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Tanggaard K, Gronlund C, Nielsen MV, la Cour K, Tvarnø CD, Børglum J, Maagaard M, Mathiesen O. Anterior quadratus lumborum blocks for postoperative pain treatment following intra-abdominal surgery: A systematic review with meta-analyses and trial sequential analyses. Acta Anaesthesiol Scand 2024. [PMID: 39420745 DOI: 10.1111/aas.14526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 09/08/2024] [Accepted: 09/10/2024] [Indexed: 10/19/2024]
Abstract
BACKGROUND The anterior quadratus lumborum (QL) block may be used for postoperative pain management for intra-abdominal surgeries, but the evidence is uncertain. We aimed to investigate the benefit and harm of the anterior QL block compared to placebo/no block for intra-abdominal surgery. METHODS We searched Medline, Embase, and CENTRAL for randomized controlled trials investigating anterior QL block for postoperative pain management for adult patients undergoing any intra-abdominal surgery. The two co-primary outcomes were cumulative 24-h opioid consumption and serious adverse events. We performed meta-analysis, trial sequential analysis (TSA), assessed the risk of bias, and present the certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluation approach. RESULTS Thirty-five trials randomizing 2418 patients were included in the meta-analyses. Anterior QL block may reduce cumulative 24-h intravenous opioid consumption compared to placebo/no block (MD -10.42 mg, 96.7% CI -14.83 to -6.01, TSA-adjusted CI -17.03 to -3.82, p < .01). Two trials reported on SAEs. Anterior QL block may have little to no effect on the number of serious adverse events compared to placebo (RR 1.49, 96.7% CI 0.19 to 11.47, p = .68), but the evidence is very uncertain. All trial results were assessed as being high risk of bias. CONCLUSIONS The anterior QL block may reduce cumulative 24-h opioid consumption. Reported serious adverse events were few and the anterior QL block may have little to no effect on the number of SAEs, but the evidence was very uncertain.
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Affiliation(s)
- Katrine Tanggaard
- Centre for Anaesthesiological Research, Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Denmark
| | - Caroline Gronlund
- Centre for Anaesthesiological Research, Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Denmark
| | - Martin V Nielsen
- Centre for Anaesthesiological Research, Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Denmark
| | - Kirstine la Cour
- Centre for Anaesthesiological Research, Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Denmark
| | - Casper D Tvarnø
- Centre for Anaesthesiological Research, Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Denmark
| | - Jens Børglum
- Centre for Anaesthesiological Research, Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Laigaard J, Karlsen A, Maagaard M, Haxholdt Lunn T, Mathiesen O, Overgaard S. Perioperative Analgesic Interventions for Reduction of Persistent Postsurgical Pain After Total Hip and Knee Arthroplasty: A Systematic Review and Meta-analysis. Anesth Analg 2024:00000539-990000000-00994. [PMID: 39418206 DOI: 10.1213/ane.0000000000007246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2024]
Abstract
BACKGROUND High pain levels immediately after surgery have been associated with persistent postsurgical pain. Still, it is uncertain if analgesic treatment of immediate postsurgical pain prevents the development of persistent postsurgical pain. METHODS We searched MEDLINE, CENTRAL, and Embase up to September 12, 2023, for randomized controlled trials investigating perioperative analgesic interventions and with reported pain levels 3 to 24 months after total hip or knee arthroplasty in patients with osteoarthritis. The primary outcome was pain score 3 to 24 months after surgery, assessed at rest and during movement separately. Two authors independently screened, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2 tool. We conducted meta-analyses and tested their robustness with trial sequential analyses and worst-best and best-worst case analyses. RESULTS We included 49 trials with 68 intervention arms. All but 4 trials were at high risk of bias for the primary outcome. Moreover, the included trials were heterogeneous in terms of exclusion criteria, baseline pain severity, and which cointerventions the participants were offered. For pain at rest, no interventions demonstrated a statistically significant difference between intervention and control. For pain during movement, perioperative treatment with duloxetine (7 trials with 641 participants) reduced pain scores at 3 to 24 months after surgery (mean difference -4.9 mm [95% confidence interval {CI}, -6.5 to -3.4] on the 0-100 visual analog scale) compared to placebo. This difference was lower than our predefined threshold for clinical importance of 10 mm. CONCLUSIONS We found no perioperative analgesic interventions that reduced pain 3 to 24 months after total hip or knee arthroplasty for osteoarthritis. The literature on perioperative analgesia focused little on potential long-term effects. We encourage the assessment of long-term pain outcomes.
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Affiliation(s)
- Jens Laigaard
- From the Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anders Karlsen
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Mathias Maagaard
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Troels Haxholdt Lunn
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Søren Overgaard
- From the Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
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Korang SK, Baker M, Feinberg J, Newth CJ, Khemani RG, Jakobsen JC. Non-invasive positive pressure ventilation for acute asthma in children. Cochrane Database Syst Rev 2024; 10:CD012067. [PMID: 39356050 PMCID: PMC11445801 DOI: 10.1002/14651858.cd012067.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2024]
Abstract
BACKGROUND Asthma is one of the most common reasons for hospital admission among children, with significant economic burden and impact on quality of life. Non-invasive positive pressure ventilation (NPPV) is increasingly used in the care of children with acute asthma, although the evidence supporting it is weak, and clinical guidelines do not offer any recommendations on its routine use. However, NPPV might be an effective way to improve outcomes for some children with asthma. A previous review did not demonstrate a clear benefit, but was limited by few studies with small sample sizes. This is an update of the previous review. OBJECTIVES To assess the benefits and harms of NPPV as an add-on therapy to usual care (e.g. bronchodilators and corticosteroids) in children (< 18 years) with acute asthma. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, and Embase. We also conducted a search of ClinicalTrials.gov and the WHO ICTRP. We searched all databases from their inception to March 2023, with no restrictions on language of publication. SELECTION CRITERIA We included randomised clinical trials (RCTs) assessing NPPV as add-on therapy to usual care versus usual care for children hospitalised for acute asthma exacerbations. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. MAIN RESULTS We included three RCTs randomising 60 children with acute asthma to NPPV and 60 children to control. All included trials assessed the effects of bilevel positive airway pressure (BiPAP) for acute asthma in a paediatric intensive care unit (PICU) setting. None of the trials used continuous positive airway pressure (CPAP). The controls received standard care. The median age of children ranged from three to six years, and asthma severity ranged from moderate to severe. Our primary outcome measures were all-cause mortality, serious adverse events, and asthma symptom score. Secondary outcomes were non-serious adverse events, health-related quality of life, arterial blood gases and pH, pneumonia, cost, and PICU length of stay. None of the trials reported any deaths or serious adverse events (except one trial that reported intubation rate). Two trials reported asthma symptom score, each demonstrating reductions in asthma symptoms in the BiPAP group. In one trial, the asthma symptom score was (mean difference (MD) -2.50, 95% confidence interval (CI) -4.70 to -0.30, P = 0.03; 19 children) lower in the BiPAP group. In the other trial, a cross-over trial, BiPAP was associated with a lower mean asthma symptom score (MD -3.7; 16 children; very low certainty evidence) before cross-over, but investigators did not report a standard deviation, and it could not be estimated from the first phase of the trial before cross-over. The reduction in both trials was above our predefined minimal important difference. Overall, NPPV with standard care may reduce asthma symptom score compared to standard care alone, but the evidence is very uncertain. The only reported serious adverse event was intubation rate in one trial. The trial had an intubation rate of 40% and showed that BiPAP may result in a large reduction in intubation rate (risk ratio 0.47, 95% CI 0.23 to 0.95; 78 children), but the evidence is very uncertain. Post hoc analysis showed that BiPAP may result in a slight decrease in length of PICU stay (MD -0.87 day, 95% CI -1.52 to -0.22; 100 children), but the evidence is very uncertain. Meta-analysis or Trial Sequential Analysis was not possible because of insufficient reporting and different scoring systems. All three trials had high risk of bias with serious imprecision of results, leading to very low certainty of evidence. AUTHORS' CONCLUSIONS The currently available evidence for NNPV is uncertain. NPPV may lead to an improvement in asthma symptom score, decreased intubation rate, and slightly shorter PICU stay; however, the evidence is of very low certainty. Larger RCTs with low risk of bias are warranted.
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Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Anesthesiology Critical Care Medicine, Childrens Hospital Los Angeles, Los Angeles, California, USA
| | | | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christopher Jl Newth
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Robinder G Khemani
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
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4
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Riberholt CG, Olsen MH, Milan JB, Hafliðadóttir SH, Svanholm JH, Pedersen EB, Lew CCH, Asante MA, Pereira Ribeiro J, Wagner V, Kumburegama BWMB, Lee ZY, Schaug JP, Madsen C, Gluud C. Major mistakes or errors in the use of trial sequential analysis in systematic reviews or meta-analyses - the METSA systematic review. BMC Med Res Methodol 2024; 24:196. [PMID: 39251912 PMCID: PMC11382479 DOI: 10.1186/s12874-024-02318-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 08/21/2024] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND Systematic reviews and data synthesis of randomised clinical trials play a crucial role in clinical practice, research, and health policy. Trial sequential analysis can be used in systematic reviews to control type I and type II errors, but methodological errors including lack of protocols and transparency are cause for concern. We assessed the reporting of trial sequential analysis. METHODS We searched Medline and the Cochrane Database of Systematic Reviews from 1 January 2018 to 31 December 2021 for systematic reviews and meta-analysis reports that include a trial sequential analysis. Only studies with at least two randomised clinical trials analysed in a forest plot and a trial sequential analysis were included. Two independent investigators assessed the studies. We evaluated protocolisation, reporting, and interpretation of the analyses, including their effect on any GRADE evaluation of imprecision. RESULTS We included 270 systematic reviews and 274 meta-analysis reports and extracted data from 624 trial sequential analyses. Only 134/270 (50%) systematic reviews planned the trial sequential analysis in the protocol. For analyses on dichotomous outcomes, the proportion of events in the control group was missing in 181/439 (41%), relative risk reduction in 105/439 (24%), alpha in 30/439 (7%), beta in 128/439 (29%), and heterogeneity in 232/439 (53%). For analyses on continuous outcomes, the minimally relevant difference was missing in 125/185 (68%), variance (or standard deviation) in 144/185 (78%), alpha in 23/185 (12%), beta in 63/185 (34%), and heterogeneity in 105/185 (57%). Graphical illustration of the trial sequential analysis was present in 93% of the analyses, however, the Z-curve was wrongly displayed in 135/624 (22%) and 227/624 (36%) did not include futility boundaries. The overall transparency of all 624 analyses was very poor in 236 (38%) and poor in 173 (28%). CONCLUSIONS The majority of trial sequential analyses are not transparent when preparing or presenting the required parameters, partly due to missing or poorly conducted protocols. This hampers interpretation, reproducibility, and validity. STUDY REGISTRATION PROSPERO CRD42021273811.
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Affiliation(s)
- Christian Gunge Riberholt
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark.
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 23, Glostrup, 2600, Denmark.
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark.
| | - Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark
| | - Joachim Birch Milan
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark
| | | | - Jeppe Houmann Svanholm
- Department of Gastrointestinal Surgery, Aalborg University Hospital South, Hobrovej 18-22, Aalborg, 9000, Denmark
| | - Elisabeth Buck Pedersen
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 23, Glostrup, 2600, Denmark
| | - Charles Chin Han Lew
- Department of Dietetics and Nutrition, Ng Teng Fong General Hospital, Singapore, Singapore
- Faculty of Health and Social Sciences, Singapore Institute of Technology, Singapore, Singapore
| | - Mark Aninakwah Asante
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark
| | - Johanne Pereira Ribeiro
- Center for Evidence-Based Psychiatry, Psychiatric Research Unit, Psychiatry Region Zealand, Faelledvej 6, Slagelse, 4200, Denmark
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
| | - Vibeke Wagner
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 23, Glostrup, 2600, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Buddheera W M B Kumburegama
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité, Berlin, Germany
| | - Julie Perrine Schaug
- Center for Evidence-Based Psychiatry, Psychiatric Research Unit, Psychiatry Region Zealand, Faelledvej 6, Slagelse, 4200, Denmark
| | - Christina Madsen
- Psychiatric Research Unit, Psychiatry Region Zealand, Region Zealand, Fælledvej 6, Slagelse, 4200, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Swierz MJ, Storman D, Mitus JW, Hetnal M, Kukielka A, Szlauer-Stefanska A, Pedziwiatr M, Wolff R, Kleijnen J, Bala MM. Transarterial (chemo)embolisation versus systemic chemotherapy for colorectal cancer liver metastases. Cochrane Database Syst Rev 2024; 8:CD012757. [PMID: 39119869 PMCID: PMC11311242 DOI: 10.1002/14651858.cd012757.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
BACKGROUND The liver is affected by two groups of malignant tumours: primary liver cancers and liver metastases. Liver metastases are significantly more common than primary liver cancer, and five-year survival after radical surgical treatment of liver metastases ranges from 28% to 50%, depending on primary cancer site. However, R0 resection (resection for cure) is not feasible in most people; therefore, other treatments have to be considered in the case of non-resectability. One possible option is based on the concept that the blood supply to hepatic tumours originates predominantly from the hepatic artery. Transarterial chemoembolisation (TACE) of the peripheral branches of the hepatic artery can be achieved by administering a chemotherapeutic drug followed by vascular occlusive agents and can lead to selective necrosis of the cancer tissue while leaving normal liver parenchyma virtually unaffected. The entire procedure can be performed without infusion of chemotherapy and is then called bland transarterial embolisation (TAE). These procedures are usually applied over a few sessions. Another possible treatment option is systemic chemotherapy which, in the case of colorectal cancer metastases, is most commonly performed using FOLFOX (folinic acid, 5-fluorouracil, and oxaliplatin) and FOLFIRI (folinic acid, 5-fluorouracil, and irinotecan) regimens applied in multiple sessions over a long period of time. These therapies disrupt the cell cycle, leading to death of rapidly dividing malignant cells. Current guidelines determine the role of TAE and TACE as non-curative treatment options applicable in people with liver-only or liver-dominant metastatic disease that is unresectable or non-ablatable, and in people who have failed systemic chemotherapy. Regarding the treatment modalities in people with colorectal cancer liver metastases, we found no systematic reviews comparing the efficacy of TAE or TACE versus systemic chemotherapy. OBJECTIVES To evaluate the beneficial and harmful effects of transarterial embolisation (TAE) or transarterial chemoembolisation (TACE) compared with systemic chemotherapy in people with liver-dominant unresectable colorectal cancer liver metastases. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, and three additional databases up to 4 April 2024. We also searched two trials registers and the European Medicines Agency database and checked reference lists of retrieved publications. SELECTION CRITERIA We included randomised clinical trials assessing beneficial and harmful effects of TAE or TACE versus systemic chemotherapy in adults (aged 18 years or older) with colorectal cancer liver metastases. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were all-cause mortality; overall survival (time to mortality); and any adverse events or complications. Our secondary outcomes were cancer mortality; health-related quality of life; progression-free survival; proportion of participants dying or surviving with progression of the disease; time to progression of liver metastases; recurrence of liver metastases; and tumour response measures (complete response, partial response, stable disease, and progressive disease). For the purpose of the review and to perform necessary analyses, whenever possible, we converted survival rates to mortality rates, as this was our primary outcome. For the analysis of dichotomous outcomes, we used the risk ratio (RR); for continuous outcomes, we used the mean difference; and for time to event outcomes, we calculated hazard ratios (HRs), all with 95% confidence intervals (CI). We used the standardised mean difference with 95% CIs when the trials used different instruments. We used GRADE to assess the certainty of evidence for each outcome. We based our conclusions on outcomes analysed at the longest follow-up. MAIN RESULTS We included three trials with 118 participants randomised to TACE versus 120 participants to systemic chemotherapy. Four participants were excluded; one due to disease progression prior to treatment and three due to decline in health. The trials reported data on one or more outcomes. Two trials were performed in China and one in Italy. The trials differed in terms of embolisation techniques and chemotherapeutic agents. Follow-up ranged from 12 months to 50 months. TACE may reduce mortality at longest follow-up (RR 0.86, 95% CI 0.79 to 0.94; 3 trials, 234 participants; very low-certainty evidence), but the evidence is very uncertain. TACE may have little to no effect on overall survival (time to mortality) (HR 0.61, 95% CI 0.37 to 1.01; 1 trial, 70 participants; very low-certainty evidence), any adverse events or complications (3 trials, 234 participants; very low-certainty evidence), health-related quality of life (2 trials, 154 participants; very low-certainty evidence), progression-free survival (1 trial, 70 participants; very low-certainty evidence), and tumour response measures (presented as the overall response rate) (RR 1.81, 95% CI 1.11 to 2.96; 3 trials, 234 participants; very low-certainty evidence), but the evidence is very uncertain. No trials reported cancer mortality, proportion of participants dying or surviving with progression of the disease, and recurrence of liver metastases. We found no trials comparing the effects of TAE versus systemic chemotherapy in people with colorectal cancer liver metastases. AUTHORS' CONCLUSIONS The evidence regarding effectiveness of TACE versus systemic chemotherapy in people with colorectal cancer liver metastases is of very low certainty and is based on three trials. Our confidence in the results is limited due to the risk of bias, inconsistency, indirectness, and imprecision. It is very uncertain whether TACE confers benefits with regard to reduction in mortality, overall survival (time to mortality), reduction in adverse events or complications, improvement in health-related quality of life, improvement in progression-free survival, and tumour response measures (presented as the overall response rate). Data on cancer mortality, proportion of participants dying or surviving with progression of the disease, and recurrence of liver metastases are lacking. We found no trials assessing TAE versus systemic chemotherapy. More randomised clinical trials are needed to strengthen the body of evidence and provide insight into the benefits and harms of TACE or TAE in comparison with systemic chemotherapy in people with liver metastases from colorectal cancer.
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Affiliation(s)
- Mateusz J Swierz
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Dawid Storman
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Jerzy W Mitus
- Department of Surgical Oncology, The Maria Sklodowska-Curie National Research Institute of Oncology, Krakow Branch; Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Marcin Hetnal
- Faculty of Medicine & Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
- Radiotherapy Centre Amethyst, Rydygier Memorial Hospital, Krakow, Poland
| | - Andrzej Kukielka
- Center for Oncology Diagnosis and Therapy, NU-MED, Zamosc, Poland
- Brachytherapy Department, University Hospital, Krakow, Poland
| | - Anastazja Szlauer-Stefanska
- Bone Marrow Transplantation and Oncohematology Department, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Michal Pedziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | | | | | - Malgorzata M Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
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Bukhari S, Leth MF, Laursen CCW, Larsen ME, Tornøe AS, Eriksen VR, Hovmand AEK, Jakobsen JC, Maagaard M, Mathiesen O. Risks of serious adverse events with non-steroidal anti-inflammatory drugs in gastrointestinal surgery: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2024; 68:871-887. [PMID: 38629348 DOI: 10.1111/aas.14425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended for perioperative opioid-sparing multimodal analgesic treatments. Concerns regarding the potential for serious adverse events (SAEs) associated with perioperative NSAID treatment are especially relevant following gastrointestinal surgery. We assessed the risks of SAEs with perioperative NSAID treatment in patients undergoing gastrointestinal surgery. METHODS We conducted a systematic review of randomised clinical trials assessing the harmful effects of NSAIDs versus placebo, usual care or no intervention in patients undergoing gastrointestinal surgery. The primary outcome was an incidence of SAEs. We systematically searched for eligible trials in five major databases up to January 2024. We performed risk of bias assessments to account for systematic errors, trial sequential analysis (TSA) to account for the risks of random errors, performed meta-analyses using R and used the Grading of Recommendations Assessment, Development and Evaluation framework to describe the certainty of evidence. RESULTS We included 22 trials enrolling 1622 patients for our primary analyses. Most trials were at high risk of bias. Meta-analyses (risk ratio 0.78; 95% confidence interval [CI] 0.51-1.19; I2 = 4%; p = .24; very low certainty of evidence) and TSA indicated a lack of information on the effects of NSAIDs compared to placebo on the risks of SAEs. Post-hoc beta-binomial regression sensitivity analyses including trials with zero events showed a reduction in SAEs with NSAIDs versus placebo (odds ratio 0.73; CI 0.54-0.99; p = .042). CONCLUSION In adult patients undergoing gastrointestinal surgery, there was insufficient information to draw firm conclusions on the effects of NSAIDs on SAEs. The certainty of the evidence was very low.
