Low-Dose Versus Standard-Dose Alteplase in Bridging Therapy for Large Vessel Stroke: A Systematic Review and Meta-Analysis.

INTRODUCTION The efficacy and safety of low- and standard-dose alteplase for acute ischemic stroke (AIS) have not been consistently compared in previous studies. Nevertheless, the distinctions in the effects of low- and standard-dose alteplase, particularly within the context of bridging therapy (BT) for large vessel occlusion (LVO), warrant further exploration. This study compared clinical outcomes between BT with low- and standard-dose alteplase in patients with LVO-related AIS. METHODS We performed a search for randomized controlled trials and prospective or retrospective cohort studies investigating the clinical outcomes of BT in AIS in the PubMed, Embase, and Cochrane Library databases from inception to November 2022. The outcomes of interest were 90-day functional independence, successful recanalization, symptomatic intracerebral hemorrhage (sICH) and mortality; these outcomes were compared between patients who received BT with low- (primarily 0.6 mg/kg) and standard-dose alteplase (0.9 mg/kg). We used the standard-dose group as the reference and calculated the odds ratio (OR) and its 95% confidence interval (CI) from the raw numbers. Meta-analysis and ethnicity-based subgroup analysis (Asian and non-Asian) were performed. RESULTS Five observational studies, published after 2017 and including 408 patients, were included. The meta-analysis results demonstrated that compared with BT with standard-dose alteplase, BT with low-dose alteplase did not improve 90-day functional independence (odds ratio, [OR] 1.02; 95% confidence interval [CI], 0.58-1.80). Nevertheless, BT with low-dose alteplase was associated with a comparable successful recanalization rate (OR, 1.35; 95% CI, 0.68-2.67) and similar sICH incidence (OR 0.36; 95% CI, 0.10-1.36), and mortality (OR, 0.64; 95% CI, 0.27-1.54) compared with BT with standard-dose alteplase; however, the above three results were nonsignificant. In the ethnicity-based subgroup analyses, no differences were noted between Asian and non-Asian participants. CONCLUSIONS In patients with LVO-related AIS, BT with low- or standard-dose alteplase may provide similar efficacy, with no significant differences in sICH incidence and mortality. Additional well-designed prospective studies are required to confirm this result.

Sphingosine-1-phosphate and CRP as potential combination biomarkers in discrimination of COPD with community-acquired pneumonia and acute exacerbation of COPD.

BACKGROUND:  Chronic obstructive pulmonary disease (COPD) is a significant public health concern. The patients with acute exacerbations of COPD (AECOPD) and pneumonia have similar clinical presentations. The use of conventional diagnostic markers, such as complete blood count with differential and C-reactive protein (CRP), is the current mainstream method for differentiating clinically relevant pneumonia from other mimics. However, those conventional methods have suboptimal sensitivity and specificity for patients with a clinical suspicion of infection. The limitations often cause the ambiguity of the initiation of antibiotic treatment. Recently, our pilot study suggested that the patients with pneumonia have significantly higher plasma Sphingosine-1-phosphate (S1P) levels than controls. The initial findings suggest that plasma S1P is a potential biomarker for predicting prognosis in pneumonia. The aim of this study was to evaluate the value of S1P and CRP for discriminating COPD with pneumonia and AECOPD in an Emergency Department (ED) setting. METHODS:  Patients diagnosed with AECOPD or COPD with pneumonia were recruited from the Emergency Department of Wan Fang Hospital. The clinical data, demographics, and blood samples were collected upon ED admission. The concentration of plasma S1P was measured by ELISA. RESULTS:  Thirty-nine patients with AECOPD and 78 with COPD plus pneumonia were enrolled in this observational study. The levels of blood S1P and CRP were significantly higher in patients with COPD plus CAP compared to those in AE COPD patients. The area under the receiver operator characteristic (ROC) curve for the S1P and CRP for distinguishing between patients with COPD plus CAP and AECOPD is 0.939 (95% CI: 0.894-0.984) and 0.886 (95% CI: 0.826-0.945), whereas the combination of S1P and CRP yielded a value of 0.994 (95% CI: 0.897-1.000). By comparing with CRP or S1P, combining CRP and S1P had significantly higher AUC value for differentiating between the COPD with pneumonia group and the AECOPD group. CONCLUSIONS: Our findings suggest that S1P is a potential diagnostic biomarker in distinguishing COPD with CAP from AECOPD. Additionally, the diagnostic ability of S1P can be improved when used in combination with CRP.

