Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis

OBJECTIVE: To assess the efficacy of topical chlorhexidine for prevention of ventilator-associated pneumonia (VAP) in a meta-analysis. DATA SOURCE: Computerized PubMed and MEDLINE search supplemented by manual searches for relevant articles. STUDY SELECTION: Randomized controlled trials evaluating efficacy of topical chlorhexidine applied to the oropharynx vs. placebo or standard care for prevention of VAP. DATA EXTRACTION: Data were extracted on patient population, inclusion and exclusion criteria, diagnostic criteria for VAP, form and concentration of topical chlorhexidine used, incidence of VAP, and overall mortality. DATA SYNTHESIS: Data on incidence of VAP and mortality were abstracted as dichotomous variables. Pooled estimates of the relative risk and 95% confidence intervals were obtained using the DerSimonian and Laird random effects model and the Mantel-Haenszel fixed effects model. Heterogeneity was assessed using the Cochran Q statistic and I. Subgroup analyses were used to explore heterogeneity. RESULTS: Seven randomized controlled trials met the inclusion criteria. Topical chlorhexidine resulted in a reduced incidence of VAP (relative risk, 0.74; 95% confidence interval, 0.56-0.96; p=.02) using a fixed effects model. Using the more conservative random effects model, the point estimate was similar (relative risk, 0.70; 95% confidence interval, 0.47-1.04; p=.07), but the results failed to achieve statistical significance. The I test showed moderate heterogeneity. Subgroup analysis showed that the benefit of chlorhexidine was most marked in cardiac surgery patients (relative risk, 0.41; 95% confidence interval, 0.17-0.98; p=.04). There was no mortality benefit with chlorhexidine although the sample size was small. CONCLUSIONS: Our analysis showed that topical chlorhexidine is beneficial in preventing VAP; the benefit is most marked in cardiac surgery patients. A large randomized trial is needed to determine the impact of topical chlorhexidine on mortality.     

Topical capsaicin for the treatment of cannabinoid hyperemesis syndrome,a systematic review and meta-analysis

IntroductionCannabinoid hyperemesis syndrome (CHS) is a condition that is being recognized and treated more frequently in emergency departments (EDs) across the United States. Currently, ED providers rely on antiemetics, antipsychotics and benzodiazepines to alleviate the symptoms. Topical capsaicin, a transient receptor potential vanilloid 1 (TRPV1) agonist, has been proposed in recent years as a low-cost and effective alternative to the traditional antiemetic regimen when treating CHS. The aim of this systematic review and meta-analysis is to demonstrate the reliability and the gaps of what is known about this treatment modality.MethodsArticles were extracted from PubMed, SCOPUS, and Google Scholar databases. Publication dates ranged from the inception of the databases to October 2020. Initial searches found 328 studies. After careful review and screening by two investigators, 7 studies met the inclusion criteria and were included for our meta-analysis. Variables that were evaluated included the prevalence of hospital admissions for patients treated with capsaicin, time to relief of symptoms after capsaicin administration, and ED length of stay (LOS). I-square and Q-statistic values were used to assess heterogeneity.ResultsAmong the 7 studies, there was a total of 106 patients. Two studies reported time to resolution of symptoms following capsaicin administration and ED LOS. Means for these outcomes were 325 (95% CI 234–787) and 379 (95% CI 10–747) minutes respectively. I-square was 44%, and Q-statistic was 11 with 6 degrees of freedom, with a p-value of 0.1.DiscussionWith acceptable time to resolution of symptoms after topical administration and ED LOS, capsaicin appears to be an effective treatment option for symptomatic relief of CHS. Further randomized controlled trials should be conducted to examine if it is the more efficacious and efficient treatment for CHS across various care settings.     

