The length of patient and primary care time interval in the pathways to treatment in symptomatic oral cancer. A quantitative systematic review.

OBJECTIVES: To examine the relative length of the patient and primary care intervals in symptomatic oral cancer. DESIGN: Quantitative systematic review. SEARCH STRATEGY: Oral cancer OR oral squamous cell carcinoma OR oropharyngeal cancer AND time interval OR diagnostic delay. SETTING: Primary and secondary care. PARTICIPANTS: Oral and oropharyngeal cancer patients. MAIN OUTCOME MEASURES: We computed five measures (patient, primary care, diagnosis, total diagnosis and total treatment intervals). Most studies did not provide any dispersion measure. We then used the sample size of each study to compute a weighted average of the mean intervals. When the median was provided, we assumed normality of the distribution of the means and used the median as a proxy of the mean. RESULTS: A total of 1089 articles were identified, and 22 met the inclusion criteria, reporting on 2710 patients from Europe, USA, India, Australia, Japan, Argentina and Iran. The weighted average of patient interval was 80.3 days. Primary care interval was five times shorter: 15.8 days. The diagnostic interval was appreciably shorter (47.9 days) when compared with the patient interval during symptomatic period. CONCLUSIONS: Patient interval represents the major component of waiting times since the detection of the first signs/symptoms to the definitive diagnosis of oral cancer. Thus, strategies focused on high-risk patients should be prioritised. Interventions aimed at optimising the health systems should be implemented by monitoring and facilitating diagnostic and treatment pathways of patients with oral cancer.

Detection of the posterior superior alveolar artery in the lateral sinus wall using computed tomography/cone beam computed tomography: a prevalence meta-analysis study and systematic review.

A systematic search of MEDLINE, Embase, and Proceedings Web of Science was undertaken to assess the prevalence of the posterior superior alveolar artery (PSAA) in the lateral sinus wall in sinus lift patients, as identified using computed tomography (CT)/cone beam computed tomography (CBCT). For inclusion, the article had to report PSAA detection in the bony wall using CT and/or CBCT in patients with subsinus edentulism. Studies on post-mortem findings, mixed samples (living and cadaveric), those presenting pooled results only, or studies performed for a sinus pathology were excluded. Heterogeneity was checked using an adapted version of the DerSimonian and Laird Q test, and quantified by calculating the proportion of the total variance due to between-study variance (Ri statistic). Eight hundred and eleven single papers were reviewed and filtered according to the inclusion/exclusion criteria. Ten studies were selected (1647 patients and 2740 maxillary sinuses (study unit)). The pooled prevalence of PSAA was 62.02 (95% confidence interval (CI) 46.33-77.71). CBCT studies detected PSAA more frequently (78.12, 95% CI 61.25-94.98) than CT studies (51.19, 95% CI 42.33-60.05). Conventional CT revealed thicker arteries than CBCT. It is concluded that PSAA detection is more frequent when CBCT explorations are used. Additional comparative studies controlling for potential confounding factors are needed to ascertain the actual diagnostic value of radiographic explorations for assessing the PSAA prior to sinus floor elevation procedures.

Influence of pollen level on hospitalizations for asthma.

The effect of pollen level on asthma hospitalizations is still under debate. The aim of this study was to analyze hospital admissions due to asthma and its relation with environmental pollen and meteorological factors. During 13 years, we included every patient admitted with asthma as primary or secondary diagnosis. For this purpose, we used a case-crossover analysis to compare pollen concentrations at the time of admission with values of the same variables 2 to 6 days before admission. We included 6,687 hospital admissions. High maximum temperature and low humidity were associated with lower risk of asthma admissions. High mean pollen levels exerted a moderate effect and high maximum pollen levels led to a dramatic increase of hospital admissions due to asthma, especially among females. In conclusion, environmental pollen level increases the risk of asthma hospital admissions.

Impact of delay in diagnosis on survival to head and neck carcinomas: a systematic review with meta-analysis.

