Source

Williams CR, Huffstetler HE, Nyamtema AS, Larkai E, Lyimo M, Kanellopoulou A, Robertson L, Choi L, Alwy Al-beity FM. (2025)

Transfusion of blood and blood products for the management of postpartum haemorrhage

Cochrane Database of Syst Rev, 2, CD016168.

URL : https://pubmed.ncbi.nlm.nih.gov/39911088/

Clinical Question

Blood loss of 500 mL or more within 24 hours after delivery defines postpartum haemorrhage (PPH). Transfusion of labile blood products may be considered for the management of PPH. The optimal transfusion strategy in the context of PPH is poorly defined.

Bottom Line

What transfusion strategy (types of labile blood products and criteria for administration) improves maternal morbidity and mortality of PPH?

Main Results

The threshold for initiating transfusion was not evaluated in the included studies. Regarding transfusion of 1 to 2 units of red blood cells compared with no transfusion : it may increase maternal morbidity, defined as mortality, admission to intensive care, major surgery, or organ failure (low level of evidence). It may increase intensive care admission (low level of evidence). No study evaluated mortality alone or adverse events. Regarding fibrinogen transfusion compared with placebo or no transfusion, the evidence on mortality is very uncertain (very low level of evidence). Regarding  morbidity: there is probably little or no difference in intensive care admission (moderate level of evidence) and little or no difference in hysterectomy rates (low level of evidence). Evidence is very uncertain regarding embolisation and adverse events (very low level of evidence). Regarding cryoprecipitate transfusion compared with no cryoprecipitate transfusion, the evidence is very uncertain for mortality, morbidity, and adverse events (very low level of evidence). It was not possible to compare red blood cell transfusion with whole blood transfusion or with combined blood product transfusions. It was not possible to compare fresh frozen plasma combined with red blood cells and fibrinogen versus fresh frozen plasma with red blood cells alone. It was not possible to compare massive transfusion protocols with non-massive transfusion protocols.

Caveats

Available data on the effects of transfused whole blood and labile blood products during PPH are largely uncertain. Further studies are needed to determine transfusion modalities (threshold, quantity, products) and their effects on mortality, morbidity, and adverse events.

Authors

Authors

Source

Doleman B, Fonnes S, Lund JN, Boyd-Carson H, Javanmard-Emamghissi H, Moug S, Hollyman M, Tierney G, Tou S, Williams JP. (2024)

Appendectomy versus antibiotic treatment for acute appendicitis.

Cochrane Database of Syst Rev 4, CD015038.

Context

Appendicitis is one of the most common surgical emergencies, with an incidence ranging from 105 to 151 cases per 100,000 people per year in Europe. In 20% of cases, it presents as uncomplicated appendicitis, defined by transmural inflammation without necrosis, perforation, or abscess. During the COVID-19 pandemic, a greater number of uncomplicated appendicitis cases were managed with antibiotic therapy due to the closure of operating rooms.

Clinical Question

What are the impacts of antibiotic treatment for uncomplicated acute appendicitis, compared to surgical management, on mortality, treatment success rate, the subsequent need for surgery, and adverse events?

Bottom Line

Regarding adverse events, it is unclear whether there is a difference in the incidence of Clostridium difficile diarrhoea (low level of evidence). Antibiotics may lead to a clinically significant reduction in wound infections (moderate level of evidence). It is uncertain whether antibiotic treatment reduces the occurrence of intra-abdominal abscesses or fluid collections, or the length of hospital stay (low level of evidence).

Authors

Source

Adão, D., Gois, A. F., Pacheco, R. L., Pimentel, C. F., & Riera, R. (2023).

Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage.

Cochrane Database of Syst Rev 2, CD013176.

Context

Upper gastrointestinal haemorrhages (UGIH) are associated with significant morbidity and mortality. Upper gastrointestinal endoscopy allows identification of the underlying cause and remains the preferred approach for delivering definitive treatment. Erythromycin promotes gastric emptying within 15 to 30 minutes following intravenous administration. However, its potential role in improving the quality and therapeutic effectiveness of upper gastrointestinal endoscopy remains uncertain.

Clinical Question

Are there benefits and/or risks associated with the use of erythromycin prior to endoscopy in adults presenting with UGIH?

