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Headache Jan 2021Primary headaches (migraine, tension headache, cluster headache, and other trigeminal autonomic cephalgias) are common in pregnancy and postpartum. It is unclear how to...
BACKGROUND
Primary headaches (migraine, tension headache, cluster headache, and other trigeminal autonomic cephalgias) are common in pregnancy and postpartum. It is unclear how to best and most safely manage them.
OBJECTIVE
We conducted a systematic review (SR) of interventions to prevent or treat primary headaches in women who are pregnant, attempting to become pregnant, postpartum, or breastfeeding.
METHODS
We searched Medline, Embase, Cochrane CENTRAL, CINAHL, ClinicalTrials.gov, Cochrane Database of SRs, and Epistemonikos for primary studies of pregnant women with primary headache and existing SRs of harms in pregnant women regardless of indication. No date or language restrictions were applied. We assessed strength of evidence (SoE) using standard methods.
RESULTS
We screened 8549 citations for studies and 2788 citations for SRs. Sixteen studies (mostly high risk of bias) comprising 14,185 patients (total) and 26 SRs met the criteria. For prevention, we found no evidence addressing effectiveness. Antiepileptics, venlafaxine, tricyclic antidepressants, benzodiazepines, β-blockers, prednisolone, and oral magnesium may be associated with fetal/child adverse effects, but calcium channel blockers and antihistamines may not be (1 single-group study and 11 SRs; low-to-moderate SoE). For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine for migraine or tension headache (1 randomized controlled trial; low SoE). Triptans may not be associated with fetal/child adverse effects (8 nonrandomized comparative studies; low SoE). Acetaminophen, prednisolone, indomethacin, ondansetron, antipsychotics, and intravenous magnesium may be associated with fetal/child adverse effects, but low-dose aspirin may not be (indirect evidence; low-to-moderate SoE). We found insufficient evidence regarding non-pharmacologic treatments.
CONCLUSIONS
For prevention of primary headache, calcium channel blockers and antihistamines may not be associated with fetal/child adverse effects. For treatment, combination metoclopramide and diphenhydramine may be more effective than codeine. Triptans and low-dose aspirin may not be associated with fetal/child adverse effects. Future research should identify effective and safe interventions in pregnancy and postpartum.
Topics: Breast Feeding; Female; Headache Disorders, Primary; Humans; Postpartum Period; Pregnancy; Pregnancy Complications
PubMed: 33433020
DOI: 10.1111/head.14041 -
Journal of Cardiothoracic and Vascular... Nov 2022TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) is carried out in various clinical settings, with an increasing importance, and sedation usually is required to perform it.... (Meta-Analysis)
Meta-Analysis Review
TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) is carried out in various clinical settings, with an increasing importance, and sedation usually is required to perform it. Several sedative agents are available, and the authors aimed to compare the cardiovascular and respiratory safety of the strategies used for sedation in TEE through a systematic review with network meta-analysis (NMA). The MEDLINE, CENTRAL, EMBASE, and PsycInfo databases were searched in December 2020 for randomized clinical trials (RCTs) comparing sedation strategies for patients undergoing TEE. The authors assessed variations in systolic blood pressure (SBP), heart rate (HR), and peripheral oxygen saturation (SpO), along with the incidences of hypotension, bradycardia, and desaturation. A random-effect meta-analysis was performed. Nine RCTs (N = 881 patients) with 20 active arms (5 dexmedetomidine; 4 propofol; 4 midazolam; 3 midazolam + opioid; 2 ketamine + propofol; 1 midazolam + ondansetron; 1 midazolam + metoclopramide) and 1 placebo arm were included. Dexmedetomidine was associated with decreases in SBP (mean difference [MD] = -18.78 mmHg; 95% CI [-26.27 to -11.28]) and HR (MD = -11.15 beats/min; 95% CI [-16.15 to -6.15]). Dexmedetomidine significantly reduced the HR compared with ketamine + propofol (-16.90 beats/min; 95% CI: -33.21 to -0.58]) and midazolam + opioid (-24.15 beats/min; 95% CI: -42.67 to -5.63). Midazolam was found to reduce SBP (-12.09 mmHg; 95% CI: -20.43 to -3.74) and was shown to reduce SpO compared with the placebo (-1.00%; 95% CI -1.74 to -0.26). Based on the NMA, the drugs with a higher likelihood of decreasing both SBP and HR were dexmedetomidine and midazolam. All of the drugs led to a small decrease (only statistically significant for midazolam) in SpO, with the systematic use of supplemental O in some trials. The risks of hypotension, bradycardia, or desaturation were not significantly different among the evaluated drugs.
