Studies Met Selection Criteria Research Articles

Chlamydia trachomatis re-infection in Spain: A STI clinic-based cohort study

BackgroundChlamydia trachomatis (C. trachomatis) is the most frequently reported sexually transmitted infection (STI) in developed countries, but there is a lack data on its incidence and population dynamics in Spain. The objectives of this study were to estimate the incidence of C. trachomatis in patients seeking medical attention in an STI clinic with a defined population catchment area, to identify factors associated with this infection, and to explore differences between factors associated with new infections and re-infections. MethodsA retrospective study was conducted on a cohort of patients from a STI clinic who underwent chlamydia testing at least twice between 2007 and 2015. ResultsOf the 2633 patients who met study selection criteria, 795 (30.2%) tested positive for C. trachomatis at baseline (baseline Chlamydia). The overall incidence was 7.97/100 person-years (95% CI: 7.2–8.8): 5.9/100 person-years (95% CI: 5.2–6.7) among patients testing negative for C. trachomatis at baseline, and 18.3 person-years (95% CI: 15.6–21.5) among those testing positive at baseline. In multivariate analysis, the factors independently associated with overall incidence were a history of infection with C. trachomatis in the previous 6 months (hazard ratio=3.6; 95% CI: 2.3–5.4), younger age (HR <20 vs ≥35 years=5.5; 95% CI: 3.2–9.5), male sex, 2 or more sexual partners in the previous month and year, and inconsistent condom use. ConclusionsGuidelines should be established for C. trachomatis in Spain, including recommendations on the need for follow-up and re-testing, independently of age. Though data concerning the optimal timing of re-testing are inconclusive, our findings support the establishment of a 3–6 month interval.

Microbleeds in Alzheimer's Disease: A Neuropsychological Overview and Meta-Analysis.

The current literature on the role of brain microbleeds (MB) on the neuropsychological outcomes of Alzheimer's disease (AD) is heterogeneous. We therefore meta-analytically examined the neuropsychological literature pertaining to MBs in AD. Using a priori selected criteria, studies with cross-sectional neuropsychological assessment on MBs and AD were reviewed. Six of 122 studies met selection criteria and provided neuropsychological data on either AD with MB and without MB, or in contrast to healthy controls. The global neuropsychological difference between AD with MB and AD without MB based on random effect model was nonsignificant, heterogeneous, and small (Effect Size =-0.155; 95% confidence interval =-0.465 to 0.155; p value =0.326; Heterogenity: Q-value =12.744; degrees of freedom =5; p =0.026; I2 =61%). The contribution of MBs to cognitive deficits in AD remains unclear. Future studies of MB in AD should strive to use standardized neuroimaging techniques with high sensitivity for MB, a common standard for MB definition, and neuropsychological tests sensitive for detecting subtle cognitive impairment.

Effectiveness of exercise in hepatic fat mobilization in non-alcoholic fatty liver disease: Systematic review.

To investigate the efficacy of exercise interventions on hepatic fat mobilization in non-alcoholic fatty liver disease (NAFLD) patients. Ovid-Medline, PubMed, EMBASE and Cochrane database were searched for randomized trials and prospective cohort studies in adults aged ≥ 18 which investigated the effects of at least 8 wk of exercise only or combination with diet on NAFLD from 2010 to 2016. The search terms used to identify articles, in which exercise was clearly described by type, duration, intensity and frequency were: "NASH", "NAFLD", "non-alcoholic steatohepatitis", "non-alcoholic fatty liver disease", "fat", "steatosis", "diet", "exercise", "MR spectroscopy" and "liver biopsy". NAFLD diagnosis, as well as the outcome measures, was confirmed by either hydrogen-magnetic resonance spectroscopy (H-MRS) or biopsy. Trials that included dietary interventions along with exercise were accepted if they met all criteria. Eight studies met selection criteria (6 with exercise only, 2 with diet and exercise with a total of 433 adult participants). Training interventions ranged between 8 and 48 wk in duration with a prescribed exercise frequency of 3 to 7 d per week, at intensities between 45% and 75% of VO2 peak. The most commonly used imaging modality was H-MRS and one study utilized biopsy. The effect of intervention on fat mobilization was 30.2% in the exercise only group and 49.8% in diet and exercise group. There was no difference between aerobic and resistance exercise intervention, although only one study compared the two interventions. The beneficial effects of exercise on intrahepatic triglyceride (IHTG) were seen even in the absence of significant weight loss. Although combining an exercise program with dietary interventions augmented the reduction in IHTG, as well as improved measures of glucose control and/or insulin sensitivity, exercise only significantly decreased hepatic lipid contents. Prescribed exercise in subjects with NAFLD reduces IHTG independent of dietary intervention. Diet and exercise was more effective than exercise alone in reducing IHTG.

