Use of Corticosteroids in Cardiac Arrest-A Systematic Review and Meta-Analysis.

OBJECTIVES: The objective of this systematic review was to evaluate the impact of intraarrest corticosteroids on neurologic outcomes and mortality in patients with cardiac arrest. DATA SOURCES: We conducted a systematic search using the Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE databases. STUDY SELECTION: We included all randomized controlled trials and comparative observational studies. We excluded single arm studies, case reports/series, narrative reviews, and studies irrelevant to the focus of this article. DATA EXTRACTION: Two reviewers independently assessed trial eligibility. Data were collected for the following outcomes: primary outcomes included good neurologic outcome, survival to hospital discharge, and survival at greater than or equal to 1 year. Secondary outcomes included incidence of return of spontaneous circulation, ICU and hospital length of stay, duration of vasopressor and inotropic treatment, and blood pressure during cardiopulmonary resuscitation and after return of spontaneous circulation. DATA SYNTHESIS: The pooled estimates from randomized controlled trials for the following subgroups were analyzed using random-effects models: 1) patients with in-hospital cardiac arrest who received vasopressin, steroids, and epinephrine; 2) patients with in-hospital cardiac arrest who used corticosteroids only (i.e., no vasopressin); and 3) patients with out-of-hospital cardiac arrest who used corticosteroids only. Results included an increase in good neurologic outcomes (relative risk, 2.84; 95% CI, 1.36-5.94) and survival to hospital discharge (relative risk, 2.58; 95% CI, 1.36-4.91) in in-hospital cardiac arrest patients receiving vasopressin, steroids, and epinephrine followed by corticosteroids for postresuscitation shock. This was further supported by an increase in return of spontaneous circulation (relative risk, 1.35; 95% CI, 1.12-1.64) and hemodynamics in this population. There was no benefit observed in in-hospital cardiac arrest or out-of-hospital cardiac arrest patients receiving corticosteroids alone. CONCLUSIONS: Our study found that there are limited high-quality data to analyze the association between corticosteroids and reducing mortality in cardiac arrest, but the available data do support future randomized controlled trials. We did find that corticosteroids given as part of a vasopressin, steroids, and epinephrine regimen in in-hospital cardiac arrest patients and for postresuscitation shock did improve neurologic outcomes, survival to hospital discharge, and surrogate outcomes that include return of spontaneous circulation and hemodynamics. We found no benefit in in-hospital cardiac arrest or out-of-hospital cardiac arrest patients receiving corticosteroids only; however, a difference cannot be ruled out due to imprecision and lack of available data.

Outcome reporting bias in Cochrane systematic reviews: a cross-sectional analysis.

BACKGROUND: Discrepancies in outcome reporting (DOR) between protocol and published studies include inclusions of new outcomes, omission of prespecified outcomes, upgrade and downgrade of secondary and primary outcomes, and changes in definitions of prespecified outcomes. DOR can result in outcome reporting bias (ORB) when changes in outcomes occur after knowledge of results. This has potential to overestimate treatment effects and underestimate harms. This can also occur at the level of systematic reviews when changes in outcomes occur after knowledge of results of included studies. The prevalence of DOR and ORB in systematic reviews is unknown in systematic reviews published post-2007. OBJECTIVE: To estimate the prevalence of DOR and risk of ORB in all Cochrane reviews between the years 2007 and 2014. METHODS: A stratified random sampling approach was applied to collect a representative sample of Cochrane systematic reviews from each Cochrane review group. DOR was assessed by matching outcomes in each systematic review with their respective protocol. When DOR occurred, reviews were further assessed if there was a risk of ORB (unclear, low or high risk). We classified DOR as a high risk for ORB if the discrepancy occurred after knowledge of results in the systematic review. RESULTS: 150 of 350 (43%) review and protocol pairings contained DOR. When reviews were further scrutinised, 23% (35 of 150) of reviews with DOR contained a high risk of ORB, with changes being made after knowledge of results from individual trials. CONCLUSIONS: In our study, we identified just under a half of Cochrane reviews with at least one DOR. Of these, a fifth were at high risk of ORB. The presence of DOR and ORB in Cochrane reviews is of great concern; however, a solution is relatively simple. Authors are encouraged to be transparent where outcomes change and to describe the legitimacy of changing outcomes in order to prevent suspicion of bias.

