Showing papers by "Deborah J. Cook published in 1996"
TL;DR: When used for vessel location andCatheter placement real-time, ultrasound guidance or Doppler ultrasound guidance improves success rates and decreases the complications associated with internal jugular and subclavian venous catheter placement.
Abstract: ObjectiveTo evaluate the effect of real-time ultrasound guidance using a regular or Doppler ultrasound technique for placement of central venous catheters.Data SourcesWe searched for published and unpublished research using MEDLINE, citation review of relevant primary and review articles, conference
893 citations
TL;DR: A meta-analysis of randomised controlled trials of respiratory rehabilitation in patients with COPD found that it relieves dyspnoea and improves the control over COPD, and the value of the improvement in exercise capacity is not clear.
794 citations
TL;DR: There is strong evidence of reduced clinically important gastrointestinal bleeding with histamine2-receptor antagonists and sucralfate may be as effective in reducing bleeding as gastric pH—altering drugs and is associated with lower rates of pneumonia and mortality.
Abstract: Purpose. —To resolve discrepancies in previous systematic overviews and provide estimates of the effect of stress ulcer prophylaxis on gastrointestinal bleeding, pneumonia, and mortality in critically ill patients. Data Identification. —Computerized search of published and unpublished research, bibliographies, pharmaceutical and personal files, and conference abstract reports. Study Selection. —Independent review of 269 articles identified 63 relevant randomized trials for inclusion. Data Abstraction. —We made independent, duplicate assessment of the methodologic quality, population, intervention, and outcomes of each trial. Results. —The source of discrepancies between prior meta-analyses included incomplete identification of relevant studies, differential inclusion of non—English language and nonrandomized trials, different definitions of bleeding, provision of additional information through direct correspondence with authors, and different statistical methods. The current overview demonstrates that prophylaxis with histamine2-receptor antagonists decreases the incidence of overt gastrointestinal bleeding (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.42 to 0.79) and clinically important bleeding (OR, 0.44; 95% CI, 0.22 to 0.88). There is a trend toward decreased overt bleeding when antacids are compared with no therapy (OR, 0.66; 95% CI, 0.37 to 1.17). Histamine2-receptor antagonists and antacids are associated with a trend toward lower clinically important bleeding rates than sucralfate is. There is a trend toward an increased risk of pneumonia associated with histamine2-receptor antagonists as compared with no prophylaxis (OR, 1.25; 95% CI, 0.78 to 2.00). Sucralfate is associated with a lower incidence of nosocomial pneumonia when compared with antacids (OR, 0.80; 95% CI, 0.56 to 1.15) and histamine2-receptor antagonists (OR, 0.77; 95% CI, 0.60 to 1.01). Sucralfate is also associated with a reduced mortality rate (OR, 0.73; 95% CI, 0.54 to 0.97) relative to antacids and to histamine2-receptor antagonists (OR, 0.83; 95% CI, 0.63 to 1.09). Conclusions. —Our results emphasize the need for registries to include all randomized trials and demonstrate the importance of explicit methodology for systematic reviews. There is strong evidence of reduced clinically important gastrointestinal bleeding with histamine2-receptor antagonists. Sucralfate may be as effective in reducing bleeding as gastric pH—altering drugs and is associated with lower rates of pneumonia and mortality. However, the data are insufficient to determine the net effect of sucralfate compared with no prophylaxis. (JAMA. 1996;275:308-314)
554 citations
TL;DR: Interventions designed to achieve supraphysiologic goals of cardiac index, DO2, and VO2 did not significantly reduce mortality rates in all critically ill patients, however, there may be a benefit in those patients in which the therapy is initiated preoperatively.
