The neutrophil‐to‐lymphocyte ratio as a marker of chronic obstructive pulmonary disease and its exacerbations: A systematic review and meta‐analysis

Introduction

The main white blood cell populations, neutrophils and lymphocytes, are involved in the pathophysiology of chronic obstructive pulmonary disease (COPD). We conducted a systematic review and meta‐analysis of studies investigating the relationship between the neutrophil to lymphocyte ratio (NLR, a marker of subclinical inflammation), presence of COPD, and its exacerbations.

Methods

A comprehensive literature search was conducted in Pubmed, Web of Science and Scopus databases; two investigators independently reviewed suitable studies.

Results

Nine studies, from 247 initially identified, were included in the meta‐analysis. Seven studies, in 775 COPD patients with stable disease and 496 healthy controls, showed a significant increase in NLR values in stable COPD (standardised mean difference, SMD, 0.773, 95% CI 0.410‐1.136; P < 0.001). Furthermore, in six studies in 527 COPD patients with acute exacerbation and 620 COPD patients with stable disease, NLR values were significantly higher in patients with exacerbations (random effects SMD 0.850, 95% CI 0.549‐1.151; P < 0.001).

Conclusions

Our meta‐analysis showed that NLR values are significantly higher in stable COPD patients when compared to healthy individuals, although the magnitude of the difference is reduced after trim and fill adjustment, and in patients with COPD exacerbations when compared to patients with stable disease. Further studies, in larger cohorts, are needed to confirm whether the NLR is a useful tool in discriminating between COPD patients with stable disease, those with acute exacerbations, and subjects without the disease.     

A case‐control study and meta‐analysis reveal the association between COX‐2 G‐765C polymorphism and primary end‐stage hip and knee osteoarthritis

Background

Osteoarthritis (OA) is a popular arthrosis featured as pain, limited joint activity, and deformity. Cyclooxygenase‐2 (COX‐2) has been reported to be up‐regulated in arthritic tissues and is integral to the progression of osteoarthritis (OA). Previous studies showed the COX‐2 promoter G‐765C polymorphism could influence COX‐2 expression. However, the relationship between the variant and OA risk is contrasting.

Methods

We conducted a case‐control study with 196 primary end‐stage hip and knee OA cases and 196 controls in a Chinese Han population. Subsequently, we integrated this case‐control study in a meta‐analysis to acquire greater statistical power. The results from our case‐control study using MassARRAY genotyping technology and binary logistic regression statistical methods.

Results

The variant carriers in the Chinese Han population had a lower primary end‐stage hip and knee OA susceptibility (C vs G: OR = 0.350, 95%CI: 0.154‐0.797, P = .012; GC vs GG: adjusted OR = 0.282, 95%CI: 0.118‐0.676, P = .005). Stratification studies indicated that a higher GC frequency in women decreased not only knee OA susceptibility but also unilateral knee OA risk. The meta‐analysis showed that the variant exhibited a significantly decreased OA risk through comparisons involving allelic, homozygous, heterozygous, and dominant models.

Conclusion

Our findings suggest that the COX‐2 G‐765C polymorphism exerts a protective effect against primary end‐stage knee osteoarthritis in a female Chinese Han population.

     

Ketamine for chronic non‐cancer pain: A meta‐analysis and trial sequential analysis of randomized controlled trials

Background

Ketamine has been suggested to be efficient in relieving chronic pain. However, there is inconsistency across studies investigating the effect of ketamine for chronic pain management. We aimed to perform a meta‐analysis in order to assess the efficacy of this compound during chronic non‐cancer pain conditions.

Methods

The study consisted in a meta‐analysis of clinical trials comparing ketamine to a placebo during chronic non‐cancer pain. The primary endpoint of this study was pain relief 4 weeks after the beginning of treatment. Secondary outcomes were: pain relief 1, 2, 8 and 12 weeks after the beginning of treatment and incidence of psychedelic manifestations.

