Systemic thrombolysis with newer thrombolytics vs anticoagulation in acute intermediate risk pulmonary embolism: a systematic review and meta-analysis.

BACKGROUND: Randomized controlled trials (RCTs) comparing systemic thrombolysis to anticoagulation in intermediate risk pulmonary embolism (PE) have yielded mixed results. A prior meta-analysis on this topic had included studies that used lower than standard dose of thrombolytics and included thrombolytic agents that are no longer available. Hence, interpreting the findings of that paper is not valid in contemporary practice. OBJECTIVES: We undertook a systematic review and meta-analysis of randomized controlled trials of systemic thrombolysis with newer thrombolytic agents vs anticoagulation in intermediate risk PE. METHODS: This systematic review and meta-analysis is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. RESULTS: Nine randomized controlled trials were included in the study. We did not find any difference in in-hospital mortality (RR: 0.79; 95% CI: 0.42-1.50; I2: 0) or risk of major bleeding (RR:2.08;95% CI: 0.98-4.42; I2: 23.9%) between systemic thrombolysis and anticoagulation. Systemic thrombolysis was associated with lower risks for vasopressor use (RR: 0.27; 95% CI: 0.11-0.64, I2: 0) and secondary/rescue thrombolysis (RR: 0.25; 95% CI: 0.14-0.45; I2: 0). But systemic thrombolysis was found to have an increased risk of intracranial hemorrhage (RR: 4.55; 95% CI: 1.30-15.91; I2:0). There was no difference in mechanical ventilation between the two groups (RR: 0.61; 95% CI: 0.31-1.19, I2:0). CONCLUSION: In our meta-analysis of randomized controlled trials of systemic thrombolysis vs anticoagulation in intermediate risk PE, we did not find any difference in in-hospital mortality or overall risk of major bleeding. With systemic thrombolysis, we found lower risks for vasopressor use and need for secondary/ rescue thrombolysis and an increased risk of intracranial hemorrhage.

Fecal Microbiota Transplantation and Medical Therapy for Clostridium difficile Infection : Meta-analysis of Randomized Controlled Trials.

GOALS: The aim was to assess the effectiveness of fecal microbiota transplantation (FMT) against medical therapy (MT). BACKGROUND: FMT has shown good outcomes in the treatment of Clostridium difficile infection (CDI). We aimed to conduct a systematic review and meta-analysis to compare the effectiveness of FMT versus MT for CDI. STUDY: We performed a comprehensive search to identify randomized controlled trials comparing FMT against MT in patients with CDI. Outcomes of interest were clinical cure as determined by the resolution of diarrhea and/or negative C. difficile testing. Primary CDI is defined as the first episode of CDI confirmed endoscopically or by laboratory analysis. Recurrent C. difficile infection (RCDI) is defined as laboratory or endoscopically confirmed episode of CDI after at least 1 course of approved antibiotic regimen. RESULTS: A total of 7 studies with 238 patients were included in meta-analysis. Compared with MT, FMT did not have a statistically significant difference for clinical cure of combined primary and RCDI after first session [risk ratio (RR): 1.52, 95% confidence interval (CI): 0.90, 2.58; P =0.12; I2 =77%] and multiple sessions of FMT (RR: 1.68; CI: 0.96, 2.94; P =0.07; I2 =82%). On subgroup analysis, FMT has statistically higher rate of response than MT (RR: 2.41; CI: 1.20, 4.83; I2 =78%) for RCDI. However, for primary CDI there is no statistically significant difference between FMT and MT (RR: 1.00; CI: 0.72, 1.39; I2 =0%). CONCLUSION: As per our analysis, FMT should not be utilized for every patient with CDI. It is more effective in RCDI, but the results were not significant in patients with primary CDI.

Pattern and burden of opioid-related hospitalizations in the USA from 2016 to 2018.

AIMS: The current opioid crisis in the USA is a formidable challenge for the healthcare system, and the general population. Our objective is to characterize the burden of opioid-related disorders in an inpatient setting in the USA for the years 2016, 2017 and 2018 using the National Inpatient Sample (NIS). METHODS: A cross-sectional analysis of the NIS was performed to identify and analyse hospitalizations with an opioid-related diagnosis in 2016, 2017 and 2018. Descriptive statistics and regression models were utilized to define the demographics of the population of interest and measure the outcomes. RESULTS: We identified 962 900 discharges with opioid-related diagnosis in 2016, 982 710 in 2017 and 942 110 in 2018. The majority were age <60 years, were found in residents of low-income zip codes and covered by Medicaid. The adjusted mean total hospitalization cost trended up from $12 828 (95% confidence interval [CI] 12 547-13 108) in 2016, to $13164.9 (95% CI 12 872.47-13 457.34) in 2017 and then to $13 626.65 (95% CI 13 325.95-13 927.34) in 2018. The adjusted mortality was highest in 2016; 2.26% (95% CI 2.16-2.35) and it trended down to 1.97% (95% CI 1.88-2.05) in 2017, and to 1.89% (95% CI 1.81-1.98) in 2018. CONCLUSIONS: Opioid-related disorders cause a significant number of hospitalizations in the USA. A large proportion of these patients are age <60 years, have lower household income, and are covered by Medicaid. Programmes directed towards this specific group can help reduce the overall burden of hospitalizations.

Updates in Treatment of Recurrent Clostridium difficile Infection.

Recurrent Clostridium difficile infection (CDI) is a perpetual problem that leads to increased economic burden, higher healthcare cost, and significant morbidity and mortality. Its treatment remains a challenge. While various treatment approaches have been attempted with different levels of success, robust data establishing the superiority of one approach over the others is lacking. In this article, we review the current evidence pertaining to conventional pharmacological treatment as well as fecal microbiota transplantation (FMT) as a novel, rapidly emerging treatment modality for recurrent CDI.