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1.
Artigo em Inglês | MEDLINE | ID: mdl-33651632

RESUMO

Background - There is considerable interest in whether genetic data can be used to improve standard cardiovascular disease risk calculators, as the latter are routinely used in clinical practice to manage preventative treatment. Methods - Using the UK Biobank (UKB) resource, we developed our own polygenic risk score (PRS) for coronary artery disease (CAD). We used an additional 60,000 UKB individuals to develop an integrated risk tool (IRT) that combined our PRS with established risk tools (either the American Heart Association/American College of Cardiology's Pooled Cohort Equations (PCE) or UK's QRISK3), and we tested our IRT in an additional, independent, set of 186,451 UKB individuals. Results - The novel CAD PRS shows superior predictive power for CAD events, compared to other published PRSs and is largely uncorrelated with PCE and QRISK3. When combined with PCE into an integrated risk tool, it has superior predictive accuracy. Overall, 10.4% of incident CAD cases were misclassified as low risk by PCE and correctly classified as high risk by the IRT, compared to 4.4% misclassified by the IRT and correctly classified by PCE. The overall net reclassification improvement for the IRT was 5.9% (95% CI 4.7-7.0). When individuals were stratified into age-by-sex subgroups the improvement was larger for all subgroups (range 8.3%-15.4%), with best performance in 40-54yo men (15.4%, 95% CI 11.6-19.3). Comparable results were found using a different risk tool (QRISK3), and also a broader definition of cardiovascular disease. Use of the IRT is estimated to avoid up to 12,000 deaths in the USA over a 5-year period. Conclusions - An integrated risk tool that includes polygenic risk outperforms current risk stratification tools and offers greater opportunity for early interventions. Given the plummeting costs of genetic tests, future iterations of CAD risk tools would be enhanced with the addition of a person's polygenic risk.

2.
F1000Res ; 9: 1193, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33082937

RESUMO

Background: Never before have clinical trials drawn as much public attention as those testing interventions for COVID-19. We aimed to describe the worldwide COVID-19 clinical research response and its evolution over the first 100 days of the pandemic. Methods: Descriptive analysis of planned, ongoing or completed trials by April 9, 2020 testing any intervention to treat or prevent COVID-19, systematically identified in trial registries, preprint servers, and literature databases. A survey was conducted of all trials to assess their recruitment status up to July 6, 2020. Results: Most of the 689 trials (overall target sample size 396,366) were small (median sample size 120; interquartile range [IQR] 60-300) but randomized (75.8%; n=522) and were often conducted in China (51.1%; n=352) or the USA (11%; n=76). 525 trials (76.2%) planned to include 155,571 hospitalized patients, and 25 (3.6%) planned to include 96,821 health-care workers. Treatments were evaluated in 607 trials (88.1%), frequently antivirals (n=144) or antimalarials (n=112); 78 trials (11.3%) focused on prevention, including 14 vaccine trials. No trial investigated social distancing. Interventions tested in 11 trials with >5,000 participants were also tested in 169 smaller trials (median sample size 273; IQR 90-700). Hydroxychloroquine alone was investigated in 110 trials. While 414 trials (60.0%) expected completion in 2020, only 35 trials (4.1%; 3,071 participants) were completed by July 6. Of 112 trials with detailed recruitment information, 55 had recruited <20% of the targeted sample; 27 between 20-50%; and 30 over 50% (median 14.8% [IQR 2.0-62.0%]). Conclusions: The size and speed of the COVID-19 clinical trials agenda is unprecedented. However, most trials were small investigating a small fraction of treatment options. The feasibility of this research agenda is questionable, and many trials may end in futility, wasting research resources. Much better coordination is needed to respond to global health threats.


