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American Journal of Obstetrics and... Jul 2013To evaluate the efficacy and safety of prophylactic misoprostol use at cesarean delivery for reducing intraoperative and postoperative hemorrhage. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the efficacy and safety of prophylactic misoprostol use at cesarean delivery for reducing intraoperative and postoperative hemorrhage.
STUDY DESIGN
Systematic review and metaanalysis of randomized controlled trials.
RESULTS
Seventeen studies (3174 women) were included of which 7 evaluated misoprostol vs oxytocin and 8 evaluated misoprostol plus oxytocin vs oxytocin alone. Overall, there were no significant differences in intraoperative and postoperative hemorrhage between sublingual or oral misoprostol and oxytocin. Rectal misoprostol, compared with oxytocin, was associated with a significant reduction in intraoperative and postoperative hemorrhage. The combined use of sublingual misoprostol and oxytocin, compared with the use of oxytocin alone, was associated with a significant reduction in the mean decrease in hematocrit (mean difference, -2.1%; 95% confidence interval, -3.4 to -0.8) and use of additional uterotonic agents (relative risk, 0.33; 95% confidence interval, 0.18-0.62). Compared with oxytocin alone, buccal misoprostol plus oxytocin reduced the use of additional uterotonic agents; rectal misoprostol plus oxytocin decreased intraoperative and postoperative blood loss, mean fall in hematocrit, and use of additional uterotonic agents; and intrauterine misoprostol plus oxytocin reduced the mean fall in hemoglobin and hematocrit. Women receiving misoprostol, alone or combined with oxytocin, had a higher risk of shivering and pyrexia.
CONCLUSION
Misoprostol combined with oxytocin appears to be more effective than oxytocin alone in reducing intraoperative and postoperative hemorrhage during cesarean section. There were no significant differences in intraoperative and postoperative hemorrhage when misoprostol was compared to oxytocin. However, these findings were based on a few trials with methodological limitations.
Topics: Cesarean Section; Female; Humans; Intraoperative Complications; Misoprostol; Oxytocics; Oxytocin; Postpartum Hemorrhage; Pregnancy; Uterine Hemorrhage
PubMed: 23507545
DOI: 10.1016/j.ajog.2013.03.015 -
The Lancet. Gastroenterology &... Feb 2017Direct oral anticoagulants are increasingly used for a wide range of indications. However, data are conflicting about the risk of major gastrointestinal bleeding with... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Direct oral anticoagulants are increasingly used for a wide range of indications. However, data are conflicting about the risk of major gastrointestinal bleeding with these drugs. We compared the risk of gastrointestinal bleeding with direct oral anticoagulants, warfarin, and low-molecular-weight heparin.
METHODS
For this systematic review and meta-analysis, we searched MEDLINE and Embase from database inception to April 1, 2016, for prospective and retrospective studies that reported the risk of gastrointestinal bleeding with use of a direct oral anticoagulant compared with warfarin or low-molecular-weight heparin for all indications. We also searched the Cochrane Library for systematic reviews and assessment evaluations, the National Health Service (UK) Economic Evaluation Database, and ISI Web of Science for conference abstracts and proceedings (up to April 1, 2016). The primary outcome was the incidence of major gastrointestinal bleeding, with all gastrointestinal bleeding as a secondary outcome. We did a Bayesian network meta-analysis to produce incidence rate ratios (IRRs) with 95% credible intervals (CrIs).
FINDINGS
We identified 38 eligible articles, of which 31 were included in the primary analysis, including 287 692 patients exposed to 230 090 years of anticoagulant drugs. The risk of major gastrointestinal bleeding with direct oral anticoagulants did not differ from that with warfarin or low-molecular-weight heparin (factor Xa vs warfarin IRR 0·78 [95% CrI 0·47-1·08]; warfarin vs dabigatran 0·88 [0·59-1·36]; factor Xa vs low-molecular-weight heparin 1·02 [0·42-2·70]; and low-molecular-weight heparin vs dabigatran 0·67 [0·20-1·82]). In the secondary analysis, factor Xa inhibitors were associated with a reduced risk of all severities of gastrointestinal bleeding compared with warfarin (0·25 [0.07-0.76]) or dabigatran (0.24 [0.07-0.77]).