Results

Six studies were included in this meta‐analysis. Overall, 99 patients received ketamine and 96 received placebo. Ketamine did not decrease pain intensity at 4 weeks (MD (on a 0 to 10 scale) = ?1.12 [?2.33, 0.09], GRADE evidence: very low). However, analysing studies with no high‐risk bias found ketamine to decrease pain intensity at 4 weeks and increased the level of GRADE evidence to moderate. Trial sequential analysis confirmed the overall result and revealed the lack of power of this meta‐analysis. Ketamine also decreased pain intensity at all other evaluated points in time. Ketamine increased the incidence of psychedelic manifestations in comparison to placebo.

Conclusion

Results of this meta‐analysis found moderate evidence suggesting the efficacy of ketamine during chronic pain. Further studies are warranted to conclude about the effect of ketamine during chronic pain conditions and to determine optimal administration regimes of this agent during this condition.

Significance

Ketamine has been found interesting for managing chronic pain. We performed a meta‐analysis aiming to confirm those results. Ketamine was found efficient in alleviating pain up to 12 weeks after the beginning of treatment. However, overall evidence favouring the use of this compound was very low.

     

Capacity for care: meta‐ethnography of acute care nurses' experiences of the nurse‐patient relationship

Aims

To synthesize evidence and knowledge from published research about nurses' experiences of nurse‐patient relationships with adult patients in general, acute inpatient hospital settings.

Background

While primary research on nurses' experiences has been reported, it has not been previously synthesized.

Design

Meta‐ethnography.

Data sources

Published literature from Australia, Europe, and North America, written in English between January 1999–October 2009 was identified from databases: CINAHL, Medline, British Nursing Index and PsycINFO.

Review methods

Qualitative studies describing nurses' experiences of the nurse‐patient relationship in acute hospital settings were reviewed and synthesized using the meta‐ethnographic method.

Results

Sixteen primary studies (18 papers) were appraised as high quality and met the inclusion criteria. The findings show that while nurses aspire to develop therapeutic relationships with patients, the organizational setting at a unit level is strongly associated with nurses' capacity to build and sustain these relationships. The organizational conditions of critical care settings appear best suited to forming therapeutic relationships, while nurses working on general wards are more likely to report moral distress resulting from delivering unsatisfactory care. General ward nurses can then withdraw from attempting to emotionally engage with patients.

Conclusion

The findings of this meta‐ethnography draw together the evidence from several qualitative studies and articulate how the organizational setting at a unit level can strongly influence nurses' capacity to build and sustain therapeutic relationships with patients. Service improvements need to focus on how to optimize the organizational conditions that support nurses in their relational work with patients.     

Reduced‐dose direct oral anticoagulants in the extended treatment of venous thromboembolism: a systematic review and meta‐analysis

Essentials

• In venous thromboembolism (VTE), benefits of extended treatment are balanced by bleeding risks.
• This is a meta‐analysis of reduced‐dose direct oral anticoagulants (DOACs) in extended treatment.
• Reduced‐dose DOACs are as effective as full anticoagulation with bleeding risks similar to placebo.
• Reduced‐dose DOACs are an attractive option for patients in the extended phase of VTE treatment.

Summary

Background

Extended‐duration anticoagulation is beneficial for preventing recurrent venous thromboembolism (VTE). Reduced‐dose direct oral anticoagulants (DOACs) may be preferable if they preserve efficacy and cause less bleeding. We conducted a systematic review and meta‐analysis of trials comparing reduced‐dose DOACs with full‐dose DOACs and aspirin or placebo in the extended phase of VTE treatment.

Methods

A literature search was conducted by use of the MEDLINE, EMBASE and CINAHL databases, supplemented by hand‐searching. One thousand three hundred and ninety‐nine titles were screened, with data from accepted studies being extracted by two independent reviewers. Major outcomes analyzed included recurrent VTE and major and clinically relevant non‐major bleeding events, presented as risk ratios (RRs) and 95% confidence intervals (CI).

