Glucose control and psychosocial outcomes with use of automated insulin delivery for 12 to 96 weeks in type 1 diabetes: a meta-analysis of randomised controlled trials.

BACKGROUND: Glycaemic control of Type 1 Diabetes Mellitus (T1DM) remains a challenge due to hypoglycaemic episodes and the burden of insulin self-management. Advancements have been made with the development of automated insulin delivery (AID) devices, yet, previous reviews have only assessed the use of AID over days or weeks, and potential benefits with longer time of AID use in this population remain unclear. METHODS:  We performed a systematic review and meta-analysis of randomised controlled trials comparing AID (hybrid and fully closed-loop systems) to usual care (sensor augmented pumps, multiple daily insulin injections, continuous glucose monitoring and predictive low-glucose suspend) for adults and children with T1DM with a minimum duration of 3 months. We searched PubMed, Embase, Cochrane Central, and Clinicaltrials.gov for studies published up until April 4, 2023. Main outcomes included time in range 70-180 mg/dL as the primary outcome, and change in HbA1c (%, mmol/mol), glucose variability, and psychosocial impact (diabetes distress, treatment satisfaction and fear of hypoglycaemia) as secondary outcomes. Adverse events included diabetic ketoacidosis (DKA) and severe hypoglycaemia. Statistical analyses were conducted using mean differences and odds ratios. Sensitivity analyses were performed according to age, study duration and type of AID device. The protocol was registered in PROSPERO, CRD42022366710. RESULTS: We identified 25 comparisons from 22 studies (six crossover and 16 parallel designs) including a total of 2376 participants (721 in adult studies, 621 in paediatric studies, and 1034 in combined studies) which were eligible for analysis. Use of AID devices ranged from 12 to 96 weeks. Patients using AID had 10.87% higher time in range [95% CI 9.38 to 12.37; p < 0.0001, I2 = 87%) and 0.37% (4.77 mmol/mol) lower HbA1c (95% CI - 0.49% (- 6.39 mmol/mol) to - 0.26 (- 3.14 mmol/mol); p < 0·0001, I2 = 77%]. AID systems decreased night hypoglycaemia, time in hypoglycaemia and hyperglycaemia and improved patient distress, with no increase in the risk of DKA or severe hypoglycaemia. No difference was found regarding treatment satisfaction or fear of hypoglycaemia. Among children, there was no difference in glucose variability or time spent in hypoglycaemia between the use of AID systems or usual care. In sensitivity analyses, results remained consistent with the overall analysis favouring AID. CONCLUSION: The use of AID systems over 12 weeks, regardless of technical or clinical differences, improved glycaemic outcomes and diabetes distress without increasing the risk of adverse events in adults and children with T1DM.

The Single-Syringe Versus the Double-Syringe Techniques of Adenosine Administration for Supraventricular Tachycardia: A Systematic Review and Meta-Analysis.

INTRODUCTION: The intravenous double-syringe technique (DST) of adenosine administration is the first-line treatment for stable supraventricular tachycardia (SVT). Alternatively, the single-syringe technique (SST) was recently found to be potentially beneficial in several studies. This study aimed to perform a meta-analysis of the SST versus the DST of adenosine administration for the treatment of SVT. METHODS: We assessed EMBASE, PubMed, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) and non-randomized studies of intervention (NRSIs) comparing the DST to the SST of adenosine administration in patients with SVT. Outcomes included termination rate, termination rate at first dose, total administered dose, adverse effects, and discharge rate. RESULTS: We included four studies (three RCTs and one NRSI) with a total of 178 patients, of whom 99 underwent the SST of adenosine administration. No significant difference was found between treatment groups regarding termination rate, termination rate restricted to RCTs, total administered dose, and discharge rate. Termination rate at first dose (odds ratio 2.87; confidence interval 1.11-7.41; p = 0.03; I2 = 0%) was significantly increased in patients who received the SST. Major adverse effects were observed in only one study. CONCLUSIONS: The SST is probably as safe as the DST and at least as effective for SVT termination, SVT termination at first dose, and discharge rate from the emergency department. However, definitive superiority of one technique is not feasible given the limited sample size. REGISTRATION: PROSPERO identifier nº CRD42022345125.

Diagnostic Accuracy of ECG to Detect Left Ventricular Hypertrophy in Patients with Left Bundle Branch Block: A Systematic Review and Meta-analysis.

