Oral Benzodiazepines Research Articles

The Combined Effects of Alcohol and Benzodiazepines on Driving-Related Neurocognitive Skills: A Systematic Review

Research concerning the combined effects of alcohol and benzodiazepines on driving-related skills is largely inconsistent. Because as many as 88% of benzodiazepine users report the additional consumption of alcohol, this review aims to provide an updated and concise synthesis of the available high-quality research. We searched EBSCOhost, PubMed, Scopus, and Web of Science until April 1, 2020, for double-blind, placebo-controlled, repeated-measures intervention trials that examined the effects of alcohol (any dose provided as blood alcohol concentration [BAC]) in combination with oral benzodiazepines on neurocognitive tasks related to driving. We identified evidence of a substance and timing-dependent interaction for measures of reaction time, tracking, divided attention, and visual functioning. Administering alcohol in conjunction with or shortly after a benzodiazepine resulted in a stronger interactive effect than when administration occurred further apart. An additive and/or synergistic effect often occurred when a therapeutic dose of benzodiazepine was combined with alcohol at a BAC below .05%. Combined alcohol and benzodiazepine use was associated with significant impairments in driving-related neurocognitive skills. There is a clear need for more high-quality research in this area to better elucidate the mechanisms of alcohol and benzodiazepine interactions. Drivers may be unaware of impairments following the combination of these drugs at legal driving limits. Thus, drivers should be warned to take caution when consuming even small amounts of alcohol while under treatment with benzodiazepines.

MP51-12 FEASIBILITY OF AWAKE INTRAVESICAL BOTULINUM TOXIN INJECTION IN PEDIATRIC NEUROGENIC BLADDER

You have accessJournal of UrologyPediatric Urology IV (MP51)1 Sep 2021MP51-12 FEASIBILITY OF AWAKE INTRAVESICAL BOTULINUM TOXIN INJECTION IN PEDIATRIC NEUROGENIC BLADDER Maya R. Overland, Natalia V. Leva, Michael DiSandro, and Hillary L. Copp Maya R. OverlandMaya R. Overland More articles by this author , Natalia V. LevaNatalia V. Leva More articles by this author , Michael DiSandroMichael DiSandro More articles by this author , and Hillary L. CoppHillary L. Copp More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002077.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cystoscopic injection of botulinum toxin is routinely performed in a clinic setting with local anesthetic in adults, but is typically performed under general anesthesia in pediatric patients – rapidly accumulating anesthetic exposures and OR costs. While performing an awake invasive procedure in a child is anathema to many urologists, most of these patients already tolerate clean intermittent catheterization (CIC) with variable sensation and so it has become our practice to offer these families a trial of awake injection. We hypothesized that higher sensory level, female sex, and absence of mental health issues or cognitive delay might predict successful first awake injection and decreased operative times. METHODS: With IRB approval, surgical records from two academic hospitals from 2018-2020 were reviewed to identify all pediatric patients with neurogenic bladder who underwent an attempt at awake intravesical botulinum toxin injection in the OR. Generalized linear models were fit to determine predictors of success and procedural length. RESULTS: 17 patients (8 female, 9 male, 4-20 years old) met criteria. All patients were managed with CIC at baseline, 13 had documented anxiety or behavioral issues, 9 had a cognitive delay, and 7 had a sensory level below S2 on exam. After informed consent/assent, we performed the procedure in the operating room to allow a low threshold to convert to general anesthesia if required and used urethral lidocaine gel and/or a lidocaine bladder soak. Only one patient required conversion to general anesthesia. She was noted to have significant underlying anxiety and subsequent patients with known anxiety were offered an oral benzodiazepine. 14 patients (82%) had or plan subsequent injections awake, 1 patient proceeded to bladder augment, and 1 patient with severe anxiety and a conduct disorder requested subsequent injections under anesthesia. Male sex and the correlated use of urethral lidocaine were the only variables predictive of increased procedure duration in univariate regression, but neither was significant in multivariate analysis. No intraoperative complications occurred. CONCLUSIONS: Our experience supports that awake botulinum toxin injection is feasible in patients with neurogenic bladder managed with CIC as young as age 4, even in the setting of intact sensation, well-managed mental health issues, or cognitive delay. Because only one patient in our series required general anesthesia, we cannot meaningfully identify predictors of failure, but pre-medication with an oral benzodiazepine may help in patients with severe anxiety. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e900-e901 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Maya R. Overland More articles by this author Natalia V. Leva More articles by this author Michael DiSandro More articles by this author Hillary L. Copp More articles by this author Expand All Advertisement Loading ...

