A global perspective of advanced practice nursing research: A review of systematic reviews.

INTRODUCTION: The World Health Organization (WHO) called for the expansion of all nursing roles, including advanced practice nurses (APNs), nurse practitioners (NPs) and clinical nurse specialists (CNSs). A clearer understanding of the impact of these roles will inform global priorities for advanced practice nursing education, research, and policy. OBJECTIVE: To identify gaps in advanced practice nursing research globally. MATERIALS AND METHODS: A review of systematic reviews was conducted. We searched CINAHL, Embase, Global Health, Healthstar, PubMed, Medline, Cochrane Library, DARE, Joanna Briggs Institute EBP, and Web of Science from January 2011 onwards, with no restrictions on jurisdiction or language. Grey literature and hand searches of reference lists were undertaken. Review quality was assessed using the Critical Appraisal Skills Program (CASP). Study selection, data extraction and CASP assessments were done independently by two reviewers. We extracted study characteristics, country and outcome data. Data were summarized using narrative synthesis. RESULTS: We screened 5840 articles and retained 117 systematic reviews, representing 38 countries. Most CASP criteria were met. However, study selection by two reviewers was done inconsistently and language and geographical restrictions were applied. We found highly consistent evidence that APN, NP and CNS care was equal or superior to the comparator (e.g., physicians) for 29 indicator categories across a wide range of clinical settings, patient populations and acuity levels. Mixed findings were noted for quality of life, consultations, costs, emergency room visits, and health care service delivery where some studies favoured the control groups. No indicator consistently favoured the control group. There is emerging research related to Artificial Intelligence (AI). CONCLUSION: There is a large body of advanced practice nursing research globally, but several WHO regions are underrepresented. Identified research gaps include AI, interprofessional team functioning, workload, and patients and families as partners in healthcare. PROSPERO REGISTRATION NUMBER: CRD42021278532.

Identifying indicators sensitive to primary healthcare nurse practitioner practice: A review of systematic reviews.

AIM: To identify indicators sensitive to the practice of primary healthcare nurse practitioners (PHCNPs). MATERIALS AND METHODS: A review of systematic reviews was undertaken to identify indicators sensitive to PHCNP practice. Published and grey literature was searched from January 1, 2010 to December 2, 2022. Titles/abstracts (n = 4251) and full texts (n = 365) were screened independently by two reviewers, with a third acting as a tie-breaker. Reference lists of relevant publications were reviewed. Risk of bias was examined independently by two reviewers using AMSTAR-2. Data were extracted by one reviewer and verified by a second reviewer to describe study characteristics, indicators, and results. Indicators were recoded into categories. Findings were summarized using narrative synthesis. RESULTS: Forty-four systematic reviews were retained including 271 indicators that were recoded into 26 indicator categories at the patient, provider and health system levels. Nineteen reviews were assessed to be at low risk of bias. Patient indicator categories included activities of daily living, adaptation to health conditions, clinical conditions, diagnosis, education-patient, mortality, patient adherence, quality of life, satisfaction, and signs and symptoms. Provider indicator categories included adherence to best practice-providers, education-providers, illness prevention, interprofessional team functioning, and prescribing. Health system indicator categories included access to care, consultations, costs, emergency room visits, healthcare service delivery, hospitalizations, length of stay, patient safety, quality of care, scope of practice, and wait times. DISCUSSION: Equal to improved care for almost all indicators was found consistently for the PHCNP group. Very few indicators favoured the control group. No indicator was identified for high/low fidelity simulation, cultural safety and cultural sensitivity with people in vulnerable situations or Indigenous Peoples. CONCLUSION: This review of systematic reviews identified patient, provider and health system indicators sensitive to PHCNP practice. The findings help clarify how PHCNPs contribute to care outcomes. PROSPERO REGISTRATION NUMBER: CRD42020198182.

A global perspective of advanced practice nursing research: A review of systematic reviews protocol.

