Heterologous expression, purification and single step efficient refolding of recombinant tissue plasminogen activator (Reteplase) from E. coli

Reteplase (recombinant plasminogen activator, rPA) is a mutant non-glycosylated tissue-type plasminogen activator (tPA) containing 355 amino acids with longer half-life and promising thrombolytic activity than its original counterpart, full length tPA. In this study, we aimed to produce and optimize the purification process of recombinant tissue-type plasminogen activator (tPA) known as Reteplase (rPA). Reteplase cDNA synthesized from total mRNA isolated from human placenta was PCR amplified, cloned into a pET-28a(+) E. coli expression vector and expressed in Rosetta-gami 2 E. coli (NovagenⓇ) host. rPA was expressed as an inclusion body in E. coli and its biological activity was achieved after single step solubilization, purification and refolding. We exploited the strategy of Slow Refolding using Gradual Dialysis (SRGD) in which a refolding buffer containing glutathione oxidized (1 mM GSSG) and glutathione reduced (3 mM GSH) and pH 9.0 was used. Using the SRGD method, we were able to successfully obtain the protein in its active form. We obtained 4.26 mg of active refolded protein from a 50 mL culture that was scaled up in a bioreactor. The purity and homogeneity of rPA was evaluated by SDS-PAGE, Western blotting and mass spectrometry. Circular dichroism spectroscopy was conducted to evaluate the refolding and stability of the refolded rPA in comparison to reference standard rPA. The thrombolytic potential of rPA was assessed by fibrin plate assay and In Vitro clot lysis assay. The presented protocol offers a viable approach for enhancing both the yield and refolding efficiency of reteplase, potentially resulting in an increase in yield.

Advancing Community Care and Access to Follow-up After Acute Kidney Injury Hospitalization: Design of the AFTER AKI Randomized Controlled Trial

Background

Acute kidney injury (AKI) is a common complication among hospitalized patients with long-term implications including chronic kidney disease (CKD). Although models are available to predict the risk of advanced CKD after AKI, there is limited evidence regarding follow-up for patients with AKI after hospital discharge, resulting in variable follow-up care. A risk-stratified follow-up approach may improve appropriateness and efficiency of management for CKD among patients at risk of declining kidney function following AKI.

Objective

The objective was to compare and evaluate the use of a risk-stratified approach to follow-up care vs usual care for patients with AKI after hospital discharge.

Design

This study was a pragmatic randomized controlled trial.

Setting

This study was conducted in 2 large urban hospitals in Alberta, Canada.

Patients

Hospitalized patients with AKI (KDIGO stage 2 or 3) not previously under the care of a nephrologist, expected to survive greater than 90 days being discharged home.

Measurements

We will evaluate whether guideline-recommended CKD care processes are initiated within 90 days, including statin use, angiotensin-converting enzyme inhibitor (ACEi)/angiotensin II receptor blocker (ARB) use in those with proteinuria or diabetes, and nephrologist follow-up if sustained eGFR <30 mL/min/1.73 m2. We will also assess the feasibility of recruitment and the proportion of patients completing the recommended blood and urine tests at 90 days.

Methods

Patients with AKI will be enrolled and randomized near the time of hospital discharge. In the intervention group, low risk patients will receive information regarding AKI, medium risk patients will additionally receive follow-up guidance sent to their primary care physician, and high-risk patients will additionally receive follow-up with a nephrologist. Participants in the intervention and usual care group will receive a requisition for urine testing and bloodwork at 90 days following hospital discharge. Telephone follow-up will be conducted for all study participants at 90 days and 1 year after hospital discharge. Bivariate tests of association will be conducted to evaluate group differences at the follow-up time points.

Limitations

We expect there may be challenges with recruitment due to the significant co-existence of comorbidity in this population.

Conclusions

If the trial shows a positive effect on these processes for kidney care, it will inform larger-scale trial to determine whether this intervention reduces the incidence of long-term clinical adverse events, including CKD progression, cardiovascular events, and mortality following hospitalization with AKI.

American Society of Hematology 2023 guidelines for management of venous thromboembolism: thrombophilia testing

Hereditary and acquired thrombophilia are risk factors for venous thromboembolism (VTE). Whether testing helps guide management decisions is controversial. These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about thrombophilia testing. ASH formed a multidisciplinary guideline panel covering clinical and methodological expertise and minimizing bias from conflicts of interest. The McMaster University GRADE Centre provided logistical support, performed systematic reviews, and created evidence profiles and evidence-to-decision tables. The Grading of Recommendations Assessment, Development, and Evaluation approach (GRADE) was used. Recommendations were subject to public comment. The panel agreed on 23 recommendations regarding thrombophilia testing and associated management. Nearly all recommendations are based on very low certainty in the evidence due to modeling assumptions. The panel issued a strong recommendation against testing the general population before starting combined oral contraceptives (COCs) and conditional recommendations for thrombophilia testing in the following scenarios: (a) patients with VTE associated with nonsurgical major transient or hormonal risk factors; (b) patients with cerebral or splanchnic venous thrombosis, in settings where anticoagulation would otherwise be discontinued; (c) individuals with a family history of antithrombin, protein C, or protein S deficiency when considering thromboprophylaxis for minor provoking risk factors and for guidance to avoid COCs/hormone replacement therapy; (d) pregnant women with a family history of high-risk thrombophilia types; and (e) patients with cancer at low or intermediate risk of thrombosis and with a family history of VTE. For all other questions, the panel provided conditional recommendations against testing for thrombophilia.

Benign Mullerian Glandular Inclusions in Men: A Metastatic Carcinoma Mimic

Introduction/Objective

Benign mullerian glandular inclusions (MGI) in lymph nodes is a well documented finding in women. However, it can also very rarely occur in men and mimic metastatic carcinoma. To our knowledge, only seven cases of benign MGI in men have been reported in the literature.

Methods/Case Report

We here-in present a case of a 62-year-old male with a three-year history of prostatic adenocarcinoma Gleason score 6, initially diagnosed on needle core biopsies. Subsequently, the patient underwent a radical prostatectomy with bilateral pelvic lymph node dissection. Histological evaluation of the right pelvic lymph node demonstrated cystically dilated glands beneath the capsule composed of cuboidal to columnar cells with minimal atypia raising concern for metastatic carcinoma to the lymph node. Immunohistochemical (IHC) stains showed the glandular cells to be positive for estrogen, progesterone, PAX-8 and WT-1; while negative for calretinin and PSA immunostains. This IHC profile in conjunction with the morphological findings are consistent with the diagnosis of benign mullerian-type glandular inclusions within the lymph node.

Results (if a Case Study enter NA)

NA.

Conclusion

As benign MGI is a rare finding in men and can easily be mistaken for metastatic carcinoma, this case demonstrates that clinical awareness of this entity is essential to avoid wrongful diagnosis of metastatic carcinoma and unnecessary therapeutic treatment. Utilizing immunohistochemical stains to further characterize the glands is critical to obtain the correct diagnosis.

Serious reporting deficiencies exist in minimal important difference studies: Current state and suggestions for improvement

OBJECTIVE

To evaluate reporting of minimal important difference (MID) estimates using anchor-based methods for patient-reported outcome measures (PROMs), and the association with reporting deficiencies on their credibility.

STUDY DESIGN AND SETTING

Systematic survey of primary studies empirically estimating MIDs. We searched Medline, EMBASE, PsycINFO, and the Patient-Reported Outcome and Quality of Life Instruments Database until October 2018. We evaluated study reporting, focusing on participants' demographics, intervention(s), characteristics of PROMs and anchors, and MID estimation method(s). We assessed the impact of reporting issues on credibility of MID estimates.

RESULTS

In 585 studies reporting on 5,324 MID estimates for 526 distinct PROMs, authors frequently failed to adequately report key characteristics of PROMs and MIDs, including minimum and maximum values of PROM scale, measure of variability accompanying the MID estimate and number of participants included in the MID calculation. Across MID estimates (n=5,324), the most serious reporting issues impacting credibility included infrequent reporting of the correlation between the anchor and PROM (66%), inadequate details to judge precision of MID point estimate (13%), and insufficient information about the threshold used to ascertain MIDs (16%).

CONCLUSION

Serious issues of incomplete reporting in the MID literature threaten the optimal use of MID estimates to inform the magnitude of effects of interventions on PROMs.

A systematic survey identified methodological issues in studies estimating anchor-based minimal important differences in patient-reported outcomes

OBJECTIVE

To systematically survey the literature addressing the reporting of studies estimating anchor-based minimal important differences (MIDs) and choice of optimal MIDs.

STUDY DESIGN AND SETTING

We searched Medline, Embase and PsycINFO from 1987 to March 2020. Teams of two reviewers independently identified eligible publications and extracted quotations addressing relevant issues for reporting and/or selecting anchor-based MIDs. Using a coding list, we assigned the same code to quotations capturing similar or related issues. For each code, we generated an 'item', i.e. a specific phrase or sentence capturing the underlying concept. When multiple concepts existed under a single code, the team created multiple items for that code. We clustered codes addressing a broader methodological issue into a 'category' and classified items as relevant for reporting, relevant for selecting an anchor-based MID, or both.

