Kelly Mrklas

Comparative efficacy of serotonin (5-HT3

BackgroundSerotonin (5-HT3) receptor antagonists are commonly used to decrease nausea and vomiting for surgery patients. We conducted a systematic review on the comparative efficacy of 5-HT3 receptor antagonists.MethodsSearches were done in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to identify studies comparing 5-HT3 receptor antagonists with each other, placebo, and/or combined with other antiemetic agents for patients undergoing surgical procedures. Screening search results, data abstraction, and risk of bias assessment were conducted by two reviewers independently. Random-effects pairwise meta-analysis and network meta-analysis (NMA) were conducted. PROSPERO registry number: CRD42013003564.ResultsOverall, 450 studies and 80,410 patients were included after the screening of 7,608 citations and 1,014 full-text articles. Significantly fewer patients experienced nausea with any drug relative to placebo, except for ondansetron plus metoclopramide in a NMA including 195 RCTs and 24,230 patients. Significantly fewer patients experienced vomiting with any drug relative to placebo except for palonosetron plus dexamethasone in NMA including 238 RCTs and 12,781 patients. All agents resulted in significantly fewer patients with postoperative nausea and vomiting versus placebo in a NMA including 125 RCTs and 16,667 patients.ConclusionsGranisetron plus dexamethasone was often the most effective antiemetic, with the number needed to treat ranging from two to nine.

Interventions encouraging the use of systematic reviews by health policymakers and managers: A systematic review

BackgroundSystematic reviews have the potential to inform decisions made by health policymakers and managers, yet little is known about the impact of interventions to increase the use of systematic reviews by these groups in decision making.MethodsWe systematically reviewed the evidence on the impact of interventions for seeking, appraising, and applying evidence from systematic reviews in decision making by health policymakers or managers. Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Health Technology Assessment Database, and LISA were searched from the earliest date available until April 2010. Two independent reviewers selected studies for inclusion if the intervention intended to increase seeking, appraising, or applying evidence from systematic reviews by a health policymaker or manager. Minimum inclusion criteria were a description of the study population and availability of extractable data.Results11,297 titles and abstracts were reviewed, leading to retrieval of 37 full-text articles for assessment; four of these articles met all inclusion criteria. Three articles described one study where five systematic reviews were mailed to public health officials and followed up with surveys at three months and two years. The articles reported from 23% to 63% of respondents declaring they had used systematic reviews in policymaking decisions. One randomised trial indicated that tailored messages combined with access to a registry of systematic reviews had a significant effect on policies made in the area of healthy body weight promotion in health departments.ConclusionsThe limited empirical data renders the strength of evidence weak for the effectiveness and the types of interventions that encourage health policymakers and managers to use systematic reviews in decision making.

Accuracy of Peripheral Thermometers for Estimating Temperature: A Systematic Review and Meta-analysis

