scholarly journals LO92: The effect of prehospital intravenous fluids on mortality in trauma: a systematic review and meta-analysis

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S41-S41
Author(s):  
M. Davison ◽  
M. Schenk ◽  
R. Ohle ◽  
D. Savage ◽  
J. Scully ◽  
...  
Keyword(s):  
Relative Risk ◽  
Hospital Mortality ◽  
Fluid Therapy ◽  
Observational Studies ◽  
Significant Risk ◽  
Risk Of Bias ◽  
Fluid Volume ◽  
Trauma Patients ◽  
Rater Agreement ◽  
Summary Relative Risk

Introduction: Hemorrhage is the primary cause of death in 39% of trauma patients. In prehospital trauma management, there is debate over pursuing a ‘scoop-and-run’ approach versus early intravenous (IV) fluid therapy. We evaluated the literature regarding the effect of prehospital IV fluid therapy on mortality in adult trauma patients. Methods: A librarian-assisted search was conducted in PubMed, Medline and Embase. The population was adults with blunt and/or penetrating trauma. The intervention was total prehospital IV fluid volume 0-500 mL, and the control was prehospital fluid volume >500 mL. The outcome of interest was in-hospital mortality. Randomized controlled trials (RCTs), cohort and case-matched studies were included. Two reviewers used the Cochrane Risk of Bias (RoB) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tools to evaluate biases, and kappa was calculated for inter-rater agreement. A summary relative risk (RR) of in-hospital mortality was calculated and heterogeneity (I2) analysis performed using RevMan 5 software. Results: Four RCT's and eleven observational studies were identified, with n = 15,448 patients. Two RCTs and four observational studies were excluded due to non-English language, and the location or volume of IV fluid administered, leaving eight studies with n = 4,568 patients. Inter-rater agreement was high with the ROBINS-I (unweighted κ=0.8841) and RoB tool (unweighted κ=0.8276). Two studies found decreased mortality, one found increased mortality, and five found no significant relationship to mortality with 0-500 mL prehospital IV fluid. The summary relative risk of mortality with 0-500 mL IV fluid compared to >500 mL IV fluid was not significant (RR = 0.98 [0.87, 1.11]). The heterogeneity for all studies was high (I2 = 84%), but was low (I2 = 0%) with removal of two studies. Conclusion: The majority of studies did not find a relationship between the volume of prehospital IV fluids and in-hospital mortality. Study heterogeneity was low except for two studies: this may be explained by mortality only being recorded at emergency department discharge in one study, and the high rate of penetrating gunshot and stabbing wounds in the other. There is a paucity of high-quality RCTs on the topic, and many studies are at significant risk of bias. Further research is needed to delineate the best approach to IV fluid therapy in adult trauma patients.

scholarly journals Tocilizumab and Mortality in Hospitalised Patients with Covid-19. A Systematic Review Comparing Randomised Trials with Observational Studies

2021 ◽  
Vol 4 (4) ◽  
pp. 01-29
Author(s):  
Nawab Qizilbash ◽  
Bélène Podmore ◽  
Alessandra Lacetera ◽  
Itziar Ubillos ◽  
Kirsty Andresen ◽  
...  
Keyword(s):  
Relative Risk ◽  
Hospital Mortality ◽  
Observational Studies ◽  
Meta Analysis ◽  
Evidence Base ◽  
Risk Of Bias ◽  
Significant Heterogeneity ◽  
Moderate Risk ◽  
Relative Risks ◽  
Hospitalised Patients

