.08; 95% CI, 3.10-11.91; P < .001), spinal drainage (adjusted OR, 2.14; 95% CI, 1.32-3.47; P = .002), and endovascular procedure (adjusted OR, 0.45; 95% CI, 0.27-0.76; P = .003). The sensitivity and specificity of MEP <25% of control value for motor deficits at discharge were 37.8% (95% CI, 26.5%-49.5%) and 95.5% (95% CI, 94.7%-96.4%), respectively. CONCLUSIONS: MEP monitoring was not significantly associated with motor deficits at discharge.