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Journal of Medical Virology Dec 2023This COVID-19 outpatient randomized controlled trials (RCTs) systematic review compares hospitalization outcomes amongst four treatment classes over pandemic period,... (Meta-Analysis)
Meta-Analysis
This COVID-19 outpatient randomized controlled trials (RCTs) systematic review compares hospitalization outcomes amongst four treatment classes over pandemic period, geography, variants, and vaccine status. Outpatient RCTs with hospitalization endpoint were identified in Pubmed searches through May 2023, excluding RCTs <30 participants (PROSPERO-CRD42022369181). Risk of bias was extracted from COVID-19-NMA, with odds ratio utilized for pooled comparison. Searches identified 281 studies with 61 published RCTs for 33 diverse interventions analyzed. RCTs were largely unvaccinated cohorts with at least one COVID-19 hospitalization risk factor. Grouping by class, monoclonal antibodies (mAbs) (OR = 0.31 [95% CI = 0.24-0.40]) had highest hospital reduction efficacy, followed by COVID-19 convalescent plasma (CCP) (OR = 0.69 [95% CI = 0.53-0.90]), small molecule antivirals (OR = 0.78 [95% CI = 0.48-1.33]), and repurposed drugs (OR = 0.82 [95% CI: 0.72-0.93]). Earlier in disease onset interventions performed better than later. This meta-analysis allows approximate head-to-head comparisons of diverse outpatient interventions. Omicron sublineages (XBB and BQ.1.1) are resistant to mAbs Despite trial heterogeneity, this pooled comparison by intervention class indicated oral antivirals are the preferred outpatient treatment where available, but intravenous interventions from convalescent plasma to remdesivir are also effective and necessary in constrained medical resource settings or for acute and chronic COVID-19 in the immunocompromised.
Topics: Humans; COVID-19; Outpatients; COVID-19 Serotherapy; Randomized Controlled Trials as Topic; Antibodies, Monoclonal; Hospitalization; Antiviral Agents
PubMed: 38105461
DOI: 10.1002/jmv.29310 -
International Orthopaedics Mar 2021To meet the increasing demands of total shoulder arthroplasty (TSA) while reducing its financial burden, there has been a shift toward outpatient surgery. This... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To meet the increasing demands of total shoulder arthroplasty (TSA) while reducing its financial burden, there has been a shift toward outpatient surgery. This systematic review and meta-analysis aimed to evaluate the safety of outpatient TSA.
METHODS
The primary objective was to compare re-admission rates and postoperative complications in outpatient versus inpatient TSA. The secondary objectives were functional outcomes and costs. PubMed, Google Scholar, and Web of Science were searched until March 28, 2020. The inclusion criteria were studies reporting at least complications or readmission rates within a period of 30 days or more.
RESULTS
Ten level III retrospective studies were included with 7637 (3.8%) and 192,025 (96.2%) patients underwent outpatient and inpatient TSA, respectively. Outpatient TSA had relatively younger and healthier patients. There were no differences between outpatient and inpatient arthroplasty for 30- and 90-day readmissions. Furthermore, unadjusted comparisons demonstrated significantly less total and major surgical complications, less total, major, and minor medical complications in favour of outpatient TSA. However, subgroup analyses demonstrated that there were no significant differences in all complication if the studies had matched controls and regardless of data source (database or nondatabase studies). The revision rates were similar between both groups at a 12-24 months follow-up. Two studies reported a significant reduction in costs in favour of outpatient TSA.
CONCLUSION
This study highlights that outpatient TSA could be a safe and effective alternative to inpatient TSA in appropriately selected patients. It was evident that outpatient TSA does not lead to increased readmissions, complications, or revision rates. A potential additional benefit of outpatient TSA was cost reduction.
