Updates in venous thromboembolism management: evidence published in 2016

The management of venous thromboembolic disease (VTE) is rapidly evolving and staying updated on practice-changing evidence can be challenging. In an attempt to alleviate this daunting task, we sought to determine the most important practice-informing articles published in 2016 relevant to the non-specialist provider managing VTE. We performed a systematic search of the literature, limiting the search to a publication date of 2016 (see Supplementary Appendix). Two reviewers screened the 3819 resulting abstracts to identify high-quality, clinically relevant publications related to VTE management.

Two hundred sixteen full-text articles were considered for inclusion. The five authors used a modified Delphi method to reach consensus on inclusion of 7 articles for in-depth appraisal, following predetermined criteria of clinical relevance to non-specialist providers, potential for practice change, and strength of the evidence.     

The capture-mark-recapture technique can be used as a stopping rule when searching in systematic reviews

ObjectiveResearchers have no empirically based search stopping rule when looking for potentially relevant articles for inclusion in systematic reviews. We tested a stopping strategy based on capture–mark–recapture (CMR; i.e., the Horizon Estimate) statistical modeling to estimate the total number of articles in the domain of clinical decision support tools for osteoporosis disease management using four large bibliographic databases (Medline, EMBASE, CINAHL, and EBM reviews).Study Design and SettingRetrospective evaluation of the Horizon Estimate using a systematic review of randomized controlled trials (RCTs) at two levels of article screening: title and abstract (1,246 potentially relevant articles) and full text (42 potentially relevant articles).ResultsThe CMR model suggests that the total number of potential articles was 1,838 for the first level of screening, and 49 for the full-text level. The four databases provided 68% of known articles for the first level of screening and 81% for full-text screening.ConclusionsThe CMR technique can be used in systematic reviews to estimate the closeness to capturing the total body of literature on a given topic. More studies are needed to objectively determine the usefulness of Horizon Estimates as a stopping rule strategy for systematic review searching.     

Use of contraceptive methods by women with current venous thrombosis on anticoagulant therapy: a systematic review

Background

As nearly all women with venous thromboembolism (VTE) will be treated with anticoagulant therapy, it is important to consider how anticoagulation affects the safety of contraceptive use.

Study design

We conducted a systematic review of the literature regarding use of contraceptive methods in women with current VTE on anticoagulant therapy. Due to the limited direct evidence that was identified, we expanded our search to include women on anticoagulant therapy for indications other than VTE and women with bleeding disorders.

Results

Six articles met our inclusion criteria. Three observational studies found the levonorgestrel-releasing IUD (LNG-IUD) was an effective treatment for menorrhagia for women on anticoagulation therapy or with bleeding disorders. Prevention of recurrent hemorrhagic ovarian cysts was seen in women on chronic anticoagulation treated with depot-medroxyprogesterone acetate (DMPA) in one small observational study. Among women with bleeding disorders, no complications were seen in 16 women with placement of the LNG-IUD. One pharmacokinetic study found no statistically significant interaction between combined oral contraceptives and warfarin. Other than one case report, no evidence was found regarding the risk of recurrent thrombosis in women on anticoagulation therapy using a contraceptive method.

Conclusion

The majority of studies in this review examined treatment effects of the LNG-IUD or DMPA on complications of anticoagulation and found overall beneficial effects of their use in these circumstances. Minimal evidence in women with inherited bleeding disorders suggests that insertion of the LNG-IUD does not pose major bleeding risks in these women with appropriate management.     

