Systematic review with meta-analysis: effectiveness and tolerability of interferon-free direct-acting antiviral regimens for chronic hepatitis C genotype 1 in routine clinical practice in Asia.

BACKGROUND: Direct-acting antiviral (DAA) regimens have shown high efficacy and tolerability for patients with HCV genotype 1/1b (GT1/1b) in clinical trials. However, robust real-world evidence of interferon (IFN)-free DAA treatment for HCV GT1-infected patients in Asia is still lacking. AIM: To systematically review and meta-analyse the effectiveness and tolerability of IFN-free DAA therapy for HCV GT1 infection in Asia. METHODS: We included studies that enrolled adult patients with HCV GT1 infection in routine clinical practice in Asia, using IFN-free DAA regimens, and reported sustained virological response (SVR) after 12/24 weeks end-of-treatment by 31 May 2017. The pooled SVR rates were computed with a random-effects model. Subgroup analysis and meta-regression as previously registered in PROSPERO were performed to determine how pre-planned variables might have affected the pooled estimates. RESULTS: We included 41 studies from eight countries and regions, comprising of 8574 individuals. The pooled SVR rates for GT1 were 89.9% (95% CI 88.6-91.1, I2  = 55.1%) with daclatasvir/asunaprevir (DCV/ASV) and 98.1% (95% CI 97.0-99.0, I2  = 41.0%) with ledipasvir/sofosbuvir ± ribavirin (LDV/SOF ± RBV). Baseline cirrhosis but not prior treatment history and age, attenuated the effectiveness of both regimens. Baseline resistance associated substitutions (RASs) severely attenuated SVR of DCV/ASV (65.4% vs 94.3%, P < 0.001) and only minimally with LDV/SOF ± RBV (94.5% vs 99.2%, P = 0.003). Patients with renal dysfunction treated with DCV/ASV showed a higher SVR rate (93.9% vs 89.8%, P = 0.046). Patients with hepatocellular carcinoma (HCC) LDV/SOF ± RBV achieved a lower SVR than those without HCC (94.1% vs 98.7%, P = 0.001). CONCLUSION: All oral DAA treatment of HCV GT1 resulted in high cure rates in Asian patients in routine clinical practice setting including elderly patients and those with end-stage renal disease.

Systematic review with meta-analysis: rifaximin for the prophylaxis of spontaneous bacterial peritonitis.

BACKGROUND: The primary and secondary prevention of spontaneous bacterial peritonitis (SBP) is recommended in high-risk patients with cirrhosis. Several studies evaluating the efficacy of rifaximin for SBP prophylaxis have yielded conflicting results. Rifaximin has the potential advantage of preventing bacterial overgrowth and translocation without the systemic side effects of broad-spectrum antibiotics. AIM: To evaluate the efficacy of rifaximin in the primary and secondary prevention of SBP. METHODS: A literature search using five databases was performed to identify studies on the association between rifaximin and SBP. We performed two meta-analyses: (1) rifaximin compared to systemic antibiotics and (2) rifaximin compared to no antibiotics. Random-effect modelling was conducted to determine overall pooled estimates and 95% confidence intervals (CIs). RESULTS: Five studies with 555 patients (295 rifaximin, 260 systemic antibiotics) compared rifaximin with systemic antibiotics. The pooled odds ratio (OR) for SBP was 0.45 (95% CI 0.16-1.27; P = .13) in patients receiving rifaximin and strengthened on sensitivity analysis (OR 0.38, 95% CI 0.19-0.76, P = .01). In the analysis comparing rifaximin with no antibiotics, there were five studies with 784 patients (186 rifaximin, 598 no antibiotics). The OR for SBP was 0.34 (95% CI 0.11-0.99; P < .05) in patients receiving rifaximin. In subgroup analysis, rifaximin reduced the risk of SBP by 47% compared to no antibiotics for primary prophylaxis and by 74% compared to systemic antibiotics for secondary prophylaxis. CONCLUSION: Rifaximin may be effective in preventing SBP in patients with cirrhosis and ascites compared to systemically absorbed antibiotics and compared to placebo.

