Histological Outcomes of Pharmacological Interventions in Eosinophilic Esophagitis for Adults and Children: A Network Meta-analysis of Randomized Controlled Trials.

INTRODUCTION: Multiple pharmacological interventions have been studied for managing eosinophilic esophagitis (EoE). We performed a comprehensive systematic review and network meta-analysis of all available randomized controlled trials (RCT) to assess the efficacy and safety of these interventions in EoE in adults and children. METHODS: We performed a comprehensive review of Embase, PubMed, MEDLINE OVID, Cochrane CENTRAL, and Web of Science through May 10, 2023. We performed frequentist approach network meta-analysis using random effects model. We calculated the odds ratio (OR) with 95% CI for dichotomous outcomes. RESULTS: Our search yielded 25 RCTs with 25 discrete interventions and 2067 patients. Compared with placebo, the following interventions improved histology (using study definitions) in decreasing order on ranking: orodispersible budesonide (ODB) low dose, ODB high dose, oral viscous budesonide (OVB) high dose, fluticasone tablet 1.5 mg twice daily, fluticasone 3 mg twice daily, esomeprazole, dupilumab every 2 weeks, dupilumab weekly, OVB medium dose, fluticasone 3 mg daily, cendakimab 180 mg, prednisone, swallowed fluticasone, fluticasone tablet 1.5 mg daily, OVB low dose, reslizumab 3 mg/kg, reslizumab 1 mg/kg, and reslizumab 2 mg/kg. CONCLUSIONS: Network meta-analysis demonstrates histological efficacy of multiple medications for EoE. Because of the heterogeneity and large effect size, we recommend more trials comparing pharmacotherapeutic interventions with each other and placebo. An important limitation of this study is absence of clinical efficacy data due to insufficient data. Other limitations include heterogeneity of operator, population, and outcome analysis.

The relationship between iodinated contrast material temperature and adverse reactions: A meta-analysis of 307,329 injections.

OBJECTIVE: The effect of iodinated contrast material (CM) temperature on injection pressures and viscosity has been well established. However, the effect of extrinsic warming of CM on allergic reactions and extravasations remains unclear. The purpose of this study is to compare the rates of allergic reactions and extravasations between warmed CM to room temperature CM. METHODS: We conducted a comprehensive systematic search using PubMed, Embase, and Web of Science databases for all studies that assess the impact of warmed CM on adverse reactions. The primary outcomes of our study were allergic reaction and extravasation rates. We calculated weighted pooled odds ratios (OR) and 95% confidence intervals (CI) for all outcomes using the random-effects model. A P-value <0.05 was considered statistically significant. We conducted subgroup analyses based on the viscosity of the CM. RESULTS: A total of five studies, including 307,329 CM injections (86,676 at room temperature and 220,653 warmed to 37 °C), were included in the analysis. For high viscosity CM, pre-warming was associated with significantly lower allergic reaction rates (OR: 0.59, 95% CI: 0.49-0.72, P < 0.00001). There was no significant difference in rates of extravasation for high viscosity CM (OR: 0.53, 95% CI: 0.20-1.43, P = 0.21). DISCUSSION: Our meta-analysis suggests that warming CM to 37 °C is a safe and effective approach to reduce the risk of allergic reactions and physiologic reactions during injection of high-viscosity CM. However, there was no significant difference in extravasation rates between warmed and room temperature CM, regardless of viscosity.

Erythromycin Improves the Quality of Esophagogastroduodenoscopy in Upper Gastrointestinal Bleeding: A Network Meta-Analysis.

BACKGROUND/AIM: Upper gastrointestinal bleeding (UGIB) usually requires esophagogastroduodenoscopy (EGD) for diagnostic and-potentially-therapeutic purposes. However, blood within the gastric lumen may hinder the procedure. Administration of prokinetics like erythromycin has shown efficacy. This network meta-analysis investigates the efficacy of this intervention prior to EGD. METHODS: We performed a systematic literature search of Embase, PubMed/Medline, and other databases through March 8, 2022 to include randomized controlled trials (RCTs) comparing prokinetic use in EGD for UGIB. We used the DerSimonian-Laird approach to pool data and compare outcomes including need for repeat endoscopy and blood transfusion. Pooled prevalence of proportional outcomes, 95% confidence interval (CI), and p-values were calculated. RESULTS: We included eight RCTs with four distinct intervention groups (erythromycin, placebo to erythromycin, nasogastric (NG) lavage and NG lavage + erythromycin) published between 2002 and 2020 with a total of 721 patients (mean age 60.0 ± 3.1 years; 73.2% male). The need for second look endoscopy was significantly lower with erythromycin than placebo (relative risk: 0.42, CI 0.22-0.83, p = 0.01). Using the frequentist approach, the combination of NG lavage and erythromycin (92.2) was rated highest, followed by erythromycin alone (73.1) for higher rates of empty stomach. Erythromycin was rated highest for lower need for packed red blood cell transfusion (72.8) as well as mean endoscopy duration (66.0). CONCLUSION: Erythromycin improved visualization at EGD, reduced requirements for blood transfusion and repeat EGD, and shortened hospital stay. The combination of erythromycin and NG lavage showed reduced mortality.

