Psoriasis and Vascular Disease—Risk Factors and Outcomes: A Systematic Review of the Literature

Background  

Psoriasis afflicts 2-3% of the world’s population. Affected patients commonly have risk factors for cardiovascular disease (CVD). In addition, psoriasis is independently associated with CVD and mortality.     

Pleural Effusion in Meigs’ Syndrome—Transudate or Exudate?: Systematic Review of the Literature

Although Meigs’ syndrome is regarded as a well-defined entity, contradictory data on pleural fluid characteristics have been presented, with some papers classifying it as a transudate, whereas others stating that it is an exudate.The aims of the study were: (1) to evaluate pleural fluid characteristics in patients with Meigs’ syndrome and (2) to analyze the prevalence of transudative and exudative pleural effusion in relation to the applied definition of the syndrome.We performed a search through medical databases (MEDLINE, EMBASE, SCOPUS, and GOOGLE SCHOLAR) to identify papers on Meigs’ syndrome published between 1940 and 2013. Two authors independently reviewed each paper searching for prespecified data: (1) signs and symptoms, (2) tumor characteristics, (3) clinical and laboratory data on ascites, (4) clinical, radiological, and laboratory data on pleural fluid, (5) clinical course after tumor removal. All case reports were reclassified according to a new unequivocal classification of Meigs’ syndrome-related entities.A total of 653 papers were initially identified, and 454 articles reporting 541 patients were included in the final analysis. After reclassification according to our case definitions, there were 196, 113, and 108 patients defined as classic Meigs’ syndrome, nonclassic Meigs’ syndrome, and pseudo-Meigs’ syndrome, respectively. Significantly more patients presented with right-sided than left-sided and bilateral pleural effusions (P < 0.001). Median volume of withdrawn pleural fluid was 2950 (1500–6000) mL. The classification of pleural effusion with the use of Light''s criteria was possible in only 7 patients. In 6 of these patients pleural effusion met the criteria for an exudate. When the protein concentration > 3.0 g/dL was applied as a criterion of pleural exudate, 88.8% (80/90) of effusions were classified as exudates. Increasing the cut-off level to 3.5 g/dL resulted in only a modest decrease in the percentage of exudative effusions (81%, 73/90).Surprisingly few reports on Meigs’ syndrome present data reliably defining the character of pleural effusion. The available data indicate, however, that the majority of pleural effusions in patients with this entity are exudates. This finding may be a prerequisite for the verification of some earlier presented concepts.     

Growing Literature,Stagnant Science? Systematic Review,Meta-Regression and Cumulative Analysis of Audit and Feedback Interventions in Health Care

BACKGROUND

This paper extends the findings of the Cochrane systematic review of audit and feedback on professional practice to explore the estimate of effect over time and examine whether new trials have added to knowledge regarding how optimize the effectiveness of audit and feedback.

METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized trials of audit and feedback compared to usual care, with objectively measured outcomes assessing compliance with intended professional practice. Two reviewers independently screened articles and abstracted variables related to the intervention, the context, and trial methodology. The median absolute risk difference in compliance with intended professional practice was determined for each study, and adjusted for baseline performance. The effect size across studies was recalculated as studies were added to the cumulative analysis. Meta-regressions were conducted for studies published up to 2002, 2006, and 2010 in which characteristics of the intervention, the recipients, and trial risk of bias were tested as predictors of effect size.

RESULTS

Of the 140 randomized clinical trials (RCTs) included in the Cochrane review, 98 comparisons from 62 studies met the criteria for inclusion. The cumulative analysis indicated that the effect size became stable in 2003 after 51 comparisons from 30 trials. Cumulative meta-regressions suggested new trials are contributing little further information regarding the impact of common effect modifiers. Feedback appears most effective when: delivered by a supervisor or respected colleague; presented frequently; featuring both specific goals and action-plans; aiming to decrease the targeted behavior; baseline performance is lower; and recipients are non-physicians.

DISCUSSION

There is substantial evidence that audit and feedback can effectively improve quality of care, but little evidence of progress in the field. There are opportunity costs for patients, providers, and health care systems when investigators test quality improvement interventions that do not build upon, or contribute toward, extant knowledge.     

