How can clinicians choose between conflicting and discordant systematic reviews? A replication study of the Jadad algorithm.

INTRODUCTION: The exponential growth of published systematic reviews (SRs) presents challenges for decision makers seeking to answer clinical, public health or policy questions. In 1997, an algorithm was created by Jadad et al. to choose the best SR across multiple. Our study aims to replicate author assessments using the Jadad algorithm to determine: (i) if we chose the same SR as the authors; and (ii) if we reach the same results. METHODS: We searched MEDLINE, Epistemonikos, and Cochrane Database of SRs. We included any study using the Jadad algorithm. We used consensus building strategies to operationalise the algorithm and to ensure a consistent approach to interpretation. RESULTS: We identified 21 studies that used the Jadad algorithm to choose one or more SRs. In 62% (13/21) of cases, we were unable to replicate the Jadad assessment and ultimately chose a different SR than the authors. Overall, 18 out of the 21 (86%) independent Jadad assessments agreed in direction of the findings despite 13 having chosen a different SR. CONCLUSIONS: Our results suggest that the Jadad algorithm is not reproducible between users as there are no prescriptive instructions about how to operationalise the algorithm. In the absence of a validated algorithm, we recommend that healthcare providers, policy makers, patients and researchers address conflicts between review findings by choosing the SR(s) with meta-analysis of RCTs that most closely resemble their clinical, public health, or policy question, are the most recent, comprehensive (i.e. number of included RCTs), and at the lowest risk of bias.

Correction: Exploring pre-surgery and post-surgery substance use disorder and alcohol use disorder in bariatric surgery: a qualitative scoping review.

In the original Article, Leo Akioyamen's surname was misspelled as "Aikiyomen." This has been updated in the XML, PDF and HTML versions of this Article.

Exploring pre-surgery and post-surgery substance use disorder and alcohol use disorder in bariatric surgery: a qualitative scoping review.

INTRODUCTION: Bariatric surgery (BS) produces superior weight loss compared to non-surgical interventions. However, studies suggest bariatric patients who have undergone gastric-bypass surgery have an increased risk of developing new onset substance use disorder (SUD) or suffer negative outcomes after surgery. As such, many bariatric programs consider alcohol/ illicit drug misuse a contraindication to BS. The purpose of this systematic review was to investigate weight loss outcomes, post-surgery substance use patterns and other morbidity/mortality in BS patients with a history of substance use/SUD. METHODS: Studies were identified by searching Ovid Medline(R), Embase, and PsychInfo. We included all study types investigating humans of any age/sex who had undergone any BS procedure with data regarding substance use before and/or after surgery. Outcome measures included metabolic outcomes and psychiatric outcomes after bariatric surgery in patients reporting substance use prior to bariatric surgery and substance use patterns after bariatric surgery. RESULTS: Fifty-eight studies were included in the review. Studies reporting weight loss after BS did not demonstrate an association between substance use and negative weight loss outcomes. Several studies reported a significant portion of participants having new onset or increased substance use after BS. Factors associated with new onset or increased substance use/SUD after BS included the type of surgery, a history of SUD, a family history of SUD, coping skills/life stressors, age, male sex and alcohol sensitization after surgery. CONCLUSION: Substance use history does not appear to influence weight loss after BS, however it may contribute to increased substance use after BS. Clinicians should ensure valid screening tools when assessing BS candidates for substance use history and ensure long term follow-up care post-operatively.

The microbiome-gut-brain axis: implications for schizophrenia and antipsychotic induced weight gain.

With the emergence of knowledge implicating the human gut microbiome in the development and regulation of several physiological systems, evidence has accumulated to suggest a role for the gut microbiome in psychiatric conditions and drug response. A complex relationship between the enteric nervous system, the gut microbiota and the central nervous system has been described which allows for the microbiota to influence and respond to a variety of behaviors and psychiatric conditions. Additionally, the use of pharmaceuticals may interact with and alter the microbiota to potentially contribute to adverse effects of the drug. The gut microbiota has been described in several psychiatric disorders including depression and anxiety, but only a few reports have discussed the role of the microbiome in schizophrenia. The following review examines the evidence surrounding the gut microbiota in behavior and psychiatric illness, the role of the microbiota in schizophrenia and the potential for antipsychotics to alter the gut microbiota and promote adverse metabolic events.

