The efficacy of non-pharmacological and non-pacing therapies in preventing vasovagal syncope: Tilt training, physical counter pressure maneuvers, and yoga - A systematic review and meta-analysis

BACKGROUND

Vasovagal syncope (VVS) is a prevalent condition characterized by a sudden drop in blood pressure and heart rate, leading to a brief loss of consciousness and postural control. Recurrent episodes of VVS significantly impact the quality of life and are a common reason for emergency department visits. Non-pharmacological interventions, such as tilt training, physical counter pressure maneuvers, and yoga, have been proposed as potential treatments for VVS. However, their efficacy in preventing VVS remains uncertain.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. PubMed, Web of Science, and Embase were searched up to March 2023 for randomized controlled trials comparing non-pharmacological interventions with control in preventing VVS recurrence. The primary outcome was the recurrence rate of VVS episodes.

RESULTS

A total of 1130 participants from 18 studies were included in the meta-analysis. The overall mean effect size for non-pharmacological interventions versus control was 0.245 (95 % CI: 0.128-0.471, p-value <0.001). Subgroup analysis showed that yoga had the largest effect size (odds ratio 0.068, 95 % CI: 0.018-0.250), while tilt training had the lowest effect size (odds ratio 0.402, 95 % CI: 0.171-0.946) compared to control. Physical counter pressure maneuvers demonstrated an odds ratio of 0.294 (95 % CI: 0.165-0.524) compared to control.

CONCLUSION

Non-pharmacological interventions show promise in preventing recurrent VVS episodes. Yoga, physical counter pressure maneuvers, and tilt training can be considered as viable treatment options. Further research, including randomized studies comparing pharmacological and non-pharmacological approaches, is needed to evaluate the safety and efficacy of these interventions for VVS treatment.

Comparison of Artificial Intelligence With Other Interventions to Improve Adenoma Detection Rate for Colonoscopy: A Network Meta-analysis

INTRODUCTION

Recent randomized controlled trials (RCTs) and meta-analysis have demonstrated improved adenoma detection rate (ADR) for colonoscopy with artificial intelligence (AI) compared with high-definition (HD) colonoscopy without AI. We aimed to perform a systematic review and network meta-analysis of all RCTs to assess the impact of AI compared with other endoscopic interventions aimed at increasing ADR such as distal attachment devices, dye-based/virtual chromoendoscopy, water-based techniques, and balloon-assisted devices.

METHODS

A comprehensive literature search of PubMed/Medline, Embase, and Cochrane was performed through May 6, 2022, to include RCTs comparing ADR for any endoscopic intervention mentioned above. Network meta-analysis was conducted using a frequentist approach and random effects model. Relative risk (RR) and 95% CI were calculated for proportional outcome.

RESULTS

A total of 94 RCTs with 61,172 patients (mean age 59.1±5.2 y, females 45.8%) and 20 discrete study interventions were included. Network meta-analysis demonstrated significantly improved ADR for AI compared with autofluorescence imaging (RR: 1.33, CI: 1.06 to 1.66), dye-based chromoendoscopy (RR: 1.22, CI: 1.06 to 1.40), endocap (RR: 1.32, CI: 1.17 to 1.50), endocuff (RR: 1.19, CI: 1.04 to 1.35), endocuff vision (RR: 1.26, CI: 1.13 to 1.41), endoring (RR: 1.30, CI: 1.10 to 1.52), flexible spectral imaging color enhancement (RR: 1.26, CI: 1.09 to 1.46), full-spectrum endoscopy (RR: 1.40, CI: 1.19 to 1.65), HD (RR: 1.41, CI: 1.28 to 1.54), linked color imaging (RR: 1.21, CI: 1.08 to 1.36), narrow band imaging (RR: 1.33, CI: 1.18 to 1.48), water exchange (RR: 1.22, CI: 1.06 to 1.42), and water immersion (RR: 1.47, CI: 1.19 to 1.82).

CONCLUSIONS

AI demonstrated significantly improved ADR when compared with most endoscopic interventions. Future RCTs directly assessing these associations are encouraged.

