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Gastroparesis in pregnancy. Am J Obstet Gynecol 2022; 228:382-394. [PMID: 36088986 DOI: 10.1016/j.ajog.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 08/21/2022] [Accepted: 09/05/2022] [Indexed: 01/30/2023]
Abstract
Gastroparesis is a functional gastrointestinal disorder that more commonly affects women, with most cases being diagnosed during childbearing age. However, there is a paucity of data and guidelines to specifically highlight the epidemiology, disease course, maternal and fetal impact, and the management of existing gastroparesis during pregnancy. Apart from metoclopramide, there is no approved therapy specifically indicated for gastroparesis. More importantly, pregnant and breastfeeding women are excluded from clinical trials evaluating pharmacologic agents in the management of gastroparesis. This poses a real challenge to healthcare providers in counseling and managing patients with gastroparesis. In this systematic review, we summarize the current available literature and the knowledge gaps in the impact of pregnancy on gastroparesis and vice versa. We also highlight the efficacy and safety profiles of available pharmacologic and nonpharmacologic therapies in the management of patients with gastroparesis, with emphasis on judicious use of dietary approaches that are deemed relatively safe during pregnancy.
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Gokalp G, Ozbeyaz NB. The impact of midazolam used in cataract surgery sedation on frontal QRS-T angle. J Clin Pharm Ther 2022; 47:1644-1649. [PMID: 35764598 DOI: 10.1111/jcpt.13715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/04/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Midazolam is one of the most commonly used drugs in procedures requiring sedoanalgesia. It affects the myocardium's ventricular depolarization and repolarization. Previous studies examining the arrhythmogenic effects of midazolam yielded conclusive results. These studies are based on QT and Tp -e distances. The frontal QRS-T angle (f-[QRS-T]a) is a new electro cardiac parameter that shows the heterogeneity of ventricular electrical activity. This study aims to examine the effect of midazolam on f-(QRS- T)a and other depolarization-repolarization parameters in patients who have had cataract surgery. METHODS The study included 177 patients administered midazolam as a sedoanalgesia during cataract surgery. The sedative effect was evaluated 2-3 minutes after a 0.05 mg/kg dose of midazolam was given. Sedation was assessed again by giving 0.5 mg every 2-3 minutes until the desired level of sedation was achieved. 12-lead electrocardiogram (ECG) recordings of all patients were taken just before and immediately after surgery. ECGs were used to calculate the QT interval, QTc interval, Tp -e interval, Tp -e/QT, Tp -e/ QTc ratios and f-(QRS-T)a. RESULTS AND DISCUSSION After cataract surgery, f-(QRS-T)a was unchanged compared to presurgery (29.14 ± 4.52 vs. 29.18 ± 5.39, p = 0.852). In addition, no significant change in QT(351.32 ± 21.98 vs. 351.94 ± 22.44, p = 0.091), QTc (384.05 ± 24.52 vs. 385.19 ± 26.12, p = 0.819), Tp -e interval (93.12 ± 9.60 vs. 94.44 ± 8.82, p = 0.179) and Tp -e/QT (0.27 ± 0.02 vs. 0.28 ± 0.03, p = 0.664), Tp -e/ QTc ratios (0.28 ± 0.02 vs. 0.29 ± 0.03, p = 0.655) was observed after surgery when compared to presurgery values. Significant ventricular and supraventricular arrhythmias were not observed in any patient during the operation. WHAT IS NEW AND CONCLUSION Midazolam did not affect f -(QRS-T) with classical repolarization parameters in patients who underwent cataract surgery, according to this study. Midazolam has been found to be safe for the heart in sedoanalgesia. These results show that sedation with midazolam can be performed without electrocardiogram monitoring.
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Affiliation(s)
- Gokhan Gokalp
- Department of Cardiology, Pursaklar State Hospital, Ankara, Turkey
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3
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Maddali MM, Thomas E, Al-Abri IA, Patel MH, Al-Maskari SN, Al-Yamani MI. Dilated Cardiomyopathy Phenotype Associated Left Ventricular Noncompaction And Congenital Long QT Syndrome Type-2 In Infancy With KCNH2 Gene Mutation: Anesthetic Considerations. J Cardiothorac Vasc Anesth 2022; 36:3662-3667. [DOI: 10.1053/j.jvca.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/25/2022] [Accepted: 05/11/2022] [Indexed: 11/11/2022]
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Gavioli EM, Guardado N, Haniff F, Deiab N, Vider E. The Risk of QTc Prolongation with Antiemetics in the Palliative Care Setting: A Narrative Review. J Pain Palliat Care Pharmacother 2021; 35:125-135. [PMID: 33974499 DOI: 10.1080/15360288.2021.1900491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Nausea and vomiting are common within the palliative care population. Antiemetic agents may help control symptoms, but may also place patients at risk for QTc prolongation. This article reviews pharmacotherapy agents including anticholinergics, antihistamines, antidopaminergics, 5-HT3 receptor antagonists, dronabinol, and medical marijuana and their associated risk of QTc prolongation. A clinical treatment pathway is provided to help guide clinicians in choosing the most appropriate antiemetic based upon patient specific factors for QTc prolongation.
