@article {36660, title = {Sevoflurane and its metabolic byproduct compound A induce nephrotoxicity: a systematic review and meta-analysis of animal studies}, journal = {Med Gas Res.}, volume = {15}, year = {2025}, pages = {254-265}, abstract = {Animal models investigating sevoflurane or compound A and renal function serve as the initial basis for concerns regarding renal injury following sevoflurane anesthesia and subsequent recommendations of minimum fresh gas flow, but this evidence basis has not been critically appraised. Primary literature searches were performed in MEDLINE OVID, PubMed, EMBASE, the Cochrane Library), the Cochrane Central Register of Controlled Trials, the International HTA Database, CINAHL, and Web of Science to identify randomized controlled trials and quasi-experimental studies in animals utilizing sevoflurane or compound A. The primary outcomes included renal function as determined by blood urea nitrogen, serum creatinine, creatinine clearance, and urine volume. The secondary outcomes included the serum fluoride concentration and histopathological findings. A total of 2537 records were screened, and 21 randomized controlled trials and 9 quasi-experimental animal studies were identified. No associations between sevoflurane exposure and subsequent changes in renal function (blood urea nitrogen, serum creatinine or changes in urine volume) were noted. A similar effect on renal function was observed following compound A exposure, but urine volume was elevated following compound A exposure. In addition, the histopathological damage following compound A exposure was observed only at concentrations that are unachievable in clinical practice. Our review of evidence from animal models revealed that sevoflurane usage was not associated with changes in renal function tests or urine volume. Histopathologic changes after sevoflurane exposure were either nonexistent or minor. Studies on compound A did not reveal an alteration in renal function, although histopathological evidence of injury was present when compound A was administered at very high, unphysiologic concentrations. In light of the existing evidence, the initial concerns of sevoflurane-related nephrotoxicity based on animal studies that leads to minimum fresh gas flow recommendations are called into question.}, url = {https://pubmed.ncbi.nlm.nih.gov/39829162/}, author = {Intek Hong and Kevin D Bingam and Brie M McConnell and Timur JP Ozelsel and Rakesh V Sondekoppam} } @article {36659, title = {A systematic review and meta-analysis of interventions to delabel low-risk penicillin allergies with consideration for sex and gender}, journal = {Br J Clin Pharmacol}, volume = {91}, year = {2025}, pages = {684-697}, abstract = {

Aims:\ Sex and gender may influence penicillin allergy label (PAL) prevalence and outcomes. This review evaluates the effectiveness and safety of direct delabelling (DD) and oral challenge (OC) for low-risk patients and examines sex and gender differences in reporting and outcomes.

Methods:\ We searched PubMed, Database of Abstracts of Reviews and Effects, ClinicalTrials.gov, Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts, medRxiv, Ovid MEDLINE, and Ovid EMBASE until February 2024 for studies including DD or OC compared to no intervention, skin testing or other methods. Two reviewers assessed quality. Meta-analyses were conducted, and subgroup analyses were carried out if I2\ \> 75\%. Descriptive data was analysed using NVivo 14 and reported narratively.

Results:\ From 1046 screened studies, 28 met inclusion criteria (two RCTs, 26 quasi-experimental studies). Sex at baseline was reported in 86\% of studies, with 61\% females: 18\% disaggregated outcomes by sex with a female mean delabelling rate of 66\%. Gender variables were not reported. OC was not found to be more or less as effective comparaed to skin testing in RCTs (risk ratio [RR] 1.04; 95\% confidence interval [CI] 0.95, 1.13, I2\ = 74\%). DD interventions had a 27\% delabelling rate (95\% CI 10\%, 50\%, I2\ = 96\%), with nursing staff achieving 29\% (95\% CI 15\%, 47\%, I2\ = 63\%) and allergists/immunologists 6\% (95\% CI 0.00, 0.00, I2\ = 20\%). Quasi-experimental studies reported 90\% delabelling for OC, with 59\% by allergists/immunologists and 90\% by pharmacists. Adverse events averaged 4\% and were non-severe.

Conclusions:\ DD and OC are effective for delabelling low-risk penicillin allergies. Comprehensive data is lacking on sex and gender differences, indicating a need for further research.

Keywords:\ allergy testing; direct delabelling; meta-analysis; oral challenge; penicillin; sex and gender; systematic review.

