Infliximab as a second-line therapy for children with refractory Kawasaki disease: A systematic review and meta-analysis of randomized controlled trials.

AIMS: Infliximab is a tumour necrosis factor-alpha inhibitor that is used to treat children with refractory Kawasaki disease (KD). Our purpose was to evaluate the safety and impact of infliximab versus intravenous immunoglobulins on the incidence of coronary artery aneurysms (CAAs) and treatment resistance in children with refractory KD. METHODS: The Medline/PubMed, Embase, CINAHL, Cochrane Central Register of Controlled Trials and clinical trials registries were searched to December 2021. Randomized controlled trials (RCTs) comparing infliximab as second-line therapy to a second dose of intravenous immunoglobulin (IVIG) in children with refractory KD, reported in abstract or full text, were included. Studies were selected and assessed for risk of bias by two reviewers. Data were extracted and pooled using conventional random-effects meta-analysis. The certainty of evidence was assessed using the GRADE system. RESULTS: A total of 199 participants from four RCTs were included. The pooled risk ratio (RR) for the incidence of treatment resistance in patients treated with infliximab was 0.40 (95% confidence interval [CI] 0.25-0.64). For incidence of CAAs RR was 1.20 (95% CI 0.54-2.63), the incidence of adverse effect "infusion reactions" RR was 0.48, (95% CI 0.12-1.92) and for "infections" RR was 0.55 (95% CI 0.27-1.12). Overall, the GRADE strength of evidence for the primary outcomes was low. Evidence on the duration of fever and inflammatory biomarkers was sparse, heterogeneous and inconclusive. CONCLUSION: Moderate-certainty evidence indicates that infliximab may reduce the incidence of treatment resistance in children with refractory KD. However, the limited strength of evidence warrants further research.

Fluid distribution timetable on adherence to fluid restriction of patients with end-stage renal disease undergoing haemodialysis: Single-blind, Randomized-Controlled Pilot Study.

AIM: To determine the effects of a fluid distribution timetable on adherence to fluid restriction of patients with end-stage renal disease undergoing haemodialysis. BACKGROUND: Fluid restriction is necessary among patients with chronic kidney disease. However, treatment adherence remains a challenge. DESIGN: Single-blind, randomized-controlled pilot study. METHODS: From September - December 2016, 24 consecutively-selected patients with end-stage renal disease from a single dialysis clinic were randomly assigned using computer-generated sequences of randomly permuted blocks stratified according to gender to receive the fluid distribution timetable or standard care. Adherence to fluid restriction was measured using two indicators-thirst and interdialytic weight gain- and were compared using One-way RM-MANOVA and MANCOVA. Secondary outcomes included baseline patient demographic and clinical characteristics and were compared according to treatment allocation. Both groups were followed-up for 4 weeks, assessing outcome measures during the second haemodialysis session for each week. RESULTS: At baseline, the demographic and clinical characteristics and indicators of adherence to fluid restriction were comparable between the two groups. Thirst scores, however, were statistically lower in the treatment group than the control group on the fourth week follow-up. There was also a remarkable decrease from baseline thirst and interdialytic weight gain scores in the treatment group, with partial eta-squared of 0.43 and 0.39, respectively. CONCLUSION: The fluid distribution timetable was an effective adjunct treatment strategy in promoting adherence to fluid restriction. However, since this is just a pilot study, further investigation must be conducted to determine the effects of fluid distribution timetable. TRIAL REGISTRATION: NCT03582592.

The Impact of a Standardized Checklist on Transition of Care During Emergency Department Resident Physician Change of Shift.

INTRODUCTION: Transitions of patient care during physicians' change of shift introduce the potential for critical information to be missed or distorted, resulting in possible morbidity. The Joint Commission, the Accreditation Council for Graduate Medical Education, and the Society of Hospital Medicine jointly encourage a structured format for patient care sign-out. This study's objective was to examine the impact of a standardized checklist on the quality of emergency medicine (EM) resident physicians' patient-care transition at shift change. METHODS: Investigators developed a standardized sign-out checklist for EM residents to complete prior to sign out. This checklist included topics of diagnoses, patient-care tasks to do, patient disposition, admission team, and patient code status. Two EM attending physicians, the incoming and departing, assessed the quality of transitions of care at this shift change using a standardized assessment form. This form also assessed overall quality of sign-out using a visual analog scale (VAS), based on a 10-centimeter scale. For two months, we collected initial, status quo data (pre-checklist [PCL] cohort) followed by two months of residents using the checklist (post-checklist [CL] cohort). RESULTS: We collected data for 77 days (July 1, 2015 - November 11, 2015), 38 days of status quo sign-out followed by 39 days of checklist utilization, comprised of 1,245 attending assessments. Global assessment of sign-out for the CL was 8 compared to 7.5 for the PCL. Aspects of transition of care that implementation of the sign-out checklist impacted included the following (reported as a frequency): "To Do" (PCL 84.3%, CL 97.8%); "Disposition" (PCL 97.2%, CL 99.4%); "Admit Team" (67.1%, CL 76.2%); and "Attending Add" (PCL 23.4%, CL 11.3%). CONCLUSION: Implementation of a sign-out checklist enhanced EM resident physician transition of care at shift end by increasing the frequency of discussion of critical tasks remaining for patient care, disposition status, and subjective assessment of quality of sign-out.