Effect of fibrinolytic therapy on ST-elevation myocardial infarction clinical outcomes during the COVID-19 pandemic:A systematic review and meta-analysis

BACKGROUND ST-elevation myocardial infarction(STEMI)is the result of transmural ischemia of the myocardium and is associated with a high mortality rate.Primary percutaneous coronary intervention(PPCI)is the recommended first-line treatment strategy for patients with STEMI.The timely delivery of PPCI became extremely challenging for STEMI patients during the coronavirus disease 2019(COVID-19)pandemic,leading to a projected steep rise in mortality.These delays were overcome by the shift from first-line therapy and the development of modern fibrinolytic-based reperfusion.It is unclear whether fibrinolytic-based reperfusion therapy is effective in improving STEMI endpoints.AIM To determine the incidence of fibrinolytic therapy during the COVID-19 pandemic and its effects on STEMI clinical outcomes.METHODS PubMed,Google Scholar,Scopus,Web of Science,and Cochrane Central Register of Controlled Trials were queried from January 2020 up to February 2022 to identify studies investigating the effect of fibrinolytic therapy on the prognostic outcome of STEMI patients during the pandemic.Primary outcomes were the incidence of fibrinolysis and the risk of all-cause mortality.Data were meta-analyzed using the random effects model to derive odds ratios(OR)and 95%confidence intervals.Quality assessment was carried out using the Newcastle-Ottawa scale.RESULTS Fourteen studies including 50136 STEMI patients(n=15142 in the pandemic arm;n=34994 in the pre-pandemic arm)were included.The mean age was 61 years;79%were male,27%had type 2 diabetes,and 47%were smokers.Compared with the pre-pandemic period,there was a significantly increased overall incidence of fibrinolysis during the pandemic period[OR:1.80(1.18 to 2.75);I2=78%;P=0.00;GRADE:Very low].The incidence of fibrinolysis was not associated with the risk of all-cause mortality in any setting.The countries with a low-and middle-income status reported a higher incidence of fibrinolysis[OR:5.16(2.18 to 12.22);I2=81%;P=0.00;GRADE:Very low]and an increased risk of all-cause mortality in STEMI patients[OR:1.16(1.03 to 1.30);I2=0%;P=0.01;GRADE:Very low].Meta-regression analysis showed a positive correlation of hyperlipidemia(P=0.001)and hypertension(P<0.001)with all-cause mortality.CONCLUSION There is an increased incidence of fibrinolysis during the pandemic period,but it has no effect on the risk of all-cause mortality.The low-and middle-income status has a significant impact on the all-cause mortality rate and the incidence of fibrinolysis.

Discharging patients home from the intensive care unit:A new trend

Discharging patients directly to home from the intensive care unit(ICU)is becoming a new trend.This review examines the feasibility,benefits,challenges,and considerations of directly discharging ICU patients.By analyzing available evidence and healthcare professionals'experiences,the review explores the potential impacts on patient outcomes and healthcare systems.The practice of direct discharge from the ICU presents both opportunities and complexities.While it can potentially reduce costs,enhance patient comfort,and mitigate complications linked to extended hospitalization,it necessitates meticulous patient selection and robust post-discharge support mechanisms.Implementing this strategy successfully mandates the availability of home-based care services and a careful assessment of the patient's readiness for the transition.Through critical evaluation of existing literature,this review underscores the significance of tailored patient selection criteria and comprehensive post-discharge support systems to ensure patient safety and optimal recovery.The insights provided contribute evidence-based recommendations for refining the direct discharge approach,fostering improved patient outcomes,heightened satisfaction,and streamlined healthcare processes.Ultimately,the review seeks to balance patientcentered care and effective resource utilization within ICU discharge strategies.

Role of octreotide in small bowel bleeding

Gastrointestinal bleeding accounts for a drastic negative impact on the quality of the patients’lives as it requires multiple diagnostic and therapeutic interventions to identify the source of the bleeding.Small bowel bleeding is the least common cause of gastrointestinal bleeding.However,it is responsible for the majority of complaints from patients with persisting or recurring bleeding where the primary source of bleeding cannot be identified despite investigation.A somatostatin analog known as octreotide is among the medical treatment modalities currently used to manage small bowel bleeding.This medication helps control symptoms of gastrointestinal bleeding by augmenting platelet aggregation,decreasing splanchnic blood flow,and antagonizing angiogenesis.In this review article,we will highlight the clinical efficacy of octreotide in small bowel bleeding and its subsequent effect on morbidity and mortality.

Overlap of diabetic ketoacidosis and hyperosmolar hyperglycemic state

Diabetic ketoacidosis(DKA)and hyperosmolar hyperglycemia state(HHS)are two life-threatening metabolic complications of diabetes that significantly increase mortality and morbidity.Despite major advances,reaching a uniform consensus regarding the diagnostic criteria and treatment of both conditions has been challenging.A significant overlap between these two extremes of the hyperglycemic crisis spectrum poses an additional hurdle.It has well been noted that a complete biochemical and clinical patient evaluation with timely diagnosis and treatment is vital for symptom resolution.Worldwide,there is a lack of large-scale studies that help define how hyperglycemic crises should be managed.This article will provide a comprehensive review of the pathophysiology,diagnosis,and management of DKA-HHS overlap.

Ketosis-prone diabetes mellitus:A phenotype that hospitalists need to understand

Diabetes has been classified mainly into types 1 and 2.Some type 2 diabetes patients,when developing ketosis,have been labeled as having atypical diabetes.Lately,syndromes of ketosis-prone diabetes,primarily in patients who we previously classified as type 2 diabetics,have emerged,and calls are being made to even reclassify diabetes.This mini-review will extensively deal with the historical,molecular,phenotypical,and clinical basis of why ketosis-prone diabetes is different than the traditional principles of type 1 and 2 diabetes and should be classified as such.Clinicians,especially those who are not diabetologists or endocrinologists,as well as hospitalists,intensivists,and primary care providers,will greatly benefit from this review.