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BMC Cardiovascular Disorders May 2024Despite their continued use, the effectiveness and safety of vasopressors in post-cardiac arrest patients remain controversial. This study examined the efficacy of... (Meta-Analysis)
Meta-Analysis
BACKGROUND & OBJECTIVE
Despite their continued use, the effectiveness and safety of vasopressors in post-cardiac arrest patients remain controversial. This study examined the efficacy of various vasopressors in cardiac arrest patients in terms of clinical, morbidity, and mortality outcomes.
METHODS
A comprehensive literature search was performed using online databases (MeSH terms: MEDLINE (Ovid), CENTRAL (Cochrane Library), Embase (Ovid), CINAHL, Scopus, and Google Scholar) from 1997 to 2023 for relevant English language studies. The primary outcomes of interest for this study included short-term survival leading to death, return of spontaneous circulation (ROSC), survival to hospital discharge, neurological outcomes, survival to hospital admission, myocardial infarction, and incidence of arrhythmias.
RESULTS
In this meta-analysis, 26 studies, including 16 RCTs and ten non-RCTs, were evaluated. The focus was on the efficacy of epinephrine, vasopressin, methylprednisolone, dopamine, and their combinations in medical emergencies. Epinephrine treatment was associated with better odds of survival to hospital discharge (OR = 1.52, 95%CI [1.20, 1.94]; p < 0.001) and achieving ROSC (OR = 3.60, 95% CI [3.45, 3.76], P < 0.00001)) over placebo but not in other outcomes of interest such as short-term survival/ death at 28-30 days, survival to hospital admission, or neurological function. In addition, our analysis indicates non-superiority of vasopressin or epinephrine vasopressin-plus-epinephrine therapy over epinephrine monotherapy except for survival to hospital admission where the combinatorial therapy was associated with better outcome (0.76, 95%CI [0.64, 0.92]; p = 0.004). Similarly, we noted the non-superiority of vasopressin-plus-methylprednisolone versus placebo. Finally, while higher odds of survival to hospital discharge (OR = 3.35, 95%CI [1.81, 6.2]; p < 0.001) and ROSC (OR = 2.87, 95%CI [1.97, 4.19]; p < 0.001) favoring placebo over VSE therapy were observed, the risk of lethal arrhythmia was not statistically significant. There was insufficient literature to assess the effects of dopamine versus other treatment modalities meta-analytically.
CONCLUSION
This meta-analysis indicated that only epinephrine yielded superior outcomes among vasopressors than placebo, albeit limited to survival to hospital discharge and ROSC. Additionally, we demonstrate the non-superiority of vasopressin over epinephrine, although vasopressin could not be compared to placebo due to the paucity of data. The addition of vasopressin to epinephrine treatment only improved survival to hospital admission.
Topics: Humans; Vasoconstrictor Agents; Treatment Outcome; Out-of-Hospital Cardiac Arrest; Risk Factors; Return of Spontaneous Circulation; Male; Middle Aged; Female; Aged; Time Factors; Cardiopulmonary Resuscitation; Epinephrine; Recovery of Function; Risk Assessment; Vasopressins; Patient Discharge; Adult
PubMed: 38816786
DOI: 10.1186/s12872-024-03962-4 -
The Cochrane Database of Systematic... May 2024The American Academy of Pediatrics and the Canadian Paediatric Society both advise that all newborns should undergo bilirubin screening before leaving the hospital, and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The American Academy of Pediatrics and the Canadian Paediatric Society both advise that all newborns should undergo bilirubin screening before leaving the hospital, and this has become the standard practice in both countries. However, the US Preventive Task Force has found no strong evidence to suggest that this practice of universal screening for bilirubin reduces the occurrence of significant outcomes such as bilirubin-induced neurologic dysfunction or kernicterus.
OBJECTIVES
To evaluate the effectiveness of transcutaneous screening compared to visual inspection for hyperbilirubinemia to prevent the readmission of newborns (infants greater than 35 weeks' gestation) for phototherapy.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, ICTRP, and ISRCTN in June 2023. We also searched conference proceedings, and the reference lists of included studies.
SELECTION CRITERIA
We included randomized controlled trials (RCTs), quasi-randomized, cluster-randomized, or prospective cohort studies with control arm that evaluated the use of transcutaneous bilirubin (TcB) screening for hyperbilirubinemia in newborns before hospital discharge.
DATA COLLECTION AND ANALYSIS
We used standard methodologic procedures expected by Cochrane. We evaluated treatment effects using a fixed-effect model with risk ratio (RR) and 95% confidence intervals (CI) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. We used the GRADE approach to evaluate the certainty of evidence.