INTERPRETATION
Our findings show no increase in risk of major gastrointestinal bleeding with direct oral anticoagulants compared with warfarin or low-molecular-weight heparin. These findings support the continued use of direct oral anticoagulants.
FUNDING
Leeds Teaching Hospitals Charitable Foundation.
Topics: Administration, Oral; Anticoagulants; Dabigatran; Factor Xa Inhibitors; Gastrointestinal Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Network Meta-Analysis; Risk Factors; Warfarin
PubMed: 28403994
DOI: 10.1016/S2468-1253(16)30162-5 -
Cellular Physiology and Biochemistry :... 2016Upper gastrointestinal hemorrhage (UGH) is a serious medical condition which affects a large number of individuals. Endoscopic therapy accompanied by medication is a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND/AIMS
Upper gastrointestinal hemorrhage (UGH) is a serious medical condition which affects a large number of individuals. Endoscopic therapy accompanied by medication is a standard approach that is used to improve the prognosis of UGH patients and a few medications have been developed including proton pump inhibitors (PPIs), histamine H2 receptor antagonist (H2RA), somatostatin analogues and tranexamic acid. This study is set to compare the efficacy and safety of various medical interventions that are used to manage upper gastrointestinal bleeding.
METHODS
We searched PubMed, Cochrane Library, and Embase for relevant articles. Eligible studies were determined by using both the inclusion and exclusion criteria. Both traditional pair-wise meta-analysis and net-work analysis were carried out to evaluate the corresponding interventions.
RESULTS AND CONCLUSION
PPI is an effective medication for UGH patients and intravenous PPI exhibits equivalent effectiveness and safety in comparison to oral PPI. H2RA is not recommended for UGH patients as patients treated with H2RA are associated with an increased risk of adverse events including rebleeding, need for surgery and all-cause mortality. Moreover, patients treated with H2RA exhibit an increased length of average hospital stay and blood transfusion amount compared to those treated with PPI. Tranexamic acid is also considered as another promising medication for UGH.
Topics: Blood Transfusion; Gastrointestinal Hemorrhage; Histamine H2 Antagonists; Hospitalization; Humans; Proton Pump Inhibitors; Treatment Outcome
PubMed: 27855401
DOI: 10.1159/000452515 -
Journal of Thrombosis and Haemostasis :... Mar 2013Lack of patient knowledge has been associated with poor anticoagulation control, but the effect of patient education on clinical outcomes is unclear. We systematically... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Lack of patient knowledge has been associated with poor anticoagulation control, but the effect of patient education on clinical outcomes is unclear. We systematically reviewed the effect of supplemental patient education vs. usual care on hemorrhage, thromboembolic events (TEEs), time in therapeutic range (TTR) and knowledge test scores for all oral anticoagulants.
DATA SOURCES
The data sources were electronic databases, including MEDLINE, EMBASE, CENTRAL, CINAHL and IPA, to February 2012 examining any oral anticoagulant. We reviewed references for additional potentially relevant studies.
METHODS
Only randomized controlled trials (RCTs) were considered. Data extraction and quality assessment were conducted with GRADE. Pooled relative risks (RRs) were calculated, and heterogeneity was determined by use of χ(2) and I(2) statistics.
RESULTS
Seven RCTs (n = 1209) were included in the systematic review, and five RCTs (n = 847) in the meta-analysis. All included studies examined vitamin K antagonists. No significant difference was found for hemorrhage (RR 0.92, 95% confidence interval [CI] 0.04-20.56), TEE (RR 0.66, 95% CI 0.10-4.39), a composite outcome of hemorrhage or TEE (RR 0.48, 95% CI 0.23-1.01), or TTR (mean absolute difference of 2.02%, 95% CI - 2.81 to 6.84). Evidence was conflicting on the impact of supplemental education on test scores. All trials had at least one substantial methodologic limitation.