OBJECTIVE: To address the contradictory information on the role of delay in diagnosis on head and neck cancer survival. STUDY DESIGN: Systematic review and meta-analysis. SEARCH STRATEGY: Search on MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011) and ISI proceedings (from inception to March 2011). The terms used were ('Head and neck cancers') AND ('delay'OR'prognostic'OR'survival') both in MeSH terms and free-text words. The reference lists of the retrieved articles were also revised manually to identify other potentially relevant papers. All searches were independently undertaken by two clinicians and one epidemiologist, and the results merged. SETTING: Primary and specialised care levels. PARTICIPANTS: Meta-analysis of data from papers on the subject published from 1966 to 2011. MAIN OUTCOME MEASURES: Survival. METHODS: After search in Medline and other databases, we computed pooled relative risks (RR) and 95% confidence interval (95%CI) from the 10 studies retrieved. RESULTS: The estimate of the relative risk of mortality related to any diagnostic delay (either patient or professional delay) was 1.34 (95%CI 1.12-1.61). Referral delay was associated with a three-fold increase in mortality. Total delay was marginally related to mortality (RR: 1.04, 95%CI: 1.01-1.07). By anatomic location, pharynx cancer shows the highest association (RR: 1.68, 95%CI: 1.22-2.31). CONCLUSIONS: Diagnostic delay is a moderate risk factor of mortality from head and neck cancer. However, part of the effect observed may be due to residual confounding (confounding from unknown variables that are not eliminated by adjustment).

Trends in hospital admissions due to asthma in north-west Spain from 1995 to 2007

Purpose: Asthma is the most common chronic disease in childhood. Hospital admissions in the child population appear to be reducing in different populations. Methods: We have retrospectively analysed admissions into hospitals in our region due to asthma in a 0 to 14 years population, between the years 1995 and 2007. The age, sex, date of admission, and length of hospital stay of each patient was recorded and analysed. Results: A total of 9106 admissions (64% males) have been included. A gradual trend towards a reduction in admissions is observed during the period analysed. There were more admissions in 1996, with 2.91 per thousand inhabitants, gradually reducing to 1.33 per thousand in 2007. There were more admissions in May and between September and December, being less frequent in July and August. The mean stay in this period was 4.18 days, which was stable during the whole period of the study. Older children tended to have a longer hospital stay. Conclusions: Our study shows that admissions due to childhood asthma tend to be decreasing, particularly due to younger males, with no change in the length of hospital stay. Asthma exacerbations seemed to be associated with infections and exposure to allergens

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Trends in hospital admissions due to asthma in north-west Spain from 1995 to 2007.

PURPOSE: Asthma is the most common chronic disease in childhood. Hospital admissions in the child population appear to be reducing in different populations. METHODS: We have retrospectively analysed admissions into hospitals in our region due to asthma in a 0 to 14 years population, between the years 1995 and 2007. The age, sex, date of admission, and length of hospital stay of each patient was recorded and analysed. RESULTS: A total of 9106 admissions (64% males) have been included. A gradual trend towards a reduction in admissions is observed during the period analysed. There were more admissions in 1996, with 2.91 per thousand inhabitants, gradually reducing to 1.33 per thousand in 2007. There were more admissions in May and between September and December, being less frequent in July and August. The mean stay in this period was 4.18 days, which was stable during the whole period of the study. Older children tended to have a longer hospital stay. CONCLUSIONS: Our study shows that admissions due to childhood asthma tend to be decreasing, particularly due to younger males, with no change in the length of hospital stay. Asthma exacerbations seemed to be associated with infections and exposure to allergens.

A meta-analysis on wood dust exposure and risk of asthma.

Work-related asthma is the most common occupational respiratory disorder in the industrialized countries. It has been postulated that wood dust exposure may increase the risk of work-related asthma. The objective of this study was to assess, through a meta-analysis, the risk of developing work-related asthma associated with wood dust exposure. A systematic search of the literature was performed. Inclusion and exclusion criteria were applied and a quality scale used to measure the quality of the included studies was developed. Using standard meta-analysis techniques, studies were pooled using both random and fixed effects models. Nineteen studies were included which consisted of three cohort studies, twelve case-control studies and four mortality studies. The pooled relative risk (RR) of asthma among workers exposed to wood dust was 1.53 (95% CI 1.25-1.87). When the analysis was restricted to studies carried out on Caucasian populations, the pooled RR was 1.59 (95% CI 1.26-2.00) while the pooled RR of studies on Asian populations was 1.15 (95% CI 0.92-1.44). Wood workers present a higher risk of asthma. Future research should include careful evaluation of ethnicity and nativity as risk modifiers.

