Triglyceride-glucose index as a predictor of cardiac adverse events in acute coronary syndrome patients undergoing percutaneous coronary intervention: role of diabetes

BACKGROUND

Triglyceride-glucose index (TyG), a surrogate marker of insulin resistance (IR), could be a potential prognostic marker in patients with acute coronary syndromes (ACS). We evaluated the effect of the TyG index on major adverse cardiac and cerebrovascular events (MACCE) in patients with ACS undergoing percutaneous coronary intervention (PCI).

METHODS

This registry-based cohort study was conducted at Tehran Heart Center from 2015 to 2021 and the median follow-up duration was 378 days. The primary outcome was MACCE and the secondary outcomes were MACCE components: all-cause mortality, myocardial infarction, stroke, target vessel revascularization, target lesion revascularization, and coronary artery bypass grafting. For comparison among TyG quartiles (Q), the log-rank test was used. Unadjusted and adjusted hazard ratios (HRs) and their 95% confidence intervals (CIs) were used to describe the association between TyG quartiles and MACCE. A subgroup of euglycemic patients was also evaluated.

RESULTS

A total of 13,542 patients were included. Patients in the fourth TyG quartile (Q4) were younger, had higher mean BMI, and higher prevalence of hypertension, diabetes, and dyslipidemia. The adjusted Cox model showed that a 1-unit increment of the TyG index was associated with a significantly higher risk of MACCE (aHR 1.18, 95% CI 1.08 to 1.30, p < 0.001). Among TyG quartiles, there was a higher MACCE incidence in Q4 compared to Q1 (aHR 1.29, 95% CI 1.08 to 1.53, p = 0.005). In the euglycemic subgroup of the population, there was no significant association between MACCE incidence and a 1-unit increase in TyG or among TyG quartiles.

CONCLUSION

Based on our findings, while higher TyG levels and quartiles were associated with higher rates of MACCE in ACS, there was no such effect in the euglycemic population. If confirmed in future studies, these results can be beneficial for clinicians to risk stratify these patients with an easy-to-use index and determine clinical plans based on their risk.

Efficacy and safety of ivermectin for treatment of non-hospitalized COVID-19 patients: A systematic review and meta-analysis of 12 randomized controlled trials with 7,035 participants

INTRODUCTION

We systematically assessed benefits and harms of the use of ivermectin in non-hospitalized patients with early COVID-19.

METHODS

Five databases were searched until October 17, 2023, for randomized controlled trials (RCTs) in adult patients with COVID-19 treated with ivermectin against standard of care (SoC), placebo, or active drug. Primary outcomes were hospitalization, all-cause mortality, and adverse events (AEs). Secondary outcomes included mechanical ventilation (MV), clinical improvement, clinical worsening, viral clearance, and severe adverse events (SAEs). Random effects meta-analyses were performed, with quality of evidence (QoE) evaluated using GRADE methods. Pre-specified subgroup analyses (ivermectin dose, control type, risk of bias, follow-up, and country income) and trial sequential analysis (TSA) were performed.

RESULTS

Twelve RCTs (n = 7,035) were included. The controls were placebo in nine RCTs, SoC in two RCTs, and placebo or active drug in one RCT. Ivermectin did not reduce hospitalization (relative risk [RR], 0.81, 95% confidence interval [95% CI] 0.64-1.03; 8 RCTs, low QoE), all-cause mortality (RR 0.98, 95% CI 0.73-1.33; 9 RCTs, low QoE), or AEs (RR 0.89, 95% CI 0.75-1.07; 9 RCTs, very low QoE) vs. controls. Ivermectin did not reduce MV, clinical worsening, or SAEs and did not increase clinical improvement and viral clearance vs. controls (very low QoE for secondary outcomes). Subgroup analyses were mostly consistent with main analyses, and TSA-adjusted risk for hospitalization was similar to main analysis.

CONCLUSIONS

In non-hospitalized COVID-19 patients, ivermectin did not have effect on clinical, non-clinical or safety outcomes versus controls. Ivermectin should not be recommended as treatment in non-hospitalized COVID-19 patients.

Efficacy of Probiotic Consumption on Oral Outcomes in Children and/or Adolescents: A Meta-Analysis

We assessed the impact of probiotics on outcomes related to caries in children and/or adolescents without underlying systemic diseases. We performed a comprehensive meta-analysis of randomised controlled trials (RCTs). Searches were performed in Embase, PubMed, Scopus and Web of Science until March 2023 for RCTs assessing probiotics with a minimum intake duration of 0.2 months vs. control (no treatment or placebo) and reporting at least one primary or secondary outcome. Primary outcomes were number of carious, Streptococcus mutans count, and Lactobacillus count; secondary outcomes were bacterial plaque index, gingival index, salivary pH, and bleeding index. We performed meta-analyses with random effects models and the inverse variance method. Effects were described as mean difference (MD) with their 95% confidence intervals (95%CI). The risk of bias was assessed with the RoB 2.0 tool. The GRADE methodology was used to assess the quality of evidence (QoE). Nineteen RCTs were included (n = 2622), with a follow-up range of 0.2 to 108 months. Probiotics had no effect on reduction of dental caries (MD -0.24 carious pieces, 95%CI -0.72 to 0.23; I2 = 52%, low QoE) or Lactobacillus count (MD -0.78 CFU/mL, 95%CI -1.65 to 0.09; I2= 52%, very low QoE) vs. control. However, probiotics probably reduced S. mutans count vs. control (MD -0.40 CFU/mL, 95%CI -0.57 to -0.24; I2 = 11%, moderate QoE). Probiotics had no effect on bacterial plaque index (MD 0.21 units of bacterial plaque, 95%CI -0. 55-0.96; I2 = 80%, very low QoE), gingival index (MD 0.04 units of gingival index, 95%CI -0.18 to 0.27; I2= 0%, low QoE), and salivary pH (MD -0.12 pH units, 95%CI -0.72 to 0.48; I2 = 92%, very low QoE) vs. control. Probiotics were found to likely reduce S. mutans counts. However, no significant effect of probiotics was observed in reducing other outcomes compared to the control group.

