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Olson LM, Perry GN, Yang S, Galyean PO, Zickmund SL, Sorenson S, Pinto NP, Maddux AB, Watson RS, Fink EL. Parents' Experiences Caring for a Child after a Critical Illness: A Qualitative Study. J Pediatr Intensive Care 2024; 13:127-133. [PMID: 38919699 PMCID: PMC11196146 DOI: 10.1055/s-0041-1740450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/07/2021] [Indexed: 10/19/2022] Open
Abstract
Objectives This article described parents' experience and identifies outcomes important to parents following their child's critical illness. Methods Semistructured interviews with 22 female and 4 male parents representing 26 critically ill children with predominately neurologic and respiratory diagnoses. Most children were younger than 5 years at discharge with a median (interquartile range) of 2 (2.0-3.0) years from discharge to interview. Results Many children returned home with life-altering physical and cognitive disabilities requiring months to years of rehabilitation. Parents remembered feeling unprepared and facing an intense, chaotic time when the child first returned home. They described how they suddenly had to center their daily activities around the child's needs amidst competing needs of siblings and partners, and in some cases, the medicalization of the home. They recounted negotiating adjustments almost daily with insurance agencies, medical doctors and therapists, employers, the child, and other family members to keep the family functioning. In the long term, families developed a new norm, choosing to focus on what the child could still do rather than what they could not. Even if the child returned to baseline, parents remembered the adjustments made to keep the child alive and the family functioning. Conclusion Heightened awareness of family experiences after pediatric critical illness will allow health care providers to improve family preparedness for the transition from hospital to home.
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Affiliation(s)
- Lenora M. Olson
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah, United States
| | - Grace N. Perry
- Qualitative Research Core, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Serena Yang
- Qualitative Research Core, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Patrick O'Roke Galyean
- Qualitative Research Core, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Susan L. Zickmund
- Informatics, Decision-Enhancement, and Analytic Sciences Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, United States
| | - Samuel Sorenson
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah, United States
| | - Neethi P. Pinto
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Aline B. Maddux
- Department of Pediatrics, Critical Care Medicine, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, United States
| | - R. Scott Watson
- Department of Pediatrics, Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle, Washington, United States
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, United States
| | - Ericka L. Fink
- Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States
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Le Marsney R, Johnson K, Chumbes Flores J, Coetzer S, Darvas J, Delzoppo C, Jolly A, Masterson K, Sherring C, Thomson H, Ergetu E, Gilholm P, Gibbons KS. Assessing the impact of risk-based data monitoring on outcomes for a paediatric multicentre randomised controlled trial. Clin Trials 2024:17407745231222019. [PMID: 38420923 DOI: 10.1177/17407745231222019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND/AIMS Regulatory guidelines recommend that sponsors develop a risk-based approach to monitoring clinical trials. However, there is a lack of evidence to guide the effective implementation of monitoring activities encompassed in this approach. The aim of this study was to assess the efficiency and impact of the risk-based monitoring approach used for a multicentre randomised controlled trial comparing treatments in paediatric patients undergoing cardiac bypass surgery. METHODS This is a secondary analysis of data from a randomised controlled trial that implemented targeted source data verification as part of the risk-based monitoring approach. Monitoring duration and source to database error rates were calculated across the monitored trial dataset. The monitored and unmonitored trial dataset, and simulated trial datasets with differing degrees of source data verification and cohort sizes were compared for their effect on trial outcomes. RESULTS In total, 106,749 critical data points across 1,282 participants were verified from source data either remotely or on-site during the trial. The total time spent monitoring was 365 hours, with a median (interquartile range) of 10 (7, 16) minutes per participant. An overall source to database error rate of 3.1% was found, and this did not differ between treatment groups. A low rate of error was found for all outcomes undergoing 100% source data verification, with the exception of two secondary outcomes with error rates >10%. Minimal variation in trial outcomes were found between the unmonitored and monitored datasets. Reduced degrees of source data verification and reduced cohort sizes assessed using simulated trial datasets had minimal impact on trial outcomes. CONCLUSIONS Targeted source data verification of data critical to trial outcomes, which carried with it a substantial time investment, did not have an impact on study outcomes in this trial. This evaluation of the cost-effectiveness of targeted source data verification contributes to the evidence-base regarding the context where reduced emphasis should be placed on source data verification as the foremost monitoring activity.
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Affiliation(s)
- Renate Le Marsney
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
| | - Kerry Johnson
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia
| | | | - Shelley Coetzer
- Paediatric Intensive Care Unit, Starship Child Health, Auckland, New Zealand
| | - Jennifer Darvas
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Carmel Delzoppo
- Paediatric Intensive Care Unit, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Arielle Jolly
- Paediatric Intensive Care Unit, Perth Children's Hospital, Perth, WA, Australia
| | - Kate Masterson
- Paediatric Intensive Care Unit, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Claire Sherring
- Paediatric Intensive Care Unit, Starship Child Health, Auckland, New Zealand
| | - Hannah Thomson
- Paediatric Intensive Care Unit, Perth Children's Hospital, Perth, WA, Australia
| | - Endrias Ergetu
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
| | - Patricia Gilholm
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
| | - Kristen S Gibbons
- Children's Intensive Care Research Program, Child Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia
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Huang E, Albrecht L, O’Hearn K, Nicolas N, Armstrong J, Weinberg M, Menon K. Reporting of social determinants of health in randomized controlled trials conducted in the pediatric intensive care unit. Front Pediatr 2024; 12:1329648. [PMID: 38361997 PMCID: PMC10867174 DOI: 10.3389/fped.2024.1329648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/19/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction The influence of social determinants of health (SDOH) on access to care and outcomes for critically ill children remains an understudied area with a paucity of high-quality data. Recent publications have highlighted the importance of incorporating SDOH considerations into research but the frequency with which this occurs in pediatric intensive care unit (PICU) research is unclear. Our objective was to determine the frequency and categories of SDOH variables reported and how these variables were defined in published PICU randomized controlled trials (RCTs). Methods We searched Medline, Embase, Lilacs, and Central from inception to Dec 2022. Inclusion criteria were randomized controlled trials of any intervention on children or their families in a PICU. Data related to study demographics and nine WHO SDOH categories were extracted, and descriptive statistics and qualitative data generated. Results 586 unique RCTs were included. Studies had a median sample size of 60 patients (IQR 40-106) with 73.0% of studies including ≤100 patients and 41.1% including ≤50 patients. A total of 181 (181/586, 30.9%) studies reported ≥1 SDOH variable of which 163 (163/586, 27.8%) reported them by randomization group. The most frequently reported categories were food insecurity (100/586, 17.1%) and social inclusion and non-discrimination (73/586, 12.5%). Twenty-five of 57 studies (43.9%) investigating feeding or nutrition and 11 of 82 (13.4%) assessing mechanical ventilation reported baseline nutritional assessments. Forty-one studies investigated interventions in children with asthma or bronchiolitis of which six reported on smoking in the home (6/41, 14.6%). Discussion Reporting of relevant SDOH variables occurs infrequently in PICU RCTs. In addition, when available, categorizations and definitions of SDOH vary considerably between studies. Standardization of SDOH variable collection along with consistent minimal reporting requirements for PICU RCT publications is needed.
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Affiliation(s)
- Emma Huang
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lisa Albrecht
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Katie O’Hearn
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Naisha Nicolas
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Jennifer Armstrong
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Maya Weinberg
- Faculty of Science, University of Ottawa, Ottawa, ON, Canada
| | - Kusum Menon
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Department of Pediatrics, Children’s Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
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Mills KI, Albert BD, Bechard LJ, Chu S, Duggan CP, Kaza A, Rakoff-Nahoum S, Sleeper LA, Newburger JW, Priebe GP, Mehta NM. Stress Ulcer Prophylaxis Versus Placebo-A Blinded Pilot Randomized Controlled Trial to Evaluate the Safety of Two Strategies in Critically Ill Infants With Congenital Heart Disease. Pediatr Crit Care Med 2024; 25:118-127. [PMID: 38240536 PMCID: PMC10829532 DOI: 10.1097/pcc.0000000000003384] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES The routine use of stress ulcer prophylaxis (SUP) in infants with congenital heart disease (CHD) in the cardiac ICU (CICU) is controversial. We aimed to conduct a pilot study to explore the feasibility of performing a subsequent larger trial to assess the safety and efficacy of withholding SUP in this population (NCT03667703). DESIGN, SETTING, PATIENTS Single-center, prospective, double-blinded, parallel group (SUP vs. placebo), pilot randomized controlled pilot trial (RCT) in infants with CHD admitted to the CICU and anticipated to require respiratory support for greater than 24 hours. INTERVENTIONS Patients were randomized 1:1 (stratified by age and admission type) to receive a histamine-2 receptor antagonist or placebo until respiratory support was discontinued, up to 14 days, or transfer from the CICU, if earlier. MEASUREMENTS AND MAIN RESULTS Feasibility was defined a priori by thresholds of screening rate, consent rate, timely drug allocation, and protocol adherence. The safety outcome was the rate of clinically significant upper gastrointestinal (UGI) bleeding. We screened 1,426 patients from February 2019 to March 2022; of 132 eligible patients, we gained informed consent in 70 (53%). Two patients did not require CICU admission after obtaining consent, and the remaining 68 patients were randomized to SUP (n = 34) or placebo (n = 34). Ten patients were withdrawn early, because of a change in eligibility (n = 3) or open-label SUP use (n = 7, 10%). Study procedures were completed in 58 patients (89% protocol adherence). All feasibility criteria were met. There were no clinically significant episodes of UGI bleeding during the pilot RCT. The percentage of patients with other nonserious adverse events did not differ between groups. CONCLUSIONS Withholding of SUP in infants with CHD admitted to the CICU was feasible. A larger multicenter RCT designed to confirm the safety of this intervention and its impact on incidence of UGI bleeding, gastrointestinal microbiome, and other clinical outcomes is warranted.
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Affiliation(s)
- Kimberly I. Mills
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Ben D. Albert
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Perioperative and Critical Care Center for Outcomes (PC-CORE), Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Lori J. Bechard
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Perioperative and Critical Care Center for Outcomes (PC-CORE), Boston Children’s Hospital, Boston, MA
| | - Stephen Chu
- Department of Pharmacy, Boston Children’s Hospital, Boston, MA
| | - Christopher P. Duggan
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Aditya Kaza
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Seth Rakoff-Nahoum
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Gregory P. Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Nilesh M. Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Perioperative and Critical Care Center for Outcomes (PC-CORE), Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
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Bruns N, Dohna-Schwake C, Olivieri M, Urschitz MS, Blomenkamp S, Frosch C, Lieftüchter V, Tomidis Chatzimanouil MK, Hoffmann F, Brenner S. Pediatric intensive care unit admissions network-rationale, framework and method of operation of a nationwide collaborative pediatric intensive care research network in Germany. Front Pediatr 2024; 11:1254935. [PMID: 38269291 PMCID: PMC10806156 DOI: 10.3389/fped.2023.1254935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
The Pediatric Intensive Care Unit Admissions (PIA) network aims to establish a nationwide database in Germany to gather epidemiological, clinical, and outcome data on pediatric critical illness. The heterogeneity of pediatric patients in intensive care units (PICU) poses challenges in obtaining sufficient case numbers for reliable research. Multicentered approaches, such as patient registries, have proven effective in collecting large-scale data. However, Germany lacks a systematic registration system for pediatric intensive care admissions, hindering epidemiological and outcome assessments. The PIA network intends to address these gaps and provide a framework for clinical and epidemiological research in pediatric intensive care. The network will interconnect PICUs across Germany and collect structured data on diagnoses, treatment, clinical course, and short-term outcomes. It aims to identify areas for improvement in care, enable disease surveillance, and potentially serve as a quality control tool. The PIA network builds upon the existing infrastructure of the German Pediatric Surveillance Unit ESPED and utilizes digitalized data collection techniques. Participating units will complete surveys on their organizational structure and equipment. The study population includes patients aged ≥28 days admitted to participating PICUs, with a more detailed survey for cases meeting specific criteria. Data will be collected by local PIA investigators, anonymized, and entered into a central database. The data protection protocol complies with regulations and ensures patient privacy. Quarterly data checks and customized quality reports will be conducted to monitor data completeness and plausibility. The network will evaluate its performance, data collection feasibility, and data quality. Eligible investigators can submit proposals for data analyses, which will be reviewed and analyzed by trained statisticians or epidemiologists. The PIA network aims to improve pediatric intensive care medicine in Germany by providing a comprehensive understanding of critical illness, benchmarking treatment quality, and enabling disease surveillance.
