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1.
Sleep Med ; 69: 19-33, 2020 Jan 11.
Artículo en Inglés | MEDLINE | ID: mdl-32045851

RESUMEN

BACKGROUND: While positive airway pressure (PAP) is effective for treating sleep-disordered breathing (SDB) in children, adherence is poor. Studies evaluating predictors of PAP adherence have inconsistent findings, and no rigorous reviews have been conducted. This systematic review aims to summarize the literature on predictors of PAP therapy adherence in children. METHODS: Studies evaluating baseline predictors of PAP therapy adherence in children (≤20 years) with SDB were included. We searched MEDLINE, Embase, CENTRAL, CINAHL, Clinicaltrials.gov, and the last four years of conference abstracts. Results were described narratively, with random-effects meta-analyses performed where feasible. Risk of bias and confidence in the evidence were assessed. RESULTS: We identified 50 factors evaluated across 28 studies (21 full text articles, seven abstracts). The highest rates of PAP therapy adherence were most consistently found with female sex, younger age, Caucasian race, higher maternal education, greater baseline apnea-hypopnea index (AHI), and presence of developmental delay. Pooled estimates included odds ratios of 1.48 (95%CI: 0.75-2.93) favoring female sex, 1.26 (95%CI: 0.68-2.36) favoring Caucasian race, and a mean difference in AHI of 4.32 (95%CI: -0.61-9.26) events/hour between adherent and non-adherent groups. There was low quality evidence to suggest that psychosocial factors like health cognitions and family environment may predict adherence. CONCLUSION: In this novel systematic review, we identified several factors associated with increased odds of PAP therapy adherence in children. These findings may help guide clinicians to identify and support children less likely to adhere to PAP therapy and should be considered when developing interventions to improve adherence.

2.
J Clin Sleep Med ; 16(1): 41-48, 2020 Jan 15.
Artículo en Inglés | MEDLINE | ID: mdl-31957650

RESUMEN

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is commonly treated with adenotonsillectomy (AT), bringing risk of perioperative respiratory adverse events (PRAEs). We aimed to concurrently identify clinical and polysomnographic predictors of PRAEs in children undergoing AT. METHODS: Retrospective study of children undergoing AT at a tertiary-care pediatric hospital, with prior in-hospital polysomnography, January 2010 to December 2016. PRAEs included those requiring oxygen, jaw thrust, positive airway pressure, or mechanical ventilation. Relationships of PRAEs to preoperative comorbidities or polysomnography results were examined with univariable logistic regression. Variables with P < .1 and age were included in backward stepwise multivariable logistic regression. Predictive performance (area under the curve, AUC) was validated with bootstrap resampling. RESULTS: Analysis included 374 children, median age 6.1 years; 286 (76.5%) had ≥ 1 comorbidity. 344 (92.0%) had sleep-disordered breathing; 232 (62.0%) moderate-severe; 66 (17.6%) had ≥ 1 PRAE. PRAEs were more frequent in children with craniofacial, genetic, cardiac, airway anomaly, or neurological conditions, AHI ≥ 5 events/h and oxygen saturation nadir ≤ 80% on preoperative polysomnography. Prediction modeling identified cardiac comorbidity (odds ratio [OR] 2.09 [1.11, 3.89]), airway anomaly (OR 3.19 [1.33, 7.49]), and younger age (OR < 3 years: 4.10 (1.79, 9.26; 3 to 6 years: 2.21 [1.18, 4.15]) were associated with PRAEs (AUC 0.74; corrected AUC 0.68). CONCLUSIONS: Prediction modeling concurrently evaluating comorbidities and polysomnography metrics identified cardiac disease, airway anomaly, and young age as independent predictors of PRAEs. These findings suggest that medical comorbidity and age are more important factors in predicting PRAEs than PSG metrics in a medically complex population.

