Effects of Sodium-Glucose Cotransporter 2 on Amputation Events: A Systematic Review and Meta-Analysis of Randomized-Controlled Trials.

INTRODUCTION: Sodium-glucose cotransporter 2 (SGLT2) inhibitors are increasingly utilized in the treatment of diabetes mellitus as well as therapeutic extra-glycemic effects. However, there are still concerns over complications such as amputation events, given the results from the Canagliflozin Cardiovascular Assessment Study (CANVAS) trial. Hence, we conducted a systematic review and meta-analysis of randomized-controlled trials to investigate the effect of SGLT2 inhibitors on amputation events. METHODS: Four electronic databases (PubMed, Embase, Cochrane, and SCOPUS) were searched on November 21, 2020, for articles published from January 1, 2000, up to November 21, 2020, for studies that examined the effect of SGLT2 inhibitors on amputation events. Random-effect pair-wise meta-analysis for hazard ratios and fixed-effect Peto odds ratio meta-analysis were utilized to summarize the studies. RESULTS: A total of 15 randomized-controlled trials were included with a combined cohort of 63,716 patients. We demonstrated that there was no significant difference in amputation events across different types of SGLT2 inhibitors, different baseline populations, and different duration of SGLT2 inhibitor use. DISCUSSION/CONCLUSIONS: In this meta-analysis, SGLT2 inhibitors were not associated with a significant difference in amputation events.

A systematic scoping review of communication skills training in medical schools between 2000 and 2020.

BACKGROUND: Communication skills training (CST) remains poorly represented and prioritised in medical schools despite its importance. A systematic scoping review (SSR) of CST is proposed to better appreciate current variability in their structure, content, and assessment. This is to guide their future design in medical school curricula. METHODS: The Systematic Evidence-Based Approach (SEBA) was used to guide concurrent SSRs of teaching and assessment in CST. After independent database searches, concurrent thematic and content analysis of included articles were conducted separately. Resultant themes/categories were combined via the jigsaw perspective to provide a more holistic view of the data. These were then compared to tabulated summaries of the included articles to create funnelled domains. RESULTS: 52,300 papers were identified, 150 full-text articles included, and four funnelled domains were identified: Indications, Design, Assessment, and Barriers and Enablers of CST. CSTs confer numerous benefits to physicians and patients. It saw increased confidence, improved diagnostic capabilities and better clinical management, as well as greater patient satisfaction and treatment compliance. Skills may be divided into core, prerequisite competencies, and advanced skills pertinent to more challenging and nuanced scenarios - such as population or setting-specific situations. CST teaching and assessment modalities were found to align with Miller's Pyramid, with didactic teaching gradually infused with experiential approaches to enhance their understanding and integration. A plethora of CST frameworks, teaching and assessment methods were identified and are presented together. CONCLUSION: While variable in approach, content and assessment, CST in medical schools often employ stage-based curricula to instil competency-based topics of increasing complexity throughout medical school education. This process builds on the application of prior knowledge and skills, influencing practice and, potentially, the students' professional identity formation. In addition, the institution plays a critical role in overseeing training, ensuring longitudinal guidance and holistic assessments of the students' progress.

Effects of Sodium/Glucose Cotransporter Inhibitors on Atrial Fibrillation and Stroke: A Meta-Analysis.

