systematic review

RPR Commentary: In infants 60 - 90 days old presenting the emergency room with a fever, the probability of serious invasive bacterial infection is apparently about 1%. James W. Mold, MD, MPH

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Abstract
Importance The prevalence of invasive bacterial infections (IBIs), specifically bacteremia and bacterial meningitis, is not well established among febrile infants in the third month of life. International guidelines exclude or vary in management recommendations for this age group.

Objective To assess the prevalence of IBIs among febrile infants aged 60 to 90 days.

Data Sources MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Scopus were searched with deliberate limitation to studies between January 1, 2000, to October 2, 2025, and analyzed in December 2025.

Study Selection Studies were included that reported on previously healthy, well-appearing febrile infants 60 to 90 days old evaluated in emergency department or outpatient settings and for whom patient-level IBI status could be ascertained.

Data Extraction and Synthesis Data were extracted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines, and risk of bias was assessed using the Joanna Briggs Institute critical appraisal Checklist for Prevalence Studies. Pooled prevalences were calculated using random-effects generalized linear mixed models of logit-transformed single proportions of cases.

Main Outcomes and Measures The primary outcome was the prevalence of IBI. Secondary outcomes included the prevalence of bacteremia and bacterial meningitis separately.

Results The search yielded 13 130 records; 59 studies were included (20 distinct datasets of 34 835 infants). The pooled prevalence of IBI was 1.11% (95% CI, 0.84%-1.47%), bacteremia was 1.01% (95% CI, 0.76%-1.34%), and bacterial meningitis was 0.11% (95% CI, 0.08%-0.16%). Results were consistent across multiple sensitivity analyses excluding (1) retrospective cohorts; (2) cohorts of only infants with fever without source; (3) cohorts with shorter clinical follow-up of less than 7 days; and (4) the largest study (66% of all included patients).

Conclusions and Relevance In this systematic review and meta-analysis, the pooled prevalence of IBI among well-appearing febrile infants in the third month of life was 1.11%; bacteremia accounted for most cases, whereas bacterial meningitis was rare. These contemporary prevalence estimates should inform guideline development and shared parent and clinician decision-making for the management of these infants.

Author/s:

Dionisopoulos, Zachary, Sabhaney, Vikram, D'Arienzo, David

The effectiveness and safety of methotrexate in the intervention of osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

Megan George — Tue, 14 Oct 2025 13:08:01 +0000

Date Added:

October 14, 2025

Journal/Publication:

Medicine

Publication Date:

October 10, 2025

URL:

The effectiveness and safety of methotrexate in the intervention of osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1097/MD.0000000000044994

Keywords

MeSH

The findings of this meta-analysis suggest that methotrexate is both safe and effective for treatment of pain and joint stiffness in patients with osteoarthritis. James W. Mold, MD, MPH

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Background:
Osteoarthritis (OA) is a prevalent chronic joint disorder among middle-aged and older adults, characterized by progressive cartilage degeneration, subchondral bone remodeling, and osteophyte formation, leading to joint pain, stiffness, dysfunction, and reduced quality of life. With the global aging population, OA imposes a growing socioeconomic burden, yet no disease-modifying therapy is currently available—particularly for moderate-to-severe stages. Emerging evidence implicates synovial inflammation as a central contributor to OA symptoms and progression, raising interest in methotrexate (MTX), a well-established, low-dose anti-inflammatory agent used safely in rheumatoid arthritis. Preliminary studies suggest MTX may alleviate OA-related pain, but findings from randomized controlled trials (RCTs) have been inconsistent and limited in number. Given recent new RCTs and the heterogeneity of existing outcomes, an updated systematic review and meta-analysis is urgently needed to clarify the efficacy and safety of MTX in OA and inform future clinical trial design.

Methods:
PubMed, ClinicalTrials, Web of Science, Cochrane Library and other databases were searched to find randomized controlled trials (RCT) of MTX treatment of OA. Methodological quality was assessed using the Cochrane "risk of bias" assessment tool, and the meta-analysis was conducted using Review Manager (RevMan) version 5.3 (The Cochrane Collaboration, London, UK).

