Michelle L. Matteson

Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials

BACKGROUND Polyethylene glycol (PEG) is a commonly used bowel preparation for colonoscopy. Unfortunately, the standard large-volume solution may reduce patient compliance. Split-dosing of PEG has been studied in various randomized, controlled trials (RCTs). However, results have been conflicting. OBJECTIVE We conducted a meta-analysis to assess the role of split-dose PEG versus full-dose PEG for bowel preparation before colonoscopy. DESIGN Multiple databases were searched (January 2011). RCTs on adults comparing full-dose and split-dose of PEG for bowel preparation before colonoscopy were included and analyzed by calculating pooled estimates of quality of bowel preparation, preparation compliance, willingness to repeat the same preparation, and side effects by using odds ratio (OR) by fixed and random-effects models. SETTING Literature search. PATIENTS Per RCTs. MAIN OUTCOME MEASUREMENTS Satisfactory bowel preparation, willingness to repeat same bowel preparation, patient compliance, and side effects. RESULTS Five trials met inclusion criteria (N = 1232). Split-dose PEG significantly increased the number of satisfactory bowel preparations (OR 3.70; 95% CI, 2.79-4.91; P < .01) and willingness to repeat the same preparation (OR 1.76; 95% CI, 1.06-2.91; P = .03) compared with full-dose PEG. Split-dose PEG also significantly decreased the number of preparation discontinuations (OR 0.53; 95% CI, 0.28-0.98; P = .04) and nausea (OR 0.55; 95% CI, 0.38-0.79; P < .01) compared with full-dose PEG. LIMITATIONS Limited number of studies. CONCLUSIONS The use of a split-dose PEG for bowel preparation before colonoscopy significantly improved the number of satisfactory bowel preparations, increased patient compliance, and decreased nausea compared with the full-dose PEG.

Interventions to improve medication-adherence after transplantation: a systematic review

Reports of interventions to improve adherence to medical regimens in solid organ transplant recipients are scarce. A systematic review identified 12 intervention studies. These studies focused on renal, heart, and liver transplant recipients. Five reports used randomized controlled trial (RCT) designs. Sample sizes varied between 18 and 110 subjects. The interventions are difficult to evaluate and categorize because of brief descriptions of intervention details. Of the 12 studies identified in this review, only five studies found a statistically significant improvement in at least one medication‐adherence outcome with the intervention. In general, most included a combination of patient‐focused cognitive/educational, counseling/behavioral, and psychologic/affective dimensions. Eight studies intervened at the healthcare provider, healthcare setting or healthcare system level, but showed a limited improvement in adherence. No single intervention proved to be superior at increasing medication‐adherence in organ transplantation, but a combination of interventions in a team approach for the chronic disease management of organ transplant patients may be effective in a long‐term perspective. In conclusion, finding the most effective combination of interventions to enhance adherence is vital. Utilizing an RCT design and adhering to the CONSORT guidelines can lead to higher quality studies and possibly more effective intervention studies to enhance medication‐adherence.

Interventions to improve hemodialysis adherence: a systematic review of randomized-controlled trials.

Over 485,000 people in the United States have chronic kidney disease, a progressive kidney disease that may lead to hemodialysis. Hemodialysis involves a complex regimen of treatment, medication, fluid, and diet management. In 2005, over 312,000 patients were undergoing hemodialysis in the United States. Dialysis nonadherence rates range from 8.5% to 86%. Dialysis therapy treatment nonadherence, including treatment, medication, fluid, and diet nonadherence, significantly increases the risk of morbidity and mortality. The purpose of this paper is to systematically review randomized‐controlled trial intervention studies designed to increase treatment, medication, fluid, and diet adherence in adult hemodialysis patients. A search of Cumulative Index of Nursing and Allied Health Literature (CINAHL) (1982 to May 2008), MEDLINE (1950 to May 2008), PsycINFO (1806 to May 2008), and all Evidence‐Based Medicine (EBM) Reviews (Cochran DSR, ACP Journal Club, DARE, and CCTR) was conducted to identify randomized‐controlled studies that tested the efficacy of interventions to improve adherence in adult hemodialysis patients. Eight randomized‐controlled trials met criteria for inclusion. Six of the 8 studies found statistically significant improvement in adherence with the intervention. Of these 6 intervention studies, all studies had a cognitive component, with 3 studies utilizing cognitive/behavioral intervention strategies. Based on this systematic review, interventions utilizing a cognitive or cognitive/behavioral component appear to show the most promise for future study.

Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis

BACKGROUND: Traditionally, tube feedings have been delayed after percutaneous endoscopic gastrostomy (PEG) placement to the next day and up to 24 h postprocedure. However, results from various randomized controlled trials (RCTs) indicate earlier feeding may be an option. We conducted a meta-analysis to analyze the effect of early feedings (≤4 h) after PEG placement.METHODS: Multiple databases were searched (November 2007). Only RCTs on adult subjects that compared early (≤4 h) versus delayed or next-day feedings after PEG placement were included. Meta-analyses for the effect of early and delayed feedings were analyzed by calculating pooled estimates of complications, death ≤72 h, and significant increases in postprocedural gastric residual volume during day 1.RESULTS: Six studies (N = 467) met the inclusion criteria. No statistically significant differences were noted between early (≤4 h) and delayed or next-day feedings for patient complications (OR 0.86, 95% CI 0.47–1.58, P = 0.63) or death in ≤72 h (OR 0.56, 95% CI 0.18–1.74, P = 0.31). A statistically significant increase in gastric residual volumes during day 1 was noted (OR 1.80, 95% CI 1.02–3.19, P = 0.04).CONCLUSIONS: Early feeding ≤4 h after PEG placement may represent a safe alternative to delayed or next-day feedings. Although an increase in significant gastric residual volumes at day 1 was noted, overall complications were not affected.

Improving Medication Adherence: Moving from Intention and Motivation to a Personal Systems Approach

Medication nonadherence is a challenging and prevalent problem in older adults. Effective medication management involves successfully completing a complex group of behaviors. Meta-analyses and narrative review findings support limited benefits to medication adherence with interventions preoccupied with personal characteristics, intention, and motivation. Evidence supports a paradigm shift toward changing personal systems in which the person lives to improve and maintain medication adherence behavior. Personal-systems change systematically improves individual systems through collaboratively shaping routines, involving supportive-others in routines, and using medication self-monitoring to improve and maintain behavior. Other advances that support personal systems change are also presented.

Administration of erythromycin before endoscopy in upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials.

Background/Aim: Erythromycin infusion before endoscopy in upper gastrointestinal bleeding (UGIB) has been hypothesized to aid in visualization and reduce the need for second-look endoscopy; however, the results have been controversial. To evaluate further, we performed a meta-analysis comparing the efficacy of erythromycin infusion before endoscopy in acute UGIB. Methods: Multiple databases were searched (March 2013). Only randomized controlled trials were included in the analysis. A meta-analysis for the effect of erythromycin or no erythromycin before endoscopy in UGIB were analyzed by calculating pooled estimates of primary (visualization of gastric mucosa and need for second endoscopy) and secondary (units of blood transfused, length of hospital stay, duration of the procedure) outcomes. Statistical analysis was performed using RevMan 5.1 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration). Results: Six studies (N = 558) met the inclusion criteria. Erythromycin infusion before endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa [odds ratio (OR) 3.43; 95% confidence interval (CI): 1.81 to 6.50, P < 0.01] compared with no erythromycin. In addition, erythromycin infusion before endoscopy resulted in a statistically significant decrease in the need for a second endoscopy (OR 0.47; 95% CI: 0.26 to 0.83, P = 0.01), units of blood transfused (WMD − 0.41; 95% CI: −0.82 to −0.01, P = 0.04), and the duration of hospital stay (WMD − 1.51; 95% CI: −2.45 to −0.56, P < 0.01). Conclusions: Erythromycin infusion before endoscopy in patients with UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy, units of blood transfused, and duration of hospital stay.

Erythromycin prior to endoscopy in acute upper gastrointestinal bleeding: A meta-analysis

Abstract Objective. Upper gastrointestinal bleeding (UGIB) is a medical emergency requiring urgent endoscopy and diagnosis. However, adequate visualization is a necessity. Studies have been performed evaluating the efficacy of erythromycin infusion prior to endoscopy to improve visibility and therapeutic potential of esophagogastroduodenoscopy (EGD) with varied results. Therefore, a meta-analysis was performed comparing the efficacy of erythromycin infusion prior to endoscopy in acute UGIB. Materials and methods. Multiple databases were searched. Meta-analysis for the effect of erythromycin prior to endoscopy in UGIB was analyzed by calculating pooled estimates of visualization of gastric mucosa, need for second endoscopy, and units of blood transfused using odds ratio (OR) and weighted mean difference (WMD). Results. Four studies (N = 269) met the inclusion criteria. Erythromycin prior to endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa (OR 4.89; 95% CI 2.85–8.38, p < 0.01), a decrease in the need for a second endoscopy (OR 0.42; 95% CI 0.24–0.74, p < 0.01), and a trend for less units of blood transfused (WMD −0.48; 95% CI −0.97 to 0.01, p = 0.05) with erythromycin as compared with no erythromycin. Conclusions. Erythromycin infusion prior to endoscopy in acute UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy. Based upon these results, erythromycin should be strongly considered prior to endoscopy in patients with UGIB.