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Affiliation(s)
- Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- TNBS, Centre for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- TNBS, Centre for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Martin Olivieri
- Pediatric Intensive Care Unit, Dr. von Hauner Childreńs Hospital, LMU Munich, Munich, Germany
| | - Michael S. Urschitz
- Division of Pediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Susanne Blomenkamp
- Division of Pediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Clara Frosch
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- TNBS, Centre for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Victoria Lieftüchter
- Pediatric Intensive Care Unit, Dr. von Hauner Childreńs Hospital, LMU Munich, Munich, Germany
| | - Markos K. Tomidis Chatzimanouil
- Pediatric Intensive Care Medicine, Department of Pediatrics, University Clinic Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Florian Hoffmann
- Pediatric Intensive Care Unit, Dr. von Hauner Childreńs Hospital, LMU Munich, Munich, Germany
| | - Sebastian Brenner
- Pediatric Intensive Care Medicine, Department of Pediatrics, University Clinic Carl Gustav Carus, TU Dresden, Dresden, Germany
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Gilholm P, Ergetu E, Gelbart B, Raman S, Festa M, Schlapbach LJ, Long D, Gibbons KS. Adaptive Clinical Trials in Pediatric Critical Care: A Systematic Review. Pediatr Crit Care Med 2023; 24:738-749. [PMID: 37195182 DOI: 10.1097/pcc.0000000000003273] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
OBJECTIVES This systematic review investigates the use of adaptive designs in randomized controlled trials (RCTs) in pediatric critical care. DATA SOURCES PICU RCTs, published between 1986 and 2020, stored in the www.PICUtrials.net database and MEDLINE, EMBASE, CENTRAL, and LILACS databases were searched (March 9, 2022) to identify RCTs published in 2021. PICU RCTs using adaptive designs were identified through an automated full-text screening algorithm. STUDY SELECTION All RCTs involving children (< 18 yr old) cared for in a PICU were included. There were no restrictions to disease cohort, intervention, or outcome. Interim monitoring by a Data and Safety Monitoring Board that was not prespecified to change the trial design or implementation of the study was not considered adaptive. DATA EXTRACTION We extracted the type of adaptive design, the justification for the design, and the stopping rule used. Characteristics of the trial were also extracted, and the results summarized through narrative synthesis. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2. DATA SYNTHESIS Sixteen of 528 PICU RCTs (3%) used adaptive designs with two types of adaptations used; group sequential design and sample size reestimation. Of the 11 trials that used a group sequential adaptive design, seven stopped early due to futility and one stopped early due to efficacy. Of the seven trials that performed a sample size reestimation, the estimated sample size decreased in three trials and increased in one trial. CONCLUSIONS Little evidence of the use of adaptive designs was found, with only 3% of PICU RCTs incorporating an adaptive design and only two types of adaptations used. Identifying the barriers to adoption of more complex adaptive trial designs is needed.
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Affiliation(s)
- Patricia Gilholm
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Endrias Ergetu
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital Melbourne, Parkville, VIC, Australia
| | - Sainath Raman
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Marino Festa
- Kids Critical Care Research, Paediatric Intensive Care Unit, Children's Hospital at Westmead, Westmead, NSW, Australia
- Sydney Children's Hospital Network, Sydney, NSW, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Debbie Long
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kristen S Gibbons
- Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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O'Hearn K, Menon K, Weiler HA, Amrein K, Fergusson D, Gunz A, Bustos R, Campos R, Catalan V, Roedl S, Tsampalieros A, Barrowman N, Geier P, Henderson M, Khamessan A, Lawson ML, McIntyre L, Redpath S, Jones G, Kaufmann M, McNally D. A phase II dose evaluation pilot feasibility randomized controlled trial of cholecalciferol in critically ill children with vitamin D deficiency (VITdAL-PICU study). BMC Pediatr 2023; 23:397. [PMID: 37580663 PMCID: PMC10424361 DOI: 10.1186/s12887-023-04205-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Vitamin D deficiency (VDD) is highly prevalent in the pediatric intensive care unit (ICU) and associated with worse clinical course. Trials in adult ICU demonstrate rapid restoration of vitamin D status using an enteral loading dose is safe and may improve outcomes. There have been no published trials of rapid normalization of VDD in the pediatric ICU. METHODS We conducted a multicenter placebo-controlled phase II pilot feasibility randomized clinical trial from 2016 to 2017. We randomized 67 critically ill children with VDD from ICUs in Canada, Chile and Austria using a 2:1 randomization ratio to receive a loading dose of enteral cholecalciferol (10,000 IU/kg, maximum of 400,000 IU) or placebo. Participants, care givers, and outcomes assessors were blinded. The primary objective was to determine whether the loading dose normalized vitamin D status (25(OH)D > 75 nmol/L). Secondary objectives were to evaluate for adverse events and assess the feasibility of a phase III trial. RESULTS Of 67 randomized participants, one was withdrawn and seven received more than one dose of cholecalciferol before the protocol was amended to a single loading dose, leaving 59 participants in the primary analyses (40 treatment, 19 placebo). Thirty-one/38 (81.6%) participants in the treatment arm achieved a plasma 25(OH)D concentration > 75 nmol/L versus 1/18 (5.6%) the placebo arm. The mean 25(OH)D concentration in the treatment arm was 125.9 nmol/L (SD 63.4). There was no evidence of vitamin D toxicity and no major drug or safety protocol violations. The accrual rate was 3.4 patients/month, supporting feasibility of a larger trial. A day 7 blood sample was collected for 84% of patients. A survey administered to 40 participating families showed that health-related quality of life (HRQL) was the most important outcome for families for the main trial (30, 75%). CONCLUSIONS A single 10,000 IU/kg dose can rapidly and safely normalize plasma 25(OH)D concentrations in critically ill children with VDD, but with significant variability in 25(OH)D concentrations. We established that a phase III multicentre trial is feasible. Using an outcome collected after hospital discharge (HRQL) will require strategies to minimize loss-to-follow-up. TRIAL REGISTRATION CLINICALTRIALS gov NCT02452762 Registered 25/05/2015.
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Affiliation(s)
- Katie O'Hearn
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Kusum Menon
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Hope A Weiler
- School of Human Nutrition, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Canada
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Dean Fergusson
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Anna Gunz
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5W9, Canada
- Child Health Research Institute, London, ON, N6A 5W9, Canada
| | - Raul Bustos
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
- Facultad de Medicine Y Ciencia, UCI Pediátrica Hospital Guillermo Grant Benavente Concepción, Universidad San Sebastián, Concepción, Chile
| | - Roberto Campos
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
| | - Valentina Catalan
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
| | - Siegfried Roedl
- Department of Paediatrics and Adolescent Medicine, Joint Facilities, Medical University of Graz, Graz, Austria
| | - Anne Tsampalieros
- Clinical Research Unit, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Nick Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Pavel Geier
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Matthew Henderson
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Newborn Screening Ontario, Ottawa, Canada
| | - Ali Khamessan
- Euro-Pharm International Canada Inc, Montreal, Canada
| | - Margaret L Lawson
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
- Division of Endocrinology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Division of Critical Care), Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Canada
| | - Stephanie Redpath
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Glenville Jones
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Martin Kaufmann
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Dayre McNally
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada.
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Roumeliotis N, Ramil J, Garros D, Alnaji F, Bourdages M, Brule V, Dryden-Palmer K, Muttalib F, Nicoll J, Sauthier M, Murthy S, Fontela PS. Designing a national pediatric critical care database: a Delphi consensus study. Can J Anaesth 2023; 70:1216-1225. [PMID: 37217736 PMCID: PMC10202532 DOI: 10.1007/s12630-023-02480-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/09/2022] [Accepted: 11/09/2022] [Indexed: 05/24/2023] Open
Abstract
PURPOSE We sought to describe the processes undertaken for the systematic selection and consensus determination of the common data elements for inclusion in a national pediatric critical care database in Canada. METHODS We conducted a multicentre Delphi consensus study of Canadian pediatric intensive care units (PICUs) participating in the creation of a national database. Participants were PICU health care professionals, allied health professionals, caregivers, and other stakeholders. A dedicated panel group created a baseline survey of data elements based on literature, current PICU databases, and expertise in the field. The survey was then used for a Delphi iterative consensus process over three rounds, conducted from March to June 2021. RESULTS Of 86 invited participants, 68 (79%) engaged and agreed to participate as part of an expert panel. Panel participants were sent three rounds of the survey with response rates of 62 (91%), 61 (90%) and 55 (81%), respectively. After three rounds, 72 data elements were included from six domains, mostly reflecting clinical status and complex medical interventions received in the PICU. While race, gender, and home region were included by consensus, variables such as minority status, indigenous status, primary language, and ethnicity were not. CONCLUSION We present the methodological framework used to select data elements by consensus for a national pediatric critical care database, with participation from a diverse stakeholder group of experts and caregivers from all PICUs in Canada. The selected core data elements will provide standardized and synthesized data for research, benchmarking, and quality improvement initiatives of critically ill children.
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Affiliation(s)
- Nadia Roumeliotis
- Department of Pediatrics, Critical Care, CHU Sainte-Justine, University of Montreal, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
| | - Joanne Ramil
- Pediatric Intensive Care Unit, Montreal Children's Hospital, Montreal, QC, Canada
| | - Daniel Garros
- Division of Critical Care, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Fuad Alnaji
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Macha Bourdages
- Centre Mère Enfant Soleil du CHU de Québec, Université de Laval, Quebec, QC, Canada
| | - Valerie Brule
- The Children's Hospital of Winnipeg, Winnipeg, MB, Canada
| | - Karen Dryden-Palmer
- Pediatric Critical Care Unit, The Hospital for Sick Children, Toronto, ON, Canada
| | - Fiona Muttalib
- Division of Pediatric Critical Care, BC Children's Hospital, Vancouver, BC, Canada
| | - Jessica Nicoll
- Pediatric Intensive Care Unit, Janeway Children's Health and Rehabilitation Centre, St John's, NL, Canada
| | - Michael Sauthier
- Department of Pediatrics, Critical Care, CHU Sainte-Justine, University of Montreal, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Srinivas Murthy
- Division of Pediatric Critical Care, BC Children's Hospital, Vancouver, BC, Canada
| | - Patricia S Fontela
- Pediatric Intensive Care Unit, Montreal Children's Hospital, Montreal, QC, Canada
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9
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The Pediatric Guideline Adherence and Outcomes (PEGASUS Argentina) program in severe traumatic brain injury: study protocol adaptations during the COVID-19 pandemic for a multisite implementation-effectiveness cluster randomized controlled trial. Trials 2022; 23:980. [PMID: 36471399 PMCID: PMC9720928 DOI: 10.1186/s13063-022-06938-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The aim of this protocol is to describe the study protocol changes made and subsequently implemented to the Pediatric Guideline Adherence and Outcomes (PEGASUS) Argentina randomized controlled trial (RCT) for care of children with severe traumatic brain injuries (TBI) imposed by the COVID-19 pandemic. The PEGASUS study group met in spring 2020 to evaluate available literature review guidance and the study design change or pausing options due to the potential interruption of research. METHODS As a parallel cluster RCT, pediatric patients with severe TBIs are admitted to 8 control (usual care) and 8 intervention (PEGASUS program) hospitals in Argentina, Chile, and Paraguay. PEGASUS is an intervention that aims to increase guideline adherence and best practice care for improving patient outcomes using multi-level implementation science-based approaches. Strengths and weaknesses of proposed options were assessed and resulted in a decision to revert from a stepped wedge to a parallel cluster RCT but to not delay planned implementation. DISCUSSION The parallel cluster design was considered more robust and flexible to secular interruptions and acceptable and feasible to the local study sites in this situation. Due to the early stage of the study, the team had flexibility to redesign and implement a design more compatible with the conditions of the research landscape in 2020 while balancing analytical methods and power, logistical and implementation feasibility, and acceptability. As of fall 2022, the PEGASUS RCT has been active for nearly 2 years of implementation and data collection, scheduled to be completed in in fall 2023. The experience of navigating research during this period will influence decisions about future research design, strategies, and contingencies. TRIAL REGISTRATION Pediatric Guideline Adherence and Outcomes-Argentina. Registered with ClinicalTrials.gov Identifier NCT03896789 on April 1, 2019.
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10
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Nostedt S, Joffe AR. Critical Care Randomized Trials Demonstrate Power Failure: A Low Positive Predictive Value of Findings in the Critical Care Research Field. J Intensive Care Med 2022; 37:1082-1093. [PMID: 35179408 DOI: 10.1177/08850666221077203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND We aimed to determine the post-hoc power of randomized controlled trials (RCTs) in critical care, and describe the implications for long-term positive (PPV) and negative predictive value (NPV) of statistically significant and non-significant findings respectively in the research field. METHODS We reviewed three cohorts of RCTs. "Adult-RCTs" were 216 multicenter RCTs with a mortality outcome from a published systematic review. "Pediatric-RCTs" were 120 RCTs with a mortality outcome, obtained by search of picutrials.net. "Consecutive-RCTs" were 90 recent RCTs obtained by screening publications in 6 journals. Post-hoc power for each study was calculated at α 0.05 and 0.005, for measures of small, medium, and large effect-size, using G*Power software. Long-run expected PPV and NPV of critical care research field findings were then calculated. RESULTS With α 0.05, post-hoc power for small effect-size was very low in all RCT-cohorts (eg, median 24% in Adult-RCTs). For medium effect-size, post-hoc power was low, except for Adult-RCTs (eg, median 9% in Pediatric-RCTs). For large effect-size, post-hoc power for non-human-animal Consecutive-RCTs was low (median 32%). With α 0.005, post-hoc power was even lower. The corollary was that both PPV and NPV were poor for small effect-size, unless α 0.005 was used. Even with α 0.005, with realistic (vs. optimistic) prior probability of the alternative hypothesis, the PPV was low (eg, in Adult-RCTs 57.1% vs. 92.3%). Adding mild bias (0.1) reduced the PPV even further. For medium effect-size both PPV and NPV were better; nevertheless, with α 0.05 and realistic prior probability of the alternative hypothesis the PPV was poor, and with α 0.005 and mild bias (0.1) the PPV was very low (eg, Adult-RCTs median 44.1%). CONCLUSIONS To improve the predictive value of findings in the critical care research field, RCTs should be designed to have 80% power for realistic effect-size at α 0.005.
