Where is the supporting evidence for treating mild to moderate chronic obstructive pulmonary disease exacerbations with antibiotics? A systematic review

Foreign language learning can improve response inhibition in individuals with lower baseline cognition: Results from a randomized controlled superiority trial

Introduction

The world's population is aging, increasing the prevalence of dementia. Recently, foreign language learning in later life has been suggested to improve cognition and thus support healthy cognitive aging. To date, however, there are only a few studies with conflicting findings. Therefore, the purpose of this study was to examine whether learning a foreign language can improve executive attention and executive functions in healthy older adults. Additionally, we sought to identify factors affecting cognitive change in foreign language learners, such as cognitive reserve, previous foreign knowledge and usage, and global cognition at baseline.

Methods

In a randomized-controlled trial, we assigned 34 monolinguals between the ages of 65 and 80 to a language learning or a waiting list control group. The participants enrolled in a Spanish course for beginners that met five days a week for 1.5 h for a total of 3 weeks. The waiting list control group received no intervention but had the opportunity to join the language training at the end of the study. All participants underwent an assessment of executive attention (primary outcome), executive functions, verbal fluency, and attention (secondary outcomes) before, immediately after the course, or after a waiting period of 3 weeks for the control group and 3 months after the course or the waiting period.

Results

Foreign language learning did not significantly improve primary or secondary outcomes, neither immediately nor 3 months after the course. However, moderation analyses revealed that participants with lower global baseline cognition tended to improve more on response inhibition than individuals with higher baseline cognition. This relationship was not evident in the waiting list control group.

Discussion

Our results suggest that studying a foreign language does not generally improve executive attention or executive functioning. Nevertheless, individuals with poorer baseline cognition may benefit cognitively from foreign language learning in response inhibition, a domain particularly affected by cognitive aging. Our findings highlight the need of focusing dementia prevention efforts on groups that are more vulnerable to cognitive decline. Additionally, more individualized approaches, including utilizing technology-assisted learning, might enable participants to practice at their performance level, increasing the likelihood of discernible cognitive gains.

Clinical trial registration

https://drks.de/search/en, identifier DRKS00016552.

Are short courses of antibiotic therapy as effective as standard courses for COPD exacerbations? A systematic review and meta-analysis

BACKGROUND

The best duration of antibiotic treatment for chronic obstructive pulmonary disease (COPD) exacerbations is uncertain.

OBJECTIVE

To evaluate whether a short course of antibiotic therapy is as effective as the standard longer treatment for exacerbations of patients with COPD.

METHODS

We searched Pubmed/MEDLINE and trials in relevant systematic reviews from the inception up to March 2021, with no language restrictions. Randomised controlled trials comparing short-course antibiotic therapy (≤5 days) with standard antibiotic therapy (≥6 days) for exacerbations of patients aged ≥40 with spirometrically-confirmed COPD were included. Three outcomes were considered: end-of-therapy clinical cure, bacterial eradication and adverse events. Statistical analyses included random effects meta-analyses using odds ratios and assessment of heterogeneity.

RESULTS

Of 1274 citations found, eight were eligible for inclusion, seven of which recruited outpatients. Overall, short-course antibiotic treatments were not significantly different from those of long-course treatments for clinical cure (odds ratio [OR] 1.14, 95% CI 0.91; 1.44) and for bacterial eradication (OR 1.16, 95% CI 0.91; 1.48). Adverse events were observed in 379 (21.1%) patients receiving short-term antibiotic regimens, while 412 (22.8%) patients receiving the standard regimens reported adverse events (OR 0.83, 95% CI 0.62; 1.11). The heterogeneity of the studies was low.

CONCLUSION

In relation to clinical and bacteriological efficacy, a short course of antibiotic treatment is equivalent to longer conventional treatment in mainly outpatients with exacerbations of COPD. Moreover, shorter exposure to antibiotics may decrease the risk developing antimicrobial resistance and, hence, might become first-line therapy for the management of ambulatory COPD patients.

Effects of foreign language learning on executive functions in healthy older adults: study protocol for a randomised controlled trial

Background

With age, most cognitive functions decline. As the number of people aged 60 years and older is expected to rise rapidly within the next decades, identifying interventions that promote healthy cognitive ageing is of utmost importance. Promising research on bilingualism has led to the notion that learning a foreign language could protect against cognitive decline. Foreign language learning likely promotes executive functions, which are higher-order cognitive abilities particularly affected by age-related cognitive decline. However, evidence is still sparse and has produced contradictory results. This study aims to investigate the effects of short and intensive foreign language learning on executive functions in healthy older adults.

