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Headache Apr 2024To assess the comparative effectiveness and safety of parenteral agents for pain reduction in patients with acute migraine. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
To assess the comparative effectiveness and safety of parenteral agents for pain reduction in patients with acute migraine.
BACKGROUND
Parenteral agents have been shown to be effective in treating acute migraine pain; however, the comparative effectiveness of different approaches is unclear.
METHODS
Nine electronic databases and gray literature sources were searched to identify randomized clinical trials assessing parenteral agents to treat acute migraine pain in emergency settings. Two independent reviewers completed study screening, data extraction, and Cochrane risk-of-bias assessment, with differences being resolved by adjudication. The protocol of the review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018100096).
RESULTS
A total of 97 unique studies were included, with most studies reporting a high or unclear risk of bias. Monotherapy, as well as combination therapy, successfully reduced pain scores prior to discharge. They also increased the proportion of patients reporting pain relief and being pain free. Across the pain outcomes assessed, combination therapy was one of the higher ranked approaches and provided robust improvements in pain outcomes, including lowering pain scores (mean difference -3.36, 95% confidence interval [CI] -4.64 to -2.08) and increasing the proportion of patients reporting pain relief (risk ratio [RR] 2.83, 95% CI 1.74-4.61). Neuroleptics and metoclopramide also ranked high in terms of the proportion of patients reporting pain relief (neuroleptics RR 2.76, 95% CI 2.12-3.60; metoclopramide RR 2.58, 95% CI 1.90-3.49) and being pain free before emergency department discharge (neuroleptics RR 4.8, 95% CI 3.61-6.49; metoclopramide RR 4.1, 95% CI 3.02-5.44). Most parenteral agents were associated with increased adverse events, particularly combination therapy and neuroleptics.
CONCLUSIONS
Various parenteral agents were found to provide effective pain relief. Considering the consistent improvements across various outcomes, combination therapy, as well as monotherapy of either metoclopramide or neuroleptics are recommended as first-line options for managing acute migraine pain. There are risks of adverse events, especially akathisia, following treatment with these agents. We recommend that a shared decision-making model be considered to effectively identify the best treatment option based on the patient's needs.
Topics: Humans; Analgesics; Emergency Service, Hospital; Metoclopramide; Migraine Disorders; Network Meta-Analysis; Pain Management; Randomized Controlled Trials as Topic
PubMed: 38644702
DOI: 10.1111/head.14704 -
Surgical Innovation Apr 2024To examine the artificial intelligence (AI) tools currently being studied in modern medical education, and critically evaluate the level of validation and the quality of... (Review)
Review
BACKGROUND
To examine the artificial intelligence (AI) tools currently being studied in modern medical education, and critically evaluate the level of validation and the quality of evidence presented in each individual study.
METHODS
This review (PROSPERO ID: CRD42023410752) was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. A database search was conducted using PubMed, Embase, and Cochrane Library. Articles written in the English language between 2000 and March 2023 were reviewed retrospectively using the MeSH Terms "AI" and "medical education" A total of 4642 potentially relevant studies were found.
RESULTS
After a thorough screening process, 36 studies were included in the final analysis. These studies consisted of 26 quantitative studies and 10 studies investigated the development and validation of AI tools. When examining the results of studies in which Support vector machines (SVMs) were employed, it has demonstrated high accuracy in assessing students' experiences, diagnosing acute abdominal pain, classifying skilled and novice participants, and evaluating surgical training levels. Particularly in the comparison of surgical skill levels, it has achieved an accuracy rate of over 92%.
CONCLUSION
AI tools demonstrated effectiveness in improving practical skills, diagnosing diseases, and evaluating student performance. However, further research with rigorous validation is required to identify the most effective AI tools for medical education.
PubMed: 38632898
DOI: 10.1177/15533506241248239 -
Canadian Journal of Anaesthesia =... Apr 2024Acetaminophen is the most common drug used to treat acute pain in the pediatric population, given its wide safety margin, low cost, and multiple routes for...
PURPOSE
Acetaminophen is the most common drug used to treat acute pain in the pediatric population, given its wide safety margin, low cost, and multiple routes for administration. We sought to determine the most efficacious route of acetaminophen administration for postoperative acute pain relief in the pediatric surgical population.
METHODS
We conducted a systematic review of randomized controlled trials (RCTs) that included children aged between 30 days and 17 yr who underwent any type of surgical procedure and that evaluated the analgesic efficacy of different routes of administration of acetaminophen for the treatment of postoperative pain. We searched MEDLINE, CENTRAL, Embase, CINAHL, LILACs, and Google Scholar databases for trials published from inception to 16 April 2023. We assessed the risk of bias in the included studies using the Cochrane Risk of Bias 1.0 tool. We performed a frequentist network meta-analysis using a random-effects model. Our primary outcome was postoperative pain using validated pain scales.