Topical antibacterial therapy for mycobacterial keratitis: potential for surgical prophylaxis and treatment

BACKGROUND: Mycobacterium chelonae and Mycobacterium fortuitum are the 2 most commonly implicated species of nontuberculous mycobacteria in cases of bacterial keratitis. OBJECTIVES: This article summarizes available data on the in vitro antibacterial activity against M chelonae or M fortuitum of 2 agents-amikacin and clarithromycin-that have been used in the treatment of bacterial keratitis. In addition, the article reviews the in vitro activity of 5 commercially available topical ocular fluoro-quinolones (in order of availability, ciprofloxacin, ofloxacin, levofloxacin, gatifloxacin, and moxifloxacin) that may have potential in the surgical prophylaxis and treatment of keratitis caused by M chelonae or M fortuitum. METHODS: A search of the English-language literature indexed on the MEDLINE, Life Sciences, EMBASE, BIOSIS, and Pharmaprojects databases from 1966 to October 7, 2003, was conducted using the terms Mycobacterium chelonae, Mycobacterium fortuitum, bacterial keratitis, topical antibiotic therapy, ocular infection-mycobacteria, and LASIK infections. Data on the minimum concentrations at which 90% of isolates were inhibited (MIC(90)s) were reviewed and compared. RESULTS: In the literature reviewed, the MIC(90) against M fortuitum was from 1 to 16 microg/mL for amikacin, from /=8 microg/mL for clarithromycin, from 0.1 to 1 microg/mL for ciprofloxacin, from 0.5 to 3.13 microg/mL for ofloxacin, and 相似文献   

Topical tacrolimus: a new therapy for atopic dermatitis

Atopic dermatitis is a common problem affecting up to 10 percent of all children. The mainstays of therapy have been oral antihistamines, topical emollients, topical doxepin, and topical corticosteroids. Side effects associated with higher potency topical corticosteroids have limited their use in children and for facial areas. Tacrolimus (Protopic) is an immunosuppressive agent typically used systemically in transplant patients. Used topically, it has been found to be effective in treating moderate to severe atopic dermatitis without causing the atrophy that might occur with prolonged use of topical corticosteroids. Tacrolimus works equally well in children and adults, with more than two thirds of both groups having an improvement of greater than 50 percent. Despite its potency, very little of the medication is systemically absorbed, and absorption decreases as the atopic dermatitis resolves. The main side effects are burning and itching, but these also decrease with improvement of the atopic dermatitis.     

Topical therapy for acne

Acne is a common problem in adolescents and young adults. The disorder is caused by abnormal desquamation of follicular epithelium that results in obstruction of the pilosebaceous canal. This obstruction leads to the formation of comedones, which can become inflamed because of overgrowth of Propionibacterium acnes. Topical retinoids such as tretinoin or adapalene are effective in many patients with comedonal acne. Patients with inflammatory lesions benefit from treatment with benzoyl peroxide, azelaic acid or topical antibiotics. Frequently, the use of comedonal and antibacterial agents is required.     

Pharmacologic therapy for the treatment and prevention of osteoporosis

Clinicians have an expanding menu of attractive pharmacologic options for the prevention and treatment of postmenopausal and age-related osteoporosis. Moreover, there exists excellent data from well-designed clinical trials documenting the effectiveness and tolerability of these therapies. Bone loss can be prevented in postmenopausal women of any age. Fracture risk can be reduced substantially in men and women with previous vertebral fractures or bone density values consistent with osteoporosis. It is clear that therapy is warranted in patients at high fracture risk. Important clinical challenges include devising effective strategies to identify those patients for whom treatment is indicated and to enhance both the accepting and long-term adherence to therapy by patients.     

Antithrombotic therapy for secondary prevention of unprovoked venous thromboembolism: a systematic review and network meta-analysis of randomized controlled trials

