11210 research outputs found
Sort by
Combined linaclotide and polyethylene glycol electrolyte for colonoscopy preparation: A network meta-analysis of 14 randomized controlled trials
No full textPurpose:Recent evidence supports linaclotide (Lin) for colonoscopy preparation. This network meta-analysis evaluates the combination of different pill numbers of Lin with polyethylene glycol (PEG) (high and low volumes in liters (L)) for bowel cleansing.
Methods:This systematic review and frequentist network meta-analysis, conducted in October 2024, assessed randomized controlled trials (RCTs) from Scopus, PubMed, Cochrane, WOS, and Embase. Risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) were calculated for categorical and continuous outcomes.
Prospero id:CRD42024618272.
Results:Fourteen RCTs with 4,764 participants showed that total Boston Bowel Preparation Scale improved significantly with 2L PEG + 2Lin (MD = 2.03, 95%CI: [0.30:3.76], P = 0.0217), 3L-PEG + 3Lin (MD = 1.30, 95%CI: [0.42:2.18], P = 0.0038), and 4L-PEG (MD = 1.11, 95%CI: 0.23-1.98, P = 0.0129). Adenoma detection was highest with 3L-PEG + 3Lin (RR = 1.60, 95%CI: [1.05:2.43], P = 0.0280), while polyp detection improved with 2L PEG + 3Lin (RR = 1.72, 95%CI: [1.13:2.62], P = 0.0114) and 3L-PEG + 3Lin (RR = 1.33, 95%CI: [1.00:1.77], P = 0.0505). Procedure times were significantly reduced with 3L-PEG + 3Lin (MD = -4.6, 95%CI: [-6.24:-3.24], P \u3c 0.0001), 3L-PEG + 1Lin (P = 0.035), and 4L-PEG (P \u3c 0.01). Abdominal pain and abdominal bloating decreased with 2L PEG + 1Lin (P \u3c 0.01) and 2L PEG + 2Lin (P = 0.021) but increased with 4L-PEG (P = 0.0178).
Conclusions:Combining PEG with Lin improves bowel cleanliness compared to 3L-PEG, with 2L PEG + 2Lin being the most effective and well-tolerated. Despite some heterogeneity, the findings suggest that adding Lin may enhance bowel preparation with comparable safety, warranting consideration of individual patient factors
General vs nongeneral anesthesia for endovascular thrombectomy in patients with large core strokes: A prespecified secondary analysis of SELECT2 trial
No full textBackground and objectives:The association of anesthesia approach during endovascular thrombectomy (EVT) with clinical outcomes in large strokes is unexplored. We aimed to evaluate whether general anesthesia (GA), compared with non-GA, was associated with better functional outcomes in the SELECT2 trial.
Methods:In a prespecified secondary analysis of the SELECT2 trial that enrolled patients with large strokes on noncontrast CT (Alberta Stroke Program Early CT Score [ASPECTS] 3-5), CT perfusion/MRI (core volume ≥50 mL), or both, functional outcomes were compared in EVT-treated patients who received GA or non-GA and whether this association was modified by stroke severity (NIH Stroke Scale score), ischemic injury estimates, and collateral status was evaluated. The primary outcome was 90-day functional status (ordinal modified Rankin Scale [mRS]). Secondary outcomes were functional independence (mRS scores 0-2), independent ambulation (mRS scores 0-3), complete dependence or death (mRS scores 5-6), and mortality.
Results:Of 178 EVT patients (median [interquartile range] age 66 [58-75] years, stroke severity 19 [15-23], CT-ASPECTS 4 [3-5], and core volume 101.5 [70-138] mL, 71 women [39.9%]), 104 (58%) received GA. Time from randomization to arterial puncture was longer with GA (40 [23-59] minutes) vs non-GA (27 [18-47] minutes), but procedural duration (GA: 57 [31.5-77] minutes vs non-GA: 49.5 [30-71] minutes) was similar. Successful reperfusion (modified treatment in cerebral infarction [mTICI] score 2b-3) rates were similar (GA 81 (78%) vs non-GA 62 (84%), adjusted relative risk [aRR] 0.91, 95% CI 0.79-1.06). In addition, mRS distribution did not differ between GA and non-GA groups (adjusted generalized odds ratio 1.21, 95% CI 0.86-1.70), as well as independent ambulation (GA: 41% vs non-GA: 34%, aRR 1.22, 95% CI 0.86-1.74) and functional independence (GA: 22% vs non-GA: 18%, aRR 1.32, 95% CI 0.75-2.35). Stroke severity, ASPECTS, ischemic core volume, or collaterals did not modify the association between anesthesia and functional outcome (all p-interaction \u3e0.05). Patients experienced systolic blood pressure (SBP) variability ≥40 mm Hg and minimum intraprocedural SBP (\u3c100 mm Hg) more frequently with GA, but this did not modify GA association with functional outcomes (p-interaction = 0.77 and 0.89, respectively).
