OBJECTIVE: We report nine consecutive percutaneous image-guided cryoablation procedures of head and neck tumors in seven patients (four men and three women; mean age, 68 years; age range, 50-78 years). Ablation of the entire tumor for local control or ablation of a region of tumor for pain relief or preservation of function was achieved in eight of nine procedures. One patient experienced intraprocedural bradycardia, and another developed a neopharyngeal abscess. There were no deaths, permanent neurologic or functional deficits, vascular complications, or adverse cosmetic sequelae due to the procedures.
CONCLUSION: Percutaneous image-guided cryoablation offers a potentially less morbid minimally invasive treatment option than salvage head and neck surgery. The complications that we encountered may be avoidable with increased experience. Further work is needed to continue improving the safety and efficacy of cryoablation of head and neck tumors and to continue expanding the use of cryoablation in patients with head and neck tumors that cannot be treated surgically.
We report percutaneous cryoablation of spine tumors in 7 consecutive patients (5 men, 2 women [mean age, 47 years; range, 17-68 years]) by using intraprocedural image monitoring of ice ball margins to protect adjacent neural elements. Complete tumor ablation was achieved in all patients without neurologic complication. Pain relief was achieved in 4 of 5 (80%) patients; the patient with persistent pain was later found to have enlarging metastases at other sites.
RATIONALE, AIMS AND OBJECTIVES: Having a quick, practical, educational tool designed for busy child-care professionals to check whether systematic reviews (SRs) contain valid information would help them regularly update their evidence-based knowledge and apply it to their patients. Continuing our annual workshop courses encouraging paediatric hospital professionals to use evidence-based information, in a preliminary study, we compared the commonly used Critical Appraisal Skill Programme (CASP) questionnaire for appraising overall internal validity in SRs with a new, practical tool designed to check internal validity quickly.
METHOD: During a course in 2010, two 'teacher-brokers' taught experienced paediatric hospital professionals to use and compare the CASP and the new practical tool to appraise a Cochrane SR on beclomethasone for asthma in children by assessing internal validity only from the two most weighted randomized controlled trials in the forest plot. At 15 days and 6 months, participants then answered questionnaires designed to assess qualitative data including feelings about working together, memorization and possibly provide feedback for Cochrane reviewers.
RESULTS: Using the CASP, participants agreed that the Cochrane SR analysed contained overall valid results. Conversely, using the new quick tool, they found poor internal validity. Participants worked well together in a group, took less time to apply the new tool than the CASP (1 vs. 2.5 hours) and provided Cochrane feedback.
CONCLUSIONS: Our quick practical tool for teaching critical appraisal encourages busy child-care hospital professionals to work together, carefully check validity in SRs, apply the findings in clinical practice and provide useful feedback for Cochrane reviewers.
OBJECTIVES: To develop explicit and transparent recommendations on controversial asthma management issues in children and to illustrate the usefulness of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach in rating the quality of evidence and strength of recommendations.
METHODS: Health care questions were formulated for 3 controversies in clinical practice: what is the most effective treatment in asthma not under control with standard-dose inhaled corticosteroids (ICS; step 3), the use of leukotriene receptor antagonist for viral wheeze, and the role of extra fine particle aerosols. GRADE was used to rate the quality of evidence and strength of recommendations after performing systematic literature searches. We provide evidence profiles and considerations about benefit and harm, preferences and values, and resource use, all of which played a role in formulating final recommendations.
RESULTS: By applying GRADE and focusing on outcomes that are important to patients and explicit other considerations, our recommendations differ from those in other international guidelines. We prefer to double the dose of ICS instead of adding a long-acting β-agonist in step 3; ICS instead of leukotriene receptor antagonist are the first choice in preschool wheeze, and extra fine particle ICS formulations are not first-line treatment in children with asthma. Recommendations are weak and based on low-quality evidence for critical outcomes.
CONCLUSIONS: We provide systematically and transparently developed recommendations about controversial asthma management options. Using GRADE for guideline development may change recommendations, enhance guideline implementation, and define remaining research gaps.
BACKGROUND AND OBJECTIVES: Laser acupuncture has often been recommended as a treatment of asthma. The technique is noninvasive, and seems particularly suitable for children. However, the results from several clinical trials are contradictory. The objective of this review was to assess the effectiveness of laser acupuncture in the treatment of childhood asthma.
METHODS: Literature searches of electronic database were conducted in The Cochrane Library, Medline, EMBASE, AMED, CINAHL, and two Chinese literature databases (CNKI and VIP) up to February 2012. Randomized controlled trials (RCTs) testing laser acupuncture for asthma in children were included. No language restrictions were applied. Three authors independently selected articles, extracted data, and assessed trial quality.
RESULTS: Our searches identified 13 potential eligible studies, of which three with a total number of 176 patients met our inclusion criteria. The quality of included RCTs were low. One RCT with a parallel group design showed positive results, while two crossover RCTs generated negative results. There was variation in the type of patients, the interventions, and outcome measures. Because of the significant clinical and methodological heterogeneity, no meta-analysis was performed.
CONCLUSIONS: The number of RCTs and their total sample sizes are small; and their methodological quality is low. Therefore, no compelling evidence exists to suggest that laser acupuncture is not an effective treatment for childhood asthma. Further rigorous studies are warranted.
