Deborah J. Cook

Bio: Deborah J. Cook is an academic researcher from McMaster University. The author has contributed to research in topics: Intensive care & Intensive care unit. The author has an hindex of 173, co-authored 907 publications receiving 148928 citations. Previous affiliations of Deborah J. Cook include McMaster University Medical Centre & Queen's University.

Albumin Administration in Patients With Sepsis

Abstract: IN RESPONSE: We thank Dr. Zhang and colleagues for their points about the administration of albumin for resuscitation in patients with sepsis. The methods of their meta-analysis differ from those of ours in several respects, and it is thus unsurprising that our results are discordant. We used an NMA framework that has the advantage of incorporating indirect evidence as opposed to only direct evidence as in a conventional meta-analysis. We excluded the ALBIOS (1) and EARSS (2) studies because albumin administration in these trials was independent of hemodynamic instability and the focus of our NMA was resuscitation fluid. We included the CRISTAL study (3) only in the pairwise meta-analysis of colloids versus crystalloids because patients were randomly assigned to receive any colloids or any crystalloids. Although the CRISTAL study presented results based on the specific fluid received, this factor was not a randomization characteristic; accordingly, we did not integrate these data in our NMA because of the potential for bias. Finally, we included the SAFE study (4), whereas Dr. Zhang and colleagues excluded it for unclear reasons. We agree that, for most patients with sepsis, the first choice of resuscitative fluid should be crystalloids. The results of our NMA suggest that a balanced crystalloid solution with a more physiologic chloride concentration may be preferred, but we believe that more research is needed to confirm or refute this finding (5). Although the CIs around the mortality estimate comparing albumin with any crystalloid (NMA odds ratio, 0.83 [95% credible interval, 0.65 to 1.04]) include the potential that albumin confers a mortality benefit, this factor must be balanced against important considerations of cost and transfusion risk. Our results show that albumin seems to be at worst similar to crystalloids with respect to mortality risk. When albumin is used for resuscitation, research is sparse to guide the choice of dose, concentration, or timing. Presently, we do not advocate that albumin be used as a first choice for resuscitation in sepsis. However, until further research becomes available suggesting otherwise, we believe that it is reasonable to include it as 1 potential resuscitative fluid. Meanwhile, in clinical practice, most patients will continue to receive a combination of fluids for resuscitation rather than a single subtype, guided by physiologic variables and sometimes such factors as institutional policies, physician preferences, or fluids readily at hand.

Scale-up and sustainability of a personalized end-of-life care intervention: a longitudinal mixed-methods study

Abstract: Scaling-up and sustaining healthcare interventions can be challenging. Our objective was to describe how the 3 Wishes Project (3WP), a personalized end-of-life intervention, was scaled-up and sustained in an intensive care unit (ICU). In a longitudinal mixed-methods study from January 12,013 - December 31, 2018, dying patients and families were invited to participate if the probability of patient death was > 95% or after a decision to withdraw life support. A research team member or bedside clinician learned more about each of the patients and their family, then elicited and implemented at least 3 personalized wishes for patients and/or family members. We used a qualitative descriptive approach to analyze interviews and focus groups conducted with 25 clinicians who cared for the enrolled patients. We used descriptive statistics to summarize patient, wish, and clinician characteristics, and analyzed outcome data in quarters using Statistical Process Control charts. The primary outcome was enrollment of terminally ill patients and respective families; the secondary outcome was the number of wishes per patient; tertiary outcomes included wish features and stakeholder involvement. Both qualitative and quantitative analyses suggested a three-phase approach to the scale-up of this intervention during which 369 dying patients were enrolled, having 2039 terminal wishes implemented. From a research project to clinical program to an approach to practice, we documented a three-fold increase in enrolment with a five-fold increase in total wishes implemented, without a change in cost. Beginning as a study, the protocol provided structure; starting gradually enabled frontline staff to experience and recognize the value of acts of compassion for patients, families, and clinicians. The transition to a clinical program was marked by handover from the research staff to bedside staff, whereby project catalysts mentored project champions to create staff partnerships, and family engagement became more intentional. The final transition involved empowering staff to integrate the program as an approach to care, expanding it within and beyond the organization. The 3WP is an end-of-life intervention which was implemented as a study, scaled-up into a clinical program, and sustained by becoming integrated into practice as an approach to care.

Is the stomach an important source of tracheal contamination and subsequent pneumonia

Abstract: Objective: To determine the role of gastric colonization in the development of tracheal contamination and subsequent pulmonary infection in critically ill patients. Design: Observational cohort study. Setting: Eight tertiary care medical-surgical intensive care units. Participants: ICU patients expected to remain ventilated > 48 hours. We excluded patients with gastrointestinal bleeding, acidaemia, and renal failure. We studied 95 patients receiving continuous enteral nutrition; 38% were female, mean age (SD) was 55.1 (±18.9) years, and mean APACHE II Score was 21.6 (±7.0). Interventions: We prospectively documented microbial growth patterns in the stomach, trachea and enteral feeding reservoir (EFR). At baseline and every Monday, Wednesday and Friday, we sampled the EFR and stomach. Specimens were sent to the microbiology laboratory for culture. Patients were followed for the development of ICU-acquired pneumonia. Measurements and results: Fifty-four patients (56.8%) had a positive tracheal culture du...

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Abstract: David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement.

Abstract: Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field,1,2 and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research,3 and some health care journals are moving in this direction.4 As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in 4 leading medical journals in 1985 and 1986 and found that none met all 8 explicit scientific criteria, such as a quality assessment of included studies.5 In 1987, Sacks and colleagues6 evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in 6 domains. Reporting was generally poor; between 1 and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement.7 In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials.8 In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Box 1 Conceptual issues in the evolution from QUOROM to PRISMA

Measuring inconsistency in meta-analyses

Abstract: Cochrane Reviews have recently started including the quantity I 2 to help readers assess the consistency of the results of studies in meta-analyses. What does this new quantity mean, and why is assessment of heterogeneity so important to clinical practice? Systematic reviews and meta-analyses can provide convincing and reliable evidence relevant to many aspects of medicine and health care.1 Their value is especially clear when the results of the studies they include show clinically important effects of similar magnitude. However, the conclusions are less clear when the included studies have differing results. In an attempt to establish whether studies are consistent, reports of meta-analyses commonly present a statistical test of heterogeneity. The test seeks to determine whether there are genuine differences underlying the results of the studies (heterogeneity), or whether the variation in findings is compatible with chance alone (homogeneity). However, the test is susceptible to the number of trials included in the meta-analysis. We have developed a new quantity, I 2, which we believe gives a better measure of the consistency between trials in a meta-analysis. Assessment of the consistency of effects across studies is an essential part of meta-analysis. Unless we know how consistent the results of studies are, we cannot determine the generalisability of the findings of the meta-analysis. Indeed, several hierarchical systems for grading evidence state that the results of studies must be consistent or homogeneous to obtain the highest grading.2–4 Tests for heterogeneity are commonly used to decide on methods for combining studies and for concluding consistency or inconsistency of findings.5 6 But what does the test achieve in practice, and how should the resulting P values be interpreted? A test for heterogeneity examines the null hypothesis that all studies are evaluating the same effect. The usual test statistic …