A systematic review of syphilis serological treatment outcomes in HIV-infected and HIV-uninfected persons: rethinking the significance of serological non-responsiveness and the serofast state after therapy.

BackgroundSyphilis remains a global public health threat and can lead to severe complications. In addition to resolution of clinical manifestations, a reduction in nontreponemal antibody titers after treatment is regarded as “proof of cure.” However, some patients manifest < 4-fold decline (“serological non-response”) or persistently positive nontreponemal titers despite an appropriate decline (“serofast”) that may represent treatment failure, reinfection, or a benign immune response. To delineate these treatment phenomena, we conducted a systematic review of the literature regarding serological outcomes and associated factors among HIV-infected and -uninfected subjects.MethodsSix databases (PubMed, Embase, CINAHL, Web of Science, Scopus, and BIOSIS) were searched with no date restrictions. Relevant articles that evaluated serological treatment responses and correlates of serological cure (≥ four-fold decline in nontreponemal titers) were included.ResultsWe identified 1693 reports in the literature, of which 20 studies met selection criteria. The median proportion of patients who had serological non-response was 12.1 % overall (interquartile range, 4.9–25.6), but varied depending on the time points after therapy. The serofast proportion could only be estimated from 2 studies, which ranged from 35.2–44.4 %. Serological cure was primarily associated with younger age, higher baseline nontreponemal titers, and earlier syphilis stage. The relationship between serological cure and HIV status was inconsistent; among HIV-infected patients, CD4 count and HIV viral load was not associated with serological cure.ConclusionsSerological non-response and the serofast state are common syphilis treatment outcomes, highlighting the importance of determining the immunological and clinical significance of persistent nontreponemal antibody titers after therapy.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-015-1209-0) contains supplementary material, which is available to authorized users.

Coronary CT Angiography with Use of Iterative Reconstruction Algorithm in Coronary Stenting: A Systematic Review of Image Quality, Diagnostic Value and Radiation Dose

The aim of this study was to perform a systematic review of the image quality, diagnostic value and radiation dose of coronary CT angiography with use of iterative reconstruction (IR) in the assessment of coronary stents when compared to the standard filtered back-projection (FBP) techniques. A search of medical databases of English literature was performed to identify studies comparing coronary CT angiography with use of IR and FBP techniques in coronary stenting. Qualitative and quantitative assessment of image quality, diagnostic accuracy and radiation dose associated with coronary CT angiography were analyzed and compared between the two reconstruction algorithms. Ten studies met selection criteria and were included in the analysis. In comparison with FBP, coronary CT angiography with use of IR showed improvement in image quality through both qualitative and quantitative analysis. The IR technique resulted in higher diagnostic value than that of FBP with the mean sensitivity, specificity and accuracy being 98%, 77.4% and 80.1% for IR technique, and 90.5%, 68.2%, and 68.6% for FBP approach, respectively, with significant difference reached in the specificity and accuracy ( p< 0� 05). Furthermore, there was significantly lower dose with use of IR compared to FBP technique (4.4 mSv vs. 7.0 mSv). Coronary CT angiography with use of IR algorithm leads to significant improvements in the assessment of coronary stents with much lower radiation dose.

A Systematic Review of Financial Incentives for Dietary Behavior Change

In light of the obesity epidemic, there is growing interest in the use of financial incentives for dietary behavior change. Previous reviews of the literature have focused on randomized controlled trials and found mixed results. The purpose of this systematic review is to update and expand on previous reviews by considering a broader range of study designs, including randomized controlled trials, quasi-experimental, observational, and simulation studies testing the use of financial incentives to change dietary behavior and to inform both dietetic practice and research. The review was guided by theoretical consideration of the type of incentive used based on the principles of operant conditioning. There was further examination of whether studies were carried out with an institutional focus. Studies published between 2006 and 2012 were selected for review, and data were extracted regarding study population, intervention design, outcome measures, study duration and follow-up, and key findings. Twelve studies meeting selection criteria were reviewed, with 11 finding a positive association between incentives and dietary behavior change in the short term. All studies pointed to more specific information on the type, timing, and magnitude of incentives needed to motivate individuals to change behavior, the types of incentives and disincentives most likely to affect the behavior of various socioeconomic groups, and promising approaches for potential policy and practice innovations. Limitations of the studies are noted, including the lack of theoretical guidance in the selection of incentive structures and the absence of basic experimental data. Future research should consider these factors, even as policy makers and practitioners continue to experiment with this potentially useful approach to addressing obesity.

