Amélie Boutin

Predictive value of S-100β protein for prognosis in patients with moderate and severe traumatic brain injury: systematic review and meta-analysis

Objectives To determine the ability and accuracy of the S-100β protein in predicting prognosis after a moderate or severe traumatic brain injury. Design Systematic review and meta-analysis of randomised controlled trials and observational studies. Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, BIOSIS (from their inception to April 2012), conference abstracts, bibliographies of eligible articles, and relevant narrative reviews. Study selection Two reviewers independently reviewed citations and selected eligible studies, defined as cohort studies or randomised control trials including patients with moderate or severe traumatic brain injury and evaluating the prognostic value of S-100β protein. Outcomes evaluated were mortality, score on the Glasgow outcome scale, or brain death. Data extraction Two independent reviewers extracted data using a standardised form and evaluated the methodological quality of included studies. Pooled results were presented with geometric means ratios and analysed with random effect models. Prespecified sensitivity analyses were performed to explain heterogeneity. Results The search strategy yielded 9228 citations. Two randomised controlled trials and 39 cohort studies were considered eligible (1862 patients). Most studies (n=23) considered Glasgow outcome score ≤3 as an unfavourable outcome. All studies reported at least one measurement of S-100β within 24 hours after traumatic brain injury. There was a significant positive association between S-100β protein concentrations and mortality (12 studies: geometric mean ratio 2.55, 95% confidence interval 2.02 to 3.21, I2=56%) and score ≤3 (18 studies: 2.62, 2.01 to 3.42, I2=79%). Sensitivity analysis based on sampling time, sampling type, blinding of outcome assessors, and timing of outcome assessment yielded similar results. Thresholds for serum S-100β protein values with 100% specificity ranged from 1.38 to 10.50 µg/L for mortality (six studies) and from 2.16 to 14.00 µg/L for unfavourable neurological prognosis as defined by the Glasgow outcome score. Conclusions After moderate or severe traumatic brain injury, serum S-100β protein concentrations are significantly associated with unfavourable prognosis in the short, mid, or long term. Optimal thresholds for discrimination remain unclear. Measuring the S-100β protein could be useful in evaluating the severity of traumatic brain injury and in the determination of long term prognosis in patients with moderate and severe injury.

Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture

To evaluate the best available evidence regarding the association between single‐layer closure and uterine rupture.

Systematic review of cesarean scar assessment in the nonpregnant state: imaging techniques and uterine scar defect.

OBJECTIVE To review the ability of imaging techniques to predict incomplete healing of uterine cesarean scars before the next pregnancy. STUDY DESIGN A systematic literature review searched for studies on women who underwent previous low-transverse cesarean, evaluated by hysterography, sonohysterography (SHG), or transvaginal ultrasound (TVU). The median prevalence of scar defects was computed with 95% confidence intervals (95% CIs). Odds ratio (OR, 95% CI) identified risk factors of incomplete healing. RESULTS The analysis included 21 studies. The proportions of suspected scar defects detected by hysterography, SGH, and TVU were 58% (33 to 70), 59% (58 to 85), and 37% (20 to 65), respectively. Two studies found that women with a large uterine scar defect had a higher risk of uterine rupture or uterine scar dehiscence than those with no scar defect or small scar defect (OR: 26.05 [2.36 to 287.61], p <0.001). The only reported risk factor for scar defect was the occurrence of more than one previous cesarean (OR: 2.24 [1.13, 4.45], p = 0.02). CONCLUSION Hysterography, SGH, and TVU can detect uterine scar defects in ~50% of women with previous cesarean.

Effect of systemic steroids on post-tonsillectomy bleeding and reinterventions: systematic review and meta-analysis of randomised controlled trials

Objective To evaluate the risk of postoperative bleeding and reintervention with the use of systemic steroids in patients undergoing tonsillectomy. Design Systematic review and meta-analysis of randomised controlled trials. Data sources Medline, Embase, Cochrane Library, Scopus, Web of Science, Intute, Biosis, OpenSIGLE, National Technical Information Service, and Google Scholar were searched. References from reviews identified in the search and from included studies were scanned. Review methods Randomised controlled trials comparing the administration of systemic steroids during tonsillectomy with any other comparator were eligible. Primary outcome was postoperative bleeding. Secondary outcomes were the rate of admission for a bleeding episode, reintervention for a bleeding episode, blood transfusion, and mortality. Results Of 1387 citations identified, 29 randomised controlled trials (n=2674) met all eligibility criteria. Seven studies presented a low risk of bias, but none was specifically designed to systematically identify postoperative bleeding. Administration of systemic steroids did not significantly increase the incidence of post-tonsillectomy bleeding (29 studies, n=2674 patients, odds ratio 0.96 (95% confidence interval 0.66 to 1.40), I²=0%). We observed a significant increase in the incidence of operative reinterventions for bleeding episodes in patients who received systemic steroids (12, n=1178, 2.27 (1.03 to 4.99), I²=0%). No deaths were reported. Sensitivity analyses were consistent with the findings. Conclusions Although systemic steroids do not appear to increase bleeding events after tonsillectomy, their use is associated with a raised incidence of operative reinterventions for bleeding episodes, which may be related to increased severity of bleeding events. Systemic steroids should be used with caution, and the risks and benefits weighed, for the prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their condition of use.

