Ahlam A. Saleh

Frailty and Technology: A Systematic Review of Gait Analysis in Those with Frailty

Background: New technologies for gait assessment are emerging and have provided new avenues for accurately measuring gait characteristics in home and clinic. However, potential meaningful clinical gait parameters beyond speed have received little attention in frailty research. Objective: To study gait characteristics in different frailty status groups for identifying the most useful parameters and assessment protocols for frailty diagnosis. Methods: We searched PubMed, Embase, PsycINFO, CINAHL, Web of Science, Cochrane Library, and Age Line. Articles were selected according to the following criteria: (1) population: individuals defined as frail, prefrail, or transitioning to frail, and (2) outcome measures: quantitative gait variables as obtained by biomechanical analysis. Effect sizes (d) were calculated for the ability of parameters to discriminate between different frailty status groups. Results: Eleven publications met inclusion criteria. Frailty definitions, gait protocols and parameters were inconsistent, which made comparison of outcomes difficult. Effect sizes were calculated only for the three studies which compared at least two different frailty status groups. Gait speed shows the highest effect size to discriminate between frailty subgroups, in particular during habitual walking (d = 0.76-6.17). Gait variability also discriminates between different frailty status groups in particular during fast walking. Prominent parameters related to prefrailty are reduced cadence (d = 1.43) and increased step width variability (d = 0.64), whereas frailty (vs. prefrail status) is characterized by reduced step length during habitual walking (d = 1.32) and increased double support during fast walking (d = 0.78). Interestingly, one study suggested that dual-task walking speed can be used to predict prospective frailty development. Conclusion: Gait characteristics in people with frailty are insufficiently analyzed in the literature and represent a major area for innovation. Despite the paucity of work, current results suggest that parameters beyond speed could be helpful in identifying different categories of frailty. Increased gait variability might reflect a multisystem reduction and may be useful in identifying frailty. In addition, a demanding task such as fast walking or adding a cognitive distractor might enhance the sensitivity and specificity of frailty risk prediction and classification, and is recommended for frailty assessment using gait analysis.

A review of the effectiveness of antidepressant medications for depressed nursing home residents

BACKGROUND Antidepressant medications are the most common psychopharmacologic therapy used to treat depressed nursing home (NH) residents. Despite a significant increase in the rate of antidepressant prescribing over the past several decades, little is known about the effectiveness of these agents in the NH population. OBJECTIVE To conduct a systematic review of the literature to examine and compare the effectiveness of antidepressant medications for treating major depressive symptoms in elderly NH residents. METHODS The following databases were searched with searches completed prior to January 2011 and no language restriction: MEDLINE, Embase, PsycINFO, CINHAL, CENTRAL, LILACS, ClinicalTrials.gov, International Standard Randomized Controlled Trial Number Register, and the WHO International Clinical Trial Registry Platform. Additional studies were identified from citations in evidence-based guidelines and reviews as well as book chapters on geriatric depression and pharmacotherapy from several clinical references. Studies were included if they described a clinical trial that assessed the effectiveness of any currently-marketed antidepressant for adults aged 65 years or older, who resided in the NH, and were diagnosed by DSM criteria and/or standardized validated screening instruments with Major Depressive Disorder, minor depression, dysthymic disorder, or Depression in Alzheimers disease. RESULTS A total of eleven studies, including four randomized and seven non-randomized open-label trials, met all inclusion and exclusion criteria. It was not feasible to conduct a meta-analysis because the studies were heterogeneous in terms of study design, operational definitions of depression, participant characteristics, pharmacologic interventions, and outcome measures. Of the four randomized trials, two had a control group and did not demonstrate a statistically-significant benefit for antidepressant pharmacotherapy over placebo. While six of the seven non-randomized studies identified a response to an antidepressant, their results must be interpreted with caution as they lacked a comparison group. CONCLUSIONS The limited amount of evidence from randomized and non-randomized open-label trials suggests that depressed NH residents have a modest response to antidepressant medications. Further research using rigorous study designs are needed to examine the effectiveness and safety of antidepressants in depressed NH residents, and to determine the various facility, provider, and patient factors associated with response to treatment.