Background: Early observational studies suggested that tocilizumab might produce clinical improvement in covid-19 patients leading to the use of tocilizumab. Early underpowered randomised controlled trials (RCTs) however did not show benefit until the most recent largest trial. RECOVERY trial. We aimed to compare the evidence from RCTs and observational studies of the effect of tocilizumab on in-hospital mortality in patients with covid-19. Materials and Methods: Embase and PubMed were searched from July 2020 until 1 March 2021. Observational studies and RCTs assessing in-hospital mortality in patients receiving tocilizumab compared with standard care or placebo were included. The primary outcome was in-hospital mortality closest to 30 days. The risk of bias in observational studies was assessed using the ROBINS-I tool. A fixed effect meta-analysis was used to combine relative risks, with random effects and risk of bias as a sensitivity analysis. Results: Of 5,792 publications screened for inclusion, eight RCTs and 33 observational studies were identified. The RCTs showed an overall relative risk reduction in in-hospital mortality at 30 days of 0.86 (95% confidence interval (CI) 0.78 to 0.96) with no statistically significant heterogeneity. 23 of the observational studies had a severe risk of bias, 10 of which did not adjust for potential confounders. The 10 observational studies with moderate risk of bias reported a larger reduction in mortality at 30-days (relative risk 0.72, 95% CI 0.64 to 0.81) but with significant heterogeneity (P<0.01). Conclusion: This meta-analysis provides strong evidence from RCTs that tocilizumab reduces the risk of mortality in hospitalised covid-19 patients. Observational studies with moderate risk of bias exaggerated the benefits on mortality two-fold and showed heterogeneity. Collectively observational studies provide a less reliable evidence base for evaluating treatments for covid-19.

scholarly journals Prevalence of Diabetes and Hypertension and Their Associated Risks for Poor Outcomes in Covid-19 Patients

2020 ◽  
Vol 4 (9) ◽  
Author(s):  
Francisco J Barrera ◽  
Skand Shekhar ◽  
Rachel Wurth ◽  
Pablo J Moreno-Pena ◽  
Oscar J Ponce ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Relative Risk ◽  
Intensive Care Unit Admission ◽  
Observational Studies ◽  
Risk Of Bias ◽  
Patients With Diabetes ◽  
Registration Number ◽  
Poor Outcomes ◽  
Study Participants

Abstract Coronavirus disease 2019 (Covid-19) has affected millions of people and may disproportionately affect those with hypertension and diabetes. Because of inadequate methods in published systematic reviews, the prevalence of diabetes and hypertension and associated risks of poor outcomes in Covid-19 patients are unknown. We searched databases from December 1, 2019, to April 6, 2020, and selected observational peer-reviewed studies in English of patients with Covid-19. Independent reviewers extracted data on study participants, interventions, and outcomes and assessed risk of bias, and the certainty of evidence. We included 65 (15 794 participants) observational studies at moderate to high risk of bias. Overall prevalence of diabetes and hypertension was 12% (95% confidence interval [CI], 10-15; n = 12 870; I2: 89%), and 17% (95% CI, 13-22; n = 12 709; I2: 95%), respectively. In severe Covid-19, the prevalence of diabetes and hypertension were 18% (95% CI, 16-20; n = 1099; I2: 0%) and 32% (95% CI, 16-54; n = 1078; I2: 63%), respectively. Unadjusted relative risk for intensive care unit admission and mortality were 1.96 (95% CI, 1.19-3.22; n = 8890; I2: 80%; P = .008) and 2.78 (95% CI, 1.39-5.58; n = 2058; I2: 75%; P = .0004) for diabetics; and 2.95 (95% CI, 2.18-3.99; n = 1737; I2: 0%; P &lt; .001) and 2.39 (95% CI, 1.54-3.73; n = 3107; I2: 66%; P &lt; .001) for hypertensives. Neither diabetes (1.50; 95% CI, 0.90-2.50; n = 1991; I2: 74%; P = .119) nor hypertension (1.48; 95% CI, 0.99-2.23; n = 2023; I2: 69%; P = .058) was associated with severe Covid-19. In conclusion, the risk of intensive care unit admission and mortality for patients with diabetes or hypertension who developed Covid-19 is increased compared with those without these comorbidities. PROSPERO registration number CRD42020176582.

scholarly journals Tocilizumab and mortality in hospitalised patients with covid-19. A systematic review comparing randomised trials with observational studies

2021 ◽  
Author(s):  
Bélène Podmore ◽  
Nawab Qizilbash ◽  
Alessandra Lacetera ◽  
Itziar Ubillos ◽  
Kirsty Andresen ◽  
...  
Keyword(s):  
Systematic Review ◽  
Hospital Mortality ◽  
Observational Studies ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Controlled Trials ◽  
Significant Heterogeneity ◽  
Moderate Risk ◽  
Randomised Controlled

