Therapies for cutaneous squamous cell carcinoma in recessive dystrophic epidermolysis bullosa: a systematic review of 157 cases.

BACKGROUND: Invasive cutaneous squamous cell carcinomas (cSCC) are a leading cause of death in recessive dystrophic epidermolysis bullosa (RDEB), a rare blistering genodermatosis. Outcomes of RDEB-cSCC therapies have primarily been described in case reports. Systematic studies are scarce. This systematic review aims to assess the pathophysiology, clinical characteristics, and outcomes of RDEB-cSCCs, with a focus on results and mechanisms of recent immunotherapies and anti-EGFR treatments. RESULTS: A systematic literature search of epidermolysis bullosa and cSCC was performed in February 2024, using PubMed, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and EudraCT databases. Cases with administration of systematic therapies and unpublished outcomes regarding death were tracked with corresponding authors. Data extraction and risk of bias assessment was performed by two independent reviewers. Of 1132 references in the original search, 163 relevant articles were identified, representing 59 case reports, 7 cohort studies, 49 abstracts, 47 in-vitro/in-vivo experiments, and 1 bioinformatic study. From these, 157 cases of RDEB-cSCCs were included. The majority of RDEB-cSCCs were well-differentiated (64.1%), ulcerated (59.6%), and at least 2 cm in size (77.6%), with a median age at diagnosis of 30 years old (range 6-68.4). Surgery was the primary form of treatment (n = 128), followed by chemotherapy and radiotherapy. Anti-EGFR therapy and immunotherapy was also reported beginning in 2009 and 2019, respectively. Survival time from first cSCC diagnosis to death was available in 50 cases. When stratified by their treatment regimen, median survival time was 1.85 years (surgery + chemotherapy, n = 6), 2 years (surgery only, n = 19), 4.0 years (+ anti-EFGR therapy, n = 10), 4 years (surgery + radiotherapy, n = 9), 4.6 years (+ immunotherapy, n = 4), and 9.5 years (surgery + chemotherapy + radiotherapy; n = 2). Treatment-related adverse events were primarily limited to impaired wound healing for immunotherapies and nausea and fatigue for anti-EGFR therapies. CONCLUSIONS: Despite the challenges of a limited sample size in a rare disease, this systematic review provides an overview of treatment options for cSCCs in RDEB. When surgical treatment options have been exhausted, the addition of immunotherapy and/or anti-EGFR therapies may extend patient survival. However, it is difficult to attribute extended survival to any single treatment, as multiple therapeutic modalities are often used to treat RDEB-cSCCs.

Osteoporosis and bone health in pediatric patients with epidermolysis bullosa: A scoping review.

Nutritional compromise, low levels of vitamin D, chronic inflammation, abnormal growth, and physical inactivity affect bone metabolism and compromise long-term bone health in individuals with epidermolysis bullosa (EB). The result is a high risk for osteopenia, osteoporosis, and pathologic fractures, but this important consequence of EB has been the focus of few investigations. Our scoping review found 21 publications that assessed the current understanding and clinical practices for monitoring of osteoporosis and its treatment in EB. Recommendations summarized from 13 of these publications include early nutritional and weight assessments before 2 years of age; bloodwork every 6-12 months starting at birth; Tanner stage assessments every 6 months to detect any pubertal delay; DEXA scans starting at age 6 years with repeated scans every 1-2 years, except in mild cases; and vitamin D supplementation of 80-320 IU daily for children 0-7 years and 720 IU for patients >8 years.

Social isolation and social connectedness among young adult cancer survivors: A systematic review.

BACKGROUND: Social isolation and connectedness are social determinants of health that have demonstrated effects on cancer-related outcomes. These constructs have been systematically evaluated among pediatric and older adult cancer populations. In this review, the authors evaluated the prevalence, correlates, and psychosocial implications of social isolation and connectedness among young adult (YA) cancer survivors aged 18-39 years. METHODS: Peer-reviewed articles published in English before June 2021 were identified from database searches and included articles' reference lists according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included articles described studies that assessed social isolation and/or connectedness among YA cancer survivors. RESULTS: In total, 5094 unique records were identified; 4143 were excluded after title/abstract screening, and 907 were excluded after full-text review. Forty-four articles were included. Few studies used validated measures or directly assessed social isolation or connectedness. Social isolation was similarly prevalent among YAs and older cancer survivors and noncancer populations. Demographic, clinical, and behavioral risk and protective factors for social isolation were identified. Social isolation was related to worse psychological well-being, whereas social connectedness was often, but not always, related to better psychological well-being. CONCLUSIONS: This growing literature underscores the relevance of social isolation and connectedness as important health determinants among YA cancer survivors. The identified risk and protective factors can identify YAs who especially may benefit from screening for social isolation. Future studies are needed that directly, reliably, and validly evaluate social isolation and connectedness to inform the development of interventions to decrease isolation and increase connectedness.