Moves Afoot To Shore Up Sagging Malpractice Coverage

Abstract

Objective: Venous thromboembolism (VTE) is a common complication in cancer patients. This review summarizes some of the most current knowledge of the epidemiology, risk factors, risk models, prophylaxis, and treatment of VTE in cancer patients. Methods: A literature search was conducted using Pub Med; the search terms were venous thromboembolism, anticoagulation, and cancer. The bibliographies of pertinent studies and review articles were reviewed for additional references. Results: Venous thromboembolism is the second leading cause of death in patients with cancer. Cancer patients with VTE have poorer outcomes compared with noncancer patients with VTE. Many risk factors have been identified for VTE in patients with cancer that are patient-related, cancer-related, or treatment-related. Several biomarkers have been identified as potentially predictive of VTE risk. Risk assessment models such as the Khorana Risk Score stratify cancer patients with low, intermediate, and high risk of developing VTE based on baseline clinical and laboratory variables. Currently, enoxaparin is the preferred anticoagulant for initial VTE treatment in cancer patients. Low molecular weight heparin (LMWH) is recommended for both initial and long-term management of cancer-related VTE. Because the optimal duration of anticoagulation in cancer patients with VTE is unknown, the decision to extend anticoagulation requires weighing the risk of recurrent thrombosis against the risk of major bleeding. Patients with recurrent VTE can be bridged with LMWH, transitioned to full-dose LMWH or treated with LMWH dose escalation. While there is insufficient data to determine whether anticoagulation should be held in the setting of thrombocytopenia, full-dose anticoagulation is typically considered unsafe when platelets are < 50 000/μL. Inferior vena cava filters are currently recommended only for patients with acute VTE and contraindications to anticoagulation. Although management of catheter-associated thrombosis has not been well studied in cancer patients, it is recommended that cancer patients with catheter-associated thrombosis be treated with therapeutic anticoagulation for ≥ 3 months. Venous thromboembolism prophylaxis with UFH, LMWH, or fondaparinux is recommended in all hospitalized nonsurgical cancer patients and cancer patients undergoing major cancer surgery. Primary thromboprophylaxis is only currently recommended in high-risk ambulatory cancer patients such as multiple myeloma patients receiving thalidomide-or lenalidomide- based therapy. Conclusion: Cancer-associated thrombosis is a common problem. As we begin to better understand the risk factors and biomarkers for cancer-associated VTE, we can further refine and develop risk-assessment models to determine those patients who would most likely benefit from anticoagulation. While LMWH products are generally preferred in cancer-related VTE, more research will continue to evolve our understanding of treatment and thrombopprophylaxis in cancer-associated VTE.     

Diagnostic test systematic reviews: Bibliographic search filters (“Clinical Queries”) for diagnostic accuracy studies perform well

BackgroundSystematic reviews of health care topics are valuable summaries of all pertinent studies on focused questions. However, finding all relevant primary studies for systematic reviews remains challenging.ObjectivesTo determine the performance of the Clinical Queries sensitive search filter for diagnostic accuracy studies for retrieving studies for systematic reviews.MethodsWe compared the yield of the sensitive Clinical Queries diagnosis search filter for MEDLINE and EMBASE to retrieve studies in diagnostic accuracy systematic reviews reported in ACP Journal Club in 2006.ResultsTwelve of 22 diagnostic accuracy reviews (452 included studies) met the inclusion criteria. After excluding 11 studies not in MEDLINE or EMBASE, 95% of articles (417 of 441) were captured by the sensitive Clinical Queries diagnosis search filter (MEDLINE and EMBASE combined). Of 24 studies not retrieved by the filter, 22 were not diagnostic accuracy studies. Reanalysis of the Clinical Queries filter without these 22 nondiagnosis articles increased its performance to 99% (417 of 419). We found no substantive impact of the two articles missed by the Clinical Queries filter on the conclusions of the systematic reviews in which they were cited.ConclusionThe sensitive Clinical Queries diagnostic search filter captured 99% of articles and 100% of substantive articles indexed in MEDLINE and EMBASE in diagnostic accuracy systematic reviews.     

Elevated hepatic enzymes and incidence of venous thromboembolism: a prospective study