Reassessment of venous thromboembolism and bleeding risk in medical patients receiving VTE prophylaxis.

RATIONALE, AIMS, AND OBJECTIVES: The majority of hospitalized nonsurgical medical patients receive pharmacological prophylaxis for venous thromboembolism (VTE), and reassessment of changes in thrombosis and bleeding risk factors during hospital admission may represent an opportunity to discontinue unnecessary or unsafe therapy. The use of validated, clinically derived risk assessment models (RAMs) represents a shift towards an individualized, patient-centred approach to VTE prophylaxis. We are interested in using these tools to assess whether risk categories for VTE and bleeding change during admission and to assess whether such changes result in discontinuation of prophylaxis. Our primary objective was to determine whether VTE and bleed risk categories changed during the course of admission to warrant discontinuation of VTE prophylaxis, using the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE and Bleed RAMs, respectively. Secondary objectives were to determine the number of patients whose risk categorizations for VTE and bleeding warranted discontinuation of VTE prophylaxis and to survey whether prophylaxis was continued or discontinued. METHODS: A retrospective review was undertaken for a cross-sectional, randomly selected sample of patients who received VTE prophylaxis while admitted to medical wards in a collection of regional hospitals. RESULTS: Of the 351 medical records reviewed, only eight patients (2.3%) changed their VTE risk category and six (1.7%) changed their bleed risk category to warrant discontinuation of VTE prophylaxis. Ninety patients (26%) were at high risk of VTE and low risk of bleed throughout admission, warranting continued VTE prophylaxis. The majority of patients remained at low risk of VTE throughout admission but remained on VTE prophylaxis until discharge. CONCLUSIONS: Risk categories for VTE and bleeding for medical patients did not appreciably change throughout hospital admission. Use of VTE RAMs at admission and prior to initiation of therapy should reduce unnecessary prophylaxis in the majority of medical patients who are at low risk of VTE.

A psychometric analysis of a newly developed summative, multiple choice question assessment adapted from Canada to a Middle Eastern context.

INTRODUCTION: Accreditation necessitates that assessment methods reflect the standards established by the accrediting body. The process of adapting assessments to a new context can present unique challenges with uncertainty around psychometric defensibility of the adapted exam. METHODS: A psychometric analysis of a summative multiple-choice-question (MCQ) assessment, adapted from Canada, for graduating pharmacy students from a Canadian accredited program in Qatar was conducted. Rates of difficult items, item discrimination measured by point biserial correlation (rpb), and non-functioning distractors (NFDs) were calculated to identify deficiencies and challenges with an adapted exam. Challenges encountered throughout the adaption process and recommendations were documented. RESULTS: Overall score of a 90-item, four option, MCQ exam ranged from 46.7% to 78.9% (mean of 61.9%). For difficulty, there were 17 items with less than 30% of students answering correctly, while 29 items had unacceptable or poor discrimination (rpb < 0.1). NFDs occurred in 78 items with 49 containing at least two NFDs. DISCUSSION AND CONCLUSIONS: Difficulty of the exam was deemed acceptable yet discriminator ability requires improvement. The high frequency of questions with NFDs suggests that faculty have difficulty developing plausible distractors for an adapted MCQ exam. This could be due to a lack of training or requirement for inclusion of too many distractor options. While it is feasible to implement an assessment adapted from a different learning environment, measures need to be taken to improve psychometric defensibility. The high number of questions with NFDs indicates that the current method of exam development does not encourage the incorporation of functional distractors.

Prevention and Treatment of Hyponatremia in Patients with Subarachnoid Hemorrhage: A Systematic Review.