Performance of risk assessment instruments for predicting osteoporotic fracture risk: a systematic review

SummaryWe systematically reviewed the literature on the performance of osteoporosis absolute fracture risk assessment instruments. Relatively few studies have evaluated the calibration of instruments in populations separate from their development cohorts, and findings are mixed. Many studies had methodological limitations making susceptibility to bias a concern.IntroductionThe aim of this study was to systematically review the literature on the performance of osteoporosis clinical fracture risk assessment instruments for predicting absolute fracture risk, or calibration, in populations other than their derivation cohorts.MethodsWe performed a systematic review, and MEDLINE, Embase, Cochrane Library, and multiple other literature sources were searched. Inclusion and exclusion criteria were applied and data extracted, including information about study participants, study design, potential sources of bias, and predicted and observed fracture probabilities.ResultsA total of 19,949 unique records were identified for review. Fourteen studies met inclusion criteria. There was substantial heterogeneity among included studies. Six studies assessed the WHO’s Fracture Risk Assessment (FRAX) instrument in five separate cohorts, and a variety of risk assessment instruments were evaluated in the remainder of the studies. Approximately half found good instrument calibration, with observed fracture probabilities being close to predicted probabilities for different risk categories. Studies that assessed the calibration of FRAX found mixed performance in different populations. A similar proportion of studies that evaluated simple risk assessment instruments (≤5 variables) found good calibration when compared with studies that assessed complex instruments (>5 variables). Many studies had methodological features making them susceptible to bias.ConclusionsFew studies have evaluated the performance or calibration of osteoporosis fracture risk assessment instruments in populations separate from their development cohorts. Findings are mixed, and many studies had methodological limitations making susceptibility to bias a possibility, raising concerns about use of these tools outside of the original derivation cohorts. Further studies are needed to assess the calibration of instruments in different populations prior to widespread use.

Type of Evidence Behind Point-of-Care Clinical Information Products: A Bibliometric Analysis

Background Point-of-care (POC) products are widely used as information reference tools in the clinical setting. Although usability, scope of coverage, ability to answer clinical questions, and impact on health outcomes have been studied, no comparative analysis of the characteristics of the references, the evidence for the content, in POC products is available. Objective The objective of this study was to compare the type of evidence behind five POC clinical information products. Methods This study is a comparative bibliometric analysis of references cited in monographs in POC products. Five commonly used products served as subjects for the study: ACP PIER, Clinical Evidence, DynaMed, FirstCONSULT, and UpToDate. The four clinical topics examined to identify content in the products were asthma, hypertension, hyperlipidemia, and carbon monoxide poisoning. Four indicators were measured: distribution of citations, type of evidence, product currency, and citation overlap. The type of evidence was determined based primarily on the publication type found in the MEDLINE bibliographic record, as well as the Medical Subject Headings (MeSH), both assigned by the US National Library of Medicine. MeSH is the controlled vocabulary used for indexing articles in MEDLINE/PubMed. Results FirstCONSULT had the greatest proportion of references with higher levels of evidence publication types such as systematic review and randomized controlled trial (137/153, 89.5%), although it contained the lowest total number of references (153/2330, 6.6%). DynaMed had the largest total number of references (1131/2330, 48.5%) and the largest proportion of current (2007-2009) references (170/1131, 15%). The distribution of references cited for each topic varied between products. For example, asthma had the most references listed in DynaMed, Clinical Evidence, and FirstCONSULT, while hypertension had the most references in UpToDate and ACP PIER. An unexpected finding was that the rate of citation overlap was less than 1% for each topic across all five products. Conclusions Differences between POC products are revealed by examining the references cited in the monographs themselves. Citation analysis extended to include key content indicators can be used to compare the evidence levels of the literature supporting the content found in POC products.

