Elizabeth Uleryk

Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies

Objective To systematically review associations between intake of saturated fat and trans unsaturated fat and all cause mortality, cardiovascular disease (CVD) and associated mortality, coronary heart disease (CHD) and associated mortality, ischemic stroke, and type 2 diabetes. Design Systematic review and meta-analysis. Data sources Medline, Embase, Cochrane Central Registry of Controlled Trials, Evidence-Based Medicine Reviews, and CINAHL from inception to 1 May 2015, supplemented by bibliographies of retrieved articles and previous reviews. Eligibility criteria for selecting studies Observational studies reporting associations of saturated fat and/or trans unsaturated fat (total, industrially manufactured, or from ruminant animals) with all cause mortality, CHD/CVD mortality, total CHD, ischemic stroke, or type 2 diabetes. Data extraction and synthesis Two reviewers independently extracted data and assessed study risks of bias. Multivariable relative risks were pooled. Heterogeneity was assessed and quantified. Potential publication bias was assessed and subgroup analyses were undertaken. The GRADE approach was used to evaluate quality of evidence and certainty of conclusions. Results For saturated fat, three to 12 prospective cohort studies for each association were pooled (five to 17 comparisons with 90 501-339 090 participants). Saturated fat intake was not associated with all cause mortality (relative risk 0.99, 95% confidence interval 0.91 to 1.09), CVD mortality (0.97, 0.84 to 1.12), total CHD (1.06, 0.95 to 1.17), ischemic stroke (1.02, 0.90 to 1.15), or type 2 diabetes (0.95, 0.88 to 1.03). There was no convincing lack of association between saturated fat and CHD mortality (1.15, 0.97 to 1.36; P=0.10). For trans fats, one to six prospective cohort studies for each association were pooled (two to seven comparisons with 12 942-230 135 participants). Total trans fat intake was associated with all cause mortality (1.34, 1.16 to 1.56), CHD mortality (1.28, 1.09 to 1.50), and total CHD (1.21, 1.10 to 1.33) but not ischemic stroke (1.07, 0.88 to 1.28) or type 2 diabetes (1.10, 0.95 to 1.27). Industrial, but not ruminant, trans fats were associated with CHD mortality (1.18 (1.04 to 1.33) v 1.01 (0.71 to 1.43)) and CHD (1.42 (1.05 to 1.92) v 0.93 (0.73 to 1.18)). Ruminant trans-palmitoleic acid was inversely associated with type 2 diabetes (0.58, 0.46 to 0.74). The certainty of associations between saturated fat and all outcomes was “very low.” The certainty of associations of trans fat with CHD outcomes was “moderate” and “very low” to “low” for other associations. Conclusions Saturated fats are not associated with all cause mortality, CVD, CHD, ischemic stroke, or type 2 diabetes, but the evidence is heterogeneous with methodological limitations. Trans fats are associated with all cause mortality, total CHD, and CHD mortality, probably because of higher levels of intake of industrial trans fats than ruminant trans fats. Dietary guidelines must carefully consider the health effects of recommendations for alternative macronutrients to replace trans fats and saturated fats.

Effectiveness of Interventions Aimed at Reducing Screen Time in Children: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE To evaluate the impact of interventions focused on reducing screen time. DATA SOURCES Medline, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, ERIC, and CINAHL through April 21, 2011. STUDY SELECTION Included studies were randomized controlled trials of children aged 18 years or younger with interventions that focused on reducing screen time. INTERVENTION Efforts to reduce screen time. MAIN OUTCOME MEASURES The primary outcome was body mass index (BMI); the secondary outcome was screen time (hours per week). RESULTS A total of 1120 citations were screened, and 13 studies were included in the systematic review. Study samples ranged in age (3.9-11.7 years) and size (21-1295 participants). Interventions ranged in length (1-24 months) and recruitment location (5 in schools, 2 in medical clinics, 1 in a community center, and 5 from the community). For the primary outcome, the meta-analysis included 6 studies, and the difference in mean change in BMI in the intervention group compared with the control group was -0.10 (95% confidence interval [CI], -0.28 to 0.09) (P = .32). The secondary outcome included 9 studies, and the difference in mean change from baseline in the intervention group compared with the control group was -0.90 h/wk (95% CI, -3.47 to 1.66 h/wk) (P = .49). A subgroup analysis of preschool children showed a difference in mean change in screen time of -3.72 h/wk (95% CI, -7.23 to -0.20 h/wk) (P = .04). CONCLUSIONS Our systematic review and meta-analysis did not demonstrate evidence of effectiveness of interventions aimed at reducing screen time in children for reducing BMI and screen time. However, interventions in the preschool age group hold promise.