INTRODUCTION: In 2020, the World Health Organization called for the expansion and greater recognition of all nursing roles, including advanced practice nurses (APNs), to better meet patient care needs. As defined by the International Council of Nurses (ICN), the two most common APN roles include nurse practitioners (NPs) and clinical nurse specialists (CNSs). They help ensure care to communities as well as patients and families with acute, chronic or complex conditions. Moreover, APNs support providers to deliver high quality care and improve access to services. Currently, there is much variability in the use of advanced practice nursing roles globally. A clearer understanding of the roles that are in place across the globe, and how they are being used will support greater role harmonization, and inform global priorities for advanced practice nursing education, research, and policy reform. OBJECTIVE: To identify current gaps in advanced practice nursing research globally. MATERIALS AND METHODS: This review of systematic reviews will provide a description of the current state of the research, including gaps, on advanced practice nursing globally. We will include reviews that examine APNs, NPs or CNSs using recognized role definitions. We will search the CINAHL, EMBASE, Global Health, HealthStar, PubMed, Medline, Cochrane Library Database of Systematic Reviews and Controlled Trials Register, Database of Abstracts of Reviews of Effects, Joanna Briggs Institute, and Web of Science electronic databases for reviews published from January 2011 onwards, with no restrictions on jurisdiction or language. We will search the grey literature and hand search the reference lists of all relevant reviews to identify additional studies. We will extract country, patient, provider, health system, educational, and policy/scope of practice data. We will assess the quality of each included review using the CASP criteria, and summarize their findings. This review of systematic reviews protocol was developed following the PRISMA-P recommendations. PROSPERO REGISTRATION NUMBER: CRD42021278532.

Identifying indicators sensitive to primary healthcare nurse practitioner practice: a review of systematic reviews protocol.

INTRODUCTION: Primary healthcare nurse practitioners (PHCNPs) practice in a wide range of clinical settings and with diverse patient populations. Several systematic reviews have examined outcomes of PHCNP roles. However, there is a lack of consistency in the definitions used for the PHCNP role across the reviews. The identification of indicators sensitive to PHCNP practice from the perspective of patients, providers and the healthcare system will allow researchers, clinicians and decision-makers to understand how these providers contribute to outcomes of care. METHODS AND ANALYSIS: A review of systematic reviews is proposed to describe the current state of knowledge about indicators sensitive to PHCNP practice using recognised role definitions. Outcomes of interest include any outcome indicator measuring the effectiveness of PHCNPs. We will limit our search to 2010 onwards to capture the most up-to-date trends. The following electronic databases will be searched: Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library Database of Systematic Reviews and Controlled Trials Register, Database of Abstracts of Reviews of Effects, EMBASE, Global Health, Health Economics Evaluation Database, Health Evidence, HealthStar, Health Systems Evidence, Joanna Briggs Institute, Medline, PDQ-Evidence, PubMed and Web of Science. The search strategies will be reviewed by an academic librarian. Reference lists of all relevant publications will be reviewed. Grey literature will be searched from 2010 onwards, and will include: CADTH Information Services, CADTH's Grey Matters tool, OpenGrey, Organisation for Economic Co-operation and Development, ProQuest Dissertation and Theses and WHO. The PROSPERO International Prospective Register of Systematic Reviews will be searched to identify registered review protocols. The review protocol was developed using Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols recommendations. A narrative synthesis will be used to summarise study findings. ETHICS AND DISSEMINATION: No ethical approval is required for the study. The data used in the study will be abstracted from published systematic reviews. Dissemination strategies will include peer-reviewed publication, conference presentations and presentations to key stakeholders. PROSPERO REGISTRATION NUMBER: CRD42020198182.

