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Objectives This was a systematic review and meta-analysis to evaluate the incidence of adverse events in adults undergoing procedural sedation in the emergency department (ED). Methods Eight electronic databases were searched, including MEDLINE, EMBASE, EBSCO, CINAHL, CENTRAL, Cochrane Database of Systematic Reviews, Web of Science, and Scopus, from January 2005 through 2015. Randomized controlled trials and observational studies of adults undergoing procedural sedation in the ED that reported a priori selected outcomes and adverse events were included. Meta-analysis was performed using a random-effects model and reported as incidence rates with 95% confidence intervals (CIs). Results The search yielded 2,046 titles for review. Fifty-five articles were eligible, including 9,652 procedural sedations. The most common adverse event was hypoxia, with an incidence of 40.2 per 1,000 sedations (95% CI = 32.5 to 47.9), followed by vomiting with 16.4 per 1,000 sedations (95% CI = 9.7 to 23.0) and hypotension with 15.2 per 1,000 sedations (95% CI = 10.7 to 19.7). Severe adverse events requiring emergent medical intervention were rare, with one case of aspiration in 2,370 sedations (1.2 per 1,000), one case of laryngospasm in 883 sedations (4.2 per 1,000), and two intubations in 3,636 sedations (1.6 per 1,000). The incidence of agitation and vomiting were higher with ketamine (164.1 per 1,000 and 170.0 per 1,000, respectively). Apnea was more frequent with midazolam (51.4 per 1,000), and hypoxia was less frequent in patients who received ketamine/propofol compared to other combinations. The case of laryngospasm was in a patient who received ketamine, and the aspiration and intubations were in patients who received propofol. When propofol and ketamine are combined, the incidences of agitation, apnea, hypoxia, bradycardia, hypotension, and vomiting were lower compared to each medication separately. Conclusions Serious adverse events during procedural sedation like laryngospasm, aspiration, and intubation are exceedingly rare. Quantitative risk estimates are provided to facilitate shared decision-making, risk communication, and informed consent.

Prompt, complete, and accurate information transfer at the time of discharge between hospital-based and primary care providers (PCPs) is needed for the provision of safe and effective care.To evaluate timeliness, quality, and interventions to improve timeliness and quality of hospital discharge summaries.PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, and Scopus database published in English between January 2007 and February 2014 were searched. We also hand-searched bibliographies of relevant articles.Observational studies investigating transfer of information at hospital discharge (n = 7) and controlled studies evaluating interventions to improve timeliness and quality of discharge information (n = 12) were included.We extracted data on availability, timeliness, and content of hospital discharge summaries and on the effectiveness of interventions targeting discharge summaries. Results of studies are presented narratively and using descriptive statistics.Across the studies, discharge summaries were completed within 48 hours in a median of 67% and were available to PCPs within 48 hours only 55% of the time. Most of the time, discharge summaries included demographics, primary diagnosis, hospital course, and discharge instructions. However, information was limited to pending test results (25%), diagnostic tests performed (60%), and postdischarge medications (78%). In 6 interventional studies, implementation of electronic discharge summaries was associated with improvement in timeliness but not quality.Delayed or insufficient transfer of discharge information between hospital-based providers and PCPs remains common. Creation of electronic discharge summaries seems to improve timeliness and availability but does not consistently improve quality.

The prognostic implications of several baseline preprocedural variables in patients with severe native valve aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) are unclear. The goal of this study was to determine the impact of reduced stroke volume index (SVI), low gradient (LG), and reduced ejection fraction (EF) on all-cause mortality. We searched MEDLINE, CENTRAL, EMBASE, Web of Science, and Scopus through October 13, 2014. We evaluated the association between low SVI (35 ml/m(2)), LG (40 mm Hg), and low EF (50% and30%) on 1-year all-cause mortality. We pooled results across studies using the random-effects model. We included 16 studies at moderate risk of bias enrolling 7,673 patients with severe AS who underwent TAVI. Low EF was associated with increased 1-year mortality after TAVI compared to preserved EF (for EF30%, hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.19 to 2.16, I(2) = 32%; and for EF50%, HR 1.52, 95% CI 1.31 to 1.76, I(2) = 17%). LG was associated with increased mortality after TAVI compared to high mean gradient (≥40 mm Hg; HR 1.60, 95% CI 1.30 to 1.97, I(2) = 36%). Low SVI was associated with increased mortality after TAVI compared to normal SVI (HR 1.59, 95% CI 1.23 to 2.05, I(2) = 27%). In conclusion, low SVI, LG, and low EF are each associated with higher mortality after TAVI. These findings highlight the importance of including these variables into TAVI risk algorithms and will better inform shared decision-making before TAVI.

To examine the evidence supporting the use of simulation-based assessments as surrogates for patient-related outcomes assessed in the workplace.The authors systematically searched MEDLINE, EMBASE, Scopus, and key journals through February 26, 2013. They included original studies that assessed health professionals and trainees using simulation and then linked those scores with patient-related outcomes assessed in the workplace. Two reviewers independently extracted information on participants, tasks, validity evidence, study quality, patient-related and simulation-based outcomes, and magnitude of correlation. All correlations were pooled using random-effects meta-analysis.Of 11,628 potentially relevant articles, the 33 included studies enrolled 1,203 participants, including postgraduate physicians (n = 24 studies), practicing physicians (n = 8), medical students (n = 6), dentists (n = 2), and nurses (n = 1). The pooled correlation for provider behaviors was 0.51 (95% confidence interval [CI], 0.38 to 0.62; n = 27 studies); for time behaviors, 0.44 (95% CI, 0.15 to 0.66; n = 7); and for patient outcomes, 0.24 (95% CI, -0.02 to 0.47; n = 5). Most reported validity evidence was favorable, though studies often included only correlational evidence. Validity evidence of internal structure (n = 13 studies), content (n = 12), response process (n = 2), and consequences (n = 1) were reported less often. Three tools showed large pooled correlations and favorable (albeit incomplete) validity evidence.Simulation-based assessments often correlate positively with patient-related outcomes. Although these surrogates are imperfect, tools with established validity evidence may replace workplace-based assessments for evaluating select procedural skills.

BackgroundBedside rounds (BR) have been proposed as an ideal method to promote patient-centred hospital care, but there is substantial variation in their implementation and effects. Our objectives were to describe the implementation of BR in hospital settings and determine their effect on patient-centred outcomes.MethodsData sources included Ovid MEDLINE, Ovid Embase, Scopus and Ovid Cochrane Central Registry of Clinical Trials from database inception through 28 July 2017. We included experimental studies comparing BR to another form of rounds in a hospital-based setting (ie, medical/surgical unit, intensive care unit (ICU)) and reporting a quantitative patient-reported or objectively measured clinical outcome. We used random effects models to calculate pooled Cohen's d effect size estimates for the patient knowledge and patient experience outcome domains.ResultsTwenty-nine studies met inclusion criteria, including 20 from adult care (17 non-ICU, 3 ICU), and nine from paediatrics (5 non-ICU, 4 ICU), the majority of which (n=23) were conducted in the USA. Thirteen studies implemented BR with cointerventions as part of a ‘bundle’. Studies most commonly reported outcomes in the domains of patient experience (n=24) and patient knowledge (n=10). We found a small, statistically significant improvement in patient experience with BR (summary Cohen’s d=0.09, 95% CI 0.04 to 0.14, p2=56%), but no significant association between BR and patient knowledge (Cohen’s d=0.21, 95% CI −0.004 to –0.43, p=0.054, I2=92%). Risk of bias was moderate to high, with methodological limitations most often relating to selective reporting, low adherence rates and missing data.ConclusionsBR have been implemented in a variety of hospital settings, often ‘bundled’ with cointerventions. However, BR have demonstrated limited effect on patient-centred outcomes.

