Contemporary Management of Concomitant Cardiac Arrest and Cardiogenic Shock Complicating Myocardial Infarction

Cardiogenic shock (CS) and cardiac arrest (CA) are the most life-threatening complications of acute myocardial infarction. Although there is a significant overlap in the pathophysiology with approximately half the patients with CS experiencing a CA and approximately two-thirds of patients with CA developing CS, comprehensive guideline recommendations for management of CA + CS are lacking. This paper summarizes the current evidence on the incidence, pathophysiology, and short- and long-term outcomes of patients with acute myocardial infarction complicated by concomitant CA + CS. We discuss the hemodynamic factors and unique challenges that need to be accounted for while developing treatment strategies for these patients. A summary of expert-based step-by-step recommendations to the approach and treatment of these patients, both in the field before admission and in-hospital management, are presented.     

Janus Kinase Inhibitors and Risk of Venous Thromboembolism: A Systematic Review and Meta-analysis

ObjectiveTo assess the risk of venous thromboembolism (VTE) in patients treated with Janus kinase (JAK) inhibitors in clinical trials.Patients and MethodsWe performed a literature search of Ovid MEDLINE and ePub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily; Ovid EMBASE; Ovid Cochrane Central Register of Controlled Trials; Ovid Cochrane Database of Systematic Reviews; and Scopus, from inception to December 4, 2019, for randomized, placebo-controlled trials with JAK inhibitors as an intervention and reported adverse events. Odds ratio with 95% CI was calculated to estimate the VTE risk using a random effects model. Two independent reviewers screened and extracted data. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to assess certainty in estimated VTE risk.ResultsWe included 29 trials (13,910 patients). No statistically significant association was found between use of JAK inhibitors and risk of VTE (odds ratio, 0.91; 95% CI, 0.57 to 1.47; P=.70; I²=0; low certainty because of serious imprecision). Results using Bayesian analysis were consistent with those of the primary analysis. Results of stratified and meta-regression analyses suggested no interaction by dose of drug, indication for treatment, or length of follow-up.ConclusionWe found insufficient evidence to support an increased risk of JAK inhibitor–associated VTE based on currently available data.     

Effect of the Renin-Angiotensin System Inhibitors on Inflammatory Markers: A Systematic Review and Meta-analysis of Randomized Controlled Trials

ObjectiveTo synthesize more conclusive evidence on the anti-inflammatory effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs).MethodsPubMed, Scopus, and Embase were searched from inception until March 1, 2021. We included randomized controlled trials (RCTs) that assessed the effect of ACEIs or ARBs, compared with placebo, on any of the following markers: C-reactive protein (CRP), interleukin 6 (IL-6), or tumor necrosis factor α (TNF-α). Mean changes in the levels of these markers were pooled as a weighted mean difference (WMD) with a 95% CI.ResultsThirty-two RCTs (n=3489 patients) were included in the final analysis. Overall pooled analysis suggested that ACEIs significantly reduced plasma levels of CRP (WMD, ?0.54 [95% CI, ?0.88 to ?0.21]; P=.002; I²=96%), IL-6 (WMD, ?0.84 [95% CI, ?1.03 to ?0.64]; P<.001; I²=0%), and TNF-α (WMD, ?12.75 [95% CI, ?17.20 to ?8.29]; P<.001; I²=99%). Moreover, ARBs showed a significant reduction only in IL-6 (WMD, ?1.34 [95% CI, ?2.65 to ?0.04]; P=.04; I²=85%) and did not significantly affect CRP (P=.15) or TNF-α (P=.97) levels. The lowering effect of ACEIs on CRP levels remained significant with enalapril (P=.006) and perindopril (P=.01) as well as with a treatment duration of less than 24 weeks (WMD, -0.67 [95% CI, ?1.07 to -0.27]; P=.001; I²=94%) and in patients with coronary artery disease (WMD, ?0.75 [95% CI, ?1.17 to ?0.33]; P<.001; I²=96%).ConclusionBased on this meta-analysis, ACEIs showed a beneficial lowering effect on CRP, IL-6, and TNF-α, whereas ARBs were effective as a class in reduction of IL-6 only.     