CONCLUSION
Current evidence does not support supplemental patient education as a means to improve patient outcomes, but the quality of this evidence is poor. Larger randomized trials are needed with longer follow-up, recruitment of patients initiating anticoagulation in primary care settings, and clearly defined education interventions.
Topics: Administration, Oral; Anticoagulants; Blood Coagulation; Chi-Square Distribution; Drug Monitoring; Health Knowledge, Attitudes, Practice; Hemorrhage; Humans; Patient Education as Topic; Risk Assessment; Risk Factors; Treatment Outcome
PubMed: 23279062
DOI: 10.1111/jth.12107 -
Medicine Oct 2023Current guidelines recommended that oral anticoagulants (OACs) should last for a minimum first 2 months after atrial fibrillation (AF) ablation and the long-term... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Current guidelines recommended that oral anticoagulants (OACs) should last for a minimum first 2 months after atrial fibrillation (AF) ablation and the long-term decision of anticoagulation after AF ablation should be based on the individual patient's risk of stroke rather than the rhythm status. There is controversy about the safety of discontinuing OACs in patients with atrial fibrillation after the blanking period due to the divergences between consensus recommendations and clinical practice.
METHODS
Electronic bibliographic sources (PubMed, Embase, and Web of Science) were searched until August 2023 to identify cohort studies about the safety of discontinuing OACs in patients with AF after the blanking period. The primary outcome was thromboembolism (TE). The secondary outcome was major bleeding events (MBEs). Two authors extracted articles independently using predefined data fields. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated based on a random-effects model.
RESULTS
A total of 16 studies (11 prospective cohorts and 5 retrospective cohorts) enrolling 23,942 patients (14,382 OFF-OAC and 9560 ON-OAC) were included in our analysis. No significant difference emerged in the risk of TE between OFF-OAC and ON-OAC patients following AF ablation after the banking period (OR = 0.66; 95%CI, 0.43-1.01). Similar results emerged in the patients with a high risk of TE after stratification by the risk level of TE (OR = 0.72; 95%CI, 0.25-2.08). A significant reduction in incidences of major bleeding was found in the OFF-OAC patients compared with the ON-OAC patients (OR = 0.23; 95%CI, 0.12-0.42). Subgroup analyses for TE found a reduction of incidences in the subgroups who switched to antiplatelet drugs and with a follow-up duration <3 years. Subgroup analyses for MBEs found a significant reduction of incidences in all subgroups.
CONCLUSIONS
Our study suggests it can be safe to discontinue OACs after successful AF ablation. Discontinuation of OACs may reduce the risk of MBEs while not increasing the risk of TE.
Topics: Humans; Atrial Fibrillation; Retrospective Studies; Prospective Studies; Stroke; Hemorrhage; Thromboembolism; Anticoagulants; Administration, Oral; Risk Factors
PubMed: 37861532
DOI: 10.1097/MD.0000000000035518 -
The Cochrane Database of Systematic... Aug 2012Prostaglandins have mainly been used for postpartum haemorrhage (PPH) when other measures fail. Misoprostol, a new and inexpensive prostaglandin E1 analogue, has been... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Prostaglandins have mainly been used for postpartum haemorrhage (PPH) when other measures fail. Misoprostol, a new and inexpensive prostaglandin E1 analogue, has been suggested as an alternative for routine management of the third stage of labour.
OBJECTIVES
To assess the effects of prophylactic prostaglandin use in the third stage of labour.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 January 2011). We updated this search on 25 May 2012 and added the results to the awaiting classification section.
SELECTION CRITERIA
Randomised trials comparing a prostaglandin agent with another uterotonic or no prophylactic uterotonic (nothing or placebo) as part of management of the third stage of labour. The primary outcomes were blood loss 1000 mL or more and the use of additional uterotonics.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed eligibility and trial quality and extracted data.
