Publications by authors named "Ahmed M Altibi"

28 Publications

  • Page 1 of 1

Characteristics and comparative clinical outcomes of prisoner versus non-prisoner populations hospitalized with COVID-19.

Sci Rep 2021 03 22;11(1):6488. Epub 2021 Mar 22.

Department of Internal Medicine, Henry Ford Allegiance Hospital, Henry Ford Health System, 205 N East Ave, Jackson, MI, 49201, USA.

Prisons in the United States have become a hotbed for spreading COVID-19 among incarcerated individuals. COVID-19 cases among prisoners are on the rise, with more than 143,000 confirmed cases to date. However, there is paucity of data addressing clinical outcomes and mortality in prisoners hospitalized with COVID-19. An observational study of all patients hospitalized with COVID-19 between March 10 and May 10, 2020 at two Henry Ford Health System hospitals in Michigan. Clinical outcomes were compared amongst hospitalized prisoners and non-prisoner patients. The primary outcomes were intubation rates, in-hospital mortality, and 30-day mortality. Multivariable logistic regression and Cox-regression models were used to investigate primary outcomes. Of the 706 hospitalized COVID-19 patients (mean age 66.7 ± 16.1 years, 57% males, and 44% black), 108 were prisoners and 598 were non-prisoners. Compared to non-prisoners, prisoners were more likely to present with fever, tachypnea, hypoxemia, and markedly elevated inflammatory markers. Prisoners were more commonly admitted to the intensive care unit (ICU) (26.9% vs. 18.7%), required vasopressors (24.1% vs. 9.9%), and intubated (25.0% vs. 15.2%). Prisoners had higher unadjusted inpatient mortality (29.6% vs. 20.1%) and 30-day mortality (34.3% vs. 24.6%). In the adjusted models, prisoner status was associated with higher in-hospital death (odds ratio, 2.32; 95% confidence interval (CI), 1.33 to 4.05) and 30-day mortality (hazard ratio, 2.00; 95% CI, 1.33 to 3.00). In this cohort of hospitalized COVID-19 patients, prisoner status was associated with more severe clinical presentation, higher rates of ICU admissions, vasopressors requirement, intubation, in-hospital mortality, and 30-day mortality.
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http://dx.doi.org/10.1038/s41598-021-85916-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985211PMC
March 2021

Assessment of right ventricular function following left ventricular assist device (LVAD) implantation-The role of speckle-tracking echocardiography: A meta-analysis.

Echocardiography 2020 12 20;37(12):2048-2060. Epub 2020 Oct 20.

Division of Cardiovascular Disease, University of Alabama, Birmingham, AL, USA.

Background: Right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation is associated with worse outcomes. Prediction of RVF is difficult with routine transthoracic echocardiography (TTE), while speckle-tracking echocardiography (STE) showed promising results. We performed systematic review and meta-analysis of published literature.

Methods: We queried multiple databases to compile articles reporting preoperative or intraoperative right ventricle global longitudinal strain (RVGLS) or right ventricle free wall strain (RVFWS) in LVAD recipients. The standard mean difference (SMD) in RVGLS and RVFWS in patients with and without RVF postoperatively was pooled using random-effects model.

Results: Seventeen studies were included. Patients with RVF had significantly lower RVGLS and RVFWS as compared to non-RVF patients; SMD: 2.79 (95% CI: -4.07 to -1.50; P: <.001) and -3.05 (95% CI: -4.11 to -1.99; P: <.001), respectively. The pooled odds ratio (OR) for RVF per percentage increase of RVGLS and RVFWS were 1.10 (95 CI: 0.98-1.25) and 1.63 (95% CI 1.07-2.47), respectively. In a subgroup analysis, TTE-derived GLS and FWS were significantly lower in RVF patients as compared to non-RVF patients; SMD of -3.97 (95% CI: -5.40 to -2.54; P: <.001) and -3.05 (95% CI: -4.11 to -1.99; P: <.001), respectively. There was no significant difference between RVF and non-RVF groups in TEE-derived RVGLS and RVFWS.

Conclusion: RVGLS and RVFWS were lower in patients who developed RVF as compared to non-RVF patients. In a subgroup analysis, TTE-derived RVGLS and RVFWS were reduced in RVF patients as compared to non-RVF patients. This difference was not reported with TEE.
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http://dx.doi.org/10.1111/echo.14884DOI Listing
December 2020

Speckle tracking echocardiography can predict subclinical myocardial involvement in patients with sarcoidosis: A meta-analysis.

Echocardiography 2020 12 15;37(12):2061-2070. Epub 2020 Oct 15.

Division of Cardiovascular Disease, University of Alabama, Birmingham, AL, USA.

Background: This meta-analysis aims to evaluate the utility of speckle tracking echocardiography (STE) as a tool to evaluate for cardiac sarcoidosis (CS) early in its course. Electrocardiography and echocardiography have limited sensitivity in this role, while advanced imaging modalities such as cardiac magnetic resonance (CMR) and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) are limited by cost and availability.

Methods: We compiled English language articles that reported left ventricular global longitudinal strain (LVGLS) or global circumferential strain (GCS) in patients with confirmed extra-cardiac sarcoidosis versus healthy controls. Studies that exclusively included patients with probable or definite CS were excluded. Continuous data were pooled as a standard mean difference (SMD), comparing sarcoidosis group with healthy controls. A random-effect model was adopted in all analyses. Heterogeneity was assessed using Q and I2 statistics.

Results: Nine studies were included in our final analysis with an aggregate of 967 patients. LVGLS was significantly lower in the extra-cardiac sarcoidosis group as compared with controls, SMD -3.98, 95% confidence interval (CI): -5.32, -2.64, P < .001, also was significantly lower in patients who suffered major cardiac events (MCE), -3.89, 95% CI -6.14, -1.64, P < .001. GCS was significantly lower in the extra-cardiac sarcoidosis group as compared with controls, SMD: -3.33, 95% CI -4.71, -1.95, P < .001.

