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1.
BMC Geriatr ; 21(1): 541, 2021 Oct 12.
Artigo em Inglês | MEDLINE | ID: mdl-34641805

RESUMO

OBJECTIVE: To assess the utility of the preoperative Sarcopenia index (SI) as a predictive marker of the risk of postoperative complications following hip fracture surgery in older adults. STUDY DESIGN: This observational study enrolled older adults with hip fracture who were hospitalized in the Department of Orthopedics of West China Hospital, Sichuan University, from December 7, 2010 - June 14, 2017, and who underwent hip fracture surgery. PRIMARY OUTCOME AND MEASURES: Clinical data were collected from medical records and serum creatinine and cystatin C were measured before surgery. Outcomes included postoperative complications such as pneumonia, urinary tract infection, respiratory failure, heart failure, and non-grade A healing. Binary logistic regression analyses were used to analyze association between SI and postoperative complications. RESULTS: A total of 897 patients aged 60 years and over were enrolled in this study (age range: 60 - 100 years), of whom 306(34.1%)were male, and 591(65.9%)were female. Postoperative complications included pneumonia (12%), urinary tract infections (1.8%), respiratory failure (1.5%), heart failure (1.6%), and non-A- grade healing (3.6%). In the patient group that received joint replacements, the incidence of pneumonia was negatively associated with SI values. After adjusting for potential confounding factors, binary logistic regression analyses showed that a higher SI was independently associated with a lower risk of pneumonia after joint replacement surgery (OR:0.39, 95% CI:0.18-0.89, P<0.05). However, we did not find statistically significant association between SI and the risk of postoperative complications other than pneumonia among patients with two types of hip fracture surgery. CONCLUSION: The SI based on serum creatinine and cystatin C can predict pneumonia rather than other postoperative complications among older patients with hip fracture after joint replacement surgery.

2.
BMC Geriatr ; 21(1): 528, 2021 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-34620118

RESUMO

BACKGROUNDS: Vitamin D deficiency and insufficiency in older adults seems to be common, but the prevalence estimates are lacking in West China. Previous studies suggested that low vitamin D status was associated with obesity. However, most of them evaluated obesity based on body mass index (BMI) and there are no studies at present exploring the association between vitamin D status and different obesity markers. The present study aims to investigate the prevalence of low vitamin D status and evaluate the association between the vitamin D status and different obesity markers among older adults in West China. METHODS: Data was based on the baseline of West China Health and Aging Trends study (WCHAT). All of the participants were older than 60 years old in the present study. Vitamin D status was based on laboratory data, and obesity markers were assessed by bioelectrical impedance analysis (BIA) using the InBody 770 analyzer. Multiple linear regression was performed to find the association between the vitamin D status and various obesity markers. RESULTS: The study included 2661 individuals (mean age: 67.7 ± 6.0 years; males: 41 %). The mean vitamin D level was 18.8 ± 6.3 ng/ml (range: 5 to 59 ng/ml); 5.2 % of participants had a sufficient level of vitamin D, 31.8 % had vitamin D insufficiency, and 63.0 % had vitamin D deficiency. Our results showed that vitamin D status was negatively associated with fat mass index (FMI), visceral fat area (VFA), and waist-hip ratio (WHR) in both sexes. Comparing to other obesity markers, WHR had the strongest correlation with vitamin D status in both sexes (ß = -6.090, P = 0.046 in males; ß = -11.253, P < 0.001 in females). No significant association was found between vitamin D status and BMI in males. CONCLUSION: The prevalence of vitamin D insufficiency and deficiency among older adults in West China was high. Among the older adults in west China, WHR showed stronger association with vitamin D status and was better for the prediction of vitamin D insufficiency or deficiency in both sexes, compared to BMI. TRIAL REGISTRATION: Chinese Clinical Trial Registry: ChiCTR1800018895 .

3.
BMJ Open ; 11(7): e049130, 2021 07 09.
Artigo em Inglês | MEDLINE | ID: mdl-34244276

RESUMO

OBJECTIVES: Assess values, preferences and burden of treatment that patients with type 2 diabetes consider when initiating glucagon-like peptide-1 receptor agonists (GLP-1 RA) or sodium-glucose cotransporter-2 inhibitors (SGLT-2i) compared with other glucose-lowering options. METHODS: Paired reviewers independently included studies reporting quantitative or qualitative methods to assess values, preferences and burden of treatment reported by patients with type 2 diabetes regarding the initiation of GLP-1 RA or SGLT-2i over other alternatives. A systematic search in MEDLINE, Scopus, EMBASE, Web of Science and Cochrane Central Register of Controlled Trials from inception until May 2020 was performed by an experienced librarian. Risk of bias was assessed with a specifically designed tool for values and preferences studies. RESULTS: 17 studies (7296 patients) proved eligible. Studies fulfilling criteria for SGLT-2i were not identified. Five studies (2662 patients) evaluated preferences for GLP-1 RA compared with other glucose-lowering medications. 12 studies (4634 patients) evaluated preferences between, at least, two kinds of GLP-1 RA or their injection devices based on the following attributes: efficacy, dose, application frequency, device characteristics. Among studies comparing GLP-1 RA to other glucose-lowering medications, some preferences were observed for dypeptil peptidase-4 inhibitors compared with once daily liraglutide. Comparing different attributes of GLP-1 RA drugs and devices, cardiovascular risk reduction, glucose lowering potential, once weekly and simple administered regimens were the most preferred. CONCLUSIONS: As no evidence for preferences on SGLT-2i was available, only preferences for GLP-1 RA were assessed; however, evidence is still limited for the latter. Studies comparing preferences for GLP1-RA to other glucose-lowering alternatives only included twice daily or once daily injection regimens of GLP-1 RA drugs. According to our findings, once weekly alternatives are widely preferred than the formers. The extent to which patients with type 2 diabetes value reduced adverse cardiovascular and kidney outcomes, weighed benefits against harms and burden of treatment is limited and with very low certainty. PROSPERO REGISTRATION NUMBER: CRD42020159284.


