Prehospital spine immobilization/spinal motion restriction in penetrating trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST).

BACKGROUND: Spine immobilization in trauma has remained an integral part of most emergency medical services protocols despite a lack of evidence for efficacy and concern for associated complications, especially in penetrating trauma patients. We reviewed the published evidence on the topic of prehospital spine immobilization or spinal motion restriction in adult patients with penetrating trauma to structure a practice management guideline. METHODS: We conducted a Cochrane style systematic review and meta-analysis and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology to construct recommendations. Qualitative and quantitative analyses were used to evaluate the literature on the critical outcomes of mortality, neurologic deficit, and potentially reversible neurologic deficit. RESULTS: A total of 24 studies met inclusion criteria, with qualitative review conducted for all studies. We used five studies for the quantitative review (meta-analysis). No study showed benefit to spine immobilization with regard to mortality and neurologic injury, even for patients with direct neck injury. Increased mortality was associated with spine immobilization, with risk ratio [RR], 2.4 (confidence interval [CI], 1.07-5.41). The rate of neurologic injury or potentially reversible injury was very low, ranging from 0.002 to 0.076 and 0.00034 to 0.055, with no statistically significant difference for neurologic deficit or potentially reversible deficit, RR, 4.16 (CI, 0.56-30.89), and RR, 1.19 (CI, 0.83-1.70), although the point estimates favored no immobilization. CONCLUSION: Spine immobilization in penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurologic deficits, even potentially reversible neurologic deficits. We recommend that spine immobilization not be used routinely for adult patients with penetrating trauma. LEVEL OF EVIDENCE: Systematic review with meta-analysis study, level III.

Use of the analytic hierarchy process for medication decision-making in type 2 diabetes.

AIM: To investigate the feasibility and utility of the Analytic Hierarchy Process (AHP) for medication decision-making in type 2 diabetes. METHODS: We conducted an AHP with nine diabetes experts using structured interviews to rank add-on therapies (to metformin) for type 2 diabetes. During the AHP, participants compared treatment alternatives relative to eight outcomes (hemoglobin A1c-lowering and seven potential harms) and the relative importance of the different outcomes. The AHP model and instrument were pre-tested and pilot-tested prior to use. Results were discussed and an evaluation of the AHP was conducted during a group session. We conducted the quantitative analysis using Expert Choice software with the ideal mode to determine the priority of treatment alternatives. RESULTS: Participants judged exenatide to be the best add-on therapy followed by sitagliptin, sulfonylureas, and then pioglitazone. Maximizing benefit was judged 21% more important than minimizing harm. Minimizing severe hypoglycemia was judged to be the most important harm to avoid. Exenatide was the best overall alternative if the importance of minimizing harms was prioritized completely over maximizing benefits. Participants reported that the AHP improved transparency, consistency, and an understanding of others' perspectives and agreed that the results reflected the views of the group. CONCLUSIONS: The AHP is feasible and useful to make decisions about diabetes medications. Future studies which incorporate stakeholder preferences should evaluate other decision contexts, objectives, and treatments.

The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis.

IMPORTANCE: Trauma is known to be one of the strongest risk factors for pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin therapy for prevention of PE, but trauma places some patients at risk of excess bleeding. Experts are divided on the role of prophylactic inferior vena cava (IVC) filters to prevent PE. OBJECTIVE: To perform a systematic review and meta-analysis examining the comparative effectiveness of prophylactic IVC filters in trauma patients, particularly in preventing PE, fatal PE, and mortality. DATA SOURCES: We searched the following databases for primary studies: MEDLINE, EMBASE, Scopus, CINAHL, International Pharmaceutical Abstracts, clinicaltrial.gov, and the Cochrane Library (all through July 31, 2012). We developed a search strategy using medical subject headings terms and text words of key articles that we identified a priori. We reviewed the references of all included articles, relevant review articles, and related systematic reviews to identify articles the database searches might have missed. STUDY SELECTION: We reviewed titles followed by abstracts to identify randomized clinical trials or observational studies with comparison groups reporting on the effectiveness and/or safety of IVC filters for prevention of venous thromboembolism in trauma patients. DATA EXTRACTION AND SYNTHESIS: Two investigators independently reviewed abstracts and abstracted data. For studies amenable to pooling with meta-analysis, we pooled using the random-effects model to analyze the relative risks. We graded the quantity, quality, and consistency of the evidence by adapting an evidence-grading scheme recommended by the Agency for Healthcare Research and Quality. RESULTS: Eight controlled studies compared the effectiveness of no IVC filter vs IVC filter on PE, fatal PE, deep vein thrombosis, and/or mortality in trauma patients. Evidence showed a consistent reduction of PE (relative risk, 0.20 [95% CI, 0.06-0.70]; I(2)=0%) and fatal PE (0.09 [0.01-0.81]; I(2)=0%) with IVC filter placement, without any statistical heterogeneity. We found no significant difference in the incidence of deep vein thrombosis (relative risk, 1.76 [95% CI, 0.50-6.19]; P=.38; I(2)=56.8%) or mortality (0.70 [0.40-1.23]; I(2)=6.7%). The number needed to treat to prevent 1 additional PE with IVC filters is estimated to range from 109 (95% CI, 93-190) to 962 (819-2565), depending on the baseline PE risk. CONCLUSIONS AND RELEVANCE: The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studies may be informative.