Should a Head-Injured Child Receive a Head CT Scan? A Systematic Review of Clinical Prediction Rules

CONTEXT: Given radiation- and sedation-associated risks, there is uncertainty about which children with head trauma should receive cranial computed tomography (CT) scanning. A high-quality and high-performing clinical prediction rule may reduce this uncertainty. OBJECTIVE: To systematically review the quality and performance of published clinical prediction rules for intracranial injury in children with head injury. METHODS: Medline and Embase were searched in December 2008. Studies were selected if they included clinical prediction rules involving children aged 0 to 18 years with a history of head injury. Prediction-rule quality was assessed by using 14 previously published items. Prediction-rule performance was evaluated by rule sensitivity and the predicted frequency of CT scanning if the rule was used. RESULTS: A total of 3357 titles and abstracts were assessed, and 8 clinical prediction rules were identified. For all studies, the rule derivations were reported; no study validated a rule in a separate population or assessed its impact in actual practice. The rules differed considerably in population, predictors, outcomes, methodologic quality, and performance. Five of the rules were applicable to children of all ages and severities of trauma. Two of these were high quality (≥11 of 14 quality items) and had high performance (lower confidence limits for sensitivity >0.95 and required ≤56% to undergo CT). Four of the 8 rules were applicable to children with minor head injury (Glasgow coma score ≥13). One of these had high quality (11 of 14 quality items) and high performance (lower confidence limit for sensitivity = 0.94 and required 13% to undergo CT). Four of the 8 rules were applicable to young children, but none exhibited adequate quality or performance. CONCLUSIONS: Eight clinical prediction-rule derivation studies were identified. They varied considerably in population, methodologic quality, and performance. Future efforts should be directed toward validating rules with high quality and performance in other populations and deriving a high-quality, high-performance rule for young children.

Mycophenolate mofetil for induction treatment of lupus nephritis: a systematic review and metaanalysis.

Objective. To systematically review the efficacy and safety of mycophenolic acid and mycophenolate mofetil (MMF) compared to cyclophosphamide (CYC) for the induction treatment of lupus nephritis (LN). Methods. Medline, Embase, the Cochrane Center Register of Controlled Trials, and abstracts presented in major international conferences were searched for randomized controlled trials. The primary outcome was renal remission (complete, partial, and overall) and secondary outcomes were adverse events during study period and longterm followup data. Data were compared between groups and relative risk (RR) and 95% CI were calculated. Results. Four trials of a total of 618 patients were included. MMF was not superior to CYC for renal remission (partial RR 0.94, 95% CI 0.80 to 1.12; complete RR 0.67, 95% CI 0.35 to 1.28, and overall RR 0.89, 95% CI 0.71 to 1.10). There was a significant reduction in alopecia (RR 5.77, 95% CI 1.56 to 21.38) and amenorrhea (RR 6.64, 95% CI 2.00 to 22.07) with the use of MMF compared to CYC. These results should be interpreted with caution given the width of the CI. There was no significant difference for infections, leukopenia, gastrointestinal symptoms, herpes zoster, endstage renal disease, and death among groups during study period and longterm followup data. Conclusion. We could not show that MMF is superior to CYC for the induction treatment of LN. Patients treated with MMF showed reduced risk of certain side effects. MMF can be used as an alternative to CYC for the induction treatment of LN.

