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Takaoka A, Heels-Ansdell D, Cook DJ, Kho ME. The Association between Frailty and Short-Term Outcomes in an Intensive Care Unit Rehabilitation Trial: An Exploratory Analysis. J Frailty Aging 2021; 10:49-55. [PMID: 33331622 DOI: 10.14283/jfa.2020.52] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Physical therapy initiated early in an ICU stay may reduce functional deficits in critically ill patients; however, the association of frailty with outcomes in those receiving early in-ICU rehabilitation is unknown. OBJECTIVE To estimate the association between frailty and 3 outcomes in patients enrolled in an ICU randomized clinical trial (RCT). DESIGN Exploratory secondary analyses of the CYCLE pilot RCT (NCT02377830). SETTING 7 Canadian ICUs. PARTICIPANTS Previously ambulatory critically ill adults. INTERVENTION Participants were randomized to early in-bed cycling plus routine physiotherapy versus early routine physiotherapy alone. MEASUREMENTS Using regression analyses, we modelled the association between pre-hospital Clinical Frailty Scale (CFS) scores, Physical Function in ICU Test-scored (PFIT-s), muscle strength, and mortality at hospital discharge, adjusting for illness severity (APACHE II) and the randomized intervention. We explored the influence of imputing mean PFIT-s and strength scores for decedents, and with listwise deletion of decedents in a sensitivity analysis. RESULTS Of 66 patients, 2 had missing data, 2 had incomplete data, and 21 died by hospital discharge. At hospital discharge for 66 patients, frailty was not associated with PFIT-s (mean difference (MD) [95% CI]=0.20, [-2.08, 2.74]) or muscle strength (1.96, [-12.6, 16.6]). A sensitivity analysis yielded consistent results. Frailty was also not associated with hospital mortality (odds ratio 0.91, [0.28 to 2.93]). CONCLUSION We found no association between pre-hospital frailty, physical function, strength, or mortality at hospital discharge in critically ill patients enrolled in an early rehabilitation trial. Larger sample sizes are needed to further explore the association of frailty with these outcomes at hospital discharge.
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Affiliation(s)
- A Takaoka
- Michelle E. Kho, PhD, PT, School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, Physiotherapy Department, St. Joseph's Healthcare Hamilton, Institute of Applied Health Sciences, 1400 Main St. W. Hamilton, ON L8S 1C7, , Telephone: (905) 525-9140 x28221, Fax Number: (905) 524-0069
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2
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Borges F, Duceppe E, Heels-Ansdell D, Ofori S, Marcucci M, Kavsak P, Pettit S, Spence J, Belley-Cote E, Lemanach Y, McGillion M, Whitlock R, Lamy A, Devereaux P. High-sensitivity troponin I predicts major cardiovascular events after noncardiac surgery. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Myocardial injury after noncardiac surgery (MINS) is common and is associated with postoperative major cardiac events and 30-day mortality. We have previously established the diagnostic criteria for MINS with the 4th-generation cardiac troponin T assay (TnT) and 5th-generation high-sensitivity TnT assay (hsTnT) based on prognostically relevant thresholds. Little is known about diagnostic criteria for MINS using the high-sensitivity troponin I (hsTnI) assay.
Purpose
To determine hsTnI thresholds associated with 30-day major cardiac events and death after noncardiac surgery.
Methods
We performed a nested prospective biobank cohort study of 4545 patients from the VISION Study. Patients were aged ≥45 years and underwent in-patient noncardiac surgery under regional or general anesthesia. Patients had samples collected and frozen preoperatively, and on postoperative days 1, 2 and 3. We measured hsTnI on thawed preoperative and postoperative samples. We used iterative Cox proportional hazard models to determine peak postoperative hsTnI thresholds independently associated with major cardiac events (i.e., composite of death, non-fatal cardiac arrest, congestive heart failure within 30 days and non-fatal myocardial infarction from postoperative days 4–30).
