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Pasteurization kills harmful microorganisms found in milk. While consumption of unpasteurized milk and its products is discouraged due to increased risk of infections, some individuals prefer unpasteurized dairy products. Our objective was to estimate the burden of illness from outbreaks arising from consumption of unpasteurized and pasteurized dairy products in Canada and the United States.We conducted a systematic review of dairy-associated outbreaks in Canada and the USA from 2007 onward. We searched MEDLINE, Embase, Cochrane Library, TRIP Database for guidelines, and North American government agency websites up to October 2020. We included outbreak reports where the pathogenic microbe was confirmed in both the patient and the dairy product through laboratory testing.Thirty-two disease outbreaks were linked to dairy consumption. Twenty outbreaks involving unpasteurized products resulted in 449 confirmed cases of illness, 124 hospitalizations, and five deaths. Twelve outbreaks involving pasteurized products resulted in 174 confirmed cases of illness, 134 hospitalizations, 17 deaths, and seven fetal losses. Listeria accounted for 10 out of 12 outbreaks from pasteurized products from 2007 through 2020.Public warnings about the risk of unpasteurized dairy consumption need to continue and pregnant women and immunocompromised hosts need to be made aware of foods at high risk of contamination with Listeria.RéSUMé: OBJECTIF: La pasteurisation tue les micro-organismes dangereux contenus dans le lait. Même si la consommation du lait non pasteurisé et ses produits fût déconseillée en raison d’un risque accru d’infection, certaines personnes préfèrent des produits laitiers non pasteurisés. Notre objectif était d’évaluer le fardeau de maladie des éclosions résultant de la consommation des produits laitiers non pasteurisés et pasteurisés au Canada et aux États-Unis. MéTHODE: Nous avons mené une revue systématique des éclosions liées aux produits laitiers au Canada et aux États-Unis depuis 2007. Nous avons cherché dans MEDLINE, Embase, Cochrane Library, TRIP Database et les sites web des agences gouvernementales Nord-Américaines pour la période 2007 jusqu’au mois d’octobre 2020. Nous avons inclus des rapports d’éclosion lorsque les essais en laboratoire ont confirmé la présence du microbe pathogène dans le patient ainsi que dans le produit laitier. RéSULTATS: Trente-deux éclosions étaient liées à la consommation des produits laitiers. Les produits non pasteurisés étaient impliqués dans 20 éclosions, avec 449 cas de maladie confirmés, 124 hospitalisations et 5 morts. Les produits pasteurisés étaient impliqués dans 12 éclosions, avec 174 cas de maladie confirmés, 134 hospitalisations, 17 morts et sept morts fœtales. Listeria comptait pour 10 des 12 éclosions des produits pasteurisés de 2007 à 2020. CONCLUSION: Les avis publics au sujet du risque de la consommation des produits laitiers non pasteurisés devraient continuer et les femmes enceintes et les hôtes immunodéprimés devraient être informés de la nourriture à haut risque de la contamination avec Listeria.

Background and aimWith the Coronavirus Disease 2019 (COVID-19) pandemic continuing to impact healthcare systems around the world, healthcare providers are attempting to balance resources devoted to COVID-19 patients while minimizing excess mortality overall (both COVID-19 and non-COVID-19 patients). To this end, we conducted a systematic review (SR) to describe the effect of the COVID-19 pandemic on all-cause excess mortality (COVID-19 and non-COVID-19) during the pandemic timeframe compared to non-pandemic times.MethodsWe searched EMBASE, Cochrane Database of SRs, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Controlled Trials Register (CENTRAL), from inception (1948) to December 31, 2020. We used a two-stage review process to screen/extract data. We assessed risk of bias using Newcastle-Ottawa Scale (NOS). We used Critical Appraisal and Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.ResultsOf 11,581 citations, 194 studies met eligibility. Of these studies, 31 had mortality comparisons (n = 433,196,345 participants). Compared to pre-pandemic times, during the COVID-19 pandemic, our meta-analysis demonstrated that COVID-19 mortality had an increased risk difference (RD) of 0.06% (95% CI: 0.06–0.06% p < 0.00001). All-cause mortality also increased [relative risk (RR): 1.53, 95% confidence interval (CI): 1.38–1.70, p < 0.00001] alongside non-COVID-19 mortality (RR: 1.18, 1.07–1.30, p < 0.00001). There was “very low” certainty of evidence through GRADE assessment for all outcomes studied, demonstrating the evidence as uncertain.InterpretationThe COVID-19 pandemic may have caused significant increases in all-cause excess mortality, greater than those accounted for by increases due to COVID-19 mortality alone, although the evidence is uncertain.Systematic review registration[https://www.crd.york.ac.uk/prospero/#recordDetails], identifier [CRD42020201256].

ContextChildren with Down syndrome are at risk for obstructive sleep apnea, which may not be resolved by adenotonsillecotmy, as well as other respiratory disorders that may impact breathing during sleep. Long-term non-invasive ventilation, including continuous and bilevel positive airway pressure delivery, is an alternate treatment strategy.ObjectiveTo assess the use and outcomes of long-term non-invasive ventilation in children with Down syndrome including comparison to other children using long-term non-invasive ventilation.Data SourcesThe search strategy for the scoping review used Medical Subject Headings (MeSH) and free-text terms for “child” and “non-invasive ventilation.” MEDLINE (Ovid), Embase (Ovid), CINAHL (Ebsco), Cochrane Library (Wiley), and PubMed databases were searched (1990-2021).Study SelectionThe scoping review results were searched to identify studies including data on at least three children with Down Syndrome using long-term non-invasive ventilation.Data ExtractionStudy characteristics, subject characteristics, technology type, and outcome measurements were extracted.ResultsA total of 28 articles included 543 children with Down syndrome using long-term non-invasive ventilation. Children with Down syndrome accounted for 18% of children using long-term non-invasive ventilation. Data on efficacy, feasibility, and adherence in children with Down syndrome are comparable to other children. Children with Down syndrome may have greater difficulty initiating long-term non-invasive ventilation, longer time to establish use, and a higher rate of inability to establish use. Outcome data is limited but suggest favorable impact on cardiac function and attention.LimitationsArticles related to long-term non-invasive ventilation use in adolescents and young adults may have been excluded.ConclusionsChildren with Down syndrome make up a significant portion of the population of children using long-term non-invasive ventilation. While there is more limited data available with respect to the use and outcomes for children with Down syndrome compared to the other children, long-term non-invasive ventilation is an effective and well-tolerated therapy with no clear differences in the use or outcomes for children with Down syndrome. Additional work is needed to understand potential challenges around establishing long-term non-invasive ventilation use in children with Down syndrome.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=206533, identifier: CRD206533.