Assuntos
Pesquisa Biomédica/tendências , Ensaios Clínicos como Assunto , Infecções por Coronavirus , Pandemias , Pneumonia Viral , Betacoronavirus , China , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/terapia , Humanos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/terapia , Estados Unidos
3.
BMJ Evid Based Med ; 2020 Jun 03.
Artigo em Inglês | MEDLINE | ID: mdl-32493831
4.
JAMA Netw Open ; 3(4): e202064, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-32242908

RESUMO

Importance: Atrial fibrillation (AF) affects more than 6 million people in the United States; however, much AF remains undiagnosed. Given that more than 265 million people in the United States own smartphones (>80% of the population), smartphone applications have been proposed for detecting AF, but the accuracy of these applications remains unclear. Objective: To determine the accuracy of smartphone camera applications that diagnose AF. Data Sources and Study Selection: MEDLINE and Embase were searched until January 2019 for studies that assessed the accuracy of any smartphone applications that use the smartphone's camera to measure the amplitude and frequency of the user's fingertip pulse to diagnose AF. Data Extraction and Synthesis: Bivariate random-effects meta-analyses were constructed to synthesize data. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) of Diagnostic Test Accuracy Studies reporting guideline. Main Outcomes and Measures: Sensitivity and specificity were measured with bivariate random-effects meta-analysis. To simulate the use of these applications as a screening tool, the positive predictive value (PPV) and negative predictive value (NPV) for different population groups (ie, age ≥65 years and age ≥65 years with hypertension) were modeled. Lastly, the association of methodological limitations with outcomes were analyzed with sensitivity analyses and metaregressions. Results: A total of 10 primary diagnostic accuracy studies, with 3852 participants and 4 applications, were included. The oldest studies were published in 2016 (2 studies [20.0%]), while most studies (4 [40.0%]) were published in 2018. The applications analyzed the pulsewave signal for a mean (range) of 2 (1-5) minutes. The meta-analyzed sensitivity and specificity for all applications combined were 94.2% (95% CI, 92.2%-95.7%) and 95.8% (95% CI, 92.4%-97.7%), respectively. The PPV for smartphone camera applications detecting AF in an asymptomatic population aged 65 years and older was between 19.3% (95% CI, 19.2%-19.4%) and 37.5% (95% CI, 37.4%-37.6%), and the NPV was between 99.8% (95% CI, 99.83%-99.84%) and 99.9% (95% CI, 99.94%-99.95%). The PPV and NPV increased for individuals aged 65 years and older with hypertension (PPV, 20.5% [95% CI, 20.4%-20.6%] to 39.2% [95% CI, 39.1%-39.3%]; NPV, 99.8% [95% CI, 99.8%-99.8%] to 99.9% [95% CI, 99.9%-99.9%]). There were methodological limitations in a number of studies that did not appear to be associated with diagnostic performance, but this could not be definitively excluded given the sparsity of the data. Conclusions and Relevance: In this study, all smartphone camera applications had relatively high sensitivity and specificity. The modeled NPV was high for all analyses, but the PPV was modest, suggesting that using these applications in an asymptomatic population may generate a higher number of false-positive than true-positive results. Future research should address the accuracy of these applications when screening other high-risk population groups, their ability to help monitor chronic AF, and, ultimately, their associations with patient-important outcomes.


Assuntos
Fibrilação Atrial/diagnóstico , Confiabilidade dos Dados , Determinação da Frequência Cardíaca/instrumentação , Smartphone/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , Coleta de Dados/métodos , Feminino , Dedos/fisiologia , Humanos , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Aplicativos Móveis/estatística & dados numéricos , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Estados Unidos/epidemiologia
8.
Lancet Digit Health ; 1(7): e344-e352, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-33323209