Results
Major cardiac events occurred in 89/4545 (2.0%) patients. Peak hsTnI values of <75 ng/L, 75 ng/L to <1000 ng/L, and ≥1000 ng/L were associated with an incidence of major cardiac events of 1.2% (95% CI 0.9–1.6), 7.1% (95% CI 4.8–10.5) and 25.9% (95% CI 16.3–38.4), respectively. Compared to peak hsTnI <75 ng/L (reference), hsTnI values 75 ng/L to <1000 ng/L and ≥1000 ng/L were associated with adjusted hazard ratios (aHR) of 4.53 (95% CI 2.75–7.48) and 16.17 (95% CI 8.70–30.07), respectively. No change from preoperative hsTnI to peak postoperative hsTnI significantly improved the model when included on top of the identified thresholds. Incidence of major cardiac events was 31/343 (9%) in patients with postoperative peak hsTnI ≥75 ng/L versus 52/4178 (1%) in patients with postoperative peak hsTnI <75 ng/L (aHR 5.76; 95% CI 3.64–9.11). A postoperative peak hsTnI ≥75 ng/L was associated with increased risk of major cardiac events either in the presence (aHR 9.35; 95% CI 5.28–16.55) or absence (aHR 3.99; 95% CI 2.19–7.25) of clinical features of myocardial injury (e.g., chest pain, ischemic electrocardiography changes).
Conclusion
A hsTnI elevation within the first 3 days after noncardiac surgery independently predicts major cardiac events at 30 days. A peak postoperative hsTnI ≥75 ng/L was associated with a 6-fold increase in the risk of subsequent major cardiac events at 30 days as compared to peak postoperative hsTnI<75 ng/L. This hsTnI threshold can be used to diagnose MINS.
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Siemens Healthcare Diagnostics Inc. Canadian Institutes of Health Research
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Affiliation(s)
| | - E Duceppe
- University of Montreal, Montreal, Canada
| | | | - S.N Ofori
- McMaster University, Hamilton, Canada
| | | | | | - S Pettit
- McMaster University, Hamilton, Canada
| | - J Spence
- McMaster University, Hamilton, Canada
| | | | | | | | | | - A Lamy
- McMaster University, Hamilton, Canada
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Simunovic N, Heels-Ansdell D, Thabane L, Ayeni OR. Femoroacetabular Impingement Randomised controlled Trial (FIRST) - a multi-centre randomized controlled trial comparing arthroscopic lavage and arthroscopic osteochondroplasty on patient important outcomes and quality of life in the treatment of young adult (18-50 years) femoroacetabular impingement: a statistical analysis plan. Trials 2018; 19:588. [PMID: 30373659 PMCID: PMC6206648 DOI: 10.1186/s13063-018-2965-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/04/2018] [Indexed: 11/29/2022] Open
Abstract
Background The research objectives of the Femoroacetabular Impingement Randomised controlled Trial (FIRST) are to assess whether surgical correction of the hip impingement morphology (arthroscopic osteochondroplasty) with or without labral repair, in adults aged 18–50 years diagnosed with non-arthritic femoroacetabular impingement (FAI), provides decreased pain and improved health-related quality of life at 12 months compared to arthroscopic lavage of the hip joint. This article describes the statistical analysis plan for the FIRST trial. Methods/design FIRST is an ongoing multi-centre, blinded randomised controlled trial of 220 patients who have been diagnosed with FAI and are optimized for surgical intervention. This article describes the overall analysis principles, including how participants will be included in each analysis, the presentation of the results, adjustments for covariates, the primary and secondary outcomes and their respective analyses. In addition, we will present the planned sensitivity and subgroup analyses. Discussion Our rationale for FIRST is based upon (1) an epidemic of FAI surgery with resultant increased healthcare costs over that last decade, (2) worldwide disparity in perceptions about its utility, and (3) consensus that definitive evidence for or against surgical approaches is lacking. Trial registration ClinicalTrials.gov, NCT01623843. Registered on 20 June 2012.
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Affiliation(s)
- Nicole Simunovic
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, 1200 Main St W, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - D Heels-Ansdell
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1200 Main St W, 2C, Hamilton, ON, L8S 4K1, Canada
| | - L Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1200 Main St W, 2C, Hamilton, ON, L8S 4K1, Canada.,Biostatistics/FORSC, 3rd Floor, H325, St. Joseph's Healthcare, 50 Charlton Ave. E, Hamilton, ON, L8N 4A6, Canada
| | - O R Ayeni
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, 1200 Main St W, 4E15, Hamilton, ON, L8N 3Z5, Canada.
