Indigenous maternal and infant outcomes and women's experiences of midwifery care: A mixed-methods systematic review.

BACKGROUND: The impact of midwifery, and especially Indigenous midwifery, care for Indigenous women and communities has not been comprehensively reviewed. To address this knowledge gap, we conducted a mixed-methods systematic review to understand Indigenous maternal and infant outcomes and women's' experiences with midwifery care. METHODS: We searched nine databases to identify primary studies reporting on midwifery and Indigenous maternal and infant birth outcomes and experiences, published in English since 2000. We synthesized quantitative and qualitative outcome data using a convergent segregated mixed-methods approach and used a mixed-methods appraisal tool (MMAT) to assess the methodological quality of included studies. The Aboriginal and Torres Strait Islander Quality Appraisal Tool (ATSI QAT) was used to appraise the inclusion of Indigenous perspectives in the evidence. RESULTS: Out of 3044 records, we included 35 individual studies with 55% (19 studies) reporting on maternal and infant health outcomes. Comparative studies (n = 13) showed no significant differences in mortality rates but identified reduced preterm births, earlier prenatal care, and an increased number of prenatal visits for Indigenous women receiving midwifery care. Quality of care studies indicated a preference for midwifery care among Indigenous women. Sixteen qualitative studies highlighted three key findings - culturally safe care, holistic care, and improved access to care. The majority of studies were of high methodological quality (91% met ≥80% criteria), while only 14% of studies were considered to have appropriately included Indigenous perspectives. CONCLUSION: This review demonstrates the value of midwifery care for Indigenous women, providing evidence to support policy recommendations promoting midwifery care as a physically and culturally safe model for Indigenous women and families.

Patient preferences for breast cancer screening: a systematic review update to inform recommendations by the Canadian Task Force on Preventive Health Care.

BACKGROUND: Different guideline panels, and individuals, may make different decisions based in part on their preferences. Preferences for or against an intervention are viewed as a consequence of the relative importance people place on the expected or experienced health outcomes it incurs. These findings can then be considered as patient input when balancing effect estimates on benefits and harms reported by empirical evidence on the clinical effectiveness of screening programs. This systematic review update examined the relative importance placed by patients on the potential benefits and harms of mammography-based breast cancer screening to inform an update to the 2018 Canadian Task Force on Preventive Health Care's guideline on screening. METHODS: We screened all articles from our previous review (search December 2017) and updated our searches to June 19, 2023 in MEDLINE, PsycINFO, and CINAHL. We also screened grey literature, submissions by stakeholders, and reference lists. The target population was cisgender women and other adults assigned female at birth (including transgender men and nonbinary persons) aged ≥ 35 years and at average or moderately increased risk for breast cancer. Studies of patients with breast cancer were eligible for health-state utility data for relevant outcomes. We sought three types of data, directly through (i) disutilities of screening and curative treatment health states (measuring the impact of the outcome on one's health-related quality of life; utilities measured on a scale of 0 [death] to 1 [perfect health]), and (ii) other preference-based data, such as outcome trade-offs, and indirectly through (iii) the relative importance of benefits versus harms inferred from attitudes, intentions, and behaviors towards screening among patients provided with estimates of the magnitudes of benefit(s) and harms(s). For screening, we used machine learning as one of the reviewers after at least 50% of studies had been reviewed in duplicate by humans; full-text selection used independent review by two humans. Data extraction and risk of bias assessments used a single reviewer with verification. Our main analysis for utilities used data from utility-based health-related quality of life tools (e.g., EQ-5D) in patients; a disutility value of about 0.04 can be considered a minimally important value for the Canadian public. When suitable, we pooled utilities and explored heterogeneity. Disutilities were calculated for screening health states and between different treatment states. Non-utility data were grouped into categories, based on outcomes compared (e.g. for trade-off data), participant age, and our judgements of the net benefit of screening portrayed by the studies. Thereafter, we compared and contrasted findings while considering sample sizes, risk of bias, subgroup findings and data on knowledge scores, and created summary statements for each data set. Certainty assessments followed GRADE guidance for patient preferences and used consensus among at least two reviewers. FINDINGS: Eighty-two studies (38 on utilities) were included. The estimated disutilities were 0.07 for a positive screening result (moderate certainty), 0.03-0.04 for a false positive (FP; "additional testing" resolved as negative for cancer) (low certainty), and 0.08 for untreated screen-detected cancer (moderate certainty) or (low certainty) an interval cancer. At ≤12 months, disutilities of mastectomy (vs. breast-conserving therapy), chemotherapy (vs. none) (low certainty), and radiation therapy (vs. none) (moderate certainty) were 0.02-0.03, 0.02-0.04, and little-to-none, respectively, though in each case findings were somewhat limited in their applicability. Over the longer term, there was moderate certainty for little-to-no disutility from mastectomy versus breast-conserving surgery/lumpectomy with radiation and from radiation. There was moderate certainty that a majority (>50%) and possibly a large majority (>75%) of women probably accept up to six cases of overdiagnosis to prevent one breast-cancer death; there was some uncertainty because of an indication that overdiagnosis was not fully understood by participants in some cases. Low certainty evidence suggested that a large majority may accept that screening may reduce breast-cancer but not all-cause mortality, at least when presented with relatively high rates of breast-cancer mortality reductions (n = 2; 2 and 5 fewer per 1000 screened), and at least a majority accept that to prevent one breast-cancer death at least a few hundred patients will receive a FP result and 10-15 will have a FP resolved through biopsy. An upper limit for an acceptable number of FPs was not evaluated. When using data from studies assessing attitudes, intentions, and screening behaviors, across all age groups but most evident for women in their 40s, preferences reduced as the net benefit presented by study authors decreased in magnitude. In a relatively low net-benefit scenario, a majority of patients in their 40s may not weigh the benefits as greater than the harms from screening whereas for women in their 50s a large majority may prefer screening (low certainty evidence for both ages). There was moderate certainty that a large majority of women 50 years of age and 50 to 69 years of age, who have usually experienced screening, weigh the benefits as greater than the harms from screening in a high net-benefit scenario. A large majority of patients aged 70-71 years who have recently screened probably think the benefits outweigh the harms of continuing to screen. A majority of women in their mid-70s to early 80s may prefer to continue screening. CONCLUSIONS: Evidence across a range of data sources on how informed patients value the potential outcomes from breast-cancer screening will be useful during decision-making for recommendations. The evidence suggests that all of the outcomes examined have importance to women of any age, that there is at least some and possibly substantial (among those in their 40s) variability across and within age groups about the acceptable magnitude of effects across outcomes, and that provision of easily understandable information on the likelihood of the outcomes may be necessary to enable informed decision making. Although studies came from a wide range of countries, there were limited data from Canada and about whether findings applied well across an ethnographically and socioeconomically diverse population. SYSTEMATIC REVIEW REGISTRATION: Protocol available at Open Science Framework https://osf.io/xngsu/ .

