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An inquiry into the treatment of sepsis using plasma exchange therapy: A systematic review and meta-analysis
Zhang L, Zhao XY, Guo SY, Jiang J, Wang G, Weng YB
International wound journal. 2023
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Abstract
Sepsis is a potentially lethal condition that occurs when the body's response to infection damages tissue and organs. The production of inflammatory mediators typically assists in defending the body against infection; however, an overreaction to inflammation can cause coagulation problems, vascular endothelial damage, and organ hypoperfusion. Blood purification methods, such as plasmapheresis, can effectively remove inflammatory mediators from plasma. The purpose of this meta-analysis was to explore the efficacy of plasma exchange for sepsis treatment as noted in recent studies. The authors searched the Pubmed (Medline), Cochrane Central Register of Controlled Trials (The Cochrane Library), Embase (Ovid), and Scopus databases and included controlled clinical studies that compared plasmapheresis or plasma filtration with conventional treatment in patients with severe sepsis. The Newcastle-Ottawa Scale literature quality assessment tool was used to assess the risk of bias. The primary study outcome was all-cause mortality. The random effects model was adopted for conducting the meta-analysis. Among the 1013 records found, the study included 5 trials, all of which carried a low risk of bias. The use of plasmapheresis was associated with a longer stay in the intensive care unit (odds ratio [OR], 0.85, 95% confidence interval [CI], 0.39-1.32, heterogeneity [I(2) ] = 0%), a significant reduction in all-cause mortality (OR, 0.54, 95% CI, 0.33-0.89, I(2) = 70%), and reduced mortality (OR, 0.29, 95% CI, 0.13-0.67, I(2) = 0%) in adults; the results for children differed from this (OR, 0.79, 95% CI, 0.36-1.72, I(2) = 89%). Four trials reported no adverse events; one trial reported an adverse event related to plasma exchange, including an instance of hypotension in one patient. Plasmapheresis appeared to be an effective treatment for patients suffering from sepsis. A large number of additional randomised controlled trials are needed to confirm this finding.
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Intravenous versus oral omeprazole on patients with high risk bleeding peptic ulcers: A prospective randomized clinical trial protocol
Zhang J, Diao P, Zhang L
Medicine. 2021;100(14):e25136
Abstract
BACKGROUND Proton pump inhibitors (PPIs) decrease the rate of rebleeding following endoscopic hemostatic therapy in patients with bleeding peptic ulcers. This study compares the efficacy of oral omeprazole vs intravenous omeprazole in decrease of rebleeding of peptic ulcer patients. METHOD The present study was authorized by the local research ethics committee of Jiangjin District Central Hospital (2020120987) and informed consent was obtained from all patients. All adult patients who were admitted to medical emergency rooms of Jiangjin District Central Hospital due to upper gastrointestinal bleeding (as evidenced by hematemesis, melena or hematochezia) were considered for inclusion in the study. Endoscopy was performed within 24 hours after admission. Patients older than 18 years with successful endoscopic therapy of high risk ulcers [defined as active bleeding (Forrest IA, IB), non-bleeding visible vessel (NBVV, Forrest IIA) or adherent clots (Forrest IIB)] were enrolled. Patients with low risk ulcers (clean base, ulcers with a simple washable clot), suspicious malignant ulcer, bleeding tendency, uremia, liver cirrhosis, Mallory Weiss tear or already on PPI as an outpatient were excluded from study. All were managed endoscopically by injecting 5-30 ml of epinephrine (diluted 1:10000) around the ulcer crater. Cavitations or flattening of bleeding vessel and disappearance of NBVV was considered as established homeostasis. A biopsy was taken from antrum for evaluating Helicobacter pylori infection. Patient with unsuccessful endoscopic therapy were not enrolled and were referred to general surgeon. Information on demography, history of previous upper gastrointestinal bleeding, NSAID or ASA ingestion, ulcer location, bleeding stigmata and blood transfusion volume at entry were recorded in all patients. In the oral omeprazole group, the patients received 40 mg omeprazole orally twice daily for 72 hours. In intravenous omeprazole group, they received omeprazole 80 mg bolus and then 8 mg/hour infusion for 48-72 hours. Then, all patients received omeprazole 20 mg orally for 30 days. On the day of discharge Helicobacter pylori infected patients received standard regimens. RESULTS Figure 1 showed the primary and secondary end points. DISCUSSION Intravenous administration of PPIs has limitations. They are expensive, require a dedicated intravenous line, need nursing supervision and hospital admission. So, it would be reasonable to prescribe oral PPIs to patients with high risk bleeding ulcers provided that it is as effective as its intravenous counterpart. Oral PPIs have a high bioavailability. Its effect initiates one hour after ingestion and the maximal plasma concentration is achieved after 2-3 hours. However, there are few studies comparing oral and intravenous PPI in decreasing risk of rebleeding in peptic ulcer patients. More high quality randomized controlled trials are still necessary. REGISTRATION NUMBER researchregistry 6588.