Abstract: Objective : To systematically review the effect of interventions designed to achieve supraphysiologic values of cardiac index, oxygen delivery (Do 2 ), and oxygen consumption (Vo 2 ) in critically ill patients. Data Sources : Computerized bibliographic search of published research, citation review of relevant articles, and contact with primary investigators. Study Selection : We included all randomized clinical trials of adult intensive care unit (ICU) patients that evaluated interventions (fluids, inotropes, and vasoactive drugs) designed to achieve supraphysiologic values of cardiac index, Do 2 , andlor Vo 2 . Independent review of 64 articles identified seven relevant studies of 1,016 patients. Data Extraction : We abstracted data on the population, interventions, outcomes, and methodologic quality of the studies by duplicate independent review. Agreement was high (weighted kappa 0.73) ; differences were resolved by consensus. Data Synthesis : Targeting therapy to achieve supraphysiologic end points in critically ill patients is associated with a nonstatistically significant trend toward decreased mortality rates (relative risk 0.86, 95% confidence intervals 0.62 to 1.20). For the two studies in which supraphysiologic goals were initiated preoperatively, the relative risk was 0.20 (95% confidence intervals 0.07 to 0.55). This value differed significantly from the combined estimate of the remaining studies, in which the intervention was started after ICU admission (relative risk 0.98, 95% confidence intervals 0.79 to 1.22 ; p <.01). However, there are several methodologic problems with the primary studies. In no trials were caregivers or outcome assessors blinded to treatment allocation. Only three of seven trials analyzed patients according to the group to which they were allocated. None adequately controlled for cointerventions, and there was considerable crossover between groups (patients in the control group achieved the goals of the intervention group and vice versa). Conclusions : Interventions designed to achieve supraphysiologic goals of cardiac index, Do 2 , and Vo 2 did not significantly reduce mortality rates in all critically ill patients. However, there may be a benefit in those patients in which the therapy is initiated preoperatively. Methodologic limitations weaken the inferences that can be drawn from these studies and preclude any evidence-based clinical recommendations.
328 citations
TL;DR: Calcium supplementation may lead to a small reduction in systolic but not diastolic blood pressure, and further studies should address the hypothesis that inadequate calcium intake is associated with increased blood pressure that can be corrected with calcium supplementation.
Abstract: Objective. —To review the effect of supplemental calcium on blood pressure. Data Source. —We searched MEDLINE and EMBASE for 1966 to May 1994. We contacted authors of eligible trials to ensure accuracy and completeness of data and to identify unpublished trials. Study Selection. —We included any study in which investigators randomized people to calcium supplementation or placebo and measured blood pressure for at least 2 weeks. Fifty-six articles met the inclusion criteria, and 33 were eligible for analysis, involving a total of 2412 patients. Data Extraction. —Two pairs of independent reviewers abstracted data and assessed validity according to six quality criteria. Data Synthesis. —We calculated the differences in blood pressure change between the calcium supplementation group and the control group and pooled the estimates, with each trial weighted with the inverse of the variance using a random-effects model. Predictors of blood pressure reduction that we examined included method of supplementation, baseline blood pressure, and the methodological quality of the studies. The pooled analysis showed a reduction in systolic blood pressure of -1.27 mm Hg (95% confidence interval [CI], -2.25 to -0.29 mm Hg;P=.01) and in diastolic blood pressure of -0.24 mm Hg (95% CI, -0.92 to 0.44 mm Hg;P=.49). None of the possible mediators of blood pressure reduction explained differences in treatment effects. Conclusions. —Calcium supplementation may lead to a small reduction in systolic but not diastolic blood pressure. The results do not exclude a larger, important effect of calcium on blood pressure in subpopulations. In particular, further studies should address the hypothesis that inadequate calcium intake is associated with increased blood pressure that can be corrected with calcium supplementation. (JAMA. 1996;275:1016-1022)
296 citations
TL;DR: In this article, the authors compared the efficacy, nephrotoxicity, and ototoxicity of once-daily aminoglycoside dosing with those of standard aminoglobal peptide regimens in immunocompetent adults.
