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Manti S, Licari A, Brambilla I, Caffarelli C, Calvani M, Cardinale F, Ciprandi G, Cravidi C, Duse M, Martelli A, Minasi D, Miraglia Del Giudice M, Pajno GB, Tosca MA, Chiappini E, Baraldi E, Marseglia G. Agreements and controversies of national guidelines for bronchiolitis: Results from an Italian survey. IMMUNITY INFLAMMATION AND DISEASE 2021; 9:1229-1236. [PMID: 34677899 PMCID: PMC8589388 DOI: 10.1002/iid3.451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 12/30/2022]
Abstract
Introduction Significant variations in the management of bronchiolitis are often recorded, and, in parallel, to recommend a univocal clinical approach is challenging and still questioned. This study is aimed to evaluate the diagnostic and therapeutic management of bronchiolitis in children adopted by Italian pediatricians following the national guidelines. Material and Methods A survey study was designed and carried out by sending an email an open‐ended questionnaire developed by an expert panel of the Scientific Board of the Italian Society of Pediatric Allergology and Immunology (SIAIP). Questions were designed according to the national intersociety consensus document on treatment and prevention of bronchiolitis in newborns and infants. Results Overall, 234 pediatricians were taking part in the study. When diagnosing bronchiolitis, only 44.01% (103/234) of participants correctly followed the national guidelines. All participants (100%) would perform laboratory tests and/or radiological exams. 44.01% administered oxygen (O2) when O2 saturation was minor than 92%. About the therapeutic regimen, marked discrepancies between national guidelines and recorded answers were reported. Indications for hospital admission and discharge criteria were in line with the national guidelines. Conclusions There is a significant practice variation in the management of acute bronchiolitis among Italian physicians. Some wrong attitudes need to be further discouraged, such use of diagnostic procedures and therapeutic approaches. Further research is urgently required to define the best management of patients with bronchiolitis and implement strategies to standardize care and improve the quality of care.
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Affiliation(s)
- Sara Manti
- Dipartimento di Medicina Clinica e Sperimentale, Unità di Broncopneumologia Pediatrica, Università di Catania, Catania, Italy
| | - Amelia Licari
- Clinica Pediatrica, Fondazione IRCCS Policlinico "S. Matteo," Università di Pavia, Pavia, Italy
| | - Ilaria Brambilla
- Clinica Pediatrica, Fondazione IRCCS Policlinico "S. Matteo," Università di Pavia, Pavia, Italy
| | - Carlo Caffarelli
- Clinica Pediatrica, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Mauro Calvani
- Dipartimento di Pediatria, Ospedale S. Camillo-Forlanini, Roma, Italy
| | - Fabio Cardinale
- UOC Pediatria, Servizio di Allergologia e Pneumologia Pediatrica, Azienda Ospedaliera-Universitaria "Consorziale-Policlinico," Ospedale Pediatrico Giovanni XXIII, Bari, Italy
| | | | | | - Marzia Duse
- Dipartimento di Pediatria, Policlinico Umberto I, Università Sapienza di Roma, Roma, Italy
| | - Alberto Martelli
- UOC Pediatria, Azienda Ospedaliera G. Salvini, Ospedali di Garbagnate Milanese e Bollate, Milano, Italy
| | - Domenico Minasi
- UOC Pediatria, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Michele Miraglia Del Giudice
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Università della Campania Luigi Vanvitelli, Napoli, Italy
| | - Giovan B Pajno
- Dipartimento di Pediatria, Unità di Allergologia, Università di Messina, Messina, Italy
| | - Maria A Tosca
- Allergologia Pediatrica, Istituto Giannina Gaslini, Genova, Italy
| | - Elena Chiappini
- SODc Malattie Infettive AOU Meyer, Dipartimento di Scienze della Salute, Università di Firenze, Firenze, Italy
| | - Eugenio Baraldi
- Dipartimento della Donna e del Bambino, Università di Padova, Padova, Italy
| | - Gianluigi Marseglia
- Clinica Pediatrica, Fondazione IRCCS Policlinico "S. Matteo," Università di Pavia, Pavia, Italy
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2
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Cashin AG, Rizzo RRN, Wand BM, O'Connell NE, Lee H, Bagg MK, O'Hagan E, Maher CG, Furlan AD, van Tulder MW, McAuley JH. Non-pharmacological and non-surgical treatments for low back pain in adults: an overview of Cochrane Reviews. Hippokratia 2021. [DOI: 10.1002/14651858.cd014691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Aidan G Cashin
- Prince of Wales Clinical School, Faculty of Medicine; The University of New South Wales; Sydney Australia
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
| | - Rodrigo RN Rizzo
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
- School of Health Sciences, Faculty of Medicine and Health; The University of New South Wales; Sydney Australia
| | - Benedict M Wand
- School of Physiotherapy; The University of Notre Dame Australia; Fremantle Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse; Brunel University London; Uxbridge UK
| | - Hopin Lee
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS); University of Oxford; Oxford UK
- School of Medicine and Public Health; The University of Newcastle; Newcastle Australia
| | - Matthew K Bagg
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
| | - Edel O'Hagan
- Prince of Wales Clinical School, Faculty of Medicine; The University of New South Wales; Sydney Australia
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
| | - Christopher G Maher
- Sydney School of Public Health; The University of Sydney; Sydney Australia
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
| | | | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth and Life Sciences; VU University Amsterdam; Amsterdam Netherlands
| | - James H McAuley
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
- School of Health Sciences, Faculty of Medicine and Health; The University of New South Wales; Sydney Australia
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3
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Elliott SA, Gaudet LA, Fernandes RM, Vandermeer B, Freedman SB, Johnson DW, Plint AC, Klassen TP, Allain D, Hartling L. Comparative Efficacy of Bronchiolitis Interventions in Acute Care: A Network Meta-analysis. Pediatrics 2021; 147:peds.2020-040816. [PMID: 33893229 DOI: 10.1542/peds.2020-040816] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Uncertainty exists as to which treatments are most effective for bronchiolitis, with considerable practice variation within and across health care sites. OBJECTIVE A network meta-analysis to compare the effectiveness of common treatments for bronchiolitis in children aged ≤2 years. DATA SOURCES Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform were searched from inception to September 1, 2019. STUDY SELECTION A total 150 randomized controlled trials comparing a placebo or active comparator with any bronchodilator, glucocorticoid steroid, hypertonic saline solution, antibiotic, helium-oxygen therapy, or high-flow oxygen therapy were included. DATA EXTRACTION Data were extracted by 1 reviewer and independently verified. Primary outcomes were admission rate on day 1 and by day 7 and hospital length of stay. Strength of evidence was assessed by using Confidence in Network Meta-Analysis . RESULTS Nebulized epinephrine (odds ratio: 0.64, 95% confidence interval [CI]: 0.44 to 0.93, low confidence) and nebulized hypertonic saline plus salbutamol (odds ratio: 0.44, 95% CI: 0.23 to 0.84, low confidence) reduced the admission rate on day 1. No treatment significantly reduced the admission rate on day 7. Nebulized hypertonic saline (mean difference: -0.64 days, 95% CI: -1.01 to -0.26, low confidence) and nebulized hypertonic saline plus epinephrine (mean difference: -0.91 days, 95% CI: -1.14 to -0.40, low confidence) reduced hospital length of stay. LIMITATIONS Because we did not report adverse events in this analysis, we cannot make inferences about the safety of these treatments. CONCLUSIONS Although hypertonic saline alone, or combined with epinephrine, may reduce an infant's stay in the hospital, poor strength of evidence necessitates additional rigorous trials.