}, url = {https://pubmed.ncbi.nlm.nih.gov/39702887/}, author = {Mira Maximos and Ryan Pelletier and Sameer Elsayed and Colleen J Maxwell and Sherilyn K D Houle and Brie M McConnell and John-Michael Gamble} } @article {36810, title = {Unpacking Oral Challenge Protocols: A Descriptive Epidemiologic Study of Reactions, Predictors, and Practices for Delabeling Low-Risk Penicillin Allergies Leveraging Data from a Systematic Review and Meta-Analysis}, journal = {Hosp Pharma.}, volume = {60}, year = {2025}, url = {https://pubmed.ncbi.nlm.nih.gov/40352615/}, author = {Maximos, M} } @article {34133, title = {Neurological injury following peripheral nerve blocks: a narrative review of estimates of risks and the influence of ultrasound guidance}, journal = {Reg Anesth Pain Med}, volume = {49}, year = {2024}, pages = {122-132}, abstract = {

Background:\ Peripheral nerve injury or post-block neurological dysfunction (PBND) are uncommon but a recognized complications of peripheral nerve blocks (PNB). A broad range of its incidence is noted in the literature and hence a critical appraisal of its occurrence is needed.

Objective:\ In this review, we wanted to know the pooled estimates of PBND and further, determine its pooled estimates following various PNB over time. Additionally, we also sought to estimate the incidence of PBND with or without US guidance.

Evidence review:\ A literature search was conducted in six databases. For the purposes of the review, we defined PBND as any new-onset sensorimotor disturbances in the distribution of the performed PNB either attributable to the PNB (when reported) or reported in the context of the PNB (when association with a PNB was not mentioned). Both prospective and retrospective studies which provided incidence of PBND at timepoints of interest (\>48 hours to \<2 weeks; \>2 weeks to 6 weeks, 7 weeks to 5 months, 6 months to 1 year and \>1 year durations) were included for review. Incidence data were used to provide pooled estimates (with 95\% CI) of PBND at these time periods. Similar estimates were obtained to know the incidence of PBND with or without the use of US guidance. Additionally, PBND associated with individual PNB were obtained in a similar fashion with upper and lower limb PNB classified based on the anatomical location of needle insertion.

Findings:\ The overall incidence of PBND decreased with time, with the incidence being approximately 1\% at \<2 weeks{\textquoteright} time (Incidence per thousand (95\% CI)= 9 (8; to 11)) to approximately 3/10 000 at 1 year (Incidence per thousand (95\% CI)= 0. 3 (0.1; to 0.5)). Incidence of PBND differed for individual PNB with the highest incidence noted for interscalene block.

Conclusions:\ Our review adds information to existing literature that the neurological complications are rarer but seem to display a higher incidence for some blocks more than others. Use of US guidance may be associated with a lower incidence of PBND especially in those PNBs reporting a higher pooled estimates. Future studies need to standardize the reporting of PBND at various timepoints and its association to PNB.

}, url = {https://pubmed.ncbi.nlm.nih.gov/37940348/}, author = {Lemke, E and Johnston, DF and Behrens, MB and Seering, MM and McConnell, BM and Singh Swaran Singh, T and Sondekoppam, RV} } @article {35845, title = {Protocol for a systematic review and meta-analysis of interventions aimed at delabeling low-risk penicillin allergies with consideration for sex and gender}, journal = {System Rev.}, volume = {13}, year = {2024}, pages = {259}, abstract = {

Background:\ Approximately, 10\% of people report a penicillin allergy; however, more than 90\% can safely undergo delabeling after a detailed history, oral challenge, or other investigations such as penicillin skin testing (PST). Although PST is the gold standard, the results can be heterogeneous, and awaiting specialist assessment may take an inordinate amount of time. Therefore, oral provocation challenge has become acceptable for individuals with low-risk penicillin allergy histories. There also appears to be an association with increased prevalence of adverse drug reaction reporting in female individuals, which may translate to penicillin allergy prevalence; however, the evidence has not been assessed through a sex and gender lens. This systematic review will identify and synthesize the findings from studies that report measures of effectiveness and safety of interventions aimed at delabeling penicillin allergies in low-risk individuals. Information related to sex and gender will be extracted, where available, to understand potential differences in allergy reporting and patient outcomes.