The Impact of Ketamine for Treatment of Post-Traumatic Stress Disorder: A Systematic Review With Meta-Analyses

BACKGROUND

Ketamine has been used in anesthesia, pain management, and major depressive disorder. It has recently been studied in patients with post-traumatic stress disorder (PTSD).

OBJECTIVE

To determine the impact of ketamine on PTSD symptomatology and depression scores.

METHODS

We conducted a literature search of Medline 1960 to May 20, 2023, and found 6 randomized controlled trials that met our inclusion criteria. We extracted data on the Clinician-Administered PTSD (CAPS), PTSD Checklist (PCL), or Montgomery-Asberg Depression Rating (MADRS) scales.

RESULTS

The use of ketamine significantly reduced CAPS scores (n = 5, MD: -10.63 [95% CI -14.95 to -6.32]), PCL scores (n = 3, MD: -6.13 [95% CI -8.61 to -3.64]), and MADRS scores (n = 3, MD: -6.33 [95% CI -8.97 to -3.69]) at the maximal follow-up times versus control. Significant benefits were found at day 1 and weeks 1, 2, and 4 for CAPS and PCL scores as well as MADRS scores at day 1, week 1, and week 4 for ketamine versus control. The time to PTSD relapse was prolonged in the patients receiving ketamine versus control (n = 2, 15.74 days [95% CI 3.57 to 29.91 days]). More dry mouth (n = 2, OR 5.85 [95% CI 1.32 to 25.95]), dizziness (n = 2, OR 3.83 [95% CI 1.28 to 11.41]), and blurred vision (n = 2, OR 7.57 [1.00 to 57.10]) occurred with ketamine than control therapy.

CONCLUSIONS AND RELEVANCE

Ketamine modestly reduced PTSD and depression scores as early as 1 day of therapy, but the longevity of effect needs to be determined. Given similar magnitude of benefit with SSRIs and venlafaxine, ketamine would not supplant these traditional options for chronic use.

Andexanet alfa versus PCC products for factor Xa inhibitor bleeding: A systematic review with meta-analysis

Previous meta-analyses assessed andexanet alfa (AA) or prothrombin complex concentrate (PCC) products for the treatment of Factor Xa inhibitor (FXaI)-associated major bleeding. However, they did not include recent studies or assess the impact of the risk of bias. We conducted a systematic review with meta-analysis on the effectiveness of AA versus PCC products for FXaI-associated major bleeding, inclusive of the studies' risk of bias. PubMed and Embase were searched for comparative studies assessing major bleeding in patients using FXaI who received AA or PCC. We used the Methodological Index for NOn-Randomized Studies (MINORS) checklist and one question from the Joanna Briggs Institute (JBI) Critical Appraisal of Case Series tool to assess the risk of bias. Random-effects meta-analyses were performed to provide a pooled estimate for the effect of AA versus PCC products on hemostatic efficacy, in-hospital mortality, 30-day mortality, and thrombotic events. Low-moderate risk of bias studies were meta-analyzed separately, as well as combined with high risk of bias studies. Eighteen comparative evaluations of AA versus PCC were identified. Twenty-eight percent of the studies (n = 5) had low-moderate risk and 72% (n = 13) had a high risk of bias. Studies with low-moderate risk of bias suggested improvements in hemostatic efficacy [Odds Ratio (OR) 2.72 (95% Confidence Interval (CI): 1.15-6.44); one study], lower in-hospital mortality [OR 0.48 (95% CI: 0.38-0.61); three studies], and reduced 30-day mortality [OR 0.49 (95% CI: 0.30-0.80); two studies] when AA was used versus PCC products. When studies were included regardless of the risk of bias, pooled effects showed improvements in hemostatic efficacy [OR 1.36 (95% CI: 1.01-1.84); 12 studies] and reductions in 30-day mortality [OR 0.53 (95% CI: 0.37-0.76); six studies] for AA versus PCC. The difference in thrombotic events with AA versus PCC was not statistically significant in the low-moderate, high, or combined risk of bias groups. The evidence from low-moderate quality real-world studies suggests that AA is superior to PCC in enhancing hemostatic efficacy and reducing in-hospital and 30-day mortality. When studies are assessed regardless of the risk of bias, the pooled hemostatic efficacy and 30-day mortality risk remain significantly better with AA versus PCC.

Prediabetes and major adverse cardiac events after acute coronary syndrome: An overestimated concept

BACKGROUND

Unlike diabetes, the effect of prediabetes on outcomes in patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI) is not much investigated. We investigated the association between fasting glycemic status and major adverse cardiovascular and cerebrovascular events (MACCE) in patients with ACS undergoing PCI and had mid to long-term follow-up after coronary stenting.

METHODS

Registry-based retrospective cohort study included ACS patients who underwent PCI at the Tehran Heart Center from 2015 to 2021 with a median follow-up of 378 days. Patients were allocated into normoglycemic, prediabetic, and diabetic groups. The primary and secondary outcomes were MACCE and its components, respectively. Unadjusted and adjusted Cox models were used to evaluate the association between glycemic status and outcomes.

RESULTS

Among 13 682 patients, 3151 (23%) were prediabetic, and 5834 (42.6%) were diabetic. MACCE risk was significantly higher for diabetic versus normoglycemic (adjusted hazard ratio [aHR]: 1.22, 95% confidence interval [CI]: 1.06-1.41), but nonsignificantly higher for prediabetic versus normoglycemic (aHR: 0.95, 95% CI: 0.78-1.10). All-cause mortality risk was significantly higher in diabetic versus normoglycemic (aHR: 1.42, 95% CI: 1.08-1.86), but nonsignificantly higher for prediabetic versus normoglycemic (aHR: 1.15, 95% CI: 0.84-1.59). Among other components of MACCE, only coronary artery bypass grafting was significantly higher in diabetic patients, and not prediabetic, compared with normoglycemic.