BackgroundExtended antithrombotic treatment is recommended for secondary prevention of unprovoked venous thromboembolism (VTE), however, there is no consensus on which antithrombotic strategy is preferable.AimTo compare the efficacy and safety of different antithrombotic strategies for secondary prevention unprovoked VTE.MethodsCochrane Central Register of Controlled Trials, Embase, and MEDLINE were systematically searched from inception to 22 July 2020 for randomized controlled trials (RCTs) that compared the efficacy and/or safety of extended antithrombotic strategies including aspirin, warfarin and direct oral anticoagulants (DOACs) for secondary prevention of unprovoked VTE. The primary outcome was risk of major bleeding and the secondary outcomes were risks of recurrent VTE and all-cause death. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using pairwise and network meta-analysis with random effect. Possible ranking of extended antithrombotic strategies was plotted using the surface under the cumulative ranking curve and mean ranks.ResultsSeventeen RCTs met the inclusion criteria, and meta-analysis results showed that warfarin was associated with significantly higher risk of major bleeding than placebo/observation (OR 2.71, 95% CI 1.32–5.55) or apixaban (OR 10.65, 95% CI 1.06–107.13). Apixaban and low-apixaban were the top two strategies according to the ranking of major bleeding. Warfarin (OR 0.25, 95%CI 0.13–0.49), rivaroxaban (OR 0.18, 95%CI 0.03–0.90), apixaban (OR 0.18, 95%CI 0.04–0.85) and low-apixaban (OR 0.18, 95%CI 0.04–0.82) were related to significantly lower risk than placebo/observation; edoxaban was non-inferior to warfarin on the risk of recurrent VTE. Furthermore, apixaban was linked with significantly lower risk of all-cause death than placebo/observation (OR 0.29, 95% CI 0.09–0.88).ConclusionApixaban showed superiority to other antithrombotic strategies on major bleeding and all-cause death for secondary prevention of unprovoked VTE. Further studies are warranted owing to the limited number of studies and positive cases.

Key messages

1. All antithrombotic strategies including warfarin, DOACs and aspirin were superior to placebo/observation on recurrent VTE for secondary prevention of unprovoked VTE.
2. Apixaban demonstrated lower risk of major bleeding than warfarin, and lower risk of all-cause death than placebo/observation.
3. Further research about the efficacy and safety of antithrombotic treatments for secondary prevention of unprovoked VTE is warranted.

     

Topical photodynamic therapy: an introduction for nurses

Non-melanoma skin cancers are the most common cancers in the UK. Although an estimated 50000 cases were registered in 1999 across England and Wales, there is likely to be significant under-reporting of cases. However, the cancer registries do not include pre-cancerous lesions of the skin and therefore the number treated will greatly outnumber the cancers (National Institute for Health and Clinical Excellence, 2006). Topical photodynamic therapy (PDT) is one of several effective treatments for pre-malignant and malignant non-pigmented skin cancers. The treatment is non-invasive and can be administered by nurses in a clinical setting. PDT is a two-step process involving the application of a light-activated substance followed by exposure to light to activate this substance. The treatment results in the elimination of tumour cells while leaving the healthy skin unharmed. This article provides an introduction to PDT for nurses who may in the future be involved in setting up a PDT service within their practice area.     

牛奶生土豆泥面膜预防放射性皮炎效果观察

放疗是恶性肿瘤的主要治疗手段之一,放射性皮炎是放疗过程中常见的并发症。轻者出现红斑、色素沉着、皮肤瘙痒、干性脱皮,重者出现水疱、渗出,甚至糜烂、坏死,影响放疗的正常进行。有效预防和治疗放射性皮炎成为亟待解决的问题。目前,最常用的治疗方法是外涂药剂,但疗效常不显著。我科护理人员在总结各种预防措施基础上,制作牛奶生土豆泥面膜湿敷放疗野皮肤,预防皮炎发生、发展,效果显著。现报道如下。     

Early mobilisation for prevention and treatment of delirium in critically ill patients: Systematic review and meta-analysis

