Jayna Holroyd-Leduc

Effects of self-management intervention on health outcomes of patients with heart failure: a systematic review of randomized controlled trials.

BackgroundHeart failure is the most common cause of hospitalization among adults over 65. Over 60% of patients die within 10 years of first onset of symptoms. The objective of this study is to determine the effectiveness of self-management interventions on hospital readmission rates, mortality, and health-related quality of life in patients diagnosed with heart failure.MethodsThe study is a systematic review of randomized controlled trials. The following data sources were used: MEDLINE (1966-11/2005), EMBASE (1980-11/2005), CINAHL (1982-11/2005), the ACP Journal Club database (to 11/2005), the Cochrane Central Trial Registry and the Cochrane Database of Systematic Reviews (to 11/2005); article reference lists; and experts in the field. We included randomized controlled trials of self-management interventions that enrolled patients 18 years of age or older who were diagnosed with heart failure. The primary outcomes of interest were all-cause hospital readmissions, hospital readmissions due to heart failure, and mortality. Secondary outcomes were compliance with treatment and quality of life scores. Three reviewers independently assessed the quality of each study and abstracted the results. For each included study, we computed the pooled odds ratios (OR) for all-cause hospital readmission, hospital readmission due to heart failure, and death. We used a fixed effects model to quantitatively synthesize results. We were not able to pool effects on health-related quality of life and measures of compliance with treatment, but we summarized the findings from the relevant studies. We also summarized the reported cost savings.ResultsFrom 671 citations that were identified, 6 randomized trials with 857 patients were included in the review. Self-management decreased all-cause hospital readmissions (OR 0.59; 95% confidence interval (CI) 0.44 to 0.80, P = 0.001) and heart failure readmissions (OR 0.44; 95% CI 0.27 to 0.71, P = 0.001). The effect on mortality was not significant (OR = 0.93; 95% CI 0.57 to 1.51, P = 0.76). Adherence to prescribed medical advice improved, but there was no significant difference in functional capabilities, symptom status and quality of life. The reported savings ranged from

The impact of the electronic medical record on structure, process, and outcomes within primary care: a systematic review of the evidence

1300 to

A Systematic Review of Amnestic and Non-Amnestic Mild Cognitive Impairment Induced by Anticholinergic, Antihistamine, GABAergic and Opioid Drugs

7515 per patient per year.ConclusionSelf-management programs targeted for patients with heart failure decrease overall hospital readmissions and readmissions for heart failure.

What Type of Urinary Incontinence Does This Woman Have

BACKGROUND The electronic medical record (EMR)/electronic health record (EHR) is becoming an integral component of many primary-care outpatient practices. Before implementing an EMR/EHR system, primary-care practices should have an understanding of the potential benefits and limitations. OBJECTIVE The objective of this study was to systematically review the recent literature around the impact of the EMR/EHR within primary-care outpatient practices. MATERIALS AND METHODS Searches of Medline, EMBASE, CINAHL, ABI Inform, and Cochrane Library were conducted to identify articles published between January 1998 and January 2010. The gray literature and reference lists of included articles were also searched. 30 studies met inclusion criteria. RESULTS AND DISCUSSION The EMR/EHR appears to have structural and process benefits, but the impact on clinical outcomes is less clear. Using Donabedians framework, five articles focused on the impact on healthcare structure, 21 explored healthcare process issues, and four focused on health-related outcomes.

Does This Patient Have Bacterial Peritonitis or Portal Hypertension?How Do I Perform a Paracentesis and Analyze the Results?

