Complications after opportunistic salpingectomy compared with tubal ligation at cesarean section: a retrospective cohort study

OBJECTIVE

To compare perioperative and postoperative complications in patients who underwent opportunistic salpingectomy (OS) (removal of the fallopian tubes for ovarian cancer risk reduction during another surgery) at the time of cesarean section (C-section) with those in patients who underwent tubal ligation.

DESIGN

A population-based, retrospective cohort study.

SETTING

British Columbia, Canada.

PATIENT(S)

A total of 18,184 patients were included in this study, of whom 8,440 and 9,744 underwent OS and tubal ligation, respectively.

INTERVENTION(S)

Patients who underwent OS during a C-section were compared with those who underwent tubal ligation during a C-section.

MAIN OUTCOME MEASURE(S)

We examined the perioperative outcomes, including operating room time, length of hospital stay, surgical complications such as infections, anemia, incision complications, injury to a pelvic organ, or operating room return; postoperative complications, including physician visits for a postoperative infection or visits that resulted in ultrasound or laboratory examinations and hospital readmissions in the 6 weeks after discharge; and likelihood to fill a prescription for antibiotics or analgesics.

RESULT(S)

The OS group had decreased odds of perioperative complications compared with the tubal ligation group (adjusted odds ratio [aOR], 0.77; 95% confidence interval [CI], 0.61-0.99). Patients who underwent OS did not have increased risks of physician visits for surgical complications, such as infection, or hospital readmissions in the 6 weeks after hospital discharge. In addition, these patients had 18% and 23% increased odds of filling prescriptions for nonsteroidal anti-inflammatory drugs (aOR, 1.18; 95% CI, 1.07-1.28) and opioids (aOR, 1.23%; 95% CI, 1.12-1.35), respectively.

CONCLUSION(S)

In this population-based, real-world study of OS at C-section, we report decreased perioperative complications and no difference in postoperative complications between patients who underwent OS and those who underwent tubal ligation. Patients who underwent OS had an increased likelihood of filling a prescription for nonsteroidal anti-inflammatory drugs and opioids in the 6 weeks after hospital discharge. This result should be interpreted with caution because we did not have data on over-the-counter medication use and, thus, not all prescription analgesics were captured in our data. Our data suggest that OS after C-section is a safe way to provide effective contraception and ovarian cancer risk reduction.

Propensity score-matched comparison of safety outcomes between high-risk and low-risk patients towards early hospital discharge after laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy (LC), a common treatment for symptomatic gallstones, has demonstrated safety in low-risk patients. However, existing data are scarce regarding the safety of LC in high-risk patients and the feasibility of early hospital discharge.

Materials and methods

This retrospective study included 2296 patients diagnosed with symptomatic gallstones who underwent LC at a tertiary care centre from January 2009 through December 2019. The authors employed propensity score matching to mitigate bias between groups. Statistical significance was set at P less than 0.05.

Results

The median age of the patients was 56 years (range 46-67), with a mean BMI of 25.2±4.3 kg/m2. Patients were classified as: American Society of Anesthesiologists (ASA) I (19.7%), II (68.3%), III (12.0%), and IV (0%). ASA I-II included low surgical risk patients (88%) and ASA III-IV comprised high-risk patients (12%). The LC-related 30-day reoperative rate was 0.2% and the readmission rate was 0.87%. Nine patients (0.4%) sustained major bile duct injuries, resulting in a conversion rate of 2.4%. The postoperative mortality rate was 0.04%, and the mean hospitalization time was 3.5 days. Patients in the high-risk group with a history of acute cholecystitis exhibited greater estimated blood loss, longer operative times, and were significantly more likely to be in the longer-stay group.

Conclusion

These findings suggest that LC can be conducted safely on high-risk patients, and early hospital discharge is achievable. However, specific factors, such as a history of acute cholecystitis, may result in prolonged hospitalization owing to increased blood loss and longer operative times.

Implementation of an Ambulatory Cleft Lip Repair Protocol: Surgical Outcomes

OBJECTIVES

Cleft lip repair has traditionally been performed as an inpatient procedure. There has been an interest toward outpatient cleft lip repair to reduce healthcare costs and avoid unnecessary hospital stay. We report surgical outcomes following implementation of an ambulatory cleft lip repair protocol and hypothesize that an ambulatory repair results in comparable safety outcomes to inpatient repair.

DESIGN/SETTING

This is a single-institution, retrospective study.

PATIENTS/PARTICIPANTS

Patients undergoing primary unilateral (UCL) and bilateral (BCL) cleft lip repair from 2012 to 2021 with a minimum 30-day follow-up. A total of 226 patients with UCL and 58 patients with BCL were included.

INTERVENTION

Ambulatory surgery protocol in 2016.

OUTCOME MEASURES

Variables include demographics and surgical data including 30-day readmission, 30-day reoperation, and postoperative complications.