Abnormalities in body temperature (that is, fever and hypothermia) are common (14). Such abnormalities are components of diagnostic criteria for certain disorders (58), influence clinical management decisions (9, 10), and are associated with increased mortality in certain patient populations (11, 12). For most adult and pediatric populations, fever is defined as a body temperature of 38.0C or higher (1315); this definition can vary according to certain patient characteristics (for example, acute brain injury [16, 17]), institutional preference (18), and different methods of assessing body temperature (Appendix Table 1). Hypothermia is also variably defined but generally accepted to occur when body temperature is less than 36.0C (19). Appendix Table 1. Temperature Measurement Sites and Methods Accurate assessment of temperature is important. Thermometers that measure temperature from an intravascular site are considered the gold standard (20). Guidelines in adults recommend measuring temperature from one of several central options (for example, the rectum) (21), whereas guidelines in children suggest measuring from a peripheral site (for example, the axilla) (22, 23, 24). Neither recommendation is based on systematic syntheses of available evidence pertaining to thermometer accuracy (15, 25, 26). Many small studies have examined the accuracy of peripheral thermometers and report generally discordant results. Systematic reviews that examined the accuracy of peripheral thermometers in adults were either focused on selectively chosen populations or did not use established meta-analytic methods (27, 28). Meta-analyses examining infrared ear and axillary thermometry compared with a rectal reference standard in children found wide limits of agreement (LOA) (25, 26). Given these drawbacks and the potential for advancements in thermometer technology (25, 26), the accuracy of peripheral thermometers is not well-defined. We therefore did a systematic review and meta-analysis to determine whether peripheral thermometers have clinically acceptable accuracy compared with central thermometers in adults and children and whether the type of peripheral thermometer is an important determinant of accuracy. Methods The primary objective was to determine the LOA in temperature between peripheral and central thermometers (29). The secondary objective was to determine the diagnostic accuracy (sensitivity, specificity, and positive and negative likelihood ratios) of peripheral thermometers for detecting fever or hypothermia. Methods for article inclusion and data analysis were prespecified in a protocol (not registered) and consistent with major systematic review reporting guidelines (3032). Data Sources and Searches We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL Plus for studies that compared the accuracy of peripheral thermometers with a central reference standard from inception to September 2014; we subsequently updated our search to 20 July 2015. In the MEDLINE and Cochrane Central Register of Controlled Trials searches, we used a combination of exploded Medical Subject Heading terms and text words that included synonyms for thermometer and validated filters for clinical trials (33), cohort studies (34), and diagnostic accuracy studies (Appendix Table 2) (35). The search strategy included similar combinations of terms and filters within the other databases and did not have any language restrictions. Additional citations were located using the related articles feature in PubMed and by hand-searching bibliographies of included studies, previously published reviews (15, 2528, 3640), and relevant societal guidelines (2124). Finally, 2 international clinical trial registries were searched to identify potentially relevant unpublished studies (41, 42). Appendix Table 2. MEDLINE Search Strategy* Selection Criteria Before reviewing all citations, 2 reviewers calibrated the citation screening form by reviewing 25 randomly selected citations. All titles and abstracts were then independently reviewed in duplicate. The full text of selected citations was then reviewed (in duplicate) against the inclusion and exclusion criteria. We used the following inclusion criteria: prospective study design (randomized clinical trial, controlled clinical trial, cohort study, or diagnostic accuracy study) of adults (aged 18 years) or children (aged <18 years) managed in acute care or ambulatory facilities; peripheral index thermometers included tympanic membrane, temporal artery, axillary (electronic, mercury, or chemical dot), or oral (electronic or mercury) thermometers (21, 23, 25, 26); central reference thermometers included pulmonary artery catheters or urinary bladder, esophageal, or rectal thermometers (21, 23, 25, 26); paired temperature measurements between index and reference thermometers were obtained within 5 minutes of one another; and mean difference and associated variance (SD or 95% CI) were reported for each indexreference comparison. The rectal thermometer was included as a central reference device because it is commonly viewed as invasive (22, 23, 26), frequently used in pediatric studies as the reference standard (25, 26), and listed in guidelines as being one of the most accurate thermometers (21). Exclusion criteria were as follows: casecontrol study, animal study, study population included healthy volunteers without medical concerns evaluated in nonclinical environments, or data presented in graphical format only. Noncontact infrared thermometers were excluded because they are not currently reported as a commonly used device for measuring temperature in clinical environments (18). Articles were excluded if they did not explicitly indicate that the mean difference estimates were derived using methods appropriate for repeated measures data (29). NonEnglish-language studies were translated and evaluated for inclusion. Agreement between authors at each stage of citation review was quantified using statistics. Data Extraction and Quality Assessment Data were abstracted independently and in duplicate, including the mean difference (and variance) in temperature between the index and reference thermometers and the data required to calculate the sensitivity and specificity for detecting fever and hypothermia (that is, the number of true-positive, false-positive, true-negative, and false-negative results). Data extraction that related to study quality included domains of the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool (43), whether the index thermometer was calibrated, and whether users received training in proper index thermometer use. Corresponding authors of selected articles were contacted for missing information as required. Data Synthesis and Analysis The primary meta-analysis determined the 95% LOA between peripheral and central thermometers; this was calculated as the pooled estimate of the mean difference in temperature measurements (peripheral minus central) 2 times the pooled estimate of the SD of the difference (29, 44). The prespecified and clinically acceptable 95% LOA were0.5C (4547). Data were pooled using a random-effects model (48), reported as the pooled mean difference (95% CI), and converted to 95% LOA. Study weights were adjusted for several indexreference comparisons. When a study used the same population to examine the accuracy of multiple index thermometers, the total study population was divided by the number of different index comparisons for pooled analyses (26); for studies that compared a given index thermometer with several reference thermometers, we restricted analyses to comparisons with the pulmonary artery catheter. The validity of pooling data across the 4 reference thermometers was examined by determining the pooled 95% LOA between each nonvascular thermometer (bladder, esophageal, or rectal) and the pulmonary artery catheter (gold standard) (21). The secondary meta-analysis determined the diagnostic accuracy of peripheral thermometers for detecting fever or hypothermia using the analytic approach outlined by the Cochrane Diagnostic Test Accuracy Working Group (32). Individual study estimates of sensitivity and specificity were determined from 22 contingency tables and used to develop the summary receiver-operating characteristic curve. Pooled estimates of sensitivity, specificity, and positive and negative likelihood ratios were then determined via bivariate random-effects models (49, 50). Interstudy heterogeneity was evaluated using the Cochran Q test and the I 2 statistic, wherein a P value less than 0.05 and an I 2 statistic greater than 25% reflected statistical evidence of interstudy heterogeneity (51). Sources of heterogeneity were examined by stratified analyses and metaregression (51). Prespecified subgroups included those pertaining to the study participants (adult vs. pediatric and medical vs. surgical), study method (high vs. low risk of bias), thermometers (index measurement site, index method of operation, index thermometer brand, user training, thermometer calibration, and type of reference standard), and temperature (fever and hypothermia). Publication bias was assessed by inspecting funnel plots and doing the Begg (primary meta-analysis) and Deek (secondary meta-analysis) funnel plot asymmetry tests (P< 0.1 was considered evidence of publication bias) (52, 53). Analyses were done in Stata, version 13.1 (Stata Corp) (54, 55). Role of the Funding Source This study received no funding. Results Study Selection and Description From 2563 citations, 75 were included in the systematic review (= 0.8 for both stages of citation review) (Appendix Figure 1). The most common reasons for exclusion after full-text review were the lack of simultaneous index and reference thermometer measurements (36%) and data pertaining to the mean difference between index and reference thermometers (34%). Sixty-nine articles were included in the primary meta