Consequences of the Coronavirus disease 2019 pandemic on child and adolescent mental, psychosocial, and physical health: A scoping review and interactive evidence map.

Effects of the Coronavirus disease 2019 (COVID-19) pandemic on children stem beyond immediate infectious and post-infectious risks. Our aim was to conduct a scoping review and produce an online Interactive Evidence Map (IEM) highlighting available literature around unintended effects of the pandemic on children's and adolescents' mental, psychosocial, and physical health. A search was run monthly in MEDLINE, PsycINFO, CENTRAL, and Cochrane COVID-19 Study Register from May 1st 2021 through April 30th 2022. All articles involving children and adolescents under 18 years of age relating to any unintended mental, psychosocial, and physical health consequences of the pandemic and resultant restrictions were included. Data were extracted and topics categorized, with corresponding data uploaded into EPPI-Reviewer and transferred to EPPI-Mapper for visualization. A total of 14,555 citations were screened and 826 (6%) articles included. Most articles reported on mental health outcomes, particularly anxiety (n = 309, 37%) and depression (n = 294, 36%). Psychosocial outcomes related to lockdowns such as loneliness (n = 120, 15%) and impact on adolescent relationships with others (n = 149, 18%) were also reported. Fewer articles examined physical consequences, but those that did mostly focused on child abuse (n = 73, 9%). Overall, currently mapped literature focuses on consequences related to mental health outcomes such as anxiety and depression.

Incidence and outcomes of critical illness in indigenous peoples: a systematic review and meta-analysis.

BACKGROUND: Indigenous Peoples experience health inequities and racism across the continuum of health services. We performed a systematic review and meta-analysis of the incidence and outcomes of critical illness among Indigenous Peoples. METHODS: We searched Ovid MEDLINE/PubMed, Ovid EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials (inception to October 2022). Observational studies, case series of > 100 patients, clinical trial arms, and grey literature reports of Indigenous adults were eligible. We assessed risk of bias using the Newcastle-Ottawa Scale and appraised research quality from an Indigenous perspective using the Aboriginal and Torres Strait Islander Quality Assessment Tool. ICU mortality, ICU length of stay, and invasive mechanical ventilation (IMV) were compared using risk ratios and mean difference (MD) for dichotomous and continuous outcomes, respectively. ICU admission was synthesized descriptively. RESULTS: Fifteen studies (Australia and/or New Zealand [n = 12] and Canada [n = 3]) were included. Risk of bias was low in 10 studies and moderate in 5, and included studies had minimal incorporation of Indigenous perspectives or consultation. There was no difference in ICU mortality between Indigenous and non-Indigenous (RR 1.14, 95%CI 0.98 to 1.34, I2 = 87%). We observed a shorter ICU length of stay among Indigenous (MD - 0.25; 95%CI, - 0.49 to - 0.00; I2 = 95%) and a higher use for IMV among non-Indigenous (RR 1.10; 95%CI, 1.06 to 1.15; I2 = 81%). CONCLUSION: Research on Indigenous Peoples experience with critical care is poorly characterized and has rarely included Indigenous perspectives. ICU mortality between Indigenous and non-Indigenous populations was similar, while there was a shorter ICU length of stay and less mechanical ventilation use among Indigenous patients. Systematic Review Registration PROSPERO CRD42021254661; Registered: 12 June, 2021.

