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Endoscopy International Open Nov 2019Guidelines recommend use of ligation and vasoactive drugs as first-line therapy and as grade A evidence for acute variceal bleeding (AVB), although Western studies... (Review)
Review
Guidelines recommend use of ligation and vasoactive drugs as first-line therapy and as grade A evidence for acute variceal bleeding (AVB), although Western studies about this issue are lacking. We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of endoscopic treatments for AVB in patients with cirrhosis. Trials that included patients with hepatocellular carcinoma, use of portocaval shunts or esophageal resection, balloon tamponade as first bleeding control measure, or that received placebo or elective treatment in one study arm were excluded. A total of 8382 publications were searched, of which 36 RCTs with 3593 patients were included. Ligation was associated with a significant improvement in bleeding control (relative risk [RR] 1.08; 95 % confidence interval [CI] 1.02 - 1.15) when compared to sclerotherapy. Sclerotherapy combined with vasoactive drugs showed higher efficacy in active bleeding control compared to sclerotherapy alone (RR 1.17; 95 % CI 1.10 - 1.25). The combination of ligation and vasoactive drugs was not superior to ligation alone in terms of overall rebleeding (RR 2.21; 95 %CI 0.55 - 8.92) and in-hospital mortality (RR 1.97; 95 %CI 0.78 - 4.97). Other treatments did not generate meta-analysis. This study showed that ligation is superior to sclerotherapy, although with moderate heterogeneity. The combination of sclerotherapy and vasoactive drugs was more effective than sclerotherapy alone. Although current guidelines recommend combined use of ligation with vasoactive drugs in treatment of esophageal variceal bleeding, this study failed to demonstrate the superiority of this combined treatment.
PubMed: 31673624
DOI: 10.1055/a-0901-7146 -
The Turkish Journal of Pediatrics 2023To describe the existing pharmacological managements for Multisystem Inflammatory Syndrome in Children (MIS-C) in a systematic way, to identify the available... (Review)
Review
BACKGROUND
To describe the existing pharmacological managements for Multisystem Inflammatory Syndrome in Children (MIS-C) in a systematic way, to identify the available pharmacological managements in MIS-C, evaluate its safety and efficacy and identify the best treatment procedures for practice recommendation.
METHODS
A systematic search using six databases was conducted on August 18, 2021, updated in January 26th 2023. Terminologies that were used in this search are children, MIS-C/PIMS and SARS-CoV-2. A PRISMA flow diagram was used to report the study selection process. Quality analysis was done based on NOS and GRADE tools. Data synthesis was conducted by extracting the information on drugs used, efficacy and side effects.
RESULTS
From the 32 articles included, a total of 2331 children with MIS-C were studied. The main pharmacological approaches were immunomodulatory therapy, i.e., intravenous immunoglobulin (IVIG) (77.3%), steroids (60.5%), and a combination of IVIG and steroids (41.3%). IVIG and steroids were found to be potentially effective and safe treatments for MIS-C. Combination of IVIG and steroids was found favorable in severe cases with higher recovery rate. Refractory treatments include second dose of initial treatment and biological response modifier drugs like anakinra, tocilizumab, infliximab. A small number of studies investigating supportive treatment consisted of vasoactive, inotropic and anticoagulation. The mortality rate was 1.28% and only three studies reported side effects from the treatment. Evidence of outcome from GRADE were mostly at moderate, low and very low levels.
CONCLUSIONS
This review provides preliminary evidence to support the current standard treatment practices in managing MIS-C pharmacologically. However, comprehensive investigation is required using clinical trials to provide stronger outcome evidence.
Topics: Child; Humans; COVID-19; SARS-CoV-2; Immunoglobulins, Intravenous; Drug-Related Side Effects and Adverse Reactions; Steroids
PubMed: 37853964
DOI: 10.24953/turkjped.2022.765 -
ESC Heart Failure Dec 2018Acute decompensated heart failure (ADHF) has a poor prognosis and limited treatment options. No direct comparisons between ularitide-a synthetic natriuretic peptide... (Meta-Analysis)
Meta-Analysis
AIMS
Acute decompensated heart failure (ADHF) has a poor prognosis and limited treatment options. No direct comparisons between ularitide-a synthetic natriuretic peptide being evaluated in ADHF-and other vasoactive substances are available. The aim of this meta-analysis was to determine haemodynamic effect sizes from randomized double-blind trials in ADHF.
