Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document.

Rationale: Pediatric-specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients' readiness for extubation. Methods: Twenty-six international experts comprised a multiprofessional panel to establish pediatrics-specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. A systematic review was conducted for questions that did not meet an a priori threshold of ⩾80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence and drafted and voted on the recommendations. Measurements and Main Results: Three questions related to systematic screening using an extubation readiness testing bundle and a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ⩾80% agreement. For the remaining eight questions, five systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials, measures of respiratory muscle strength, assessment of risk of postextubation upper airway obstruction and its prevention, use of postextubation noninvasive respiratory support, and sedation. Most recommendations were conditional and based on low to very low certainty of evidence. Conclusions: This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.

Ethical Aspects of Involving Adolescents in HIV Research: A Systematic Review of the Empiric Literature.

OBJECTIVE: To evaluate the ethics of involving adolescents in HIV research, we conducted a systematic review of the empiric literature. METHODS: Electronic databases Ovid Medline, Embase, and CINAHL were systematically searched using controlled vocabulary terms related to ethics, HIV, specified age groups, and empiric research studies. We reviewed titles and abstracts, including studies that collected qualitative or quantitative data, evaluated ethical issues in HIV research, and included adolescents. Studies were appraised for quality, data were extracted, and studies were analyzed using narrative synthesis. RESULTS: We included 41 studies: 24 qualitative, 11 quantitative, 6 mixed methods; 22 from high-income countries (HIC), 18 from low- or middle-income countries (LMIC), and 1 from both HIC and LMIC. Adolescent, parent, and community perspectives assert the benefits of involving minors in HIV research. Participants in LMIC expressed mixed views regarding parental consent requirements and confidentiality, given adolescents' both increasing autonomy and continued need for adult support. In studies in HIC, sexual or gender minority youth would not participate in research if parental consent were required or if there were confidentiality concerns. There was variation in the comprehension of research concepts, but adolescents generally demonstrated good comprehension of informed consent. Informed consent processes can be improved to increase comprehension and study accessibility. Vulnerable participants face complex social barriers that should be considered in study design. CONCLUSIONS: Data support the inclusion of adolescents in HIV research. Empiric research can inform consent processes and procedural safeguards to ensure appropriate access.

Clinical non-effectiveness of clopidogrel use for peripheral artery disease in patients with CYP2C19 polymorphisms: a systematic review.

PURPOSE: To conduct a systematic review to identify studies that assessed the association between CYP2C19 polymorphisms and clinical outcomes in peripheral artery disease (PAD) patients who took clopidogrel. METHODS: We systematically searched Ovid EMBASE, PubMed, and Web of Science from November 1997 (inception) to September 2020. We included observational studies evaluating how CYP2C19 polymorphism is associated with clopidogrel's effectiveness and safety among patients with PAD. We extracted relevant information details from eligible studies (e.g., study type, patient population, study outcomes). We used the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) Tool to assess the risk of bias for included observational studies. RESULTS: The outcomes of interest were the effectiveness and safety of clopidogrel. The effectiveness outcomes included clinical ineffectiveness (e.g., restenosis). The safety outcomes included bleeding and death related to the use of clopidogrel. We identified four observational studies with a sample size ranging from 50 to 278. Outcomes and comparison groups of the studies varied. Three studies (75%) had an overall low risk of bias. All included studies demonstrated that carrying CYP2C19 loss of function (LOF) alleles was significantly associated with reduced clinical effectiveness and safety of clopidogrel. CONCLUSIONS: Our systematic review showed an association between CYP2C19 LOF alleles and reduced functions of clopidogrel. The use of CYP2C19 testing in PAD patients prescribed clopidogrel may help improve the clinical outcomes. However, based on the limited evidence, there is a need for randomized clinical trials in PAD patients to test both the effectiveness and safety outcomes of clopidogrel.

Except for my commute, everything is the same: the shared lived experience of health sciences libraries during the COVID-19 pandemic.