Since the first national guideline for managing obesity in adults and children in Canada was published in 2007, new evidence has emerged and guideline standards have evolved. Our purpose is to describe the protocol used to update the Canadian clinical practice guideline for managing pediatric obesity.This guideline will update the pediatric components of the 2007 Canadian clinical practice guideline for the management of obesity. In partnership with Obesity Canada, we began preliminary work in 2019; activities are scheduled for completion in 2022. The guideline will follow standards developed by the National Academy of Medicine and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group. Guideline development will be informed by 5 complementary literature reviews: a scoping review that focuses on clinical assessment in pediatric obesity management and 4 systematic reviews to synthesize evidence regarding families' values and preferences as well as the safety and effectiveness of interventions (psychological and behavioural; pharmacotherapeutic; and surgical). We will use standard systematic review methodology, including summarizing and assessing the certainty of evidence and determining the strength of recommendations. Competing interests will be managed proactively according to recommendations from the Guidelines International Network. Diverse stakeholders, including families and clinicians, will be engaged throughout guideline development.The guideline will support Canadian families and clinicians to make informed, value-sensitive and evidence-based clinical decisions related to managing pediatric obesity. The guideline and accompanying resources for end-users will be published in English and French, and we will partner with Obesity Canada to optimize dissemination using integrated and end-of-project knowledge translation.

Backgroud An increasing number of original studies suggest that exposure to shift work and long working hours during pregnancy could be associated with the risk of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. Objective To examine the influences of shift work and longer working hours during pregnancy on maternal and fetal health outcomes. Data Sources Five electronic databases and three gray literature sources were searched up to March 15, 2019. Methods of Study Selection: Studies of all designs (except case studies and reviews) were included, which contained information on the relevant population (women who engaged in paid work during pregnancy); exposure (rotating shift work [shifts change according to a set schedule], fixed night shift [typical working period is between 11:00 pm to 11:00 am] or longer working hours [h] [>40 h per week]);comparator (fixed day shift [typical working period between 8:00 am- 6:00 pm] or standard working hours [≤40 h per week]); and outcomes (preterm delivery, low birth weight [birth weight Tabulation, Integration, and Results From 3305 unique citations, 62 observational studies (196,989 women) were included. “Low” to “very low” certainty evidence from these studies revealed that working rotating shifts was associated with an increased odds of preterm delivery (OR=1.13, 95% CI: 1.00 to 1.28, I 2 =31%), having a small for gestational age baby (OR=1.18, 95% CI: 1.01 to 1.38, I 2 =0%), preeclampsia (OR=1.75, 95% CI: 1.01 to 3.01, I 2 =75%) and gestational hypertension (OR=1.19, 95% CI: 1.10 to 1.29, I 2 =0%), compared to those who worked a fixed day shift. Working fixed night shifts was associated with an increased odds of preterm delivery (OR=1.21, 95% CI: 1.03 to 1.42, I 2 =36%) and miscarriage (OR=1.23, 95% CI: 1.03 to 1.47, I 2 =37%). Compared with standard hours, working longer hours was associated with an increased odds of miscarriage (OR=1.38, 95% CI: 1.08 to 1.77, I 2 =73%), preterm delivery (OR=1.21, 95% CI: 1.11 to 1.33, I 2 =30%), an infant of low birth weight (OR=1.43, 95% CI: 1.11 to 1.84, I 2 =0%), or an infant of small for gestational age (OR=1.16, 95% CI: 1.00 to 1.36, I 2 =57%). Dose-response analysis showed women working more than 55.5 hours per week (versus 40) had a 10% increase in the odds of having a preterm delivery. Conclusion Pregnant women who work rotating shifts, fixed night shifts, or longer hours have an increased risk of adverse pregnancy outcomes.

Background As the Coronavirus Disease-2019 (COVID-19) pandemic continues, healthcare providers struggle to manage both COVID-19 and non-COVID patients while still providing high-quality care. We conducted a systematic review/meta-analysis to describe the effects of the COVID-19 pandemic on patients with non-COVID illness and on healthcare systems compared to non-pandemic epochs. Methods We searched Ovid MEDLINE/EMBASE/Cochrane Database of Systematic Reviews/CENTRAL/CINAHL (inception to December 31, 2020). All study types with COVID-pandemic time period (after December 31, 2019) with comparative non-pandemic time periods (prior to December 31, 2019). Data regarding study characteristics/case-mix/interventions/comparators/ outcomes (primary: mortality; secondary: morbidity/hospitalizations/disruptions-to-care. Paired reviewers conducted screening and abstraction, with conflicts resolved by discussion. Effect sizes for specific therapies were pooled using random-effects models. Risk of bias was assessed by Newcastle-Ottawa Scale, with evidence rating using GRADE methodology. Results Of 11,581 citations, 167 studies met eligibility. Our meta-analysis showed an increased mortality of 16% during the COVID pandemic for non-COVID illness compared with 11% mortality during the pre-pandemic period (RR 1.38, 95% CI: 1.28–1.50; absolute risk difference: 5% [95% CI: 4–6%], p Conclusions There was a significant increase in mortality during the COVID pandemic compared to pre-pandemic times for non-COVID illnesses. When significant changes were reported, there was increased morbidity, decreased hospitalizations and increased disruptions in standards-of-care. Systematic review registration PROSPERO CRD42020201256 (Sept 2, 2020).

ObjectivesAcute respiratory distress syndrome (ARDS) is a life-threatening respiratory injury with multiple physiological sequalae. Shunting of deoxygenated blood through intra and extra-pulmonary shunts is one consequence that may complicate ARDS management. Therefore, we conducted a systematic review to determine the prevalence of sonographically detected shunt and its association with oxygenation and mortality in patients with ARDS.Data SourcesWe searched MEDLINE, EMBASE, Cochrane Library and DARE databases on March 26, 2021Study SelectionArticles relating to respiratory failure and sonographic shunt detection.Data ExtractionArticles were independently screened and extracted in duplicate. Data pertaining to study demographics and shunt detection were compiled for mortality and oxygenation outcomes. Risk of bias was appraised using the Joanna Briggs Institute and Newcastle-Ottawa Scale tools with evidence rating certainty using GRADE methodology.Data SynthesisFrom 4,617 citations, 10 observational studies met eligibility criteria. Sonographic detection of right-to-left shunt was present in 21.8% of patients (range:14.4-30.0%) amongst included studies using transthoracic, transesophageal and transcranial bubble Doppler sonography. Shunt prevalence may be associated with increased mortality (risk ratio: 1.22, 95% CI: 1.01-1.49, p=0.04, very low certainty evidence) with no difference in oxygenation as measured by PaO2:FiO2 ratio (mean difference -0.7, 95% CI: -18.6 to 17.2, p=0.94, very low certainty evidence).ConclusionsIntra- and extra-pulmonary shunts are detected frequently in ARDS with ultrasound techniques. Shunts may increase mortality amongst patients with ARDS, but its association with oxygenation is uncertain. Future research should explore the role of shunt in ARDS, their association with mortality, and whether targeted precision medicine interventions can improve outcomes.PROSPERO Registration Number: CRD42021245194 (March 26, 2021)Key PointsQuestion: In adult critically ill ARDS patients, what is the prevalence of right-to-left shunts, and what are their effects on mortality and/or oxygenation?Findings: In this systematic review and meta-analysis, shunts be may prevalent in ∼1 in 5 ARDS patients. They may be associated with a statistically significant increase in mortality, with no difference in oxygenation parameters.Meaning: Intra- and extra-pulmonary shunts are detected frequently in ARDS with ultrasound techniques, and may increase mortality amongst patients with ARDS (although its association with oxygenation is uncertain).

