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Objectives Bleeding remains a common complication post-thoracic surgery. Although intravenous tranexamic acid (TXA) has been shown to decrease blood loss, its use has been associated with adverse effects. Accordingly, topical TXA has been proposed as an alternative to reduce bleeding with fewer systemic complications. Methods We searched Medline, Embase, and Cochrane Central databases for randomized controlled trials (RCTs) comparing topical TXA versus control (i.e., placebo) in patients undergoing thoracic procedures. The primary outcome was total postoperative blood loss at 24 hours. Secondary outcomes included were the number of red blood cell (RBC) transfusions, and hospital length of stay (LOS). Meta-analyses were pooled using mean difference with inverse-variance weighting and random-effects. Results Out of the 575 unique studies that were screened, we identified three randomized controlled trials (RCTs) involving 399 patients. Out of the three RCTs analyzed, two studies, accounting for 67% of the total, were found to have a low risk of bias. The primary outcome of 24-h post-operative blood loss was significantly lower in patients who received TXA (mean difference [MD] −93.6 ml, 95% CI −121.8 to −65.4 ml, I2 = 45%). In addition, the need for RBC transfusion was significantly lower in the topical TXA group compared to control (MD −0.5 units, 95% CI −0.8 to −0.3 units, I2 = 60%). However, there was no significant difference in the hospital length of stay (LOS) (MD −0.3 days, 95% CI −0.9 to 0.4 days, I2 = 0%). These results remained consistent after several sensitivity analyses. The use of topical intrapleural tranexamic acid has also been found to be safe without any significant safety concerns. Conclusion Topical intrapleural TXA reduces blood loss and the need for blood transfusions during thoracic surgery. In addition, there is no evidence of the increased safety concerns associated with its use. Larger trials are necessary to validate these findings and evaluate the safety and efficacy of different dosages.

Background Induction therapy with IL-2 receptor antagonist (IL2-RA) is recommended as a first-line agent in low immunological risk kidney transplant recipients. However, the role of IL2-RA in the setting of tacrolimus-based immunosuppression has not been fully investigated. Aims To compare different induction therapeutic strategies with 2 doses of basiliximab vs. no induction in low immunologic risk kidney transplant recipients as per KFSHRC protocol. Methods Prospective, randomized, double blind, non-inferiority, controlled clinical trial Expected outcomes 1. Primary outcomes: Biopsy-proven acute rejection within first year following transplant 2. Secondary outcomes: a. Patient and graft survival at 1 year b. eGFR at 6 months and at 12 months c. Emergence of de novo donor-specific antibodies (DSAs) Trial registration The study has been prospectively registered at clinicaltrials.gov (NTC: 04404127). Registered on 27 May 2020.

The prevalence of venous thromboembolism is high in patients with COVID-19, despite prophylactic anticoagulation. The evidence that supports the preferred thromboprophylaxis regimen in non-critically ill patients with mild to moderate COVID-19 is still limited. Therefore, this systematic review and meta-analysis aimed to compare the clinical outcomes of hospitalized patients with mild to moderate COVID-19 who received standard thromboprophylaxis anticoagulation with intermediate to high prophylaxis regimens. We systematically searched MEDLINE and Embase databases for published studies until August 17th, 2022. We included studies on patients with mild to moderate COVID-19 who received thromboprophylaxis during their hospital stay. Patients who received standard prophylaxis dose “control group” were compared to patients who received intermediate to high prophylaxis “intervention group”. Random effect models were used when pooling crude numbers and adjusted effect estimates of study outcomes. A comprehensive analysis was conducted, encompassing seven studies involving a total of 1931 patients. The risk of all-cause thrombosis was not statistically different between the two groups (risk ratio [RR] 1.48, 95% confidence interval [CI] [0.11, 20.21]). The risk of minor bleeding was reported to be lower in patients who received intermediate to high prophylaxis (RR 0.64, 95% CI 0.21, 1.97), while had a higher risk of major bleeding compared with the standard prophylaxis (RR 1.40, 95% CI 0.43, 4.61); however, did not reach the statistical significance. The overall risk for all hospital mortality favored the utilization of intermediate to high doses over the standard thromboprophylaxis dosing (RR 0.47, 95%CI 0.29, 0.75). In medically ill patients with COVID-19, there is no difference between standard and intermediate to high prophylaxis dosing regarding thrombosis and bleeding. However, it appears that intermediate to high prophylaxis regimens are linked to additional survival benefits.

