Systematic review and meta-analysis

Background: About a third of home-dwelling older people fall each year, and institutionalized older people even report a two- or threefold higher rate for falling

Sensitivity and false alarm rate of a fall sensor in long-term fall detection in the elderly

Objectives To undertake a systematic review of the long-term effects of obesity treatments on body weight, risk factors for disease, and disease. Methods The study encompassed three systematic reviews that examined different aspects of obesity treatments. (1) A systematic review of obesity treatments in adults where the methods of the Cochrane Collaboration were applied and randomised controlled trials (RCTs) with a follow-up of at least 1 year were evaluated. (2) A systematic epidemiological review, where studies were sought on long-term effects of weight loss on morbidity and/or mortality, and examined through epidemiological modelling. (3) A systematic economic review that sought reports with both costs and outcomes of treatment, including recent reports that assessed the cost-effectiveness of pharmaceutical and surgical interventions. A Markov model was also adopted to examine the cost-effectiveness of a low-fat diet and exercise intervention in adults with obesity and impaired glucose tolerance. Results The addition of the drugs orlistat or sibutramine was associated with weight loss and generally improved risk factors, apart from diastolic blood pressure for sibutramine. Metformin was associated with decreased mortality after 10 years in obese people with type 2 diabetes. Low-fat diets were associated with continuing weight loss for 3 years and improvements in risk factors, as well as prevention of type 2 diabetes and improved control of hypertension. Insufficient evidence was available to demonstrate the benefits of low calorie or very low calorie diets. The addition of an exercise or behaviour programme to diet was associated with improved weight loss and risk factors for at least 1 year. Studies combining low-fat diets, exercise and behaviour therapy suggested improved hypertension and cardiovascular disease. Family therapy was associated with improved weight loss for 2 years compared to individual therapy. There was insufficient evidence to conclude that individual therapy was more beneficial than group therapy. Weight lost more quickly (within 1 year), from the epidemiology review, may be more beneficial with respect to the risk of mortality. The effects of intentional weight loss need further investigation. Weight loss from surgical and non-surgical interventions for people suffering from obesity was associated with decreased risk of development of diabetes, and a reduction in low-density lipoprotein cholesterol, total cholesterol and blood pressure, in the long term. Targeting high-risk individuals with drugs or surgery was likely to result in a cost per additional life-year or quality-adjusted life-year (QALY) of no more than 13,000 British pounds. There was also suggestive evidence of cost saving from treatment of people with type 2 diabetes with metformin. Targeting surgery on people with severe obesity and impaired glucose tolerance was likely to be more cost-effective at 2329 British pounds per additional life-year. Economic modelling over 6 years for diet and exercise for people with impaired glucose tolerance was associated with a high initial cost per additional QALY, but by the sixth year the cost per QALY was 13,389 British pounds. Results did not include cost savings from diseases other than diabetes, and therefore may be conservative. Conclusions The drugs orlistat and sibutramine appear beneficial for the treatment of adults with obesity, and metformin for obese patients with type 2 diabetes. Exercise and/or behaviour therapy appear to improve weight loss when added to diet. Low-fat diets with exercise, or with exercise and behaviour therapy are associated with the prevention of type 2 diabetes and hypertension. Long-term weight loss in epidemiological studies was associated with reduced risk of type 2 diabetes, and may be beneficial for cardiovascular disease. Low-fat diets and exercise interventions in individuals at risk of obesity-related illness are of comparable cost to drug treatments. Long-term pragmatic RCTs of obesity treatments in populations with obesity-related illness or at high risk of developing such illness are needed (to include an evaluation of risk factors, morbidity, quality of life and economic evaluations). Drug trials that include dietary advice, plus exercise and/or behaviour therapy are also needed. Research exploring effective types of exercise, diet or behaviour and also interventions to prevent obesity in adults is required.

Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement

ContextAlthough postmenopausal hormone replacement therapy (HRT) is widely
used in the United States, new evidence about its benefits and harms requires
reconsideration of its use for the primary prevention of chronic conditions.ObjectiveTo assess the benefits and harms of HRT for the primary prevention of
cardiovascular disease, thromboembolism, osteoporosis, cancer, dementia, and
cholecystitis by reviewing the literature, conducting meta-analyses, and calculating
outcome rates.Data SourcesAll relevant English-language studies were identified in MEDLINE (1966-2001),
HealthSTAR (1975-2001), Cochrane Library databases, and reference lists of
key articles. Recent results of the Women's Health Initiative (WHI) and the
Heart and Estrogen/progestin Replacement Study (HERS) are included for reported
outcomes.Study Selection and Data ExtractionWe used all published studies of HRT if they contained a comparison
group of HRT nonusers and reported data relating to HRT use and clinical outcomes
of interest. Studies were excluded if the population was selected according
to prior events or presence of conditions associated with higher risks for
targeted outcomes.Data SynthesisMeta-analyses of observational studies indicated summary relative risks
(RRs) for coronary heart disease (CHD) incidence and mortality that were significantly
reduced among current HRT users only, although risk for incidence was not
reduced when only studies that controlled for socioeconomic status were included.
The WHI reported increased CHD events (hazard ratio [HR], 1.29; 95% confidence
interval [CI], 1.02-1.63). Stroke incidence but not mortality was significantly
increased among HRT users in the meta-analysis and the WHI. The meta-analysis
indicated that risk was significantly elevated for thromboembolic stroke (RR,
1.20; 95% CI, 1.01-1.40) but not subarachnoid or intracerebral stroke. Risk
of venous thromboembolism among current HRT users was increased overall (RR,
2.14; 95% CI, 1.64-2.81) and was highest during the first year of use (RR,
3.49; 95% CI, 2.33-5.59) according to a meta-analysis of 12 studies. Protection
against osteoporotic fractures is supported by a meta-analysis of 22 estrogen
trials, cohort studies, results of the WHI, and trials with bone density outcomes.
Current estrogen users have an increased risk of breast cancer that increases
with duration of use. Endometrial cancer incidence, but not mortality, is
increased with unopposed estrogen use but not with estrogen with progestin.
A meta-analysis of 18 observational studies showed a 20% reduction in colon
cancer incidence among women who had ever used HRT (RR, 0.80; 95% CI, 0.74-0.86),
a finding supported by the WHI. Women symptomatic from menopause had improvement
in certain aspects of cognition. Current studies of estrogen and dementia
are not definitive. In a cohort study, current HRT users had an age-adjusted
RR for cholecystitis of 1.8 (95% CI, 1.6-2.0), increasing to 2.5 (95% CI,
2.0-2.9) after 5 years of use.ConclusionsBenefits of HRT include prevention of osteoporotic fractures and colorectal
cancer, while prevention of dementia is uncertain. Harms include CHD, stroke,
thromboembolic events, breast cancer with 5 or more years of use, and cholecystitis.

https://jamanetwork.com/journals/jama/articlepdf/195214/JSR20014.pdf

Postmenopausal Hormone Replacement Therapy: Scientific Review

Objective: To describe the epidemiology of nosocomial infections in combined medical-surgical (MS) intensive care units (ICUs) participating in the National Nosocomial Infection Surveillance (NNIS) System. Design: Analysis of surveillance data on 498,998 patients with 1,554,070 patient-days, collected between 1992 and 1998 from 205 MS ICUs following the NNIS Intensive Care Unit protocol, representing 152 participating NNIS hospitals in the United States. Results: Infections at three major sites represented 68% of all reported infections (nosocomial pneumonia, 31%; urinary tract infections (UTIs), 23%; and primary bloodstream infections (BSIs), 14%: 83% of episodes of nosocomial pneumonia were associated with mechanical ventilation, 97% of UTIs occurred in catheterized patients, and 87% of primary BSIs in patients with a central line. In patients with primary BSIs, coagulase-negative staphylococci (39%) were the most common pathogens reported; Staphylococcus aureus (12%) was as frequently reported as enterococci (11%). Coagulase-negative staphylococcal BSIs were increasingly reported over the 6 years, but no increase was seen in candidemia or enterococcal bacteremia. In patients with pneumonia, S aureus (17%) was the most frequently reported isolate. Of reported isolates, 59% were gram-negative bacilli. In patients with UTIs, Escherichia coli (19%) was the most frequently reported isolate. Of reported isolates, 31% were fungi. In patients with surgical-site infections, Enterococcus (17%) was the single most frequently reported pathogen. Device-associated nosocomial infection rates for BSIs, pneumonia, and UTIs did not correlate with length of ICU stay, hospital bed size, number of beds in die ICU, or season. Combined MS ICUs in major teaching hospitals had higher device-associated infection rates compared to all other hospitals with combined medical-surgical units. Conclusions: Nosocomial infections in MS ICUs at the most frequent infection sites (bloodstream, urinary, and respiratory tract) almost always were associated with use of an invasive device. Device-associated infection rates were die best available comparative rates between combined MS ICUs, but the distribution of device-associated rates should be stratified by a hospital's major teaching affiliation status.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/C5A1B06E85C31B90EE9080894D592262/S0195941700043137a.pdf/div-class-title-nosocomial-infections-in-combined-medical-surgical-intensive-care-units-in-the-united-states-div.pdf