Acquired abdominal intercostal hernia: case report and systematic review of the literature

The protrusion of abdominal viscera through an intercostal space under an intact diaphragm is a very rare condition. The aim of this study is to elucidate the etiology, clinical features, and therapeutic options on what several authors call "abdominal intercostal hernia" (AIH). A typical case of AIH of the 9th left intercostal space in a 48-year-old man is presented. A literature search was conducted on the Medline and Scopus databases. Only acquired AIHs (AAIHs) were considered, while lung, transdiaphragmatic, and congenital intercostal hernias were excluded. Eighteen studies met selection criteria and a total of 20 patients were useful for analysis. Etiology was related mainly to traumatism (65%) or to previous surgery (20%). The intercostal defects were mostly located under the 9th rib without significant differences as to side. The main symptom was chest swelling (85%), often associated with discomfort or pain (76%). Acute complications such as incarceration and strangulation occurred in three patients. CT was the most employed diagnostic tool (80%). Early diagnosis was made in 25% of cases. Seventeen patients underwent hernia repair with either open (73%) or laparoscopic approach (28%), and various techniques with and without prosthesis were described. Recurrence occurred in 28.6% of patients, during a mean follow-up of 8.6months. AAIH should be always suspected when chest swelling occurs after a minor or major trauma, and CT must be promptly performed to rule out diaphragmatic or abdominal viscera injury. This condition requires surgery to prevent serious complications, the first-choice technique should be mesh tension-free repair.

Inflammation in new‐onset atrial fibrillation after cardiac surgery: a systematic review

Postoperative new-onset atrial fibrillation (PNAF) is the most common complication following cardiac surgery. The pathogenesis of PNAF is multifactorial. The concept of the postoperative inflammatory response, as a potential underlying mechanism has been extensively studied. This review aims to provide a comprehensive summary of literature relevant to the association between the inflammatory response following cardiac surgery and PNAF. MEDLINE, EMBASE and the Cochrane Central Register were systematically reviewed by two independent investigators for studies published between January 1980 and May 2012, in which an association between serum markers of inflammation and PNAF was evaluated, or the effect of drugs with anti-inflammatory properties on the risk of PNAF. Sixty-three studies met selection criteria (39 observational and 24 randomized studies) including 27,363 patients. The mean incidence of PNAF after cardiac surgery was 25·5%. Elevated levels of various inflammatory mediators were associated with PNAF, and the most consistent association was found between white blood cell count and PNAF. Of the drugs with anti-inflammatory properties, statins gave the best protective effect against PNAF, followed by anti-oxidants, steroids and colchicine. Nonsteroidal anti-inflammatory drugs did not prevent PNAF significantly. The postoperative inflammation response may play a role in the pathogenesis of PNAF. However, of the inflammation biomarkers, only elevated white blood cell count reliably predicts PNAF. Pre- and perioperative use of statins and several other drugs with anti-inflammatory properties reduce the incidence of PNAF.

Measuring antimicrobial use in hospitalized patients: a systematic review of available measures applicable to paediatrics

The optimal measure to use for surveillance of antimicrobial usage in hospital settings, especially when including paediatric populations, is unknown. This systematic review of literature aims to list, define and compare existing measures of antimicrobial use that have been applied in settings that included paediatric inpatients, to complement surveillance of resistance. We identified cohort studies and repeated point-prevalence studies presenting data on antimicrobial use in populations of inpatients or validations/comparisons of antimicrobial measures through a systematic search of literature using MEDLINE, EMBASE, CINAHL and LILACS (1975-2011) and citation tracking. Study populations needed to include hospitalized paediatric patients. Two reviewers independently extracted data on study characteristics and results. Overall, 3878 records were screened and 79 studies met selection criteria. Twenty-six distinct measures were found, the most frequently used being defined daily doses (DDD)/patient-days and exposed patients/patients. Only two studies compared different measures quantitatively, showing (i) a positive correlation between proportion of exposed patients and antimicrobial-days/patient-days and (ii) a strong correlation between doses/patient-days and agent-days/patient-days (r = 0.98), with doses/patient-days correlating more with resistance rates (r = 0.80 versus 0.55). The measure of antimicrobial use that best predicts antimicrobial resistance prevalence and rates, for surveillance purposes, has still not been identified; additional evidence on this topic is a necessity.

