Showing papers by "Deborah J. Cook published in 2002"
Book•
01 Jan 2002
TL;DR: The third edition of this landmark resource is now completely revised and refreshed throughout, with expanded coverage of both basic and advanced issues in using evidence-based medicine in clinical practice.
Abstract: The #1 guide to the principles and clinical applications of evidence-based medicine is better than ever! No other resource helps clinicians to put key evidence-based medicine protocols into daily clinical practice better than Users' Guides to the Medical Literature. An instant classic in its first edition, this detailed, yet highly readable reference demystifies the statistical, analytical, and clinical principles of evidence-based medicine, giving you a hands-on, practical resource that no other text can match. Readers will learn how to distinguish solid medical evidence from poor medical evidence, devise the best search strategies for each clinical question, critically appraise the medical literature, and optimally tailor evidence-based medicine for each patient. The third edition of this landmark resource is now completely revised and refreshed throughout, with expanded coverage of both basic and advanced issues in using evidence-based medicine in clinical practice. Completely updated with new medical studies, new chapters, and new methods for applying EBM principles to patient care Contributors represent the world's most prominent assembly of EBM experts Covers both basic principles and clinical application
1,140 citations
TL;DR: The Quality of Reporting of Meta‐analyses (QUOROM) conference was convened to address standards for improving the quality of reporting of meta-analyses of clinical randomised controlled trials (RCTs).
Abstract: Background
The Quality of Reporting of Meta-analyses (QUOROM) conference was convened to address standards for improving the quality of reporting of meta-analyses of clinical randomised controlled trials (RCTs).
Methods
The QUOROM group consisted of 30 clinical epidemiologists, clinicians, statisticians, editors, and researchers. In conference, the group was asked to identify items they thought should be included in a checklist of standards. Whenever possible, checklist items were guided by research evidence suggesting that failure to adhere to the item proposed could lead to biased results. A modified Delphi technique was used in assessing candidate items.
Findings
The conference resulted in the QUOROM statement, a checklist, and a flow diagram. The checklist describes our preferred way to present the abstract, introduction, methods, results, and discussion sections of a report of a meta-analysis. It is organised into 21 headings and subheadings regarding searches, selection, validity assessment, data abstraction, study characteristics, and quantitative data synthesis, and in the results with ‘trial flow’, study characteristics, and quantitative data synthesis; research documentation was identified for eight of the 18 items. The flow diagram provides information about both the numbers of RCTs identified, included, and excluded and the reasons for exclusion of trials.
Interpretation
We hope this report will generate further thought about ways to improve the quality of reports of meta-analyses of RCTs and that interested readers, reviewers, researchers, and editors will use the QUOROM statement and generate ideas for its improvement. © 2000 British Journal of Surgery Society Ltd
1,055 citations
TL;DR: Most family members were highly satisfied with the care provided to them and their critically ill relative in the intensive care unit, and efforts to improve the nature of interactions and communication with families are likely to lead to improvements in satisfaction.
Abstract: Objective: To determine the level of satisfaction of family members with the care that they and their critically ill relative received. Design: Prospective cohort study. Setting: Six university-affiliated intensive care units across Canada. Methods: We administered a validated questionnaire to family members who made at least one visit to intensive care unit patients who received mechanical ventilation for >48 hrs. We obtained selfrated levels of satisfaction with 25 key aspects of care related to the overall intensive care unit experience, communication, and decision making. For family members of survivors, the questionnaire was administered while the patient was still in the hospital. For family members of nonsurvivors, the questionnaire was mailed out to the family member 3‐ 4 wks after the patient’s death. Main Results: A total of 891 family members received questionnaires; 624 were returned (70% response rate). The majority of respondents were satisfied with overall care and with overall decision making (mean SD item score, 84.3 15.7 and 75.9 26.4, respectively). Families reported the greatest satisfaction with nursing skill and competence (92.4 14.0), the compassion and respect given to the patient (91.8 15.4), and pain management (89.1 16.7). They were least satisfied with the waiting room atmosphere (65.0 30.6) and frequency of physician communication (70.7 29.0). The variables significantly associated with overall satisfaction in a regression analysis were completeness of information received, respect and compassion shown to the patient and family member, and the amount of health care received. Satisfaction varied significantly across sites. Conclusions: Most family members were highly satisfied with the care provided to them and their critically ill relative in the intensive care unit. Efforts to improve the nature of interactions and communication with families are likely to lead to improvements in satisfaction. (Crit Care Med 2002; 30:1413‐1418)
439 citations
Journal Article•
TL;DR: A systematic review and meta-analysis of studies comparing the mortality rates of private for- Profit hospitals and those of private not-for-profit hospitals suggests that private for the-profit ownership of hospitals, in comparison with private not thefor-profits ownership, results in a higher risk of death for patients.