Hybrid Coronary Revascularization vs Complete Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Hybrid coronary revascularization (HCR) has emerged as a potential alternative to complete coronary artery bypass graft (CABG) surgery. However, the efficacy and safety of HCR vs CABG remain unclear. We therefore conducted a systematic review and meta-analysis to compare these interventions. METHODS: We systematically searched PubMed, MEDLINE (via Ovid), EMBASE (via Ovid), Cochrane Library of Clinical Trials, and the Web of Science for studies comparing HCR to CABG in patients with multivessel coronary artery disease. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE) and its components (myocardial infarction, stroke, mortality, and target-vessel revascularization [TVR]) at ≥1 year. Secondary outcomes included MACCE at ≤30 days, its components, and postoperative safety outcomes (renal failure, blood transfusion, new-onset atrial fibrillation, and infection). RESULTS: One randomized controlled trial and 9 cohort studies were included in our systematic review. Pooled results indicate that HCR is associated with a lower risk for postoperative blood transfusion (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.27-0.68) and infection (OR, 0.19; 95% CI, 0.04-0.98), and a shorter hospital stay (6.0 days for HCR vs 7.8 days for CABG) and intensive care unit (ICU) stay (25.4 hours for HCR vs 45.7 hours for CABG). Long-term outcome data showed an association between HCR and long-term TVR (OR, 3.10; 95% CI, 1.39-6.90). CONCLUSIONS: Our results suggest that compared to CABG, HCR is associated with a lower risk of postoperative blood transfusion and infection, as well as a shorter ICU stay and hospital stay. HCR was also associated with a higher risk of long-term TVR.

Intravenous beta-blockers in ST-segment elevation myocardial infarction: A systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: The role of intravenous (IV) beta-blockers in conjunction with percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) remains unclear. We therefore conducted a meta-analysis to assess their role in the acute phase of STEMI. METHODS: We systematically searched the Cochrane Libraries, Medline, and EMBASE for RCTs comparing IV beta-blockers with inactive controls in STEMI patients undergoing PCI. The primary outcome was left ventricular ejection fraction (LVEF). Pooling was performed using DerSimonian and Laird random-effects models. RESULTS: Four RCTs (n=1149) were included in our meta-analysis. All RCTs only enrolled patients with confirmed STEMI with symptoms lasting <6 or <12hours, and presenting in Killip Class 1 or 2. Mean age ranged across trials from 58.5-62.5years. Most patients were male (range: 74.8%-86.3%). Data suggest that IV beta-blockers may improve LVEF at 0-2weeks (weighted mean difference [WMD]: 1.9%; 95% confidence interval [CI]: -0.7%, 4.5%) and 4-6weeks (WMD: 1.4%; 95% CI: -3.1%, 5.9%) post-infarct, reaching statistical significance at 24weeks (WMD: 2.6%; 95% CI: 0.6%, 4.6%). Rates of ventricular arrhythmia (risk ratio [RR]: 0.65; 95% CI: 0.33, 1.29), any arrhythmia (RR: 0.67; 95% CI: 0.36, 1.27), and cardiogenic shock (RR: 0.77; 95% CI: 0.31, 1.95) during index hospitalization were numerically lower with IV beta-blockers, but 95% CIs were wide. CONCLUSIONS: In STEMI patients presenting in Killip Class 1 or 2, IV beta-blockers in conjunction with PCI are associated with improved LVEF at 24weeks relative to PCI alone.

Stent Retrievers for the Treatment of Acute Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