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Affiliation(s)
- Sarah Alexandra Elliott
- Alberta Research Centre for Health Evidence and.,Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada
| | | | - Ricardo M Fernandes
- Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada.,Clinical Pharmacology and Therapeutics Laboratory, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal.,Department of Pediatrics, Hospital de Santa Maria, Avenida Professor Egas Moniz, Lisboa, Portugal
| | - Ben Vandermeer
- Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada
| | - Stephen B Freedman
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary and Alberta Children's Hospital Foundation, Calgary, Canada
| | - David W Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary and Alberta Children's Hospital Foundation, Calgary, Canada
| | - Amy C Plint
- Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba and Department of Pediatrics and Child Health, Max Rudy School of Medicine, University of Manitoba, Winnipeg, Canada; and
| | - Dominic Allain
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta and Stollery Children's Hospital, Edmonton, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence and .,Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada
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LOCATE: a prospective evaluation of the value of Leveraging Ongoing Citation Acquisition Techniques for living Evidence syntheses. Syst Rev 2021; 10:116. [PMID: 33875014 PMCID: PMC8056603 DOI: 10.1186/s13643-021-01665-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Living systematic reviews (LSRs) can expedite evidence synthesis by incorporating new evidence in real time. However, the methods needed to identify new studies in a timely manner are not well established. OBJECTIVES To explore the value of complementary search approaches in terms of search performance, impact on results and conclusions, screening workload, and feasibility compared to the reference standard. METHODS We developed three complementary search approaches for a systematic review on treatments for bronchiolitis: Automated Full Search, PubMed Similar Articles, and Scopus Citing References. These were automated to retrieve results monthly; pairs of reviewers screened the records and commented on feasibility. After 1 year, we conducted a full update search (reference standard). For each complementary approach, we compared search performance (proportion missed, number needed to read [NNR]) and reviewer workload (number of records screened, time required) to the reference standard. We investigated the impact of the new trials on the effect estimate and certainty of evidence for the primary outcomes. We summarized comments about feasibility. RESULTS Via the reference standard, reviewers screened 505 titles/abstracts, 24 full texts, and identified four new trials (NNR 127; 12.4 h). Of the complementary approaches, only the Automated Full Search located all four trials; these were located 6 to 12 months sooner than via the reference standard but did not alter the results nor certainty in the evidence. The Automated Full Search was the most resource-intensive approach (816 records screened; NNR 204; 17.1 h). The PubMed Similar Articles and Scopus Citing References approaches located far fewer records (452 and 244, respectively), thereby requiring less screening time (9.4 and 5.2 h); however, each approach located only one of the four new trials. Reviewers found it feasible and convenient to conduct monthly screening for searches of this yield (median 15-65 records/month). CONCLUSIONS The Automated Full Search was the most resource-intensive approach, but also the only to locate all of the newly published trials. Although the monthly screening time for the PubMed Similar Articles and Scopus Citing Articles was far less, most relevant records were missed. These approaches were feasible to integrate into reviewer work processes. SYSTEMATIC REVIEW REGISTRATION Open Science Framework. https://doi.org/10.17605/OSF.IO/6M28H .
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5
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Cashin AG, Wand BM, O'Connell NE, Lee H, Bagg MK, O'Hagan E, Maher CG, Furlan AD, van Tulder MW, McAuley JH. Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews. Hippokratia 2020. [DOI: 10.1002/14651858.cd013815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Aidan G Cashin
- Prince of Wales Clinical School, Faculty of Medicine; The University of New South Wales; Sydney Australia
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
| | - Benedict M Wand
- School of Physiotherapy; The University of Notre Dame Australia; Fremantle Australia
| | - Neil E O'Connell
- Health Economics Research Group, Institute of Environment, Health and Societies, Department of Clinical Sciences; Brunel University London; Uxbridge UK
| | - Hopin Lee
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS); University of Oxford; Oxford UK
- School of Medicine and Public Health; University of Newcastle; Newcastle Australia
| | - Matthew K Bagg
- Prince of Wales Clinical School, Faculty of Medicine; The University of New South Wales; Sydney Australia
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
- New College Village; University of New South Wales; Sydney Australia
| | - Edel O'Hagan
- Prince of Wales Clinical School, Faculty of Medicine; The University of New South Wales; Sydney Australia
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
| | - Christopher G Maher
- Sydney School of Public Health; The University of Sydney; Sydney Australia
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
| | | | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth and Life Sciences; VU University Amsterdam; Amsterdam Netherlands
| | - James H McAuley
- Centre for Pain IMPACT; Neuroscience Research Australia; Sydney Australia
- School of Medical Sciences, Faculty of Medicine; University of New South Wales; Sydney Australia
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6
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Kirolos A, Manti S, Blacow R, Tse G, Wilson T, Lister M, Cunningham S, Campbell A, Nair H, Reeves RM, Fernandes RM, Campbell H. A Systematic Review of Clinical Practice Guidelines for the Diagnosis and Management of Bronchiolitis. J Infect Dis 2020; 222:S672-S679. [PMID: 31541233 DOI: 10.1093/infdis/jiz240] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Bronchiolitis is the leading cause of hospital admission for respiratory disease among infants aged <1 year. Clinical practice guidelines can benefit patients by reducing the performance of unnecessary tests, hospital admissions, and treatment with lack of a supportive evidence base. This review aimed to identify current clinical practice guidelines worldwide, appraise their methodological quality, and discuss variability across guidelines for the diagnosis and management of bronchiolitis. METHODS A systematic literature review of electronic databases EMBASE, Global Health, and Medline was performed. Manual searches of the gray literature, national pediatric society websites, and guideline-focused databases were performed, and select international experts were contacted to identify additional guidelines. The Appraisal of Guidelines for Research and Evaluation assessment tool was used by 2 independent reviewers to appraise each guideline. RESULTS Thirty-two clinical practice guidelines met the selection criteria. Quality assessment revealed significant shortcomings in a number of guidelines, including lack of systematic processes in formulating guidelines, failure to state conflicts of interest, and lack of consultation with families of affected children. There was widespread agreement about a number of aspects, such as avoidance of the use of unnecessary diagnostic tests, risk factors for severe disease, indicators for hospital admission, discharge criteria, and nosocomial infection control. However, there was variability, even within areas of consensus, over specific recommendations, such as variable thresholds for oxygen therapy. Guidelines showed significant variability in recommendations for the pharmacological management of bronchiolitis, with conflicting recommendations over whether use of nebulized epinephrine, hypertonic saline, or bronchodilators should be routinely trialled. CONCLUSIONS Future guidelines should aim to be compliant with international standards for clinical guidelines to improve their quality and clarity and to promote their adoption into practice. Variable recommendations between guidelines may reflect the evolving evidence base for bronchiolitis management, and platforms should be created to understand this variability and promote evidence-based recommendations.