3.
J Shoulder Elbow Surg ; 29(2): 225-234, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31780337

RESUMEN

BACKGROUND: Controversy exists regarding the optimal technique of subscapularis tendon mobilization during anatomic shoulder arthroplasty. The purpose of this prospective, randomized, double-blind study was to compare internal rotation strength in the belly-press position and functional outcomes between the subscapularis tenotomy and subscapularis peel approaches during shoulder arthroplasty. METHODS: Patients undergoing anatomic shoulder arthroplasty were randomized to either a tenotomy or peel approach. The primary outcome was internal rotation strength in the belly-press position, measured by an electronic handheld dynamometer at 24 months postoperatively. Secondary outcomes included the Western Ontario Osteoarthritis of the Shoulder (WOOS) index score, American Shoulder and Elbow Surgeons (ASES) score, range of motion, radiographic lucencies, and adverse events. RESULTS: We randomized 100 patients to subscapularis tenotomy (n = 47) or peel (n = 53). Eighty-one percent of the cohort returned for 24 months' follow-up. Compared with baseline measures, mean internal rotation strength in the belly-press position and WOOS and ASES scores improved in both groups at final follow-up (P < .0001). Intention-to-treat analysis for internal rotation strength at 24 months revealed no significant difference (P = .57) between tenotomy (mean, 4.9 kg; SD, 3.8 kg) and peel (mean, 5.4 kg; SD, 3.9 kg). Comparison of WOOS and ASES scores demonstrated no significant differences between groups at any time point. The healing rates by ultrasound were 72% for tenotomy and 71% for peel (P = .99). DISCUSSION: No statistically significant difference in internal rotation strength was identified between the tenotomy and peel groups. The secondary outcomes were not significantly different between groups.

4.
Drug Alcohol Depend ; 206: 107702, 2020 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-31761476

RESUMEN

BACKGROUND: Respondent-driven sampling (RDS) is a successful data collection method used in hard-to-reach populations, like those experiencing or at high risk of drug dependence. Since its introduction in 1997, identifying appropriate methods for estimating population means and sampling variances has been challenging and numerous approaches have been developed for making inferences about these quantities. To guide researchers and practitioners in deciding which approach to use, this article reviews the literature on these methodological developments. METHODS: A systematic review using four electronic databases was conducted in order to summarize the progress of RDS inference over the last 20 years and to provide insight to researchers on using the appropriate estimators in analyzing RDS data. Two independent reviewers selected the relevant abstracts and articles; thirty-two studies were included. The content of the studies was further categorized into developing and evaluating RDS mean and variance estimators. RESULTS: The population mean estimator RDSIEGO and the sampling variance estimators associated with tree boot strapping were identified as promising methods as the most robust population mean and variance estimate, respectively; as these estimators rely on a fewer assumptions. CONCLUSIONS: RDS holds substantial promise as a sampling method for understanding populations at high risk. The varied approaches to inference with RDS data each rely on different assumptions, but some require fewer assumptions than others and provide more robust and accurate inferences, when their corresponding assumptions are met.

5.
J Clin Sleep Med ; 2019 Nov 27.
Artículo en Inglés | MEDLINE | ID: mdl-31771750

RESUMEN

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is commonly treated with adenotonsillectomy (AT), bringing risk of perioperative respiratory adverse events (PRAEs). We aimed to concurrently identify clinical and polysomnographic predictors of PRAEs in children undergoing AT. METHODS: Retrospective study of children undergoing AT at a tertiary-care pediatric hospital, with prior in-hospital polysomnography, January 2010 to December 2016. PRAEs included those requiring oxygen, jaw thrust, positive airway pressure, or mechanical ventilation. Relationships of PRAEs to preoperative comorbidities or polysomnography results were examined with univariable logistic regression. Variables with P < .1 and age were included in backward stepwise multivariable logistic regression. Predictive performance (area under the curve, AUC) was validated with bootstrap resampling. RESULTS: Analysis included 374 children, median age 6.1 years; 286 (76.5%) had ≥ 1 comorbidity. 344 (92.0%) had sleep-disordered breathing; 232 (62.0%) moderate-severe; 66 (17.6%) had ≥ 1 PRAE. PRAEs were more frequent in children with craniofacial, genetic, cardiac, airway anomaly, or neurological conditions, AHI ≥ 5 events/h and oxygen saturation nadir ≤ 80% on preoperative polysomnography. Prediction modeling identified cardiac comorbidity (odds ratio [OR] 2.09 [1.11, 3.89]), airway anomaly (OR 3.19 [1.33, 7.49]), and younger age (OR < 3 years: 4.10 (1.79, 9.26; 3 to 6 years: 2.21 [1.18, 4.15]) were associated with PRAEs (AUC 0.74; corrected AUC 0.68). CONCLUSIONS: Prediction modeling concurrently evaluating comorbidities and polysomnography metrics identified cardiac disease, airway anomaly, and young age as independent predictors of PRAEs. These findings suggest that medical comorbidity and age are more important factors in predicting PRAEs than PSG metrics in a medically complex population.