Bottom Line

Intravenous erythromycin has been compared to placebo. In this context, erythromycin may slightly improve visualisation of gastric mucosa and reduce blood transfusion requirements (moderate level of evidence). No differences have been observed in mortality or adverse events; however, the evidence is very uncertain (low level of evidence).

Nasogastric tube lavage, whether used alone or in combination with erythromycin, has not shown any significant difference in terms of visualisation of gastric mucosa, mortality, or blood transfusion, but the evidence remains very uncertain (low level of evidence).

Caveats

The administration protocols for erythromycin varied significantly across the 11 included studies. This heterogeneity contributes to the inconsistency between studies, thereby lowering the overall certainty of evidence in the meta-analysis.

Authors

Source

Roqué-Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J. (2023)

Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old.

Cochrane Database of Systematic Reviews 2023, Issue 4. Art. No.: CD004873. DOI: 10.1002/14651858.CD004873.pub6

Context

Bronchiolitis is the leading reason for consultation in emergency departments during the winter season in children younger than two years of age. The majority of episodes are benign, but between 1 and 3% of children require hospitalization. Various respiratory physiotherapy techniques are employed to reduce airway obstruction and improve the child's respiratory condition.

Clinical Question

What is the efficacy of different respiratory physiotherapy techniques compared to standard care in children younger than two years of age with bronchiolitis ?

Bottom Line

Conventional respiratory physiotherapy through vibration and percussion failed to show an effect on bronchiolitis severity, length of hospital stay, duration of oxygen supplementation, use of bronchodilators, or parents' impression of physiotherapy benefit (high level of evidence). Forced expiratory airflow technique failed to show an effect on bronchiolitis severity (high level of evidence) but increased serious adverse effects such as vomiting and worsening of respiratory condition (high level of evidence). Slow passive expiratory technique may lead to a mild to moderate improvement in the severity of bronchiolitis (low level of evidence) without affecting other outcome measures.

Caveats

The modest efficacy of slow passive expiratory physiotherapy techniques seems to be primarily related to children admitted to the hospital for moderate bronchiolitis. Data is limited for children with severe bronchiolitis and for those managed on an outpatient basis.

Authors

Source

Raphael CK, El Hage Chehade NA, Khabsa J, Akl EA, Aouad-Maroun M, Kaddoum R.

Ultrasound-guided arterial cannulation in the paediatric population.

Cochrane Database of Systematic Reviews 2023, Issue 3. Art. No.: CD011364.

DOI: 10.1002/14651858.CD011364.pub3.

Context

The anatomy and the smaller size of pediatric patients can make arterial line cannulation more difficult than in adults. For both radial and femoral sites, ultrasound guidance may increase success rates and improve the safety of arterial cannulation compared to palpation or Doppler auditory assistance.

Clinical Question

Is ultrasound guidance better than palpation or Doppler auditory assistance in pediatric arterial line cannulation?

Bottom Line

Compared with palpation or Doppler assistance, ultrasound-guided arterial line cannulation in the pediatric population probably increases first-attempt success rate, success within the first two attempts and overall successful cannulation (moderate level of evidence). It probably decreases both the number of cannulation attempts as well as the duration of the procedure (moderate level of evidence). It also probably decreases hematoma formation (moderate level of evidence).

Caveats

Performance bias was present in all studies, as medical providers could not be blinded to the guidance technique. Some studies did not describe allocation concealment leading to potential selection bias. Finally, studies did not specify if the primary outcome - first pass successful arterial cannulation - included redirection of the needle.

Authors

Source

Li M, Li J, Wang X, Hui X, Wang Q, Xie S, Yan P, Tian J, Li J, Xie P, Yang K, Yao L. (2023)

Oral direct thrombin inhibitors or oral factor Xa inhibitors versus conventional anticoagulants for the treatment of pulmonary embolism.

Cochrane Database of Syst Rev 4, CD010957.

Context

Historically, conventional anticoagulants (heparin, fondaparinux, vitamin K antagonists) have been the standard treatment for pulmonary embolism. Their major drawbacks include the need for regular biological monitoring, as well as potential drug interactions and severe adverse effects. Direct oral anticoagulants (DOACs), including thrombin inhibitors and factor Xa inhibitors, offer the main advantages of being administered orally and not requiring dose adjustments.

Clinical Question

Are direct oral anticoagulants (DOACs) as effective and safe as conventional anticoagulants in the management of pulmonary embolism?

