An Economic Evaluation of Venous Thromboembolism Prophylaxis Strategies in Critically Ill Trauma Patients at Risk of Bleeding

Using decision analysis, Henry Stelfox and colleagues estimate the cost-effectiveness of three venous thromboembolism prophylaxis strategies in patients with severe traumatic injuries who were also at risk for bleeding complications

Frailty in the critically ill: a novel concept

The concept of frailty has been defined as a multidimensional syndrome characterized by the loss of physical and cognitive reserve that predisposes to the accumulation of deficits and increased vulnerability to adverse events. Frailty is strongly correlated with age, and overlaps with and extends aspects of a patient's disability status (that is, functional limitation) and/or burden of comorbid disease. The frail phenotype has more specifically been characterized by adverse changes to a patient's mobility, muscle mass, nutritional status, strength and endurance. We contend that, in selected circumstances, the critically ill patient may be analogous to the frail geriatric patient. The prevalence of frailty amongst critically ill patients is currently unknown; however, it is probably increasing, based on data showing that the utilization of intensive care unit (ICU) resources by older people is rising. Owing to the theoretical similarities in frailty between geriatric and critically ill patients, this concept may have clinical relevance and may be predictive of outcomes, along with showing important interaction with several factors including illness severity, comorbid disease, and the social and structural environment. We believe studies of frailty in critically ill patients are needed to evaluate how it correlates with outcomes such as survival and quality of life, and how it relates to resource utilization, such as length of mechanical ventilation, ICU stay and duration of hospitalization. We hypothesize that the objective measurement of frailty may provide additional support and reinforcement to clinicians confronted with end-of-life decisions on the appropriateness of ICU support and/or withholding of life-sustaining therapies

History of the Innovation of Damage Control for Management of Trauma Patients: 1902-2016

Objective: To review the history of the innovation of damage control (DC) for management of trauma patients. Background: DC is an important development in trauma care that provides a valuable case study in surgical innovation. Methods: We searched bibliographic databases (1950-2015), conference abstracts (2009-2013), Web sites, textbooks, and bibliographies for articles relating to trauma DC. The innovation of DC was then classified according to the Innovation, Development, Exploration, Assessment, and Long-term study model of surgical innovation. Results: The innovation\u27\u27 of DC originated from the use of therapeutic liver packing, a practice that had previously been abandoned after World War II because of adverse events. It then developed\u27\u27 into abbreviated laparotomy using rapid conservative operative techniques.\u27\u27 Subsequent exploration\u27\u27 resulted in the application of DC to increasingly complex abdominal injuries and thoracic, peripheral vascular, and orthopedic injuries. Increasing use of DC laparotomy was followed by growing reports of postinjury abdominal compartment syndrome and prophylactic use of the open abdomen to prevent intra-abdominal hypertension after DC laparotomy. By the year 2000, DC surgery had been widely adopted and was recommended for use in surgical journals, textbooks, and teaching courses ( assessment\u27\u27 stage of innovation). Long-term study\u27\u27 of DC is raising questions about whether the procedure should be used more selectively in the context of improving resuscitation practices. Conclusions: The history of the innovation of DC illustrates how a previously abandoned surgical technique was adapted and readopted in response to an increased understanding of trauma patient physiology and changing injury patterns and trauma resuscitation practices

Improving End-of-Life Communication and Decision Making: The Development of a Conceptual Framework and Quality Indicators

AbstractContextThe goal of end-of-life (EOL) communication and decision making is to create a shared understanding about a person’s values and treatment preferences that will lead to a plan of care that is consistent with these values and preferences. Improvements in communication and decision making at the EOL have been identified as a high priority from a patient and family point of view.ObjectivesThe purpose of this study was to develop quality indicators related to EOL communication and decision making.MethodsWe convened a multidisciplinary panel of experts to develop definitions, a conceptual framework of EOL communication and decision making, and quality indicators using a modified Delphi method. We generated a list of potential items based on literature review and input from panel members. Panel members rated the items using a seven-point Likert scale (1 = very little importance to 7 = extremely important) over four rounds of review until consensus was achieved.ResultsAbout 24 of the 28 panel members participated in all four rounds of the Delphi process. The final list of quality indicators comprised 34 items, divided into the four categories of our conceptual framework: Advance care planning (eight items), Goals of care discussions (13 items), Documentation (five items), and Organization/System aspects (eight items). Eleven items were rated “extremely important” (median score). All items had a median score of five (moderately important) or greater.ConclusionWe have developed definitions, a conceptual framework, and quality indicators that researchers and health care decision makers can use to evaluate and improve the quality of EOL communication and decision making