Determining the efficacy of low-dose oral benzodiazepine administration and use of wide-bore magnet in assisting claustrophobic patients to undergo MRI brain examination

PurposeClaustrophobia remains a challenging barrier for a significant number of patients to successfully complete a Magnetic Resonance Imaging (MRI) examination. While use of wide-bore machines and pre-exam administration of a low-dose benzodiazepine are commonly employed, there is little published research to determine which modality is the most efficacious based on the patient's specific degree of claustrophobia. This retrospective case-control study examines the efficacy of using a low-dose oral benzodiazepine and wide-bore magnet to successfully aid the claustrophobic patient in completing an MRI Brain examination. Methods3966 non-contrast MRI brain examinations were considered for this study. The sample was filtered to include only patients who were older than 18 years of age, not currently experiencing symptoms which may hinder MRI examination, and did not undergo any additional MR studies at the time of their exam, resulting in a final sample of 2358 examinations for analysis. Patients were then sub-divided based on severity of claustrophobia and analyzed using logistic regression analysis. ResultsUse of wide-bore magnet increased odds of successfully completing the MRI Brain examination in mild, moderately, and severely claustrophobic patients (OR: 1.79, 95% CI: 1.17–2.75). The administration of pre-examination low-dose oral benzodiazepine increased odds of successfully completing the MRI Brain examination in severely claustrophobic patients (OR: 6.21, 95% CI: 1.63–19.28). ConclusionUse of a wide-bore magnet is effective in assisting mild, moderately, and severely claustrophobic patients in completing an MRI Brain exam. However, the efficacy of low-dose oral benzodiazepine is limited to severely claustrophobic patients.

Pharmacological and neurosurgical interventions for individuals with cerebral palsy and dystonia: a systematic review update and meta-analysis.

AimTo update a systematic review of evidence published up to December 2015 for pharmacological/neurosurgical interventions among individuals with cerebral palsy (CP) and dystonia.MethodSearches were updated (January 2016 to May 2020) for oral baclofen, trihexyphenidyl, benzodiazepines, clonidine, gabapentin, levodopa, botulinum neurotoxin (BoNT), intrathecal baclofen (ITB), and deep brain stimulation (DBS), and from database inception for medical cannabis. Eligible studies included at least five individuals with CP and dystonia and reported on dystonia, goal achievement, motor function, pain/comfort, ease of caregiving, quality of life (QoL), or adverse events. Evidence certainty was evaluated using GRADE.ResultsNineteen new studies met inclusion criteria (two trihexyphenidyl, one clonidine, two BoNT, nine ITB, six DBS), giving a total of 46 studies (four randomized, 42 non‐randomized) comprising 915 participants when combined with those from the original systematic review. Very low certainty evidence supported improved dystonia (clonidine, ITB, DBS) and goal achievement (clonidine, BoNT, ITB, DBS). Low to very low certainty evidence supported improved motor function (DBS), pain/comfort (clonidine, BoNT, ITB, DBS), ease of caregiving (clonidine, BoNT, ITB), and QoL (ITB, DBS). Trihexyphenidyl, clonidine, BoNT, ITB, and DBS may increase adverse events. No studies were identified for benzodiazepines, gabapentin, oral baclofen, and medical cannabis.InterpretationEvidence evaluating the use of pharmacological and neurosurgical management options for individuals with CP and dystonia is limited to between low and very low certainty. What this paper adds Meta‐analysis suggests that intrathecal baclofen (ITB) and deep brain stimulation (DBS) may improve dystonia and pain.Meta‐analysis suggests that DBS may improve motor function.Clonidine, botulinum neurotoxin, ITB, and DBS may improve achievement of individualized goals.ITB and DBS may improve quality of life.No direct evidence is available for oral baclofen, benzodiazepines, gabapentin, or medical cannabis.

Botulinum Neurotoxin Injections in Childhood Opisthotonus.