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Affiliation(s)
- Amir Kirolos
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | - Sara Manti
- Department of Pediatrics, University of Messina, Sicily, Italy
| | - Rachel Blacow
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | - Gabriel Tse
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | - Thomas Wilson
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | | | - Steve Cunningham
- Department of Child Life and Health, Edinburgh
- Centre for Inflammation Research, University of Edinburgh, Edinburgh
| | | | - Harish Nair
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | - Rachel M Reeves
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | - Ricardo M Fernandes
- Clinical Pharmacology and Therapeutics, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon
| | - Harry Campbell
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
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7
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El Basha NR, Marzouk H, Sherif MM, El Kholy AA. Prematurity, a significant predictor for worse outcome in viral bronchiolitis: a comparative study in infancy. J Egypt Public Health Assoc 2019; 94:15. [PMID: 32218612 PMCID: PMC7091660 DOI: 10.1186/s42506-019-0015-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/28/2019] [Indexed: 11/14/2022]
Abstract
Background The rate of admissions to hospital with bronchiolitis has increased over the past years. The reasons for this are likely to be multifactorial including improved survival of preterm infants. Aim To assess the severity of viral bronchiolitis in preterm compared to term infants admitted at a tertiary hospital in Cairo, Egypt, based on the outcome. Patients and methods This prospective study was conducted throughout a 3-year period from September 2011 to October 2014. It included 153 infants, 74 healthy preterm, and 79 healthy term infants admitted with clinical diagnosis of bronchiolitis at a tertiary hospital in Cairo, Egypt. Bronchiolitis severity score (BSS) was recorded, and nasopharyngeal swabs were obtained from each patient at the time of presentation. Viruses were identified using reverse transcription polymerase chain reaction (RT-PCR). The clinical course and patient’s outcome were recorded. Results This study recorded a significantly more severe BSS for preterm compared to term infants. The preterm group had an increased mean length of hospital stay and oxygen therapy and was more likely to need intensive care unit admission and mechanical ventilation (MV) compared to the term group. The mean (± SD) BSS for infections with h-MPV, RSV, and para-influenza 3 was more significantly severe in preterm compared to term infants. Bacterial co-infection was significantly correlated with severity scoring in both groups. Conclusion Prematurity significantly affects the severity of bronchiolitis, and this underscores the importance of early categorization as a high-risk group on their first visit. The physician should be aware that their illness runs a more severe course, even if they have no underlying disorders.
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Affiliation(s)
- Noussa R El Basha
- 1Department of Pediatrics, Faculty of Medicine, Cairo University, 2 Atteia Abd El Hadi St., El Maadi, Cairo, 11562 Egypt
| | - Huda Marzouk
- 1Department of Pediatrics, Faculty of Medicine, Cairo University, 2 Atteia Abd El Hadi St., El Maadi, Cairo, 11562 Egypt
| | - May M Sherif
- 2Department of Clinical Pathology, Faculty of Medicine, Cairo University, 2 Atteia Abd El Hadi St., El Maadi, Cairo, 11562 Egypt
| | - Amani A El Kholy
- 2Department of Clinical Pathology, Faculty of Medicine, Cairo University, 2 Atteia Abd El Hadi St., El Maadi, Cairo, 11562 Egypt
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Pollock M, Fernandes RM, Newton AS, Scott SD, Hartling L. A decision tool to help researchers make decisions about including systematic reviews in overviews of reviews of healthcare interventions. Syst Rev 2019; 8:29. [PMID: 30670086 PMCID: PMC6341524 DOI: 10.1186/s13643-018-0768-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 07/03/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Overviews of reviews of healthcare interventions (overviews) integrate information from multiple systematic reviews (SRs) to provide a single synthesis of relevant evidence for decision-making. Overviews may identify multiple SRs that examine the same intervention for the same condition and include some, but not all, of the same primary studies. Different researchers use different approaches to manage these "overlapping SRs," but each approach has advantages and disadvantages. This study aimed to develop an evidence-based decision tool to help researchers make informed inclusion decisions when conducting overviews of healthcare interventions. METHODS We used a two-stage process to develop the decision tool. First, we conducted a multiple case study to obtain empirical evidence upon which the tool is based. We systematically conducted seven overviews five times each, making five different decisions about which SRs to include in the overviews, for a total of 35 overviews; we then examined the impact of the five inclusion decisions on the overviews' comprehensiveness and challenges, within and across the seven overview cases. Second, we used a structured, iterative process to transform the evidence obtained from the multiple case study into an empirically based decision tool with accompanying descriptive text. RESULTS The resulting decision tool contains four questions: (1) Do Cochrane SRs likely examine all relevant intervention comparisons and available data? (2) Do the Cochrane SRs overlap? (3) Do the non-Cochrane SRs overlap? (4) Are researchers prepared and able to avoid double-counting outcome data from overlapping SRs, by ensuring that each primary study's outcome data are extracted from overlapping SRs only once? Guidance is provided to help researchers answer each question, and empirical evidence is provided regarding the advantages, disadvantages, and potential trade-offs of the different inclusion decisions. CONCLUSIONS This evidence-based decision tool is designed to provide researchers with the knowledge and means to make informed inclusion decisions in overviews. The tool can provide practical guidance and support for overview authors by helping them consider questions that could affect the comprehensiveness and complexity of their overviews. We hope this tool will be a useful resource for researchers conducting overviews, and we welcome discussion, testing, and refinement of the proposed tool.
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Affiliation(s)
- Michelle Pollock
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, 4-472 Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, AB, T6G-1C9, Canada
| | - Ricardo M Fernandes
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal.,Department of Pediatrics, Santa Maria Hospital, Lisbon, Portugal
| | - Amanda S Newton
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | | | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, 4-472 Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, AB, T6G-1C9, Canada.
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9
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Pollock M, Fernandes RM, Newton AS, Scott SD, Hartling L. The impact of different inclusion decisions on the comprehensiveness and complexity of overviews of reviews of healthcare interventions. Syst Rev 2019; 8:18. [PMID: 30635048 PMCID: PMC6329144 DOI: 10.1186/s13643-018-0914-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 12/09/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Overviews of reviews (overviews) compile information from multiple systematic reviews (SRs) to provide a single synthesis of relevant evidence for decision-making. Overviews may identify multiple SRs that examine the same intervention for the same condition and include some, but not all, of the same primary studies. There is currently limited guidance on whether and how to include these overlapping SRs in overviews. Our objectives were to assess how different inclusion decisions in overviews of healthcare interventions affect their comprehensiveness and results, and document challenges encountered when making different inclusion decisions in overviews. METHODS We used five inclusion decisions to conduct overviews across seven topic areas, resulting in 35 overviews. The inclusion decisions were (1) include all Cochrane and non-Cochrane SRs, (2) include only Cochrane SRs, or consider all Cochrane and non-Cochrane SRs but include only non-overlapping SRs, and in the case of overlapping SRs, select (3) the Cochrane SR, (4) the most recent SR (by publication or search date), or (5) the highest quality SR (assessed using AMSTAR). For each topic area and inclusion scenario, we documented the amount of outcome data lost and changed and the challenges involved. RESULTS When conducting overviews, including only Cochrane SRs, instead of all SRs, often led to loss/change of outcome data (median 31% of outcomes lost/changed; range 0-100%). Considering all Cochrane and non-Cochrane SRs but including only non-overlapping SRs and selecting the Cochrane SR for groups of overlapping SRs (instead of the most recent or highest quality SRs) allowed the most outcome data to be recaptured (median 42% of lost/changed outcome recaptured; range 28-86%). Across all inclusion scenarios, challenges were encountered when extracting data from overlapping SRs. CONCLUSIONS Overlapping SRs present a methodological challenge for overview authors. This study demonstrates that different inclusion decisions affect the comprehensiveness and results of overviews in different ways, depending in part on whether Cochrane SRs examine all intervention comparisons relevant to the overview. Study results were used to develop an evidence-based decision tool that provides practical guidance for overview authors.