MAIN RESULTS
We included 72 trials (52,678 women). Oral or sublingual misoprostol compared with placebo is effective in reducing severe PPH (oral: seven trials, 6225 women, not totalled due to significant heterogeneity; sublingual: risk ratio (RR) 0.66; 95% confidence interval (CI) 0.45 to 0.98; one trial, 661 women) and blood transfusion (oral: RR 0.31; 95% CI 0.10 to 0.94; four trials, 3519 women).Compared with conventional injectable uterotonics, oral misoprostol was associated with higher risk of severe PPH (RR 1.33; 95% CI 1.16 to 1.52; 17 trials, 29,797 women) and use of additional uterotonics, but with a trend to fewer blood transfusions (RR 0.84; 95% CI 0.66 to 1.06; 15 trials; 28,213 women). Additional uterotonic data were not totalled due to heterogeneity. Misoprostol use is associated with significant increases in shivering and a temperature of 38º Celsius compared with both placebo and other uterotonics.
AUTHORS' CONCLUSIONS
Oral or sublingual misoprostol shows promising results when compared with placebo in reducing blood loss after delivery. The margin of benefit may be affected by whether other components of the management of the third stage of labour are used or not. As side-effects are dose-related, research should be directed towards establishing the lowest effective dose for routine use, and the optimal route of administration.Neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the management of the third stage of labour especially for low-risk women; however, evidence has been building for the use of oral misoprostol to be effective and safe in areas with low access to facilities and skilled healthcare providers and future research on misoprostol use in the community should focus on implementation issues.
Topics: Administration, Oral; Administration, Sublingual; Female; Fever; Humans; Labor Stage, Third; Misoprostol; Oxytocics; Postpartum Hemorrhage; Pregnancy; Prostaglandins; Randomized Controlled Trials as Topic; Shivering
PubMed: 22895917
DOI: 10.1002/14651858.CD000494.pub4 -
Frontiers in Pharmacology 2023The benefits and risks of starting anticoagulation therapy, such as direct oral anticoagulations (DOACs) or warfarin, in atrial fibrillation (AF) patients with a... (Review)
Review
The benefits and risks of starting anticoagulation therapy, such as direct oral anticoagulations (DOACs) or warfarin, in atrial fibrillation (AF) patients with a history of intracranial hemorrhage (ICH) remain controversial. We performed a systematic review and meta-analysis to compare the safety and efficacy of starting oral anticoagulation (OAC) and non-oral anticoagulation in these patients. PubMed, Cochrane Library, and Embase were searched from inception to 01 May 2022 for randomized controlled trials and cohort studies, reporting effectiveness and safety outcomes for anticoagulation therapy in atrial fibrillation patients with intracranial hemorrhage. The Newcastle-Ottawa Scale (NOS) and the Cochrane Collaboration tool were used to evaluate bias risks for all randomized controlled trials (RCTs) and cohort studies. An effects model was applied to calculate adjusted hazard ratios (aHRs) for randomized controlled trials and cohort studies. We analyzed data from two randomized controlled trials (304 patients) and seven Cohort studies (17,477 patients). Compared to non-oral anticoagulation, starting oral anticoagulation therapy reduced the risk of Ischemic Stroke/Systemic Embolism (SE) (aHR: 0.64, 95% CI: 0.55-0.57) and all-cause death (aHR: 0.53, 95% CI: 0.35-0.80) in atrial fibrillation patients and a prior history intracranial hemorrhage. Starting oral anticoagulation therapy did not increase the risk of recurrent intracranial hemorrhage (aHR: 1.07, 95% CI: 0.66-1.74), but increased the risk of major bleeding (aHR: 1.38, 95% CI: 1.00-1.91) than no oral anticoagulation therapy. The DOACs had a lower risk of Ischemic Stroke/SE (aHR: 0.84, 95% CI: 0.70-1.00), recurrent intracranial hemorrhage (aHR: 0.63, 95% CI: 0.49-0.82), and all-cause death (aHR: 0.65, 95% CI: 0.48-0.88) compared to warfarin. According to subgroup analyses, starting oral anticoagulation therapy have a higher risk of recurrent intracranial hemorrhage than non-oral anticoagulation therapy (aHR: 1.57, 95% CI: 1.36-1.81) for Asians. After intracranial hemorrhage in atrial fibrillation patients, restarting or initiating oral anticoagulation therapy decreased the risk of Ischemic Stroke/SE and all-cause death but did not increase the risk for recurrent intracranial hemorrhage. Direct oral anticoagulations have better efficacy and safety than warfarin if oral anticoagulation therapy is started. However, starting oral anticoagulation increases the risk for recurrent intracranial hemorrhage in the Asian region.