Opisthotonus refers to abnormal axial extension and arching of the trunk produced by excessive contractions of the paraspinal muscles. In childhood, the abnormal posture is most often related to dystonia in the setting of hypoxic injury or a number of other acquired and genetic etiologies. The condition is often painful, interferes with ambulation and quality of life, and is challenging to treat. Therapeutic options include oral benzodiazepines, oral and intrathecal baclofen, botulinum neurotoxin injections, and deep brain stimulation. Management of opisthotonus within the pediatric population has not been systematically reviewed. Here, we describe a series of seven children who presented to our institution with opisthotonus in whom symptom relief was achieved following administration of botulinum neurotoxin injections.

Effect of Sugammadex on Postoperative Myasthenic Crisis in Myasthenia Gravis Patients: Propensity Score Analysis of a Japanese Nationwide Database.

In myasthenia gravis (MG) patients, postoperative myasthenic crisis, and residual neuromuscular blocking agent (NMBA) can cause respiratory failure that requires mechanical ventilation. However, it remains unclear whether the use of sugammadex for NMBA reversal reduces postoperative myasthenic crisis in MG patients undergoing surgery. We analyzed the association between use of sugammadex and postoperative myasthenic crisis in patients with MG using a national inpatient database. Adult patients with MG who received thymectomy under general anesthesia were identified in the Japanese Diagnosis Procedure Combination database from July 1, 2010 to March 31, 2016. Patients who received sugammadex (sugammadex group) were compared with those who did not receive sugammadex (control group). The primary outcome was postoperative myasthenic crisis, and the secondary outcomes were postoperative pneumonia, tracheostomy, 28-day mortality, total hospitalization costs, and length of stay after surgery. Propensity scores were estimated by logistic regression based on the following variables: age; sex; body mass index (BMI); smoking index; history of cancer; Charlson comorbidity index (CCI); type of thymectomy; time from hospital admission to surgery; use of plasma exchange, immunosuppressants, corticosteroids, anticholinesterase, and oral benzodiazepine before surgery; type of hospital; and treatment year. The outcomes were compared using stabilized inverse probability of treatment weighting (IPTW) analyses to obtain good between-group balance. Of 795 patients identified, 506 patients received sugammadex and 289 patients did not. After stabilized IPTW, the sugammadex group was associated with a decrease in postoperative myasthenic crisis (22/507 [4.3%] vs 25/288 [8.7%]; odds ratio [OR], 0.48; 95% confidence interval [CI], 0.25-0.91), but not associated with a decrease in postoperative pneumonia (5/507 [1.0%] vs 7/288 [2.4%]; OR, 0.44; 95% CI, 0.17-1.14) or tracheostomy (7/507 [1.4%] vs 10/288 [3.5%]; OR, 0.38; 95% CI, 0.12-1.22) compared with the control group. The sugammadex group had significantly lower median (interquartile range) total hospitalization costs ($13,186 [$11,250-$16,988] vs $14,119 [$11,713-$20,207]; P < .001) and median length of stay after surgery (10 [8-15] vs 11 [8-18] days; P < .001), compared with the control group. In this retrospective observational study, sugammadex was associated with reductions in postoperative myasthenic crisis and total hospitalization costs in adult patients with MG who received thymectomy. Given the present findings, sugammadex should be routinely administered for MG patients undergoing thymectomy.

Italian consensus on treatment of spasticity in multiple sclerosis.

Spasticity is a frequent multifactorial manifestation of multiple sclerosis (MS), affecting mostly the chronic courses of the disease. Its impact on patient functioning and quality of life is profound. Treatment of spasticity includes oral and intrathecal anti-spastic drugs, muscle injections with relaxant agents, physical therapy, electrical and magnetic stimulation and peripheral nerve stimulation, alone or in various combinations. This Italian consensus on the treatment of spasticity in MS was produced by a large group of Italian MS experts in collaboration with neurophysiologists, experts in the production of guidelines and patients' representatives operating under the umbrella of the Italian Neurological Society, the Associazione Italiana Sclerosi Multipla and the European Charcot Foundation. This guideline was developed in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. A total of 11 questions were formulated following the PICO framework (patients, intervention, comparator, outcome). Controlled studies only were included in the analysis. Despite some consistent limitations due to the poor methodological quality of most studies, there was a consensus on a strong recommendation for the use of intrathecal baclofen, oromucosal spray of nabiximols and intramuscular injection of botulinum toxin. The level of recommendation was weak for oral baclofen, tizanidine, gabapentin, benzodiazepines and transcranial magnetic stimulation. There is a clear need for new larger multicentre well-designed clinical trials with a duration that allows the persistence of the effects and the long-term safety of the interventions to be evaluated.

