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Rib fractures, common among trauma victims, lead to significant morbidity and mortality. Managing the associated pain is challenging, with IV opioids and thoracic epidural analgesia (TEA) being utilized. While epidural analgesia is often preferred for fractured rib pain, existing data encompasses both lumbar and thoracic approaches. This review aimed to compare TEA and IV opioids for persistent rib fracture pain. A comprehensive search across five databases yielded 987 articles, of which seven met the eligibility criteria. Outcomes were categorized into primary (pain reduction) and secondary (mortality, hospital/ICU stays, analgesia-related complications) endpoints. Analyzed with Review Manager (RevMan) Version 5.4.1 (2020; The Cochrane Collaboration, London, United Kingdom), the pooled data from two sources showed TEA significantly more effective in reducing pain than IV opioids (standardized mean difference (SMD): 2.23; 95%CI: 1.65-2.82; p < 0.00001). Similarly, TEA was associated with shorter ICU stays (SMD: 0.73; 95%CI: 0.33-1.13; p = 0.0004), while hospitalization duration showed no substantial difference (SMD: 0.82; 95%CI: -0.34-1.98). Mortality rates also did not significantly differ between TEA and IV opioids (risk ratio (RR): 1.20; 95%CI: 0.36-4.01; p = 0.77). Subgroup analysis revealed fewer pneumonia cases with TEA (RR: 2.06; 95%CI: 1.07-3.96; P = 0.03), with no notable disparities in other complications. While TEA's superiority in pain relief for rib fractures suggests it is the preferred analgesic, the recommendation's strength is tempered by the low methodological quality of supporting articles.
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The United Kingdom (UK) has a sustainable healthcare system. Nonetheless, the burden of acute coronary syndrome (ACS) is still a significant challenge. A scarcity of literature primarily focuses on the continuum of care for ACS patients in the UK. Moreover, limited research studies highlight the clinical trajectories of ACS patients across the UK. Therefore, the current study was designed to explore clinical trajectories and the continuum of care for patients with ACS in the UK. Secondary data was obtained from the Myocardial Ischaemia National Audit Project (MINAP) database. The latest data available in the MINAP database was used. As our objective was to explore clinical trajectories and the continuum of care for patients, we retrieved data regarding the care received by ACS patients admitted to hospitals across the UK. The data of 85574 ACS patients was retrieved. A large number (n=47035) of patients were estimated to be eligible for the angiogram; however, an angiogram was performed for 87.15% (n=40995) of eligible patients. Angioplasty within 72 hours of admission was required for most (n=26313) ACS patients. Nonetheless, angioplasty within 72 hours of admission was performed for 59.7% (n=15703) of the eligible patients. There was a significant difference (P<0.05) between different regions of the UK and the percentage of patients for whom angioplasty was performed within 72 hours of admission. Primary percutaneous coronary intervention (PCI) was performed for 23923 ACS patients, of which the door-to-balloon interval for 17590 (73.5%) patients was ≤60 minutes while the door-to-balloon interval for 3086 (12.9%) patients was ≤90 minutes. Out of the total 85574 ACS patients, 65959 (77.08%) patients were discharged on appropriate medications, while 19615 (22.92%) were transferred to another hospital or died there. A total of 75361 were eligible to be referred to cardiac rehabilitation settings. Nonetheless, 64518 (85.61%) were referred to cardiac rehabilitation. About 85000 patients were reported in the UK (England, Northern Ireland, Wales). Optimal care was provided to most patients in the UK. However, some patients received sub-optimal care, highlighting the disparity in the healthcare system. There is a need to explore further the factors that might be responsible for the sub-optimal care to the patients.
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High blood pressure (HBP) is usually prominent after the onset of acute ischemic stroke (AIS). Although previous studies have found that about half of patients with AIS have a background of hypertension, there is no clear etiology for HBP in AIS. The literature reveals discrepancies in the relationship between HBP and clinical outcomes of AIS, pointing toward the contested effect of blood pressure (BP) reduction clinical outcomes. Thus, the potential benefits and hazards of HBP treatment were explored in the context of clinical outcomes after AIS. An electronic database and a manual search were carried out to identify all the articles related to this topic and published between 2000 and January 2023. The Review Manager software was also used to perform the meta-analysis and quality appraisal. In analyses related to patients not treated with reperfusion therapies, mortality, and dependency outcomes were categorized as short-term (<3 months) or long-term (≥3 months). Our search strategy yielded 2459 articles, of which only 15 met the inclusion criteria. The results of our meta-analysis demonstrate that in patients not treated with reperfusion therapies, BP lowering had no significant impact on either short-term or long-term mortality (risk ratio (RR): 1.18; 95% confidence interval (CI): 0.81-1.73; p = 0.39, and RR: 1.04; 95% CI: 0.77-1.40; p = 0.81, respectively) and dependency (RR: 1.12; 95% CI: 0.97-1.30; p = 0.11, and RR: 0.98; 95% CI: 0.90-1.07; p = 0.61, respectively). Furthermore, BP lowering prior to reperfusion showed no significant effect on mortality (RR: 0.7; 95% CI: 0.23-2.26; p = 0.58), but it did significantly reduce the risk of dependency (RR: 0.89; 95% CI: 0.85-0.94; p < 0.00001). When the dataset was restricted to patients who had successful reperfusion, intensive BP lowering (target systolic BP <120 mmHg) was found to increase the risk of dependency (RR: 1.23; 95% CI: 1.09-1.39; p = 0.0009). In addition, BP reduction had an insignificant effect on the risk of recurrent strokes and combined vascular events (RR: 1.00; 95% CI: 0.54-1.84; p = 1.00, and RR: 0.99; 95% CI: 0.70-1.41; p = 0.95, respectively). Lowering BP in patients not treated with reperfusion therapies is not beneficial in reducing the risk of either short or long-term mortality and dependency. However, BPR before reperfusion reduces the risk of dependency, while aggressive BPR (target systolic blood pressure (SBP) <120 mmHg) after successful reperfusion increases the risk of dependency. Therefore, we recommend BPR as early as possible for patients undergoing reperfusion therapies but suggest against aggressive BPR in patients who have undergone successful reperfusion.