BACKGROUND: Current guidelines for the management of hyponatremia in patients with subarachnoid hemorrhage (SAH) are not based on a systematic assessment of the literature. We evaluated published studies on the efficacy and safety of current preventative and treatment strategies for hyponatremia in patients with SAH. METHODS: We searched the Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PubMed for relevant studies. Primary outcomes of interest included neurologic functional outcomes, symptomatic vasospasm, and others. Secondary outcomes included measures of sodium and volume status. RESULTS: We included 5 out of 117 identified studies: 1 before-and-after observational trial (using fludrocortisone) and 4 randomized controlled trials (2 using fludrocortisone; 2 using hydrocortisone). All 5 trials had a high risk of bias in at least 1 domain. We could not perform a meta-analysis of functional outcomes; however, individual studies did not demonstrate statistically significant differences. Mineralocorticoid use did not statistically significantly reduce the incidence of symptomatic vasospasm (relative risk, 0.60; 95% confidence interval, 0.35-1.03; I2 = 0%). The studies did not report other primary outcomes. In the 4 RCTs, mineralocorticoid use reduced natriuresis and volume contraction. CONCLUSIONS: Current evidence does not demonstrate a benefit of preventative treatment with mineralocorticoids in clinically important outcomes, although a difference cannot be ruled out due to imprecision. Larger well-designed trials are needed to establish the impact of mineralocorticoids and fluid and sodium supplementation strategies on clinically relevant outcomes in the prevention and treatment of hyponatremia in patients with SAH.

Learner : preceptor ratios for practice-based learning across health disciplines: a systematic review.

CONTEXT: Practice-based learning is a cornerstone of developing clinical and professional competence in health disciplines. Practice-based learning systems have many interacting components, but a key facet is the number of learners per preceptor. Different learner : preceptor ratios may have unique benefits and pose unique challenges for participants. This is the first comprehensive systematic review of the topic. Our research questions were: What are the benefits and challenges of each learner : preceptor ratio in practice-based learning from the perspectives of the learners, preceptors, patients and stakeholder organisations (i.e. the placing and health care delivery organisations)? Are any ratios superior to others with respect to these characteristics and perspectives? METHODS: Qualitative systematic review of published English-language literature since literature database inception, including multiple health disciplines. RESULTS: Seventy-three articles were included in this review. Eight learner : preceptor ratio arrangements were identified involving nursing, physiotherapy, occupational therapy, pharmacy, dietetics, speech and language therapy, and medicine. Each arrangement offers unique benefits and challenges from the perspectives of learners, preceptors, programmes and health care delivery organisations. Patient perspectives were absent. Despite important advantages of each ratio for learners, preceptors and organisations, some of which may be profession specific, the 2 : 1 and 2+ : 2+ learner : preceptor ratios appear to be most likely to successfully balance the needs of all stakeholders. CONCLUSIONS: Regardless of the learner : preceptor ratio chosen for its expected benefits, our results illuminate challenges that can be anticipated and managed. Patient perspectives should be incorporated into future studies of learner : preceptor ratios.

Decentralized automated dispensing devices: systematic review of clinical and economic impacts in hospitals.

