Lindsey Sikora

A systematic review of the risks factors associated with the onset and natural progression of spina bifida.

&NA; The purpose of this study was to systematically assess and synthesize the world literature on risk factors for the onset and natural progression of spina bifida, thereby providing a basis for policy makers to identify appropriate risk management measures to mitigate the burden of disease in Canada. Searches of several health literature databases from inception to February 2013 were conducted by a health sciences librarian. A total of three meta‐analyses that studied a risk factor for the onset of spina bifida were included. Pooled results showed that paternal exposure to Agent Orange (RR = 2.02; 95% CI 1.48–2.74) and maternal obesity prior to pregnancy (OR = 2.24; 95% CI 1.86–2.74) each increased the risk of having a child with spina bifida. Paternal exposure to organic solvents was also close to the limit of significance (OR = 1.59; 95% CI 0.99–2.56). A total of 63 observational studies, encompassing hundreds of potential risk factors, were included for risk factors for the onset of disease. One meta‐analysis and four observational studies examined the impact of genetic risk factors. Only specified mutations in the 5,10‐methylenetetrahydrofolate reductase (MTHFR) and dihydrofolate reductase (DHFR) genes were found to be linked to disease onset. One observational study evaluated a risk factor for the natural progression of disease. An extensive number of potential risk factors for the onset of spina bifida have been studied, though most lack sufficient evidence to confirm an association. Currently, strong evidence exists to suggest a causal association for maternal obesity prior to pregnancy, and paternal exposure to Agent Orange. HighlightsSpina bifida (SB), a neural tube birth defect occurring within the first four weeks of pregnancy and is the most common life disabling birth defect.In this neurological condition the spinal column fails to develop properly—one or more vertebrae do not form completely leaving a gap in the spine.The aetiology of SB is unknown, but both genetic and environmental risk factors are considered important for its onset and progression.Risk factors for onset include maternal obesity, paternal Agent Orange exposure and lack of folic acid intake in the periconceptional period.All the risk factors mentioned above are modifiable hence should be targeted as preventative strategies to reduce the burden of SB.

Health-related quality-of-life among survivors of acute kidney injury in the intensive care unit: a systematic review.

PurposeTo summarize evidence on long-term health-related quality-of-life (HRQL) among survivors of acute kidney injury (AKI) in the intensive care unit (ICU).MethodsWe performed a comprehensive search of the literature for studies reporting original data describing HRQL utilizing validated instruments. Search, study selection and data abstraction were performed in duplicate. Study quality was appraised. Due to study heterogeneity, data are primarily summarized qualitatively.Results Our search yielded 2193 articles of which 18 were selected for detailed analysis. The quality of these 18 studies was generally good. Numerous HRQL instruments were utilized, and assessment occurred at variable follow-up duration (range 2 months to 14.5 years). HRQL among AKI survivors was reduced when compared to age/sex-matched populations. HRQL among survivors with and without AKI was generally described as similar beyond 6 months. Physical component domains were consistently more impaired than mental component domains. Survivors had considerable limitations in activities of daily living, implying newly acquired disability, with few returning to work. Despite diminished HRQL, patients’ HRQL was generally perceived as satisfactory, and the majority would receive similar treatment again, including renal replacement therapy in the ICU, if necessary.ConclusionsAmong survivors of critical illness complicated by AKI, HRQL was impaired when referenced to population norms, but it was not significantly different from that of survivors without AKI. Physical limitations and disabilities were more commonly exhibited by AKI patients. Importantly, the impaired HRQL was generally perceived as acceptable to patients, most of whom expressed willingness to undergo similar treatment in the future.

Factors associated with the onset and progression of neurotrauma: A systematic review of systematic reviews and meta-analyses

