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PubMed2004

Policy implications associated with the socioeconomic and health system impact of telehealth: a case study from Canada.

This research was undertaken to inform future telehealth policy directions regarding the socioeconomic impact of telehealth. Fifty-seven sources were identified and analyzed through a comprehensive literature search of electronic databases, the Internet, journals, conference proceedings, as well as personal communication with consultants in the field. The review revealed a focus on certain socioeconomic indicators such as cost, access, and satisfaction. It also identified areas of opportunity for further research and policy analysis and development (e.g., social isolation, life stress, poverty), along with various barriers and challenges to the advancement of telehealth. These included confidentiality, reimbursement, and legal and ethical considerations. To become fully integrated into the health care system, telehealth must be viewed as more than an add-on service. This paper offers 19 general and 20 subject-specific telehealth recommendations, as well as seven policy strategies.

Alberta↗
PubMed2003

Relative efficacy of differential methods of dietary advice: a systematic review.

BACKGROUND: Dietary advice to lower blood cholesterol may be given by a variety of means. The relative efficacy of the different methods is unknown. OBJECTIVE: The objective was to assess the effects of dietary advice given by dietitians compared with advice from other health professionals, or self-help resources, in reducing blood cholesterol in adults. DESIGN: We performed a systematic review, identifying potential studies by searching the electronic databases of the Cochrane Library, MEDLINE, EMBASE, CINAHL, Human Nutrition, Science Citation Index, and Social Sciences Citation Index. We also hand-searched relevant conference proceedings, reference lists in trial reports, and review articles. Finally, we contacted experts in the field. The selection criteria included randomized trials of dietary advice given by dietitians compared with advice given by other health professionals or self-help resources. The main outcome was difference in blood cholesterol between the dietitian group compared with other intervention groups. Inclusion decisions and data extraction were duplicated. RESULTS: Eleven studies with 12 comparisons met the inclusion criteria. Four studies compared dietitians with doctors, 7 with self-help resources, and 1 with nurses. Participants receiving advice from dietitians experienced a greater reduction in blood total cholesterol than those receiving advice from doctors (-0.25 mmol/L, 95% CI -0.37, -0.12 mmol/L). There was no statistically significant difference in change in blood cholesterol between dietitians and self-help resources (-0.10 mmol/L, 95% CI -0.22, 0.03 mmol/L). CONCLUSIONS: Dietitians appeared to be better than doctors at lowering blood cholesterol in the short to medium term, though the difference was small (about 4%), but there was no evidence that they were better than self-help resources or nurses.

Cholesterol↗
PubMed2006

Association between Agent Orange and birth defects: systematic review and meta-analysis.

BACKGROUND: The association between parental exposure to Agent Orange or dioxin and birth defects is controversial, due to inconsistent findings in the literature. The principal aim of this study was to conduct a meta-analysis of relevant epidemiological studies that examined this association and to assess the heterogeneity among studies. METHODS: Relevant studies were identified through a computerized literature search of Medline and Embase from 1966 to 2002; reviewing the reference list of retrieved articles and conference proceedings; and contacting researchers for unpublished studies. A specified protocol was followed to extract data on study details and outcomes. Both fixed-effects and random-effects models were used to synthesize the results of individual studies. The Cochrane Q test and index of heterogeneity (I2) were used to evaluate heterogeneity, and a funnel plot and Egger's test were used to evaluate publication bias. RESULTS: In total, 22 studies including 13 Vietnamese and nine non-Vietnamese studies were identified. The summary relative risk (RR) of birth defects associated with exposure to Agent Orange was 1.95 [95% confidence interval (95% CI) 1.59-2.39], with substantial heterogeneity across studies. Vietnamese studies showed a higher summary RR (RR = 3.00; 95% CI 2.19-4.12) than non-Vietnamese studies (RR = 1.29; 95% CI 1.04-1.59). Sub-group analyses found that the magnitude of association tended to increase with greater degrees of exposure to Agent Orange, rated on intensity and duration of exposure and dioxin concentrations measured in affected populations. CONCLUSION: Parental exposure to Agent Orange appears to be associated with an increased risk of birth defects.