Conclusion: LVGLS and GCS were significantly lower in extra-cardiac sarcoidosis patients despite not exhibiting any cardiac symptoms. LVGLS correlates with MCEs in CS. Further studies are required to investigate the role of STE in the early screening of CS.
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http://dx.doi.org/10.1111/echo.14886DOI Listing
December 2020

Protocol registration issues of systematic review and meta-analysis studies: a survey of global researchers.

BMC Med Res Methodol 2020 08 25;20(1):213. Epub 2020 Aug 25.

School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, 852-8523, Japan.

Background: Although protocol registration of systematic reviews/meta-analysis (SR/MA) is still not mandatory, it is highly recommended that authors publish their SR/MA protocols prior to submitting their manuscripts for publication as recommended by the Cochrane guidelines for conducting SR/MAs. our aim was to assess the awareness, obstacles, and opinions of SR/MA authors about the protocol registration process.

Methods: A cross-sectional survey study included the authors who published SR/MAs during the period from 2010 to 2016, and they were contacted for participation in our survey study. They were identified through the literature search of SR/MAs in Scopus database. An online questionnaire was sent to each participant via e-mail after receiving their approval to join the study. We have sent 6650 emails and received 275 responses.

Results: A total of 270 authors responses were complete and included in the final analysis. Our results has shown that PROSPERO was the most common database used for protocol registration (71.3%). The registration-to-acceptance time interval in PROSPERO was less than 1 month (99.1%). Almost half of the authors (44.2%) did not register their protocols prior to publishing their SR/MAs and according to their opinion that the other authors lack knowledge of protocol importance and mandance to be registered, was the most commonly reported reason (44.9%). A significant percenatge of respondents (37.4%) believed that people would steal their ideas from protocol databases, while only 5.3% reported that their SR/MA had been stolen. However, the majority (72.9%) of participants have agreed that protocol registries play a role in preventing unnecessary duplication of reviews. Finally, 37.4% of participants agree that SR/MA protocol registration should be mandatory.

Conclusion: About half of the participants believes that the main reason for not registering protocols, is that the other authors lack knowledge concerning obligation and importance to register the SR/MA protocols in advance. Therefore, tools should be available to mandate protocol registration of any SRs beforehand and increasing awareness about the benefits of protocol registration among researchers.
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http://dx.doi.org/10.1186/s12874-020-01094-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7448304PMC
August 2020

Cutaneous Fusariosis in a Patient with Job's (Hyper-IgE) Syndrome.

Case Rep Infect Dis 2020 15;2020:3091806. Epub 2020 Jun 15.

Henry Ford Allegiance Health (HFAH), Jackson, MI, USA.

is a filamentous fungus that is ubiquitous in nature and can cause severe opportunistic infections in immunocompromised hosts. The association between and hyper-IgE syndrome is exceedingly rare and has only been documented in a single report previously. A 44-year-old male, working as marijuana grower, with prior diagnosis of hyper-IgE syndrome and recurrent infections presented with enlarging right knee ulcer that did not respond to antimicrobial treatment. The patient was diagnosed with cutaneous fusariosis, confirmed with punch biopsy and positive wound cultures. The patient was managed with extended antifungal therapy (i.e., posaconazole) and surgical debridement resulting in remarkable improvement with wound healing leaving a pale scar. should be considered in differential for cutaneous and invasive fungal infections in presence of cutaneous manifestations. Exposure to plants is a noticeable risk factor. Multimodal approach involving systemic antifungals and wound debridement is essential for favorable outcome. Posaconazole was demonstrated to be a highly efficacious antifungal choice.
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http://dx.doi.org/10.1155/2020/3091806DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315260PMC
June 2020

Cardiogenic shock in autoimmune rheumatologic diseases: an insight on etiologies, management, and treatment outcomes.

Heart Fail Rev 2020 Jun 20. Epub 2020 Jun 20.

Heart and Vascular Institute, West Virginian University, 1 Medical Center Dr., Morgantown, WV, 26505, USA.

Autoimmune rheumatological disorders are known to have an increased risk for cardiovascular diseases including coronary artery disease (CAD), myocarditis, pericarditis, valvulopathy, and in consequence cardiogenic shock. Data on cardiogenic shock in rheumatological diseases are scarce; however, several reports have highlighted this specific entity. We sought to review the available literature and highlight major outcomes and the management approaches in each disease. Systematic literature search, including PubMed, Ovid/Medline, Cochrane Library, and Web of Science, was conducted between January 2000 and December 2009. We reviewed all cases reporting cardiogenic shock with rheumatologic conditions, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Takayasu's arteritis (TA), granulomatosis with polyangiitis (GPA), giant cell arteritis (GCA), and antiphospholipid syndrome (APS). We selected 45 papers reporting a total of 48 cases. Mean age was 39 ± 7.3 years and 68.8% were females. Most common rheumatologic conditions associated with cardiogenic shock were SLE (31%), GPA (23%), TA (14.6%), APA (10.4%), and RA (8.3%). Cardiogenic shock was found to be caused by eosinophilic myocarditis in 58% of cases, CAD in 19% of cases, and valvulopathy in 6% of cases. Most patient required high-dose steroids and second immunosuppressant therapy. Mechanical circulatory supported was required in 23 cases, IABP in 16 cases, and ECMO in 12 cases. Complete recovery occurred in 37 patients while 9 patients died and 2 required heart transplant. Responsible for two-thirds of cases, eosinophilic myocarditis should be suspected in young cardiogenic shock patients with underlying rheumatologic conditions. Lupus and GPA are the two most common conditions.
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http://dx.doi.org/10.1007/s10741-020-09990-4DOI Listing
June 2020

Spontaneous Biliary Pericardial Tamponade: A Case Report and Literature Review.

Curr Cardiol Rev 2021 ;17(2):204-208

State University of New York: Downstate Medical Center, Brooklyn, NY 11202, United States.

Background: Biliary pericardial tamponade (BPT) is a rare form of pericardial tamponade, characterized by yellowish-greenish pericardial fluid upon pericardiocentesis. Historically, BPT reported to occur in the setting of an associated pericardiobiliary fistula. However, BPT in the absence of a detectable fistula is extremely rare.