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Sprague S, Bhandari M, Heetveld MJ, Liew S, Scott T, Bzovsky S, Heels-Ansdell D, Zhou Q, Swiontkowski M, Schemitsch EH. Factors associated with health-related quality of life, hip function, and health utility after operative management of femoral neck fractures. Bone Joint J 2018; 100-B:361-369. [PMID: 29589490 DOI: 10.1302/0301-620x.100b3.bjj-2017-0853.r1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The primary aim of this prognostic study was to identify baseline factors associated with physical health-related quality of life (HRQL) in patients after a femoral neck fracture. The secondary aims were to identify baseline factors associated with mental HRQL, hip function, and health utility. Patients and Methods Patients who were enrolled in the Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH) trial completed the 12-item Short Form Health Survey (SF-12), Western Ontario and McMaster Universities Arthritis Index, and EuroQol 5-Dimension at regular intervals for 24 months. We conducted multilevel mixed models to identify factors potentially associated with HRQL. Results The following were associated with lower physical HRQL: older age (-1.42 for every ten-year increase, 95% confidence interval (CI) -2.17 to -0.67, p < 0.001); female gender (-1.52, 95% CI -3.00 to -0.05, p = 0.04); higher body mass index (-0.69 for every five-point increase, 95% CI -1.36 to -0.02, p = 0.04); American Society of Anesthesiologists class III ( versus class I) (-3.19, 95% CI -5.73 to -0.66, p = 0.01); and sustaining a displaced fracture (-2.18, 95% CI -3.88 to -0.49, p = 0.01). Additional factors were associated with mental HRQL, hip function, and health utility. Conclusion We identified several baseline factors associated with lower HRQL, hip function, and utility after a femoral neck fracture. These findings may be used by clinicians to inform treatment and outcomes. Cite this article: Bone Joint J 2018;100-B:361-9.
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Affiliation(s)
- S Sprague
- Division of Orthopaedic Surgery, Department of Surgery and Department of Health Research Methods, Evidence, and Impact, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
| | - M Bhandari
- Division of Orthopaedic Surgery, Department of Surgery and Department of Health Research Methods, Evidence, and Impact, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
| | - M J Heetveld
- Department of Surgery, Spaarne Gasthuis, 999 Vondelweg, Haarlem 2026 BW, The Netherlands
| | - S Liew
- Department of Surgery, Monash University, Level 5, Block E, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - T Scott
- Department of Health Research Methods, Evidence and Impact, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
| | - S Bzovsky
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University
| | - D Heels-Ansdell
- Department of Health Research Methods, Evidence and Impact, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
| | - Q Zhou
- Department of Health Research Methods, Evidence and Impact, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
| | - M Swiontkowski
- Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, Minnesota 55454, USA
| | - E H Schemitsch
- Department of Surgery, University of Western Ontario, 268 Grosvenor Street, Room E3-117, London, Ontario N6A 4V2, Canada
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Sprague S, Petrisor B, Jeray K, McKay P, Heels-Ansdell D, Schemitsch E, Liew S, Guyatt G, Walter SD, Bhandari M. Wound irrigation does not affect health-related quality of life after open fractures: results of a randomized controlled trial. Bone Joint J 2018; 100-B:88-94. [PMID: 29305456 PMCID: PMC6413805 DOI: 10.1302/0301-620x.100b1.bjj-2017-0955.r1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The Fluid Lavage in Open Fracture Wounds (FLOW) trial was a multicentre, blinded, randomized controlled trial that used a 2 × 3 factorial design to evaluate the effect of irrigation solution (soap versus normal saline) and irrigation pressure (very low versus low versus high) on health-related quality of life (HRQL) in patients with open fractures. In this study, we used this dataset to ascertain whether these factors affect whether HRQL returns to pre-injury levels at 12-months post-injury. PATIENTS AND METHODS Participants completed the Short Form-12 (SF-12) and the EuroQol-5 Dimensions (EQ-5D) at baseline (pre-injury recall), at two and six weeks, and at three, six, nine and 12-months post-fracture. We calculated the Physical Component Score (PCS) and the Mental Component Score (MCS) of the SF-12 and the EQ-5D utility score, conducted an analysis using a multi-level generalized linear model, and compared differences between the baseline and 12-month scores. RESULTS We found no clinically important differences between irrigating solutions or pressures for the SF-12 PCS, SF-12 MCS and EQ-5D. Irrespective of treatment, participants had not returned to their pre-injury function at 12-months for any of the three outcomes (p < 0.001). CONCLUSION Neither the composition of the irrigation solution nor irrigation pressure applied had an effect on HRQL. Irrespective of treatment, patients had not returned to their pre-injury HRQL at 12 months post-fracture. Cite this article: Bone Joint J 2018;100-B:88-94.
