Objective:There is a paucity of information regarding the mortality profile in community-dwelling elderly as well as the associated risk factors for mortality. The primary objective was to report the 6-year mortality profile in free-living elderly population aged 65 years and above from Ernakulam, Kerala, India via longitudinal follow-up. Methods:The study was a prospective cohort with stratified random cluster sampling. We collected baseline information via house visits using a predefined questionnaire. The subjects were followed up after recruitment for a median of 60 months by phone calls at regular intervals. Calls not answered were followed up by house visits by research personnel. All deaths were verified by reviewing medical records available at subjects' homes. Results:We recruited a total of 1000 participants from 40 individual predesignated clusters (cluster size=25). The median follow-up was 71.8 (70.5-72.8) months and the cumulative follow-up was 5352.16 person years. A total of 262 (26.2%) subjects died during the follow-up period. The mortality rate for the overall cohort was 48.95 per 1000 person years. The corresponding figures for elderly men and women were 54.25 and 45.07 per 1000 person years, respectively. The mortality rate for elderly subjects residing in rural and urban areas was 57.59 and 45.33 per 1000 person years, respectively. Independent predictors of mortality in the study population identified by Cox regression-based analysis were age, sex, orthostatic hypotension, dependence in instrumental activities of daily living and adiposity. Conclusions:Approximately a quarter of community-dwelling elderly individuals died within the next 6 years. Future interventions targeting a reduction in mortality among the elderly need to focus on modifiable risk factors like orthostatic hypotension, adiposity and dependence in instrumental activities of daily living.

BACKGROUND:No data compare newer-generation transcatheter heart valves (THVs) in terms of next-day discharge (NDD) following transfemoral (TF) transcatheter aortic valve implantation (TAVI). AIMS:We aimed to evaluate the safety of NDD in unselected patients who received ACURATE (neo/neo2), Evolut (PRO/PRO+/FX) and the SAPIEN (3/Ultra) THVs. METHODS:This multicentre registry included patients who underwent TF-TAVI without a preprocedural permanent pacemaker implantation (PPI) and were discharged the next day without a new PPI. The primary endpoint was unplanned readmissions at 30 days. Multinomial gradient-boosted inverse probability of treatment-weighted (IPTW) propensity scores (stage 1) followed by the modified Poisson regression (stage 2) approach were used to compare the average effects of the THVs on the primary outcome. RESULTS:A total of 963 all-comer patients (ACURATE=264, Evolut=306, and SAPIEN=393) were included in this study. ACURATE patients were older (p<0.001) and included a greater proportion of females (p<0.001), whereas Evolut patients had a higher risk profile as assessed by the Society of Thoracic Surgeons score (p=0.01). There were no differences between the groups in terms of right or left bundle branch block (p=0.75). At 30 days, the overall readmission rate was 8%, and there were no differences in cardiac (ACURATE 4.6% vs Evolut 4.2% vs SAPIEN 3.1%; p=0.56) or non-cardiac readmissions (ACURATE 4.6% vs Evolut 3.3% vs SAPIEN 4.6%; p=0.64). Readmission for new PPI was 2.7%, 1.0% and 1.8% (p=0.32) and for heart failure (HF) was 1.5%, 2.0% and 1.3% (p=0.76) in ACURATE, Evolut and SAPIEN patients, respectively. The IPTW propensity score model followed by modified Poisson regression indicate that, using ACURATE as the reference, no significant differences were found in 30-day readmissions (relative risk [RR] 0.76, 95% confidence interval [CI]: 0.38-1.52; p=0.38 for Evolut and RR 0.74, 95% CI: 0.44-1.22; p=0.28 for SAPIEN). CONCLUSIONS:In pacemaker-naïve patients undergoing TF-TAVI with newer-generation THVs, NDD was not associated with a negative impact on overall 30-day readmissions, cardiac or non-cardiac readmissions, readmissions for PPI or HF after discharge, or mortality, regardless of the type of THV.

