Question In patients with diabetes mellitus, what is the effect of antihypertensive treatment at ... more Question In patients with diabetes mellitus, what is the effect of antihypertensive treatment at different blood pressure (BP) levels? Review scope Included studies compared any antihypertensive drug with placebo, any 2 drugs with 1 drug, or any BP target with another in 100 patients with diabetes for 12 months. Exclusion criteria were trials comparing 2 individual drugs or combined interventions. Outcomes included all-cause mortality, cardiovascular (CV) mortality, myocardial infarction (MI), stroke, heart failure, and end-stage renal disease (ESRD). Review methods MEDLINE, EMBASE/Excerpta Medica, Cochrane CENTRAL, BIOSIS (all to Feb 2013), and reference lists were searched for randomized controlled trials (RCTs). Authors, pharmaceutical companies, and authorities were contacted. 49 RCTs (n =73738, mean follow-up 3.7 y) met selection criteria. 24 RCTs included only patients with diabetes, and 25 included subgroups with diabetes; most patients had type 2 diabetes. 38 RCTs compared antihypertensive treatment with placebo. Risk for bias was low for randomization (45 RCTs), concealed allocation (39 RCTs), blinding of patients and personnel (26 RCTs), and blinding of outcome assessors (36 RCTs). Meta-analysis presented in this abstract was stratified by mean baseline systolic BP (SBP) within trials. Main results For trials with mean baseline SBP >150 mm Hg, antihypertensive treatment reduced all-cause mortality, CV mortality, MI, stroke, and ESRD (Table). For mean baseline SBP 140 to 150 mm Hg, antihypertensive treatment reduced all-cause mortality, MI, and heart failure (Table). For baseline SBP <140 mm Hg, antihypertensive treatment showed a borderline increase in CV mortality and did not differ for other outcomes (Table). Metaregression showed that, for each 10-mm Hg lower baseline SBP, hypertensive treatment increased risk for CV mortality (relative risk [RR] 1.15, 95% CI 1.03 to 1.29) and MI (RR 1.12, CI 1.03 to 1.22). Conclusions In patients with diabetes mellitus and systolic blood pressure 140 mm Hg, antihypertensive treatment reduces mortality and myocardial infarction. In patients with systolic blood pressure <140 mm Hg, antihypertensive treatment does not reduce mortality and is associated with increased cardiovascular mortality. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus* Outcomes Relative risk (95% CI) SBP >150 mm Hg SBP 140 to 150 mm Hg SBP <140 mm Hg All-cause mortality 0.89 (0.80 to 0.99) 0.87 (0.78 to 0.98) 1.05 (0.95 to 1.16) Cardiovascular mortality 0.75 (0.57 to 0.99) 0.87 (0.71 to 1.05) 1.15 (1.00 to 1.32) Myocardial infarction 0.74 (0.63 to 0.87) 0.84 (0.76 to 0.93) 1.00 (0.87 to 1.15) Stroke 0.77 (0.65 to 0.91) 0.92 (0.83 to 1.01) 0.81 (0.53 to 1.22) Heart failure 0.73 (0.53 to 1.01) 0.80 (0.66 to 0.97) 0.90 (0.79 to 1.02) End-stage renal disease 0.82 (0.71 to 0.94) 0.91 (0.74 to 1.12) 0.97 (0.80 to 1.17) *SBP = systolic blood pressure; other abbreviations defined in Glossary. Meta-analysis was stratified by mean baseline SBP within trials. Commentary Establishing optimal BP targets in patients with and without diabetes remains controversial. The systematic review by Brunstrm and Carlberg supports the view that lowering BP is most beneficial for patients with higher BP levels who are at increased risk for adverse CV outcomes. Further, it provides context for studies showing that intensive BP control is not necessarily beneficial to all patients, such as those with mildly elevated BP, low CV risk, frailty, or multiple morbidities (1, 2). The controversy continues, in part because the evidence is primarily from industry trials designed to compare the efficacy of antihypertensive agents, often with placebo, rather than to evaluate specific BP targets or reductions. The reliability of the review is affected by use of summary rather than individual patient data (which increases the risk for so-called ecological bias in the analyses stratified by baseline mean SBP) and analyses stratified by attained SBP (an outcome of the trials). Current guidelines seem to strike the right balance: After reduction of SBP levels to about 140 to 150 mm Hg, lower BP targets should take into account potential harms, inconvenience of additional treatment, personal and social contexts of patients, and CV risk and comorbidities (3). For many patients, perfect BP may turn out to be the enemy of good enough.
