BACKGROUND: Excessive drinking is a significant cause of mortality, morbidity and social problems in many countries. Brief interventions aim to reduce alcohol consumption and related harm in hazardous and harmful drinkers who are not actively seeking help for alcohol problems. Interventions usually take the form of a conversation with a primary care provider and may include feedback on the person's alcohol use, information about potential harms and benefits of reducing intake, and advice on how to reduce consumption. Discussion informs the development of a personal plan to help reduce consumption. Brief interventions can also include behaviour change or motivationally-focused counselling.This is an update of a Cochrane Review published in 2007.
OBJECTIVES: To assess the effectiveness of screening and brief alcohol intervention to reduce excessive alcohol consumption in hazardous or harmful drinkers in general practice or emergency care settings.
SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and 12 other bibliographic databases to September 2017. We searched Alcohol and Alcohol Problems Science Database (to December 2003, after which the database was discontinued), trials registries, and websites. We carried out handsearching and checked reference lists of included studies and relevant reviews.
SELECTION CRITERIA: We included randomised controlled trials (RCTs) of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. The comparison group was no or minimal intervention, where a measure of alcohol consumption was reported. 'Brief intervention' was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 minutes. Any more was considered an extended intervention. Digital interventions were not included in this review.
DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We carried out subgroup analyses where possible to investigate the impact of factors such as gender, age, setting (general practice versus emergency care), treatment exposure and baseline consumption.
MAIN RESULTS: We included 69 studies that randomised a total of 33,642 participants. Of these, 42 studies were added for this update (24,057 participants). Most interventions were delivered in general practice (38 studies, 55%) or emergency care (27 studies, 39%) settings. Most studies (61 studies, 88%) compared brief intervention to minimal or no intervention. Extended interventions were compared with brief (4 studies, 6%), minimal or no intervention (7 studies, 10%). Few studies targeted particular age groups: adolescents or young adults (6 studies, 9%) and older adults (4 studies, 6%). Mean baseline alcohol consumption was 244 g/week (30.5 standard UK units) among the studies that reported these data. Main sources of bias were attrition and lack of provider or participant blinding. The primary meta-analysis included 34 studies (15,197 participants) and provided moderate-quality evidence that participants who received brief intervention consumed less alcohol than minimal or no intervention participants after one year (mean difference (MD) -20 g/week, 95% confidence interval (CI) -28 to -12). There was substantial heterogeneity among studies (I² = 73%). A subgroup analysis by gender demonstrated that both men and women reduced alcohol consumption after receiving a brief intervention.We found moderate-quality evidence that brief alcohol interventions have little impact on frequency of binges per week (MD -0.08, 95% CI -0.14 to -0.02; 15 studies, 6946 participants); drinking days per week (MD -0.13, 95% CI -0.23 to -0.04; 11 studies, 5469 participants); or drinking intensity (-0.2 g/drinking day, 95% CI -3.1 to 2.7; 10 studies, 3128 participants).We found moderate-quality evidence of little difference in quantity of alcohol consumed when extended and no or minimal interventions were compared (-14 g/week, 95% CI -37 to 9; 6 studies, 1296 participants). There was little difference in binges per week (-0.08, 95% CI -0.28 to 0.12; 2 studies, 456 participants; moderate-quality evidence) or difference in days drinking per week (-0.45, 95% CI -0.81 to -0.09; 2 studies, 319 participants; moderate-quality evidence). Extended versus no or minimal intervention provided little impact on drinking intensity (9 g/drinking day, 95% CI -26 to 9; 1 study, 158 participants; low-quality evidence).Extended intervention had no greater impact than brief intervention on alcohol consumption, although findings were imprecise (MD 2 g/week, 95% CI -42 to 45; 3 studies, 552 participants; low-quality evidence). Numbers of binges were not reported for this comparison, but one trial suggested a possible drop in days drinking per week (-0.5, 95% CI -1.2 to 0.2; 147 participants; low-quality evidence). Results from this trial also suggested very little impact on drinking intensity (-1.7 g/drinking day, 95% CI -18.9 to 15.5; 147 participants; very low-quality evidence).Only five studies reported adverse effects (very low-quality evidence). No participants experienced any adverse effects in two studies; one study reported that the intervention increased binge drinking for women and two studies reported adverse events related to driving outcomes but concluded they were equivalent in both study arms.Sources of funding were reported by 67 studies (87%). With two exceptions, studies were funded by government institutes, research bodies or charitable foundations. One study was partly funded by a pharmaceutical company and a brewers association, another by a company developing diagnostic testing equipment.