RESULTS
We screened 2,344 studies and included 14 trials with 829 participants in the analysis. We conducted a network meta-analysis for the period from zero to two hours, including six trials with 496 participants. There was no evidence of differences between intravenous vs rectal routes of administration of acetaminophen (difference in means, -0.28; 95% confidence interval [CI], -0.62 to 0.06; very low certainty of the evidence) and intravenous vs oral acetaminophen (difference in means, -0.60; 95% CI, -1.20 to 0.01; low certainty of the evidence). For the comparison of oral vs rectal routes, we found evidence favouring the oral route (difference in means, -0.88; 95% CI, -1.44 to -0.31; low certainty of the evidence). Few trials reported secondary outcomes of interest; when comparing the oral and rectal routes in the incidence of nausea and vomiting, there was no evidence of differences (relative risk, 1.20; 95% CI, 0.81 to 1.78).
CONCLUSION
The available evidence on the effect of the administration route of acetaminophen on postoperative pain in children is very uncertain. The outcomes of postoperative pain control and postoperative vomiting may differ very little between the oral and rectal route. Better designed and executed RCTs are required to address this important clinical question.
STUDY REGISTRATION
PROSPERO (CRD42021286495); first submitted 19 November 2021.
PubMed: 38622469
DOI: 10.1007/s12630-024-02760-y -
International Angiology : a Journal of... Apr 2024Inferior vena cava (IVC) filters act in preventing pulmonary embolisms (PE). Various complications have been reported with their use. However, a credible urological...
INTRODUCTION
Inferior vena cava (IVC) filters act in preventing pulmonary embolisms (PE). Various complications have been reported with their use. However, a credible urological complication rate, filter characteristics, and clinical presentation has yet to be summarized. Thus, we reported these complications in the form of a systematic review.
EVIDENCE ACQUISITION
A search strategy was designed using PubMed, MEDLINE, and EMBASE on February 10, 2022. The design of this search strategy did not include any language restrictions. The key words (and wildcard terms) used in the search strategy were urolog*, ureter*, bladder, kidney coupled with filter, inferior vena cava, and cava*. Inclusion criteria were: patients older than 18, with previous IVC filter placement, and urologic complication reported. Exclusion criteria were: patients younger than 18, no IVC filter placement, and no urologic complication reported. Other case series and reviews were excluded to avoid patient duplication.
EVIDENCE SYNTHESIS
Thirty-five articles were selected for full-text screening. Thirty-seven patient cases were reviewed, and the median age was 53 (range: 21-92 years old). Abdominal and or flank pain was reported in 16 (43%) patients, hematuria was seen in eight (22%) and two (5%) patients died due to acute renal failure resulting from the urologic complications of the IVC filter. Indications for IVC filter placement were recurrent pulmonary embolism (PE), contraindication to or noncompliance with anticoagulant therapy. The IVC filters were infrarenal in 29 (78.4%) patients, suprarenal in five (13.5%) patients, not reported in two patients, and misplaced into the right ovarian vein in one patient. Three or more imaging modalities were obtained in 19 patients (51%) for planning. IVC filter removal was not performed in 17 (45.9%) patients, endovascular retrieval occurred in nine (24.3%) patients, and open removal was performed in seven (18.9%) patients, and tissue interposition was performed in two (5.4%) patients. One patient did not have the management reported.
CONCLUSIONS
Urological complications caused by IVC filters although rare, are likely underreported, require extensive workup, and pose surgical challenges. Due to their complex management, filter retrieval should be planned for as soon as feasible, and plans should be made as early as during the IVC filter implant. For those that do develop complications, clinical judgement must be exercised in management, and open surgical, endovascular or even conservative management strategies can be viable options and should be discussed in a multidisciplinary setting.
Topics: Vena Cava Filters; Humans; Aged; Female; Pulmonary Embolism; Middle Aged; Adult; Aged, 80 and over; Male; Hematuria; Young Adult; Device Removal; Risk Factors; Vena Cava, Inferior; Urologic Diseases
PubMed: 38619204
DOI: 10.23736/S0392-9590.24.05041-7 -
Pain Management Nursing : Official... Jun 2024To identify chronic pain management strategies aimed to reduce pain intensity and enhance functional outcomes in veterans of wars and armed conflict.
OBJECTIVES
To identify chronic pain management strategies aimed to reduce pain intensity and enhance functional outcomes in veterans of wars and armed conflict.