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Affiliation(s)
- Shaheer Bukhari
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Morten F Leth
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Christina C W Laursen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Mia E Larsen
- Department of Anesthesiology, Nykøbing Falster Hospital, Nykøbing Falster, Denmark
| | - Anders S Tornøe
- Department of Anesthesiology, Nordland Hospital Trust, Bodø, Norway
| | - Vibeke R Eriksen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Alfred E K Hovmand
- Department of Anesthesiology, University Hospital Northern Norway, Tromsø, Norway
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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7
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Andreasen TH, Madsen FA, Barbateskovic M, Lindschou J, Gluud C, Møller K. Ketamine for Critically Ill Patients with Severe Acute Brain Injury: A Systematic Review with Meta-analysis and Trial Sequential Analysis of Randomized Clinical Trials. Neurocrit Care 2024:10.1007/s12028-024-02075-2. [PMID: 39085508 DOI: 10.1007/s12028-024-02075-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 07/09/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Patients with severe acute brain injury have a high risk of a poor clinical outcome due to primary and secondary brain injury. Ketamine reportedly inhibits cortical spreading depolarization, an electrophysiological phenomenon that has been associated with secondary brain injury, making ketamine potentially attractive for patients with severe acute brain injury. The aim of this systematic review is to explore the current literature regarding ketamine for patients with severe acute brain injury. METHODS We systematically searched international databases for randomized clinical trials comparing ketamine by any regimen versus placebo, no intervention, or any control drug for patients with severe acute brain injury. Two authors independently reviewed and selected trials for inclusion, extracted data, assessed risk of bias, and performed analysis using Review Manager and Trial Sequential Analysis. Evidence certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation. The primary outcomes were the proportion of participants with an unfavorable functional outcome, the proportion of participants with one or more serious adverse events, and quality of life. RESULTS We identified five randomized trials comparing ketamine versus sufentanil, fentanyl, other sedatives, or saline (total N = 149 participants). All outcomes were at overall high risk of bias. The proportions of participants with one or more serious adverse events did not differ between ketamine and sufentanil or fentanyl (relative risk 1.45, 95% confidence interval 0.81-2.58; very low certainty). Trial sequential analysis showed that further trials are needed. CONCLUSIONS The level of evidence regarding the effects of ketamine on functional outcome and serious adverse events in patients with severe acute brain injury is very low. Ketamine may markedly, modestly, or not at all affect these outcomes. Large randomized clinical trials at low risk of bias are needed.
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Affiliation(s)
- Trine Hjorslev Andreasen
- Department of Neurosurgery, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Frederik Andreas Madsen
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, The Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Pisljagic S, Temberg JL, Steensbæk MT, Yousef S, Maagaard M, Chafranska L, Lange KHW, Rothe C, Lundstrøm LH, Nørskov AK. Peripheral nerve blocks for closed reduction of distal radius fractures-A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2024. [PMID: 39039732 DOI: 10.1111/aas.14474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/26/2024] [Accepted: 06/04/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Peripheral nerve blocks may provide better conditions for closed reduction of distal radius fractures as compared to other more frequently used modalities. In this systematic review, we evaluate existing evidence on the effect and harm of peripheral nerve blocks for closed reduction of distal radius fractures in adults. METHODS We performed a systematic review with meta-analysis and trial sequential analysis including trials investigating the use of peripheral nerve blocks for closed reduction of distal radius fractures. Co-primary outcomes were (1) the quality of the closed reduction measured as the proportion of participants needing surgery afterwards and (2) pain during closed reduction. RESULTS Six trials (n = 312) met the inclusion criteria. One trial reported on the need for surgery with 4 of 25 participants receiving nerve block compared to 7 of 25 receiving haematoma block needing surgery (RR 0.57, 96.7% CI [0.19; 1.71], p = .50). Four trials reported pain during closed reduction. In a meta-analysis, pain was not statistically significantly reduced with a nerve block (-2.1 Numeric Rating Scale (NRS) points (0-10), 96.7% CI [-4.4; 0.2], p = .07, tau2 = 5.4, I2 = 97%, TSA-adj. 95% CI [-11.5; 7.3]). No trial sequential boundaries were crossed, and the required information size was not met. Pre-planned subgroup analysis on trials evaluating ultrasound guided peripheral nerve blocks (patients = 110) showed a significant decrease in 'pain during reduction' (-4.1 NRS, 96.7% CI [-5.5; -2.6], p < .01, tau2 = 0.9, I2 = 80%). All trial results were at high risk of bias and the certainty of the evidence was very low. CONCLUSION The certainty of evidence on the effect of peripheral nerve blocks for closed reduction of distal radius fractures is currently very low. Peripheral nerve blocks performed with ultrasound guidance may potentially reduce pain during closed reduction. High-quality clinical trials are warranted.
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Affiliation(s)
- Sanja Pisljagic
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Jens L Temberg
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Mathias T Steensbæk
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Sina Yousef
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Lana Chafranska
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Kai H W Lange
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Rothe
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Lars H Lundstrøm
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anders K Nørskov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Zhou Y, Wang G, Zhao Y, Chen W, Chen X, Qiu Y, Liu Y, Wu S, Guan J, Chang P, Liu Y, Liu Z. Efficacy and safety of different polymyxin-containing regimens for the treatment of pneumonia caused by multidrug-resistant gram-negative bacteria: a systematic review and network meta-analysis. Crit Care 2024; 28:239. [PMID: 39004760 PMCID: PMC11247855 DOI: 10.1186/s13054-024-05031-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 07/09/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND The optimal administration of polymyxins for treating multidrug-resistant gram-negative bacterial (MDR-GNB) pneumonia remains unclear. This study aimed to systematically assess the efficacy and safety of three polymyxin-containing regimens by conducting a comprehensive network meta-analysis. METHODS We comprehensively searched nine databases. Overall mortality was the primary outcome, whereas the secondary outcomes encompassed microbial eradication rate, clinical success, acute kidney injury, and incidence of bronchospasm. Extracted study data were analyzed by pairwise and network meta-analyses. Version 2 of the Cochrane risk-of-bias tool and the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) assessment tool were used to assess the risk of bias in randomized trials and cohort studies, respectively. RESULTS This study included 19 observational studies and 3 randomized controlled trials (RCTs), encompassing 3318 patients. Six studies with high risk of bias were excluded from the primary analysis. In the pairwise meta-analysis, compared to the intravenous (IV) polymyxin-containing regimen, the intravenous plus inhaled (IV + IH) polymyxin-containing regimen showed a significant decrease in overall mortality, while no statistically significant difference was found in the inhaled (IH) polymyxin-containing regimen. The network meta-analysis indicated that the IV + IH polymyxin-containing regimen had significantly lower overall mortality (OR 0.67; 95% confidence interval [CI] 0.50-0.88), higher clinical success rate (OR 1.90; 95% CI 1.20-3.00), better microbial eradication rate (OR 2.70; 95% CI 1.90-3.90) than the IV polymyxin-containing regimen, and significantly better microbial eradication rate when compared with the IH polymyxin-containing regimen (OR 2.30; 95% CI 1.30-4.20). Furthermore, compared with IV + IH and IV polymyxin-containing regimens, the IH polymyxin-containing regimen showed a significant reduction in acute kidney injury. CONCLUSIONS Our study indicates that among the three administration regimens, the IV + IH polymyxin-containing regimen may be the most effective for treating MDR-GNB pneumonia, with a significantly lower overall mortality compared to the IV regimen and a considerably higher microbial eradication rate compared to the IH regimen. The IH regimen may be considered superior to the IV regimen due to its substantially lower incidence of acute kidney injury, even though the reduction in overall mortality was not significant.
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Affiliation(s)
- Yi Zhou
- Department of Critical Care Medicine, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Rd, Guangzhou, 510282, China
| | - Guizhong Wang
- Department of Critical Care Medicine, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Rd, Guangzhou, 510282, China
| | - Ying Zhao
- Department of Critical Care Medicine, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Rd, Guangzhou, 510282, China
| | - Weijia Chen
- Department of Critical Care Medicine, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Rd, Guangzhou, 510282, China
| | - Xuyan Chen
- Department of Critical Care Medicine, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Rd, Guangzhou, 510282, China
| | - Yuqi Qiu
- Department of Critical Care Medicine, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Rd, Guangzhou, 510282, China
| | - Yuanyu Liu
- Department of Critical Care Medicine, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Rd, Guangzhou, 510282, China
| | - Shuqi Wu
- Department of Critical Care Medicine, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Rd, Guangzhou, 510282, China
| | - Jianbin Guan
- Department of Critical Care Medicine, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Rd, Guangzhou, 510282, China
| | - Ping Chang
- Department of Critical Care Medicine, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Rd, Guangzhou, 510282, China
| | - Yong Liu
- Department of Intensive Care Unit, Shenzhen Hospital, Southern Medical University, Shenzhen, China.
| | - Zhanguo Liu
- Department of Critical Care Medicine, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Rd, Guangzhou, 510282, China.
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Tsuchiya EA, Jensen-Abbew J, Krag M, Møller MH, Vestergaard MR, Overgaard-Steensen C, Helleberg M, Holmgaard R, Heiberg J. Selective decontamination of the digestive tract in burn patients: Protocol for a systematic review. Acta Anaesthesiol Scand 2024. [PMID: 38981497 DOI: 10.1111/aas.14498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 07/02/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Nosocomial infections contribute significantly to mortality and morbidity in burn patients. Selective decontamination of the digestive tract is an infection prevention measure that has been shown to improve survival in mechanically ventilated intensive care unit (ICU) patients. It has been hypothesized that burn patients may benefit from selective decontamination of the digestive tract. METHODS/DESIGN We will conduct a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials (RCTs) assessing the patient-important effects of selective decontamination of the digestive tract in burn patients, as compared with placebo or no intervention/standard of care. The primary outcome will be 30-day mortality. Secondary outcomes include serious adverse events, anti-microbial resistance, pneumonia, blood stream infections, ICU- and hospital-free days and 90-day mortality. We will search the following databases: CENTRAL, MEDLINE, EMBASE, BIOSIS, Web of Science and CINAHL and follow the recommendations provided by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The certainty of evidence will be assessed according to the GRADE approach: Grading of Recommendations Assessment, Development and Evaluation. DISCUSSION There is clinical equipoise about the use of selective decontamination of the digestive tract in burn patients. In the outlined systematic review and meta-analysis, we will assess the desirable and undesirable effects of selective decontamination of the digestive tract in burn patients.
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Affiliation(s)
- Emma Atsuko Tsuchiya
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jacob Jensen-Abbew
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mette Krag
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Martin Risom Vestergaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Marie Helleberg
- Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
- Centre of Excellence for Health, Immunity and Infections, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Rikke Holmgaard
- Department of Plastic Surgery and Burn Treatment, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Johan Heiberg
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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11
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Schou NK, Svensson LGT, Cleemann R, Andersen JH, Mathiesen O, Maagaard M. The efficacy and safety of ankle blocks for foot and ankle surgery: A systematic review with meta-analysis and trial sequential analysis. Foot Ankle Surg 2024; 30:355-365. [PMID: 38492998 DOI: 10.1016/j.fas.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/12/2023] [Accepted: 02/29/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Peripheral nerve blocks may be essential elements in a multimodal pain management regime following foot and ankle surgery. We assessed the effects of ankle blocks compared with no intervention/sham block or a sciatic nerve block in patients undergoing surgery of the foot or ankle. METHODS We searched CENTRAL, Medline, and Embase for randomised clinical trials comparing ankle block with no intervention/sham block or a sciatic nerve block for patients undergoing surgery of the foot or ankle. Our primary outcomes were duration of analgesia and cumulative 24-hour opioid consumption. We followed the recommendations of the Cochrane Handbook, and performed meta-analysis, Trial Sequential Analysis (TSA), and assessed the risk of bias and certainty of the evidence using the GRADE approach. RESULTS We included five trials (362 participants) comparing ankle block with no intervention/sham block and three trials (247 participants) comparing ankle block with a sciatic nerve block. Ankle block may increase the duration of analgesia when compared with no intervention/sham block (MD 431 min; 96.7% CI 208 to 654), but the evidence was very uncertain. Duration was decreased when compared with a sciatic nerve block (MD -410 min; 96.7% CI -462 to -358). The ankle block duration was probably important in both comparisons. The effects on cumulative 24-hour opioid consumption were very uncertain in both comparisons. CONCLUSIONS Ankle block may increase the duration of analgesia when compared with no intervention/sham block, but the evidence was very uncertain, and decrease the duration of analgesia when compared with a sciatic nerve block. The ankle block duration was probably clinically important in both comparisons. The effects on cumulative 24-hour opioid consumption were very uncertain.
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Affiliation(s)
- Nikolaj K Schou
- Department of Anaesthesiology, Zealand University Hospital, Lykkebaekvej 1, 4600 Koege, Denmark.
| | - Lisa G T Svensson
- Department of Anaesthesiology, Zealand University Hospital, Lykkebaekvej 1, 4600 Koege, Denmark
| | - Rasmus Cleemann
- Department of Orthopaedic Surgery, Bispebjerg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
| | - Jakob H Andersen
- Department of Anaesthesiology, Zealand University Hospital, Lykkebaekvej 1, 4600 Koege, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Zealand University Hospital, Lykkebaekvej 1, 4600 Koege, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Mathias Maagaard
- Department of Anaesthesiology, Zealand University Hospital, Lykkebaekvej 1, 4600 Koege, Denmark
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Scurt FG, Hammoud B, Bose K, Mertens PR, Chatzikyrkou C. Short-Term, Mid-Term, and Long-Term Outcomes after Deceased Donor Kidney Transplantation in Patients with AKI: A Systematic Review and Meta-Analysis. KIDNEY360 2024; 5:1012-1031. [PMID: 38668857 PMCID: PMC11296548 DOI: 10.34067/kid.0000000000000450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/17/2024] [Indexed: 07/26/2024]
Abstract
Key Points This study reviews the willingness to use kidneys from donors who have experienced AKI during transplantation and provides a thorough analysis of the existing literature. While delayed graft function is more common, primary nonfunction and acute rejection rates appear comparable, as do allograft function and graft survival compared with non-AKI donor kidneys. Considering the shortage of available organs and the high mortality rate of patients on dialysis, the use of donors with AKI as a source for kidney transplantation is a viable alternative. Background AKI is a common complication in hospitalized patients and may occur in potential kidney donors. Observational studies have suggested that kidney transplantation in patients with AKI is feasible and safe, but no systematic evaluation has been performed. Methods We performed a systematic review and meta-analysis to evaluate the outcomes of kidney transplantation in patients with AKI. We searched MEDLINE, Embase, Cochrane, Google Scholar, and other databases for studies reporting outcomes of donor kidneys with AKI. We included single-center, multicenter, and registry-based studies and analyzed them according to the definition and severity of AKI. End points were primary and delayed graft function (DGF), primary nonfunction (PNF), length of hospital stay, rejection, graft function, and patient and graft survival at 1, 3, 5, and 8–10 years after transplantation. This study was registered in PROSPERO, number CRD42021260088. Results We identified 33 single-center, four multicenter, and seven registry studies with more than 100,000 patients published between 2005 and 2022. Recipients from donors with AKI had a higher risk of DGF (relative risk, 1.51; 95% confidence interval [CI], 1.35 to 1.68). Graft function at discharge was worse in the AKI group (MDCrea [95% CI]: 0.96 mg/dl [0.36 to 1.56, I2=96%], MDGFR [95% CI]: −8.88 ml/min per 1.73 m2 [−15.32 to −2.44, I2=93%]), but improved thereafter and was similar in both groups at 3 months after transplantation (MDCrea [95% CI]: −0.05 mg/dl [−0.18 to 0.07, I2=0%], MDGFR [95% CI]: −1.83 ml/min per 1.73 m2 [−5.29 to 1.63, I2=91%]). Primary nonfunction and patient and graft survival were similar at 1, 3, 5, and 8–10 years after transplantation. There were no differences in rejections regardless of AKI definition and severity. Conclusions Transplantation of kidneys with AKI is associated with satisfactory short-term and long-term outcomes and should be pursued to increase the donor pool.
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Affiliation(s)
- Florian G. Scurt
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Ben Hammoud
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Katrin Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Peter R. Mertens
- University Clinic for Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital Magdeburg, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Chen JW, Du WQ, Zhu K. Optimal exercise intensity for improving executive function in patients with attention deficit hyperactivity disorder: systematic review and network meta-analysis. Eur Child Adolesc Psychiatry 2024:10.1007/s00787-024-02507-6. [PMID: 38922348 DOI: 10.1007/s00787-024-02507-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 06/17/2024] [Indexed: 06/27/2024]
Abstract
This study aimed to compare and rank the effectiveness of optimal exercise intensity in improving executive function in patients with ADHD (Attention deficit hyperactivity disorder, ADHD) through a comprehensive comparison of direct and indirect evidence. A systematic search was performed in five electronic databases to explore the optimal exercise intensity for improving executive function in patients with ADHD by directly and indirectly comparing a variety of exercise intervention intensities. In addition, the isolated effects of exercise on improving executive function in patients with ADHD were explored through classical meta-analysis of paired direct comparisons. Twenty-nine studies were retrieved and included in this study. Classical paired meta-analysis showed that for the patients with ADHD in the age group of 7-17 years, statistical difference was observed for all the parameters of exercise interventions (intensity, frequency, period, and training method), the three dimensions of executive function, the use of medication or not, the high and low quality of the methodological approach. Network meta-analysis showed that high-intensity exercise training was optimal for improving working memory (97.4%) and inhibitory function (85.7%) in patients with ADHD. Meanwhile, moderate-intensity exercise training was optimal for improving cognitive flexibility (77.3%) in patients with ADHD. Moderate to high intensity exercise training shows potential for improving executive function in these patients. Therefore, we recommend applying high-intensity exercise intervention to improve executive function in patients with ADHD to achieve substantial improvement.
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Affiliation(s)
- Ji-Wei Chen
- Shanghai University of Sport, Shanghai, China
| | - Wen-Qian Du
- Shanghai University of Sport, Shanghai, China
| | - Kun Zhu
- Shanghai University of Sport, Shanghai, China.