Bottom Line

The administration of thrombin inhibitors, compared to conventional anticoagulants, is likely to result in little to no difference in terms of recurrence of venous thromboembolism, pulmonary embolism, deep vein thrombosis, and major bleeding (moderate level of evidence).

The administration of factor Xa inhibitors, compared to conventional anticoagulants, is likely to result in little to no difference in terms of recurrence of venous thromboembolism, pulmonary embolism, deep vein thrombosis, and mortality (moderate level of evidence). Additionally, it may result in little to no difference in the occurrence of major bleeding (low level of evidence).

Caveats

Future studies should individualize the analysis of each molecule and focus on identifying the effects of DOACs on subgroups of at-risk patients (such as cancer patients, obese individuals, thrombophilic patients). Additionally, it would be valuable to assess the quality of life in these patient populations.

Authors

Source

Wang X, Ma Y, Hui X, Li M, Li J, Tian J, Wang Q, Yan P, Li J, Xie P, Yang K, Yao L. (2023)

Oral direct thrombin inhibitors or oral factor Xa inhibitors versus conventional anticoagulants for the treatment of deep vein thrombosis.

Cochrane Database Syst Rev, 4: CD010956.

Context

Historically, deep vein thrombosis (DVT) has been treated with heparin, fondaparinux, or vitamin K antagonists. The major drawbacks of these treatments include the need for regular biological monitoring, drug interactions, and serious adverse effects. Direct oral anticoagulants (DOACs), including thrombin inhibitors and factor Xa inhibitors, have replaced these traditional treatments and are now widely used.

Clinical Question

Are DOACs as effective and safe as conventional anticoagulants in the management of DVT? Does the use of DOACs influence the risk of post-thrombotic syndrome (chronic sequelae of DVT) and quality of life?

Bottom Line

Regardless of the anticoagulant treatment chosen, there is likely no statistically significant difference in the occurrence of DVT recurrence, thromboembolism, pulmonary embolism, or all-cause mortality (moderate level of evidence). However, DOACs significantly reduce the risk of major bleeding (high level of evidence).

Post-thrombotic syndrome has been evaluated in a single study. The use of rivaroxaban compared to warfarin reduces its incidence. As for quality of life, assessed in a single study, the use of dabigatran compared to warfarin appears to improve it, but in a non-significant manner.

Caveats

Due to the significant interindividual variability in the anticoagulant effect of DOACs, further research is needed to study the adjustment of dosing for different subgroups (elderly individuals, cancer patients, those with severe trauma, and thrombophilic abnormalities). Moreover, it is important to compare DOACs with one another, as their effects vary, and to investigate the impact of extended anticoagulant therapy and the discontinuation of DOACs. Post-thrombotic syndrome and quality of life are also crucial outcomes to be studied.

Authors

Source

Florez ID, Sierra J, Pérez-Gaxiola G.

Balanced crystalloid solutions versus 0.9% saline for treating acute diarrhea and severe dehydration in children.

Cochrane Database of Systematic Reviews 2023, Issue 5. Art. No.: CD013640. DOI:10.1002/14651858.CD013640.pub2

Context

In the event of acute diarrhea and severe dehydration in children, management may require the administration of intravenous fluids. The most commonly used solution is 0.9% isotonic saline solution (ISS). Balanced solutions, recommended in the management of sepsis, have a composition closer to human plasma and limit the risk of hyperchloremic acidosis.

Clinical Question

What are the advantages and disadvantages of administering balanced solutions to children requiring rehydration for severe dehydration (as defined by the WHO) due to acute diarrhea?

Bottom Line

Compared with ISS, balanced solutions (lactated Ringer's evaluated in 4 studies and Plasma-Lyte in 1 study) are associated with a modest reduction in hospital length of stay (moderate level of evidence). The effect of balanced solutions on in-hospital mortality is uncertain (very low level of evidence). The use of balanced solutions seems to be associated with a higher pH and a lower risk of hypokalemia (low level of evidence). The use of balanced solutions does not appear to be associated with a different volume of rehydration (low level of evidence). No notable disadvantages were observed in the studies analyzed.

Caveats

The use of balanced solutions compared to ISS in children with severe dehydration following acute diarrhea appears to provide a slight clinical benefit, but with a low level of evidence. Further, larger, blinded studies would provide a better answer to this question.

