Assessing heterogeneity of effects on blood pressure in a meta-analysis of pharmacist interventions trials

Background: Recent reviews of randomized control trials have shown that pharmacist interventions improve cardiovascular diseases (CVD) risk factors in outpatients. Various interventions were evaluated in different settings, and a substantial heterogeneity was observed in the effect estimates. To better express uncertainties in the effect estimates, prediction intervals (PI) have been proposed but are, however, rarely reported. Objective: Pooling data from two systematic reviews, we estimated the effect of pharmacist interventions on systolic blood pressure (BP), computed PI, and evaluated potential causes of heterogeneity. Methods: Data were pooled from systematic reviews assessing the effect of pharmacist interventions on CVD risk factors in patients with or without diabetes, respectively. Effects were estimated using random effect models. Results: Systolic BP was the outcome in 31 trials including 12 373 patients. Pharmacist interventions included patient educational interventions, patient-reminder systems, measurement of BP, medication management and feedback to physician, or educational intervention to health care professionals. Pharmacist interventions were associated with a large reduction in systolic BP (-7.5 mmHg; 95% CI: -9.0 to -5.9). There was a substantial heterogeneity (I2: 66%). The 95% PI ranged from -13.9 to -1.0 mmHg. The effect tended to be larger if the intervention was conducted in a community pharmacy and if the pharmacist intervened at least monthly. Conclusion: On average, the effect of pharmacist interventions on BP was substantial. However, the wide PI suggests that the effect differed between interventions, with some having modest effects and others very large effects on BP. Part of the heterogeneity could be due to differences in the setting and in the frequency of the interventions.

Dépistage et prévention chez les aînés: quelles interventions proposer, à qui, et jusqu'à quel âge [Screening and prevention in the elderly: which interventions should be proposed, to whom, and up to what age?].

Recommendations on preventive services rarely mention how to apply them to older people. Even though general criteria (prevalence of disease, quality of screening tests) that influence screening's efficacy remain important, appropriateness of screening in older persons depends much more on individual criteria, such as comorbidity, functional status, and life expectancy. More than with any other age group, patients preferences regarding future investigation and treatment guide the clinical decision. This article focuses on primary and secondary prevention, and discusses specific criteria to consider in each patient. A table summarizes the appropriate recommendations.

Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials.

BACKGROUND: Control of blood pressure (BP) remains a major challenge in primary care. Innovative interventions to improve BP control are therefore needed. By updating and combining data from 2 previous systematic reviews, we assess the effect of pharmacist interventions on BP and identify potential determinants of heterogeneity. METHODS AND RESULTS: Randomized controlled trials (RCTs) assessing the effect of pharmacist interventions on BP among outpatients with or without diabetes were identified from MEDLINE, EMBASE, CINAHL, and CENTRAL databases. Weighted mean differences in BP were estimated using random effect models. Prediction intervals (PI) were computed to better express uncertainties in the effect estimates. Thirty-nine RCTs were included with 14 224 patients. Pharmacist interventions mainly included patient education, feedback to physician, and medication management. Compared with usual care, pharmacist interventions showed greater reduction in systolic BP (-7.6 mm Hg, 95% CI: -9.0 to -6.3; I(2)=67%) and diastolic BP (-3.9 mm Hg, 95% CI: -5.1 to -2.8; I(2)=83%). The 95% PI ranged from -13.9 to -1.4 mm Hg for systolic BP and from -9.9 to +2.0 mm Hg for diastolic BP. The effect tended to be larger if the intervention was led by the pharmacist and was done at least monthly. CONCLUSIONS: Pharmacist interventions - alone or in collaboration with other healthcare professionals - improved BP management. Nevertheless, pharmacist interventions had differential effects on BP, from very large to modest or no effect; and determinants of heterogeneity could not be identified. Determining the most efficient, cost-effective, and least time-consuming intervention should be addressed with further research.

Vaccine and immunotherapeutic interventions.

PURPOSE OF REVIEW: As we enter the fourth decade in HIV epidemic, advances in understanding HIV pathogenesis and development of potent and safer antiretroviral drugs have been spectacular. More than 30 antiviral drugs have been registered and the impact of combination antiviral therapy on morbidity and mortality has been dramatic. However, despite long-term virus suppression, HIV invariably rebounds after interruption of therapy. Long-term antiviral therapy does not cure HIV infection nor does it induce restoration/development of virus-specific immune responses capable of controlling HIV replication. Therefore, development of immune-based interventions is needed to restore effective defenses that can lead to HIV functional cure and ultimately eradication. RECENT FINDINGS: Therapeutic vaccination and immune interventions that generate de-novo or that boost preexisting HIV-specific T-cell responses are being investigated as a potential means to achieve a 'functional HIV cure'. One major hurdle in the quest of an HIV cure is control and elimination of the HIV latent reservoir. Several immune interventions that target the latent reservoir have been tried in recent years. In parallel, several therapeutic vaccination strategies have been developed and tested in early clinical studies. Recent encouraging studies show for the first time that vaccination can have an impact on HIV load. SUMMARY: This review summarizes the main immune interventions evaluated over the last years. Ways to improve them, as well as challenges in monitoring/evaluating effects of such strategies, are being discussed. In addition, clinical efficacy and potential clinical benefits of immunotherapeutic interventions are particularly difficult to measure. This review highlights current assays used and their shortcoming.