Abstract: Background: Canadians are engaged in an intense debate about the relative merits of private for-profit versus private not-for-profit health care delivery. To inform this debate, we undertook a systematic review and meta-analysis of studies comparing the mortality rates of private for-profit hospitals and those of private not-for-profit hospitals. Methods: We identified studies through an electronic search of 11 bibliographical databases, our own files, consultation with experts, reference lists, PubMed and SciSearch. We masked the study results before determining study eligibility. Our eligibility criteria included observational studies or randomized controlled trials that compared private for-profit and private not-for-profit hospitals. We excluded studies that evaluated mortality rates in hospitals with a particular profit status that subsequently converted to the other profit status. For each study, we calculated a relative risk of mortality for private for-profit hospitals relative to private not-for-profit hospitals and pooled the studies of adult populations that included adjustment for potential confounders (e.g., teaching status, severity of illness) using a random effects model. Results: Fifteen observational studies, involving more than 26 000 hospitals and 38 million patients, fulfilled the eligibility criteria. In the studies of adult populations, with adjustment for potential confounders, private for-profit hospitals were associated with an increased risk of death (relative risk [RR] 1.020, 95% confidence interval [CI] 1.003–1.038; p = 0.02). The one perinatal study with adjustment for potential confounders also showed an increased risk of death in private for-profit hospitals (RR 1.095, 95% CI 1.050–1.141; p < 0.0001). Interpretation: Our meta-analysis suggests that private for-profit ownership of hospitals, in comparison with private not-for-profit ownership, results in a higher risk of death for patients.
276 citations
TL;DR: The overall quality of reporting in abstracts proved inadequate, and inconsistencies between the final published paper and the original abstract occurred frequently, meaning the routine use of abstracts as a guide to orthopaedic practice needs to be reconsidered.
Abstract: Background: Research abstracts are frequently referenced in orthopaedic textbooks and influence orthopaedic care. However, little is known about the quality of information provided in the abstracts, the frequency of publication of complete papers after presentation of abstracts, or any discrepancies between abstracts and published papers. The objective of this study was to determine the quality of information provided in orthopaedic abstracts, rates of publication of full-text articles after presentation of abstracts, predictors of publication of full-text articles, and consistency between abstracts and full-text articles.
Methods: We retrieved all abstracts from the 1996 scientific program of the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons. For each abstract, we recorded the completeness of reporting and key features of the study design, conduct, analysis, and interpretation. A computerized Medline and PubMed search established whether the abstract had been followed by publication of a full-text article. Finally, we evaluated the consistency of reporting between abstracts and final publications.
Results: The program included 465 abstracts, 66% of which were on prognostic studies. All abstracts described the study design, and 70.7% of the designs were observational. Key methodological issues were reported in less than half of the abstracts, and information on data analysis was reported in <15%. One hundred and fifty-nine (34%) of the 465 abstracts were followed by publication of a full-text article. The mean time to publication (and standard deviation) was 17.6 ±; 12 months (range, one to fifty-six months). Inconsistencies between the abstract and the full-text article included the primary outcome measure, which differed 14% of the time, and the results, which differed 19% of the time.