Topics: Ambulatory Surgical Procedures; Arthroplasty, Replacement, Shoulder; Humans; Outpatients; Postoperative Complications; Retrospective Studies
PubMed: 33486581
DOI: 10.1007/s00264-021-04940-7 -
European Urology Focus Jan 2022Management of non-muscle-invasive bladder cancer (NMIBC) is costly and associated with negative health-related quality-of-life effects, in part because of the frequent... (Review)
Review
CONTEXT
Management of non-muscle-invasive bladder cancer (NMIBC) is costly and associated with negative health-related quality-of-life effects, in part because of the frequent need for repeated transurethral resections under general/regional anaesthesia. Outpatient-based diathermy or laser ablation is another option, but evidence for its efficacy is mixed and its use is controversial.
OBJECTIVE
To systematically review evidence regarding the efficacy and safety of outpatient diathermy and laser ablation for the treatment of recurrent NMIBC.
EVIDENCE ACQUISITION
The EMBASE, MEDLINE/PubMed, and Cochrane Library were searched from inception to June 26, 2020. All studies evaluating the use of diathermy or laser ablation for bladder tumours (new or recurrent) in an outpatient setting under local anaesthetic were included. Two reviewers independently screened all articles, searched the reference lists of retrieved articles, and performed the data extraction. The quality of evidence and risk of bias were assessed using the GRADE and ROBINS-I tools.
EVIDENCE SYNTHESIS
The search yielded 1328 studies. After excluding duplicates, 1319 titles and abstracts were screened and 17 studies (1584 patients) were eligible for inclusion in the final review. The majority of patients had small, low-grade tumours, but there was heterogeneity in the inclusion criteria. Overall, laser ablation and diathermy resulted in mean recurrence rates of 47% and 32% at follow-up of 22-38 mo, respectively, with a mean progression rate of 3-12% (low certainty of evidence). Both procedures were well tolerated, with low pain scores and low periprocedural complication rates (moderate certainty of evidence).
CONCLUSIONS
Outpatient diathermy and laser ablation have good short-term efficacy in patients with low-grade NMIBC and reduce the need for intervention under general/regional anaesthesia. The procedures are well tolerated with low complication rates. The overall certainty of evidence is low, with heterogeneity between studies and methodological limitations. However, we have highlighted the need for randomised trials with long-term follow-up using standardised risk classification and outcome measures. Despite these limitations, the findings will aid in patient counselling regarding this less invasive treatment option that avoids the morbidity of transurethral resection.
PATIENT SUMMARY
Outpatient diathermy and laser ablation have good success rates in treating recurrent low-grade bladder tumours in the short term, avoiding the need for more invasive procedures under general/regional anaesthesia, with low rates of side effects. Further studies are needed to determine whether these treatments remain safe and effective in the long term.
Topics: Humans; Laser Therapy; Outpatients; Urinary Bladder Neoplasms; Urologic Surgical Procedures
PubMed: 33602641
DOI: 10.1016/j.euf.2021.01.019 -
Obstetrics and Gynecology Feb 2022To evaluate whether outpatient cervical ripening with a balloon catheter results in a shorter amount of time in the labor and delivery unit when compared with use in the... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To evaluate whether outpatient cervical ripening with a balloon catheter results in a shorter amount of time in the labor and delivery unit when compared with use in the inpatient setting.
DATA SOURCES
PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov were searched from their inception until December 2020. No restrictions for language or geographic location were applied.
METHODS OF STUDY SELECTION
Using a predefined protocol and search strategy, 1,152 titles were identified and screened. Randomized controlled trials that compared outpatient and inpatient cervical ripening with balloon catheters were included.
TABULATION, INTEGRATION, AND RESULTS
Data extraction and risk of bias assessments were performed by two reviewers. Meta-analysis was performed to produce mean difference for continuous data and risk ratio (RR) for dichotomous data, both with a 95% CI. The primary outcome was the amount of time from admission to the labor ward until delivery. Additional secondary maternal and neonatal outcomes were evaluated. Eight trials (740 patients) were included; six studies (571 patients) reported on our primary outcome. Compared with the inpatient group, outpatient balloon cervical ripening was associated with significantly less time in the labor and delivery unit (outpatient 16.3±9.7 hours vs inpatient 23.8±14.0 hours; mean difference -7.24 hours, 95% CI -11.03 to -3.34). There were no differences in total induction time or total hospital admission. The outpatient group was significantly less likely than the inpatient group to undergo cesarean delivery (21% vs 27%), RR 0.76 (95% CI 0.59-0.98). There were no differences in other maternal or neonatal outcomes. There were no deliveries outside of the hospital and no stillbirths.