Rendimiento e impacto de los primeros respondedores en la evolución de la medicina de emergencias prehospitalaria en Suiza / Comparing performance and impact of first responders on outcome in prehospital emergency medicine in Switzerland

Introducción: Existen resultados contradictorios sobre la eficacia de los primeros respondedores en emergencias extrahospitalarias. Este estudio evalúa el rendimiento y el impacto de estos profesionales en el resultado. Método: Es un estudio de cohortes retrospectivo donde se evalúa la precisión de los médicos de emergencia, paramédicos y médicos generales. Se comparó el diagnóstico realizado en la situación de emergencia prehospitalaria frente al diagnóstico al alta del hospital. El resultado primario fue el impacto de la precisión del diagnóstico sobre la mortalidad. Los resultados secundarios fueron: 1) tiempo en la escena, y 2) duración de la hospitalización. Se valoró especialmente la influencia de la experiencia clínica y de la formación de postgrado. Resultados: Se evaluaron 1.241 diagnósticos. Los pacientes ingresados con el diagnóstico incorrecto o sin diagnóstico mostraron un mayor riesgo de mortalidad (p = 0,04,OR 1,9, IC 1,04-3,34). El tiempo en la escena y el tiempo de ingreso hospitalario fue menor si el diagnóstico fue el correcto. Los médicos de emergencias, paramédicos y médicos generalistas diagnostican con una precisión comparable (p = 0,139), pero en el caso de los médicos de emergencias se demostró un aumento significativo de la precisión en relación a sus años de experiencia (p < 0,001). Después de 6 años de experiencia, alcanzan una precisión diagnóstica mayor del 90%. Este efecto no se pudo demostrar en paramédicos ni en médicos generales. Conclusión: El diagnóstico prehospitalario correcto reduce la mortalidad y la estancia hospitalaria. Los médicos formados en emergencias tienen una nivel de precisión diagnóstica mayor. Por lo tanto, estos médicos deben ser incluidos en el sistema de emergencias prehospitalarias, sobre todo para los casos más graves (AU)

Background: Contradictory results are reported in the medical literature on effectiveness of first responders inprehospital emergency medicine. In this study we evaluated responders performance and impact on outcome. Methods: In a retrospective cohort study we evaluated the accuracy of diagnoses by emergency physicians, paramedics, and general practitioners. We compared the diagnosis made in the prehospital emergency situation to the diagnosis at discharge from the hospital. Primary outcome was the impact of accuracy of diagnosis on mortality. Secondary outcomes were, 1) time on scene, 2) duration of hospitalization. The influence of clinical experience and postgraduate training on accuracy of diagnoses was of particular interest. Results: We evaluated 1241 diagnoses. Patients admitted with a wrong or missing diagnosis showed an increased mortality risk (P = 0.04, OR 1.9; CI 1.04-3.34). The time spent on scene and the duration of his/her hospital stay was shorter if the diagnosis was correct. Emergency physicians, paramedics and general practitioners made diagnoses with comparable accuracy (P = 0.139) but emergency physicians showed a significant increase in accuracy correlated to their years of clinical experience (P < 0.001). After postgraduate year six they reached a level of diagnostic accuracy > 90%.This effect could not be shown for paramedics or general practitioners. Conclusion: A correct diagnosis in prehospital emergency medicine reduces mortality and length of hospital stay. Trained emergency physicians make diagnoses with a high degree of accuracy. Therefore, they should be increasingly integrated into prehospital emergency medicine, particularly for more severe cases (AU)

Systematic review: the relationship between interstitial lung diseases and gastro-oesophageal reflux disease.

BACKGROUND A potential relationship has been suggested between gastro-oesophageal reflux disease (GERD) and interstitial lung diseases (ILDs). AIM To evaluate whether there is a causal relationship between GERD and different ILDs. METHODS We conducted a systematic search of literature published between 1980 and 2010. After a review by two independent authors, each study was assigned an evidence-based rating according to a standard scoring system. RESULTS We identified 319 publications and 22 of them met the entry criteria. Of those, the relationship between GERD and idiopathic pulmonary fibrosis (IPF) was investigated in 14 articles, pulmonary involvement in systemic sclerosis (SSc) in six articles and pulmonary involvement in mixed connective tissue disease (MCTD) in two articles. We found the prevalence of GERD and/or oesophageal dysmotility to be higher in patients with different types of ILD as compared with those without ILD [Evidence B]. Among patients with IPF, 67-76% demonstrated abnormal oesophageal acid exposure off PPI treatment. No relationship was demonstrated between severity of GERD and severity of IPF [Evidence B]. Data are scant on outcomes of antireflux treatment in patients with IPF. There is a correlation between the severity of ILD and the degree of oesophageal motor impairment in patients with SSc and MCTD [Evidence B]. CONCLUSIONS Based on the currently available data, a causal relationship between GERD and idiopathic pulmonary fibrosis cannot be established. There is scant evidence about antireflux therapy in idiopathic pulmonary fibrosis patients. There may be an association between lung and oesophageal involvement in systemic sclerosis and mixed connective tissue disease, but a causal relationship cannot be established.