Abstract: Objective : To compare the efficacy, nephrotoxicity, and ototoxicity of once-daily aminoglycoside dosing with those of standard aminoglycoside regimens in immunocompetent adults. Data Sources : A structured MEDLINE search from 1966 to April 1995 using the keywords aminoglycosides, drug administration schedule, and adult ; bibliographic searching of review articles, position papers, and references of the selected articles ; contact with primary authors of selected articles to obtain information not in the published reports and lists of potentially relevant articles. Study Selection : Randomized, controlled trials that 1) compared an intravenous once-daily aminoglycoside regimen with a standard aminoglycoside regimen in infected immunocompetent adults and 2) examined efficacy, mortality, or toxicity. Data Extraction : For each selected study, two independent reviewers assessed methodologic quality and abstracted data. The heterogeneity of individual study risk ratios was assessed and data were pooled using a random-effects model. Results : Forty-two studies were reviewed for possible inclusion. Thirteen independent studies met the selection criteria, and their results were pooled. The trials had a mean methodologic quality score of 0.69 (range, 0.50 to 0.91). Heterogeneity exists among the individual risk ratios for clinical cure (P = 0.07) ; significant heterogeneity does not exist for the other outcomes. For the pooled efficacy outcomes, the risk ratio for bacteriologic cure is 1.02 (95% CI, 0.99 to 1.05), and the risk ratio for mortality is 0.91 (CI, 0.63 to 1.31). For the pooled toxicity outcomes, the risk ratio for nephrotoxicity is 0.87 (CI, 0.60 to 1.26), and the risk ratio for ototoxicity is 0.67 (CI, 0.35 to 1.28). Conclusions : Standard and once-daily aminoglycoside dosing regimens are equivalent with regard to bacteriologic cure, and once-daily dosing shows a trend toward reduced mortality and toxicity. However, additional studies are needed for more precise estimates of mortality and toxicity risk ratios. The equivalency of the dosing regimens, the ease of administration, reduced nursing time, and reduced variability in the timing of drug administration that are associated with once-daily dosing may mean that the once-daily regimen is clinically advantageous.
256 citations
TL;DR: There is strong evidence of reduced clinically important gastrointestinal bleeding with histamine2-receptor antagonists and sucralfate is as effective in reducing bleeding as gastric pH-altering drugs and is associated with lower rates of pneumonia and mortality.
Abstract: Purpose. —To resolve discrepancies in previous systematic overviews and provide estimates of the effect of stress ulcer prophylaxis on gastrointestinal bleeding, pneumonia, and mortality in critically ill patients. Data Identification. —Computerized search of published and unpublished research, bibliographies, pharmaceutical and personal files, and conference abstract reports. Study Selection. —Independent review of 269 articles identified 63 relevant randomized trials for inclusion. Data Abstraction. —We made independent, duplicate assessment of the methodologic quality, population, intervention, and outcomes of each trial. Results. —The source of discrepancies between prior meta-analyses included incomplete identification of relevant studies, differential inclusion of non—English language and nonrandomized trials, different definitions of bleeding, provision of additional information through direct correspondence with authors, and different statistical methods. The current overview demonstrates that prophylaxis with histamine2-receptor antagonists decreases the incidence of overt gastrointestinal bleeding (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.42 to 0.79) and clinically important bleeding (OR, 0.44; 95% CI, 0.22 to 0.88). There is a trend toward decreased overt bleeding when antacids are compared with no therapy (OR, 0.66; 95% CI, 0.37 to 1.17). Histamine2-receptor antagonists and antacids are associated with a trend toward lower clinically important bleeding rates than sucralfate is. There is a trend toward an increased risk of pneumonia associated with histamine2-receptor antagonists as compared with no prophylaxis (OR, 1.25; 95% CI, 0.78 to 2.00). Sucralfate is associated with a lower incidence of nosocomial pneumonia when compared with antacids (OR, 0.80; 95% CI, 0.56 to 1.15) and histamine2-receptor antagonists (OR, 0.77; 95% CI, 0.60 to 1.01). Sucralfate is also associated with a reduced mortality rate (OR, 0.73; 95% CI, 0.54 to 0.97) relative to antacids and to histamine2-receptor antagonists (OR, 0.83; 95% CI, 0.63 to 1.09). Conclusions. —Our results emphasize the need for registries to include all randomized trials and demonstrate the importance of explicit methodology for systematic reviews. There is strong evidence of reduced clinically important gastrointestinal bleeding with histamine2-receptor antagonists. Sucralfate may be as effective in reducing bleeding as gastric pH—altering drugs and is associated with lower rates of pneumonia and mortality. However, the data are insufficient to determine the net effect of sucralfate compared with no prophylaxis. (JAMA. 1996;275:308-314)
228 citations
TL;DR: It may not be harmful to follow biochemical and clinical status even in the presence of nonspecific symptoms potentially associated with hypothyroidism, and no measure of symptoms or HRQL either showed clinically important trends in favor of treatment, or approached conventional levels of statistical significance.