High-Intensity Interval Training in Cardiac Rehabilitation: Impact on Fat Mass in Patients With Myocardial Infarction

ObjectiveTo examine the effect of high-intensity interval training (HIIT) on body fat mass and distribution in patients with myocardial infarction (MI) who underwent cardiac rehabilitation (CR).Patients and MethodsWe retrospectively screened 391 consecutive patients with MI enrolled in CR between September 1, 2015, and February 28, 2018. We included 120 patients who completed 36 CR sessions and underwent pretest-posttest dual-energy x-ray absorptiometry; 90 engaged in HIIT, and 30 engaged in moderate-intensity continuous training (MICT). High-intensity interval training included 4 to 8 alternating intervals of high- (30-60 seconds at a rating of perceived exertion [RPE] of 15-17 [Borg scale range, 6-20]) and low-intensity (1-5 minutes at RPE <14), and MICT performed for 20 to 45 minutes of exercise at an RPE of 12 to 14. Body weight, fat mass, and lean mass were measured via dual-energy x-ray absorptiometry with lipid profile measured via clinical procedures.ResultsThe HIIT and MICT groups were similar in age (67 vs 67 years), sex (26.7% [24 of 90 patients in the HIIT group] vs 26.7% [8 of 30 in the MICT group), and body mass index (30.3 vs 29.5 kg/m²) at baseline. The HIIT group had greater reductions in body fat percentage (P<.001), fat mass (P<.001), abdominal fat percentage (P<.001), waist circumference (P=.01), total cholesterol (P=.002), low-density lipoprotein cholesterol (P<.001), and triglycerides (P=.006). Improvements in total body mass and body mass index were not different across groups. After matching exercise duration, exercise intensity, and energy expenditure, HIIT-induced improvements in total fat mass (P=.02), body fat percentage (P=.01), and abdominal fat percentage (P=.02) persisted.ConclusionOur data suggest that supervised HIIT results in significant reductions in total fat mass (P<.001) and abdominal fat percentage (P<.001) and improved lipid profile in patients with MI who undergo CR.     

Outcomes of Patients With Type 2 Myocardial Infarction Complicating Acute Ischemic Stroke

ObjectiveTo study the patient profiles and the prognostic impact of type 2 myocardial infarction (MI) on outcomes of acute ischemic stroke (AIS).MethodsThe National Readmission Database 2018 was queried for patients with primary AIS hospitalizations with and without type 2 MI. Baseline characteristics, inpatient outcomes, and 30-day all-cause readmissions between cohorts were compared.ResultsOf 587,550 AIS hospitalizations included in the study, 4182 (0.71%) had type 2 MI. Patients with type 2 MI were older (73.6 years vs 70.1 years; P<.001) and more likely to be female (52% vs 49.7%; P<.001), and they had a higher prevalence of heart failure (32.6% vs 15.5%; P<.001), atrial fibrillation (38.5% vs 24.2%; P<.001), prior MI (8.8% vs 7.7%; P<.001), valvular heart disease (17% vs 9.8%; P<.001), peripheral vascular disease (12.2% vs 9.2%; P<.001), and chronic kidney disease (24.4% vs 16.7%; P<.001). Compared with patients without type 2 MI, AIS patients with type 2 MI had significantly higher in-hospital mortality (adjusted odds ratio [aOR], 1.96; 95% CI, 1.65 to 2.32), poor functional outcome (aOR, 1.80; 95% CI, 1.62 to 2.00), more hospital costs (adjusted parameter estimate, $5618; 95% CI, $4480 to $6755), higher rate of discharge to a facility (aOR, 1.70; 95% CI, 1.52 to 1.90), increased length of stay (adjusted parameter estimate, 2.22; 95% CI, 1.72 to 2.72), and higher rate of 30-day all-cause readmissions (aOR, 1.38; 95% CI, 1.18 to 1.60).ConclusionType 2 MI in patients hospitalized with AIS is associated with poor prognosis and higher resource utilization.     

