Hyperphosphatemia and phosphate binders: effectiveness and safety

In patients with kidney dysfunction hyperphosphatemia is more evident as renal failure progresses. It is related to increased FGF-23 levels, secondary hyperparathyroidism, and accelerated progressive vascular calcification. In CKD patients advanced coronary artery calcification is strongly associated with future cardiovascular events, cardiovascular death, and all-cause mortality. Apart from the above, phosphate per se is suspected as a causal risk factor for CKD progression. Keeping serum phosphorus within the target values are linked to improvement in life expectancy. A low phosphate diet, an efficient dialysis removal of phosphate load, and the administration of phosphate binders are the main recommended steps to control hyperphosphatemia. Calcium-based phosphate binders can lead to a positive calcium balance, hypercalcaemia, parathyroid gland suppression, adynamic bone disease, and coronary artery and aortic calcification. On the other hand Sevelamer hydrochloride and Lanthanum carbonate has been shown to be effective, safe and useful therapeutic tools for hyperphosphatemia. When prescribe pharmacological agents, one must take into account the large increase in health-care expenditure and the choice of phosphate binder should be individualized.     

Effectiveness on high-grade cervical abnormalities and long-term safety of the quadrivalent human papillomavirus vaccine in Japanese women

This study for the first time assessed quadrivalent human papillomavirus (qHPV) vaccine effectiveness against HPV6/11/16/18-related high-grade cervical disease in Japanese women (16–26 years old), as previously demonstrated in overseas trials, and vaccine safety in a longer term (48-month) open-label study (NCT01544478). Participants received three doses of qHPV vaccine (Day 1, Month 2, Month 6). Effectiveness endpoints, assessed in the per-protocol population, included incidence of HPV6/11/16/18-related cervical intraepithelial neoplasia (CIN) Grade 2 or worse (CIN Grade 2 and 3, adenocarcinoma in situ, and/or cervical cancer) as primary endpoint and incidence of external genital lesions (EGLs). Disease related to other high-risk HPV types was also assessed. Adverse events (AEs) and serious AEs (SAEs) were collected from Days 1–15 after any vaccination; vaccine-related SAEs, deaths, and new medical conditions were collected throughout the study. A total of 1030 women received at least one vaccination. No cases of CIN2 or worse or EGLs were reported in the per-protocol population. Injection site-related AEs were reported in 14.5% of participants; most were mild and resolved within 15 days. Vaccine-related systemic AEs occurred in 8.6% of participants, most commonly headache (2.3%), malaise (1.7%), and pyrexia (1.3%). There were no vaccine-related SAEs; one participant discontinued due to a vaccine-related AE of mild uticaria. Overall, qHPV vaccine effectiveness against HPV6/11/16/18-related high-grade cervical disease and EGLs was indicated in Japanese women. The vaccine was well-tolerated, without new safety signals throughout the 48-month study period. Findings are consistent with overseas qHPV vaccine pivotal trials.Clinical trial registryclinicaltrials.gov; NCT01544478.     

Association between teaching and support skills and subjective effectiveness of nutritional guidance of registered dietitians at hospitals in a Japanese prefecture

Objective

The aim of this study is to clarify the association between teaching and support skills and the subjective effectiveness of nutritional guidance of registered dietitians working at hospitals.

Methods

We carried out a questionnaire survey of registered dietitians at hospitals in a Japanese prefecture. The utilization of nutritional teaching skills in nutritional guidance was investigated using a self-produced 36-item questionnaire that was designed to be mainly used for diabetic patients in 4 settings: first guidance, first assessment, contemplation stage, and preparation stage. The support skills were evaluated by Kikuchi’s Scale of Social Skills: 18 items. The subjective effectiveness of nutritional guidance was defined by the behavioral change of the patients after nutritional guidance as evaluated by a registered dietitian.

Results

There were 75 respondents (response rate 46.6 %). Among the teaching skills, basic skills in an interview were often used, but some related to coaching skills were not in common use in nutritional guidance. Based on the results of principal component analysis, we created a scale for scoring the utilization of nutritional teaching skills in each setting. Multiple linear regression analysis illustrated that high subjective effectiveness of nutritional guidance was associated with high score of teaching skills in the preparation stage setting and high score of support skills.

Conclusions

These results show that, in addition to frequent use of nutritional teaching skills, improvement of support skills is also necessary to enhance the effectiveness of nutritional guidance.     

Beyond direct impact: Evidence synthesis towards a better understanding of effectiveness of environmental health interventions

Systematic reviews are a cornerstone of evidence-based public health, and there is much discussion on how this method may need to be modified to do justice to complex interventions, such as environmental health interventions. This paper asserts that intervention effectiveness is influenced by variability in five distinct layers – direct (intrinsic) impact, user compliance, delivery, programming and policy measures – which are embedded in the broader geographical, socio-economic, political and cultural context. The multi-component, multi-sectoral nature of most environmental health interventions results in a complex relationship between these layers of influence, involving systemic interactions. As illustrated with examples, understanding environmental health interventions critically relies on considering all of these layers. These distinct layers of influence can serve as a framework towards the comprehensive analysis of environmental health interventions in systematic reviews, drawing on quantitative and qualitative methods and a variety of disciplines.     