RESULTS

There were no differences in rates of 30-day readmission, reoperation, wound complications, or postoperative complications between the pre- and post-protocol groups. Following ambulatory protocol implementation, 80% of the UCL group and 56% of the BCL group received ambulatory surgery. Average length of stay dropped from 24 h pre-protocol to 8 h post-protocol. The 20% of the UCL group and 44% of the BCL group chosen for overnight stay had a significantly higher proportion of congenital abnormalities and higher American Society of Anesthesiology (ASA) class. Reasons for overnight stay included cardiac/airway monitoring, prematurity, and monitoring of comorbidities. There were no differences in surgical outcomes between the ambulatory and overnight stay groups.

CONCLUSIONS

An ambulatory cleft lip repair protocol can significantly reduce average length of stay without adversely affecting surgical outcomes.

Developing a Core Outcome Set for Assessing Clinical Safety Outcomes of Prostate Cancer in Clinical Trials of Traditional Chinese Medicine: Protocol for a Mixed Methods Study

BACKGROUND

Among the common malignant tumors in men worldwide, the incidence of prostate cancer ranks second to lung cancer. This disease will bring an economic burden to patients and their families and can reduce the quality of life of patients. Researchers have conducted numerous clinical trials on the efficacy and safety of different interventions in the treatment of prostate cancer with traditional Chinese medicine (TCM) combined with standard treatment regimens. However, the currently published clinical trials exhibit inconsistent and irregular reporting of outcome measures.

OBJECTIVE

The objective of this paper is to emphasize the need for a core outcome set (COS) to facilitate future prostate cancer research, aiming to improve the quality of trials and generate high-quality evidence.

METHODS

This mixed methods project has three phases, as follows: (1) a scoping review of the literature to identify outcomes that have been reported in clinical trials and systematic reviews of interventions involving TCM for the treatment of prostate cancer as well as a qualitative component using interviews to obtain the views of patients with prostate cancer, their families, and their caregivers who have a history of TCM treatment; (2) a Delphi survey among stakeholders to prioritize the core outcomes-Participants will include traditional Chinese and Western medicine clinicians in prostate cancer-related directions, nurses, and methodology experts who will participate in 2 rounds of the Delphi method expert consultation to score each outcome in the list of outcome indicators; and (3) a face-to-face consensus meeting to discuss and agree on the final COS for the application of TCM in the treatment of prostate cancer.

RESULTS

The protocol has been registered in PROSPERO (CRD42022356184) before the start of the review process, and we will initiate the review on August 1, 2023; results should be expected by September 1, 2023. The Delphi survey among stakeholders is expected to start in October 2023.

CONCLUSIONS

The development of a core outcome set for assessing clinical safety outcomes of prostate cancer in clinical trials of TCM will provide a significant first step to assist Chinese doctors, researchers, and policy makers.

TRIAL REGISTRATION

PROSPERO CRD42022356184; https://tinyurl.com/ysakz74r.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46794.

Improving the Hospital Transfer Process for Acute Type A Aortic Dissections

Patients with acute type A aortic dissection who arrive at hospitals that lack the facilities to treat them must be transferred to a tertiary care facility to receive treatment. The transfer process involves a checkpoint at which the transfer is accepted or denied. Delays in making this decision may lead to suboptimal health outcomes. In light of this, the goal of this project was to devise a way to reduce the time to decision of transfer requests for patients with an acute type A aortic dissection. The project followed the Define-Measure-Analyze-Improve-Control (DMAIC) approach. To better understand the process, data were obtained from the University of Texas Southwestern Medical Center regarding reasons for patient transfer cancellation and the average time until a transfer was denied or accepted. After data analysis, a fishbone diagram was used to display 23 root causes of the delays in time to decision of the transfer request. These were narrowed down to the following four significant causes using a nominal voting technique: (1) no standard on disease-specific information for the handoff, (2) lack of a real-time database, (3) incompatible electronic health record system between facilities, and (4) multiple communication handoffs causing confusion. Solutions to each root cause were evaluated using a solution selection matrix. The final two solutions proposed for implementation were as follows: (1) to establish checklists of required documents and patient transfer criteria and (2) to create a regional database to provide real-time information on hospital capacity.

Effectiveness and safety of empagliflozin in routine care patients: Results from the EMPagliflozin compaRative effectIveness and SafEty (EMPRISE) study

AIM

To investigate effectiveness and safety outcomes among patients with type 2 diabetes (T2D) initiating empagliflozin versus dipeptidyl peptidase-4 (DPP-4) inhibitor treatment across the broad spectrum of cardiovascular risk.

METHODS

In a population-based cohort study we identified 39 072 pairs of 1:1 propensity score-matched adult patients with T2D initiating empagliflozin or DPP-4 inhibitors, using data from 2 US commercial insurance databases and Medicare between August 2014 and September 2017. The primary outcomes were a composite of myocardial infarction (MI)/stroke, and hospitalization for heart failure (HHF). Safety outcomes were bone fractures, lower-limb amputations (LLAs), diabetic ketoacidosis (DKA), and acute kidney injury (AKI). We estimated pooled hazard ratios (HRs) and 95% confidence intervals (CIs) adjusting for more than 140 baseline covariates.

