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The Lancet. Global Health May 2016The risk factors contributing to maternal mortality from anaesthesia in low-income and middle-income countries and the burden of the problem have not been... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The risk factors contributing to maternal mortality from anaesthesia in low-income and middle-income countries and the burden of the problem have not been comprehensively studied up to now. We aimed to obtain precise estimates of anaesthesia-attributed deaths in pregnant women exposed to anaesthesia and to identify the factors linked to adverse outcomes in pregnant women exposed to anaesthesia in low-income and middle-income countries.
METHODS
In this systematic review and meta-analysis, we searched major electronic databases from inception until Oct 1, 2015, for studies reporting risks of maternal death from anaesthesia in low-income and middle-income countries. Studies were included if they assessed maternal and perinatal outcomes in pregnant women exposed to anaesthesia for an obstetric procedure in countries categorised as low-income or middle-income by the World Bank. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990 to ensure that the estimates reflect the current burden of the condition. Two independent reviewers undertook quality assessment and data extraction. We computed odds ratios for risk factors and anaesthesia-related complications, and pooled them using a random effects model. This study is registered with PROSPERO, number CRD42015015805.
FINDINGS
44 studies (632,556 pregnancies) reported risks of death from anaesthesia in women who had an obstetric surgical procedure; 95 (32,149,636 pregnancies and 36,144 deaths) provided rates of anaesthesia-attributed deaths as a proportion of maternal deaths. The risk of death from anaesthesia in women undergoing obstetric procedures was 1·2 per 1000 women undergoing obstetric procedures (95% CI 0·8-1·7, I(2)=83%). Anaesthesia accounted for 2·8% (2·4-3·4, I(2)=75%) of all maternal deaths, 3·5% (2·9-4·3, I(2)=79%) of direct maternal deaths (ie, those that resulted from obstetric complications), and 13·8% (9·0-20·7, I(2)=84%) of deaths after caesarean section. Exposure to general anaesthesia increased the odds of maternal (odds ratio [OR] 3·3, 95% CI 1·2-9·0, I(2)=58%), and perinatal deaths (2·3, 1·2-4·1, I(2)=73%) compared with neuraxial anaesthesia. The rate of any maternal death was 9·8 per 1000 anaesthetics (5·2-15·7, I(2)=92%) when managed by non-physician anaesthetists compared with 5·2 per 1000 (0·9-12·6, I(2)=95%) when managed by physician anaesthetists.
INTERPRETATION
The current international priority on strengthening health systems should address the risk factors such as general anaesthesia and rural setting for improving anaesthetic care in pregnant women.
FUNDING
Ammalife Charity and ELLY Appeal, Bart's Charity.
Topics: Anesthesia, General; Anesthesia, Obstetrical; Anesthesiologists; Cesarean Section; Developing Countries; Female; Humans; Infant, Newborn; Maternal Mortality; Nurse Anesthetists; Obstetric Surgical Procedures; Odds Ratio; Perinatal Death; Pregnancy; Risk Factors
PubMed: 27102195
DOI: 10.1016/S2214-109X(16)30003-1 -
Neurology India 2022New controversies have raised on brain death (BD) diagnosis when lesions are localized in the posterior fossa. (Review)
Review
BACKGROUND
New controversies have raised on brain death (BD) diagnosis when lesions are localized in the posterior fossa.
OBJECTIVE
The aim of this study was to discuss the particularities of BD diagnosis in patients with posterior fossa lesions.
MATERIALS AND METHODS
The author made a systematic review of literature on this topic.
RESULTS AND CONCLUSIONS
A supratentorial brain lesion usually produces a rostrocaudal transtentorial brain herniation, resulting in forebrain and brainstem loss of function. In secondary brain lesions (i.e., cerebral hypoxia), the brainstem is also affected like the forebrain. Nevertheless, some cases complaining posterior fossa lesions (i.e., basilar artery thrombotic infarcts, or hemorrhages of the brainstem and/or cerebellum) may retain intracranial blood flow and EEG activity. In this article, I discuss that if a posterior fossa lesion does not produce an enormous increment of intracranial pressure, a complete intracranial circulatory arrest does not occur, explaining the preservation of EEG activity, evoked potentials, and autonomic function. I also addressed Jahi McMath, who was declared braindead, but ancillary tests, performed 9 months after initial brain insult, showed conservation of intracranial structures, EEG activity, and autonomic reactivity to "Mother Talks" stimulus, rejecting the diagnosis of BD. Jahi McMath's MRI study demonstrated a huge lesion in the pons. Some authors have argued that in patients with primary brainstem lesions it might be possible to find in some cases partial recovery of consciousness, even fulfilling clinical BD criteria. This was the case in Jahi McMath.