This study is a systematic review of human clinical studies of stem cell therapy for discogenic pain. To summarize the current human trials and feasibility studies involving mesenchymal stem cell (MSC) therapy for treatment of discogenic pain. A search of Ovid databases and Clinicaltrials.gov was conducted from inception through July 2016. We included human clinical trials and case reports that evaluated treatment with injected MSCs for patients with discogenic back pain. The outcomes of interest for published studies included pain score, Oswestry Disability Index, and T2-weighted magnetic resonance imaging signal intensity indicative of water content of the nucleus pulposus. The initial search in Ovid databases using the selected search terms identified 408 results, of which 11 were included in this review based on selection criteria. This includes 6 completed studies and 5 ongoing clinical trials, 4 of which were confirmed active at the time of retrieval. In the 6 completed studies involving intradiscal stem cell injections, improvement in pain score, Oswestry Disability Index, and T2-weighted magnetic resonance imaging signal intensity of nucleus pulposus were reported. Currently active clinical trials focus on establishing safety, tolerability, and efficacy with respect to injected MSCs for discogenic pain. Although pain and functional benefit have been reported in association with stem cell therapy, longer-term safety studies and more randomized controlled trials are needed to examine the safety and efficacy of stem cell therapy for discogenic pain.

In the original publication, the given and family name of the author Mohammad Hassan Murad was incorrect. This has been corrected with this erratum.

Background Clinical care review is the process of retrospectively examining potential errors or gaps in medical care, aiming for future practice improvement. The objective of our systematic review is to identify the current state of care review reported in peer-reviewed publications and to identify domains that contribute to successful systems of care review. Methods A librarian designed and conducted a comprehensive literature search of eight electronic databases. We evaluated publications from January 1, 2000, through May 31, 2016, and identified common domains for care review. Sixteen domains were identified for further abstraction. Results We found that there were few publications that described a comprehensive care review system and more focus on individual pathways within the overall systems. There is inconsistent inclusion of the identified domains of care review. Conclusion While guidelines for some aspects of care review exist and have gained traction, there is no comprehensive standardized process for care review with widespread implementation. Electronic supplementary material The online version of this article (10.1186/s12245-018-0166-y) contains supplementary material, which is available to authorized users.

Interventions that grow patient capacity to do the work of health care and life are needed to support the health of cancer survivors. Health coaching may grow capacity. This systematic review of health coaching interventions explored coaching's ability to grow capacity of cancer survivors. The authors included randomized trials or quasi-experimental studies comparing coaching to alternative interventions, and adhered to PRISMA reporting guidelines. Data were analyzed using the Theory of Patient Capacity (BREWS: Capacity is affected by factors that influence ability to reframe Biography ["B"], mobilize or recruit Resources ["R"], interact with the Environment of care ["E"], accomplish Work ["W"]), and function Socially ["S"]). The authors reviewed 2210 references and selected 12 studies (6 randomized trials and 6 pre-post). These studies included 1038 cancer survivors, mean age 57.2 years, with various type of cancers: breast, colorectal, prostate, and lung. Health coaching was associated with improved quality of life, mood, and physical activity but not self-efficacy. Classified by potential to support growth in patient capacity, 67% of included studies reported statistically significant outcomes that support "B" (quality of life, acceptance, spirituality), 75% "R" (decreased fatigue, pain), 67% "W" (increased physical activity), and 33% "S" (social deprivation index). None addressed changing the patient's environment of care. In cancer survivors, health coaching improved quality of life and supported patient capacity by several mechanisms, suggesting an important role for "Capacity Coaching." Future interventions that improve self-efficacy and patients' environments of care are needed. Capacity Coaching may improve health and quality of life of cancer survivors.

BACKGROUND Vitamin D insufficiency has been associated with immune dysfunction and linked to the epidemic of atopic diseases in the Western hemisphere, yet there are studies with conflicting results, and the risk has not been quantified uniformly across studies. OBJECTIVE To perform a systematic review and meta-analysis to evaluate and quantify if vitamin D deficiency is associated with the presence and persistence of food allergy. METHODS A systematic review was undertaken to assess for the association between food allergy and vitamin D status in children. RESULTS A total of 368 citations relevant to this systematic review were identified. In the whole review, 5105 children were included. We did not find a significant association between 25 hydroxy vitamin D (25(OH)D) status and risk of food allergy in children (odds ratio [OR] 1.35 [95% confidence interval {CI}, 0.79-2.29]; p = 0.27, I2 = 58.3%). We conducted subgroup analyses based on different cutoffs of the 25(OH)D status (20 versus 30 ng/mL). Only one study used 30 ng/mL and found that children with

Study objective We evaluate the safety and efficacy of intravenous lidocaine in adult patients with acute and chronic pain who are undergoing pain management in the emergency department (ED). Methods We searched Ovid CENTRAL, Ovid EMBASE, and Ovid MEDLINE databases for randomized controlled trials and observational studies from inception to January 2017. Efficacy outcomes included reduction in pain scores from baseline to postintervention and need for rescue analgesia. Safety outcomes included incidence of serious (eg, cardiac arrest) and nonserious (eg, dizziness) adverse events. We used the Cochrane Collaboration tool and a modified Newcastle-Ottawa Scale to evaluate the risk of bias across studies. The Grading of Recommendations Assessment, Development and Evaluation approach was used to evaluate the confidence in the evidence available. Results From a total of 1,947 titles screened, 61 articles were selected for full-text review. Eight studies met the inclusion criteria and underwent qualitative analysis, including 536 patients. The significant clinical heterogeneity and low quality of studies precluded a meta-analysis. Among the 6 randomized controlled trials included, intravenous lidocaine had efficacy equivalent to that of active controls in 2 studies, and was better than active controls in 2 other studies. In particular, intravenous lidocaine had pain score reduction comparable to or higher than that of intravenous morphine for pain associated with renal colic and critical limb ischemia. Lidocaine did not appear to be effective for migraine headache in 2 studies. There were 20 adverse events reported by 6 studies among 225 patients who received intravenous lidocaine in the ED, 19 nonserious and 1 serious (rate 8.9%, 95% confidence interval 5.5% to 13.4% for any adverse event; and 0.4%, 95% confidence interval 0% to 2.5% for serious adverse events). The confidence in the evidence available for the outcomes evaluated was deemed to be very low because of methodological limitations, including risk of bias, inconsistency, and imprecision. Conclusion There is limited current evidence to define the role of intravenous lidocaine as an analgesic for patients with acute renal colic and critical limb ischemia pain in the ED. Its efficacy for other indications has not been adequately tested. The safety of lidocaine for ED pain management has not been adequately examined.

Background The segment involvement score (SIS) is a semiquantitative measure of the extent of atherosclerosis burden by coronary computed tomography angiography (CTA). We sought to evaluate by meta-analysis the prognostic value of SIS, and to compare it with other CTA measures of coronary artery disease (CAD). Methods Electronic databases from 1946 to January 2016 were searched. Studies reporting SIS, or an equivalent measure by coronary CTA, and clinical outcomes were included. Maximally adjusted hazard ratios (HR), predominantly for clinical variables, were extracted for SIS, obstructive CAD, Agatston coronary artery calcium score, and plaque composition. These were pooled using DerSimonian-Laird random effects models. Results Eleven nonrandomized studies with good methodological quality enrolling 9777 subjects (mean age 61 ± 11 years, 57% male, mean follow up 3.3 years) who had 472 (4.8%) MACE (cardiac or all cause death, non-fatal myocardial infarction or late revascularization), were included. SIS (per segment increase) had pooled HR of 1.25 (95% CI: 1.16,1.35; I 2 = 71.4%, p 2 = 95.6%, p 2 = 87.8%, p = 0.001) for obstructive CAD (binary variable) and 1.00 (95% CI: 1.00,1.01; I 2 = 75.0%, p = 0.490) for Agatston score (per unit increase). HRs by plaque composition (calcified, non-calcified and mixed; per segment change) were 1.24 (95% CI: 1.10,1.39; I 2 = 81.6%, p = 0.001), 1.20 (95% CI: 0.97,1.48; I 2 = 92.9%, p = 0.093) and 1.27 (95% CI: 1.03,1.58; I 2 = 89.8%, p = 0.029), respectively. Conclusion Despite heterogeneity in endpoints, extent of CAD as quantified by SIS on coronary CTA is a strong, independent predictor of cardiovascular events.

