Lead toxicity from retained bullet fragments: A systematic review and meta-analysis.

BACKGROUND: Firearm injury remains a public health epidemic in the United States. A large proportion of individuals with gunshot wounds subsequently have retained bullet fragments (RBF). There are no standard medical guidelines regarding bullet removal and the full extent of the consequences of RBF remains unknown. OBJECTIVE: To determine whether there is an association among RBF, elevated blood lead levels (BLL) and lead toxicity in survivors of firearm injury 16 years and older. METHODS: PubMed, EMBASE, CINAHL, Scopus, Cochrane Library, and Sociological Abstracts electronic databases were searched for all randomized controlled trials, prospective and retrospective cohort, case-control and cross-sectional studies published in the English language between 1988 and 2018. Quality assessment and risk of bias was evaluated using the Newcastle Ottawa Scale. A meta-analysis was performed using a random-effects model. RESULTS: The search yielded 2,012 articles after removal of duplicates. Twelve were included after full article review. Eleven studies supported an association between elevated BLL and RBF. Bony fractures were associated with increased risk of elevated BLL in three studies. A positive relationship between BLL and the number of RBF was also shown in three studies, with one study demonstrating 25.6% increase in BLL for every natural-log increase in RBF (1-228, p < 0.01). Meta-analysis demonstrated BLL significantly higher in individuals with RBF as compared to controls (5.47 µg/dL, p < 0.01). CONCLUSION: Patients with bony fractures or multiple RBF, who are at higher risk of elevated BLL, should be monitored for BLL in intervals of 3 months within the first year of injury. For patients who return with BLL above 5 µg/dL, all efforts must be undertaken to remove fragments if there is no potential to worsen the injury. LEVEL OF EVIDENCE: Systematic review, Meta-analysis, level III.

Deprescribing Medications for Chronic Diseases Management in Primary Care Settings: A Systematic Review of Randomized Controlled Trials.

OBJECTIVES: Perform a systematic review to evaluate the outcome of deprescription compared with standard care. The focus was on chronic medical and mental health conditions managed in primary care. DESIGN: The databases searched include PubMed, Medline, EMBASE, the Cochrane Library, Scopus, and Web of Science. Each study was assessed for bias with the Cochrane Collaboration tool. SETTINGS AND PARTICIPANTS: This review included outpatient, assisted living, nursing home, and acute care settings (if medications for chronic disease were deprescribed). Subjects were non-terminally ill adults 18 years and older. MEASURES: Primary outcome was successful deprescription, defined as a statistically significant reduction in medication burden between the intervention group and the standard care or control group, or when more than 50% of intervention subjects were able to tolerate medication discontinuation compared with control by the end of the study. RESULTS: Fifty-eight articles met the study criteria. Thirty-three (58%) had a high risk of bias. Studies varied in duration from 4 weeks to 5 years and were conducted across a diverse array of primary health care settings. The most successful interventions used pharmacist-led educational interventions and patient-specific drug recommendations. Cardiovascular drugs including antihypertensives/diuretics and nitrates were the most successfully deprescribed class of drugs. Psychotropic medications and proton-pump inhibitors were the classes most resistant to deprescribing, despite intense intervention. CONCLUSIONS/IMPLICATIONS: Deprescription may be successful and effective in select classes of drugs, with collaboration of clinical pharmacists for patient and provider education, and patient-specific drug recommendations, complemented by close clinical follow-up to detect early signs of exacerbation of chronic diseases. This review also suggests that deprescription may (1) require expensive intensive, ongoing interventions by clinical teams; (2) not lead to expected outcomes such as improved falls rate, cognition, and quality of life, or a lower admission rate; and (3) have unexpected adverse outcomes affecting patients' quality of life.