Results:
Fifteen RCTs involving 1591 participants were included in this review. The meta-analysis results showed that the ineffective rate in the experimental group was lower [RR: 0.40 (0.24, 0.67), P = .004]; the VAS in the experimental group was lower [WMD: −0.66 (−1.08, −0.24), P = .002]; the WOMAC score-stiffness in the experimental group was lower [WMD: −0.72 (−1.04, −0.41), P < .00001]; the WOMAC score-function in the experimental group was lower [WMD: −7.72 (−13.56, −1.87), P = .01]. The adverse events in the experimental group were not statistically significant compared with the control group [RR: 1.04 (0.77, 1.42), P = .78].

Conclusion:
MTX demonstrates potential in effectively alleviating pain, improving joint function, and slowing disease progression in patients with OA. Its safety profile is comparable to that of control treatments, making it a viable and reliable therapeutic option worthy of broader clinical application.

Author/s:

Wan, Lifei, Yang, Qianyue, Yang, Kailin, Zeng, Liuting, Sun, Lingyun

Lipid-lowering therapies for cardiovascular disease prevention and management in primary care

Rowan Hutchins — Sun, 15 Oct 2023 05:00:00 +0000

Date Added:

October 15, 2023

Journal/Publication:

CFP

Publisher:

College of Family Physicians of Canada

Publication Date:

October 1, 2023

Issue:

Volume:

Pages:

701-711

URL:

Lipid-lowering therapies for cardiovascular disease prevention and management in primary care

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.46747/cfp.6910701

Keywords

randomised controlled trials

systematic review

PMID (1):

37833094

MeSH

PCSK9 Inhibitors

Hydroxymethylglutaryl-CoA Reductase Inhibitors

cardiovascular diseases

An analysis of the evidence of the impact of various lipid lowering strategies in cardiovascular events and mortality. James W. Mold, MD, MPH

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Objective: To assess the benefits and harms of lipid-lowering therapies used to prevent or manage cardiovascular disease including bile acid sequestrants (BAS), ezetimibe, fibrates, niacin, omega-3 supplements, proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, and statins.

Author/s:

Nicolas Dugré, Adrienne J. Lindblad, Danielle Perry, G. Michael Allan, Émélie Braschi, Jamie Falk, Liesbeth Froentjes, Scott R. Garrison, Jessica E.M. Kirkwood, Christina S. Korownyk

Long-Term Health Outcomes in Obstructive Sleep Apnea: A Systematic Review of Comparative Studies Evaluating Positive Airway Pressure and the Validity of Breathing Measures as Surrogate Outcomes

Aubrey Delammermore — Sun, 11 Dec 2022 06:00:00 +0000

Date Added:

December 11, 2022

Journal/Publication:

Agency for Healthcare Research and Quality

Publisher:

US Department of Health and Human Services

Publication Date:

December 1, 2022

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

CPAP

Obstructive sleep apnea

sleep apnea

systematic review

breathing measures

MeSH

Sleep Apnea, Obstructive

Patient Acuity

united states food and drug administration

continuous positive airway pressure

Sleepiness

An AHRQ-sponsored systematic review of evidence relating to the impact of CPAP on various outcomes in adults with obstructive sleep apnea. The abstract is on pages vi-vii. Spoiler alert: Very little hard evidence of benefit on key outcomes. James W. Mold MD, MPH.