Predictors of gastrointestinal bleeding in patients following left ventricular assist device implantation: a systematic review and meta-analysis.

Aim: Our study aims to provide a more holistic understanding of the available data and predictive risk factors for gastrointestinal bleed (GIB). Materials & methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Web of Science Core Collection and calculated relative risk and meta-regression was utilized to evaluate for risk factors in order to assess the effect of covariates. Results: Our meta-analysis reported a pooled prevalence rate of GIB of 24.4%. Meta-regression analysis did not yield a statistically significant association between GIB and risk factors, including age, gender, hypertension, chronic kidney disease and diabetes. Conclusion: Studies investigating larger sample sizes are required for conclusive findings.

Does timing of endoscopy affect outcomes in patients with upper gastrointestinal bleeding: a systematic review and meta-analysis.

BACKGROUND AND AIMS: The timing of esophagogastroduodenoscopy (EGD) for the management of upper gastrointestinal bleeding (UGIB) remains controversial. Early EGD (E-EGD) (within 24 h of presentation) has been compared to late EGD (L-EGD) (after 24 h) in numerous studies with conflicting results. The previous systematic review included three randomized controlled trials (RCTs); however, the cutoff time for performing EGD was arbitrary. We performed an updated systematic review and meta-analysis of the studies comparing the outcomes of E-EGD and L-EGD group. METHODS: A comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science was undertaken to include both RCTs and cohort studies. Primary outcomes including overall mortality and secondary outcomes (recurrent bleeding, need for transfusion, and length of stay) were compared. Risk ratios and standardized mean difference (SMD) with 95% confidence interval (CI) were calculated. RESULTS: A total of 13 observational studies (with over 1.8 million patients) were included in the final analysis. No significant difference in overall mortality (risk ratio: 0.97; CI, 0.74-1.27), recurrent bleeding (risk ratio: 1.12; CI, 0.62-2.00), and length of stay (SMD: -0.07, CI, -0.31 to 0.18) was observed for E-EGD group compared to L-EGD group. The possibility of endoscopic intervention was higher in E-EGD group (risk ratio: 1.70, CI, 1.28-2.27). Consistent results were obtained for subgroup analysis of studies with 100% nonvariceal bleed (NVB) patient (risk ratio: 1.12; CI, 0.84-1.50). CONCLUSION: Given the outcomes and limitations, our meta-analysis did not demonstrate clear benefit of performing EGD within 24 h of presentation for UGIB (particularly NVB).

Trends and outcomes of fungal infections in hospitalized patients of inflammatory bowel disease: a nationwide analysis.

BACKGROUND: Immunosuppressive therapy is being increasingly used in the management of inflammatory bowel disease (IBD) which comprises of ulcerative colitis (UC) and Crohn's disease (CD). Patients on immunosuppressive therapy are at increased risk of developing opportunistic fungal infections. We conducted this analysis to describe the epidemiology of opportunistic fungal infections in this cohort. METHODS: We analyzed the National Inpatient Sample (NIS) database for all subjects with discharge diagnosis of IBD (UC and Crohn's disease) & Fungal infections (Histoplasmosis, Pneumocystosis, Cryptococcosis, Aspergillosis, Blastomycosis, candidiasis, Coccidioidomycosis) as primary or secondary diagnosis via ICD 9 codes during the period from 2002-2014. RESULTS: In UC, the incidence of all fungal infections was more in age above 50 (except for pneumoconiosis) male gender (except Candidiasis) and in Caucasians. In CD, the incidence was more in age above 50 (except Pneumocystosis, Blastomycosis & Coccidioidomycosis), female gender (except Histoplasmosis, Pneumocystosis & Cryptococcosis) and in Caucasians. Histoplasmosis and Blastomycosis were more prevalent in Midwest, Cryptococcosis and Candidiasis in South, Coccidioidomycosis in west in both UC and CD. Age above 50, south region, HIV, Congestive heart failure, underlying malignancies, diabetes mellitus with complications, chronic pulmonary disease, anemia, rheumatoid arthritis, collagen vascular disease, pulmonary circulation disorders, weight loss were significant predictors of fungal infections in IBD. The yearly trend showed a consistent small rise in incidence, and the mortality dropped till 2006 to peak again in 2008 with a subsequent decline. CONCLUSIONS: Our study is the first one to describe the basic demographics features and characteristics of opportunistic fungal infections in hospitalized patients with IBD. The yearly incidence of fungal infections did not show a significant rise. The mortality increased between 2006-2008 and a significant difference remains between IBD patients with and without fungal infections. One explanation of rise in mortality but a consistent incidence could be due to the use of biologics that did not increase but compromised the ability of IBD patients to fight opportunistic fungal infections.