Endoscopic Versus Conservative Therapy for Bleeding Peptic Ulcer with Adherent Clot: A Comprehensive Systematic Review and Meta-Analysis

INTRODUCTION

Peptic ulcers with adherent clots are associated with a high-risk of rebleeding and mortality. However, the optimal management of bleeding ulcers with adherent clots remains unclear. We conducted this systematic review and meta-analysis to compare endoscopic therapy and conservative therapy to manage bleeding ulcers with adherent clots.

METHODS

We systematically searched PubMed, Embase, and Web of Science databases through October 2022 to include all studies comparing the endoscopic and conservative therapeutic approaches for bleeding ulcers with adherent clots. Our primary outcome was rebleeding (overall and 30-day). The secondary outcomes were mortality (overall and 30-day), need for surgery, and length of hospital stay (LOS). The random-effects model was used to calculate the pooled odds ratios (OR) and mean differences (MD) with the corresponding confidence intervals (CI) for proportional and continuous variables, respectively.

RESULTS

Eleven studies (9 RCTs) with 833 patients (431 received endoscopic therapy vs. 402 received conservative therapy) were included. Overall, endoscopic therapy was associated with lower overall rebleeding (OR 0.41, 95% CI 0.22-0.79, P = 0.007), 30-day rebleeding (OR 0.43, 95% CI 0.21-0.89, P = 0.002), overall mortality (OR 0.47, 95% CI 0.23-0.95, P = 0.04), 30-day mortality (OR 0.43, 95% CI 0.21-0.89, P = 0.002), need for surgery (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and LOS (MD - 3.17 days, 95% CI - 4.14, - 2.19, P < 0.00001). However, subgroup analysis of randomized controlled trials (RCTs) showed no significant difference in overall mortality (OR 0.78, 95% CI 0.24-2.52, P = 0.68) between the two strategies, with numerically lower but statistically non-significant rates of overall rebleeding (7.2% vs. 18.5%, respectively; OR 0.42, 95% CI 0.17-1.05, P = 0.06), statistically lower rate of need for surgery (OR 0.28, 95% CI 0.08-0.96, P = 0.04) with endoscopic therapy compared to conservative therapy.

CONCLUSIONS

Our meta-analysis demonstrates that endoscopic therapy was overall associated with lower rates of rebleeding (overall and 30-day), mortality (overall and 30-day), need for surgery, and LOS, compared to conservative therapy for the management of bleeding ulcers with adherent clots. However, subgroup analysis of RCTs showed that endoscopic therapy was associated with numerically lower but statistically non-significant rates of overall rebleeding and a statistically lower rate of need for surgery compared to conservative therapy with similar overall mortality rates. Combined treatment with thermal therapy and injection therapy was the most effective treatment modality in reducing rebleeding risk. Further large-scale RCTs are needed to validate our findings.

Lumen-Apposing Metal Stent With and Without Concurrent Double-Pigtail Plastic Stent for Pancreatic Fluid Collections: A Comparative Systematic Review and Meta-Analysis

Background

Lumen-apposing metal stents (LAMSs) are often used to drain pancreatic fluid collections (PFCs). However, adverse events, such as stent obstruction, infection, or bleeding, have been reported. Concurrent double-pigtail plastic stent (DPPS) deployment has been suggested to prevent these adverse events. This meta-analysis aimed to compare the clinical outcomes of LAMS with DPPS vs. LAMS alone in the drainage of PFCs.

Methods

An extensive search was conducted in the literature to include all the eligible studies that compared LAMS with DPPS vs. LAMS alone for drainage of PFCs. Pooled risk ratios (RRs) with the 95% confidence intervals (CIs) were obtained within a random-effect model. The outcomes were technical and clinical success, and overall adverse events, including stent migration and occlusion, bleeding, infection, and perforation.

Results

Five studies involving 281 patients with PFCs (137 received LAMS plus DPPS vs. 144 received LAMS alone) were included. LAMS plus DPPS group was associated with comparable technical success (RR: 1.01, 95% CI: 0.97 - 1.04, P = 0.70) and clinical success (RR: 1.01, 95% CI: 0.88 - 1.17). Lower trends of overall adverse events (RR: 0.64, 95% CI: 0.32 - 1.29), stent occlusion (RR: 0.63, 95% CI: 0.27 - 1.49), infection (RR: 0.50, 95% CI: 0.15 - 1.64), and perforation (RR: 0.42, 95% CI: 0.06 - 2.78) were observed in LAMS with DPPS group compared to LAMS alone but without a statistical significance. Stent migration (RR: 1.29, 95% CI: 0.50 - 3.34) and bleeding (RR: 0.65, 95% CI: 0.25 - 1.72) were similar between the two groups.