Abstract: OBJECTIVE: To determine if health-related quality of life (HRQL) in patients of middle age and older with elevated thyroid-stimulating hormone (TSH) and normal total thyroid hormone levels—subclinical hypothyroidism—improves withl-thyroxine replacement therapy. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Outpatient clinic. PATIENTS: Thirty-seven patients with subclinical hypothyroidism, most with symptoms consistent with hypothyroidism, over 55 years of age. INTERVEJVTIOJVS: Placebo or L-thyroxine replacement therapy to achieve normal TSH level. MEASUREMENTS AND MAIN RESULTS: Disease-specific and general HRQL, cognitive function, bone mineral density, lipid levels. The mean daily dose of L-thyroxine replacement in the active group was 68±21 µg. TSH decreased by 8.6 mIU/L (95% confidence interval [CI] 4.1 to 13.1) and T4 increased by 27.9 nmol/L (95% CI 14.8 to 41.2). There was a statistically significant improvement in a composite psychometric memory score in treated versus control patients; all other outcomes showed similar findings in the two groups. Although confidence intervals for most measures did not exclude an important improvement in HRQL with thyroid replacement, no measure of symptoms or HRQL either showed clinically important trends in favor of treatment, or approached conventional levels of statistical significance. CONCLUSIONS: In middle-aged and older patients with elevated TSH and normal T4, it may not be harmful to follow biochemical and clinical status even in the presence of nonspecific symptoms potentially associated with hypothyroidism.
222 citations
TL;DR: Gastric emptying is delayed in critically ill patients and the important consequences of this phenomenon include intolerance to enteral nutrition and gastric colonization, and strategies to minimize the use of narcotics may improve gastric empties.
Abstract: Objective
To measure gastric emptying in critically ill patients using an acetaminophen absorption model and determine which variables are associated with impaired gastric emptying.
222 citations
TL;DR: There is within medicine, somewhere beneath the pessimism and discouragement resulting from the disarray of the health care system and its stupendous cost, an undercurrent of almost outrageous optimism about what may lie ahead for the treatment of human disease if only the authors can keep learning.
Abstract: There is within medicine, somewhere beneath the pessimism and discouragement resulting from the disarray of the health care system and its stupendous cost, an undercurrent of almost outrageous optimism about what may lie ahead for the treatment of human disease if only we can keep learning.
216 citations
TL;DR: An evidence-based approach is outlined to the assessment of preclinical animal studies evaluating novel therapeutic interventions in sepsis and the steps that are necessary to assess the internal validity of an individual study are discussed.
Abstract: Objectives To discuss theoretical and practical aspects relating to the design of animal studies investigating the efficacy of novel therapeutic agents for the treatment of sepsis, and to make explicit the process whereby these studies can be evaluated for the purpose of designing clinical trials in humans. Data Sources Relevant articles from the pertinent literature were reviewed. Study Selection Studies relevant to an evidence-based assessment of clinical studies on therapeutic efficacy, and studies relevant to the design of animal models of sepsis were selected. Data Extraction Concepts relevant to an evidence-based assessment of the animal literature were extracted. Data Synthesis Articles were reviewed and an evidence-based framework for the assessment of animal studies was developed. In this process, we discuss the steps that are necessary to assess the internal validity of an individual study and review topics relevant to the application of animal data to the design of clinical trials. Conclusions The success of clinical trials of sepsis therapies is predicated on the generation and interpretation of sound preclinical data. In this review, we have attempted to outline an evidence-based approach to the assessment of preclinical animal studies evaluating novel therapeutic interventions in sepsis. (Crit Care Med 1996; 24:2059-2070)
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TL;DR: The prevalence of psychological abuse, physical assault and discrimination on the basis of gender and sexual orientation experienced by residents during medical training, prevalence and residents9 perceived frequency of sexual harassment was assessed by as mentioned in this paper.