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Affiliation(s)
- Sarah Nostedt
- Department of Pediatrics, Division of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada.,Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Ari R Joffe
- Department of Pediatrics, Division of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada.,Stollery Children's Hospital, Edmonton, Alberta, Canada
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11
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Bruns N, Sorg AL, Felderhoff-Müser U, Dohna-Schwake C, Stang A. Administrative data in pediatric critical care research-Potential, challenges, and future directions. Front Pediatr 2022; 10:1014094. [PMID: 36245724 PMCID: PMC9554413 DOI: 10.3389/fped.2022.1014094] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
Heterogenous patient populations with small case numbers constitute a relevant barrier to research in pediatric critical care. Prospective studies bring along logistic barriers and-if interventional-ethical concerns. Therefore, retrospective observational investigations, mainly multicenter studies or analyses of registry data, prevail in the field of pediatric critical care research. Administrative health care data represent a possible alternative to overcome small case numbers and logistic barriers. However, their current use is limited by a lack of knowledge among clinicians about the availability and characteristics of these data sets, along with required expertise in the handling of large data sets. Specifically in the field of critical care research, difficulties to assess the severity of the acute disease and estimate organ dysfunction and outcomes pose additional challenges. In contrast, trauma research has shown that classification of injury severity from administrative data can be achieved and chronic disease scores have been developed for pediatric patients, nurturing confidence that the remaining obstacles can be overcome. Despite the undoubted challenges, interdisciplinary collaboration between clinicians and methodologic experts have resulted in impactful publications from across the world. Efforts to enable the estimation of organ dysfunction and measure outcomes after critical illness are the most urgent tasks to promote the use of administrative data in critical care. Clever analysis and linking of different administrative health care data sets carry the potential to advance observational research in pediatric critical care and ultimately improve clinical care for critically ill children.
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Affiliation(s)
- Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Anna-Lisa Sorg
- Division of Pediatric Epidemiology, Institute of Social Pediatrics and Adolescent Medicine, Ludwig Maximilian University Munich, Munich, Germany.,University Children's Hospital, Eberhard Karls University, Tübingen, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Andreas Stang
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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12
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Consent models in Canadian critical care randomized controlled trials: a scoping review. Can J Anaesth 2021; 69:513-526. [PMID: 34907503 DOI: 10.1007/s12630-021-02176-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/06/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Our primary objective was to describe consent models used in Canadian-led adult and pediatric intensive care unit (ICU/PICU) randomized controlled trials (RCTs). Our secondary objectives were to determine the consent rate of ICU/PICU RCTs that did and did not use an alternate consent model to describe consent procedures. SOURCE Using scoping review methodology, we searched MEDLINE, Embase, and CENTRAL databases (from 1998 to June 2019) for trials published in English or French. We included Canadian-led RCTs that reported on the effects of an intervention on ICU/PICU patients or their families. Two independent reviewers assessed eligibility, abstracted data, and achieved consensus. PRINCIPAL FINDINGS We identified 48 RCTs of 17,558 patients. Included RCTs had ethics approval to use prior informed consent (43/48; 90%), deferred consent (13/48; 27%), waived consent (5/48; 10%), and verbal consent (1/48; 2%) models. Fifteen RCTs (15/48; 31%) had ethics approval to use more than one consent model. Twice as many trials used alternate consent between 2010 and 2019 (13/19) than between 2000 and 2009 (6/19). The consent rate for RCTs using only prior informed consent ranged from 54 to 91% (ICU) and 43 to 94% (PICU) and from 78 to 100% (ICU) and 74 to 87% (PICU) in trials using an alternate/hybrid consent model. CONCLUSION Alternate consent models were used in the minority of Canadian-led ICU/PICU RCTs but have been used more frequently over the last decade. This suggests that Canadian ethics boards and research communities are becoming more accepting of alternate consent models in ICU/PICU trials.
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13
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Auclair I. Letter to the Editor on "Exploring the efficacy of music in palliative care: A scoping review". Palliat Support Care 2021; 19:780. [PMID: 34407904 DOI: 10.1017/s1478951521001334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Isabelle Auclair
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
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14
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Nostedt S, Joffe AR. Reverse Bayesian Implications of p-Values Reported in Critical Care Randomized Trials. J Intensive Care Med 2021; 37:954-964. [PMID: 34841950 PMCID: PMC9149268 DOI: 10.1177/08850666211053793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Misinterpretations of the p-value in null-hypothesis statistical testing are
common. We aimed to determine the implications of observed p-values in
critical care randomized controlled trials (RCTs). Methods We included three cohorts of published RCTs: Adult-RCTs reporting a mortality
outcome, Pediatric-RCTs reporting a mortality outcome, and recent
Consecutive-RCTs reporting p-value ≤.10 in six higher-impact journals. We
recorded descriptive information from RCTs. Reverse Bayesian implications of
obtained p-values were calculated, reported as percentages with
inter-quartile ranges. Results Obtained p-value was ≤.005 in 11/216 (5.1%) Adult-RCTs, 2/120 (1.7%)
Pediatric-RCTs, and 37/90 (41.1%) Consecutive-RCTs. An obtained p-value
.05–.0051 had high False Positive Rates; in Adult-RCTs, minimum (assuming
prior probability of the alternative hypothesis was 50%) and realistic
(assuming prior probability of the alternative hypothesis was 10%) False
Positive Rates were 16.7% [11.2, 21.8] and 64.3% [53.2, 71.4]. An obtained
p-value ≤.005 had lower False Positive Rates; in Adult-RCTs the realistic
False Positive Rate was 7.7% [7.7, 16.0]. The realistic probability of the
alternative hypothesis for obtained p-value .05–.0051 (ie, Positive
Predictive Value) was 28.0% [24.1, 34.8], 30.6% [27.7, 48.5], 29.3% [24.3,
41.0], and 32.7% [24.1, 43.5] for Adult-RCTs, Pediatric-RCTs,
Consecutive-RCTs primary and secondary outcome, respectively. The maximum
Positive Predictive Value for p-value category .05–.0051 was median 77.8%,
79.8%, 78.8%, and 81.4% respectively. To have maximum or realistic Positive
Predictive Value >90% or >80%, RCTs needed to have obtained p-value
≤.005. The credibility of p-value .05–.0051 findings were easy to challenge,
and the credibility to rule-out an effect with p-value >.05 to .10 was
low. The probability that a replication study would obtain p-value ≤.05 did
not approach 90% unless the obtained p-value was ≤.005. Conclusions Unless the obtained p-value was ≤.005, the False Positive Rate was high, and
the Positive Predictive Value and probability of replication of
“statistically significant” findings were low.
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Affiliation(s)
- Sarah Nostedt
- University of Alberta, Edmonton, Alberta, Canada.,Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Ari R Joffe
- University of Alberta, Edmonton, Alberta, Canada.,Stollery Children's Hospital, Edmonton, Alberta, Canada
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15
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Pensier J, De Jong A, Chanques G, Futier E, Azoulay E, Molinari N, Jaber S. A multivariate model for successful publication of intensive care medicine randomized controlled trials in the highest impact factor journals: the SCOTI score. Ann Intensive Care 2021; 11:165. [PMID: 34837580 PMCID: PMC8626742 DOI: 10.1186/s13613-021-00954-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background Critical care randomized controlled trials (RCTs) are often published in high-impact journals, whether general journals [the New England Journal of Medicine (NEJM), The Lancet, the Journal of the American Medical Association (JAMA)] or critical care journals [Intensive Care Medicine (ICM), the American Journal of Respiratory and Critical Care Medicine (AJRCCM), Critical Care Medicine (CCM)]. As rejection occurs in up to 97% of cases, it might be appropriate to assess pre-submission probability of being published. The objective of this study was to develop and internally validate a simplified score predicting whether an ongoing trial stands a chance of being published in high-impact general journals. Methods A cohort of critical care RCTs published between 1999 and 2018 in the three highest impact medical journals (NEJM, The Lancet, JAMA) or the three highest impact critical care journals (ICM, AJRCCM, CCM) was split into two samples (derivation cohort, validation cohort) to develop and internally validate the simplified score. Primary outcome was journal of publication assessed as high-impact general journal (NEJM, The Lancet, JAMA) or critical care journal (ICM, AJRCCM, CCM). Results A total of 968 critical care RCTs were included in the predictive cohort and split into a derivation cohort (n = 510) and a validation cohort (n = 458). In the derivation cohort, the sample size (P value < 0.001), the number of centers involved (P value = 0.01), mortality as primary outcome (P value = 0.002) or a composite item including mortality as primary outcome (P value = 0.004), and topic [ventilation (P value < 0.001) or miscellaneous (P value < 0.001)] were independent factors predictive of publication in high-impact general journals, compared to high-impact critical care journals. The SCOTI score (Sample size, Centers, Outcome, Topic, and International score) was developed with an area under the ROC curve of 0.84 (95% Confidence Interval, 0.80–0.88) in validation by split sample. Conclusions The SCOTI score, developed and validated by split sample, accurately predicts the chances of a critical care RCT being published in high-impact general journals, compared to high-impact critical care journals. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00954-x.
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Affiliation(s)
- Joris Pensier
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214 CEDEX 5, Montpellier, France
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214 CEDEX 5, Montpellier, France
| | - Gerald Chanques
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214 CEDEX 5, Montpellier, France
| | - Emmanuel Futier
- Department of Peri-Operative Medicine, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Groupe FAMIREA, Hôpital Saint-Louis, Université de Paris, Paris, France
| | - Nicolas Molinari
- IDESP, INSERM, Univ Montpellier, CHU Montpellier, Montpellier, France.,Universite de Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214 CEDEX 5, Montpellier, France. .,Département d'Anesthésie Réanimation B (DAR B), 80 Avenue Augustin Fliche, 34295, Montpellier, France.
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16
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Lee JJ, Price JC, Gewandter J, Kleykamp BA, Biagas KV, Naim MY, Ward D, Dworkin RH, Sun LS. Design and reporting characteristics of clinical trials investigating sedation practices in the paediatric intensive care unit: a scoping review by SCEPTER (Sedation Consortium on Endpoints and Procedures for Treatment, Education and Research). BMJ Open 2021; 11:e053519. [PMID: 34649849 PMCID: PMC8522672 DOI: 10.1136/bmjopen-2021-053519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To conduct a scoping review of sedation clinical trials in the paediatric intensive care setting and summarise key methodological elements. DESIGN Scoping review. DATA SOURCES PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature and grey references including ClinicalTrials.gov from database inception to 3 August 2021. STUDY SELECTION All human trials in the English language related to sedation in paediatric critically ill patients were included. After title and abstract screening, full-text review was performed. 29 trials were eligible for final analysis. DATA EXTRACTION A coding manual was developed and pretested. Trial characteristics were double extracted. RESULTS The majority of trials were single centre (22/29, 75.9%), parallel group superiority (17/29, 58.6%), double-blinded (18/29, 62.1%) and conducted in an academic setting (29/29, 100.0%). Trial enrolment (≥90% planned sample size) was achieved in 65.5% of trials (19/29), and retention (≥90% enrolled subjects) in 72.4% of trials (21/29). Protocol violations were reported in nine trials (31.0%). The most commonly studied cohorts were mechanically ventilated patients (28/29, 96.6%) and postsurgical patients (11/29, 37.9%) with inclusion criteria for age ranging from 0±0.5 to 15.0±7.3 years (median±IQR). The median age of enrolled patients was 1.7 years (IQR=4.4 years). Patients excluded from trials were those with neurological impairment (21/29, 72.4%), complex disease (20/29, 69.0%) or receipt of neuromuscular blockade (10/29, 34.5%). Trials evaluated drugs/protocols for sedation management (20/29, 69.0%), weaning (3/29, 10.3%), daily interruption (3/29, 10.3%) or protocolisation (3/29, 10.3%). Primary outcome measures were heterogeneous, as were assessment instruments and follow-up durations. CONCLUSIONS There is substantial heterogeneity in methodological approach in clinical trials evaluating sedation in critically ill paediatric patients. These results provide a basis for the design of future clinical trials to improve the quality of trial data and aid in the development of sedation-related clinical guidelines.
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Affiliation(s)
| | - Jerri C Price
- Anesthesiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Jennifer Gewandter
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Bethea A Kleykamp
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Katherine V Biagas
- Pediatrics, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Maryam Y Naim
- Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Denham Ward
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Robert H Dworkin
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Lena S Sun
- Anesthesiology and Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
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17
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Harris J, Tibby SM, Endacott R, Latour JM. Neurally Adjusted Ventilator Assist in Infants With Acute Respiratory Failure: A Literature Scoping Review. Pediatr Crit Care Med 2021; 22:915-924. [PMID: 33852545 DOI: 10.1097/pcc.0000000000002727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To map the evidence for neurally adjusted ventilatory assist strategies, outcome measures, and sedation practices in infants less than 12 months with acute respiratory failure using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidance. DATA SOURCES CINAHL, MEDLINE, COCHRANE, JBI, EMBASE, PsycINFO, Google scholar, BNI, AMED. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register. Also included were Ethos, Grey literature, Google, dissertation abstracts, EMBASE conference proceedings. STUDY SELECTION Abstracts were screened followed by review of full text. Articles incorporating a heterogeneous population of both infants and older children were assessed, and where possible, data for infants were extracted. Fifteen articles were included. Ten articles were primary research: randomized controlled trial (n = 3), cohort studies (n = 4), retrospective data analysis (n = 2), case series (n = 1). Other articles are expert opinion (n = 2), neurally adjusted ventilatory assist updates (n = 1), and a literature review (n = 2). Three studies included exclusively infants. We also included 12 studies reporting jointly on infants and children. DATA EXTRACTION A standardized data extraction tool was used. DATA SYNTHESIS Key findings were that evidence related to neurally adjusted ventilatory assist ventilation strategies in infants and related to specific primary conditions is limited. The setting of neurally adjusted ventilatory assist level is not consistent, and how to optimize this mode of ventilation was not documented. Outcome measures varied considerably, most studies focused on improvements in respiratory and physiological variables. Sedation use is variable with regard to medication type and dose. There is an indication that less sedation is required in patients receiving neurally adjusted ventilatory assist, but no conclusive evidence to support this. CONCLUSIONS This review highlights a lack of standardized strategies for neurally adjusted ventilatory assist ventilation and sedation practices among infants with acute respiratory failure. Studies were limited by small sample sizes and a lack of focus on specific patient groups. Robust studies are needed to provide evidence-based clinical recommendations for the use of neurally adjusted ventilatory assist in infants with acute respiratory failure.