Topics: Brain; Brain Death; Brain Diseases; Brain Stem; Humans; Intracranial Pressure
PubMed: 35532637
DOI: 10.4103/0028-3886.344634 -
American Journal of Obstetrics &... Nov 2020This study aimed to determine whether routine third-trimester ultrasounds in low-risk pregnancies decrease the rate of perinatal death compared with regular antenatal... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This study aimed to determine whether routine third-trimester ultrasounds in low-risk pregnancies decrease the rate of perinatal death compared with regular antenatal care with serial fundal height measurements.
DATA SOURCES
This was a systematic review and meta-analysis of randomized control trials to identify relevant studies published from inception to October 2019. The databases used were Ovid, PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials using a combination of key words related to "third trimester ultrasound" and "low-risk."
STUDY ELIGIBILITY CRITERIA
We included all randomized control trials of singleton, nonanomalous low-risk pregnancies that were randomized to either one or more third-trimester ultrasounds (ultrasound group) or serial fundal height (fundal height group). Exclusion criteria were patients with multiple gestations, maternal medical complications, or fetal abnormalities requiring a third-trimester ultrasound.
STUDY APPRAISAL AND SYNTHESIS METHODS
The primary outcome was the rate of perinatal death. The secondary outcomes were rates of fetal growth restriction, suspected large for gestational age, polyhydramnios, oligohydramnios, fetal anomalies, antenatal interventions, stillbirth, neonatal death, cesarean delivery, induction of labor, and other neonatal outcomes. This meta-analysis was performed with the use of the random effects model of DerSimonian and Laird to produce relative risk or mean difference with a corresponding 95% confidence interval.
RESULTS
A total of 7 randomized control trials with 23,643 participants (12,343 in the ultrasound group vs 11,300 in the fundal height group) were included. The total rate of perinatal death was similar among the groups (41 of 11,322 [0.4%] vs 34 of 10,285 [0.3%]; relative risk, 1.14; 95% confidence interval, 0.68-1.89). The rate of fetal growth restriction was higher in the ultrasound group (763 of 10,388 [7%] vs 337 of 9021 [4%]; relative risk, 2.11; 95% confidence interval, 1.86-2.39) and the rate of suspected large for gestational age (1060 of 3513 [30%] vs 375 of 3558 [11%]; relative risk, 2.84; 95% confidence interval, 2.6-3.2). Polyhydramnios was also significantly higher in the ultrasound group than the fundal height group (18 of 323 [6%] vs 4 of 322 [1%] relative risk, 3.93; 95% confidence interval, 1.4-11). The rates of the remainder of the secondary outcomes were similar among the groups.
CONCLUSION
Routine third-trimester ultrasounds do not decrease the rate of perinatal death compared with serial fundal height in low-risk pregnancies. Ideally, an adequately powered trial is warranted to determine whether perinatal mortality in the fundal height group can be reduced by one-third with third-trimester ultrasound.
Topics: Female; Fetal Growth Retardation; Humans; Infant, Newborn; Perinatal Death; Pregnancy; Pregnancy Trimester, Third; Stillbirth; Ultrasonography, Prenatal
PubMed: 33345941
DOI: 10.1016/j.ajogmf.2020.100242 -
Journal of Affective Disorders Mar 2022The use of suicide methods largely determines the outcome of suicide acts. However, no existing meta-analysis has assessed the case fatality rates (CFRs) by different... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The use of suicide methods largely determines the outcome of suicide acts. However, no existing meta-analysis has assessed the case fatality rates (CFRs) by different suicide methods. The current study aimed to fill this gap.
METHODS
We searched Scopus, Web of Science, PubMed, ProQuest and Embase for studies reporting method-specific CFRs in suicide, published from inception to 31 December 2020. A random-effect model meta-analysis was applied to compute pooled estimates.
RESULTS
Of 10,708 studies screened, 34 studies were included in the meta-analysis. Based on the suicide acts that resulted in death or hospitalization, firearms were found to be the most lethal method (CFR:89.7%), followed by hanging/suffocation (84.5%), drowning (80.4%), gas poisoning (56.6%), jumping (46.7%), drug/liquid poisoning (8.0%) and cutting (4.0%). The rank of the lethality for different methods remained relatively stable across study setting, sex and age group. Method-specific CFRs for males and females were similar for most suicide methods, while method-CFRs were specifically higher in older adults.