Abstract: OBJECTIVE: To assess the prevalence of psychological abuse, physical assault, and discrimination on the basis of gender and sexual orientation, and to examine the prevalence and impact of sexual harassment in residency training programs. DESIGN: Self-administered questionnaire. SETTING: McMaster University, Hamilton, Ont. PARTICIPANTS: Residents in seven residency training programs during the academic year from July 1993 to June 1994. Of 225 residents 186 (82.7%) returned a completed questionnaire, and 50% of the respondents were women. OUTCOME MEASURES: Prevalence of psychological abuse, physical assault and discrimination on the basis of gender and sexual orientation experienced by residents during medical training, prevalence and residents9 perceived frequency of sexual harassment. RESULTS: Psychological abuse was reported by 50% of the residents. Some of the respondents reported physical assault, mostly by patients and their family members (14.7% reported assaults by male patients and family members, 9.8% reported assaults by female patients and family members), 5.4% of the female respondents reported assault by male supervising physicians. Discrimination on the basis of gender was reported to be common and was experienced significantly more often by female residents than by male residents (p
TL;DR: In this paper, the authors describe the philosophy and approach to patient care called evidence based medicine, and highlight how it can enhance the practice of intensive care, and describe the benefits of using evidence-based medicine in intensive care.
Abstract: ObjectiveTo describe the philosophy and approach to patient care called evidence based medicine, and to highlight how it can enhance the practice of intensive care.Data SourcesWe searched MEDLINE, reference lists, and our personal files to identify relevant literature.Study SelectionArticles on inte
TL;DR: Evaluation of the jugular venous pulse provides important information about pressure and other hemodynamic events in the right atrium and provides a useful estimate of central venous pressure (CVP) and thus the patient's intravascular volume status.
Abstract: A 65-YEAR-OLD woman has had dyspnea for 2 months. She has had to give up her hobby of hiking and is now short of breath climbing even one flight of stairs. Her dyspnea is sometimes worse at night. She has no chest pain, cough, or sputum, and the review of systems is otherwise negative. On physical examination, her blood pressure is 135/90 mm Hg, and she has a regular cardiac rhythm at a rate of 72 beats per minute. You turn your attention to the jugular veins and next ask yourself, "Does this patient have abnormal central venous pressure?" WHY IS THIS QUESTION IMPORTANT? Evaluation of the jugular venous pulse provides important information about pressure and other hemodynamic events in the right atrium.1-3Via the former, it provides a useful estimate of central venous pressure (CVP) and thus the patient's intravascular volume status. Inspection of the waveforms can assist
TL;DR: It is concluded that cisapride enhances gastric emptying in critically ill patients and studies to examine the effect of cisap Ride on tolerance to enteral nutrition, infectious morbidity, and other clinically important outcomes are warranted.
Abstract: We conducted a randomized, double-blind, placebo-controlled trial in mechanically ventilated intensive care unit (ICU) patients to evaluate the effect of cisapride on gastric emptying using an acetaminophen absorption model. We enrolled 72 patients expected to remain in the ICU for more than 48 h; 39% were female; the average age was 54.0 +/- 19.1 yr; 47% were postoperative, 83% were receiving narcotics, and the mean simplified acute physiology score (SAPS) was 9.5 +/- 3.0. Within 72 h of admission to ICU, 1.6 g of acetaminophen suspension was administered via a nasogastric tube into the stomach (Day 1). Blood samples were drawn at baseline, 30, 60, 90, 120, and 180 min for measurement of plasma acetaminophen levels. The following morning (Day 2), patients were randomized to receive 20 mg of cisapride or placebo and gastric emptying was again assessed. The difference (Day 2-Day 1) in the maximal plasma concentration was 49.1 mumol/L in the cisapride groups compared with 12.3 mumol/L in the placebo group (p = 0.005) and the time to reach maximal concentration was significantly shorter in the cisapride group (-40.8 min versus -4.2 min, p = 0.02). The difference in area under the time-acetaminophen concentration curve was also greater in the patients receiving cisapride (5,534 versus 2,832, p = 0.09). We conclude that cisapride enhances gastric emptying in critically ill patients. Studies to examine the effect of cisapride on tolerance to enteral nutrition, infectious morbidity, and other clinically important outcomes are warranted.
