Should video laryngoscopy or direct laryngoscopy be used for adults undergoing endotracheal intubation in the pre-hospital setting? A critical appraisal of a systematic review.

The safety and utility of endotracheal intubation by paramedics in the United Kingdom is a matter of debate. Considering the controversy surrounding the safety of paramedic-performed endotracheal intubation, any interventions that enhance patient safety should be evaluated for implementation based on solid evidence of their effectiveness. A systematic review performed by Hansel and colleagues (2022) sought to assess compare video laryngoscopes against direct laryngoscopes in clinical practice. This commentary aims to critically appraise the methods used within the review by Hansel et al (2022) and expand upon the findings in the context of clinical practice.

Impact of COVID-19 on out-of-hospital cardiac arrest care processes.

Early bystander cardiopulmonary resuscitation, use of defibrillators (including automated external defibrillators) and timely treatment by emergency medical services are known to increase the chances of survival for a patient experiencing an out-of-hospital cardiac arrest (OHCA); however, the impact of the COVID-19 pandemic on this is unclear from examining previous literature. This commentary critically appraises a recent systematic review and meta-analysis which assesses the effect of the COVID-19 pandemic on pre-hospital care for OHCA.

Dynamic contrast-enhanced CT compared with positron emission tomography CT to characterise solitary pulmonary nodules: the SPUtNIk diagnostic accuracy study and economic modelling.

BACKGROUND: Current pathways recommend positron emission tomography-computerised tomography for the characterisation of solitary pulmonary nodules. Dynamic contrast-enhanced computerised tomography may be a more cost-effective approach. OBJECTIVES: To determine the diagnostic performances of dynamic contrast-enhanced computerised tomography and positron emission tomography-computerised tomography in the NHS for solitary pulmonary nodules. Systematic reviews and a health economic evaluation contributed to the decision-analytic modelling to assess the likely costs and health outcomes resulting from incorporation of dynamic contrast-enhanced computerised tomography into management strategies. DESIGN: Multicentre comparative accuracy trial. SETTING: Secondary or tertiary outpatient settings at 16 hospitals in the UK. PARTICIPANTS: Participants with solitary pulmonary nodules of ≥ 8 mm and of ≤ 30 mm in size with no malignancy in the previous 2 years were included. INTERVENTIONS: Baseline positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography with 2 years' follow-up. MAIN OUTCOME MEASURES: Primary outcome measures were sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computerised tomography. Incremental cost-effectiveness ratios compared management strategies that used dynamic contrast-enhanced computerised tomography with management strategies that did not use dynamic contrast-enhanced computerised tomography. RESULTS: A total of 380 patients were recruited (median age 69 years). Of 312 patients with matched dynamic contrast-enhanced computer tomography and positron emission tomography-computerised tomography examinations, 191 (61%) were cancer patients. The sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography were 72.8% (95% confidence interval 66.1% to 78.6%), 81.8% (95% confidence interval 74.0% to 87.7%), 76.3% (95% confidence interval 71.3% to 80.7%) and 95.3% (95% confidence interval 91.3% to 97.5%), 29.8% (95% confidence interval 22.3% to 38.4%) and 69.9% (95% confidence interval 64.6% to 74.7%), respectively. Exploratory modelling showed that maximum standardised uptake values had the best diagnostic accuracy, with an area under the curve of 0.87, which increased to 0.90 if combined with dynamic contrast-enhanced computerised tomography peak enhancement. The economic analysis showed that, over 24 months, dynamic contrast-enhanced computerised tomography was less costly (£3305, 95% confidence interval £2952 to £3746) than positron emission tomography-computerised tomography (£4013, 95% confidence interval £3673 to £4498) or a strategy combining the two tests (£4058, 95% confidence interval £3702 to £4547). Positron emission tomography-computerised tomography led to more patients with malignant nodules being correctly managed, 0.44 on average (95% confidence interval 0.39 to 0.49), compared with 0.40 (95% confidence interval 0.35 to 0.45); using both tests further increased this (0.47, 95% confidence interval 0.42 to 0.51). LIMITATIONS: The high prevalence of malignancy in nodules observed in this trial, compared with that observed in nodules identified within screening programmes, limits the generalisation of the current results to nodules identified by screening. CONCLUSIONS: Findings from this research indicate that positron emission tomography-computerised tomography is more accurate than dynamic contrast-enhanced computerised tomography for the characterisation of solitary pulmonary nodules. A combination of maximum standardised uptake value and peak enhancement had the highest accuracy with a small increase in costs. Findings from this research also indicate that a combined positron emission tomography-dynamic contrast-enhanced computerised tomography approach with a slightly higher willingness to pay to avoid missing small cancers or to avoid a 'watch and wait' policy may be an approach to consider. FUTURE WORK: Integration of the dynamic contrast-enhanced component into the positron emission tomography-computerised tomography examination and the feasibility of dynamic contrast-enhanced computerised tomography at lung screening for the characterisation of solitary pulmonary nodules should be explored, together with a lower radiation dose protocol. STUDY REGISTRATION: This study is registered as PROSPERO CRD42018112215 and CRD42019124299, and the trial is registered as ISRCTN30784948 and ClinicalTrials.gov NCT02013063. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 17. See the NIHR Journals Library website for further project information.