Objective: To understand the experience of academic health sciences libraries during the pandemic using a phenomenological approach. Methods: This study used a multisite, mixed-method approach to capture the direct experience of academic health sciences libraries as they evolved during the COVID-19 pandemic. Phase one of the study involved administering a qualitative survey to capture to capture current evolutions of programs and services. The survey for phases two (August 2020) and three (February 2021) contained eight questions asking participants to share updates on their evolution and experiences. Results: Qualitative data were analyzed using open coding techniques to ensure emergent themes were allowed to surface. Additional post-hoc sentiment analysis ascertained the frequency of positive and negative words in each data set. Of the 193 possible AAHSL libraries, 45 (23.3%) responded to the April 2020 survey, 26 to the August 2020 survey, and 16 to the February 2021 survey. Libraries represented 23 states and the District of Columbia. The majority of libraries closed in March 2020. The ease of transferring library services to a remote environment varied by type of service. For the quantitative analysis, ten distinct areas were analyzed using text coded as "Staff" as a lens for understanding the connection between codes. Conclusion: Innovations by libraries during the early stages of the pandemic are having a long-term impact on library culture and the delivery of services. Even as libraries returned to in-person services, elements of telecommuting, using online conferencing software, safety precautions, and monitoring of staff well-being persisted.

Implementing an institution-wide electronic lab notebook initiative.

Background: To strengthen institutional research data management practices, the Indiana University School of Medicine (IUSM) licensed an electronic lab notebook (ELN) to improve the organization, security, and shareability of information and data generated by the school's researchers. The Ruth Lilly Medical Library led implementation on behalf of the IUSM's Office of Research Affairs. Case Presentation: This article describes the pilot and full-scale implementation of an ELN at IUSM. The initial pilot of the ELN in late 2018 involved fifteen research labs with access expanded in 2019 to all academic medical school constituents. The Ruth Lilly Medical Library supports researchers using the electronic lab notebook by (1) delivering trainings that cover strategies for adopting an ELN and a hands-on demo of the licensed ELN, (2) providing one-on-one consults with research labs or groups as needed, and (3) developing best practice guidance and template notebooks to assist in adoption of the ELN. The library also communicates availability of the ELN to faculty, students, and staff through presentations delivered at department meetings and write-ups in the institution's newsletter as appropriate. Conclusion: As of August 2021, there are 829 users at IUSM. Ongoing challenges include determining what support to offer beyond the existing training, sustaining adoption of the ELN within research labs, and defining "successful" adoption at the institution level. By leading the development of this service, the library is more strongly integrated and visible in the research activities of the institution, particularly as related to information and data management.

Ethical considerations for research involving pregnant women living with HIV and their young children: a systematic review of the empiric literature and discussion.

BACKGROUND: The proper and ethical inclusion of PWLHIV and their young children in research is paramount to ensure valid evidence is generated to optimize treatment and care. Little empirical data exists to inform ethical considerations deemed most critical to these populations. Our study aimed to systematically review the empiric literature regarding ethical considerations for research participation of PWLHIV and their young children. METHODS: We conducted this systematic review in partnership with a medical librarian. A search strategy was designed and performed within the following electronic databases: Ovid MEDLINE, Embase and CINAHL. We screened titles and abstracts using the following inclusion criteria: (1) a study population of PWLHIV or children under 5 years of age; and (2) collection of qualitative or quantitative data regarding ethics of research participation. Excluded were reviews, commentaries, policy statements, clinical care-related ethics concerns, abstracts, case studies, or studies unrelated to HIV research. Studies were appraised for quality, data were extracted, and studies were qualitatively analyzed using a principle-based ethical framework within the Belmont Report. RESULTS: Of the 7470 titles identified, 538 full-text articles were reviewed for eligibility and only three articles met full criteria for inclusion within this review. While we allowed for inclusion of studies involving young children born to mothers with HIV, only articles focused on PWLHIV were identified. Within the results of these studies, four themes emerged: (1) adequacy of informed consent; (2) consideration of paternal involvement; (3) balancing risks; and (4) access to research and treatment. A strength of this review is that it included perspectives of international research investigators, community leaders, and male partners. However, only two studies collected empiric data from PWLHIV regarding their experiences participating in research CONCLUSION: Researchers and funding agencies should be aware of these considerations and appreciate the value of and critical need for formative research to ensure clinical trials involving PWLHIV promote ethical, well-informed research participation and, ultimately, improve care outcomes. More research is needed to create a comprehensive ethical framework for researchers when conducting studies with PWLHIV.