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Affiliation(s)
- S Sprague
- McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
| | - B Petrisor
- McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
| | - K Jeray
- Greenville Health System, 2nd Floor Support Tower, 701 Grove Road, Greenville, South Carolina 29605, USA
| | - P McKay
- McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
| | - D Heels-Ansdell
- McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
| | - E Schemitsch
- University of Western Ontario, 268 Grosvenor Street, Room E3-117, London, Ontario N6A 4V2, Canada
| | - S Liew
- Monash University, Level 5, Block E, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - G Guyatt
- McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
| | - S D Walter
- McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
| | - M Bhandari
- McMaster University, 293 Wellington Street North, Suite 110, Hamilton, Ontario L8L 8E7, Canada
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Mrkobrada M, Hill M, Chan M, Sigamani A, Cowan D, Kurz A, Sessler D, Jacka M, Graham M, Dasgupta M, Dunlop V, Emery D, Gulka I, Guyatt G, Heels-Ansdell D, Murkin J, Pettit S, Sahlas D, Sharma M, Sharma M, Srinathan S, St John P, Tsai S, Gelb A, O’Donnell M, Siu D, Chiu P, Sharath V, George A, Devereaux P. Covert stroke after non-cardiac surgery: a prospective cohort study. Br J Anaesth 2016; 117:191-7. [DOI: 10.1093/bja/aew179] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2016] [Indexed: 11/13/2022] Open
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7
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Centofanti J, Swinton M, Dionne J, Barefah A, Boyle A, Woods A, Shears M, Heels-Ansdell D, Cook D. Resident reflections on end-of-life education: a mixed-methods study of the 3 Wishes Project. BMJ Open 2016; 6:e010626. [PMID: 27033962 PMCID: PMC4823392 DOI: 10.1136/bmjopen-2015-010626] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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: 12/01/2015] [Revised: 02/22/2016] [Accepted: 03/09/2016] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The objectives of this study were to describe residents' experiences with end-of-life (EOL) education during a rotation in the intensive care unit (ICU), and to understand the possible influence of the 3 Wishes Project. DESIGN We enrolled dying patients, their families and 1-3 of their clinicians in the 3 Wishes Project, eliciting and honouring a set of 3 wishes to bring peace to the final days of a critically ill patient's life, and ease the grieving process for families. We conducted semistructured interviews with 33 residents who had cared for 50 dying patients to understand their experiences with the project. Interviews were recorded, transcribed verbatim, then analysed using a qualitative descriptive approach. SETTING 21-bed medical surgical ICU in a tertiary care, university-affiliated hospital. RESULTS 33 residents participated from internal medicine (24, 72.7%), anaesthesia (8, 24.2%) and laboratory medicine (1, 3.0%) programmes in postgraduate years 1-3. 3 categories and associated themes emerged. (1) EOL care is a challenging component of training in that (a) death in the ICU can invoke helplessness, (b) EOL education is inadequate, (c) personal connections with dying patients is difficult in the ICU and (d) EOL skills are valued by residents. (2) The project reframes the dying process for residents by (a) humanising this aspect of practice, (b) identifying that family engagement is central to the dying process, (c) increasing emotional responsiveness and (d) showing that care shifts, not stops. (3) The project offers experiential education by (a) intentional role modelling, (b) facilitating EOL dialogue, (c) empowering residents to care in a tangible way and (d) encouraging reflection. CONCLUSIONS For residents, the 3 Wishes Project integrated many forms of active learning for residents. Practice-based rather than classroom-based programmes may engage trainees to develop EOL skills transferable to other settings.