Edaravone for Acute Ischemic Stroke: A Systematic Review and Meta-analysis

PurposeThe management of acute stroke is challenging. The aim of this meta-analysis was to determine the efficacy and tolerability of edaravone, with or without thrombolytic therapy, in the treatment of patients with acute ischemic stroke.MethodsThe PubMed, EMBASE, and Cochrane databases were searched for randomized controlled trials (RCTs) and cohort studies. Mean differences (MD), risk ratios (RR), 95% confidence interval (CI), and heterogeneity were calculated.FindingsTotals of nine RCTs and four cohort studies were included, for a total of 2102 patients. In patients with acute ischemic stroke, edaravone monotherapy was associated with significantly improved Barthel Index of functioning in activities for daily living (MD, 23.95; 95% CI, 18.48 to 29.41; P < 0.001) and neurologic deficit, (as measured using the National Institutes of Health Stroke Scale score) (MD = –3.49; 95% CI, –5.76 to 1.22; P = 0.003), on short-term follow-up. However, edaravone was not associated with an improved rate of death or disability (RR = 0.75; 95% CI, 0.45 to 1.23; P = 0.25) on long-term follow-up.When plus to thrombolytic therapy, edaravone was associated with significant improvements in recanalization rate (RR = 1.71; 95% CI, 1.05 to 2.77; P = 0.03) and neurologic deficit (MD = 3.97; 95% CI, 5.14 to 2.79; P < 0.001), without an increase in the prevalence of bleeding events (RR = 1.11; 95% CI, 0.76 to 1.62; P = 0.59). However, edaravone did not have a significant effect on death or disability (RR = 0.85; 95% CI, 0.69 to 1.04; P = 0.12).ImplicationsBased on the findings from the present meta-analysis, edaravone was an effective and well-tolerated neuroprotective agent in these patients with ischemic stroke. With the use of edaravone, activities of daily living and neurologic deficits, along with recanalization rates, were improved on short-term follow-up, but the long-term effects still need confirmation in larger-scale clinical trials.     

Clinical Characteristics,Management Strategies and Outcomes of Acute Myocardial Infarction Patients With Prior Coronary Artery Bypass Grafting

ObjectiveTo investigate the management strategies, temporal trends, and clinical outcomes of patients with a history of coronary artery bypass graft (CABG) surgery and presenting with acute myocardial infarction (MI).Patients and MethodsWe undertook a retrospective cohort study using the National Inpatient Sample database from the United States (January 2004–September 2015), identified all inpatient MI admissions (7,250,768 records) and stratified according to history of CABG (group 1, CABG-naive [94%]; group 2, prior CABG [6%]).ResultsPatients in group 2 were older, less likely to be female, had more comorbidities, and were more likely to present with non-ST-elevation myocardial infarction compared with group 1. More patients underwent coronary angiography (68% vs 48%) and percutaneous coronary intervention (PCI) (44% vs 26%) in group 1 compared with group 2. Following multivariable logistic regression analyses, the adjusted odd ratio (OR) of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.98; 95% CI, 0.95 to 1.005; P=.11), all-cause mortality (OR, 1; 95% CI, 0.98 to 1.04; P=.6) and major bleeding (OR, 0.99; 95% CI, 0.94 to 1.03; P=.54) were similar to group 1. Lower adjusted odds of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.64; 95% CI, 0.57 to 0.72; P<.001), all-cause mortality (OR, 0.45; 95% CI, 0.38 to 0.53; P<.001), and acute ischemic stroke (OR, 0.71; 95% CI, 0.59 to 0.86; P<.001) were observed in group 2 patients who underwent PCI compared with those managed medically without any increased risk of major bleeding (OR, 1.08; 95% CI, 0.94 to 1.23; P=.26).ConclusionsIn this national cohort, MI patients with prior-CABG had a higher risk profile, but similar in-hospital adverse outcomes compared with CABG-naive patients. Prior-CABG patients who received PCI had better in-hospital clinical outcomes compared to those who received medical management.     