Topics: Analgesics, Opioid; Bradycardia; Dexmedetomidine; Echocardiography, Transesophageal; Humans; Hypnotics and Sedatives; Hypotension; Ketamine; Metoclopramide; Midazolam; Network Meta-Analysis; Ondansetron; Propofol
PubMed: 36028379
DOI: 10.1053/j.jvca.2022.07.003 -
Emergency Medicine Australasia : EMA Apr 2024Ketamine is commonly used for procedural sedation anaesthesia in paediatric patients undergoing painful procedures in the ED. Ketamine's safety profile is excellent, but... (Meta-Analysis)
Meta-Analysis Review
Review article: Efficacy of prophylactic ondansetron versus placebo or control in reducing vomiting in children undergoing ketamine procedural sedation in the emergency department: A systematic review and meta-analysis.
Ketamine is commonly used for procedural sedation anaesthesia in paediatric patients undergoing painful procedures in the ED. Ketamine's safety profile is excellent, but ketamine-associated vomiting (KAV) is common. Routine ondansetron prophylaxis could reduce KAV incidence. This literature review evaluated the efficacy of prophylactic ondansetron in reducing KAV incidence. A systematic literature review was performed on databases and trial registries on 14 January 2023 to identify randomised controlled trials. The primary outcome was reduction in KAV incidence, for any route of prophylactic ondansetron, in ED and up to 24 h post-discharge. ED length of stay, parental satisfaction and time to resumption of normal diet were secondary outcomes. Data analysis was performed using Revman 5.3. Meta-analysis was performed using random effects modelling. Risk of bias was assessed using the Cochrane Risk-of-Bias 2 tool. Evidence quality was assessed using Grading of Recommendation, Assessment Development and Evaluation methodology. Five trials with 920 participants met the eligibility criteria. Prophylactic ondansetron resulted in a reduction in KAV incidence overall odds ratio of 0.51 (95% confidence interval: 0.36-0.73). Intravenous and intramuscular prophylactic ondansetron showed benefit whereas the effect of oral administration was unclear. There was no difference between groups for secondary outcomes overall. The quality of evidence was deemed to be low overall because of high risk of bias and imprecision in outcome measures. This review found low to moderate certainty evidence that prophylactic ondansetron reduces KAV incidence. Methodologically rigorous research, with appropriately timed prophylactic ondansetron based on the route of administration, would further elucidate prophylactic oral ondansetron's efficacy.
Topics: Humans; Child; Ondansetron; Ketamine; Antiemetics; Aftercare; Patient Discharge; Vomiting; Anesthesia; Emergency Service, Hospital; Randomized Controlled Trials as Topic
PubMed: 38220580
DOI: 10.1111/1742-6723.14372 -
The American Journal of Emergency... May 2024Traumatic brain injury (TBI) results in 2.5 million emergency department (ED) visits per year in the US, with mild traumatic brain injury (mTBI) accounting for 90% of... (Review)
Review
INTRODUCTION
Traumatic brain injury (TBI) results in 2.5 million emergency department (ED) visits per year in the US, with mild traumatic brain injury (mTBI) accounting for 90% of cases. There is considerable evidence that many experience chronic symptoms months to years later. This population is rarely represented in interventional studies. Management of adult mTBI in the ED has remained unchanged, without consensus of therapeutic options. The aim of this review was to synthesize existing literature of patient-centered ED treatments for adults who sustain an mTBI, and to identify practices that may offer promise.
METHODS
A systematic review was conducted using the PubMed and Cochrane databases, while following PRISMA guidelines. Studies describing pediatric patients, moderate to severe TBI, or interventions outside the ED were excluded. Two reviewers independently performed title and abstract screening. A third blinded reviewer resolved discrepancies. The Mixed Methods Appraisal Tool (MMAT) was employed to assess the methodological quality of the studies.
RESULTS
Our search strategy generated 1002 unique titles. 95 articles were selected for full-text screening. The 26 articles chosen for full analysis were grouped into one of the following intervention categories: (1) predictive models for Post-Concussion Syndrome (PCS), (2) discharge instructions, (3) pharmaceutical treatment, (4) clinical protocols, and (5) functional assessment. Studies that implemented a predictive PCS model successfully identified patients at highest risk for PCS. Trials implementing discharge related interventions found the use of video discharge instructions, encouragement of daily light exercise or bed rest, and text messaging did not significantly reduce mTBI symptoms. The use of electronic clinical practice guidelines (eCPG) and longer leaves of absence from work following injury reduced symptoms. Ondansetron was shown to reduce nausea in mTBI patients. Studies implementing ED Observation Units found significant declines in inpatient admissions and length of hospital stay. The use of tablet-based tasks was found to be superior to many standard cognitive assessments.