RESUMO

BACKGROUND: Smartphone apps might enable interventions to increase physical activity, but few randomised trials testing this hypothesis have been done. The MyHeart Counts Cardiovascular Health Study is a longitudinal smartphone-based study with the aim of elucidating the determinants of cardiovascular health. We aimed to investigate the effect of four different physical activity coaching interventions on daily step count in a substudy of the MyHeart Counts Study. METHODS: In this randomised, controlled crossover trial, we recruited adults (aged ≥18 years) in the USA with access to an iPhone smartphone (Apple, Cupertino, CA, USA; version 5S or newer) who had downloaded the MyHeart Counts app (version 2.0). After completion of a 1 week baseline period of interaction with the MyHeart Counts app, participants were randomly assigned to receive one of 24 permutations (four combinations of four 7 day interventions) in a crossover design using a random number generator built into the app. Interventions consisted of either daily prompts to complete 10 000 steps, hourly prompts to stand following 1 h of sitting, instructions to read the guidelines from the American Heart Association website, or e-coaching based upon the individual's personal activity patterns from the baseline week of data collection. Participants completed the trial in a free-living setting. Due to the nature of the interventions, participants could not be masked from the intervention. Investigators were not masked to intervention allocation. The primary outcome was change in mean daily step count from baseline for each of the four interventions, assessed in the modified intention-to-treat analysis set, which included all participants who had completed 7 days of baseline monitoring and at least 1 day of one of the four interventions. This trial is registered with ClinicalTrials.gov, NCT03090321. FINDINGS: Between Dec 12, 2016, and June 6, 2018, 2783 participants consented to enrol in the coaching study, of whom 1075 completed 7 days of baseline monitoring and at least 1 day of one of the four interventions and thus were included in the modified intention-to-treat analysis set. 493 individuals completed the full set of assigned interventions. All four interventions significantly increased mean daily step count from baseline (mean daily step count 2914 [SE 74]): mean step count increased by 319 steps (75) for participants in the American Heart Association website prompt group (p<0·0001), 267 steps (74) for participants in the hourly stand prompt group (p=0·0003), 254 steps (74) for participants in the cluster-specific prompts group (p=0·0006), and by 226 steps (75) for participants in the 10 000 daily step prompt group (p=0·0026 vs baseline). INTERPRETATION: Four smartphone-based physical activity coaching interventions significantly increased daily physical activity. These findings suggests that digital interventions delivered via a mobile app have the ability to increase short-term physical activity levels in a free-living cohort. FUNDING: Stanford Data Science Initiative.


Assuntos
Doenças Cardiovasculares/prevenção & controle , Exercício Físico/fisiologia , Promoção da Saúde , Aplicativos Móveis/estatística & dados numéricos , Adulto , Estudos Cross-Over , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Smartphone , Estados Unidos
9.
BMC Med ; 16(1): 229, 2018 12 20.
Artigo em Inglês | MEDLINE | ID: mdl-30567539

RESUMO

BACKGROUND: The UK's National Health Service (NHS) is currently subject to unprecedented financial strain. The identification of unnecessary healthcare resource use has been suggested to reduce spending. However, there is little very research quantifying wasteful test use, despite the £3 billion annual expenditure. Geographical variation has been suggested as one metric in which to quantify inappropriate use. We set out to identify tests ordered from UK primary care that are subject to the greatest between-practice variation in their use. METHODS: We used data from 444 general practices within the Clinical Practice Research Datalink to calculate a coefficient of variation (CoV) for the ordering of 44 specific tests from UK general practices. The coefficient of variation was calculated after adjusting for differences between practice populations. We also determined the tests that had both a higher-than-average CoV and a higher-than-average rate of use. RESULTS: In total, 16,496,218 tests were ordered for 4,078,091 patients over 3,311,050 person-years from April 1, 2015, to March 31, 2016. The tests subject to the greatest variation were drug monitoring 158% (95%CI 153 to 163%), urine microalbumin (52% (95%CI 49.9 to 53.2%)), pelvic CT (51% (95%CI 50 to 53%)) and Pap smear (49% (95%CI 48 to 51%). Seven tests were classified as high variability and high rate (clotting, vitamin D, urine albumin, prostate-specific antigen (PSA), bone profile, urine MCS and C-reactive protein (CRP)). CONCLUSIONS: There are wide variations in the use of common tests, which is unlikely to be explained by clinical indications. Since £3 billion annually are spent on tests, this represents considerable variation in the use of resources and inefficient management in the NHS. Our results can be of value to policy makers, researchers, patients and clinicians as the NHS strives towards identifying overuse and underuse of tests.