ObjectivesIn the care of patients with type 2 diabetes, self-management is emphasised and studied... more ObjectivesIn the care of patients with type 2 diabetes, self-management is emphasised and studied while theory and observations suggest that patients also benefit from social support. We sought to assess the effect of social network interventions on social support, glycaemic control and quality of life in patients with type 2 diabetes.Research design and methodsWe searched Ovid MEDLINE, Ovid EBM Reviews, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO and CINAHL through April 2017 for randomised clinical trials (RCTs) of social network interventions in patients with type 2 diabetes. Reviewers working independently and in duplicate assessed eligibility and risk of bias, and extracted data from eligible RCTs. We pooled estimates using inverse variance random effects meta-analysis.ResultsWe found 19 eligible RCTs enrolling 2319 participants. Social network interventions were commonly based on individual behaviour change rather than social or interpersonal theories of s...
Objectives To evaluate the comparative effectiveness and safety of treatments for childhood anxie... more Objectives To evaluate the comparative effectiveness and safety of treatments for childhood anxiety disorders, including panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, and separation anxiety. Data sources We searched MEDLINE®, Embase®, PsycINFO®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and SciVerse Scopus through February 1, 2017, and reviewed bibliographies and the gray literature. Review methods We included randomized and non-randomized comparative studies that compared psychotherapy, pharmacotherapy, or a combination in children ages 3 to 18 years with panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, or separation anxiety. Pairs of independent reviewers selected studies using pre-specified inclusion and exclusion criteria. Results We included 206 studies. Compared with pill placebo, selective serotonin reuptake inhibitors and serotonin-norepinephrine ...
The Journal of Clinical Endocrinology & Metabolism
Background The efficacy of lipid-lowering agents on patient-important outcomes in older individua... more Background The efficacy of lipid-lowering agents on patient-important outcomes in older individuals is unclear. Methods We included randomized trials that enrolled individuals aged 65 years or older and that included at least 1 year of follow-up. Pairs of reviewers selected and appraised the trials. Results We included 23 trials that enrolled 60,194 elderly patients. For primary prevention, statins reduced the risk of coronary artery disease [CAD; relative risk (RR): 0.79, 95% CI: 0.68 to 0.91] and myocardial infarction (MI; RR: 0.45, 95% CI: 0.31 to 0.66) but not all-cause or cardiovascular mortality or stroke. These effects were imprecise in patients with diabetes, but there was no significant interaction between diabetes status and the intervention effect. For secondary prevention, statins reduced all-cause mortality (RR: 0.80, 95% CI: 0.73 to 0.89), cardiovascular mortality (RR: 0.68, 95% CI: 0.58 to 0.79), CAD (RR: 0.68, 95% CI: 0.61 to 0.77), MI (RR: 0.68, 95% CI: 0.59 to 0.79...
Childhood anxiety is common. Multiple treatment options are available, but existing guidelines pr... more Childhood anxiety is common. Multiple treatment options are available, but existing guidelines provide inconsistent advice on which treatment to use. To evaluate the comparative effectiveness and adverse events of cognitive behavioral therapy (CBT) and pharmacotherapy for childhood anxiety disorders. We searched MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and SciVerse Scopus from database inception through February 1, 2017. Randomized and nonrandomized comparative studies that enrolled children and adolescents with confirmed diagnoses of panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, or separation anxiety and who received CBT, pharmacotherapy, or the combination. Independent reviewers selected studies and extracted data. Random-effects meta-analysis was used to pool data. Primary anxiety symptoms (measured by child, parent, or clinician), remission, response, and adverse...
To evaluate the diagnostic accuracy of fractional exhaled nitric oxide (FeNO) measurement in indi... more To evaluate the diagnostic accuracy of fractional exhaled nitric oxide (FeNO) measurement in individuals with suspected asthma. We searched MEDLINE, EMBASE, PsycINFO, Cochrane databases, and SciVerse Scopus from the databases' inception through April 4, 2017, for studies that enrolled patients aged 5 years and older with suspected asthma and evaluated FeNO diagnostic accuracy. Independent reviewers selected studies and extracted data. We used the symmetric hierarchical summary receiver operating characteristic models to estimate test performance. We included 43 studies with a total of 13,747 patients. In adults, using FeNO cutoffs of less than 20, 20 to 29, 30 to 39, and 40 or more parts per billion, FeNO testing had sensitivities of 0.80, 0.69, 0.53, and 0.41, respectively, and specificities of 0.64, 0.78, 0.85, and 0.93, respectively. In children, using FeNO cutoffs of less than 20 and 20 to 29 parts per billion, FeNO testing had sensitivities of 0.78 and 0.61, respectively, a...