Systematic review: the effects of carbonated beverages on gastro-oesophageal reflux disease.

BACKGROUND: Carbonated beverages have unique properties that may potentially exacerbate gastro-oesophageal reflux disease (GERD), such as high acidity and carbonation. Cessation of carbonated beverage consumption is commonly recommended as part of lifestyle modifications for patients with GERD. AIMS: To evaluate the relationship of carbonated beverages with oesophageal pH, oesophageal motility, oesophageal damage, GERD symptoms and GERD complications. METHODS: A systematic review. RESULTS: Carbonated beverage consumption results in a very short decline in intra-oesophageal pH. In addition, carbonated beverages may lead to a transient reduction in lower oesophageal sphincter basal pressure. There is no evidence that carbonated beverages directly cause oesophageal damage. Carbonated beverages have not been consistently shown to cause GERD-related symptoms. Furthermore, there is no evidence that these popular drinks lead to GERD complications or oesophageal cancer. CONCLUSIONS: Based on the currently available literature, it appears that there is no direct evidence that carbonated beverages promote or exacerbate GERD.

Inequalities in dementia care across Europe: key findings of the Facing Dementia Survey.

The Facing Dementia Survey was undertaken to assess the awareness of and behaviours surrounding Alzheimer's disease (AD) and dementia among all key stakeholders in Europe. Interviews were conducted with more than 2500 persons, including caregivers, members of the general population, physicians, persons with AD and influencers of health care policy. Four key messages emerged from the results. First, AD often remains undiagnosed until symptoms become moderate or severe. This delay may be because of the difficulty of recognising the symptoms of early AD and the attribution of symptoms to so-called normal ageing, the fear of AD common among older people, inadequate screening tools for use by physicians and/or a delay in the confirmation of the diagnosis once suspicion is raised. Second, a majority of respondents perceive their governments as indifferent to the economic, social and treatment burdens associated with AD. Third, a substantial majority of caregivers, physicians and the general population appreciate the wide-ranging impact that AD can have on the quality of life of people who suffer from it and their informal caregivers. While most caregivers reported life-changing negative effects, a few also noted some positive aspects to their experience. Finally, survey results revealed that most caregivers and members of the general public do not have sufficient information about the benefits of treatment and care. The findings of the Facing Dementia Survey support the development of an agenda for change in dementia care across Europe.

Implications of the Facing Dementia Survey for the general population, patients and caregivers across Europe.

The Facing Dementia Survey included interviews with approximately 1200 members of the general public, 600 persons who served as primary caregivers for a person with Alzheimer's disease (AD) and 96 persons with AD. Members of the general public and the caregivers indicated level of agreement on a 5-point scale to a series of attitudinal statements about the disease as well as other diagnostic questions. Persons with AD underwent a qualitative interview. Results indicate that Europeans are acutely aware of the potentially devastating consequences of AD, but few are familiar with the early-stage symptoms. Most members of the general population accept that early intervention and therapy are key to slowing the effects of the disease. Caregivers often delayed consulting a physician about a loved one's behaviour, partly because of uncertainty about early signs of AD. They also expressed doubt about the ability of physicians to make the diagnosis. Caregivers experience profound effects of AD in every area of their life--emotional, physical, social and financial. Persons with AD responded to their diagnosis in one of three ways: a fatalistic attitude, a belief that their problems are linked to old age or a lack of acceptance. Survey respondents from three populations were critical of the level of government investment in and support of AD.

Implications of the Facing Dementia Survey for health care professionals across Europe.