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Asante MA, Michelsen ME, Balakumar MM, Kumburegama B, Sharifan A, Thomsen AR, Korang SK, Gluud C, Menon S. Heterologous versus homologous COVID-19 booster vaccinations for adults: systematic review with meta-analysis and trial sequential analysis of randomised clinical trials. BMC Med 2024; 22:263. [PMID: 38915011 PMCID: PMC11197367 DOI: 10.1186/s12916-024-03471-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 06/06/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND To combat coronavirus disease 2019 (COVID-19), booster vaccination strategies are important. However, the optimal administration of booster vaccine platforms remains unclear. Herein, we aimed to assess the benefits and harms of three or four heterologous versus homologous booster regimens. METHODS From November 3 2022 to December 21, 2023, we searched five databases for randomised clinical trials (RCT). Reviewers screened, extracted data, and assessed bias risks independently with the Cochrane risk-of-bias 2 tool. We conducted meta-analyses and trial sequential analyses (TSA) on our primary (all-cause mortality; laboratory confirmed symptomatic and severe COVID-19; serious adverse events [SAE]) and secondary outcomes (quality of life [QoL]; adverse events [AE] considered non-serious). We assessed the evidence with the GRADE approach. Subgroup analyses were stratified for trials before and after 2023, three or four boosters, immunocompromised status, follow-up, risk of bias, heterologous booster vaccine platforms, and valency of booster. RESULTS We included 29 RCTs with 43 comparisons (12,538 participants). Heterologous booster regimens may not reduce the relative risk (RR) of all-cause mortality (11 trials; RR 0.86; 95% CI 0.33 to 2.26; I2 0%; very low certainty evidence); laboratory-confirmed symptomatic COVID-19 (14 trials; RR 0.95; 95% CI 0.72 to 1.25; I2 0%; very low certainty); or severe COVID-19 (10 trials; RR 0.51; 95% CI 0.20 to 1.33; I2 0%; very low certainty). For safety outcomes, heterologous booster regimens may have no effect on SAE (27 trials; RR 1.15; 95% CI 0.68 to 1.95; I2 0%; very low certainty) but may raise AE considered non-serious (20 trials; RR 1.19; 95% CI 1.08 to 1.32; I2 64.4%; very low certainty). No data on QoL was available. Our TSAs showed that the cumulative Z curves did not reach futility for any outcome. CONCLUSIONS With our current sample sizes, we were not able to infer differences of effects for any outcomes, but heterologous booster regimens seem to cause more non-serious AE. Furthermore, more robust data are instrumental to update this review.
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Affiliation(s)
- Mark Aninakwah Asante
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Martin Ekholm Michelsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Mithuna Mille Balakumar
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Buddheera Kumburegama
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Amin Sharifan
- Department of Pharmaceutical Care, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Allan Randrup Thomsen
- Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Sonia Menon
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Epitech Research, Brussels, Belgium.
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van Bruggen FH, Zuidema SU, Luijendijk HJ. Quantitative assessment of baseline imbalances in evolocumab and alirocumab trials: a meta-epidemiological study. BMC Med Res Methodol 2024; 24:137. [PMID: 38909176 PMCID: PMC11193208 DOI: 10.1186/s12874-024-02260-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 06/07/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Baseline imbalances have been identified in randomized trials of evolocumab and alirocumab. Our aim was to quantitatively assess (1) the presence of systematic baseline differences, and (2) the relationship of baseline differences with effects on low-density lipoprotein-cholesterol (LDL-c) and clinical outcomes in the trials. METHODS We performed a meta-epidemiological study. PubMed, Embase, regulatory reports, ClinicalTrials.gov and company websites were searched for trials. Seven baseline characteristics (mean age, LDL-c, BMI, percentage males, diabetics, smokers, and hypertensives) and five outcomes (LDL-c, major adverse cardiac events, serious adverse events, any adverse events, all-cause mortality) were extracted. We calculated (1) range and distribution of baseline imbalances (sign-test), (2) pooled baseline differences and heterogeneity (meta-analysis), (3) differences in SDs around continuous variables (sign-test and pooling), and (4) the relationship of baseline differences with outcomes (meta-regression). The comparisons of PCSK9-inhibitor groups with either placebo or ezetimibe were analysed separately and combined. RESULTS We identified 43 trials with 63,193 participants. Baseline characteristics were frequently missing. Many trials showed small baseline imbalances, but some large imbalances. Only baseline BMI showed a statistically significant lower pooled mean for the drug versus placebo groups (MD -0.16; 95% CI -0.24 to -0.09). Heterogeneity in baseline imbalances was present in six placebo- and five ezetimibe-comparisons. Heterogeneity was statistically significant for BMI, males, diabetics and hypertensives in the combined comparisons. There was a statistically significant preponderance for larger SDs in the PCSK9-inhibitor versus control groups (sign-test age 0.014; LDL-c 0.014; BMI 0.049). Meta-regression showed clinically relevant relationships of baseline imbalances in age, BMI and diabetics with the risk of any adverse events and the risk of mortality. Two relationships were statistically significant: A higher mean BMI in the drug versus control group with a decreased risk of mortality (beta - 0.56; 95% CI -1.10 to -0.02), and a higher proportion of diabetics with an increased risk of any adverse events (beta 0.02; 95% 0.01 to 0.04). CONCLUSIONS Heterogeneous baseline imbalances and systematically different SDs were present in evolocumab and alirocumab trials, so study groups cannot be assumed to be comparable. These findings raise concerns about the design and conduct of the randomization procedures.
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Affiliation(s)
- F H van Bruggen
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen (UMCG), PO Box 196, Groningen, AD, 9700, The Netherlands
| | - S U Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen (UMCG), PO Box 196, Groningen, AD, 9700, The Netherlands
| | - H J Luijendijk
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Centre Groningen (UMCG), PO Box 196, Groningen, AD, 9700, The Netherlands.
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Sillassen CDB, Kamp CB, Petersen JJ, Faltermeier P, Siddiqui F, Grand J, Dominguez H, Frølich A, Gæde PH, Gluud C, Mathiesen O, Jakobsen J. Adverse effects with semaglutide: a protocol for a systematic review with meta-analysis and trial sequential analysis. BMJ Open 2024; 14:e084190. [PMID: 38908837 PMCID: PMC11331358 DOI: 10.1136/bmjopen-2024-084190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/24/2024] [Indexed: 06/24/2024] Open
Abstract
INTRODUCTION Semaglutide is increasingly used for the treatment of type 2 diabetes mellitus, overweight and other conditions. It is well known that semaglutide lowers blood glucose levels and leads to significant weight loss. Still, a systematic review has yet to investigate the adverse effects with semaglutide for all patient groups. METHODS AND ANALYSIS We will conduct a systematic review and search major medical databases (Cochrane Central Register of Controlled Trials, Medline, Embase, Latin American and Caribbean Health Sciences Literature, Science Citation Index Expanded, Conference Proceedings Citation Index-Science) and clinical trial registries from their inception and onwards to identify relevant randomised clinical trials. We expect to conduct the literature search in July 2024. Two review authors will independently extract data and perform risk-of-bias assessments. We will include randomised clinical trials comparing oral or subcutaneous semaglutide versus placebo. Primary outcomes will be all-cause mortality and serious adverse events. Secondary outcomes will be myocardial infarction, stroke, all-cause hospitalisation and non-serious adverse events. Data will be synthesised by meta-analyses and trial sequential analysis; risk of bias will be assessed with Cochrane Risk of Bias tool-version 2, an eight-step procedure will be used to assess if the thresholds for statistical and clinical significance are crossed, and the certainty of the evidence will be assessed by Grading of Recommendations, Assessment, Development and Evaluations. ETHICS AND DISSEMINATION This protocol does not present any results. Findings of this systematic review will be published in international peer-reviewed scientific journals. PROSPERO REGISTRATION NUMBER CRD42024499511.
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Affiliation(s)
- Christina Dam Bjerregaard Sillassen
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
- Department of Cardiology and Endocrinology, Slagelse Hospital, Slagelse, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Caroline Barkholt Kamp
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Johanne Juul Petersen
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Pascal Faltermeier
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
- MSH Medical School Hamburg University of Applied Sciences and Medical University, Hamburg, Germany
| | - Faiza Siddiqui
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
| | - Johannes Grand
- Amager-Hvidovre Hospital, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Helena Dominguez
- Bispebjerg and Frederiksberg Hospital, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Biomedicine, Health Faculty, University of Copenhagen, Copenhagen, Denmark
| | - Anne Frølich
- Innovation and Research Centre for Multimorbidity, Slagelse Hospital, Slagelse, Denmark
- Section of General Practice, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Peter Haulund Gæde
- Department of Cardiology and Endocrinology, Slagelse Hospital, Slagelse, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Gluud
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Zealand University Hospital Koge Centre for Anaesthesiological Research, Koge, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Janus Jakobsen
- Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Trial Unit, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Marcolin P, Mazzola Poli de Figueiredo S, Oliveira Trindade B, Bueno Motter S, Brandão GR, Mao RMD, Moffett JM. Prophylactic mesh augmentation in emergency laparotomy closure: a meta-analysis of randomized controlled trials with trial sequential analysis. Hernia 2024; 28:677-690. [PMID: 38252397 DOI: 10.1007/s10029-023-02943-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/08/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Prophylactic mesh augmentation in emergency laparotomy closure is controversial. We aimed to perform a meta-analysis of randomized controlled trials (RCT) evaluating the placement of prophylactic mesh during emergency laparotomy. METHODS We performed a systematic review of Cochrane, Scopus, and PubMed databases to identify RCT comparing prophylactic mesh augmentation and no mesh augmentation in patients undergoing emergency laparotomy. We excluded observational studies, conference abstracts, elective surgeries, overlapping populations, and trial protocols. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. Risk of bias was assessed using the revised Cochrane risk-of-bias tool (RoB 2). The review protocol was registered at PROSPERO (CRD42023412934). RESULTS We screened 1312 studies and 33 were thoroughly reviewed. Four studies comprising 464 patients were included in the analysis. Mesh reinforcement was significantly associated with a decrease in incisional hernia incidence (OR 0.18; 95% CI 0.07-0.44; p < 0.001; I2 = 0%), and synthetic mesh placement reduced fascial dehiscence (OR 0.07; 95% CI 0.01-0.53; p = 0.01; I2 = 0%). Mesh augmentation was associated with an increase in operative time (MD 32.09 min; 95% CI 6.39-57.78; p = 0.01; I2 = 49%) and seroma (OR 3.89; 95% CI 1.54-9.84; p = 0.004; I2 = 0%), but there was no difference in surgical-site infection or surgical-site occurrences requiring procedural intervention or reoperation. CONCLUSIONS Mesh augmentation in emergency laparotomy decreases incisional hernia and fascial dehiscence incidence. Despite the risk of seroma, prophylactic mesh augmentation appears to be safe and might be considered for emergency laparotomy closure. Further studies evaluating long-term outcomes are still needed.
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Affiliation(s)
- P Marcolin
- School of Medicine, Universidade Federal da Fronteira Sul, Passo Fundo, RS, Brazil.
| | | | - B Oliveira Trindade
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - S Bueno Motter
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - G R Brandão
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - R-M D Mao
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - J M Moffett
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
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Lukoschewitz JD, Miger KC, Olesen ASO, Caidi NOE, Jørgensen CK, Nielsen OW, Hassager C, Hove JD, Seven E, Møller JE, Jakobsen JC, Grand J. Vasodilators for Acute Heart Failure - A Systematic Review with Meta-Analysis. NEJM EVIDENCE 2024; 3:EVIDoa2300335. [PMID: 38804781 DOI: 10.1056/evidoa2300335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
BACKGROUND Acute heart failure is a public health concern. This study systematically reviewed randomized clinical trials (RCTs) to evaluate vasodilators in acute heart failure. METHODS The search was conducted across the databases of Medline, Embase, Latin American and the Caribbean Literature on Health Sciences, Web of Science, and the Cochrane Central Register of Controlled Trials. Inclusion criteria consisted of RCTs that compared vasodilators versus standard care, placebo, or cointerventions. The primary outcome was all-cause mortality; secondary outcomes were serious adverse events (SAEs), tracheal intubation, and length of hospital stay. Risk of bias was assessed in all trials. RESULTS The study included 46 RCTs that enrolled 28,374 patients with acute heart failure. Vasodilators did not reduce the risk of all-cause mortality (risk ratio, 0.95; 95% confidence interval [CI], 0.87 to 1.04; I2=9.51%; P=0.26). No evidence of a difference was seen in the risk of SAEs (risk ratio, 1.01; 95% CI, 0.97 to 1.05; I2=0.94%) or length of hospital stay (mean difference, -0.10; 95% CI, -0.28 to 0.08; I2=69.84%). Vasodilator use was associated with a lower risk of tracheal intubation (risk ratio, 0.54; 95% CI, 0.30 to 0.99; I2=51.96%) compared with no receipt of vasodilators. CONCLUSIONS In this systematic review with meta-analysis of patients with acute heart failure, vasodilators did not reduce all-cause mortality.
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Affiliation(s)
- Jasmin D Lukoschewitz
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
| | - Kristina C Miger
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
| | - Anne Sophie O Olesen
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
| | - Nora O E Caidi
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
| | - Caroline K Jørgensen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Olav W Nielsen
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Christian Hassager
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen
| | - Jens D Hove
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Ekim Seven
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
| | - Jacob E Møller
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Copenhagen
- Department of Clinical Medicine, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, University of Southern Denmark, Odense, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Johannes Grand
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Copenhagen
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Bjelakovic G, Nikolova D, Bjelakovic M, Pavlov CS, Sethi NJ, Korang SK, Gluud C. Effects of primary or secondary prevention with vitamin A supplementation on clinically important outcomes: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. BMJ Open 2024; 14:e078053. [PMID: 38816049 PMCID: PMC11141198 DOI: 10.1136/bmjopen-2023-078053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 05/20/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVES This systematic review with meta-analyses of randomised trials evaluated the preventive effects of vitamin A supplements versus placebo or no intervention on clinically important outcomes, in people of any age. METHODS We searched different electronic databases and other resources for randomised clinical trials that had compared vitamin A supplements versus placebo or no intervention (last search 16 April 2024). We used Cochrane methodology. We used the random-effects model to calculate risk ratios (RRs), with 95% CIs. We analysed individually and cluster randomised trials separately. Our primary outcomes were mortality, adverse events and quality of life. We assessed risks of bias in the trials and used Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) to assess the certainty of the evidence. RESULTS We included 120 randomised trials (1 671 672 participants); 105 trials allocated individuals and 15 allocated clusters. 92 trials included children (78 individually; 14 cluster randomised) and 28 adults (27 individually; 1 cluster randomised). 14/105 individually randomised trials (13%) and none of the cluster randomised trials were at overall low risk of bias. Vitamin A did not reduce mortality in individually randomised trials (RR 0.99, 95% CI 0.93 to 1.05; I²=32%; p=0.19; 105 trials; moderate certainty), and this effect was not affected by the risk of bias. In individually randomised trials, vitamin A had no effect on mortality in children (RR 0.96, 95% CI 0.88 to 1.04; I²=24%; p=0.28; 78 trials, 178 094 participants) nor in adults (RR 1.04, 95% CI 0.97 to 1.13; I²=24%; p=0.27; 27 trials, 61 880 participants). Vitamin A reduced mortality in the cluster randomised trials (0.84, 95% CI 0.76 to 0.93; I²=66%; p=0.0008; 15 trials, 14 in children and 1 in adults; 364 343 participants; very low certainty). No trial reported serious adverse events or quality of life. Vitamin A slightly increased bulging fontanelle of neonates and infants. We are uncertain whether vitamin A influences blindness under the conditions examined. CONCLUSIONS Based on moderate certainty of evidence, vitamin A had no effect on mortality in the individually randomised trials. Very low certainty evidence obtained from cluster randomised trials suggested a beneficial effect of vitamin A on mortality. If preventive vitamin A programmes are to be continued, supporting evidence should come from randomised trials allocating individuals and assessing patient-meaningful outcomes. PROSPERO REGISTRATION NUMBER CRD42018104347.
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Affiliation(s)
- Goran Bjelakovic
- Department of Internal Medicine, Medical Faculty, University of Nis, Nis, Serbia
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Clinic of Gastroenterohepatology, University Clinical Centre, Nis, Serbia
| | - Dimitrinka Nikolova
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Milica Bjelakovic
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Clinic of Gastroenterohepatology, University Clinical Centre, Nis, Serbia
| | - Chavdar S Pavlov
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Gastroenterology, Botkin Hospital, Moscow, Russian Federation
- Department of Therapy, I.M. Sechenov, First Moscow State Medical University, Moscow, Russian Federation
| | - Naqash J Sethi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
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Yamanouchi K, Funao H, Fujita N, Ebata S, Yagi M. Safety and Efficacy of Tranexamic Acid in Spinal Surgery: A Systematic Review and Meta-Analysis. Spine Surg Relat Res 2024; 8:253-266. [PMID: 38868794 PMCID: PMC11165496 DOI: 10.22603/ssrr.2023-0244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/14/2023] [Indexed: 06/14/2024] Open
Abstract
Background Tranexamic acid (TXA) has gained popularity in spinal surgery because of its potential to reduce blood loss. However, concerns regarding its safety and efficacy remain. This systematic review and meta-analysis aimed to evaluate the efficacy of TXA in reducing blood loss and its safety profile in spinal surgeries. Methods A comprehensive search was conducted in electronic databases for randomized controlled trials and prospective studies evaluating the use of TXA in spinal surgery. The primary outcomes were intraoperative and total estimated blood loss (EBL), and the secondary outcomes included the incidence and types of complications associated with TXA use. Meta-analyses were performed using random-effects models. Results Thirteen studies involving 1,213 participants were included in the meta-analysis. The use of TXA was associated with significant reductions in both intraoperative (mean difference: -46.56 mL [-73.85, -19.26], p<0.01]) and total EBL (mean difference: -210.17 mL [-284.93, -135.40], p<0.01) while also decreasing the need for blood transfusions (risk ratio: 0.68 [0.51, 0.90], p<0.01). No significant difference was found in the incidence and types of thrombotic complications when TXA was used in spinal surgery. Subgroup analysis showed consistent results in instrumentation and fusion surgery and different doses of TXA. Conclusions TXA is effective in reducing intraoperative and overall blood loss in spinal surgery without increasing the risk of complications. These findings support the use of TXA to improve patient outcomes. However, caution should be exercised because of the heterogeneity among the included studies. Further research is needed to confirm these findings and explore potential long-term complications.
