Интересные ссылки

[Maltsev]

[Ссылки доступны только зарегистрированным пользователям ]

1. Регистрируемся на форуме;
2. Выбираем интересующее (книга, журнал и т.п.);
3. Постим в форуме ответ (обычно это банальное thank you);
4. В первом посте после ответа появляется ссылка на файлик на рапиде, который, собственно и качаем. Вот, собссно, и все.


Ориентировано большей частью на буржуйских студентов и резидентов, но можно найти что нибудь стоящее . Например - последние 4 номера European Heart.

Выяснено при расследовании материалов поста Vlad34 (см. выше).

--
С Уважением,
Мальцев А.А.

[Gilarov]

Яркий пример - рекомендации по клапанным порокам. Сплошной уровень С.
Еще на ту же тему:
ACC/AHA guidelines largely based on weak evidence and expert opinion
February 24, 2009 | Michael O'Riordan
Durham, NC - The number of recommendations in the American Heart Association/American College of Cardiology (AHA/ACC) clinical-practice guidelines have progressively increased over time, but these recommendations are often based on weak evidence and expert opinion, a new study, published in the February 25, 2009 issue of the Journal of the American Medical Association, has shown.

Among guidelines reporting an update in recent years, the number of recommendations has increased 48% from the first to the current version, with the largest increase in recommendations for which there is conflicting evidence and/or a divergence of opinion about the efficacy of a procedure or treatment (class 2). In addition, roughly half of all recommendations are based on expert opinion, case studies, or standard of care rather than on data from multiple clinical trials or meta-analyses.

"It's a sobering result," lead investigator Dr Pierluigi Tricoci (Duke Clinical Research Institute, Durham, NC) told heartwire. "Almost half of the recommendations have a level of evidence C, meaning they have no supporting evidence or just a little supporting evidence. This means that situations where we are sure of what to do are small in number, while the situations where we are not so sure of what to do are the majority."



Guidelines changing over the years


In this study, the investigators wanted to assess how the guidelines changed since the AHA/ACC began publishing clinical-practice guidelines more than 20 years ago. The guidelines currently use a grading system based on the level of evidence and class of recommendation. The level of evidence—A, B, or C—includes a description of the existence and types of studies available supporting the recommendation and expert consensus. The class of recommendation—1, 2, 2a, 2b, and 3—indicates the strength of the recommendation based on an objective judgment about the relative merits of the data.

This means that situations where we are sure of what to do are small in number, while the situations where we are not so sure of what to do are the majority. From 1984 to 2008, the ACC/AHA issued 53 guidelines on 22 topics for a total of 7196 recommendations. Among these guidelines, 24 were disease-based, 15 were for interventional procedures, and 14 were for diagnostics. The disease-based and interventional-based guidelines were updated approximately every five years, while the diagnostic-procedure-based guidelines were updated eight years after the last publication.

Among guidelines with at least one revision, the number of recommendations increased 48% from the first guidelines to the most recent version. The increase in recommendations was driven primarily by increases in the number of class 2 recommendations—those with conflicting evidence and/or divergent opinions. Of the 16 current guidelines reporting levels of evidence, just 11% of recommendations were classified as evidence A, those based on data from multiple clinical trials or meta-analyses. Just under half of the recommendations, 48%, were based on expert opinion, case studies, or standards of care (level of evidence C).

Among the class 1 recommendations of guidelines reporting level of evidence, just 19% had a level of evidence A. There was also wide variation across the different specialties, with the disease-based and interventional-based guidelines having slightly better levels of evidence than the diagnostic-procedure guidelines. Roughly 70% of the recommendations within the valvular-heart-disease guidelines are evidence level C, with just one recommendation with evidence based on clinical trials. Heart-failure, secondary-prevention, and unstable-angina guidelines had the most recommendations based on clinical trial data or meta-analyses, or evidence level A.

"Some fields are in better shape than others, but this is a general problem afflicting all the fields of cardiology," said Tricoci.



Ignore the guidelines altogether


In an editorial accompanying the published study [2], Drs Terrence Shaneyfelt and Robert Centor (University of Alabama School of Medicine, Birmingham) write that the "overreliance on expert opinion in guidelines is problematic," particularly since the guideline committees come to the table with implicit biases, values, and goals that aren't typically disclosed. Moreover, too many current guidelines are marketing- and opinion-based pieces, "delivering directive rather than assistive statements," they add.

In addition, they argue that guidelines are not patient-specific enough to be useful and do not allow for individualization of care, instead adopting a one-size-fits-all mentality. Moreover, there are simply too many guidelines on the same topic. The editorialists write that if the guidelines continue to exist, they need to undergo major changes, including limiting committee members with financial ties to industry or other potential conflicts of interest. Guideline development should also be centralized under a governing body to reduce bias and redundancy, something that might be achieved by allowing the US Department of Health and Human Services to oversee their drafting.