Background Minimally invasive aortic valve replacement (mAVR) is increasingly preferred over conventional AVR (cAVR). However, data comparing these procedures present conflicting results. Hence, we conducted a systematic review and meta-analysis comparing clinical results in these cohorts. Method Only randomized controlled trials (RCT) and propensity-matched observational studies (POS) (1998–2013) comparing clinical outcome of patients subjected to mAVR or cAVR were pooled. Continuous data was compared using mean/standardized mean difference (MD/SMD) while categorical results were pooled to obtain an odds ratio (OR) with a 95% confidence interval. Results A total of 18 studies (6 RCT and 12 POS) (1973 mAVR patients; 2697 cAVR patients) were analyzed. The mean ischemic time was significantly longer with mAVR (MD 9.42 minutes [4.25–14.59]; p

Background Underrepresentation of racial and ethnic minorities in clinical trials remains a reality while they have disproportionately higher rates of health disparities. Objective The purpose of this study was to identify successful community-engaged interventions that included health care providers as a key strategy in addressing barriers to clinical trial enrollment of underrepresented patients. Design A systematic review of the literature on interventions addressing enrollment barriers to clinical trials for racial and ethnic minorities was performed in Ovid MEDLINE, EBSCO Megafile, and EBSCO CINAHL. The systematic review identified 360 studies, and 20 were selected using the inclusion criteria. An iterative process extracted information from the eligible studies. Results The 20 selected studies were analyzed and then grouped by first author, nature of the clinical research initiative, priority populations, key strategies, and study outcomes. Nine of the studies addressed cancer clinical trials and 11 related to chronic medical conditions, including diabetes, hypertension management, and chronic kidney disease. The key strategies employed were categorized according to their presumed impact on barriers incurred at distinct steps in study recruitment: clinical trial awareness, opportunity to participate, and acceptance of enrollment. The strategies were further categorized by whether they would address barriers associated with minority perceptions of the research process and barriers related to how studies were designed and implemented. Conclusion Multiple and flexible strategies targeting providers and participants at provider sites and within communities might be needed to enroll underrepresented populations into clinical trials.

Data comparing long-term results after percutaneous intervention with drug-eluting stents (DES/PCI) and coronary artery grafting (CABG) in diabetic patients (pts) with multi-vessel disease is conflicting. We have conducted a systematic review and meta-analysis to help answer this issue.MEDLINE, WoS, and Scopus were systematically analysed to yield observational studies (OBS) or randomised controlled trials (RCT) fulfilling search criteria. Odds ratio (OR) for studied end-points were obtained with inverse variance random effects analysis. Results are presented with 95% confidence intervals with significance at p0.05.A total of 14 studies (5 RCT; 9 OBS) including more than 5000 pts were selected for review. Early/30-day was lower in the DES/PCI cohort [OR 0.49(0.27, 0.88); p=0.02; I(2)=0%]. Post-procedural stroke was higher in the CABG (1.8%) cohort compared to DES/PCI (0.17%; p0.01). A pooled analysis of RCT demonstrated that stroke rate was similar in both cohorts at the end of one year [OR 0.84(0.19, 3.74); p=0.82; I(2) =67%]. During a follow-up of three to five years, repeat intervention was much higher in the DES/PCI cohort [OR 3.02(2.13, 4.28; p0.01]. The odds of suffering an adverse cardiovascular /cerebrovascular event were 1.71 (1.27, 2.3) times higher in the DES/PCI cohort compared to CABG.In diabetic patients with multivessel disease, early mortality is lower in the DES/PCI cohort. While peri-procedural stroke rates are lower with PCI, they are, however, comparable at the end of one year. Use of drug-eluting stents leads to a higher rate of re-intervention and major cardiovascular/cerebrovascular events at three to five years.

We conducted a metaanalysis comparing early and midterm cardiovascular adverse events associated with minimally invasive direct coronary artery bypass graft surgery (MIDCABG) and percutaneous coronary intervention (PCI), with a focus on drug-eluting stents (DES).A systematic literature review (MEDLINE, EMBASE, Scopus, and so forth) yielded 12 studies (7 randomized controlled trials; 5 observational) pooling more than 2,000 patients. A random effect, inverse variance metaanalysis was conducted, and a subgroup analysis of the PCI-DES cohort was performed. Events were compared as risk ratios using a 95% confidence interval (CI). Heterogeneity of results was evaluated by Eggers I(2) test. Results are presented as early (0 to 1 year) and midterm (2 to 5 years).Midterm mortality in the PCI and MIDCABG groups (3.6% and 2.6%, respectively) was comparable (1.24, 95% CI: 0.66 to 2.33; p = 0.5; I(2) = 0%). Risk of early restenosis was lower in the MIDCABG cohort compared with PCI (0.40, 95% CI: 0.16 to 0.99; p = 0.05; I(2) = 57%). Although the early risk of recurrence of angina was comparable, over time it was 61% (43% to 74%) lower for MIDCABG patients (p0.001). Midterm results on analysis of the entire cohort demonstrated an increased risk for target vessel reinterventions (3.84, 95% CI: 2.7 to 5.5; p0.001) in the PCI cohort. Subgroup analysis revealed that the PCI-DES cohort (4 studies; 456 patients) had a higher risk of recurrent angina (risk ratio 3.4, 95% CI: 1.9 to 6.2; p0.001; I(2) = 0%) and target vessel reinterventions (risk ratio 4.16, 95% CI: 2.7 to 6.6; p 0.001; I(2) = 0%) at midterm follow-up (2 to 5 years).Survival rates are comparable after either MIDCABG or PCI for proximal LAD disease. However, even the use of DES was associated with significantly higher rates of angina recurrence and the need for target vessel reintervention as compared with MIDCABG.

ObjectivesTreatment burden is the workload of healthcare for people with long-term conditions (LTC) and its impact on well-being. A method of measurement is required to identify those experiencing high burden and to measure intervention efficacy. Our aim was to identify, examine and appraise validated patient-reported measures (PRMs) of treatment burden in stroke. Here, stroke serves as an exemplar LTC of older adults.DesignA systematic review of published studies that describe the development and validation of PRMs measuring treatment burden in stroke survivors.Data sourcesWe searched MEDLINE, Embase, CINAHL and PsycINFO electronic databases.Eligibility criteriaStudies published between January 2000 and 12 April 2019 inclusive, in English language. No restrictions were set based on clinical setting or geographical location.Data extraction and synthesisScreening, data extraction and quality appraisal were conducted by two independent reviewers. Content of the PRMs was compared with a published taxonomy of treatment burden. Quality appraisal was conducted using International Society for Quality of Life Research standards.ResultsFrom 3993 articles, 6 relevant PRMs were identified: 3 were stroke specific: The Satisfaction with Stroke Care questionnaire; The Stroke Patient-Reported Outcome Measure and The Barriers to Physical Activity after Stroke scale. Three were generic but validated in stroke: The WHO Quality of Life-100; The Patient’s Questionnaire on Participation in Discharge Planning and The Chao Perception of Continuity scale. None comprehensively measured treatment burden. Examples of omitted burdens included developing coping strategies, managing finances and returning to driving. The most notable issue regarding quality appraisal was that three PRMs lacked any underpinning qualitative research relevant to the sample.ConclusionThere is a need to develop a comprehensive PRM of treatment burden for use in stroke, with potential for use in other older populations.

Objectives We aimed to explore whether weight loss may improve central hemodynamics in obesity Hypothesis Hemodynamic abnormalities in obese HFpEF patients are correlated with the amount of excess body mass, suggesting a possible causal relationship. Methods We systematically searched relevant databases from inception to May 2018, without language restriction. Studies reporting invasive hemodynamic measures prior to and following therapeutic weight loss interventions in patients with obesity but no clinically-overt HF were extracted. Results A total of 9 studies were identified, providing data for 111 patients. Six studies tested dietary intervention and 3 studies tested bariatric surgery. Over a median duration of 9.7 months [range 0.75 to 23], median weight loss of 43 kg [range 10-58] was associated with significant reductions in heart rate [-9 bpm, 95% CI -12 to -6, p Conclusion Therapeutic weight loss in obese patients without HF is associated with favorable hemodynamic effects that could improve symptoms in patients with obesity and HF. Randomized controlled trials evaluating strategies for weight loss in obesity-related HFpEF are needed.

