Incidence of acute kidney injury in patients with acute ischaemic stroke undergoing CT angiography (CTA) and CT perfusion (CTP): a systematic review and meta-analysis

Background and purpose

We conducted a systematic review and meta-analysis to assess the incidence of acute kidney injury (AKI) in patients undergoing CT angiography (CTA) and CT perfusion (CTP) for acute ischaemic stroke (AIS). Concerns over contrast-induced nephropathy (CIN) often lead medical centres to mandate pre-imaging serum creatinine level assessments, causing unnecessary delays. We aim to confirm further the practice of conducting CTA/CTP without first testing creatinine.

Methods

We searched PubMed, Cochrane Central and Scopus from inception until March 2023 for studies reporting on AKI in patients with AIS receiving CTA/CTP. Outcomes of interest were (1) the odds of AKI in patients receiving CTA/CTP versus non-contrast CT and (2) the overall incidence of AKI and haemodialysis in patients with AIS undergoing CTA/CTP.

Results

Results were pooled using a random effects model. 13 studies were included (5 cohort and 8 single-arm studies) with 5104 patients in total, out of which 4347 patients received CTA/CTP and 757 patients received no contrast. In case-control studies, 4.8% (OR=0.66, 95% CI 0.35 to 1.22, Z=1.32, p=0.19) of patients who received CTA/CTP developed AKI, compared with 7.7% of patients in the control group. Temporary haemodialysis was required for two patients in the analysed studies.

Conclusions

Non-randomised evidence suggests that CTA/CTP is not associated with a statistically significant increase in the risk of AKI in patients with stroke. Further well-designed prospective studies are required to explore potential risk factors of CIN in specific patient populations such as diabetes mellitus and chronic kidney disease.

Comparative efficacy of dexamethasone versus surgery for chronic subdural hematoma: A systematic review and meta-analysis

OBJECTIVE

To assess the comparative efficacy of dexamethasone (DXM) as monotherapy in comparison to surgery among the patients of chronic subdural hematoma (CSDH).

METHODS

We searched MEDLINE, PUBMED, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception till September 2023. Data was extracted, pooled and analyzed from all the studies that assessed the comparative efficacy of DXM as monotherapy in contrast with surgery as the primary treatment of CSDH.

RESULTS

A total of 6 studies involving 704 patients were included in our meta-analysis. Comparison of surgery to DXM revealed there was no statistically significant difference between the two groups regarding mortality [RR=1.09; 95% CI; 0.52-2.28 P = 0.83]. However, a significantly higher incidence of secondary surgical intervention was observed in the DXM group [RR 4.24; 95% CI; 2.06-8.71 P < 0.0001]. No significant difference in performance was observed in terms of poor postoperative outcomes within hospital stay [RR 1.12, 95% CI, 0.40-3.19 P=0.83] and at 6 months [RR 0.92, 95%CI, 0.40-2.13 P=0.85].

CONCLUSION

DXM had a significantly higher incidence of secondary surgical intervention. However, there was no difference regarding mortality and other safety outcomes between surgery and DXM for the patients with CSDH. Observational studies showed that DXM was associated with a lower risk of poor postoperative outcomes within hospital stay and had shorter duration of hospital stay, but the recurrence rate was lower in the surgery group.

Association of bilateral oophorectomy with incidence of Parkinson's disease: A systematic review and meta-analysis

INTRODUCTION

Current evidence in the literature is inconclusive due to conflicting results with regards to an association between B/L (B/L) oophorectomy and Parkinson's disease (PD). We included large, powered studies to assess the association of PD in women who have undergone B/L oophorectomy.

METHODS

We conducted a comprehensive search across three databases from inception to October 2022 for observational studies including pre-menopausal or post-menopausal women undergoing B/L oophorectomy. Primary outcome of interest was incidence of PD or parkinsonism. The results for these associations were presented as Risk Ratios (RR) with 95% confidence intervals (CI), which were pooled using a generic invariance weighted random effects model using Review Manager (RevMan).