Results

Two trials met the prespecified inclusion criteria. Data from 5847 patients were analyzed for efficacy outcomes, and from 5842 patients for safety outcomes. Reduced‐dose DOACs were as effective as full‐dose treatment in preventing recurrent VTE at 1 year (RR 1.12 [95% CI 0.67–1.87]), and more effective than aspirin or placebo (RR 0.26 [95% CI 0.14–0.46]). Rates of major or clinically relevant non‐major bleeding events were similar between patients receiving reduced‐dose DOACs and and those receiving aspirin or placebo (RR 1.19 [95% CI 0.81–1.77]). There was a trend towards less bleeding when reduced‐dose and full‐dose DOACs were compared (RR 0.74 [95% CI 0.52–1.05]).

Conclusions

Extended‐duration treatment of VTE with reduced‐dose DOACs may be as efficacious as full‐dose treatment, with rates of major bleeding being similar to those in patients receiving treatment with aspirin or placebo, but further long‐term studies are needed.

     

A systematic review and Bayesian network meta‐analysis of risk of intracranial hemorrhage with direct oral anticoagulants

Essentials

• Risk of intracranial hemorrhage (ICH) may differ between direct oral anticoagulants (DOACs).
• We compared the risk of ICH between DOACs using network meta‐analysis.
• Dabigatran 110 mg and 150 mg were safer than rivaroxaban on Bayesian analysis.
• Dabigatran 110 mg ranked as the safest DOAC while rivaroxaban ranked last.

Summary

Background

The comparative risk of intracranial hemorrhage (ICH) among direct oral anticoagulants (DOACs) (dabigatran, rivaroxaban, apixaban and edoxaban) remains unclear.

Objective

To determine the difference in risk of ICH between DOACs

Methods

Seventeen randomized controlled trials (RCTs) were selected using PubMed/MEDLINE, EMBASE and CENTRAL (Inception, 31 December 2017). Estimates were reported as odds ratio (OR) with 95% credible interval (CR.I) in Bayesian network meta‐analysis (NMA), and OR with 95% confidence interval (CI) in traditional meta‐analyses. Relative ranking probability of each group was generated based on surface under the cumulative ranking curve (SUCRA).

Results

In NMA of 116 618 patients from 17 RCTs (apixaban = 19 495 patients, rivaroxaban = 14 157 patients, dabigatran = 16 074 patients, edoxaban = 11 652 patients, and comparator = 55 315 patients), all DOACs were safer than warfarin for risk of ICH. Dabigatran 110 mg ranked as the safest drug (SUCRA, 0.85) and reduced the risk of ICH by 56% compared to rivaroxaban (OR, 0.44; 95% Cr.I, 0.22–0.82). Pairwise meta‐analysis validated these findings, showing that DOACs were safer than warfarin (OR, 0.46; 95% CI, 0.35–0.59). Subgroup analysis showed that the benefit was present when DOACs were used in non‐valvular atrial fibrillation (NVAF) (OR, 0.51; 95% CI, 0.38–0.68) or venous thromboembolism (VTE) (OR, 0.32; 95% CI, 0.18–0.58).

Conclusion

Dabigatran 110 mg may be the safest choice among any anticoagulant regarding risk of ICH. Both dabigatran 110 mg and 150 mg were safer than rivaroxaban.

     

Complementary and alternative medicine for treatment of irritable bowel syndrome

OBJECTIVE

To review the evidence supporting selected complementary and alternative medicine approaches used in the treatment of irritable bowel syndrome (IBS).

QUALITY OF EVIDENCE

MEDLINE (from January 1966), EMBASE (from January 1980), and the Cochrane Database of Systematic Reviews were searched until March 2008, combining the terms irritable bowel syndrome or irritable colon with complementary therapies, alternative medicine, acupuncture, fiber, peppermint oil, herbal, traditional, yoga, massage, meditation, mind, relaxation, probiotic, hypnotherapy, psychotherapy, cognitive therapy, or behavior therapy. Results were screened to include only clinical trials, systematic reviews, and meta-analyses. Level I evidence was available for most interventions.