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Affiliation(s)
- Elizabeth M Gavioli
- Elizabeth M. Gavioli, PharmD., Nerli Guardado, BA, Farah Haniff, BS, Nouran Deiab, BPS, and Etty Vider, PharmD, are with Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Brooklyn, New York, USA
| | - Nerli Guardado
- Elizabeth M. Gavioli, PharmD., Nerli Guardado, BA, Farah Haniff, BS, Nouran Deiab, BPS, and Etty Vider, PharmD, are with Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Brooklyn, New York, USA
| | - Farah Haniff
- Elizabeth M. Gavioli, PharmD., Nerli Guardado, BA, Farah Haniff, BS, Nouran Deiab, BPS, and Etty Vider, PharmD, are with Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Brooklyn, New York, USA
| | - Nouran Deiab
- Elizabeth M. Gavioli, PharmD., Nerli Guardado, BA, Farah Haniff, BS, Nouran Deiab, BPS, and Etty Vider, PharmD, are with Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Brooklyn, New York, USA
| | - Etty Vider
- Elizabeth M. Gavioli, PharmD., Nerli Guardado, BA, Farah Haniff, BS, Nouran Deiab, BPS, and Etty Vider, PharmD, are with Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Brooklyn, New York, USA
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Soghomonyan S, Stoicea N, Ackermann W, Bhandary SP. PONV management in patients with QTc prolongation on the EKG. Front Pharmacol 2021; 11:565704. [PMID: 33551794 PMCID: PMC7861054 DOI: 10.3389/fphar.2020.565704] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/25/2020] [Indexed: 11/15/2022] Open
Abstract
Postoperative nausea and vomiting (PONV) is a commonly encountered problem in surgical practice. It delays discharge from the post-anesthesia care unit, requires additional resources to treat, and may increase the morbidity in some patients. Many effective drugs are available to treat or prevent PONV, however many of these drugs have the potential to prolong the QTc on the electrocardiogram (EKG) and increase the risk of serious ventricular arrhythmias, in particular, torsade de pointes. The QTc prolongation may be a manifestation of a genetic mutation resulting in abnormal myocyte repolarization or it may be acquired and associated with the use of various medications, electrolyte disorders, and physiological conditions. Patients predisposed to QTc prolongation presenting for surgery constitute a challenging group, since many drugs commonly used for PONV management will put them at risk for perioperative serious arrhythmias. This is an important topic, and our mini-review is an attempt to highlight the problem, summarize the existing experience, and generate recommendations for safe management of PONV for patients, who are at increased risk of QTc prolongation and arrhythmias. Focused prospective studies will help to find definitive answers to the discussed problems and challenges and develop specific guidelines for clinical application.
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Affiliation(s)
- S Soghomonyan
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - N Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - W Ackermann
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - S P Bhandary
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Niimi N, Yuki K, Zaleski K. Long QT Syndrome and Perioperative Torsades de Pointes: What the Anesthesiologist Should Know. J Cardiothorac Vasc Anesth 2020; 36:286-302. [PMID: 33495078 DOI: 10.1053/j.jvca.2020.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/16/2020] [Accepted: 12/07/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Naoko Niimi
- Department of Anesthesiology, Juntendo University, Tokyo, Japan.