Efficacy of doxycycline versus azithromycin for the treatment of rectal chlamydia: a systematic review and meta-analysis.

BACKGROUND: Chlamydia trachomatis infection is the most common sexually transmitted infectious disease and carries a risk of complications. However, the optimal treatment for rectal chlamydial infection remains unclear. OBJECTIVES: To compare the efficacy of doxycycline and azithromycin for the treatment of rectal chlamydia by undertaking a systematic review and meta-analysis of published data. METHODS: We searched PubMed, EMBASE, Cochrane Library, Web of Science and clinicaltrials.gov databases from inception to 7 July 2021 for randomized controlled trials (RCTs) and observational studies that compared the efficacy of doxycycline and single-dose azithromycin on rectal chlamydia cure rates. Data were synthesized using a random-effects model, and subgroup analysis was conducted. RESULTS: All included studies were conducted in developed countries. Two RCTs and nine observational studies, with a total of 2457 patients, were analysed. Doxycycline had a higher microbiological cure rate than azithromycin (risk ratio = 1.21; 95% CI = 1.15-1.28; P < 0.05). Pooled results from two RCTs also revealed a higher microbiological cure rate for doxycycline than azithromycin (risk ratio = 1.27; 95% CI = 1.20-1.35; P < 0.05). The results remained consistent in subgroups of different study designs, countries and sexes. CONCLUSIONS: On the basis of our findings, we recommend doxycycline rather than azithromycin as a first-line treatment for rectal chlamydia in developed countries. More RCTs from developing countries are warranted.

Safety and efficacy of clonidine on postoperative vomiting and pain in pediatric ophthalmic surgery: A systematic review and meta-analysis.

BACKGROUND: Postoperative vomiting and pain are common, unpleasant phenomena in pediatric patients undergoing ophthalmic surgery. Clonidine has antiemetic and analgesic properties and thus may be used as premedication to reduce postoperative vomiting and pain. AIM: To assess whether clonidine premedication may safely decrease postoperative vomiting and postoperative pain in pediatric patients who received an ophthalmic surgery. METHODS: We systematically searched PubMed, EMBASE, Cochrane Library, and Scopus databases from their inception to September 2018. Randomized clinical trials comparing clonidine premedication with a placebo or an active comparator that investigated postoperative vomiting or postoperative pain in pediatric patients undergoing ophthalmic surgery were included. The primary outcome was postoperative vomiting. The secondary outcome was postoperative pain. We also evaluated the safety of clonidine premedication by tracking hemodynamic instability associated with its use. RESULTS: Ten studies with 979 patients were eligible for inclusion. Clonidine achieved a significantly lower incidence of postoperative vomiting within 6 hours postoperatively, 6-24 hours postoperatively, and at the end of the study (risk difference: -0.15; 95% confidence interval: -0.32 to -0.05; risk difference: -0.15; 95% confidence interval: -0.29 to 0.01; and risk difference: -0.23; 95% confidence interval: -0.34 to -0.12, respectively) than placebo. For the subgroup of patients who received strabismus surgery, clonidine produced a lower incidence of postoperative vomiting than placebo (risk difference: -0.19; 95% confidence interval: -0.29 to -0.05). Compared to benzodiazepine, clonidine achieved a lower incidence of postoperative vomiting at the end of the study (risk difference: -0.19; 95% confidence interval: -0.31 to -0.07); the effect was only observed in patients receiving clonidine 4 µg/kg. Furthermore, children receiving clonidine had lower postoperative pain scores, lower analgesic requirements, and more of them were pain-free compared to those who received a placebo. No patient using clonidine had any major hemodynamic instability. CONCLUSION: Compared to placebo or benzodiazepine, clonidine premedication was effective in reducing postoperative vomiting in pediatric patients undergoing ophthalmic surgery. Clonidine premedication also provided more reduction in postoperative pain when compared to placebo. The use of clonidine premedication was not associated with adverse hemodynamic events.

Focused Ultrasound Assists in Diagnosis and Management of Difficult Airway in Ludwig's Angina.