Methods

In a randomised controlled trial, we will assign 60 native German-speaking monolingual healthy older adults, aged 65–80 years, to either a foreign language learning or a waiting list control group. Language learners will attend a face-to-face, group-based Spanish course for beginners for 1.5 h a day, 5 days a week, for a total of 3 weeks. Cognitive performance in executive functions will be assessed before and after the intervention or after a waiting period of 3 weeks (waiting list control group). Participants will be tested again after 3 months to evaluate longitudinal effects of foreign language learning. The waiting list control group will receive Spanish lessons only after the final assessment and will be invited to an additional voluntary evaluation after completion of the course.

Discussion

To the best of our knowledge, we are conducting the first randomised controlled trial on the effects of short and intensive foreign language learning in older adulthood on executive functions. Enhanced cognitive performance after foreign language learning would indicate that learning a foreign language could enlarge cognitive reserve and thus promote healthy cognitive ageing in older adults.

Trial registration

German Clinical Trials Register DRKS00016552. Registered on 11 February 2019.

Links Between Inflammatory Bowel Disease and Chronic Obstructive Pulmonary Disease

Inflammatory bowel disease (IBD) and chronic obstructive pulmonary disease (COPD) are chronic inflammatory diseases of the gastrointestinal and respiratory tracts, respectively. These mucosal tissues bear commonalities in embryology, structure and physiology. Inherent similarities in immune responses at the two sites, as well as overlapping environmental risk factors, help to explain the increase in prevalence of IBD amongst COPD patients. Over the past decade, a tremendous amount of research has been conducted to define the microbiological makeup of the intestine, known as the intestinal microbiota, and determine its contribution to health and disease. Intestinal microbial dysbiosis is now known to be associated with IBD where it impacts upon intestinal epithelial barrier integrity and leads to augmented immune responses and the perpetuation of chronic inflammation. While much less is known about the lung microbiota, like the intestine, it has its own distinct, diverse microflora, with dysbiosis being reported in respiratory disease settings such as COPD. Recent research has begun to delineate the interaction or crosstalk between the lung and the intestine and how this may influence, or be influenced by, the microbiota. It is now known that microbial products and metabolites can be transferred from the intestine to the lung via the bloodstream, providing a mechanism for communication. While recent studies indicate that intestinal microbiota can influence respiratory health, intestinal dysbiosis in COPD has not yet been described although it is anticipated since factors that lead to dysbiosis are similarly associated with COPD. This review will focus on the gut-lung axis in the context of IBD and COPD, highlighting the role of environmental and genetic factors and the impact of microbial dysbiosis on chronic inflammation in the intestinal tract and lung.

Antibiotics for exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Many patients with an exacerbation of chronic obstructive pulmonary disease (COPD) are treated with antibiotics. However, the value of antibiotics remains uncertain, as systematic reviews and clinical trials have shown conflicting results.

OBJECTIVES

To assess effects of antibiotics on treatment failure as observed between seven days and one month after treatment initiation (primary outcome) for management of acute COPD exacerbations, as well as their effects on other patient-important outcomes (mortality, adverse events, length of hospital stay, time to next exacerbation).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, MEDLINE, Embase, and other electronically available databases up to 26 September 2018.

SELECTION CRITERIA

We sought to find randomised controlled trials (RCTs) including people with acute COPD exacerbations comparing antibiotic therapy and placebo and providing follow-up of at least seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references and extracted data from trial reports. We kept the three groups of outpatients, inpatients, and patients admitted to the intensive care unit (ICU) separate for benefit outcomes and mortality because we considered them to be clinically too different to be summarised as a single group. We considered outpatients to have a mild to moderate exacerbation, inpatients to have a severe exacerbation, and ICU patients to have a very severe exacerbation. When authors of primary studies did not report outcomes or study details, we contacted them to request missing data. We calculated pooled risk ratios (RRs) for treatment failure, Peto odds ratios (ORs) for rare events (mortality and adverse events), and mean differences (MDs) for continuous outcomes using random-effects models. We used GRADE to assess the quality of the evidence. The primary outcome was treatment failure as observed between seven days and one month after treatment initiation.