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Katherine Zaleski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA
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Sessa M, Mascolo A, Dalhoff KP, Andersen M. The risk of fractures, acute myocardial infarction, atrial fibrillation and ventricular arrhythmia in geriatric patients exposed to promethazine. Expert Opin Drug Saf 2020; 19:349-357. [PMID: 31903798 DOI: 10.1080/14740338.2020.1711882] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objectives: This study aimed to compare the risk of fractures, acute myocardial infarction, atrial fibrillation, and ventricular arrhythmia among Danish citizens aged ≥ 65 which were new users of promethazine or domperidone, triazolam, loratadine, and betahistine. Secondly, the study aimed to perform a risk stratification to identify the most relevant predictors for the study outcomes.Methods: The study period was 01/01/2015 to 31/12/2016. The data sources were the Danish registers. Each patient was followed for 90 days. A logistic regression model was used to compute the unadjusted and adjusted odds ratios (OR), and a conditional inference tree was used to identify the most relevant predictors for the study outcomes.Results: Promethazine had a higher risk of hospitalization for atrial fibrillation than loratadine and betahistine (OR 1.58; 95% CI 1.07-2.63 and OR 3.22; 95% CI 1.69-7.14, respectively). For fractures, acute myocardial infarction, and ventricular arrhythmia hospitalizations, no statistically significant differences were found among drugs under investigation. The medical history of cardiac arrhythmia (OR 4.14; 95% CI 2.94-5.78, p < 0.0001) was the most relevant predictor for atrial fibrillation hospitalizations.Conclusion: This study found an increased risk of atrial fibrillation hospitalization among promethazine users, and the risk was higher among patients with prior cardiac arrhythmia.
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Affiliation(s)
- Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, København Ø, Denmark
| | - Annamaria Mascolo
- Campania Pharmacovigilance and Pharmacoepidemiology Regional Center, Department of Experimental Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | - Kim Peder Dalhoff
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg University Hospital, København, Denmark
| | - Morten Andersen
- Department of Drug Design and Pharmacology, University of Copenhagen, København Ø, Denmark
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Setya A, Nair P, Cheng SX. Gastric electrical stimulation: An emerging therapy for children with intractable gastroparesis. World J Gastroenterol 2019; 25:6880-6889. [PMID: 31908392 PMCID: PMC6938723 DOI: 10.3748/wjg.v25.i48.6880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/13/2019] [Accepted: 12/22/2019] [Indexed: 02/06/2023] Open
Abstract
Management of gastroparesis remains challenging, particularly in pediatric patients. Supportive care and pharmacological therapies for symptoms remain the mainstay treatment. Although they are effective for mild and some moderately severe cases, often time they do not work for severe gastroparesis. There are a few prokinetics available, yet the use of these drugs is limited by a lack of persistent efficacy and/or safety concerns. Currently, the only modality for adult patients with severe intractable gastroparesis is surgery, e.g., pyloroplasty and partial gastrectomy, however, this option is generally considered too radical for a growing child. Novel therapeutic approaches, particularly those which are less invasive, are needed. This article explores gastric electrical stimulation (GES), a new therapy for gastroparesis. Unlike others, it neither needs medications nor gastrectomy; rather, it treats through the use of microelectrodes to deliver high-frequency low energy electric stimulation to the pacemaker area of the stomach. Thus, it is tolerated and safe in children. Like in adult patients, GES appears to work in releasing symptoms, improving nutrition, and enhancing the quality of life; it also helps wean off medications and eliminate many needs for hospitalization. Considering the transient nature of gastroparesis in children in many occasions, GES is considered a “bridging” therapy after failed medical interventions and before surgery.
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Affiliation(s)
- Aniruddh Setya
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
| | - Priyanka Nair
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
| | - Sam Xianjun Cheng
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
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Loganathan P, Gajendran M, McCallum R. Current and future treatment management strategies for gastroparesis. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1617694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Priyadarshini Loganathan
- Department of Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Richard McCallum
- Division of Gastroenterology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine, El Paso, TX, USA
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Abstract
SUMMARY‘Rapid tranquillisation’ refers to the use of medication to calm highly agitated individuals experiencing mental disorder who have not responded to non-pharmacological approaches. Commonly it is the initial stage in the treatment of severe and enduring illness. Using medication in this way requires particularly robust evidence of efficacy and the management of side-effects. This article attempts to integrate current understanding of the neurochemical mechanisms of underlying illness and drug actions with therapeutic interventions. It distinguishes arousal from agitation, and effects on sedation from tranquillisation. It reviews critically the practice of rapid tranquillisation in the light of new evidence, changes in the NICE guidelines and British National Formulary recommendations and a national audit (POMH-UK). Broader aspects of management, known as ‘restrictive practices’ (such as control and restraint and seclusion), psychological support of team members, incident reporting, risk assessment, monitoring and medico-legal aspects are not covered.LEARNING OBJECTIVES•Recognise the role of brain transmitter pathways leading to arousal and to agitation•Be aware of mechanisms of action of benzodiazepines, antipsychotics and antihistamines and distinguishing sedation from calming effects•Know the recommendations of NICE guidelines for rapid tranquillisation and the findings of the national POMH-UK audit and be able to contribute to local policiesDECLARATION OF INTERESTNone.
