Anti-vascular endothelial growth factor therapy for age-related macular degeneration: a systematic review and network meta-analysis.

BACKGROUND: The comparative safety and efficacy between anti-vascular endothelial growth factor agents (anti-VEGFs) and between combined therapies for patients with neovascular age-related macular degeneration (nAMD) is unclear. We conducted a systematic review to examine the comparative safety and efficacy anti-VEGFs for adults with nAMD. METHODS: Studies were identified through MEDLINE, EMBASE, and Cochrane CENTRAL (inception to June 3, 2019), grey literature, and scanning reference lists. Two reviewers independently screened citations and full-text articles to identify randomized controlled trials (RCTs), extracted data, and appraised risk of bias. Pairwise random-effects meta-analysis and Bayesian network meta-analysis (NMA) were conducted. The primary outcomes were the proportion of patients experiencing moderate vision gain (≥ 15 letters on the Early Treatment Diabetic Retinopathy Study chart) and the proportion of patients experiencing moderate vision loss (≤ 15 letters). RESULTS: After screening 3647 citations and 485 potentially relevant full-text articles, 92 RCTs with 24,717 patients were included. NMA (34 RCTs, 8809 patients, 12 treatments) showed small differences among anti-VEGFs in improving the proportion of patients with moderate vision gain, with the largest for conbercept versus broluczumab (OR 0.15, 95% CrI: 0.05-0.56), conbercept versus ranibizumab (OR 0.17, 95% CrI: 0.05-0.59), conbercept versus aflibercept (OR 0.19, 95% CrI: 0.06-0.65), and conbercept versus bevacizumab (OR 0.2, 95% CrI: 0.06-0.69). In NMA (36 RCTs, 9081 patients, 13 treatments) for the proportion of patients with moderate vision loss, small differences were observed among anti-VEGFs, with the largest being for conbercept versus aflibercept (OR 0.24, 95% CrI: 0-4.29), conbercept versus brolucizumab (OR 0.24, 95% CrI: 0-4.71), conbercept versus bevacizumab (OR 0.26, 95% CrI: 0-4.65), and conbercept versus ranibizumab (OR 0.27, 95% CrI: 0-4.67). CONCLUSION: The only observed differences were that ranibizumab, bevacizumab, aflibercept, and brolucizumab were statistically superior to conbercept in terms of the proportion of patients with nAMD who experienced moderate vision gain. However, this finding is based on indirect evidence through one small trial comparing conbercept with placebo. This does not account for drug-specific differences when assessing anatomic and functional treatment efficacy in variable dosing regimens. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number CRD42015022041.

Anti-vascular endothelial growth factor treatment for retinal conditions: a systematic review and meta-analysis.

OBJECTIVES: To evaluate the comparative effectiveness and safety of intravitreal bevacizumab, ranibizumab and aflibercept for patients with choroidal neovascular age-related macular degeneration (cn-AMD), diabetic macular oedema (DMO), macular oedema due to retinal vein occlusion (RVO-MO) and myopic choroidal neovascularisation (m-CNV). DESIGN: Systematic review and random-effects meta-analysis. METHODS: Multiple databases were searched from inception to 17 August 2017. Eligible head-to-head randomised controlled trials (RCTs) comparing the (anti-VEGF) drugs in adult patients aged ≥18 years with the retinal conditions of interest. Two reviewers independently screened studies, extracted data and assessed risk of bias. RESULTS: 19 RCTs involving 7459 patients with cn-AMD (n=12), DMO (n=3), RVO-MO (n=2) and m-CNV (n=2) were included. Vision gain was not significantly different in patients with cn-AMD, DMO, RVO-MO and m-CNV treated with bevacizumab versus ranibizumab. Similarly, vision gain was not significantly different between cn-AMD patients treated with aflibercept versus ranibizumab. Patients with DMO treated with aflibercept experienced significantly higher vision gain at 12 months than patients receiving ranibizumab or bevacizumab; however, this difference was not significant at 24 months. Rates of systemic serious harms were similar across anti-VEGF agents. Posthoc analyses revealed that an as-needed treatment regimen (6-9 injections per year) was associated with a mortality increase of 1.8% (risk ratio: 2.0 [1.2 to 3.5], 2 RCTs, 1795 patients) compared with monthly treatment in cn-AMD patients. CONCLUSIONS: Intravitreal bevacizumab was a reasonable alternative to ranibizumab and aflibercept in patients with cn-AMD, DMO, RVO-MO and m-CNV. The only exception was for patients with DME and low visual acuity (<69 early treatment diabetic retinopathy study [ETDRS] letters), where treatment with aflibercept was associated with significantly higher vision gain (≥15 ETDRS letters) than bevacizumab or ranibizumab at 12 months; but the significant effects were not maintained at 24 months. The choice of anti-VEGF drugs may depend on the specific retinal condition, baseline visual acuity and treatment regimen. PROSPERO REGISTRATION NUMBER: CRD42015022041.

Diabetes mHealth Apps: Designing for Greater Uptake.

mHealth apps are not being used. Over 45,000 mhealth apps are languishing in mobile app stores. We evaluated over 200 diabetes mobile apps found in the Apple and Google app stores using a framework that we recently published. None of the apps met all 15 criteria identified by our framework. The largest number of apps fell into the category of Type 1 diabetes blood sugar and medication trackers. Other types of apps included educational apps such as recipe apps, guideline dissemination apps, simple diabetes education apps, etc. There is a need for more Type 2 apps and for all types of apps that are better integrated into EMRs for more holistic care that can be prescribed by clinicians and monitored and supported by the health care team.

Impact of patient-centered discharge tools: A systematic review.

BACKGROUND: Patient-centered discharge tools provide an opportunity to engage patients, enhance patient understanding, and improve capacity for self-care and postdischarge outcomes. PURPOSE: To review studies that engaged patients in the design or delivery of discharge instruction tools and that tested their effect among hospitalized patients. DATA SOURCES: We conducted a search of 12 databases and journals from January 1994 through May 2014, and references of retrieved studies. STUDY SELECTION: English-language studies that tested discharge tools meant to engage patients were selected. Studies that measured outcomes after 3 months or without a control group or period were excluded. DATA EXTRACTION: Two independent reviewers assessed the full-text papers and extracted data on features of patient engagement. DATA SYNTHESIS: Thirty articles met inclusion criteria, 28 of which examined educational tools. Of these, 13 articles involved patients in content creation or tool delivery, with only 6 studies involving patients in both. While many of these studies (10 studies) demonstrated an improvement in patient comprehension, few studies found improvement in patient adherence despite their engagement. A few studies demonstrated an improvement in self-efficacy (2 studies) and a reduction in unplanned visits (3 studies). CONCLUSIONS: Improving patient engagement through the use of media, visual aids, or by involving patients when creating or delivering a discharge tool improves comprehension. However, further studies are needed to clarify the effect on patient experience, adherence, and healthcare utilization postdischarge. Better characterization of the level of patient engagement when designing discharge tools is needed given the heterogeneity found in current studies. Journal of Hospital Medicine 2017;12:110-117.