National Association of Medical Examiners position paper: Recommendations for the investigation and certification of deaths in people with epilepsy.

Sudden unexpected death of an individual with epilepsy can pose a challenge to death investigators, as most deaths are unwitnessed, and the individual is commonly found dead in bed. Anatomic findings (eg, tongue/lip bite) are commonly absent and of varying specificity, thereby limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention constituted an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden unexpected death in a person with epilepsy is encountered.

National Association of Medical Examiners Position Paper: Recommendations for the Investigation and Certification of Deaths in People with Epilepsy.

Sudden unexpected death of an individual with epilepsy (SUDEP) can pose a challenge to death investigators, as most deaths are unwitnessed and the individual is commonly found dead in bed. Anatomic findings (e.g., tongue/lip bite) are commonly absent and of varying specificity, limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus, it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden, unexpected death in a person with epilepsy is encountered.

Collaboration challenges in systematic reviews: a survey of health sciences librarians.

OBJECTIVE: While many librarians have been asked to participate in systematic reviews with researchers, often these researchers are not familiar with the systematic review process or the appropriate role for librarians. The purpose of this study was to identify the challenges and barriers that librarians face when collaborating on systematic reviews. To take a wider view of the whole process of collaborating on systematic reviews, the authors deliberately focused on interpersonal and methodological issues other than searching itself. METHODS: To characterize the biggest challenges that librarians face while collaborating on systematic review projects, we used a web-based survey. The thirteen-item survey included seventeen challenges grouped into two categories: methodological and interpersonal. Participants were required to indicate the frequency and difficulty of the challenges listed. Open-ended questions allowed survey participants to describe challenges not listed in the survey and to describe strategies used to overcome challenges. RESULTS: Of the 17 challenges listed in the survey, 8 were reported as common by over 40% of respondents. These included methodological issues around having too broad or narrow research questions, lacking eligibility criteria, having unclear research questions, and not following established methods. The remaining challenges were interpersonal, including issues around student-led projects and the size of the research team. Of the top 8 most frequent challenges, 5 were also ranked as most difficult to handle. Open-ended responses underscored many of the challenges included in the survey and revealed several additional challenges. CONCLUSIONS: These results suggest that the most frequent and challenging issues relate to development of the research question and general communication with team members. Clear protocols for collaboration on systematic reviews, as well as a culture of mentorship, can help librarians prevent and address these challenges.

Mental health stigma and barriers to mental health care for first responders: A systematic review and meta-analysis.

OBJECTIVE: It is unclear how many first responders experience barriers to care and stigma regarding mental health care, and how this influences their help-seeking. A systematic review and meta-analysis was conducted on barriers to care and mental health stigma in first responders and their empirical relationship with psychosocial and psychiatric variables. METHODS: The databases Medline, Embase PsycINFO, CINAHL, PILOTS, LILACS, Sociological Abstracts, SocINDEX, and Social Citation Index were searched to identify relevant studies. A quality assessment and meta-analysis was performed. RESULTS: Fourteen articles met inclusion criteria, from which data from 12 samples were extracted for meta-analyses. All studies measured stigma regarding mental health care and 33.1% of first responders (95% CI 26.7-40.1; 12 individual samples) endorsed stigma items. The systematic review revealed that the most frequently endorsed items were fears regarding confidentiality and negative career impact. Five of 14 studies measured barriers to mental health care and 9.3% of first responders (95% CI 7.0-12.3; 4 individual samples) endorsed barriers to care items. The most frequently endorsed barriers were scheduling concerns and not knowing where to get help. Indications were found for more stigma and barriers in individuals with mental health problems. CONCLUSIONS: Stigma and barriers to care are experienced by a significant proportion of firs responders, which can potentially lead to delayed presentation in mental health care and therefore, increased risk of chronicity of post-trauma psychopathology for these groups. The current systematic review draws attention to the paucity of research in this area, particularly in non-Western samples.

Pulmonary and cardiac pathology in sudden unexpected death in epilepsy (SUDEP).