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Eskander JP, Rapoport Y, Cornett E, Gennuso S, Franklin M, Kaye AD, Fox CJ. Does promethazine shorten the length of stay in the post anesthesia care unit? J Perioper Pract 2018; 28:194-198. [PMID: 29737920 DOI: 10.1177/1750458918776548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The combination of promethazine and opioids is known to have an opioid-sparing effect, thereby facilitating a reduction in total patient opioid consumption. In recent years, this practice has fallen out of favor in many healthcare facilities, except primarily in the post anesthesia care unit (PACU). The goal of this study was to highlight the potential of promethazine as a direct or indirect adjuvant medication in acute pain management. The present investigation was undertaken with a case series of adult female patients who underwent open total abdominal hysterectomies. Data from the PACU was reviewed with patients being separated into two groups. Group 1 received only intravenous opioids for acute pain management. Group 2 received a combination of intravenous opioids for acute pain management and intravenous promethazine for nausea and/or vomiting. Patients were discharged from the PACU with a modified Aldrete score of 9 or 10. The study showed that patients who received promethazine in addition to opioids were discharged from the PACU an average of 19.2 minutes earlier than those patients who received only opioids (p=0.003). The time to achieve modified Aldrete score of 9 or higher was more quickly achieved when open abdominal hysterectomy patients received promethazine in addition to opioids in the PACU. The study concluded that promethazine, in combination with opioids, could potentially decrease PACU stay postoperatively. Based on the present investigation, the prospect of using promethazine in other facets of pain management are intriguing and warrant future studies. Specifically, it may be worth investigating whether promethazine is truly an adjunct in combination with opioids and to determine if there are any other antihistamines or neuroleptics which may have similar clinical effects to promethazine.
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Affiliation(s)
- Jonathan P Eskander
- 1 Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Yury Rapoport
- 1 Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Elyse Cornett
- 1 Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Sonja Gennuso
- 1 Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Michael Franklin
- 1 Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Alan D Kaye
- 2 Department of Anesthesiology, LSU School of Medicine New Orleans, 1542 Tulane Ave, Suite 659, New Orleans, LA, 70112, USA
| | - Charles J Fox
- 1 Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
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Perioperative management of patients with congenital or acquired disorders of the QT interval. Br J Anaesth 2018; 120:629-644. [DOI: 10.1016/j.bja.2017.12.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/16/2017] [Accepted: 01/14/2018] [Indexed: 12/19/2022] Open
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Rochoy M, Auffret M, Béné J, Gautier S. [Antiemetics and cardiac effects potentially linked to prolongation of the QT interval: Case/non-case analysis in the national pharmacovigilance database]. Rev Epidemiol Sante Publique 2016; 65:1-8. [PMID: 27988172 DOI: 10.1016/j.respe.2016.06.335] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 06/01/2016] [Accepted: 06/21/2016] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Observational retrospective studies have linked domperidone and prolonged QT interval, ventricular arrhythmias and risk of sudden death. Since then, antiemetic prescription was applied to other molecules (including metopimazine). The aim of this study was to evaluate the profile of adverse cardiac effects associated with QT prolongation for each antiemetic available in France. METHODS We conducted disproportionality analyses (case/non-case method), based on the observations recorded consecutively in the French national pharmacovigilance database between 2004 and 2013. Cases were defined by following MedDRA terms: prolongation of the QT interval, syncope, sudden death, cardiac arrest, ventricular arrhythmias including torsades de pointes; non-cases were other adverse events reported during the same period. We analyzed the presence of each antiemetic among cases and non-cases and measured the disproportionality by reporting odds ratios (ROR). We validate the assay with a positive control (methadone) and a negative control (acetaminophen). RESULTS We compared 2093 cases (94 with antiemetics) to 253,665 non-cases (7015 with antiemetics). Among antiemetics, adverse cardiac effects studied were more frequently found with notifications including domperidone (ROR=2.0, 95% CI=[1.3; 3.0]), ondansetron (ROR=1.8, 95% CI=[1.3; 2.6]) and granisetron (ROR=3.4, 95% CI=[1.5; 7.6]). Metopimazine was not statistically associated with that risk (ROR=2.0; 95% CI=[0.8; 4.8]). CONCLUSION We confirmed a risk of cardiac adverse event related to prolongation of the QT interval with domperidone and setrons. These results suggest caution when prescribing antiemetics and encourage systematic reporting of adverse cardiac effects observed with these molecules.