Impact of Parental HIV/AIDS on Children’s Psychological Well-Being: A Systematic Review of Global Literature

This review examines the global literature regarding the impact of parental HIV/AIDS on children’s psychological well-being. Fifty one articles reporting quantitative data from a total of 30 studies were retrieved and reviewed. Findings were mixed but tended to show that AIDS orphans and vulnerable children had poorer psychological well-being in comparison with children from HIV-free families or children orphaned by other causes. Limited longitudinal studies suggested a negative effect of parental HIV on children’s psychological well-being in an early stage of parental HIV-related illness and such effects persisted through the course of parental illness and after parental death. HIV-related stressful life events, stigma, and poverty were risk factors that might aggravate the negative impact of parental HIV/AIDS on children. Individual coping skills, trusting relationship with caregivers and social support were suggested to protect children against the negative effects of parental HIV/AIDS. This review underlines the vulnerability of children affected by HIV/AIDS. Culturally and developmentally appropriate evidence-based interventions are urgently needed to promote the psychological well-being of children affected by HIV/AIDS.     

Efficacy of Creative Arts Therapy in Treatment of Alzheimer’s Disease and Dementia: A Systematic Literature Review

This systematic literature review identifies existing evidence regarding the effectiveness of creative arts therapies among persons with memory loss and their care providers. A total of 112 articles were analyzed. Data from each article were extracted and synthesized to identify patterns in published results. Findings suggest that creative arts therapy is effective for treatment of behavioral and emotional challenges of the disease, but not for treatment of cognitive decline. However, small sample sizes, short (or nonexistent) follow-up, and the difficulty quantifying findings remain as challenges when interpreting the efficacy of creative arts therapy for persons with memory loss.     

Are Peer Interventions for HIV Efficacious? A Systematic Review

Behavioral interventions to prevent HIV or assist HIV-positive persons often incorporate peers, yet empirical support for their efficacy is only recently accumulating. We describe the results of a review of the global literature, identifying 117 studies evaluating the efficacy of peer-based interventions in the area of HIV/AIDS. About half were conducted in the developing world and half in Western nations. Across a range of populations and intervention modalities, the majority of studies provided some support for peer interventions according to outcome indicators in the domains of sexual risk behavior, attitudes and cognitions, HIV knowledge, and substance use. However, outcomes assessed using biomarkers and other non-self-report variables were less likely to indicate intervention efficacy. Overall, findings suggest that we can have some confidence in peer interventions, yet more data are needed demonstrating an effect in the most rigorous study designs and with outcomes that are not potentially affected by respondent bias.     

Access to Care After Massachusetts’ Health Care Reform: A Safety Net Hospital Patient Survey

BACKGROUND

Massachusetts’ health care reform substantially decreased the percentage of uninsured residents. However, less is known about how reform affected access to care, especially according to insurance type.

OBJECTIVE

To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type.

DESIGN AND PARTICIPANTS

We surveyed a convenience sample of 431 patients presenting to the Emergency Department of Massachusetts’ second largest safety net hospital between July 25, 2009 and March 20, 2010.

MAIN MEASURES

Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care.

KEY RESULTS

Patients with Commonwealth Care and Medicaid, the two forms of insurance most often newly-acquired under the reform, reported similar or higher utilization of and access to outpatient visits and rates of having a usual source of care, compared with the privately insured. Compared with the privately insured, a significantly higher proportion of patients with Medicaid or Commonwealth Care Type 1 (minimal cost sharing) reported delaying or not getting dental care (42.2 % vs. 27.1 %) or medication (30.0 % vs. 7.0 %) due to cost; those with Medicaid also experienced cost-related barriers to seeing a specialist (14.6 % vs. 3.5 %) or getting recommended tests (15.6 % vs. 5.9 %). Those with Commonwealth Care Types 2 and 3 (greater cost sharing) reported significantly more cost-related barriers to obtaining care than the privately insured (45.0 % vs. 16.0 %), to seeing a primary care doctor (25.0 % vs. 6.0 %) or dental provider (58.3 % vs. 27.1 %), and to obtaining medication (20.8 % vs. 7.0 %). No differences in cost-related barriers to preventive care were found between the privately and publicly insured.

CONCLUSIONS

Access to care improved less than access to insurance following Massachusetts’ health care reform. Many newly insured residents obtained Medicaid or state subsidized private insurance; cost-related barriers to access were worse for these patients than for the privately insured.     

