PURPOSE: Prone positioning (PP) in awake patients has been recently proposed as an adjunctive treatment for spontaneously breathing non-intubated coronavirus disease 2019 (COVID-19) patients requiring oxygen therapy to reduce the risk of intubation.However, the magnitude of the effect of PP on clinical outcomes (e.g., the risk of endotracheal intubation, intensive care unit [ICU] admission, or mortality) in these patients remains uncertain.Therefore, we performed a systematic review and metaanalysis to evaluate the effectiveness of PP to improve the clinical outcomes in non-intubated patients with COVID-19. METHODS:We performed a comprehensive literature search using PubMed, Embase, and Cochrane Library databases from inception through February 24, 2020 for all the studies all studies that all compared PP versus no PP in non-intubated patients with COVID-19.The primary outcome of interest was the rate of endotracheal intubation.The secondary outcomes were inhospital mortality and intensive care unit (ICU) rates.Pooled odds risk (OR) and 95% confidence intervals (CIs) were obtained by the Mantel-Haenszel method within a random-effect model. RESULTS:A total of five studies (two randomized controlled trials and three observational studies), involving 470 non-intubated patients with COVID-19 (185 patients received PP and 285 did not) were included.The mean age was 59.82 years, and males represented 67% of total patients.The follow-up period ranged from 14 to 30 days.The endotracheal intubation rate was similar between PP and control groups (OR 0.75, 95% CI 0.41-1.35,P = 0.33, I2 = 20%).There was no difference in the in-hospital mortality rate between the two groups (OR 0.68, 95% CI 0.16-2.85,P = 0.60, I2 = 60%).Four studies reported the risk of ICU admission and demonstrated no difference between the two groups (OR 0.77, 95% CI 0.30-1.95,P = 0.58, I2 = 37%). CONCLUSIONS:Our meta-analysis demonstrated that prone positioning in non-intubated COVID-19 patients did not reduce the risk of endotracheal intubation.Furthermore, PP failed to reduce in-hospital mortality and ICU admission rates.CLINICAL IMPLICATIONS: Although our meta-analysis showed that prone positioning might not reduce the risks of intubation, in-hospital mortality, or ICU admission rate in spontaneously breathing non-intubated COVID-19 patients, more large-scale trials with a standardized protocol for prone positioning are needed to better evaluate the effectiveness of prone positioning in this select population.
Introduction: Given the high recurrence rate and the risk of fecal incontinence with surgical options, Injection of adipose tissue-derived stem cells (ASC) has been arising as a novel method for treating complex perianal fistulas (CPAF). Therefore, we conducted a meta-analysis to evaluate the efficacy and safety of ASC in the management of CPAF not associated with Crohn’s disease. Methods: We systematically searched Medline and Embase databases through April 20, 2022, for all studies that assessed the efficacy and safety of ASC for the treatment of CPAF not associated with Crohn’s disease. We excluded patients with rectovaginal fistulas and perianal fistulas associated with Crohn’s disease. Our primary outcome was the complete closure. The secondary outcomes included overall nonserious adverse events (NSAE), serious adverse events (SAE), and perianal abscess rate. All meta-analyses were conducted using a random-effect model. The publication bias was assessed by Egger’s test. Results: Ten studies (eight clinical trials and two observational studies) with 271 patients were included in the pooled analysis. Eight studies used autologous stem cells, one used allogeneic stem cells, and one did not report the source of stem cells. The mean age of the patients was 43.7 years. The follow-up period ranged from 3 months to 2 years. The pooled complete closure rate was 59.7% (95% confidence interval (CI): 0.46-0.73, Figure 1A). On subgroup analysis based on country of origin, six studies with 213 patients were conducted in European countries, and four studies with 58 patients were conducted in non-European countries. The complete closure rate was higher in European countries than non-European countries, 64.1% vs. 52.6%. Eight studies reported overall NSAEs with the pooled NSAE rate of 22.5% (95% CI: 0.11-0.34, Figure 1B). Seven studies reported SAEs with the pooled SAE rate of 1.7% (95% CI: 0.001-0.034, Figure 1C). Seven studies reported the perianal abscess rate with a pooled perianal abscess rate of 7.1% (95% CI: 0.016-0.125, Figure 1D). No evidence of publication bias was found (Egger’s test: P=0.36). Conclusion: Our meta-analysis demonstrated that ASC is a promising therapeutic option for CPAF not associated with Crohn’s disease with a clinically adequate efficacy and low rate of adverse events. However, more studies with larger sample sizes are needed to provide a definitive assessment of the effectiveness of ASCs for CPAF not associated with Crohn’s disease.Figure 1