Conclusions

Deployment of DPPS across LAMS for drainage of PFCs has no significant impact on efficacy or safety outcomes. Randomized, controlled trials are necessary to confirm our study results, especially in walled-off pancreatic necrosis.

Complement-Mediated Thrombotic Microangiopathy and Spontaneous Splenic Rupture Associated With Cytomegalovirus Infection

This is a case report of a previously healthy female patient with complement-mediated thrombotic microangiopathy (TMA) caused by a systemic cytomegalovirus infection that was successfully treated with plasmapheresis, steroids, and parenteral valganciclovir. Complement-mediated TMA is the result of various genetic mutations leading to complement abnormalities with overactivation of alternate complement pathway in response to a triggering infection. She also had splenic rupture without splenomegaly and was managed successfully without splenectomy.

Real-world effectiveness of COVID-19 vaccination in liver cirrhosis: a systematic review with meta-analysis of 51,834 patients

SARS-CoV-2 vaccinations were found to be highly effective in phase 3 clinical trials. However, these trials have not reported data regarding the subgroup of liver disease or excluded patients with liver disease. The effectiveness of COVID-19 vaccines among liver cirrhosis (LC) patients is unclear. We conducted this meta-analysis to assess the effectiveness of SARS-CoV-2 vaccination in LC patients. A comprehensive literature search was conducted to include all the relevant studies that compared the outcomes of LC patients who received SARS-CoV-2 vaccines vs. unvaccinated patients. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated by the Mantel-Haenszel method within a random-effect model. Four studies with 51,834 LC patients (20,689 patients received at least one dose vs 31,145 were unvaccinated) were included. COVID-19-related complications, including hospitalization (RR 0.73, 95% CI 0.59-0.91, P = 0.004), mortality (RR 0.29, 95% CI 0.16-0.55, P = 0.0001), and need for invasive mechanical ventilation (RR 0.29, 95% CI 0.11-0.77, P = 0.01), were significantly lower in the vaccinated group compared to the unvaccinated group. SARS-CoV-2 vaccination in LC patients reduced COVID-19-related mortality, intubation, and hospitalization. SARS-CoV-2 vaccination is highly effective in LC. Further prospective studies, preferably randomized controlled trials, are necessary to validate our findings and determine which vaccine is superior in patients with LC.

Triglyceride glucose index for the prediction of subclinical atherosclerosis and arterial stiffness: A meta-analysis of 37,780 individuals

Insulin resistance (IR), which can be assessed by triglyceride-glucose (TyG) index, is a major contributor to the pathogenesis of cardiovascular diseases. Arterial stiffness is an index of subclinical atherosclerosis. We conducted this systematic review and meta-analysis to summarize the existing studies and provide a quantitative assessment of the significance of the TyG index in predicting the incidence of subclinical atherosclerosis and arterial stiffness. A comprehensive literature search in PubMed, EMBASE, and Web of Science databases from inception until 30 April 2022 was conducted. Published observational studies that evaluated the association between TyG index and arterial stiffness among the adult population and reported odds ratio (OR) for this association after multivariate analysis were included. The random-effects model was used for the estimation of pooled ORs with the corresponding confidence intervals (CIs). A total of 9 observational studies, including 37780 participants, were included. Seven out of the 9 studies analyzed the TyG index as a categorical variable and showed a statistically significant association between TyG index and incident arterial stiffness (pooled OR 1.96, 95% CI 1.52-2.53, P<0.00001, I²=82%). Additionally, similar results were in the three studies that analyzed TyG index as a continuous variable (pooled OR 1.37, 95% CI 1.26-1.49, P<0.00001, I²=0%). In conclusion, our meta-analysis demonstrates that a higher TyG index is associated with higher odds of subclinical atherosclerosis and arterial stiffness. TyG index may be used as an independent predictor of an increased risk of subclinical atherosclerosis and arterial stiffness.

