Infectious complications following regional anesthesia: a narrative review and contemporary estimates of risk.

INTRODUCTION: Infectious complications following regional anesthesia (RA) while rare, can be devastating. The objective of this review was to estimate the risk of infectious complications following central neuraxial blocks (CNB) such as epidural anesthesia (EA), spinal anesthesia (SA) and combined spinal epidural (CSE), and peripheral nerve blocks (PNB). MATERIALS AND METHODS: A literature search was conducted in PubMed, Embase and Cochrane databases to identify reference studies reporting infectious complications in the context of RA subtypes. Both prospective and retrospective studies providing incidence of infectious complications were included for review to provide pooled estimates (with 95% CI). Additionally, we explored incidences specifically associated with spinal anesthesia, incidences of central nervous system (CNS) infections and, the incidences of overall and CNS infections following CNB in obstetric population. RESULTS: The pooled estimate of overall infectious complications following all CNB was 9/100 000 (95% CI: 5, 13/100 000). CNS infections following all CNB was estimated to be 2/100 000 (95% CI: 1, 3/100 000) and even rarer following SA (1/100 000 (95% CI: 1, 2/100 000)). Obstetric population had a lower rate of overall (1/100 000 (95% CI: 1, 3/100 000)) and CNS infections (4 per million (95% CI: 0.3, 1/100 000)) following all CNB. For PNB catheters, the reported rate of infectious complications was 1.8% (95% CI: 1.2, 2.5/100). DISCUSSION: Our review suggests that the risk of overall infectious complications following neuraxial anesthesia is very rare and the rate of CNS infections is even rarer. The infectious complications following PNB catheters seems significantly higher compared with CNB. Standardizing nomenclature and better reporting methodologies are needed for the better estimation of the infectious complications.

Publication Delay of Systematic Reviews in Dentistry: Findings, Implications, and Potential Solutions.

Clinicians, researchers, and policymakers often rely on the available scientific evidence to make strategic decisions. Systematic reviews (SRs) occupy an influential position in the hierarchy of scientific evidence. The findings of wellconducted SRs may provide valuable information to answer specific research questions1,2 and identify existing gaps for future research.3 Therefore, it is of supreme importance that SRs are published promptly, reducing as much as possible the time elapsed between the last date of the search for primary studies and the actual publication date. A study published in 2014 assessed the publication delay of SRs in orthodontics, revealing that the median time interval from the last search to publication was more than 1 year (13.2 months).4 Delays in the publication of SRs or original research articles may depend on author-related factors (eg, timing of resubmission after receiving feedback from reviewers) or journal-related factors (eg, time taken to process a submission).5-7 Regardless of the reasons, clinical recommendations and translation of SR findings may be affected by publication delay. We assessed the extent of publication delay of systematic reviews in dentistry with the purpose of addressing its implications and presenting potential solutions.

The Safety of Cold Versus Hot Snare Polypectomy in Polyps 10-20 mm: A Systematic Review and Meta-Analysis.

Colonoscopy remains the primary method for preventing colorectal cancer. Traditionally, hot snare polypectomy (HSP) was the method of choice for removing polyps larger than 5 mm. Yet, for polyps smaller than 10 mm, cold snare polypectomy (CSP) has become the favored approach. Lately, the use of CSP has expanded to include the removal of sessile polyps that are between 10 and 20 mm in size. Our systematic review and meta-analysis aimed to evaluate the safety of cold snare polypectomy (CSP) compared to hot snare polypectomy (HSP) for resecting polyps measuring 10-20 mm. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, and Cochrane databases up to April 2020 to find studies that directly compared CSP to HSP for polyps larger than 10 mm. Our main focus was on assessing the risk of delayed bleeding after polypectomy; a secondary focus was the incidence of any adverse events that required medical intervention post procedure. Our search yielded three comparative studies, two observational studies, and one randomized controlled trial (RCT), together encompassing 1,193 polypectomy procedures. Of these, 485 were performed using CSP and 708 with HSP. The pooled odds ratio (OR) for post-polypectomy bleeding (PPB) was 0.36 (95% confidence interval {CI}: 0.02, 7.13), with a Cochran Q test P-value of 0.11 and an I2 of 53%. For the risk of any adverse events necessitating medical care, the pooled OR was 0.15 (95% CI: 0.01, 2.29), with a Cochran Q test P-value of 0.21 and an I2 of 35%. The quality of the two observational studies was deemed moderate, and the RCT was only available in abstract form, preventing quality assessment. Our analysis suggests that there is no significant difference in the incidence of delayed post-polypectomy bleeding or other adverse events requiring medical attention between CSP and HSP for polyps measuring 10-20 mm.

