We performed a systematic review and meta-analysis to estimate the decrease in liver stiffness, measured by vibration-controlled transient elastrography (VCTE), in patients with hepatitis C virus ...infection who achieved a sustained virologic response (SVR).
We searched the literature through October 2016 for observational studies or randomized controlled trials of adults with hepatitis C virus infection who received antiviral therapy (either direct-acting antiviral agents or interferon-based therapies), underwent liver stiffness measurement using VCTE before starting therapy, and had at least 1 follow-up VCTE after completion of therapy; studies also provided data on mean or median liver stiffness measurements for patients who did and did not achieve an SVR. We identified 24 studies, and estimated weighted mean difference (and 95% confidence interval) in liver stiffness in patients with versus without SVR using random-effects meta-analysis.
In patients who achieved SVR, liver stiffness decreased by 2.4 kPa at the end of therapy (95% CI, -1.7 to -3.0), by 3.1 kPa 1-6 months after therapy (95% CI, -1.6 to -4.7), by 3.2 kPa 6-12 months after therapy (90% CI, -2.6 to -3.9), and 4.1 kPa 12 months or more after therapy (95% CI, -3.3 to -4.9) (median decrease, 28.2%; interquartile range, 21.8-34.8). In contrast, there was no significant change in liver stiffness in patients who did not achieve an SVR (at 6-12 months after therapy, decrease of 0.6 kPa; 95% CI, -1.7 to 0.5). Decreases in liver stiffness were significantly greater in patients treated with direct-acting antiviral agents than with interferon-based therapy (decrease of 4.5 kPa vs decrease of 2.6 kPa; P = .03), cirrhosis at baseline (decrease of 5.1 kPa vs decrease of 2.8 kPa in patients with no cirrhosis; P = .02), or high pretreatment levels of alanine aminotransferase (P < .01). Among patients with baseline liver stiffness >9.5 kPa, 47% (95% CI, 27%-68%) achieved posttreatment liver stiffness of <9.5 kPa.
In a systematic review and meta-analysis, we associated eradication of hepatitis C virus infection (SVR) with significant decreases in liver stiffness, particularly in patients with high baseline level of inflammation or patients who received direct-acting antiviral agents. Almost half the patients considered to have advanced fibrosis, based on VCTE, before therapy achieved posttreatment liver stiffness levels <9.5 kPa. Clinical Trial Registration no: CRD42016051034.
Chronic liver diseases (CLDs), due to chronic hepatitis C; hepatitis B; nonalcoholic fatty liver diseases (NAFLD); and alcoholic liver disease, are a leading cause of morbidity and mortality ...globally. Early identification of patients with cirrhosis at high risk of progression to liver-related complications may facilitate timely care and improve outcomes. With risks and misclassification associated with invasive tests, such as liver biopsy, noninvasive imaging modalities for liver fibrosis assessment have gained popularity. Therefore, the American Gastroenterological Association prioritized clinical guidelines on the role of elastography in CLDs, focusing on vibration-controlled transient elastography (VCTE) and magnetic resonance elastography (MRE). To inform these clinical guidelines, the current technical review was developed in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework for diagnostic accuracy studies. This technical review addresses focused questions related to: (1) comparative diagnostic performance of VCTE and MRE relative to nonproprietary, serum-based fibrosis markers for detection of cirrhosis in patients with hepatitis C virus (HCV), hepatitis B virus (HBV), NAFLD, and alcoholic liver diseases; (2) performance of specific VCTE-defined liver stiffness cutoffs as a test replacement strategy (to replace liver biopsy) in making key decisions in the management of patients with CLDs; and (3) performance of specific VCTE-defined liver stiffness cutoffs as a triage test to identify patients with low likelihood of harboring high-risk esophageal varices (EVs) or having clinically significant portal hypertension (for presurgical risk stratification). This technical review does not address performance of other noninvasive modalities for assessing fibrosis (eg, acoustic radiation force pulse imaging or shear wave elastography) or steatosis (controlled attenuation parameter or magnetic resonance imaging−estimated proton density fat fraction).
Aim
To update a systematic review of evidence published up to December 2015 for pharmacological/neurosurgical interventions among individuals with cerebral palsy (CP) and dystonia.
Method
Searches ...were updated (January 2016 to May 2020) for oral baclofen, trihexyphenidyl, benzodiazepines, clonidine, gabapentin, levodopa, botulinum neurotoxin (BoNT), intrathecal baclofen (ITB), and deep brain stimulation (DBS), and from database inception for medical cannabis. Eligible studies included at least five individuals with CP and dystonia and reported on dystonia, goal achievement, motor function, pain/comfort, ease of caregiving, quality of life (QoL), or adverse events. Evidence certainty was evaluated using GRADE.
Results
Nineteen new studies met inclusion criteria (two trihexyphenidyl, one clonidine, two BoNT, nine ITB, six DBS), giving a total of 46 studies (four randomized, 42 non‐randomized) comprising 915 participants when combined with those from the original systematic review. Very low certainty evidence supported improved dystonia (clonidine, ITB, DBS) and goal achievement (clonidine, BoNT, ITB, DBS). Low to very low certainty evidence supported improved motor function (DBS), pain/comfort (clonidine, BoNT, ITB, DBS), ease of caregiving (clonidine, BoNT, ITB), and QoL (ITB, DBS). Trihexyphenidyl, clonidine, BoNT, ITB, and DBS may increase adverse events. No studies were identified for benzodiazepines, gabapentin, oral baclofen, and medical cannabis.