Discussion:In patients with large core strokes randomized in SELECT2, EVT outcomes did not differ significantly based on anesthesia approach (GA or non-GA) without heterogeneity across stroke severity and size. While GA was associated with higher SBP variability and lower minimum SBP, this did not modify GA association with functional outcomes. While allocation to anesthesia approach was nonrandomized, our findings suggest that optimizing institutional protocols for preferred anesthesia technique, whether GA or non-GA, may enhance EVT procedural outcomes.
Trial registration information:ClinicalTrials.gov ID: NCT03876457
Myasthenia gravis: Mechanisms, clinical syndromes, and diagnosis
No full textMyasthenia gravis (MG) is an autoimmune neuromuscular disorder characterized by muscle weakness and fatiguability. The pathogenesis of MG is mediated in most cases by autoantibodies directed against the nicotinic acetylcholine receptor at the neuromuscular junction, although less commonly autoantibodies may target muscle-specific kinase (MuSK) or low-density lipoprotein receptor-related protein 4 (LRP4). These autoantibodies disrupt cholinergic transmission at the neuromuscular junction through several mechanisms, including direct functional blocking, downregulation, destruction, or disruption of receptor clustering in the postsynaptic membrane. MG is characterized by fatigable muscle weakness in the ocular, bulbar, respiratory or limb muscles. Clinical manifestations can vary significantly among individuals depending on the type of autoantibody or presence of thymoma. Due to the variable presentation of symptoms, diagnosing MG can be challenging. A comprehensive approach that combines clinical assessment, serological testing, electrophysiological studies, and imaging is essential for accurate diagnosis
Boarding battles: Pharmacist perils in the land of limbo
No full textPurpose:Emergency departments (EDs) across the country have grappled with overcrowded conditions for decades, which has only intensified in recent years, leading to the current crisis of ED boarding. The magnitude of boarding in the ED today is an unprecedented challenge faced by hospitals across North America and results in ambulance diversions, complications due to delays in care, and unacceptable numbers of individuals leaving without being seen by a provider. Boarding has significant immediate and downstream effects, including delayed care, medication errors, delirium, higher rates of morbidity and in-hospital mortality, and greater healthcare costs. As expected, ED boarding has also led to burnout and dissatisfaction among members of the medical team due to increased workload, patient safety concerns, lack of knowledge, resources, and/or training, and poor communication.
Summary:Clinical pharmacists, particularly those specializing in emergency medicine, are well positioned to address the multifaceted challenges of ED boarding. Emergency medicine pharmacists (EMPs) play a pivotal role in mitigating many challenges of ED boarding by providing tangible interventions, including continuous pharmacotherapy monitoring and management, supporting smooth transitions of care, enhancing electronic medical records, and fully leveraging automated dispensing cabinets. This article details how EMPs can optimize these elements of care for boarding patients with commonly available resources.
Conclusion:Despite the adverse impact ED boarding has on patient outcomes and quality of care, solutions remain scarce and long-term fixes likely require large-scale health-system reformation. Until then, we must institute protocols and workflows to improve the care of boarding patients within existing patient care constraints
Labyrinthectomy improves dizziness in patients with vestibular schwannoma
No full textObjective: Dizziness is one of the most prevalent and debilitating symptoms associated with vestibular schwannoma (VS), and there are little data on contributing or alleviating factors in the perioperative setting. In this study, we aimed to evaluate whether vestibular nerve sectioning or labyrinthectomy concomitant with surgical resection would improve dizziness in the postoperative period.
Methods: This is a retrospective study of a consecutive series of VS patients who underwent resection at a large tertiary care center between 2009 and 2023. Dizziness at 6 months was the primary endpoint, whereas facial nerve and hearing outcomes were secondary endpoints. Fisher\u27s exact test was used to identify significant differences between categorical variables, and multivariate logistic regression analysis was performed to identify predictors of dizziness as well as facial nerve and hearing outcomes.
Results: A total of 333 patients underwent resection of VS at our institution. There was no significant difference in binary reported dizziness based on surgical approach (p= 0.14). However, patients reported significantly less dizziness at discharge (p \u3c0.01) as well as 6-month (p= 0.02) and 1-year (p \u3c0.01) follow-up in the translabyrinthine group. On the other hand, patients who underwent labyrinth-sparing approaches reported a significant increase in dizziness that remained up to 1 year from the time of surgery.
Conclusion: Our data suggest that labyrinthectomy may improve dizziness symptoms in patients with VS. Selective VN sectioning does not appear to affect dizziness or hearing outcomes. Finally, surgical approach does not affect facial nerve outcomes
Patient perspectives on Lambert-Eaton myasthenic syndrome
No full textTo better understand what it\u27s like to live with Lambert-Eaton myasthenic syndrome (LEMS), we spoke to two individuals who have been living with non-tumor LEMS for years. They graciously shared stories that shed light on the day to day impact of this rare condition extending from mobility and daily functioning to identity, relationships, and mental health. In sharing their experiences, they also offered insights and advice for others newly diagnosed with LEMS or managing its challenges long-term