PurposeApproximately 10% of the general population has elevated blood concentrations of hepatic enzymes, which are linked to increased coagulation markers. We tested whether elevated hepatic enzymes are associated with increased risk of venous thromboembolism (VTE).MethodsWe followed 12,604 adults with measurements of alanine transaminase, aspartate aminotransferase (AST), and gamma-glutamyl transpeptidase (GGT) prospectively for VTE occurrence.ResultsAST and GGT above the laboratory normal values were associated over two decades of follow-up with increased risk of total (n = 532) and provoked VTE (n = 332), but with not unprovoked VTE (n = 200). In a model adjusted for age, race, sex, hormone replacement, alcohol intake, diabetes, body mass index, estimated glomerular filtration rate, and C-reactive protein, the hazard ratios (HR) (95% confidence interval) for high versus normal AST were 1.46 (1.00–2.11) for total VTE and 1.83 (1.21–2.79) for provoked VTE. For high GGT, the HR were 1.34 (1.06–1.69) for total VTE and 1.43 (1.07–1.91) for provoked VTE. When follow-up was limited to the first 10 years, associations were even stronger (HR ≈ 1.7 for total VTE).ConclusionsElevated concentrations of two hepatic enzymes (AST and GGT) in this general middle-aged population are associated with a modestly increased risk of VTE.     

Progestin-only contraception and thromboembolism: A systematic review

BackgroundWomen with medical conditions associated with increased risk for thrombosis generally should not use estrogen-containing contraceptives; however, less is known about progestin-only contraceptives (POCs) and thrombosis risk.ObjectivesThe objective was to identify evidence regarding the risk of venous thromboembolism (VTE) or arterial thromboembolism [stroke or acute myocardial infarction (AMI)] among women using POCs.MethodsWe searched the PubMed database for all articles published from database inception through January 2016 for studies examining thrombosis among women using POCs. We included studies which examined women with medical conditions associated with thrombosis risk, as well as studies of women in the general population (either without these conditions or who were not specified to have these conditions). Hormonal contraceptives of interest included progestin-only pills (POPs), injectables, implants and levonorgestrel-releasing intrauterine devices (LNG-IUDs). Outcomes of interest included VTE, stroke and AMI.ResultsThere were 26 articles of good to poor quality that met inclusion criteria; 9 studies examined women with medical conditions and 20 examined women in the general population. Two studies found that, among smokers and women with certain thrombogenic mutations, use of depot medroxyprogesterone acetate (DMPA) had elevated odds of VTE compared with nonsmokers or those without mutations, although confidence intervals were wide and overlapped with odds among nonusers. One study found that, among women with previous VTE, use of POCs (including DMPA) was associated with a nonsignificant increased odds of recurrent VTE (all of which were among DMPA users); two other studies that examined POCs other than DMPA did not observe an association with recurrent VTE. Two studies found that use of DMPA among healthy women was also associated with increased odds of VTE. Two studies found that use of POCs for therapeutic indications was associated with increased odds of VTE. Studies did not find increased odds of VTE with POPs for contraceptive purposes, implants or LNG-IUDs nor were there increased odds of stroke or AMI with any POCs.ConclusionThe majority of evidence identified by this systematic review did not suggest an increase in odds for venous or arterial events with use of most POCs. Limited evidence suggested increased odds of VTE with use of injectables (three studies) and use of POCs for therapeutic indications (two studies, one with POCs unspecified and the other with POPs). Any increase in risk likely translates to a small increase in absolute numbers of thrombotic events at the population level.     

Complementary approaches to searching MEDLINE may be sufficient for updating systematic reviews

ObjectivesTo maximize the proportion of relevant studies identified for inclusion in systematic reviews (recall), complex time-consuming Boolean searches across multiple databases are common. Although MEDLINE provides excellent coverage of health science evidence, it has proved challenging to achieve high levels of recall through Boolean searches alone.Study Design and SettingRecall of one Boolean search method, the clinical query (CQ), combined with a ranking method, support vector machine (SVM), or PubMed-related articles, was tested against a gold standard of studies added to 6 updated Cochrane reviews and 10 Agency for Healthcare Research and Quality (AHRQ) evidence reviews. For the AHRQ sample, precision and temporal stability were examined for each method.ResultsRecall of new studies was 0.69 for the CQ, 0.66 for related articles, 0.50 for SVM, 0.91 for the combination of CQ and related articles, and 0.89 for the combination of CQ and SVM. Precision was 0.11 for CQ and related articles combined, and 0.11 for CQ and SVM combined. Related articles showed least stability over time.ConclusionsThe complementary combination of a Boolean search strategy and a ranking strategy appears to provide a robust method for identifying relevant studies in MEDLINE.     