CONCLUSIONS
This study is the first meta-analysis that provides significant evidence for the wide variation of the lethality of suicide methods. Restricting highly lethal methods based on local context is vital in suicide prevention.
Topics: Aged; Drowning; Female; Firearms; Gas Poisoning; Hospitalization; Humans; Male; Suicide
PubMed: 34953923
DOI: 10.1016/j.jad.2021.12.054 -
BMJ Open Quality Mar 2021To identify approaches, enablers, barriers and outcomes of facility stillbirth and neonatal death audit in low-income and middle-income countries (LMICs). (Review)
Review
PURPOSE
To identify approaches, enablers, barriers and outcomes of facility stillbirth and neonatal death audit in low-income and middle-income countries (LMICs).
DATA SOURCES
We searched MEDLINE, CINAHL Complete, Academic Search Index, Science Citation Index, Complementary index and Global health electronic databases.
STUDY SELECTION
Studies were considered eligible when reporting the approaches, enablers, barriers and outcomes of facility-based stillbirth and neonatal death audit in LMICs.
DATA EXTRACTION
Two authors independently performed the data extraction using predefined templates made before data extraction.
RESULTS OF DATA SYNTHESIS
A total of 10 articles from 7 countries were included in the final analysis. Facility or external multidisciplinary teams performed death audits on a weekly or monthly basis. A total of 1018 stillbirths and neonatal deaths were audited. Of 18 audit enablers identified, nine were at the health provider level while 18 of 23 barriers to audit that were identified occurred at the facility level. The facility-level barriers cited by more than one study included: failure to implement change; inadequate training; limited time; increased workload; too many cases and poor documentation. Six studies reported that death audits resulted in structural improvements in physical structure, training, service organisation, supplies and equipment in the wards. Five studies reported that death audits improved the standard of care, with one study showing a significant improvement in measured standards. One study reported a significant reduction in newborn mortality rate of 29.4% (95% CI 0.6% to 2.4%; p=0.0015) and one study a reduction in perinatal mortality of 4.9% (52.8% in 2007 to 47.9% in 2008) before and after perinatal audit implementation.
CONCLUSION
Stillbirth and neonatal death audit improves facility structures, processes of care and health outcomes in neonatal care. There is a need to enhance enablers and address barriers identified at both health provider and facility levels to improve the audit process.
Topics: Developing Countries; Female; Humans; Infant Mortality; Infant, Newborn; Perinatal Death; Perinatal Mortality; Pregnancy; Stillbirth
PubMed: 33722879
DOI: 10.1136/bmjoq-2020-001266 -
Epilepsy & Behavior : E&B Nov 2017The objective of this study was to determine the association of sleep with sudden unexpected death in epilepsy (SUDEP). (Review)
Review
OBJECTIVE
The objective of this study was to determine the association of sleep with sudden unexpected death in epilepsy (SUDEP).
METHODS
We conducted a systematic review and meta-analysis based on literature search from databases PubMed, Web of Science, and Scopus using keywords "SUDEP", or "sudden unexpected death in epilepsy", or "sudden unexplained death in epilepsy". Sudden unexpected death in epilepsy was considered to occur during sleep if the patient was found in bed, if the SUDEP cases were documented as in sleep, or if the patient was found at bedside on the bedroom floor.
RESULTS
Circadian pattern was documented in 880 of the 1025 SUDEP cases in 67 studies meeting the inclusion and exclusion criteria. Of the 880 SUDEP cases, 69.3% occurred during sleep and 30.7% occurred during wakefulness. Sudden unexpected death in epilepsy was significantly associated with sleep as compared to wakefulness (P<0.001). In the subgroup of 272 cases in which circadian pattern and age were documented, patients 40years old or younger were more likely to die in sleep than those older than 40years (OR: 2.0; 95% CI=1.0, 3.8; P=0.05). In the subgroup of 114 cases in which both circadian pattern and body position at the time of death were documented, 87.6% (95% CI=81.1%, 94.2%) of patients who died during sleep were in the prone position, whereas 52.9% (95% CI=24.7%, 81.1%) of patients who died during wakefulness were in the prone position. Patients with nocturnal seizures were 6.3 times more likely to die in a prone position than those with diurnal seizures (OR: 6.3; 95% CI=2.0, 19.5; P=0.002).
CONCLUSIONS
There is a strong association of SUDEP with sleep, suggesting that sleep is a significant risk factor for SUDEP. Although the risks of SUDEP associated with sleep are unknown and likely multifactorial, the prone position might be an important contributory factor.
