Citations

Background and Purpose— There is currently controversy on the ideal anesthesia strategy during mechanical thrombectomy for acute ischemic stroke. We performed a systematic review and meta-analysis of studies comparing clinical and angiographic outcomes of patients undergoing general anesthesia (GA group) and those receiving either local anesthesia or conscious sedation (non-GA group). Methods— A literature search on anesthesia and endovascular treatment of acute ischemic stroke was performed. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome at 90 days (modified Rankin Score≤2), symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, and time to groin puncture. Results— Twenty-two studies (3 randomized controlled trials and 19 observational studies), including 4716 patients (1819 GA and 2897 non-GA) were included. In the nonadjusted analysis, patients in the GA group had higher odds of death (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.66–2.45) and respiratory complications (OR, 1.70; 95% CI, 1.22–2.37) and lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48–0.64) compared with the non-GA group. There was no difference in procedure time between the 2 primary comparison groups. When adjusting for baseline National Institutes of Health Stroke Scale, GA was still associated with lower odds of good functional outcome (OR, 0.59; 95% CI, 0.29–0.94). When considering studies performed in the stent-retriever/aspiration era, there was no significant difference in good neurological outcome rates (OR, 0.84; 95% CI, 0.67–1.06). Conclusions— Acute ischemic stroke patients undergoing intra-arterial therapy may have worse outcomes when treated with GA as compared with conscious sedation/local anesthesia. However, major limitations of current evidence (ie, retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to answer this question.

Hepatocellular carcinoma (HCC) is a complex disease most commonly arising in the background of chronic liver disease. In the past two decades, there has been a significant increase in our understanding of both the clinical and molecular heterogeneity of HCC. There has been a robust increase in clinical trial activity in patients with poor prognostic factors, such as macrovascular invasion and extrahepatic spread (EHS). We aimed to synthesize the evidence for the treatment of patients with advanced HCC based on these baseline characteristics, including patients with both Child‐Pugh (CP) scores of A and B. A comprehensive search of several databases from each database inception to February 15, 2016 any language was conducted. We included 14 studies (three randomized controlled studies [RCTs] and 11 observational studies). We included studies that compared sorafenib, transarterial bland embolization/transarterial chemoembolization, yttrium‐90/radiation therapy, ablation (or combination), and no therapy. Two RCTs comparing sorafenib to best supportive care demonstrated a consistent improvement in overall survival (OS) for patients with advanced HCC and metastatic vascular invasion (MVI) and/or EHS and CP A liver disease (hazard ratio, 0.66 [95% confidence interval, 0.51‐0.87]; I 2 = 0%). Several observational studies evaluated locoregional therapies alone or in combination with other treatments and were limited by very‐low‐quality of evidence. This was true for both patients with EHS and MVI. Conclusion : In patients with advanced HCC and CP A liver function, sorafenib is the only treatment that has been shown to improve OS in randomized studies. High‐quality data supporting the use of other treatment modalities in this setting, or in the setting of patients with less compensated (CP B) liver disease, are lacking. (H epatology 2018;67:422‐435)

Background Hospital discharge summaries enable communication between inpatient and outpatient physicians. Despite existing guidelines for discharge summaries, they are frequently suboptimal. Objective The aim of this study was to assess physicians’ perspectives about discharge summaries and the differences between summaries’ authors (hospitalists) and readers (primary care physicians [PCPs]). Methods A national survey of 1600 U.S. physicians was undertaken. Primary measures included physicians’ preferences in discharge summary standardization, content, format, and audience. Results A total of 815 physicians responded (response rate = 51%). Eighty-nine percent agreed that discharge summaries “should have a standardized format.” Most agreed that summaries should “document everything that was done, found, and recommended in the hospital” (64%) yet “only include details that are highly pertinent to the hospitalization” (66%). Although 74% perceived patients as an important audience of discharge summaries, only 43% agreed that summaries “should be written in language that patients…can easily understand,” and 68% agreed that it “should be written solely for provider-to-provider communication.” Compared with hospitalists, PCPs preferred comprehensive summaries (68% versus 59%, P = 0.002). More PCPs agreed that separate summaries should be created for patients and for provider-to-provider communication than hospitalists (60% versus 47%, P < 0.001). Compared with PCPs, more hospitalists believe that “hospitalists are too busy to prepare a high-quality discharge summary” (44% versus 23%, P < 0.001) and “PCPs have insufficient time to read an entire discharge summary” (60% versus 38%, P < 0.001). Conclusions Physicians believe that discharge summaries should have a standardized format but do not agree on how comprehensive or in what format they should be. Efforts are necessary to build consensus toward the ideal discharge summary.

Summary 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.

