Multiple versus fewer antiplatelet agents for preventing early recurrence after ischaemic stroke or transient ischaemic attack
Imama A Naqvi, Ayeesha K Kamal, Hasan Rehman
In the high‐risk phase after stroke, multiple antiplatelet agents are more effective than single agents at preventing stroke recurrence. The evidence is strongest for secondary stroke prevention in people with ischaemic stroke.
Intravenous versus intramuscular prophylactic oxytocin for reducing blood loss in the third stage of labour
Olufemi T Oladapo, Babasola O Okusanya, Edgardo Abalos, Ioannis D Gallos, Argyro Papadopoulou
Intravenous administration of oxytocin appears to be more effective than its intramuscular administration in preventing postpartum hemorrhage during vaginal birth. Intravenous oxytocin administration presents no additional safety concerns and has a comparable side effects profile with intramuscular oxytocin administration.
Financial conflicts of interest in systematic reviews: associations with results, conclusions, and methodological quality
Camilla Hansen, Andreas Lundh, Kristine Rasmussen, Asbjørn Hróbjartsson
Systematic reviews with financial conflicts of interest more often have favourable conclusions and tend to have lower methodological quality than systematic reviews without financial conflicts of interest. However, it is uncertain whether financial conflicts of interest are associated with the results of systematic reviews. We suggest that patients, clinicians, developers of clinical guidelines, and planners of further research could primarily use systematic reviews without financial conflicts of interest. If only systematic reviews with financial conflicts of interest are available, we suggest that users read the review conclusions with skepticism, critically appraise the methods applied, and interpret the review results with caution.
Corticosteroids as standalone or add‐on treatment for sore throat
Simone de Cassan, Matthew J Thompson, Rafael Perera, Paul P Glasziou, Chris B Del Mar, Carl J Heneghan, Gail Hayward
In participants with sore throat, pain can be reduced and resolution hastened by use of a single dose of oral or intramuscular corticosteroids in conjunction with antibiotic therapy. Our finding of a reduction in the duration of pain by six hours seems modest. However, the decision to use any treatment involves balancing the potential benefits and harms of the therapy.
High‐flow nasal cannulae for respiratory support in adult intensive care patients
Sharon R Lewis, Philip E Baker, Roses Parker, Andrew F Smith
High-Flow Nasal Canulae (HFNC) for respiratory support for adults in the intensive care unit may lead to less treatment failure when compared to standard oxygen therapy. When compared to NIV (Non Invasive Ventilation) or NIPPV (Non Invasive Positive Pressure Ventilation), we found no evidence of a difference in treatment failure according to the type of respiratory support used, and this evidence was also low‐certainty. For most other outcomes, we found no evidence of a difference in the effect of using either HFNC or standard oxygen therapy, NIV, or NIPPV. The ratio of PaO2/FiO2 may be lower with HFNC up to 24 hours after initiation of therapy when compared with NIV or NIPPV but the certainty of this evidence is low. The evidence in this review is generalizable to participants who have been weaned from mechanical ventilation as well as participants who have not previously been supported by mechanical ventilation.
Atovaquone‐proguanil for treating uncomplicated Plasmodium falciparum malaria
Andrew Blanshard, Paul Hine
Atovaquone‐proguanil is efficacious against uncomplicated Plasmodium falciparum malaria, but treatment failure exceeded 5% in two studies, the level at which the WHO recommends avoiding adoption of antimalarial medicines in country programmes. Although it is efficacious, we cannot conclude with certainty that it has comparable clinical efficacy to WHO‐recommended Artemisinin-based combination therapys.
The addition of artesunate to atovaquone‐proguanil may reduce the treatment failure rates. Artesunate‐atovaquone‐proguanil is not currently available in coformulation, therefore it is unlikely that this combination could be readily adopted in clinical settings. Potential resistance to atovaquone‐proguanil is likely to be a barrier to its widespread uptake, but there may be strategies to delay the emergence of resistance that require further exploration.
Rapid diagnostic tests (RDT) for Plasmodium vivax malaria in endemic countries
Ridhi Agarwal, Leslie Choi, Samuel Johnson, Yemisi Takwoingi
Differentiating between Plasmodium species is particularly important in areas of co‐endemicity whereby P vivax malaria is increasing proportionally, compared to P falciparum malaria. The main analysis included in this review was CareStart Malaria Pf/Pv Combo test against microscopy as the reference standard, and this RDT was found to be both highly sensitive and specific.
Peripheral nerve blocks for hip fractures in adults
Joanne Guay, Sandra Kopp
Peripheral nerve blocks (PNBs) reduce pain on movement at 30 minutes after block placement, as well as the risk of an acute confusional state and probably also the risk of chest infection, compared with systemic analgesia alone. Whether or not these benefits justify the use of PNBs in clinical practice probably has to be judged on a case‐by‐case basis. Although randomized clinical trials may not be the best way to establish risks associated with an intervention, our review confirms the low risk of permanent injury associated with PNBs, as found by others (Neal 2015).
Covid Reviews
Chloroquine or hydroxychloroquine for prevention and treatment of COVID‐19
Bhagteshwar Singh, Hannah Ryan, Tamara Kredo, Marty Chaplin, Tom Fletcher
Hydroxychloroquine for treatment
Hydroxychloroquine (HCQ) has no clinical benefit in treating COVID‐19 in hospitalized patients, with moderate‐ to high‐certainty evidence, and a probable increase in adverse events associated with its use.
