Surgical Outcome of Low-Power-Density Blue Laser for Vascular Lesions of the Vocal Fold.
Photoangiolytic lasers such as the 532-nm potassium-titanyl-phosphate (KTP) and the novel 445-nm blue laser (introduced into the United States in 2020) are absorbed selectively by hemoglobin, permitting targeted ablation of vascular structures such as vascular malformations of the vocal fold (VF). Previously, we reported the high rate of success of KTP laser photocoagulation for VF vascular lesions. Compared with other photoangiolytic lasers, blue laser has the highest absorption in hemoglobin, and therefore it can be operated at lower power densities to minimize thermal injury to adjacent tissue.
The purpose of this study was to determine the efficacy and safety of blue laser for treatment of VF vascular lesions using low power densities, and to compare outcomes of blue laser with those of KTP laser.
Adult voice patients who underwent blue laser treatment of VF vascular lesions in the operating room at the lowest power densities that appeared clinically to cause the effect desired were included in this retrospective study. Baseline lesion characteristics and postoperative outcomes were assessed with a model that we had described previously. Postoperative outcomes were compared to those of previously reported KTP laser.
Thirty-one subjects (54 VFs treated) underwent blue laser vaporization of VF vascular lesions (average age was 40.63 ± 17.51). Data were compared to those of 66 subjects (100 VFs) who had undergone KTP laser vaporization of VF vascular lesions. There were no significant differences in subject demographics, past medical or surgical history, or preoperative location or severity of vascular lesions. Surgical success for blue laser at the low power densities used was 3.74 ± 0.50, 3.55 ± 0.94, 3.90 ± 0.94, and 3.70 ± 1.11 (out of 5) at postoperative visits 1-4, respectively. Surgical objective score was significantly greater following KTP laser at every postoperative visit. Treatment with KTP laser resulted in significantly greater generalized postoperative edema, and blue laser resulted in significantly greater localized edema at postoperative visits one and two. At visit three and four, there are no significant differences. VF stiffness following blue laser was 2.41 ± 0.67, 1.91 ± 0.69, 1.33 ± 0.47, and 1.10 ± 0.18 (out of 4) at postoperative visits 1-4, respectively. Postoperative VF stiffness did not differ significantly from KTP laser. Postoperative hemorrhage severity after blue laser was 1.79 ± 0.54, 1.59 ± 0.48, 1.15 ± 0.25, and 1.14 ± 0.26 (out of 4) at postoperative visits 1-4, respectively. Blue laser resulted in significantly less VF hemorrhage than KTP laser at the first (1.79 ± 0.54 versus 2.26 ± 0.83) and second (1.59 ± 0.48 versus 1.98 ± 0.72) postoperative visits. Vascular lesions treated with low-power-density blue laser were significantly more likely to recur than those treated with KTP laser (40.74% versus 10.00%). New vascular malformations were significantly more likely to form after blue laser than KTP (24.07% versus 6.00%). Subjects treated with low-power-density blue laser were significantly more likely to undergo repeat surgery than those treated with KTP (31.48% versus 14.00%). Significant predictors for the need for repeat blue laser included lesion recurrence, a lower surgical objective score at the third or fourth postoperative visit and a higher baseline lesion severity grade.
Blue laser is an effective tool for the surgical management of VF vascular lesions. Although overall surgical success ratings were inferior to KTP laser at the power densities used, the severity of postoperative edema and VF hemorrhage were significantly less with blue laser. Re-evaluation of blue laser using higher power densities is in progress.
Balouch B
，Ranjbar PA
，Alnouri G
，Omari AIA
，Martha V
，Brennan M
，Sataloff RT
... -
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Falls prevention interventions for community-dwelling older adults: systematic review and meta-analysis of benefits, harms, and patient values and preferences.
About 20-30% of older adults (≥ 65 years old) experience one or more falls each year, and falls are associated with substantial burden to the health care system, individuals, and families from resulting injuries, fractures, and reduced functioning and quality of life. Many interventions for preventing falls have been studied, and their effectiveness, factors relevant to their implementation, and patient preferences may determine which interventions to use in primary care. The aim of this set of reviews was to inform recommendations by the Canadian Task Force on Preventive Health Care (task force) on fall prevention interventions. We undertook three systematic reviews to address questions about the following: (i) the benefits and harms of interventions, (ii) how patients weigh the potential outcomes (outcome valuation), and (iii) patient preferences for different types of interventions, and their attributes, shown to offer benefit (intervention preferences).