The Representation of Causality and Causation with Ontologies: A Systematic Literature Review

ObjectiveTo explore how disease-related causality is formally represented in current ontologies and identify their potential limitations.MethodsWe conducted a systematic literature search on eight databases (PubMed, Institute of Electrical and Electronic Engendering (IEEE Xplore), Association for Computing Machinery (ACM), Scopus, Web of Science databases, Ontobee, OBO Foundry, and Bioportal. We included studies published between January 1, 1970, and December 9, 2020, that formally represent the notions of causality and causation in the medical domain using ontology as a representational tool. Further inclusion criteria were publication in English and peer-reviewed journals or conference proceedings. Two authors (SS, RM) independently assessed study quality and performed content analysis using a modified validated extraction grid with pre-established categorization.ResultsThe search strategy led to a total of 8,501 potentially relevant papers, of which 50 met the inclusion criteria. Only 14 out of 50 (28%) specified the nature of causation, and only 7 (14%) included clear and non-circular natural language definitions. Although several theories of causality were mentioned, none of the articles offers a widely accepted conceptualization of how causation and causality can be formally represented.ConclusionNo current ontology captures the wealth of available concepts of causality. This provides an opportunity for the development of a formal ontology of causation/causality.     

Improving Venous Thromboembolism Performance: A Comprehensive Guide for Physicians and Hospitalists

Abstract

Venous thromboembolism (VTE) is a major potentially preventable cause of hospital deaths and is associated with a substantial clinical and economic burden in the United States. Despite the availability of effective thromboprophylactic agents and evidence-based management guidelines, VTE prophylaxis is commonly underused and inappropriately prescribed in real-world practice. Several US organizations have developed quality-improvement initiatives to close the gap between guideline recommendations and clinical practice, and thus reduce VTE-associated morbidity and mortality. The Surgical Care Improvement Project and the National Quality Forum, in collaboration with The Joint Commission, have developed performance measures to allow assessment of the quality and appropriateness of VTE prevention practices. A number of potential barriers to optimal VTE performance exist, including underestimation of the risks posed by VTE, overestimation of the risk of bleeding complications, and a lack of familiarity with clinical guidelines. Hospitals are urged to develop an institution-wide policy to improve VTE prevention and employ several quality-improvement initiatives to overcome barriers and optimize prescribing practices. In particular, multiple integrated, active strategies are required to raise awareness of the need for appropriate VTE prophylaxis. Hospital-wide education, risk-assessment tools, electronic alerts, computerized decision-support systems, together with audit and feedback mechanisms, are valuable tools that can be used to promote the use of performance measures to drive improvement of VTE prophylaxis and clinical outcomes.     

Combined hormonal contraceptive use among obese women and risk for cardiovascular events: A systematic review

ContextCombined hormonal contraceptive (CHC) use may modify the risk of cardiovascular events in obese [body mass index (BMI) ≥ 30 kg/m²] women.ObjectiveThe objective was to evaluate from the literature whether CHC use modifies the risk of acute myocardial infarction (AMI), stroke, cerebral venous thrombosis (CVT) and venous thromboembolism (VTE) in obese women and to evaluate evidence for a dose–response relationship between BMI and VTE.MethodsWe searched PubMed for all articles published between database inception and February 2016 providing direct evidence on BMI, CHCs, and cardiovascular outcomes. We also searched for indirect evidence related to a dose–response relationship between BMI and risk of VTE in the general population, as these data were lacking for CHC users. The quality of each individual study was assessed using the system for grading evidence developed by the United States Preventive Services Task Force.ResultsThe direct evidence search yielded 3 pooled analyses, 11 case–control studies and 1 cohort study. There was conflicting evidence about the risk of AMI or stroke among obese combined oral contraceptive (COC) users compared to obese nonusers, with one study finding no increased risk for AMI or stroke for COC users overall or stratified by BMI. A second study found significantly increased risk of AMI and stroke for COC users, with the highest risk estimates for high-BMI COC users. A single study suggested that obese COC users may be at higher risk for CVT compared with normal-weight nonusers. For VTE, obese COC users consistently had a risk that was 5 to 8 times that of obese nonusers and approximately 10 times that of nonobese nonusers. Five prospective cohort studies were identified as indirect evidence, and all found increased risk for VTE as BMI increased, suggesting a dose–response relationship between BMI and risk for VTE. No studies on the contraceptive patch or vaginal ring were identified that met the inclusion criteria.ConclusionLimited evidence of Level II-2, fair quality, concerning whether CHC use modifies the risk of AMI and stroke in obese women is inconclusive, while a single study of Level II-2, poor quality, found that obese COC users may be at higher risk for CVT compared with normal-weight nonusers. Both COC use and higher BMI increase risk for VTE, and the greatest relative risks are for those with both risk factors based on a body of evidence graded as Level II-2, fair to poor quality. It is not possible to estimate absolute risk of VTE among women with both of these risk factors; however, the absolute risk of VTE in healthy women of reproductive age is small.     

