A systematic review of the outcomes reported in cardiac arrest clinical trials: the need for a core outcome set.

BACKGROUND: There is a limited guidance for outcome reporting for cardiac arrest trials. This review was conducted to explore the degree of variation and identify trends in outcome reporting. METHODS: Randomised controlled trials enrolling patients with cardiac arrest (2002-2012) were identified by applying a search strategy to four databases. Titles, abstracts and short-listed studies were independently assessed for eligibility. Data on the primary and secondary outcome measures, details of outcome reporting and reproducibility were extracted. RESULTS: 61 studies matched the inclusion criteria. There was wide variation in the focus, method and timing of assessment. Outcomes most commonly reported across studies were: survival (85.2%), activities (52.5%), body structure or function (41.0%), and processes of care (26.2%). Over 160 individual outcomes were reported including 39 different reports of survival measures of which 11 were measurements of ROSC (return of spontaneous circulation). Twenty different assessments of activity limitation were reported; only one was patient-reported. Many assessments were poorly defined or non-reproducible. The majority of outcomes were assessed up to hospital discharge (89.3%). There was no one outcome measure that was assessed across all trials. CONCLUSIONS: Outcome reporting in cardiac arrest RCTs lacks consistency and transparency. Guidance for improved outcome reporting is urgently required to reduce this heterogeneity in reporting, improve the quality of assessment in clinical trials, and to support the synthesis of trial data. The results highlight the importance of working towards a core outcome set for cardiac arrest clinical trials to maximise the utility of future research.

Ambulance handovers: can a dedicated ED nurse solve the delay in ambulance turnaround times?

With ever increasing concern over ambulance handover delays this paper looks at the impact of dedicated A&E nurses for ambulance handovers and the effect it can have on ambulance waiting times. It demonstrates that although such roles can bring about reduced waiting times, it also suggests that using this as a sole method to achieve these targets would require unacceptably low staff utilisation.

Patients who leave emergency departments without being seen: literature review and English data analysis.

OBJECTIVES: The purpose of this review was to determine the rate of those that leave the emergency department (ED) without being seen and their reasons, to clarify if such behaviour poses a health risk, to analyse the impact initiatives have made on the leave without being seen (LWBS) rate, and to discuss the implications of using it as a national performance indicator within the NHS. METHODS: A combination of data sources was reviewed: a 'realistic' literature review, analysis of hospital episode statistics data from England and a local NHS trust audit. MAJOR FINDINGS: LWBS rates vary across the world, from 15% to 0.36%. Also initiatives to reduce LWBS rates demonstrated mixed outcomes, with reductions in the rate by as much as 96%, while others were ineffective. The most common reason quoted for LWBS was long waiting times and there were few data to suggest LWBS posed a risk to patient health. CONCLUSIONS: LWBS is an issue experienced in many countries that has responded in a varying manner to many initiatives in attempts to reduce it; however, it is clearly associated with the waiting times experienced in ED and therefore working within a packet of performance measures it would assess the effect of waiting times from another perspective.

Insulin pump therapy in children and adolescents: improvements in key parameters of diabetes management including quality of life.

AIMS: To determine the impact of insulin pump therapy (continuous subcutaneous insulin infusion) on key parameters of diabetes management including quality of life in children and adolescents with Type 1 diabetes mellitus (T1DM). METHODS: All patients started on insulin pump therapy were prospectively followed before and after institution of insulin pump therapy. Data collected included age, duration of diabetes, glycated haemoglobin levels (HbA1c), anthropometric data and episodes of severe hypoglycaemia defined as hypoglycaemia resulting in coma or convulsion. A subset of patients also completed the Diabetes Quality of Life Instrument (DQOL) and Self-Efficacy for Diabetes Scale (SED) questionnaires to assess quality of life. RESULTS: At the time of analysis, 100 patients had been managed with insulin pump therapy. The mean age when starting pump therapy was 12.5 (3.9-19.6) years. Duration of therapy ranged from 0.2 to 4.0 years (mean 1.4 years, median 1.5 years). HbA1c decreased from 8.3 +/- 0.1% prior to pump therapy to 7.8 +/- 0.1% (P < 0.0001). Episodes of severe hypoglycaemia decreased from 32.9 to 11.4 per 100 patient years. Components of quality of life measures showed improvement on pump treatment. BMI standard deviation scores (z scores) did not increase. CONCLUSIONS: Pump therapy is proving an effective means of insulin therapy in the young patient that shows promise to improve glycaemic control with a reduction in hypoglycaemia frequency. Quality of Life measures suggest that psychosocial outcomes may be improved.

Relationship between renal volume and increased albumin excretion rates in children and adolescents with type 1 diabetes mellitus.

OBJECTIVE: To compare renal volume in a group of prepubertal and pubertal children with type 1 diabetes mellitus (DM) and either borderline microalbuminuria (BM) or intermittent microalbuminuria (IM) with a matched group of normoalbuminuric (NA) controls with DM. RESEARCH DESIGN AND METHODS: Twenty-one patients with BM or IM were matched for age, gender and duration of DM with an NA control group. Total renal volume (RV), measured by ultrasound, was corrected for body surface area. Long-term diabetes control was assessed by glycosylated haemoglobin levels. RESULTS: There were no significant differences in age, duration of DM or glycosylated haemoglobin levels between the groups. Those with BM or IM had significantly increased total renal volume (303 +/- 8.4 ml/1.73 m2) compared to those with NA (276.3 +/- 10 ml/1.73 m2) (T40=2.04, P=0.05). Multivariate modelling suggested that this association was independent of potential confounding covariates. While not formally significant (chi2(1)=2.53, P=0.12), the frequency of nephromegaly (RV >300 ml/1.73 m2) was doubled in children with BM or IM (47.6%) compared to controls (23.8%). Nephromegaly was not found in prepubertal patients. CONCLUSIONS: This study suggests that nephromegaly is more common in patients with borderline increases in urinary albumin excretion rates (AER) than those with normoalbuminuria. Prospective follow-up of those with increased renal volume is needed to determine whether nephromegaly is an early marker of incipient nephropathy.