1.
Time and Predictors of Treatment for Aneurysmal Subarachnoid Haemorrhage (ASAH): A Systematic Review
Nguyen TP, Rehman S, Stirling C, Chandra R, Gall S
International journal for quality in health care : journal of the International Society for Quality in Health Care. 2021
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) is a serious form of stroke, for which rapid access to specialist neurocritical care is associated with better outcomes. Delays in the treatment of aSAH appears to be common and may contribute to poor outcomes. We have a limited understanding of the extent and causes of these delays, which hinders the development of interventions to reduce delays and improve outcomes. The aim of this systematic review was to quantify and identify factors associated with time to treatment in aSAH. METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and was registered in PROSPERO (Reg No. CRD42019132748). We searched four electronic databases databases (MEDLINE, EMBASE, Web of Science, and Google Scholar) for manuscripts published from January 1998 using pre-designated search terms and search strategy. Main outcomes were duration of delays of time intervals from onset of aSAH to definitive treatment and/or factors related to time to treatment. RESULTS A total of 64 studies with 16 different time intervals in the pathway of aSAH patients were identified. Measures of time to treatment varied between studies (e.g. cut-off timepoints or absolute mean/median duration). Factors associated with time to treatment fell into two categories - individual (n=9 factors e.g. age, sex, clinical characteristics) and health system (n=8 factors, e.g. pre-hospital delay or presentation out-of-hours). Demographic factors were not associated with time to treatment. More severe aSAH reduced treatment delay in most studies. Pre-hospital delays (patients delay, late referral, late arrival of ambulance, being transferred between hospitals or arriving at the hospital outside of office hours) were associated with treatment delay. In-hospital factors (patients with complications, procedure before definitive treatment, slow work-up, type of treatment) were less associated with treatment delay. CONCLUSIONS The pathway from onset to definitive treatment of a patients with aSAH consists of multiple stages with multiple influencing factors. This review provides the first comprehensive understanding of extent and factors associated with time to treatment of aSAH. There is an opportunity to target modifiable factors to reduce time to treatment but further research considering more factors are needed.
2.
Efficacy and safety of tranexamic acid in orthopaedic fracture surgery: a meta-analysis and systematic literature review
Amer KM, Rehman S, Amer K, Haydel C
Journal of Orthopaedic Trauma. 2017;31((10)):520-525.
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug that has been shown to be effective in reducing blood loss and the need for transfusions after several orthopaedic surgeries. However, the effectiveness of TXA use in orthopaedic fracture surgeries still remains unclear. The purpose of this meta-analysis was to review existing literature with interest in the effectiveness and safety of TXA treatment in reducing total blood loss and transfusion rates for patients who underwent surgery for fracture repairs. METHODS An electronic literature search of PubMed, Embase, OVID, and the Cochrane Library was conducted to identify studies published before December 2016. All randomized controlled trials and cohort studies evaluating the efficacy of TXA during fracture repair surgeries were identified. Primary outcome measures included the number of patients receiving a blood transfusion and perioperative total blood loss. Data were analyzed using Comprehensive Meta-Analysis (CMA) statistical software. RESULTS Seven studies encompassing 559 patients met the inclusion criteria for the meta-analysis. Our meta-analysis indicated that when compared with the placebo control group, the use of TXA in fracture surgeries significantly reduced total blood loss by approximately 330 mL (P = 0.009), reduced the transfusion rate with a relative risk of 0.54 (P < 0.001), and decreased the drop of hemoglobin by 0.76 g/dL (P < 0.001). There was no significant difference between the number of thromboembolic events among the study groups (P = 0.24). CONCLUSIONS This study demonstrated that tranexamic acid may be used in orthopaedic fracture surgeries to reduce total blood loss, transfusion rates, and the drop in hemoglobin level, without increasing risk of venous thrombo-embolism. A limitation to these findings is the small number of studies available. Further studies need to be conducted to confirm these findings. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.