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Affiliation(s)
- Kento Yamanouchi
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Naruhito Fujita
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Shigeto Ebata
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
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Rasoul D, Zhang J, Farnell E, Tsangarides AA, Chong SC, Fernando R, Zhou C, Ihsan M, Ahmed S, Lwin TS, Bateman J, Hill RA, Lip GY, Sankaranarayanan R. Continuous infusion versus bolus injection of loop diuretics for acute heart failure. Cochrane Database Syst Rev 2024; 5:CD014811. [PMID: 38775253 PMCID: PMC11110107 DOI: 10.1002/14651858.cd014811.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Acute heart failure (AHF) is new onset of, or a sudden worsening of, chronic heart failure characterised by congestion in about 95% of cases or end-organ hypoperfusion in 5% of cases. Treatment often requires urgent escalation of diuretic therapy, mainly through hospitalisation. This Cochrane review evaluated the efficacy of intravenous loop diuretics strategies in treating AHF in individuals with New York Heart Association (NYHA) classification III or IV and fluid overload. OBJECTIVES To assess the effects of intravenous continuous infusion versus bolus injection of loop diuretics for the initial treatment of acute heart failure in adults. SEARCH METHODS We identified trials through systematic searches of bibliographic databases and in clinical trials registers including CENTRAL, MEDLINE, Embase, CPCI-S on the Web of Science, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry platform (ICTRP), and the European Union Trials register. We conducted reference checking and citation searching, and contacted study authors to identify additional studies. The latest search was performed on 29 February 2024. SELECTION CRITERIA We included randomised controlled trials (RCTs) involving adults with AHF, NYHA classification III or IV, regardless of aetiology or ejection fraction, where trials compared intravenous continuous infusion of loop diuretics with intermittent bolus injection in AHF. We excluded trials with chronic stable heart failure, cardiogenic shock, renal artery stenosis, or end-stage renal disease. Additionally, we excluded studies combining loop diuretics with hypertonic saline, inotropes, vasoactive medications, or renal replacement therapy and trials where diuretic dosing was protocol-driven to achieve a target urine output, due to confounding factors. DATA COLLECTION AND ANALYSIS Two review authors independently screened papers for inclusion and reviewed full-texts. Outcomes included weight loss, all-cause mortality, length of hospital stay, readmission following discharge, and occurrence of acute kidney injury. We performed risk of bias assessment and meta-analysis where data permitted and assessed certainty of the evidence. MAIN RESULTS The review included seven RCTs, spanning 32 hospitals in seven countries in North America, Europe, and Asia. Data collection ranged from eight months to six years. Following exclusion of participants in subgroups with confounding treatments and different clinical settings, 681 participants were eligible for review. These additional study characteristics, coupled with our strict inclusion and exclusion criteria, improve the applicability of the body of the evidence as they reflect real-world clinical practice. Meta-analysis was feasible for net weight loss, all-cause mortality, length of hospital stay, readmission, and acute kidney injury. Literature review and narrative analysis explored daily fluid balance; cardiovascular mortality; B-type natriuretic peptide (BNP) change; N-terminal-proBNP change; and adverse incidents such as ototoxicity, hypotension, and electrolyte imbalances. Risk of bias assessment revealed two studies with low overall risk, four with some concerns, and one with high risk. All sensitivity analyses excluded trials at high risk of bias. Only narrative analysis was conducted for 'daily fluid balance' due to diverse data presentation methods across two studies (169 participants, the evidence was very uncertain about the effect). Results of narrative analysis varied. For instance, one study reported higher daily fluid balance within the first 24 hours in the continuous infusion group compared to the bolus injection group, whereas there was no difference in fluid balance beyond this time point. Continuous intravenous infusion of loop diuretics may result in mean net weight loss of 0.86 kg more than bolus injection of loop diuretics, but the evidence is very uncertain (mean difference (MD) 0.86 kg, 95% confidence interval (CI) 0.44 to 1.28; 5 trials, 497 participants; P < 0.001, I2 = 21%; very low-certainty evidence). Importantly, sensitivity analysis excluding trials with high risk of bias showed there was insufficient evidence for a difference in bodyweight loss between groups (MD 0.70 kg, 95% CI -0.06 to 1.46; 3 trials, 378 participants; P = 0.07, I2 = 0%). There may be little to no difference in all-cause mortality between continuous infusion and bolus injection (risk ratio (RR) 1.53, 95% CI 0.81 to 2.90; 5 trials, 530 participants; P = 0.19, I2 = 4%; low-certainty evidence). Despite sensitivity analysis, the direction of the evidence remained unchanged. No trials measured cardiovascular mortality. There may be little to no difference in the length of hospital stay between continuous infusion and bolus injection of loop diuretics, but the evidence is very uncertain (MD -1.10 days, 95% CI -4.84 to 2.64; 4 trials, 211 participants; P = 0.57, I2 = 88%; very low-certainty evidence). Sensitivity analysis improved heterogeneity; however, the direction of the evidence remained unchanged. There may be little to no difference in the readmission to hospital between continuous infusion and bolus injection of loop diuretics (RR 0.85, 95% CI 0.63 to 1.16; 3 trials, 400 participants; P = 0.31, I2 = 0%; low-certainty evidence). Sensitivity analysis continued to show insufficient evidence for a difference in the readmission to hospital between groups. There may be little to no difference in the occurrence of acute kidney injury as an adverse event between continuous infusion and bolus injection of intravenous loop diuretics (RR 1.02, 95% CI 0.70 to 1.49; 3 trials, 491 participants; P = 0.92, I2 = 0%; low-certainty evidence). Sensitivity analysis continued to show that continuous infusion may make little to no difference on the occurrence of acute kidney injury as an adverse events compared to the bolus injection of intravenous loop diuretics. AUTHORS' CONCLUSIONS Analysis of available data comparing two delivery methods of diuretics in acute heart failure found that the current data are insufficient to show superiority of one strategy intervention over the other. Our findings were based on trials meeting stringent inclusion and exclusion criteria to ensure validity. Despite previous reviews suggesting advantages of continuous infusion over bolus injections, our review found insufficient evidence to support or refute this. However, our review, which excluded trials with clinical confounders and RCTs with high risk of bias, offers the most robust conclusion to date.
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Affiliation(s)
- Debar Rasoul
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Cardiology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Juqian Zhang
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Ebony Farnell
- General Medicine, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Andreas A Tsangarides
- Emergency Department, The University of New South Wales, The Prince of Wales Hospital, Sydney, Australia
| | - Shiau Chin Chong
- Pharmacy, Hospital Sultan Ismail, Ministry of Health Malaysia, Johor Bahru, Malaysia
| | - Ranga Fernando
- General Medicine, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Can Zhou
- Cardiology, King's College Hospital, London, UK
| | - Mahnoor Ihsan
- Acute Medicine, Mid-Cheshire Hospital NHS Foundation Trust, Crewe, UK
| | - Sarah Ahmed
- Nephrology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Tin S Lwin
- Cardiology, Castle Hill Hospital, Hull, UK
| | | | - Ruaraidh A Hill
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
- Liverpool John Moores University, Liverpool, UK
- Cardiology, Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Rajiv Sankaranarayanan
- Cardiology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
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22
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Nielsen FM, Klitgaard TL, Siegemund M, Laake JH, Thormar KM, Cole JM, Aagaard SR, Bunzel AMG, Vestergaard SR, Langhoff PK, Pedersen CH, Hejlesen JØ, Abdelhamid S, Dietz A, Gebhard CE, Zellweger N, Hollinger A, Poulsen LM, Weihe S, Andersen-Ranberg NC, Pedersen UG, Mathiesen O, Andreasen AS, Brix H, Thomsen JJ, Petersen CH, Bestle MH, Wichmann S, Lund MS, Mortensen KM, Brand BA, Haase N, Iversen SA, Marcussen KV, Brøchner AC, Borup M, Grøfte T, Hildebrandt T, Kjær MBN, Engstrøm J, Lange T, Perner A, Schjørring OL, Rasmussen BS. Lower vs Higher Oxygenation Target and Days Alive Without Life Support in COVID-19: The HOT-COVID Randomized Clinical Trial. JAMA 2024; 331:1185-1194. [PMID: 38501214 PMCID: PMC10951852 DOI: 10.1001/jama.2024.2934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/28/2024] [Indexed: 03/20/2024]
Abstract
Importance Supplemental oxygen is ubiquitously used in patients with COVID-19 and severe hypoxemia, but a lower dose may be beneficial. Objective To assess the effects of targeting a Pao2 of 60 mm Hg vs 90 mm Hg in patients with COVID-19 and severe hypoxemia in the intensive care unit (ICU). Design, Setting, and Participants Multicenter randomized clinical trial including 726 adults with COVID-19 receiving at least 10 L/min of oxygen or mechanical ventilation in 11 ICUs in Europe from August 2020 to March 2023. The trial was prematurely stopped prior to outcome assessment due to slow enrollment. End of 90-day follow-up was June 1, 2023. Interventions Patients were randomized 1:1 to a Pao2 of 60 mm Hg (lower oxygenation group; n = 365) or 90 mm Hg (higher oxygenation group; n = 361) for up to 90 days in the ICU. Main Outcomes and Measures The primary outcome was the number of days alive without life support (mechanical ventilation, circulatory support, or kidney replacement therapy) at 90 days. Secondary outcomes included mortality, proportion of patients with serious adverse events, and number of days alive and out of hospital, all at 90 days. Results Of 726 randomized patients, primary outcome data were available for 697 (351 in the lower oxygenation group and 346 in the higher oxygenation group). Median age was 66 years, and 495 patients (68%) were male. At 90 days, the median number of days alive without life support was 80.0 days (IQR, 9.0-89.0 days) in the lower oxygenation group and 72.0 days (IQR, 2.0-88.0 days) in the higher oxygenation group (P = .009 by van Elteren test; supplemental bootstrapped adjusted mean difference, 5.8 days [95% CI, 0.2-11.5 days]; P = .04). Mortality at 90 days was 30.2% in the lower oxygenation group and 34.7% in the higher oxygenation group (risk ratio, 0.86 [98.6% CI, 0.66-1.13]; P = .18). There were no statistically significant differences in proportion of patients with serious adverse events or in number of days alive and out of hospital. Conclusion and Relevance In adult ICU patients with COVID-19 and severe hypoxemia, targeting a Pao2 of 60 mm Hg resulted in more days alive without life support in 90 days than targeting a Pao2 of 90 mm Hg. Trial Registration ClinicalTrials.gov Identifier: NCT04425031.
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Affiliation(s)
- Frederik M. Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Thomas L. Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Martin Siegemund
- Department of Intensive Care and Department of Clinical Research, Basel University Hospital, Basel, Switzerland
| | - Jon H. Laake
- Department of Anaesthesia and Intensive Care, Division of Emergencies and Critical Care, Rikshospitalet Medical Centre, Oslo University Hospital, Oslo, Norway
| | - Katrin M. Thormar
- Department of Anesthesia and Intensive Care, Landspitali, University Hospital of Reykjavik, Reykjavik, Iceland
| | - Jade M. Cole
- Department of Intensive Care, Cardiff University Hospital of Wales, Cardiff, Wales
| | - Søren R. Aagaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne-Marie G. Bunzel
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Stine R. Vestergaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Peter K. Langhoff
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Caroline H. Pedersen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Josefine Ø. Hejlesen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Salim Abdelhamid
- Department of Intensive Care and Department of Clinical Research, Basel University Hospital, Basel, Switzerland
| | - Anna Dietz
- Department of Intensive Care and Department of Clinical Research, Basel University Hospital, Basel, Switzerland
| | - Caroline E. Gebhard
- Department of Intensive Care and Department of Clinical Research, Basel University Hospital, Basel, Switzerland
| | - Nuria Zellweger
- Department of Intensive Care and Department of Clinical Research, Basel University Hospital, Basel, Switzerland
| | - Alexa Hollinger
- Department of Intensive Care and Department of Clinical Research, Basel University Hospital, Basel, Switzerland
| | - Lone M. Poulsen
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Sarah Weihe
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | | | - Ulf G. Pedersen
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Ole Mathiesen
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Anne Sofie Andreasen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Herlev, Denmark
| | - Helene Brix
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Herlev, Denmark
| | - Jonas J. Thomsen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Herlev, Denmark
| | - Christina H. Petersen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Herlev, Denmark
| | - Morten H. Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Hillerød, Denmark
| | - Sine Wichmann
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Hillerød, Denmark
| | - Martin S. Lund
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Hillerød, Denmark
| | - Karoline M. Mortensen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Hillerød, Denmark
| | - Björn A. Brand
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai Haase
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Susanne A. Iversen
- Department of Anaesthesia and Intensive Care, Slagelse Hospital, Slagelse, Denmark
| | - Klaus V. Marcussen
- Department of Anaesthesia and Intensive Care, Slagelse Hospital, Slagelse, Denmark
| | - Anne C. Brøchner
- Department of Anaesthesia and Intensive Care, Kolding Hospital, Kolding, Denmark
| | - Morten Borup
- Department of Anaesthesia and Intensive Care, Kolding Hospital, Kolding, Denmark
| | - Thorbjørn Grøfte
- Department of Anaesthesia and Intensive Care, Randers Hospital, Randers, Denmark
| | - Thomas Hildebrandt
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Maj-Brit N. Kjær
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Janus Engstrøm
- Copenhagen Trial Unit, Centre for Clinical Intervention, Capital Region, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Olav L. Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Bodil S. Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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23
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Nahiz N, Lukoschewitz JD, Seven E, Olsen El Caidi N, Hove JD, Jakobsen J, Grand J. Combination of diuretics for acute heart failure: a protocol for a systematic review of randomised clinical trials with network meta-analysis and trial sequential analysis. BMJ Open 2024; 14:e081890. [PMID: 38589262 PMCID: PMC11015281 DOI: 10.1136/bmjopen-2023-081890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/22/2024] [Indexed: 04/10/2024] Open
Abstract
INTRODUCTION Acute heart failure (AHF) is a critical, costly condition with high mortality rates, affecting millions annually. Despite advances in cardiovascular care, AHF treatment lacks robust evidence. AHF commonly manifests with sudden heart failure symptoms such as pulmonary congestion, and the pathophysiology involves fluid overload. Initial treatment is based on intravenous diuretics typically, but the optimal combination of drugs remains uncertain. METHODS AND ANALYSIS We will systematically review randomised controlled trials enrolling patients with AHF and volume overload undergoing in-hospital diuretic treatment. We aim to investigate any diuretic intervention. Our search strategy includes the following databases: Embase, Medline, Latin American and Caribbean Health Sciences Literature, Web of Science and the Cochrane Central Register of Controlled Trials. The primary outcome is all-cause mortality. Secondary outcomes are serious adverse events, hospital readmission and kidney failure. Study results reported at the most extended follow-up will be used for all outcomes. If appropriate, we will conduct meta-analysis, trial sequential analysis and network meta-analysis. ETHICS AND DISSEMINATION No ethics approval is required for this study. The results will be published in a peer-reviewed journal in this field. PROSPERO REGISTRATION NUMBER CRD42023463979.
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Affiliation(s)
- Nihal Nahiz
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jasmin Dam Lukoschewitz
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Hvidovre, Denmark
| | - Ekim Seven
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nora Olsen El Caidi
- Department of Cardiology, Hvidovre Hospital, Copenhagen University Hospital, Hvidovre, Denmark
| | - Jens Dahlgaard Hove
- Department of Cardiology, Amager Hvidovre University Hospital, Hvidovre, Denmark
- Center of Functional Imaging and Research, Hvidovre Hospital, Copenhagen University Hospital, Hvidovre, Denmark
| | - Janus Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Johannes Grand
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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24
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Mheissen S. Trial sequential analysis: A simple guide for judging the conclusiveness of the effect. J Orthod 2024:14653125241245140. [PMID: 38587295 DOI: 10.1177/14653125241245140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Meta-analysis is a statistical method used in systematic reviews to provide a quantitative estimate of the effect. However, including very few studies and participants may increase the risk of spurious findings. Trial sequential analysis (TSA) has been introduced to enhance the robustness of meta-analysis. TSA is a cumulative meta-analysis method that weighs type I and II errors while estimating the effect. The application of TSA can lead to a more accurate estimation of the clinical effectiveness of the intervention. The aim of the present paper was to introduce the TSA to orthodontic clinicians and researchers using continuous data from an orthodontic systematic review.
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Affiliation(s)
- Samer Mheissen
- Syrian Board in Orthodontics, Specialist Orthodontist, Private Practice, Damascus, Syria
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25
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Cheng P, Wang H, Guo L, Wang M, Xu H, Gu P, Wu J, Yang M. Survival and neurological function in patients treated with extracorporeal membrane oxygenation and therapeutic hypothermia: a protocol for updating a systematic review. BMJ Open 2024; 14:e081207. [PMID: 38531575 PMCID: PMC10966782 DOI: 10.1136/bmjopen-2023-081207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 03/08/2024] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION The widespread application of extracorporeal membrane oxygenation (ECMO) has enhanced clinical outcomes for patients experiencing cardiac arrest. However, its effectiveness is still limited and falls short of the desired level. Therapeutic hypothermia, which maintains body temperatures between 32°C and 36°C in cardiac arrest patients treated with ECMO, has been proposed as a potential means of neuroprotection and increased survival rates. Nevertheless, it remains controversial, and its impact on patient complications has yet to be fully understood. Thus, this paper aims to update the protocol for a systematic review of patients treated with ECMO and therapeutic hypothermia, in order to explore its effects on survival and neurological function. METHOD AND ANALYSIS This protocol has been developed in compliance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols 2015. The following databases will be systematically searched: PubMed, Web of Science, Cochrane Library, Embase, Ovid, CNKI, Wanfang and China Biology Medicine Disc. The database search strategy will use a combination of subject terms and free-text keywords. The search will encompass articles from the inception of each database up to 15 June 2023. Inclusion criteria encompass randomised controlled trials, cohort studies, case-control studies and quasi-experimental studies. Two researchers will independently review articles and extract relevant data based on these criteria. Any disagreements will be resolved through discussion. Data analysis will be performed using Review Manager software. ETHICS AND DISSEMINATION Since no patient data were collected in this study, ethical approval was not required. Research findings will be released in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023435353.