Transcarotid Arterial Revascularization of Symptomatic Internal Carotid Artery Disease: A Systematic Review and Study-Level Meta-Analysis.

BACKGROUND: Transcarotid artery revascularization (TCAR) is an interventional therapy for symptomatic internal carotid artery disease. Currently, the utilization of TCAR is contentious due to limited evidence. In this study, we evaluate the safety and efficacy of TCAR in patients with symptomatic internal carotid artery disease compared with carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: A systematic review was conducted, spanning from January 2000 to February 2023, encompassing studies that used TCAR for the treatment of symptomatic internal carotid artery disease. The primary outcomes included a 30-day stroke or transient ischemic attack, myocardial infarction, and mortality. Secondary outcomes comprised cranial nerve injury and major bleeding. Pooled odds ratios (ORs) for each outcome were calculated to compare TCAR with CEA and CAS. Furthermore, subgroup analyses were performed based on age and degree of stenosis. In addition, a sensitivity analysis was conducted by excluding the vascular quality initiative registry population. RESULTS: A total of 7 studies involving 24 246 patients were analyzed. Within this patient cohort, 4771 individuals underwent TCAR, 12 350 underwent CEA, and 7125 patients underwent CAS. Compared with CAS, TCAR was associated with a similar rate of stroke or transient ischemic attack (OR, 0.77 [95% CI, 0.33-1.82]) and myocardial infarction (OR, 1.29 [95% CI, 0.83-2.01]) but lower mortality (OR, 0.42 [95% CI, 0.22-0.81]). Compared with CEA, TCAR was associated with a higher rate of stroke or transient ischemic attack (OR, 1.26 [95% CI, 1.03-1.54]) but similar rates of myocardial infarction (OR, 0.9 [95% CI, 0.64-1.38]) and mortality (OR, 1.35 [95% CI, 0.87-2.10]). CONCLUSIONS: Although CEA has traditionally been considered superior to stenting for symptomatic carotid stenosis, TCAR may have some advantages over CAS. Prospective randomized trials comparing the 3 modalities are needed.

Norepinephrine versus epinephrine for hemodynamic support in post-cardiac arrest shock: A systematic review.

PURPOSE: The preferred vasopressor in post-cardiac arrest shock has not been established with robust clinical outcomes data. Our goal was to perform a systematic review and meta-analysis comparing rates of in-hospital mortality, refractory shock, and hemodynamic parameters in post-cardiac arrest patients who received either norepinephrine or epinephrine as primary vasopressor support. METHODS: We conducted a search of PubMed, Cochrane Library, and CINAHL from 2000 to 2022. Included studies were prospective, retrospective, or published abstracts comparing norepinephrine and epinephrine in adults with post-cardiac arrest shock or with cardiogenic shock and extractable post-cardiac arrest data. The primary outcome of interest was in-hospital mortality. Other outcomes included incidence of arrhythmias or refractory shock. RESULTS: The database search returned 2646 studies. Two studies involving 853 participants were included in the systematic review. The proposed meta-analysis was deferred due to low yield. Crude incidence of in-hospital mortality was numerically higher in the epinephrine group compared with norepinephrine in both studies, but only statistically significant in one. Risk of bias was moderate to severe for in-hospital mortality. Additional outcomes were reported differently between studies, minimizing direct comparison. CONCLUSION: The vasopressor with the best mortality and hemodynamic outcomes in post-cardiac arrest shock remains unclear. Randomized studies are crucial to remedy this.

What influences dental students' attitudes regarding the treatment of older adults? A scoping review.

PURPOSE: The aim of this study is to investigate the literature to evaluate dental students' attitudes regarding the treatment of older adults. METHODS: A scoping review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses/PRISMA guidelines to identify articles from four electronic databases: MEDLINE via the PubMed interface, Embase, Cumulative Index to Nursing and Allied Health Literature, and AgeLine. Gray literature searches were also performed in Scopus, Web of Science, and ProQuest Dissertations and Theses-Health and Medicine. RESULTS: Eleven articles were assessed. The majority (72, 72%) were published between 2011 and 2020, evidencing various contexts of dental students, such as different countries and cultures, and levels of education. The most commonly used tool/instrument to survey dental students' attitudes was the Aging Semantic Differential Scale. Student age, race, and marital status did not seem to interfere with dental students' attitudes regarding the treatment of older adults. CONCLUSIONS: Dental students tend to have a positive attitude toward older people. In this context, female students, students who interact with older people, and clinical students have more positive attitudes than male and nonclinical students.

