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Psychiatry and Clinical Neurosciences Sep 2022Brexpiprazole augmentation is an effective treatment strategy for antidepressant-refractory depression, but its optimal dosage remains unclear. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Brexpiprazole augmentation is an effective treatment strategy for antidepressant-refractory depression, but its optimal dosage remains unclear.
AIMS
To find the optimal dosage of brexpiprazole as augmentation of other antidepressants.
METHODS
We searched multiple electronic databases (from inception to September 16th, 2021) to identify double-blind, randomized placebo-controlled fixed-dose trials evaluating brexpiprazole augmentation therapy in adults (≥18 years old, both genders) with major depressive disorder not adequately responding to one or more antidepressant treatment. Our outcomes of interest at 8 weeks (range 4-12 weeks) were efficacy (treatment response defined as 50% or greater reduction in depression severity), tolerability (dropouts due to adverse effects) and acceptability (dropouts for any reason). We performed a random-effects, one-stage dose-effect meta-analysis with restricted cubic splines.
RESULTS
Six studies met the inclusion criteria, including 1671 participants in total. The dose-efficacy curve showed an increase up to doses around 2 mg (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.12-2.06) and then a decreasing trend through the higher licensed dose up to 3 mg (OR 1.40, 95% CI 0.95-2.08). The shape of the dose-tolerability curve was comparable to that of the efficacy and the dose-acceptability curve showed a monotonic increasing trend but both had wide confidence bands.
CONCLUSIONS
One to two milligrams of brexpiprazole as augmentation treatment may achieve an optimal balance between efficacy, tolerability, and acceptability in the acute treatment of antidepressant-refractory depression. However, the small number of included studies limit the reliability of the results. Further research is required to validate the findings.
Topics: Adolescent; Adult; Antidepressive Agents; Depressive Disorder, Major; Depressive Disorder, Treatment-Resistant; Female; Humans; Male; Quinolones; Randomized Controlled Trials as Topic; Reproducibility of Results; Thiophenes
PubMed: 35716011
DOI: 10.1111/pcn.13438 -
The Western Journal of Emergency... May 2023Ketamine can be particularly helpful in situations where the clinician is not able to administer opioids and require an alternate analgesic, such as for patients who are... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Ketamine can be particularly helpful in situations where the clinician is not able to administer opioids and require an alternate analgesic, such as for patients who are already on high-dose opioids, have a history of addiction, or for opioid-naïve children and adults. In this review, our goal was to obtain a comprehensive estimate of the efficacy and safety of low-dose ketamine (dose less than 0.5 milligrams per kilogram or equivalent) compared to opiates for the control of acute pain in the emergency setting.
METHODS
We conducted systematic searches in PubMed Central, EMBASE, MEDLINE, the Cochrane Library, ScienceDirect, and Google Scholar from inception until November 2021. We used the Cochrane risk-of-bias tool to assess the quality of included studies.
RESULTS
We carried out a meta-analysis with a random-effects model and reported pooled standardized mean difference (SMD) and risk ratio (RR) with 95% confidence intervals depending on the type of the outcome. We analyzed a total of 15 studies with 1,613 participants. Half of them had high risk of bias and were conducted in the United States of America. The pooled SMD for pain score was -0.12 (95% CI -0.50-0.25; I2=68.8%) within 15 minutes, -0.45 (95% CI -0.84--0.07; I2=83.3%) within 30 minutes, -0.05 (95% CI -0.41-0.31; I2=86.9%) within 45 minutes, -0.07 (95% CI -0.41-0.26; I2=82%) within 60 minutes, and after 60 minutes the pooled SMD was 0.17 (95% CI -0.07-0.42; I2=64.8%). The pooled RR for need of rescue analgesics was 1.35 (95% CI 0.73-2.50; I2=82.2%). The pooled RRs were as follows: 1.18 (95% CI 0.76-1.84; I2=28.3%) for gastrointestinal side effects; 1.41 (95% CI 0.96-2.06; I2=29.7%) for neurological side effects; 2.83 (95% CI 0.98-8.18; I2=47%) for psychological side effects; and 0.58 (95% CI 0.23-1.48; I2=36.1%) for cardiopulmonary side effects.
CONCLUSION
Low-dose ketamine might have higher or equivalent efficacy and safety when compared to opioids for managing acute pain among patients presenting to the emergency setting. However, further studies are required to establish conclusive evidence, owing to the heterogeneity and poor quality of existing studies.