CONCLUSIONS

Prediabetic ACS patients undergoing PCI, unlike diabetics, are not at increased risk of MACCE and all-cause mortality. While prediabetic patients could be regarded as having the same risk as nondiabetics, careful consideration to provide more intensive pre- and post-PCI care in diabetic patients is mandatory.

Efficacy of routine second-look endoscopy after endoscopic hemostasis in patients with acute peptic ulcer bleeding: systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of scheduled second-look endoscopy in patients with acute peptic ulcer bleeding (PUB).

MATERIALS AND METHODS

We systematically search in four databases for randomized controlled trials (RCTs) that evaluated the usefulness of scheduled second-look endoscopy vs. single endoscopy in patients with PUB. Our primary outcome was rebleeding. Secondary outcomes were surgery, mortality, and the number of units of blood transfused (NUBT). All meta-analyses were performed using a random-effects model. Pooled risk ratio (RR) and mean difference (MD), with their 95% confidence intervals (CIs) were calculated for categorical and continuous outcomes, respectively. The risk of bias was assessed using the Cochrane RoB 2.0 tool, and the quality of evidence (QoE) was rated with the GRADE approach.

RESULTS

Eight full-text RCTs and two RCT abstracts were included (n=1513). We did not find differences in rebleeding (RR, 0.78; 95% CI, 0.53-1.14, moderate QoE), surgery (RR, 0.58; 95% CI, 0.29-1.15, moderate QoE), mortality (RR, 0.89; 95% CI, 0.46-1.71, moderate QoE) or NUBT (MD, -0.01 units; 95% CI, -0.3 to 0.28, low QoE) between second-look and single endoscopy. Sensitivity analyses had similar results to the main analyses.

CONCLUSIONS

Routine second-look endoscopy was not more efficacious than single endoscopy in patients with PUB.

Long-Term Neuropsychiatric, Neurocognitive, and Functional Outcomes of Patients Receiving ECMO: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Despite the common occurrence of neurologic complications during extracorporeal membrane oxygenation (ECMO) support, data on long-term neuropsychiatric, neurocognitive, and functional outcomes are sparse. We aimed to determine the prevalence of long-term neuropsychiatric symptoms, neurocognitive and functional impairment, and favorable neurologic outcomes in adult patients who receive ECMO.

METHODS

PubMed, Embase, Cochrane, Web of Science, and Scopus were searched for text related to ECMO and neuropsychiatric, neurocognitive, and functional outcomes from inception to May 3, 2023. Our primary outcome was the prevalence of neuropsychiatric symptoms (pain/discomfort, anxiety, depression, posttraumatic stress disorder [PTSD], and sleep disturbance) at long-term (≥6 months) follow-up. Our secondary outcomes were the prevalence of neurocognitive impairment (memory, attention, and reasoning), functional impairment (daily activities, physical activity/mobility, and personal/self-care), and favorable neurologic outcomes (Cerebral Performance Category ≤2, modified Rankin scale ≤3, or Glasgow Outcome Scale ≥4). This study was registered in PROSPERO (CRD42023420565).

RESULTS

We included 59 studies with 3,280 patients (median age 54 years, 69% male). The cohort consisted of 86% venoarterial (VA)-ECMO (n = 2,819) and 14% venovenous (VV)-ECMO (n = 461) patients. More than 10 tools were used to assess neuropsychiatric and neurocognitive outcomes, indicating a lack of standardization in assessment methodologies. The overall prevalence of neuropsychiatric symptoms was 41% (95% CI 33%-49%): pain/discomfort (52%, 95% CI 42%-63%), sleep disturbance (37%, 95% CI 0%-98%), anxiety (36%, 95% CI 27%-46%), depression (31%, 95% CI 22%-40%), and PTSD (18%, 95% CI 9%-29%). The prevalence of neurocognitive impairment was 38% (95% CI 13%-65%). The prevalence of functional impairment was 52% (95% CI 40%-64%): daily activities (54%, 95% CI 41%-66%), mobility (41%, 95% CI 28%-54%), and self-care (21%, 95% CI 13%-31%). The prevalence of neuropsychiatric symptoms in VV-ECMO patients was higher than that in VA-ECMO patients (55% [95% CI 34%-75%] vs 32% [95% CI 23%-41%], p = 0.01), though the prevalence of neurocognitive and functional impairment was not different between the groups. The prevalence of favorable neurologic outcomes was not different at various follow-ups: 3 months (23%, 95% CI 12%-36%), 6 months (25%, 95% CI 16%-35%), and ≥1 year (28%, 95% CI 21%-36%, p = 0.68).

DISCUSSION

A substantial proportion of ECMO patients seemed to experience neuropsychiatric symptoms and neurocognitive and functional impairments at long-term follow-up. Considerable heterogeneity in methodology for gauging these outcomes exists, warranting the need for standardization. Multicenter prospective observational studies are indicated to further investigate risk factors for these outcomes in ECMO-supported patients.

The impact of psychedelics on patients with alcohol use disorder: a systematic review with meta-analysis

OBJECTIVES

Critique the available systematic review and de novo assessment of the role of psychedelics in the treatment of alcohol use disorder.

METHODS

A systematic literature search of PubMed was completed from 1960 to 9/9/2023. We pooled randomized controlled trials comparing psychedelics to control therapy for the treatment of alcohol use disorder.

RESULTS

At the first recorded follow-up, LSD [n = 3, Odds Ratio (OR) 1.99 (95% Confidence interval (CI): 1.10 to 3.61)] and any psychedelic [n = 4, OR 2.16 (95%CI: 1.26 to 3.69)] enhanced the odds of patients achieving abstinence or a substantial reduction in drinking alcohol versus placebo in randomized, double-blind, placebo-controlled trials. When the inclusion criteria were relaxed to include controlled trials without double-blinding or placebo control, LSD [n = 5, OR 1.79 (95%CI: 1.36 to 2.34)] and any psychedelic therapy [n = 6, OR 1.89 (95%CI: 1.42 to 2.50)] still enhanced the odds of patients achieving abstinence or a substantial reduction in drinking alcohol. Four of 6 trials had high risk of bias and other methodological issues. One trial found an instance of suicidal ideation as well as transient increases in blood pressure that requires further exploration before the balance of benefits to harms can be determined.