Tooth Agenesis Patterns in Orofacial Clefting Using Tooth Agenesis Code: A Meta-Analysis.

Individuals with orofacial clefting (OFC) have a higher prevalence of tooth agenesis (TA) overall. Neither the precise etiology of TA, nor whether TA occurs in patterns that differ by gender or cleft type is yet known. This meta-analysis aims to identify the spectrum of tooth agenesis patterns in subjects with non-syndromic OFC and controls using the Tooth Agenesis Code (TAC) program. An indexed search of databases (PubMed, EMBASE, and CINAHL) along with cross-referencing and hand searches were completed from May to June 2019 and re-run in February 2022. Additionally, unpublished TAC data from 914 individuals with OFC and 932 controls were included. TAC pattern frequencies per study were analyzed using a random effects meta-analysis model. A thorough review of 45 records retrieved resulted in 4 articles meeting eligibility criteria, comprising 2182 subjects with OFC and 3171 controls. No TA (0.0.0.0) was seen in 51% of OFC cases and 97% of controls. TAC patterns 0.2.0.0, 2.0.0.0, and 2.2.0.0 indicating uni- or bi-lateral missing upper laterals, and 16.0.0.0 indicating missing upper right second premolar, were more common in subjects with OFC. Subjects with OFC have unique TA patterns and defining these patterns will help increase our understanding of the complex etiology underlying TA.

Are Root-Supported Overdentures Still an Alternative to Implant-Supported Overdentures? A Scoping Review.

PURPOSE: To compare the outcomes of prosthodontic treatment for subjects wearing a complete maxillary denture opposing a root-supported mandibular overdenture (RSO) or an implant-supported mandibular overdenture (ISO). METHODS: A literature search was performed in seven electronic databases: MEDLINE via PubMed interface, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Scopus, Web of Science, and AgeLine. The search terms were developed by the primary investigators and the health sciences librarian, who then started with PubMed and adapted the original search strategy for the other databases. Included articles were those that compared the outcomes for mandibular RSOs and those with ISOs, for persons wearing a maxillary complete denture. RESULTS: Seven articles were included in the review. There were limitations in this review because of small sample sizes, short study durations, and different methodologies. Also, no comparative studies were identified for clinically important outcomes, such as survival rates of abutments, prosthodontics/maintenance problems, and longitudinal cost of care. For prosthodontic complications, patient satisfaction, and ability to clean, no differences were reported. For oral tactile sensibility, RSOs presented significantly improved sensibility, whereas ISOs had higher maximum bite force capability, but the difference was not statistically significant, except when subjects had a cross-bite or a lingualized occlusion. CONCLUSIONS: The results of this scoping review were not conclusive, except for maximum bite force, where ISOs seem to perform better than RSOs by the measured criteria. ISOs had higher survival rates than RSOs, and required less maintenance, but were more expensive. It was disappointing to find so few studies comparing these clinical treatment modalities, which suggests that either treatment may be clinically acceptable and depends upon a shared decision between patients and their dentists.

Delivery and financing of oral health care in long-term services and supports: A scoping review.

BACKGROUND: The oral health of older adults requiring long-term services and supports is reported to be poor as there is no national standard of care for the provision of oral health care. The purpose of this scoping review was to understand the breadth of models of delivery and financing of oral health care in the full spectrum of long-term services and supports. TYPES OF STUDIES REVIEWED: A literature search was performed in 4 electronic databases: MEDLINE via PubMed interface, Embase, Cumulative Index to Nursing and Allied Health Literature, and AgeLine. Included articles were those that were regarding a nursing home population or dependent older adults living in the community, included a delivery or financing model for oral health care, and included an outcome measurement. RESULTS: Sixteen articles were included in the review. Delivery mechanisms included onsite mobile oral health care at nursing homes and adult day health care centers for those living in the community or home visits for those who were homebound. Other mechanisms included teledentistry or using alternative workforce models such as certified public health dental hygienists. Numerous studies reported positive oral health outcomes when comprehensive care was provided in a variety of settings. Other reported outcomes included oral health stability, caries indexes, cost, and oral health-related quality of life. CONCLUSIONS AND PRACTICAL IMPLICATIONS: If providing onsite oral health care is not possible at facilities, programs can consider home visits, teledentistry, and alternative workforce models.

Hierarchical Machine Learning for High-Fidelity 3D Printed Biopolymers.