A drug interaction study investigating the effect of Rifabutin on the pharmacokinetics of Maraviroc in healthy subjects.

Effects of steady-state rifabutin on the pharmacokinetics of steady-state maraviroc were investigated in fourteen healthy adult female and male volunteers. Maraviroc 300 mg twice daily (BID) was given orally with food for fifteen days. On day six, rifabutin 300 mg once daily (QD, P.O.) was added to the regimen. Formal pharmacokinetic (PK) sampling was performed on days five and fifteen. Individual plasma drug concentration-time data for maraviroc, and rifabutin on day fifteen, were obtained using validated High Performance Liquid Chromatography (HPLC) tandem Mass Spectrometry (MS/MS). Rifabutin steady state exposure was comparable to data in the literature. Maraviroc area under the curve (AUC) and minimum plasma concentration (Clast or Cmin) were reduced by 17% and 30% respectively when co-administered with rifabutin. No unexpected or serious adverse eventsoccurred. Based on the reduced exposure of maraviroc observed in this study, increasing the dose of maraviroc may be studied to normalize its moderately reduced exposure following rifabutin co-administration, a moderate inducer of CYP3A4.

Comparison of pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a protocol for a systematic review incorporating network meta-analyses.

BACKGROUND: Delirium is characterized by acute changes in mental status including inattention, disorganized thinking, and altered level of consciousness, and is highly prevalent in critically ill adults. Delirium has adverse consequences for both patients and the healthcare system; however, at this time, no effective treatment exists. The identification of effective prevention strategies is therefore a clinical and research imperative. An important limitation of previous reviews of delirium prevention is that interventions were considered in isolation and only direct evidence was used. Our systematic review will synthesize all existing data using network meta-analysis, a powerful statistical approach that enables synthesis of both direct and indirect evidence. METHODS: We will search Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science from 1980 to March 2016. We will search the PROSPERO registry for protocols and the Cochrane Library for published systematic reviews. We will examine reference lists of pertinent reviews and search grey literature and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We will include randomized and quasi-randomized trials of critically ill adults evaluating any pharmacological, non-pharmacological, or multi-component intervention for delirium prevention, administered in or prior to (i.e., peri-operatively) transfer to the ICU. Two authors will independently screen search results and extract data from eligible studies. Risk of bias assessments will be completed on all included studies. To inform our network meta-analysis, we will first conduct conventional pair-wise meta-analyses for primary and secondary outcomes using random-effects models. We will generate our network meta-analysis using a Bayesian framework, assuming a common heterogeneity parameter across all comparisons, and accounting for correlations in multi-arm studies. We will perform analyses using WinBUGS software. DISCUSSION: This systematic review will address the existing knowledge gap regarding best practices for delirium prevention in critically ill adults by synthesizing evidence from trials of pharmacological, non-pharmacological, and multi-component interventions administered in or prior to transfer to the ICU. Use of network meta-analysis will clarify which delirium prevention strategies are most effective in improving clinical outcomes while causing least harm. The network meta-analysis is a novel approach and will provide knowledge users and decision makers with comparisons of multiple interventions of delirium prevention strategies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016036313.

Regiospecific esterification of estrogens by lecithin:cholesterol acyltransferase.