Objective: To summarise and compare evidence from randomised controlled trials and observational studies of the effect of tocilizumab on in-hospital mortality in patients with covid-19. Design: Systematic review and meta-analysis. Data sources: Searches conducted in Embase and PubMed from July 2020 until 1 March 2021. Study Selection: Observational studies and randomised controlled trials (RCTs) assessing in-hospital mortality in patients receiving tocilizumab compared with standard care or placebo. Data extraction: The primary outcome was in-hospital mortality at 30 days. The risk of bias in observational studies was assessed using the ROBINS-I tool. A fixed effect meta-analysis was used to combine relative risks, with random effects and risk of bias as a sensitivity analysis. Results: Of 5,792 publications screened for inclusion, eight RCTs and 35 observational studies were identified. The RCTs showed an overall relative risk reduction in in-hospital mortality at 30 days of 0.86 (95% CI 0.78 to 0.96) with no statistically significant heterogeneity. 23 of the observational studies had a severe risk of bias, 10 of which did not adjust for potential confounders. The 10 observational studies with moderate risk of bias reported a larger reduction in mortality at 30-days (relative risk 0.72, 95% CI 0.64 to 0.81) but with significant heterogeneity (P<0.01). Conclusion: This meta-analysis provides strong evidence from RCTs that tocilizumab reduces the risk of mortality in hospitalised covid-19 patients. Observational studies with moderate risk of bias exaggerated the benefits on mortality two-fold and showed heterogeneity. Collectively observational studies provide a less reliable evidence base for evaluating treatments for covid-19.

A Multi-Institutional Analysis of Damage Control Laparotomy in Elderly Trauma Patients: Do Geriatric Trauma Protocols Matter?

2020 ◽  
Vol 86 (9) ◽  
pp. 1135-1143
Author(s):  
Alison Smith ◽  
Alexandra Onyiego ◽  
Juan Duchesne ◽  
Danielle Tatum ◽  
Charles Harris ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Multivariate Analyses ◽  
Damage Control ◽  
Significant Risk ◽  
Retrospective Chart Review ◽  
Geriatric Trauma ◽  
Trauma Patients ◽  
Trauma Centers ◽  
Damage Control Laparotomy ◽  
Elderly Trauma Patients

Background Trauma centers are receiving increasing numbers of older trauma patients. There is a lack of literature on the outcomes for elderly trauma patients who undergo damage control laparotomy (DCL). We hypothesized that trauma centers with geriatric protocols would have better outcomes in elderly patients after DCL. Methods A retrospective chart review of consecutive adult trauma patients with DCL at 8 level 1 trauma centers was conducted from 2012 to 2018. Patients aged 40 or older were included. Age ≥ 55 years was defined as elderly. Demographics, injury information, clinical outcomes, including mortality, and complications were recorded. Univariate and multivariate analyses were performed. Results A total of 379 patients with DCLs were identified with an average age of 54.8 ± 0.4 years with 39.3% (n = 149/379) of patients aged ≥ 55. Geriatric protocols or a consulting geriatric service was present at 37.5% (n = 3/8) of institutions. Age ≥ 55 was a significant risk factor for in-hospital mortality (OR 2, 95% CI 1.0-4.0, P = .04). Institutions without dedicated geriatric trauma protocols/services had higher overall in-hospital mortality on both univariate (57.9% vs 34.3%, P = .02) and multivariate analyses (OR 2.1, 95% CI 1.3-3.4, P < .001). Conclusions Surgical management of older trauma patients remains a challenge. Geriatric protocols or dedicated services were found to be associated with improved outcomes. Future efforts should focus on standardizing the availability of these resources at trauma centers.

scholarly journals Cannabis and its derivatives for the use of motor symptoms in Parkinson’s disease: a systematic review and meta-analysis