MAIN RESULTS

We included 19 trials with 2663 participants (11 with outpatients, seven with inpatients, and one with ICU patients).For outpatients (with mild to moderate exacerbations), evidence of low quality suggests that currently available antibiotics statistically significantly reduced the risk for treatment failure between seven days and one month after treatment initiation (RR 0.72, 95% confidence interval (CI) 0.56 to 0.94; I² = 31%; in absolute terms, reduction in treatment failures from 295 to 212 per 1000 treated participants, 95% CI 165 to 277). Studies providing older antibiotics not in use anymore yielded an RR of 0.69 (95% CI 0.53 to 0.90; I² = 31%). Evidence of low quality from one trial in outpatients suggested no effects of antibiotics on mortality (Peto OR 1.27, 95% CI 0.49 to 3.30). One trial reported no effects of antibiotics on re-exacerbations between two and six weeks after treatment initiation. Only one trial (N = 35) reported health-related quality of life but did not show a statistically significant difference between treatment and control groups.Evidence of moderate quality does not show that currently used antibiotics statistically significantly reduced the risk of treatment failure among inpatients with severe exacerbations (i.e. for inpatients excluding ICU patients) (RR 0.65, 95% CI 0.38 to 1.12; I² = 50%), but trial results remain uncertain. In turn, the effect was statistically significant when trials included older antibiotics no longer in clinical use (RR 0.76, 95% CI 0.58 to 1.00; I² = 39%). Evidence of moderate quality from two trials including inpatients shows no beneficial effects of antibiotics on mortality (Peto OR 2.48, 95% CI 0.94 to 6.55). Length of hospital stay (in days) was similar in antibiotic and placebo groups.The only trial with 93 patients admitted to the ICU showed a large and statistically significant effect on treatment failure (RR 0.19, 95% CI 0.08 to 0.45; moderate-quality evidence; in absolute terms, reduction in treatment failures from 565 to 107 per 1000 treated participants, 95% CI 45 to 254). Results of this trial show a statistically significant effect on mortality (Peto OR 0.21, 95% CI 0.06 to 0.72; moderate-quality evidence) and on length of hospital stay (MD -9.60 days, 95% CI -12.84 to -6.36; low-quality evidence).Evidence of moderate quality gathered from trials conducted in all settings shows no statistically significant effect on overall incidence of adverse events (Peto OR 1.20, 95% CI 0.89 to 1.63; moderate-quality evidence) nor on diarrhoea (Peto OR 1.68, 95% CI 0.92 to 3.07; moderate-quality evidence).

AUTHORS' CONCLUSIONS

Researchers have found that antibiotics have some effect on inpatients and outpatients, but these effects are small, and they are inconsistent for some outcomes (treatment failure) and absent for other outcomes (mortality, length of hospital stay). Analyses show a strong beneficial effect of antibiotics among ICU patients. Few data are available on the effects of antibiotics on health-related quality of life or on other patient-reported symptoms, and data show no statistically significant increase in the risk of adverse events with antibiotics compared to placebo. These inconsistent effects call for research into clinical signs and biomarkers that can help identify patients who would benefit from antibiotics, while sparing antibiotics for patients who are unlikely to experience benefit and for whom downsides of antibiotics (side effects, costs, and multi-resistance) should be avoided.

When should acute exacerbations of COPD be treated with systemic corticosteroids and antibiotics in primary care: a systematic review of current COPD guidelines

Not all patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) benefit from treatment with systemic corticosteroids and antibiotics. The aim of the study was to identify criteria recommended in current COPD guidelines for treating acute exacerbations with systemic corticosteroids and antibiotics and to assess the underlying evidence. Current COPD guidelines were identified by a systematic literature search. The most recent guidelines as per country/organisation containing recommendations about treating acute exacerbations of COPD were included. Guideline development and criteria for treating acute exacerbations with systemic corticosteroids and antibiotics were appraised. Randomised controlled trials directly referred to in context with the recommendations were evaluated in terms of study design, setting, and study population. A total of 19 COPD guidelines were included. Systemic corticosteroids were often universally recommended to all patients with acute exacerbations. Criteria for treatment with antibiotics were mainly an increase in respiratory symptoms. Objective diagnostic tests or clinical examination were only rarely recommended. Only few criteria were directly linked to underlying evidence, and the trial patients represented a highly specific group of COPD patients. Current COPD guidelines are of little help in primary care to identify patients with acute exacerbations probably benefitting from treatment with systemic corticosteroids and antibiotics in primary care, and might contribute to overuse or inappropriate use of either treatment.

Accumulating research: a systematic account of how cumulative meta-analyses would have provided knowledge, improved health, reduced harm and saved resources

Background

“Cumulative meta-analysis” describes a statistical procedure to calculate, retrospectively, summary estimates from the results of similar trials every time the results of a further trial in the series had become available. In the early 1990s, comparisons of cumulative meta-analyses of treatments for myocardial infarction with advice promulgated through medical textbooks showed that research had continued long after robust estimates of treatment effects had accumulated, and that medical textbooks had overlooked strong, existing evidence from trials. Cumulative meta-analyses have subsequently been used to assess what could have been known had new studies been informed by systematic reviews of relevant existing evidence and how waste might have been reduced.

Methods and Findings

We used a systematic approach to identify and summarise the findings of cumulative meta-analyses of studies of the effects of clinical interventions, published from 1992 to 2012. Searches were done of PubMed, MEDLINE, EMBASE, the Cochrane Methodology Register and Science Citation Index. A total of 50 eligible reports were identified, including more than 1,500 cumulative meta-analyses. A variety of themes are illustrated with specific examples. The studies showed that initially positive results became null or negative in meta-analyses as more trials were done; that early null or negative results were over-turned; that stable results (beneficial, harmful and neutral) would have been seen had a meta-analysis been done before the new trial; and that additional trials had been much too small to resolve the remaining uncertainties.

