To guarantee the healthy development of a fetus, a woman’s metabolism and hormones undergo essential changes throughout pregnancy (1). Insulin production increases with gestational age to better feed the growing fetus with glucose. However, this state can increase the chance of the woman developing gestational diabetes mellitus (GDM) if the increased insulin production is not well regulated by insulin secretion from increased β-cell mass and responsiveness (2). Pregnancy-onset glucose intolerance of any severity that does not meet the criteria for full-blown diabetes is considered to be GDM (3). A growing number of pregnant women are experiencing difficulties such as preeclampsia and are having babies with complications such as macrosomia, hyperbilirubinemia, newborn hypoglycemia, and the need for admission to the neonatal intensive care unit (NICU) because of this condition (4,5).

Atrial fibrillation accounts for 1/6 of all strokes, potentially leading to significant disability and death. The left atrial appendage (LAA) is the primary location for thrombus formation. Excluding the LAA has been hypothesized to decrease the risk of ischemic stroke.This study examines LAA occlusion (LAAO) with otherwise indicated cardiac surgery and its effect on surgical outcomes.We followed the standards recommended by the Cochrane Collaborative Group and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist to prepare this systematic review and meta-analysis. Studies were retrieved through an online bibliographic search, studies were screened, and data were extracted. We compared the 2 study arms (LAAO and cardiac surgery without LAAO). A total of 10 studies have been included in this study, and 6 randomized controlled trials were included in the meta-analysis, with data pooled from over 10,000 patients.LAAO is associated with no significant difference in the overall mortality (p = 0.98) and systemic embolism (p = 0.31). Strokes, particularly, ischemic strokes, have significantly lower risk in patients who underwent LAAO (p <0.0001 and p = 0.0007), respectively.In conclusion, LAAO can be done safely as a concomitant surgery with other cardiac surgeries, with a minimal incremental cost when performed concurrently. LAAO is associated with a lower risk of all stroke and ischemic strokes. Further studies are needed to shape guidance on the continuation versus discontinuation of anticoagulation after LAAO, especially in patient populations with a higher risk of bleeding.

The study aims to compare the use of hypothermia in patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) with control. We systematically searched four electronic databases until March 2022. The inclusion criteria were any study design that compared hypothermia in patients with MI undergoing PCI with control. The risk of bias assessment of the included randomized controlled trials was conducted through Cochrane Tool, while the quality of the included cohort studies was assessed by the NIH tool. The meta-analysis was performed on RevMan. A total of 19 studies were entered. Regarding the mortality, there were nonsignificant differences between hypothermia and control (odds ratio [OR] = 1.06, 95% confidence interval [CI] 0.75 to 1.50, p = 0.73). There was also no significant difference between the control and hypothermia in recurrent MI (OR = 1.21, 95% CI 0.64 to 2.30, p = 0.56). On the other hand, the analysis showed a significant favor for hypothermia over the control infarct size (mean difference = -1.76, 95% CI -3.04 to -0.47, p = 0.007), but a significant favor for the control over hypothermia in the overall bleeding complications (OR = 1.88, 95% CI 1.11 to 3.18, p = 0.02). Compared with the control, hypothermia reduced the infarct size of the heart, but this finding was not consistent across studies. However, the control had lower rates of bleeding problems. The other outcomes, such as death and the incidence of recurrent MI, were similar between the two groups.