METHODS AND RESULTS
Eligible studies enrolled patients with ADHF requiring hospitalization and haemodynamic monitoring. Patients received 24-48 h of infusion with a vasoactive substance or comparator. Primary outcome measure was pulmonary artery wedge pressure (PAWP). Treatment effects were quantified as changes from baseline using mean differences between study drug and comparator. Results were analysed using random-effects (primary analysis) and fixed-effects meta-analyses. Twelve randomized, double-blind studies were identified with data after 3, 6, and 24 h of treatment (n = 622, 644, and 644, respectively). At 6 h, significant PAWP benefits for ularitide over placebo were seen (Hedges' g effect size, -0.979; P < 0.0001). On meta-analysis, treatment difference between ularitide and pooled other agents was statistically significant (-0.501; P = 0.0303). Effect sizes were numerically higher with ularitide than other treatments at 3 and 24 h. After 6 h, a significant difference in effect size between ularitide and all other treatments was observed for right atrial pressure (Hedges' g, -0.797 for ularitide and -0.304 for other treatments; P = 0.0274).
CONCLUSIONS
After 6 h, ularitide demonstrated high effect sizes for PAWP and right atrial pressure. Improvements in these parameters were greater with ularitide vs. pooled data for other vasoactive drugs.
Topics: Acute Disease; Atrial Natriuretic Factor; Diuretics; Dose-Response Relationship, Drug; Double-Blind Method; Heart Failure; Hemodynamics; Humans; Peptide Fragments; Randomized Controlled Trials as Topic
PubMed: 30246939
DOI: 10.1002/ehf2.12349 -
Journal of Voice : Official Journal of... Jul 2023Laryngopharyngeal reflux-associated symptoms embrace a wide variety of head and neck manifestations. Its participation in eye disorders has recently been postulated, and... (Review)
Review
BACKGROUND
Laryngopharyngeal reflux-associated symptoms embrace a wide variety of head and neck manifestations. Its participation in eye disorders has recently been postulated, and there is currently no consensus in this regard. The aim of this manuscript is to review the role of reflux in the development of ocular signs and symptoms, and its physio-pathological mechanisms.
METHODS
A systematic approach based on the preferred reporting Items for a systematic review and meta-analysis checklist with a modified population, intervention, comparison, and outcome framework was used to structure the review process of studies that evaluated the possible association, with clear diagnostic methods, of laryngopharyngeal reflux and ocular signs and symptoms. Search was conducted in different indexed databases (PubMed/MEDLINE, the Cochrane Library, Scielo and Web of Science) and through the meta-searcher Trip Database with the keywords: reflux, laryngitis, laryngopharyngeal, gastroesophageal, ocular, eye, symptoms, signs, conjunctivitis, keratitis, dacryocystitis, dry eye.
RESULTS
Seven studies met the inclusion criteria, in which the primary acquired nasolacrimal duct obstruction and the ocular surface disease were evaluated. The local increase of eye pepsin concentration (>2.5 ng/mL) may affect ocular surface though its direct proteolytic activity and the local expression of proinflammatory cytokines. The H. Pylori, with a similar mechanism to reach the lacrimonasal duct, would be associated with the release of proinflammatory and vasoactive substances that would lead to a mucosa injury and chronic inflammation. Ocular Surface Disease Index seems to correlate directly with the reflux severity, with cut-off of 41.67 score as predictor for disease.
DISCUSSION
The role of laryngopharyngeal reflux in the development of ocular disorders has not yet been demonstrated and data are limited and heterogeneous. It seems theoretically conceivable that pepsin may reach lachrymal duct area through hypopharyngeal-nasal gaseous reflux events. Future studies using objective testing for diagnosis and pepsin detection into the tear and nasal mucosa are needed in order to explore this potential relationship.