Conclusions

This large, unique collection of cumulative meta-analyses highlights how a review of the existing evidence might have helped researchers, practitioners, patients and funders make more informed decisions and choices about new trials over decades of research. This would have led to earlier uptake of effective interventions in practice, less exposure of trial participants to less effective treatments, and reduced waste resulting from unjustified research.

Twenty-year perspective of randomized controlled trials for surgery of chronic nonspecific low back pain: citation bias and tangential knowledge

BACKGROUND CONTEXT

After decades of clinical research, the role of surgery for chronic nonspecific low back pain (CNLBP) remains equivocal. Despite significant intellectual, human, and economic investments into randomized controlled trials (RCTs) in the past two decades, the role of surgery in the treatment for CNLBP has not been clarified.

PURPOSE

To delineate the historical research agenda of surgical RCTs for CNLBP performed between 1993 and 2012 investigating whether conclusions from earlier published trials influenced the choice of research questions of subsequent RCTs on elucidating the role of surgery in the management of CNLBP.

STUDY DESIGN

Literature review.

METHODS

We searched the literature for all RCTs involving surgery for CNLBP. We reviewed relevant studies to identify the study question, comparator arms, and sample size. Randomized controlled trials were classified as "indication" trials if they evaluated the effectiveness of surgical therapy versus nonoperative care or as "technical" if they compared different surgical techniques, adjuncts, or procedures. We used citation analysis to determine the impact of trials on subsequent research in the field.

RESULTS

Altogether 33 technical RCTs (3,790 patients) and 6 indication RCTs (981 patients) have been performed. Since 2007, despite the unclear benefits of surgery reported by the first four indication trials published in 2001 to 2006, technical trials have continued to predominate (16 vs. 2). Of the technical trials, types of instrumentation (13 trials, 1,332 patients), bone graft materials and substitutes (11 trials, 833 patients), and disc arthroplasty versus fusion (5 trials, 1,337 patients) were the most common comparisons made. Surgeon authors have predominantly cited one of the indication trials that reported more favorable results for surgery, despite a lack of superior methodology or sample size. Trials evaluating bone morphogenic protein, instrumentation, and disc arthroplasty were all cited more frequently than the largest trial of surgical versus nonsurgical therapy.

CONCLUSIONS

The research agenda of RCTs for surgery of CNLBP has not changed substantially in the last 20 years. Technical trials evaluating nuances of surgical techniques significantly predominate. Despite the publication of four RCTs reporting equivocal benefits of surgery for CNLBP between 2001 and 2006, there was no change in the research agenda of subsequent RCTs, and technical trials continued to outnumber indication trials. Rather than clarifying what, if any, indications for surgery exist, investigators in the field continue to analyze variations in surgical technique, which will probably have relatively little impact on patient outcomes. As a result, clinicians unfortunately have little evidence to advise patients regarding surgical intervention for CNLBP.

Phenotyping the heterogeneity of chronic obstructive pulmonary disease

COPD (chronic obstructive pulmonary disease) is a heterogeneous disease associated with significant morbidity and mortality. Current diagnostic criteria based on the presence of fixed airflow obstruction and symptoms do not integrate the complex pathological changes occurring within lung, do not define different airway inflammatory patterns, nor do they define different physiological changes or differences in structure as can be defined by imaging. Over recent years, there has been interest in describing this heterogeneity and using this information to subgroup patients into COPD phenotypes. Most approaches to phenotyping have considered disease at a single scale and have not integrated information from different scales (e.g. organ-whole person, tissue-organ, cell-tissue and gene-cell) of disease to provide multi-dimensional phenotypes. Integration of disease biology with clinical expression is critical to improve understanding of this disease. When combined with biostatistical modelling, this information may lead to identification of new drug targets, new end points for clinical trials and targeted treatment for subgroups of COPD patients. It is hoped this will ultimately improve COPD outcomes and represent a move towards personalised medicine. In the present review, we will consider these aspects of multi-dimensional phenotyping in more detail.

SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials

High quality protocols facilitate proper conduct, reporting, and external review of clinical trials. However, the completeness of trial protocols is often inadequate. To help improve the content and quality of protocols, an international group of stakeholders developed the SPIRIT 2013 Statement (Standard Protocol Items: Recommendations for Interventional Trials). The SPIRIT Statement provides guidance in the form of a checklist of recommended items to include in a clinical trial protocol. This SPIRIT 2013 Explanation and Elaboration paper provides important information to promote full understanding of the checklist recommendations. For each checklist item, we provide a rationale and detailed description; a model example from an actual protocol; and relevant references supporting its importance. We strongly recommend that this explanatory paper be used in conjunction with the SPIRIT Statement. A website of resources is also available (www.spirit-statement.org). The SPIRIT 2013 Explanation and Elaboration paper, together with the Statement, should help with the drafting of trial protocols. Complete documentation of key trial elements can facilitate transparency and protocol review for the benefit of all stakeholders.

