Association between newborn hypoglycemia screening and breastfeeding success in an Ottawa, Ontario, hospital: a retrospective cohort study.

BACKGROUND: There has been limited investigation of the unintended effects of routine screening for asymptomatic hypoglycemia in at-risk newborns. This study aimed to explore whether rates of exclusive breastfeeding were lower in screened babies than in unscreened babies. METHODS: This retrospective cohort study conducted in Ottawa, Canada, used data from Hôpital Montfort's electronic health information system. Healthy singleton newborns discharged between Feb. 1, 2014, and June 30, 2018, were included. We excluded babies and mothers with conditions expected to interfere with breastfeeding (e.g., twins). We investigated the association between postnatal screening for hypoglycemia and initial exclusive breastfeeding (in the first 24 hours of life). RESULTS: We included 10 965 newborns; of these, 1952 (17.8%) were fully screened for hypoglycemia. Of screened newborns, 30.6% exclusively breastfed and 64.6% took both formula and breastmilk in the first 24 hours of life. Of unscreened newborns, 45.4% exclusively breastfed and 49.8% received both formula and breastmilk. The adjusted odds ratio for exclusive breastfeeding in the first 24 hours of life among newborns screened for hypoglycemia was 0.57 (95% confidence interval 0.51-0.64). INTERPRETATION: The association of routine newborn hypoglycemia screening with a lower initial rate of exclusive breastfeeding suggests a potential effect of screening on early breastfeeding success. Confirmation of these findings might warrant a re-evaluation of the net benefit of asymptomatic postnatal hypoglycemia screening for different newborn populations at risk of hypoglycemia.

Key issues for stakeholder engagement in the development of health and healthcare guidelines.

Established in 2015, the Multi-Stakeholder Engagement (MuSE) Consortium is an international network of over 120 individuals interested in stakeholder engagement in research and guidelines. The MuSE group is developing guidance for stakeholder engagement in the development of health and healthcare guideline development. The development of this guidance has included multiple meetings with stakeholders, including patients, payers/purchasers of health services, peer review editors, policymakers, program managers, providers, principal investigators, product makers, the public, and purchasers of health services and has identified a number of key issues. These include: (1) Definitions, roles, and settings (2) Stakeholder identification and selection (3) Levels of engagement, (4) Evaluation of engagement, (5) Documentation and transparency, and (6) Conflict of interest management. In this paper, we discuss these issues and our plan to develop guidance to facilitate stakeholder engagement in all stages of the development of health and healthcare guideline development.

A group of international researchers, patient partners, and other stakeholders are working together to create a checklist for when and how to involve stakeholders in health guideline development. Health guidelines include clinical practice guidelines, which your healthcare provider uses to determine treatments for health conditions. While working on this checklist, the team identified key issues to work on, including: (1) Definitions, roles, and settings (2) Stakeholder identification and selection (3) Levels of engagement, (4) Evaluation of engagement, (5) Documentation and transparency, and (6) Conflict of interest management. This paper describes each issue and how the team plans to produce guidance papers to address them.

Scoping review of evidence for managing postnatal hypoglycaemia.

OBJECTIVES: To identify what is known empirically about the screening, treatment and harm of exposure to neonatal hypoglycaemia. DESIGN: Scoping review that applied a preregistered protocol based on established frameworks. DATA SOURCES: Medline and Embase, up to 12 May 2020. STUDY SELECTION: Comparative and case-series studies, as well as guidelines, published in English or French, on the topic of immediate inpatient postnatal glucose screening in newborns. DATA GATHERING: Article selection and characterisation were performed in duplicate using predefined data extraction forms specific to primary studies and guidelines. RESULTS: 12 guidelines and 74 primary studies were included. A neurodevelopmental outcome was primary in 32 studies: 30 observational studies followed up posthypoglycaemic, and the 2 intervention studies included 1 randomised controlled trial (RCT) about treatment thresholds. Three other RCTs assessed dextrose gel (two) and oral sucrose (one). 12 of 30 studies that evaluated non-neurodevelopmental primary outcomes were intervention studies. Only one cohort study compared outcomes in screened vs unscreened newborns. The guidelines did not arrive at a consensus definition of postnatal hypoglycaemic, and addressed potential harms of screening more often than primary studies. CONCLUSIONS: The primary literature that informs hypoglycaemia screening is a series of studies that relate neurodevelopmental outcomes to postnatal hypoglycaemia. Further research is needed to better define an optimal threshold for hypoglycaemia that warrants intervention, based on long-term neurodevelopmental outcomes and a better delineation of potential screening harms.