AUTHORS' CONCLUSIONS: We found moderate-quality evidence that brief interventions can reduce alcohol consumption in hazardous and harmful drinkers compared to minimal or no intervention. Longer counselling duration probably has little additional effect. Future studies should focus on identifying the components of interventions which are most closely associated with effectiveness.
Antecedentes: La pancreatitis aguda es una de las razones más comunes y costosas de hospitalización en los Estados Unidos. El reposo intestinal, el control del dolor y los líquidos intravenosos son las piedras angulares del tratamiento, pero la alimentación temprana también podría ser beneficiosa. OBJETIVO: Comparar la duración de la estancia hospitalaria, la mortalidad y la readmisión en adultos hospitalizados con pancreatitis que recibieron alimentación temprana versus tardía. SELECCIÓN DEL ESTUDIO: Dos autores revisaron y seleccionaron estudios de manera independiente si se trataban de ensayos clínicos aleatorizados, incluidos adultos hospitalizados con pancreatitis aguda, y se compararon los resultados de las pruebas de detección precoz Versus la alimentación retardada (≤48 frente a> 48 horas después de la hospitalización). EXTRACCIÓN DE DATOS: Dos investigadores independientemente extrajeron los datos del estudio y clasificaron el riesgo de sesgo mediante la herramienta Cochrane Collaboration. SÍNTESIS DE DATOS: Once ensayos aleatorios (8 publicaciones revisadas por pares, 3 presentaciones abstractas) que incluyeron 948 pacientes fueron elegibles. Siete ensayos (3 con bajo riesgo de sesgo) incluyeron pacientes con pancreatitis leve a moderada. Cuatro ensayos (1 con bajo riesgo de sesgo) incluyeron pacientes con pancreatitis grave pronosticada. Las rutas utilizadas para la alimentación temprana incluyeron orales (4 estudios), nasogástricas (2 estudios), nasojejunales (4 estudios) y orales o nasoentéricas (1 estudio). Entre los pacientes con pancreatitis leve a moderada, la alimentación temprana se asoció con la reducción de la duración de la estancia en 4 de 7 estudios (incluyendo 2 de 3 con bajo riesgo de sesgo). Otros resultados fueron heterogéneos e informados de manera variable, pero ningún estudio mostró un aumento en los eventos adversos con la alimentación temprana. Entre los pacientes con pancreatitis severa, la evidencia limitada no reveló ninguna diferencia estadísticamente significativa en los resultados entre la alimentación temprana y tardía. LIMITACIÓN: Heterogeneidad de los protocolos y resultados de la alimentación, datos escasos y riesgo de sesgo poco claro o alto en varios estudios. CONCLUSIÓN: Los datos limitados sugieren que la alimentación temprana en pacientes con pancreatitis aguda no parece aumentar los eventos adversos y, en pacientes con pancreatitis leve a moderada, puede reducir la duración de la estancia hospitalaria. FUENTE DE FINANCIACIÓN PRIMARIA: Ninguna. (PROSPERO: CRD42015016193).
OBJETIVOS: Evaluar la influencia de la infección sobre la mortalidad en la pancreatitis necrotizante. MÉTODOS: Los estudios prospectivos y retrospectivos elegibles fueron identificados mediante búsquedas manuales y electrónicas (agosto de 2015). El riesgo de sesgo se evaluó utilizando la Escala Newcastle-Ottawa (NOS). Se realizaron metaanálisis con subgrupos, sensibilidad y análisis de meta-regresión para evaluar fuentes de heterogeneidad. Resultados Se incluyeron 71 estudios (n = 6970 pacientes). Treinta y siete (52%) estudios utilizaron un diseño prospectivo y 25 puntuaron ≥ 5 puntos en la NOS, lo que sugiere un bajo riesgo de sesgo. Cuarenta estudios fueron descriptivos y 31 estudios evaluaron intervenciones invasivas. En total, 801 de 2842 pacientes (28%) con necrosis infectadas y 537 de 4128 pacientes (13%) con necrosis estériles murieron con una odds ratio [OR] de 2,57 (intervalo de confianza del 95% [IC], 2,00-3,31) En todos los estudios y 2,02 (IC del 95%, 1,61-2,53) en los estudios con el menor riesgo de sesgo. La OR para los estudios prospectivos fue 2,96 (IC del 95%, 2,51-3,50). En los análisis de sensibilidad excluyendo los estudios que evaluaron las intervenciones invasivas, el OR fue 3,30 (IC del 95%, 2,81-3,88). Los pacientes con necrosis e insuficiencia de órganos infectados tuvieron una mortalidad del 35,2%, mientras que la necrosis estéril concomitante y la insuficiencia orgánica se asociaron con una mortalidad del 19,8%. Si los pacientes tenían necrosis infectada sin insuficiencia orgánica, la mortalidad fue del 1,4%. CONCLUSIONES: Los pacientes con pancreatitis necrotizante tienen más del doble de probabilidades de morir si la necrosis se infecta. Tanto la insuficiencia de órganos como la necrosis infectada aumentan la mortalidad en la pancreatitis necrotizante.