Diagnostic aid to rule out pneumonia in adults with cough and feeling of fever. A validation study in the primary care setting

Background

We recently reported the derivation of a diagnostic aid to rule out pneumonia in adults presenting with new onset of cough or worsening of chronic cough and increased body temperature. The aim of the present investigation was to validate the diagnostic aid in a new sample of primary care patients.

Methods

From two group practices in Zurich, we included 110 patients with the main symptoms of cough and subjective feeling of increased body temperature, and C-reactive protein levels below 50 μg/ml, no dyspnea, and not daily feeling of increased body temperature since the onset of cough. We excluded patients who were prescribed antibiotics at their first consultation. Approximately two weeks after inclusion, practice assistants contacted the participants by phone and asked four questions regarding the course of their complaints. In particular, they asked whether a prescription of antibiotics or hospitalization had been necessary within the last two weeks.

Results

In 107 of 110 patients, pneumonia could be ruled out with a high degree of certainty, and no prescription of antibiotics was necessary. Three patients were prescribed antibiotics between the time of inclusion in the study and the phone interview two weeks later. Acute rhinosinusitis was diagnosed in one patient, and antibiotics were prescribed to the other two patients because their symptoms had worsened and their CRP levels increased. Use of the diagnostic aid could have missed these two possible cases of pneumonia. These observations correspond to a false negative rate of 1.8% (95% confidence interval: 0.50%-6.4%).

Conclusions

This diagnostic aid is helpful to rule out pneumonia in patients from a primary care setting. After further validation application of this aid in daily practice may help to reduce the prescription rate of unnecessary antibiotics in patients with respiratory tract infections.

Antibiotics for exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Many patients with an exacerbation of chronic obstructive pulmonary disease (COPD) are treated with antibiotics. However, the value of antibiotics remains uncertain as systematic reviews and clinical trials have shown conflicting results.

OBJECTIVES

To assess the effects of antibiotics in the management of acute COPD exacerbations on treatment failure as observed between seven days and one month after treatment initiation (primary outcome) and on other patient-important outcomes (mortality, adverse events, length of hospital stay).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and other electronically available databases up to September 2012.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in people with acute COPD exacerbations comparing antibiotic therapy and placebo with a follow-up of at least seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references and extracted data from trial reports. We kept the three groups of outpatients, inpatients and patients admitted to the intensive care unit (ICU) separate for benefit outcomes and mortality because we considered them to be clinically too different to be summarised in one group. We considered outpatients to have a mild to moderate exacerbation, inpatients to have a severe exacerbation and ICU patients to have a very severe exacerbation. Where outcomes or study details were not reported we requested missing data from the authors of the primary studies. We calculated pooled risk ratios (RR) for treatment failure, Peto odds ratios (OR) for rare events (mortality and adverse events) and weighted mean differences (MD) for continuous outcomes using fixed-effect models. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

Sixteen trials with 2068 participants were included. In outpatients (mild to moderate exacerbations), there was evidence of low quality that antibiotics did statistically significantly reduce the risk for treatment failure between seven days and one month after treatment initiation (RR 0.75; 95% CI 0.60 to 0.94; I(2) = 35%) but they did not significantly reduce the risk when the meta-analysis was restricted to currently available drugs (RR 0.80; 95% CI 0.63 to 1.01; I(2) = 33%). Evidence of high quality showed that antibiotics statistically significantly reduced the risk of treatment failure in inpatients with severe exacerbations (ICU not included) (RR 0.77; 95% CI 0.65 to 0.91; I(2) = 47%) regardless of whether restricted to current drugs. The only trial with 93 patients admitted to the ICU showed a large and statistically significant effect on treatment failure (RR 0.19; 95% CI 0.08 to 0.45; high-quality evidence).Evidence of low-quality from four trials in inpatients showed no effect of antibiotics on mortality (Peto OR 1.02; 95% CI 0.37 to 2.79). High-quality evidence from one trial showed a statistically significant effect on mortality in ICU patients (Peto OR 0.21; 95% CI 0.06 to 0.72). Length of hospital stay (in days) was similar in the antibiotics and placebo groups except for the ICU study where antibiotics statistically significantly reduced length of hospital stay (mean difference -9.60 days; 95% CI -12.84 to -6.36 days). One trial showed no effect of antibiotics on re-exacerbations between two and six weeks after treatment initiation. Only one trial (N = 35) reported health-related quality of life but did not show a statistically significant difference between the treatment and control group.Evidence of moderate quality showed that the overall incidence of adverse events was higher in the antibiotics groups (Peto OR 1.53; 95% CI 1.03 to 2.27). Patients treated with antibiotics experienced statistically significantly more diarrhoea based on three trials (Peto OR 2.62; 95% CI 1.11 to 6.17; high-quality evidence).