DESIGN
Systematic review without meta-analysis.
DATA SOURCES
Key words "chronic pain," "veterans," and "injuries" were used to search for articles in the MEDLINE, CINAHL, APA PsycInfo, and Embase databases. Articles published in English between 2000 and 2023 were included.
REVIEW/ANALYSIS METHODS
A systematic literature search was conducted in June 2020, updated in April 2023, and managed using Covidence review software. Inclusion criteria focused on combat-injured veterans with chronic pain, excluding nonveterans and civilians treated for acute or chronic pain. Data from included studies were extracted, summarized, and critically appraised using the 2018 Mixed Methods Appraisal Tool. This review is registered with PROSPERO (CRD42020207435).
RESULTS
Fourteen studies met the inclusion criteria, with 10 of them supporting nonpharmacological approaches for managing chronic pain among veterans of armed conflicts and wars. Interventions included psychological/behavioral therapies, peer support, biofeedback training via telephone-based therapy, manual therapy, yoga, cognitive processing therapy, cognitive-behavioral therapy, and social and community integration to reduce pain intensity and enhance functional outcomes.
CONCLUSION
Nonpharmacological treatments for chronic pain have increased in recent years, a shift from earlier reliance on pharmacological treatments. More evidence from randomized controlled trials on the benefits of combined pain interventions could improve pain management of veterans with complex care needs.
Topics: Humans; Chronic Pain; Veterans; Pain Management; Armed Conflicts
PubMed: 38604820
DOI: 10.1016/j.pmn.2024.03.008 -
Zeitschrift Fur Gastroenterologie Apr 2024Phytotherapeutics are gaining influence in the treatment of gastroenterological diseases. Their popularity and growing evidence of efficacy contribute to their...
Phytotherapeutics are gaining influence in the treatment of gastroenterological diseases. Their popularity and growing evidence of efficacy contribute to their integration into medical guidelines. A systematic screening identified recommended phytotherapeutic approaches. Based on current scientific data, some recommendations for the use of phytotherapeutic agents are given. For the use of is "strongly recommended", especially for pain and flatulence. Other phytotherapeutics such as , Tibetan or warm pads have proven effective in alleviating symptoms. It is "recommended" to integrate them into the treatment concept. For , 30g of fiber per day is recommended. Best data exists for with moderate evidence and . In case of , as well as the combination of , and can be used as a complementary treatment in maintaining remission. There is also an "open recommendation" for for both, remission induction and maintenance. Some phytotherapeutic treatments (e.g., , ) show evidence of effectiveness for the treatment of , but data are not yet sufficient for recommendations. Cannabis-based medicines can be considered for abdominal pain and clinically relevant appetite loss if standard therapy is ineffective or contraindicated, but they should not be used for acute inflammation in active Crohn's disease. Further recommendations for other gastroenterological diseases are discussed. The safety and tolerability of the phytotherapeutics were rated as predominantly "very good" to "acceptable". Some clear recommendations for the use of phytotherapeutics to treat gastroenterological diseases show their great potential. Due to their wide range of effects, phytotherapeutics can be used very well as a complement to conventional medicines in case of complex regulatory disorders. However, further methodologically well-conducted impact studies would be helpful in order to be able to make further recommendations.
PubMed: 38604221
DOI: 10.1055/a-2279-5045 -
International Journal of Emergency... Apr 2024
PubMed: 38600463
DOI: 10.1186/s12245-024-00625-1 -
Revista Da Sociedade Brasileira de... 2024Chikungunya fever is an emerging global infection transmitted by Aedes mosquitoes that manifests as an acute febrile illness with joint pain and can lead to chronic...
BACKGROUND
Chikungunya fever is an emerging global infection transmitted by Aedes mosquitoes that manifests as an acute febrile illness with joint pain and can lead to chronic arthritis. The mechanism underlying chronic joint damage remains unclear; however, chronic chikungunya arthritis shares similarities with rheumatoid arthritis. Disease-modifying antirheumatic drugs have revolutionized rheumatoid arthritis treatment by preventing joint damage. However, the role of these therapies in chronic chikungunya arthritis has not been determined. We conducted a systematic review to evaluate the burden of joint structural damage in chronic chikungunya arthritis to help to define the role of disease-modifying therapy in this disease.
METHODS
This systematic review included retrospective and prospective studies, trials, and case reports evaluating joint damage caused by chikungunya virus. Various databases were searched without any date or language restrictions. Study selection was conducted independently by two researchers, and data were extracted from the articles selected.