Comparative safety of serotonin (5-HT3) receptor antagonists in patients undergoing surgery: a systematic review and network meta-analysis

BackgroundSerotonin (5-HT3) receptor antagonists are commonly used to decrease nausea and vomiting for surgery patients, but these agents may be harmful. We conducted a systematic review on the comparative safety of 5-HT3 receptor antagonists.MethodsSearches were done in MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to identify studies comparing 5-HT3 receptor antagonists with each other, placebo, and/or other antiemetic agents for patients undergoing surgical procedures. Screening search results, data abstraction, and risk of bias assessment were conducted by two reviewers independently. Random-effects pairwise meta-analysis and network meta-analysis (NMA) were conducted. PROSPERO registry number: CRD42013003564.ResultsOverall, 120 studies and 27,787 patients were included after screening of 7,608 citations and 1,014 full-text articles. Significantly more patients receiving granisetron plus dexamethasone experienced an arrhythmia relative to placebo (odds ratio (OR) 2.96, 95 % confidence interval (CI) 1.11–7.94), ondansetron (OR 3.23, 95 % CI 1.17–8.95), dolasetron (OR 4.37, 95 % CI 1.51–12.62), tropisetron (OR 3.27, 95 % CI 1.02–10.43), and ondansetron plus dexamethasone (OR 5.75, 95 % CI 1.71–19.34) in a NMA including 31 randomized clinical trials (RCTs) and 6,623 patients of all ages. No statistically significant differences in delirium frequency were observed across all treatment comparisons in a NMA including 18 RCTs and 3,652 patients.ConclusionGranisetron plus dexamethasone increases the risk of arrhythmia.