OBJECTIVE: To review studies on structural pulmonary and cardiac changes in SUDEP cases as well as studies showing pulmonary or cardiac structural changes in living epilepsy patients. METHODS: We conducted electronic literature searches using the PubMed database for articles published in English, regardless of publication year, that included data on cardiac and/or pulmonary structural abnormalities in SUDEP cases or in living epilepsy patients during the postictal period. RESULTS: Fourteen postmortem studies reported pulmonary findings in SUDEP cases. Two focused mainly on assessing lung weights in SUDEP cases versus controls; no group difference was found. The other 12 reported descriptive autopsy findings. Among all SUDEP cases with available descriptive postmortem pulmonary examination, 72% had pulmonary changes, most often pulmonary edema/congestion, and, less frequently, intraalveolar hemorrhage. Eleven studies reported on cardiac pathology in SUDEP. Cardiac abnormalities were found in approximately one-fourth of cases. The most common findings were myocyte hypertrophy and myocardial fibrosis of various degrees. Among living epilepsy patients, postictal pulmonary pathology was the most commonly reported pulmonary abnormality and the most common postictal cardiac abnormality was transient left ventricular dysfunction - Takotsubo or neurogenic stunned myocardium. SIGNIFICANCE: Cardiac and pulmonary pathological abnormalities are frequent among SUDEP cases, most commonly pulmonary edema/congestion and focal interstitial myocardial fibrosis. Most findings are not quantified, with subjective elements and undefined interobserver reliability, and lack of controls such as matched epilepsy patients who died from other causes. Further, studies have not systematically evaluated potential confounding factors, including postmortem interval to autopsy, paramedic resuscitation and IV fluids administration, underlying heart/lung disease, and risk factors for cardiac or pulmonary disease. Prospective studies with controls are needed to define the heart and lung changes in SUDEP and understand their potential relationship to mechanisms of death in SUDEP.

Regional versus general anaesthesia for improved cognitive function after procedures other than cardiac surgery or neurosurgery in adult and paediatric patients.

This is the protocol for a review and there is no abstract. The objectives are as follows: The objective of this review is to compare the effects of regional versus general anaesthesia on cognitive function after procedures other than cardiac surgery or neurosurgery in adult and in paediatric patients.

Starting the data conversation: informing data services at an academic health sciences library.

OBJECTIVE: The research obtained information to plan data-related products and services. METHODS: Biomedical researchers in an academic medical center were selected using purposive sampling and interviewed using open-ended questions based on a literature review. Interviews were conducted until saturation was achieved. RESULTS: Interview responses informed library planners about researchers' key data issues. CONCLUSIONS: This approach proved valuable for planning data management products and services and raising library visibility among clients in the research data realm.

Health sciences librarians, patient contact, and secondary traumatic stress.

OBJECTIVE: The purpose of this study was to determine the prevalence of secondary traumatic stress (STS) in health sciences librarians (HSLs) who have direct contact with traumatized individuals and their families. METHODS: A twenty-five-item survey and the Secondary Traumatic Stress Scale (STSS) were distributed via email to three Medical Library Association email discussion lists. RESULTS: A total of fifty-five HSLs responded to the survey. Survey results indicate moderate levels of STS and variability of symptoms among participants. CONCLUSIONS: Library and employee assistance program managers should be aware of the emotional toll of patient and/or family contact for HSLs.

Pharmacologic androgen deprivation and cardiovascular disease risk factors: a systematic review.

BACKGROUND: Pharmacologic androgen deprivation therapy (ADT) is widely used to treat prostate cancer. Observational studies suggest ADT is associated with cardiovascular disease and its risk factors; however, such studies may be subject to bias. Our objective was to evaluate the effect of ADT on cardiovascular disease risk factors using data from randomized controlled trials (RCTs). MATERIALS AND METHODS: We conducted a systematic review using MEDLINE and MEDLINE In-Process (1950-June 2013), EMBASE (1974-June 2013) and Web of Science (1900-June 2013) for all RCTs in men with prostate cancer that compared pharmacologic ADT (i.e. use of gonadotropin-releasing hormone agonist or antagonist) with a group that did not receive ADT and reported data on cardiovascular disease risk factors including blood pressure, cholesterol, triglycerides, fibrinogen, biomarkers of insulin sensitivity, adiposity and C-reactive protein. We also searched for ongoing or unpublished trials. This study was registered at the PROSPERO International Prospective Register of Systematic Reviews (CRD42013005035). RESULTS: Of the 3272 unique publications identified in our systematic review, we did not identify a single RCT that reported data on any cardiovascular disease risk factor. We were unable to locate unreported data from corresponding authors or study sponsors. CONCLUSIONS: There is a lack of published, reliable evidence describing the effects of ADT on cardiovascular disease risk factors. RCTs have likely collected data on these risk factors as part of routine study monitoring; however, these data have not been published. To understand the effect of ADT on cardiovascular morbidity, these data must be made available to the scientific community.

Leveraging technology and staffing in developing a new liaison program.

With nearly all library resources and services delivered digitally, librarians working for the New York University Health Sciences Library struggled with maintaining awareness of changing user needs, understanding barriers faced in using library resources and services, and determining knowledge management challenges across the organization. A liaison program was created to provide opportunities for librarians to meaningfully engage with users. The program was directed toward a subset of high-priority user groups to provide focused engagement with these users. Responsibility for providing routine reference service was reduced for liaison librarians to provide maximum time to engage with their assigned user communities.

Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases.