BackgroundMild cognitive deficits are experienced by 18% of community-dwelling older adults, many of whom do not progress to dementia. The effect of commonly used medication on subtle impairments in cognitive function may be under-recognized.ObjectiveThe aim of the review was to examine the evidence attributing amnestic or non-amnestic cognitive impairment to the use of medication with anticholinergic, antihistamine, GABAergic or opioid effects.MethodsMEDLINE and EMBASE were searched for randomized, doubleblind, placebo-controlled trials of adults without underlying central nervous system disorders who underwent detailed neuropsychological testing prior to and after oral administration of drugs affecting cholinergic, histaminergic, GABAergic or opioid receptor pathways. Seventy-eight studies were identified, reporting 162 trials testing medication from the four targeted drug classes. Two investigators independently appraised study quality and extracted relevant data on the occurrence of amnestic, non-amnestic or combined cognitive deficits induced by each drug class. Only trials using validated neuropsychological tests were included. Quality of the evidence for each drug class was assessed based on consistency of results across trials and the presence of a dose-response gradient.ResultsIn studies of short-, intermediate- and long-acting benzodiazepine drugs (n = 68 trials), these drugs consistently induced both amnestic and non-amnestic cognitive impairments, with evidence of a dose-response relationship. H1-antihistamine agents (n = 12) and tricyclic antidepressants (n = 15) induced non-amnestic deficits in attention and information processing. Non-benzodiazepine derivatives (n = 29) also produced combined deficits, but less consistently than benzodiazepine drugs. The evidence was inconclusive for the type of cognitive impairment induced by different bladder relaxant antimuscarinics (n = 9) as well as for narcotic agents (n = 5) and antipsychotics (n = 5). Among healthy volunteers >60 years of age, low doses of commonly used medications such as lorazepam 0.5 mg, oxybutynin immediate release 5 mg and oxycodone 10 mg produced combined deficits.ConclusionNon-amnestic mild cognitive deficits are consistently induced by first-generation antihistamines and tricyclic antidepressants, while benzodiazepines provoke combined amnestic and non-amnestic impairments. Risk-benefit considerations should be discussed with patients in order to enable an informed choice about drug discontinuation or substitution to potentially reverse cognitive adverse effects.

How can delirium best be prevented and managed in older patients in hospital

CONTEXT Urinary incontinence is a prevalent condition and treatment options can depend on what type of incontinence is present. OBJECTIVE To systematically review the evidence about the most accurate way to determine the type of urinary incontinence during an office assessment. DATA SOURCES A search of MEDLINE using Ovid (1966-July 2007) and EMBASE (1980-July 2007), and the bibliographies of retrieved articles to identify relevant studies. Search terms included urinary incontinence, diagnostic tests, medical history taking, physical examination, cough stress test, and urodynamics. STUDY SELECTION English-language articles were identified that addressed the office diagnosis of urinary incontinence in adults, in which data was not limited to case reports. Cohort studies of patients undergoing history, physical examination, and/or office procedures (excluding urodynamics) for diagnosing the type of urinary incontinence were included. Case-control studies were considered when there was insufficient data available from cohort studies. The accepted reference standard for categorization of incontinence type was diagnosis confirmed by an expert, urodynamic studies, or both. DATA EXTRACTION Two investigators independently appraised study quality and extracted relevant data. Minimum inclusion criteria were completion of an appropriate reference standard in all patients and the ability to extract relevant data. DATA SYNTHESIS Forty articles were identified for inclusion. A random-effects model was used for quantitative synthesis. Minimal data was available for men. In women, simple questions modestly helped diagnose stress urinary incontinence (summary positive likelihood ratio [LR], 2.2; 95% confidence interval [CI], 1.6-3.2; summary negative LR, 0.39; 95% CI, 0.25-0.61) but are more helpful in diagnosing urge urinary incontinence (summary positive LR, 4.2; 95% CI, 2.3-7.6; summary negative LR, 0.48; 95% CI, 0.36-0.62). A positive bladder stress test may help diagnose stress urinary incontinence (summary LR, 3.1; 95% CI, 1.7-5.5); however, a negative test is not as useful (summary LR, 0.36; 95% CI, 0.21-0.60). A systematic assessment combining the history, physical examination, and results of bedside tests to establish a clinical diagnosis appears to be of modest value in diagnosing stress urinary incontinence (summary positive LR, 3.7; 95% CI, 2.6-5.2; summary negative LR, 0.20; 95% CI, 0.08-0.51). The systematic assessment is less helpful in diagnosing urge urinary incontinence (summary positive LR, 2.2; 95% CI, 0.55-8.7; summary negative LR, 0.63; 95% CI, 0.34-1.17). CONCLUSIONS The most helpful component for diagnosing urge urinary incontinence is a history of urine loss associated with urgency. A bladder stress test may be helpful for diagnosing stress urinary incontinence.

Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis

CONTEXT Abdominal paracenteses are performed in patients with ascites, most commonly to assess for infection or portal hypertension and to manage refractory ascites. OBJECTIVES To systematically review evidence for paracentesis methods that may decrease risk of adverse events or improve diagnostic yield and to determine the accuracy of ascitic fluid analysis for spontaneous bacterial peritonitis or portal hypertension. DATA SOURCES Relevant English-language studies from Medline (1966-April 2007) and EMBASE (1980-April 2007). STUDY SELECTION Paracentesis studies evaluating interventions (use of preprocedure coagulation parameters, needle type, insertion location, ultrasound guidance, bedside inoculation into blood culture bottles, and use of plasma expanders in therapeutic taps) for reducing adverse events or improving the diagnostic yield, and studies assessing the accuracy of ascitic fluid biochemical analyses for spontaneous bacterial peritonitis or portal hypertension. DATA EXTRACTION For technique studies, data on intervention and outcome; and for diagnostic studies, data on parameters for diagnosing spontaneous bacterial peritonitis and portal hypertension (ie, ascitic fluid white blood cell and polymorphonuclear leukocyte [PMN] count, ascitic fluid pH, blood-ascitic fluid pH gradient, and serum-ascites albumin gradient). DATA SYNTHESIS Thirty-seven studies met inclusion criteria: 2 showed that obtaining preprocedure coagulation was likely unnecessary prior to paracentesis; 1 showed the 15-gauge, 3.25-inch needle-cannula results in less multiple peritoneal punctures [P = .05] and termination due to poor fluid return [P = .02] vs a 14-gauge needle in therapeutic paracentesis; 1 showed immediate inoculation of culture bottles improves diagnostic yield vs delayed (from 77% to 100% [95% CI for the difference, 5.3%-40.0%]); 9 evaluated therapeutic paracentesis, performed with or without albumin or nonalbumin plasma expanders, and found no consistent effect on morbidity or mortality; 16 showed the accuracy of biochemical analysis of ascitic fluid in patients suspected of having spontaneous bacterial peritonitis to increase the likelihood of spontaneous bacterial peritonitis (PMN count >250 cells/microL [summary likelihood ratio {LR}, 6.4] 95% CI, 4.6-8.8; ascitic fluid leukocyte count >1000 cells/microL [summary LR, 9.1] 95% CI, 5.5-15.1; pH < 7.35 [summary LR, 9.0] 95% CI, 2.0-40.6; or a blood-ascitic fluid pH gradient > or = 0.10 [LR, 11.3] 95% CI, 4.3-29.9) and other levels lowered the likelihood (PMN count < or = 250 cells/microL [summary LR, 0.2] 95% CI, 0.11-0.37; or a blood-ascitic fluid pH gradient < 0.10 [summary LR, 0.12] 95% CI, 0.02-0.77); and 4 showed the diagnostic accuracy of the serum-ascites albumin gradient lowers the likelihood of portal hypertension (< 1.1 g/dL [summary LR, 0.06] 95% CI, 0.02-0.20). CONCLUSIONS Ascitic fluid should be inoculated into blood culture bottles at the bedside. Spontaneous bacterial peritonitis is more likely at predescribed parameters of ascitic PMN count or blood-ascitic fluid pH, and portal hypertension is less likely below a predescribed serum-ascites albumin gradient.