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Affiliation(s)
- Julia Harris
- Department of Advanced and Integrated Practice, London South Bank University, London, United Kingdom
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
| | - Shane M Tibby
- Pediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Ruth Endacott
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, Australia
| | - Jos M Latour
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
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18
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Saito H, Watanabe Y, Kutsuna T, Futohashi T, Kusumoto Y, Chiba H, Kubo M, Takasaki H. Spinal movement variability associated with low back pain: A scoping review. PLoS One 2021; 16:e0252141. [PMID: 34029347 PMCID: PMC8143405 DOI: 10.1371/journal.pone.0252141] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/10/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To identify suggestions for future research on spinal movement variability (SMV) in individuals with low back pain (LBP) by investigating (1) the methodologies and statistical tools used to assess SMV; (2) characteristics that influence the direction of change in SMV; (3) the methodological quality and potential biases in the published studies; and (4) strategies for optimizing SMV in LBP patients. Methods We searched literature databases (CENTRAL, Medline, PubMed, Embase, and CINAHL) and comprehensively reviewed the relevant papers up to 5 May 2020. Eligibility criteria included studies investigating SMV in LBP subjects by measuring trunk angle using motion capture devices during voluntary repeated trunk movements in any plane. The Newcastle-Ottawa risk of bias tool was used for data quality assessment. Results were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Results Eighteen studies were included: 14 cross-sectional and 4 prospective studies. Seven linear and non-linear statistical tools were used. Common movement tasks included trunk forward bending and backward return, and object lifting. Study results on SMV changes associated with LBP were inconsistent. Two of the three interventional studies reported changes in SMV, one of which was a randomized controlled trial (RCT) involving neuromuscular exercise interventions. Many studies did not account for the potential risk of selection bias in the LBP population. Conclusion Designers of future studies should recognize that each of the two types of statistical tools assesses functionally different aspects of SMV. Future studies should also consider dividing participants into subgroups according to LBP characteristics, as three potential subgroups with different SMV characteristics were proposed in our study. Different task demands also produced different effects. We found preliminary evidence in a RCT that neuromuscular exercises could modify SMV, suggesting a rationale for well-designed RCTs involving neuromuscular exercise interventions in future studies.
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Affiliation(s)
- Hiroki Saito
- Department of Physical Therapy, Tokyo University of Technology, Ota-ku, Tokyo, Japan
- * E-mail:
| | - Yoshiteru Watanabe
- Department of Physical Therapy, Tokyo University of Technology, Ota-ku, Tokyo, Japan
| | - Toshiki Kutsuna
- Department of Physical Therapy, Tokyo University of Technology, Ota-ku, Tokyo, Japan
| | - Toshihiro Futohashi
- Department of Physical Therapy, Tokyo University of Technology, Ota-ku, Tokyo, Japan
| | - Yasuaki Kusumoto
- Department of Physical Therapy, Tokyo University of Technology, Ota-ku, Tokyo, Japan
| | - Hiroki Chiba
- Department of Physical Therapy, Secomedic Hospital, Funabashi, Chiba, Japan
- Postgraduate School, Saitama Prefectural University, Koshigaya, Saitama, Japan
| | - Masayoshi Kubo
- Department of Physical Therapy, Niigata University of Health and Welfare, Niigata, Niigata, Japan
| | - Hiroshi Takasaki
- Department of Physical Therapy, Saitama Prefectural University, Koshigaya, Saitama, Japan
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Morbidity and Mortality in Critically Ill Children. II. A Qualitative Patient-Level Analysis of Pathophysiologies and Potential Therapeutic Solutions. Crit Care Med 2021; 48:799-807. [PMID: 32301845 DOI: 10.1097/ccm.0000000000004332] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe at the individual patient level the pathophysiologic processes contributing to morbidity and mortality in PICUs and therapeutic additions and advances that could potentially prevent or reduce morbidity and mortality. DESIGN Qualitative content analysis of intensivists' conclusions on pathophysiologic processes and needed therapeutic advances formulated by structured medical record review. SETTING Eight children's hospitals affiliated with the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. PATIENTS A randomly selected cohort of critically ill children with a new functional morbidity or mortality at hospital discharge. New morbidity was assessed using the Functional Status Scale and defined as worsening by two or more points in a single domain from preillness baseline. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 292 children, 175 (59.9%) had a new morbidity and 117 (40.1%) died. The most common pathophysiology was impaired substrate delivery (n = 158, 54.1%) manifesting as global or regional hypoxia or ischemia due to low cardiac output or cardiac arrest. Other frequent pathophysiologies were inflammation (n = 104, 35.6%) related to sepsis, respiratory failure, acute respiratory distress syndrome, or multiple organ dysfunction; and direct tissue injury (n = 64, 21.9%) including brain and spinal cord trauma. Chronic conditions were often noted (n = 156, 53.4%) as contributing to adverse outcomes. Drug therapies (n = 149, 51.0%) including chemotherapy, inotropes, vasoactive agents, and sedatives were the most frequently proposed needed therapeutic advances. Other frequently proposed therapies included cell regeneration (n = 115, 39.4%) mainly for treatment of neuronal injury, and improved immune and inflammatory modulation (n = 79, 27.1%). CONCLUSIONS Low cardiac output and cardiac arrest, inflammation-related organ failures, and CNS trauma were the most common pathophysiologies leading to morbidity and mortality in PICUs. A research agenda focused on better understanding and treatment of these conditions may have high potential to directly impact patient outcomes.
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Tume LN, Menzies JC, Ray S, Scholefield BR. Research Priorities for U.K. Pediatric Critical Care in 2019: Healthcare Professionals' and Parents' Perspectives. Pediatr Crit Care Med 2021; 22:e294-e301. [PMID: 33394942 DOI: 10.1097/pcc.0000000000002647] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Paediatric Intensive Care Society Study Group conducted a research prioritization exercise with the aim to identify and agree research priorities in Pediatric Critical Care in the United Kingdom both from a healthcare professional and parent/caregiver perspective. DESIGN A modified three-round e-Delphi survey, followed by a survey of parents of the top 20 healthcare professional priorities. SETTING U.K. PICUs. PATIENTS U.K. PICU healthcare professionals who are members of the professional society and parents and family members of children, with experience of a U.K. PICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty-nine healthcare professional submitted topics in round 1, 98 participated in round 2, and 102 in round 3. These topics were categorized into eight broad domain areas, and within these, there were 73 specific topics in round 2. At round 3, 18 topics had a mean score less than 5.5 and were removed, leaving 55 topics for ranking in round 3. Ninety-five parents and family members completed the surveys from at least 17 U.K. PICUs. Both parents and healthcare professional prioritized research topics associated with the PICU workforce. Healthcare professional research priorities reflected issues that impacted on day-to-day management and practice. Parents' prioritized research addressing acute situations such as infection identification of and sepsis management or research addressing long-term outcomes for children and parents after critical illness. Parents prioritized research into longer term outcomes more than healthcare professional. Parental responses showed clear support for the concept of research in PICU, but few novel research questions were proposed. CONCLUSIONS This is the first research prioritization exercise within U.K. PICU setting to include parents' and families' perspectives and compare these with healthcare professional. Results will guide both funders and future researchers.
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Affiliation(s)
- Lyvonne N Tume
- School of Health & Society, University of Salford, Salford, United Kingdom
| | - Julie C Menzies
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Samiran Ray
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
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Long-Term Outcomes and the Post-Intensive Care Syndrome in Critically Ill Children: A North American Perspective. CHILDREN-BASEL 2021; 8:children8040254. [PMID: 33805106 PMCID: PMC8064072 DOI: 10.3390/children8040254] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/17/2021] [Accepted: 03/20/2021] [Indexed: 12/14/2022]
Abstract
Advances in medical and surgical care for children in the pediatric intensive care unit (PICU) have led to vast reductions in mortality, but survivors often leave with newly acquired or worsened morbidity. Emerging evidence reveals that survivors of pediatric critical illness may experience a constellation of physical, emotional, cognitive, and social impairments, collectively known as the “post-intensive care syndrome in pediatrics” (PICs-P). The spectrum of PICs-P manifestations within each domain are heterogeneous. This is attributed to the wide age and developmental diversity of children admitted to PICUs and the high prevalence of chronic complex conditions. PICs-P recovery follows variable trajectories based on numerous patient, family, and environmental factors. Those who improve tend to do so within less than a year of discharge. A small proportion, however, may actually worsen over time. There are many gaps in our current understanding of PICs-P. A unified approach to screening, preventing, and treating PICs-P-related morbidity has been hindered by disparate research methodology. Initiatives are underway to harmonize clinical and research priorities, validate new and existing epidemiologic and patient-specific tools for the prediction or monitoring of outcomes, and define research priorities for investigators interested in long-term outcomes.
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Abstract
OBJECTIVES To examine the gender distribution of authorship of pediatric critical care randomized control trials. DATA SOURCES The 415 randomized control trials in pediatric critical care published before 2019. STUDY SELECTION We included all randomized control trials enrolling children in a PICU. We used PICUtrials.net, which uses comprehensive search strategies of multiple databases, to identify published randomized control trials. DATA EXTRACTION We manually extracted the name and profession of each listed author from each publication and classified each author as male or female based on their name. RESULTS We included 2,146 authors and were able to classify 1,888 (88%) as men or women. Overall, 38% of authors were women, this varied with the authorship position: 37% of first, 38% of middle, and 25% of last authors were women (p < 0.001). The three most common professions were physician (63%), nonclinician (11%), and nurse (6%)-of which 30%, 45%, and 97%, respectively, were women. The percentage of female authorship overall has increased from 28% in 1985-1989 to 39% in 2015-2018 (p for trend = 0.004). There were no significant differences in the characteristics of randomized control trials published with a female first or last author versus those with both male first and last authors with respect to the median number of children randomized (60 vs. 50; p = 0.41), multicentred trials (17% vs. 24%; p = 0.12), trials at low risk of bias (50% vs. 66%; p = 0.26), reporting any funding (55% vs. 51%; p = 0.66), or median number of citations per year (1.5 vs. 2.4; p = 0.09). CONCLUSIONS Although increasing over time, the percentage of researchers publishing pediatric critical care randomized control trials who are women still lags behind the percentage clinicians who are women. Trials that female researchers publish are similar in characteristics and impact as male researchers. Further work should identify barriers to gender diversity and potential solutions in pediatric critical care research.
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McGee RG, Dawson AC. Fake news and fake research: Why meta-research matters more than ever. J Paediatr Child Health 2020; 56:1868-1871. [PMID: 33085816 PMCID: PMC7821256 DOI: 10.1111/jpc.15237] [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: 08/06/2020] [Accepted: 09/24/2020] [Indexed: 11/29/2022]
Abstract
Research is in a crisis of credibility, and this is to the peril of all paediatricians. Billions of dollars are being wasted each year because research is not planned, badly conducted or poorly reported, and this is on a background of rapidly reducing research budgets. How can paediatricians, families and patients make informed treatment choices if the evidence base is absent or not trustworthy? This article discusses why meta-research now matters more than ever, how it can help solve this crisis of credibility and how this should lead to more efficient and effective clinical care. The field of meta-research or research-on-research is the ultimate big picture approach to identifying and solving issues of bias, error, misconduct and waste in research. Meta-researchers value authenticity over aesthetics and quality over quantity. The utility of meta-research does not rely on accusations or critical assessments of individual research, but through highlighting where and how the scientific method and research standards across all fields can be improved. Meta-researchers study, analyse and critique the research pathway, focusing on elements such as methods (how to conduct), evaluation (how to test), reporting (how to communicate), reproducibility (how to verify) and incentives (how to reward). In the current climate it is now more critical than ever that we make use of meta-research and prioritise high-quality high-impact research, ultimately leading to improved patient outcomes.
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Affiliation(s)
- Richard G McGee
- The Central Coast Clinical School, School of Medicine and Public HealthThe University of NewcastleNewcastleNew South WalesAustralia,Department of PaediatricsGosford HospitalNewcastleNew South WalesAustralia
| | - Amanda C Dawson
- The Central Coast Clinical School, School of Medicine and Public HealthThe University of NewcastleNewcastleNew South WalesAustralia,Department of SurgeryGosford HospitalGosfordNew South WalesAustralia
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Fink EL, Maddux AB, Pinto N, Sorenson S, Notterman D, Dean JM, Carcillo JA, Berg RA, Zuppa A, Pollack MM, Meert KL, Hall MW, Sapru A, McQuillen PS, Mourani PM, Wessel D, Amey D, Argent A, de Carvalho WB, Butt W, Choong K, Curley MA, del Pilar Arias Lopez M, Demirkol D, Grosskreuz R, Houtrow AJ, Knoester H, Lee JH, Long D, Manning JC, Morrow B, Sankar J, Slomine BS, Smith M, Olson LM, Watson RS. A Core Outcome Set for Pediatric Critical Care. Crit Care Med 2020; 48:1819-1828. [PMID: 33048905 PMCID: PMC7785252 DOI: 10.1097/ccm.0000000000004660] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES More children are surviving critical illness but are at risk of residual or new health conditions. An evidence-informed and stakeholder-recommended core outcome set is lacking for pediatric critical care outcomes. Our objective was to create a multinational, multistakeholder-recommended pediatric critical care core outcome set for inclusion in clinical and research programs. DESIGN A two-round modified Delphi electronic survey was conducted with 333 invited research, clinical, and family/advocate stakeholders. Stakeholders completing the first round were invited to participate in the second. Outcomes scoring greater than 69% "critical" and less than 15% "not important" advanced to round 2 with write-in outcomes considered. The Steering Committee held a virtual consensus conference to determine the final components. SETTING Multinational survey. PATIENTS Stakeholder participants from six continents representing clinicians, researchers, and family/advocates. MEASUREMENTS AND MAIN RESULTS Overall response rates were 75% and 82% for each round. Participants voted on seven Global Domains and 45 Specific Outcomes in round 1, and six Global Domains and 30 Specific Outcomes in round 2. Using overall (three stakeholder groups combined) results, consensus was defined as outcomes scoring greater than 90% "critical" and less than 15% "not important" and were included in the final PICU core outcome set: four Global Domains (Cognitive, Emotional, Physical, and Overall Health) and four Specific Outcomes (Child Health-Related Quality of Life, Pain, Survival, and Communication). Families (n = 21) suggested additional critically important outcomes that did not meet consensus, which were included in the PICU core outcome set-extended. CONCLUSIONS The PICU core outcome set and PICU core outcome set-extended are multistakeholder-recommended resources for clinical and research programs that seek to improve outcomes for children with critical illness and their families.