Learning Objective: A biliary pericardial tamponade is a rare form of tamponade warranting a prompt workup (e.g., MRCP or HIDA scan) for a potential fistula between the biliary system and the pericardial space. A pericardio-biliary fistula can be iatrogenic or traumatic. People with a history of chest wall trauma, abdominal surgery, or chest surgery are at increased risk. The use of HIDA scanning plays a salient role in effectively surveilling for the presence of a fistula - especially when MRCP is contraindicated.

Case Presentation: A 75-year-old Hispanic male presenting with dyspnea and diagnosed with cardiac tamponade is the subject of the study. Subsequent pericardiocentesis revealed biliary pericardial fluid (bilirubin of 7.6 mg/dl). The patient underwent extensive workup to identify a potential fistula between the hepatobiliary system and the pericardial space, which was non-revealing. The mechanism of bile entry into the pericardial space remains to be unidentified.

Literature Review: A total of six previously published BPT were identified: all were males, with a mean age of 53.3 years (range: 31-73). Mortality was reported in two out of the six cases. The underlying etiology for pericardial tamponade varied across the cases: incidental pericardio-biliary fistula, traumatic pericardial injury, and presence of associated malignancy. - Conclusion: Biliary pericardial tamponade is a rare form of tamponade that warrants a prompt workup (e.g., Hepatobiliary Iminodiacetic Acid - HIDA scan) for an iatrogenic vs. traumatic pericardio- biliary fistula. As a first case in the literature, our case exhibits a biliary tamponade in the absence of an identifiable fistula.
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http://dx.doi.org/10.2174/1573403X16666200611132045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8226206PMC
June 2021

The Utility of Intraoperative Lateral Spread Recording in Microvascular Decompression for Hemifacial Spasm: A Systematic Review and Meta-Analysis.

Neurosurgery 2020 09;87(4):E473-E484

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Background: Microvascular decompression (MVD) is the surgical treatment of choice for hemifacial spasm (HFS). During MVD, monitoring of the abnormal lateral spread response (LSR), an evoked response to facial nerve stimulation, has been traditionally used to monitor adequacy of cranial nerve (CN) VII decompression.

Objective: To assess the utility of LSR monitoring in predicting spasm-free status after MVD postoperatively.

Methods: We searched PubMed, Web of Science, and Embase for relevant publications. We included studies reporting on intraoperative LSR monitoring during MVD for HFS and spasm-free status following the procedure. Sensitivity of LSR, specificity, diagnostic odds ratio, and positive predictive value were calculated.

Results: From 148 studies, 26 studies with 7479 patients were ultimately included in this meta-analysis. The final intraoperative LSR status predicted the clinical outcome of MVD with the following specificities and sensitivities: 89% (0.83- 0.93) and 40% (0.30- 0.51) at discharge, 90% (0.84-0.94) and 41% (0.29-0.53) at 3 mo, 89% (0.83-0.93) and 40% (0.30-0.51) at 1 yr. When LSR persisted after MVD, the probability (95% CI) for HFS persistence was 47.8% (0.33-0.63) at discharge, 40.8% (0.23-0.61) at 3 mo, and 24.4% (0.13-0.41) at 1 yr. However, when LSR resolved, the probability for HFS persistence was 7.3% at discharge, 4.2% at 3 mo, and 4.0% at 1 yr.

Conclusion: Intraoperative LSR monitoring has high specificity but modest sensitivity in predicting the spasm-free status following MVD. Persistence of LSR carries high risk for immediate and long-term facial spasm persistence. Therefore, adequacy of decompression should be thoroughly investigated before closing in cases where intraoperative LSR persists.
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http://dx.doi.org/10.1093/neuros/nyaa069DOI Listing
September 2020

Correction to: Readmission-free period and in-hospital mortality at the time of first readmission in acute heart failure patients-NRD-based analysis of 40,000 heart failure readmissions.

Heart Fail Rev 2020 05;25(3):551

Heart and Vascular Institute, West Virginia University, 1 Medical Center Dr, Morgantown, WV, 26505, USA.

The original version of this article unfortunately contained a mistake. Unfortunately, the name of one of the authors (Dr. Pradhum Ram) has been misspelled as (Prathaum Ram) instead.
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http://dx.doi.org/10.1007/s10741-020-09922-2DOI Listing
May 2020

Global longitudinal strain assessment of the left ventricle by speckle tracking echocardiography detects acute cellular rejection in orthotopic heart transplant recipients: A systematic review and meta-analysis.

Echocardiography 2020 02 22;37(2):302-309. Epub 2020 Jan 22.

Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.

Background: In orthotopic heart transplant recipients, surveillance with endomyocardial biopsy is crucial to detect acute cellular rejection (ACR) early. ACR is a common and serious complication of transplantation with substantial morbidity and mortality. Speckle tracking echocardiography with global longitudinal strain (GLS) assessment of the left ventricle has emerged as a possible noninvasive screening modality. We have conducted a systematic literature review and meta-analysis to evaluate the role of GLS in diagnosing ACR.

Methods: The following databases were queried: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Embase. We compiled all articles evaluating changes in GLS in comparison to endomyocardial biopsy in ACR dated prior to September 2019. Weighted mean differences (WMD) and 95% confidence intervals (CIs) were pooled by using a random effects model. In order to determine the risk of bias, we used the revised version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.

Results: Twelve studies met inclusion criteria of which ten were chosen. These studies encompassed 511 patients and 1267 endomyocardial biopsies. There was a significant difference in GLS between patients who did and did not have ACR proven by biopsy (WMD = 2.18; 95% CI: 1.57-2.78, P = <.001; I  = 76%). The overall sensitivity for GLS in detecting ACR was 78% (CI: 63%-90%, P = .123; I  = 52.2%) while the overall specificity was 68% (CI: 50%-83%, P = <.001; I  = 88.3%).

Conclusion: Global longitudinal strain assessment of the left ventricle by speckle tracking echocardiography is useful in detecting ACR and could potentially reduce the burden of frequent endomyocardial biopsies in heart transplant recipients.
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http://dx.doi.org/10.1111/echo.14586DOI Listing
February 2020

Readmission-free period and in-hospital mortality at the time of first readmission in acute heart failure patients-NRD-based analysis of 40,000 heart failure readmissions.