Objective: To determine whether children with neuromuscular disorders using long-term non-invasive ventilation, continuous or bilevel positive airway pressure, have improved health outcomes compare...

To assess randomized controlled trials evaluating the impact of nurse practitioner-led cardiovascular care.Systematic review of nurse practitioner-led care in patients with cardiovascular disease has not been completed.Systematic review and meta-analysis.The Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, Web of Science, Scopus and ProQuest were systematically searched for studies published between January 2007 - June 2017.Cochrane methodology was used for risk of bias, data extraction and meta-analysis. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation approach.Out of 605 articles, five articles met the inclusion criteria. There was no statistical difference between nurse practitioner-led care and usual care for 30-day readmissions, health-related quality of life and length of stay. A 12% reduction in Framingham risk score was identified.There are a few randomized control trials assessing nurse practitioner-led cardiovascular care.Low to moderate quality evidence was identified with no statistically significant associated outcomes of care. Nurse practitioner roles need to be supported to conduct and publish high-quality research.目的: 在于评估随机对照试验,从而评估执业护士主导型护理心血管护理的影响。 背景: 尚未完成对心血管疾病患者进行执业护士主导型护理的系统综述。 设计: 系统综述和荟萃分析。 资料来源: 在 Cochrane Central Register of Controlled Trials (CENTRAL)、Medline、Embase、CINAHL、Web of Science、Scopus和ProQuest上系统地搜索了2007年1月至2017年6月间发表的研究。 综述方法: Cochrane方法学用于偏倚风险、数据提取和荟萃分析。证据质量的评估采用了GRADE(Grading of Recommendations Assessment, Development and Evaluation)法。 结果: 在605篇文章中,有5篇符合纳入标准。执业护士主导型护理和30天再度入院的常规护理、健康相关生活质量和住院天数之间没有统计学差异。确定Framingham 风险评分降低了12%。 结论: 有一些随机对照试验评估了执业护士主导型心血管护理。 影响: 确定了低等至中等质量的证据,没有统计学意义的相关护理结果。需要支持执业护士的角色,从而开展和发布高质量研究。.

Background Living systematic reviews (LSRs) can expedite evidence synthesis by incorporating new evidence in real time. However, the methods needed to identify new studies in a timely manner are not well established. Objectives To explore the value of complementary search approaches in terms of search performance, impact on results and conclusions, screening workload, and feasibility compared to the reference standard. Methods We developed three complementary search approaches for a systematic review on treatments for bronchiolitis: Automated Full Search, PubMed Similar Articles, and Scopus Citing References. These were automated to retrieve results monthly; pairs of reviewers screened the records and commented on feasibility. After 1 year, we conducted a full update search (reference standard). For each complementary approach, we compared search performance (proportion missed, number needed to read [NNR]) and reviewer workload (number of records screened, time required) to the reference standard. We investigated the impact of the new trials on the effect estimate and certainty of evidence for the primary outcomes. We summarized comments about feasibility. Results Via the reference standard, reviewers screened 505 titles/abstracts, 24 full texts, and identified four new trials (NNR 127; 12.4 h). Of the complementary approaches, only the Automated Full Search located all four trials; these were located 6 to 12 months sooner than via the reference standard but did not alter the results nor certainty in the evidence. The Automated Full Search was the most resource-intensive approach (816 records screened; NNR 204; 17.1 h). The PubMed Similar Articles and Scopus Citing References approaches located far fewer records (452 and 244, respectively), thereby requiring less screening time (9.4 and 5.2 h); however, each approach located only one of the four new trials. Reviewers found it feasible and convenient to conduct monthly screening for searches of this yield (median 15–65 records/month). Conclusions The Automated Full Search was the most resource-intensive approach, but also the only to locate all of the newly published trials. Although the monthly screening time for the PubMed Similar Articles and Scopus Citing Articles was far less, most relevant records were missed. These approaches were feasible to integrate into reviewer work processes. Systematic review registration Open Science Framework. 10.17605/OSF.IO/6M28H.

Aim To systematically review the literature to compare the performance of head ultrasound (HUS) and magnetic resonance imaging (MRI) in their ability to detect brain injury and their predictive value for neurodevelopmental outcomes. Methods This was a systematic review based on literature search in three electronic databases (MEDLINE, EMBASE, Cochrane Library) and additional sources for studies on routine brain injury screening in preterm neonates published during 2000 - May 2020. Studies were included if they reported on the comparative performance of HUS and MRI in detecting preterm brain injury and/or their predictive value for neurodevelopmental outcomes. Findings from the included studies underwent narrative synthesis. Results Forty-six studies were included. In comparison to HUS, MRI detected more anomalies and provided more details on the severity and the extent of preterm brain injury, particularly for white matter injury and cerebellar hemorrhage. Neonatal neuroimaging predicted outcomes with high negative predictive value but relatively low positive predictive value. The prognostic value of neonatal neuroimaging varied according to several factors including modality and timing of imaging, and tools used for grading brain injury. Conclusion Compared to HUS, MRI offers a better characterization of preterm brain injury and may enhance the ability to predict neurodevelopmental outcomes.

OBJECTIVE To conduct a systematic review of the literature for strategies designed to reduce attrition in managing paediatric obesity. METHODS We searched Ovid Medline (1946 to May 6, 2020), Ovid Embase (1974 to May 6, 2020), EBSCO CINAHL (inception to May 6, 2020), Elsevier Scopus (inception to April 14, 2020), and ProQuest Dissertations & Theses (inception to April 14, 2020). Reports were eligible if they included any obesity management intervention, included 2 to 18 year olds with overweight or obesity (or if the mean age of participants fell within this age range), were in English, included experimental study designs, and had attrition reduction as a main outcome. Two team members screened studies, abstracted data, and appraised study quality. RESULTS Our search yielded 5,415 original reports; six met inclusion criteria. In three studies, orientation sessions (n = 2) and motivational interviewing (MI) (n = 1) were used as attrition-reduction strategies before treatment enrollment; in three others, text messaging (n = 2) and MI (n = 1) supplemented existing obesity management interventions. Attrition-reduction strategies led to decreased attrition in two studies, increased in one, and no difference in three. For the two strategies that reduced attrition, (a) pre-treatment orientation and (b) text messaging between children and intervention providers were beneficial. The quality of the six included studies varied (good [n = 4]; poor [n = 2]). CONCLUSION Some evidence suggests that attrition can be reduced. The heterogeneity of approaches applied and small number of studies included highlight the need for well-designed, experimental research to test the efficacy and effectiveness of strategies to reduce attrition in managing paediatric obesity.