"However, it seems unlikely that substantial change will occur because many guideline developers seem set in their ways," write Shaneyfelt and Centor. "If all that can be produced are biased, minimally applicable consensus statements, perhaps guidelines should be avoided completely. Unless there is evidence of appropriate changes in the guideline process, clinicians and policy makers must reject calls for adherence to guidelines."

Speaking with heartwire, Tricoci, rather than fault the guideline committees, said the findings represent a failure of the current research system. With clinical trials performed predominantly by industry, unaddressed clinical questions are overlooked, as these companies are interested primarily in bringing new products to market.

"While it's certainly great to have newer and newer products, there are a lot of things that we don't know about the products that we currently use or even decisions that do not necessarily involve products, such as treatment strategies or timing issues," said Tricoci. "There is not a lot of funding supporting this type of research."

In addition, clinical trials are costly and complex and require long periods of time to complete, said Tricoci. This limits the funding available for the study, as well as the number of questions that can be answered by the trialists. Streamlining clinical trials that focus on areas with deficient research would partly alleviate the knowledge gaps in the clinical guidelines.

[Maltsev]

И в самом деле: в наш циничный век,
когда разъеден скепсисом рассудок,
когда мамоной души смущены,
потерян смысл, и лгут ориентиры -
должно же быть хоть что-то, наконец,
не тронутое варварской уценкой?!


(С) - Виктор Шендерович.

--
С Уважением,
Мальцев А.А.

[Igor73]

Сообщение от Gilarov

Яркий пример - рекомендации по клапанным порокам. Сплошной уровень С.

И моя баночка дегтя:
1. Очень понравились последние рекомендации по реваскуляризации своим новым (бальным) подходом, тщательным отбором экспертов (хирурги, ангиографисты и кардиологи-терапевты) и участием статистика при оценки разброса ответов экспертов.
2. И конечно же было интересно познакомиться со статьей в JAMA, потому что 11% рекомендаций класса IА это, конечно, внушает.
В итоге, там уже задумываются над изменениям стратегии написания/выработки рекомендаций, к которым мы даже еще не дошли.

[dmblok]

Хочется высказать две крамольные мысли по вышесказанному. Собственно говоря они уже обсуждались.
1)Мнение экспертов подчас имеет большее значение, чем РКИ, потому что оно учитывает национальные и местные особенности. Если нужны примеры, могу привести. Особенно это касается клинических ситуаций, когда задействована высокотехнологичная медицинская помощь, с большим количеством оборудования и требующая одновременной работы многих специалистов.
2)Вызывает сомнение жизнеспособность аккуратного обсчета стенозов КА в реальной клинической практике. Сергей Александрович энд компани, сколько нужно времени, что бы дать оценку состояния коронарного русла по Syntax score у многососудистого больного?

[rsp]

Сообщение от dmblok

2)Вызывает сомнение жизнеспособность аккуратного обсчета стенозов КА в реальной клинической практике. Сергей Александрович энд компани, сколько нужно времени, что бы дать оценку состояния коронарного русла по Syntax score у многососудистого больного?

минуты 2-3....вместе с письменным заключением. кстати видел анонс, что Патрик Серойс представит на ближайшем PCR электронный и веб-вариант этого калькулятора.

[dmblok]

Сообщение от rsp

минуты 2-3....вместе с письменным заключением. кстати видел анонс, что Патрик Серойс представит на ближайшем PCR электронный и веб-вариант этого калькулятора.

А сколько лично Вам требуется для этого времени? На сегодняшний момент. Откуда данные про такое короткое время?

[rsp]

Сообщение от dmblok

А сколько лично Вам требуется для этого времени? На сегодняшний момент. Откуда данные про такое короткое время?

Из личного опыта. Вначале освоения, безусловно, времени требуется больше, но после осознания принципов особо времени, имхо, не занимает. Основной вопрос, собственно, не в потраченном времени,а в клинической значимости и необходимости.
Напрашивается встречный вопрос: насколько часто Вы используете оценку рисков по TIMI или GRACE у больных с ОКС и ОИМ? звучат ли эти бальные системы в Ваших докладах о состоянии поступивших пациентов?

[dmblok]

Сообщение от rsp

Напрашивается встречный вопрос: насколько часто Вы используете оценку рисков по TIMI или GRACE у больных с ОКС и ОИМ? звучат ли эти бальные системы в Ваших докладах о состоянии поступивших пациентов?

Не используем напрямую. Высокий риск оцениваем индивидуально, без калькуляторов. И я не знаю, правильно это или нет.
Обсчет ангиографической картинки, если подходить к нему неформально, имхо дело куда более трудоемкое. Впрочем Вам, конечно, виднее.