Topics: Death, Sudden; Epilepsy; Female; Humans; Male; Posture; Prone Position; Risk Factors; Seizures; Sleep; Wakefulness
PubMed: 28917499
DOI: 10.1016/j.yebeh.2017.08.021 -
Scientific Reports Sep 2023Outcomes of conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation (HFOV) in patients with congenital diaphragmatic hernia (CDH) were... (Meta-Analysis)
Meta-Analysis
Outcomes of conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation (HFOV) in patients with congenital diaphragmatic hernia (CDH) were compared through a systematic review and meta-analysis. Outcome measures included mortality and incidence of chronic lung disease (CLD). Odds ratio (OR) and 95% confidence interval (95%CI) were evaluated. Subgroup analyses were performed according to the strategy for applying HFOV in CDH patients. Group A: CMV was initially applied in all CDH patients, and HFOV was applied in unstable patients. Group B: chronologically analyzed. (CMV and HFOV era) Group C: CMV or HFOV was used as the initial MV. Of the 2199 abstracts screened, 15 full-text articles were analyzed. Regarding mortality, 16.7% (365/2180) and 32.8% (456/1389) patients died in CMV and HFOV, respectively (OR, 2.53; 95%CI 2.12-3.01). Subgroup analyses showed significantly worse, better, and equivalent mortality for HFOV than that for CMV in group A, B, and C, respectively. CLD occurred in 32.4% (399/1230) and 49.3% (369/749) patients in CMV and HFOV, respectively (OR, 2.37; 95%CI 1.93-2.90). The evidence from the literature is poor. Mortality and the incidence of CLD appear worse after HFOV in children with CDH. Cautious interpretation is needed due to the heterogeneity of each study.
Topics: Child; Humans; Respiration, Artificial; Hernias, Diaphragmatic, Congenital; High-Frequency Ventilation; Death; Cytomegalovirus Infections
PubMed: 37752154
DOI: 10.1038/s41598-023-42344-2 -
JACC. Heart Failure Jan 2023Despite hypertrophic cardiomyopathy (HCM) being the most common inherited heart disease and conferring increased risk for heart failure (HF) and sudden cardiac death... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Despite hypertrophic cardiomyopathy (HCM) being the most common inherited heart disease and conferring increased risk for heart failure (HF) and sudden cardiac death (SCD), risk assessment in HCM patients is still largely unresolved.
OBJECTIVES
This study aims to synthesize and compare the prognostic impact of demographic, clinical, biochemical, and imaging findings in patients with HCM.
METHODS
The authors searched PubMed, Embase, and Cochrane Library for studies published from 1955 to November 2020, and the endpoints were: 1) all-cause death; 2) an arrhythmic endpoint including SCD, sustained ventricular tachycardia, ventricular fibrillation, or aborted SCD; and 3) a composite endpoint including (1) or (2) plus hospitalization for HF or cardiac transplantation. The authors performed a pairwise meta-analysis obtaining the pooled estimate separately for the association between baseline variables and study endpoints. A random-effects network meta-analysis was subsequently used to comparatively assess the prognostic value of outcome associates.
RESULTS
A total of 112 studies with 58,732 HCM patients were included. Among others, increased brain natriuretic peptide/N-terminal pro-B-type natriuretic peptide, late gadolinium enhancement (LGE), positive genotype, impaired global longitudinal strain, and presence of apical aneurysm conferred increased risk for the composite endpoint. At network meta-analysis, LGE showed the highest prognostic value for all endpoints and was superior to all other associates except New York Heart Association functional class >class II. A multiparametric imaging-based model was superior in predicting the composite endpoint compared to a prespecified model based on conventional risk factors.
CONCLUSIONS
This network meta-analysis supports the development of multiparametric risk prediction algorithms, including advanced imaging markers additively to conventional risk factors, for refined risk stratification in HCM. (Long-term prognosis of hypertrophic cardiomyopathy according to genetic, clinical, biochemical and imaging findings: a systemic review and meta-analysis; CRD42020185219).