RESULTS
A total of 108 studies were initially evaluated, with 8 meeting the inclusion criteria. Longitudinal studies have reported persistent joint pain from chikungunya infection and the progression of radiographic joint damage up to 13 years post-infection. Joint imaging revealed synovial inflammation, bone erosion, and cartilage destruction in patients with chronic chikungunya arthritis.
CONCLUSIONS
Few studies have addressed chikungunya-induced joint damage, limiting our understanding of chronic chikungunya arthritis. Nevertheless, chronic chikungunya arthritis has similarities to rheumatoid arthritis. The success of early disease-modifying antirheumatic drug therapy in rheumatoid arthritis underscores the need for comprehensive research on its role in chikungunya arthritis.
Topics: Humans; Antirheumatic Agents; Arthralgia; Arthritis, Rheumatoid; Chikungunya Fever; Chikungunya virus; Prospective Studies; Retrospective Studies
PubMed: 38597523
DOI: 10.1590/0037-8682-0433-2023 -
Obesity Reviews : An Official Journal... Jul 2024Preoperative depression is prevalent among patients undergoing metabolic and bariatric surgery (MBS) and is a potentially modifiable risk factor. However, the impact of... (Review)
Review
Preoperative depression is prevalent among patients undergoing metabolic and bariatric surgery (MBS) and is a potentially modifiable risk factor. However, the impact of preoperative depression on MBS outcomes has not been systematically reviewed. A search of MEDLINE, Embase, Cochrane, and PsychINFO (inception to June 2023) was conducted for studies reporting associations between preoperative depression and any clinical or patient-reported outcomes after MBS. Eighteen studies (5 prospective and 13 retrospective) reporting on 5933 participants were included. Most participants underwent gastric bypass or sleeve gastrectomy. Meta-analyses were not conducted due to heterogeneity in reported outcomes; findings were instead synthesized using a narrative and tabular approach. Across 13 studies (n = 3390) the associations between preoperative depression and weight loss outcomes at 6-72 months were mixed overall. This may be related to differences in cohort characteristics, outcome definitions, and instruments used to measure depression. A small number of studies reported that preoperative depression was associated with lower quality of life, worse acute pain, and more perioperative complications after surgery. Most of the included studies were deemed to be at high risk of bias, resulting in low or very low certainty of evidence according to the Risk of Bias In Non-randomized Studies - of Exposure (ROBINS-E) tool. While the impact of preoperative depression on weight loss after MBS remains unclear, there is early evidence that depression has negative consequences on other patient-important outcomes. Adequately powered studies using more sophisticated statistical methods are needed to accurately estimate these associations.
Topics: Humans; Bariatric Surgery; Depression; Treatment Outcome; Quality of Life; Preoperative Period; Weight Loss; Obesity, Morbid; Postoperative Complications
PubMed: 38572605
DOI: 10.1111/obr.13743 -
Journal of Orthopaedics Aug 2024Syndesmotic injuries are frequently stabilized using syndesmotic screws. Traditionally, these screws were routinely removed during the postoperative period, however... (Review)
Review
BACKGROUND
Syndesmotic injuries are frequently stabilized using syndesmotic screws. Traditionally, these screws were routinely removed during the postoperative period, however recent literature has brought into question the necessity of routine removal, citing no change in functional outcomes and the inherent risks of a second surgery. Our study aimed to compare outcomes of patients undergoing routine syndesmotic screw removal versus those undergoing an on-demand approach to removal.
METHODS
A systematic search of studies comparing routine syndesmotic screw removal to on-demand screw removal following an acute ankle fracture, or an isolated syndesmotic injury was conducted across seven databases. Only Prospective randomized controlled trials were eligible for inclusion. Data reported on by at least 2 studies was pooled for analysis.
RESULTS
Three studies were identified that met inclusion and exclusion criteria. No significant difference in Olerud-Molander Ankle Score (MD -2.36, 95% CI -6.50 to 1.78, p = 0.26), American Orthopedic Foot and Ankle Hindfoot Score (MD -0.45, 95% CI -1.59 to .69, p = 0.44), or dorsiflexion (MD 2.20, 95% CI -0.50 to 4.89, p = 0.11) was found between the routine removal group and on-demand removal group at 1-year postoperatively. Routine removal was associated with a significantly higher rate of complications than on-demand removal (RR 3.02, 95% CI 1.64 to 5.54, p = 0.0004). None of the included studies found significant differences in pain scores or range of motion by 1-year postoperatively.
CONCLUSION
Given the increased risk of complications with routine syndesmotic screw removal and the comparable outcomes when screws are retained, an as-needed approach to syndesmotic screw removal should be considered.
PubMed: 38567192
DOI: 10.1016/j.jor.2024.03.012