ObjectiveDoes early mobilisation as standalone or part of a bundle intervention, compared to usual care, prevent and/or shorten delirium in adult patients in Intensive Care Units?BackgroundEarly mobilisation is recommended for the prevention and treatment of delirium in critically ill patients, but the evidence remains inconclusive.MethodSystematic literature search in Pubmed, CINAHL, PEDRo, Cochrane from inception to March 2022, and hand search in previous meta-analysis. Included were randomized trials or quality-improvement projects. meta-analysis was performed for Odds Ratios or mean differences including 95% Confidence Intervals for presence/duration of delirium. Risk of bias was assessed by using Joanna Briggs Quality criteria. meta-regression was performed to analyse heterogeneity.ResultsThe search led to 13 studies of low-moderate risk of bias including 2,164 patients. Early mobilisation reduced the risk of delirium by 47 % (13 studies, 2,164 patients, low to moderate risk of bias: Odds Ratio 0.53 (95 % Confidence Interval 0.34 till 0.83, p = 0.01), with significant heterogeneity (I² = 78 %, p < 0.001). Early mobilisation also reduced the duration of delirium by 1.8 days (3 studies, 296 patients, low-moderate risk of bias: Mean difference −1.78 days (95 % Confidence Interval −2.73 till −0.83 days, p < 0.001), heterogeneity 0 % (p = 0.41). Other analyses such as low risk of bias studies, randomised trials, studies published ≥ 2017, high intensity, and mobilisation as stand-alone intervention showed no significant results, with conflicting certainty of evidence and high heterogeneity. meta-regression could not explain heterogeneity.ConclusionThere is an uncertain effect of mobilisation on delirium. Provision of early mobilisation to critical ill patients might prevent delirium. There is a possible effect of early mobilisation to shorten the duration of delirium. Due to the heterogeneity in the findings, further research to define the best method and dosage of early rehabilitation is required.     

Echinacea for the prevention and treatment of upper respiratory tract infections: A systematic review and meta-analysis

BackgroundEchinacea preparations are commonly used to prevent and treat upper respiratory tract infection.ObjectivesTo assess current evidence for the safety and efficacy of echinacea containing preparations in preventing and treating upper respiratory tract infection.Data sourcesMEDLINE, EMBASE, CAB extracts, Web of Science, Cochrane DARE, clinicaltrials.gov and the WHO ICTRP – 1980 to present day.Eligibility criteriaRandomised double-blind placebo-controlled trials using an echinacea preparation to prevent or treat upper respiratory tract infections.Participants and interventionsParticipants who are otherwise healthy of any age and sex. We considered any echinacea containing preparation.Study appraisal and synthesis methodsWe used the Cochrane collaborations tool for quality assessment of included studies and performed three meta-analyses; on the prevention, duration and safety of echinacea.ResultsFor the prevention of upper respiratory tract infection using echinacea we found a risk ratio of 0.78 [95% CI 0.68–0.88], for the treatment of upper respiratory tract infection using echinacea we found a mean difference in average duration of −0.45 [95% 1.85–0.94] days, finally for the safety meta-analyses we found a risk ratio of 1.09 [95% CI 0.95–1.25].LimitationsThe limitations of our review include the clinical heterogeneity – for example many different preparations were tested, the risk of selective reporting, deviations from our protocol and lack of contact with study authors.ConclusionsOur review presents evidence that echinacea might have a preventative effect on the incidence of upper respiratory tract infections but whether this effect is clinically meaningful is debatable. We did not find any evidence for an effect on the duration of upper respiratory tract infections. Regarding the safety of echinacea no risk is apparent in the short term at least. The strength of these conclusions is limited by the risk of selective reporting and methodological heterogeneity.Implications of key findingsBased on the results of this review users of echinacea can be assured that echinacea preparations are safe to consume in the short term however they should not be confident that commercially available remedies are likely to shorten the duration or effectively prevent URTI. Researchers interested in the potential preventative effects of echinacea identified in this study should aim to increase the methodological strength of any further trials.PROSPERO IDCRD42018090783.     

Duration of antibiotic therapy for bacteremia: a systematic review and meta-analysis

Introduction  

The optimal duration of antibiotic therapy for bloodstream infections is unknown. Shorter durations of therapy have been demonstrated to be as effective as longer durations for many common infections; similar findings in bacteremia could enable hospitals to reduce antibiotic utilization, adverse events, resistance and costs.     