A nodule found on a lung scan can cause concern as it may be a sign of cancer. Finding lung cancer nodules when they are small (i.e. < 3 cm) is very important. Most nodules are not cancerous. Computerised tomography (cross-sectional images created from multiple X-rays) and positron emission tomography­computerised tomography (a technique that uses a radioactive tracer combined with computerised tomography) are used to see whether or not a nodule is cancerous; although they perform well, improvements are required. This study compared dynamic contrast-enhanced computerised tomography with positron emission tomography­computerised tomography scans to find out which test is best. Dynamic contrast-enhanced computerised tomography involves injection of a special dye into the bloodstream, followed by repeated scans of the nodule over several minutes. We assessed the costs to the NHS of undertaking the different scans, relative to their benefits, to judge which option was the best value for money. We recruited 380 patients from 16 hospitals across England and Scotland, of whom 312 had both dynamic contrast-enhanced computerised tomography and positron emission tomography­computerised tomography scans. We found that current positron emission tomography­computerised tomography is more accurate, providing a correct diagnosis in 76% of cases, than the new dynamic contrast-enhanced computerised tomography, which provides a correct diagnosis in 70% of cases. Although dynamic contrast-enhanced computerised tomography cannot replace positron emission tomography­computerised tomography, it may represent good-value use of NHS resources, especially if it is performed before positron emission tomography­computerised tomography and they are used in combination. Although more research is required, it may be possible in the future to perform dynamic contrast-enhanced computerised tomography at the same time as positron emission tomography­computerised tomography in patients with suspected lung cancer or if a lung nodule is found on a lung screening programme at the time of the computerised tomography examination. This may reduce the need for some people to have positron emission tomography­computerised tomography.

Preclinical Safety and Efficacy Assessments for Novel Femtosecond Lasers in Corneal Refractive Surgery.

Preclinical safety requirements and test methods have been standardized over time to guide medical device developers in the path needed to manufacture safe devices and achieve regulatory approval. Today, femtosecond lasers are commonly used in cataract and refractive surgeries. Currently, an industry standard to guide developers in preclinical testing of ophthalmic lasers does not exist. Consequently, the data presented in regulatory submissions may vary between manufacturers, making the regulatory review process more ambiguous. Here, the authors present a comprehensive discussion of preclinical test methods applied to the evaluation of an ophthalmic laser. We include in vitro and ex vivo models, as well as an in vivo rabbit model subject to corneal refractive treatments, for consideration in a preclinical safety evaluation plan. Scientific rationale to support the ocular endpoints of evaluation in the rabbit model to demonstrate safety is also presented and discussed.

Prehospital triage tools in major trauma: a critical appraisal of a systematic review.

Effective triage is critical to ensure patients suffering major trauma are identified and access a pathway to definitive major trauma care, typically provided in a major trauma centre as part of an established major trauma system. The pre-hospital triage of trauma patients often relies upon the use of major trauma triage tools; this commentary critically appraises a recent systematic review which sought to evaluate and compare the accuracy of pre-hospital triage tools for major trauma.

Understanding the key components of effective dementia education and training.

Inadequate and poor care can lead to reduced quality of life for people living with dementia and a higher overall cost to healthcare. Dementia education and training for health and social care staff has been set as a priority by the Department of Health. It is vital to identify what specific factors are important when undertaking dementia care training. This commentary article critically appraises and evaluates a systematic review based on identifying key factors in delivering effective dementia care training.

The effectiveness of quality improvement collaboratives in improving stroke care and the facilitators and barriers to their implementation: a systematic review.