6.
Paediatr Child Health ; 24(5): 306-312, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31379431

RESUMEN

Objectives: To describe variations in the monitoring, treatment, and discharge of children hospitalized with bronchiolitis among physicians across Canadian paediatric teaching hospitals. Methods: We conducted an electronic survey of paediatricians with experience in the management of inpatient bronchiolitis at 20 Canadian paediatric teaching hospitals. Only physicians who worked a minimum of 6 weeks on their hospital inpatient unit in the 2015 calendar year were eligible to participate in the study. The questionnaire explored the monitoring, treatment, and discharge of children with bronchiolitis. Central tendency (mean) and dispersion (SD) statistics were produced for continuous variables and frequency distributions for categorical variables. Results: A total of 142 respondents were included in the analysis. 45.1% reported the routine use of continuous oxygen saturation monitoring. 27.5% used a higher cut-off for oxygen supplementation of 92% and 12.7% use a lower cut-off of 88%. 29.6% routinely used deep nasal suctioning. Seventy-three per cent reported using nebulized therapies. 55.6% reported having preprinted order sheets or guidelines for management of inpatient bronchiolitis at their institutions and 28.2% reported having specific discharge criteria. The length of time required to be off oxygen prior to discharge varied (31% at 12 hours, 27.5% at 24 hours, and 24.6% after the last sleep period without oxygen). Conclusion: There is significant practice variation in the monitoring, treatment, and discharge of children hospitalized with bronchiolitis within and between Canadian paediatric teaching hospitals. Future research is needed to establish best practices, effective knowledge translation, and implementation strategies to standardize care and decrease length of stay.

7.
Palliat Med ; 33(8): 865-877, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-31184538

RESUMEN

BACKGROUND: Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed. AIM: Expanding on a 2013 review, this systematic review examines the incidence and prevalence of delirium across all palliative care settings. DESIGN: This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment. DATA SOURCES: Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included. RESULTS: Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer (n = 34) and mixed diagnoses (n = 8) were represented. Delirium point prevalence estimates were 4%-12% in the community, 9%-57% across hospital palliative care consultative services, and 6%-74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings (n = 8) was 42%-88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29-0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used. CONCLUSION: Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.

8.
Crit Rev Toxicol ; 49(3): 215-261, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31192763

RESUMEN

The potential association between major adverse cardiovascular events (MACE) and concomitant treatment with proton pump inhibitors (PPIs) and clopidogrel has been debated since 2009. Recent reports, however, suggest that PPIs may increase the risk of MACE independently of clopidogrel. This review evaluates epidemiological findings relevant to the association between PPIs, taken alone or concomitantly with antiplatelets, and the risk of MACE. A systematic review and meta-analysis were conducted. Relevant studies were identified from MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials and then screened. Included studies were categorized into three groups: Group A: PPIs versus no PPIs; Group B: combined PPIs and clopidogrel versus clopidogrel alone; Group C: combined PPIs and other drugs versus other drugs. Pooled risk ratios (RRs) were calculated for each outcome of interest in each comparison group. Of the 1667 studies identified, 118 were included in the systematic review, of which 66 were included in the meta-analyses. Among Group A observational studies, RRs for MACE outcomes were statistically significant for some patient populations but not others. Pooled RRs from Group A RCTs were not statistically significant for any outcome. Pooled RRs for Group B observational studies were statistically significant for all-cause mortality and MI, but were diminished in magnitude when pooling was restricted to propensity score matched studies or post hoc analyses of RCTs. Group C studies did not demonstrate an association with MACE. Findings do not consistently support an association between MACE and PPIs when taken alone, or concomitantly with antiplatelets.

9.
Pediatr Crit Care Med ; 20(7): e293-e300, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-31149966

RESUMEN

OBJECTIVES: To identify the clinical findings available at the time of hospitalization from the emergency department that are associated with deterioration within 24 hours. DESIGN: A retrospective case-control study. SETTING: A pediatric hospital in Ottawa, ON, Canada. PATIENTS: Children less than 18 years old who were hospitalized via the emergency department between January 1, 2008, and December 31, 2012. Cases (n = 98) had an unplanned admission to the PICU or unexpected death on the hospital ward within 24 hours of hospitalization and controls (n = 196) did not. INTERVENTIONS: None. MAIN RESULTS: Ninety-eight children (53% boys; mean age 63.2 mo) required early unplanned admission to the PICU. Multivariable conditional logistic regression resulted in a model with five predictors reaching statistical significance: higher triage acuity score (odds ratio, 4.1; 95% CI, 1.7-10.2), tachypnea in the emergency department (odds ratio, 4.6; 95% CI, 1.8-11.8), tachycardia in the emergency department (odds ratio, 2.6; 95% CI, 1.1-6.5), PICU consultation in the emergency department (odds ratio, 8.0; 95% CI, 1.1-57.7), and admission to a ward not typical for age and/or diagnosis (odds ratio, 4.5; 95% CI, 1.7-11.6). CONCLUSIONS: We have identified risk factors that should be included as potential predictor variables in future large, prospective studies to derive and validate a weighted scoring system to identify hospitalized children at high risk of early clinical deterioration.

