Showing papers by "Ryan Zarychanski published in 2016"

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

Abstract: [This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Systematic review and meta-analysis of interventions for depression and anxiety in persons with multiple sclerosis

Abstract: Background Depression and anxiety are common in persons with multiple sclerosis (MS), and adversely affect fatigue, medication adherence, and quality of life. Though effective treatments for depression and anxiety exist in the general population, their applicability in the MS population has not been definitively established. Objective To determine the overall effect of psychological and pharmacological treatments for depression or anxiety in persons with MS. Methods We searched the Medline, EMBASE, PsycINFO, PsycARTICLES Full Text, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and Scopus databases using systematic review methodology from database inception until March 25, 2015. Two independent reviewers screened abstracts, extracted data, and assessed risk of bias and strength of evidence. We included controlled clinical trials reporting on the effect of pharmacological or psychological interventions for depression or anxiety in a sample of persons with MS. We calculated standardized mean differences (SMD) and pooled using random effects meta-analysis. Results Of 1753 abstracts screened, 21 articles reporting on 13 unique clinical trials met the inclusion criteria. Depression severity improved in nine psychological trials of depression treatment ( N =307; SMD: − 0.45 (95%CI: − 0.74, − 0.16)). The severity of depression also improved in three pharmacological trials of depression treatment (SMD: − 0.63 ( N =165; 95%CI: − 1.07, − 0.20)). For anxiety, only a single trial examined psychological therapy for injection phobia and reported no statistically significant improvement. Conclusion Pharmacological and psychological treatments for depression were effective in reducing depressive symptoms in MS. The data are insufficient to determine the effectiveness of treatments for anxiety.

Early Exposure to Nonnutritive Sweeteners and Long-term Metabolic Health: A Systematic Review

Abstract: CONTEXT: Nonnutritive sweetener (NNS) consumption is increasing among children, yet its long-term health impact is unclear, particularly when exposure occurs during early life. OBJECTIVE: To synthesize evidence from prospective studies evaluating the association of early-life NNS exposure and long-term metabolic health. DATA SOURCES: Medline, Embase, and Cochrane Library (inception to July 2015). STUDY SELECTION: We aimed to include randomized controlled trials (RCTs) evaluating NNS-based interventions and prospective cohort studies reporting NNS exposure among pregnant women, infants, or children ( DATA EXTRACTION: The primary outcome was BMI; secondary outcomes included growth velocity, overweight/obesity, adiposity, and adverse metabolic effects. Study quality and risk of bias were evaluated using validated assessment tools. RESULTS: We identified 6 eligible cohort studies and 2 RCTs (n = 15 641 children). Half of the cohorts reported increasing weight gain or fat mass accumulation with increasing NNS intake, and pooled data from 2 cohorts showed a significant correlation with BMI gain (weighted mean correlation 0.023, 95% confidence interval 0.006 to 0.041). RCTs reported contradictory effects on weight change in children receiving NNSs. No eligible studies evaluated prenatal or infant NNS exposure. LIMITATIONS: Meta-analysis was limited because of the small number of eligible studies and heterogeneity of populations and outcomes. CONCLUSIONS: There is limited and inconsistent evidence of the long-term metabolic effects of NNS exposure during gestation, infancy, and childhood. Further research is needed to inform recommendations for the use of NNSs in this sensitive population.

Extracellular Histones Increase Tissue Factor Activity and Enhance Thrombin Generation by Human Blood Monocytes

Abstract: Objectives:Sepsis is characterized by systemic activation of inflammatory and coagulation pathways in response to infection. Recently, it was demonstrated that histones released into the circulation by dying/activated cells may contribute to sepsis pathology. Although the ability of extracel

Systematic review of interventions for depression and anxiety in persons with inflammatory bowel disease

Abstract: Background Depression and anxiety are common in inflammatory bowel disease (IBD) and can affect disease outcomes, including quality of life and success of disease treatment. Successful management of psychiatric comorbidities may improve outcomes, though the effectiveness of existing treatments in IBD is unknown.