Assuntos
Diabetes Mellitus Tipo 2 , Preparações Farmacêuticas , Inibidores do Transportador 2 de Sódio-Glicose , Adulto , Diabetes Mellitus Tipo 2/tratamento farmacológico , Receptor do Peptídeo Semelhante ao Glucagon 1 , Humanos , Hipoglicemiantes/uso terapêutico , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico
4.
BMC Geriatr ; 21(1): 370, 2021 06 16.
Artigo em Inglês | MEDLINE | ID: mdl-34134662

RESUMO

OBJECTIVES: To investigate the role of a preoperative modified frailty index (mFI) based on data from medical records in predicting postoperative complications among older Chinese patients with hip fractures. METHODS: This retrospective cohort study included consecutive older patients with hip fracture admitted to the Department of Orthopaedics, West China Hospital, Sichuan University, from December 2010 to June 2017 who underwent surgical repair. We selected 33 variables, including characteristics of hip fracture, to construct a mFI. Each variable was coded with a value of 0 when a deficit was absent or 1 when it was present. We calculated the mFI as the proportion of positive items and defined frailty as mFI value greater than or equal to 0.21 according to threshold proposed by Hoover et al. We examined the relationship between mFI and severity of postoperative complications and the occurrence of in-hospital pneumonia including statistical adjustment for several demographics (e.g. age, gender, and marital status) and habits (smoking and alcohol intake), time from fracture to surgery in the multivariable model. RESULTS: We included 965 patients (34% male; mean age: 76.77 years; range: 60 to 100 years) with a prevalence of frailty of 13.06%. The presence of frailty was associated with a higher severity of complications (OR: 2.07; 95% CI: 1.40 to 3.05). Frail patients were more likely to develop in-hospital pneumonia than non-frail patients (OR: 2.08; 95% CI: 1.28 to 3.39). CONCLUSION: The preoperative modified frailty index based on data from medical records proved significantly associated with postoperative complications among older patients with hip fractures undergoing hip surgery.


Assuntos
Fragilidade , Fraturas do Quadril , Idoso , China/epidemiologia , Feminino , Idoso Fragilizado , Fragilidade/diagnóstico , Fragilidade/epidemiologia , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/cirurgia , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
5.
J Gerontol A Biol Sci Med Sci ; 76(11): 2030-2038, 2021 Oct 13.
Artigo em Inglês | MEDLINE | ID: mdl-34170316

RESUMO

BACKGROUND: The aim of this study was to determine the relative and absolute reliabilities of 5 key performance-based measures of physical function in the Canadian Longitudinal Study on Aging (CLSA). METHODS: An age-stratified subsample of 147 participants from the CLSA who were undergoing their 3-year data collection visit participated in 2 repeat visits (within 1 week). Participants underwent tests of grip strength, 4-m gait speed, Timed Up and Go (TUG), chair rise, and single-leg stance (left, right, mean, maximum). Intraclass correlation coefficients (ICCs), standard error of measurement, and minimal detectable change (MDC) values were calculated. RESULTS: The relative reliability for grip strength was excellent (ICC = 0.95); the TUG and single-leg stance tests had good reliability (ICC = 0.80 or 0.78-0.82, respectively); gait speed and the chair-rise test had moderate reliability (ICC = 0.64 for both) for participants overall. For participants between 50 and 64 years, TUG and gait speed had poor reliabilities (ICC = 0.38 or 0.33, respectively). For participants aged 75 years and older, the single-leg stance had poor reliability (ICC = 0.30-0.39). The MDC90 was about 6 kg for grip strength, 2.3 seconds for TUG, 0.2 m/second for gait speed, 5.2 seconds for chair rise, and ranged from 22.8 to 26.2 seconds for the single-leg stance. CONCLUSIONS: Among community-dwelling Canadians older than 50 years, the reliabilities of the CLSA measures were moderate to excellent. The TUG and gait speed in the youngest age group, and the single-leg stance in the oldest age group, showed poor reliability. MDC values can be used to interpret changes over time.