10.
Pediatr Nephrol ; 34(11): 2361-2370, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31254112

RESUMEN

BACKGROUND: Children with chronic kidney disease (CKD) are at risk for obstructive sleep apnea (OSA) and hypertension. The objectives of this study were to explore associations between OSA severity using the apnea-hypopnea-index(AHI) and obstructive apnea-hypopnea-index(OAHI) on polysomnography (PSG), OSA symptoms, and measures of hypertension in children with CKD. METHODS: One-night in-laboratory PSGs and 24-h ambulatory blood pressure monitoring (ABPM) were performed on children with CKD stages 2-5 (non-dialysis dependent). Sleep questionnaires, including the modified Epworth Sleepiness Scale (ESS) and the Pediatric Sleep Questionnaire (PSQ), were administered during the sleep study. RESULTS: Nineteen children and adolescents completed a PSG and questionnaires and thirteen completed ABPMs. Mean (standard deviation) age at the time of the sleep study was 14.1 (3.2) years. Eleven (58%) participants had CKD stage two, and eight (42%) had stage 3-4. None of the participants were found to have OSA on PSG. One participant had a positive ESS score (≥ 11) and five participants had positive PSQ scores (≥  eight). Night systolic and diastolic pressures were strongly correlated with the OAHI (r = 0.67 and r = 0.69, respectively, p < 0.05), while the AHI was not correlated with any blood pressure measures. CONCLUSIONS: Our study did not find OSA on PSG in children with predominantly mild to moderate CKD. The OAHI was found to be strongly correlated with nighttime blood pressures. Future prospective studies with a larger sample size are needed to monitor for potential progression of symptoms and findings on PSG in pediatric patients as they evolve across the spectrum of CKD.

11.
J Epidemiol Community Health ; 73(5): 401-406, 2019 May.
Artículo en Inglés | MEDLINE | ID: mdl-30728201

RESUMEN

BACKGROUND: Tuberculosis (TB) remains a significant health burden among Inuit in Canada. Social determinants of health (SDH) play a key role in TB infection, disease and ongoing transmission in this population. The objective of this research was to estimate the prevalence of social determinants of Inuit health as they relate to latent TB infection (LTBI) among people living in residential areas at high risk for TB in Iqaluit, Nunavut. METHODS: Inperson home surveys were conducted among those who lived in predetermined residential areas at high risk for TB identified in a door-to-door TB prevention campaign in Iqaluit, Nunavut in 2011. Risk ratios for SDH and LTBI were estimated, and multiple imputation was used to address missing data. RESULTS: 261 participants completed the questionnaire. Most participants identified as Inuit (82%). Unadjusted risk ratios demonstrated that age, education, smoking tobacco, crowded housing conditions and Inuit ethnicity were associated with LTBI. After adjusting for other SDH, multivariable analysis showed an association between LTBI with increasing age (relative risk, RR 1.07, 95% CI 1.04 to 1.11), crowded housing (RR 1.48, 95% CI 1.10 to 2.00) and ethnicity (RR 2.76, 95% CI 1.33 to 5.73) after imputing missing data. CONCLUSION: Among high-risk residential areas for TB in a remote Arctic region of Canada, crowded housing and Inuit ethnicity were associated with LTBI after adjusting for other SDH. In addition to strong screening and treatment programmes, alleviating the chronic housing shortage will be a key element in the elimination of TB in the Canadian Inuit Nunangat.