Screening tools for anxiety in people with multiple sclerosis: A systematic review

Abstract: Background: Anxiety is prevalent in people with multiple sclerosis (MS). Screening measures are used to identify symptoms of anxiety, but the optimal measure to screen for anxiety disorders in MS has not been established. Methods: We searched the MEDLINE, Embase, PsycINFO, PsycARTICLES Full Text, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Scopus databases from database inception until August 7, 2015. Two independent reviewers screened abstracts and full-text reports for study inclusion, extracted data, and assessed risk of bias. We included studies that evaluated the criterion validity of anxiety screening tools when measuring anxiety in individuals with well-documented MS, as measured by sensitivity, specificity, and positive and negative predictive values. Results: Of the 3181 abstracts screened, 18 articles were reviewed in full text, of which 4 met the inclusion criteria. The criterion validity of three screening tools was assessed: the Hospital Anxiety and Depressio...

Multicountry survey of emergency and critical care medicine physicians’ fluid resuscitation practices for adult patients with early septic shock

Abstract: Objectives Evidence to guide fluid resuscitation evidence in sepsis continues to evolve. We conducted a multicountry survey of emergency and critical care physicians to describe current stated practice and practice variation related to the quantity, rapidity and type of resuscitation fluid administered in early septic shock to inform the design of future septic shock fluid resuscitation trials. Methods Using a web-based survey tool, we invited critical care and emergency physicians in Canada, the UK, Scandinavia and Saudi Arabia to complete a self-administered electronic survey. Results A total of 1097 physicians’ responses were included. 1 L was the most frequent quantity of resuscitation fluid physicians indicated they would administer at a time (46.9%, n=499). Most (63.0%, n=671) stated that they would administer the fluid challenges as quickly as possible. Overall, normal saline and Ringer9s solutions were the preferred crystalloid fluids used ‘often’ or ‘always’ in 53.1% (n=556) and 60.5% (n=632) of instances, respectively. However, emergency physicians indicated that they would use normal saline ‘often’ or ‘always’ in 83.9% (n=376) of instances, while critical care physicians said that they would use saline ‘often’ or ‘always’ in 27.9% (n=150) of instances. Only 1.0% (n=10) of respondents indicated that they would use hydroxyethyl starch ‘often’ or ‘always’; use of 5% (5.6% (n=59)) or 20–25% albumin (1.3% (n=14)) was also infrequent. The majority (88.4%, n=896) of respondents indicated that a large randomised controlled trial comparing 5% albumin to a crystalloid fluid in early septic shock was important to conduct. Conclusions Critical care and emergency physicians stated that they rapidly infuse volumes of 500–1000 mL of resuscitation fluid in early septic shock. Colloid use, specifically the use of albumin, was infrequently reported. Our survey identifies the need to conduct a trial on the efficacy of albumin and crystalloids on 90-day mortality in patients with early septic shock.

The prognostic value of magnetic resonance imaging in moderate and severe traumatic brain injury: a systematic review and meta-analysis protocol

Abstract: Traumatic brain injury (TBI) is a devastating condition with significant long-term mortality and morbidity. Despite current need for objective indicators to guide initial decision-making, few reliable acute phase prognostic factors have been identified. Early magnetic resonance imaging (MRI) has been investigated as a prognostic tool, but uncertainty remains in both its discriminative predictive value and which acute phase lesion patterns correlate with long-term outcome. We will conduct a systematic review of observational cohort studies and randomized controlled trials of adult moderate or severe TBI patients who underwent MRI in the acute phase after trauma. A high sensitivity search strategy will be employed in MEDLINE, EMBASE, BIOSIS, and Cochrane CENTRAL to identify citations. Two reviewers will independently screen all identified references for eligibility and extract data into a standardized form. Data will be collected on study design, baseline demographics, trauma characteristics, magnetic resonance (MR) technical specifications, lesion patterns, and outcomes as related to acute MRI imaging. If meta-analysis is possible, quantitative data for each outcome will be pooled per type of lesion pattern using random effects models and expressed as Mantel-Haenszel relative risks in order to determine the prognostic value of lesions detected on acute MRI and their strength as discriminatory predictors of long-term outcome. Statistical heterogeneity will be evaluated with the I 2 statistics, and risk of bias and reporting quality will be assessed with standardized scales. Subgroup analyses are planned as a function of TBI severity, MRI-timing post-TBI, MRI field strength, MRI sequence, timing of outcome assessment, and risk of bias. We expect significant clinical heterogeneity, as eligible studies will likely encompass different periods in evolving MRI technology in addition to significant variability of image sequence protocols and timing of acquisition between centers. Based on existing studies in TBI, we expect lesions detected in the brainstem to be of significant predictive value as MRI is particularly sensitive for imaging the brain’s posterior fossa. Our systematic review will allow clinicians to more accurately interpret MRI in the context of determining prognosis for moderate and severe TBI patients and inform researchers in this domain to improve the methodology of future studies. Prospero CRD42015017074