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Background. Obstructive sleep apnea (OSA) is a disorder characterized by periods of airflow
cessation (apnea) or reduced airflow (hypopnea) during sleep. The diagnosis and severity of
OSA, and response to therapy, have historically been assessed using the apnea-hypopnea index
(AHI). However, several definitions of this measure exist, and the utility of the AHI and
associated measures as valid surrogate measures of health outcomes has been questioned. OSA is
commonly treated with the use of continuous positive airway pressure (CPAP) devices during
sleep. The efficacy of CPAP, including for Food and Drug Administration (FDA)
clearance/approval, has been based on changes in AHI, but the long-term effect of CPAP on
health outcomes and the role of disease severity (as measured by AHI) or sleepiness symptoms
on the putative effect of CPAP are unclear.
Methods. We searched Medline, Embase, the Cochrane databases, CINAHL, and
ClinicalTrials.gov from January 2010 through March 22, 2021; we screened reference lists of the
2011 Agency for Healthcare Research and Quality (AHRQ) OSA report and other systematic
reviews for earlier studies. We included only randomized controlled trials (RCT) and
nonrandomized comparative studies (NRCS) of CPAP that adjusted for potential confounders for
CPAP evaluation. We also included other comparative studies that reported both changes in
potential intermediate or surrogate measures (e.g., AHI) and effects on health outcomes. All
studies had to report effects on prespecified long-term (12 months for most outcomes) health
outcomes in adults with OSA. We did not evaluate sleepiness, other symptoms, or intermediate
outcomes. We excluded observational studies that did not directly compare treatment options.
Results. The 52 identified studies used highly inconsistent criteria to define breathing measures
(apneas, hypopneas, and oxygen desaturation). Definitions of respiratory disturbance events
(e.g., apneas, hypopneas) and criteria to define or categorize severity of OSA are highly
inconsistent across studies, despite frequent claims of using standard national or international
definitions. Possible differences in study findings based on heterogeneity of OSA and sleep study
measures could not be elucidated. Among 31 studies that directly compared CPAP and no CPAP
(29 studies) or sham CPAP (2 studies), 14 were RCTs (12 intention-to-treat [ITT]) and 17 were
NRCSs (11 analyses of CPAP users versus nonusers).
With one exception, RCTs did not find statistically significant effects for any cardiovascular
(CV) outcome. RCTs did not provide evidence that CPAP affects the risk of all-cause mortality
(summary effect size [ES] 0.89, 95% confidence interval [CI] 0.66 to 1.21), CV mortality
(summary ES 0.99, 95% CI 0.64 to 1.53), stroke (summary ES 0.99, 95% CI 0.73 to 1.35),
myocardial infarction (summary ES 1.05, 95% CI 0.78 to 1.41), or composite CV outcomes (ES
range 0.42 to 1.10 across studies, all statistically nonsignificant); all with low strength of
evidence (SoE). The three RCTs that aimed to be powered for composite CV events failed to
vi
show a significant or clinically meaningful effect. The NRCSs, overall, found significant
adjusted associations between CPAP use and all-cause mortality. Combining the RCTs and
NRCSs, the summary ES for all-cause mortality was ES 0.61 (95% CI 0.49 to 0.76), supporting a
low SoE of an association between CPAP use and lower risk of death. Data from the NRCSs did
not change other conclusions. Both RCTs and NRCSs provide insufficient evidence regarding
the effect of CPAP on the risk of transient ischemic attack, angina, coronary artery
revascularization, congestive heart failure, and atrial fibrillation.
RCTs also did not provide evidence that CPAP affects the risk of driving accidents or the risk of
incident diabetes (both low SoE), or that CPAP results in clinically significant changes in
depression or anxiety scores, executive cognitive function measures, or nonspecific quality of
life measures (all low SoE). RCTs provide insufficient evidence regarding the effect of CPAP on
incident hypertension, functional status measures, male or female sexual function, or days of
work missed. Data from the NRCSs did not change these conclusions.
Eligible studies provided insufficient evidence regarding possible differences in the effect of
CPAP based on patient characteristics (such as disease severity or comorbidities), different
diagnostic criteria, or whether RCTs were analyzed as ITT or “as-treated”.
Eligible studies provided insufficient evidence about adverse events due to CPAP use. Many
studies did not collect such data. Adverse events reported in the U.S. Food and Drug
Administration (FDA) database mostly related to inadequate humidification, user errors, or
device malfunction. No deaths were attributed to CPAP use.
Review of the FDA database found 163 CPAP devices used to treat adults with sleep apnea. The
large majority of FDA 510(k) Premarket Notification records cite other previously approved
CPAP devices to support claims of equivalence. The available data did not reference clinical
studies to support the device manufacturers’ claims.
Review of the National Institutes of Health’s RePORTER revealed no germane funded trials.
Review of ClinicalTrials.gov revealed a single large RCT with a mortality endpoint, but no
updating of the site since 2015 and five additional small trials (2 addressing events in patients
with paroxysmal atrial fibrillation or hypertensive pulmonary edema; 3 measuring AHI,
cognition, or kidney function).
RCTs comparing CPAP and mandibular advancement devices found no differences in depression
or anxiety symptoms (low SoE). There was insufficient evidence for other outcomes. RCTs
comparing fixed and autoCPAP found no differences in functional status; other long-term
outcomes were not reported. No eligible studies evaluated comparisons of other types of CPAP.
No studies have evaluated the validity of changes in intermediate or surrogate measures (such as
change in AHI during a clinical trial) as predictors of long-term health outcomes. No studies
reported surrogacy or mediation analyses, nor did any compare the concordance of changes in
different sleep study and symptom measures with health outcomes. Across the 15 studies that
reported both changes in intermediate or surrogate measures and effects on long-term health
vii
outcomes, data were too sparse to allow adequate cross-study evaluation of concordance between
change in any specific measure and health outcome or sleep questionnaires.
Conclusions. Studies are highly inconsistent as to how they define breathing measures during
sleep studies and OSA itself. Insufficient evidence exists to assess the validity of change in AHI
as a surrogate or intermediate measure for long-term health outcomes. Until such validation has
been conducted, it cannot be assumed that changes (e.g., improvements) in intermediate or
surrogate outcomes are correlated with long-term health outcomes.
RCTs do not provide evidence that CPAP prescription affects long-term, clinically important
outcomes. Specifically, with low SoE, RCTs do not demonstrate that CPAP affects all-cause
mortality, various CV outcomes, clinically important changes in psychosocial measures, or other
clinical events. NRCSs reported associations between CPAP use and reduced risk of all-cause
death. NRCS results did not differ from RCTs for other outcomes. We have limited confidence
that the summary estimates are close to any true effect.
Comparative studies did not adequately address whether the effect of CPAP varies based on
disease severity (e.g., as assessed by AHI), symptoms (e.g., as assessed by sleepiness scales),
other patient characteristics, different features or modes or CPAP, or different criteria or
definitions of sleep measures or OSA diagnosis.
Additional well-conducted comparative studies are needed to better assess the potential effects of
CPAP on long-term outcomes for patients with OSA, whether any particular group of patients
may benefit to a greater or lesser degree from CPAP treatment, and whether of changes in AHI
(and/or other breathing measures) are valid intermediate or surrogate measures of health
outcomes. Associations identified in comparative studies could serve as the basis for more
rigorous trials.