CONCLUSIONS

The use of psychedelics to treat alcohol use disorder is promising, but the weaknesses in the literature base preclude making definitive statements about its value. Future trials with greater methodological rigor are needed.

Diagnostic prediction models to identify patients at risk for healthcare-facility-onset Clostridioides difficile: A systematic review of methodology and reporting

OBJECTIVE

To systematically review the methodology, performance, and generalizability of diagnostic models for predicting the risk of healthcare-facility-onset (HO) Clostridioides difficile infection (CDI) in adult hospital inpatients (aged ≥18 years).

BACKGROUND

CDI is the most common cause of healthcare-associated diarrhea. Prediction models that identify inpatients at risk of HO-CDI have been published; however, the quality and utility of these models remain uncertain.

METHODS

Two independent reviewers evaluated articles describing the development and/or validation of multivariable HO-CDI diagnostic models in an inpatient setting. All publication dates, languages, and study designs were considered. Model details (eg, sample size and source, outcome, and performance) were extracted from the selected studies based on the CHARMS checklist. The risk of bias was further assessed using PROBAST.

RESULTS

Of the 3,030 records evaluated, 11 were eligible for final analysis, which described 12 diagnostic models. Most studies clearly identified the predictors and outcomes but did not report how missing data were handled. The most frequent predictors across all models were advanced age, receipt of high-risk antibiotics, history of hospitalization, and history of CDI. All studies reported the area under the receiver operating characteristic curve (AUROC) as a measure of discriminatory ability. However, only 3 studies reported the model calibration results, and only 2 studies were externally validated. All of the studies had a high risk of bias.

CONCLUSION

The studies varied in their ability to predict the risk of HO-CDI. Future models will benefit from the validation on a prospective external cohort to maximize external validity.

The association between metabolic syndrome and major adverse cardiac and cerebrovascular events in patients with acute coronary syndrome undergoing percutaneous coronary intervention

Metabolic syndrome (MetS) poses an additional risk for the development of coronary artery disease and major adverse cardiac and cerebrovascular events (MACCE). In this study, we investigated the association between MetS and its components and MACCE after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). The presence of MetS was calculated at baseline using the NCEP-ATP III criteria. The primary outcome was MACCE and its components were secondary outcomes. Unadjusted and adjusted Cox Regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CI) of the association between MetS or its components and MACCE and its components. A total of 13,459 ACS patients who underwent PCI (MetS: 7939 and non-MetS: 5520) with a mean age of 62.7 ± 11.0 years (male: 72.5%) were included and median follow-up time was 378 days. Patients with MetS had significantly higher MACCE risk (adjusted HR [aHR] 1.22, 95% CI 1.08-1.39). The only component of MACCE that exhibited a significantly higher incidence in MetS patients was myocardial infarction (aHR 1.43, 95% CI 1.15-1.76). MetS components that were significantly associated with a higher incidence of MACCE were hypertension and impaired fasting glucose. Having three MetS components did not increase MACCE (aHR 1.12, 95% CI 0.96-1.30) while having four (aHR 1.32, 95% CI 1.13-1.55) or five (aHR 1.42, 95% CI 1.15-1.75) MetS components was associated with a higher incidence of MACCE. MetS was associated with a higher risk of MACCE in ACS patients undergoing PCI. Among MACCE components, myocardial infarction was significantly higher in patients with MetS. Impaired fasting glucose and hypertension were associated with a higher risk of MACCE. Identifying these patterns can guide clinicians in choosing appropriate preventive measures.

Vegetarian diets on anthropometric, metabolic and blood pressure outcomes in people with overweight and obesity: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

It is unknown whether vegetarian diets (VDs) may improve outcomes in people with overweight and obesity.

OBJECTIVE

To systematically assess the effects of VDs vs. omnivore diets on anthropometric, metabolic, and blood pressure outcomes in people with overweight and obesity.

METHODS

We searched for randomized controlled trials (RCTs) in EMBASE, PubMed, Web of Science, and Scopus until February 2, 2022. Primary outcomes were anthropometric risk factors (weight, body mass index [BMI], waist circumference [WC], hip circumference [HC], and body fat percentage). Secondary outcomes were metabolic risk factors (fasting serum glucose, HbA1c, insulin levels) and blood pressure (systolic blood pressure [SBP], diastolic blood pressure [DBP]). Random-effects meta-analyses were performed and effects were expressed as mean difference (MD) and their 95% confidence intervals (CI). The quality of evidence was assessed using GRADE methods.

RESULTS

Nine RCTs (n = 1628) were included. VDs decreased weight (MD -3.60 kg, 95%CI -4.75 to -2.46) and glucose (MD -10.64 mg/dL, 95%CI -15.77 to -5.51), but did not decrease WC (MD -3.00 cm, 95%CI -6.20 to 0.20), BMI (MD -0.87 kg/m2, 95%CI -1.80 to 0.06), or HC (MD: -0.86 cm, 95%CI -3.46 to 1.74). VDs did not decrease HbA1c (MD -0.40%, 95%CI -0.89 to 0.10), insulin (MD -3.83 mU/L, 95%CI -8.06 to 0.40), SBP (MD -0.25 mmHg, 95%CI -2.58 to 2.07), or DBP (MD -1.57 mmHg, 95%CI -3.93 to 0.78). Subgroup analyses by type of VD (four RCTs evaluated lacto-ovo-vegetarian diets and five RCTs vegan diets) showed similar results to the main analyses. QoE was very low for most of the outcomes.

CONCLUSIONS

In comparison to an omnivorous diet, VDs may reduce weight and glucose, but not blood pressure or other metabolic or anthropometric outcomes. However, the QoE was mostly very low. Larger RCTs are still needed to evaluate the effects of VD on anthropometric, metabolic factors, and blood pressure in people with overweight and obesity.