MAIN MESSAGE

Soluble fibre improves constipation and global IBS symptoms. Peppermint oil alleviates IBS symptoms, including abdominal pain. Probiotic trials show overall benefit for IBS but there is little evidence supporting the use of any specific strain. Hypnotherapy and cognitive-behavioural therapy are also effective therapeutic options for appropriate patients. Certain herbal formulas are supported by limited evidence, but safety is a potential concern. All interventions are supported by systematic reviews or meta-analyses.

CONCLUSION

Several complementary and alternative therapies can be recommended as part of an evidence-based approach to the treatment of IBS; these might provide patients with satisfactory relief and improve the therapeutic alliance.     

Major bleeding risks of different low‐molecular‐weight heparin agents: a cohort study in 12 934 patients treated for acute venous thrombosis

Essentials

• Low‐molecular‐weight‐heparins (LMWH) kinetics differ which may result in different bleeding risks.
• A cohort of 12 934 venous thrombosis patients on LMWH was followed until major bleeding.
• The absolute major bleeding risk was low among patients registered at the anticoagulation clinic.
• Once‐daily dosing was associated with a lower bleeding risk as compared with twice‐daily.

Summary

Background

Low‐molecular‐weight heparins (LMWHs) are considered members of a class of drugs with similar anticoagulant properties. However, pharmacodynamics and pharmacokinetics between LMWHs differ, which may result in different bleeding risks. As these agents are used by many patients, small differences may lead to a large effect on numbers of major bleeding events.

Objectives

To determine major bleeding risks for different LMWH agents and dosing schedules.

Methods

A cohort of acute venous thrombosis patients from four anticoagulation clinics who used an LMWH and a vitamin K antagonist were followed until they ceased LMWH treatment or until major bleeding. Exposures were classified according to different types of LMWHs and for b.i.d. and o.d. use. Cumulative incidences for major bleeding per 1000 patients and risk ratios were calculated and adjusted for study center.

Results

The study comprised 12 934 patients with a mean age of 59 years; 6218 (48%) were men. The cumulative incidence of major bleeding was 2.5 per 1000 patients (95% confidence interval [CI], 1.7–3.5). Enoxaparin b.i.d. or o.d. was associated with a relative bleeding risk of 1.7 (95% CI, 0.2–17.5) compared with nadroparin o.d. In addition, a nadroparin b.i.d. dosing schedule was associated with a 2.0‐fold increased major bleeding risk (95% CI, 0.8‐5.1) as compared with a nadroparin o.d. dosing schedule.

Conclusions

Absolute major bleeding rates were low for all LMWH agents and dosing schedules in a large unselected cohort. Nevertheless, twice‐daily dosing with nadroparin appeared to be associated with an increased major bleeding risk as compared with once‐daily dosing, as also suggested in a meta‐analysis of controlled clinical trials.     

Homoarginine and all‐cause mortality: A systematic review and meta‐analysis

Background

Homoarginine, a basic amino acid and analogue of L‐arginine, has been shown to exert salutary effects on vascular homoeostasis, possibly through interaction with the enzymes nitric oxide synthase and arginase. This might translate into improved survival outcomes, particularly in subjects with moderate‐high cardiovascular risk. We conducted a systematic review and meta‐analysis to investigate the association between circulating homoarginine concentrations and all‐cause mortality in observational studies of human cohorts.

Materials and methods

Studies reporting baseline circulating homoarginine concentrations and all‐cause mortality as outcome were searched using the MEDLINE, Scopus and Cochrane databases until January 2018. Hazard ratios (HRs) with 95% confidence intervals (CIs) derived from multivariate Cox's proportional‐hazards analysis were extracted from individual studies.

Results

A total of 13 studies in 11 964 participants were included in the final analysis. Homoarginine concentrations were inversely associated with all‐cause mortality (HR 0.64, 95% CI 0.57‐0.73). This association remained significant in participant sub‐groups with predominant cardiovascular disease (HR 0.64, 95% CI 0.55‐0.76) and renal disease (HR 0.60, 95% CI 0.46‐0.68).

