Tranexamic acid for the prevention of blood loss after cesarean section: an updated systematic review and meta-analysis of randomized controlled trials

Objective: Tranexamic acid (TXA) is a cost-effective intervention for the prevention of postpartum hemorrhage (PPH) in women undergoing cesarean section but the evidence to support its use is conflicting. We conducted this meta-analysis to evaluate the efficacy and safety of TXA in low- and high-risk cesarean deliveries. Data sources: We searched MEDLINE (via PubMed), Embase, the Cochrane Library, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform (ICTRP) portal from inception to April 2022 (updated October 2022 and February 2023) with no language restrictions. Additionally, grey literature sources were also explored. Study eligibility criteria: All randomized controlled trials (RCTs) investigating the prophylactic use of intravenous TXA in addition to standard uterotonic agents in women undergoing cesarean deliveries as compared to placebo, standard treatment, or prostaglandins were included in this meta-analysis. Methods: We used the revised Cochrane "Risk of Bias" tool (RoB 2.0) to assess the quality of included RCTs. RevMan 5.4 was used to conduct all statistical analyses under a random-effects model. Results: We included 50 RCTs (6 in only high-risk patients and 2 with prostaglandins as the comparator) evaluating TXA in our meta-analysis. TXA reduced the risk of blood loss >1000 mL, mean total blood loss, and the need for blood transfusion in both low- and high-risk patients. TXA was associated with a beneficial effect in our secondary outcomes including decline in hemoglobin levels and the need for additional uterotonic agents. TXA increased the risk of non-thromboembolic adverse events but, based on limited data, did not increase the incidence of thromboembolic events. The administration of TXA before skin incision, but not after cord clamping, was associated with a large benefit. The quality of evidence was rated as low to very low for outcomes in the low-risk population and moderate for most outcomes in the high-risk subgroup. Conclusions: TXA may reduce the risk of blood loss in cesarean deliveries with a higher benefit observed in high-risk patients but the lack of high-quality evidence precludes any strong conclusions. Additional studies, especially in the high-risk population and evaluating the timing of TXA administration, are needed to confirm or refute these findings

Probiotics for the prevention of ventilator-associated pneumonia: an updated systematic review and meta-analysis of randomised controlled trials

Background: Presently, there is conflicting evidence regarding the efficacy of probiotics in the prevention of ventilator-associated pneumonia (VAP). This meta-analysis was conducted to update current clinical evidence and evaluate the efficacy and safety of probiotics for the prevention of VAP. Methods: We searched three databases and two trial registers to retrieve randomised controlled trials (RCTs) comparing probiotics or synbiotics with placebo or standard treatment for the prevention of VAP in adult patients receiving mechanical ventilation in the intensive care unit (ICU). Results: Our meta-analysis included 18 RCTs involving 4893 patients. Our results showed that probiotics may reduce the incidence of VAP (RR 0.68, 95% CI: 0.55–0.84; low certainty). However, in our subgroup and sensitivity analyses, the effect was not significant in double-blind studies, and in studies with a low risk of bias in the randomisation process. Probiotics reduced the length of ICU stay (MD −2.22 days, 95% CI: −4.17 to −0.28; moderate certainty) and the duration of antibiotic use (MD −1.25 days, 95% CI −1.86 to −0.64; moderate certainty). Conclusions: Probiotics may reduce the incidence of VAP but due to the low quality of pooled evidence, the use of probiotics warrants caution. Further, large-scale, high-quality RCTs need to be conducted to provide conclusive evidence

Efficacy and safety of corticosteroids for the treatment of community-acquired pneumonia: A systematic review and meta-analysis of randomized controlled trials