6.
BMJ ; 373: n1091, 2021 05 11.
Artigo em Inglês | MEDLINE | ID: mdl-33975892

RESUMO

CLINICAL QUESTION: What are the benefits and harms of sodium-glucose cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists when added to usual care (lifestyle interventions and/or other diabetes drugs) in adults with type 2 diabetes at different risk for cardiovascular and kidney outcomes? CURRENT PRACTICE: Clinical decisions about treatment of type 2 diabetes have been led by glycaemic control for decades. SGLT-2 inhibitors and GLP-1 receptor agonists are traditionally used in people with elevated glucose level after metformin treatment. This has changed through trials demonstrating atherosclerotic cardiovascular disease (CVD) and chronic kidney disease (CKD) benefits independent of medications' glucose-lowering potential. RECOMMENDATIONS: The guideline panel issued risk-stratified recommendations concerning the use of SGLT-2 inhibitors or GLP-1 receptor agonists in adults with type 2 diabetes• Three or fewer cardiovascular risk factors without established CVD or CKD: Weak recommendation against starting SGLT-2 inhibitors or GLP-1 receptor agonists.• More than three cardiovascular risk factors without established CVD or CKD: Weak recommendation for starting SGLT-2 inhibitors and weak against starting GLP-1 receptor agonists.• Established CVD or CKD: Weak recommendation for starting SGLT-2 inhibitors and GLP-1 receptor agonists.• Established CVD and CKD: Strong recommendation for starting SGLT-2 inhibitors and weak recommendation for starting GLP-1 receptor agonists.• For those committed to further reducing their risk for CVD and CKD outcomes: Weak recommendation for starting SGLT-2 inhibitors rather than GLP-1 receptor agonists. HOW THIS GUIDELINE WAS CREATED: An international panel including patients, clinicians, and methodologists created these recommendations following standards for trustworthy guidelines and using the GRADE approach. The panel applied an individual patient perspective. THE EVIDENCE: A linked systematic review and network meta-analysis (764 randomised trials included 421 346 participants) of benefits and harms found that SGLT-2 inhibitors and GLP-1 receptor agonists generally reduce overall death, and incidence of myocardial infarctions, and end-stage kidney disease or kidney failure (moderate to high certainty evidence). These medications exert different effects on stroke, hospitalisations for heart failure, and key adverse events in different subgroups. Absolute effects of benefit varied widely based on patients' individual risk (for example, from five fewer deaths in the lowest risk to 48 fewer deaths in the highest risk, for 1000 patients treated over five years). A prognosis review identified 14 eligible risk prediction models, one of which (RECODe) informed most baseline risk estimates in evidence summaries to underpin the risk-stratified recommendations. Concerning patients' values and preferences, the recommendations were supported by evidence from a systematic review of published literature, a patient focus group study, a practical issues summary, and a guideline panel survey. UNDERSTANDING THE RECOMMENDATION: We stratified the recommendations by the levels of risk for CVD and CKD and systematically considered the balance of benefits, harms, other considerations, and practical issues for each risk group. The strong recommendation for SGLT-2 inhibitors in patients with CVD and CKD reflects what the panel considered to be a clear benefit. For all other adults with type 2 diabetes, the weak recommendations reflect what the panel considered to be a finer balance between benefits, harms, and burdens of treatment options. Clinicians using the guideline can identify their patient's individual risk for cardiovascular and kidney outcomes using credible risk calculators such as RECODe. Interactive evidence summaries and decision aids may support well informed treatment choices, including shared decision making.


Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Receptor do Peptídeo Semelhante ao Glucagon 1/uso terapêutico , Transportador 2 de Glucose-Sódio/uso terapêutico , Doenças Cardiovasculares/prevenção & controle , Receptor do Peptídeo Semelhante ao Glucagon 1/agonistas , Humanos , Nefropatias/prevenção & controle , Guias de Prática Clínica como Assunto , Medição de Risco
7.
Cochrane Database Syst Rev ; 4: CD004437, 2021 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-33857326

