Kerry Macdonald

Association of frailty and physical function in patients with non-dialysis CKD: a systematic review

BackgroundFrailty is a condition characterized by a decline in physical function and functional capacity. Common symptoms of frailty, such as weakness and exhaustion, are prevalent in patients with chronic kidney disease (CKD). The increased vulnerability of frail patients with coexisting CKD may place them at a heightened risk of encountering additional health complications. The purpose of this systematic review was to explore the link between frailty, CKD and clinical outcomes.MethodsWe searched for cross sectional and prospective studies in the general population and in the CKD population indexed in EMBASE, Pubmed, Web of Science, CINAHL, Cochrane and Ageline examining the association between frailty and CKD and those relating frailty in patients with CKD to clinical outcomes.ResultsWe screened 5,066 abstracts and retrieved 108 studies for full text review. We identified 7 studies associating frailty or physical function to CKD. From the 7 studies, we identified only two studies that related frailty in patients with CKD to a clinical outcome. CKD was consistently associated with increasing frailty or reduced physical function [odds ratios (OR) 1.30 to 3.12]. In patients with CKD, frailty was associated with a greater than two-fold higher risk of dialysis and/or death [OR from 2.0 to 5.88].ConclusionsCKD is associated with a higher risk of frailty or diminished physical function. Furthermore, the presence of frailty in patients with CKD may lead to a higher risk of mortality. Further research must be conducted to understand the mechanisms of frailty in CKD and to confirm its association with clinical outcomes.

Long-Term Effects of Postoperative Delirium in Patients Undergoing Cardiac Operation: A Systematic Review

Delirium is an acute syndrome that involves fluctuating changes in attention and cognition. Although delirium is the most common neurologic complication after cardiac operation, data about its impact on long-term outcomes are lacking. The purpose of this systematic review was to examine the effect of postoperative delirium (PoD) on long-term outcomes, including morbidity, probability of death, cognitive decline, institutionalization, and health-related quality of life (HRQoL) in patients undergoing cardiac operation. After performing this systematic review we determined that PoD after cardiac operation is associated with an increased risk of probability of death and readmission to the hospital and a decrease in cognitive function, overall function, and HRQoL.

The Effect of Erythropoietin-Stimulating Agents on Health-Related Quality of Life in Anemia of Chronic Kidney Disease: A Systematic Review and Meta-analysis