Enteral feeding within three hours after percutaneous endoscopic gastrostomy placement: a meta-analysis.

Background Traditionally, tube feedings have been delayed after gastrostomy placement to the next day and up to 24 hours postprocedure. However, results from various randomized clinical trials (RCTs) indicate earlier feeding may be an option. Therefore, we conducted a meta-analysis to analyze the effect of earlier feedings (⩽3 h) after percutaneous endoscopic gastrostomy (PEG) placement. Methods Various medical databases and recent abstracts from major conference proceedings were searched (8/09). Only RCTs on adult subjects that compared early (⩽3 h) versus delayed or next-day feedings after PEG placement were included. Meta-analysis was performed using pooled estimates of complications, death ⩽72 hours, and significant increases in the number of postprocedural gastric residual volume during day 1 using odds ratio (OR) with the fixed and random effects models. Heterogeneity was assessed by calculating the I2 measure of inconsistency. RevMan 5.0 was utilized for statistical analysis. Results Five studies (N=355) met the inclusion criteria. No significant differences were noted between early (⩽3 h) and delayed or next day feedings for patient complications [OR 0.78; 95% confidence interval (CI), 0.39-1.53; P=0.47], death in ⩽72 hours (OR 0.60; 95% CI, 0.18-1.99; P=0.40), and number of significant gastric residual volume during day 1 (OR 1.46; 95% CI, 0.75-2.84; P=0.27). No publication bias and no significant heterogeneity were noted. Conclusions Early tube feeding ⩽3 hours after PEG placement has no significant differences to delayed or next-day feeding in respect to complications, death in ⩽72 hours, or number of significant gastric residual volumes at day 1.

Endoscopy after acute myocardial infarction: an evaluation of safety.

Objectives Upper gastrointestinal bleeding in the setting of acute myocardial infarction (MI) has substantial morbidity and mortality. Several studies have been performed on the safety of esophagogastroduodenoscopy (EGD) after MI; however, these studies vary in definitions and results. We evaluated the safety and effect of EGD in patients with acute MI in a tertiary center. Methods A retrospective, single tertiary-care center study was undertaken of 87 patients who underwent EGD within 30 days of an acute MI between January 2001 and March 2012. Type of MI (ST segment elevation MI [STEMI] and non–ST segment elevation MI [NSTEMI]), peak troponin I, time from MI to EGD, Acute Physiology and Chronic Health Evaluation (APACHE) II score at EGD, cardiac catheterization before EGD, and medical complications within 24 hours of EGD were noted. Medical complications were defined as major complications (death, life-threatening arrhythmias) and minor complications (chest pain, abnormal vital signs, or minor arrhythmias). Results Eighty-seven patients underwent EGD within 30 days of having an MI. No major complications were observed. Minor complications occurred in 27 of 87 patients (31.0%), including mild hypotension, mild bradycardia, or increased chest pain. Patients with STEMI demonstrated statistically significant quicker endoscopy (P = 0.01) and were more likely to undergo cardiac catheterization in advance of EGD (P < 0.01) than those with NSTEMI. No statistically significant differences were noted for peak troponin I (P = 0.21), APACHE II score at EGD (P = 0.55), or minor complications (P = 0.08) among patients with STEMI versus NSTEMI. Cardiac catheterization before EGD did not seem to affect results. Patients with APACHE II scores >16 experienced more minor complications (P = 0.02). Conclusions EGD appears relatively safe for the diagnosis and management of upper gastrointestinal bleeding in patients with acute MI.

Digital rectal examination versus spontaneous passage of stool for fecal occult blood testing

Background The diagnostic value of a positive fecal occult blood test (FOBT) at the time of digital rectal examination (DRE) is disputed despite being used commonly by a significant number of physicians. A meta-analysis was conducted to evaluate FOBT by DRE for detecting neoplasia versus FOBT on stool passed spontaneously (SPS) in asymptomatic patients undergoing colorectal cancer screening. Methods MEDLINE, the Cochrane Central Register of Controlled Trials and the Cochrane database of systematic reviews, CINAHL, PubMed, and recent abstracts from major conferences were searched in August 2011. We included all of the studies that compared stool sampling techniques for FOBT. Separate analyses were performed for each main outcome (normal, nonadvanced adenoma, advanced adenoma, and colon cancer). Results Seven studies (N = 1835) met the inclusion criteria. The use of DRE for FOBT demonstrated statistically significant fewer advanced adenomas than SPS for FOBT. No statistically significant differences were noted for normal findings, neoplasia, nonadvanced adenoma, or colon cancer with DRE compared with SPS for FOBT. Conclusions DRE for FOBT appears to be less effective at detecting advanced adenomas as compared with SPS despite cancer detection being similar. FOBT by SPS appears to be statistically superior to FOBT by DRE.