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Affiliation(s)
- J Centofanti
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - M Swinton
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - J Dionne
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - A Barefah
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - A Boyle
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine and Critical Care, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - A Woods
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine and Critical Care, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - M Shears
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - D Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - D Cook
- Department of Critical Care, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine and Critical Care, St. Joseph's Healthcare, Hamilton, Ontario, Canada
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Sallinen V, Akl EA, You JJ, Agarwal A, Shoucair S, Vandvik PO, Agoritsas T, Heels-Ansdell D, Guyatt GH, Tikkinen KAO. Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis. Br J Surg 2016; 103:656-667. [PMID: 26990957 PMCID: PMC5069642 DOI: 10.1002/bjs.10147] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 12/22/2015] [Accepted: 02/08/2016] [Indexed: 12/12/2022]
Abstract
Background For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non‐perforated appendicitis. Methods A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non‐perforated appendicitis. Key outcomes were analysed using random‐effects meta‐analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference −2·6 (95 per cent c.i. –6·3 to 1·1) per cent (low‐quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference −7·2 (−18·1 to 3·8) per cent (very low‐quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high‐quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high‐quality evidence). For every 100 patients with non‐perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year. Conclusion The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value‐ and preference‐dependent, suggesting a change in practice towards shared decision‐making is necessary. Limitations of each evolving
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Affiliation(s)
- V Sallinen
- Departments of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Departments of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - E A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.,Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - J J You
- Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.,Departments of Medicine, McMaster University, Hamilton, Canada
| | - A Agarwal
- Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.,Departments of Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - S Shoucair
- University of Balamand, Tripoli, Lebanon
| | - P O Vandvik
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - T Agoritsas
- Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.,Division of General Internal Medicine, Department of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - D Heels-Ansdell
- Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - G H Guyatt
- Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.,Departments of Medicine, McMaster University, Hamilton, Canada
| | - K A O Tikkinen
- Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Ebrahim S, Akl E, Mustafa R, Sun X, Walter S, Heels-Ansdell D, Alonso-Coello P, Johnston B, Guyatt G. 056 Addressing Continuous Data For Participants Excluded From Trial Analysis: A Guide. BMJ Qual Saf 2013. [DOI: 10.1136/bmjqs-2013-002293.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Santesso N, Akl EA, Bianchi M, Mente A, Mustafa R, Heels-Ansdell D, Schünemann HJ. Effects of higher- versus lower-protein diets on health outcomes: a systematic review and meta-analysis. Eur J Clin Nutr 2012; 66:780-8. [PMID: 22510792 PMCID: PMC3392894 DOI: 10.1038/ejcn.2012.37] [Citation(s) in RCA: 172] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES Numerous randomised controlled trials (RCTs) published in first tier medical journals have evaluated the health effects of diets high in protein. We conducted a rigorous systematic review of RCTs comparing higher- and lower-protein diets. METHODS We searched several electronic databases up to July 2011 for studies focusing on patient-important outcomes (for example, cardiovascular disease) and secondary outcomes such as risk factors for chronic disease (for example, adiposity). RESULTS We identified 111 articles reporting on 74 trials. Pooled effect sizes using standardised mean differences (SMDs) were small to moderate and favoured higher-protein diets for weight loss (SMD -0.36, 95% confidence interval (CI) -0.56 to -0.17), body mass index (-0.37, CI -0.56 to 0.19), waist circumference (-0.43, CI -0.69 to -0.16), blood pressure (systolic: -0.21, CI -0.32 to -0.09 and diastolic: -0.18, CI -0.29 to -0.06), high-density lipoproteins (HDL 0.25, CI 0.07 to 0.44), fasting insulin (-0.20, CI -0.39 to -0.01) and triglycerides (-0.51, CI -0.78 to -0.24). Sensitivity analysis of studies with lower risk of bias abolished the effect on HDL and fasting insulin, and reduced the effect on triglycerides. We observed nonsignificant effects on total cholesterol, low-density lipoproteins, C-reactive protein, HbA1c, fasting blood glucose, and surrogates for bone and kidney health. Adverse gastrointestinal events were more common with high-protein diets. Multivariable meta-regression analysis showed no significant dose response with higher protein intake. CONCLUSIONS Higher-protein diets probably improve adiposity, blood pressure and triglyceride levels, but these effects are small and need to be weighed against the potential for harms.