Incidence, risk factors, natural history, and hypothesised mechanisms of myocarditis and pericarditis following covid-19 vaccination: living evidence syntheses and review.

OBJECTIVES: To synthesise evidence on incidence rates and risk factors for myocarditis and pericarditis after use of mRNA vaccination against covid-19, clinical presentation, short term and longer term outcomes of cases, and proposed mechanisms. DESIGN: Living evidence syntheses and review. DATA SOURCES: Medline, Embase, and the Cochrane Library were searched from 6 October 2020 to 10 January 2022; reference lists and grey literature (to 13 January 2021). One reviewer completed screening and another verified 50% of exclusions, using a machine learning program to prioritise records. A second reviewer verified all exclusions at full text, extracted data, and (for incidence and risk factors) risk of bias assessments using modified Joanna Briggs Institute tools. Team consensus determined certainty of evidence ratings for incidence and risk factors using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Large (>10 000 participants) or population based or multisite observational studies and surveillance data (incidence and risk factors) reporting on confirmed myocarditis or pericarditis after covid-19 mRNA vaccination; case series (n≥5, presentation, short term clinical course and longer term outcomes); opinions, letters, reviews, and primary studies focused on describing or supporting hypothesised mechanisms. RESULTS: 46 studies were included (14 on incidence, seven on risk factors, 11 on characteristics and short term course, three on longer term outcomes, and 21 on mechanisms). Incidence of myocarditis after mRNA vaccines was highest in male adolescents and male young adults (age 12-17 years, range 50-139 cases per million (low certainty); 18-29 years, 28-147 per million (moderate certainty)). For girls and boys aged 5-11 years and women aged 18-29 years, incidence of myocarditis after vaccination with BNT162b2 (Pfizer/BioNTech) could be fewer than 20 cases per million (low certainty). Incidence after a third dose of an mRNA vaccine had very low certainty evidence. For individuals of 18-29 years, incidence of myocarditis is probably higher after vaccination with mRNA-1273 (Moderna) compared with Pfizer (moderate certainty). Among individuals aged 12-17, 18-29, or 18-39 years, incidence of myocarditis or pericarditis after dose two of an mRNA vaccine for covid-19 might be lower when administered ≥31 days compared with ≤30 days after dose one (low certainty). Data specific to men aged 18-29 years indicated that the dosing interval might need to increase to ≥56 days to substantially drop myocarditis or pericarditis incidence. For clinical course and short term outcomes, only one small case series (n=8) was found for 5-11 year olds. In adolescents and adults, most (>90%) myocarditis cases involved men of a median 20-30 years of age and with symptom onset two to four days after a second dose (71-100%). Most people were admitted to hospital (≥84%) for a short duration (two to four days). For pericarditis, data were limited but more variation than myocarditis has been reported in patient age, sex, onset timing, and rate of admission to hospital. Three case series with longer term (3 months; n=38) follow-up suggested persistent echocardiogram abnormalities, as well as ongoing symptoms or a need for drug treatments or restriction from activities in >50% of patients. Sixteen hypothesised mechanisms were described, with little direct supporting or refuting evidence. CONCLUSIONS: These findings indicate that adolescent and young adult men are at the highest risk of myocarditis after mRNA vaccination. Use of a Pfizer vaccine over a Moderna vaccine and waiting for more than 30 days between doses might be preferred for this population. Incidence of myocarditis in children aged 5-11 years is very rare but certainty was low. Data for clinical risk factors were very limited. A clinical course of mRNA related myocarditis appeared to be benign, although longer term follow-up data were limited. Prospective studies with appropriate testing (eg, biopsy and tissue morphology) will enhance understanding of mechanism.

LOCATE: a prospective evaluation of the value of Leveraging Ongoing Citation Acquisition Techniques for living Evidence syntheses.

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. https://doi.org/10.17605/OSF.IO/6M28H .

Treatment strategies for cerebrospinal shunt infections: a systematic review of observational studies.