Lecithin:cholesterol acyltransferase (LCAT), the enzyme that esterifies cholesterol in blood, also esterifies other steroids at the 3beta-hydroxyl. These steroids, like cholesterol, are delta5-3beta-hydroxysteroids, such as pregnenolone and dehydroepiandrosterone. One unusual LCAT substrate is the estrogen, estradiol, which is esterified at the 17beta-hydroxyl. The esterification of estradiol by LCAT has been reported to produce a powerful antioxidant that protects low density lipoprotein (LDL) from oxidation. We investigated the substrate specificity of LCAT, comparing the esterification of four different steroids (estradiol, estriol, testosterone, and 5-androstene-3beta, 17beta-diol) by human LCAT in blood and by acyl-coenzyme A:acyltransferase in tissue (placenta and fat). Estradiol was esterified only at the D ring 17beta-hydroxyl group in both blood and tissue. In contrast, although testosterone has a D ring structure identical to that of estradiol, and it was esterified at the 17beta-hydroxyl by acyl-coenzyme A:acyltransferase in tissue, it was not esterified by LCAT. When 5-androstenediol was the substrate in the tissues, both the 3beta- and 17beta-esters were synthesized, but the major product was the 17beta-ester. Conversely, although 5-androstenediol was an excellent substrate for LCAT, only the 3beta-hydroxyl was esterified. No 17beta-ester was formed. The comparison of the esterification of estriol by acyl-coenzyme A:acyltransferase and LCAT was also surprising. In the tissues, estriol is esterified at both D ring hydroxyls, and both are esterified about equally. Although estriol is an extremely polar estrogen, it is esterified by LCAT, albeit at a very slow rate. Although again both D ring hydroxyls were esterified, the LCAT esterification site was mainly at the 17beta-hydroxyl. Esterification of estriol at the 17beta-hydroxyl in preference to the 16alpha-hydroxyl is especially striking, because the 17beta-hydroxyl group is sterically shielded by the C-18 methyl group, making esterification at this position energetically much more difficult. Furthermore, these studies demonstrate that esterification of the 17beta-hydroxyl group by LCAT is unique to estrogens. It suggests that this unusual regiospecific esterification of C-17 of the estrogens underlies a distinct stereochemical requirement for the powerful antioxidant action that has reported for the estradiol esters formed by LCAT.

Recombinant human activated protein C, drotrecogin alfa (activated): a novel therapy for severe sepsis.

Sepsis remains a major cause of death in hospitalized patients. Despite a massive research effort over the past 2 decades to identify innovative therapies for sepsis, current treatment strategies consist primarily of antiinfective agents and a variety of supportive measures. Activated protein C, an endogenous protein that inhibits thrombosis and inflammation while promoting fibrinolysis, plays an important role in the pathogenesis of sepsis. Recombinant human activated protein C, drotrecogin alfa (activated), when compared with placebo in a randomized, double-blind study of 1690 patients with severe sepsis (Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis [PROWESS] trial), decreased the relative risk of death at 28 days by 19.4% (95% confidence interval 6.6-30.5%, p=0.005), although there was a trend for more serious bleeding (3.5% vs 2.0%, p=0.06) with its use. Drotrecogin alfa is the first antisepsis drug found to have a mortality benefit. It should be administered only to patients with severe sepsis who meet the PROWESS study inclusion criteria and should be avoided when risk factors for bleeding are present. Ongoing research will help determine the cost-effectiveness of drotrecogin alfa, as well as its role in critically ill populations not studied in the PROWESS trial.

Kruppel-like factor 2 (KLF2) regulates monocyte differentiation and functions in mBSA and IL-1ß-induced arthritis.

Kruppel-like factor 2 (KLF2) plays an important role in the regulation of a variety of immune cells, including monocytes. We have previously shown that KLF2 inhibits proinflammatory activation of monocytes. However, the role of KLF2 in arthritis is yet to be investigated. In the current study, we show that recruitment of significantly greater numbers of inflammatory subset of CD11b(+)F4/80(+)Ly6C+ monocytes to the inflammatory sites in KLF2 hemizygous mice compared to the wild type littermate controls. In parallel, inflammatory mediators, MCP-1, Cox-2 and PAI-1 were significantly up-regulated in bone marrow-derived monocytes isolated from KLF2 hemizygous mice, in comparison to wild-type controls. Methylated-BSA and IL-1ß-induced arthritis was more severe in KLF2 hemizygous mice as compared to the littermate wild type controls. Consistent with this observation, monocytes isolated from KLF2 hemizygous mice showed an increased number of cells matured and differentiated towards osteoclastic lineage, potentially contributing to the severity of cartilage and bone damage in induced arthritic mice. The severity of arthritis was associated with the higher expression of proteins such as HSP60, HSP90 and MMP13 and attenuated levels of pPTEN, p21, p38 and HSP25/27 molecules in bone marrow cells of arthritic KLF2 hemizygous mice compared to littermate wild type controls. The data provide new insights and evidences of KLF2-mediated transcriptional regulation of arthritis via modulation of monocyte differentiation and function.