MAIN RESULTS
We identified one RCT (1858 participants) that met our inclusion criteria. The study included 1858 African newborns at 35 weeks' gestation or greater who were receiving routine care at a well-baby nursery, and were randomly recruited prior to discharge to undergo TcB screening. The study had good methodologic quality. TcB screening versus visual assessment of hyperbilirubinemia in newborns: - may reduce readmission to the hospital for hyperbilirubinemia (RR 0.25, 95% CI 0.14 to 0.46; P < 0.0001; moderate-certainty evidence); - probably has little or no effect on the rate of exchange transfusion (RR 0.20, 95% CI 0.01 to 14.16; low-certainty evidence); - may increase the number of newborns who require phototherapy prior to discharge (RR 2.67, 95% CI 1.56 to 4.55; moderate-certainty evidence). - probably has little or no effect on the rate of acute bilirubin encephalopathy (RR 0.33, 95% CI 0.01 to 8.18; low-certainty evidence). The study did not evaluate or report cost of care.
AUTHORS' CONCLUSIONS
Moderate-certainty evidence suggests that TcB screening may reduce readmission for hyperbilirubinemia compared to visual inspection. Low-certainty evidence also suggests that TcB screening probably has little or no effect on the rate of exchange transfusion compared to visual inspection. However, moderate-certainty evidence suggests that TcB screening may increase the number of newborns that require phototherapy before discharge compared to visual inspection. Low-certainty evidence suggests that TcB screening probably has little or no effect on the rate of acute bilirubin encephalopathy compared to visual inspection. Given that we have only identified one RCT, further studies are necessary to determine whether TcB screening can help to reduce readmission and complications related to neonatal hyperbilirubinemia. In settings with limited newborn follow-up after hospital discharge, identifying newborns at risk of severe hyperbilirubinemia before hospital discharge will be important to plan targeted follow-up of these infants.
Topics: Humans; Infant, Newborn; Bilirubin; Jaundice, Neonatal; Randomized Controlled Trials as Topic; Infant, Premature; Neonatal Screening; Patient Readmission; Bias; Hyperbilirubinemia, Neonatal; Phototherapy; Term Birth
PubMed: 38804265
DOI: 10.1002/14651858.CD011060.pub2 -
Journal of Gynecology Obstetrics and... May 2024Outpatient surgery in gynaecology may offer advantages including cost reduction, patient convenience and hospital bed optimisation without compromising patient safety... (Review)
Review
BACKGROUND
Outpatient surgery in gynaecology may offer advantages including cost reduction, patient convenience and hospital bed optimisation without compromising patient safety and satisfaction. With the continual rise in health costs since 2000, outpatient surgery could be a line of action to improve financial resource utilisation and a solution for continuing to treat patients during crises such as the coronavirus disease 2019 pandemic.
OBJECTIVE
This systematic review provides an overview of the literature on minimally invasive outpatient hysterectomy for benign indications.
METHOD
A focused systematic review of the medical literature between 2018 and 2022 on outpatient gynaecological surgery for a benign indication was conducted using the PubMed and Google Scholar search engines. We then narrowed our selection to articles that referred to hysterectomy. Successful same-day discharge (SDD) was defined as the patient's return home on the day of the procedure without an overnight stay.
RESULTS
Fifteen articles that focused on minimally invasive surgery were included in this review. Most of the studies (n = 11) were conducted in the United States. Outpatient surgery had a mean success rate of 60 % and a mean readmission rate of 3 %. The main reasons for SDD failure were patient choice, failed voiding, the need for pain management, nausea or vomiting, or both and the late timing of surgery. SDD was not associated with more complications and readmissions compared with inpatient care. The three main attribute predictors of SDD were young age, early timing of surgery and short total operative time. Patient satisfaction with SDD was high in absolute terms and relative to satisfaction with hospitalisation.
CONCLUSION
Minimally invasive outpatient hysterectomy for a benign indication is feasible and safe but is associated with a notable risk of failure. To increase the success rate of outpatient management, patients must be well selected and surgery pathways must be planned in advance. The implementation of enhanced recovery protocols may help promote outpatient hysterectomy for a benign indication.