IMPORTANCE: Stent retrievers are a promising alternative for the treatment of acute ischemic stroke (AIS). Several recently completed clinical trials have examined the use of stent retrievers with intravenous recombinant tissue plasminogen activator (rtPA) compared with rtPA alone. OBJECTIVE: To conduct a systematic review and meta-analysis of randomized clinical trials to quantify the benefits and risks of using stent retrievers in addition to rtPA for the treatment of AIS. DATA SOURCES: The MEDLINE, EMBASE, and Cochrane Library of Clinical Trials databases were searched from inception to July 2015 for the keywords stent*, retriev*, Solitaire, Trevo, Revive, and stroke. Trial registries were also searched. A total of 326 publications were identified and 213 potentially relevant records were screened. STUDY SELECTION: Randomized clinical trials that examined stent retrievers with rtPA vs rtPA alone were included in the meta-analysis. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted study data and performed quality assessment using the Cochrane Risk of Bias Tool. DerSimonian and Laird random-effects models were used to estimate relative risks (RRs), risk differences (RDs), and numbers needed to treat. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of patients achieving functional independence (defined as a score of 0-2 on the modified Rankin Scale, with 0 indicating no disability and 6 indicating death) at 90 days. Risks of all-cause mortality, intracranial hemorrhage, and parenchymal hematoma at 90 days were also assessed. RESULTS: Five randomized clinical trials met our inclusion criteria (n = 1287 patients). Patients randomized to stent-retriever therapy with rtPA had significantly improved rates of functional independence at 90 days compared with those randomized to rtPA alone (RR, 1.72; 95% CI, 1.48-1.99; RD, 0.19; 95% CI, 0.13-0.25). When data were pooled across trials, the effect of stent-retriever therapy on all-cause mortality at 90 days was inconclusive (RR, 0.82; 95% CI, 0.60-1.11; RD, -0.04; 95% CI, -0.08 to 0.1). There were similarly no detectable differences in the risks of intracranial hemorrhage (RR, 1.15; 95% CI, 0.67-1.97; RD, 0.00; 95% CI, -0.02 to 0.03) or parenchymal hematoma (RR, 1.18; 95% CI, 0.71-1.94; RD, 0.01; 95% CI, -0.01 to 0.04), although the 95% CIs were wide. Fixed-effects sensitivity analyses produced similar results for all outcomes. CONCLUSIONS AND RELEVANCE: The use of stent retrievers in conjunction with rtPA vs rtPA alone is associated with significant improvement of functional independence 90 days after AIS.

Systematic Review of the Mediterranean Diet for Long-Term Weight Loss.

BACKGROUND: Although the long-term health benefits of the Mediterranean diet are well established, its efficacy for weight loss at ≥12 months in overweight or obese individuals is unclear. We therefore conducted a systematic review of randomized controlled trials (RCTs) to determine the effect of the Mediterranean diet on weight loss and cardiovascular risk factor levels after ≥12 months. METHODS: We systematically searched MEDLINE, EMBASE, and the Cochrane Library of Clinical Trials for RCTs published in English or French and with follow-up ≥12 months that examined the effect of the Mediterranean diet on weight loss and cardiovascular risk factor levels in overweight or obese individuals trying to lose weight. RESULTS: Five RCTs (n = 998) met our inclusion criteria. Trials compared the Mediterranean diet to a low-fat diet (4 treatment arms), a low-carbohydrate diet (2 treatment arms), and the American Diabetes Association diet (1 treatment arm). The Mediterranean diet resulted in greater weight loss than the low-fat diet at ≥12 months (range of mean values: -4.1 to -10.1 kg vs 2.9 to -5.0 kg), but produced similar weight loss as other comparator diets (range of mean values: -4.1 to -10.1 kg vs -4.7 to -7.7 kg). Moreover, the Mediterranean diet was generally similar to comparator diets at improving other cardiovascular risk factor levels, including blood pressure and lipid levels. CONCLUSION: Our findings suggest that the Mediterranean diet results in similar weight loss and cardiovascular risk factor level reduction as comparator diets in overweight or obese individuals trying to lose weight.

A meta-analysis of randomized controlled trials of the risk of bleeding with apixaban versus vitamin K antagonists.

Apixaban is one of the new oral anticoagulants, which is prescribed as an alternative to vitamin K antagonists (VKAs). Concerns regarding its bleeding profile persist and require further evaluation. Therefore, we conducted a meta-analysis of randomized controlled trials (RCTs) to compare the risks of bleeding and all-cause mortality between apixaban and VKAs. The MEDLINE, EMBASE, and Cochrane Library of Clinical Trials databases were systematically searched for RCTs comparing the risks of bleeding and all-cause mortality of apixaban (2.5 or 5 mg twice daily) with those of VKAs. We included RCTs conducted in adults and published in English or French. Data were pooled across RCTs using random-effects meta-analytical models. Our systematic search identified 5 RCTs meeting our inclusion criteria (n = 24,435). They included patients with atrial fibrillation (n = 18,358), total knee replacement surgery (n = 458), and venous thromboembolism (n = 5,619). Data pooled across RCTs revealed that apixaban was associated with reduced risks of any bleeding (relative risk [RR] 0.73, 95% confidence interval [CI] 0.59 to 0.90) and a composite of major or clinically relevant nonmajor bleeding (RR 0.60, 95% CI 0.40 to 0.88). Apixaban was also associated with a lower risk of intracranial bleeding (RR 0.42, 95% CI 0.31 to 0.58) whereas analyses of major and minor bleeding were inconclusive. Moreover, apixaban was associated with decreased all-cause mortality (RR 0.89, 95% CI 0.81 to 0.99) although this finding was driven by the results of the ARISTOTLE trial. In conclusion, our meta-analysis found that apixaban is associated with a lower risk of bleeding than VKAs, providing some reassurance regarding its safety.