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Affiliation(s)
- Pengfei Cheng
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haizhen Wang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Luyao Guo
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Meiling Wang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - He Xu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Peipei Gu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jinjing Wu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Minfei Yang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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26
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Win TZ, Perinpanathan T, Mukadi P, Smith C, Edwards T, Han SM, Maung HT, Brett-Major DM, Lee N. Antibiotic prophylaxis for leptospirosis. Cochrane Database Syst Rev 2024; 3:CD014959. [PMID: 38483067 PMCID: PMC10938880 DOI: 10.1002/14651858.cd014959.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND Leptospirosis is a global zoonotic and waterborne disease caused by pathogenic Leptospira species. Antibiotics are used as a strategy for prevention of leptospirosis, in particular in travellers and high-risk groups. However, the clinical benefits are unknown, especially when considering possible treatment-associated adverse effects. This review assesses the use of antibiotic prophylaxis in leptospirosis and is an update of a previously published review in the Cochrane Library (2009, Issue 3). OBJECTIVES To evaluate the benefits and harms of antibiotic prophylaxis for human leptospirosis. SEARCH METHODS We identified randomised clinical trials through electronic searches of the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and other resources. We searched online clinical trial registries to identify unpublished or ongoing trials. We checked reference lists of the retrieved studies for further trials. The last date of search was 17 April 2023. SELECTION CRITERIA We included randomised clinical trials of any trial design, assessing antibiotics for prevention of leptospirosis, and with no restrictions on age, sex, occupation, or comorbidity of trial participants. We looked for trials assessing antibiotics irrespective of route of administration, dosage, and schedule versus placebo or no intervention. We also included trials assessing antibiotics versus other antibiotics using these criteria, or the same antibiotic but with another dose or schedule. DATA COLLECTION AND ANALYSIS We followed Cochrane methodology. The primary outcomes were all-cause mortality, laboratory-confirmed leptospirosis regardless of the presence of an identified clinical syndrome (inclusive of asymptomatic cases), clinical diagnosis of leptospirosis regardless of the presence of laboratory confirmation, clinical diagnosis of leptospirosis confirmed by laboratory diagnosis (exclusive of asymptomatic cases), and serious adverse events. The secondary outcomes were quality of life and the proportion of people with non-serious adverse events. We assessed the risk of bias of the included trials using the RoB 2 tool and the certainty of evidence using GRADE. We presented dichotomous outcomes as risk ratios (RR) and continuous outcomes as mean difference (MD), with their 95% confidence intervals (CI). We used a random-effects model for our main analyses and the fixed-effect model for sensitivity analyses. Our primary outcome analyses included trial data at the longest follow-up. MAIN RESULTS We identified five randomised clinical trials comprising 2593 participants that compared antibiotics (doxycycline, azithromycin, or penicillin) with placebo, or one antibiotic compared with another. Four trials assessed doxycycline with different durations, one trial assessed azithromycin, and one trial assessed penicillin. One trial had three intervention groups: doxycycline, azithromycin, and placebo. Three trials assessed pre-exposure prophylaxis, one trial assessed postexposure prophylaxis, and one did not report this clearly. Four trials recruited residents in endemic areas, and one trial recruited soldiers who experienced limited time exposure. The participants' ages in the included trials were 10 to 80 years. Follow-up ranged from one to three months. Antibiotics versus placebo Doxycycline compared with placebo may result in little to no difference in all-cause mortality (RR 0.15, 95% CI 0.01 to 2.83; 1 trial, 782 participants; low-certainty evidence). Prophylactic antibiotics may have little to no effect on laboratory-confirmed leptospirosis, but the evidence is very uncertain (RR 0.56, 95% CI 0.25 to 1.26; 5 trials, 2593 participants; very low-certainty evidence). Antibiotics may result in little to no difference in the clinical diagnosis of leptospirosis regardless of laboratory confirmation (RR 0.76, 95% CI 0.53 to 1.08; 4 trials, 1653 participants; low-certainty evidence) and the clinical diagnosis of leptospirosis with laboratory confirmation (RR 0.57, 95% CI 0.26 to 1.26; 4 trials, 1653 participants; low-certainty evidence). Antibiotics compared with placebo may increase non-serious adverse events, but the evidence is very uncertain (RR 10.13, 95% CI 2.40 to 42.71; 3 trials, 1909 participants; very low-certainty evidence). One antibiotic versus another antibiotic One trial assessed doxycycline versus azithromycin but did not report mortality. Compared to azithromycin, doxycycline may have little to no effect on laboratory-confirmed leptospirosis regardless of the presence of an identified clinical syndrome (RR 1.49, 95% CI 0.51 to 4.32; 1 trial, 137 participants), on the clinical diagnosis of leptospirosis regardless of the presence of laboratory confirmation (RR 4.18, 95% CI 0.94 to 18.66; 1 trial, 137 participants), on the clinical diagnosis of leptospirosis confirmed by laboratory diagnosis (RR 4.18, 95% CI 0.94 to 18.66; 1 trial, 137 participants), and on non-serious adverse events (RR 1.12, 95% CI 0.36 to 3.48; 1 trial, 137 participants), but the evidence is very uncertain. The certainty of evidence for all the outcomes was very low. None of the five included trials reported serious adverse events or assessed quality of life. One study is awaiting classification. Funding Four of the five trials included statements disclosing their funding/supporting sources, and the remaining trial did not include this. Three of the four trials that disclosed their supporting sources received the supply of trial drugs directly from the same pharmaceutical company, and the remaining trial received financial support from a governmental source. AUTHORS' CONCLUSIONS We do not know if antibiotics versus placebo or another antibiotic has little or have no effect on all-cause mortality or leptospirosis infection because the certainty of evidence is low or very low. We do not know if antibiotics versus placebo may increase the overall risk of non-serious adverse events because of very low-certainty evidence. We lack definitive rigorous data from randomised trials to support the use of antibiotics for the prophylaxis of leptospirosis infection. We lack trials reporting data on clinically relevant outcomes.
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Affiliation(s)
- Tin Zar Win
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Tanaraj Perinpanathan
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Patrick Mukadi
- Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
- Program for Nurturing Global Leaders in Tropical and Emerging Communicable Diseases, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- Institut National de Recherche Biomedicale (INRB), Kinshasa, DRC
| | - Chris Smith
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Tansy Edwards
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Su Myat Han
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Hsu Thinzar Maung
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - David M Brett-Major
- Department of Preventive Medicine and Biometrics, Uniformed Services University, Bethesda, MD, USA
| | - Nathaniel Lee
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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27
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Win TZ, Han SM, Edwards T, Maung HT, Brett-Major DM, Smith C, Lee N. Antibiotics for treatment of leptospirosis. Cochrane Database Syst Rev 2024; 3:CD014960. [PMID: 38483092 PMCID: PMC10938876 DOI: 10.1002/14651858.cd014960.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
BACKGROUND Leptospirosis is a disease transmitted from animals to humans through water, soil, or food contaminated with the urine of infected animals, caused by pathogenic Leptospira species. Antibiotics are commonly prescribed for the management of leptospirosis. Despite the widespread use of antibiotic treatment for leptospirosis, there seems to be insufficient evidence to determine its effectiveness or to recommend antibiotic use as a standard practice. This updated systematic review evaluated the available evidence regarding the use of antibiotics in treating leptospirosis, building upon a previously published Cochrane review. OBJECTIVES To evaluate the benefits and harms of antibiotics versus placebo, no intervention, or another antibiotic for the treatment of people with leptospirosis. SEARCH METHODS We identified randomised clinical trials following standard Cochrane procedures. The date of the last search was 27 March 2023. SELECTION CRITERIA We searched for randomised clinical trials of various designs that examined the use of antibiotics for treating leptospirosis. We did not impose any restrictions based on the age, sex, occupation, or comorbidities of the participants involved in the trials. Our search encompassed trials that evaluated antibiotics, regardless of the method of administration, dosage, and schedule, and compared them with placebo or no intervention, or compared different antibiotics. We included trials regardless of the outcomes reported. DATA COLLECTION AND ANALYSIS During the preparation of this review, we adhered to the Cochrane methodology and used Review Manager. The primary outcomes were all-cause mortality and serious adverse events (nosocomial infection). Our secondary outcomes were quality of life, proportion of people with adverse events considered non-serious, and days of hospitalisation. To assess the risk of bias of the included trials, we used the RoB 2 tool, and for evaluating the certainty of evidence we used GRADEpro GDT software. We presented dichotomous outcomes as risk ratios (RR) and continuous outcomes as mean differences (MD), both accompanied by their corresponding 95% confidence intervals (CI). We used the random-effects model for all our main analyses and the fixed-effect model for sensitivity analyses. For our primary outcome analyses, we included trial data from the longest follow-up period. MAIN RESULTS We identified nine randomised clinical trials comprising 1019 participants. Seven trials compared two intervention groups and two trials compared three intervention groups. Amongst the trials comparing antibiotics versus placebos, four trials assessed penicillin and one trial assessed doxycycline. In the trials comparing different antibiotics, one trial evaluated doxycycline versus azithromycin, one trial assessed penicillin versus doxycycline versus cefotaxime, and one trial evaluated ceftriaxone versus penicillin. One trial assessed penicillin with chloramphenicol and no intervention. Apart from two trials that recruited military personnel stationed in endemic areas or military personnel returning from training courses in endemic areas, the remaining trials recruited people from the general population presenting to the hospital with fever in an endemic area. The participants' ages in the included trials was 13 to 92 years. The treatment duration was seven days for penicillin, doxycycline, and cephalosporins; five days for chloramphenicol; and three days for azithromycin. The follow-up durations varied across trials, with three trials not specifying their follow-up periods. Three trials were excluded from quantitative synthesis; one reported zero events for a prespecified outcome, and two did not provide data for any prespecified outcomes. Antibiotics versus placebo or no intervention The evidence is very uncertain about the effect of penicillin versus placebo on all-cause mortality (RR 1.57, 95% CI 0.65 to 3.79; I2 = 8%; 3 trials, 367 participants; very low-certainty evidence). The evidence is very uncertain about the effect of penicillin or chloramphenicol versus placebo on adverse events considered non-serious (RR 1.05, 95% CI 0.35 to 3.17; I2 = 0%; 2 trials, 162 participants; very low-certainty evidence). None of the included trials assessed serious adverse events. Antibiotics versus another antibiotic The evidence is very uncertain about the effect of penicillin versus cephalosporin on all-cause mortality (RR 1.38, 95% CI 0.47 to 4.04; I2 = 0%; 2 trials, 348 participants; very low-certainty evidence), or versus doxycycline (RR 0.93, 95% CI 0.13 to 6.46; 1 trial, 168 participants; very low-certainty evidence). The evidence is very uncertain about the effect of cefotaxime versus doxycycline on all-cause mortality (RR 0.18, 95% CI 0.01 to 3.78; 1 trial, 169 participants; very low-certainty evidence). The evidence is very uncertain about the effect of penicillin versus doxycycline on serious adverse events (nosocomial infection) (RR 0.62, 95% CI 0.11 to 3.62; 1 trial, 168 participants; very low-certainty evidence) or versus cefotaxime (RR 1.01, 95% CI 0.15 to 7.02; 1 trial, 175 participants; very low-certainty evidence). The evidence is very uncertain about the effect of doxycycline versus cefotaxime on serious adverse events (nosocomial infection) (RR 1.01, 95% CI 0.15 to 7.02; 1 trial, 175 participants; very low-certainty evidence). The evidence is very uncertain about the effect of penicillin versus cefotaxime (RR 3.03, 95% CI 0.13 to 73.47; 1 trial, 175 participants; very low-certainty evidence), versus doxycycline (RR 2.80, 95% CI 0.12 to 67.66; 1 trial, 175 participants; very low-certainty evidence), or versus chloramphenicol on adverse events considered non-serious (RR 0.74, 95% CI 0.15 to 3.67; 1 trial, 52 participants; very low-certainty evidence). Funding Six of the nine trials included statements disclosing their funding/supporting sources and three trials did not mention funding source. Four of the six trials mentioning sources received funds from public or governmental sources or from international charitable sources, and the remaining two, in addition to public or governmental sources, received support in the form of trial drug supply directly from pharmaceutical companies. AUTHORS' CONCLUSIONS As the certainty of evidence is very low, we do not know if antibiotics provide little to no effect on all-cause mortality, serious adverse events, or adverse events considered non-serious. There is a lack of definitive rigorous data from randomised trials to support the use of antibiotics for treating leptospirosis infection, and the absence of trials reporting data on clinically relevant outcomes further adds to this limitation.
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Affiliation(s)
- Tin Zar Win
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Su Myat Han
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Tansy Edwards
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Hsu Thinzar Maung
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - David M Brett-Major
- Department of Preventive Medicine and Biometrics, Uniformed Services University, Bethesda, Maryland, USA
| | - Chris Smith
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Nathaniel Lee
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
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Massetti GM, Stamatakis C, Charania S, Annor FB, Rice CE, Hegle J, Ramphalla P, Sechache M, Motheo M. Prevalence of Functional Disabilities and Associations Among Disabilities, Violence, and HIV Among Adolescents and Young Adults in Lesotho. J Epidemiol Glob Health 2024; 14:223-233. [PMID: 38498114 PMCID: PMC11043310 DOI: 10.1007/s44197-023-00184-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/22/2023] [Indexed: 03/20/2024] Open
Abstract
INTRODUCTION Lesotho has the second-highest prevalence of HIV. Despite progress in achieving HIV epidemic control targets, inequities persist among certain groups, particularly associations between disability, HIV, and violence. We assessed the prevalence of disability and examined associations between disability and HIV and violence using data from the 2018 Lesotho Violence Against Children and Youth Survey (VACS). METHODS Lesotho VACS was a nationally representative survey of females and males ages 13-24. We assessed the associations between disability status and HIV, sexual risk behaviours, and violence using logistic regression, incorporating survey weights. RESULTS Weighted functional disability prevalence was 14.1% for females (95% confidence interval [CI] 12.7-15.4) and 7.3% for males (5.3-9.2). Compared with females with no disabilities, females with disabilities had higher odds of being HIV positive (adjusted odds ratio [aOR] 1.92, 1.34-2.76), having transactional sex (aOR 1.79, 1.09-2.95), and experiencing any lifetime violence (aOR 2.20, 1.82-2.65), sexual violence (aOR 1.77, 1.36-2.31), emotional violence (2.02. 1.61-2.53), physical violence (aOR 1.85, 1.54-2.24), witnessing interparental violence (aOR 1.71, 1.46-2.01), and witnessing community violence (aOR 1.52, 1.26-1.84). Males with disabilities had higher odds of having transactional sex (aOR 4.30, 1.35-13.73), having recent multiple sex partners (aOR 2.31, 1.13-4.75), experiencing emotional violence (aOR 2.85, 1.39-5.82), and witnessing interparental violence (aOR 1.78, 1.12-2.84). HIV models for males did not converge due to low numbers. CONCLUSION Findings emphasize the importance of inclusion and accessibility for adolescents and young adults with disabilities in prevention and services for violence and HIV. Ending HIV in Lesotho depends on addressing the vulnerabilities that lead to potential infection including violence and ensuring equitable services for all.
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Affiliation(s)
- Greta M Massetti
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA.
| | - Caroline Stamatakis
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Sana Charania
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Francis B Annor
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Catherine E Rice
- Divison of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Atlanta, USA
| | - Jennifer Hegle
- Division of Global HIV and TB, Global Health Center, Centers for Disease Control and Prevention, Atlanta, USA
| | - Puleng Ramphalla
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Maseru, Lesotho
| | | | - Mookho Motheo
- Ministry of Social Development, Government of Lesotho, Maseru, Lesotho
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Pisljagic S, Temberg JL, Steensbaek MT, Yousef S, Maagaard M, Chafranska L, Lange KHW, Rothe C, Lundstrøm LH, Nørskov AK. Peripheral nerve blocks for closed reduction of distal radius fractures-A protocol for a systematic review. Acta Anaesthesiol Scand 2024; 68:423-429. [PMID: 37932228 DOI: 10.1111/aas.14353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Current methods of anaesthesia used for closed reduction of distal radial fractures may be insufficient for pain relief and muscle relaxation, potentially compromising reduction quality and patient satisfaction. Peripheral nerve blocks have already been implemented for surgery of wrist fractures and may provide optimal conditions for closed reduction due to complete motor and sensory blockade of the involved nerves. However, existing literature on peripheral nerve blocks for closed reduction is sparse, and no updated systematic review or meta-analysis exists. AIMS This protocol is developed according to the PRISMA-P statement. The systematic review and meta-analysis aim to consolidate the literature regarding the effect and harm of peripheral nerve blocks compared with other anaesthesia modalities for closed reduction of distal radius fractures in adults. METHODS The two primary outcomes are the proportion of participants needing surgery after closed reduction and pain during closed reduction. We will only include randomised clinical trials. Two review authors will each independently screen literature, extract data, and assess risk of bias with Risk of Bias 2 Tool. Meta-analysis will be carried out with Rstudio. We will also perform a Trial Sequential Analysis. The certainty of evidence will be judged using GRADE guidelines. DISCUSSION We will use up-to-date methodology when conducting the systematic review outlined in this protocol. The results may guide clinicians in their decision-making regarding the use of anaesthesia for closed reduction of distal radius fractures in adults.
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Affiliation(s)
- Sanja Pisljagic
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Jens L Temberg
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Mathias T Steensbaek
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Sina Yousef
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Lana Chafranska
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Kai H W Lange
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Rothe
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Lars H Lundstrøm
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anders K Nørskov
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
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30
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Temberg JL, Pisljagic S, Steensbaek MT, Yousef S, Chafranska L, Lange KHW, Rothe C, Nørskov AK, Maagaard M, Lundstrøm LH. Mixing short- and long-acting local anaesthetics in peripheral nerve blocks: Protocol for a systematic review and meta-analysis. Acta Anaesthesiol Scand 2024; 68:417-422. [PMID: 37947347 DOI: 10.1111/aas.14352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION This protocol describes a systematic review and meta-analysis to evaluate the clinical effects of mixing short- and long-acting local anaesthetics in peripheral nerve blocks. Clinicians often combine short- and long-acting local anaesthetics to achieve a briefer onset time. However, this may come with a prize, namely a shorter total duration of the block, which is of clinical importance. OBJECTIVE This systematic review aims to strengthen the knowledge of the clinical effects associated with this practice. The primary outcome is the duration of block analgesia. Secondary outcomes are block onset time, sensory and motor block duration. Exploratory outcomes are postoperative pain scores, cumulative 24-h opioid consumption and the prevalence of serious adverse events. METHODS We will conduct a meta-analysis of the extracted data, and the risk of bias for each study will be evaluated. We will perform a Trial Sequential Analysis, subgroup, and sensitivity analyses and assess the overall risk of publication bias. Finally, we will evaluate the review using the GRADE principles.
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Affiliation(s)
- Jens L Temberg
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Sanja Pisljagic
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Mathias T Steensbaek
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Sina Yousef
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Lana Chafranska
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Kai H W Lange
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Rothe
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Anders K Nørskov
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Lars H Lundstrøm
- Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Rijal A, Adhikari TB, Dhakal S, Maagaard M, Piri R, Nielsen EE, Neupane D, Jakobsen JC, Olsen MH. Effect of exercise on functional capacity and body weight for people with hypertension, type 2 diabetes, or cardiovascular disease: a systematic review with meta-analysis and trial sequential analysis. BMC Sports Sci Med Rehabil 2024; 16:38. [PMID: 38321506 PMCID: PMC10848448 DOI: 10.1186/s13102-024-00829-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/28/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Hypertension, type 2 diabetes, and cardiovascular disease affect the activities of daily living at varying degree. While the effects of aerobic exercise on functional capacity are well-documented, the extent of change for different types of exercise in these chronic conditions remains unexplored. Additionally, there is conflicting evidence regarding the role of exercise in reducing body weight. METHODS We conducted systematic review with meta-analysis and trial sequential analysis and searched various databases from inception to July 2020. We included randomised clinical trials adding any form of trialist defined exercise to usual care versus usual care in people with either hypertension, type 2 diabetes, and/or cardiovascular disease irrespective of setting, publication status, year, and language. The outcomes assessed were i) functional capacity assessed through different scales separately i.e., Maximal Oxygen Uptake (VO2max), 6-min walk test (6MWT), 10-m walk test (10MWT), and ii) body weight. RESULTS We included 950 studies out of which 444 trials randomising 20,098 participants reported on various functional outcomes (355 trials) and body weight (169 trials). The median follow-up was 3 months (Interquartile ranges (IQR): 2.25 to 6). Exercise added to the usual care, improved VO2max (Mean Difference (MD):2.72 ml/kg/min; 95% Confidence Interval (CI) 2.38 to 3.06; p < 0.01; I2 = 96%), 6MWT (MD: 42.5 m; 95%CI 34.95 to 50.06; p < 0.01; I2 = 96%), and 10MWT (MD: 0.06 m/s; 95%CI 0.03 to 0.10; p < 0.01; I2 = 93%). Dynamic aerobic and resistance exercise showed a consistent improvement across various functional outcomes, whereas body-mind therapies (MD: 3.23 ml/kg/min; 95%CI 1.97 to 4.49, p < 0.01) seemed especially beneficial for VO2max and inspiratory muscle training (MD: 59.32 m; 95%CI 33.84 to 84.80; p < 0.01) for 6MWT. Exercise yielded significant reduction in body weight for people with hypertension (MD: -1.45 kg; 95%CI -2.47 to -0.43; p < 0.01), and type 2 diabetes (MD: -1.53 kg; 95%CI -2.19 to -0.87; p < 0.01) but not for cardiovascular disease with most pronounced for combined exercise (MD: -1.73 kg; 95%CI -3.08 to -0.39; p < 0.05). The very low certainty of evidence warrants cautious interpretations of the results. CONCLUSION Exercise seemed to improve functional capacity for people with hypertension, type 2 diabetes, and/or cardiovascular disease but the effectiveness seems to vary with different forms of exercise. The potentially superior improvement in VO2max and 6MWT by body-mind therapies and inspiratory muscle training calls for further exploration. Additionally, prescribing exercise for the sole purpose of losing weight may be a potential strategy for people with hypertension and type 2 diabetes. The extent of improvement in functional capacity and body weight reduction differed with different exercise regimens hence personalised exercise prescriptions tailored to individual needs may be of importance. PROSPERO REGISTRATION: PROSPERO registration number: CRD42019142313.