Chronic kidney disease (CKD) is a global health epidemic (1) that is increasing in incidence and prevalence (2, 3). Anemia is common in CKD (4); its treatment with erythropoietin-stimulating agents (ESAs) reduces the need for blood transfusions and has varying effects on morbidity and mortality (57). The optimal hemoglobin targets for treating anemia with ESAs are controversial, with safety concerns around the normalization of hemoglobin levels due to the increased risk for cardiovascular events (812). Clinical practice guidelines recommend hemoglobin targets of 10 to 11 g/L (13, 14), but individualization of hemoglobin targets remains relatively common among clinicians. In 2007, the U.S. Food and Drug Administration placed black box warnings on ESAs (15). Publication of the trial by Pfeffer and colleagues (16), combined with changes in Medicare reimbursement in 20102011, has led to decreased ESA use. Nonetheless, higher hemoglobin targets for some patients (that is, individualization of treatment) continues to be discussed and practiced. Most clinicians believe that treatment of anemia in CKD influences health-related quality of life (HRQOL) and its various domains (17, 18). In particular, younger, healthier patients may benefit from higher hemoglobin targets, and the harm may be concentrated in older individuals with preexisting cardiovascular risk factors. Previous systematic reviews have examined the use of ESAs to improve HRQOL in anemia of CKD (1922). However, these studies have focused only on dialysis recipients (20) or have included only specific HRQOL domains (2022). In addition, findings from recent large randomized trials have not been included (19). We performed an updated systematic review and meta-analysis on the effect of achieving higher hemoglobin targets with ESAs on HRQOL in patients with CKD and those undergoing dialysis. Methods Data Sources and Searches We developed and followed a protocol summarized in a document that included PICO (population, intervention, comparison, outcomes) criteria for search strategy and subgroup analyses (see protocol in the Supplement). We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (23) for reporting of systematic reviews and meta-analyses. Supplement. Study Protocol We identified studies evaluating the treatment of anemia with ESAs in patients with CKD who were receiving or not receiving dialysis. The studies had to report HRQOL measurements according to ESA treatment strategies to achieve 2 hemoglobin targets: a combined placebo or low-hemoglobin target versus a higher hemoglobin target. We included only prospective, randomized trials; placed no limits on sample size, duration of follow-up, type of ESA, or use of iron; and included only studies reported in English. In collaboration with a medical librarian (K.M.), we retrieved information for the study from the following databases: PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov. Our search of these databases ranged from the date of their establishment until 1 November 2015. The search strategy was tailored to each database and used a combination of key terms, such as quality of life, erythropoietin, outcome, health status, and quality-adjusted life-years. Medical Subject Heading terms (Appendix Table 1) were applied in the search strategy. We downloaded all of the received citations into RefWorks, version 2.0 (RefWorks-COS, Bethesda, Maryland). Appendix Table 1. Medical Subject Headings Search Terms Two reviewers (R.G. and B.L.) independently reviewed each citation by title and abstract, and articles were selected for full-text review. Two reviewers (R.G. and F.E.) screened the reference lists of articles selected for full-text review. Full-text articles were finalized for inclusion after consultation with third and fourth reviewers (Y.X and N.T.). All disagreements were resolved by consensus. Data Extraction and Quality Assessment We created a data extraction form to capture relevant information from the included studies. Two reviewers (R.G. and F.E.) independently extracted data; inconsistencies were corrected and resolved by consensus and consultation with third and fourth reviewers (Y.X and N.T.). Two reviewers (R.G. and D.C.) assessed studies for their quality of reporting and risk of bias using the Cochrane Collaborations tool for assessing risk of bias (24). Categories included random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, and selective reporting. Conflict was resolved by a third reviewer (N.T.). Data Synthesis and Analysis The primary measure was the change in baseline and follow-up scores of HRQOL instruments, specifically the Short Form-36 Health Survey (SF-36) (25) and the Kidney Disease Questionnaire (KDQ) (26). The SF-36 has been validated in earlier studies of patients with CKD and consists of 8 domains: physical function, physical role, bodily pain, general health, vitality, emotional role, social function, and mental health. Scales were standardized to scores ranging from 0 to 100, with higher scores indicating better health. A clinically meaningful difference in the SF-36 is a 5-point change (27). The KDQ has also been validated in the CKD setting and contains 26 questions, with scores in 5 dimensions: fatigue, depression, relationships with others, frustration, and physical symptoms. All dimensions are scored on a Likert scale between 7 (no problem) and 1 (a severe problem), with higher scores indicating better health. A clinically meaningful difference in KDQ is a 0.5-point change (28). A meta-analysis was performed to determine whether the change in HRQOL between 2 time points differed between hemoglobin target strategies. For this analysis, each of the 8 domains of the SF-36 and the 3 domains of the KDQ were analyzed individually. If the SE of the change was not available, we calculated its estimated value by assuming a normal distribution and independence between the 2 variables (29). Because the degree of heterogeneity between study estimates was expected to differ among the SF-36 and KDQ domains, we decided a priori to report aggregate estimates and corresponding 95% CIs using the HartungKnappSidikJonkman random-effects method (30). For each domain, a Cochran Q test was conducted to assess heterogeneity and an I 2 statistic was calculated to estimate the percentage of total variation resulting from between-study variation (31). We performed subgroup analyses on the SF-36 domains to examine the differences in aggregate estimates and heterogeneity when certain studies were excluded from the analysis. A subgroup analysis included studies that were deemed to have a low risk of bias, as determined by the Cochrane Collaborations tool for assessing risk of bias (24). Other subgroup analyses included nondialysis versus dialysis status, mean age of study participants younger or older than 60 years, publication before or after 2000, study follow-up of less than or greater than 1 year, and studies with reported incomplete follow-up less than 20%. All statistical analyses were performed by using SAS software, version 9.3 (SAS Institute). Role of the Funding Source The primary funding sources were KRESCENT and the Manitoba Health Research Council Establishment award, which had no role in the studys design, conduct, or reporting or in the decision to submit the manuscript for publication. Results A flow diagram outlining the selection strategy is shown in Appendix Figure 1. Our search strategy retrieved 5798 studies, including duplicates, for abstract screening. Of these, 43 studies were selected for full-text review, and 16 met criteria for inclusion in our systematic review. An additional study was identified for inclusion after review of included study references, for a total of 17 studies. Appendix Figure 1. Summary of evidence search and selection. Performed 1 November 2015. Quality of Reporting and Risk of Bias Four studies had a low risk of bias (3235) (Appendix Figure 2). A subgroup analysis including only the studies with low risk of bias was performed for SF-36 domains; no statistically significantly differences were seen between groups (Appendix Table 2). Allocation concealment and blinding were infrequent, which could have influenced the results of a subjective HRQOL assessment. Incomplete outcome data were common and were driven by the initiation of dialysis in predialysis studies, renal transplantation in the dialysis population, and a variety of adverse events that did not significantly differ between treatment groups. Appendix Figure 2. Risk-of-bias assessment of included studies. USREPSG= U.S. Recombinant Human Erythropoietin Predialysis Study Group. Appendix Table 2. Meta-analysis of Studies Using SF-36 With a Low Risk of Bias Characteristics of Selected Studies Of the 17 included studies, 12 were in the nondialysis CKD population, 4 were in the dialysis population, and 1 was in a combined sample. Three studies compared treatment with erythropoietin alfa (EPO) with placebo, 2 studies compared darbepoetin (DPO) with placebo, 1 study compared EPO with DPO, and 11 compared EPO with EPO. The follow-up ranged from 8 weeks to 36 months, with achieved hemoglobin ranging from 7.4 to 12 g/L for the placebo/lower hemoglobin target and 10.2 to 13.6 g/L for the higher hemoglobin target (Appendix Table 3). Thirteen studies measured SF-36 domains (Appendix Table 4) and 4 studies measured KDQ domains (Appendix Table 5). Other HRQOL tools included the Sickness Impact Profile, Functional Assessment of Chronic Illness Therapy, and Linear Analogue Self-Assessment. Heterogeneity for studies using SF-36 was moderate (I 2= 0% to 63.1%; see Figure 1 ). Appendix Table 3. Characteristics of Included Studies Appendix Table 4. Mean Scores on SF-36 Appendix Table 5. HRQOL Tools and Results Figure 1. Forest plot of all reported data o