Question In patients with diabetes mellitus, what is the effect of antihypertensive treatment at ... more Question In patients with diabetes mellitus, what is the effect of antihypertensive treatment at different blood pressure (BP) levels? Review scope Included studies compared any antihypertensive drug with placebo, any 2 drugs with 1 drug, or any BP target with another in 100 patients with diabetes for 12 months. Exclusion criteria were trials comparing 2 individual drugs or combined interventions. Outcomes included all-cause mortality, cardiovascular (CV) mortality, myocardial infarction (MI), stroke, heart failure, and end-stage renal disease (ESRD). Review methods MEDLINE, EMBASE/Excerpta Medica, Cochrane CENTRAL, BIOSIS (all to Feb 2013), and reference lists were searched for randomized controlled trials (RCTs). Authors, pharmaceutical companies, and authorities were contacted. 49 RCTs (n =73738, mean follow-up 3.7 y) met selection criteria. 24 RCTs included only patients with diabetes, and 25 included subgroups with diabetes; most patients had type 2 diabetes. 38 RCTs compared antihypertensive treatment with placebo. Risk for bias was low for randomization (45 RCTs), concealed allocation (39 RCTs), blinding of patients and personnel (26 RCTs), and blinding of outcome assessors (36 RCTs). Meta-analysis presented in this abstract was stratified by mean baseline systolic BP (SBP) within trials. Main results For trials with mean baseline SBP >150 mm Hg, antihypertensive treatment reduced all-cause mortality, CV mortality, MI, stroke, and ESRD (Table). For mean baseline SBP 140 to 150 mm Hg, antihypertensive treatment reduced all-cause mortality, MI, and heart failure (Table). For baseline SBP <140 mm Hg, antihypertensive treatment showed a borderline increase in CV mortality and did not differ for other outcomes (Table). Metaregression showed that, for each 10-mm Hg lower baseline SBP, hypertensive treatment increased risk for CV mortality (relative risk [RR] 1.15, 95% CI 1.03 to 1.29) and MI (RR 1.12, CI 1.03 to 1.22). Conclusions In patients with diabetes mellitus and systolic blood pressure 140 mm Hg, antihypertensive treatment reduces mortality and myocardial infarction. In patients with systolic blood pressure <140 mm Hg, antihypertensive treatment does not reduce mortality and is associated with increased cardiovascular mortality. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus* Outcomes Relative risk (95% CI) SBP >150 mm Hg SBP 140 to 150 mm Hg SBP <140 mm Hg All-cause mortality 0.89 (0.80 to 0.99) 0.87 (0.78 to 0.98) 1.05 (0.95 to 1.16) Cardiovascular mortality 0.75 (0.57 to 0.99) 0.87 (0.71 to 1.05) 1.15 (1.00 to 1.32) Myocardial infarction 0.74 (0.63 to 0.87) 0.84 (0.76 to 0.93) 1.00 (0.87 to 1.15) Stroke 0.77 (0.65 to 0.91) 0.92 (0.83 to 1.01) 0.81 (0.53 to 1.22) Heart failure 0.73 (0.53 to 1.01) 0.80 (0.66 to 0.97) 0.90 (0.79 to 1.02) End-stage renal disease 0.82 (0.71 to 0.94) 0.91 (0.74 to 1.12) 0.97 (0.80 to 1.17) *SBP = systolic blood pressure; other abbreviations defined in Glossary. Meta-analysis was stratified by mean baseline SBP within trials. Commentary Establishing optimal BP targets in patients with and without diabetes remains controversial. The systematic review by Brunstrm and Carlberg supports the view that lowering BP is most beneficial for patients with higher BP levels who are at increased risk for adverse CV outcomes. Further, it provides context for studies showing that intensive BP control is not necessarily beneficial to all patients, such as those with mildly elevated BP, low CV risk, frailty, or multiple morbidities (1, 2). The controversy continues, in part because the evidence is primarily from industry trials designed to compare the efficacy of antihypertensive agents, often with placebo, rather than to evaluate specific BP targets or reductions. The reliability of the review is affected by use of summary rather than individual patient data (which increases the risk for so-called ecological bias in the analyses stratified by baseline mean SBP) and analyses stratified by attained SBP (an outcome of the trials). Current guidelines seem to strike the right balance: After reduction of SBP levels to about 140 to 150 mm Hg, lower BP targets should take into account potential harms, inconvenience of additional treatment, personal and social contexts of patients, and CV risk and comorbidities (3). For many patients, perfect BP may turn out to be the enemy of good enough.