Hemoglobin levels and transfusions in neurocritically ill patients: a systematic review of comparative studies

IntroductionAccumulating evidence suggests that, in critically ill patients, a lower hemoglobin transfusion threshold is safe. However, the optimal hemoglobin level and associated transfusion threshold remain unknown in neurocritically ill patients.MethodsWe conducted a systematic review of comparative studies (randomized and nonrandomized) to evaluate the effect of hemoglobin levels on mortality, neurologic function, intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, and multiple organ failure in adult and pediatric neurocritically ill patients. We searched MEDLINE, The Cochrane Central Register of Controlled Trials, Embase, Web of Knowledge, and Google Scholar. Studies focusing on any neurocritical care conditions were included. Data are presented by using odds ratios for dichotomous outcomes and mean differences for continuous outcomes.ResultsAmong 4,310 retrieved records, six studies met inclusion criteria (n = 537). Four studies were conducted in traumatic brain injury (TBI), one in subarachnoid hemorrhage (SAH), and one in a mixed population of neurocritically ill patients. The minimal hemoglobin levels or transfusion thresholds ranged from 7 to 10 g/dl in the lower-Hb groups and from 9.3 to 11.5 g/dl in the higher-Hb groups. Three studies had a low risk of bias, and three had a high risk of bias. No effect was observed on mortality, duration of mechanical ventilation, or multiple organ failure. In studies reporting on length of stay (n = 4), one reported a significant shorter ICU stay (mean, -11.4 days (95% confidence interval, -16.1 to -6.7)), and one, a shorter hospital stay (mean, -5.7 days (-10.3 to -1.1)) in the lower-Hb groups, whereas the other two found no significant association.ConclusionsWe found insufficient evidence to confirm or refute a difference in effect between lower- and higher-Hb groups in neurocritically ill patients. Considering the lack of evidence regarding long-term neurologic functional outcomes and the high risk of bias of half the studies, no recommendation can be made regarding which hemoglobin level to target and which associated transfusion strategy (restrictive or liberal) to favor in neurocritically ill patients.

Hysterosalpingosonography for diagnosing tubal occlusion in subfertile women: a systematic review with meta-analysis