There are no guidelines for the most effective medication to reduce hepatic encephalopathy (HE) or the associated mortality. The purpose of this study is to determine the most effective possible treatment among the single treatment options or the combined treatment options for decreasing the morbidity and mortality of HE. We evaluated the outcomes by various parameters such as the quality of life, reduction in ammonia, all causes of mortality, adverse events, reversal of minimal HE, and development of overt HE. We systematically searched PubMed, Cochrane, Web of Science, and Scopus till the 19th of January 2023 for studies that assess various treatment options for HE. Data were extracted from eligible studies and pooled in a frequentist network meta -analysis as standardized mean difference (SMD) and their 95% confidence interval (CI) using the MetaInsight web -based tool. The Cochrane Tool was used to assess the randomized controlled trials' quality (RCT), while the NIH tool was used to assess the quality of the included cohort studies. Utilizing the R software, the network meta -analysis was conducted. In addition to a significant variation in cases of (Lactulose and Rifaximin) compared with Rifaximin (RR= 0.39, 95% CI [0.17; 0.89]), the results demonstrated a significantly lower incidence of overt HE in (Lactulose and Rifaximin) compared with placebo (RR=0.19, 95% CI [0.09; 0.40]). Most arms demonstrated a statistically significant reduction in the incidence of overt HE compared to albumin and placebo. The results also demonstrated a significant reduction in ammonia between L-ornithine-L-aspartate (LOLA) and probiotics (MD= -19.17, 95% CI [-38.01; -0.32]), as well as a significant difference in the incidence of LOLA compared to placebo (MD= -22.62, 95% CI [-39.16; -6.07]). This network meta -analysis has significant data for managing subclinical HE in people without a history of overt HE. Our analysis showed that (Lactulose and Rifaximin), followed by (Rifaximin and L-carnitine), followed by (Lactulose and Rifaximin with zinc) were the best combinations regarding overt HE. LOLA reduced ammonia best, followed by Nitazoxanide and finally Lactulose. (Lactulose and Nitazoxanide) have the least adverse effects, followed by (Rifaximin and L-carnitine), then Probiotics. Yet, all mortality outcomes and quality of life changes yielded no useful findings. Future studies like RCTs must be done to compare our therapies directly.

This study aims to compare the outcomes and advantages of total knee arthroplasty (TKA) performed using conventional surgical techniques with those conducted using robotic-assisted methods in terms of operation time, Oxford knee score, range of motion, tourniquet time, and Western Ontario and McMaster Universities Arthritis index. We performed a literature search through five databases, namely, PubMed, Cochrane Central, Scopus, Embase, and Web of Science, from inception until July 3, 2023. Randomized clinical trials (RCTs) and cohorts comparing conventional TKA with robotic-assisted TKA were included. The risk of bias of the included RCTs was determined using the Cochrane risk of bias tool and the National Institutes of Health tool for cohort studies. We conducted a meta-analysis using Review Manager 5.4. To analyze continuous data, we calculated the mean difference (MD) along with its corresponding 95% confidence interval (CI). By synthesizing data from a comprehensive analysis, the study unveiled noteworthy distinctions between robotic-assisted arthroplasty and conventional arthroplasty across critical parameters. First, a substantial alteration in the hip-knee-ankle (HKA) angle was observed, with the robotic-assisted approach demonstrating a significant difference (MD = 0.84, 95% CI = 0.25-1.43, p = 0.005). Second, in terms of operative time, a notable reduction in surgical duration was noted with conventional TKA (MD = 16.85, 95% CI = 8.08-25.63, p = 0.0002). The assessment of tourniquet time exhibited a significantly longer duration for robotic-assisted arthroplasty (MD = 35.70, 95% CI = 27.80-43.61, p < 0.001). Our findings indicate that conventional TKA outperforms robotic-assisted TKA, primarily due to its shorter operative and tourniquet times, along with a more favorable change in the HKA angle. However, it is worth noting that robotic-assisted TKA showed a slight advantage in pain outcomes, although this advantage was not statistically significant. To gain a more comprehensive understanding, we recommend conducting a large-scale randomized controlled trial that directly compares both TKA methods. This trial should evaluate costs and long-term outcomes while ensuring consistent follow-up durations among studies. Such an approach would greatly assist orthopedic decision-making and contribute to improved TKA outcomes.