Women Are Less Likely to Survive AMI Presenting With Out-of-Hospital Cardiac Arrest: A Nationwide Study

ObjectiveTo assess the impact of patient’s sex on outcomes and management of acute myocardial infarction (AMI) patients presenting with out-of-hospital cardiac arrest (OHCA).Patients and MethodsWe conducted a population-based retrospective cohort study in AMI patients admitted with OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) registry. We used multivariable logistic regression models to evaluate the role of sex as a predictor of clinical outcomes and treatment strategy.ResultsOf 16,278 patients, women constituted almost one-quarter of the population (n=3710 [22.7%]). Women were older (median age 69 [IQR, 57-79] years vs 63 [IQR, 54-72] years, P<.001), experienced longer call-to-hospital-arrival time (median, 1.2 hours vs 1.1 hours; P=.008), were less likely to present with shockable rhythm (86.8% vs 91.5%, P<.001), and less likely to receive dual antiplatelet therapy (73.8% vs 78.6%, P<.001), beta blockers (64.7% vs 72.3%, P<.001), angiotensin-converting enzyme inhibitors (49.0% vs 55.3%, P<.001), coronary angiography (73.7% vs 83.3%, P<.001), and percutaneous coronary intervention (37.5% vs. 40.7%, p 0.004). After adjusting for patient characteristics and management, women had significantly higher odds of in-hospital death compared with men (odds ratio [OR], 1.3; 95% CI, 1.1 to 1.5) and lower odds of receiving coronary angiography (OR, 0.67; 95% CI, 0.59 to 0.75) and coronary artery bypass graft (OR, 0.28; 95% CI, 0.19 to 0.40).ConclusionWomen were less likely to survive following OHCA secondary to AMI. Hospital protocols that minimize physician bias and improve women-physician communication are needed to close this gap.     

Effectiveness of Physical Therapy Interventions in Reducing Fear of Falling Among Individuals With Neurologic Diseases: A Systematic Review and Meta-analysis

ObjectiveTo summarize the effectiveness of physical therapy interventions to reduce fear of falling (FOF) among individuals living with neurologic diseases.Data SourcesPubMed, Physiotherapy Evidence Database, Scopus, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health, and SportDiscuss were searched from inception until December 2019.Study SelectionClinical trials with either the primary or secondary aim to reduce FOF among adults with neurologic diseases were selected.Data ExtractionPotential articles were screened for eligibility, and data were extracted by 2 independent researchers. Risk of bias was assessed by the Cochrane Risk of Bias tool for randomized controlled trials and the National Institutes of Health Quality Assessment Tool for pre-post studies. A meta-analysis was performed among trials presenting with similar clinical characteristics. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to rate the overall quality of evidence.ResultsSixty-one trials with 3954 participants were included in the review and 53 trials with 3524 participants in the meta-analysis. The included studies presented, in general, with a low to high risk of bias. A combination of gait and balance training was significantly more effective compared with gait training alone in reducing FOF among individuals with Parkinson disease (PD) (mean difference [MD]=11.80; 95% CI, 8.22-15.38; P<.001). Home-based exercise and leisure exercise demonstrated significant improvement in reducing FOF over usual care in multiple sclerosis (MS) (MD=15.27; 95% CI, 6.15-24.38; P=.001). No statistically significant between-groups differences were reported among individuals with stroke and spinal cord injury. The overall quality of evidence presented in this review ranges from very low to moderate according to the assessment with the GRADE approach.ConclusionsGait with lower limb training combined with balance training is effective in reducing FOF in individuals with PD. Also, home-based or leisure exercise is effective among individuals with MS. However, because of several limitations of the included studies, further research is needed to examine the effectiveness of FOF intervention among individuals with neurologic diseases.     