Conclusions

This meta‐analysis of observational studies showed an inverse association between circulating homoarginine concentrations and all‐cause mortality. Further research is warranted to investigate the direct effects of homoarginine on cardiovascular homoeostasis, the associations between homoarginine and all‐cause mortality in other population groups, and the effects of interventions on homoarginine concentrations on clinical outcomes.     

中医药治疗痛风性关节炎的研究进展

对痛风性关节炎中医药治疗研究进展情况进行研究和分析。论述了中医辨证思路及痛风性关节炎中医药治疗等相关知识。对于痛风性关节炎,采用中医药治疗较为普遍,临床效果较好,患者无明显不良反应。     

Clinical prediction rules for mortality in patients with pulmonary embolism and cancer to guide outpatient management: a meta‐analysis

Essentials

• Clinical prediction rules (CPRs) can stratify patients with pulmonary embolism (PE) and cancer.
• A meta‐analysis was done to assess prognostic accuracy in CPRs for mortality in these patients.
• Eight studies evaluating ten CPRs were included in this study.
• CPRs should continue to be used with other patient factors for mortality risk stratification.

Summary

Background

Cancer treatment is commonly complicated by pulmonary embolism (PE), which remains a leading cause of morbidity and mortality in these patients. Some guidelines recommend the use of clinical prediction rules (CPRs) to help clinicians identify patients at low risk of mortality and therefore guide care.

Objective

To determine and compare the accuracy of available CPRs for identifying cancer patients with PE at low risk of mortality.

Methods

A literature search of Medline and Scopus (January 2000 to August 2017) was performed. Studies deriving/validating ≥ 1 CPR for early post‐PE all‐cause mortality were included. A bivariate, random‐effects model was used to pool sensitivity and specificity estimates for each CPR. Traditional random‐effects meta‐analysis was performed to estimate the weighted proportion of patients deemed at low risk of early mortality, mortality in low risk patients and odds ratios for death compared with higher‐risk patients.

Results

Eight studies evaluating 10 CPRs were included. The highest sensitivities were observed with Hestia (98.1%, 95% confidence interval [CI] = 75.6–99.9%) and the EPIPHANY index (97.4%, 95% CI = 93.2–99.0%); sensitivities of remaining rules ranged from 59.9 to 96.6%. Of the six CPRs with sensitivities ≥ 95%, none had specificities > 33%. Random‐effects meta‐analysis suggested that 6.6–51.6% of cancer patients with PE were at low risk of mortality, 0–14.3% of low‐risk patients died and low‐risk patients had a 43–94% lower odds of death compared with those at higher risk.

Conclusions

Because of the limited total body of evidence regarding CPRs, their results, in conjunction with other pertinent patient‐specific clinical factors, should continue to be used in identifying appropriate management for PE in patients with cancer.

     

Mechanism of Action of Colchicine in the Treatment of Gout

Purpose

The aims of this article were to systematically review the literature about the mechanism of action of colchicine in the multimodal pathology of acute inflammation associated with gout and to consider the clinical utility of colchicine in other chronic inflammatory diseases.

Methods

The English-language literature on PubMed was searched for articles published between 1990 and October 2013, with a cross-reference to citations across all years. Relevant articles pertaining to the mechanism of action of colchicine and the clinical applications of colchicine in gout and other inflammatory conditions were identified and reviewed.

Findings

The molecular pathology of acute inflammation associated with gouty arthritis involves several concurrent pathways triggered by a variety of interactions between monosodium urate crystals and the surface of cells. Colchicine modulates multiple pro- and antiinflammatory pathways associated with gouty arthritis. Colchicine prevents microtubule assembly and thereby disrupts inflammasome activation, microtubule-based inflammatory cell chemotaxis, generation of leukotrienes and cytokines, and phagocytosis. Many of these cellular processes can be found in other diseases involving chronic inflammation. The multimodal mechanism of action of colchicine suggests potential efficacy of colchicine in other comorbid conditions associated with gout, such as osteoarthritis and cardiovascular disease.