Robotic-assisted surgery is a computer-controlled technique that may improve the accuracy and outcomes of unicompartmental total knee arthroplasty (TKA), a partial knee replacement surgery. The purpose of a meta-analysis about robotic-assisted versus conventional surgery for unicompartmental TKA is to compare the effectiveness of these two methods based on the current evidence. Our meta-analysis can help inform clinical decisions and guidelines for surgeons and patients who are considering unicompartmental TKA as a treatment option. We searched four online databases for studies that compared the two methods until March 2023. We used RevMan software to combine the data from the studies. We calculated the mean difference (MD) and the 95% confidence interval (CI) for each outcome, which are statistical measures of the difference and the uncertainty between the two methods. We included 16 studies in our analysis. We found that robotic-assisted surgery had a better hip-knee-ankle angle, which is a measure of how well the knee is aligned, than conventional surgery (MD = 0.86, 95% CI = 0.16-1.56). We also found that robotic-assisted surgery had a better Oxford Knee score, which is a measure of how well the knee functions, than conventional surgery (MD = 3.03, 95% CI = 0.96-5.110). This study compared the results of conventional and robotic-assisted unicompartmental knee arthroplasty in 12 studies. We concluded that robotic-assisted surgery may have some benefits over conventional surgery in terms of alignment and function of the knee. However, we did not find any significant difference between the two methods in terms of other outcomes, such as pain, range of motion, health status, and joint awareness. Therefore, we suggest that more research is needed to confirm these results and evaluate the long-term effects and cost-effectiveness of robotic -assisted surgery.

Background We aim to evaluate the efficacy and safety of a new marine oligosaccharide drug, sodium oligomannate (GV-971), developed in China to treat Alzheimer’s disease (AD). Methods We researched the following databases: Embase, Web of Science, PubMed, Cochrane library, and Scopus until Sep 2022. We used the Cochrane risk of bias tool to assess the risk of bias and the GRADE scale to assess the quality of the evidence. The meta-analysis was performed using review manager 5.4. Results We included three randomized controlled trials with 1108 patients. Sodium oligomannate improved the AD assessment scale-cognitive subscale compared to the placebo at 12, 24, and 36 weeks (mean difference (MD) = − 0.69, 95% confidence interval (CI) [− 1.23 to − 0.14], p = 0.01), (MD = − 0.68, 95% CI [− 1.26 to − 0.10], P = 0.02), and (MD = − 3.84, 95% CI [− 6.40 to − 1.27], and P = 0.003), respectively. On the other hand, results showed no significance in terms of adverse events and other assessed scales (Clinician’s Interview-Based Impression of Change with caregiver input, AD Cooperative Study-Activities of Daily Living, and Neuropsychiatric Inventory) ( p > 0.05). Conclusions Sodium oligomannate is a well-tolerated and promising drug for Alzheimer’s patients. However, to better evaluate sodium oligomannate’s efficacy in the clinical setting, we need more randomized controlled trials with larger samples and higher quality.

Objective: Since the evidence on the efficacy and safety of edaravone in the treatment of Amyotrophic Lateral Sclerosis (ALS) is still debatable, we conducted a systematic review and meta-analysis. Background: ALS as a neurodegenerative disorder is becoming more prevalent, with a higher incidence rate in all regions worldwide. High concentrations of reactive oxygen species and mitochondrial dysfunction are hallmarks of neurodegenerative disorders' pathogenesis. Edaravone was the first free-radical scavenger discovered, and it has been shown that it can preserve cells in both humans and animals. Design/Methods: We searched PubMed, Web of Science, Cochrane, Scopus, and Embase for relevant articles till October 2022. We included randomized controlled trials and cohort studies comparing edaravone plus riluzole or edaravone alone with riluzole or placebo as a control for ALS. In the case of continuous data, we used the mean difference (MD) with 95% CI, and in the case of dichotomous data, we used the risk ratio (RR) with 95% CI. Results: We pooled data from 12 studies involving 2845 participants. Of those patients, 1141 (40.1%) were given edaravone and 1704 (59.9%) were given the control. We detected a significant difference in survival rate at 18 months (RR=1.13, 95% CI [1.02, 1.24]), 24 months (RR=1.22, 95% CI [1.06, 1.41]), and 30 months (RR=1.17, 95% CI [1.01, 1.34]) but not at 6 months (RR=1.04, 95% CI [0.94, 1.14]) and 12 months (1.09, 95% CI [0.97, 1.23]). Our comparison found that edaravone therapy has no significant effect on the change in ALSFRS-R score (MD=1.14, 95% CI [−0.30, 2.58]). As regards adverse events, we didn't find any significant difference (RR=1.04, 95% CI [0.96, 1.13]). Conclusions: Edaravone treatment improves long-term survival with no effect on the ALSFRS-R score. Adverse events occurred at similar rates between the two groups. Disclosure: Dr. Nourelden has nothing to disclose. Dr. Ibrahim has nothing to disclose. Mr. Younis has nothing to disclose. Dr. Elhady has nothing to disclose. Mr. Hagrass has nothing to disclose. Dr. Fathallah has nothing to disclose. Mr. Zaazouee has nothing to disclose.