&NA; Neurotrauma, including traumatic brain injury (TBI) and spinal cord injury (SCI), is a preventable condition that imposes an important burden on the Canadian society. In this study, the current evidence on risk factors for the onset and progression of neurotrauma is systematically reviewed and synthesized. Searches of the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Medline and Medline in Process (via OVID), EMBASE and PsycINFO from inception to February 2013 were conducted to identify relevant systematic reviews and meta‐analyses published in English or French. Two referees screened and assessed the quality of the studies using the AMSTAR tool. Thirty‐two studies examined at least one risk factor for the onset of neurotrauma. Thirteen studies passed the quality assessment and the majority evaluated the impact of protective equipment in sports. Helmets effectively reduce TBI from bicycling, skiing, snowboarding, ice hockey and motorcycling. There was no evidence of a protective effect of helmets for SCI. No studies contributed evidence on risk factors for the onset of SCI. Of two studies examining risk factors for the progression of neurotrauma, only injury severity was found to be associated with poorer post‐injury outcomes. Substantial evidence supports the use of helmets for the prevention of TBI in sports and motorcycling and face shields in ice hockey. Addressing bicycle helmet legislation across Canada may be an effective option for reducing TBI caused by bicycle accidents. Limited evidence on relevant risk factors for spinal cord injuries and neurotrauma progression was available. HighlightsNeurotrauma, including traumatic brain injury (TBI) and spinal cord injury (SCI), is a preventable condition.The incidence of severe TBI is estimated to be 11.4 cases per 100,000 and mild TBI (MBI) is estimated to be about 600 cases per 100,000 annually.MBI occurs mainly due to sport injury whereas TBI could result from falls, assaults, or motor vehicle accidents/collisions.Alcohol use may not be a direct risk factor for injury, but may modify behavior to cause the injury.The study identified that protective factors include air bags, seat belts, head rests in motor vehicles, sports helmets, and face shields.

A systematic review of the risks factors associated with the onset and natural progression of hydrocephalus

&NA; The purpose of this study was to systematically assess and synthesize the world literature on risk factors for the onset and natural progression of hydrocephalus, thereby providing a basis for policy makers to identify appropriate risk management measures to mitigate the burden of disease in Canada. Evidence for risk factors was limited for both onset and progression. Two meta‐analyses that examined a risk factor for onset met the inclusion criteria. One found a significant protective effect of prenatal vitamins among case control studies, but not cohort/randomized controlled trials (RCTs). The second found maternal obesity to be a significant risk factor for congenital hydrocephalus. Significant risk factors among 25 observational studies included: biological (multiple births, maternal parity, common cold with fever, maternal thyroid disease, family history, preterm birth, hypertension, ischemic heart disease, ischemic ECG changes, higher cerebrospinal fluid protein concentration following vestibular schwannoma); lifestyle (maternal obesity, high‐density lipoprotein (HDL) cholesterol, maternal diabetes, maternal age), healthcare‐related (caesarean section, interhospital transfer, drainage duration following subarachnoid hemorrhage, proximity to midline for craniectomy following traumatic brain injury); pharmaceutical (prenatal exposure to: tribenoside, metronidazole, anesthesia, opioids); and environmental (altitude, paternal occupation). Three studies reported on genetic risk factors: no significant associations were found. There are major gaps in the literature with respect to risk factors for the natural progression of hydrocephalus. Only two observational studies were included and three factors reported. Many risk factors for the onset of hydrocephalus have been studied; for most, evidence remains limited or inconclusive. More work is needed to confirm any causal associations and better inform policy. HighlightsWith hydrocephalus, excessive accumulation of cerebrospinal fluid (CSF) results in abnormal widening of cavities (ventricles) in the brain, creating potentially harmful pressure on neural tissues.Hydrocephalus can be congenital (CHC) (developed prior to birth) or acquired (AHC) (developed during or after birth) and can occur at any age. Incidence of congenital hydrocephalus is estimated at about 3 per 1,000 live births in the US.The limited evidence available suggests that both congenital and acquired hydrocephalus may be linked to modifiable risk factors, such as maternal obesity, lack of prenatal multivitamin supplement use, and high HDL cholesterol in adults.Health care policy could focus on the following risk mitigation strategies: i) providing and improving access to adequate prenatal education and care, particularly for mothers at greater risk of pre‐term delivery (e.g., teens and older primiparous mothers); ii) better counselling for women using artificial reproductive technologies such as in‐vitro fertilization and are, thus, at a greater risk of having a multiple birth; and iii) use of safety equipment across a broad range of uses, from infant car seats and seatbelts, to workplace hardhats and harnesses, to sporting and recreation gear (e.g., bicycle helmets), all of which may help to prevent hydrocephalus due to head injuries.

Effectiveness of personal protective measures in reducing pandemic influenza transmission: A systematic review and meta-analysis

The goal of this review was to examine the effectiveness of personal protective measures in preventing pandemic influenza transmission in human populations. We collected primary studies from Medline, Embase, PubMed, Cochrane Library, CINAHL and grey literature. Where appropriate, random effects meta-analyses were conducted using inverse variance statistical calculations. Meta-analyses suggest that regular hand hygiene provided a significant protective effect (OR=0.62; 95% CI 0.52-0.73; I2=0%), and facemask use provided a non-significant protective effect (OR=0.53; 95% CI 0.16-1.71; I2=48%) against 2009 pandemic influenza infection. These interventions may therefore be effective at limiting transmission during future pandemics. PROSPERO Registration: 42016039896.

Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients: a systematic review

BackgroundHemodynamic instability related to renal replacement therapy (HIRRT) may increase the risk of death and limit renal recovery. Studies in end-stage renal disease populations on maintenance hemodialysis suggest that some renal replacement therapy (RRT)-related interventions (e.g., cool dialysate) may reduce the occurrence of HIRRT, but less is known about interventions to prevent HIRRT in critically ill patients receiving RRT for acute kidney injury (AKI). We sought to evaluate the effectiveness of RRT-related interventions for reducing HIRRT in such patients across RRT modalities.MethodsA systematic review of publications was undertaken using MEDLINE, MEDLINE in Process, EMBASE, and Cochrane’s Central Registry for Randomized Controlled Trials (RCTs). Studies that assessed any intervention’s effect on HIRRT (the primary outcome) in critically ill patients with AKI were included. HIRRT was variably defined according to each study’s definition. Two reviewers independently screened abstracts, identified articles for inclusion, extracted data, and evaluated study quality using validated assessment tools.ResultsFive RCTs and four observational studies were included (n = 9; 623 patients in total). Studies were small, and the quality was mostly low. Interventions included dialysate sodium modeling (n = 3), ultrafiltration profiling (n = 2), blood volume (n = 2) and temperature control (n = 3), duration of RRT (n = 1), and slow blood flow rate at initiation (n = 1). Some studies applied more than one strategy simultaneously (n = 5). Interventions shown to reduce HIRRT from three studies (two RCTs and one observational study) included higher dialysate sodium concentration, lower dialysate temperature, variable ultrafiltration rates, or a combination of strategies. Interventions not found to have an effect included blood volume and temperature control, extended duration of intermittent RRT, and slower blood flow rates during continuous RRT initiation. How HIRRT was defined and its frequency of occurrence varied widely across studies, including those involving the same RRT modality. Pooled analysis was not possible due to study heterogeneity.ConclusionsSmall clinical studies suggest that higher dialysate sodium, lower temperature, individualized ultrafiltration rates, or a combination of these strategies may reduce the risk of HIRRT. Overall, for all RRT modalities, there is a paucity of high-quality data regarding interventions to reduce the occurrence of HIRRT in critically ill patients.

Interventions to prevent hemodynamic instability during renal replacement therapy for acute kidney injury: a systematic review protocol

BackgroundHemodynamic instability during renal replacement therapy (HIRRT) in the form of intradialytic hypotension (IDH) is a frequent complication of hemodialysis in end-stage kidney disease (ESKD), and most studies have focused on this chronic population. However, HIRRT is also an important concern for critically ill ICU patients with acute kidney injury (AKI), complicating an estimated 30% of dialysis treatments in this population. HIRRT can exacerbate organ hypoperfusion in the setting of critical illness and may negatively impact renal recovery in the AKI population. This is a protocol for a systematic review to synthesize the evidence surrounding dialysis-related interventions used to minimize HIRRT in critically ill patients with RRT-requiring AKI. This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) database.Methods/designWe will search MEDLINE, EMBASE, and CENTRAL databases in collaboration with a health information specialist using a comprehensive search strategy. We will also supplement our search with a scan of the “gray literature” to identify relevant ongoing trials or conference abstracts. Observational studies and clinical trials will be included in our analysis. Our outcomes will include the incidence of HIRRT, dialysis-related complications, in-hospital mortality, and renal recovery. Prior to our search, we performed an initial search of these databases and PROSPERO, which yielded no prior or ongoing systematic reviews on this topic. Two reviewers will independently screen the list of identified abstracts using pre-defined inclusion and exclusion criteria. Two reviewers will then independently extract data from selected studies and undertake an assessment of their quality using validated tools.DiscussionHIRRT is a common complication of renal replacement therapy not only in ESKD but also in the critically ill AKI population. It can result in early discontinuation of dialysis, further organ injury from hypoperfusion, and possibly negatively impact renal recovery. This systematic review will synthesize the existing evidence on the interventions employed to predict or prevent episodes HIRRT in critically ill patients with RRT-requiring AKI. This systematic review will allow for an understanding the current evidence for interventions to limit HIRRT in AKI and, in doing so, may also highlight areas in need of further research.Systematic review registrationPROSPERO CRD42016037754

Underrepresentation of men in gender based humanitarian and refugee trauma research: a scoping review

Sex and gender are important considerations within refugee studies. Risks to health and wellbeing may manifest differently for refugee women and men, as may the use of health and social services and responses to interventions. Since the 1980s, increased attention has been paid to the experience of girls and women in refugee and humanitarian research, however, much less attention has been paid to boys and men. The purpose of this systematic scoping review was to investigate whether there is a gender bias in refugee and humanitarian research on refugee trauma. Findings demonstrate that since 1988, fully 95% of gender focused refugee research addressed women’s issues, while only 5% addressed the experience of refugee men. This article offers possible explanations for this gap and discusses its ramifications for both research and clinical practice.