Midostaurin in advanced systemic mastocytosis: A systematic review and meta-analysis

e19084

Background: Midostaurin, an oral multikinase inhibitor including inhibition of KIT D816V, is approved for the treatment of advanced systemic mastocytosis (SM). Few studies have investigated the use of midostaurin in patients with advanced SM, but the data on its efficacy and safety in this population remains limited and uncertain. Therefore, we conducted this systematic review and meta-analysis to better assess the efficacy and safety of midostaurin in advanced SM. Methods: We systematically searched the following databases: PubMed/MEDLINE, Embase, and Cochrane through February 02, 2022, to include all studies that assessed the effect of midostaurin on clinical outcomes of patients with advanced SM. Our primary outcome was the overall response rate (ORR). The secondary outcomes included the rates of progressive disease (PD), stable disease (SD), and treatment discontinuation due to adverse events (AEs). All statistical analyses were performed using Open Meta Analyst (CEBM, University of Oxford). Pooled rates and corresponding 95% confidence intervals (CI) were calculated using DerSimonian-Laird/Random-effects approach. Results: Four studies (two clinical trials and two observational studies) with a total of 156 patients with advanced SM were included in the pooled analysis. The mean age of the patients was 59.6±15.8 years, and males represented 64.7% of total patients. The most common subtype of advanced SM was SM associated with hematological neoplasm (59%) followed by aggressive SM (23.1%). Three studies reported the KIT D816V mutation status, and 85.2% of patients were positive for KIT D816V mutation. The mean duration of treatment with midostaurin was 10±15.3 months. The pooled ORR was 60% (95% CI 46.5%-73.5%) over a mean follow-up duration of 41.1±38.7 months. The PD and SD rates were 12.8% (95% CI 7.6%-18%) and 10.6% (5.3%-15.9%), respectively. Treatment discontinuation due to AEs occurred in 25.6% (95% CI 18.8%-32.4%). The most common hematological grade ≥3 treatment-related AE was anemia (29%), while fatigue (7.1%) was the most common non-hematological grade ≥3 treatment-related AE. Conclusions: Our study demonstrated that midostaurin is very effective in patients with advanced SM with an acceptable safety profile. Our meta-analysis is hampered by a limited number of studies, a small sample size, and a lack of a control group. Future large-scale comparative studies are warranted to evaluate the efficacy and safety of midostaurin in these patients.

Triglyceride-Glucose Index for Early Prediction of Nonalcoholic Fatty Liver Disease: A Meta-Analysis of 121,975 Individuals

Insulin resistance (IR) is a major contributor to the pathogenesis of nonalcoholic fatty liver disease (NAFLD). The triglyceride-glucose (TyG) index has recently gained popularity for the assessment of IR and NAFLD due to its ease of acquisition and calculation. Therefore, we conducted this systematic review and meta-analysis to summarize the existing studies in the literature and provide a quantitative assessment of the significance of the TyG index in predicting the incidence of NAFLD. A comprehensive literature search in PubMed, EMBASE, and Web of Science databases from inception until 25 March 2022 was conducted. Published observational studies that evaluated the association between TyG index and NAFLD among the adult population and reported the hazard ratio (HR) or odds ratio (OR) for this association after multivariate analysis were included. The random-effects model was used as the primary statistical analysis model in the estimation of pooled ORs and HRs with the corresponding confidence intervals (CIs). A total of 17 observational studies, including 121,975 participants, were included. For studies analyzing the TyG index as a categorical variable, both pooled OR (6.00, CI 4.12–8.74) and HR (1.70, CI 1.28–2.27) were significant for the association between TyG index and incident NAFLD. For studies analyzing the TyG index as a continuous variable, pooled OR (2.25, CI 1.66–3.04) showed similar results. Consistent results were obtained in subgroup analyses according to the study design, sample size, ethnicity, and diabetic status. In conclusion, our meta-analysis demonstrates that a higher TyG index is associated with higher odds of NAFLD. TyG index may serve as an independent predictive tool to screen patients at high risk of NAFLD in clinical practice, especially in primary care settings. Patients with a high TyG index should be referred for a liver ultrasound and start intense lifestyle modifications. However, further large-scale prospective cohort studies are necessary to validate our findings.