Keloid treatments: an evidence-based systematic review of recent advances.

BACKGROUND: Keloids are pathologic scars that pose a significant functional and cosmetic burden. They are challenging to treat, despite the multitude of treatment modalities currently available. OBJECTIVE: The aim of this study was to conduct an evidence-based review of all prospective data regarding keloid treatments published between 2010 and 2020. METHODS: A systematic literature search of PubMed (National Library of Medicine), Embase (Elsevier), and Cochrane Library (Wiley) was performed in November of 2020. Search strategies with the keywords "keloid" and "treatment" were performed by a medical librarian. The search was limited to prospective studies that were peer-reviewed, reported on clinical outcomes of keloid therapies, and were published in the English language between January 1, 2010, and November 24, 2020. RESULTS: A total of 3462 unique citations were identified, of which 108 studies met inclusion criteria. Current literature supports silicone gel or sheeting with corticosteroid injections as first-line therapy for keloids. Adjuvant intralesional 5-fluorouracil (5-FU), bleomycin, or verapamil can be considered, although mixed results have been reported with each. Laser therapy can be used in combination with intralesional corticosteroids or topical steroids with occlusion to improve drug penetration. Excision of keloids with immediate post-excision radiation therapy is an effective option for recalcitrant lesions. Finally, silicone sheeting and pressure therapy have evidence for reducing keloid recurrence. CONCLUSIONS: This review was limited by heterogeneity of subject characteristics and study outcome measures, small sample sizes, and inconsistent study designs. Larger and more robust controlled studies are necessary to further understand the variety of existing and emerging keloid treatments, including corticosteroids, cryotherapy, intralesional injections, lasers, photodynamic therapy, excision and radiation, pressure dressings, and others.

Designing a Checklist for Directly Observing Use of One-Minute Preceptor Steps on Inpatient Rounds: A Pilot Study.

BACKGROUND: "One-minute preceptor" (OMP) is a well-established educational technique; however, primary literature on OMP lacks a tool to assess behavioral change after delivery of curricula.Primary aim of this pilot study was to design a checklist for direct observation of teachers using OMP on general medicine rounds and obtain inter-rater reliability evidence for the checklist. METHODS: This study pilots an internally designed 6-item checklist to assess change in directly observed behavior. We describe the process of developing the checklist and training the observers. We calculated a percent agreement and Cohen's kappa to assess inter-rater reliability. RESULTS: Raters had a high percent agreement ranging from 0.8 to 0.9 for each step of OMP. Cohen's kappa ranged from 0.49 to 0.77 for the five OMP steps. The highest kappa obtained was for getting a commitment (κ = 0.77) step, whereas the lowest agreement was for correcting mistakes (κ = 0.49). CONCLUSION: We showed a percent agreement ≥0.8 and moderate agreement based on Cohen's kappa with most steps of OMP on our checklist. A reliable OMP checklist is an important step in further improving the assessment and feedback of resident teaching skills on general medicine wards.

Behavioral Therapy for Tremor or Dystonia Affecting Voice in Speakers with Hyperkinetic Dysarthria: A Systematic Review.