Impact of Frailty on Clinical Outcomes in Patients With Atrial Fibrillation Who Underwent Cardiac Ablation Using a Nationwide Database

This study aimed to assess the association between frailty and clinical outcomes in patients with atrial fibrillation (AF) who undergo catheter ablation. We conducted a retrospective cohort study using the National Inpatient Sample database from 2017 to 2019. Adult patients hospitalized with a primary diagnosis of AF who underwent catheter ablation were included. Frailty was assessed using the Hospital Frailty Risk Score. The primary outcome was the presence of any complication (vascular, cardiac, respiratory, neurologic, or infectious), and secondary outcomes were in-hospital mortality, length of hospital stay, and hospital charges. A total of 21,075 weighted hospitalizations were included, and 14% were classified as intermediate or great risk of frailty. Patients with intermediate (adjusted relative risk 2.86, 95% confidence interval 2.24 to 3.67) and great (adjusted relative risk 6.68, 95% confidence interval 3.77 to 11.84) risk of frailty were associated with a greater risk of any complication than that of the group at less risk. The in-hospital mortality rate was significantly higher among patients at intermediate risk than among those at less risk of frailty (2.6% vs 0.1%, p <0.001). Patients with great and intermediate risk had significantly longer hospital stays than did the group with less risk (median 14 vs 5 vs 2 days, p <0.001), in addition to greater total charges (median $189,072 vs $161,598 vs $130,672, p <0.001), respectively. In conclusion, frailty was associated with a greater risk of poor short-term outcomes in patients with AF who underwent catheter ablation. The Hospital Frailty Risk Score is a useful tool for identifying patients at increased risk of adverse events and could aid in preoperative optimization and postoperative management.

Echocardiographic Criteria to Differentiate Constrictive Pericarditis From Restrictive Cardiomyopathy: A Meta-analysis

Background

To assess the diagnostic accuracy of the Mayo Clinic echocardiographic criteria for differentiating between constrictive pericarditis and restrictive cardiomyopathy.

Methods

We searched electronic databases for the date range from their inception to July 1, 2022. The index tests were the Mayo Clinic echocardiographic criteria. We performed a bivariate random-effects model to estimate the pooled sensitivity and specificity, each with 95% confidence interval (CI). The area under the curve of the summary receiver operator characteristic curves, with 95% CI, was also calculated.

Results

We included 17 case-control studies involving 889 patients. The pooled sensitivity and specificity (95% CI), respectively, were as follows: ventricular septal shift, 82% (60%-94%) and 78% (65%-87%); respiratory variation in mitral inflow ≥ 14.6%, 71% (51%-85%) and 82% (66%-91%); septal e' velocity ≥ 8 cm/s, 83% (80%-87%) and 90% (83%-95%); septal e' velocity/lateral e' velocity ≥ 0.88, 74% (64%-82%) and 81% (70%-88%); and hepatic vein ratio in expiration ≥ 0.79, 73% (65%-81%) and 71% (19%-96%). The area under the curve of the summary receiver operator characteristic curves varied from 0.75 to 0.85, with overlapping CIs across index tests.

Conclusions

Our meta-analysis suggests that all echocardiographic parameters from the Mayo Clinic criteria have good diagnostic accuracy for differentiating between constrictive pericarditis and restrictive cardiomyopathy.

Severe cardiac events induced by combination immunotherapy in patients with cancer: a meta-analysis

Introduction

The use of combined immunotherapy could increase non-severe and severe cardiac events in patients with cancer. To examine the occurrence of severe cardiac adverse events of combined immunotherapy compared to single immunotherapy, we analysed 4 electronic databases from inception to August 2021.

Material and methods

We selected randomized controlled trials (RCTs) comparing combined versus single immunotherapy, for the treatment of melanoma, oesophagogastric cancer, renal cell carcinoma, and non-small cell lung cancer. Pre-defined combined immunotherapy included monoclonal antibodies against programmed cell death 1 (PD-1 inhibitors) plus against cytotoxic T lymphocyte antigen 4 (CTLA-4 inhibitors) or against programmed cell death ligand 1 (PD-L1 inhibitors) plus CTLA-4 inhibitors. The pooled risk ratios (RR) with their 95% confidence intervals (CI) were estimated using a random-effects model.

Results

Four RCTs involving 1581 patients were included, with a follow-up time between 18 and 39 months. The use of combined immunotherapy in comparison with single immunotherapy was not associated with an increased risk of severe cardiac adverse events: acute coronary syndromes (RR = 1.76, 95% CI: 0.29-10.83, very low certainty of evidence (CoE)), myocardial infarction (RR = 3.93, 95% CI: 0.44-35.39, very low CoE), heart failure (RR = 2.99, 95% CI: 0.61-14.79, very low CoE), and atrial fibrillation (RR = 2.26, 95% CI: 0.62-8.16, very low CoE).

Conclusions

Our meta-analysis shows that the risk of severe cardiac adverse events with combined immunotherapy seems similar to single immunotherapy, but the evidence is very uncertain. Therefore, more RCTs with longer follow-ups and adequately powered to assess cardiac adverse events are needed to confirm these findings.

