Gordon H. Guyatt

Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: A meta-analysis

Endoscopic hemostatic therapy for upper gastrointestinal bleeding is gaining widespread acceptance despite often conflicting results of randomized controlled trials. To examine the effect of endoscopic therapy in acute nonvariceal upper gastrointestinal hemorrhage, a meta-analysis was performed using a computerized search of the English-language literature and a bibliographic review. The methodology, population, intervention, and outcomes of each relevant trial were evaluated by duplicate independent review. Thirty randomized controlled trials evaluating hemostatic endoscopic treatment were identified. Endoscopic therapy significantly reduced rates of further bleeding (odds ratio, 0.38; 95% confidence interval, 0.32-0.45), surgery (odds ratio, 0.36; 95% confidence interval, 0.28-0.45), and mortality (odds ratio, 0.55; 95% confidence interval, 0.40-0.76). When analyzed separately, thermal-contact devices (monopolar and bipolar electrocoagulation and heater probe), laser treatment, and injection therapy all significantly decreased further bleeding and surgery rates. The reductions in mortality were comparable for all three forms of therapy, but the decrease reached statistical significance only for laser therapy. Further examination of subgroups indicated that endoscopic treatment decreased rates of further bleeding, surgery, and mortality in patients with high-risk endoscopic features of active bleeding or nonbleeding visible vessels. Rebleeding was not reduced by endoscopic therapy in patients with ulcers containing flat pigmented spots or adherent clots. Endoscopic hemostatic therapy provides a clinically important reduction in morbidity and mortality in patients with acute nonvariceal upper gastrointestinal hemorrhage.

An Evidence-Based Approach to Gastroenterology Diagnosis

PHILIP SCHOENFELD,* GORDON GUYATT,‡ FRANK HAMILTON,§ LOREN LAINE,\ DEBORAH COOK,‡ DAVID BJORKMAN,¶ DAVID MORGAN,# and WALTER PETERSON** for the EVIDENCE BASED GASTEROENTEROLOGY STEERING GROUP *Division of Gastroenterology, National Naval Medical Center, Bethesda, Maryland; ‡Department of Clinical Epidemiology and Biostatistics, McMaster University School of Medicine, Hamilton, Ontario, Canada; §Digestive Diseases Program, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; \Division of Gastrointestinal and Liver Diseases, University of Southern California School of Medicine, Los Angeles, California; ¶Division of Gastroenterology, University of Utah Medical Center, Salt Lake City, Utah; #Division of Gastroenterology, McMaster University Medical Center, Hamilton, Ontario, Canada; and **University of Texas Southwestern Medical School and Medical Service, Dallas Veterans Administration Medical Center, Dallas, Texas

Factors associated with the duration of disability benefits claims among Canadian workers: a retrospective cohort study

BACKGROUND Disability insurance protects workers from total loss of income in case of a disabling injury or illness by providing wage-replacement benefits. To better inform early identification of claims at risk of prolonged recovery, we explored predictors of the duration of disability benefits claims. METHODS We conducted a retrospective cohort study using claims data provided by SSQ Life Insurance Company Inc., a private Canadian disability insurer. We examined all claims SSQ approved for short- and long-term disability benefits from Jan. 1, 2007, to Mar. 31, 2014, and evaluated the association between 9 variables and duration of short- and long-term disability benefits using Cox proportional hazards regression analyses. RESULTS For both short- (n = 70 776) and long-term disability (n = 22 205) claims, and across all disorders, older age, female sex, heavy job demands, presence of comorbidity, attending an independent medical evaluation, receipt of rehabilitation therapy and longer time to claim approval were associated with longer claim duration. Higher predisability salary was associated with longer short-term disability claim duration. Quebec residency was associated with longer short-term disability claim duration among workers with psychological disorders, but shorter short-term disability claim duration among those with musculoskeletal complaints and other illnesses. For long-term disability claims, however, residing in Quebec was associated with shorter claim duration, although the size of the association differed across clinical conditions. INTERPRETATION The factors we found to be associated with the duration of short- and long-term disability claims may be helpful to identify claims at risk of prolonged recovery. Our study has limitations, however, and well-designed prospective studies are needed to confirm our findings and identify other promising predictors.