The Evidence Base for Revascularisation of Chronic Total Occlusions

When patients with ischaemic heart disease are considered for revascularisation the Heart Team’s aim is to choose a therapy that will provide complete relief of angina for an acceptable procedural risk. Complete functional revascularisation of ischaemic myocardium is thus the goal and for this reason the presence of a chronic total occlusion (CTO) - which remain the most technically challenging lesions to revascularise percutaneously - is the most common reason for selecting coronary artery bypass surgery [1]. From the behaviour of Heart Teams it is clear that physicians believe that CTOs are important. Yet when faced with patients with CTOs for whom surgery appears excessive (e.g. nonproximal LAD) or too high risk, there remains a reluctance to undertake CTO PCI, despite significant recent advances in procedural success and safety and a considerable body of evidence supporting a survival benefit following successful CTO PCI. This article reviews the relationship between CTOs, symptoms of angina, ischaemia and left ventricular dysfunction and further explores the evidence relating their treatment to improved quality of life and prognosis in patients with these features.     

Interventions to support recovery after domestic and sexual violence in primary care

Abstract

Experiences of domestic and sexual violence are common in patients attending primary care. Most often they are not identified due to barriers to asking by health practitioners and disclosure by patients. Women are more likely than men to experience such violence and present with mental and physical health symptoms to health practitioners. If identified through screening or case finding as experiencing violence they need to be supported to recover from these traumas. This paper draws on systematic reviews published in 2013–2015 and a further literature search undertaken to identify recent intervention studies relevant to recovery from domestic and sexual violence in primary care. There is limited evidence as to what interventions in primary care assist with recovery from domestic violence; however, they can be categorized into the following areas: first line response and referral, psychological treatments, safety planning and advocacy, including through home visitation and peer support programmes, and parenting and mother–child interventions. Sexual violence interventions usually include trauma informed care and models to support recovery. The most promising results have been from nurse home visiting advocacy programmes, mother–child psychotherapeutic interventions, and specific psychological treatments (Cognitive Behaviour Therapy, Trauma informed Cognitive Behaviour Therapy and, for sexual assault, Exposure and Eye Movement Desensitization and Reprocessing Interventions). Holistic healing models have not been formally tested by randomized controlled trials, but show some promise. Further research into what supports women and their children on their trajectory of recovery from domestic and sexual violence is urgently needed.     

Improving the analysis of routine outcome measurement data: what a Bayesian approach can do for you

Since recent decades, clinicians offering interventions against mental problems must systematically collect data on how clients change over time. Since these data typically contain measurement error, statistical tests have been developed which should disentangle true changes from random error. These statistical tests can be subdivided into two types: classical tests and Bayesian tests. Over the past, there has been much confusion among analysts regarding the questions that are answered by each of these tests. In this paper we discuss each type of test in detail and explain which questions are, and which are not, answered by each of the types of tests. We then apply a test of each type on an empirical data set and compare the results. Copyright © 2015 John Wiley & Sons, Ltd     

Developing a culture of nursing research through clinical-academic partnership

Evidence based practice is essential to advanced practice nursing, enabling the delivery of quality care and improved patient outcomes. As the name suggests, it requires healthcare decisions to be based on the best available and current evidence. Advanced practice nurses need astute critical analysis skills to appraise the evolving literature, and require research skills to lead on scientific inquiry and develop the profession. Yet, advanced practice nurses may not recognize themselves as research leaders. Participation in a journal club can promote evidence-based practice, improve clinician's critical thinking skills, and expose members to different research methodologies, however, nurses continue to face barriers to participation in these clubs. Establishing a clinical-academic partnership appears to be both mutually beneficial for clinicians and academics and is a significant enabler in the sustainability and functioning of the club through sharing expertise and experience. A supportive workplace culture is favourable to research utilization and knowledge translation. This paper outlines the role, practicalities, challenges, and benefits of setting up a hybrid urology journal and research club for advanced practice nurses in a clinical-academic partnership.     

丹参多酚酸盐注射液联合西医常规治疗对慢性心力衰竭疗效及安全性的系统评价及试验序贯分析

目的 系统评价丹参多酚酸盐注射液联合西医常规治疗对慢性心力衰竭的有效性和安全性。方法 计算机检索中国知网、万方、维普、PubMed等数据库中相关随机对照试验(randomized controlled trials,RCTs),检索时间限定为建库至2022年3月20日。采用偏倚风险评估工具进行文献质量评价,使用RevMan 5.3、Stata 15.0软件进行Meta分析,通过TSA 0.9.5.10 Beta软件进行试验序贯分析,并按照GRADE标准进行证据质量评价。结果 最终共纳入23个RCTs,共计2421例患者,纳入研究的整体方法学质量较低。Meta分析结果显示,与西医常规治疗相比,联合丹参多酚酸盐注射液可显著提高临床总有效率[OR=3.95,95% CI(2.92,5.35),P<0.000 01],降低Lee心衰评分[MD=−0.95,95% CI(−1.37,−0.52),P<0.000 1],提高6 min步行距离[MD=44.50,95% CI(32.02,56.97),P<0.000 01],降低血浆B型脑钠肽(B-type natriuretic peptide,BNP)浓度[MD=−74.78,95% CI(−89.24,−60.33),P<0.000 01];改善心功能指标,包括提高射血分数(left ventricular ejection fraction,LVEF)[MD=5.33,95% CI(4.33,6.32),P<0.000 01],降低左室收缩末期内径(left ventricular end systolic diameter,LVESD)[MD=−5.73,95% CI(−8.04,−3.43),P<0.000 01]、左室舒张末期内径(left ventricular end-diastolic diameter,LVEDD)[MD=−5.12,95% CI(−7.16,−3.08),P<0.000 01]及室间隔厚度(interventricular septal thickness,IVST)[MD=−1.12,95% CI(−1.60,−0.64),P<0.000 01],提高心输出量(cardiac output,CO)[MD=1.12,95% CI(1.00,1.23),P<0.000 01]、心脏指数(cardiac index,CI)[MD=1.12,95% CI(1.00,1.25),P<0.000 01]及每搏量(stroke volume,SV)[MD=9.34,95% CI(5.39,13.29),P<0.000 01];降低炎症指标,包括白细胞介素-6(interleukin-6,IL-6)[MD=−1.84,95% CI(−2.36,−1.31),P<0.000 01]、肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)[MD=−0.74,95% CI(−0.83,−0.66),P<0.000 01]及超敏C反应蛋白(high-sensitivity C-reactive protein,hs-CRP)[MD=−0.97,95% CI(−1.27,−0.67),P<0.000 01];降低心型脂肪酸结合蛋白(heart fatty acid binding protein,H-FABP)表达[MD=−9.74,95% CI(−12.21,−7.27),P<0.000 01]。在不良反应发生率方面,两组比较差异无统计学意义[RR=0.63,95% CI(0.18,2.17),P=0.47]。试验序贯分析进一步肯定了联合丹参多酚酸盐注射液对慢性心力衰竭患者的疗效。GRADE证据质量分级显示临床总有效率为中等质量证据,Lee心衰评分、LVESD等8项结局指标均为低质量证据,其余均为极低质量证据。结论 与西医常规治疗相比,联合丹参多酚酸盐注射液能显著提高临床疗效,无明显不良反应,然而证据等级不高,期待开展更多高质量、大样本、多中心的RCTs,为丹参多酚酸盐注射液治疗慢性心力衰竭提供更充分的循证证据。