Significant Difference In Short-term Mortality Research Articles

Prevalence and Mortality of Infective Endocarditis in Community-Acquired and Healthcare-Associated Staphylococcus aureus Bacteremia: A Danish Nationwide Registry-Based Cohort Study.

Staphylococcus aureus bacteremia (SAB) can be community-acquired or healthcare-associated, and prior small studies have suggested that this mode of acquisition impacts the subsequent prevalence of infective endocarditis (IE) and patient outcomes. First-time SAB was identified from 2010 to 2018 using Danish nationwide registries and categorized into community-acquired (no healthcare contact within 30 days) or healthcare-associated (SAB >48 hours of hospital admission, hospitalization within 30 days, or outpatient hemodialysis). Prevalence of IE (defined from hospital codes) was compared between groups using multivariable adjusted logistic regression analysis. One-year mortality of S aureus IE (SAIE) was compared between groups using multivariable adjusted Cox proportional hazard analysis. We identified 5549 patients with community-acquired SAB and 7491 with healthcare-associated SAB. The prevalence of IE was 12.1% for community-acquired and 6.6% for healthcare-associated SAB. Community-acquired SAB was associated with a higher odds of IE as compared with healthcare-associated SAB (odds ratio, 2.12 [95% confidence interval {CI}, 1.86-2.41]). No difference in mortality was observed with 0-40 days of follow-up for community-acquired SAIE as compared with healthcare-associated SAIE (HR, 1.07 [95% CI, .83-1.37]), while with 41-365 days of follow-up, community-acquired SAIE was associated with a lower mortality (HR, 0.71 [95% CI, .53-.95]). Community-acquired SAB was associated with twice the odds for IE, as compared with healthcare-associated SAB. We identified no significant difference in short-term mortality between community-acquired and healthcare-associated SAIE. Beyond 40 days of survival, community-acquired SAIE was associated with a lower mortality.

Comparison of the effects of lidocaine and amiodarone for out-of-hospital cardiac arrest patients with shockable rhythms: a retrospective observational study from a multicenter registry

BackgroundOut-of-hospital cardiac arrest (OHCA) with shockable rhythms, including ventricular fibrillation and pulseless ventricular tachycardia, is associated with better prognosis and neurological outcome than OHCA due to other rhythms. Antiarrhythmic drugs, including lidocaine and amiodarone, are often used for defibrillation. This study aimed to compare the effects of lidocaine and amiodarone on the prognosis and neurological outcome of patients with OHCA due to shockable rhythms in a real-world setting.MethodsWe conducted a retrospective observational study using a multicenter OHCA registry of 91 participating hospitals in Japan. We included adult patients with shockable rhythms, such as ventricular fibrillation and pulseless ventricular tachycardia, who were administered either lidocaine or amiodarone. The primary outcome was 30-day survival, and the secondary outcome was a good neurological outcome at 30 days. We compared the effects of lidocaine and amiodarone for patients with OHCA due to shockable rhythms for these outcomes using logistic regression analysis after propensity score matching (PSM).ResultsOf the 51,199 patients registered in the OHCA registry, 1970 patients were analyzed. In total, 105 patients (5.3%) were administered lidocaine, and 1865 (94.7%) were administered amiodarone. After performing PSM with amiodarone used as the reference, the odds ratios and 95% confidence intervals of lidocaine use for 30-day survival and 30-day good neurological outcome were 1.44 (0.58–3.61) and 1.77 (0.59–5.29), respectively.ConclusionThe use of lidocaine and amiodarone for patients with OHCA due to shockable rhythms within a real-world setting showed no significant differences in short-term mortality or neurological outcome. There is no evidence that either amiodarone or lidocaine is superior in treatment; thus, either or both drugs could be administered.

Acetate- versus lactate-buffered crystalloid solutions: A systematic review with meta-analysis and trial sequential analysis.