Interpretation
Evidence evaluating the use of pharmacological and neurosurgical management options for individuals with CP and dystonia is limited to between low and very low certainty.
What this paper adds
Meta‐analysis suggests that intrathecal baclofen (ITB) and deep brain stimulation (DBS) may improve dystonia and pain.
Meta‐analysis suggests that DBS may improve motor function.
Clonidine, botulinum neurotoxin, ITB, and DBS may improve achievement of individualized goals.
ITB and DBS may improve quality of life.
No direct evidence is available for oral baclofen, benzodiazepines, gabapentin, or medical cannabis.
Intervenciones farmacológicas y neuroquirúrgicas para individuos con parálisis cerebral y distonía: una actualización de revisión sistemática y meta‐ análisis
Objetivo
Actualizar una revisión sistemática sobre evidencia publicada hasta Diciembre del 2015 para intervenciones farmacológicas y neuroquirúrgicas entre individuos con parálisis cerebral (PC) y distonía.
Método
Se actualizaron las búsquedas (desde Enero 2016 hasta Mayo del 2020) para baclofeno oral, trihexifenidilo, benzodiacepinas, clonidina, gabapentina, levodopa, neurotoxina botulinica (BoNT), baclofeno intratecal (ITB), y estimulación cerebral profunda (DBS), y desde el inicio de la base de datos para el cannabis medicinal. Los estudios elegibles incluyeron al menos 5 individuos con PC y distonía e informaron sobre distonía, logro de metas, función motora, dolor/comorbilidad, facilidad para brindar cuidados, calidad de vida (QoL) o eventos adversos. La certeza de la evidencia se evaluó mediante GRADE.
Resultados
Diez y nueve estudios reunieron los criterios de inclusión (2 trihexifenidilo, uno clonidina, 2 BoNT, 9 ITB, 6 DBS). Cuando se combinan con los de la revisión sistemática original, dan un total de 46 estudios (cuatro aleatorios, 42 no aleatorios) que comprenden 915 participantes. Evidencia de certeza muy baja apoyó la mejoría de la distonía (clonidina, BoNT, ITB, DBS). La certeza baja a una muy baja apoyó una mejor función motora (DBS), dolor/comorbilidad (clonidina, BoNT, ITB, DBS), facilidad de cuidado (clonidina, BoNT, ITB) y CdV (ITB, DBS). Trihexifenidilo, clonidina, BoNT, ITB y DBS pueden aumentar los eventos adversos. No se identificaron estudios para benzodiacepinas, gabapentina, baclofeno oral, y cannabis medicinal.
Interpretación
La evidencia que evalúa el uso de opciones de manejo farmacológico y neuroquirúrgico para personas con parálisis cerebral y distonía se limita a evidencia entre baja y muy baja certeza.
Intervenções farmacológicas e neurocirúrgicas para indivíduos com paralisia cerebral e dystonia: uma atualização de revisão sistemática e metanálise
Objetivo
Atualizar uma revisão sistemática da evidência publicada até dezembro de 2015 para intervenções farmacológicas/neurocirúrgicas entre indivíduos com paralisia cerebral (PC) e distonia.
Método
As buscas foram atualizadas (Janeiro 2016 a Maio 2020) quanto a baclofeno oral, triexifenidil, benzodiazepínicos, clonidina, gabapentina, levodopa, neurotoxina botulínica (NTBo), baclofeno intratecal (BIT), e estimulação cerebral profunda (ECB), e desde o início da base de dados para cannabis medicinal. Estudos elegíveis incluíram ao menos cinco indivíduos com PC e dystonia, e reportaram os objetivos atingidos, função motora, dor/conforto, facilidade do cuidado, qualidade de vida (QV), ou efeitos adversos. A certeza da evidência foi avaliada usando GRADE.
Resultados
Dezenove novos estudos atenderam aos critérios de inclusão (dois com triexifenidil 1 com clonidina, dois com NTBo, nove com BIT e seis com ECB), dando um total de 46 estudos (quatro randomizados, 42 não randomizados) compreendendo 915 participantes quando combinados com aqueles da revisão sistemática original. Evidência com certeza muito baixa suporta a melhora da distonia (clonidina, BIT, ECB) e atingimento de objetivos (clonidina, NTBo, BIT, ECB). Evidência com certeza baixa a muito baixa apóia melhora da função motora (ECB), dor/conforto (clonidina, NTBo, BIT, ECB), facilidade de cuidado (clonidina, NTBo, BIT), e QV (BIT, ECB). Triexifenidil, clonidina, NTBo, BIT, e ECB podem aumentar efeitos adversos. Não foram identificados estudos com benzodiazepínicos, gabapentina, baclofeno oral, e cannabis medicinal.
Interpretação
A evidência avaliando o uso de opções de manejo farmacológico e cirúrgico para indivíduos com PC e distonia é limitada a certeza baixa e muito baixa.
What this paper adds
Meta‐analysis suggests that intrathecal baclofen (ITB) and deep brain stimulation (DBS) may improve dystonia and pain.
Meta‐analysis suggests that DBS may improve motor function.
Clonidine, botulinum neurotoxin, ITB, and DBS may improve achievement of individualized goals.
ITB and DBS may improve quality of life.
No direct evidence is available for oral baclofen, benzodiazepines, gabapentin, or medical cannabis.
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Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert ...panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.
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