Lipidcsökkentés Covid-19-járvány alatt

2021 ◽  
Vol 31 (5-6) ◽  
pp. 185-190
Author(s):  
László Márk
Keyword(s):  
Mortality Rate ◽  
Meta Analysis ◽  
Lipid Lowering ◽  
Evidence Based ◽  
Clinical Experiences ◽  
Angiotensin Converting Enzyme 2 ◽  
Cholesterol Levels ◽  
Threatening Condition ◽  
Life Threatening ◽  
Based Medicine

The COVID-19 pandemic posed significant challenges to all healthcare systems of the world as created a new situations above the large number of people infected, solutions of which were lacking any previous patterns. Former experiences were specifically needed among physicians who practised usually with therapies supported by evidence based clinical experiences thus they were working along the principles of Evidence-Based Medicine. The new observations and recommendations for treating infected patients increased gradually, however they were not always well-founded by the general urgency. In this situation, physicians faced often problems of the patient’s former medications since they had to focus on the therapy of the prevalent life-threatening condition. In such cases, therapy as lipid lowering, which is inherently inimically and lightly taken, may be omitted even more often. Basic drugs of lipid lowering are statins. They are used to reduce cholesterol levels and the risk of cardiovascular events, but they have also been described as having beneficial effect on the new viral infection. In this effect, the statins beyond the well-known anti-inflammatory impact and increasing the expression of angiotensin-converting enzyme-2 further mechanisms can take part as well. These may include among others the promoted breakdown of lipid rafts, which directly inhibits the entry of coronavirus into the cell through the S protein by decreasing the level of cholesterol required for this proceeding. In a group of more than 1200 statin treated and SARS-COV-2 infected patients the overall mortality rate by the 28th day was 48% lower than among the non-statin-users. According to a meta-analysis of nearly nine thousand COVID-19-infected statin users, they had 30% lower mortality rate or serious complications. Up to date observational studies suggest that statin therapy and the administration of other lipid lowering drugs should be continued or initiated according to the guidelines also during the COVID-19 infection.

scholarly journals Electronic Record Linkage cohort study of evidence-based management and outcomes in patients with ischaemic heart disease and atrial fibrillation

2021 ◽  
Author(s):  
◽  
Edward Daniel Harris
Keyword(s):  
Atrial Fibrillation ◽  
Heart Disease ◽  
Ischaemic Heart Disease ◽  
Evidence Based Medicine ◽  
Lipid Lowering ◽  
Evidence Based ◽  
Lipid Lowering Therapy ◽  
Lipid Levels ◽  
Increased Risk ◽  
Based Medicine

BACKGROUND Implementation of evidence-based medicine is often suboptimal. The objectives of this thesis are to explore the delivery of evidence-based medicine and outcomes in patients with ischaemic heart disease (IHD) and atrial fibrillation (AF). METHODS Retrospective observational cohort studies were conducted using linked anonymised data from the secure anonymised information linkage (SAIL) databank. Patients included (i) those undergoing percutaneous coronary intervention, (ii) patients prescribed vitamin K antagonist (VKA) for AF, and (iii) patients with AF who had undergone successful PCI. RESULTS Amongst patients directed to take clopidogrel for one-year post-PCI, discontinuation was far lower (~6%) than in previous studies where the treatment duration was not known. Despite this, early discontinuation and/or bleeding was associated with an increased risk of adverse events. In a national cohort of PCI patients, we observed a low rate of achievement of international guideline target lipid levels (<25%) and low prescribing of intensive lipid lowering therapy amongst those not at target. Females and patients who had undergone elective PCI were least likely to have their lipid levels documented and be at target. In patients prescribed VKA for AF guideline defined poor anticoagulation control was common and associated with significantly higher bleeding event rates, independent of common comorbidities that are recognised as risk factors for stroke and bleeding. In patients with AF who had undergone PCI outcomes were poor: approximately 1 in 5 had either a stroke, acute coronary syndrome (ACS) or died in the year follow-up. Bleeding events were also common and associated with a five, three and four-fold increased risk of stroke, ACS, and death. CONCLUSION This thesis has characterised the nature of multiple therapeutic gaps and associated adverse outcomes with common clinical conditions. Thus, identifying opportunities to improve outcomes in individual patients and at population level.

