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

PCSK9 inhibitors and ezetimibe for the reduction of cardiovascular events: a clinical practice guideline with risk-stratified recommendations.

CLINICAL QUESTION In adults with low density lipoprotein (LDL) cholesterol levels >1.8 mmol/L (>70 mg/dL) who are already taking the maximum dose of statins or are intolerant to statins, should another lipid-lowering drug be added, either a proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitor or ezetimibe, to reduce the risk of major cardiovascular events? If so, which drug is preferred? Having decided to use one, should we add the other lipid-lowering drug? CURRENT PRACTICE Most guidelines emphasise LDL cholesterol targets in their recommendations for prescribing PCSK9 inhibitors and/or ezetimibe in adults at high risk of experiencing a major adverse cardiovascular event. However, to achieve these goals in very high risk patients with statins alone is almost impossible, so physicians are increasingly considering other lipid-lowering drugs solely for achieving LDL cholesterol treatment goals rather than for achieving important absolute cardiovascular risk reduction. Most guidelines do not systematically assess the cardiovascular benefits of adding PCSK9 inhibitors and/or ezetimibe for all risk groups across primary and secondary prevention, nor do they report, in accordance with explicit judgments of assumed patients' values and preferences, absolute benefits and harms and potential treatment burdens. RECOMMENDATIONS The guideline panel provided mostly weak recommendations, which means we rely on shared decision making when applying these recommendations. For adults already using statins, the panel suggests adding a second lipid-lowering drug in people at very high and high cardiovascular risk but recommends against adding it in people at low cardiovascular risk. For adults who are intolerant to statins, the panel recommends using a lipid-lowering drug in people at very high and high cardiovascular risk but against adding it in those at low cardiovascular risk. When choosing to add another lipid-lowering drug, the panel suggests ezetimibe in preference to PCSK9 inhibitors. The panel suggests further adding a PCSK9 inhibitor to ezetimibe for adults already taking statins at very high risk and those at very high and high risk who are intolerant to statins. HOW THIS GUIDELINE WAS CREATED An international panel including patients, clinicians, and methodologists produced these recommendations following standards for trustworthy guidelines and using the GRADE approach. The panel identified four risk groups of patients (low, moderate, high, and very high cardiovascular risk) and primarily applied an individual patient perspective in moving from evidence to recommendations, though societal issues were a secondary consideration. The panel considered the balance of benefits and harms and burdens of starting a PCSK9 inhibitor and/or ezetimibe, making assumptions of adults' average values and preferences. Interactive evidence summaries and decision aids accompany multi-layered recommendations, developed in an online authoring and publication platform (www.magicapp.org) that also allows re-use and adaptation. THE EVIDENCE A linked systematic review and network meta-analysis (14 trials including 83 660 participants) of benefits found that PCSK9 inhibitors or ezetimibe probably reduce myocardial infarctions and stroke in patients with very high and high cardiovascular risk, with no impact on mortality (moderate to high certainty evidence), but not in those with moderate and low cardiovascular risk. PCSK9 inhibitors may have similar effects to ezetimibe on reducing non-fatal myocardial infarction or stroke (low certainty evidence). These relative benefits were consistent, but their absolute magnitude varied based on cardiovascular risk in individual patients (for example, for 1000 people treated with PCSK9 inhibitors in addition to statins over five years, benefits ranged from 2 fewer strokes in the lowest risk to 21 fewer in the highest risk). Two systematic reviews on harms found no important adverse events for these drugs (moderate to high certainty evidence). PCSK9 inhibitors require injections that sometimes result in injection site reactions (best estimate 15 more per 1000 in a 5 year timeframe), representing a burden and harm that may matter to patients. The MATCH-IT decision support tool allows you to interact with the evidence and your patients across the alternative options: https://magicevidence.org/match-it/220504dist-lipid-lowering-drugs/. UNDERSTANDING THE RECOMMENDATIONS The stratification into four cardiovascular risk groups means that, to use the recommendations, physicians need to identify their patient's risk first. We therefore suggest, specific to various geographical regions, using some reliable risk calculators that estimate patients' cardiovascular risk based on a mix of known risk factors. The largely weak recommendations concerning the addition of ezetimibe or PCSK9 inhibitors reflect what the panel considered to be a close balance between small reductions in stroke and myocardial infarctions weighed against the burdens and limited harms.Because of the anticipated large variability of patients' values and preferences, well informed choices warrant shared decision making. Interactive evidence summaries and decision aids linked to the recommendations can facilitate such shared decisions. The strong recommendations against adding another drug in people at low cardiovascular risk reflect what the panel considered to be a burden without important benefits. The strong recommendation for adding either ezetimibe or PCSK9 inhibitors in people at high and very high cardiovascular risk reflect a clear benefit.The panel recognised the key uncertainty in the evidence concerning patient values and preferences, namely that what most people consider important reductions in cardiovascular risks, weighed against burdens and harms, remains unclear. Finally, availability and costs will influence decisions when healthcare systems, clinicians, or people consider adding ezetimibe or PCSK9 inhibitors