INTRODUCTION: Hyperkinetic dysarthria is characterized by atypical involuntary movements within the speech mechanism that may affect the respiratory, laryngeal, pharyngeal-oral, or velopharyngeal-nasal subsystems and may alter speech production. Although articulatory impairments are commonly considered in hyperkinetic dysarthria, speakers with hyperkinetic dysarthria may also present with changes in voice quality, pitch, and loudness. In approximately 70% of speakers with hyperkinetic dysarthria, these voice alterations are associated with tremor or dystonia. The purpose of this systematic review was to investigate the association between behavioral therapy for tremor or dystonia affecting voice in speakers with hyperkinetic dysarthria and improvement in the functional, perceptual, acoustical, aerodynamic, or endoscopic characteristics of voice. METHOD: MEDLINE (PubMed), Embase, PsycINFO, and ClinicalTrials.gov online databases were searched in August 2017, December 2018, and April 2020 for relevant studies. The searches provided 4,921 unique records, and six additional unique records were added from other sources. Twelve studies met the criteria for inclusion in the systematic review. Participants who received concurrent medical treatment were included in this review to ensure that the search was inclusive of all relevant studies and informative for typical clinical scenarios. RESULTS: The most commonly administered treatment ingredient was relaxation training, which was investigated in three of the four studies on tremor and three of the eight studies on dystonia. Of these six studies, only one used an experimental design and administered relaxation training as the only behavioral approach. This single-case experiment reported a significant reduction in participant ratings of tremor severity and interference with activities of daily living, although the speaking subscale reportedly did not improve and oral medications were administered concurrently. In two group studies that tested potential behavioral therapy targets, production of a low pitch improved acoustical measures for participants with essential tremor and improved auditory-perceptual judgments for participants with laryngeal dystonia. Behavioral therapy improved functional, acoustical, and aerodynamic outcomes in participants with laryngeal dystonia who were also receiving botulinum toxin injections in a randomized cross-over study and a non-randomized controlled study. Because one study employed easy onset and breathing exercises, while the other employed loud voice exercises, the mechanism of action for improvement in voice associated with behavioral therapy requires further investigation. CONCLUSION: This systematic review describes the current evidence for treatment of tremor and dystonia affecting voice in speakers with hyperkinetic dysarthria and highlights the need for future research on behavioral therapy for these disorders.

Uses of the NIH Toolbox® in Clinical Samples: A Scoping Review.

Background and Objectives: The NIH Toolbox® for the Assessment of Neurologic and Behavioral Function is a compilation of computerized measures designed to assess sensory, motor, emotional, and cognitive functioning of individuals across the life span. The NIH Toolbox was initially developed for use with the general population and was not originally validated in clinical populations. The objective of this scoping review was to assess the extent to which the NIH Toolbox has been used with clinical populations. Methods: Guided by the Joanna Briggs Methods Manual for Scoping Reviews, records were identified through searches of PubMed MEDLINE, PsycINFO, ClinicalTrials.gov, EMBASE, and ProQuest Dissertations and Theses Global (2008-2020). Database searches yielded 5,693 unique titles of original research that used at least one NIH Toolbox assessment in a sample characterized by any clinical diagnosis. Two reviewers screened titles, abstracts, and full texts for inclusion in duplicate. Conflicts at each stage of the review process were resolved by a group discussion. Results: Ultimately, 281 publication records were included in this scoping review (nJournal Articles = 104, nConference Abstracts = 84, nClinical Trial Registrations = 86, and nTheses/Dissertations = 7). The NIH Toolbox Cognition Battery was by far the most used of the 4 batteries in the measurement system (nCognition = 225, nEmotion = 49, nMotor = 29, and nSensation = 16). The most represented clinical category was neurologic disorders (n = 111), followed by psychological disorders (n = 39) and cancer (n = 31). Most (96.8%) of the journal articles and conference abstracts reporting the use of NIH Toolbox measures with clinical samples were published in 2015 or later. As of May 2021, these records had been cited a total of nearly 1,000 times. Discussion: The NIH Toolbox measures have been widely used among individuals with various clinical conditions across the life span. Our results lay the groundwork to support the feasibility and utility of administering the NIH Toolbox measures in research conducted with clinical populations and further suggest that these measures may be of value for implementation in fast-paced clinical settings as part of routine practice.

Evidence-Based Clinical Practice Guidelines for Laser-Assisted Drug Delivery.