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Affiliation(s)
- M Rochoy
- Département de médecine générale, université de Lille, 59000 Lille, France; Inserm, U1171, degenerative and vascular cognitive disorders, 59000 Lille, France.
| | - M Auffret
- Inserm, U1171, degenerative and vascular cognitive disorders, 59000 Lille, France; Centre régional de pharmacovigilance, CHU de Lille, faculté de médecine, 1, place de Verdun, 59000 Lille, France
| | - J Béné
- Inserm, U1171, degenerative and vascular cognitive disorders, 59000 Lille, France; Centre régional de pharmacovigilance, CHU de Lille, faculté de médecine, 1, place de Verdun, 59000 Lille, France
| | - S Gautier
- Inserm, U1171, degenerative and vascular cognitive disorders, 59000 Lille, France; Centre régional de pharmacovigilance, CHU de Lille, faculté de médecine, 1, place de Verdun, 59000 Lille, France
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Burdette S, Roppolo LP, Green W, Shinthia N, Ye P, Hynan LS. The Effect of Antiemetics and Antihistamines on the QTc Interval in Emergent Dialysis Patients With Baseline QTc Prolongation. J Emerg Med 2016; 51:99-105. [PMID: 27614302 DOI: 10.1016/j.jemermed.2016.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 04/02/2016] [Accepted: 04/20/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Unfunded patients with end-stage renal disease (ESRD) who do not have routinely scheduled hemodialysis often receive medications known to prolong the QTc interval for their uremic symptoms even though they may have pre-existing QTc prolongation. OBJECTIVES The purpose of this study was to determine the effects of these medications on the QTc interval in these patients. METHODS Unfunded patients with ESRD presenting to the emergency department (ED) for emergent hemodialysis (HD) with QTc prolongation on their initial electrocardiogram (ECG) were recruited. Approximately 2 hours after receiving an antihistamine or antiemetic, a second ECG was ordered and the QTc was measured. The patients were followed-up 1 week later. RESULTS Twenty-nine percent (44/152) of the unfunded patients with ESRD presenting for HD at a county hospital had QT prolongation and were included with 107 total ED visits during the 4-week study period. The mean QTc was 483.7 msec on presentation to the ED, and the mean QTc measured 2 hours after receiving an antihistamine or antiemetic was 483.8 msec. None of the patients were admitted for life-threatening dysrhythmias. Thirty-six percent (16/44) of the recruited patients had QTc intervals >500 msec with a combined total of 31 patient visits, of which only 25.8% (8/31) had an increase in the QTc interval after an antihistamine or antiemetic medication was given. None of these patients had adverse outcomes, such a dysrhythmia or death, at 1-week follow-up. CONCLUSION This study shows that medications known to cause QTc prolongation are safe to use in therapeutic doses in patients with ESRD who have pre-existing QT prolongation. Few patients in this cohort had significantly prolonged QTc intervals at baseline.
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Affiliation(s)
- Scott Burdette
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Lynn P Roppolo
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Walter Green
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Nashid Shinthia
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Peter Ye
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Linda S Hynan
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas
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Abstract
Gastroparesis is a syndrome of delayed gastric emptying in the absence of mechanical obstruction. Symptoms can be debilitating, affect nutritional states, and significantly impact patients' quality of life. The management of these patients can prove quite difficult to many providers. This article will review the current management recommendations of gastroparesis, discuss investigational medications and interventions, and summarize future directions of therapies targeting the underlying disease process. Current therapies are subdivided into those improving gastric motility and those directly targeting symptoms. Non-pharmacologic interventions, including gastric stimulator implantation and intra-pyloric botulinum toxic injection are reviewed. A discussion of expert opinion in the field, a look into the future of gastroparesis management, and a key point summary conclude the article.
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Affiliation(s)
- James Langworthy
- a Temple University Hospital , Department of Internal Medicine , Philadelphia , PA , USA
| | - Henry P Parkman
- b Temple University Hospital , Section of Gastroenterology , Philadelphia , PA , USA
| | - Ron Schey
- b Temple University Hospital , Section of Gastroenterology , Philadelphia , PA , USA
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Tracz K, Owczuk R. Small doses of droperidol do not present relevant torsadogenic actions: a double-blind, ondansetron-controlled study. Br J Clin Pharmacol 2015; 79:669-76. [PMID: 25293524 DOI: 10.1111/bcp.12527] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
AIM Drugs used for postoperative nausea and vomiting prophylaxis are believed to provoke torsadogenic changes in cardiac repolarization. The aim of this study was to assess the effect of small doses of droperidol on the parameters of cardiac repolarization, including the QTc interval and transmural dispersion of repolarization. METHODS A total of 75 patients were randomly allocated to receive 0.625 or 1.25 mg droperidol or 8 mg ondansetron. The QTc interval was calculated using Bazett's formula and the Framingham correction. The transmural dispersion of repolarization was determined as Tpeak -Tend time. RESULTS Transient QT prolongation, corrected with both formulae, followed 1.25 mg of droperidol 10 min after administration. No change in the QTc value was observed in the other groups. When corrected with Bazett's formula, QTc was prolonged above 480 ms in two patients receiving 1.25 mg droperidol (at the 10(th) and 20(th) minute of the study) and in one receiving ondansetron. No patients developed a QTc B prolongation over 500 ms. No increase above 480 ms was observed relative to the Framingham correction method. There were no significant differences in the Tpeak -Tend time either between or within the groups. CONCLUSION In men without cardiovascular disorders small doses (1.25 mg) of droperidol prophylaxis induced transient QTc prolongation without changes in transmural dispersion of repolarization. The apparently low risk of the drug applies only in low risk male patients with a low pro-QTc score.