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Affiliation(s)
- N Santesso
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Lauzier F, Arnold D, Rabbat C, Heels-Ansdell D, Dodek P, Ashley B, Albert M, Khwaja K, Ostermann M, Skrobik Y, Fowler R, McIntyre L, Nates J, Karachi T, Lopes R, Zytaruk N, Crowther M, Cook D. In medical-surgical ICU patients, major bleeding is common but independent of heparin prophylaxis. Crit Care 2012. [PMCID: PMC3363853 DOI: 10.1186/cc11042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Ostermann M, McIntyre L, Lauzier F, Alhashemi J, Qushmaq I, Langevin S, Dodek P, Albert M, Khwaja K, Kutsiogiannis J, Burry L, Granton J, Friedrich J, Ferguson N, Marshall J, Finfer S, Heels-Ansdell D, Zytaruk N, Cook D, Sheppard J, Warkentin T, Crowther M. Consequences of suspected heparin-induced thrombocytopenia in the ICU. Crit Care 2012. [PMCID: PMC3363841 DOI: 10.1186/cc11030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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13
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Kavsak P, Worster A, Devereaux P, Heels-Ansdell D, Guyatt G, Opie J, Mookadam F, Hill S. A clinically sensitive cardiac troponin I assay (AccuTnI) versus the high sensitive cardiac troponin T assay to predict early serious cardiac outcomes in patients with potential acute coronary syndrome. Clin Biochem 2011. [DOI: 10.1016/j.clinbiochem.2011.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zytaruk N, Heels-Ansdell D, Vallance S, Marshall J, Skrobik Y, Cooper DJ, Finfer S, Seppelt I, Ostermann M, Qushmaq I, Alsultan M, Arabi Y, Alhashemi J, Al-Hazmi M, Alzem A, Shaikh N, Mandourah Y, Cook DJ. Antiembolic stockings and pneumatic compression devices in a medical-surgical thromboprophylaxis trial. Crit Care 2011. [PMCID: PMC3061651 DOI: 10.1186/cc9441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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15
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Zytaruk N, Lamontagne F, McIntyre L, Dodek P, Vlahakis N, Lewis B, Schiff D, Moody A, Ostermann M, Padayachee S, Heels-Ansdell D, Vallance S, Davies A, Cooper JD, Cook DJ. Upper extremity thromboses in medical-surgical critically ill patients. Crit Care 2011. [PMCID: PMC3061652 DOI: 10.1186/cc9442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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16
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Heels-Ansdell D, Zytaruk N, Meade M, Mehta S, Hall R, Zarychanski R, Rocha M, Lim W, Lamontagne F, McIntyre L, Dodek P, Vallance S, Davies A, Cooper DJ, Cook DJ. Pulmonary embolism in medical-surgical ICU patients. Crit Care 2011. [PMCID: PMC3061649 DOI: 10.1186/cc9439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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17
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Douketis J, Cook D, Zytaruk N, Heels-Ansdell D, Anderson D, Geerts W, Meade M, Guyatt G, Crowther M. DALTEPARIN THROMBOPROPHYLAXIS IN CRITICALLY ILL PATIENTS WITH SEVERE RENAL INSUFFICIENCY: THE DIRECT STUDY. J Thromb Haemost 2007. [DOI: 10.1111/j.1538-7836.2007.tb00774.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, Mills E, Heels-Ansdell D, Johanson JF, Guyatt G. Meta-analysis of flavonoids for the treatment of haemorrhoids. Br J Surg 2006; 93:909-20. [PMID: 16736537 DOI: 10.1002/bjs.5378] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Abstract
Background
The aim of the study was to evaluate the impact of flavonoids on those symptoms important to patients with symptomatic haemorrhoids.