OBJECTIVE: A systematic review was conducted of studies comparing time to cerebrospinal fluid (CSF) sterilisation or rate of recurrence with different treatment strategies for CSF shunt infections. METHODS: A librarian-directed search was conducted of Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid Medline Daily and Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL Plus with Full Text via EBSCOhost, Scopus Advanced Search, and Web of Science Core Collection from 1990 to May 2019. Studies of any design that compared outcomes in groups of any age with different management strategies were included. Studies that compared complete versus incomplete shunt removal were excluded. Quality assessment was performed with the Newcastle-Ottawa Scale. RESULTS: The search identified 2208 records, of which 8 met the inclusion criteria. All were cohort studies of moderate quality. Four studies compared the duration of antibiotics; none demonstrates that a longer course prevented recurrences. Two studies analysed addition of rifampin, with one showing a decrease in recurrences while the other had a small sample size. No studies analysed the addition of intraventricular antibiotics, but one showed equally good results with once versus twice daily administration. One study reported no difference in recurrences with placement of antibiotic-impregnated catheters. Recurrence rates did not differ with shunt replacement minimum of 7 days vs less than 7 days after CSF became sterile. There were no recurrences in either group when shunt replacement was performed after sterile CSF cultures were obtained at 24 vs 48 hours after antibiotics were discontinued. A new shunt entry site did not decrease recurrences. DISCUSSION: The main limitations are the lack of high-quality studies, the small sample sizes and the heterogeneity which precluded meta-analysis. Addition of rifampin for staphylococcal infections may decrease relapse but requires further study.

Vitamin D supplementation to improve pregnancy and perinatal outcomes: an overview of 42 systematic reviews.

OBJECTIVE: To review the evidence to assess effectiveness of vitamin D supplementation during pregnancy and associations of serum vitamin D levels with perinatal outcomes. DESIGN: Overview of systematic reviews (SRs). DATA SOURCES: Searches conducted in January 2019: Ovid Medline (1946-), Cochrane Library databases. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Two reviewers independently screened titles and abstracts, and full texts using predefined inclusion criteria: SRs evaluating vitamin D supplementation in pregnant women and/or examining the association between serum vitamin D levels reporting at least one predefined perinatal outcome. Only SRs with high AMSTAR scores were analysed. DATA EXTRACTION AND SYNTHESIS: Data were extracted independently by one reviewer and checked by a second. Results were assessed for quality independently by two reviewers using GRADE criteria. RESULTS: Thirteen SRs were included, synthesising evidence from 204 unique primary studies. SRs of randomised controlled trials (RCTs) with the highest level of evidence showed no significant benefit from vitamin D in terms of preterm birth (RR 1.00 (95% CI 0.77, 1.30); high quality), pre-eclampsia (RR 0.91 (0.45, 1.86); low quality), gestational diabetes (RR 0.65 (0.39, 1.08); very low quality), stillbirth (RR 0.75 (0.50, 1.12); high quality), low birth weight (RR 0.74 (0.47, 1.16); low quality), caesarean section (RR 1.02 (0.93, 1.12); high quality). A significant difference was found for small for gestational age (RR 0.72 (0.52, 0.99); low quality). SRs of observational studies showed associations between vitamin D levels and preterm birth (RR 1.19 (1.08, 1.31); moderate quality), pre-eclampsia (RR 1.57 (1.21, 2.03) for 25-hydroxy vitamin D (25 (OH)D)<50 nmol/L subgroup; low quality), gestational diabetes (RR 1.12 (1.02, 1.22) for 25 (OH)D<50 nmol/L and RR 1.09 (1.03, 1.15)<75 nmol/L; moderate quality) and small for gestational age (RR 1.35 (1.18, 1.54)<50 nmol/L; low quality). SRs showed mixed results for associations between vitamin D and low birth weight (very low quality) and caesarean section (very low quality). CONCLUSION: There is some evidence from SRs of observational studies for associations between vitamin D serum levels and some outcomes; however SRs examining effectiveness from RCTs showed no effect of vitamin D supplementation in pregnancy with the exception of one predefined outcome, which had low quality evidence. Credibility of the evidence in this field is compromised by study limitations (in particular, the possibility of confounding among observational studies), inconsistency, imprecision and potential for reporting and publication biases.

Barriers and facilitators for implementation of electronic consultations (eConsult) to enhance access to specialist care: a scoping review.

