Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review

Objective To review systematically the evidence of effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses

A systematic review of recent clinical practice guidelines on the diagnosis, assessment and management of hypertension.

BACKGROUND: Despite the availability of clinical practice guidelines (CPGs), optimal hypertension control is not achieved in many parts of the world; one of the challenges is the volume of guidelines on this topic and their variable quality. To systematically review the quality, methodology, and consistency of recommendations of recently-developed national CPGs on the diagnosis, assessment and the management of hypertension. METHODOLOGY/PRINCIPAL FINDINGS: MEDLINE, EMBASE, guidelines' websites and Google were searched for CPGs written in English on the general management of hypertension in any clinical setting published between January 2006 and September 2011. Four raters independently appraised each CPG using the AGREE-II instrument and 2 reviewers independently extracted the data. Conflicts were resolved by discussion or the involvement of an additional reviewer. Eleven CPGs were identified. The overall quality ranged from 2.5 to 6 out of 7 on the AGREE-II tool. The highest scores were for "clarity of presentation" (44.4%-88.9%) and the lowest were for "rigour of development" (8.3%-30% for 9 CGPs). None of them clearly reported being newly developed or adapted. Only one reported having a patient representative in its development team. Systematic reviews were not consistently used and only 2 up-to-date Cochrane reviews were cited. Two CPGs graded some recommendations and related that to levels (but not quality) of evidence. The CPGs' recommendations on assessment and non-pharmacological management were fairly consistent. Guidelines varied in the selection of first-line treatment, adjustment of therapy and drug combinations. Important specific aspects of care (e.g. resistant hypertension) were ignored by 6/11 CPGs. The CPGs varied in methodological quality, suggesting that their implementation might not result in less variation of care or in better health-related outcomes. CONCLUSIONS/SIGNIFICANCE: More efforts are needed to promote the realistic approach of localization or local adaptation of existing high-quality CPGs to the national context

Preconception care for diabetic women for improving maternal and fetal outcomes : a systematic review and meta-analysis

Background Preexisting diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. Despite improvement in the access and quality of antenatal care recent population based studies demonstrating increased congenital abnormalities and perinatal mortality in diabetic mothers as compared to the background population. This systematic review was carried out to evaluate the effectiveness and safety of preconception care in improving maternal and fetal outcomes for women with preexisting diabetes mellitus. Methods We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINAHL up to December 2009, without language restriction, for any preconception care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women of reproductive age group with type I or type II diabetes. Study design were trials (randomized and non-randomized), cohort and case-control studies. Of the 1612 title scanned 44 full papers were retrieved of those 24 were included in this review. Twelve cohort studies at low and medium risk of bias, with 2502 women, were included in the meta-analysis. Results Meta-analysis suggested that preconception care is effective in reducing congenital malformation, RR 0.25 (95% CI 0.15-0.42), NNT17 (95% CI 14-24), preterm delivery, RR 0.70 (95% CI 0.55-0.90), NNT = 8 (95% CI 5-23) and perinatal mortality RR 0.35 (95% CI 0.15-0.82), NNT = 32 (95% CI 19-109). Preconception care lowers HbA1c in the first trimester of pregnancy by an average of 2.43% (95% CI 2.27-2.58). Women who received preconception care booked earlier for antenatal care by an average of 1.32 weeks (95% CI 1.23-1.40). Conclusion Preconception care is effective in reducing diabetes related congenital malformations, preterm delivery and maternal hyperglycemia in the first trimester of pregnancy