Author/s:

Balk, E. M., Adam, G. P., Cao, W., Bhuma, M. R., Forbes, S., Mehta, S., Panagiotou, O., D'Ambrosio, C., Trikalinos, T. A.

The effect of lead exposure on IQ test scores in children under 12 years: a systematic review and meta-analysis of case-control studies

Saige Blanchard — Tue, 14 Jun 2022 05:00:00 +0000

Date Added:

June 14, 2022

Journal/Publication:

Systematic Reviews

Publisher:

BioMed Central Ltd

Publication Date:

May 30, 2022

Issue:

Volume:

URL:

The effect of lead exposure on IQ test scores in children under 12 years: a systematic review and meta-analysis of case-control studies

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1186/s13643-022-01963-y

Keywords

PMID (1):

35637522

MeSH

Quantification of the impact of lead exposure in children on IQ scores. James W. Mold, MD, MPH

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An inevitable exposure to the toxic heavy metal such as lead in our environmental can have irreversible effects on children's mental performance.In this study, 3316 children in 8 case-control studies were selected for review. The case group was exposed to a concentration of lead above 10 μg/dL, and the control group was exposed to a concentration of less than 10 μg/dL, but the duration of exposure was different among studies, and the subgroup analysis was performed based on this variable.In the subgroup with duration of exposure less than the average of 4.5 years, the difference of IQ test score between two groups was significant (MD = -3.53) (P-value <0.05). Also, in the subgroup with more than 4.5 years of duration, the difference of IQ test score was significant (MD = -22.63) (P-value < 0.001).This study demonstrates that the concentration and duration of lead exposure have a large effect on mental function in children.

