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Alpha blockers may facilitate the expulsion of larger ureteric stones
CLINICAL QUESTION: Are alpha blockers efficacious in patients with ureteric stones?
STUDY DESIGN: Systematic review & meta-analysis.
SETTING: Randomized controlled trials (RCTs); most conducted in Europe and Asia.
SYNOPSIS: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.
Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.
Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.
The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.
BOTTOM LINE: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.
CITATIONS: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Are alpha blockers efficacious in patients with ureteric stones?
STUDY DESIGN: Systematic review & meta-analysis.
SETTING: Randomized controlled trials (RCTs); most conducted in Europe and Asia.
SYNOPSIS: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.
Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.
Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.
The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.
BOTTOM LINE: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.
CITATIONS: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Are alpha blockers efficacious in patients with ureteric stones?
STUDY DESIGN: Systematic review & meta-analysis.
SETTING: Randomized controlled trials (RCTs); most conducted in Europe and Asia.
SYNOPSIS: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.
Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.
Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.
The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.
BOTTOM LINE: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.
CITATIONS: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Interventions, especially those that are organization-directed, reduce burnout in physicians
CLINICAL QUESTION: How efficacious are interventions to reduce burnout in physicians?
BACKGROUND: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.
SETTING: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.
SYNOPSIS: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.
Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.
The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.
BOTTOM LINE: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.
CITATIONS: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: How efficacious are interventions to reduce burnout in physicians?
BACKGROUND: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.
SETTING: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.
SYNOPSIS: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.
Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.
The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.
BOTTOM LINE: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.
CITATIONS: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: How efficacious are interventions to reduce burnout in physicians?
BACKGROUND: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.
SETTING: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.
SYNOPSIS: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.
Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.
The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.
BOTTOM LINE: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.
CITATIONS: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Alpha blockers may facilitate the expulsion of larger ureteric stones
Clinical Question: Are alpha blockers efficacious in patients with ureteric stones?
Background: A multicenter, randomized controlled trial by Pickard and colleagues demonstrated an alpha blocker to be no more efficacious than placebo as medical expulsive therapy. There are no systematic reviews that include this recent study.
Setting: Randomized controlled trials (RCTs); most conducted in Europe and Asia.
Synopsis: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.
Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.
Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.
The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.
Bottom Line: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.
Citations: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: Are alpha blockers efficacious in patients with ureteric stones?
Background: A multicenter, randomized controlled trial by Pickard and colleagues demonstrated an alpha blocker to be no more efficacious than placebo as medical expulsive therapy. There are no systematic reviews that include this recent study.
Setting: Randomized controlled trials (RCTs); most conducted in Europe and Asia.
Synopsis: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.
Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.
Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.
The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.
Bottom Line: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.
Citations: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: Are alpha blockers efficacious in patients with ureteric stones?
Background: A multicenter, randomized controlled trial by Pickard and colleagues demonstrated an alpha blocker to be no more efficacious than placebo as medical expulsive therapy. There are no systematic reviews that include this recent study.
Setting: Randomized controlled trials (RCTs); most conducted in Europe and Asia.
Synopsis: Fifty-five unique RCTs (5,990 subjects) examining alpha blockers as the main treatment of ureteric stones versus placebo or control were included regardless of language and publication status.
Treatment with alpha blockers resulted in a 49% greater likelihood of stone passage (RR, 1.49; CI, 1.39-1.61) with a number needed to treat of four. A priori subgroup analysis revealed treatment was only beneficial in patients with larger stones (5mm or greater) independent of stone location or type of alpha blocker.
Secondary outcomes included reduced time to stone passage, fewer episodes of pain, decreased risk of surgical intervention, and lower risk of hospital admission with alpha blocker treatment without an increase in serious adverse events.
The meta-analysis was limited by the overall lack of methodological rigor of and clinical heterogeneity between the pooled studies.
Bottom Line: Based on available evidence, it is reasonable to utilize an alpha blocker as medical expulsive therapy in patients with larger ureteric stones.
Citations: Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016;355:i6112.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Interventions, especially those that are organization-directed, reduce burnout in physicians
Clinical Question: How efficacious are interventions to reduce burnout in physicians?
Background: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.
Setting: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.
Synopsis: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.
Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.
The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.
Bottom Line: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.
Citations: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: How efficacious are interventions to reduce burnout in physicians?
Background: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.
Setting: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.
Synopsis: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.
Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.
The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.
Bottom Line: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.
Citations: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: How efficacious are interventions to reduce burnout in physicians?
Background: Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. It is driven by workplace stressors and affects nearly half of physicians practicing in the U.S.
Setting: Randomized controlled trials and controlled before-after studies in primary, secondary, or intensive care settings; most conducted in North America and Europe.
Synopsis: Twenty independent comparisons from 19 studies (1,550 physicians of any specialty including trainees) were included. All reported burnout outcomes after either physician- or organization-directed interventions designed to relieve stress and/or improve physician performance. Most physician-directed interventions utilized mindfulness-based stress reduction techniques or other educational interventions. Most organizational-directed interventions introduced reductions in workload or schedule changes.
Interventions were associated with small, significant reductions in burnout (standardized mean difference, –0.29; CI –0.42 to –0.16). A pre-specified subgroup analysis revealed organization-directed interventions had significantly improved effects, compared with physician-directed ones.
The generalizability of this meta-analysis is limited as the included studies significantly differed in their methodologies.
Bottom Line: Burnout intervention programs for physicians are associated with small benefits, and the increased efficacy of organization-directed interventions suggest burnout is a problem of the health care system, rather than of individuals.
Citations: Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
Dr. Ecker is the assistant director of education, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.