Direct Oral Anticoagulants Compared With Dalteparin for Treatment of Cancer-Associated Thrombosis: A Living,Interactive Systematic Review and Network Meta-analysis

ObjectiveTo maintain living, interactive evidence (LIvE) on the benefits and harms of different treatment options in adults with cancer-associated thrombosis (CAT).MethodsWe have used a novel LIvE synthesis framework to maintain this living, interactive systematic review since September 19, 2018. Randomized controlled trials evaluating the efficacy and safety of direct oral anticoagulants (DOACs) compared with low-molecular-weight heparin for CAT are included in this analysis. Details of LIvE synthesis framework are available at the website https://cat.network-meta-analysis.com.ResultsThe results are constantly updated as new information becomes available (https://cat.network-meta-analysis.com/CAT.html). The living, interactive systematic review currently includes 4 randomized controlled trials (N=2894). Direct comparisons show that DOACs significantly decrease recurrent venous thromboembolism (VTE) events compared with dalteparin (odds ratio [OR], 0.59; 95% CI, 0.41 to 0.86; I², 25%) without significantly increasing major bleeding (OR, 1.34; 95% CI, 0.83 to 2.18; I², 28%). Mixed treatment comparisons show that apixaban (OR, 0.41; 95% credible interval [CrI], 0.16 to 0.95) and rivaroxaban (OR, 0.58; 95% CrI, 0.37 to 0.90) significantly decrease VTE recurrent events compared with dalteparin. Edoxaban significantly increases major bleeding compared with dalteparin (OR, 1.73; 95% CrI, 1.04 to 3.16), and rivaroxaban significantly increases clinically relevant nonmajor bleeding compared with dalteparin and other DOACs. There are no significant differences between DOACs in terms of VTE recurrences and major bleeding.ConclusionDOACs should be considered a standard of care for the treatment of CAT except in patients with a high risk of bleeding. Current evidence favors the use of apixaban for the treatment of CAT among other DOACs.RegistrationOpen Science Framework (https://osf.io/dth86).     

The Effectiveness and Safety of Platelet-Rich Plasma for Chronic Wounds: A Systematic Review and Meta-analysis

ObjectiveTo evaluate the effectiveness and adverse events of autologous platelet-rich plasma (PRP) in individuals with lower-extremity diabetic ulcers, lower-extremity venous ulcers, and pressure ulcers.Patients and MethodsWe searched multiple databases from database inception to June 11, 2020, for randomized controlled trials and observational studies that compared PRP to any other wound care without PRP in adults with lower-extremity diabetic ulcers, lower-extremity venous ulcers, and pressure ulcers.ResultsWe included 20 randomized controlled trials and five observational studies. Compared with management without PRP, PRP therapy significantly increased complete wound closure in lower-extremity diabetic ulcers (relative risk, 1.20; 95% CI, 1.09 to 1.32, moderate strength of evidence [SOE]), shortened time to complete wound closure, and reduced wound area and depth (low SOE). No significant changes were found in terms of wound infection, amputation, wound recurrence, or hospitalization. In patients with lower-extremity venous ulcers or pressure ulcers, the SOE was insufficient to estimate an effect on critical outcomes, such as complete wound closure or time to complete wound closure. There was no statistically significant difference in adverse events.ConclusionAutologous PRP may increase complete wound closure, shorten healing time, and reduce wound size in individuals with lower-extremity diabetic ulcers. The evidence is insufficient to estimate an effect on wound healing in individuals with lower-extremity venous ulcers or pressure ulcers.Trial RegistrationPROSPERO Identifier: CRD42020172817     

Acute Myocardial Infarction in Autoimmune Rheumatologic Disease: A Nationwide Analysis of Clinical Outcomes and Predictors of Management Strategy