Introduction: Our main aim for the study is to measure the efficacy and safety of different anticoagulants in patients with advanced liver disease. Methods: We systematically searched PubMed, Cochrane, Web of Science, and Scopus till the 19th of January 2023. Data were extracted from eligible studies and pooled in a frequentist network meta-analysis as standardized mean difference (SMD) and their 95% confidence interval (CI) using the MetaInsight web-based tool. The quality assessment of the included randomized controlled trials was conducted through Cochrane Tool, while the quality of the included cohort studies was assessed by the NIH tool. The network meta-analysis was performed through the R software. Results: We included 54 studies with 91218 patients, The results showed a significant variation in cases of DOACs compared with UnFractioned Heparin in the lower risk of major bleeding (relative risk (RR)= 0.03) with another significantly lower risk in DOACs compared with low molecular-weight heparin (LMWH) (RR= 0.39) with another significantly lower risk in direct oral anticoagulants (DOAC) compared with warfarin or LMWH (RR= 0.48), The results showed no significant variation between fondaparinux and warfarin (RR= 0.85), On the other hand, warfarin showed a significantly lower risk of major bleeding compared to LMWH and UFH respectively (RR= 0.48) and (RR= 0.04). The recurrence of thrombosis was significantly decreased with the use of DOACs; when compared with (Warfarin or LMWH) (RR= 0.38), was also significant when compared with control (RR= 0.28), and was significant when compared with LMWH ( RR= 0.11). The results showed a significant decrease in the recurrence of thrombosis when patients use LMWH and Warfarin together in comparison with control and LMWH alone respectively ( RR= 0.38), ( RR= 0.15). The results showed a significant decrease in the recurrence of thrombosis when patients use warfarin in comparison with control ( RR= 0.41, 95% CI [0.21; 0.82]). Also, The recurrence of thrombosis was significantly decreased with the use of (LMWH and acenocoumarol); when compared with with control (RR= 0.09), and was significant when compared with LMWH alone (RR= 0.03). Conclusion: Our meta-network study found that DOACs showed the least major incidence of major bleeds, especially when compared with vitamin K antagonists (VKAs). The most significant results in decreasing the progression of thrombosis were LMWH and Acenocoumarol followed by DOACs which showed better results compared to VKA (Figure 1).Figure 1.: Recurrence or progression of thrombosis (A) Network graph showing direct evidence between the evaluated drugs. (B) A forest plot comparing all drugs with control. (C) The league table represents the network meta-analysis estimates for all drugs' comparisons.

In this study, we aim to explore the differences among the three types of fixation methods for the components of the knee joint in patients who underwent total knee arthroplasty (TKA).These methods are cemented, uncemented, and hybrid fixation.Cemented fixation means that a special type of grout is used to attach the components to the bone.Uncemented fixation means that the components are designed to fit tightly into the bone and allow new bone growth to secure them.Hybrid fixation means that a combination of cemented and uncemented fixation is used for different components.We searched four online databases to find studies relevant to our research question.We use the R program (R Foundation for Statistical Computing, Vienna, Austria) for network meta-analysis (NMA) to analyze the data from the studies.We calculate the mean difference (MD) and the 95% confidence interval (CI) for each outcome, which are statistical measures of the difference and the uncertainty between methods.We use these measures for continuous outcomes, meaning they can have any value.For dichotomous outcomes, meaning they can only have two values, we use the risk ratio (RR) and the 95% CI, which are statistical measures of the relative risk and the uncertainty between methods.We assess the quality of randomized controlled trials, which are studies that randomly assign participants to different methods, using the Cochrane Risk of Bias Assessment Tool 1, a tool that evaluates the potential biases in the studies.We include 21 studies, and our analysis shows that cemented TKA reveals a statistically significant decrease in pain with hybrid TKA (MD = -2.82).That said, we find no significant differences between uncemented and cemented or hybrid (MD = -0.80 and -2.02, respectively).The results show that there is no significant difference between uncemented TKA and cemented TKA or hybrid technique (RR = 0.87, 95% CI 0.35-2.14;RR = 0.73, 95% CI 0.22-2.39,respectively).Also, we find no significant difference between cemented TKA and hybrid TKA (RR = 0.84, 95% CI 0.24-2.93).Cemented TKA is associated with a lower risk of deep vein thrombosis (DVT) incidence rate.Moreover, it shows a significant decrease in pain compared to hybrid TKA.Future research is needed to compare among the three interventions.