Topics: Adult; Child; Humans; Analgesics, Opioid; Ketamine; Acute Pain; Randomized Controlled Trials as Topic; Analgesics
PubMed: 37278798
DOI: 10.5811/westjem.2023.2.58368 -
International Journal of Surgery... Aug 2023The role of transversus thoracic muscle plane blocks (TTMPBs) during cardiac surgery is controversial. We conducted a systematic review to establish the effectiveness of... (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVE
The role of transversus thoracic muscle plane blocks (TTMPBs) during cardiac surgery is controversial. We conducted a systematic review to establish the effectiveness of this procedure.
DESIGN
Systematic review. We searched PubMed, Embase, Web of Science, CENTRAL, WanFang Data, and the China National Knowledge Infrastructure to June 2022, and followed the GRADE approach to evaluate the certainty of evidence.
STUDY ELIGIBILITY CRITERIA
Eligible studies enrolled adult patients scheduled to undergo cardiac surgery and randomized them to receive a TTMPB or no block/sham block.
MAIN RESULTS
Nine trials that enrolled 454 participants were included. Compared to no block/sham block, moderate certainty evidence found that TTMPB probably reduces postoperative pain at rest at 12 h [weighted mean difference (WMD) -1.51 cm on a 10 cm visual analogue scale for pain, 95% CI -2.02 to -1.00; risk difference (RD) for achieving mild pain or less (≤3 cm), 41%, 95% CI 17-65) and 24 h (WMD -1.07 cm, 95% CI -1.83 to -0.32; RD 26%, 95% CI 9-37). Moderate certainty evidence also supported that TTMPB probably reduces pain during movement at 12 h (WMD -3.42 cm, 95% CI -4.47 to -2.37; RD 46%, 95% CI 12-80) and at 24 h (WMD -1.73 cm, 95% CI -3.24 to -0.21; RD 32%, 95% CI 5-59), intraoperative opioid use [WMD -28 milligram morphine equivalent (MME), 95% CI -42 to -15], postoperative opioid consumption (WMD -17 MME, 95% CI -29 to -5), postoperative nausea and vomiting (absolute risk difference 255 less per 1000 persons, 95% CI 140-314), and intensive care unit (ICU) length of stay (WMD -13 h, 95% CI -21 to -6).
CONCLUSION
Moderate certainty evidence showed TTMPB during cardiac surgery probably reduces postoperative pain at rest and with movement, opioid consumption, ICU length of stay, and the incidence of nausea and vomiting.
Topics: Adult; Humans; Analgesics, Opioid; Pain, Postoperative; Postoperative Nausea and Vomiting; Cardiac Surgical Procedures; Muscles
PubMed: 37246971
DOI: 10.1097/JS9.0000000000000470 -
Cureus Apr 2023Intraosseous basivertebral nerve ablation has shown sustained efficacy in treating chronic axial low back pain (LBP) in patients with type 1 or 2 Modic changes. This... (Review)
Review
Intraosseous basivertebral nerve ablation has shown sustained efficacy in treating chronic axial low back pain (LBP) in patients with type 1 or 2 Modic changes. This systematic review aims to determine the efficacy of intraosseous basivertebral nerve radiofrequency ablation in treating nonradiating axial chronic LBP compared to standard therapy, sham, or without contrast. The population of interest is individuals greater than or equal to 18 years old with chronic nonradiating vertebrogenic pain. The key outcome was the percentage of patients with greater than or equal to 50% pain reduction, greater than or equal to 10-point improvement in function and disability measured by the Oswestry Disability Index (ODI), greater than or equal to two-point pain reduction in the visual analog scale (VAS) or numerical pain rating scale, and a decrease in opioid utilization by 10 morphine milligram equivalents. Three databases, PubMed, MEDLINE, and Google Scholar, were used to retrieve the studies for the review. Two independent reviewers assessed the studies for inclusion using the validated tools for quality appraisal. There were 286 articles in total; however, only 11 publications with extensive data on 413 participants matched the inclusion criteria and were used for this review. At three months, a majority of the participants reported greater than or equal to 10-point improvement in the ODI, a measure of functional and disability improvement on a 10-point scale, and greater than or equal to two-point improvement in the VAS. A good number of patients in the basivertebral nerve ablation (BVNA) arm reported complete pain resolution demonstrating therapy success and the superiority of BVNA over sham and standard treatment. Basivertebral nerve radiofrequency ablation, among other criteria, is a safe and minimally invasive therapy that significantly lowers pain and impairment in individuals with vertebrogenic pain with distinct Modic type 1 and 2 changes at lumbar vertebra three-sacral vertebra one (L3-S1) vertebral levels. Proper patient selection and exact procedural methods are essential to the success of basivertebral nerve neurotomy. The findings of the existing investigations require confirmation by nonindustry-funded, large-scale, high-quality trials using generalizable study participants.