CONCLUSION
Outpatient balloon cervical ripening in low-risk patients is associated with a decreased amount of time from admission to labor and delivery until delivery. Outpatient balloon cervical ripening is a safe alternative for low-risk patients and has the potential for significant benefits to patients, and labor and delivery units.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42019140503.
Topics: Ambulatory Care; Cervical Ripening; Delivery Rooms; Female; Humans; Inpatients; Labor, Induced; Outpatients; Pregnancy; Time Factors
PubMed: 34991144
DOI: 10.1097/AOG.0000000000004644 -
World Neurosurgery Nov 2022The coronavirus disease 2019 (COVID-19) pandemic has sparked interest in telemedicine, resulting in an increase in neurosurgical publications focused on it. We summarize...
OBJECTIVE
The coronavirus disease 2019 (COVID-19) pandemic has sparked interest in telemedicine, resulting in an increase in neurosurgical publications focused on it. We summarize this new literature to evaluate telemedicine applications to neurosurgery.
METHODS
A systematic literature review was performed in accordance with the PRISMA guidelines by searching PubMed, Embase, and Scopus for journal articles published after January 1, 2020. All journal articles that included data after the start of COVID-19 and evaluated any aspect of telemedicine relevant to outpatient neurosurgical visits were included. The premise and key findings of each included study were extracted, as well as patient and provider satisfaction with and preference for telemedicine.
RESULTS
Thirty-seven articles met the inclusion criteria. Four studies proposed and evaluated a remote neurologic examination. Two studies reported similar postvisit outcomes between remote and in-person visits. Twenty-four studies reported a combination of patient and provider opinions toward telemedicine. Of 9834 patients and 116 providers, 82.4% and 65.2% were satisfied overall with telemedicine, respectively. Of 3526 patients and 168 providers, 57.0% and 66.5% preferred telemedicine to in-person visits, respectively.
CONCLUSIONS
Overall, most patients and providers have a high opinion of telemedicine for outpatient visits, and increasing evidence suggests that remote visits yield favorable clinical outcomes. The high rates of patient and provider satisfaction and preference may be considered for further adoption of remote neurosurgical visits beyond the COVID-19 era.
Topics: Humans; COVID-19; Neurosurgery; SARS-CoV-2; Outpatients; Telemedicine
PubMed: 36115568
DOI: 10.1016/j.wneu.2022.08.145 -
Frontiers in Endocrinology 2023Subacute thyroiditis (SAT) is a self-limiting thyroid inflammatory disease occurring specifically after upper respiratory tract infections. Since COVID-19 is a...
BACKGROUND
Subacute thyroiditis (SAT) is a self-limiting thyroid inflammatory disease occurring specifically after upper respiratory tract infections. Since COVID-19 is a respiratory disease leading to multi-organ involvements, we aimed to systematically review the literature regarding SAT secondary to COVID-19.
METHODS
We searched Scopus, PubMed/MEDLINE, Cochrane, Web of Science, ProQuest, and LitCovid databases using the terms "subacute thyroiditis" and "COVID-19" and their synonyms from inception to November 3, 2022. We included the original articles of the patients with SAT secondary to COVID-19. Studies reporting SAT secondary to COVID-19 vaccination or SAT symptoms' manifestation before the COVID-19 infection were not included.