RESUMO

BACKGROUND: Thrombolytic therapy is usually reserved for people with clinically serious or massive pulmonary embolism (PE). Evidence suggests that thrombolytic agents may dissolve blood clots more rapidly than heparin and may reduce the death rate associated with PE. However, there are still concerns about the possible risk of adverse effects of thrombolytic therapy, such as major or minor haemorrhage. This is the fourth update of the Cochrane review first published in 2006. OBJECTIVES: To assess the effects of thrombolytic therapy for acute pulmonary embolism. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 17 August 2020. We undertook reference checking to identify additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared thrombolytic therapy followed by heparin versus heparin alone, heparin plus placebo, or surgical intervention for people with acute PE (massive/submassive). We did not include trials comparing two different thrombolytic agents or different doses of the same thrombolytic drug. DATA COLLECTION AND ANALYSIS: Two review authors (ZZ, QH) assessed the eligibility and risk of bias of trials and extracted data. We calculated effect estimates using the odds ratio (OR) with a 95% confidence interval (CI) or the mean difference (MD) with a 95% CI. The primary outcomes of interest were death, recurrence of PE and haemorrhagic events. We assessed the certainty of the evidence using GRADE criteria. MAIN RESULTS: We identified three new studies for inclusion in this update. We included 21 trials in the review, with a total of 2401 participants. No studies compared thrombolytics versus surgical intervention. We were not able to include one study in the meta-analysis because it provided no extractable data. Most studies carried a high or unclear risk of bias related to randomisation and blinding. Meta-analysis showed that, compared to control (heparin alone or heparin plus placebo), thrombolytics plus heparin probably reduce both the odds of death (OR 0.58, 95% CI 0.38 to 0.88; 19 studies, 2319 participants; low-certainty evidence), and recurrence of PE (OR 0.54, 95% CI 0.32 to 0.91; 12 studies, 2050 participants; low-certainty evidence). Effects on mortality weakened when six studies at high risk of bias were excluded from analysis (OR 0.71, 95% CI 0.45 to 1.13; 13 studies, 2046 participants) and in the analysis of submassive PE participants (OR 0.61, 95% CI 0.37 to 1.02; 1993 participants). Effects on recurrence of PE also weakened after removing one study at high risk of bias for sensitivity analysis (OR 0.60, 95% CI 0.35 to 1.04; 11 studies, 1949 participants). We downgraded the certainty of evidence to low because of 'Risk of bias' concerns. Major haemorrhagic events were probably more common in the thrombolytics group than in the control group (OR 2.84, 95% CI 1.92 to 4.20; 15 studies, 2101 participants; moderate-certainty evidence), as were minor haemorrhagic events (OR 2.97, 95% CI 1.66 to 5.30; 13 studies,1757 participants; low-certainty evidence). We downgraded the certainty of the evidence to moderate or low because of 'Risk of bias' concerns and inconsistency. Haemorrhagic stroke may occur more often in the thrombolytics group than in the control group (OR 7.59, 95% CI 1.38 to 41.72; 2 studies, 1091 participants). Limited data indicated that thrombolytics may benefit haemodynamic outcomes, perfusion lung scanning, pulmonary angiogram assessment, echocardiograms, pulmonary hypertension, coagulation parameters, composite clinical outcomes, need for escalation and survival time to a greater extent than heparin alone. However, the heterogeneity of the studies and the small number of participants involved warrant caution when interpreting results. The length of hospital stay was shorter in the thrombolytics group than in the control group (mean difference (MD) -1.40 days, 95% CI -2.69 to -0.11; 5 studies, 368 participants). Haemodynamic decompensation may occur less in the thrombolytics group than in the control group (OR 0.36, 95% CI 0.20 to 0.66; 3 studies, 1157 participants). Quality of life was similar between the two treatment groups. None of the included studies provided data on post-thrombotic syndrome or on cost comparison. AUTHORS' CONCLUSIONS: Low-certainty evidence suggests that thrombolytics may reduce death following acute pulmonary embolism compared with heparin (the effectiveness was mainly driven by one trial with massive PE). Thrombolytic therapy may be helpful in reducing the recurrence of pulmonary emboli but may cause more major and minor haemorrhagic events, including haemorrhagic stroke. More studies of high methodological quality are needed to assess safety and cost effectiveness of thrombolytic therapy for people with pulmonary embolism.


Assuntos
Fibrinolíticos/uso terapêutico , Heparina/uso terapêutico , Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica/métodos , Doença Aguda , Viés , Causas de Morte , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Heparina/efeitos adversos , Humanos , Embolia Pulmonar/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Terapia Trombolítica/efeitos adversos
8.
Heart ; 2021 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-33833070

RESUMO

OBJECTIVE: To inform a clinical practice guideline (BMJ Rapid Recommendations) considering sodium glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists for treatment of adults with type 2 diabetes, we summarised the available evidence regarding the performance of validated risk models on cardiovascular and kidney outcomes in these patients. METHODS: We systematically searched bibliographic databases in January 2020 to identify observational studies evaluating risk models for all-cause and cardiovascular mortality, heart failure (HF) hospitalisations, end-stage kidney disease (ESKD), myocardial infarction (MI) and ischaemic stroke in ambulatory adults with type 2 diabetes. Using a random effects model, we pooled discrimination measures for each model and outcome, separately, and descriptively summarised calibration plots, when available. We used the Prediction Model Risk of Bias Assessment Tool to assess risk of bias of each included study and the Grading of Recommendations, Assessment, Development, and Evaluation approach to evaluate our certainty in the evidence. RESULTS: Of 22 589 publications identified, 15 observational studies reporting on seven risk models proved eligible. Among the seven models with >1 validation cohort, the Risk Equations for Complications of Type 2 Diabetes (RECODe) had the best calibration in primary studies and the highest pooled discrimination measures for the following outcomes: all-cause mortality (C-statistics 0.75, 95% CI 0.70 to 0.80; high certainty), cardiovascular mortality (0.79, 95% CI 0.75 to 0.84; low certainty), ESKD (0.73, 95% CI 0.52 to 0.94; low certainty), MI (0.72, 95% CI 0.69 to 0.74; moderate certainty) and stroke (0.71, 95% CI 0.68 to 0.74; moderate certainty). This model does not, however, predict risk of HF hospitalisations. CONCLUSION: Of available risk models, RECODe proved to have satisfactory calibration in primary validation studies and acceptable discrimination superior to other models, though with high risk of bias in most primary studies. TRIAL REGISTRATION NUMBER: CRD42020168351.

