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The Journal of Arthroplasty Oct 2022Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine.
METHODS
The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of PAI.
RESULTS
Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine.
CONCLUSION
Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine.
Topics: Analgesics, Opioid; Anesthetics, Local; Arthroplasty, Replacement, Knee; Bupivacaine; Clonidine; Epinephrine; Humans; Injections, Intra-Articular; Ketorolac; Morphine; Pain Management; Pain Measurement; Pain, Postoperative; Ropivacaine
PubMed: 36162925
DOI: 10.1016/j.arth.2022.03.045 -
L'Encephale Dec 2022Drug-induced hypersalivation is a frequent drug adverse event of psychotropic drugs. This excess salivary pooling in the mouth can cause an impairment of a patient's...
OBJECTIVES
Drug-induced hypersalivation is a frequent drug adverse event of psychotropic drugs. This excess salivary pooling in the mouth can cause an impairment of a patient's quality of life leading to low rates of medication adherence. The optimal management of hypersalivation is thus crucial to improve patient care. To date, no recommendations for limiting drug-induced hypersalivation have been published. In this study, we conducted a systematic review to investigate the effectiveness of interventions aimed at reducing drug-induced hypersalivation.
METHODS
Treatment of drug-induced sialorrhea based on case reports and clinical studies were sought in May 2021 from PubMed, Google Scholar and Science Direct (keywords : « treatment », « hypersalivation », « induced », « drug », « clozapine »). Articles published between 1966 to May 2021 on the treatment of drug-induced hypersalivation were included in this study.
RESULTS
Sixty-seven articles were selected in this narrative review. First, patient education associated with non-drug related management are essential to improve the compliance to drugs inducing hypersalivation. The non-drug related management should be initiated with an increase in the frequency of swallowing with chewing gum. In the case of ineffectiveness, the dosage of drug responsive of sialorrhea can be adjusted according to the patient's response and his/her medical history (i.e. reducing the dose or splitting the daily dose). Finally, if the problem persists, a symptomatic treatment can be added according to the type of sialorrhea (diurnal or nocturnal), preferred galenic by patient, tolerance and availability of drugs. Several drugs have been tested to reduce hypersalivation induced by clozapine (61/67), risperidone (3/67), quetiapine (2/67) and aripiprazole (2/67). Among the 63 articles targeting a specific corrective treatment, anticholinergic agents were most described in the literature (41 cases out of 63) with atropine, glycopyrrolate and scopolamine (6/41 each). Other agents were described as clinically effective on hypersalivation: dopamine antagonists (9/63) with amisulpride (5/9), alpha-2-adrenergic agonists (5/63) with clonidine (3/5), botulinic toxin (4/63), and terazosine, moclobemide, bupropion and N-acetylcysteine (for each 1/63).
CONCLUSIONS
In the case of drug-induced hypersalivation, after failure of non-drug therapies and dosage optimization of the causative treatment, an anticholinergic drug can be initiated. In case of insufficient response, the different treatments presented can be used depending on the galenic form, tolerance and access to those medications. The assessment of the risk-benefit balance should be systematic. The heterogeneity of the studies, the little knowledge about the pharmacological mechanism of saliva flow modulation and the unavailability of corrective drugs are different factors contributing to the complexity of therapeutic optimization.
Topics: Female; Humans; Male; Sialorrhea; Clozapine; Quality of Life; Amisulpride; Scopolamine; Cholinergic Antagonists; Antipsychotic Agents
PubMed: 35989107
DOI: 10.1016/j.encep.2022.03.013 -
Journal of Plastic, Reconstructive &... Sep 2022Although local anesthetics have been extensively studied, limited evidence is available regarding the optimal solution for maximizing patient comfort in minor... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Although local anesthetics have been extensively studied, limited evidence is available regarding the optimal solution for maximizing patient comfort in minor oculoplastic procedures.
OBJECTIVES
To determine the optimal anesthetic solution for local infiltration in minor oculoplastic surgeries to maximize patient comfort.