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Affiliation(s)
- Ericka L. Fink
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Aline B. Maddux
- Department of Pediatrics, Critical Care Medicine, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, USA
| | - Neethi Pinto
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Samuel Sorenson
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - J. Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Murray M Pollack
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
| | - Mark W Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Peter M Mourani
- Department of Pediatrics, Critical Care Medicine, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, USA
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - Deborah Amey
- Advocate, Collaborative Pediatric Critical Care Research Network Family Collaborative, Great Falls, Virginia, USA
| | - Andrew Argent
- Department of Paediatrics and Child Health, University of Cape Town, and Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | | | - Warwick Butt
- Intensive Care Department of Paediatrics, The Royal Childrens Hospital, Melbourne, Australia
| | - Karen Choong
- Departments of Pediatrics and Critical Care, McMaster University, Ontario, Canada
| | - Martha A.Q. Curley
- Department of Family and Community Health (Nursing), Anesthesiology and Critical Care (Perelman School of Medicine), University of Pennsylvania; Research Institute, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Demet Demirkol
- Istanbul University, Child Health Institute and Istanbul Faculty of Medicine, Department of Pediatric Intensive Care, Istanbul, Turkey
| | - Ruth Grosskreuz
- Department of Pediatrics, Critical Care Medicine, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, USA
| | - Amy J. Houtrow
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hennie Knoester
- Department of Paediatrics, Centrum Universiteit van Amsterdam, the Netherlands
| | - Jan Hau Lee
- Department of Pediatric Subspecialities, KK Women’s and Children’s Hospital, Singapore
| | - Debbie Long
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, and PCCRG, Centre for Children’s Health Research, The University of Queensland, Australia
| | - Joseph C. Manning
- Children and Young People Health Research, School of Health Sciences, University of Nottingham and Nottingham Children’s Hospital, Nottingham University Hospitals NHS Trust, United Kingdom
| | - Brenda Morrow
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
| | - Jhuma Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, Chandigarh, India
| | - Beth S. Slomine
- Department of Neuropsychology, Kennedy Krieger Institute and Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - McKenna Smith
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lenora M. Olson
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - R. Scott Watson
- Department of Pediatrics, University of Washington School of Medicine and Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA, USA
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Fayed N, Cameron S, Fraser D, Cameron JI, Al-Harbi S, Simpson R, Wakim M, Chiu L, Choong K. Priority Outcomes in Critically Ill Children: A Patient and Parent Perspective. Am J Crit Care 2020; 29:e94-e103. [PMID: 32869071 DOI: 10.4037/ajcc2020188] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Outcomes in pediatric critical care research are typically selected by the researcher. OBJECTIVES (1) To identify outcomes prioritized by patients and their families following a critical illness and (2) to determine the overlap between patient-centered and researcher-selected study outcomes. METHODS An exploratory descriptive qualitative study nested within a longitudinal cohort study conducted in 2 pediatric intensive care units (PICUs). Participants were purposively sampled from the primary cohort to ensure adequate demographic representation. Qualitative descriptive approaches based on naturalistic observation were used to collect data and analyze results. Data were coded by using the International Classification of Functioning, Disability, and Health Children and Youth (ICF-CY) framework. RESULTS Twenty-one participants were interviewed a mean of 5.1 months after PICU discharge. Outcomes fell into 2 categories: patient-centered and family-centered. In the former, diagnosis, survival, and prognosis were key priorities during the acute critical illness. Once survival appears possible, functioning (physical, cognitive, and emotional), and factors that influence recovery (ie, rehabilitation, environment, and quality of life) are prioritized. Family-centered outcomes consisted of parents' psychosocial functioning and experience of care. Patient-centered outcomes were covered well by the selected study measures of functioning, but not by the clinical outcome measures. CONCLUSION Functioning and quality of life are key patient-centered outcomes during recovery from critical illness. These are not well captured by end points typically used in PICU studies. These results justify the importance of patient- and family-centered outcomes in PICU research and a need to determine how these outcomes can be comprehensively measured.
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Affiliation(s)
- Nora Fayed
- Nora Fayed and Karen Choong contributed equally to the execution of this study and the writing of this manuscript. Nora Fayed is an assistant professor, Maha Wakim and Lily Chiu are occupational therapy students, School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
| | - Saoirse Cameron
- Saoirse Cameron is a research coordinator and Douglas Fraser is a professor, Department of Pediatrics, Western University, and Lawson Health Research Institute, London, Ontario, Canada
| | - Douglas Fraser
- Saoirse Cameron is a research coordinator and Douglas Fraser is a professor, Department of Pediatrics, Western University, and Lawson Health Research Institute, London, Ontario, Canada
| | - Jill I. Cameron
- Jill I. Cameron is an associate professor, Department of Occupational Science and Occupational Therapy, Rehabilitation Sciences Institute, Rehabilitation Sciences, University of Toronto, Canada
| | - Samah Al-Harbi
- Samah Al-Harbi is an assistant professor, Department of Pediatrics, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Racquel Simpson
- Racquel Simpson is a research coordinator and Karen Choong is a professor, Department of Pediatrics and Critical Care, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maha Wakim
- Nora Fayed is an assistant professor, Maha Wakim and Lily Chiu are occupational therapy students, School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
| | - Lily Chiu
- Nora Fayed is an assistant professor, Maha Wakim and Lily Chiu are occupational therapy students, School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
| | - Karen Choong
- Nora Fayed and Karen Choong contributed equally to the execution of this study and the writing of this manuscript. Racquel Simpson is a research coordinator and Karen Choong is a professor, Department of Pediatrics and Critical Care, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Mills KI, Albert BD, Bechard LJ, Duggan CP, Kaza A, Rakoff-Nahoum S, Vlamakis H, Sleeper LA, Newburger JW, Priebe GP, Mehta NM. Stress ulcer prophylaxis versus placebo-a blinded randomized control trial to evaluate the safety of two strategies in critically ill infants with congenital heart disease (SUPPRESS-CHD). Trials 2020; 21:590. [PMID: 32600393 PMCID: PMC7322718 DOI: 10.1186/s13063-020-04513-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 06/15/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Critically ill infants with congenital heart disease (CHD) are often prescribed stress ulcer prophylaxis (SUP) to prevent upper gastrointestinal bleeding, despite the low incidence of stress ulcers and limited data on the safety and efficacy of SUP in infants. Recently, SUP has been associated with an increased incidence of hospital-acquired infections, community-acquired pneumonia, and necrotizing enterocolitis. The objective of this pilot study is to investigate the feasibility of performing a randomized controlled trial to assess the safety and efficacy of withholding SUP in infants with congenital heart disease admitted to the cardiac intensive care unit. METHODS A single center, prospective, double-blinded, randomized placebo-controlled pilot feasibility trial will be performed in infants with CHD admitted to the cardiac intensive care unit and anticipated to require respiratory support for > 24 h. Patients will be randomized to receive a histamine-2 receptor antagonist (H2RA) or placebo until they are discontinued from respiratory support. Randomization will be performed within 2 strata defined by admission type (medical or surgical) and age (neonate, age < 30 days, or infant, 1 month to 1 year). Allocation will be a 1:1 ratio using permuted blocks to ensure balanced allocations across the two treatment groups within each stratum. The primary outcomes include feasibility of screening, consent, timely allocation of study drug, and protocol adherence. The primary safety outcome is the rate of clinically significant upper gastrointestinal bleeding. The secondary outcomes are the difference in the relative and absolute abundance of the gut microbiota and functional microbial profiles between the two study groups. We plan to enroll 100 patients in this pilot study. DISCUSSION Routine use of SUP to prevent upper gastrointestinal bleeding in infants is controversial due to a low incidence of bleeding events and concern for adverse effects. The role of SUP in infants with CHD has not been examined, and there is equipoise on the risks and benefits of withholding this therapy. In addition, this therapy has been discontinued in other neonatal populations due to the concern for hospital-acquired infections and necrotizing enterocolitis. Furthermore, exploring changes to the microbiome after exposure to SUP may highlight the mechanisms by which SUP impacts potential microbial dysbiosis of the gut and its association with hospital-acquired infections. Assessment of the feasibility of a trial of withholding SUP in critically ill infants with CHD will facilitate planning of a larger multicenter trial of safety and efficacy of SUP in this vulnerable population. TRIAL REGISTRATION ClinicalTrials.gov , NCT03667703. Registered 12 September 2018, https://clinicaltrials.gov/ct2/show/NCT03667703?term=SUPPRESS+CHD&draw=2&rank=1 . All WHO Trial Registration Data Set Criteria are met in this manuscript.
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Affiliation(s)
- Kimberly I. Mills
- grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Ben D. Albert
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Lori J. Bechard
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Christopher P. Duggan
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Center for Nutrition, Boston Children’s Hospital, Boston, MA USA
| | - Aditya Kaza
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA USA
| | - Seth Rakoff-Nahoum
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Hera Vlamakis
- grid.66859.34Broad Institute of MIT and Harvard, Boston, MA USA
| | - Lynn A. Sleeper
- grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Jane W. Newburger
- grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Gregory P. Priebe
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Nilesh M. Mehta
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA ,grid.2515.30000 0004 0378 8438Center for Nutrition, Boston Children’s Hospital, Boston, MA USA
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Abstract
OBJECTIVES Occupational therapists have specialized expertise to enable people to perform meaningful "occupations" that support health, well-being, and participation in life roles. Given the physical, cognitive, and psychologic disability experienced by ICU survivors, occupational therapists could play an important role in their recovery. We conducted a scoping review to determine the state of knowledge of interventions delivered by occupational therapists in adult ICU patients. DATA SOURCES Eight electronic databases from inception to 05/2018. STUDY SELECTION We included reports of adult patients receiving direct patient care from an occupational therapist in the ICU, all study designs, and quantitative and qualitative traditions. DATA EXTRACTION Independently in duplicate, interprofessional team members screened titles, abstracts, and full texts and extracted report and intervention characteristics. From original research articles, we also extracted study design, number of patients, and primary outcomes. We resolved disagreements by consensus. DATA SYNTHESIS Of 50,700 citations, 221 reports met inclusion criteria, 74 (79%) published after 2010, and 125 (56%) appeared in critical care journals. The three most commonly reported types of interventions were mobility (81%), physical rehabilitation (61%), and activities of daily living (31%). We identified 46 unique original research studies of occupational therapy interventions; the most common study research design was before-after studies (33%). CONCLUSIONS The role of occupational therapists in ICU rehabilitation is not currently well established. Current interventions in the ICU are dominated by physical rehabilitation with a growing role in communication and delirium prevention and care. Given the diverse needs of ICU patients and the scope of occupational therapy, there could be an opportunities for occupational therapists to expand their role and spearhead original research investigating an enriched breadth of ICU interventions.
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Fink EL, Jarvis JM, Maddux AB, Pinto N, Galyean P, Olson LM, Zickmund S, Ringwood M, Sorenson S, Dean JM, Carcillo JA, Berg RA, Zuppa A, Pollack MM, Meert KL, Hall MW, Sapru A, McQuillen PS, Mourani PM, Watson RS. Development of a core outcome set for pediatric critical care outcomes research. Contemp Clin Trials 2020; 91:105968. [PMID: 32147572 DOI: 10.1016/j.cct.2020.105968] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/19/2020] [Accepted: 02/22/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pediatric Intensive Care Unit (PICU) teams provide care for critically ill children with diverse and often complex medical and surgical conditions. Researchers often lack guidance on an approach to select the best outcomes when evaluating this critically ill population. Studies would be enhanced by incorporating multi-stakeholder preferences to better evaluate clinical care. This manuscript outlines the methodology currently being used to develop a PICU Core Outcome Set (COS). This PICU COS utilizes mixed methods, an inclusive stakeholder approach, and a modified Delphi consensus process that will serve as a resource for PICU research programs. METHODS A Scoping Review of the PICU literature evaluating outcomes after pediatric critical illness, a qualitative study interviewing PICU survivors and their parents, and other relevant literature will serve to inform a modified, international Delphi consensus process. The Delphi process will derive a set of minimum domains for evaluation of outcomes of critically ill children and their families. Delphi respondents include researchers, multidisciplinary clinicians, families and former patients, research funding agencies, payors, and advocates. Consensus meetings will refine and finalize the domains of the COS, outline a battery instruments for use in future studies, and prepare for extensive dissemination for broad implementation. DISCUSSION The PICU COS will be a guideline resource for investigators to assure that outcomes most important to all stakeholders are considered in PICU clinical research in addition to those deemed most important to individual scientists. TRIAL REGISTRATION COMET database (http://www.comet-initiative.org/, Record ID 1131, 01/01/18).