Hepatitis C virus infection and post-transplant diabetes mellitus among renal transplant patients: a meta-analysis.

OBJECTIVE: To examine the association between HCV infection and the occurrence of post-transplant diabetes mellitus (PTDM) among renal transplant patients. DESIGN: Meta-analysis of observational studies. DATA SOURCES: We retrieved studies published in any language by systematically searching Medline, and Embase and by manually examining the references of the original articles, reviews, and monographs retrieved. REVIEW METHODS: We included cohort and case-control studies reporting relative risk estimates and 95% confidence intervals (CIs) for PTDM occurrence with HCV after renal transplantation. Thirteen studies providing information on a total of 30,099 unique patients were included in our meta-analysis. RESULTS: Study-specific relative risks were weighted by the inverse of their variance to obtain fixed and a 95% confidence interval (CI) of 1.94; 3.83 (10 studies). In a stratified analysis including only large studies (2 studies), the pooled RR was 1.36 (95% CI, 1.21; 1.54). Egger's regression test showed some evidence of publication bias (p=0.0001), but our sensitivity analysis showed that this issue did not meaningfully change the results. CONCLUSIONS: Our study shows a marked increase of the risk of post-transplant diabetes mellitus in anti-hepatitis C virus-positive renal transplant recipients. The excess risk of death in hepatitis C virus-positive renal transplant recipients may be at least partially attributed to post-transplant diabetes mellitus with its attendant complications.

Exposure to furry pets and the risk of asthma and allergic rhinitis: a meta-analysis.

BACKGROUND: Exposure to pets has been implicated as a risk factor for asthma. However, this relation has been difficult to assess in individual studies because of the large potential of selection bias. We sought to examine the association between exposure to furry pets and asthma and allergic rhinitis by means of a meta-analysis. METHODS: We retrieved studies published in any language by searching systematically Medline (1966-March 2007), Embase, LILACS and ISI Proceedings computerized databases, and by examining manually the references of the original articles and reviews retrieved. We included cohort and case-control studies reporting relative risk estimates and confidence intervals of exposure to cats, dogs and unspecified furry animals and subsequent asthma and allergic rhinitis. We excluded cross-sectional studies and those studies that did not measure exposure but rather sensitization to pets. RESULTS: Thirty-two studies were included. For asthma, the pooled relative risk related to dog exposure was 1.14 (95% CI 1.01-1.29), that related to exposure to any furry pet was 1.39 (95% CI 1.00-1.95). Among cohort studies, exposure to cats yielded a relative risk of 0.72 (95% CI 0.55-0.93). For rhinitis, the pooled relative risk of exposure to any furry pet was 0.79 (95% CI 0.68-0.93). CONCLUSIONS: Exposure to cats exerts a slight preventive effect on asthma, an effect that is more pronounced in cohort studies. On the contrary, exposure to dogs increases slightly the risk of asthma. Exposure to furry pets of undermined type is not conclusive. More studies with exact measurement of exposure are needed to elucidate the role of pet exposures in atopic diseases.

The impact of hepatitis C virus infection on survival in dialysis patients: meta-analysis of observational studies.