Nosocomial infections in combined medical-surgical intensive care units in The United States

The aim of this prospective cohort study was to identify the risk factors involved in falls in 190 elderly residents of two geriatric centres in Granada (Andalusia, Spain). Because different types of falls may be associated with different factors, falls were classified according to the precipitating cause, either extrinsic or intrinsic. The incidence density and the ratios for crude and adjusted density were calculated. Cox proportional risk analysis was used to calculate adjusted incidence density ratios. Of the 121 falls identified, 63 (52.1%) had a extrinsic precipitating cause, 43 (35.5%) had an intrinsic precipitating cause, and no precipitating cause was determined in 15 falls. The rate of falls with an extrinsic precipitating cause was 0.39 per person per year, while falls with an intrinsic precipitating cause showed a frequency of 0.27 per person per year. For falls with an extrinsic precipitating cause, the most significant risk factors were: age, diabetes mellitus, a history of falling, and treatment with neuroleptics or oral bronchodilators. The number of illnesses acted as a protective factor. For falls with an intrinsic precipitating cause, the independent risk factors were: age, diabetes, dementia, alterations of gait and balance, previous falls, and treatment with digitalins, neuroleptics or antidepressants. These results suggest that the susceptibility to a fall with an intrinsic precipitating cause is easier to identify and has a greater potential for being controlled.

Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes.

Objective: To assess the impact of nosocomial infection on the mortality rate in an intensive care unit (ICU) Design: Prospective cohort study Setting: The ICU of the University of Granada Hospital in Spain Patients: All patients (n=279) admitted for ≥48 hrs at the ICU between December 1986 and April 1988 Measurements: Nosocomial infections were diagnosed according to Study on the Efficacy of Nosocomial Infection Control (SENIC) and Centers for Disease Control criteria Patient severity on admission (using Acute Physiology and Chronic Health Evaluation (APACHE II) and Therapeutic Intensity Scoring Systems were also used Results: Mortality risk was 248 times higher in patients with a nosocomial infection than in noninfected patients Relative risk of mortality in nosocomially infected patients was higher in young and less severely ill patients, in those patients with respiratory diseases, and in those patients with longer ICU stays Logistic stepwise regression analysis, adjusting for several confounding factors (affected organ system, APACHE II score, and therapeutic intensity), showed that the risk of death in nosocomially infected patients was 21 times greater (95% confidence interval = 10 to 441) than in patients without such infection Conclusions: Nosocomial infection increases the risk of death The effect is stronger in younger and less severely ill patients (Crit Care Med 1994; 22:55-60)

Influence of nosocomial infection on mortality rate in an intensive care unit

Menopausal hormone replacement therapy and breast cancer: a meta-analysis.

Objective: To assess the effect of driver dependent factors on the risk of causing a collision for two wheeled motor vehicles (TWMVs). Design: Case control study. Setting: Spain, from 1993 to 2002. Subjects: All drivers of TWMVs involved in the 181 551 collisions between two vehicles recorded in the Spanish registry which did not involve pedestrians, and in which at least one of the vehicles was a TWMV and only one driver had committed a driving infraction. The infractor and non-infractor drivers constituted the case and control groups, respectively. Main outcome measures: Logistic regression analyses were used to obtain crude and adjusted odds ratio estimates for each of the driver related factors recorded in the registry (age, sex, nationality, psychophysical factors, and speeding infractions, among others). Results: Inappropriate speed was the variable with the greatest influence on the risk of causing a collision, followed by excessive speed and driving under the influence of alcohol. Younger and older drivers, foreign drivers, and driving without a valid license were also associated with a higher risk of causing a collision. In contrast, helmet use, female sex, and longer time in possession of a driving license were associated with a lower risk. Conclusions: Although the main driver dependent factors related to the risk of causing a collision for a TWMV were similar to those documented for four wheeled vehicles, several differences in the pattern of associations support the need to study moped and motorcycle crashes separately from crashes involving other types of vehicles.

https://injuryprevention.bmj.com/content/injuryprev/11/4/225.full.pdf

Ramón Gálvez-Vargas

Papers

Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes.

Influence of nosocomial infection on mortality rate in an intensive care unit

Menopausal hormone replacement therapy and breast cancer: a meta-analysis.

Driver dependent factors and the risk of causing a collision for two wheeled motor vehicles

Unplanned pregnancy as a major determinant in inadequate use of prenatal care.