Authors

Source

Aboursheid T, Albaroudi O, Alahdab F.

Inhaled nitric oxide for treating pain crises in people with sickle cell disease. CochraneDatabase of Systematic Reviews 2022, Issue 7. Art. No.: CD011808.

DOI: 10.1002/14651858.CD011808.pub3

Context

In sickle cell disease patients, vaso-occlusive crises can cause severe pain lasting from several hours to several days. The vasodilatory properties of inhaled nitric oxide (NO) could have a beneficial effect in this indication, but its actual efficacy remains debated.

Clinical Question

What is the efficacy and what are the adverse effects of inhaled NO in the management of pain during vaso-occlusive crises in sickle cell patients?

Bottom Line

Inhaled NO appears to have little or no effect on the duration of pain resolution and on pain recurrence (low level of evidence). There was no difference in the reduction of pain intensity during the first 8 hours. The use of inhaled NO was not associated with a reduction in the use of other analgesics. No serious adverse effects appear to be associated with the use of inhaled NO (low level of evidence).

Caveats

Only three small studies (188 patients in total) were included in this review. The results are inconclusive as to the effect of inhaled NO in treating pain in sickle cell patients with vaso-occlusive crises. Larger studies, with longer follow-up and more robust endpoints, should be carried out.

Authors

Source

Ni H, Aye SZ, Naing C.

Magnesium sulfate for acute exacerbations of chronic obstructive pulmonary disease.

Cochrane Database of Systematic Reviews 2022, Issue 5. Art. No.: CD013506.

DOI: 10.1002/14651858.CD013506.pub2

Clinical Question

What are the effects of intravenous (IV) or inhaled magnesium sulphate (MgSO4) in adult patients with chronic obstructive pulmonary disease (COPD) exacerbations?

Bottom Line

Compared with placebo, the administration of MgSO4 by the IV route may reduce the number of hospitalisations via the emergency department (low level of evidence) as well as the length of hospitalization stay (low level of evidence). The use of inhaled MgSO4 may reduce the length of hospitalization stay (very low level of evidence) without reducing their number (very low level of evidence). Whatever the route of administration, MgSO4 seems not altering the need for ventilatory support (very low level of evidence).

IV or inhaled MgSO4 compared with inhaled ipratropium bromide seems not altering the number of hospital admissions, the use of ventilatory support or the length of hospital stay (very low level of evidence). There was not enough evidence to say that magnesium inhalation was not associated with important harms such as all-cause mortality, adverse events or serious adverse events.

Caveats

Given the limited number of patients and the considerable heterogeneity between studies, the benefit of MgSO4 in COPD exacerbations remains to be demonstrated.

Authors

Source

Tada M, Yamada N, Matsumoto T, Takeda C, Furukawa TA, Watanabe N.

Ultrasound guidance versus landmark method for peripheral venous cannulation in adults.

Cochrane Database of Systematic Reviews 2022, Issue 12. Art. No.: CD013434.

DOI:10.1002/14651858.CD013434.pub2.

Context

Peripheral intravenous cannulation (PIC) is a common and important procedure for patients requiring a blood test or intravenous (IV) therapies. The landmark method, which relies on touch and visualization of veins on the skin, can be complex and may result in treatment delays, multiple painful punctures, and the need for intraosseous or central lines. The effectiveness of ultrasound guidance for PIC is still unclear.

Clinical Question

Are ultrasound-guided techniques for PIC in adults both safe and effective when compared to landmark method? Does the efficacy of this technique vary depending on the level of PIC difficulty (difficult, moderate, easy) in patients?

Bottom Line

In difficult participants, ultrasound guidance could increase the success rate on the first attempt (low level of evidence), overall success rate (very low level of evidence), and patient satisfaction (very low level of evidence), but may result in a longer insertion time (low level of evidence). There is no significant difference in the pain experienced by the patient during the procedure (very low level of evidence), nor in the occurrence of complications (low level of evidence).

In moderate participants, ultrasound guidance increases success on the first attempt (moderate level of evidence) and patient satisfaction (very low level of evidence) at the cost of an increase in intravenous canulation time on the first attempt (high level of evidence). There is no evidence to suggest that the patient will experience different levels of pain during the procedure. Additionally, there is moderate evidence to suggest that there will be no difference in the occurrence of complications.