The effect of helicobacter pylori eradication on NSAID-induced gastrointestinal toxicity.

OBJECTIVE: To review the data to determine whether Helicobacter pylori eradication alters nonsteroidal antiinflammatory drug (NSAID)-induced gastrointestinal toxicity. DATA SOURCE: Literature accessed through MEDLINE from 1966 to May2000 and abstracts of recently presented data at scientific meetings. DATA SYNTHESIS: NSAID use and H. pylon infection are independent risk factors for the development of gastrointestinal ulcers. An evaluation of the relationship between these two risk factors and the impact of H. pylori eradication on NSAID-induced gastrointestinal toxicity was conducted. CONCLUSIONS: H. pylori colonization and NSAID use are independent risk factors for the development of gastrointestinal ulcers. The data regarding the interaction between these two risk factors in the development of gastrointestinal ulcers are conflicting. Eradication of H. pylori does not appear to decrease the risk of NSAID-induced gastrointestinal toxicity in the majority of patients. As there is little evidence to support a clear benefit of eradicating H. pylori in patients requiring NSAID therapy, routine screening for and eradication of H. pylori in these patients is not recommended.

[Proliferative signal transmission mediated by EpoR in leukemic cell lines].

OBJECTIVE: To investigate the expression of erythropoietin receptor (EpoR) in leukemic cell lines and to clarify the mechanism of proliferative signal transmission in the leukemic cell line KOCL-33 mediated by EpoR. METHODS: Biotinylated Epo and flow cytometry were used for EpoR expression, (3)H-TdR incorporation for cell proliferation, immunoprecipitation and Western blot analysis for the tyrosine phosphorylation of signal transmission proteins. RESULTS: (1) All the cell lines tested expressed EpoR except for T-lymphoid cell lines. The positivity rates ranged from 18% to 99% with an average of 52%, and was no difference among T, B and non-lymphoid cells. (2) The cell proliferation was significantly enhanced in response to Epo in 7 of 9 cell lines tested. The stimulating effects of Epo did not correlate with the densities of EpoR expressed on the cells. (3) The proliferation of KOCL-33 cells was significantly enhanced in response to Epo. Dimerization and tyrosine phosphorylation of EpoR and tyrosine phosphorylation of JAK2 occurred in 1 min and tyrosine phosphorylation of STAT5 in 5 minutes after Epo stimulation. CONCLUSION: (1) There was EpoR expression in leukemic cell lines. (2) The cell proliferation could be stimulated by Epo in some leukemic cell lines. The stimulating effect of Epo did not correlate with the densities of EpoR expressed on the cells. (3) Dimerization and tyrosine phosphorylation of EpoR occurred, and JAK2, STAT5 involved in the proliferative signal transmission in KOCL-33 cells mediated by EpoR.

Sedation assessment in critically ill adults.

OBJECTIVE: To review methods for assessing sedation in critically ill adults, discuss their impact on patient outcomes, and provide recommendations for implementing these methods into clinical practice in the intensive care unit (ICU). DATA SOURCES: A computerized search of MEDLINE from 1980 through June 2000 and a manual search of abstracts presented at recent critical care meetings were performed. STUDY SELECTION AND DATA EXTRACTION: Sedation assessment tools that have been used to titrate therapy in adult, critically ill patients were identified. Special emphasis was placed on sedation assessment instruments that have been prospectively validated. Objective methods that have been used to assess sedation therapy were also identified. DATA SYNTHESIS: Twenty-three adult sedation assessment instruments were identified. Few scales have been prospectively evaluated for validity (n = 6) or reliability (n = 7). Other methods of sedation assessment were identified (e.g., bispectral index monitor); however, most of these methods have only been studied in small subsets of critically ill patients. CONCLUSIONS: Incorporation of sedation assessment into ICU clinical practice may improve patient care. These sedation assessment instruments must be further evaluated to determine their impact on quality of care and ICU length of stay.