12.
Int Arch Occup Environ Health ; 92(5): 747-762, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-30737558

RESUMEN

It is well established that high radon exposures increase the risk of lung cancer mortality. The effects of low occupational exposures and the factors that confound and modify this risk are not clear and are needed to inform current radiation protection of miners. The risk of lung cancer mortality at low radon exposures (< 100 working-level months) was assessed in the joint cohort analysis of Czech, French, and Canadian uranium miners, employed in 1953 or later. Statistical analysis was based on linear Poisson regression modeling with grouped cohort survival data. Two sensitivity analyses were used to assess potential confounding from tobacco smoking. A statistically significant linear relationship between radon exposure and lung cancer mortality was found. The excess relative risk per working-level month was 0.022 (95% confidence intervals: 0.013-0.034), based on 408 lung cancer deaths and 394,236 person-years of risk. Time since exposure was a statistically significant modifier; risk decreased with increasing time since exposure. A tendency for a decrease in risk with increasing attained age was observed, but this was not statistically significant. Exposure rate was not found to be a modifier of the excess relative risk. The potential confounding effect of tobacco smoking was estimated to be small and did not substantially change the radon-lung cancer mortality risk estimates. This joint cohort analysis provides strong evidence for an increased risk of lung cancer mortality from low occupational radon exposures. The results suggest that radiation protection measures continue to be important among current uranium miners.


Asunto(s)
Neoplasias Pulmonares/mortalidad , Mineros , Neoplasias Inducidas por Radiación/mortalidad , Exposición Profesional/efectos adversos , Radón/efectos adversos , Uranio , Anciano , Anciano de 80 o más Años , Canadá/epidemiología , Estudios de Cohortes , República Checa/epidemiología , Francia/epidemiología , Humanos , Neoplasias Pulmonares/epidemiología , Masculino , Persona de Mediana Edad , Neoplasias Inducidas por Radiación/epidemiología , Enfermedades Profesionales/epidemiología , Fumar Tabaco
13.
Eur J Clin Pharmacol ; 75(2): 227-235, 2019 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-30324301

RESUMEN

PURPOSE: The US Food and Drug Administration (FDA) issued three safety announcements between January 2009 and October 2010 warning against concomitant use of clopidogrel and proton pump inhibitors (PPIs) due to a potential drug-drug interaction that may attenuate clopidogrel's antiplatelet activity. This primary objective of this study was to examine trends in concomitant clopidogrel/PPI use among acute coronary syndrome (ACS) inpatients in the US between 2000 and 2016, in relation to the FDA safety communications. METHODS: Adult inpatients with a primary diagnosis of ACS were identified from the Cerner Health Facts® database. The standardized (age, sex, race, and census region) prevalence of clopidogrel use with PPIs was calculated yearly and quarterly. Findings were stratified by PPIs' potential to inhibit clopidogrel's activity and by age. RESULTS: A total of 204,533 inpatients were identified. In 2008, the prevalence of concomitant clopidogrel and PPI treatment was 34.9%, decreasing to 24.4 and 16.4% in 2009 and 2010, respectively, with the decline being similar across age groups. Treatment with inhibiting PPIs (omeprazole and esomeprazole) and clopidogrel has continued to decrease since 2010, with a prevalence of 0.8% in 2016. A similar reduction was not observed with clopidogrel and non-inhibiting PPIs (pantoprazole, lansoprazole, rabeprazole, and dexlansoprazole). During the FDA warning period, the combined treatment with clopidogrel and H2 receptor antagonists, an alternative to PPIs suggested by the FDA, temporarily increased from 7.8% in 2008 to 12.8 and 14.5% in 2009 and 2010, respectively. CONCLUSIONS: Findings suggest that clinical practice recommendations made by the FDA were followed. Further research is needed to determine how changes in drug labels and the availability of new drugs may have influenced the observed trends.


Asunto(s)
Síndrome Coronario Agudo/tratamiento farmacológico , Clopidogrel/uso terapéutico , Inhibidores de la Bomba de Protones/uso terapéutico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Interacciones de Drogas/fisiología , Quimioterapia Combinada/métodos , Femenino , Humanos , Pacientes Internos , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/uso terapéutico , Estados Unidos , United States Food and Drug Administration , Adulto Joven
14.
J Obstet Gynaecol Can ; 41(6): 824-831.e1, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-30361160

RESUMEN

OBJECTIVE: Cervical cancer accounts for the highest mortality rate from cancer in women worldwide. Despite widespread availability of cervical cancer screening programs in Canada, immigrant women are largely underscreened. The most recently published Canadian-wide study evaluated screening uptake from 2001 to 2002. The objectives included identifying the prevalence of underscreened women in Canada, determining the risk of underscreening for cervical cancer among immigrant women, and providing an update on Canadian screening practices. METHODS: This study included women aged 20 to 69 who completed the Canadian Community Health Survey 2012. The prevalence of underscreening among Canadian-born and immigrant women was estimated. A log-binomial model was fit to estimate the relative risk (RR) of underscreening for immigrant women while controlling for age, income level, visible minority status, smoking status, and access to a regular physician. A secondary analysis compared immigrants residing in Canada for greater or less than 10 years to Canadian-born women. RESULTS: Of the 17 854 women eligible for this study, 18.6% of Canadian-born women and 28.9% of immigrant women were underscreened (P < 0.05). Immigrant women were at significantly higher risk of being underscreened compared with Canadian-born women (RR 1.32; 95% CI 1.20-1.45). The relative risk did not change when stratifying by length of time since immigration (RRrecent immigrant 1.32; 95% CI 1.16-1.50; and RRlong-term immigrant 1.32; 95% CI 1.19-1.47). CONCLUSION: Immigrant status continues to be associated with a significantly higher risk of underscreening, irrespective of time in Canada. Social and educational programs targeted towards immigrants are needed to mitigate the disparity in cervical cancer screening.