Methods:\ The Cochrane Handbook for Systematic Reviews of Interventions and the Centre for Review and Dissemination{\textquoteright}s Guidance for Undertaking Reviews in Health Care will be used as frameworks for conducting this systematic review. The literature search will be conducted by a medical librarian (B. M. M.) and will consist of a search strategy to identify and retrieve published studies that meet our inclusion criteria. Studies that require penicillin skin testing (PST) as a step prior to other interventions will be excluded. Integrated knowledge translation involving co-design was carried out for this systematic review protocol creation. Data extraction will be conducted at four levels: (1) study level, (2) patient level, (3) intervention level, and (4) outcome level. A narrative descriptive synthesis of results and risk of bias of all included studies will be provided, and, if relevant, a meta-analysis will be performed.

Discussion:\ The dissemination of findings from this knowledge synthesis to various stakeholders is intended to inform on options for evidence-based interventions to aid in delabeling penicillin allergies in individuals with a low risk of experiencing a hypersensitivity reaction. Detailed reporting on the characteristics of delabeling interventions as well as the effectiveness of similar interventions will benefit policy makers considering the implementation of a penicillin allergy delabeling protocol. Additionally, findings from this systematic review will report on the current evidence regarding the role of sex and gender in both the prevalence and outcomes associated with the presence of penicillin allergies.

Systematic review registration:\ PROSPERO CRD42022336457.

Keywords:\ Allergy; Amoxicillin; Antibiotic; Beta-lactam; Delabeling; Hypersensitivity; Oral challenge; Penicillin; Testing.

}, url = {https://pmc.ncbi.nlm.nih.gov/articles/PMC11472534/}, author = {Mira Maximos and Sameer Elsayed and Colleen Maxwell and Sherilyn KD Houle and Ryan Pelletier and Brie M McConnell and Andrew Pylypiak and John-Micahel Gamble} } @article {32302, title = {Peripartum mental health and the role of the pharmacist: A scoping review}, journal = {Res Social Adm Pharm}, volume = {19}, year = {2023}, pages = {1243-1255}, abstract = {

Background:\ The global prevalence of peripartum mental illness is 20\%, though estimates have increased since the start of the COVID-19 pandemic. Chronic illnesses affect one in five pregnancies and may be associated with higher rates of peripartum mental illness. Though pharmacists are well-positioned to facilitate appropriate and timely care of co-occurring mental and physical health conditions during this period, little is understood regarding their potential roles.

Objectives:\ To understand the current evidence examining the role of pharmacists to improve the outcomes of women with peripartum mental illness, with and without chronic illness.

Methods:\ A scoping review was performed with assistance from an interdisciplinary team following the Joanna Briggs Institute framework. MEDLINE, Embase, PsychNet and International Pharmaceutical Abstracts databases were searched. English-language articles (published up to May 30, 2022) were screened and assessed for eligibility, and data were charted to collate results, by dual independent reviewers.

Results:\ The search strategy produced 922 articles. After screening, 12 articles were included (5 narrative reviews, 7 primary research). There was limited discussion or empirical data regarding specific interventions (screening, counseling), opportunities (accessibility, managing stigma, forming trusting relationships and building rapport with patients) or barriers (lack of privacy, time constraints, adequate remuneration, training) associated with an expanded role of pharmacists in peripartum mental health care. The clinical complexity arising from co-occurring mental health and chronic illnesses was not explored, other than a small pilot study involving pharmacists screening for depression among pregnant women with diabetes.

Conclusions:\ This review highlights the limited evidence available on the explicit role of pharmacists in supporting women with peripartum mental illness, including those with comorbidity. More research, including pharmacists as study participants, is required to fully understand the potential roles, barriers, and facilitators of integrating pharmacists into peripartum mental healthcare to improve the outcomes of women in the peripartum period.

}, url = {https://pubmed.ncbi.nlm.nih.gov/37210239/}, author = {Urslak, R and Evans, C and Nakhla, N and Marrie, RA and McConnell, BM and Maxwell, CJ} } @article {32305, title = {The impact of sevoflurane anesthesia on postoperative renal function: a systematic review and meta-analysis of randomized-controlled trials.}, journal = {Can J Anaesth.}, volume = {67}, year = {2020}, pages = {1595-1623}, abstract = {

Purpose:\ Renal damage secondary to fluoride ions and compound A (CpdA) after sevoflurane anesthesia remains unclear. For safety reasons, some countries still recommend minimum fresh-gas flows (FGFs) with sevoflurane. We review the evidence regarding the intraoperative use of sevoflurane for anesthesia maintenance and postoperative renal function compared with other anesthetic agents used for anesthetic maintenance. Secondarily, we examine the effects of peak plasma fluoride and CpdA levels and the effect of FGF and duration of anesthesia on these parameters.