Assuntos
Testes Diagnósticos de Rotina/estatística & dados numéricos , Padrões de Prática Médica , Atenção Primária à Saúde , Adulto , Testes Diagnósticos de Rotina/economia , Feminino , Política de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde , Padrões de Prática Médica/economia , Atenção Primária à Saúde/economia , Estudos Retrospectivos , Reino Unido
10.
BMJ ; 363: k4666, 2018 Nov 28.
Artigo em Inglês | MEDLINE | ID: mdl-30487169

RESUMO

OBJECTIVES: To assess the temporal change in test use in UK primary care and to identify tests with the greatest increase in use. DESIGN: Retrospective cohort study. SETTING: UK primary care. PARTICIPANTS: All patients registered to UK General Practices in the Clinical Practice Research Datalink, 2000/1 to 2015/16. MAIN OUTCOME MEASURES: Temporal trends in test use, and crude and age and sex standardised rates of total test use and of 44 specific tests. RESULTS: 262 974 099 tests were analysed over 71 436 331 person years. Age and sex adjusted use increased by 8.5% annually (95% confidence interval 7.6% to 9.4%); from 14 869 tests per 10 000 person years in 2000/1 to 49 267 in 2015/16, a 3.3-fold increase. Patients in 2015/16 had on average five tests per year, compared with 1.5 in 2000/1. Test use also increased statistically significantly across all age groups, in both sexes, across all test types (laboratory, imaging, and miscellaneous), and 40 of the 44 tests that were studied specifically. CONCLUSION: Total test use has increased markedly over time, in both sexes, and across all age groups, test types (laboratory, imaging, and miscellaneous) and for 40 of 44 tests specifically studied. Of the patients who underwent at least one test annually, the proportion who had more than one test increased significantly over time.


Assuntos
Técnicas e Procedimentos Diagnósticos/tendências , Atenção Primária à Saúde/tendências , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Reino Unido , Adulto Jovem
11.
Sci Rep ; 8(1): 14663, 2018 10 02.
Artigo em Inglês | MEDLINE | ID: mdl-30279510

RESUMO

The incidence of cancer in the United Kingdom has increased significantly over the last four decades. The aim of this study was to examine trends in UK cancer incidence and mortality by cancer site and assess the potential for overdiagnosis. Using Cancer Research UK incidence and mortality data for the period (1971-2014) we estimated percentage change in incidence and mortality rates and the incidence-mortality ratio (IMR) for cancers in which incidence had increased >50%. Incidence and mortality trend plots were used to assess the potential for overdiagnosis. Incidence rates increased from 67% (uterine) to 375% (melanoma). Change in mortality rates ranged from -69% (cervical) to +239% (liver). The greatest divergences occurred in uterine (IMR = 132), prostate (IMR = 9.6), oral (IMR = 9.8) and thyroid cancer (IMR = 5.3). Only in liver cancer did mortality track incidence (IMR = 1.1). For four cancer sites; uterine, prostate, oral and thyroid, incidence and mortality trends are suggestive of overdiagnosis. Trends in melanoma and kidney cancer suggest potential overdiagnosis and an underlying increase in true risk, whereas for cervical and breast cancer, trends may also reflect improvements in treatments or earlier diagnosis. A more detailed analysis is required to fully understand these patterns.


Assuntos
Sobremedicalização/tendências , Neoplasias/epidemiologia , Neoplasias/mortalidade , Estudos de Coortes , Feminino , Humanos , Incidência , Masculino , Mortalidade/tendências , Reino Unido/epidemiologia
13.
BMJ ; 361: k2387, 2018 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-29914908