Conclusions: Two-thirds of the orthopaedic abstracts in this sample were not followed by publication of a full-text paper. The overall quality of reporting in abstracts proved inadequate, and inconsistencies between the final published paper and the original abstract occurred frequently. The routine use of abstracts as a guide to orthopaedic practice needs to be reconsidered.
235 citations
TL;DR: The pooled estimate demonstrated that private for-profit dialysis centers were associated with an increased risk of death and suggested that there are annually 2500 excessive premature deaths in US for- Profit dialysis Centers.
Abstract: ContextPrivate for-profit and private not-for-profit dialysis facilities provide
the majority of hemodialysis care in the United States. There has been extensive
debate about whether the profit status of these facilities influences patient
mortality.ObjectiveTo determine whether a difference in adjusted mortality rates exists
between hemodialysis patients receiving care in private for-profit vs private
not-for-profit dialysis centers.Data SourcesWe searched 11 bibliographic databases, reviewed our own files, and
contacted experts in June 2001–January 2002. In June 2002, we also searched
PubMed using the "related articles" feature, SciSearch, and the reference
lists of all studies that fulfilled our eligibility criteria.Study SelectionWe included published and unpublished observational studies that directly
compared the mortality rates of hemodialysis patients in private for-profit
and private not-for-profit dialysis centers and provided adjusted mortality
rates. We masked the study results prior to determining study eligibility,
and teams of 2 reviewers independently evaluated the eligibility of all studies.
Eight observational studies that included more than 500 000 patient-years
of data fulfilled our eligibility criteria.Data ExtractionTeams of 2 reviewers independently abstracted data on study characteristics,
sampling method, data sources, and factors controlled for in the analyses.
Reviewers resolved disagreements by consensus.Data SynthesisThe studies reported data from January 1, 1973, through December 31,
1997, and included a median of 1342 facilities per study. Six of the 8 studies
showed a statistically significant increase in adjusted mortality in for-profit
facilities, 1 showed a nonsignificant trend toward increased mortality in
for-profit facilities, and 1 showed a nonsignificant trend toward decreased
mortality in for-profit facilities. The pooled estimate, using a random-effects
model, demonstrated that private for-profit dialysis centers were associated
with an increased risk of death (relative risk, 1.08; 95% confidence interval,
1.04-1.13; P<.001). This relative risk suggests
that there are annually 2500 (with a plausible range of 1200-4000) excessive
premature deaths in US for-profit dialysis centers.ConclusionsHemodialysis care in private not-for-profit centers is associated with
a lower risk of mortality compared with care in private for-profit centers.
189 citations
TL;DR: Under-utilization of semirecumbency for pneumonia prevention is influenced by insufficient awareness of its benefit, real and perceived deterrents, poor agreement about implementation responsibility, and lack of enabling and reinforcing strategies.