ObjectivesTo examine national-level differences in management strategies and outcomes in patients with autoimmune rheumatic disease (AIRD) with acute myocardial infarction (AMI) from 2004 through 2014.MethodsAll AMI hospitalizations were analyzed from the National Inpatient Sample, stratified according to AIRD diagnosis into 4 groups: no AIRD, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis (SSC). The associations between AIRD subtypes and (1) receipt of coronary angiography and percutaneous coronary intervention (PCI) and (2) clinical outcomes were examined compared with patients without AIRD.ResultsOf 6,747,797 AMI hospitalizations, 109,983 patients (1.6%) had an AIRD diagnosis (RA: 1.3%, SLE: 0.3%, and SSC: 0.1%). The prevalence of RA rose from 1.0% (2004) to 1.5% (2014), and SLE and SSC remained stable. Patients with SLE were less likely to receive invasive management (odds ratio [OR] [95% CI]: coronary angiography—0.87; 0.84 to 0.91; PCI—0.93; 0.90 to 0.96), whereas no statistically significant differences were found in the RA and SSC groups. Subsequently, the ORs (95% CIs) of mortality (1.15; 1.07 to 1.23) and bleeding (1.24; 1.16 to 1.31) were increased in patients with SLE; SSC was associated with increased ORs (95% CIs) of major adverse cardiovascular and cerebrovascular events (1.52; 1.38 to 1.68) and mortality (1.81; 1.62 to 2.02) but not bleeding or stroke; the RA group was at no increased risk for any complication.ConclusionIn a nationwide cohort of AMI hospitalizations we found lower use of invasive management in patients with SLE and worse outcomes after AMI in patients with SLE and SSC compared with those without AIRD.     

Effectiveness and Safety of Clopidogrel vs Aspirin in Elderly Patients With Ischemic Stroke

ObjectiveTo evaluate the risks of recurrent stroke and major bleeding events with clopidogrel and aspirin use among patients aged 80 years or older.Patients and MethodsThis retrospective cohort study was conducted using the Full Population Data of the Health and Welfare Database in Taiwan. Patients aged 80 years or older who received monotherapy with clopidogrel or aspirin following hospitalization for primary acute ischemic stroke between January 1, 2009, and December 31, 2018, were included. Inverse probability of treatment weighting was used to balance measured covariates between clopidogrel and aspirin users. Measured outcomes included recurrent acute ischemic stroke, acute myocardial infarction, composite cardiovascular events (recurrent stroke or acute myocardial infarction), intracranial hemorrhage, major gastrointestinal tract bleeding, and composite major bleeding events (intracranial hemorrhage or major gastrointestinal tract bleeding).ResultsA total of 15,045 patients were included in the study, 1979 of whom used clopidogrel and 13,066 who used aspirin following hospitalization for primary acute ischemic stroke. Clopidogrel use was associated with significantly lower risk of recurrent acute ischemic stroke (hazard ratio [HR], 0.89; 95% CI, 0.83 to 0.96; P=.002), composite cardiovascular events (HR, 0.88; 95% CI, 0.82 to 0.95; P<.001), intracranial hemorrhage (HR, 0.71; 95% CI, 0.56 to 0.90; P=.005), and composite major bleeding events (HR, 0.89; 95% CI, 0.80 to 0.99; P=.04) compared with aspirin use.ConclusionIn patients aged 80 years or older with primary acute ischemic stroke, clopidogrel users had lower risks of recurrent stroke and the composite cardiovascular events compared with aspirin users. Clopidogrel users also had lower risks of intracranial hemorrhage and the composite major bleeding events compared with aspirin users.     

Comparative Effectiveness of Orthoses for Thumb Osteoarthritis: A Systematic Review and Network Meta-analysis

