Clinical effectiveness of nirmatrelvir plus ritonavir on the short- and long-term outcome in high-risk children with COVID-19.

This study investigated the clinical effectiveness of nirmatrelvir plus ritonavir (NMV-r) on short-term outcome and the risk of postacute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC) among pediatric patients with coronavirus disease 2019 (COVID-19). This retrospective cohort study used the TriNetX research network to identify pediatric patients between 12 and 18 years with COVID-19 between January 1, 2022 and August 31, 2023. The propensity score matching (PSM) method was used to match patients receiving NMV-r (NMV-r group) with those who did not receive NMV-r (control group). Two cohorts comprising 633 patients each (NMV-r and control groups), with balanced baseline characteristics, were identified using the PSM method. During the initial 30 days, the NMV-r group showed a lower incidence of all-cause hospitalization, mortality, or ED visits (hazard ratio [HR] = 0.546, 95% confidence interval [CI]: 0.372-0.799, p = 0.002). Additionally, the NMV-r group had a significantly lower risk of all-cause hospitalization compared with the control group (HR = 0.463, 95% CI: 0.269-0.798), with no deaths occurring in either group. In the 30-180-day follow-up period, the NMV-r group exhibited a non-significantly lower incidence of post-acute sequelae of SARS-CoV-2 infection (PASC), encompassing symptoms such as fatigue, cardiopulmonary symptoms, pain, cognitive impairments, headache, dizziness, sleep disorders, anxiety, and depression, compared to the control group. This study underscores the potential effectiveness of NMV-r in treating high-risk pediatric patients with COVID-19, demonstrating significant reductions in short-term adverse outcomes such as emergency department visits, hospitalization, or mortality within the initial 30-day period. Additionally, NMV-r shows promise in potentially preventing the development of PASC.

Efficacy and acceptability of noninvasive brain stimulation for treating posttraumatic stress disorder symptoms: A network meta-analysis of randomized controlled trials.

INTRODUCTION: Despite its high lifetime prevalence rate and the elevated disability caused by posttraumatic stress disorder (PTSD), treatments exhibit modest efficacy. In consideration of the abnormal connectivity between the dorsolateral prefrontal cortex (DLPFC) and amygdala in PTSD, several randomized controlled trials (RCTs) addressing the efficacy of different noninvasive brain stimulation (NIBS) modalities for PTSD management have been undertaken. However, previous RCTs have reported inconsistent results. The current network meta-analysis (NMA) aimed to compare the efficacy and acceptability of various NIBS protocols in PTSD management. METHODS: We systematically searched ClinicalKey, Cochrane Central Register of Controlled Trials, Embase, ProQuest, PubMed, ScienceDirect, Web of Science, and ClinicalTrials.gov to identify relevant RCTs. The targeted RCTs was those comparing the efficacy of NIBS interventions, such as transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), and transcutaneous cervical vagal nerve stimulation, in patients with PTSD. The NMA was conducted using a frequentist model. The primary outcomes were changes in the overall severity of PTSD and acceptability (to be specific, rates of dropouts for any reason). RESULTS: We identified 14 RCTs that enrolled 686 participants. The NMA demonstrated that among the investigated NIBS types, high-frequency rTMS over bilateral DLPFCs was associated with the greatest reduction in overall PTSD severity. Further, in comparison with the sham controls, excitatory stimulation over the right DLPFC with/without excitatory stimulation over left DLPFC were associated with significant reductions in PTSD-related symptoms, including depression and anxiety symptoms, and overall PTSD severity. CONCLUSIONS: This NMA demonstrated that excitatory stimulation over the right DLPFC with or without excitatory stimulation over left DLPFC were associated with significant reductions in PTSD-related symptoms. TRIAL REGISTRATION: PROSPERO CRD42023391562.

Effect of hydrocortisone-fludrocortisone combination on mortality in septic shock: a systematic review and meta-analysis.

BACKGROUND: This study assessed the effect of hydrocortisone-fludrocortisone combination therapy on the mortality of patients with septic shock. METHODS: A literature search was conducted using Medline, Embase, the Cochrane Library, ClinicalTrials.gov, and other databases for articles published until October 1, 2023. Only clinical studies that assessed the clinical efficacy and safety of hydrocortisone-fludrocortisone therapy for the treatment of septic shock were included. The primary outcome was the in-hospital mortality rate. RESULTS: Seven studies with a total of 90, 756 patients were included. The study group exhibited lower in-hospital mortality rates (40.8% vs. 42.8%; OR, 0.86; 95% CI, 0.80-0.92). Compared to the control group, the study group also had lower intensive care unit (ICU) mortality (OR, 0.77; 95% CI, 0.63-0.95), 28-day mortality (OR, 0.85; 95% CI, 0.72-1.00), 90-day mortality (OR, 0.85; 95% CI, 0.71-1.01), 180-day mortality (OR, 0.82; 95% CI, 0.68-0.90), and one-year mortality (OR, 0.70; 95% CI, 0.42-1.16). Subgroup analyses showed a similar trend, particularly prominent in the pooled analysis of randomized clinical trials, multicenter studies, and ICU patients, the study drug regimen involved hydrocortisone at a dose of 50 mg every 6 h in combination with fludrocortisone at 50 µg daily, with the control group receiving either placebo or standard care. Hydrocortisone-fludrocortisone also increased vasopressor-free days and reduced vasopressor duration, without elevating the risk of adverse events. CONCLUSIONS: This study emphasizes the potential survival benefits of hydrocortisone-fludrocortisone combination therapy for patients with septic shock and its additional advantages, including reduced vasopressor use.