RESULTS

Study participants had a mean age of 60 years and only 28% had established cardiovascular disease. Compared to DPP-4 inhibitors, empagliflozin was associated with similar risk of MI/stroke (HR 0.99 [95% CI 0.81-1.21]), and lower risk of HHF (HR 0.48 [95% CI 0.35-0.67] and 0.63 [95% CI 0.54-0.74], based on a primary and any heart failure discharge diagnosis, respectively). The HR was 0.52 (95% CI 0.38-0.72) for all-cause mortality (ACM) and 0.83 (95% CI 0.70-0.98) for a composite of MI/stroke/ACM. Empagliflozin was associated with a similar risk of LLA and fractures, an increased risk of DKA (HR 1.71 [95% CI 1.08-2.71]) and a decreased risk of AKI (HR 0.60 [95% CI 0.43-0.85]).

CONCLUSIONS

In clinical practice, the initiation of empagliflozin versus a DPP-4 inhibitor was associated with a lower risk of HHF, ACM and MI/stroke/ACM, a similar risk of MI/stroke, and a safety profile consistent with documented information.

Comparative Effectiveness and Safety of Low-Dose Oral Anticoagulants in Patients With Atrial Fibrillation

Aims: Observational studies of various dose levels of direct oral anticoagulants (DOACs) for patients with atrial fibrillation (AF) found that a high proportion of patients received a dose lower than the target dose tested in randomized controlled trials. There is a need to compare low-dose DOACs with warfarin or other DOACs on effectiveness and safety. Methods: Using administrative data from Quebec province, Canada, we built a cohort of new warfarin or DOAC users discharged from hospital between 2011 and 2017. We determined CHA₂DS₂-VASc and HAS-BLED scores, and comorbidities for 3-year prior cohort entry. The primary effectiveness endpoint was a composite of ischemic stroke/systemic embolism (SE), and secondary outcomes included a safety composite of major bleeding (MB) events and effectiveness composite (stroke/SE, death) at 1-year follow-up. We contrasted each low-dose DOAC with warfarin or other DOACs as references using inverse probability of treatment weighting to estimate marginal Cox hazard ratios (HRs). Results: The cohort comprised 22,969 patients (mean age: 80-86). We did not find a significant risk reduction for the stroke/SE primary effectiveness endpoint for DOACs vs. warfarin; however, we observed a significantly lower risk for low-dose dabigatran vs. warfarin (HR [95%CI]: 0.59 [0.42-0.81]) for effectiveness composite, mainly due to a lower death rate. The differences in effectiveness and safety composites between low-dose rivaroxaban vs. warfarin were not significant. However, low-dose apixaban had a better safety composite (HR: 0.68 [0.53-0.88]) vs. warfarin. Comparisons of dabigatran vs. apixaban showed a lower risk of stroke/SE (HR: 0.53 [0.30-0.93]) and a 2-fold higher risk of MB. The MB risk was higher for rivaroxaban than for apixaban (HR: 1.58 [1.09-2.29]). Conclusions: The results of this population-based study suggest that low-dose dabigatran has a better effective composite than warfarin. Compared with apixaban, low-dose dabigatran had a better effectiveness composite but a worse safety profile. Low-dose apixaban had a better safety composite than warfarin and other low-dose DOACs. Given that the comparative effectiveness and safety seem to vary from one DOAC to another, pharmacokinetic data for specific populations are now warranted.

Leukoaraiosis severity and post-reperfusion outcomes in acute ischaemic stroke: A meta-analysis

OBJECTIVES

Severity of leukoaraiosis may mediate outcomes after reperfusion therapy in acute ischaemic stroke (AIS) patients. However, the level of the association remains poorly understood. We performed a meta-analysis to investigate the impact of leukoaraiosis severity on functional outcome, survival, haemorrhagic complications, and procedural success in AIS patients treated with intravenous thrombolysis and/or endovascular thrombectomy.

MATERIALS AND METHODS

PubMed, EMBASE and the Cochrane library were searched for studies on leukoaraiosis in AIS receiving reperfusion therapy. A random-effects meta-analysis was conducted for post-reperfusion outcomes in AIS patients with absent-to-mild leukoaraiosis and moderate-to-severe leukoaraiosis. The strength of association between moderate-to-severe leukoaraiosis and poor outcomes was quantified using odds ratios (OR).

RESULTS

A total of 15 eligible studies involving 6460 patients (1451 with moderate-to-severe leukoaraiosis and 5009 with absent-to-mild leukoaraiosis) were included in the meta-analysis. Moderate-to-severe leukoaraiosis was significantly associated with poor 90-day functional outcome (OR 3.16; 95% confidence interval (CI) 2.69-3.72; p < .0001), 90-day mortality (OR 3.11; 95% CI 2.27-4.26; p < .0001) and increased risk of symptomatic intracerebral haemorrhage (OR 1.69; 95% CI 1.24-2.32; p = .001) after reperfusion therapy. Overall, no significant association of leukoaraiosis severity with haemorrhagic transformation (HT) and angiographic recanalization status were observed. However, subgroup analysis revealed a significant association of WML severity with HT in patients receiving EVT.

CONCLUSION

Leukoaraiosis is a useful prognostic biomarker in AIS. Patients with moderate-to-severe leukoaraiosis on baseline imaging are likely to have worse clinical and safety outcomes after reperfusion therapy.