Background Long-term prescription of opioids by healthcare professionals has been linked to poor individual patient outcomes and high resource utilization. Supportive strategies in this population regarding acute healthcare settings may have substantial impact. Methods We performed a systematic review and meta-analysis of primary studies. The studies were included according to the following criteria: 1) age 18 and older; 2) long-term prescribed opioid therapy; 3) acute healthcare setting presentation from a complication of opioid therapy; 4) evaluating a supportive strategy; 5) comparing the effectiveness of different interventions; 6) addressing patient or healthcare related outcomes. We performed a qualitative analysis of supportive strategies identified. We pooled patient and system related outcome data for each supportive strategy. Results A total of 5664 studies were screened and 19 studies were included. A total of 9 broad categories of supportive strategies were identified. Meta-analysis was performed for the “supports for patients in pain” supportive strategy on two system-related outcomes using a ratio of means. The number of emergency department (ED) visits were significantly reduced for cohort studies (n = 6, 0.36, 95% CI [0.20–0.62], I2 = 87%) and randomized controlled trials (RCTs) (n = 3, 0.71, 95% CI [0.61–0.82], I2 = 0%). The number of opioid prescriptions at ED discharge was significantly reduced for RCTs (n = 3, 0.34, 95% CI [0.14–0.82], I2 = 78%). Conclusion For patients presenting to acute healthcare settings with complications related to long-term opioid therapy, the intervention with the most robust data is “supports for patients in pain”.

BackgroundLong-term prescription of opioids by healthcare professionals has been linked to poor individual patient outcomes and high resource utilization. Harm reduction strategies in this population in regard to acute healthcare settings may have substantial impact.MethodsWe performed a systematic review and meta-analysis of primary studies. The studies were included according to the following criteria: 1) age 18 and older; 2) long-term/chronic prescribed opioid therapy; 3) acute healthcare setting presentation from a complication of opioid therapy; 4) evaluating a harm reduction strategy; 5) comparing the effectiveness of different interventions; 6) addressing patient or healthcare related outcomes. We performed a qualitative analysis of harm reduction strategies identified. We pooled patient and system related outcome data for each harm reduction strategy.ResultsA total of 5664 studies were screened and 21 studies were included. A total of 11 broad categories of harm reduction strategies were identified. Meta-analysis was performed for the “supports for patients in pain” harm reduction strategy on two system-related outcomes using a ratio of means. The number of emergency department (ED) visits were significantly reduced for cohort studies (n=6, 0.36, 95% CI [0.20-0.62], I2 = 87%) and randomized controlled trials (RCTs) (n=3, 0.71, 95% CI [0.61-0.82], I2 = 0%). The number of opioid prescriptions at ED discharge was significantly reduced for RCTs (n=3, 0.34, 95% CI [0.14-0.82], I2 = 78%).InterpretationFor patients presenting to acute healthcare settings with complications related to long-term opioid therapy, the intervention with the most robust data is “supports for patients in pain”.Study registrationCRD42018088962

IntroductionRenal replacement therapy (RRT) is associated with high mortality and costs; however, no clinical guidelines currently provide specific recommendations for clinicians on when and how to stop RRT in recovering patients. Our objective was to systematically review the current evidence for clinical and biochemical parameters that can be used to predict successful discontinuation of RRT.MethodsA systematic review and meta-analysis were performed with a peer-reviewed search strategy combining the themes of renal replacement therapy (IHD, CRRT, SLED), predictors of successful discontinuation or weaning (defined as an extended period of time free from further RRT), and patient outcomes. Major databases were searched and citations were screened using predefined criteria. Studied parameters were reported and, where possible, data was analyzed in the pooled analysis.ResultsOur search yielded 23 studies describing 16 variables for predicting the successful discontinuation of RRT. All studies were observational in nature. None were externally validated. Fourteen studies described conventional biochemical criteria used as surrogates of glomerular filtration rate (serum urea, serum creatinine, creatinine clearance, urine urea excretion, urine creatinine excretion). Thirteen studies described physiologic parameters such as urine output before and after cessation of RRT, and 13 studies reported on newer kidney biomarkers, such as serum cystatin C and serum neutrophil gelatinase-associated lipocalin (NGAL). Six studies reported sensitivity and specificity characteristics of multivariate models. Urine output prior to discontinuation of RRT was the most-studied variable, with nine studies reporting. Pooled analysis found a sensitivity of 66.2% (95% CI, 53.6–76.9%) and specificity of 73.6% (95% CI, 67.5–79.0%) for urine output to predict successful RRT discontinuation. Due to heterogeneity in the thresholds of urine output used across the studies, an optimal threshold value could not be determined.ConclusionsNumerous variables have been described to predict successful discontinuation of RRT; however, available studies are limited by study design, variable heterogeneity, and lack of prospective validation. Urine output prior to discontinuation of RRT was the most commonly described and robust predictor. Further research should focus on the determination and validation of urine output thresholds, and the evaluation of additional clinical and biochemical parameters in multivariate models to enhance predictive accuracy.

Background Predicting successful liberation from mechanical ventilation (MV) in critically ill patients is challenging. Brain natriuretic peptide (BNP) has been proposed to help guide decision-making for readiness to liberate from MV following a spontaneous breathing trial (SBT). Methods We performed a systematic review and meta-analysis of randomized and prospective observational studies that measured BNP levels at the time of SBT in patients receiving MV. The primary endpoint was successful liberation from MV (absence of reintubation or non-invasive ventilation at 48 h). Statistical analyses included bi-variate and Moses-Littenberg models and DerSimonian-Laird pooling of areas under ROC curve (AUROC). Results A total of 731 articles were screened. Eighteen adult and 2 pediatric studies were fulfilled pre-specified eligibility. The measure of the relative variation of BNP during SBT (ΔBNP%) after exclusion of SBT failure by clinical criteria in adults yielded a sensitivity and specificity of 0.889 [0.831–0.929] and 0.828 [0.730–0.896] for successful liberation from MV, respectively, with a pooled AUROC of 0.92 [0.88–0.97]. The pooled AUROC for any method of analysis for absolute variation of BNP (ΔBNP), pre-SBT BNP, and post-SBT BNP were 0.89 [0.83–0.95], 0.77 [0.63–0.91], and 0.85 [0.80–0.90], respectively. Conclusion The relative change in BNP during a SBT has potential value as an incremental tool after successful SBT to predict successful liberation from MV in adults. There is insufficient data to support the use of BNP in children or as an alternate test to clinical indices of SBT, or the use of ΔBNP, BNP-pre, and BNP-post as an alternate or incremental test. Trial registration PROSPERO CRD42018087474 (6 February 2018)