TL;DR: In the critical care literature, very little useful economic information exists to help decision-makers maximize efficiency in their own setting.
Abstract: Objective To determine the extent to which economic evaluations published in the critical care literature provide information that can help us to improve the efficiency of our unit. Data sources We searched computerized bibliographic databases and manually searched key critical care journals to retrieve all economic evaluations. Study selection We included economic evaluations that dealt with clinical problems relevant to the practice of adult critical care and that compared competing healthcare interventions. Data abstraction Included articles were further evaluated using criteria for minimal methodologic soundness, adopted from the literature, and criteria that we developed to assess the generalizability of results to our clinical setting. Data synthesis We screened 4,167 papers manually and > 450 abstracts and titles in our computer search. One hundred fifty-one papers were retrieved for further evaluation; 29 papers met our inclusion criteria. Of these 29 papers, only 14 (48%) adequately described competing healthcare interventions, 17 (59%) provided sufficient evidence of clinical efficacy, six (21%) identified, measured, and valuated costs appropriately, and three (10%) performed a sensitivity analysis. None of the papers met all four of these criteria for a minimum level of methodologic soundness. Four (14%) of 29 studies which adequately dealt with issues of cost and efficacy were evaluated using our generalizability criteria. Different costing methods precluded the application of the results of three of the four studies to our intensive care unit. Conclusions In the critical care literature, very little useful economic information exists to help decision-makers maximize efficiency in their own setting.
TL;DR: In this article, the extent to which residents experience abuse and discrimination in their training was surveyed through a literature review and resident focus groups, and respondents were asked to record the frequency with which they experienced and witnessed different types of abuse during residency training using a 7-point Likert scale.
Abstract: OBJECTIVE: To survey the extent to which internal medicine housestaff experience abuse and discrimination in their training. DESIGN: Through a literature review and resident focus groups, we developed a self-administered questionnaire. In this cross-sectional survey, respondents were asked to record the frequency with which they experienced and witnessed different types of abuse and discrimination during residency training, using a 7-point Likert scale. PARTICIPANTS: Internal medicine housestaff in Canada. MEASUREMENTS AND MAIN RESULTS: Of 543 residents in 13 programs participating (84% response rate), 35% were female. Psychological abuse, as reported by attending physicians (68%), patients (79%), and nurses or other health workers (77%), was widespread. Female residents experienced gender discrimination by attending physicians (70%), patients (88%), and nurses (71%); rates for males were 23%, 38%, and 35%, respectively. Females reported being sexually harassed more often than males, by attending physicians (35% vs 4%,p<.01), peers (30% vs 6%,p<.01), and patients (56% vs 18%,p<.01). Physical assault by patients was experienced by 40% of residents. Half of the residents surveyed reported racial discrimination and homophobic remarks in the workplace, perpetrated by all groups of health professionals. CONCLUSIONS: Psychological abuse, gender discrimination, sexual harassment, physical abuse, homophobia, and racial discrimination are prevalent problems during residency training. Housestaff, medical educators, allied health workers, and the public need to work together to address these problems in the training environment.
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Journal Article•
TL;DR: Anemia is common among elderly patients in hospital, however, iron deficiency is underrecognized and underinvestigated.