A systematic review of the effectiveness of discharge care bundles for patients with COPD

Background A COPD discharge bundle is a set of evidence-based practices aimed at improving patient outcomes after discharge from acute care settings following an exacerbation. We conducted a systematic review on the effectiveness of COPD discharge bundles and summarised their individual care elements. Methods Biomedical electronic databases and clinical trial registries were searched from database inception through April 2016 to identify experimental studies evaluating care bundles offered to patients with COPD at discharge. Random-effects meta-analyses of clinical trials data were conducted for hospital readmissions, mortality, and quality of life (QoL). Results The review included 14 studies (5 clinical trials, 7 uncontrolled trials, and 2 interrupted time series). A total of 26 distinct elements of care were included in the bundles of individual studies. Evidence from four clinical trials with moderate-to-high risk of bias showed that COPD discharge bundles reduced hospital readmissions (pooled risk ratio (RR): 0.80; 95% CI 0.65 to 0.99). There was insufficient evidence that care bundles influence long-term mortality (RR: 0.74; 95% CI 0.43 to 1.28; four trials) or QoL (mean difference in St. Georges Respiratory Questionnaire: 1.84; 95% CI −2.13 to 5.8). Conclusions Discharge bundles for patients with COPD led to fewer readmissions but did not significantly improve mortality or QoL. Future studies should employ higher quality research methods, fully report care bundle elements, implementation strategies and intervention fidelity to better evaluate the effectiveness of packaging evidence-based interventions together to improve outcomes of patients with COPD discharged from acute care settings.

Mixed methods systematic review exploring mentorship outcomes in nursing academia

AIMS The aim of this study was to report on a mixed methods systematic review that critically examines the evidence for mentorship in nursing academia. BACKGROUND Nursing education institutions globally have issued calls for mentorship. There is emerging evidence to support the value of mentorship in other disciplines, but the extant state of the evidence in nursing academia is not known. A comprehensive review of the evidence is required. DESIGN A mixed methods systematic review. DATA SOURCES Five databases (MEDLINE, CINAHL, EMBASE, ERIC, PsycINFO) were searched using an a priori search strategy from inception to 2 November 2015 to identify quantitative, qualitative and mixed methods studies. Grey literature searches were also conducted in electronic databases (ProQuest Dissertations and Theses, Index to Theses) and mentorship conference proceedings and by hand searching the reference lists of eligible studies. REVIEW METHODS Study quality was assessed prior to inclusion using standardized critical appraisal instruments from the Joanna Briggs Institute. A convergent qualitative synthesis design was used where results from qualitative, quantitative and mixed methods studies were transformed into qualitative findings. Mentorship outcomes were mapped to a theory-informed framework. RESULTS Thirty-four studies were included in this review, from the 3001 records initially retrieved. In general, mentorship had a positive impact on behavioural, career, attitudinal, relational and motivational outcomes; however, the methodological quality of studies was weak. CONCLUSION This review can inform the objectives of mentorship interventions and contribute to a more rigorous approach to studies that assess mentorship outcomes.

Mentorship in nursing academia: a systematic review protocol

BackgroundMentorship is perceived as vital to attracting, training, and retaining nursing faculty members and to maintaining high-quality education programs. While there is emerging evidence to support the value of mentorship in academic medicine, the extant state of the evidence for mentorship in nursing academia has not been established. We describe a protocol for a mixed-methods systematic review to critically appraise the evidence for mentorship in nursing academia.MethodsStudies examining the effectiveness of mentorship interventions with nursing faculty who teach in registered nursing education programs will be included. Mentee, mentor, and nursing education institutional outcomes will be explored. Quantitative, qualitative, and mixed method studies will be eligible for inclusion, without restrictions on publication status, year of publication, or language. We will search electronic databases (for example, MEDLINE, CINAHL, ERIC) and gray literature (for example, conference proceedings, key journals, relevant organizational websites) for relevant citations. Using pilot-tested screening and data extraction forms, two reviewers will independently review the studies in three steps: (1) abstract/title screening, (2) full-text screening of accepted studies, and (3) data extraction of accepted studies. Studies will be aggregated for meta-synthesis (qualitative) and meta-analysis (quantitative), should the data permit.DiscussionThis study is the first systematic review of existing global evidence for mentorship in nursing academia. It will help identify key evidence gaps and inform the development and implementation of mentorship interventions. The mentorship outcomes that result from this review could be used to guide the practice of mentorship to increase positive outcomes for nursing faculty and the students they teach and ultimately effect improvements for the patients they care for. This review will also identify key considerations for future research on mentorship in nursing academia and the enhancement of nursing science.