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Affiliation(s)
- Michelle Pollock
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Canada
| | - Ricardo M Fernandes
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal.,Department of Pediatrics, Santa Maria Hospital, Lisbon, Portugal
| | - Amanda S Newton
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | | | - Lisa Hartling
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Canada. .,4-472 Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, AB, T6G-1C9, Canada.
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10
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van Miert C, Fernandes RM, Eccleson H, Bedson E, Lane S, Peak M, Thorburn K, Compton V, Woolfall K, Lacy D, Williamson P, McNamara PS. Non-invasive ventilation for the management of children with bronchiolitis (NOVEMBR): a feasibility study and core outcome set development protocol. Trials 2018; 19:627. [PMID: 30428935 PMCID: PMC6236891 DOI: 10.1186/s13063-018-2969-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 10/08/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Bronchiolitis is an acute lower respiratory infection which predominantly affects young children. Treatment for bronchiolitis is limited to supportive therapy. Nasal oxygen therapy is part of routine care, and delivery now incorporates varying levels of non-invasive continuous positive airway pressure and/or high-flow nasal cannula oxygen therapy. Despite wide clinical use, there remains a lack of evidence on the comparative effectiveness and safety of these interventions. Furthermore, research in this field is hampered by the use of multiple outcome measures in current clinical trials. METHODS/DESIGN This mixed methods study includes a systematic review of outcome measures, telephone interviews with parents, focus group workshops and a Delphi survey with healthcare professionals and parents. These methods will be used to identify and prioritise outcomes for inclusion in a core outcome set and to explore issues pertinent to the design of a future randomised controlled trial comparing different modes of oxygen therapy for bronchiolitis. UK hospitals will also be contacted and asked to complete a survey to provide an overview of current practice to enable assessment of capability and capacity to run a future clinical trial. DISCUSSION This study will facilitate the design of a future clinical trial of non-invasive ventilation in children with bronchiolitis which is acceptable to important stakeholders. Furthermore, core outcome set development will improve standardisation, measurement and reporting of clinically important outcomes in bronchiolitis. TRIAL REGISTRATION ISRCTN Registry, ISRCTN75766048. Registered on 18 December 2017. This study was retrospectively registered in the ISRCTN Registry and on the Core Outcome Measures in Effectiveness Trials (COMET) Initiative database (15 September 2017).
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Affiliation(s)
- Clare van Miert
- School of Nursing and Allied Health, Liverpool John Moores University, Room 3.12 Henry Cotton Building, 15-21 Webster Street, Liverpool, L3 2ET UK
- Paediatric Medicines Research Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Ricardo M. Fernandes
- Clinical Pharmacology Lab/Unit, Faculty of Medicine and Instituto de Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal
- Department of Pediatrics, Hospital Santa Maria, Lisbon, Portugal
| | - Helen Eccleson
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool, Institute of Child Health, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP UK
| | - Emma Bedson
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool, Institute of Child Health, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP UK
| | - Steven Lane
- Department of Biostatistics, Block F, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Matthew Peak
- Paediatric Medicines Research Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Kent Thorburn
- Paediatric Intensive Care Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Vanessa Compton
- Paediatric Intensive Care Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Kerry Woolfall
- MRC North West Hub for Trials Methodology Research Institute of Psychology, Health and Society, Block B, Room B112, 1st Floor Waterhouse Building, Liverpool, L69 3GL UK
| | - David Lacy
- Department of Paediatrics, Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Road, Upton, Wirral, CH49 5PE UK
| | - Paula Williamson
- Department of Biostatistics, Block F, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Paul S. McNamara
- Institute of Child Health, University of Liverpool, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK
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11
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Dyson MP, Newton AS, Shave K, Featherstone RM, Thomson D, Wingert A, Fernandes RM, Hartling L. Social Media for the Dissemination of Cochrane Child Health Evidence: Evaluation Study. J Med Internet Res 2017; 19:e308. [PMID: 28864427 PMCID: PMC5600964 DOI: 10.2196/jmir.7819] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/23/2017] [Accepted: 07/10/2017] [Indexed: 01/20/2023] Open
Abstract
Background Health care providers value ready access to reliable synthesized information to support point-of-care decision making. Web-based communities, facilitated by the adoption of social media tools such as Facebook, Twitter, and YouTube, are increasingly being used for knowledge dissemination, bridging the gap between knowledge generation and synthesis and knowledge implementation. Objective Our objective was to implement and evaluate a structured social media strategy, using multiple platforms, to disseminate Cochrane Child Health evidence to health care providers caring for children. Methods Our social media strategy had three components: daily “tweets” using the Cochrane Child Health Twitter account, weekly WordPress blog posts, and a monthly journal club on Twitter (“tweet chat”). Each tweet, blog, and journal club shared Cochrane evidence on a child health topic. We evaluated the strategy through (1) Twitter and blog site analytics, (2) traceable link (Bitly) statistics, (3) Altmetric.com scores for promoted evidence, and (4) participant feedback. We also tracked the resources required to write the blog, tweet content, and manage the strategy. Results The 22-week social media strategy ran between November 2014 and April 2015. We created 25 blog posts, sent 585 tweets, and hosted 3 tweet chats. Monthly blog visits and views and Twitter account followers increased over time. During the study period, the blog received 2555 visitors and 3967 page views from a geographically diverse audience of health care providers, academics, and health care organizations. In total, 183 traceable Bitly links received 3463 clicks, and the Twitter account gained 469 new followers. The most visited and viewed blog posts included gastrointestinal topics (lactose avoidance), research on respiratory conditions (honey for cough and treatments for asthma), and maternal newborn care (skin-to-skin contact). On Twitter, popular topics were related to public health (vaccination) and pain management. We collected Altmetric.com scores for 61 studies promoted during the study period and recorded an average increase of 11 points. Research staff (n=3) contributed approximately 433 hours to promotion activities and planning (6.5 hours each per week) to implement the social media strategy, and study investigators reviewed all content (blog posts and tweets). Conclusions This study provides empirical evidence on the use of a coordinated social media strategy for the dissemination of evidence to professionals providing health services to children and youth. The results and lessons learned from our study provide guidance for future knowledge dissemination activities using social media tools.
