Retrospective study on the possible existence of a treatment paradox in sepsis scores in the emergency department

OBJECTIVE

The quick Sequential Organ Failure Assessment (qSOFA) is developed as a tool to identify patients with infection with increased risk of dying from sepsis in non-intensive care unit settings, like the emergency department (ED). An abnormal score may trigger the initiation of appropriate therapy to reduce that risk. This study assesses the risk of a treatment paradox: the effect of a strong predictor for mortality will be reduced if that predictor also acts as a trigger for initiating treatment to prevent mortality.

DESIGN

Retrospective analysis on data from a large observational cohort.

SETTING

ED of a tertiary medical centre in the Netherlands.

PARTICIPANTS

3178 consecutive patients with suspected infection.

PRIMARY OUTCOME

To evaluate the existence of a treatment paradox by determining the influence of baseline qSOFA on treatment decisions within the first 24 hours after admission.

RESULTS

226 (7.1%) had a qSOFA ≥2, of which 51 (22.6%) died within 30 days. Area under receiver operating characteristics of qSOFA for 30-day mortality was 0.68 (95% CI 0.61 to 0.75). Patients with a qSOFA ≥2 had higher odds of receiving any form of intensive therapy (OR 11.4 (95% CI 7.5 to 17.1)), such as aggressive fluid resuscitation (OR 8.8 95% CI 6.6 to 11.8), fast antibiotic administration (OR 8.5, 95% CI 5.7 to 12.3) or vasopressic therapy (OR 17.3, 95% CI 11.2 to 26.8), compared with patients with qSOFA <2.

CONCLUSION

In ED patients with suspected infection, a qSOFA ≥2 was associated with more intensive treatment. This could lead to inadequate prediction of 30-day mortality due to the presence of a treatment paradox.

TRIAL REGISTRATION NUMBER

6916.

Keep Moving Toward Recovery! Function-Focused Care in Hospitalized Stroke and Geriatric Patients

Many hospitalized patients experience decline in functional status. Function Focused Care (FFC) has demonstrated to improve patients’ functional status in long-term care. In a stepped wedge cluster trial in 893 hospitalized geriatric and stroke patients, we investigated the effectiveness of FFC compared to usual care (FFC: n=427, UC: n=466) on ADL and mobility. We measured the Barthel Index and the Elderly Mobility Scale, and analysed using a mixed-model multi-level method. At discharge, 3 month and 6 months, the mean difference (MD) was in favour of FFC, although at none of the time points the level of significance was reached: the MD for ADL was respectively: 0.79 (95%CI: -0.98-2.56), 0.43 (95%CI: 0.10-1.79), and 0.57 (95%CI: -1.34- 2.48). For mobility, the MD was respectively 0.89 (95%CI: -1.01-2.80), 0.78 (95%CI: -1.18; 2.75), and 1.09 (95%CI: -0.88-3.07). Although the results are inconclusive, FFC shows a tendency to improve ADL and mobility in hospitalized patients. Part of a symposium sponsored by Nursing Care of Older Adults Interest Group.

Adaptive trial designs in diagnostic accuracy research

The aim of diagnostic accuracy studies is to evaluate how accurately a diagnostic test can distinguish diseased from nondiseased individuals. Depending on the research question, different study designs and accuracy measures are appropriate. As the prior knowledge in the planning phase is often very limited, modifications of design aspects such as the sample size during the ongoing trial could increase the efficiency of diagnostic trials. In intervention studies, group sequential and adaptive designs are well established. Such designs are characterized by preplanned interim analyses, giving the opportunity to stop early for efficacy or futility or to modify elements of the study design. In contrast, in diagnostic accuracy studies, such flexible designs are less common, even if they are as important as for intervention studies. However, diagnostic accuracy studies have specific features, which may require adaptations of the statistical methods or may lead to specific advantages or limitations of sequential and adaptive designs. In this article, we summarize the current status of methodological research and applications of flexible designs in diagnostic accuracy research. Furthermore, we indicate and advocate future development of adaptive design methodology and their use in diagnostic accuracy trials from an interdisciplinary viewpoint. The term "interdisciplinary viewpoint" describes the collaboration of experts of the academic and nonacademic research.