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Affiliation(s)
- Krzysztof Tracz
- Department of Anaesthesiology and Intensive Therapy, Copernicus Medical Centre, Gdańsk, Poland
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Bolat E, Çelikbilek M, Sarıkaya S, Yılmaz YK, Doğan S, Özbakır Ö. Effects of balanced propofol sedation on QT, corrected QT, and P-wave dispersion on upper endoscopy. Anatol J Cardiol 2015; 16:328-32. [PMID: 26488380 PMCID: PMC5336780 DOI: 10.5152/anatoljcardiol.2015.6264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective: Combined sedation with propofol and benzodiazepines, known as balanced propofol sedation (BPS), was developed to increase patient comfort during endoscopy. However, the effects of BPS on P-wave dispersion (Pwd), QT interval, and corrected QT (QTc) interval after endoscopy have not been investigated. Methods: The study population consisted of 40 patients with BPS and 42 without sedation who were scheduled to undergo upper endoscopy in this cross-sectional prospective study. Patients with hypertension, diabetes mellitus, renal failure, chronic obstructive pulmonary disease, coronary artery disease, or valvular heart disease and those on medications that interfere with cardiac conduction times were excluded. Electrocardiograms (ECGs) was recorded in all patients pre-endoscopy and 10 min post-endoscopy. QT, QT dispersion (QTd), and Pwd were defined from 12-lead ECG. The QTc interval was calculated using Bazett’s formula. All analyses were performed using SPSS 15.0. Results: Post-endoscopy P max duration and Pwd were prolonged compared with baseline values (86±13 ms vs. 92±10 ms and 29±12 ms vs. 33±12 ms, respectively; p<0.05). Post-endoscopy QTc and QTd were decreased compared with baseline values, but these decreases were not statistically significant (431±25 ms vs. 416±30 ms and 62±28 ms vs. 43±22 ms, respectively; p>0.05). Conclusion: The present study showed that P-wave duration and Pwd values increased after endoscopy with a combination of midazolam and propofol sedation. Physicians should be made aware of the potential effects of BPS in terms on P-wave duration and Pwd values.
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Affiliation(s)
- Esef Bolat
- Department of Anesthesiology, Faculty of Medicine, Bozok University; Yozgat-Turkey.
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Abstract
INTRODUCTION Gastroparesis is a syndrome defined by delayed gastric emptying in the absence of mechanical obstruction. Gastroparesis has significant symptomatology and negative impacts on the patient's quality of life. AREAS COVERED This article reviews current treatment options for gastroparesis, recent advances in treatment and future directions that treatment may head. Current options are broadly divided into prokinetics and symptom modulators. Within each group, current modalities as well as recent advances are discussed according to agent mechanism of action. Lastly, findings regarding the cellular pathophysiology involved in gastroparesis will be briefly reviewed along with their implications for future treatments. EXPERT OPINION The numerous motor functions and neural inputs that control gastric motility are complex and not fully understood. Our lack of understanding of its pathophysiology has led to treatment options which are empirical, palliative and often ineffective. Newly intensified interest in the cellular pathophysiology behind gastroparesis provides promise for a new era of treatments. Identification of common cellular changes in gastroparesis has provided targets for treatment that may allow us to one day better treat the symptoms of gastroparesis related to its underlying pathophysiology. This is the future of gastroparesis therapy.