Importance: Laser-assisted drug delivery (LADD) is used for various medical and cosmetic applications. However, there is insufficient evidence-based guidance to assist clinicians performing LADD. Objective: To develop recommendations for the safe and effective use of LADD. Evidence Review: A systematic literature review of Cochrane Central Register of Controlled Trials, Embase, and MEDLINE was conducted in December 2019 to identify publications reporting research on LADD. A multidisciplinary panel was convened to draft recommendations informed by the systematic review; they were refined through 2 rounds of Delphi survey, 2 consensus meetings, and iterative review by all panelists until unanimous consensus was achieved. Findings: Of the 48 published studies of ablative fractional LADD that met inclusion criteria, 4 were cosmetic studies; 21, oncologic; and 23, medical (not cosmetic/oncologic), and 6 publications of nonablative fractional LADD were included at the request of the expert panel, producing a total of 54 studies. Thirty-four studies (63.0%) were deemed to have low risk of bias, 17 studies (31.5%) had moderate risk, and 3 (5.5%) had serious risk. The key findings that informed the guidelines developed by the expert panel were as follows: LADD is safe in adults and adolescents (≥12 years) with all Fitzpatrick skin types and in patients with immunosuppression; it is an effective treatment for actinic keratosis, cutaneous squamous cell carcinoma in situ, actinic cheilitis, hypertrophic scars, and keloids; it is useful for epidermal and dermal analgesia; drug delivery may be increased through the application of heat, pressure, or occlusion, or by using an aqueous drug solution; laser settings should be selected to ensure that channel diameter is greater than the delivered molecule; antibiotic prophylaxis is not recommended, except with impaired wound healing; antiviral prophylaxis is recommended when treating the face and genitalia; and antifungal prophylaxis is not recommended. The guideline's 15 recommendations address 5 areas of LADD use: (I) indications and contraindications; (II) parameters to report; (III) optimization of drug delivery; (IV) safety considerations; and (V) prophylaxis for bacterial, viral, and fungal infections. Conclusions and Relevance: This systematic review and Delphi consensus approach culminated in an evidence-based clinical practice guideline for safe and effective use of LADD in a variety of applications. Future research will further improve our understanding of this novel treatment technique.

Surgical excision margins for fibrohistiocytic tumors, including atypical fibroxanthoma and undifferentiated pleomorphic sarcoma: A probability model based on a systematic review.

BACKGROUND: Mohs micrographic surgery or wide local excision is the treatment of choice for fibrohistiocytic tumors with metastatic potential, including atypical fibroxanthoma (AFX) and cutaneous undifferentiated pleomorphic sarcoma (cUPS). Since margin clearance is the strongest predictor of clinical recurrence, improved recommendations for appropriate surgical margins help delineate uniform excision margins when intraoperative margin assessment is not available. OBJECTIVE: To determine appropriate surgical wide local excision margins for AFX and cUPS. METHODS: Literature search (Ovid MEDLINE, Embase, Web of Science, and Cochrane Library from inception to March 2020) to detect case-level data. Estimation of margins required using a mathematical model based on extracted cases without recurrences. RESULTS: Probabilistic modeling based on 100 cases extracted from 37 studies showed peripheral clearance margin (ie, wide local excision margin) calculated to clear 95% of all tumors was 2 cm for AFX and 3 cm for cUPS. AFX tumors 1 cm or less required a margin of 1 cm. LIMITATIONS: Data were extracted from published cases. CONCLUSIONS: Atypical fibroxanthoma removed with at least a 2-cm peripheral excision margin is less likely to recur. Smaller tumors 1 cm or less can be treated with a more conservative margin. Margin-control surgical techniques are recommended to ensure complete removal while minimizing surgical morbidity.

The safety and efficacy of autologous adipose-derived stromal vascular fraction for nonscarring alopecia: A systematic review.

IMPORTANCE: Nonscarring alopecia, including androgenetic alopecia and alopecia areata, are common and can negatively impact quality of life. Recent clinical studies have investigated autologous, adipose-derived stromal vascular fraction (SVF) as a potentially beneficial treatment option. OBJECTIVE: To assess the available evidence on the utility and safety of SVF for nonscarring alopecia. EVIDENCE REVIEW: A systematic review of the literature was performed using MEDLINE (PubMed), Embase, and CENTRAL from inception to November 2020. Included articles were prospective, observational or interventional studies of SVF for nonscarring alopecia in humans. FINDINGS: Six studies of 188 patients were identified, including three randomized controlled trials. There were no reported severe adverse events. All studies found improved hair density with SVF compared to control or pre-treatment baseline. One study reported that improvement in hair density varied based on time for follow-up, severity of hair loss, and concentration of adipose-derived stem cells (ADSCs) within the SVF. Two studies reported an increase in hair diameter from baseline, and two studies reported an improvement in hair pull test outcomes. CONCLUSIONS AND RELEVANCE: SVF may be safe and effective for nonscarring alopecia in the appropriate patients. Hair loss severity, method of SVF preparation and frequency of treatment, and adjunctive therapies may be important considerations for treatment success. Additional studies evaluating appropriate patient selection and treatment methods are needed.