We searched four databases for benefits and harms (MEDLINE, Embase, AgeLine, CENTRAL, to August 25, 2023) and three for outcome valuation and intervention preferences (MEDLINE, PsycINFO, CINAHL, to June 9, 2023). For benefits and harms, we relied heavily on a previous review for studies published until 2016. We also searched trial registries, references of included studies, and recent reviews. Two reviewers independently screened studies. The population of interest was community-dwelling adults ≥ 65 years old. We did not limit eligibility by participant fall history. The task force rated several outcomes, decided on their eligibility, and provided input on the effect thresholds to apply for each outcome (fallers, falls, injurious fallers, fractures, hip fractures, functional status, health-related quality of life, long-term care admissions, adverse effects, serious adverse effects). For benefits and harms, we included a broad range of non-pharmacological interventions relevant to primary care. Although usual care was the main comparator of interest, we included studies comparing interventions head-to-head and conducted a network meta-analysis (NMAs) for each outcome, enabling analysis of interventions lacking direct comparisons to usual care. For benefits and harms, we included randomized controlled trials with a minimum 3-month follow-up and reporting on one of our fall outcomes (fallers, falls, injurious fallers); for the other questions, we preferred quantitative data but considered qualitative findings to fill gaps in evidence. No date limits were applied for benefits and harms, whereas for outcome valuation and intervention preferences we included studies published in 2000 or later. All data were extracted by one trained reviewer and verified for accuracy and completeness. For benefits and harms, we relied on the previous review team's risk-of-bias assessments for benefit outcomes, but otherwise, two reviewers independently assessed the risk of bias (within and across study). For the other questions, one reviewer verified another's assessments. Consensus was used, with adjudication by a lead author when necessary. A coding framework, modified from the ProFANE taxonomy, classified interventions and their attributes (e.g., supervision, delivery format, duration/intensity). For benefit outcomes, we employed random-effects NMA using a frequentist approach and a consistency model. Transitivity and coherence were assessed using meta-regressions and global and local coherence tests, as well as through graphical display and descriptive data on the composition of the nodes with respect to major pre-planned effect modifiers. We assessed heterogeneity using prediction intervals. For intervention-related adverse effects, we pooled proportions except for vitamin D for which we considered data in the control groups and undertook random-effects pairwise meta-analysis using a relative risk (any adverse effects) or risk difference (serious adverse effects). For outcome valuation, we pooled disutilities (representing the impact of a negative event, e.g. fall, on one's usual quality of life, with 0 = no impact and 1 = death and ~ 0.05 indicating important disutility) from the EQ-5D utility measurement using the inverse variance method and a random-effects model and explored heterogeneity. When studies only reported other data, we compared the findings with our main analysis. For intervention preferences, we used a coding schema identifying whether there were strong, clear, no, or variable preferences within, and then across, studies. We assessed the certainty of evidence for each outcome using CINeMA for benefit outcomes and GRADE for all other outcomes.
A total of 290 studies were included across the reviews, with two studies included in multiple questions. For benefits and harms, we included 219 trials reporting on 167,864 participants and created 59 interventions (nodes). Transitivity and coherence were assessed as adequate. Across eight NMAs, the number of contributing trials ranged between 19 and 173, and the number of interventions ranged from 19 to 57. Approximately, half of the interventions in each network had at least low certainty for benefit. The fallers outcome had the highest number of interventions with moderate certainty for benefit (18/57). For the non-fall outcomes (fractures, hip fracture, long-term care [LTC] admission, functional status, health-related quality of life), many interventions had very low certainty evidence, often from lack of data. We prioritized findings from 21 interventions where there was moderate certainty for at least some benefit. Fourteen of these had a focus on exercise, the majority being supervised (for > 2 sessions) and of long duration (> 3 months), and with balance/resistance and group Tai Chi interventions generally having the most outcomes with at least low certainty for benefit. None of the interventions having moderate certainty evidence focused on walking. Whole-body vibration or home-hazard assessment (HHA) plus exercise provided to everyone showed moderate certainty for some benefit. No multifactorial intervention alone showed moderate certainty for any benefit. Six interventions only had very-low certainty evidence for the benefit outcomes. Two interventions had moderate certainty of harmful effects for at least one benefit outcome, though the populations across studies were at high risk for falls. Vitamin D and most single-component exercise interventions are probably associated with minimal adverse effects. Some uncertainty exists about possible adverse effects from other interventions. For outcome valuation, we included 44 studies of which 34 reported EQ-5D disutilities. Admission to long-term care had the highest disutility (1.0), but the evidence was rated as low certainty. Both fall-related hip (moderate certainty) and non-hip (low certainty) fracture may result in substantial disutility (0.53 and 0.57) in the first 3 months after injury. Disutility for both hip and non-hip fractures is probably lower 12 months after injury (0.16 and 0.19, with high and moderate certainty, respectively) compared to within the first 3 months. No study measured the disutility of an injurious fall. Fractures are probably more important than either falls (0.09 over 12 months) or functional status (0.12). Functional status may be somewhat more important than falls. For intervention preferences, 29 studies (9 qualitative) reported on 17 comparisons among single-component interventions showing benefit. Exercise interventions focusing on balance and/or resistance training appear to be clearly preferred over Tai Chi and other forms of exercise (e.g., yoga, aerobic). For exercise programs in general, there is probably variability among people in whether they prefer group or individual delivery, though there was high certainty that individual was preferred over group delivery of balance/resistance programs. Balance/resistance exercise may be preferred over education, though the evidence was low certainty. There was low certainty for a slight preference for education over cognitive-behavioral therapy, and group education may be preferred over individual education.
To prevent falls among community-dwelling older adults, evidence is most certain for benefit, at least over 1-2 years, from supervised, long-duration balance/resistance and group Tai Chi interventions, whole-body vibration, high-intensity/dose education or cognitive-behavioral therapy, and interventions of comprehensive multifactorial assessment with targeted treatment plus HHA, HHA plus exercise, or education provided to everyone. Adding other interventions to exercise does not appear to substantially increase benefits. Overall, effects appear most applicable to those with elevated fall risk. Choice among effective interventions that are available may best depend on individual patient preferences, though when implementing new balance/resistance programs delivering individual over group sessions when feasible may be most acceptable. Data on more patient-important outcomes including fall-related fractures and adverse effects would be beneficial, as would studies focusing on equity-deserving populations and on programs delivered virtually.
Not registered.
Pillay J
，Gaudet LA
，Saba S
，Vandermeer B
，Ashiq AR
，Wingert A
，Hartling L
... -
《Systematic Reviews》
ResearchGate
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