RESUMO

OBJECTIVE: To provide an overview of the evidence on prevalence and outcomes of incidental imaging findings. DESIGN: Umbrella review of systematic reviews. DATA SOURCES: Searches of MEDLINE, EMBASE up to August 2017; screening of references in included papers. ELIGIBILITY CRITERIA: Criteria included systematic reviews and meta-analyses of observational studies that gave a prevalence of incidental abnormalities ("incidentalomas"). An incidental imaging finding was defined as an imaging abnormality in a healthy, asymptomatic patient or an imaging abnormality in a symptomatic patient, where the abnormality was not apparently related to the patient's symptoms. Primary studies that measured the prevalence of incidentalomas in patients with a history of malignancy were also considered in sensitivity analyses. RESULTS: 20 systematic reviews (240 primary studies) were identified from 7098 references from the database search. Fifteen systematic reviews provided data to quantify the prevalence of incidentalomas, whereas 18 provided data to quantify the outcomes of incidentalomas (13 provided both). The prevalence of incidentalomas varied substantially between imaging tests; it was less than 5% for chest computed tomography for incidental pulmonary embolism in patients with and without cancer and whole body positron emission tomography (PET) or PET/computed tomography (for patients with and without cancer). Conversely, incidentalomas occurred in more than a third of images in cardiac magnetic resonance imaging (MRI), chest computed tomography (for incidentalomas of thorax, abdomen, spine, or heart), and computed tomography colonoscopy (for extra-colonic incidentalomas). Intermediate rates occurred with MRI of the spine (22%) and brain (22%). The rate of malignancy in incidentalomas varied substantially between organs; the prevalence of malignancy was less than 5% in incidentalomas of the brain, parotid, and adrenal gland. Extra-colonic, prostatic, and colonic incidentalomas were malignant between 10% and 20% of the time, whereas renal, thyroid, and ovarian incidentalomas were malignant around a quarter of the time. Breast incidentalomas had the highest percentage of malignancy (42%, 95% confidence interval 31% to 54%). Many assessments had high between-study heterogeneity (15 of 20 meta-analyses with I2 >50%). CONCLUSIONS: There is large variability across different imaging techniques both in the prevalence of incidentalomas and in the prevalence of malignancy for specific organs. This umbrella review will aid clinicians and patients weigh up the pros and cons of requesting imaging scans and will help with management decisions after an incidentaloma diagnosis. Our results can underpin the creation of guidelines to assist these decisions. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42017075679.


Assuntos
Diagnóstico por Imagem , Achados Incidentais , Diagnóstico por Imagem/estatística & dados numéricos , Humanos , Prevalência , Resultado do Tratamento
14.
Sci Rep ; 8(1): 8354, 2018 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-29795282

RESUMO

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has not been fixed in the paper.

15.
Sci Rep ; 8(1): 4752, 2018 03 19.
Artigo em Inglês | MEDLINE | ID: mdl-29556075

RESUMO

Efforts to reduce healthcare costs have led to the development of metrics to identify unwarranted variation in care. Previous work assessing diagnostic tests is limited, despite their substantial contribution to expenditure. We explored C-reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) tests ordered across Oxfordshire NHS General Practices, and the proportion of tests that yielded an abnormal result, and identified practices that had a proportion of abnormal CRP and ESR results 3 standard deviations below the mean. We estimated the adjusted average proportion of abnormal CRP and ESR tests that yielded abnormal results from each practice, after adjusting for differences in practice populations. These proportions were plotted against the total CRP and ESR requests per practice. We constructed funnel plots to identify practices 3 standard deviations below the mean proportion of abnormal CRP and ESR tests. We analysed 143,745 CRP and 30,758 ESR requests from 69 practices. Twelve (17%) and 7 (10%) practices were more than 3 standard deviations below the mean for CRP and ESR testing respectively. Two practices (3%) were below the 99.8% limit for both CRP and ESR ordering. Variation in the proportion of tests with an abnormal result shows promise for auditing variation in care.


Assuntos
Testes Diagnósticos de Rotina/estatística & dados numéricos , Informática Médica/métodos , Biomarcadores/sangue , Sedimentação Sanguínea , Proteína C-Reativa/análise , Humanos , Análise de Regressão , Estudos Retrospectivos , Estatística como Assunto
16.
BMJ Evid Based Med ; 23(2): 54-55, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29595130

RESUMO

This article is part of the Catalogue of Bias series. We present a description of verification bias, and outline its potential impact on research studies and the preventive steps to minimise its risk. We also present teaching slides in the online supplementary file. Verification bias (sometimes referred to as 'work-up bias') concerns the test(s) used to confirm a diagnosis within a diagnostic accuracy study. Verification bias occurs when only a proportion of the study participants receive confirmation of the diagnosis by the reference standard test, or if some participants receive a different reference standard test.