Ludwig's angina is a rapidly progressive and life-threatening medical emergency. The mortality rate is about 8%. Management of the difficult airway in Ludwig's angina has been challenging for clinical physicians. We reported an otherwise healthy 49-year-old female, who visited our emergency department with progressive swelling of her chin, drooling, and dyspnea. Ludwig's angina with impending airway compromise was promptly identified. The precise anatomy of the distorted neck was accessed using ultrasound as an adjunct. Emergent tracheostomy was then established successfully within minutes. Physicians should consider using ultrasound as an adjunct to define anatomy before performing emergent surgical airways.

Timely Identified Early Migration of Peripherally Inserted Central Catheter by Focused Ultrasound.

A peripherally inserted central venous catheter (PICC) has been widely applied to central venous assess. There were some known complications such as phlebitis, leakage, blockage, dislodgment, breakage, or malposition of PICC. Catheter migration was assessed by using chest radiograph or administering contrast medium. Herein, we report a 77-year-old woman presenting to emergency department with odynophagia and left neck swelling of 3 days duration. The initial impression was deep neck infection. Focused ultrasound identified a hyperechoic tube with thrombosis in left jugular vein, which indicated migration of PICC. Clinical symptoms immediately resolved after removal of PICC and anticoagulation therapy.

Methodological flaws in"diagnostic accuracy of blood biomarkers for Alzheimer's disease and amnestic mild cognitive impairment: A meta-analysis".

We read with interest the review by Chen et al. They intended to examine the diagnostic accuracy of blood-based biomarkers for detecting Alzheimer's disease and amnestic mild cognitive impairment. We believe that there were substantial methodological flaws in their meta-analysis. These methodological flaws included no comprehensive literature search details, neglect of the negative result research, no prespecified cut-off values, erroneous data input in their meta-analysis, and the issue of prevalence determined by the included studies. These factors potentially contributed to overestimation of the discriminative accuracy of blood-based biomarkers. Subsequently, the conclusion that blood-based biomarkers are effective tools for detecting Alzheimer's disease is debatable without correction of these methodological flaws and providing robust and trustworthy estimates.

Improvement of the Identification of Seniors at Risk scale for predicting adverse health outcomes of elderly patients in the emergency department.

OBJECTIVES: To explore the validity of the Chinese version of the Identification of Seniors at Risk (ISAR) screening tool in emergency rooms (ERs) to identify elderly patients prone to adverse outcomes after being discharged from the ER. METHODS: A prospective single-center observational study design was adopted and included 497 elderly (aged ≥65 years) ER patients of a medical center in northern Taiwan. Before discharge from the ER, baseline sociodemographic and clinic data were collected by researchers and the ISAR was administered. Adverse health outcomes (ER revisits, readmissions, and mortality) at 30 days were evaluated by medical records and follow-up telephone interviews. RESULTS: ISAR screening showed that 334 (67.2%) elderly patients in the ER were at high risk after discharge. Higher-risk patients were older, had had a fall within the previous 6 months, and had complex comorbidities. The ISAR had good sensitivity (0.77∼1.00) for screening adverse health outcomes in these elderly patients. The discrimination of the ISAR for adverse health outcomes was 0.60∼0.77, and it increased to 0.64∼0.80 when the age-adjusted Charlson comorbidity index (ACCI) was simultaneously considered. CONCLUSIONS: The ISAR exhibited good sensitivity for screening adverse outcomes for elderly patients at risk. The ACCI is recommended to simultaneously be considered to improve the prognostic performance of the ISAR.

The factor influencing the rate of ROSC for nontraumatic OHCA in New Taipei city.