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Affiliation(s)
- Ericka L Fink
- Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 2nd floor, Pittsburgh, PA 15224, United States of America.
| | - Jessica M Jarvis
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Suite 910, 3471 Fifth Avenue, Pittsburgh, PA, United States of America.
| | - Aline B Maddux
- Department of Pediatrics, Critical Care Medicine, University of Colorado School of Medicine, Children's Hospital Colorado, 13121 E 17(th) Ave, MS 8414, Aurora, CO 80045, United States of America.
| | - Neethi Pinto
- Department of Pediatrics, Section of Critical Care, The University of Chicago, 5741 S. Maryland Ave. MC 1145, Chicago, IL 60637, United States of America.
| | - Patrick Galyean
- Qualitative Research Core, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America.
| | - Lenora M Olson
- Department of Pediatrics, Critical Care Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, United States of America.
| | - Susan Zickmund
- VA Health Services Research, VA Salt Lake City Medical Center, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84132, United States of America.
| | - Melissa Ringwood
- Department of Pediatrics, Critical Care Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, United States of America.
| | - Samuel Sorenson
- Department of Pediatrics, Critical Care Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, United States of America.
| | - J Michael Dean
- Department of Pediatrics, Critical Care Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, United States of America.
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 2nd floor, Pittsburgh, PA 15224, United States of America.
| | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, PA, United States of America.
| | - Athena Zuppa
- Children's Hospital of Philadelphia, Philadelphia, PA, United States of America.
| | - Murray M Pollack
- Children's National Medical Center, Washington, DC, United States of America.
| | - Kathleen L Meert
- Children's Hospital of Michigan, Detroit, MI, United States of America.
| | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH, United States of America.
| | - Anil Sapru
- Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, United States of America.
| | - Patrick S McQuillen
- Benioff Children's Hospital, University of California, San Francisco, CA, United States of America.
| | - Peter M Mourani
- Department of Pediatrics, Critical Care Medicine, University of Colorado School of Medicine, Children's Hospital Colorado, 13121 E 17(th) Ave, MS 8414, Aurora, CO 80045, United States of America.
| | - R Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine and Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, 4800 Sand Point Way NE, Seattle, WA 98105, United States of America.
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Gadhvi KR, Valla FV, Tume LN. Review of Outcomes Used in Nutrition Trials in Pediatric Critical Care. JPEN J Parenter Enteral Nutr 2020; 44:1210-1219. [PMID: 32010996 DOI: 10.1002/jpen.1765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 12/04/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Generating robust evidence within pediatric intensive care (PIC) can be challenging because of low patient numbers and patient heterogeneity. Systematic reviews may overcome small study biases but are limited by lack of standardization in outcome measures and their definition. Trials of nutrition interventions in PIC are increasing; thus, we wanted to examine the outcome measures being used in these trials. OBJECTIVE Our objective was to systematically describe outcome measures used when a nutrition intervention has been evaluated in a PIC randomized controlled trial. METHODS A systematic literature review of all studies involving a PIC trial of a nutrition intervention was undertaken from January 1, 1996, until February 20, 2018. RESULTS Twenty-nine trials met the criteria and were reviewed. They included a total of 3226 patients across all trials. Thirty-seven primary outcomes and 83 secondary outcomes were found. These were categorized into PIC-related outcomes (infection, intensive care dependency, organ dysfunction, and mortality) and nutrition outcomes (energy targets, nutrition parameters, and feeding tolerance). We found large variation in the outcome measures used. Outcome domains of energy targets, feeding tolerance, and infection were not adequately defined. CONCLUSIONS Considerable variation in the outcome measures chosen and their definitions exist within PIC nutrition trials. Optimal nutrition outcomes for PIC must be agreed upon and defined, specifically domains of nutrition efficiency, nutrition tolerance, and non-nutrition PIC outcomes. The next step is to conduct an international Delphi study to gain expert consensus and develop a core outcome set to be reported in future pediatric nutrition trials.
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Affiliation(s)
- Kunal R Gadhvi
- Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, The University of the West of England, Stapleton, Bristol, UK
| | - Frédéric V Valla
- Faculty of Health and Applied Sciences, The University of the West of England, Stapleton, Bristol, UK.,Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, CarMEN INSERM UMR 1060, Lyon-Bron, France
| | - Lyvonne N Tume
- Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, The University of the West of England, Stapleton, Bristol, UK
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Improving Pediatric Extracorporeal Cardiopulmonary Resuscitation Means Delivering Best Care and Measuring Impact Beyond Survival. Crit Care Med 2020; 47:613-615. [PMID: 30882435 DOI: 10.1097/ccm.0000000000003673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gildea MR, Moler FW, Page K, Meert K, Holubkov R, Dean JM, Christensen JR, Slomine BS. Methods Used to Maximize Follow-Up: Lessons Learned From the Therapeutic Hypothermia After Pediatric Cardiac Arrest Trials. Pediatr Crit Care Med 2020; 21:4-11. [PMID: 31464818 PMCID: PMC6942220 DOI: 10.1097/pcc.0000000000002098] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To describe telephone interview completion rates among 12-month cardiac arrest survivors enrolled in the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital and Out-of-Hospital trials, identify key characteristics of the completed follow-up interviews at both 3- and 12-month postcardiac arrest, and describe strategies implemented to promote follow-up. SETTING Centralized telephone follow-up interviews. DESIGN Retrospective report of data collected for Therapeutic Hypothermia after Pediatric Cardiac Arrest trials, and summary of strategies used to maximize follow-up completion. PATIENTS Twelve-month survivors (n = 251) from 39 Therapeutic Hypothermia after Pediatric Cardiac Arrest PICU sites in the United States, Canada, and United Kingdom. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS The 3- and 12-month telephone interviews included completion of the Vineland Adaptive Behavior Scales, Second Edition. Vineland Adaptive Behavior Scales, Second Edition data were available on 96% of 3-month survivors (242/251) and 95% of 12-month survivors (239/251) with no differences in demographics between those with and without completed Vineland Adaptive Behavior Scales, Second Edition. At 12 months, a substantial minority of interviews were completed with caregivers other than parents (10%), after calls attempts were made on 6 or more days (18%), and during evenings/weekends (17%). Strategies included emphasizing the relationship between study teams and participants, ongoing communication between study team members across sites, promoting site engagement during the study's final year, and withholding payment for work associated with the primary outcome until work had been completed. CONCLUSIONS It is feasible to use telephone follow-up interviews to successfully collect detailed neurobehavioral outcome about children following pediatric cardiac arrest. Future studies should consider availability of the telephone interviewer to conduct calls at times convenient for families, using a range of respondents, ongoing engagement with site teams, and site payment related to primary outcome completion.
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Affiliation(s)
| | - Frank W Moler
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Kent Page
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Kathleen Meert
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - James R Christensen
- Department of Pediatric Rehabilitation, Kennedy Krieger Institute, Baltimore, MD
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Beth S Slomine
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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33
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Affiliation(s)
- Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine; Department of Pediatrics; and Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD
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Research Collaboration in Pediatric Critical Care Randomized Controlled Trials: A Social Network Analysis of Coauthorship. Pediatr Crit Care Med 2020; 21:12-20. [PMID: 31577694 DOI: 10.1097/pcc.0000000000002120] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Clinical research is a collaborative enterprise; researchers benefit from the expertise, experience, and resources of their collaborators. We sought to describe the extent and patterns of collaboration among pediatric critical care trialists, and to identify the most influential individuals, centers, and countries. DESIGN Social network analysis of coauthorship. DATA SOURCES Publications of pediatric critical care randomized controlled trials (1986-2018). DATA EXTRACTION We manually extracted the names of all authors and their affiliations. We used productivity (number of randomized controlled trials), influence (number of citations), and four measures of prominence in the social network (degree, betweenness, closeness, and eigenvector centrality) to identify the most influential individuals. MEASUREMENTS AND MAIN RESULTS From 415 randomized controlled trials in pediatric critical care, we identified 2,176 trialists from 377 centers in 43 countries. The coauthorship network is highly disconnected and dominated by a single large cluster of trialists publishing 142 (34%) of the randomized controlled trials. However, 119 (29%) of the randomized controlled trials were published by 28 smaller clusters-a median (interquartile range) of 3 (2-4) randomized controlled trials each. The remaining 154 (37%) randomized controlled trials were coauthored by researchers publishing a single randomized controlled trial each. This overall structure has remained constant with the publication of new randomized controlled trials over 33 years. The most influential trialists and centers varied according to the metric we used; only one trialist and three centers ranked in the top 10 for all measures of influence. Thirty-five of the 40 trialists (88%) ranking in the top 10 of any of the measures were from the United States, the United Kingdom, and Canada. CONCLUSIONS Pediatric critical care has made considerable progress in the number of trialists and randomized controlled trials, but the research enterprise remains highly clustered and fragmented, particularly geographically. Efforts to further increase the quantity and quality of research in the field should include steps to increase the level and range of collaboration.
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Abstract
PURPOSE OF REVIEW Randomized controlled trials leading to innovations that improve outcomes in acute life-threatening illnesses in children are scarce. A key issue is how we refocus research on outcomes that matter and are more relevant to those making emergency decisions, and those involved with managing and living with the late-outcome. We have used information from recent trials in critically ill children - in particular those illnesses without any primary neurologic involvement - to develop an approach to brain-related outcomes that will maximize child and family benefit from research. RECENT FINDINGS Fifteen recent pediatric critical care trials illustrate four types of brain-related outcomes assessment: death or organ-system-failures - as illustrated by studies in systemic illness; neurological and neuropsychological outcomes - as illustrated by the glycemic control studies; cognitive outcomes - as illustrated by a sedative trial; and composite outcomes - as illustrated by the therapeutic hypothermia studies. SUMMARY The 15 research trials point to five areas that will need to be addressed and incorporated into future trial design, including use of: neurologic monitoring during intensive care unit admission; postdischarge outcomes assessments; strategies to improve retention in long-term follow-up; child and family-centered outcomes; and core outcomes datasets.
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Affiliation(s)
- Ericka L. Fink
- Departments of Critical Care Medicine & Pediatrics, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine Pittsburgh, PA, USA
| | - Robert C Tasker
- Departments of Anesthesiology, Critical Care and Pain Medicine & Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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Jensen MM, Marker S, Do HQ, Perner A, Møller MH. Stress ulcer prophylaxis in critically ill children: Protocol for a systematic review. Acta Anaesthesiol Scand 2019; 63:966-972. [PMID: 30907441 DOI: 10.1111/aas.13361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/04/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Stress ulcer prophylaxis is the considered standard of care in many critically ill patients in the intensive care unit (ICU). Whether there is overall benefit or harm of stress ulcer prophylaxis in critically ill children is unknown. Accordingly, we aim to assess patient-important benefits and harms of stress ulcer prophylaxis versus placebo or no treatment in critically ill children in the ICU. METHODS/DESIGN We will conduct a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis and assess the use of proton pump inhibitors (PPIs) or histamine-2-receptor antagonists (H2RAs) versus placebo or no prophylaxis. We will systematically search the Cochrane Library, MEDLINE, EMBASE, Science Citation Index, BIOSIS, and Epistemonikos for relevant literature. We will follow the recommendations by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The risk of systematic errors (bias) and random errors will be assessed, and the overall quality of evidence will be evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION There is a need for an updated systematic review to summarize the benefits and harms of stress ulcer prophylaxis in critically ill children to inform practice and future research.
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Affiliation(s)
- Martine Marker Jensen
- Department of Intensive Care, 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Søren Marker
- Department of Intensive Care, 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Hien Quoc Do
- Department of Intensive Care, 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care, 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
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The Fragility of Statistically Significant Findings in Pediatric Critical Care Randomized Controlled Trials. Pediatr Crit Care Med 2019; 20:e258-e262. [PMID: 31013262 DOI: 10.1097/pcc.0000000000001922] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The Fragility Index measures the number of events on which the statistical significance of a result depends and has been suggested as an adjunct statistical assessment for interpretation of trial results. This study aimed to assess the robustness of statistically significant results from pediatric critical care randomized controlled trials with dichotomous outcomes. DATA SOURCES A previously published scoping review of pediatric critical care randomized controlled trials (www.PICUtrials.net). STUDY SELECTION A total of 342 trials were screened for inclusion. After applying inclusion/exclusion criteria, 43 fulfilled eligibility criteria and were included in the analysis. DATA EXTRACTION Calculation of Fragility Index for trials reporting a statistically significant dichotomous outcome, and analysis of the relationship between trial characteristics and Fragility Index. DATA SYNTHESIS The median Fragility Index was 2 (interquartile range, 1-6). The median sample size was 98 (interquartile range, 50-148) and sample size demonstrated a strong correlation with the Fragility Index (r = 0.729; n = 43; p < 0.001). The median number of outcome events was 8 (interquartile range, 4-15) and the total number of outcome events also showed a strong correlation with the Fragility Index (r = 0.728; n = 43; p < 0.001). CONCLUSIONS Results from pediatric critical care randomized controlled trials with dichotomous outcomes reporting statistically significant findings often hinge on a small number of outcome events. Clinicians should exercise caution when interpreting results of trials with a low Fragility Index.