PubMed: 38797369
DOI: 10.1016/j.jogoh.2024.102804 -
Infectious Diseases and Therapy Jul 2024Respiratory syncytial virus (RSV) can cause severe respiratory infections in adults; however, information on associated sequelae is limited. This systematic literature... (Review)
Review
INTRODUCTION
Respiratory syncytial virus (RSV) can cause severe respiratory infections in adults; however, information on associated sequelae is limited. This systematic literature review aimed to identify sequelae in adults within 1 year following RSV-related hospitalization or resolution of acute infection.
METHODS
Studies were identified from Embase, MEDLINE, LILACS, SciELO, and grey literature. Random-effects meta-analyses using restricted maximum likelihood were used to calculate the proportions and relative risks of sequelae in patients with RSV compared with controls (patients with RSV-negative influenza-like illness, influenza, and parainfluenza) per follow-up period, population, and treatment setting, where possible.
RESULTS
Twenty-one relevant studies covering the period from 1990 to 2019 were included. Among the general population, the most frequent clinical sequela was sustained function loss (33.5% [95% CI 27.6-39.9]). Decline in lung function and cardiovascular event or congestive heart failure were also identified. Utilization sequelae were readmission (highest at > 6 months after discharge) and placement in a skilled nursing facility. The only subpopulation with data regarding sequelae was transplant patients. Among lung transplant patients, the most frequently reported clinical sequelae were decline in lung function, followed by graft dysfunction and bronchiolitis obliterans syndrome. Pooled relative risks were calculated for the following sequela with controls (primarily influenza-positive patients): cardiovascular event (general population) and pulmonary impairment (hematogenic-transplant patients) both 1.4 (95% CI 1.0-2.0) and for readmission (general population) 1.2 (95% CI 1.1-1.3).
CONCLUSIONS
Although less data are available for RSV than for influenza or other lower respiratory tract infections, RSV infection among adults is associated with medically important sequelae, with a prevalence similar to other respiratory pathogens. RSV sequelae should be included in disease burden estimates.
PubMed: 38789901
DOI: 10.1007/s40121-024-00974-7 -
PloS One 2024To synthesize the impact of improvement interventions related to care coordination, discharge support and care transitions on patient experience measures.
AIM
To synthesize the impact of improvement interventions related to care coordination, discharge support and care transitions on patient experience measures.
METHOD
Systematic review. Searches were completed in six scientific databases, five specialty journals, and through snowballing. Eligibility included studies published in English (2015-2023) focused on improving care coordination, discharge support, or transitional care assessed by standardized patient experience measures as a primary outcome. Two independent reviewers made eligibility decisions and performed quality appraisals.
RESULTS
Of 1240 papers initially screened, 16 were included. Seven studies focused on care coordination activities, including three randomized controlled trials [RCTs]. These studies used enhanced supports such as improvement coaching or tailoring for vulnerable populations within Patient-Centered Medical Homes or other primary care sites. Intervention effectiveness was mixed or neutral relative to standard or models of care or simpler supports (e.g., improvement tool). Eight studies, including three RCTs, focused on enhanced discharge support, including patient education (e.g., teach back) and telephone follow-up; mixed or neutral results on the patient experience were also found and with more substantive risks of bias. One pragmatic trial on a transitional care intervention, using a navigator support, found significant changes only for the subset of uninsured patients and in one patient experience outcome, and had challenges with implementation fidelity.
CONCLUSION
Enhanced supports for improving care coordination, discharge education, and post-discharge follow-up had mixed or neutral effectiveness for improving the patient experience with care, compared to standard care or simpler improvement approaches. There is a need to advance the body of evidence on how to improve the patient experience with discharge support and transitional approaches.
Topics: Humans; Patient Discharge; Transitional Care; Patient-Centered Care; Patient Satisfaction; Continuity of Patient Care; Randomized Controlled Trials as Topic
PubMed: 38771768
DOI: 10.1371/journal.pone.0299176 -
International Journal of Nursing... Dec 2023Intensive care units deliver care to a heterogeneous group of patients with pre-existing co-morbid disease. Focus has shifted to improving health related quality of life... (Review)
Review
Patients' experiences and perspectives of post-hospital follow-up care to improve physical recovery for intensive care survivors: A systematic review of qualitative research.
BACKGROUND
Intensive care units deliver care to a heterogeneous group of patients with pre-existing co-morbid disease. Focus has shifted to improving health related quality of life with more patients surviving beyond hospital discharge. Randomised controlled trials evaluating follow-up interventions, to improve physical recovery, have not demonstrated a health-related quality of life benefit. Qualitative research may provide the context to understand the experiences of intensive care survivors during follow-up care addressing physical limitations.
OBJECTIVE
To synthesise qualitative studies and explore Intensive Care survivors' experiences and perspectives of physical symptoms in the context of follow-up care.
