Effectiveness of interventions to prevent delirium in hospitalized patients: a systematic review.

OBJECTIVE: To determine the effectiveness of interventions to prevent delirium in hospitalized patients. DATA SOURCES: Two databases, MEDLINE and CINAHL, were searched for relevant articles published from January 1966 to May 1995 and from January 1982 to May 1995 respectively. The bibliographies of identified articles were searched for additional references. STUDY SELECTION: Ten articles met the following three inclusion criteria: (a) original research article, (b) published in English or French and (c) controlled trial (nonrandomized or randomized) of an intervention to prevent delirium in hospitalized patients. The validity of the studies was independently assessed according to the criteria for intervention studies proposed by the Evidence-Based medicine Working Group. DATA EXTRACTION: Information about study design, patient population, sample size, diagnostic criteria, interventions and results was systematically abstracted from each report. Absolute risk reduction (ARR) for delirium was calculated for each study. DATA SYNTHESIS: Eight trials involved surgical patients and two involved elderly medical patients; most of the studies had serious methodological limitations. Among the surgical patients the ARRs ranged from -13% to 81% and were not related to the type or timing of the intervention, or to the personnel involved. Among the elderly medical patients the ARRs ranged from -3% to 3%. CONCLUSION: Interventions to prevent delirium among surgical patients may be modestly effective, but further trials are necessary.     

Counselling problem drinkers in medical wards: a controlled study

Seven hundred and thirty one men admitted to medical wards were interviewed to identify problem drinkers who had not received previous treatment for alcoholism and who had some social support. One hundred and sixty one met the diagnostic criteria; 156 agreed to a follow up interview and were allocated to one of two groups. One group received a session of counselling about their drinking habits from a nurse while the other received only routine medical care. Both groups reported a reduction in alcohol consumption when interviewed 12 months later, but the counselled group had a significantly better outcome than the control group. It is concluded that systematic screening for alcohol consumption and related problems should become a routine part of medical assessment and that advice on drinking habits is effective if given before irreversible physical or psychosocial problems have developed.     

Effectiveness of specialized palliative care: a systematic review

Camilla Zimmermann, MD, MSc; Rachel Riechelmann, MD; Monika Krzyzanowska, MD, MPH; Gary Rodin, MD; Ian Tannock, MD, PhD

JAMA. 2008;299(14):1698-1709.

Context  Specialized palliative care teams are increasingly providing care for the terminally ill. However, the impact of such teams on quality of life, satisfaction with care, and economic cost has not been examined systematically using detailed criteria for study quality.

Objective  To systematically review the evidence for effectiveness of specialized palliative care.

Data Sources  We performed a keyword search of the following databases from their inception to January 2008: MEDLINE, Ovid Healthstar, CINAHL, EMBASE, and the Cochrane Central Register of Controlled Trials.

Study Selection  We included all randomized controlled trials in which specialized palliative care was the intervention and for which outcomes included quality of life, satisfaction with care, or economic cost.

Data Extraction  Data on population, intervention, outcome, methods, and methodological quality were extracted by 2 investigators using standardized criteria.

Results  Of 396 reports of randomized controlled trials, 22 met our inclusion criteria. There was most consistent evidence for effectiveness of specialized palliative care in improvement of family satisfaction with care (7 of 10 studies favored the intervention). Only 4 of 13 studies assessing quality of life and 1 of 14 assessing symptoms showed a significant benefit of the intervention; however, most studies lacked statistical power to report conclusive results, and quality-of-life measures were not specific for terminally ill patients. There was evidence of significant cost savings of specialized palliative care in only 1 of the 7 studies that assessed this outcome. Methodological limitations were identified in all trials, including contamination of the control group, failure to account for clustering in cluster randomization studies, and substantial problems with recruitment, attrition, and adherence.

Conclusions  The evidence for benefit from specialized palliative care is sparse and limited by methodological shortcomings. Carefully planned trials, using a standardized palliative care intervention and measures constructed specifically for this population, are needed.