Heart Fail Rev 2021 Jan;26(1):57-64

Heart and Vascular Institute, West Virginia University, 1 Medical Center Dr., Morgantown, WV, 26505, USA.

The 30-day readmission rates, predictors, and outcomes for acute heart failure (AHF) patients are well published, but data beyond 30 days and the association between readmission-free period (RFP) and in-hospital readmission-related mortality remain unknown. We queried the National Readmission Database to analyze comparative outcomes of AHF. Patients were divided into three groups based on their RFP: group 1 (1-30 days), group 2 (31-90 days), and group 3 (91-275 days). AHF cases and clinical variables were identified using ICD-9 codes. The primary outcome was in-hospital mortality at the time of readmission. A total of 39,237 unplanned readmissions occurred within 275 days; 15,181 within group 1, 11,925 within group 2, and 12,131 within group 3. In-hospital mortality in groups 1, 2, and 3 were 7.4%, 5.1%, and 4.1% (p < 0.001). Group 1 had higher percentages of patients with cardiogenic shock (1.3% vs. 0.9% vs. 0.9%; p < 0.001), acute kidney injury (30.2% vs. 25.9% vs. 24.0%; p < 0.001), dialysis use (8.6% vs. 7.5% vs. 6.9%; p < 0.001), and non-ST elevation myocardial infarction (4.4% vs. 3.8% vs. 3.6%; p < 0.001), but there was no statistical difference among the three groups for ST-elevation myocardial infarction, percutaneous coronary intervention (PCI), or ventricular assist device use at the time of index admission. However, group 3 had higher PCI (1.7%) compared with groups 1 and 2 (p < 0.001). In multivariable logistic regression, groups 2 and 3 had odd ratio of 0.70 and 0.55, respectively, for in-hospital mortality compared with group 1. Longer RFP is associated with decreased risk of in-hospital mortality at the time of first readmission.
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http://dx.doi.org/10.1007/s10741-019-09912-zDOI Listing
January 2021

Native valve endocarditis caused by : presenting with refractory heart failure and requiring surgical valve replacement-report on a rare zoonosis.

BMJ Case Rep 2019 Dec 19;12(12). Epub 2019 Dec 19.

Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia, USA

is a Gram-positive bacillus that is ubiquitous in nature. The bacterium is a zoonotic pathogen known to infect wild and domestic animals. Human infections, however, are uncommon and typically present with localised or generalised cutaneous lesions. Systemic infection in the form of bacteraemia with seeding to various organs is the least common form of the disease. Infections in humans tend to be associated with occupational exposure and close contact with animals. Clinical data of a 61-year-old male patient with Gram-positive bacilli bacteraemia and -induced endocarditis are presented here. The patient presented with refractory congestive heart failure secondary to severe acute aortic regurgitation mandating surgical valve replacement. The described case has special clinical merit given the lack of fever and leukocytosis, absence of erysipeloid cutaneous manifestations and refractoriness to medical management. should be considered in the differential diagnosis for Gram-positive bacilli bacteraemia and endocarditis. In the proper clinical setting, occupational exposure and animal contacts are helpful clues to raise suspicion for this bacillus. The high mortality associated with the pathogen should urge for early identification and initiation of antimicrobial treatment.
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http://dx.doi.org/10.1136/bcr-2019-230891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936573PMC
December 2019

Perioperative Stroke in Carotid Artery Stenting as a Surrogate Marker and Predictor for 30-day Postprocedural Mortality - A Pooled Analysis of 156,000 Patients with Carotid Artery Disease.

Neurol India 2019 Nov-Dec;67(6):1423-1428

Department of Neurology; Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Background: Carotid artery stenosis (CAS) is being recognized as an effective alternative for carotid endarterectomy (CEA). CAS is especially preferred over CEA in high-risk surgical patients with severe carotid stenosis. However, CAS carries an increased risk of stroke and transient ischemic attack (TIA).

Objective: To assess the association between periprocedural stroke/TIA and 30-day mortality in carotid stenosis patients undergoing CAS.

Methods: We searched PubMed, Embase, and World Science for relevant publications. Studies reporting on perioperative neurologic status (stroke/TIA) and 30-day mortality in patients undergoing CAS were included. Sensitivity, specificity, pooled odds ratio (OR), and relative risk (RR) of perioperative stroke in predicting 30-day mortality following CAS were calculated.

Results: 146 studies with 156,854 patients were included in the meta-analysis. The mean patient age was 70.7 years, and 57.6% were males. Only 26.5% of the CAS cohort were symptomatic and 15.2% had bilateral carotid disease. The incidence of perioperative TIA and stroke were 2.4 and 2.7 per 100 CAS procedure, respectively. Around 11.8% of stroke-events were fatal. The pooled OR of 30-day mortality after perioperative stroke was 24.58 (95% CI, 19.92-30.32) and the pooled RR was 21.65 (95% CI, 17.87-26.22). Perioperative stroke had a sensitivity of 42.0% (95% CI 37.8-46.4%) and specificity of 97.0% (95% CI 96.7-97.3%) in predicting 30-day mortality.

Conclusions: Perioperative stroke drastically increases the risk of 30-day mortality. The occurrence of perioperative stroke exhibited high specificity but modest sensitivity in predicting 30-day mortality following CAS. This highlights the importance of neurophysiologic monitoring to detect intraoperative cerebral ischemia and perform timely interventions.
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http://dx.doi.org/10.4103/0028-3886.273642DOI Listing
June 2020

Wearable Cardioverter-Defibrillator Therapy for the Prevention of Sudden Cardiac Death: A Systematic Review and Meta-Analysis.

JACC Clin Electrophysiol 2019 02 30;5(2):152-161. Epub 2019 Jan 30.

Division of Cardiology, Albany Medical College, Albany, New York.

Objectives: This study sought to synthesize the available evidence on the use of the wearable cardioverter-defibrillator (WCD).

