Chunhu Shi

Safety and efficacy of a new parenteral lipid emulsion (Smof) for surgical patients: a systematic review and meta-analysis of randomized controlled trials

To assess the comparative safety and efficacy of a new parenteral lipid emulsion containing soybean oil, medium-chain triglycerides, olive oil, and fish oil (SMOFlipid20%) for postoperative patients, a meta-analysis of randomized controlled trials (RCTs) was conducted. Six RCTs with a total of 306 patients were included in the analysis. The overall quality of evidence for each outcome was evaluated using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) software. Compared with a soybean-based (Lipoven20%) and a soybean- and olive oil-based (ClinOleic20%) lipid emulsion, SMOFlipid20% was associated with lower levels of hepatic enzymes, suggesting less toxicity. Changes in low-density lipoprotein triglyceride and C-reactive protein levels were also lower with SMOFlipid20% compared with Lipoven20%. Differences between SMOFlipid20% and a lipid emulsion containing medium- and long-chain triglycerides (MCT/LCT20%) were not statistically significant. For all trials, there were no significant differences in adverse events and length of hospital stay. The quality of evidence from the RCTs evaluating SMOF20% versus Lipoven20% was moderate, while most of the evidence from RCTs of SMOF20% versus ClinOleic20% and MCT/LCT20% lipid emulsions was low.

How equity is addressed in clinical practice guidelines: a content analysis

Objectives Considering equity into guidelines presents methodological challenges. This study aims to qualitatively synthesise the methods for incorporating equity in clinical practice guidelines (CPGs). Setting Content analysis of methodological publications. Eligibility criteria for selecting studies Methodological publications were included if they provided checklists/frameworks on when, how and to what extent equity should be incorporated in CPGs. Data sources We electronically searched MEDLINE, retrieved references, and browsed guideline development organisation websites from inception to January 2013. After study selection by two authors, general characteristics and checklists items/framework components from included studies were extracted. Based on the questions or items from checklists/frameworks (unit of analysis), content analysis was conducted to identify themes and questions/items were grouped into these themes. Primary outcomes The primary outcomes were methodological themes and processes on how to address equity issues in guideline development. Results 8 studies with 10 publications were included from 3405 citations. In total, a list of 87 questions/items was generated from 17 checklists/frameworks. After content analysis, questions were grouped into eight themes (‘scoping questions’, ‘searching relevant evidence’, ‘appraising evidence and recommendations’, ‘formulating recommendations’, ‘monitoring implementation’, ‘providing a flow chart to include equity in CPGs’, and ‘others: reporting of guidelines and comments from stakeholders’ for CPG developers and ‘assessing the quality of CPGs’ for CPG users). Four included studies covered more than five of these themes. We also summarised the process of guideline development based on the themes mentioned above. Conclusions For disadvantaged population-specific CPGs, eight important methodological issues identified in this review should be considered when including equity in CPGs under the guidance of a scientific guideline development manual.

Support surfaces for pressure ulcer prevention: A network meta-analysis

Background Pressure ulcers are a prevalent and global issue and support surfaces are widely used for preventing ulceration. However, the diversity of available support surfaces and the lack of direct comparisons in RCTs make decision-making difficult. Objectives To determine, using network meta-analysis, the relative effects of different support surfaces in reducing pressure ulcer incidence and comfort and to rank these support surfaces in order of their effectiveness. Methods We conducted a systematic review, using a literature search up to November 2016, to identify randomised trials comparing support surfaces for pressure ulcer prevention. Two reviewers independently performed study selection, risk of bias assessment and data extraction. We grouped the support surfaces according to their characteristics and formed evidence networks using these groups. We used network meta-analysis to estimate the relative effects and effectiveness ranking of the groups for the outcomes of pressure ulcer incidence and participant comfort. GRADE was used to assess the certainty of evidence. Main results We included 65 studies in the review. The network for assessing pressure ulcer incidence comprised evidence of low or very low certainty for most network contrasts. There was moderate-certainty evidence that powered active air surfaces and powered hybrid air surfaces probably reduce pressure ulcer incidence compared with standard hospital surfaces (risk ratios (RR) 0.42, 95% confidence intervals (CI) 0.29 to 0.63; 0.22, 0.07 to 0.66, respectively). The network for comfort suggested that powered active air-surfaces are probably slightly less comfortable than standard hospital mattresses (RR 0.80, 95% CI 0.69 to 0.94; moderate-certainty evidence). Conclusions This is the first network meta-analysis of the effects of support surfaces for pressure ulcer prevention. Powered active air-surfaces probably reduce pressure ulcer incidence, but are probably less comfortable than standard hospital surfaces. Most prevention evidence was of low or very low certainty, and more research is required to reduce these uncertainties.

