Non-steroidal Anti-inflammatory Drugs and the Risk of Pneumonia Complications: A Systematic Review.

There have been concerns regarding the safety of nonsteroidal antiinflammatory drugs (NSAIDs) in patients with respiratory infections. However, to date, the quality of the evidence has not been systematically assessed. The purpose of this systematic review was to evaluate the role of NSAIDs on pneumonia complications. OVID MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Google Scholar were searched. Studies that examined pneumonia complications in patients who had taken NSAIDs before onset of symptoms were identified. Quality assessment was conducted using the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) assessment tool, which was adapted to include biases that were pertinent to this question. The search strategy identified 1721 potential studies through the 5 primary databases and searching reference lists. Of these, 10 studies met the inclusion criteria, including 5 nested case-control studies, 2 population-based case-control studies, and 3 cohort studies. In total, 59,724 adults were included from 4 of the studies (range = 57-59,250) and 1217 children from 5 studies (range = 148-540). All studies demonstrated a positive association; in adults (odds ratio/risk ratio range = 1.8-8.1) and children (odds ratio/risk ratio range = 1.9-6.8). Studies were limited by moderate or serious risk of confounding bias, exposure misclassification, and protopathic biases and sparse data bias. The results of this review demonstrate that published studies on the effect of NSAIDs use and risk of pneumonia complications are subject to a number of biases. These results should not be extrapolated as evidence of harm for NSAIDs, including ibuprofen, in respiratory ailments but highlight the need for more methodologically robust studies to evaluate this potential relationship.

Using Exploratory Focus Groups to Inform the Development of a Peer-Supported Pulmonary Rehabilitation Program: DIRECTIONS FOR FURTHER RESEARCH.

PURPOSE: There has been limited research on the role of peer support in self-management for patients with chronic obstructive pulmonary disease (COPD) attending pulmonary rehabilitation (PR) programs. This research explored patient acceptability of "peer supporters" in promoting sustained self-management practices after PR and to assess their perceived self-efficacy to manage their disease. METHODS: This qualitative study used focus groups and individual interviews to identify perspectives of peer supporters and benefits of participation in a PR program. The analysis included systematically reading and reviewing transcripts of the sessions, establishing themes, and sorting responses into thematic categories. RESULTS: A total of 28 patients with COPD (15 males) participated in either a focus group or interview. The majority of participants considered peer supporters to be good facilitators for motivating ongoing exercise after completing PR. Exercise sessions were viewed as extremely beneficial for disease management, and many were satisfied with the care they had received. Most subjects wanted to receive followup sessions with either a professional or peer after the intensive phase of PR. Overall, the concept of having a peer supporter involved in ongoing maintenance of self-management efforts after PR was generally viewed as positive. CONCLUSIONS: Integrating a peer support model into PR programs may improve better long-term health outcomes for COPD management as many participants endorsed the need for continued support after the program. It also improved our understanding of the role of "peer supports" in exercise and self-care maintenance after PR. The selection of peers and the specific model used warrants further investigation in a randomized controlled trial.

Assessing the effect of culturally specific audiovisual educational interventions on attaining self-management skills for chronic obstructive pulmonary disease in Mandarin- and Cantonese-speaking patients: a randomized controlled trial.

BACKGROUND: Patient education is a key component in the management of chronic obstructive pulmonary disease (COPD). Delivering effective education to ethnic groups with COPD is a challenge. The objective of this study was to develop and assess the effectiveness of culturally and linguistically specific audiovisual educational materials in supporting self-management practices in Mandarin- and Cantonese-speaking patients. METHODS: Educational materials were developed using participatory approach (patients involved in the development and pilot test of educational materials), followed by a randomized controlled trial that assigned 91 patients to three intervention groups with audiovisual educational interventions and one control group (pamphlet). The patients were recruited from outpatient clinics. The primary outcomes were improved inhaler technique and perceived self-efficacy to manage COPD. The secondary outcome was improved patient understanding of pulmonary rehabilitation procedures. RESULTS: Subjects in all three intervention groups, compared with control subjects, demonstrated postintervention improvements in inhaler technique (P<0.001), preparedness to manage a COPD exacerbation (P<0.01), ability to achieve goals in managing COPD (P<0.01), and understanding pulmonary rehabilitation procedures (P<0.05). CONCLUSION: Culturally appropriate educational interventions designed specifically to meet the needs of Mandarin and Cantonese COPD patients are associated with significantly better understanding of self-management practices. Self-management education led to improved proper use of medications, ability to manage COPD exacerbations, and ability to achieve goals in managing COPD. CLINICAL IMPLICATION: A relatively simple culturally appropriate disease management education intervention improved inhaler techniques and self-management practices. Further research is needed to assess the effectiveness of self-management education on behavioral change and patient empowerment strategies.