CONCLUSION
Validated instruments are available to aid clinicians in identifying patients at risk for PCS or serious cognitive impairment. EDOU management and evidence-based modifications to discharge instructions may improve mTBI outcomes. Additional research is needed to establish the therapeutic value of medications and lifestyle changes for the treatment of mTBI in the ED.
Topics: Adult; Humans; Child; Brain Concussion; Post-Concussion Syndrome; Brain Injuries, Traumatic; Emergency Service, Hospital; Patient-Centered Care
PubMed: 38460465
DOI: 10.1016/j.ajem.2024.02.038 -
European Journal of Pediatrics Aug 2020In high-income countries. ondansetron is an effective antiemetic in children with gastroenteritis, but data from low- and middle-income countries are sparse. This study... (Meta-Analysis)
Meta-Analysis
In high-income countries. ondansetron is an effective antiemetic in children with gastroenteritis, but data from low- and middle-income countries are sparse. This study aimed to evaluate evidences of the effectiveness of ondansetron in preventing vomiting and reducing the use of intravenous fluids in children with gastroenteritis in developing countries. A total of nine randomized controlled trials (RCTs) involving 2313 participants met the inclusion criteria. Compared with placebo, ondansetron reduced the use of intravenous rehydration (three RCTs, n = 1126, relative risk (RR) 0.60, 95% confidence interval (CI) 0.38-0.95, no significant heterogeneity, I = 43%), the risk of failure of oral rehydration therapy among children with gastroenteritis-associated vomiting and dehydration (four RCTs, n = 1370, RR 0.58, 95% CI 0.43-0.79; no significant heterogeneity was found, I = 39%) and risk of hospitalization (2 RCTs, n = 264, RR 0.25, 95% CI 0.09-0.73, no heterogeneity, I = 0).Conclusions: Compared with placebo, ondansetron reduced the use of intravenous fluids in children with gastroenteritis and dehydration. It has no effect on children with gastroenteritis who do not present with dehydration in developing countries. While ondansetron is effective in controlling vomiting and reducing the rate of hospitalization, there is no evidence that it is effective in reducing the rate of readmission. What is Known: • In high-income countries, ondansetron can reduce the use of intravenous fluids in children with gastroenteritis and dehydration. • No systematic review and meta-analysis of randomized controlled trials were done in a developing country setting. What is New: • In developing countries, ondansetron reduces the use of intravenous fluids in children with gastroenteritis and dehydration. • It has no effect on children with gastroenteritis but without dehydration.
Topics: Acute Disease; Adolescent; Antiemetics; Child; Child, Preschool; Dehydration; Developing Countries; Fluid Therapy; Gastroenteritis; Humans; Infant; Infant, Newborn; Models, Statistical; Ondansetron; Treatment Outcome; Vomiting
PubMed: 32495146
DOI: 10.1007/s00431-020-03680-x -
Turkish Journal of Anaesthesiology and... Aug 2022Intraoperative shivering is quite common after regional anaesthesia, which not only increases the total body oxygen requirement but also causes discomfort to the...
Pharmacological Interventions for the Treatment and Control of Shivering in Adult Patients Undergoing Elective Surgery Under Regional Anaesthesia: A Systematic Review and Meta-Analysis.
Intraoperative shivering is quite common after regional anaesthesia, which not only increases the total body oxygen requirement but also causes discomfort to the patients. The aim of this systematic review is to determine the effectiveness of pharmacological agents administered intra-operatively for treating shivering in adult patients who are undergoing elective surgery under regional (i.e., central neuraxial) anaesthesia so that an optimal choice of an agent can be recommended for clinical application. A literature search was carried out using PubMed, Cochrane Library, CINAHL databases, and hand searches to identify relevant studies. After literature screening and information extraction, a systematic review was performed. Meta-analysis was performed for the primary outcome. The primary outcome was to evaluate the effectiveness of pharmacological agents used for the treatment and control of intraoperative shivering and the time taken to control shivering. The secondary outcome includes recurrence of shivering after pharmacological intervention and identification of common adverse effects related to them. In total, 10 studies (791 patients) were included. Common interventions were opioids, central α2 receptor agonist, and few other medications like magnesium sulfate, ondansetron, nefopam, and amitriptyline. Tramadol and dexmedetomidine were the most frequently documented drugs compared with other drugs to resolve shivering. The most effective drug with approximately 100% response rate was dexmedetomidine with the dose of 0.5 μg kg-1 intravenously given just after the appearance of shivering. Studies showed that tramadol is also an effective drug used to control shivering in most patients, and its effect is comparable with the pethidine.