INTRODUCTION: Electronic consultation (eConsult)-provider-to-provider electronic asynchronous exchanges of patient health information at a distance-is emerging as a potential tool to improve the interface between primary care providers and specialists. Despite growing evidence that eConsult has clinical benefits, it is not widely adopted. We investigated factors influencing the adoption and implementation of eConsult services. METHODS: We applied established methods to guide the review, and the recently published Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews to report our findings. We searched five electronic databases and the grey literature for relevant studies. Two reviewers independently screened titles and full texts to identify studies that reported barriers to and/or facilitators of eConsult (asynchronous (store-and-forward) use of telemedicine to exchange patient health information between two providers (primary and secondary) at a distance using secure infrastructure). We extracted data on study characteristics and key barriers and facilitators were analysed thematically and classified using the Quadruple Aim framework taxonomy. No date or language restrictions were applied. RESULTS: Among the 2579 publications retrieved, 130 studies met eligibility for the review. We identified and summarised key barriers to and facilitators of eConsult adoption and implementation across four domains: provider, patient, healthcare system and cost. Key barriers were increased workload for providers, privacy concerns and insufficient reimbursement for providers. Main facilitators were remote residence location, timely responses from specialists, utilisation of referral coordinators, addressing medicolegal concerns and incentives for providers to use eConsult. CONCLUSION: There are multiple barriers to and facilitators of eConsult adoption across the domains of Quadruple Aim framework. Our findings will inform the development of practice tools to support the wider adoption and scalability of eConsult implementation.

Evidence available for patient-identified priorities in depression research: results of 11 rapid responses.

OBJECTIVES: Patient 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. DESIGN: Eleven rapid responses. DATA SOURCES: Single electronic database (PubMed). ELIGIBILITY CRITERIA: Each 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. RESULTS: For 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. CONCLUSIONS: We 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.

Barriers and facilitators for implementation of electronic consultations (eConsult) to enhance specialist access to care: a scoping review protocol.

INTRODUCTION: Electronic consultations (eConsult), asynchronous exchanges of patient health information at a distance, are increasingly used as an option to facilitate patient care and collaboration between primary care providers and specialists. Although eConsult has demonstrated success in increasing efficiency in the referral process and enhancing access to care, little is known about the factors influencing its wider adoption and implementation by end users. In this paper, we describe a protocol to conduct a scoping review of the literature on the barriers and facilitators to a wider adoption and implementation of eConsult service. METHODS AND ANALYSIS: This scoping review will be based on the framework pioneered by Arksey and O'Malley and later developed by Levac et al. We will use the guidance for scoping reviews developed by the Joanna Briggs Institute to report our findings. In addition to several electronic databases (Medline, Embase, Cochrane Library, CINAHL, EBSCOhost and PsycINFO) studies will be identified by including relevant grey literature. Two reviewers will independently screen titles and full texts for inclusion. Studies reporting on barriers and/or facilitators in settings similar to eConsult will be included. Data on study characteristics and key barriers and facilitators will be extracted. Data will be analysed thematically and classified using the Quadruple Aim framework. ETHICS AND DISSEMINATION: Approval by research ethics board is not required since the review will only include published and publicly accessible data. Review findings will be used to inform future studies and the development of practice tools to support the wider adoption and success of eConsult implementation. We plan to publish our findings in a peer-reviewed journal and develop a useful and accessible summary of the results.

Pediatric Emergency Research Canada (PERC): Patient/Family-informed Research Priorities for Pediatric Emergency Medicine.

BACKGROUND: A growing body of literature supports patient and public involvement in the design, prioritization, and dissemination of research and evidence-based medicine. The objectives of this project were to engage patients and families in developing a prioritized list of research topics for pediatric emergency medicine (PEM) and to compare results with prior research prioritization initiatives in the emergency department (ED) setting. METHODS: We utilized a systematic process to combine administrative data on frequency of patient presentations to the ED with multiple stakeholder input including an initial stakeholder survey followed by a modified Delphi consensus methodology consisting of two Web-based surveys and a face-to-face meeting. RESULTS: The prioritization process resulted in a ranked list of 15 research priorities. The top five priorities were mental health presentations, pain and sedation, practice tools, quality of care delivery, and resource utilization. Mental health, pain and sedation, clinical prediction rules, respiratory illnesses/wheeze, patient safety/medication error, and sepsis were identified as shared priorities with prior initiatives. Topics identified in our process that were not identified in prior work included resource utilization, ED communication, antibiotic stewardship, and patient/family adherence with recommendations. CONCLUSIONS: This work identifies key priorities for research in PEM. Comparing our results with prior initiatives in the ED setting identified shared research priorities and opportunities for collaboration among PEM research networks. This work in particular makes an important contribution to the existing literature by including the patient/family perspective missing from prior work.

Pediatric Emergency Research Canada: Origins and Evolution.