INTRODUCTION: Diagnostic paracentesis is recommended for patients with cirrhosis admitted to the hospital, but adherence is suboptimal with unclear impact on clinical outcomes. The aim of this meta-analysis was to assess the outcomes of early vs delayed diagnostic paracentesis among hospitalized patients with cirrhosis and ascites. METHODS: We searched multiple databases for studies comparing early vs delayed diagnostic paracentesis among hospitalized patients with cirrhosis and ascites. The pooled odds ratio (OR) and mean difference with confidence intervals (CIs) for proportional and continuous variables were calculated using the random-effects model. Early diagnostic paracentesis was defined as receiving diagnostic paracentesis within 12–24 hours of admission. The primary outcome was in-hospital mortality. Secondary outcomes were length of hospital stay, acute kidney injury, and 30-day readmission. RESULTS: Seven studies (n = 78,744) (n = 45,533 early vs n = 33,211 delayed diagnostic paracentesis) were included. Early diagnostic paracentesis was associated with lower in-hospital mortality (OR 0.61, 95% CI 0.46–0.82, P = 0.001), length of hospital stay (mean difference −4.85 days; 95% CI −6.45 to −3.20; P < 0.001), and acute kidney injury (OR 0.62, 95% CI 0.42–0.92, P = 0.02) compared with delayed diagnostic paracentesis, with similar 30-day readmission (OR 1.11, 95% CI 0.52–2.39, P = 0.79). Subgroup analysis revealed consistent results for in-hospital mortality whether early diagnostic paracentesis performed within 12 hours (OR 0.51, 95% CI 0.32–0.79, P = 0.003, I 2 = 0%) or within 24 hours of admission (OR 0.67, 95% CI 0.45–0.98, P = 0.04, I 2 = 82%). Notably, the mortality OR was numerically lower when diagnostic paracentesis was performed within 12 hours, and the results were precise and homogenous ( I 2 = 0%). DISCUSSION: Findings from this meta-analysis suggest that early diagnostic paracentesis is associated with better patient outcomes. Early diagnostic paracentesis within 12 hours of admission may be associated with the greatest mortality benefit. Data from large-scale randomized trials are needed to validate our findings, especially if there is a greater mortality benefit for early diagnostic paracentesis within 12 hours.
This systematic review aims to evaluate the risk factors, clinical features, and outcomes of bowel perforation caused by stent migration after endoscopic retrograde cholangiopancreatography (ERCP).
In the setting of out-of-hospital cardiac arrest, therapeutic hypothermia (TH) has been shown to improve clinical outcomes. However, trials showing the advantage of TH did not include patients with cardiogenic shock (CS). We performed a comprehensive literature search for studies that evaluated the efficacy and safety of adjunctive TH compared with the standard of care (SOC) in patients with CS. The primary outcome was the mortality rate (in-hospital, short-, and mid-term). The secondary outcomes were the TH-related complications, duration of Intensive Care Unit (ICU) stay, duration of mechanical ventilation (MV-days), and improvement in cardiac function. Relative risk (RR) or the standardized mean difference (SMD) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model. A total of 7 clinical studies (3 RCTs included), and 712 patients (341 in the TH group and 371 in the SOC group) were included. As compared with the SOC, TH was not associated with a statistically significant improvement in the in-hospital (RR: 0.73%, 95% CI: 0.51–1.03; p = 0.08), short-term (RR: 0.90%, 95% CI: 0.75–1.06; p = 0.21), or mid-term (RR: 0.93%, 95% CI: 0.78–1.10; p = 0.38) mortality rates. Despite the improvement in the cardiac function in the TH group (SMD: 1.08, 95% CI: 0.02–2.1; p = 0.04), the TH strategy did not significantly shorten the MV days, or the ICU stay (p-values >0.05). Finally, there was a trend toward higher risks for infection, major bleeding, and the need for blood transfusion in the TH group. According to our meta-analysis of published clinical studies, TH is not beneficial in patients with CS and has a marginal safety profile. Larger-scale RCTs are needed to further clarify our results.