Interprofessional Education in Medical-Legal Partnerships (MLPs) to Address Social Determinants of Health.

Medical-legal partnerships (MLP) address legal needs that contribute to health inequities. Health providers express discomfort accessing legal services and a desire for greater training, however best practices remain unclear. METHODS: We conducted a scoping literature review and interviews with key informants to identify essential components of MLP training and best practices in MLP training. RESULTS: Twenty-one articles out of an initial 1,247 met criteria. Most learners were medical (11; 52%) or law (13; 62%) students or residents (12; 57%). Training was primarily led by lawyers (18; 86%). Educational approaches included didactics (15; 71%). Content was focused on skill-acquisition (18; 86%). Most training was presented as stand-alone (5; 24%) courses. Essential skills included issuespotting, adaptability, and trauma-informed care. CONCLUSION: Medical-legal partnerships make use of varied perspectives to address unmet legal needs. This review helped identify best practices in training and a need for future study on evaluation. Future research should explore how best to evaluate the effectiveness of MLP training.

Outcomes of Total Knee Arthroplasty in Patients With Rheumatoid Arthritis.

The purpose of this study was to examine current literature regarding the efficacy of total knee arthroplasty for patients with rheumatoid arthritis. Studies that assessed total knee arthroplasty outcomes in patients with rheumatoid arthritis were identified on MEDLINE from January 2009 to November 2018. All 4 studies that assessed knee pain and 9 of 11 studies that assessed knee function noted significant improvement in average knee score. However, between 10% and 47% of patients had significant knee pain at final follow-up. Total knee arthroplasty provides significant improvement in knee pain and function for patients with rheumatoid arthritis. However, the rates of postoperative pain vary widely. [Orthopedics. 2021;44(5):e626-e632.].

Postpartum NSAID Use and Adverse Outcomes among Women with Hypertensive Disorders of Pregnancy: A Systematic Review and Meta-analysis.

OBJECTIVE: This study was aimed to perform a systematic review and meta-analysis of the association between postpartum nonsteroidal anti-inflammatory drug (NSAID) use among women with hypertensive disorders of pregnancy (HDP) and risks of adverse postpartum outcomes. STUDY DESIGN: Studies were eligible if they included women who had been diagnosed with HDP and were postpartum, reported exposure to NSAIDs, were written in English, and were published between January 2000 and November 2019. Assessment of bias was performed using the Newcastle-Ottawa scale for observational studies or the Cochrane Collaborative tool for randomized trials. The primary outcome was maternal blood pressure ≥ 150 mm Hg systolic and/or 100 mm Hg diastolic. Secondary outcomes were persistent blood pressures ≥ 160 mm Hg systolic and/or 110 mm Hg diastolic, mean arterial pressure (MAP), initiation or up-titration of antihypertensive medication, length of hospital stay, rehospitalization for blood pressure control, and postpartum opioid use. A random-effect meta-analysis was performed using RevMan, with a p-value < 0.05 used to indicate statistical significance (PROSPERO CRD no.: 42019127043). RESULTS: Among 7,395 abstracts identified, seven studies (four randomized and three cohort studies, n = 777 patients) met inclusion criteria. All cohort analyses exhibited low levels of bias, while two randomized controlled trials exhibited a high risk of bias in blinding and inclusion criteria. There was no association between NSAID use and blood pressures ≥ 150 mm Hg systolic and/or 100 mm Hg diastolic (risk ratio [RR]: 1.21, 95% confidence interval [CI]: 0.89-1.64). Conversely, NSAID use was associated with a statistically significant, but clinically insignificant, increase in length of postpartum stay (0.21 days, 95% CI: 0.05-0.38). No other secondary outcomes were significantly different between groups. CONCLUSION: Postpartum NSAID use among women with HDP was not associated with maternal hypertension exacerbation. These findings support the recent American College of Obstetricians and Gynecologists' guideline change, wherein preeclampsia is no longer a contraindication to postpartum NSAID use. KEY POINTS: · Postpartum (PP) NSAID use does not worsen hypertension in preeclampsia.. · PP NSAID use is associated with a longer, though clinically insignificant, length of stay.. · Our findings support ACOG's recommendations for PP NSAID use..