Is Intramuscular Pressure a Valid Diagnostic Criterion for Chronic Exertional Compartment Syndrome?

To compare the intramuscular pressure (IMP) of the tibialis anterior in healthy persons under several exercise conditions with the IMP diagnostic criteria in use for diagnosing chronic exertional compartment syndrome (CECS). A search of MEDLINE for the period 1966 to March 2010 used the words "intramuscular," "intracompartment," "anterior compartment," and "anterior tibial compartment" linked with "pressure." Reference lists of relevant studies were searched for further articles. Articles published in English that tested IMP in the tibialis anterior in asymptomatic humans were included if they used no interventions before or during IMP testing. Studies were excluded if data were given as a percentage of IMP or if the data could not be extracted for the tibialis anterior compartment alone. From 515 articles identified, 38 studies met selection criteria : Details of the studies included IMP measurement technique, timing of measurement (before, during, and/or after exercise), type and duration of exercise, the number of compartments measured, and participants' ages. Mean or median pressure was recorded in mm Hg. Criteria for the upper limit of normal pressure under different conditions were the Pedowitz criterion for preexercise IMP (15 mm Hg), the Puranen criterion for IMP during exercise (50 mm Hg), the Styf criterion for relaxation pressure (30-55 mm Hg), and the Pedowitz criteria for mean 1-minute postexercise and 5-minutes postexercise pressures (30 mm Hg and 50 mm Hg, respectively). Exercise was mostly treadmill walking/running (duration, 1.5-120 min) or ankle dorsiflexion (duration, 10 sec-20 min). Methods of measuring IMP varied from study to study. The lowest mean IMP was identified preexercise at rest (range, 0-20 mm Hg). Five of the 34 studies found a higher mean resting pressure than the criterion (15 mm Hg). Mean pressure during exercise (10 studies, 9 of running, with durations of 5-20 min) varied between 23 mm Hg and 66 mm Hg. Two of these studies found a higher mean peak pressure during exercise than the criterion (50 mm Hg). Mean relaxation IMP, measured in 9 studies, was approximately 25 mm Hg in the 1 treadmill study in which it was measured, whereas studies of dorsiflexion found a range of approximately 5 to 15 mm Hg. All the studies found lower mean relaxation IMP than the criterion (35-50 mm Hg). One of 11 studies and 1 of 10 studies found the mean postexercise IMP after 1 minute and 5 minutes to be above the criteria of 30 mm Hg and 20 mm Hg, respectively. The limits of anterior tibialis IMP before, during, and after exercise that are used as diagnostic criteria for CECS would include many asymptomatic persons. Intramuscular pressure values were not valid criteria for the presence of the syndrome.

Epigenetic Modifications of Preeclamptic Placenta-A Systematic Review

We searched OVID, PubMed and Web of Science, using MSH terms related to epigenetic changes, placenta, and preeclampsia, limiting the results to humans, English language, non-review articles, and publications between 2004 to 2014. 51 out of 207 studies met selection criteria for full data extraction. Array and profiling studies were included only if their results were validated by other methods. Next, 23 of 42 articles satisfied methodological quality criteria, including gestational age-matching and/or controlling or adjusting for confounders. Then, studies with a total score <10 out of 15 quality assessment points were excluded. MicroRNAs and genes resulting from review were investigated for interactions using Ingenuity Pathways Analysis. Ten studies met the inclusion criteria for our review: 3 concerning DNA methylation and 7 studies regarding miRNA. There were no studies on histone modification by acetylation. Seventeen differentially regulated miRNAs were identified, with three reported in two studies. Nine miRNAs were upregulated, six downregulated, one was either upregulated or downregulated depending on the severity of preeclampsia, and one had conflicting results. Our review observed nine genes that were hypomethylated, one hypermethylated, while one was found not different between groups. IPA’s microRNA analysis revealed that 16 miRNA from our list could be targeting 8,005 mRNAs. miRNAs were associated with 3 networks and 1 toxicity phenotype, hypomethylated genes with 2 networks and 5 toxicity, and one hypermethylated gene was not associated with any networks, while its toxicity list included regulation of mitochondria and renal necrosis. The common toxicity phenotype within upregulated miRNAs, downregulated miRNAs, and hypermethylated genes was associated with regulation of mitochondria. Our review spotlights the gaps in knowledge about histone modifications associated with the preeclamptic placenta, emphasizes the importance of verifying the array results by other methods, and stresses the need to meticulously design future studies to included comparable samples groups.