BACKGROUND: To successfully reduce the negative impacts of stroke, high-quality health and care practices are needed across the entire stroke care pathway. These practices are not always shared across organisations. Quality improvement collaboratives (QICs) offer a unique opportunity for key stakeholders from different organisations to share, learn and 'take home' best practice examples, to support local improvement efforts. This systematic review assessed the effectiveness of QICs in improving stroke care and explored the facilitators and barriers to implementing this approach. METHODS: Five electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO, and Cochrane Library) were searched up to June 2020, and reference lists of included studies and relevant reviews were screened. Studies conducted in an adult stroke care setting, which involved multi-professional stroke teams participating in a QIC, were included. Data was extracted by one reviewer and checked by a second. For overall effectiveness, a vote-counting method was used. Data regarding facilitators and barriers was extracted and mapped to the Consolidated Framework for Implementation Research (CFIR). RESULTS: Twenty papers describing twelve QICs used in stroke care were included. QICs varied in their setting, part of the stroke care pathway, and their improvement focus. QIC participation was associated with improvements in clinical processes, but improvements in patient and other outcomes were limited. Key facilitators were inter- and intra-organisational networking, feedback mechanisms, leadership engagement, and access to best practice examples. Key barriers were structural changes during the QIC's active period, lack of organisational support or prioritisation of QIC activities, and insufficient time and resources to participate in QIC activities. Patient and carer involvement, and health inequalities, were rarely considered. CONCLUSIONS: QICs are associated with improving clinical processes in stroke care; however, their short-term nature means uncertainty remains as to whether they benefit patient outcomes. Evidence around using a QIC to achieve system-level change in stroke is equivocal. QIC implementation can be influenced by individual and organisational level factors, and future efforts to improve stroke care using a QIC should be informed by the facilitators and barriers identified. Future research is needed to explore the sustainability of improvements when QIC support is withdrawn. TRIAL REGISTRATION: Protocol registered on PROSPERO ( CRD42020193966 ).

Factors influencing implementation of aerobic exercise after stroke: a systematic review.

OBJECTIVES: This systematic review aimed to explore the perspectives of healthcare, exercise, and fitness professionals working with people post-stroke regarding the factors affecting the implementation of aerobic exercise after stroke. DATA SOURCES: OVID SP MEDLINE, OVID SP EMBASE, and CINAHL were searched from inception to December 2018 using a combination of search terms with synonyms of stroke, aerobic exercise and barriers/facilitators. REVIEW METHODS: Studies focusing on the factors affecting implementation of aerobic exercise after stroke from staff perspectives were included with no restriction on the types of study design. For inclusivity, a broad definition of aerobic exercise was used. Review authors independently extracted data from included studies using domains from the Consolidated Framework for Implementation Research, then synthesised using a framework synthesis approach. Retrospective automated screening was conducted using Rayyan software. RESULTS: Twenty studies were included. Four reported on implementation of aerobic exercise, sixteen on general exercise interventions, all post-stroke. Factors identified as influencing implementation of aerobic exercise after stroke included professionals' self-efficacy and knowledge about stroke, patients' needs, communication and collaboration within and between organisations and resources such as equipment, staff and training. CONCLUSIONS: Key factors influencing the implementation of aerobic exercise after stroke included characteristics of the staff and intervention and system-level issues, some of which are modifiable. Further research should evaluate strategies which specifically target these modifiable factors to facilitate implementation in practice.IMPLICATIONS FOR REHABILITATIONAerobic exercise after stroke is an effective intervention but there are challenges to implementation from a staff and system perspective.Any changes to the identified factors should be tailored to suit the staff group and setting.Provision of training and knowledge-sharing could improve staff's confidence in the prescription and delivery of aerobic exercise after stroke though other implementation strategies should also be considered.

The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review.