Sedation with oral benzodiazepines in dental practice in cardiac patients

There are different types of sedation used for performing medical and dental procedures. The medications most commonly used for this purpose are benzodiazepines, which are considered safe and effective in the hospital or outpatient dental practice. However, in dental clinical practice, they are underutilized, especially in patients with cardiovascular disease. The aim of this study was to address the use of benzodiazepines as oral sedatives, their indications, contraindications, and peculiarities, as well as their correlation with cardiac patients, through a literature review. Sedation or minimum anxiolysis is a drug-induced state during which patients respond normally to verbal commands and airway reflexes, while respiratory and cardiovascular functions are unaffected. The beneficial effects of benzodiazepines include reduced anxiety, sleep induction and maintenance, muscle relaxation, and treatment and prevention of epileptic seizures. Benzodiazepines are indicated for patients with anxiety but should be used with caution in patients with serious illnesses, pregnancy or using other central nervous system depressants. Its use in cardiac patients is safe and effective because it reduces the hemodynamic function. It is important for the dentist to know and use this class of medications, improving the quality of care for the cardiac patient.

Nonpharmacological Relaxation Technology for Office-Based Rhinologic Procedures

Background: Office-based rhinologic procedures are increasingly performed to control costs and enhance patient convenience. Adequate management of pain and anxiety is essential for the technical performance of these procedures, in addition to ensuring patient comfort. Pharmacologic agents are often used to manage anxiety and pain. Nonpharmacological adjuncts may be useful for achieving these effects without oral opioids and benzodiazepines. Methods: Charts of patients who underwent office-based rhinologic procedures with the NuCalm system (Solace Lifesciences, Inc., Wilmonton, DE, USA) in combination with local anesthesia were reviewed. NuCalm is a proprietary system that combines cranial electrotherapy stimulation, neuroacoustic software, light-blocking lenses, and topical γ-­aminobutyric acid. Patients rated their pain and anxiety before, during, and after the procedure. Results: Twenty-five patients underwent office procedures using the NuCalm system. Preoperative anxiety (2.00) was significantly higher than postoperative anxiety (1.25) according to patient reporting on a 5-point scale (p = 0.005). Preoperative pain (1.83) was not significantly different from intraoperative (2.54) and postoperative pain (2.04, p = 0.054). Conclusions: A variety of office-based rhinologic procedures are technically feasible and can be performed with adequate patient comfort without the use of oral drugs. Adjuncts to pharmacologic agents may enhance pain control and anxiety management and improve patient tolerance of these procedures.

PMH28 - Cost Analysis Model for the Treatment of Acute Agitation Among Patients with Schizophrenia in China

To assess the healthcare resource utilization and cost associated with the inpatient treatment of short-acting intramuscular (IM) ziprasidone, oral risperidone + oral benzodiazepine, oral olanzapine, short-acting IM haloperidol, and electroconvulsive therapy (ECT) for the management of acute agitation among patients with schizophrenia in China from a hospital’s perspective. Cost measures included hospital room and board, antipsychotics, ECT, and medications for the management of extrapyramidal symptoms (EPS). Input for standard antipsychotic regimens and unit cost were obtained from literature. Hospital length of stay (LOS), utilization of ECT, and incidence of EPS were derived from the literature and supplemented/validated with a survey of 9 psychiatrists in China. Cost was presented in 2017 RMB (¥). Based on the survey, the average (range) estimated LOS was 29 (14-42) days with ziprasidone, 33 (15-60) days with risperidone + benzodiazepine, 32 (15-50) days with olanzapine, 35 (25-50) days with haloperidol, and 29 (12-42) days with ECT. The cost of antipsychotics was ¥1,261 with ziprasidone, ¥137 with risperidone + benzodiazepine, ¥913 with olanzapine, ¥210 with haloperidol; ECT treatment cost ¥1,585. The base-case analysis suggested that higher antipsychotic cost with ziprasidone was offset by savings with shorter LOS. Total costs including all the cost measures during the inpatient stay was the lowest with ziprasidone among all regimens (¥11,157 with ziprasidone, ¥11,406 with ECT, ¥11,422 with risperidone plus benzodiazepine, ¥11,711 with olanzapine, and ¥11,923 with haloperidol). The cost of antipsychotics and ECT accounted for 1.2% to 13.9% of the total cost. Varying LOS between the lower and upper bounds of the 95% confidence interval, total cost was comparable between these regimens. Overall, the cost for the management of acute agitation was similar between IM ziprasidone and other antipsychotics. Compared to other antipsychotics, higher medication cost of IM ziprasidone can be offset by savings with shorter hospital stay.