Author/s:

Heidari, S., Mostafaei, S., Razazian, N., Rajati, M., Saeedi, A., Rajati, F.

Comparison of Amitriptyline and US Food and Drug Administration–Approved Treatments for Fibromyalgia A Systematic Review and Network Meta-analysis

Saige Blanchard — Tue, 07 Jun 2022 05:00:00 +0000

Date Added:

June 7, 2022

Journal/Publication:

JAMA Network Open

Publisher:

JAMA Network Open

Publication Date:

May 19, 2022

Issue:

Volume:

URL:

Comparison of Amitriptyline and US Food and Drug Administration–Approved Treatments for Fibromyalgia A Systematic Review and Network Meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2022.12939

Keywords

PMID (1):

35587348

MeSH

duloxetine hydrochloride

A review of studies of medications used to treat fibromyalgia. Results of interest mainly involved amitriptyline and duloxetine (Cymbalta). James W. Mold, MD, MPH

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Importance: Amitriptyline is an established medication used off-label for the treatment of fibromyalgia, but pregabalin, duloxetine, and milnacipran are the only pharmacological agents approved by the US Food and Drug Administration (FDA) to treat fibromyalgia.

Objective: To investigate the comparative effectiveness and acceptability associated with pharmacological treatment options for fibromyalgia.

Data sources: Searches of PubMed/MEDLINE, Cochrane Library, Embase, and Clinicaltrials.gov were conducted on November 20, 2018, and updated on July 29, 2020.

Study selection: Randomized clinical trials (RCTs) comparing amitriptyline or any FDA-approved doses of investigated drugs.

Data extraction and synthesis: This study follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Four independent reviewers extracted data using a standardized data extraction sheet and assessed quality of RCTs. A random-effects bayesian network meta-analysis (NMA) was conducted. Data were analyzed from August 2020 to January 2021.

Main outcomes and measures: Comparative effectiveness and acceptability (defined as discontinuation of treatment owing to adverse drug reactions) associated with amitriptyline (off-label), pregabalin, duloxetine, and milnacipran (on-label) in reducing fibromyalgia symptoms. The following doses were compared: 60-mg and 120-mg duloxetine; 150-mg, 300-mg, 450-mg, and 600-mg pregabalin; 100-mg and 200-mg milnacipran; and amitriptyline. Effect sizes are reported as standardized mean differences (SMDs) for continuous outcomes and odds ratios (ORs) for dichotomous outcomes with 95% credible intervals (95% CrIs). Findings were considered statistically significant when the 95% CrI did not include the null value (0 for SMD and 1 for OR). Relative treatment ranking using the surface under the cumulative ranking curve (SUCRA) was also evaluated.

Results: A total of 36 studies (11 930 patients) were included. The mean (SD) age of patients was 48.4 (10.4) years, and 11 261 patients (94.4%) were women. Compared with placebo, amitriptyline was associated with reduced sleep disturbances (SMD, -0.97; 95% CrI, -1.10 to -0.83), fatigue (SMD, -0.64; 95% CrI, -0.75 to -0.53), and improved quality of life (SMD, -0.80; 95% CrI, -0.94 to -0.65). Duloxetine 120 mg was associated with the highest improvement in pain (SMD, -0.33; 95% CrI, -0.36 to -0.30) and depression (SMD, -0.25; 95% CrI, -0.32 to -0.17) vs placebo. All treatments were associated with inferior acceptability (higher dropout rate) than placebo, except amitriptyline (OR, 0.78; 95% CrI, 0.31 to 1.66). According to the SUCRA-based relative ranking of treatments, duloxetine 120 mg was associated with higher efficacy for treating pain and depression, while amitriptyline was associated with higher efficacy for improving sleep, fatigue, and overall quality of life.

