Patient Discomfort Associated with the Use of Intra-arterial Iodinated Contrast Media: A Meta-Analysis of Comparative Randomized Controlled Trials

<p>Abstract</p> <p>Background</p> <p>Discomfort characterized by pain and warmth are common adverse effects associated with the use of intra-arterial iodinated contrast media (CM). The objective of this review was to pool patient-reported outcomes available from head-to-head randomized controlled trials (RCTs) and to compare the discomfort rates associated with iso-osmolar contrast media (IOCM; i.e., iodixanol) to those reported with various low-osmolar contrast media (LOCM).</p> <p>Methods</p> <p>A review of the literature published between 1990 and 2009 available through Medline, Medline Preprints, Embase, Biological Abstracts, BioBase, Cab Abstracts, International Pharmaceutical Abstracts, Life Sciences Collection, Inside Conferences, Energy Database, Engineering Index and Technology Collection was performed to compare rates of discomfort associated with the use of the IOCM (iodixanol) vs. various LOCM agents in head-to-head RCTs. All trials with a Jadad score ≥2 that reported patient discomfort data following intra-arterial administration of CM were reviewed, coded, and extracted.</p> <p>Results</p> <p>A total of 22 RCTs (n = 8087) were included. Overall discomfort (regardless of severity) was significantly different between patients receiving IOCM and various LOCMs (risk difference [RD] -0.049; 95% confidence interval [CI]: -0.076, -0.021; p = 0.001). IOCM was favored over all LOCMs combined with a summary RD value of -0.188 (95% CI: -0.265, -0.112; p < 0.001) for incidence of pain, regardless of severity. A greater reduction in the magnitude of pain was observed with IOCM (iodixanol), particularly with selective limb and carotid/intracerebral procedures. Similarly, the meta-analysis of warmth sensation, regardless of severity, favored IOCM over LOCMs with an RD of -0.043 (95% CI: -0.074, -0.011; p = 0.008). A positive linear relationship was observed between the discomfort effect size and age and a negative relationship with increasing proportion of women. The opposite trends were observed with warmth sensation.</p> <p>Conclusions</p> <p>IOCM was associated with less frequent and severe patient discomfort during intra-arterial administration. These data support differences in osmolality as a possible determinant of CM discomfort.</p

Whale barnacles and Neogene cetacean migration routes

An exceptional fossil assemblage of the ectoparasitic whale barnacle Coronula diadema was recently discovered from late Pliocene-Pleistocene sediments outcropping on the coast of Ecuador where today humpback whales (Megaptera novaeangliae) migrate for breeding. A similar occurrence is recorded in New Zealand and in Vanuatu, where late Pliocene-Pleistocene fossil coronulids have been found in sediments along the coasts that are current humpback whale migration routes. In both Ecuador and New Zealand we have collected fragmentary whale remains in association with these barnacle assemblages. Considering that detachment of whale barnacles from extant humpback whales has only been observed in breeding areas or along migratory routes, we view the Ecuador and New Zealand fossil barnacle assemblages as indirect evidence of whale migration during the late Neogene. Application of this hypothesis to the distribution pattern of fossil Coronula in the Mediterranean Basin, indicates that, unlike the present, mysticete whales may have used the Mediterranean as a breeding ground during the Pliocene and Pleistocene

Developing green infrastructure ‘thinking’: devising and applying an interactive group-based methodology for practitioners

Recent years have witnessed a wave of interest in the concept of green infrastructure (GI) as a means of applying an ecosystem approach to spatial planning practice; however, more limited attention has been paid to decision-making processes or tools to enhance GI within spatial plans and guidance. We address this deficit by reporting on the development and application of an interactive group-based methodology to enhance GI ‘thinking’ and interdisciplinary collaboration, drawing on the literature on the sociology of interactions. Our findings suggest that a game-based approach to GI problem-solving was successful in breaking down professional barriers by creating an informal learning arena, providing an enabling opportunity for participants to solve problems in an iterative, non-linear style to develop principles for action with transferability to ongoing plan formation. This style of problem-solving was characterised by shifting norms and routines of interaction, leading to problem re-framing and a search for alternative solutions

An Evidence-Based Theory About PRO Use in Kidney Care: A Realist Synthesis

Background: There is international interest on the use of patient-reported outcomes (PROs) in nephrology. Objectives: Our objectives were to develop a kidney-specific program theory about use of PROs in nephrology that may enhance person-centered care, both at individual and aggregated levels of care, and to test and refine this theory through a systematic review of the empirical literature. Together, these objectives articulate what works or does not work, for whom, and why. Methods: Realist synthesis methodology guided the electronic database and gray literature searches (in January 2017 and October 2018), screening, and extraction conducted independently by three reviewers. Sources included all nephrology patients and/or practitioners. Through a process of extraction and synthesis, each included source was examined to assess how contexts may trigger mechanisms to influence specific outcomes. Results: After screening 19,961 references, 84 theoretical and 34 empirical sources were used. PROs are proposed to be useful for providing nephrology care through three types of use. The first type is use of individual-level PRO data at point of care, receiving the majority of theoretical and empirical explorations. Clinician use to support person-centered care, and patient use to support patient engagement, are purported to improve satisfaction, health, and quality of life. Contextual factors specific to the kidney care setting that may influence the use of PRO data include the complexity of kidney disease symptom burden, symptoms that may be stigmatized, comorbidities, and time or administrative constraints in dialysis settings. Electronic collection of PROs may facilitate PRO use given these contexts. The second type is use of aggregated PRO data at point of care, including public reporting of PROs to inform decisions at point of care and improve quality of care, and use of PROs for treatment decisions. The third type is use of aggregated PRO data by organizations, including publicly available PRO data to compare centers. In single-payer systems, regular collection of PROs by dialysis centers can be achieved through economic incentives. Both the second and third types of PRO use include pressures that may trigger quality improvement processes. Conclusion: The current state of the evidence is primarily theoretical. There is pressing need for empirical research to improve the evidence-base of PRO use at individual and aggregated levels of nephrology care