Death, Dying, and End-of-Life Care in the US and the Netherlands: A Scoping Review

Introduction: The aim of End of Life (EOL)-care in any setting is to improve the quality of life of patients and families through medical or non-medical interventions. The study aims at identifying gaps in the literature produced on the topic and informs areas for future research in the field. Objective: To identify articles that discuss death and dying, with the elderly > = 70, living at home, or in nursing homes, in assisted living, or community centres, in hospice or palliative care, in hospitals or emergency care. Methods: A scoping review of studies in the U. S. and in the Netherlands. Using the inclusion and exclusion criteria, the selected studies were analysed and categorized by themes, and then summarized based on positive, negative and ambiguous views on death discussions at all four (4) levels of discussion. Results: From a total of one hundred and fifty-nine studies, twenty-five studies passed the selection criteria. Twenty-one were for the U. S., and four were for the Netherlands. The selected studies were analysed and categorized by themes. Conclusion: The review pointed to a dearth of material that measured the outcome of discussions on the subject of death and dying with the elderly. Future studies could consider discussions on death and dying from the perspective of patients’ anxiety and distress, instead of concerns over financial support, religious and ethnic issues, ethical and legal parameters, and extra medical training.publishedVersio

Timing of referral for vascular access placement: A systematic review

Objective: This review was conducted to determine the optimal timing for referring patients with end-stage renal disease to vascular surgery for access placement. Methods: A systematic review of the electronic databases (MEDLINE, EMBASE, Current Contents, Cochrane CENTRAL and Web of Science) was conducted through March 2007. Randomized and observational studies were eligible if they compared an early referral cohort with a late referral cohort in terms of patient-important outcomes such as death, access-related sepsis, and hospitalization related to access complications. Results: We found no studies that fulfilled eligibility criteria. Conclusion: At the present time, the optimal timing for referral to vascular surgery for vascular access placement is based on expert opinion and choices made by patients and physicians. © 2008 The Society for Vascular Surgery

Surveillance of arteriovenous hemodialysis access: A systematic review and meta-analysis

Objectives: Hemodialysis centers regularly survey arteriovenous (AV) accesses for signs of dysfunction. In this review, we synthesize the available evidence to determine to what extent proactive vascular access monitoring affects the incidence of AV access thrombosis and abandonment compared with clinical monitoring. Methods: We searched electronic databases (MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, and SCOPUS) and sought references from experts, bibliographies of included trials, and articles that cited included studies. Two reviewers independently assessed trial quality and extracted data. We used random effects meta-analysis to estimate the pooled relative risk (RR) and 95% confidence interval (CI) across studies and conducted subgroup analyses to explain heterogeneity. The I2 statistic was used to assess heterogeneity of treatment effect among trials. Results: Nine studies (1363 patients) compared a strategy of surveillance vs clinical monitoring. A vascular intervention to maintain or restore patency was provided to both groups if needed. Surveillance followed by intervention led to a nonsignificant reduction of the risk of access thrombosis (RR, 0.82; 95% CI, 0.58-1.16; I2 = 37%) and access abandonment (RR, 0.80; 95% CI, 0.51-1.25; I2 = 60%). Three studies (207 patients) compared the effect of vascular interventions vs observation in patients with abnormal surveillance result. Vascular interventions after an abnormal AV access surveillance led to a significant reduction of the risk of access thrombosis (RR, 0.53; 95% CI, 0.36-0.76) and a nonsignificant reduction of the risk of access abandonment (RR, 0.76; 95% CI, 0.43-1.37). Conclusion: Very low quality evidence yielding imprecise results suggests a potentially beneficial effect of AV access surveillance followed by interventions to restore patency. This inference, however, is weak and will require randomized trials of AV access surveillance vs clinical monitoring for rejection or confirmation. © 2008 The Society for Vascular Surgery

Autogenous versus prosthetic vascular access for hemodialysis: A systematic review and meta-analysis

Objectives: The autogenous arteriovenous access for chronic hemodialysis is recommended over the prosthetic access because of its longer lifespan. However, more than half of the United States dialysis patients receive a prosthetic access. We conducted a systematic review to summarize the best available evidence comparing the two accesses types in terms of patient-important outcomes. Methods: We searched electronic databases (MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science and SCOPUS) and included randomized controlled trials and controlled cohort studies. We pooled data for each outcome using a random effects model to estimate the relative risk (RR) and its associated 95% confidence interval (CI). We estimated inconsistency caused by true differences between studies using the I2 statistic. Results: Eighty-three studies, of which 80 were nonrandomized, met eligibility criteria. Compared with the prosthetic access, the autogenous access was associated with a significant reduction in the risk of death (RR, 0.76; 95% CI, 0.67-0.86; I2 = 48%, 27 studies) and access infection (RR, 0.18; 95% CI, 0.11-0.31; I2 = 93%, 43 studies), and a nonsignificant reduction in the risk of postoperative complications (hematoma, bleeding, pseudoaneurysm and steal syndrome, RR 0.73; 95% CI, 0.48-1.16; I2 = 65%, 31 studies) and length of hospitalization (pooled weighted mean difference -3.8 days; 95% CI, -7.8 to 0.2; P = .06). The autogenous access also had better primary and secondary patency at 12 and 36 months. Conclusion: Low-quality evidence from inconsistent studies with limited protection against bias shows that autogenous access for chronic hemodialysis is superior to prosthetic access. © 2008 The Society for Vascular Surgery

Thigh-length compression stockings and DVT after stroke

Controversy exists as to whether neoadjuvant chemotherapy improves survival in patients with invasive bladder cancer, despite randomised controlled trials of more than 3000 patients. We undertook a systematic review and meta-analysis to assess the effect of such treatment on survival in patients with this disease