Bibliometric Analysis of the English Musculoskeletal Literature over the Last 30 Years.

Publication and authorship are important in academia for career advancement, obtaining grants, and improved patient care. There has been a recent interest in bibliometric changes over time, especially regarding the gender gap. The purpose of this study was to explore bibliometric changes in the musculoskeletal literature. Bibliometric variables (number of authors, institutions, countries, pages, references, corresponding author position, author gender, geographic region of origin, and editorial board makeup) were analyzed for 5 basic science and 12 clinically oriented musculoskeletal journals from 1985 through 2016. Statistical analyses comprised bivariate analyses, multifactorial ANOVAs, and logistic regression analyses. A p < 0.005 was considered significant. Nearly, all variables increased over time. Asia had the highest number of authors and corresponding author positions, Australia/New Zealand the highest number of institutions and references, North America the highest number of pages, and Europe the highest number of countries. Those with a female first author had more authors, institutions, countries, references, and pages. Likewise, those with a female corresponding author had more authors, institutions, countries, references, and pages. Single-authored manuscripts decreased over time. The percentage of female first authors rose from 10.8% in 1985-1987 to 23.7% in 2015-2016. There were more female 1st authors in the basic science journals compared to the clinical journals (33.2% vs. 12.7%). Single-authored manuscripts were more likely to be written by males (5.1 vs. 2.4%) and decreased over time. The many differences by geographic region of origin likely reflect different socio/cultural attitudes regarding academia and research, as well as the gender composition of the disciplines by geographic region. Overall, there has been an increase in the number of female 1st and corresponding authors, editorial board members, and chief editors, indicating a slow but progressive narrowing of the gender gap.

A Bibliometric Study of Authorship and Collaboration Trends Over the Past 30 Years in Four Major Musculoskeletal Science Journals.

This study explored changes in bibliometric variables over the last 30 years for four major musculoskeletal science journals (BONE®), Calcified Tissue International® (CTI®), Journal of Bone and Mineral Research® (JBMR®), and Journal of Orthopaedic Research® (JOR®), with a specific focus on author gender. Bibliometric data were collected for all manuscripts in 1985 (BONE®, CTI®, JOR®), 1986 (JBMR®), 1995, 2005, and 2015; 2776 manuscripts met inclusion criteria. Manuscripts from Europe were more often published in BONE® or CTI®, while those from North America in JBMR® or JOR®. All journals demonstrated an increase over time in the number of authors (3.67-7.3), number of countries (1.1-1.4), number of institutions (1.4-3.1), and number of references (25.1-45.4). The number of manuscript pages increased (6.6-8.9) except for JOR® which showed a decline. CTI® had the lowest number of authors (4.9 vs. 5.6-6.8). There was a change in the corresponding author position from first to last for all journals; this change was highest for CTI® (35%) and lowest for BONE® (14.0%). All journals demonstrated an increase over time in female authors; however, CTI® was the highest amongst these four journals. The percentage of female first authors rose from 24.6 to 44.3% (CTI® 29.1-52.3%). The percentage of corresponding female authors rose from 17.5 to 33.6% (CTI® 22.9-40.0%). The proportion of female authors is increasing, likely reflecting the increasing number of women obtaining doctorates in science, medicine, and engineering.

A comprehensive review and meta-analysis of risk factors for statin-induced myopathy.

