Claire Infante-Rivard

Role of Endoscopic Variceal Sclerotherapy in the Long-Term Management of Variceal Bleeding: A Meta-analysis

Seven randomized clinical trials evaluating the effect of repeated endoscopic variceal sclerotherapy on the long-term survival of patients with variceal hemorrhage have been published in the English-language literature. In four trials, the sclerotherapy-treated patients showed an improved long-term survival (follow-up periods longer than a year) when compared with patients in the medical regimen group, whereas in the other three trials, the long-term survival did not differ between the compared groups. Sample sizes in these negative trials were too small to detect a true moderate effect for serial sclerotherapy. To resolve this controversy, we combined the findings from all trials using a meta-analysis and determined the overall effect of repeated endoscopic variceal sclerotherapy on the survival of patients who had previously bled from esophageal varices. An overall risk difference of -0.15 (95% confidence limits, -0.21 to -0.08; p less than 0.0005) was estimated, indicating that sclerotherapy reduced the number of deaths by 25%. The estimated overall risk difference remained negative even when all patients in the sclerotherapy group with an unknown survival status were pessimistically considered dead at the end of the follow-up period. The results of this quantitative synthesis suggest that patients with bleeding esophageal varices benefit from the inclusion of repeated sclerotherapy in their long-term management regimen.

Prophylaxis of upper gastrointestinal bleeding in intensive care units: a meta-analysis.

A meta-analysis was performed of 15 randomized studies on the prophylaxis with cimetidine and/or ant-acids of upper GI bleeding acquired in the ICU. There were eight comparisons of a group receiving cimetidine with a control group, nine comparisons of a group receiving antacids with a control group, and ten comparisons of a group receiving cimetidine with a group receiving antacids. The incidence of upper GI bleeding ranged from 3.4% to 52.7% among 866 control patients who received either a placebo or no prophylaxis. In five of eight comparisons, cimetidine was significantly more effective than no treatment or a placebo to prevent occult and overt upper GI bleeding; the typical odds ratio was 0.32 (95% confidence interval 0.21 to 0.49). In six of nine comparisons, antacids were significantly more effective than no treatment or a placebo; the typical odds ratio was 0.12 (0.08 to 0.19). Finally, antacids were significantly more effective than cimetidine in two of ten comparisons; the typical odds ratio was 1.61 (0.97 to 2.65). However, weaknesses in the study designs, heterogeneity of treatment effects, the lack of strength of the accumulated evidence, and the fact that no utility has been shown in terms of reducing morbidity (shock, need for transfusion) or mortality, prevent any definitive conclusion in regard to compulsory use of upper GI bleeding prophylaxis for ICU patients.

Protected specimen brush or bronchoalveolar lavage to diagnose bacterial nosocomial pneumonia in ventilated adults : A meta-analysis

OBJECTIVEnWe conducted a meta-analysis by using summary receiver operating characteristic curves to compare the diagnostic value for bacterial nosocomial pneumonia of the following: a) quantitative culture (colony-forming units per milliliter or CFU/mL) of respiratory secretions collected with a bronchoscopic protected specimen brush (PSB); b) quantitative culture of a bronchoscopic bronchoalveolar lavage (BAL); and c) the percentage of infected cells (IC) in BAL.nnnDATA SOURCESnAll studies published in the English or the French language, through January 1, 1995, on the evaluation of PSB or BAL for the diagnosis of pneumonia were considered for analysis. The relevant literature was identified through computer and reference searching and by experts in the field.nnnSTUDY SELECTIONnA study was included if at least two of three independent readers regarded its purpose as the evaluation of CFU-PSB, CFU-BAL, or IC-BAL for the diagnosis in human beings of bacterial nosocomial pneumonia in ventilated adults and if the study was prospective and published in a peer-reviewed journal.nnnDATA EXTRACTIONnThree readers reviewed all published articles and decided whether to include each study; consensus was defined as agreement by at least two readers. The authors of each original article included in the meta-analysis were asked to complete a questionnaire in which they were asked to check and to correct the data extracted by one of the independent readers.nnnDATA SYNTHESISnSummary receiver operating characteristic curves were used to compare the efficacy of three diagnostic tests. Eighteen studies on CFU-PSB (795 patients) were included, as well as 11 studies on CFU-BAL (435 patients) and 11 on IC-BAL (766 patients). The accuracy of these tests was not different. However, it seems that administration of previous antibiotics markedly decreased accuracy of CFU-PSB (p = .0002) but not the accuracy of CFU-BAL and that of IC-BAL.nnnCONCLUSIONnBoth PSB and BAL are reliable to diagnose bacterial nosocomial pneumonia. Because CFU-BAL and IC-BAL seemed more resistant to the effects of antibiotics, we recommend BAL rather than PSB if the patient is already receiving antibiotics.

Socioeconomic Status and Utilization of Health Care Services Among Asthmatic Children

We evaluated the relation between socioeconomic factors and hospitalization as well as emergency department (ED) visits among asthmatic children who had universal access to health care. Newly diagnosed asthmatic children 3–4 years of age were followed up for a period of 6 years. Information on hospitalization and ED visits was obtained by interviewing parents. Socioeconomic status (SES) was measured by paternal occupation, race, type of dwelling, and an index of crowding. After adjusting for asthma severity, logistic regression analysis showed that children with fathers in the economically least advantaged occupations were more likely to be hospitalized due to their asthma [fathers occupation group 3 (FOG3), odds ratio (OR)=2.1, 95% confidence interval (95% CI)=0.2–19.8; fathers occupation group 4 (FOG4), OR=13.9, 95% CI=1.1–181.4]. The probability of emergency department visits was not significantly different according to the studied variables. Emergency department visits were not influenced by SES variables, probably due to the absence of financial barriers to access health care. However, SES differences in hospitalization may suggest differential management and/or treatment practices according to socioeconomic status at the emergency departments.