General considerations

2020 ◽  
pp. 11-72
Keyword(s):  
Intensive Care ◽  
Meta Analysis ◽  
Surgical Patient ◽  
Evidence Based ◽  
Paediatric Surgery ◽  
Neurologically Impaired ◽  
Legal Requirements ◽  
Day Case Surgery ◽  
Case Surgery ◽  
Based Medicine

This chapter covers the general considerations in safely and effectively performing paediatric surgery. It starts with the ethical and legal requirements, including withdrawal of treatment, treating children in the Jehovah’s Witness faith, and safeguarding. It then outlines evidence-based medicine, including meta-analysis, statistics, and reporting trials. Transport of the sick child, anaesthesia, analgesia, intensive care, sepsis, and the use of antibiotics in children are all covered. Day-case surgery, from its history to indications, pre- and postoperative care, and proper documentation, is described. Pre-assessment, care of the neurologically impaired child, basics of vascular access and radiology, and nutrition in the surgical patient are all covered.

Evidence-based approaches to psychiatry

2017 ◽  
pp. 119-134
Author(s):  
Paul Harrison ◽  
Philip Cowen ◽  
Tom Burns ◽  
Mina Fazel
Keyword(s):  
Patient Experience ◽  
Meta Analysis ◽  
Psychiatric Research ◽  
Evidence Based ◽  
High Quality ◽  
Qualitative Methodologies ◽  
Meta Analyses ◽  
Based Medicine ◽  
Quality Evidence

‘Evidence-based approaches to psychiatry’ describes the application of evidence-based medicine (EBM) to psychiatric practice. The chapter covers the key processes in EBM, including the formulation of a clinically relevant question, the systematic search for high-quality evidence and the meta-analytic synthesis of data. It demonstrates how evidence-based approaches to psychiatry have led to important developments showing quantitative effects of different treatments through advanced meta-analysis of data from randomized trials. This has underpinned the development of clinical guidelines that have the aim of improving the reliability and quality of treatments that patients receive. The chapter also describes how meta-analyses should be critically reviewed, as well as their problems and limitations. Not all relevant questions in psychiatric research are susceptible to the quantitative approach offered by EBM, and the chapter also outlines how qualitative methodologies can play a key role in answering important questions related, for example, to the patient experience.

Diverting Loop Ileostomy for Clostridium Difficile Colitis: A Systematic Review and Meta-analysis

2020 ◽  
Vol 86 (10) ◽  
pp. 1269-1276
Author(s):  
Adam D. Shellito ◽  
Marcia M. Russell
Keyword(s):  
Clostridium Difficile ◽  
Meta Analysis ◽  
Loop Ileostomy ◽  
Patient Characteristics ◽  
Specific Patient ◽  
Entire Cohort ◽  
Significant Difference ◽  
Threatening Condition ◽  
Life Threatening ◽  
Diverting Loop Ileostomy

Diverting loop ileostomy (DLI) with colonic lavage has been proposed as an alternative to total abdominal colectomy (TAC) for fulminant Clostridium difficile infection (CDI). Controversy exists regarding the mortality benefit and outcomes of this surgical approach. We conducted a MEDLINE database search for articles between 1999 and 2019 pertaining to DLI for the surgical treatment of CDI. Five articles met the inclusion criteria. Four studies were retrospective and one was a prospective matched cohort study. 3683 patients were included in the 5 studies; 733 patients (20%) underwent DLI, while 2950 patients (80%) underwent TAC. The only shared outcome measure across all 5 studies was mortality. The overall mortality rate for the entire cohort undergoing both procedures was 30.3%. There was no statistically significant difference in pooled mortality between DLI and TAC (OR: .73; 95% CI, .45-1.2; P = .22). Reporting of other postoperative outcomes was variable. Fulminant CDI remains a life-threatening condition with high mortality. Loop ileostomy may be a viable surgical alternative to total colectomy with similar mortality; however, further work is needed to determine specific patient characteristics that warrant routine use of DLI.