Nursing care mapping for patients at risk of falls in the Nursing Interventions Classification

Objective: Identifying the prescribed nursing care for hospitalized patients at risk of falls and comparing them with the interventions of the Nursing Interventions Classifications (NIC). Method: A cross-sectional study carried out in a university hospital in southern Brazil. It was a retrospective data collection in the nursing records system. The sample consisted of 174 adult patients admitted to medical and surgical units with the Nursing Diagnosis of Risk for falls. The prescribed care were compared with the NIC interventions by the cross-mapping method. Results: The most prevalent care were the following: keeping the bed rails, guiding patients/family regarding the risks and prevention of falls, keeping the bell within reach of patients, and maintaining patients’ belongings nearby, mapped in the interventions Environmental Management: safety and Fall Prevention. Conclusion: The treatment prescribed in clinical practice was corroborated by the NIC reference.


Effectiveness of interventions targeting frequent users of emergency departments: a systematic review

Texte intégral: http://www.springerlink.com/content/3q68180337551r47/fulltext.pdf

Chirurgie bariatrique en 2013: principes, avantages et inconvénients des interventions a disposition [Bariatric surgery in 2013: principles, advantages and disadvantages of the available procedures].

For severe obesity (BMI > 35 kg/m2), bariatric surgery is not only the best, but often the only means of obtaining sufficient and durable weight loss. This article aims to review the available bariatric procedures. Gastric bypass remains the reference when it comes to the risk/benefit ratio. Gastric banding is declining rapidly due to the high prevalence of long-term complications. Primary malabsorptive procedures remain largely unpopular because of their potential nutritional complications. Sleeve gastrectomy, although it is not reversible as it includes a significant gastric resection, increases currently in popularity because of its apparent simplicity and the fact that early results regarding weight loss mimic those obtained with gastric bypass.

Supply side interventions and redistribution

In this paper we study the welfare impact of alternative tax schemes on laborand capital. We evaluate the e_ect of lowering capital income taxes on thedistribution of wealth in a model with heterogeneous agents, restricting ourattention to policies with constant tax rates.We calibrate and simulate the economy; we find that lowering capital taxeshas two effects: i) it increases effciency in terms of aggregate production, andii) it redistributes wealth in favor of those agents with a low wage/wealth ratio.We find that the redistributive effect dominates, and that agents with a lowwage wealth ratio would experience a large loss in utility if capital income taxeswere eliminated.

The impact of generic reference pricing interventions in the statin market

The objective of this study was to evaluate the intended and unintended impact on pharmaceutical use and sales of three public financing reforms applied to the prescription of statins: a Spanish generic reference pricing (RP) system for lovastatin and simvastatin, and two competing policies introduced by the Andalusian Public Health Service (APHS) for all statins, first a maximum consumer price (MCP) and then a so called quality prescribing incentive for general practitioners (MCP plus PI).This study is designed as an observational, retrospective, interrupted time series analysis with comparison series (APHS and the rest of Spain) of 46 monthly drug use and sales ratios from January 2001 to October 2004 for each active ingredient in the group of statins.RP has been effective at reducing the volume of sales growth of the off-patent statins, yet its overall impact on sales of all statins has been relatively modest. The quantity and volume of sales impact heavily depends on regulatory RP details such as when the system is introduced, how often it is updated, and how the reference price is calculated.

Therapist interventions using the Psychodynamic Interventions Rating Scale (PIRS) in dynamic therapy, psychoanalysis and CBT.

Abstract One requirement for psychotherapy research is an accurate assessment of therapeutic interventions across studies. This study compared frequency and depth of therapist interventions from a dynamic perspective across four studies, conducted in four countries, including three treatment arms of psychodynamic psychotherapy, and one each of psychoanalysis and CBT. All studies used the Psychodynamic Intervention Rating Scales (PIRS) to identify 10 interventions from transcribed whole sessions early and later in treatment. The PIRS adequately categorized all interventions, except in CBT (only 91-93% categorized). As hypothesized, interpretations were present in all dynamic therapies and relatively absent in CBT. Proportions of interpretations increased over time. Defense interpretations were more common than transference interpretations, which were most prevalent in psychoanalysis. Depth of interpretations also increased over time. These data can serve as norms for measuring where on the supportive-interpretive continuum a dynamic treatment lies, as well as identify potentially mutative interventions for further process and outcome study.