9.
Gerontology ; 67(4): 386-396, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33596568

RESUMO

INTRODUCTION: The aim of this study was to investigate the prevalence and associated factors of sarcopenia defined by different criteria in community-dwelling adults of west China using the baseline data of West-China Health and Aging Trend (WCHAT) study. METHODS: Adults aged 50 years or older in communities of Yunnan, Guizhou, Sichuan, and Xinjiang provinces were enrolled in this study. We applied 6 -diagnostic criteria (AWGS 2019, AWGS 2014, EWGSOP1, -EWGSOP2, IWGS, and FNIH) to define sarcopenia. Muscle mass was measured based on bioimpedance analysis. Handgrip strength and walking speed were recorded, respectively. Different variables like anthropometry measures, lifestyles, chronic disease, and blood test were collected. RESULTS: We included 4,500 participants. The prevalence of sarcopenia was 22.8, 19.3, 57.1, 11.8, 24.1, and 18.1% according to the AWGS 2019, AWGS 2014, EWGSOP 1, EWGSOP 2, IWGS, and FNIH criteria, respectively. We found that serum albumin level was independently associated with sarcopenia using AWGS 2019 and IWGS. And vitamin D level was independently associated with sarcopenia using AWGS 2014, -EWGSOP2, and FNIH. While age, depressive status, BMI, hemoglobin, vitamin D, and insulin level were all significantly associated with sarcopenia using AWGS 2014, but all of these factors were not significant using AWGS 2019. CONCLUSIONS: Sarcopenia was highly prevalent in west China regardless of the diagnostic criteria. Serum albumin and vitamin D level were mostly associated with sarcopenia defined by different criteria. While most risk factors associated with the AWGS 2014-defined sarcopenia exhibited no consistent pattern with AWGS 2019, the validity of the AWGS 2019 consensus needs to be confirmed in further prospective studies.

10.
BMJ ; 372: m4573, 2021 01 13.
Artigo em Inglês | MEDLINE | ID: mdl-33441402

RESUMO

OBJECTIVE: To evaluate sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists in patients with type 2 diabetes at varying cardiovascular and renal risk. DESIGN: Network meta-analysis. DATA SOURCES: Medline, Embase, and Cochrane CENTRAL up to 11 August 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials comparing SGLT-2 inhibitors or GLP-1 receptor agonists with placebo, standard care, or other glucose lowering treatment in adults with type 2 diabetes with follow up of 24 weeks or longer. Studies were screened independently by two reviewers for eligibility, extracted data, and assessed risk of bias. MAIN OUTCOME MEASURES: Frequentist random effects network meta-analysis was carried out and GRADE (grading of recommendations assessment, development, and evaluation) used to assess evidence certainty. Results included estimated absolute effects of treatment per 1000 patients treated for five years for patients at very low risk (no cardiovascular risk factors), low risk (three or more cardiovascular risk factors), moderate risk (cardiovascular disease), high risk (chronic kidney disease), and very high risk (cardiovascular disease and kidney disease). A guideline panel provided oversight of the systematic review. RESULTS: 764 trials including 421 346 patients proved eligible. All results refer to the addition of SGLT-2 inhibitors and GLP-1 receptor agonists to existing diabetes treatment. Both classes of drugs lowered all cause mortality, cardiovascular mortality, non-fatal myocardial infarction, and kidney failure (high certainty evidence). Notable differences were found between the two agents: SGLT-2 inhibitors reduced mortality and admission to hospital for heart failure more than GLP-1 receptor agonists, and GLP-1 receptor agonists reduced non-fatal stroke more than SGLT-2 inhibitors (which appeared to have no effect). SGLT-2 inhibitors caused genital infection (high certainty), whereas GLP-1 receptor agonists might cause severe gastrointestinal events (low certainty). Low certainty evidence suggested that SGLT-2 inhibitors and GLP-1 receptor agonists might lower body weight. Little or no evidence was found for the effect of SGLT-2 inhibitors or GLP-1 receptor agonists on limb amputation, blindness, eye disease, neuropathic pain, or health related quality of life. The absolute benefits of these drugs vary substantially across patients from low to very high risk of cardiovascular and renal outcomes (eg, SGLT-2 inhibitors resulted in 5 to 48 fewer deaths in 1000 patients over five years; see interactive decision support tool (https://magicevidence.org/match-it/200820dist/#!/) for all outcomes. CONCLUSIONS: In patients with type 2 diabetes, SGLT-2 inhibitors and GLP-1 receptor agonists reduced cardiovascular and renal outcomes, with notable differences in benefits and harms. Absolute benefits are determined by individual risk profiles of patients, with clear implications for clinical practice, as reflected in the BMJ Rapid Recommendations directly informed by this systematic review. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019153180.


Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Receptor do Peptídeo Semelhante ao Glucagon 1/agonistas , Hipoglicemiantes/uso terapêutico , Mortalidade , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Doenças Cardiovasculares/epidemiologia , Humanos , Hipoglicemiantes/efeitos adversos , Metanálise em Rede , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Renal/epidemiologia , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos
11.
Ann Intern Med ; 174(1): JC10, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33395336

RESUMO

SOURCE CITATION: Bonaca MP, Wiviott SD, Zelniker TA, et al. Dapagliflozin and cardiac, kidney, and limb outcomes in patients with and without peripheral artery disease in DECLARE-TIMI 58. Circulation. 2020;142:734-47. 32795086.


Assuntos
Diabetes Mellitus Tipo 2 , Doença Arterial Periférica , Inibidores do Transportador 2 de Sódio-Glicose , Compostos Benzidrílicos , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Glucosídeos , Humanos , Rim , Doença Arterial Periférica/tratamento farmacológico , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos
13.
J Clin Epidemiol ; 133: 61-71, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33321175