PubMed: 35979970
DOI: 10.5152/TJAR.2021.20008 -
Journal of Perioperative Practice Mar 2022The incidence rates of spinal anaesthesia-induced hypotension vary depending on the surgical procedures. This systematic review and meta-analysis evaluates the efficacy... (Meta-Analysis)
Meta-Analysis
The incidence rates of spinal anaesthesia-induced hypotension vary depending on the surgical procedures. This systematic review and meta-analysis evaluates the efficacy of prophylactic ondansetron in reducing the incidence of spinal anaesthesia-induced hypotension in non-caesarean delivery. Thirteen trials consisting of 1166 patients were included for analysis. Compared to placebo, there is a low quality of evidence that ondansetron was effective in reducing the incidence of spinal anaesthesia-induced hypotension (RR 0.62, 95% CI 0.44 to 0.87; = 0.005) and bradycardia (RR 0.54, 95% CI 0.32 to 0.90; = 0.02). We also found a moderate quality of evidence that ondansetron lowered the number of rescue ephedrine (RR 0.61, 95% CI 0.43 to 0.87; = 0.007). Patients treated with ondansetron have higher mean arterial pressure 15 to 20 minutes after spinal anaesthesia induction and higher systolic arterial pressure 5, 10, 15 and 20 minutes after spinal anaesthesia. The evidence suggests that prophylactic administration of ondansetron results in the reduction of the incidence of spinal anaesthesia-induced hypotension, bradycardia and rescue ephedrine in patients undergoing non-caesarean delivery under spinal anaesthesia.
Topics: Anesthesia, Obstetrical; Anesthesia, Spinal; Bradycardia; Ephedrine; Humans; Hypotension; Incidence; Ondansetron
PubMed: 33599544
DOI: 10.1177/1750458920964157 -
Cellular and Molecular Biology... Sep 2022Nausea and vomiting are known as side effects after surgery. Since serotonin antagonist drugs are widely used to prevent nausea and vomiting after surgery, the present... (Meta-Analysis)
Meta-Analysis
Evaluating the effect of anti-nausea drugs in IDO enzyme gene expression and preventing postoperative vomiting and nausea in patients undergoing general anesthesia: A Meta-analysis.
Nausea and vomiting are known as side effects after surgery. Since serotonin antagonist drugs are widely used to prevent nausea and vomiting after surgery, the present study was conducted to compare the effectiveness of this group's drugs, namely, ondansetron and palonosetron. On the other hand, recent studies have shown that the metabolites of the kynurenine pathway in the Suppression of the immune response play a role. Indoleamine 2,3 dioxygenase (IDO) is the main enzyme controlling this pathway. Therefore, the effect of these two drugs on IDO gene expression was evaluated. The present study is a systematic review with meta-analysis. The search was conducted in the Cochrane, PubMed, Clinical K, and CRD databases for randomized clinical trial articles that compared two drugs, palonosetron, and ondansetron, regarding nausea and vomiting in patients undergoing surgery with general anesthesia. In the end, eight studies were included in the meta-analysis. STATA13 statistical software was used to estimate the overall risk, relative risk, and data analysis. The results showed that the number of samples in all articles was 739. The analysis of the results between 0 and 24 hours showed that palonosetron reduces the incidence of nausea by 50% and the incidence of vomiting by 79% compared to ondansetron (p=0.001). Also, there was no difference between the IDO gene expression in the two drug groups (p>0.05). In general, the analysis of the results related to the effectiveness of palonosetron and ondansetron 24 hours after surgery with a dose of 0.075 mg of palonosetron versus 4 mg of ondansetron showed that palonosetron is more effective in reducing the incidence of nausea and vomiting in patients than ondansetron.