ObjectiveThere is a widespread use of buffered crystalloid solutions in clinical practice. However, guidelines do not distinguish between specific types of buffered solutions and clinical equipoise exists. We aimed to assess the desirable and undesirable effects of acetate‐ versus lactate‐buffered solutions in hospitalised patients.MethodsWe conducted a systematic review with meta‐analysis and trial sequential analysis of randomised clinical trials assessing the use of acetate‐ versus lactate‐buffered solutions for intravenous administration in hospitalised adults and children. The primary outcome was all‐cause short‐term mortality. We adhered to our published protocol, the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) statement, the Cochrane Handbook and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology.ResultsWe included five RCTs enrolling 390 patients. We found no statistically significant difference in short‐term mortality (random effects, risk ratio [RR] 0.29; 95% confidence interval [CI] 0.06–1.51, p = .14, I 2 = 0%) or hospital length of stay (LOS) (random effects, mean difference [MD]—1.31, 95% CI −3.66 to 1.05, p = .28, I 2 = 0%) between acetate‐ versus lactate‐buffered solutions. The quality of evidence was very low. Data regarding intensive care unit LOS were reported by three trials and duration of vasopressor treatment by one trial; none of these data allowed for pooling in meta‐analyses. No trials reported data on long‐term mortality, health‐related quality of life, adverse events, duration of mechanical ventilation or renal replacement therapy.ConclusionIn this systematic review, we found very low quantity and quality of evidence on the use of acetate‐ versus lactate‐buffered solutions in hospitalised patients.

Lyophilized plasma resuscitation downregulates inflammatory gene expression in a mouse model of sepsis.

Plasma resuscitation may improve outcomes by targeting endotheliopathy induced by severe sepsis or septic shock. Given the logistical constraints of using fresh frozen plasma in military settings or areas with prolonged prehospital care, dried products such as lyophilized plasma (LP) have been developed. We hypothesized that resuscitation with LP would decrease lung injury, inflammation, and mortality in a mouse sepsis model. Adult male C57BL/6J mice received an intraperitoneal injection of cecal slurry. Twenty-two hours later, the mice were anesthetized, the femoral artery was cannulated, and the mice were randomized to receive resuscitation with LP (10 mL/kg) or lactated Ringer's (LR; 30 mL/kg) for 1 hour. At 48-hours post-cecal slurry injection, bronchoalveolar lavage fluid was collected, the lungs were harvested, and plasma was obtained. Mortality and bronchoalveolar lavage total protein concentration (as an indicator of permeability) were compared between groups. The lungs were analyzed for histopathology and inflammatory gene expression using NanoString, and the plasma was analyzed for biomarkers of inflammation and endothelial function. There was no significant difference in short-term mortality between LR and LP mice, 38% versus 47%, respectively ( p = 0.62). Bronchoalveolar lavage protein levels were similar among mice resuscitated with LR or LP, and there was a lack of significant histopathologic lung injury in all groups. However, LP resuscitation resulted in downregulation of pulmonary inflammatory genes, including signaling pathways such as Janus kinase-signal transducer and activator of transcription and nuclear factor κB, and a circulating inflammatory biomarker profile similar to sham animals. Resuscitation with LP did not improve mortality or reduce permeability or injury in this model compared with LR. However, LP downregulated pulmonary inflammatory gene signaling and may also reduce circulating biomarkers of inflammation. Future studies should evaluate LP resuscitation in combination with antibiotics and other therapeutics to determine whether the anti-inflammatory effects of LP may improve outcomes in sepsis.

Use of Impella device in cardiogenic shock and its clinical outcomes: A systematic review and meta-analysis.

Cardiogenic shock (CS) is a life-threatening condition and mechanical circulatory support (MCS) might exert a relevant impact on its clinical course. Among MCS devices, Impella is very promising. Yet, its usefulness is still debated. We performed a meta-analysis of all studies evaluating the clinical impact of Impella in CS. All studies including patients with CS and treated with Impella were included. The primary endpoint was short-term mortality. Secondary endpoints were vascular access complications and major bleeding. Data synthesis was obtained using random-effects metanalysis. Thirty-three studies and 5204 patients were included. Short-term mortality was 47%. Meta-regression analysis showed that patients age (p=0.01), higher support level (p=0.004) and pre-PCI insertion (p<0.001) were significant moderators for the primary endpoint. Vascular access complications were registered in 6.4% of cases, whereas age (p=0.05) and diabetes (p=0.007) were significant predictors. Major bleeding occurred in 16.4% of patients. Meta-analysis of the subgroup of studies comparing Impella to IABP showed no significant difference in short-term mortality (RR=1.08, p=0.45), while rates of vascular access complications (p<0.001) or major bleeding (p<0.001) were significantly higher with Impella. Subgroup and metaregression analyses showed that these results were influenced by lower adoption rates of higher degree of MCS support (p=0.003), and by higher vascular complications rates (p=0.014). Our results suggest that the choice of adequate device size, careful patients selection and optimal timing of MCS initiation are key to clinical success with Impella in CS. Large prospective studies are mandatory to confirm these results deriving from retrospective studies.