EPA-0622 – Men's expression and experience of depression: a systematic review

Data from the American National Comorbidity Survey Replication (Martin et al., 2013; JAMA Psychiatry) - a nationally represented mental health survey - provides evidence that current diagnostic criteria for depression in men may be incomplete. To conduct and present findings of a systematic review of the biological, psychological and social depression research literature relating to men. (1) To provide a comprehensive summary of current knowledge about the expression of depression in men; (2) To examine the accuracy of current diagnostic criteria for identifying depression in men. The PRISMA statement was used to guide a multiple database search in February and July 2012 and June 2013. Search terms included: ‘men’, ‘depression’, ‘signs’ or ‘symptoms’, ‘gender’, and ‘sex differences’. Initial database searches together with forward and backward searches found 15,966 studies that were assessed for eligibility. Thirty studies met selection criteria and were included in the review. The review challenges findings that are commonly reported in the depression literature. The majority of studies in the review did not find significant differences between males and females in global depression rates, but instead, found significant differences between males and females in specific depressive symptoms that are expressed. Depressed men commonly reported alternative symptoms, including social withdrawal, functional impairment and sexual disturbance, together with maladaptive coping mechanisms. Current diagnostic criteria may not accurately identify depression in men. Targeted research needs to further clarify which symptoms are required to accurately detect depression in men.

Musculoskeletal physical outcome measures in individuals with tension-type headache: A scoping review

Individuals with tension-type headache (TTH), in addition to headache pain, typically suffer from pericranial muscle tenderness and increased cervical muscle tone. Physical and physiological outcomes related to musculoskeletal function, however, are not commonly assessed in clinical studies and not systematically proposed as outcome measures in headache-related practice guidelines. To review which musculoskeletal outcomes are used in the clinical assessment of patients with TTH and which are associated with headache pain and related dysfunction. Literature searches were performed in MEDLINE, PubMed, the Cochrane databases and EMBASE using terms relating to musculoskeletal physical outcomes in TTH. Twenty-six studies met selection criteria. Physiological outcomes typically reported in laboratory studies were trigger points, pressure pain threshold, range of motion and tenderness. A greater number of trigger points and lower pressure pain threshold were reported in patients with episodic TTH in comparison with healthy subjects. Individuals with chronic TTH, when compared with non-headache controls, consistently showed a greater number of trigger points, a lower value of pressure pain threshold and a more severe forward head posture. Musculoskeletal outcomes, such as trigger points, pressure pain threshold and forward head posture should inform TTH pathophysiology, diagnosis and interdisciplinary patient care.

The Ecological and Population Validity of Reading Interventions for Adolescents

This article examined the ecological and population validity of research on reading interventions for adolescents in Grades 6 through 12. The 26 studies meeting selection criteria were analyzed to determine the characteristics of the students, interventionists, classroom structures, and school environments used, as well as whether there were differential effects of treatments across those characteristics. In the 20+ years since the calls by the Council for Learning Disabilities and National Joint Committee on Learning Disabilities for greater specificity in descriptions of study participants and contexts, the findings of this study suggest that researchers have provided greater detail on participants, but many questions remain about the extent to which findings can be generalized. Specifically, gaps in the research exist with regard to African American and Native American students; English language learners; students in suburban, rural, and adjudicated schools; students in high school; interventions delivered by regular classroom teachers; interventions focused on vocabulary; and interventions in large groups and general education classrooms.