     

Questionnaire detection of problem drinkers among acute medical admissions

The study was designed to determine the prevalence of alcoholism/problem drinking among emergency medical admissions. Of 203 emergency admissions to two medical wards, 18% were found to be problem drinkers, using the brief Michigan alcoholic screening test (MAST) questionnaire. Problem drinking was found in 31% of males and 5% of females. Most drinking was done with friends (77%) and at the "rum shop" (62%). Fifty-one per cent of problem drinkers started between the ages of sixteen and twenty years. Seventy per cent of all problem drinkers had a first degree family relative who drank compared to 28% of non-drinkers. A high prevalence of alcoholism (48%) was found among smokers. Housestaff detected just over half of male (56%) and female (60%) alcoholics who were MAST-positive. Medical diagnoses among MAST-positive patients were gastrointestinal (cirrhosis, pancreatitis and hepatitis) in 32%, neurological (delirium tremens, seizures and subdural hematoma) in 27% and cardiovascular (cardiomyopathy, heart failure and dysrhythmias) in 16%. The detected level of problem drinking is likely to cause significant morbidity, and allows an important opportunity for intervention. The use of questionnaire methods to screen for alcoholism needs further evaluation in the region.     

No magic bullets: a systematic review of 102 trials of interventions to improve professional practice.

OBJECTIVE: To determine the effectiveness of different types of interventions in improving health professional performance and health outcomes. DATA SOURCES: MEDLINE, SCISEARCH, CINAHL and the Research and Development Resource Base in CME were searched for trials of educational interventions in the health care professions published between 1970 and 1993 inclusive. STUDY SELECTION: Studies were selected if they provided objective measurements of health professional performance or health outcomes and employed random or quasi-random allocation methods in their study designs to assign individual subjects or groups. Interventions included such activities as conferences, outreach visits, the use of local opinion leaders, audit and feedback, and reminder systems. DATA EXTRACTION: Details extracted from the studies included the study design; the unit of allocation (e.g., patient, provider, practice, hospital); the characteristics of the targeted health care professionals, educational interventions and patients (when appropriate); and the main outcome measure. DATA SYNTHESIS: The inclusion criteria were met by 102 trials. Areas of behaviour change included general patient management, preventive services, prescribing practices, treatment of specific conditions such as hypertension or diabetes, and diagnostic service or hospital utilization. Dissemination-only strategies, such as conferences or the mailing of unsolicited materials, demonstrated little or no changes in health professional behaviour or health outcome when used alone. More complex interventions, such as the use of outreach visits or local opinion leaders, ranged from ineffective to highly effective but were most often moderately effective (resulting in reductions of 20% to 50% in the incidence of inappropriate performance). CONCLUSION: There are no "magic bullets" for improving the quality of health care, but there are a wide range of interventions available that, if used appropriately, could lead to important improvements in professional practice and patient outcomes.     

静脉输注免疫球蛋白对呼吸机相关肺炎疗效的系统评价

目的：系统评价免疫球蛋白( IVIG)治疗呼吸机相关性肺炎( VAP)相关研究,分析其有效性,为临床治疗策略提供依据。方法系统检索CNKI、万方、CBM、Pubmed、Embase、ISI及Cochrane数据库中相关文献,采用Cochrane标准评价纳入研究偏倚风险,Meta分析结合描述性分析研究数据。结果①纳入6个随机对照研究,435例低体质量儿、早产儿及婴儿VAP患者,质量一般。②Meta分析结果显示IVIG组死亡率低于非IVIG组[RR=0．33,95%CI(0．18~0．60),P=0．0002];IVIG组血液免疫球蛋白浓度比对照组高3．19 mg/L [MD=3．19,95%CI(3．02~3．37),P<0．05];③IVIG组败血症[RR=0．14,95%CI(0．04~0．51),P=0．003]和多器官功能衰竭发生率[RR=0．51,95%CI(0．30~0．88),P=0．02]低于对照。结论 IVIG主要用于早产儿及低体质量儿VAP患者,可能提高体液免疫,降低败血症和多器官功能衰竭发生率,减少患者病死率,改善预后。     