Context: There is limited data related to compliance of secondary prevention strategies for coronary artery diseases (CAD) among patients with and without diabetes. Objectives: The objective was to compare compliance to secondary prevention strategies for CAD including smoking cessation, weight management, blood pressure (BP) control, Low density lipoprotein (LDL) cholesterol control and adequate physical activity between patients with and without diabetes. Settings and Design: This is a hospital-based cross-sectional analytical study. Methods and Materials: The study questionnaire was used to collect data through interviews of CAD patients. Compliance to secondary prevention strategies was documented using European Society of Cardiology guidelines. Statistical Analysis: We used modified Poisson model to estimate adjusted prevalence ratios (Adj. PR) for estimating compliance. Results: Among 1,206 participants with CAD, 609 (50.5%) had diabetes. The Adj. PR s for three targets – smoking cessation (Adj. PR 1.01, 95% CI 0.97, 1.06, P 0.50), ideal BMI (Adj. PR 0.99, 95% CI 0.92, 1.09, P 0.99) and adequate physical activity (Adj. PR 1.12, 95% CI 0.97, 1.29, P 0.12) showed no significant difference between the groups. There was poor BP control in patients with diabetes compared to those without the same (Adj. PR 0.19, 95% CI 0.15, 0.23, P < 0.0001). LDL cholesterol control was better in patients with diabetes in comparison to those without the same (Adj. PR 1.19, 95% CI 1.08, 1.31, P 0.0005). Conclusion: The compliance for secondary prevention of CAD among patients with diabetes is similar to those without diabetes except for poor control of hypertension and better control of LDL cholesterol.

Background: Health-related quality of life (HRQOL) is emerging as an important outcome among patients with documented coronary artery disease (CAD). The primary objective of this study was to report the HRQOL of CAD patients under secondary prevention-related treatment and follow-up using the 36-Item Short Form (SF-36) tool. Methods: This was an analytical cross-sectional survey done in a hospital/clinic setting. We recruited CAD patients 30 to 80 years old with 1 to 6 years of follow-up. Patients self-reported HRQOL using SF-36. Results: We recruited 1206 patients, among whom 879 (72.9%) were male. The mean age of patients was 61.3 (9.6) years. Mean (± standard deviation) scores for physical functioning, role limitations due to physical health, pain, and general health were 66.48 ± 29.41, 78.96 ± 28.01, 80.96 ± 21.15, and 51.49 ± 20.19, respectively. The scores for role limitations due to emotional problems, energy/fatigue, emotional well-being, and social functioning were 76.62 ± 28.0, 66.18 ± 23.92, 76.91 ± 20.47, and 74.49 ± 23.55. In subgroup analysis, age, sex, type of CAD, and treatment showed no significant association with any of the 8 domains of QOL. In addition, hypertension and diabetes showed no significant association with the individual domains of HRQOL. Conclusion: Patients with coronary artery disease under secondary prevention-related treatment have suboptimal HRQOL under both physical and mental domains. The role of demographic factors, comorbidities, disease subtypes, and treatment options in modifying HRQOL among patients with CAD appears to be minimal.

Background Contrast‐induced acute kidney injury (CI‐AKI) is a serious complication after percutaneous coronary intervention. The mainstay of CI‐AKI prevention is represented by intravenous hydration. Tailoring infusion rate to patient volume status has emerged as advantageous over fixed infusion‐rate hydration strategies. Methods and Results A systematic review and network meta‐analysis with a frequentist approach were conducted. A total of 8 randomized controlled trials comprising 2312 patients comparing fixed versus tailored hydration strategies to prevent CI‐AKI after percutaneous coronary intervention were included in the final analysis. Tailored hydration strategies included urine flow rate–guided, central venous pressure–guided, left ventricular end‐diastolic pressure–guided, and bioimpedance vector analysis–guided hydration. Primary endpoint was CI‐AKI incidence. Safety endpoint was incidence of pulmonary edema. Urine flow rate–guided and central venous pressure–guided hydration were associated with a lower incidence of CI‐AKI compared with fixed‐rate hydration (odds ratio [OR], 0.32 [95% CI, 0.19–0.54] and OR, 0.45 [95% CI, 0.21–0.97]). No significant difference in pulmonary edema incidence was observed between the different hydration strategies. P score analysis showed that urine flow rate–guided hydration is advantageous in terms of both CI‐AKI prevention and pulmonary edema incidence when compared with other approaches. Conclusions Currently available hydration strategies tailored on patients' volume status appear to offer an advantage over guideline‐supported fixed‐rate hydration for CI‐AKI prevention after percutaneous coronary intervention. Current evidence suggests that urine flow rate–guided hydration as the most convenient strategy in terms of effectiveness and safety.