Innovative teaching methods for capacity building in knowledge translation

Abstract Background In some current healthcare settings, there is a noticeable absence of national institutions committed to the synthesis and use of evidence in healthcare decision- and policy-making. This absence creates a need to broaden the responsibilities of healthcare providers to include knowledge brokering and advocacy in order to optimize knowledge translation to other stakeholders, especially policy-makers. However, this process requires practitioners and researchers to acquire certain types of knowledge and skills. This article introduces two innovative methods for capacity building in knowledge translation (KT). Methods During a workshop aimed at preparing 21 trainers in evidence-based medicine, two innovative methods were used: (1) debate and (2) a knowledge translation project (KTP). The main objective of the debates approach was to strengthen participants' critical thinking abilities by requiring them to search for and appraise evidence and defend their arguments. The KTP was used to introduce participants to the essential steps of knowledge translation and to suggest an extended role for healthcare practitioners, i.e., using evidence to manage not only individual patients but also to a community of patients. Participants' performances were assessed according to a pre-designed scheme. At the end of the workshop, participants' opinions and experiences with the innovative teaching methods were evaluated based on their answers to a questionnaire and the results of small-group discussions. Results The participants performed well in both the debate and KTP methods. During post-workshop group discussions, they indicated that the debate approach had added a new dimension to their evidence-based medicine skills by adding purpose and motivation. However, they felt that their performances would have been better if they had been offered practical demonstrations of how to conduct the debate. The participants indicated that the KTP enhanced their understanding of the relationships between evidence and implementation, and motivated them to investigate public health problems in addition to individual patient problems. However, some participants maintained that these issues fell outside the scope of their role as doctors. Conclusion Debates and evidence implementation through KTP are generally well accepted by healthcare practitioners as methods by which they can improve their skills in KT.</p

Family violence among female medical students: Its prevalence and impact on their mental health status – A cross-sectional study

AbstractObjectivesViolence against women is recognized worldwide as a major public health problem. Studies show that violence affects the mental well-being of the victims. The study explores the prevalence of family violence among Saudi female medical students and its relationship with students' mental well-being and seeks to identify the effect of violence on students' academic achievements.MethodsThis was a cross-sectional study on 1st- to 5th-year Saudi female medical students, utilizing a validated violence screening questionnaire that asked the respondents about how often they were physically Hurt, Insulted, Threatened with harm, and Screamed at (HITS). Furthermore, the study administered a validated mental well-being questionnaire, the Mental Health Inventory 5 (MHI-5), for the assessment of the mental status of the respondents. The analyses included simple univariate analyses, bivariate analyses and linear regression modelling.ResultsOf the total of 460 Saudi female medical students, 363 (79%) students participated in this study. Nineteen (5.3%) students confirmed being the victims of family violence. The victims had a mean MHI-5 score of 52%. A negative correlation was observed between violence and mental well-being scores. Significant association between the MHI-5 score and academic achievement was observed.ConclusionThe prevalence of family violence in this study is less than the reported figures in other studies. We could not demonstrate a direct relationship between family violence and academic achievement. Students' academic achievement was indirectly associated with the presence of family violence through changes in mental well-being

Evidence-Based Decision Making in Public Health: Capacity Building for Public Health Students at King Saud University in Riyadh

Translation of research evidence into public health programs is lagging in Eastern Mediterranean Region. Graduate level public health curriculum at King Saud University (KSU), College of Medicine, Riyadh, is designed to equip students to integrate best available evidence in public health decision making. The objectives of study were to explore students’ opinion about the evidence based public health (EBPH) courses and to survey the knowledge, opinion, and attitude of the students towards EBPH and perceived barriers for implementation of EBPH in decision making in public health. EBPH courses are designed based on a sequential framework. A survey was conducted at the completion of EBPH courses. Forty-five graduate students were invited to complete a validated self-administered questionnaire. It included questions about demography, opinion, and attitude towards EBPH and perceived barriers towards implementation of EBPH in the work environment. The response rate was 73%. Mean age of students was 30.1 (SD 2.3) years, and 51% were males. More than 80% had sound knowledge and could appreciate the importance of EBPH. The main perceived barriers to incorporate EBPH in decision making were lack of system of communication between researchers and policy makers and scarcity of research publications related to the public health problems