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Affiliation(s)
- Michele P Dyson
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Amanda S Newton
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Kassi Shave
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Robin M Featherstone
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Cochrane Child Health, University of Alberta, Edmonton, AB, Canada
| | - Denise Thomson
- Cochrane Child Health, University of Alberta, Edmonton, AB, Canada
| | - Aireen Wingert
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Ricardo M Fernandes
- Cochrane Child Health, University of Alberta, Edmonton, AB, Canada.,Faculty of Medicine, Universidade de Lisboa, Lisbon, Portugal.,Cochrane Portugal, Universidade de Lisboa, Lisbon, Portugal
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Cochrane Child Health, University of Alberta, Edmonton, AB, Canada
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12
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Pollock M, Fernandes RM, Hartling L. Evaluation of AMSTAR to assess the methodological quality of systematic reviews in overviews of reviews of healthcare interventions. BMC Med Res Methodol 2017; 17:48. [PMID: 28335734 PMCID: PMC5364717 DOI: 10.1186/s12874-017-0325-5] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 03/14/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Overviews of reviews (overviews) compile information from multiple systematic reviews (SRs) to provide a single synthesis of relevant evidence for decision-making. It is recommended that authors assess and report the methodological quality of SRs in overviews-for example, using A MeaSurement Tool to Assess systematic Reviews (AMSTAR). Currently, there is variation in whether and how overview authors assess and report SR quality, and limited guidance is available. Our objectives were to: examine methodological considerations involved in using AMSTAR to assess the quality of Cochrane and non-Cochrane SRs in overviews of healthcare interventions; identify challenges (and develop potential decision rules) when using AMSTAR in overviews; and examine the potential impact of considering methodological quality when making inclusion decisions in overviews. METHODS We selected seven overviews of healthcare interventions and included all SRs meeting each overview's inclusion criteria. For each SR, two reviewers independently conducted AMSTAR assessments with consensus and discussed challenges encountered. We also examined the correlation between AMSTAR assessments and SR results/conclusions. RESULTS Ninety-five SRs were included (30 Cochrane, 65 non-Cochrane). Mean AMSTAR assessments (9.6/11 vs. 5.5/11; p < 0.001) and inter-rater reliability (AC1 statistic: 0.84 vs. 0.69; "almost perfect" vs. "substantial" using the Landis & Koch criteria) were higher for Cochrane compared to non-Cochrane SRs. Four challenges were identified when applying AMSTAR in overviews: the scope of the SRs and overviews often differed; SRs examining similar topics sometimes made different methodological decisions; reporting of non-Cochrane SRs was sometimes poor; and some non-Cochrane SRs included other SRs as well as primary studies. Decision rules were developed to address each challenge. We found no evidence that AMSTAR assessments were correlated with SR results/conclusions. CONCLUSIONS Results indicate that the AMSTAR tool can be used successfully in overviews that include Cochrane and non-Cochrane SRs, though decision rules may be useful to circumvent common challenges. Findings support existing recommendations that quality assessments of SRs in overviews be conducted independently, in duplicate, with a process for consensus. Results also suggest that using methodological quality to guide inclusion decisions (e.g., to exclude poorly conducted and reported SRs) may not introduce bias into the overview process.
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Affiliation(s)
- Michelle Pollock
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Ricardo M. Fernandes
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
- Department of Pediatrics, Santa Maria Hospital, Lisbon, Portugal
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Canada
- 4-472 Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, AB T6G-1C9 Canada
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13
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Monteiro AIMP, Bellei NCJ, Sousa AR, dos Santos AMN, Weckx LY. Respiratory infections in children up to two years of age on prophylaxis with palivizumab. ACTA ACUST UNITED AC 2016; 32:152-8. [PMID: 25119744 PMCID: PMC4183017 DOI: 10.1590/0103-0582201432214813] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 11/27/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify the viruses involved in acute respiratory tract infections and to analyze the rates of hospitalization and death in children on palivizumab prophylaxis. METHODS Prospective cohort of 198 infants up to one year old who were born before 29 weeks of gestational age and infants under two years old with hemodynamically unstable cardiopathy or chronic pulmonary disease who received prophylactic palivizumab against severe respiratory syncytial virus infections in 2008. During the study period, in each episode of acute respiratory tract infection, nasopharyngeal aspirate was collected to identify respiratory syncytial virus, adenovirus, parainfluenza 1, 2 and 3, influenza A and B by direct immunofluorescence, rhinovirus and metapneumovirus by polymerase chain reaction preceded by reverse transcription. Data regarding hospitalization and deaths were monitored. RESULTS Among the 198 studied infants, 117 (59.1%) presented acute respiratory tract infections, with a total of 175 episodes. Of the 76 nasopharyngeal aspirates collected during respiratory tract infections, 37 were positive, as follow: rhinovirus (75.7%), respiratory syncytial virus (18.9%), parainfluenza (8.1%), adenovirus 2 (2.7%), metapneumovirus (2.7%) and three samples presented multiple agents. Of the 198 children, 48 (24.4%) were hospitalized: 30 (15.2%) for non-infectious etiology and 18 (9.1%) for respiratory causes. Among these 18 children, one case of respiratory syncytial virus was identified. Two deaths were reported, but respiratory syncytial virus was not identified. CONCLUSIONS During the prophylaxis period, low frequency of respiratory syncytial virus infections and low rates of hospitalization were observed, suggesting the benefit of palivizumab prophylaxis.
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Affiliation(s)
| | | | | | | | - Lily Yin Weckx
- Escola Paulista de Medicina, Unifesp, São Paulo, SP, Brasil
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14
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Diagnosing and treating respiratory syncytial virus bronchiolitis. Nurse Pract 2016; 41:1-4. [PMID: 27552683 DOI: 10.1097/01.npr.0000490395.74098.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Respiratory syncytial virus (RSV) is one of the major causes of respiratory tract illness in children and can lead to significant infection and death. This article discusses the incidence, clinical presentation, diagnosis, current treatment, and prevention options to successfully diagnose and treat infections caused by RSV.
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15
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Davies CJ, Waters D, Marshall A. A systematic review of the psychometric properties of bronchiolitis assessment tools. J Adv Nurs 2016; 73:286-301. [PMID: 27509019 DOI: 10.1111/jan.13098] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2016] [Indexed: 11/26/2022]
Abstract
AIM The aim of this study was to assess the psychometric properties of tools developed for the purpose of assessing infants with bronchiolitis. BACKGROUND Bronchiolitis is the leading cause of hospitalization in infants under the age of 1 year. Several bronchiolitis assessment tools have been developed primarily for use in randomized control trials of medical treatments for infants with bronchiolitis, however, the reliability and validity of many of these tools is not well reported. DESIGN Systematic review. DATA SOURCES CINAHL, MEDLINE, EMBASE and PubMed electronic databases were searched between January 1960-December 2015 using the key words 'bronchiolitis' and 'assessment' or 'screen' or 'tool' or 'scale' or 'score'. REVIEW METHODS A systematic review of the psychometric properties of bronchiolitis assessment tools was undertaken using the COSMIN checklist. RESULTS Fourteen studies meeting the inclusion criteria were reviewed and the methodological quality of the studies and reported psychometric properties of 11 instruments were assessed. Overall, the reliability and validity of bronchiolitis assessment tools was poorly established. Although several studies reported that their tools had good inter-rater reliability, the methodological quality of these studies was generally poor. Only one study underwent psychometric testing that was assessed as being of excellent quality. The Respiratory Distress Assessment Index was deemed to have undergone the most rigorous psychometric testing but had poor to moderate construct validity and considerable test-retest error. CONCLUSION Current bronchiolitis assessment tools lack clearly established reliability and validity and may not be sensitive to clinically meaningful outcomes for patients.