Artificial Intelligence–Based Clinical Decision Support Systems in Geriatrics: An Ethical Analysis

ObjectivesTo provide an ethical analysis of the implications of the usage of artificial intelligence–supported clinical decision support systems (AI-CDSS) in geriatrics.DesignEthical analysis based on the normative arguments regarding the use of AI-CDSS in geriatrics using a principle-based ethical framework.Setting and ParticipantsNormative arguments identified in 29 articles on AI-CDSS in geriatrics.MethodsOur analysis is based on a literature search that was done to determine ethical arguments that are currently discussed regarding AI-CDSS. The relevant articles were subjected to a detailed qualitative analysis regarding the ethical considerations Supplementary Datamentioned therein. We then discussed the identified arguments within the frame of the 4 principles of medical ethics according to Beauchamp and Childress and with respect to the needs of frail older adults.ResultsWe found a total of 5089 articles; 29 articles met the inclusion criteria and were subsequently subjected to a detailed qualitative analysis. We could not identify any systematic analysis of the ethical implications of AI-CDSS in geriatrics. The ethical considerations are very unsystematic and scattered, and the existing literature has a predominantly technical focus emphasizing the technology's utility. In an extensive ethical analysis, we systematically discuss the ethical implications of the usage of AI-CDSS in geriatrics.Conclusions and ImplicationsAI-CDSS in geriatrics can be a great asset, especially when dealing with patients with cognitive disorders; however, from an ethical perspective, we see the need for further research. By using AI-CDSS, older patients’ values and beliefs might be overlooked, and the quality of the doctor-patient relationship might be altered, endangering compliance to the 4 ethical principles of Beauchamp and Childress.     

EGPRN: EUROPEAN GENERAL PRACTICE RESEARCH NETWORK

Abstract

Background: In patients with superficial venous thrombosis (SVT) co-existence of deep venous thrombosis (DVT) can be present. Varicosities are considered as a risk factor for both SVT and DVT separately. However, current evidence is contradictory whether varicosities are associated with an increased or reduced prevalence of concomitant DVT in patients with SVT.

Objectives: To determine the diagnostic value of both presence and absence of varicosities in the detection of concomitant DVT in non-hospitalized patients with SVT.

Methods: In MEDLINE and EMBASE, a systematic search was performed to collect all published studies on this topic. The selected papers were critically appraised. By diagnostic 2 × 2 tables prior probabilities and predictive values were computed.

Results: Six relevant articles were identified. The prior probability of concomitant DVT in patients referred from primary care to the outpatient clinic varied between 13 and 34%. In five studies, absence of varicosities was related to a higher probability of concomitant DVT (33–44%) compared to a presence of varicosities (3–23%). The sixth study showed an inversed, non-significant association: DVT was present in 21% of patients with SVT on non-varicose veins versus in 35% of patients with SVT on varicose veins.

Conclusion: In five out of six studies on patients with SVT in outpatient settings, absence of varicosities was related to a higher probability of concomitant DVT. Further research is needed to determine whether an assessment of varicosities in general practice could result in an improved selection of patients who require additional imaging to detect or exclude DVT.     