RESUMO

OBJECTIVES: The objective of the study was to develop an inventory summarizing all anchor-based minimal important difference (MID) estimates for patient-reported outcome measures (PROMs) available in the medical literature. STUDY DESIGN AND SETTING: We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Patient-Reported Outcome and Quality of Life Instruments Database internal library (January 1989-October 2018). We included primary studies empirically calculating an anchor-based MID estimate for any PROM in adults and adolescents. Pairs of reviewers independently screened and selected studies, extracted data, and evaluated the credibility of the MIDs. RESULTS: We identified 585 eligible studies, the majority conducted in Europe (n = 211) and North America (n = 179), reporting 5,324 MID estimates for 526 distinct PROMs. Investigators conducted their studies in the context of patients receiving surgical (n = 105, 18%), pharmacological (n = 85, 15%), rehabilitation (n = 65, 11%), or a combination of interventions (n = 194, 33%). Of all MID estimates, 59% (n = 3,131) used a global rating of change anchor. Major credibility limitations included weak correlation (n = 1,246, 23%) or no information regarding the correlation (n = 3,498, 66%) between the PROM and anchor and imprecision in the MID estimate (n = 2,513, 47%). CONCLUSION: A large number of MIDs for assisting in the interpretation of PROMs exist. The MID inventory will facilitate the use of MID estimates to inform the interpretation of the magnitude of treatment effects in clinical research and guideline development.


Assuntos
Tratamento Farmacológico/estatística & dados numéricos , Variações Dependentes do Observador , Medidas de Resultados Relatados pelo Paciente , Satisfação do Paciente/estatística & dados numéricos , Reabilitação/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , América do Norte , Adulto Jovem
14.
Blood Adv ; 4(15): 3528-3549, 2020 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-32761235

RESUMO

BACKGROUND: Older adults with acute myeloid leukemia (AML) represent a vulnerable population in whom disease-based and clinical risk factors, patient goals, prognosis, and practitioner- and patient-perceived treatment risks and benefits influence treatment recommendations. OBJECTIVE: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about management of AML in older adults. METHODS: ASH formed a multidisciplinary guideline panel that included specialists in myeloid leukemia, geriatric oncology, patient-reported outcomes and decision-making, frailty, epidemiology, and methodology, as well as patients. The McMaster Grading of Recommendations Assessment, Development and Evaluation (GRADE) Centre supported the guideline-development process, including performing systematic evidence reviews (up to 24 May 2019). The panel prioritized clinical questions and outcomes according to their importance to patients, as judged by the panel. The panel used the GRADE approach, including GRADE's Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS: The panel agreed on 6 critical questions in managing older adults with AML, mirroring real-time practitioner-patient conversations: the decision to pursue antileukemic treatment vs best supportive management, the intensity of therapy, the role and duration of postremission therapy, combination vs monotherapy for induction and beyond, duration of less-intensive therapy, and the role of transfusion support for patients no longer receiving antileukemic therapy. CONCLUSIONS: Treatment is recommended over best supportive management. More-intensive therapy is recommended over less-intensive therapy when deemed tolerable. However, these recommendations are guided by the principle that throughout a patient's disease course, optimal care involves ongoing discussions between clinicians and patients, continuously addressing goals of care and the relative risk-benefit balance of treatment.


Assuntos
Hematologia , Leucemia Mieloide Aguda , Tromboembolia Venosa , Idoso , Medicina Baseada em Evidências , Humanos , Leucemia Mieloide Aguda/diagnóstico , Leucemia Mieloide Aguda/terapia , Estados Unidos
15.
PLoS One ; 15(3): e0230721, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32226046

RESUMO

BACKGROUND: A number of studies have reported on associations between reproductive factors, such as delivery methods, number of birth and breastfeeding, and incidence of cancer in children, but systematic reviews addressing this issue to date have important limitations, and no reviews have addressed the impact of reproductive factors on cancer over the full life course of offspring. METHODS: We performed a comprehensive search in MEDLINE, and Embase up to January 2020 and Web of Science up to 2018 July, including cohort studies reporting the association between maternal reproductive factors of age at birth, birth order, number of births, delivery methods, and breastfeeding duration and cancer in children. Teams of two reviewers independently extracted data and assessed risk of bias. We conducted random effects meta-analyses to estimate summary relative estimates, calculated absolute differences between those with and without risk factors, and used the GRADE approach to evaluate the certainty of evidence. RESULTS: For most exposures and most cancers, we found no suggestion of a causal relation. We found low to very low certainty evidence of the following very small possible impact: higher maternal age at birth with adult multiple myeloma and lifetime uterine cervix cancer incidence; lower maternal age at birth with childhood overall cancer mortality (RR = 1.15, 95% CI = 1.01-1.30; AR/10,000 = 1, 95% CI = 0 to 2), adult leukemia and lifetime uterine cervix cancer incidence; higher birth order with adult melanoma, cervix uteri, corpus uteri, thyroid cancer incidence, lifetime lung, corpus uteri, prostate, testis, sarcoma, thyroid cancer incidence; larger number of birth with childhood brain (RR = 1.27, 95% CI = 1.06-1.52; AR/10,000 = 1, 95% CI = 0 to 2), leukemia (RR = 2.11, 95% CI = 1.62-2.75; AR/10,000 = 9, 95% CI = 5 to 14), lymphoma (RR = 4.66, 95% CI = 1.40-15.57; AR/10,000 = 11, 95% CI = 1 to 44) incidence, adult stomach, corpus uteri cancer incidence and lung cancer mortality, lifetime stomach, lung, uterine cervix, uterine corpus, multiple myeloma, testis cancer incidence; Caesarean delivery with childhood kidney cancer incidence (RR = 1.25, 95% CI = 1.01-1.55; AR/10,000 = 0, 95% CI = 0 to 1); and breastfeeding with adult colorectal cancer incidence. CONCLUSION: Very small impacts existed between a number of reproductive factors and cancer incidence and mortality in children and the certainty of evidence was low to very low primarily due to observational design.