Topics: Humans; Anesthesia, General; Antiemetics; Gene Expression; Isoquinolines; Ondansetron; Palonosetron; Postoperative Nausea and Vomiting; Quinuclidines; Randomized Controlled Trials as Topic
PubMed: 36905254
DOI: 10.14715/cmb/2022.68.9.29 -
Emergency Medicine Journal : EMJ Sep 2023Nausea and vomiting is a common ED chief complaint. However, randomised trials comparing antiemetic agents to placebo have not demonstrated superiority. This systematic... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Nausea and vomiting is a common ED chief complaint. However, randomised trials comparing antiemetic agents to placebo have not demonstrated superiority. This systematic review investigates the efficacy of inhaled isopropyl alcohol (IPA) compared with usual care or placebo in adults presenting to the ED with nausea and vomiting.
METHODS
We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, other relevant trial registries, journals, and conference proceedings up to September 2022. Randomised controlled trials using IPA to treat adult ED patients with nausea and vomiting were included. The primary outcome was change in severity of nausea, measured by a validated scale. A secondary outcome was vomiting during the ED stay. We used a random-effects model for the meta-analysis, and assessed certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation system.
RESULTS
Two trials comparing inhaled IPA to saline placebo and including a total of 195 patients were pooled for meta-analysis of the primary outcome. A third study comparing a group receiving inhaled IPA and oral ondansetron to another group receiving inhaled saline placebo and oral ondansetron did not qualify for the original registered protocol, but was included in a secondary analysis. All studies were judged to be at low or unclear risk of bias. The pooled mean difference for the primary analysis was a reduction in reported nausea of 2.18 on a 0-10 scale (95% confidence interval (CI) 1.60 to 2.76), favouring IPA over placebo, where the minimum clinically significant difference was defined as 1.5. The evidence level was graded as moderate, due to imprecision from low patient numbers. Only the study included in the secondary analysis assessed the secondary outcome of vomiting, and did not find a difference between intervention and control.
CONCLUSION
This review suggests that IPA likely has a modest effect in reducing nausea in adult ED patients, compared with placebo. Larger multicentre trials are needed, as the evidence is limited by few trials and patients.
PROSPERO REGISTRATION NUMBER
CRD42022299815.
Topics: Humans; Adult; Ondansetron; 2-Propanol; Nausea; Vomiting; Emergency Service, Hospital
PubMed: 37076258
DOI: 10.1136/emermed-2022-212871 -
Journal of Psychiatric Research Nov 2023The benefits of serotonin 3 receptor antagonists (5-HT3R-As) in obsessive-compulsive disorder (OCD) treatment remain unclear. Thus, this study aimed to perform a... (Meta-Analysis)
Meta-Analysis
The benefits of serotonin 3 receptor antagonists (5-HT3R-As) in obsessive-compulsive disorder (OCD) treatment remain unclear. Thus, this study aimed to perform a systematic review and a random-effects meta-analysis, including double-blind, randomized, placebo-controlled trials (DBRPCTs). The outcomes include the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) total score (primary), Y-BOCS obsession subscale score, Y-BOCS compulsive subscale score, treatment response, remission rate, all-cause discontinuation, and incidence of individual adverse events (nervousness/restlessness/anxiety, insomnia, headache, dizziness/lightheadedness, decreased appetite, constipation, nausea/vomiting, diarrhea, dry mouth, sweating/increased perspiration, itching/pruritus, tremor, and sexual dysfunction/decreased libido). The mean differences (MD) for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals (CIs) were calculated. Our study included 10 DBRPCTs (n = 628). Pooled 5-HT3R-As outperformed placebo regarding Y-BOCS total score (MD = -5.08, 95% CI = -7.04, -3.12, N = 9, n = 560), Y-BOCS obsession subscale score, Y-BOCS compulsive subscale score, treatment response, and remission rate. Individually, all 5-HT3R-As outperformed placebo regarding Y-BOCS total score (granisetron: MD = -5.59, 95% CI = -8.79, -2.39, N = 3, n = 178, ondansetron: MD = -5.72, 95% CI = -8.06, -3.37, N = 6, n = 331, tropisetron: MD = -2.87, 95% CI = -5.19, -0.550, N = 1, n = 96). However, all-cause discontinuation and incidence of individual adverse events between pooled 5-HT3R-As and placebo were not significantly different. In conclusion, our meta-analysis suggested 5-HT3R-As as efficacious for symptom improvement in individuals with OCD. However, the number of individuals included in each study was small; thus, a replication randomized trial of 5-HT3R-As should be conducted using a larger sample size.
Topics: Humans; Obsessive-Compulsive Disorder; Serotonin 5-HT3 Receptor Antagonists; Randomized Controlled Trials as Topic; Outcome Assessment, Health Care
PubMed: 37866327
DOI: 10.1016/j.jpsychires.2023.10.029