The safety of BCG revaccination: A systematic review

IntroductionRevaccination with Bacillus Calmette-Guérin (BCG) vaccine is not generally recommended due to a lack of proven efficacy of repeat doses for protection against tuberculosis. However, there is a growing interest in the use of BCG vaccine for its ‘off-target’ effects which might involve revaccination. We did a systematic review of the safety of BCG revaccination.MethodsMEDLINE (1946 to March 2020) and the BCG World Atlas (updated 2017) were searched, limiting to studies of BCG administration by the intradermal or percutaneous route. Adverse events as well as patient and vaccine characteristics were reviewed.ResultsThe search identified 388 articles, of which 24 met the inclusion criteria. These reported 22 studies comprising eight randomised trials, four case-control studies, four observational studies and six case series or reports. Overall, there was evidence for a small increase in the rate of mild local and systemic reactions. No serious adverse events were reported in immunocompetent individuals.ConclusionsEvidence to date suggests that revaccination with BCG vaccine carries minimal risk. Future studies of BCG vaccine for novel applications should report adverse event data stratified by prior BCG vaccination status.     

Challenges with coverage with evidence development schemes for medical devices: A systematic review

ObjectivesCoverage with evidence development (CED) schemes are particularly relevant for medical devices (MDs), since clinical evidence is often limited at the time of launch and their long-term (cost-) effectiveness heavily depends on how they are adopted into routine clinical practice. The objective of this study was to identify and describe the challenges that payers and manufacturers might face when assessing the desirability of, choosing the research design for, implementing, and evaluating CED schemes for MDs.MethodsA systematic literature review was performed on six databases following PRISMA guidelines. Two independent reviewers assessed the eligibility of studies based on predefined criteria and extracted data from the included articles by using a pre-defined extraction template. The data were synthesised in a narrative review.ResultsThe systematic search yielded 4293 articles of which 27 were eligible for inclusion. We identified 20 challenges that are associated with CED schemes for MDs. Five of these challenges relate directly to the characteristics of MDs, and hence are specific to MDs. These challenges concern deciding on whether a CED scheme is required, understanding the relevant uncertainties and risks, identifying meaningful outcomes, defining an adequate duration for a scheme, and market entry of new technologies.ConclusionsPayers and manufacturers of MDs have to address the identified challenges to improve a CED scheme's chance of success. This can be further improved by public sharing of information about the outcome of applied schemes and way in which stakeholders have addressed the challenges they faced when applying a CED scheme.     

Searching for Indirect Evidence and Extending the Network of Studies for Network Meta-Analysis: Case Study in Venous Thromboembolic Events Prevention Following Elective Total Knee Replacement Surgery

ObjectiveTo evaluate the effect of study identification methods and network size on the relative effectiveness and cost-effectiveness of recommended pharmacological venous thromboembolic events (VTEs) prophylaxis for adult patients undergoing elective total knee replacement surgery in the United Kingdom.MethodsA stepwise literature search specifically designed to identify indirect evidence was conducted to extend the original clinical review from the latest National Institute for Health and Care Excellence (NICE) VTE technology appraisal. Different network sizes or network orders, based on the successive searches, informed three network meta-analyses (NMAs), which were compared with a replicated base case. The resulting comparative estimates were inputted in an economic model to investigate the effect of network size on cost-effectiveness probabilities.ResultsSearches increased the number of indirect comparisons between VTE interventions, progressively widening the relevant network of studies for NMA. Precision around mean relative treatment effects was increased as the network was extended from the base case to first-order NMA, but further extensions had limited effect. Cost-effectiveness analysis results were largely insensitive to variation in clinical inputs from the different NMA orders.ConclusionsNo standard methodology is currently recommended by NICE to identify the most relevant network of studies for NMA. Our study showed that optimizing the identification of studies for NMA can extend the evidence base for analysis and reduce the uncertainty in relative effectiveness estimates. Although in our example network extensions did not affect the acceptability of available treatments in VTE prevention based on cost-effectiveness results, it may in other applications.     