Abstract: Objective: Randomized trials show that the semirecumbent position compared with the supine position is associated with less gastroesophageal aspiration and pneumonia in patients receiving mechanical ventilation. However, semirecumbency is inconsistently used in practice. The objective of this study was to understand the perspectives of intensive care unit clinicians regarding the determinants and consequences of semirecumbency. Design: Qualitative study using semistructured interviews and focus groups. Setting: Three university-affiliated intensive care units. Participants: A total of 93 intensive care unit clinicians, including bedside nurses, respiratory therapists, physiotherapists, nutritionists, residents, fellows, and intensivists. Methods: We elicited perceptions about benefits and harms of semirecumbency, factors promoting and deterring use, and health systems changes to encourage semirecumbency. Interview and focus group notes were analyzed inductively to identify emerging themes. Validation methods involved triangulation by multidisciplinary analysis of several data sources collected through multiple methods and member checking. Measurements and Main Results: Intensivists and nutritionists were familiar with semirecumbency as a potential pneumonia prevention strategy, whereas other clinicians were not. When made aware of the evidence, all participants endorsed semirecumbency. Nurses perceived that the main determinant of semirecumbency was physicians’ orders, whereas intensivists perceived that the main determinant was nursing preference. Participants identified barriers to semirecumbency related to useful alternative positions (e.g., lateral position), contraindications (e.g., hemodynamic instability), risk of harm (e.g., decubitus ulcers), safety (e.g., sliding out of the bed), and resources (e.g., insufficient beds facilitating semirecumbency). Education, guidelines, reminders, audit and feedback, charting, and quality improvement initiatives were advocated to promote semirecumbency. Conclusions: Under-utilization of semirecumbency for pneumonia prevention is influenced by insufficient awareness of its benefit, real and perceived deterrents, poor agreement about implementation responsibility, and lack of enabling and reinforcing strategies. Cognitive, behavioral, and administrative approaches to enhancing evidence uptake may be needed in the complex, dynamic intensive care unit setting. (Crit Care Med 2002; 30:1472‐1477)
159 citations
Journal Article•
TL;DR: It is recommended all CEAs in the critically ill include a PCEHM reference case, where the cost-effectiveness ratio is calculated by adopting a societal perspective, estimating long-term costs and quality of life after ICU care, applying a 3% annual discount rate to costs and effects, and conducting multiway sensitivity analyses.
Abstract: Economic evaluations are increasingly common in the critical care literature, although approaches to their conduct are not standardized. The American Thoracic Society convened a workshop to address methodologic and reporting issues for economic analyses in critical care and to determine how guidelines from the U.S. Public Health Service Panel on Cost-effectiveness in Health and Medicine (PCEHM) were applicable to critical care. We identified several issues that hamper cost-effectiveness analyses (CEAs) in the critically ill. Data on the effectiveness of intensive care unit (ICU) interventions are often lacking; ICU patients are complex, with multiple concurrent problems and interventions; most ICU therapies are only supportive, and therefore may not individually result in improved outcome; accurate cost data are not commonly available and are difficult to obtain; there is no standardized approach for measuring or valuing costs across countries; typical outcomes in ICU studies (e.g., short-term mortality) are not ideal for CEAs while preferred outcomes for CEAs (e.g., long-term quality-adjusted survival) are rarely collected; valuing the importance of appropriate end-of-life care, an important aspect of ICU care, is difficult, and the burden of critical illness on family members is not easily captured in a CEA. Nevertheless, many of these problems are not unique to critical care, and we believe the PCEHM guidelines can be adapted to the critical care setting. We recommend all CEAs in the critically ill include a PCEHM reference case, where the cost-effectiveness ratio is calculated by adopting a societal perspective, estimating long-term costs and quality of life after ICU care, applying a 3% annual discount rate to costs and effects, and conducting multiway sensitivity analyses. Because elements of the reference case, such as long-term costs and quality of life, may only be estimated using modeling and assumptions, we also recommend inclusion of a "data-rich" case, where the cost-effectiveness ratio is generated as closely as possible from data on actual patient outcomes and costs (e.g., hospital costs per hospital survivor). We recommend that investigators conducting a CEA concurrently with a randomized trial make the proposed model available (e.g., via the Internet) before unblinding of trial data to minimize bias. Adopting a standard approach to CEAs of ICU therapies will provide a valid and more transparent evidence base for health care policy with regard to care of the critically ill.
134 citations
TL;DR: Data on the epidemiology of VTE and its prevention in critically ill patients are very limited and further research is needed to better define patient risk factors for VTE, optimal methods of thromboprophylaxis, and strategies to improve compliance with prophylaxis recommendations.
126 citations
TL;DR: Greater extents of reversibility on dipyridamole myocardial stress perfusion imaging increase the risk of perioperative complications after noncardiac vascular surgery, but the quality and amount of data regarding greater extented reversibility are limited.