OBJECTIVE: The objective of the study was to describe the origins, growth, and progress of a national research network in pediatric emergency medicine. METHODS: The success of Pediatric Emergency Research Canada (PERC) is described in terms of advancing the pediatric emergency medicine agenda, grant funding, peer-reviewed publications, mentoring new investigators, and global collaborations. RESULTS: Since 1995, clinicians and investigators within PERC have grown the network to 15 active tertiary pediatric emergency medicine sites across Canada. Investigators have advanced the research agenda in numerous areas, including gastroenteritis, bronchiolitis, croup, head injury, asthma, and injury management. Since the first PERC Annual Scientific meeting in 2004, the attendance has increased by approximately 400% to 152 attendees, 65 presentations, and 13 project/investigator meetings. More than $33 million in grant funding has been awarded to the network, and has published 76 peer-reviewed articles. In 2011, PERC's success was recognized with a Top Achievement Award in Health Research from Canadian Institutes of Health Research and the Canadian Medical Association Journal. CONCLUSIONS: Moving forward, PERC will continue to focus on the creation of new knowledge, the mentorship of new investigators and fellows in developing research projects, and promoting a pediatric emergency medicine-focused research agenda guided by the pooling of expertise from individuals across the nation. Through collaborations with networks across the globe, PERC will continue to strive for the conduct of high-quality, impactful research that improves outcomes in children with acute illness and injury.

A meta-epidemiological study to examine the association between bias and treatment effects in neonatal trials.

BACKGROUND: Randomized controlled trials are considered the gold standard for evidence on therapeutic interventions; however, they are susceptible to bias. The objectives of this observational study were to describe the methodological quality of neonatal randomized controlled trials and quantify the bias related to specific methodological and study-level characteristics. METHODS: Twenty-five systematic reviews yielding 208 neonatal trials were included. Two independent reviewers assessed risk of bias (RoB) on seven domains consisting of nine items. For each domain, meta-analyses with at least one high/unclear and one low risk study were included in the analysis. For the primary outcome within each meta-analysis a ratio of odds ratios with a 95% confidence interval was generated. The ratio of odds ratios for each meta-analysis were combined using meta-analytic techniques with inverse-variance weighting and a random effects model to obtain a summary ratio of odds ratio. RESULTS: None of the studies had an overall low RoB. Most studies had a low RoB for the domain of incomplete outcome data (89%), while 63%, 55% and 46% of trials had low RoB for sequence generation, other sources of bias, and blinding of outcome assessors, respectively. For all other domains (allocation concealment, blinding of parents and investigators and selective outcome reporting), the majority of trials were assessed as unclear. Selective outcome reporting was rated as unclear RoB for 55% and high for 42% of studies. The only domain that showed a statistically significant association with the treatment effect was selective outcome reporting: trials at unclear/high risk of bias for this domain significantly overestimated the treatment effects compared with those assessed at low risk of bias (ROR = 1.87, 95% confidence interval: 1.26-2.78). CONCLUSIONS: This observational study of a sample of neonatal trials showed that most were at high risk of bias, indicating that there is room for improvement in the design, conduct and reporting of neonatal trials to ensure valid results for the most clinically important outcomes. We did not find an association between most risk of bias domains and effect estimates; however, we found that randomized controlled trials at high risk for selective outcome reporting were associated with overestimates of treatment benefits. These results need to be confirmed in larger samples.

Glucocorticoids for acute viral bronchiolitis in infants and young children.

BACKGROUND: Previous systematic reviews have not shown clear benefit of glucocorticoids for acute viral bronchiolitis, but their use remains considerable. Recent large trials add substantially to current evidence and suggest novel glucocorticoid-including treatment approaches. OBJECTIVES: To review the efficacy and safety of systemic and inhaled glucocorticoids in children with acute viral bronchiolitis. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 12), MEDLINE (1950 to January week 2, 2013), EMBASE (1980 to January 2013), LILACS (1982 to January 2013), Scopus® (1823 to January 2013) and IRAN MedEx (1998 to November 2009). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing short-term systemic or inhaled glucocorticoids versus placebo or another intervention in children under 24 months with acute bronchiolitis (first episode with wheezing). Our primary outcomes were: admissions by days 1 and 7 for outpatient studies; and length of stay (LOS) for inpatient studies. Secondary outcomes included clinical severity parameters, healthcare use, pulmonary function, symptoms, quality of life and harms. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data on study and participant characteristics, interventions and outcomes. We assessed risk of bias and graded strength of evidence. We meta-analysed inpatient and outpatient results separately using random-effects models. We pre-specified subgroup analyses, including the combined use of bronchodilators used in a protocol. MAIN RESULTS: We included 17 trials (2596 participants); three had low overall risk of bias. Baseline severity, glucocorticoid schemes, comparators and outcomes were heterogeneous. Glucocorticoids did not significantly reduce outpatient admissions by days 1 and 7 when compared to placebo (pooled risk ratios (RRs) 0.92; 95% confidence interval (CI) 0.78 to 1.08 and 0.86; 95% CI 0.7 to 1.06, respectively). There was no benefit in LOS for inpatients (mean difference -0.18 days; 95% CI -0.39 to 0.04). Unadjusted results from a large factorial low risk of bias RCT found combined high-dose systemic dexamethasone and inhaled epinephrine reduced admissions by day 7 (baseline risk of admission 26%; RR 0.65; 95% CI 0.44 to 0.95; number needed to treat 11; 95% CI 7 to 76), with no differences in short-term adverse effects. No other comparisons showed relevant differences in primary outcomes. AUTHORS' CONCLUSIONS: Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalisation. Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited. Future research should further assess the efficacy, harms and applicability of combined therapy.

