Titles versus titles and abstracts for initial screening of articles for systematic reviews

PMC3933432BACKGROUND: There is no consensus on whether screening titles alone or titles and abstracts together is the preferable strategy for inclusion of articles in a systematic review. METHODS: TWO METHODS OF SCREENING ARTICLES FOR INCLUSION IN A SYSTEMATIC REVIEW WERE COMPARED: titles first versus titles and abstracts simultaneously. Each citation found in MEDLINE or Embase was reviewed by two physician reviewers for prespecified criteria: the citation included (1) primary data; (2) the exposure of interest; and (3) the outcome of interest. RESULTS: There were 2965 unique citations. The titles first strategy resulted in an immediate rejection of 2558 (86%) of the records after reading the title alone, requiring review of 239 titles and abstracts, and subsequently 176 full text articles. The simultaneous titles and abstracts review led to rejection of 2782 citations (94%) and review of 183 full text articles. Interreviewer agreement to include an article for full text review using the titles-first screening strategy was 89%-94% (kappa = 0.54) and 96%-97% (kappa = 0.56) for titles and abstracts combined. The final systematic review included 13 articles, all of which were identified by both screening strategies (yield 100%, burden 114%). Precision was higher in the titles and abstracts method (7.1% versus 3.2%) but recall was the same (100% versus 100%), leading to a higher F-measure for the titles and abstracts approach (0.1327 versus 0.0619). CONCLUSION: Screening via a titles-first approach may be more efficient than screening titles and abstracts together.JH Libraries Open Access Fun

Factors Influencing CAM-ICU Documentation and Inappropriate "Unable to Assess" Responses.

BackgroundDetecting delirium with standardized assessment tools such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is important, but such detection is frequently hampered by poor documentation and inappropriate "unable to assess" responses (in noncomatose patients).ObjectiveTo identify patient, clinical, and workplace factors that may impede or facilitate appropriate delirium assessment through use of the CAM-ICU, specifically documentation and inappropriate "unable to assess" responses.MethodsAn electronic health record-based data set was used to quantify CAM-ICU documentation and inappropriate "unable to assess" responses during 24 months. Associated patient (eg, age), clinical (eg, diagnosis), and workplace (eg, geographic location within the ICU, shift) factors were evaluated with multivariable regression.ResultsOf 28 586 CAM-ICU documentation opportunities, 66% were documented; 16% of documentations in alert or lightly sedated patients had inappropriate "unable to assess" responses. Night shift was associated with lower CAM-ICU documentation rates (P = .001), whereas physical restraints and location on side B (rather than side A) of the ICU were associated with higher documentation rates (P < .05 for both). Age older than 80 years, non-White race, intubation, and physical restraints were associated with more inappropriate "unable to assess" responses (all P < .05), as was infusion of propofol, midazolam, dexmedetomidine, or fentanyl (all P < .05).ConclusionData from electronic health records can identify patient, clinical, and workplace factors associated with CAM-ICU documentation and inappropriate "unable to assess" responses, which can help target quality improvement efforts related to delirium assessment

Modeling success: How to work effectively with your biostatistician

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/174824/1/jgs17888_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/174824/2/jgs17888.pd

Secondary peritonitis in a patient with cirrhosis involving Hyphopichia burtonii, an emerging fungal pathogen

We present a case where Hyphopichia burtonii, a yeast, speciated from peritoneal fluid in a cirrhotic patient with secondary peritonitis. The patient, a man in his 60s with decompensated cirrhosis, was admitted for an upper gastrointestinal (GI) bleed. On admission, he was treated empirically for spontaneous bacterial peritonitis (SBP) but failed to improve with antibiotics. Serial paracenteses revealed polymicrobial peritonitis and rising peritoneal polymorphonuclear leukocytes (PMNs). These findings raised concerns for secondary peritonitis, prompting an abdominal computed tomography (CT) scan which revealed ischemic bowel. Among the peritoneal microbiota isolated, Hyphopichia burtonii predominated. Hyphopichia burtonii has only recently been reported as a human pathogen, previously it had only reported as a pathogen in bats[1,2]

Sleep in the Intensive Care Unit: Strategies for Improvement.