Factors to Consider During Identification and Invitation of Individuals in a Multi-stakeholder Research Partnership.

BACKGROUND: Health research teams increasingly partner with stakeholders to produce research that is relevant, accessible, and widely used. Previous work has covered stakeholder group identification. OBJECTIVE: We aimed to develop factors for health research teams to consider during identification and invitation of individual representatives in a multi-stakeholder research partnership, with the aim of forming equitable and informed teams. DESIGN: Consensus development. PARTICIPANTS: We involved 16 stakeholders from the international Multi-Stakeholder Engagement (MuSE) Consortium, including patients and the public, providers, payers of health services/purchasers, policy makers, programme managers, peer review editors, and principal investigators. APPROACH: We engaged stakeholders in factor development and as co-authors of this manuscript. Using a modified Delphi approach, we gathered stakeholder views concerning a preliminary list of 18 factors. Over two feedback rounds, using qualitative and quantitative analysis, we concentrated these into ten factors. KEY RESULTS: We present seven highly desirable factors: 'expertise or experience', 'ability and willingness to represent the stakeholder group', 'inclusivity (equity, diversity and intersectionality)', 'communication skills', 'commitment and time capacity', 'financial and non-financial relationships and activities, and conflict of interest', 'training support and funding needs'. Additionally, three factors are desirable: 'influence', 'research relevant values', 'previous stakeholder engagement'. CONCLUSIONS: We present factors for research teams to consider during identification and invitation of individual representatives in a multi-stakeholder research partnership. Policy makers and guideline developers may benefit from considering the factors in stakeholder identification and invitation. Research funders may consider stipulating consideration of the factors in funding applications. We outline how these factors can be implemented and exemplify how their use has the potential to improve the quality and relevancy of health research.

Journal impact factor, trial effect size, and methodological quality appear scantly related: a systematic review and meta-analysis.

BACKGROUND: As systematic reviews' limited coverage of the medical literature necessitates decision-making based on unsystematic review, we investigated a possible advantage of systematic review (aside from dataset size and systematic analysis): does systematic review avoid potential bias in sampling primary studies from high impact factor journals? If randomized controlled trials (RCTs) reported in higher-impact journals present different treatment benefits than RCTs reported in lower-impact journals, readers who focus on higher-impact journals for their rapid literature reviews may introduce bias which could be mitigated by complete, systematic sampling. METHODS: We randomly sampled Cochrane Library (20 July 2005) treatment reviews that measured mortality as a binary outcome, published in English or French, with at least five RCTs with one or more deaths. Our domain-based assessment of risk of bias included funding source, randomness of allocation sequence, blinding, and allocation concealment. The primary analysis employed logistic regression by a generalized linear model with a generalized estimating equation to estimate the association between various factors and publication in a journal with a high journal impact factor (JIF). RESULTS: From the 29 included systematic reviews, 189 RCTs contributed data. However, in the primary analyses comparing RCT results within meta-analyses, there was no statistically significant association: unadjusted odds of greater than 50% mortality protection in high-JIF (> 5) journals were 1.4 (95% CI 0.42, 4.4) and adjusted, 2.5 (95% CI 0.6, 10). Elements of study quality were weakly, inconsistently, and not statistically significantly correlated with journal impact factor. CONCLUSIONS: Journal impact factor may have little to no association with study results, or methodological quality, but the evidence is very uncertain.

Quality of reporting and evidence in American Academy of Pediatrics guidelines.

