1
|
Spataru A, Eiben P, Pluddemann A. Performance of closed-loop systems for intravenous drug administration: a systematic review and meta-analysis of randomised controlled trials. J Clin Monit Comput 2024; 38:5-18. [PMID: 37695449 DOI: 10.1007/s10877-023-01069-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/13/2023] [Indexed: 09/12/2023]
Abstract
Closed-loop drug delivery systems are autonomous computers able to administer medication in response to changes in physiological parameters (controlled variables). While limited evidence suggested that closed-loop systems can perform better than manual drug administration in certain settings, this technology remains a research tool with an uncertain risk/benefit profile. Our aim was comparing the performance of closed-loop systems with manual intravenous drug administration in adults. We searched MEDLINE, CENTRAL, and Embase from inception until November 2022, without restriction to language. We assessed for inclusion randomised controlled trials comparing closed-loop and manual administration of intravenous drugs in adults, intraoperatively or in the Intensive Care Unit. We identified 32 studies on closed-loop administration of propofol, noradrenaline, phenylephrine, insulin, neuromuscular blockers, and vasodilators. Most studies were at moderate or high risk of bias. The results showed that closed-loop systems reduced the duration of blood pressure outside prespecified targets during noradrenaline (MD 14.9%, 95% CI 9.6-20.2%, I2 = 66.6%) and vasodilators administration (MD 7.4%, 95% CI 5.2-9.7%, I2 = 62.3%). Closed-loop systems also decreased the duration of recovery after propofol (MD 1.3 min, 95% CI 0.4-2.1 min, I2 = 58.6%) and neuromuscular blockers (MD 9.0 min, 95% CI 7.9-10.0 min, I2 = 0%). The certainty of the evidence was low or very low for most outcomes. Automatic technology may be used to improve the hemodynamic profile during noradrenaline and vasodilators administration and reduce the duration of postanaesthetic recovery.Registration: This systematic review was registered with PROSPERO (CRD42022336950) on the 7th of June 2022.
Collapse
Affiliation(s)
- Ana Spataru
- Department of Neurocritical Care, Southampton General Hospital, Hampshire, SO164YO, UK.
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK.
| | - Paola Eiben
- Department of Anaesthesia, St. Bartholomew's Hospital, Barts Health NHS Trust, London, EC1A7BE, UK
| | - Annette Pluddemann
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX26GG, UK
| |
Collapse
|
2
|
McLellan J, Heneghan C, Roberts N, Pluddemann A. Accuracy of self-diagnosis in conditions commonly managed in primary care: diagnostic accuracy systematic review and meta-analysis. BMJ Open 2023; 13:e065748. [PMID: 36627158 PMCID: PMC9835960 DOI: 10.1136/bmjopen-2022-065748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES To assess the diagnostic accuracy of self-diagnosis compared with a clinical diagnosis for common conditions in primary care. DESIGN Systematic review. DATA SOURCES Medline, Embase, Cochrane CENTRAL, Cochrane Database of Systematic Reviews and CINAHL from inception to 25 January 2021. STUDY SELECTION Eligible studies were prospective or retrospective studies comparing the results of self-diagnosis of common conditions in primary care to a relevant clinical diagnosis or laboratory reference standard test performed by a healthcare service provider. Studies that considered self-testing only were excluded. DATA EXTRACTION Two authors independently extracted data using a predefined data extraction form and assessed risk of bias using Quality Assessment of Diagnostic Accuracy Studies-2. METHODS AND RESULTS 5047 records identified 18 studies for inclusion covering the self-diagnosis of three common conditions: vaginal infection (five studies), common skin conditions (four studies) and HIV (nine studies). No studies were found for any other condition. For self-diagnosis of vaginal infection and common skin conditions, meta-analysis was not appropriate and data were reported narratively. Nine studies, using point-of-care oral fluid tests, reported on the accuracy of self-diagnosis of HIV and data were pooled using bivariate meta-analysis methods. For these nine studies, the pooled sensitivity was 92.8% (95% CI, 86% to 96.5%) and specificity was 99.8% (95% CI, 99.1% to 99.9%). Post hoc, the robustness of the pooled findings was tested in a sensitivity analysis only including four studies using laboratory testing as the reference standard. The pooled sensitivity reduced to 87.7% (95% CI, 81.4% to 92.2%) and the specificity remained the same. The quality of all 18 included studies was assessed as mixed and overall study methodology was not always well described. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Overall, there was a paucity of evidence. The current evidence does not support routine self-diagnosis for vaginal infections, common skin conditions and HIV in primary care. PROSPERO REGISTRATION NUMBER CRD42018110288.
Collapse
Affiliation(s)
- Julie McLellan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, Oxfordshire, UK
| | - Annette Pluddemann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| |
Collapse
|
3
|
Pluddemann A, Heneghan C. Short course penicillin for treating patients with pharyngotonsillitis. BMJ Evid Based Med 2021; 26:137-138. [PMID: 32098760 DOI: 10.1136/bmjebm-2019-111314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Annette Pluddemann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
4
|
Pluddemann A. C reactive protein testing to guide antibiotic therapy for COPD exacerbations. BMJ Evid Based Med 2020; 25:182. [PMID: 31744809 DOI: 10.1136/bmjebm-2019-111294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Annette Pluddemann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
5
|
Affiliation(s)
- Annette Pluddemann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
6
|
Affiliation(s)
- Annette Pluddemann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Igho Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
7
|
Abstract
This article is part of the Catalogue of Bias series. We present a description of verification bias, and outline its potential impact on research studies and the preventive steps to minimise its risk. We also present teaching slides in the online supplementary file. Verification bias (sometimes referred to as 'work-up bias') concerns the test(s) used to confirm a diagnosis within a diagnostic accuracy study. Verification bias occurs when only a proportion of the study participants receive confirmation of the diagnosis by the reference standard test, or if some participants receive a different reference standard test.