RESULTS

Data was included from a total of 4 studies. No significant association was found between B/L oophorectomy and PD (RR: 1.38; 95% CI: 0.76 to 2.49; I2:89 %) in contrast significant association was found with parkinsonism (RR: 1.80; 95% CI: 1.29 to 2.52). Age at surgery didn't significantly affect Parkinsonism incidence (RR: 0.88; 95% CI: 0.59 to 1.3). No significant association was found between ovarian indication and Parkinsonism (RR: 1.08; 95% CI: 0.69 to 1.68). B/L oophorectomy with hysterectomy was associated with higher Parkinson's risk compared to without hysterectomy (RR: 1.4; 95% CI: 1.13 to 1.74). Lastly, there was no significant association between Post Menopausal Hormonal (PMH) use and Parkinson's disease (RR: 1.07; 95% CI: 0.92 to 1.26).

CONCLUSION

Our findings suggest that B/L oophorectomy is significantly associated with the incidence of Parkinsonism. Further research is needed to understand the potential relationship between oophorectomy and Parkinson's disease.

Is Using the Harmonic Scalpel Better than Conventional Hemostasis in Neck Dissection? A Meta-Analysis

Study Design

Systematic review and meta-analysis.

Objective

The clinical decision to pursue harmonic scalpel (HS) method vs conventional hemostasis to treat head and neck cancers has been arguably predicated on the clinical outcomes observed. This study aims to evaluate the surgical outcomes of neck dissection between both techniques and perform an updated meta-analysis using the available literature.

Methods

We searched PubMed, Scopus, and Cochrane Library through 31st December 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcome metrics included operative time and intraoperative blood loss. Secondary outcomes consisted of length of hospital stay, length of drain stay, total drain output, and postoperative complications. A meta-analysis was conducted using Review Manager Version 5.3 (RevMan) software employing the Random Effects Model.

Results

We identified 114 articles, out of which 10 randomized control trials (RCTs) analyzing a combined total of 558 patients met the inclusion criteria after title and full-text screening. Meta-analysis shows the group treated with HS had a significantly shorter operative time. [MD = -23.21, 95% CI (-34.30, -12.12) P value <.0001 I2 = 92%] but an insignificant lesser intraoperative blood loss [MD = -61.53, 95% CI (-88.61, -34.45) P < .00001 I2 = 79%].

Conclusions

This study confirms that that HS use in neck dissection yields a reduced operative time and intra operative blood loss relative to conventional hemostasis. Furthermore, our paper shows no superiority of HS method over conventional hemostasis where length of hospital stays, length of drain stays, and postoperative complications are concerned. Future RCTs with high-level evidence may further elucidate the relative effectiveness of HS method over conventional hemostasis in treating head and neck cancers.

Evaluating the Safety and Efficacy of Erythropoietin Therapy for Neonatal Hypoxic-Ischemic Encephalopathy: A Systematic Review and Meta-Analysis

BACKGROUND

Erythropoietin (EPO) is a proposed drug for the treatment of neonatal hypoxic-ischemic encephalopathy (HIE). Multiple studies have linked its use, either as a monotherapy or in conjunction with therapeutic hypothermia (TH), with improved neonatal outcomes including death and neurodisability. However, there is also evidence in the literature that raises concerns about its efficacy and safety for the treatment of neonatal encephalopathy (NE).

METHODS

We searched MEDLINE, Cochrane CENTRAL, and Embase for both observational studies and randomized controlled trials (RCTs) investigating the effectiveness of EPO in treating NE. Only studies in which at least 300 U/kg of EPO was used and reported any one of the following outcomes: death, death or neurodisability, and cerebral palsy, were included.

RESULTS

Seven studies with 903 infants with the diagnosis of NE were included in our meta-analysis. EPO did not reduce the risk of death or neurodisability (risk ratio 0.68 [95% confidence interval [CI]: 0.43 to 1.09]) (P = 0.11). Similarly, the risk of cerebral palsy was not reduced by the administration of EPO (risk ratio 0.68 [95% CI: 0.33 to 1.40]) (P = 0.30). The risk of death was also not reduced at any dose of EPO regardless of the use of TH.