Abstract: OBJECTIVE: To determine whether anemia is documented and appropriately investigated for iron deficiency in hospitalized elderly people. DESIGN: Retrospective chart review. SETTING: Medical clinical teaching unit (CTU) in secondary care hospital in Hamilton, Ont. PARTICIPANTS: Consecutive patients 65 years of age or older admitted between April 1992 and March 1993. OUTCOME MEASURES: Proportion of anemic patients for whom documentation was adequate (included in problem list in patient chart) and for whom adequate investigations were performed (measurement of serum ferritin level in anemic patients in whom iron deficiency was suspected, bone-marrow aspiration for those with intermediate probability of iron deficiency after determination of serum ferritin level, and endoscopy of upper or lower gastrointestinal tract, or both, in patients with iron deficiency). RESULTS: Of 183 eligible patients admitted to the CTU 66 (36%) had anemia, in 47 cases (71%) the anemia was documented by house staff or attending physicians. Of the 66 anemic patients 49 had a non-macrocytic anemia of unknown cause: 26 had their serum ferritin level measured, 5 underwent bone-marrow aspiration, and 21 were referred for gastrointestinal endoscopy. Six of eight patients with probable iron deficiency (i.e., a serum ferritin level that was diagnostic [less than 18 micrograms/L] or suggestive [18 to 45 micrograms/L]) underwent endoscopy, two were found to have cancer of the stomach or cecum. Only 26 of the 49 patients had adequate investigation. CONCLUSIONS: Anemia is common among elderly patients in hospital. However, iron deficiency is underrecognized and underinvestigated.
TL;DR: To assess tolerance of intragastric enteral nutrition started within 24 hours of admission to an intensive care unit (ICU), a prospective cohort study evaluated 73 consecutive eligible patients with an expected length of stay and anticipated intolerance to oral nutrition of more than three days.
Abstract: Objective: To assess tolerance of intragastric enteral nutrition started within 24 hours of admission to an intensive care unit (ICU). Design: A prospective cohort study. Setting: A medical/surgical university-affiliated ICU. Subjects: We evaluated 73 consecutive eligible patients with an expected length of stay and anticipated intolerance to oral nutrition of more than three days. We enrolled 45 patients (27 [60%] male), aged 55.4±19.0 years with a mean Simplified Acute Physiology Score (SAPS) of 11.0±4.3. Admitting diagnoses included medical (n=16), trauma (n=13), neurosurgical (n=12) and neurological (n=4) conditions. Interventions: We utilised a protocol in which intragastric feedings were initiated at 10 ml/hr within 24 hours of admission, checking gastric residuals every 4 hours. Every 12 hours, the rate was increased by 25 ml/hr if the residual volume was 200 ml and accompanied by nausea, vomiting or abdominal distension, feeds were discontinued for 4 hour...
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TL;DR: The practical approach presented here will allow clinicians to conduct their own N of 1 RCTs and is potentially of great use in psychopharmacology and in drug development.
Abstract: Large-scale randomized trials are not available for all disorders, and conventional "trials of therapy" are susceptible to bias. Randomized controlled trials (RCTs) in individual patients (N of 1 RCTs) may provide a solution. In an N of 1 RCT, a patient receives treatments in pairs (one period of the experimental therapy and one period of either an alternative treatment or placebo, in random order), both patient and clinician are kept blind to allocation, and treatment targets are monitored. This type of RCT is useful in chronic, stable conditions in which the proposed treatment has a short half-life. Treatment targets usually include quantitative measurement of symptoms tracked through patient diaries. Pairs of treatment periods are continued until effectiveness is proved or refuted. The N of 1 RCT is potentially of great use in psychopharmacology and in drug development. The practical approach presented here will allow clinicians to conduct their own N of 1 RCTs.
TL;DR: Oxygen prescribing and monitoring practices were suboptimal on a busy medical teaching ward and practice guidelines based on best available evidence are needed to increase the efficiency of oxygen use.