Abstract Introduction: Autoimmune polyglandular syndrome (APS) is a multiorgan genetic autoimmune disease. APS-3B subtype is autoimmune thyroiditis with pernicious anemia. In this case, we will discuss an elderly female patient diagnosed with APS-3B. Case Presentation: A 69-year-old Caucasian female patient with a past medical history of autoimmune thyroiditis presented to the emergency department with a two-month history of generalized weakness and nausea. Associated symptoms included shortness of breath and diarrhea. Review of systems was otherwise unremarkable. Physical exam was positive for depigmented skin macules over the upper extremities. Lab results showed hemoglobin 8.2 [11.7 - 15.5 g/dL], MCV 121[80 - 100 fL], platelets 144,000 [150 - 450 X10E9/L], WBC 1.9 [4.0 - 11.0 X10E9/L], LDH 1153[100 - 235 U/L], TSH 0.28[0.49 - 4.67 uIU/mL], free T4 1.7 [0.61 - 1.60 ng/dL], direct Coombs test negative. Iron saturation 55%, vitamin B12 level <50 [180 - 914 pg/mL], folate >25[>5.8 ng/mL], total bilirubin 2.3 [0.3 - 1.2 mg/dL], haptoglobin <30 [32 - 228 mg/dL], AST 43 [0 - 41 U/L], reticulocyte 1.4%. Blood smear showed absolute neutropenia with flow cytometry unremarkable. Chest x-ray and urinalysis were negative. Immunofixation showed low IgM 44 [45 - 281 mg/dL], low IgG 619 [635 - 1,741 mg/dL]. Intrinsic factor antibodies (IF-Ab) were positive. Hematology reported that hemolytic anemia is less likely given Coombs test was negative. About 1.5% of Vitamin B12 deficiency present with a hemolytic picture due to ineffective erythropoiesis while Coombs test help to differentiate it from autoimmune hemolytic anemia. Diagnosis of pernicious anemia was made and the patient started on vitamin B12 injections. The combination of pernicious anemia, autoimmune thyroiditis, and vitiligo supported the diagnosis of autoimmune APS-3B. There was a normalization of vitamin B12 level and symptomatic improvement on a one-week follow-up. Discussion: The patient was diagnosed with autoimmune thyroiditis in 2014 with positive anti-TPO antibodies and elevated TSH; she required levothyroxine supplementation since diagnosis. Hypothyroidism causes macrocytic anemia, which may delay pernicious anemia diagnosis. APS-3B is associated with HLA-B8 and/or DR3 and DR5. Many studies reported that autoantibodies can be detected before developing symptoms of organ involvement. Thorough family history provides support for autoantibody testing to detect cases of APS-3B earlier. Active surveillance and early diagnosis will help minimize invasive testing such as bone marrow biopsy, so proper history taking is a key factor to early diagnose these conditions. Conclusion: APS-3B is a rare disorder. Diagnosis is difficult hypothyroidism causes macrocytic anemia. Early detection of APS-3B may help to prevent complications that increase the risk of mortality and morbidity, particularly in the elderly population.