Pharmacologic and mechanical strategies for preventing venous thromboembolism after bariatric surgery: a systematic review and meta-analysis.

We sought to assess the comparative effectiveness and safety of pharmacologic and mechanical strategies to prevent venous thromboembolism (VTE) in patients undergoing bariatric surgery. We searched (through August 2012) for primary studies that had at least 2 different interventions. Of 30,902 citations, we identified 8 studies of pharmacologic strategies and 5 studies of filter placement. No studies randomized patients to receive different interventions. One study suggested that low-molecular-weight heparin is more efficacious than unfractionated heparin in preventing VTE (0.25% vs 0.68%, P < .001), with no significant difference in bleeding. One study suggested that prolonged therapy (after discharge) with enoxaparin sodium may prevent VTE better than inpatient treatment only. There was insufficient evidence supporting the hypothesis that filters reduce the risk of pulmonary embolism, with a point estimate suggesting increased rates with filters (pooled relative risk [RR], 1.21 95% CI, 0.57-2.56). There was low-grade evidence that filters are associated with higher mortality (pooled RR, 4.30 95% CI, 1.60-11.54) and higher deep vein thrombosis rates (2.94 1.35-6.38). There was insufficient evidence to support that augmented subcutaneous enoxaparin doses (>40 mg daily or 30 mg twice daily) are more efficacious than standard dosing, with a trend toward increased bleeding. Of note, for both filters and augmented pharmacologic dosing strategies, patients at highest risk for VTE were more likely to receive more intensive interventions, limiting our ability to attribute outcomes to prophylactic strategies used.

Alcohol consumption and domain-specific cognitive function in older adults: longitudinal data from the Johns Hopkins Precursors Study.

OBJECTIVES: The association of alcohol consumption with performance in different cognitive domains has not been well studied. METHODS: The Johns Hopkins Precursors Study was used to examine associations between prospectively collected information about alcohol consumption ascertained on multiple occasions starting at age 55 years on average with domain-specific cognition at age 72 years. Cognitive variables measured phonemic and semantic fluency, attention, verbal memory, and global cognition. RESULTS: Controlling for age, hypertension, smoking status, sex, and other cognitive variables, higher average weekly quantity and frequency of alcohol consumed in midlife were associated with lower phonemic fluency. There were no associations with four other measures of cognitive function. With respect to frequency of alcohol intake, phonemic fluency was significantly better among those who drank three to four alcoholic beverages per week as compared with daily or almost daily drinkers. A measure of global cognition was not associated with alcohol intake at any point over the follow-up. DISCUSSION: Results suggest that higher alcohol consumption in midlife may impair some components of executive function in late life.

A new model to monitor the virological efficacy of antiretroviral treatment in resource-poor countries.

Monitoring the efficacy of antiretroviral treatment in developing countries is difficult because these countries have few laboratory facilities to test viral load and drug resistance. Those that exist are faced with a shortage of trained staff, unreliable electricity supply, and costly reagents. Not only that, but most HIV patients in resource-poor countries do not have access to such testing. We propose a new model for monitoring antiretroviral treatment in resource-limited settings that uses patients' clinical and treatment history, adherence to treatment, and laboratory indices such as haemoglobin level and total lymphocyte count to identify virological treatment failure, and offers patients future treatment options. We believe that this model can make an accurate diagnosis of treatment failure in most patients. However, operational research is needed to assess whether this strategy works in practice.