114 citations
TL;DR: Evaluating the current use of strategies to prevent ventilator-associated pneumonia (VAP) and to identify interventions to target for quality-improvement initiatives found significant opportunities exist to improve VAP prevention practices in Canada.
TL;DR: The methodological limitations identified in this article can help to target further improvement in trial design to enhance the validity of findings from future randomized clinical trials of sepsis.
Abstract: Objective: To systematically evaluate the methodological quality of randomized clinical trials and to determine whether randomized clinical trials of sepsis improved in methodological quality over time. Data Sources: Computerized MEDLINE search of articles published in any language from 1966 to 1998 combined with a manual search of bibliographies of published articles and communication with known experts in the field. Study Selection: All randomized clinical trials of sepsis, severe sepsis, and septic shock performed in adults and published as full articles. Data Extraction: Abstracts of all retrieved records were reviewed and the inclusion criteria were applied. All selected articles were classified into (a) trials designed to detect differences in mortality as the primary end point, or (b) trials focusing on surrogate outcome measures (i.e., physiological or biochemical parameters). All retrieved trials were then graded for methodological quality using an objective grading scheme developed specifically for this study. The data selection and extraction process was carried out independently by two of the authors; any disagreement was resolved by discussion. Data Synthesis: Seventy-four randomized clinical trials involving septic patients qualified for inclusion in this study (40 reporting mortality outcomes, 34 reporting other surrogate outcomes). Trials reporting mortality as the primary outcome had significantly higher quality scores compared with trials reporting surrogate outcome measures (29.6 1.0 vs. 24.3 0.8, p .0006). From 1976 to 1998, trial methodology improved significantly over time (an average of 0.36 points per year, p .021). Mortality outcome trials improved an average of 0.58 points per year (p .0011) whereas surrogate outcome trials did not demonstrate an improvement in methodological quality over time (p .249). Conclusion: The methodological limitations identified in this article can help to target further improvement in trial design to enhance the validity of findings from future randomized clinical trials of sepsis. (Crit Care Med 2002; 30:461‐472)
TL;DR: Experiential, case-based, patient-centered curricula are associated with resident confidence in withdrawal of life support decisions in the intensive care unit.
Abstract: Objective: To examine the influence of education and clinical experience on residents' attitudes toward withdrawal of life support. Design: Self-administered survey. Setting: Four Canadian teaching hospitals. Subjects: Residents rotating through four intensive care units. Measurements and Main Results: The survey examined ethics education and experience regarding end-of-life care, importance of factors influencing withdrawal of life support, confidence in decisions, and recommendations for enhancing end-of-life education. The response rate was 83.9% (52 of 62). A minority of residents reported an appropriate amount of formal teaching on ethical principles (17.3%), patient-centered education (28.8%), and informal discussion (28.8%) before their intensive care unit rotation. During their rotation, most residents cared for patients in whom withdrawal of life support was considered. Although they usually attended family meetings, residents were never (34.6%) or rarely (42.3%) the primary discussant. Before the intensive care unit rotation, confidence in withdrawal decisions was related to male sex (p = .001) and previous patient-centered ethics education (p = .02). At the end of the intensive care unit rotation, only resident involvement in family meetings (p = .02) and being the primary discussant at such meetings (p = .01) were associated with confidence. After we adjusted for prerotation confidence in withdrawal of life support decision-making, the only predictor of postrotation confidence was family meeting involvement (p < .001). Residents recommended more patient-centered discussion, observation of attending physicians discussing end-of-life issues, and opportunity to lead family meetings. Conclusions: Experiential, case-based, patient-centered curricula are associated with resident confidence in withdrawal of life support decisions in the intensive care unit.
TL;DR: Among patients with allergies and asthma, use of air filters is associated with fewer symptoms and Rigorous sufficiently powered randomized clinical trials are needed to more precisely define the influence of air filtration on health-related quality of life and symptom control for asthmatic patients.
TL;DR: Some of the major challenges and possible solutions to help a potential investigator through the myriad of difficulties in initiating an RCT in a complex environment are described.