Overinterpretation and misreporting of prognostic factor and biomarker studies in medical oncology

e14023

Background: To generate empirical evidence, classify and estimate the frequency of distorted presentation and overinterpretation of results in prognostic factor (PF) studies in oncology. Methods: We selected 17 oncology journals with an impact factor of 7 or more. PubMed was searched to identify primary clinical studies evaluating one or more PFs published in 2015. Each article was independently evaluated by 2 reviewers using a data extraction form that was extensively pilot-tested. We classified aspects of overinterpretation as misleading reporting, interpretation and extrapolation. Results: Our search identified 10 844 articles, 98 met eligibility criteria. The PF was assessed prospectively in 8 of 56 observational studies, and in 16 of 42 clinical trials. The median number of PFs per study was 2 (Q1-Q3, 1-5). Overall survival was used as the outcome in 77 studies. The median number of statistical analyses reported with regards to the PF effect assessment was 42.5 per study (Q1-Q3, 15.5-86.5). Thirty-three reports reported using 2 or more different multivariable models to assess the PF effect and 21 did not adjust. Misleading reporting included selective and incomplete reporting of the PF effect (n = 26 and n = 8, respectively). The conclusions focused solely on significant results in 80 reports, and in those where there was at least one NS result, 80% of studies focused their conclusions solely on the significant results. Misleading interpretation included not reporting the PF effect within a multivariable model (n = 23 and n = 54 in full-texts and abstracts, respectively). One out of 5 conclusions used linguistic spin with strong statements in both full-text and abstract. Linguistic spin of NS results was found in 28 Results sections in the full-text and in 18 abstract conclusions. The conclusions were inconsistent with the study findings in one out of five articles (both in the full-text and abstract). Discrepancies between the conclusions presented in the full-text and in the abstract were found in 18 reports. Conclusions: Our study provides insight into the level of reporting and overinterpretation of findings that were frequently inconsistent with the results in oncology journals with high impact factors.

Erratum to: Methods for evaluating medical tests and biomarkers

[This corrects the article DOI: 10.1186/s41512-016-0001-y.].

Optimal duration of event recording for diagnosis of arrhythmias in patients with palpitations and light-headedness in the general practice

BACKGROUND

Patient-activated continuous-loop event recorders (CER) are useful as a diagnostic tool in new episodes of palpitations and/or dizziness. So far, no analysis of optimal duration for monitoring in unselected patients has been published.

METHODS

During a period of 30 days, we prospectively evaluated the time until diagnosis using CER in patients with symptoms of palpitations and/or dizziness in general practice.

RESULTS

In total, 127 patients received an event recorder for a maximum duration of 30 days. Events were recorded by 104 patients (82%), of whom 83 (78%) showed an arrhythmia. After 2 weeks, 75% of all diagnoses and 83.3% of all clinically relevant diagnoses could be established.

CONCLUSION

The yield of event recording in general practice diminishes with recording time. A minimum recording time of 2 weeks seems necessary.

Impact of Adjustment for Quality on Results of Metaanalyses of Diagnostic Accuracy

Background: We examined whether and to what extent different strategies of defining and incorporating quality of included studies affect the results of metaanalyses of diagnostic accuracy.

Methods: We evaluated the methodological quality of 487 diagnostic-accuracy studies in 30 systematic reviews with the QUADAS (Quality Assessment of Diagnostic-Accuracy Studies) checklist. We applied 3 strategies that varied both in the definition of quality and in the statistical approach to incorporate the quality-assessment results into metaanalyses. We compared magnitudes of diagnostic odds ratios, widths of their confidence intervals, and changes in a hypothetical clinical decision between strategies.

Results: Following 2 definitions of quality, we concluded that only 70 or 72 of 487 studies were of “high quality”. This small number was partly due to poor reporting of quality items. None of the strategies for accounting for differences in quality led systematically to accuracy estimates that were less optimistic than ignoring quality in metaanalyses. Limiting the review to high-quality studies considerably reduced the number of studies in all reviews, with wider confidence intervals as a result. In 18 reviews, the quality adjustment would have resulted in a different decision about the usefulness of the test.

Conclusions: Although reporting the results of quality assessment of individual studies is necessary in systematic reviews, reader wariness is warranted regarding claims that differences in methodological quality have been accounted for. Obstacles for adjusting for quality in metaanalyses are poor reporting of design features and patient characteristics and the relatively low number of studies in most diagnostic reviews.

Epidemiology of reflex syncope

Cost-effective diagnostic approaches to reflex syncope require knowledge of its frequency and causes in different age groups. For this purpose we reviewed the available literature dealing with the epidemiology of reflex syncope. The incidence pattern of reflex syncope in the general population and general practice is bimodal with peaks in teenagers and in the elderly. In the young almost all cases of transient loss of consciousness are due to reflex syncope. The life-time cumulative incidence in young females ( congruent with 50 %) is about twice as high as in males ( congruent with 25 %). In the elderly, cardiac causes, orthostatic and postprandial hypotension, and the effects of medications are common, whereas typical vasovagal syncope is less frequent. In emergency departments, cardiac causes and orthostatic hypotension are more frequent especially in elderly subjects. Reflex syncope, however, remains the most common cause of syncope, but all-cause mortality in subjects with reflex syncope is not higher than in the general population. This knowledge about the epidemiology of reflex syncope can serve as a benchmark to develop cost-effective diagnostic approaches.