PubMed: 36969833
DOI: 10.3389/fphar.2023.1122564 -
Orthopaedics & Traumatology, Surgery &... Apr 2023Direct oral anticoagulants (DOACs) are recommended as a possible pharmacologic venous thromboembolism (VTE) prophylaxis in patients undergoing total hip arthroplasty... (Meta-Analysis)
Meta-Analysis Review
The effectiveness and safety of direct oral anticoagulants compared to conventional pharmacologic thromboprophylaxis in hip fracture patients: A systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Direct oral anticoagulants (DOACs) are recommended as a possible pharmacologic venous thromboembolism (VTE) prophylaxis in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, current guidelines did not introduce recommendations for administration of DOACs as an option for pharmacologic VTE prophylaxis in patients undergoing hip fracture surgery (HFS). The purpose of this study is to compare the effectiveness and safety of DOACs administered for pharmacologic VTE prophylaxis in patients undergoing HFS to conventional pharmacologic VTE prophylaxis, as well as mortality between these thromboprophylaxis medications.
METHODS
We performed a systematic review of multiple electronic databases for randomized controlled trials (RCTs) including patients who were subjected to HFS and prescribed either DOACs as pharmacologic VTE prophylaxis or a conventional VTE prophylaxis drug. We conducted a meta-analysis comparing effectiveness, safety and mortality of these agents between the patient groups studied. Three endpoints were studied. The first one regarding the effectiveness of the agents included clinical manifestations of VTE. The second one regarding the safety of the agents included clinical presentation of bleeding. The latter endpoint studied was mortality of patient groups studied. We generated forest plots to depict the relative risk of the above clinical manifestations between the two studied patient groups and to investigate if there is statistical significance for each patient group to present any of these clinical manifestations. Additionally, we calculated the inconsistency (I) statistic and assessed the risk of bias of RCTs included in our meta-analysis by using the modified Cochrane collaboration tool.
RESULTS
We selected 2 RCTs in this review including 279 patients totally. Patients of control groups in both eligible studies were administered enoxaparin, which is a low molecular weight heparin (LMWH). The meta-analysis found no statistically significant difference between patients prescribed DOACs and patients prescribed LMWH for VTE (95% CI 0.19 to 1.13, RR=0.46, p=0.09), deep vein thrombosis (DVT) (95% CI 0.21 to 1.32, RR=0.53, p=0.17) and pulmonary embolism (PE) (95% CI 0.03 to 3.12, RR=0.33, p=0.33), major bleeding events (95% CI 0.57 to 1.78, RR=1.01, p=0.97), minor bleeding events (95% CI 0.72 to 1.64, RR=1.09, p=0.69), all bleeding events (95% CI 0.79 to 1.38, RR=1.05, p=0.74) and mortality (95% CI 0.01 to 8.0, RR=0.33, p=0.5). The major risk of bias of the selected RCTs was the fact that either the researchers or the patients could have knowledge whether the latter were administered DOACs or LMWHs.
DISCUSSION
DOACs are not inferior compared to LMWHs regarding their effectiveness, safety and mortality in patients subjected to HFS. Further studies with larger patient samples should be conducted in the future, so that safer results and conclusions could be reached.