Topics: Humans; Cardiomyopathy, Hypertrophic; Contrast Media; Death, Sudden, Cardiac; Demography; Gadolinium; Heart Failure; Network Meta-Analysis; Prognosis; Risk Assessment; Risk Factors
PubMed: 36599547
DOI: 10.1016/j.jchf.2022.08.022 -
Journal of Community Health Feb 2016Sleep-related infant deaths remain a major public health issue. Multiple interventions have been implemented in efforts to increase adherence to safe sleep... (Review)
Review
Sleep-related infant deaths remain a major public health issue. Multiple interventions have been implemented in efforts to increase adherence to safe sleep recommendations. We conducted a systematic review of the international research literature to synthesize research on interventions to reduce the risk of sleep-related deaths and their effectiveness in changing infant sleep practices. We searched PubMed, CINAHL, PsycINFO, and Google Scholar for peer-reviewed articles published between 1990 and 2015 which described an intervention and reported results. Twenty-nine articles were included for review. Studies focused on infant caregivers, health care professionals, peers, and child care professionals. Targeted behaviors included sleep position, location, removing items from the crib, breastfeeding, smoke exposure, clothing, pacifier use, and knowledge of Sudden Infant Death Syndrome. Most articles described multi-faceted interventions, including: one-on-one or group education, printed materials, visual displays, videos, and providing resources such as cribs, pacifiers, wearable blankets, and infant t-shirts. Two described public education campaigns, one used an educative questionnaire, and one encouraged maternal note taking. Health professional interventions included implementing safe sleep policies, in-service training, printed provider materials, eliciting agreement on a Declaration of Safe Sleep Practice, and sharing adherence data. Data collection methods included self-report via surveys and observational crib audits. Over half of the studies utilized comparison groups which helped determine effectiveness. Most articles reported some degree of success in changing some of the targeted behaviors; no studies reported complete adherence to recommendations. Future studies should incorporate rigorous evaluation plans, utilize comparison groups, and collect demographic and collect follow-up data.
Topics: Caregivers; Health Education; Health Knowledge, Attitudes, Practice; Health Personnel; Humans; Infant; Sleep; Sudden Infant Death
PubMed: 26143241
DOI: 10.1007/s10900-015-0060-y -
ESC Heart Failure Apr 2023This systematic review evaluated the clinical effectiveness and safety of subcutaneous implantable cardioverter-defibrillator (S-ICD) in patients at an increased risk of... (Review)
Review
This systematic review evaluated the clinical effectiveness and safety of subcutaneous implantable cardioverter-defibrillator (S-ICD) in patients at an increased risk of sudden cardiac death and with an ICD indication for primary or secondary prevention. A systematic literature search was conducted in four databases (Medline via Ovid, Embase, the Cochrane Library, and HTA-INAHTA). Randomized controlled trials (RCTs) and controlled observational studies with ≥100 S-ICD patients and a low to moderate risk of bias were eligible for inclusion. The studies' quality and the available evidence's strength were assessed using the Cochrane risk of bias tool, the ROBINS-I tool, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. One RCT, a post hoc analysis of the RCT (n = 849) and four controlled observational studies (n = 7149) were included. The quality of the available evidence was graded as low to very low, except for the primary composite endpoint of the RCT, which was rated as moderate quality. After 4 years, the RCT showed that S-ICD was non-inferior to TV-ICD regarding the composite endpoint of inappropriate shocks and device-related complications (68 [15.1%] vs. 68 [15.7%], hazard ratio [HR] 0.99, 95% confidence interval [CI] [0.71, 1.39], non-inferiority margin 1.45, P = 0.001). The RCT and two observational studies reported statistically significantly fewer lead complications in S-ICD patients (after 4 years: 1.4% vs. 6.6%, HR 0.24, 95% CI [0.10, 0.54]; after 3 years: 0.3% vs. 2.3%, P = 0.03; and after 5 years: 0.8% vs. 11.5%, P = 0.03). Identified evidence about appropriate and inappropriate shocks was inconclusive: The RCT detected statistically significantly more appropriate shocks in patients with S-ICD (83 [19.2%] vs. 57 [11.5%], HR 1.52, 95% CI [1.08, 2.12], P = 0.02), whereas one observational study showed a statistically significantly lower rate in the S-ICD group (9.9%, 95% CI [7.0, 13.9], vs. 13.9%, 95% CI [10.8, 17.8], P = 0.003). Regarding inappropriate shocks, one observational study reported statistically significantly higher rates in the S-ICD cohort (11.9% vs. 7.5%, P = 0.007), whereas the RCT and two other observational studies did not detect a statistically significant difference between the treatment groups (P > 0.05). None of the included studies showed a statistically significant difference in overall mortality and shock efficacy between patients with S-ICD and TV-ICD (P > 0.05). The available evidence is insufficient to show the superiority of S-ICD compared with TV-ICD, hindering the widespread use of the technology. Results of the recently completed ATLAS trial are to be awaited, and the anticipated role of the S-ICD needs to be clearly formulated.
Topics: Humans; Defibrillators, Implantable; Death, Sudden, Cardiac; Treatment Outcome; Observational Studies as Topic
PubMed: 36444868
DOI: 10.1002/ehf2.14249