Beta-blocker use and COPD mortality: a systematic review and meta-analysis.

BACKGROUND: Despite the benefits of beta-blockers in patients with established or sub-clinical coronary artery disease, their use in patients with chronic obstructive pulmonary disease (COPD) has been controversial. Currently, no systematic review has examined the impact of beta-blockers on mortality in COPD. METHODS: We systematically searched electronic bibliographic databases including MEDLINE, EMBASE and Cochrane Library for clinical studies that examine the association between beta-blocker use and all cause mortality in patients with COPD. Risk ratios across studies were pooled using random effects models to estimate a pooled relative risk across studies. Publication bias was assessed using a funnel plot. RESULTS: Our search identified nine retrospective cohort studies that met the study inclusion criteria. The pooled relative risk of COPD related mortality secondary to beta-blocker use was 0.69 (95% CI: 0.62-0.78; I2=82%). CONCLUSION: The results of this review are consistent with a protective effect of beta-blockers with respect to all cause mortality. Due to the observational nature of the included studies, the possibility of confounding that may have affected these results cannot be excluded. The hypothesis that beta blocker therapy might be of benefit in COPD needs to be evaluated in randomised controlled trials.

Intensive nursing work schedules and the risk of hypoglycaemia in critically ill patients who are receiving intravenous insulin.

RATIONALE: Nurses in the intensive care unit (ICU) commonly work frequent 12 h shifts, potentially leading to fatigue and reduced vigilance. The authors hypothesised that rates of hypoglycaemia in patients receiving an insulin infusion would be associated with the intensity of work of the bedside nurse in the preceding 72 h. METHODS: The authors identified ICU patients who had hypoglycaemia (glucose ≤3.5 mmol/l, 63 mg/dl) between October 2006 and June 2007. The number of shifts worked in the previous 72 h was calculated for the nurse caring for the patient when the event occurred (case shift). For each case shift, the authors identified up to three control shifts (24, 48 and 72 h before the event in the same patient) and calculated the number of shifts worked by nurses on these shifts in the previous 72 h. Conditional logistic regression was used to determine whether the number of shifts worked was associated with hypoglycaemia. RESULTS: There were 41 events (32 patients). Each additional shift worked in the previous 72 h was associated with a significantly increased risk of hypoglycaemia (OR = 1.65/shift, 95% CI 1.01 to 2.68, p = 0.04) after controlling for nurse age and experience. The association was greater for the 23 events associated with an error in management according to the insulin protocol (OR = 2.93/shift, 1.15 to 7.44, p = 0.02) compared with events not associated with an error (OR = 1.34/shift, 0.73 to 2.45, p = 0.34). CONCLUSIONS: Intensive nursing work schedules are associated with hypoglycaemic events in ICU patients.

The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: a patient simulator study.

OBJECTIVE: To evaluate the impact of prolonged continuous wakefulness on resident performance under controlled experimental conditions. DESIGN: Experimental within-subjects comparison. SETTING: High-fidelity patient simulator. PARTICIPANTS: Twelve residents in an Internal Medicine Program at various stages of training (range, 1-35 mos). MEASUREMENTS: Performance was studied during 26 hrs of continuous wakefulness at four time points (8:00-10:00 am, 2:00-4:00 pm, 2:00-4:00 am, and 8:00-10:00 am the next day) using high-fidelity patient simulation. At each session, residents managed eight simulated dysrhythmias according to advanced cardiac life support protocols (advanced cardiac life support scenarios) and then managed a simulated critically ill patient (e.g., patient with meningitis) to test more complicated clinical decision-making (complex scenario). The frequency of previously defined major medical errors (i.e., action or inaction that likely would have resulted in significant harm in a real patient) was assessed by a scorer blinded to the time of the session. For each complex scenario, a global score between 0 and 100 was also given for overall performance. The impact of wakefulness on performance was assessed by using longitudinal mixed-effects models. RESULTS: For the complex scenarios, the mean number of errors increased from 0.92 +/- 0.90 in the first session to 1.58 +/- 0.79 in the fourth session (p = .09), and mean global score decreased from 56.8 +/- 14.6 to 49.6 +/- 12.6 (p = .02). For the advanced cardiac life support scenarios, the mean number of major errors committed in the advanced cardiac life support scenarios decreased during the study period (p = .01). However, essentially all of the improvement occurred between the first and second time points, suggesting that a substantial learning effect accounted for the findings. CONCLUSIONS: During prolonged continuous wakefulness of medical residents, clinical performance in the management of a simulated critically ill patient deteriorates. The practice of scheduling residents for extended work shifts (>24 hrs) should be reconsidered.