The diagnostic accuracy of tests for latent tuberculosis infection in hemodialysis patients: a systematic review and meta-analysis.

Background Reactivation of latent Mycobacterium tuberculosis infection is an important health concern for patients on hemodialysis because of their immunosuppressed state and in kidney transplant patients receiving immunosuppressive therapy to prevent organ rejection. There are several tests available to determine the presence of latent tuberculosis infection: the tuberculin skin test (TST), QuantiFERON-TB Gold (QFT-G), and T-SPOT.TB. The objective of this study is to evaluate the diagnostic accuracy of these tests in determining latent tuberculosis infection in the hemodialysis population. Methods The study design was a systematic review. We selected studies with adequate information to ascertain test sensitivity or specificity of the TST, QFT-G, and TSPOT.TB with regards to determining latent tuberculosis infection in the hemodialysis population. Results One hundred two articles were selected for full review, and 17 were included in the meta-analysis. The TST had a pooled sensitivity of 31% (26%–36%, 95% confidence interval) and specificity of 63% (60%–65%) across eight studies. The QFT-G test had a pooled sensitivity of 53% (46%–59%) and specificity of 69% (65%–72%) across nine studies. The T-SPOT.TB test had a pooled sensitivity of 50% (42%–59%) and specificity of 67% (61%–73%) across three studies. Conclusion The QFT-G and the T-SPOT.TB tests were more sensitive than the TST for diagnosis of latent tuberculosis infection in patients on hemodialysis while offering a comparable level of specificity. This systematic review calls into question the practice of using the TST to screen in this population, especially in patients considered for kidney transplantation.