ObjectivesIn the care of patients with type 2 diabetes, self-management is emphasised and studied... more ObjectivesIn the care of patients with type 2 diabetes, self-management is emphasised and studied while theory and observations suggest that patients also benefit from social support. We sought to assess the effect of social network interventions on social support, glycaemic control and quality of life in patients with type 2 diabetes.Research design and methodsWe searched Ovid MEDLINE, Ovid EBM Reviews, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO and CINAHL through April 2017 for randomised clinical trials (RCTs) of social network interventions in patients with type 2 diabetes. Reviewers working independently and in duplicate assessed eligibility and risk of bias, and extracted data from eligible RCTs. We pooled estimates using inverse variance random effects meta-analysis.ResultsWe found 19 eligible RCTs enrolling 2319 participants. Social network interventions were commonly based on individual behaviour change rather than social or interpersonal theories of s...
Objectives To evaluate the comparative effectiveness and safety of treatments for childhood anxie... more Objectives To evaluate the comparative effectiveness and safety of treatments for childhood anxiety disorders, including panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, and separation anxiety. Data sources We searched MEDLINE®, Embase®, PsycINFO®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and SciVerse Scopus through February 1, 2017, and reviewed bibliographies and the gray literature. Review methods We included randomized and non-randomized comparative studies that compared psychotherapy, pharmacotherapy, or a combination in children ages 3 to 18 years with panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, or separation anxiety. Pairs of independent reviewers selected studies using pre-specified inclusion and exclusion criteria. Results We included 206 studies. Compared with pill placebo, selective serotonin reuptake inhibitors and serotonin-norepinephrine ...
The Journal of Clinical Endocrinology & Metabolism
Background The efficacy of lipid-lowering agents on patient-important outcomes in older individua... more Background The efficacy of lipid-lowering agents on patient-important outcomes in older individuals is unclear. Methods We included randomized trials that enrolled individuals aged 65 years or older and that included at least 1 year of follow-up. Pairs of reviewers selected and appraised the trials. Results We included 23 trials that enrolled 60,194 elderly patients. For primary prevention, statins reduced the risk of coronary artery disease [CAD; relative risk (RR): 0.79, 95% CI: 0.68 to 0.91] and myocardial infarction (MI; RR: 0.45, 95% CI: 0.31 to 0.66) but not all-cause or cardiovascular mortality or stroke. These effects were imprecise in patients with diabetes, but there was no significant interaction between diabetes status and the intervention effect. For secondary prevention, statins reduced all-cause mortality (RR: 0.80, 95% CI: 0.73 to 0.89), cardiovascular mortality (RR: 0.68, 95% CI: 0.58 to 0.79), CAD (RR: 0.68, 95% CI: 0.61 to 0.77), MI (RR: 0.68, 95% CI: 0.59 to 0.79...
Childhood anxiety is common. Multiple treatment options are available, but existing guidelines pr... more Childhood anxiety is common. Multiple treatment options are available, but existing guidelines provide inconsistent advice on which treatment to use. To evaluate the comparative effectiveness and adverse events of cognitive behavioral therapy (CBT) and pharmacotherapy for childhood anxiety disorders. We searched MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and SciVerse Scopus from database inception through February 1, 2017. Randomized and nonrandomized comparative studies that enrolled children and adolescents with confirmed diagnoses of panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, or separation anxiety and who received CBT, pharmacotherapy, or the combination. Independent reviewers selected studies and extracted data. Random-effects meta-analysis was used to pool data. Primary anxiety symptoms (measured by child, parent, or clinician), remission, response, and adverse...
To evaluate the diagnostic accuracy of fractional exhaled nitric oxide (FeNO) measurement in indi... more To evaluate the diagnostic accuracy of fractional exhaled nitric oxide (FeNO) measurement in individuals with suspected asthma. We searched MEDLINE, EMBASE, PsycINFO, Cochrane databases, and SciVerse Scopus from the databases' inception through April 4, 2017, for studies that enrolled patients aged 5 years and older with suspected asthma and evaluated FeNO diagnostic accuracy. Independent reviewers selected studies and extracted data. We used the symmetric hierarchical summary receiver operating characteristic models to estimate test performance. We included 43 studies with a total of 13,747 patients. In adults, using FeNO cutoffs of less than 20, 20 to 29, 30 to 39, and 40 or more parts per billion, FeNO testing had sensitivities of 0.80, 0.69, 0.53, and 0.41, respectively, and specificities of 0.64, 0.78, 0.85, and 0.93, respectively. In children, using FeNO cutoffs of less than 20 and 20 to 29 parts per billion, FeNO testing had sensitivities of 0.78 and 0.61, respectively, a...
Uploads
Papers by Laura Larrea Mantilla