Background: Observational WCD studies for the prevention of sudden cardiac death have provided conflicting data. The VEST (Vest Prevention of Early Sudden Death) trial was the first randomized controlled trial (RCT) showing no reduction in sudden cardiac death as compared to medical therapy only.

Methods: We searched PubMed, EMBASE, and Google Scholar for studies reporting on the outcomes of patients wearing WCDs from January 1, 2001, through March 20, 2018. Rates of appropriate and inappropriate WCD therapies were pooled. Estimates were derived using DerSimonian and Laird's method.

Results: Twenty-eight studies were included (N = 33,242; 27 observational, 1 RCT-WCD arm). The incidence of appropriate WCD therapy was 5 per 100 persons over 3 months (95% confidence interval [CI]: 3.0 to 6.0, I = 93%). In studies on ischemic cardiomyopathy, the appropriate WCD therapy incidence was lower in the VEST trial (1 per 100 persons over 3 months; 95% CI: 1.0 to 2.0) as compared with observational studies (11 per 100 persons over 3 months; 95% CI: 11.0 to 20.0; I = 93%). The incidence of inappropriate therapy was 2 per 100 persons over 3 months (95% CI: 1.0 to 3.0; I = 93%). Mortality while wearing WCD was rare at 0.7 per 100 persons over 3 months (95% CI: 0.3 to 1.7; I = 94%).

Conclusions: The rate of appropriately treated WCD patients over 3 months of follow-up was substantial; higher in-observational studies as compared with the VEST trial. There was significant heterogeneity. More RCTs are needed to justify continued use of WCD in primary prevention.
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http://dx.doi.org/10.1016/j.jacep.2018.11.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383782PMC
February 2019

Diagnostic accuracy of dobutamine stress echocardiography in the detection of cardiac allograft vasculopathy in heart transplant recipients: A systematic review and meta-analysis study.

Echocardiography 2019 03 6;36(3):528-536. Epub 2019 Feb 6.

Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama.

Background: Dobutamine stress echocardiography (DSE) is a well-established imaging modality used to screen patients with mild-to-moderate risk for coronary artery disease. In heart transplantation recipients, cardiac allograft vasculopathy (CAV) is a common and lethal complication. The use of DSE to detect CAV showed promising results initially, but later studies showed limitation in its use to detect CAV. It is unclear if this cohort of patients derives benefit from DSE.

Methods: We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Scopus from inception through March 2018 for studies examining the accuracy of DSE in correlation to coronary angiography (CA) or intravascular ultrasound (IVUS) to detect CAV. Original studies comparing the ability of DSE to detect CAV in comparison with CA or IVUS were included. Relevant data were extracted and hierarchical summary receiver operating characteristic analysis was conducted to test the overall diagnostic accuracy of DSE for patients with CAV.

Results: Eleven studies (749 participants) met the inclusion criteria. The sensitivity of DSE varied from 1.7% to 93.8%, and specificity, from 54.8% to 98.8%. Pooled sensitivity was 60.2% (95% confidence interval (CI), 33.0%-82.3%) and specificity 85.7% (95% CI, 73.8%-92.7%). DSE had an overall diagnostic odds ratio (OR) of 9.1 (95% CI, 4.6-17.8), positive likelihood ratio (LR+) of 4.1 (95% CI, 2.8-6.1), negative likelihood ratio (LR-) of 0.47 (95% CI: 0.23-0.73), and area under curve (AUC) of 0.73 (95% CI, 0.72-0.75). Heterogeneity among studies was not statistically significant (τ = 0.32, Cochran's Q = 9.5, P = 0.483).

Conclusion: Dobutamine stress echocardiography has a limited sensitivity to detect early CAV but its specificity is much higher. There remains a need for an alternative noninvasive modality which will have both high sensitivity and high specificity for detecting CAV.
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http://dx.doi.org/10.1111/echo.14268DOI Listing
March 2019

Cardiac Dysfunction Among People Living With HIV: A Systematic Review and Meta-Analysis.

JACC Heart Fail 2019 Feb;7(2):98-108

South African Medical Research Council and University of Cape Town, South Africa.

Objective: To synthesize existing epidemiological data on cardiac dysfunction in HIV.

Background: Data on the burden and risk of human immunodeficiency virus (HIV) infection-associated cardiac dysfunction have not been adequately synthesized. We performed meta-analyses of extant literature on the frequency of several subtypes of cardiac dysfunction among people living with HIV.

Methods: We searched electronic databases and reference lists of review articles and combined the study-specific estimates using random-effects model meta-analyses. Heterogeneity was explored using subgroup analyses and meta-regressions.

Results: We included 63 reports from 54 studies comprising up to 125,382 adults with HIV infection and 12,655 cases of various cardiac dysfunctions. The pooled prevalence (95% confidence interval) was 12.3% (6.4% to 19.7%; 26 studies) for left ventricular systolic dysfunction (LVSD); 12.0% (7.6% to 17.2%; 17 studies) for dilated cardiomyopathy; 29.3% (22.6% to 36.5%; 20 studies) for grades I to III diastolic dysfunction; and 11.7% (8.5% to 15.3%; 11 studies) for grades II to III diastolic dysfunction. The pooled incidence and prevalence of clinical heart failure were 0.9 per 100 person-years (0.4 to 2.1 per 100 person-years; 4 studies) and 6.5% (4.4% to 9.6%; 8 studies), respectively. The combined prevalence of pulmonary hypertension and right ventricular dysfunction were 11.5% (5.5% to 19.2%; 14 studies) and 8.0% (5.2% to 11.2%; 10 studies), respectively. Significant heterogeneity was observed across studies for all the outcomes analyzed (I > 70%, p < 0.01), only partly explained by available study level characteristics. There was a trend for lower prevalence of LVSD in studies reporting higher antiretroviral therapy use or lower proportion of acquired immune deficiency syndrome. The prevalence of LVSD was higher in the African region. After taking into account the effect of regional variation, there was evidence of lower prevalence of LVSD in studies published more recently.

