Lessons from contemporary trials of cardiovascular prevention and rehabilitation: A systematic review and meta-analysis

Background: Meta-analyses of cardiac rehabilitation trials up to 2010 showed a significant reduction in all-cause mortality but many of these trials were conducted before the modern management of acute coronary syndromes. Methods: We undertook a meta-analysis of contemporary randomised controlled trials published in the period 2010 to 2015, including patients with other forms of atherosclerotic cardiovascular disease, to investigate the impact of cardiovascular prevention and rehabilitation on hard outcomes including survival. Results: 18 trials randomising 7691 patients to cardiovascular prevention and rehabilitation or usual care were selected. All-cause mortality was not reduced (RR 1.00, 95% CI 0.88 to 1.14), but cardiovascular mortality was by 58% (95% CI 0.21, 0.88). Myocardial infarction was also reduced by 30% (95% CI 0.54, 0.91) and cerebrovascular events by 60% (95% CI 0.22, 0.74). Comprehensive programmes managing six or more risk factors reduced all-cause mortality in a subgroup analysis (RR 0.63, 95% CI 0.43, 0.93) but those managing less did not. In the three programmes that prescribed and monitored cardioprotective medications for blood pressure and lipids all-cause mortality was also reduced (RR 0.35, 95% CI 0.18, 0.70). Conclusions: Comprehensive prevention and rehabilitation programmes managing six or more risk factors, and those prescribing and monitoring medications within programmes to lower blood pressure and lipids, continue to reduce all-cause mortality. In addition, these comprehensive programmes not only reduced cardiovascular mortality and myocardial infarction but also, for the first time, cerebrovascular events, and all these outcomes across a broader spectrum of patients with atherosclerotic disease

Medical students’ perception of general practice:a cross-sectional survey

Background: An increase in the demand for general practitioners is expected in many countries, but only a minority of medical students consider a career in general practice. More detailed and up-to-date knowledge about medical student’s perception of general practice would be helpful for efforts to encourage medical students to consider a career in general practice. Methods: We performed a cross-sectional single center survey among Dutch medical students to evaluate their perception of general practice at three different stages in their study: Ba1: first-year bachelor students; Ba3: third-year bachelor students; Ma3: third-year master students. The impact of different factors on their attitudes and perceptions was quantified. A multivariate logistic regression was performed with ‘interest in general practice’ as the outcome variable. Results: The median age for Ba1 was 18 (IQR: 18–19) and 71.5% were female, for Ba3 the median age was 20 (IQR: 20–21) and 70.6% were female and for Ma3 the median age was 25 years (IQR: 24–26) and 73.3% were female. On average, 31.2% of the respondents had a migration background. The mean response rate for this study was 77.1%. Of the participating Ba1 students (n = 340) only 22.4% considered working as a GP after medical school; for Ba3 students (n = 231) this percentage was 33.8%, and for Ma3 students (n = 210) it was significantly higher at 70.5%; in the final multivariate model this corresponded to an odds ratio (OR) of 4.3 (95%-CI:2.6–6.9) compared to Ba1 students. The strongest predictor in the final model was the opinion that general practice provides a pleasant working environment (OR 9.5; 95%-CI: 6.2–14.5). Conclusion: This study showed that multiple factors are significantly related to medical students’ interest in general practice. Although students believed that general practice does not have a high status within the medical profession, they acknowledged the social importance and the pleasant working environment of general practice. Knowledge obtained in this study can be used when designing a medical curriculum or a general practice course.</p

Different potencies of topical corticosteroids for a better treatment strategy in children with atopic dermatitis (The Rotterdam Eczema study): Protocol for an observational cohort study with an embedded randomised open-label controlled trial