PubMed: 37034146
DOI: 10.7759/cureus.37114 -
Pain Physician Aug 2022Postoperative pain management in breast surgery and video-assisted thoracic surgeries (VATS) remains challenging. Oral or intravenous infusion of opioids were early... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Postoperative pain management in breast surgery and video-assisted thoracic surgeries (VATS) remains challenging. Oral or intravenous infusion of opioids were early treatments, but they can result in gastrointestinal reactions, respiratory inhibition, and other adverse reactions. In recent years, various regional block techniques have been employed for postoperative analgesia of these surgeries. However, a pair-wise meta-analysis cannot comprehensively rank and evaluate the analgesic effects and adverse events of various regional blocks.
OBJECTIVE
The purpose of this network meta-analysis (NMA) was to compare the analgesic effects and adverse events of different regional block techniques after breast surgery and VATS.
STUDY DESIGN
NMA of randomized controlled trials (RCTs) for comparing multiple regional block techniques in breast surgery and VATS.
METHODS
Pubmed, Embase, and Cochrane databases were searched systematically for RCTs comparing analgesic effects and adverse events after breast surgery and VATS. After critical appraisal, a random-effects NMA was mainly used to compare all the regional blocks' analgesic effects and adverse events. The Population, Interventions, Comparators, Outcomes, and Study design (PICOS) framework was used to build the search strategies and present the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. The primary endpoint was opioid consumption within 24 hours after the operation; secondary endpoints included dynamic and static pain scores and the incidence of nausea and vomiting. This study is registered in the Prospective Register of Systematic Reviews (PROSPERO) with a PROSPERO number of CRD42021283907.
RESULTS
A total of 21 clinical trials, including 1,284 patients and 6 different regional block techniques (paravertebral block pectoral nerve block serratus anterior plane block [SAPB], intercostal nerve block [ICNB], erector spinal plane block and thoracic epidural anesthesia), were included and analyzed. There was no significant difference between the consistent and the inconsistent models. Based on limited evidence, SAPB may be the most effective regional block technique for relieving postoperative pain, while ICNB had the lowest probability of nausea and vomiting. There was no significant difference in the pair-wise comparisons. In this study, we found no obvious publication bias.
LIMITATIONS
Limitations include: morphine milligram equivalents were not used to calculate opioid consumption; the scales used in the studies were different; the number of studies and total sample size included was limited; non-English literature and gray literature were not included; more databases were not searched.
CONCLUSIONS
After a comprehensive evaluation of postoperative analgesic effects and adverse events based on the NMA, we hypothesize that SAPB and ICNB have distinct advantages in postoperative analgesia and reduce the incidence of nausea and vomiting, respectively. However, conclusions drawn from more RCTs may be more convincing.
Topics: Analgesics, Opioid; Breast Neoplasms; Female; Humans; Nausea; Network Meta-Analysis; Pain, Postoperative; Vomiting
PubMed: 35901474
DOI: No ID Found -
Medicina (Kaunas, Lithuania) May 2023Abdominal hysterectomy is a major surgery that is often associated with pronounced postsurgical pain. The objective of this research is to conduct a systematic review... (Meta-Analysis)
Meta-Analysis Review
Abdominal hysterectomy is a major surgery that is often associated with pronounced postsurgical pain. The objective of this research is to conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) and nonrandomized comparative trials (NCTs) that have surveyed the analgesic benefits and morbidity of intraoperative superior hypogastric plexus (SHP) block (intervention) compared with no SHP block (control) during abdominal hysterectomy. The Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, Web of Science, PubMed, Scopus, and Embase were searched from inception until 8 May 2022. The Cochrane Collaboration tool and Newcastle-Ottawa Scale were used to evaluate the risk of bias of RCTs and NCTs, respectively. In a random effects mode, the data were pooled as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Five studies (four RCTs and one NCT) comprising 210 patients (SHP block = 107 and control = 103) were analyzed. The overall postsurgical pain score (n = 5 studies, MD = -1.08, 95% CI [-1.41, -0.75], < 0.001), postsurgical opioid consumption (n = 4 studies, MD = -18.90 morphine milligram equivalent, 95% CI, [-22.19, -15.61], < 0.001), and mean time to mobilization (n = 2 studies, MD = -1.33 h, 95% CI [-1.98, -0.68], < 0.001) were significantly decreased in the SHP block group contrasted with the control arm. Nevertheless, there was no significant variance between both arms regarding operation time, intraoperative blood loss, postsurgical NSAID consumption, and hospital stay. There were no major side effects or sympathetic block-related aftermaths in both groups. During abdominal hysterectomy and receiving perioperative multimodal analgesia, the administration of intraoperative SHP block is largely safe and exhibits better analgesic effects compared to cases without administration of SHP block.