A telephone support service to reduce medical care use among the elderly.

A randomized controlled trial was performed to determine whether a telephone support system could reduce the frequency of ambulatory physician encounters. A total of 182 elderly persons were enrolled in the study. The experimental group was regularly called by a public health nurse and could call the nurse every weekday during normal working hours. The control group received no intervention. A year later, the experimental group reported 7.40 ambulatory encounters with a physician (SD = 4.94) and the control group reported 8.61 encounters (SD = 6.85). The difference between the groups, after adjusting for various prognostic factors, was 1.20 (95% confidence interval, −0.84 to 3.24). Although the difference did not achieve statistical significance, the results suggest that telephone support may bring about a substantial decrease in medical care utilization. Further research assessing the cost‐advantage ratio for this type of intervention is recommended.

Upper gastrointestinal tract bleeding acquired in a pediatric intensive care unit: Prophylaxis trial with cimetidine

Essai controle en double-insu des effets de la cimetidine (n=19) contre placebo (n=21), chez des enfants de 10 jours a 14 ans. La cimetidine accroit le pH du suc gastrique dans les 3 heures apres la 1ere injection intraveineuse mais ne previent pas les saignements macroscopiques gastro-intertinaux (SMGI) chez les sujets a risque. Le type de prophylaxie est conteste et les transfusions sanguines demeurent indiquees chez les sujets a risque

The Changing Frequency of Childhood Asthma

Hospital admission rates for childhood asthma have increased markedly in many countries since the beginning of the 1970s. Prevalence of asthma, as reported by parents or children in occasional surveys, has also increased during this period. In Montreal, 7.2 per 1000 3-year-old children were admitted to the hospital with a diagnosis of asthma in 1980-1981, whereas the rate was 11.9 per 1000 in 1984-1985. For 7-year-old children, these rates were 3.2 per 1000 and 4.8 per 1000, respectively. On the other hand, the length of hospital stay decreased steadily during this period, and the mean number of admissions per child did not show a tendency to increase. For 3- and 7-year-old children together, the prevalence of asthma, determined from health insurance data, increased by 71%, from 3.76% in 1980 to 6.45% in 1983. Prevalence of other medical conditions also increased in this community, but much less than for asthma. An increase in the incidence of the disease cannot be excluded as the cause for the changing prevalence of asthma.

Descriptive Epidemiology of Primary Biliary Cirrhosis in the Province of Quebec

Primary biliary cirrhosis (PBC) is a rare disease, but is usually recognized because of the characteristic clinical picture and the diagnostic specificity of antimitochondrial antibody (AMA) determination. Information on the epitlemiology of PBC is limited. The authors have examined the incidence and prevalence of PBC in the province of Quebec, where all short term hospitals are required to classify discharge summary diagnoses according to the International Classification of Diseases. Code 571.6 designates primary or secondary biliary cirrhosis. The authors reviewed the charts of all patients to whom this code was assigned during a six year period (1980-86). Two hundred and twenty-eight subjects satisfied predetermined diagnostic criteria for PBC. The mean annual incidence rate was 3.9 per 106 population, and the point prevalence in 1986 was 25.4 per 106 population. Ninety-two patients were female, with a mean age at the time of diagnosis of 55.7 years; 89.4% had positive AMA, and 10.5% were asymptomatic. As of January 1, 1989, 126 patients were alive, 91 had died, and 11 had undergone liver transplantation. Cumulative five and 10 year survivals from the time of initial diagnosis were 69% and 49%, respectively. In patients with serum bilirubins greater than 100u2009μmol/L (n=66), cumulative two year survival was 5.5%. These data indicate that the incidence and prevalence of PBC in Quebec arc similar to chose reported in Ontario and at the lower end of the range of chose reported in western Europe. The clinical features and evolution of PBC are also similar, and serum bilirubin is a major prognostic factor.

Folate deficiency among institutionalized elderly. Public health impact.

All patients 65 years and older who had been living in an institution for at least six months had a measurement of red blood cell folate (RBCF), serum folate (SF), vitamin B12, hemoglobin, and mean corpuscular volume. Twenty‐two percent of the 97 studied subjects were found deficient in RBCF, although only 6% had anemia. Length of stay at the institution was significantly associated with deficiency in RBCF and this association was uncon‐founded by age. The proportion of RBCF deficiency among the studied subjects attributable to length of stay is 80%. The prophylactic administration of folate among long‐term nursing home type of patients should be considered.

Quality of care in public health well child clinics: A neglected issue

The process of well child care in public health clinics was evaluated using a peer review approach based on explicit criteria formulated by the peers themselves. The criteria defined what should be done in order to ensure good preventive care during a client-provider encounter. The data from this study suggest that the traditional goals of public health are being pursued, but that a broader spectrum of preventive care, including attention to the childs psychosocial development, is still lacking.