The Impact of Mild Cognitive Impairment on Gait and Balance: A Systematic Review and Meta-Analysis of Studies Using Instrumented Assessment

Background: In addition to cognitive deficits, people with mild cognitive impairment (MCI) can experience motor dysfunction, including deficits in gait and balance. Objective, instrumented motor performance assessment may allow the detection of subtle MCI-related motor deficits, allowing early diagnosis and intervention. Motor assessment under dual-task conditions may increase diagnostic accuracy; however, the sensitivity of different cognitive tasks is unclear. Objective: To systematically review the extant literature focusing on instrumented assessment of gait and balance parameters for discriminating MCI patients from cognitively intact peers. Methods: Database searches were conducted in PubMed, EMBASE, Cochrane Library, PsycINFO and Web of Science. Inclusion criteria were: (1) clinically confirmed MCI; (2) instrumented measurement of gait and/or balance; (3) English language, and (4) reporting gait or balance parameters which could be included in a meta-analysis for discriminating between MCI patients and cognitively intact individuals based on weighted effect size (d). Results: Fourteen studies met the inclusion criteria and reported quantitative gait (n = 11) or postural balance (n = 4) parameters to be included in the meta-analysis. The meta-analysis revealed that several gait parameters including velocity (d = -0.74, p < 0.01), stride length (d = -0.65, p < 0.01), and stride time (mean: d = 0.56, p = 0.02; coefficient of variation: d = 0.50, p < 0.01) discriminated best between MCI and healthy controls under single-task conditions. Importantly, dual-task assessment increased the discriminative power of gait variables wherein gait variables with counting tasks appeared to be more sensitive (range d = 0.84-1.35) compared to verbal fluency tasks such as animal naming (range d = 0.65-0.94). Balance parameters identified as significant discriminators were anterior-posterior (d = 0.49, p < 0.01) and mediolateral (d = -0.34, p = 0.04) sway position in the eyes-open condition but not eyes-closed condition. Conclusion: Existing studies provide evidence that MCI affects specific gait parameters. MCI-related gait changes were most pronounced when subjects are challenged cognitively (i.e., dual task), suggesting that gait assessment with an additional cognitive task is useful for diagnosis and outcome analysis in the target population. Static balance seems to also be affected by MCI, although limited evidence exists. Instrumented motor assessment could provide a critical opportunity for MCI diagnosis and tailored intervention targeting specific deficits and potentially slowing progression to dementia. Further studies are required to confirm our findings.

Grey Literature Searching for Health Sciences Systematic Reviews: A Prospective Study of Time Spent and Resources Utilized

Objective To identify estimates of time taken to search grey literature in support of health sciences systematic reviews and to identify searcher or systematic review characteristics that may impact resource selection or time spent searching. Methods A survey was electronically distributed to searchers embarking on a new systematic review. Characteristics of the searcher and systematic review were collected along with time spent searching and what resources were searched. Time and resources were tabulated and resources were categorized as grey or non-grey. Data was analyzed using Kruskal-Wallis tests. Results Out of 81 original respondents, 21% followed through with completion of the surveys in their entirety. The median time spent searching all resources was 471 minutes, and of those a median of 85 minutes were spent searching grey literature. The median number of resources used in a systematic review search was four and the median number of grey literature sources searched was two. The amount of time spent searching was influenced by whether the systematic review was grant funded. Additionally, the number of resources searched was impacted by institution type and whether systematic review training was received. Conclusions This study characterized the amount of time for conducting systematic review searches including searching the grey literature, in addition to the number and types of resources used. This may aid searchers in planning their time, along with providing benchmark information for future studies. This paper contributes by quantifying current grey literature search patterns and associating them with searcher and review characteristics. Further discussion and research into the search approach for grey literature in support of systematic reviews is encouraged.

Brentuximab vedotin for treatment of non-Hodgkin lymphomas: A systematic review.

