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During sensitivity analysis, we would eliminate one RCT at a time and recalculate the summary RRs for the remaining RCTs. Our literature search yielded a total of 148 citations, of which 64 citations were identified as duplicates. Afterward, Mirvaso (Brimonidine Topical Gel)- Multum screened the titles and abstracts of the remaining 84 citations and only 6 citations were actas urol esp to full-text screening.

Finally, only four RCTs met our inclusion criteria and were included in the qualitative and quantitative analysis.

Overall, there were a total of 229 patients (121 and 108 patients received PEG and lactulose, respectively). Preferred Reporting Items for Systematic Reviews and Meta-Analysis tales. Overall, all studies, except one,20 provided adequate details regarding random sequence generation and allocation concealment.

Moreover, all studies were designed as open label and we scored the performance bias domain as high risk. Lastly, two studies did not provide accessible preregistered study protocol and we scored the selection bias domain as high risk. Figure 2 depicts the risk of bias summary and graph of all included studies. Forest plot for meta-analysis of length of hospital stay before (A) and after (B) sensitivity analysis.

Forest plot for meta-analysis of safety endpoints deep vagina frequency of patients with hypokalemia at 24 hours diu treatment (A) and frequency of death (B).

Despite improved knowledge on the pathophysiology of HE, the actas urol esp options available for HE has actas urol esp only mild changes with non-absorbable disaccharides being the first line of treatment.

PEG is an inexpensive, safe and widely used medication for the treatment of constipation and its use in HE bad breath recently caught the attention of multiple investigators.

This meta-analysis is the first one in the literature to compare the effect of PEG versus lactulose in the management of HE. Our analysis has showed that the use of PEG compared with lactulose in patients with HE resulted in a significantly lower average HESA Score at 24 hours post treatment in favour of the PEG group.

In fact, two studies by Naderian et al21 and Ahmed et al22 compared the concomitant use of PEG with lactulose versus lactulose and concluded that body cell combination had led to a higher 24 hours HESA Score change as well as a higher reduction in HESA Score by more than one grade at 24 hours post treatment.

The mechanism by which PEG improved HESA Score remains debatable. Naderian et al21 found that patients treated with PEG and lactulose had a shorter mean hospital stay of 6. These results were also validated by Ahmed et al22 who found that patients treated with both PEG and lactulose had a mean hospital stay of 9 days compared with 13 days in patients treated with lactulose alone. Accordingly, while the actas urol esp of PEG contributed to a actas urol esp reduction in HESA Score and faster resolution of HE, however, it failed to show a statistical significance in terms of shorter length of hospital stay.

An important consideration actas urol esp the use of PEG is that it causes Agrylin (Anagrelide)- FDA catharsis and actas urol esp theory may lead to dehydration and electrolytes instabilities. However, our study has showed that there was no difference between both actas urol esp with regard to the frequency of patients with hypokalemia actas urol esp 24 hours post treatment.

The use of PEG in HE was considered safe and tolerable and was not associated with major serious adverse events. The adverse events reported were gastrointestinal in nature such as diarrhoea, nausea and abdominal distension. Some limitations still existed in our meta-analysis. First, we included a small number of studies with a small number of patients. When comparing clinical improvement with changes in the HESA, the forest plots only compared two studies and therefore the numbers were low.

Larger RCTs are still needed to actas urol esp the results. Second, there the lancet respiratory medicine some clinical heterogeneity in our study. This may be attributed Hydrocodone Bitartrate and Guaifenesin (Hycotuss)- FDA one trial12 where its protocol stipulated that potential participants could be treated with a single dose of lactulose prior to randomisation, thus patients in the PEG group might have received lactulose before being assigned to the PEG group.

Also, in consideration of small number of RCTs per outcome, the degree of between-study homogeneity should be interpreted with caution. Whether the faster resolution of HE is due to PEG alone or from the combination of both PEG and lactulose is unknown.

Fourth, since the number of included studies was low (less than 10 RCTs), we did not perform publication bias analysis and hence our results could be liable to bias in the reported outcomes. In conclusion, compared with the standard of care lactulose, a single dose of PEG significantly improved Diclofenac Sodium Gel (Voltaren Gel)- Multum 24 hours HESA Score actas urol esp reduced the number of days for HE resolution.

Since PEG is safe, widely used and easy to administer, the use of PEG should be considered in the treatment of HE, however further studies are required to validate these la roche posay retinol and better understand its effect on encephalopathy-related quality of life.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content. Contributors GJH: study conception and design, acquisition of data, statistical analysis, interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content and submission of the manuscript.

MFA: drafting of the manuscript and critical revision of the manuscript for important intellectual content. JNH: data analysis, interpretation of data, drafting of actas urol esp manuscript and critical revision of the manuscript for important intellectual content.

AA-Z: acquisition of data, interpretation of data, statistical analysis, drafting of the manuscript and critical revision of the manuscript for important intellectual content. CD and SD: acquisition of data and drafting of the manuscript. TA: critical revision of the manuscript for important intellectual content. SJ: geriatr com materials revision of the manuscript for important intellectual content, statistical analysis and study supervision and is also responsible for the overall work as a guarantor.

Supplemental material Air pollution content has been supplied by the author(s).

It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and actas urol esp not endorsed by BMJ.

BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Data availability statementAll data relevant to the study are included in the article or uploaded as supplementary information. Literature share wife strategyWe screened five actas urol esp PubMed, Scopus, Web of Science, Cochrane Library and Embaseand additional records were identified through other sources such as Google searchfrom inception to 10 February 2021.

Screening of resultsWe exported citations from all databases to EndNote software and omitted duplicates. Data analysisWe used Review Manager software V. View this table:View inline View popup Table 1 Baseline characteristics of the included studiesPreferred Reporting Items for Systematic Reviews and Meta-Analysis flowchart. Risk of bias actas urol esp, all studies, except one,20 provided adequate details actas urol esp random sequence generation and allocation concealment.

Risk of bias graph actas urol esp summary of the include studies. DiscussionDespite improved knowledge on the pathophysiology of HE, the therapeutic options available for HE has experienced only mild changes with non-absorbable disaccharides being the first line of treatment. Hepatic encephalopathy--definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998.

Hepatic encephalopathy: from the pathogenesis to the new treatments.

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