Source:\ The databases of MEDLINE (OVID and Pubmed), EMBASE, the Cochrane Library, Health Technology Assessment Database, CINAHL, and Web of Science were searched from inception until 23 April 2020 to identify randomized-controlled trials (RCTs) in humans utilizing sevoflurane or an alternative anesthetic for anesthesia maintenance with subsequent measurements of renal function. Two different paired reviewers independently selected the studies and extracted data. The quality of the evidence was appraised using GRADE recommendations.

Principal findings:\ Of 3,766 publications screened, 41 RCTs in human patients were identified. There was no difference between creatinine at 24 hr (21 studies; n = 1,529), or creatinine clearance (CCR) at 24 hr (12 studies; n = 728) in the sevoflurane vs alternative anesthetic groups. Peak fluoride and fluoride measured at 24 hr were higher with sevoflurane compared with other inhaled anesthetics. Subgroup analyses for sevoflurane usage in various contexts showed no significant difference between sevoflurane and alternative anesthetics for creatinine or CCR at 24 hr at varying FGF, duration of exposure, baseline renal function, or absorbent use.

Conclusions:\ We did not find any association between the use of sevoflurane and postoperative renal impairment compared with other agents used for anesthesia maintenance. The scientific basis for recommending higher FGF with the use of sevoflurane needs to be revisited.

Keywords:\ compound A; fluoride ions; fresh-gas flow; nephrotoxicity; sevoflurane.

}, url = {https://pubmed.ncbi.nlm.nih.gov/32812189/}, author = {RV Sondekoppam and KH Narsingani and TA Schimmel and BM McConnell and K Buo and TJP Ozelsel} } @article {32304, title = {Dexmedetomidine for craniotomy under general anesthesia: A systematic review and meta-analysis of randomized clinical trials.}, journal = {J Clin Anesth}, volume = {54}, year = {2019}, pages = {114-125}, abstract = {

Study objective:\ To assess the efficacy and safety of dexmedetomidine as an adjunct to general anesthesia for craniotomy.

Design:\ A meta-analysis after systematically searching PubMed, Medline, EMBASE, and Cochrane library for randomized trials (RCTs). Relative risk (RR) and weighted mean difference (WMD) were calculated using random-effects meta-analysis.

Setting:\ Perioperative setting.

Patients:\ Twenty-two RCTs (1348 patients) with craniotomy under general anesthesia were included.

Interventions:\ Dexmedetomidine as an adjunct to general anesthesia versus placebo or other anesthetics.

Measurements:\ Primary outcomes included procedure success and postoperative pain; Secondary outcomes included cardiac adverse events, postoperative nausea and vomiting (PONV) and other clinically important outcomes.

Main results:\ Dexmedetomidine vs. Placebo: High to moderate quality evidence suggested that dexmedetomidine reduced postoperative pain (WMD -0.25 cm, 95\%CI -0.43 to -0.07 cm on a 10 cm visual analogue scale), postoperative nausea and vomiting (PONV, RR 0.57, 95\%CI 0.39 to 0.84), hypertension (RR 0.37, 95\%CI 0.22 to 0.61) and tachycardia (RR 0.32, 95\%CI 0.12 to 0.85) with no significant increase of hypotension and bradycardia. Moderate quality evidence suggested no significant difference in procedural success. Dexmedetomidine vs. Active Comparators (including remifentanil, fentanyl, or propofol): Moderate quality evidence showed no difference in procedural success and postoperative pain.

Conclusions:\ Dexmedetomidine as an adjunct to general anesthesia shows small benefits in reduction of pain, PONV, and maintains more stable hemodynamics with comparable effects on procedural success versus placebo. Very limited evidence explored comparative effects between dexmedetomidine and active controls. Further evidence is required to evaluate patient-important outcomes and optimal dosing strategies, particularly versus active comparators.

Keywords:\ Craniotomy; Dexmedetomidine; General anesthesia; Meta-analysis; Randomized controlled clinical trial.