Objectives There is limited knowledge regarding epidemiology and risk of falls among the elderly living in low-income and middle-income countries. In this situation, the current study aims to report the incidence of falls and associated risk factors among free living elderly population from Kerala, India. Design Prospective cohort study with stratified random cluster sampling. Setting The study location was Ernakulam, Kerala, India, and we collected information via house visits using a questionnaire. During the research, the subjects were followed up prospectively for 1 year by phone at intervals of 3 months and missing subjects were contacted by house visits. Participants Community-dwelling elderly above 65 years of age. Results We recruited a total of 1000 participants out of which a total of 201 (20.1%) subjects reported a fall during the follow-up. The incidence rate of falls was 31 (95% CI 27.7 to 34.6) per 100 person-years. Female sex (OR 1.48, 95% CI 1.05 to 2.10, p=0.027), movement disorders including Parkinsonism (OR 2.26, 95% CI 1.00 to 5.05, p=0.048), arthritis (OR 1.48, 95% CI 1.05 to 2.09, p=0.026), dependence in basic activities of daily living (OR, 3.49, 95% CI 2.00 to 6.09, p<0.001), not using antihypertensive medications (OR, 1.53, 95% CI 1.10 to 2.13, p=0.012), living alone during daytime (OR 3.27, 95% CI 1.59 to 6.71, p=0.001) and a history of falls in the previous year (OR, 2.25, 95% CI 1.60 to 3.15, p<0.001) predicted a fall in the following year. Conclusions One in five community-dwelling senior citizen fall annually and one in four who fall are prone to fall again in the following year. Interventions targeting falls among the elderly need to focus on modifiable risk factors such as living alone during daytime, movement disorders, arthritis and dependence on basic activities of daily living.

Objectives The primary objective of the study was to report the compliance to secondary prevention strategies for coronary artery disease (CAD), such as smoking cessation, weight management, low-density lipoprotein (LDL) cholesterol control, blood pressure control, glycaemic control, physical activity and cardiovascular drug therapy from a resource-limited setting. Design Analytical cross-sectional survey with data collection using questionnaire administered by study personnel. Setting Institutional—two tertiary care hospitals and two cardiology clinics. Participants Patients in the age group of 30–80 years with documented CAD with a minimum of 1 year and a maximum of 6 years of follow-up after diagnosis. Main outcome measures The main outcome measures were the prevalence of individual compliance to secondary prevention strategies for CAD such as smoking cessation, weight management, LDL cholesterol control, blood pressure control, glycaemic control, physical activity and cardiovascular drug therapy. The secondary outcomes were the association of secondary prevention strategies with age, sex, domicile, socioeconomic status, insurance and type of treatment. Results We recruited a total of 1206 patients among whom 879 (72.9%) were males. The median age of patients was 62 (14) years. The compliance to smoking cessation was 93.86% (95% CI 91.66% to 96.06%), ideal body mass index was 63.76% (95% CI 61.05% to 66.47%), blood pressure control was 65.11% (95% CI 62.42% to 67.80%), LDL compliance was 36.50% (95% CI 33.18% to 39.82%), diabetes control was 51.23% (95% CI 46.10% to 56.36%) and adequate physical activity was 39.22% (95% CI 36.46% to 41.98%)respectively. Reported compliance for cardiovascular drugs therapy was 96% for antiplatelets, 89.4% for statins, 68.2% for beta blockers, 37.7% for renin angiotensin aldosterone system blockers, 81.28% for oral hypoglycaemic agents and 22% for insulin therapy. Conclusion Compliance to secondary prevention strategies for CAD in resource limited settings are moderate. This needs further improvement for better outcomes related to CAD in future.