2,4,5-Trichlorophenoxyacetic Acid↗
PubMed2004

Anti-inflammatory effects of macrolides--an underappreciated benefit in the treatment of community-acquired respiratory tract infections and chronic inflammatory pulmonary conditions?

BACKGROUND: It has been recognized for more than 20 years that the macrolides have immunomodulatory effects that are beneficial for those suffering from chronic pulmonary inflammatory syndromes, such as diffuse panbronchiolitis, cystic fibrosis, asthma and bronchiectasis. The macrolides have consistently been associated with decreased length of stay and mortality when used alone or in combination with beta-lactam antibiotics. This effect can be demonstrated against combinations consisting of beta-lactams and other antibiotics active against 'atypical chest pathogens' when treating community-acquired pneumonia (CAP) in hospitalized patients. As such, it appears that the macrolides' effects in CAP patients are more than just antibacterial in nature. AIMS OF THIS REVIEW: This review aims: to give the reader information on the background areas described, as well as related areas; to review the CAP benefits with macrolides and how they may be related to the immunomodulatory properties they demonstrate, albeit in a shorter period of time than previously demonstrated with chronic pulmonary disorders; to use ex vivo data to support these extrapolations. LITERATURE SEARCH: A literature search using Medline was conducted from 1966 onwards, searching for articles with relevant key words such as macrolide, diffuse panbronchiolitis, community-acquired pneumonia, biofilm, immunomodulation, cystic fibrosis, erythromycin, clarithromycin, roxithromycin and azithromycin, bronchiectasis and asthma. When appropriate, additional references were found from the bibliographies of identified papers of interest. Any relevant scientific conference proceedings or medical texts were checked when necessary. CONCLUSIONS: (1) Research into macrolide immunomodulation for chronic pulmonary disorders demonstrates consistent positive effects, although of types other than seen with diffuse panbronchiolitis. These effects, together with their inhibitory activity on biofilms, have the potential to make them a useful option. (2) The benefits for CAP are consistent, and higher when a macrolide is given with another atypical agent than if the other atypical agent is given alone, suggesting a non-antibacterial benefit. (3) Recent research of the immunomodulatory properties of azithromycin imply that azithromycin may have a previously unknown short-term biphasic effect on inflammation modulation: enhancement of host defence mechanisms shortly after initial administration followed by curtailment of local infection/inflammation in the following period. (4) Additional in vivo research is needed prior to developing any firm conclusions.

Anti-Bacterial Agents↗
PubMed2005

Empirical antibiotics against Gram-positive infections for febrile neutropenia: systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: To assess the value of empirical anti-Gram-positive antibiotics for the treatment of febrile neutropenia. METHODS: Systematic review and meta-analysis of randomized controlled trials comparing antibiotics with anti-Gram-positive spectrum to control or placebo, in addition to the same baseline antibiotic regimen in both arms. We searched MEDLINE, EMBASE, LILACS, the Cochrane Library, conference proceedings, and references. No restrictions on inclusion were imposed. Two reviewers independently applied selection criteria, carried out quality assessment, and extracted the data. Relative risks with 95% confidence intervals were pooled using the fixed effect model. The primary outcome assessed was all-cause mortality. RESULTS: Thirteen studies met inclusion criteria, including 2392 participants. Glycopeptides were assessed in nine trials. Empirical anti-Gram-positive antibiotics were assessed for the initial treatment in 11 studies, and for persistent fever in two. No significant difference in all-cause mortality was seen [RR 0.86 (0.58-1.26), seven studies, 852 participants]. Overall failure at end of therapy occurred equally [RR 1.00 (0.79-1.27), six studies, 943 participants]. Failure associated with treatment modifications was more frequent in the control arm when empirical initial glycopeptides were assessed [RR 0.70 (0.61-0.80), five studies, 1178 participants]. Bacterial superinfections, mainly Gram-positive, were detected less frequently in the intervention arm. Adverse events were significantly more common with the additional antibiotic, and nephrotoxicity was significantly more common with additional glycopeptides [RR 1.88 (1.10-3.22), six studies, 1282 participants]. No significant heterogeneity was present in these comparisons. CONCLUSIONS: The use of glycopeptides can be safely deferred until the documentation of a resistant Gram-positive infection.