An official American Thoracic Society/European Society of intensive care medicine/society of critical care medicine clinical practice guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome

Background: This document provides evidence‐based clinical practice guidelines on the use of mechanical ventilation in adult patients with acute respiratory distress syndrome (ARDS). Methods: A multidisciplinary panel conducted systematic reviews and metaanalyses of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: For all patients with ARDS, the recommendation is strong for mechanical ventilation using lower tidal volumes (4‐8 ml/kg predicted body weight) and lower inspiratory pressures (plateau pressure < 30 cm H2O) (moderate confidence in effect estimates). For patients with severe ARDS, the recommendation is strong for prone positioning for more than 12 h/d (moderate confidence in effect estimates). For patients with moderate or severe ARDS, the recommendation is strong against routine use of high‐frequency oscillatory ventilation (high confidence in effect estimates) and conditional for higher positive end‐expiratory pressure (moderate confidence in effect estimates) and recruitment maneuvers (low confidence in effect estimates). Additional evidence is necessary to make a definitive recommendation for or against the use of extracorporeal membrane oxygenation in patients with severe ARDS. Conclusions: The panel formulated and provided the rationale for recommendations on selected ventilatory interventions for adult patients with ARDS. Clinicians managing patients with ARDS should personalize decisions for their patients, particularly regarding the conditional recommendations in this guideline.

Does this child have appendicitis? A systematic review of clinical prediction rules for children with acute abdominal pain.

OBJECTIVES To systematically identify clinical prediction rules (CPRs) for children with suspected appendicitis and compare their methodological quality and performance. STUDY DESIGN AND SETTING Included studies involved children aged 0-18 years with suspected appendicitis identified through MEDLINE and EMBASE from 1950 to 2012. The quality was assessed using 17 previously published items. The performance was evaluated using the sensitivity, negative likelihood ratio, and predicted frequency of appendicitis diagnosis that would result if the rule was used. RESULTS Twelve studies fulfilled the inclusion criteria describing the derivation or validation of six unique CPRs involving 4,201 children with suspected appendicitis. Migratory pain, nausea or vomiting, and right lower quadrant tenderness were common predictors to all rules. Methodological quality varied widely. The most poorly addressed quality items were the predictor and outcome assessor blinding, predictor description, and reproducibility of predictor assessment. The most well-validated CPRs were the Pediatric Appendicitis Score (PAS) and MANTRELS (Migration, Anorexia, Nausea/vomiting, Tenderness in the right lower quadrant, Rebound pain, Elevation in temperature, Leukocytosis, Shift to the left)/Alvarado Score. Overall, the PAS validation studies outperformed the Alvarado validation studies. CONCLUSION The PAS and Alvarado scores were the most well validated but neither met the current performance benchmarks. A high quality, well validated, and consistently high-performing CPR was not identified. Further research is needed before a CPR for children with suspected appendicitis can be used in routine practice.

Child vs Adult Randomized Controlled Trials in Specialist Journals: A Citation Analysis of Trends, 1985-2005

OBJECTIVE To compare secular trends in the age representation of published randomized controlled trials (RCTs) in specialty journals during a period of 20 years. DATA SOURCE A validated electronic search strategy using Ovid MEDLINE was conducted to identify RCTs published in the years 1985 through 2005. STUDY SELECTION The publications retrieved were subdivided into age-specific groups: adults, children, both adults and children, and studies with no age group identified. Within 31 specialties, we chose up to 5 specialty journals and 5 pediatric specialty journals. MAIN OUTCOME MEASURE Number of RCTs targeting children compared with adults over time. Linear trends were identified using regression modeling, and an interaction term was included to compare rates of increase between age groups. RESULTS A total of 174 unique journals with 43 326 unique RCTs with age-specific categorization were included. Adult RCTs increased by 90.5 RCTs per year (95% confidence interval [CI], 78-103), which was significantly higher than either pediatric RCTs, which rose by 16.9 RCTs per year (95% CI, 12-22) or RCTs involving both children and adults, which rose by 22.7 RCTs per year (95% CI, 10-35). Twenty-four of 31 specialties (77%) demonstrated a greater rise in the number of published RCTs per year involving adults than those enrolling children. CONCLUSION Adult RCT publications are increasing at a faster rate than pediatric RCTs in almost all specialties.

