Yuji Oba

Abandoning Daily Routine Chest Radiography in the Intensive Care Unit: Meta-Analysis

PURPOSE To systematically examine whether abandoning daily routine chest radiography would adversely affect outcomes, such as mortality and length of stay (LOS), and identify a subgroup in which daily routine chest radiography might be beneficial. MATERIALS AND METHODS This was a meta-analysis of clinical trials that examined the effect of abandoning daily routine chest radiography in adults in intensive care units (ICUs). Studies were identified through searches of MEDLINE, Cochrane Database, Database of Abstracts of Reviews of Effects, Biological Abstracts, and CINAHL. The results were expressed as odds ratios (ORs) or weighted mean difference (WMD) along with their 95% confidence intervals (CIs). RESULTS Eight studies with a total of 7078 patients were identified. A pooled analysis revealed that the elimination of daily routine chest radiography did not affect either hospital or ICU mortality (OR, 1.02;[95% CI: 0.89, 1.17; P = .78 and OR, 0.92; 95% CI: 0.76, 1.11; P = .4, respectively). There was no significant difference in ICU LOS (WMD = 0.19 days; 95% CI: -0.13, 0.51; P = .25), hospital LOS (WMD = -0.29 days; 95% CI: -0.71, 0.13; P = .18), and ventilator days (WMD = 0.33 days; 95% CI: -0.12, 0.78; P = .15) between the on-demand and daily routine groups. Regression analyses failed to identify any subgroup in which performing daily routine chest radiography was beneficial. CONCLUSION Systematic but unselective daily routine chest radiography can likely be eliminated without increasing adverse outcomes in adult patients in ICUs. Further studies are necessary to identify the specific patient population that would benefit from daily routine chest radiographs.

Efficacy and safety of roflumilast in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

Background: Roflumilast, a phosphodiesterase 4 inhibitor, has been shown to improve lung function and reduce exacerbation rates, but is associated with adverse events (AEs). The purpose of this study was to systematically review the clinical effectiveness and safety of roflumilast. Methods: A systematic search was made of MEDLINE, Cochrane trials database, DARE and CINAHL. Randomized, controlled trials of more than 12 weeks’ duration comparing roflumilast with placebo were reviewed. Studies were pooled to yield relative risk (RR), incident rate difference or weighted mean differences with 95% confidence intervals (CIs). Results: Eight trials (8698 patients) met the inclusion criteria. Roflumilast significantly reduced moderate to severe exacerbations (RR 0.85; 95% CI 0.80−0.91) compared with placebo, but not severe exacerbations (RR 0.83; 95% CI 0.68–1.01) or mortality (RR 0.90; 95% CI 0.63–1.28). Roflumilast significantly improved lung function relative to placebo, but not quality of life measures. AEs (RR 1.11; 95% CI 1.03–1.19) and discontinuations of treatment due to AEs (RR 1.63; 95% CI 1.45–1.84) were significantly more frequent with roflumilast than placebo. In the chronic obstructive pulmonary disease (COPD) Safety Pool (12,054 patients), the overall incidence of serious AEs did not differ between groups. However, atrial fibrillation (0.4% versus 0.2%; p = 0.02) and suicidality (0.08% versus 0%) were more frequent with roflumilast than placebo. Conclusions: The efficacy of roflumilast appears modest compared with other available therapies for COPD. Further studies are needed to investigate the risk–benefit ratio and long-term safety of roflumilast before its wider use.

Efficacy and safety of long-acting β-agonist/long-acting muscarinic antagonist combinations in COPD: a network meta-analysis

Background The place of long-acting β agonist/long-acting muscarinic antagonist (LABA/LAMA) combinations in stable patients with COPD is not well defined. The purpose of this study was to systematically review the efficacy and safety of LABA/LAMA combinations. Methods Several databases and manufacturers’ websites were searched for relevant clinical trials. Randomised control trials, at least 12 weeks duration, comparing a LABA/LAMA combination with placebo and/or monotherapy were included. The data were pooled using a network as well as a traditional direct comparison meta-analysis. Results Twenty-three trials with a total of 27 172 patients were included in the analysis. LABA/LAMA combinations were associated with a greater improvement in lung function, St. Georges Respiratory Questionnaire (SGRQ) score, and Transitional Dyspnoea Index (TDI) than monotherapies. LABA/LAMA combinations were associated with a significantly greater proportion of SGRQ and TDI responders than monotherapies (OR 1.23 (95% credible interval (CrI) 1.06–1.39), OR 1.34 (95% CrI 1.19–1.50) versus LABAs and OR 1.24 (95% CrI 1.11–1.36), OR 1.31 (95% CrI 1.18–1.46) versus LAMAs, respectively) and fewer moderate-to-severe exacerbations compared with LABAs (HR 0.82 (95% CrI 0.73–0.93)), but not when compared with LAMAs (HR 0.92 (95% CrI 0.84–1.00)). There were no statistically significant differences associated with LABA/LAMA combinations compared with monotherapies in safety outcomes as well as in severe exacerbations. Conclusions The combination therapy was the most effective strategy in improving lung function, quality of life, symptom scores and moderate-to-severe exacerbation rates, and had similar effects on safety outcomes and severe exacerbations as compared with monotherapies.

Cost-Effectiveness of Long-Acting Bronchodilators for Chronic Obstructive Pulmonary Disease

OBJECTIVE To evaluate and compare the cost-effectiveness of long-acting bronchodilators by estimating incremental costs per quality-adjusted life-year (QALY) gained in patients with moderate to severe chronic obstructive pulmonary disease. METHODS This cost-effective analysis was conducted from a third-party payers perspective. The study was a retrospective pooled analysis, and the effectiveness evidence was derived from a systematic review of literature published from January 1, 1980, to April 14, 2006. Incremental QALYs were estimated by converting the St Georges Respiratory Questionnaire scores into EuroQoL-5D scores and using these combined scores as the summary benefit measure. RESULTS The incremental cost per additional QALY was

High levels of PEEP may improve survival in acute respiratory distress syndrome: A meta-analysis

26,094 (range,

Safety, tolerability and risk benefit analysis of tiotropium in COPD

11,780-

The Prevalence and Diagnostic Significance of Eosinophilic Pleural Effusions: A Meta-Analysis and Systematic Review

77,214) for tiotropium and

Mortality benefit of vasopressor and inotropic agents in septic shock: A Bayesian network meta-analysis of randomized controlled trials

41,000 (range,

Comparative efficacy of inhaled corticosteroid and long-acting beta agonist combinations in preventing COPD exacerbations: a Bayesian network meta-analysis.

23,650-

Comparative efficacy of long-acting muscarinic antagonists in preventing COPD exacerbations: a network meta-analysis and meta-regression

98,750) for salmeterol compared with placebo. The cost per QALY gained was lower with tiotropium compared with salmeterol or ipratropium based on either the pooled data of available trials or a head-to-head trial. Treatment with tiotropium could save