STUDY QUESTION Is hysterosalpingosonography (sono-HSG) an accurate test for diagnosing tubal occlusion in subfertile women and how does it perform compared with hysterosalpingography (HSG)? SUMMARY ANSWER sono-HSG is an accurate test for diagnosing tubal occlusion and performs similarly to HSG. WHAT IS KNOWN ALREADY sono-HSG and HSG are both short, well-tolerated outpatient procedures. However, sono-HSG has the advantage over HSG of obviating ionizing radiation and the risk of iodine allergy, being associated with a greater sensitivity and specificity in detecting anomalies of the uterine cavity and permitting concomitant visualization of the ovaries and myometrium. STUDY DESIGN, SIZE, DURATION A systematic review and meta-analysis of studies published in any language before 14 November 2012 were performed. All studies assessing the accuracy of sono-HSG for diagnosing tubal occlusion in a subfertile female population were considered. PARTICIPANTS/MATERIALS, SETTING, METHODS We searched Medline, Embase, Cochrane Library, Web of Science and Biosis as well as related articles, citations and reference lists. Diagnostic studies were eligible if they compared sono-HSG (±HSG) to laparoscopy with chromotubation in women suffering from subfertility. Two authors independently screened for eligibility, extracted data and assessed the quality of included studies. Risk of bias and applicability concerns were investigated according to the Quality Assessment of Diagnostic Accuracy Study (QUADAS-2). Bivariate random-effects models were used to estimate pooled sensitivity and specificity with their 95% confidence intervals (95% CIs), to generate summary receiver operating characteristic curves and to evaluate sources of heterogeneity. MAIN RESULTS AND THE ROLE OF CHANCE Of the 4221 citations identified, 30 studies were eligible. Of the latter, 28 reported results per individual tube and were included in the meta-analysis, representing a total of 1551 women and 2740 tubes. In nine studies, all participants underwent HSG in addition to sono-HSG and laparoscopy, allowing direct comparison of the accuracy of sono-HSG and HSG. Pooled estimates of sensitivity and specificity of sono-HSG were 0.92 (95% CI: 0.82-0.96) and 0.95 (95% CI: 0.90-0.97), respectively. In nine studies (582 women, 1055 tubes), sono-HSG and HSG were both compared with laparoscopy, giving pooled estimates of sensitivity and specificity of 0.95 (95% CI: 0.78-0.99) and 0.93 (95% CI: 0.89-0.96) for sono-HSG, and 0.94 (95% CI: 0.74-0.99) and 0.92 (95% CI: 0.87-0.95) for HSG, respectively. Doppler sonography was associated with significantly greater sensitivity and specificity of sono-HSG compared with its non-use (0.93 and 0.95 versus 0.86 and 0.89, respectively, P = 0.0497). Sensitivity analysis regarding methodological quality of studies was consistent with these findings. We also found no benefit of the commercially available contrast media over saline solution in regard to the diagnostic accuracy of sono-HSG. LIMITATIONS, REASONS FOR CAUTION Methodological quality varied greatly between studies. However, sensitivity analysis, taking methodological quality of studies into account, did not modify the results. This systematic review did not allow the distinction between distal and proximal occlusion. This could be interesting to take into account in further studies, as the performance of the test may differ for each localization. WIDER IMPLICATIONS OF THE FINDINGS Given our findings and the known benefits of sono-HSG over HSG in the context of subfertility, sono-HSG should replace HSG in the initial workup of subfertile couples. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by personal funds. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER This review has been registered at PROSPERO: Registration number #CRD42013003829.

Red Blood Cell Transfusion in Patients With Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Our objectives were to evaluate the frequency of red blood cell (RBC) transfusion in patients with traumatic brain injury (TBI) as well as potential determinants and outcomes associated with RBC transfusion in this population. We conducted a systematic review of cohort studies and randomized trials of patients with TBI. We searched Medline, Embase, the Cochrane Library, and BIOSIS databases from their inception up to April 2015. We selected studies of adult patients with acute TBI reporting data on RBC transfusions. Cumulative incidences of transfusion were pooled using random-effect models with a DerSimonian approach. To evaluate the association between RBC transfusion and potential determinants or clinical outcomes, we pooled risk ratios or mean differences with random-effect models and the Mantel-Haenszel method. We identified 24 eligible studies (17414 patients). After pooling data from 23 studies (7524 patients), approximately 36% (95% confidence interval [CI], 28-44; I(2) = 98%) of patients received RBC transfusion at some point during their hospital stay. Hemoglobin thresholds for transfusion were rarely available (reported in 9 studies) and varied from 6 to 10 g/dL. Glasgow Coma Scale scores at admission were lower in patients who were transfused than those who were not (3 cohort studies; 1371 patients; mean difference of 1.38 points [95% CI, 0.86-1.89]; I(2) = 12%). Mortality was not significantly different among transfused and nontransfused patients in univariate and multivariate meta-analyses. Hospital length of stay was longer among patients receiving RBC transfusion compared to those who did not (3 studies; n = 455; mean difference, 9.58 days [95% CI, 3.94-15.22]; I(2) = 74%). Results should be considered cautiously due to the high heterogeneity and high risk of confounding from the observational nature of included studies. Red blood cell transfusion is frequent in patients with TBI, and transfusion practices varied widely between studies. Current published data highlight the lack of clinical evidence guiding transfusion strategies in TBI.

Clinical outcomes, predictors, and prevalence of anterior pituitary disorders following traumatic brain injury: a systematic review.

