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Predictors of Short-Term Outcomes after Syncope: A Systematic Review and Meta-Analysis.

ABSTRACT: We performed a systematic review and meta-analysis to identify predictors of serious clinical outcomes after an acute-care evaluation for syncope.We identified studies that assessed for predictors of short-term (?30 days) serious clinical events after an emergency department (ED) visit for syncope. We performed a MEDLINE search (January 1, 1990 - July 1, 2017) and reviewed reference lists of retrieved articles. The primary outcome was the occurrence of a serious clinical event (composite of mortality, arrhythmia, ischemic or structural heart disease, major bleed, or neurovascular event) within 30 days. We estimated the sensitivity, specificity, and likelihood ratio of findings for the primary outcome. We created summary estimates of association on a variable-by-variable basis using a Bayesian random-effects model.We reviewed 2,773 unique articles; 17 met inclusion criteria. The clinical findings most predictive of a short-term, serious event were the following: 1) An elevated blood urea nitrogen level (positive likelihood ratio [LR+]: 2.86, 95% confidence interval [CI] [1.15, 5.42]); 2); history of congestive heart failure (LR+: 2.65, 95%CI [1.69, 3.91]); 3) initial low blood pressure in the ED (LR+: 2.62, 95%CI [1.12, 4.9]); 4) history of arrhythmia (LR+: 2.32, 95%CI [1.31, 3.62]); and 5) an abnormal troponin value (LR+: 2.49, 95%CI [1.36, 4.1]). Younger age was associated with lower risk (LR-: 0.44, 95%CI [0.25, 0.68]). An abnormal electrocardiogram was mildly predictive of increased risk (LR+ 1.79, 95%CI [1.14, 2.63]).We identified specific risk factors that may aid clinical judgment and that should be considered in the development of future risk-prediction tools for serious clinical events after an ED visit for syncope.

SUBMITTER: Gibson TA

PROVIDER: S-EPMC5942019 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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Predictors of Short-Term Outcomes after Syncope: A Systematic Review and Meta-Analysis.

Gibson Thomas A TA Weiss Robert E RE Sun Benjamin C BC

The western journal of emergency medicine 20180313 3

<h4>Introduction</h4>We performed a systematic review and meta-analysis to identify predictors of serious clinical outcomes after an acute-care evaluation for syncope.<h4>Methods</h4>We identified studies that assessed for predictors of short-term (≤30 days) serious clinical events after an emergency department (ED) visit for syncope. We performed a MEDLINE search (January 1, 1990 - July 1, 2017) and reviewed reference lists of retrieved articles. The primary outcome was the occurrence of a seri ...[more]

PMID: 29760850

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Project description:Introduction: The TaTME surgery has been developed to overcome the difficulties encountered in the practice of laparoscopic surgery for rectal cancer, especially in male, obese patients with a narrow pelvis and mid and low rectal tumours. Although the TaTME shows some promising results regarding oncological and operative outcomes, some pitfalls have been indicated. Thus, the real benefits of this novel technique over the laparoscopic surgery remain unknown. The aim of the present study was to perform a systematic review and meta-analysis of the currently available literature on the outcomes of TaTME in comparison with laparoscopic procedure. Methods: A systematic literature search was conducted using the web-based databases MEDLINE, EMBASE, and Cochrane CENTRAL, followed by a manual search of the references of the initially identified articles. The study information, patient characteristics, oncological outcomes, perioperative outcomes, as well as short- and long-term postoperative outcomes were collected and critically evaluated. Results: Nine retrospective cohort studies were identified, comprising 751 patients (348 with TaTME, 403 with LaTME). The positive circumferential resection margin (P = 0.01) was better in patients treated with TaTME; whereas the quality of mesorectum, circumferential resection margin, distal resection margin, and harvested lymph nodes were comparable. The TaTME was associated with shorter operative time (P = 0.05; P = 0.0006 in subgroup analysis), less blood loss (P = 0.02), less conversion (P = 0.007), and shorter hospital stay (P = 0.06; P = 0.003 in subgroup analysis). The intraoperative complications were similar. As for the postoperative outcomes, the overall postoperative complications (P = 0.02) and the readmission (P = 0.003) were found less in patients treated with TaTME; however, the individual postoperative complications were found comparable. Conclusion: The present systematic review and meta-analysis suggested some advantages of TaTME, in terms of circumferential resection margin involvement, operative time, blood loss, conversion, hospital stay, overall postoperative complications, and readmission. It appears that the TaTME procedure achieved a better resection quality and smoother recovery in selected patients, without compromising the short-term safety. Nevertheless, it is too early to draw any conclusion, since results of high quality clinical evidence from randomized controlled trials have to be awaited. As it is technically demanding, the procedure needs to be taught and learned systematically to ensure safe implementation.

Project description:To summarize data on long-term ipsilateral local recurrence (LR) and breast cancer death rate (BCDR) for patients with ductal carcinoma in situ (DCIS) who received different treatments.Systematic review and study-level meta-analysis of prospective (n?=?5) and retrospective (n?=?21) studies of patients with pure DCIS and with median or mean follow-up time of ?10 years. Meta-regression was performed to assess and adjust for effects of potential confounders - the average age of women, period of initial treatment, and of bias - follow-up duration on recurrence- and death-rates in each treatment group. LR and BCDR rates by local treatment used were reported. Outside of randomized trials, remaining studies were likely to have tailored patient treatment according to the clinical situation.Nine thousand four hundred and four DCIS cases in 9391 patients with 10-year follow-up were included. The adjusted meta-regression LR rate for mastectomy was 2.6 % (95 % CI, 0.8-4.5); breast-conserving surgery with radiotherapy (RT), 13.6 % (95 % CI, 9.8-17.4); breast-conserving surgery without RT, 25.5 % (95 % CI, 18.1-32.9); and biopsy-only (residual predominately low-grade DCIS following inadequate excision), 27.8 % (95 % CI, 8.4-47.1). RT?+?tamoxifen (TAM) in conservation surgery (CS) patients resulted in lower LR compared to one or no adjuvant treatments: LR rate for CS?+?RT?+?TAM, 9.7 %; CS?+?RT(no TAM), 14.1 %; CS?+?TAM(no RT), 24.7 %; CS(alone), 25.1 % (linear trend for treatment P?<?0.0001). Compared to CS?+?RT?+?TAM, a significantly higher invasive LR was observed for CS(alone), odds ratio (OR) 2.61 (P?<?0.0001); CS?+?TAM(no RT), OR 2.52 (P?=?0.001); CS?+?RT(no TAM), OR 1.59 (P?=?0.022). BCDR was similar for mastectomy, breast-conserving surgery with or without RT (1.3-2.0 %) and non-significantly higher for biopsy-only (2.7 %). Additionally, the 15-year follow-up was reported where all like-studies had???15-year data sets; the biopsy-only patients had a meta-analysed total LR rate of 40.2 % and the invasive LR rate was 28.1 %. The biopsy-only patients had a???15-year BCDR (that included women with metastatic disease) of 17.9 %; the???15-year BCDR was 55.2 % for those with invasive LR.More local intervention was associated with greater local control for patients with DCIS at long-term follow-up. For patients undergoing breast-conservation, invasive LR was significantly lower when two rather than one adjuvant treatment modalities were given.

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Predictors of Short-Term Outcomes after Syncope: A Systematic Review and Meta-Analysis.

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Predictors of Short-Term Outcomes after Syncope: A Systematic Review and Meta-Analysis.

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