Implications

Colchicine has multiple mechanisms of action that affect inflammatory processes and result in its utility for treating and preventing acute gout flare. Other chronic inflammatory diseases that invoke these molecular pathways may represent new therapeutic applications for colchicine.     

The dilemma of monotherapy or combination therapy in community‐acquired pneumonia

Scope

To study the factors associated with mortality in hospitalized patients with community‐acquired pneumonia treated with monotherapy or combination therapy.

Methods

PubMed and Scopus were searched. Patients receiving macrolides, β‐lactams and fluoroquinolones, as monotherapy or in combination, were included. Meta‐analyses and meta‐regressions were performed.

Results

Fifty studies were included. Overall, monotherapy was not associated with higher mortality than combination (RR 1.14, 95% CI 0.99‐1.32, I² 84%). Monotherapy was associated with higher mortality than combination in North American and retrospective studies. β‐lactam monotherapy was associated with higher mortality than β‐lactam/macrolide combination in the primary (1.32, 1.12‐1.56, I² 85%) and most sensitivity analyses. There was no difference in mortality between fluoroquinolone monotherapy and β‐lactam/macrolide combination (0.98, 0.78‐1.23, I² 73%). In meta‐regressions, the moderators that could partially explain the observed statistical heterogeneity were the frequency of cancer patients (P = .03) and Pneumonia Severity Index score IV (P = .008).

Conclusion

Due to the considerable heterogeneity and inclusion of unadjusted data, it is difficult to recommend a specific antibiotic regimen over another. Specific antibiotic regimens, study design and the characteristics of the population under study seem to influence the reported outcomes.     

Fluid Resuscitation in Patients With Severe Burns: A Meta‐analysis of Randomized Controlled Trials

Objectives

Fluid resuscitation is the mainstay treatment to reconstitute intravascular volume and maintain end‐organ perfusion in patients with severe burns. The use of a hyperosmotic or isoosmotic solution in fluid resuscitation to manage myocardial depression and increased capillary permeability during burn shock has been debated. We conducted a systematic review and meta‐analysis to compare the efficacies of hyperosmotic and isoosmotic solutions in restoring hemodynamic stability after burn injuries.

Methods

PubMed, Embase, Cochrane Library, Scopus, and ClinicalTrials.gov registry were searched. Randomized control trials evaluating the efficacy and safety of hyperosmotic and isoosmotic fluid resuscitation in patients with burn injuries were selected. Eligible trials were abstracted and assessed for the risk of bias by two reviewers and results of hemodynamic indicators in the included trials were analyzed.

Results

Ten trials including 502 participants were published between 1983 and 2013. Compared with isoosmotic group, the hyperosmotic group exhibited a significant decrease in the fluid load (vol/% total body surface area [TBSA]/weight) at 24 hours postinjury, with a mean difference of ?0.54 (95% confidence interval = ?0.92 to ?0.17). No differences were observed in the urine output, creatinine level, and mortality at 24 hours postinjury between groups.

Conclusions

Hyperosmotic fluid resuscitation appears to be an attractive choice for severe burns in terms of TBSA or burn depth. Further investigation is recommended before conclusive recommendation.

     

Bajiaolian poisoning—a poisoning with high misdiagnostic rate

Background

One of the oldest Chinese herbal medicine, bajiaolian is widely used in traditional therapy. In Taiwan, bajiaolian is the fifth highest cause of poisoning among herbal medicines. The diagnosis is difficult because physicians are unfamiliar with this medicine's multiple presentations in different stages of intoxication.

Procedures

The records of 4 major poison centers in Taiwan were searched for all bajiaolian intoxication from July 1985 (the opening of first poison center) to March 2003. Two emergency physicians with toxicologic training reviewed the admission charts and visited case patients for follow-up.