Effectiveness of teaching quality improvement to clinicians: a systematic review

Context  Accreditation requirements mandate teaching quality improvement (QI) concepts to medical trainees, yet little is known about the effectiveness of teaching QI. Objectives  To perform a systematic review of the effectiveness of published QI curricula for clinicians and to determine whether teaching methods influence the effectiveness of such curricula. Data Sources  The electronic literature databases of MEDLINE, EMBASE, CINAHL, and ERIC were searched for English-language articles published between January 1, 1980, and April 30, 2007. Experts in the field of QI were queried about relevant studies. Study Selection  Two independent reviewers selected studies for inclusion if the curriculum taught QI principles to clinicians and the evaluation used a comparative study design. Data Extraction  Information about the features of each curriculum, its use of 9 principles of adult learning, and the type of educational and clinical outcomes were extracted. The relationship between the outcomes and the number of educational principles used was assessed. Results  Of 39 studies that met eligibility criteria, 31 described team-based projects; 37 combined didactic instruction with experiential learning. The median number of adult learning principles used was 7 (range, 2-8). Evaluations included 22 controlled trials (8 randomized and 14 nonrandomized) and 17 pre/post or time series studies. Fourteen studies described educational outcomes (attitudes, knowledge, or skills or behaviors) and 28 studies described clinical process or patient outcomes. Nine of the 10 studies that evaluated knowledge reported only positive effects but only 2 of these described a validated assessment tool. The 6 assessments of attitudes found mixed results. Four of the 6 studies on skill or behavior outcomes reported only positive effects. Eight of the 28 studies of clinical outcomes reported only beneficial effects. Controlled studies were more likely than other studies to report mixed or null effects. Only 4 studies evaluated both educational and clinical outcomes, providing limited evidence that educational outcomes influence the clinical effectiveness of the interventions. Conclusions  Most published QI curricula apply sound adult learning principles and demonstrate improvement in learners' knowledge or confidence to perform QI. Additional studies are needed to determine whether educational methods have meaningful clinical benefits.      

老年慢性心力衰竭患者的心理护理干预效果分析

目的：探讨心理护理干预对老年慢性心力衰竭（CHF）患者心理状况和心功能的影响。方法：将130例CHF患者随机分为实验组和对照组,各65例。对照组接受常规治疗和护理,而实验组在此基础上接受心理护理干预。结果：干预前两组患者的SAS和SDS评分均明显高于国内常模,干预后实验组的SAS和SDS评分明显低于对照组,且6MWT明显长于对照组,差异均有统计学意义（P〈0.01）。结论：理护理干预能明显改善CHF患者的心理状况,促进其心脏功能的恢复。     

Effectiveness of azithromycin mass drug administration on trachoma: a systematic review

Backgrounds:Azithromycin mass drug administration (MDA) is a key part of the strategy for controlling trachoma. This systematic review aimed to comprehensively summarize the present studies of azithromycin MDA on trachoma; provide an overview of the impact of azithromycin MDA on trachoma in different districts; and explore the possible methods to enhance the effectiveness of azithromycin MDA in hyperendemic districts.Methods:PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov were searched up to February 2021 with no language restriction. Studies reporting the effect of azithromycin MDA on trachoma were included. Mathematical modeling studies, animal studies, case reports, and reviews were excluded. The trachomatous inflammation-follicular (TF) <5.0% was used to judge the effect of azithromycin MDA on eliminating trachoma as a public health problem. Two researchers independently conducted the selection process and risk of bias assessment.Results:A total of 1543 studies were screened, of which 67 studies including 13 cluster-randomized controlled trials and 54 non-randomized studies were included. The effect of azithromycin MDA on trachoma was closely related to the baseline prevalence in districts. For the districts with baseline prevalence between 5.0% and 9.9%, a single round of MDA achieved a TF <5.0%. For the districts with baseline between 10.0% and 29.9%, annual MDA for 3 to 5 years reduced TF <5.0%. However, for the districts with high level of baseline prevalence (TF >30.0%), especially with baseline TF >50.0%, annual MDA was unable to achieve the TF <5.0% even after 5 to 7 years of treatment. Quarterly MDA is more effective in controlling trachoma in these hyperendemic districts.Conclusions:Azithromycin MDA for controlling trachoma depends on the baseline prevalence. The recommendation by the World Health Organization that annual MDA for 3 to 5 years in the districts with TF baseline >10.0% is not appropriate for all eligible districts.     