Abstract: Objectives: To examine the oxygen-prescribing habits and monitoring patterns on a medical teaching ward and to review the literature in this area. Design: A continuous quality improvement study. Setting: A 29-bed medical clinical teaching unit in a 453-bed university-affiliated tertiary care hospital. Patients: We studied 50 consecutive patients who required 79 oxygen treatments. Methods: We recorded the indication, prescriber, documentation of prior hypoxemia, method and mode of delivery, oxygenation assessment after initiation, and duration of therapy. Results: Patients received oxygen for a mean (±SD) of 4.7±4.5 days. Oxygen therapy was ordered on a continuous basis 60.3% of the time. It was ordered by house staff in 54 cases (68%); nurses initiated oxygen therapy in 14 cases (18%) but discontinued it more often than any other health care workers. The most common indications for starting oxygen therapy were dyspnea and tachypnea. In 15 patients (30%), none of the American College of Chest Physicians and National Heart, Lung, and Blood Institute criteria for starting oxygen therapy were fulfilled. For 16 patients (32%), arterial blood gas values were measured within 1 hour of oxygen administration; for 29 patients, oximetry was performed. For 9 patients (18%), no testing of adequate oxygenation was performed within 24 hours. Oxygenation status was assessed daily for 23 patients (46%). Conclusions: Oxygen prescribing and monitoring practices were suboptimal on our busy medical teaching ward. Practice guidelines based on best available evidence are needed to increase the efficiency of oxygen use. A physiologic, multidisciplinary educational focus on the benefits and hazards of supplemental oxygen is necessary, and randomized trials of such educational interventions should be conducted. Arch Intern Med. 1996;156:1797-1801
Journal Article•
TL;DR: A meta-analysis of the randomized, clinical trials that compared once-daily aminoglycoside regimens with standard aminglycoside dosing regimens in immunocompetent adults found both the efficacy and the toxicity of the regimens were evaluated.
Abstract: Objective: To compare the efficacy, nephrotoxicity, and ototoxicity of once-daily aminoglycoside dosing with those of standard aminoglycoside regimens in immunocompetent adults. Data Sources: A str...
TL;DR: In particular, the absence of pupillary light reflexes, corneal reflexes or motor response to pain, at three days post-injury, can predict poor outcome with apparent 100% accuracy.
Abstract: Purpose: To determine the neurological clinical signs predicting poor outcome in patients with coma of hypoxic/ anoxic origin through a systematic review and critical appraisal of the literature. Data sources: A structured search was performed using MEDLINE; search terms were 'prognosis' and 'coma'. Study selection: Articles published since 1980 were selected if they studied an adult population, had a sample size greater than 50 patients, focused on bedside clinical signs, and addressed long-term recovery and functional status. Data extraction: We reviewed all selected articles and abstracted pertinent information. Results: The overall outcome in hypoxic/anoxic coma is quite poor, with 65% of patients dying within two weeks and 10% surviving to one year. In particular, the absence of pupillary light reflexes, corneal reflexes or motor response to pain, at three days post-injury, can predict poor outcome with apparent 100% accuracy. Conclusions: The absence of any of three simple clinical signs correlates ...
TL;DR: Synthesizing the results of randomized trials comparing these agents in terms of their effect on pneumonia prevention, sucralfate appears to be associated with a lower incidence of pneumonia.
Abstract: Epidemiologic trends in bleeding definitions indicate a move to study primarily clinically important upper gastrointestinal bleeding. The two major risk factors for this are the presence of coagulopathy and the need for mechanical ventilation. Antacids, histamine-2-receptor antagonists and sucralfate appear equally efficacious at bleeding prevention. Synthesizing the results of randomized trials comparing these agents in terms of their effect on pneumonia prevention, sucralfate appears to be associated with a lower incidence of pneumonia. This awaits confirmation in large rigorous studies to minimize random and systematic error. Clinical policy needs to incorporate both the clinical and the economic consequences of administering these drugs.
TL;DR: In the conduct of systematic reviews, care has to be taken to avoid the biases that can affect all retrospective research, including systematic reviews.
Abstract: Systematic reviews (overviews and meta-analysis) are retrospective research studies addressing specific health care questions. The questions asked determine which studies and data are relevant, and how they should be synthesized. In the conduct of systematic reviews, care has to be taken to avoid the biases that can affect all retrospective research, including systematic reviews. Often collaboration with the primary investigators is necessary.