Findings

Seventeen patients were identified, of which 15 (88.2%) had been misdiagnosed initially. In the beginning of their medical care, 14 cases were diagnosed as acute gastroenteritis.

Conclusion

Bajiaolian intoxication is probably misdiagnosed because of early gastrointestinal symptoms followed by neurologic symptoms. A detailed patient history should be taken, and symptoms should be reviewed systemically to improve diagnostic accuracy.     

Expectations about the effectiveness of pain‐ and itch‐relieving medication administered via different routes

Background

Placebo effects on pain have been found to vary in size for different routes of medication administration (e.g. oral vs. injection). This has important implications for both clinical research and practice. To enhance our understanding of these differential placebo effects, research on the underlying expectations about multiple routes and symptoms other than pain is vital.

Methods

A cross‐sectional, Internet‐based survey was conducted in a representative sample of the Dutch population (n = 508). Respondents rated the expected effectiveness of pain‐ and itch‐relieving medication in six forms, representing oral, injection and topical routes of administration.

Results

Injected medication was expected to be most effective for relieving pain, and topical medication for relieving itch. Furthermore, exploratory analyses showed that injections were expected to have the most rapid onset and long‐lasting effects, and to be most frightening and expensive, while topical medication was expected to be the safest and the easiest to use, and oral medication was expected to have the most side effects. Higher expected effectiveness was moderately associated with expectations of more rapid onset and long‐lasting effects, and better safety and ease of use. Associations of expected effectiveness with respondent characteristics (e.g. medication use and personality characteristics) were statistically small or nonsignificant.

Conclusions

Expected effectiveness of medication differed depending on route of administration and targeted symptom. These findings have important implications for the design and interpretation of clinical trials and suggest that medication effects might be enhanced by prescribing medicine via the route that patients expect to be most effective for their complaint.

Significance

Differences in the expected effectiveness of medication depend on the route of administration (oral, injection, topical) and targeted symptom (pain, itch). These findings have important implications for clinical practice and the design and interpretation of clinical trials.     

Clinical effectiveness and cost‐effectiveness of nurse‐led care in Chinese patients with rheumatoid arthritis: A randomized trial comparing with rheumatologist‐led care

Background and aim

The concept of nurse‐led care (NLC) was not familiar in China. This study was designed to evaluate the clinical effectiveness and cost‐effectiveness of NLC versus rheumatologist‐led care (RLC) in Chinese patients with rheumatoid arthritis (RA).

Methods

Patients of either gender (aged ≥18 years) with RA were enrolled at Wenhai Central Hospital, China (January 2015 to December 2015). The participants were then randomized to NLC or RLC. Outcomes of both the groups were compared in terms of effectiveness by measuring the Disease Activity Score 28, visual analogue scores pertaining to pain and fatigue, and duration of morning stiffness. Costs associated with resource use for RA were assessed and compared between both groups.

Results

A total of 214 RA patients in 2 groups (n = 107 in each group) were enrolled and analysed. Improvements in clinical outcomes (disease activity, pain, fatigue, and morning stiffness) over 12 months were significantly greater in the NLC group compared to RLC (P < 0.001). Overall, costs associated with resource use were higher in the RLC group compared to the NLC group (P < 0.05).

Conclusions

Our preliminary finding suggested that RA patients managed by NLC compared to RLC may have better clinical outcomes and more cost‐effective care in China.     

Outcomes following a negative computed tomography pulmonary angiography according to pulmonary embolism prevalence: a meta‐analysis of the management outcome studies

Essentials

• Computed tomographic pulmonary angiography (CTPA) is used to exclude pulmonary embolism.
• This meta‐analysis explores the occurrence of venous thromboembolic events (VTE) after a CTPA.
• Occurrence of VTE after a negative CTPA is ?8% in study subgroups with a prevalence of PE ≥ 40%.
• CTPA may be insufficient to safely rule out VTE as a stand‐alone diagnostic test for this subgroup.