15.
Epidemiology ; 30(1): 145-153, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30299406

RESUMEN

BACKGROUND: MOBI-Kids is a 14-country case-control study designed to investigate the potential effects of electromagnetic field exposure from mobile telecommunications devices on brain tumor risk in children and young adults conducted from 2010 to 2016. This work describes differences in cellular telephone use and personal characteristics among interviewed participants and refusers responding to a brief nonrespondent questionnaire. It also assesses the potential impact of nonparticipation selection bias on study findings. METHODS: We compared nonrespondent questionnaires completed by 77 cases and 498 control refusers with responses from 683 interviewed cases and 1501 controls (suspected appendicitis patients) in six countries (France, Germany, Israel, Italy, Japan, and Spain). We derived selection bias factors and estimated inverse probability of selection weights for use in analysis of MOBI-Kids data. RESULTS: The prevalence of ever-regular use was somewhat higher among interviewed participants than nonrespondent questionnaire respondents 10-14 years of age (68% vs. 62% controls, 63% vs. 48% cases); in those 20-24 years, the prevalence was ≥97%. Interviewed controls and cases in the 15- to 19- and 20- to 24-year-old age groups were more likely to have a time since start of use of 5+ years. Selection bias factors generally indicated a small underestimation in cellular telephone odds ratios (ORs) ranging from 0.96 to 0.97 for ever-regular use and 0.92 to 0.94 for time since start of use (5+ years), but varied in alternative hypothetical scenarios considered. CONCLUSIONS: Although limited by small numbers of nonrespondent questionnaire respondents, findings generally indicated a small underestimation in cellular telephone ORs due to selective nonparticipation.


Asunto(s)
Neoplasias Encefálicas/epidemiología , Teléfono Celular , Campos Electromagnéticos , Adolescente , Sesgo , Neoplasias Encefálicas/etiología , Estudios de Casos y Controles , Niño , Femenino , Francia , Alemania , Humanos , Israel , Italia , Japón , Masculino , Oportunidad Relativa , Factores de Riesgo , España , Encuestas y Cuestionarios , Adulto Joven
16.
J Pain Symptom Manage ; 57(3): 661-681.e12, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30550832

RESUMEN

CONTEXT: Based on the clinical care pathway of delirium in palliative care (PC), a published analytic framework (AF) formulated research questions in key domains and recommended a scoping review to identify evidence gaps. OBJECTIVES: To produce a literature map for key domains of the published AF: screening, prognosis and diagnosis, management, and the health-related outcomes. METHODS: A standard scoping review framework was used by an interdisciplinary study team of nurse- and physician-delirium researchers, an information specialist, and review methodologists to conduct the review. Knowledge user engagement provided context in refining 19 AF questions. A peer-reviewed search strategy identified citations in Medline, PsycINFO, Embase, and CINAHL databases between 1980 and 2018. Two reviewers independently screened records for inclusion using explicit study eligibility criteria for the population, design, delirium diagnosis, and investigational intent. RESULTS: Of 104 studies reporting empirical data and meeting eligibility criteria, most were conducted in patients with cancer (73.1%) and in inpatient PC units (52%). The most frequent study design was a one or more group, nonrandomized trial or cohort (67.3%). Evidence gaps were identified: delirium risk prediction; comparative effectiveness and harms of prevention, variability in delirium management across PC settings, advanced directive and substitute decision-maker input, and transition of care location; and estimating delirium reversibility. Future rigorous primary studies are required to address these gaps and preliminary concerns regarding the quality of extant literature. CONCLUSION: Substantial evidence gaps exist, providing opportunities for future research regarding the assessment, prognosis, and management of delirium in PC settings.