Clinical Efficacy and Safety of Novel Anticoagulants for the Management of Venous Thromboembolism in Patients with Cancer: A Systematic Review and Meta-Analysis.

PURPOSE: Cancer patients face a four- to sevenfold higher risk of venous thromboembolism (VTE) than the general population. Novel oral anticoagulants (NOACs) provide convenient alternatives to traditional therapies. METHODS: We performed a systematic literature search across PubMed, Embase, and the Cochrane Library, targeting studies that examined the use of NOACs in cancer-associated VTE. The search included randomized controlled trials (RCTs). Selected studies compared NOACs with low-molecular-weight heparin (LMWH) or vitamin K antagonists (VKA) in cancer patients diagnosed with VTE. A meta-analysis using a random-effects model was applied to estimate pooled effect sizes for outcomes. RESULTS: In this meta-analysis, we included 12 RCTs. Results showed NOACs were more effective than LMWH in preventing VTE recurrence (RR 0.66, 95% CI 0.52-0.83, p = 0.0004). Compared with VKAs, NOACs showed no significant difference (RR 0.63, 95% CI 0.34-1.15, p = 0.13). However, this finding is limited by the small patient sample. Major bleeding outcomes were similar between NOACs and LMWH/VKAs (RR 1.24, 95% CI 0.85-1.80, p = 0.28; RR 0.77, 95% CI 0.39-1.53, p = 0.46, respectively). Meta-regression analysis indicated a statistically significant positive correlation between mortality and major bleeding events when comparing NOACs with LMWH (p = 0.049). There was no significant difference in all-cause mortality between patients treated with NOACs and those treated with LMWH (RR 1.04, 95% CI 0.92-1.18, p = 0.54) or VKAs (RR 0.94, 95% CI 0.72-1.23, p = 0.65). CONCLUSION: Meta-analysis shows NOACs, especially factor Xa inhibitors, reduce VTE recurrence in cancer patients more effectively than LMWH. Comparison between NOACs and VKAs is inconclusive due to limited patient data. Further research is needed to assess NOACs' efficacy and safety against VKAs.

The impact of perioperative ketamine or esketamine on the subjective quality of recovery after surgery: a meta-analysis of randomised controlled trials.

BACKGROUND: This meta-analysis aimed to evaluate the impact of ketamine/esketamine on postoperative subjective quality of recovery (QoR). METHODS: MEDLINE, Embase, Cochrane library, and Google Scholar were searched for randomised controlled trials (RCTs) that examined the impacts of perioperative ketamine/esketamine use and postoperative QoR. The primary outcome was subjective QoR (QoR-9, QoR-15, QoR-40) on postoperative day (POD) 1-3, whereas the secondary outcomes included pain severity, anxiety scores, depression scores, risk of adverse events (i.e. nausea, vomiting, dizziness, drowsiness), and length of stay. RESULTS: The analysis included 18 RCTs (1554 participants; ketamine: seven trials, esketamine: 11 trials), of which 15 were conducted in China. Ketamine/esketamine improved the QoR scores on PODs 1 and 2 compared with the control (standardised mean difference [SMD]: 0.63, P<0.0001 for POD 1; SMD: 0.56, P=0.04 for POD 2), without beneficial effect on POD 3. Subgroup analyses revealed significant differences in QoR scores on POD 1 by regimen (SMD: esketamine 1.14, ketamine 0.01) and country (SMD: China 0.82, other countries -0.21). The emotional domain of QoR was improved from PODs 1 to 3, whereas the other domains were only improved on POD 1. Lower postoperative anxiety (SMD: -0.48, P=0.003) and depression (SMD: -0.72, P=0.001) scores were also observed with ketamine/esketamine use. Furthermore, pain severity was reduced on PODs 1 and 2, with no difference in the risk of adverse events or length of stay. CONCLUSIONS: This meta-analysis demonstrated that ketamine/esketamine use in the perioperative period is associated with improved early subjective QoR, pain severity, and psychological symptoms without an increase in the likelihood of adverse events. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42023477580).

Efficacy of intravenous iron supplementation in reducing transfusion risk following cardiac surgery: an updated meta-analysis of randomised controlled trials.

BACKGROUND: Previous meta-analyses of intravenous iron supplementation for reducing red blood cell (RBC) transfusion risk after cardiac surgery were inconclusive because of limited data. This updated meta-analysis incorporates recent evidence. METHODS: Major databases were searched on May 2, 2024 for randomised controlled trials comparing the incidence of RBC transfusion between adult patients receiving intravenous iron supplementation and those receiving controls (i.e. oral iron or placebo) after cardiac surgery. The secondary outcomes included the number of RBC units transfused, postoperative haemoglobin levels, iron status, complications, and length of hospital stay. Trial sequential analysis was conducted to examine the robustness of evidence. RESULTS: Fourteen randomised controlled trials including 2043 subjects were identified. Intravenous iron supplementation was found to reduce the RBC transfusion risk compared with controls (relative risk 0.77, 95% confidence interval [CI] 0.65-0.91, P=0.002, n=1955, I2=61%, certainty of evidence: moderate). The trial sequential analysis supported the robustness of the evidence. Furthermore, haemoglobin levels were higher in the intravenous iron supplementation group on postoperative days 4-10 (mean difference 0.17 g dl-1, 95% CI 0.06-0.29, n=1989) and >21 days (mean difference 0.66 g/dl-1, 95% CI 0.36-0.95, n=1008). Postoperative iron status also improved with Intravenous iron supplementation, particularly on postoperative days 4-10. There were no significant differences in other outcomes, including mortality. CONCLUSIONS: Intravenous iron supplementation can reduce RBC transfusion risk and improve postoperative haemoglobin level and iron status after cardiac surgery, supporting the implementation of Intravenous iron supplementation in perioperative blood management strategies. SYSTEMATIC REVIEW PROTOCOL: CRD42024542206 (PROSPERO).