In easy participants, ultrasound guidance reduces success on the first attempt (high level of evidence) and increases the pain felt by the patient during the procedure (moderate level of evidence) as well as the procedure time for first-pass cannulation (high level of evidence). There was no difference in terms of the occurrence of complications (moderate level of evidence).

Caveats

The level of evidence in the data is low due to the inconsistent definition of different levels of PIC difficulty in the studies included. This has resulted in heterogeneous results and unreliable interpretation. Future studies should aim to use common definitions.

Authors

Source

Lingappan K, Neveln N, Arnold JL, Fernandes CJ, Pammi M.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates.

Cochrane Database of Systematic Reviews 2023, Issue 5. Art. No.: CD009975.

DOI: 10.1002/14651858.CD009975.pub4.

Context

Rapid establishment of a secure airway is key in neonatal resuscitation. Videolaryngoscopy is emerging

as a new technique for intubation, and it may accelerate successful endotracheal intubation when

compared to direct laryngoscopy in neonates.

Clinical Question

Is videolaryngoscopy better than direct laryngoscopy in neonatal intubation?

Bottom Line

Compared with direct laryngoscopy in neonates, videolaryngoscopy may increase the success rate of

first-try intubation (low certainty evidence) and may reduce intubation attempts (low certainty

evidence). Also, videolaryngoscopy probably reduces airway trauma (moderate certainty evidence).

However, it may not reduce the time for successful intubation and has very little effect on desaturation

during intubation attempts (low certainty evidence).

Caveats

Some of the studies reviewed received equipment and funding that were not stated as conflict of

interest. Also, the providers were not blinded, and the studies had small samples.

Authors

Source

Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF.

Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation.

Cochrane Database of Systematic Reviews 2022, Issue 4. Art. No.: CD011136.

DOI: 10.1002/14651858.CD011136.pub3.

Context

Tracheal intubation is a common procedure in operating theatres, emergency departments,

outpatient departments and critical care units. In around 10% of cases, intubation is difficult and

associated with a risk of complications: hypoxemia, inhalation pneumonitis, rhythm disorders,

cardiac arrest and death. The use of a videolaryngoscope (VL) could reduce this risk when used in

patients with difficult intubation criteria, or when the difficulty was not predicted. There are 3

different types of VL: Macintosh-style VL, hyperangulated VL and tunnelled VL.

Clinical Question

Is the use of different types of VL in adults requiring orotracheal intubation associated with better

results compared with direct laryngoscopy? What are the benefits of these devices in selected

population groups, users, and settings?

Bottom Line

Compared with direct laryngoscopy, the 3 types of VL probably significantly reduce the intubation

failure rate (moderate certainty evidence), probably improve glottic vision (moderate certainty

evidence) and the intubation success rate on the first attempt (low certainty evidence for

Macintosh-style LV and hyperangulated LV, and very-low certainty evidence for tunnelled LV).

Macintosh-style LV and tunnelled LV probably reduce the rate of hypoxemia (moderate certainty

evidence), and hyperangulated LV is probably associated with a lower rate of esophageal intubation

(moderate certainty evidence). Combining all 3 types of VL, their use is associated with a reduced

rate of intubation failure in patients at risk of difficult intubation and in obese patients. The use of

VLs may also be beneficial outside the operating theatre. Results do not appear to be influenced by

operator experience.

Caveats

This review did not compare the 3 types of VL. None appears to be associated with a better outcome

than the others. It is important to point out that only 9% of the included studies were conducted

outside the operating room, which precludes generalization to out-of-hospital settings, emergency

departments and critical care units.

Authors

Source

Jat KR, Dsouza JM, Mathew JL. Continuous positive airway pressure (CPAP) for acute bronchiolitis in children. Cochrane Database of Systematic Reviews 2022, Issue 4. Art. No.: CD010473. DOI: 10.1002/14651858.CD010473.pub4

Context

Bronchiolitis is a common cause for pediatric emergency visits and hospitalization. There is no specific treatment for bronchiolitis, yet continuous positive airway pressure (CPAP) has been used to prevent the need for mechanical ventilation.

Clinical Question

In patients less than three years of age with bronchiolitis, what is the efficacy and safety of CPAP compared to no CPAP?