Efficacy and Safety of Thromboprophylaxis Post-Orthopedic Surgery

Given the high risk of venous thromboembolism (VTE) post-orthopedic surgery and the vital role of thromboprophylaxis in preventing VTEs, this meta-analysis aimed to assess the efficacy of thromboprophylaxis post major orthopedic surgery and the relevant safety measures. In this review, we conducted a computer-aided search of Google Scholar, PubMed, CINAHL, Cochrane, Medline, and EMBASE databases. We included all published randomized clinical trials (RCTs) that utilized enoxaparin, fondaparinux, dabigatran, rivaroxaban, apixaban, and aspirin for VTE prophylaxis in patients undergoing total hip arthroplasty (THA), hip fracture surgery, and total knee arthroplasty (TKA) based on primary and secondary outcomes. The Cochrane Collaboration tool was used to evaluate the risk of bias. All statistical analyses were performed using Review Manager Software. A total of 23 RCTs were included with a total sample of 48,424 patients and an overall low risk of bias. The efficacy of enoxaparin in preventing VTEs in the TKA group was significantly better than fondaparinux. In the THA group, the efficacy of enoxaparin was significantly better than apixaban. The efficacies of fondaparinux, dabigatran, rivaroxaban, apixaban, and aspirin were comparable to that of enoxaparin in reducing VTE-associated mortality, major bleeding, and adverse events. In conclusion, we found that all included drugs were non-inferior to enoxaparin in VTE-associated mortality, major bleeding, and adverse events.

Ten-year analysis of the risk of severe outcomes related to low-dose glucocorticoids in early rheumatoid arthritis

OBJECTIVES

To explore the 10-year tolerability profile of glucocorticoids (GC) use in patients with early RA.

METHODS

Analysis of 10-year outcome from the early arthritis ESPOIR cohort. Patients were stratified in two groups, without or with GC treatment at least once during their follow-up. The primary outcome was a composite of deaths, cardiovascular diseases (CVD), severe infections and fractures. The weighted Cox time-dependent analysis model was used with inverse probability of treatment weighting (IPTW) propensity score method.

RESULTS

Among the 608 patients [480 women, mean age of 47.5  (12.1) years], 397 (65%) received low-dose GC [median 1.9 mg/day (IQR 0.6-4.2), mean cumulative prednisone dose 8468 mg (8376), mean duration 44.6 months (40.1)]. In univariate analysis, over 95 total events (10 deaths, 18 CVDs, 32 fractures and 35 severe infections), patients taking GC experienced more events (n = 71) than those without GC (n = 24) (P =0.035). Highest cumulative exposure of GC (≥8.4 g) was associated with highest risk of occurrence of the primary outcome (24.3%, P =0.007), CVDs (7.9%, P =0.001) and severe infections (9.9%, P =0.024). The risk of events over time was significantly associated with GC, age, hypertension and ESR. The risk associated with GC treatment increased between the first follow-up visit [hazard ratio (HR) at 1 year = 0.46, 95% CI: 0.23, 0.90] and 10 years (HR = 6.83, 95% CI: 2.29, 20.35).

CONCLUSION

The 10-year analysis of this prospective early RA cohort supports a dose and time-dependent impact of low-dose GC treatment, with a long-term high risk of severe outcomes.

TRIAL REGISTRATION

(ClinicalTrials.gov Identifier: NCT03666091).

Final 3-year clinical outcomes following transcatheter aortic valve implantation with a supra-annular self-expanding repositionable valve in a real-world setting: Results from the multicenter FORWARD study

Objectives

The Evolut R FORWARD study confirmed safety and effectivenesss of the Evolut R THV in routine clinical practice out to 1 year. Herein, we report the final 3‐year clinical follow up of the FORWARD study.

Background

Transcatheter aortic valve replacement (TAVR) is a proven alternative to surgery in elderly patients with symptomatic severe aortic stenosis. Long‐term clinical outcome data with the Evolut R platform are scarce.

Methods

FORWARD is a prospective multicenter observational study that evaluated the Evolut R system in routine clinical practice at 53 centres. Eligible patients had symptomatic native aortic valve stenosis or failed surgical aortic bioprosthesis and elevated operative risk per Heart‐Team assessment. TAVR was attempted in 1039 patients.

Results

Mean age was 81.8 ± 6.2 years, 64.9% were women, STS score was 5.5 ± 4.5% and 34.2% were frail. Rates of all‐cause mortality and disabling stroke were 24.8% and 4.8% at 3 years. Early need for a new pacemaker implantation after TAVR (all‐cause mortality: with new PPI; 21.0% vs. without; 22.8%, p = 0.55) and the presence of > trace paravalvular regurgitation (all‐cause mortality: no or trace; 22.0% vs. ≥ mild; 25.5%, p = 0.29) did not affect survival. Between 1 and 3 years incidence rates of valve related intervention, endocarditis and clinically relevant valve thrombosis were low.

Conclusions

The Evolut R valve maintained a favorable safety profile through 3 years in routine clinical practice. Rates of transcatheter heart valve‐related adverse events were low.