Risk Assessment and Considerations for Proper Management of Elderly Men with Advanced Prostate Cancer: A Systematic Review.

CONTEXT: Treatment decisions for elderly men with prostate cancer are complicated by the intersection of competing risks of cancer, potential complications of treatment, and individual patients' comorbidities. OBJECTIVE: To perform a systematic review of data guiding the assessment of elderly prostate cancer patients that addresses the risk from cancer and treatment, and to discuss a patient-centered approach to incorporating these factors into decision making. EVIDENCE ACQUISITION: Evidence was gathered via a systematic review of the current literature. The search strategy used the terms prostate cancer, elderly, geriatric, >75 yr of age, risk assessment, and treatment in several combinations, and was limited to phase ≥ II clinical trials published between January 2008 and November 2018. Additional supporting literature for the discussion was pulled by hand search. EVIDENCE SYNTHESIS: The benefits of treatment identified for systemic therapies commonly used to treat men with prostate in general extend to elderly patients. Evidence supports a multifaceted assessment of the risks of cancer and aging, and an understanding of the side effects of treatment to optimally guide therapeutic decision making for elderly patients. There is little evidence defining a geriatric risk stratification system specific to prostate cancer, and recommendations are predominantly based on adapted geriatric oncology approaches and expert consensus. CONCLUSIONS: The care of elderly men with prostate cancer should incorporate a review of cancer risk, an assessment of aging, and an understanding of the effects of treatment to provide the patient with thorough and personalized guidance for treatment decisions. Future studies of elderly men with prostate cancer can define and validate ideal risk stratification methods as well as management approaches that may be distinct from those for younger populations. PATIENT SUMMARY: Treatment decisions for elderly men with prostate cancer require consideration of the risk posed by the cancer coupled with an understanding of the patient's general health status.

Breaking with Tradition: A Scoping Meta-Analysis Analyzing the Effects of Student-Centered Learning and Computer-Aided Instruction on Student Performance in Anatomy.

While prior meta-analyses in anatomy education have explored the effects of laboratory pedagogies and histology media on learner performance, the effects of student-centered learning (SCL) and computer-aided instruction (CAI) have not been broadly evaluated. This research sought to answer the question, "How effective are student-centered pedagogies and CAI at increasing student knowledge gains in anatomy compared to traditional didactic approaches?" Relevant studies published within the past 51 years were searched using five databases. Predetermined eligibility criteria were applied to the screening of titles and abstracts to discern their appropriateness for study inclusion. A summary effect size was estimated to determine the effects of SCL and CAI on anatomy performance outcomes. A moderator analysis of study features was also performed. Of the 3,035 records screened, 327 underwent full-text review. Seven studies, which comprised 1,564 participants, were included in the SCL analysis. An additional 19 studies analyzed the effects of CAI in the context of 2,570 participants. Upon comparing SCL to traditional instruction, a small positive effect on learner performance was detected (standardized mean difference (SMD = 0.24; [CI = 0.07, 0.42]; P = 0.006). Likewise, students with CAI exposure moderately outscored those with limited or no access to CAI (SMD = 0.59; [CI = 0.20, 0.98]; P = 0.003). Further analysis of CAI studies identified effects (P ≤ 0.001) for learner population, publication period, interventional approach, and intervention frequency. Overall, learners exposed to SCL and supplemental CAI outperformed their more classically-trained peers as evidenced by increases in short-term knowledge gains. Anat Sci Educ. © 2018 American Association of Anatomists.

Systemic Thyroid Hormone Status During Levothyroxine Therapy In Hypothyroidism: A Systematic Review and Meta-Analysis.