PURPOSE: To aid prescribers in assessing a patient's risk for statin-induced myopathy (SIM), we performed a comprehensive review of currently known risk factors and calculated aggregated odds ratios for each risk factor through a meta-analysis. METHODS: This meta-analysis was done through four phases: (1) Identification of the relevant primary literature; (2) abstract screening using inclusion and exclusion criteria; (3) detailed review and data extraction; and (4) synthesis and statistical analysis. RESULTS: Out of 44 papers analyzed from 836 papers searched from MEDLINE, 18 different potential risk factors were collected, divided into three categories: three demographics (11 papers), ten clinical factors (31 papers), and five pharmacogenetics/biomarkers (12 papers). Risk factors significant for myopathy and/or rhabdomyolysis included age, gender, diabetes, renal impairment, cardiovascular disease, certain interacting drugs, and mutations of the SLCO1B1 gene, which encodes a transporter protein in the liver. Several factors, such as gender, race, cardiovascular disease, and the GATM gene, which encodes a protein for creatine synthesis, appeared to be protective in terms of the outcomes of interest. CONCLUSIONS: This comprehensive assessment of risk factors can help support clinicians in reducing the incidence of SIM in their patient population on statins.

Historical Analysis of Bibliometric Trends in the Journal of Pediatric Orthopaedics With a Particular Focus on Sex.

BACKGROUND: Orthopaedics is the clinical discipline with the lowest percentage of female residents and faculty. Pediatric orthopaedics has a higher percentage of women than other orthopaedic subspecialties. It was the purpose of this study to examine bibliometric trends in the Journal of Pediatric Orthopaedics (JPO) with a specific focus on sex. METHODS: A bibliometeric analysis for the years 2015, 2005, 1995, 1985, 1981 was performed. The names of first and corresponding authors; corresponding author position; country of origin; number of institutions, countries, authors, printed pages, and references was tabulated. Author sex was identified for the first and corresponding authors using the "Baby Name Guesser" (www.gpeters.com/names/baby-names.php). A P<0.05 was considered significant. RESULTS: There were 746 publications; 68.7% were from North America. The average number of authors, corresponding author position, collaborating institutions, countries, and number of references increased, whereas the number of printed pages decreased. Asia had the greatest number of authors (4.4), with Australia/New Zealand the fewest (3.4). Sex was determined for 98.3% of the first authors and 98.5% of the corresponding authors. There was a significant increase in the number of female first authors over time (5.9% to 25.6%, P<10), especially in Europe and North America. There were significant increase in the number of female corresponding authors over time (5.8% to 17.6%, P=0.000009). There was a significant trend to have a greater percentage of both female first and corresponding authors over time (P=0.0005) with a reverse trend for both male first and corresponding authors (P<10). CONCLUSIONS: In this study, we noted that the number of female first and corresponding authors in Journal of Pediatric Orthopaedics has been steadily increasing. This should result in more female pediatric orthopaedic surgeons in academic faculty positions.

Combat-related Mild Traumatic Brain Injury: Association between Baseline Diffusion-Tensor Imaging Findings and Long-term Outcomes.

Purpose To determine whether functional outcomes of veterans who sustained combat-related mild traumatic brain injury (TBI) are associated with scalar metrics derived from diffusion-tensor (DT) imaging at their initial postdeployment evaluation. Materials and Methods This HIPAA-compliant retrospective study was approved by the institutional review board, and the requirement to obtain informed consent was waived. From 2010 to 2013, initial postdeployment evaluation, including clinical assessment and brain magnetic resonance (MR) examination with DT imaging, was performed in combat veterans who sustained mild TBI while deployed. Outcomes from chart review encompassed initial postdeployment clinical assessment as well as later functional status, including evaluation of occupational status and health care utilization. Scalar diffusion metrics from the initial postdeployment evaluation were compared with outcomes by using multivariate analysis. Veterans who did and did not return to work were also compared for differences in clinical variables by using t and χ(2) tests. Results Postdeployment evaluation was performed a mean of 3.8 years after injury (range, 0.5-9 years; standard deviation, 2.5 years). After a mean follow-up of 1.4 years (range, 0.5-2.5 years; standard deviation, 0.8 year), 34 of 57 veterans (60%) had returned to work. Return to work was associated with diffusion metrics in multiple regions of white matter, particularly in the left internal capsule and the left frontal lobe (P = .02-.05). Overall, veterans had a mean of 46 health care visits per year during the follow-up period (range, 3-196 visits per year; standard deviation, 41 visits per year). Cumulative health care visits over time were inversely correlated with diffusion anisotropy of the splenium of the corpus callosum and adjacent parietal white matter (P < .05). Clinical measures obtained during initial postdeployment evaluation were not predictive of later functional status (P = .12-.8). Conclusion Differences in white matter microstructure may partially account for the variance in functional outcomes among veterans who sustained combat-related mild TBI. (©) RSNA, 2016.