BACKGROUND: Efforts to improve the quality, safety, and efficiency of health care provision have often focused on changing approaches to the way services are organized and delivered. Continuous quality improvement (CQI), an approach used extensively in industrial and manufacturing sectors, has been used in the health sector. Despite the attention given to CQI, uncertainties remain as to its effectiveness given the complex and diverse nature of health systems. This review assesses the effectiveness of CQI across different health care settings, investigating the importance of different components of the approach. METHODS: We searched 11 electronic databases: MEDLINE, CINAHL, EMBASE, AMED, Academic Search Complete, HMIC, Web of Science, PsycINFO, Cochrane Central Register of Controlled Trials, LISTA, and NHS EED to February 2019. Also, we searched reference lists of included studies and systematic reviews, as well as checking published protocols for linked papers. We selected randomized controlled trials (RCTs) within health care settings involving teams of health professionals, evaluating the effectiveness of CQI. Comparators included current usual practice or different strategies to manage organizational change. Outcomes were health care professional performance or patient outcomes. Studies were published in English. RESULTS: Twenty-eight RCTs assessed the effectiveness of different approaches to CQI with a non-CQI comparator in various settings, with interventions differing in terms of the approaches used, their duration, meetings held, people involved, and training provided. All RCTs were considered at risk of bias, undermining their results. Findings suggested that the benefits of CQI compared to a non-CQI comparator on clinical process, patient, and other outcomes were limited, with less than half of RCTs showing any effect. Where benefits were evident, it was usually on clinical process measures, with the model used (i.e., Plan-Do-Study-Act, Model of Improvement), the meeting type (i.e., involving leaders discussing implementation) and their frequency (i.e., weekly) having an effect. None considered socio-economic health inequalities. CONCLUSIONS: Current evidence suggests the benefits of CQI in improving health care are uncertain, reflecting both the poor quality of evaluations and the complexities of health services themselves. Further mixed-methods evaluations are needed to understand how the health service can use this proven approach. TRIAL REGISTRATION: Protocol registered on PROSPERO (CRD42018088309).

Leak-Free Clear Corneal Incisions in Human Cadaver Tissue: Femtosecond Laser-Created Multiplanar Incisions.

OBJECTIVES: To evaluate femtosecond (FS) laser-assisted leak-free clear corneal incisions (CCI) and paracentesis (P) in human eyes of deceased donors. METHODS: Multiplanar CCI and P were created using an FS laser on human eyes of deceased donors (whole globe and corneal rims). Laser settings were programmed to multiplanar for CCI and single plane for P. Corneas were imaged by optical coherence tomography (OCT) and evaluated for leak by Seidel testing at various intraocular pressure (IOP) levels, and the wound was manipulated to mimic cataract surgery. Corneal endothelium cell damage and histological architecture were evaluated by microscopy. RESULTS: The corneal incision software of the FS laser was used to create homogeneous CCI and P incisions. Morphological changes assessed by OCT and light microscopy/scanning electron microscopy showed consistent true multiplanar incisions with predefined intersecting planes. All Seidel testing was negative, indicating that FS laser-assisted incisions did not leak. Trypan blue stain of the endothelial surface showed limited cell damage from the FS laser incisions. CONCLUSIONS: The FS laser-created incisions corresponded well with the treatment plans, as evidenced by true multiplanar architecture. Incisions were sharply demarcated and demonstrated limited cell damage. No postprocedure leaking at extreme IOP or postcataract surgery-simulated conditions was noted. The FS laser may potentially reduce postoperative complications, such as infections that may be associated with CCI.

Optimizing rice yields while minimizing yield-scaled global warming potential.

To meet growing global food demand with limited land and reduced environmental impact, agricultural greenhouse gas (GHG) emissions are increasingly evaluated with respect to crop productivity, i.e., on a yield-scaled as opposed to area basis. Here, we compiled available field data on CH4 and N2 O emissions from rice production systems to test the hypothesis that in response to fertilizer nitrogen (N) addition, yield-scaled global warming potential (GWP) will be minimized at N rates that maximize yields. Within each study, yield N surplus was calculated to estimate deficit or excess N application rates with respect to the optimal N rate (defined as the N rate at which maximum yield was achieved). Relationships between yield N surplus and GHG emissions were assessed using linear and nonlinear mixed-effects models. Results indicate that yields increased in response to increasing N surplus when moving from deficit to optimal N rates. At N rates contributing to a yield N surplus, N2 O and yield-scaled N2 O emissions increased exponentially. In contrast, CH4 emissions were not impacted by N inputs. Accordingly, yield-scaled CH4 emissions decreased with N addition. Overall, yield-scaled GWP was minimized at optimal N rates, decreasing by 21% compared to treatments without N addition. These results are unique compared to aerobic cropping systems in which N2 O emissions are the primary contributor to GWP, meaning yield-scaled GWP may not necessarily decrease for aerobic crops when yields are optimized by N fertilizer addition. Balancing gains in agricultural productivity with climate change concerns, this work supports the concept that high rice yields can be achieved with minimal yield-scaled GWP through optimal N application rates. Moreover, additional improvements in N use efficiency may further reduce yield-scaled GWP, thereby strengthening the economic and environmental sustainability of rice systems.

Optimal fertilizer nitrogen rates and yield-scaled global warming potential in drill seeded rice.