Diabetes Monotherapies versus Metformin-Based Combination Therapy for the Treatment of Type 2 Diabetes

Step-wise addition of antihyperglycemic agents (AHA) after the initiation of metformin monotherapy has been the traditional approach for the treatment of type 2 diabetes mellitus (T2DM) world-wide. Emerging evidence increasingly suggests that metformin-based combination therapy, especially with the newer AHA that lowers HbA1c glucose-dependently and do not potentiate hypoglycemia, could be a potentially better option for durable glycemic control with good tolerability compared to diabetes monotherapy. In this review, we descriptively analyzed the evidence available from the systematic reviews and meta-analyses of randomized head-to-head trials that reported the efficacy and safety outcomes of diabetes monotherapy, metformin-based combination therapies, and monotherapy versus metformin-based combination therapies.

Efficacy and safety of Lianhuaqingwen for mild or moderate coronavirus disease 2019: A meta-analysis of randomized controlled trials

BACKGROUND

: Coronavirus disease 2019 (COVID-19) is an emerging and rapidly evolving disease, with no recommended effective anti-coronavirus treatments. Traditional Chinese Medicine (TCM) has been widely used to treat COVID-19 in China, and the most used one is Lianhuaqingwen (LH). This study aimed to assess the efficacy and safety of LH combined with usual treatment vs usual treatment alone in treating mild or moderate COVID-19 by a meta-analysis of randomized controlled trials (RCTs).

METHODS AND ANALYSIS

: We systematically searched the Medline (OVID), Embase, the Cochrane Library, and 4 Chinese databases from inception to July 2020 to include the RCTs that evaluated the efficacy and safety of LH in combination with usual treatment vs usual treatment for mild or moderate COVID-19. A meta-analysis was performed to calculate the risk ratio (RR) and 95% confidence interval (CI) for binary outcomes and mean difference (MD) for continuous outcomes.

RESULTS

: A total of 5 RCTs with 824 individuals with mild or moderate COVID 19 were included. Compared with the usual treatment alone, LH in combination with usual treatment significantly improved the overall clinical efficacy (RR = 2.39, 95% CI 1.61-3.55), increased the rate of recovery of chest computed tomographic manifestations (RR = 1.80, 95% CI 1.08-3.01), reduced the rate of conversion to severe cases (RR = 0.47, 95% CI 0.29-0.74), shorten the duration of fever (MD = -1.00, 95% CI -1.17 to -0.84). Moreover, LH in combination with usual treatment did not increase the occurrence of the adverse event compared to usual treatment alone.

CONCLUSION

: Our meta-analysis of RCTs indicated that LH in combination with usual treatment may improve the clinical efficacy in patients with mild or moderate COVID-19 without increasing adverse events. However, given the limitations and poor quality of included trials in this study, further large-sample RCTs or high-quality real-world studies are needed to confirm our conclusions.

Exploring the Relationships between Safety Compliance, Safety Participation and Safety Outcomes: Considering the Moderating Role of Job Burnout

Safety compliance (SC) and safety participation (SP), which are key factors predicting safety outcomes (e.g., accidents, injuries and near misses), are related but distinct. However, which component is more significant remains controversial. Job burnout is a typical occupational psychological syndrome of employees that impacts safety outcomes, but the role that it plays in the relationship between SC, SP and safety outcomes is ambiguous. To clarify these relationships, Chinese coal mine workers were sampled. Then, hypotheses on the influencing mechanisms were initially proposed and later tested empirically. To conduct this testing, SC and SP scales were revised, and a job burnout scale was developed. The results showed that there were significant relationships between workers' SC and SP and safety outcomes; meanwhile, exhaustion, cynicism and low professional efficacy had significant effects on these relationships. Job burnout acted as a significant and indispensable moderator. Moreover, workers' occupational psychological health condition should be considered when improving safety outcomes.

Incidence of Immune Checkpoint Inhibitor-Associated Diabetes: A Meta-Analysis of Randomized Controlled Studies

Background: Immune checkpoint inhibitors (ICIs) are now an important option for more than 14 different cancers. Recent series case reports have described that ICIs are associated with new-onset diabetes in patients, yet the definitive risk is not available. We thus performed a meta-analysis of randomized controlled trials (RCTs) to assess the incidence and risk of developing new-onset diabetes following the use of ICIs.

Methods: The PubMed, EMBASE, Cochrane Library databases, and ClinicalTrials.gov for RCTs were searched. Statistical analyses were performed using STATA 15 and R language. Fifty-two RCTs were included, and 12 did not report any events of ICI-associated diabetes.

Results: A meta-analysis of 40 trials was performed, which reported at least one diabetes-related event among 24,596 patients. Although specific diabetes-related events were rare, compared with the placebo or other therapeutic strategies, the rates of serious hyperglycemia (OR 2.41, 95% CI 1.52 to 3.82), diabetes (3.54, 1.32 to 9.51), all-grade T1D (6.60, 2.51 to 17.30), and serious-grade T1D (6.50, 2.32 to 18.17) were increased with ICI drugs. Subgroup analysis according to the type of control, type of ICIs, and the combination mode suggested that ICIs plus conventional treatments significantly decreased the risks of diabetes and serious-grade hyperglycemia. There was little heterogeneity across the studies in all results except hyperglycemic events, which in part was attributable to data from everolimus-based control group.