Objectives:To assess the clinical outcomes, predictors, and prevalence of anterior pituitary disorders following traumatic brain injury. Data Sources:We searched Medline, Embase, Cochrane Registry, BIOSIS, and Trip Database up to February 2012 and consulted bibliographies of narrative reviews and selected articles. Study Selection:We included cohort, case-control, cross-sectional studies and randomized trials enrolling at least five adults with blunt traumatic brain injury in whom at least one anterior pituitary axis was assessed. We excluded case series and studies in which other neurological conditions were indistinguishable from traumatic brain injury. Data Extraction:Two independent reviewers selected citations, extracted data, and assessed the risk of bias using a standardized form. Data Synthesis:We performed meta-analyses using random effect models and assessed heterogeneity using the I2 index. Results:We included 66 studies (5,386 patients) evaluating prevalence, 14 evaluating clinical outcomes, and 27 evaluating predictors. Thirty studies were at low risk of bias. Anterior pituitary disorders were associated with a trend toward increased ICU mortality (risk ratio, 1.79; 95% CI, 0.99–3.21; four studies) and no difference in Glasgow Outcome Scale score (mean difference, –0.45; 95% CI, –1.10 to 0.20; three studies). Age (mean difference, 3.19; 95% CI, 0.31–6.08; 19 studies), traumatic brain injury severity (risk ratio, 2.15; 95% CI, 1.20–3.86 for patients with severe vs nonsevere traumatic brain injury; seven studies), and skull fractures (risk ratio, 1.73; 95% CI, 1.03–2.91; six studies) predicted anterior pituitary disorders. Over the long term, 31.6% (95% CI, 23.6–40.1%; 27 studies) of patients had at least one anterior pituitary disorder. We observed significant heterogeneity that was not solely explained by the risk of bias or traumatic brain injury severity. Conclusions:Approximately one third of traumatic brain injury patients have persistent anterior pituitary disorder. Older age, traumatic brain injury severity, and skull fractures predict anterior pituitary disorders, which in turn may be associated with higher ICU mortality. Further high-quality studies are warranted to better define the burden of anterior pituitary disorders and to identify high-risk patients.

Treatment of periodontal disease and prevention of preterm birth: systematic review and meta-analysis.

OBJECTIVE There is a controversy regarding the benefits of periodontal treatment during pregnancy. We aimed to evaluate its effect on the risk of preterm birth and to explore the heterogeneity between studies. STUDY DESIGN A systematic review and meta-analysis of randomized controlled trials were performed. Studies in which women were randomized for periodontal treatment versus no treatment were included. Pooled risk ratios (RRs) with their 95% confidence intervals (CIs) were calculated using random-effect models. A sensitivity analysis was performed. RESULTS Twelve randomized trials were included in the meta-analysis. Pooled estimates showed no significant reduction of preterm birth with periodontal treatment (RR: 0.89; 95% CI: 0.73 to 1.08). However, the substantial heterogeneity among studies (I2 = 52%) could be explained either by the risk of bias, the level of income, or by the use of chlorhexidine mouthwashes as a cointervention. Daily use of chlorhexidine mouthwash was associated with a reduction of preterm birth (RR: 0.69; 95% CI 0.50 to 0.95), with moderate heterogeneity among the five studies included (I2 = 43%). CONCLUSION There is an important heterogeneity between randomized trials that evaluated the effect of periodontal treatment on the risk of preterm birth. Chlorhexidine mouthwash as a preventive agent should be further evaluated.

Trauma center performance indicators for nonfatal outcomes: a scoping review of the literature.

BACKGROUND: According to Donabedians framework, outcomes covering the following six domains should be used to evaluate health care quality: death, adverse events, readmissions to hospital, resource use, quality of life, and ability to function in daily activities. The objective of this study was to identify the nonfatal outcomes that have been used to evaluate the performance of trauma hospitals. Secondary objectives were to describe definitions and methodological quality. METHODS: We performed a scoping literature review of studies using at least one nonfatal outcome to evaluate the performance of acute care hospitals for the treatment of general trauma populations. We searched MEDLINE, EMBASE, Cochrane central, CINAHL, BIOSIS, TRIP and ProQuest databases. Methodological quality was evaluated using elements of the STROBE statement and the Downs and Black tool. RESULTS: Of 14,521 citations, 40 were eligible for inclusion. We identified 14 nonfatal outcomes as follows: (i) adverse events including complications (used in 35 evaluations), missed injuries (n = 4), reintubation (n = 2), unplanned intensive care unit admissions (n = 2), and unplanned surgeries (n = 4); (ii) resource use including hospital (n = 19), intensive care unit (n = 15), and ventilator (n = 4) length of stay, inappropriate hospital stay (n = 1), and potentially unnecessary care (n = 1); (iii) hospital readmissions (n = 4); and (iv) ability to function in daily activities including functional capacity (n = 2), and discharge destination (n = 3). No measures of quality of life were identified. There was high heterogeneity in the definitions used. Only 18% of studies had high methodological quality. CONCLUSION: Among recommended domains of nonfatal outcomes, adverse events and resource use were frequently used to evaluate trauma care, readmissions and function in daily activities were rarely used, and quality of life was never used. In addition, definitions of nonfatal outcomes were variable, and methodological quality was low. There is a need to develop valid and reliable performance indicators based on each domain of Donabedians framework to evaluate trauma care.