Leena Jalota

Transdermal Scopolamine for the Prevention of Postoperative Nausea and Vomiting: A Systematic Review and Meta-Analysis

BACKGROUND Transdermal scopolamine (TDS) is a potential long-acting prophylactic antiemetic initially developed to prevent motion sickness. TDS is a centrally acting anticholinergic agent that was approved in 2001 by the US Food and Drug Administration for the prevention of postoperative nausea and vomiting (PONV). Although TDS has been reported to be clinically efficacious in the prevention of PONV, several adverse events (AEs), such as sedation, dry mouth, blurred vision, central cholinergic syndrome, and confusion (particularly in elderly patients with mild cognitive impairment), are potential concerns. OBJECTIVE The aim of this study was to explore the efficacy and tolerability of TDS in the prevention of PONV in adults. METHODS A systematic search of PubMed, EMBASE, and the Cochrane Library for randomized controlled trials in adults that compared the effects of TDS and placebo on postoperative nausea, vomiting, and PONV was conducted in March 2009, and an update was conducted in July 2010. Without any language restrictions, a search with the following terms was performed: postoperative, postoperative, postanesthe*, postanaesthe*, post-anesthe*, post-anaesthe*, anesthesia, anaesthesia, surgery, surgeries, surgical, nausea, vomiting, emesis, retching, scopolamine, and hyoscine. Identified studies were then hand-searched for further relevant literature. RESULTS Data from 25 randomized controlled trials were analyzed (N = 3298). In the postanesthesia care unit, TDS was associated with a significantly reduced risk for postoperative nausea compared with placebo (relative risk [RR] = 0.77; 95% CI, 0.61-0.98; P = 0.03). TDS was also associated with a significantly reduced risk for postoperative nausea (RR = 0.59; 95% CI, 0.48-0.73; P < 0.001), postoperative vomiting (RR = 0.68; 95% CI, 0.61-0.76; P < 0.001), and PONV (RR = 0.73; 95% CI, 0.60-0.88; P = 0.001) during the first 24 hours after the start of anesthesia. TDS appeared to be effective compared with placebo in the prevention of postoperative nausea when treatment was initiated the night before (early application) (RR = 0.56; 95% CI, 0.41-0.75; P < 0.001) or on the day of surgery (late application) (RR = 0.61; 95% CI, 0.47-0.79; P < 0.001). TDS was associated with a higher prevalence of visual disturbances at 24 to 48 hours compared with placebo (RR = 3.35; 95% CI, 1.78-6.32). Analyses of confusion and other AEs did not show a significant association with TDS. CONCLUSIONS In this systematic review and metaanalysis, TDS was associated with significant reductions in PONV with both early and late patch application during the first 24 hours after the start of anesthesia. TDS was associated with a higher prevalence of visual disturbances at 24 to 48 hours after surgery, but no other AEs, compared with placebo.

Amplatzer PFO occluder device may prevent recurrent stroke in patients with patent foramen ovale and cryptogenic stroke: a meta-analysis of randomised trials.

OBJECTIVE To review efficacy of percutaneous closure of patent foramen ovale compared with medical therapy in prevention of recurrent strokes in patients with cryptogenic stroke. METHODS AND RESULTS Electronic databases; PUBMED, EMBASE, Cochrane registry and web of knowledge were searched for relevant studies. In three randomised clinical trials involving 2303 participants, risk of the recurrent strokes (pooled HR 0.62, 95% CI=0.36-1.07, P=0.09, I(2) =10%) did not show benefit with device closure when compared with medical therapy group on meta-analysis of all three trials. However, on sensitivity analysis in trials using Amplatzer PFO occluder device, the closure of PFO was associated with significantly lower recurrent strokes (pooled HR=0.44, 95% CI=0.21-0.94, P=0.03, I(2)=0%) compared with medical therapy. CONCLUSION The closure of PFO with Amplatzer PFO occluder device was associated with significant reduction in recurrent strokes in patients with cryptogenic stroke and patent foramen ovale. The better outcome in prevention of secondary stroke in patients with cryptogenic stroke and PFO may be associated with type of closure device used.