TL;DR: The development, organization, and operational methods of these groups illustrate several collaborative models for clinical investigations in the intensive care unit, highlighting a cohesive spirit, a sense of mission to achieve shared research goals, and acknowledgment that such an organization is much more than the sum of its parts.
Abstract: ObjectiveTo describe the development, organization, and operation of several collaborative groups conducting investigator-initiated multicenter clinical research in adult critical care.DesignTo review the process by which investigator-initiated critical care clinical research groups were created usi
TL;DR: This survey highlights perceptions and practices related to the determinants and consequences of airway humidification and suggests differences in the cost of mechanical ventilation between countries.
Abstract: Objective. To understand the national utilization pattern of heat and moisture exchangers (HME) and heated humidifiers (HH) in mechanically ventilated ICU patients.
TL;DR: The authors have summarized the clinical trials that have assessed specific strategies to prevent VAP and the current controversies regarding the diagnosis and therapeutic approach to this condition.
TL;DR: It is concluded that vitamin K deficiency is common among critically ill patients, particularly on admission to the ICU, and that additional clinical research is warranted to determine whether vitamin K supplementation on admitted patients reduces the risk of ICU-acquired vitaminK deficiency and its attendant complications over the course of the ICu stay.
Abstract: Patients in the intensive care unit (ICU) are at risk for the development of vitamin K deficiency. We sought to determine the frequency of this deficiency by performing a prospective cohort study in which patients were screened for vitamin K deficiency on ICU admission and every other day thereafter. Vitamin K deficiency was diagnosed by a functional coagulation factor II to Echis factor II ratio < 0.70. Activity of the coagulation cascade was measured by D-dimer. In total, 40 patients were enrolled into the study. Seven of the patients had ratios < 0.70 on the day of admission to the ICU, and three patients developed ratios < 0.70. Thus, 10 of 40 patients (25%; 95% confidence interval, 12-38%) had vitamin K deficiency. Two patients developed coagulopathy, as indicated by an International Normalized Ratio of more than 1.4. D-dimer levels were elevated in 86 of 111 samples. We conclude that vitamin K deficiency is common among critically ill patients, particularly on admission to the ICU. Our findings suggest that additional clinical research is warranted to determine whether vitamin K supplementation on admission to the ICU reduces the risk of ICU-acquired vitamin K deficiency and its attendant complications over the course of the ICU stay.
TL;DR: In mechanically ventilated patients, it is found that clinical estimates of trunk position were moderatelyGood, agreement amongst caregivers was moderately good, but that all clinicians tended to overestimate the angle of semirecumbency.
Abstract: Objectives: Trunk position at 45 degrees from the horizontal is associated with a decreased risk of gastroesophageal aspiration. The objectives of this study were to determine the accuracy of trunk flexion estimates compared to a reference standard measurement, and to determine agreement about trunk flexion among ICU clinicians. Design: Prospective observational study. Setting: Two university-affiliated medical-surgical ICUs. Patients and participants: Thirty-three mechanically ventilated ICU patients, seven residents, two fellows, three intensivists, and twenty-eight bedside nurses. Interventions: Prospectively, concurrently, and independently during rounds, one bedside nurse, one resident, one fellow, and one intensivist clinically estimated the trunk flexion of mechanically ventilated patients. To record the reference standard, a trained investigator measured trunk position in the vertical plane using a goniometer. Measurements and results: We made 438 clinical assessments on 33 patients aged 57.2±19.4 (SD) years with an APACHE II score of 27.3±9.4. Mean trunk flexion estimates were: nurses 24.3±12.3 degrees from the horizontal, residents 20.2±13.7, fellows 20.3±10.8, and intensivists 21.1±13.1 compared to the reference standard measurement 16.2±9.0 degrees. The accuracy of trunk flexion estimates was fair to moderate [intraclass correlation for reference standard versus nurses (ICC 0.42), residents (ICC 0.52), fellows (ICC 0.36), and intensivists (ICC 0.55)]. The agreement among different groups of clinicians was moderate. Conclusions: In mechanically ventilated patients, we found that clinical estimates of trunk position were moderately good, agreement amongst caregivers was moderately good, but that all clinicians tended to overestimate the angle of semirecumbency.