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND: Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID‐19) caused by SARS‐CoV‐2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review published in 2007, 2009, 2010, and 2011. The evidence summarised in this review does not include results from studies from the current COVID‐19 pandemic. OBJECTIVES: To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses. SEARCH METHODS: We searched CENTRAL, PubMed, Embase, CINAHL on 1 April 2020. We searched ClinicalTrials.gov, and the WHO ICTRP on 16 March 2020. We conducted a backwards and forwards citation analysis on the newly included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and cluster‐RCTs of trials investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, and gargling) to prevent respiratory virus transmission. In previous versions of this review we also included observational studies. However, for this update, there were sufficient RCTs to address our study aims.   DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Three pairs of review authors independently extracted data using a standard template applied in previous versions of this review, but which was revised to reflect our focus on RCTs and cluster‐RCTs for this update. We did not contact trialists for missing data due to the urgency in completing the review. We extracted data on adverse events (harms) associated with the interventions. MAIN RESULTS: We included 44 new RCTs and cluster‐RCTs in this update, bringing the total number of randomised trials to 67. There were no included studies conducted during the COVID‐19 pandemic. Six ongoing studies were identified, of which three evaluating masks are being conducted concurrent with the COVID pandemic, and one is completed. Many studies were conducted during non‐epidemic influenza periods, but several studies were conducted during the global H1N1 influenza pandemic in 2009, and others in epidemic influenza seasons up to 2016. Thus, studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID‐19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high‐income countries; crowded inner city settings in low‐income countries; and an immigrant neighbourhood in a high‐income country. Compliance with interventions was low in many studies. The risk of bias for the RCTs and cluster‐RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included nine trials (of which eight were cluster‐RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and seven in the community). There is low certainty evidence from nine trials (3507 participants) that wearing a mask may make little or no difference to the outcome of influenza‐like illness (ILI) compared to not wearing a mask (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.82 to 1.18. There is moderate certainty evidence that wearing a mask probably makes little or no difference to the outcome of laboratory‐confirmed influenza compared to not wearing a mask (RR 0.91, 95% CI 0.66 to 1.26; 6 trials; 3005 participants). Harms were rarely measured and poorly reported. Two studies during COVID‐19 plan to recruit a total of 72,000 people. One evaluates medical/surgical masks (N = 6000) (published Annals of Internal Medicine, 18 Nov 2020), and one evaluates cloth masks (N = 66,000). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). There is uncertainty over the effects of N95/P2 respirators when compared with medical/surgical masks on the outcomes of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; very low‐certainty evidence; 3 trials; 7779 participants) and ILI (RR 0.82, 95% CI 0.66 to 1.03; low‐certainty evidence; 5 trials; 8407 participants). The evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirator compared to a medical/surgical mask probably makes little or no difference for the objective and more precise outcome of laboratory‐confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; moderate‐certainty evidence; 5 trials; 8407 participants). Restricting the pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies. One ongoing study recruiting 576 people compares N95/P2 respirators with medical surgical masks for healthcare workers during COVID‐19. Hand hygiene compared to control Settings included schools, childcare centres, homes, and offices. In a comparison of hand hygiene interventions with control (no intervention), there was a 16% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.84, 95% CI 0.82 to 0.86; 7 trials; 44,129 participants; moderate‐certainty evidence), suggesting a probable benefit. When considering the more strictly defined outcomes of ILI and laboratory‐confirmed influenza, the estimates of effect for ILI (RR 0.98, 95% CI 0.85 to 1.13; 10 trials; 32,641 participants; low‐certainty evidence) and laboratory‐confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials; 8332 participants; low‐certainty evidence) suggest the intervention made little or no difference. We pooled all 16 trials (61,372 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. The pooled data showed that hand hygiene may offer a benefit with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.84 to 0.95; low‐certainty evidence), but with high heterogeneity. Few trials measured and reported harms. There are two ongoing studies of handwashing interventions in 395 children outside of COVID‐19. We identified one RCT on quarantine/physical distancing. Company employees in Japan were asked to stay at home if household members had ILI symptoms. Overall fewer people in the intervention group contracted influenza compared with workers in the control group (2.75% versus 3.18%; hazard ratio 0.80, 95% CI 0.66 to 0.97). However, those who stayed at home with their infected family members were 2.17 times more likely to be infected. We found no RCTs on eye protection, gowns and gloves, or screening at entry ports. AUTHORS' CONCLUSIONS: The high risk of bias in the trials, variation in outcome measurement, and relatively low compliance with the interventions during the studies hamper drawing firm conclusions and generalising the findings to the current COVID‐19 pandemic. There is uncertainty about the effects of face masks. The low‐moderate certainty of the evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of randomised trials did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks during seasonal influenza. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness. Harms associated with physical interventions were under‐investigated. There is a need for large, well‐designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, especially in those most at risk of ARIs.

Quality of the 11 Hypertension Clinical Practice Guidelines for the six domains of the AGREE-II Instrument (D1–D6) and the Overall Impression of the 4 Assessors.