CONCLUSIONS

The results of our meta-analysis do not support the use of EPO for the treatment of neonatal encephalopathy. However, future large-scale RCTs are needed to strengthen these findings.

Long-term efficacy of spinal cord stimulation for chronic primary neuropathic pain in the contemporary era: a systematic review and meta-analysis

INTRODUCTION

Spinal cord stimulation (SCS) is a modern neuromodulation technique extensively proven to be an effective modality for treatment of chronic neuropathic pain. It has been mainly studied for complex regional pain syndrome (CRPS) and failed back surgery syndrome (FBSS) and recent data almost uniformly establishes its statistically significant positive therapeutic results. It has also been compared with other available treatment modalities across various studies. However, long term data on maintenance of its efficacious potential remains less explored. Few studies have reported data on long follow-up times (>= 12 months) and have compared its efficacy with other treatment options for chronic pain, respectively. Our study pools and analyzes the available data and compares SCS with other treatment options. It also analyzes the efficacy of SCS in long term management of patients with chronic pain.

EVIDENCE ACQUISITION

We reviewed all the data available on MEDLINE, Embase and Cochrane CENTRAL using a search strategy designed to fit our pre-set inclusion and exclusion criteria. Both single-arm and double-arm studies were included. The primary outcome was defined as decrease of visual analogue scale (VAS) by >50% at 6, 12 and/or 24 months after SCS.

EVIDENCE SYNTHESIS

According to the pooled data of double-arm studies, SCS has unanimously proven its superiority over other treatment options at 6 months follow-up; however it fails to prove statistically significant difference in results at longer treatment intervals. Dorsal root ganglion stimulation, a relatively recent technique with the same underlying physiologic mechanisms as SCS, showed far more promising results than SCS. Single-arm studies show around 70% patients experiencing greater than 50% reduction in their VAS scores at 6 and 12 months.

CONCLUSIONS

SCS is a viable option for management of chronic neuropathic pain secondary to FBSS and CRPS. However, data available for its long term efficacy remains scarce and show no further statistically significant results.

Evaluating the safety and efficacy of daprodustat for anemia of chronic kidney disease: a meta-analysis of randomized clinical trials

PURPOSE

Anemia of chronic kidney disease (CKD) has traditionally been treated with recombinant human erythropoietin (rhEPO). Recently, daprodustat, a hypoxia-inducible factor prolyl-hydroxylase inhibitor, has also been shown to increase hematocrit. It remains unclear whether daprodustat or rhEPO should be the treatment of choice for anemia of CKD. We aimed to assess the efficacy and cardiovascular safety of daprodustat versus rhEPO in CKD patients.

METHODS

Online databases were queried in April 2022 for articles comparing the efficacy and safety of daprodustat in DD-CKD and NDD-CKD subgroups. Results from trials were pooled using a random-effects model.

RESULTS

Data on 8245 CKD patients from eight clinical trials were included. Our results show that in comparison to rhEPO, daprodustat maintained the same efficacy in increasing hemoglobin levels in both the DD-CKD (MD: 0.10; 95% CI [- 0.13,0.34]; p = 0.50) and NDD-CKD (MD: - 0.01; 95% CI [- 0.38,0.35]; p = 0.95) subgroups. Daprodustat significantly lowered hepcidin levels and significantly increased TIBC in both subgroups. Additionally, daprodustat significantly reduced the incidence of major adverse cardiovascular events (MACE) (RR: 0.89; 95% CI: 0.89-0.98; p = 0.02) and its myocardial infarction (MI) component (RR: 0.74; 95% CI: 0.59-0.92; p = 0.006) in the DD-CKD subgroup.

CONCLUSION

Daprodustat has similar efficacy compared to rhEPO for the treatment of anemia of CKD. On treatment, the reduced experience of MACE was reported in DD-CKD patients as compared to rhEPO. Furthermore, effects on iron metabolism varied by parameter, with daprodustat being superior to rhEPO in some cases and inferior in others.

Is it safe and effective to administer COVID-19 vaccines during pregnancy? A systematic review and meta-analysis

OBJECTIVE

To evaluate the safety and efficacy of COVID-19 vaccines in pregnant women performing an updated meta-analysis.