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Venous thromboembolism (VTE) is a condition often seen in patients diagnosed with cancer and is recognized as a predictor of poor outcomes in these patients. The probability of VTE recurring is generally higher in people with cancer than in those without; hence, addressing this issue is essential when making healthcare decisions. Therefore, our systematic review was primarily designed to compare low-weight- molecular heparin (LMWH) to warfarin in reducing recurrent VTE among cancer patients. However, other outcomes were also evaluated, such as mortality and bleeding events observed more in cancer patients. The selection of relevant articles was carried out using a database search and a manual search, which involved reviewing reference lists of articles eligible for inclusion in the current review. The methodological quality of each included study was then assessed using Cochrane's risk of bias tool in the Review Manager software (RevMan 5.4.1). Additionally, pooled results were examined using the Review Manager software and presented as forest plots. Our search of electronic databases elicited a total of 2163 articles, of which only six were deemed eligible for inclusion and analysis. Data pooled from the six studies demonstrated the effectiveness of LMWH in minimizing the reoccurrence of VTE over warfarin [risk ratio (RR): 0.67; 95% CI: 0.47 - 0.95; p = 0.03]. However, LMWH had a similar effect statistically as warfarin on the major bleeding events (RR: 1.05; 95% CI: 0.62 - 1.77; p = 0.85), minor bleeding events (RR: 0.80; 95% CI: 0.54 - 1.20; p = 0.28), and all-cause mortality (RR: 1.00; 95% CI: 0.88 - 1.13; p = 0.99). While LMWH demonstrated its effectiveness in minimizing the incidence of VTE recurrence over warfarin in cancer patients, it had no statistical difference in terms of mortality or bleeding events when compared to warfarin. Based on our findings, we recommend that LMWH continues to be used as a first-line treatment regimen to mitigate recurrent VTE in cancer patients.
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Since the 1940s, Macintosh laryngoscopy (Mac laryngoscopy) has been the gold standard for tracheal intubation, offering visualization of the glottis entrance. However, recent years have witnessed the emergence of various video laryngoscopy (VL) techniques. This systematic review and meta-analysis aims to assess the clinical outcomes of VL versus Mac laryngoscopy in an elective setting. We comprehensively searched five medical databases - PubMed, EMBASE, Medline, Cochrane Library, and Web of Science. All the databases were last searched in January 2023. We only included studies with full texts comparing VL to Mac laryngoscopy clinical outcomes. Studies were excluded if they were non-full text or non-randomized controlled trials (RCTs) and did not compare VL to Mac laryngoscopy. We extracted data comprising author names, publication year, key study outcomes (first-attempt intubation success rate, Cormack and Lehane grade, hypoxia incidence, and glottis view quality), video laryngoscope types, and sample sizes of both VL and Mac laryngoscopy groups. The Cochrane risk of bias tool was used to assess the risk of bias in the included studies. Statistical analysis was performed using Review Manager (RevMan, version 5.4; Cochrane Collaboration, London, UK), presenting results as odds ratio (OR) and risk ratios (RR) at a 95% confidence interval (CI). This facilitated the identification of relevant and appropriate studies of our analysis. The search produced 19 studies that were included in this review. The evaluated sample size ranges from 40 to 802, with 3,238 participants. The rate of success at the first attempt in the use of VL was 1,558/1,890 (82.43%), while the success rate for Mac laryngoscopy was 982/1,348 (72.85%; OR: 1.98 (1.25, 3.12)) at a 95% confidence interval. Pooled analysis indicated no significant difference for hypoxia concerning the type of device used RR (random effects: 1.02; 95% CI: 0.80-1.29). A video laryngoscope had a higher likelihood of visualizing the vocal cords categorized as category 1 in the Cormack-Lehane system of classification (RR: 2.45; 95% CI: 1.43-4.21). Additionally, considerably better glottis views were attained during VL than Mac laryngoscopy (OR: 1.77; 95% CI: 1.19-2.62). In elective tracheal intubation, VL demonstrates superior first-attempt success rates, offers improved glottis visualization, and reduces instances where the glottis cannot be viewed compared to Mac laryngoscopy.