Background The optimal treatment for multivessel coronary artery disease in patients with end-stage renal disease (ESRD) is unresolved. Aim of Study Compare clinical adverse events after percutaneous intervention with drug-eluting stents (DESs) and coronary artery bypass grafting (CABG) in patients with ESRD. Methods MEDLINE, Web of Science, and Scopus were searched for appropriate studies published in the English language (between January 2000 and August 2013). The pooled odds ratio (OR) was estimated by the Peto method with a random effect model. Data are presented with 95% confidence interval; p

Objectives This study sought to perform a meta-analysis of randomized controlled trials comparing device closure with medical therapy in the prevention of recurrent neurological events in patients with cryptogenic stroke and patent foramen ovale. Background The optimal strategy for secondary prevention of cryptogenic stroke with a patent foramen ovale is unclear. Methods Several databases were searched from their inception to March 2013, which yielded 3 eligible studies. The results were pooled as per the different patient populations defined in the studies:—intention-to-treat, per-protocol, and as-treated cohorts. A generic inverse method was used based on time-to-event outcomes in a fixed-effect model. A supplementary analysis pooled the results from only 2 trials (RESPECT [Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment] and PC Trial [Randomized Clinical Trial Comparing the Efficacy of Percutaneous Closure of Patent Foramen Ovale (PFO) With Medical Treatment in Patients With Cryptogenic Embolism]) as a similar device was used in them. Results Our meta-analysis yielded effect-estimate hazard ratios of 0.67 (95% confidence interval [CI]: 0.44 to 1.00, I2 = 0%) in the intention-to-treat cohort, 0.62 (95% CI: 0.40 to 0.95). I2 = 0%) in the per-protocol cohort, and 0.61 (95% CI: 0.40 to 0.95, I2 = 38%) in the as-treated cohort, showing beneficial effects of device closure. The results became more robust with pooled results from RESPECT and the PC Trial: The effect-estimate hazard ratios being 0.54 (95% CI: 0.29 to 1.01, I2 = 0%), 0.48 (95% CI: 0.24 to 0.94, I2 = 26%), and 0.42 (95% CI: 0.21 to 0.84, I2 = 26%) in the intention-to-treat, per-protocol, and as-treated populations, respectively. Conclusions Our meta-analysis suggests that PFO closure is beneficial as compared to medical therapy in the prevention of recurrent neurological events. This meta-analysis helps to further strengthen the role of device closure in cryptogenic stroke.

Hispanics, the largest minority in the U.S., have a higher prevalence of several cardiovascular (CV) risk factors than non-Hispanic whites (NHW). However, some studies have shown a paradoxical lower rate of CV events among Hispanics than NHW.To perform a systematic review and a meta-analysis of cohort studies comparing CV mortality and all-cause mortality between Hispanic and NHW populations in the U.S.We searched EMBASE, MEDLINE, Web of Science, and Scopus databases from 1950 through May 2013, using terms related to Hispanic ethnicity, CV diseases and cohort studies. We pooled risk estimates using the least and most adjusted models of each publication.We found 341 publications of which 17 fulfilled the inclusion criteria; data represent 22,340,554 Hispanics and 88,824,618 NHW, collected from 1950 to 2009. Twelve of the studies stratified the analysis by gender, and one study stratified people by place of birth (e.g. U.S.-born, Mexican-born, and Central/South American-born). There was a statistically significant association between Hispanic ethnicity and lower CV mortality (OR 0.67; 95% CI, 0.57-0.78; p0.001), and lower all-cause mortality (0.72; 95% CI, 0.63-0.82; p0.001). A subanalysis including only studies that reported prevalence of CV risk factors found similar results. OR for CV mortality among Hispanics was 0.49; 95% CI 0.30-0.80; p-value0.01; and OR for all-cause mortality was 0.66; 95% CI 0.43-1.02; p-value 0.06.These results confirm the existence of a Hispanic paradox regarding CV mortality. Further studies are needed to identify the mechanisms mediating this protective CV effect in Hispanics.

Polycystic ovary syndrome (PCOS) is common among women of childbearing age and the available pharmacological therapies have different side-effect profiles.We summarized the evidence about the side effects of oral contraceptive pills, metformin, and anti-androgens in women with PCOS.Sources included Ovid Medline, OVID EMBASE, OVID Cochrane Library, Web of Science, Scopus, PsycInfo, and CINAHL from inception through April 2011.We included comparative observational studies enrolling women with PCOS who received the agents of choice for at least 6 months and reported adverse effects.Using a standardized, piloted, and Web-based data extraction form and working in duplicate, we abstracted data from each study and performed meta-analysis when possible.We found 22 eligible studies of which 20 were randomized. No study reported severe side effects (eg, lactic acidosis, thromboembolic episodes, liver toxicity, cancer incidence, or pregnancy loss). Meta-analysis demonstrated no significant change in weight in oral contraceptive pills or flutamide users. Indirect evidence from populations without PCOS demonstrated no increased risk of lactic acidosis with metformin, only case reports of liver toxicity with flutamide (no comparative evidence), and increased relative risk difference of venous thromboembolism with oral contraceptive pills but very low absolute risk. Evidence on mortality, cardiovascular mortality, and cancer was inconclusive.Drugs commonly used to treat PCOS appear to be associated with very low risk of severe adverse effects although data are extrapolated from other populations.

Coronary artery disease is highly prevalent in patients with end-stage renal disease. Yet randomised controlled trials are lacking, and decisions are based on retrospective cohort studies which present conflicting outcomes. Hence we conducted a systematic review and meta-analysis comparing outcomes in patients with end-stage renal disease and renal dysfunction undergoing percutaneous intervention (PCI) and coronary artery bypass grafting (CABG), with a particular focus on contemporary studies implementing drug-eluting stents.MEDLINE, EMBASE, World of Science, and the Cochrane library were searched for randomised controlled (RCT) and observational studies comparing clinical outcomes such as early mortality, myocardial infarction, need for repeat revascularisation and angina in patients undergoing PCI or CABG. We used random effect models to compare risk ratios (RR) within groups.One RCT and 15 observational studies (7588 PCI and 9206 CABG patients) met inclusion criteria. Early mortality favoured the PCI cohort (4.2% vs 8.5%) [risk ratio=0.51(0.40, 0.64), p0.01]. The need for repeat revascularisation was significantly lower in the CABG cohort (7.3% vs 17.8%; p0.01). Pooled analysis of studies implementing a drug eluting stent still favoured CABG with regards to repeat revascularisation (5% vs 14%; p0.01) and MACE (15% vs 27%; p=0.03), while early mortality was less in the DES-PCI cohort (2.4% vs 5.1%; p=0.04).Compared to percutaneous intervention, coronary artery bypass grafting is associated with higher early/30-day mortality in patients with renal dysfunction or end-stage renal disease. The need for repeat revascularisation is significantly higher with percutaneous intervention, even with the use of a drug-eluting stent.

BACKGROUND: The use of 2 agonist as an intervention for acute lung injury (ALI) and ARDS patients is controversial, so we performed a systematic review and meta-analysis of the published randomized controlled trials of using 2 agonists to improve outcomes (mortality and ventilator free days) among patients with ALI/ARDS. METHODS: A comprehensive search of 7 major databases (Ovid MEDLINE In-Process and other non-indexed citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Cochrane Database of Systematic Reviews, Web of Science, and Scopus) for randomized controlled trials using 2 agonists for ALI from their origin to March 2013 was conducted. The effect size was measured by relative risk for dichotomous outcomes, and mean difference for continuous outcomes, with 95% CI. The statistical heterogeneity between the studies was assessed with the Cochran Q test and I 2 statistic. The heterogeneity of > 50% was considered significant for the analysis. The Cochrane risk of bias tool was used to ascertain the quality of the included studies. RESULTS: Out of 219 studies screened, 3 randomized controlled trials reported mortality and ventilator-free days, in 646 ALI/ ARDS subjects. Of the 646 subjects, 334 (51.7%) received 2 agonist and 312 (48.3%) received placebo. There was no significant decrease in 28-day mortality or hospital mortality in the 2agonist group: relative risk 1.04, 95% CI 0.50–2.16, and relative risk 1.22, 95% CI 0.95–1.56, respectively. The ventilator-free days and organ-failure-free days were significantly lower for the ALI subjects who received 2 agonists: mean difference 2.19 days (95% CI 3.68 to 1.99 d) and mean difference 2.04 days (95% CI 3.74 to 0.35 d), respectively. CONCLUSIONS: In subjects with ALI/ARDS, 2 agonists were not only nonbeneficial in improving the survival, but were harmful and increased morbidity (reduced organ-failure-free days and ventilator-free days). The current evidence discourages the use of 2 agonist in ALI/ARDS patients. (International Prospective Register of Systematic Reviews, http://www.crd.york.ac.uk/prospero, 2012:CRD42012002616.)