Clinical significance of micronutrient supplements in patients with coronavirus disease 2019: A comprehensive systematic review and meta-analysis

BACKGROUND AND AIMS

Micronutrient supplements such as vitamin D, vitamin C, and zinc have been used in managing viral illnesses. However, the clinical significance of these individual micronutrients in patients with Coronavirus disease 2019 (COVID-19) remains unclear. We conducted this meta-analysis to provide a quantitative assessment of the clinical significance of these individual micronutrients in COVID-19.

METHODS

We performed a comprehensive literature search using MEDLINE, Embase, and Cochrane databases through December 5th, 2021. All individual micronutrients reported by ≥ 3 studies and compared with standard-of-care (SOC) were included. The primary outcome was mortality. The secondary outcomes were intubation rate and length of hospital stay (LOS). Pooled risk ratios (RR) and mean difference (MD) with corresponding 95% confidence intervals (CI) were calculated using the random-effects model.

RESULTS

We identified 26 studies (10 randomized controlled trials and 16 observational studies) involving 5633 COVID-19 patients that compared three individual micronutrient supplements (vitamin C, vitamin D, and zinc) with SOC. Nine studies evaluated vitamin C in 1488 patients (605 in vitamin C and 883 in SOC). Vitamin C supplementation had no significant effect on mortality (RR 1.00, 95% CI 0.62-1.62, P = 1.00), intubation rate (RR 1.77, 95% CI 0.56-5.56, P = 0.33), or LOS (MD 0.64; 95% CI -1.70, 2.99; P = 0.59). Fourteen studies assessed the impact of vitamin D on mortality among 3497 patients (927 in vitamin D and 2570 in SOC). Vitamin D did not reduce mortality (RR 0.75, 95% CI 0.49-1.17, P = 0.21) but reduced intubation rate (RR 0.55, 95% CI 0.32-0.97, P = 0.04) and LOS (MD -1.26; 95% CI -2.27, -0.25; P = 0.01). Subgroup analysis showed that vitamin D supplementation was not associated with a mortality benefit in patients receiving vitamin D pre or post COVID-19 diagnosis. Five studies, including 738 patients, compared zinc intake with SOC (447 in zinc and 291 in SOC). Zinc supplementation was not associated with a significant reduction of mortality (RR 0.79, 95% CI 0.60-1.03, P = 0.08).

CONCLUSIONS

Individual micronutrient supplementations, including vitamin C, vitamin D, and zinc, were not associated with a mortality benefit in COVID-19. Vitamin D may be associated with lower intubation rate and shorter LOS, but vitamin C did not reduce intubation rate or LOS. Further research is needed to validate our findings.

Interventional cardiac catheterization predictors at Al-Arabi heart Center in Palestine in 2017

Background

Cardiac catheterization is performed for both therapeutic and diagnostic reasons, in which the outcome may vary from only medical treatment to the need of percutaneous coronary intervention and ending with coronary artery bypass graft. The primary goal of this study was to determine predictors of revascularization.

Methods

A retrospective cohort study was conducted on data collected from records of patients who underwent cardiac catheterization at Al-Arabi Heart Center in Palestine in 2017. Multivariate logistic regression analysis was carried out to assess the association of sociodemographic and pre-catheterization clinical predictors with revascularization.

Results

A total of 1550 patients were included in the study. The participants mean age was 58 with a SD of 11.7 years, 73.6% were males. 50.2% of patients who underwent an interventional cardiac catheterization tested negative for troponin on presentation. Multivariate logistic regression showed Troponin (RR = 4.5), Age (RR = 1.0), Female gender (RR = 0.4) previous catheterization (RR = 2.0), and existence of diabetes as significant predictors for revascularization. The correlation between ECG on presentation and the subsequent need for an interventional cardiac catheterization was significant only in case of ST-Elevation (RR = 1.5), and T wave inversion (RR = 1.6). CK-MB, Hypertension and ECG with ST-depression were not significant predictors.

Conclusion

This study assessed revascularization predictors in addition to characteristics and outcomes of patients who have undergone cardiac catheterization. The results showed the especially high predictive value of troponin in determining the need for revascularization which outweighed the importance of ECG findings on presentation in making clinical decision regarding catheterization.