The impact of hepatitis C virus (HCV) infection on mortality of patients receiving regular dialysis remains unclear. The assessment of the natural history of HCV in dialysis population is difficult because of the low progression of HCV-related liver disease over time and the reduced life expectancy in patients with end-stage renal disease. The aim of the study was to conduct a systematic review of the published medical literature concerning the impact of HCV infection on the survival of patients undergoing maintenance dialysis. The relative risk of mortality was regarded as the most reliable outcome end-point. Study-specific relative risks were weighted by the inverse of their variance to obtain fixed- and random-effects pooled estimates for mortality with HCV across the published studies. We identified seven studies involving 11 589 unique patients on maintenance dialysis; two (29%) were case-control studies. Pooling of study results demonstrated that presence of anti-HCV antibody was an independent and significant risk factor for death in patients on maintenance dialysis. The summary estimate for adjusted relative risk (aRR) (all-cause mortality) was 1.34 with a 95% confidence interval (CI) of 1.13-1.59. Heterogeneity statistics, R(i) = 0.48 (P-value by Q-test = 0.13). In a sensitivity analysis including only (n = 5) cohort studies, the pooled aRR was 1.38 (95% CI, 1.20-1.59); heterogeneity statistics R(i) = 0.46. As a cause of death, hepatocellular carcinoma and liver cirrhosis were significantly more frequent among anti-HCV-positive than -negative dialysis patients. Our meta-analysis indicates that anti-HCV-positive patients on dialysis have an increased risk of mortality compared with HCV-negative patients. The excess risk of death in HCV-positive patients may be at least partially attributed to chronic liver disease with its attendant complications.

Effects of antihypertensive drug treatments on fracture outcomes: a meta-analysis of observational studies.

OBJECTIVE: To quantitatively pool findings from observational studies on the risk of fracture outcomes associated with exposure to five antihypertensive drug classes: angiotensin-converting enzyme (ACE) inhibitors, diuretics (in particular thiazide diuretics), beta-blockers, calcium-channel blockers and alpha-blockers. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Publications listed in the MEDLINE, EMBASE and LILACS databases, the ISI proceedings, and bibliographies of retrieved articles. Sources were searched from the earliest possible dates through December 2005. REVIEW METHODS: We included case-control and cohort studies presenting relative risks and confidence intervals (CIs) for the association between exposure to antihypertensive agents and fracture outcomes. Data were extracted onto a standardized computer worksheet. Study quality was assessed using a 10-point questionnaire specific to case-control or cohort study design. RESULTS: Fifty-four studies were identified. Pooled estimates were computed using the software HEpiMA. The pooled relative risk (RR) of any fracture with use of thiazide diuretics was 0.86 (95% CI 0.81-0.92) and 1.14 (95% CI 0.84-1.54) with use of nonthiazide diuretics. There was a statistically significant reduction of any fracture with use of beta-blockers, (RR 0.86, 95% CI 0.70-0.98). The one study with ACE inhibitor data showed protection (RR 0.81, 95% CI 0.73-0.89). No significant associations were found between fractures and exposure to alpha-blockers or calcium-channel blockers. CONCLUSIONS: Thiazide diuretics and beta-blockers appear to lower the risk of fractures in older adults. However, these agents cannot be recommended as preventive therapies for fractures until data from randomized controlled trials have established their efficacy. Patients who use these inexpensive drugs as treatments for hypertension may also benefit from a reduction in fracture risk.

[Respiratory symptoms and lung function in a geriatric population of a Galician rural community: a pilot study]. / Sintomatología respiratoria y función pulmonar en población geriátrica de una comunidad rural gallega: un estudio piloto.

INTRODUCTION: Respiratory diseases are a frequent cause of health demands and have a large impact on morbidity and mortality of the Galician population, especially among the older one. Recent work shows that the diagnosis and treatment of these diseases is not optimal. This increases the utilisation of health care resources. MATERIAL AND METHODS: We studied 28 patients of the municipality of Val del Dubra (Northwest Spain) aged between 65 and 74 years. We performed a spirometric exploration and carried out a questionnaire interview on respiratory symptoms, life style, and occupational and health-related antecedents. RESULTS: Among men, 54% of were or are smokers. None of the women ever smoked. Respiratory symptoms were more frequent among women than among men (80% versus 54%). In the spirometric study, the largest volumes and flux are observed among non-smoking males who do not report dyspnea. DISCUSSION: Respiratory symptoms are frequent in the rural population aged between 65 and 74 years. Tobacco consumption is similar to other Spanish communities, but different from that seen in other countries. Male gender, non-smoking status and absence of respiratory symptoms are associated with higher spirometric figures.