The prescription of oxygen, and its patient-specific target range, is an essential part of a patients journey through hospital - but is often incomplete. The British Thoracic Society (BTS) 2015 audit identified a national-level deficit in oxygen and patient-specific target saturation prescriptions. However, this is not an issue isolated to the UK. Cousins et al (2016) summarised available international data, concluding that universally oxygen prescribing practice is poor. Hyperoxia, particularly in groups susceptible to type II respiratory failure, is also associated with excess morbidity and mortality, further highlighting the need for correct target saturations to identified on admission. As electronic prescribing becomes increasingly common practice, we sought to determine if this could be used to achieve the BTS expected standard: "a target [oxygen saturation] range for all hospital patients at the time of admission". At our district general hospital (DGH), we used electronic patient records (capturing a 96-hour admission period) to monitor oxygen target saturation prescriptions at admission. Initially just 17% of patients had oxygen prescribed at admission. To improve this, we introduced an "admission orderset" prescription, which, alongside venous thromboembolism prophylaxis, included an oxygen target saturation prescription. Following implementation we achieved a sustained improvement over the following 10 months, with an average of 53.2% of patients being prescribed oxygen and its target saturations on admission - with further changes planned. As technology continues to be integrated into healthcare, simple additions identified at our DGH could be applied internationally to improve patient safety in this area.

AimThe study aims to increase understanding of edaravone's efficacy and safety as an amyotrophic lateral sclerosis (ALS) treatment and provide significant insights regarding this field's future research.MethodsWe conducted a comprehensive search of the Embase, PubMed, Cochrane Library, Web of Science, and Scopus databases for randomized controlled trials and observational studies up until September 2022. We evaluated the studies' quality using the Cochrane risk of bias tool and the National Institutes of Health tool.ResultsWe included 11 studies with 2845 ALS patients. We found that edaravone improved the survival rate at 18, 24, and 30 months (risk ratio (RR) = 1.03, 95% confidence interval (CI) [1.02 to 1.24], P = 0.02), (RR = 1.22, 95% CI [1.06 to 1.41], P = 0.007), and (RR = 1.17, 95% CI [1.01 to 1.34], P = 0.03), respectively. However, the administration of edaravone did not result in any significant difference in adverse effects or efficacy outcomes between the two groups, as indicated by a P value greater than 0.05.ConclusionEdaravone improves survival rates of ALS patients at 18, 24, and 30 months with no adverse effects. However, edaravone does not affect functional outcomes. In order to ensure the validity of our findings and assess the results in accordance with the disease stage, it is essential to carry out additional prospective, rigorous, and high-quality clinical trials. The current study offers preliminary indications regarding the effectiveness and safety of edaravone. However, further comprehensive research is required to establish the generalizability and sustainability of the findings.