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Affiliation(s)
- Mark Malamood
- Temple University Hospital, Department of Internal Medicine , Philadelphia, PA , USA
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Lynch KL, Shapiro BJ, Coffa D, Novak SP, Kral AH. Promethazine use among chronic pain patients. Drug Alcohol Depend 2015; 150:92-7. [PMID: 25754939 PMCID: PMC4389782 DOI: 10.1016/j.drugalcdep.2015.02.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/24/2015] [Accepted: 02/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Concomitant use of opioids and promethazine has been reported in various subpopulations, including methadone maintenance patients, injection drug users, and at-risk teenagers. Promethazine is thought to potentiate the "high" from opioids. However, to date, the prevalence of promethazine use has not been determined among patients prescribed opioids for chronic pain. METHODS Urine samples from 921 patients prescribed opioids for chronic pain were analyzed for promethazine. Demographic data, toxicology results, and opioid prescription information were obtained through medical record abstraction. We assessed the prevalence and factors associated with promethazine use with bivariable and multivariable statistics. RESULTS The prevalence of promethazine-positive urine samples among chronic pain patients was 9%. Only 50% of promethazine-positive patients had an active prescription for promethazine. Having benzodiazepine-positive urine with no prescription for a benzodiazepine was statistically associated with promethazine use. Also, having a prescription for methadone for pain or being in methadone maintenance for the treatment of opioid dependence were both statistically associated with promethazine use. Chronic pain patients prescribed only a long-acting opioid were more likely to have promethazine-positive urines than patients prescribed a short-acting opioid. CONCLUSIONS The study provides compelling evidence of significant promethazine use in chronic pain patients. Promethazine should be considered as a potential drug of abuse that could cause increased morbidity in opioid-using populations.
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Affiliation(s)
- Kara L. Lynch
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA,Address Correspondence to this author at: University of California San Francisco, San Francisco General Hospital, 1001 Potrero Ave. NH2M16, San Francisco, CA 94110 Phone: 415-206-5477, Fax: 415-206-3045,
| | - Brad J. Shapiro
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA,Department of Psychiatry, University of California San Francisco, San Francisco, CA
| | - Diana Coffa
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA
| | - Scott P. Novak
- RTI International, Behavioral Health Epidemiology, Research Triangle Park, NC
| | - Alex H. Kral
- RTI International, Urban Health Program, San Francisco, CA
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Vonderlin N, Fischer F, Zitron E, Seyler C, Scherer D, Thomas D, Katus HA, Scholz EP. Anesthetic drug midazolam inhibits cardiac human ether-à-go-go-related gene channels: mode of action. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:867-77. [PMID: 25733807 PMCID: PMC4338257 DOI: 10.2147/dddt.s72765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Midazolam is a short-acting benzodiazepine that is in wide clinical use as an anxiolytic, sedative, hypnotic, and anticonvulsant. Midazolam has been shown to inhibit ion channels, including calcium and potassium channels. So far, the effects of midazolam on cardiac human ether-à-go-go-related gene (hERG) channels have not been analyzed. The inhibitory effects of midazolam on heterologously expressed hERG channels were analyzed in Xenopus oocytes using the double-electrode voltage clamp technique. We found that midazolam inhibits hERG channels in a concentration-dependent manner, yielding an IC50 of 170 μM in Xenopus oocytes. When analyzed in a HEK 293 cell line using the patch-clamp technique, the IC50 was 13.6 μM. Midazolam resulted in a small negative shift of the activation curve of hERG channels. However, steady-state inactivation was not significantly affected. We further show that inhibition is state-dependent, occurring within the open and inactivated but not in the closed state. There was no frequency dependence of block. Using the hERG pore mutants F656A and Y652A we provide evidence that midazolam uses a classical binding site within the channel pore. Analyzing the subacute effects of midazolam on hERG channel trafficking, we further found that midazolam does not affect channel surface expression. Taken together, we show that the anesthetic midazolam is a low-affinity inhibitor of cardiac hERG channels without additional effects on channel surface expression. These data add to the current understanding of the pharmacological profile of the anesthetic midazolam.
