Standardized Management for Hypoxemic Respiratory Failure and ARDS: Systematic Review and Meta-analysis.

BACKGROUND: Treatment of hypoxemic respiratory failure (HRF) and ARDS is complex. Standardized management of HRF and ARDS may improve adherence to evidence-informed practice and improve outcomes. RESEARCH QUESTION: What is the effect of standardized treatment compared with usual care on survival of patients with HRF and ARDS? STUDY DESIGN AND METHODS: MEDLINE, EMBASE, Cochrane, CINAHL, Scopus, and Web-of-Science were searched (inception to 2018). Included studies were randomized clinical trials or quasi-experimental studies that examined the effect of standardized treatment (care-protocol, care-pathway, or bundle) compared with usual treatment among mechanically ventilated adult patients admitted to an ICU with HRF or ARDS. Study characteristics, pathway components, and patient outcomes were abstracted independently by two reviewers. RESULTS: From 15,932 unique citations, 14 studies were included in the systematic review (three randomized clinical trials and 11 quasi-experimental studies). Twelve studies (including 5,767 patients) were included in the meta-analysis. Standardized management of HRF was associated with a 23% relative reduction in mortality (relative risk, 0.77; 95% CI, 0.65-0.91; I2, 70%; P = .002). In studies targeting patients with ARDS (n = 8), a 21% pooled mortality reduction was observed (relative risk, 0.79; 95% CI, 0.71-0.88; I2, 3.1%). Standardized management was associated with increased 28-day ventilator-free days (weighted mean difference, 3.48 days; 95% CI, 2.43-4.54 days; P < .001). Standardized management was also associated with a reduction in tidal volume (weighted mean difference, -1.80 mL/kg predicted body weight; 95% CI, -2.80 to -0.80 mL/kg predicted body weight; P < .001). Meta-regression demonstrated that the reduction in mortality was associated with provision of lower tidal volume (P = .045). INTERPRETATION: When compared with usual treatment, standardized treatment of patients with HRF and ARDS is associated with increased ventilator-free days, lower tidal volume ventilation, and lower mortality. ICUs should consider the use of standardized treatment to improve the processes and outcomes of care for patients with HRF and ARDS. CLINICAL TRIAL REGISTRATION: PROSPERO; No.: CRD42019099921; URL: www.crd.york.ac.uk/prospero/.

Systematic review: medical therapy for fibrostenosing Crohn's disease.

BACKGROUND: Medical therapy and/or endoscopic balloon dilation with intralesional therapies are options for the treatment of small bowel fibrostenotic Crohn's disease (CD). AIM: To perform a systematic review summarising evidence for efficacy of systemic and endoscopic intralesional medical therapy in established small bowel strictures in adult CD patients. METHODS: A systematic search of MEDLINE, EMBASE, CENTRAL and Scopus was conducted. Primary outcomes were rates of surgical resection and repeat endoscopic dilation. Pooled event rates from random effects models across studies with 95% confidence intervals were reported. RESULTS: Ten studies describing systemic medical therapy and eight studies of intralesional injection were included. One randomised controlled trial each for systemic therapy and intrastricture injection were identified. Only observational studies were found for systemic biologic therapies, which exclusively included tumour necrosis factor (TNF) antagonists, while intralesional therapies all involved corticosteroids except for one study that evaluated infliximab. Pooled event rates for surgical resection after systemic and intralesional therapy were 28.3% (95% CI: 18.2%-41.3%) and 18.5% (95% CI: 8.3%-36.2%), respectively over a median follow-up of 23 months (range 5.5-105.8), and 21.8 months (range 5-47). Risk of repeat endoscopic balloon dilation in those with intralesional therapy was 58.3% (95% CI: 36.6%-77.3%) over a median follow-up of 21.8 months (range 5-47). CONCLUSIONS: There are no favoured therapies for patients with stricturing small bowel CD. Data are lacking for ustekinumab and vedolizumab. No endoscopic intralesional medications provided a clear benefit for prevention of repeat EBD or surgery.

Systematic review and meta-analysis of cardiac involvement in mitochondrial myopathy.