Pharmacological and neurosurgical interventions for managing dystonia in cerebral palsy: a systematic review.

To systematically review evidence for pharmacological/neurosurgical interventions for managing dystonia in individuals with cerebral palsy (CP) to inform a care pathway. Searches included studies with a minimum of five participants with dystonia in CP receiving oral baclofen, benzodiazepines (clonazepam, diazepam, lorazepam), clonidine, gabapentin, levodopa, trihexyphenidyl, botulinum toxin, intrathecal baclofen (ITB), or deep brain stimulation (DBS). Evidence was classified according to American Academy of Neurology guidelines. Twenty-eight articles underwent data extraction: one levodopa, five trihexyphenidyl, three botulinum toxin, six ITB, and 13 DBS studies. No articles for oral baclofen, benzodiazepines, clonidine, or gabapentin met the inclusion criteria. Evidence for reducing dystonia was level C (possibly effective) for ITB and DBS; level C (possibly ineffective) for trihexyphenidyl; and level U (inadequate data) for botulinum toxin. For dystonia reduction, ITB and DBS are possibly effective, whereas trihexyphenidyl was possibly ineffective. There is insufficient evidence to support oral medications or botulinum toxin to reduce dystonia. There is insufficient evidence for pharmacological and neurosurgical interventions to improve motor function, decrease pain, and ease caregiving. The majority of the pharmacological and neurosurgical management of dystonia in CP is based on clinical expert opinion. Intrathecal baclofen and deep brain stimulation are possibly effective in reducing dystonia. Current evidence does not support effectiveness of oral medications or botulinum toxin to reduce dystonia. Evidence is inadequate for pharmacological/neurosurgical interventions impact on improving motor function, pain/comfort, and easing caregiving. The majority of the care pathway rests on expert opinion.

P3.12-003 Optimized Inhaler Therapy Is Superior to Supportive Care Alone for Dyspnea in Patients with Coexisting COPD and Lung Cancer

Breathlessness is a common, debilitating symptom associated with both COPD and lung cancer. Opiates remain the mainstay of treatment for breathlessness in oncology. Lung cancer patients were prospectively enrolled in this single-center, open-label, randomized controlled trial. Eligible patients met British Thoracic Society diagnostic criteria for COPD, had a visual analogue score (VAS) dyspnea ≥4 and had other reversible causes for breathlessness excluded. Patients were randomly assigned (1:1) between the intervention arm of salbutamol 100 mcg, 2 puffs QDS and tiotropium 18 mcg OD ± salmeterol 50 mcg/fluticasone 500 mcg 1 puff BD (if FEV1 <50% predicted) in combination with best supportive care (BSC) or to BSC alone (control). Control arm patients could continue on any short-acting bronchodilators and BSC included oral morphine and/or benzodiazepines. Patients underwent spirometry, 6 minute walk test (6MWT), VAS dyspnea and quality of life questionnaires (QOLQ) at baseline and after 2 and 4 weeks. The primary endpoint was the proportion of patients with ≥2 point improvement in VAS dyspnea at 4 weeks. Among the intention to treat population (n=63), 53 patients (84%) had NSCLC and 10 (16%) had SCLC. The median baseline VAS was 7.1 and the median baseline FEV1 was 1.5L (63% predicted). The primary endpoint response rate (RR) was higher in the intervention group n= 32 [RR: 53% (95%CI 35% to 71%)] than in the control group n= 31 [RR: 26% (95% CI 12% to 45%) p = 0.02]. There were no statistically significant differences between the groups for change in 6MWT or QOLQ between baseline and the 4 week assessments. For patients with co-existing COPD and lung cancers, VAS dyspnea is significantly improved by the addition of inhaled therapies to best supportive care. This study highlights the importance of diagnosing and treating COPD in all lung cancer patients.