ESICM LIVES 2016: part two

Abstract: Introduction In addition to systemic hemodynamics, the management of neurocritically ill patients is often informed by neuromonitoring. In the absence of high-level evidence clinicians are often guided by personal and local expertise. Little is known about practices as they pertain to the use of such monitoring in patients with acute brain injury (ABI). Objectives To investigate practices in bedside monitoring for ABI patients. Particularly interested in differences among “neurointensivists” (NIs; defined here as intensivists whose clinical practice is comprised > 1/3 by neurocritical care) and other intensivists (OIs). Also, to explore patterns specific to traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH), as well as preferences and availability of particular technologies/devices. Methods Electronic survey of 22 items including two case-based scenarios; endorsed by SCCM (9,000 recipients) and ESICM (on-line newsletter) in 2013. A sample size of 370 was calculated based on a population of 10,000 physician members, a 5 % margin error, and 95 % confidence interval. We summarized results using descriptive statistics (proportions with 95 % confidence intervals). A chi-square test was used to compare proportions of responses between NIs and OIs with a significance p < 0.05. Results There were 655 responders (66 % completion rate); 422(65 %) were classified as OIs and 226(35 %) as NIs. More NIs follow hemodynamic protocols for neurocritically-ill patients (56 % vs. 43 %, p 0.001), in TBI (44.5 % vs. 33.3 %, p 0.007), and in SAH (38.1 % vs. 21.3 %, p < 000.1). For delayed cerebral ischemia (DCI), more NIs target cardiac index (CI) (35 % vs. 21 %, p 0.0001), and fluid responsiveness (62 % vs. 53 %, p 0.03), use more bedside ultrasound (BUS) (42 % vs. 29 %, p 0.005) and arterial waveform analysis (40 % vs. 29 %, p 0.02). For DCI neuromonitoring, NIs use more angiography (57 % vs. 43 %, p 0.004), TCD (46 % vs. 38 %, p 0.0001), and CTP (32 % vs.16 %, p 0.0001). For CPP optimization in TBI, NIs use more arterial waveform analysis (45 % vs. 35 %, p 0.019), and BUS (37 % vs. 27.7 %, p 0.023), while more OIs monitor mixed venous oxygen saturation (54.1 % vs. 45 %, p 0.045). For TBI neuromonitoring, NIs use more PbtO2 (28 % vs. 10 %, p 0.0001). In the case scenario of raised ICP/low PbtO2, most employ analgosedation (47 %) and osmotherapy (38 %). Fewer make use of preserved pressure reactivity, particularly OIs (vasopressor use 23 % vs. 34 %, p 0.014). Conclusions There is large heterogeneity in the use of monitoring protocols, variables, and technologies/devices. “Neurointensivists” not only employ more neuromonitoring but also more hemodynamic monitoring in patients with acute brain injury. ICP/CPP remain the most commonly followed neuro-variables in TBI patients, with low use of other brain-physiology parameters, sugg

New modalities to deliver surfactant in premature infants: a systematic review and meta-analysis.

Abstract: Context: Surfactant is the principle treatment of respiratory distress syndrome, but the ideal method of its administration remains controversial. The intubation, surfactant administration and extubation (InSurE) method is proven to work but is invasive. The objective of this systematic review is to evaluate the efficacy and safety of the modalities of surfactant administration.Methods: We searched MEDLINE, EMBASE and CENTRAL (inception to December 2015) for randomized trials comparing new modalities with InSurE method. The primary outcome was mortality and development of bronchopulmonary dysplasia (BPD).Results: We screened 1837 citations and identified five unique trials were included; all were of unclear risk of bias. Four trials (400 infants) compared endotracheal catheters with InSurE, and one trial (70 infants) compared laryngeal masks (LMA) with InSurE. There was no significant difference between using endotracheal catheters compared with InSurE regarding infant mortality (risk ratio 1.05, ...