The added value of hypertonic saline solution to furosemide monotherapy in patients with acute decompensated heart failure: A meta-analysis and trial sequential analysis

We assessed the effects of hypertonic saline solution (HSS) plus furosemide versus furosemide alone in patients with acute decompensated heart failure (ADHF). We searched four electronic databases for randomized controlled trials (RCTs) until June 30, 2022. The quality of evidence (QoE) was assessed using the GRADE approach. All meta-analyses were performed using a random-effects model. A trial sequential analysis (TSA) was also conducted for intermediate and biomarker outcomes. Ten RCTs involving 3013 patients were included. HSS plus furosemide significantly reduced the length of hospital stay (mean difference [MD]: -3.60 days; 95% confidence interval [CI]: -4.56 to -2.64; QoE: moderate), weight (MD: -2.34 kg; 95% CI: -3.15 to -1.53; QoE: moderate), serum creatinine (MD: -0.41 mg/dL; 95% CI: -0.49 to -0.33; QoE: low), and type-B natriuretic peptide (MD: -124.26 pg/mL; 95% CI: -207.97 to -40.54; QoE: low) compared to furosemide alone. HSS plus furosemide significantly increased urine output (MD: 528.57 mL/24 h; 95% CI: 431.90 to 625.23; QoE: moderate), serum Na+ (MD: 6.80 mmol/L; 95% CI: 4.92 to 8.69; QoE: low), and urine Na+ (MD: 54.85 mmol/24 h; 95% CI: 46.31 to 63.38; QoE: moderate) compared to furosemide alone. TSA confirmed the benefit of HSS plus furosemide. Due to the heterogeneity in mortality and heart failure readmission, meta-analysis was not performed. Our study shows that HSS plus furosemide, compared to furosemide alone, improved surrogated outcomes in ADHF patients with low or intermediate QoE. Adequately powered RCTs are still needed to assess the benefit on heart failure readmission and mortality.

The Impact of Psychedelic Drugs on Anxiety and Depression in Advanced Cancer or other Life-threatening Disease: A Systematic Review With Meta-analysis

OBJECTIVES

Life-threatening cancer or other diseases can induce anxiety and depressive symptoms. We performed a systematic review with meta-analyses of randomized controlled trials assessing patients with cancer or other life-threatening diseases using validated anxiety and depression scales.

METHODS

PubMed was searched up to November 15, 2022 and citations were applied to prespecified inclusion criteria. Disease rating scales for anxiety or depression included the State-Trait Anxiety Inventory (STAI) (STAI Trait [STAI-T], STAI-State [STAI-S]), Beck Depression Inventory (BDI), Hospital Anxiety and Depression Scale (HADS) (HADS-Anxiety [HADS-A]; HADS-Depression [HADS-D]), Profile of Mood States (POMS), and the Hamilton Rating Scale for Depression (HAM-D or GRID-HAM-D-17). Safety outcomes included assessments of blood pressure and heart rate.

RESULTS

Five trials, predominantly in cancer patients, had data assessing anxiety and depressive symptoms. These trials found promising results for psychedelics versus placebo in several anxiety and depression scales but increases in blood pressure and heart rate also occurred. There were some concerns of risk of bias because it is difficult to truly randomize a psychedelic trial and there was a high percentage of patients in the trials who had used psychedelics in the past. There was high heterogeneity for all analyses that we could not explain.

CONCLUSIONS

Although the results are promising, future trials are needed to assess the optimal psychedelic, dose, number of sessions required, and how psychedelic naïve patients would respond both psychologically and hemodynamically before this therapy can be considered for widescale clinical use.

Weight and Metabolic Outcomes in Naïve HIV Patients Treated with Integrase Inhibitor-Based Antiretroviral Therapy: A Systematic Review and Meta-Analysis

BACKGROUND

The use of integrase inhibitor-based antiretroviral therapy could be associated with worse weight and metabolic outcomes in patients with HIV infection.

METHODS

PubMed, EMBASE, and Scopus were searched from inception to March 2022. We selected randomized controlled trials (RCTs) comparing integrase inhibitors with other antiretroviral classes (efavirenz-based or protease inhibitor-based therapies) in naïve HIV patients. Random effects meta-analysis was used to assess the effects of integrase inhibitors vs. controls on weight and lipid outcomes. Effects were described as mean differences (MD) and their 95% confidence intervals (CI). Certain pieces of evidence (CoE) were evaluated using the GRADE methodology.

RESULTS

Six RCTs (n = 3521) were included, with patients followed up between 48 and 96 weeks. The use of integrase inhibitors in comparison with other antiretroviral classes was associated with an increase in weight (MD 2.15 kg, 95%CI 1.40 to 2.90, I² = 0%, moderate CoE), and decreases in total cholesterol (MD -13.44 mg/dL, 95%CI -23.49 to -3.39, I² = 96%, low CoE), LDL cholesterol (MD -1.37 mg/dL, 95%CI -19.24 to -3.50, I² = 83%, low CoE), HDL cholesterol (MD -5.03 mg/dL, 95%CI -10.61 to 0.54, I² = 95%, low CoE), and triglycerides (MD -20.70 mg/dL, 95%CI -37.25 to -4.15, I² = 92%, low CoE). There was a high risk of bias in two RCTs and some concerns about bias in two RCTs.

CONCLUSIONS

In HIV patients, the use of integrase inhibitor-based therapy in comparison with protease inhibitor- or NNRTI-based therapy was associated with a small increase in weight and small decreases in lipid serum levels.

Efficacy and safety of sacubitril/valsartan in heart failure compared to renin-angiotensin-aldosterone system inhibitors: a systematic review and meta-analysis of randomised controlled trials

Introduction

Heart failure (HF) is still a major cause of morbidity and mortality all over the world. Aim of the study was to assess the benefits and harms of sacubitril/valsartan (S/V) compared to angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) in patients with HF.

Material and methods

We systematically searched for randomised controlled trials (RCTs) evaluating S/V vs. ACEI or ARB in acute or chronic HF in August 2021. Primary outcomes were HF hospitalisations and cardiovascular (CV) mortality; secondary outcomes included all-cause mortality, biomarkers, and renal function.