Oral Medication for Agitation of Psychiatric Origin: A Scoping Review of Randomized Controlled Trials

BackgroundUnderstanding more about the efficacy and safety of oral second-generation antipsychotic medications in reducing the symptoms of acute agitation could improve the treatment of psychiatric emergencies. ObjectiveThe objective of this scoping review was to examine the evidence base underlying expert consensus panel recommendations for the use of oral second-generation antipsychotics to treat acute agitation in mentally ill patients. MethodsThe Cochrane Schizophrenia Group's Study-Based Register was searched for randomized controlled trials comparing oral second-generation antipsychotics, benzodiazepines, or first-generation antipsychotics with or without adjunctive benzodiazepines, irrespective of route of administration of the drug being compared. Six articles were included in the final review. ResultsTwo oral second-generation antipsychotic medications were studied across the six included trials. While the studies had relatively small sample sizes, oral second-generation antipsychotics were similarly effective to intramuscular first-generation antipsychotics in treating symptoms of acute agitation and had similar side-effect profiles. ConclusionsThis scoping review identified six randomized trials investigating the use of oral second-generation antipsychotic medications in the reduction of acute agitation among patients experiencing psychiatric emergencies. Further research will be necessary to make clinical recommendations due to the overall dearth of randomized trials, as well as the small sample sizes of the included studies.

Anesthetic considerations for pediatric electroconvulsive therapy.

Electroconvulsive therapy is being used more frequently in the treatment of many chronic and acute psychiatric illnesses in children. The most common psychiatric indications for pediatric electroconvulsive therapy are refractory depression, bipolar disorder, schizophrenia, catatonia, and autism. In addition, a relatively new indication is the treatment of pediatric refractory status epilepticus. The anesthesiologist may be called upon to assist in the care of this challenging and vulnerable patient population. Unique factors for pediatric electroconvulsive therapy include the potential need for preoperative anxiolytic and inhalational induction of anesthesia, which must be weighed against the detrimental effects of anesthetic agents on the evoked seizure quality required for a successful treatment. Dexmedetomidine is likely the most appropriate preoperative anxiolytic as oral benzodiazepines are relatively contraindicated. Methohexital, though becoming less available at many institutions, remains the gold standard for induction of anesthesia for pediatric electroconvulsive therapy though ketamine, propofol, and sevoflurane are becoming increasingly viable options. Proper planning and communication between the multidisciplinary teams involved in the care of children presenting for electroconvulsive therapy treatments is vital to mitigating risks and achieving the greatest therapeutic benefit.

Diagnosis and management of lobular capillary haemangioma (pyogenic granuloma) in an adult female lactating Bonobo (Pan paniscus)

An adult female lactating bonobo (Pan paniscus) presented with an acutely enlarging skin nodule, readily susceptible to haemorrhage, on the third digit of her left foot, which was subsequently removed under anaesthesia when it had reached a diameter of approximately 10 mm. The bonobo had five-year-old and three-month-old infants, which had to be managed sensitively during the procedure. Risk management was carefully planned with the keeping team. Oral benzodiazepines were used in the dam and five-year-old infant to reduce stress, and careful planning ensured a time-efficient anaesthetic procedure. Radiographs were taken to investigate the involvement of underlying tissue, and the skin mass was removed by partial amputation of the digit including a segment of bone. Histopathology yielded a diagnosis of lobular capillary haemangioma (pyogenic granuloma). Although the clinical presentation was extremely similar to that seen in humans, the entity has not been commonly reported in apes.

The sedative effects of the intranasal administration of dexmedetomidine in children undergoing surgeries compared to other sedation methods: A systematic review and meta-analysis