Prophylaxis for paediatric emergence delirium in desflurane-based anaesthesia: a network meta-analysis.

PURPOSE: The prevalence of postoperative emergence delirium in paediatric patients (pedED) following desflurane anaesthesia is considerably high at 50-80%. Although several pharmacological prophylactic strategies have been introduced to reduce the risk of pedED, conclusive evidence about the superiority of these individual regimens is lacking. The aim of the current study was to assess the potential prophylactic effect and safety of individual pharmacotherapies in the prevention of pedED following desflurane anaesthesia. METHODS: This frequentist model network meta-analysis (NMA) of randomized controlled trials (RCTs) included peer-reviewed RCTs of either placebo-controlled or active-controlled design in paediatric patients under desflurane anaesthesia. RESULTS: Seven studies comprising 573 participants were included. Overall, the ketamine + propofol administration [odds ratio (OR) = 0.05, 95% confidence intervals (95%CIs) 0.01-0.33], dexmedetomidine alone (OR = 0.13, 95%CIs 0.05-0.31), and propofol administration (OR = 0.30, 95%CIs 0.10-0.91) were associated with a significantly lower incidence of pedED than the placebo/control groups. In addition, only gabapentin and dexmedetomidine were associated with a significantly higher improvement in the severity of emergence delirium than the placebo/control groups. Finally, the ketamine + propofol administration was associated with the lowest incidence of pedED, whereas gabapentin was associated with the lowest severity of pedED among all of the pharmacologic interventions studied. CONCLUSIONS: The current NMA showed that ketamine + propofol administration was associated with the lowest incidence of pedED among all of the pharmacologic interventions studied. Future large-scale trials to more fully elucidate the comparative benefits of different combination regimens are warranted. TRIAL REGISTRATION: PROSPERO CRD42021285200.

Prediction of early postoperative pain using sleep quality and heart rate variability.

PURPOSE: Accurate predictions of postoperative pain intensity are necessary for customizing analgesia plans. Insomnia is a risk factor for severe postoperative pain. Moreover, heart rate variability (HRV) can provide information on the sympathetic-parasympathetic balance in response to noxious stimuli. We developed a prediction model that uses the insomnia severity index (ISI), HRV, and other demographic factors to predict the odds of higher postoperative pain. METHODS: We recruited gynecological surgery patients classified as American Society of Anesthesiologists class 1-3. An ISI questionnaire was completed 1 day before surgery. HRV was calculated offline using intraoperative electrocardiogram data. Pain severity at the postanesthesia care unit (PACU) was assessed with the 0-10 numerical rating scale (NRS). The primary outcome was the model's predictive ability for moderate-to-severe postoperative pain. The secondary outcome was the relationship between individual risk factors and opioid consumption in the PACU. RESULTS: Our study enrolled 169 women. Higher ISI scores (p = 0.001), higher parasympathetic activity (rMSSD, pNN50, HF; p < 0.001, p < 0.001, p < 0.001), loss of fractal dynamics (SD2, alpha 1; p = 0.012, p = 0.039) in HRV analysis before the end of surgery were associated with higher NRS scores, while laparoscopic surgery (p = 0.031) was associated with lower NRS scores. We constructed a multiple logistic model (area under the curve = 0.852) to predict higher NRS scores at PACU arrival. The five selected predictors were age (OR: 0.94; p = 0.020), ISI score (OR: 1.14; p = 0.002), surgery type (laparoscopic or open; OR: 0.12; p < 0.001), total power (OR: 2.02; p < 0.001), and alpha 1 (OR: 0.03; p < 0.001). CONCLUSION: We employed a multiple logistic regression model to determine the likelihood of moderate-to-severe postoperative pain upon arrival at the PACU. Physicians could personalize analgesic regimens based on a deeper comprehension of the factors that contribute to postoperative pain.

Nutritional deficiency anemia and post-acute sequelae in patients with severe acute respiratory syndrome coronavirus 2 infection: A six-month retrospective cohort analysis of 30 892 patients.

