Comparison of Various Pharmacologic Agents in the Management of Hemodynamically Significant Patent Ductus Arteriosus in Preterm: A Network Meta-Analysis and Risk-Benefit Analysis.

Introduction: Various pharmacological treatments are available for preterm infants with patent ductus arteriosus (PDA), but their risks and benefits are controversial. This study aimed to identify the best treatment for PDA using network meta-analysis (NMA) and risk-benefit assessment (RBA). Methods: Relevant randomized controlled trials (RCTs) were identified from MEDLINE, Scopus, and the Cochrane Library. RCTs were eligible if they were studied for preterm or low birth weight infants with presymptomatic PDA and hemodynamically significant PDA (hsPDA). The outcomes were PDA closure for a benefit and the composite risk outcome of adverse effects (AEs) for risk. An NMA was used to estimate the treatment effects of benefit and risk. The RBA helped to incorporate the risk and benefits of multiple treatments. Then, an incremental risk-benefit ratio was calculated by dividing the incremental risk by benefit using data from NMA, and they were jointly simulated using Monte Carlo methods. Finally, net clinical benefit (NCB) probability curves were constructed at varying acceptability thresholds. Results: Seventy RCTs with hsPDA were eligible considering 13 different interventions, but data on presymptomatic PDA were not enough for pooling. The clustered ranking plot from NMA indicated that 3 interventions (i.e., high-dose oral ibuprofen, standard-dose oral acetaminophen, and standard-dose oral ibuprofen) yielded high PDA closure and low AE. These three treatments and additional commonly used indomethacin were considered in the RBA. Given an acceptable threshold of 25% or having one AE out of four PDA closures, high-dose oral ibuprofen had a 36% chance of having the highest NCB, followed by standard-dose oral acetaminophen (27%), and oral ibuprofen (23.7%). Subgroup analysis indicated that the chances of having the highest NCB of GA ≥28 weeks were similar to that of all available studies. The best for GA <28 weeks, no data for high-dose oral ibuprofen, was standard-dose oral acetaminophen, followed by standard-dose oral ibuprofen. Conclusions: Trade-off RBA indicated that high-dose oral ibuprofen might be the best treatment for preterm, GA ≥28 weeks, with hsPDA followed by the standard-dose oral acetaminophen and ibuprofen. Preferably, optimal high doses, postnatal age to start treatment, and long-term outcomes are needed to study in the future.

Concomitant rapidly progressive glomerulonephritis and acute rheumatic fever after streptococcus infection: a case report.

Acute post-streptococcal glomerulonephritis (APSGN) and acute rheumatic fever (ARF) are common immune-mediated complications after group A streptococcus (GAS) infection. The causative antigenic epitopes on GAS are different for APSGN and ARF, and their simultaneous occurrence is uncommon. A 12-year-old boy presented with fever and gross haematuria. He had subcutaneous nodules on the dorsum of both feet along with a new holosystolic murmur at the apex, and he developed hypertension and generalised oedema after admission. Investigation confirmed the diagnosis of ARF with APSGN. He received a corticosteroid to control inflammation of both the conditions. His clinical signs gradually improved but he still had rheumatic heart disease. As both diseases can occur in the same patient, treatment should be provided for both conditions.Abbreviations: APSGN: acute post-streptococcal glomerulonephritis; ARF: acute rheumatic fever; ASO: antistreptolysin O; Cr: serum creatinine; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; GAS: group A streptococcus; RBC: red blood cells; RPGN: rapidly progressive glomerulonephritis; S1: first heart sound; S2: second heart sound; TTE: transthoracic echocardiogram.

The association of serum magnesium and mortality outcomes in heart failure patients: A systematic review and meta-analysis.

BACKGROUND: Low serum magnesium (Mg) has been independently shown to increase risk of heart failure (HF), but data on the association between serum Mg concentration and the outcome of patients with HF are conflicting. The purpose of this systematic review and meta-analysis was to estimate the prognostic effects of hypermagnesemia and hypomagnesemia on cardiovascular (CV) mortality and all-cause mortality (ACM) of patients with HF. METHODS: Relevant studies were identified from Medline and Scopus databases. Included and excluded criteria were defined. Effects (i.e., log [risk ratio [RR]]) of hypomagnesemia and hypermagnesemia versus normomagnesemia were estimated using Poisson regression, and then a multivariate meta-analysis was applied for pooling RRs across studies. Heterogeneity was explored using a meta-regression and subgroup analysis. RESULTS: On analysis, 7 eligible prospective studies yielded a total of 5172 chronic HF patients with 913 and 1438 deaths from CV and ACM, respectively. Most participants were elderly men with left ventricular (LV) ejection fraction ≤40%. Those patients with baseline hypermagnesemia had a significantly higher risk of CV mortality (RR, 1.38; 95% confidence interval [CI], 1.07-1.78) or ACM (RR, 1.35; 95% CI, 1.18-1.54) than those with baseline normomagnesemia. However, baseline hypomagnesemia was not associated with the risk of CV mortality (RR, 1.11; 95% CI, 0.79-1.57) and ACM (RR, 1.11; 95% CI, 0.87-1.41). A subgroup analysis by Mg cutoff suggested a dose-response trend for hypermagnesemia effects, that is, the pooled RRs for CV mortality were 1.28 (95% CI, 1.05-1.55) and 1.92 (95% CI, 1.00-3.68) for the cutoff of 0.89 to 1.00 and 1.05 to 1.70 mmol/L, respectively. CONCLUSION: The present systematic review and meta-analysis suggested that, in HF patients, hypermagnesemia with serum Mg ≥ 1.05 mmol/L was associated with an increased risk of CV mortality and ACM but this was not observed for hypomagnesemia. This finding was limited to the elderly patients with chronic HF who had reduced LV systolic function.