Background and Aim
Proton pump inhibitors (PPIs) are among the most widely used medications worldwide. Dementia is an increasingly common cause of disability in older populations. Recent studies have ...suggested an increased risk of cognitive impairment and dementia diagnosis among people who consume PPIs. This systematic review explores dementia, cognitive impairment, and the use of PPIs.
Methods
Systematic searches were conducted in the databases of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), PSYCinfo, Scopus, Web of Science, and ClinicalTrials.gov for articles published from inception to June 30, 2016. Primary outcomes of interest were the use of PPIs and diagnosis of dementia or acute cognitive impairment. Studies conducted on people aged less than 18 years old were excluded. All study designs were eligible for inclusion. Two reviewers independently assessed study quality and extracted data from included studies.
Results
The systematic search strategy and screening process yielded 11 studies for inclusion in the systematic review. Four studies explored PPI use and dementia, and seven studies explored PPI use and acute cognitive impairment. Three of the four studies exploring dementia identified a positive association with PPI use. A positive association was also observed in the majority of studies exploring acute cognitive impairment.
Conclusions
Based on the current published literature, this systematic review has identified that the reported association between PPI use and dementia is limited by methodological issues and conflicting results. Further longitudinal studies with robust bias limitation are required to explore the use of PPIs and dementia or acute cognitive impairment, and to ascertain the existence of any causal relationships.
Abstract
There is growing evidence from Phase III randomized clinical trials of the cardiovascular benefits of sodium glucose cotransporter 2 (SGLT2) inhibitors in patients with diabetes mellitus. It ...is hypothesized that these benefits are mediated by mechanisms other than glucose control. To address this, we performed a systematic review of data from preclinical studies examining the direct cardioprotective effects of SGLT2 inhibitors. Medline, EMBASE, CINAHL, and International Pharmaceutical Abstracts databases were searched for preclinical studies that examined the potential cardioprotective effects of SGLT2 inhibitors. Submission documents to the US Food and Drug Administration, European Medicines Agency, and Japanese Pharmaceutical and Medical Devices Agency for the registration of SGLT2 inhibitors were also reviewed. A total of 36 reports were included in the final analysis. The potential direct cardiovascular benefits of SGLT2 inhibitors include: augmentation of signal transducer and activator of transcription 3; inhibition of sodium hydrogen exchange; reduction of atherosclerosis; modulation of natriuretic peptides; vasodilation; modulation of sympathetic tone; and reduction of inflammation, oxidative stress, endoplasmic reticulum stress, and cardiac glucose uptake via down-regulation of SGLT1 expression. There are a number of mechanisms by which SGLT2 inhibitors may exert cardiovascular benefits beyond glycaemic control.
Strict isolation of COVID-19 patients to prevent cross infection may inadvertently cause serious adverse outcomes including psychological harm, limitations to care, increased incidence of delirium, ...deconditioning and reduced quality of life. Previous research exploring the staff perspective of the effect of isolation on patients is limited. The aim of this study is to understand staff perceptions and interpretations of their experiences of the care and treatment of isolated patients and the impact of isolation on patients, families, and staff.
This qualitative, exploratory study is set in a major metropolitan, quaternary hospital in Melbourne, Australia. Data was collected in focus groups with clinical and non-clinical staff and analysed using content analysis. The hospital ethics committee granted approval. Each participant gave informed verbal consent.
Participants included 58 nursing, medical, allied health, and non-clinical staff. Six main themes were identified: 1) Communication challenges during COVID-19; 2) Impact of isolation on family; 3) Challenges to patients' health and safety; 4) Impact on staff; 5) Challenging standards of care; 6) Contextual influences: policy, decision-makers and the environment.
Isolating patients and restricting visitors resulted in good pandemic management, but staff perceived it came at considerable cost to staff and consumers. Innovative communication technology may facilitate improved connection between all parties. Mental health support is needed for patients, families, and staff. Further research using a co-design model with input from patients, families and staff is recommended to determine appropriate interventions to improve care. Preventing the spread of infection is essential for good pandemic management, but the cost to consumers and staff must be mitigated. Preparation for future pandemics must consider workforce preparedness, adapted models of care and workflow.