Backgroud An increasing number of original studies suggest that exposure to shift work and long working hours during pregnancy could be associated with the risk of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. Objective To examine the influences of shift work and longer working hours during pregnancy on maternal and fetal health outcomes. Data Sources Five electronic databases and three gray literature sources were searched up to March 15, 2019. Methods of Study Selection: Studies of all designs (except case studies and reviews) were included, which contained information on the relevant population (women who engaged in paid work during pregnancy); exposure (rotating shift work [shifts change according to a set schedule], fixed night shift [typical working period is between 11:00 pm to 11:00 am] or longer working hours [h] [>40 h per week]);comparator (fixed day shift [typical working period between 8:00 am- 6:00 pm] or standard working hours [≤40 h per week]); and outcomes (preterm delivery, low birth weight [birth weight Tabulation, Integration, and Results From 3305 unique citations, 62 observational studies (196,989 women) were included. “Low” to “very low” certainty evidence from these studies revealed that working rotating shifts was associated with an increased odds of preterm delivery (OR=1.13, 95% CI: 1.00 to 1.28, I 2 =31%), having a small for gestational age baby (OR=1.18, 95% CI: 1.01 to 1.38, I 2 =0%), preeclampsia (OR=1.75, 95% CI: 1.01 to 3.01, I 2 =75%) and gestational hypertension (OR=1.19, 95% CI: 1.10 to 1.29, I 2 =0%), compared to those who worked a fixed day shift. Working fixed night shifts was associated with an increased odds of preterm delivery (OR=1.21, 95% CI: 1.03 to 1.42, I 2 =36%) and miscarriage (OR=1.23, 95% CI: 1.03 to 1.47, I 2 =37%). Compared with standard hours, working longer hours was associated with an increased odds of miscarriage (OR=1.38, 95% CI: 1.08 to 1.77, I 2 =73%), preterm delivery (OR=1.21, 95% CI: 1.11 to 1.33, I 2 =30%), an infant of low birth weight (OR=1.43, 95% CI: 1.11 to 1.84, I 2 =0%), or an infant of small for gestational age (OR=1.16, 95% CI: 1.00 to 1.36, I 2 =57%). Dose-response analysis showed women working more than 55.5 hours per week (versus 40) had a 10% increase in the odds of having a preterm delivery. Conclusion Pregnant women who work rotating shifts, fixed night shifts, or longer hours have an increased risk of adverse pregnancy outcomes.

Backgroud An increasing number of studies suggest that exposure to physically demanding work during pregnancy could be associated with increased risks of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. Objective To examine the influence of occupational activities during pregnancy on maternal and fetal health outcomes. Data sources Five electronic databases and three gray literature sources were searched up to March 15, 2019. Methods Of Study Selection Studies of all designs (except case studies and reviews) were included, which contained information on the relevant population (women who engaged in paid work during pregnancy), occupational exposures (heavy lifting, prolonged standing, prolonged walking, prolonged bending, and heavy physical workload), comparator (no exposure to the listed physical work demands), and outcomes (preterm birth, low birth weight, small for gestational age, miscarriage, gestational hypertension, pre-eclampsia, gestational diabetes mellitus, stillbirth, and intrauterine growth restriction). Tabulation, Integration, And Results Eighty observational studies (N=853,149) were included. ‘Low’ to ‘very low’ certainty evidence revealed that lifting objects ≥ 11 kilograms (kg) was associated with an increased odds ratio (OR) of miscarriage (OR: 1.31, 95% CI: 1.08 to 1.58, I2=79%), and pre-eclampsia (OR: 1.35, 95% CI: 1.07 to 1.71, I2=0%). Lifting objects for a combined weight of > 100kg per day was associated with an increased odds of preterm delivery (OR: 1.31, 95% CI: 1.11 to 1.56, I2=0%) and having a low-birth-weight neonate (OR: 2.08, 95% CI: 1.06 to 4.11, I2=73%). Prolonged standing was associated with increased odds of preterm delivery (OR: 1.11, 95% CI: 1.02 to 1.22, I2=30%), and having a small-for-gestational-age neonate (OR: 1.17, 95% CI: 1.01 to 1.35, I2=41%. A heavy physical workload was associated with increased odds of preterm delivery (OR: 1.23, 95% CI: 1.07 to 1.41, I2=32%), and having a low-birth-weight neonate (OR: 1.79, 95% CI: 1.11 to 2.87, I2=87%). All other associations were not statistically significant. Dose-response analysis showed women standing more than 2.5 hours per day (versus no standing) had a 10% increase in the odds of having a preterm delivery. Conclusion Physically demanding work during pregnancy is associated with an increased risk of adverse pregnancy outcomes.

IntroductionChildhood respiratory syncytial virus (RSV) infection is a global phenomenon that can lead to fatal respiratory illness. Palivizumab is a drug that is routinely used in affluent countries as a prophylaxis against RSV infection; nevertheless, breakthrough infections are often reported. In light of new findings on potential RSV resistance to palivizumab, an up-to-date synthesis of evidence on effectiveness is needed. Furthering existing reviews, a broadened scope to better reflect effectiveness in a ‘real world’ clinical context is also important. This systematic review and meta-analysis will enhance our understanding of the effectiveness of palivizumab in varying populations of children. Findings from this review will inform recommendations for best practices regarding palivizumab use for childhood RSV infection as well as research priorities in RSV vaccine development.Methods and analysisWe will conduct a systematic review of primary population-based studies that examine the incidence of palivizumab breakthrough infections in children, published between 1997 to present. In collaboration with a research librarian, four electronic databases (MEDLINE, Embase, Cochrane Library, Web of Science) and additional sources will be searched. Study screening and quality assessment will be performed in duplicate. Data will be extracted by one reviewer, with partial and random verification by a second reviewer. The primary outcomes to assess breakthrough RSV infection will be hospitalisation, length of stay and the need for intensive care unit admission and mechanical ventilation in children receiving palivizumab. The secondary outcome will be RSV-associated mortality. We will conduct a meta-analysis using pooled effectiveness data, and include subgroup analyses by patient comorbidities and drug compliance. Sensitivity analyses for risk of bias and study design will also be performed.Ethics and disseminationThis systematic review will only include data from previously published literature and is therefore exempt from ethics approval. Final results will be disseminated through peer-reviewed publication and presented at academic conferences and scientific meetings engaging paediatric researchers and healthcare providers. Should findings from this review necessitate updates to current clinical practice guidelines, we intend to establish a working group to engage relevant health administrators and decision makers.PROSPERO registration numberCRD42019122120.