ObjectiveTo evaluate the best option among orthoses for carpometacarpal (CMC) osteoarthritis (OA) of the thumb, using a network meta-analysis.Data SourcesMedline, Embase, Cochrane, and ClinicalTrials.gov registry databases were used. PubMed, Embase, Cochrane Controlled Trials Register, Cochrane, and other databases were used without language restrictions.Study SelectionWe searched randomized controlled trials (RCTs) on adults with OA of the thumb by studying any orthosis from the beginning to March 10, 2020.Data ExtractionData were extracted and checked for accuracy and completeness by pairs of reviewers. Outcomes were pain and function. Comparative treatment effects were analyzed by random-effects model for direct pairwise comparisons and Bayesian network meta-analyses to integrate direct and indirect evidence.Data SynthesisEleven RCTs involving 619 patients were included. We evaluated 5 groups, for 4 different orthoses: short thermoplastic CMC splint (rigid CMC) (n=5), long thermoplastic carpometacarpal-metacarpophalangeal splint (rigid CMC-MCP) (n=7), short neoprene CMC splint (soft CMC) (n=1), long neoprene CMC-MCP splint (soft CMC-MCP) (n=5), and one as a control group (n=5). Our results show that all splints were superior to placebo to reduce pain intensity and the top-ranked intervention was the rigid CMC-MCP (surface under the cumulative ranking curve analysis [SUCRA], score: 65.4). In function evaluation, we report a 71.6 SUCRA for rigid CMC.ConclusionsAlthough the current evidence is unclear on the use of the splint in OA of the thumb, it is not known which orthosis is more effective and whether the orthosis is more effective than other interventions. The network meta-analysis shows that a long thermoplastic splint it is the best choice for pain relief and the short thermoplastic CMC splint is the best treatment to increase function. These results may suggest initial treatment with a long rigid orthosis and then a short rigid orthosis.     

The Effect of Convalescent Plasma Therapy on Mortality Among Patients With COVID-19: Systematic Review and Meta-analysis

To determine the effect of COVID-19 convalescent plasma on mortality, we aggregated patient outcome data from 10 randomized clinical trials, 20 matched control studies, 2 dose-response studies, and 96 case reports or case series. Studies published between January 1, 2020, and January 16, 2021, were identified through a systematic search of online PubMed and MEDLINE databases. Random effects analyses of randomized clinical trials and matched control data demonstrated that patients with COVID-19 transfused with convalescent plasma exhibited a lower mortality rate compared with patients receiving standard treatments. Additional analyses showed that early transfusion (within 3 days of hospital admission) of higher titer plasma is associated with lower patient mortality. These data provide evidence favoring the efficacy of human convalescent plasma as a therapeutic agent in hospitalized patients with COVID-19.     

Association of Physical Activity With Primary Cardiac Arrest Risk in the General Population: A Nationwide Cohort Study of the Dose-Response Relationship

ObjectiveTo quantify the dose-response relationship between moderate to vigorous physical activity and primary cardiac arrest (PCA).Patients and MethodsThere were 504,840 participants older than 18 years who underwent the Korean National Health Screening Program, including a self-administered questionnaire for physical activity from January 1, 2009, through December 31, 2014. Physical activity levels were converted into metabolic equivalent tasks (METs) per week and categorized to correspond with multiples of public health recommendations. We evaluated the quantitative and categorical dose-response relationship between physical activity and PCA.ResultsA curvilinear dose-response relationship between physical activity and PCA was observed; the benefits started at two-thirds (5 MET-hour/week) of the United States and World Health Organization guidelines–recommended minimum (7.5 MET-hour/week) and continued to 5 times (40 MET-hour/week) the recommended minimum (P nonlinearity <.001). The largest benefit was noted at a level of 2 to 3 times the recommended minimum (hazard ratio, 0.6; 95% CI, 0.4 to 0.8). In addition, there was no evidence of an increased PCA risk at a level more than 5 times the recommended minimum (hazard ratio, 0.7; 95% CI, 0.5 to 1.1). These associations were consistent regardless of age, sex, body mass index, comorbid conditions, and estimated 10-year risk for cardiovascular disease.ConclusionThe beneficial effect of physical activity on PCA started at two-thirds of the recommended minimum and continued to 5 times the recommended minimum. No excess risk for PCA was present among individuals with activity levels more than 5 times the recommended minimum regardless of cardiovascular disease or lifestyle risk factor presence.     