ABSTRACT: Return of spontaneous circulation (ROSC) from out-of-hospital cardiac arrest (OHCA) is critical for the Emergency Medical Services System. When compared to other developed countries, Taiwan has lower rate of ROSC in OHCA patients.We conducted a retrospective study of cardiac arrest using The Emergency Medical Service Dispatching Center in Northern Taiwan and The Prehospital Care System of New Taipei City Paramedic Service. Patients suffering from nontraumatic OHCA between August of 2019 to February of 2020 were included. We analyzed the cardiopulmonary resuscitation (CPR) quality parameters such as chest compression interruptions, bystander CPR, shockable rhythm, CPR interruption, chest compression fraction (CCF) average, patient transportation in buildings, and adrenaline injection during CPR. Multivariable logistic regression analysis was performed to assess the relationship between potential independent variables and ROSC.In our study, we involved 1265 subjects suffering from nontraumatic OHCA, among which 587 patients met inclusion criteria. We identified that CCF> 0.8, chest compression interruption greater than 3 times, and patient transportation in the building were the most critical factors influencing ROSC. However, patient transportation in a building was identified as a dependent predictor variable (P = .4752).We concluded that CCF > 0.8 and chest compression interruption greater than 3 times were essential factors affecting the CPR ROSC rate. The most significant reason for suboptimal CCF and CPR interruption is patient transportation in a building. Improving the latter point could facilitate high-quality CPR.

Diagnostic Performance of Conventional X-ray for Detecting Foreign Bodies in the Upper Digestive Tract: A Systematic Review and Diagnostic Meta-Analysis.

Foreign body (FB) ingestion is a common clinical problem in acute settings. Detecting FBs in the upper digestive tract is challenging. The conventional X-ray is usually the first-line imaging tool to detect FBs. However, its diagnostic performance is inconsistent in the literature. In this study, we performed a systematic review and meta-analysis to determine the diagnostic performance of the conventional X-ray for detecting FBs in the upper digestive tract. We conducted a systematic search of PubMed, Embase, Cochrane Library, Web of Science, and Scopus until 1 August 2020. Prospective or retrospective studies investigating the diagnostic accuracy of conventional X-rays for detecting FBs in the upper digestive tract in patients of all ages were included. The Quality Assessment of Studies of Diagnostic Accuracy-2 tool was used to review the quality of included studies. We used a bivariate random-effects model to calculate diagnostic accuracy parameters. Heterogeneity was assessed using I2 statistics. We included 17 studies (n = 4809) in the meta-analysis. Of the 17 studies, most studies were rated as having a high risk of bias. Conventional X-rays had a pooled sensitivity of 0.58 (95% confidence interval [CI] = 0.36-0.77, I2 = 98.52) and a pooled specificity of 0.94 (95% CI = 0.87-0.98, I2 = 94.49) for detecting FBs in the upper digestive tract. The heterogeneity was considerable. The area under the summary receiver operating characteristic curve was 0.91 (95% CI = 0.88-0.93). Deek's funnel plot asymmetry test results revealed no significant publication bias (p = 0.41). The overall sensitivity and specificity of conventional X-rays were low and high, respectively, for detecting FBs in the upper digestive tract. Hence, conventional X-rays to exclude patients without upper FBs in the digestive tract are not recommended. Further imaging or endoscopic examinations should be performed for at-risk patients.

Does tranexamic acid reduce risk of mortality on patients with hemoptysis?: A protocol for systematic review and meta-analysis.

BACKGROUND: Although tranexamic acid (TXA), a readily accessible antifibrinolytic agent, is widely adopted in hemorrhage scenarios, its role on mortality in patients with hemoptysis remains uncertain. New evidence is yet to be generated to evaluate the risk of mortality after using TXA in patients with hemoptysis. METHODS: PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were searched from inception to May 2020. Randomized controlled trials and observational studies that evaluated the effect of TXA on patients with hemoptysis were included. Data were independently extracted by 2 reviewers and synthesized using a random-effects model. MAIN RESULTS: Five studies with a total of 20,047 patients were analyzed. When compared with the control, administration of TXA was associated with a reduction in short-term mortality (risk ratio = 0.78, 95% confidence interval [CI] 0.72-0.85; I2 = 0), shorter bleeding time (mean difference = - 24.61 hours, 95% CI - 35.96 to -13.26, I2 = 0), shorter length of hospital stay (mean difference = -1.94 days, 95% CI -2.48 to -1.40, I2 = 0), and lower need for intervention (risk ratio = 0.38, 95% CI 0.16-0.87, I2 = 0) in patients with hemoptysis. Compared with control, administration of TXA did not cause increased major or minor adverse effects. CONCLUSIONS: TXA provided benefits in terms of a lower short-term mortality rate, less bleeding time, shorter length of hospital stays, and less need for intervention in patients with hemoptysis. Use of TXA was not associated with increased adverse effects.