PS02.056: TIMELY LIGATION OF THORACIC DUCT IN POST ESOPHAGECTOMY CHYLE LEAK: KEY TO SUCCESSFUL MANAGEMENT

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 136-136
Author(s):  
Sanjeev Parshad ◽  
Parvinder Sandu ◽  
Shekar Gogna ◽  
Abhijeet Beniwal ◽  
Rajendra Karwasra
Keyword(s):  
Mortality Rate ◽  
Thoracic Duct ◽  
Conflicts Of Interest ◽  
Surrounding Tissue ◽  
Chyle Leak ◽  
Threatening Condition ◽  
Life Threatening ◽  
Carcinoma Esophagus ◽  
Esophagectomy For Cancer

Abstract Background Chyle leak after esophagectomy for carcinoma esophagus is a rare but life threatening condition with reported an incidence of 1–6%. Mortality rate of up to 50% have been reported. Management of chyle leak is controversial. We reviewed our experience with iatrogenic chylothorax after esophagectomy for carcinoma esophagus. Methods From 2003 to 2017, 560 patients underwent esophagectomy for cancer at our department of oncosurgery. Eight patients developed post operative chyle leak. Transthoracic or transabdominal ligation of duct was done in six patients with in first week. 100 ml of cream was given 30 min before induction to visualize the leak intraoperatively. We used 4–0 prolene pledgeted suture to ligate the duct. Results Six patients who underwent early ligation could be salvaged and the two who were managed conservatively succumbed. Oringer et al. pointed towards conservative treatment having little place in the management of chylothorax in nutritionally depleted patients. Hence, prompt ligation of thoracic duct decreases morbidity and mortality of chylothorax. Thus the role of early surgery needs to stressed. There is a wide difference of mortality rate of conservative management of 82% with respect to the mortality rate of surgery of 10–16%. Though no conclusion data are available regarding the indication and time point of surgical ligation of the thoracic duct, it is important not to procrastinate while the condition deteriorates to a level at which surgery would be detrimental.Administration of cream to the patient (through feeding jejunostomy) around half an hour before surgery makes identification of site of leak simpler.The importance of pledgeted sutures cannot be denied as the thoracic duct is paper thin and chyle contains no fibrin. Thus non pledgeted sutures will tear it further. Infact, stitching should not be done through the duct but into the surrounding tissue around the duct and should allow the pledgets to close the duct. Conclusion Disclosure All authors have declared no conflicts of interest.

Evidence-based medicine in anaesthesia

2017 ◽  
Author(s):  
Ann Merete Møller
Keyword(s):  
Evidence Based Medicine ◽  
Meta Analysis ◽  
Consort Statement ◽  
Current Evidence ◽  
Evidence Based ◽  
Clinical Question ◽  
Clinical Expertise ◽  
Clinical Databases ◽  
Patient Values ◽  
Based Medicine

Evidence-based medicine (EBM) is defined as ‘The judicious use of the best current evidence in making decisions about the care of individual patients’. Evidence-based medicine (EBM) is meant to integrate clinical expertise with the best available research evidence and patient values. The purpose of EBM is to assist clinicians in making the best decisions. Practising EBM includes asking an answerable, well-defined clinical question, searching for information, critically appraising information retrieved, extracting data, synthesizing data, and making conclusions about the overall effect. The clinical question includes information of the following elements: the population, the intervention, and the clinically relevant outcomes in focus. The clinical question is a tool to make the focus of the question clearer, and an aid to build the following search strategy. A comprehensive and reproducible literature search is essential for conducting a high-quality and up-to-date search. The search should include all relevant clinical databases. Papers retrieved after the search must be critically appraised and evaluated for the risk of bias. Evidence-based methods are used in the production of systematic reviews, and the development of clinical guidelines. Whether a meta-analysis should be performed depends on the quality and nature of the extracted data. Practising EBM may be challenged by a lack of well-performed trials, various types of bias (including publication bias), and heterogeneity between existing trials. Several tools have been constructed to help the process; examples are the CONSORT statement, the PRISMA statement, and the AGREE instrument.

scholarly journals What is a multiple treatments meta-analysis?