The effect of anemia on the post-acute outcome of patients with severe acute respiratory syndrome coronavirus 2 infection was unclear. This study aimed to investigate the potential association between nutritional deficiency anemia (NDA) status and post-acute sequelae of patients with SARS-CoV-2 infection. This retrospective cohort study included patients with coronavirus disease (COVID-19) from January 1, 2022 to November 30, 2022 using the TriNetX research network. The patients were grouped into the NDA group comprising patients diagnosed with NDA and the control group comprising patients without NDA, and propensity score matching (PSM) was performed to balance the two groups. The primary outcome was a composite of post-COVID-19 condition, all-cause hospitalization, and all-cause death. The secondary outcomes were any individual outcomes of the primary composite. The follow-up period was set at 90-180 days after COVID-19 diagnosis. Two cohorts comprising 15 446 nonhospitalized patients with COVID-19 in each group with balanced baseline characteristics were created using PSM. During the follow-up period, the NDA group demonstrated a higher risk of the composite primary outcome, including post-COVID-19 condition, all-cause hospitalization, or all-cause death (hazard ratio [HR], 1.896; 95% confidence interval [CI] = 1.757-2.045). Regarding secondary outcomes, the NDA group was associated with worse outcomes, including post-COVID-19 condition (HR, 1.992; 95% CI = 1.403-2.828), all-cause hospitalization (HR, 1.856; 95% CI = 1.714-2.009), and all-cause death (HR, 3.922; 95% CI = 2.910-5.285) compared to the control group. Among nonhospitalized patients with COVID-19, NDA was associated with a higher risk of post-COVID-19 condition, all-cause hospitalization, and all-cause death during the 90-180-day follow-up period.

A meta-analysis on the therapeutic efficacy of repetitive transcranial magnetic stimulation for cognitive functions in attention-deficit/hyperactivity disorders.

BACKGROUND: Therapeutic efficacies of repetitive transcranial magnetic stimulation (rTMS) for improving cognitive functions in patients with deficit/hyperactivity disorder (ADHD) remained unclear. The aim of this meta-analysis was to investigate the therapeutic efficacy of rTMS focusing on different cognitive performances. METHODS: Major databases were searched electronically from inception to February 2023 by using keywords mainly "rTMS" and "ADHD" to identify randomized controlled trials (RCTs) that investigated the therapeutic efficacy of rTMS for improving cognitive functions assessed by standardized tasks in patients with ADHD. The overall effect size (ES) was calculated as standardized mean difference (SMD) based on a random effects model. RESULTS: Meta-analysis of five RCTs with 189 participants (mean age of 32.78 and 8.53 years in adult and child/adolescent populations, respectively) demonstrated that rTMS was more effective for improving sustained attention in patients with ADHD compared with the control groups (SMD = 0.54, p = 0.001).Our secondary analysis also showed that rTMS was more effective for improving processing speed than the control groups (SMD = 0.59, p = 0.002) but not for enhancing memory or executive function. CONCLUSIONS: Our results supported the therapeutic efficacy of rTMS for improving sustained attention and processing speed. However, the limitation of available data warrants further studies to verify these findings.

Incidence change of postoperative delirium after implementation of processed electroencephalography monitoring during surgery: a retrospective evaluation study.

BACKGROUND: Postoperative delirium (POD) is a common complication in the elderly, which is associated with poor outcomes after surgery. Recognized as predisposing factors for POD, anesthetic exposure and burst suppression during general anesthesia can be minimized with intraoperative processed electroencephalography (pEEG) monitoring. In this study, we aimed to evaluate whether implementation of intraoperative pEEG-guided anesthesia is associated with incidence change of POD. METHODS: In this retrospective evaluation study, we analyzed intravenous patient-controlled analgesia (IVPCA) dataset from 2013 to 2017. There were 7425 patients using IVPCA after a noncardiac procedure under general anesthesia. Patients incapable of operating the device independently, such as cognitive dysfunction or prolonged sedation, were declined and not involved in the dataset. After excluding patients who opted out within three days (N = 110) and those with missing data (N = 24), 7318 eligible participants were enrolled. Intraoperative pEEG has been implemented since July 2015. Participants having surgery after this time point had intraoperative pEEG applied before induction until full recovery. All related staff had been trained in the application of pEEG-guided anesthesia and the assessment of POD. Patients were screened twice daily for POD within 3 days after surgery by staff in the pain management team. In the first part of this study, we compared the incidence of POD and its trend from 2013 January-2015 July with 2015 July-2017 December. In the second part, we estimated odds ratios of risk factors for POD using multivariable logistic regression in case-control setting. RESULTS: The incidence of POD decreased from 1.18 to 0.41% after the administration of intraoperative pEEG. For the age group ≧ 75 years, POD incidence decreased from 5.1 to 1.56%. Further analysis showed that patients with pEEG-guided anesthesia were associated with a lower odd of POD (aOR 0.33; 95% CI 0.18-0.60) than those without after adjusting for other covariates. CONCLUSIONS: Implementation of intraoperative pEEG was associated with a lower incidence of POD within 3 days after surgery, particularly in the elderly. Intraoperative pEEG might be reasonably considered as part of the strategy to prevent POD in the elder population. TRIAL REGISTRATION: Not applicable.

Factors affecting spiritual care competency of mental health nurses: a questionnaire-based cross-sectional study.