Antimicrobial Prophylaxis and Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy: American Society of Clinical Oncology Clinical Practice Guideline

To provide guidelines on antimicrobial prophylaxis for adult neutropenic oncology outpatients and on selection and treatment as outpatients of those with fever and neutropenia. A literature search identified relevant studies published in English. Primary outcomes included: development of fever and/or infections in afebrile neutropenic outpatients and recovery without complications and overall mortality in febrile neutropenic outpatients. Secondary outcomes included: in afebrile neutropenic outpatients, infection-related mortality; in outpatients with fever and neutropenia, defervescence without regimen change, time to defervescence, infectious complications, and recurrent fever; and in both groups, hospital admissions, duration, and adverse effects of antimicrobials. An Expert Panel developed guidelines based on extracted data and informal consensus. Forty-seven articles from 43 studies met selection criteria. Antibacterial and antifungal prophylaxis are only recommended for patients expected to have < 100 neutrophils/μL for > 7 days, unless other factors increase risks for complications or mortality to similar levels. Inpatient treatment is standard to manage febrile neutropenic episodes, although carefully selected patients may be managed as outpatients after systematic assessment beginning with a validated risk index (eg, Multinational Association for Supportive Care in Cancer [MASCC] score or Talcott's rules). Patients with MASCC scores ≥ 21 or in Talcott group 4, and without other risk factors, can be managed safely as outpatients. Febrile neutropenic patients should receive initial doses of empirical antibacterial therapy within an hour of triage and should either be monitored for at least 4 hours to determine suitability for outpatient management or be admitted to the hospital. An oral fluoroquinolone plus amoxicillin/clavulanate (or plus clindamycin if penicillin allergic) is recommended as empiric therapy, unless fluoroquinolone prophylaxis was used before fever developed.

Advancing HIV/AIDS Combination Prevention through mass media: a review of practices in sub-Saharan Africa

This paper presents an assessment of the literature on the use of mass media campaigns to advance biomedical, structural and behavioural approaches to HIV/AIDS prevention in sub-Saharan Africa over the past decade (2000–2010). Studies on the use of mass media in HIV/AIDS prevention efforts were searched from two main electronic databases – Web of Science and PubMed. Studies meeting selection criteria were examined for the themes of the mass media programs studied in a content analytic approach. The findings suggest that while there are several biomedical and structural issues which the mass media could well have been instrumental for, their utilization in sub-Saharan Africa seems to be limited to behavioural interventions. It is concluded that at a time when recommendations for Combination Prevention are prevailing, the utilization of the mass media largely limited to a certain domain of HIV/AIDS prevention appears to be worthy of attention.

Diagnostic value of coronary CT angiography with prospective ECG-gating in the diagnosis of coronary artery disease: a systematic review and meta-analysis

To perform a systematic review and meta-analysis of the diagnostic value of prospective ECG-gating coronary CT angiography in the diagnosis of coronary artery disease. A search of biomedical databases for English literature was performed to identify studies investigating the diagnostic value of 64- or more slice CT angiography with use of prospective ECG-gating in the diagnosis of coronary artery disease. Sensitivity, specificity, positive and negative predictive value estimates pooled across studies were tested using a fixed effects model. Fourteen studies met selection criteria for inclusion in the analysis. Pooled estimates and 95% confidence interval (CI) of sensitivity, specificity, positive and negative predictive value of prospective ECG-gating coronary CT angiography for diagnosis of significant coronary stenosis were 99% (95% CI: 98, 100%), 91% (95% CI: 88, 94%), 94% (95% CI: 91, 96%) and 99% (95% CI: 97, 100%), according to the patient-based assessment. The mean values of sensitivity, specificity, positive and negative predictive value of prospective ECG-gating coronary CT angiography were 95% (95% CI: 93, 96%), 95% (95% CI: 93, 95%), 88% (95% CI: 86, 90%), and 98% (95% CI: 97, 98%), according to vessel-based assessment; 92% (95% CI: 90, 93%), 97% (95% CI: 97, 98%), 84% (95% CI: 82, 86%), 99% (95% CI: 99, 99%), according to segment-based assessment, respectively. The mean effective dose was 3.3 mSv (95% CI: 2.3, 4.1 mSv) for the prospective ECG-gating coronary CT angiography. This analysis shows that for a predominantly male population with a high disease prevalence the use of coronary CT angiography with prospective ECG gating allows for a reduced radiation exposure without a sacrifice in diagnostic efficacy.

The effect of telemedicine in critically ill patients: systematic review and meta-analysis.