17.
BMJ Open ; 8(2): e018557, 2018 02 11.
Artigo em Inglês | MEDLINE | ID: mdl-29440142

RESUMO

BACKGROUND: Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste. OBJECTIVE: To identify overuse and underuse of diagnostic tests in primary care. DESIGN: Systematic review and meta-analysis. DATA SOURCES AND ELIGIBILITY CRITERIA: We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care. RESULTS: We included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests.The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%-100%)%).17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%-78%, n=8).Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%-92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%-54% (n=10) and 8%-52% (n=2), respectively. CONCLUSIONS: There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy. PROSPERO REGISTRATION NUMBER: CRD42016048832.


Assuntos
Testes Diagnósticos de Rotina/estatística & dados numéricos , Atenção Primária à Saúde/organização & administração , Procedimentos Desnecessários/estatística & dados numéricos , Adulto , Ecocardiografia/estatística & dados numéricos , Endoscopia do Sistema Digestório/estatística & dados numéricos , Humanos , Testes de Função Respiratória/estatística & dados numéricos
18.
Cochrane Database Syst Rev ; 11: CD011360, 2016 11 25.
Artigo em Inglês | MEDLINE | ID: mdl-27886368

RESUMO

BACKGROUND: Acute upper respiratory tract infections (URTIs) are frequently managed in primary care settings. Although many are viral, and there is an increasing problem with antibiotic resistance, antibiotics continue to be prescribed for URTIs. Written patient information may be a simple way to reduce antibiotic use for acute URTIs. OBJECTIVES: To assess if written information for patients (or parents of child patients) reduces the use of antibiotics for acute URTIs in primary care. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Web of Science, clinical trials.gov, and the World Health Organization (WHO) trials registry up to July 2016 without language or publication restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) involving patients (or parents of child patients) with acute URTIs, that compared written patient information delivered immediately before or during prescribing, with no information. RCTs needed to have measured our primary outcome (antibiotic use) to be included. DATA COLLECTION AND ANALYSIS: Two review authors screened studies, extracted data, and assessed study quality. We could not meta-analyse included studies due to significant methodological and statistical heterogeneity; we summarised the data narratively. MAIN RESULTS: Two RCTs met our inclusion criteria, involving a total of 827 participants. Both studies only recruited children with acute URTIs (adults were not involved in either study): 558 children from 61 general practices in England and Wales; and 269 primary care doctors who provided data on 33,792 patient-doctor consultations in Kentucky, USA. The UK study had a high risk of bias due to lack of blinding and the US cluster-randomised study had a high risk of bias because the methods to allocate participants to treatment groups was not clear, and there was evidence of baseline imbalance.In both studies, clinicians provided written information to parents of child patients during primary care consultations: one trained general practitioners (GPs) to discuss an eight-page booklet with parents; the other conducted a factorial trial with two comparison groups (written information compared to usual care and written information plus prescribing feedback to clinicians compared to prescribing feedback alone). Doctors in the written information arms received 25 copies of two-page government-sponsored pamphlets to distribute to parents.Compared to usual care, we found moderate quality evidence (one study) that written information significantly reduced the number of antibiotics used by patients (RR 0.53, 95% CI 0.35 to 0.80; absolute risk reduction (ARR) 20% (22% versus 42%)) and had no significant effect on reconsultation rates (RR 0.79, 95% CI 0.47 to 1.32), or parent satisfaction with consultation (RR 0.95, 95% CI 0.87 to 1.03). Low quality evidence (two studies) demonstrated that written information also reduced antibiotics prescribed by clinicians (RR 0.47, 95% CI 0.28 to 0.78; ARR 21% (20% versus 41%); and RR 0.84, 95% CI 0.81 to 0.86; 9% ARR (45% versus 54%)). Neither study measured resolution of symptoms, patient knowledge about antibiotics for acute URTIs, or complications for this comparison.Compared to prescribing feedback, we found low quality evidence that written information plus prescribing feedback significantly increased the number of antibiotics prescribed by clinicians (RR 1.13, 95% CI 1.09 to 1.17; absolute risk increase 6% (50% versus 44%)). Neither study measured reconsultation rate, resolution of symptoms, patient knowledge about antibiotics for acute URTIs, patient satisfaction with consultation or complications for this comparison. AUTHORS' CONCLUSIONS: Compared to usual care, moderate quality evidence from one study showed that trained GPs providing written information to parents of children with acute URTIs in primary care can reduce the number of antibiotics used by patients without any negative impact on reconsultation rates or parental satisfaction with consultation. Low quality evidence from two studies shows that, compared to usual care, GPs prescribe fewer antibiotics for acute URTIs but prescribe more antibiotics when written information is provided alongside prescribing feedback (compared to prescribing feedback alone). There was no evidence addressing resolution of patients' symptoms, patient knowledge about antibiotics for acute URTIs, or frequency of complications.To fill evidence gaps, future studies should consider testing written information on antibiotic use for adults with acute URTIs in high- and low-income settings provided without clinician training and presented in different formats (such as electronic). Future study designs should endeavour to ensure blinded outcome assessors. Study aims should include measurement of the effect of written information on the number of antibiotics used by patients and prescribed by clinicians, patient satisfaction, reconsultation, patients' knowledge about antibiotics, resolution of symptoms, and complications.