Assuntos
Mães , Neoplasias/epidemiologia , Reprodução , Humanos , Risco
16.
Med J Aust ; 212(6): 258-262, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32092160

RESUMO

OBJECTIVE: To assess whether a practical intervention based upon a smartphone application (app) would improve self-management and seizure control in adults with epilepsy. DESIGN, SETTING: Randomised, controlled trial in western China, December 2017 to August 2018. PARTICIPANTS: 380 eligible people with epilepsy were recruited; 327 completed the 6-month follow-up (176 in the app group, 151 in the control group). MAIN OUTCOME MEASURES: Self-management of epilepsy (measured with the validated Chinese Epilepsy Self-Management Scale, C-ESMS) and self-reported seizure frequency. RESULTS: In the intention-to-treat analysis, the mean C-ESMS score increased significantly in the app group between baseline and the 6-month evaluation (from 121.7 [SD, 12.1] to 144.4 [SD, 10.0]; P < 0.001); improvements on the information management, medication management, and safety management subscales were also statistically significant. At 6 months, the mean overall C-ESMS score for the app group was significantly higher than that for the control group (125.4 [SD, 1.5];  P < 0.001). The proportion of patients who were seizure-free at the 6-month follow-up was larger for the app than the control group (54 of 190, 28% v 22 of 190, 12%), as was the proportion with reductions in frequency of between 75 and 100% (22 of 190, 12% v 8 of 190, 4%). Changes in C-ESMS score were not statistically associated with seizure frequency. CONCLUSIONS: Using a smartphone app improved epilepsy self-management scores in people in western China. It should be further tested in larger populations in other areas. Our preliminary investigation of building digital communities for people with epilepsy should encourage similar approaches to managing other chronic diseases. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR1900026864, 24 October 2019.


Assuntos
Epilepsia/complicações , Aplicativos Móveis , Convulsões/prevenção & controle , Autogestão/métodos , Adulto , China , Feminino , Humanos , Análise de Intenção de Tratamento , Masculino , Convulsões/etiologia , Smartphone
17.
BMC Geriatr ; 20(1): 63, 2020 02 17.
Artigo em Inglês | MEDLINE | ID: mdl-32066390

RESUMO

BACKGROUND: Sarcopenia is a condition that is characterized by loss of muscle mass, muscle strength and muscle functional impairment with ageing. It is associated with poor health outcomes, premature death and a significant burden on the global health economy. The prevalence of sarcopenia in China is unknown since most of the studies are lack of uniform standard. The study was undertaken to study the prevalence of sarcopenia and the association with cognitive impairment among multi-ethnic adults aged 50 years old or older in western China. METHODS: We measured gait speed, handgrip strength and muscle mass by using bioelectrical impedance analysis (BIA) for all eligible participants and 4500 participants were eligible for the analysis. We defined sarcopenia using the diagnostic algorithm recommended by the Asian Working Group for Sarcopenia (AWGS). We assessed the participants' cognitive functions using the 10-item Short Portable Mental Status Questionnaire (SPMSQ). Relationships between sarcopenia and cognitive impairment were analyzed using univariate and multivariate analyses. RESULTS: Of 4500 participants (mean age 62.4 ± 8.3 years), 869 (19.31%) adults were sarcopenia. 446 (9.9%) participants were identified as having mild cognitive impairment, 144 (3.2%) adults were identified as having moderate/severe cognitive impairment. After adjusting for age, gender, ethnics and other potential cofounders, cognitive impairment was found to be independently associated with sarcopenia with a dosage effect (mild cognitive impairment: odds ratio [OR]: 1.41, 95% CI 1.10-1.82; moderate/severe cognitive impairment: OR: 3.05, 95% CI 2.08-4.49). After gender stratification, the association between mild cognitive impairment with sarcopenia in male is not significant, while is still significant in female. While the association between moderate/severe cognitive impairment is independently associated with sarcopenia in both male and female. CONCLUSIONS: The prevalence rates of sarcopenia, mild cognitive impairment, moderate/severe cognitive impairment among the communities aged 50 or older in western China were 19.31, 9.9 and 3.2%, respectively. Cognitive impairment was significantly associated with sarcopenia with a dosage effect, especially in female.


Assuntos
Envelhecimento , Disfunção Cognitiva/epidemiologia , Avaliação Geriátrica/métodos , Sarcopenia/epidemiologia , Idoso , Envelhecimento/fisiologia , Envelhecimento/psicologia , China/epidemiologia , Disfunção Cognitiva/diagnóstico , Estudos Transversais , Feminino , Força da Mão/fisiologia , Humanos , Masculino , Prevalência , Sarcopenia/diagnóstico , Sarcopenia/etnologia
18.
Aging Clin Exp Res ; 32(8): 1435-1442, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31489598