Background: Electrocardiographic (ECG) criteria to detect left ventricular hypertrophy (LVH) in patients with left bundle branch block (LBBB) remain under debate. We conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of different ECG criteria for diagnosing LVH in patients with LBBB. Methods: We searched PubMed, Embase, Cochrane, and LILACS for articles evaluating the diagnostic accuracy of ECG criteria for LVH in patients with LBBB published between 1984 and 2023. Echocardiogram, magnetic resonance imaging, or autopsy were used as the reference standard for diagnosis of LVH. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. The co-primary outcomes were sensitivity, specificity, the diagnostic odds ratio, and likelihood ratios, estimated using a bivariate generalized linear mixed model for each ECG criterion. The prespecified protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO). Results: We included 12 studies with a total of 1023 patients. We analyzed 10 criteria for LVH on ECG, including the Sokolow-Lyon criterion, the Cornell criterion, the RaVL (R wave in aVL) criterion, the Gubner-Ungerleider criterion, and the Dálfo criterion, among others. The Dalfó criterion was used for 487 patients and had the highest pooled sensitivity of 86% (95% confidence interval [CI] 57%-97%). All the other criteria had poor sensitivities. The Gubner-Ungerleider criterion and the RV5 or RV6 > 25 mm criterion had the highest specificities, with the former being used for 805 patients, obtaining a specificity of 99% (95% CI 80%-100%) and the latter being used for 355 patients, obtaining a specificity of 99% (95% CI 94%-100%). Conclusions: In patients with LBBB, the use of ECG criteria had poor performance for ruling out LVH, mostly due to low sensitivities. None of the criteria analyzed demonstrated a balanced tradeoff between sensitivity and specificity, suggesting that ECG should not be used routinely to screen for LVH.

Contexte: Les critères électrocardiographiques (ECG) visant à détecter une hypertrophie ventriculaire gauche (HVG) chez les patients présentant un bloc de branche gauche (BBG) font encore l'objet de discussions. Nous avons réalisé une synthèse des publications et une méta-analyse afin d'évaluer l'exactitude diagnostique de différents critères ECG pour le diagnostic de l'HVG chez les patients présentant un BBG. Méthodologie: Nous avons effectué une recherche dans les bases de données PubMed, Embase, Cochrane et LILACS afin de recenser les articles publiés entre 1984 et 2023 portant sur l'évaluation de l'exactitude de critères ECG pour le diagnostic d'une HVG chez les patients présentant un BBG. L'échocardiographie, l'imagerie par résonance magnétique et l'autopsie ont servi de normes de référence pour le diagnostic de l'HVG. Le risque de biais a été évalué au moyen de l'outil QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies). Les principaux critères d'évaluation étaient la sensibilité, la spécificité, le risque relatif approché diagnostique et les rapports de vraisemblance, estimés au moyen d'un modèle linéaire mixte généralisé à deux variables pour chaque critère ECG. Le protocole défini au préalable a été enregistré dans le registre international de revues systématiques prospectives PROSPERO. Résultats: Nous avons recensé 12 études, comptant au total 1 023 patients. Nous avons analysé 10 critères pour le diagnostic d'HVG à l'ECG, notamment l'indice de Sokolow-Lyon, l'indice de Cornell, l'onde R en aVL, l'indice de Gubner-Ungerleider et l'indice de Dálfo. Ce dernier a été utilisé pour 487 patients et avait la sensibilité regroupée la plus élevée, soit 86 % (intervalle de confiance [IC] à 95 % : 57-97 %). La sensibilité de tous les autres critères était faible. L'indice de Gubner-Ungerleider et le critère de l'onde R en V5 ou V6 > 25 mm étaient associés aux spécificités les plus élevées. Le premier a été utilisé pour 805 patients et présentait une spécificité de 99 % (IC à 95 % : 80-100 %). Le second a été utilisé pour 355 patients et présentait une spécificité de 99 % (IC à 95 % : 94-100 %). Conclusions: Chez les patients présentant un BBG, l'utilisation de critères ECG a été associée à un rendement médiocre pour exclure un diagnostic d'HVG, principalement en raison de la faible sensibilité de ces critères. Aucun des critères analysés n'offrait un compromis équilibré entre la sensibilité et la spécificité, ce qui porte à croire que l'ECG ne devrait pas être utilisée systématiquement pour dépister une HVG.