Summary

Background

Outcome studies have reported the safety of computed tomographic pulmonary angiography (CTPA) as a stand‐alone imaging technique to rule out pulmonary embolism (PE). Whether this can be applied to all clinical probabilities remains controversial.

Objectives

We performed a meta‐analysis to determine the proportion of patients with venous thromboembolic events (VTE) despite a negative CTPA according to pretest PE prevalence.

Methods

We searched MEDLINE, EMBASE and the Cochrane Library (January 1990 to May 2017) for outcome studies recruiting patients with suspected PE using CTPA as a diagnostic strategy. The primary outcome was the cumulative occurrence of VTE at 3 months following a negative CTPA.

Results

Twenty‐two different studies were identified. VTE was confirmed in 2.4% of patients (95% CI, 1.3–3.8%) either at the time of the index event or in the 3 months follow‐up. Subgroup analyses suggested that the cumulative occurrence of VTE was related to pretest prevalence of PE, as VTE occurred in 1.8% (95% CI, 0.5–3.7%), 1.4% (95% CI, 0.7–2.3%), 1.0% (95% CI, 0.5–1.8%) and 8.1% (95% CI, 3.5–14.5%) of subgroups of patients with a PE prevalence < 20%, 20–29%, 30–39% and ≥ 40%, respectively. This was further confirmed using meta‐regression analysis.

Conclusions

The negative predictive value of CTPA for VTE varies according to pretest prevalence of PE, and is likely to be insufficient to safely rule out VTE as a stand‐alone diagnostic test amongst patients at the highest pretest probability of VTE. Prospective studies are required to validate the appropriate diagnostic algorithm for this subgroup of patients.

     

No need for rescue medication (NNR) as an easily interpretable efficacy outcome measure in analgesic trials: validation in an individual‐patient meta‐analysis of dental pain placebo‐controlled trials of naproxen

What is known and Objective: In analgesic trials, pain relief is often assessed using a pain‐relief score. We aimed to assess, through a meta‐analysis, whether absence of need for rescue medication (NNR) is a reliable outcome measure in the evaluation of acute pain relief. Methods: Individual‐patient meta‐analysis of placebo‐controlled trials of single‐dose naproxen sodium 220 or 440 mg in dental pain. Efficacy estimates were based on NNR and compared with the more commonly used 50% maximum total pain relief score (50% TOTPAR). The trials included were the full set of trials sponsored by one manufacturer. Results and Discussion: Need for rescue medication and 50% TOTPAR gave comparable estimates of efficacy of naproxen sodium (220 and 440 mg) relative to placebo in dental pain at both 8 and 12 h after dosing. What is new and Conclusion: No need for rescue medication is a reliable outcome measure for use in acute pain trials. As it is more readily understandable than 50% TOTPAR, it should be the preferred primary outcome measure in acute pain trials.     

电针联合西药治疗急性痛风性关节炎疗效的Meta分析

目的系统评价电针联合西药治疗急性痛风性关节炎的有效性。方法计算机检索PubMed、Web of Science、The Cochrane Library、Embase、CNKI、CBM、WanFang Data、VIP数据库,搜集电针联合西药治疗急性痛风性关节炎的随机对照试验,检索时限为建库至2021年3月,采用stata 11.2软件进行Meta分析。结果共纳入6个研究,包括468例患者。Meta分析结果显示,电针联合西药在提高总有效率[RR=1.16,95%CI(1.08,1.25)]、减轻疼痛视觉模拟评分法(VAS)[WMD=-1.71,95%CI (-2.58,-0.86)]、降低红细胞沉降率(ESR)[WMD=-6.40,95%CI (-10.73,-2.07)]及白介素-1β(IL-1β)[SMD=-2.73,95%CI (-4.54,-0.93)]方面优于单纯西药治疗,但在降低血尿酸和C反应蛋白(CRP)方面与单纯西药治疗相比差异无统计学意义。结论当前证据表明,电针联合西药治疗急性痛风性关节炎在提高总有效率、缓解疼痛、降低ESR、IL-1β方面优于单纯西药治疗。