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Affiliation(s)
- Anupa Rijal
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
- Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark.
| | - Tara Ballav Adhikari
- Department of Public Health, Research Unit for Environment, Occupation & Health, Aarhus University, Aarhus, Denmark
| | - Sarmila Dhakal
- Center for Research on Environment, Health and Population Activities (CREPHA), Kusunti, Lalitpur, Nepal
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koge, Denmark
| | - Reza Piri
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Emil Eik Nielsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Dinesh Neupane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University Baltimore, Maryland, USA
| | - Janus Christian Jakobsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Michael Hecht Olsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
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Madden AM, Smeeton NC, Culkin A, Trivedi D. Modified dietary fat intake for treatment of gallstone disease in people of any age. Cochrane Database Syst Rev 2024; 2:CD012608. [PMID: 38318932 PMCID: PMC10845213 DOI: 10.1002/14651858.cd012608.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND The prevalence of gallstones varies between less than 1% and 64% in different populations and is thought to be increasing in response to changes in nutritional intake and increasing obesity. Some people with gallstones have no symptoms but approximately 2% to 4% develop them each year, predominantly including severe abdominal pain. People who experience symptoms have a greater risk of developing complications. The main treatment for symptomatic gallstones is cholecystectomy. Traditionally, a low-fat diet has also been advised to manage gallstone symptoms, but there is uncertainty over the evidence to support this. OBJECTIVES To evaluate the benefits and harms of modified dietary fat intake in the treatment of gallstone disease in people of any age. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE ALL Ovid, Embase Ovid, and three other databases to 17 February 2023 to identify randomised clinical trials in people with gallstones. We also searched online trial registries and pharmaceutical company sources, for ongoing or unpublished trials to March 2023. SELECTION CRITERIA We included randomised clinical trials (irrespective of language, blinding, or status) in people with gallstones diagnosed using ultrasonography or conclusive imaging methods. We excluded participants diagnosed with another condition that may compromise dietary fat tolerance. We excluded trials where data from participants with gallstones were not reported separately from data from participants who did not have gallstones. We included trials that investigated other interventions (e.g. trials of drugs or other dietary (non-fat) components) providing that the trial groups had received the same proportion of drug or other dietary (non-fat) components in the intervention. DATA COLLECTION AND ANALYSIS We intended to undertake meta-analysis and present the findings according to Cochrane recommendations. However, as we identified only five trials, with data unsuitable and insufficient for analyses, we described the data narratively. MAIN RESULTS We included five trials but only one randomised clinical trial (69 adults), published in 1986, reported outcomes of interest to the review. The trial had four dietary intervention groups, three of which were relevant to this review. We assessed the trial at high risk of bias. The dietary fat modifications included a modified cholesterol intake and medium-chain triglyceride supplementation. The control treatment was a standard diet. The trial did not report on any of the primary outcomes in this review (i.e. all-cause mortality, serious adverse events, and health-related quality of life). The trial reported on gallstone dissolution, one of our secondary outcomes. We were unable to apply the GRADE approach to determine certainty of evidence because the included trial did not provide data that could be used to generate an estimate of the effect on this or any other outcome. The trial expressed its finding as "no significant effect of a low-cholesterol diet in the presence of ursodeoxycholic acid on gallstone dissolution." There were no serious adverse events reported. The included trial reported that they received no funding that could bias the trial results through conflicts of interest. We found no ongoing trials. AUTHORS' CONCLUSIONS The evidence about the effects of modifying dietary fat on gallstone disease versus standard diet is scant. We lack results from high-quality randomised clinical trials which investigate the effects of modification of dietary fat and other nutrient intakes with adequate follow-up. There is a need for well-designed trials that should include important clinical outcomes such as mortality, quality of life, impact on dissolution of gallstones, hospital admissions, surgical intervention, and adverse events.
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Affiliation(s)
- Angela M Madden
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Nigel C Smeeton
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Alison Culkin
- Nutrition & Dietetic Department, St Mark's Hospital, Harrow, UK
| | - Daksha Trivedi
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
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Munch MW, Granholm A, Maláska J, Stašek J, Rodriguez PO, Pitre T, Wilson R, Savović J, Rochwerg B, Svobodnik A, Kratochvíl M, Taboada M, Jha V, Vijayaraghavan BKT, Myatra SN, Venkatesh B, Perner A, Møller MH. Dexamethasone doses in patients with COVID-19 and hypoxia: A systematic review and meta-analysis. Acta Anaesthesiol Scand 2024; 68:146-166. [PMID: 37881881 DOI: 10.1111/aas.14346] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/08/2023] [Accepted: 10/07/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The optimal dose of dexamethasone for severe/critical COVID-19 is uncertain. We compared higher versus standard doses of dexamethasone in adults with COVID-19 and hypoxia. METHODS We searched PubMed and trial registers until 23 June 2023 for randomised clinical trials comparing higher (>6 mg) versus standard doses (6 mg) of dexamethasone in adults with COVID-19 and hypoxia. The primary outcome was mortality at 1 month. Secondary outcomes were mortality closest to 90 days; days alive without life support; and the occurrence of serious adverse events/reactions (SAEs/SARs) closest to 1 month. We assessed the risk of bias using the Cochrane RoB2 tool, risk of random errors using trial sequential analysis, and certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS We included eight trials (2478 participants), of which four (1293 participants) had low risk of bias. Higher doses of dexamethasone probably resulted in little to no difference in mortality at 1 month (relative risk [RR] 0.97, 95% CI: 0.79-1.19), mortality closest to Day 90 (RR 1.01, 95% CI: 0.86-1.20), and SAEs/SARs (RR 1.00, 95% CI: 0.97-1.02). Higher doses of dexamethasone probably increased the number of days alive without invasive mechanical ventilation and circulatory support but had no effect on days alive without renal replacement therapy. CONCLUSIONS Based on low to moderate certainty evidence, higher versus standard doses of dexamethasone probably result in little to no difference in mortality, SAEs/SARs, and days alive without renal replacement therapy, but probably increase the number of days alive without invasive mechanical ventilation and circulatory support.
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Affiliation(s)
- Marie Warrer Munch
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Jan Maláska
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- 2nd Department of Anaesthesiology University Hospital Brno, Brno, Czech Republic
| | - Jan Stašek
- Department of Internal Medicine and Cardiology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Pablo O Rodriguez
- Pulmonary and Critical Care Medicine, Instituto Universitario CEMIC (Centro de Educación Médica e Investigación Clínica), Buenos Aires, Argentina
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Wilson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Applied Research Collaboration West (ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Applied Research Collaboration West (ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Adam Svobodnik
- Department of Pharmacology/CZECRIN, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Milan Kratochvíl
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Manuel Taboada
- Department of Anaesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Vivekanand Jha
- The George Institute for Global Health, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | | | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Intensive Care Medicine, Wesley Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
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Chen JW, Zhu K. Single Exercise for Core Symptoms and Executive Functions in ADHD: A Systematic Review and Meta-Analysis. J Atten Disord 2024; 28:399-414. [PMID: 38156611 DOI: 10.1177/10870547231217321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVES A systematic review and meta-analysis of studies of single exercise on core symptoms and executive function in adolescents with ADHD. METHODS Four databases were searched for studies of the effects of single exercise on core symptoms and executive functioning in adolescents with ADHD. RESULTS Thirteen studies were included, and a single session of exercise had small effect-size improvements in core symptoms and executive function in adolescents with ADHD: 10 to 13 year olds in the early adolescent-elementary school years and 18 to 24 year olds in the late adolescent-college years. Moderate-intensity continuous training, high-intensity interval training, single sessions of less than 30 minutes, and single sessions of 30 minutes and more significantly improved cycling training, attention, inhibition, substance use, and pre-study abstinence. CONCLUSIONS A single session of exercise had an overall ameliorative effect on core symptoms and executive function in adolescents with ADHD.
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Affiliation(s)
| | - Kun Zhu
- Shanghai University of Sport, China
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Bijkerk V, Jacobs LM, Albers KI, Gurusamy KS, van Laarhoven CJ, Keijzer C, Warlé MC. Deep neuromuscular blockade in adults undergoing an abdominal laparoscopic procedure. Cochrane Database Syst Rev 2024; 1:CD013197. [PMID: 38288876 PMCID: PMC10825891 DOI: 10.1002/14651858.cd013197.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Laparoscopic surgery is the preferred option for many procedures. To properly perform laparoscopic surgery, it is essential that sudden movements and abdominal contractions in patients are prevented, as it limits the surgeon's view. There has been a growing interest in the potential beneficial effect of deep neuromuscular blockade (NMB) in laparoscopic surgery. Deep NMB improves the surgical field by preventing abdominal contractions, and it is thought to decrease postoperative pain. However, it is uncertain if deep NMB improves intraoperative safety and thereby improves clinical outcomes. OBJECTIVES To evaluate the benefits and harms of deep neuromuscular blockade versus no, shallow, or moderate neuromuscular blockade during laparoscopic intra- or transperitoneal procedures in adults. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 31 July 2023. SELECTION CRITERIA We included randomised clinical trials (irrespective of language, blinding, or publication status) in adults undergoing laparoscopic intra- or transperitoneal procedures comparing deep NMB to moderate, shallow, or no NMB. We excluded trials that did not report any of the primary or secondary outcomes of our review. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. health-related quality of life, and 3. proportion of participants with serious adverse events. Our secondary outcomes were 4. proportion of participants with non-serious adverse events, 5. readmissions within three months, 6. short-term pain scores, 7. measurements of postoperative recovery, and 8. operating time. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 42 randomised clinical trials with 3898 participants. Most trials included participants undergoing intraperitoneal oncological resection surgery. We present the Peto fixed-effect model for most dichotomous outcomes as only sparse events were reported. Comparison 1: deep versus moderate NMB Thirty-eight trials compared deep versus moderate NMB. Deep NMB may have no effect on mortality, but the evidence is very uncertain (Peto odds ratio (OR) 7.22, 95% confidence interval (CI) 0.45 to 115.43; 12 trials, 1390 participants; very low-certainty evidence). Deep NMB likely results in little to no difference in health-related quality of life up to four days postoperative (mean difference (MD) 4.53 favouring deep NMB on the Quality of Recovery-40 score, 95% CI 0.96 to 8.09; 5 trials, 440 participants; moderate-certainty evidence; mean difference lower than the mean clinically important difference of 10 points). The evidence is very uncertain about the effect of deep NMB on intraoperatively serious adverse events (deep NMB 38/1150 versus moderate NMB 38/1076; Peto OR 0.95, 95% CI 0.59 to 1.52; 21 trials, 2231 participants; very low-certainty evidence), short-term serious adverse events (up to 60 days) (deep NMB 37/912 versus moderate NMB 42/852; Peto OR 0.90, 95% CI 0.56 to 1.42; 16 trials, 1764 participants; very low-certainty evidence), and short-term non-serious adverse events (Peto OR 0.94, 95% CI 0.65 to 1.35; 11 trials, 1232 participants; very low-certainty evidence). Deep NMB likely does not alter the duration of surgery (MD -0.51 minutes, 95% CI -3.35 to 2.32; 34 trials, 3143 participants; moderate-certainty evidence). The evidence is uncertain if deep NMB alters the length of hospital stay (MD -0.22 days, 95% CI -0.49 to 0.06; 19 trials, 2084 participants; low-certainty evidence) or pain scores one hour after surgery (MD -0.31 points on the numeric rating scale, 95% CI -0.59 to -0.03; 22 trials, 1823 participants; very low-certainty evidence; mean clinically important difference 1 point) and 24 hours after surgery (MD -0.60 points on the numeric rating scale, 95% CI -1.05 to -0.15; 16 trials, 1404 participants; very low-certainty evidence; mean clinically important difference 1 point). Comparison 2: deep versus shallow NMB Three trials compared deep versus shallow NMB. The trials did not report on mortality and health-related quality of life. The evidence is very uncertain about the effect of deep NMB compared to shallow NMB on the proportion of serious adverse events (RR 1.66, 95% CI 0.50 to 5.57; 2 trials, 158 participants; very low-certainty evidence). Comparison 3: deep versus no NMB One trial compared deep versus no NMB. There was no mortality in this trial, and health-related quality of life was not reported. The proportion of serious adverse events was 0/25 in the deep NMB group and 1/25 in the no NMB group. AUTHORS' CONCLUSIONS There was insufficient evidence to draw conclusions about the effects of deep NMB compared to moderate NMB on all-cause mortality and serious adverse events. Deep NMB likely results in little to no difference in health-related quality of life and duration of surgery compared to moderate NMB, and it may have no effect on the length of hospital stay. Due to the very low-certainty evidence, we do not know what the effect is of deep NMB on non-serious adverse events, pain scores, or readmission rates. Randomised clinical trials with adequate reporting of all adverse events would reduce the current uncertainties. Due to the low number of identified trials and the very low certainty of evidence, we do not know what the effect of deep NMB on serious adverse events is compared to shallow NMB and no NMB. We found no trials evaluating mortality and health-related quality of life.
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Affiliation(s)
- Veerle Bijkerk
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lotte Mc Jacobs
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kim I Albers
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Christiaan Keijzer
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
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Pludowski P, Grant WB, Karras SN, Zittermann A, Pilz S. Vitamin D Supplementation: A Review of the Evidence Arguing for a Daily Dose of 2000 International Units (50 µg) of Vitamin D for Adults in the General Population. Nutrients 2024; 16:391. [PMID: 38337676 PMCID: PMC10857599 DOI: 10.3390/nu16030391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/26/2024] [Accepted: 01/27/2024] [Indexed: 02/12/2024] Open
Abstract
Vitamin D deficiency is considered a public health problem due to its worldwide high prevalence and adverse clinical consequences regarding musculoskeletal health. In addition, vitamin D may also be crucial for the prevention of certain extraskeletal diseases. Despite decades of intensive scientific research, several knowledge gaps remain regarding the precise definition of vitamin D deficiency and sufficiency, the health benefits of improving vitamin D status, and the required vitamin D intakes. Consequently, various societies and expert groups have released heterogeneous recommendations on the dosages for vitamin D supplementation. In this brief narrative review, we outline and discuss recent advances regarding the scientific evidence arguing for a daily vitamin D supplementation with 2000 international units (IU) (50 µg) of vitamin D3 to prevent and treat vitamin D deficiency. According to data from randomized controlled trials (RCTs), such a dose may improve some health outcomes and is sufficient to raise and maintain serum 25(OH)D concentrations above 50 nmol/L (20 ng/mL) and above 75 nmol/L (30 ng/mL) in >99% and >90% of the general adult population, respectively. According to large vitamin D RCTs, there are no significant safety concerns in supplementing such a dose for several years, even in individuals with an already sufficient vitamin D status at baseline. A daily vitamin D supplementation with 2000 IU (50 µg) may be considered a simple, effective, and safe dosage to prevent and treat vitamin D deficiency in the adult general population.
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Affiliation(s)
- Pawel Pludowski
- Department of Clinical Biochemistry, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - William B. Grant
- Sunlight, Nutrition, and Health Research Center, P.O. Box 641603, San Francisco, CA 94164-1603, USA;
| | - Spyridon N. Karras
- Laboratory of Biological Chemistry, Medical School, Aristotle University, 54636 Thessaloniki, Greece;
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen (NRW), Ruhr University Bochum, 32545 Bad Oeynhausen, Germany;
| | - Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
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Kamp CB, Petersen JJ, Faltermeier P, Juul S, Siddiqui F, Barbateskovic M, Kristensen AT, Moncrieff J, Horowitz MA, Hengartner MP, Kirsch I, Gluud C, Jakobsen JC. Beneficial and harmful effects of tricyclic antidepressants for adults with major depressive disorder: a systematic review with meta-analysis and trial sequential analysis. BMJ MENTAL HEALTH 2024; 27:e300730. [PMID: 39093721 PMCID: PMC10806869 DOI: 10.1136/bmjment-2023-300730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/11/2023] [Indexed: 08/04/2024]
Abstract
QUESTION Tricyclic antidepressants are used to treat depression worldwide, but the adverse effects have not been systematically assessed. Our objective was to assess the beneficial and harmful effects of all tricyclic antidepressants for adults with major depressive disorder. STUDY SELECTION AND ANALYSIS We conducted a systematic review with meta-analysis and trial sequential analysis. We searched CENTRAL, MEDLINE, Embase, LILACS and other sources from inception to January 2023 for randomised clinical trials comparing tricyclic antidepressants versus placebo or 'active placebo' for adults with major depressive disorder. The primary outcomes were depressive symptoms measured on the 17-item Hamilton Depression Rating Scale (HDRS-17), serious adverse events and quality of life. The minimal important difference was defined as three points on the HDRS-17. FINDINGS We included 103 trials randomising 10 590 participants. All results were at high risk of bias, and the certainty of the evidence was very low or low. All trials only assessed outcomes at the end of the treatment period at a maximum of 12 weeks after randomisation. Meta-analysis and trial sequential analysis showed evidence of a beneficial effect of tricyclic antidepressants compared with placebo (mean difference -3.77 HDRS-17 points; 95% CI -5.91 to -1.63; 17 trials). Meta-analysis showed evidence of a harmful effect of tricyclic antidepressants compared with placebo on serious adverse events (OR 2.78; 95% CI 2.18 to 3.55; 35 trials), but the required information size was not reached. Only 2 out of 103 trials reported on quality of life and t-tests showed no evidence of a difference. CONCLUSIONS The long-term effects of tricyclic antidepressants and the effects on quality of life are unknown. Short-term results suggest that tricyclic antidepressants may reduce depressive symptoms while also increasing the risks of serious adverse events, but these results were based on low and very low certainty evidence. PROSPERO REGISTRATION NUMBER CRD42021226161.