Topics: Humans; Lacrimal Duct Obstruction; Laryngitis; Laryngopharyngeal Reflux; Nasolacrimal Duct; Pepsin A
PubMed: 33849761
DOI: 10.1016/j.jvoice.2021.03.010 -
European Review For Medical and... Jul 2023The optimal time to start renal replacement therapy (RRT) for acute kidney injury (AKI) remains controversial. We aim to compare the effects of early vs. delayed RRT... (Meta-Analysis)
Meta-Analysis
Early strategy vs. late initiation of renal replacement therapy in adult patients with acute kidney injury: an updated systematic review and meta-analysis of randomized controlled trials.
OBJECTIVE
The optimal time to start renal replacement therapy (RRT) for acute kidney injury (AKI) remains controversial. We aim to compare the effects of early vs. delayed RRT initiation on clinical outcomes in adult patients with AKI.
MATERIALS AND METHODS
PubMed, Embase, Cochrane Library, Web of Science, Chinese Biomedical Literature Database, ClinicalTrials.gov, and the International Clinical Trial registry platform were systematically searched from inception to 7 August 2022. The review included randomized clinical trials (RCTs) comparing early and delayed initiation of RRT in AKI patients. The selected primary outcomes were short-term and long-term mortality. Secondary outcomes included RRT dependency, intensive care unit (ICU) length of stay, hospital length of stay, mechanical ventilator-free days, vasoactive agents-free days, RRT-free days, and adverse events.
RESULTS
Overall, 15 RCTs, including 5,625 patients, were analyzed. Early RRT showed no survival benefit when compared to the delayed therapy (28-or 30-day mortality: RR, 1.01, 95% CI: 0.94-1.08, p = 0.87; 60-day mortality: RR, 0.87, 95% CI: 0.71-1.06, p = 0.16; 90-day mortality: RR, 1.00, 95% CI: 0.88-1.13, p = 0.97; in-hospital mortality: RR, 1.05, 95% CI: 0.88-1.24, p = 0.58; ICU mortality: RR, 1.00, 95% CI: 0.91-1.10, p = 0.98). The delayed RRT did not lead to a higher risk of RRT dependency, ICU, or hospital length of stay than the early RRT. Similarly, early initiation of RRT did not lead to longer ventilator-free, vasoactive agent-free, and RRT-free days. However, early RRT initiation was associated with more adverse events.
CONCLUSIONS
Our study suggested that early RRT initiation was not associated with survival benefits or better clinical outcomes and increased the risk of RRT-associated adverse events. Current evidence does not support the use of early RRT for AKI patients without urgent indications.
Topics: Humans; Adult; Time-to-Treatment; Randomized Controlled Trials as Topic; Renal Replacement Therapy; Acute Kidney Injury; Continuous Renal Replacement Therapy; Intensive Care Units
PubMed: 37458646
DOI: 10.26355/eurrev_202307_32959 -
Zhongguo Zhong Yao Za Zhi = Zhongguo... Oct 2020To systematically evaluate the efficacy and safety of Yangwei Granules combined with conventional Western medicine for chronic gastritis. CNKI, SinoMed, WanFang, VIP,... (Meta-Analysis)
Meta-Analysis
To systematically evaluate the efficacy and safety of Yangwei Granules combined with conventional Western medicine for chronic gastritis. CNKI, SinoMed, WanFang, VIP, PubMed, Cochrane Library and EMbase database were electronically retrieved to collect randomized controlled trial(RCT) of Yangwei Granules combined with conventional Western medicine for chronic gastritis. Two reviewers independently screened out literatures according to the inclusion and exclusion criteria and extracted data, and evaluated the risk of bias of included studies. Meta-analysis was conducted by using RevMan 5.3 software. A total of 12 RCTs involving 1 164 patients were included. The results of Meta-analysis showed that:(1) The total effective rate of Yangwei Granules combined with conventional Western medicine for chronic gastritis was better than that of conventional Western medicine group, with a statistically significant difference(RR=1.24,95%CI[1.17,1.31],P<0.000 01).(2) Compared with the conventional Western medicine group, the Yangwei Granules combined with conventional Western medicine group was conducive to improving the Hp eradication rate, with a statistically significant difference(RR=1.24,95%CI[1.15,1.34],P<0.000 01).