To perform a systematic review and meta-analysis of clinical trials evaluating the efficacy and safety of midodrine in orthostatic hypotension (OH). We searched major databases and related conference proceedings through June 30, 2012. Two reviewers independently selected studies and extracted data. Random-effects meta-analysis was used to pool the outcome measures across studies. Seven trials were included in the efficacy analysis (enrolling 325 patients, mean age 53 years) and two additional trials were included in the safety analysis. Compared to placebo, the mean change in systolic blood pressure was 4.9 mmHg (p = 0.65) and the mean change in mean arterial pressure from supine to standing was −1.7 mmHg (p = 0.45). The change in standing systolic blood pressure before and after giving midodrine was 21.5 mmHg (p

Background: Anti-platelet therapy is an important component of medical therapy post coronary artery bypass grafting (CABG). While aspirin administration is a Class I indication after CABG, the benefit of concomitant clopidogrel is a controversial issue. Methods: We searched OVID Medline, Cochrane, Scopus, and EMBASE for randomized control trials and observational studies comparing aspirin W placebo to aspirin R clopidogrel after CABG. Results: Eleven articles (five randomized control trials and six observational studies) including 25,728 patients met inclusion criteria. Early saphenous vein graft occlusion was reduced with the use of dual anti-platelet therapy (risk ratio (RR) = 0.59, 95% CI 0.43-0.82, p = 0.02). In- hospital or 30-day mortality was lower with aspirin R clopidogrel (0.8%) compared to aspirin alone (1.9%) (p < 0.0001), while risk of angina or perioperative myocardial infarction was comparable (RR = 0.60, 95% CI 0.31-1.14, p = 0.12). Patients treated with aspirin R clopidogrel demonstrated a trend towards a higher incidence of major bleeding episodes as compared to patients treated with aspirin alone (RR = 1.17, 95% CI 1.00-1.37, p = 0.05). In a pooled analysis of studies involving off-pump CABG compared to aspirin alone, dual anti-platelet therapy reduced the risk of perioperative myocardial infarction and saphenous graft occlusion by 68% (47% to 71%) and 55% (2% to 79%) respectively. Conclusion: Dual anti-platelet therapy after CABG improved early saphenous vein graft patency, but may increase the risk of bleeding. The use of dual anti- platelet therapy appears to be most beneficial in patients undergoing off-pump CABG. Prospective randomized studies are necessaryto determine whetherthis beneficial effect of dualtherapy is alsoachieved in patients undergoing on pump CABG. doi: 10.1111/jocs.12074 (J Card Surg 2013;28:109-116)

Background Coronary artery bypass graft surgery is superior to percutaneous intervention in diabetic patients with multivessel disease. The use of bilateral internal thoracic arteries (BITA) may provide better long-term graft patency, but the risk of postoperative deep sternal wound infection has limited its use in diabetic patients. However, studies have reported conflicting results, and require systematic evaluation. Methods MEDLINE, EMBASE, World of Science, and the Cochrane library were searched for randomized controlled trials and observational studies comparing the incidence of deep sternal wound infection in diabetic patients undergoing either left internal thoracic artery (LITA) or BITA harvest. We used random effect models to compare risk ratios within groups. Results One randomized controlled trial and 10 observational studies (126,235 diabetic patients: 122,465 LITA, 3,770 BITA) met inclusion criteria. Deep sternal wound infection occurred in 3.1% and 1.6% for the BITA and LITA cohorts, respectively. The risk ratio for deep sternal wound infection development was 1.71 (1.37 to 2.14) for BITA compared with LITA. Patients who underwent skeletonized BITA harvest had a similar risk of deep sternal wound infection compared with LITA (0.9 [0.42 to 2.09]), although pedicled harvest demonstrated increased risk (1.77 [1.4 to 2.23]). Early mortality was comparable in the LITA cohort (2.5%) and the BITA cohort (2.3%; p = 0.8). Conclusions The risk of deep sternal wound infection can be minimized in diabetic patients undergoing coronary artery bypass graft surgery by performing ITA harvested in a skeletonized manner with meticulous attention to preserving sternal blood flow. Pedicled harvest is to be discouraged when utilizing both ITA owing to a significant increase in the risk of postoperative deep sternal wound infection.

Systematic reviews provide clinicians and policymakers estimates of diagnostic test accuracy and their usefulness in clinical practice. We identified all available systematic reviews of diagnosis in endocrinology, summarized the diagnostic accuracy of the tests included, and assessed the credibility and clinical usefulness of the methods and reporting. We searched Ovid MEDLINE, EMBASE, and Cochrane CENTRAL from inception to December 2015 for systematic reviews and meta-analyses reporting accuracy measures of diagnostic tests in endocrinology. Experienced reviewers independently screened for eligible studies and collected data. We summarized the results, methods, and reporting of the reviews. We performed subgroup analyses to categorize diagnostic tests as most useful based on their accuracy. We identified 84 systematic reviews; half of the tests included were classified as helpful when positive, one-fourth as helpful when negative. Most authors adequately reported how studies were identified and selected and how their trustworthiness (risk of bias) was judged. Only one in three reviews, however, reported an overall judgment about trustworthiness and one in five reported using adequate meta-analytic methods. One in four reported contacting authors for further information and about half included only patients with diagnostic uncertainty. Up to half of the diagnostic endocrine tests in which the likelihood ratio was calculated or provided are likely to be helpful in practice when positive as are one-quarter when negative. Most diagnostic systematic reviews in endocrine lack methodological rigor, protection against bias, and offer limited credibility. Substantial efforts, therefore, seem necessary to improve the quality of diagnostic systematic reviews in endocrinology.

Background Little is known about determinants of quality of life (QoL) in autosomal dominant polycystic kidney disease (ADPKD). Recent studies suggest that QoL in ADPKD is determined by more factors than mere renal function. We investigated the effect of ADPKD on QoL and evaluated how Qol is affected by disease severity markers renal function, kidney volume and liver volume. Methods We performed a systematic review, meta-analysis and meta-regression analyses of cohort studies and randomized controlled trials investigating patient-reported QoL in adult patients with ADPKD not yet on dialysis. EMBASE, MEDLINE, and Web of Science were searched to August 2015 without language restrictions. Two investigators independently reviewed title, abstracts and full text of potentially relevant citations to determine eligibility. We compared pooled QoL summary scores of ADPKD patients using a random-effects meta-analytic model. These scores were compared with mean and age-corrected reference scores of the general population. In a meta-regression analysis, we investigated the univariate effect of renal function, kidney volume and liver volume on QoL. Results We included nine studies in meta-analysis including 1623 patients who completed the SF-36 questionnaire. Pooled physical (PCS) and mental component scores (MCS) of the SF-36 of individuals with ADPKD were lower than those of the reference population (45.7 vs. 50.0 and 47.8 vs. 50.0 points, both P

Background Chronic conditions are increasingly more common and negatively impact quality of life, disability, morbidity, and mortality. Health coaching has emerged as a possible intervention to help individuals with chronic conditions adopt health supportive behaviors that improve both quality of life and health outcomes. Methods/design We planned a systematic review and meta-analysis of the contemporary health coaching literature published in the last decade to evaluate the effect of health coaching on clinically important, disease-specific, functional, and behavioral outcomes. We will include randomized controlled trials or quasi-experimental studies that compared health coaching to alternative interventions or usual care. To enable adoption of effective interventions, we aim to explore how the effect of intervention is modified by the intervention components, delivering personnel (i.e., health professionals vs trained lay or peer persons), dose, frequency, and setting. Analysis of intervention outcomes will be reported and classified using an existing theoretical framework, the Theory of Patient Capacity, to identify the areas of patients’ capacity to access and use healthcare and enact self-care where coaching may be an effective intervention. Discussion This systematic review and meta-analysis will identify and synthesize evidence to inform the practice of health coaching by providing evidence on components and characteristics of the intervention essential for success in individuals with chronic health conditions. Systematic review registration PROSPERO CRD42016039730 Electronic supplementary material The online version of this article (doi:10.1186/s13643-016-0316-3) contains supplementary material, which is available to authorized users.