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Affiliation(s)
- Clare J Davies
- Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Donna Waters
- Sydney Nursing School, The University of Sydney, Camperdown, New South Wales, Australia
| | - Andrea Marshall
- NHMRC Centre of Research Excellence in Nursing, Menzies Health Institute, Queensland, Griffith University and Gold Coast Health, Southport, Queensland, Australia
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16
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Fernandes RM, Andrade MG, Constant C, Malveiro D, Magalhães M, Abreu D, Azevedo I, Sousa E, Salgado R, Bandeira T. Acute viral bronchiolitis: Physician perspectives on definition and clinically important outcomes. Pediatr Pulmonol 2016; 51:724-32. [PMID: 26595365 DOI: 10.1002/ppul.23346] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 08/09/2015] [Accepted: 08/22/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Two key limitations hamper intervention research in bronchiolitis: the absence of a clear definition of disease, and the heterogeneous choice of outcome measures in current clinical trials. We assessed how paediatricians and general practitioners (GPs) perceived definition and clinically important outcomes in bronchiolitis. METHODS A nationwide online survey (ABBA study) was conducted through the Portuguese Society of Paediatrics and GPs' mailing lists. We assessed agreement with statements on bronchiolitis definition, and participants were asked to score the relative importance of several outcomes. Principal component analysis (PCA) explored dimensions underlying disease definition. Outcomes were ranked by mean score and proportion given highest score. RESULTS We included 514 paediatricians and 165 GPs (overall 59% were board-certified). Most paediatricians (76.5%) agreed with a definition based on coryza, wheezing and/or crackles/rales, compared to 38.1% GPs (P < 0.001). Less than 5% physicians agreed with a definition commonly used in clinical trials (<12 months, first episode of wheeze). We retained three dimensions on PCA: one based on coryza, rales/crepitations and no sudden onset; another on number of episodes and age; and a third on wheeze. Dimensions varied by physician specialization and training (P < 0.01). Hospital admission and respiratory distress were top rated outcomes by both groups of physicians. CONCLUSIONS Physician definitions of bronchiolitis have considerable variability and often mismatch those of clinical trials. Rating of important outcomes was consistent. Our results highlight the need for a robust standardized definition of acute bronchiolitis in infants and support the development of a core outcome set for future clinical trials. Pediatr Pulmonol. 2016;51:724-732. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Ricardo M Fernandes
- Department of Paediatrics, Hospital de Santa Maria, Centro Académico de Medicina de Lisboa, Lisboa, Portugal.,Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Maria Gabriela Andrade
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Carolina Constant
- Department of Paediatrics, Hospital de Santa Maria, Centro Académico de Medicina de Lisboa, Lisboa, Portugal.,Department of Paediatrics, Unidade de Torres Vedras, Centro Hospitalar do Oeste, Torres Vedras, Portugal
| | - Duarte Malveiro
- Department of Paediatrics, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Manuel Magalhães
- Department of Paediatrics, Faculty of Medicine, University of Porto, Porto, Portugal.,CINTESIS-Center for Research in Health Technologies and Information Systems, Porto, Portugal
| | - Daisy Abreu
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Inês Azevedo
- Department of Paediatrics, Faculty of Medicine, University of Porto, Porto, Portugal.,EPI Unit, Institute of Public Health, University of Porto, Porto, Portugal
| | - Eduarda Sousa
- Department of Paediatrics, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Rizério Salgado
- Unidade de Saúde Familiar S. Julião, Centro de Saúde de Oeiras, Oeiras, Portugal
| | - Teresa Bandeira
- Department of Paediatrics, Hospital de Santa Maria, Centro Académico de Medicina de Lisboa, Lisboa, Portugal.,Clínica Universitária de Pediatria, Faculty of Medicine, University of Lisbon, Portugal
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17
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Fernandes RM, Plint AC, Terwee CB, Sampaio C, Klassen TP, Offringa M, van der Lee JH. Validity of bronchiolitis outcome measures. Pediatrics 2015; 135:e1399-408. [PMID: 25986025 DOI: 10.1542/peds.2014-3557] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Respiratory Distress Assessment Instrument (RDAI) and Respiratory Assessment Change Score (RACS) are frequently used in bronchiolitis clinical trials, but evidence is limited on their measurement properties. We investigated their validity, reliability, and responsiveness. METHODS We included data from up to 1765 infants with bronchiolitis enrolled in 2 studies conducted in pediatric emergency departments. We assessed RDAI construct validity by testing hypotheses of associations with physiologic measures (respiratory rate, oxygen saturation) and with constructs related to hospitalization, using correlation coefficients, and multivariable analysis. RDAI/RACS responsiveness was evaluated by using anchors of change based on these constructs; measures of responsiveness included the area under the curve. RDAI test-retest agreement and interrater reliability were evaluated by using limits of agreement and intraclass correlation coefficients. RESULTS Baseline RDAI scores were weakly correlated with respiratory rate (r = 0.38, P < .001), and scores increased in lower oxygen saturation categories (P < .001). Higher RDAI scores were associated with hospitalization (odds ratio: 1.36; 95% confidence interval: 1.26-1.47); scores differed between participants who were discharged, admitted, or stayed in the emergency department (P < .001). Our hypotheses were met, but the magnitude of associations was below our predefined thresholds. RDAI test-retest limits of agreement were -3.80 to 3.64 (20% of the range), whereas interrater reliability was good (intraclass correlation coefficient = 0.93). Formulated hypotheses for responsiveness were confirmed, with moderate responsiveness (area under the curve: RDAI, 0.64-0.70; RACS, 0.72). CONCLUSIONS RDAI has poor to moderate construct validity, with good discriminative properties but considerable test-retest measurement error. The RDAI and RACS are responsive measures of respiratory distress in bronchiolitis but do not encompass all determinants of disease severity.