RESUMO

BACKGROUND: There is very limited guidance in regard to how biological age should be estimated and how different comorbidity conditions influence the benefit-risk ration of interventions. Frailty is an important health-related problem in patients, especially in older adults. It is a reflection of biologic rather than chronologic age; frailty may explain why there remains substantial heterogeneity in clinical outcomes within the older patients' population. AIMS: We aimed to review the prognostic value of frailty for adverse outcomes in older patients with acute coronary syndrome (ACS). METHODS: Studies published until December 31, 2018, identified by systematic Medline, Embase, and Cochrane Controlled Register of Trials (CENTRAL) searches were reviewed for the association between frailty and mortality in older patients with ACS. We used the Newcastle-Ottawa Quality Assessment Scale to assess the quality of the included studies. We extracted the information of hazard ratios (HR) and odds ratios (OR) with accompanying 95% confidence intervals (CI), and P values of multivariable analysis. Heterogeneity across studies was determined using the Cochran Q value by Review Manager 5.3. RESULTS: A total of 11 articles involving 7212 patients were included in this meta-analysis. Two studies (Sujino, Y 2015 and Alonso, S.GL 2016; n = 264) reported that frailty was significantly associated with in-hospital mortality in patients with ACS (range of reported OR between 6.38 and 12.0). We performed a subgroup analysis of the other nine studies based on differences in the follow-up time. Pooled meta-analysis demonstrates that frailty was associated with short-term, medium-term, and long-term mortality (HR = 3.67, 4.09, 1.66). There was no association between frailty and bleeding in older patients with ACS. CONCLUSIONS: Frailty measured by Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS), the Edmonton Frail Scale (EFS), Fried score, Green scores, frailty instrument from the Survey of Health, Ageing and Retirement in Europe (SHARE-FI) index, and FRAIL (Fatigue, Resistance, Ambulation, Illnesses, Loss of weight) scale, leads to significantly higher mortality rates in older patients with ACS.


Assuntos
Síndrome Coronariana Aguda , Idoso Fragilizado , Fragilidade , Idoso , Canadá , Europa (Continente) , Humanos , Prognóstico
19.
Aging Clin Exp Res ; 32(10): 1977-1983, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31776857

RESUMO

BACKGROUND: Length of hospital stay (LOS) and readmission are important outcomes for older inpatients. The association between functional status on admission and outcomes has not been well investigated in Chinese elderly. OBJECTIVES: To detect the impact of function impairments on LOS and 90-day readmission in a population of Chinese elderly inpatients. METHODS: This is a prospective cohort study. All new patients over 60 years in geriatrics department of a university hospital in Western China from June to August 2016 were enrolled. Activities of daily living (ADL) and Instrumental ADL (IADL) on admission were evaluated with Barthel Index and Lawton IADL. Outcomes were LOS and 90-day readmission. LOS was calculated as the total days of hospital stay. Readmission was investigated through telephone interviews after discharge. Pearson Chi-square test was used to detect the associations. Binary logistic regression was used to detect the association of function status on admission with LOS and readmission. RESULTS: A total of 225 patients were enrolled. Mean age 82.41 (± 7.316; 63-99), 31.1% were females. Overall, 64.9% of the patients were hospitalized longer than 14 days and 33.30% experienced a 90-day readmission. Following an adjustment for age, gender, marital status, education level, smoking, alcohol, nutrition status, and admission location, the binary logistic regression models showed that both ADL impairment (OR 2.03; 95% CI 1.06-3.87) and IADL impairment (OR 2.54; 95% CI 1.28-5.01) were independent predictors for LOS. ADL impairment was an independent predictor for 90-day readmission (OR 2.26; 95% CI 1.14-4.47), while IADL impairment was not associated with readmission (OR 1.43; 95% CI 0.68-3.02). CONCLUSION: Functional status on admission is the predictor of LOS and 90-day readmission in Chinese older inpatients from the geriatric department of a university hospital.


Assuntos
Atividades Cotidianas , Geriatria , Idoso , Idoso de 80 Anos ou mais , China , Estudos de Coortes , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Estudos Prospectivos
20.
Hum Gene Ther ; 30(12): 1494-1504, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31668086

RESUMO

Wilson's disease (WD) is an autosomal recessive disorder of copper metabolism caused by mutations in the ATP7B gene encoding a liver active copper transport enzyme. Gene therapy with adeno-associated virus (AAV) carrying full-length ATP7B, which is about 4.4 kb, was shown to rescue copper metabolism disorder in WD mouse model. However, due to its relatively large size, the AAV vector containing full-length ATP7B could be oversized for its packaging capacity, which could lead to inefficient packaging. To this purpose, we engineered a truncated ATP7B mutant (tATP7B) that is about 3.3 kb in length and used for AAV gene therapy for WD mice. In vitro test showed that the excretion of copper outside the cells could be achieved with tATP7B as efficient as the full-length ATP7B. In vivo delivery of tATP7B to WD mice by AAV8 vectors corrected their copper metabolisms and significantly rescued copper accumulation-related syndromes, including reduced urinary copper excretion, increased serum ceruloplasmin, and improved liver damages. Thus, our study demonstrated that AAV gene therapy based on truncated ATP7B is a promising strategy in the treatment of WD.


Assuntos
ATPases Transportadoras de Cobre/genética , Dependovirus/genética , Vetores Genéticos/farmacologia , Degeneração Hepatolenticular/terapia , Animais , Cobre/metabolismo , Modelos Animais de Doenças , Técnicas de Transferência de Genes , Terapia Genética , Vetores Genéticos/genética , Degeneração Hepatolenticular/genética , Degeneração Hepatolenticular/metabolismo , Degeneração Hepatolenticular/virologia , Humanos , Fígado/metabolismo , Fígado/patologia , Camundongos , Mutação
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