Should Adults With Mild Head Injury Who Are Receiving Direct Oral Anticoagulants Undergo Computed Tomography Scanning? A Systematic Review.

STUDY OBJECTIVE: Patients receiving direct oral anticoagulant medications commonly undergo computed tomography head scanning after mild traumatic brain injury, regardless of symptoms or signs. International guidelines have noted a lack of evidence to support management decisions for such patients. This systematic review aims to identify, appraise, and synthesize the current evidence for the risk of adverse outcome in patients receiving direct oral anticoagulants after mild head injury. METHODS: A protocol was registered with PROSPERO and review methodology followed Cochrane Collaboration recommendations. Studies of adult patients with mild head injury (Glasgow Coma Scale score 13 to 15) and who were receiving direct oral anticoagulants that reported the risk of adverse outcome after the head injury were eligible for inclusion. A comprehensive range of bibliographic databases and gray literature was examined with a sensitive search strategy. Selection of eligible studies, data extraction, and risk of bias were evaluated independently by separate reviewers. A random-effects meta-analysis was used to provide a pooled estimate of the risk of adverse outcome. The overall quality of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation Working Group approach. RESULTS: A total of 4,886 articles were screened for inclusion, of which 7 cohort studies including 346 patients met inclusion criteria. All studies were at high or unclear risk of bias as a result of selection and information bias. Estimates of adverse outcome (any death, intracranial hematoma, or neurosurgery) ranged from 0.0% to 8.3%. A random-effects meta-analysis showed a weighted composite outcome risk of 3.7% (95% confidence interval 1.7% to 5.8%; I2=3.3%). The overall quality of the body of evidence was low as a result of imprecision, indirectness, and risk of bias. CONCLUSION: There are limited data available to characterize the risk of adverse outcome in patients receiving direct oral anticoagulants after mild traumatic brain injury. A sufficiently powered prospective cohort study is required to validly define this risk, identify clinical features predictive of adverse outcome, and inform future head injury guidelines.

The Relationship between Hospital or Surgeon Volume and Outcomes in Lower Limb Vascular Surgery in the United Kingdom and Europe.

BACKGROUND: Peripheral vascular disease is a major cause of death and disability. The extent to which volume influences outcome of lower limb (LL) vascular surgery remains unclear. This review evaluated the relationship between hospital/surgeon volume and outcome in LL surgery. METHODS: Electronic databases-MEDLINE, Embase, the Cochrane Library Databases, Science Citation Index, and CINAHL-proceedings from conferences, citations, and references of included studies were searched. Studies from Europe, of adults undergoing LL vascular surgery reporting outcomes by hospital or surgeon volume were included. The quality of studies was assessed using a modified Cochrane Risk Of Bias Assessment Tool: for Non-Randomized Studies of Interventions (Robins1) tool. The association between hospital/surgeon volume and outcome was summarized using tables. RESULTS: Nine studies from different European countries, comprising 67,445 patients who had undergone diverse LL surgeries were included. The increase in hospital/surgeon volume was associated with a decrease in post-operative amputations (hospital at 30 days [odds ratio {OR}: 0.20, 95% confidence interval {CI} 0.29-0.45, P = 0.01; OR: 0.67, 95% CI 0.44-0.9, P = 0.05; OR: 0.96, 95% CI 0.92-1.00, P = 0.06], at 1 year [OR: 0.96, 95% CI 0.93-0.98, P = 0.002; OR: 0.66, 95% CI 0.52-0.84, P < 0.001; OR: 2.05, 95% CI 1.24-3.42, P = 0.01], surgeon at 30 days [OR: 0.53, 95% CI 0.36-0.87, P = 0.01; OR: 0.40, 95% CI 0.18-0.91, P = 0.03; OR: 0.41, 95% CI 0.24-0.69, P = 0.0006]). The evidence on an association between hospital/surgeon volume and mortality was contradictory, but mortality and amputations may covary by hospital volume. There were an insufficient number of studies reporting on the other variables to draw firm conclusions, but their results suggest that high-volume hospitals may undertake more repeated surgeries/revascularizations and limb salvage. The impact of hospital/surgical volume on adverse events and length of hospitalization could not be determined. CONCLUSIONS: High-volume hospitals/surgeons may undertake fewer amputations and mortality and amputations may covary. The finding that hospital and surgeon volume affected the number of secondary amputations has implications on reorganization of vascular surgery services. However, due to the small number and poor quality of some of the included studies, decisions on reorganization of LL vascular surgery services should be supplemented by results from clinical audits. There is need for standardization of definition of volume stratification of outcomes by patient's clinical conditions.

Implementing health promotion in schools: protocol for a realist systematic review of research and experience in the United Kingdom (UK).

BACKGROUND: School-based interventions and campaigns are used to promote health and address a wide variety of public health problems. Schools are considered to be key sites for the implementation of health promotion programmes for their potential to reach the whole population in particular age-groups and instil healthy patterns of behavior early in life. However, evidence for the effectiveness of school-based health promotion interventions is highly variable. Systematic reviews of the evidence of school-based interventions tend to be highly problem- or intervention- specific, thereby missing potential generic insights into implementation and effectiveness of such programmes across problems. METHODS/DESIGN: A realist systematic review will be undertaken to explain how, why and in what circumstances schools can provide feasible settings for effective health promotion programmes in the United Kingdom (UK). The review will be conducted in two phases. Phase 1 will identify programme theories about implementation (ideas about what enables or inhibits effective health promotion to be delivered in a school setting). Phase 2 will test the programme theories so that they can be challenged, endorsed and/or refined. A Review Advisory Group of education and health professionals will be convened to help identify and choose potential programme theories, provide a 'reality check' on the clarity and explanatory strength of the mechanisms to be tested, and help shape the presentation of findings to be usable by practitioners and decision-makers. Review findings will be disseminated through liaison with decision-makers, and voluntary and professional groups in the fields of education and health.