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Affiliation(s)
- Ricardo M Fernandes
- Department of Pediatrics, Santa Maria Hospital, Lisbon Academic Medical Centre, Lisbon, Portugal; Clinical Pharmacology Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal;
| | - Amy C Plint
- University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Caroline B Terwee
- Department of Epidemiology and Biostatistics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, Netherlands
| | - Cristina Sampaio
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Terry P Klassen
- Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Canada
| | - Martin Offringa
- ChildHealth Evaluative Sciences, Hospital for Sick Children, Toronto, Canada; and
| | - Johanna H van der Lee
- Division of Woman and Child, Pediatric Clinical Research Office, Academic Medical Centre, Amsterdam, Netherlands
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18
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Saad K, Abd Aziz NH, El-Houfey AA, El-Asheer O, Mohamed SA, Ahmed AE, Abdel Baseer KA, Darwish MM. Trial of Vitamin D Supplementation in Infants with Bronchiolitis: A Randomized, Double-Blind, Placebo-Controlled Study. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2015. [DOI: 10.1089/ped.2015.0492] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Khaled Saad
- Department of Pediatrics, Assiut University, Assiut, Egypt
| | | | - Amira A. El-Houfey
- Department of Community Health Nursing, Faculty of Nursing, Assiut University, Assiut, Egypt
| | | | | | - Ahmed E. Ahmed
- Department of Pediatrics, Qena Faculty of Medicine, South Valley University, Egypt
| | | | - Manal M. Darwish
- Department of Public Health and Community Medicine, Faculty of Medicine; Assiut University, Assiut, Egypt
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19
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Roh EJ, Won YK, Lee MH, Chung EH. Clinical characteristics of patients with acute bronchiolitis who visited 146 Emergency Department in Korea in 2012. ALLERGY ASTHMA & RESPIRATORY DISEASE 2015. [DOI: 10.4168/aard.2015.3.5.334] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Eui Jung Roh
- Department of Pediatrics, Sun General Hospital, Daejeon, Korea
| | - Youn Kyung Won
- Department of Pediatrics, National Medical Center, Seoul, Korea
| | - Mi-Hee Lee
- Department of Pediatrics, Seoul Women's Hospital, Incheon, Korea
| | - Eun Hee Chung
- Department of Pediatrics, National Medical Center, Seoul, Korea
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20
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Ralston S, Comick A, Nichols E, Parker D, Lanter P. Effectiveness of quality improvement in hospitalization for bronchiolitis: a systematic review. Pediatrics 2014; 134:571-81. [PMID: 25092947 DOI: 10.1542/peds.2014-1036] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Bronchiolitis causes nearly 20% of all acute care hospitalizations for young children in the United States. Unnecessary testing and medication for infants with bronchiolitis contribute to cost without improving outcomes. OBJECTIVES The goal of this study was to systematically review the quality improvement (QI) literature on inpatient bronchiolitis and to propose benchmarks for reducing unnecessary care. METHODS Assisted by a medical librarian, we searched Medline, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library. Studies describing any active QI intervention versus usual care in hospitalized children <2 years of age were included. Data were extracted and confirmed by multiple investigators and pooled by using a random effects model. Benchmarks were calculated by using achievable benchmarks of care methods. RESULTS Fourteen studies involving >12000 infants were reviewed. QI interventions resulted in 16 fewer patients exposed to repeated doses of bronchodilators per 100 hospitalized (7 studies) (risk difference: 0.16 [95% confidence interval: 0.11-0.21]) and resulted in 5.3 fewer doses of bronchodilator given per patient (95% confidence interval: 2.1-8.4). Interventions resulted in fewer hospitalized children exposed to steroids (5 per 100), chest radiography (9 per 100), and antibiotics (4 per 100). No significant harms were reported. Benchmarks derived from the reported data are: repeated bronchodilator use, 16%; steroid use, 1%; chest radiography use, 42%; and antibiotic use, 17%. The study's heterogeneity limited the ability to classify specific characteristics of effective QI interventions. CONCLUSIONS QI strategies have been demonstrated to achieve lower rates of unnecessary care in children hospitalized with viral bronchiolitis than are the norm.
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Affiliation(s)
- Shawn Ralston
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Allison Comick
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Elizabeth Nichols
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Devin Parker
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Patricia Lanter
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
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21
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Hartling L, Vandermeer B, Fernandes RM. Systematic reviews, overviews of reviews and comparative effectiveness reviews: a discussion of approaches to knowledge synthesis. ACTA ACUST UNITED AC 2014; 9:486-94. [DOI: 10.1002/ebch.1968] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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22
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Robinson J, Thomson D. Connecting with our readers--a look at what is most often downloaded. EVIDENCE-BASED CHILD HEALTH : A COCHRANE REVIEW JOURNAL 2014; 9:299-300. [PMID: 25404603 DOI: 10.1002/ebch.1969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Joan Robinson
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
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van Miert C, Abbott J, Verheoff F, Lane S, Carter B, McNamara P. Development and validation of the Liverpool infant bronchiolitis severity score: a research protocol. J Adv Nurs 2014; 70:2353-62. [PMID: 24673581 DOI: 10.1111/jan.12387] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2014] [Indexed: 11/30/2022]
Abstract
AIM To develop and validate a bronchiolitis severity scoring instrument for use by nurses and other healthcare professions. BACKGROUND Bronchiolitis is a viral lower respiratory tract infection of infancy. In industrialized countries, admission rates have increased over the last decade with up to 3% of all infants born being admitted to hospital. A small number of these hospitalized infants will require admission to critical care for either invasive or non-invasive ventilation. During the seasonal epidemic, the number of unplanned admissions to critical care with bronchiolitis substantially increases. DESIGN We will use a mixed methods study design. METHODS We will use scale development and psychometric methods to develop a scoring instrument and to test the instrument for content, construct and criterion validity and reliability in several different clinical locations. This study protocol has been reviewed and approved by the NHS National Research Ethics Service, January 2011. DISCUSSION There is an urgent need to develop a valid and reliable severity scoring instrument sensitive to clinical changes in the infant, to facilitate clinical decision-making and help standardize patient care. Furthermore, a valid and reliable scoring instrument could also be used as a proxy patient-reported outcome measure to evaluate the efficacy of clinical interventions in randomized controlled trials.
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Affiliation(s)
- Clare van Miert
- R&D, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Hasegawa K, Tsugawa Y, Brown DF, Mansbach JM, Camargo CA. Temporal trends in emergency department visits for bronchiolitis in the United States, 2006 to 2010. Pediatr Infect Dis J 2014; 33:11-8. [PMID: 23934206 PMCID: PMC3984903 DOI: 10.1097/inf.0b013e3182a5f324] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To examine temporal trends in emergency departments (EDs) visits for bronchiolitis among US children between 2006 and 2010. METHODS Serial, cross-sectional analysis of the Nationwide Emergency Department Sample, a nationally representative sample of ED patients. We used International Classification of Diseases, Ninth Revision, Clinical Modification code 466.1 to identify children <2 years of age with bronchiolitis. Primary outcome measures were rate of bronchiolitis ED visits, hospital admission rate and ED charges. RESULTS Between 2006 and 2010, weighted national discharge data included 1,435,110 ED visits with bronchiolitis. There was a modest increase in the rate of bronchiolitis ED visits, from 35.6 to 36.3 per 1000 person-years (2% increase; Ptrend = 0.008), due to increases in the ED visit rate among children from 12 months to 23 months (24% increase;Ptrend < 0.001). By contrast, there was a significant decline in the ED visit rate among infants (4% decrease; Ptrend < 0.001). Although unadjusted admission rate did not change between 2006 and 2010 (26% in both years), admission rate declined significantly after adjusting for potential patient- and ED-level confounders (adjusted odds ratio for comparison of 2010 with 2006, 0.84; 95% confidence interval: 0.76-0.93; P < 0.001). Nationwide ED charges for bronchiolitis increased from $337 million to $389 million (16% increase; Ptrend < 0.001), adjusted for inflation. This increase was driven by a rise in geometric mean of ED charges per case from $887 to $1059 (19% increase; Ptrend < 0.001). CONCLUSIONS Between 2006 and 2010, we found a divergent temporal trend in the rate of bronchiolitis ED visits by age group. Despite a significant increase in associated ED charges, ED-associated hospital admission rates for bronchiolitis significantly decreased over this same period.