Abstract 13614: Pulmonary Artery Catheter Guided Therapy of Cardiogenic Shock is Associated With Lower Short-Term Mortality: A Systematic Review and Meta-Analysis

The utility of pulmonary artery catheterization (PAC) in treatment of cardiogenic shock (CS) is questionable. In this meta-analysis we aimed to evaluate the impact of PAC guided treatment on survival in CS patients. We performed a comprehensive literature search of multiple databases for studies that evaluated the clinical utility of PAC-guided management versus standard care for patients with CS. The primary outcome of interest was short-term mortality. The secondary outcomes were the use of mechanical circulatory support (MCS) and inotropes. Pooled relative risk (RR) and corresponding 95% confidence intervals (CIs) were calculated and combined using random effects model meta-analysis. A total of 9 studies including 364,001 patients with CS (29609 managed with PAC guided therapy vs. 334392 managed with slandered of care) were included in the final analysis. There was a significant difference in short-term mortality favoring PAC guided management (RR:0.83; 95% CI:0.76-0.92; P &lt;0.00001). Standard of care guided management was associated with higher use of MCS and inotropic agents (RR:1.30; 95% CI:1.15-1.46; P &lt;0.0001) and (RR:1.18; 95% CI:1.09-1.29; P &lt;0.001) respectively. Our meta-analysis demonstrates that PAC-guided therapy for patients with CS was associated with lower short-term mortality and a lower likelihood to use MCS and inotropes with their potential associated complications. Further randomized clinical trials are needed to evaluate the utility of PAC as an adjunct tool in the management of CS.

Intermittent Convective Therapies in Patients with Acute Kidney Injury: A Systematic Review with Meta-Analysis

Introduction: In critically ill patients requiring intermittent renal replacement therapy (RRT), the benefits of convective versus diffusive clearance remain uncertain. We conducted a systematic review and meta-analysis to determine the safety, clinical efficacy, and clearance efficiency of hemofiltration (HF) and hemodiafiltration (HDF) compared to hemodialysis (HD) in patients with acute kidney injury (AKI) receiving intermittent RRT. Method: We searched Medline, Embase, Cochrane Library, and PROSPERO. We included clinical trials and observational studies that reported the use of intermittent HF or HDF in adult patients with AKI. The following outcomes were included: mortality, renal recovery, clearance efficacy, intradialytic hemodynamic stability, circuit loss, and inflammation modulation. Results: A total of 3,169 studies were retrieved and screened. Four randomized controlled trials and 4 observational studies were included (n: 615 patients). Compared with conventional HD, intermittent convective therapies had no effect on in-hospital mortality (relative risk, 1.23; 95% confidence interval (CI), 0.76–1.99), renal recovery at 30 days (RR, 0.98; 95% CI, 0.82–1.16), time-to-renal recovery (mean difference [MD], 0.77; 95% CI, −6.56 to 8.10), and number of dialysis sessions until renal recovery (MD, −1.34; 95% CI, −3.39 to 0.72). The overall quality of included studies was low, and dialysis parameters were suboptimal for all included studies. Conclusion: This meta-analysis suggests that there is no significant difference in short-term mortality and renal recovery in patients with severe AKI when treated with intermittent HF or HDF compared to conventional HD. This systematic review emphasizes the need for further trials evaluating optimal convective parameters in AKI patients treated with intermittent dialysis.