BACKGROUND: Because of concerns about the safety of long-acting β(2)-agonist (LABA) use in patients with asthma, withdrawal of the LABA is recommended by the US Food and Drug Administration once asthma is controlled by combination therapy with a LABA and inhaled corticosteroid (ICS).
OBJECTIVE: To perform a systematic review and meta-analysis assessing evidence supporting the discontinuation of LABA therapy once asthma control has been achieved with a combination of ICS and LABA.
DATA SOURCES: MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched (through August 2010), references of identified studies and selected narrative review articles were evaluated, registries of clinical trials were reviewed, and manufacturers of LABAs were contacted.
STUDY SELECTION: Randomized controlled trials of discontinuation of LABA therapy in patients with asthma controlled with a combination of ICS and LABA.
DATA EXTRACTION: Two reviewers independently screened each title and abstract in the initial searches and then the full text of each nominated article to extract data for analyses.
RESULTS: Of 1492 screened articles, only 5 trials involving patients aged 15 years or older fulfilled a priori–specified inclusion criteria. Results did not favor the LABA step-off approach compared with no change in treatment. The LABA step-off regimen increased asthma impairment, with worse Asthma Quality of Life Questionnaire score (mean difference [95% CI], 0.32 [0.14-0.51] points lower); worse Asthma Control Questionnaire score (0.24 [0.13-0.35] points higher); fewer symptom-free days (9.15% [1.62%-16.69%] less); and greater risk of withdrawal from study resulting from lack of efficacy or loss of asthma control (risk ratio, 3.27 [2.16-4.96]). Risk of exacerbations and deaths after LABA step-off were not evaluable because of the small number of events and short duration of follow-up.
CONCLUSIONS: Evidence suggests that discontinuing LABA therapy in adults and older children with asthma controlled with a combination of ICSs and LABAs results in increased asthma-associated impairment. Additional trials measuring all long-term patient-important outcomes are needed.
OBJECTIVE: To compare the efficacy of inhaled corticosteroids (ICS) plus long-acting β2 agonist (LABA) versus higher doses of ICS in children/adolescents with uncontrolled persistent asthma.
METHODS: Randomized, prospective, controlled trials published January 1996 to January 2012 with a minimum of 4 weeks of LABA+ICS versus higher doses of ICS were retrieved through Medline, Embase, Central, and manufacturer's databases. The primary outcome was asthma exacerbations requiring systemic corticosteroids; secondary outcomes were the pulmonary function test (PEF), withdrawals during the treatment period, days without symptoms, use of rescue medication, and adverse events.
RESULTS: Nine studies (n = 1641 patients) met criteria for inclusion (7 compared LABA+ICS versus double ICS doses and 2 LABA+ICS versus higher than double ICS doses). There was no statistically significant difference in the number of patients with asthma exacerbations requiring systemic corticosteroids between children receiving LABA+ICS and those receiving higher doses of ICS (odds ratio = 0.76; 95% confidence interval: 0.48-1.22, P = .25, I(2) = 16%). In the subgroup analysis, patients receiving LABA+ICS showed a decreased risk of asthma exacerbations compared with higher than twice ICS doses (odds ratio = 0.48; 95% confidence interval: 0.28-0.82, P = .007, I(2)= 0). Children treated with LABA+ICS had significantly higher PEF, less use of rescue medication, and higher short-term growth than those on higher ICS doses. There were no other significant differences in adverse events.
CONCLUSIONS: There were no statistically significant group differences between ICS+LABA and double doses of ICS in reducing the incidence of asthma exacerbations but it did decrease the risk comparing to higher than double doses of ICS.
BACKGROUND AND OBJECTIVE: A number of studies have shown that the +252A/G polymorphism (rs909253) in the lymphotoxin-α (LT-α) gene is implicated in susceptibility to asthma. However, the findings have been inconclusive. The aim of this study was to investigate the association between the +252A/G polymorphism in the LT-α gene and the risk of asthma by performing a meta-analysis.
METHODS: The Pubmed and Embase databases were searched for all studies relating to this polymorphism and the risk of asthma. Statistical analyses were performed using the Revman4.2 and STATA 10.0 software.
RESULTS: Thirteen case-control studies that included a total of 2220 cases and 6428 controls were included in the meta-analysis. There was no significant association between this polymorphism and the risk of asthma in the all-combined analysis (odds ratio (OR) 1.14, 95% confidence interval (CI): 0.89-1.45 for GG+GA vs AA). In a subgroup analysis by ethnicity, no significant association with asthma risk was identified in Asians (OR 1.31, 95% CI: 0.97-1.77) or Europeans (OR 1.08, 95% CI: 0.77-1.53). In a subgroup analysis by age, a significantly increased risk was identified among adults (OR 1.25, 95% CI: 1.03-1.50) but not children (OR 1.04, 95% CI: 0.28-3.89). In a subgroup analysis by atopic status, a significantly elevated risk was identified among atopic (OR 1.55, 95% CI: 1.28-1.87) but not non-atopic individuals (OR 0.94, 95% CI: 0.53-1.68).
CONCLUSIONS: This meta-analysis suggested that the +252A/G polymorphism in the LT-α gene is a risk factor for asthma in adults and atopic populations.