METHODS

We searched PubMed, Cochrane Central, and SCOPUS from inception to March 2022. Outcomes of interest were incidence of adverse maternal, fetal and neonatal consequences pertaining to safety of the vaccines. Secondarily, we analyzed the number of SARS-CoV-2 infections, hospitalization for COVID-19, and admission to the I.C.U. for COVID-19 assessing effectiveness of vaccines. Results were pooled using a random effects model.

RESULTS

Ten observational studies (n=326,499) analyzing pregnant women were included. Our results suggest that COVID-19 vaccination prevents infection (OR: 0.56, 95% CI: 0.47, 0.67; P = <0.00001) and related hospitalizations (OR: 0.50, 95% CI: 0.31, 0.82; P = 0.006) effectively. It was also observed that vaccination does not change adverse outcomes in pregnancy, namely preeclampsia or eclampsia, stroke (four weeks of delivery), meconium-stained amniotic fluid, spontaneous vaginal delivery, operative vaginal delivery, cesarean delivery, postpartum hemorrhage, and blood transfusions. Furthermore, the vaccine was observed to be protective against neonatal COVID-19 I.C.U. admissions (OR: 0.85; 95% CI: 0.81, 0.90; P = <0.00001).

CONCLUSION

Our pooled analysis suggests that the COVID-19 vaccination in pregnant women prevents infection effectively and has no adverse outcomes. Future large-scale trials in a randomized fashion are needed to confirm our results.

The time-varying cardiovascular benefits of glucagon-like peptide-1 receptor agonist therapy in patients with type 2 diabetes mellitus: Evidence from large multinational trials

AIMS

To evaluate the time-varying cardio-protective effect of glucagon-like peptide-1 receptor agonists (GLP-1RAs) using pooled data from eight contemporary cardiovascular outcome trials using the difference in the restricted mean survival time (ΔRMST) as the effect estimate.

MATERIAL AND METHODS

Data from eight multinational cardiovascular outcome randomized controlled trials of GLP-1RAs for type 2 diabetes mellitus were pooled. Flexible parametric survival models were fit from published Kaplan-Meier plots. The differences between arms in RMST (ΔRMST) were calculated at 12, 24, 36 and 48 months. ΔRMST values were pooled using an inverse variance-weighted random-effects model; heterogeneity was tested with Cochran's Q statistic. The endpoints studied were: three-point major adverse cardiovascular events (MACE), all-cause mortality, stroke, cardiovascular mortality and myocardial infarction.

RESULTS

We included eight large (3183-14 752 participants, total = 60 080; median follow-up range: 1.5 to 5.4 years) GLP-1RA trials. Among GLP-1RA recipients, we observed an average delay in three-point MACE of 0.03, 0.15, 0.37 and 0.63 months at 12, 24, 36 and 48 months, respectively. At 48 months, while cardiovascular mortality was comparable in both arms (pooled ΔRMST 0.163 [-0.112, 0.437]; P = 0.24), overall survival was higher (ΔRMST = 0.261 [0.08-0.43] months) and stroke was delayed (ΔRMST 0.22 [0.15-0.33]) in patients receiving GLP-1RAs.

CONCLUSIONS

Glucagon-like peptide-1 receptor agonists may delay the occurrence of MACE by an average of 0.6 months at 48 months, with meaningfully larger gains in patients with cardiovascular disease. This metric may be easier for clinicians and patients to interpret than hazard ratios, which assume a knowledge of absolute risk in the absence of treatment.

How well do we represent ourselves: an analysis of cardiology fellowships website content

Background: The Internet is the primary source of information for prospective cardiology fellowship aspirants. The objective of this study was to evaluate cardiology fellowship programs' online profile. Materials & methods: Two independent reviewers accessed 221 US based cardiology fellowship program websites obtained through Fellowship and Residency Electronic Interactive Database for pre-selected 20 criteria. The update status of websites was assessed using 6-point criteria. Results: Only 25 (11.3%) websites were fully up-to-date; 23 (10.4%) fulfilled 80% of the 20-point criteria and 85 (38.5%) program websites had fewer than 50% of the criteria listed. Conclusion: Most cardiology fellowship program websites lack crucial details. In this technology driven age, efforts should be made to ensure updated websites.

