Long-Term Quality of Life After Extracorporeal Membrane Oxygenation in ARDS Survivors: Systematic Review and Meta-Analysis.

PURPOSE: Extracorporeal membrane oxygenation (ECMO) is an increasingly prevalent treatment for acute respiratory failure (ARF). To evaluate the impact of ECMO support on long-term outcomes for critically ill adults with ARF. METHODS: We searched electronic databases 1948 through to November 30 2016; selected controlled trials or observational studies of critically ill adults with acute respiratory distress syndrome, examining long-term morbidity specifically health-related quality of life (HRQL); 2 authors independently selected studies, extracted data, and assessed methodological quality. ANALYSIS: Of the 633 citations, 1 randomized controlled trial and 5 observational studies met the selection criteria. Overall quality of observational studies was moderate to high (mean score on Newcastle-Ottawa scale, 7.2/9; range, 6-8). In 3 studies (n = 245), greater decrements in HRQL were seen for survivors of ECMO when compared to survivors of conventional mechanical ventilation (CMV) as measured by the Short Form 36 (SF-36) scores ([ECMO-CMV]: 5.40 [95% confidence interval, CI, 4.11 to 6.68]). As compared to CMV survivors, those who received ECMO experienced significantly less psychological morbidity (2 studies; n = 217 [ECMO-CMV]: mean weighted difference [MWD], -1.31 [95% CI, -1.98 to -0.64] for depression and MWD, -1.60 [95% CI, -1.80 to -1.39] for anxiety). CONCLUSIONS: Further studies are required to confirm findings and determine prognostic factors associated with more favorable outcomes in survivors of ECMO.

Medication coverage for lawmakers may worsen access for everyone else.

Despite numerous recommendations for universal public coverage of prescription drugs in Canada based on evidence that millions of Canadians cannot afford medications, no province or territory has adopted first dollar coverage for all residents. However, one group unaffected by the lack of public coverage are lawmakers. Lawmakers receive excellent drug coverage plans for themselves and their immediate families. Evidence suggests that lawmakers' decisions are influenced by their personal circumstances; in this case, they are insulated from the effects of poor access to medications by their drug coverage plans. In contrast, a patchwork system of 46 programs across Canada provides some drug coverage to vulnerable populations. Reducing the disparity in prescription drug access between Canadian lawmakers and the public may promote progress towards better medication access for everyone. This could be achieved either by reducing lawmaker coverage or improving upon the public patchwork system. Since the goal should be to improve the overall access of medications for all Canadians, lawmakers included, the latter method is preferred. A universal drug plan with first dollar coverage could replace the current patchwork system and expand coverage to all Canadians.

A study protocol for an observational cohort investigating COGnitive outcomes and WELLness in survivors of critical illness: the COGWELL study.

INTRODUCTION: Up to 9 out of 10 intensive care unit (ICU) survivors will suffer some degree of cognitive impairment at hospital discharge and approximately half will have decrements that persist for years. The mechanisms for this newly acquired brain injury are poorly understood. The purpose of this study is to describe the prevalence of sleep abnormalities and their association with cognitive impairment, examine a well-known genetic risk factor for dementia (Apolipoprotein E ε4) that may allow for genetic risk stratification of ICU survivors at greatest risk of cognitive impairment and determine if electroencephalography (EEG) is an independent predictor of long-term cognitive impairment and possibly a candidate intermediate end point for future clinical trials. METHODS AND ANALYSIS: This is a multisite, prospective, observational cohort study. The setting for this trial will be medical and surgical ICUs of five large tertiary care referral centres. The participants will be adult patients admitted to a study ICU and invasively ventilated for ≥3 days . Participants will undergo follow-up within 7 days of ICU discharge, 6 months and 1 year. At each time point, patients will have an EEG, blood work (biomarkers; gene studies), sleep study (actigraphy), complete a number of questionnaires as well as undergo neuropsychological testing. The primary outcome of this study will be long-term cognitive function at 12 months follow-up as measured by the Repeatable Battery for the Assessment of Neuropsychological Status and Trails Making Test B. ETHICS AND DISSEMINATION: The study has received the following approvals: University Health Network Research Ethics Committee (13-6425-BE), Sunnybrook Health Centre Research Ethics Committee (365-2013), Mount Sinai Research Ethics Committee (14-0194-E) and St. Michael's Hospital Research Ethics Committee (14-295). Results will be made available to critical care survivors, their caregivers, the funders, the critical care societies and other researchers. TRIAL REGISTRATION NUMBER: NCT02086877; Pre-results.

Development of a preliminary essential medicines list for Canada.

BACKGROUND: Some evidence supports the use of a short list of essential medicines to improve prescribing. We aimed to create a preliminary essential medicines list for use in Canada. METHODS: The 2013 World Health Organization Model List of Essential Medicines was initially adapted by the research team. Fourteen Canadian clinicians gave suggestions for changes to the list. Literature relevant to each unique suggestion was gathered and presented to 3 clinician-scientists who used a modified nominal group technique to make recommendations on the suggested changes. Audits of prescriptions of 2 Toronto-based family health teams (an inner city clinic and a suburban site) between Aug. 1, 2013, and July 30, 2014, were performed to identify common prescriptions that were not on the draft list. Literature relevant to these additional medications was gathered and shared with the clinician-scientist review panel to determine whether each should be added to the list, and a list was developed. The audits were repeated based on the final list to provide a preliminary assessment of the coverage of the list. RESULTS: The multistep process produced a list of 125 medications. The medications included on this list covered 90.8% and 92.6% of prescriptions at the inner city clinic and the suburban site, respectively. In total, 93% of the patients seen at the inner city clinic and 96% of the patients seen at the suburban clinic had all or all but 1 of their medications covered by the list. INTERPRETATION: A preliminary list of essential medicines was developed that covered most, but not all, prescriptions at 2 primary care sites. The list should be further refined based on wider input.