OBJECTIVE: To conduct a systematic review to identify surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy (LSG). BACKGROUND: LSG is growing in popularity as a primary bariatric procedure. Technical aspects of LSG including bougie size remain controversial. METHODS: Our systematic review yielded 112 studies encompassing 9991 LSG patients. A general estimating equation (GEE) model was used to calculate the odds ratio (OR) for leak based on bougie size, distance from the pylorus, and use of buttressing on the staple line. Baseline characteristics, including age and body mass index (BMI), were included. A linear repeated measures regression model compared excess weight loss (%EWL) between bougie sizes. RESULTS: A total of 198 leaks in 8922 patients (2.2%) were identified. The GEE model revealed that the risk of leak decreased with bougie ≥40 Fr (OR = 0.53, 95% CI = [0.37-0.77]; P = 0.0009). Buttressing did not impact leak. There was no difference in %EWL between bougie <40 Fr and bougie ≥40 Fr up to 36 months (mean: 70.1% EWL; P = 0.273). Distance from the pylorus did not affect leak or %EWL. CONCLUSIONS: Utilizing bougie ≥40 Fr may decrease leak without impacting %EWL up to 3 years. Distance from the pylorus does not impact leak or weight loss. Buttressing does not seem to impact leak; however, if surgeons desire to buttress, bioabsorbable material is the most common type used. Longer-term studies are needed to definitively determine the effect of bougie size on weight loss after LSG.

Agent of opportunity risk mitigation: people, engineering, and security efficacy.

BACKGROUND: Agents of opportunity (AO) are potentially harmful biological, chemical, radiological, and pharmaceutical substances commonly used for health care delivery and research. AOs are present in all academic medical centers (AMC), creating vulnerability in the health care sector; AO attributes and dissemination methods likely predict risk; and AMCs are inadequately secured against a purposeful AO dissemination, with limited budgets and competing priorities. We explored health care workers' perceptions of AMC security and the impact of those perceptions on AO risk. METHODS: Qualitative methods (survey, interviews, and workshops) were used to collect opinions from staff working in a medical school and 4 AMC-affiliated hospitals concerning AOs and the risk to hospital infrastructure associated with their uncontrolled presence. Secondary to this goal, staff perception concerning security, or opinions about security behaviors of others, were extracted, analyzed, and grouped into themes. RESULTS: We provide a framework for depicting the interaction of staff behavior and access control engineering, including the tendency of staff to "defeat" inconvenient access controls. In addition, 8 security themes emerged: staff security behavior is a significant source of AO risk; the wide range of opinions about "open" front-door policies among AMC staff illustrates a disparity of perceptions about the need for security; interviewees expressed profound skepticism concerning the effectiveness of front-door access controls; an AO risk assessment requires reconsideration of the security levels historically assigned to areas such as the loading dock and central distribution sites, where many AOs are delivered and may remain unattended for substantial periods of time; researchers' view of AMC security is influenced by the ongoing debate within the scientific community about the wisdom of engaging in bioterrorism research; there was no agreement about which areas of the AMC should be subject to stronger access controls; security personnel play dual roles of security and customer service, creating the negative perception that neither role is done well; and budget was described as an important factor in explaining the state of security controls. CONCLUSIONS: We determined that AMCs seeking to reduce AO risk should assess their institutionally unique AO risks, understand staff security perceptions, and install access controls that are responsive to the staff's tendency to defeat them. The development of AO attribute fact sheets is desirable for AO risk assessment; new funding and administrative or legislative tools to improve AMC security are required; and security practices and methods that are convenient and effective should be engineered.

Developing a consensus framework and risk profile for agents of opportunity in academic medical centers: implications for public health preparedness.

Agents of opportunity (AO) in academic medical centers (AMC) are defined as unregulated or lightly regulated substances used for medical research or patient care that can be used as "dual purpose" substances by terrorists to inflict damage upon populations. Most of these agents are used routinely throughout AMC either during research or for general clinical practice. To date, the lack of careful regulations for AOs creates uncertain security conditions and increased malicious potential. Using a consensus-based approach, we collected information and opinions from staff working in an AMC and 4 AMC-affiliated hospitals concerning identification of AO, AO attributes, and AMC risk and preparedness, focusing on AO security and dissemination mechanisms and likely hospital response. The goal was to develop a risk profile and framework for AO in the institution. Agents of opportunity in 4 classes were identified and an AO profile was developed, comprising 16 attributes denoting information critical to preparedness for AO misuse. Agents of opportunity found in AMC present a unique and vital gap in public health preparedness. Findings of this project may provide a foundation for a discussion and consensus efforts to determine a nationally accepted risk profile framework for AO. This foundation may further lead to the implementation of appropriate regulatory policies to improve public health preparedness. Agents of opportunity modeling of dissemination properties should be developed to better predict AO risk.