RESULTS

We identified 136 eligible publications that provided 6 categories (MID definition, anchors, patient-reported outcome measures, generalizability and statistics) and 24 codes. These codes contained 34 items related to reporting MID studies, of which 29 were also related to selecting MIDs.

CONCLUSION

The systematic survey identified items related to reporting of anchor-based MID studies and selecting optimal MIDs. These provide a conceptual framework to inform the design of studies related to MIDs, and a basis for developing a reporting standard and a selection approach for MIDs.

Colonic Large Cell Neuroendocrine Carcinoma with Extensive Carcinomatosis: A Highly Aggressive Tumor

Introduction/Objective

Large cell neuroendocrine carcinoma (LCNEC) of the colon is an exceedingly rare and aggressive neuroendocrine carcinoma. These tumors are associated with a poor prognosis, as they are commonly diagnosed in advanced stages with distant metastases. We present a case of a patient with colonic LCNEC with carcinomatosis peritonei who underwent surgical resection and hyperthermic intraperitoneal chemotherapy.

Methods/Case Report

The patient is a 49-year-old Caucasian male who presented with several months history of occasional hematochezia, constipation, 40-pound unintentional weight loss, and reflux. An initial diagnosis of adenocarcinoma of colorectal origin was rendered. Subsequently, the patient underwent a low-anterior resection with hyperthermic intraperitoneal chemotherapy (HIPEC). Histological evaluation of the rectosigmoid lesion demonstrated sheets of malignant epithelial cells with scant amphophilic cytoplasm, large pleomorphic vesicular nuclei, prominent nucleoli, and numerous mitotic figures. The tumor invaded the entire colonic wall and extended to the visceral peritoneum with extensive small vessel lymphovascular and perineural invasion with widespread involvement of the diaphragm, spleen, falciform ligament, and omentum. Immunohistochemical stains showed the tumor to be diffusely positive for CK20, CDX2, and synaptophysin; while negative for CK7, PAP, PSA, chromogranin, and p40. These findings are consistent with the diagnosis of a large cell neuroendocrine carcinoma. In addition, CD31 highlighted lymphatic spaces that were extensively filled with tumor cells. One-month post-operative, the patient remains in critical but stable condition with features of acute hypoxic respiratory failure and possible metastatic disease to the lung associated with pleural effusion.

Results (if a Case Study enter NA)

NA

Conclusion

Colonic large cell neuroendocrine carcinoma (LCNEC) is a rare, highly aggressive neuroendocrine carcinoma that frequently presents with distant metastases. Clinical awareness of the entity with early diagnosis and surgical resection remains the essential initial step. Utilizing immunohistochemistry stains to further characterize the tumor is critical to reach the correct diagnosis. Accumulating appropriate clinical data will aid in the establishment of future treatment protocols.

Plastid-mediated singlet oxygen in regulated cell death

Reactive oxygen species (ROS) generation within a cell is a natural process of specific subcellular components involved in redox reactions. Within a plant cell, chloroplasts are one of the major sources of ROS generation. Plastid-generated ROS molecules include singlet oxygen (¹ O₂ ), superoxide radical (O₂ ^- ), hydroxyl radical (OH^• ) and hydrogen peroxide (H₂ O₂ ), which are produced mainly during photochemical reactions of photosynthesis and chlorophyll biosynthetic process. Under normal growth and developmental, generated ROS molecules act as a secondary messenger controlling several metabolic reactions; however, perturbed environmental conditions lead to multi-fold amplification of cellular ROS that eventually kill the target cell. To maintain homeostasis between production and scavenging of ROS, the cell has instituted several enzymatic and non-enzymatic antioxidant machineries to maintain ROS at a physiological level. Among chloroplastic ROS molecules, excess generation of singlet oxygen (¹ O₂ ) is highly deleterious to the cell metabolic functions and survival. Interestingly, within cellular antioxidant machinery, enzymes involved in detoxification of ¹ O₂ are lacking. Recent studies suggest that under optimal concentrations, ¹ O₂ acts as a signalling molecule and drives the cell to either the acclimation pathway or regulated cell death (RCD). Stress-induced RCD is a survival mechanism for the whole plant, while the involvement of chloroplasts and chloroplast-localized molecules that execute RCD are not well understood. In this review, we advocate for participation of chloroplasts-generated ¹ O₂ in signalling and RCD in plants.

Guidelines that use the GRADE approach often fail to provide complete economic information for recommendations: A systematic survey

OBJECTIVE

Little is known about how developers and panel members report cost and cost effectiveness considerations in GRADE guideline Evidence-to-Decision (EtD) frameworks. A systematic survey was conducted to explore approaches and factors contributing to variability in economic information reporting.

STUDY DESIGN AND SETTING

Guideline organization websites were systematically searched to create a convenience sample of guidelines. Reviewers screened published EtD frameworks and generated frequencies of reporting approaches. We used thematic analysis to summarize factors related to variability of economic information reporting.

RESULTS

We included 142 guidelines. The overall rate of reporting economic information was high (91%); however, there was variability across completion of predefined EtD Likert-type judgments (70%), noting information as not identified across EtD framework domains (57%), and providing remarks to justify recommendations (38%). Six themes contributing to variability emerged, related to: intervention, population, payor, provider, healthcare resource use, and economic model building factors. Only 2 guidelines performed a GRADE certainty appraisal of economic outcomes.

CONCLUSION

Completing predefined EtD Likert-type judgments, specifically reporting a literature review approach, study selection criteria and economic model building limitations, as well as linking these to recommendation justification remarks are potential areas for improved use, adoption and adaptation of recommendation, and transparency of GRADE EtD frameworks.

GRADE notes: How to use GRADE when there is "no" evidence? A case study of the expert evidence approach

OBJECTIVES

One essential requirement of trustworthy guidelines is that they should be based on systematic reviews of the best available evidence. The GRADE Working Group has provided guidance for evaluating the certainty of evidence based on several domains. However, for many clinical questions, published evidence may be limited, too indirect or simply not exist. In this brief report (GRADE notes), we describe our method of developing evidence-based recommendations when publisheddirect evidence was lacking.

STUDY DESIGN AND SETTING

When direct published literature was absent, an expert evidence survey was administered to panel members about their unpublished observations and case series. Focus was on collecting data about cases and outcome, not panel opinions.

RESULTS

Out of 26 questions prioritized by the panel for pediatric venous thromboembolism, 12 had no, very limited, or very low certainty of evidence to inform them. The panel survey was administered for these questions.

CONCLUSIONS

Areas of sparse evidence often reflect key questions that are critical to address in clinical practice guidelines due to the uncertainty among health care providers. The expert evidence approach used in this study is one method for panels totransparently deal with the lack of published evidence to directly inform recommendations.

Development and initial implementation of electronic clinical decision supports for recognition and management of hospital-acquired acute kidney injury

Background

Acute kidney injury (AKI) is common in hospitalized patients and is associated with poor patient outcomes and high costs of care. The implementation of clinical decision support tools within electronic medical record (EMR) could improve AKI care and outcomes. While clinical decision support tools have the potential to enhance recognition and management of AKI, there is limited description in the literature of how these tools were developed and whether they meet end-user expectations.

Methods

We developed and evaluated the content, acceptability, and usability of electronic clinical decision support tools for AKI care. Multi-component tools were developed within a hospital EMR (Sunrise Clinical Manager™, Allscripts Healthcare Solutions Inc.) currently deployed in Calgary, Alberta, and included: AKI stage alerts, AKI adverse medication warnings, AKI clinical summary dashboard, and an AKI order set. The clinical decision support was developed for use by multiple healthcare providers at the time and point of care on general medical and surgical units. Functional and usability testing for the alerts and clinical summary dashboard was conducted via in-person evaluation sessions, interviews, and surveys of care providers. Formal user acceptance testing with clinical end-users, including physicians and nursing staff, was conducted to evaluate the AKI order set.

Results

Considerations for appropriate deployment of both non-disruptive and interruptive functions was important to gain acceptability by clinicians. Functional testing and usability surveys for the alerts and clinical summary dashboard indicated that the tools were operating as desired and 74% (17/23) of surveyed healthcare providers reported that these tools were easy to use and could be learned quickly. Over three-quarters of providers (18/23) reported that they would utilize the tools in their practice. Three-quarters of the participants (13/17) in user acceptance testing agreed that recommendations within the order set were useful. Overall, 88% (15/17) believed that the order set would improve the care and management of AKI patients.

Conclusions

Development and testing of EMR-based decision support tools for AKI with clinicians led to high acceptance by clinical end-users. Subsequent implementation within clinical environments will require end-user education and engagement in system-level initiatives to use the tools to improve care.

