Aaron M Tejani

Minimum clinically important differences identified for commonly used depression rating scales

[1] Seshasai SR, Wijesuriya S, Sivakumaran R, Nethercott S, Erqou S, Sattar N, et al. Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials. Arch Intern Med 2012; 172:209e16. [2] Mancini GB, Schulzer M. Reporting risks and benefits of therapy by use of the concepts of unqualified success and unmitigated failure: applications to highly cited trials in cardiovascular medicine. Circulation 1999;99:377e83. [3] Schulzer M, Mancini GB. ‘Unqualified success’ and ‘unmitigated failure’: number-needed-to-treat-related concepts for assessing treatment efficacy in the presence of treatment-induced adverse events. Int J Epidemiol 1996;25:704e12.

Systematic Review of Evidence for the Use of Intradialytic Parenteral Nutrition in Malnourished Hemodialysis Patients

OBJECTIVE Intradialytic parenteral nutrition (IDPN) is widely used to treat malnourished hemodialysis (HD) patients. However, the benefits of this treatment are unknown. Moderate protein-energy malnutrition (PEM) is thought to affect 15% to 43% of maintenance HD patients, and is independently associated with mortality in this population. This study systematically reviews the current literature, to assess whether IDPN improves survival, quality of life, or nutritional status in those receiving maintenance HD. METHODS Two investigators undertook a formal systematic review of the literature, using the following key search words: intradialytic parenteral nutrition or intradialytic total parenteral nutrition plus any combination of renal dialysis or kidney-failure or chronic kidney disease and parenteral nutrition or intravenous nutrition or intravenous feeding. RESULTS The search identified three suitable randomized, controlled trials, only one of which investigated hard clinical endpoints. There were insufficient data to undertake a meta-analysis. CONCLUSIONS The evidence from clinical studies is insufficient to demonstrate either a net benefit or a net harm associated with the providing IDPN to malnourished HD patients. We recommend that any patient in whom IDPN was deemed necessary be entered into a clinical trial or registry, to record hard clinical outcomes associated with the use of this treatment.

Ten Commandments for patient-centred treatment

When deciding on a treatment, the first diagnosis you need to reach is about the nature of the illness. The second diagnosis you need concerns what the individual would like to achieve.1 Both are of equal importance and this is as true in simple one-off encounters as in complex lifelong illness. But the balance needs particularly careful thought when beginning long-term treatment. Always make sure that you understand your patient’s aims before you propose a course of action. It may require 3 minutes in a situation like an acute sore throat, or years of ongoing dialogue in a situation like multiple sclerosis or heart failure. Do not assume that you know what your patient has come for, and do not assume that the treatments you have on offer meet the goals of everyone in the same way. Both health professionals and lay people tend to overestimate the benefits of treatments and underestimate their harms. The traditional way to express these is as the number-needed-to-treat (NNT) and the number-needed-to-harm (NNH). It is important to have a ‘ball-park’ idea of these figures in common clinical situations, but also important to bear in mind their limitations. First, patients mostly find NNTs and NNHs hard to understand.2 Second, the numbers do not apply to individuals equally but are just average figures across the populations of clinical trials. Third, people vary widely in how they would balance a given benefit against a given harm.3 So we need better ways of a) knowing the true NNT and the NNH in the populations we treat; b) sharing this knowledge with people in ways they can understand; and c) applying this knowledge to the goals and preferences of the individual in front of us. The first commandment assumes that there will be two diagnoses in …

Statins for primary prevention

We wish to address an important issue that relates to the analysis of serious adverse events in the systematic review of statins for primary prevention by Tonelli and colleagues.[1][1] In the results section, the authors indicate “… the pooled risk of serious adverse events did not differ

Biomedical journals lack a consistent method to detect outcome reporting bias: a cross-sectional analysis

An increasing amount of recently published literature has implicated outcome reporting bias (ORB) as a major contributor to skewing data in both randomized controlled trials and systematic reviews; however, little is known about the current methods in place to detect ORB. This study aims to gain insight into the detection and management of ORB by biomedical journals.

Impact of Academic Detailing on Proton Pump Inhibitor Prescribing Behaviour in a Community Hospital

C P J / R P C • M A R C H / A P R I L 2 0 1 1 • V O L 1 4 4 , N O 2 Introduction Proton pump inhibitors (PPIs) are one of the most commonly prescribed class of drugs. Approximately 25% to 30% of patients receive a PPI in the hospital. Of these PPIs, approximately 40% to 60% are prescribed inappropriately. Despite the common use of PPIs, they are not without risks. Some of the common adverse effects include diarrhea and headache, which can occur in up to 10% of patients. Observational studies have shown that PPI use may be associated with an increased risk of community-acquired pneumonia, Clostridium difficile diarrhea and Campylobacter jejuni gastroenteritis, though evidence for a direct correlation remains inconclusive. In addition, the treatment of dyspeptic symptoms with PPIs prior to endoscopy can mask and delay the detection of gastric and esophageal carcinoma. Therefore, overuse of PPIs potentially poses negative health consequences and optimization of PPI prescribing may be of benefit to patients. Academic detailing (AD) is an effective method of improving physicians’ prescribing behaviour. It is defined as a one-on-one visit with a physician in his or her own setting, aimed at providing evidence-based information with the purpose of improving physician prescribing. An example of AD aimed at PPI use is providing the most recent guidelines pertaining to the physician’s specialty and a 1-hour presentation emphasizing the risks and benefits of using PPIs in stress ulcer prophylaxis. In a systematic review, Grindrod et al. found that reminders, audit and feedback, patientmediated interventions (i.e., patient educational materials and reminders via telephone, postcard or mail) and AD were consistently effective in positively influencing health practitioners’ prescribing behaviours. Another recent systematic review suggested that AD combined with social marketing — defined as a process that identifies the motivation for a behaviour, the barriers to change and the strategies to overcome those barriers — can improve prescribing. Most AD studies that have focused on PPIs were conducted in the community setting and data on the effectiveness of AD in changing prescribing behaviour of PPIs in hospitals are lacking. Therefore, we conducted a before-and-after study in order to determine if a simple AD intervention could reduce inappropriate PPI prescribing in a Canadian community hospital setting and optimize prescribing practices.