Coronary artery bypass surgery in a patient with Haemophilia A: a case report.

Abstract: laboratory because of improved precision, specificity and speed of assay [3]. However, it is important that laboratories recognize the limitations of their assay of choice including the interference from a number of substance including icterus, lipaemia and certain antibodies. The Siemens and Werfen VWF:Ag both use polyclonal rabbit anti-human VWF antibodies. The BC VWF:RCo, Werfen VWF:RCo and manual assay do not contain any antibodies whereas mouse monoclonal antibodies are present in the Innovance VWF Ac and Werfen VWF Act reagents. The chemiluminescent VWF:RCo does contains mouse monoclonal antibodies but includes a blocking agent for HAMA up to 1 lg mL . The Werfen VWF Act assay also contains a blocking agent against HAMA, but it is likely that the level in our patient swamps this agent. Acquired Von Willebrand Syndrome with a bleeding diathesis is a rare disorder [8], however, AVWS in the absence of bleeding appears to be more prevalent, particularly in patients secondary to lymphoor myelo-proliferative or cardiovascular diseases [9]. At present it is unknown how many humans develop anti-animal antibodies that interfere with assays employed in coagulation laboratories. The results presented in this report clearly demonstrate that some automated VWF activity assays may misdiagnose patients with AVWS and VWD. When using these VWF activity assays, which do not include ristocetin and platelets, in the initial diagnosis of acquired haemophilia and VWS, it is imperative that a VWF antigen should be tested at the same time. Where a discrepancy between a low VWF:Ag and higher VWF activity is found then an alternative, ristocetin-based assay, should be performed to exclude an erroneously high result and monitor subsequent replacement therapy.

Resuscitation Prior to Emergency Endotracheal Intubation: Results of a National Survey.

Abstract: Author(s): Green, MD, Robert S.; Fergusson, PhD, Dean A.; Turgeon, MD, MSc, Alexis F.; McIntyre, MD, MHSc, Lauralyn A.; Kovacs, MD, MHPE, George J.; Griesdale, MD, MPH, Donald E.; Zarychanski, MD, MSc, Ryan; Butler, MSc, Michael B.; Kureshi, MBBS, Nelofar; Erdogan, PhD, Mete | Abstract: Introduction: Respiratory failure is a common problem in emergency medicine (EM) and critical care medicine (CCM). However, little is known about the resuscitation of critically ill patients prior to emergency endotracheal intubation (EETI). Our aim was to describe the resuscitation practices of EM and CCM physicians prior to EETI. Methods: A cross-sectional survey was developed and tested for content validity and retest reliability by members of the Canadian Critical Care Trials Group. The questionnaire was distributed to all EM and CCM physician members of three national organizations. Using three clinical scenarios (trauma, pneumonia, congestive heart failure), we assessed physician preferences for use and types of fluid and vasopressor medication in pre-EETI resuscitation of critically ill patients. Results: In total, 1,758 physicians were surveyed (response rate 50.2%, 882/1758). Overall, physicians would perform pre-EETI resuscitation using either fluids or vasopressors in 54% (1,193/2,203) of cases. Most physicians would “always/often” administer intravenous fluid pre-EETI in the three clinical scenarios (81%, 1,484/1,830). Crystalloids were the most common fluid physicians would “always/often” administer in congestive heart failure (EM 43%; CCM 44%), pneumonia (EM 97%; CCM 95%) and trauma (EM 96%; CCM 96%). Pre-EETI resuscitation using vasopressors was uncommon (4.9%). Training in CCM was associated with performing pre-EETI resuscitation (odds ratio, 2.20; 95% CI, 1.44-3.36, p l 0.001). Conclusion: Pre-EETI resuscitation is common among Canadian EM and CCM physicians. Most physicians use crystalloids pre-EETI as a resuscitation fluid, while few would give vasopressors. Physicians with CCM training were more likely to perform pre-EETI resuscitation. [West J Emerg Med. 2016;17(5)542-548.]