Development and validation of methods for assessing the quality of diagnostic accuracy studies

OBJECTIVES

To develop a quality assessment tool which will be used in systematic reviews to assess the quality of primary studies of diagnostic accuracy.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE, BIOSIS and the methodological databases of both CRD and the Cochrane Collaboration.

REVIEW METHODS

Three systematic reviews were conducted to provide an evidence base for the development of the quality assessment tool. A Delphi procedure was used to develop the quality assessment tool and the information provided by the reviews was incorporated into this. A panel of nine experts in the area of diagnostic accuracy studies took part in the Delphi procedure to agree on the items to be included in the tool. Panel members were also asked to provide feedback on various other items and whether they would like to see the development of additional topic and design specific items. The Delphi procedure produced the quality assessment tool, named the QUADAS tool, which consisted of 14 items. A background document was produced describing each item included in the tool and how each of the items should be scored.

RESULTS

The reviews produced 28 possible items for inclusion in the quality assessment tool. It was found that the sources of bias supported by the most empirical evidence were variation by clinical and demographic subgroups, disease prevalence/severity, partial verification bias, clinical review bias and observer/instrument variation. There was also some evidence of bias for the effects of distorted selection of participants, absent or inappropriate reference standard, differential verification bias and review bias. The evidence for the effects of other sources of bias was insufficient to draw conclusions. The third review found that only one item, the avoidance of review bias, was included in more than 75% of tools. Spectrum composition, population recruitment, absent or inappropriate reference standard and verification bias were each included in 50-75% of tools. Other items were included in less than 50% of tools. The second review found that the quality assessment tool should have the potential to be discussed narratively, reported in a tabular summary, used as recommendations for future research, used to conduct sensitivity or regression analyses and used as criteria for inclusion in the review or a primary analysis. This suggested that some distinction is needed between high- and low-quality studies. Component analysis was considered the best approach to incorporate quality into systematic reviews of diagnostic studies and this was taken into consideration when developing the tool.

CONCLUSIONS

This project produced an evidence-based quality assessment tool to be used in systematic reviews of diagnostic accuracy studies. Through the various stages of the project the current lack of such a tool and the need for a systematically developed validated tool were demonstrated. Further work to validate the tool continues beyond the scope of this project. The further development of the tool by the addition of design- and topic-specific criteria is proposed.

The effect of the gastrointestinal lipase inhibitor, orlistat, on serum lipids and lipoproteins in patients with primary hyperlipidaemia

The effect of orlistat, a nonabsorbed inhibitor of gastric and pancreatic lipases, was examined in patients with primary hyperlipidaemia (serum cholesterol > or = 6.2 mmol.l-1 and triglycerides < or = 5.0 mmol.l-1) not responsive to dietary change alone. In a multicentre, randomised, double-blind study, 103 men and 70 women received 30, 90, 180, or 360 mg or orlistat or placebo for 8 weeks. Total and low-density lipoprotein cholesterol levels were reduced by 4% and 5% with 30 mg orlistat, by 7% and 8% with 90 mg orlistat, by 7% and 7% with 180 mg orlistat and by 11% and 10% with 360 mg orlistat compared to placebo. High density lipoprotein cholesterol levels significantly decreased in the 360 mg orlistat group. Triglyceride levels significantly increased in the placebo group but not in the drug groups. Body weight decreased by 1.2 kg with 360 mg orlistat, despite a weight maintenance diet. Decreases in vitamin E and D levels occurred, although both vitamins remained within the normal range. Adverse effects from the gastrointestinal tract were frequent, but led to discontinuation of therapy in only seven patients. Orlistat is a new therapeutic drug for the treatment of hyperlipidaemia that may be particularly useful among overweight patients. Its potential place in therapy will await long-term studies. Vitamin supplementation should be considered during treatment.

[Effects of diabetes education in children]

This article presents the results of a research project on psychological as well as medical effects of diabetes-education on young children. The education programme influences some aspects of the emotional attitude of children towards their diabetes in a positive way. Significant results are found on three topics: the emotional attitude towards diabetes(care), speaking up about diabetes in the social environment, and taking own responsibility towards diabetes(care). The medical effects tested are not significantly influenced. Children and parents experience (the results of) the education programme commonly in a positive way.