干细胞、运动疗法与糖尿病防治的相关性

干细胞是一类具有自我复制能力的多潜能细胞,在一定条件下可以定向分化成为机体内的功能细胞,形成多种类型组织和器官以代替损伤和坏死的相关组织,从而达到治疗疾病的目的.胰岛干细胞和骨髓干细胞对糖尿病的防治具有重要的作用,胰岛干细胞可以通过移植、诱导等识别其特异分子标志,从中筛选胰岛素分泌细胞调整胰岛素的分泌量,但对其研究的机制仍存在较多不足;而骨髓干细胞可以通过直接的转分化和间接分化、移植诱导微嵌合状态,形成免疫耐受、细胞融合以及参与细胞的修复和再生等方式治疗糖尿病患者.运动疗法对于2型糖尿病患者来说,具有药物所不可替代的重要治疗作用,运动疗法能够通过降低血糖、改善肥胖和胰岛素抵抗,调节自身免疫能力,推迟或避免糖尿病并发症的发生,但目前有关运动疗法对影响糖尿病患者干细胞尤其是影响移植效果方面的实验研究仍是一项空白.     

Massage therapy for the treatment of neonatal jaundice: A systematic review and network meta-analysis

Neonatal jaundice is a common health problem seen in 60–80% of newborns. Electronic search in nine databases was done for randomized controlled trials. Twenty seven studies were eligible for quantitative analysis. For neonates requiring phototherapy (PT), in 3rd and 4th days of life, massage and phototherapy was more effective in reducing bilirubin, compared to phototherapy alone. However, this effect became insignificant in the 14th day of life. In contrast, massage with enema and phototherapy significantly reduced bilirubin at the age of 14 days. For neonates not requiring PT, the best reduction was observed with the acupressure massage between the 3rd and 7th days. In the 14th day, massage combined with bathing appears to be the most effective. Massage therapy could be an effective adjuvant to PT in order to reduce the PT duration. However, it did not reduce the requirement for PT.     

集束化干预方案预防谵妄有效性的Meta分析

目的:通过Meta分析明确集束化谵妄预防措施的有效性。方法:检索万方、PubMed等数据库,对纳入研究进行质量评价后,应用RevMan 5.3软件进行分析。结果:共纳入12篇文献,发现针对谵妄危险因素的干预措施对降低谵妄发生率和住院病死率具有综合效应,分别下降40%和79%。结论:集束化措施可有效降低谵妄发生率和病死率。     

Statin therapy: rationale for a new agent,rosuvastatin

Cardiovascular disease (CVD) remains a major cause of death in industrialised societies, and elevated serum lipids are a significant, highly prevalent and undertreated risk factor for this condition. The 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) have revolutionised the treatment of hyperlipidaemia, and results from large-scale, long-term clinical trials have shown that the substantial reductions in low-density lipoprotein cholesterol (LDL-C) achieved with these drugs are associated with dramatic decreases in cardiovascular risk. Results from recent comparative clinical trials that have included a new drug in this class, rosuvastatin (Crestor), have demonstrated that it is significantly superior to atorvastatin, pravastatin and simvastatin in reducing total cholesterol, LDL-C and apolipoprotein B (Apo B). It is also significantly more effective than atorvastatin in increasing high-density lipoprotein cholesterol (HDL-C) and apolipoprotein A-I (Apo A-I). Rosuvastatin was also superior to all these agents in helping patients meet European Atherosclerosis Society (EAS) and National Cholesterol Education Programme (NCEP) goals for LDL-C. The results of an increasing number of studies indicate that statins have a wide range of pleiotropic properties that almost certainly contribute to their ability to decrease cardiovascular risk and may also make them valuable for treatment of other diseases. These actions include plaque stabilisation, improvement of endothelial function, inhibition of smooth muscle cell proliferation and migration, reduction of expression of adhesion molecules, prevention of cholesterol esterification and accumulation, reduction of secretion of matrix metalloproteinases by macrophages, reduction of platelet activity, reduction of formation of thrombogenic factors, chemoprotection and induction of bone morphogenic protein-2 (BMP-2). Further exploration of these actions will provide key information about class effects and properties of specific members of this highly useful group of drugs.