Classifying publications from the clinical and translational science award program along the translational research spectrum: a machine learning approach.

BACKGROUND: Translational research is a key area of focus of the National Institutes of Health (NIH), as demonstrated by the substantial investment in the Clinical and Translational Science Award (CTSA) program. The goal of the CTSA program is to accelerate the translation of discoveries from the bench to the bedside and into communities. Different classification systems have been used to capture the spectrum of basic to clinical to population health research, with substantial differences in the number of categories and their definitions. Evaluation of the effectiveness of the CTSA program and of translational research in general is hampered by the lack of rigor in these definitions and their application. This study adds rigor to the classification process by creating a checklist to evaluate publications across the translational spectrum and operationalizes these classifications by building machine learning-based text classifiers to categorize these publications. METHODS: Based on collaboratively developed definitions, we created a detailed checklist for categories along the translational spectrum from T0 to T4. We applied the checklist to CTSA-linked publications to construct a set of coded publications for use in training machine learning-based text classifiers to classify publications within these categories. The training sets combined T1/T2 and T3/T4 categories due to low frequency of these publication types compared to the frequency of T0 publications. We then compared classifier performance across different algorithms and feature sets and applied the classifiers to all publications in PubMed indexed to CTSA grants. To validate the algorithm, we manually classified the articles with the top 100 scores from each classifier. RESULTS: The definitions and checklist facilitated classification and resulted in good inter-rater reliability for coding publications for the training set. Very good performance was achieved for the classifiers as represented by the area under the receiver operating curves (AUC), with an AUC of 0.94 for the T0 classifier, 0.84 for T1/T2, and 0.92 for T3/T4. CONCLUSIONS: The combination of definitions agreed upon by five CTSA hubs, a checklist that facilitates more uniform definition interpretation, and algorithms that perform well in classifying publications along the translational spectrum provide a basis for establishing and applying uniform definitions of translational research categories. The classification algorithms allow publication analyses that would not be feasible with manual classification, such as assessing the distribution and trends of publications across the CTSA network and comparing the categories of publications and their citations to assess knowledge transfer across the translational research spectrum.

Meta-analysis and review of learner performance and preference: virtual versus optical microscopy.

CONTEXT: Over nearly two decades, a wealth of literature describing the various capabilities, uses and adaptations of virtual microscopy (VM) has been published. Many studies have investigated the effects on and benefits to student learning of VM compared with optical microscopy (OM). OBJECTIVES: This study statistically aggregated the findings of multiple comparative studies through a meta-analysis in order to summarise and substantiate the pedagogical efficacy of teaching with VM. METHODS: Using predefined eligibility criteria, teams of paired researchers screened the titles and abstracts of VM studies retrieved from seven different databases. After two rounds of screening, numerical and thematic data were extracted from the eligible studies for analysis. A summary effect size and estimate of heterogeneity were calculated to determine the effects of VM on learner performance and the amount of variance between studies, respectively. Trends in student perceptions were also analysed and reported. RESULTS: Of the 725 records screened, 72 studies underwent full-text review. In total, 12 studies were viable for meta-analysis and additional studies were reviewed to extract themes relating to learners' perceptions of VM. The meta-analysis detected a small yet significant positive effect on learner performance (standardised mean difference 0.28, 95% confidence interval 0.09-0.47; p = 0.003), indicating that learners experience marked knowledge gains when exposed to VM over OM. Variation among studies was evident as high heterogeneity was reported. An analysis of trends in learner perceptions noted that respondents favoured VM over OM by a large margin. CONCLUSIONS: Although many individual studies have reported non-significant findings in comparisons of VM and OM, the enhanced power afforded by meta-analysis revealed that the pedagogical approach of VM is modestly superior to that of OM and is preferred by learners.