Association of Non-Invasive Respiratory Support with Mortality and Intubation Rates in Acute Respiratory Failure: A Systematic Network Meta-Analysis

Background: Non-invasive respiratory support devices may reduce the tracheal intubation rate compared with conventional oxygen therapy (COT). To date, few studies have compared high-flow nasal cannula (HFNC) use with non-invasive positive-pressure ventilation(NPPV). We conducted a network meta-analysis (NMA) to compare the effectiveness of three respiratory support devices in patients with acute respiratory failure. Methods: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. Adults ≥16 years of age with acute hypoxic respiratory failure and randomised controlled trials that compared two different respiratory support devices(COT,NPPV, or HFNC) before tracheal intubation were included. NMA was performed using a frequentist-based approach with multivariate random effects meta-analysis. The meta-analysis was performed using the GRADE Working Group Approach for an NMA. The primary outcome was short-term mortality, and the secondary outcome was the rate of intubation. Findings: Among 5,093 records, 25 studies (4,372 patients) were included. Compared with COT, NPPV and HFNC tended to reduce mortality (relative risk, 0·88 and 0·92; 95% confidence interval 0·76–1.01 and 0·80–1·07; low and moderate certainties, respectively); however, a significantly lower risk of endotracheal intubation(0·81 and 0·79; 0·71–0·91 and 0·69–0·91; low and moderate certainty, respectively) was observed. There were no significant differences in short-term mortality or endotracheal intubation (0·95 and 1·02;0·78–1·16 and0·86–1·20; respectively; both low certainty) for NPPV and HFNC use. Interpretation: NPPV and HFNC are associated with decreased endotracheal intubation risk, but there are no significant differences in short-term mortality. Funding: None. Declaration of Interests: The authors declare no competing interests.

Intraoperative Continuous Renal Replacement Therapy During Liver Transplantation: A Meta-Analysis.

Continuous renal replacement therapy (CRRT) is frequently used to treat recipients with renal failure before or after liver transplantation (LT), though evidence supporting its use during surgery remains unclear. Therefore, we conducted a quantitative meta-analysis to evaluate the effect of intraoperative continuous renal replacement therapy (IORRT) in recipients with pretransplant severe renal dysfunction. We searched PubMed, Embase, and the Cochrane database for trials focusing on LT recipients supported with or without IORRT. Outcomes assessed were mortality, preoperative characteristics, intraoperative data, and predefined postoperative outcomes. Seven trials with 1051 recipients were eligible. Preoperatively, the IORRT group recipients had higher Model for End-Stage Liver Disease scores (weighted mean difference [WMD], 6.19; 95% confidence interval [CI], 2.51-9.87), Charlson scores (WMD, 0.45; 95% CI, 0.09-0.80), acute liver failure (odds ratio [OR], 1.82; 95% CI, 1.27-2.61), serum creatinine (WMD, 71.33 μmol/L; 95% CI, 1.98-140.69 μmol/L), total bilirubin level (WMD, 5.05 μmol/L; 95% CI, 1.75-8.35 μmol/L), intensive care unit admission (OR, 3.53; 95% CI, 1.23-10.13), vasoactive therapy (OR, 3.80; 95% CI, 2.64-5.46), ventilator care (OR, 2.52; 95% CI, 1.18-5.35), and renal replacement therapy (RRT) (OR, 29.37; 95% CI, 7.66-112.54) compared with control patients. IORRT patients also required more intraoperative blood product transfusion and had more post-LT RRT (OR, 25.67; 95% CI, 4.92-133.85). However, there were no significant differences in short-term mortality (OR, 2.12; 95% CI, 0.82-5.44) between the groups. In addition, worse longterm mortality was seen in the IORRT group. In conclusion, IORRT is feasible and safe and may help sicker recipients tolerate the LT procedure to achieve short-term clinical outcomes comparable with less ill patients without IORRT. More high-quality evidence is needed to verify our conclusion in the future.

Use of High-Flow Nasal Cannula for Immunocompromise and Acute Respiratory Failure: A Systematic Review and Meta-Analysis.