2021 ◽  
Vol 14 ◽  
pp. 175628642110185
Author(s):  
Susan J. Thanabalasingam ◽  
Brandan Ranjith ◽  
Robyn Jackson ◽  
Don Thiwanka Wijeratne
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Motor Function ◽  
Observational Studies ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Motor Symptom ◽  
Quality Data ◽  
Symptom Improvement ◽  
Motor Symptoms

Background: Recent changes to the legal status of cannabis across various countries have renewed interest in exploring its use in Parkinson’s disease (PD). The use of cannabinoids for alleviation of motor symptoms has been extensively explored in pre-clinical studies. Objective: We aim to systematically review and meta-analyze literature on the use of medical cannabis or its derivatives (MC) in PD patients to determine its effect on motor function and its safety profile. Methods: We reviewed and analyzed original, full-text randomized controlled trials (RCTs) and observational studies. Primary outcomes were change in motor function and dyskinesia. Secondary outcomes included adverse events and side effects. All studies were analyzed for risk of bias. Results: Fifteen studies, including six RCTs, were analyzed. Of these, 12/15 (80%) mention concomitant treatment with antiparkinsonian medications, most commonly levodopa. Primary outcomes were most often measured using the Unified Parkinson Disease Rating Scale (UPDRS) among RCTs and patient self-report of symptom improvement was widely used among observational studies. Most of the observational data lacking appropriate controls had effect estimates favoring the intervention. However, the controlled studies demonstrated no significant motor symptom improvement overall. The meta-analysis of three RCTs, including a total of 83 patients, did not demonstrate a statistically significant improvement in UPDRS III score variation (MD −0.21, 95% CI −4.15 to 3.72; p = 0.92) with MC use. Only one study reported statistically significant improvement in dyskinesia ( p < 0.05). The intervention was generally well tolerated. All RCTs had a high risk of bias. Conclusion: Although observational studies establish subjective symptom alleviation and interest in MC among PD patients, there is insufficient evidence to support its integration into clinical practice for motor symptom treatment. This is primarily due to lack of good quality data.

scholarly journals Efficacy of Miniscrew-Assisted Rapid Palatal Expansion (MARPE) in late adolescents and adults: a systematic review and meta-analysis

2021 ◽  
Author(s):  
Aldin Kapetanović ◽  
Christina I Theodorou ◽  
Stefaan J Bergé ◽  
Jan G J H Schols ◽  
Tong Xi
Keyword(s):  
Systematic Review ◽  
Success Rate ◽  
Observational Studies ◽  
Risk Of Bias ◽  
Late Adolescents ◽  
Maxillary Expansion ◽  
Palatal Expansion ◽  
Rapid Palatal Expansion ◽  
Adolescents And Adults ◽  
Maxillary Deficiency

Summary Background Miniscrew-Assisted Rapid Palatal Expansion (MARPE) is a non-surgical treatment for transverse maxillary deficiency. However, there is limited evidence concerning its efficacy. Objectives This systematic review aims to evaluate the efficacy of MARPE in late adolescents and adults by assessing success rate and skeletal and dental transverse maxillary expansion, as well as treatment duration, dental and periodontal side effects and soft tissue effects. Search methods Seven electronic databases were searched (MEDLINE, Embase, Cochrane Library, Web of Science, Scopus, ProQuest and ClinicalTrials.gov) without limitations in November 2020. Selection criteria Randomized and non-randomized clinical trials and observational studies on patients from the age of 16 onwards with transverse maxillary deficiency who were treated with MARPE and which included any of the predefined outcomes. Data collection and analysis Inclusion eligibility screening, data extraction and risk of bias assessment were performed independently in duplicate. When possible, exploratory meta-analyses of mean differences (MDs) with their 95% confidence intervals (CIs) were conducted, followed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis of the evidence quality. Results Eight articles were included: two prospective and six retrospective observational studies. One study had a moderate risk of bias, whereas seven studies had a serious risk of bias. GRADE quality of evidence was very low. MARPE showed a high success rate (mean: 92.5%; 95%CI: 88.7%–96.3%), resulting in a significant skeletal width increase (MD: 2.33 mm; 95%CI: 1.63 mm–3.03 mm) and dental intermolar width increase (MD: 6.55 mm; 95%CI: 5.50 mm–7.59 mm). A significant increase in dental tipping, a decrease in mean buccal bone thickness and buccal alveolar height, as well as nasal soft tissue change was present (P &lt; 0.05). The mean duration of expansion ranged from 20 to 126 days. Limitations One of the main drawbacks was the lack of high-quality prospective studies in the literature. Conclusions and implications MARPE is a treatment modality that is associated with a high success rate in skeletal and dental maxillary expansion. MARPE can induce dental and periodontal side effects and affect peri-oral soft tissues. Given the serious risk of bias of the included studies, careful data interpretation is necessary and future research of higher quality is strongly recommended. Registration PROSPERO (CRD42020176618). Funding No grants or any other support funding were received.