OBJECTIVES: Recent clinical trials have shown the potential of sodium glucose cotransporter (SGLT) 2 inhibitors to reduce the risk of atrial fibrillation but not stroke. We conducted a systematic review and meta-analysis to clarify if SGLT2 or combined SGLT1/2 inhibitors affect the risk of atrial fibrillation and stroke in patients regardless of diabetic status. MATERIALS AND METHODS: Four electronic databases were searched on 21st November 2020 for studies evaluating outcomes of stroke and atrial fibrillation with SGLT2 or combined SGLT1/2 inhibitors in both diabetic and non-diabetic patients. Both random and fixed effect, pair-wise meta-analysis models were used to summarize the results of the studies. RESULTS: A total of 13 placebo-controlled, randomized-controlled trials were included. Eight trials comprising 35,702 patients were included in the analysis of atrial fibrillation outcomes and eight trials comprising 47,910 patients were included in the analysis of stroke outcomes. Patients on SGLT inhibitors, particularly SGLT2 inhibitors, had lower odds of atrial fibrillation (Peto odds ratio [95% confidence interval] = 0.76 [0.63-0.92]) compared to placebo. This effect remained significant with a follow-up duration longer than 1 year, in studies utilizing dapagliflozin, patients with type 2 diabetes mellitus, and patients with cardiovascular disease. No difference was observed in the odds of atrial fibrillation in patients with baseline heart failure. No effect was seen on the risk of stroke in patients taking SGLT inhibitors. CONCLUSIONS: SGLT2 inhibitors significantly reduced the odds of atrial fibrillation in diabetic patients. However, SGLT inhibitors did not significantly affect the risk of stroke.

Transitional care strategies at emergency department for elderly patients: A multicentre study in Singapore.

Introduction: Transitional care strategies (TCS) initiated for elderly patients prior to emergency department (ED) discharge are important for ensuring effective transition to other care settings. Such strategies have been shown to reduce avoidable acute admissions. This first nationwide study is targeted at public acute hospital EDs in Singapore, and aims to characterise TCS for ED-discharged elderly patients and understand the experiences of healthcare staff in the delivery of TCS. Method: Seven key informants (KIs), one per ED, completed an online structured questionnaire and semi-structured video conference interview from 8 May to 31 August 2021. The KIs were ED specialists and an ED-trained senior staff nurse who were knowledgeable in geriatric emergency care and had contributed to at least one elder-related TCS. Field notes were compiled, transcribed, anonymised and analysed using thematic analysis. Results: All 7 EDs have TCS as "usual care" available during office hours, at no extra cost to patients. Common components of TCS include screening, evaluation with comprehensive geriatric assessment, health education and follow-up telecare. TCS implementation was facilitated by organisational support in terms of established protocols and communication platforms, training and collaboration of a multidisciplinary team, and caregiver involvement. Obstacles faced include fragmented communication between personnel, limited resources, and poor buy-in from stakeholders. Conclusion: Understanding the heterogeneous characteristics of ED-TCS at various hospitals will aid the development of service typology and identify service opportunities. Provider experiences grouped into themes help to inform future strategies for TCS implementation. More research is needed to evaluate patient outcomes and cost-effectiveness of TCS.

Prevalence, types and treatment of bradycardia in obstructive sleep apnea - A systematic review and meta-analysis.

BACKGROUND: The association of obstructive sleep apnea (OSA) with bradycardia is not well-characterized, which may confer significant morbidity and mortality if left untreated. We sought to clarify the prevalence of comorbid OSA and bradycardia, and the effect of continuous positive airway pressure (CPAP) therapy on bradycardia outcomes. METHODS: We systematically searched four electronic databases (PubMed, Embase, Cochrane Library, Scopus) for randomized or observational studies reporting the co-prevalence of sleep apnea and bradycardia or evaluated the use of CPAP on the incidence of bradycardias. We used random-effects models in all meta-analyses and evaluated heterogeneity using I2. RESULTS: We included 34 articles from 7204 records, comprising 4852 patients. Among patients with OSA, the pooled prevalence of daytime and nocturnal bradycardia were 25% (95% CI: 18.6 to 32.7) and 69.8% (95% CI: 41.7 to 88.2) respectively. Among patients with bradycardia, the pooled prevalence of OSA was 56.8% (95% CI: 21.5 to 86.3). CPAP treatment, compared to those without, did not significantly reduce the risk of daytime (two randomized trials; RR: 0.50; 95% CI: 0.11 to 2.21) or nocturnal bradycardia (one randomized-controlled trial and one cohort study; RR: 0.76; 95% CI: 0.48 to 1.20). CONCLUSIONS: This meta-analysis demonstrates a high comorbid disease burden between OSA and bradycardia. Future research should explore the treatment effect of CPAP on bradycardia incidence, as compared to placebo.