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Lai NM, Ong JMJ, Chen KH, Chaiyakunapruk N, Ovelman C, Soll R. Are Neonatal Trials Better Conducted and Reported over the Last 6 Decades? An Analysis on Their Risk-of-Bias Status in Cochrane Reviews. Neonatology 2019; 116:123-131. [PMID: 31108494 DOI: 10.1159/000497423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/02/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The introduction of Neonatology as a subspecialty in 1960 has stimulated an enormous amount of neonatal research. A large proportion of neonatal randomized-controlled trials (RCTs) have been included in the Cochrane reviews, within which methodological quality or risk-of-bias (ROB) assessment is an integral feature. OBJECTIVES We described the ROB profile of neonatal RCTs published since the 1950s. METHODS We analyzed individual studies within the Cochrane Neonatal reviews published up to December 2016. We extracted the reviewers' judgments on the ROB domains including random sequence generation, allocation concealment, blinding, incomplete outcome data, and selective reporting. We evaluated blinding of personnel in trials in which blinding was considered feasible. RESULTS We assessed 1980 RCTs published between 1952 and 2016 from 294 Cochrane Neonatal systematic reviews, with full ROB assessments performed in 848 trials (42.8%). Among the ROB domains, the highest proportion of trials (73%) were judged as satisfactory ("low risk") in handling incomplete outcome data, while fewest trials achieved blinding of outcome assessor (38.4%). In the last 6 decades, a progressive increase has been observed in the proportion of trials that were rated as low risk in random sequence generation, allocation concealment, and selective reporting. However, blinding was achieved in less than half of the trials with no clear improvement across decades (23-44% since the 1980s). CONCLUSIONS Despite steady improvement in the overall quality of neonatal RCTs over the last 6 decades, blinding remained unsatisfactory in the majority of the trials.
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Affiliation(s)
- Nai Ming Lai
- School of Medicine, Taylor's University, Selangor, Malaysia, .,Cochrane Malaysia, Selangor, Malaysia,
| | | | - Kee-Hsin Chen
- Post-Baccalaureate Program in Nursing, College of Nursing and Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.,Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Nathorn Chaiyakunapruk
- Asian Centre for Evidence Synthesis, Monash University, Selangor, Malaysia.,Center of Pharmaceutical Outcome Research (CPOR), Phitsanulok, Thailand.,Department of Pharmacy Practice, Naresuan University, Phitsanulok, Thailand
| | | | - Roger Soll
- Cochrane Neonatal, Burlington, Vermont, USA.,Division of Pediatrics-Neonatology, The University of Vermont Medical Center, Burlington, Vermont, USA
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Advancing Randomized Controlled Trials in Pediatric Critical Care: The Perspectives of Trialists. Pediatr Crit Care Med 2018; 19:e595-e602. [PMID: 30074981 DOI: 10.1097/pcc.0000000000001696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Clinical research is a complex scientific and social enterprise. Our objective was to identify strategies that pediatric critical care trialists consider acceptable, feasible, and effective to improve the design and conduct randomized controlled trials in pediatric critical care. DESIGN Qualitative descriptive study using semistructured individual interviews. SUBJECTS We interviewed 26 pediatric critical care researchers from seven countries who have published a randomized controlled trial (2005-2015). We used purposive sampling to achieve diversity regarding researcher characteristics and randomized controlled trial characteristics. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Most participants (24 [92%]) were from high-income countries, eight (31%) had published more than one randomized controlled trial, 17 (65%) had published a multicenter randomized controlled trial, and eight (31%) had published a multinational randomized controlled trial. An important theme was "building communities"-groups of individuals with similar interests, shared experiences, and common values, bound by professional and personal relationships. Participants described a sense of community as a source of motivation and encouragement and as a means to larger, more rigorous trials, increasing researcher and clinician engagement and maintaining enthusiasm. Strategies to build communities stressed in-person interactions (both professional and social), capable leadership, and trust. Another important theme was "getting started." Participants highlighted the importance of formal research training and high-quality experiential learning through collaboration on other's projects, guided by effective mentorship. Also important was "working within the system"-ensuring academic credit for a range of contributions, not only for the principal investigator role. The longitudinal notion of "building on success" was also underscored as a cross-cutting theme. CONCLUSIONS Coordinated, deliberate actions to build community and ensure key training and practical experiences for new investigators may strengthen the research enterprise in pediatric critical care. These strategies, potentially in combination with other novel approaches, may vitalize clinical research in this field.
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Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, Hempel S, Akl EA, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C, Lewin S, Godfrey CM, Macdonald MT, Langlois EV, Soares-Weiser K, Moriarty J, Clifford T, Tunçalp Ö, Straus SE. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med 2018; 169:467-473. [PMID: 30178033 DOI: 10.7326/m18-0850] [Citation(s) in RCA: 12809] [Impact Index Per Article: 2134.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Scoping reviews, a type of knowledge synthesis, follow a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps. Although more scoping reviews are being done, their methodological and reporting quality need improvement. This document presents the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist and explanation. The checklist was developed by a 24-member expert panel and 2 research leads following published guidance from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network. The final checklist contains 20 essential reporting items and 2 optional items. The authors provide a rationale and an example of good reporting for each item. The intent of the PRISMA-ScR is to help readers (including researchers, publishers, commissioners, policymakers, health care providers, guideline developers, and patients or consumers) develop a greater understanding of relevant terminology, core concepts, and key items to report for scoping reviews.
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Affiliation(s)
- Andrea C Tricco
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada (A.C.T., S.E.S.)
| | - Erin Lillie
- St. Michael's Hospital, Toronto, Ontario, Canada (E.L., W.Z.)
| | - Wasifa Zarin
- St. Michael's Hospital, Toronto, Ontario, Canada (E.L., W.Z.)
| | - Kelly K O'Brien
- University of Toronto, Toronto, Ontario, Canada (K.K.O., H.C.)
| | | | | | - David Moher
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.M., C.G.)
| | - Micah D J Peters
- University of South Australia and University of Adelaide, Adelaide, South Australia, Australia (M.D.P.)
| | - Tanya Horsley
- Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, Canada (T.H.)
| | - Laura Weeks
- Canadian Agency for Drugs and Technologies in Health, Ottawa, Ontario, Canada (L.W., T.C.)
| | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon (E.A.A.)
| | - Christine Chang
- Agency for Healthcare Research and Quality, Rockville, Maryland (C.C.)
| | | | | | - Lisa Hartling
- University of Alberta, Edmonton, Alberta, Canada (L.H.)
| | | | | | - Chantelle Garritty
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.M., C.G.)
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway, and South African Medical Research Council, Cape Town, South Africa (S.L.)
| | | | | | | | | | - Jo Moriarty
- King's College London, London, United Kingdom (J.M.)
| | - Tammy Clifford
- Canadian Agency for Drugs and Technologies in Health, Ottawa, Ontario, Canada (L.W., T.C.)
| | - Özge Tunçalp
- World Health Organization, Geneva, Switzerland (E.V.L., Ö.T.)
| | - Sharon E Straus
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada (A.C.T., S.E.S.)
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Gildea MR, Moler FW, Page K, Pemberton VL, Holubkov R, Nadkarni VM, Dean JM, Olson LM. Practice Patterns after the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital Trial: A Survey of Pediatric Critical Care Physicians. J Pediatr Intensive Care 2018; 8:71-77. [PMID: 31093458 DOI: 10.1055/s-0038-1667380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/24/2018] [Indexed: 12/30/2022] Open
Abstract
The Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital (THAPCA-OH) Trial showed therapeutic hypothermia, versus normothermia, did not significantly improve 1-year survival with good neurobehavioral outcome. Our survey of pediatric critical care physicians, designed to assess the use of targeted temperature management (TTM) after publication of the main THAPCA-OH Trial results, found most respondents were aware of trial results, and over 90% agreed THAPCA-OH was well-designed with important clinical outcomes. While most respondents reported TTM usage consistent with THAPCA-OH results in different patient scenarios, 15% did not select TTM for fever management. Since trials prior to THAPCA-OH established that fever is harmful following brain injury, the continued incomplete adoption of TTM warrants further research on challenges and facilitators to the adoption of clinical trial findings.
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Affiliation(s)
- Marianne R Gildea
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Frank W Moler
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Kent Page
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Victoria L Pemberton
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, United States
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Lenora M Olson
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
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Nie X, Guang P, Peng X. Critical components for designing and implementing randomized controlled trials. Pediatr Investig 2018; 2:124-130. [PMID: 32851246 PMCID: PMC7331429 DOI: 10.1002/ped4.12042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 06/12/2018] [Indexed: 01/04/2023] Open
Abstract
Randomized controlled trials (RCTs) are considered the first level of evidence to assess the efficacy of novel interventions/therapies. Proper design and implementation of an RCT can result in convincing causal inferences. RCTs often represent the gold standard for clinical trials when appropriately designed, conducted and reported. However, there are limitations in implementation of RCTs, including sufficiency of randomized allocation (especial for allocation concealment), implementing standard intervention, maintaining follow-up and statement of conflicting interests. Therefore, the basic principles of RCTs are outlined here so that pediatric investigators can further understand what is the best evidence based on RCTs. More importantly, the quality of pediatric RCTs may be improved by following challenges in pediatric clinical trials outlined here.
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Affiliation(s)
- Xiaolu Nie
- Center for Clinical Epidemiology and Evidence‐based MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina100045
| | - Pengya Guang
- Center for Clinical Epidemiology and Evidence‐based MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina100045
| | - Xiaoxia Peng
- Center for Clinical Epidemiology and Evidence‐based MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina100045
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Liu A, Menon K. Contributions of a survey and retrospective cohort study to the planning of a randomised controlled trial of corticosteroids in the treatment of paediatric septic shock. Trials 2018; 19:283. [PMID: 29784051 PMCID: PMC5963179 DOI: 10.1186/s13063-018-2664-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/03/2018] [Indexed: 11/19/2022] Open
Abstract
Background Randomised controlled trials (RCTs) are challenging to conduct in a paediatric critical-care environment. Background work, including surveys and observational studies, is often used to determine disease estimates, sample sizes and design protocols when planning such RCTs. Our objective was to determine the necessity of performing a survey or a retrospective chart review or both when planning an RCT on corticosteroids in the treatment of paediatric septic shock. Methods We compared information on corticosteroid use for moderate to severe paediatric septic shock obtained from a survey of physician beliefs and stated practices with that obtained from a retrospective cohort study. The survey was conducted between February and March 2012 and the retrospective study included children from birth to 17 years of age admitted from January 2010 to June 2011. The survey and the retrospective study were conducted at four academic tertiary care centres in Canada. Results Survey responses from 23 physicians and retrospective data from 81 septic shock patients were included. The survey identified time to discontinuation of vasoactive infusions as the most feasible and clinically important outcome for an RCT on corticosteroids for paediatric septic shock. The retrospective chart review provided means and standard deviations for the suggested primary outcome, from which we could estimate sample sizes and justify the minimal clinically important difference. The survey found that physicians believe that patients with severe septic shock were most likely to benefit from corticosteroid administration but the majority stated they would be unwilling to randomise such patients, suggesting a lack of individual physician equipoise. The combined information from the survey and retrospective study suggested that enrolment of patients with moderate septic shock would be more feasible but that strategies would still have to be implemented to prevent open-label corticosteroid use. Conclusions The survey provided valuable information on the choice of primary outcome, target population and physician equipoise. The retrospective study provided estimates of patient numbers, the minimal clinically important difference, evidence for community equipoise and physician practice patterns. Strong consideration should be given to performing both types of studies prior to conducting RCTs in paediatric critical-care environments.
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Affiliation(s)
- Anna Liu
- University of Ottawa, Ottawa, K1H 8M5, Canada
| | - Kusum Menon
- University of Ottawa, Ottawa, K1H 8M5, Canada. .,Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
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Wulff A, Haarbrandt B, Tute E, Marschollek M, Beerbaum P, Jack T. An interoperable clinical decision-support system for early detection of SIRS in pediatric intensive care using openEHR. Artif Intell Med 2018; 89:10-23. [PMID: 29753616 DOI: 10.1016/j.artmed.2018.04.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 04/26/2018] [Accepted: 04/30/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Clinical decision-support systems (CDSS) are designed to solve knowledge-intensive tasks for supporting decision-making processes. Although many approaches for designing CDSS have been proposed, due to high implementation costs, as well as the lack of interoperability features, current solutions are not well-established across different institutions. Recently, the use of standardized formalisms for knowledge representation as terminologies as well as the integration of semantically enriched clinical information models, as openEHR Archetypes, and their reuse within CDSS are theoretically considered as key factors for reusable CDSS. OBJECTIVE We aim at developing and evaluating an openEHR based approach to achieve interoperability in CDSS by designing and implementing an exemplary system for automated systemic inflammatory response syndrome (SIRS) detection in pediatric intensive care. METHODS We designed an interoperable concept, which enables an easy integration of the CDSS across different institutions, by using openEHR Archetypes, terminology bindings and the Archetype Query Language (AQL). The practicability of the approach was tested by (1) implementing a prototype, which is based on an openEHR based data repository of the Hannover Medical School (HaMSTR), and (2) conducting a first pilot study. RESULTS We successfully designed and implemented a CDSS with interoperable knowledge bases and interfaces by reusing internationally agreed-upon Archetypes, incorporating LOINC terminology and creating AQL queries, which allowed retrieving dynamic facts in a standardized and unambiguous form. The technical capabilities of the system were evaluated by testing the prototype on 16 randomly selected patients with 129 days of stay, and comparing the results with the assessment of clinical experts (leading to a sensitivity of 1.00, a specificity of 0.94 and a Cohen's kappa of 0.92). CONCLUSIONS We found the use of openEHR Archetypes and AQL a feasible approach to bridge the interoperability gap between local infrastructures and CDSS. The designed concept was successfully transferred into a clinically evaluated openEHR based CDSS. To the authors' knowledge, this is the first openEHR based CDSS, which is technically reliable and capable in a real context, and facilitates clinical decision-support for a complex task. Further activities will comprise enrichments of the knowledge base, the reasoning processes and cross-institutional evaluations.