Objective To investigate demographics, clinical patterns and outcomes of rapid response reviews in hospital, reviewing indications for and outcomes of rapid response reviews initiated for clinical ...concern and to understand the role of clinical concern in identifying the deteriorating patient and at-risk patient populations. Method This was a retrospective analysis of General Medical inpatients at Alfred Hospital from 1 January 2018 to 31 July 2020. Data extraction from electronic medical records identified patients who had a rapid response review during admission. Demographic and clinical data, investigations and clinical outcomes from rapid response reviews were investigated. Comparisons were performed using χ 2 or Fisher's exact test where appropriate. Odds ratios and 95% confidence intervals were calculated for factors associated with rapid response reviews for clinical concern and clinical outcomes. Results There were 10 797 admissions of 7409 individual patients. There were 2359 rapid response reviews during the study period, occurring in 13% of admissions. Patients were majority female (50.4%), and the median age was 79 ± 17.6 years. Rapid response reviews were for cardiovascular (46.8%), respiratory (25.3%) and neurological (14.3%) indications. A total of 11% of rapid response reviews (n = 258) were for clinical concern. Inpatient falls accounted for a significant proportion of rapid response reviews for clinical concern. Reviews were more common in older patients, those admitted after-hours, and patients with disabilities. The latter group weremore likely to have rapid response reviews for clinical concern. Rapid response reviews initiated for clinical concern were more likely than those initiated for standard criteria to change patients' clinical status, particularly the withdrawal of active management. Conclusions Rapid response reviews for clinical concern are important triggers to identify clinical deterioration in vulnerable patients. Reviews were initiated for clinical concern were more likely than those initiated for standard criteria to result in a change in patients' resuscitation status and care trajectory. Clinician concern, even when prompting review for parameters outside of standard clinical review criteria, remains an important factor in recognising the deteriorating patient.
Abstract
Aims
Socioeconomic status (SES) is recognizably linked with incident heart failure (HF) risk and the association of SES with geography presents a potential target for geographical location ...of preventive health services. To better inform policy we sought to quantify the independent association between SES and incident HF and investigate differences by type of SES measure.
Methods and results
MEDLINE and EMBASE were searched up to August 2018. Observational studies and randomized trials reporting adjusted HF incidence by stratified socioeconomic measures were included. Effect sizes reflected HF incidence in the lowest vs. highest SES stratum and were pooled using a random-effects model. Low SES referred to the lowest resource stratum, the definition of which varied across studies: meta-analysis was only performed where strata were comparable. Statistical heterogeneity was assessed using the I2 statistic. Eleven studies comprising 6 308 006 individuals and 104 217 HF events found that low SES was associated with an increase in risk of incident HF ranging between 43% and 87% depending on SES measure, with an overall estimate of 62% hazard ratio (HR) 1.62, 95% confidence interval (CI) 1.50–1.76. By individual measure, HRs of 1.66 (95% CI 1.3–2.11), 1.87 (95% CI 1.33–2.62), and 1.54 (95% CI 1.22–1.95) were observed for education, income, and occupation, respectively. For area-level indexes, HRs were 1.43 (95% CI 1.2–1.69) (Carstairs index) and 1.61 (95% CI 1.56–1.65) (index of multiple deprivation).
Conclusion
Low SES assessed by all common measures confers independent risk for incident HF. These findings carry implications for the design and delivery of HF prevention programmes.