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Affiliation(s)
- Caroline Barkholt Kamp
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Johanne Juul Petersen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Pascal Faltermeier
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- MSH Medical School Hamburg, University of Applied Sciences and Medical University, Hamburg, Germany
| | - Sophie Juul
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Psychotherapeutic Center Stolpegård, Gentofte, Denmark
| | - Faiza Siddiqui
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | | | - Joanna Moncrieff
- Division of Psychiatry, University College London (honorary for MAH), London, UK
- Department of Research and Development, North East London NHS Foundation Trust, London, UK
| | - Mark Abie Horowitz
- Division of Psychiatry, University College London (honorary for MAH), London, UK
- Department of Research and Development, North East London NHS Foundation Trust, London, UK
| | | | - Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Gonzalez-Garay AG, Serralde-Zúñiga AE, Velasco Hidalgo L, Flores García NC, Aguirre-Salgado MI. Transjugular intrahepatic portosystemic shunts for adults with hepatorenal syndrome. Cochrane Database Syst Rev 2024; 1:CD011039. [PMID: 38235907 PMCID: PMC10795102 DOI: 10.1002/14651858.cd011039.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND Hepatorenal syndrome is a condition that occurs in people with chronic liver disease (such as alcoholic hepatitis, advanced cirrhosis, or fulminant liver failure) and portal hypertension. The prognosis is dismal, often with a survival of weeks to months. Hepatorenal syndrome is characterised by the development of intense splanchnic vasodilation favouring ascites and hypotension leading to renal vasoconstriction and acute renal failure. Therefore, treatment attempts focus on improving arterial pressure through the use of vasopressors, paracentesis, and increasing renal perfusion pressure. Several authors have reported that the placement of transjugular intrahepatic portosystemic shunts (TIPS) may be a therapeutic option because it decreases portal pressure and improves arterial and renal pressures. However, the evidence is not clearly documented and TIPS may cause adverse events. Accordingly, it is necessary to evaluate the evidence of the benefits and harms of TIPS to assess its value in people with hepatorenal syndrome. OBJECTIVES To evaluate the benefits and harms of transjugular intrahepatic portosystemic shunts (TIPS) in adults with hepatorenal syndrome compared with sham, no intervention, conventional treatment, or other treatments. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 2 June 2023. SELECTION CRITERIA We included only randomised clinical trials with a parallel-group design, which compared the TIPS placement with sham, no intervention, conventional therapy, or other therapies, in adults aged 18 years or older, regardless of sex or ethnicity, diagnosed with chronic liver disease and hepatorenal syndrome. We excluded trials of adults with kidney failure due to causes not related to hepatorenal syndrome, and we also excluded data from quasi-randomised, cross-over, and observational study designs as we did not design a separate search for such studies. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. morbidity due to any cause, and 3. serious adverse events. Our secondary outcomes were 1. health-related quality of life, 2. non-serious adverse events, 3. participants who did not receive a liver transplant, 4. participants without improvement in kidney function, and 5. length of hospitalisation. We performed fixed-effect and random-effects meta-analyses using risk ratio (RR) or Peto odds ratio (Peto OR), with 95% confidence intervals (CI) for the dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) for the continuous outcomes. We used GRADE to assess certainty of evidence. MAIN RESULTS We included two randomised clinical trials comparing TIPS placement (64 participants) versus conventional treatment (paracentesis plus albumin 8 g/L of removed ascites) (66 participants). The co-interventions used in the trials were dietary treatment (sodium less than 60 mmoL/day), spironolactone (300 mg/day to 400 mg/day), and furosemide (120 mg/day). Follow-up was up to 24 months. Both were multicentre trials from Spain and the USA, and Germany, conducted between 1993 and 2002. Most participants were men (aged 18 to 75 years). We are uncertain about the effect of TIPS placement compared with conventional treatment, during the first 24 months of follow-up, on all-cause mortality (RR 0.88, 95% CI 0.55 to 1.38; 2 trials, 130 participants; I2 = 58%; very low-certainty evidence) and on the development of any serious adverse event (RR 1.60, 95% CI 0.10 to 24.59; 2 trials, 130 participants; I2 = 78%; very low-certainty evidence). The use of TIPS may or may not result in a decrease in overall morbidity such as bacterial peritonitis, encephalopathy, or refractory ascites, during the first 24 months of follow-up, compared with the conventional treatment (RR 0.95, 95% CI 0.77 to 1.18; 2 trials, 130 participants; I2 = 0%; low-certainty evidence). We are uncertain about the effect of TIPS placement versus conventional treatment on the number of people who did not receive a liver transplant (RR 1.03, 95% CI 0.93 to 1.14; 2 trials, 130 participants; I2 = 0%; very low-certainty evidence) or on the length of hospitalisation (MD -20.0 days, 95% CI -39.92 to -0.08; 1 trial, 60 participants; very low-certainty evidence). Kidney function may improve in participants with TIPS placement (RR 0.53, 95% CI 0.27 to 1.02; 1 trial, 70 participants; low-certainty evidence). No trials reported health-related quality of life, non-serious adverse events, or number of participants with improvement in liver function associated with the TIPS placement. Funding No trials reported sources of commercial funding or conflicts of interest between researchers. Ongoing studies We found one ongoing trial comparing TIPS with conventional therapy (terlipressin plus albumin) and listed one study as awaiting classification as no full-text article could be found. AUTHORS' CONCLUSIONS TIPS placement was compared with conventional treatment, with a follow-up of 24 months, in adults with hepatorenal syndrome type 2. Based on two trials with insufficient sample size and trial limitations, we assessed the overall certainty of evidence as low or very low. We are unsure if TIPS may decrease all-cause mortality, serious adverse events, the number of people who did not receive a liver transplant, and the days of hospitalisation because of the very low-certainty evidence. We are unsure if TIPS, compared with conventional treatment, has better effects on overall morbidity (bacterial peritonitis, encephalopathy, or refractory ascites). TIPS may improve kidney function, but the certainty of evidence is low. The trials included no data on health-related quality of life, non-serious adverse events, and liver function associated with the TIPS placement. We identified one ongoing trial and one study awaiting classification which may contribute to the review when information becomes available.
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Affiliation(s)
| | - Aurora E Serralde-Zúñiga
- Clinical Nutrition Service, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Nayelli Cointa Flores García
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ma Isabel Aguirre-Salgado
- Medical Library, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Guo S, Jia D, Liu X, Gao L, Wang H, Chen C, Wu Y. The positive efficacy of dexmedetomidine on the clinical outcomes of patients undergoing renal transplantation: evidence from meta-analysis. Aging (Albany NY) 2023; 15:14192-14209. [PMID: 38085644 PMCID: PMC10756127 DOI: 10.18632/aging.205296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/02/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION Whether dexmedetomidine (DEX), an anesthetic adjuvant, can improve renal transplant outcomes is not clear. METHODS We systematically identified clinical trials in which DEX was administered in renal transplantation (RT). On November 1, 2022, we searched The Cochrane Library, MEDLINE, EMBASE and https://www. CLINICALTRIALS gov/. The main outcomes were delayed graft function and acute rejection. RESULTS A total of seven studies were included in the meta-analysis. The results showed that compared with the control, DEX significantly reduced the occurrence of delayed graft function (RR 0.76; 95% CI 0.60-0.98), short-term serum creatinine [postoperative day (POD) 2: (MD -22.82; 95% CI -42.01 - -3.64)] and blood urea nitrogen [POD 2: (MD -2.90; 95% CI -5.10 - -0.70); POD 3: (MD 2.07; 95% CI -4.12 - -0.02)] levels, postoperative morphine consumption (MD -4.27; 95% CI -5.92 - -2.61) and the length of hospital stay (MD -0.85; 95% CI-1.47 - -0.23). However, DEX did not reduce the risk of postoperative acute rejection (RR 0.75; 95% CI 0.45-1.23). The results of the subgroup analysis showed that country type, donor type, and average age had a certain impact on the role of DEX. CONCLUSIONS DEX may improve the short-term clinical outcome of RT and shorten the length of hospital stay of patients.
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Affiliation(s)
- Shanshan Guo
- Department of Nephropathy, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, PR China
| | - Degong Jia
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Xueqi Liu
- Department of Nephropathy, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, PR China
| | - Li Gao
- Department of Nephropathy, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, PR China
| | - Huaying Wang
- Department of Nephropathy, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, PR China
| | - Chaoyi Chen
- Department of Nephropathy, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, PR China
| | - Yonggui Wu
- Department of Nephropathy, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, PR China
- Center for Scientific Research of Anhui Medical University, Hefei, Anhui 230022, PR China
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Peng Z, Luo W, Yan Z, Zhang H. The effect of general anesthesia and conscious sedation in endovascular thrombectomy for acute ischemic stroke: an updated meta-analysis of randomized controlled trials and trial sequential analysis. Front Neurol 2023; 14:1291211. [PMID: 38145125 PMCID: PMC10740157 DOI: 10.3389/fneur.2023.1291211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/21/2023] [Indexed: 12/26/2023] Open
Abstract
Objectives General anesthesia (GA) and conscious sedation (CS) are common methods for endovascular thrombectomy (EVT) in acute ischemic stroke (AIS). However, the risks and benefits of each strategy are unclear. This study aimed to summarize the latest RCTs and compare the postoperative effects of the two methods on EVT patients. Materials and methods We systematically searched the database for GA and CS in AIS patients during EVT. The retrieval time was from the creation of the database until March 2023. The quality of the studies was evaluated using the Cochrane risk of bias tool. Random-effects or fixed-effects meta-analyses were used to assess all outcomes. Results We preliminarily identified 304 studies, of which 8 were included. Based on the pooled estimates, there were no significant differences between the GA group and the CS group in terms of good functional outcomes (mRS0-2) and mortality rate at 3 months (RR = 1.09, 95% CI: 0.95-1.24, p = 0.23) (RR = 0.95, 95% CI: 0.75-1.22, p = 0.70) as well as in NHISS at 24 h after treatment (SMD = -0.01, 95% CI: -0.13 to 0.11, p = 0.89). However, the GA group had better outcomes in terms of achieving successful recanalization of the blood vessel (RR = 1.13, 95% CI: 1.07-1.19, p < 0.0001). The RR value for the risk of hypotension was 1.87 (95% CI: 1.42-2.47, p < 0.00001); for pneumonia, RR was 1.43 (95% CI: 1.07-1.90, p = 0.01); and for symptomatic intracerebral hemorrhage, RR was 0.94 (95% CI: 0.74-1.26, p = 0.68). The pooled RR value for complications after intervention was 1.03 (95% CI, 0.87-1.22, p = 0.76). Conclusion In patients undergoing EVT for AIS, GA, and CS are associated with similar rates of functional independence. Further trials of a larger scale are needed to confirm these findings.
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Affiliation(s)
- Zhi Peng
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
- Department of Neurosurgery, Affiliated Renhe Hospital of China Three Gorges University, Yichang, China
| | - Wenmiao Luo
- Department of Neurosurgery, Xiamen Susong Hospital, Xiamen, China
| | - Zhengcun Yan
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Hengzhu Zhang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
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Arain H, Patel T, Mureanu N, Efthymiou A, Lombardi G, Tree T, Nicolaides KH, Shangaris P. Regulatory T cells in the peripheral blood of women with gestational diabetes: a systematic review and meta-analysis. Front Immunol 2023; 14:1226617. [PMID: 38111588 PMCID: PMC10726109 DOI: 10.3389/fimmu.2023.1226617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 11/08/2023] [Indexed: 12/20/2023] Open
Abstract
Background Gestational diabetes (GDM) affects approximately 14% of pregnancies globally and is associated with short- and long-term complications for both the mother and child. In addition, GDM has been linked to chronic low-grade inflammation with recent research indicating a potential immune dysregulation in pathophysiology and a disparity in regulatory T cells. Objective This systematic review and meta-analysis aimed to determine whether there is an association between GDM and the level of Tregs in the peripheral blood. Methods Literature searches were conducted in PubMed, Embase, and Ovid between the 7th and 14th of February 2022. The inclusion criteria were any original studies published in the English language, measuring differentiated Tregs in women with GDM compared with glucose-tolerant pregnant women. Meta-analysis was performed between comparable Treg markers. Statistical tests were used to quantify heterogeneity: τ 2, χ 2, and I 2. Study quality was assessed using a modified version of the Newcastle-Ottawa scale. Results The search yielded 223 results: eight studies were included in the review and seven in the meta-analysis (GDM = 228, control = 286). Analysis of Tregs across all trimesters showed significantly lower Treg numbers in women with GDM (SMD, -0.76; 95% CI, -1.37, -0.15; I 2 = 90%). This was reflected in the analysis by specific Treg markers (SMD -0.55; 95% CI, -1.04, -0.07; I 2 = 83%; third trimester, five studies). Non-significant differences were found within subgroups (differentiated by CD4+FoxP3+, CD4+CD127-, and CD4+CD127-FoxP3) of both analyses. Conclusion GDM is associated with lower Treg numbers in the peripheral maternal blood. In early pregnancy, there is clinical potential to use Treg levels as a predictive tool for the subsequent development of GDM. There is also a potential therapeutic intervention to prevent the development of GDM by increasing Treg populations. However, the precise mechanism by which Tregs mediate GDM remains unclear. Systematic review registration https://www.crd.york.ac.uk/prospero, identifier CRD42022309796.
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Affiliation(s)
- Hania Arain
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine King’s College London, London, United Kingdom
| | - Tina Patel
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine King’s College London, London, United Kingdom
| | - Nicoleta Mureanu
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine King’s College London, London, United Kingdom
- Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, United Kingdom
| | - Athina Efthymiou
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine King’s College London, London, United Kingdom
- Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, United Kingdom
| | - Giovanna Lombardi
- Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Timothy Tree
- Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Kypros H. Nicolaides
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine King’s College London, London, United Kingdom
- Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, United Kingdom
| | - Panicos Shangaris
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine King’s College London, London, United Kingdom
- Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, United Kingdom
- Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
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Barbateskovic M, Klingenberg SL, Krauss SR, Kong D, Wu Z, Petersen SB, Kenfelt M, Gluud C. Concentrations, Number of Doses, and Formulations of Aluminium Adjuvants in Vaccines: A Systematic Review with Meta-Analysis and Trial Sequential Analysis of Randomized Clinical Trials. Vaccines (Basel) 2023; 11:1763. [PMID: 38140168 PMCID: PMC10871092 DOI: 10.3390/vaccines11121763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
Aluminium adjuvants are commonly used in vaccines to boost the effects of vaccination. Here, we assessed the benefits and harms of different aluminium adjuvants vs. other aluminium adjuvants or vs. the same aluminium adjuvant at other concentrations, administered a different number of doses, or at different particle sizes used in vaccines or vaccine excipients. We conducted a systematic review with meta-analysis and Trial Sequential Analysis to assess the certainty of evidence with Grading of Recommendations Assessment, Development and Evaluation (GRADE). We obtained data from major medical databases until 20 January 2023 and included 10 randomized clinical trials of healthy volunteers. The comparisons assessed higher vs. lower aluminium adjuvant concentrations; higher vs. lower number of doses of aluminium adjuvant; and aluminium phosphate adjuvant vs. aluminium hydroxide adjuvant. For all three comparisons, meta-analyses showed no evidence of a difference on all-cause mortality, serious adverse events, and adverse events considered non-serious. The certainty of evidence was low to very low. None of the included trials reported on quality of life or proportion of participants who developed the disease being vaccinated against. The benefits and harms of different types of aluminium adjuvants, different aluminium concentrations, different number of doses, or different particle sizes, therefore, remain uncertain.
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Affiliation(s)
- Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark (S.L.K.)
| | - Sarah Louise Klingenberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark (S.L.K.)
| | - Sara Russo Krauss
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark (S.L.K.)
| | - Dezhao Kong
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark (S.L.K.)
- The Evidence-Based Medicine Research Center of Traditional Chinese Medicine, Liaoning University of Traditional Chinese Medicine, Shenyang 110032, China
- Department of Evidence-Based Chinese Medicine Research Centre, The Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang 110032, China
| | - Zhangtong Wu
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark (S.L.K.)
- The Evidence-Based Medicine Research Center of Traditional Chinese Medicine, Liaoning University of Traditional Chinese Medicine, Shenyang 110032, China
- Department of Evidence-Based Chinese Medicine Research Centre, The Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang 110032, China
| | - Sesilje B. Petersen
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital—Bispebjerg and Frederiksberg, 2400 Copenhagen, Denmark
| | | | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital—Rigshospitalet, 2100 Copenhagen, Denmark (S.L.K.)
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, 5230 Odense, Denmark
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Stehr-Pingel L, Maagaard M, Tvarnø CD, Andersen LPK, Andersen JH, Mathiesen O. Remimazolam for sedation: A protocol for a systematic review with meta-analysis, trial sequential analysis, and GRADE approach. Acta Anaesthesiol Scand 2023; 67:1432-1438. [PMID: 37580880 DOI: 10.1111/aas.14316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/07/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Procedural sedation aims to facilitate a successful diagnostic or therapeutic procedure. The pharmacokinetic properties and pharmacodynamic effects need to be taken into consideration when choosing the ideal sedative. Midazolam and propofol are frequently employed. However, they are associated with respiratory depression with increasing dosage. Also, midazolam has a potentially unpredictable pharmacodynamic response and propofol may cause hypotension and injection site pain. Remimazolam may provide a superior alternative due to its rapid pharmacodynamic profile and insignificant circulatory effects. METHODS This protocol employs the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The review aims to assess the beneficial and harmful clinical effects of remimazolam versus placebo or other sedatives in adult patients requiring sedation in relation to a diagnostic or therapeutic procedure, or due to other circumstances. Three primary outcomes are identified: Sedation success rate, respiratory complications, and hemodynamic complications. Six secondary outcomes are identified: among these are quality of recovery and serious adverse events. All randomized trials are included. The search strategy includes six major biomedical databases. Literature screening and data extraction will be performed independently by two authors. Risk of systemic error will be assessed with Risk of Bias 2 Tool. Risk of random error will be assessed with trial sequential analysis. Heterogeneity will be evaluated by appropriate statistical tests. The certainty of the evidence will be judged using Grading of Recommendations Assessment, Development, and Evaluation. Meta-analysis will be carried out with Rstudio. A "Summary of Findings" table will be presented with our primary and secondary outcome results. DISCUSSION The systematic review with up-to-date methodology outlined in this protocol investigates the clinical effects of remimazolam in relation to procedural sedation. The results may guide clinicians in the clinical use of remimazolam.