Methodological Reporting of Randomized Trials in Five Leading Chinese Nursing Journals

Background Randomized controlled trials (RCTs) are not always well reported, especially in terms of their methodological descriptions. This study aimed to investigate the adherence of methodological reporting complying with CONSORT and explore associated trial level variables in the Chinese nursing care field. Methods In June 2012, we identified RCTs published in five leading Chinese nursing journals and included trials with details of randomized methods. The quality of methodological reporting was measured through the methods section of the CONSORT checklist and the overall CONSORT methodological items score was calculated and expressed as a percentage. Meanwhile, we hypothesized that some general and methodological characteristics were associated with reporting quality and conducted a regression with these data to explore the correlation. The descriptive and regression statistics were calculated via SPSS 13.0. Results In total, 680 RCTs were included. The overall CONSORT methodological items score was 6.34±0.97 (Mean ± SD). No RCT reported descriptions and changes in “trial design,” changes in “outcomes” and “implementation,” or descriptions of the similarity of interventions for “blinding.” Poor reporting was found in detailing the “settings of participants” (13.1%), “type of randomization sequence generation” (1.8%), calculation methods of “sample size” (0.4%), explanation of any interim analyses and stopping guidelines for “sample size” (0.3%), “allocation concealment mechanism” (0.3%), additional analyses in “statistical methods” (2.1%), and targeted subjects and methods of “blinding” (5.9%). More than 50% of trials described randomization sequence generation, the eligibility criteria of “participants,” “interventions,” and definitions of the “outcomes” and “statistical methods.” The regression analysis found that publication year and ITT analysis were weakly associated with CONSORT score. Conclusions The completeness of methodological reporting of RCTs in the Chinese nursing care field is poor, especially with regard to the reporting of trial design, changes in outcomes, sample size calculation, allocation concealment, blinding, and statistical methods.

Mobile phone messaging for facilitating self-management of long-term illnesses: Summaries of Nursing Care-Related Systematic Reviews from the Cochrane Library

School of Basic Medical Sciences, Evidence-Based Medicine Centre of Lanzhou University, Lanzhou, Gansu, China.

Evaluating the development and validation of empirically-derived prognostic models for pressure ulcer risk assessment: a systematic review

BACKGROUND Researchers advocate developing empirically-derived prognostic models to predict pressure ulcer risk. However, there remains a scarcity of evidence about the performance and clinical value of these models. OBJECTIVES To identify and describe empirically-derived models for predicting pressure ulcer risk; to assess the predictive performance of these models; and to evaluate their clinical impact in reducing pressure ulcer incidence. METHODS We performed a comprehensive database search up to February 2017 and searched other resources to identify longitudinal studies that developed and/or validated prognostic models for predicting pressure ulcer risk and studies evaluating the clinical effects of such models. There were no language or publication date restrictions. Two reviewers independently conducted study selection. Using a pre-prepared data extraction form, one reviewer collected data on the characteristics and performance of the included models and assessed study risk of bias. A second reviewer checked all the data. Using narrative synthesis, we summarised the characteristics of the included studies and models. Using meta-analysis, we combined performance (discrimination and calibration) measurement statistics for relevant models. RESULTS We included 24 studies with 28 data sources in the review and identified 22 models that were developed using these data. Of the 22 models, only seven had further external validations (one model was validated twice). In development, a third of models used univariate analysis alone to identify statistically significant predictors for subsequent multivariable analysis; and nine of the 16 developed models were formed using stepwise selection processes in multivariable analysis. Missing data were often incompletely reported, and continuous predictors were correctly handled in only two models (e.g., using restricted cubic spline). Sample sizes of the model development studies were small with 13 models involving fewer than 10 events per variable. The risk of bias associated with the development of all 22 models and eight validations was judged as high or unclear. The predictive performance was reported as: c-statistic point estimates ranging from 0.65 to 0.89, and total Observed:Expected risk ratios between 0.94 and 1.00. Compared with heuristic tools, relevant included models had better discrimination and calibration. No eligible study was identified that evaluated the clinical impact of any included model. CONCLUSIONS Whilst many prognostic models for predicting ulcer risk have been developed few have been validated. The methods used for model development are generally flawed which reduces the potential for using these models in practice. Future research should address these weaknesses.

Skin status for predicting pressure ulcer development: A systematic review and meta-analyses

BACKGROUND People with altered skin status are conventionally considered to have a higher risk of developing new ulcers. However, the evidence underpinning this potentially prognostic relationship is unclear. OBJECTIVES To systematically review the evidence for the prognostic association of skin status with pressure ulcer risk. METHODS We performed a comprehensive electronic database search in February 2017 to identify longitudinal studies that considered skin status in multivariable analysis for predicting pressure ulcer risk in any population. Study selection was conducted by two reviewers independently. We collected data on the characteristics of studies, participants, skin status, and results of multivariable analyses of skin status-pressure ulcer incidence associations. We applied the Quality In Prognosis Studies tool to assess risk of bias. We conducted meta-analyses using STATA where data were available from multivariable analyses. We used the Grades of Recommendation Assessment, Development and Evaluation approach to assess the certainty of evidence generated from each meta-analysis. RESULTS We included 41 studies (with 162,299 participants, and 7382 having new ulcers) that investigated 15 skin descriptors. Participants were predominantly hospitalised adults and long-term care residents (with a median age of 75.2 years). Studies had a median follow-up duration of 7.5 weeks. 61.0% (25/41) of studies were judged as being high risk of bias. 53.7% (22/41) of studies had small sample sizes. Subsequently, the certainty of evidence was rated as low or very low for all 13 meta-analyses that we conducted though all analyses showed statistically significant associations of specific skin descriptors-pressure ulcer incidence. People with non-blanchable erythema may have higher odds of developing pressure ulcers than those without (Odds Ratio 3.08, 95% Confidence Interval 2.26-4.20 if pressure ulcer preventive measures were not adjusted in multivariable analysis; 1.99, 1.76-2.25 if adjusted) (both low-certainty evidence). The evidence for other skin descriptors was judged as very low-certainty and their prognostic value is uncertain. CONCLUSIONS There is low-certainty evidence that people with non-blanchable erythema may be more likely to develop new pressure ulcers than those without non-blanchable erythema. The evidence for the prognostic effects of other skin descriptors (e.g., history of pressure ulcer) is of very low-certainty. The findings support regular skin assessment and preventive action being taken in the presence of non-blanchable erythema. Given the millions at risk of ulceration and the widely recommended use of skin status as part of risk assessment there is a need for more, high quality confirmatory studies.