Recognition of Depression by Non-psychiatric Physicians—A Systematic Literature Review and Meta-analysis

BACKGROUND Depression, with up to 11.9% prevalence in the general population, is a common disorder strongly associated with increased morbidity. The accuracy of non-psychiatric physicians in recognizing depression may influence the outcome of the illness, as unrecognized patients are not offered treatment for depression. OBJECTIVES To describe and quantitatively summarize the existing data on recognition of depression by non-psychiatric physicians. METHODS We searched the following databases: MEDLINE (1966–2005), Psych INFO (1967–2005) and CINAHL (1982–2005). To summarize data presented in the papers reviewed, we calculated the Summary receiver operating characteristic (ROC) and the summary sensitivity, specificity and odds ratios (ORs) of recognition, and their 95% confidence intervals using the random effects model. MEASUREMENTS AND MAIN RESULTS The summary sensitivity, specificity, and OR of recognition using the random effects model were: 36.4% (95% CI: 27.9–44.8), 83.7% (95% CI: 77.5–90.0), and 4.0 (95% CI: 3.2–4.9), respectively. We also calculated the Summary ROC. We performed a metaregression analysis, which showed that the method of documentation of recognition, the age of the sample, and the date of study publication have significant effect on the summary sensitivity and the odds of recognition, in the univariate model. Only the method of documentation had a significant effect on summary sensitivity, when the age of the sample and the date of publication were added to the model. CONCLUSION The accuracy of depression recognition by non-psychiatrist physicians is low. Further research should focus on developing standardized methods of documenting non-psychiatric physicians’ recognition of depression.     

A Systematic Review and Meta-Analysis of the Treatment for Barrett’s Esophagus

As evidence-based strategies to the clinical management of Barrett’s esophagus (BE) are lacking, we have carried out a systematic review and meta-analysis of all published randomized controlled trials with the aim of evaluating the value of different approaches in the treatment of BE. Searches were conducted in the databases PUBMED, EMBASE, and Cochrane Library. Thirteen randomized clinical trials that fulfilled the inclusion criteria and addressed the clinical questions of this analysis were assessed in more detail. Based on our search, neither the pharmacological nor surgical therapies currently available for reflux appear to achieve complete regression of BE and the elimination of the cancer risk associated with it. In contrast, endoscopic ablative techniques are capable of achieving endoscopic and histological reversal of BE, with ablation by argon plasma coagulation (APC) appearing to be more effective than treatment with photodynamic therapy (PDT) [odds ratio (OR) 3.46, 95% confidence interval (CI) 1.67–7.81, P = 0.0008]. There was no statistically significant difference between APC and multipolar electrocoagulation (MPEC) in terms of the efficacy to achieve regression of BE (OR 2.01, 95% CI 0.77–5.23, P = 0.15). In conclusion, there have been only a limited number of randomized controlled trials that compare treatments for BE. The pharmacological therapy, antireflux surgery, and endoscopic ablative techniques are promising in terms of treating BE, but the studies carried out to date have had no adequate power to assess the effect of treatment on reducing and preventing progression to adenocarcinoma.     

Does the Addition of Zinc Oxide Nanoparticles Improve the Antibacterial Properties of Direct Dental Composite Resins? A Systematic Review

A promising approach to improve the poor antibacterial properties of dental composite resins has been the addition of metal oxide nanoparticles into the resin matrix. This systematic review aimed to determine whether the addition of zinc oxide nanoparticles (ZnO-NPs) improves the antibacterial properties of direct dental composite resins. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered with the PROSPERO database: CRD42019131383. A systematic literature search was conducted using the following databases: Medline (Ovid), the Cochrane Library, SCOPUS, CINAHL, Web of Science, Trove, Google Scholar, World Cat, and OpenGrey. The initial search retrieved 3178 results, which were then screened against inclusion and exclusion criteria, resulting in a total of four studies that were eligible for qualitative synthesis within this review. All the included studies were in vitro non-randomized post-test design experimental studies. A lack of congruity in the results obtained from these studies that used different tests to evaluate antibacterial activity was evident. Although some studies demonstrated a significant improvement of antibacterial properties in composites containing at least 1% ZnO-NPs (wt %), they are unlikely to present any clear clinical advantage due to the short lifetime of observed antibacterial properties.     