Methods
A comprehensive search strategy was used. All published and unpublished randomized controlled trials comparing any type of flavonoid to placebo or no therapy in patients with symptomatic haemorrhoids were included. Two reviewers independently screened studies for inclusion, retrieved all potentially relevant studies and extracted data.
Results
Fourteen eligible trials randomized 1514 patients. Studies were of moderate quality and showed variability in the results with potential publication bias. Meta-analyses using random-effects models suggested that flavonoids decrease the risk of not improving or persisting symptoms by 58 per cent (relative risk (RR) 0·42 (95 per cent confidence interval (c.i.) 0·28 to 0·61)) and showed an apparent reduction in the risk of bleeding (RR 0·33 (95 per cent c.i. 0·19 to 0·57)), persistent pain (RR 0·35 (95 per cent c.i. 0·18 to 0·69)), itching (RR 0·65 (95 per cent c.i. 0·44 to 0·97)) and recurrence (RR 0·53 (95 per cent c.i. 0·41 to 0·69)).
Conclusion
Limitations in methodological quality, heterogeneity and potential publication bias raise questions about the apparent beneficial effects of flavonoids in the treatment of haemorrhoids.
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Affiliation(s)
- P Alonso-Coello
- Iberoamerican Cochrane Centre, Clinical Epidemiology and Public Health Department, Hospital Sant Pau, Barcelona, Spain.
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Puhan MA, Guyatt GH, Armstrong D, Wiklund I, Fallone CA, Heels-Ansdell D, Degl'Innocenti A, Veldhuyzen van Zanten SJO, Tanser L, Barkun AN, Chiba N, Austin P, El-Dika S, Schünemann HJ. Validation of a symptom diary for patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2006; 23:531-41. [PMID: 16441474 DOI: 10.1111/j.1365-2036.2006.02775.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Symptom diaries are potentially attractive but, because of concerns about patient compliance, they have had limited use in clinical trials. We assessed the validity and responsiveness of a symptom diary for patients with gastro-oesophageal reflux disease. METHODS We included 215 patients with gastro-oesophageal reflux disease after starting treatment for 4 weeks with 40 mg esomeprazole once daily. Patients recorded whether they experienced night-time heartburn (yes/no), the severity of daytime heartburn on a scale from 1 (no heartburn) to 4 (severe heartburn) and their antacid use. Patients also completed a number of disease-specific and preference-based Health-related Quality of Life questionnaires at baseline and follow-up. RESULTS Consistent with a priori predictions, daytime heartburn showed moderate to strong correlations with the Quality of Life in Reflux and Dyspepsia questionnaire (0.36-0.67) and four scales of symptom severity (0.36-0.70) for baseline, follow-up and change scores, but low correlations with the Standard Gamble. Responsiveness of the daytime heartburn item was excellent with a mean change from baseline to follow-up of -1.3 (95% CI -1.4 to -1.1) and a standardized response mean of 1.33 while responsiveness of the daily antacid use item was moderate (mean change scores -1.8 tablets taken, 95% CI -2.3 to -1.3 and standardized response mean of 0.64). CONCLUSIONS The excellent psychometric properties of this simple gastro-oesophageal reflux disease diary make it an attractive measure for future trials.