IntroductionThe world is undergoing a demographic transition to an older population. Preventive healthcare has reduced the burden of chronic illness at younger ages but there is limited evidence that ...these advances can improve health at older ages. Statins are one class of drug with the potential to prevent or delay the onset of several causes of incapacity in older age, particularly major cardiovascular disease (CVD). This paper presents the protocol for the STAtins in Reducing Events in the Elderly (STAREE) trial, a randomised double-blind placebo-controlled trial examining the effects of statins in community dwelling older people without CVD, diabetes or dementia.Methods and analysisWe will conduct a double-blind, randomised placebo-controlled trial among people aged 70 years and over, recruited through Australian general practice and with no history of clinical CVD, diabetes or dementia. Participants will be randomly assigned to oral atorvastatin (40 mg daily) or matching placebo (1:1 ratio). The co-primary endpoints are disability-free survival defined as survival-free of dementia and persistent physical disability, and major cardiovascular events (cardiovascular death or non-fatal myocardial infarction or stroke). Secondary endpoints are all-cause death, dementia and other cognitive decline, persistent physical disability, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, heart failure, atrial fibrillation, fatal and non-fatal cancer, all-cause hospitalisation, need for permanent residential care and quality of life. Comparisons between assigned treatment arms will be on an intention-to-treat basis with each of the co-primary endpoints analysed separately in time-to-first-event analyses using Cox proportional hazards regression models.Ethics and disseminationSTAREE will address uncertainties about the preventive effects of statins on a range of clinical outcomes important to older people. Institutional ethics approval has been obtained. All research outputs will be disseminated to general practitioner co-investigators and participants, published in peer-reviewed journals and presented at national and international conferences.Trial registration numberNCT02099123.
With technological advances, there has been increasing interest in developing contactless and/or non-invasive wearable technologies that continuously monitor vital signs in the clinical setting, and ...in particular in the deteriorating patient. These devices as of yet have not been well validated in the clinical setting in the clinical ranges observed in a critically unwell patient. We will perform a systematic review of all novel wearable and contactless devices in the clinical setting with focus on degree of novelty and the range of vital signs captured.
Ovid MEDLINE including Epub Ahead of Print and In-Process & Other Non-Indexed Citations, Ovid Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL) Health Technology Assessment (HTA) database (Ovid), CINAHL with Full Text, searches of the grey literature, cited references of eligible studies through Web of Science, and reference lists of eligible studies will be searched. Outcomes of interest will include the quality of studies in relation to reporting guidelines, limitations of non-invasive technology, and application in different clinical populations. We will perform a qualitative assessment of the novelty of the device and discuss its validation in deteriorating patients.
While novel monitoring devices are often proposed as a solution to problems with infection, discomfort, and frequency of monitoring in the clinical setting it has not yet been established which devices have been validated in clinical settings in the pathological ranges of vital signs that reflect patient deterioration. It is equally unclear what additional value these devices might provide. This systematic review will synthesize published data regarding devices that have been tested and validated in patients AND in a clinical setting AND in reference ranges that reflect severe illness.
PROSPERO CRD42019130091.
Highlights • RDN was associated with reductions in NT-proBNP and the 120-minute glucose tolerance test in HF patients with renal dysfunction 12 months after treatment. • No deterioration in other ...indices of cardiac and renal function 12 months after RDN treatment was observed. • No serious adverse events were adjudicated as related to the device, procedure, or therapy. There was one renal artery occlusion that was possibly related to the denervation procedure.
Abstract Background Heart failure (HF) therapy involves use of multiple medications. There is little guidance on the safety and impact on clinical outcomes of stopping HF medications. Methods and ...Results A comprehensive systematic search for studies of drug therapy withdrawal in HF was performed. Meta-analysis of the risk ratio (RR) was performed with the use of the Mantel-Haenszel random effects model for all-cause mortality and cardiovascular outcomes. Twenty-six studies met the inclusion criteria. Studies on withdrawal of renin-angiotensin-aldosterone system (RAAS) inhibitors and beta-blockers in HF are scarce and small, yet show relatively convincingly that such withdrawals have untoward effects on cardiac structure, symptoms, and major outcomes. Meta-analysis of 7 studies of digoxin withdrawal (2,987 participants) without background beta-blocker showed increased HF hospitalizations (RR 1.30, 95% confidence interval CI 1.16–1.46; P < .0001), but no impact on all-cause mortality (RR 1.00, 95% CI 0.90–1.12; P = .06) nor reduction in all-cause hospitalization (RR 1.03, 95% CI 0.98–1.09; P = .27). Diuretic withdrawal trials demonstrated an ongoing need for these agents in chronic HF. Studies in peripartum cardiomyopathy showed that medications could be successfully withdrawn after recovery. Conclusion Current evidence discourages any attempt to discontinue RAAS inhibitors or beta-blockers in patients with stable HF, regardless of clinical and/or echocardiographic status. Formal withdrawal trials of other classes are needed.
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