}, url = {https://pubmed.ncbi.nlm.nih.gov/30445412/}, author = {Wang, Li and Shen, J and Ge, J and Arango, MF and Tang, X and Moodie, J and McConnell, BM and Martin, J and Cheng, D} } @article {32301, title = {A review of diagnostic accuracy and clinical impact from the focused use of perioperative ultrasound.}, journal = {Can J Anaesth.}, volume = {65}, year = {2018}, pages = {371-380}, abstract = {

Purpose:\ To perform a narrative review of the current trials examining the use of perioperative ultrasound to diagnose common issues related to the heart, lungs, stomach, and airway.

Method:\ A review of the current literature was conducted in June 2017 on all trials involving ultrasound, including both surface and transesophageal ultrasound, in the perioperative period. The search included the terms {\textquoteright}ultrasonography{\textquoteright}, {\textquoteright}perioperative care{\textquoteright}, {\textquoteright}point-of-care{\textquoteright}, and {\textquoteright}bedside{\textquoteright}. Trials were limited to human subjects with no language or time restrictions being applied. The results were then collected and a narrative review was completed with the available information.

Results:\ In total 1,176 reports of original investigation or systematic reviews were collected and reviewed. Of those 1,176 reports and reviews, a total of 80 original articles met the inclusion criteria for this review. Topics were broadly defined based on common themes emerging from the literature including cardiac disease, lung pathology (pneumothorax, pleural effusion, pulmonary edema, and pulmonary consolidation), volume and contents of the stomach, confirmation of endotracheal tube position, confirmation of lung isolation, and the application of ultrasound for guiding cricothyroidotomy. Where possible, the sensitivity and specificity of the trials are presented. Few trials reported on patient outcomes, although several discussed provider outcomes such as a change in anesthesia practice. In addition, trials reporting outcomes, although few in number, were included.

Conclusion:\ Perioperative point-of-care ultrasound is a useful method for the diagnosis of many important perioperative conditions. The impact of this diagnostic approach on patient outcomes however remains to be determined.

}, url = {https://pubmed.ncbi.nlm.nih.gov/29396742/}, author = {Bainbridge, D and McConnell, BM and Royse, C} } @article {32303, title = {A systematic review of transthoracic and transesophageal echocardiography in non-cardiac surgery: implications for point-of-care ultrasound education in the operating room}, journal = {Can J Anaesth.}, volume = {63}, year = {2016}, pages = {480-7.}, abstract = {

Purpose:\ Point-of-care ultrasound (POCU) is an evolving field in anesthesia. Therefore a systematic review of common diagnoses made by POCU during non-cardiac surgery was conducted. The information obtained from the review may be used to develop POCU curricula for the perioperative setting during non-cardiac surgery.

Source:\ A systematic review was conducted for perioperative use of transthoracic /transesophageal echocardiography (TTE/TEE) in high-risk patients or in other patients experiencing periods of hemodynamic instability. The diagnoses included segmental wall motion abnormalities (SWMAs), low left ventricular ejection fraction (LVEF), hypovolemia, air embolism, cardiac/aortic thrombus, pulmonary embolus (PE), aortic valve disease, mitral valve disease, tricuspid valve disease, right ventricular (RV) failure, pericardial disease, and patent foramen ovale.

Principal findings:\ Three hundred twenty-one studies were found using our search terms, and thirteen studies were retained that met our inclusion criteria for review. The studies included 968 patients analyzed as either preoperative exams in high-risk patients (n = 568) or intraoperative exams during times of hemodynamic compromise/cardiac arrest (n = 400). The most common diagnoses in the preoperative exam group were low ejection fraction (25.4\%), aortic valve disease (24.4\%), mitral valve disease (20.0\%), RV failure (6.6\%), and hypovolemia (6.3\%). In the intraoperative exam group, the most common diagnoses were hypovolemia (33.2\%), low ejection fraction (20.5\%), RV failure (13.1\%), SWMAs (10.1\%), and PE (5.8\%).

Conclusion:\ In this systematic review examining the use of TTE or TEE in non-cardiac surgery, the most frequent diagnoses were valvulopathy, low LVEF, hypovolemia, PE, SWMAs, and RV failure. This information should be used to inform evidence-based curricula for POCU in anesthesiology.

}, url = {https://pubmed.ncbi.nlm.nih.gov/26514983/}, author = {Amanda Jasudavisius and Ramiro Arellano and Janet Martin and Brie M McConnell and Daniel Bainbridge} }