BACKGROUND: Although providing spiritual care is an important part of holistic nursing care for psychiatric patients, factors associated with spiritual care competency in mental health nurses remain unclear. The aim of our study was to explore a possible association of personal and external factors with spiritual care competency in mental health nurses. METHODS: This prospective questionnaire-based cross-sectional study was conducted by inviting mental health nurses from mental health hospitals and tertiary referral centers. Personality traits and spiritual care competency were assessed by using [1] "big-five Mini-Markers" questionnaire, and [2] spiritual care competency scale, respectively. From the 250 mental health nurses being invited, 239 valid questionnaires were valid for final analysis. Statistical analyses including descriptive statistics, ANOVAs, t-tests, and hierarchical multiple regression models were used to investigate the associations between personal/external factors and their spiritual care competency in mental health nurses. RESULTS: The mean age of the 239 participants was 35.96 ± 8.11 and the mean years of working experience was 9.41 ± 7.06. Over 90% of them had no experience of providing spiritual care. There were significant positive correlations of spiritual care competency with the experience of delivering spiritual care (p < 0.001), previous participation in spiritual care education programs (p = 0.045), a longer working experience (p = 0.014), and a higher education level (postgraduate vs. college, p = 0.006), as well as the personality components of "Conscientiousness" (p < 0.001), "Agreeableness" (p < 0.001), "Extraversion" (p = 0.03), and "Openness/Intellect" (p < 0.001). CONCLUSIONS: Both personal and external factors may be related to the self-perception of spiritual care competency among mental health nurses. These findings may help mental health nurses understand the possible positive and negative associations of their personality components with their spiritual care abilities. Moreover, our identification of the positive impacts of educational programs and previous experience of spiritual care on spiritual care competency may underscore the importance of tailoring appropriate training programs to cater for the individual needs of mental health nurses.

Association of scalp block with intraoperative hemodynamic profiles and postoperative pain outcomes at 24-48 hours following craniotomy: An updated systematic review and meta-analysis of randomized controlled studies.

BACKGROUND: Despite the demonstrated analgesic efficacy of scalp block (SB) during the immediate postoperative period, the impact of SB on pain outcomes at postoperative 24 and 48 h in adults receiving craniotomy remains unclear. METHODS: The databases of Medline, Embase, and Cochrane Central Register were searched from inception to January 2022 for available randomized controlled trials (RCTs). The primary outcome was the severity of pain at postoperative 24 and 48 h, while the secondary outcomes included morphine consumption, hemodynamic profiles after surgical incision and in the postanesthesia care unit (PACU), and risk of postoperative nausea/vomiting (PONV). RESULTS: Meta-analysis of 12 studies revealed a lower pain score [MD = -0.83, p = 0.03, 375 patients, certainty of evidence (COE): low] and morphine consumption (MD = -9.21 mg, p = 0.03, 246 patients, COE: low) at postoperative 24 h, while there were no differences in these pain outcomes at postoperative 48 h (COE: low). The use of SB significantly decreased intraoperative heart rate (MD = -10.9 beats/min, p < 0.0001, 189 patients, COE: moderate) and mean blood pressure (MD = -13.02 mmHg, p < 0.00001, 189 patients, COE: moderate) after surgical incision, but these hemodynamic profiles were comparable in both groups in the PACU setting. There was also no difference in the risk of PONV between the two groups (RR = 0.78, p = 0.2, 299 patients, COE: high). CONCLUSION: This meta-analysis demonstrated that scalp block not only provided hemodynamic stability immediately after surgical incision but was also associated with a lower pain score and morphine consumption at postoperative 24 h. Further studies are needed for elucidation of its findings.

Therapeutic effects of antidepressants for global improvement and subdomain symptoms of autism spectrum disorder: a systematic review and meta-analysis.

BACKGROUND: No established pharmacological treatment is available for the core symptoms of autism spectrum disorder (ASD). This study aimed at investigating the efficacy of antidepressants for the core and associated symptoms of ASD. METHODS: We searched PubMed, Embase, ClinicalKey, Cochrane CENTRAL, ScienceDirect, Web of Science and ClinicalTrials.gov using the keywords "ASD" and "antidepressants." We searched from database inception to June 2021 for randomized controlled trials of antidepressant use in patients with ASD. We calculated pooled effect sizes based on a random-effects model. RESULTS: Analysis of 16 studies with 899 participants showed improvements in restricted and repetitive behaviours (effect size = 0.27) and global symptoms (effect size = 1.0) in patients with ASD taking antidepressants versus those taking placebos (p ≤ 0.01). We found no differences between the 2 groups (p ≥ 0.36) in terms of dropout rate (odds ratio [OR] = 1.17) or rate of study discontinuation because of adverse events (OR = 1.05). We also noted improvements in irritability and hyperactivity in the antidepressant group (Hedges g = 0.33 and 0.22, respectively, both p < 0.03). Subgroup analyses showed significant effects of medication type (i.e., clomipramine was better than SSRIs) and age (antidepressants were more effective in adults than in children or adolescents) on both restricted and repetitive behaviours and global improvement (p < 0.05). Meta-regression demonstrated that better therapeutic effects were associated with lower symptom severity and older age. LIMITATIONS: The small effect sizes and variations in treatment response that we found warrant further study. CONCLUSION: Our results supported the effectiveness of antidepressants for global symptoms and symptom subdomains of ASD, with tolerable adverse effects. Low symptom severity and adulthood were associated with better outcomes.

Impact of intravenous and topical lidocaine on clinical outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: a meta-analysis of randomised controlled trials.