Acute respiratory failure (ARF) is a common cause of emergency department (ED) and intensive care unit (ICU) admissions. High-flow nasal cannula oxygen therapy (HFNC) is widely used for patients with ARF. Our aim was to evaluate the latest evidence regarding the application of HFNC in immunocompromised patients with ARF. We searched PubMed, Embase, and Cochrane databases from inception to January 2019. The primary outcome was short-term mortality and the secondary outcomes were intubation rate and length of ICU stay. Eight studies involving 2,179 immunocompromised subjects with ARF were included. No significant differences for short-term mortality were observed when comparing HFNC with conventional oxygen therapy (COT) (risk ratio [RR] 0.89; 95% confidence interval [CI] 0.73 to 1.09; p=0.25, I2=47%) and with noninvasive ventilation (NIV) (RR 0.66; 95% CI 0.37 to 1.18; p=0.16, I2=58%). Lower intubation rates were found when comparing HFNC with COT (RR 0.89; 95% CI 0.80 to 0.99; p=0.03, I2=0%) and no significant difference was found between HFNC and NIV (RR 0.74; 95% CI 0.46 to 1.19; p=0.22, I2=67%). The length of ICU stay was similar when comparing HFNC with COT (mean difference [MD] 0.59; 95% CI -1.68 to 2.85; p=0.61, I2=56%), but was significantly shorter when HFNC was compared with NIV (MD -2.13; 95% CI -3.98 to -0.29; p=0.02, I2=0%). There was no significant difference in short-term mortality with use of HFNC when compared with COT or NIV for immunocompromised patients with ARF. A lower intubation rate than COT and a shorter length of ICU stay than NIV were observed in the HFNC group.

High flow nasal therapy in immunocompromised patients with acute respiratory failure: A systematic review and meta-analysis

PurposeThe role of high-flow nasal therapy (HFNT) as compared to conventional oxygen therapy (COT) in immunocompromised patients admitted to intensive care unit (ICU) with acute respiratory failure (ARF) remains unclear. We conducted a systematic review and meta-analysis in order to address this issue. MethodsWe searched PubMed, Medline and Embase until November 7th, 2018. Randomized controlled trials (RCTs), non-randomized prospective and retrospective evidence were selected. Observational studies were considered for sensitivity analysis. Primary outcome was mortality rate; intubation rate was a secondary outcome. ResultsWe included four studies in the primary analysis: one RCT, two RCT's post-hoc analyses and one retrospective study. We found no significant difference in short-term mortality comparing HFNT vs. COT: 1) ICU: n = 872 patients, odds ratio (OR) = 0.80 [0.44,1.45], p = 0.46, I2 = 30%, p = 0.24; 2) 28-day: n = 996 patients, OR = 0.79 [0.45,1.38], p = 0.40, I2 = 52%, p = 0.12). Conversely, we found a reduction of intubation rate in the HFNT group (n = 1052 patients, OR = 0.74 [0.55,0.98], p = 0.03, I2 = 7%, p = 0.36). The inclusion of one observational study for sensitivity analysis did not grossly change results. ConclusionsWe found no benefit of HFNT over COT on mortality in immunocompromised patients with ARF. However, HFNT was associated with a lower intubation rate warranting further research.

Impact of Hospital Case Volume on Outcomes Following Radical Nephrectomy and Inferior Vena Cava Thrombectomy