The design, implementation, and evaluation of online credit nutrition courses: a systematic review

ObjectiveTo assess how postsecondary online nutrition education courses (ONEC) are delivered, determine ONEC effectiveness, identify theoretical models used, and identify future research needs.DesignSystematic search of database literature.SettingPostsecondary education.ParticipantsNine research articles evaluating postsecondary ONEC.Main Outcome MeasuresKnowledge/performance outcomes and student satisfaction, motivation, or perceptions.AnalysisSystematic search of 922 articles and review of 9 articles meeting search criteria.ResultsLittle research regarding ONEC marketing/management existed. Studies primarily evaluated introductory courses using email/websites (before 2000), or course management systems (after 2002). None used true experimental designs; just 3 addressed validity or reliability of measures or pilot-tested instruments. Three articles used theoretical models in course design; few used theories to guide evaluations. Four quasi-experimental studies indicated no differences in nutrition knowledge/performance between online and face-to-face learners. Results were inconclusive regarding student satisfaction, motivation, or perceptions.Conclusions and ImplicationsStudents can gain knowledge in online as well as in face-to-face nutrition courses, but satisfaction was mixed. More up-to-date investigations on effective practices are warranted, using theories to identify factors that enhance student outcomes, addressing emerging technologies, and documenting ONEC marketing, management, and delivery. Adequate training/support for faculty is needed to improve student experiences and faculty time management.     

Impact of Interventions on Medication Adherence and Blood Pressure Control in Patients with Essential Hypertension: A Systematic Review by the ISPOR Medication Adherence and Persistence Special Interest Group

ObjectivesTo systematically review the evidence on the impact of interventions to improve medication adherence in adults prescribed antihypertensive medications.MethodsAn electronic search was undertaken of articles published between 1979 and 2009, without language restriction, that focused on interventions to improve antihypertensive medication adherence among patients (≥18 years) with essential hypertension. Studies must have measured adherence as an outcome of the intervention. We followed standard guidelines for the conduct and reporting of the review and conducted a narrative synthesis of reported data.ResultsNinety-seven articles were identified for inclusion; 35 (35 of 97, 36.1%) examined interventions to directly improve medication adherence, and the majority (58 of 97, 59.8%) were randomized controlled trials. Thirty-four (34 of 97, 35.1%) studies reported a statistically significant improvement in medication adherence.Discussion/ConclusionsInterventions aimed at improving patients’ knowledge of medications possess the greatest potential clinical value in improving adherence with antihypertensive therapy. However, we identified several limitations of these studies, and advise future researchers to focus on using validated adherence measures, well-designed randomized controlled trials with relevant adherence and clinical outcomes, and guidelines on the appropriate design and analysis of adherence research.     

Pharmacologic Treatment for Hypoactive Delirium in Adult Patients: A Brief Report of the Literature

ObjectivesThe purpose of this report was to identify medications that can be used to treat hypoactive delirium.DesignA systematic search of PubMed and Web of Science from inception through September 20, 2020.Setting and ParticipantsReports evaluating different pharmacologic treatments for hypoactive delirium in adults (age 18 years and older) and geriatric patients were included.MethodsThree independent investigators reviewed the abstracts, using the Rayyan QCRI review tool to decide which articles were eligible for inclusion. Hereafter, articles were read completely for final inclusion. Study quality was assessed using the guidelines from the National Institute for Health and Care Excellence for cohort studies and randomized control trials.ResultsOf the 52 relevant articles, only 4 (8%) met the selection criteria. Two were cohort studies whereas the other 2 were randomized control trials. After further review, one of the reports was excluded because the same data were used as in one of the randomized control trials. In total, 4 different pharmacologic therapies were used in the selected studies: haloperidol, ziprasidone, aripiprazole, and methylphenidate. Aripiprazole showed a complete resolution of hypoactive delirium (P < .001), and methylphenidate showed a significant amelioration in cognitive function (P < .001). Ziprasidone and haloperidol did not show significant differences compared with placebo.Conclusions and ImplicationsA limited number of clinical studies on the treatment of hypoactive delirium are available. Aripiprazole and methylphenidate showed promising results in the treatment of hypoactive delirium.