Conclusions: New-onset diabetes is uncommon with ICIs but the risk is increased compared with placebo or another therapeutic strategy. However, more studies are warranted to substantiate these findings across ICIs.

Beyond Patient Satisfaction: Optimizing the Patient Experience

High patient satisfaction is not simply a customer service goal; it is an important dimension of quality and part of financial incentives and public reporting requirements. However, patient experience is often siloed within health system organizational charts and considered separately from quality and safety initiatives, instead of being seen predominantly as a "customer service" initiative. Representatives from 52 health care systems across the United States completed an online survey to explore both the processes and infrastructure hospitals employ to improve patient experience, and the metrics hospitals use to assess the quality of patient experience beyond patient satisfaction survey data. When asked about performance metrics beyond satisfaction, most hospitals or systems noted other metrics of the entire patient experience such as the rate of complaints or grievances and direct feedback from patient and family advisors. Additionally, respondents suggested that a broader definition of "quality of the patient experience" may be appropriate to encompass measures of access, clinical processes, and quality of care and patient safety outcomes. Almost all respondents that we surveyed listed metrics from these less traditional categories, indicating that performance improvement within the patient experience domain in these organizations is linked with other areas of hospital performance that rely on the same metrics, such as clinical quality and patient safety.

Effects of sodium-glucose cotransporter (SGLT) inhibitors in addition to insulin therapy on glucose control and safety outcomes in adults with type 1 diabetes: A meta-analysis of randomized controlled trials

Sodium-glucose cotransporter (SGLT) inhibitors added to insulin therapy have been proposed as treatment strategy for type 1 diabetes (T1D). We thus conducted a meta-analysis of randomized controlled trials (RCTs) to assess the efficacy and adverse effects of this combination in T1D. We searched the PubMed, EMBASE, and Cochrane Library databases and ClinicalTrials.gov for RCTs. Statistical analyses were performed using STATA 15. Ten eligible placebo-controlled trials involving 5961 patients were included. Compared with placebo, SGLT inhibitors were associated with a reduction in HbA1c of -0.39% (95% CI, -0.43 to -0.36), an improved mean amplitude of glucose excursion (MAGE) of -14.81 mg/dL (95% CI, -19.08 to -10.54), and a reduction in body weight of -3.47% (95% CI, -3.78 to -3.16), as well as no increased relative risk of hypoglycaemia (1.01; 95% CI, 0.99-1.02) or severe hypoglycaemia (0.91; 95% CI, 0.77-1.07). SGLT inhibitors decreased fasting plasma glucose and insulin requirement but increased the risk of genital infection (3.57; 95% CI, 2.97-4.29) and diabetic ketoacidosis (3.11; 95% CI, 2.11-4.58). However, the very low dose empagliflozin (2.5 mg) did not increase the risk of diabetic ketoacidosis (risk ratio [RR] 0.67; 95% CI, 0.11-3.95). SGLT inhibitors had no effect on overall adverse events, urinary tract infection, or bone fracture but slightly increased the risk of serious adverse events (1.35; 95% CI, 1.16-1.58), severe adverse events (1.84; 95% CI, 1.20-2.84), adverse events leading to discontinuation (1.50; 95% CI, 1.22-1.84), drug-related adverse events (1.78; 95% CI, 1.44-2.19), and diarrhoea (1.54; 95% CI, 1.15-2.05). Although adverse events exist, the available data provide evidence that the combination of SGLT inhibitors with basal insulin treatment is beneficial in patients with T1D.

Safety outcomes of new versus old generation transcatheter aortic valves

OBJECTIVE

To compare procedural outcomes of transcatheter aortic valve implantation (TAVI) patients who were implanted with older versus newer generation valves.

BACKGROUND

The current evidence base for improved safety of the newer commercially available TAVI valves is limited.

METHODS

A retrospective analysis of the Israeli multicenter TAVI registry was performed. Patients were stratified by valve generation of four commercially available devices: Edwards Sapien (ESX) Edwards Sapien S3 (ES3), Medtronic CoreValve (MCV), and Medtronic Evolut R (MER).

RESULTS

The cohort consisted of 737 patients with new generation valves (NGVs; ES3 n = 223; MER n = 514) and 1,869 with old generation valves (OGVs; MCV n = 1,181; ESX n = 688). Device success rates were significantly higher in NGV (97.5 versus 95.4%), with less post-procedural paravalvular leak (3 versus 5.8%), and valve mal-positioning (1.2 versus 3.4%); all P-values<0.05. There were no differences in rates of permanent pacemaker implantation, stroke or acute kidney injury (AKI) of any stage between the groups, although stage ≥2 AKI was more prevalent in NGV. After adjustment to significant differences in baseline patient and procedural characteristics, device success was higher (OR 1.86, 95% confidence interval (CI) 1.09-3.18, P = 0.023) and the 1-month safety outcome was significantly lower (OR 0.72, 95% CI 0.55-0.96, P = 0.025) for NGV. Device success was driven mainly by improved rates of PVL of ES3, while the safety outcome was mainly driven by improved rates of life-threatening bleeding and valve mal-positioning of MER.