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Affiliation(s)
- Kohei Hasegawa
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Yusuke Tsugawa
- Harvard Medical School, Boston, MA
- Beth Israel Deaconess Medical Center, Boston, MA
- Center for Clinical Epidemiology of St. Luke's Life Science Institute, Tokyo, Japan
| | - David F.M. Brown
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jonathan M. Mansbach
- Beth Israel Deaconess Medical Center, Boston, MA
- Boston Children's Hospital, Boston, MA
| | - Carlos A. Camargo
- Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Hypertonic saline in acute bronchiolitis: Is it worth the salt? Indian Pediatr 2013; 50:733-4. [DOI: 10.1007/s13312-013-0202-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, Johnson DW, Klassen TP, Hartling L. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 2013; 2013:CD004878. [PMID: 23733383 PMCID: PMC6956441 DOI: 10.1002/14651858.cd004878.pub4] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Previous systematic reviews have not shown clear benefit of glucocorticoids for acute viral bronchiolitis, but their use remains considerable. Recent large trials add substantially to current evidence and suggest novel glucocorticoid-including treatment approaches. OBJECTIVES To review the efficacy and safety of systemic and inhaled glucocorticoids in children with acute viral bronchiolitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 12), MEDLINE (1950 to January week 2, 2013), EMBASE (1980 to January 2013), LILACS (1982 to January 2013), Scopus® (1823 to January 2013) and IRAN MedEx (1998 to November 2009). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing short-term systemic or inhaled glucocorticoids versus placebo or another intervention in children under 24 months with acute bronchiolitis (first episode with wheezing). Our primary outcomes were: admissions by days 1 and 7 for outpatient studies; and length of stay (LOS) for inpatient studies. Secondary outcomes included clinical severity parameters, healthcare use, pulmonary function, symptoms, quality of life and harms. DATA COLLECTION AND ANALYSIS Two authors independently extracted data on study and participant characteristics, interventions and outcomes. We assessed risk of bias and graded strength of evidence. We meta-analysed inpatient and outpatient results separately using random-effects models. We pre-specified subgroup analyses, including the combined use of bronchodilators used in a protocol. MAIN RESULTS We included 17 trials (2596 participants); three had low overall risk of bias. Baseline severity, glucocorticoid schemes, comparators and outcomes were heterogeneous. Glucocorticoids did not significantly reduce outpatient admissions by days 1 and 7 when compared to placebo (pooled risk ratios (RRs) 0.92; 95% confidence interval (CI) 0.78 to 1.08 and 0.86; 95% CI 0.7 to 1.06, respectively). There was no benefit in LOS for inpatients (mean difference -0.18 days; 95% CI -0.39 to 0.04). Unadjusted results from a large factorial low risk of bias RCT found combined high-dose systemic dexamethasone and inhaled epinephrine reduced admissions by day 7 (baseline risk of admission 26%; RR 0.65; 95% CI 0.44 to 0.95; number needed to treat 11; 95% CI 7 to 76), with no differences in short-term adverse effects. No other comparisons showed relevant differences in primary outcomes. AUTHORS' CONCLUSIONS Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalisation. Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited. Future research should further assess the efficacy, harms and applicability of combined therapy.
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Affiliation(s)
- Ricardo M Fernandes
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Instituto de Medicina Molecular,Lisboa, Portugal.
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Thomson D, Foisy M, Oleszczuk M, Wingert A, Chisholm A, Hartling L. Overview of reviews in child health: evidence synthesis and the knowledge base for a specific population. ACTA ACUST UNITED AC 2013; 8:3-10. [DOI: 10.1002/ebch.1897] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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28
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Abstract
Pediatric respiratory illnesses are a huge burden to emergency departments worldwide. This article reviews the latest evidence in the epidemiology, assessment, management, and disposition of children presenting to the emergency department with asthma, croup, bronchiolitis, and pneumonia.
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Affiliation(s)
- Joseph Choi
- McGill University FRCP Emergency Medicine Residency Program, Royal Victoria Hospital, 687 Pine Avenue West, Room A4.62, Montreal, Quebec, Canada H3A 1A1.
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29
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Managing the morbidity associated with respiratory viral infections in children with congenital heart disease. Int J Pediatr 2012; 2012:646780. [PMID: 22518179 PMCID: PMC3299251 DOI: 10.1155/2012/646780] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 12/24/2011] [Indexed: 11/17/2022] Open
Abstract
Children with congenital heart disease (CHD) are at risk for increased morbidity from viral lower respiratory tract infections because of anatomical cardiac lesions than can worsen an already compromised respiratory status. Respiratory syncytial virus (RSV) remains an important pathogen in contributing toward the morbidity in this population. Although the acute treatment of RSV largely remains supportive, the development of monoclonal antibodies, such as palivuzumab, has reduced the RSV-related hospitalization rate in children with CHD. This review highlights the specific cardiac complications of RSV infection, the acute treatment of bronchiolitis in patients with CHD, and the search for new therapies against RSV, including an effective vaccine, because of the high cost associated with immunoprophylaxis and its lack of reducing RSV-related mortality.
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Thomson D, Russell K, Becker L, Klassen T, Hartling L. The evolution of a new publication type: Steps and challenges of producing overviews of reviews. Res Synth Methods 2011; 1:198-211. [PMID: 26061466 DOI: 10.1002/jrsm.30] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 01/20/2011] [Accepted: 02/16/2011] [Indexed: 01/08/2023]
Abstract
BACKGROUND To date, the Cochrane Child Health Field has published 18 overviews of reviews in our journal, Evidence-based Child Health: A Cochrane Review Journal. In this article, we highlight some of the logistical and methodological challenges of producing such syntheses. As this is a new and evolving publication type, we hope that our experience will benefit others who engage in this process. Current Methods: We discuss the process we have developed to produce overviews of reviews relevant to our mandate, including identification of the research question, establishment of the author team, selection of outcomes and included SRs, and presentation of findings. Ongoing Development: We discuss the lessons we have learned, outstanding challenges for overview authors, and the limitations of overviews. CONCLUSIONS Overviews of reviews are only as good as the SRs and primary studies on which they are based; gaps or lack of currency in this evidence will weaken the overview of reviews. Future directions in this work must address questions of bias and loss of information. Methods for overviews of reviews targeted for specific groups, such as children, need more elaboration. Copyright © 2011 John Wiley & Sons, Ltd.
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Affiliation(s)
- Denise Thomson
- Cochrane Child Health Field, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
| | - Kelly Russell
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Lorne Becker
- Cochrane Comparing Multiple Interventions Methods Group and Department of Family Medicine, SUNY Upstate Medical University, Syracuse, New York, U.S.A
| | - Terry Klassen
- Manitoba Institute of Child Health and Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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