CONTEXTO: La utilidad de los principios de la colangiopancreatografía retrógrada endoscópica (CPRE) ± esfinterotomía endoscópica (EE) en el tratamiento de la pancreatitis biliar (SGP) sigue siendo polémica.
OBJETIVOS: El objetivo era llevar a cabo un meta-análisis de ensayos controlados aleatorios (ECA) que investiga el tratamiento del SGP por CPRE temprana ± ES frente a tratamiento conservador y el análisis de los resultados de los pacientes.
FUENTES DE DATOS: Una búsqueda en Medline, Embase, Science Citation Index, Current Contents, PubMed, y la Base de Datos Cochrane de Revisiones Sistemáticas identificado todos los ECA que compararon CPRE temprana al tratamiento conservador en GSP publicados entre enero de 1970 y enero de 2014. Los términos de búsqueda incluyeron "la colangiopancreatografía retrógrada endoscópica (CPRE)"; "Esfinterotomía endoscópica"; "Los cálculos biliares"; "cálculos del conducto biliar"; "Pancreatitis por cálculos biliares"; "Pancreatitis biliar"; "Randomize / Ensayos controlados aleatorios"; "El tratamiento conservador / tratamiento"; "Humano"; "Inglés."
CRITERIOS DE ELEGIBILIDAD estudio, los participantes y las intervenciones: Sólo ECA prospectivos que compararon la intervención temprana (es decir, entre 24 y 72 h) con la CPRE se incluyeron ± ES frente a tratamiento conservador en el SGP.
EVALUACIÓN DE ESTUDIOS Y MÉTODOS DE SÍNTESIS: Extracción de los datos y la evaluación crítica se llevó a cabo de forma independiente por 2 autores (MJB y MAM) usando campos de datos predefinidos. Las variables analizadas incluyeron la severidad de la pancreatitis (leve o grave), la mortalidad general, las complicaciones generales que incluyeron la formación de pseudoquiste, insuficiencia orgánica (renal, respiratoria y cardiaca), coagulación anormal, sepsis biliar, y el desarrollo de páncreas absceso / flemón. La calidad de los ECA se evaluó mediante sistema de puntuación de Jadad. Modelo de efectos aleatorios se utilizó para calcular los resultados de ambos datos binarios y continuos. La heterogeneidad entre las variables de resultado de estos ensayos se determinó mediante el estadístico y el índice Q de Cochran. El meta-análisis se ha elaborado de acuerdo con el PRISMA (Reporting Preferred Artículos para Revisiones Sistemáticas y Meta-análisis directrices).
RESULTADOS: Once ECA que consisten en 1.314 pacientes (tratamiento conservador = 662, CPRE = 652) fueron analizados. Hubo una disminución significativa cerca de la mortalidad para el grupo de CPRE en comparación con los pacientes manejados conservadoramente con pancreatitis grave [odds ratio (OR) 0,45; Intervalo de confianza del 95% (IC), 0,19, 1,09; P = 0,08]. En los pacientes con pancreatitis leve, resultados de mortalidad fueron similares en ambos grupos (OR 0,66; IC del 95%, 0,02, 28,75; P = 0,83). Complicaciones totales se redujeron significativamente en el grupo de CPRE en pacientes pancreáticos graves (OR 0,32; IC del 95%, 0,17, 0,61, p = 0,00). En aquellos con enfermedad leve, una fuerte tendencia a la disminución de las complicaciones en el grupo de CPRE fue visto, sin embargo, esto no fue significativa (OR 0,67; IC del 95%, 0,43, 1,03, p = 0,06).