Long-term effects of 4 popular diets on weight loss and cardiovascular risk factors: a systematic review of randomized controlled trials.

BACKGROUND: We conducted a systematic review to examine the efficacy of the Atkins, South Beach, Weight Watchers (WW), and Zone diets, with a particular focus on sustained weight loss at ≥12 months. METHODS AND RESULTS: We systematically searched MEDLINE, EMBASE, and the Cochrane Library of Clinical Trials to identify randomized controlled trials (RCTs) published in English with follow-up ≥4 weeks that examined the effects of these 4 popular diets on weight loss and cardiovascular risk factors. We identified 12 RCTs (n=2559) with follow-up ≥12 months: 10 versus usual care (5 Atkins, 4 WW, and 1 South Beach) and 2 head-to-head (1 of Atkins, WW, and Zone, and 1 of Atkins, Zone, and control). At 12 months, the 10 RCTs comparing popular diets to usual care revealed that only WW was consistently more efficacious at reducing weight (range of mean changes: -3.5 to -6.0 kg versus -0.8 to -5.4 kg; P<0.05 for 3/4 RCTs). However, the 2 head-to-head RCTs suggest that Atkins (range: -2.1 to -4.7 kg), WW (-3.0 kg), Zone (-1.6 to -3.2 kg), and control (-2.2 kg) all achieved modest long-term weight loss. Twenty-four-month data suggest that weight lost with Atkins or WW is partially regained over time. CONCLUSIONS: Head-to-head RCTs, providing the most robust evidence available, demonstrated that Atkins, WW, and Zone achieved modest and similar long-term weight loss. Despite millions of dollars spent on popular commercial diets, data are conflicting and insufficient to identify one popular diet as being more beneficial than the others.

Meta-analysis of randomized controlled trials on the risk of bleeding with dabigatran.

Dabigatran is a univalent low-molecular-weight direct thrombin inhibitor that has been developed as an alternative to vitamin K antagonists (VKAs). However, uncertainty remains regarding dabigatran's safety profile with respect to bleeding. Our objective was to compare the risk of bleeding and all-cause mortality of dabigatran with that of VKAs in a systematic review and meta-analysis of randomized controlled trials (RCTs). We systematically searched MEDLINE, Embase, and the Cochrane Library of clinical trials to identify RCTs comparing the bleeding risk of dabigatran (150 mg twice daily) with that of VKAs. Included RCTs had treatment duration ≥90 days and were published in English or French. Data were meta-analyzed using random-effects models. Five RCTs (n = 20,332) were included in our systematic review. Study populations consisted of patients with atrial fibrillation (n = 18,615) and venous thromboembolism (n = 7,998). When data were pooled across the 4 RCTs (n = 17,466) without overlapping populations, dabigatran was not associated with an increased risk of major bleeding compared with VKAs (relative risk [RR] 0.92, 95% confidence interval [CI] 0.81 to 1.05). Dabigatran was associated with a decreased risk of intracranial bleeding (RR 0.40, 95% CI 0.27 to 0.59) but an increased risk of gastrointestinal bleeding (RR 1.51, 95% CI 1.23 to 1.84). Dabigatran was also associated with a trend toward decreased all-cause mortality (RR 0.90, 95% CI 0.80 to 1.01). In conclusion, results suggest that dabigatran has a favorable safety profile with respect to bleeding compared with VKAs.