Clinical decision-making and importance of the AAE/AAOMR position statement for CBCT examination in endodontic cases

AIM

To compare conventional radiographic and cone beam computed tomography (CBCT) findings with reference to the American Association of Endodontics and American Academy of Oral and Maxillofacial Radiology (AAE/AAOMR) joint position statement and to determine the effect of the CBCT on the initial diagnoses and treatment plans in a single-centre Postgraduate Endodontic Programme.

METHODOLOGY

The clinical CBCT scans of patients, treated at the Endodontic Department of the University of British Columbia, were reviewed for CBCT referrals by comparing them with corresponding radiographs. The features considered were periapical lesions, missed/extra canals, root fractures, complex anatomy, calcified canals and root resorption of tooth/teeth in question. Reasons for the CBCT prescriptions were assigned to 3 groups: to formulate the primary diagnosis, to confirm the diagnosis achieved by clinical examination and conventional radiographs, and to assist in treatment planning. Variables were compared statistically using chi-square and McNemar tests.

RESULTS

A total of 128 CBCT examinations were performed on 110 patients. No CBCT examination was performed more than once on the same tooth. Overall, 76% of CBCT examinations were performed on previously root filled teeth. CBCT images revealed a significantly higher incidence of periapical lesions (P = 0.002), missed canals (P < 0.001), vertical root fractures (P = 0.004) and complex anatomy (P = 0.008) than periapical radiographs. CBCT was prescribed most frequently to assist surgical treatment planning (62%) rather than for generating a diagnosis (9%) or confirming diagnoses (29%). Both the diagnosis (P = 0.001) and the treatment plan (P = 0.005) initially made by examining periapical radiographs were altered significantly by the subsequent CBCT examination by revealing information such as new periapical lesions, missed canals or involvement of buccal or lingual cortical bone.

CONCLUSION

CBCT examinations were prescribed mainly to assist treatment planning rather than for diagnosis. The majority of CBCT examinations were performed on previously root filled teeth. The additional information obtained from CBCT scans resulted in the alteration of the initial diagnoses as well as subsequent treatment plans in 59 out of 128 cases.

Training of the spiritual dimension of health in India – an innovative ‘thought model’ approach

Background

The complexities in defining Spirituality, its association with religions, and misfit in modern scientific healthcare settings are the reasons behind the neglected attitude in training of spiritual dimension of health in religiously diverse and secular India.

Objectives

To define spirituality independent from religious views and scientifically sound for modern healthcare practices in a diverse society of India. For this, a 'Thought Model' developed with spirituality as the most evolved thought in the form of humanity and human values with transcendence, connectedness, and purpose of human life, which works as a controlling, communicating, and correcting thought in the ecosystem of human thought processes. Review and testing with healthcare professionals (completed in Nov 2019), leading to few pilot projects (in progress till Sept 2020), and finally working with academia to finetune it for training curricula for health systems.

Results

The 'thought model' presented to health experts from July to October 2019. 98% [80 out of 82(N)] considered this simple, comfortable to belief systems, and practice. 96% found it helpful in solving the issues where the physician and patient or the members of the medical team are from different religions. 99% considered this model scientific and useful in responding to the spiritual needs of all, including atheists. So, we planned to start a pilot project in two selected medical institutions for medical interns with the new session; results are awaiting.

Conclusions

Review results by health experts indicated that the 'thought model' can address the complexities and ambiguities in defining spirituality on religious grounds by simplifying its definition and independent of religious beliefs for the training of the spiritual dimension of health and healthcare in diverse and secular societies makes it easy to discuss spiritual aspects of health in communities with various religions and belief systems.

Key messages

Religiosity makes spirituality complex, communal, and unscientific in religiously diverse societies leading to reluctance in public health practices and training. Simplifying spirituality as an evolved thought can change the perspective by abolishing religiosity; it becomes comfortable with belief systems and science and suitable for training and research.

Treatment Outcomes in Patients With Opioid Use Disorder Who Were First Introduced to Opioids by Prescription: A Systematic Review and Meta-Analysis

OBJECTIVE

Prescription opioid misuse has led to a new cohort of opioid use disorder (OUD) patients who were introduced to opioids through a legitimate prescription. This change has caused a shift in the demographic profile of OUD patients from predominantly young men to middle age and older people. The management of OUD includes medication-assisted treatment (MAT), which produces varying rates of treatment response. In this study, we will examine whether the source of first opioid use has an effect on treatment outcomes in OUD. Using a systematic review of the literature, we will investigate the association between source of first opioid introduction and treatment outcomes defined as continuing illicit opioid use and poly-substance use while in MAT.

METHODS

Medline, EMBASE, CINHAL, and PsycInfo were searched from inception to December 31st, 2019 inclusive using a comprehensive search strategy. Five pairs of reviewers conducted screening and data extraction independently in duplicate. The review is conducted and reported according to the PRISMA guidelines. A random-effects model was used for meta analyses assuming heterogeneity among the included studies.

RESULTS

The initial search results in 27,345 articles that were screened, and five observational studies were included in the qualitative and quantitative analyses. Our results found that those who were introduced to opioids through a legitimate prescription were significantly less likely to have illicit opioid use (0.70, 95% CI 0.50, 0.99) while on MAT. They were also less likely to use cannabis (0.54, 95% CI 0.32, 0.89), alcohol (0.75, 95% CI 0.59, 0.95), cocaine (0.50, 95% CI 0.29, 0.85), and injection drug use (0.25, 95% CI 0.14, 0.43) than those introduced to opioids through recreational means.

CONCLUSION

This study shows that the first exposure to opioids, whether through a prescription or recreationally, influences prognosis and treatment outcomes of opioid use disorder. Although the increased pattern of prescribing opioids may have led to increased OUD in a new cohort of patients, these patients are less likely to continue to use illicit drugs and have a different prognostic and clinical profile that requires a tailored approach to treatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017058143.

Evaluating the credibility of anchor based estimates of minimal important differences for patient reported outcomes: instrument development and reliability study

OBJECTIVE

To develop an instrument to evaluate the credibility of anchor based minimal important differences (MIDs) for outcome measures reported by patients, and to assess the reliability of the instrument.

DESIGN

Instrument development and reliability study.

DATA SOURCES

Initial criteria were developed for evaluating the credibility of anchor based MIDs based on a literature review (Medline, Embase, CINAHL, and PsycInfo databases) and the experience of the authors in the methodology for estimation of MIDs. Iterative discussions by the team and pilot testing with experts and potential users facilitated the development of the final instrument.

PARTICIPANTS

With the newly developed instrument, pairs of masters, doctoral, or postdoctoral students with a background in health research methodology independently evaluated the credibility of a sample of MID estimates.

MAIN OUTCOME MEASURES

Core credibility criteria applicable to all anchor types, additional criteria for transition rating anchors, and inter-rater reliability coefficients were determined.

RESULTS

The credibility instrument has five core criteria: the anchor is rated by the patient; the anchor is interpretable and relevant to the patient; the MID estimate is precise; the correlation between the anchor and the outcome measure reported by the patient is satisfactory; and the authors select a threshold on the anchor that reflects a small but important difference. The additional criteria for transition rating anchors are: the time elapsed between baseline and follow-up measurement for estimation of the MID is optimal; and the correlations of the transition rating with the baseline, follow-up, and change score in the patient reported outcome measures are satisfactory. Inter-rater reliability coefficients (ĸ) for the core criteria and for one item from the additional criteria ranged from 0.70 to 0.94. Reporting issues prevented the evaluation of the reliability of the three other additional criteria for the transition rating anchors.

CONCLUSIONS

Researchers, clinicians, and healthcare policy decision makers can consider using this instrument to evaluate the design, conduct, and analysis of studies estimating anchor based minimal important differences.

Feasibility of behavioral activation group therapy in reducing depressive symptoms and improving quality of life in patients with depression: the BRAVE pilot trial

BACKGROUND

Depression impacts the lives of millions of people worldwide. Behavioral activation (BA), derived from cognitive behavioral therapy, has the potential for improving depressive symptoms in patients with depression. Studies evaluating the effectiveness of BA specifically in the context of group therapy programs in a hospital setting for patients with depression are limited. In this study, we report findings from a pilot trial evaluating group BA for major depressive disorder.

OBJECTIVE

The objectives of this pilot trial are to assess the potential of a full trial of BA group therapy in a large-scale tertiary care setting and to provide preliminary information about possible results regarding mood symptoms and quality of life in adults with depression.

METHODS

Using a parallel single-cohort pragmatic pilot randomized controlled trial design, we evaluated the potential of conducting a large trial of BA effectiveness among adults with depression. Participants were randomized to the intervention (BA in addition to usual care) or control (support group in addition to usual care) groups and were assessed weekly for 18 consecutive weeks. Participants randomized to intervention underwent 28 2-h group BA therapy visits administered by trained therapists and completed assessments to examine treatment outcomes. Feasibility was measured in terms of enrollment rates (min. 20%), completion rates of study (min. 80%), and completion rates of weekly measurement scales (min. 80%). The reporting of this pilot trial is in accordance with the CONSORT extension for randomized pilot and feasibility trials.