Introduction Topical corticosteroids (TCS) of different potencies are the main treatment to control atopic dermatitis (AD). The Dutch guideline on AD for general practitioners (GPs) recommends a stepwise approach in which treatment steps are tailored to the severity of the disease, starting with the lowest possible potency of TCS. However, it remains unclear whether the recommended stepwise approach is most efficient. This randomised open-label controlled trial aims to determine whether a potent TCS is more effective than a low-potency TCS in the initial treatment of children with a moderate flare-up of AD in primary care. In the observational cohort, the overall aim is to determine the frequency, burden and determinants of flare-ups of AD during follow-up. Methods and analysis The study is an observational cohort study with an embedded pragmatic randomised controlled, open-label trial. Eligible are patients diagnosed with AD (aged 12 weeks to 18 years) who visited the GP for AD or received repeated prescriptions for AD in the previous 12 months; follow-up of the cohort is 1 year. Children are enrolled in the trial if they have a flare-up of AD during follow-up in the cohort. Eligible children are randomised to the intervention group (with a potent TCS once daily) or to the GP guideline group (with a low potency TCS once daily). Primary outcome is the difference in average subjective disease severity over 24 weeks follow-up in the trial, measured with the patient-oriented eczema measure. As secondary outcome, the Eczema Area and Severity Index is measured. Ethics and dissemination This study tests the hypothesis that immediate treatment with a potent TCS during a flare-up of AD leads to faster and more efficacious results as compared with starting with a TCS with low potency with less overall use of TCS. The study protocol is approved by the Medical Ethics Committee (MEC) of the Erasmus Medical Center Rotterdam, the Netherlands (MEC-2017-328). The results of the study will be published in international peer-reviewed journals and presented at national and international conferences. Trial registration number NTR: 6679; Pre-results

Report from the fifth international consensus meeting to harmonize core outcome measures for atopic eczema/dermatitis clinical trials (HOME initiative)

This is the report from the fifth meeting of the Harmonising Outcome Measures for Eczema initiative (HOME V). The meeting was held on 12–14 June 2017 in Nantes, France, with 81 participants. The main aims of the meeting were (i) to achieve consensus over the definition of the core domain of long-term control and how to measure it and (ii) to prioritize future areas of research for the measurement of the core domain of quality of life (QoL) in children. Moderated whole-group and small-group consensus discussions were informed by presentations of qualitative studies, systematic reviews and validation studies. Small-group allocations were performed a priori to ensure that each group included different stakeholders from a variety of geographical regions. Anonymous whole-group voting was carried out using handheld electronic voting pads according to predefined consensus rules. It was agreed by consensus that the long-term control domain should include signs, symptoms, quality of life and a patient global instrument. The group agreed that itch intensity should be measured when assessing long-term control of eczema in addition to the frequency of itch captured by the symptoms domain. There was no recommendation of an instrument for the core outcome domain of quality of life in children, but existing instruments were assessed for face validity and feasibility, and future work that will facilitate the recommendation of an instrument was agreed upon. The Harmonising Outcome Measures for Eczema (HOME) initiative is an international group working together to develop a core outcome set (COS) for clinical trials in eczema (synonymous with atopic eczema and atopic dermatitis). HOME is coordinated from the Centre of Evidence Based Dermatology, University of Nottingham, U.K. Participation in HOME is open to anyone with an interest in outcomes for eczema. A COS is the agreed upon minimum set of instruments that should be included in all clinical trials for a particular condition. Use of a COS does not preclude using other instruments; other domains and instruments can also be included to meet the specific requirements of individual trials. COS initiatives are active across many fields of medicine and should enable better synthesis of trial data and reduce selective outcome reporting bias. The HOME initiative follows the best current guidance on developing a COS. Four core domains have been identified: clinician-reported signs; patient-reported symptoms; quality of life; and long-term control. The core outcome measurement instruments for clinician-reported signs and patient-reported symptoms have been established: the Eczema Area and Severity Index (EASI) for measuring clinician reported signs was agreed on at the HOME III meeting, and the Patient-Oriented Eczema Measure (POEM) was chosen to measure patient-reported symptoms at the HOME IV meeting. This is a report from the fifth consensus meeting of the HOME initiative (HOME V), which was held on 12–14 June 2017 in Nantes, France. The local organizers were Sebastien Barbarot and Jean-Francois Stalder of Nantes University Hospital, France