Vacunas para la prevención de la gripe en personas de edad avanzada

Antecedentes: Durante las últimas cuatro décadas, las vacunas han sido la principal arma global para disminuir la repercusión de la gripe en las personas de edad avanzada, y a nivel mundial se recomiendan para los individuos de 65 años o más de edad. El objetivo principal de la vacunación contra la gripe en las personas de edad avanzada es reducir el riesgo de complicaciones en quienes son más vulnerables. Objetivos: Evaluar la efectividad de las vacunas sobre la prevención de la gripe, la enfermedad similar a la gripe, los ingresos hospitalarios, las complicaciones y la mortalidad en las personas de edad avanzada. Identificar y evaluar los estudios comparativos que evalúan los efectos de las vacunas para la gripe en las personas de edad avanzada. Documentar los tipos y la frecuencia de los efectos adversos asociados con las vacunas contra la gripe en las personas de edad avanzada. Estrategia de búsqueda: Se realizaron búsquedas en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL), que contiene el Registro Especializado de Ensayos Controlados del Grupo Cochrane de Infecciones Respiratorias Agudas (Cochrane Acute Respiratory Infections [ARI]) (The Cochrane Library número 4 de 2009), MEDLINE (enero de 1966 hasta la primera semana de octubre de 2009); EMBASE (1974 hasta octubre de 2009) y Web of Science (1974 hasta octubre de 2009). Criterios de selección: Ensayos controlados aleatorios (ECAs), ensayos controlados cuasialeatorios, estudios de cohortes y estudios de casos y controles que evalúan la eficacia contra la gripe (casos confirmados por laboratorio), la efectividad contra la enfermedad similar a la gripe (ESG) o la seguridad. Se consideró cualquier vacuna administrada de forma independiente, en cualquier dosis, preparación o cronograma de administración, comparada con placebo o ninguna intervención. Obtención y análisis de los datos: Los informes se agruparon en primer lugar según el contexto del estudio (comunidad o establecimientos de atención a largo plazo) y luego por el nivel de circulación vírica y de pareamiento de la vacuna. Se estratificó adicionalmente por la administración concomitante de la vacuna de polisacárido antineumocócico (PPV) y por diferentes tipos de vacunas contra la gripe. Se analizaron los siguientes resultados: gripe, enfermedad similar a la gripe, ingresos hospitalarios, complicaciones y muertes. Resultados principales: Se incluyeron 75 estudios. En general se identificaron 100 conjuntos de datos. Se identificó un ECA que evaluó la eficacia y la efectividad. Aunque el mismo pareció mostrar un efecto contra los síntomas de la gripe no tuvo poder estadístico suficiente para detectar efectos sobre las complicaciones (1348 participantes). La base de pruebas restante incluyó ensayos controlados no aleatorios. Debido a la baja calidad general de los ensayos controlados no aleatorios y la probable presencia de sesgos, que dificultan la interpretación de estos datos y hacen que cualquier conclusión sólida se torne potencialmente engañosa, no fue posible establecer conclusiones claras acerca de los efectos de las vacunas en las personas de edad avanzada. Conclusiones de los autores: Las pruebas disponibles son de calidad deficiente y no proporcionan orientación con respecto a la seguridad, la eficacia o la efectividad de las vacunas contra la gripe en las personas de 65 años de edad o más. Para resolver la incertidumbre se debe realizar un ensayo aleatorio controlado con placebo, con financiamiento público y con poder estadístico adecuado, durante varias estaciones

A validation study comparing the sensitivity and specificity of the new Dr. KSU H1N1 RT-PCR kit with real-time RT-PCR for diagnosing influenza A (H1N1)

<b>Background and Objectives:</b> A new test (Dr. KSU H1N1 RT-PCR kit) was recently developed to provide a less expensive alternative to real-time reverse transcriptase-polymerase chain reaction (RT-PCR). We report the findings of a validation study designed to assess the diagnostic accuracy, including sensitivity and specificity, of the new kit, as compared to real-time RT-PCR. <b>Design and Setting:</b> Cross-sectional validation study conducted from 18-22 November 2009 at a primary care clinic for H1N1 at a tertiary care teaching hospital in Riyadh. <b>Patients and Methods:</b> Nasopharyngeal swab samples and data on socio-demographic characteristics and symptoms were collected from 186 patients. Swab samples were sent to the laboratory for testing with both real-time RT-PCR and the new Dr. KSU H1N1 RT-PCR kit. We measured the sensitivity and specificity of the new test across the entire sample size and investigated how these values were affected by patient socio-demographic characteristics and symptoms. <b>Results</b>: The outcomes of the two tests were highly correlated (kappa=0.85; <i>P</i>&lt;.0001). The sensitivity and specificity of the new test were 99.11&#x0025; and 83.78&#x0025;, respectively. The sensitivity of the new test was affected only minimally (96&#x0025;-100&#x0025;) by patient characteristics and number of symptoms. On the other hand, the specificity of the new test varied depending on how soon patients were tested after onset of symptoms (100&#x0025; specificity when swabs were taken on the first day of the symptoms, decreasing to 75&#x0025; when swabs were taken on or after the third day). The specificity of the new test also increased with increasing body temperature. <b>Conclusion:</b> The new test seems to provide a cost-effective alternative to real-time RT-PCR for diagnosing H1N1 influenza. However, further testing may be needed to verify the efficacy of the test in different settings and communities

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