Study objectiveAdministration of intranasal dexmedetomidine for sedation is comfortable and effective in children who are afraid of needles, and it offers efficient sedation similar to that of intravenous administration. We performed a systematic review and meta-analysis to evaluate the clinical effects of the pre-procedural administration of intranasal dexmedetomidine. DesignWe identified randomized controlled trials (RCTs) that compared intranasal dexmedetomidine administration to other administration methods of various sedatives or placebo from MEDLINE, EMBASE, Cochrane, KoreaMed and hand searches of trial registries. SettingPediatrics who underwent interventional procedures and surgeries. PatientsChildren under the age of 18. InterventionsStudies were included if they were compatible with the criteria that dexmedetomidine was administered intranasally. MeasurementsWe pooled data on the sedation status as the primary outcome and considered the behavioral score, blood pressure, heart rate and side effects to be secondary outcomes. Risk ratio (RR) and the standardized mean difference (SMD) with 95% confidence intervals (CIs) were calculated for dichotomous and continuous outcomes, respectively. Main resultsThis meta-analysis included 11 RCTs. The SMD for the sedative effects of intranasal dexmedetomidine was −2.45 (random, 95% CI; −3.33, −1.58) for continuous outcomes and RR of unsatisfactory patient outcome was 0.42 (M-H, random 95% CI; 0.26, 0.68 I2=45%) for dichotomous outcomes compared to that of intranasal saline. The SMD for the sedative effects of intranasal dexmedetomidine was −0.41 (random, 95% CI; −1.09, 0.27 I2=69%) for continuous outcomes and RR was 0.43 (M-H, random 95% CI; 0.32, 0.58 I2=0%) for dichotomous outcomes compared to that of per os benzodiazepines. ConclusionsThis review suggests that intranasal dexmedetomidine is associated with better sedative effects than oral benzodiazepines without producing respiratory depression, but it had a significantly delayed onset of effects.

The Efficacy and Safety of Clonazepam in Patients with Anxiety Disorder Taking Newer Antidepressants: A Multicenter Naturalistic Study.

ObjectiveThis study compared the efficacy and tolerability of clonazepam with other benzodiazepines in patients with anxiety disorders.MethodsInclusion criteria were as follows: age >20 years, diagnosis of anxiety disorder according to the Diagnostic and Statistical Manual of Mental Disorders 4th edition, text revision (DSM-IV-TR) criteria, taking only one type of antidepressant, and prescribed one of three oral benzodiazepines (alprazolam, clonazepam, or lorazepam). At baseline and week 6, clinical benefit was evaluated using the Clinical Global Impression-Severity Scale (CGI-S), Clinical Global Impression-Anxiety Scale (CGI-anxiety), and Clinical Global Impression-Sleep Scale (CGI-sleep).ResultsAmong 180 patients, no differences in demographic characteristics among the three benzodiazepine groups were noted. After six weeks of treatment, all benzodiazepine groups showed significant improvements in CGI-S, CGI-anxiety, and CGI-sleep scores (p<0.001). There were no differences in mean changes in CGI-S, CGI-anxiety and CGI-sleep among the three benzodiazepine groups. The incidence of side effects was significantly lower in the clonazepam group than with the other benzodiazepines. The incidences of adverse events for the clonazepam, alprazolam, and lorazepam groups were 26.7% (n=20), 48.4% (n=31), and 43.9% (n=18), respectively.ConclusionThe present study suggests that clonazepam is as efficacious as other benzodiazepines for the treatment of various anxiety disorders. Furthermore, the safety profile of clonazepam was superior to the other benzodiazepines in this study.

Nonpharmacologic Options Come First for Cancer Palliation

Nonpharmacologic Options Come First for Cancer Palliation

An Evidence-Based Guideline for the Pre-Operative Sedation of Children

There are numerous sedative pharmacological agents currently administered to children as premedicants to facilitate the induction of anaesthesia. When preoperative sedation is required, selection of the appropriate drug is imperative to provide adequate anxiolysis whilst minimising unwanted side effects. We review the literature regarding the merits and limitations of the commonly used agents and suggest evidence based practical guidance. For the anxious but cooperative child, oral midazolam is often adequate; however with more anxious younger and uncooperative children, combined oral midazolam and ketamine is more effective. Other oral benzodiazepines and oral clonidine all have their role when used in the appropriate circumstances. Intranasal clonidine is useful in the child refusing oral medication. Intramuscular ketamine should be reserved for extreme circumstances, administered only by anaesthetists experienced in its use, with full monitoring and resuscitative equipment immediately available.

Massive Pulmonary Embolism after Overdose of Oral Benzodiazepine

Overdose of benzodiazepines rarely causes morbidity or mortality. A 58-year-old woman presented to the emergency department in coma after ingestion of 30 tablets of 0.5 mg alprazolam. She recovered after flumazenil was administered. However, massive pulmonary embolism developed during observation in the emergency department. Endotracheal intubation and recombinant tissue plasminogen activator infusion were initiated. This case report highlights that benzodiazepine overdose can contribute to pulmonary embolism which is a life-threatening condition.