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BACKGROUND: The best initial strategy for managing epistaxis is unclear. We performed a systematic review and network meta-analysis (NMA) to compare the effectiveness of various noninvasive treatments for patients with epistaxis. METHODS: We searched PubMed, Embase, and the Cochrane Library from inception to September 2022 without language restrictions. Randomized controlled trials (RCTs) assessing immediate hemostasis, 2-day and 7-day rebleeding outcomes, as well as the use of noninvasive interventions for the treatment of epistaxis were selected. Frequentist NMA was performed. RESULTS: The systematic review included 20 RCTs (2994 participants) involving 12 different interventions. The NMA demonstrated that topical treatment with tranexamic acid (TXA) significantly reduced the odds of 2-day rebleeding compared with the control conservative treatment (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.21-0.61) and traditional anterior nasal packing (OR 0.45, 95% CI 0.26-0.76). The sensitivity analysis yielded robust results, and the overall evidence was high. Topical TXA significantly reduced the odds of 7-day rebleeding compared with traditional nasal packing (OR 0.33, 95% CI 0.15-0.70), with moderate evidence owing to the heterogeneous results. Despite the significant effects of topical TXA on achieving immediate hemostasis and Rapid Rhino nasal packing on preventing 2-day rebleeding compared to the control and traditional nasal packing, the evidence is low to very low due to heterogeneity, inconsistency, and within-study bias. CONCLUSIONS: In the treatment of epistaxis, topical TXA may be superior to conservative treatment or traditional nasal packing, particularly in preventing 2-day rebleeding.
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In pre-hospital settings, efficient cardiopulmonary resuscitation (CPR) is challenging; therefore, the application of mechanical CPR devices continues to increase. However, the evidence of the benefits of using mechanical CPR devices in pre-hospital settings for adult out-of-hospital cardiac arrest (OHCA) is controversial. This meta-analysis compared the effects of mechanical and manual CPR applied in the pre-hospital stage on clinical outcomes after OHCA. Cochrane Library, PubMed, Embase, and ClinicalTrials.gov were searched from inception until October 2021. Studies comparing mechanical and manual CPR applied in the pre-hospital stage for survival outcomes of adult OHCA were eligible. Data abstraction, quality assessment, meta-analysis, trial sequential analysis (TSA), and grading of recommendations, assessment, development, and evaluation were conducted. Seven randomized controlled and 15 observational studies were included. Compared to manual CPR, pre-hospital use of mechanical CPR showed a positive effect in achieving return of spontaneous circulation (ROSC) and survival to admission. No difference was found in survival to discharge and discharge with favorable neurological status, with inconclusive results in TSA. In conclusion, pre-hospital use of mechanical CPR devices may benefit adult OHCA in achieving ROSC and survival to admission. With low certainty of evidence, more well-designed large-scale randomized controlled trials are needed to validate these findings.
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INTRODUCTION: Erythrodermic psoriasis (EP) is a rare variant of psoriasis. Due to its rarity, evidence supporting its treatment is limited. Patients with erythrodermic psoriasis often respond less favorably to conventional treatment and have lower biologic drug survival compared with patients with plaque-type psoriasis. Guselkumab is an anti-interleukin-23 (IL-23) monoclonal antibody and has shown excellent and sustained treatment effect in moderate-to-severe plaque-type psoriasis. Until now, there is only one phase III open-label study reporting the effectiveness of guselkumab in this patient group. METHODS: Patients with chronic erythrodermic psoriasis who had been commenced on guselkumab were included in this retrospective study. All except one of our patients had plaque-type psoriasis prior to EP, and they met the criteria for EP before use of guselkumab. Due to inadequate response to previous treatment, including biologics, they were switched to guselkumab treatment. There was no washout period. They received guselkumab 100 mg at weeks 0 and 4, then every 8 weeks until at least week 28. Data were collected for patient demographics, Patient Area and Severity Index (PASI), and previous treatments. RESULTS: A total of 13 patients (12 male, 1 female) were included. The mean PASI improvement at weeks 4, 12, 20, and 28 was 37.5%, 60.9%, 67.5%, and 64.7%, respectively. The percentage of PASI 75 responders at weeks 4, 12, 20, and 28 was 15.4%, 38.5%, 53.9%, and 46.2%, respectively. At week 12, eight patients (61.5%) could achieve PASI 50 response. These PASI 50 responders at week 12 showed sustained and improved effectiveness during follow-up. CONCLUSION: Guselkumab is an effective biologic for treatment of moderate-to-severe plaque-type psoriasis, but the efficacy and drug survival are still compromised in EP patients. Our data describe the real-world experience of guselkumab treatment in this rare group of patients. Despite previous failure of other biologics, PASI response at week 12 is a good predictor of patient response and drug survival of guselkumab.