Evidence for prevention of hospital admission in outpatients with COVID‐19 is very uncertain. However, given the lack of benefit in hospitalized patients, and limited available evidence suggesting little or no effect on clearance of the virus from the respiratory tract, benefit from treatment of outpatients appears unlikely.
Hydroxychloroquine for pre‐ or post‐exposure prophylaxis
The lack of any demonstrable clinical benefit in the treatment of COVID‐19 makes it less likely the drug will prevent the illness in those who are exposed, but this effect is not excluded.
No trials of the use of HCQ for prophylaxis of COVID‐19 in those at risk of exposure to SARS‐CoV‐2 were identified.
Evidence that HCQ is effective as prophylaxis for COVID‐19 in people exposed to SARS‐CoV‐2 is limited. However, HCQ probably increases adverse events, although there does not appear to be a difference between comparison groups for serious adverse events.
Thoracic imaging tests for the diagnosis of COVID‐19
Nayaar Islam, Sanam Ebrahimzadeh, Jean-Paul Salameh, Sakib Kazi, Nicholas Fabiano, Lee Treanor, Marissa Absi, Zachary Hallgrimson, Mariska MG Leeflang, Lotty Hooft, Christian B van der Pol, Ross Prager, Samanjit S Hare, Carole Dennie, René Spijker, Jonathan J Deeks, Jacqueline Dinnes, Kevin Jenniskens, Daniël A Korevaar, Jérémie F Cohen, Ann Van den Bruel, Yemisi Takwoingi, Janneke van de Wijgert, Johanna AAG Damen, Junfeng Wang, Matthew DF McInnes, Cochrane COVID-19 Diagnostic Test Accuracy Group
The uncertainty resulting from high or unclear risk of bias and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results. Our findings indicate that chest computed tomography (CT), chest X‐ray and ultrasound all give higher proportions of positive results for individuals with COVID‐19 as compared to those without. For chest CT, the chances of getting a positive result are 87.9% (95% CI 84.6 to 90.6) in individuals with COVID‐19 and 20.0% (95% CI 15.7 to 25.1) in those without. For chest X‐ray, the chances of getting a positive result are 80.6% (95% CI 69.1 to 88.6) in individuals with COVID‐19 and 28.5% (95% CI 19.2 to 40.2) in those without. For ultrasound of the lungs, the chances of getting a positive result are 86.4% (95% CI 72.7 to 93.9) in individuals with COVID‐19 and 45.4% (95% CI 27.4 to 64.7) in those without. Due to the limited availability of data, accuracy estimates of chest X‐ray and ultrasound of the lungs for the diagnosis of COVID‐19 in suspected participants should be carefully interpreted.
Systemic corticosteroids for the treatment of COVID‐19
Carina Wagner, Mirko Griesel, Agata Mikolajewska, Anika Mueller, Monika Nothacker, Karoline Kley, Maria-Inti Metzendorf, Anna-Lena Fischer, Marco Kopp, Miriam Stegemann, Nicole Skoetz, Falk Fichtner
Based on the current evidence, we are moderately certain that systemic corticosteroids probably reduce mortality slightly amongst hospitalised, symptomatic COVID‐19 patients. Most of the participants in the studies were treated with invasive mechanical ventilation and non‐invasive ventilation/continuous positive airway pressure or high‐flow oxygen. In a subgroup analysis by baseline respiratory support, evidence of an increased risk of mortality with corticosteroids in symptomatic, hospitalised COVID‐19 patients without any need for additional oxygen, was limited by a lack of statistical significance. In a subgroup analysis of different types of systemic corticosteroids on mortality, we did not identify evidence for a subgroup difference.
Routine laboratory testing to determine if a patient has COVID‐19
Inge Stegeman, Eleanor A Ochodo, Fatuma Guleid, Gea A. Holtman, Bada Yang, Clare Davenport, Jonathan J Deeks, Jacqueline Dinnes, Sabine Dittrich, Devy Emperador, Lotty Hooft, René Spijker, Yemisi Takwoingi, Ann Van den Bruel, Junfeng Wang, Miranda Langendam, Jan Y Verbakel, Mariska MG Leeflang, Cochrane COVID-19 Diagnostic Test Accuracy Group
None of the routine laboratory markers as stand‐alone tests are useful for accurately ruling in or ruling out COVID‐19. As a triage test would require a high sensitivity (< 80%), these tests have limited value as triage tests. Although there is low or very low certainty about the summary estimates in this review, we do not expect that studies with a low risk of bias will show a better performance than the tests included.
Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID‐19
Thomas Struyf, Jonathan J Deeks, Jacqueline Dinnes, Yemisi Takwoingi, Clare Davenport, Mariska MG Leeflang, René Spijker, Lotty Hooft, Devy Emperador, Julie Domen, Sebastiaan R A Horn, Ann Van den Bruel, Cochrane COVID-19 Diagnostic Test Accuracy Group
Until results of further studies become available, broad investigation of people with suspected SARS‐CoV‐2 infection remains necessary. Neither absence nor presence of individual signs are accurate enough to rule in or rule out disease. Within the context of selection bias of all the studies in this review, the presence of fever, cough, or 'anosmia or ageusia' may be useful to identify people for further testing for COVID‐19.