RESULTS

We randomized 20 individuals of mean age of 48.8 years (standard deviation = 9.7) with a DSM-5 diagnosis of major depressive disorder to intervention (n = 10) or control (n = 10) groups. Based on our feasibility criteria, our recruitment rate was excellent (20/27; 74%), study completion was found to be a moderate (80% of the total participants in both arms completed the study; BA = 100%, control = 60%), and completeness of measurements on a weekly basis was adequate overall (82%; BA = 86%, control = 79%).

CONCLUSIONS

The study has demonstrated the potential feasibility to perform a larger scale trial upon modifications to the control group to avoid the low rate of study completion (60%) in this group.

TRIAL REGISTRATION

ClinicalTrials NCT02045771, Registered January 22, 2014.

Long-term outcomes of acute kidney injury and strategies for improved care

Acute kidney injury (AKI), once viewed predominantly as a self-limited and reversible condition, is now recognized as a growing problem associated with significant risks of adverse long-term health outcomes. Many cohort studies have established important relationships between AKI and subsequent risks of recurrent AKI, hospital re-admission, morbidity and mortality from cardiovascular disease and cancer, as well as the development of chronic kidney disease and end-stage kidney disease. In both high-income countries (HICs) and low-income or middle-income countries (LMICs), several challenges exist in providing high-quality, patient-centered care following AKI. Despite advances in our understanding about the long-term risks following AKI, large gaps in knowledge remain about effective interventions that can improve the outcomes of patients. Therapies for high blood pressure, glycaemic control (for patients with diabetes), renin-angiotensin inhibition and statins might be important in improving long-term cardiovascular and kidney outcomes after AKI. Novel strategies that incorporate risk stratification approaches, educational interventions and new models of ambulatory care following AKI have been described, and some of these are now being implemented and evaluated in clinical studies in HICs. Care for AKI in LMICs must overcome additional barriers due to limited resources for diagnosis and management.

Obesity and muscle-macrophage crosstalk in humans and mice: A systematic review

Obesity is associated with the production of inflammatory cytokines that are implicated in insulin resistance (IR), and if not addressed, can lead to type 2 diabetes (T2D). The role of the immune system in skeletal muscle (SM) inflammation and insulin sensitivity is not yet well characterized. As SM IR is an important determinant of glycaemia, it is critical that the muscle-immune phenotype is mapped to help design interventions to target T2D. This systematic review synthesized the evidence for SM macrophage content and phenotype in humans and murine models of obesity, and the association of muscle macrophage content and phenotype with IR. Results were synthesized narratively, as we were unable to conduct a meta-analysis. We included 28 studies (n=10 human, n=18 murine), and all studies detected macrophage markers in SM. Macrophage content was positively associated with IR. In humans and mice, there was variability in muscle macrophage content and phenotype in obesity. Overall certainty in the evidence was low due to heterogeneity in detection methods and incompleteness of data reporting. Macrophages are detected in human and murine SM in obesity and a positive association between macrophage content and IR is noted; however, the standardization of markers, detection methods, and reporting of study details is warranted to accurately characterize macrophages and improve the potential for creating specific and targeted immune-based therapies in obesity.

The association between health conditions and cannabis use in patients with opioid use disorder receiving methadone maintenance treatment

BACKGROUND

Cannabis is the most commonly used substance among patients in methadone maintenance treatment (MMT) for opioid use disorder. Current treatment programmes neither screen nor manage cannabis use. The recent legalisation of cannabis in Canada incites consideration into how this may affect the current opioid crisis.

AIMS

Investigate the health status of cannabis users in MMT.

METHOD

Patients were recruited from addiction clinics in Ontario, Canada. Regression analyses were used to assess the association between adverse health conditions and cannabis use. Further analyses were used to assess sex differences and heaviness of cannabis use.

RESULTS

We included 672 patients (49.9% cannabis users). Cannabis users were more likely to consume alcohol (odds ratio 1.46, 95% CI 1.04-2.06, P = 0.029) and have anxiety disorders (odds ratio 1.75, 95% CI 1.02-3.02, P = 0.043), but were less likely to use heroin (odds ratio 0.45, 95% CI 0.24-0.86, P = 0.016). There was no association between cannabis use and pain (odds ratio 0.98, 95% CI 0.94-1.03, P = 0.463). A significant association was seen between alcohol and cannabis use in women (odds ratio 1.79, 95% CI 1.06-3.02, P = 0.028), and anxiety disorders and cannabis use in men (odds ratio 2.59, 95% CI 1.21-5.53, P = 0.014). Heaviness of cannabis use was not associated with health outcomes.

CONCLUSIONS

Our results suggest that cannabis use is common and associated with psychiatric comorbidities and substance use among patients in MMT, advocating for screening of cannabis use in this population.

DECLARATION OF INTEREST

None.

Cannabis use during methadone maintenance treatment for opioid use disorder: a systematic review and meta-analysis

BACKGROUND

Rates of cannabis use among patients receiving methadone maintenance therapy are high, and cannabis use may be associated with outcomes of methadone maintenance therapy. We examined the effect of cannabis use on opioid use in patients receiving methadone maintenance therapy to test the hypothesis that cannabis use is associated with a reduction in opioid use.

METHODS

In this systematic review, we searched MEDLINE/PubMed, Embase, PsycINFO, CINAHL and ProQuest Dissertations and Theses Global from inception to July 12, 2018. We summarized the effects of cannabis use on opioid use during methadone maintenance therapy and treatment retention. We conducted meta-analyses using a random effects model.

RESULTS

We included 23 studies in our review. We performed a meta-analysis of 6 studies, with a total number of participants of 3676, examining use of cannabis and opioids during methadone maintenance therapy. Owing to high heterogeneity, we described the studies qualitatively but provide the forest plots as supplemental material. The overall quality of evidence was very low, with a high risk of bias, owing to the nature of observational studies.

INTERPRETATION

We found no consensus among studies that cannabis use is associated with reduced opioid use or longer treatment retention when used during methadone maintenance therapy in patients with opioid use disorder. PROSPERO Registration: CRD42015029372.

Changing trend in bacterial etiology and antibiotic resistance in sepsis of intramural neonates at a tertiary care hospital

Background:

Septicemia is an important cause of neonatal morbidity and mortality. However, organized data on causative organisms and their resistant pattern are scanty from developing countries. The changing trend in causative organisms and their antibiotic resistance is yet to be documented in India. The present study examines the trends in bacterial profile and antibiotic resistance of the organisms causing sepsis in hospitalized neonates.

Materials and Methods:

A retrospective laboratory-based analysis of blood cultures obtained from Neonatal Intensive Care Unit of a tertiary care hospital in New Delhi was done for the period of 1999–2014, divided into five phases.

Results:

A total of 4700 isolates were considered. Over time, Gram-negative organisms have replaced Gram-positives as frequent isolates. Initially, there was predominance of Klebsiella pneumoniae, then of Staphylococcus aureus which recently has been changed with coagulase negative-Staphylococcus and Acinetobacter. Growing resistance against the first and second line of drugs has been noted, including methicillin-resistant S. aureus and vancomycin-resistant Enterococcus.

Conclusion:

The etiological profile of neonatal sepsis has changed tremendously in the past 15 years. High resistance against common drugs necessitates continued surveillance and review of empirical antibiotic policy for neonatal sepsis. These steps are important to effectively curtail the surge of further antibiotic resistance.

Adverse Outcomes Associated with Prescription Opioids for Acute Low Back Pain: A Systematic Review and Meta-Analysis

BACKGROUND

Acute low back pain (ALBP) is a common clinical complaint that can last anywhere from 24 hours to 12 weeks. In recent years, there has been an opioid epidemic which is linked to the increased availability of prescription opioids. Though guidelines recommend that in the treatment of ALBP, opioids should be used when other treatments fail, we have seen an increase in opioid prescriptions for ALBP. With this crisis, it is important to examine if there are any adverse outcomes associated with prescribing opioids for ALBP.

OBJECTIVE

We aim to review the published literature to examine the adverse outcomes associated with opioid use for ALBP.

STUDY DESIGN

We performed a systematic review with meta-analysis in accordance with our published protocol and PRISMA guidelines.

SETTING

The review was conducted at McMaster University.

METHODS

Various electronic databases for articles published from inception to September 30, 2017, inclusive. Both randomized clinical trials and observational studies on the impact of opioid use in ALBP in the adult population were included. Eight pairs of independent reviewers performed screening, data extraction, and assessment of methodological quality. The identified articles were assessed for risk of bias using sensitivity analysis. Trials with comparative outcomes were reported in a meta-analysis using a fixed effects model.