Topics: Female; Humans; Hypogastric Plexus; Nerve Block; Analgesics; Pain, Postoperative; Analgesics, Opioid; Hysterectomy; Randomized Controlled Trials as Topic
PubMed: 37241125
DOI: 10.3390/medicina59050893 -
The Western Journal of Emergency... May 2020In March 2020, the World Health Organization declared the spread of SARS-CoV-2 a global pandemic. To date, coronavirus disease-2019 (COVID-19) has spread to over 200...
In March 2020, the World Health Organization declared the spread of SARS-CoV-2 a global pandemic. To date, coronavirus disease-2019 (COVID-19) has spread to over 200 countries, leading to over 1.6 million cases and over 99,000 deaths. Given that there is neither a vaccine nor proven treatment for COVID-19, there is currently an urgent need for effective pharmacotherapy. To address the need for an effective treatment of SARS-CoV-2 during the worldwide pandemic, this systematic review of intravenous (IV) remdesivir was performed. Remdesivir, an anti-viral prodrug originally developed to treat Ebola virus disease, has shown broad spectrum activity against the Coronavirus family. A recent case report reported improvement of clinical symptoms with remdesivir in a patient with COVID-19. After conducting a systematic search of 18 clinical trial registries and three large scientific databases, we identified 86 potentially eligible items. Following removal of duplicates (n = 21), eligible studies were reviewed independently by two authors. After the first round of screening, inter-rater agreement was 98.5% (κ = 0.925). After the second round of full-text screening, inter-rater agreement was 100%. A total of seven ongoing and recruiting clinical trials of remdesivir (100-200 milligrams, intravenous [IV]) were included. We identified the following primary outcomes: patients discharged (n = 2); time to clinical status improvement (n = 2); improved O2 saturation (n = 2); body temperature normalization (n = 2); and clinical status (n = 1). Secondary outcomes in all identified studies included documentation of adverse events. Phase 3 trials are expected to be completed between April 2020-2023. Therefore, despite supportive data from in vitro and in vivo studies, the clinical effectiveness of IV remdesivir for treatment of COVID-19 and potential side effects remain incompletely defined in the human population.
Topics: Adenosine Monophosphate; Administration, Intravenous; Alanine; Antiviral Agents; Betacoronavirus; COVID-19; Clinical Trials as Topic; Coronavirus Infections; Humans; Pandemics; Pneumonia, Viral; SARS-CoV-2; Treatment Outcome; COVID-19 Drug Treatment
PubMed: 32726230
DOI: 10.5811/westjem.2020.5.47658 -
Orthopaedic Journal of Sports Medicine Jul 2022Postoperative treatment plans after orthopaedic procedures frequently include opioids for pain relief. (Review)
Review
BACKGROUND
Postoperative treatment plans after orthopaedic procedures frequently include opioids for pain relief.
PURPOSE
To evaluate opioid use in the early postoperative phase after arthroscopic rotator cuff repair (ARCR) to develop a procedure-specific understanding of the current role of opioids in pain management for this procedure.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
A PubMed search was used to identify eligible studies. Data on patient demographics, visual analog scale pain scores, and opioid use patterns (in morphine milligram equivalents [MMEs]) were collected and assessed. Cumulative MMEs were reported on postoperative day (POD) zero, and mean MMEs were reported on subsequent PODs (days 1, 2, 3, 5, 7, and 14). Metaregression, indices, and Cochran tests were used to evaluate study variation, heterogeneity, and variance.
RESULTS
A total of 1487 patients in 22 studies were included in the analysis. An estimated 51% (95% CI, 31%-70%) of patients with nerve blocks (NBs) were opioid-free through POD-0 versus 40% (95% CI, 1.2%-97%) of patients without NBs, which increased to 65% (95% CI, 55%-74%) versus 25% (95% CI, 1.7%-86%) by POD-1. Opioid requirements were highest in the first 72 hours after ARCR. NB use reduced opioid requirement on POD-0 compared with no NB use (15.8 vs 45.0 MMEs, respectively; < .001) but did not reduce requirements after that. In addition, NB use led to a statistically significant increase in opioid requirements on POD-7 (28.6 vs 9.5 MMEs, respectively; < .001). Using a model that assumes stable opioid requirements between our time points, weighted mean cumulative opioid consumption was 163 MMEs in the first week and 273 MMEs in the first 2 weeks (150 and 287 MMEs in patients with NB; 180 and 261 MMEs in patients without NB, respectively).