scholarly journals Outcomes of major trauma among patients with chronic kidney disease and receiving dialysis in Nova Scotia: a retrospective analysis

2021 ◽  
Vol 6 (1) ◽  
pp. e000672
Author(s):  
Ryan Pratt ◽  
Mete Erdogan ◽  
Robert Green ◽  
David Clark ◽  
Amanda Vinson ◽  
...  
Keyword(s):  
Chronic Kidney Disease ◽  
Nova Scotia ◽  
Kidney Disease ◽  
Hospital Mortality ◽  
Major Trauma ◽  
Injury Severity ◽  
Cox Regression ◽  
Trauma Patients ◽  
Risk Of Death ◽  
Increased Risk

BackgroundThe risk of death and complications after major trauma in patients with chronic kidney disease (CKD) is higher than in the general population, but whether this association holds true among Canadian trauma patients is unknown.ObjectivesTo characterize patients with CKD/receiving dialysis within a regional major trauma cohort and compare their outcomes with patients without CKD.MethodsAll major traumas requiring hospitalization between 2006 and 2017 were identified from a provincial trauma registry in Nova Scotia, Canada. Trauma patients with stage ≥3 CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2) or receiving dialysis were identified by cross-referencing two regional databases for nephrology clinics and dialysis treatments. The primary outcome was in-hospital mortality; secondary outcomes included hospital/intensive care unit (ICU) length of stay (LOS) and ventilator-days. Cox regression was used to adjust for the effects of patient characteristics on in-hospital mortality.ResultsIn total, 6237 trauma patients were identified, of whom 4997 lived within the regional nephrology catchment area. CKD/dialysis trauma patients (n=101; 28 on dialysis) were older than patients without CKD (n=4896), with higher rates of hypertension, diabetes, and cardiovascular disease, and had increased risk of in-hospital mortality (31% vs 11%, p<0.001). No differences were observed in injury severity, ICU LOS, or ventilator-days. After adjustment for age, sex, and injury severity, the HR for in-hospital mortality was 1.90 (95% CI 1.33 to 2.70) for CKD/dialysis compared with patients without CKD.ConclusionIndependent of injury severity, patients without CKD/dialysis have significantly increased risk of in-hospital mortality after major trauma.

Abstract P75: Cerebrovascular Events and Outcomes in Hospitalized Patients With Covid-19: The Society of Vascular and Interventional Neurology Multinational Registry

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
James E Siegler ◽  
Pere Portela ◽  
Juan F Arenillas ◽  
Alba Chavarria-Miranda ◽  
Ana Guillen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Mortality Rate ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
Cryptogenic Stroke ◽  
Significant Risk ◽  
Stroke Severity ◽  
Cerebrovascular Event ◽  
Cerebrovascular Events ◽  
Observational Cohort

Background: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. Aims: To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. Methods: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in 4 countries (2/1/2020 - 06/16/2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). Results: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970-1320/100,000), 68/171 (40.5%) of whom were female and 96/172 (55.8%) were between the ages 60-79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920-1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130 - 280/100,000) and 3 with CVST (0.02%; 20/100,000, 95%CI 4-60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p<0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63-15.44, p<0.01), older age (aOR 1.78, 95%CI 1.07-2.94, p=0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34-0.98 p=0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. Conclusions: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19 associated cerebrovascular complications, therefore aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.

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