RESULTS

A total of 13,889 studies were initially screened for the review and a total of 4 studies were included in the full review, of which 2 studies were meta-analyzed. Our results showed that prescribing opioids for ALBP was significantly associated with long-term continued opioid use (1.57, 95% CI, 1.06-2.33). There was no significant association found between unemployment duration and prescribing opioids for ALBP (3.54, 95% CI, -7.57 to 14.66).

LIMITATIONS

Due to the limited number of studies that considered unemployment, only an unpooled analysis was conducted. Among the included studies there was both statistical and clinical heterogeneity due to differences in methodology, study design, risk of selection or performance bias. Most of the studies had an unclear or high risk of bias and poorly defined side effects.

CONCLUSIONS

Due to the lack of literature examining long-term adverse outcomes associated with prescribing opioids for ALBP, no definitive conclusions can be made. However, with the literature available, there does seem to be risk associated with prescribing opioids for ALBP so there is a great need to conduct further investigations examining these adverse outcomes for ALBP patients.

KEY WORDS

Acute low back pain, opioids, prescriptions, low back pain, long-term use, opioid use disorder.

Phylogenetic analysis of haemagglutinin gene deciphering a new genetically distinct lineage of canine distemper virus circulating among domestic dogs in India

Canine distemper (CD) is one of the highly contagious and invariably fatal viral diseases of dogs and other carnivores. Despite the widespread use of modified live vaccines to control CD, the prevalence of disease has increased at an alarming rate in recent years. Although a number of factors may be ascribed for vaccine failure, antigenic differences among the vaccine and wild-type strains have gained the interest of researchers. Considering the high genetic variability of haemagglutinin gene (H gene) and its role in eliciting the immune response to canine distemper virus (CDV), we have generated nine full-length CDV H gene sequences from infected dogs including three vaccinated cases. Bayesian analysis was performed using 102 full-length H gene nucleotide sequences over a time frame of 76 years (1940-2016) from 18 countries. The time to the most recent common ancestor (tMRCA) of CDV was estimated to be 1696 AD. Phylogenetic reconstruction clustered Indian wild-type viruses into a distinct monophyletic group clearly separated from the previously established CDV lineages. This signifies the presence of a novel genetic variant (proposed as "Lineage India-1/Asia-5") circulating among dog population in India. To investigate the importance of substitutions at amino acid residues 530 and 549 of CDV H protein in determining the host switches from canid to non-canid hosts, we analysed 125 H gene sequences including nine sequences generated in this study. Selection pressure analysis and analysis of amino acid sequences revealed a trend towards adaptation of 549H variants in non-canid hosts although no role of G/E530R/D/N substitution could be identified. This is the first comprehensive study about the nature and ecology of CDV circulating among dog population in India. Outbreaks in vaccinated animals as observed in this study have raised a concern towards the effectiveness of current vaccine strains warranting detailed investigation.

Sociodemographic characteristics of patients with children in a methadone maintenance program: a cross-sectional study

Background

Ever-increasing numbers of opioid use disorder (OUD) in Canada has created the recent opioid crisis. One common treatment for OUD is methadone maintenance treatment (MMT). Various factors, including being a parent which entails specific stressors, may increase susceptibility to negative treatment outcomes. This study aims to investigate differences between OUD patients with and without children in socio-demographic and clinical outcomes.

Methods

Data for this study are part of a larger program. All participants are 18+ years old with OUD, provided consent, and receiving MMT. We performed a multivariable logistic regression to examine the differences between participants’ parental status, sociodemographic variables, and clinical parameters including MMT outcomes. We performed subgroup analyses on individuals with children younger than 18.

Results

A total of 1099 participants were included, with 64% having children. Participants with children were older (OR 1.06, 95% CI 1.04, 1.08), more likely to be female (OR 2.39, 95% CI 1.75, 3.27), living with a partner (OR 1.75, 95% CI 1.27, 2.41), first exposed to opioids through a prescription (OR 1.517, 95% CI 1.13, 2.04) and had lower levels of education (OR 1.86, 95% CI 1.20, 2.87). There was no significant difference in illicit opioid use patterns between groups. Same results held true in the subgroup analyses based on the age of the children except for participant age.

Conclusion

Our results demonstrate social and demographic differences between parents and non-parents receiving MMT. These differences highlight the need to understand necessary additional support for parents such as child support and other necessary therapies.

American Society of Hematology 2018 Guidelines for management of venous thromboembolism: treatment of pediatric venous thromboembolism

BACKGROUND

Despite an increasing incidence of venous thromboembolism (VTE) in pediatric patients in tertiary care settings, relatively few pediatric physicians have experience with antithrombotic interventions.

OBJECTIVE

These guidelines of the American Society of Hematology (ASH), based on the best available evidence, are intended to support patients, clinicians, and other health care professionals in their decisions about management of pediatric VTE.

METHODS

ASH formed a multidisciplinary guideline panel that included 2 patient representatives and was balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews (up to April of 2017). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 30 recommendations, covering symptomatic and asymptomatic deep vein thrombosis, with specific focus on management of central venous access device-associated VTE. The panel also addressed renal and portal vein thrombosis, cerebral sino venous thrombosis, and homozygous protein C deficiency.

CONCLUSIONS

Although the panel offered many recommendations, additional research is required. Priorities include understanding the natural history of asymptomatic thrombosis, determining subgroup boundaries that enable risk stratification of children for escalation of treatment, and appropriate study of newer anticoagulant agents in children.

American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy

BACKGROUND

Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE).

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants.

CONCLUSIONS

Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.

The quality of clinical practice guidelines for management of pediatric type 2 diabetes mellitus: a systematic review using the AGREE II instrument

AIMS

Pediatric type 2 diabetes mellitus (T2DM) is a relatively new disease with increasing incidence corresponding to the obesity epidemic among youth. It is important for clinicians to have access to high-quality clinical practice guidelines (CPGs) for appropriate management of pediatric patients with T2DM. The objective of this systematic review was to evaluate overall quality of CPGs for the management of pediatric T2DM using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

METHODS

We searched MEDLINE, Embase, CINAHL, Trip, National Guideline Clearinghouse, and grey literature to identify eligible CPGs. We also searched the webpages of national and international diabetes and pediatric organizations globally. We included CPGs from national and international diabetes and pediatric associations that were published as standalone guidelines for T2DM in children and adolescents (2-18 years of age). We also included pediatric and adult guidelines for type 1 diabetes if they included a section addressing T2DM management in children and adolescents. We retrieved the two most recent guidelines from each organization when available to assess change in quality over time. We excluded individual studies and systematic reviews that made treatment recommendations as well as CPGs that were developed for a single institution.

RESULTS

We included 21 unique CPGs in this systematic review. Of the included guidelines, 12 were developed or updated between 2012 and 2014. Five of all included CPGs were specific to pediatric populations. The analysis revealed that "Rigour of Development" (mean 45%, SD 28.68) and "Editorial Independence" (mean 45%, SD 35.19) were the lowest scoring domains on the AGREE II for the majority of guidelines, whereas "Clarity of Presentation" was the highest scoring domain (mean 72%, SD 18.89).

CONCLUSIONS

Overall, two thirds of the pediatric T2DM guidelines were moderate to low quality and the remaining third ranked higher in quality. Low quality was especially due to the scores for the "Rigour of Development" domain, which directly measures guideline development methodology. It is important that future guidelines and updates of existing guidelines improve the methodology of development and quality of reporting in order to appropriately guide physicians managing children and adolescents with T2DM.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016034187.

Association Between Socio-Demographic and Health Functioning Variables Among Patients with Opioid Use Disorder Introduced by Prescription: A Prospective Cohort Study

BACKGROUND

Prescription opioid misuse in Canada has become a serious public health concern and has contributed to Canada's opioid crisis. There are thousands of Canadians who are currently receiving treatment for opioid use disorder, which is a chronic relapsing disorder with enormous impact on individuals and society.

OBJECTIVES

The aim of this study was to compare the clinical and demographic differences between cohorts of patients who were introduced to opioids through a prescription and those introduced to opioids for non-medical purposes.

STUDY DESIGN

This was an observational, prospective cohort study.

SETTING

The study took place in 19 Canadian Addiction Treatment Centres across Ontario.

METHODS

We included a total of 976 participants who were diagnosed with Opioid Use Disorder and currently receiving methadone maintenance treatment. We excluded participants who were on any other type of prescription opioid or who were missing their 6-month follow-up urine screens. We measured the participants' initial source of introduction to opioids along with other variables using the Maudsley Addiction Profile. We also measured illicit opioid use using urine screens at baseline and at 6-months follow-up.

RESULTS

Almost half the sample (n = 469) were initiated to opioids via prescription. Women were more likely to be initiated to opioids via a prescription (OR = 1.385, 95% CI 1.027-1.866, P = .033). Those initiated via prescription were also more likely to have post-secondary education, older age of onset of opioid use, less likely to have hepatitis C and less likely to have use cannabis. Chronic pain was significantly associated with initiation to opioids through prescription (OR = 2.720, 95% CI 1.998-3.722, P < .0001). Analyses by gender revealed that men initiated by prescription were less likely to have liver disease and less likely to use cannabis, while women initiated by prescription had a higher methadone dose.