Background and Aim Management of genotype 4 hepatitis C virus (HCV) has shifted to interferon‐free regimens with a high sustained virological response (SVR‐12), especially with NS5B/NS5A inhibitor combinations such as sofosbuvir and ledipasvir (Sof‐Led). The guidelines have recommended the combination of sofosbuvir and another NS5A inhibitor, daclatasvir, to manage HCV genotypes 1–3. However, its use was extended to genotype 4 HCV based on extrapolating evidence. Our aim is to assess the efficacy of generic sofosbuvir + branded daclatasvir (Sof‐Dac) compared to the Sof‐Led combination in treating genotype 4 HCV. Methods This study is an open‐label, 2‐period, noninferiority study that compared patients receiving a combination of generic sofosbuvir 400 mg and daclatasvir 60 mg orally daily (Group 2) prospectively to a historical control (Group 1) that included patients who received a combination of sofosbuvir/ledipasvir 400/90 mg orally daily. The primary endpoint is the proportion of patients who achieved SVR‐12. Results The study included 111 patients in the (Sof‐Led) Group 1 and 109 patients (Sof‐Dac) Group 2. For the primary outcome, SVR‐12 was achieved in 106 (95.5%) of the patients in Group 1 versus 108 (99.1%) in Group 2 (p = 0.2). In addition, all patients who achieved SVR‐12 also achieved SVR‐24. Conclusion Generic sofosbuvir combined with branded daclatasvir was safe and effective for treating genotype 4 HCV compared to Sof‐Led. This combination may significantly reduce the cost burden, enabling a larger pool of treated patients. Office of research affairs at KFSHRC RAC# 2171 036.

Purpose: To evaluate the effectiveness and safety of anticoagulation regimens in COVID-19 critically ill patients with new-onset Atrial fibrillation (Afib) during their intensive care unit (ICU) stays. Methods: A multicenter, retrospective cohort study included critically ill patients with COVID-19 admitted to the ICUs. Patients with new-onset Afib were categorized into two groups based on anticoagulation doses (Prophylaxis vs Treatment). The primary outcome was the bleeding rate; other outcomes were considered secondary. Logistic, negative binomial regression, and Cox proportional hazards regression analyses were applied as appropriate after PS matching. Results: A total of 107 patients were eligible. After PS matching (1:1 ratio), 56 patients were included in the final analysis. A higher odd for major and minor bleeding were observed in the patients who received treatment doses of anticoagulation; however, it did not reach the statistically significant (OR 1.46; 95% CI 0.29, 7.42; P=0.65 and OR 2.04; 95% CI 0.17, 24.3; P=0.57, respectively). The hospital length of stay and in-hospital mortality showed no differences between the two groups (beta coefficient -0.00; CI -0.38, 0.37; P=0.99 and HR 1.12, 95% CI 0.58-2.14; p = 0.74, respectively). On the other hand, patients in the treatment group had a statistically significant higher requirement of RBCs transfusion than patients who received a prophylaxis dose (beta coefficient 1.17; 95% CI 0.11, 2.22, P=0.03). Conclusion: The use of treatment anticoagulation doses in COVID-19 critically ill patients with new-onset Afib did not show better effectiveness over prophylactic anticoagulation doses; however, patients who received treatment anticoagulation doses had higher RBCs transfusion requirements. Our results must be cautious; thus, larger randomized interventional studies with a larger sample size are required to confirm our findings. Keywords: COVID-19, anticoagulation, prophylaxis, treatment dose, thrombosis, bleeding, atrial fibrillation, critically ill, mortality

To evaluate the effectiveness and safety of anticoagulation regimens in COVID-19 critically ill patients with new-onset Atrial fibrillation (Afib) during their intensive care unit (ICU) stays. A multicenter, retrospective cohort study included critically ill patients with COVID-19 admitted to the ICUs. Patients with new-onset Afib were categorized into two groups based on anticoagulation doses (Prophylaxis vs Treatment). The primary outcome was the bleeding rate; other outcomes were considered secondary. Logistic, negative binomial regression, and Cox proportional hazards regression analyses were applied as appropriate after PS matching. A total of 107 patients were eligible. After PS matching (1:1 ratio), 56 patients were included in the final analysis. A higher odd for major and minor bleeding were observed in the patients who received treatment doses of anticoagulation; however, it did not reach the statistically significant (OR 1.46; 95% CI 0.29, 7.42;  =0.65 and OR 2.04; 95% CI 0.17, 24.3;  =0.57, respectively). The hospital length of stay and in-hospital mortality showed no differences between the two groups (beta coefficient -0.00; CI -0.38, 0.37; =0.99 and HR 1.12, 95% CI 0.58-2.14; p = 0.74, respectively). On the other hand, patients in the treatment group had a statistically significant higher requirement of RBCs transfusion than patients who received a prophylaxis dose (beta coefficient 1.17; 95% CI 0.11, 2.22,  0.03). The use of treatment anticoagulation doses in COVID-19 critically ill patients with new-onset Afib did not show better effectiveness over prophylactic anticoagulation doses; however, patients who received treatment anticoagulation doses had higher RBCs transfusion requirements. Our results must be cautious; thus, larger randomized interventional studies with a larger sample size are required to confirm our findings.