(3) The incidence of adverse reactions in Yangwei Granules combined with conventional Western medicine group was lower than that in the control group, but with no statistically significant diffe-rence(RR=0.83, 95%CI[0.39, 1.79], P=0.64).(4) Compared with the conventional Western medicine group, the Yangwei Granules combined with conventional Western medicine group was beneficial to the reduction of motilin level(MD=-17.31,95%CI[-21.83,-12.79],P<0.000 01) and endothelin level(MD=-6.60,95%CI[-10.07,-3.13],P=0.000 2), while the increase of gastrin level(SMD=0.94,95%CI[0.50,1.38],P=0.003) was related to calcitonin gene the level of peptide(MD=5.82,95%CI[4.25,7.39],P<0.000 01), with statistically significant differences.(5) Compared with conventional Western medicine group, Yangwei Granules combined with conventional Western medicine group could increase PGⅠ(MD=6.40,95%CI[4.26,8.54],P<0.000 01) and PGR(MD=0.89,95%CI[0.71,1.07],P<0.000 01), while decrease PGⅡ(MD=-1.24,95%CI[-2.15,-0.33],P=0.007), with statistically significant differences. Current evidence showed that the clinical efficacy and Hp eradication rate of Yangwei Granules combined with conventional Western medicine in the treatment of chronic gastritis were better than those of the conventional Western medicine group alone, and could effectively improve the level of gastrointestinal hormones, vasoactive peptide and the pepsinogen level in patients with chronic atrophic gastritis, without increasing the incidence of adverse reactions. However, due to the limited quality and quantity of included studies, the above conclusions need to be confirmed by more large-scale and high-quality RCTs.
Topics: Drugs, Chinese Herbal; Gastritis, Atrophic; Humans; Treatment Outcome
PubMed: 33350276
DOI: 10.19540/j.cnki.cjcmm.20200314.503 -
Frontiers in Cardiovascular Medicine 2021Vitamin D (VitD) is an important pleiotropic hormone for organ systems. Studies have focused on the level of VitD, especially that of 25-hydroxyvitamin D...
Vitamin D (VitD) is an important pleiotropic hormone for organ systems. Studies have focused on the level of VitD, especially that of 25-hydroxyvitamin D (25-(OH)-VitD), in patients after cardiac surgery and the relationship between VitD deficiency and adverse outcomes, but the results have been inconsistent. We carried out a meta-analysis to evaluate differences in the 25-(OH)-VitD level before and after cardiac surgery, and evaluated the predictive value of 25-(OH)-VitD level in the clinical outcomes of patients undergoing cardiac surgery. Studies related to VitD level and cardiac surgery were searched from PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases from inception to October 2020. We applied the Newcastle-Ottawa Scale to assess the risk of a bias in individual studies. We examined the heterogeneity and publication bias and performed subgroup analyses and sensitivity analyses. Fifteen studies were included in our analysis. The 25-(OH)-VitD level was significantly lower immediately after surgery [stand mean difference (SMD), 0.69; 95%CI (0.1, 1.28), = 0.023] and 24-h after surgery [0.84; (0.47, 1.21), 0.000] compared with that before surgery. A higher prevalence of 25-(OH)-VitD deficiency was recorded 24 h after surgery [RR, 0.59; 95%CI (0.47, 0.73), = 0.00]. Pooled results demonstrated a significant relationship between the preoperative 25-(OH)-VitD level and vasoactive-inotropic score (VIS) [SMD, -3.71; 95%CI (-6.32, -1.10); = 0.005], and patients with 25-(OH)-VitD deficiency revealed a comparatively poor prognosis and severe condition after cardiac surgery [-0.80; (-1.41, -0.19), 0.01]. However, 25-(OH)-VitD deficiency was not associated with the duration of stay in the intensive care unit. Cardiac surgery would leads to deficiency of 25-(OH)-VitD. And the preoperative and postoperative levels of 25-(OH)-VitD are associated with adverse events, which is eligible to work as an indicator to demonstrate clinical outcomes.