CONCLUSIONES: Este metanálisis demuestra una disminución significativa de las complicaciones en pacientes con severa SGP logró con los primeros CPRE / ES en comparación con el tratamiento conservador. En lo que se refiere a la mortalidad, no se observó disminución significativa de la mortalidad incluso en pacientes SGP graves tratados con CPRE temprana / ES.
BACKGROUND: Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines.
METHODS: A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines.
RESULTS: Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles.
CONCLUSIONS: The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.
UNLABELLED: Varios estudios han mostrado resultados contradictorios en cuanto al rol de la profilaxis antibiótica en pancreatitis aguda necrotizante. Se llevó a cabo un metanálisis para investigar el impacto de la profilaxis antibiótica en la incidencia de pancreatitis necrotizante infectada y mortalidad.
MÉTODOS: Se recuperaron de la base de datos en línea ensayos controlados aleatorios y estudios de cohorte que investigaron el impacto del uso de antibióticos profilácticos en pancreatitis aguda necrotizante. Se realizó un análisis general con todos los estudios (Grupo 1), seguido de análisis de subgrupos con ensayos controlados aleatorios (Grupo 2) y estudios de cohorte (Grupo 3). Se usó el modelo de efectos aleatorios y se calculó en cada grupo los riesgos relativos (RR) según el impacto de la profilaxis antibiótica en la incidencia de necrosis pancreática infectada y mortalidad.
RESULTADOS: Se incluyeron once estudios que involucraron 864 pacientes. No se observaron diferencias significativas en la incidencia de necrosis pancreática infectada con el uso de profilaxis antibiótica utilizada en todos los grupos. El uso de antibióticos profilácticos no se asoció con diferencias significativas en mortalidad en el Grupo 2 (RR = 0,75; p = 0,24), pero se asoció con una reducción de mortalidad en los Grupos 1(RR = 0.66, p = 0.02) y 3 (RR = 0.55, p = 0.04). No hubo diferencia estadísticamente significativa en la incidencia de infecciones micóticas e intervenciones quirúrgicas.
CONCLUSIÓN: La profilaxis antibiótica no reduce significativamente la incidencia de necrosis pancreática infectada, pero puede afectar en la mortalidad en pancreatitis aguda necrotizante.
OBJETIVO: Revisar la literatura sobre terapia de fluidos objetivo dirigido y evaluar la calidad de la evidencia para cada combinación de objetivo y el método de monitoreo.
MATERIALES Y MÉTODOS: Se realizó una búsqueda de las principales bases de datos digitales y búsqueda manual de referencias. Fueron incluidos todos estudios de evaluación de la utilidad clínica de un objetivo o conjunto de objetivos que utilizan cualquier método de monitoreo fluidoterapia específico. Los datos se extrajeron mediante un pre-determinado pro forma y los papeles fueron evaluados utilizando los principios de GRADE para evaluar la calidad de las pruebas.
RESULTADOS: Ochenta y un documentos cumplieron los criterios de inclusión, la investigación de 31 metas y 22 métodos de control de la fluidoterapia en 13.052 pacientes. En total fueron 118 combinaciones objetivo / método diferente. Objetivos con alta calidad de las pruebas eran lactato venoso central y el índice de volumen sistólico. Objetivos con evidencia de calidad moderada fueron flujo sublingual microcirculación, la relación de extracción de oxígeno, índice cardíaco, el gasto cardíaco y el índice colapsabilidad SVC.
Conclusiones: Esta revisión ha puesto de manifiesto la gran cantidad de objetivos y métodos de control de la terapia de fluidos. Sorprendentemente, hay escasa evidencia de alta calidad, en particular para las combinaciones no invasivos G / M en los centros de atención no quirúrgicos y no intensivos. Hay una necesidad urgente de abordar esta brecha de investigación, que será ayudado por las metodologías para comparar la utilidad de combinaciones G / M.
Excessive drinking is a significant cause of mortality, morbidity and social problems in many countries. Brief interventions aim to reduce alcohol consumption and related harm in hazardous and harmful drinkers who are not actively seeking help for alcohol problems. Interventions usually take the form of a conversation with a primary care provider and may include feedback on the person's alcohol use, information about potential harms and benefits of reducing intake, and advice on how to reduce consumption. Discussion informs the development of a personal plan to help reduce consumption. Brief interventions can also include behaviour change or motivationally-focused counselling.This is an update of a Cochrane Review published in 2007.