CONCLUSION

As compared to OGV, use of NGV for TAVI was associated with higher rates of device success and lower rates of adverse events.

The efficacy and safety of memantine for the treatment of Alzheimer's disease

INTRODUCTION

Currently, five pharmacotherapeutic options are available to treat Alzheimer's disease: memantine; the three cholinesterase inhibitors donepezil, galantamine, and rivastigmine; and combination treatments with memantine and one cholinesterase inhibitor. Selection of the best course of treatment is based upon the evidence gathered by systematic reviews and meta-analyses of randomized controlled trials. Areas covered: This article provides a risk-benefit analysis of these treatments using evidence from meta-analyses on their safety and their efficacy. Expert opinion: Memantine improves cognitive functions and behavioral disturbances more efficiently than the placebo, both as monotherapy and in combination with donepezil. Although memantine monotherapy and combination therapy are associated with a few individual adverse events such as somnolence, it is well-tolerated and its safety (all-cause discontinuation) is comparable or superior to that of the placebo (agitation). Pooled cholinesterase inhibitors are superior to the placebo in the improvement of cognitive functions, but not behavioral disturbances and they are not well-tolerated, as evaluated by the high discontinuation rate. Donepezil (10 mg/day) and oral rivastigmine and galantamine monotherapies carry the risk for some adverse events including gastrointestinal symptoms. Therefore, we consider that combined treatment with memantine and donepezil is the most useful treatment for Alzheimer's disease.

Effect of metformin on glycaemic control in patients with type 1 diabetes: A meta-analysis of randomized controlled trials

BACKGROUND

For type 1 diabetes (T1D) patients, adding metformin to insulin therapies is thought to improve blood glucose levels, but current evidence does not support this clinical benefit. Additional data from large clinical trials are now available; therefore, we conducted a meta-analysis of studies on assessing the efficacy and adverse effects of metformin.

METHODS

We searched the MEDLINE, EMBASE, and Cochrane Library databases for data from randomized controlled trials. We performed statistical analyses by using Review Manager 5.2.

RESULTS

Thirteen randomized controlled trials that compared metformin versus placebo met our inclusion criteria and were included in the study. The final meta-analysis included a total of 1183 participants with T1D. Metformin was associated with reductions in BMI (-1.14, 95% CI -2.05 to -0.24, P = .01), insulin requirements (-0.47, 95% CI -0.70 to -0.23, P = .0001), total cholesterol (-0.23, 95% CI -0.34 to -0.12, P < .0001), and low-density lipoprotein cholesterol (-0.20, 95% CI -0.29 to -0.11, P < .0001) in T1D patients. No clear evidence indicated that metformin improved HbA1c, triglyceride, or high-density lipoprotein cholesterol levels. A safety analysis showed that metformin slightly increased the risk of severe hypoglycaemia (1.23, 95% CI 1.00 to 1.52, P = .05) and mainly gastrointestinal adverse events (2.67, 95% CI 2.06 to 3.45, P < .00001). No evidence showed that metformin increased diabetic ketoacidosis events.

CONCLUSIONS

Compared with placebo, metformin was not associated with glycaemic control in T1D patients. Although it exhibited other benefits, such as lower BMI and reduced insulin requirements, total cholesterol, and low-density lipoprotein cholesterol, negative outcomes, such as gastrointestinal adverse effects and severe hypoglycaemia, should also be considered in the use of metformin for T1D patients.

Comparison of the efficacy and safety of 4 and 2 mg/day brexpiprazole for acute schizophrenia: a meta-analysis of double-blind, randomized placebo-controlled trials

PURPOSE

The purpose of this study was to compare the efficacy and safety of brexpiprazole 4 mg/day (B4) and 2 mg/day (B2) for treating acute schizophrenia.

PATIENTS AND METHODS

We performed three categorical meta-analyses (B4 vs placebo, B2 vs placebo, and B4 vs B2) of double-blind, randomized placebo-controlled trials (DBRCTs) that reported improvements in the Positive and Negative Syndrome Scale (PANSS) scores, response rate, Clinical Global Impression-Improvement and Severity (CGI-I and CGI-S) scores, discontinuation rate, and incidence of individual adverse events.

RESULTS

We identified three DBRCTs with 1,444 patients. Both B4 and B2 were superior to placebo for PANSS total score (B4: standardized mean difference [SMD] =-0.30, 95% CI =-0.43, -0.17; B2: SMD =-0.30, 95% CI =-0.46, -0.13), PANSS negative score, response rate, CGI-S score, and CGI-I score. B2, but not B4, was superior to placebo for the PANSS positive score. However, there was considerable heterogeneity in the meta-analysis for B4's PANSS positive score, which disappeared after excluding a 2018 Japanese study from the meta-analysis that included more patients on a high-dose antipsychotic prior to their participation. A meta-analysis that excluded the data from the abovementioned patients showed B4 to be superior to the placebo in terms of the PANSS positive score (SMD =-0.22, 95% CI =-0.40, -0.03). B2, but not B4, was associated with a lower incidence of all-cause discontinuation compared with placebo. Both B4 and B2 were superior to placebo for discontinuation due to adverse events and schizophrenia, but both were associated with a higher incidence of weight gain compared with placebo. B4 was also associated with a higher risk of extrapyramidal symptoms than B2.