METHODS
This systematic review with network meta-analysis of prospective studies was conducted to understand the efficacy of different local anesthetics in combination to maximize patient comfort. The study was designed according to the Cochrane Handbook for Systematic Reviews of Interventions. The population comprised patients receiving local infiltration anesthesia in minor oculoplastic surgeries. Various anesthetics with adjuvants were compared with respect to injection pain, operative bleeding, and complications. Random-effects model was performed. The primary outcome of injection pain was measured using the visual analog scale (VAS) or a preference question (which intervention was the least painful). Other outcomes were operative bleeding and complications, which were evaluated with a similar preference question.
RESULTS
Eleven randomized controlled trials (RCTs) of 521 patients (917 eyes) were included. The network meta-analysis revealed that "bicarbonate-buffered lidocaine with epinephrine" led to a significant decrease in injection pain (preference question) compared to "prilocaine with felypressin" and "lidocaine with epinephrine," whereas no significant differences were detected in the analysis of injection pain measured using the VAS.
CONCLUSIONS
"Bicarbonate-buffered lidocaine with epinephrine" may be the optimal anesthetic solution for local infiltration in minor oculoplastic surgeries due to reduced injection pain, operative bleeding, and postoperative swelling. However, this should be interpreted cautiously as the confidence in the evidence was very low.
THE CLINICAL TRIAL REGISTRATION NUMBER
CRD42021260332 (PROSPERO).
Topics: Humans; Anesthesia, Local; Anesthetics, Local; Bicarbonates; Double-Blind Method; Epinephrine; Felypressin; Lidocaine; Network Meta-Analysis; Pain; Patient Comfort; Prilocaine
PubMed: 35961926
DOI: 10.1016/j.bjps.2022.06.058 -
Ophthalmic & Physiological Optics : the... Nov 2022To determine the diagnostic agreement of non-cycloplegic and cycloplegic refraction in children. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To determine the diagnostic agreement of non-cycloplegic and cycloplegic refraction in children.
METHOD
The study methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic databases were searched for comparative studies exploring refraction performed on children under non-cycloplegic and cycloplegic conditions. There was no restriction on the year of publication; however, only publications in the English language were eligible. Inclusion criteria consisted of children aged ≤12 years, any degree or type of refractive error, either sex and no ocular or binocular co-morbidities. The QUADAS-2 tool was used to evaluate the risk of bias. Meta-analysis was conducted to synthesise data from all included studies. Subgroup and sensitivity analyses were undertaken for those studies with a risk of bias.
RESULTS
Ten studies consisting of 2724 participants were eligible and included in the meta-analysis. The test for overall effect was not significant when comparing non-cycloplegic Plusoptix and cycloplegic autorefractors (Z = 0.34, p = 0.74). The pooled mean difference (MD) was -0.08 D (95% CI -0.54 D, +0.38 D) with a prediction interval of -1.72 D to +1.56 D. At less than 0.25 D, this indicates marginal overestimation of myopia and underestimation of hyperopia under non-cycloplegic conditions. When comparing non-cycloplegic autorefraction with a Retinomax and Canon autorefractor to cycloplegic refraction, a significant difference was found (Z = 9.79, p < 0.001) and (Z = 4.61, p < 0.001), respectively.
DISCUSSION
Non-cycloplegic Plusoptix is the most useful autorefractor for estimating refractive error in young children with low to moderate levels of hyperopia. Results also suggest that cycloplegic refraction must remain the test of choice when measuring refractive error ≤12 years of age. There were insufficient data to explore possible reasons for heterogeneity. Further research is needed to investigate the agreement between non-cycloplegic and cycloplegic refraction in relation to the type and level of refractive error at different ages.