Conclusions and relevance: These findings suggest that clinicians should consider how treatments could be tailored to individual symptoms, weighing the benefits and acceptability, when prescribing medications to patients with fibromyalgia.

Author/s:

Farag, H. M., Yunusa, I., Goswami, H., Sultan, I., Doucette, J. A., Eguale, T.

Acupuncture for Recurrent Urinary Tract Infection in Women: A Systematic Review and Meta-Analysis

Brian Desmarais — Thu, 09 Jul 2020 20:03:36 +0000

Date Added:

July 9, 2020

Journal/Publication:

An International Journal of Obstetrics & Gynaecology

Publication Date:

May 4, 2020

URL:

Acupuncture for Recurrent Urinary Tract Infection in Women: A Systematic Review and Meta-Analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1111/1471-0528.16315.

Keywords

recurrent urinary tract infection

For reasons that are unclear to me, acupuncture may be at least as effective for prevention and management of recurrent urinary tract infections in women as antibiotics. Though the quality of the evidence is only low to moderate, and the quality of acupuncture was probably high, it may still be worth trying in selected cases. James W. Mold, MD, MPH

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Abstract

Background: Increasing antibiotic resistance has motivated interest in non-antibiotic prophylaxis of recurrent urinary tract infections (rUTI).

Objectives: To conduct a systematic review of the current state of evidence of acupuncture for uncomplicated rUTI in women.

Search strategy: Nine databases (PubMed, Embase, CENTRAL, CINAHL, AMED, CBM, CNKI, CQVIP, Wanfang) were searched from inception to February 2019.

Selection criteria: Randomised controlled trials (RCTs) evaluating the effects of acupuncture and related therapies for prophylaxis or treatment of uncomplicated rUTI in women were included.

Data collection and analysis: Risk of bias was assessed, and the quality and strength of evidence evaluated using the GRADE framework. Results were reported as risk ratios (RR) for dichotomous outcomes or mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI).

Main results: Five RCTs involving 341 participants were included. Methodological quality of studies and strength of the evidence were low to moderate. The chance of achieving a composite cure with acupuncture therapies was greater than that with antibiotics (three studies, 170 participants, RR 1.92, 95% CI 1.31-2.81, I2 = 38%). The risk of UTI recurrence was lower with acupuncture than with no treatment (two studies, 135 participants, RR 0.39, 95% CI 0.26-0.58, I2= 0%) and sham acupuncture (one study, 53 participants, RR 0.45, 95% CI 0.22-0.92).

Conclusions: Acupuncture appeared to be beneficial for treatment and prophylaxis of rUTIs, noting the limitations of the current evidence. Given the growing challenge of antibiotic resistance, there is a need for high-quality RCTs of non-pharmacological interventions such as acupuncture.

Tweetable abstract: This review found that acupuncture may improve treatment and prevent recurrence of urinary tract infection in women.

Keywords: Acupuncture; prophylaxis; recurrent urinary tract infection; systematic review; treatment.

Author/s:

Qin, X., Corle, M.E., Yang, L., Liang, J., Wang, K., Guo, X., Zhang, A.L., Mao, L., Lu, C., Xue, C.C., Liu, X.

Craniosacral therapy for chronic pain: a systematic review and meta-analysis of randomized controlled trials

John Bayhi — Fri, 03 Jan 2020 17:40:28 +0000

Date Added:

January 3, 2020

Journal/Publication:

BMC Musculoskeletal Disorders

Publisher:

BioMed Central Ltd

Publication Date:

December 31, 2019

Issue:

Volume:

URL:

Craniosacral therapy for chronic pain: a systematic review and meta-analysis of randomized controlled trials

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1186/s12891-019-3017-y

Keywords

chronic pain

Complementary Therapies

Craniosacral therapy

meta-analysis

systematic review

PMID (1):

31892357

MeSH

Craniosacral therapy is an apparently effective therapy, about which many of you may be unfamiliar, for patients with chronic pain syndromes. James W. Mold, MD, MPH

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OBJECTIVES:

To systematically assess the evidence of Craniosacral Therapy (CST) for the treatment of chronic pain.