Introduction: Eosinophilic esophagitis (EoE) is an immune mediated disorder that may be related to exposure to additive chemicals in crops, air pollutants, or supplements found within livestock. Co-occurring allergic or atopic diseases including atopic dermatitis, food allergies, and asthma are also commonly seen in 70% of cases and help guide diagnosis. Diagnosis of EoE requires eosinophilic infiltration greater than 15 eosinophils per high power field with endoscopic evidence of abnormal esophageal changes. Here, we discuss a rare presentation of food bolus impaction secondary to EoE after ingestion of a nasal decongestant and antihistamine pill that has previously never been described in the literature. Case Description/Methods: A 22-year-old- male with no significant past medical history presented to the emergency department (ED) with a chief complaint of a sudden onset respiratory distress, regurgitation of clear oral secretions, and globus sensation post ingestion of a fexofenadine-pseudoephedrine tablet. Prior to intake of the capsule, the patient was consuming liquids and solids appropriately. The patient was afebrile, hypertensive at 172/114, found to have a normal heart rate of 88 bpm, and respiration rate of 18 breaths per minute. A esophagogastroduodenoscopy (EGD) was performed and revealed a fexofenadine-pseudoephedrine capsule at 23 cm from the incisors along with a superficial ulceration at the corresponding level in the esophagus (Fig. 1A). The foreign body was successfully removed using raptor forceps (Fig. 1B). Further visualization demonstrated trachealization of the esophagus and furrowing and severe narrowing (< 10mm) which raised suspicion for eosinophilic esophagitis (Fig. 1C). Proximal biopsy indicated 16 intraepithelial eosinophils per high-power field within the squamous epithelium likely compatible with eosinophilic esophagitis. The patient tolerated the procedure well and was discharged on a 8 week course of proton pump inhibitors. Discussion: Eosinophilic esophagitis is defined as an immune-mediated esophageal disease characterized histologically by eosinophil-predominant inflammation. Our patient was reported to have up to 30 eosinophil per HPF from the proximal esophageal biopsy which satisfies the requirements for an EoE diagnosis. Based on current literature review, there have been no other reported cases of symptomatic food bolus impaction secondary to eosinophilic esophagitis after ingestion of antihistamines.Figure 1.: EGD results; A: Exofenadine-pseudoephedrine capsule at 23 cm from the incisors along with a superficial ulceration at the corresponding level in the esophagus. B: Foreign body was successfully removed using raptor forceps. C: Trachealization of the esophagus and furrowing with severe narrowing (< 10mm)
Introduction: The differential diagnosis for a patient presenting with right upper quadrant pain is broad, and it commonly includes hepatobiliary pathology. Appendicitis in the subhepatic region is a rare condition that can present as acute cholecystitis. We present a case of acute appendicitis, not diagnosed until surgery, presenting as right upper quadrant pain and causing inflammation of the gall bladder. Case Description/Methods: A 35-year-old female with no significant past medical history presented to the hospital with constant, severe, and sharp right upper quadrant pain of one day duration. This was associated with nausea and chills. She reported no vomiting or similar pain in the past. On presentation, patient’s vital signs were significant for a heart rate of 55 beats/min and a blood pressure of 88/43 mm/Hg. She was afebrile. Physical exam revealed right upper quadrant abdominal tenderness with no guarding or rebound tenderness. Labs showed a white blood cell count of 12.1 x 109/L. Liver function tests were within normal limits. CT abdomen and pelvis showed abnormal appearance of the liver diffusely, suggesting hepatocellular disease. Ultrasound of the abdomen revealed heterogeneously thickened gallbladder wall which might represent acute cholecystitis. HIDA scan showed no evidence of acute cholecystitis though gallbladder ejection fraction was at 0 percent suggesting biliary dyskinesia. During her hospital stay, patient was then taken to the operating room for presumed cholecystitis. During the surgery, an acutely inflamed appendix was identified in the right upper quadrant adjacent to the gallbladder. There was gallbladder wall edema and mild inflammation. Purulent fluid was noted in the peritoneal cavity. Laparoscopic appendectomy and cholecystectomy were performed with eventual improvement in patient’s symptoms. Discussion: Inflammation of a subhepatic appendix is rare, and it accounts for only 0.09 percent of all appendicitis cases. During embryonic development, failure of descent of the cecum can result in a subhepatic position of the appendix. This abnormal position makes it very challenging to diagnose appendicitis. In this patient, the acutely inflamed appendix adjacent to the gallbladder might have caused inflammation in the gallbladder wall resulting in concurrent cholecystitis. Concurrent acute appendicitis and cholecystitis is rare, but it should be considered when patients present with right upper quadrant paint.Figure 1.: CT abdomen and pelvis: abnormal appearance of the liver diffusely suggesting hepatocellular disease.
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