CONTEXT: The standard of care for overt hypothyroidism is levothyroxine at doses that normalize serum TSH levels. Whether this approach universally restores thyroid hormone signaling is unknown. OBJECTIVE: To review studies of overt hypothyroidism in which participants were treated with levothyroxine to normalize serum TSH levels and measured other objective markers of thyroid hormone signaling. DESIGN: Databases were searched for studies that reported objective markers of thyroid hormone signaling (serum low-density lipoprotein (LDL), total cholesterol (TC), sex hormone-binding globulin (SHBG), creatine kinase and/or ferritin levels; cognition, energy expenditure, and/or renal function) in levothyroxine monotherapy for overt, primary hypothyroidism among nonpregnant adults with normal serum TSH levels. For studies with LDL, TC and SHBG outcomes, data were pooled using random effects meta-analysis. RESULTS: A total of 99 studies met inclusion criteria, including 65 that reported serum cholesterol data. Meta-analysis showed that levothyroxine-treated hypothyroid participants with normal serum TSH levels had 3.31 ± 1.64 mg/dL higher serum LDL levels (p=0.044) and 9.60 ± 3.55 mg/dL higher serum TC levels (p=0.007) compared to controls. In studies that did not concomitantly assess healthy controls, serum LDL levels were 138.3 ± 4.6 mg/dL (p<0.001) and serum TC levels were 209.6 ± 3.4 mg/dL (p<0.001). Meta-analysis of 2 studies showed no significant difference between SHBG levels of levothyroxine-treated participants and controls. CONCLUSIONS: In studies that utilized levothyroxine monotherapy at doses that normalized the serum TSH for overt, primary hypothyroidism, not all systemic biological markers of thyroid hormone signaling were normalized, including serum LDL and TC levels.

A meta-analysis of anatomy laboratory pedagogies.

The debate regarding anatomy laboratory teaching approaches is ongoing and controversial. To date, the literature has yielded only speculative conclusions because of general methodological weaknesses and a lack of summative empirical evidence. Through a meta-analysis, this study compared the effectiveness of instructional laboratory approaches used in anatomy education to objectively and more conclusively synthesize the existing literature. Studies published between January 1965 and December 2015 were searched through five databases. Titles and abstracts of the retrieved records were screened using eligibility criteria to determine their appropriateness for study inclusion. Only numerical data were extracted for analysis. A summary effect size was estimated to determine the effects of laboratory pedagogies on learner performance and perceptions data were compiled to provide additional context. Of the 3,035 records screened, 327 underwent full-text review. Twenty-seven studies, comprising a total of 7,731 participants, were included in the analysis. The meta-analysis detected no effect (standardized mean difference = -0.03; 95% CI = -0.16 to 0.10; P = 0.62) on learner performance. Additionally, a moderator analysis detected no effects (P ≥ 0.16) for study design, learner population, intervention length, or specimen type. Across studies, student performance on knowledge examinations was equivalent regardless of being exposed to either dissection or another laboratory instructional strategy. This was true of every comparison investigated (i.e., dissection vs. prosection, dissection vs. digital media, dissection vs. models/modeling, and dissection vs. hybrid). In the context of short-term knowledge gains alone, dissection is no better, and no worse, than alternative instructional modalities. Clin. Anat. 31:122-133, 2018. © 2017 Wiley Periodicals, Inc.

Utilizing Respiratory Therapists to Reduce Costs of Care.

INTRODUCTION: Changes to the reimbursement of respiratory care services over the past 26 years make it imperative that respiratory therapists (RTs) demonstrate cost savings to establish their value. Therefore, this systematic review evaluated the cost-related impacts from utilizing RTs to deliver care when compared to other care providers. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to guide the search process. The study addressed articles across all age groups and care settings that compared the cost of care provided by RTs to a comparison group. Studies were excluded if they were not written in English, described care provided outside of the United States, did not provide quantitative data, or lacked a comparison group. RESULTS: A total of 4,120 articles emerged from the search process, of which 60 qualified for a full text review. Cost savings were evaluated for the 28 articles included in this review, noting the study design, the specific respiratory care practice, use of protocols, clinical setting, and age group. The most frequently studied topic was mechanical ventilation, which along with disease management represented by the most randomized, controlled trials for the study design. The clinical practice area notably absent was home care. CONCLUSIONS: Although cost comparisons across studies could not be made due to the inconsistent manner in which data were reported, evidence demonstrated that care provided by RTs yielded both direct and indirect cost reductions, which were achieved through protocol utilization, specialized expertise, and autonomous decision making. The care provided was consistent with care provided by other disciplines. It is critical for the respiratory care profession to highlight key clinical practice areas for future research, to establish uniform reporting measures for outcomes, and to foster the development of future respiratory care researchers to affirm the value that respiratory therapists add to patient care.