Background Life and healthcare demand work from patients, more so from patients living with multimorbidity. Patients must respond by mobilizing available abilities and resources, their so-called capacity. We sought to summarize accounts of challenges that reduce patient capacity to access or use healthcare or to enact self-care while carrying out their lives. Methods We conducted a systematic review and synthesis of the qualitative literature published since 2000 identifying from MEDLINE, EMBASE, Psychinfo, and CINAHL and retrieving selected abstracts for full text assessment for inclusion. After assessing their methodological rigor, we coded their results using a thematic synthesis approach. Results The 110 reports selected, when synthesized, showed that patient capacity is an accomplishment of interaction with (1) the process of rewriting their biographies and making meaningful lives in the face of chronic condition(s); (2) the mobilization of resources; (3) healthcare and self-care tasks, particularly, the cognitive, emotional, and experiential results of accomplishing these tasks despite competing priorities; (4) their social networks; and (5) their environment, particularly when they encountered kindness or empathy about their condition and a feasible treatment plan. Conclusion Patient capacity is a complex and dynamic construct that exceeds “resources” alone. Additional work needs to translate this emerging theory into useful practice for which we propose a clinical mnemonic (BREWS) and the ICAN Discussion Aid. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0525-9) contains supplementary material, which is available to authorized users.

Obliterative bronchiolitis (OB) is a major cause of morbidity and mortality in patients undergoing hematopoietic stem cell transplantation (HSCT). Our objective was to perform a systematic review and meta-analysis of the impact of azithromycin on change in forced expiratory volume in 1 second (FEV1). We searched MEDLINE, EMBASE, Web of Science, Cochrane CENTRAL and Scopus databases and included studies that compared azithromycin with placebo or no intervention in the treatment of OB or bronchiolitis obliterans syndrome (BOS) in patients who had undergone allogeneic HSCT. Ninety-one unique publications were identified, and 4 studies met inclusion criteria, with a total of 90 patients. Changes in FEV1 were measured between 12 and 24 weeks after initiation of treatment. The meta-analysis demonstrated a mean increase in FEV1 of 30 mL (95% confidence interval, −260 to +330 mL; P = .82) after initiation of azithromycin. One patient death was reported but not attributed to azithromycin therapy. In conclusion, current evidence can neither support nor refute the use of azithromycin in the treatment of patients who develop OB/BOS after HSCT. Further studies are needed to determine whether azithromycin is beneficial for the treatment of OB/BOS in this setting.

The benefit of complete surgical metastasectomy for patients with metastatic renal cell carcinoma remains controversial due to limited outcome data. We performed a systematic review and meta-analysis to determine whether complete surgical metastasectomy confers a survival benefit compared to incomplete or no metastasectomy for patients with metastatic renal cell carcinoma.Ovid Embase®, MEDLINE®, Cochrane and Scopus® databases were searched for studies evaluating complete surgical metastasectomy for metastatic renal cell carcinoma through January 19, 2016. Only comparative studies reporting adjusted hazard ratios (aHRs) for all cause mortality of incomplete surgical metastasectomy vs complete surgical metastasectomy were included in the analysis. Generic inverse variance with random effects models was used to determine the pooled aHR. Risk of bias was assessed with the Newcastle-Ottawa Scale.Eight published cohort studies with a low or moderate potential for bias were included in the final analysis. The studies reported on a total of 2,267 patients (958 undergoing complete surgical metastasectomy and 1,309 incomplete surgical metastasectomy). Median overall survival ranged between 36.5 and 142 months for those undergoing complete surgical metastasectomy, compared to 8.4 to 27 months for incomplete surgical metastasectomy. Complete surgical metastasectomy was associated with a reduced risk of all cause mortality compared with incomplete surgical metastasectomy (pooled aHR 2.37, 95% CI 2.03-2.87, p 0.001), with low heterogeneity (IComplete surgical metastasectomy for metastatic renal cell carcinoma is associated with improved survival compared with incomplete surgical metastasectomy based on meta-analysis of observational data. Consideration should be given to performing complete surgical metastasectomy, when technically feasible, in patients with metastatic renal cell carcinoma who are surgical candidates.

Moderate ischemic mitral regurgitation (MR) is often present in patients undergoing coronary artery bypass grafting (CABG). However, the clinical benefit of repairing moderate MR during CABG is unproven. We searched multiple databases to identify original studies comparing isolated CABG versus combined CABG and MR surgery (mitral valve surgery with coronary artery bypass grafting [MVCABG]); survival (either early or midterm) was the primary end point. Risk ratio (RR) or standardize mean difference was selected as the effect estimates; survival was compared by pooling hazard ratios. All results are presented with 95% CIs; p0.05 is statistically significant. Eleven studies (7 retrospective and 4 randomized controlled trials; 547 MVCABG and 900 CABG patients) were included in our meta-analysis. Concomitant mitral valve repair significantly prolonged surgical duration (p0.01). Early mortality (MVCABG 6.9% and CABG 6%) was comparable (RR 1.3 [0.9 to 1.8]; p = 0.11). At follow-up, the MVCABG patients had similar New York Heart Association class (standardize mean difference -0.73 (-1.64 to 0.18; p = 0.11). However, patients who underwent concomitant mitral valve surgery had less MR at follow-up (recurrent significant MR, RR 0.37 [0.22 to 0.62]; p = 0.001; mean MR grade, mean difference = 0.39 [0.26 to 0.59]; p0.001). Midterm survival rate (mean follow-up 5 years) was comparable in both groups (hazard ratio for mortality in the MVCABG cohort 1.1 [0.9 to 1.3]; p = 0.38). In conclusion, concomitant repair of moderate ischemic MR leads to improved mitral valve competence at follow-up; however, this was not translated into any functional or survival benefit for adding valve repair to CABG for these patients at 5 years of follow-up.

Background Scribes offer a potential solution to the clerical burden and time constraints felt by health care providers. Objectives This is a systematic review and meta-analysis to evaluate scribe effect on patient throughput, revenue, and patient and provider satisfaction. Methods Six electronic databases were systematically searched from inception until May 2015. We included studies where clinicians used a scribe. We collected throughput metrics, billing data, and patient/provider satisfaction data. Meta-analyses were conducted using a random effects model and mean differences (MDs) with 95% confidence intervals (CIs) with adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Results From a total of 210 titles, 17 studies were eligible and included. Qualitative analysis suggests improvement in provider/patient satisfaction. Meta-analysis on throughput data was derived from 3 to 5 studies depending on the metric; meta-analysis revealed no impact of scribes on length of stay (346 minutes for scribes, 344 minutes for nonscribed; MD −1.6 minutes, 95% CI −22.3 to 19.2 minutes) or provider-to-disposition time (235 minutes for scribes, 216 for nonscribed; MD −18.8 minutes, 95% CI −22.3 to 19.2) with an increase in patients seen per hour (0.17 more patient per hour; 95% CI 0.02-32). Two studies reported relative value units, which increased 0.21 (95% CI 0-0.42) per patient with scribe use. Conclusion We found no difference in length of stay or time to disposition with a small increase in the number of patients per hour seen when using scribes. Potential benefits include revenue and patient/provider satisfaction.

Objective To compare efficacy of pharmacotherapies for chronic idiopathic constipation (CIC) based on comparisons to placebo using Bayesian network meta-analysis. Data sources We conducted searches (inception to May 2015) of MEDLINE, EMBASE, Scopus and Cochrane Central, as well as original data from authors or drug companies for the medications used for CIC. Study selection Phase IIB and phase III randomised, placebo-controlled trials (RCT) of ≥4 weeks9 treatment for CIC in adults with Rome II or III criteria for functional constipation; trials included at least one of four end points. Data extraction and synthesis Two investigators independently evaluated all full-text articles that met inclusion criteria and extracted data for primary and secondary end points, risk of bias and quality of evidence. Outcomes Primary end points were ≥3 complete spontaneous bowel movements (CSBM)/week and increase over baseline by ≥1 CSBM/week. Secondary end points were change from baseline (Δ b ) in the number of SBM/week and Δ b CSBM/week. Results Twenty-one RCTs (9189 patients) met inclusion and end point criteria: 9 prucalopride, 3 lubiprostone, 3 linaclotide, 2 tegaserod, 1 each velusetrag, elobixibat, bisacodyl and sodium picosulphate (NaP). All prespecified end points were unavailable in four polyethylene glycol studies. Bisacodyl, NaP, prucalopride and velusetrag were superior to placebo for the ≥3 CSBM/week end point. No drug was superior at improving the primary end points on network meta-analysis. Bisacodyl appeared superior to the other drugs for the secondary end point, Δ b in number of SBM/week. Conclusions Current drugs for CIC show similar efficacy. Bisacodyl may be superior to prescription medications for Δ b in the number of SBM/week in CIC.