Background: The relationship among pain catastrophizing, emotional disorders, and total joint arthroplasty (TJA) outcomes is an emerging area of study. The purpose of this study is to examine the association of these factors with 1-year postoperative pain and functional outcomes. Methods: A prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Postoperative outcomes included Visual Analog Scale (VAS) pain, Oxford, Harris Hip (HHS) and Knee Society (KSS) scores. Median regression was used to assess the pattern of relationship among preoperative clinically relevant catastrophizing (CRC) pain, abnormal HADS, and 1-year postoperative outcomes. Results: We recruited 463 TJA patients, all of which completed 1-year follow-up. At 1 year, CRC-rumination (adjusted median difference 1; 95% confidence interval [CI] 0.31-1.69, P=.005) and abnormal HADS-A (adjusted median difference 1; 95% CI 0.36-1.64, P=.002) were predictors of VAS pain, CRC magnification a predictor of HHS/KSS (adjusted median difference 1.3; 95% CI 5.23-0.11, P=.041), and abnormal HADS-A a predictor of Oxford (adjusted median difference 3.68; 95% CI 1.38-5.99, P=.002). CRC patients demonstrated inferior VAS pain (P=.001), Oxford (P<.0001), and HHS/KSS (P=.025). Abnormal HADS patients demonstrated inferior postoperative VAS (HADS-A, P=.025; HADS-D, P=.030) and Oxford (HADS-A, P=.001; HADS-D, P=.030). However, patients with CRC experienced significant improvement in VAS, Oxford, and HHS/KSS (P<.05) from preoperative to 1 year. Similarly, patients with abnormal HADS showed significant improvement in VAS pain and HHS/KSS (P<.05). Conclusion: TJA patients who are anxious, depressed, or pain catastrophizing have inferior preoperative and postoperative pain and function. However, as compared to their preoperative status, clinically significant improvement can be expected following hip/knee arthroplasty. (C) 2021 Elsevier Inc. All rights reserved.

The relationship between pain catastrophizing and emotional disorders including anxiety and depression in patients with hip or knee osteoarthritis undergoing total joint replacement (TJR) is an eme...

Objective To assess the effects of different oral antithrombotic drugs that prevent saphenous vein graft failure in patients undergoing coronary artery bypass graft surgery. Design Systematic review and network meta-analysis. Data sources Medline, Embase, Web of Science, CINAHL, and the Cochrane Library from inception to 25 January 2019. Eligibility criteria for selecting studies Randomised controlled trials of participants (aged ≥18) who received oral antithrombotic drugs (antiplatelets or anticoagulants) to prevent saphenous vein graft failure after coronary artery bypass graft surgery. Main outcome measures The primary efficacy endpoint was saphenous vein graft failure and the primary safety endpoint was major bleeding. Secondary endpoints were myocardial infarction and death. Results This review identified 3266 citations, and 21 articles that related to 20 randomised controlled trials were included in the network meta-analysis. These 20 trials comprised 4803 participants and investigated nine different interventions (eight active and one placebo). Moderate certainty evidence supports the use of dual antiplatelet therapy with either aspirin plus ticagrelor (odds ratio 0.50, 95% confidence interval 0.31 to 0.79, number needed to treat 10) or aspirin plus clopidogrel (0.60, 0.42 to 0.86, 19) to reduce saphenous vein graft failure when compared with aspirin monotherapy. The study found no strong evidence of differences in major bleeding, myocardial infarction, and death among different antithrombotic therapies. The possibility of intransitivity could not be ruled out; however, between-trial heterogeneity and incoherence were low in all included analyses. Sensitivity analysis using per graft data did not change the effect estimates. Conclusions The results of this network meta-analysis suggest an important absolute benefit of adding ticagrelor or clopidogrel to aspirin to prevent saphenous vein graft failure after coronary artery bypass graft surgery. Dual antiplatelet therapy after surgery should be tailored to the patient by balancing the safety and efficacy profile of the drug intervention against important patient outcomes. Study registration PROSPERO registration number CRD42017065678.

BackgroundFragmented QRS (fQRS) on electrocardiography is potentially valuable in prognosticating acute pulmonary embolism (PE). ECG is one of the first tests performed in the emergency department, quickly interpretable, noninvasive, inexpensive, and available in remote areas. We aimed to review fQRS's role in PE prognostication.MethodsWe searched MEDLINE, EMBASE, Google Scholar, Web of Science, abstracts, conference proceedings, and reference lists until October 2017. Eligible studies used fQRS to prognosticate patients for the main outcomes of death and clinical deterioration or escalation of therapy. Two authors independently selected studies, with disagreement resolved by consensus. Ad hoc piloted forms were used to extract data and assess risk of bias. We used a random‐effects model to pool relevant data in meta‐analysis with odds ratios (OR) and 95% confidence intervals (CI), while all other data were synthesized qualitatively. Statistical heterogeneity was assessed using the I2 index.ResultsWe included five studies (1,165 patients). There was complete agreement in study selection. fQRS significantly predicted in‐hospital mortality (OR [95% CI], 2.92 [1.73–4.91]; p < .001), cardiogenic shock (OR [95% CI], 4.71 [1.61–13.70]; p = .005), and total mortality at 2‐year follow‐up (OR [95% CI], 4.42 [2.57–7.60]; p < .001). Adjusted analyses were generally consistent with these results.ConclusionAlthough few studies have explored the current study's question, they showed that fQRS is potentially valuable in PE prognostication. fQRS should be considered as an entry, along with other clinical and ECG findings, in a PE risk score.