BackgroundRadical nephrectomy with inferior vena cava thrombectomy (RN-IVCT) is a complicated procedure for which the impact of hospital case volume on overall survival (OS) is unknown. ObjectiveTo assess the degree to which renal cell carcinoma (RCC) with inferior vena cava tumor thrombus (IVC-TT) care is centralized and to evaluate the impact of hospital case volume on outcomes following RN-IVCT. Design, setting, and participantsThe National Cancer Data Base was queried for patients with pT3b–c RCC treated with RN-IVCT. Hospitals were classified by case volume percentile as low (<75th percentile, <0.67 cases annually), intermediate (75th–95th percentile, 0.67–2.99 cases annually), or high (>95th percentile, >3 cases annually). Outcome measurements and statistical analysisThe primary outcome was OS. Secondary outcomes were short-term (30- and 90-d) mortality rates according to hospital case volume. Kaplan-Meier curves and Cox regression model were used to evaluate OS and the effect of covariables. Results and limitationsThere were 2664 cases of RN-IVCT for pT3b–c tumors reported by 573 institutions, of which 435, 108, and 30 were classified as low, intermediate, and high volume, accounting for 28.5%, 34.5%, and 37% of cases, respectively. Treatment at high-volume institutions was associated with better OS: the median OS was 42, 53, and 60 months for low, intermediate and high-volume centers, respectively (p=0.009). After multivariable adjustment, treatment at a high-volume institution was associated with a 24% relative risk reduction for all-cause mortality compared to treatment at a low-volume institution (hazard ratio 0.76, 95% confidence interval 0.65–0.89; p=0.001). There was no significant difference in short-term mortality following RN-IVCT when stratified by hospital case volume. ConclusionsHigher hospital case volume was associated with longer OS for patients undergoing RN-IVCT. These findings support efforts to centralize care for cases of advanced RCC. Patient summaryIn this study we looked at the impact of hospital case volume on survival following surgery for renal cell carcinoma and inferior vena cava thrombectomy. Survival was significantly better in high-volume hospitals performing three or more procedures per year.

Defining polytrauma by abbreviated injury scale ≥ 3 for a least two body regions is insufficient in terms of short-term outcome: A cross-sectional study at a level I trauma center

BackgroundPatients with polytrauma are expected to have a higher risk of mortality than the summation of expected mortality for their individual injuries. This study was designed to investigate the outcome of polytrauma patients, diagnosed by abbreviated injury scale (AIS) ≥ 3 for at least two body regions, at a level I trauma center. MethodsDetailed data of 694 polytrauma patients and 2104 non-polytrauma patients with an overall Injury Severity Score (ISS) ≥ 16 and hospitalized between January 1, 2009, and December 31, 2014 for treatment of all traumatic injuries, were retrieved from the Trauma Registry System. Two-sided Fisher exact or Pearson chi-square tests were used to compare categorical data. The unpaired Student t-test was used to analyze normally distributed continuous data, and the Mann–Whitney U-test was used to compare non-normally distributed data. Propensity-score matching in a 1:1 ratio was performed using NCSS software with logistic regression to evaluate the effect of polytrauma on in-hospital mortality. ResultsThere was no significant difference in short-term mortality between polytrauma and non-polytrauma patients, regardless of whether the comparison was made among the total patients (11.4% vs. 11.0%, respectively; p = 0.795) or among the selected propensity score-matched groups of patients following controlled covariates including sex, age, systolic blood pressure, co-morbidities, Glasgow Coma Scale scores, injury region based on AIS. ConclusionsPolytrauma defined by AIS ≥3 for at least two body regions failed to recognize a significant difference in short-term mortality among trauma patients.

Is Hemoglobin Below 7.0 g/dl an Optimal Trigger for Allogenic Red Blood Cell Transfusion in Patients Admitted to Intensive Care Units? A Meta-Analysis and Systematic Review

Background: Allogenic red blood cell (RBC) transfusion remains a commonly used and crucial treatment for patients admitted to intensive care units. Every year, approximately 75 million units of blood are reportedly obtained worldwide; this figure suggests the need for the cautious use of RBCs due to the substantial cost and supply shortage. Data Sources: We performed systematical searches for relevant randomized controlled studies in the Cochrane Library, EMBASE, and PubMed databases up to May 1, 2018. The clinical outcomes, including short-term mortality, length of hospital stay, length of ICU stay, myocardial infarction(MI), and ischemic events, were screened and analyzed after data collection. We applied odds ratios (ORs) to analyze dichotomous outcomes and mean differences to analyze continuous outcomes with a random effects model. Results: Nine RCTs with 3551 patients were included. Compared with a more liberal threshold, an RBC transfusion threshold < 7 g/dl hemoglobin showed no significant difference in short-term mortality (OR: 0.92, 95% CI: 0.70-1.20; P=0.52; I2=47%), length of ICU stay (MD: -0.05, 95% CI: -0.70-0.61, P=0.89, I2=0%), MI (OR: 0.56, 95% CI: 0.30-1.04, P=0.07; I2=0%), or ischemic events (OR, 0.80; 95% CI, 0.43-1.48; P=0.48; I2=51%). However, the length of hospital stay was shorter in the group with the threshold < 7 g/dl than that with the more liberal threshold. Conclusions: An RBC transfusion threshold < 7 g/dl hemoglobin is incapable of decreasing short-term mortality in ICU patients according to currently published evidence. Further studies are needed to for determine the optimal RBC transfusion strategy. Funding Statement: This work was supported by grants from the National Natural Science Foundation (No. 81730057) and the National Key Research and Development Program of China (No. 2017YFC1103302). Declaration of Interests: The authors have declared that no conflicts of interest exist. Ethics Approval Statement: This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