Perceptions about the causes and consequences of concussion, and individual representations and interpretations of these factors, can influence the post-concussive recovery process. The goal of this project was to synthesize evidence on perceptions related to concussions as experienced by children, adolescents, and parents, and to evaluate how these perceptions impact post-concussive recovery in physical, behavioural, cognitive, and psychological domains. We undertook a systematic review based on the Cochrane Handbook, conducting a comprehensive search of six databases and Google Scholar. Duplicate, independent screening was employed and the quality of studies was assessed using the Mixed Methods Appraisal Tool (MMAT). A total of 1552 unique records were identified, and six records (5 scientific articles and 1 thesis, published between 1990 and 2018; N = 26 to 412, age range from 2 to 18 years) were included. Perceptions about concussions were assessed differently between studies, with a range in types of measures and respondents. Some evidence suggested that perceptions could negatively impact concussion recovery, mostly post-concussive symptoms. However, results were not consistent between studies and the methodological quality was variable (and often low). There is limited evidence of the impact of perceptions of children, adolescents, and their parents on concussion recovery. Priorities for future research investigating concussion recovery should include recruiting representative samples, accounting for potential confounders, and measuring perceptions in children, adolescents and parents using validated measures. Higher quality studies are needed to better understand the role of perceptions in concussion recovery and to inform clinical care.

BACKGROUND: Children with intestinal failure are dependent on total parenteral nutrition (TPN) via a central venous catheter (CVC) for survival. These patients require long-term use of CVCs, and are at high risk of catheter-related bloodstream infections (CRBSIs). Prevention of these infections is imperative, as they result in line removal and loss of an access site. Eventually there may be no available sites for a CVC, and a child will need an intestinal transplant. Antimicrobial locks (AML) are solutions instilled in CVCs to prevent CRBSI. Presently, there are many different solutions available, and limited evidence guiding the optimal choice, frequency, and duration of prophylactic AML solution in children with intestinal failure. A guideline for appropriate prophylactic AML use has the potential to decrease rates of CRBSIs and reduce morbidity and mortality in pediatric intestinal failure patients. AIMS: In children with intestinal failure who require a CVC, does using an AML solution decrease the rate of new CRBSI? METHODS: A systematic review of available literature on AMLs used for CRBSI prophylaxis in children with intestinal failure will be performed to determine the optimal AML(s) choice(s) for use in this population. Randomized and nonrandomized trials, case studies, and cohort studies that use comparator groups (including historical controls) with study participants including children (age 0–17) with intestinal failure, who have a CVC (2 days or greater) for TPN will be screened. If the data is sufficiently homogenous, both clinically and methodologically, we will pool outcomes in a meta-analysis using a DerSimonian Laird random effects model. If possible we also plan to do network meta-analyses (NMA), simultaneously pooling common outcomes across multiple interventions. RESULTS: The primary outcomes of interest are the rate of new CRBSI with AML versus controls, as well as a comparison of each type of AML versus controls. Secondary outcomes that will be assessed include: unplanned CVC removal (all cause), CVC removal due to CRBSI, recurrence of CRBSI with the same pathogen, all adverse events/side effects attributed to antimicrobial lock solutions by the authors, development of infections with antibiotic resistance at any point (in particular resistance to antibiotics used in the AML solution), length of hospital stay attributed to CRBSI, need for intensive care, any other morbidities or outcomes that were compared in cases and controls and mortality. CONCLUSIONS: This research in progress aims to provide clinicians with guidance on the use of AML for prophylaxis of CRBSI in pediatric patients with intestinal failure. We will provide data for the efficacy of this practice and clarify which solutions have the best outcomes. FUNDING AGENCIES: None

ObjectivesPatient priority setting projects (PPSPs) can reduce research agenda bias. A key element of PPSPs is a review of available literature to determine if the proposed research priorities have been addressed, identify research gaps, recognise opportunities for knowledge translation (KT) and avoid duplication of research efforts. We conducted rapid responses for 11 patient-identified priorities in depression to provide a map of the existing evidence.DesignEleven rapid responses.Data sourcesSingle electronic database (PubMed).Eligibility criteriaEach rapid response had unique eligibility criteria. For study designs, we used a stepwise inclusion process that started with systematic reviews (SRs) if available, then randomised controlled trials and observational studies as necessary.ResultsFor all but one of the rapid responses we identified existing SRs (median 7 SRs per rapid response, range 0–179). There were questions where extensive evidence exists (ie, hundreds of primary studies), yet uncertainties remain. For example, there is evidence supporting the effectiveness of many non-pharmacological interventions (including psychological interventions and exercise) to reduce depressive symptoms. However, targeted research is needed that addresses comparative effectiveness of promising interventions, specific populations of interest (eg, children, minority groups) and adverse effects.ConclusionsWe identified an extensive body of evidence addressing patient priorities in depression and mapped the results and limitations of existing evidence, areas of uncertainty and general directions for future research. This work can serve as a solid foundation to guide future research in depression and KT activities. Integrated knowledge syntheses bring value to the PPSP process; however, the role of knowledge synthesis in PPSPs and methodological approaches are not well defined at present.

ObjectiveTo systematically review screening and treatment effectiveness, and patient preferences, to inform recommendations by the Canadian Task Force on Preventive Health Care on screening for asymptomatic bacteriuria in pregnancy.DesignWe searched multiple databases (inception to September 2017) and grey literature sources for studies on screening effectiveness and patient preferences. For treatment with antibiotics, we searched three databases for systematic reviews and obtained search results of the Cochrane Pregnancy and Childbirth Group’s Trials Register to update a Cochrane review. Study selection, risk of bias assessment and evaluation of the quality for each outcome using Grading of Recommendations Assessment, Development and Evaluation was completed independently by two reviewers with consensus. Meta-analysis was conducted when appropriate as were analyses based on planned subgroup variables.OutcomesFor screening and treatment effectiveness: maternal and perinatal mortality, maternal and neonatal sepsis, pyelonephritis, spontaneous abortion, preterm delivery, low birth weight and serious adverse events. Valuation of outcomes for patient preferences.ResultsFour studies compared outcomes before and after the introduction of a screening programme or between different screening programmes. All evidence on screening effectiveness was considered very low quality. Women have conflicting opinions about antibiotic use during pregnancy. Fifteen trials compared antibiotic treatment with no treatment or placebo in women with confirmed bacteriuria. Low-quality evidence found that treatment lowered rates of pyelonephritis (12 trials, relative risk [RR] 0.24; 95% CI 0.13 to 0.42; absolute risk reduction [ARR] 17.6%; number needed to treat [NNT] 6, 95% CI 5 to 7) and low birth weight (seven trials, RR 0.63; 95% CI 0.45 to 0.90; ARR 4.4%; NNT 23, 95% CI 15 to 85).ConclusionsAntibiotic treatment for women having significant bacteriuria likely reduces the incidence of pyelonephritis and low birth weight, but we are uncertain about the magnitude of the effect and about the extent to which we can apply these results to asymptomatic populations and screening programmes.PROSPERO registration numberCRD42016045263.