Topics: Child; Child, Preschool; Humans; Hyperopia; Mydriatics; Myopia; Refraction, Ocular; Refractive Errors; Vision Tests
PubMed: 35913773
DOI: 10.1111/opo.13022 -
Clinics and Practice Jun 2022Diabetic retinopathy is a vascular disease of the retina that affects patients with uncontrolled diabetes. Untreated diabetic retinopathy (DR) can eventually lead to... (Review)
Review
Diabetic retinopathy is a vascular disease of the retina that affects patients with uncontrolled diabetes. Untreated diabetic retinopathy (DR) can eventually lead to blindness. To date, diabetic retinopathy is the third leading cause of vision loss in the working class globally. Frequent retinal screening for all diabetic people is an effective method of preventing diabetic retinopathy blindness. This has relied on the use of ophthalmologists, but due to scarce resources, such as a shortage of human resources for eye health, this has denied many patients quality eye health care in a resource-limited setting. The recent advances on the use of teleophthalmology are promising to close this gap. This study aimed to map available evidence on the use of teleophthalmology in the screening of DR globally and to explore how this can be used to complement short-staffed eye clinics, especially in resource-constrained contexts. Studies were sourced from Google Scholar, PubMed, Science Direct, and EBSCO host. The final study selection was presented using a PRISMA chart. The mixed method appraisal tool was used to assess the quality of the nine studies included. The random effect model was used to estimate pooled prevalence estimates. Levels of heterogeneity were evaluated using Cochran's Q statistic and I. Of nine included studies, eight were from high-income countries. The screening was performed at the primary healthcare level in eight of nine included studies. Only one study used a mydriatic agent, and the commonly used fundus camera was the non-mydriatic fundus camera. The overall estimated pooled prevalence of DR was 29 (95%CI: 10-34). Teleophthalmology at the primary health care level showed that early intervention in diabetic retinopathy reduced avoidable blindness and ensured remote access to eye health professionals, thus alleviating the burden on them.
PubMed: 35892436
DOI: 10.3390/clinpract12040050 -
Diabetologia Oct 2022The physiological counterregulatory response to hypoglycaemia is reported to be organised hierarchically, with hormone responses usually preceding symptomatic awareness... (Review)
Review
AIM/HYPOTHESIS
The physiological counterregulatory response to hypoglycaemia is reported to be organised hierarchically, with hormone responses usually preceding symptomatic awareness and autonomic responses preceding neuroglycopenic responses. To compare thresholds for activation of these responses more accurately between people with or without type 1 diabetes, we performed a systematic review on stepped hyperinsulinaemic-hypoglycaemic glucose clamps.
METHODS
A literature search in PubMed and EMBASE was conducted. We included articles published between 1980 and 2018 involving hyperinsulinaemic stepped hypoglycaemic glucose clamps among people with or without type 1 diabetes. Key exclusion criteria were as follows: data were previously published; other patient population; a clamp not the primary intervention; and an inadequate clamp description. Glycaemic thresholds for counterregulatory hormone and/or symptom responses to hypoglycaemia were estimated and compared using generalised logrank test for interval-censored data, where the intervals were either extracted directly or calculated from the data provided by the study. A glycaemic threshold was defined as the glucose level at which the response exceeded the 95% CI of the mean baseline measurement or euglycaemic control clamp. Because of the use of interval-censored data, we described thresholds using median and IQR.
RESULTS
A total of 63 articles were included, whereof 37 papers included participants with type 1 diabetes (n=559; 67.4% male sex, aged 32.7±10.2 years, BMI 23.8±1.4 kg/m) and 51 papers included participants without diabetes (n=733; 72.4% male sex, aged 31.1±9.2 years, BMI 23.6±1.1 kg/m). Compared with non-diabetic control individuals, in people with type 1 diabetes, the median (IQR) glycaemic thresholds for adrenaline (3.8 [3.2-4.2] vs 3.4 [2.8-3.9 mmol/l]), noradrenaline (3.2 [3.2-3.7] vs 3.0 [2.8-3.1] mmol/l), cortisol (3.5 [3.2-4.2]) vs 2.8 [2.8-3.4] mmol/l) and growth hormone (3.8 [3.3-3.8] vs. 3.2 [3.0-3.3] mmol/l) all occurred at lower glucose levels in people with diabetes than in those without diabetes (all p≤0.01). Similarly, although both autonomic (median [IQR] 3.4 [3.4-3.4] vs 3.0 [2.8-3.4] mmol/l) and neuroglycopenic (median [IQR] 3.4 [2.8-N/A] vs 3.0 [3.0-3.1] mmol/l) symptom responses were elicited at lower glucose levels in people with type 1 diabetes, the thresholds for autonomic and neuroglycopenic symptoms did not differ for each individual subgroup.
CONCLUSIONS/INTERPRETATION
People with type 1 diabetes have glycaemic thresholds for counterregulatory hormone and symptom responses at lower glucose levels than people without diabetes. Autonomic and neuroglycopenic symptoms responses are generated at about similar levels of hypoglycaemia. There was a considerable variation in the methodology of the articles and the high insulin doses in most of the clamps may affect the counterregulatory responses.