Capture-mark-recapture to estimate the number of missed articles for systematic reviews in surgery

Abstract BACKGROUND: Systematic reviews are an important knowledge synthesis tool, but with new literature available each day, reviewers must balance identifying all relevant literature against timely synthesis. METHODS: This study tested capture-mark-recapture (CMR), an ecology-based technique, to estimate the total number of articles in the literature identified in a systematic review of adult trauma care quality indicators. RESULTS: The systematic review included 40 articles identified from online searches and citation references. The CMR model suggested that 3 (95% confidence interval [CI]: 0 to 6) articles were missed and the database search provided 93% (one-sided 95% CI: R83%) of known articles for inclusion in the systematic review. The search order used for identifying the articles was optimal among the 24 that could have been used. CONCLUSIONS: The CMR technique can be used in systematic reviews in surgery to estimate the closeness to capturing the total body of literature for a specific topic. Ó 2013 Elsevier Inc. All rights reserved. Systematic reviews are increasingly used in surgery to synthesize knowledge so that evidence can inform clinical practice (eg, guideline development). Exhaustive searching in multiple large bibliographic databases is time consuming and resource intensive, but it needs to be efficient so the results are presented before the information becomes outdated. However, this is difficult because the amount of literature that exists on any given topic is unknown. Capture-mark-recapture (CMR) is a technique originating in ecology that has been applied to systematic reviews of randomized controlled trials of interventions in osteoporosis, gastroenterology, and hematology 1-3 to estimate The project was supported by a Synthesis Grant (KRS-91770) from the Canadian Institutes of Health Research. Dr. Stelfox is supported by a New Investigator Award from the Canadian Institutes of Health Research and a Population Health Investigator Award from Alberta Innovates. Funding sources had no role in the design, conduct, or reporting of this study and we are unaware of any conflicts of interest. None of the authors have financial or professional conflicts of interest that would influence the conduct or reporting of this study. Drs. Stelfox, Foster, and Goldsmith had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Presented at the Cochrane Canada Symposium May 9, 2012, Winnipeg, Canada. * Corresponding author. The American Journal of Surgery (2013) 206, 439-440 the number of articles in the literature. The technique has not been evaluated in observational studies or surgical studies. We therefore tested CMR to estimate the total number of articles in the literature identified in a systematic review of adult trauma care quality indicators. We performed a scoping review to identify quality indicators for evaluating trauma care 4 and subsequently systematically reviewed the evidence. 5 Horizon estimates (estimated total population of articles) were calculated for full text review and final inclusion using the 4 step CMR technique: (1) capture an initial sample from a population of interest (eg, catch fish in lake); (2) mark the elements in the sample (eg, tag the fish); (3) release the sample back into the population (eg, release tagged fish back into lake); and (4) resample the population (catch fish from same lake to see how many are tagged). Articles found in our 1st database (MEDLINE) were marked as being retrieved from that search and compared with articles retrieved through subsequent searches (eg, Embase was the 2nd database). Articles identified through bibliography reviews were attributed to the originating electronic database. Poisson regression models were used to calculate fitted estimates of the cell counts (number of articles missed) and estimate the total horizon of articles (SAS v 9.2; SAS, Cary, NC). The results of the horizon estimate are shown in We repeated the process for articles selected for inclusion in the systematic review. The final horizon estimate was 43 (40 to 46) articles, representing a difference of 3 (0 to 6) articles between the projected total literature and the number of articles captured (40 articles). Thus, selection of articles for inclusion in the systematic review represents the capture of 93% (87% to 100%) of the estimated pool of available articles. The search order used for identifying the articles was optimal among the 24 that could have been used. CMR is a technique that can be applied to estimate the total number of relevant articles for a given topic. This study demonstrates that CMR can be successfully used for systematic reviews of observational studies in surgery. Future systematic reviews may consider including horizon estimates as possible stopping rules (eg, search until 80% of articles captured) to identify when a sufficient literature search has been completed. CMR may help improve the completeness and efficiency of systematic reviews

Temporal Artery versus Bladder Thermometry during Adult Medical-Surgical Intensive Care Monitoring: An Observational Study