The relationship between pain catastrophising and emotional disorders including anxiety and depression in patients with osteoarthritis (OA) undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between pain catastrophising, anxiety, depression and preoperative patient characteristics.A prospective cohort study of preoperative TJR patients at one centre over 12-months was conducted. We examined association between catastrophising, anxiety, depression and preoperative patient characteristics including demographics, pain and function. Pain catastrophising was assessed using the Pain Catastrophising Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D). Patient perceived level of hip/knee pain was measured using a visual analogue (VAS) pain scale. Patient perception of function was measured using the Oxford Score. Preoperative radiographic grading of OA was determined using the Kellgren and...

Introduction The current evidence for the prevention of saphenous vein graft failure (SVGF) after coronary artery bypass graft (CABG) surgery consists of direct head-to-head comparison of treatments (including placebo) in randomised-controlled trials (RCTs) and observational studies. However, summarising the evidence using traditional pairwise meta-analyses does not allow the inclusion of data from treatments that have not been compared head to head. Exclusion of such comparisons could impact the precision of pooled estimates in a meta-analysis. Hence, to address the challenge of whether aspirin alone or in addition to another antithrombotic agent is a more effective regimen to improve SVG patency, a network meta-analysis (NMA) is necessary. The objectives of this study are to synthesise the available evidence on antithrombotic agents (or their combination) and estimate the treatment effects among direct and indirect treatment comparisons on SVGF and major adverse cardiovascular events, and to generate a treatment ranking according to their efficacy and safety outcomes. Methods We will perform a systematic review of RCTs evaluating antithrombotic agents in patients undergoing CABG. A comprehensive English literature search will be conducted using electronic databases and grey literature resources to identify published and unpublished articles. Two individuals will independently and in duplicate screen potential studies, assess the eligibility of potential studies and extract data. Risk of bias and quality of evidence will also be evaluated independently and in duplicate. We will investigate the data to ensure its suitability for NMA, including adequacy of the outcome data and transitivity of treatment effects. We plan to estimate the pooled direct, indirect and the mixed effects for all antithrombotic agents using a NMA. Ethics and dissemination Due to the nature of the study, there are no ethical concerns nor informed consent required. We anticipate that this NMA will be the first to simultaneously assess the relative effects of multiple antithrombotic agents in patients undergoing CABG. The results of this NMA will inform clinicians, patients and guideline developers the best available evidence on comparative effects benefits of antithrombotic agents after CABG while considering the side effect profile to support future clinical decision-making. We will disseminate the results of our systematic review and NMA through a peer-reviewed journal. PROSPERO registration number CRD42017065678.

Background: A cross-sectional study of total knee arthroplasty (TKA) patients was conducted to determine the association of lower-extremity arterial calcification (LEAC) with acute perioperative cardiovascular events (CVEs). Methods: Regression modeling was used to examine the association of radiographic presence of LEAC and acute myocardial infarction (MI), perioperative CVE, 30-day CVE readmit, and 30-day and 1-year mortality. Results: Of 900 TKA patients, LEAC was identified in 21.1%. Of LEAC cases, 1.6% had an acute MI vs 0.1% of non-LEAC cases (P = .031). Perioperative CVE rate was 5.8% for LEAC vs 1.5% for non-LEAC (P = .002). Having LEAC was identified as a significant risk factor for a perioperative CVE (odds ratio [OR] 2.83; 95% confidence interval [CI] 1.09-7.35). Because of limited number of acute MI events, absence of 30-day CVE readmit, 30-day mortality, and few 1-year mortality events, computing OR for these was not possible. Likewise, because of small number of events (n = 3), estimates for the odds of LEAC cases having an acute MI are less reliable, yielding extremely large random errors (OR 11.37; 95% CI 0.09-597.93) and must be interpreted with caution. The OR for 1-year mortality was 1.88 (95% CI 0.17-13.20), but again with large random errors. Conclusion: Our study shows that LEAC around the knee is associated with an increased risk of having a perioperative CVE. Crude radiographic detection of LEAC around the knee has the potential to improve risk stratification for TKA patients by informing the surgeon of the need for further preoperative cardiac workup. (c) 2017 Elsevier Inc. All rights reserved.