AUTHORS' CONCLUSIONS

Antibiotics for COPD exacerbations showed large and consistent beneficial effects across outcomes of patients admitted to an ICU. However, for outpatients and inpatients the results were inconsistent. The risk for treatment failure was significantly reduced in both inpatients and outpatients when all trials (1957 to 2012) were included but not when the analysis for outpatients was restricted to currently used antibiotics. Also, antibiotics had no statistically significant effect on mortality and length of hospital stay in inpatients and almost no data on patient-reported outcomes exist. These inconsistent effects call for research into clinical signs and biomarkers that help identify patients who benefit from antibiotics and patients who experience no effect, and in whom downsides of antibiotics (side effects, costs and multi-resistance) could be avoided.

Guidelines for randomized clinical trial protocol content: a systematic review

BACKGROUND

All randomized clinical trials (RCTs) require a protocol; however, numerous studies have highlighted protocol deficiencies. Reporting guidelines may improve the content of research reports and, if developed using robust methods, may increase the utility of reports to stakeholders. The objective of this study was to systematically identify and review RCT protocol guidelines, to assess their characteristics and methods of development, and to compare recommendations.

METHODS

We conducted a systematic review of indexed literature (MEDLINE, EMBASE and the Cochrane Methodology Register from inception to September 2010; reference lists; related article features; forward citation searching) and a targeted search of supplementary sources, including a survey of major trial funding agencies in six countries. Records were eligible if they described a content guideline in English or French relevant to RCT protocols. Guidelines were excluded if they specified content for protocols for trials of specific procedures or conditions or were intended to assess trial quality. We extracted guideline characteristics and methods. Content was mapped for a subset of guidelines that described development methods or had institutional endorsement.

RESULTS

Forty guidelines published in journals, books and institutional reports were included in the review; seven were specific to RCT protocols. Only eight (20%) described development methods which included informal consensus methods, pilot testing and formal validation; no guideline described all of these methods. No guideline described formal consensus methods or a systematic retrieval of empirical evidence to inform its development. The guidelines included a median of 23 concepts per guideline (interquartile range (IQR) = 14 to 34; range = 7 to 109). Among the subset of guidelines (n = 23) for which content was mapped, approximately 380 concepts were explicitly addressed (median concepts per guideline IQR = 31 (24,80); range = 16 to 150); most concepts were addressed in a minority of guidelines.

CONCLUSIONS

Existing guidelines for RCT protocol content varied substantially in their recommendations. Few reports described the methods of guideline development, limiting comparisons of guideline validity. Given the importance of protocols to diverse stakeholders, we believe a systematically developed, evidence-informed guideline for clinical trial protocols is needed.

Calculating additive treatment effects from multiple randomized trials provides useful estimates of combination therapies

OBJECTIVE

Many clinicians and decision makers want to know the combined effects of treatments that have not been evaluated in combination. It is possible to determine such treatment effects by making assumptions about the additive effects. We discuss here the prerequisites and methods of applying additivity assumptions in synthesizing the evidence from randomized trials and multiple treatment meta-analyses.

STUDY DESIGN AND SETTING

Using statistical approaches, we demonstrate the utility of additivity of both pairwise randomized trials and multiple treatment comparison meta-analyses.

RESULTS

We present illustratively an example on estimating the treatment effects of drug combinations for chronic obstructive pulmonary disease. We confirm the additive treatment effects by comparing with direct combination treatment trial results.

CONCLUSION

Additive effects may be a useful tool to estimate the effectiveness of treatment combinations.

Blood eosinophils to direct corticosteroid treatment of exacerbations of chronic obstructive pulmonary disease: a randomized placebo-controlled trial

RATIONALE

Exacerbations of chronic obstructive pulmonary disease (COPD) and responses to treatment are heterogeneous.

OBJECTIVES

Investigate the usefulness of blood eosinophils to direct corticosteroid therapy during exacerbations.

METHODS

Subjects with COPD exacerbations were entered into a randomized biomarker-directed double-blind corticosteroid versus standard therapy study. Subjects in the standard arm received prednisolone for 2 weeks, whereas in the biomarker-directed arm, prednisolone or matching placebo was given according to the blood eosinophil count biomarker. Both study groups received antibiotics. Blood eosinophils were measured in the biomarker-directed and standard therapy arms to define biomarker-positive and -negative exacerbations (blood eosinophil count > and ≤ 2%, respectively). The primary outcome was to determine noninferiority in health status using the chronic respiratory questionnaire (CRQ) and in the proportion of exacerbations associated with a treatment failure between subjects allocated to the biomarker-directed and standard therapy arms.