A hierarchical machine learning (HML) framework is presented that uses a small dataset to learn and predict the dominant build parameters necessary to print high-fidelity 3D features of alginate hydrogels. We examine the 3D printing of soft hydrogel forms printed with the freeform reversible embedding of suspended hydrogel method based on a CAD file that isolated the single-strand diameter and shape fidelity of printed alginate. Combinations of system variables ranging from print speed, flow rate, ink concentration to nozzle diameter were systematically varied to generate a small dataset of 48 prints. Prints were imaged and scored according to their dimensional similarity to the CAD file, and high print fidelity was defined as prints with less than 10% error from the CAD file. As a part of the HML framework, statistical inference was performed, using the least absolute shrinkage and selection operator to find the dominant variables that drive the error in the final prints. Model fit between the system parameters and print score was elucidated and improved by a parameterized middle layer of variable relationships which showed good performance between the predicted and observed data (R2 = 0.643). Optimization allowed for the prediction of build parameters that gave rise to high-fidelity prints of the measured features. A trade-off was identified when optimizing for the fidelity of different features printed within the same construct, showing the need for complex predictive design tools. A combination of known and discovered relationships was used to generate process maps for the 3D bioprinting designer that show error minimums based on the chosen input variables. Our approach offers a promising pathway toward scaling 3D bioprinting by optimizing print fidelity via learned build parameters that reduce the need for iterative testing.

Elucidating the Physicochemical Basis of the Glass Transition Temperature in Linear Polyurethane Elastomers with Machine Learning.

The glass transition temperature (Tg) is a fundamental property of polymers that strongly influences both mechanical and flow characteristics of the material. In many important polymers, configurational entropy of side chains is a dominant factor determining it. In contrast, the thermal transition in polyurethanes is thought to be determined by a combination of steric and electronic factors from the dispersed hard segments within the soft segment medium. Here, we present a machine learning model for the Tg in linear polyurethanes and aim to uncover the underlying physicochemical parameters that determine this. The model was trained on literature data from 43 industrially relevant combinations of polyols and isocyanates using descriptors derived from quantum chemistry, cheminformatics, and solution thermodynamics forming the feature space. Random forest and regularized regression were then compared to build a sparse linear model from six descriptors. Consistent with empirical understanding of polyurethane chemistry, this study indicates the characteristics of isocyanate monomers strongly determine the increase in Tg. Accurate predictions of Tg from the model are demonstrated, and the significance of the features is discussed. The results suggest that the tools of machine learning can provide both physical insights as well as accurate predictions of complex material properties.

Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness of chlorhexidine (CHG) dressings to prevent catheter-related bloodstream infections (CRBSIs). DESIGN: Systematic review and meta-analysis. METHODS: We searched PubMed, CINAHL, EMBASE, and ClinicalTrials.gov for studies (randomized controlled and quasi-experimental trials) with the following criteria: patients with short- or long-term catheters; CHG dressings were used in the intervention group and nonantimicrobial dressings in the control group; CRBSI was an outcome. Random-effects models were used to obtain pooled risk ratios (pRRs). Heterogeneity was evaluated using the I2 test and the Cochran Q statistic. RESULTS: In total, 20 studies (18 randomized controlled trials; 15,590 catheters) without evidence of publication bias and mainly performed in intensive care units (ICUs) were included. CHG dressings significantly reduced CRBSIs (pRR, 0.71; 95% CI, 0.58-0.87), independent of the CHG dressing type used. Benefits were limited to adults with short-term central venous catheters (CVCs), including onco-hematological patients. For long-term CVCs, CHG dressings decreased exit-site/tunnel infections (pRR, 0.37; 95% CI, 0.22-0.64). Contact dermatitis was associated with CHG dressing use (pRR, 5.16; 95% CI, 2.09-12.70); especially in neonates and pediatric populations in whom severe reactions occurred. Also, 2 studies evaluated and did not find CHG-acquired resistance. CONCLUSIONS: CHG dressings prevent CRBSIs in adults with short-term CVCs, including patients with an onco-hematological disease. CHG dressings might reduce exit-site and tunnel infections in long-term CVCs. In neonates and pediatric populations, proof of CHG dressing effectiveness is lacking and there is an increased risk of serious adverse events. Future studies should investigate CHG effectiveness in non-ICU settings and monitor for CHG resistance.

Spin in abstracts of randomized controlled trials in dentistry: A cross-sectional analysis.