OBJECTIVE: Our goal was to perform a systematic review of the literature to demonstrate the prevalence of cardiac abnormalities identified using cardiac investigations in patients with mitochondrial myopathy (MM). METHODS: This systematic review surveys the available evidence for cardiac investigations in MM from a total of 21 studies including 825 participants. Data were stratified by genetic mutation and clinical syndrome. RESULTS: We identified echocardiogram and ECG as the principal screening modalities that identify cardiac structural (29%) and conduction abnormalities (39%) in various MM syndromes. ECG abnormalities were more prevalent in patients with m.3243A>G mutations than other gene defects, and patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) had a higher prevalence of ECG abnormalities than patients with other clinical syndromes. Echocardiogram abnormalities were significantly more prevalent in patients with m.3243A>G or m.8344A>G mutations compared with other genetic mutations. Similarly, MELAS and MERRF had a higher prevalence compared with other syndromes. We observed a descriptive finding of an increased prevalence of ECG abnormalities in pediatric patients compared with adults. CONCLUSIONS: This analysis supports the presence of a more severe cardiac phenotype in MELAS and myoclonic epilepsy with ragged red fibres syndromes and with their commonly associated genetic mutations (m.3243A>G and m.8344A>G). This provides the first evidence basis on which to provide more intensive cardiac screening for patients with certain clinical syndromes and genetic mutations. However, the data are based on a small number of studies. We recommend further studies of natural history, therapeutic response, pediatric participants, and cardiac MRI as areas for future investigation.

Antenatal predictors of outcome in prenatally diagnosed congenital diaphragmatic hernia (CDH).

BACKGROUND: Pulmonary hypoplasia is the main cause of mortality in isolated congenital diaphragmatic hernia (CDH) and its prediction is paramount when counseling parents. We sought to identify antenatal parameters that predicted neonatal mortality in CDH. METHOD: Search was conducted in MEDLINE, EMBASE, Cochrane Database of Systematic reviews, PubMed, Scopus, and Web of Science on the ability of lung-to-head ratio (LHR), observed-to-expected LHR (o/e LHR), total fetal lung volume (TFLV), o/e TFLV, percentage predicted lung volume (PPLV) and degree of liver herniation to predict neonatal morbidity and mortality in fetuses with CDH. Primary outcome was perinatal survival and secondary was the use of extracorporeal membrane oxygenation (ECMO). RESULTS: Until April 2016, 1067 articles were found, of which 22 were included in our meta-analysis. This showed that the odds of survival with LHR <1.0 and liver herniation on ultrasound were 0.14 (CI 0.10-0.27) and 0.21 (CI 0.13-0.35) respectively. Mean LHR, o/e LHR, absolute TFLV, o/e TFLV, PPLV and liver herniation all predicted survival, however o/e LHR and o/e TFLV performed best in this prediction. When the longest diameter measurement method was used, the o/e TFLV (summary area under curve (AUC) 0.8) was slightly superior to o/e LHR (summary AUC 0.78). This difference disappeared when LHR was measured by the trace method. The most discriminatory threshold for O/E LHR and O/E TFLV was 25%. LHR <1 was predictive of extracorporeal life support (ECLS) use. CONCLUSION: O/E LHR, o/e TFLV (thresholds of 25%) and liver herniation are good predictors of mortality in CDH. LEVEL OF EVIDENCE: Level II Type of study: Systematic review and meta-analysis.

The status of accreditation in primary care.

BACKGROUND: One method utilised to improve the quality of health care is accreditation. Although accreditation has been extensively used in the acute care sector, its presence in primary care is limited and so is our understanding of its nature, uptake and associated outcomes. Because acute care and primary care environments are vastly different, our understanding of acute care accreditation cannot simply be translated to primary care. AIM: The purpose of this paper was to explore the current state of primary care accreditation. METHODS: An extensive search was completed examining peer-reviewed and grey literature. In addition, interviews with key stakeholders involved in primary care accreditation were undertaken. RESULTS: From the 501 reviewed abstracts, 62 papers were used in this review in addition to 72 sources from grey literature. Eight interviews were also held with key informants. CONCLUSIONS: In this review of the available literature of accreditation within primary care, it was found that accreditation in this sector is generally non-government funded and voluntary with some countries offering financial incentives. It was evident that there is a dearth of research on the nature and uptake of accreditation in this sector, along with how accreditation affects outcomes of care, whether it is an effective method to improve quality, perceptions of care, healthcare utilisation and costs. These findings imply that further research is required to examine the possible impact accreditation may have on health care within primary care.