Treatment of Coronary In-Stent Restenosis: A Systematic Review

Coronary stent implantation has significantly improved percutaneous coronary intervention and enabled the management of early complications of plain balloon angioplasty. However, a new complication has accompanied these improvements: in-stent restenosis (ISR) arising from neointimal hyperplasia. ISR after coronary angioplasty is currently one of the main limitations of this method, leading to the recurrence of exertional angina pectoris or acute coronary syndromes. The clinical incidence of ISR after bare-metal stent (BMS) implantation is approximately 20%–35%. The use of drug-eluting stents (DES) has led to a further decrease in the occurrence of ISR to 5%–10%. Evidence resulting from controlled clinical studies suggests that DES and drug-eluting balloon catheters (DEB) provide the best clinical and angiographic results in the treatment of ISR. We undertook a systematic review of the pathophysiology, diagnostics and treatment options for BMS- and DES-ISR. We discuss recent randomised studies, comparing different DES or DEB used for BMS or DES-ISR treatment, as well as the use of new biovascular scafolds and the topic of scafold restenosis.     

Is Caffeine Addictive?—A Review of the Literature

The common-sense use of the term addiction is that regular consumption is irresistible and that it creates problems. Caffeine use does not fit this profile. Its intake does no harm to the individual or to society and its users are not compelled to consume it. Though cessation of regular use may result in symptoms such as headache and lethargy, these are easily and reliably reversed by ingestion of caffeine. Some have argued that continued caffeine use is an attempt to suppress low grade withdrawal symptoms such as sleepiness and lethargy. In some moderate users, this is possible; however, in experimental contexts, the phenomenon is too inconsistent to constitute a reliably valid syndrome.     

Does Surgical Repair of Moderate Ischemic Mitral Regurgitation Improve Survival? A Systematic Review

Mitral regurgitation (MR) is one of the common complications in myocardial infarction (MI) patients. Almost half of the post MI patients have MR (ischemic MR)¹⁷ which is moderate to severe (grade II-IV). Whether there is a mortality benefit of performing mitral valve repair (MVR) along with coronary artery bypass grafting (CABG) in patients with post MI moderate MR remains inconclusive. Literature search was done from PubMed, Google scholar, Ovid, and Medline databases. Studies which included post MI patients with moderate ischemic MR and reported mortality outcomes of performing CABG and MVR were chosen for the systematic review. Our preliminary literature search identified 194 studies, of which 11 studies met our inclusion criteria. Nine studies showed no survival benefit of performing simultaneous MVR and CABG. One study demonstrated survival benefit of performing CABG plus MVR only in the New York Heart Association (NYHA) class III–IV, and one study suggested survival benefit of performing CABG plus MVR as compared to CABG alone in patient with ischemic MR irrespective of preoperative NYHA functional class. Review of current literature showed mixed results in terms of improvement in functional status but failed to show any survival benefit of performing MVR along with CABG. Limitations of studies include small sample size, difference in baseline demographic variables, and short follow-up period which might influence the outcome of the study. Prospective randomized studies are required to establish clear benefit of performing MVR simultaneously with CABG.     

A Systematic Review of Psychological Functioning of Children Exposed to HIV: Using Evidence to Plan for Tomorrow’s HIV Needs

Prevention of mother to child transmission of HIV can virtually eliminate paediatric HIV infection. Studies are needed to understand child development outcomes for children exposed to HIV in utero but born HIV negative (HIV affected children). This systematic review examined cognitive, developmental and behavioural outcomes for HIV affected children compared to control unexposed and uninfected children. Key word searches of electronic databases generated 1,739 hits and 11 studies with adequate quality design and measures of standardised cognitive, behavioural and developmental indices. Cognitive performance, behaviour and developmental delay were measured with 15 different standardised scales from 650 HIV affected children, 736 control children and 205 HIV positive children. Performance scores for HIV affected children were significantly lower than controls in at least one measure in 7/11 studies. An emerging pattern of delay seems apparent. HIV affected children will grow in number and their development needs to be monitored and provided for.     

Does Vitamin E Improve the Outcomes of Pediatric Nonalcoholic Fatty Liver Disease? A Systematic Review and Meta-analysis

Background and Aims:

To systemically evaluate the efficacy of adjuvant vitamin E on the outcomes of nonalcoholic fatty liver disease (NAFLD) and/or nonalcoholic steatohepatitis (NASH) in children.