Is Fatigue Associated With Aerobic Capacity and Muscle Strength in People With Multiple Sclerosis: A Systematic Review and Meta-analysis

ObjectiveTo determine the relationship between self-reported fatigue and aerobic capacity and muscle strength in people with multiple sclerosis (MS).Data SourcesFour databases (Cumulative Index to Nursing and Allied Health, MEDLINE, ProQuest, and Web of Science Core Collections) were searched up to October 2018.Study SelectionCross-sectional or longitudinal studies that reported the association between self-reported fatigue and aerobic capacity or objectively measured muscle strength in people with MS were included.Data ExtractionStudy details, participant demographics, outcome measurement protocols, and the correlation coefficient derived from the association between fatigue and aerobic capacity or muscle strength at baseline was extracted, and methodological quality of included studies was assessed using the Joanna Briggs Institute Appraisal Checklist for Analytical Cross-sectional Studies.Data SynthesisTen studies were identified, of which 5 examined the association between fatigue and aerobic capacity and 7 examined the association between fatigue and muscle strength. Meta-analysis of the extracted correlation coefficients was performed using the Hedges-Olkin method, and pooled correlation coefficients demonstrated a moderate negative association between fatigue and aerobic capacity (r=−0.471; 95% CI, −0.644 to −0.251; P<.001) and a weak negative association between fatigue and muscle strength (r=−0.224; 95% CI, −0.399 to −0.032; P=.022).ConclusionsThe results of this meta-analysis suggest that higher levels of aerobic capacity are associated with lower fatigue. Therefore, this finding highlights the potential role of aerobic exercise interventions in managing fatigue. Conversely, the relationship between fatigue and muscle strength was weak and inconsistent, and further studies are required to examine the association between these variables.     

Effectiveness of Botulinum Toxin A in Treatment of Hemiplegic Shoulder Pain: A Systematic Review and Meta-analysis

ObjectiveTo evaluate the effectiveness of botulinum toxin A (BTX-A) in the treatment of hemiplegic shoulder pain.Data SourcesPubMed, EMBASE, Elsevier, Springer, Cochrane Library, Physiotherapy Evidence Database, CNKI, and VIP were researched from the earliest records to September 1, 2020.Study SelectionRandomized controlled trials that compared shoulder BTX-A injections vs a control intervention in patients with a history of hemiplegic shoulder pain after stroke were selected. Among the 620 records screened, 9 trials with 301 eligible patients were included.Data ExtractionOutcome data were pooled according to follow-up intervals (1, 2, 4, and 12 wk). The primary evaluation indices were pain reduction (visual analog scale [VAS] score) and range of motion (ROM) improvement. The second evaluation indices were upper limb functional improvement, spasticity improvement, and incidence of adverse events. Cochrane risk-of-bias was used to assess the methodological quality of studies independently by 2 evaluators.Data SynthesisMeta-analysis revealed a statistically significant decrease in the VAS score in the BTX group vs the control group at 1, 4, and 12 weeks postinjection (wk 1: standardized mean difference [SMD], 0.91; 95% confidence interval [CI], 0.27 to 1.54; wk 4: SMD, 1.63; 95% CI, 0.76 to 2.51; wk 12: SMD, 1.96; 95% CI, 1.44 to 2.47). Furthermore, the meta-analysis demonstrated a statistically significant increase in abduction at 1, 4, and 12 weeks postinjection (wk 1: SMD, 3.71; 95% CI, 0 to 7.41; wk 4: SMD, 8.8; 95% CI, 2.22 to 15.37; wk 12: SMD, 19.59; 95% CI, 9.05 to 30.13) and external rotation at 1, 2, 4 weeks postinjection (wk 1: SMD, 5.67; 95% CI, 0.88 to 10.47; wk 2: SMD, 9.62; 95% CI, 5.57 to 13; wk 4: SMD, 6.89; 95% CI, 2.45 to 11.33) in the BTX group.ConclusionsBTX-A injection provided greater analgesic effects and increased shoulder abduction and external rotation ROM compared with steroid or placebo injection for the treatment of HSP.