Bottom Line

Compared to no CPAP, patients with CPAP had a lower respiratory rate (low certainty evidence). Mechanical ventilation, change in pCO2, hospital stay duration did not differ between the two groups (low certainty evidence). However, time to recovery, change in arterial oxygen saturation, change in pO2, hospital admission rate (from emergency department tohospital), duration of emergency department stay, or need for intensive care unit admission were not assessed. No side effects such as pneumothorax, local nasal effects or shock were reported but two children in the CPAP group experienced irritability (low certainty evidence).

Caveats

Low certainty evidence suggests a decreased respiratory rate amongst children with bronchiolitis who receive CPAP, but there is a lack of evidence favoring the use of CPAP for other outcomes. Given the low level of evidence in this review, it is highly likely that future studies will modify the results. Larger, adequately powered trials are needed to evaluate the effects of CPAP in children with acute bronchiolitis.

Authors

Source

Minhas, J. S., Chithiramohan, T., Wang, X., Barnes, S. C., Clough, R. H., Kadicheeni, M., Beishon, L. C., & Robinson, T. (2022). Oral antiplatelet therapy for acute ischaemic stroke.

Cochrane Database Syst Rev, 1, CD000029

Context

Strokes constitute a major public health problem worldwide (15 million cases/year) and are mostly ischaemic. Oral antiplatelet agents aim to reduce the risk of cerebral ischemia by inhibiting platelet adhesion and aggregation. However, antiplatelet agents could also increase the risk of fatal or disabling intracranial haemorrhage.

Clinical Question

Does the immediate or early administration (started within the first 15 days) of oral antiplatelet therapy, compared to no treatment or placebo, in people with acute presumed ischaemic stroke, effective and safe?

Context

COVID-19 presents a diagnostic challenge with reverse transcription polymerase chain reaction (RT-PCR) tests having limitations. The potential contribution of additional thoracic imaging is unclear.

Clinical Question

What is the diagnostic accuracy of chest imaging studies (CT, X-ray, ultrasound) in patients of any age suspected of having COVID-19?

Bottom Line

Nearly 38,000 patients were included, 53% of whom were found to have COVID-19. All studies used at least one RT-PCR test as a reference for the diagnosis of COVID-19.

For radiographic evaluation, the sensitivity and specificity were 73.1% and 73.3%, respectively.

For ultrasound evaluation, the sensitivity and specificity are 88.9 % and 72.2% respectively.

For CT evaluation, the sensitivity was 86.9% and specificity 78.3%. Eleven studies used a precise classification system, the COVID-19 Reporting and Data system (CO-RADS), which has 5 thresholds to define the positivity of the test (from unlikely (1) to highly suggestive (5)). With a CO-RADS threshold of 5 for CT evaluation, the sensitivity was 67.3% and the specificity was 92.2%.

Moreover, since the beginning of this health crisis, there has been a significant increase in the specificity of the CT assessment while the sensitivity remained stable.

In an indirect comparison of the imaging tests with each other, CT and ultrasound were sensitive and moderately specific in the diagnosis of COVID-19. Radiography is moderately sensitive and specific in the diagnosis of COVID-19.

Caveats

Chest CT and chest ultrasound may be more useful in ruling out COVID-19 than in differentiating SARS-CoV-2 infection from other causes of respiratory disease. Because of the heterogeneity between studies (methodology, inclusion criteria), the confidence in the results should be limited. Additional studies are needed to establish more reliable results, particularly considering the time of evolution of COVID-19 and the symptomatology presented.

Authors

Context

Gout is one of the most common rheumatic diseases worldwide. Colchicine is the first-line treatment but evidence on its dosage, benefits and harms is limited.

Clinical Question

How effective is colchicine for acute gout compared to placebo or other treatments for pain, inflammation and target joint function? What are the adverse events (AEs) and serious adverse events (SAEs) of this treatment?

Bottom Line

Compared to placebo, low-dose colchicine may be more effective in reducing pain within 32-36 h (low level of evidence) with few or no AEs (low level of evidence). Inflammation and function of target joint were not assessed. At high-doses, colchicine may reduce pain and inflamation at the cost of a significant increase in AEs (low level of evidence). Pain and function of target joint have not been evaluated.