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Affiliation(s)
- Nadine Vonderlin
- Department of Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany
| | - Fathima Fischer
- Department of Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany
| | - Edgar Zitron
- Department of Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany ; German Centre for Cardiovascular Research, Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Claudia Seyler
- Department of Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniel Scherer
- Department of Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany
| | - Dierk Thomas
- Department of Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany ; German Centre for Cardiovascular Research, Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Hugo A Katus
- Department of Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany ; German Centre for Cardiovascular Research, Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Eberhard P Scholz
- Department of Internal Medicine III, University Hospital Heidelberg, Heidelberg, Germany
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Staikou C, Stamelos M, Stavroulakis E. Impact of anaesthetic drugs and adjuvants on ECG markers of torsadogenicity. Br J Anaesth 2014; 112:217-230. [DOI: 10.1093/bja/aet412] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Fazio G, Vernuccio F, Grutta G, Re GL. Drugs to be avoided in patients with long QT syndrome: Focus on the anaesthesiological management. World J Cardiol 2013; 5:87-93. [PMID: 23675554 PMCID: PMC3653016 DOI: 10.4330/wjc.v5.i4.87] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 03/05/2013] [Accepted: 03/29/2013] [Indexed: 02/06/2023] Open
Abstract
Long QT syndrome incidence is increasing in general population. A careful pre-, peri- and post-operative management is needed for patients with this syndrome because of the risk of Torsades de Pointes and malignant arrhythmias. The available data regarding prevention of lethal Torsades de Pointes during anesthesia in patients with long QT syndrome is scant and conflicting: only case reports and small case series with different outcomes have been published. Actually, there are no definitive guidelines on pre-, peri- and post-operative anesthetic management of congenital long QT syndrome. Our review focuses on anesthetic recommendations for patients diagnosed with congenital long QT syndrome furnishing some key points for preoperative optimization, intraoperative anesthetic agents and postoperative care plan, which could be the best for patients with c-long QT syndrome who undergo surgery.
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Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L. Clinical guideline: management of gastroparesis. Am J Gastroenterol 2013; 108:18-37; quiz 38. [PMID: 23147521 PMCID: PMC3722580 DOI: 10.1038/ajg.2012.373] [Citation(s) in RCA: 688] [Impact Index Per Article: 62.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This guideline presents recommendations for the evaluation and management of patients with gastroparesis. Gastroparesis is identified in clinical practice through the recognition of the clinical symptoms and documentation of delayed gastric emptying. Symptoms from gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain. Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying and, in diabetics, glycemic control. Patient nutritional state should be managed by oral dietary modifications. If oral intake is not adequate, then enteral nutrition via jejunostomy tube needs to be considered. Parenteral nutrition is rarely required when hydration and nutritional state cannot be maintained. Medical treatment entails use of prokinetic and antiemetic therapies. Current approved treatment options, including metoclopramide and gastric electrical stimulation (GES, approved on a humanitarian device exemption), do not adequately address clinical need. Antiemetics have not been specifically tested in gastroparesis, but they may relieve nausea and vomiting. Other medications aimed at symptom relief include unapproved medications or off-label indications, and include domperidone, erythromycin (primarily over a short term), and centrally acting antidepressants used as symptom modulators. GES may relieve symptoms, including weekly vomiting frequency, and the need for nutritional supplementation, based on open-label studies. Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. Most of these treatments are based on open-label treatment trials and small numbers. Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients. Attention should be given to the development of new effective therapies for symptomatic control.
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Affiliation(s)
- Michael Camilleri
- Department of Gastroenterology, Mayo Clinic, Rochester, MN 55905, USA.
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Kavanagh JJ, Grant GD, Anoopkumar-Dukie S. Low dosage promethazine and loratadine negatively affect neuromotor function. Clin Neurophysiol 2011; 123:780-6. [PMID: 21880544 DOI: 10.1016/j.clinph.2011.07.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 07/12/2011] [Accepted: 07/22/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Determine how the sedating antihistamine promethazine and non-sedating antihistamine loratadine at a dose of 10mg influence voluntary and involuntary motor processes in the hours following ingestion and the morning after ingestion. METHODS Eight healthy young adults were recruited into a human double-blind, placebo-controlled, three-way crossover study. Neuromotor function was examined using a battery of controlled reaction time, postural tremor, and heart rate variability measures. Neuromotor function was assessed 4 times for each of the promethazine, loratadine and placebo interventions; pre-ingestion, 1h post-ingestion, 2h post-ingestion, and the following day. RESULTS Self-perceived levels of drowsiness increased only after ingestion of promethazine. However, both antihistamines had negative effects on simple reaction time, choice reaction time, the RMS and peak power amplitude of postural tremor, and autonomic cardiac regulation. CONCLUSIONS The presence of selective neuromotor deficits following ingestion of promethazine and loratadine suggest that sedating and non-sedating antihistamines alter neuromotor function. It is possible that the H(1) antagonists used in this study have antimuscarinic effects, which may impact on the central dopaminergic system that plays a role in modulating several CNS processes associated with movement. SIGNIFICANCE Antihistamines are one of the most commonly procured over-the-counter medications. The current study suggests that taking non-sedating antihistamines to avoid the adverse drug reaction of drowsiness may not avoid unwanted motor control side-effects.
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Affiliation(s)
- Justin J Kavanagh
- School of Physiotherapy and Exercise Science, Griffith University, Gold Coast, Australia.
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