CONCLUSION
Opioid use is relatively common in the early postoperative period after ARCR. Pain scores and opioid requirements may spike on POD-1; however, patients should be educated and reassured that they will gradually decrease usage over the initial 2-week postoperative period.
PubMed: 35898204
DOI: 10.1177/23259671221112086 -
Integrative Cancer Therapies 2023Safe and effective management of cancer-related pain is a worldwide challenge. In the search for treatment options, natural products used in Chinese herbal medicines... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND OBJECTIVES
Safe and effective management of cancer-related pain is a worldwide challenge. In the search for treatment options, natural products used in Chinese herbal medicines (CHMs) have received attention in clinical studies for their effects on cancer-related pain. The objective of this systematic review is to evaluate the clinical evidence for topically applied CHMs as adjunctive treatments for cancer pain management.
METHODS
Nine biomedical databases and 4 clinical trial registries were searched for randomized-controlled trials (RCTs) that reported measures of pain and/or quality of life. Risk of bias was assessed using the Cochrane tool. Meta-analysis employed mean difference (MD) with 95% confidence intervals (random effects).
RESULTS
Twenty (20) RCTs (1636 participants) met the inclusion criteria. Meta-analyses were grouped based on the comparisons and outcome measures. For pain intensity, there was a greater reduction in the topical CHM group versus placebo (MD -0.72 [-1.04, -0.40]), no difference when compared to tramadol (MD -0.15 [-0.38, 0.08]), and a greater reduction when topical CHMs were combined with conventional analgesic medications (MD -0.67 [-0.93, -0.40]). Analgesic onset time was reduced in the CHM group compared to tramadol (MD -26.02 [-27.57, -24.47] minutes), and for CHMs combined with conventional medications (MD -19.17 [-21.83, -16.52] minutes). When CHMs were combined with analgesic medications, improvements were found for duration of analgesia (MD 1.65 [0.78, 2.51] hours), analgesic maintenance dose (MD -31.72 [-50.43, -13.01] milligrams/day), and quality of life.
CONCLUSION
Addition of topical CHMs to conventional analgesic medications was associated with improved outcomes for pain intensity, some other pain-related outcomes, and measures of quality of life. Limitations included methodological issues in some studies and considerable heterogeneity in some pooled results.
Topics: Humans; Cancer Pain; Tramadol; Randomized Controlled Trials as Topic; Medicine, Chinese Traditional; Analgesics; Neoplasms
PubMed: 37962002
DOI: 10.1177/15347354231210870 -
BMC Anesthesiology Dec 2022The objective of this systematic review and network meta-analysis was to compare the effects of single-shot ultrasound-guided regional anesthesia techniques on... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The objective of this systematic review and network meta-analysis was to compare the effects of single-shot ultrasound-guided regional anesthesia techniques on postoperative opioid consumption in patients undergoing open cardiac surgery.
METHODS
This systematic review and network meta-analysis involved cardiac surgical patients (age > 18 y) requiring median sternotomy. We searched PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science. The effects of the single-shot ultrasound-guided regional anesthesia technique were compared with those of placebo and no intervention. We conducted a risk assessment of bias for eligible studies and assessed the overall quality of evidence for each outcome.
RESULTS
The primary outcome was opioid consumption during the first 24 h after surgery. The secondary outcomes were pain after extubation at 12 and 24 h, postoperative nausea and vomiting, extubation time, intensive care unit discharge time, and length of hospital stay. Fifteen studies with 849 patients were included. The regional anesthesia techniques included pecto-intercostal fascial block, transversus thoracis muscle plane block, erector spinae plane (ESP) block, and pectoralis nerve block I. All the regional anesthesia techniques included significantly reduced postoperative opioid consumption at 24 h, expressed as morphine milligram equivalents (MME). The ESP block was the most effective treatment (-22.93 MME [-34.29;-11.56]).
CONCLUSIONS
In this meta-analysis, we concluded that fascial plane blocks were better than placebo when evaluating 24 h MMEs. However, it is still challenging to determine which is better, given the paucity of studies available in the literature. More randomized controlled trials are required to determine which regional anesthesia technique is better.
TRIAL REGISTRATION
PROSPERO; CRD42022315497.
Topics: Humans; Adult; Middle Aged; Analgesics, Opioid; Network Meta-Analysis; Pain, Postoperative; Anesthesia, Conduction; Cardiac Surgical Procedures; Ultrasonography, Interventional
PubMed: 36581838
DOI: 10.1186/s12871-022-01952-7