Efficacy of Rectal Misoprostol versus Oxytocin on Reducing Blood Loss during Cesarean Section: A Meta-Analysis of Randomized Clinical Trials

Introduction: Blood loss is an inevitable complication and a major contributor to maternal morbidity and mortality at cesarean deliveries. Several trials have investigated the of using Misoprostol to prevent hemorrhage-related complications in women undergoing cesarean section. Objective: We aimed to detect a potential preference regarding the efficacy and safety of rectal Misoprostol over Oxytocin as a uterotonic agent. Methods: We searched PubMed, Scopus, Web of Science, Cochrane, and other databases for the relevant trials from inception to September 2022. We included randomized clinical trials (RCTs) that compared rectal Misoprostol versus Oxytocin to control bleeding in women undergoing cesarean delivery. Our primary outcomes were the intra- and postoperative blood loss, and hemoglobin drop after delivery. Secondary outcomes included need for blood transfusion, need for additional uterotonics, difference in operative time, as well as safety outcomes such as the incidence of shivering, pyrexia, nausea, and vomiting. Results: Our search strategy revealed 1007 unique records, of them we retrieved full texts of 19 articles to check their adherence to our eligibility criteria. Nine RCTs with 1490 participants were included. We found a significant reduction in postoperative blood loss (MD: -27.9 mL; 95% CI: -53.8, -2.1, p = 0.03), and Hb drop after delivery (MD: 0.11 mg/dl, 95% CI: 0.04, 0.19, p = 0.003). There is no significant difference regarding intraoperative blood loss, operative time, need for blood transfusion, or need for additional uterotonics. We could not find a significant difference between the 2 groups regarding safety outcomes except for a higher shivering incidence in Misoprostol group (RR: 2.99; 95% CI: 1.69, 5.29, p = 0.002). Conclusion: We found a significant reduction in postoperative blood loss with a potential favorable safety profile in women who administrated rectal Misoprostol compared to Oxytocin administration. Our findings recommend and prefer rectal Misoprostol as a cheaper and effective uterotonic agent over Oxytocin which is expensive and require adequate cold chain for transportation and storage

Studying the Role of Cerebrovascular Changes in Different Compartments in Human Brains in Hypertension Prediction

Hypertension is a major cause of mortality of millions of people worldwide. Cerebral vascular changes are clinically observed to precede the onset of hypertension. The early detection and quantification of these cerebral changes would help greatly in the early prediction of the disease. Hence, preparing appropriate medical plans to avoid the disease and mitigate any adverse events. This study aims to investigate whether studying the cerebral changes in specific regions of human brains (specifically, the anterior, and the posterior compartments) separately, would increase the accuracy of hypertension prediction compared to studying the vascular changes occurring over the entire brain’s vasculature. This was achieved by proposing a computer-aided diagnosis system (CAD) to predict hypertension based on cerebral vascular changes that occur at the anterior compartment, the posterior compartment, and the whole brain separately, and comparing corresponding prediction accuracy. The proposed CAD system works in the following sequence: (1) an MRA dataset of 72 subjects was preprocessed to enhance MRA image quality, increase homogeneity, and remove noise artifacts. (2) each MRA scan was then segmented using an automatic adaptive local segmentation algorithm. (3) the segmented vascular tree was then processed to extract and quantify hypertension descriptive vascular features (blood vessels’ diameters and tortuosity indices) the change of which has been recorded over the time span of the 2-year study. (4) a classification module used these descriptive features along with corresponding differences in blood pressure readings for each subject, to analyze the accuracy of predicting hypertension by examining vascular changes in the anterior, the posterior, and the whole brain separately. Experimental results presented evidence that studying the vascular changes that take place in specific regions of the brain, specifically the anterior compartment reported promising accuracy percentages of up to 90%. However, studying the vascular changes occurring over the entire brain still achieve the best accuracy (of up to 100%) in hypertension prediction compared to studying specific compartments

Local Revenue Development in Egypt / الإيرادات المحلية في مصر

Local administration in Egypt faces several challenges that hinder fulfilling its responsibilities towards citizens sufficiently. The main challenges are the lack of financial resources due to over-regulation as well as the non-enforcement of laws and regulations that allow the local administration to collect its own tax share, the local administration staff’s lack of skills to manage and develop revenue sources, and lack of accountability mechanisms. This policy paper seeks to propose policies to aid the local administration in increasing its financial resources. In this paper, the authors depended on desk research as well as interviews held with officials from the Ministry of Finance and the Ministry of Local Development. Based on the information gathered, the authors proposed three policy options. Finally, they selected the “Local Non-Tax Revenue Mobilization” policy option based on the evaluation criteria and provided recommendations for this policy’s successful implementation

Identification of potential transcription factors that enhance human iPSC generation