RESULTS
Totally, 820 articles were retained. Having removed the duplicates, 250 articles remained, out of which 43 articles (40 case reports and three case series) with a total of 100 patients, were eventually selected. The patients aged 18-85 years (Mean: 42.70, SD: 11.85) and 68 (68%) were women. The time from the onset of COVID-19 to the onset of SAT symptoms varied from zero to 168 days (Mean: 28.31, SD: 36.92). The most common symptoms of SAT were neck pain in 69 patients (69%), fever in 54 (54%), fatigue and weakness in 34 (34%), and persistent palpitations in 31 (31%). The most common ultrasonographic findings were hypoechoic regions in 73 (79%), enlarged thyroid in 46 (50%), and changes in thyroid vascularity in 14 (15%). Thirty-one patients (31%) were hospitalized, and 68 (68%) were treated as outpatients. Corticosteroids were the preferred treatment in both the inpatient and outpatient settings (25 inpatients (81%) and 44 outpatients (65%)). Other preferred treatments were nonsteroidal anti-inflammatory drugs (nine inpatients (29%) and 17 outpatients (25%)) and beta-blockers (four inpatients (13%) and seven outpatients (10%)). After a mean duration of 61.59 days (SD: 67.07), 21 patients (23%) developed hypothyroidism and thus, levothyroxine-based treatment was used in six of these patients and the rest of these patients did not receive levothyroxine.
CONCLUSION
SAT secondary to COVID-19 seems to manifest almost similarly to the conventional SAT. However, except for the case reports and case series, lack of studies has limited the quality of the data at hand.
Topics: Humans; Female; Male; COVID-19; Thyroxine; COVID-19 Vaccines; Thyroiditis, Subacute
PubMed: 37091856
DOI: 10.3389/fendo.2023.1126637 -
The Journal of the American Academy of... Apr 2021The term "outpatient" has a variety of meanings regarding the location of arthroplasty and the duration of stay postoperatively. The purpose of this systematic review...
INTRODUCTION
The term "outpatient" has a variety of meanings regarding the location of arthroplasty and the duration of stay postoperatively. The purpose of this systematic review was to evaluate the literature and more accurately define the term "outpatient."
METHODS
A PubMed search (2014 to 2019) using the terms "outpatient AND arthroplasty" identified 76 studies; 35 studies that met the inclusion criteria were assessed to determine the definition of "outpatient." The level of evidence, type of arthroplasty, location of surgery (hospital or ambulatory surgery center [ASC]), approach used for hip arthroplasty, number of patients, number of surgeons, and length of time the patients were kept at the location after surgery were evaluated.
RESULTS
Arthroplasties analyzed were total hip (11), total knee (seven), unicompartmental knee (five), and hip and knee (12). Only 16.8% of surgeries defined as outpatient hip or knee arthroplasty were done in a freestanding ASC, and 44.2% of patients defined as outpatients were kept overnight for the 23-hour observation.
DISCUSSION
We propose "DASH" (Discharge from ASC to Home) as a new term to define arthroplasties done in an outpatient setting with the patient discharged home the same day.
Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Humans; Knee Joint; Outpatients; Patient Discharge
PubMed: 32925385
DOI: 10.5435/JAAOS-D-19-00636 -
The Journal of the American Academy of... Jan 2022Changes in healthcare policy have driven many hospital-based surgeries to the outpatient environment. Multiple studies have shown outpatient total shoulder arthroplasty...
INTRODUCTION
Changes in healthcare policy have driven many hospital-based surgeries to the outpatient environment. Multiple studies have shown outpatient total shoulder arthroplasty (TSA) is a safe alternative to the inpatient setting. This systematic review evaluates patient selection, perioperative protocols, complications, costs, patient satisfaction, and clinical outcomes of outpatient TSA and compares these with their inpatient counterparts.
METHODS
The Emnbase, Medline, and CENTRAL databases were queried on April 30, 2020, for outpatient TSA studies, identifying 232 articles, with 21 meeting inclusion criteria. This involved 25,808 and 231,408 patients undergoing outpatient and inpatient TSA, respectively. Failed same-day discharge, readmissions, revision surgeries, cost, and complications among outpatient TSA were aggregated when raw numbers were available. Statistical significance for comparisons among outpatient and inpatient TSA within individual studies was alpha = 0.05.