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Affiliation(s)
- Lasse Stehr-Pingel
- Centre for Anaesthesiological Research, Department of Anaesthesia, Zealand University Hospital, Køge, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesia, Zealand University Hospital, Køge, Denmark
| | - Casper Duevang Tvarnø
- Centre for Anaesthesiological Research, Department of Anaesthesia, Zealand University Hospital, Køge, Denmark
| | - Lars Peter Kloster Andersen
- Centre for Anaesthesiological Research, Department of Anaesthesia, Zealand University Hospital, Køge, Denmark
| | - Jakob Hessel Andersen
- Centre for Anaesthesiological Research, Department of Anaesthesia, Zealand University Hospital, Køge, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesia, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Sivapalan P, Ellekjaer KL, Jessen MK, Meyhoff TS, Cronhjort M, Hjortrup PB, Wetterslev J, Granholm A, Møller MH, Perner A. Lower vs Higher Fluid Volumes in Adult Patients With Sepsis: An Updated Systematic Review With Meta-Analysis and Trial Sequential Analysis. Chest 2023; 164:892-912. [PMID: 37142091 PMCID: PMC10567931 DOI: 10.1016/j.chest.2023.04.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 03/06/2023] [Accepted: 04/19/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND IV fluids are recommended for adults with sepsis. However, the optimal strategy for IV fluid management in sepsis is unknown, and clinical equipoise exists. RESEARCH QUESTION Do lower vs higher fluid volumes improve patient-important outcomes in adult patients with sepsis? STUDY DESIGN AND METHODS We updated a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials assessing lower vs higher IV fluid volumes in adult patients with sepsis. The coprimary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. We followed the recommendations from the Cochrane Handbook and used the Grading of Recommendations Assessment, Development and Evaluation approach. Primary conclusions were based on trials with low risk of bias if available. RESULTS We included 13 trials (N = 4,006) with four trials (n = 3,385) added to this update. The meta-analysis of all-cause mortality in eight trials with low risk of bias showed a relative risk of 0.99 (97% CI, 0.89-1.10; moderate certainty evidence). Six trials with predefined definitions of serious adverse events showed a relative risk of 0.95 (97% CI, 0.83-1.07; low certainty evidence). Health-related quality of life was not reported. INTERPRETATION Among adult patients with sepsis, lower IV fluid volumes probably result in little to no difference in all-cause mortality compared with higher IV fluid volumes, but the interpretation is limited by imprecision in the estimate, which does not exclude potential benefit or harm. Similarly, the evidence suggests lower IV fluid volumes result in little to no difference in serious adverse events. No trials reported on health-related quality of life. TRIAL REGISTRATION PROSPERO; No.: CRD42022312572; URL: https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Praleene Sivapalan
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark.
| | - Karen L Ellekjaer
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Marie K Jessen
- Research Center for Emergency Medicine, Aarhus University and University Hospital, Aarhus N, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Tine S Meyhoff
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Maria Cronhjort
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Section of Anaesthesia and Intensive Care, Stockholm, Sweden
| | - Peter B Hjortrup
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark; Department of Cardiothoracic Anaesthesia and Intensive Care, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Anders Granholm
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
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Klitgaard TL, Schjørring OL, Nielsen FM, Meyhoff CS, Perner A, Wetterslev J, Rasmussen BS, Barbateskovic M. Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit. Cochrane Database Syst Rev 2023; 9:CD012631. [PMID: 37700687 PMCID: PMC10498149 DOI: 10.1002/14651858.cd012631.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND This is an updated review concerning 'Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit'. Supplementary oxygen is provided to most patients in intensive care units (ICUs) to prevent global and organ hypoxia (inadequate oxygen levels). Oxygen has been administered liberally, resulting in high proportions of patients with hyperoxemia (exposure of tissues to abnormally high concentrations of oxygen). This has been associated with increased mortality and morbidity in some settings, but not in others. Thus far, only limited data have been available to inform clinical practice guidelines, and the optimum oxygenation target for ICU patients is uncertain. Because of the publication of new trial evidence, we have updated this review. OBJECTIVES To update the assessment of benefits and harms of higher versus lower fractions of inspired oxygen (FiO2) or targets of arterial oxygenation for adults admitted to the ICU. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, BIOSIS Previews, and LILACS. We searched for ongoing or unpublished trials in clinical trial registers and scanned the reference lists and citations of included trials. Literature searches for this updated review were conducted in November 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared higher versus lower FiO2 or targets of arterial oxygenation (partial pressure of oxygen (PaO2), peripheral or arterial oxygen saturation (SpO2 or SaO2)) for adults admitted to the ICU. We included trials irrespective of publication type, publication status, and language. We excluded trials randomising participants to hypoxaemia (FiO2 below 0.21, SaO2/SpO2 below 80%, or PaO2 below 6 kPa) or to hyperbaric oxygen, and cross-over trials and quasi-randomised trials. DATA COLLECTION AND ANALYSIS Four review authors independently, and in pairs, screened the references identified in the literature searches and extracted the data. Our primary outcomes were all-cause mortality, the proportion of participants with one or more serious adverse events (SAEs), and quality of life. We analysed all outcomes at maximum follow-up. Only three trials reported the proportion of participants with one or more SAEs as a composite outcome. However, most trials reported on events categorised as SAEs according to the International Conference on Harmonisation Good Clinical Practice (ICH-GCP) criteria. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single SAE with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with an SAE in each trial. Two trials reported on quality of life. Secondary outcomes were lung injury, myocardial infarction, stroke, and sepsis. No trial reported on lung injury as a composite outcome, but four trials reported on the occurrence of acute respiratory distress syndrome (ARDS) and five on pneumonia. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single lung injury event with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with ARDS or pneumonia in each trial. We assessed the risk of systematic errors by evaluating the risk of bias in the included trials using the Risk of Bias 2 tool. We used the GRADEpro tool to assess the overall certainty of the evidence. We also evaluated the risk of publication bias for outcomes reported by 10b or more trials. MAIN RESULTS We included 19 RCTs (10,385 participants), of which 17 reported relevant outcomes for this review (10,248 participants). For all-cause mortality, 10 trials were judged to be at overall low risk of bias, and six at overall high risk of bias. For the reported SAEs, 10 trials were judged to be at overall low risk of bias, and seven at overall high risk of bias. Two trials reported on quality of life, of which one was judged to be at overall low risk of bias and one at high risk of bias for this outcome. Meta-analysis of all trials, regardless of risk of bias, indicated no significant difference from higher or lower oxygenation strategies at maximum follow-up with regard to mortality (risk ratio (RR) 1.01, 95% confidence interval (C)I 0.96 to 1.06; I2 = 14%; 16 trials; 9408 participants; very low-certainty evidence); occurrence of SAEs: the highest proportion of any specific SAE in each trial RR 1.01 (95% CI 0.96 to 1.06; I2 = 36%; 9466 participants; 17 trials; very low-certainty evidence), or quality of life (mean difference (MD) 0.5 points in participants assigned to higher oxygenation strategies (95% CI -2.75 to 1.75; I2 = 34%, 1649 participants; 2 trials; very low-certainty evidence)). Meta-analysis of the cumulated number of SAEs suggested benefit of a lower oxygenation strategy (RR 1.04 (95% CI 1.02 to 1.07; I2 = 74%; 9489 participants; 17 trials; very low certainty evidence)). However, trial sequential analyses, with correction for sparse data and repetitive testing, could reject a relative risk increase or reduction of 10% for mortality and the highest proportion of SAEs, and 20% for both the cumulated number of SAEs and quality of life. Given the very low-certainty of evidence, it is necessary to interpret these findings with caution. Meta-analysis of all trials indicated no statistically significant evidence of a difference between higher or lower oxygenation strategies on the occurrence of lung injuries at maximum follow-up (the highest reported proportion of lung injury RR 1.08, 95% CI 0.85 to 1.38; I2 = 0%; 2048 participants; 8 trials; very low-certainty evidence). Meta-analysis of all trials indicated harm from higher oxygenation strategies as compared with lower on the occurrence of sepsis at maximum follow-up (RR 1.85, 95% CI 1.17 to 2.93; I2 = 0%; 752 participants; 3 trials; very low-certainty evidence). Meta-analysis indicated no differences regarding the occurrences of myocardial infarction or stroke. AUTHORS' CONCLUSIONS In adult ICU patients, it is still not possible to draw clear conclusions about the effects of higher versus lower oxygenation strategies on all-cause mortality, SAEs, quality of life, lung injuries, myocardial infarction, stroke, and sepsis at maximum follow-up. This is due to low or very low-certainty evidence.
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Affiliation(s)
- Thomas L Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Olav L Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Frederik M Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Private Office, Hellerup, Denmark
| | - Bodil S Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Mei TTY, Aung HH, Tung WS, Naing C. Association between IL-10 gene polymorphisms (- 1082 A/G, -819 T/C, -592 A/C) and hepatocellular carcinoma: a meta-analysis and trial sequential analysis. BMC Cancer 2023; 23:842. [PMID: 37684564 PMCID: PMC10492326 DOI: 10.1186/s12885-023-11323-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND The carcinogenesis of hepatocellular carcinoma is complicated, and genetic factor may have the role in the malignant transformation of liver cells. IL-10 gene polymorphisms have been investigated for their potential roles in hepatocellular carcinoma This study aimed to investigate the relationship between polymorphisms of IL-10 (-1082 A/G, -819 T/C, -592 A/C), and hepatocellular carcinoma by performing a meta-analysis with eligible individual studies. METHODS This study followed the PRISMA 2020 Checklist. Relevant studies were searched in health-related databases. The Newcastle-Ottawa Scale criteria were used to evaluate the studies quality. Pooled odds ratio (OR) and its 95% confidence interval (CI) were used to determine the strength of association between each polymorphism and hepatocellular carcinoma using five genetic models. Stratification was done by ethnic groups. Trial sequential analysis (TSA) was performed to determine the required information size. RESULTS Fifteen case-control studies (n = 8182) were identified. Overall, the heterozygous model showed a marginal significant association only between IL-10 (-1082 A/G) and hepatocellular carcinoma risk (OR: 0.82, 95% CI: 0.67-1.00, 9 studies). On stratification, IL-10 (-1082 A/G) was significantly associated with hepatocellular carcinoma risk in the non-Asian population under dominant (OR: 0.62, 95% CI: 0.45-0.86, 4 studies), heterozygous (OR: 0.60, 95% CI: 0.43-0.85) and allelic models (OR: 0.79, 95% CI: 0.64-0.99). IL-10 (-819 T/C) was significantly associated with hepatocellular carcinoma risk only among non-Asians under the dominant (OR: 1.47, 95% CI: 1.02-2.13, 8 studies), recessive (OR: 1.99, 95% CI: 1.03-3.86, and homozygous models (OR: 2.18, 95% CI: 1.13-4.23). For IL-10 (-592 A/C) with 11 studies, there was no significant association with hepatocellular carcinoma in all five genetic models (P values > 0.5). TSA plots indicated that the information size for firm evidence of effect was sufficient only for the analysis of IL-10 (-592 A/C), but not for the - 1082 A/G or -819 T/C. CONCLUSIONS Findings suggest that IL-10 (-1082 A/G and - 819 T/C) polymorphisms are associated with hepatocellular carcinoma in ethnic-specific manner. However, this evidence is not conclusive because the sample size was insufficient. IL-10 (-592 A/C) polymorphism was not associated with hepatocellular carcinoma albeit with sufficient information size. Future well-designed large case-control studies on IL-10 (-1082 A/G and - 819 T/C) with different ethnicities are recommended.
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Affiliation(s)
- Teresa Tan Yen Mei
- School of Medicine, International Medical University, Kuala Lumpur, Malaysia
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Htar Htar Aung
- School of Medicine, International Medical University, Kuala Lumpur, Malaysia.
| | - Wong Siew Tung
- School of Medicine, International Medical University, Kuala Lumpur, Malaysia
| | - Cho Naing
- Faculty of Tropical Health and Medicine, James Cook University, Queensland, Australia
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Li H, Yang M, Ma M, Li Z, Li M, Zhu L, Yao L, Li J, Zhong L, Yang K. Tenofovir for children and adults with chronic hepatitis B. Cochrane Database Syst Rev 2023; 2023:CD015586. [PMCID: PMC10485896 DOI: 10.1002/14651858.cd015586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the benefits and harms of tenofovir versus no intervention or placebo for children and adults with chronic hepatitis B.
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Mathiesen AS, Zoffmann V, Lindschou J, Jakobsen JC, Gluud C, Due-Christensen M, Rasmussen B, Marqvorsen EHS, Lund-Jacobsen T, Skytte TB, Thomsen T, Rothmann MJ. Self-determination theory interventions versus usual care in people with diabetes: a systematic review with meta-analysis and trial sequential analysis. Syst Rev 2023; 12:158. [PMID: 37674180 PMCID: PMC10483731 DOI: 10.1186/s13643-023-02308-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 08/04/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Autonomy-supporting interventions, such as self-determination theory and guided self-determination interventions, may improve self-management and clinical and psychosocial outcomes in people with diabetes. Such interventions have never been systematically reviewed assessing both benefits and harms and concurrently controlling the risks of random errors using trial sequential analysis methodology. This systematic review investigates the benefits and harms of self-determination theory-based interventions compared to usual care in people with diabetes. METHODS We used the Cochrane methodology. Randomized clinical trials assessing interventions theoretically based on guided self-determination or self-determination theory in any setting were eligible. A comprehensive search (latest search April 2022) was undertaken in CENTRAL, MEDLINE, Embase, LILACS, PsycINFO, SCI-EXPANDED, CINAHL, SSCI, CPCI-S, and CPCI-SSH to identify relevant trials. Two authors independently screened, extracted data, and performed risk-of-bias assessment of included trials using the Cochrane risk-of-bias tool 1.0. Our primary outcomes were quality of life, all-cause mortality, and serious adverse events. Our secondary outcomes were diabetes distress, depressive symptoms, and nonserious adverse events not considered serious. Exploratory outcomes were glycated hemoglobin and motivation (autonomy, controlled, amotivation). Outcomes were assessed at the end of the intervention (primary time point) and at maximum follow-up. The analyses were conducted using Review Manager 5.4 and Trial Sequential Analysis 0.9.5.10. Certainty of the evidence was assessed by GRADE. RESULTS Our search identified 5578 potentially eligible studies of which 11 randomized trials (6059 participants) were included. All trials were assessed at overall high risk of bias. We found no effect of self-determination theory-based interventions compared with usual care on quality of life (mean difference 0.00 points, 95% CI -4.85, 4.86, I2 = 0%; 225 participants, 3 trials, TSA-adjusted CI -11.83, 11.83), all-cause mortality, serious adverse events, diabetes distress, depressive symptoms, adverse events, glycated hemoglobulin A1c, or motivation (controlled). The certainty of the evidence was low to very low for all outcomes. We found beneficial effect on motivation (autonomous and amotivation; low certainty evidence). CONCLUSIONS We found no effect of self-determination-based interventions on our primary or secondary outcomes. The evidence was of very low certainty. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020181144.
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Affiliation(s)
- Anne Sophie Mathiesen
- Department of Endocrinology, Center for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark.
- The Interdisciplinary Research Unit of Women's, Children's and Families' Health, the Julie Marie Center, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark.
| | - Vibeke Zoffmann
- The Interdisciplinary Research Unit of Women's, Children's and Families' Health, the Julie Marie Center, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark
- Sector of Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health, School of Nursing and Midwifery, Deakin University, Melbourne, Australia
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, The Capital Region, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, The Capital Region, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, The Capital Region, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - Mette Due-Christensen
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
- Steno Diabetes Center Copenhagen, The Capital Region of Denmark, Herlev, Denmark
| | - Bodil Rasmussen
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
- Sector of Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health, School of Nursing and Midwifery, Deakin University, Melbourne, Australia
| | - Emilie Haarslev Schröder Marqvorsen
- The Interdisciplinary Research Unit of Women's, Children's and Families' Health, the Julie Marie Center, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark
| | - Trine Lund-Jacobsen
- Department of Endocrinology, Center for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Tine Bruhn Skytte
- The Interdisciplinary Research Unit of Women's, Children's and Families' Health, the Julie Marie Center, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark
| | - Thordis Thomsen
- Department of Anaesthesiology, Department of Clinical Medicine, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mette Juel Rothmann
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
- Faculty of Health, School of Nursing and Midwifery, Deakin University, Melbourne, Australia
- Department of Clinical Research, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
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Farid Mojtahedi M, Sepidarkish M, Almukhtar M, Eslami Y, Mohammadianamiri F, Behzad Moghadam K, Rouholamin S, Razavi M, Jafari Tadi M, Fazlollahpour-Naghibi A, Rostami Z, Rostami A, Rezaeinejad M. Global incidence of surgical site infections following caesarean section: a systematic review and meta-analysis. J Hosp Infect 2023; 139:82-92. [PMID: 37308061 DOI: 10.1016/j.jhin.2023.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is a health-threatening complication following caesarean section (CS); however, to the authors' knowledge, there is no worldwide estimate of the burden of post-CS SSIs. Therefore, this systematic review and meta-analysis aimed to estimate the global and regional incidence of post-CS SSIs and associated factors. METHODS International scientific databases were searched systematically for observational studies published from January 2000 to March 2023, without language or geographical restrictions. The pooled global incidence rate was estimated using a random-effects meta-analysis (REM), and then stratified by World-Health-Organization-defined regions as well as by sociodemographic and study characteristics. Causative pathogens and associated risk factors of SSIs were also analysed using REM. Heterogeneity was assessed with I2. RESULTS In total, 180 eligible studies (207 datasets) involving 2,188,242 participants from 58 countries were included in this review. The pooled global incidence of post-CS SSIs was 5.63% [95% confidence interval (CI) 5.18-6.11%]. The highest and lowest incidence rates for post-CS SSIs were estimated for the African (11.91%, 95% CI 9.67-14.34%) and North American (3.87%, 95% CI 3.02-4.83%) regions, respectively. The incidence was significantly higher in countries with lower income and human development index levels. The pooled incidence estimates have increased steadily over time, with the highest incidence rate during the coronavirus disease 2019 pandemic (2019-2023). Staphylococcus aureus and Escherichia coli were the most prevalent pathogens. Several risk factors were identified. CONCLUSION An increasing and substantial burden from post-CS SSIs was identified, especially in low-income countries. Further research, greater awareness and the development of effective prevention and management strategies are warranted to reduce post-CS SSIs.
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Affiliation(s)
- M Farid Mojtahedi
- Department of Obstetrics and Gynaecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - M Sepidarkish
- Department of Biostatistics and Epidemiology, School of Public Health, Babol University of Medical Sciences, Babol, Iran
| | | | - Y Eslami
- Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - F Mohammadianamiri
- Infectious Diseases and Tropical Medicine Research Centre, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | | | - S Rouholamin
- Department of Obstetrics and Gynaecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - M Razavi
- Department of Obstetrics and Gynaecology, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - M Jafari Tadi
- Department of Cell and Molecular Medicine, Rush University Medical Center, Chicago, IL, USA
| | - A Fazlollahpour-Naghibi
- Infectious Diseases and Tropical Medicine Research Centre, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Z Rostami
- Infectious Diseases and Tropical Medicine Research Centre, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - A Rostami
- Infectious Diseases and Tropical Medicine Research Centre, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - M Rezaeinejad
- Department of Obstetrics and Gynaecology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
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Chang PC, Chen PH, Chang TH, Chen KH, Jhou HJ, Chou SH, Chang TW. Incentive spirometry is an effective strategy to improve the quality of postoperative care in patients. Asian J Surg 2023; 46:3397-3404. [PMID: 36437210 DOI: 10.1016/j.asjsur.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/15/2022] [Accepted: 11/11/2022] [Indexed: 11/27/2022] Open
Abstract
Postoperative pulmonary complications (PPCs) most commonly occur after thoracic surgery. Not only prolonged hospital stay and increased financial expenses but also morbidity and even mortality may be troublesome for those with PPCs. Herein, we aimed to conduct a comprehensive systematic review and meta-analysis of available data to examine the effectiveness of incentive spirometry (IS) to reduce PPCs and shorten hospital stay. This systematic review and meta-analysis included 5 randomized controlled trials (RCT) and 3 retrospective cohort study (10,322 patients in total) in PubMed, Embase and Cochrane Library until September 31, 2021. We assessed the clinical efficacy of IS using length of hospital stay, PPCs, postoperative pneumonia, and postoperative atelectasis with meta-analysis, meta-regression and trial sequential analysis (TSA). With this meta-analysis, the length of hospital stay in patients undergoing IS was significantly shorter (1.8 days) than that in patients not receiving IS (MD = -1.80, 95% CI = -2.95 to -0.65). Patients undergoing IS also had reduced risk of PPCs (32%) and postoperative pneumonia (17.9%) with statistical significance than patients not undergoing IS (PPC: OR = 0.68, 95% CI = 0.51-0.90) (Pneumonia: OR = 0.821, 95% CI = 0.677-0.995).In meta-regression, the benefits of undergoing IS in patients with preoperative predicted FEV1 of <80% in a linear fashion with decreasing PPCs. IS is an effective modality to improve the quality of postoperative care for patients after pulmonary resection, compared with the control group without using IS; and applying IS has favorable outcomes of shorter length of hospital stay (1.8 days) and lower occurrence of PPCs (32% of risk reduction), which are conclusive and robust based on our validation via TSA. Moreover, the IS device is more beneficial for patients with preoperative predicted FEV1 of <80% than that in others.
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Affiliation(s)
- Po-Chih Chang
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital/Kaohsiung Medical University, Kaohsiung City, Taiwan; Weight Management Center, Kaohsiung Medical University Hospital/Kaohsiung Medical University, Kaohsiung City, Taiwan; Ph. D. Program in Biomedical Engineering, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan; Department of Sports Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Po-Huang Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
| | - Ting-Hsuan Chang
- School of Medicine, China Medical University, Taichung City, Taiwan
| | - Kai-Hua Chen
- Department of Surgery, Kaohsiung Medical University Hospital/Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Shah-Hwa Chou
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital/Kaohsiung Medical University, Kaohsiung City, Taiwan; Department of Surgery, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Ting-Wei Chang
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital/Kaohsiung Medical University, Kaohsiung City, Taiwan.
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