Results

We selected 11 RCTs (n = 18766) with 2-48 months follow-up. Five RCTs had ACEIs as control, 5 RCTs had ARBs as control, and one RCT had both ACEI and ARB as control. Compared to ACEI or ARB, S/V reduced HF hospitalisations by 20% (HR = 0.80, 95% CI: 0.68-0.94; 3 RCTs; I2 = 65%; high CoE), CV mortality by 14% (HR = 0.86, 95% CI: 0.73-1.01; 2 RCTs; I2 = 57%; high CoE), and all-cause mortality by 11% (HR = 0.89, 95% CI: 0.78-1.00; 3 RCTs; I2 = 36%; high CoE). S/V reduced NTproBNP (SMD = -0.34, 95% CI: -0.52 to -0.16; 3 RCTs; I2 = 62%) and hs-TNT (ratio of differences = 0.84, 95% CI: 0.79-0.88; 2 RCTs; I2 = 0%), and caused a decline in renal function by 33% (HR = 0.67, 95% CI: 0.39-1.14; 2 RCTs; I2 = 78%; high CoE). S/V increased hypotension (RR = 1.69, 95% CI: 1.33-2.15; 9 RCTs; I2 = 65%; high CoE). Hyperkalaemia and angioedema events were similar. Effects were in the same direction when stratified by type of control (ACEI vs. ARB).

Conclusions

Sacubitril/valsartan had better clinical, intermediate, and renal outcomes in HF in comparison to ACEI or ARB. There was no difference in angioedema and hyperkalaemia events, but there were more hypotension events.

Impact of Berberine or Berberine Combination Products on Lipoprotein, Triglyceride and Biological Safety Marker Concentrations in Patients with Hyperlipidemia: A Systematic Review and Meta-Analysis

Monoclonal antibody Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) inhibitors reduce total cholesterol (TC), low density lipoproteins (LDL), high density lipoproteins (HDL), and triglycerides (TG). We assessed the ability of berberine, a natural PCSK9 inhibitor, to reduce lipid concentrations either alone or combined with other nutraceuticals. We searched PubMed, Scopus and EMBASE from inception to September 30th, 2022 for randomized controlled trials (RCTs) assessing 8-18 wk of berberine therapy on. A total of 41 RCTs with 4,838 patients met our inclusion criteria. Berberine containing products significantly reduced TC (MD -17.42 mg/dL [95%CI: -22.91 to -11.93]), LDL (MD -14.98 mg/dL [95%CI: -20.67 to -9.28]), and TG (MD -18.67 mg/dL [95%CI: -25.82 to -11.51]) while raising HDL (MD 1.97 mg/dL [95%CI: 1.16 to 2.78]) versus control (I2 > 72% for all analyses). Products with berberine alone had less robust effects on TC (MD -12.08 mg/dL [95%CI: -21.79 to -2.37]), LDL (MD -9.26 mg/dL [95%CI: -20.31 to 1.78]), and HDL (MD 1.38 mg/dL [95%CI: -1.27 to 4.03]) but TG effects were similar (MD -17.40 mg/dL [95%CI: -32.57 to -2.23]). Berberine along with red yeast rice reduced TC (MD -19.62 mg/dL [95%CI: -28.56 to -10.68]) and LDL (MD -18.79 mg/dL [95%CI: -28.03 to -9.54]) as did combination therapy with Silybum maranium for TC (MD -31.81 mg/dL [95%CI: -59.88 to -3.73]) and LDL (MD -30.82 mg/dL [95%CI: -56.48 to -5.16]). Berberine, alone or with other nutraceuticals, can provide a modest positive impact on lipid concentrations.

Disease State Transition Probabilities Across the Spectrum of NAFLD: A Systematic Review and Meta-Analysis of Paired Biopsy or Imaging Studies

BACKGROUND & AIMS

We conducted a meta-analysis to summarize the rates of progression to and regression of nonalcoholic fatty liver (NAFL), nonalcoholic steatohepatitis (NASH), and fibrosis in adults with nonalcoholic fatty liver disease (NAFLD).

METHODS

We searched PubMed/Medline and 4 other databases from 1985 through 2020. We included observational studies and randomized controlled trials in any language that used liver biopsy or imaging to diagnose NAFLD in adults with a follow-up period ≥48 weeks. Rates were calculated as incident cases per 100 person-years and pooled using the random-effects Poisson distribution model. Heterogeneity was assessed using the I2 statistic.

RESULTS

We screened 9744 articles and included 54 studies involving 26,738 patients. Among observational studies, 20% of healthy adults developed NAFL (incidence rate, 4.8/100 person-years) while 21% of people with fatty liver had resolution of NAFL (incidence rate, 2.4/100 person-years) after a median of approximately 4.5 years. In addition, 31% of patients developed NASH after 4.7 years (incidence rate, 7.4/100 person-years), whereas in 29% of those with NASH, resolution occurred after a median of 3.5 years (incidence rate, 5.1/100 person-years). Time to progress by 1 fibrosis stage was 9.9, 10.3, 13.3, and 22.2 years for F0, F1, F2, and F3, respectively. Time to regress by 1 stage was 21.3, 12.5, 20.4, and 40.0 years for F4, F3, F2, and F1, respectively. Rates estimated from randomized controlled trials were higher than those from observational studies.

CONCLUSIONS

In our meta-analysis, progression to NASH was more common than regression from NASH. Rates of fibrosis progression were similar across baseline stage, but patients with advanced fibrosis were more likely to regress than those with mild fibrosis.

Effects of Probiotics on Intermediate Cardiovascular Outcomes in Patients with Overweight or Obesity: A Systematic Review and Meta-Analysis