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Diabetes mellitus (DM) is a global epidemic causing significant morbidity and mortality. The most occurring DM is type 2 diabetes mellitus (T2DM) which has similar symptoms as type 1 diabetes mellitus (T1DM). However, it is less marked, making it difficult to diagnose during the early stages. The management of T2DM is usually based on weight and glycemic control, which can be achieved through dietary interventions such as intermittent fasting (IF) and the ketogenic diet (KD). Therefore, this systematic review and meta-analysis aim to demonstrate the role of IF and KD in glycemic and weight control among patients with T2DM. Two methods, including an electronic database search through ScienceDirect, Google Scholar, PubMed, Scopus, Embase, and Web of Science, and a manual search were used to identify relevant studies published between 2000 and 2022. The search yielded 1299 articles, of which only 12 met the inclusion criteria. In addition, study quality appraisal was performed using Review Manager software (RevMan 5.4.1). The pooled results have shown that IF had a similar effect on HBA1c reduction as control interventions (standardized mean differences [SMD]: 0.36%; 95% CI; -0.37, 1.10; P = 0.33, I2 = 87%). Similarly, an insignificant difference in weight reduction between IF and control interventions was recorded (SMD: -1.05%; 95% CI; -2.29, 0.19; P = 0.10, I2 = 96%). On the other hand, KD significantly reduced body weight compared with control diets (SMD: -1.91 kg; 95% CI; -2.96 kg, -0.85 kg; P = 0.0004, I2 = 96%). Similarly, KD had a better effect on the HBA1c percentage reduction than control diets (SMD: -2.00%; 95% CI; -3.76, -0.25; P = 0.03, I2 = 97%). IF and KD have shown reductions in HBA1c and body weight among patients with T2DM. However, the interventions are subject to side effects and should be used with caution and under the supervision of a health professional.
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Carpal tunnel syndrome (CTS) is the most common upper extremity neuropathy. The disease initially manifests as a sensory disorder in the form of paresthesia, numbness, or tingling of the fingers. The diagnosis is usually made based on history and clinical symptoms, which are confirmed using nerve conduction studies (NCS) and electromyography. More recently, ultrasound has gained more use in CTS diagnosis due to its advantages, which include patients' comfort during diagnosis, better visualization of anatomy and nerve forms directly, and cost-effectiveness. However, a literature review shows that the diagnostic accuracy of ultrasound over NCS is still in question; therefore, the present systematic review was carried out to compare the diagnostic accuracy of ultrasound to NCS and electromyography. A systematic literature search was performed on five electronic databases: PubMed, Medline, Web of Science, Embase, and Google Scholar. The search strategy limited the retrieval of literature published between 2000 and 2022. Of the 1098 articles retrieved from the electronic databases, only 12 met the inclusion criteria. A meta-analysis of outcomes from the included studies showed that the pooled sensitivity and specificity of the ultrasound were 0.80 (95% CI: 0.73, 0.88) and 0.90 (0.83, 0.96), respectively. On the other hand, combing the outcomes of electromyography and NCS resulted in sensitivity and specificity values of 0.89 (95% CI: 0.84, 0.95) and 0.77 (95% CI; 0.64, 0.90), respectively. The results show that ultrasound has comparable sensitivity and slightly higher specificity than NCS and electromyography; therefore, ultrasound can be used as an alternative diagnostic test for CTS. However, it cannot replace NCS and electromyography since more research needs to be done on doubtful and secondary cases of CTS.
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Procedural sedation and analgesia (PSA) is a treatment approach involving treating patients with agents with dissociative, sedative, or analgesic properties to suppress their consciousness to variable levels. Ketamine and propofol have been used historically for PSA. Because they each have their demerits, it was postulated that combining both drugs (ketofol) would result in a mixture with additive properties and lessen or eliminate the demerits attributed to each drug. The primary objective of this systematic review and meta-analysis is to compare ketamine alone and a combination of ketamine and propofol (ketofol) for procedural sedation and analgesia from an emergency perspective. A systematic search was conducted on published studies from the databases of Scopus, ScienceDirect, PubMed, Google Scholar, APA PsycInfo, and the Cochrane Central Register of Controlled Trial (CENTRAL) until July 2022. The articles that were published on the online databases were authored between January 2007 and 2018. The selected papers were scanned and examined to check whether they met the eligibility criteria for the study. The search produced six articles that were included in the systematic review and meta-analysis. All six articles that passed the eligibility criteria were viable for the analysis. All the trials focused on the effectiveness of ketofol versus ketamine for PSA from an emergency perspective. Ketofol was found to be safe and more effective in comparison to ketamine for PTA.