LIMITATIONS

This project was limited by its study design being observational in nature; no causal relationships can be inferred. Also, the data did not allow determination of the role that the prescribed opioids played in developing opioid use disorder.

CONCLUSIONS

Our results have revealed that almost half of this methadone maintenance treatment (MMT) population has been introduced to opioids through a prescription. Given that the increasing prescribing rates of opioids has an impact on this at-risk population, alternative treatments for pain should be considered to help decrease this opioid epidemic in Canada.

KEY WORDS

Opioid use disorder, chronic pain relief, methadone maintenance treatment, prescriptions, male, female.

Does the medical literature remain inadequately described despite having reporting guidelines for 21 years? - A systematic review of reviews: an update

PURPOSE

Reporting guidelines (eg, Consolidated Standards of Reporting Trials [CONSORT] statement) are intended to improve reporting standards and enhance the transparency and reproducibility of research findings. Despite accessibility of such guidelines, researchers are not required to adhere to them. Our goal was to determine the current status of reporting quality in the medical literature and examine whether adherence of reporting guidelines has improved since the inception of reporting guidelines.

MATERIALS AND METHODS

Eight reporting guidelines, such as CONSORT, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), STrengthening the Reporting of OBservational studies in Epidemiology (STROBE), Quality of Reporting of Meta-analysis (QUOROM), STAndards for Reporting of Diagnostic accuracy (STARD), Animal Research: Reporting In Vivo Experiments (ARRIVE), Consolidated Health Economic Evaluation Reporting Standards (CHEERS), and Meta-analysis of Observational Studies in Epidemiology (MOOSE) were examined. Our inclusion criteria included reviews published between January 1996 to September 2016 which investigated the adherence to reporting guidelines in the literature that addressed clinical trials, systematic reviews, observational studies, meta-analysis, diagnostic accuracy, economic evaluations, and preclinical animal studies that were in English. All reviews were found on Web of Science, Excerpta Medical Database (EMBASE), MEDLINE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL).

RESULTS

Among the general searching of 26,819 studies by using the designed searching method, 124 studies were included post screening. We found that 87.9% of the included studies reported suboptimal adherence to reporting guidelines. Factors associated with poor adherence included non-pharmacological interventions, year of publication, and trials concluding with significant results. Improved adherence was associated with better study designs such as allocation concealment, random sequence, large sample sizes, adequately powered studies, multiple authorships, and being published in journals endorsing guidelines.

CONCLUSION

We conclude that the level of adherence to reporting guidelines remains suboptimal. Endorsement of reporting guidelines by journals is important and recommended.

The association between cannabis use and suicidal behavior in patients with psychiatric disorders: an analysis of sex differences

BACKGROUND

Cannabis is the most commonly used illicit drug. In the general population, its use has been linked to a heightened propensity for suicidal behavior (SB). We hypothesize that this association varies in patients with psychiatric disorders. SB is known to vary by sex and therefore an investigation of cannabis' association with SB must consider sex differences. The purpose of this study is to investigate the association between cannabis use and suicide attempts in men and women with psychiatric disorders.

METHODS

We merged data collected for two studies based in Ontario, Canada (n = 985). We employed a multivariable logistic regression to assess the association between cannabis use and suicide attempts in men and women with psychiatric disorders.

RESULTS

We analyzed data from 465 men and 444 women. Amongst these, 112 men and 158 women had attempted suicide. The average age of our participants was 40 years (standard deviation (SD) 12.4). We found no significant association between suicide attempts and cannabis use in men (odds ratio (OR) = 1.34, 95% confidence interval (CI) 0.81, 2.22, p = 0.260) or women (OR = 0.97, 95% CI 0.61, 1.54, p = 0.884). In a sensitivity analysis using a sample of patients with substance use disorder only, the heaviness of cannabis use was associated with small but significant association with SB in men (OR = 1.03, 95% CI 1.01, 1.05, p = 0.007).

CONCLUSION

Our findings indicate that there is no association between cannabis use and suicidal behavior in men or women with psychiatric disorders unlike what was reported for the general population, though the heaviness of cannabis use may have an effect in men. The impact of cannabis use in psychiatric disorders needs ongoing examination in light of its common use, impending legalization with expected increased access and the uncertainty about cannabis' effects on prognosis of psychiatric disorders. In addition, research should continue to investigate modifiable risk factors of SB in this population of which cannabis is not a significant factor based on this study.

Profile of suicide attempts and risk factors among psychiatric patients: A case-control study

BACKGROUND

Suicidal behaviour remains challenging for clinicians to predict, with few established risk factors and warning signs among psychiatric patients.

AIM

We aimed to describe characteristics and identify risk factors for suicide attempts among patients with psychiatric disorders.

METHODS

Multivariable logistic regression analysis, adjusted for clinically important confounders, was employed to determine risk factors for suicide attempts within a psychiatric patient population.

RESULTS

The case (n = 146) and control groups (n = 104) did not differ significantly with regards to sociodemographic characteristics. The majority of the participants who had attempted suicide did so with high intent to die, and expected to die without medical intervention. The primary method of attempt was pharmaceutical overdose among the case participants (73.3%). Results showed impulsivity (odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.03-1.30) and borderline personality symptoms (OR = 1.07, 95% CI = 1.01-1.13) were significantly associated with attempted suicide.

CONCLUSIONS

Our findings indicate that known sociodemographic risk factors for suicide may not apply within psychiatric populations. Prevention strategies for suicidal behaviour in psychiatric patients may be effective, including limited access to means for suicide attempts (i.e. excess pharmaceutical drugs) and target screening for high-risk personality and impulsivity traits.

Treatment outcomes in patients with opioid use disorder initiated by prescription: a systematic review protocol

BACKGROUND

In North America, opioid use has become a public health crisis with policy makers declaring it a state of emergency. Opioid substitution therapy (OST) is a harm-reduction method used in treating opioid use disorder. While OST has shown to be successful in improving treatment outcomes, there is still a great degree of variability among patients. This cohort of patients has shifted from young males using heroin to a greater number of older people and women using prescription opioids. The primary objective of this review is to examine the literature on the association between the first exposure to opioids through prescription versus illicit use and OST treatment outcomes.

METHOD

An electronic search will be conducted on the EMBASE, MEDLINE, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Two independent reviewers will conduct the initial title and abstract screenings using predetermined criteria for inclusion and exclusion. Reviewers will then conduct full-text data extraction using a pilot-tested data extraction form in duplicate. A third author will resolve disagreements if consensus cannot be reached. Quality and risk of bias assessment will be conducted along with a sensitivity analysis for all included studies. Qualitative summary of the evidence will be provided, and when possible, a meta-analysis will be conducted, along with heterogeneity calculation. The reporting of this protocol follows the PRISMA-P.

DISCUSSION

We expect that this review will help determine whether patients that were initially exposed to opioids through a prescription differ in OST treatment outcomes in comparison to people who used opioids through illicit means. We hope that this review will provide evidence related to prescription opioids exposure and future treatment outcomes, which will aid clinicians in their decisions to prescribe opioids or not for specific populations at risk.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017058143.

A systematic review of comparisons between protocols or registrations and full reports in primary biomedical research

BACKGROUND

Prospective study protocols and registrations can play a significant role in reducing incomplete or selective reporting of primary biomedical research, because they are pre-specified blueprints which are available for the evaluation of, and comparison with, full reports. However, inconsistencies between protocols or registrations and full reports have been frequently documented. In this systematic review, which forms part of our series on the state of reporting of primary biomedical, we aimed to survey the existing evidence of inconsistencies between protocols or registrations (i.e., what was planned to be done and/or what was actually done) and full reports (i.e., what was reported in the literature); this was based on findings from systematic reviews and surveys in the literature.

METHODS

Electronic databases, including CINAHL, MEDLINE, Web of Science, and EMBASE, were searched to identify eligible surveys and systematic reviews. Our primary outcome was the level of inconsistency (expressed as a percentage, with higher percentages indicating greater inconsistency) between protocols or registration and full reports. We summarized the findings from the included systematic reviews and surveys qualitatively.

RESULTS

There were 37 studies (33 surveys and 4 systematic reviews) included in our analyses. Most studies (n = 36) compared protocols or registrations with full reports in clinical trials, while a single survey focused on primary studies of clinical trials and observational research. High inconsistency levels were found in outcome reporting (ranging from 14% to 100%), subgroup reporting (from 12% to 100%), statistical analyses (from 9% to 47%), and other measure comparisons. Some factors, such as outcomes with significant results, sponsorship, type of outcome and disease speciality were reported to be significantly related to inconsistent reporting.