Topics: Humans; Anticoagulants; Venous Thromboembolism; Randomized Controlled Trials as Topic; Heparin, Low-Molecular-Weight; Enoxaparin; Hemorrhage; Hip Fractures
PubMed: 35817368
DOI: 10.1016/j.otsr.2022.103364 -
Australian Dental Journal Dec 2017The focus on oral manifestations of dengue fever (DF) is not common in the scientific literature and the patient affected can present signs and symptoms that may not be... (Review)
Review
The focus on oral manifestations of dengue fever (DF) is not common in the scientific literature and the patient affected can present signs and symptoms that may not be noticed by dental professionals. This systematic review article was conducted to identify and discuss the oral manifestations related to DF. The electronic databases PubMed, Latin American and Caribbean Literature in Sciences (LILACS), Web of Science and Scopus were searched from November to December 2016 by two authors, simultaneously, using the search terms 'dengue and oral manifestation' combined. We included complete original articles, clinical trials and clinical case reports published in Portuguese, Spanish and English. No limits were applied to the year of publication. Review articles and those with no health outcomes were removed. A limited number of studies aimed to investigate the oral manifestations of DF (N = 25). However, several manifestations were identified in the oral cavity of patients diagnosed with DF such as acute gingival and palate bleeding, dryness of the mouth, taste changes, and erythematous plaque and vesicles on the tongue and palate. Osteonecrosis of jaw associated with DF was also reported. In conclusion, oral manifestations may represent a relevant contributory factor to identify DF disease among patients undergoing dental procedures in general practise.
Topics: Dengue; Dental Plaque; Gingival Hemorrhage; Humans; Mouth Diseases; Palate; Taste Disorders; Xerostomia
PubMed: 28379606
DOI: 10.1111/adj.12516 -
Frontiers in Pharmacology 2023A lack of clarity persists regarding the efficacy and risks associated with direct oral anticoagulants (DOACs) in end-stage renal disease (ESRD) patients with atrial...
A lack of clarity persists regarding the efficacy and risks associated with direct oral anticoagulants (DOACs) in end-stage renal disease (ESRD) patients with atrial fibrillation (AF) undergoing dialysis, primarily due to limited retrospective studies. Therefore, the objective of this study was to evaluate the existing data and propose a practical protocol for the clinical utilization of DOACs in ESRD patients with AF undergoing dialysis. PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for clinical studies evaluating DOACs in ESRD patients with AF on dialysis published up to 2 February 2023. DOACs included warfarin, dabigatran, apixaban, edoxaban, and rivaroxaban. The outcomes were mortality, ischemic stroke, hemorrhagic stroke, any stroke, gastrointestinal bleeding, major bleeding, intracranial bleeding, and minor bleeding. Compared with placebo, apixaban (HR = 0.97, 95% CI: 0.88-1.07), rivaroxaban (HR = 0.91, 95% CI: 0.76-1.10), and warfarin (HR = 0.96, 95% CI: 0.90-1.01) did not reduce mortality. Regarding direct comparisons of mortality, the comparisons of warfarin vs. apixaban (HR = 0.99, 95% CI: 0.92-1.06), placebo vs. warfarin (HR = 1.04, 95% CI: 0.99-1.11), and rivaroxaban vs. warfarin (HR = 0.96, 95% CI: 0.80-1.14) did not significantly reduce mortality. Based on the surface under the cumulative ranking curve, rivaroxaban (75.53%), warfarin (62.14%), and apixaban (45.6%) were the most effective interventions for managing mortality, and placebo (16.74%) was the worst. In conclusion, rivaroxaban demonstrated efficacy in reducing mortality and the incidence of ischemic stroke, gastrointestinal bleeding, and intracranial hemorrhage. Dabigatran is recommended for the prevention of hemorrhagic stroke. However, caution should be exercised due to the risk of major bleeding. Warfarin can effectively reduce minor bleeding but does not offer significant protection against gastrointestinal or intracranial bleeding. Apixaban was not recommended for mortality reduction or for preventing ischemic or hemorrhagic strokes. Further research will be necessary to establish specific clinical protocols.
PubMed: 38161701
DOI: 10.3389/fphar.2023.1320939