Comment on dexmedetomidine systematic review and meta-analysis methodology

Dear Editor, We were reading a recently published systematic review and meta-analysis of dexmedetomidine in critically ill mechanically ventilated patients [1] and wanted to point out some areas that concerned us with respect to the methodology used. More importantly our issues with the methodology have important implications on the conclusions that may be drawn by the authors and the readers of this important piece of work. If our observations are indeed accurate, a re-analysis of the data might lead the authors (and readers) to come to a completely different conclusion regarding the efficacy and safety of dexmedetomidine in this patient population. Our concerns are outlined below. First, we noticed that the Moldanado study (Ref. 32 in the article) was entered into the meta-analysis twice for the length of ICU stay outcome and the duration of mechanical ventilation. Our understanding is that this is incorrect because the patients who received dexmedetomidine were accounted for twice in these analyses. The more appropriate method would be to enter the study twice (i.e., once for each comparator) but for each entry use a denominator of 20 for dexmedetomidine (i.e., half the patients randomized to dexmedetomidine). Second, the studies by Martin (Ref. 20 in the article) and Herr (Ref. 19 in the article) appeared to have measured the incidence of ‘‘agitation’’. However, the data from these trials were entered into the meta-analysis as ‘‘delirium’’. As far as we understand, delirium and agitation are not synonymous and cannot be analyzed together. Third, the studies that were combined in Fig. 6 all measured delirium in substantially different ways, making the meta-analysis less meaningful. One study measured CAM-ICU positive patients plus those with an ADR of delirium or confusion, another measured CAMICU positives, and another measured CAM-ICU positives only when RASS scores were between -2 to ?1. Either the reader should be alerted to the differences more explicitly or the appropriateness of pooling the data should be reconsidered (especially in light of the significant statistical heterogeneity). The fourth issue had to do with heterogeneity in general. Several of the meta-analyses found significant heterogeneity and the authors do mention several possible reasons for this. They do not, however, explore any of those reasons in detail (i.e., by conducting specific post hoc sensitivity analyses). In our opinion, if any of their explanations for heterogeneity are correct, then there may be a strong argument to not meta-analyze the data.

Descriptive Analysis of Timing of Administration of Antimicrobial Therapy for Septic Shock in a Medical—Surgical Intensive Care Unit

Background:Septic shock remains a major cause of morbidity and mortality in intensive care units worldwide. According to the guidelines of the Society of Critical Care Medicine, antimicrobial therapy should be initiated within the first hour after recognition of severe sepsis. Furthermore, initiation of antibiotic administration within this timeframe has been associated with better survival to hospital discharge among adult patients, whereas survival declined with delays beyond 1 hour. We undertook this study to evaluate the timing of administration of antibiotics in relation to diagnosis of septic shock in an 11-bed medical—surgical intensive care unit (ICU) within a community hospital to compare the findings with international guidelines and best evidence.Methods:We performed a retrospective chart audit for adult patients (>18 years of age) with septic shock who were admitted to the Burnaby Hospital medical—surgical ICU between January and June 2006. We extracted from each chart the time of initiation o...

5-Alpha Reductase Inhibitors for Treatment of Benign Prostatic Hyperplasia:A Systematic Review and Meta-Analysis

Introduction: Finasteride and dutasteride are competitive inhibitors of 5-alpha reductase (5AR) enzymes and are commonly used for the treatment of symptomatic benign prostatic hyperplasia (BPH). This study is intended to evaluate the literature regarding the relative efficacy of these two agents on clinically important outcomes. Method: Randomized control trials, quasi-randomized trials, and systematic reviews comparing finasteride to dutasteride either as monotherapy or in combination with alpha-blockers in men with BPH were included. The outcomes studied included need for prostate-related surgery, acute urinary retention episodes, withdrawal due to adverse events, total serious adverse events, mortality, and sexual dysfunction. Results: There were no differences in need for prostate-related surgery (OR 2.01, 95% CI: 0.18, 22.24), acute urinary retention episodes (OR 1.47, 95% CI: 0.68, 3.19), number of withdrawals due to adverse events (OR 1.10, 95% CI: 0.68, 1.75) or serious adverse events (1.31, 95% CI: 0.87, 1.97). The odds ratios for sexual dysfunction and total adverse events were 0.83 (95% CI: 0.64, 1.08) and 0.94 (95% CI: 0.78, 1.14) respectively. Conclusion: There is insufficient evidence to suggest clinically important differences between finasteride and dutasteride at this time.

Review overemphasises benefits and downplays serious harms

We recently conducted a systematic review of bisphosphonates in postmenopausal women with osteoporosis. Our critical appraisal of evidence from 33 randomised controlled trials (25 375 women) of at least one year’s duration reached different conclusions from those of Poole and Compston.1 2 The goal of treatment is prevention of fragility fractures. Effects on bone mineral …