Conclusions: Cardiac dysfunction is frequent in people living with HIV. Additional prospective studies are needed to better understand the burden and risk of various forms of cardiac dysfunction related to HIV and the associated mechanisms. (Cardiac dysfunction in people living with HIV-a systematic review and meta-analysis; CRD42018095374).
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http://dx.doi.org/10.1016/j.jchf.2018.10.006DOI Listing
February 2019

Clinicopathological implications of MET exon 14 mutations in non-small cell lung cancer - A systematic review and meta-analysis.

Lung Cancer 2018 09 6;123:76-82. Epub 2018 Jul 6.

Department of Pathology, University of Yamanashi, Chuo, Yamanashi, 409-3898, Japan. Electronic address:

MET exon 14 mutation is an uncommon genomic alteration in non-small cell lung cancer (NSCLC). This meta-analysis aimed at investigating the clinicopathological and prognostic features of NSCLCs with MET exon 14 mutation in comparison with other genetic events. We performed a search in four electronic databases including PubMed, Web of Science, Scopus, and Virtual Health Library from inception to February 2018. Relevant data were extracted and pooled into odds ratio (OR), mean differences (MD), and corresponding 95% confidence intervals (CI) using the random-effect model. From 168 studies, we included 12 studies comprising of 18,464 NSCLCs for final analyses. Overall, the prevalence of MET exon 14 mutation in NSCLC was 3% (95% CI = 2-3), with being most commonly found in pulmonary sarcomatoid carcinoma (13%; 95% CI = 4-21). The mutation was more likely to occur in females (OR = 0.55; 95% CI = 0.33 - 0.90), patients with advanced age (MD = 7.48; 95% CI = 3.99-10.98), non-smoker (OR = 0.48; 95% CI = 0.28 - 0.83), and was associated with a worse prognosis (HR = 1.82; 95% CI = 1.04-3.19). Patients with MET exon 14 mutation had a distinct clinicopathological profile compared to other NSCLC genetic events. To summarize, MET exon 14 is a rare mutation in NSCLC and might be associated with a dismal survival. Patients harboring MET exon 14 skipping are eligible for targeted therapy with c-MET inhibitors, thus emphasizing the need to screen for this mutation in advanced NSCLCs.
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http://dx.doi.org/10.1016/j.lungcan.2018.07.006DOI Listing
September 2018

Definitions for warning signs and signs of severe dengue according to the WHO 2009 classification: Systematic review of literature.

Rev Med Virol 2018 07 24;28(4):e1979. Epub 2018 Apr 24.

Evidence Based Medicine Research Group & Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Vietnam.

Since warning signs and signs of severe dengue are defined differently between studies, we conducted a systematic review on how researchers defined these signs. We conducted an electronic search in Scopus to identify relevant articles, using key words including dengue, "warning signs," "severe dengue," and "classification." A total of 491 articles were identified through this search strategy and were subsequently screened by 2 independent reviewers for definitions of any of the warning or severe signs in the 2009 WHO dengue classification. We included all original articles published in English after 2009, classifying dengue by the 2009 WHO classification or providing the additional definition or criterion of warning signs and severity (besides the information of 2009 WHO). Analysis of the extracted data from 44 articles showed wide variations among definitions and cutoff values used by physicians to classify patients diagnosed with dengue infection. The establishment of clear definitions for warning signs and severity is essential to prevent unnecessary hospitalization and harmonizing the interpretation and comparability of epidemiological studies dedicated to dengue infection.
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http://dx.doi.org/10.1002/rmv.1979DOI Listing
July 2018

Clinical outcomes of current medical approaches for Middle East respiratory syndrome: A systematic review and meta-analysis.

Rev Med Virol 2018 05 17;28(3):e1977. Epub 2018 Apr 17.

Evidence Based Medicine Research Group & Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Vietnam.

Middle East respiratory syndrome (MERS) is a respiratory disease caused by MERS coronavirus. Because of lack of vaccination, various studies investigated the therapeutic efficacy of antiviral drugs and supportive remedies. A systematic literature search from 10 databases was conducted and screened for relevant articles. Studies reporting information about the treatment of MERS coronavirus infection were extracted and analyzed. Despite receiving treatment with ribavirin plus IFN, the case fatality rate was as high as 71% in the IFN-treatment group and exactly the same in patients who received supportive treatment only. Having chronic renal disease, diabetes mellitus and hypertension increased the risk of mortality (P < .05), and chronic renal disease is the best parameter to predict the mortality. The mean of survival days from onset of illness to death was 46.6 (95% CI, 30.5-62.6) for the IFN group compared with 18.8 (95% CI, 10.3-27.4) for the supportive-only group (P = .001). Delay in starting treatment, older age group, and preexisting comorbidities are associated with worse outcomes. In conclusion, there is no difference between IFN treatment and supportive treatment for MERS patients in terms of mortality. However, ribavirin and IFN combination might have efficacious effects with timely administration and monitoring of adverse events. Large-scale prospective randomized studies are required to assess the role of antiviral drugs for the treatment of this high mortality infection.
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http://dx.doi.org/10.1002/rmv.1977DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7169085PMC
May 2018

TERT promoter mutation and its interaction with IDH mutations in glioma: Combined TERT promoter and IDH mutations stratifies lower-grade glioma into distinct survival subgroups-A meta-analysis of aggregate data.

Crit Rev Oncol Hematol 2017 Dec 3;120:1-9. Epub 2017 Oct 3.

Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, United States.