IntroductionPredicting successful liberation from mechanical ventilation (MV) among critically ill patients receiving MV can be challenging. The current parameters used to predict successful extubation have shown variable predictive value. Brain natriuretic peptide (BNP) has been proposed as a novel biomarker to help guide decision-making in readiness for liberation of MV following a spontaneous breathing trial (SBT). Current evidence on the predictive ability of BNP has been uncertain, and BNP has not been integrated into clinical practice guidelines.Methods and analysisWe will perform a systematic review and meta-analysis to evaluate the value of BNP during SBT to predict success of liberation from MV. A search strategy will be developed in collaboration with a research librarian, and electronic databases (MEDLINE, EMBASE, Cochrane Library, Web of Science) and additional sources will be searched. Search themes will include: (1) BNP and (2) weaning, extubation and/or liberation from MV. Citation screening, selection, quality assessment and data abstraction will be performed in duplicate. The primary outcome will be liberation from MV; secondary outcomes will include time to reintubation, mortality, MV duration, total and postextubation intensive care unit (ICU) stay, hospitalisation duration, tracheostomy rate, ICU-acquired weakness rate and ventilator-free days. Primary statistical analysis will include predictive value of BNP by receiver operating characteristic curve, sensitivity/specificity and likelihood ratios for combination of BNP and SBT parameters for failure of liberation from MV. Secondary statistical analysis will be performed on individual and combinations of extracted metrics.Ethics and disseminationOur review will add knowledge by mapping the current body of evidence on the value of BNP testing for prediction of successful liberation from MV, and describe knowledge gaps and research priorities. Our findings will be disseminated through peer-reviewed publication, presentation at a scientific congress, through regional/national organisations and social media. Research ethics approval is not required.PROSPERO registration numberCRD42018087474.

IntroductionRenal replacement therapy (RRT) is a complex and expensive form of life-sustaining therapy, reserved for our most acutely ill patients. While a number of randomised trials have evaluated the optimal timing to start RRT among critically ill patients in the intensive care unit (ICU), there has been a paucity of trials providing guidance on when and under what circumstances to ideally liberate a patient from RRT. We are conducting a systematic review and meta-analysis to identify clinical and biochemical markers that predict kidney recovery and successful liberation from acute RRT among critically ill patients with acute kidney injury.Methods and analysisOur comprehensive search strategy was developed in consultation with a research librarian and independently peer-reviewed by a second librarian. We will search electronic databases: Ovid Medline, Ovid Embase and Wiley Cochrane Library. Selected grey literature sources will also be searched. Our search strategies will focus on concepts related to RRT (ie, intermittent haemodialysis, slow low-efficiency dialysis, continuous renal replacement therapy), intensive care (ie, involving any ICU setting) and discontinuation of therapy (ie, either clinical, physiological and biochemical parameters of weaning acute RRT) from 1990 to October 10, 2017. Citation screening, selection, quality assessment and data abstraction will be performed in duplicate. Studies will, where possible, be pooled in statistical meta-analysis. When deemed sufficiently clinically homogenous, and we have four or more studies reporting, sensitivities and specificities will be pooled simultaneously using a hierarchical summary receiver operator characteristic curve and bivariate analysis.Ethics and disseminationOur systematic review will synthesise the literature on clinical and biochemical markers that predict liberation from RRT. Research ethics approval is not required.Trial registration numberCRD42018074615.

We sought to evaluate whether case ascertainment using administrative health data would be a feasible way to identify peripheral artery disease (PAD) patients from the community. Subjects’ ankle–brachial index (ABI) scores from two previous prospective observational studies were linked with International Classification of Diseases (ICD) and Canadian Classification of Interventions (CCI) codes from three administrative databases from April 2002 to March 2012, including the Alberta Inpatient Hospital Database (ICD-10-CA/CCI), Ambulatory Care Database (ICD-10-CA/CCI), and the Practitioner Payments Database (ICD-9-CM). We calculated diagnostic statistics for putative case definitions of PAD consisting of individual code or sets of codes, using an ABI score ⩽ 0.90 as the gold standard. Multivariate logistic regression was performed to investigate additional predictive factors for PAD. Different combinations of diagnostic codes and predictive factors were explored to find out the best algorithms for identifying a PAD study cohort. A total of 1459 patients were included in our analysis. The average age was 63.5 years, 66% were male, and the prevalence of PAD was 8.1%. The highest sensitivity of 34.7% was obtained using the algorithm of at least one ICD diagnostic or procedure code, with specificity 91.9%, positive predictive value (PPV) 27.5% and negative predictive value (NPV) 94.1%. The algorithm achieving the highest PPV of 65% was age ⩾ 70 years and at least one code within 443.9 (ICD-9-CM), I73.9, I79.2 (ICD-10-CA/CCI), or all procedure codes, validated with ABI < 1.0 (sensitivity 5.56%, specificity 99.4% and NPV 84.6%). In conclusion, ascertaining PAD using administrative data scores was insensitive compared with the ABI, limiting the use of administrative data in the community setting.

To estimate incidence and prevalence of FASD by sex and age in Alberta, Canada.We included all patients recorded in the Alberta provincial health databases of inpatients, outpatients, and practitioner claims from 2003 to 2012. The number of people with FASD were calculated from available data on FAS (ICD-9 code 760.71; ICD-10 codes Q86.0 and P04.3) and estimated prevalence of FASD among individuals diagnosed with 21 FASD-related conditions (identified by a literature review) for which there are ICD codes, such as learning disability, mental retardation, and nervous system defects (Table 1). Fractions of FASD-related diagnoses that can be attributed to alcohol use during pregnancy were estimated by a systematic review. The incidence was measured as the number of new cases per 1000 births. The prevalence was measured as the number of cases per 1000 population in 2012.Annually, 739 to 1884 people were born with FASD in Alberta establishing an incidence of 14.2 to 43.8 per 1000 births, depending on the length of follow-up. There were about 46,000 people living with FASD in Alberta 2012, including 6,000 FAS cases and 40,000 FASD-related cases. The prevalence of FASD was 11.7 (range 8.2 to 15.1) per 1000 population. The incidence and prevalence varied greatly by sex and age group. Generally, male and younger outnumbered female and older.This study suggests new incidence and prevalence of FASD, which are higher than what has been commonly used (1%), and its variations among sex and age groups.