Effect of sodium-glucose cotransporter-2 (SGLT2) inhibitors on serum urate levels in patients with and without diabetes: a systematic review and meta-regression of 43 randomized controlled trials.

Objectives: Sodium-glucose cotransporter-2 (SGLT2) inhibitors have been found to reduce serum urate in patients with type 2 diabetes mellitus. To evaluate if this effect applies to both patients with and without diabetes, we conducted a systematic review and meta-analysis of SGLT2 inhibitors on serum urate levels in this population. Methods: Four electronic databases (PubMed, Embase, Cochrane and SCOPUS) were searched on 25 September 2021 for articles published from 1 January 2000 up to 25 September 2021, for studies that examined the effect of SGLT2 inhibitors on serum urate in study subjects. Random-effects meta-analysis was performed, with subgroup analyses on the type of SGLT2 inhibitor agent administered, presence of type 2 diabetes mellitus, presence of chronic kidney disease and drug dose. Results: A total of 43 randomized controlled trials, with a combined cohort of 31,921 patients, were included. Both patients with [-31.48 µmol/L; 95% confidence interval (CI): -37.35 to -25.60] and without diabetes (-91.38 µmol/L; 95% CI: -126.53 to -56.24) on SGLT2 inhibitors had significantly lower urate levels when compared with placebo. This treatment effect was similarly observed across different types of SGLT2 inhibitors. However, in type 2 diabetes mellitus (T2DM) patients with chronic kidney disease, the reduction in serum urate with SGLT2 inhibitors became insignificant (95% CI: -22.17 to 5.94, p < 0.01). Conclusion: This study demonstrated that SGLT2 inhibitors are beneficial in reducing serum urate in patients with and without diabetes. SGLT2 inhibitors could therefore contribute to the general treatment of hyperuricaemia.

Effects of Sodium/Glucose Cotransporter 2 (SGLT2) Inhibitors on Cardiac Imaging Parameters: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Recent studies have shown that sodium/glucose cotransporter 2 (SGLT2) inhibitors might exert favourable changes on cardiac parameters as observed on cardiovascular imaging. We conducted a systematic review and meta-analysis to determine the effects of SGLT2 inhibitors on cardiac imaging parameters. Four electronic databases (PubMed, Embase, Cochrane, Scopus) were searched for studies in which the effects of SGLT2 inhibitors on cardiac imaging parameters were examined. Studies in which a population was administered SGLT2 inhibitors and analysed by echocardiography and/or cardiac magnetic resonance (CMR) imaging were included. Random-effects pair-wise meta-analysis models were utilized to summarize the studies. A total of 11 randomized controlled trials was included with a combined cohort of 910 patients. Comparing patients receiving SGLT2 inhibitors with subjects receiving placebo, the mean change in CMR-measured left ventricular mass (LVM) was -3.87 g (95% confidence interval [CI], -7.77 to 0.04), that in left ventricular end-systolic volume (LVESV) was -5.96 mL (95% CI, -10.52 to -1.41) for combined LVESV outcomes, that in left atrial volume index (LAVi) was -1.78 mL/m² (95% CI, -3.01 to -0.55) for combined LAVi outcomes, and that in echocardiography-measured E/e' was -0.73 (95% CI, -1.43 to -0.03). Between-group differences were not observed in LVM and LVESV after indexation. The only between-group difference that persisted was for LAVi. Treatment with SGLT2 inhibitors resulted in reduction in LAVi and E/e' on imaging, indicating they might have an effect on outcomes associated with LV diastolic function.