The clinical significance of telomerase reverse transcriptase (TERT) promoter mutation in glioma remains unclear. The aim of our meta-analysis is to investigate the prognostic impact TERT promoter mutation in glioma patients and its interaction with other molecular markers, particularly Isocitrate Dehydrogenase (IDH) mutation from aggregate level data. Relevant articles were searched in four electronic databases including PubMed, Scopus, Web of Science and Virtual Health Library. Pooled HRs were calculated using random effect model weighted by inverse variance method. From 1010 studies, we finally included 28 studies with 11519 patients for meta-analyses. TERT mutation is significantly associated with compromised overall survival (OS) (HR=1.38; 95% CI=1.15-1.67) and progression-free survival (PFS) (HR=1.31; 95% CI=1.06-1.63) in glioma patients. In studying its reaction with IDH, TERT promoter mutation was associated with reduced OS in both IDH-mutant (IDH-mut) and IDH-wild type (IDH-wt) glioblastomas but shown to have inverse effects on IDH-mut and IDH-wt grade II/III tumors. Our analysis categorized WHO grade II/III glioma patients into four distinct survival subgroups with descending survival as follow: TERT-mut/IDH-mut≫TERT-wt/IDH-mut≫TERT-wt/IDH-wt≫TERT-mut/IDH-wt. Prognostic value of TERT promoter mutations in gliomas is dependent on tumor grade and the IDH mutational status. With the same tumor grade in WHO grade II and III tumors and the same IDH mutation status, TERT-mut is a prognostic factor.
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http://dx.doi.org/10.1016/j.critrevonc.2017.09.013DOI Listing
December 2017

Prognostic implication of BRAF and TERT promoter mutation combination in papillary thyroid carcinoma-A meta-analysis.

Clin Endocrinol (Oxf) 2017 Nov 2;87(5):411-417. Epub 2017 Aug 2.

Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.

Introduction: The use of molecular markers, especially BRAF and TERT promoter mutations, for risk stratification in papillary thyroid carcinoma (PTC) is subject to continuing debate. In this study, we aimed to investigate the clinicopathological implication of each genotype when combining BRAF and TERT promoter mutations in PTCs.

Methods: We searched four electronic databases including PubMed, Scopus, Web of Science and Virtual Health Library for relevant studies. Pooled estimates of odds ratios and corresponding 95% confidence intervals were calculated using random-effect model.

Results: From 111 results, we finally included 11 studies with 3911 PTC patients for meta-analyses. Our results demonstrated that PTCs with concurrent BRAF and TERT promoter mutations were associated with increased tumour aggressiveness in comparison with PTCs harbouring BRAF or TERT promoter mutation alone. The combination of BRAF and TERT promoter mutations could classify PTCs into four distinct risk groups with decreasing aggressiveness as follows: coexisting BRAF and TERT > TERT alone=BRAF alone > no mutations.

Conclusion: The risk stratification of PTC based on these four genotypes can help improve the clinical management of PTCs by identifying the group of PTCs with the highest aggressiveness.
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http://dx.doi.org/10.1111/cen.13413DOI Listing
November 2017

BRAF Mutation is Associated with an Improved Survival in Glioma-a Systematic Review and Meta-analysis.

Mol Neurobiol 2018 May 22;55(5):3718-3724. Epub 2017 May 22.

Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA.

Newly emerged molecular markers in gliomas provide prognostic values beyond the capabilities of histologic classification. BRAF mutation, especially BRAF V600E, is common in a subset of gliomas and may represent a potential prognostic marker. The aim of our study is to investigate the potential use of BRAF mutations on prognosis of glioma patients. Four electronic databases were searched for potential articles, including PubMed, Scopus, ISI Web of Science, and Virtual Health Library (VHL). Data of hazard ratio (HR) for overall survival (OS) and progression-free survival (PFS) were directly obtained from original papers or indirectly estimated from Kaplan Meier curve (KMC). A random effect model weighted by inverse variance method was used to calculate the pooled HR. From 705 articles, we finally included 11 articles with 1308 glioma patients for the final analysis. The overall estimates showed that BRAF V600E was associated with an improved overall survival (OS) in glioma patients (HR = 0.60; 95% CI = 0.44-0.80). Results for progression-free survival (PFS), however, were not statistically significant (HR = 1.39; 95% CI = 0.82-2.34). In subgroup analyses, BRAF V600E showed its effect in improving survival in pediatric and young adult gliomas (under 35 years) but did not have prognostic value in old adult. Additionally, BRAF V600E was only associated with a favorable prognosis in lower grade glioma. Our meta-analysis provides evidence that BRAF mutation has a favorable prognostic impact in gliomas and its prognostic value might be dependent on patient age and tumor grade. This mutation can be used as a prognostic factor in glioma but additional studies are required to clarify its prognostic value taking into account other confounding factors.
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http://dx.doi.org/10.1007/s12035-017-0599-yDOI Listing
May 2018

Progressive cutaneous Cryptococcosis complicated with meningitis in a myasthenia gravis patient on long-term immunosuppressive therapy - a case report.

BMC Infect Dis 2017 04 26;17(1):311. Epub 2017 Apr 26.

Department of Dermatology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.

Background: Cryptococcosis is an opportunistic infection caused by the encapsulated yeast Cryptococcus neoformans and most remarkably manifests in HIV-infected individuals, especially in the settings of very low CD4 count. Development of cryptococcosis in HIV-uninfected individuals is exceedingly rare and usually signifies a marked immunodeficiency. Cryptococcosis in association with myasthenia gravis or thymoma has been previously documented in only very few cases in the literature.

Case Presentation: We reported a complicated case of severe cutaneous cryptococcosis in a 39-year-old Vietnamese male patient with myasthenia gravis on long-term immunosuppressive therapy. The patient presented with a five month history of recurrent and progressive skin lesions that later on progressed into cryptococcal meningitis.

Conclusion: Through this case, we aimed to emphasize the importance of including cutaneous cryptococcosis in the differential diagnosis of cutaneous lesions in patients on chronic immunosuppressive therapy. The cutaneous manifestations of cryptococcosis can be the first clue for a disseminated disease, which makes early recognition crucial and life-saving.
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http://dx.doi.org/10.1186/s12879-017-2415-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5406963PMC
April 2017

A meta-analysis of prognostic roles of molecular markers in papillary thyroid carcinoma.

Endocr Connect 2017 Apr 20;6(3):R8-R17. Epub 2017 Feb 20.

Department of PathologyUniversity of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.