CONCLUSIONS

We found that inconsistent reporting between protocols or registrations and full reports of primary biomedical research is frequent, prevalent and suboptimal. We also identified methodological issues such as the need for consensus on measuring inconsistency across sources for trial reports, and more studies evaluating transparency and reproducibility in reporting all aspects of study design and analysis. A joint effort involving authors, journals, sponsors, regulators and research ethics committees is required to solve this problem.

A scoping review of comparisons between abstracts and full reports in primary biomedical research

BACKGROUND

Evidence shows that research abstracts are commonly inconsistent with their corresponding full reports, and may mislead readers. In this scoping review, which is part of our series on the state of reporting of primary biomedical research, we summarized the evidence from systematic reviews and surveys, to investigate the current state of inconsistent abstract reporting, and to evaluate factors associated with improved reporting by comparing abstracts and their full reports.

METHODS

We searched EMBASE, Web of Science, MEDLINE, and CINAHL from January 1st 1996 to September 30th 2016 to retrieve eligible systematic reviews and surveys. Our primary outcome was the level of inconsistency between abstracts and corresponding full reports, which was expressed as a percentage (with a lower percentage indicating better reporting) or categorized rating (such as major/minor difference, high/medium/low inconsistency), as reported by the authors. We used medians and interquartile ranges to describe the level of inconsistency across studies. No quantitative syntheses were conducted. Data from the included systematic reviews or surveys was summarized qualitatively.

RESULTS

Seventeen studies that addressed this topic were included. The level of inconsistency was reported to have a median of 39% (interquartile range: 14% - 54%), and to range from 4% to 78%. In some studies that separated major from minor inconsistency, the level of major inconsistency ranged from 5% to 45% (median: 19%, interquartile range: 7% - 31%), which included discrepancies in specifying the study design or sample size, designating a primary outcome measure, presenting main results, and drawing a conclusion. A longer time interval between conference abstracts and the publication of full reports was found to be the only factor which was marginally or significantly associated with increased likelihood of reporting inconsistencies.

CONCLUSIONS

This scoping review revealed that abstracts are frequently inconsistent with full reports, and efforts are needed to improve the consistency of abstract reporting in the primary biomedical community.

Acceptability of the Fitbit in behavioural activation therapy for depression: a qualitative study

INTRODUCTION

Major depressive disorder is characterised by low mood and poor motivation. Literature suggests that increased physical activity has positive effects on alleviating depression. Fitness-tracking devices may complement behavioural activation (BA) therapy to improve physical activity and mental health in patients with depression.

OBJECTIVES

To understand patients' perceived benefit from the Fitbit and explore themes associated with patient experiences. To compare perceived benefit, patient factors, Fitbit usage and Beck's Depression Inventory (BDI) scores.

METHODS

Semistructured interviews were conducted with patients (n=36) who completed a 28-week BA group programme in a mood disorders outpatient clinic. All patients were asked to carry a Fitbit One device. We conducted thematic analyses on the interviews and exploratory quantitative analyses on patient characteristics, Fitbit usage, steps recorded, perceived benefit and BDI scores.

FINDINGS

Twenty-three patients found the Fitbit helpful for their physical activity. Themes of positive experiences included self-awareness, peer motivation and goal-setting opportunities. Negative themes included inconvenience, inaccuracies and disinterest. Age, baseline and change in BDI scores, prior physical activity goals and familiarity with technology were not associated with perceived benefit from the Fitbit or usage. Perceived benefit was significantly (p<0.01) associated with usage.

CONCLUSIONS

Overall, the Fitbit is an acceptable tool to complement BA therapy for patients with depression. Many positive themes were concordant with current literature; however, patients also reported negative aspects that may affect use.

CLINICAL IMPLICATIONS

Clinicians and researchers should consider both strengths and limitations of activity trackers when implementing them to motivate patients with depression.

TRIAL REGISTRATION NUMBER

NCT02045771; Pre-results.

Adverse outcomes associated with opioid prescription for acute low back pain: a systematic review protocol

BACKGROUND

Acute low back pain (ALBP) is the top cause of global disability, demonstrating a significant impact on individuals and society and demanding the need for appropriate management. There is a trend towards an increasing number of opioid prescriptions for ALBP despite the lack of investigation for its various short- and long-term outcomes. The objective of this review is to examine adverse outcomes associated with opioid use for ALBP.

METHODS/DESIGN

Using a search strategy, the search will be conducted using the following electronic databases: PubMed/MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Cochrane Library, the National Institutes for Health Clinical Trials Registry and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We will include randomized clinical trials and observational studies investigating the impact of opioid use in ALBP in the adult population. All phases of screening, data extraction and assessment of methodological quality will be performed by two independent reviewers. We will perform quality and risk of bias assessment for the included articles and compare high and low risk of bias with a sensitivity analysis. We will conduct random- and fixed-effects meta-analyses with heterogeneity calculated using the I ² statistic and evaluate publication bias.

DISCUSSION

There are current guidelines published to alert clinicians in prescribing opioids for ALBP due to its likelihood of misuse, yet there is little change in prescribing patterns. To date, there is an absence of systematic information about the outcomes of prescription opioid in patients with ALBP. We will address this gap by providing evidence that will be useful for clinical practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016033090.

Evaluating the evidence for macrophage presence in skeletal muscle and its relation to insulin resistance in obese mice and humans: a systematic review protocol

Objectives

The current global rates of obesity and type 2 diabetes are staggering. In order to implement effective management strategies, it is imperative to understand the mechanisms of obesity-induced insulin resistance and diabetes. Macrophage infiltration and inflammation of the adipose tissue in obesity is a well-established paradigm, yet the role of macrophages in muscle inflammation, insulin resistance and diabetes is not adequately studied. In this systematic review, we will examine the evidence for the presence of macrophages in skeletal muscle of obese humans and mice, and will assess the association between muscle macrophages and insulin resistance. We will identify published studies that address muscle macrophage content and phenotype, and its association with insulin resistance. We will search MEDLINE/PubMed, EMBASE, and Web of Science for eligible studies. Grey literature will be searched in ProQuest. Quality assessment will be conducted using the Systematic Review Centre for Laboratory Animal Experimentation risk of bias Tool for animal studies.

Results

The findings of this systematic review will shed light on immune-metabolic crosstalk in obesity, and allow the consideration of targeted therapies to modulate muscle macrophages in the treatment and prevention of diabetes. The review will be published in a peer-reviewed journal and presented at conferences.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2686-6) contains supplementary material, which is available to authorized users.

Association between cannabis use and methadone maintenance treatment outcomes: an investigation into sex differences

Background

Cannabis will soon become legalized in Canada, and it is currently unclear how this will impact public health. Methadone maintenance treatment (MMT) is the most common pharmacological treatment for opioid use disorder (OUD), and despite its documented effectiveness, a large number of patients respond poorly and experience relapse to illicit opioids. Some studies implicate cannabis use as a risk factor for poor MMT response. Although it is well established that substance-use behaviors differ by sex, few of these studies have considered sex as a potential moderator. The current study aims to investigate sex differences in the association between cannabis use and illicit opioid use in a cohort of MMT patients.

Methods

This multicentre study recruited participants on MMT for OUD from Canadian Addiction Treatment Centre sites in Ontario, Canada. Sex differences in the association between any cannabis use and illicit opioid use were investigated using multivariable logistic regression. A secondary analysis was conducted to investigate the association with heaviness of cannabis use.

Results

The study included 414 men and 363 women with OUD receiving MMT. Cannabis use was significantly associated with illicit opioid use in women only (OR = 1.82, 95% CI 1.18, 2.82, p = 0.007). Heaviness of cannabis use was not associated with illicit opioid use in men or women.

Conclusions

This is the largest study to date examining the association between cannabis use and illicit opioid use. Cannabis use may be a sex-specific predictor of poor response to MMT, such that women are more likely to use illicit opioids if they also use cannabis during treatment. Women may show improved treatment outcomes if cannabis use is addressed during MMT.

"Don't Judge a Book Its Cover": A Qualitative Study of Methadone Patients' Experiences of Stigma

Introduction:

Despite its efficacy and widespread use, methadone maintenance treatment (MMT) continues to be widely stigmatized. Reducing the stigma surrounding MMT will help improve the accessibility, retention, and treatment outcomes in MMT.

Methods:

Semi-structured interviews were conducted with 18 adults undergoing MMT. Thematic content analysis was used to identify overarching themes.

Results:

In total, 78% of participants reported having experienced stigma surrounding MMT. Common stereotypes associated with MMT patients included the following: methadone as a way to get high, incompetence, untrustworthiness, lack of willpower, and heroin junkies. Participants reported that stigma resulted in lower self-esteem; relationship conflicts; reluctance to initiate, access, or continue MMT; and distrust toward the health care system. Public awareness campaigns, education of health care workers, family therapy, and community meetings were cited as potential stigma-reduction strategies.

Discussion and Conclusion:

Stigma is a widespread and serious issue that adversely affects MMT patients’ quality of life and treatment. More efforts are needed to combat MMT-related stigma.