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Affiliation(s)
- M A Puhan
- Horten Centre, University of Zurich, Switzerland
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Abstract
BACKGROUND Symptomatic hemorrhoids are a common medical condition, which increase in prevalence in women during pregnancy and postpartum. Although the evidence appears to be inconclusive, narrative reviews and clinical practice guidelines recommend the use of laxatives (and fiber) for the treatment of hemorrhoids and relief of symptoms. This is due to their safety and low cost. OBJECTIVES To evaluate the impact of laxatives on a wide range of symptoms in people with symptomatic hemorrhoids. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to 2005), EMBASE (1980 to 2005), CINAHL (1982 to 2005), BIOSIS, and AMED (Allied and Alternative Medicine Database), for eligible trials (including conference proceedings). We sought missing and additional information from authors, industry, and experts in the field. SELECTION CRITERIA We selected all published and unpublished randomised controlled trials that compared any type of laxative to placebo or no therapy in any patient population. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for inclusion and retrieved all potentially relevant studies. Data were extracted from studies that met our selection criteria on study population, intervention used, pre-specified outcomes, and methodology. We extracted methodological information for the assessment of internal validity: existence and method of generation of the randomization schedule, and method of allocation concealment; blinding of caregivers and outcomes assessors; numbers of and reasons for participants lost to follow up; and use of validated outcome measures. MAIN RESULTS Seven randomised trials enrolling a total of 378 participants to fiber or a non-fiber control were identified. Meta-analyses using random-effects models showed that laxatives in the form of fiber had a beneficial effect in the treatment of symptomatic hemorrhoids. The risk of not improving hemorrhoids and having persisting symptoms decreased by 53% in the fiber group (risk reduction (RR) 0.47, 95% CI 0.32 to 0.68). These results are compatible with large treatment effects regarding prolapse, pain, itching, although the pooled analyses showed a tendency toward no-effect for these parametres. The effect on bleeding showed a significant difference in favour of the fiber (RR 0.50, 95% CI 0.28 to 0.89). Studies including data on multiple follow ups (usually after six weeks and three months) showed consistent results over time. However, we have to stress two possible limitations of this review: the risk of publication bias, and only moderate study quality. AUTHORS' CONCLUSIONS The use of fiber shows a consistent beneficial effect for relieving overall symptoms and bleeding in the treatment of symptomatic hemorrhoids.
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Affiliation(s)
- P Alonso-Coello
- Hospital de la Santa Creu i Sant Pau, Iberoamerican Cochrane Centre, C/ Sant Antoni M Claret, 171, Barcelona, Spain 08041.
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Mcdonald E, Clarke F, Dale C, Davidson C, Farrell R, Hand L, Mcardle T, Smith O, Steinberg M, Watpool I, Ward R, Heels-ansdell D, Cook D. Crit Care 2005; 9:P267. [DOI: 10.1186/cc3330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Lim W, Qushmaq I, Tkacyzk A, Donahoe L, Heels-ansdell D, Hancock J, Mcdonald E, Crowther M, Devereaux P, Cook R, Cook D. Crit Care 2005; 9:P320. [DOI: 10.1186/cc3383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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23
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Fallone CA, Guyatt GH, Armstrong D, Wiklund I, Degl'Innocenti A, Heels-Ansdell D, Barkun AN, Chiba N, Zanten SJOV, El-Dika S, Austin P, Tanser L, Schünemann HJ. Do physicians correctly assess patient symptom severity in gastro-oesophageal reflux disease? Aliment Pharmacol Ther 2004; 20:1161-9. [PMID: 15569119 DOI: 10.1111/j.1365-2036.2004.02257.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The accuracy of physicians' assessment of the severity of gastro-oesophageal reflux disease is unclear. AIM To correlate physician and patient assessment of gastro-oesophageal reflux disease severity and its response to treatment. METHODS Adult uninvestigated gastro-oesophageal reflux disease patients (n = 217) completed symptom and health-related quality of life questionnaires at baseline and after treatment with esomeprazole 40 mg p.o. daily. Pearson coefficients quantified correlations between physician assessments and patient responses. RESULTS At baseline, the strongest correlations were heartburn severity (0.31), overall symptom severity (0.44) and a domain of the quality of life in reflux and dyspepsia questionnaire (0.31) (P < 0.001). Correlations of change with treatment were greater than baseline correlations: heartburn (0.39), overall symptoms (0.50) and global rate of change -- stomach problems (0.72, all P < 0.001). The mean difference between the physicians' assessment of change and the patients' global rating of change was 0.20 (95% confidence intervals: 0.10-0.29) with physicians overestimating benefit. CONCLUSIONS Correlations were often significant, although weak to moderate and better with symptom severity than with health-related quality of life instruments as well as with change after therapy than at baseline. Increasing attention to health-related quality of life may help physicians better understand patients' experience. In clinical trials, treatment success should be assessed by the patient as well as the physician.
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Affiliation(s)
- C A Fallone
- Division of Gastroenterology, McGill University Health Center, Montreal, QC, Canada.
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