BACKGROUND: The efficacy of i.v. or topical lidocaine as an anaesthesia adjunct in improving clinical outcomes in patients receiving gastrointestinal endoscopic procedures under propofol sedation remains unclear. METHODS: Electronic databases (MEDLINE, EMBASE, and Cochrane Library) were searched for RCTs comparing the clinical outcomes with or without lidocaine application (i.v. or topical) in patients receiving propofol for gastrointestinal endoscopic procedures from inception to 29 March 2021. The primary outcome was propofol dosage, while secondary outcomes included procedure time, recovery time, adverse events (e.g. oxygen desaturation), post-procedural pain, and levels of endoscopist and patient satisfaction. RESULTS: Twelve trials (1707 patients) published between 2011 and 2020 demonstrated that addition of i.v. (n=7) or topical (n=5) lidocaine to propofol sedation decreased the level of post-procedural pain (standardised mean difference [SMD]=-0.47, 95% confidence interval [CI]: -0.8 to -0.14), risks of gag events (risk ratio [RR]=0.51, 95% CI: 0.35-0.75), and involuntary movement (RR=0.4, 95% CI: 0.16-0.96). Subgroup analysis demonstrated that only i.v. lidocaine reduced propofol dosage required for gastrointestinal endoscopic procedures (SMD=-0.83, 95% CI: -1.19 to -0.47), increased endoscopist satisfaction (SMD=0.75, 95% CI: 0.21-1.29), and shortened the recovery time (SMD=-0.83, 95% CI: -1.45 to -0.21). Intravenous or topical lidocaine did not affect the incidence of oxygen desaturation (RR=0.72, 95% CI: 0.41-1.24) or arterial hypotension (RR=0.6, 95% CI: 0.22-1.65) and procedure time (SMD=0.21, 95% CI: -0.09 to 0.51). CONCLUSION: This meta-analysis demonstrated that i.v. or topical lidocaine appears safe to use and may be of benefit for improving propofol sedation in patients undergoing gastrointestinal endoscopic procedures. Further large-scale trials are warranted to support our findings.

Impact of comprehensive geriatric assessment on the risk of adverse events in the older patients receiving anti-cancer therapy: a systematic review and meta-analysis.

BACKGROUND: to assess the efficacy of comprehensive geriatric assessment (CGA) for preventing treatment-related toxicity in older people undergoing non-surgical cancer therapies. METHODS: MEDLINE, EMBASE and Cochrane library databases were searched from inception till January 2022 to identify randomised controlled trials (RCTs) on the incidence of toxicity measured by the Common Terminology Criteria for Adverse Events (primary outcome) and that of therapeutic modifications, early treatment discontinuation, progression-free survival, overall survival and hospitalisation (secondary outcomes). RESULTS: analysis of six RCTs published from 2016 to 2021 recruiting 2,126 participants (median age: 71-77) who received chemotherapy as the major therapeutic approach revealed 51.7% and 64.7% of Grade 3+ toxicity in the CGA and control (i.e. standard care) groups, respectively (RR = 0.81, 95% CI: 0.7-0.94, P = 0.005, I2 = 65%, certainty of evidence [COE]: moderate). There were no significant differences in the incidence of early treatment discontinuation (RR = 0.88, P = 0.47; I2 = 63%,1,408 participants, COE: low), initial reduction in treatment intensity (RR = 0.99, P = 0.94; I2 = 83%, 2055 participants, COE: low), treatment delay (RR = 1.06, P = 0.77, I2 = 0%, 309 participants, COE: moderate), hospitalisation (RR = 0.86, P = 0.39, I2 = 41%, 914 participants, COE: moderate), progression-free and overall survival with or without CGA. However, there was an association between CGA and a lower incidence of dose reduction during treatment (RR = 0.73, P < 0.00001, 956 participants, COE: moderate). CONCLUSIONS: our results demonstrated that comprehensive geriatric assessment may be associated with a lower incidence of treatment-related toxicity and dose reduction compared to standard care in older people receiving non-surgical cancer treatments. Further large-scale studies are warranted to support our findings.

Association of peripheral nerve blocks with patient-reported quality of recovery in female patients receiving breast cancer surgery: a systematic review and meta-analysis of randomized controlled studies.

PURPOSE: This systematic review and meta-analysis investigated the impact of peripheral nerve blocks (PNBs) on patient-reported quality of recovery (QoR) following breast cancer surgery. SOURCE: Medline, EMBASE, Cochrane Library, and Google scholar databases were searched for randomized controlled trials (RCTs) comparing the QoR with or without PNBs in patients receiving breast cancer surgery from inception to September 2021. Using a random effects model, the primary outcome was total scores of postoperative QoR scales (i.e., QoR-15 and QoR-40). PRINCIPAL FINDINGS: Eight RCTs (QoR-15, n = 4; QoR-40, n = 4) involving 653 patients published from 2018 to 2021 were included. For the QoR-40 scale, pooled results revealed a significantly higher total score (mean difference [MD], 12.8 [8.2%]; 95% confidence interval [CI], 10.6 to 14.9; I2 = 59%; five RCTs; n = 251) and scores on all subscales, except psychological support, in the PNB group than in controls at 24 hr after surgery. For the QoR-15 scale, pooled results also showed favorable QoR (MD, 7.7 [5.2%]; 95% CI, 4.9 to 10.5; I2 = 75%; four RCTs; n = 402) in the PNB group at 24 hr after surgery. Sensitivity analysis showed no effect on the QoR-40 score and the difference in total QoR-15 score was no longer significant when a single trial was omitted. The use of PNBs was associated with a significantly lower opioid consumption and risk of postoperative nausea and vomiting without significant differences in the pain score between the two groups. CONCLUSION: Our results verified the efficacy of PNBs for enhancing postoperative QoR using two validated patient-reported tools in female patients receiving breast cancer surgery under general anesthesia. STUDY REGISTRATION: PROSPERO (CRD42021272575); first submitted 9 August 2021.