The Efficacy of Postoperative Iron Therapy in Improving Clinical and Patient-Centered Outcomes Following Surgery: A Systematic Review and Meta-Analysis.

Postoperative anemia is a common occurrence in surgical patients and leads to an increased risk for allogeneic blood transfusions. The efficacy of iron therapy in treating postoperative anemia has not been firmly established. The objective of this systematic review was to evaluate the efficacy of postoperative oral and intravenous (IV) iron therapy in increasing hemoglobin levels and improving patient outcomes following elective surgery. The databases Medline, EMBASE, CENTRAL, the Transfusion Evidence Library, and ClinicalTrials.gov were searched. Eligible studies were randomized controlled trials or prospective cohorts having a control group, where postoperative oral or IV iron was administered to elective surgery patients. Primary outcomes were hemoglobin levels and patient-centered outcomes of quality of life and functioning. Secondary outcomes were the safety of postoperative iron and blood transfusion requirement. Meta-analysis using a random-effects model was performed. Seventeen relevant studies were identified, of which 7 investigated IV iron, 7 investigated oral iron, and 3 compared IV with oral iron. Postoperative oral and IV iron therapies were ineffective in improving quality of life and functioning (the Grading of Recommendations Assessment, Development and Evaluation [GRADE]: moderate-low quality). Compared with control, IV iron increased mean hemoglobin levels by 3.40 g/L (95% confidence interval [CI]: 1.18-5.62) (GRADE: moderate quality); however, this increase is likely not clinically meaningful. Overall, oral iron was ineffective in increasing hemoglobin concentrations compared with control (mean difference=0.77, 95% CI: -1.48-3.01) (GRADE: moderate quality). Postoperative iron therapy did not significantly reduce the risk of blood transfusion (relative risk=0.75; 95% CI: 0.53-1.07) (GRADE: low quality). IV iron was not associated with a significantly increased risk of adverse events (relative risk=4.50, 95% CI: 0.64-31.56). There was insufficient information to determine the risk of adverse events for postoperative oral iron. This systematic review found no evidence to support the routine use of postoperative iron therapy in all elective surgery patient populations; however, results are based largely on studies with non-iron-deficient patients preoperatively. Further research on the role of postoperative IV iron is warranted for certain high-risk groups, including patients with iron deficiency or anemia prior to surgery. This systematic review is registered in PROSPERO (CRD42017057837).

Problematising risk in stroke rehabilitation.

Abstract Purpose: Following stroke, re-engagement in personally valued activities requires some experience of risk. Risk, therefore, must be seen as having positive as well as negative aspects in rehabilitation. Our aim was to identify the dominant understanding of risk in stroke rehabilitation and the assumptions underpinning these understandings, determine how these understandings affect research and practise, and if necessary, propose alternate ways to conceptualise risk in research and practise. Method: Alvesson and Sandberg’s method of problematisation was used. We began with a historical overview of stroke rehabilitation, and proceeded through five steps undertaken in an iterative fashion: literature search and selection; data extraction; syntheses across texts; identification of assumptions informing the literature and; generation of alternatives. Results: Discussion of risk in stroke rehabilitation is largely implicit. However, two prominent conceptualisations of risk underpin both knowledge development and clinical practise: the risk to the individual stroke survivor of remaining dependent in activities of daily living and the risk that the health care system will be overwhelmed by the costs of providing stroke rehabilitation. Conclusions: Conceptualisation of risk in stroke rehabilitation, while implicit, drives both research and practise in ways that reinforce a focus on impairment and a generic, decontextualised approach to rehabilitation. Implications for rehabilitation Much of stroke rehabilitation practise and research seems to centre implicitly on two risks: risk to the patient of remaining dependent in ADL and risk to the health care system of bankruptcy due to the provision of stroke rehabilitation. The implicit focus on ADL dependence limits the ability of clinicians and researchers to address other goals supportive of a good life following stroke. The implicit focus on financial risk to the health care system may limit access to rehabilitation for people who have experienced either milder or more severe stroke. Viewing individuals affected by stroke as possessing a range of independence and diverse personally valued activities that exist within a network of relations offers wider possibilities for action in rehabilitation.