BACKGROUND: Technologies have been developed over the past 20 years to automate the stages of drug distribution in hospitals, including ordering, dispensing, delivery, and administration of medications, in attempts to decrease medication error rates. Decentralized automated dispensing devices (ADDs) represent one such technology that is being adopted by hospitals across Canada, but the touted benefits, in terms of improved patient safety and cost savings, are increasingly being questioned. OBJECTIVE: To summarize and evaluate the existing literature reporting the clinical and economic impacts of using decentralized ADDs in hospitals. DATA SOURCES: A literature search was conducted in MEDLINE, Embase, and all evidence-based medicine databases for the years 1992 to 2012 to identify English-language articles reporting on the use of ADDs in hospital wards. STUDY SELECTION AND DATA EXTRACTION: All randomized controlled trials, observational studies, before-and-after studies, time series analyses, cost-effectiveness and cost-benefit analyses, and review articles were considered for inclusion. Studies evaluating pharmacy-based ADDs, such as bar code-based medication dispensing carousels, automated dispensing shelves, and combinations of various dispensing modalities, were excluded. DATA SYNTHESIS: Of 175 studies initially identified, 8 were retained for evidence synthesis. It appears that ADDs were effective in reducing medication storage errors and the time that nurses spent taking inventory of narcotics and controlled substances. There was no definitive evidence that using ADDs increased the time that nurses or pharmacists spent with patients, reduced medication errors resulting in patient harm, or reduced costs in Canadian hospitals. However, pharmacy technicians spent more time stocking the machines. CONCLUSION: ADDs have limited potential to decrease medication errors and increase efficiencies, but their impact is highly institution-specific, and use of this technology requires proper integration into an institution's medication distribution process. Before deploying this technology, it is recommended that Canadian hospitals carefully examine their current systems and the benefits they hope to gain with the changes.

CONTEXTE: Au cours des vingt dernières années, des technologies ont été développées afin d'automatiser les étapes de la distribution des médicaments dans les hôpitaux, notamment pour ce qui est de l'émission d'ordonnances et de la dispensation, de la délivrance et de l'administration des médicaments, le tout dans le but de réduire le nombre d'erreurs de médication. Les cabinets automatisés décentralisés (CAD) font partie de ces technologies qui sont adoptées par les hôpitaux du Canada, mais leurs bienfaits très publicisés, en ce qui a trait à l'amélioration de la sécurité des patients et aux économies pouvant être réalisées, sont de plus en plus remis en question. OBJECTIF: Résumer et évaluer la littérature faisant état des retombées cliniques et économiques de l'utilisation de CAD dans les hôpitaux. SOURCES DES DONNÉES: Une recherche documentaire a été effectuée dans MEDLINE, Embase ainsi que dans l'ensemble des bases de données médicales fondées sur des preuves pour la période allant de 1992 à 2012 afin de trouver les articles rédigés en anglais qui font état de l'utilisation des CAD dans les services d'hôpitaux. SÉLECTION DES ÉTUDES ET EXTRACTION DES DONNÉES: Cette revue a pris en considération toutes les études cliniques aléatoires, les études observationnelles, les études avant-après, les analyses de séries chronologiques, les analyses coût-avantage et coût-efficacité, et les articles de synthèse. Les études évaluant les CAD en usage dans les pharmacies, robots parmi lesquels on compte les carrousels de distribution de médicaments utilisant des codes-barres, les rayonnages de distribution automatisés et les combinaisons de différents moyens de distribution, n'ont pas été retenues. SYNTHÈSE DES DONNÉES: Des 175 études d'abord recensées, huit ont été retenues pour la synthèse des données probantes. Les CAD semblent avoir été utiles pour réduire le nombre d'erreurs d'entreposage de médicaments ainsi que le temps nécessaire au personnel infirmier pour faire l'inventaire des narcotiques et des substances contrôlées. Aucune donnée probante ne permet d'affirmer que le temps passé par le personnel infirmier et les pharmaciens auprès des patients a augmenté, que le nombre d'erreurs de médication causant du tort aux patients a baissé ou que les coûts des hôpitaux canadiens ont chuté grâce à l'utilisation des CAD. Par contre, les techniciens en pharmacie ont passé plus de temps à remplir les machines. CONCLUSION: Les CAD présentent un faible potentiel de réduction du nombre d'erreurs de médication et d'augmentation de l'efficacité des ressources. Cependant, leur incidence est propre à chaque établissement et l'utilisation de cette technologie nécessite une intégration réfléchie dans le processus de distribution des médicaments d'un établissement. Avant de mettre en place cette technologie, il est recommandé aux hôpitaux canadiens de bien étudier leurs systèmes actuels et de réfléchir aux avantages qu'ils espèrent obtenir par ce changement. [Traduction par l'éditeur].