Elaborate Tongue Fasciculations Going Down to the Neck: A Rare Case of Sporadic, Young-onset Amyotrophic Lateral Sclerosis with Bulbar Symptoms, from Pakistan

Amyotrophic lateral sclerosis (ALS) is a rare, progressive neurodegenerative disease, part of the spectrum of motor neuron diseases. This disease is divided on the bases of heritability, with majority of the cases being sporadic and phenotype, with eight recognized patterns-each with its respective symptoms, rate of progression, and prognosis. Here, we report a case of sporadic, bulbar-onset ALS, unique in its presentation as our patient had fully progressed bulbar symptoms, at the age of 28 years-where other cases of bulbar ALS are associated with much older ages and have a predisposition for the female gender. His prominent and elaborate tongue fasciculations going all the way down to the neck and rendering him incapable of holding his tongue out made for an additional reason of our special interest in the case and the keenness to report it.

Sulfasalazine-induced Pancytopenia Indicating Bone Marrow Suppression: A Rare Pediatric Case Report from Pakistan

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic condition in children. The treatment of JIA is mainly by drug therapy, which includes non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and disease-modifying antirheumatic drugs (DMARDs). Sulfasalazine is a DMARD that is used as the second-line of therapy. Although believed to have an effective and safe profile, it has side effects ranging from mild gastrointestinal discomfort to hematopoietic alterations. In this study, we present a case of JIA with sulfasalazine-induced bone marrow suppression in a five-year-old child, which is rarely reported within the pediatric age group across the literature.

Affected Children of Healthy Parents: Multiple Pediatric Cases of Autosomal Recessive Charcot-Marie-Tooth Disease in a Pakistani Family

Charcot-Marie-Tooth (CMT) disease, also referred to as hereditary motor and sensory neuropathy (HMSN), is a heterogeneous group of disorders which primarily affects the peripheral nervous system. Clinically, the main features are progressive muscle weakness seen distally, along with wasting seen predominantly in the anterior compartments of the lower legs. The disease can broadly be classified into two groups, CMT1 and CMT2-based on inheritance patterns, paired with anatomical or electrophysiological findings. It can be inherited in the autosomal dominant, X-linked and rarely, the autosomal recessive fashions. Here, we present an unusual case of autosomal recessive CMT disease, in four out of six children of unaffected parents in a family.

Infiltrating the Heart and Kidney: A Rare Pediatric Case of Multisystem Langerhans Cell Histiocytosis from Pakistan

Langerhans cell histiocytosis (LCH) is a rare, clonal disease of the monocyte-macrophage system, varying in its clinical presentation from mere self-healing skin and bone lesions to life-threatening multi-system disease. In descending order of frequency, the disease is known to involve the skeleton, skin, lymph nodes and lesser often, the liver, spleen, lungs, hematopoietic and central nervous systems. Here, we present a pediatric case of multi-system LCH in a five-year-old child, unique in its evident cardiac and renal involvement alongside other organ systems and important in how the diagnosis was aided by a fine needle aspiration cytology instead of the costlier histopathological procedures, in a setting with limited resources.

Risk Calculator to Predict 30-Day Readmission After Coronary Artery Bypass: A Strategic Decision Support Tool

BACKGROUND

Re-admission is an important source of patient dissatisfaction and increased hospital costs. A simple calculator to determine the probability of re-admission may help guide patient dismissal planning.

METHODS

Using the national readmissions database (NRD), we identified admissions for isolated primary coronary artery bypass (CABG) and stratified them according to 30-day readmission. Including pre, intra and postoperative variables, we prepared a logistic regression model to determine the probability for re-admission. The model was tested for reliability with boot-strapping and 10-fold cross-validation.