Background: Clinical trials evaluating the effect of probiotics on cardiovascular intermediate outcomes have been scarce in recent years. We systematically evaluated the efficacy of probiotics on intermediate cardiovascular outcomes in patients with overweight or obesity. Methods: We searched for randomized controlled trials (RCTs) in four databases (until August 2021) that evaluated the effects of probiotics versus controls on intermediate cardiovascular outcomes. The outcomes were body mass index (BMI), weight, systolic blood pressure (SBP), diastolic blood pressure (DBP), glucose, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) levels. Inverse variance random effects meta-analyses were used. The effects were reported as mean difference (MD), with their 95% confidence intervals (95% CI). The quality of evidence (QoE) was assessed with GRADE (grading of recommendations, assessment, development and evaluations) methodology. Results: A total of 25 RCTs were included (n = 2170), with a range of follow-up from two to six months. Probiotics likely reduced BMI (MD −0.27 kg/m2, 95%CI: −0.35 to −0.19; 17 RCTs; I2 = 26%, QoE: moderate), as well as likely reduced weight (MD −0.61 kg, 95%CI: −0.89 to −0.34; 15 RCTs; I2 = 0%, QoE: moderate), and may have slightly reduce LDL (MD −4.08 mg/dL; 95%CI: −6.99 to −1.17; 9 RCTs; I2 = 87%, QoE: low) in comparison to the controls. However, probiotics had no effect on SBP (MD −0.40 mmHg; 95%CI: −5.04 to 4.25; 7 RCTs; I2 = 100%, QoE: very low), DBP (MD −1.73 mmHg; 95%CI: −5.29 to 1.82; 5 RCTs; I2 = 98%, QoE: very low), glucose (MD −0.07 mg/dL; 95%CI −0.89 to 0.75; I2 = 96%, QoE: very low), HDL (MD −1.83 mg/dL; 95%CI: −4.14 to 2.47; 14 RCTs; I2 = 98%, QoE: very low), or triglycerides (MD −3.29 mg/dL, 95%CI −17.03 to 10.45; 14 RCTs, I2 = 95%, QoE: very low) compared to control arms, and the evidence was very uncertain. Conclusions: In obese or overweight patients, BMI, weight, and LDL were lower in patients who received probiotics compared to those who received controls. Other lipids, glucose, and blood pressure were not affected by the probiotics.

Short-term outcomes of endoscopic submucosal dissection for the treatment of superficial gastric neoplasms in non-Asian countries: a systematic review and meta-analysis

Background

Endoscopic submucosal dissection (ESD) is now considered the standard treatment for early gastric cancer (EGC). However, the widespread adoption of ESD in western countries has been slow. We performed a systematic review to evaluate short-term outcomes of ESD for EGC in non-Asian countries.

Methods

We searched 3 electronic databases from inception until October 26, 2022. Primary outcomes were en bloc, R0 and curative resections rate by region. Secondary outcomes were overall complications, bleeding, and perforation rate by region. The proportion of each outcome, with the 95% confidence interval (CI), was pooled using a random-effects model with the Freeman-Tukey double arcsine transformation.

Results

Twenty-seven studies from Europe (n=14), South America (n=11) and North America (n=2) were included, involving 1875 gastric lesions. Overall, en bloc, R0, and curative resection rates were achieved in 96% (95%CI 94-98%), 85% (95%CI 81-89%), and 77% (95%CI 73-81%) of cases, respectively. Considering only information from lesions with adenocarcinoma, the overall curative resection was 75% (95CI 70-80%). Bleeding and perforation were observed in 5% (95%CI 4-7%) and 2% (95%CI 1-4%) of cases, respectively.

Conclusion

Our results suggest that short-term outcomes of ESD for the treatment of EGC are acceptable in non-Asian countries.

Nutraceutical approaches to non-alcoholic fatty liver disease (NAFLD): A position paper from the International Lipid Expert Panel (ILEP)

Non-Alcoholic Fatty Liver Disease (NAFLD) is a common condition affecting around 10-25% of the general adult population, 15% of children, and even > 50% of individuals who have type 2 diabetes mellitus. It is a major cause of liver-related morbidity, and cardiovascular (CV) mortality is a common cause of death. In addition to being the initial step of irreversible alterations of the liver parenchyma causing cirrhosis, about 1/6 of those who develop NASH are at risk also developing CV disease (CVD). More recently the acronym MAFLD (Metabolic Associated Fatty Liver Disease) has been preferred by many European and US specialists, providing a clearer message on the metabolic etiology of the disease. The suggestions for the management of NAFLD are like those recommended by guidelines for CVD prevention. In this context, the general approach is to prescribe physical activity and dietary changes the effect weight loss. Lifestyle change in the NAFLD patient has been supplemented in some by the use of nutraceuticals, but the evidence based for these remains uncertain. The aim of this Position Paper was to summarize the clinical evidence relating to the effect of nutraceuticals on NAFLD-related parameters. Our reading of the data is that whilst many nutraceuticals have been studied in relation to NAFLD, none have sufficient evidence to recommend their routine use; robust trials are required to appropriately address efficacy and safety.

A systematic review of primary care-focused, self-reported medication adherence tools

BACKGROUND

Clinician recognition of nonadherence is generally low. Tools that clinicians have used to assess medication adherence are self-reported adherence instruments that ask patients questions about their medication use experience. There is a need for more structured reviews that help clinicians comprehensively distinguish which tool might be most useful and valuable for their clinical setting and patient populations.

OBJECTIVES

This systematic review aimed to (1) identify validated, self-reported medication adherence tools that are applicable to the primary care setting and (2) summarize selected features of the tools as an assessment of clinical feasibility and applicability.

METHODS

The investigators systematically reviewed MEDLINE via Ovid, Embase via Ovid, International Pharmaceutical Abstracts, and CINAHL from inception to December 1, 2020. Investigators independently screened 3394 citations, identifying 43 articles describing validation parameters for 25 unique adherence tools. After screening each tool, 17 tools met the inclusion criteria and were qualitatively summarized.

RESULTS

Findings highlight 25 various tool characteristics (i.e., descriptions, parameters and diseases, measures and validity comparators, and other information), which clinicians might consider when selecting a self-reported adherence tool with strong measurement validity that is practical to administer to patients. There was much variability about the nature and extent of adherence measurement. Considerable variation was noted in the objective measures used to correlate to the self-reported tools' measurements. There were wide ranges of correlation between self-reported and objective measures. Several included tools had relatively low to moderate criterion validities. Many manuscripts did not describe whether tools were associated with costs, had copyrights, and were available in other languages; how much time was required for patients to complete self-report tools; and whether patient input informed tool development.

CONCLUSION

There is a critical need to ensure that adherence tool developers establish a key list of tool characteristics to report to help clinicians and researchers make practical comparisons among tools.