One trial compared low-dose to high-dose colchicine. Efficacy was similar but at the cost of more AEs with high-dose colchicine. Another trial compared low-dose colchicine with non-steroidal anti-inflammatory drugs (NSAIDs). Efficacy was comparable in terms of pain reduction at 7 days. There was no significant difference in the number of AEs reported. Finally, a trial comparing Chuanhu mixture with low-dose colchicine showed that the frequency of acute gout was comparable. However, the occurrence of AEs appears to be more frequent with low-dose colchicine without being responsible for premature treatment discontinuation.

Caveats

This review was unable to estimate the risk of AEs for most comparisons because few events were reported in the trials. Given the low level of evidence in this meta-analysis, it is very likely that future studies will change the outcome.

Pragmatic studies taking into account the patient's profile, co-morbidities and assessing in particular the frequency of acute gout, pain and uric acid concentration should help to identify the most appropriate treatment for each patient (low-dose colchicine, NSAIDs or corticosteroid infiltration).

Authors

Source

Roaldsen MB, Lindekleiv H, Mathiesen EB. (2021)

Intravenous thrombolytic treatment and endovascular thrombectomy for ischaemic wake-up stroke.

Cochrane Database Syst Rev 12:CD010995

Context

About one in 5 strokes occurs during sleep. Stroke of awakening has long been excluded from emergency care for lack of information on the time between the onset of stroke and awakening. Some waking strokes, via rigorous selection based on imaging criteria,seem to benefit from aggressive management with improved outcomes in some patients.

Clinical Question

Are intravenous (IV) thrombolysis and endovascular thrombectomy in ischaemic stroke of awakening effective compared to usual treatments?

Bottom Line

Thrombectomy and IV thrombolysis signficantly improve favourable neurological course at 90 days(high-certainty

evidence). The effect is greater for thrombectomy than for IV thrombolysis. There is no significant effect for the 2 treatments on 90 day mortality (high-certainty evidence). The risk of symptomatic cerebral haemorrhage is not significantly modified by IV thrombolysis (high-certainty evidence). The effectiveness of thrombolysis is similar regardless of age, sex, initial severity of stroke (NIHSS score), diameter of the occluded vessel or the time elapsed between awakening and thrombolysis.

Caveats

Patients in the controlled clinical trials included in this meta-analysis were carefully selected according to sophisticated imaging criteria (MRI and infusion scan). Only strokes with occlusion of the large vessels of the anterior carotid circulation were included and alteplase was the only drug evaluated. The authors highlight a possible increased risk of symptomatic

intracranial hemorrhages with thrombolysis.

Authors

Source

Wang X, Ouyang M, Yang J, Song L, Yang M, Anderson CS. (2021)

Anticoagulants for acute ischaemic stroke.

Cochrane Database Syst Rev 10:CD000024

Context

Stroke is the third leading cause of premature death worldwide. Most strokes are ischaemic. The use of anticoagulants could be proposed to improve patient outcomes and limit recurrence without increasing the risk of bleeding events.

Clinical Question

Is early administration of anticoagulants in patients with suspected or confirmed acute ischaemic stroke effective in terms of mortality, disability and recurrence? Does this administration limit the occurrence of venous thrombosis events without increasing the risk of bleeding?

Bottom Line

Early anticoagulation does not reduce the occurrence of death or long-term disability, regardless of the dose and type of anticoagulant (high-certainty evidence). Anticoagulant therapy started within the first 14 days after stroke onset does not reduce the risk of early death from all causes (low-certainty evidence). Although early anticoagulant therapy is associated with a decrease in the number of recurrent ischaemic strokes (moderate-certainty evidence), it is also associated with an increase in symptomatic intracranial haemorrhages (moderate-certainty evidence). Early anticoagulation reduces the occurrence of symptomatic pulmonary embolisms (moderate-certainty evidence) but unfortunately increases the

occurrence of extracranial haemorrhages (moderate-certainty evidence).

Caveats

This is an update of a Cochrane Review first published in 1995. The anticoagulants tested are standard unfractionated heparin, low molecular weight heparins, heparinoids, oral anticoagulants and thrombin inhibitors. The majority of studies were published more than twenty years ago, well before the creation of neurovascular units and with different therapeutic protocols. Ninety percent of the data come from anticoagulant treatments initiated within the first 48 hours of disease onset. It might be reasonable to consider safer alternatives for immobile patients such as aspirin, pneumatic restraints or early mobilization.

Authors