Does This Patient Have a Pleural Effusion

You are asked to conduct a preoperative assessment of an 86-year-old woman recently admitted to hospital with a fractured right hip. She reports having fallen while getting out of her bathtub but denies any prior history of falls. She has no other injuries. She lives alone at home and was

Systematic review of recent dementia practice guidelines

Importance Falls result in substantial burden for patients and health care systems, and given the aging of the population worldwide, the incidence of falls continues to rise. Objective To assess the potential effectiveness of interventions for preventing falls. Data Sources MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Ageline databases from inception until April 2017. Reference lists of included studies were scanned. Study Selection Randomized clinical trials (RCTs) of fall-prevention interventions for participants aged 65 years and older. Data Extraction and Synthesis Pairs of reviewers independently screened the studies, abstracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis were conducted. Main Outcomes and Measures Injurious falls and fall-related hospitalizations. Results A total of 283 RCTs (159 910 participants; mean age, 78.1 years; 74% women) were included after screening of 10 650 titles and abstracts and 1210 full-text articles. Network meta-analysis (including 54 RCTs, 41 596 participants, 39 interventions plus usual care) suggested that the following interventions, when compared with usual care, were associated with reductions in injurious falls: exercise (odds ratio [OR], 0.51 [95% CI, 0.33 to 0.79]; absolute risk difference [ARD], −0.67 [95% CI, −1.10 to −0.24]); combined exercise and vision assessment and treatment (OR, 0.17 [95% CI, 0.07 to 0.38]; ARD, −1.79 [95% CI, −2.63 to −0.96]); combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30 [95% CI, 0.13 to 0.70]; ARD, −1.19 [95% CI, −2.04 to −0.35]); and combined clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (eg, comprehensive geriatric assessment), calcium supplementation, and vitamin D supplementation (OR, 0.12 [95% CI, 0.03 to 0.55]; ARD, −2.08 [95% CI, −3.56 to −0.60]). Pairwise meta-analyses for fall-related hospitalizations (2 RCTs; 516 participants) showed no significant association between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care (OR, 0.78 [95% CI, 0.33 to 1.81]). Conclusions and Relevance Exercise alone and various combinations of interventions were associated with lower risk of injurious falls compared with usual care. Choice of fall-prevention intervention may depend on patient and caregiver values and preferences.

Detecting depression in Parkinson disease: A systematic review and meta-analysis.

CONTEXT Pleural effusion is a common finding among patients presenting with respiratory symptoms. The value of the bedside examination to detect pleural effusion is unclear. OBJECTIVE To systematically review the evidence regarding the accuracy of the physical examination in assessing the probability of a pleural effusion. DATA SOURCES We searched MEDLINE (1950-October 2008) and EMBASE (1980-October 2008) using Ovid to identify English-language studies conducted in a clinical setting. Additional studies were identified by searching the bibliographies of retrieved articles and contacting experts in the field. STUDY SELECTION We included prospective studies of diagnostic accuracy that compared at least 1 physical examination maneuver with radiographic confirmation of pleural effusion. DATA EXTRACTION Three authors independently appraised study quality and extracted relevant data. Data regarding participant recruitment, reference standard, diagnostic test(s), and test accuracy were extracted. Disagreements were resolved by consensus. DATA SYNTHESIS We identified 310 unique citations, but only 5 prospectively conducted studies met inclusion criteria (N = 934 patients). A random-effects model was used for quantitative synthesis. Of the 8 physical examination maneuvers evaluated in the included studies (conventional percussion, auscultatory percussion, breath sounds, chest expansion, tactile vocal fremitus, vocal resonance, crackles, and pleural friction rub), dullness to conventional percussion was most accurate for diagnosing pleural effusion (summary positive likelihood ratio, 8.7; 95% confidence interval, 2.2-33.8), while the absence of reduced tactile vocal fremitus made pleural effusion less likely (negative likelihood ratio, 0.21; 95% confidence interval, 0.12-0.37). CONCLUSIONS Based on the limited number of studies, dullness to percussion and tactile fremitus are the most useful findings for pleural effusion. Dull chest percussion makes the probability of a pleural effusion much more likely but requires a chest radiograph to confirm the diagnosis. When the pretest probability of pleural effusion is low, the absence of reduced tactile vocal fremitus makes pleural effusion less likely so that a chest radiograph might not be necessary depending on the overall clinical situation.