TL;DR: This review reviewed bibliographies of previous meta-analyses, review articles, and other investigations involving albumin using data from the Cochrane Controlled Trials Register, Cochrane Medical Editors Trial Amnesty, and relevant internet resources.
Abstract: Source Citation Wilkes MM, Navickis RJ. Patient survival after human albumin administration. A meta-analysis of randomized, controlled trials. Ann Intern Med. 2001 Aug 7;135:149-64. 11487482 (All 2...
Journal Article•
TL;DR: The Critical Care Symposium as mentioned in this paper reviewed clinical trials with potential practical impact on day-to-day practice and revisited older scientific questions (such as steroids in sepsis) which are now being re-evaluated in a new light.
Abstract: Critical care provides constant challenges to the practitioner whose attempt to remain up to date is made more difficult by the breadth and amount of new information available. This critical care symposium aptly captured bench-to-bedside areas of interesting new basic research, reviewed clinical trials with potential practical impact on day-to-day practice, and revisited older scientific questions (such as steroids in sepsis) which are now being re-evaluated in a new light.
01 Jan 2002
TL;DR: This critical care symposium aptly captured bench-to-bedside areas of interesting new basic research, reviewed clinical trials with potential practical impact on day- to-day practice, and revisited older scientific questions which are now being re-evaluated in a new light.
Abstract: HE Toronto Critical Care Medicine Symposium (TCCMS) is organized every October by members of the Toronto academic critical care community, with the collaboration of a group of national scientific advisors. Because of the quality of invited speakers and topics, the event is popular among Canadian and international clinicians who practice in the intensive care unit (ICU) setting (physicians, as well as nurses, and respiratory therapists). The symposium has become, over time, the premier Canadian critical care meeting. In October 2001, the conference featured several talks on cutting edge or changing issues in the area. Herein, we report selected messages of interest to critical care practitioners, and hope this summary will find favour with the Canadian Journal of Anesthesia readership. Information about the yearly symposium can be obtained on the internet at the “TCCSM” website (www.tccms.com). The high risk pulmonary artery catheter (PAC) study A large trial conducted in collaboration with the Canadian Critical Care (CCC) Trials Group was recently completed by Dean Sandham and colleagues. One thousand nine hundred and ninety-four ASA class III or IV patients aged 65 yr or more who underwent major noncardiac surgery were randomized to preoperative PAC and protocol-driven fluid and drug management, or a control group, managed by the ICU team, using a central venous catheter without protocolized care. Patients in the PAC group received significantly more colloids, inotropes and vasopressors. The main endpoint, hospital mortality, was the same in the two groups: 7.7% in control and 7.8% in PAC group. At one year, mortality was not significantly different. This large multicentre randomized trial suggests that peri- and postoperative management using a PAC in the ICU does not decrease mortality. The incidence of pulmonary embolism was significantly higher in the PAC group. The observed 0.8% incidence of pulmonary embolism could translate into a 12,000/yr PAC attributable incidence across North America. Sepsis strategies/forum Reliability/validity Reliability and validity criteria for the terms “sepsis” and “septic shock” are not well established. A literature review of the overlap between reliability and validity criteria and diagnostic categories such as “sepsis” or even “Adult Respiratory Distress Syndrome” (ARDS) compared poorly to a number of other illnesses, including psychiatric diseases. Depression, for example, has more reliable characterizing criteria that enable correct diagnosis, thereby making the right diagnosis for the application of potential therapy a lot more likely across heterogeneous groups of treating physicians. The high cost of emerging therapeutic options makes the development of accurate assessment of severe sepsis more pressing.