Aims To compare the effectiveness of transitional care services in decreasing all-cause death and all-cause readmissions following hospitalization for heart failure (HF). Methods and results We searched PubMed, Embase, CINAHL, and Cochrane Clinical Trials Register for randomized controlled trials (RCTs) published in 2000-2015 that tested the efficacy of transitional care services in patients hospitalized for HF, provided >= 1month of follow-up, and reported all-cause mortality or all-cause readmissions. Our network meta-analysis included 53 RCTs (12 356 patients). Among services that significantly decreased all-cause mortality compared with usual care, nurse home visits were most effective [ranking P-score 0.6794; relative risk (RR) 0.78, 95% confidence intervals (CI) 0.62-0.98], followed by disease management clinics (DMCs) (ranking P-score 0.6368; RR 0.80, 95% CI 0.67-0.97). Among services that significantly decreased all-cause readmission, nurse home visits were most effective [ranking P-score 0.8365; incident rate ratio (IRR) 0.65, 95% CI 0.49-0.86], followed by nurse case management (NCM) (ranking P-score 0.6168; IRR 0.77, 95% CI 0.63-0.95), and DMCs (ranking P-score 0.5691; IRR 0.80, 95% CI 0.66-0.97). There was no significant difference in the comparative effectiveness of services that improved each outcome. Nurse home visits had the greatest pooled cost-savings (3810 USD, 95% CI 3682-3937), followed by NCM (3435 USD, 95% CI 3224-3645), and DMCs (245 USD, 95% CI -70 to 559). Telephone, telemonitoring, pharmacist, and education interventions did not significantly improve clinical outcomes. Conclusion Nurse home visits and DMCs decrease all-cause mortality after hospitalization for HF. Along with NCM, they also reduce all-cause readmissions, with no significant difference in comparative effectiveness. These services reduce healthcare system costs to varying degrees.

This study sought to identify the primary indicators for evaluating shelter assistance following natural disasters and then to develop a shelter evaluation instrument based on these indicators. Electronic databases and the 'grey' literature were scoured for publications with a relation to post-disaster shelter assistance. Indicators for evaluating such assistance were extracted from these publications. In total, 1,525 indicators were extracted from 181 publications. A preliminary evaluation instrument was designed from these 1,525 indicators. Shelter experts checked the instrument for face and content validity, and it was revised subsequently based on their input. The revised instrument comprises a version for use by shelter agencies (48 questions that assess 23 indicators) and a version for use by beneficiaries (52 questions that assess 22 indicators). The instrument can serve as a standardised tool to enable groups to gauge whether or not the shelter assistance that they supply meets the needs of disaster-affected populations.

The role of electrocardiography (ECG) in prognosticating pulmonary embolism (PE) is increasingly recognized. ECG is quickly interpretable, noninvasive, inexpensive, and available in remote areas. We hypothesized that ECG can provide useful information about PE prognostication. We searched MEDLINE, EMBASE, Google Scholar, Web of Science, abstracts, conference proceedings, and reference lists through February 2017. Eligible studies used ECG to prognosticate for the main outcomes of death and clinical deterioration or escalation of therapy. Two authors independently selected studies; disagreement was resolved by consensus. Ad hoc piloted forms were used to extract data and assess risk of bias. We used a random-effects model to pool relevant data in meta-analysis with odds ratios (ORs) and 95% confidence intervals (CIs); all other data were synthesized qualitatively. Statistical heterogeneity was assessed using the I 2 value. We included 39 studies (9198 patients) in the systematic review. There was agreement in study selection (κ: 0.91, 95% CI: 0.86-0.96). Most studies were retrospective; some did not appropriately control for confounders. ECG signs that were good predictors of a negative outcome included S1Q3T3 (OR: 3.38, 95% CI: 2.46-4.66, P < 0.001), complete right bundle branch block (OR: 3.90, 95% CI: 2.46-6.20, P < 0.001), T-wave inversion (OR: 1.62, 95% CI: 1.19-2.21, P = 0.002), right axis deviation (OR: 3.24, 95% CI: 1.86-5.64, P < 0.001), and atrial fibrillation (OR: 1.96, 95% CI: 1.45-2.67, P < 0.001) for in-hospital mortality. Several ischemic patterns also were significantly predictive. Our conclusion is that ECG is potentially valuable in prognostication of acute PE.