METHODS:

PubMed, Central, Scopus, PsycInfo and Cinahl were searched up to August 2018. Randomized controlled trials (RCTs) assessing the effects of CST in chronic pain patients were eligible. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for pain intensity and functional disability (primary outcomes) using Hedges' correction for small samples. Secondary outcomes included physical/mental quality of life, global improvement, and safety. Risk of bias was assessed using the Cochrane tool.

RESULTS:

Ten RCTs of 681 patients with neck and back pain, migraine, headache, fibromyalgia, epicondylitis, and pelvic girdle pain were included. CST showed greater post intervention effects on: pain intensity (SMD = -0.32, 95%CI = [- 0.61,-0.02]) and disability (SMD = -0.58, 95%CI = [- 0.92,-0.24]) compared to treatment as usual; on pain intensity (SMD = -0.63, 95%CI = [- 0.90,-0.37]) and disability (SMD = -0.54, 95%CI = [- 0.81,-0.28]) compared to manual/non-manual sham; and on pain intensity (SMD = -0.53, 95%CI = [- 0.89,-0.16]) and disability (SMD = -0.58, 95%CI = [- 0.95,-0.21]) compared to active manual treatments. At six months, CST showed greater effects on pain intensity (SMD = -0.59, 95%CI = [- 0.99,-0.19]) and disability (SMD = -0.53, 95%CI = [- 0.87,-0.19]) versus sham. Secondary outcomes were all significantly more improved in CST patients than in other groups, except for six-month mental quality of life versus sham. Sensitivity analyses revealed robust effects of CST against most risk of bias domains. Five of the 10 RCTs reported safety data. No serious adverse events occurred. Minor adverse events were equally distributed between the groups.

DISCUSSION:

In patients with chronic pain, this meta-analysis suggests significant and robust effects of CST on pain and function lasting up to six months. More RCTs strictly following CONSORT are needed to further corroborate the effects and safety of CST on chronic pain.

Author/s:

Haller, H, Lauche, R, Sundberg, T, Dobos, G, Cramer, H

Pharmacologic and Nonpharmacologic Therapies in Adult Patients With Exacerbation of COPD: A Systematic Review

John Bayhi — Fri, 18 Oct 2019 13:01:46 +0000

Date Added:

October 18, 2019

Journal/Publication:

AHRQ Website

Publisher:

Agency for Healthcare Research and Quality

Publication Date:

October 11, 2019

URL:

Pharmacologic and Nonpharmacologic Therapies in Adult Patients With Exacerbation of COPD

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.23970/AHRQEPCCER221

Keywords

copd

chronic obstructive pulmonary disease

therapy

randomized control trial

systematic review

Key points are on page ii. Antibiotics and corticosteroids and some non-pharmacologic strategies are effective. We still don’t know the best corticosteroid dose or route. James W. Mold, MD, MPH

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Objectives. To synthesize existing knowledge about the effectiveness and harms of pharmacologic and nonpharmacologic treatments for exacerbations of chronic obstructive pulmonary disease (ECOPD).

Data sources. Embase®, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, MEDLINE® Daily, MEDLINE, Cochrane Central Registrar of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus from database inception to January 2, 2019.

Review methods. We included randomized controlled trials (RCTs) that evaluated pharmacologic intervention or nonpharmacologic interventions for ECOPD. The strength of evidence (SOE) was graded for critical final health outcomes.

