ABSTRACT
Introduction: Tocilizumab (TCZ) is an anti-interleukin-6 antibody that has been used for the treatment of severe coronavirus disease 2019 (COVID-19). However, concrete evidence of its benefit in reducing mortality in severe COVID-19 is lacking. Therefore, we performed a systematic review and meta-analysis of relevant studies that compared the efficacy of TCZ in severe COVID-19 vs. standard of care (SOC) alone. Methods: A literature search for studies that compared "tocilizumab" and "standard of care" in the treatment of COVID-19 was done using major online databases from December 2019 to June 14, 2020. Search words "Tocilizumab," "anti-interleukin-6 antibody," and "COVID-19" or "coronavirus 2019" in various combinations were used. Articles in the form of abstracts, letters without original data, case reports, and reviews were excluded. Data were gathered on an Excel sheet, and statistical analysis was performed using Review Manager 5.3. Results: Sixteen studies were eligible from 693 initial studies, including 3,641 patients (64% males). There were 13 retrospective studies and three prospective studies. There were 2,488 patients in the SOC group (61.7%) and 1,153 patients (68.7%) in the TCZ group. The death rate in the TCZ group, 22.4% (258/1,153), was lower than in the SOC group, 26.21% (652/2,488) [pooled odds ratio 0.57 (95% CI 0.36-0.92), p = 0.02]. There was a significant heterogeneity (inconsistency index = 80%) among the included studies. Conclusion: The addition of TCZ to the SOC might reduce mortality in severe COVID-19. More extensive randomized clinical trials are needed to validate these findings.
ABSTRACT
Cirrhosis of liver is a major problem in the western world. Portal hypertension is a complication of cirrhosis and can lead to a myriad of pathology of which include the development of porto-systemic collaterals. Gastrointestinal varices are dilated submucosal veins, which often develop at sites near the formation of gastroesophageal collateral circulation. The incidence of varices is on the rise due to alcohol and obesity. The most significant complication of portal hypertension is life-threatening bleeding from gastrointestinal varices, which is associated with substantial morbidity and mortality. In addition, this can cause a significant burden on the health care facility. Gastrointestinal varices can happen in esophagus, stomach or ectopic varices. There has been considerable progress made in the understanding of the natural history, pathophysiology and etiology of portal hypertension. Despite the development of endoscopic and medical treatments, early mortality due to variceal bleeding remains high due to significant illness of the patient. Recurrent variceal bleed is common and in some cases, there is refractory variceal bleed. This article aims to provide a comprehensive review of the management of gastrointestinal varices with an emphasis on endoscopic interventions, strategies to handle refractory variceal bleed and newer endoscopic treatment modalities. Early treatment and improved endoscopic techniques can help in improving morbidity and mortality.
ABSTRACT
Management of acute cholecystitis includes initial stabilization and antibiotics. However, the most definitive treatment is cholecystectomy. A small percentage of patients who are not suitable for surgery due to the severity of cholecystitis or comorbidities will require a temporary measure as a bridge to surgery or permanent nonoperative management to decrease the mortality and morbidity. Most of these patients who require conservative management were managed with percutaneous transhepatic cholecystostomy or trans-papillary drainage of gallbladder drainage with cystic duct stenting through endoscopic retrograde cholangiopancreaticography (ERCP). Although, these conservative measures are effective, they can cause significant discomfort to the patients especially if used as a long-term measure. In view of this, there is a need for further minimally invasive procedures, which is safe, effective and comfortable to patients. Endoscopic ultrasound (EUS) guided gallbladder drainage is a novel method of gallbladder drainage first described in 2007[1]. Over the last decade, EUS guided gallbladder drainage has evolved as an effective alternative to percutaneous cholecystostomy and trans-papillary gallbladder drainage. Our goal is to review available literature regarding the scope of EUS guided gallbladder drainage as a viable alternative to percutaneous cholecystostomy or cystic duct stenting through ERCP among patients who are not suitable for cholecystectomy.