Network meta-analysis is an extension of the conventional pair wise meta-analysis to include treatments that have not been compared head to head. It has in recent years caught the interest of clinical investigators in comparative effectiveness research. While allowing a simultaneous comparison of a large number of treatment effects, an inclusion of indirect effects (i.e., estimating effects using treatments that have not been randomized head to head) may introduce bias. This bias occurs from not accounting for covariates differences in the analysis, in a way that allows transfer of causal information across trials. Although this problem might not be entirely new to network meta-analysis researchers, it has not been given a formal treatment. Occasionally it is tackled by fitting a meta-regression model to account for imbalance of covariates. However, this approach may still produce biased estimates if covariates responsible for disparity across studies are post-treatment variables. To address the problem, we use the graphical method known as transportability to demonstrate whether and how indirect treatment effects can validly be estimated in network meta-analysis. See Video Abstract at http://links.lww.com/EDE/B37.

Background: Allergic rhinitis is the most common form of allergy worldwide. The accuracy of skin testing for allergic rhinitis is still debated. Our primary objective was to evaluate the diagnostic accuracy of skin-prick testing for allergic rhinitis using the nasal provocation as the reference standard. We also evaluated the diagnostic accuracy of intradermal testing as a secondary objective.Methods: We searched EBM Reviews from 2005 to March 2015; Embase from 1980 to March 2015; and Ovid MEDLINE(R) from 1946 to until March 2015. We included any study with at least 10 subjects including children. We excluded non-English studies. We performed data extraction and quality assessment using the QUADAS-2 tool.Results: We meta-analysed seven studies assessing the accuracy of skin-prick testing using the bivariate random-effects model, including a total of 430 patients. The pooled estimate for sensitivity and specificity for skin-prick testing was 85 and 77 % respectively. We did not pool results for intradermal testing due to few number of studies (n = 4), each with very small sample size. Of these, two evaluated the accuracy of intradermal testing in confirming skin-prick testing results, with sensitivity ranging from 27 to 50 % and specificity ranging from 60 to 100 %. The other two evaluated the accuracy of intradermal testing as a stand-alone test for diagnosing allergic rhinitis with sensitivity ranging from 60 to 79 % and specificity ranging from 68 to 69 %.Conclusions: Findings from this review suggest that skin-prick testing is accurate in discriminating subjects with or without allergic rhinitis.

BACKGROUND:The relationship between pain catastrophizing and emotional disorders including anxiety and depression in osteoarthritic patients undergoing total joint arthroplasty (TJA) is an emerging area of study. The purpose of this study was to examine the association of these factors with preoperative patient characteristics. METHODS:A prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale (PCS) and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Preoperative measures included visual analog pain scale (VAS), Harris Hip and Knee Society scores, Oxford Score, and Kellgren-Lawrence grade. Logistic and quantile regression were used to assess the relationship between preoperative characteristics and PCS or HADS, adjusting for covariate effects. RESULTS:We recruited 463 TJA patients. VAS pain (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.04-1.45) and Oxford (OR 1.13; 95% CI 1.07-1.20) were significant predictors for PCS and its subdomains excluding rumination. Oxford was the only significant predictor for abnormal HADS-A (OR 1.10; 95% CI 1.04-1.17). VAS pain (OR 1.27; 95% CI 1.02-1.52) and Oxford (OR 1.09; 95% CI 1.01-1.17) were significant predictors for abnormal HADS-D. The quantile regression showed similar patterns of association, with female gender, younger age, and higher ASA also associated with HADS-A. CONCLUSION:The most important predictor of catastrophizing, anxiety and/or depression in TJA patients is preoperative pain and poor subjective function. At-risk patients include those with increased pain and generally good clinical function, as well as younger women with significant comorbidities. Such patients should be identified and targeted psychological therapy implemented preoperatively to optimize coping strategies and adaptive behavior to mitigate potential for inferior TJA outcomes including pain and patient dissatisfaction.