17.
Can J Psychiatry ; 64(1): 59-67, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30016882

RESUMEN

BACKGROUND: Major depression is prevalent, impactful, and treatable in military populations, but not all depressed personnel seek professional care in a given year. Care-seeking patterns (including the use of primary vs. specialty care) and factors associated with the likelihood of mental health service utilization in depressed military personnel are poorly understood. METHODS: Our sample included 520 Regular Force respondents to the 2013 Canadian Forces Mental Health Survey. All study participants had past-year major depression. Subjects reported whether they had spoken about their mental health with at least one health professional in the past 12 months. We used multivariate Poisson regression to explore factors associated with past-year mental health service use. RESULTS: Three-quarters of Canadian military personnel with past-year depression had sought mental health care in the previous 12 months. Among care-seeking personnel, 70% had seen a psychologist or psychiatrist, while 5% had exclusively received care from a primary care physician. Belief in the effectiveness of mental health care was the factor most strongly associated with care seeking. Female gender, functional impairments, and psychiatric comorbidities were also associated with care seeking. Surprisingly, stigma perceptions had no independent association with care seeking. CONCLUSIONS: The proportion of depressed Canadian Armed Forces personnel who seek professional care and who access specialty mental health care is higher than in most other populations. However, an important minority of patients are not accessing health services. Efforts to further increase mental health service utilization in the Canadian military should continue to target beliefs about the effectiveness of mental health care.

18.
BMC Musculoskelet Disord ; 19(1): 299, 2018 Aug 18.
Artículo en Inglés | MEDLINE | ID: mdl-30121091

RESUMEN

BACKGROUND: Proximal humerus fractures are the third most common fracture in the elderly population and are expected to increase due to the aging population. Surgical fixation with locking plate technology has increased over the last decade despite a lack of proven superiority in the literature. Three previous randomized controlled trials have not shown a difference in patient-centered outcomes when comparing non-operative treatment with open reduction and internal fixation. Low patient enrollment and other methodological concerns however limit the generalizability of these conclusions and as a result, management of these fractures remains a controversy. By comparing the functional outcomes of locked plate surgical fixation versus non-operative treatment of displaced three and four-part proximal humerus fractures in the elderly population with a large scale, prospective, multi-centered randomized controlled trial, the optimal management strategy for this common injury may be determined. METHODS: We will conduct a prospective, single blind randomized controlled parallel arm trial to compare non-operative management of proximal humerus fractures with open reduction and internal fixation using locked plating technology. One-hundred and sixty patients > age 60 with acute 3- or 4- part proximal humerus fractures will be randomized to either open reduction and internal fixation with locked plating technology or non-operative management treatment arms. The primary outcome measure is the Constant Score at 24 months post-operative. Secondary outcome measures include the American Shoulder and Elbow Surgeon's Score (ASES), EuroQol EQ-5D-5 L Health Questionnaire Score, short form PROMIS upper extremity score and IPAQ for the elderly score. Further outcome measures include assessment of the initial classification, displacement and angulation and the quality of surgical reduction via a standard computed tomography (CT) scan; rates of non-union, malunion, arthrosis, osteopenia or other complications including infection, nerve injury, intra-articular screw penetration, reoperation rates and hospital re-admission rates. DISCUSSION: The results of this trial will provide Level 1 evidence to guide decision-making in the treatment of proximal humerus fractures in the elderly population. TRIAL REGISTRATION: ClinicalTrials.gov NCT02362100 . Registered 5 Feb 2015.


Asunto(s)
Fijación Interna de Fracturas , Curación de Fractura , Reducción Abierta , Fracturas del Hombro/terapia , Placas Óseas , Protocolos Clínicos , Evaluación de la Discapacidad , Femenino , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/instrumentación , Humanos , Masculino , Persona de Mediana Edad , Ontario , Reducción Abierta/efectos adversos , Reducción Abierta/instrumentación , Readmisión del Paciente , Medición de Resultados Informados por el Paciente , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Recuperación de la Función , Proyectos de Investigación , Fracturas del Hombro/diagnóstico por imagen , Fracturas del Hombro/fisiopatología , Método Simple Ciego , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento
19.
Trials ; 19(1): 261, 2018 May 02.
Artículo en Inglés | MEDLINE | ID: mdl-29716640