MEASUREMENTS AND MAIN RESULTS

There were 86 and 80 exacerbations in the biomarker-directed and standard treatment groups, respectively. In the biomarker-directed group, 49% of the exacerbations were not treated with prednisolone. CRQ improvement after treatment in the standard and biomarker-directed therapy groups was similar (0.8 vs. 1.1; mean difference, 0.3; 95% confidence interval, 0.0-0.6; P = 0.05). There was a greater improvement in CRQ in biomarker-negative exacerbations given placebo compared with those given prednisolone (mean difference, 0.45; 95% confidence interval, 0.01-0.90; P = 0.04). In biomarker-negative exacerbations, treatment failures occurred in 15% given prednisolone and 2% of those given placebo (P = 0.04).

CONCLUSIONS

The peripheral blood eosinophil count is a promising biomarker to direct corticosteroid therapy during COPD exacerbations, but larger studies are required.

Factors associated with hospital admission in patients reaching the emergency department with COPD exacerbation

BACKGROUND

The aim of this study was to determine the frequency of COPD exacerbations in our Emergency Department, as well as the hospitalization-related factors.

METHODS

Prospective observational study conducted in the Emergency Department of Salnés County Hospital among patients admitted for COPD exacerbation. Admission predictors were determined by multivariate analysis.

RESULTS

There were 409 exacerbations in 239 patients (79% male, mean age 75). 57% of exacerbations required hospitalization. Hospitalization-related factors were impaired oxygenation (p < 0.001), presence of neutrophilia (p < 0.01) and prescription of antibiotics in the Emergency Department (p < 0.05).

CONCLUSIONS

COPD exacerbation accounts for over 1% of all visits to our Emergency Department. 57% of them required hospitalization. Impaired oxygenation, greater neutrophilia and prescription of antibiotics in the Emergency Department were associated with greater probability of admission.

Acute exacerbations of chronic obstructive pulmonary disease: identification of biologic clusters and their biomarkers

RATIONALE

Exacerbations of chronic obstructive pulmonary disease (COPD) are heterogeneous with respect to inflammation and etiology.

OBJECTIVES

Investigate biomarker expression in COPD exacerbations to identify biologic clusters and determine biomarkers that recognize clinical COPD exacerbation phenotypes, namely those associated with bacteria, viruses, or eosinophilic airway inflammation.

METHODS

Patients with COPD were observed for 1 year at stable and exacerbation visits. Biomarkers were measured in sputum and serum. Viruses and selected bacteria were assessed in sputum by polymerase chain reaction and routine diagnostic bacterial culture. Biologic phenotypes were explored using unbiased cluster analysis and biomarkers that differentiated clinical exacerbation phenotypes were investigated.

MEASUREMENTS AND MAIN RESULTS

A total of 145 patients (101 men and 44 women) entered the study. A total of 182 exacerbations were captured from 86 patients. Four distinct biologic exacerbation clusters were identified. These were bacterial-, viral-, or eosinophilic-predominant, and a fourth associated with limited changes in the inflammatory profile termed “pauciinflammatory.” Of all exacerbations, 55%, 29%, and 28% were associated with bacteria, virus, or a sputum eosinophilia. The biomarkers that best identified these clinical phenotypes were sputum IL-1β, 0.89 (area under receiver operating characteristic curve) (95% confidence interval [CI], 0.83–0.95); serum CXCL10, 0.83 (95% CI, 0.70–0.96); and percentage peripheral eosinophils, 0.85 (95% CI, 0.78–0.93), respectively.

CONCLUSIONS

The heterogeneity of the biologic response of COPD exacerbations can be defined. Sputum IL-1β, serum CXCL10, and peripheral eosinophils are biomarkers of bacteria-, virus-, or eosinophil-associated exacerbations of COPD. Whether phenotype-specific biomarkers can be applied to direct therapy warrants further investigation.

A decision aid to rule out pneumonia and reduce unnecessary prescriptions of antibiotics in primary care patients with cough and fever

BACKGROUND

Physicians fear missing cases of pneumonia and treat many patients with signs of respiratory infection unnecessarily with antibiotics. This is an avoidable cause for the increasing worldwide problem of antibiotic resistance. We developed a user-friendly decision aid to rule out pneumonia and thus reduce the rate of needless prescriptions of antibiotics.

METHODS

This was a prospective cohort study in which we enrolled patients older than 18 years with a new or worsened cough and fever without serious co-morbidities. Physicians recorded results of a standardized medical history and physical examination. C-reactive protein was measured and chest radiographs were obtained. We used Classification and Regression Trees to derive the decision tool.