OBJECTIVES:
To assess the effectiveness of screening and brief alcohol intervention to reduce excessive alcohol consumption in hazardous or harmful drinkers in general practice or emergency care settings.
SEARCH METHODS:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and 12 other bibliographic databases to September 2017. We searched Alcohol and Alcohol Problems Science Database (to December 2003, after which the database was discontinued), trials registries, and websites. We carried out handsearching and checked reference lists of included studies and relevant reviews.
SELECTION CRITERIA:
We included randomised controlled trials (RCTs) of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. The comparison group was no or minimal intervention, where a measure of alcohol consumption was reported. 'Brief intervention' was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 minutes. Any more was considered an extended intervention. Digital interventions were not included in this review.
DATA COLLECTION AND ANALYSIS:
We used standard methodological procedures expected by Cochrane. We carried out subgroup analyses where possible to investigate the impact of factors such as gender, age, setting (general practice versus emergency care), treatment exposure and baseline consumption.
MAIN RESULTS:
We included 69 studies that randomised a total of 33,642 participants. Of these, 42 studies were added for this update (24,057 participants). Most interventions were delivered in general practice (38 studies, 55%) or emergency care (27 studies, 39%) settings. Most studies (61 studies, 88%) compared brief intervention to minimal or no intervention. Extended interventions were compared with brief (4 studies, 6%), minimal or no intervention (7 studies, 10%). Few studies targeted particular age groups: adolescents or young adults (6 studies, 9%) and older adults (4 studies, 6%). Mean baseline alcohol consumption was 244 g/week (30.5 standard UK units) among the studies that reported these data. Main sources of bias were attrition and lack of provider or participant blinding. The primary meta-analysis included 34 studies (15,197 participants) and provided moderate-quality evidence that participants who received brief intervention consumed less alcohol than minimal or no intervention participants after one year (mean difference (MD) -20 g/week, 95% confidence interval (CI) -28 to -12). There was substantial heterogeneity among studies (I² = 73%). A subgroup analysis by gender demonstrated that both men and women reduced alcohol consumption after receiving a brief intervention.We found moderate-quality evidence that brief alcohol interventions have little impact on frequency of binges per week (MD -0.08, 95% CI -0.14 to -0.02; 15 studies, 6946 participants); drinking days per week (MD -0.13, 95% CI -0.23 to -0.04; 11 studies, 5469 participants); or drinking intensity (-0.2 g/drinking day, 95% CI -3.1 to 2.7; 10 studies, 3128 participants).We found moderate-quality evidence of little difference in quantity of alcohol consumed when extended and no or minimal interventions were compared (-14 g/week, 95% CI -37 to 9; 6 studies, 1296 participants). There was little difference in binges per week (-0.08, 95% CI -0.28 to 0.12; 2 studies, 456 participants; moderate-quality evidence) or difference in days drinking per week (-0.45, 95% CI -0.81 to -0.09; 2 studies, 319 participants; moderate-quality evidence). Extended versus no or minimal intervention provided little impact on drinking intensity (9 g/drinking day, 95% CI -26 to 9; 1 study, 158 participants; low-quality evidence).Extended intervention had no greater impact than brief intervention on alcohol consumption, although findings were imprecise (MD 2 g/week, 95% CI -42 to 45; 3 studies, 552 participants; low-quality evidence). Numbers of binges were not reported for this comparison, but one trial suggested a possible drop in days drinking per week (-0.5, 95% CI -1.2 to 0.2; 147 participants; low-quality evidence). Results from this trial also suggested very little impact on drinking intensity (-1.7 g/drinking day, 95% CI -18.9 to 15.5; 147 participants; very low-quality evidence).Only five studies reported adverse effects (very low-quality evidence). No participants experienced any adverse effects in two studies; one study reported that the intervention increased binge drinking for women and two studies reported adverse events related to driving outcomes but concluded they were equivalent in both study arms.Sources of funding were reported by 67 studies (87%). With two exceptions, studies were funded by government institutes, research bodies or charitable foundations. One study was partly funded by a pharmaceutical company and a brewers association, another by a company developing diagnostic testing equipment.
AUTHORS' CONCLUSIONS:
We found moderate-quality evidence that brief interventions can reduce alcohol consumption in hazardous and harmful drinkers compared to minimal or no intervention. Longer counselling duration probably has little additional effect. Future studies should focus on identifying the components of interventions which are most closely associated with effectiveness.
Pregunta de la revisión sistemática»Revisión sistemática de intervenciones