BACKGROUND: Spin in randomized controlled trial (RCT) abstracts can misguide clinicians. In this cross-sectional analysis, the authors assessed the prevalence of spin in RCT abstracts and explored the factors potentially influencing it. METHODS: In this cross-sectional analysis, the authors conducted a systematic search in top 10 dental journals based on Eigenfactor score and selected RCTs published in 2015 with statistically nonsignificant primary outcomes. The dentistry disciplines covered in these journals include general dentistry, dental research, oral implantology, endodontics, oral surgery, periodontology, and oral oncology. In these RCT abstracts, the authors assessed the prevalence of 3 different categories of spin and factors that could influence its presence using the t test and χ2 test. RESULTS: Spin assessment performed in the included 75 RCTs revealed the existence of spin in 23 abstracts (30.7%). Associations between the presence of spin in abstracts and the variables international collaborations, commercial support type, number of treatment arms, and journal impact factor were found to be statistically nonsignificant (P ≥ .05). CONCLUSIONS: Approximately one-third of the 75 RCT abstracts published in high-impact dental journals in 2015 with nonsignificant outcomes presented with some form of spin, irrespective of funding type and journal impact factor. PRACTICAL IMPLICATIONS: Clinicians should be aware of the potential existence of spin in abstracts and be diligent in reading and appraising the full trial before incorporating its recommendations in clinical practice.

Bilateral vs unilateral placement of metal stents for inoperable high-grade hilar biliary strictures: A systemic review and meta-analysis.

BACKGROUND: Bilateral vs unilateral biliary stenting is used for palliation in malignant biliary obstruction. No clear data is available to compare the efficacy and safety of bilateral biliary stenting over unilateral stenting. AIM: To assess the efficacy and safety of bilateral vs unilateral biliary drainage in inoperable malignant hilar obstruction. METHODS: PubMed, Embase, Scopus, and Cochrane databases, as well as secondary sources (bibliographic review of selected articles and major GI proceedings), were searched through January 2019. The primary outcome was the re-intervention rate. Secondary outcomes were a technical success, early and late complications, and stent malfunction rate. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated for each outcome. RESULTS: A total of 9 studies were included (2 prospective Randomized Controlled Study, 5 retrospective studies, and 2 abstracts), involving 782 patients with malignant hilar obstruction. Bilateral stenting had significantly lower re-intervention rate compared with unilateral drainage (OR = 0.59, 95%CI: 0.40-0.87, P = 0.009). There was no difference in the technical success rate (OR = 0.7, CI: 0.42-1.17, P = 0.17), early complication rate (OR = 1.56, CI: 0.31-7.75, P = 0.59), late complication rate (OR = 0.91, CI: 0.58-1.41, P = 0.56) and stent malfunction (OR = 0.69, CI: 0.42-1.12, P = 0.14) between bilateral and unilateral stenting for malignant hilar biliary strictures. CONCLUSION: Bilateral biliary drainage had a lower re-intervention rate as compared to unilateral drainage for high grade inoperable malignant biliary strictures, with no significant difference in technical success, and early or late complication rates.

Nontherapeutic celiotomy incidence is not affected by volume of pancreaticoduodenectomy for pancreatic adenocarcinoma.

Nontherapeutic celiotomy for pancreatic adenocarcinoma is detrimental to patients by delaying medical treatment as a result of unnecessarily incurred postoperative recovery time. This study was undertaken to evaluate whether surgeon volume of pancreaticoduodenectomy for pancreatic adenocarcinoma impacted the incidence of nontherapeutic celiotomy. All patients undergoing an intended pancreaticoduodenectomy for pancreatic adenocarcinoma were evaluated from 2003 to 2012. Survival was calculated using Kaplan-Meier analysis. The association between surgeon volume of pancreaticoduodenectomy and occurrence of nontherapeutic celiotomy was assessed using Fisher's exact test. Median data are presented. Eight surgeons undertook 443 intended pancreaticoduodenectomies for patients with pancreatic adenocarcinoma; 329 (74%) patients underwent pancreaticoduodenectomy, whereas 114 (26%) patients underwent nontherapeutic celiotomies. Two surgeons undertook 85 per cent of operations. Surgeon volume did not impact the incidence of nontherapeutic celiotomies (P = 0.26). Seventy-seven (68%) patients had metastatic disease at the time of the operation, whereas 37 (32%) patients had locally advanced unresectable disease. These patients had survivals of 5.0 and 6.0 months, respectively (P = 0.77). A high proportion of patients--one in four--undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma will ultimately undergo a nontherapeutic celiotomy. Surgeon volume of pancreaticoduodenectomy for pancreatic adenocarcinoma does not lessen the incidence of nontherapeutic celiotomies. Preoperative prediction of patients with imaging-occult metastatic or locally advanced disease remains a challenge, even for high-volume surgeons. Attempts to create algorithms for patients with high risk of imaging-occult metastatic or locally advanced disease to undergo staging laparoscopy and/or positron emission tomography scanning may decrease the burden of patients undergoing nontherapeutic celiotomies.