RESULTS

A total of 621 consenting eligible patients were studied, 598 were attending a primary care facility, were 48 years on average and 50% were male. Radiographic signs for pneumonia were present in 127 (20.5%) of patients. Antibiotics were prescribed to 234 (48.3%) of patients without pneumonia. In patients with C-reactive protein values below 10 μg/ml or patients presenting with C-reactive protein between 11 and 50 μg/ml, but without dyspnoea and daily fever, pneumonia can be ruled out. By applying this rule in clinical practice antibiotic prescription could be reduced by 9.1% (95% confidence interval (CI): 6.4 to 11.8).

CONCLUSIONS

Following validation and confirmation in new patient samples, this tool could help rule out pneumonia and be used to reduce unnecessary antibiotic prescriptions in patients presenting with cough and fever in primary care. The algorithm might be especially useful in those instances where taking a medical history and physical examination alone are inconclusive for ruling out pneumonia.

Antibiotics in acute exacerbations of chronic bronchitis

Acute exacerbations of chronic bronchitis (AECB) are a major contributor to morbidity and mortality in patients with chronic obstructive pulmonary disease, accounting for more than 16 million physician office visits and over 500,000 hospitalizations in the USA each year. Antimicrobials have been recognized by clinical guidelines as an important component in the management of AECB with a bacterial etiology. The challenge of identifying patients most likely to benefit from antimicrobial therapy is difficult in the clinical setting. However, appropriate risk stratification of patients, and the use of antimicrobials within the correct spectrum and for a suitable duration, can improve clinical outcomes while minimizing induction of antimicrobial resistance. With an improved design in pharmacologic and clinical studies, differences can be appreciated among the various antimicrobial agents available to treat AECB. Factors to be considered in antimicrobial agent selection include local tissue penetration, effects on bacteriological eradication, duration of therapy, speed of resolution and prevention or delay of recurrences.

Management and prevention of chronic obstructive pulmonary disease exacerbations: a state of the art review

Exacerbations of chronic obstructive pulmonary disease (COPD) are important events in the natural history of this prevalent and devastating condition. This review provides a concise, state of the art summary on prevention and management of exacerbations. Considerable new data underpins evidence in support of many preventative interventions, pharmacological and non-pharmacological, that are now available. Challenges remain in developing new approaches, and delivering those that already exist to the right patient at the right time. Management of an exacerbation remains stepwise according to clinical severity, but there is now additional focus on addressing comorbidities and taking the opportunity at acute events to optimise preventative strategies for the future. Ultimately, exacerbations are heterogeneous events in a heterogeneous disease, and an individualised approach is paramount.

Treatment of acute bacterial exacerbations of chronic bronchitis

BACKGROUND

Controversies persist regarding the optimal management of patients with acute exacerbations of chronic bronchitis (AECB).

OBJECTIVE

To evaluate the available evidence on relevant issues, namely the need for administering antimicrobials in patients with AECB, the identification of the subgroup of patients with AECB needing antibiotics, the antimicrobial regimen of choice and its optimal duration, the existence of new agents, and the value of non-antimicrobial regimens for AECB.

METHODS

Data from various sources of evidence, including recent relevant meta-analyses, were appraised.

CONCLUSION

Administration of antimicrobial agents, combined with bronchodilators and systemic corticosteroids, is warranted in approximately half of AECBs (i.e., in bacterial exacerbations) to achieve a survival benefit. Simple clinical parameters, mainly sputum purulence, and biomarkers, such as procalcitonin, are useful in identifying patients requiring antibiotics. Advanced antibiotics (quinolones, macrolides, or amoxicillin/clavulanic acid) are more effective than 'old' antibiotics in AECB; regimens of short duration (for 5 days) are preferred. There is no difference between several classes of advanced antibiotics regarding their short-term effectiveness; however, quinolones are associated with better long-term outcomes than macrolides. Newer quinolones and new formulations of macrolides enrich clinicians' armamentarium against AECB.

The problems of meta-analysis for antibiotic treatment of chronic obstructive pulmonary disease, a heterogeneous disease: a commentary on Puhan et al

Exacerbations are a major cause of morbidity and mortality in chronic obstructive pulmonary disease. Exacerbations can be of bacterial, viral or mixed etiology, with bacteria involved in 50% of exacerbations. Consequently, current management of exacerbations frequently involves the use of antibiotics. The paper by Puhan et al published this month in BMC Medicine examines the benefit of antibiotics in placebo-controlled trials in mild to moderate outpatient exacerbations. The authors use a meta-analytic approach and rightly conclude that more trials are needed in this area. However, the heterogeneity of chronic obstructive pulmonary disease patients and exacerbations and the limited end-points in past trials do not allow firm conclusions to be drawn about antibiotic use in outpatient exacerbations based on this meta-analysis. Future trials need to take into account this heterogeneity as well as incorporate novel end-points to address this important issue.