Anemia and mortality in acute coronary syndromes: a systematic review and meta-analysis.

BACKGROUND: Anemia is a common comorbidity among patients with acute coronary syndromes (ACS) and may adversely affect cardiovascular outcomes in these patients. We conducted a systematic review and meta-analysis to examine the association between anemia and mortality among patients with ACS. METHODS: We systematically searched MEDLINE to identify cohort studies and secondary analyses of randomized controlled trials examining the association between anemia and all-cause mortality among patients with ACS. Data were aggregated at 4 follow-up times (inhospital, 30 days, 1 year, and maximal available follow-up) using random-effects meta-analysis models. RESULTS: Twenty-seven studies met the inclusion criteria, involving 233,144 patients. Anemia was present in 44,519 (19.1%) of these patients. Anemic patients were generally older and had a higher prevalence of comorbidities including diabetes mellitus, congestive heart failure, cerebrovascular disease, and history of major bleeding. Anemia was associated with an increased risk of crude all-cause mortality (relative risk 2.08, 95% CI 1.70-2.55) and reinfarction (relative risk 1.25, 95% CI 1.02-1.53) at maximal available follow-up. When adjusted risk ratios from individual studies' multivariable regression analyses were pooled, the magnitude of the associated mortality risk was attenuated but remained significant at maximal follow-up (hazard ratio 1.49, 95% CI 1.23-1.81). Clinically and statistically significant increases in mortality were observed as early as at 30 days post-ACS and persisted at 1 year. CONCLUSIONS: Anemia in patients with ACS is independently associated with a significantly increased risk of early and late mortality.

Ceacam1 separates graft-versus-host-disease from graft-versus-tumor activity after experimental allogeneic bone marrow transplantation.

BACKGROUND: Allogeneic bone marrow transplantation (allo-BMT) is a potentially curative therapy for a variety of hematologic diseases, but benefits, including graft-versus-tumor (GVT) activity are limited by graft-versus-host-disease (GVHD). Carcinoembryonic antigen related cell adhesion molecule 1 (Ceacam1) is a transmembrane glycoprotein found on epithelium, T cells, and many tumors. It regulates a variety of physiologic and pathological processes such as tumor biology, leukocyte activation, and energy homeostasis. Previous studies suggest that Ceacam1 negatively regulates inflammation in inflammatory bowel disease models. METHODS: We studied Ceacam1 as a regulator of GVHD and GVT after allogeneic bone marrow transplantation (allo-BMT) in mouse models. In vivo, Ceacam1(-/-) T cells caused increased GVHD mortality and GVHD of the colon, and greater numbers of donor T cells were positive for activation markers (CD25(hi), CD62L(lo)). Additionally, Ceacam1(-/-) CD8 T cells had greater expression of the gut-trafficking integrin α(4)ß(7), though both CD4 and CD8 T cells were found increased numbers in the gut post-transplant. Ceacam1(-/-) recipients also experienced increased GVHD mortality and GVHD of the colon, and alloreactive T cells displayed increased activation. Additionally, Ceacam1(-/-) mice had increased mortality and decreased numbers of regenerating small intestinal crypts upon radiation exposure. Conversely, Ceacam1-overexpressing T cells caused attenuated target-organ and systemic GVHD, which correlated with decreased donor T cell numbers in target tissues, and mortality. Finally, graft-versus-tumor survival in a Ceacam1(+) lymphoma model was improved in animals receiving Ceacam1(-/-) vs. control T cells. CONCLUSIONS: We conclude that Ceacam1 regulates T cell activation, GVHD target organ damage, and numbers of donor T cells in lymphoid organs and GVHD target tissues. In recipients of allo-BMT, Ceacam1 may also regulate tissue radiosensitivity. Because of its expression on both the donor graft and host tissues, this suggests that targeting Ceacam1 may represent a potent strategy for the regulation of GVHD and GVT after allogeneic transplantation.