Background The role of corticosteroids in the treatment of community-acquired pneumonia (CAP) remains uncertain. We conducted an updated meta-analysis to investigate the effectiveness and potential effect modifiers of adjunctive corticosteroids in patients with CAP. Methods The protocol of this meta-analysis was registered with PROSPERO (CRD42022354920). We searched MEDLINE, Embase, the Cochrane Library and trial registers from inception till March 2023 to identify randomized controlled trials (RCTs) investigating corticosteroids in adult patients with CAP. Our primary outcome was the risk of all-cause mortality within 30 days after randomization (if not reported at day 30, we extracted the outcome closest to 30 days). Risk ratios (RR) and mean differences (MDs) were pooled under a random-effects model. Results Fifteen RCTs (n = 3252 patients) were included in this review. Corticosteroids reduced the risk of all-cause mortality in CAP patients (RR: 0.69, 95% CI: 0.53–0.89; high certainty). This significant result was restricted to hydrocortisone therapy and patients with severe CAP. Additionally, younger patients demonstrated a greater reduction in mortality. Corticosteroids reduced the incidence of shock and the need for mechanical ventilation (MV), and decreased the length of hospital and ICU stay (moderate certainty). Conclusions Corticosteroids reduce the risk of all-cause mortality, especially in younger patients receiving hydrocortisone, and probably decrease the need for MV, the incidence of shock, and the length of hospital and ICU stay in patients with CAP. Our findings indicate that patients with CAP, especially severe CAP, will benefit from adjunctive corticosteroid therapy

Role of a medical student neuro-society organized neurosurgical conference: the Glasgow neuro experience

Background: Entering neurosurgical training in the United Kingdom demands extensive prior commitment and achievement, despite little to no exposure to the specialty in medical school. Conferences run by student “neuro-societies” offer a means to bridge this gap. This paper describes one student-led neuro-society’s experience of curating a 1-day national neurosurgical conference supported by our neurosurgical department. Methods: A pre-and post-conference survey was distributed to attendees to ascertain baseline opinions and conference impact using a five-point Likert Scale, and free text questions explored medical students’ opinions of neurosurgery and neurosurgical training. The conference offered four lectures and three workshops; the latter provided practical skills and networking opportunities. There were also 11 posters displayed throughout the day. Results: 47 medical students participated in our study. Post-conference, participants were more likely to understand what a neurosurgical career involves and how to secure training. They also reported increased knowledge about neurosurgery research, electives, audits, and project opportunities. Respondents enjoyed the workshops provided and suggested the inclusion of more female speakers in future. Conclusion: Neurosurgical conferences organized by student neuro-societies successfully address the gap between a lack of neurosurgery exposure and a competitive training selection. These events give medical students an initial understanding of a neurosurgical career through lectures and practical workshops; attendees also gain insight into attaining relevant achievements and have an opportunity to present research. Student neuro-society-organized conferences have the potential to be adopted internationally and used as a tool to educate on a global level and greatly aid medical students who are aspiring neurosurgeons

Efficacy and Safety of Enteral Human Recombinant Insulin to Reduce the Time to Full Enteral Feeding in Preterm Infants: A Meta-Analytical Study

Recombinant human insulin plays an important role in the gut maturation of preterm infants. This meta-analysis was carried out to assess the efficacy and safety of enteral recombinant human insulin in decreasing the time to full enteral feeding in preterm infants. The pooling of data from four clinical trials yielded a significant decrease in the time to full enteral feeding in preterm infants under both low (Mean difference [MD] −3.43 days; 95% CI: −6.18 to −0.69 days; I2 = 48%) and high doses of insulin (MD −7.10 days; 95% CI: −10.02 to −4.18 days; I2 = 0%). These findings require confirmation by further large trials that evaluate the efficacy and safety of enteral insulin, especially at supraphysiological doses

Singapore's Dengue Outbreak Amidst the COVID-19 Pandemic: Challenges, Responses, and Lessons.