Meta-Analysis Comparing Primary Percutaneous Coronary Intervention Versus Pharmacoinvasive Therapy in Transfer Patients with ST-Elevation Myocardial Infarction

ST-elevation myocardial infarction patients presenting at non-percutaneous coronary intervention (PCI)-capable hospitals often need to be transferred for primary percutaneous coronary intervention (PPCI). This increases time to revascularization, leading to increased risk of in-hospital mortality. With recent focus on total ischemic time rather than door-to-balloon time as the principal determinant of outcomes in ST-elevation myocardial infarction patients, pharmacoinvasive therapy (PIT) has gained attention as a possible improvement over PPCI in patients requiring transfer. Our objective was to observe how PIT stands against PPCI in terms of safety and efficacy. Electronic databases were searched for randomized controlled trials and observational studies comparing PPCI to PIT. PIT was defined as administration of thrombolytic drugs followed by immediate PCI only in case of failed thrombolysis. Results from studies were pooled using a random-effects model. We identified 17 relevant studies (6 randomized controlled trials, 11 observational studies) including 13,037 patients. Overall, there was no significant difference in short-term mortality (odds ratio [OR] = 1.20 [0.97 to 1.49]; I2 = 14.2%; p = 0.099); however, PIT significantly decreased short-term mortality (OR = 1.46 [1.08 to 1.96]; I2 = 0%; p = 0.01) in those studies with a symptom-onset-to-device time ≥200 minutes. There was a significantly lower risk reinfarction (OR = 0.69 [0.49 to 0.97]; I2 = 0%; p = 0.033) in the PPCI group, while the risk of cardiogenic shock was significantly higher (OR = 1.48 [1.13 to 1.94]; I2 = 0%; p = 0.005). In conclusion, PIT versus PPCI decisions should preferably be customized in patients presenting to non-PCI capable hospitals. Factors that need to be considered include symptom-onset to first medical contact time, expected time of transfer to a PCI-capable hospital, and patients risk factors.

Culprit Vessel-Only Versus Multivessel Percutaneous Coronary Intervention in Patients With Cardiogenic Shock Complicating ST-Segment-Elevation Myocardial Infarction: A Collaborative Meta-Analysis.

The optimal revascularization strategy in patients with multivessel disease presenting with cardiogenic shock complicating ST-segment-elevation myocardial infarction remains unknown. Databases were searched from 1999 to October 2016. Studies comparing immediate/single-stage multivessel percutaneous coronary intervention (MV-PCI) versus culprit vessel-only PCI (CO-PCI) in patients with multivessel disease, ST-segment-elevation myocardial infarction, and cardiogenic shock were included. Primary end point was short-term (in-hospital or 30 days) mortality. Secondary end points included long-term mortality, cardiovascular death, reinfarction, and repeat revascularization. Safety end points were in-hospital stroke, renal failure, and major bleeding. The meta-analysis included 11 nonrandomized studies and 5850 patients (1157 MV-PCI and 4693 CO-PCI). There was no significant difference in short-term mortality with MV-PCI versus CO-PCI (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.81-1.43; P=0.61). Similarly, there were no significant differences in long-term mortality (OR, 0.84; 95% CI, 0.54-1.30; P=0.43), cardiovascular death (OR, 0.72; 95% CI, 0.42-1.23; P=0.23), reinfarction (OR, 1.65; 95% CI, 0.84-3.26; P=0.15), or repeat revascularization (OR, 1.13; 95% CI, 0.76-1.69; P=0.54) between the 2 groups. There was a nonsignificant trend toward higher in-hospital stroke (OR, 1.64; 95% CI, 0.98-2.72; P=0.06) and renal failure (OR, 1.30; 95% CI, 0.98-1.72; P=0.06), with no difference in major bleeding (OR, 1.47; 95% CI, 0.39-5.63; P=0.57) with MV-PCI when compared with CO-PCI. This meta-analysis of nonrandomized studies suggests that in patients with cardiogenic shock complicating ST-segment-elevation myocardial infarction, there may be no significant benefit with single-stage MV-PCI compared with CO-PCI. Given the limitations of observational data, randomized trials are needed to determine the role of MV-PCI in this setting.