Interventions for preventing falls in older people in care facilities and hospitals.

95% CI 0.94 to 1.23; 8 trials, 1887 participants). Post hoc subgroup analysis by level of care suggested that exercise might reduce falls in people in intermediate level facilities, and increase falls in facilities providing high levels of nursing care. In care facilities, vitamin D supplementation reduced the rate of falls (RaR 0.63, 95% CI 0.46 to 0.86; 5 trials, 4603 participants), but not risk of falling (RR 0.99, 95% CI 0.90 to 1.08; 6 trials, 5186 participants). For multifactorial interventions in care facilities, the rate of falls (RaR 0.78, 95% CI 0.59 to 1.04; 7 trials, 2876 participants) and risk of falling (RR 0.89, 95% CI 0.77 to 1.02; 7 trials, 2632 participants) suggested possible benefits, but this evidence was not conclusive. In subacute wards in hospital, additional physiotherapy (supervised exercises) did not significantly reduce rate of falls (RaR 0.54, 95% CI 0.16 to 1.81; 1 trial, 54 participants) but achieved a significant reduction in risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 2 trials, 83 participants). In one trial in a subacute ward (54 participants), carpet flooring significantly increased the rate of falls compared with vinyl flooring (RaR 14.73, 95% CI 1.88 to 115.35) and potentially increased the risk of falling (RR 8.33, 95% CI 0.95 to 73.37). One trial (1822 participants) testing an educational session by a trained research nurse targeting individual fall risk factors in patients at high risk of falling in acute medical wards achieved a significant reduction in risk of falling (RR 0.29, 95% CI 0.11 to 0.74). Overall, multifactorial interventions in hospitals reduced the rate of falls (RaR 0.69, 95% CI 0.49 to 0.96; 4 trials, 6478 participants) and risk of falling (RR 0.71, 95% CI 0.46 to 1.09; 3 trials, 4824 participants), although the evidence for risk of falling was inconclusive. Of these, one trial in a subacute setting reported the effect was not apparent until after 45 days in hospital. Multidisciplinary care in a geriatric ward after hip fracture surgery compared with usual care in an orthopaedic ward significantly reduced rate of falls (RaR 0.38, 95% CI 0.19 to 0.74; 1 trial, 199 participants) and risk of falling (RR 0.41, 95% CI 0.20 to 0.83). More trials are needed to confirm the effectiveness of multifactorial interventions in acute and subacute hospital settings. Authors’ conclusions In care facilities, vitamin D supplementation is effective in reducing the rate of falls. Exercise in subacute hospital settings appears effective but its effectiveness in care facilities remains uncertain due to conflicting results, possibly associated with differences in interventions and levels of dependency. There is evidence that multifactorial interventions reduce falls in hospitals but the evidence for risk of falling was inconclusive. Evidence for multifactorial interventions in care facilities suggests possible benefits, but this was inconclusive. P L A I N L A N G U A G E S U M M A R Y Interventions for preventing falls in older people in care facilities and hospitals Falls by older people in residential or nursing care facilities and hospitals are common events that may cause loss of independence, injuries, and sometimes death as a result of injury. Effective interventions to prevent falls are important as they will have significant health benefits. This review included 60 randomised controlled trials involving 60,345 participants. Forty-three trials (30,373 participants) were in care facilities, and 17 (29,972 participants) in hospitals. Despite the large number of trials, there was limited evidence to support any one intervention. In care facilities, the prescription of vitamin D reduced the number of falls, probably because residents have low vitamin D levels. Results from 13 trials testing exercise interventions in care facilities were inconsistent and overall did not show a benefit. It may be that exercise programmes increase falls in frail residents and reduce falls in less frail residents. Interventions targeting multiple risk factors may be effective in reducing the number of falls. Additional physiotherapy reduced the number of people falling in hospital rehabilitation wards and interventions targeting multiple risk factors reduced falls in hospital. 2 Interventions for preventing falls in older people in care facilities and hospitals (Review) Copyright