[Abugov]

Публичность вредна:

Public Reporting of State PCI Results May Backfire

By Jason Kahn
Monday, March 02, 2009

Rather than fostering more informed patient decisions about the quality of a hospital’s interventional care, public reporting of in-hospital mortality figures for percutaneous coronary intervention (PCI) procedures may have an unintended consequence. Physicians may shy away from offering PCI to the patients at highest risk, instead performing PCI more liberally in low-risk patients whose potential benefits are marginal at best, according to a review article in the March 10, 2009, issue of the Journal of the American College of Cardiology.

[Gilarov]

Наконец-то появился консенсус.
Мне понравилось введение понятий клинической и лабораторной резистентности.
Ссылка: [Ссылки доступны только зарегистрированным пользователям ]

[Igor73]

Risk of Adverse Outcomes Associated With Concomitant Use of Clopidogrel and Proton Pump Inhibitors Following Acute Coronary Syndrome
Context Prior mechanistic studies reported that omeprazole decreases the platelet inhibitory effects of clopidogrel, yet the clinical significance of these findings is not clear.
Objective To assess outcomes of patients taking clopidogrel with or without a proton pump inhibitor (PPI) after hospitalization for acute coronary syndrome (ACS).
Design, Setting, and Patients Retrospective cohort study of 8205 patients with ACS taking clopidogrel after discharge from 127 Veterans Affairs hospitals between
October 1, 2003, and January 31, 2006. Vital status information was available for all patients through September 30, 2006.
Main Outcome Measures All-cause mortality or rehospitalization for ACS.
Results Of 8205 patients taking clopidogrel after discharge, 63.9%(n=5244) were prescribed PPI at discharge, during follow-up, or both and 36.1%(n=2961) were not prescribed PPI. Death or rehospitalization for ACS occurred in 20.8%(n=615) of patients taking clopidogrel without PPI and 29.8% (n=1561) of patients taking clopidogrel plus PPI. In multivariable analyses, use of clopidogrel plus PPI was associated with an increased risk of death or rehospitalization for ACS compared with use of clopidogrel without PPI (adjusted odds ratio [AOR], 1.25; 95%confidence interval [CI],
1.11-1.41). Among patients taking clopidogrel after hospital discharge and prescribed PPI at any point during follow-up (n=5244), periods of use of clopidogrel plus PPI (compared with periods of use of clopidogrel without PPI) were associated with a higher risk of death or rehospitalization for ACS (adjusted hazard ratio, 1.27; 95%CI, 1.10-1.46). In analyses of secondary outcomes, patients taking clopidogrel plus PPI had a higher risk of hospitalizations for recurrent ACS compared with patients taking clopidogrel without PPI (14.6% vs 6.9%; AOR, 1.86 [95% CI, 1.57-2.20]) and revascularization procedures (15.5% vs 11.9%; AOR, 1.49 [95% CI, 1.30-1.71]), but not for all-cause mortality (19.9% vs 16.6%; AOR, 0.91 [95% CI, 0.80-1.05]). The association between use of clopidogrel plus PPI and increased risk of adverse outcomes also was consistent using a nested case-control study design (AOR, 1.32; 95% CI, 1.14-1.54). In addition, use of PPI without clopidogrel was not associated with death or rehospitalization for ACS among patients not taking clopidogrel after hospi-
tal discharge (n=6450) (AOR, 0.98; 95% CI, 0.85-1.13).
Conclusion Concomitant use of clopidogrel and PPI after hospital discharge for ACS was associated with an increased risk of adverse outcomes than use of clopidogrel without PPI, suggesting that use of PPI may be associated with attenuation of benefits of clopidogrel after ACS.
JAMA. 2009;301(9):937-944

[dmblok]

Возвращаясь к ранней реполяризации...
[Ссылки доступны только зарегистрированным пользователям ]

[Gilarov]

Для любителей пампинга:A systematic review and meta-analysis of intra-aortic balloon pump therapy in ST-elevation myocardial infarction: should we change the guidelines?
[Ссылки доступны только зарегистрированным пользователям ]
У меня по прочтении возникла мысль, что без PCI ВАБК не слишком помогает. А что скажет уважаемый dmblok?

[dmblok]

Сообщение от Gilarov

У меня по прочтении возникла мысль, что без PCI ВАБК не слишком помогает. А что скажет уважаемый dmblok?

В тексте скорее наоборот.

The meta-analysis of cohort studies in the setting of STEMI complicated by cardiogenic shock supported IABP therapy adjunctive to thrombolysis. In contrast, the observational data did not support IABP therapy adjunctive to primary PCI.

Дизайн исследований которые мне известны по этой теме, в том числе вошедшие в этот мета-анализ, вызывают сомнения. Вообще, когда читаешь подобные результаты, у меня возникает ощущение - "не верь глазам своим". В той же степени это касается примения инотропов при левожелудочковой недостаточности.