Utilizing an integrated infrastructure for outcomes research: a systematic review.

OBJECTIVE: To explore the ability of an integrated health information infrastructure to support outcomes research. METHODS: A systematic review of articles published from 1983 to 2012 by Regenstrief Institute investigators using data from an integrated electronic health record infrastructure involving multiple provider organisations was performed. Articles were independently assessed and classified by study design, disease and other metadata including bibliometrics. RESULTS: A total of 190 articles were identified. Diseases included cognitive, (16) cardiovascular, (16) infectious, (15) chronic illness (14) and cancer (12). Publications grew steadily (26 in the first decade vs. 100 in the last) as did the number of investigators (from 15 in 1983 to 62 in 2012). The proportion of articles involving non-Regenstrief authors also expanded from 54% in the first decade to 72% in the last decade. During this period, the infrastructure grew from a single health system into a health information exchange network covering more than 6 million patients. Analysis of journal and article metrics reveals high impact for clinical trials and comparative effectiveness research studies that utilised data available in the integrated infrastructure. DISCUSSION: Integrated information infrastructures support growth in high quality observational studies and diverse collaboration consistent with the goals for the learning health system. More recent publications demonstrate growing external collaborations facilitated by greater access to the infrastructure and improved opportunities to study broader disease and health outcomes. CONCLUSIONS: Integrated information infrastructures can stimulate learning from electronic data captured during routine clinical care but require time and collaboration to reach full potential.

A Network Meta-analysis of Dexamethasone for Preventing Postextubation Upper Airway Obstruction in Children.

Rationale: Periextubation corticosteroids are commonly used in children to prevent upper airway obstruction (UAO). However, the best timing and dose combination of corticosteroids is unknown. Objectives: To compare effectiveness of different corticosteroid regimens in preventing UAO and reintubation. Methods: MEDLINE, CINAHL, and Embase search identified randomized trials in children using corticosteroids to prevent UAO. All studies used dexamethasone. The studies were categorized based on timing of initiation of dexamethasone (early use: >12 h before extubation) and the dose (high dose: ⩾0.5 mg/kg/dose). We performed Bayesian network meta-analysis with studies grouped into four regimens: high dose, early use (HE); low dose, early use (LE); high dose, late use (HL); and low dose, late use. Results: Eight trials (n = 903) were included in the analysis. For preventing UAO (odds ratio; 95% credible interval), HE (0.13; 0.04-0.36), HL (0.39; 0.19-0.74), and LE (0.15; 0.04-0.58) regimens appear to be more effective than no dexamethasone (low certainty). HE and LE had the highest probability of being the top-ranked regimens for preventing UAO (surface under the cumulative ranking curve 0.901 and 0.808, respectively). For preventing reintubation, the effect estimate was imprecise for all four dexamethasone regimens compared with no dexamethasone (very low certainty). HE and LE were the top-ranked regimens (surface under the cumulative ranking curve 0.803 and 0.720, respectively) for preventing reintubation. Sensitivity analysis showed that regimens that started >12 hours before extubation were likely more effective than regimens started >6 hours before extubation. Conclusions: Periextubation dexamethasone can prevent postextubation UAO in children, but effectiveness is highly dependent on timing and dosing regimen. Early initiation (ideally >12 h before extubation) appears to be more important than the dose of dexamethasone. Ultimately, the specific steroid strategy should be personalized, considering the potential for adverse events associated with dexamethasone and the individual risk of UAO and reintubation.

Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children: A Systematic Review and Network Meta-Analysis.

Importance: Extubation failure (EF) has been associated with worse outcomes in critically ill children. The relative efficacy of different modes of noninvasive respiratory support (NRS) to prevent EF is unknown. Objective: To study the reported relative efficacy of different modes of NRS (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and bilevel positive airway pressure [BiPAP]) compared to conventional oxygen therapy (COT). Data Sources: MEDLINE, Embase, and CINAHL Complete through May 2022. Study Selection: Randomized clinical trials that enrolled critically ill children receiving invasive mechanical ventilation for more than 24 hours and compared the efficacy of different modes of postextubation NRS. Data Extraction and Synthesis: Random-effects models were fit using a bayesian network meta-analysis framework. Between-group comparisons were estimated using odds ratios (ORs) or mean differences with 95% credible intervals (CrIs). Treatment rankings were assessed by rank probabilities and the surface under the cumulative rank curve (SUCRA). Main Outcomes and Measures: The primary outcome was EF (reintubation within 48 to 72 hours). Secondary outcomes were treatment failure (TF, reintubation plus NRS escalation or crossover to another NRS mode), pediatric intensive care unit (PICU) mortality, PICU and hospital length of stay, abdominal distension, and nasal injury. Results: A total of 11 615 citations were screened, and 9 randomized clinical trials with a total of 1421 participants were included. Both CPAP and HFNC were found to be more effective than COT in reducing EF and TF (CPAP: OR for EF, 0.43; 95% CrI, 0.17-1.0 and OR for TF 0.27, 95% CrI 0.11-0.57 and HFNC: OR for EF, 0.64; 95% CrI, 0.24-1.0 and OR for TF, 0.34; 95% CrI, 0.16- 0.65). CPAP had the highest likelihood of being the best intervention for both EF (SUCRA, 0.83) and TF (SUCRA, 0.91). Although not statistically significant, BiPAP was likely to be better than COT for preventing both EF and TF. Compared to COT, CPAP and BiPAP were reported as showing a modest increase (approximately 3%) in nasal injury and abdominal distension. Conclusions and Relevance: The studies included in this systematic review and network meta-analysis found that compared with COT, EF and TF rates were lower with modest increases in abdominal distension and nasal injury. Of the modes evaluated, CPAP was associated with the lowest rates of EF and TF.

Operational Definitions Related to Pediatric Ventilator Liberation.

BACKGROUND: Common, operational definitions are crucial to assess interventions and outcomes related to pediatric mechanical ventilation. These definitions can reduce unnecessary variability among research and quality improvement efforts, to ensure findings are generalizable, and can be pooled to establish best practices. RESEARCH QUESTION: Can we establish operational definitions for key elements related to pediatric ventilator liberation using a combination of detailed literature review and consensus-based approaches? STUDY DESIGN AND METHODS: A panel of 26 international experts in pediatric ventilator liberation, two methodologists, and two librarians conducted systematic reviews on eight topic areas related to pediatric ventilator liberation. Through a series of virtual meetings, we established draft definitions that were voted upon using an anonymous web-based process. Definitions were revised by incorporating extracted data gathered during the systematic review and discussed in another consensus meeting. A second round of voting was conducted to confirm the final definitions. RESULTS: In eight topic areas identified by the experts, 16 preliminary definitions were established. Based on initial discussion and the first round of voting, modifications were suggested for 11 of the 16 definitions. There was significant variability in how these items were defined in the literature reviewed. The final round of voting achieved ≥ 80% agreement for all 16 definitions in the following areas: what constitutes respiratory support (invasive mechanical ventilation and noninvasive respiratory support), liberation and failed attempts to liberate from invasive mechanical ventilation, liberation from respiratory support, duration of noninvasive respiratory support, total duration of invasive mechanical ventilation, spontaneous breathing trials, extubation readiness testing, 28 ventilator-free days, and planned vs rescue use of post-extubation noninvasive respiratory support. INTERPRETATION: We propose that these consensus-based definitions for elements of pediatric ventilator liberation, informed by evidence, be used for future quality improvement initiatives and research studies to improve generalizability and facilitate comparison.