IntroductionTelemedicine extends intensivists' reach to critically ill patients cared for by other physicians. Our objective was to evaluate the impact of telemedicine on patients' outcomes.MethodsWe searched electronic databases through April 2012, bibliographies of included trials, and indexes and conference proceedings in two journals (2001 to 2012). We selected controlled trials or observational studies of critically ill adults or children, examining the effects of telemedicine on mortality. Two authors independently selected studies and extracted data on outcomes (mortality and length of stay in the intensive care unit (ICU) and hospital) and methodologic quality. We used random-effects meta-analytic models unadjusted for case mix or cluster effects and quantified between-study heterogeneity by using I2 (the percentage of total variability across studies attributable to heterogeneity rather than to chance).ResultsOf 865 citations, 11 observational studies met selection criteria. Overall quality was moderate (mean score on Newcastle-Ottawa scale, 5.1/9; range, 3 to 9). Meta-analyses showed that telemedicine, compared with standard care, is associated with lower ICU mortality (risk ratio (RR) 0.79; 95% confidence interval (CI), 0.65 to 0.96; nine studies, n = 23,526; I2 = 70%) and hospital mortality (RR, 0.83; 95% CI, 0.73 to 0.94; nine studies, n = 47,943; I2 = 72%). Interventions with continuous patient-data monitoring, with or without alerts, reduced ICU mortality (RR, 0.78; 95% CI, 0.64 to 0.95; six studies, n = 21,384; I2 = 74%) versus those with remote intensivist consultation only (RR, 0.64; 95% CI, 0.20 to 2.07; three studies, n = 2,142; I2 = 71%), but effects were statistically similar (interaction P = 0.74). Effects were also similar in higher (RR, 0.83; 95% CI, 0.68 to 1.02) versus lower (RR, 0.69; 95% CI, 0.40 to 1.19; interaction, P = 0.53) quality studies. Reductions in ICU and hospital length of stay were statistically significant (weighted mean difference (telemedicine-control), -0.62 days; 95% CI, -1.21 to -0.04 days and -1.26 days; 95% CI, -2.49 to -0.03 days, respectively; I2 > 90% for both).ConclusionsTelemedicine was associated with lower ICU and hospital mortality among critically ill patients, although effects varied among studies and may be overestimated in nonrandomized designs. The optimal telemedicine technology configuration and dose tailored to ICU organization and case mix remain unclear.

The use of pharmacotherapy in pregnancies with suspected diabetic fetopathy

Objective: To review the evidence supporting incorporation of sonographic fetal measurements in deciding whether or not to add insulin to diet therapy independent of maternal glucose measures for women who have gestational diabetes. Methods: A literature search was conducted for studies incorporating sonographic estimates of fetal measures in the selection of treatment. Only randomized controlled trials were selected for review. Results: Four studies meeting selection criteria were identified. Methods of randomization, sonographic measurements used to indicate the addition of insulin for treatment, and clinical endpoints differed somewhat from study to study. Most studies reported a decrease in large neonates among women whose insulin treatment was indicated by ultrasound. In each study the targeted glucose values for patients treated with insulin based on sonographic measurements were lower than for those treated exclusively with diet. Conclusions: Available evidence suggests a benefit in reducing the incidence of large birth weight babies to mothers who have gestational diabetes by utilizing designated sonographic parameters in the decision to add pharmacotherapy in addition to using glucose thresholds. To support these findings, studies are needed in which glycemic targets comparing groups whose insulin treatment is based on maternal glucose results with those based on ultrasound measurements are identical.

Valproic Acid in Dementia

Valproic acid is widely used in the treatment of behavioral disturbances in patients with dementia; however, there is uncertainty about its dosing and studies have reported mixed findings. The current article examines published trials of valproic acid in the treatment of patients with dementia to identify whether an optimal dosing strategy exists. Secondarily, valproic acid dosing from published studies is compared with a real-world 5-year sample of valproic acid prescribing. Twenty studies met selection criteria and were included in the review. Based primarily on uncontrolled trials and the current retrospective study, valproic acid serum levels between 40 and 60 mcg/mL and relatively low doses (ie, 7-12 mg/kg per d) are associated with improvements in agitation in some patients with dementia. At the same time, similar valproic acid levels produced no significant behavioral improvements in most placebo-controlled studies and led to substantial side effects in some patients. Considerable trial design differences exist between controlled and uncontrolled trials. Overall, valproic acid appears to have limited efficacy as monotherapy in many patients with dementia. Its optimal role may be in combination with other psychotropics as a treatment of agitation associated with dementia.