The prognostic role of molecular markers in papillary thyroid carcinoma (PTC) is a matter of ongoing debate. The aim of our study is to investigate the impact of , , promoter mutations and rearrangements on the prognosis of PTC patients. We performed a search in four electronic databases: PubMed, Scopus, Web of Science and Virtual Health Library (VHL). Data of hazard ratio (HR) and its 95% confidence interval (CI) for disease-specific survival (DSS) and disease-free survival (DFS) were directly obtained from original papers or indirectly estimated from Kaplan-Meier curve (KMC). Pooled HRs were calculated using random-effect model weighted by inverse variance method. Publication bias was assessed by using Egger's regression test and visual inspection of funnel plots. From 2630 studies, we finally included 35 studies with 17,732 patients for meta-analyses. promoter mutation was significantly associated with unfavorable DSS (HR = 7.64; 95% CI = 4.00-14.61) and DFS (HR = 2.98; 95% CI = 2.27-3.92). mutations significantly increased the risk for recurrence (HR = 1.63; 95% CI = 1.27-2.10) but not for cancer mortality (HR = 1.41; 95% CI = 0.90-2.23). In subgroup analyses, mutation only showed its prognostic value in short-/medium-term follow-up. Data regarding mutations and fusions were insufficient for meta-analyses. promoter mutation can be used as an independent and reliable marker for risk stratification and predicting patient's outcomes. The use of mutation to assess patient prognosis should be carefully considered.
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http://dx.doi.org/10.1530/EC-17-0010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5424840PMC
April 2017

Primary cerebral echinoccocosis in a child: Case report - Surgical technique, technical pitfalls, and video atlas.

Surg Neurol Int 2016 21;7(Suppl 37):S893-S898. Epub 2016 Nov 21.

Faculty of Medicine, University of Jordan, Jordan; Department of Neurosurgery, University of Jordan, Jordan.

Background: Hydatid disease is a life-threatening parasitic infestation caused by . Infection with typically results in the formation of hydatid cysts in the liver, lungs, kidney, and spleen. Primary intracranial hydatid cyst disease is extremely rare. Here, we are reporting an unusual case of , where the only identifiable lesion was a hydatid cyst in the brain without liver or lung involvement. We are also providing a description for the surgical technique used to remove the cyst, highlighting the possible surgical pitfalls.

Case Description: The patient is a 13-year-old male with a history of progressive headache for 1 month. Intracranial hydatid cyst was suspected based on computed tomography and magnetic resonance imaging findings. The cyst was delivered without rupture using hydrostatic dissection (Dowling's technique), and pathological analysis confirmed the diagnosis. Postoperatively, the patient showed marked neurological improvement and all signs and symptoms resolved.

Conclusion: Intracranial hydatid cyst is very rare. Nevertheless, it should always be considered as a differential diagnosis in cerebral cystic lesions, especially in children. The surgical technique used to remove the cyst appears to be safe. However, several precautions must be applied intraoperatively to avoid the catastrophe of cyst rupture.
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http://dx.doi.org/10.4103/2152-7806.194512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154201PMC
November 2016

The changing characteristics and molecular profiles of papillary thyroid carcinoma over time: a systematic review.

Oncotarget 2017 Feb;8(6):10637-10649

Department of Pathology, University of Yamanashi, Yamanashi, Japan.

Background: The genetic alterations of papillary thyroid carcinoma (PTC) have been reported to change over the past few decades. We performed this systematic review to further examine the trends and modifications of patient demographic, clinicopathological features and molecular profiles of PTC over time.

Methods: A literature search was performed within six electronic databases to identify relevant articles. The inclusion criteria were published studies investigating BRAF mutations, RET/PTC rearrangements or RAS mutations in PTCs or classical PTCs. Two teams of reviewers independently screened titles and abstracts of all articles. Full texts of potential articles were read and extracted data were listed and stratified into an excel file according to country, city, institution, and surgical time period. Student t test and Pearson Chi-square were used to analyze the trends of demographic and clinicopathological features of PTC patients and the prevalence of each genetic alteration in individual institutions.

Results: From 3139 articles, we included 16 articles for final analysis. Our results showed an increasing trend of BRAF and a decreasing trend of RET/PTC prevalence over time in PTCs and classical PTCs, accompanied by an older age of PTC patients, an increase in proportion of PTMC and less aggressive behaviours of tumours.

Conclusions: The demographic and clinicopathological characteristics and molecular profile of PTCs have been changing over the past few decades. These modifications suggest changes in etiologies and risk factors of thyroid cancer that influence the tumorigenesis of PTCs.
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http://dx.doi.org/10.18632/oncotarget.12885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5354688PMC
February 2017

Therapeutic efficacy and safety of Botulinum Toxin A Therapy in Trigeminal Neuralgia: a systematic review and meta-analysis of randomized controlled trials.

J Headache Pain 2016 Dec 5;17(1):63. Epub 2016 Jul 5.

Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN), Leading Graduate School Program, and Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan.

Background: Several different interventions have been examined to alleviate pain and reduce frequency of trigeminal neuralgia (TN) paroxysms. However, some patients continue to have persistent or recurrent painful attacks. Using a systematic review and meta-analysis approach, we aimed to synthesize evidence from published randomized controlled trials (RCTs) regarding safety and efficacy of botulinum toxin type A (BTX-A) as a possible emerging choice of treatment for TN.

Methods: We conducted an electronic search in 10 databases/electronic search engines to access relevant publications. All articles in all languages reporting RCTs on the efficacy and safety of BTX-A in the treatment of TN were included for systematic review and meta-analysis.

Results: A total of four RCTs (n = 178) were identified for final meta-analysis. The overall effect favored BTX-A versus placebo in terms of proportion of responders (risk ratio RR = 2.87, 95 % confidence interval CI [1.76, 4.69], p <0.0001) with no significant detected heterogeneity (p = 0.31; I(2) = 4 %). Paroxysms frequency per day was significantly lower for BTX-A group (mean difference MD = -29.79, 95 % CI [-38.50,-21.08], p <0.00001) with no significant heterogeneity (p = 0.21; I(2) = 36 %).

Conclusion: Despite limited data, our results suggest that BTX-A may be an effective and safe treatment option for patients with TN. Further larger and well-designed RCTs are encouraged to translate these findings into better clinical outcome and better quality of life for TN patients.
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http://dx.doi.org/10.1186/s10194-016-0651-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932020PMC
December 2016