Assuntos
Antibacterianos/uso terapêutico , Prescrição Inadequada/prevenção & controle , Infecções Respiratórias/tratamento farmacológico , Doença Aguda , Criança , Medicina Geral , Humanos , Prescrição Inadequada/estatística & dados numéricos , Folhetos , Pais , Educação de Pacientes como Assunto/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Infecções Respiratórias/virologia , Viroses/tratamento farmacológico
19.
Int J Cardiol ; 177(1): 182-6, 2014 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-25499373

RESUMO

OBJECTIVES: The aim of this study is to compare a new improved point of care cardiac troponin assay (new POC-cTnI) with 1. its predecessor (old POC-cTnI) and 2. a high sensitivity assay (hs-cTnI) for the diagnosis of acute myocardial infarction (AMI) and for major adverse cardiac events (MACE) by 30 days. METHODS: This is a single centre observational study, set in Christchurch Hospital, New Zealand. Patients presenting to the emergency department with non-traumatic chest pain underwent blood sampling at 0 h and 2h post presentation for analysis with the 3 cTnI assays for the outcome of AMI and for analysis using an accelerated diagnostic protocol (ADP-normal 2h troponins, normal electrocardiograms and Thrombolysis In Myocardial Infarction (TIMI) score of 0 or ≤ 1) for 30 day MACE. RESULTS: Of 962 patients, 220 (22.9%) had AMI. Old POC-cTnI was least sensitive at 70.0% (65.4-73.9%) by 2h (p<0.001). New POC-cTnI, sensitivity 93.6% (89.9-96.2%) had similar sensitivity to hs-cTnI, sensitivity 95.0% (91.5-97.3%) (p = 0.508). There were 231 (24.0%) patients with 30 day MACE. When used as part of the ADP, all assays had 100% (98.0-100%) sensitivity using TIMI = 0. Sensitivities of new POC-cTnI ADP, 98.3% (95.4-99.4%), old POC-cTnI, 96.5% (93.2-98.4%) and hs-cTnI, 98.7% (96.0-99.7%) were similar (p = 0.063-0.375) using TIMI ≤ 1. CONCLUSIONS: A new POC-cTnI has improved sensitivity for AMI and MACE compared with its predecessor and comparable sensitivity to a high sensitivity assay. Now that sensitivities of the POC assay are improved, the new assay may be a useful alternative to central laboratory assays when rapid turn-around times are not possible.


Assuntos
Infarto do Miocárdio/diagnóstico , Sistemas Automatizados de Assistência Junto ao Leito , Troponina/sangue , Idoso , Biomarcadores/sangue , Diagnóstico Diferencial , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Prognóstico , Curva ROC , Reprodutibilidade dos Testes , Estudos Retrospectivos
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