FUNDING
This article has received funding from the Innovative Medicines Initiative 2 Joint Undertaking (JU) under grant agreement no. 777460.
REGISTRATION
This systematic review is registered in PROSPERO (CRD42019120083).
Topics: Blood Glucose; Diabetes Mellitus, Type 1; Epinephrine; Female; Growth Hormone; Humans; Hydrocortisone; Hypoglycemia; Hypoglycemic Agents; Insulin; Male; Norepinephrine
PubMed: 35867127
DOI: 10.1007/s00125-022-05749-8 -
Journal of the American Heart... Jul 2022Background Diagnosis is particularly challenging in concealed or asymptomatic long QT syndrome (LQTS). Provocative testing, unmasking the characterization of LQTS, is a... (Meta-Analysis)
Meta-Analysis Review
Background Diagnosis is particularly challenging in concealed or asymptomatic long QT syndrome (LQTS). Provocative testing, unmasking the characterization of LQTS, is a promising alternative method for the diagnosis of LQTS, but without uniform standards. Methods and Results A comprehensive search was conducted in PubMed, Embase, and the Cochrane Library through October 14, 2021. The fixed effects model was used to assess the effect of the provocative testing on QTc interval. A total of 22 studies with 1137 patients with LQTS were included. At baseline, QTc interval was 40 ms longer in patients with LQTS than in controls (mean difference [MD], 40.54 [95% CI, 37.43-43.65]; <0.001). Compared with the control group, patients with LQTS had 28 ms longer ΔQTc upon standing (MD, 28.82 [95% CI, 23.05-34.58]; <0.001), nearly 30 ms longer both at peak exercise (MD, 27.31 [95% CI, 21.51-33.11]; <0.001) and recovery 4 to 5 minutes (MD, 29.85 [95% CI, 24.36-35.35]; <0.001). With epinephrine infusion, QTc interval was prolonged both in controls and patients with QTS, most obviously in LQT1 (MD, 68.26 [95% CI, 58.91-77.60]; <0.001) and LQT2 (MD, 60.17 [95% CI, 50.18-70.16]; <0.001). Subgroup analysis showed QTc interval response to abrupt stand testing and exercise testing varied between LQT1, LQT2, and LQT3, named Type Ⅰ, Type Ⅱ, and Type Ⅲ. Conclusions QTc trend Type Ⅰ and Type Ⅲ during abrupt stand testing and exercise testing can be used to propose a prospective evaluation of LQT1 and LQT3, respectively. Type Ⅱ QTc trend combined epinephrine infusion testing could distinguish LQT2 from control. A preliminary diagnostic workflow was proposed but deserves further evaluation.
Topics: Electrocardiography; Epinephrine; Exercise Test; Genotype; Humans; Long QT Syndrome
PubMed: 35861842
DOI: 10.1161/JAHA.122.025246 -
Current Opinion in Allergy and Clinical... Aug 2022To identify patterns and key issues though a systematic review in order to support prevention strategies and reduce avoidable deaths related to drug-induced anaphylaxis...
PURPOSE OF REVIEW
To identify patterns and key issues though a systematic review in order to support prevention strategies and reduce avoidable deaths related to drug-induced anaphylaxis (DAF).
RECENT FINDINGS
DAF rate has been estimated by 0.13-0.53/106 population/year. General global trends of DAF are increasing over time, mostly occurring at healthcare settings (62%) with a similar gender distribution and an average age of 53 years. Antibiotics, anaesthetics, radio-contrast media and NSAIDs were the most frequently implicated agents. Main comorbidities were personal history of drug allergy, cardiovascular diseases and asthma. Main manifestations were cardiovascular and respiratory commitments. Use of adrenaline is mentioned in only 29% of the articles.
SUMMARY
DAF is increasing worldwide and most cases are iatrogenic. This first systematic review of DAF identified key gaps and served as a wake-up call to prevent avoidable deaths. Phenotype at risk for DAF was represented by patients aged more than 54 years, with personal history of drug allergy/hypersensitivity with no or incomplete allergological work-up, cardiovascular disease and/or asthma with need of hospitalization and/or frequent healthcare assistance. Additional risk for those who need frequent use of intravenous antibiotics and/or undergoing surgery or image investigation with radiocontrast media.