Pediatric Emergency Medicine Fellows Education Day: Addressing CanMEDS objectives at a national subspecialty conference.

Canadian subspecialty residency training programs are developed around the learning objectives listed in the seven Canadian Medical Education Directives for Specialists (CanMEDS) criteria. Delivering content on objectives outside of those traditionally acquired in clinical rotations can be a challenge. In the present article, the planning process, curriculum development, and evaluation and assessment of a national subspecialty conference model in providing CanMEDS objective-based content sessions in the categories other than Medical Expert (Professional, Scholar, Communicator, Collaborator, Manager and Health Advocate) is described. It is hypothesized that the development of a CanMEDS objective-based curriculum would be positively received by subspecialty residents attending this conference. Attendees of sessions in a two-year curriculum cycle assessed the content as valuable, relevant and effective. The application of this process can be useful to other subspecialty residency training programs to meet the needs of their CanMEDS objective-based training requirements.

Les programmes canadiens de formation de résidence en surspécialité sont élaborés conformément aux objectifs d'apprentissage énumérés dans les sept rôles CanMEDS. Il peut être difficile de présenter du contenu au sujet de rôles qui ne font pas partie de ceux habituellement acquis lors des rotations cliniques. Dans le présent article, les chercheurs décrivent le processus de planification, l'élaboration du programme et l'évaluation d'un modèle de congrès national de surspécialité au moyen de séances fondées sur les autres rôles CanMEDS que celui d'expert médical (professionnel, érudit, communicateur, collaborateur, gestionnaire et professionnel de la santé). Ils postulaient que les résidents en surspécialité qui participaient au congrès accueilleraient favorablement un programme reposant sur les rôles CanMEDS. D'après l'évaluation des participants aux séances faisant partie d'un programme de deux ans, le contenu était perçu comme digne d'intérêt, pertinent et efficace. La mise en application de ce processus peut être utile à d'autres programmes de formation en surspécialité qui désirent respecter leurs besoins de formation reposant sur les rôles CanMEDS.

Epinephrine for bronchiolitis.

BACKGROUND: Bronchodilators are commonly used for acute bronchiolitis, despite uncertain effectiveness. OBJECTIVES: To examine the efficacy and safety of epinephrine in children less than two with acute viral bronchiolitis. SEARCH STRATEGY: We searched CENTRAL (2010, Issue 3) which contains the Acute Respiratory Infections Group's Specialized Register, MEDLINE (1950 to September Week 2, 2010), EMBASE (1980 to September 2010), Scopus (1823 to September 2010), PubMed (March 2010), LILACS (1985 to September 2010) and Iran MedEx (1998 to September 2010). SELECTION CRITERIA: We included randomized controlled trials comparing epinephrine to placebo or another intervention involving children less than two years with acute viral bronchiolitis. Studies were included if the trials presented data for at least one quantitative outcome of interest.We selected primary outcomes a priori, based on clinical relevance: rate of admission by days one and seven of presentation for outpatients, and length of stay (LOS) for inpatients. Secondary outcomes included clinical severity scores, pulmonary function, symptoms, quality of life and adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the searches, applied inclusion criteria, assessed risk of bias and graded the evidence. We conducted separate analyses for different comparison groups (placebo, non-epinephrine bronchodilators, glucocorticoids) and for clinical setting (inpatient, outpatient). MAIN RESULTS: We included 19 studies (2256 participants). Epinephrine versus placebo among outpatients showed a significant reduction in admissions at Day 1 (risk ratio (RR) 0.67; 95% confidence interval (CI) 0.50 to 0.89) but not at Day 7 post-emergency department visit. There was no difference in LOS for inpatients. Epinephrine versus salbutamol showed no differences among outpatients for admissions at Day 1 or 7. Inpatients receiving epinephrine had a significantly shorter LOS compared to salbutamol (mean difference -0.28; 95% CI -0.46 to -0.09). One large RCT showed a significantly shorter admission rate at Day 7 for epinephrine and steroid combined versus placebo (RR 0.65; 95% CI 0.44 to 0.95). There were no important differences in adverse events. AUTHORS' CONCLUSIONS: This review demonstrates the superiority of epinephrine compared to placebo for short-term outcomes for outpatients, particularly in the first 24 hours of care. Exploratory evidence from a single study suggests benefits of epinephrine and steroid combined for later time points. More research is required to confirm the benefits of combined epinephrine and steroids among outpatients. There is no evidence of effectiveness for repeated dose or prolonged use of epinephrine or epinephrine and dexamethasone combined among inpatients.

Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis.

OBJECTIVE: To evaluate and compare the efficacy and safety of bronchodilators and steroids, alone or combined, for the acute management of bronchiolitis in children aged less than 2 years. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, Embase, Central, Scopus, PubMed, LILACS, IranMedEx, conference proceedings, and trial registers. Inclusion criteria Randomised controlled trials of children aged 24 months or less with a first episode of bronchiolitis with wheezing comparing any bronchodilator or steroid, alone or combined, with placebo or another intervention (other bronchodilator, other steroid, standard care). REVIEW METHODS: Two reviewers assessed studies for inclusion and risk of bias and extracted data. Primary outcomes were selected by clinicians a priori based on clinical relevance: rate of admission for outpatients (day 1 and up to day 7) and length of stay for inpatients. Direct meta-analyses were carried out using random effects models. A mixed treatment comparison using a Bayesian network model was used to compare all interventions simultaneously. RESULTS: 48 trials (4897 patients, 13 comparisons) were included. Risk of bias was low in 17% (n = 8), unclear in 52% (n = 25), and high in 31% (n = 15). Only adrenaline (epinephrine) reduced admissions on day 1 (compared with placebo: pooled risk ratio 0.67, 95% confidence interval 0.50 to 0.89; number needed to treat 15, 95% confidence interval 10 to 45 for a baseline risk of 20%; 920 patients). Unadjusted results from a single large trial with low risk of bias showed that combined dexamethasone and adrenaline reduced admissions on day 7 (risk ratio 0.65, 0.44 to 0.95; number needed to treat 11, 7 to 76 for a baseline risk of 26%; 400 patients). A mixed treatment comparison supported adrenaline alone or combined with steroids as the preferred treatments for outpatients (probability of being the best treatment based on admissions at day 1 were 45% and 39%, respectively). The incidence of reported harms did not differ. None of the interventions examined showed clear efficacy for length of stay among inpatients. CONCLUSIONS: Evidence shows the effectiveness and superiority of adrenaline for outcomes of most clinical relevance among outpatients with acute bronchiolitis, and evidence from a single precise trial for combined adrenaline and dexamethasone.

Glucocorticoids for acute viral bronchiolitis in infants and young children.

BACKGROUND: Previous systematic reviews have not shown clear benefit of glucocorticoids for acute viral bronchiolitis, but their use remains considerable. Recent large trials add substantially to current evidence and suggest novel glucocorticoid-including treatment approaches. OBJECTIVES: To review the efficacy and safety of systemic and inhaled glucocorticoids in children with acute viral bronchiolitis. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, issue 4); MEDLINE (1950 to November 2009); EMBASE (1980 to Week 47 2009); LILACS (1982 to November 2009); Scopus® (1823 to November 2009); and IRAN MedEx (1998 to November 2009). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing short-term systemic or inhaled glucocorticoids versus placebo or another intervention in children < 24 months with acute bronchiolitis (first episode with wheezing). Our primary outcomes were: admissions by days 1 and 7 for outpatient studies; and length of stay (LOS) for inpatient studies. Secondary outcomes included clinical severity parameters, healthcare use, pulmonary function, symptoms, quality of life and harms. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data on study and participant characteristics, interventions and outcomes. We assessed risk of bias and graded strength of evidence. Inpatient and outpatient results were meta-analysed separately using random-effects models. We pre-specified subgroup analyses, including the combined use of protocolised bronchodilators. MAIN RESULTS: We included 17 trials (2596 participants); only two had low overall risk of bias. Baseline severity, glucocorticoid schemes, comparators and outcomes were heterogeneous. Glucocorticoids did not significantly reduce outpatient admissions by days 1 and 7 when compared to placebo (pooled risk ratios (RRs) 0.92; 95% CI 0.78 to 1.08; and 0.86; 95% CI 0.7 to 1.06, respectively). There was no benefit in LOS for inpatients (mean difference -0.18 days; 95% CI -0.39 to 0.04). Unadjusted results from a large factorial low risk of bias RCT found combined high-dose systemic dexamethasone and inhaled epinephrine reduced admissions by day 7 (baseline risk of admission 26%; RR 0.65, 95% CI 0.44 to 0.95; number needed to treat 11, 95% CI 7 to 76), with no differences in short-term adverse effects. No other comparisons showed relevant differences in primary outcomes. AUTHORS' CONCLUSIONS: Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalization. Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited. Future research should further assess the efficacy, harms and applicability of combined therapy.