<p>D1 : Scope & purpose, D2: Stakeholder involvement, D3: Rigor of involvement, D4: Clarity of presentation, D5: Applicability, D6: editorial independence.</p><p>All the 23 items of the AGREE-II instrument are rated on a 7-point scale where a score of 1 is given when there is no information that is relevant to the item or if the concept is very poorly reported; a score of 7 is given if the quality of reporting is exceptional and where the full criteria and considerations articulated in the AGREE-II User's Manual have been met; and a score between 2 and 6 is assigned when the reporting of the AGREE II item does not meet the full criteria or considerations. Scores increase as more criteria are met and considerations addressed. In other words, the higher the score, the better the quality of the CPG item.</p><p>SOA: South Africa; IND: India; POL: Poland; MAL: Malaysia; EUR: Europe; JAP: Japan; LAT: Latin America; AUS: Australia; CAN: Canada; SAU: Saudi Arabia and NICE: UK's National Institute for Health and Clinical Excellence).</p>*<p>Although the scoring is done in integers, the numbers in this column represent the averages of the scoring done by 4 assessors.</p>**<p>Risk of bias: +++ high, ++ intermediate, + low.</p>***<p>This is based on the subjective assessment made individually by each of the 4 assessors in response to: “Do you recommend this CPG for use?”</p

Recommendations from Clinical Practice Guidelines About Diagnosis and Assessment of Patients with Hypertension.

<p>NR: Not reported, √: Recommended, ×: Not Recommended; SOA: South Africa; IND: India; POL: Poland; MAL: Malaysia; EUR: Europe; JAP: Japan; LAT: Latin America; AUS: Australia; CAN: Canada; SAU: Saudi Arabia and NICE (The UK's National Institute for Health and Clinical Excellence).</p>$<p>not endorsed by NICE. ABI: ankle-brachial index ECD: Echo Carotid Doppler, RAU: Renal artery duplex ultrasound.</p

Domain Scores (%) for the 11 Clinical Practice Guidelines Using the AGREE-II Instrument.

<p>SOA: South Africa; IND: India; POL: Poland; MAL: Malaysia; EUR: Europe; JAP: Japan; LAT: Latin America; AUS: Australia; CAN: Canada; SAU: Saudi Arabia and NICE: UK's National Institute for Health and Clinical Excellence.</p

Recommendations from Clinical Practice Guidelines about Managing Patients with Hypertension.

<p>SOA: South Africa; IND: India; POL: Poland; MAL: Malaysia; EUR: Europe; JAP: Japan; LAT: Latin America; AUS: Australia; CAN: Canada and SAU: Saudi Arabia and NICE (The UK's National Institute for Health and Clinical Excellence). NR: not reported. A: angiotensin converting enzyme inhibitor (ACEI), or angiotensin receptor blockers (ARB), C: calcium channel blocker (CCB), D: Diuretic.</p>1<p>And if SBP>150 and or DBP>95- treat.</p>2<p>If the SBP> or  = 140 mm Hg or DBP> or  = 90 mm Hg across 5 visits.</p>3<p>if SBP = 120–159 mmHg AND/OR DBP = 80–99 mmHg.</p>4<p>If, at visit 2 within one month, SBP is > or  = 140 mm Hg and/or DBP is > or  = 90 mm Hg.</p>5<p>If SBP = 120–159 mmHg AND/OR DBP = 80–99 mmHg with high risk or if SBP 160 mmHg AND/OR DBP 100 mmHg regardless of risk.</p>6<p>NICE CPG favored A for those below 55 years and C, D, for those aged 55 years or older and for black patients.</p>7<p>Yes if SBP>10 mmHg above target.</p>8<p>Recommended in at least certain high risk groups.</p>9<p>Recommended for those with atherosclerotic renal artery stenosis only.</p>10<p>No target level stated.</p>11<p>A1c<6.5 mmol/L.</p>12<p>A1c between 6.5–7% in patients with HTN, DM and nephropathy.</p>13<p>Referred to previous guideline version.</p>14<p>Every 3–6 months;</p>15<p>Every 3 months for high risk patients and every 6 months for low risk patients;</p>16<p>Every 3 months for the first year then 6-monthly thereafter;</p>17<p>Once a year.</p>18<p>For pheochromocytoma cases only.</p

Flow chart using the PRISMA statement for the systematic review.

<p>Flow chart using the PRISMA statement for the systematic review.</p