Body Mass Index Is an Important Predictor for Suicide: Results from a Systematic Review and Meta-Analysis

Public health concerns for the independent management of obesity and suicidal behavior are rising. Emerging evidence suggests body weight plays an important role in quantifying the risk of suicide. In light of these findings, we aimed to clarify the association between body mass index (BMI) and suicidal behavior by systematically reviewing and evaluating the literature. Studies were identified by searching MEDLINE, EMBASE, PsycINFO, and CINAHL from inception to January 2015, supplemented by hand and grey literature searches. Study screening, data extraction, and risk of bias assessment were conducted in duplicate. We included 38 observational studies. Meta-analyses supported an inverse association between BMI and completed suicide. Pooled summary estimates demonstrated that underweight was significantly associated with an increased risk of completed suicide (HR = 1.21, 95% CI 1.07 to 1.36, p = .002), and obesity (HR = 0.71, 95% CI 0.56 to 0.89, p = .003) and overweight (HR = 0.78, 95% CI 0.75 to 0.82, p < .0001) were significantly associated with a decreased risk of completed suicide relative to normal weight. A qualitative summary of the literature demonstrated conflicting evidence regarding the association between BMI and attempted suicide and revealed no association between BMI and suicidal ideation. BMI may be used to aid the assessment of suicide risk, especially that of completed suicide. However, unmeasured confounders and systematic biases of individual studies limit the quality of evidence.

Efficacy and safety of psychostimulants for amphetamine and methamphetamine use disorders: a systematic review and meta-analysis

BACKGROUND

Amphetamine and methamphetamine use disorders are associated with severe health and social consequences. No pharmacological therapy has been approved for the treatment of these disorders. Psychostimulants can act as maintenance-like therapies for managing substance use among these patients. The aim of this study is to evaluate the literature examining the efficacy and safety of psychostimulant agents for increasing abstinence and treatment retention among patients with amphetamine and methamphetamine use disorders.

METHODS

We searched MEDLINE, EMBASE, PsycInfo, Cochrane Central, and CINAHL from inception to August 2016. Selection of studies, data extraction, and risk of bias assessment were conducted independently by two reviewers. We conducted meta-analyses to provide a pooled summary estimate for included trials and report the review according to PRISMA guidelines.

RESULTS

We identified and selected 17 studies with 1387 participants. Outcome reporting across trials was inconsistent, and the overall quality of evidence was very low due to high risk of bias and indirectness. A meta-analysis of five trials (642 participants) found no effect of psychostimulants for end-of-study abstinence (odds ratio = 0.97, 95% confidence interval 0.65 to 1.45). Additionally, the pooled estimate from 14 studies (1184 participants) showed no effect of psychostimulants for treatment retention (odds ratio = 1.20, 95% confidence interval = 0.91 to 1.58). The incidence of serious adverse events did not differ between intervention and placebo groups based on qualitative reports from trials.

CONCLUSIONS

Quantitative analyses showed no effect of psychostimulants for sustained abstinence or treatment retention. We also identified the need for more rigorous studies in this research area with clinician and patient important outcomes.

Association between cannabis use and treatment outcomes in patients receiving methadone maintenance treatment: a systematic review protocol

BACKGROUND

With the non-medical use of prescription opioids increasingly becoming a method of abuse in Canada, the number of patients requiring methadone maintenance treatment (MMT) for opioid use disorder has increased dramatically. The rate of cannabis use in this population is disproportionately high (~50 %). Because its use is generally perceived as harmless, cannabis use is often not monitored during MMT. Current literature regarding the effects of cannabis use on MMT is conflicting, and the presence and nature of an association has not been clearly established. The primary objective of this review will be to conduct a systematic review of the literature and, if appropriate, a meta-analysis to determine whether there is an association between cannabis use and MMT outcomes. A secondary objective will be to perform subgroup analyses (by age, sex, method of cannabis measurement, and country) to determine whether cannabis use differentially influences MMT outcomes within these subgroups.

METHODS/DESIGN

The search will be conducted on the following electronic databases using a predefined search strategy: MEDLINE, EMBASE, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Two authors (LZ and MB) will independently screen articles using predetermined inclusion/exclusion criteria and will extract data from included articles using a pilot-tested data extraction form. Disagreements at all stages of the screening process will be settled through discussion, and when consensus cannot be reached, a third author (ZS) will be consulted. An assessment of quality and risk of bias will be conducted on all included articles, and a sensitivity analysis will be used to compare results of studies with high and low risk of bias. We will perform random- and fixed-effects meta-analyses, if appropriate, with heterogeneity calculated using the I (2) statistic and formal evaluation of publication bias.

DISCUSSION

Results of this systematic review will elucidate the association between cannabis use and methadone maintenance treatment outcomes. We will provide evidence that will be useful to clinicians regarding whether monitoring cannabis use during MMT is advantageous for optimizing MMT outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015029372.

Effect of non-genetic factors on the prevalence of Stilesia globipunctata in the goat

Despite its high prevalence and pathogenicity, Stilesia globipunctata is a neglected cestode infection of ruminants in the tropics and sub-tropics. The present study reports the effect of sex, age, year and month on the prevalence of S. globipunctata in the goat. A total of 5208 eviscerated intestines of the goat carcasses were screened for a period of seven years, from January 2001 to December 2007. The overall prevalence of 36.6 % was significantly affected by the factors studied (P<0.05). Male goats were more susceptible to the S. globipunctata infection than that of female (P<0.05). Goat aged between 6 months and 1 year were found to be significantly more susceptible (P<0.05) which was followed by animals between 1 and 4 years of age and then more than 4 years of age. Morbidity was high (59 to 86 %) in animals of less than one year of age. The striking observation was that the prevalence peaked during monsoon and at nadir in May.

Light therapy for non-seasonal depression: systematic review and meta-analysis

BACKGROUND

Light therapy is a known treatment for patients with seasonal affective disorder. However, the efficacy of light therapy in treating patients with non-seasonal depression remains inconclusive.

AIMS

To provide the current state of evidence for efficacy of light therapy in non-seasonal depressive disorders.

METHOD

Systematic review of randomised controlled trials (RCTs) was conducted by searching MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL from their inception to September 2015. Study selection, data abstraction and risk of bias assessment were independently conducted in duplicate. Meta-analyses were performed to provide a summary statistic for the included RCTs. The reporting of this systematic review follows the PRISMA guidelines.

RESULTS

A meta-analysis including 881 participants from 20 RCTs demonstrated a beneficial effect of light therapy in non-seasonal depression (standardised mean difference in depression score -0.41 (95% CI -0.64 to -0.18)). This estimate was associated with significant heterogeneity (I2=60%, P=0.0003) that was not sufficiently explained by subgroup analyses. There was also high risk of bias in the included trials limiting the study interpretation.

CONCLUSIONS

The overall quality of evidence is poor due to high risk of bias and inconsistency. However, considering that light therapy has minimal side-effects and our meta-analysis demonstrated that a significant proportion of patients achieved a clinically significant response, light therapy may be effective for patients with non-seasonal depression and can be a helpful additional therapeutic intervention for depression.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Computational Fluid Dynamic Simulations of Maternal Circulation: Wall Shear Stress in the Human Placenta and Its Biological Implications

Introduction

In the human placenta the maternal blood circulates in the intervillous space (IVS). The syncytiotrophoblast (STB) is in direct contact with maternal blood. The wall shear stress (WSS) exerted by the maternal blood flow on the STB has not been evaluated. Our objective was to determine the physiological WSS exerted on the surface of the STB during the third trimester of pregnancy.

Material and Methods

To gain insight into the shear stress levels that the STB is expected to experience in vivo, we have formulated three different computational models of varying levels of complexity that reflect different physical representations of the IVS. Computations of the flow fields in all models were performed using the CFD module of the finite element code COMSOL Multiphysics 4.4. The mean velocity of maternal blood in the IVS during the third trimester was measured in vivo with dynamic MRI (0.94±0.14 mm.s^-1). To investigate if the in silico results are consistent with physiological observations, we studied the cytoadhesion of human parasitized (Plasmodium falciparum) erythrocytes to primary human STB cultures, in flow conditions with different WSS values.

Results

The WSS applied to the STB is highly heterogeneous in the IVS. The estimated average values are relatively low (0.5±0.2 to 2.3±1.1 dyn.cm^-2). The increase of WSS from 0.15 to 5 dyn.cm^-2 was associated with a significant decrease of infected erythrocyte cytoadhesion. No cytoadhesion of infected erythrocytes was observed above 5 dyn.cm^-2 applied for one hour.

Conclusion

Our study provides for the first time a WSS estimation in the maternal placental circulation. In spite of high maternal blood flow rates, the average WSS applied at the surface of the chorionic villi is low (<5 dyn.cm^-2). These results provide the basis for future physiologically-relevant in vitro studies of the biological effects of WSS on the STB.