Results. We included 98 RCTs (13,401 patients, mean treatment duration 9.9 days, mean followup 3.7 months). Final health outcomes, including mortality, resolution of exacerbation, hospital readmissions, repeat exacerbations, and need for intubation, were infrequently evaluated and often showed no statistically significant differences between groups. Antibiotic therapy increases the clinical cure rate and reduces the clinical failure rate regardless of the severity of ECOPD (moderate SOE). There is insufficient evidence to support a particular antibiotic regimen. Oral and intravenous corticosteroids improve dyspnea and reduce the clinical failure rate (low SOE). Despite the ubiquitous use of inhaled bronchodilators in ECOPD, we found only a small number of trials that assessed lung function tests, and not final health outcomes. The evidence is insufficient to support the effect of aminophyllines, magnesium sulfate, mucolytics, inhaled corticosteroids, inhaled antibiotics, 5-lipoxygenase inhibitor, and statins on final health outcomes. Titrated oxygen reduces mortality compared with high flow oxygen (low SOE). Low SOE suggested benefit from some nonpharmacologic interventions such as chest physiotherapy using vibration/percussion/massage or breathing technique (on dyspnea), resistance training (on dyspnea and quality of life), early pulmonary rehabilitation commenced before hospital discharge during the initial most acute phase of exacerbation rather than the convalescence period (on dyspnea) and whole body vibration training (on quality of life). Vitamin D supplementation may improve quality of life (low SOE).

Conclusions. Although chronic obstructive pulmonary disease is a common condition, the evidence base for most interventions in ECOPD remains limited. Systemic antibiotics and corticosteroids are associated with improved outcomes in mild and moderate to severe ECOPD. Titrated oxygen reduces mortality. Future research is required to assess the effectiveness of several emerging nonpharmacologic and dietary treatments.

Author/s:

Dobler, CC, Morrow, AS, Farah, MH, Beuschel, B, Majzoub, AM, Wilson, ME, Hasan, B, Seisa, MO, Daraz, L, Prokop, LJ, Murad, MH, Wang, Z

Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review

John Bayhi — Fri, 27 Sep 2019 16:56:05 +0000

Date Added:

September 27, 2019

Journal/Publication:

Annals of Family Medicine

Publisher:

Annals of Family Medicine, Inc.

Publication Date:

September 17, 2019

Issue:

Volume:

Pages:

448-458

URL:

Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review

Type:

Practice Management Research Results

Format:

Article

DOI (1):

10.1370/afm.2419

Keywords

PMID (1):

31501208

MeSH

Outcome Assessment (Health Care)

The results of this study should be of interest and helpful to practices that provide care management services. James W. Mold, MD, MPH

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PURPOSE:

Case management (CM) interventions are effective for frequent users of health care services, but little is known about which intervention characteristics lead to positive outcomes. We sought to identify characteristics of CM that yield positive outcomes among frequent users with chronic disease in primary care.

METHODS:

For this systematic review of both quantitative and qualitative studies, we searched MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) and included articles meeting the following criteria: (1)population: adult frequent users with chronic disease, (2)intervention: CM in a primary care setting with a postintervention evaluation, and (3)primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Independent reviewers screened abstracts, read full texts, appraised methodologic quality (Mixed Methods Appraisal Tool), and extracted data from the included studies. Sufficient and necessary CM intervention characteristics were identified using configurational comparative methods.

RESULTS:

Of the 10,687 records retrieved, 20 studies were included; 17 quantitative, 2 qualitative, and 1 mixed methods study. Analyses revealed that it is necessary to identify patients most likely to benefit from a CM intervention for CM to produce positive outcomes. High-intensity intervention or the presence of a multidisciplinary/interorganizational care plan was also associated with positive outcomes.

CONCLUSIONS:

Policy makers and clinicians should focus on their case-finding processes because this is the essential characteristic of CM effectiveness. In addition, value should be placed on high-intensity CM interventions and developing care plans with multiple types of care providers to help improve patient outcomes.

Author/s:

Hudon, C, Chouinard, MC, Pluye, P, El Sherif, R, Bush, PL, Rihoux, B, Poitras, ME, Lambert, M, Zomahoun, HTV, Legare, F