Anti-Bacterial Agents↗
PubMed2005

Empirical antibiotic monotherapy for febrile neutropenia: systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: Early, empirical broad-spectrum antibiotic treatment is the established practice for febrile neutropenia. Several beta-lactams are accepted for monotherapy. We asked whether patients' outcomes are influenced by the chosen beta-lactam. METHODS: Systematic review and meta-analysis of randomized controlled trials comparing anti-pseudomonal beta-lactams administered as empirical monotherapy for febrile neutropenia, with or without vancomycin. The search included The Cochrane Library, PubMed, Embase, Lilacs databases, bibliography, conference proceedings, trial registries and FDA new drug approvals. Two reviewers independently applied selection criteria, performed quality assessment and extracted the data. Trials assessing the same beta-lactam were pooled using the fixed effect model. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated. The primary outcome assessed was all-cause mortality. RESULTS: Thirty-three trials fulfilled inclusion criteria. Cefepime was associated with higher all-cause mortality at 30 days than other beta-lactams (RR 1.44, 95% CI 1.06-1.94, 3123 participants). Carbapenems were associated with fewer treatment modifications, including addition of glycopeptides, than ceftazidime or other comparators. Adverse events were significantly more frequent with carbapenems, specifically pseudomembranous colitis (RR 1.94, 95% CI 1.24-3.04, 2025 participants). All-cause mortality was unaltered. Piperacillin/tazobactam was compared only with cefepime and carbapenems, in six trials. No significant differences were demonstrated with paucity of data for all-cause mortality. CONCLUSIONS: The use of cefepime for febrile neutropenia is associated with increased mortality and should be carefully considered pending further analysis. Empirical use of carbapenems entails fewer treatment modifications, but an increased rate of pseudomembranous colitis. Ceftazidime, piperacillin/tazobactam, imipenem/cilastatin and meropenem appear to be suitable agents for monotherapy.

Anti-Bacterial Agents↗
PubMed2006

Antifungal agents for preventing fungal infections in non-neutropenic critically ill and surgical patients: systematic review and meta-analysis of randomized clinical trials.

OBJECTIVES: This study aims to systematically identify and summarize the effects of antifungal prophylaxis in non-neutropenic critically ill adult patients on all-cause mortality and the incidence of invasive fungal infections. METHODS: Systematic review and meta-analysis of randomized controlled trials in all languages comparing the prophylactic use of any antifungal agent or regimen with placebo, no antifungal or another antifungal agent or regimen in non-neutropenic critically ill adult patients. We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2005), MEDLINE (1966 to 2 September 2005) and EMBASE (1980 to week 36, 2005). We also hand-searched reference lists, abstracts of conference proceedings and scientific meetings (1998-2004) and contacted authors of included studies and pharmaceutical manufacturers. The primary outcomes assessed were all-cause mortality and proven invasive fungal infections. Two reviewers independently applied selection criteria, performed quality assessment and extracted data using an intention-to-treat approach. Data were synthesized using the random effects model and expressed as relative risk with 95% confidence intervals. RESULTS: Twelve unique trials (eight comparing fluconazole and four ketoconazole with no antifungal or a non-absorbable agent) involving 1606 randomized patients were included. For both outcomes of total mortality and invasive fungal infections, almost all trials of fluconazole and ketoconazole separately showed a non-significant risk reduction with prophylaxis. When combined, fluconazole/ketoconazole reduced total mortality by one-quarter (relative risk 0.76, 95% confidence interval 0.59-0.97) and invasive fungal infections by about one-half (relative risk 0.46, 95% confidence interval 0.31-0.68). No significant increase in the incidence of infection or colonization with the azole-resistant fungal pathogens Candida glabrata or Candida krusei was demonstrated, although the confidence intervals of the summary effect measures were wide. Adverse effects requiring treatment discontinuation were not more common amongst patients receiving prophylaxis. Results across all trials were homogeneous despite considerable heterogeneity in clinical and methodological characteristics. CONCLUSIONS: Prophylaxis with fluconazole or ketoconazole in critically ill patients reduces invasive fungal infections by one-half and total mortality by one-quarter. Although no significant increase in azole-resistant Candida species associated with prophylaxis was demonstrated, trials were not powered to exclude such an effect. In patients at increased risk of invasive fungal infections, antifungal prophylaxis with fluconazole should be considered.