PubMed: 34869636
DOI: 10.3389/fcvm.2021.734504 -
Headache Jun 2020The aim of this systematic review and meta-analysis (SR-MA) was to identify signaling molecule profiles and blood-derived biomarkers in migraine and cluster headache... (Meta-Analysis)
Meta-Analysis
Serotonin and Neuropeptides in Blood From Episodic and Chronic Migraine and Cluster Headache Patients in Case-Control and Case-Crossover Settings: A Systematic Review and Meta-Analysis.
OBJECTIVE
The aim of this systematic review and meta-analysis (SR-MA) was to identify signaling molecule profiles and blood-derived biomarkers in migraine and cluster headache (CH) patients.
BACKGROUND
Currently no migraine and CH valid biomarkers are available. Blood tests based on biomarker profiles have been used to gather information about the nervous system. Such tests have not yet been established within the primary headache field.
METHODS
Case-control and case-crossover studies investigating whole blood, plasma, and serum were identified worldwide. The qualitative synthesis focused on 9 signaling molecules (serotonin [5-HT], calcitonin gene-related peptide [CGRP], endothelin-1 [ET-1], neurokinin A, neurokinin B, neuropeptide Y, pituitary adenylate cyclase-activating peptide 38 [PACAP-38], substance P (SP), and vasoactive intestinal peptide) and the quantitative synthesis on 5-HT and CGRP (≥5 comparisons available). The meta-analysis was conducted using standard and 3-level random effect models.
RESULTS
Fifty-four eligible studies were identified (87.0% migraine, 9.3% CH, 3.7% migraine, and CH), and 2768 headache patients and 1165 controls included. Comparable fluctuations of 5-HT, CGRP, ET-1, PACAP-38, and SP in blood were generally observed between migraine and CH. Significant findings were observed for some subgroups and strata, for example, higher interictal and ictal 5-HT venous blood levels (ratio of means = 1.32, 95% CI: 1.08; 1.61; ratio of means = 1.23, 95% CI: 1.01; 1.49) in episodic migraine with aura with a female-dominated case group, higher interictal CGRP blood levels in episodic migraine (ratio of means = 1.63, 95% CI: 1.18; 2.26), and chronic migraine (ratio of means = 1.89, 95% CI: 1.33; 2.68), and higher ictal CGRP blood levels (ratio of means = 1.35, 95% CI: 1.09; 1.68) in episodic migraine were observed. In most subgroups, the quantitative synthesis revealed a high degree of heterogeneity between studies in part explained by the blood sampling site, specimen source, blood specimen, and sex distribution. Other potential confounders were age, aura, study quality, menstrual cycle, and methodology (eg, storage temperature).
CONCLUSIONS
Potential migraine and CH signaling molecule profiles and biomarkers were revealed. Nevertheless, the high degree of heterogeneity between studies impedes identification of valid biomarkers but allowed us to assess the presence of confounders. Consideration of the potential confounders identified in this SR-MA might be of importance in the experimental planning of future studies. This consideration could be incorporated through establishment of specific guidelines.
Topics: Biomarkers; Cluster Headache; Humans; Migraine Disorders; Neuropeptides; Serotonin
PubMed: 32293721
DOI: 10.1111/head.13802 -
The Lancet. Gastroenterology &... Feb 2017Several drugs have been studied to improve outcomes for patients with hepatorenal syndrome, but trials have reported variable efficacy. We aimed to compare the efficacy... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Several drugs have been studied to improve outcomes for patients with hepatorenal syndrome, but trials have reported variable efficacy. We aimed to compare the efficacy of different management strategies for type 1 hepatorenal syndrome.
METHODS
For this systematic review and network meta-analysis, we searched Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Scopus, and Web of Science for papers published up to June 9, 2016. We selected randomised controlled trials of adults (>18 years) with decompensated cirrhosis and type 1 hepatorenal syndrome that compared the efficacy of active vasoactive drugs (terlipressin, midodrine, octreotide, noradrenaline, and dopamine; alone or in combination) with placebo or each other. The primary outcome was reduction in short-term mortality. Secondary outcomes were reversal of hepatorenal syndrome, relapse of hepatorenal syndrome after initial reversal, and adverse events. We did pairwise and network meta-analyses to produce odds ratios (ORs) and 95% CIs. We used the GRADE criteria to appraise quality of evidence.