Prevalence of excessive or problem drinkers among patients attending somatic outpatient clinics: a study of alcohol related medical care

The prevalence of alcohol related morbidity was studied among 2038 patients attending somatic outpatient clinics. A further 76 patients had refused the study, giving an overall drop out rate of 3.6%. Several methods were combined so as to detect as many patients with problem drinking as possible. According to the criteria and definitions employed 17% of men (confidence interval 15% to 19%) and 4% of women (confidence interval 3% to 5%) were excessive consumers of alcohol or problem drinkers. The highest proportion of such patients--that is, 17%--was noted in the emergency rooms (27% of men, 8% of women). At other clinics the proportions varied from 11% to 17% of men and from 2% to 4% of women. The strongest relations between overconsumption of alcohol and consultation at the clinic were among patients attending the medical outpatient clinic and the emergency rooms; in 86% (confidence interval 75% to 97%) and 88% (confidence interval 81% to 95%) of problem drinkers attending these clinics, respectively, alcohol was related to the consultation. Consultations were related to alcohol in 82% of women with excessive or problem drinking and 73% of men defined in this way. There was a tendency to a higher proportion of men with excessive or problem drinking in the age group 40-49 years. These findings show that among patients classified as excessive or problem drinkers attending somatic outpatient clinics there was a close relation between alcohol consumption and utilisation of medical resources, especially in women.     

Spectrum of drinkers and intervention opportunities.

Most adults in North America are either light drinkers or abstainers, so alcohol does not cause them problems. However, a small but often highly visible minority--approximately 5% of the adult population--show major symptoms of alcohol dependence. Between these extremes, there is a sizable group of about 20% of the population, particularly young men, who are drinking at risk levels and have encountered some problems related to their alcohol use. Traditionally, physicians' efforts have focused on diagnosing and treating patients with a substantial history of alcohol dependence, and relatively little attention has been given to early intervention with nondependent problem drinkers, such as identifying patients who present in primary care settings with alcohol-related morbidity or an accidental injury. Recent evidence indicates that early intervention by primary care physicians is an effective strategy for reducing alcohol problems among patients.     

基于患者社会网络的干预对COPD自我管理等影响的系统评价

目的 评价基于患者社会网络的干预对慢性阻塞性肺疾病(COPD)患者自我管理、生活质量的影响。 方法 采用主题检索与自由检索相结合的方式,计算机检索中文数据库如中国期刊全文数据库、万方数据库、中国生物医学文献服务系统、维普数据库,以及英文数据库(The Cochrane Library、PubMed、Embase、Web of science、Proquest)中基于患者社会网络的干预措施对COPD患者自我管理、生活质量影响的随机对照试验,检索时限为建库至2019年12月。由2名研究者按照纳入和排除标准筛选文献、提取资料、并评价纳入研究的偏倚风险,然后采用RevMan 5.3进行Meta分析或进行描述性分析。 结果 共纳入10项研究,共包括967例COPD患者。Meta分析结果显示,干预组自我管理量表评分高于对照组,差异有统计学意义[SMD=1.89,95%CI(0.24,3.54),P=0.020],干预组患者生活质量优于对照组,差异有统计学意义[MD=-8.43,95%CI(-11.10,-2.77),P<0.001)]。 结论 现有证据显示,基于患者社会网络的干预对提高COPD患者自我管理能力有积极作用,有利于改善患者生活质量。由于研究设计和样本的限制,需要更多大样本研究以进一步证实。