Adult↗
PubMed2006

Effect of quinolone prophylaxis in afebrile neutropenic patients on microbial resistance: systematic review and meta-analysis.

OBJECTIVES: To assess the effect of quinolone prophylaxis following chemotherapy for malignancies on the emergence of resistant bacteria in neutropenic patients. METHODS: Systematic review and meta-analysis of randomized controlled trials comparing quinolone prophylaxis with placebo or no intervention, or another antibiotic, for the prevention of bacterial infections in afebrile neutropenic patients. The Cochrane Library, PubMed, Embase, conference proceedings and references were searched. Two reviewers independently applied selection criteria, carried out quality assessment and extracted the data. Relative risks (RR) with 95% confidence intervals (CIs) were estimated and pooled. Primary outcomes were rates of colonization and infection by quinolone-resistant bacteria. RESULTS: The search yielded 56 trials, 22 compared quinolones with placebo or no intervention. Data on colonization by resistant organisms could be extracted from 27 trials (48%). When compared with placebo or no intervention, there was a statistically non-significant increase in colonization with organisms resistant to quinolones (RR 1.68; 95% CI 0.71-4.00). There was no difference in the number of patients developing infections caused by resistant pathogens (RR 1.04; 95% CI 0.73-1.50). In trials comparing quinolones with trimethoprim/sulfamethoxazole, there were fewer incidents of colonization by bacteria resistant to the prophylactic agent in the quinolone arm than in the trimethoprim/sulfamethoxazole arm (RR 0.49; 95% CI 0.37-0.66). Data on baseline resistance of colonizing isolates, resistance development and cross-resistance to beta-lactam antibiotics were too scarce to analyse. CONCLUSIONS: Patients treated with quinolones have a non-significant increase in colonization by quinolone-resistant bacteria. There is no difference in the number of infections caused by pathogens resistant to quinolones. As quinolone prophylaxis reduces the risk of death in neutropenic patients, the risk associated with colonization and infections caused by quinolone-resistant organisms does not outweigh the gain. Future trials should focus on better documentation of infections caused by resistant organisms.

Anti-Infective Agents↗
PubMed2006

Recombinant human erythropoietins and cancer patients: updated meta-analysis of 57 studies including 9353 patients.

This is an updated systematic review of 57 trials and 9353 cancer patients from articles, abstracts, and reports published between January 1, 1985, and April 30, 2005, on the effects of epoetin alfa and beta (i.e., epoetin) and darbepoetin alfa (i.e., darbepoetin). We included randomized controlled trials comparing epoetin or darbepoetin plus red blood cell transfusion with red blood cell transfusion alone for prophylaxis or treatment of anemia in cancer patients with or without concurrent antineoplastic therapy. The Cochrane Library, MEDLINE, EMBASE, and conference proceedings were searched. Effect estimates and 95% confidence intervals (CIs) were calculated with fixed-effects models. Treatment with epoetin or darbepoetin statistically significantly reduced the risk for red blood cell transfusions (relative risk [RR] = 0.64, 95% CI = 0.60 to 0.68; 42 trials and 6510 patients) and improved hematologic response (RR = 3.43, 95% CI = 3.07 to 3.84; 22 trials and 4307 patients). Treatment with epoetin or darbepoetin increased the risk of thrombo-embolic events (RR = 1.67, 95% CI = 1.35 to 2.06; 35 trials and 6769 patients). Uncertainties remain as to whether and how epoetin or darbepoetin affects overall survival (hazard ratio = 1.08, 95% CI = 0.99 to 1.18; 42 trials and 8167 patients). Caution is advised when using epoetin or darbepoetin in combination with thrombogenic chemotherapeutic agents or for cancer patients who are at high risk for thrombo-embolic events.