CONCLUSION

Both B4 and B2 benefitted patients with schizophrenia, particularly those who were not previously on high-dose antipsychotics. Both the regimens were well-tolerated, but carried a risk of weight gain and extrapyramidal symptoms, although the latter risk was higher for B4 than B2.

A model for meta-analysis of correlated binary outcomes: The case of split-body interventions

In several areas of clinical research, it is common for trials to assign different sites of the participants’ bodies to different interventions. For example, a randomized controlled trial comparing surgical techniques for correcting myopia may randomize each eye of a participant to a different operation. Under such bilateral (‘split-body’) interventions, the observations from each participant are correlated. It is challenging to account for these correlations at the meta-analysis level, especially when the outcome is rare. Here, we present a meta-analysis model based on the bivariate binomial distribution. Our model can synthesize studies on patients who received one intervention at one body site, patients who received two interventions at different sites or a mixture of these two groups. The model can analyse studies with zero events in one or both treatment arms and can handle the case of incomplete data reporting. We use simulations to assess the performance of our model and to compare it with the bivariate beta-binomial model. In the case of bilateral interventions, our model performed well and outperformed the bivariate beta-binomial model in all scenarios explored. We illustrate our methods using two previously published meta-analyses from the fields of orthopaedics and ophthalmology. We conclude that our model constitutes a useful new tool for the meta-analysis of binary outcomes in the presence of split-body interventions.

Associations between safety climate and safety management practices in the construction industry

BACKGROUND

Safety climate, a group-level measure of workers' perceptions regarding management's safety priorities, has been suggested as a key predictor of safety outcomes. However, its relationship with actual injury rates is inconsistent. We posit that safety climate may instead be a parallel outcome of workplace safety practices, rather than a determinant of workers' safety behaviors or outcomes.

METHODS

Using a sample of 25 commercial construction companies in Colombia, selected by injury rate stratum (high, medium, low), we examined the relationship between workers' safety climate perceptions and safety management practices (SMPs) reported by safety officers.

RESULTS

Workers' perceptions of safety climate were independent of their own company's implementation of SMPs, as measured here, and its injury rates. However, injury rates were negatively related to the implementation of SMPs.

CONCLUSIONS

Safety management practices may be more important than workers' perceptions of safety climate as direct predictors of injury rates.

Sex differences in utilization and outcomes of catheter-directed thrombolysis in patients with proximal lower extremity deep venous thrombosis - Insights from the Nationwide Inpatient Sample

Catheter-directed thrombolysis (CDT) is being increasingly used for the treatment of proximal lower extremity (LE) deep venous thrombosis (DVT). However, sex differences in utilization and safety outcomes of CDT in these patients are unknown. The Nationwide Inpatient Sample (NIS) database was used to identify all patients with a principal discharge diagnosis of proximal LE or caval DVT who underwent CDT between January 2005 and December 2011 in the United States. We evaluated the comparative safety outcomes of CDT among a propensity-matched group of 1731 men versus 1731 women. Among 108,243 patients with proximal LE or caval DVT, 4826 patients (4.5%) underwent CDT. Overall, women underwent CDT less often compared to men (4.1% vs 4.9%, p<0.01, respectively). The rates of CDT increased between 2005 and 2011 for both women (2.1% to 5.9%, p<0.01) and men (2.5% to 7.5%, p<0.01). There was no significant difference in in-hospital mortality (1.2% vs 1.3%, p=0.76). Women were noted to have higher rates of blood transfusions (11.7% vs 8.8%, p<0.01), but lower rates of intracranial hemorrhage (0.5% vs 1.2%, p=0.03) and gastrointestinal bleeding (0.9% vs 2.2%, p<0.01) compared with men. Women were more likely to undergo inferior vena cava filter placement (37.0% vs 32.1%, p<0.01). In this large nationwide cohort, women with proximal DVT were less likely to receive CDT compared to men. Although mortality rates were similar, women were noted to have higher blood transfusion rates while men had more episodes of intracranial and gastrointestinal bleeding.

The perception of hospital safety culture and selected outcomes among nurses: An exploratory study

The objectives of this study were to examine nurses' perceptions of the hospital safety culture in Jordan and to identify the relationships between aspects of hospital safety culture and selected safety outcomes. Data from 242 registered nurses in five Jordanian hospitals were analyzed. Aspects of hospital safety culture and outcomes were measured using the Hospital Survey on Patient Safety Culture. Among various aspects of hospital safety culture, teamwork within units had the highest average percentage of positive responses (49.8%). Additionally, participants reported deficits in other aspects of safety culture, particularly in staffing and nonpunitive response to errors, with average percentages of positive responses of 30.4% and 30.7%, respectively. Pearson correlation analysis revealed that 9 of 10 subscales of hospital safety culture were significantly correlated to one or more of the hospital safety outcomes. The findings of this study can help policymakers and healthcare administrators identify the weaknesses and strengths of hospital safety issues in order to propose effective strategies to improve patient safety and quality of care.