RESULTS
Ten studies evaluated same-day discharge rate, with 440 of 446 patients (98.7%) meeting the goals. Fourteen studies evaluated readmissions, revision surgeries, and complications, with readmissions in 238 of 6,133 patients (3.9%), revision surgeries in 32 of 1,484 patients (2.1%), and complications in 376 of 4,977 patients (7.6%). Readmission rates were similar between inpatients and outpatients, with only one study finding more readmissions after inpatient TSA. Complications were more common in inpatient TSA in five studies. Outpatient TSA demonstrated a charge reduction of $25,509 to $53,202 per patient, and patient satisfaction after outpatient TSA was "good to excellent" in more than 95% of patients. Patient selection for outpatient TSA used patient age, medical comorbidities, social support, living proximity to location of surgery, and lack of preoperative opioid use.
DISCUSSION
Outpatient TSA in appropriately selected patients is a safe and cost-effective alternative to inpatient TSA. However, the literature is limited to national database or small retrospective studies. Large prospective, cohort studies are necessary to further assess differences in complication profiles between outpatient and inpatient TSA.
LEVEL OF EVIDENCE
Level IV; systematic review.
Topics: Arthroplasty, Replacement, Shoulder; Cost-Benefit Analysis; Humans; Outpatients; Postoperative Complications; Prospective Studies; Retrospective Studies
PubMed: 34644715
DOI: 10.5435/JAAOS-D-21-00562 -
JBJS Reviews May 2021Orthopaedic surgical procedures are increasingly being performed in outpatient settings. The drive for cost reduction without compromising patient safety and outcomes...
BACKGROUND
Orthopaedic surgical procedures are increasingly being performed in outpatient settings. The drive for cost reduction without compromising patient safety and outcomes has increased interest in outpatient total shoulder arthroplasty (TSA). The primary aim of this study was to perform a review of the evidence regarding the outcomes and cost-effectiveness of outpatient TSA.
METHODS
A search of the PubMed, Embase, and Cochrane Library databases was performed using several keywords: "outpatient," "shoulder replacement," "ambulatory," "day case," "day-case," "shoulder arthroplasty," "same day," and "shoulder surgery." Studies that were published from May 2010 to May 2020 in the English language were considered. Research design, questions, and outcomes were recorded for each study. Qualitative and quantitative pooled analysis was performed on the data where appropriate.
RESULTS
Twenty studies met the inclusion criteria. Six retrospective studies compared complication rates between inpatient and outpatient cohorts and found no significant differences. Four studies found that the complication rate was lower in the outpatient cohort compared with the inpatient cohort. In a pooled analysis, the readmission rate after outpatient TSA was significantly lower than the readmission rate after inpatient TSA at 30 days (0.65% vs. 0.95%) and 90 days (2.03% vs. 2.87%) postoperatively (p < 0.05 for both). Four studies evaluated the cost of outpatient TSA in comparison with inpatient TSA. All of these studies found that TSA at an ambulatory surgery center was significantly less costly than TSA at an inpatient facility, both for the health-care system and for the patient. Patient selection for outpatient TSA may depend on several important factors, including the presence or absence of diabetes, chronic obstructive pulmonary disease, chronic kidney disease, congestive heart failure, poor functional status, higher American Society of Anesthesiologists class, chronic narcotic use, higher body mass index, and older age.
CONCLUSIONS
Our results show that patient selection is the most critical factor that predicts the success of outpatient TSA. While outpatient TSA is significantly less costly than inpatient TSA, patients undergoing outpatient TSA are more likely to be healthier than patients undergoing inpatient TSA. More high-quality long-term studies are needed to add to this body of evidence.
LEVEL OF EVIDENCE
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Topics: Arthroplasty, Replacement, Shoulder; Cost-Benefit Analysis; Humans; Inpatients; Outpatients; Retrospective Studies
PubMed: 33956691
DOI: 10.2106/JBJS.RVW.20.00189 -
The Cochrane Database of Systematic... Sep 2022Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI) that has been approved for the treatment of depression, obsessive-compulsive disorder, and a variety of... (Review)
Review
BACKGROUND
Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI) that has been approved for the treatment of depression, obsessive-compulsive disorder, and a variety of anxiety disorders; it is available as an oral preparation. Fluvoxamine has not been approved for the treatment of infections, but has been used in the early treatment of people with mild to moderate COVID-19. As there are only a few effective therapies for people with COVID-19 in the community, a thorough understanding of the current evidence regarding the efficacy and safety of fluvoxamine as an anti-inflammatory and possible anti-viral treatment for COVID-19, based on randomised controlled trials (RCTs), is needed.