Although many factors have been identified and used to enhance the iPSC reprogramming process, its efficiency remains quite low. In addition, reprogramming efficacy has been evidenced to be affected by disease mutations that are present in patient samples. In this study, using RNA-seq platform we have identified and validated the differential gene expression of five transcription factors (TFs) (GBX2, NANOGP8, SP8, PEG3, and ZIC1) that were associated with a remarkable increase in the number of iPSC colonies generated from a patient with Parkinson's disease. We have applied different bioinformatics tools (Gene ontology, protein–protein interaction, and signaling pathways analyses) to investigate the possible roles of these TFs in pluripotency and developmental process. Interestingly, GBX2, NANOGP8, SP8, PEG3, and ZIC1 were found to play a role in maintaining pluripotency, regulating self-renewal stages, and interacting with other factors that are involved in pluripotency regulation including OCT4, SOX2, NANOG, and KLF4. Therefore, the TFs identified in this study could be used as additional transcription factors that enhance reprogramming efficiency to boost iPSC generation technology.This study was supported by QBRI internal grant (QB16) and the Qatar University Student grant (QUST-2-CMED-2019-1)

A meta-review of meta-analyses and an updated meta-analysis on the efficacy of chloroquine and hydroxychloroquine in treating COVID19 infection

Objective: To synthesize the findings presented in systematic reviews and meta-analyses as well as to update the evidence using a meta-analysis in evaluating the efficacy and safety of CQ and HCQ with or without Azithromycin for the treatment of COVID19 infection.Methods: The design of this meta-review followed the Preferred Reporting Items for Overviews of Systematic Reviews including harms checklist (PRIO-harms). A comprehensive search included several electronic databases in identifying all systematic reviews and metaanalyses as well as experimental studies which investigated the efficacy and safety of CQ, HCQ with or without antibiotics as COVID19 treatment. Findings from the systematic reviews and meta-analyses were reported using a structured summary including tables and forest plots. The updated meta-analysis of experimental studies was carried out using the distributional assumption-free quality effects model. Risk of bias was assessed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool for reviews and the MethodologicAl STandard for Epidemiological Research (MASTER) scale for the experimental studies. The main outcome for both the meta-review and the updated meta-analysis was mortality. Secondary outcomes included transfer to the intensive care unit (ICU) or mechanical ventilation, worsening of illness, viral clearance and the occurrence of adverse events. Results: A total of 13 reviews with 40 primary studies comprising 113,000 participants were included. Most of the primary studies were observational (n=27) and the rest were experimental studies. Two meta-analyses reported a high risk of mortality with similar ORs of 2.5 for HCQ with Azithromycin. However, four other meta-analyses reported contradictory results with two reporting a high risk of mortality and the other two reporting no significant association between HCQ with mortality. Most reviews reported that HCQ with or without Azithromycin had no significant effect on virological cure, disease exacerbation or the risk of transfer to the ICU, need for intubation or mechanical ventilation. After exclusion of studies that did not meet the eligibility criteria, the updated meta-analysis contained eight experimental studies (7 RCTs and 1 quasiexperimental trial), with a total of 5279 participants of whom 1856 were on either CQ/HCQ or combined with Azithromycin. CQ/HCQ with or without Azithromycin was significantly associated with a higher risk of adverse events. HCQ was not effective in reducing mortality transfer to the ICU, intubation or need for mechanical ventilation virological cure (RR 1.0, 95%CI 0.9-1.2, I2 =55%, n=5 studies) nor disease exacerbation (RR 1.2, 95%CI 0.3-5.0, I2 =29%, n=3 studies). Conclusion: There is conclusive evidence that CQ and HCQ, with or without Azithromycin are not effective in treating COVID-19 or its exacerbation

Prevalence and global trends of polypharmacy among people living with HIV: a systematic review and meta-analysis