Collapse
Affiliation(s)
- Jack W O'Sullivan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amitava Banerjee
- Farr Institute of Health Informatics, University College London, London, UK
| | - Carl Heneghan
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annette Pluddemann
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
8
|
Heneghan CJ, Goldacre B, Onakpoya I, Aronson JK, Jefferson T, Pluddemann A, Mahtani KR. Trials of transvaginal mesh devices for pelvic organ prolapse: a systematic database review of the US FDA approval process. BMJ Open 2017; 7:e017125. [PMID: 29212782 PMCID: PMC5728256 DOI: 10.1136/bmjopen-2017-017125] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 10/06/2017] [Accepted: 11/24/2017] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Transvaginal mesh devices are approved in the USA by the Food and Drug Administration (FDA), through the 510(k) system. However, there is uncertainty about the benefit to harm balance of mesh approved for pelvic organ prolapse. We, therefore, assessed the evidence at the time of approval for transvaginal mesh products and the impact of safety studies the FDA mandated in 2012 because of emerging harms. METHODS We used FDA databases to determine the evidence for approval of transvaginal mesh. To create a 'family tree' of device equivalence, we used the 510(k) regulatory approval of the 1985 Mersilene Mesh (Ethicon) and the 1996 ProteGen Sling (Boston Scientific), searched for all subsequently related device approvals, and for the first published randomised trial evidence. We assessed compliance with all FDA 522 orders issued in 2012 requiring postmarketing surveillance studies. RESULTS We found 61 devices whose approval ultimately relied on claimed equivalence to the Mersilene Mesh and the ProteGen Sling. We found no clinical trials evidence for these 61 devices at the time of approval. Publication of randomised clinical trials occurred at a median of 5 years after device approval (range 1-14 years). Analysis of 119 FDA 522 orders revealed that in 79 (66%) the manufacturer ceased market distribution of the device, and in 26 (22%) the manufacturer had changed the indication. Only seven studies (six cohorts and new randomised controlled trial) covering 11 orders were recruiting participants (none had reported outcomes). CONCLUSIONS Transvaginal mesh products for pelvic organ prolapse have been approved on the basis of weak evidence over the last 20 years. Devices have inherited approval status from a few products. A publicly accessible registry of licensed invasive devices, with details of marketing status and linked evidence, should be created and maintained at the time of approval.
Collapse
Affiliation(s)
- Carl J Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Ben Goldacre
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Igho Onakpoya
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Tom Jefferson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
- Cochrane Vaccines Field, Anguillara Sabazia (Roma), Italy
| | - Annette Pluddemann
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Kamal R Mahtani
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| |
Collapse
|
9
|
Abstract
In this article we signpost readers to 10 papers we consider essential reading for anyone starting out on an evidence-based medicine journey. We have considered papers consisting a mix of old and new, seminal and cutting-edge that offer insight into what evidence-based medicine is, where it came from, why it matters and what it has achieved. This is balanced against some of the common criticisms of evidence-based medicine and efforts to tackle them. We have also highlighted papers acknowledging the importance of teaching and learning of the principles of evidence-based medicine and how health professionals can better use evidence in clinical decisions with patients.
Collapse
Affiliation(s)
- David Nunan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Jack O'Sullivan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Annette Pluddemann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Jeffrey Aronson
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Kamal Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
10
|
Coombs C, Onakpoya I, Mahtani K, Aronson J, O'Sullivan J, Pluddemann A, Heneghan C. What evidence affects clinical practice? An analysis of Evidence-Based Medicine commentaries. Evid Based Med 2017; 22:197. [PMID: 29150553 DOI: 10.1136/ebmed-2017-110856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 06/07/2023]
Affiliation(s)
| | - Igho Onakpoya
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Kamal Mahtani
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Jeffrey Aronson
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Jack O'Sullivan
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Annette Pluddemann
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
11
|
Abstract
Scavenger receptors (SRs) are structurally diverse but functionally related innate immune receptors involved in defence and clearance mechanisms. Their broad specificity relies on evolutionarily conserved pattern recognition domains which interact with a variety of microbial, apoptotic and modified self ligands. Studies of immune functions of SR-expressing cells require the identification of interaction partners for SRs. We have developed an ELISA-based method which allows for large-scale high-throughput screening of complex mixtures. The assay successfully identified bacterial and plasma ligands for macrophage scavenger receptor A and can be adapted to screen for novel exogenous or endogenous ligands for any immune receptor of interest.
Collapse
Affiliation(s)
- Claudine Neyen
- Department of Biochemistry, Sir William Dunn School of Pathology, University of Oxford, Oxford, UK
| | | | | |
Collapse
|