RESUMEN

BACKGROUND: Radical cystectomy for bladder cancer is associated with a high risk of needing red blood cell transfusion. Tranexamic acid reduces blood loss during cardiac and orthopedic surgery, but no study has yet evaluated tranexamic acid use during cystectomy. METHODS: A randomized, double-blind (surgeon-, anesthesiologist-, patient-, data-monitor-blinded), placebo-controlled trial of tranexamic acid during cystectomy was initiated in June 2013. Prior to incision, the intervention arm participants receive a 10 mg/kg loading dose of intravenously administered tranexamic acid, followed by a 5 mg/kg/h maintenance infusion. In the control arm, the patient receives an identical volume of normal saline that is indistinguishable from the intervention. The primary outcome is any blood transfusion from the start of surgery up to 30 days post operative. There are no strict criteria to mandate the transfusion of blood products. The decision to transfuse is entirely at the discretion of the treating physicians who are blinded to patient allocation. Physicians are allowed to utilize all resources to make transfusion decisions, including serum hemoglobin concentration and vital signs. To date, 147 patients of a planned 354 have been randomized to the study. DISCUSSION: This protocol reviews pertinent data relating to blood transfusion during radical cystectomy, highlighting the need to identify methods for reducing blood loss and preventing transfusion in patients receiving radical cystectomy. It explains the clinical rationale for using tranexamic acid to reduce blood loss during cystectomy, and outlines the study methods of our ongoing randomized controlled trial. TRIAL REGISTRATIONS: Canadian Institute for Health Research (CIHR) Protocol: MOP-342559; ClinicalTrials.gov, ID: NCT01869413. Registered on 5 June 2013.


Asunto(s)
Antifibrinolíticos/administración & dosificación , Pérdida de Sangre Quirúrgica/prevención & control , Transfusión Sanguínea , Cistectomía , Ácido Tranexámico/administración & dosificación , Neoplasias de la Vejiga Urinaria/cirugía , Antifibrinolíticos/efectos adversos , Canadá , Cistectomía/efectos adversos , Método Doble Ciego , Esquema de Medicación , Humanos , Infusiones Intravenosas , Estudios Multicéntricos como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Tiempo , Ácido Tranexámico/efectos adversos , Resultado del Tratamiento , Neoplasias de la Vejiga Urinaria/patología
20.
Am J Emerg Med ; 36(12): 2225-2231, 2018 12.
Artículo en Inglés | MEDLINE | ID: mdl-29661668

RESUMEN

OBJECTIVE: There is a lack of definitive pediatric literature on effective pharmacotherapy for persistent post-concussion headache symptoms. This study assessed whether acute metoclopramide treatment in the Emergency Department (ED) was associated with a reduction in persistent headache in children at 1- and 4-weeks post-concussion. METHODS: Children aged 8-17years with acute concussion presenting to 9-Canadian Pediatric EDs were enrolled in a prospective cohort study, from August 2013-June 2015. Primary and secondary outcomes were persistent headache at 1- and 4-week post-injury respectively. Headache persistence was based on the one and four-week headache scores minus recalled pre-injury score using the Post-Concussion Symptom Inventory. The association between metoclopramide and headache persistence at 1- and 4-weeks were examined using unadjusted and adjusted regression and 1:4 propensity score matching model. RESULTS: Baseline assessments were completed in 2095 participants; 65 (3.1%) received metoclopramide within 48-hours of injury. At 1- and 4-weeks, 54% (963/1808) and 26% (456/1780) of participants had persistent headache relative to baseline respectively. In unadjusted analysis, no association between metoclopramide and headache persistence at 1-week was found [treated vs. untreated: 1-week (53% vs. 53%; relative risk (RR)=1.0 (95%CI: 0.8, 1.3); 4-weeks (27.3% vs. 25.6%; RR=1.0 (95% CI: 0.9, 1.2)]. Metoclopramide was not associated with lower headache risk on propensity score matching [treated vs. untreated: 1-week, n=220 (52% vs. 59.4%; RR=0.8 (95%CI: 0.6, 1.2) and 4-weeks, n=225 (27.1% vs. 32.8%; RR=0.9 (95%CI: 0.8, 1.1)]. CONCLUSION: Metoclopramide administration was not associated with a reduction in headache persistence in children seeking ED care due to a concussion. Further research is necessary to determine which pharmacotherapies may be effective for acute and persistent post-concussive headache.


Asunto(s)
Antagonistas de los Receptores de Dopamina D2/administración & dosificación , Metoclopramida/administración & dosificación , Síndrome Posconmocional/complicaciones , Cefalea Postraumática/tratamiento farmacológico , Administración Intravenosa , Adolescente , Canadá , Niño , Servicio de Urgencia en Hospital , Femenino , Humanos , Modelos Logísticos , Masculino , Análisis Multivariante , Dimensión del Dolor , Puntaje de Propensión , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento
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