A systematic review of RIFLE criteria in children, and its application and association with measures of mortality and morbidity

The RIFLE criteria were developed to improve consistency in the assessment of acute kidney injury. The high face validity, collaborative development method, and validation against mortality have supported the widespread adoption of the RIFLE to evaluate adult patients; however, its inconsistent application in adult studies is associated with significant effects on the estimated incidence of acute kidney injury. As the RIFLE criteria are now being used to determine acute kidney injury in children, we conducted a systematic review to describe its application and assess associations between the RIFLE and measures of mortality and morbidity in pediatric patients. In 12 studies we found wide variation in the application of the RIFLE, including the range of assessed RIFLE categories, omission of urine output criteria, varying definitions of baseline renal function, and methods for handling missing baseline measurements. Limited and conflicting associations between the RIFLE and mortality, length of stay, illness severity, and measures of kidney function were found. Thus, although the RIFLE was developed to improve the consistency of defining acute kidney injury, there are still major discrepancies in its use in pediatric patients that may undermine its potential utility as a standardized measure of acute kidney injury in children.

The relationship between sleep and postpartum mental disorders: A systematic review

BACKGROUND Postpartum mental disorders (e.g., anxiety, depression, psychosis) are serious conditions that affect approximately 10-15% of women after childbirth, and up to 40% of women at risk for these disorders. Research reveals an association between poor sleep quality/quantity and symptoms of anxiety, depression and psychosis. The aim of this systematic review was to evaluate the available evidence for the relationship between sleep and postpartum mental disorders. METHODS Searches included MEDLINE, EMBASE, and EBM Reviews - Cochrane Central Register of Controlled Trials, PsycINFO and EBSCOHost CINAHL through June 30, 2014. Manual searching was performed on reference lists of included articles. Published primary research in any language was included. RESULTS There were 3187 unique titles/abstracts and 44 full-text articles reviewed. Thirty-one studies were included. Evidence was found for the impact of self-reported poor sleep during pregnancy and the postpartum on the development of postpartum depression, with not enough evidence for either postpartum anxiety or psychosis. The evidence for objectively assessed sleep and the development of postpartum disorders was mixed. Among the 31 studies included, 1 was strong, 13 were moderate and 17 were weak. LIMITATIONS Research design, method of assessment, timing of assessment, recruitment strategies, representative adequacy of the samples and inclusion/exclusion criteria all varied widely. Many studies did not use tools validated for the perinatal population and had small sample sizes without power analysis. CONCLUSIONS Sleep interventions represent a potential low-cost, non-pharmacological prevention and treatment strategy for postpartum mental illness. Further high-quality research is needed on this topic area.

A systematic review of the role of C4d in the diagnosis of acute antibody-mediated rejection

In this study, we conducted a systematic review of the literature to re-evaluate the role of C4d in the diagnosis of acute antibody-mediated rejection of kidney allografts. Electronic databases were searched until September 2013. Eligible studies allowed derivation of diagnostic tables for the performance of C4d by immunofluorescence or immunohistochemistry with comparison to histopathological features of acute antibody-mediated rejection and/or donor-specific antibody (DSA) assays. Of 3492 unique abstracts, 29 studies encompassing 3485 indication and 868 surveillance biopsies were identified. Assessment of C4d by immunofluorescence and immunohistochemistry exhibited slight to moderate agreement with glomerulitis, peritubular capillaritis, solid-phase DSA assays, DSA with glomerulitis, and DSA with peritubular capillaritis. The sensitivity and specificity of C4d varied as a function of C4d and comparator test thresholds. Prognostically, the presence of C4d was associated with inferior allograft survival compared with DSA or histopathology alone. Thus, our findings support the presence of complement-dependent and -independent phenotypes of acute antibody-mediated rejection. Whether the presence of C4d in combination with histopathology or DSA should be considered for the diagnosis of acute antibody-mediated rejection warrants further study.