BACKGROUND Brentuximab vedotin (BV) is an antibody-drug conjucate (ADC) comprising a CD30-directed antibody, conjugated to the microtubule-disrupting agent MMAE via a protease cleavable linker. BV is FDA approved for use in relapsed classical Hodgkin lymphoma (HL) and relapsed systemic anaplastic large cell lymphoma (sALCL). There are multiple publications for its utility in other malignancies such as diffuse large B-cell lymphoma (DLBCL), mycosis fungoides (MF), Sézary syndrome (SS), T-cell lymphomas (TCL), primary mediastinal lymphoma (PMBL), and post-transplant lymphoproliferative disorders (PTLD). We believe that BV could potentially provide a strong additional treatment option for patients suffering from NHL. OBJECTIVE Perform a systematic review on the use of BV in non-Hodgkin lymphoma (NHL) and other CD30+ malignancies in humans. DATA SOURCES We searched various databases including PubMed (1946-2015), EMBASE (1947-2015), and Cochrane Central Register of Controlled Trials (1898-2015). ELIGIBILITY CRITERIA Inclusion criteria specified all studies and case reports of NHLs in which BV therapy was administered. INCLUDED STUDIES A total of 28 articles met these criteria and are summarized in this manuscript. CONCLUSION Our findings indicate that BV induces a variety of responses, largely positive in nature and variable between NHL subtypes. With additional, properly powered prospective studies, BV may prove to be a strong candidate in the treatment of various CD30+ malignancies.

What Can Be Learned from the Types of Community Benefit Programs that Hospitals Already Have in Place

After implementation of the Patient Protection and Affordable Care Act (ACA) how will tax-exempt hospitals adjust their community benefit programs to maintain their non-profit status? This literature review categorized existing hospital-based community benefit programs by reviewing published articles that met the following inclusion criteria: affiliated or funded by a hospital; described the program design; focused on community benefit or outreach; evaluated program outcomes; located within the United States. Of 4,917 original citations, we reviewed 265 full-text articles. One hundred and six (106) programs met all inclusion criteria and were used to develop a hospital-based community benefit program taxonomy. Results indicate that programs to enhance patient care, clinic-based programs and programs with a community partner make up the majority of community benefit programs (25%, 28% and 31%, respectively). Few programs were rigorously evaluated or provide evidence of program impact. Hospitals should work with public health professionals to design, implement, and evaluate their community benefit programs.

Role of Maintenance Therapy after High-Dose Chemotherapy and Autologous Hematopoietic Cell Transplantation in Aggressive Lymphomas: A Systematic Review

Significant uncertainty exists in regard to the efficacy of maintenance therapy after high-dose chemotherapy (HDC) as well as autologous stem cell transplantation (ASCT) for the treatment of patients with aggressive lymphoma. A systematic review was performed to evaluate the effectiveness of post-ASCT maintenance therapy in patients with relapsed/refractory lymphoma. A comprehensive literature search yielded 4476 studies and a total of 42 studies (11 randomized controlled trials [RCT], 9 retrospective comparative studies, and 22 single-arm studies) were included in the systematic review. There was significant heterogeneity in study design, chemotherapeutic regimens, post-ASCT maintenance strategies, patient enrollment criteria, and study endpoints. Our findings suggest that post-ASCT maintenance immune-targeting strategies, including PD-1/PD-L1 blocking antibodies, rituximab, and brentuximab, may improve progression-free survival but not overall survival. Collectively, the results indicate a need for testing new strategies with well-designed and adequately powered RCTs to better address the role of post-ASCT maintenance in relapsed/refractory lymphomas.

The triple aim and its implications on the management of chronic rhinosinusitis

Introduction Accountable care organizations (ACO) and alternative payment models are a sign of the change in reimbursement from fee-for-service to value-based reimbursement. The focus of health care under ACOs is represented by the Triple Aim: to improve the experience of health care, improve the health of populations, and reduce the per capita costs. Individuals with chronic rhinosinusitis (CRS) are heavy consumers of health care services. Results of recent studies have indicated that there is the potential for improved outcomes and cost savings from early surgical intervention. Adhering to the principles of the Triple Aim may signal a paradigm shift in regard to timing of intervention for CRS in certain patients. Methods A scoping review was performed to analyze the current literature related to management of CRS and the impact on cost, population health outcomes, and the patients experience of health care. Results A growing body of literature indicates that, in appropriately selected patients, when compared with medical management, endoscopic sinus surgery has the potential to improve patient outcomes and reduce the long-term cost burden of CRS. Conclusion With the advent of ACOs, a paradigm shift in the treatment of CRS is inevitable to better conform to the goals of the Triple Aim. Future treatment algorithms will need to account for the heterogeneity within CRS and seek to identify appropriate timing and interventions for patients on an individual basis if the value of health care is to be improved.