OBJECTIVES
To assess the efficacy and safety of fluvoxamine in addition to standard care, compared to standard care (alone or with placebo), or any other active pharmacological comparator with proven efficacy for the treatment of COVID-19 outpatients and inpatients.
SEARCH METHODS
We searched the Cochrane COVID-19 Study Register (including Cochrane Central Register of Controlled Trials, MEDLINE, Embase, ClinicalTrials.gov, WHO ICTRP, medRxiv), Web of Science and WHO COVID-19 Global literature on COVID-19 to identify completed and ongoing studies up to 1 February 2022.
SELECTION CRITERIA
We included RCTs that compared fluvoxamine in addition to standard care (also including no intervention), with standard care (alone or with placebo), or any other active pharmacological comparator with proven efficacy in clinical trials for the treatment of people with confirmed COVID-19, irrespective of disease severity, in both inpatients and outpatients. Co-interventions needed to be the same in both study arms. We excluded studies comparing fluvoxamine to other pharmacological interventions with unproven efficacy.
DATA COLLECTION AND ANALYSIS
We assessed risk of bias of primary outcomes using the Cochrane Risk of Bias 2 tool for RCTs. We used GRADE to rate the certainty of evidence to treat people with asymptomatic to severe COVID-19 for the primary outcomes including mortality, clinical deterioration, clinical improvement, quality of life, serious adverse events, adverse events of any grade, and suicide or suicide attempt.
MAIN RESULTS
We identified two completed studies with a total of 1649 symptomatic participants. One study was conducted in the USA (study with 152 participants, 80 and 72 participants per study arm) and the other study in Brazil (study with 1497 high-risk participants for progression to severe disease, 741 and 756 participants per study arm) among outpatients with mild COVID-19. Both studies were double-blind, placebo-controlled trials in which participants were prescribed 100 mg fluvoxamine two or three times daily for a maximum of 15 days. We identified five ongoing studies and two studies awaiting classification (due to translation issues, and due to missing published data). We found no published studies comparing fluvoxamine to other pharmacological interventions of proven efficacy. We assessed both included studies to have an overall high risk of bias. Fluvoxamine for the treatment of COVID-19 in inpatients We did not identify any completed studies of inpatients. Fluvoxamine for the treatment of COVID-19 in outpatients Fluvoxamine in addition to standard care may slightly reduce all-cause mortality at day 28 (RR 0.69, 95% CI 0.38 to 1.27; risk difference (RD) 9 per 1000; 2 studies, 1649 participants; low-certainty evidence), and may reduce clinical deterioration defined as all-cause hospital admission or death before hospital admission (RR 0.55, 95% CI 0.16 to 1.89; RD 57 per 1000; 2 studies, 1649 participants; low-certainty evidence). We are very uncertain regarding the effect of fluvoxamine on serious adverse events (RR 0.56, 95% CI 0.15 to 2.03; RD 54 per 1000; 2 studies, 1649 participants; very low-certainty evidence) or adverse events of any grade (RR 1.06, 95% CI 0.82 to 1.37; RD 7 per 1000; 2 studies, 1649 participants; very low-certainty evidence). Neither of the studies reported on symptom resolution (clinical improvement), quality of life or suicide/suicide attempt.
AUTHORS' CONCLUSIONS
Based on a low-certainty evidence, fluvoxamine may slightly reduce all-cause mortality at day 28, and may reduce the risk of admission to hospital or death in outpatients with mild COVID-19. However, we are very uncertain regarding the effect of fluvoxamine on serious adverse events, or any adverse events. In accordance with the living approach of this review, we will continually update our search and include eligible trials as they arise, to complete any gaps in the evidence.
Topics: Clinical Deterioration; Fluvoxamine; Humans; Randomized Controlled Trials as Topic; Selective Serotonin Reuptake Inhibitors; COVID-19 Drug Treatment
PubMed: 36103313
DOI: 10.1002/14651858.CD015391