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Effectiveness of prothrombin complex concentrate (PCC) in neonates and infants with bleeding or risk of bleeding: a systematic review and meta-analysis
Zeng L, Choonara I, Zhang L, Li Y, Shi J
European Journal of Pediatrics. 2017;176((5):):581-589
Abstract
To systematically evaluate the effectiveness of prothrombin complex concentrate (PCC) in neonates and infants, we performed a systematic review and meta-analysis based on current evidence. Quality of studies was assessed by Cochrane Collaboration's risk of bias tool and Newcastle-Ottawa quality assessment scale. For dichotomous data, we obtained the number of events and total number and calculated the relative risk (RR) with 95% confidence intervals (CI). For continuous variables, we obtained mean and standard deviation (SD) values and calculated mean difference (MD) with 95% CI. We identified six trials and two cohort studies. For trials, selection bias and performance bias were high, while detection bias, attrition bias, and reporting bias were relatively low. For cohort studies, selection bias was low. Both individual studies and meta-analysis failed to find any benefit of PCC on mortality. Meta-analysis also failed to show any benefit in reducing intracranial hemorrhage. The effectiveness of PCC on the correction of hemostatic defects was inconsistent among studies. In addition, PCC was not more effective than fresh frozen plasma (FFP) in correcting hemostatic defects. CONCLUSION There is insufficient evidence to allow a recommendation for use of PCC in neonates and infants. What is Known: * Prothrombin Complex Concentrate is becoming increasingly used off-label for treatment of neonates and infants with severe bleeding or risk of severe bleeding. * Some case reports showed PCC seemed to be effective for infants and children with coagulation factor deficiency, but evidence about the effectiveness of PCC to reverse serious Vitamin K Deficiency Bleeding is limited. What is New: * As far as we know, this is the first systematic review that evaluates the effectiveness of PPC in neonates with bleeding or risk of bleeding. * There is insufficient evidence to allow a recommendation for use of PCCs in neonates and infants.
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A meta-analysis of the protective effect of recombinant human erythropoietin (rhEPO) for neurodevelopment in preterm infants
Wang H, Zhang L, Jin Y
Cell Biochemistry & Biophysics. 2015;71((2):):795-802.
Abstract
The purpose of this study is to assess the efficacy and safety of recombinant human erythropoietin (rhEPO) for improving neurodevelopment outcomes in preterm infants. According to the requirements of Cochrane systematic review, a literature search was performed among PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure, Wan Fang Data, and VIP INFORMATION from the establishment of the database from January 1999 to December 2011. Quality assessments of clinical trials were carried out. Randomized controlled trials (RCTs) or quasi-RCTs with rhEPO in preterm infants were enrolled, and RevMan5.0 software was used for meta-analysis. Data extraction, quality assessment, and meta-analysis for the results of homogeneous studies were done by two reviewers. The trials were analyzed using weighted mean difference (WMD) for continuous data and odds ratio (OR) for dichotomous data, both kinds of data were expressed by 95 % CI. For homogenous data (P > 0.10), fixed effect model was calculated. Two RCTs and 3 quasi-RCTs including 233 preterm infants (119 of treatment group and 114 of control group) were included in the analysis. The results of quality assessment were that 1 study was A, 1 was B, and 3 were C. There was evidence of a significant effect of therapeutic rhEPO on the outcomes of MDI scores [WMD = 7.77, 95 % CI (3.49-12.06), P = 0.0004], PDI scores [WMD = 3.85, 95 % CI (0.62-7.09), P = 0.02] at 18-22 months and NBNA scores [WMD = 1.96, 95 % CI (1.56-2.37), P < 0.00001] at 40 weeks of corrected gestational age. However, rhEPO had no effect on MDI <70 (OR = 0.70, 95 % CI 0.31-1.61), PDI <70 (OR = 2. 46, 95 % CI 0.94-6.45), cerebral palsy (OR = 1.08, 95 % CI 0.39-2.99), blindness (OR = 0.34, 95 % CI 0.01-8.56), and hearing loss (OR = 1.04, 95 % CI 0.06-17.15). There were no differences between groups with respect to the percentage of preterm infants with severe retinopathy of prematurity of stage III or above (OR = 1.30, 95 % CI 0.50-3.43), severe intraventricular hemorrhage of stage III or above (OR = 2. 91, 95 % CI 0.64-13.23), necrotizing enterocolitis (OR = 0.57, 95 % CI 0.13-2.54), and borderline personality disorder (OR = 1. 06, 95 % CI 0.50-2.26). The rhEPO treatment has beneficial effect on the neurodevelopment outcomes without severe adverse side effect in preterm infants.