Percutaneous endoscopic gastrostomy (PEG) tubes are common enteral access devices for long-term enteral nutrition. Jejunostomy tubes (J-tubes) are able to provide postpyloric enteral access in patients who are not PEG tube candidates. There is a scarcity of literature comparing complication rates of J-tubes to PEG tubes.To compare and characterize J-tube and PEG tube complications requiring tube replacement.A retrospective chart review was performed on 560 patients discharged from the Northern Alberta Home Enteral Nutrition Support Program (NAHENSP) from January 2010 to December 2011. Patients were followed for 3 years from initial tube insertion or until discharge from the NAHENSP, whichever was earliest. Comparisons were made in terms of complications requiring tube replacement, tube patency to first replacement, and indications for tube replacement.A total of 64 J-tube patients were identified and compared with 65 PEG tube patients. Tube replacement rates for the J-tube group included 3.2 cases per 1000 patient days compared with 0.86 cases per 1000 patient days in the PEG group (P.001). The mean ± SEM duration to first tube replacement for J-tube and PEG tube patients was 160 ± 26.3 days and 331 ± 53.6 days, respectively (P = .010). The most common causes for tube replacement in J-tube patients were dislodgement (35.6%) and obstruction (22.2%) compared with routine replacement (54.5%) and dislodgement (27.2%) in the PEG tube group.J-tubes are associated with higher complication rates requiring tube replacement compared with PEG tubes. The main causes of J-tube replacement are dislodgement and obstruction.

Hemodialysis patients experience poor outcomes associated with the presence of atherosclerosis, particularly lower-extremity peripheral artery disease (PAD). Prevalence of PAD is known to vary between ethnic groups; however, no information on ethnic-specific PAD prevalence in a hemodialysis cohort is available.Data from the Canadian Kidney Dialysis Cohort Study was used in a secondary analysis of 1293 adults starting hemodialysis in three major Canadian centres. PAD diagnosis was determined through structured interview and supplemented by clinical record. Ethnicity was self-reported.Overall PAD prevalence was 19.1 % with no significant difference between ethnic groups. Ethnic differences observed in diabetes prevalence in the full hemodialysis group were not present in the subset of PAD patients.The prevalence of PAD in patients undergoing hemodialysis is high, however we found no apparent ethnic differences in prevalence between ethnic groups.

Peripheral artery disease (PAD) is strongly associated with coronary artery disease and poor outcomes after coronary revascularization. The aim of this study was to test the hypothesis that patients with PAD diagnosed by a low ankle-brachial index (ABI; ≤0.90) have more complex coronary artery disease and more myocardium at risk than patients with normal ABIs (1.00 to 1.40) and that subsequent coronary revascularization is less complete. Adults referred for coronary angiography underwent ABI measurement using a standard Doppler ultrasound technique. Blinded reviewers calculated SYNTAX scores and Duke jeopardy scores at baseline and 3 months after angiography. Of 814 patients, 8% had PAD (ABI ≤0.90), 9% had borderline PAD (ABI 0.91 to 0.99), 77% were normal (ABI 1.00 to 1.40), and 7% had vascular calcification artifact (ABI >1.40). Patients with PAD were more likely to have high SYNTAX scores (≥33), with an odds ratio of 4.3 (95% confidence interval 1.2 to 14.9), compared with those with normal ABIs after adjustment for traditional cardiovascular risk factors. Similarly, there was a positive association between baseline high Duke jeopardy score (≥8) and PAD (adjusted odds ratio 3.5, 95% confidence interval 1.7 to 7.1). Postrevascularization high Duke jeopardy scores (≥5) were also positively associated with PAD (adjusted odds ratio 3.0, 95% confidence interval 1.1 to 8.8). In conclusion, PAD is associated with higher SYNTAX scores, more myocardium at risk, and less complete coronary revascularization than in patients with normal ABIs. More complex coronary artery disease and incomplete revascularization may contribute to worse cardiovascular outcomes in patients with PAD.

While people of South Asian (SA) descent have higher rates of cardiovascular disease compared with people of White European (WE) descent, a lower prevalence of lower extremity peripheral arterial disease (PAD) has been suggested in SA. Our intent was to systematically review the literature on PAD prevalence in people of SA descent and to conduct a meta-analysis to identify differences in PAD prevalence between SA and WE.Standard Cochrane systematic review methodology was used for conducting a literature review of published research. Population prevalence studies of PAD in SA with a WE comparison group were included. Full text studies were selected and reviewed by two authors with independent data extraction. Prevalence differences between SA and WE were analysed using ORs.129 studies were initially identified and ultimately 15 (n=240 003 patients) studies were included. Only one study reported direct comparative general PAD prevalence between SA and WE (OR=0.26, 95%CI 0.17 to 0.38, p0.001, n=77 855). Fourteen studies with comparative prevalence data between SA and WE in high-risk populations confirm significantly lower odds of PAD in SA with coronary artery disease (CAD) (OR=0.47, 95%CI 0.39 to 0.56, p0.001, n=139 313) and diabetes (OR=0.44; 95% CI 0.30 to 0.63, p0.001, n=22 835).Reported PAD prevalence is significantly lower in SA than WE for both the CAD and diabetes populations. Explanations for these findings, if true, are unclear. These results underscore the need for further study to clarify mechanisms of ethnic divergence in PAD prevalence.

Background Lower extremity peripheral arterial disease (PAD) is underdiagnosed and undertreated in Canada, although data are limited. We sought to measure PAD prevalence and treatment patterns in ambulatory settings. Methods Five trained undergraduate pharmacy students screened subjects > 50 years of age in 10 community pharmacies and 4 physician offices in northern and central Alberta. We assessed cardiovascular risk factors, cardiovascular disease (CVD), and use of evidence-based therapies; administered the Edinburgh Claudication Questionnaire; and measured the ankle-brachial index (ABI). Patients with definite claudication but ABI > 0.90, or patients with ABI > 1.30 were referred to the study vascular medicine physician for further assessment. PAD was defined as an ABI ≤ 0.90 at the initial community screening or an exercise ABI of ≤ 0.90 and 20% lower than the resting ABI, or toe-brachial index of ≤ 0.70. Results We recruited 361 patients (65.1 ± 9.5 years old, 55% female, 85% white) between July 1 and November 30, 2008. Sixteen subjects had PAD (prevalence 4.4%; 95% confidence interval [CI], 2.3-6.5), and all were previously unaware that they had PAD. Nine patients (2.5%) had PAD only, 7 (1.9%) had both PAD and CVD, 87 (24%) had CVD only, and 259 (72%) had neither PAD nor CVD. Use of antiplatelet agents (44%), angiotensin blockade (56%), or statins (44%) was low in patients with newly diagnosed PAD and without other CVD. Conclusions About 1 in 20 ambulatory persons > 50 years of age screened had PAD. All cases of PAD that we found were previously undiagnosed, and there was a large treatment gap for those without concomitant CVD.