Anemia, Hypochromic↗
PubMed2004

Midodrine appears to be safe and effective for dialysis-induced hypotension: a systematic review.

BACKGROUND: Dialysis-induced hypotension is an important complication of haemodialysis. Midodrine is an oral alpha-1 agonist that has been used in several small studies to prevent intradialytic hypotension (IDH). METHODS: The authors searched MEDLINE, EMBASE, ASN conference proceedings, and references of potentially relevant articles, and contacted industry (Shire Pharmaceuticals) for unpublished data. Observational studies, randomized controlled trials, crossover studies and pre- and post-intervention design studies with >/=5 haemodialysis patients were included. Study outcomes assessed were: hypotensive symptoms, changes in systolic and/or diastolic blood pressure, dry weight and length of stay after treatment. Data were abstracted on: study design, patient characteristics, intradialytic changes in blood pressure, nadir blood pressure and symptom improvement with midodrine. Thirty-seven full text articles were retrieved and nine met the selection criteria, in addition to one unpublished study. Midodrine dosing regimens ranged from 2.5 to 10 mg of midodrine given 15-30 min before dialysis. RESULTS: Post-dialysis systolic blood pressure was higher by 12.4 mmHg [95% confidence interval (CI) 7.5-17.7] and diastolic pressure was higher by 7.3 mmHg (95% CI 3.7-10.9) during midodrine treatment vs control. Likewise, the nadir systolic blood pressure was higher by 13.3 mmHg (95% CI 8.6-18.0), with a difference in nadir diastolic pressure of 5.9 mmHg (95% CI 2.7-9.1). Six of 10 studies report improvement in symptoms of IDH, and there were no reported serious adverse events ascribed to midodrine. CONCLUSIONS: This systematic review would suggest that midodrine has a role in the therapy of haemodialysis patients experiencing IDH. This conclusion must be viewed with caution, however, given the quality and sample size of the studies included in this review.

Adrenergic alpha-Agonists↗
PubMed2005

Measured creatinine clearance from timed urine collections substantially overestimates glomerular filtration rate in patients with liver cirrhosis: a systematic review and individual patient meta-analysis.

BACKGROUND: Accurate glomerular filtration rate (GFR) assessment in patients with liver cirrhosis is important for prognostication, chronic kidney disease staging, drug dosing and identifying combined liver-kidney transplantation candidates. The objective of this study was to review the accuracy of measured creatinine clearance (MCrCl) from timed urine collections for estimating true GFR. METHODS: A systematic review and individual patient meta-analysis was performed. MEDLINE, old MEDLINE, Index Medicus and Cochrane library bibliographic databases and conference proceedings were searched up to June 2004. Reference lists of relevant studies were searched and experts were contacted. Comparative diagnostic studies describing stable adult patients with cirrhosis categorized according to the Child-Pugh classification were included if a gold standard GFR measurement was performed within 3 days of MCrCl. Individual patient data were abstracted from graphs of primary articles to allow a pooled analysis of agreement between renal measures. RESULTS: Seven studies of 193 patients from 1974 to 2002 were summarized. MCrCl overestimated inulin clearance (CIn) by a mean of +13 ml/min/1.73 m2 and the limits of agreement (mean of the differences+/-2 SD) were +60 ml/min/1.73 m2 and -34 ml/min/1.73 m2. This overestimation was highest in patients with lower GFR. The mean clearance ratios [95% confidence interval (CI)] between MCrCl and CIn in the high (> or =60 ml/min/1.73 m2) and low (<60 ml/min/1.73 m2) GFR subgroups were 1.18 (1.12-1.23) and 1.49 (1.33-1.66), respectively (P<0.0001). Fourteen percent of patients with a MCrCl > or =60 ml/min/1.73 m2 had a CIn of <30 ml/min/1.73 m2. CONCLUSIONS: For patients with liver cirrhosis, MCrCl from timed urine collections consistently overestimates the true GFR. For patients requiring complete clinical evaluation, GFR assessment by CIn is justified.