Sintomatología respiratoria y función pulmonar en población geriátrica de una comunidad ruralgallega: un estudio piloto / Respiratory symptoms and lung function in a geriatric population of a galician rural community: a pilot study

Introducción: Las enfermedades respiratorias representan una causa frecuente de demanda sanitaria, con significativa repercusión en la morbimortalidad de la población de nuestra comunidad, en especial en la población geriátrica. Resultados de trabajos recientes muestran que el manejo diagnóstico y terapéutico de estos procesos no parece adecuado, relacionándose esto con el incremento del consumo de recursos sanitarios. Material y métodos: Se han estudiado 28 individuos del municipio de Valle del Dubra, entre 65 y 74 años. Se ha realizado una exploración espirométrica y una entrevista por cuestionario sobre síntomas respiratorios, estilo de vida, antecedentes personales sanitarios y laborales. Resultados: El 54 por ciento de los varones de esta población son o han sido fumadores, mientras nunca ha fumado ninguna de las mujeres. Los síntomas respiratorios son más frecuentes entre el sexo femenino, refiriendo algún síntoma el 80 por ciento de estas y el 54 por ciento de los varones. En la espirometría los mayores volúmenes y flujos se obtienen en el sexo masculino, entre los no fumadores y entre los que no refieren disnea. Discusión: La sintomatología respiratoria parece ser frecuente entre la población rural gallega entre 65 y 74 años. La prevalencia de tabaquismo es similar a otras comunidades de nuestro país, observándose un comportamiento distinto en poblaciones de otros países. El sexo masculino, la condición de no fumador y la ausencia de síntomas respiratorios parecen asociarse con mayores valores espirométricos (AU)

Physicians' attitudes towards voluntary reporting of adverse drug events.

At the time a new drug is placed on the market, information on its therapeutic effect and toxicity is limited. Because of its simplicity and widespread use, the voluntary reporting by clinical physicians is the main method for detecting rare or unexpected adverse drug events (ADEs). However, the usefulness of this method may be compromised if the reporting rate is low. We present the results of a questionnaire-based case-control study carried out among 692 physicians from Galicia (north-west region of Spain), in which we assessed their attitudes and opinions towards ADEs. In general, the Galician physicians think it is difficult to link a given ADE with a drug (P < 0.05) and have very heterogeneous opinions on the fact that very severe ADEs are known before the drug is commercialized. They globally disagree with the proposal that ADE reporting should be renumerated and the fact that ADE reporting can be risky for the physician. Some of the beliefs concerning ADEs are incorrect. It is crucial to improve the training of the physicians through active educational strategies based on personal contact.

Increased risk of somnolence with the new dopamine agonists in patients with Parkinson's disease: a meta-analysis of randomised controlled trials.

BACKGROUND: Recent case reports and letters have alerted practitioners to the risk of sleep attacks, usually preceded by somnolence, in patients with Parkinson's disease treated with pramipexole and ropinirole. OBJECTIVE: To quantify the risk of somnolence with the new dopamine agonists pramipexole and ropinirole in patients with Parkinson's disease. METHODS: We searched MEDLINE, EMBASE, International Pharmaceutical Abstracts and Cochrane Library, contacted experts and pharmaceutical manufacturers, and manually reviewed all references retrieved to identify possible articles to include. Information on randomisation, blinding, type of treatment and reporting of somnolence were abstracted by 2 independent reviewers. Disagreements were resolved by a third author. ANALYSIS: We made 2 separate analyses. The first analysis compared the risk of somnolence in patients taking either pramipexole or ropinirole to that in patients taking placebo. The second analysis compared the risk of somnolence with these drugs (plus levodopa) versus that with levodopa alone. We calculated pooled relative risk estimates using the random effects model and when no heterogeneity was detected we used the fixed effects model. RESULTS: Four trials were included in the analysis of patients taking pramipexole or ropinirole compared with those taking placebo. The pooled relative risk of somnolence in this analysis was 4.98 [95% confidence interval (CI) 1.79 to 13.89]. Seven trials were included in the analysis of patients taking levodopa and pramipexole or ropinirole compared with those taking levodopa alone. The pooled relative risk was 2.06 (95% CI 1.47 to 2.88). CONCLUSION: Patients with Parkinson's disease using pramipexole or ropinirole are at higher risk of experiencing somnolence relative to patients taking placebo. Patients taking levodopa plus either one of these dopamine agonists are at higher risk than those taking levodopa alone. Clinicians should carefully weigh this risk against the benefit of these agents when prescribing these drugs.