Approximately 600 general practitioners, primary care physicians and specialists in six European nations (France, Germany, Italy, Poland, Spain and UK) who treat patients with Alzheimer's disease (AD) were interviewed during the Facing Dementia Survey. Compared with generalists, specialists displayed the most optimism regarding the effects of age, believing that health and memory do not inevitably deteriorate as one grows older. Most physician respondents agreed that the diagnosis of AD is too often delayed. A primary reason cited for this delay was the difficulty experienced by both physicians and the general public in identifying early signs of AD. Many physicians believed treatments are available that can slow the disease course. The vast majority surveyed in each nation believed that early treatment of AD can delay disease progression [mean, 87%; range, 68% (United Kingdom) to 96% (Poland)]. More than half of physicians who initiate treatment in France (66%), Germany (59%), Italy (82%), Poland (82%) and Spain (69%) said they institute treatment for AD immediately after diagnosis. The exception was the United Kingdom, where 48% initiated treatment immediately, whereas more than half waited at least a month to start therapy. To a large extent, physicians saw the governments of their countries as a hindrance rather than a help in caring for persons with AD.

Implications of the Facing Dementia Survey for policy makers and third-party organisations across Europe.

The Facing Dementia Survey included qualitative interviews conducted with 60 persons who influence health care policies in six European countries (France, Germany, Italy, Poland, Spain and the United Kingdom). Respondents generally reinforced the perception of other survey participants that governments do not adequately fund research into the causes and cure of Alzheimer's disease (AD) and dementia. (AD is the most common cause of dementia, and throughout this discussion, issues raised in reference to AD apply also to dementia in general.) Access to care services and treatment remains highly restricted in some countries and may vary even within countries. Yet, AD presents an enormous but unappreciated social and economic burden for a growing segment of society. AD is associated with unique challenges to health care systems, because diagnosis is difficult and the disease has an enormous impact on the affected persons and their caregivers alike. Moreover, there is a lack of trained professionals to diagnose and manage the disease, a lack of human and financial resources to provide care and services for people with AD as well as their families and a lack of infrastructure to deliver needed services. These difficulties are compounded by inadequate education of both the general public and physicians. Pressure to change current governmental policy towards neurodegenerative diseases may come from the increasing prevalence of AD as the population ages and from broader awareness of the total societal costs of long-term care.

The role of general practitioners in the diagnosis and treatment of Alzheimer's disease: a multinational survey.

Alzheimer's disease (AD) is a growing healthcare problem. Early diagnosis and effective treatment would benefit patients and caregivers, as well as having economic implications. We conducted a survey of 741 caregivers of patients with AD in Australia, France, Italy, Spain and the UK to assess the current situation regarding the diagnosis and treatment of AD in routine clinical practice. The average time from when symptoms were first noticed by the caregiver to making the first doctor's appointment was 4 months, but 22% of caregivers waited more than 1 year before consulting a doctor. Although the majority of patients (74%) consulted their general practitioner first, the diagnosis was more likely to be made by a specialist; on average, there was a 1-year delay from when symptoms were first noticed by the caregiver to diagnosis. Access to AD care is restricted by many national healthcare systems. The delay in diagnosis imposed by such restrictions impacts on access to early and effective treatment.

The health sciences librarian as Internet navigator and interpreter.

Over the past several years, thousands of networked information resources have become available to individuals and institutions with access to the Internet. Unfortunately, the dizzying array of computing and networking environments often frustrates end users' attempts to navigate the Internet. Librarians have begun to take responsibility not only for instructing users in the use of basic network tools such as file transfer, remote log-in, and electronic mail, but also for answering questions concerning network access and even information system design. The authors show how, by continuing to adapt to this new and volatile environment, health sciences librarians find themselves playing increasingly important roles in shaping the information policies and practices of their institutions. To illustrate these new roles, the authors review the experiences of health sciences librarians at the University of California, Los Angeles, and the University of California, San Diego. These institutions have varying and complex networking environments, and their biomedical libraries have taken lead roles in clarifying and interpreting their particular Internet features.

An analysis of vacancy rates, turnover, and wages among nursing occupations in New York state hospitals, nursing homes, and diagnostic and treatment facilities.

This study investigates the balance between the supply and demand for nurses and nurse assistive personnel in New York state. Data collected in 1992 and 1993 from three surveys of hospitals, nursing homes, and diagnostic and treatment facilities are combined, reported, and analyzed. Although there were regional differences, the mean non-New York City vacancy rate was 4% for registered nurses and 5% for licensed practical nurses. The 6-month mean turnover rate for registered nurses was 8%; however, licensed practical nurses, nurse technicians, and nurse attendants had mean turnover rates of 16% and over. Turnover rates were lowest in hospitals. Nurse anesthetists earned the highest salary, a mean of about $61,000 per year. Salaries for nurse anesthetists and other nurses varied substantially by region.