Sleep in the intensive care unit (ICU) is considered to be subjectively poor, highly fragmented, and sometimes referred to as "atypical." Although sleep is felt to be crucial for patient recovery, little is known about the association of sleep with physiologic function among critically ill patients, or those with clinically important outcomes in the ICU. Research involving ICU-based sleep disturbance is challenging due to the lack of objective, practical, reliable, and scalable methods to measure sleep and the multifactorial etiologies of its disruption. Despite these challenges, research into sleep-promoting techniques is growing and has demonstrated a variety of causes leading to ICU-related sleep loss, thereby motivating multifaceted intervention efforts. Through a focused review of (1) sleep measurement in the ICU; (2) outcomes related to poor sleep in the ICU; and (3) ICU-based sleep promotion efforts including environmental, nonpharmacological, and pharmacological interventions, this paper examines research regarding sleep in the ICU and highlights the need for future investigation into this complex and dynamic field

Use of actigraphy to characterize inactivity and activity in patients in a medical ICU.

BackgroundIn the intensive care unit (ICU), inactivity is common, contributing to ICU-acquired weakness and poor outcomes. Actigraphy may be useful for measuring activity in the ICU.ObjectivesTo use actigraphy to characterize inactivity and activity in critically ill patients.MethodsThis prospective observational study involved 48-h wrist actigraphy in medical ICU (MICU) patients, with activity data captured across 30-s epochs. Inactivity (zero-activity epochs) and activity (levels of non-zero activity) were summarized across key patient (e.g., age) and clinical (e.g., mechanical ventilation status) variables, and compared using multivariable regression.ResultsOverall, 189,595 30-s epochs were collected in 34 MICU patients. Zero-activity (inactivity) comprised 122,865 (65%) of epochs; these epochs were 24% and 13% more prevalent, respectively, in patients receiving mechanical ventilation (versus none, p < 0.001) and in the highest (versus lowest) organ failure score tertile (p = 0.03). Ambulatory (versus non-ambulatory) patients exhibited more non-zero activity (35 more movements per epoch, p < 0.001), while those in the highest (versus lowest) organ failure score tertile exhibited less activity (22 fewer movements per epoch, p = 0.03). Significant inactivity/activity differences were not observed when evaluated based on age, sedation, or restraint status.ConclusionsActigraphy demonstrated that MICU patients are profoundly inactive, including those who are young, non-sedated and non-restrained. Hence, ICU-specific, non-patient-related factors may contribute to inactivity, an issue requiring further investigation

Circadian rest-activity misalignment in critically ill medical intensive care unit patients.

Circadian alignment of rest-activity rhythms is an essential biological process that may be vulnerable to misalignment in critically ill patients. We evaluated circadian rest-activity rhythms in critically ill patients and their association with baseline (e.g. age) and clinical (e.g. mechanical ventilation status) variables, along with intensive care unit light-dark cycles. Using wrist actigraphy, we collected 48-hr activity and light exposure data from critically ill patients in a tertiary care medical intensive care unit. We evaluated circadian rest-activity rhythms using COSINOR and non-parametric circadian rhythm analysis models, and stratified these data across baseline and clinical variables. We used linear regression to evaluate the association of circadian rest-activity and light-dark exposure rhythms. In COSINOR and non-parametric circadian rhythm analysis analyses, the 34 medical intensive care unit patients completing 48-hr actigraphy recordings exhibited mean MESOR (mean activity levels of a fitted curve) and amplitudes of 0.50 ± 0.32 and 0.20 ± 0.19 movements per 30-s epoch, with high interdaily variability. Patients who were older, mechanically ventilated, sedated, restrained and with higher organ failure scores tended to exhibit greater circadian rest-activity misalignment, with three of 34 (9%) patients exhibiting no circadian rhythmicity. Circadian light-dark exposure misalignment was observed as well and was associated with rest-activity misalignment (p = 0.03). Critically ill patients in our MICU experienced profound circadian rest-activity misalignment, with mostly weak or absent rhythms, along with circadian light-dark exposure misalignment. Potentially modifiable factors contributing to rest-activity misalignment (i.e. mechanical ventilation, restraints, low daytime light levels) highlight possible targets for future improvement efforts