Abstract Background We sought to evaluate agreement between a new and widely implemented method of temperature measurement in critical care, temporal artery thermometry and an established method of core temperature measurement, bladder thermometry as performed in clinical practice. Methods Temperatures were simultaneously recorded hourly (n = 736 observations) using both devices as part of routine clinical monitoring in 14 critically ill adult patients with temperatures ranging ≥1°C prior to consent. Results The mean difference between temporal artery and bladder temperatures measured was -0.44°C (95% confidence interval, -0.47°C to -0.41°C), with temporal artery readings lower than bladder temperatures. Agreement between the two devices was greatest for normothermia (36.0°C to < 38.3°C) (mean difference -0.35°C [95% confidence interval, -0.37°C to -0.33°C]). The temporal artery thermometer recorded higher temperatures during hypothermia (< 36°C) (mean difference 0.66°C [95% confidence interval, 0.53°C to 0.79°C]) and lower temperatures during hyperthermia (≥38.3°C) (mean difference -0.90°C [95% confidence interval, -0.99°C to -0.81°C]). The sensitivity for detecting fever (core temperature ≥38.3°C) using the temporal artery thermometer was 0.26 (95% confidence interval, 0.20 to 0.33), and the specificity was 0.99 (95% confidence interval, 0.98 to 0.99). The positive likelihood ratio for fever was 24.6 (95% confidence interval, 10.7 to 56.8); the negative likelihood ratio was 0.75 (95% confidence interval, 0.68 to 0.82). Conclusions Temporal artery thermometry produces somewhat surprising disagreement with an established method of core temperature measurement and should not to be used in situations where body temperature needs to be measured with accuracy

Coronavirus disease 2019 (COVID-19) excess mortality outcomes associated with pandemic effects study (COPES): A systematic review and meta-analysis

Background and aimWith the Coronavirus Disease 2019 (COVID-19) pandemic continuing to impact healthcare systems around the world, healthcare providers are attempting to balance resources devoted to COVID-19 patients while minimizing excess mortality overall (both COVID-19 and non-COVID-19 patients). To this end, we conducted a systematic review (SR) to describe the effect of the COVID-19 pandemic on all-cause excess mortality (COVID-19 and non-COVID-19) during the pandemic timeframe compared to non-pandemic times.MethodsWe searched EMBASE, Cochrane Database of SRs, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Controlled Trials Register (CENTRAL), from inception (1948) to December 31, 2020. We used a two-stage review process to screen/extract data. We assessed risk of bias using Newcastle-Ottawa Scale (NOS). We used Critical Appraisal and Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.ResultsOf 11,581 citations, 194 studies met eligibility. Of these studies, 31 had mortality comparisons (n = 433,196,345 participants). Compared to pre-pandemic times, during the COVID-19 pandemic, our meta-analysis demonstrated that COVID-19 mortality had an increased risk difference (RD) of 0.06% (95% CI: 0.06–0.06% p &lt; 0.00001). All-cause mortality also increased [relative risk (RR): 1.53, 95% confidence interval (CI): 1.38–1.70, p &lt; 0.00001] alongside non-COVID-19 mortality (RR: 1.18, 1.07–1.30, p &lt; 0.00001). There was “very low” certainty of evidence through GRADE assessment for all outcomes studied, demonstrating the evidence as uncertain.InterpretationThe COVID-19 pandemic may have caused significant increases in all-cause excess mortality, greater than those accounted for by increases due to COVID-19 mortality alone, although the evidence is uncertain.Systematic review registration[https://www.crd.york.ac.uk/prospero/#recordDetails], identifier [CRD42020201256]

Low-value clinical practices in adult traumatic brain injury : an umbrella review

Despite numerous interventions and treatment options, the outcomes of traumatic brain injury (TBI) have improved little over the last 3 decades, which raises concern about the value of care in this patient population. We aimed to synthesize the evidence on 14 potentially low-value clinical practices in TBI care. Using umbrella review methodology, we identified systematic reviews evaluating the effectiveness of 14 potentially low-value practices in adults with acute TBI. We present data on methodological quality (Assessing the Methodological Quality of Systematic Reviews), reported effect sizes, and credibility of evidence (I to IV). The only clinical practice with evidence of benefit was therapeutic hypothermia (credibility of evidence II to IV). However, the most recent meta-analysis on hypothermia based on high-quality trials suggested harm (credibility of evidence IV). Meta-analyses on platelet transfusion for patients on antiplatelet therapy were all consistent with harm but were statistically non-significant. For the following practices, effect estimates were consistently close to the null: computed tomography (CT) in adults with mild TBI who are low-risk on a validated clinical decision rule; repeat CT in adults with mild TBI on anticoagulant therapy with no clinical deterioration; antibiotic prophylaxis for external ventricular drain placement; and decompressive craniectomy for refractory intracranial hypertension. We identified five clinical practices with evidence of lack of benefit or harm. However, evidence could not be considered to be strong for any clinical practice as effect measures were imprecise and heterogeneous, systematic reviews were often of low quality, and most included studies had a high risk of bias