Objective To consolidate the evidence from the literature to evaluate the role of prazosin in the treatment of posttraumatic stress disorder (PTSD). Data sources Major databases, including PubMed, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Ovid PsycINFO, and Scopus, were searched through August 2015 for studies reporting the role of prazosin in the treatment of PTSD with no language constraints. Keywords included (PTSD OR posttraumatic stress OR posttraumatic stress OR nightmares) AND prazosin. Study selection Of 402 screened articles, 6 studies were included in the systematic review and meta-analysis. Data extraction Two reviewers independently extracted relevant data (study characteristics, type of intervention, outcome measures, and follow-up) from the included studies using a standardized data extraction form. Only randomized controlled trials comparing prazosin to a placebo or control group in patients with PTSD were included. Results The patients with PTSD receiving prazosin showed significant improvement in nightmares (standardized mean difference [SMD] = 1.01; 95% CI, 0.72-1.30), overall PTSD symptoms (SMD = 0.77; 95% CI, 0.48-1.06), and clinical global improvement (SMD = 0.94; 95%, CI 0.6-1.29) compared to the placebo/control group. Prazosin improved sleep quality (SMD = 0.87; 95% CI, 0.55-1.19), hyperarousal symptoms (SMD = 1.04; 95% CI, 0.23-1.84), dream content (SMD = 1.33; 95% CI, 0.69-1.97), and total sleep time (60.98 minutes; 95% CI, 18.69-103.26). Prazosin was fairly well tolerated. Minor side effects were reported, which were similar between the prazosin and placebo groups. Conclusions This study suggests that prazosin improves nightmares and overall PTSD symptoms including hyperarousal, sleep disturbances, total sleep time, and sleep quality.

To perform a systematic review and meta-analysis to compare the simplified motor score (SMS) and Glasgow Coma Scale (GCS) in predicting outcomes in patients with traumatic brain injury (TBI).Ovid EMBASE, Ovid Medline, Ovid PsycInfo, evidence-based medicine reviews and Scopus and related conference proceedings were searched through 28 February 2012 for studies comparing SMS and GCS in predicting the outcomes [emergency tracheal intubation (ETI), clinically significant brain injuries (CSBI), neurosurgical intervention (NSI) and mortality] in patients with TBI. A random-effects model was used for meta-analysis.Five retrospective studies were eligible, enrolling a total of 102 132 subjects with TBI (63.4% males), with 14 670 (14.4%) ETI, 16 201 (15.9%) CSBI, 4730 (4.6%) NSI and 6725 (6.6%) mortality. Pooled AUC of the GCS and SMS were as follows: CSBI 0.79 and 0.75 (p = 0.16), NSI 0.83 and 0.81 (p = 0.34), ETI 0.85 and 0.82 (p = 0.31) and mortality 0.90 and 0.87 (p = 0.01). The difference in AUC for mortality was 0.03. Large heterogeneity between the studies was observed in all analyses (I(2 ) 50%).In patients with TBI, SMS predicts different outcomes with similar accuracy as GCS except mortality. However, due to heterogeneity and limited numbers of studies, further prospective studies are required.

International audience; BACKGROUND: Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex. METHODS: We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions. FINDINGS: In 2010, there were 52*8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24*9% of deaths worldwide in 2010, down from 15*9 million (34*1%) of 46*5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2*5 to 1*4 million), lower respiratory infections (from 3*4 to 2*8 million), neonatal disorders (from 3*1 to 2*2 million), measles (from 0*63 to 0*13 million), and tetanus (from 0*27 to 0*06 million). Deaths from HIV/AIDS increased from 0*30 million in 1990 to 1*5 million in 2010, reaching a peak of 1*7 million in 2006. Malaria mortality also rose by an estimated 19*9% since 1990 to 1*17 million deaths in 2010. Tuberculosis killed 1*2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34*5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1*5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12*9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1*3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5*1 million deaths) was marginally higher in 2010 (9*6%) compared with two decades earlier (8*8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1*3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted. INTERPRETATION: Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis. FUNDING: Bill & Melinda Gates Foundation.

Infectious complications of cardiac surgery are often severe and life threatening. Statins having both immunomodulatory and anti-inflammatory effects were intuitively thought to influence the development of postsurgical infections. We sought to systematically examine whether any association exists between statin use and risk of infectious complications in patients undergoing cardiac surgery. We searched Ovid MEDLINE, Ovid EMBASE, Thomson Scientific Web of Science, and Elsevier Scopus from inception through February 2011 for comparative studies examining the association between statin use and risk of postoperative infections in patients undergoing cardiac surgery. We contacted a study's author for missing information. We conducted a random-effects meta-analysis of individual studies' odds ratios (adjusted for potential confounders). We identified 6 cohort studies for inclusion, 3 of which were conducted in Canada and 3 of which were conducted in the United States. Four were single-center studies, and 2 were population based. Exposure ascertainment was based on a review of admission medication list or prescription databases. Infectious outcomes were heterogeneous and included surgical site infections within 30 days, serious infections (sepsis), or any other postoperative infection. Statin use in the preoperative period was associated with a trend toward reduction in the incidence of postoperative infections in patients who underwent cardiac surgery (odds ratio, 0.81 [95% confidence interval, 0.64–1.01];P= .06;I2= 75%). Heterogeneity was explained by country effect. Studies performed in Canada showed weaker associations than studies performed in the United States. This difference could not be attributed to study quality alone. We did not find good evidence to support an association between statin use and postoperative infectious complications. However, the trend toward statistical significance for this association indicates that further investigation is warranted.

To determine the comparative effectiveness of technology-enhanced simulation, we summarized the results of studies comparing technology-enhanced simulation training with nonsimulation instruction for health professions learners. We systematically searched databases including MEDLINE, Embase, and Scopus through May 2011 for relevant articles. Working in duplicate, we abstracted information on instructional design, outcomes, and study quality. From 10,903 candidate articles, we identified 92 eligible studies. In random-effects meta-analysis, pooled effect sizes (positive numbers favoring simulation) were as follows: satisfaction outcomes, 0.59 (95% confidence interval, 0.36-0.81; n = 20 studies); knowledge, 0.30 (0.16-0.43; n = 42); time measure of skills, 0.33 (0.00-0.66; n = 14); process measure of skills, 0.38 (0.24-0.52; n = 51); product measure of skills, 0.66 (0.30-1.02; n = 11); time measure of behavior, 0.56 (-0.07 to 1.18; n = 7); process measure of behavior, 0.77 (-0.13 to 1.66; n = 11); and patient effects, 0.36 (-0.06 to 0.78; n = 9). For 5 studies reporting comparative costs, simulation was more expensive and more effective. In summary, in comparison with other instruction, technology-enhanced simulation is associated with small to moderate positive effects.

Objective: Given that atypical antipsychotic medications have been increasingly prescribed for improving weight gain in anorexia nervosa (AN), we conducted a systematic review and meta-analyses to estimate the influence of atypical antipsychotics on BMI, eating disorder, and psychiatric symptoms in individuals with AN. Method: Independent reviewers selected studies and extracted study characteristics, methodologic quality, and outcomes for the intention-to-treat group from randomized clinical trials comparing the effect of atypical antipsychotic use to placebo or an active control treatment on BMI. Results: Compared with placebo, atypical antipsychotics were associated with a nonsignificant increase in BMI (weighted mean difference, WMD = 0.18, 95% CI: −0.36, 0.72; I2 = 26%) and a nonsignificant effect on the drive for thinness and body dissatisfaction. Compared with placebo or active control, these medications led to an increase in anxiety and overall eating disorder symptoms. However, there was a significant reduction over placebo or active control on level of depression. © 2012 by Wiley Periodicals, Inc. (Int J Eat Disord 2013)