Materials and Methods:

We searched MEDLINE, PUBMED, EMBASE, the Cochrane Central Register Controlled Trials, and the Cochrane Database of Systematic Reviews over the period between January 1980 and September 2012 for the studies that examined the role of adjuvant vitamin E given at any dose or duration, alone or in combination with other interventions, on the outcome of pediatric NAFLD. The outcomes are alanine aminotransferase (ALT) normalization and histological improvement.

Results:

Five randomized trials were eligible to be included in our analysis, with a total of 270 participants. There was no statistically significant difference in the effect of adjuvant vitamin E on normalizing serum ALT [risk ratio (RR) =1.18, confidence interval (CI) =0.92-1.53, P = 0.77 for heterogeneity, I² = 0%]. Sensitivity analysis showed that using higher doses of vitamin E, a longer duration of therapy or adding vitamin C did not change the effect on the measured outcome. Only two studies looked at histological changes as an outcome. We observed substantial heterogeneity between the two studies.

Conclusions:

Our meta-analysis did not find a significant effect of adjuvant vitamin E over placebo in normalizing serum ALT. Data on the long-term effect of adjuvant vitamin E on histological improvements in NAFLD patients are still lacking. Larger, well-designed randomized controlled trials (RCTs) in children with histological endpoints are still needed to answer this question.     

The Use of Cytokeratin Stain to Distinguish Barrett’s Esophagus from Contiguous Tissues: A Systematic Review

Our objective was to systematically review the existing literature regarding the use of cytokeratin (CK) stain in differentiating Barrett’s esophagus (BE) from tissues of the gastric cardia, corpus, or antrum, with or without intestinal metaplasia (IM). Pubmed was searched for full publications in English (1983–2005) addressing the use of CK for differentiation of BE from contiguous tissues. Information was collected on the study sample, blinding, the methods used for CK staining, and for defining and applying the gold standard tests. Test characteristics were obtained or calculated. Sixteen studies (containing 46 comparisons) met the inclusion and exclusion criteria. Immunostaining for CK 7 and 20 was generally highly specific in distinguishing long-segment BE from antrum IM, fundus IM, or noncardiac gastric IM; 27 comparisons showed statistically significant differences. However, only 8 of 15 comparisons (6 of 12 studies) reported significant differences in CK staining patterns between BE and gastric cardia IM with a high sensitivity (89%–100%) and specificity (83%–100%) for long-segment BE and lower estimates for short-segment BE, while the other seven comparisons showed no significant differences and a very low sensitivity. Examination by a blinded pathologist was reported in five of six positive studies and in only one of six of the negative studies. In addition, variation in the patient populations, use of surgical resection versus endoscopic biopsies, and biopsy sampling technique in endoscopic studies may have accounted for these differences. Finally, two studies did not find significant differences in CK staining patterns between BE and normal cardiac mucosa. In conclusions, CK immunostaining has not performed well in differentiating BE, especially short-segment BE, from cardia IM. There seems to be a spectrum bias where the accuracy varies with different tested populations. CK immunostaining distinguished well between BE and IM in noncardiac segments of the stomach; however, these comparisons are not clinically relevant.     

Listening to Patients’ Own Goals: A Key to Goals of Care Decisions in Cardiac Care

Cardiology spans the spectrum of patient care from the stable outpatient to acute preterminal inpatient. This article provides a narrative account of challenges, learnings, and experiences that we have used as a means to reflect on our own goals of care (GOC) conversations. We detail experiential and evidence-based insights on identifying and overcoming common GOC discussion barriers and building frameworks for effectively addressing patient interests and values through the course of medical care. Existing practices around advance care planning result in GOC discussions being postponed in favour of task-focused medical care and physicians avoiding these discussions out of a perceived lack of time. Physicians struggle to be flexible with existing care plans and in an effort to respect patient autonomy sometimes inappropriately relegate care decisions solely onto patients and families. Instead, we suggest conceiving of the GOC process as involving multiple conversations, taking time to get to know a patient and their personal priorities, sharing a patient’s expected medical course when having GOC discussions, admitting prognostic uncertainty when it exists, giving patients and families the space to adjust to these discussions and remaining flexible with plans as a patient’s health course fluctuates. Furthermore, our approach stresses being decisive and proactive in providing GOC recommendations when properly equipped to do so and enables recognition and recourse for patient-physician goal misalignment. In conclusion, we stress the importance of advising a treatment course that is responsive to patient considerations via practical communication strategies.