Corticosteroids Versus Pentoxifylline for Severe Alcoholic Hepatitis: A Sequential Analysis of Randomized Controlled Trials.

Despite the significant morbidity and mortality associated with alcoholic hepatitis, a consensus or generally accepted therapeutic strategy has not yet been reached. The purpose of this analysis was to evaluate the effects of corticosteroids and pentoxifylline on short-term mortality, incidence of hepatorenal syndrome, and sepsis in patients with severe alcoholic hepatitis. We conducted a comprehensive search of the Cochrane library, PUBMED, Scopus, EMBASE, and published proceedings from major hepatology and gastrointestinal meetings from January 1970 to June 2015. All relevant articles irrespective of language, year of publication, type of publication, or publication status were included. Two independent reviewers extracted data and scored publications; a third investigator adjudicated discrepancies. The κ scores were measured to assess the agreement between the 2 initial reviewers. The review and meta-analyses were performed following the recommendations of The Cochrane Collaboration. Conventional meta-analysis and Trial sequential analysis were performed. GRADEpro version 3.6 was used to appraise the quality of epidemiologic evidence. A total of 14 studies satisfied inclusion criteria comparing corticosteroids, pentoxifylline, or placebo. Compared with placebo, corticosteroids reduced 28-day mortality (RR=0.53; 95% CI, 0.33-0.84; P=0.006). There was no statistically significant difference in short-term mortality between pentoxifylline and placebo (RR=0.74; 95% CI, 0.46-1.18; P=0.21). Neither corticosteroids nor pentoxifylline impacted the incidence of hepatorenal syndrome or sepsis. Trial sequential analysis confirmed the results of our conventional meta-analysis. Corticosteroids demonstrated a decrease in 28-day mortality in patients with severe alcoholic hepatitis. The evidence from this study is insufficient to support any recommendations regarding the mortality benefit of pentoxifylline in severe alcoholic hepatitis.

Reappraisal of Continuous Positive Airway Pressure Therapy in Acute Cardiogenic Pulmonary Edema: Short-term Results and Long-term Follow-up

To investigate whether serial incremental continuous positive airway pressure (CPAP) has any short-term or long-term advantages over face-mask oxygen therapy by way of intrapulmonary shunt reduction, 100 patients admitted to the coronary care unit for the treatment of acute cardiogenic pulmonary edema were studied. All patients received Swan-Ganz catheterization. Hemodynamic and pulmonary function parameters were recorded over the next 6 h, and the patients were followed until hospital discharge. All survivors received regular follow-up at 1-month intervals in the outpatient clinic. During the first-stage investigation period (3 h) PaO2 in the CPAP group showed a significant increase, whereas the intrapulmonary shunt and alveolar-arterial oxygen tension gradient (P[A-a]O2) was significantly reduced (p < 0.005). The CPAP group had significantly lower rate-pressure product and higher stroke volume index compared with the control group. The therapeutic failure rate over 6 h was 24% in the CPAP group and 50% in the control group (p < 0.01). The CPAP group had a significantly lower incidence of tracheal intubation and ventilator therapy than the control group; however, there was no significant difference in short-term mortality and hospital stay between the two groups. In conclusion, although study size was not large enough to demonstrate a difference in mortality, CPAP therapy resulted in physiologic cardiovascular and pulmonary function improvement and significantly reduced the need for intubation; however, it did not decrease mortality in patients with acute cardiogenic pulmonary edema, and a much larger study is needed to investigate this possibility.