Background: Although technology-enhanced simulation is increasingly used in health professions education, features of effective simulation-based instructional design remain uncertain. Aims: Evaluate the effectiveness of instructional design features through a systematic review of studies comparing different simulation-based interventions. Methods: We systematically searched MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO, Scopus, key journals, and previous review bibliographies through May 2011. We included original research studies that compared one simulation intervention with another and involved health professions learners. Working in duplicate, we evaluated study quality and abstracted information on learners, outcomes, and instructional design features. We pooled results using random effects meta-analysis. Results: From a pool of 10 903 articles we identified 289 eligible studies enrolling 18 971 trainees, including 208 randomized trials. Inconsistency was usually large (I 2 4 50%). For skills outcomes, pooled effect sizes ( positive numbers favoring the instructional design feature) were 0.68 for range of difficulty (20 studies; p5 0.001), 0.68 for repetitive practice (7 studies; p ¼ 0.06), 0.66 for distributed practice (6 studies; p ¼ 0.03), 0.65 for interactivity (89 studies; p5 0.001), 0.62 for multiple learning strategies (70 studies; p5 0.001), 0.52 for individualized learning (59 studies; p5 0.001), 0.45 for mastery learning (3 studies; p ¼ 0.57), 0.44 for feedback (80 studies; p5 0.001), 0.34 for longer time (23 studies; p ¼ 0.005), 0.20 for clinical variation (16 studies; p ¼ 0.24), and � 0.22 for group training (8 studies; p ¼ 0.09). Conclusions: These results confirm quantitatively the effectiveness of several instructional design features in simulation-based education.

Background: The accuracy of intraoperative periprosthetic frozen section histologic evaluation in predicting a diagnosis of periprosthetic joint infection prior to microbiologic culture results is unknown. Methods: We performed a systematic review and meta-analysis of all longitudinal studies that compared frozen section histologic results with simultaneously obtained microbiologic culture at the time of revision total hip or total knee arthroplasty. The data sources were Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, ISI Web of Science, and SCOPUS, from the inception of each database to January 2010. Results: Twenty-six studies involving 3269 patients undergoing revision hip or knee arthroplasty met the inclusion criteria. A culture-positive periprosthetic joint infection was confirmed in 796 (24.3%) of the patients. Frozen section results, using any of the diagnostic criteria chosen by the investigating pathologist, had a pooled diagnostic odds ratio of 54.7 (95% confidence interval [CI], 31.2 to 95.7), a likelihood ratio of a positive test of 12.0 (95% CI, 8.4 to 17.2), and a likelihood ratio of a negative test of 0.23 (95% CI, 0.15 to 0.35) for the diagnosis of periprosthetic joint infection. Fifteen studies utilizing a threshold of five polymorphonuclear leukocytes (PMNs) per high-power field to define a positive frozen section had a diagnostic odds ratio of 52.6 (95% CI, 23.7 to 116.2), and six studies utilizing a diagnostic threshold of ten PMNs per high-power field had a diagnostic odds ratio of 69.8 (95% CI, 33.6 to 145.0). There was no significant difference between the diagnostic odds ratio or likelihood ratios associated with these thresholds. The moderate to high heterogeneity among the included studies was unexplained by variability in the study design, diagnostic criteria for acute inflammation, reference standard for periprosthetic joint infection, or prevalence of infection. This heterogeneity could be due to differences in the inclusion and exclusion criteria, tissue sampling error, experience or technique of the pathologists, number of microscopic fields visualized, and field diameter examined. Conclusions: Intraoperative frozen sections of periprosthetic tissues performed well in predicting a diagnosis of culture-positive periprosthetic joint infection but had moderate accuracy in ruling out this diagnosis. Frozen section histopathology should therefore be considered a valuable part of the diagnostic work-up for patients undergoing revision arthroplasty, especially when the potential for infection remains after a thorough preoperative evaluation. The optimum diagnostic threshold (number of PMNs per high-power field) required to distinguish periprosthetic joint infection from aseptic failure could not be discerned from the included studies. There was no significant difference between the diagnostic accuracy of frozen section histopathology utilizing the most common thresholds of five or ten PMNs per high-power field.

Objetivos. Evaluar si la taquipnea y las retracciones subcostales son predictoras eficientes para el diagnostico de neumonia adquirida en la comunidad (NAC) en ninos. Materiales y metodos. Se revisaron las bases de datos: PubMed, LILACS, The African Journal Database y The Cochrane Central Library. Se incluyeron estudios originales que evaluaron el rendimiento diagnostico de los criterios clinicos de taquipnea o retracciones subcostales, definidos segun los criterios de la Organizacion Mundial de la Salud (OMS) para el diagnostico de NAC en ninos de hasta cinco anos de edad con tos y fiebre. Se estimaron las razones de probabilidades (LR), el odds ratio diagnostico (DOR) y sus respectivos intervalos de confianza al 95% (IC95%) para cada prueba clinica evaluada. Resultados. Se encontraron 975 estudios, incluyendo ocho en la revision. Se enrolaron 4740 pacientes y analizaron 3584 (75%), de los cuales 916 (19%) tuvieron el diagnostico de NAC. Al combinar los datos, la taquipnea obtuvo una LR positiva de 3,16, (IC95% 2,11-4,73) y una LR negativa de 0,36 (IC95% 0,23-0,57). El DOR fue de 10,63 (IC95% 4,4-25,66, I2=93%). Al realizar el analisis para retracciones subcostales se obtuvo un LR positivo de 2,49 (IC95% 1,41-4,37) y un LR negativo de 0,59 (IC95% 0,4-0,87). El DOR fue de 5,32 (IC95% 1,88-15,05, I2=89%). Conclusiones. Se puede tomar en cuenta la presencia o ausencia de taquipnea y retracciones subcostales en el diagnostico de NAC, cabe considerar la incertidumbre relativa en su poder diagnostico y los LR relativamente modestos. La confianza en estos resultados es baja por la inadecuada calidad de la evidencia en este tema

ACADEMIC EMERGENCY MEDICINE 2012; 19:959–967 © 2012 by the Society for Academic Emergency Medicine Abstract Background: Many decisions in the emergency department (ED) may benefit from patient involvement, even though this setting has been considered least conducive to shared decision-making (SDM). Objectives: The objective was to conduct a systematic review to evaluate the approaches, methods, and tools used to engage patients or their surrogates in SDM in the ED. Methods: Five electronic databases were searched in conjunction with contacting content experts, reviewing selected bibliographies, and conducting citation searches using the Web of Knowledge database. Two reviewers independently selected eligible studies that addressed patient involvement and engagement in decision-making in the ED setting via the use of decision support interventions (DSIs), defined as decision aids or decision support designed to communicate probabilistic information on the risks and benefits of treatment options to patients as part of an SDM process. Eligible studies described and assessed at least one of the following outcomes: patient knowledge, experiences and perspectives on participating in treatment or management decisions, clinician or patient satisfaction, preference for involvement and/or degree of engagement in decision-making and treatment preferences, and clinical outcomes (e.g., rates of hospital admission/readmission, rates of medical or surgical interventions). Two reviewers extracted data on study characteristics, methodologic quality, and outcomes. The authors also assessed the extent to which SDM interventions adhered to good practice for the presentation of information on outcome probabilities (eight probability items from the International Patient Decision Aid Standards Instrument [IPDASi]) and had comprehensive development processes. Results: Five studies met inclusion criteria and were synthesized using a narrative approach. Each study was of satisfactory methodologic quality and used a DSI to engage patients or their surrogates in decision-making in the ED across four domains: 1) management options for children with small lacerations; 2) options for rehydrating children presenting with vomiting or diarrhea or both; 3) risk of bacteremia (and associated complications), tests, and treatment options for febrile children; and 4) short-term risk of acute coronary syndrome (ACS) in adults with low-risk nontraumatic chest pain. Three studies had poor IPDASi probabilities and development process scores and lacked development informed by theory or involvement of clinicians and patients in development and usability testing. Overall, DSIs were associated with improvements in patients’ knowledge and satisfaction with the explanation of their care, preferences for involvement, and engagement in decision-making and demonstrated utility for eliciting patients’ preferences and values about management and treatment options. Two computerized DSIs (designed to predict risk of ACS in adults presenting to the ED with chest pain) were shown to reduce health care use without evidence of harm. None of the studies reported lack of feasibility of SDM in the ED. Conclusions: Early investigation of SDM in the ED suggests that patients may benefit from involvement in decision-making and offers no empirical evidence to suggest that SDM is not feasible. Future work is needed to develop and test additional SDM interventions in the ED and to identify contextual barriers and facilitators to implementation in practice.