RéSUMé: OBJECTIF: Cette revue systématique et méta-analyse a étudié l'impact des blocs nerveux périphériques (BNP) sur la qualité de récupération (QoR) rapportée par les patientes après une chirurgie du cancer du sein. SOURCES: Les bases de données Medline, EMBASE, Cochrane Library et Google Scholar ont été analysées pour en tirer les études randomisées contrôlées (ERC) comparant la QoR avec ou sans BNP chez les patientes bénéficiant d'une chirurgie de cancer du sein, de leur création jusqu'en septembre 2021. À l'aide d'un modèle à effets aléatoires, le critère d'évaluation principal était les scores totaux sur les échelles de QoR postopératoire (c.-à-d. QoR-15 et QoR-40). CONSTATATIONS PRINCIPALES: Huit ERC (QoR-15, n = 4; QoR-40, n = 4) impliquant 653 patientes publiées de 2018 à 2021 ont été incluses. Pour l'échelle QoR-40, les résultats regroupés ont révélé un score total (différence moyenne [DM], 12,8 [8,2 %]; intervalle de confiance [IC] à 95 %, 10,6 à 14,9; I2 = 59 %; cinq ECR; n = 251) et des scores sur toutes les sous-échelles significativement plus élevés, à l'exception du soutien psychologique, dans le groupe BNP que dans le groupe témoin 24 heures après la chirurgie. Pour l'échelle QoR-15, les résultats groupés ont également montré un QoR favorable (DM, 7,7 [5,2 %]; IC 95 %, 4,9 à 10,5; I2 = 75 %; quatre ECR; n = 402) dans le groupe BNP 24 heures après la chirurgie. L'analyse de sensibilité n'a montré aucun effet sur le score de QoR-40 et la différence dans le score total de QoR-15 n'était plus significative lorsqu'une seule étude était omise. L'utilisation de BNP a été associée à une consommation d'opioïdes significativement plus faible et à un risque de nausées et vomissements postopératoires sans différences significatives dans le score de douleur entre les deux groupes. CONCLUSION: Nos résultats ont confirmé l'efficacité des BNP pour améliorer la QoR postopératoire à l'aide de deux outils validés rapportés par les patientes recevant une chirurgie du cancer du sein sous anesthésie générale. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021272575); soumis pour la première fois le 9 août 2021.

Effect of Intraoperative Phrenic Nerve Infiltration on Postoperative Ipsilateral Shoulder Pain After Thoracic Surgeries: A Systematic Review and Meta-Analysis of Randomized Controlled Studies.

OBJECTIVES: This meta-analysis was aimed at investigating the effectiveness and safety of phrenic nerve infiltration (PNI) against ipsilateral shoulder pain (ISP) after thoracic surgery. DESIGN: A systematic review and meta-analysis of randomized controlled trials (RCTs). SETTING: Operating room. PARTICIPANTS: Patients undergoing thoracic surgery. INTERVENTIONS: PNI. MEASUREMENTS AND MAIN RESULTS: MEDLINE, Cochrane Library, and EMBASE databases were searched from inception through December 2021. The primary outcome was the overall incidence of ISP, with secondary outcomes including incidence and severity of ISP at postoperative 6, 24, and 48 hours. Six RCTs involving 482 patients undergoing thoracic surgery were included. Pooled results found a significantly lower incidence of overall ISP in patients with PNI (ie, 23.6%) compared to those without (ie, 53.2%; risk ratio: 0.46, 95% confidence interval: 0.34-0.61; I2 = 19%; 6 RCTs; n = 474; certainty of evidence = high). At postoperative 6, 24, and 48 hours, there was also a significantly lower incidence of ISP in the PNI group than in the control group (certainty of evidence for all outcomes = high). Besides, the severity of ISP was lower in the PNI group at 6 (certainty of evidence = moderate) and 24 hours (certainty of evidence = high), with insufficient data for analysis at 48 hours because of only 1 trial. CONCLUSION: This meta-analysis showed that PNI not only reduced the incidence but also improved the severity of ipsilateral shoulder pain after thoracic surgery with a prophylactic effect lasting up to 48 hours. The limited number of included studies warrants further research to support these findings.

Association between teeth loss and nasogastric tube feeding dependency in older adults from Taiwan: a retrospective cohort study.