2012 ◽  
Vol 21 (2) ◽  
pp. 151-153 ◽  
Author(s):  
A. Cipriani ◽  
C. Barbui ◽  
C. Rizzo ◽  
G. Salanti
Keyword(s):  
Evidence Based Medicine ◽  
Treatment Effects ◽  
Meta Analysis ◽  
Evidence Based ◽  
Relative Efficacy ◽  
Analytical Technique ◽  
Multiple Treatments ◽  
Meta Analyses ◽  
Based Medicine ◽  
Indirect Comparisons

Standard meta-analyses are an effective tool in evidence-based medicine, but one of their main drawbacks is that they can compare only two alternative treatments at a time. Moreover, if no trials exist which directly compare two interventions, it is not possible to estimate their relative efficacy. Multiple treatments meta-analyses use a meta-analytical technique that allows the incorporation of evidence from both direct and indirect comparisons from a network of trials of different interventions to estimate summary treatment effects as comprehensively and precisely as possible.

scholarly journals Long-term efficacy of lipoprotein apheresis and lomitapide in the treatment of homozygous familial hypercholesterolemia (HoFH): a cross-national retrospective survey

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Laura D’Erasmo ◽  
Antonio Gallo ◽  
Angelo Baldassare Cefalù ◽  
Alessia Di Costanzo ◽  
Samir Saheb ◽  
...  
Keyword(s):  
Familial Hypercholesterolemia ◽  
Treatment Algorithm ◽  
Lipid Lowering ◽  
Homozygous Familial Hypercholesterolemia ◽  
Lipoprotein Apheresis ◽  
Term Efficacy ◽  
Threatening Condition ◽  
Life Threatening

Abstract Background Homozygous familial hypercholesterolemia (HoFH) is a rare life-threatening condition that represents a therapeutic challenge. The vast majority of HoFH patients fail to achieve LDL-C targets when treated with the standard protocol, which associates maximally tolerated dose of lipid-lowering medications with lipoprotein apheresis (LA). Lomitapide is an emerging therapy in HoFH, but its place in the treatment algorithm is disputed because a comparison of its long-term efficacy versus LA in reducing LDL-C burden is not available. We assessed changes in long-term LDL-C burden and goals achievement in two independent HoFH patients’ cohorts, one treated with lomitapide in Italy (n = 30) and the other with LA in France (n = 29). Results The two cohorts differed significantly for genotype (p = 0.004), baseline lipid profile (p < 0.001), age of treatment initiation (p < 0.001), occurrence of cardiovascular disease (p = 0.003) as well as follow-up duration (p < 0.001). The adjunct of lomitapide to conventional lipid-lowering therapies determined an additional 58.0% reduction of last visit LDL-C levels, compared to 37.1% when LA was added (padj = 0.004). Yearly on-treatment LDL-C < 70 mg/dl and < 55 mg/dl goals were only achieved in 45.5% and 13.5% of HoFH patients treated with lomitapide. The long-term exposure to LDL-C burden was found to be higher in LA than in Lomitapide cohort (13,236.1 ± 5492.1 vs. 11,656.6 ± 4730.9 mg/dL-year respectively, padj = 0.002). A trend towards fewer total cardiovascular events was observed in the Lomitapide than in the LA cohort. Conclusions In comparison with LA, lomitapide appears to provide a better control of LDL-C in HoFH. Further studies are needed to confirm this data and establish whether this translates into a reduction of cardiovascular risk.

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