Background: There has been a rising prevalence of polypharmacy among people living with HIV (PLWH). Uncertainty however remains regarding the exact estimates of polypharmacy among these cohorts of patients. Methods: We conducted a systematic search of PubMed; EMBASE, CROI, Cochrane Database of Systematic Reviews; Science Citation Index and Database of Abstracts of Reviews of Effects for studies between 1 January 2000 and 30 June 2021 that reported on the prevalence of polypharmacy (ingestion of > 5 non-ART medications) among PLWH on antiretroviral therapy regimen (ART). Prevalence of polypharmacy among HIV-positive patients on ART with Clopper–Pearson 95% confidence intervals were presented. The heterogeneity between studies was evaluated using (Formula presented.) and (Formula presented.) statistics. Results: One hundred ninety-seven studies were initially identified, 23 met the inclusion criteria enrolling 55,988 PLWH, of which 76.7% [95% confidence interval (CI): 76.4–77.1] were male. The overall pooled prevalence of polypharmacy among PLWH was 33% (95% CI: 25–42%) (I2 = 100%, τ2 = 0.9170, p < 0.0001). Prevalence of polypharmacy is higher in the Americas (44%, 95% CI: 27–63%) (I2 = 100%, τ2 = 1.0886, p < 0.01) than Europe (29%, 95% CI: 20–40%) (I2 = 100%, τ2 = 0.7944, p < 0.01). Conclusion: The pooled prevalence estimates from this synthesis established that polypharmacy is a significant and rising problem among PLWH. The exact interventions that are likely to significantly mitigate its effect remain uncertain and will need exploration by future prospective and systematic studies. Registration: PROSPERO: CRD42020170071 Plain Language Summary: Background: In people living with HIV (PLWH), what is the prevalence of polypharmacy and is this influenced by sociodemographic factors? Methods and Results: In this systematic review and meta-analysis of 23 studies comprising 55,988 participants, we have for the first time found an estimated polypharmacy pooled prevalence of 33% among PLWH. There was a relatively higher pooled prevalence of polypharmacy among the America’s compared with European cohorts of PLWH. Conclusion: Polypharmacy among PLWH is a rising morbidity that needs urgent intervention both at policy and patient levels of care.This research was supported by the Qatar National Library

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Concurrent Oral 1 - Therapy of rheumatic disease: OP4. Effectiveness of Rituximab in Rheumatoid Arthritis: Results from the British Society for Rheumatology Biologics Register (BSRBR)

Background: Rituximab (RTX) in combination with methotrexate (MTX) has been licensed since 2006 for the management of severe active rheumatoid arthritis (RA) in patients who have failed at least one anti-tumour necrosis factor (anti-TNF) therapy. Published clinical trials have demonstrated the efficacy of RTX in improving both clinical symptoms and patients' physical function. This study aimed to assess the effectiveness of RTX in RA patients treated in routine clinical practice by examining clinical and patient reported outcomes six months after receiving a first course of RTX. Methods: The analysis involved 550 RA patients registered with the BSRBR, who were starting RTX and were followed up for at least 6 months. Change in Disease Activity Score (DAS28) and European League Against Rheumatism (EULAR) response were used to assess the clinical response while change in Health Assessment Questionnaire (HAQ) score was used to assess the physical function of the patients 6 months after starting RTX. The change in DAS28 and HAQ was compared between seronegative and seropositive patients and anti-TNF naïve patients versus anti-TNF failures. The response was also compared between patients receiving RTX in combination with MTX, other non-biologic disease modifying anti-rheumatic drugs (nbDMARDs) or no nbDMARDs. Results: The mean (s.d.) age of the cohort was 59 (12) years and 78% of the patients were females. The patients had a mean (s.d.) of 15 (10) years of disease duration. 16% were biologic naïve while 84% were anti-TNF failures. 32% of the patients were seronegative and 68% were seropositive. The mean (95% CI) DAS28 at baseline was 6.2 (6.1, 6.3) which decreased to 4.8 (4.7, 4.9) at 6 months of follow up. 16% were EULAR good responders, 43% were moderate responders and 41% were non responders. The mean (95% CI) change in HAQ was −0.1 (−0.2, −0.1) (Table 1). The mean change in DAS28 was similar in seropositive and seronegative patients (p = 0.18) while the anti-TNF naïve patients showed a greater reduction in DAS28 scores than anti-TNF failures (p = 0.05). Patients receiving RTX in combination with MTX showed similar changes in DAS28 and HAQ compared to patients receiving RTX alone or with other nbDMARDs. Conclusions: RTX has proven to be effective in the routine clinical practice. Anti-TNF naïve patients seem to benefit more from RTX treatment than anti-TNF failures. Disclosure statement: The authors have declared no conflicts of interes

Multi-ethnic genome-wide association study for atrial fibrillation

Atrial fibrillation (AF) affects more than 33 million individuals worldwide and has a complex heritability. We conducted the largest meta-analysis of genome-wide association studies (GWAS) for AF to date, consisting of more than half a million individuals, including 65,446 with AF. In total, we identified 97 loci significantly associated with AF, including 67 that were novel in a combined-ancestry analysis, and 3 that were novel in a European-specific analysis. We sought to identify AF-associated genes at the GWAS loci by performing RNA-sequencing and expression quantitative trait locus analyses in 101 left atrial samples, the most relevant tissue for AF. We also performed transcriptome-wide analyses that identified 57 AF-associated genes, 42 of which overlap with GWAS loci. The identified loci implicate genes enriched within cardiac developmental, electrophysiological, contractile and structural pathways. These results extend our understanding of the biological pathways underlying AF and may facilitate the development of therapeutics for AF