Drill seeded rice ( L.) is the dominant rice cultivation practice in the United States. Although drill seeded systems can lead to significant CH and NO emissions due to anaerobic and aerobic soil conditions, the relationship between high-yielding management practices, particularly fertilizer N management, and total global warming potential (GWP) remains unclear. We conducted three field experiments in California and Arkansas to test the hypothesis that by optimizing grain yield through N management, the lowest yield-scaled global warming potential (GWP = GWP Mg grain) is achieved. Each growing season, urea was applied at rates ranging from 0 to 224 kg N ha before the permanent flood. Emissions of CH and NO were measured daily to weekly during growing seasons and fallow periods. Annual CH emissions ranged from 9.3 to 193 kg CH-C ha yr across sites, and annual NO emissions averaged 1.3 kg NO-N ha yr. Relative to NO emissions, CH dominated growing season (82%) and annual (68%) GWP. The impacts of fertilizer N rates on GHG fluxes were confined to the growing season, with increasing N rate having little effect on CH emissions but contributing to greater NO emissions during nonflooded periods. The fallow period contributed between 7 and 39% of annual GWP across sites years. This finding illustrates the need to include fallow period measurements in annual emissions estimates. Growing season GWP ranged from 130 to 686 kg CO eq Mg season across sites and years. Fertilizer N rate had no significant effect on GWP; therefore, achieving the highest productivity is not at the cost of higher GWP.

Seasonal losses of dissolved organic carbon and total dissolved solids from rice production systems in northern California.

Water quality concerns have arisen related to rice (Oryza sativa L.) field drain water, which has the potential to contribute large amounts of dissolved organic carbon (DOC) and total dissolved solids (TDS) to the Sacramento River. Field-scale losses of DOC or TDS have yet to be quantified. The objectives of this study were to evaluate the seasonal concentrations of DOC and TDS in rice field drain water and irrigation canals, quantify seasonal fluxes and flow-weighted (FW) concentrations of DOC and TDS, and determine the main drivers of DOC and TDS fluxes. Two rice fields with different straw management practices (incorporation vs. burning) were monitored at each of four locations in the Sacramento Valley. Fluxes of DOC ranged from 3.7 to 34.6 kg ha(-1) during the growing season (GS) and from 0 to 202 kg ha(-1) during the winter season (WS). Straw management had a significant interaction effect with season, as the greatest DOC concentrations were observed during winter flooding of straw incorporated fields. Fluxes and concentrations of TDS were not significantly affected by either straw management or season. Total seasonal water flux accounted for 90 and 88% of the variability in DOC flux during the GS and WS, respectively. Peak DOC concentrations occurred at the onset of drainflow; therefore, changes in irrigation management may reduce peak DOC concentrations and thereby DOC losses. However, the timing of peak DOC concentrations from rice fields suggest that rice field drainage water is not the cause of peak DOC concentrations in the Sacramento River.

Classification of the degree of obesity by body mass index or by deviation from ideal weight.

BACKGROUND: The purpose of this study was to compare classifications of subjects as underweight, normal weight, or obese by body mass index (BMI) and the ratio of body weight to ideal weight (W/IW). METHODS: We performed a theoretical comparison of the 2 indices. We compared classifications of the degree of obesity in 1839 women and 5914 men who were followed up in the primary care clinics of a United States federal hospital. Information was extracted from computerized records. Subjects were classified as underweight (BMI < 18.5 kg/m2, W/IW < 0.9), obese (BMI > or = 30.0 kg/m2, W/IW > or = 1.2), or normal weight (BMI, W/IW values between the cutoff values for underweight and obesity). W/IW values were computed assuming small, medium, and large skeletal frame for all. We compared the classifications of subjects as underweight, normal weight, or obese by BMI and W/IW. We used Cohen's kappa ratio to evaluate the agreement between these classifications. RESULTS: Theoretically, the cutoff values of BMI and W/IW for underweight and obesity are not in agreement. Patient data revealed substantial differences in the classifications of subjects as underweight, normal weight, or obese. Kappa ratios ranged between 0.18 (poor agreement) and 0.71 (reasonable, but not high degree of agreement). In general, kappa ratios were higher when assuming large or medium skeletal frame versus small frame. CONCLUSIONS: There are substantial discrepancies in classifying the subjects of a population as underweight, normal weight, or obese by BMI or W/IW. These discrepancies may cause confusion when 2 or more indices are used simultaneously to classify the degree of obesity.