RESULTS

From 135,699 procedures, 19,355 were readmitted at least once within 30days of dismissal. Patients who were readmitted were older (67±10 vs 65 ± 10 years, p<0.01), females (32% vs 24%; p<0.01) and had a higher Elixhauser comorbidity score (1.5±1.4 vs 1.1±1.2; p<0.01). Our final model (c- statistic=0.65) consisted of 16 pre and three postoperative factors. End-stage renal disease (OR 1.79 [1.57-2.04]) and length of stay>9days (OR 1.60 [1.52-1.68]) were most prominent indicators for readmission. Compared to Medicaid beneficiaries, those with private insurance (OR 0.62 [0.57-0.68]) and Medicare (OR 0.85 [0.79-0.92]) coverage were less likely to be readmitted.

CONCLUSIONS

Our simple 30-days CABG readmission calculator can be used as a strategic tool to help reduce readmissions after coronary artery bypass surgery.

Paving a Shorter Path Towards Diagnosis: A Case on Adult Onset Still's Disease from Pakistan

Adult onset Still’s disease (AOSD) is a rare clinical entity with unknown etiology, characterized by arthritis, fever, erythematous rash, and other systemic presentations. We report a case of a 21-year-old male who presented with high spiking fever, dry cough, generalized body ache, arthralgia, and an erythematous rash. He was eventually diagnosed to have AOSD based on the Yamaguchi criteria, after a month of visiting three different healthcare facilities and receiving two misdiagnoses and treatment regimes not specific to his diagnosis. The patient immediately responded to prednisoloneand was healthy upon discharge.

Heart transplantation after the circulatory death; The ethical dilemma

Donors after brain death (DBD) have been the major source of organ donation due to good perfusion of the organs. However, owing to the mismatch in demand and supply of the organ donors and recipients, donors after circulatory death (DCDDs) has increased recently all over the world. Kidneys, liver, and lungs are being used for transplantation from DCDDs. Recently, heart transplantation from DCDDs has been started, which is under the firestorm of scrutiny by the ethicists. The ethical dilemma revolves around the question whether the donors are actually dead when they are declared dead by cardiocirculatory death criteria for organ procurement. The subsequent literature review addresses all the perspectives by differentiating between the donation methods known as DBDs and DCDDs, explaining the implications of the dead-donor rule on the organ donation pool, and categorizing the determinants of death leading to separation of the arguments under the two methods of donations.

Barriers to Colorectal Cancer Screening in Pakistan

Background

The prevalence of colorectal cancer (CRC) is growing in Pakistan; however, there are no national screening programs or guidelines in place to curb its development. This study was conducted with the aim of ascertaining public awareness and attitudes regarding CRC and current screening practices. Furthermore, the study assessed perceived barriers which could impact future screening processes.

Methods

A cross-sectional, questionnaire-based study was conducted among urban dwellers of Karachi, Pakistan. We excluded any individuals belonging to the medical profession, those diagnosed previously with CRC or having any significant co-morbidity. The validated and pre-tested questionnaire was administered among the study participants to record demographic information, awareness of CRC risk factors, symptoms and screening tests. Attitudes towards screening and perceived barriers to screening were also assessed. Data were analyzed using Statistical Package for Social Sciences (SPSS version 20.0) (IBM Corp., Armonk, NY). A knowledge score, out of a total of 14 points was calculated to reflect a participant’s overall knowledge regarding CRC risk factors and signs/symptoms.

Results

The prevalence of CRC screening in eligible individuals (50 years or older) was 2.6% in our study population. Positive attitudes towards CRC management and screening were observed, with 75.1% (n = 296) acknowledging the preventive role of screening tests. Despite this only 14.9% (n = 58) of study participants expressed a future desire to undergo screening. Major barriers to screening were reported to be “a lack of knowledge regarding the screening procedure”, a “lack of screening facilities” and that the “screening procedure is too expensive”. A majority (n = 285, 72.3%) of the participants expressed a greater willingness to undergo screening if their doctor recommended it.

Conclusion

A national CRC screening and awareness program should be launched to promote awareness and facilitate screening in risk groups. General practitioners are needed to play a key role in counseling patients and endorsing healthy screening practices.