Dengue outbreaks have been documented in Singapore since 1901, occurring almost annually in the 1960s and disproportionately affecting the paediatric population. In January 2020, virological surveillance detected a shift from DENV-2, which was the previous dominant strain, to DENV-3. As of 20 September 2022, 27,283 cases have been reported in 2022. Singapore is currently also responding to the COVID-19 pandemic, overcoming another wave of infections with 281,977 cases recorded in the past two months as of 19 September 2022. While Singapore has adopted several policies and interventions to combat dengue, primarily through environmental control but also innovations such as the Wolbachia mosquito programme, there is a need for further efforts to deal with the dual threat of dengue and COVID-19. Drawing lessons from Singapore's experience, countries facing such dual epidemics should enact clear policy responses, including establishing a multisectoral dengue action committee and action plan prior to potential outbreaks. Key indicators should be agreed upon and tracked at all healthcare levels as part of dengue surveillance and incorporated into the national health information system. Digitizing dengue monitoring systems and implementing telemedicine solutions are innovative measures that would facilitate the response to dengue in the context of restrictions during the COVID-19 pandemic that hinder the detection and response to new cases. There is a need for greater international collaboration in reducing or eradicating dengue in endemic countries. Further research is also required on how best to establish integrated early warning systems and extend our knowledge of the effects of COVID-19 on dengue transmission in affected countries

Higher versus lower blood pressure targets after cardiac arrest: A meta-analysis of randomized controlled trials

A few mostly underpowered randomized controlled trials (RCTs) have been used to study the impact of blood pressure (BP) targets in out-of-hospital cardiac arrest (OHCA) patients. We aimed to perform an updated meta-analysis to compare the outcomes between the higher BP target and the lower BP target groups following OHCA. A systematic search was conducted on PubMed, Embase and the Cochrane Library until December 2022. We pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) using RevMan 5.4. Our search yielded four RCTs with a total of 1114 patients. Regarding our primary outcome of all-cause mortality, there was no significant difference between higher versus lower BP target goals in post-OHCA patients (OR 1.12, 95% CI: 0.86 to 1.45). Furthermore, there were no significant differences between the two groups in good neurological outcome, the incidence of arrhythmia, need for renal replacement therapy, and the levels of neuron-specific enolase at 48 h. The length of ICU stay of patients treated with the higher BP target was significantly lower but by a small margin. These findings do not support the use of a higher BP target but are subject to confirmation by large-scale RCTs investigating homogenous BP goals

Oxygen targets following cardiac arrest: A meta-analysis of randomized controlled trials

Introduction: The appropriate oxygen target post-resuscitation in out-of-hospital cardiac arrest (OHCA) patients is uncertain. We sought to compare lower versus higher oxygen targets in patients following OHCA. Methods: We searched MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov until January 2023 to include all randomized controlled trials (RCTs) that evaluated conservative vs. liberal oxygen therapy in OHCA patients. Our primary outcome was all-cause mortality at 90 days while our secondary outcomes were the level of neuron-specific enolase (NSE) at 48 h, ICU length of stay (LOS), and favorable neurological outcome (the proportion of patients with Cerebral Performance Category scores of 1–2 at end of follow-up). We used RevMan 5.4 to pool risk ratios (RRs) and mean differences (MDs). Results: Nine trials with 1971 patients were included in our review. There was no significant difference between the conservative and liberal oxygen target groups regarding the rate of all-cause mortality (RR 0.95, 95% CI: 0.80 to 1.13; I2 = 55%). There were no significant differences between the two groups when assessing favorable neurological outcome (RR 1.01, 95% CI: 0.92 to 1.10; I2 = 4%), NSE at 48 h (MD 0.04, 95% CI: −0.67 to 0.76; I2 = 0%), and ICU length of stay (MD −2.86 days, 95% CI: −8.00 to 2.29 days; I2 = 0%). Conclusions: Conservative oxygen therapy did not decrease mortality, improve neurologic recovery, or decrease ICU LOS as compared to a liberal oxygen regimen. Future large-scale RCTs comparing homogenous oxygen targets are needed to confirm these findings