Objective: Randomized control trials (RCT) conducted on myocardial infarction (MI) patients regarding the efficacy of therapeutic hypothermia (TH) as an adjunct to percutaneous coronary intervention (PCI) have shown inconsistent results. This study aims to compare the use of TH in patients with MI undergoing PCI with control groups. Methods: We systematically searched four databases; PubMed, Scopus, Web of Science, and Cochrane for studies conducted until March 2022. The inclusion criteria were any study design that compared TH in patients with MI undergoing PCI with a control group. Infarct size percentage and recurrent MI were primary efficacy outcomes. Mortality, major adverse cardiovascular events (MACE), and overall bleeding complications were primary safety outcomes. The risk of bias assessment of the included RCTs was conducted through Cochrane tool, while the quality of the included cohort studies was assessed by the NIH tool. The meta-analysis was performed on RevMan. Results: A total of 19 studies were included; 15 RCTs, one case-control, and three cohort studies. Infarct size percentage was significantly reduced in TH group as compared to control (MD= -1.76, 95% CI [-3.04, -0.47), p=0.007), but the TH group had a higher incidence of bleeding complications (OR= 1.88, 95% CI [1.11, 3.18), p=0.02). There were no significant differences between TH and control groups in mortality (OR= 1.06, 95% CI [0.75, 1.50), p=0.73) or recurrent MI (OR= 1.21, 95% CI [0.64, 2.30), p=0.56). Conclusion: In patients with MI, TH reduces infarct size while increasing bleeding complications. Mortality and recurrent MI outcomes are not significantly reduced.

Objective: Low molecular weight heparin (LMWH) has been established for the treatment of cancer-associated thromboembolism (CAT). Recent guidelines suggest Direct Oral Anti-Coagulants (DOACs) may have a role in the management of CAT, however these recommendations were conditional. This study aims to compare DOACs with LMWH and Vitamin K Antagonists (VKAs) in CAT. Methods: We conducted a meta-analysis of studies through a systematic search of four electronic databases (PubMed, Scopus, Web of Science, and Cochrane) published before January 25, 2022. Our criteria included studies in patients with all cancer types who received DOACs, VKAs, or LMWH for prevention or treatment of CAT. We analyzed outcomes including recurrent venous thromboembolism, major bleeding, clinically relevant non-major bleeding (CRNMB), and all-cause mortality. The quality assessment of the included RCTs was conducted through Cochrane Tool, while the quality of the included cohort studies was assessed by the NIH tool. The network meta-analysis was performed using the netmeta package in R software. Results: A total of 55 studies were included; 18 RCTs, and 37 cohort studies. DOACs (RR= 0.72, 95% CI [0.63; 0.83]) and LMWH (RR= 0.78, 95% CI [0.64; 0.94]) had a significantly lower risk of major bleeding than VKAs. There was also a significantly decreased risk of clinically relevant non-major bleeding (CRNMB) with LMWH than DOACs (RR= 0.63, 95% CI [0.55; 0.73]) and DOACs compared to VKA (RR= 0.83, 95% CI [0.72; 0.95]). With regards to recurrent venous thromboembolism risk (VTE), DOACs showed a significantly lower risk compared with either LMWH (RR=0.70, 95% CI [0.59; 0.83]) or VKA (RR=0.66, 95% CI [0.54; 0.80]). Conclusion: We conclude that DOACs are more effective in the management of CAT when compared to LMWH and VKA. DOACs and LMWH have significantly lower risk of major bleeding when compared to VKA. More research is needed to determine the best anticoagulation strategy for distinct types of cancers.

Introduction: Auscultation of chest is limited during COVID-19 pandemic. We wanted to investigate the relationship between auscultatory findings and the severity of the Chest x-ray(CXR) changes and the oxygen(O2) administered. Methods: 19 RT-PCR confirmed COVID-19 pneumonia patients were studied. Patients on assisted ventilation, known underlying lung or heart disease were excluded. Chest auscultation was undertaken by 2 respiratory consultants and 2 middle grade respiratory doctors using a 3M™ Littmann® Stethoscope. Inspiratory crackles were graded between 0 to 10. Upper, middle and lower zones of the chest were auscultated posteriorly and average of total grades for each area were recorded. CXR done around the day of auscultation were reported by a consultant chest radiologist blinded to the auscultatory findings. COVID-19 changes on CXR were graded as none, mild, moderate, or severe. O2 administered to respective patients at the time of auscultation was documented. Statistical relationship between the variables were caliculated using correlation co-efficient. Results: On Auscultation, crackles were heard in 89% of patients. 84% of patients in both the middle and lower zones and 5% of patients in the lower zone only. They were not heard in upper zones. Measurements and Main Results: There is an association between the crackles on chest auscultation and severity of the COVID-19 CXR findings and the O2 administered.