A cohort study of stress and the common cold.

The common cold is one of the major causes of work absenteeism. Former studies, based on artificial inoculation of rhinovirus, implicated psychological stress in the occurrence of this syndrome, either by increasing susceptibility to the virus or by causing the subject to overrate the perception of the symptoms. Nevertheless, few studies on the effect of stress on the naturally acquired common cold have been conducted. We carried out a 1-year prospective cohort study among the faculty and staff of a Spanish university (N = 1,149). By means of standardized questionnaires, validated in a random sample of the population, we assessed the relation between the occurrence of common cold episodes and exposure to four dimensions of stress: stressful life events, negative affect, positive affect, and perceived stress. All four aspects of stress were related to the occurrence of the common cold. Subjects with a high (fourth quartile) index of negative affect showed an incidence rate ratio of 3.7 (95% confidence interval = 2.2-6.2). The incidence rate ratios for the fourth quartile were 2.5 (95% confidence interval = 1.5-4.1) and 1.9 (95% confidence interval = 1.1-3.2) for perceived stress and stressful events, respectively. A high index of positive affect was associated with an incidence rate ratio of 0.6 (95% confidence interval = 0.3-1.0). These findings suggest that psychological stress is a risk factor for the common cold.

HEpiMA: software for the identification of heterogeneity in meta-analysis.

Meta-analysis is a quantitative method available to epidemiologists, psychologists, social scientists and others who wish to produce a summary measure of the effect of exposure on disease, based on results from published studies along with a summary measure of uncertainty. The magnitude of the effect vary from study to study because of differences in the features of these studies (design, population, control of confounding variables etc.). From the various studies an estimator is formed by pooling the results found in each study in one summary measure. This summary (or pooled) measure is meaningful only if the magnitude of heterogeneity between study effects is small and can be explained by sampling variation. In this paper, we present HEpiMA, a new comprehensive and user-friendly software program for epidemiologic meta-analysis. HEpiMA has new features that are not available in other programs. The program carries out a complete study of heterogeneity of study effects with 11 hypothesis test results. In addition to model-based methods, the program also implements bootstrap methodology. New useful estimators of heterogeneity, Ri and CV(B), developed by the authors are given in the output. In addition to these unique features, the major advantage of this software is the option for direct entry of adjusted relative risk estimates of individual studies, the most common form of presentation of results in the epidemiologic literature. This program may also be useful for meta-analysts of clinical trials, in which the relative risk is the parameter of interest as it also allows the entry of crude data under the form of 2x2 tables.

Evaluation of old and new tests of heterogeneity in epidemiologic meta-analysis.

The identification of heterogeneity in effects between studies is a key issue in meta-analyses of observational studies, since it is critical for determining whether it is appropriate to pool the individual results into one summary measure. The result of a hypothesis test is often used as the decision criterion. In this paper, the authors use a large simulation study patterned from the key features of five published epidemiologic meta-analyses to investigate the type I error and statistical power of five previously proposed asymptotic homogeneity tests, a parametric bootstrap version of each of the tests, and tau2-bootstrap, a test proposed by the authors. The results show that the asymptotic DerSimonian and Laird Q statistic and the bootstrap versions of the other tests give the correct type I error under the null hypothesis but that all of the tests considered have low statistical power, especially when the number of studies included in the meta-analysis is small (<20). From the point of view of validity, power, and computational ease, the Q statistic is clearly the best choice. The authors found that the performance of all of the tests considered did not depend appreciably upon the value of the pooled odds ratio, both for size and for power. Because tests for heterogeneity will often be underpowered, random effects models can be used routinely, and heterogeneity can be quantified by means of R(I), the proportion of the total variance of the pooled effect measure due to between-study variance, and CV(B), the between-study coefficient of variation.