Prolonged effectiveness of coronary artery bypass surgery versus drug-eluting stents in diabetics with multi-vessel disease: An updated systematic review and meta-analysis

Background

Currently, the appropriateness of percutaneous coronary intervention (PCI) using drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) for patients with diabetes (DM) and multi-vessel disease (MVD) is uncertain due to limited evidence from few randomised controlled trials (RCTs). We aimed to compare the clinical effectiveness of CABG versus PCI-DES in DM-MVD patients using an evidence-based approach.

Methods

A systematic review and meta-analyses were conducted to compare the risk of all-cause mortality, myocardial infarction (MI), repeat revascularisation, cerebrovascular events (CVE), and major adverse cardiac or cerebrovascular events (MACCE).

Results

A total of 1,837 and 3,052 DM-MVD patients were pooled from four RCTs (FREEDOM, SYNTAX, VA CARDS, and CARDia) and five non-randomised studies. At mean follow-up of 3 years, CABG compared with PCI-DES was associated with a lower risk of all-cause mortality and MI in RCTs. By contrast, no significant differences were observed in the mean 3.5-year risk of all-cause mortality and MI in non-randomised trials. However, the risk of repeat revascularisations following PCI-DES compared with CABG was 2.3 (95% CI = 1.8–2.8) and 3.0 (2.3–4.2)-folds higher in RCTs and non-randomised trials, respectively. Accordingly, the risk of MACCE at 3 years following CABG compared with PCI-DES was lower in both RCTs and non-randomised trials [0.65 (: 0.55–0.77); and 0.77 (0.60–0.98), respectively].

Conclusions

Based on our pooled results, we recommend CABG compared with PCI-DES for patients with DM-MVD. Although non-randomised trials suggest no additional survival-, MI-, and CVE- benefit from CABG over PCI-DES, these results should be interpreted with care.     

The effectiveness of nurse practitioner care for patients with mental health conditions in primary care settings: A systematic review

BackgroundThe nurse practitioner (NP) workforce is key to meeting the demand for mental health services in primary care settings.PurposeThe purpose of this study is to synthesize the evidence focused on the effectiveness of NP care for patients with mental health conditions in primary care settings, particularly focused on primary care NPs and psychiatric mental health NPs and patients with anxiety, depression, and substance use disorders.MethodsStudies published since 2014 in the United States studying NP care of patients with anxiety, depression, or substance use disorders in primary care settings were included.FindingsSeventeen studies were included. Four high-quality studies showed that NP evidence-based care and prescribing were comparable to that of physicians. Seven low-quality studies suggest that NP-led collaborative care is associated with reduced symptoms.DiscussionMore high-quality evidence is needed to determine the effectiveness of NP care for patients with mental health conditions in primary care settings.     

Effectiveness of Procedural Sedation and Analgesia in Pediatric Emergencies. A Cross-Sectional Study

IntroductionPain is defined as an unpleasant emotional and sensory experience associated with bodily harm or with situations that cause fear and anxiety. However, it is often undertreated in pediatric emergency departments. This study aims to assess the effectiveness of sedation-analgesia techniques, level of satisfaction among health care professionals and relatives, and agreement between the satisfaction of health care professionals and relatives.MethodsA cross-sectional design was conducted. Sociodemographic and clinical variables were recorded, together with those for effectiveness using the Face, Legs, Activity, Cry, and Consolability scale and the Wong-Baker FACES scale, and the satisfaction using the 10-point Likert scale. Stata 16.1 was used for data analysis.ResultsA total of 94 procedures were registered. The results suggested that these techniques were effective or mildly effective in only half of the cases. Satisfaction was considered good across the board, and the agreement between health care professionals (ie, pediatric nurses and pediatricians) was considered substantial. However, the agreement between health care professionals and relatives was moderate.DiscussionOur results suggested that the adequate management of pain in pediatric emergency departments is still a challenge, despite the availability of international guidelines. Future research lines should be focused on analyzing possible causes of the inefficacy of some sedation-analgesia techniques and the causes of the differences between the perspectives of health care professionals and relatives. These research lines may be useful to improve quality of care and pediatric patient comfort.     

中西医结合治疗单纯性卵巢囊肿临床分析

目的：研究中西医结合治疗单纯性卵巢囊肿的有效性。方法选取2007年3月～2012年6月我科收治的单纯性卵巢囊肿170例进行回顾性分析,所选患者囊肿直径均＜6cm,根据治疗方法将患者分为治疗组和对照组,治疗组85例,在患者月经来潮前1周进行中西医结合治疗,即采用一般西药和口服中药治疗。对照组85例,患者采用一般西药治疗,两组均为3个月为1个疗程,1个疗程后在月经干净后3～7d,用B超检测其囊肿变化情况。结果治疗组治愈46例,好转37例,无效2例,总有效率达到97.6%;对照组治愈27例,好转43例,无效15例,总有效率达到82.4%。两组比较差异具有统计学意义（P＜0.05）。结论中西医结合治疗单纯性卵巢囊肿比单纯的西药治疗更有效,可供临床参考。