OBJECTIVES: The primary objectives were to evaluate the quality of development and reporting of American Academy of Pediatrics (AAP) guidelines and to determine the level of evidence underlying the recommendations. METHODS: Two reviewers scored each guideline by using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument and determined the level of evidence for each recommendation in each guideline. Subgroup analyses compared AAP guidelines published before and after key changes in AAP guideline development policy and compared internal with endorsed guidelines. RESULTS: For the 28 current guidelines, the highest average scores on AGREE-II were in scope and purpose (75%) and clarity of presentation (73%). The lowest average scores were in editorial independence (17%) and applicability (30%). The only domain that improved after AAP policy updates was editorial independence (P = .01). Of the 190 treatment recommendations, 43% were based on experimental studies, 30% on observational studies, and 27% on expert opinion or no reference. Compared with early guidelines, late guidelines included a higher proportion of treatment recommendations based on experimental studies (P = .05). CONCLUSIONS: There was no clear improvement in the quality of development and reporting of AAP clinical practice guidelines over time. Routine application of AGREE-II to guideline development could enhance guideline quality. The proportion of guideline recommendations based on experimental evidence has increased slightly over time. Pediatric research agendas should be matched to vital gaps in the evidence underlying pediatric guidelines.

The uptake of technologies designed to influence medication safety in Canadian hospitals.

BACKGROUND: There are many technologies designed to improve medication safety. Although limited evidence supports their use, there are pressures to implement them. OBJECTIVE: To determine the uptake of technologies designed to improve medication safety, plans for adopting technologies, attitudes towards technology use, and perceptions of medication error. Methods We performed a cross-sectional survey of pharmacy directors at Canada's 100 largest acute-care hospitals. RESULTS: Seventy-eight per cent of surveyed hospitals responded. Responding hospitals averaged 499 beds and 29% were teaching facilities. Hospital frequently used clinical pharmacy services (97% of hospitals), pharmacy-based intravenous admixture services (81%), computerized decision support modules for pharmacy order entry systems (77%), unit-dose drug distribution systems (75%) and computerized medication administration records (67%). Hospitals infrequently used bar-coding (9% of hospitals) and computerized physician order entry (9%). A majority of respondents and hospitals favoured expanded use of new technologies and planned for increased uptake. Respondents chose as their hospital's next investment: automated dispensing (33%), bar-coding (25%) and computerized physician order entry (12%). CONCLUSION: Canadian hospitals appear poised to make sizeable investments in poorly evaluated technologies that address medication safety.

Transcutaneous electrical nerve stimulation for the treatment of chronic low back pain: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVE: To determine the effectiveness of transcutaneous electrical nerve stimulation (TENS) in the management of chronic LBP. SUMMARY OF BACKGROUND DATA: Chronic low back pain (LBP) affects a significant proportion of the population. TENS was introduced more than 30 years ago as an adjunct to pharmacologic pain management. However, despite its widespread use, the usefulness of TENS in chronic LBP is still controversial. METHODS: We searched MEDLINE, EMBASE, PEDro, and the Cochrane Central Register of Controlled Trials (Issue 2, 2005), up to April 1, 2005. Only randomized controlled clinical trials (RCTs) evaluating the effect of TENS on chronic LBP were included. Two reviewers independently selected trials and extracted data using predetermined forms. Heterogeneity was tested with Cochrane's Q test. A fixed effect model was used throughout for calculating continuous variables, except where heterogeneity existed, in which case a random effects model was used. Results are presented as weighted mean differences with 95% confidence intervals (95% CI), where the difference between the treated and control groups was weighted by the inverse of the variance. Standardized mean differences were calculated by dividing the difference between the treated and control by the baseline variance. Standardized mean differences were used when different scales were used to measure the same concept. Dichotomous outcomes were analyzed with odds ratios. RESULTS: Two RCTs (175 patients) were included. They differed with respect to study design, methodologic quality, inclusion and exclusion criteria, characteristics of TENS application, treatment schedule, cointerventions, and measured outcomes. In one RCT, TENS produced significantly greater pain relief than the placebo control. However, in the other RCT, no statistically significant differences between treatment and control groups were shown for multiple outcome measures. Preplanned subgroup analyses, intended to examine the impact of different stimulation parameters, sites of TENS application, treatment durations, and baseline patient characteristics were not possible because of the small number of included trials. CONCLUSIONS: Evidence for the efficacy of TENS as an isolated intervention in the management of chronic LBP is limited and inconsistent. Larger, multicenter, RCTs are needed to better resolve its role in this condition. Increased attention should be given to the risks and benefits of long-term use, which more appropriately addresses the realities of managing chronic low back pain.