SETTINGS
A systematic search of electronic databases (MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Web of Science, Applied Social Sciences Index and Abstracts, Ovid Nursing and Ovid Emcare) was conducted to identify peer-reviewed primary qualitative studies. No date parameters were applied. Inclusion/exclusion criteria guided the screening process.
PARTICIPANTS
The data from eligible primary research studies was extracted into NVivo (v12).
METHODS
Critical appraisal was completed using the Joanna Briggs Critical Appraisal Tool. Thematic analysis, guided by Braun and Clarke (2022), informed the data synthesis.
RESULTS
From 2457 studies, ten relevant studies were included. Two main themes were identified: 1. Recovery as uncertain; which outlines the uncertainty experienced by intensive care unit survivors during recovery. This theme pertained to system-level factors (role of healthcare professional and information provision) which provides the context for delivering follow-up care. 2. Self-determination of recovery; outlines individual characteristics in determining recovery which is conceptualised by patient-level factors (motivation, support network and perception of health).
CONCLUSIONS
For intensive care survivors, the recovery trajectory is uncertain with a gap in information provision during the acute phase following hospital discharge. Patients' self-determination of recovery is an important consideration to ensure follow-up care addresses the needs of individual patients. The impact of pre-existing co-morbid disease and subgroups of patients deriving benefit from follow-up care remains uncertain.
REGISTRATION
PROSPERO Registration no. CRD42022355711.
TWEETABLE ABSTRACT
Patients' experiences of post-hospital follow-up care to improve physical recovery for intensive care survivors: A Systematic Review of Qualitative Research.
PubMed: 38746570
DOI: 10.1016/j.ijnsa.2023.100168 -
Journal of Clinical Medicine Apr 2024Heart failure (HF) affects around 60 million individuals worldwide. The primary aim of this study was to evaluate the efficacy of lung ultrasound (LUS) in managing HF... (Review)
Review
Heart failure (HF) affects around 60 million individuals worldwide. The primary aim of this study was to evaluate the efficacy of lung ultrasound (LUS) in managing HF with the goal of reducing hospital readmission rates. A systematic search was conducted on PubMed, Embase, Google Scholar, Web of Science, and Scopus, covering clinical trials, meta-analyses, systematic reviews, and original articles published between 1 January 2019 and 31 December 2023, focusing on LUS for HF assessment in out-patient settings. There is a potential for bias as the effectiveness of interventions may vary depending on the individuals administering them. The PRISMA method synthesized the findings. Out of 873 articles identified, 33 were selected: 19 articles focused on prognostic assessment of HF, 11 centred on multimodal diagnostic assessments, and two addressed therapeutic guidance for HF diagnosis. LUS demonstrates advantages in detecting subclinical congestion, which holds prognostic significance for readmission and mortality during out-patient follow-up post-hospital-discharge, especially in complex scenarios, but there is a lack of standardization. there are considerable uncertainties in their interpretation and monitoring changes. The need for an updated international consensus on the use of LUS seems obvious.
PubMed: 38730988
DOI: 10.3390/jcm13092460 -
Journal of Robotic Surgery May 2024Colorectal surgery has progressed greatly via minimally invasive techniques, laparoscopic and robotic. With the advent of ERAS protocols, patient recovery times have...
Colorectal surgery has progressed greatly via minimally invasive techniques, laparoscopic and robotic. With the advent of ERAS protocols, patient recovery times have greatly shortened, allowing for same day discharges (SDD). Although SDD have been explored through laparoscopic colectomy reviews, no reviews surrounding robotic ambulatory colorectal resections (RACrR) exist to date. A systematic search was carried out across three databases and internet searches. Data were selected and extracted by two independent reviewers. Inclusion criteria included robotic colorectal resections with a length of hospital stay of less than one day or 24 h. 4 studies comprising 136 patients were retrieved. 56% of patients were female and were aged between 21 and 89 years. Main surgery indications were colorectal cancer and recurrent sigmoid diverticulitis (43% each). Most patients had low anterior resections (48%). Overall, there was a 4% complication rate postoperatively, with only 1 patient requiring readmission due to postoperative urinary retention (< 1%). Patient selection criteria involved ASA score cut-offs, nutritional status, and specific health conditions. Protocols employed shared similarities including ERAS education, transabdominal plane blocks, early removal of urinary catheters, an opioid-sparing regime, and encouraged early oral intake and ambulation prior to discharge. All 4 studies had various follow-up methods involving telemedicine, face-to-face consultations, and virtual ward teams. RACrRs is safe and feasible in a highly specific patient population; however, further high-quality studies with larger sample sizes are needed to draw more significant conclusions. Several limitations included small sample size and the potential of recall bias due to retrospective nature of 2 studies.
Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Young Adult; Ambulatory Surgical Procedures; Colectomy; Colorectal Neoplasms; Laparoscopy; Length of Stay; Postoperative Complications; Robotic Surgical Procedures
PubMed: 38713324
DOI: 10.1007/s11701-024-01961-3 -
Arthroplasty (London, England) May 2024Artificial intelligence (AI) uses computer systems to simulate cognitive capacities to accomplish goals like problem-solving and decision-making. Machine learning (ML),...
BACKGROUND
Artificial intelligence (AI) uses computer systems to simulate cognitive capacities to accomplish goals like problem-solving and decision-making. Machine learning (ML), a branch of AI, makes algorithms find connections between preset variables, thereby producing prediction models. ML can aid shoulder surgeons in determining which patients may be susceptible to worse outcomes and complications following shoulder arthroplasty (SA) and align patient expectations following SA. However, limited literature is available on ML utilization in total shoulder arthroplasty (TSA) and reverse TSA.
METHODS
A systematic literature review in accordance with PRISMA guidelines was performed to identify primary research articles evaluating ML's ability to predict SA outcomes. With duplicates removed, the initial query yielded 327 articles, and after applying inclusion and exclusion criteria, 12 articles that had at least 1 month follow-up time were included.
RESULTS
ML can predict 30-day postoperative complications with a 90% accuracy, postoperative range of motion with a higher-than-85% accuracy, and clinical improvement in patient-reported outcome measures above minimal clinically important differences with a 93%-99% accuracy. ML can predict length of stay, operative time, discharge disposition, and hospitalization costs.
CONCLUSION
ML can accurately predict outcomes and complications following SA and healthcare utilization. Outcomes are highly dependent on the type of algorithms used, data input, and features selected for the model.
LEVEL OF EVIDENCE
III.
PubMed: 38702749
DOI: 10.1186/s42836-024-00244-4 -
Headache Apr 2024To assess the comparative effectiveness and safety of parenteral agents for pain reduction in patients with acute migraine. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
To assess the comparative effectiveness and safety of parenteral agents for pain reduction in patients with acute migraine.
BACKGROUND
Parenteral agents have been shown to be effective in treating acute migraine pain; however, the comparative effectiveness of different approaches is unclear.
METHODS
Nine electronic databases and gray literature sources were searched to identify randomized clinical trials assessing parenteral agents to treat acute migraine pain in emergency settings. Two independent reviewers completed study screening, data extraction, and Cochrane risk-of-bias assessment, with differences being resolved by adjudication. The protocol of the review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018100096).
RESULTS
A total of 97 unique studies were included, with most studies reporting a high or unclear risk of bias. Monotherapy, as well as combination therapy, successfully reduced pain scores prior to discharge. They also increased the proportion of patients reporting pain relief and being pain free. Across the pain outcomes assessed, combination therapy was one of the higher ranked approaches and provided robust improvements in pain outcomes, including lowering pain scores (mean difference -3.36, 95% confidence interval [CI] -4.64 to -2.08) and increasing the proportion of patients reporting pain relief (risk ratio [RR] 2.83, 95% CI 1.74-4.61). Neuroleptics and metoclopramide also ranked high in terms of the proportion of patients reporting pain relief (neuroleptics RR 2.76, 95% CI 2.12-3.60; metoclopramide RR 2.58, 95% CI 1.90-3.49) and being pain free before emergency department discharge (neuroleptics RR 4.8, 95% CI 3.61-6.49; metoclopramide RR 4.1, 95% CI 3.02-5.44). Most parenteral agents were associated with increased adverse events, particularly combination therapy and neuroleptics.
CONCLUSIONS
Various parenteral agents were found to provide effective pain relief. Considering the consistent improvements across various outcomes, combination therapy, as well as monotherapy of either metoclopramide or neuroleptics are recommended as first-line options for managing acute migraine pain. There are risks of adverse events, especially akathisia, following treatment with these agents. We recommend that a shared decision-making model be considered to effectively identify the best treatment option based on the patient's needs.
Topics: Humans; Analgesics; Emergency Service, Hospital; Metoclopramide; Migraine Disorders; Network Meta-Analysis; Pain Management; Randomized Controlled Trials as Topic
PubMed: 38644702
DOI: 10.1111/head.14704