The effect of goal-directed fluid therapy on delayed graft function in kidney transplant recipients: A systematic review and meta-analysis.

Delayed graft function (DGF) is a common post-operative complication with potential long-term sequelae for many kidney transplant recipients, and hemodynamic factors and fluid status play a role. Fixed perioperative fluid infusions are the standard of care, but more recent evidence in the non-transplant population has suggested benefit with goal-directed fluid strategies based on hemodynamic targets. We searched MEDLINE, EMBASE, Cochrane Controlled Trials Registry and Google Scholar through December 2022 for randomized controlled trials comparing risk of DGF between goal-directed and conventional fluid therapy in adults receiving a living or deceased donor kidney transplant. Effect estimates were reported with odds ratios (OR) and pooled using random effects meta-analysis. We identified 4 studies (205 participants) that met the inclusion criteria. The use of goal-directed fluid therapy had no significant effect on DGF (OR 1.37 95% CI, 0.34-5.6; p = 0.52; I2 = 0.11). Subgroup analysis examining effects among deceased and living kidney donation did not reveal significant differences in the effects of fluid strategy on DGF between subgroups. Overall, the strength of the evidence for goal-directed versus conventional fluid therapy to reduce DGF was of low certainty. Our findings highlight the need for larger trials to determine the effect of goal-directed fluid therapy on this patient-centered outcome.

Why do some physicians choose to tackle inequities in healthcare?

BACKGROUND: Despite the reputation of Canada's healthcare system as being accessible to all Canadians, certain populations continue to face inequities within our healthcare system. In addition to promoting fairness, addressing healthcare inequities has the potential to reduce healthcare costs, which is increasingly important as healthcare costs continue to rise. Intentionally or otherwise, physicians are often leaders in healthcare teams, but there is a paucity of literature on physicians' perceptions of the problem of healthcare inequities and their potential role in addressing inequities. In this pilot study, we use a grounded theory approach to explore contextual factors and mechanisms that associate with an individual physician's involvement (or otherwise) in initiatives to reduce healthcare inequity. METHODS: Using purposeful sampling and a set of a priori questions, we interviewed ten physicians - five of whom self-identified as being actively involved and five not actively involved in addressing healthcare inequities - to explore potential reasons for physicians choosing to address the causes of healthcare inequities. RESULTS: We identified contextual barriers (e.g., lack of knowledge and time) and facilitators (prior experience, protected time, mentorship and system supports) that we interpreted as interacting with the underlying mechanism (motivation to address inequities) to influence a physician's decision on whether or not to address healthcare inequities. CONCLUSION: Based upon our findings we propose further studies to understand and/or overcome barriers to physicians being involved in addressing healthcare inequities.

The Mental Health Acute Assessment Team: a collaborative approach to treating mental health patients in the community.

OBJECTIVE: Many models of community-based mental health crisis teams have been reported. We present our experience of an outreach team made up of a paramedic and mental health nurse. METHODS: A proof-of-concept was conducted in Western Sydney. The primary outcome was the proportion of patients where the team were able to facilitate the most appropriate care. RESULTS: Nearly 70% of patients were able to be treated outside the Emergency Department, with about two-thirds being transported directly to a mental health facility. CONCLUSION: We have demonstrated that our model of care is successful in enabling appropriate physical and mental health care for patients suffering an acute mental health crisis.