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Affiliation(s)
- Antje Wulff
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany.
| | - Birger Haarbrandt
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany
| | - Erik Tute
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany
| | - Michael Marschollek
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany
| | - Philipp Beerbaum
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Germany
| | - Thomas Jack
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Germany
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Drury NE, Patel AJ, Oswald NK, Chong CR, Stickley J, Barron DJ, Jones TJ. Randomized controlled trials in children's heart surgery in the 21st century: a systematic review. Eur J Cardiothorac Surg 2018; 53:724-731. [PMID: 29186478 PMCID: PMC5848812 DOI: 10.1093/ejcts/ezx388] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 09/27/2017] [Accepted: 10/17/2017] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Randomized controlled trials are the gold standard for evaluating health care interventions, yet are uncommon in children's heart surgery. We conducted a systematic review of clinical trials in paediatric cardiac surgery to evaluate the scope and quality of the current international literature. METHODS We searched MEDLINE, CENTRAL and LILACS, and manually screened retrieved references and systematic reviews to identify all randomized controlled trials reporting the effect of any intervention on the conduct or outcomes of heart surgery in children published in any language since January 2000; secondary publications and those reporting inseparable adult data were excluded. Two reviewers independently screened studies for eligibility and extracted data; the Cochrane Risk of Bias tool was used to assess for potential biases. RESULTS We identified 333 trials from 34 countries randomizing 23 902 children. Most were early phase (313, 94.0%), recruiting few patients (median 45, interquartile range 28-82), and only 11 (3.3%) directly evaluated a surgical intervention. One hundred and nine (32.7%) trials calculated a sample size, 52 (15.6%) reported a CONSORT diagram, 51 (15.3%) were publicly registered and 25 (7.5%) had a Data Monitoring Committee. The overall risk of bias was low in 22 (6.6%), high in 69 (20.7%) and unclear in 242 (72.7%). CONCLUSIONS The recent literature in children's heart surgery contains few late-phase clinical trials. Most trials did not conform to the accepted standards of reporting, and the overall risk of bias was low in few studies. There is a need for high-quality, multicentre clinical trials to provide a robust evidence base for contemporary paediatric cardiac surgical practice.
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Affiliation(s)
- Nigel E Drury
- Department of Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Akshay J Patel
- Department of Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Nicola K Oswald
- Department of Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Cher-Rin Chong
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - John Stickley
- Department of Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - David J Barron
- Department of Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
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Siemens K, Sangaran DP, Hunt BJ, Murdoch IA, Tibby SM. Strategies for Prevention and Management of Bleeding Following Pediatric Cardiac Surgery on Cardiopulmonary Bypass: A Scoping Review. Pediatr Crit Care Med 2018; 19:40-47. [PMID: 29189637 DOI: 10.1097/pcc.0000000000001387] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We aimed to systematically describe, via a scoping review, the literature reporting strategies for prevention and management of mediastinal bleeding post pediatric cardiopulmonary bypass surgery. DATA SOURCES MEDLINE, EMBASE, PubMed, and Cochrane CENTRAL Register. STUDY SELECTION Two authors independently screened publications from 1980 to 2016 reporting the effect of therapeutic interventions on bleeding-related postoperative outcomes, including mediastinal drain loss, transfusion, chest re-exploration rate, and coagulation variables. Inclusions: less than 18 years, cardiac surgery on cardiopulmonary bypass. DATA EXTRACTION Data from eligible studies were extracted using a standard data collection sheet. DATA SYNTHESIS Overall, 299 of 7,434 screened articles were included, with observational studies being almost twice as common (n = 187, 63%) than controlled trials (n = 112, 38%). The most frequently evaluated interventions were antifibrinolytic drugs (75 studies, 25%), blood products (59 studies, 20%), point-of-care testing (47 studies, 16%), and cardiopulmonary bypass circuit modifications (46 studies, 15%). The publication rate for controlled trials remained constant over time (4-6/yr); however, trials were small (median participants, 51; interquartile range, 57) and overwhelmingly single center (98%). Controlled trials originated from 22 countries, with the United States, India, and Germany accounting for 50%. The commonest outcomes were mediastinal blood loss and transfusion requirements; however, these were defined inconsistently (blood loss being reported over nine different time periods). The majority of trials were aimed at bleeding prevention (98%) rather than treatment (10%), nine studies assessed both. CONCLUSIONS Overall, this review demonstrates small trial sizes, low level of evidence, and marked heterogeneity of reported endpoints in the included studies. The need for more, higher quality studies reporting clinically relevant, comparable outcomes is highlighted. Emerging fields such as the use of coagulation factor concentrates, goal-directed guidelines, and anti-inflammatory therapies appear to be of particular interest. This scoping review can potentially guide future trial design and form the basis for therapy-specific systematic reviews.
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Affiliation(s)
- Kristina Siemens
- PICU, Evelina London Children's Hospital, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Dilanee P Sangaran
- PICU, Evelina London Children's Hospital, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Beverley J Hunt
- Department of Haematology, St Thomas' Hospital, London, United Kingdom
| | - Ian A Murdoch
- PICU, Evelina London Children's Hospital, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Shane M Tibby
- PICU, Evelina London Children's Hospital, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
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Midia M, Odedra D, Haider E, Shuster A, Muir J. Choosing Wisely Canada and Diagnostic Imaging: What Level of Evidence Supports the Recommendations? Can Assoc Radiol J 2017; 68:359-367. [DOI: 10.1016/j.carj.2017.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 06/14/2017] [Accepted: 06/15/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- Mehran Midia
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
- Joseph Brant Hospital, Burlington, Ontario, Canada
| | - Devang Odedra
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Ehsan Haider
- St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Anatoly Shuster
- Department of Radiology, Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ontario, Canada
| | - Jeff Muir
- Motion Research, Ancaster, Ontario, Canada
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Duffett M, Choong K, Foster J, Gilfoyle E, Lacroix J, Cook DJ. Need for a Randomized Controlled Trial of Stress Ulcer Prophylaxis in Critically Ill Children: A Canadian Survey. Can J Hosp Pharm 2017; 70:288-293. [PMID: 28894313 DOI: 10.4212/cjhp.v70i4.1679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Stress ulcer prophylaxis is commonly used in pediatric critical care, to prevent upper gastrointestinal bleeding. The most frequently used agents are histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs). The risk-benefit ratio for stress ulcer prophylaxis is uncertain, because data from randomized clinical trials (RCTs) on the effectiveness and harms of prophylaxis in children are limited. OBJECTIVE To describe the views of Canadian pediatric intensivists about a future RCT of stress ulcer prophylaxis. METHODS We conducted an online survey of Canadian pediatric critical care physicians. We e-mailed information about the study and a link to a 10-item survey to 111 potential respondents, with 2 reminders for nonrespondents. We assessed the relationship between respondents' characteristics and their views about the need for and potential participation in a trial using logistic regression and assessed regional differences using the χ2 test. RESULTS The 68 physicians who replied (61% of potential respondents) had a median of 12 (interquartile range 5-20) years of experience. Forty-four (65%) of the respondents stated that a large, rigorous RCT of stress ulcer prophylaxis in children is needed, and 94% (62 of 66) indicated that it should include a placebo group. The 3 most common designs suggested were a 3-arm trial comparing PPI, H2RA, and placebo (56% [37 of 66 respondents to this question]) and 2-arm trials comparing PPI with placebo (15% [n = 10]) and H2RA with placebo (8% [n = 5]). The 5 patient groups that respondents most commonly stated should be excluded (because they should not receive placebo) were children receiving acid suppression at home (66% [42 of 64 respondents to this question]) or corticosteroids (59% [n = 38]), those with severe coagulopathy or receiving extracorporeal membrane oxygenation (both 36% [n = 23]), and those with burns (31% [n = 20]). Most respondents indicated a willingness to participate in an RCT (64% [42 of 66 respondents to this question]), whereas some (29% [n = 19]) indicated that participation would depend on trial design or funding; only 8% (n = 5) were disinclined to participate. CONCLUSIONS There is considerable interest in a placebo-controlled RCT of stress ulcer prophylaxis among pediatric critical care physicians in Canada, but consensus on key elements of the trial design is needed.
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Affiliation(s)
- Mark Duffett
- , PhD, RPh, is with the Department of Pediatrics, McMaster University, Hamilton, Ontario
| | - Karen Choong
- MB, BCh, MSc, is with the Departments of Pediatrics and of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario
| | - Jennifer Foster
- , MD, is with the Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia
| | - Elaine Gilfoyle
- , MD, MMEd, is with the Department of Paediatrics, University of Calgary, Calgary, Alberta
| | - Jacques Lacroix
- , MD, is with the Department of Pediatrics, Université de Montréal, Montréal, Quebec
| | - Deborah J Cook
- , MD, MSc, is with the Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario
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Bartoszko J, Vorobeichik L, Jayarajah M, Karkouti K, Klein AA, Lamy A, Mazer CD, Murphy M, Richards T, Englesakis M, Myles PS, Wijeysundera DN. Defining clinically important perioperative blood loss and transfusion for the Standardised Endpoints for Perioperative Medicine (StEP) collaborative: a protocol for a scoping review. BMJ Open 2017; 7:e016743. [PMID: 28667227 PMCID: PMC5726101 DOI: 10.1136/bmjopen-2017-016743] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION 'Standardised Endpoints for Perioperative Medicine' (StEP) is an international collaboration undertaking development of consensus-based consistent definitions for endpoints in perioperative clinical trials. Inconsistency in endpoint definitions can make interpretation of trial results more difficult, especially if conflicting evidence is present. Furthermore, this inconsistency impedes evidence synthesis and meta-analyses. The goals of StEP are to harmonise definitions for clinically meaningful endpoints and specify standards for endpoint reporting in clinical trials. To help inform this endeavour, we aim to conduct a scoping review to systematically characterise the definitions of clinically important endpoints in the existing published literature on perioperative blood loss and transfusion. METHODS AND ANALYSIS The scoping review will be conducted using the widely adopted framework developed by Arksey and O'Malley, with modifications from Levac. We refined our methods with guidance from research librarians as well as researchers and clinicians with content expertise. The electronic literature search will involve several databases including Medline, PubMed-not-Medline and Embase. Our review has three objectives, namely to (1) identify definitions of significant blood loss and transfusion used in previously published large perioperative randomised trials; (2) identify previously developed consensus-based definitions for significant blood loss and transfusion in perioperative medicine and related fields; and (3) describe the association between different magnitudes of blood loss and transfusion with postoperative outcomes. The multistage review process for each question will involve two reviewers screening abstracts, reading full-text articles and performing data extraction. The abstracted data will be organised and subsequently analysed in an iterative process. ETHICS AND DISSEMINATION This scoping review of the previously published literature does not require research ethics approval. The results will be used to inform a consensus-based process to develop definitions of clinically important perioperative blood loss and transfusion. The results of the scoping review will be published in a peer-reviewed scientific journal.
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Affiliation(s)
| | | | | | - Keyvan Karkouti
- University of Toronto, Toronto, Canada
- Toronto General Hospital, Toronto, Canada
| | | | - Andre Lamy
- Department of Surgery, McMaster University, Hamilton, Canada
| | - C David Mazer
- University of Toronto, Toronto, Canada
- St. Michael’s Hospital, Toronto, Canada
| | - Mike Murphy
- Oxford University Hospitals, University of Oxford, NHS Blood and Transplant, Oxford, UK
| | - Toby Richards
- Division of Surgery & Interventional Surgery, University College London, London, UK
| | - Marina Englesakis
- Department of Library and Information Services, University Health Network, Toronto, Canada
| | - Paul S Myles
- Alfred Hospital, Monash University, Melbourne, Australia
| | - Duminda N Wijeysundera
- University of Toronto, Toronto, Canada
- Toronto General Hospital, Toronto, Canada
- St. Michael’s Hospital, Toronto, Canada
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Abstract
OBJECTIVE To determine the feasibility of conducting a randomized controlled trial of corticosteroids in pediatric septic shock. DESIGN Randomized, double-blind, placebo controlled trial. SETTING Seven tertiary level PICUs in Canada. PATIENTS Children newborn to 17 years old inclusive with suspected septic shock. INTERVENTION Administration of IV hydrocortisone versus placebo until hemodynamic stability is achieved or for a maximum of 7 days. MEASUREMENTS AND MAIN RESULTS One hundred seventy-four patients were potentially eligible of whom 101 patients met eligibility criteria. Fifty-seven patients were randomized, and 49 patients (23 and 26 patients in the hydrocortisone and placebo groups, respectively) were included in the final analysis. The mean time from screening to randomization was 2.4 ± 2.1 hours and from screening to first dose of study drug was 3.8 ± 2.6 hours. Forty-two percent of potentially eligible patients (73/174) received corticosteroids prior to randomization: 38.5% (67/174) were already on corticosteroids for shock at the time of screening, and in 3.4% (6/174), the treating physician wished to administer corticosteroids. Six of 49 randomized patients (12.2%) received open-label steroids, three in each of the hydrocortisone and placebo groups. Time on vasopressors, days on mechanical ventilation, PICU and hospital length of stay, and the rate of adverse events were not statistically different between the two groups. CONCLUSIONS This study suggests that a large randomized controlled trial on early use of corticosteroids in pediatric septic shock is potentially feasible. However, the frequent use of empiric corticosteroids in otherwise eligible patients remains a significant challenge. Knowledge translation activities, targeted recruitment, and alternative study designs are possible strategies to mitigate this challenge.
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