Topics: Anaphylaxis; Anti-Bacterial Agents; Asthma; Contrast Media; Drug Hypersensitivity; Epinephrine; Humans
PubMed: 35852895
DOI: 10.1097/ACI.0000000000000835 -
Minerva Anestesiologica Dec 2022Multiple studies have compared varying prophylactic and therapeutic doses of norepinephrine and phenylephrine given as either intermittent bolus or fixed-rate infusion... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Multiple studies have compared varying prophylactic and therapeutic doses of norepinephrine and phenylephrine given as either intermittent bolus or fixed-rate infusion to combat postspinal hypotension in patients undergoing cesarean section (CS). We conducted a systematic review to figure out the best alternative to treat postspinal hypotension.
EVIDENCE ACQUISITION
PubMed and Cochrane databases were extensively searched for eligible RCTs. A total of 15 studies were found eligible and analyzed for the incidence of maternal bradycardia as the primary outcome and other maternal adverse effects, fetal acidosis and Apgar scores at 1 and 5 min as the secondary outcome. Data was analyzed using Review Manager Version 5.3. software.
EVIDENCE SYNTHESIS
There was no significant difference in the efficacy of norepinephrine and phenylephrine for managing postspinal hypotension (OR=1.15 [95% CI: 0.91-1.45], P=0.24, I=0%,moderate quality) in parturients undergoing CS. Odds of incidence of maternal bradycardia decrease significantly by 61% with norepinephrine versus phenylephrine (OR=0.39 [95% CI: 0.31-0.49], P<0.00001, I=27%, high quality evidence). Significant higher umbilical artery mean pH values were observed with NE versus PE (MD=0.0 [95% CI: 0.00 to 0.01], P=0.03), although not clinical relevant. However, no significant difference was found in the incidence of other maternal adverse effects and fetal outcomes.
CONCLUSIONS
Comparable efficacy for management of postspinal hypotension, though, norepinephrine was found to cause less incidence of maternal bradycardia as compared to phenylephrine.
Topics: Humans; Pregnancy; Female; Phenylephrine; Cesarean Section; Norepinephrine; Anesthesia, Spinal; Bradycardia; Vasoconstrictor Agents; Hypotension; Anesthesia, Obstetrical; Double-Blind Method
PubMed: 35785931
DOI: 10.23736/S0375-9393.22.16654-X -
Neuropsychopharmacology : Official... Nov 2022Alcohol use disorder (AUD) is a significant public health concern, contributing to a myriad of social, psychological, and physiological issues. Despite substantial...
Alcohol use disorder (AUD) is a significant public health concern, contributing to a myriad of social, psychological, and physiological issues. Despite substantial efforts within the alcohol research field, promising preclinical findings have failed to translate to clinical use, highlighting the necessity to develop safe and effective pharmacological probes with the ability to be used in preclinical and clinical research. Yohimbine, an α2 adrenergic receptor antagonist, is a well-validated pharmacological tool that has been widely employed in alcohol studies to evaluate noradrenergic activation. This scoping systematic review examines published literature in rodent and human studies involving the use of yohimbine relevant to alcohol research. We conducted a systematic literature review of MEDLINE, Embase, Web of Science Core Collection, CINAHL, PsycInfo, and Cochrane Central Register of Controlled Trials to identify: (1) Experimental Characteristics and Methodology, (2) Sex Differences, (3) Neurochemical Systems and Brain Regions, and (4) Discussion of Applications for Medication Development. Sixty-seven (62 preclinical and 5 clinical) studies were identified meeting the stated criteria, comprising extensive evidence supporting the use of yohimbine as a safe, titratable pharmacological agent for translational alcohol research. Support for the use of yohimbine as a fully translational tool, however, is hindered by limited available findings from human laboratory studies, as well as a dearth of studies examining sex differences in yohimbine's mechanistic actions. Additional consideration should be given to further translational modeling, ideally allowing for parallel preclinical and clinical assessment of yohimbine, methodological assessment of neurochemical systems and brain regions.
Topics: Adrenergic alpha-2 Receptor Antagonists; Alcohol Drinking; Animals; Ethanol; Female; Humans; Male; Rodentia; Yohimbine
PubMed: 35760866
DOI: 10.1038/s41386-022-01363-9