Background and Purpose— Because of the perceived risk of contrast-induced acute kidney injury (AKI), many centers require pre-imaging serum creatinine levels, potentially delaying care. We performed a systematic review and meta-analysis evaluating AKI rates in patients with acute ischemic stroke receiving computed tomographic angiography (CTA) and computed tomographic perfusion (CTP). Methods— We searched MEDLINE, EMBASE, and the Web of Science through December 2016 for studies reporting on AKI in patients with acute ischemic stroke receiving CTA/CTP. Using a random-effects model, estimates were pooled across studies. Outcomes of interest were (1) the odds of AKI in patients receiving CTA/CTP versus noncontrast computed tomography, (2) overall rate of AKI and hemodialysis in patients with acute ischemic stroke undergoing CTA/CTP, and (3) the odds of CTA/CTP-associated AKI among patients with and without chronic kidney disease. Results— Fourteen studies were included (6 case–control studies and 8 single-arm studies) with 5727 CTA/CTP and 981 noncontrast computed tomography patients. In case–control studies, AKI was significantly lower among CTA/CTP patients compared with noncontrast computed tomography patients (odds ratio=0.47; 95% confidence interval=0.33–0.68; P <0.01). Adjusting for baseline creatinine, there was no difference in AKI rates between groups (odds ratio=0.34; 95% confidence interval=0.10–1.21). The overall rate of AKI in CTA/CTP patients was 3% (95% confidence interval=2%–4%). The overall rate of hemodialysis in the CTA/CTP group was 0.07% (3 of 4373). There was no difference in AKI among CTA/CTP patients with and without chronic kidney disease (odds ratio=0.63; 95% confidence interval=0.34–1.12). Conclusions— Nonrandomized evidence suggests that CTA/CTP are not associated with statistically significant increase in risk of AKI in patients with stroke, even those with known chronic kidney disease.

AbstractBackgroundThe acquisition of intravenous (IV) access in the actively convulsing patient is difficult. This often delays the administration of the IV benzodiazepine (BDZ) necessary for seizure cessation. Delays in seizure cessation are associated with increased pharmacoresistance, increased risk of neuronal injury, worse patient outcomes, and increased morbidity.ObjectiveThe objective was to assess whether the delay imposed by IV access acquisition is justified by improved outcomes. We compared IV versus non‐IV BDZ efficacy in the real world with regard to failure rates (primary outcome), interval to seizure control, and observed complications (secondary outcomes).MethodsA systematic review was performed using Medline, Embase, and the Cochrane Library. All studies published or in press from the inception of the respective database to July 2016 were included. Only randomized and quasi‐randomized controlled trials directly comparing IV to non‐IV (buccal, rectal, intranasal, or intramuscular) BDZ were included.ResultsOur search strategy retrieved 2,604 citations for review. A total of 11 studies were finally included in qualitative synthesis and 10 in quantitative analysis. Only one was of high quality. For treatment failure, non‐IV BDZ was superior to IV BDZ (odd ratio [OR] = 0.72; 95% confidence interval [CI] = 0.56–0.92). However, no significant difference was found between the two treatments in the pediatric subgroup (OR = 1.16; 95% CI = 0.74–1.81). Non‐IV BDZ was administered faster than IV BDZ and therefore controlled seizures faster (mean difference = 3.41 minutes; 95% CI = 1.69–5.13 minutes) despite a longer interval between drug administration and seizure cessation (mean difference = 0.74 minutes; 95% CI = 0.52–0.95 minutes). Respiratory complications requiring intervention were similar between non‐IV BDZ and IV BDZ, regardless of administration route (risk difference = 0.00; 95% CI = –0.02 to 0.01).ConclusionNon‐IV BDZ, compared to IV BDZ, terminate seizures faster and have a superior efficacy and side effect profile. Higher‐quality studies and further evaluation in different age groups are warranted.

AbstractObjectivesWe performed a systematic review and meta‐regression analysis of randomized control trials to investigate the association between response to initial treatment and survival outcomes in patients with newly diagnosed multiple myeloma (MM).MethodsResponse outcomes included complete response (CR) and the combined outcome of CR or very good partial response (VGPR), while survival outcomes were overall survival (OS) and progression‐free survival (PFS). We used random‐effect meta‐regression models and conducted sensitivity analyses based on definition of CR and study quality.ResultsSeventy‐two trials were included in the systematic review, 63 of which contributed data in meta‐regression analyses. There was no association between OS and CR in patients without autologous stem cell transplant (ASCT) (regression coefficient: .02, 95% confidence interval [CI] −0.06, 0.10), in patients undergoing ASCT (−.11, 95% CI −0.44, 0.22) and in trials comparing ASCT with non‐ASCT patients (.04, 95% CI −0.29, 0.38). Similarly, OS did not correlate with the combined metric of CR or VGPR, and no association was evident between response outcomes and PFS. Sensitivity analyses yielded similar results.ConclusionsThis meta‐regression analysis suggests that there is no association between conventional response outcomes and survival in patients with newly diagnosed MM.