The Cost Effectiveness of Erythropoietin-Stimulating Agents for Treating Anemia in Patients on Dialysis: A Systematic Review

Background: Anemia is a common complication associated with kidney failure and is marked by poor health and increased risk of morbidity and mortality. There are ongoing concerns with the use of Erythropoietin Stimulating Agents (ESAs) to treat anemia in patients with kidney failure on dialysis. Questions as to their benefits, harms and overall effect on quality of life are still relevant today. Our objective was to systematically review studies evaluating the cost-effectiveness of ESAs in patients with kidney failure on dialysis. Methods: We performed a systematic review of studies determining the cost-effectiveness of ESAs in adult patients on dialysis. Databases, including PubMed, EMBASE, and Cochrane Database of Systematic Reviews, were searched from their establishment until June 2013. Studies that reported an incremental cost-effectiveness ratio of hemoglobin correction strategies based on ESA treatments in comparison to red blood cell transfusions, lower hemoglobin targets, or no ESA treatment were included. Results: Seven studies met inclusion criteria. Reported cost/quality-adjusted life-year (QALY) ratios ranged from USD 931-677,749/QALY across five studies comparing ESAs to red blood cell transfusions. There was heterogeneity in results when considering higher hemoglobin targets, with studies finding higher targets to be both dominant and dominated. Mortality, hospitalization, and utility estimates were major drivers. Conclusions: There is substantial variability in the estimates of the cost-effectiveness of using ESAs in the dialysis population. New models incorporating recent meta-analyses for estimates of utility, mortality, and hospitalization changes would allow for a more comprehensive answer to this question.

Honoring Our Hospital's History: A Preservation and Digitization Initiative

ABSTRACT There is limited literature on hospital archives projects. Hospitals understandably have a strong focus on patient care, but there is still a critical need to keep institutional archives. Among their many uses, institutional archives preserve corporate memory, provide evidence of interactions with community, and assist in contemporary decision making. This column describes a university-hospital partnership to undertake a one-year project to preserve, detail, and digitize ten boxes, or approximately 3.8 meters, of materials dating from 1980 to 2006. This project serves as a model for other hospital or health care facilities wanting to preserve and more actively engage with their archival collections.

Systematic review of preoperative physical activity and its impact on postcardiac surgical outcomes

Objectives The objective of this systematic review was to study the impact of preoperative physical activity levels on adult cardiac surgical patients’ postoperative: (1) major adverse cardiac and cerebrovascular events (MACCEs), (2) adverse events within 30 days, (3) hospital length of stay (HLOS), (4) intensive care unit length of stay (ICU LOS), (5) activities of daily living (ADLs), (6) quality of life, (7) cardiac rehabilitation attendance and (8) physical activity behaviour. Methods A systematic search of MEDLINE, Embase, AgeLine and Cochrane library for cohort studies was conducted. Results Eleven studies (n=5733 patients) met the inclusion criteria. Only self-reported physical activity tools were used. Few studies used multivariate analyses to compare active versus inactive patients prior to surgery. When comparing patients who were active versus inactive preoperatively, there were mixed findings for MACCE, 30 day adverse events, HLOS and ICU LOS. Of the studies that adjusted for confounding variables, five studies found a protective, independent association between physical activity and MACCE (n=1), 30-day postoperative events (n=2), HLOS (n=1) and ICU LOS (n=1), but two studies found no protective association for 30-day postoperative events (n=1) and postoperative ADLs (n=1). No studies investigated if activity status before surgery impacted quality of life or cardiac rehabilitation attendance postoperatively. Three studies found that active patients prior to surgery were more likely to be inactive postoperatively. Conclusion Due to the mixed findings, the literature does not presently support that self-reported preoperative physical activity behaviour is associated with postoperative cardiac surgical outcomes. Future studies should objectively measure physical activity, clearly define outcomes and adjust for clinically relevant variables. Registration Trial registration number NCT02219815. PROSPERO number CRD42015023606.

Collaborative Partnerships for Library Services: Examples From a Hospital Library

This article highlights the library service initiatives of a small academic satellite hospital library. The success of these initiatives is dependent on the partnerships that have been forged between the librarian and the health care professionals in various hospital departments. The service initiatives include a collaborative training program on point-of-care resources, health literacy training, participation in orientation, NICHE (Nurses Improving Care for Healthsystem Elders) program support, e-mail alerts for senior administration, movie programming, and research support. These initiatives are described in detail.