Third-year medical students' knowledge of privacy and security issues concerning mobile devices.

BACKGROUND: The use of mobile devices are ubiquitous in medical-care professional settings, but information on privacy and security concerns of mobile devices for medical students is scarce. AIMS: To gain baseline information about third-year medical students' mobile device use and knowledge of privacy and security issues concerning mobile devices. METHODS: We surveyed 67 third-year medical students at a Midwestern university on their use of mobile devices and knowledge of how to protect information available through mobile devices. Students were also presented with clinical scenarios to rate their level of concern in regards to privacy and security of information. RESULTS: The most used features of mobile devices were: voice-to-voice (100%), text messaging (SMS) (94%), Internet (76.9%), and email (69.3%). For locking of one's personal mobile phone, 54.1% never physically lock their phone, and 58% never electronically lock their personal PDA. Scenarios considering definitely privacy concerns include emailing patient information intact (66.7%), and posting de-identified information on YouTube (45.2%) or Facebook (42.2%). CONCLUSIONS: As the ease of sharing data increases with the use of mobile devices, students need more education and training on possible privacy and security risks posed with mobile devices.

Use of social network analysis tools to validate a resources infrastructure for interinstitutional translational research: a case study.

QUESTION: How can knowledge management and innovative technology, cornerstones of library practice, be leveraged to validate the progress of Clinical and Translational Science Awards? SETTING: The Indiana Clinical and Translational Sciences Institute (Indiana CTSI) promotes interdisciplinary research across academic institutions. METHODS: Using social networking tools and knowledge management skills enabled the department of knowledge informatics and translation to create a visualization of utilization of resources across different Indiana CTSI programs and coauthorship and citation patterns. RESULTS: Contacts with different resources per investigator increased; every targeted program was shown to be linked to another. Analysis of publications established a baseline to further analyze the scientific contribution of Indiana CTSI projects. CONCLUSION: Knowledge management and social networking utilities validated the efficacy of the Indiana CTSI resources infrastructure and demonstrated visualization of collaboration. The bibliometric analysis of publications provides a basis for assessing longer-term contributions of support to scientific discovery and transdisciplinary science.

Risk Factors for Bleeding and Clinical Ineffectiveness Associated With Clopidogrel Therapy: A Comprehensive Meta-Analysis.

Although clopidogrel is a frequently used antiplatelet medication to treat and prevent atherothrombotic disease, clinicians must balance its clinical effectiveness with the potential side effect of bleeding. However, many previous studies have evaluated beneficial and adverse factors separately. The objective of our study was to perform a comprehensive meta-analysis of studies of clopidogrel's clinical effectiveness and/or risk of bleeding in order to identify and assess all reported risk factors, thus helping clinicians to balance patient safety with drug efficacy. We analyzed randomized controlled trials (RCTs) of maintenance use in four stages: search for relevant primary articles; abstract and full article screening; quality assessment and data extraction; and synthesis and data analysis. Screening of 7,109 articles yielded 52 RCTs that met the inclusion criteria. Twenty-seven risk factors were identified. "Definite risk factors" were defined as those with aggregated odds ratios (ORs) > 1 and confidence intervals (CIs) > 1 if analyzed in more than one study. Definite risk factors for major bleeding were concomitant aspirin use (OR 2.83, 95% CI 2.04-3.94) and long duration of clopidogrel therapy (> 6 months) (OR 1.74, 95% CI 1.21-2.50). Dual antiplatelet therapy, extended clopidogrel therapy, and high maintenance dose (150 mg/day) of clopidogrel were definite risk factors for any bleeding. Reduced renal function, both mild and severe, was the only definite risk factor for clinical ineffectiveness. These findings can help clinicians predict the risks and effectiveness of clopidogrel use for their patients and be used in clinical decision support tools.