FINDINGS
We identified 13 randomised controlled trials done in 739 adults with type 1 hepatorenal syndrome. All participants received supportive therapy with albumin. Moderate-quality evidence might support the use of terlipressin over placebo for reduction of short-term mortality (OR 0·65, 95% CI 0·41-1·05), whereas only low-quality evidence supported the use of noradrenaline, midodrine plus octreotide, and dopamine plus furosemide over placebo to reduce mortality, and no ORs for any of the comparisons versus placebo were significant. Moderate-quality evidence supported the use of terlipressin over midodrine plus octreotide (OR 26·25, 95% CI 3·07-224·21) to reverse hepatorenal syndrome, with low-quality evidence supporting the use of noradrenaline over placebo (4·17, 1·37-12·50) and over midodrine plus octreotide (10·00, 1·49-50·00) for this outcome. A median of 16% (range 5-20) of terlipressin-treated patients, and 33% (range 6-40) noradrenaline-treated patients with reversal of hepatorenal syndrome had recurrence on discontinuation of therapy. A median of 8% (range 4-22) terlipressin-treated patients required discontinuation of therapy due to serious adverse events.
INTERPRETATION
Terlipressin with albumin might reduce short-term mortality compared with placebo in patients with type 1 hepatorenal syndrome. Terlipressin with albumin and noradrenaline with albumin are both superior to midodrine plus octreotide with albumin for reversal of hepatorenal syndrome. Pragmatic clinical trials of terlipressin with albumin are warranted to evaluate real-world effectiveness and safety in patients with type 1 hepatorenal syndrome.
FUNDING
None.
Topics: Dopamine; Drug Therapy, Combination; Gastrointestinal Agents; Hepatorenal Syndrome; Humans; Lypressin; Midodrine; Network Meta-Analysis; Norepinephrine; Octreotide; Terlipressin; Treatment Outcome; Vasoconstrictor Agents
PubMed: 28403995
DOI: 10.1016/S2468-1253(16)30157-1 -
Current Opinion in Anaesthesiology Oct 2017Enthusiasm for regional anesthesia has been driven by multimodal benefits to patient outcomes. Despite widespread awareness and improved techniques (including the... (Review)
Review
PURPOSE OF REVIEW
Enthusiasm for regional anesthesia has been driven by multimodal benefits to patient outcomes. Despite widespread awareness and improved techniques (including the increasing use of ultrasound guidance for block placement), intravascular sequestration and the attendant risk of local anesthetic systemic toxicity (LAST) remains. Intravenous lipid emulsion (ILE) for the treatment of LAST has been endorsed by anesthetic regulatory societies on the basis of animal study and human case report data. The accumulated mass of reporting now permits objective interrogation of published literature.
RECENT FINDINGS
Although incompletely elucidated the mechanism of action for ILE in LAST seemingly involves beneficial effects on initial drug distribution (i.e., pharmacokinetic effects) and positive cardiotonic and vasoactive effects (i.e., pharmacokinetic effects) acting in concert. Recent systematic review by collaborating international toxicologic societies have provided reserved endorsement for ILE in bupivacaine-induced toxicity, weak support for ILE use in toxicity from other local anesthetics, and largely neutral recommendation for all other drug poisonings. Work since publication of these recommendations has concluded that there is a positive effect on survival for ILE when animal models of LAST are meta-analyzed and evidence of a positive pharmacokinetic effect for lipid in human models of LAST.
SUMMARY
Lipid emulsion remains first-line therapy (in conjunction with standard resuscitative measures) in LAST. Increasing conjecture as to the clinical efficacy of ILE in LAST, however, calls for high-quality human data to refine clinical recommendations.
Topics: Anesthesia, Conduction; Anesthetics, Local; Fat Emulsions, Intravenous; Humans
PubMed: 28692439
DOI: 10.1097/ACO.0000000000000498