A literature review of mentorship programs in academic nursing

BACKGROUND Nursing education institutions have issued recurring, global calls for mentorship; however, evidence-based program development guidance is scarce. To date, there are no comprehensive syntheses of current mentorship models, objectives, and program components to inform mentorship program development in nursing academia. The purpose of this review is to identify published articles that (1) described models for mentoring programs for academic nurses, and (2) described the objectives and core components of these programs. METHOD A systematic search of five databases (Medline, CINAHL, Embase, ERIC, and PsycINFO) was conducted to identify articles describing mentorship programs for academic nurses. Program objectives and components were extracted and narratively synthesized to identify important patterns and themes across mentorship programs. RESULTS A total of 34 articles describing 30 mentorship programs were identified. Mentoring models included dyad, peer, group, online, distance, learning partnerships, highly relevant, and constellation mentorship models. Key mentoring program components included: (a) having a program coordinator; (b) orientation to the program; (c) selectively matching dyads; (d) developing clear purpose and goals; (e) frequent communication between mentors and mentees; (f) faculty development workshops; (g) mentee reflective journaling; (h) facilitation of socialization and networking opportunities; and (i) administrative support. CONCLUSIONS In synthesizing the mentorship literature in academic nursing it is apparent that mentorship models and mentorship components look different in every setting with no empirical evidence that one mentorship model is more effective than another. Given the significant resources required to support mentorship innovations, understanding the benefits and shortcomings of various mentorship components can help ensure scarce resources are invested in the most effective mentorship strategies.

Barriers, supports, and effective interventions for uptake of human papillomavirus- and other vaccines within global and Canadian Indigenous peoples: a systematic review protocol.

BackgroundDespite the existence of human papilloma virus (HPV) vaccines with demonstrated safety and effectiveness and funded HPV vaccination programs, coverage rates are persistently lower and cervical cancer burden higher among Canadian Indigenous peoples. Barriers and supports to HPV vaccination in Indigenous peoples have not been systematically documented, nor have interventions to increase uptake in this population. This protocol aims to appraise the literature in Canadian and global Indigenous peoples, relating to documented barriers and supports to vaccination and interventions to increase acceptability/uptake or reduce hesitancy of vaccination. Although HPV vaccination is the primary focus, we anticipate only a small number of relevant studies to emerge from the search and will, therefore, employ a broad search strategy to capture literature related to both HPV vaccination and vaccination in general in global Indigenous peoples.MethodsEligible studies will include global Indigenous peoples and discuss barriers or supports and/or interventions to improve uptake or to reduce hesitancy, for the HPV vaccine and/or other vaccines. Primary outcomes are documented barriers or supports or interventions. All study designs meeting inclusion criteria will be considered, without restricting by language, location, or data type. We will use an a priori search strategy, comprised of key words and controlled vocabulary terms, developed in consultation with an academic librarian, and reviewed by a second academic librarian using the PRESS checklist. We will search several electronic databases from date of inception, without restrictions. A pre-defined group of global Indigenous websites will be reviewed for relevant gray literature. Bibliographic searches will be conducted for all included studies to identify relevant reviews. Data analysis will include an inductive, qualitative, thematic synthesis and a quantitative analysis of measured barriers and supports, as well as a descriptive synthesis and quantitative summary of measures for interventions.DiscussionTo our knowledge, this study will contribute the first systematic review of documented barriers, supports, and interventions for vaccination in general and for HPV vaccination. The results of this study are expected to inform future research, policies, programs, and community-driven initiatives to enhance acceptability and uptake of HPV vaccination among Indigenous peoples.Systematic review registrationPROSPERO Registration Number: CRD42017048844