Adult↗
PubMedDate not supplied

Assessing the evidence submitted in the development of a workplace smoking regulation: the case of Maryland.

OBJECTIVE: This study compared the characteristics of the basic science, biomedical, and socioeconomic literature submitted in 1993-1994 by supporters and opponents of the proposed workplace regulation of tobacco smoke developed by the Maryland Occupational Safety and Health (MOSH) Advisory Board. METHODS: The authors retrospectively analyzed 544 written publications submitted to the MOSH Advisory Board regarding the proposed workplace regulation of tobacco smoke. Outcome measures included the type and year of publication and, for journal articles, the journal's peer review policy and impact factor. RESULTS: Supporters of regulation submitted fewer documents (n = 164) than opponents (n = 380). Supporters of regulation submitted a lower proportion of conference proceedings and a higher proportion of government reports. The publications submitted to the regulators by the supporters of regulation were more recently published than the materials submitted by opponents. Journal articles represented more than half of the publications submitted; most were peer-reviewed. Supporters of regulation submitted articles from journals with higher impact factors (median impact factor 2.78) than did opponents of regulation (median 1.66; p = 0.0005), and articles that were published more recently (median year of publication 1990) than those submitted by opponents (median 1989; p = 0.0001). CONCLUSIONS: Public health advocates should highlight the scientific evidence base that supports tobacco control regulations. Public health advocates should encourage and support regulatory officials' use of the criteria of peer review, impact factor, and date of publication to prioritize their review of submitted documents in order to base policy on the best available evidence.

Air Pollution, Indoor↗
PubMed2006

Acupuncture for peripheral joint osteoarthritis: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the evidence for the effectiveness of acupuncture in peripheral joint osteoarthritis (OA). METHODS: Systematic searches were conducted on Medline, Embase, AMED, Cochrane Library, CINAHL, British Nursing Index, PsychINFO and CAMPAIN until July 2005. Hand-searches included conference proceedings and our own files. There were no restrictions regarding the language of publication. All randomized controlled trials (RCTs) of acupuncture for patients with peripheral joint OA were considered for inclusion. Trials assessing needle acupuncture with or without electrical stimulation were considered if sham- or placebo-controlled or controlled against a comparator intervention. Trials testing other forms of acupuncture were excluded. Methodological quality was assessed and, where possible, meta-analyses were performed. RESULTS: Thirty-one possibly relevant studies were identified and 18 RCTs were included. Ten trials tested manual acupuncture and eight trials tested electro-acupuncture. Overall, ten studies demonstrated greater pain reduction in acupuncture groups compared with controls. The meta-analysis of homogeneous data showed a significant effect of manual acupuncture compared with sham acupuncture (standardized mean difference 0.24, 95% confidence interval 0.01-0.47, P = 0.04, n = 329), which is supported by data for knee OA. The extent of heterogeneity in trials of electro-acupuncture prevented a meaningful meta-analysis. CONCLUSIONS: Sham-controlled RCTs suggest specific effects of acupuncture for pain control in patients with peripheral joint OA. Considering its favourable safety profile acupuncture seems an option worthy of consideration particularly for knee OA. Further studies are required particularly for manual or electro-acupuncture in hip OA.

Acupuncture Analgesia↗