BACKGROUND: To examine the association between teeth loss and nasogastric tube feeding dependency in older people. METHODS: The National Health Interview Survey (NHIS) 2005, 2009, and 2013 in Taiwan. Participants were selected by a multistage stratified sampling method and baseline characteristics, including socioeconomic status and health habits, were obtained by well-trained interviewers. The NHIS was linked with the National Health Insurance research database 2000-2016 and the National Deaths Dataset, which contains all the medical information of ambulatory and inpatient care. Cox regression was used to examine the association between the number of teeth lost and nasogastric tube feeding dependency. RESULTS: There were 6165 adults older than 65 years old enrolled in the analysis, with 2959 male (48%) and the mean (SD) age was 73.95(6.46) years old. The mean follow-up duration was 6.5(3.3) years. Regarding the teeth loss categories, 1660 (26.93%), 2123 (34.44%), and 2382 (38.64%) of participants were categorized as having no teeth loss, loss of 1-9 teeth, and loss of 10-28 teeth, respectively. During 39,962 person-years of follow-up, new-onset nasogastric feeding dependency was recognized in 220(13.25%), 256(12.06%), and 461(19.35%) participants who were categorized as having no teeth loss, loss of 1-9 teeth, and loss of 10-28 teeth, respectively. Kaplan-Meier curves demonstrated significant findings (Log-rank P < 0.01). After potential confounders were adjusted, compared with those without teeth loss, older adults who had lost 10-28 teeth had significantly increased risks of occurrence nasogastric feeding dependency (AHR, 1.31; 95% CI, 1.05-1.62; p-value = 0.02). Furthermore, a significant dose-response relation between the number of teeth lost and increased risk of nasogastric feeding was found (p for trend< 0.01). CONCLUSIONS: Older adults who had lost 10-28 teeth had a significantly increased risk of nasogastric tube feeding dependency. Early identification of the oral disease is crucial for the prevention of the occurrence of teeth loss and the following nutrition problems, which would reduce risk of nasogastric tube feeding dependency.

The effect of cricoid pressure on tracheal intubation in adult patients: a systematic review and meta-analysis.

PURPOSE: This meta-analysis aimed to assess the impact of cricoid pressure (CP) application on intubation outcomes. SOURCE: Electronic databases (i.e., MEDLINE, PubMed, Embase, and Cochrane review) were searched from inception to 2 June 2020 for randomized-controlled trials that assessed the intubation outcomes in adult patients using laryngoscopic approaches with and without the application of CP (i.e., CP vs non-CP group). The primary outcome was the successful first-attempt intubation rate (SFAIR), and the secondary outcomes were intubation time, incidences of poor laryngoscopic views (i.e., Cormack and Lehane grade 3-4), airway complications, and pulmonary aspiration. PRINCIPAL FINDINGS: A total of five trials (published from 2005 to 2018) were included, and all tracheal intubations were performed by anesthesiologists or nurse anesthetists with a video (n = 3) or Macintosh laryngoscope (n = 2) in the operating room. We found no significant difference in SFAIR (risk ratio [RR], 0.98; P = 0.37), incidence of poor laryngoscopic views (RR, 1.49; P = 0.21), and risk of sore throat (RR, 1.17; P = 0.73) between the two groups. Nevertheless, the intubation time on the first successful attempt was slightly longer (weighted mean difference = 4.40 sec, P = 0.002) and risk of hoarseness was higher (RR, 1.70; P = 0.03) in the CP group compared with in the non-CP group. The secondary outcome "pulmonary aspiration" was not analyzed because only one trial was available. CONCLUSION: The application of CP did not have a negative impact on the SFAIR or laryngoscopic view. Nevertheless, this maneuver may slightly prolong intubation time and increase the risk of postoperative hoarseness.

RéSUMé: OBJECTIF : Cette méta-analyse a pour but d'évaluer l'impact de l'application d'une pression cricoïdienne (PC) sur les résultats de l'intubation. SOURCE : Les bases de données électroniques (c.-à-d., MEDLINE, PubMed, Embase, et Cochrane review) ont été examinées de leur création jusqu'au 2 juin 2020 pour en tirer les études randomisées contrôlées évaluant les résultats d'intubation chez les patients adultes utilisant des approches laryngoscopiques avec ou sans application de PC (soit groupe PC et non-PC). Le critère d'évaluation principal était le taux d'intubations réussies à la première tentative, et les critères secondaires incluaient le temps d'intubation, l'incidence de mauvaises vues laryngoscopies (grades 3-4 de Cormack et Lehane), les complications au niveau des voies aériennes et l'aspiration pulmonaire. CONSTATATIONS PRINCIPALES : Cinq études au total (publiées entre 2005 et 2018) ont été incluses, et toutes les intubations trachéales ont été réalisées par des anesthésiologistes ou infirmiers anesthésistes à l'aide d'un vidéolaryngoscope (n = 3) ou d'une lame de Macintosh (n = 2) en salle d'opération. Nous n'avons trouvé aucune différence significative dans le taux d'intubations réussies à la première tentative (risque relatif [RR], 0,98; P = 0,37), dans l'incidence de mauvaises vues laryngoscopiques (RR, 1,49; P = 0,21) ou dans le risque de maux de gorge (RR, 1,17; P = 0,73) entre les deux groupes. En revanche, le temps d'intubation lors de la première tentative réussie était légèrement plus long (différence moyenne pondérée = 4,40 sec, P = 0,002) et le risque d'enrouement était plus élevé (RR, 1,70; P = 0,03) dans le groupe PC que dans le groupe non-PC. Le critère d'évaluation secondaire « aspiration pulmonaire ¼ n'a pas été analysé parce qu'une seule étude le mesurait. CONCLUSION : L'application de PC n'a pas eu d'impact négatif sur le taux d'intubations réussies à la première tentative ou la vue laryngoscopique. Par contre, cette manœuvre pourrait légèrement prolonger le temps d'intubation et augmenter le risque d'enrouement postopératoire.