Cangrelor versus clopidogrel in percutaneous coronary intervention: a systematic review and meta-analysis

AIMS Cangrelor is a new antiplatelet agent that has been used in percutaneous coronary intervention (PCI) with mixed results. We aimed to review the evidence on the efficacy of cangrelor in comparison to clopidogrel in reducing ischaemic endpoints at 48 hours in patients undergoing PCI in large randomised trials. METHODS AND RESULTS In three large clinical trials involving 25,107 participants, the risk of the primary composite efficacy endpoint of death, MI and ischaemia-driven revascularisation at 48 hours, (pooled OR 0.94; 95% CI: 0.77-1.14, p=0.51, I2=68%), death from all cause (pooled OR 0.72, 95% CI: 0.36-1.43, p=0.34, I2=52%), myocardial infarction (pooled OR 0.94, 95% CI: 0.77-1.14, p=0.51, I2=68%) was not significantly different between cangrelor and clopidogrel. Likewise, severe or life-threatening bleeding was similar between cangrelor and clopidogrel (pooled OR 1.21, 95% CI: 0.70-2.12, p=0.50, I2=0%). The risk of stent thrombosis (pooled OR 0.59, 95% CI: 0.43-0.81, p=0.001, I2=0%), Q-wave myocardial infarction (pooled OR 0.53, 95% CI: 0.30-0.92, p=0.02, I2=0%) and ischaemia-driven revascularisation (pooled OR 0.71, 95% CI: 0.52-0.98, p=0.04, I2=0%) was lower in the cangrelor group. CONCLUSIONS Based on this meta-analysis, we did not find any difference in the risk of the primary composite efficacy endpoint of all-cause death, ischaemia-driven revascularisation, and myocardial infarction at 48hours between cangrelor and clopidogrel use. Given that cangrelor was associated with a lower risk of stent thrombosis, ischaemia-driven revascularisation and Q-wave myocardial infarction compared to clopidogrel, cangrelor can be considered as a suitable alternative during PCI.

Action plans for COPD: strategies to manage exacerbations and improve outcomes

COPD is the third-largest killer in the world, and certainly takes a toll on the health care system. Recurrent COPD exacerbations accelerate lung-function decline, worsen mortality, and consume over US

Office spirometry correlates with laboratory spirometry in patients with symptomatic asthma and COPD

50 billion in health care spending annually. This has led to a tide of payment reforms eliciting interest in strategies reducing preventable COPD exacerbations. In this review, we analyze and discuss the evidence for COPD action plan-based self-management strategies. Although action plans may provide stabilization of acute symptomatology, there are several limitations. These include patient-centered attributes, such as comprehension and adherence, and nonadherence of health care providers to established guidelines. While no single intervention can be expected independently to translate into improved outcomes, structured together within a comprehensive integrated disease-management program, they may provide a robust paradigm.

EFFICACY OF HIGH-DOSE STATIN FOR PREVENTION OF CONTRAST- INDUCED NEPHROPATHY (CIN) IN PATIENTS UNDERGOING CORONARY ANGIOGRAPHY: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CLINICAL TRIALS

Spirometry remains underutilized in the evaluation of obstructive lung disease. While office spirometry (OS) has been compared to formal laboratory‐based spirometry (LS) in healthy subjects, the correlation has never been formally assessed in patients with symptomatic obstructive lung disease. The aim of this study was to investigate the correlation in this population.

A case of disseminated recurrent retroperitoneal plasmacytoma with left obstructive hydronephrosis.

Contrast-induced nephropathy (CIN) is a leading cause of hospital-acquired acute kidney injury. Previous trials on statins for CIN prevention are conflicting and meta-analyses of these are inconclusive. We systematically reviewed randomized controlled trials (RCTs) comparing high-dose versus low-

Iatrogenic venous air embolism from central femoral vein catheterisation

Retroperitoneal extramedullary plasmacytoma (EMP) is a rare condition that often poses a diagnostic challenge. This is mainly due to its unusual location and non-specific symptoms especially in its early stages. Retroperitoneal plasmacytoma with renal involvement is an extremely rare entity and to date, less than 25 cases have been reported in the literature. We describe a case of a 65-year-old woman with primary retroperitoneal plasmacytoma, confirmed by ultrasound-guided biopsy and histopathological examination, with unilateral left obstructive hydronephrosis and metastasis to the lungs. Our patient was started on chemotherapy to which she did not respond. Subsequently, she resorted to palliative measures. Our case highlights key aspects of clinical presentation, diagnosis and treatment options available for management of retroperitoneal plasmacytoma.

Meta-Analysis of Efficacy and Safety of Rivaroxaban Compared With Warfarin or Dabigatran in Patients Undergoing Catheter Ablation for Atrial Fibrillation

A woman in her late 40s was brought to the emergency room with abdominal pain and was found to be septic and in hypoxemic respiratory failure. As part of the initial resuscitation a right-sided femoral catheter was placed by the emergency room physician and the patient moved to the intensive care unit. A CT scan of the chest, abdomen and pelvis …